Treatments for depression

Photo of a female patient and a psychotherapist (AdamGregor / iStockphoto / Thinkstock) 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. During a depressive episode, people feel like they're in a deep, dark pit for weeks or months, and often can't see any way out. In chronic depression, the symptoms last for years. Treatment can shorten depressive episodes and relieve the symptoms.

Does depression always need 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're 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 and family play a very important 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.

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. 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.

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 haven't disappeared completely despite acute and continuation treatment, or if the patient’s personal circumstances are still very difficult. People who have chronic depression often take medication for many years too.

What are the psychological treatment options?

Psychological treatment usually involves talking about things in depth and doing 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 systemic therapy. They are often offered by specially trained therapists.

If someone is going through an acute depressive episode, the doctor will usually recommend short-term psychological support, sometimes together with medication. Then you can apply for a full course of outpatient psychological treatment.

Cognitive behavioral therapy

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.

Cognitive behavioral therapy combines two treatment approaches:

  • Cognitive therapy: Cognitive therapy is based on the idea that problems are often caused less by things and situations themselves, but rather by the importance that people attach to them. So changing the way people see things can be an important step.
  • Behavioral therapy: 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, then work at them and change them.

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.

Psychoanalytic approaches

Psychoanalytic approaches include analytical psychotherapy and methods based on depth psychology. They are based on the belief that unresolved, unconscious conflicts can cause depression. The aim is to identify and work 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.

Systemic therapy

Systemic therapy approaches place 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 reduce the symptoms of depression.

How do I find a psychotherapist?

Family doctors often recommend a particular psychotherapist. But you can also contact the private practice of a psychotherapist or psychiatrist. In Germany, the association of statutory health insurance physicians (Kassenärztliche Vereinigung) can help you get an appointment.

You can have an initial appointment in a psychotherapy practice without being referred by a doctor or sending an application to your health insurer. In urgent cases, you can also turn to psychiatric practices with an emergency service, outpatient psychotherapy clinics in hospitals, as well as psychiatric or psychosomatic hospitals.

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.

When are the different medications considered?

Medication doesn't help in mild depression. There may be other good reasons to not take medication (at first). For instance, 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 the symptoms may be so bad that it makes sense to use medication. This is particularly true for people who have severe and regularly recurring depression – especially if they are thinking of harming themselves or committing suicide. Sometimes people are only capable of starting psychological treatment once their symptoms have improved a bit due to medication.

Antidepressants

Various medications and groups of drugs are classified as antidepressants. They can have a mood-lifting effect and increase motivation. Antidepressants are often used in combination with psychological treatment. 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 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 years to prevent further depressive episodes.

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.

Different people react a bit 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.

Herbal products

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.

Research summaries

Are there other treatment options?

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.

Relaxation techniques and yoga

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

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

Light therapy, also known as phototherapy, is used in the treatment of seasonal affective disorder (SAD). This form of depression affects some people during the darker months of the year. 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.

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

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. Electroconvulsive therapy is usually only considered as a treatment option for people with severe depression if other treatments haven't helped.

Research summaries