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'''Management of depression''' is the treatment of [[Depression (mood)|depression]] that may involve a number of different therapies: medications, [[behavior therapy]], [[psychotherapy]], and [[medical device]]s.
[[Depression (mood)|Depression]] is a symptom of some physical diseases; a [[side effect]] of some drugs and medical treatments; and a symptom of some [[mood disorders]] such as [[major depressive disorder]] or [[dysthymia]].<ref name="DSM-5(2013)">{{cite book |title= Diagnostic and Statistical Manual of Mental Disorders | edition = Fifth Edition (DSM-5) |year= 2013 |publisher= American Psychiatric Association }}</ref>
Though [[psychiatric medication]] is the most frequently prescribed therapy for major depression,<ref name="Carson_2000">{{cite book | vauthors = Carson VB | date = 2000 | url = https://books.google.com/books?id=QM5rAAAAMAAJ | title = Mental health nursing: the nurse-patient journey | publisher = W.B. Saunders | isbn = 978-0-7216-8053-8 | page = 423 | access-date = 2016-09-24 | archive-date = 2023-01-11 | archive-url = https://web.archive.org/web/20230111101323/https://books.google.com/books?id=QM5rAAAAMAAJ | url-status = live }}</ref> [[psychotherapy]] may be effective, either alone or in combination with medication.<ref name="merckmanuals.com">{{cite book | chapter-url = http://www.merckmanuals.com/professional/psychiatric_disorders/mood_disorders/depressive_disorders.html#v1028131 | chapter = Psychotherapy
Psychotherapy is the treatment of choice in those under the age of 18, with medication offered only in conjunction with the former and generally not as a first line agent. The possibility of depression, substance misuse or other mental health problems in the parents should be considered and, if present and if it may help the child, the parent should be treated in parallel with the child.<ref name=NICEkids5>{{cite book |author=NICE |title=NICE Guidelines:depression in children and adolescents |publisher=
== Psychotherapy and behavior therapy ==
{{Main|Psychotherapy}}
There are a number of different psychotherapies for depression which are provided to individuals or groups by psychotherapists, psychiatrists, psychologists, [[clinical social work]]ers, counselors or psychiatric nurses. With more chronic forms of depression, the most effective treatment is often considered to be a combination of medication and psychotherapy.<ref name="merckmanuals.com"/><ref name="Thase_1999">{{cite journal | vauthors = Thase ME | title = When are psychotherapy and pharmacotherapy combinations the treatment of choice for major depressive disorder? | journal = The Psychiatric Quarterly | volume = 70 | issue = 4 | pages = 333–346 | year = 1999 | pmid = 10587988 | doi = 10.1023/A:1022042316895 | s2cid = 45091134 }}</ref> Psychotherapy is the treatment of choice in people under 18.<ref name=NICEkids5/> A meta-analysis examined the effectiveness of psychotherapy for depression across ages from younger than 13 years to older than 75 years. It summarizes results from 366 trials included 36,702 patients. It found that the best results were for young adults, with an average [[effect size]] of ''g''=.98 ([[Confidence interval|95% ''CI'']], 0.
