No matter how severe depression can be, treatment is available. The two most common types of treatment, psychotherapy and medications, may be used on their own or in combination. Each case of depression is different, so there may be a period of trial and error before the best treatment option is found. If several classes and combinations of medication and different types of psychotherapy do not improve symptoms, your doctor may suggest trying brain stimulation techniques or an experimental therapy.
Also known as talk therapy or simply as therapy, various forms of psychotherapy have been used to treat depression since the late 1800s. Therapy may be used to treat depression on its own or in combination with antidepressant medications. The goal of psychotherapy is to treat the psychological causes of depression. Therapy can help depressed people deal with grief or losses, find better ways to handle relationship conflicts, and resolve difficulties surrounding life transitions. Most talk therapy is done with a licensed, trained mental health professional. Psychotherapy can be one-on-one with a therapist, or involve a group (group therapy), a relationship partner (couples therapy), or family (family therapy). Therapy involving others can add an element of social support as well as education for partners or family members about depression. Therapy can be short-term, involving a few sessions, or long-term, lasting over months or years.
Before selecting a therapist, read about the different approaches to talk therapy below and find one that feels right to you. Then, once you’ve received referrals from your doctor or researched therapists on your own, schedule a preliminary conversation with each. Ask about how they would treat your depression and use your conversation to determine whether you feel comfortable with them. Being able to trust your therapist is essential.
Cognitive behavioral therapy (CBT) is one type of psychotherapy. A therapist may use only CBT techniques or CBT in combination with other types of psychotherapy. CBT focuses on identifying and correcting negative ways of thinking that lead to depression. CBT can provide insight to view situations more clearly and teach more effective ways to deal with problems. As you work with your therapist, you might be asked to do “homework,” such as reading or activities that implement processes learned during therapy sessions. CBT sessions are commonly scheduled once a week for 10 to 15 weeks.
Interpersonal psychotherapy (IPT) focuses on identifying and improving patterns in interpersonal relationships. During IPT, the therapist aims to be a supportive and relaxed ally for you to help you navigate painful interpersonal transitions. IPT sessions are typically scheduled once a week for 12 to 16 weeks and are kept to that window so as to pressure you to take action.
Psychodynamic therapy focuses on your interactions with the world. Your therapist will ask you open-ended questions and may use free association in order to pinpoint and understand negative feelings and behavior, even those that are unconscious. Once these have been identified and accepted, you can work to overcome them. Psychodynamic therapy is especially beneficial to people who have a hard time developing and sustaining friendships.
Most medications prescribed to treat depression target one or more of the three neurotransmitters (chemical messengers in the brain) believed to regulate mood: serotonin, norepinephrine, and dopamine. Antidepressants are categorized by the effects they have on these chemicals.
Common side effects of most antidepressants include sexual dysfunction, drowsiness, weight gain, and gastrointestinal (digestive system) upset.
It is important to remember that you may need to try more than one antidepressant before you find one that is right for you. When deciding on an antidepressant, your doctor will consider your symptoms, potential side effects or interactions with medications you are already taking, whether a particular medication worked well for a parent or sibling, and any other health conditions you have. For women, it is also important to discuss with your doctor whether you are trying to conceive, currently pregnant, or breastfeeding.
The most common classes of antidepressants are highlighted below.
Selective serotonin reuptake inhibitors (SSRIs) are often the first type of medication prescribed for depression. These drugs work by increasing the brain’s level of serotonin, which is often called the brain’s “feel good” chemical. SSRIs include Prozac (Fluoxetine), Zoloft (Sertraline), and Celexa (Citalopram). They generally have fewer side effects at high doses than other antidepressants.
Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs, but in addition to making more serotonin available, they also boost the levels of norepinephrine. Low levels of norepinephrine are believed to cause the brain fog often experienced by people with depression. Commonly prescribed SNRIs are Cymbalta (Duloxetine) and Effexor (Venlafaxine).
Monoamine oxidase inhibitors (MAOIs) are the oldest class of prescription antidepressants. These medicines prevent the breakdown of the neurotransmitters responsible for mood regulation. MAOIs aren’t frequently prescribed as they can have more severe side effects and potentially life-threatening reactions with food or other medications. Therefore, if you take an MAOI, you may need to restrict your diet. MAOIs include Parnate (Tranylcypromine) and Nardil (Phenelzine).
