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Treatments for moderate or severe depression

Treatments for moderate or severe depression

If you have moderate depression, you should be offered an antidepressant or a psychological treatment – this should be either CBT or behavioural couples therapy (see table below).

If you have severe depression, you may be offered both individual CBT (see table below) and an antidepressant.

Psychological treatments for depression in people with a long-term physical health problem (Where possible, treatment should be provided in your preferred language.)

What treatment have I been offered?

What does it involve?

How long does it usually last?

Cognitive behavioural therapy (CBT)

CBT is based on the idea that the way we feel is affected by our thoughts and beliefs and by how we behave. People with depression tend to have negative thoughts (such as 'I am a failure'), which can lead to negative behaviour (such as stopping doing things that used to be pleasurable). CBT encourages people to engage in activities and to write down their thoughts and problems. It helps them to identify and counteract negative thoughts.

  • Group CBT is where a therapist works with a group of six to eight people who have the same physical health problem.

  • Individual CBT takes place in one-to-one sessions with a therapist. It is an option for people with moderate depression who prefer it, if group CBT isn't suitable for them or if a group is not available. It should also be offered to people with severe depression.

Group CBT: usually 6 to 8 weeks.

Individual CBT:

  • usually 6 to 8 weeks for people with moderate depression

  • usually 16 to 18 weeks for people with severe depression

  • follow-up sessions may be added.

Behavioural couples therapy

A treatment that enables couples to understand any links between their behaviour with each other and the symptoms of depression. The aim of the therapy is to help couples develop a more supportive relationship.

Between 15 and 20 sessions over 5 to 6 months.

Taking an antidepressant

Choice of antidepressants

If you decide to start taking an antidepressant, your healthcare professional should discuss with you which antidepressant is most suitable for you. They should take into account:

  • any other physical health problems you may have (in addition to the long-term problem)

  • the side effects of antidepressants that may affect your long-term physical health problem.

Some antidepressants cannot be taken alongside certain types of medication used to treat physical health problems. Your doctor should discuss the risks and benefits of particular antidepressants with you, and monitor you carefully.

You should usually be offered a type of antidepressant called a selective serotonin reuptake inhibitor (or SSRI for short). Ones called citalopram and sertraline are less likely to affect any other medication you are taking. If it is likely that an SSRI will affect your physical health problem or can't be taken alongside your other medication, you may be offered another type of antidepressant. Possibilities include mianserin, mirtazapine, moclobemide, reboxetine or trazodone.

Certain medicines should only be prescribed by a specialist mental health professional, including:

  • a type of antidepressant called a non-reversible monoamine oxidase inhibitor (such as phenelzine)

  • lithium in addition to an antidepressant

  • two antidepressants taken together.

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.

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 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, or the antidepressant is causing distressing side effects, your healthcare professional may discuss a range of options with you. These might include psychological treatment or trying a different antidepressant. When changing antidepressants, the dose should be increased gradually and you should be monitored carefully.

Stopping antidepressants

If an antidepressant has helped you, your healthcare professional should encourage you to continue taking it for at least 6 months after you feel better. This reduces the risk of your depression coming back. They should then discuss with you whether you need to stay on medication after this.

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.

Further treatment and support

If you do not feel better after taking an antidepressant and having psychological treatment, you may be offered long-term treatment and support from a dedicated team of healthcare professionals – this is called 'collaborative care'. One of these professionals (called the 'care coordinator') will coordinate the treatment of both your depression and your physical health problem. Other people involved will usually include:

  • your GP

  • anyone else who is providing care for your physical health problem

  • specialist mental health professionals, such as a psychiatrist.

As part of collaborative care you will be offered the same range of treatments as described in this information.

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