What are the treatment options?

Treatment of depression involves a number of important components, each of which can be tailored to the needs of the individual and the stage of the condition. The main components are: medication and psychosocial therapies, while complementary therapies may be a useful adjunct for some people.

Medication

The mainstay of this aspect of treatment is antidepressant medication. These are usually prescribed in the treatment of all depression. Other medicines may be used according to individual need and symptoms, especially during episodes of depression.

Finding the right medication can be a matter of trial and error - there is no way to predict which medication will be effective and tolerated (have fewer troublesome side effects) by any one person.
 
If you are prescribed medication you are entitled to know the names of the medicines; what symptoms they are supposed to treat; how long it will be before they take effect; how long you will have to take them for and what their side effects (short and long-term) are.

If you are pregnant or breast-feeding no medication is entirely safe. Before making any decisions about taking medication in pregnancy you should talk with you doctor about the potential benefits and problems associated with each particular type of medication.

Psychosocial treatments

Psychosocial treatments are non-medical treatments which address the person's thinking, behaviour, relationships and environment, including their culture. They may include problem-solving which is a treatment as effective as antidepressants for milder forms of depression.
 
Psychoeducation is a process where the person and their family or whanau have the opportunity to learn about depression and about how to work together to communicate effectively and deal with stress. This is particularly used for moderate or severe depression, where it has been shown to contribute to improved outcome.

Psychological therapies (often referred to as therapy or psychotherapy) involve a trained professional who uses clinically researched techniques, usually talking therapies, to assess and help people understand what has happened to them and to make positive changes in their lives.
 
They may involve the use of specific therapies such as cognitive-behavioural therapy (CBT), which largely focuses on overcoming unhelpful beliefs, or interpersonal therapy (ITP), which focuses on exploring relationships. Both of these have been shown to be slightly more effective in treating mild to moderate depression than antidepressants.

Used with medication, there is often an improved effect. Counselling may include some techniques used in psychological therapies, but it is mainly based on supportive listening, practical problem-solving and information giving.

Complementary therapies

Complementary therapies which enhance the person's life may be used in addition to psychosocial treatments and prescription medicines.

What are the main types of medication?

Antidepressants
Antidepressants are the main medications used to treat depression. Antidepressants are not addictive. Apart from the risk of the depression recurring, there are usually no withdrawal effects, although if stopped suddenly there may be mild symptoms such as feeling shaky.

The first antidepressant was discovered in the 1950s by accident. It was a new treatment of tuberculosis (TB), and it was noticed that people with both TB and depression became less depressed when they took this drug.

Tricyclic antidepressants (TCAs)
The two earliest classes of antidepressants were the tricyclic antidepressant (TCAs) and the monoamine oxidase inhibitors (MAOIs). These medications work by increasing the amounts of noradrenaline and serotonin, two brain chemical messengers which seem to be reduced when a person has depression.

The TCAs also affect other neurotransmitter systems which in some people can cause unwanted side effects such as weight gain, dry mouth, constipation, drowsiness and dizziness. Nevertheless, TCAs can be very effective at treating depression and are still useful for many people.

Each TCA has a different pattern of side effects, so when one is not tolerated there is likely to be another that causes less of that side effect. Because of these side effects, it is necessary to start on a low dose and increase slowly over two weeks or more to reach the effective dose (usually about 150mg per day).

MAOIs/ RIMAs
The MAOIs can interact with some foods and medicines to cause potentially dangerous hypertension and this class of antidepressant is rarely used nowadays. A newer form of this type of antidepressant has been developed which does not have these dangerous side effects. These are the RIMAs (Reversible Inhibitors of Monoamine oxidase A).

SSRIs/new generation antidepressants
Over the past decade the Selective Serotonin Re-uptake Inhibitors (SSRI) antidepressants have become available. SSRIs have their effect specifically on serotonin, and can often be started at the usual effective dose from day one, although the antidepressant effect may take some weeks to occur.

The newest generations of antidepressants target serotonin and noradrenaline neurotransmitter systems with less effect on other neurotransmitter systems, therefore fewer side effects. These new antidepressants may not be subsidised and therefore the patient would have to pay the full cost if deciding on this treatment.

Length of antidepressant treatment
After recovery from a first episode of depression it is recommended that the person stay on medication for six to 12 months, as there is a high risk of symptoms returning if it is stopped sooner than this. With subsequent episodes of depression, the risk of further episodes increases dramatically.

It is now recommended that after a second episode, medication be continued for two to three years. If a person experiences more than two episodes they may need to consider long term medication.

