Treatments for moderate or severe depression

If you have moderate or severe depression, you should be offered both an antidepressant and a psychological treatment – this should be either cognitive behavioural therapy (CBT) or interpersonal therapy (see table, psychological treatments for depression).

Taking an antidepressant

Choice of antidepressants

If you decide to start taking an antidepressant, your healthcare professional should discuss with you the different types of antidepressants, any possible side effects, and whether they can affect you if you are taking other medication or have a physical illness. They should also discuss with you any previous antidepressants you have taken and how well they worked.

You should usually be offered a type of antidepressant called a selective serotonin reuptake inhibitor (or SSRI for short) because they typically have fewer side effects than other types of antidepressants and are just as effective.

If you are offered a type of antidepressant called a non-reversible monoamine oxidase inhibitor (such as phenelzine), this should only be prescribed by a specialist mental health professional. You should not be offered an antidepressant called dosulepin because it is associated with an increased risk of heart problems.

Starting treatment

If you think that your care does not match what is described in this information, please talk to a member of your healthcare team in the first instance.

Your healthcare professional should discuss any concerns you have about your medication. For example, they should explain that:

  • you will not crave antidepressants or need to take more of the medication to feel the same effect as time goes on

  • the antidepressant might take some time to work

  • you should follow carefully the instructions about taking your medication, even if you are not sure it is working at first

  • you should continue with treatment even if you feel better

  • you may experience side effects

  • there is a possibility that the antidepressant may affect any other medication you are taking.

You should also be offered full written information about taking antidepressants.

If you are aged 30 or over and are not considered to be at increased risk of suicide, your healthcare professional should usually see you 2 weeks after starting treatment. You should then be seen every 2 to 4 weeks for the first 3 months, with less frequent appointments after that if the treatment is working.

There are some concerns about how young people respond to antidepressants in the early stages of treatment. So if you are under 30 you should usually be seen 1 week after starting an antidepressant, and then as often as needed after that.

If you are thought to be at risk of suicide, you should be seen 1 week after starting an antidepressant and then as often as needed, whatever your age.

If you get side effects when you first start taking an antidepressant but they are not too distressing, your healthcare professional should monitor you closely. If you prefer, your medication may be stopped or you can try a different antidepressant. If you are anxious or agitated or not sleeping very well, you may be offered another medicine called a benzodiazepine to take as well as your antidepressant – although you shouldn't usually take this for more than 2 weeks.

Questions about antidepressants

  • How long will it take before I start to feel better?

  • How long will I have to take an antidepressant for?

  • Are there any risks associated with this treatment?

  • Will I become addicted to antidepressants?

  • What are the side effects of this antidepressant?

  • What should I do if I get any of these side effects?

  • How long do the side effects last?

  • Will it be easy to stop taking the antidepressant?

What happens if I don't feel better after taking an antidepressant?

If, at any stage of your antidepressant treatment, you have questions or you feel you are not getting better, you should go back and see your healthcare professional and discuss your concerns.

If you don't feel any better after 2 to 4 weeks, they should check that you have been taking the medicine as prescribed. If you have been taking the correct dose but there's little or no improvement after 3 to 4 weeks of treatment, they may discuss increasing the dose of your medication with you. But if you have had distressing side effects, or if you prefer, you may be offered a different antidepressant.

If your symptoms have still not improved after you have completed your course of antidepressants, your healthcare professional should arrange to see you more often to check how you are feeling. They will consider a range of options including trying a previous treatment again, increasing the dose of your medication or trying a different antidepressant. Changing antidepressants usually takes about a week; during this time you should be monitored carefully.

If you are offered two medicines to take together, this should usually be started under the care of a specialist. The specialist should advise you that there is a risk of having more side effects than if you were taking a single antidepressant. You should be monitored carefully. In addition to the first antidepressant you may be offered non-antidepressant medication, such as lithium or antipsychotic medication, or you may be offered another antidepressant (such as mianserin or mirtazapine).

If you are offered lithium, you should have blood tests to check your kidneys and thyroid before your treatment starts and every 6 months during treatment, and you may need to have an electrocardiogram (ECG for short) to check your heart. You should also have the lithium levels in your blood measured 1 week after starting lithium, every time the dose is changed and then every 3 months.

If you are taking antipsychotic medication you should have your physical health checked, including your weight, blood pressure, blood sugar levels and cholesterol levels. You should also be asked whether you have had any side effects.

You should not normally be offered buspirone, carbamazepine, lamotrigine, pindolol, valproate or thyroid hormones to take alongside your antidepressant because it's not clear whether these treatments can help people with depression. If your healthcare professional offers you one of these drugs, they should explain why they think it might help and should review the treatment with you after a short time to see if it is helping.

