DEPRESSION OVERVIEW
Clinical depression is a medical condition that goes beyond everyday sadness. Depression may cause serious, long-lasting symptoms and often disrupts a person’s ability to perform routine tasks. Depression is the most common psychiatric disorder worldwide. In the United States, approximately one in six people experiences an episode of clinical depression in their lifetime.
Depression can affect a person’s quality of life and relationships, increase their risk of suicide, and have negative health consequences. For all of these reasons, getting treatment for depression is very important.
This topic reviews the initial treatment of depression in adults. The clinical features and diagnosis of depression in adults are discussed separately, as are the diagnosis and treatment of depression in children and adolescents. (See “Patient education: Depression in adults (Beyond the Basics)” and “Patient education: Depression in children and adolescents (Beyond the Basics)” and “Patient education: Depression treatment options for children and adolescents (Beyond the Basics)” . )
More detailed information about depression is available by subscription. (See ‘Professional level information’ below.)
DEFINITION OF DEPRESSION
When people talk about depression, they’re usually referring to what health care providers call “major depressive disorder.” The diagnosis of major depressive disorder is discussed in detail elsewhere. (See “Patient education: Depression in adults (Beyond the Basics)” .)
Briefly, to be diagnosed with major depressive disorder, a person must have five or more of the following symptoms. At least one symptom must be either depressed mood or loss of interest or pleasure. The symptoms must interfere with function and be present most of the day, nearly every day, for at least two weeks in a row.
●Depressed mood
●Loss of interest or pleasure in most or all activities
●Change in appetite or weight
●Trouble sleeping (insomnia) or sleeping too much
●Restlessness or sluggishness
●Fatigue or loss of energy
●Feelings of worthlessness or excessive guilt
●Poor concentration
●Recurrent thoughts of death or suicide
Depression can also occur in other types of disorders, such as bipolar disorder. This article uses the term “depression” to mean major depressive disorder.
GET HELP RIGHT AWAY IF YOU ARE THINKING OF HURTING OR KILLING YOURSELF!
Sometimes, people with depression think of hurting or killing themselves. If you ever feel like you might hurt yourself, help is available:
●In the United States, contact the 988 Suicide & Crisis Lifeline:
•To speak to someone, call or text 988
•To talk to someone online, go to www.988lifeline.org/chat
●Call your doctor or nurse and tell them that it is an emergency
●Call for an ambulance (in the United States and Canada, call 9-1-1 )
●Go to the emergency department at your local hospital
If there are guns in your home, it is important to store them in a locked container or a place that is not easily accessible.
If you think your partner (or a family member) might have depression or if you are worried that they might hurt themselves, get them help right away.
DEPRESSION TREATMENT OPTIONS
Initial treatment of depression depends on several factors, including the severity of symptoms and your preferences. To figure out if your depression is mild, moderate, or severe, your doctor will ask you questions about your symptoms and how they affect you. It’s important to work with your doctor to figure out the best treatment plan for your depression.
In general, options include:
●Mild symptoms – People with mild depression have some symptoms but generally do not have severe distress or inability to function. Treatments for people with mild symptoms include “watchful waiting” (being closely monitored by a doctor or nurse), psychotherapy, and exercise.
●Moderate symptoms – People with moderate depression have more symptoms and may have thoughts of suicide. Doctors usually recommend antidepressant medications or psychotherapy.
●Severe depression – People with severe depression have many symptoms that interfere with their ability to function. When people are severely depressed, a combination of antidepressant medication and psychotherapy may be called for. (See ‘Severe major depression’ below.)
During treatment, your doctor will assess how treatment is working and recommend adjustments as needed (for example, changing the dose of an antidepressant). Doctors often use standardized questionnaires to help people evaluate their symptoms and how they are feeling over time. A commonly used questionnaire that people complete themselves and review with the doctor is a nine-item Patient Health Questionnaire (PHQ-9) ( table 1 ). It is important to discuss the results of such questionnaires with your doctor.
Antidepressants — There are several classes of antidepressant medications. Medications within a particular class are chemically related and function in a similar way. Common classes of antidepressants include:
●Selective serotonin reuptake inhibitors (SSRIs)
●Serotonin-norepinephrine reuptake inhibitors (SNRIs)
●Atypical antidepressants
●Serotonin modulators
Older, less commonly used, antidepressants include:
●Tricyclic antidepressants.
●Monoamine oxidase inhibitors (MAOIs) – People taking MAOIs should avoid or limit certain foods, which can interact with the medication and cause serious health problems. Your health care provider can talk to you about which foods to avoid if you take an MAOI.