As the most studied form of psychotherapy for depression, ''[[cognitive behavioral therapy]]'' (CBT) is thought to work by teaching clients to learn a set of cognitive and behavioral skills, which they can employ on their own. Earlier research suggested that cognitive behavioral therapy was not as effective as antidepressant medication in the treatment of depression; however, more recent research suggests that it can perform as well as antidepressants in treating patients with moderate to severe depression.<ref>{{cite book | vauthors = Roth A, Fonagy P |year=2006 |chapter=Cognitive-Behavioral Therapy Alone and in Combination with medication: University of Minnesota and University of Pennsylvania–Vanderbilt University Studies |chapter-url=https://books.google.com/books?id=tCQbJTsUPz4C&pg=PA76 |pages=76–8 |title=What Works for Whom?: A Critical Review of Psychotherapy Research |edition=2nd |publisher=Guilford Press |isbn=978-1-59385-272-6}}</ref> Beck's treatment manual, ''Cognitive therapy of depression'', has undergone the most research and accumulated the most evidence for its use.<ref>{{cite book | vauthors = Beck AT, Rush J, Shaw B, Emery G | title = Cognitive therapy of depression. | location = New York | publisher = Guilford Press | date = 1979 }}</ref><ref>{{cite journal | vauthors = Pagano J, Kyle BN, Johnson TL | title = A Manual by Any Other Name: Identifying Psychotherapy Manuals for Resident Training | journal = Academic Psychiatry | volume = 41 | issue = 1 | pages = 44–50 | date = February 2017 | pmid = 27048607 | doi = 10.1007/s40596-016-0492-4 | name-list-style = vanc | s2cid = 26071140 }}</ref><ref>{{cite journal | vauthors = Pagano J, Kyle BN, Johnson TL, Saeed SA | title = Training Psychiatry Residents in Psychotherapy: The Role of Manualized Treatments | journal = The Psychiatric Quarterly | volume = 88 | issue = 2 | pages = 285–294 | date = June 2017 | pmid = 27785752 | doi = 10.1007/s11126-016-9476-5 | name-list-style = vanc | s2cid = 3440253 }}</ref> However, a number of other CBT manuals also have evidence to support their effectiveness with depression.<ref>{{cite book | vauthors = Beck JS | title = Cognitive therapy: basics and beyond. | location = New York | publisher = Guilford Press | date = 1995 }}</ref><ref>{{cite book | vauthors = DeRubeis RJ, Beck AK | chapter = Cognitive therapy. | veditors = Dobson KS | title = Handbook of cognitive behavioral therapies. | location = New York | publisher = Guilford Press | date = 1988 | pages = 273–306 }}</ref><ref>{{cite book | vauthors = Munoz RF, Miranda J | title = Group therapy for cognitive behavioral treatment of depression. | location = San Francisco | publisher = San Francisco General Hospital Depression Clinic | date = 1986 }}</ref><ref>{{cite book | vauthors = Yost EB, Beutler LE, Corbishley MA, Allender JR | title = Group cognitive therapy: a treatment approach for depressed older adults. | location = Elmsford | publisher = Pergamon | date = 1986 }}</ref>
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A systematic review of data comparing low-intensity CBT (such as guided self-help by means of written materials and limited professional support, and website-based interventions) with usual care found that patients who initially had more severe depression benefited from low-intensity interventions at least as much as less-depressed patients.<ref name=BMJ>{{cite journal | vauthors = Bower P, Kontopantelis E, Sutton A, Kendrick T, Richards DA, Gilbody S, Knowles S, Cuijpers P, Andersson G, Christensen H, Meyer B, Huibers M, Smit F, van Straten A, Warmerdam L, Barkham M, Bilich L, Lovell K, Liu ET | display-authors = 6 | title = Influence of initial severity of depression on effectiveness of low intensity interventions: meta-analysis of individual patient data | journal = BMJ | volume = 346 | pages = f540 | date = February 2013 | pmid = 23444423 | pmc = 3582703 | doi = 10.1136/bmj.f540 }}</ref>
A smartphone application designed to treat depression using the principles of Cognitive Behavioral Therapy, named [[Rejoyn]], was approved by the US FDA in 2024.<ref name="rejoyn-fda-approval">{{cite web |last1=FDA Newsroom |title=FDA Roundup: April 2nd, 2024 |url=https://www.fda.gov/news-events/press-announcements/fda-roundup-april-2-2024 |website=FDA Press Releases |publisher=US Food and Drug Administration |access-date=4 April 2024 |date=2024-04-02}}</ref>
