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Depression

How this information can help you or someone you care for

•  Reduce your risk of depression.
•  Know when to seek treatment and what good depression care is.
•  Find out what you can do to recover from depression.

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including all the information you need and where to get help in your area.

Treating depression 

 Find out more about the treatment options available and what good care for depression looks like.

What is good depression care? hide

NICE has identified a model of good depression care, in consultation with clinicians and patients. For most patients with depression, your GP will help manage your condition. But for some patients, particularly those with more severe depression or where treatment is not successful, more specialised care, including inpatient care, may be needed. NICE guidelines include:

  • Recognition of depression, in both primary care and hospital, with particular attention to high-risk groups, such as patients with a past history of depression, long-term illness or disability, or other mental health problems such as dementia.
  • Patient preferences, and the experience and outcome of previous treatments, should be considered when deciding on a treatment.
  • Patients should have access to accessible information about treatments and self-help and support groups.
  • For people with mild depression, further assessment is required, usually within two weeks. The patient may recover without intervention. Antidepressants are not recommended for the initial treatment of mild depression. Guided self help, such as computerised cognitive behavioural therapy, should be considered.
  • For people with mild and moderate depression, psychological treatments (such as CBT or counselling) should be considered.
  • Treatment with antidepressant drugs: selective serotonin reuptake inhibitors (SSRIs) should be considered over tricyclic antidepressants because of better safety and fewer side effects. All patients should be informed that withdrawal symptoms may occur when stopping, missing a dose or reducing the dose.
  • For people with severe depression, a combination of antidepressants and individual CBT should be considered as combining the treatments is more effective than using them on their own. This approach has also been found to be most effective in patients who are resistant to treatment with medication.
  • Patients should give meaningful and properly informed consent to treatment, in particular if they have more severe depression or are subject to the Mental Health Act. 
  • There should be a clear agreement about all patient care, and this should be shared with the patient and their families and carers.

New Horizons builds on the achievements of the national service framework (NSF) over the past 10 years and supports the local development of higher quality, more personalised services. It also sets out NHS plans for achieving better mental health and wellbeing for the whole population.

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Find out how your local NHS manages depression care

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Medical treatments show

Antidepressants are medicines that treat the symptoms of depression. There are almost 30 different kinds of antidepressants, which fall into four main categories.

Most people with moderate or severe depression benefit from antidepressants. But not everybody does. Some people respond to one antidepressant, but not to another, and people with depression may need to try two or more treatments before finding one that works for them.

The different types of antidepressant work about as well as each other, but the side effects vary between types of treatment, between individual treatments and between different people.

Normally you'll take only one type of antidepressant at a time, but specialists in mental health (including some GPs) may add other treatments to antidepressants.

Antidepressants are usually recommended for moderate to severe depression. There's some question about their effectiveness in mild depression. There's good evidence that you need to take antidepressants for at least six months to benefit fully from their effect, and for 24 months if the depression is long-term, or keeps coming back.

Selective serotonin re-uptake inhibitors (SSRIs)

SSRIs work by blocking the ‘reuptake’ of the brain chemical serotonin, which is important in the transmission of nerve messages from one nerve to another. The science is complex but, generally, serotonin is regarded as a ‘good mood’ brain chemical. Examples of this type of antidepressant are sertraline, paroxetine, fluoxetine, citalopram, escitalopram and fluvoxamine.

They have fewer of the side effects associated with tricyclics and monoamine oxidase inhibitors, and are less likely to cause drowsiness and dizziness. They can, however, cause nausea and headaches, as well as dry mouth, and problems of sexual functioning. Because they have fewer side effects, people are more likely to carry on using them.

Used to treat: moderate to severe depression.

Considering this treatment

NICE recommends SSRIs in routine care, because they're effective, and those taking them are less likely to stop because of side effects.

What does NICE say about this treatment?

Tricyclic antidepressants (TCAs)

This group of antidepressants have been used for a long time, and have found to be effective in 50-60% of people, about the same as other antidepressants, and cognitive behavioural therapy.

There's little difference in how well the tricyclics and SSRIs work when prescribed by GPs, but the tricyclic treatments seem to be slightly better when used in hospitals. The drawback to the tricyclics is that they tend to have more numerous and more severe side effects. They’re often not prescribed until you've tried SSRIs first without seeing any improvement. Side effects of tricyclics, which vary from person to person, may include dry mouth, blurred vision, constipation, problems passing urine, sweating, light-headedness and excessive drowsiness.

Used to treat: moderate to severe depression.

Considering this treatment

NICE says that the lofepramine (a tricyclic) should be used as a second choice if an SSRI does not work.

What does NICE say about this treatment?

Monoamine oxidase inhibitors (MAOIs)

Monoamine oxidase inhibitors (MAOIs) are not usually a leading choice of antidepressant because they're strongly affected by what you eat and other medicines you take. They sometimes produce side effects such as high blood pressure, which can be dangerous. In addition, it's difficult to switch from MAOIs to other types of antidepressant, so doctors tend to keep them in reserve to use if other antidepressants don’t work. They remain important, despite the development of newer treatments, because for some people they work when other antidepressants don't.

MAOIs require strict dietary restrictions, and those taking them need to avoid certain foods such as cheese, some meats, pickled herrings and yeast extracts such as Marmite.

Used to treat: moderate to severe depression.

Considering this treatment

NICE says that moclobemide is a reasonable second choice.

What does NICE say about this treatment?

Other antidepressants

Venlafaxine and duloxetine are serotonin and noradrenaline reuptake inhibitors (SNRIs) that act, like SSRIs, on serotonin, but also on noradrenaline, which is another important brain chemical associated with mood.

