• 'depression' means depressive illness. This is very different to the normal, brief periods of feeling down that all people occasionally have in response to circumstances in their day-to-day lives.
• It is a serious and persistent feeling of sadness that can be accompanied by changes in patterns of sleep, appetite, concentration and energy.
• It can also sometimes involve feelings that life is not worth living or even thoughts of suicide.

Why treat depression?

• It is treatable. A number of effective treatments are available for depression and the right one or the right combination of them can usually be found for each person with the illness.
• It does not just quickly go away on its own, and it can be a disabling and potentially serious condition.
• In a small number of cases it can be fatal because of suicide or because of self-neglect if the sufferer is no longer able to look after his/herself as a result of the illness.

Types of treatment

There are many types of treatment for depression and some of the most frequently used include:

• antidepressant tablets.
• 'talking treatments', such as counseling and various types of psychotherapy.
• mood stabilizing medications.
• support with day-to-day matters while ill or recovering.

Treatments that are used less often, but which can be helpful, especially in depression that is severe, of a specific type, or has proved difficult to treat include:

• electroconvulsive therapy (ECT)
• special types of operation (psychosurgery)
• bright light therapy for seasonal affective disorder (SAD).

Lastly, there are potential treatments that are either still experimental, or for which more evidence needs to be found before they can be considered truly effective and safe:

• herbal remedies (eg St John's wort).
• trans-cranial magnetic stimulation (TMS), which involves applying brief magnetic pulses to the brain. This is done with the patient awake and sitting in a chair. A doctor holds an electric coil near to the head that emits repeated short magnetic pulses. The procedure is painless. At the present time, TMS is still under investigation as a treatment for depression, but current evidence suggests that it may be as effective as ECT but safer.

Broadly speaking, treatments for depression can be broken down into two types.

• Firstly, there are those that aim to correct the chemical and biological abnormalities that occur in the illness. These are: antidepressants, mood stabilising medications, ECT and psychosurgery.
• Secondly, there are the psychological ones - 'talking treatments'.
  These involve regular appointments to talk to a professional person who is skilled in a particular type of counselling or psychotherapy to help with depression.

The biological and psychological treatments are certainly not mutually exclusive and are often used in combination.

Neither should one group of treatments or therapies be considered better than the other. The treatment (or combination of treatments) used should be the one most likely to help the person when all the different factors that have led to their illness are taken into account. This is the reason that approaching a professional is so important in deciding how best to cope with and treat depression.

Antidepressant tablets

There are a number of different groups of these and they include:

• tricyclic antidepressants (TCAs), eg amitriptyline, imipramine, lofepramine.
• selective serotonin re-uptake inhibitors (SSRIs), eg fluoxetine, paroxetine, citalopram, escitalopram.
• monoamine oxidase inhibitors (MAOIs), eg phenelzine, tranylcypromine, moclobemide.
• other medications that do not quite fit neatly into these groups, but that have effects similar to one or more of these groups (e.g. venlafaxine, mirtazepine, reboxetine, trazodone hydrochloride).

The oldest antidepressants are the monoamine-oxidase inhibitors (MAOIs) and tricylic antidepressants (TCAs). The TCAs are still in wide use today and remain effective medicines. The MAOIs require a special diet to avoid unpleasant and potentially serious side effects, and they can interact with many other medicines. They are therefore generally used only for people whose depression has not responded to other treatments.

The SSRIs are a much newer group of antidepressants, but they have been widely and successfully used for a number of years.

How do they work?

• All of these medications work by boosting one or more chemicals (called neurotransmitters) in the nervous system. These chemicals may be present in insufficient amounts in depression, resulting in the symptoms of the illness.

Do they work straight away?

• No.
• All antidepressants take a minimum of two weeks (and sometimes up to eight weeks) to start to work, and once they have started working the depression recovers gradually.
• It is vitally important, therefore, that if a person is given antidepressants they should keep taking them regularly, even if they don't seem to make much difference to begin with.

Are they addictive?

• No.
• Some antidepressants can cause mild unpleasant effects if they are stopped very suddenly, but even these can normally be avoided if the medication is tailed off over a short time.

How long should they be taken for?

• A rule of thumb is that antidepressants should be taken for at least six months after the person has recovered. This reduces the risk of the depression coming back again.
• A few people whose depression does return every time they come off antidepressants may need to be on treatment on a long-term basis.