Mood stabilising medications - lithium carbonate 
Lithium carbonate is mainly used to treat bipolar affective disorder (manic depression). However, in depression which fails to improve with antidepressants and psychological treatments, it is sometimes effective when given with antidepressants. Because the difference between beneficial and toxic levels of lithium is small, blood tests must be done to ensure the right dose.

If the blood level of lithium becomes too high, immediate side effects are nausea, diarrhoea, shaking, thirst, and a metallic taste in the mouth. This may progress to the person seeming drunk, with slurred speech and staggering. If these occur it is very important to contact your doctor.

For those on long-term lithium, weight gain (average three to four kilos) can occur. Thyroid and kidney problems are other uncommon delayed effects. Three to six-monthly blood tests are needed to detect these early before problems occur.

If a woman taking lithium plans to get pregnant it is important to reduce and stop the lithium with the help of her doctor. There is a slightly increased risk of birth defects if lithium is taken during the first trimester of pregnancy. Recent studies have shown that the risk of birth defects is lower than previously thought and if necessary lithium can be used, particularly later in pregnancy with appropriate monitoring such as ultrasound scans.

Benzodiazepines for anxiety
Benzodiazepines (the valium type of medications) are used to treat anxiety symptoms which often accompany depression and sleep problems. They increase the activity of a chemical in the brain called GABA (gamma amino butyric acid) which regulates alertness. This lessens anxiety, induces sleepiness, and makes the muscles relax. Benzodiazepines work almost immediately and have few side effects. The main side effect of drowsiness or fatigue may be useful during the acute phase. This usually wears off.

Benzodiazepines are known to be addictive so they are usually only prescribed for two weeks at a time. Stopping them needs to be done gradually. Sudden stopping may produce withdrawal symptoms such as anxiety, insomnia, headaches, nausea and dizziness and, occasionally, may induce epileptic seizures. People with epilepsy must be careful as withdrawal can also make seizures more likely.

Benzodiazepines are not advised in pregnancy, especially near birth, as they can affect the baby and some of them get into breast milk.

Benzodiazepines are safe with almost all other medicines. Because they magnify the effects of alcohol, it should be avoided.

Antipsychotics
Antipsychotic medications are used to treat severe depression where symptoms of psychosis (loss of touch with reality) are present. In this case antidepressants alone are ineffective. Usually, antipsychotics are prescribed first, then antidepressants once the psychotic symptoms begin to decrease.

Antipsychotics work by blocking the effect of a brain chemical messenger called dopamine. Overactivity of dopamine is thought to be part of the problem causing psychotic symptoms. Beneficial effects often have gradual onset over one week or more. In low doses, these medicines are also effective in reducing symptoms of anxiety. This effect is usually immediate.

Antipsychotics are not addictive. The high potency antipsychotics (see below) are generally considered safe during pregnancy.

There is a considerable range of these medicines, all of which share different side effects, though in low doses many people will have no or very few side effects. The traditional (older) antipsychotics are either low-potency or high-potency, according to the size of dose required to give benefit. They mainly cause sedation (tiredness), dry mouth, constipation, dizziness, and various sexual function problems. 

The high potency drugs mainly cause muscle side effects such as shaking, muscle spasm, and restlessness. These muscle side effects can be blocked by the use of side effect medications.

More recently the atypical (or new) antipsychotic drugs have become available - they cause fewer side effects but, because they are much more expensive, their use has until recently been limited to people with illnesses such as schizophrenia who must take them long-term. However, they are also prescribed where people have severe side effects with the traditional antipsychotic drugs.

Medicine interactions

Most psychiatric medicines tend to react with each other when taken in combination. Their sedative effect in particular may make you feel sleepy. Your doctor will, where possible, limit the number of medications prescribed.

The effects of alcohol and many illegal drugs will also be heightened, so they should be avoided. It is important the doctor knows all the medications (including any herbal medicines) you are taking, as some taken together can be dangerous.

Psychosocial treatments

Problem solving
This therapy involves teaching the person to use their own skills and resources to cope with problems and worries. It is as effective as antidepressants in milder forms of depression, and is usually given over six to eight weekly sessions. It has the advantage of requiring little training, and is readily able to be used in a general practice setting (which is where most people with depression are seen).

The steps in problem solving are:

• identify and clarify the problem
• set clear achievable goals
• brainstorm solutions
• select the preferred option
• evaluate progress in putting the chosen option into action.

Psychoeducation
Psychoeducation is a process where a health professional works with people with severe forms of depression, and with their families and whanau, to provide information about the illness, its treatment, and how to support the steps to recovery.