Reboxetine (a noradrenaline reuptake inhibitor (NRI) acts on the brain chemical noradrenaline.

Mirtazapine affects both noradrenaline and serotonin pathways in the brain.

Tryptophan is an amino acid (also found in some food proteins), which the body needs to make serotonin, one of the neurotransmitters involved in controlling and regulating mood.

Lithium is used to boost the effect of antidepressants when they haven’t worked fully, and is also commonly used in bipolar disorder (‘manic depression’).

Considering this treatment

NICE warns that high blood pressure must be brought under control before people with depression use venlafaxine. NICE also says there's an increased risk of side effects with venlafaxine. Mirtazepine and robeoxetine are identified as reasonable second choices if treatment with an SSRI doesn't work at first.

What does NICE say about this treatment?
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Talking therapies show

Psychological treatments, commonly called 'talking treatments', are a set of techniques used to treat mental health and emotional problems. There are many different forms and the choice may depend on what's available, your own preferences and how severe your depression is.

Counselling, cognitive behavioural therapy (CBT), problem-solving therapy and some forms of psychotherapy are recommended to treat depression.

There are many other forms of talking therapy that are used, but there may be little evidence to show whether or not they work.

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Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) helps you understand your current thoughts and behaviours and how they're affecting you. While CBT recognises that events in your past may have shaped you, it concentrates mostly on how you can change the way you think, feel and behave in the present day.

CBT is the most well-known and best-studied talking treatment for depression. But there are others which may be used, although it's not clear how effective some of them are in reducing depression symptoms. Local primary care trusts offer some form of CBT, following recommendations from the National Institute for Health and Clinical Excellence (NICE). More therapists are currently being trained so that people with depression can receive CBT faster. Ask your GP for advice about how to get the right treatment for you.

Used to treat: all types of depression.

Considering this treatment

Studies show that CBT can have the same impact on improving symptoms of depression as antidepressant drugs in about half the people who try it, a similar success rate to antidepressants.

What does NICE say about this treatment?

Computerised cognitive behavioural therapy (CBT)

Computerised CBT is a form of CBT that works via a computer screen, rather than face to face with a therapist. It can be delivered on a personal computer, via the internet, or by telephone using voice-response systems. It can help people who don't want to take antidepressants or who don't want to interact with a therapist. It may also be useful for those who have phobias about going out because people with depression can use it at home. Ask your GP if it's available in your area.

Used to treat: mild to moderate depression.

Considering this treatment

NICE recommends some forms of computerised CBT as a treatment for depression.

What does NICE say about this treatment?

Counselling

The person with depression talks about their difficulties with a counsellor, who plays a supportive role and may sometimes give advice on problem solving.

Used to treat: mild to moderate depression.

Considering this treatment

What does NICE say about this treatment?

Psychodynamic psychotherapy

Psychodynamic psychotherapy may last for several years and be aimed at changing several different ways in which an individual functions. The therapist may not say much, but hopes to establish a therapeutic relationship of trust and acceptance to allow intimate information to be revealed. The aim is to explore hidden parts of the personality and mind, looking at the links between events in the past and current experience and feelings, so that the individual gains some insight into their own emotions and actions.

Shorter versions of psychodynamic psychotherapy lasting 10-20 sessions may focus on a particular area of a person’s life.

Used to treat: depression if a person also has more complex pscyhological conditions.

Considering this treatment

There's little evidence to support the use of psychodynamic psychotherapy to relieve the symptoms of depression. NICE suggests that it may be considered for treatment for depression when someone has other complex psychological conditions as well.

What does NICE say about this treatment?
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Hospital treatments show

If your depression is severe or the treatment prescribed by your GP isn't working, you may be referred for treatment in hospital.

An alternative is treatment by a mental health team made up of psychologists, psychiatrists, specialist nurses and occupational therapists. They often provide intensive specialist 'talking treatments', such as cognitive behaviour therapy or other forms of talking therapy.

Admission to hospital may be needed to allow careful monitoring and more intensive treatment if other treatments aren't working, or if the depression is thought to be life-threatening.

These treatments may include antidepressants, other specialist medicines and electro-convulsive therapy (ECT).

Electro-convulsive therapy (ECT)

During electro-convulsive therapy (ECT), electrodes are put onto the head and an electric current is briefly passed through them to cause a seizure (or ‘fit’). ECT is given under a general anaesthetic with a drug to relax the muscles and prevent body spasms. It is usually given twice a week for 3-6 weeks.

ECT has been used since the 1930s. It is still not clear how it works, but it may change the response of nerves to brain chemicals called neurotransmitters which have effects on mood.

For some severely depressed people who do not respond to any other form of treatment, it is effective, lifts severe suicidal depression, and allows a return to the activities of daily living. But it can have adverse effects including severe confusion and damage to the ability to think and remember in both the short and long terms.

Some mental health specialists say the good that it can do outweighs the potential harm, others disagree.

Considering this treatment

The NICE recommendations are that ECT should only be used with caution, and that a balance of risks and benefits for each individual should be made. Doctors are called on to keep strictly to guidelines on consent and encourage the involvement of both carers and ‘advocates’ who speak on the patient’s behalf.

What does NICE say about this treatment?

Transcranial magnetic stimulation (TMS)

Transcranial magnetic stimulation (TMS) aims to stimulate electrical activity in the brain by passing an electromagnet over the skill.

There are no major concerns about the safety of TMS, according the National Institute for Health and Clinical Excellence (NICE), but there are doubts about whether or not it works.

Considering this treatment

NICE says there are doubts about whether or not TMS is effective, and that it should only be used in large research studies.

NICE guidance on managing depression
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Last reviewed: 26/06/2008

Next review due: 26/06/2010

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