For the treatment of [[Depression in childhood and adolescence|adolescent depression]], one published study found that CBT without medication performed no better than a [[placebo]], and significantly worse than the antidepressant [[fluoxetine]]. However, the same article reported that CBT and fluoxetine outperformed treatment with only fluoxetine.<ref>{{cite journal | vauthors = March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J | display-authors = 6 | title = Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial | journal = JAMA | volume = 292 | issue = 7 | pages = 807–820 | date = August 2004 | pmid = 15315995 | doi = 10.1001/jama.292.7.807 }}</ref> Combining fluoxetine with CBT appeared to bring no additional benefit in two different studies<ref>{{cite journal | vauthors = Goodyer I, Dubicka B, Wilkinson P, Kelvin R, Roberts C, Byford S, Breen S, Ford C, Barrett B, Leech A, Rothwell J, White L, Harrington R | display-authors = 6 | title = Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial | journal = BMJ | volume = 335 | issue = 7611 | pages = 142 | date = July 2007 | pmid = 17556431 | pmc = 1925185 | doi = 10.1136/bmj.39224.494340.55 }}</ref><ref>{{cite journal | vauthors = Goodyer IM, Dubicka B, Wilkinson P, Kelvin R, Roberts C, Byford S, Breen S, Ford C, Barrett B, Leech A, Rothwell J, White L, Harrington R | display-authors = 6 | title = A randomised controlled trial of cognitive behaviour therapy in adolescents with major depression treated by selective serotonin reuptake inhibitors. The ADAPT trial | journal = Health Technology Assessment | volume = 12 | issue = 14 | pages = iii–iv, ix–60 | date = May 2008 | pmid = 18462573 | doi = 10.3310/hta12140 | doi-access = free }}</ref> or, at the most, only marginal benefit, in a fourth study.<ref>{{cite journal | vauthors = Domino ME, Burns BJ, Silva SG, Kratochvil CJ, Vitiello B, Reinecke MA, Mario J, March JS | display-authors = 6 | title = Cost-effectiveness of treatments for adolescent depression: results from TADS | journal = The American Journal of Psychiatry | volume = 165 | issue = 5 | pages = 588–596 | date = May 2008 | pmid = 18413703 | doi = 10.1176/appi.ajp.2008.07101610 }}</ref>▼
▲For the treatment of [[Depression in childhood and adolescence|adolescent depression]], one published study found that CBT without medication performed no better than a [[placebo]], and significantly worse than the antidepressant [[fluoxetine]]. However, the same article reported that CBT and fluoxetine outperformed treatment with only fluoxetine.<ref>{{cite journal | vauthors = March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J | display-authors = 6 | title = Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial | journal = JAMA | volume = 292 | issue = 7 | pages = 807–820 | date = August 2004 | pmid = 15315995 | doi = 10.1001/jama.292.7.807 | doi-access = free }}</ref> Combining fluoxetine with CBT appeared to bring no additional benefit in two different studies<ref>{{cite journal | vauthors = Goodyer I, Dubicka B, Wilkinson P, Kelvin R, Roberts C, Byford S, Breen S, Ford C, Barrett B, Leech A, Rothwell J, White L, Harrington R | display-authors = 6 | title = Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial | journal = BMJ | volume = 335 | issue = 7611 | pages = 142 | date = July 2007 | pmid = 17556431 | pmc = 1925185 | doi = 10.1136/bmj.39224.494340.55 }}</ref><ref>{{cite journal | vauthors = Goodyer IM, Dubicka B, Wilkinson P, Kelvin R, Roberts C, Byford S, Breen S, Ford C, Barrett B, Leech A, Rothwell J, White L, Harrington R | display-authors = 6 | title = A randomised controlled trial of cognitive behaviour therapy in adolescents with major depression treated by selective serotonin reuptake inhibitors. The ADAPT trial | journal = Health Technology Assessment | volume = 12 | issue = 14 | pages = iii–iv, ix–60 | date = May 2008 | pmid = 18462573 | doi = 10.3310/hta12140 | doi-access = free }}</ref> or, at the most, only marginal benefit, in a fourth study.<ref>{{cite journal | vauthors = Domino ME, Burns BJ, Silva SG, Kratochvil CJ, Vitiello B, Reinecke MA, Mario J, March JS | display-authors = 6 | title = Cost-effectiveness of treatments for adolescent depression: results from TADS | journal = The American Journal of Psychiatry | volume = 165 | issue = 5 | pages = 588–596 | date = May 2008 | pmid = 18413703 | doi = 10.1176/appi.ajp.2008.07101610 }}</ref>
