Depression is a significant health problem. It affects men and women of all ages and social backgrounds. Around one in five of the population of world will experience depression at some point in their lives. Prevalence is higher in women than men. It can range in severity from a mild disturbance to a severe illness with a high risk of suicide. The impact of the disorder will also be experienced by family, friends and colleagues. In 2006/07 there were around 500,000 general practitioner consultations with depression and other affective disorders. Over half of those with depression do not seek formal treatment. As well as the personal and social consequences of depression there are also negative economic effects. Depression is associated with sickness absence and prevents many people seeking, maintaining or returning to employment. In an economic analysis the total loss of output due to depression and chronic anxiety in England in 2002/3 was estimated at £12 billion.5. The most common intervention for depression is prescribed antidepressant medication. Managing depression in the primary care and general practice setting is challenging. The common reasons leading to this challenge are:
The constraints of time
Insufficient training at the undergraduate level
Somatisation of symptoms
The use of pharmacological agents often enables the physician to circumvent time constraints. Difficulties arise when knowledge about the properties and use of these agents is lacking. The other factor that often hinders the management of the depressed patient is that psychological and social issues are inadequately addressed. Psychological and social interventions should accompany pharmacological therapy in order to bring about remission of symptoms in the depressed patient. Appropriate management of depression requires knowledge of the severity and type of depressive disorders. Depressive disorders can be categorised as mild, moderate or severe. Severe depression can result in psychosis. A chronic mild to moderate depression lasting more than two years is termed dysthymia. Depression can also be part of bipolar disorder. There is a variation in the management of each of the above.
Mild depression can be handled in primary care and does not need pharmacological therapy. The watchful waiting, guided self-help, exercise and brief psychological interventions. Moderate to severe depression can also be handled in the primary care setting with medication, psychological interventions and social support. Severe depression with psychosis and risk of suicide, recurrent atypical and treatment-resistant depression should be managed by mental health specialists.
Therapies used to treat depression has been divided into parts
The drugs used in mental depression are classified as
First generation antidepressants
Tricyclic antidepressant eg imipramine, despiramine, amitriptyline, nortryptyline, doxepine, clomipramine, trimipramine
Monoamine oxidase inhibitors egPhanalzine, Pargyline
Lithium carbonate (antimanic drug)
Second generation antidepressants
Selective serotonin reuptake inhibitors
Selective norepinephrine reuptake inhibitors
Serotonin norepinephrine reuptake inhibitors
Reversible inhibitors of MAO-A
Non pharmacological can be sub divided into three therapies
1. Psychological therapies
Cognitive behavioural therapy
Mindfulness based cognitive therapy
Problem solving therapy
Other psychological therapies
Common factors in psychological therapies
2. Self help
Self help support groups
Guided self help
Computerised self help
3. Exercise and lifestyle modification
4. Herbal remedies and nutritional supplements
Hypericumextract (St John’s wort)
Polyunsaturated fatty acids
Other nutritional supplements and herbal remedies
5. Complementary and alternative therapies
Animal assisted therapy
2. Psychological therapies
2.1. Psychological therapies
Although there are some studies comparing psychological therapies for depression, the majority of studies involve comparisons of psychological therapies with prescribed antidepressant medication treatment. There is very less evidence to support detailed recommendations on the number of therapy sessions required for efficacy, maintenance of effect or prevention of relapse. Practitioners delivering psychological therapies should be trained to approve levels of competency, participate in continuing professional development and be registered with the appropriate governing body. Several types of psychotherapy are used in individual and group settings and with families. Patients must be medically stable to be able to participate meaningfully in any type of psychological therapy. Thus, a patient who has required hospitalization for refeeding and to stabilize his/her medical condition will ordinarily not be able to participate in therapy until after he/she has recovered sufficiently to enable cognitive function to return to normal. A given psychologist or psychiatrist may use several different approaches tailored to the situation. Two types of psychotherapy used for the patient with stabilized medical condition; Cognitive behavior therapy (CBT) and behavior therapy (BT)
Cognitive therapy is the most extensively researched psychological treatment for nonpsychotic unipolar outpatient depressive disorders.This is a type of psychotherapeutic treatment that attempts to change a patient’s feelings and behaviors by changing the way the patient thinks about or perceives his/her significant life experiences whereas behavior Therapy (BT) is a type of psychotherapy that uses principles of learning to increase the frequency of desired behaviors and/or decrease the frequency of problem behaviors. A meta-analysis of 16 studies found behavioural activation to be effective in reducing depressive symptoms in adults and older adults compared to treatment as usual and waiting list control, and as effective as cognitive therapy. This is consistent with the conclusions of a study incorporating behavioural activation therapy as part of a larger meta-analysis specifically in patients aged over 50 with depression.
