Depression 

Treating depression 

What is good depression care?

In most cases, your GP will help manage your depression. However, for some patients, particularly those with more severe depression or where treatment is not successful, more specialised care, including a stay in hospital, may be needed. The National Institute for Health and Clinical Excellence (NICE) recommends that:

  • Depression should be recognised in both GP practices and hospital, with particular attention given to high-risk groups, such as patients with a history of depression, long-term illness, head injury or disability, or other mental health problems such as dementia.
  • Patients' preferences, and the experience and outcome of previous treatments, should be considered when deciding on a treatment.
  • Patients should have access to information about treatments and self-help and support groups.
  • Patients should give meaningful and properly informed consent to treatment, in particular if they have more severe depression or are subject to the Mental Health Act. 
  • There should be a clear agreement about all patient care, and this should be shared with the patient and their families and carers.

The New Horizons programme aims to improve adult mental health services in England. It supports the development of higher quality, more personalised services and sets out NHS plans for achieving better mental health and wellbeing for the whole population.

Want to know more?

Treatment overview hide

Treatment for depression usually involves a combination of drugs, talking therapies and self help. Treatment is based on the type of depression you have.

Mild depression

If you are diagnosed with mild depression, it may improve by itself. In this case, you will have another assessment after two weeks to monitor your progress. This is known as watchful waiting.

Antidepressants are not usually recommended as a first treatment for mild depression. 

Exercise seems to help some people. While your progress is being monitored, your GP may refer you to a qualified fitness trainer for an exercise scheme.

Talking through your feelings may also be helpful. You may wish to talk to a friend or relative, or your GP may suggest a local self-help group.

Your GP may recommend self-help books and computerised cognitive behavioural therapy (CBT). See below for further details.

Chronic mild depression (which is present for two years or more) is called dysthymia. This is more common in people over 55 years old and can be difficult to treat. If you are diagnosed with dysthymia, your GP may suggest that you start a course of antidepressants.

Moderate depression

If you have mild depression that is not improving, or you have moderate depression, your GP may recommend a talking treatment or prescribe an antidepressant (see below for further details).

Severe depression

If you have severe depression, your GP may recommend that you take an antidepressant, together with talking therapy. A combination of an antidepressant and cognitive behavioural therapy (CBT) usually works better than having just one of these treatments.

You may be referred to a mental health team. These teams are usually made up of psychologists, psychiatrists, specialist nurses and occupational therapists. They often provide intensive specialist talking treatments, such as psychotherapy.

Want to know more?

back to top

Talking treatments show

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) helps you understand your current thoughts and behaviours and how they affect you. While CBT recognises that events in your past may have shaped you, it concentrates mostly on how you can change the way you think, feel and behave in the present. It teaches you to behave in ways that challenge negative thoughts, for example being active to challenge feelings of hopelessness.

You normally have a fixed number of sessions, usually six to eight sessions over 10-12 weeks. In some cases, you may be offered group CBT.

Computerised cognitive behavioural therapy (CCBT)

Computerised CBT is a form of CBT that works through a computer screen, rather than face to face with a therapist. It is delivered in a series of weekly sessions and should be supported by a healthcare professional. Ask your GP about what is available.

Interpersonal therapy (IPT)

IPT focuses on your relationships with other people and on problems, such as difficulties with communication or coping with bereavement. There is some evidence that IPT can be as effective as medication or CBT, but more research is needed.

Counselling

Counselling is a form of therapy that helps you think about the problems you are experiencing in your life to find new ways of dealing with them. Counsellors support you in finding solutions to problems, but do not tell you what to do.

Want to know more?

back to top

Antidepressants show

Antidepressants are medicines that treat the symptoms of depression. There are almost 30 different kinds of antidepressant, which fall into four main categories.

Most people with moderate or severe depression benefit from antidepressants, but not everybody does. Some people respond to one antidepressant, but not to another, and people with depression may need to try two or more treatments before they find one that works for them.

The different types of antidepressant work about as well as each other. However, side effects vary between different treatments and people.