[[Behavior therapy]] for depression is sometimes referred to as [[behavioral activation]].<ref>{{cite journal | vauthors = Hopko DR, Lejuez CW, LePage JP, Hopko SD, McNeil DW | title = A brief behavioral activation treatment for depression. A randomized pilot trial within an inpatient psychiatric hospital | journal = Behavior Modification | volume = 27 | issue = 4 | pages = 458–469 | date = September 2003 | pmid = 12971122 | doi = 10.1177/0145445503255489 | url = http://web.utk.edu/~dhopko/BAinpatient.pdf | url-status = dead | s2cid = 30950124 | archive-url = https://web.archive.org/web/20150402162244/http://web.utk.edu/~dhopko/BAinpatient.pdf | archive-date = 2015-04-02 }}</ref> In addition, behavioral activation appears to take less time and lead to longer lasting change.<ref>{{cite journal | vauthors = Spates CR, Pagoto SL, Kalata A | year = 2006 | title = A Qualitative And Quantitative Review of Behavioral Activation Treatment of Major Depressive Disorder | journal = The Behavior Analyst Today | volume = 7 | issue = 4| pages = 508–518 | doi=10.1037/h0100089|url=https://escholarship.umassmed.edu/cgi/viewcontent.cgi?article=1106&context=prevbeh_pp }}</ref> Two well-researched treatment manuals include ''Social skills training for depression''<ref>{{cite journal | vauthors = Bellack AS, Hersen M, Himmelhoch J | title = Social skills training for depression: a treatment manual. | journal = J Select Ab Serv Cat Select Doc Psychol. | date = 1981 | volume = 10 | pages = 36–92 }}</ref> and ''Behavioral activation treatment for depression''.<ref>{{cite journal | vauthors = Jacobson NS, Martell CR, Dimidjian S | title = Behavioral activation treatment for depression: Returning to contextual roots. | journal = Clinical Psychology: Science and Practice | date = September 2001 | volume = 8 | issue = 3 | pages = 255–70 | doi = 10.1093/clipsy.8.3.255 }}</ref>▼
▲[[Behavior therapy]] for depression is sometimes referred to as [[behavioral activation]].<ref>{{cite journal | vauthors = Hopko DR, Lejuez CW, LePage JP, Hopko SD, McNeil DW | title = A brief behavioral activation treatment for depression. A randomized pilot trial within an inpatient psychiatric hospital | journal = Behavior Modification | volume = 27 | issue = 4 | pages = 458–469 | date = September 2003 | pmid = 12971122 | doi = 10.1177/0145445503255489 | url = http://web.utk.edu/~dhopko/BAinpatient.pdf | url-status = dead | s2cid = 30950124 | archive-url = https://web.archive.org/web/20150402162244/http://web.utk.edu/~dhopko/BAinpatient.pdf | archive-date = 2015-04-02 }}</ref> In addition, behavioral activation appears to take less time and lead to longer lasting change.<ref>{{cite journal | vauthors = Spates CR, Pagoto SL, Kalata A | year = 2006 | title = A Qualitative And Quantitative Review of Behavioral Activation Treatment of Major Depressive Disorder | journal = The Behavior Analyst Today | volume = 7 | issue = 4 | pages = 508–518 | doi = 10.1037/h0100089 | s2cid = 3337916 | url = https://escholarship.umassmed.edu/cgi/viewcontent.cgi?article=1106&context=prevbeh_pp | access-date = 2019-07-14 | archive-date = 2022-02-21 | archive-url = https://web.archive.org/web/20220221073529/https://escholarship.umassmed.edu/cgi/viewcontent.cgi?article=1106&context=prevbeh_pp | url-status = live }}</ref> Two well-researched treatment manuals include ''Social skills training for depression''<ref>{{cite journal | vauthors = Bellack AS, Hersen M, Himmelhoch J | title = Social skills training for depression: a treatment manual. | journal = J Select Ab Serv Cat Select Doc Psychol. | date = 1981 | volume = 10 | pages = 36–92 }}</ref> and ''Behavioral activation treatment for depression''.<ref>{{cite journal | vauthors = Jacobson NS, Martell CR, Dimidjian S | title = Behavioral activation treatment for depression: Returning to contextual roots. | journal = Clinical Psychology: Science and Practice | date = September 2001 | volume = 8 | issue = 3 | pages = 255–70 | doi = 10.1093/clipsy.8.3.255 }}</ref>
[[Emotionally focused therapy]], founded by Sue Johnson and Les Greenberg in 1985, treats depression by identifying and processing underlying emotions. The treatment manual, ''Facilitating emotional change'', outlines treatment techniques.<ref>{{cite book | vauthors = Greenberg LS, Rice LN, Elliott R | title = Facilitating emotional change: the moment-by-moment process. | location = New York | publisher = Guilford Press | date = 1993 }}</ref>▼
▲[[Emotionally focused therapy]], founded by Sue Johnson and Les Greenberg in 1985, treats depression by identifying and processing underlying emotions. The treatment manual, ''Facilitating emotional change'', outlines treatment techniques.<ref>{{cite book | vauthors = Greenberg LS, Rice LN, Elliott R | title = Facilitating emotional change: the moment-by-moment process. | location = New York | publisher = Guilford Press | date = 1993 }}</ref> This kind of therapy assumes that our emotions have a strong connection to our sense of identity. It believes that if we are able to foster and understand our emotions, our sense of identity will be healed as a result.