Denmen concluded that cognitive behavior therapy was more effective than behavior therapy, other psychotherapies, and pharmacotherapy. An important advantage to cognitive behavior therapy might be in treating depression in patients with personality disorder, who are recognized as responding less well to all forms of therapy.
The cognitive and behavioral therapies have evolved as an alternative to more traditional nondirective and insight oriented modes of psychotherapy. The family of cognitive and behavioral therapies includes a diverse group of interventions. Nevertheless, the treatments shareseveral pragmatic and theoretical assumptions. First, these therapies emphasize psychoeducation: patients learn about the nature of their difficulties and are providedreasons for use of particular treatment strategies. Second, the cognitive and behavioral therapies typically employ homework and self-help assignments to provide patients theopportunity to practice therapeutic methods that enhance the generalization of newly acquired skills outside of the therapy hour. Third, objective assessment of psychiatricillness is an integral part of treatment, and the selection of therapeutic strategies derives logically from such assessments. Fourth, the therapeutic methods used are structured and directive, and as such require a high level of therapist activity (often they are described in treatment manuals). Fifth, for most disorders, the cognitive and behavioral therapies are time-limited interventions. Sixth, and perhaps most important, these therapies are built on empirical evidence that validates their theoretical orientation and guides the choice of therapeutic techniques. Specifically, learning theories (i.e., classical, operant, and observational models of learning) and the principles of cognitive psychology are relied on heavily in constructing cognitive–behavioral treatment models.
Counselling is the skilled and principled use of relationships which develop self knowledge, emotional acceptance and growth, and personal resources. The overall aim is to live more fully and satisfyingly. Counselling may be concerned with addressing and resolving specific problems, making decisions, coping with crises, working through inner feelings and inner conflict, or improving relationships with others. The counsellor’s role is to facilitate the patient’s work in ways that respect the patient’s values, personal resources, and capacity for self determination.
During a study of 12 months on the patient, counselling was as effective as antidepressants but antidepressants may result in more rapid recovery and are likely to be chosen by those who are more severely depressed.
2.1.2. Couple-focused therapy
Couple-focused therapy has the twofold aim of modifying negative interaction patterns and increasing mutually supportive aspects of couple relationships, thus changing the interpersonal context linked to depression. A review identified eight studies evaluating the effect of marital therapy on depression. A variety of treatment models were subsumed within the marital therapy approach, including CBT, emotion-focused, interpersonal and systemic therapy. A variety of control comparisons were used, including CBT, interpersonal therapy, drug therapy, combined individual and drug therapy. Duration of treatment ranged from 10-20 weeks and follow up ranged from post-test to two years. Studies were characterised by small sample size, lack of intention to treat analysis and high numbers lost to follow up. The review concluded there was no evidence to support marital therapy being any more or less effective than one to one therapies or drug therapy in the treatment of depression, even when associated with marital distress. In comparison to no/minimal treatment the outcome for depression was better in the marital therapy group, although this was based on only two small studies.A couple-focused approach should be considered where the current relationship is contributing to the depression, or where involvement of a partner is considered to be of potential therapeutic benefit.
2.1.3. Family therapy
Family therapy helps people in a close relationship help each other. It enables family members to express and explore difficult thoughts and emotions safely, to understand each other’s experiences and views, appreciate each other’s needs, build on family strengths and make useful changes in their relationships and their lives.
Hypnosis is used in this therapy as main techniques. When Cognitive Behaviour Therapy supplemented by hypnotherapy produced a significantly larger reduction in depressive symptoms than CBT alone.
2.1.5. Interpersonal therapy
A time-limited intervention, which aims to reduce symptoms by working on improving the quality of the patient’s interpersonal relationships. IPT focuses on specific interpersonal problem areas such as grief, role transition and interpersonal disputes. A positive therapeutic alliance is encouraged and a range of therapeutic strategies are employed to encourage the open expression of affect and problem resolution. Patient literacy is not required. A study examining achievement of complete remission in major depression found that interpersonal therapy (IPT), CBT and medication were equally effective.
