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Depression Treatment

Depression Treatment

There is a wide variety of treatment options available for depression, and it’s highly likely you will find one—or a combination—that works for you.

Research studies do not predict individual responses to a specific depression treatment. In other words, just because a treatment works for some (or even most) people does not mean it will work for you. It’s important to keep this in mind as you or a loved one undergoes treatment for depression, because the first treatment or set of treatments you try may not be effective.

Depression is a complex disorder. Most clinicians practicing today believe it’s caused by a combination of biological (including genetics and bacterial), social, and psychological factors. A treatment approach that focuses exclusively on one of these factors is not likely to be as beneficial as a treatment approach that addresses both psychological and biological aspects (through, for example, psychotherapy and medication). In fact, the combination of psychotherapy and medication may provide the quickest, strongest results.

Still, depression treatment takes time. It typically takes up to 8 weeks to feel the effects of medication. But not everyone feels better after taking the first prescribed medication. You may have to try two or three different medications before finding the one that works for you. The same might be true for psychotherapy—the first therapist might not be the one you end up working with. Most psychotherapy treatments for depression take 6 to 12 months, with weekly 50-minute sessions.


Psychotherapy for Depression

Today, there’s a number of effective psychosocial treatments for depression. Some types of psychotherapy have undergone more rigorous research than others. However, as a whole, the below treatments are helpful options. All are short-term therapies, lasting anywhere from 10 to 20 sessions.

  • Cognitive-behavioral therapy (CBT) is the most popular and commonly-used therapy for depression. Hundreds of research studies have been conducted that verify its safety and effectiveness. CBT focuses on changing negative or distorted thoughts and behaviors that perpetuate your depression. Your therapist will help you identify these thoughts (e.g., “I am worthless,” “I can’t do anything right,” “I’ll never feel better,” “This situation will never improve”), and replace them with more realistic thoughts that support your well-being and your goals. CBT typically doesn’t focus on the past, but on changing your thoughts, feelings, and behaviors right now.
  • Interpersonal therapy (IPT) addresses an individual’s social relationships, and how to improve them. It’s believed that good, stable social support is imperative to a person’s overall well-being. When relationships falter, a person directly suffers from the negativity and unhealthiness of that relationship. Therapy seeks to improve a person’s relationship skills, such as: communicating effectively, expressing emotions appropriately, and being properly assertive in personal and professional situations. IPT is usually conducted, like CBT, on an individual basis but also can be used in a group setting.
  • Behavioral activation therapy (BA) focuses on helping individuals change their behavior, which helps to change their mood. You’ll learn to notice when you’re starting to get depressed, and to engage in activities that are aligned with your wants and values (which is critical, because depression causes isolation, lethargy, and lack of interest). These activities might include anything from spending time with loved ones to taking a yoga class. BA is pragmatic and helps you identify your goals, and achieve them. Recent research also suggests that BA may be effective in a group format.
  • Acceptance and commitment therapy (ACT) helps you to focus on the present (instead of getting tangled up in thoughts about the past or future); observe and accept negative thoughts and feelings, so you don’t get stuck; identify what’s most meaningful and important to you; and act on these values, so you can build a rich, fulfilling life.
  • Problem-solving therapy (PST) helps individuals with depression learn to cope effectively with stressful problems in their daily lives. People with depression might view problems as threats and believe they’re incapable of solving them. Your therapist will help you define the problem, brainstorm alternative realistic solutions, select a helpful solution, and implement that strategy and evaluate it.
  • Short-term psychodynamic psychotherapy (STPP) focuses on interpersonal relationships and unconscious thoughts and feelings. The primary goal is to reduce your symptoms, and the secondary goal is to decrease your vulnerability to depression, and increase your resilience. STPP is a family of treatments that’s rooted in theories of psychoanalysis, including drive psychology, ego psychology, object relations psychology, attachment theory, and self psychology. Research is currently underway to see which individuals specifically benefit from STPP.
  • Family or couples therapy should be considered when your depression is directly affecting family dynamics or the health of significant relationships. Such therapy focuses on the interpersonal relationships among family members and seeks to ensure that communications are clear and without double (hidden) meanings. Also examined are the roles various family members play in reinforcing your depression. In addition, everyone receives education about depression.

