Depression: Treatment​

Key points

• Consider client preference, symptom severity, onset triggers and previous treatment outcomes when choosing treatment options.
• For mild and moderate cases of depression, evidence-based psychotherapy is as effective as medication.
• Consider recommending that your client increase exercise and other activity, in addition to undergoing psychosocical treatment and psychopharmacology.

Mild and moderate symptoms

Initial treatments for people with mild or moderate symptoms of depression include:

• psychoeducation
• supported self-management
• print and multimedia support materials
• support from a health care professional (face-to-face or telephone)
• exercise and activity
• light therapy (exposure to bright light using a fluorescent light box) for seasonal affective disorder (recurrent winter depressive episodes).

No response to low-intensity treatments

Treatment options for people whose depression does not ease with low-intensity treatments should consider:

• client preference
• length of the episode and whether the symptoms are increasing in severity
• history of depression episodes
• co-occurring physical health problems.

Psychotherapy options

• cognitive-behavioural therapy (CBT): 12–16 weekly sessions
• interpersonal therapy: 14–16 weekly sessions
• problem-solving therapy: 4–6 weekly sessions

Watch a mock CBT scenario with a physician and a mother who is depressed.

Watch a mock problem-solving therapy session.

Psychopharmacology

Antidepressant medications

When discussing the choice of antidepressant with clients, cover:

• probability and nature of side-effects
• client's history, including the person's experience of efficacy and tolerability of any antidepressant medication
• potential interactions with other medications
• potential effects on co-occurring illnesses.

Download the client handout Understanding Psychiatric Medications: Antidepressants.

The newer antidepressants (selective serotonin reuptake inhibitors [SSRIs], bupropion, mirtazapine and venlafaxine) are first-line medications that offer improved tolerability and safety than tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs).

Maintenance treatment

The goal of maintenance treatment is prevention of relapse and recurrence.

• Most people who take antidepressants should continue to take them for at least four to six months after they achieve remission.
• People with risk factors (chronic, recurrent, severe or difficult-to-treat depressive episodes) should continue on antidepressants for at least two years. Some people will require treatment for the rest of lives.

Stopping medications

When stopping medications, gradually taper doses (e.g., at least one week for each dose reduction) whenever possible. Caution clients about, and monitor for, discontinuation symptoms (which are usually mild and transient).

No response to treatment

When the person does not respond to treatment, consider these options:

• Check the diagnosis. Look for bipolar disorder, co-occurring physical or mental health problems or addiction issues.
• Reassess management of side-effects.
• Add psychotherapy.
• Switch to another antidepressant.
• Add an augmenting agent (e.g., lithium, a typical antipsychotic agent).
• Combine with another antidepressant in a different class. Watch for drug-drug interactions and/or increased side-effects.

Evidence summary

Kennedy, S.H., Lam, R.W., Parikh, S.V., Patten, S.B. & Ravindran, A.V. (2009). Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical Guidelines for the Management of Major Depressive Disorder in Adults. Journal of Affective Disorders, 117(Suppl. 1). S44–53.

Lam, R.W. (2011). In D. Goldbloom & J. Davine (Eds.), Psychiatry in Primary Care: A Concise Canadian Pocket Guide (pp. 13–26). Toronto, ON: Centre for Addiction and Mental Health.

National Institute for Health and Care Excellence. (2009). Depression in Adults: The Treatment and Management of Depression in Adults (Clinical Guideline 90). London, UK: Author.