Depression

Treatment for depression usually involves a combination of drug and psychological therapies.

Psychotherapy: Psychotherapy involves talking to a healthcare professional about one's problems and life situation. There are several types of psychotherapy that have been shown to be effective for depression including cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). Research has shown that mild to moderate depression can often be treated successfully with either of these therapies used alone. However, severe depression appears more likely to respond to a combination of psychotherapy and medication.

Cognitive-behavioral therapy (CBT): CBT helps to change the negative thinking and unsatisfying behavior associated with depression, while teaching individuals how to unlearn the behavioral patterns that contribute to their depression.

Interpersonal therapy (IPT): IPT focuses on improving troubled personal relationships and on adapting to new life roles that may have been associated with a person's depression.

Medications: Drugs used for depression often take two to four weeks to start having an effect, and 6-12 weeks to have their full effect. The first antidepressant medications were introduced in the 1950s. Research has reported that imbalances in neurotransmitters like serotonin, dopamine, and norepinephrine can be improved with antidepressant use.

Selective serotonin reuptake inhibitors (SSRIs): SSRIs act specifically on the neurotransmitter (brain chemical) serotonin. Serotonin is mainly involved with mood balance. SSRIs are the most common agents prescribed for depression worldwide. These agents increase the amount of serotonin that is available for use by the brain. SSRIs include fluoxetine (Prozac®), sertraline (Zoloft®), paroxetine (Paxil®), citalopram (Celexa®), escitalopram (Lexapro®), and fluvoxamine (Luvox®).

Serotonin and norepinephrine reuptake inhibitors (SNRIs): SNRIs are the second-most popular antidepressants worldwide. These agents increase the amount of both serotonin and norepinephrine. SNRIs include venlafaxine (Effexor®) and duloxetine (Cymbalta®). SSRIs and SNRIs tend to have fewer side effects than other types of antidepressants. Side effects include nausea, nervousness, insomnia, diarrhea, rash, agitation, or sexual side effects (problems with arousal or orgasm).

Norepinephrine-dopamine reuptake inhibitor (NDRI): NDRIs acts by increasing the amounts of dopamine and norepinephrine available to the brain. Bupropion (Wellbutrin®) is commonly used as an antidepressant in this class.

Tricyclic antidepressants (TCAs): TCAs are older antidepressants that are not used as frequently now. They work similarly to the SNRIs, but have other properties that result in very high side effect rates, as compared to almost all other antidepressants. They are sometimes used in cases where other antidepressants have not worked. TCAs include amitriptyline (Elavil®), desipramine (Norpramin®), doxepin (Sinequan®), imipramine (Norpramin®, Tofranil®), nortriptyline (Pamelor®, Aventyl®), and protriptyline (Vivactil®). TCAs cause side effects that include dry mouth, constipation, bladder problems, sexual problems, blurred vision, dizziness, drowsiness, skin rash, and weight gain or loss.

Monoamine oxidase inhibitors (MAOIs): MAOs are seldom used now for depression. They also increase amounts of serotonin, norepinephrine, and dopamine for the brain to use in mood stabilization. They can sometimes be effective for people who do not respond to other medications or who have atypical depression with marked anxiety, excessive sleeping, irritability, hypochondria (health anxiety), or phobic (obsessive) characteristics. However, they are the least safe antidepressants to use, as they have important medication interactions, including causing dangerously high blood pressure, and require adherence to a diet free of tyramines, chemicals found in certain foods such as fish (especially dried and salted), chocolate, alcoholic beverages (chianti wine), and fermented foods such as cheese and soy sauce, sauerkraut, and processed meat. MAOIs include phenelzine (Nardil®), isocarboxazid (Marplan®), and tranylcypromine sulfate (Parnate®). A range of other, less serious side effects occur including weight gain, constipation, dry mouth, dizziness, headache, drowsiness, insomnia, and sexual side effects (problems with arousal or satisfaction).