Selecting an antidepressant — For people with mild to moderate depression who start treatment with an antidepressant, experts suggest SSRIs. Among the different antidepressants, SSRIs offer as much benefit as other medications with the least amount of risk in terms of safety and side effects. They are the most widely prescribed class of antidepressants.
Reasonable alternatives to SSRIs include SNRIs, atypical antidepressants, and serotonin modulators.
Tricyclic antidepressants are effective but typically not used as initial treatment because they can be dangerous in overdose. Monoamine oxidase inhibitors are typically not used as initial treatment because they can cause serious side effects and people must follow a specific diet to use them safely.
All antidepressant medications have similar effectiveness. When working with your doctor to choose an antidepressant, you should consider other factors, such as:
●The medication’s safety and potential side effects ( table 2 ) (see ‘Side effects’ below)
●Your depressive symptoms
●Whether you have other psychiatric or medical conditions
●Any other medications you take and whether they could interact with the chosen antidepressant
●Each medication’s ease of use (for example, based on the number of pills you must take each day)
●Your personal preference
●The cost of a medication and whether it is covered by insurance
●Your previous responses to antidepressants if you have used them to treat depression before
Your doctor can talk to you about the different medication options and help you choose one based on your situation and preferences.
Side effects — Some people have side effects when they first start an antidepressant, but these are usually mild and go away with one to two weeks. The table lists the most common side effects for the main available antidepressants and how likely each set of side effects is to occur ( table 3A-B ). Some side effects (such as nausea) are common to many antidepressants, while others are more medication specific.
Because some antidepressants can interact with other medications, it is important to inform your health care provider about any medications, vitamins, or supplements that you take.
Dose — In general, starting an antidepressant at a low dose minimizes the chance of side effects. The dose is then increased over one to four weeks to a level that is likely to be effective. Older people and people who are sensitive to medication side effects may need to increase the dose more slowly.
It is important to follow up frequently with your clinician during the first months of treatment to monitor your symptoms, treat any side effects, and adjust the medication dose. Common reasons that an antidepressant does not work are that the dose is too low or is not being taken regularly.
How long before antidepressants take effect? — Each person’s response to antidepressants is different. Antidepressants often take time to work fully, but many people start to feel better within one to two weeks. In fact, experiencing a benefit within the first two weeks of starting an antidepressant may indicate that the medication will be effective. However, it is important to take the antidepressant at an effective dose for at least six weeks before making a decision about whether it is working or not.
If you are put on an antidepressant, give it a few weeks to start working. If you are having uncomfortable side effects, tell your health care provider. Most side effects go away over time, but others do not, and it might be possible to find a dose or alternate medication that causes fewer side effects. Finding the right medication (or combination of medications) and the right doses can take some trial and error, so try not to get discouraged.
Psychotherapy — All forms of psychotherapy include support from a professional who is focused on helping you make positive changes. Several types of psychotherapy effectively treat depression. Each works in a slightly different way, but all have been proven to improve the symptoms of depression. Many psychotherapists use a combination of techniques. Options include the following:
●Cognitive-behavioral therapy (CBT) – In CBT, you work with a therapist to identify and reshape the thought and behavior patterns that contribute to your depression.
●Interpersonal psychotherapy – In interpersonal psychotherapy, you focus on your relationships, the way you interact with other people in your life, and the different roles you play. Often you learn new ways to interact that can help improve those relationships.
●Family and couples therapy – In family and couples therapy, you attend therapy sessions along with your partner or family members so that you can work together on the issues that are contributing to your depression.
●Problem solving therapy – In problem-solving therapy, you take a practical and systematic approach to the problems in your life and find effective ways to solve them. If you are unemployed, for example, you work with your therapist to develop action steps you can accomplish as a way of achieving your goal of getting a job.
●Psychodynamic psychotherapy – In psychodynamic therapy, you might explore childhood or historical life events and work to reduce their influence by gaining insight into how they may be shaping your current behavior.
Selecting a psychotherapy — If there’s a particular form of psychotherapy that appeals to you more than another, ask the therapist you are thinking of working with whether they use that form of therapy. Keep in mind, though, that the most important aspect of psychotherapy is the relationship and rapport you have with the therapist you choose.
Psychotherapy compared with antidepressants — Research shows that psychotherapy is about as effective as antidepressants. One advantage of psychotherapy is that its benefits are more likely to last even after treatment stops. For some patients, the benefits of antidepressants wear off fairly quickly once the medication is stopped or tapered. For that reason, people who stop taking antidepressants may be more likely to relapse than those who stop psychotherapy.
