Treatment for depression usually involves a combination of drugs, talking therapies and self help. Hardly anyone with depression is admitted to a psychiatric hospital. Most get treatment from their GP and make a good recovery.
Mild depression
- If you are diagnosed with mild depression but your GP thinks you’ll improve, you can have another assessment in two weeks' time to monitor your progress. This is known as 'watchful waiting'.
- Antidepressants are not usually recommended as a first treatment.
- Exercise seems to help some people. While your progress is being monitored, your GP may refer you to an exercise scheme with a qualified fitness trainer.
- Talking through your feelings may also be helpful. You may wish to talk to a friend or relative, or your GP may suggest a local self-help group.
- Your GP may recommend self-help books and computerised cognitive behaviour therapy (CBT) (see below for further details).
Chronic mild depression (present for two years or more) is called dysthymia. This is more likely in people over 55 years and can be difficult to treat. If you are diagnosed with dysthymia, your GP may suggest that you start a course of antidepressants.
Moderate depression
- If you have mild depression that is not improving, or you have moderate depression, your GP may recommend a 'talking treatment' or prescribe an antidepressant (see below for further details).
Severe depression
- Your GP may recommend that you take an antidepressant, together with talking therapy. A combination of an antidepressant and cognitive behavioural therapy (CBT) usually works better than having just one of these treatments.
- You may be referred to a mental health team. These teams are usually made up of psychologists, psychiatrists, specialist nurses and occupational therapists. They often provide intensive specialist talking treatments, such as psychotherapy.
Talking treatments
Cognitive behavioural therapy (CBT)
You normally have a fixed number of sessions - usually six to eight sessions over 10-12 weeks. Some GP practices have counsellors specifically to help patients with depression.
CBT is based on the principle that the way we feel is partly dependent on the way we think about things. It teaches you to behave in ways that challenge negative thoughts - for example, being active to challenge feelings of hopelessness.
Interpersonal therapy (IPT)
IPT focuses on your relationships with other people and on problems, such as difficulties with communication or coping with bereavement. There is some evidence that IPT can be as effective as medication or CBT, but more research is needed.
Counselling
Counselling is a form of therapy that helps you to think about the problems you are experiencing in your life, in order to find new ways of dealing with them. Counsellors support you in finding solutions to problems, but do not tell you what to do.
Antidepressants
Antidepressants take two to four weeks to take effect. If the first antidepressant you try is not effective or causes side effects, it may be necessary to change the dose. Sometimes, a different type of antidepressant will be recommended.
Your GP or specialist nurse should see you every one to two weeks when you start taking antidepressants. You should continue taking the antidepressants for at least four weeks (six weeks if you are elderly) to see how well they are working. If your antidepressants are working, treatment should be continued at the same dose for at least four to six months (12 months if you are elderly) after your symptoms have eased. If you have a history of depression, you should continue to receive antidepressants for up to five years, or longer.
Antidepressants are not addictive but withdrawal symptoms are quite common if you stop taking them suddenly, or you miss a dose.
SSRIs
If your GP thinks you would benefit from taking an antidepressant, you will usually be prescribed an SSRI (selective serotonin reuptake inhibitor).These are as effective as the older TCAs (tricyclic antidepressants) and have fewer side effects. Fluoxetine, citalopram and sertraline are all examples of SSRIs.
SSRIs increase the level of a natural chemical in your brain called serotonin, which helps to lift your mood. You may have some side effects when you start taking SSRIs, such as nausea, headache, sleep problems and anxiety. However, these tend to improve over time.
Some SSRIs should not be prescribed for children under the age of 18 years. Research shows that the risk of self-harm and suicidal behaviour may increase if they are used to treat depression in this age range. Fluoxetine is the only SSRI that may be prescribed for under-18s, but only when specialist advice has been given.
Other antidepressants
These include:
- TCAs (tricyclic antidepressants), such as dothiepin, imipramine and amitryptyline. These are used to treat moderate to severe depression. They work by raising the levels of the chemicals serotonin and noradrenaline in your brain, which both help to lift your mood. You should not smoke cannabis if you are taking TCAs because it can cause your heart to beat rapidly.
- MAOIs (monoamine oxidase inhibitors), such as phenelzine sulphate, is sometimes used to treat 'atypical depression'. This is when you tend to eat and sleep more than usual. You should not smoke cannabis if you are taking MAOIs because it may affect the way these medicines work, and it is not clear what effect this may have on you.
- New antidepressants, such as venlafaxine, nefazodone, and mirtazapine, work in a slightly different way from SSRIs and tricyclics. These drugs are known as SSNIs (Serotonin-norepinephrine reuptake inhibitors). Like TCAs, these antidepressants work by changing the levels of serotonin and noradrenaline in your brain. Studies have shown that a SSNI like venlafaxine can be more effective than a SSRI, though it is not routinely prescribed as it can lead to a rise in blood pressure.
St John's wort
St John's wort is a herbal treatment that some people take for depression. Though there is some evidence that it may be of benefit in treating mild or moderate depression, its use is not recommended. This is because the quantity of its active ingredients vary among individual brands and batches, so it is uncertain what sort of effect it could have on you.
Taking St John's wort with other medications, such as anticonvulsants, anticoagulants, antidepressants and the contraceptive pill, can also cause serious problems.
You should not use St John's wort if you are pregnant or breastfeeding as there is not enough evidence that its use is safe in these situations.
Electroconvulsive therapy (ECT)
Sometimes, other treatments, such as specialist medicines or electroconvulsive therapy (ECT), may be advised if you have severe depression. Electroconvulsive therapy (ECT) works for severe depression, but it is only used when antidepressants and other treatments have not worked.
If ECT is recommended for you, you will first be given an anaesthetic and medication to relax your muscles. You will then receive an electrical 'shock' to your brain through electrodes placed on your head. You may be given a series of ECT sessions. For most people, the treatment works well in relieving severe depression, but the effect may not be permanent. Some people may experience unpleasant side effects, including memory problems.
Lithium
If you have tried several different antidepressants and have experienced no improvement, your doctor may offer you a type of medication called lithium, in addition to your current treatment.
There are two types of lithium - lithium carbonate and lithium citrate. Both are usually effective, but if you are taking one that is effective, it is best not to change. In order to work, you have to have a certain level of lithium in your blood. If this level becomes too high, the lithium can become toxic. Therefore you will need blood tests every three months to check your lithium levels. You should also avoid going on a low-salt diet because this can also cause the lithium to become toxic - consult your GP for advice about your diet.
Before you start taking lithium, you should have an electrocardiograph (ECG) to check your heart.
Carers
If you are looking after someone who suffers from depression that affects them so much that they need you to help them with their activities, Carers Direct can help you. On Carers Direct you can find out all about how to get help with caring for the person you look after, your legal and employment rights, and getting benefits on Carers Direct.
Withdrawal symptoms
Antidepressants are not addictive in the way illegal drugs are, but when you stop taking them you will probably have some withdrawal symptoms, including:
- stomach upsets,
- flu-like symptoms,
- anxiety,
- dizziness,
- vivid dreams at night, and
- sensations in the body that feel like electric shocks.
In most cases, these effects are mild. But, for a small number of people, they can be quite severe. They seem to be most likely to occur with paroxetine (Seroxat) and venlafaxine (Efexor).
