This article outlines some general treatment information and guidelines for the treatment of clinical depression (major depressive disorder). There are a wide variety of treatment options available for depression, and it’s highly likely you will find one that works for you.
Research studies do not predict individual responses to a specific depression treatment. In other words, just because it 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.
Most clinicians practicing today believe that depression is caused by an equal 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).
Depression remains a complicated, complex disorder and researchers are only beginning to fully grasp the multitude of factors — personal, genetic, biological, societal, gut bacteria, neurological, and environmental — that are involved. Any explanation or approach which emphasizes only one factor as the cause of depression is misleading and simplistic. Individuals should avoid accepting a simplistic answer to such a devastating and complex disorder.
Treatment for depression, like for most mental disorders, usually relies on psychotherapy and medication for the quickest, strongest effects. Treatment usually begins immediately after the initial clinical interview with a mental health professional. A mental health specialist is recommended in the treatment of this condition. Relying on a general practitioner or family doctor for treatment alone is likely to result in prolonging the length of the depressive episode, or failure of treatment altogether.
Learn more: Psychotherapy, Medication or Both?
Depression treatment takes time, and patience is needed. The effects of medications will usually be felt within 8 weeks of taking an antidepressant, but not everyone feels better after taking the first prescribed medication. Some antidepressants don’t work for everyone. You may have to try 2 or 3 different medications before finding the one that works for you. The same may also be true for psychotherapy — the first therapist may not be the one you end up working with. Most modern psychotherapy treatment for depression takes 6 to 12 months, going once per week for 50 minutes at a time.
Topics covered in this article about the treatment of clinical depression include:
- Electroconvulsive Therapy (ECT) and Repetitive Transcranial Magnetic Stimulation (rTMS)
- Psychotherapy, Medication or Both?
There is a wide number of effective therapeutic approaches utilized for the treatment of depression today. These range from cognitive behavioral therapy, to behavioral therapy (e.g., Lewinsohn), to interpersonal therapy, to rational emotive therapy, to family and psychodynamic approaches. Both individual and group modalities are commonly used, depending upon the severity of the depressive episode and the local resources within an individual’s community.
Cognitive-behavioral therapy is the most popular and commonly-used therapy for the effective treatment of depression. Hundreds of research studies have been conducted to date which verify its safety and effectiveness in treating people who suffer from this disorder. Aaron T. Beck is the father of this therapeutic technique, and he has authored books and studies supporting cognitive-behavioral therapy. Consisting of a number of useful and simple techniques which focus on the internal dialogue which takes place within a person’s mind, cognitive-behavioral therapy is not concerned with causes of the depression so much as what a person can do, right now, to help change the way they are feeling.
Therapy begins by establishing a supportive therapeutic environment which is positive and reinforcing for the individual. Educating the client within the first session or two is usually the next step to learning how depression–for many people–is caused by faulty cognitions. The numerous types of faulty thinking that we as humans do are discussed (e.g., “all or nothing thinking,” “misattribution of blame,” “overgeneralization,” etc.) and the client is encouraged to begin noting his or her thoughts as they occur throughout the day. This is imperative to further success in treatment, for the individual must understand how common and often these thoughts are occurring during a single day.
In cognitive-behavioral therapy, emphasis is placed on discussing these thoughts and the behaviors associated with depression. While emotions are certainly a focus of some of the time throughout therapy, it is thought within this theoretical framework that thoughts and behaviors are more likely to change emotions than trying to attempt a post-mortem analysis of why a person is feeling the way they are. Because of this approach, cognitive-behavioral therapy is short-term (usually conducted under two dozen sessions) and works best for people experiencing a fair amount of distress relating to their depression. Individuals who can approach a problem from a unique perspective and those who are more cognitively-oriented are also likely to do better with this approach.
