How is depression treated?

People with moderate or severe depression can have very serious symptoms that don’t get better quickly. So it’s particularly important they get psychotherapy or antidepressant treatment as soon as possible. This is also true if they have chronic depression or are thinking of harming or killing themselves (committing suicide).

If the depression is minor or just starting, it's possible to try other approaches first and see if they help. It is important to stay in touch with the doctor and have regular appointments to discuss how you're feeling and how you can cope with the situation. Some people find it helpful to spend more time doing things like sports and hobbies – even if they have trouble motivating themselves because they don't feel like it. Others take (online) courses to learn how to deal with their symptoms better. If it helps, they can also talk to a psychiatrist or psychotherapist.

It is also important for people to be able to talk with others. Partners, friends and family play a key role here. Support and information centers can offer help and guidance too. Sometimes it can help to talk to people who have gone through similar experiences, for example in a support group.

If your mood doesn't improve within a few weeks – or if it gets even worse – then help from a therapist may be a good idea.

Psychological treatment usually involves talking about things in depth and doing behavioral exercises. Cognitive behavioral therapy (often called “CBT” for short) is often used to treat depression. Statutory health insurance companies in Germany cover the costs of CBT as well as other outpatient treatments, including depth psychology, analytical psychotherapy and systemic therapy. They are often offered by specially trained therapists.

If someone is going through an acute depressive episode, they can usually get short-term psychological support, sometimes together with medication. They can start by seeing their family doctor or organizing an appointment with a therapist. Then they can apply for a full course of outpatient psychological treatment.

In depression, negative thought patterns such as self-doubt and feelings of guilt often make the problem worse. Cognitive behavioral therapy aims to break these patterns bit by bit, so that people feel better about themselves. The first step is for them to form a clear idea of their own thoughts, attitudes, and behavioral patterns so that they can recognize and change false and distressing beliefs.

For example, people who have developed depressive thoughts often tend to become withdrawn and give up their hobbies. As a result, they feel even more unhappy and isolated. Cognitive behavioral therapy can help them realize what's happening. Then they can work with their therapist to find ways to become more active again.

Psychoanalytic approaches include analytical psychotherapy and depth psychology. They are based on the belief that unresolved, unconscious conflicts or losses can cause depression. They use therapy to identify and work through previously unknown issues, the aim being to change attitudes and behaviors that are causing problems. People who have psychoanalytic therapy have to be prepared to face potentially painful past experiences.

Psychoanalysis usually takes longer than approaches based on depth psychology.

Systemic therapy places a lot of importance on the relationships between people – for instance, within your family, your group of friends or at work. These relationships can play a role in the development of depression. The therapy might involve trying to improve communication within the family, for instance. The aim is to use the strengths and resources of the people involved to change problematic attitudes and behaviors and find solutions to conflicts. This can help to reduce the symptoms of depression. The therapy sessions are typically one-on-one, but other people, like family members, can also be included.

For more information on whether therapy can help and how to get treatment, take a look at the information “How effective is psychological treatment?”

Depression is treated with medications called antidepressants. They can have a mood-lifting effect and increase motivation. Antidepressants are often used in combination with psychological treatment. Medication is hardly effective in mild depression, and sometimes not at all. It is only prescribed for people with mild depression in certain situations, like if the symptoms don't go away or are likely to get worse.

The symptoms sometimes get better without antidepressants after a short while. The possible side effects will also play a role when deciding whether or not to take antidepressants.

But it usually takes several days or weeks for antidepressants to start working. In acute depression they have to be taken every day for several weeks or months before they start having a noticeable effect. This is often followed by continuation treatment, which lasts several months, and sometimes long-term therapy as well in order to prevent the depression from coming back.

The possible side effects of antidepressants include a dry mouth, headaches and feeling faint, restlessness and a decreased sex drive. These usually arise within the first few weeks of taking antidepressants. Whether or not someone has side effects, which side effects they have, and how frequent the side effects are will depend on the specific drug and dose that is used.

And everyone reacts slightly differently to drugs too. That’s why it’s important to see a doctor regularly while on medication, so they can see how things are going and adjust the treatment if necessary. Towards the end of the treatment, the dose of antidepressants is gradually reduced over the course of several weeks. If someone stops taking antidepressants suddenly, they might (temporarily) have problems sleeping, feel nauseous or restless. Stopping taking the medication as soon as you start to feel better without consulting your doctor can increase the risk of depression returning.

There's more information about how antidepressants work and what side effects they can have in the information “How effective are antidepressants?”

Acute treatment usually lasts six to eight weeks. The aim is to

• ease the symptoms enough to enable the person to lead a normal life again, and
• shorten the depressive episode.

The next phase of treatment is called continuation treatment. This usually lasts four to nine months. The aim of continuation treatment is to

• further relieve the symptoms, until they go away, and
• sustain the progress made through treatment.

