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Main article: Management of depression The three most common treatments for depression are psychotherapy, medication, and electroconvulsive therapy. Psychotherapy is the treatment of choice for people under 18, while electroconvulsive therapy is used only as a last resort. Care is usually given on an outpatient basis, whereas treatment in an inpatient unit is considered if there is a significant risk to self or others. Physical exercise is recommended for management of mild depression,[154] and has a moderate effect on symptoms.[155] It is equivalent to the use of medications or psychological therapies in most people.[155] In the older people it does appear to decrease depression.[156] Stopping smoking has benefits in depression as large as or larger than those of medications.[157] Treatment options are much more limited in developing countries, where access to mental health staff, medication, and psychotherapy is often difficult. Development of mental health services is minimal in many countries; depression is viewed as a phenomenon of the developed world despite evidence to the contrary, and not as an inherently life-threatening condition.[158] PsychotherapyPsychotherapy can be delivered, to individuals, groups, or families by mental health professionals, including psychotherapists, psychiatrists, psychologists, clinical social workers, counselors, and suitably trained psychiatric nurses. With more complex and chronic forms of depression, a combination of medication and psychotherapy may be used.[159][160] Cognitive behavioral therapy (CBT) currently has the most research evidence for the treatment of depression in children and adolescents, and CBT and interpersonal psychotherapy (IPT) are preferred therapies for adolescent depression.[161] In people under 18, according to the National Institute for Health and Clinical Excellence, medication should be offered only in conjunction with a psychological therapy, such as CBT, interpersonal therapy, or family therapy.[162] Psychotherapy has been shown to be effective in older people.[163][164] Successful psychotherapy appears to reduce the recurrence of depression even after it has been terminated or replaced by occasional booster sessions. The most-studied form of psychotherapy for depression is CBT, which teaches clients to challenge self-defeating, but enduring ways of thinking (cognitions) and change counter-productive behaviors. Research beginning in the mid-1990s suggested that CBT could perform as well or better than antidepressants in patients with moderate to severe depression.[165][166] CBT may be effective in depressed adolescents,[167] although its effects on severe episodes are not definitively known.[168] Several variables predict success for cognitive behavioral therapy in adolescents: higher levels of rational thoughts, less hopelessness, fewer negative thoughts, and fewer cognitive distortions.[169] CBT is particularly beneficial in preventing relapse.[170][171] Several variants of cognitive behavior therapy have been used in depressed patients, the most notable being rational emotive behavior therapy,[172] and more recently mindfulness-based cognitive therapy.[173] Psychoanalysis is a school of thought, founded by Sigmund Freud, which emphasizes the resolution of unconscious mental conflicts.[174] Psychoanalytic techniques are used by some practitioners to treat clients presenting with major depression.[175] A more widely practiced, eclectic technique, called psychodynamic psychotherapy, is loosely based on psychoanalysis and has an additional social and interpersonal focus.[176] In a meta-analysis of three controlled trials of Short Psychodynamic Supportive Psychotherapy, this modification was found to be as effective as medication for mild to moderate depression.[177] Logotherapy, a form of existential psychotherapy developed by Austrian psychiatrist Viktor Frankl, addresses the filling of an "existential vacuum" associated with feelings of futility and meaninglessness. It is posited that this type of psychotherapy may be useful for depression in older adolescents.[178] Antidepressants Zoloft (sertraline) is used primarily to treat major depression in adult outpatients. In 2007, it was the most prescribed antidepressant on the U.S. retail market, with 29,652,000 prescriptions.[179]The effectiveness of antidepressants is none to minimal in those with mild or moderate depression but significant in those with very severe disease.[180] The effects of antidepressants are somewhat superior to those of psychotherapy, especially in cases of chronic major depression, although in short-term trials more patients—especially those with less serious forms of depression—cease medication than cease psychotherapy, most likely due to adverse effects from the medication and to patients' preferences for psychological therapies over pharmacological treatments.[181][182] To find the most effective antidepressant medication with minimal side-effects, the dosages can be adjusted, and if necessary, combinations of different classes of antidepressants can be tried. Response rates to the first antidepressant administered range from 50–75%, and it can take at least six to eight weeks from the start of medication to remission.