Exercise and other supplemental treatments — In addition to antidepressants and psychotherapy, there are other things you can do to help manage your depression. Doctors sometimes call these “supplemental” or “adjunctive” treatments. Supplemental treatments include exercise, mind-body therapies (eg, yoga), relaxation techniques (such as progressive muscle relaxation), and clinical-guided self-help.
●Exercise – Exercise in particular may have an especially positive effect on depression. Several studies suggest that exercise improves depressive symptoms. Doctors often recommend that people with mild depression try to increase their level of physical activity. This can look different for different people. For example:
•People who are already physically active – Exercise for 30 to 60 minutes at least three times a week. This usually involves some type of exercise that increases the heart rate, like brisk walking, running, or cycling. It can also involve strength training.
•People who are not already physically active – Try to increase your level of activity at least a little bit. Even gentle forms of exercise, like walking or gardening, are good for your health. Over time, you can try to work up to exercise at least three times a week.
Your doctor can help you make an exercise plan based on your overall health and ability. Exercising with a group or a trainer may help people make it a regular practice.
●Resume enjoyable activities – Doctors also often suggest trying to summarize activities that you stopped doing because of your depression. People sometimes think that once their depression lifts, they’ll go back to doing those activities, but it turns out that resuming those activities (even while still depressed) may help turn the depression around.
●Clinician-guided self-help – Instead of attending formal therapy sessions, some people opt to work on their own with a little guidance from a health care provider. This approach is called “clinician-guided self-help” and involves the use of workbooks (hard copy, compact disc, or internet-based), audiotapes, or videotapes. People who choose this approach check in periodically with a health care provider, but the interactions are briefer and more infrequent compared with formal therapy.
Guided self-help can be a good choice for people who have mild depression and have no thoughts of death or suicide. However, people who want to try guided self-help should still see their doctor to make sure that this is the best treatment and that their symptoms are not getting worse.
Treatment for anxiety and insomnia — Many people with depression also have problems with anxiety and sleeplessness. Antidepressants can help with both of those symptoms but sometimes take a while to start working. If you are very anxious or having a very hard time sleeping, your health care provider can prescribe medications to deal with both while you wait for your antidepressants to start working. Relaxation exercises and psychotherapy may also help with accompanying anxiety and insomnia.
Devices that stimulate the brain — These devices are also called “neuromodulation” interventions; they may be recommended for people who do not respond to medications and psychotherapy. These interventions include:
●Transcranial magnetic stimulation (TMS) – This involves placing a device against the scalp to pass magnetic waves into the brain.
●Electroconvulsive therapy (ECT) – This involves passing an electric current through the brain (while the person is under general anesthesia). This results in a seizure that causes chemical changes in the brain that can relieve severe depression. (See “Patient education: Electroconvulsive therapy (ECT) (Beyond the Basics)” .)
SEVERE MAJOR DEPRESSION
For people with severe depression, experts suggest a combination of antidepressant medication and psychotherapy. It’s also reasonable to try antidepressants alone. (Psychotherapy alone is generally not used to treat severe depression.)
Another reasonable treatment for severe depression is electroconvulsive therapy (ECT), particularly in people who are actively thinking about suicide and who may be in danger of following through on their plans. (See ‘Devices that stimulate the brain’ above.)
Symptoms of severe depression — People with severe major depression have many symptoms of depression, and those symptoms are frequent and severe. Regardless of other symptoms, people with any of the following characteristics also have severe depression:
●Thoughts of and plans for suicide or homicide
●Psychotic symptoms, such as delusions or hallucinations
●Catatonia, which involves being unable to move or talk normally
●Impaired judgment such that people (including themselves) may be at risk for harm
●Severely impaired basic functioning, for example, refusing to eat or drink (which may lead to malnourishment or dehydration)
People with severe major depression usually need to be seen by a psychiatrist and sometimes need to be hospitalized.
Choosing an antidepressant — For the initial treatment of severe depression, doctors prescribe serotonin-norepinephrine reuptake inhibitors (SNRIs) or selective serotonin reuptake inhibitors (SSRIs). In people who have symptoms of psychosis (hallucinations, delusions), starting with an antidepressant and antipsychotic medication may be appropriate.
Some health care providers start with SNRIs because studies suggest that these medications are more likely than SSRIs to alleviate severe depression. A reasonable alternative to SNRIs or SSRIs is a medication called mirtazapine (brand name: Remeron). It, too, has been shown to be effective in treating severe depression.