Normally, you will take only one type of antidepressant at a time, but specialists in mental health (including some GPs) may add other treatments to antidepressants.

Your GP or specialist nurse should see you every one to two weeks when you start taking antidepressants. You should continue taking the antidepressants for at least four weeks (six weeks if you are elderly) to see how well they are working. If your antidepressants are working, treatment should be continued at the same dose for at least four to six months (12 months if you are elderly) after your symptoms have eased. If you have a history of depression, you should continue to receive antidepressants for up to five years or longer.

Antidepressants are not addictive, but withdrawal symptoms are quite common if you stop taking them suddenly or you miss a dose.

Selective serotonin reuptake inhibitors (SSRIs)

If your GP thinks you would benefit from taking an antidepressant, you will usually be prescribed a selective serotonin reuptake inhibitor (SSRI). These help increase the level of a natural chemical in your brain called serotonin, which is thought to be a ‘good mood’ chemical.

SSRIs are as effective as older antidepressants (TCAs or tricyclic antidepressants) and have fewer side effects. For example, they are less likely to cause drowsiness and dizziness. They can, however, cause nausea and headaches, as well as dry mouth and problems with sexual functioning. However, these usually improve over time.

Examples of this type of antidepressant include sertraline, paroxetine, fluoxetine, citalopram, escitalopram and fluvoxamine.

Some SSRIs should not be prescribed for children under the age of 18. Research shows that the risk of self-harm and suicidal behaviour may increase if they are used to treat depression in people in this age range. Fluoxetine is the only SSRI that may be prescribed for under-18s, but only when specialist advice has been given.

Tricyclic antidepressants (TCAs)

This group of antidepressants, which includes dothiepin, imipramine and amitriptyline, is used to treat moderate to severe depression.

TCAs work by raising the levels of the chemicals serotonin and noradrenaline in your brain. These both help lift your mood. Do not smoke cannabis if you are taking TCAs because it can cause your heart to beat rapidly.

Side effects of TCAs, which vary from person to person, may include dry mouth, blurred vision, constipation, problems passing urine, sweating, light-headedness and excessive drowsiness. The side effects should ease after 7 to 10 days, as your body gets used to the medication.

Monoamine oxidase inhibitors (MAOIs)

MAOIs, such as phenelzine sulphate, are sometimes used to treat depression.

If you are taking MAOIs, you will have to avoid food that contains the chemical tyramine. This is normally found in foods that have been fermented or cured to increase their flavour, such as cheese, pickled meat or fish. Your GP will give you a list of food and drink to avoid.

Do not drink any alcohol or fermented liquids (even if they are alcohol free). Do not smoke cannabis if you are taking MAOIs because it may affect the way these medicines work, and it is not clear what effect this may have on you.

As MAOIs have the potential to interact with a wide range of medication, do not take any other drug or medicine, including over-the-counter medication, without checking with your GP first.

Common side effects of MAOIs include blurred vision, dizziness, drowsiness, increased appetite, nausea, restlessness, shaking or trembling, and difficulty sleeping.

There have been a number of cases where MAOIs have caused a dangerous rise in blood pressure.

If you experience a stiff neck, severe headache, chest pains, vomiting or nausea, or a fast heartbeat, seek emergency help immediately by dialling 999 and asking for an ambulance.

The dietary restrictions and potential for side effects mean that MAOIs are used very rarely, and are normally only prescribed when other treatments have not been effective.

Other antidepressants

New antidepressants, such as venlafaxine, nefazodone and mirtazapine, work in a slightly different way from SSRIs and TCAs. These drugs are known as SNRIs (Serotonin-norepinephrine reuptake inhibitors). Like TCAs, these antidepressants change the levels of serotonin and noradrenaline in your brain. Studies have shown that an SNRI such as venlafaxine can be more effective than an SSRI, though it is not routinely prescribed as it can lead to a rise in blood pressure.