Whatever treatment you choose, it’s important to take a proactive approach. This includes voicing your concerns with your therapist, and doing any daily or weekly assignments between therapy sessions. Therapy is an active collaboration between therapist and client.


Medications for Depression

Your doctor will choose your medication based on various factors, such as: your prior experience with the medication (e.g., your responses and adverse effects); co-occurring medical and psychological disorders (e.g., you also have an anxiety disorder); any other medications you’re taking; personal preference; the medication’s short- and long-term side effects; toxicity of overdose (if you’re at risk for suicide); history of first-degree relatives responding to the medication; and any financial constraints.

The most commonly prescribed medications for depression are antidepressants. Most antidepressants prescribed today are both safe and effective when taken as directed by your physician or psychiatrist. Although antidepressants in the U.S. are often prescribed by family doctors or general practitioners, you should nearly always seek out a psychiatrist for the best treatment of depression with medications.

Today, selective serotonin reuptake inhibitors (SSRIs) are frequently prescribed for depression—with Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), and Luvox (fluvoxamine) being the most commonly prescribed brand names. SSRIs should not be prescribed in conjunction with monoamine oxidase inhibitors (MAOIs, an older class of medication more popular in Europe than in the U.S.). SSRIs work on increasing the amount of serotonin in the brain. Researchers are not sure why an increase in serotonin helps relieve depression, but decades’ worth of studies suggest such medications nonetheless help improve mood.

SSRIs were once thought to have fewer side effects than other antidepressants, but research in the past decade suggests otherwise. While SSRIs appear to be safe, most people will experience side effects while taking them, such as nausea, diarrhea, agitation, insomnia, or headache. For most people, these initial side effects dissipate within 3 to 4 weeks.

Many people taking an SSRI complain of sexual side effects, such as decreased sexual desire (decreased libido), delayed orgasm, or an inability to have an orgasm. Some people also experience tremors with SSRIs. Serotonin syndrome is a rare but serious neurological condition associated with the use of SSRIs. It is characterized by high fevers, seizures, and heart-rhythm disturbances.

Long-term side effects of taking SSRIs for more than a year include sleep disturbance, sexual dysfunction, and weight gain.

The large-scale, multi-clinic government research study called STAR*D found that people with depression who take medication often need to try different brands and be patient before they find one that works for them. The effects of medications will usually be felt within 6 to 8 weeks of taking an antidepressant. But not everyone feels better with the first medication they try—and needs to try several other medications to find the best one for them.

Atypical antidepressants are often prescribed when a person hasn’t improved with a common SSRI. Such medications include nefazodone (Serzone), trazodone (Desyrel), and bupropion (Wellbutrin).

Your doctor also might prescribe an atypical antipsychotic to boost the effectiveness of your antidepressant. The FDA has approved the following atypical antipsychotics for “add-on treatment”: aripiprazole (Abilify) in 2007; quetiapine XR (Seroquel XR) and olanzapine-fluoxetine (Symbyax) in 2009; and brexpiprazole (Rexulti) in 2015.

Other medications that are used to augment the effectiveness of an antidepressant are the mood stabilizer lithium and thyroid hormones.

Ketamine is the newest treatment for severe forms of depression. In March 2019, the FDA approved a prescription nasal spray called esketamine (Spravato), a fast-acting drug derived from ketamine, to be used in conjunction with an antidepressant for treatment-resistant depression. Spravato must be administered at a certified doctor’s office or clinic, where patients have to be monitored for at least 2 hours after receiving a dose. This is because Spravato has the potential for abuse and misuse, and an increased risk of sedation and dissociation. The results of esketamine trials were mixed.

There are also clinics who offer ketamine intravenously. An initial set of treatment sessions of ketamine infusion runs anywhere from $4,000 – $8,000, with regular booster treatments needed every month or two. This form of newer treatment is rarely covered by health insurance. While apparently effective for many people who try it, treatment appears to be life-long; furthermore, long-term effects of chronic ketamine treatments haven’t been studied yet.