2.1.6. Music therapy
A therapeutic approach where music-making forms the primary basis for communication. A review of five small, diverse and poor quality studies concluded that music therapy on its own or as an adjunct to psychological therapies, is acceptable to people with depression and is associated with improvements in mood. The small number and poor methodological quality of studies mean that it is not possible to be confident about its effectiveness.
2.1.7. Problem solving therapy
A brief focused psychological intervention that is delivered by an individual trained in problem solving approaches. These are often highly individualised and have a pragmatic focus, in which the professional and individual work through a series of defined steps to clarify the person’s problems, desired goals, generate potential solutions and help to implement the chosen solution
2.1.8. Psychodynamic psychotherapy
Based on psychodynamic theories of development and of the mind and includes attention to unconscious as well as conscious mental processes. The approach places emphasis on the importance of the therapeutic relationship, including transference and counter transference, how difficulties from the past can be repeated in the therapeutic relationship as well as in current relationships and therefore understood and changed. The therapy involves both expressive and supportive elements.
2.1.9. Reminiscence therapy
Entails a progressive return to an awareness of past experiences, both successful and unsuccessful, so that salient life experiences may be re-examined and re-integrated. The life review process gives older people opportunities to place their accomplishments in perspective, to resolve lingering conflicts, and to find new significance and meaning in their lives, thereby relieving the despair and depression that often accompany ageing.
2.2. Self help
2.2.1. Self help support groups
There is no standard definition of support groups in the literature. No studies were identified on self help groups as a stand-alone intervention for patients with depression. Practitioners referring patients to self help groups should consider the following parameters of good practice:
Groups should be:
linked to an organisation or well established group that can offer the necessary
resources, support and promotion of the groups
subject to regular review and evaluation
held in accessible, non-stigmatising and welcoming venues
recovery-focused and with clear confidentiality policies maintained by members and facilitators
led by facilitators who are trained in listening, conflict management and facilitation skills; and who are supervised and supported themselves.
2.2.2. Self help
Computerised self help Online or computer based packages of self help material. Guided self help Self help interventions which incorporate some form of therapist support.Self help interventions Self help interventions cover a range of interactive packages,paper or web-based written self help materials.
2.3. Exercise and lifestyle modification
Exercise is a subset of physical activity, which is any movement of the body that results in energy expenditure rising above resting level, and includes activities of daily living, domestic chores, gardening and walking whereas Structured exercise that is undertaken three or more times a week for 30-40 minutes at an intensity sufficient to provide an energy expenditure of 70-80% of heart rate reserve; this equates to the public health dose of accumulating 30 minutes of moderate
2.3.2. Lifestyle modification
reducing alcohol consumption
No good quality evidence was identified on the effect of reducing alcohol consumption ondepressive symptoms.
Examination of alcohol consumption as a causative factor in depression was outside the scopeof the guideline.
Primary care interventions for patients with alcohol dependence, hazardous or harmful drinkingare described in SIGN 74.62
reducing caffeine intakeNo good quality evidence was identified on the effects of reducing caffeine intake on depressivesymptoms.
return to work
good practice in lifestyle advice for patients with depression
2.4. Herbal remedies and nutritional supplements
This section considers herbal remedies and nutritional supplements which have been subjected to evaluate their efficacy in the treatment of depression. They are not licensed medications and have not been subjected to the rigorous regulatory approval process required for prescription medications. In addition to this there are issues around quality control and lack of standardisation of herbal remedies and nutritional supplements.
A well conducted systematic review of folate for depression was identified. There was only one study of folate as a stand-alone treatment for depression. This did not find significant benefit.
2.4.2. Hypericum extract (St John’s Wort)
A perennial herb of the genus Hypericum.Inositol An isomer of glucose. It is a naturally occuring compound which is widely available as a dietary supplement. Polyunsaturated fatty acids (PUFAs)
“Essential fatty acids” that humans cannot synthesise de novo; intake is dependent on dietary sources such as fish and seafood. The examples most studied are the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). S-adenosyl-Lmethionine
(SAMe) A coenzyme involved in methyl group transfers. It is available as a nutritional supplement. Selenium A non-metallic element which rarely occurs in its elemental state in nature.
A good quality systematic review of small, short term RCTs reported that current evidence is unclear whether or not inositol is of benefit in the treatment of depression.