Want to know more?

back to top

Other treatments  show

St John's wort

St John's wort is a herbal treatment that some people take for depression. Though there is some evidence that it may be of benefit in treating mild or moderate depression, its use is not recommended. This is because the quantity of its active ingredients varies among individual brands and batches, so it is unclear what sort of effect it could have on you. Side effects of St John’s wort include nausea, dizziness and a dry mouth.

Taking St John's wort with other medications, such as anticonvulsants, anticoagulants, antidepressants and the contraceptive pill, can also cause serious problems.

You should not use St John's wort if you are pregnant or breastfeeding as there is not enough evidence that its use is safe in these situations.

Electroconvulsive therapy (ECT)

Sometimes, other treatments, such as specialist medicines or electroconvulsive therapy (ECT), may be advised if you have severe depression. Electroconvulsive therapy (ECT) works for severe depression, but it is only used when antidepressants and other treatments have not worked.

If ECT is recommended for you, you will first be given an anaesthetic and medication to relax your muscles. You will then receive an electrical 'shock' to your brain through electrodes placed on your head. You may be given a series of ECT sessions. It is usually given twice a week for 3-6 weeks. For most people, the treatment works well in relieving severe depression, but the effect may not be permanent. Some people may experience unpleasant side effects, including short-term headaches, memory problems, nausea and muscle aches.

Lithium

If you have tried several different antidepressants and have experienced no improvement, your doctor may offer you a type of medication called lithium, in addition to your current treatment.

There are two types of lithium: lithium carbonate and lithium citrate. Both are usually effective, but if you are taking one that is effective, it is best not to change. In order for lithium to work, you have to have a certain level of it in your blood. If this level becomes too high, the lithium can become toxic. Therefore, you will need blood tests every three months to check your lithium levels. Avoid eating a low-salt diet because this can also cause the lithium to become toxic. Ask your GP for advice about your diet.

Before you start taking lithium, you should have an electrocardiogram (ECG) to check your heart.

back to top

Withdrawal symptoms show

Antidepressants are not addictive in the same way that illegal drugs are, but when you stop taking them you may have some withdrawal symptoms, including:

  • upset stomach
  • flu-like symptoms
  • anxiety
  • dizziness
  • vivid dreams at night
  • sensations in the body that feel like electric shocks

In most cases, these effects are mild. However, for a small number of people, they can be quite severe. They seem to be most likely to occur with paroxetine (Seroxat) and venlafaxine (Effexor).

back to top

Last reviewed: 09/09/2010

Next review due: 09/09/2012

Ratings

How helpful is this page?

Average rating

Based on 25 ratings

All ratings

Add your rating

The short dude said on 02 February 2011

Thank you Cedders :

Cedders said on 18 October 2010....
..."I know SSRIs cause less dry mouth and "anticholinergic" effects, but I don't agree they cause less dizziness: the withdrawal effects from paroxetine meant it continually felt like the pavement was spinning around me."


I was diagnosed with labyrinthitis many years ago, but it went away. I have lived with the fear of it returning, but it may have been withdrawal effects from paroxetine.

Thank you.

Peace.

Report this content as offensive or unsuitable

Liz905 said on 16 January 2011

I suffered from depression for 3 years. I went to see my GP and was offered antidepressants but I dind't want to take them as I am not a fan of taking medication and I prefered the idea of talking therapies. I was bluntly told that talking therapies in my area were reserved for serious cases and that any way, there was a very long waiting list.
I was very discouraged after this and waited for things to improve but they didn't. So eventually I decided to go and see a psychiatrist privately. It was expensive but definitely worth it. We had a long discussion about my life and how I was. I felt he took everything into consideration and then said to me that I may benefit from psychoanalytic psychotherapy. I got refered to another psychiatrist that was able to offer that and I have been having weekly sessions for nearly 2 years now. It is a long term type of treatment and I was warned not to expect results immediately but gradually, I have noticed great improvements in my life. The depression has gone, but also I interact far better with people, I am much more confident, not so anxious. My self esteem has definitely increased and I just feel deeply at peace with myself. I feel like the therapy treated the root cause of my problems.
If you had asked me at the beginning why I was depressed, I would have said there was no reason. But now I understand that there were. Small things, but that gradually built up inside me and left me feeling terrible. Now, I am working through these things and becoming much more aware of how I am and how things influence me.
Financially and emotionally, it has been a huge investment. But I think that the benefits I have got out of it are worth every penny.
It's a real shame that therapy can be hard to access on the NHS but I would really urge people that think they would benefit from it to fight for it.
And don't' give up. It is possible to get better. It takes time, but you can rebuild your life.