Watch Our Recommended Video on Medications for Depression

Electroconvulsive Therapy (ECT) and Repetitive Transcranial Magnetic Stimulation (rTMS)

Electroconvulsive therapy (ECT) is the treatment of last resort for severe, chronic depressive symptoms. ECT is never the initial treatment for depression, and there are serious questions regarding memory loss which have yet to be adequately answered by the research literature. Please see ECT.org for more information about ECT.

Repetitive transcranial magnetic stimulation (rTMS) is now the preferred treatment method over ECT. It uses an electromagnet placed on the scalp that generates magnetic field pulses roughly the strength of an MRI scan. The magnetic pulses pass readily through the skull and stimulate the underlying cerebral cortex.

In the treatment of depression, rTMS is generally used with high frequencies, stimulating the left dorsolateral prefrontal cortex of the brain. This gives positive results with significant decrease of scores on depressive scales applied to resistant and non-resistant depressions.

The procedure is generally not painful, but can be uncomfortable: A tingling or knocking sensation is produced against the scalp. Scalp and facial muscle contractions sometimes occur during TMS. There is a very small risk of seizure; the risk is significant only for patients who have a prior history of seizures.

NeuroStar TMS Therapy is specifically FDA-approved for the treatment of major depressive disorder in adults who’ve failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. In clinical trials, patients had been treated with a median of four medication treatment attempts, one of which achieved criteria for adequate dose and duration.

NeuroStar TMS Therapy is an outpatient procedure prescribed by a psychiatrist and performed in a psychiatrist’s office. The treatment typically takes around 20 to 40 minutes, and is administered 5 days a week for 4-6 weeks.

The benefits of TMS observed in its clinical trials include: no systemic side effects, such as weight gain, sexual dysfunction, sedation, nausea, or dry mouth; no adverse effects on concentration or memory; no seizures; and no device-drug interactions.

The most common adverse event related to treatment was scalp pain or discomfort at the treatment area during active treatments, which was transient and mild to moderate in severity. The incidence of this side effect declined markedly after the first week of treatment.

There was a less than 5 percent discontinuation rate due to adverse events. During a 6-month follow-up period, there were no new safety observations compared to those seen during acute treatment.


Hospitalization

Hospitalization is necessary when a person with depression has attempted suicide or has serious suicidal thoughts (ideation) or plans. Most individuals who suffer from major depression, however, are usually only mildly suicidal and most often lack the energy (at least initially) to carry out any suicidal plan.

Care must be taken with regard to any hospitalization. When possible, your consent and full understanding should first be obtained and you should be encouraged to check yourself in. Hospitalization is usually relatively short, until you’re fully stabilized and the therapeutic effects of an appropriate antidepressant medication are realized (3 to 4 weeks). A partial hospitalization program also should be considered.

Suicidal ideation should be assessed during regular intervals throughout therapy (every week during the therapy session is not uncommon). Often, as you start to feel the energizing effects of a medication, you’ll be at higher risk for acting on your suicidal thoughts. Care should be used at this time and hospitalization may need to be considered again.


Self-Help Strategies

One of the most effective self-help strategies is to join a depression-focused support group (in-person or online). Support groups provide the opportunity to socialize, develop healthy relationships, and be around other people who are experiencing common experiences and feelings. Psych Central has online support groups.

Another excellent strategy is to read self-help books or workbooks on overcoming depression (a classic example is The Feeling Good Handbook). In fact, some self-help books are effective for some people and no other type of treatment is needed, especially for people who have a mild form of depression. Some books emphasize a cognitive-behavioral approach, which is similar to those used within individual therapy and therefore may be helpful even before you begin therapy.

In addition, engaging in physical activities and getting outside are critical. Both sunlight and exercise are well-established mood boosters. If there’s currently not much sunshine, consider buying a light box (which can be especially helpful for winter-time seasonal affective disorder).

