Depression Journal: Treating depression: not one-size-fits-all

by Bianca Nogrady

Depression treatments and how people respond to them vary considerably, which is why it's so important to seek professional help to get the right treatment.

Updated: 26/07/2013

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[Image source: iStockPhoto]

Depression is a complex disease with a variety of causes, symptoms and degrees of severity. As such, it cannot be treated with a one-size-fits-all approach; different types of depression and different individuals will respond very differently to treatment.

If you think you are depressed, or are concerned about someone you know, then the first step is to seek help from a doctor, who can determine whether you have depression, assess the type of depression it may be and develop an appropriate treatment regime.

Treatments for depression include approaches as simple as regular physical activity and meditation, to psychological therapies, such as cognitive behavioural therapy or interpersonal psychotherapy, medication and even electroconvulsive therapy.

Psychological therapy

Psychological therapy is often described as 'talking' therapy. While people with non-melancholic depression , which tends to be brought on by a stressful life event or personality type, generally respond well to psychological therapy, this approach is much less successful in initially treating melancholic depression and not at all effective with psychotic depression if used in isolation.

Cognitive behavioural therapy (CBT) can help you to challenge your negative internal dialogue about yourself and the world around you, showing you how such thinking affects your mood and how to turn that around. It's a structured treatment approach, and has been found to be extremely effective in treating non-melancholic depression. Therapy usually involves a series of sessions with a trained therapist, which may be a GP but is usually a psychologist. It can also be conducted over the internet.

Counselling can help if you are dealing with stressful situations or life events by providing you with an opportunity to work out coping mechanisms or strategies to solve challenges. Counselling generally refers to a less structured approach than other psychological therapies.

Interpersonal psychotherapy examines problems in your relationships and explores your social functioning, helping you to recognise destructive patterns in relationships and how these contribute to your depression. This form of therapy usually involves 12 to 16 sessions with three main phases; an evaluation of your history, an exploration of your problem areas and construction of a treatment 'contract', and an examination and consolidation of progress (what you have learned, and how you might recognise and deal with depressive problems in an ongoing way).

Psychotherapy is generally a more long-term therapy that enables you to build a relationship with a therapist and for you to work together to address the causes and triggers of depression. It's often about examining your past experiences and how that links to your present troubles. (The term psychotherapy is also sometimes used more generically to mean 'psychological therapy'.)

Mindfulness is a strategy that encourages individuals to focus on, live in and accept what is happening in the present moment rather than stressing over what has happened in the past or what might happen in the future. It can also be incorporated into meditation or in other forms of therapy such as cognitive behavioural therapy.

Medication

Whether medication is the best treatment option depends on how severe the person's depression is, their history of illness, their age (medication is not recommended as a first choice for children and adolescents), and their personal preferences.

Melancholic and psychotic depression invariably need to be treated with medication.

Depending on your type of depression and your response to treatment, there are different types of medicines you might be offered. Antidepressants are the main medicine used for depression. People with psychotic depression or bipolar disorder (what used to be called manic depression) may be prescribed antipsychotic medicines or mood stabilisers.

Antidepressants are the most common medications used for most people with depression and there is a wide variety available.

Side effects are an important factor to consider with antidepressants. The side effect profiles vary between different drugs and some are more severe than others. When deciding on a first-line treatment, a doctor might try to match the patient's particular symptoms with the side-effect profile of the drug – for example, if sleeping too much is a problem, you wouldn't choose an antidepressant known to cause drowsiness. However, individuals can respond very differently to medicines and it's not always possible to predict your response or the side effects.

Not all depression will benefit from antidepressants, and they are generally not recommended for use as a first-line option in children or adolescents. Pregnant or breast-feeding women can take antidepressants but it's important to talk to your doctor about your treatment options. Also antidepressants can take two to three weeks to have any effect, and another four to six weeks to have a significant effect.

The main classes of antidepressants are:

Tricyclic antidepressants (TCAs) include nortriptyline; clomipramine; dothiepin; imipramine and amitriptyline. These are an older class of antidepressants and while effective, they have more harmful side effects than some of the newer drugs. Some of their side effects include drowsiness, anxiety, reduced sex drive, dry mouth, weight gain, fatigue and low blood pressure.

