Treatment Options for Depression

The Best Therapy is Individualized To Your Needs

Depression treatment that is effective

Depression Treatment

Depression Treatment Is Multidimensional

It takes courage to admit being depressed and seeking help. How to treat depression is a question over 350 million people worldwide face every year. Thankfully, many different strategies exist to help fight depression and overcome this leading cause of global disability.

The general approach to depression treatment is to first seek professional help from a physician or therapist. Depression treatment usually involves a combination of therapy, medication, and lifestyle modification. For severe cases, one or more medications may be needed to help you recover and find balance in your life again.

Sometimes medication is not needed. Some cases of mild to moderate depression may be treated sufficiently using therapy and lifestyle modification. For more severe cases, anti-depressants plus therapy and lifestyle modification are usually used to achieve effective treatment. There are many facets to depression treatment.

Follow the advice of a doctor regarding depression treatment. This website does not give medical advice. The purpose of this website is to provide information, not to make medical recommendations.

The Triad of Depression Treatment: Therapy, Medication, Lifestyle Modification

Triad of Depression Treatment

Step 1: Give A Complete History

Find a doctor you trust and feel comfortable with, and feel free to share how you arrived at this point in your life. Giving a complete history to your doctor is the first step to improvement. As a patient, it is in your best interest to give your doctor a complete and accurate history of your depressive symptoms. Be sure to include details about onset, factors that make it better or worse, previous therapies and/or medications that have helped. Be sure to also share an accurate drug abuse history including alcohol use. If you have a suicidal past or self-injurious past then discuss this. Your doctor will want to know about sleep patterns and eating habits. Feel free to discuss sources of stress, guilt, hopelessness, and anxiety. Even the personal relationships in your life are important to share with a good psychiatrist. If you experience physical pain then this should be discussed as well. Be sure to talk about your past medical conditions including past and current medications, surgeries, and hospitalizations. All of these facts are important in determining proper depression treatment.

Step 2: Consider Treatment Options With Your Doctor

Should you use therapy, medication, or lifestyle changes? A combination of depression treatment options are usually used for most people. While psychotherapy alone or medication alone may be sufficient to treat mild to moderate depression, randomized clinical trials found that a combination of pharmacotherapy and psychotherapy is more effective than either alone. [1,2] Severe major depression certainly requires medication, and most likely therapy as adjunct along with lifestyle modifications. Brain stimulation is typically reserved for severe refractory cases.

Option 1: Antidepressant Medications

Several large categories of antidepressants exist and include the Selective serotonin reuptake inhibitors (SSRIs), Serotonin-norepinephrine reuptake inhibitors (SNRIs), Serotonin Modulators, Atypical antidepressants, Tricyclics, and MAOIs.

Selective serotonin reuptake inhibitors (SSRIs)

Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Desvenlafaxine
Duloxetine
Milnacipran
Venlafaxine

Serotonin Modulators

Nfazodone
Trazodone
Vilazodone

Atypical antidepressants

Bupropion
Mirtazapine
Vortioxetine
Agomelatine (unavailable in the USA)

Tricyclic antidepressants (TCAs)

Amitriptyline
Clomipramine
Doxepin
Amoxapine
Imipramine
Trimipramine
Desipramine
Nortriptyline
Protriptyline
Maprotiline

Monoamine oxidase inhibitors (MAOIs)

Tranylcypromine
Phenelzine
Selegiline transdermal
Isocarboxazid

Picking the Right Medication

The choice of antidepressant depends on a number of factors: cost, safety, drug-drug interactions, personal preference, ease of use, previous response to treatments, side effects best avoided for a given body weight, medical condition, and desired life style. The decision for depression treatment is best left between a patient and a doctor. Given the lack of clear superiority in efficacy among antidepressants, the choice of medication comes down to considerations of:

Side effects
Specific depressive symptoms
Patient preference
Cost
Safety
Ease of use (eg, frequency of administration)
Patient response to antidepressants during prior depressive episodes
Family (eg, first-degree relative) history of response to antidepressants
Comorbid illnesses
Concurrent medications and potential drug-drug interactions

Option 2: Therapy

Therapy offers many patients a long-term strategy to overcome depression. Many patients prefer therapy to medication because therapy encourages people to find strength and personal strategies to improve mood and thought that can last for months and even years after the sessions end. This is very different from medication, the beneficial effects of which wear off typically a few weeks after discontinuation. The types of psychotherapy available to individuals for improving mood include:

Cognitive-behavioral therapy (CBT)
Interpersonal psychotherapy
Psychodynamic psychotherapy
Problem solving therapy
Family and couples therapy
Supportive psychotherapy

Deciding which therapy to enroll in is a personal choice to be made with a therapist and/or doctor. There is no compelling evidence that one is superior to the rest for depression treatment; [3,4,5] CBT and interpersonal psychotherapy are often chosen for treatment of mild to moderate depression because they are the most studied therapy modalities. [6-10] Research suggests that each form of therapy offers patients moderate to large clinical benefits. [11]

Option 3: Lifestyle Modification

– Self-Help

For many patients, their therapist or physician will work with them in face-to-face guided self help. Guided self help is very helpful for depression treatment. Clinician-guided self-help therapy utilizes structured workbooks presented in hard-copy form or internet form. Self help therapy may utilize videos and audiotapes, with occasional guidance and followup with a doctor or therapist who monitors progress or setbacks. Self-help has improved many lives.

– Activities and Relaxation

Adding relaxation techniques such as relaxation imagery, progressive muscle relaxation, and autogenic training to mild to moderate depression treatment can have very beneficial effects. A meta-analysis of 5 randomized trials (136 patients) compared relaxation with no treatment and found a clinically moderate benefit favoring relaxation. [12] Pursuing enjoyable activities that are safe may also help relieve daily depression.

– Exercise

Exercise is critical to effective depression treatment, especially for those with mild to moderate major depression. Physical activity in the form of daily exercise has numerous health benefits, from improving lymphatic flow of the immune system, enhancing muscle performance, lowering fat and cholesterol levels, to enhancing cardiac contractility and overall function, just to name a few. Exercise improves the mind and causes the release of endorphins which helps to decrease pain and increase positive emotions. For adults who are healthy without serious medical issues, the Department of Health and Human Services recommends the following exercise guidelines:

Aerobic Activity
At least 2 hours and 30 minutes a week of moderate aerobic activity, or 75 minutes a week of vigorous aerobic activity is recommended. People are encouraged to do a combination of moderate and vigorous activity spread out over the week.
Strength Training
Strength training exercises should be done at least twice a week. No specific amount of time for each strength training session is included in the guidelines from the Department of Health and Human Services.
5
Min Per Week Moderate Activity
5
Min Per Week Vigorous Activity
0
Times a Week Strength Training

Option 4: Brain Stimulation

Brain stimulation is typically seen as a last resort in depression treatment. People with unipolar major depression who do not respond adequately to medication and therapy may become candidates for brain stimulation procedures, also known as neuromodulation procedures, which are broken down into invasive and non-invasive categories. Noninvasive procedures include Repetitive transcranial magnetic stimulation (rTMS), Electroconvulsive therapy (ECT), Magnetic seizure therapy (MST), Focal electrically administered seizure therapy (FEAST), Transcranial direct current stimulation (tDCS), and Transcranial low voltage pulsed electromagnetic fields stimulation (T-PEMF). Invasive brain stimulation procedures include Vagus nerve stimulation, Deep brain stimulation, Sirect cortical stimulation, and Ablative neurosurgery.

Step 3: Follow Through with the Therapies

Once you and your doctor find the right combination of treatments that work, you must continue on those treatments to keep depression away. If you should write in your journal and take medication daily, and attend group therapy weekly, then you should stick to that plan. Rates of recurrence for depression reach high numbers in people who stop therapies. Always consult with your doctor before starting or stopping any medication due to potential unwanted side effects. Stopping medications can be just as dangerous as starting them.