Report this content as offensive or unsuitable

nigeles said on 13 December 2010

It has now been a year. I have lost the psychosis, hallucinations and nightmares but still have chronic insomnia (despite 10mg diazepam and 4 welldorm)
I still get panic attacks and am generally depresses despite 200mg Lyrica per day. Lyrica chemically castrates men which is an effect I do not want. Still no prescribed stimulant to overcome depression hurdle and do something. Still 3 month between psych evals.

Report this content as offensive or unsuitable

nigeles said on 01 December 2010

In my experience psychoactive medication is for life. I would expect symptoms to come back or even get worse if medicines that were correcting a permanent brain chemistry problem are withdrawn.

Report this content as offensive or unsuitable

nigeles said on 01 December 2010

After 12 months treatment at 3 month intervals (much too long) I have no faith in CBT and am recovering with medication that corrects my brain chemistry. Only problem is that neither doctors nor psychiatrists take into account need for a stimulant to be added to the mix as is the norm in attention deficit disorder. I find this to be essential as I need both the nergy and mood to do something to avoid returning to hibernation mode.

Report this content as offensive or unsuitable

Midlandsboy said on 22 November 2010

You don't want to hear about me too much, tried anti-depressants several times with no long-term benefit. I thought stress/depression/anxiety was for wimps when I was in my twenties. I will be 40 next year and now realise I was wrong. I have the best wife in the world and two wonderful children. On the outside I am a confident bloke who has done OK for himself. I am a sales manager and have been in work all of my life. On the inside I have to deal with at times the most terrible angst that I do not now how to deal with or how to treat long-term. When things get bad for me I go to my Grandpa's grave and shut myself off from the world. My worry is that one day I lose my job or worse still my wife. Travelsweety I agree with your comments about diet, I have thought that for along time. I think we all know that exercise, good diet and things like that help us but better education for our children and more information on where to get help for us has got to come. I think the answer for me is change my working life. I have enjoyed my work up to now but have lately become bored and do not want the same things. I would love to be involved in work that actually meant something, the only problem is that a big change in career is difficult to orchestrate. No qualifications or experience in the new direction makes it difficult and the disruption in your career has a massive effect on your earnings. If anyone knows how I can do this and not disrupt my family life too much then I am all ears. A big hug a lots of love to anyone with similar thoughts. Even though I find it difficult myself at times, please remember that you are normal, there are lots of people who feel the way you do maybe your boss, maybe your neighbour but you are not the only one. Thing will get better but don’t give up and surround yourself with the things you love and enjoy doing, lots of love

Report this content as offensive or unsuitable

Cedders said on 18 October 2010

I have long-term low-grade depression (a diagnosis of dysthymia) and still haven't found much in the way of treatment that helps, although have come to accept it more. The most useful thing for me was being referred to clinical psychologists for monthly "systemic consultation". I can see intensive behavioural activation might be useful too: anything which helps making difficult changes in life as well as in attitude. Certain types of therapy (analytical and CAT) actually made me feel worse because they seemed to offer no hope of progress.

I've tried half-a-dozen different types of antidepressant, but none really helped. Some made me sleep a lot more although reboxetine (not listed above, a norepinephrine reuptake inhibitor) was a bit of a stimulant and might have helped with the lethargy a bit. I know SSRIs cause less dry mouth and "anticholinergic" effects, but I don't agree they cause less dizziness: the withdrawal effects from paroxetine meant it continually felt like the pavement was spinning around me.

