Treatments for depression

Introduction

A large number of different treatments are available for depression. New treatments (particularly medications) appear regularly. Continuing research means that the evidence for how well a treatment works is always changing too. This Fact Sheet provides only a brief summary of treatments for depression.

At the Institute we believe there are different types of depression, and that treatments should be selected according to the particular type of depression a person has.

Those types of depression that are more biological in their origins (melancholic depression and psychotic melancholia) are more likely to need physical treatments and less likely to be resolved with psychological treatments alone. Non‐melancholic depression appears similarly responsive to physical treatments (antidepressants) and psychological treatments.

Physical treatments

The main physical treatments for depression comprise drug treatments and Electroconvulsive therapy (ECT). A third physical treatment with, as yet, narrow application is Transcranial Magnetic Stimulation (TMS).

1.
Drug Treatments
There are three groups of drugs most likely to be used for depression:

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Antidepressants
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Tranquillisers
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Anti‐manic drugs or mood stabilisers.

Antidepressants
There are a large number of antidepressants − they have a role in many types of depression and vary in their effectiveness across the more biological depressive conditions.

Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclics (TCAs) and Irreversible Monoamine Oxidase Inhibitors (MAOIs) are three common classes of antidepressants,

with the latter two having ‘broader’ actions. They each work in different ways and have different applications.

At the Institute we believe that they are not, however, equally effective− and that it is necessary to find the right antidepressant for each person.

If the first antidepressant does not work, it is sensible to move to a different kind of antidepressant. For the biological depressive disorders, more broad action antidepressants are usually more effective.

A well‐informed health provider should be able to use their assessment of the type of depression, its likely causes and their understanding of the person to identify the medication most likely to benefit their condition.

Finally, being able to decide not to use medication is important, too.

Tranquillisers
These medications are usually called 'minor' or 'major' tranquillisers.

Minor tranquillisers (typically benzodiazepines) are not helpful in depression; they are addictive and can make the depression worse. Major tranquillisers are very useful in people with a psychotic or melancholic depression where the person is not being helpd by other medications.

Mood stabilisers
These drugs are of great importance in bipolar disorder. Their use in treating mania makes them 'anti‐manic', while their ability to reduce the severity and frequency of mood swings makes them ‘mood stabilisers’. Lithium, valproate and carbamazepine are the most common.

It is important to remember that the anti−depressants and mood stabilisers are often necessary both to treat the depression that is occurring now, and to make a relapse in the future less likely. So, people sometimes need to continue taking medication for some time after they are better.


2.

Electroconvulsive Therapy (ECT)

Because of its controversial past many people feel the need to think carefully before having ECT or allowing it to be given to elatives.

Clinicians at the Institute firmly believe that ECT has a small but important role in treatment, particularly in cases of:

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Psychotic depression
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Severe melancholic depression where there is a high risk of suicide or the patient is too ill to eat, drink or take medications
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Life‐threatening mania

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Severe post‐natal depression.

While there are some short‐term side‐effects, ECT is a relatively safe and, because an anaesthetic is used, not too unpleasant.

3.
Transcranial Magnetic Stimulation (TMS)

A possible alternative to ECT is transcranial magnetic stimulation (TMS). TMS is a procedure used by neurologists, both as a treatment and as diagnostic strategy. A coil is held next to the patient's head and a magnetic field created to stimulate relevant parts of the brain. Unlike ECT, there is no need for a general anaesthetic nor is a convulsion induced.

In our view, the evidence in favour of this treatment is not yet in, but it is a major area of research at the Institute and elsewhere. If TMS is shown to be as effective as ECT this would be a distinct advance in the treatment of many mood disorders. No clear evidence about its utility is expected for a number of years.

Psychological treatments
There are a wide range of psychological treatments for depression. Some of the main ones are:

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Cognitive Behaviour Therapy (CBT)

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Interpersonal Therapy (IPT)

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Psychotherapies
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Counselling
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Narrative Therapy
CBT, IPT, psychotherapy and counselling all provide either an alternative to medication or work alongside medication. As always, a thorough assessment of the person is needed in order to decide on the best set of approaches.

Cognitive Behaviour Therapy (CBT)

People suffering from depression ‐ particularly 'non‐melancholic depression' ‐ will often have an ongoing negative view about themselves and the world around them. This negative way of thinking is often not confined to depression, but is an ongoing part of how the person thinks about life. Many or all of their experiences are distorted through a negative filter and their thinking patterns become so entrenched tha they don't even notice the errors of judgement caused by thinking irrationally.

