Treatment options for moderate or severe depression

Antidepressant medicines
Antidepressant medicines are commonly used to treat moderate or severe depression. A medicine cannot alter your circumstances. However, symptoms such as low mood, poor sleep, poor concentration, etc, are often eased with an antidepressant. This may then allow you to function more normally, and increase your ability to deal with any problems or difficult circumstances.

An antidepressant does not usually work straight away. It can take 2-4 weeks before the effect builds up fully. A common problem is that some people stop the medicine after a week or so as they feel it is not helping. You need to give it time. Also, if it is helping, follow the course that a doctor recommends. A normal course of an antidepressant lasts for at least six months after symptoms have eased. Some people stop their medication too early and the depression may then quickly return.

There are several types of antidepressants, each with various pros and cons. For example, they differ in their possible side-effects. (The leaflet that comes in the medicine packet provides a full list of possible side-effects.) If the first one that you try does not suit, then another may be found that will suit. So, tell your doctor if you have any problems with an antidepressant. Antidepressants are not tranquillisers and are not thought to be addictive. 

People with moderate or severe depression have a good chance of improving within a few weeks of starting an antidepressant. But, they do not work in everybody. However, some antidepressants work better in some people than in others. Therefore, tell your doctor if symptoms do not start to improve after about 3-4 weeks of taking an antidepressant. In this situation it is common to advise either an increase in dose (if the maximum dose is not yet reached) or a switch to another type of antidepressant. 

At the end of a course of treatment it is usual to reduce the dose gradually over about four weeks before finally stopping. This is because some people develop withdrawal symptoms if an antidepressant is stopped abruptly.

Psychological (talking) treatments
Various psychological treatments have been shown in research trials to be good treatments for depression. These are briefly listed below. In general, a combination of an antidepressant plus a psychological treatment is better than either treatment alone. Therefore, if available, you should consider having both treatments. However, there may be a shortage in some areas of trained therapists who can perform psychological treatments. Typically, most psychological treatments for depression last in the range of 12-20 weekly sessions of 1-2 hours per session. 

Those most commonly used for moderate or severe depression are:

Cognitive behavioural therapy (CBT). Briefly, cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as depression. The therapist helps you to understand your thought patterns. In particular, to identify any harmful or unhelpful ideas or thoughts which you have that can make you depressed. The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. Behavioural therapy aims to change any behaviours which are harmful or not helpful. CBT is a combination of cognitive therapy and behavioural therapy. In short, CBT helps people to achieve changes in the way that they think, feel and behave. (See separate leaflet called 'Cognitive Behavioural Therapy (CBT)' for more details.)
Interpersonal therapy (IPT). This is sometimes offered instead of CBT. IPT is based on the idea that your personal relationships may play a large role in affecting your mood and mental state. The therapist helps you to change your thinking and behaviour and improve your interaction with others. For example, IPT may focus on issues such as bereavement or disputes with others that may be contributing to the depression.
Other types of therapy sometimes used, depending on circumstances, include:

Behavioural activation. The basis of this therapy is that behaviours such as inactivity and ruminating on certain thoughts can be key factors in maintaining depression. The therapist aims to help you to combat these unhelpful behaviours.
Couple therapy. This may be an option for people who have a regular partner and where the relationship contributes to the depression. Or, where involving the partner is considered to be of potential useful benefit.
Other treatments
Electroconvulsive therapy (ECT) may be advised as a last resort if you have severe depression which has not improved with other treatments.

What about exercise?
It is difficult to give firm advice about exercise as a treatment. Some people claim that regular exercise helps to lift their mood and help to combat depression. But, there is conflicting evidence about this from research trials. The national guideline published in 2009 by NICE advises regular exercise as a possible treatment. A large review  published in 2012 supports this advice concluding that exercise, on average, seems to improve depressive symptoms. In contrast, a large research trial published in 2012 found that the addition of an exercise programme to the usual care for depression did not improve the outcome of depression or reduce the use of antidepressants compared with usual care alone. 

But also bear in mind that regular exercise is generally a good thing to do anyway.