For mild to moderate depression, evidence-based psychotherapy is as effective as antidepressants. For patients with chronic, severe or treatment- resistant depression, or with a comorbid disorder (e.g., anxiety disorder, personality disorder), combined psychotherapy and medication works better than either treatment alone.
Various forms of psychotherapy for depression exist:
- Problem-solving therapy: focuses on identifying problems and developing simple problem-solving techniques. Usually four to six weekly sessions.
- Behavioural activation: focuses on increasing and reinforcing activities, scheduling and monitoring, and problem solving. Usually six to eight weekly sessions.
- Cognitive-behavioural therapy (CBT): focuses on identifying negative cognitions and behaviours, substituting more realistic thinking and pro- moting behavioural activation. Usually 12 to 16 weekly sessions.
- Interpersonal therapy: focuses on identifying and dealing with inter- personal conflicts and problems. Usually 14 to 16 weekly sessions.
- Mindfulness-based cognitive therapy: focuses on understanding depression and individual vulnerabilities, and making connections between external and internal standards that lead to feelings of inadequacy. Primarily effective as maintenance treatment. Usually eight weekly session.
Giving the patient these simple, accurate messages improves medication adherence:
- “Antidepressants have a lag time of two to three weeks to response.”
- “Take medications daily.”
- “Side-effects are usually mild and transient.”
- “Continue on medications for at least six months, even after you feel better, or else your symptoms may return.”
- “Do not stop taking antidepressants before checking with your doctor.”
Always provide patient education regardless of the treatment approach. Involve patients in managing their illness by collaborating with them in diagnosis and treatment planning.
Self-management resources, including manuals and programs that are based on CBT techniques, are listed in the Resources section.
Work and occupational function
Engaging in work or other occupational activities is an important part of treatment and contributes to improved psychosocial functioning.
Patients with depression may not need to take time off work. Discuss the risks and benefits of staying at work. Benefits can include social interaction, a regular schedule and a sense of accomplishment. Risks can include accidents, reduced productivity and interpersonal conflict. Make the decision with your patient based on these considerations.
Avoiding stress is often counterproductive in dealing with depression. Help the patient to manage work stress using cognitive techniques, and promote self-management.
- Light therapy involves exposure to bright light using a fluorescent light box. It treats seasonal affective disorder (recurrent winter depressive episodes) and may be helpful for non-seasonal depression.
- Activity and exercise: “Prescribe” at least one brisk walk a day, and progress to 30 minutes of moderate exercise at least three times per week for at least nine weeks.
- Electroconvulsive therapy (ECT) is safe and effective for severe or medication-resistant depression.
- Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neurostimulation technique used for treatment-resistant depression. It has fewer side-effects than ECT. However, it requires daily treatment for four to six weeks.