Other: Mirtazapine (Remeron®) is an antidepressant used commonly in the elderly that helps cause weight gain. A common side effect is drowsiness. Often psychiatrists will combine antidepressants with each other or with agents that are not antidepressants themselves. A class of drugs called atypical antipsychotic agents, including aripiprazole (Abilify®), olanzapine (Zyprexa®), quetiapine (Seroquel®), ziprasidone (Geodon®), and risperidone (Risperdal®) may be used. Side effects for these drugs are high, including excessive sedation and tardive dyskinesia (a nervous system disorder causing facial grimaces, lip smacking, and uncontrollable shaking). According to the American Diabetes Association (ADA), certain antipsychotic drugs may increase the risk of diabetes, obesity and high blood pressure.

Stimulants, such as methylphenidate (Ritalin®) or dextroaphetamine (Dexedrine®) can be added. Stimulants may cause dry mouth, disturbances in sleep patterns, nervousness, anxiousness, and weight loss.

Lithium and mood-stabilizing medications may be prescribed, including lithium (Eskalith®, Lithobid®), valproic acid (Depakene®), divalproex (Depakote®), and carbamazepine (Tegretol®) to treat bipolar depression. Medications called atypical antipsychotics such as olanzapine (Zyprexa), risperidone (Risperdal) and quetiapine (Seroquel) were initially developed for treatment of psychotic disorders.

Hormone therapy: For women with postpartum depression or premenstrual dysphoric disorder (PMDD), hormonal replacement with estrogen and/or progesterone may help with depression. However, there is an increased risk of heart disease and cancer (breast and ovarian) with the use of these medications.

Electroconvulsive therapy:Electroconvulsive therapy (ECT) involves the use of electrical current to stimulate various parts of the brain, and is used mainly in people who have episodes of major depression associated with suicidal tendencies, or in people whose medication has proved to be ineffective. ECT profoundly affects brain metabolism and blood flow to various areas of the brain. How that correlates to easing depression remains unknown, but this therapy is often highly effective. Safety of ECT is controversial, and adverse effects such as confusion, memory loss, headache, hypotension (low blood pressure), and tachycardia (increased heart rate) may occur.

Light therapy: This therapy may help if the individual has seasonal affective disorder (SAD). This disorder involves periods of depression that recur at the same time each year, usually when days are shorter in the fall and winter. Scientists believe fewer hours of sunlight may increase levels of melatonin, a brain hormone thought to induce sleep and depress mood. Treatment in the morning with a specialized type of bright light, which suppresses production of melatonin, may help with this disorder. Melatonin is a hormone for the sleep-wake cycle and may be decreased during depression.

Mild depression: If mild depression is diagnosed, antidepressant drugs are not usually recommended as a first treatment. Exercise seems to help some people with depression. Talking through feelings using counselling may also be helpful for mild depression. Talking to a friend or relative, self-help reading material, or a local self-help group are good choices. If the depression is mild but there is a past history of depression, antidepressants may be used.

Chronic (long term) mild depression or dysthymia (present for two or more years) is more likely in people over 55 years and can be difficult to treat. Individuals diagnosed with dysthymia are usually started on a course of antidepressants.

Moderate depression: If mild depression does not improve, antidepressants or talking treatments are generally used. Research has shown that antidepressants and psychological therapies are equally effective in treating mild or moderate depression but having the two types of treatment together does not seem to offer any extra benefits.

Severe depression: If severe depression is diagnosed, both antidepressant therapy together with psychotherapy are usually used in combination.

Although major depression can be a devastating illness, it is highly treatable. Between 80-90% of individuals diagnosed with major depression can be effectively treated and return to their usual daily activities and feelings.

Hospitalization: Depression is a serious medical illness. Urgent care and hospitalization may be necessary when someone seems to be a danger to themselves or others, or if they are psychotic. A person experiencing extreme major depression should be brought to the hospital immediately to prevent suicide or possible violence to another person. An acute episode is treated with medications and a low-stimulation environment. Depending on the individual's symptoms and history, longer-term hospitalization may be required.