[[Acceptance and commitment therapy]] (ACT), a mindfulness form of CBT, which has its roots in behavior analysis, also demonstrates that it is effective in treating depression, and can be more helpful than traditional CBT, especially where depression is accompanied by anxiety and where it is resistant to traditional CBT.<ref>{{cite journal | vauthors = Ruiz FJ |year=2010 |title=A review of Acceptance and Commitment Therapy (ACT) empirical evidence: Correlational, experimental psychopathology, component and outcome studies |journal=International Journal of Psychology and Psychological Therapy |volume=10 |issue=1 |pages=125–62 |url=http://www.ijpsy.com/volumen10/num1/256.html}}</ref><ref>{{cite web|title=APA website on empirical treatments |url=http://www.div12.org/PsychologicalTreatments/treatments.html |access-date=2009-09-01 |url-status=dead |archive-url=https://web.archive.org/web/20101005034058/http://www.div12.org/PsychologicalTreatments/treatments.html |archive-date=2010-10-05 }}</ref><ref name="evidence">{{cite web | vauthors = Hayes S |author-link=Steven C. Hayes |title=State of the ACT Evidence |publisher=ContextualPsychology.org |url=http://www.contextualpsychology.org/state_of_the_act_evidence/}}</ref>▼
▲[[Acceptance and commitment therapy]] (ACT), a mindfulness form of CBT, which has its roots in behavior analysis, also demonstrates that it is effective in treating depression, and can be more helpful than traditional CBT, especially where depression is accompanied by anxiety and where it is resistant to traditional CBT.<ref>{{cite journal |
A review of four studies on the effectiveness of [[mindfulness-based cognitive therapy]] (MBCT), a recently developed class-based program designed to prevent relapse, suggests that MBCT may have an additive effect when provided with the usual care in patients who have had three or more depressive episodes, although the usual care did not include antidepressant treatment or any psychotherapy, and the improvement observed may have reflected non-specific or placebo effects.<ref>{{cite journal | vauthors = Coelho HF, Canter PH, Ernst E | title = Mindfulness-based cognitive therapy: evaluating current evidence and informing future research | journal = Journal of Consulting and Clinical Psychology | volume = 75 | issue = 6 | pages = 1000–1005 | date = December 2007 | pmid = 18085916 | doi = 10.1037/0022-006X.75.6.1000 }}</ref> Of note, although ''Mindfulness-based cognitive therapy for depression'' prevented relapse of future depressive episodes, there is no research on whether it can cause the remission of a current depressive episode.<ref>{{cite book | vauthors = Segal ZV, Williams JM, Teasdale JD | title = Mindfulness-based cognitive therapy for depression: a new approach to preventing relapse. | location = New York | publisher = Guilford Press | date = 2002 }}</ref>
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''[[Interpersonal psychotherapy]]'' (IPT) focuses on the social and interpersonal triggers that may cause depression. There is evidence that it is an effective treatment for depression.<ref>{{cite book | vauthors = Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES | title = Interpersonal psychotherapy of depression. | location = New York | publisher = Basic Books | date = 1984 }}</ref><ref>{{cite journal | vauthors = Lipsitz JD, Markowitz JC | title = Mechanisms of change in interpersonal therapy (IPT) | journal = Clinical Psychology Review | volume = 33 | issue = 8 | pages = 1134–1147 | date = December 2013 | pmid = 24100081 | pmc = 4109031 | doi = 10.1016/j.cpr.2013.09.002 }}</ref><ref name="Cuijpers_2011">{{cite journal | vauthors = Cuijpers P, Geraedts AS, van Oppen P, Andersson G, Markowitz JC, van Straten A | title = Interpersonal psychotherapy for depression: a meta-analysis | journal = The American Journal of Psychiatry | volume = 168 | issue = 6 | pages = 581–592 | date = June 2011 | pmid = 21362740 | pmc = 3646065 | doi = 10.1176/appi.ajp.2010.10101411 }}</ref> Here, the therapy takes a fairly structured course (often 12 sessions, as in the original research versions) as in the case with CBT; however, the focus is on relationships with others. Unlike family therapy, IPT is an individual format, so it is possible to work on interpersonal themes even if other family members do not come to the session. Therapy can be used to help a person develop or improve [[interpersonal skills]] in order to allow him or her to communicate more effectively and reduce stress.