Some people have depressive episodes on a regular basis, which has a major impact on their lives. Long-term treatment is a possible option for them. It can last several years and the aim is to prevent the depression from coming back (relapse). People who have chronic depression also often take medication for many years and need psychological treatment for a longer time as well. This eases persistent symptoms.

Doctors check regularly to see whether the treatment is working properly. If necessary, they make adjustments.

The most common and best-known herbal medicines for the treatment of depression are made from St. John’s wort. These products can provide relief from the symptoms of mild and moderate depression. Omega-3 fatty acids, on the other hand, are not effective for treating depression. A number of studies have come to this conclusion. Herbal products can have side effects and interact with other medications too, so it’s important to consult a doctor before taking things like St. John’s wort.

Even though lots of people with depression have trouble sleeping, doctors tend not to recommend sleeping pills or sedatives for them. They're only an option for people whose depression is moderate to severe and whose insomnia or restlessness is causing major problems that can't be helped with other methods (like changes to their bedtime habits) Sleeping pills and sedatives that have to be prescribed shouldn't be taken for longer than two to four weeks because they can lead to dependence. They are not recommended for people who've had problems with addiction in the past.

The doctor might prescribe antipsychotics (usually in combination with antidepressants) if the person has psychosis too. The symptoms of psychosis include hallucinations, delusional thoughts, and an urge to move about without any particular purpose. Antipsychotics can also be an option when antidepressants aren't having the necessary effect and need to be backed up with additional medication.

Psychoeducation involves providing information about what causes depression, how it progresses, what treatments are available, and strategies for coping with the illness. It's intended to improve the person's knowledge of their illness and point them to ways of changing their attitude and behavior. Ultimately, the aim is to help them develop the skills they need to deal with the illness.

The information is typically provided by a doctor or therapist, in information material, or on courses. Most of these courses take place in clinics. They're offered for individuals or groups. Online programs sometimes include a psychoeducation component too.

A number of web-based tools are available to help people with depression. Most of them are apps that can be downloaded. Some are free, some have to be paid for. They're designed to help people cope better with depression. They include things like information on psychotherapy techniques and symptom diary tools.

They can be helpful for people with minor depression and as additional support for people being treated for more severe depression. Experts recommend that people who use these online programs should talk to a therapist about them.

In Germany, some apps can be prescribed by a doctor or therapist. They're referred to as "Digital Health Applications" (DiGAs) and they’re covered by statutory health insurance. DiGAs are assessed and certified by Germany’s Federal Institute for Drugs and Medical Devices (BfArM). This means they meet certain requirements to do with things like data privacy and content quality.

The BfArM can supply a list of all DiGAs that deal with depression. The list contains additional information on the content of each app and what it does.

A lot of other treatments and strategies are offered to people with depression. But many of these haven't been clearly proven to help reduce the symptoms. Some can be a useful addition or alternative to other treatments in certain situations.

There is some evidence that relaxation techniques can help relieve mild to moderate depression. These include approaches such as progressive muscle relaxation, autogenic training, music therapy and yoga. But they aren't as effective as other treatments, such as cognitive behavioral therapy. Psychotherapists sometimes teach relaxation techniques as part of the therapy, though.

Sports and exercise – such as Nordic walking, jogging, cycling, swimming or hiking – are often recommended for the relief or prevention of depression. Many people find that physical activity improves their mood and gives them more energy. Often, sports and exercise aren't enough on their own but they can be useful as a way of backing up other treatment.

The most suitable activity will depend on the person’s symptoms and situation. For instance, people who have severe depression are often not capable of doing intensive exercise. People with milder depression are more likely to be able to. But just going for regular walks in the fresh air or for bike rides can help if it's difficult to find the motivation to go for a jog or to the gym.

This form of depression affects some people during the darker months of the year. Light therapy, also known as phototherapy, is used in the treatment of seasonal affective disorder (SAD). Treatment with artificial light is an option here if the lack of natural bright daylight is thought to be affecting their mood. Light therapy involves sitting in front of a special bright light (a light therapy device) for about half an hour every morning.

This treatment involves temporarily depriving the patient of sleep. They stay awake for a whole night and only go to sleep the following night. It is thought that sleep deprivation changes the metabolism in the brain, and that this might lead to an improvement in mood. Sleep deprivation therapy only aims to improve the symptoms temporarily. It can be used in addition to other treatments.

Electroconvulsive therapy is usually only considered as a treatment option for people with severe depression if other treatments haven't helped. Electroconvulsive therapy is usually carried out in a hospital, under general anesthetic. Electrodes are placed on the patient’s head and a short burst of electric current is passed through the brain, inducing a seizure. The patient can’t feel anything because the procedure is carried out under general anesthesia.

Transcranial magnetic stimulation is also only considered when other treatments haven’t been effective enough. It involves a coil being placed on the person's head to produce magnetic fields that stimulate the nerve cells in their brain. The aim is to relieve the symptoms by changing the brain’s activity.