Monoamine oxidase inhibitors (MAOIs), which include tranylcypromine and phenelzine. These were the first class of antidepressants ever developed but they are now rarely used because of their side effects. They require a special diet because they can lead to dangerously high blood pressure when taken in combination with certain foods. However, they are still used for some people who are very depressed who do not respond to other medications.

Reversible inhibitors of monoamine oxidase A (RIMAs), such as moclobemide, are a newer version of the older monoamine oxidase inhibitors, so they don't have the same reactions to certain foods. However, they can interact with other medications.

Selective serotonin reuptake inhibitors (SSRIs), which include sertraline; citalopram; escitalopram; paroxetine; fluoxetine and fluvoxamine. These are the most commonly used antidepressants, are generally well tolerated and have less of a sedative effect than some other types.

Serotonin and noradrenalin reuptake inhibitors (SNRIs), which include venlafaxine; desvenlafaxine; duloxetine. These are generally prescribed for more severe depression or if someone doesn't respond to an SSRI, as they have fewer serious side effects than some of the older antidepressants.

Other antidepressants include

- mirtazapine, which may be useful for people with anxiety or problems sleeping because they are slightly sedating, although they are associated with side effects such as weight gain and drowsiness.

- reboxetine which is less likely to cause drowsiness but on the flip side, can lead to trouble sleeping, and can be associated with problems such as sweating, sexual problems, difficulty urinating and increased heart rate.

Sedatives or sleep medicines such as benzodiazepines (eg diazepam) are generally only used very short-term to manage severe anxiety symptoms as they can be addictive and lead to withdrawal symptoms.

Mood stabilisers such as lithium carbonate and sodium valproate are used in bipolar disorder to help reduce the mania or hypomania and stabilise mood swings. Antipsychotic medicines may also be used.

Antidepressants and suicide risk in young people

In Australia, no antidepressant is currently registered for treating depression in people below the age of 18. Antidepressants are still prescribed for young people, usually under the supervision of a specialist psychiatrist.

Concern has been raised that young people are at greater risk of suicidal thoughts and acts when they first start taking antidepressants – especially SSRIs.

While there is ongoing debate about this issue, analysis of a large number of studies shows that there may be a small increase in suicidal thinking or behaviour in children, adolescents and young adults when they first start taking an antidepressant.

However suicidal thoughts and acts are a common symptom of depression, and often someone is at their lowest point when they first start taking an antidepressant. It can also take a few weeks for an antidepressant to work. This makes it difficult to assess whether people who think about suicide when they first start taking an antidepressant do so because of the medicine or the depression.

It is important to get appropriate treatment for young people with depression, because of the high risk of suicide in 15 to 24 year olds. Psychological therapy is the first choice for less severe depression but an antidepressant may be considered for more severe depression or if psychological therapy is not possible. If an antidepressant is prescribed, close monitoring and regular contact with a health professional is recommended, especially in the first four weeks of treatment. For more information go to: Antidepressants and suicide risk

Electroconvulsive therapy

Electroconvulsive therapy (ECT) is a medical treatment that induces controlled seizures by placing small electrodes at specific locations on the head.

While ECT has a dark past, much smaller doses are used today. There is clinical evidence that it can help relieve symptoms of psychotic depression or severe melancholic depression where there is a high risk of suicide or the patient is too ill to eat, drink or take medications. It can also be used to treat life-threatening mania or severe postnatal depression.

Therapy is given under general anaesthetic so the person being treated has no memory of the experience. Some people respond after just a few sessions while others may need as many as 20 to 25 rounds of treatment. Treatments are usually given 2 to 3 times a week.

Memory impairment lasting some weeks after treatment is a common side effect but otherwise the treatment is considered to be relatively safe.

Alternative therapies

Alternative (or complementary) therapies, including herbal medicines, are increasingly popular. But like conventional therapies, what suits one person may not suit another.

