Treating clinical depression 

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) aims to help you understand your thoughts and behaviour and how they affect you.

CBT recognises that events in your past may have shaped you, but it concentrates mostly on how you can change the way you think, feel and behave in the present.

It teaches you how to overcome negative thoughts – for example, being able to challenge hopeless feelings.

CBT is available on the NHS for people with depression or any other mental health problem that it's been shown to help.

You normally have a short course of sessions, usually six to eight sessions, over 10 to 12 weeks on a one-to-one basis with a counsellor trained in CBT. In some cases, you may be offered group CBT.

Online CBT

Online CBT is a type of CBT that's delivered through a computer, rather than face-to-face with a therapist.

You'll have a series of weekly sessions and you should receive support from a healthcare professional. For example, online CBT is usually prescribed by your GP and you may have to use the surgery computer to access the programme.

Ask your GP for more information or read more about online CBT and the courses available.

Interpersonal therapy (IPT)

Interpersonal therapy (IPT) focuses on your relationships with others and on problems you may be having in your relationships, such as difficulties with communication or coping with bereavement.

There's some evidence that IPT can be as effective as antidepressants or CBT, but more research is needed.

Psychodynamic psychotherapy

In psychodynamic (psychoanalytic) psychotherapy, a psychoanalytic therapist will encourage you to say whatever is going through your mind.

This will help you become aware of hidden meanings or patterns in what you do or say that may be contributing to your problems.

Read more about psychotherapy.

Counselling

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

Counselling on the NHS usually consists of six to 12 hour-long sessions. You talk in confidence to a counsellor, who supports you and offers practical advice.

Counselling is ideal for people who are basically healthy but need help coping with a current crisis, such as anger, relationship issues, bereavement, redundancy, infertility or a serious illness.

Getting help

See your GP for more information about accessing NHS talking treatments. They can refer you for local talking treatments for depression.

In some parts of the country, you also have the option of self-referral. This means that if you prefer not to talk to your GP, you can go directly to a professional therapist.

Find counselling and psychological therapies in your area.

Antidepressants are medicines that treat the symptoms of depression. There are almost 30 different types available.

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

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

When you start taking antidepressants, you should see your GP or specialist nurse every week or two for at least four weeks to assess how well they're working. If they're working, you'll need to continue taking them at the same dose for at least four to six months after your symptoms have eased.

If you've had episodes of depression in the past, you may need to continue to take antidepressants for up to five years or longer.

Antidepressants aren't addictive, but you may get some withdrawal symptoms if you stop taking them suddenly or you miss a dose (see below).

Selective serotonin reuptake inhibitors (SSRIs)

If your GP thinks you would benefit from taking an antidepressant, you'll usually be prescribed a modern type called a selective serotonin reuptake inhibitor (SSRI). Examples of commonly used SSRI antidepressants are paroxetine (Seroxat), fluoxetine (Prozac) and citalopram (Cipramil).

They help increase the level of a natural chemical in your brain called serotonin, which is thought to be a "good mood" chemical.

SSRIs work just as well as older antidepressants and have fewer side effects, although they can cause nausea, headaches, a dry mouth and problems having sex. However, these side effects usually improve over time.

Some SSRIs aren't suitable for children and young people under 18 years of age. Research shows that the risk of self-harm and suicidal behaviour may increase if they're taken by under-18s. Fluoxetine is the only SSRI that can be prescribed for under-18s, and even then only when a specialist has given the go-ahead.

Vortioxetine (Brintellix or Lundbeck) is an SSRI that's recommended by the National Institute for Health and Care Excellence (NICE) for treating severe depression in adults.

Common side effects associated with vortioxetine include abnormal dreams, constipation, diarrhoea, dizziness, itching, nausea and vomiting.

Tricyclic antidepressants (TCAs)

Tricyclic antidepressants (TCAs) are a group of antidepressants that are used to treat moderate to severe depression.

TCAs, including imipramine (Imipramil) and amitriptyline, have been around for longer than SSRIs.

They work by raising the levels of the chemicals serotonin and noradrenaline in your brain. These both help lift your mood.

They're generally quite safe, but it's a bad idea to smoke cannabis if you're taking TCAs because it can cause your heart to beat rapidly.

Side effects of TCAs vary from person to person but may include a dry mouth, blurred vision, constipation, problems passing urine, sweating, light-headedness and excessive drowsiness.