Psychotherapy for Depression Continued…
Interpersonal therapy is another short-term therapy utilized in the treatment of depression. Focus of this treatment approach is usually on an individual’s social relationships, and specifically on how to improve them. It is thought that good, stable social support is imperative to a person’s overall well-being and health within this framework. When relationships falter, a person directly suffers from the negativity and unhealthiness of that relationship. Therapy seeks to improve a person’s relationship skills, working on communication more effectively, expressing emotions appropriately, being properly assertive in social and occupational situations, etc. It is usually conducted, like cognitive-behavioral therapy, on an individual basis but can also be used within a group therapy framework.
Most individual psychotherapy approaches, whether they are cognitive-behavioral, interpersonal, behavioral, rational-emotive, etc., will emphasize the importance of the client taking a proactive approach in therapy. That is, the patient is encouraged to do daily or weekly homework assignments in between therapy sessions which are imperative to the success of the treatment approach. Therapy is an active collaboration between therapist and client. If the client is not yet able to participate actively in therapy, then a supportive environment should be provided until medication helps energize the individual further.
Psychoanalytic or psychodynamic approaches in the treatment of depression have little research data available to support their use at this time. While many therapists may make use of psychodynamic theoretical constructs to help conceptualize an individual’s personality or specific case, it is likely that applied approaches in these areas are ineffective and should be avoided.
Family or couples therapy should be considered when the individual’s depression is directly affecting family dynamics or the health of significant relationships. Such therapy focuses on the interpersonal relationships shared amongst family members and seeks to ensure that communications are clear and without double (hidden) meanings. The roles played by various family members in reinforcing the depression within the patient are often examined as well. Education about depression, in general, can also be an important role of such therapy. 
Individuals who suffer from seasonal affective disorder, a form of depression which is related to the change of the seasons within their geographic location, may benefit from bright light phototherapy. 
Hospitalization of an individual is necessary when that person has attempted suicide or has serious suicidal ideation or plan for doing so. Such suicidal intentions must be carefully and fully assessed during an initial meeting with the client. The individual must be in imminent danger of harming themselves (or another). Daily, routine functioning will likely be negatively affected by the presence of a clear and severe major depression. Most individuals who suffer from major depression, however, are usually only mildly suicidal and most also often lack the energy or will (at least initially) to carry out any suicidal plan.
Care must be taken with regard to any hospitalization procedure. When possible, the patient’s consent and full understanding should first be obtained and the client encouraged to check him or herself in. Hospitalization is usually relatively short, until the patient becomes fully stabilized and the therapeutic effects of an appropriate antidepressant medication can be realized (3 to 4 weeks). A partial hospitalization program should also be considered.
Suicidal ideation should be assessed during regular intervals throughout therapy (every week during the therapy session is not uncommon). Often, as the individual who suffers from a depressive disorder is beginning to feel the energizing effects of a medication, they will be at higher risk for acting on their suicidal thoughts. Care should be used at this time and hospitalization may need to be again considered.
The most commonly prescribed medications for depression are referred to as antidepressants. Most antidepressants prescribed today are both safe and effective when taken as directed by your physician or psychiatrist. Although most antidepressants in the U.S. are prescribed by family doctors or general practitioners, you should nearly always seek out a psychiatrist for the best treatment of depression with medications.
A class of antidepressants called selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed medication for depression today. Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline) and Luvox (fluvoxamine) are the most commonly prescribed brand names. SSRI medications should not be prescribed in conjunction with the older MAOIs (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 (there’s little evidence of support for the serotonin theory of depression), but decades’ worth of studies suggest such medications nonetheless help improve mood.
SSRI antidepressant medications were once thought to have lesser side effects than other antidepressants, but research in the past decade suggests differently. While SSRI antidepressants 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 will go away 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 SSRI medications 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 on the first medication tried. You may have to try 2 or 3 different medications before finding the one that works for you.