2.4.4. Polyunsaturated fatty acids
Five systematic reviews of the use of polyunsaturated fatty acids (PUFAs) in the treatment of patients with depression were identified. Most trials included in the reviews examined the use of PUFAs as supplements to antidepressant medication with only two small RCTs examining the use of PUFAs as a stand-alone treatment of depression.
One well conducted systematic review of 28 small and heterogeneous studies found a modest benefit of S-adenosyl-L-methionine (SAMe) over placebo in the treatment of depression. There were no significant differences in outcome when SAMe was compared with tricyclic antidepressants.
A mineral that humans require in trace amounts.Folate Folic acid and folate (the anionic form) are forms of the water soluble vitamin B9. These occur naturally in food and can also be taken as supplements.
A perennial plant which grows in eastern Asia. The root extract is widely available as a herbal remedy. Ginkgo biloba Ginkgo biloba, also known as the Maidenhair tree, is a unique species of tree, the fruits and seeds of which are used in traditional Chinese medicine. Leaf extracts are available as supplements.
2.5. Complementary and alternative therapies
A family of procedures involving the stimulation of anatomical locations on or in the skin by a variety of techniques. There are a number of different approaches to diagnosis and treatment in acupuncture that incorporate medical traditions from China, Japan, Korea, and other countries. Depression is widely experienced in our communities. In clinical depression, people report a lack of interest in life and activities which they otherwise normally enjoy. This can be accompanied by other symptoms including weight loss, over-eating, feelings of uselessness, sleep disturbance, self neglect and social withdrawal, insomnia or hypersomnia (sleeping too much), loss of energy, low self esteem and poor concentration. Acupuncture has a long history of use in China and Japan. Traditional Chinese medicine theory describes a state of health maintained by a balance of energy in the body. Acupuncture involves the insertion of fine needles into different parts of the body to correct the imbalance of energy in the body. There are a range of styles of acupuncture from traditional/classical acupuncture, auricular acupuncture, trigger point acupuncture, and single point acupuncture.
2.5.2. Animal assisted therapy
A therapy that uses dogs or other pets to improve the physical and mental health of patients with certain acute or chronic diseases. There is evidence from one systematic review that the introduction of animal assisted activities may have beneficial effects on the severity of depressive symptoms in older people resident in nursing homes and psychiatric institutions. The degree to which the benefits found are a result of animal contact or human contact with the animal facilitator is unclear and requires further investigation.
Homeopathy A system of medicine which is based on treating the individual with highly diluted substances given mainly in tablet form, which trigger the body’s natural system of healing.
2.5.4. Light therapy
Treatment that involves regular use of a certain spectrum of lights in a light panel or light screen that bathes the person in that light. Light therapy is also used to treat conditions such as seasonal affective disorder (seasonal depression).
2.5.5. Massage therapy
The manipulation of the soft tissues of the body - the muscles, tendons and ligaments. The therapeutic value of massage has been recorded in several studies. It has been shown to reduce stress and anxiety; relax muscles; aid in circulation, digestion, and excretion; and reduce pain perception. There are many different types of massage -- effleurage, deep tissue, and relaxation massage. Even the simplest massage may convey to the recipient a feeling of being cared for. Both maternal and infant massage have been evaluated in the treatment of postpartum depression.
A therapy based on the use of very concentrated “essential” oils from the flowers, leaves, bark, branches, rind or roots of plants with purported healing properties. Aromatherapy involves the administration of pure essential oils of fragrant plants either through breathing the aromatic vapours using an aroma diffuser, or absorbing diluted oils through the skin in a bath or during massage.
An ancient system of breathing practices, physical exercises and postures, and meditation, intended to integrate the practitioner’s body, mind, and spirit.
A hands-on alternative healing technique that involves the exchange of energy between practitioner and patient to restore mental, physical, emotional, and spiritual balance.
Involves massage of reflex areas found in the feet and the hands.
2.5.10. T’ai Chi
A Chinese exercise system that uses slow, smooth, body movements to achieve a state of relaxation of both body and mind. Thought field therapy Involves tapping with the fingers at meridian points on the upper body and hands.
In the present review, a number of drug and non-drug strategies group setting may be considered as a treatment option to reduce relapse in patients with depression who have had three or more episodes. Whereas, problem solving therapy and short term psychodynamic psychotherapy may be considered as a treatment option in depressed patients. Structured exercise may be considered as a treatment option for patients with depression. No applicable evidences were identified on which to base a recommendation for complementary and alternative therapies.