So which is the best type to take?

• There is no evidence to suggest that any one antidepressant or antidepressant group is better than any other in terms of the number of people who will benefit from it. (Generally around two-thirds of people will find that their symptoms improve on any particular medication).
• But one may be a better choice than another on the grounds of its side effects: for instance a person who finds that their sleep is disturbed may benefit from an antidepressant that is also quite sedative. By contrast, someone who is sleeping reasonably and has to be able to listen out for their children would clearly find this effect a problem, and would be better with a non-sedative medication.
• If an antidepressant from one group does not work very well, then there is a good chance that one from another group may work.

Mood stabilisers

• In depression, these drugs are used to boost the effects of antidepressants.
• The best-known mood stabiliser is lithium. It is also the best-proven one, but one drawback is that regular blood tests are needed to check its level. (Lithium is also used in bipolar affective disorder - 'manic depression'.)
• There are some newer mood stabilisers available now that offer alternatives to lithium.

Electroconvulsive therapy

Electroconvulsive therapy (ECT) is a treatment for depression that has been used for many decades, but one that remains controversial.

The facts are:

• it is a very effective treatment for depression - perhaps the single most effective treatment there is.
• it is especially effective for severe depression and depression that has a lot of physical symptoms, such as changes in appetite, sleep and concentration.
• it is as safe as any minor procedure that needs a general anaesthetic.
• it can be lifesaving as it can work more quickly than antidepressant drugs.
• there is no good evidence for any permanent damage to the nervous system.

Like all treatments, ECT does have some side effects. These can include:

• headache.
• forgetfulness around the time of treatment.

Psychological treatments

Psychological treatments for depression are many and varied. They range from the psychological support provided when someone has the regular opportunity to talk about their feelings to a professional such as a GP or psychiatrist, right through to very specialized forms of psychotherapy. They include:

• supportive counseling
• analytic psychotherapy
• cognitive behavioral therapy (CBT)
• cognitive analytic therapy.

There is no evidence to suggest that any one type of therapy is better than any other, and reasonably good evidence that, for the right person, psychotherapy can be as successful as antidepressant medication in milder depression.

It can also be used very successfully in conjunction with antidepressants and may add to the effect of the latter.

Having said this, psychotherapy is not the treatment of choice for everyone (in just the same way antidepressants are not the right treatment for everybody). If it is used, the type of psychotherapy that will best suit any individual has to be carefully considered, highlighting the need for an experienced clinician (e. GP, psychiatrist, nurse, psychologist) to be involved in this decision.

Psychotherapy can take place with:

• individuals
• couples
• families
• groups.

It depends on the specific problems and the best ways of approaching them.

Psychotherapy is carried out by a wide range of health professionals including:

• doctors
• nurses
• psychologists
• occupational therapists
• social workers.

Psychosurgery

Psychosurgery is a form of specialized brain surgery and has been used to treat depressive illness that has failed to respond to long trials of many other treatments. It is performed very infrequently nowadays, and although it does not work for all those who undergo it, it can have beneficial effects.

Social therapies

This term refers to things that can be done to help a person to function as well as possible while they are ill and, crucially in depression, help them to rebuild/strengthen their self-esteem as they recover.

Social therapies can range from planning activities to help someone avoid brooding on problems that may worsen depression, to schemes designed with the help of health and social work staff to help someone build back up to their normal routine.

Depression that is resistant to treatment

Whilst most depressive illnesses will be successfully treated with one of the treatments mentioned, some will not respond as well and may need more specialised combinations of therapies than others. People with these more difficult to treat depressive illnesses should be referred to a psychiatrist.

Where does treatment take place and who arranges it?

• The vast majority of depressive illness is treated by GPs.
• Many GPs have counsellors who can offer supportive sessions.
• Community psychiatric nurses (CPNs) may be available via some GPs or via hospital psychiatry departments.
• GPs will refer patients to psychiatrists and community psychiatric teams (made up typically of psychiatrists, nurses, social workers and psychologists) for further help if needed.
• Most people seeing members of a psychiatric team will have appointments at outpatient clinics or at home.
• Occasionally, if depression is very severe, an admission to hospital may be needed to offer more intensive help.

In summary

• Depression is a readily treatable illness.
• There are many treatments available.
• Even people with the most severe and difficult to treat depressive illnesses can normally be helped.