Results from the STAR*D study indicate that if a first treatment with one SSRI fails, about one in four people who choose to switch to another medication will get better, regardless of whether the second medication is another SSRI or a medication of a different class. And if people choose to add a new medication to the existing SSRI, about one in three people will get better. It appears to make some — but not much — difference if the second medication is an antidepressant from a different class (e.g., bupropion) or if it is a medication that is meant to enhance the SSRI (e.g., buspirone). Because the switch group and the add-on group cannot be directly compared to each other, it is not known whether patients are more likely to get better by switching medications or by adding another medication.
Results from one of the findings of the study apply to those who do not get better after two medication treatment steps. At this stage, by switching to a different antidepressant medication, about one in seven people will get better, and by adding a new medication to the existing one, about one in five people will get better. Finally, for patients with the most treatment-resistant depression, additional results suggest that tranylcypromine is limited in its tolerability and that up to 10 percent may benefit from the combination of venlafaxine-XR/mirtazapine.
An overall analysis of the STAR*D results indicates that patients with difficult-to-treat depression can get well after trying several treatment strategies, but the odds of beating the depression diminish with every additional treatment strategy needed. In addition, those who become symptom-free have a better chance of remaining well than those who experience only symptom improvement. And those who need to undergo several treatment steps before they become symptom-free are more likely to relapse during the follow-up period. Those who required more treatment levels tended to have more severe depressive symptoms and more co-existing psychiatric and general medical problems at the beginning of the study than those who became well after just one treatment level.
Other medications may also be of help. 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). Abilify (aripiprazole) is also an aytpical antipsychotic that is approved for the use in the treatment of depression. It is the first medication approved by the U.S. Food and Drug Administration for “add-on treatment.” That is, your doctor can prescribe it to you even if you’re already taking an antidepressant. In clinical studies, when Abilify was added to an antidepressant treatment, many people experienced significant improvement of their depressive symptoms.
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. rTMS (below) is now the preferred treatment method over ECT.
Reptitive transcranial magnetic stimulation (rTMS) utilizes 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. Low frequency (once per second) TMS has been shown to induce sustained reductions in cortical activation in multiple studies.
In use for 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.
rTMS given to the front of the brain is generally not painful, but can be uncomfortable insofar as 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 associated with TMS, but for the frequency of stimulation used in this study (one stimulation per second), the risk is significant only for patients who have a prior history of seizures.
NeuroStar TMS Therapy is specifically indicated for the treatment of major depressive disorder in adult patients who have 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 with NeuroStar TMS Therapy, these patients had been treated with a median of 4 medication treatment attempts, one of which achieved criteria for adequate dose and duration. It is a 40-minute outpatient procedure that is prescribed by a psychiatrist and performed in a psychiatrist’s office. The treatment is typically administered daily 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
- 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% 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.
Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Depression-oriented support groups are especially effective, since they allow the individual an opportunity to socialize and be with others who suffer from similar feelings. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.
There are many useful self-help books (such as The Feeling Good Handbook) that are available on the market today to help an individual overcome depression on their own. Some of these may be effective for some people and no other type of treatment may be needed, especially for people who suffer from a mild case of this disorder. Some books emphasize a cognitive-behavioral approach, which is similar to those used within individual therapy and therefore may be of use to an individual before they even begin therapy.
Patients can be encouraged to try out new coping skills and explore their emotions with people they meet within online support groups. They can be an important part of expanding the individual’s skill set and develop new, healthier social relationships.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Beck, A.T., Rush, A.J., Shaw, B.F. & Emery, G. (1987). Cognitive Therapy of Depression. New York: Guilford.
Gelenberg, A.J. et al. (2010). Practice Guideline for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association.
Gotlib, I.H. & Hammen, C.L. (2015). Handbook of Depression: Third Edition. New York: Guilford.
National Institute of Mental Health. (2018). Depression. Retrieved from https://www.nimh.nih.gov/health/publications/depression/index.shtml on February 27, 2018.
Muneer, A. (2018). Major Depressive Disorder and Bipolar Disorder: Differentiating Features and Contemporary Treatment Approaches. In Understanding depression. New York: Springer.