It can also be difficult to compare alternative treatments to more conventional therapies (antidepressants and psychological therapies), because less research has been done on alternative therapies. However, this is starting to change.

If you or someone you know is depressed it is best to speak to a health professional, and discuss your situation and your choice of treatment.

Some popular complementary or alternative therapies include:

St John's wort, also called hypericum, is an extract of a weedy plant (Hypericum perforatum) that has been used for so-called 'nervous disorders' for a couple of thousand years. Studies comparing St John's wort with either conventional antidepressants or a placebo (dummy pill) have had mixed results. The quality of the research has also varied. Some studies suggest that if St John's wort is taken at a sufficiently high dose, it can be as effective as pharmaceutical antidepressants for mild, and possibly moderate, depression. However, it is unlikely to benefit people with more severe or melancholic depression. St John's wort interacts with many medicines and you should not take it as well as conventional antidepressants because of the risk of side effects. For more see the NPS website.

Exercise is not an obvious solution to depression but it can help lift someone's mood. Research by the Black Dog Institute has found those suffering clinical depression reported exercise provides more relief than any other alternative therapies or techniques (not including drug and psychotherapies). The study found yoga/meditation, relaxation and massage can also help with the symptoms of depression.

Relaxation therapy (structured exercises for relaxing both the body and the mind) is often suggested in conjunction with CBT. Few well-designed trials have been done, but there have been a few promising results. The same goes for acupuncture, massage therapy and yoga.

Folate (folic acid) is a B-vitamin needed for red blood cell formation, new cell division, and protein metabolism. People who do not respond well to antidepressants are more likely to have low folate levels than others, and though it may not improve depression on its own, folate has been suggested as a supplement in these cases. Folate is found in green leafy vegetables, liver, legumes, and seeds.

Omega-3 (fish oil) is a polyunsaturated fat commonly found in fish and some plants. There is growing evidence to support a link between major depression and low levels of omega-3 in the diet. However, further studies are needed to look at whether or not omega-3 supplements may help prevent or treat depression.

Emergency contacts

Mental health crises don't always happen during office hours. But if you find yourself having to help someone there are people who can help – at any time.

National crisis and counselling contacts available 24/7:

Ambulance/police/fire – 000

Lifeline – 13 1114

Kids Help Line – 1800 55 1800 – Provides counselling and support for young people aged 5-25.

Men's Line Australia – 1300 78 99 78 – Provides counselling and support services for men – especially those involved in the breakdown of relationships.

Suicide Call Back service – 1300 659 467 – Provides free nationwide professional telephone or online counseling.

Other national information and support services contacts available during business hours:

beyondblue information line – 1300 22 4636

SANE Helpline – 1800 18 SANE (1800 18 7263)

Telstra directory assistance – 1223 Call this number for contact details to the nearest public hospital, which can provide information on local services.

State-based resources

NSW

Salvo Crisis Line (suicide prevention) – 02 8736 3295

Salvo Care Line (regional) – 1300 36 36 22

Salvo Youth Line – 02 9360 3000

Victoria

Suicide Line – 1300 651 251

Victorian Government Mental Health Advice Line – 1300 280 737

South Australia

South Australian Assessment and Crisis Intervention Service – 131 465

Western Australia

Mental Health Emergency Response Line – 1300 555 788 for Peel residents 1800 676 822

Rurallink Psychiatric Emergency Team – 1800 552 002 | TTY: 1800 720 101 (rural WA only)

Samaritans Suicide Emergency Line – 1800 198 313

Crisis Care Helpline – 1800 199 008 | TTY: 08 9325 1232

Tasmania

Tasmanian Mental Health Services Helpline – 1800 332 388

Australian Capital Territory

Mental Health Triage Service/Crisis Assessment and Treatment Team – 1800 629 354

Northern Territory

Northern Territory Crisis Assessment Telephone Triage and Liaison – 1800 NTCATT (1800 682 288)

Queensland

General information about depression

Black Dog Institue

beyondblue

This article was reviewed by Associate Professor Vijaya Manicavasagar, the director of psychological services at the Black Dog Institute. The NPS also reviewed the section on medications.

First published: 25/07/2013