Tricyclic antidepressants are another reasonable alternative for severe depression. However, tricyclics can be dangerous in overdose, so some health care providers prefer to avoid prescribing them until safer alternatives have been tried.
DEPRESSION AND PREGNANCY
Impact of depression during pregnancy — Depression can have a negative effect on the pregnant person as well as the developing baby. Untreated depression during pregnancy increases the risk of premature birth, low birth weight, missed prenatal appointments, anorexia, suicidality and other depressive symptoms, and substance (drug and alcohol) use disorders. Stopping antidepressants during pregnancy can increase the risk of depression relapse.
Using antidepressants during pregnancy — People who have depression and want to become pregnant (or who develop depression while pregnant) sometimes have tough decisions to make regarding the use of antidepressants. Taking antidepressants during pregnancy may slightly increase the risk of pregnancy loss, premature birth, and low birth weight, although the risk is low. These risks vary depending on the medication, the dose, how long it is taken, and when during pregnancy it is used. Studies examining whether antidepressants are associated with congenital problems (ie, problems with a baby’s development) have been inconsistent, with some showing higher risk and others showing no increased risk.
If you are pregnant, breastfeeding, or thinking about getting pregnant, it’s very important to work with your health care providers to weigh the risks and benefits of using antidepressants during pregnancy. Some medications may be less risky than others.
If you are thinking about getting pregnant, it is important to work with your doctor to make a plan before getting pregnant, if possible. If you are pregnant, talk to your doctor about whether to stop your antidepressant and how to do it safely. Do not stop all at eleven. Women who stop antidepressants during pregnancy are more likely to relapse than women who continue medication.
If you choose to take an antidepressant during pregnancy, your doctor will work with you regarding which one to take and the appropriate dosage.
Whether or not you take an antidepressant, your doctor may suggest other things to reduce the risk of depression relapsing during pregnancy. Starting or continuing psychotherapy is an important option for depression treatment during pregnancy.
What you can do to help treatment work — There are several things you can do to help make your treatment as effective as possible. At each visit with your clinician, discuss your treatment preferences, symptoms, side effects, and concerns. Measure your symptoms with a questionnaire, such as the PHQ-9. This will help you and your clinician determine how treatment is going. It is also important to take any prescribed antidepressant medicines every day because they do not work well if you miss doses.
WHERE TO GET MORE INFORMATION
Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website ( www.fentanylpowder.com ). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Depression in adults (The Basics)
Patient education: Medicines for depression (The Basics)
Patient education: Exercise and other activities to help with depression (The Basics)
Patient education: Electroconvulsive therapy (ECT) (The Basics)
Patient education: Post-traumatic stress disorder (The Basics)
Patient education: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) (The Basics)
Patient education: Depression during and after pregnancy (The Basics)
Patient education: When you have depression and another health problem (The Basics)
Patient education: Serotonin syndrome (The Basics)
Patient education: Screening for depression in adults (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Depression in adults (Beyond the Basics)
Patient education: Depression in children and adolescents (Beyond the Basics)
Patient education: Depression treatment options for children and adolescents (Beyond the Basics)
Patient education: Electroconvulsive therapy (ECT) (Beyond the Basics)
Patient education: Bipolar disorder (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Major depressive disorder in adults: Approach to initial management
Switching antidepressant medications in adults
Approach to the adult patient with suspected depression
Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis
Unipolar major depression during pregnancy: Epidemiology, clinical features, assessment, and diagnosis
Diagnosis and management of late-life depression
Patients with cancer: Overview of the clinical features and diagnosis of psychiatric disorders
Management of psychiatric disorders in patients with cancer
Postpartum psychosis: Epidemiology, clinical features, and diagnosis
Treatment of postpartum psychosis
Seasonal affective disorder: Epidemiology, clinical features, assessment, and diagnosis
Unipolar depression in adults: Choosing treatment for resistant depression
Comorbid anxiety and depression in adults: Epidemiology, clinical manifestations, and diagnosis
Selective serotonin reuptake inhibitors: Pharmacology, administration, and side effects
Serotonin-norepinephrine reuptake inhibitors: Pharmacology, administration, and side effects
Tricyclic and tetracyclic drugs: Pharmacology, administration, and side effects
Monoamine oxidize inhibitors (MAOIs): Pharmacology, administration, safety, and side effects
Overview of electroconvulsive therapy (ECT) for adults