Tricyclic antidepressants, also known as tetracyclic or cyclic antidepressants, are another early class of depression medications. Tricyclics work by preventing nerve cells from reabsorbing norepinephrine and serotonin, freeing them for use in the brain. Common tricyclics include Elavil (Amitriptyline), Pamelor (Nortriptyline), and Sinequan (Doxepin).
Atypical antidepressants are newer drugs that don’t fit into one of the other categories. They work by altering levels of one or more neurotransmitters, but they each use different approaches. Remeron (Mirtazapine), Wellbutrin (Buproprion), and Oleptro (Trazodone) are in this class. Wellbutrin is known to be one of a small number of antidepressants that does not have sexual dysfunction as a side effect.
There are a few other classes of drugs used to treat depression and anxiety. Antipsychotics, used mostly for bipolar disorder, include Seroquel (Quetiapine) and Zyprexa (Olanzapine). Anxiolytics and benzodiazepines, such as Ativan (Lorazepam) and Klonopin (Clonazepam), are prescribed for anxiety. When a drug is prescribed for a different purpose than originally intended, its use is considered “off-label.” Mood stabilizers, which were developed originally to treat trigeminal neuralgia and seizures, are prescribed off-label to treat bipolar disorder and certain types of depression. Mood stabilizers include Lamictal (Lamotrigine), Eskalith (Lithium), and Neurontin (Gabapentin). Stimulants, approved to treat people with attention deficit disorder (ADD) and attention deficit-hyperactivity disorder (ADHD), include Adderall (Amphetamine/Dextroamphetamine) and Ritalin (Methylphenidate). Stimulants may be prescribed off-label to treat some people with depression.
Never change your dose or stop your medication without consulting with your doctor.
Although antidepressants are not addictive, suddenly stopping your medication can lead to withdrawal symptoms or a relapse. Some classes of drugs prescribed off-label for depression, including benzodiazepines and stimulants, may cause addiction. Use them only as directed by your doctor.
For the most part, antidepressants are safe to take. However, the US Food and Drug Administration (FDA) requires all antidepressants to have a “black box" warning on the label. The most severe warning issued by the FDA, the black box warning is required because some children, teenagers, and young adults may experience suicidal behavior or thoughts while taking an antidepressant. The risk for this serious side effect is highest during the first month of taking a new drug or after a dosage change.
If you are experiencing suicidal thoughts or behavior, contact your doctor immediately or get emergency help.
Other treatments for depression
Light therapy for seasonal affective disorder involves exposure to a light box each morning. Exposure should last 20 to 30 minutes, and the light box should be positioned 16 to 24 inches from the face. During light therapy, you should keep your eyes open, but do not gaze directly at the light. You may read or perform another activity during light therapy. Light boxes are not regulated by the FDA for safety or effectiveness. To be safest, choose a light box that filters out most or all ultraviolet (UV) light. Different styles of light box may be more or less effective for each individual.
Brain stimulation therapy may be tried if medication and psychotherapy are not effective. There are three common types of brain stimulation. Electroconvulsive therapy (ECT) uses a controlled electrical current to induce a brief seizure. Transcranial magnetic stimulation (TMS) uses magnetic fields to stimulate the mood centers of the brain. The Fisher-Wallace Stimulator is a device that sends gentle electrical impulses to the brain. These therapies are used during a set period of time and are not meant to be used long-term or as a maintenance treatment.
Many people with depression try complementary and alternative treatments such as acupuncture, yoga, meditation, and supplements containing St. John’ wort, S-adenosylmethionine (SAMe), or omega-3 fatty acids. Some people report feeling better when they try natural treatments, but most have not been proven safe or effective in clinical trials. The FDA does not evaluate the purity or safety of nutritional supplements. Due to the potential for dangerous medication interactions, it is important to discuss any plans to use natural or complementary treatments with your healthcare provider.
Several clinical trials have shown exercise to be significantly beneficial to people with depression. It is important to choose a type of physical activity you like and can do regularly and to start with a small amount each day. Once you become accustomed to the activity, exercise for longer periods and consider exercising with friends or family.
Nutrition can play an important role in mental health. Researchers have found that people who eat a nutritious, balanced diet are less likely to report being depressed and to develop chronic diseases.
Experimental therapies such as ketamine and deep brain stimulation (DBS) show promise but have not yet received FDA approval for treating depression. Ketamine is an anesthetic but is sometimes used off-label to treat depression. Researchers think it works by repairing connections between brain cells that have been damaged by depression. DBS was developed as a treatment for Parkinson’s disease, but is now being studied as a potential therapy for depression.
Some people with depression participate in clinical trials to gain access to new treatments.
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