What happens if I don't feel better after either psychological treatment or medication?

If you have tried both psychological treatment and medication separately and they have not helped, you should be offered combined treatment with an antidepressant and cognitive behavioural therapy (CBT).

If you have tried various combinations of medicines or an antidepressant together with CBT and you don't feel better, you may be offered an appointment with a specialist service.

Stopping antidepressants

When it is time to stop taking your antidepressant, this should be done gradually over 4 weeks, although some drugs might need longer (such as paroxetine and venlafaxine). Fluoxetine can be stopped more quickly. You may have symptoms when you stop taking antidepressants or reduce the dose – these can include mood changes, restlessness, sleep problems, dizziness and stomach ache. Symptoms can also occur if you miss doses. These symptoms are usually mild and soon disappear. But they can sometimes be severe, especially if the antidepressant is stopped suddenly.

If you experience severe symptoms while your medication is being reduced or after you have stopped taking it, you should contact your healthcare professional. They might try you on your original dose, or try a similar antidepressant, before gradually reducing the dose again while monitoring your symptoms.

Is there any other support available?

If you have had severe depression for a long time and need extra support, you may be offered social support through a befriending service, as well as any treatment you are having. This should be provided by trained volunteers who will see you at least once a week for between 2 and 6 months. They will talk and listen to you, and offer practical advice and support.

If your depression has lasted a long time, you may need some help to regain your confidence and resume your usual activities, which may mean returning to work. For example, if you have been out of work for some time, your healthcare professional may offer you a place on a rehabilitation programme to help you address these difficulties.

Treatment and care for people who are referred to a specialist mental health service or hospital

People with severe depression who are worried about harming themselves or are at risk of doing so, have hallucinations or delusions, and/or need care from a team of professionals may be referred to a specialist mental health service.

Here your symptoms should be assessed and a member of your care team should discuss in detail with you any previous treatments you have had. They may also talk with you about different treatments you could try, or they may suggest a treatment that you have already tried if there is a reason that could explain why it did not work before.

Your specialist team should develop a 'care plan' with you so that you can receive the treatment and support that is most appropriate for you. It should identify the professionals who are responsible for different aspects of your treatment and care. You and your GP should be given a copy of the plan. The plan should include what should happen in a crisis (a situation where you need help urgently).

If you have severe depression and you and your healthcare professional feel that you are likely to harm yourself or you are finding it difficult to look after yourself, you may be advised to have treatment in hospital. If you need to stay in hospital for treatment, you should be offered the full range of psychological treatments (see table, psychological treatments for depression). Your healthcare professional should make sure that you can continue with the treatment once you leave hospital.

Crisis resolution and home treatment teams can help you to cope with a crisis and care for you after you leave hospital. They will visit you regularly and provide high levels of care and support to help you adjust to being at home.

Electroconvulsive therapy

A course of electroconvulsive therapy (ECT for short) is sometimes used as a treatment for severe depression if there is a risk to the person's life and urgent treatment is required, or for moderate or severe depression when all other treatments have not helped. ECT is always given in hospital under general anaesthetic and works by passing an electric current through the brain. The person may experience some loss of memory.

You should feel able to give your consent to treatment with ECT freely without feeling obliged or forced into making a decision. You should also be reminded that you can withdraw your consent at any time. Your healthcare professional should ideally involve your carer or advocate when discussing consent with you. If you are not well enough to give your consent, your healthcare professional should take into account any written instructions (such as advance decisions) you have made and your advocate or carer should be consulted.

You should be given full and clear information on how ECT works, and an explanation of the advantages and disadvantages. There are different types of ECT (called unilateral or bilateral ECT) and you should be given information about how they compare in terms of how well they work and their side effects.

Your health should be monitored after each session of ECT and the treatment should stop as soon as you feel better, or if the side effects outweigh the benefits. You should also have your memory and cognition (thought processes) assessed before the treatment starts, at least after every three to four sessions of ECT, and at the end of the course of treatment.

If a course of ECT has helped you, you should be offered an antidepressant or you should continue with any antidepressants you are already taking because this can help you to stay well.

If a course of ECT has not helped you, you should be offered another course only after all other possible treatments have been considered and your healthcare professional has discussed the advantages and disadvantages of treatment with you.

Treatment for people with seasonal depression

If you have depression that usually occurs in winter and gets better in the lighter months, your healthcare professional should offer you the same treatments (psychological treatment and/or antidepressants) as for other forms of depression. If you wish to try light therapy instead of the recommended treatments, your healthcare professional should advise you that it is unclear whether light therapy is helpful for people with depression.

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