Report this content as offensive or unsuitable

nigeles said on 19 May 2010

I was treated with fluoxetine. Many people get side effects from taking it and from stopping. I did not suffer ill effects until I had been taking it for 6 weeks. The depression then suddenly worsened and the medication was doubled twice in ten days. At the end of that time I was unable to leave the house. I slowly reduced the dosage to zero but still had severe withdrawal including dizziness, nausea, fatigue, numbness and lethargy.
Even this does not look so bad when compared to the delirium and incapacity caused by quietapine and mirtrazepine in combination with trazadone..
Before the current acute depression sertraline and temazepam did help but they made no impact on the latest episode.

Report this content as offensive or unsuitable

ozzgirl said on 15 May 2010

have been treated for depression for nearly ten years now. catalyst was marriage breakdown although family death four years earlier no doubt played a part. have tried different antidepressants. they seem to work for a while then back to feeling same as ever; lethargic, lack of interest in anything, over-eating, sleeplessness etc. now trying group therapy. really hoping it works cos i am desperate to get rid of this depression. it is ruining my life. i'm in my mid forties and feel as tho life is just draining away from me and i am helpless to do anything about it. i get cross with myself cos i know i want a good life but i just cannot seem to 'pull myself together'. the thought that there will never be an end to this doesn't help either.

Report this content as offensive or unsuitable

travelsweety said on 24 April 2010

Do look at your diet, I was treated for depression by my GP for 15 years, CBT, anti depressants, counselling etc. all helped me cope with the symptoms, but of course it kept recurring because the root cause was not addressed. I initially found cutting out aspartame (diet drinks) really helped, I've subsequently cut out dairy, grains, highly processed foods and all chemical additives and I've never felt so well, physically and mentally.
One day, I hope, a depression sufferers diets will be considered by clinicians before they dish out drugs.
Good luck to you all, my heart goes out to you, I know how you suffer, please believe me, things you are eating and drinking may well be making you ill, the 'experts' are not always right.

Report this content as offensive or unsuitable

mel80 said on 14 April 2010

Hello just seen your comment. I know it is a long time ago when you posted it but just thought i would add a little note any way. I have had Severe Depression for 6 years. I have been on different meds, Citolopram 20,40,60 , Duluxotine 60 etc.. When I started to feel abit better and I was totally fed up of having depression I decided to ask the doctor to cut my meds down and was adament that i didnt need them any more. within a month i noticed that all my symptons was coming back with a vengance!! Anger, frusration, lack of interest etc. I decided to go back to my GP and he explained that it could be down to the chemical imbalance. So it meant me going back on them again. Depression can come back and in some cases you may need medicating again. And it is about finding the medication that suits too. Only recently have I been signed off work again and now I am on a new medication called venfaxine 150. Depression is an illness and can come and go. so I would recommend going back to GP if you havent.

Report this content as offensive or unsuitable

Newdawn said on 09 February 2010

Been on anti-depressants of one sort or another for some 20years!
I can be my own worst enemy by fiddling around with the doses and even stopping taking the drugs!
I think my major problem is that there's an underlying cause to my depression which must be fixed first........
I suggest you see your GP, explain what is happening and either go back on the treatment you were on (as it worked) or maybe your GP will alter the dose or change the drugs.
Hope things improve for you.
Regards

Report this content as offensive or unsuitable

loopilou said on 20 December 2009

Been on citalopram for 4 yrs and had counselling ...which did help....many things have happened in the 4yrs and recently felt that i was in a good place mentally to come off meds which was done gradually as instructed by gp....
Been off meds now for a month approx and for last couple of weeks symptoms seem to be returning
anger...frustration..anxiety...tearful..tired...not sleeping
lack of interest...impatient ..etc
cant understand why its all happening again as i have no reason to feel like this now
has this happened to anyone else ??

Report this content as offensive or unsuitable

Talking therapies

In this video, learn about different talking therapies that can help people overcome a range of problems, from depression to stress.

Be an expert