Treatments for depression
There are various treatment options for depression. They include psychological treatments, medication and general measures such as relaxation techniques. Different treatment options are often combined.
Depression is one of the most common mental illnesses. People who have depression fall into an emotional black hole for weeks or months, and often can’t see any way out. Treatment can shorten depressive episodes and relieve the symptoms in many cases.
Does depression always have to be treated?
If someone has mild depression, or it has only just started, one option is to wait and see whether the symptoms go away again without treatment. This “watchful waiting” approach doesn’t mean that the symptoms are ignored and nothing is done, though. It is important to stay in touch with the doctor and have regular appointments to discuss how you are feeling and how you can cope with the situation. If the symptoms get worse or last several weeks, further treatment may be needed.
It is also important for people to be able to talk with others. Partners, friends, family, and support centers can offer help and guidance. Sometimes it can help to talk to people who have gone through similar experiences, for example in a self-help group.
Particularly in moderate or severe depression, it is usually very important to get immediate treatment because the symptoms are very distressing and can last quite a while. This is also true if someone has chronic depression or is thinking of harming or killing themselves (committing suicide).
How long does treatment last?
A distinction is made between different phases of treatment, referred to as “acute,” “continuation” and “maintenance” treatment (relapse prevention). Acute treatment usually lasts six to eight weeks. The aim is to
- relieve symptoms enough to enable the person to cope in everyday life again, and
- make the symptoms go away sooner, preventing the depression from further affecting their lives.
The next phase of treatment is called continuation treatment and usually lasts four to nine months. It aims to
- further relieve the symptoms, until they go away, and
- sustain the progress made through treatment.
For people with a high risk of recurring depression, long-term treatment may be considered in order to prevent a relapse. This "relapse prevention" can sometimes last for years – for example, if the symptoms have not disappeared completely despite acute and continuation treatment, or if the patient’s personal circumstances are still difficult.
What are the psychological treatment options?
Psychological treatment usually involves talking about things in depth and behavioral exercises. The kind of psychological treatment that is most commonly used for depression is known as cognitive behavioral therapy (often called “CBT” for short). Statutory health insurance companies in Germany cover the costs of CBT as well as other outpatient treatments including depth psychology and psychoanalysis. They are usually offered by specially trained therapists.
If someone has an acute depressive episode, the doctor will usually offer short-term psychotherapeutic support, as well as treatment with medication. This can be followed by outpatient psychological treatment.
Cognitive behavioral therapy
Cognitive behavioral therapy is a combination of two therapeutic approaches known as cognitive therapy and behavioral therapy. The goal of cognitive behavioral therapy is to become more aware of your own thoughts, attitudes and expectations. This makes it possible to identify false and distressing beliefs, and then change them.
Cognitive therapy is based on the idea that problems are often not only caused by things and situations themselves, but also by the importance that people attach to them. So changing the way people see things can be a decisive step.
Behavioral therapy is based on the assumption that behavior is learned and can also be unlearned. The goal of behavioral therapy is to identify destructive patterns of behavior, work at them and change them.
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.
Psychoanalytic approaches include analytical psychotherapy and methods based on depth psychology. Here it is believed that unresolved, unconscious conflicts can cause depression. The aim is to identify and work your way through previously unknown issues by talking to a therapist. 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.
How do I find a psychotherapist?
For outpatient psychotherapy to work, it is very important to find a psychotherapist who you can trust and feel comfortable with. In Germany, the first three to five psychotherapy sessions in an outpatient setting are considered to be trial sessions, to see whether the chemistry between the client and therapist is right and whether the client is happy with the therapist’s treatment approach. On top of this, the therapist and health insurance company have to check whether psychological treatment is a suitable and promising approach in each individual case. Statutory health insurers cover the costs of the trial sessions, even if the therapy isn’t continued.
If people change to a different therapist they can have trial sessions there too. It sometimes takes a while to find the right therapist. Even if someone has been going to a therapist for a while and then starts to feel like things aren’t quite working out, they can still try out another therapist. The insurer will determine whether a new application for therapy needs to be submitted.
If someone has a bad relationship with their therapist, psychological treatment can sometimes be harmful. For instance, the depression might get worse, or further problems might arise.
Are there other treatment options?
There are a number of other treatments and strategies that are offered to people with depression. Many of these have not been proven to help relieve depression. 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 and yoga. But they are not as effective as other approaches like cognitive behavioral therapy. Therapists sometimes teach relaxation techniques as part of the treatment, though.