[183] Antidepressant medication treatment is usually continued for 16 to 20 weeks after remission, to minimize the chance of recurrence,[183] and even up to one year of continuation is recommended.[184] People with chronic depression may need to take medication indefinitely to avoid relapse.[4] Selective serotonin reuptake inhibitors (SSRIs) are the primary medications prescribed, owing to their relatively mild side-effects, and because they are less toxic in overdose than other antidepressants.[185] Patients who do not respond to one SSRI can be switched to another antidepressant, and this results in improvement in almost 50% of cases.[186] Another option is to switch to the atypical antidepressant bupropion.[187] Venlafaxine, an antidepressant with a different mechanism of action, may be modestly more effective than SSRIs.[188] However, venlafaxine is not recommended in the UK as a first-line treatment because of evidence suggesting its risks may outweigh benefits,[189] and it is specifically discouraged in children and adolescents.[190][191] For adolescent depression, fluoxetine[190] and escitalopram[192] are the two recommended choices. Antidepressants have not been found to be beneficial in children.[193] There is also insufficient evidence to determine effectiveness in those with depression complicated by dementia.[194] Any antidepressant can cause low serum sodium levels (also called hyponatremia);[195] nevertheless, it has been reported more often with SSRIs.[185] It is not uncommon for SSRIs to cause or worsen insomnia; the sedating antidepressant mirtazapine can be used in such cases.[196][197] Irreversible monoamine oxidase inhibitors, an older class of antidepressants, have been plagued by potentially life-threatening dietary and drug interactions. They are still used only rarely, although newer and better-tolerated agents of this class have been developed.[198] The safety profile is different with reversible monoamine oxidase inhibitors such as moclobemide where the risk of serious dietary interactions is negligible and dietary restrictions are less strict.[199] For children, adolescents, and probably young adults between 18 and 24 years old, there is a higher risk of both suicidal ideations and suicidal behavior in those treated with SSRIs.[200][201] For adults, it is unclear whether or not SSRIs affect the risk of suicidality.[201] One review found no connection;[202] another an increased risk;[203] and a third no risk in those 25–65 years old and a decrease risk in those more than 65.[204] Epidemiological data has found that the widespread use of antidepressants in the new "SSRI-era" is associated with a significant decline in suicide rates in most countries with traditionally high baseline suicide rates.[205] The causality of the relationship is inconclusive.[206] A black box warning was introduced in the United States in 2007 on SSRI and other antidepressant medications due to increased risk of suicide in patients younger than 24 years old.[207] Similar precautionary notice revisions were implemented by the Japanese Ministry of Health.[208] There is some evidence that fish oil supplements containing high levels of eicosapentaenoic acid (EPA) to docosahexaenoic acid (DHA) may be effective in major depression,[209] but other meta-analysis of the research conclude that positive effects may be due to publication bias.[210] There is some preliminary evidence that COX-2 inhibitors have a beneficial effect on major depression.[57] Lithium appears effective at lowering the risk of suicide in those with bipolar disorder and unipolar depression to nearly the same levels as the general population.[211] Electroconvulsive therapyElectroconvulsive therapy (ECT) is a procedure whereby pulses of electricity are sent through the brain via two electrodes, usually one on each temple, to induce a seizure while the person is under a brief period of general anesthesia. Hospital psychiatrists may recommend ECT for cases of severe major depression that have not responded to antidepressant medication or, less often, psychotherapy or supportive interventions.[212] ECT can have a quicker effect than antidepressant therapy and thus may be the treatment of choice in emergencies such as catatonic depression where the person has stopped eating and drinking, or where a person is severely suicidal.[212] ECT is probably more effective than pharmacotherapy for depression in the immediate short-term,[213] although a landmark community-based study found much lower remission rates in routine practice.[214] When ECT is used on its own, the relapse rate within the first six months is very high; early studies put the rate at around 50%,[215] while a more recent controlled trial found rates of 84% even with placebos.[216] The early relapse rate may be reduced by the use of psychiatric medications or further ECT[217][218] (although the latter is not recommended by some authorities)[219] but remains high.[220] Common initial adverse effects from ECT include short and long-term memory loss, disorientation and headache.[221] Although memory disturbance after ECT usually resolves within one month, ECT remains a controversial treatment, and debate on its efficacy and safety continues.[222][223] |
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