Strong scientific evidence:

Music therapy: Music has been referred to as an ancient tool of healing. Many different forms of music intervention have been used to reduce depression and anxiety in a variety of medical conditions and medical procedures. There is evidence that music therapy may increase responsiveness to antidepressant medication. In elderly adults with depression, a home-based program of music therapy may have long-lasting effects. In depressed adult women, music therapy may lead to reductions in heart rate, respiratory rate, blood pressure, and depressed mood.

St. John's wort: Extracts of St. John's wort (Hypericum perforatum) have been recommended traditionally for a wide range of medical conditions, with the most common modern-day use being the treatment of depression. St. John's wort has been extensively studied in Europe over the last two decades, with more recent research in the United States. Short-term studies (one to three months) suggest that St. John's wort is more effective than placebo (sugar pill), and equally effective as tricyclic antidepressants (TCAs) in the treatment of mild-to-moderate major depression. Comparisons to the more commonly prescribed selective serotonin reuptake inhibitor (SSRI) antidepressants, such as fluoxetine (Prozac®) or sertraline (Zoloft®), are more limited. However, other data suggest that St. John's wort may be just as effective as SSRIs with fewer side effects. Safety concerns exist as with most conventional and complementary therapies. Studies of St. John's wort for severe depression have not provided clear evidence of effectiveness.

In published studies, St. John's wort has generally been well tolerated at recommended doses for up to one to three months. The most common adverse effects include gastrointestinal upset, skin reactions, fatigue/sedation, restlessness or anxiety, sexual dysfunction (including impotence), dizziness, headache, and dry mouth. Caution is advised when taking St. John's wort, as numerous adverse effects including many drug interactions are possible. Drug interactions with St. John's wort can have severe consequences. One small study reported elevated thyroid stimulating hormone (TSH) levels to be associated with taking St. John's wort. St. John's wort should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.

Good scientific evidence:

5-hydroxytryptophan (5-HTP): Supplement use of 5-HTP may help balance serotonin in the body. Serotonin is the brain chemical associated with sleep, mood, movement, eating and nervousness. While cells outside the brain, such as platelets in the blood and some cells in the intestine, produce and utilize serotonin, all serotonin used by brain cells must be made within the neurons themselves. When serotonin is not properly constructed within the brain, the result can be irritability, aggression, impatience, anxiety and depression. It has been suggested that 5-HTP may reduce psychotic symptoms and mania or aid in panic disorder when used short-term (up to one year), but studies in people with schizophrenia have shown different results. Caution is advised when taking 5-HTP supplements, as numerous adverse effects including drug interactions are possible. 5-HTP is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Art therapy: Art therapy enables the expression of inner thoughts or feelings when verbalization is difficult or not possible. It involves the application of a variety of art modalities including drawing, painting, clay and sculpture. Art therapy may be an effective intervention for hospitalized, suicidal adolescents. There is evidence that it can be used to aid in developing a sense of identity and optimism about the future. It may also aid in relaxation and willingness to communicate, and may result in shorter hospitalization.

Dehydroepiandoseterone (DHEA): DHEA is a hormone made in the human body that serves as precursor to male and female sex hormones (androgens and estrogens). The majority of clinical trials investigating the effect of DHEA on depression support its use for this purpose under the guidance of a healthcare provider. Further research is needed to confirm these results. Few side effects are reported when DHEA supplements are taken by mouth in recommended doses. Side effects may include fatigue, nasal congestion, headache, acne, or rapid/irregular heartbeats. In women, the most common side effects are abnormal menses, emotional changes, headache, and insomnia. Individuals with a history of abnormal heart rhythms, blood clots or hypercoagulability, and those with a history of liver disease, should avoid DHEA supplements. Caution is advised when taking DHEA supplements, as numerous drug interactions are possible. DHEA is not recommended during pregnancy or breastfeeding.

Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). A broad range of psychotherapies are effective for the treatment of depression, including behavior therapy, cognitive-behavioral therapy, and interpersonal therapy. Brief dynamic therapy, marital therapy, and family therapy may work best, depending on the patient's problems and circumstances. Although prescription medication is the most effective treatment for bipolar disorder, psychotherapy may help patients take their medication, prevent relapses, and reduce suicidal behavior.

Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Several human studies support the use of yoga for depression in both children and adults. Although this preliminary research is promising, better studies are needed.

Unclear or conflicting scientific evidence:

Acupressure: Acupressure, or shiatsu, has been used in China for thousands of years for health and healing. Several studies suggest that fatigue and depressive mood may improve with acupressure therapy. Further research is necessary to confirm these findings.

Acupuncture: Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. A small number of studies have sought to compare acupuncture with antidepressant medications used in depression. More studies are needed on this use.

Aromatherapy: Fragrant oils have been used for thousands of years. Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Preliminary research suggests that lavender (Lavendula officinalis) aromatherapy may be helpful as an adjunct to prescription antidepressant medications. Additional research is necessary before a firm conclusion can be drawn.

Ayurveda: Ayurveda, which originated in ancient India over 5,000 years ago, is probably the world's oldest system of natural medicine. Early evidence suggests that a traditional Ayurvedic formula containing extracts of four Indian herbs, Ashvatha, Kapikachu, Dhanvayasa, and Bhuriphali, may have benefits similar to conventional anti-depressant medication. Further studies are needed to confirm these results.

Folic acid: Folic acid or folate deficiency has been found among many individuals suffering from depression and has been linked to poor response to antidepressant therapies. Folate supplements have been used for enhancing treatment response to antidepressants. Limited clinical research suggests that folic acid is not effective as a replacement for conventional antidepressant therapy. Folate appears to be well tolerated in recommended doses. Blood tests can determine if an individual is low in vitamins such as folic acid.

Ginkgo: Preliminary study of seasonal affective disorder (SAD) suggests that ginkgo (Ginkgo biloba) is not effective in preventing the development of depression during the winter months. Other research in elderly patients with depression shows possible minor benefits. Ginkgo may also help in decreasing sexual side effects such as loss of libido in individuals taking antidepressants. Overall, there is not enough evidence to form a clear conclusion. Caution is advised when taking ginkgo supplements as numerous adverse effects including an increase in bleeding and drug interactions are possible. Ginkgo is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Healing touch (HT): Preliminary data from one small study suggests a series of HT sessions over time may contribute to reducing depression. However, data are insufficient to form definitive conclusions, and studies of better design are needed.

Kundalini yoga: is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. It is an elaborate system focused on healing and "purifying" the mind, body, and emotions. There is evidence from one small clinical trial where Kundlini yoga was practiced of benefit in depression. More trials are needed to establish whether this is a viable therapy for depression before a recommendation can be made.

L-carnitine: L-carnitine (also known as acetyl-L-carnitine) is an antioxidant and may help blood flow as well as neurological function. Although the results are promising there is insufficient evidence to support the use of acetyl-L-carnitine in the treatment of depression. Well-designed clinical trials with adequate subject number are required. When acetyl-L-carnitine is taken orally for one year. Caution is advised when taking acetyl-L-carnitine supplements as numerous adverse effects including drug interactions are possible.

Massage: Various forms of therapeutic superficial tissue manipulation have been practiced for thousands of years across cultures. Massage is relaxing and may decrease stress. There is insufficient evidence to determine if massage is beneficial in patients with depression. Additional research is necessary in order to form a scientifically based recommendation.