Sports and exercise
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, and it has been found to help relieve depression in some people too. But research has also shown that physical activity doesn’t generally have a very big impact in people with depression. And there is little research on whether the benefits of exercise last in the longer term. Sports and exercise can be a useful addition to other treatments, though.
It is also not clear how much people might benefit from different types of sports and exercise. Physical activity might not necessarily be suitable for all types of depression either. For instance, people who have severe depression are often not capable of being physically active. Being advised to do more exercise might make them feel even worse.
Light therapy is used to treat seasonal affective disorder (SAD), a mood disorder that affects some people during the darker winter months. Treatment with artificial light is an option here if the lack of 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.
Sleep deprivation therapy
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 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 anesthetic. Electroconvulsive therapy is usually only considered as a treatment option for people with severe depression who have not responded to other treatments.
What medications can be used?
Psychological treatment sometimes requires a lot of motivation and strength. There is often a long waiting list to see a therapist. Depending on how severe someone’s symptoms are and on their personal circumstances, it can make sense to start taking medication first. Sometimes people are only capable of starting psychological treatment once their symptoms have improved a bit due to medication.
A lot of people who have acute depression are reluctant to start taking medication because, for instance, they’re scared that it could change their personality. Some people are also afraid of becoming dependent on the medication. Others see taking tablets to cope with their problems as a sign of weakness.
There are sometimes good reasons to not take medication (at first). But there is no reason to feel ashamed of taking medication to treat a mental illness. Depression is not something to be taken lightly. It is often a serious illness. Medication can help people recover from depression, and is sometimes even necessary. This is particularly true for people who have severe depression, people who keep on having depressive episodes, and people who are thinking of harming themselves or committing suicide. Inpatient treatment is then sometimes advisable or might be necessary.
Various medications and groups of drugs are classified as antidepressants. Antidepressants can be used alone or in combination with psychological treatment. In acute depression they have to be taken every day for several weeks or months before they can start having a noticeable effect. This is often followed by continuation treatment, which lasts four to nine months. How long people take medication for will depend on factors like their symptoms and their risk of having another depressive episode. Some people take antidepressants for several years to prevent further depressive episodes.
Nerve impulses in the brain have been found to travel more slowly in people who have depression. That probably plays a role in the development of depression. Changes in certain chemical processes (the metabolism) in the brain probably play a role too. Antidepressants affect the brain’s metabolism and influence the transmission of impulses between nerve cells. They can have a mood-lifting effect and increase motivation. But it usually takes several days or weeks for antidepressants to start working. Antidepressants do not lead to dependence, unlike some painkillers, sleeping pills and sedatives.
The possible adverse 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. Different people react slightly differently to medication 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.
The most common and best-known herbal medicines for the treatment of depression are made from St. John’s wort. These products are often used to treat mild depression. Some are used to treat moderate depression too.
Some St. John’s wort products for moderate depression have to be prescribed by a doctor. When considering taking prescription-free St. John’s wort products (or most other herbal medicines, for that matter), it is important to be aware that there are a wide variety of products on the market, with very different doses and ingredients. Many St. John’s wort products only have a small amount of the extract in them. Herbal products can have side effects and interact with other medications too, so it’s important to consult a doctor before taking St. John’s wort.
What can help to start psychological treatment?
Some people find it hard to take the necessary steps to start psychological treatment. If that’s the case, it can help to
- talk to other people who have had similar therapy in the past, for example by contacting a self-help group;
- call a psychotherapy practice anonymously and find out what the therapy they offer typically involves;
- look for a psychotherapy practice in a different area, further away;
- walk past the building that the practice is located in and take a look at it from the outside;
- ask a friend or family member to go to the first appointment with you.
Depression is a disease, not a sign of weakness. Even so, people still don’t like to talk about it. They often don’t admit how bad they're feeling – perhaps because they feel ashamed or guilty, or doubt that anyone can help them.
Yet many people who have started or completed therapy say they feel better and wish they had reached out for help earlier. After all, there are a number of places you can turn to for support and understanding.
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Institute for Quality and Efficiency in Health Care (IQWiG, Germany). Selective serotonin and norepinephrine re-uptake inhibitors (SNRI) in the treatment of depression: Executive summary; commssion A05-20A. June 17, 2009. (IQWiG repors; volume 55).
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National Institute for Health and Care Excellence (NICE). Depression: recognition and management. Clinical Guideline. October 2009.
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