Central to this approach is that family or whanau, along with the person with depression, are critical members of the treatment team. Together they identify ways of dealing with symptoms, difficult to understand behaviour and stress. The early signs which indicate a possible relapse are identified and a plan of early response developed. There is also attention to the kinds of support that everyone needs, and how to get this.

Psychological therapies and counselling
Psychological therapies have been found to be effective in the treatment of depression. Often they will be recommended in addition to medication, or as an alternative to medication in the case of less severe depression or where a person does not choose medication. Therapy may be held on a one-to-one basis, include partners or families and whanau for some sessions, or be held in a group.

The focus of psychotherapy or counselling in treatment of depression is on education and support for the person to understand what is happening to them, to learn coping strategies, and to pursue a path of recovery. Through these processes people can regain the confidence and belief in themselves that is critical to recovery. Specific therapeutic approaches can then be used within this supportive setting.

Two such approaches, cognitive-behavioural therapy (CBT) and interpersonal psychotherapy (IPT) have been clinically researched and found to be effective in the treatment of depression.

Treatment for severe depression may be available free of charge at a community mental health service. At a number of community service agencies, charges are based on your ability to pay. Private therapists' fees may range from $60 to $200 per session but many also have a sliding scale of fees.

Cognitive-behavioural therapy (CBT)
The basic theory of cognitive-behavioural therapy is that our thoughts and beliefs influence our feelings and behaviour. The focus of treatment is on identifying specific negative thoughts and actions, and developing ways to change these. The cognitive part of the therapy helps the person to identify and challenge these thoughts. They may, for example, say that they are always sad.
 
With encouragement from the therapist and careful exploration of their thoughts, they come to see that in reality it is only certain situations which make them sad. At other times they may experience some pleasure. The therapist may then encourage them into developing behavioural strategies to help lift their mood, such as going for a short walk or doing some small thing which they may once have enjoyed.
 
These activities are often in the form of small homework tasks. CBT also incorporates other techniques useful in helping depression, such as teaching the person relaxation skills, stress management and problem solving (as outlined above).

CBT alone is effective in all but severe depression, but people with severe depression may also benefit from this treatment as they recover. Unlike antidepressants, which are only effective as long as they are taken, the benefits of CBT may protect people against future episodes of depression. Treatment is usually time limited and may include eight to 12 sessions over three to six months.

Interpersonal therapy (IPT)
This therapy is based on the theory that depression may be triggered by difficulties in the person's relationships with others. These difficulties are often increased when a person is depressed, so IPT aims to identify the interpersonal difficulties very clearly.

Typical problems can include conflict in relationships, changes in roles and relationships (eg, a woman giving up work and becoming a mother after the birth of a child), grief after loss of a relationship, or social isolation. The therapist spends time working with the person to develop ways to overcome their difficulties, and to find ways of relating to others which work better for the person. People may be taught specific techniques such as effective communication skills, assertiveness, and problem-solving.

IPT is a time-limited, focused treatment which may include up to 16 sessions. Research studies have found it to be effective in the treatment of depression.

Complementary therapies

The term complementary therapy is generally used to indicate therapies and treatments which differ from conventional Western medicine and which may be used to complement, support or sometimes replace it. There is an ever-growing awareness that it is vital to treat the whole person and assist them to find ways to address the causes of mental health problems rather than merely alleviating the symptoms. This is often referred to as an holistic approach.

Complementary therapies often support an holistic approach and are seen as a way to address physical, nutritional, environmental, emotional, social, spiritual and lifestyle needs.
 
Many cultures have their own treatment and care practices which many people find helpful and which can often provide additional benefits to health and wellbeing.  Rongoa Maori is the indigenous health and healing practice of New Zealand.  Tohunga Puna Ora is a traditional healing practitioner. Traditional healing for many Pacific Island people involves massage, herbal remedies and spiritual healers.

In general, meditation, hypnotherapy, yoga, exercise, relaxation, massage, mirimiri and aromatherapy have all been shown to have some effect in alleviating mental distress. Complementary therapies can include using a number of herbal and other medicinal preparations to treat particular conditions. It is recommended that care is taken as prescription medicines, herbal and medicinal preparations can interact with each other.
 
When considering taking any supplement, herbal or medicinal preparation it is recommended that you consult a doctor to make sure it is safe and will not harm your health.
 
Women who may be pregnant or breastfeeding are advised to take extra care and to consult a doctor about any supplements, herbal or medicinal preparations they are considering using, to make sure they are safe and that they will not harm their own or their baby's health.

See also: Depression; Causes of depression; Living with depression

Support groups

See the support organisations (which include helplines) under Further information and support below.

Original material provided by the Mental Health Foundation of New Zealand, 2002. Edited by everybody, May 2005.