<ref>{{cite book |vauthors=Weissman MM, Markowitz JC, Klerman GL |title=Comprehensive Guide to Interpersonal Psychotherapy |publisher=Basic Books |location=New York |year=2000 |isbn= 978-0-465-09566-7}}<!--PAGE NUMBER NEEDED--></ref> In a meta-analysis of 16 studies and 4,356 patients, the average improvement in depressive symptoms was an [[effect size]] of ''d'' = 0.63 (95% ''CI'', 0.36 to 0.90).<ref name="Cuijpers_2011" /> IPT combined with pharmacotherapy was more effective in preventing relapse than pharmacotherapy alone, number needed to treat = 7.63.<ref name="Cuijpers_2011" />
''[[Psychoanalysis]]'', a school of thought founded by [[Sigmund Freud]] that emphasizes the resolution of unconscious mental conflicts,<ref>{{cite book |author=Dworetzky J |title= Psychology |publisher=Brooks/Cole Pub. Co |location=Pacific Grove, CA, USA |year=1997 |pages=602 |isbn=978-0-314-20412-7}}</ref> is used by its practitioners to treat clients presenting with major depression.<ref>{{cite journal | vauthors = Doidge N, Simon B, Lancee WJ, First M, Brunshaw J, Brauer L, Grant DC, Stevens A, Oldham JM, Mosher P | display-authors = 6 | title = Psychoanalytic patients in the U.S., Canada, and Australia: II. A DSM-III-R validation study | journal = Journal of the American Psychoanalytic Association | volume = 50 | issue = 2 | pages = 615–627 | year = 2002 | pmid = 12206545 | doi = 10.1177/00030651020500021101 | s2cid = 25110425 }}</ref> A more widely practiced technique, called ''[[psychodynamic psychotherapy]]'', is loosely based on psychoanalysis and has an additional social and interpersonal focus.<ref>{{cite book |vauthors=Durand VM, Barlow D |title=Abnormal psychology: An integrative approach |url=https://archive.org/details/abnormalpsycholo0000barl_j5m2 |url-access=registration |publisher=Brooks/Cole Pub. Co |location=Pacific Grove, CA, USA |year=1999 |isbn= 978-0-534-34742-0}}<!--PAGE NUMBER NEEDED--></ref> In a meta-analysis of three controlled trials, psychodynamic psychotherapy was found to be as effective as medication for mild to moderate depression.<ref>{{cite journal | vauthors = de Maat S, Dekker J, Schoevers R, van Aalst G, Gijsbers-van Wijk C, Hendriksen M, Kool S, Peen J, Van R, de Jonghe F | display-authors = 6 | title = Short psychodynamic supportive psychotherapy, antidepressants, and their combination in the treatment of major depression: a mega-analysis based on three randomized clinical trials | journal = Depression and Anxiety | volume = 25 | issue = 7 | pages = 565–574 | date = June 2007 | pmid = 17557313 | doi = 10.1002/da.20305 | s2cid = 20373635 | doi-access = free }}</ref>
=== Shared care ===
Shared decision making is an approach whereby patients and clinicians freely share important evidence when tasked with decision making and where patients are guided to consider the best available options to make an informed decision.<ref>{{cite journal | vauthors = Sanda MG, Cadeddu JA, Kirkby E, Chen RC, Crispino T, Fontanarosa J, Freedland SJ, Greene K, Klotz LH, Makarov DV, Nelson JB, Rodrigues G, Sandler HM, Taplin ME, Treadwell JR | display-authors = 6 | title = Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Part I: Risk Stratification, Shared Decision Making, and Care Options | journal = The Journal of Urology | volume = 199 | issue = 3 | pages = 683–690 | date = March 2018 | pmid = 29203269 | doi = 10.1016/j.juro.2017.11.095 | publisher = Ovid Technologies (Wolters Kluwer Health) | s2cid = 21405694 }}</ref> The principles are well documented, but there is a gap in that it's hard to apply them in routine clinical practice.