Herbal supplements—including St. John’s wort and kava—have extensive clinical research demonstrating their effectiveness and safety for the treatment of mild to moderate clinical depression. While they should not be taken if you’re already taking an antidepressant, many people turn to supplements as a first-line treatment, especially if their episode isn’t severe. Like medications, these herbal supplements may or may not work for you, but are generally safe to try. Always talk to your doctor first before starting any supplements or other kinds of alternative treatments, as some may interact with other medications or treatments you’re currently using.

References

Acceptance and commitment therapy (ACT). Retrieved from https://www.mentalhealth.va.gov/depression/act-d.asp.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bauer, M., Severus, E., Moller, H., Young, A.H., et al. (2017). Pharmacological treatment of unipolar depressive disorders: summary of WFSBP guidelines. International Journal of Psychiatry in Clinical Practice, 21 (3), 166-176.

Carey, B. (2019, March 5). Fast-Acting Depression Drug, Newly Approved, Could Help Millions. The New York Times. Retrieved from https://www.nytimes.com/2019/03/05/health/depression-treatment-ketamine-fda.html.

Cuijpers, P., de Wit, L., Kleiboer, A., Karyotaki, E., Ebert, D.D. (2018). Problem-solving therapy for adult depression: An updated meta-analysis. European Psychiatry, 48, 27-37.

Driessen E., Abbass A.A., Barber J.P., et al. (2018). Which patients benefit specifically from short-term psychodynamic psychotherapy (STPP) for depression? Study protocol of a systematic review and meta-analysis of individual participant data. BMJ Open, 8, (2).

Driessen, E., Cuijpers, P., de Maat, S.C.M., Abbass, A.A., de Jonghe, F., & Dekker, J.J.M. (2010). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis. Clinical Psychology Review, 30 (1), 25–36.

FDA approves new nasal spray medication for treatment-resistant depression; available only at a certified doctor’s office or clinic. (2019, March 5). Retrieved from https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm632761.htm.

Gotlib, I.H. & Hammen, C.L. (2015). Handbook of Depression: Third Edition. New York: Guilford.

Muneer, A. (2018). Major Depressive Disorder and Bipolar Disorder: Differentiating Features and Contemporary Treatment Approaches. In Yong-Ku Kim (Ed.), Understanding Depression: Volume 2. Clinical Manifestations, Diagnosis and Treatment (pp.15-34). New York: Springer.

Schroeder, M.O. (2016). Behavioral Activation: The Depression Therapy You’ve Likely Never Heard of. U.S. News & World Report. Retrieved from https://health.usnews.com/wellness/mind/articles/2016-11-24/behavioral-activation-the-depression-therapy-youve-likely-never-heard-of.

Simmonds-Buckley, M., Kellett, S., Waller, G. (2019). Acceptability and efficacy of group behavioral activation for depression among adults: A meta-analysis. Behavior Therapy.


Margarita Tartakovsky, MS & John M. Grohol, Psy.D.

Margarita Tartakovsky, M.S. is an Associate Editor and regular contributor at Psych Central. She blogs regularly about body and self-image issues on her blog, Weightless, and about creativity on her second blog Make a Mess.

Dr. John Grohol is the founder, Editor-in-Chief & CEO of Psych Central. He is an author, researcher and expert in mental health online, and has been writing about online behavior, mental health and psychology issues -- as well as the intersection of technology and human behavior -- since 1992. Dr. Grohol sits on the editorial board of the journal Computers in Human Behavior and is a founding board member and treasurer of the Society for Participatory Medicine. He writes regularly and extensively on mental health concerns, the intersection of technology and psychology, and advocating for greater acceptance of the importance and value of mental health in today's society. You can learn more about Dr. John Grohol here.

APA Reference
John M. Grohol, M. (2019). Depression Treatment. Psych Central. Retrieved on December 9, 2019, from https://psychcentral.com/depression/depression-treatment/
Scientifically Reviewed
Last updated: 18 Jul 2019 (Originally: 9 Jan 2017)
Last reviewed: By a member of our scientific advisory board on 18 Jul 2019
Published on Psych Central.com. All rights reserved.