CBT aims to show people how their thinking affects their mood and to teach them to think in a less negative way about life and hemselves. It is based on the understanding that thinking negatively is a habit, and, like any other bad habit, it can be broken.
CBT is conducted by trained therapists either in one‐on‐one therapy sessions or in small groups. People are trained to look logically at the evidence for their negative thoughts, and to adjust the way they view the world around them. The therapist will provide 'homework' for between sessions. Between 6−10 sessions can be required but the number will vary from person to person.

CBT can be very beneficial for some individuals who have depression but there will be others for whom it is irrelevant.

Interpersonal Therapy (IPT)

The causes of depression, or our vulnerabilities to developing depression, can often be traced to aspects of social functioning (work, relationships, social roles) and personality.

Therefore, the underlying assumption with interpersonal therapy is that depression and interpersonal problems are interrelated.

The goal of interpersonal therapy is to help the person understand how these factors are operating in the person's current lifesituation to lead them to become depressed and put them at risk to future depression.

The therapy occurs in three main phases:

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an evaluation of the patient's history
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an exploration of the patient's interpersonal problem area and a contract for treatment
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recognition and consolidation by the patient of what has been learnt and developing ways of identifying and countering depressie symptoms in the future.

Usually 12−16 sessions of IPT will be required.

Psychotherapies
Psychotherapy is an extended treatment (months to years) in which a relationship is built up between the therapist and the patient. The relationship is then used to explore aspects of the person's past in great depth and to show how these have led to the curent depression. Understanding this link between past and present − insight − is thought to resolve the depression and make the person less vulnerable to becoming depressed again.

Counselling
Counselling encompasses a broad set of approaches and goals that are essentially aimed at helping an individual with problem soving −solving long‐standing problems in the family or at work; or solving sudden major problems (crisis counselling).

Narrative Therapy
Narrative Therapy is a form of counselling based on understanding the 'stories' that people use to describe their lives. The therapist listens to how people describe their problems as stories and helps the person to consider how the stories may retrict them from overcoming their present difficulties. It sees problems as being separate from people and assists the individual to recognise the range of skills, beliefs and abilities that they already have (but may not recognise) and that they can apply to the problems in their lives.

Narrative Therapy differs from many therapies in that it puts a major emphasis on identifying people's strengths, particularly as they have mastered situations in the past, and therefore seeks to build on their resilience rather than focus on their negatives.

Self‐help & alternative therapies
There are a wide range of self‐help measures and alternate therapies which can be useful for some types of depression, either alone or in conjunction with physical treatments (such as antidepressants) or psychological treatments.

However, the more biological types of depression (melancholic and psychotic depression) are very unlikely to respond to self‐help and alternative therapies alone although these can be valuable adjuncts to physical treatments.

Among the self‐help and alternative therapies that may be useful for depression are the following:

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Meditation
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Relaxation
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Good nutrition
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Alcohol and drug avoidance
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Exercise
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Bibliotherapy
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Omega‐3
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St John's Wort
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Light therapy
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Yoga
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Aromatherapy
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Massage therapy
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Acupuncture.

Key points to remember
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Different types of depression respond best to different sorts of treatment.

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A thorough and thoughtful assessment needs to be carried out before any treatment is prescribed.
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Treatments for depression include physical therapies (e.g. medications) and psychological therapies.

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Depression can sometimes go away of its own accord but, if left untreated, may last for many months. Allow yourself to seek help.

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Depending on the nature of your depression, self‐help and alternative therapies can also be helpful, either alone or in conjunction with physical and psychological treatments.

Where to get more information
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See our Online Depression Education Program (DepEd) to learn more about treatments for depression www.blackdoginstitute.org.au
Fact Sheet
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www.depressionet.com.au
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Dealing with Depression: A Common Sense Guide to Mood Disorders, by Gordon Parker, published by Allen & Unwin, 2004.

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Tanner, S. and Ball, J (1999) Beating the Blues: A Self‐help Approach to Overcoming Depression, Tower Books, Sydney.

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Better Health Channel – information on complementary medicine www.betterhealth.vic.gov.au
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MoodGYM program − an online cognitive behaviour therapy program provided free of charge by the Centre for Mental Health Research at the Australin National University www.moodgym.anu.edu.au
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Goodtherapy − Australian online mental health resource. Website includes a Directory of
Practitioners, Public Forum, Calendar of Workshops and Book Shop www.goodtherapy.com.au

sOURCE:'www.blackdoginstitute.org.au