Melatonin: There is limited study of melatonin given to patients with sleep disturbances associated with bipolar disorder (such as insomnia or irregular sleep patterns). No clear benefits have been reported. Depression may be associated with neuroendocrine and sleep abnormalities, such as reduced time before dream sleep (REM latency). Melatonin has been suggested for the improvement of sleep patterns in patients with depression, although research is limited in this area. Further studies are needed before a clear conclusion can be reached. Melatonin is not to be used for extended periods of time. Caution is advised when taking melatonin supplements as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Omega: Essential fatty acids (including omega-3 fatty acids) have many roles in the body, including proper nerve and brain function. There have been several studies on the use of omega-3 fatty acids in depression; however, not enough reliable evidence is available to form a clear conclusion or replace standard treatments. Omega-3 fatty acids found in fish oils are normally used. It is important to choose quality fish oil supplements, as heavy metals have been reported in some fish oil supplements. The label should say if the product has been tested for heavy metal contamination (such as lead and mercury).

Qi gong: Qi gong is a type of Traditional Chinese Medicine (TCM) that is thought to be at least 4,000 years old. Preliminary study shows that Qi gong may be beneficial for relieving stress. Available data remains inconclusive, yet thousands of years of effectiveness in China for stress and anxiety must be appreciated.

Reiki: Reiki is a Buddhist practice that is approximately 2,500 years old. It is used for stress reduction and relaxation and is administered by "laying on hands" and moving around the "energy" of the body. There is evidence that Reiki can reduce symptoms of distress when compared to placebo. More information is needed before a conclusion can be drawn.

Relaxation therapy: Relaxation therapy includes self-control relaxation, paced respiration, and deep breathing. There is promising early evidence from human trials supporting the use of relaxation to reduce symptoms of depression,^{although effects appear to be short-lived. Better quality research is necessary before a firm conclusion can be drawn.}

Riboflavin (Vitamin B2): Riboflavin is a water-soluble vitamin, which is involved in many processes in the body, and is necessary for normal cell function, growth, and energy production. Adequate nutrient supplementation with riboflavin may be required for the maintenance of adequate cognitive function. Treatment with B-vitamins, including riboflavin, has been reported to improve depression scores in patients taking tricyclic antidepressants.

SAMe: S-adenosylmethionine, or SAMe, is normally formed in the body from the essential amino acid methionine. SAMe supplements are used in depression and mood disorders. SAMe has been studied for use in depression for many decades. However, the majority of trials that have been performed have significant methodological flaws limiting their clinical usefulness. A small number of randomized placebo controlled trials suggest an antidepressant effect that is greater than that observed with placebo. Although some studies have suggested that SAMe has a more rapid onset of action in depression than tricyclic antidepressants (TCAs), it is uncertain whether these effects result in improved patient outcomes. Large randomized placebo controlled trials that compare SAMe to other antidepressants such as the Selective Serotonin Reuptake Inhibitors (SSRIs) are needed. Until these trials are available, it is difficult to justify the use of SAMe in patients with depression since there are many effective antidepressants available to this patient population. Caution should be used when taking SAMe supplements as drug interactions are possible. SAMe is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Tai Chi: Tai chi is a system of movements and positions believed to have developed in 12th Century China. Tai chi techniques aim to address the body and mind as an interconnected system, and are traditionally believed to have mental and physical health benefits to improve posture, balance, flexibility and strength. Preliminary research suggests that tai chi may alleviate depression, anger, and fatigue. Better studies are needed before conclusions can be drawn.

Vitamin B6 (Pyridoxine): Some research suggests that pyridoxine supplementation alone or in combination with high doses of other B vitamins might help with depression. Pyridoxine helps increase the "calming" neurochemicals serotonin and gamma amino butyric acid (GABA) levels in the blood, possibly benefiting people in dysphoric mental states. Well-designed clinical trials are needed to confirm potential benefit. Vitamin B6 may be found in a multivitamin or a B-complex vitamin supplement.

Healthcare providers recommend that an individual suffering from depression reduce stress and try to develop regular sleep patterns. Sleep disturbances may signal the early phase of a depressive episode.

Learn to recognize the early warning signs and triggers of depression. Warning signs of relapse vary from patient to patient, and may include thoughts of death, or slight changes in sleep patterns (a common indicator), mood, energy, self-esteem, sexual interest, concentration, and willingness to take on new projects, and dress or grooming.