Depression is a major problem globally, affecting an estimated 4.4 percent of the world population in 2017, roughly equivalent to 300 million people.<ref>{{cite report |title=Depression and Other Common Mental Disorders: Global Health Estimates |date=2017 |publisher=World Health Organisation |location=Geneva |page=5 |url=https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf |access-date=17 January 2022 |archive-date=20 January 2022 |archive-url=https://web.archive.org/web/20220120033754/https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf |url-status=live }}</ref> The depression is multifactorial and has been on the increase due to societal pressure, genetic association and increase in use of drugs (Zhang et al. 2016){{Full citation needed|date=February 2019}}. incorporation of nursing in management of depression may seem important in that nursing hold a pivotal role in health care delivery where they are they are the health practitioners that have been trained to be versatile from clinical to psychological care Their incorporation shared decision making in treating depression may be important as nurses are known to have the best interpersonal relationship with the patients thus a better collaborative model can be achieved due to this fact (Williams et al. 2016){{Full citation needed|date=February 2019}}. With this in mind, the nurses may serve to administer drugs in management, prepare and maintain the patient's records, interaction with other care staff to achieve optimum care, and organizing therapy sessions (Lu et al. 2019){{Full citation needed|date=February 2019}}.
Kathleen Walsh, 2017, recognizes that Dr. Velligan{{who|date=January 2022|reason=There is no context for who Velligan is or why we should care what they said.}} stated that SDM is of importance in demonstrating patient preferences in decision making when there is no clear approach to treatment. In addition, numerous tools can be used to make the decision making the process easier these include the Controlled Preferences Scale that informs clinicians on how to actively involve patients. She further gives the suggestion that providers need to embrace shared decision making by making sure the patients participate actively in their management thus enabling the success of the model.<ref>{{cite journal | vauthors = Walsh K, Sandars J | title = Shared decision-making tools: do they really involve patients? | journal = British Journal of Hospital Medicine | volume = 78 | issue = 6 | pages = 304–305 | date = June 2017 | pmid = 28614022 | doi = 10.12968/hmed.2017.78.6.304 | publisher = Mark Allen Group | url = https://research.edgehill.ac.uk/en/publications/0d29f628-5514-4c7c-b49e-fc6effb40817 | access-date = 2022-06-11 | archive-date = 2024-02-24 | archive-url = https://web.archive.org/web/20240224184811/https://research.edgehill.ac.uk/en/publications/shared-decision-making-toolsdo-they-really-involve-patients-2 | url-status = live }}</ref>
== Medication ==
{{see also|List of antidepressants}}
To find the most effective [[pharmaceutical drug]] treatment, the dosages of medications must often be adjusted, different combinations of antidepressants tried, or antidepressants changed.{{citation needed|date=April 2023}} Some of the medications have side effects that affect certain people in different ways. The combinations of medication can change these side effects, so it is essential to monitor the changes that occur once we begin medication.