The side effects usually ease after seven to 10 days, as your body gets used to the medication.

Other antidepressants

New antidepressants, such as venlafaxine (Efexor), duloxetine (Cymbalta or Yentreve) and mirtazapine (Zispin Soltab), work in a slightly different way from SSRIs and TCAs.

Venlafaxine and duloxetine are known as serotonin-noradrenaline reuptake inhibitors (SNRIs). Like TCAs, they change the levels of serotonin and noradrenaline in your brain.

Studies have shown that an SNRI can be more effective than an SSRI, but they're not routinely prescribed because they can lead to a rise in blood pressure.

Withdrawal symptoms

Antidepressants aren't addictive in the same way that illegal drugs and cigarettes 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 are quite mild and last no longer than a week or two, but occasionally they can be quite severe. They seem to be most likely to occur with paroxetine (Seroxat) and venlafaxine (Efexor).

Withdrawal symptoms occur very soon after stopping the tablets, so are easy to distinguish from symptoms of depression relapse, which tend to occur after a few weeks.

Further information:

How long does it take for antidepressants to work?

Can I drink alcohol if I'm taking antidepressants?

How should antidepressants be stopped?

Mindfulness

Mindfulness involves paying closer attention to the present moment and focusing on your thoughts, feelings, bodily sensations, and the world around you to improve your mental wellbeing.

The aim is to develop a better understanding of your mind and body, and learn how to live with more appreciation and less anxiety.

Mindfulness is recommended by the National Institute for Health and Care Excellence (NICE) as a way of preventing depression in people who've had three or more bouts of depression in the past.

Read more about mindfulness.

St John's wort

St John's wort is a herbal treatment that some people take for depression. It's available from health food shops and pharmacies.

There's some evidence that it may help mild to moderate depression, but it's not recommended by doctors. This is because the amount of active ingredients varies among individual brands and batches, so you can never be sure what sort of effect it will have on you.

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

You shouldn't take St John's wort if you're pregnant or breastfeeding, as we don't know for sure that it's safe.

Also, St John's wort can interact with the contraceptive pill, reducing its contraceptive effect.

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) is sometimes recommended in cases of severe depression where other treatments, including antidepressants, haven't worked.

For most people, ECT is effective at relieving severe depression, although the beneficial effect tends to wear off after several months.

Some people also experience unpleasant side effects after having ECT, including short-term headaches, memory problems, nausea and muscle aches.

There are two types of ECT recommended by NICE – transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS). These are discussed below.

Transcranial direct current stimulation (tDCS)

Transcranial direct current stimulation (tDCS) involves placing electrodes on your head.

The electrodes are attached to a small, portable battery-operated stimulator, which delivers a constant, low-strength current to the brain. The electric current stimulates brain activity to help improve the symptoms of depression.

You'll remain awake and alert throughout the procedure, which is usually carried out by a trained clinician. However, it's sometimes possible for tDCS to be self-administered. The treatment can be used on its own or in addition to other treatments for depression.

Treatment sessions are carried out daily and last for about 20-30 minutes, with a course of treatment typically lasting several weeks.

Treatment with tDCS is safe and has been found to be effective in some cases. There's some uncertainty about the way tDCS is delivered, the number of treatments needed, and how long its effects last, so further research in these areas is needed.

NICE has more information about transcranial direct current stimulation for depression.

Repetitive transcranial magnetic stimulation (rTMS)

Repetitive transcranial magnetic stimulation (rTMS) involves holding an electromagnetic coil against your head, which delivers repetitive pulses of electromagnetic energy are at various frequencies or intensities. This stimulates a part of the brain called the cerebral cortex.

Treatment with rTMS usually involves a two to six week course of daily sessions that last about 30 minutes.

Evidence suggests that rTMS for depression is safe, although the effectiveness of treatment can vary between individuals.

NICE has more information about repetitive transcranial magnetic stimulation for depression.

Lithium

If you've tried several different antidepressants and there's been 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're taking one that works for you, it's best not to change.

If the level of lithium in your blood becomes too high, it can become toxic. You'll therefore need blood tests every three months to check your lithium levels while you're on the medication.

You'll also need to avoid eating a low-salt diet because it can also cause the lithium to become toxic. Ask your GP for advice about your diet.