Depression Treatment For Mild to Moderate Major Depression

Mild to moderate depression can generally be treated in an outpatient setting or a partial program at a mental health clinic or hospital using a combination of therapy, group sessions, and medication. People with mild to moderate depression are generally able to care for themselves and others, do not have psychotic features, and do not pose a threat to themselves or others.

Depression Treatment For Severe Major Depression

For people with severe depression, the practice guidelines from the American Psychiatric Association and the United Kingdom National Institute for Clinical Excellence (NICE) recommend three possible modes of therapy: combination therapy using medication with psychotherapy, medication alone, or ECT (electroconvulsive therapy). [6,7,13]

In clinical practice, doctors typically begin depression treatment with prescribing an antidepressant tailored to the patient. The choice of medication is best left to a doctor. Introduction to therapy soon thereafter usually happens under the guidance of either a psychiatrist, or a psychologist. For people with severe unipolar major depression, initial treatment with combined pharmacotherapy and psychotherapy is recommended. The importance of therapy should not be underestimated. In a study of 124 patients with major depression who were hospitalized for five weeks, [14] the reduction in depressive symptoms occurred more in patients treated with both medication and interpersonal therapy instead of medication alone, and daily functioning improved more in the combined therapy group. What was remarkable was that the benefits of interpersonal therapy persisted for up to 12 months.

Last updated 10/01/14



References:

[1] Cuijpers P, Dekker J, Hollon SD, Andersson G. Adding psychotherapy to pharmacotherapy in the treatment of depressive disorders in adults: a meta-analysis. J Clin Psychiatry 2009; 70:1219.
[2] Cuijpers P, van Straten A, Warmerdam L, Andersson G. Psychotherapy versus the combination of psychotherapy and pharmacotherapy in the treatment of depression: a meta-analysis. Depress Anxiety 2009; 26:279.
[3] Cuijpers P, van Straten A, Andersson G, van Oppen P. Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. J Consult Clin Psychol 2008; 76:909.
[4] Shinohara K, Honyashiki M, Imai H, et al. Behavioural therapies versus other psychological therapies for depression. Cochrane Database Syst Rev 2013; 10:CD008696.
[5] Cuijpers P, Karyotaki E, Weitz E, et al. The effects of psychotherapies for major depression in adults on remission, recovery and improvement: A meta-analysis. J Affect Disord 2014; 159:118.
[6] American Psychiatric Association: Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition, 2010. http://psychiatryonline.org/guidelines.aspx (Accessed on April 17, 2012).
[7] American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder, third edition. Am J Psychiatry 2010; 167 (supplement):1.
[8] Khan A, Faucett J, Lichtenberg P, et al. A systematic review of comparative efficacy of treatments and controls for depression. PLoS One 2012; 7:e41778.
[9] Hollon SD, Ponniah K. A review of empirically supported psychological therapies for mood disorders in adults. Depress Anxiety 2010; 27:891.
[10] Lampe L, Coulston CM, Berk L. Psychological management of unipolar depression. Acta Psychiatr Scand Suppl 2013; :24.
[11] Barth J, Munder T, Gerger H, et al. Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis. PLoS Med 2013; 10:e1001454.
[12] Jorm AF, Morgan AJ, Hetrick SE. Relaxation for depression. Cochrane Database Syst Rev 2008; :CD007142.
[13] National Institute for Health & Clinical Excellence. The Treatment and Management of Depression in Adults (updated edition). National Clinical Practice Guideline 90, 2010. http://www.nice.org.uk/ (Accessed on December 09, 2012).
[14] Schramm E, van Calker D, Dykierek P, et al. An intensive treatment program of interpersonal psychotherapy plus pharmacotherapy for depressed inpatients: acute and long-term results. Am J Psychiatry 2007; 164:768.