=== Selective serotonin reuptake inhibitors ===
[[Selective serotonin reuptake inhibitors]] (SSRIs), such as [[sertraline]] (Zoloft, Lustral), [[escitalopram]] (Lexapro, Cipralex), [[fluoxetine]] (Prozac), [[paroxetine]] (Seroxat), and [[citalopram]], are the primary medications considered, due to their relatively mild side effects and broad effect on the symptoms of depression and anxiety, as well as reduced risk in overdose, compared to their older tricyclic alternatives. Those who do not respond to the first SSRI tried can be switched to another. If sexual dysfunction is present prior to the onset of depression, SSRIs should be avoided.<ref>{{cite journal | vauthors = Sutherland JE, Sutherland SJ, Hoehns JD | title = Achieving the best outcome in treatment of depression | journal = The Journal of Family Practice | volume = 52 | issue = 3 | pages = 201–209 | date = March 2003 | pmid = 12620174 | url = http://www.jfponline.com/Pages.asp?AID=1406 | url-status = dead | archive-url = https://web.archive.org/web/20091002083433/http://www.jfponline.com/Pages.asp?AID=1406 | archive-date = 2009-10-02 }}</ref> Another popular option is to switch to the atypical antidepressant [[bupropion]] (Wellbutrin) or to add bupropion to the existing therapy;<ref>{{cite journal | vauthors = Zisook S, Rush AJ, Haight BR, Clines DC, Rockett CB | title = Use of bupropion in combination with serotonin reuptake inhibitors | journal = Biological Psychiatry | volume = 59 | issue = 3 | pages = 203–210 | date = February 2006 | pmid = 16165100 | doi = 10.1016/j.biopsych.2005.06.027 | s2cid = 20997303 }}</ref> this strategy is possibly more effective.<ref>{{cite journal | vauthors = Rush AJ, Trivedi MH, Wisniewski SR, Stewart JW, Nierenberg AA, Thase ME, Ritz L, Biggs MM, Warden D, Luther JF, Shores-Wilson K, Niederehe G, Fava M | display-authors = 6 | title = Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression | journal = The New England Journal of Medicine | volume = 354 | issue = 12 | pages = 1231–1242 | date = March 2006 | pmid = 16554525 | doi = 10.1056/NEJMoa052963 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Trivedi MH, Fava M, Wisniewski SR, Thase ME, Quitkin F, Warden D, Ritz L, Nierenberg AA, Lebowitz BD, Biggs MM, Luther JF, Shores-Wilson K, Rush AJ | display-authors = 6 | title = Medication augmentation after the failure of SSRIs for depression | journal = The New England Journal of Medicine | volume = 354 | issue = 12 | pages = 1243–1252 | date = March 2006 | pmid = 16554526 | doi = 10.1056/NEJMoa052964 | doi-access = free }}</ref> It is not uncommon for SSRIs to cause or worsen insomnia; the sedating [[noradrenergic and specific serotonergic antidepressant]] (NaSSA) antidepressant [[mirtazapine]] (Zispin, Remeron) can be used in such cases.<ref>{{cite journal | vauthors = Mayers AG, Baldwin DS | title = Antidepressants and their effect on sleep | journal = Human Psychopharmacology | volume = 20 | issue = 8 | pages = 533–559 | date = December 2005 | pmid = 16229049 | doi = 10.1002/hup.726 | s2cid = 17912673 }}</ref><ref>{{cite journal | vauthors = Winokur A, DeMartinis NA, McNally DP, Gary EM, Cormier JL, Gary KA | title = Comparative effects of mirtazapine and fluoxetine on sleep physiology measures in patients with major depression and insomnia | journal = The Journal of Clinical Psychiatry | volume = 64 | issue = 10 | pages = 1224–1229 | date = October 2003 | pmid = 14658972 | doi = 10.4088/JCP.v64n1013 }}</ref><ref>{{cite journal | vauthors = Lawrence RW | title = Effect of mirtazapine versus fluoxetine on "sleep quality" | journal = The Journal of Clinical Psychiatry | volume = 65 | issue = 8 | pages = 1149–1150 | date = August 2004 | pmid = 15323610 | doi = 10.4088/JCP.v65n0818i | doi-access = free }}</ref>
For children and adolescents with moderate-to-severe depressive disorder, fluoxetine seems to be the best treatment (either with or without [[Cognitive behavioral therapy|cognitive behavioural therapy]]) but more research is needed to be certain.<ref name="NIHR_Prozac">{{Cite journal |date=2020-10-12 |title=Prozac may be the best treatment for young people with depression – but more research is needed |url=https://evidence.nihr.ac.uk/alert/prozac-may-be-the-best-treatment-for-young-people-with-depression-but-more-research-is-needed/ |journal=NIHR Evidence |type=Plain English summary |language=en |publisher=National Institute for Health and Care Research |doi=10.3310/alert_41917 |s2cid=242952585 |access-date=2022-11-06 |archive-date=2022-11-06 |archive-url=https://web.archive.org/web/20221106195344/https://evidence.nihr.ac.uk/alert/prozac-may-be-the-best-treatment-for-young-people-with-depression-but-more-research-is-needed/ |url-status=live }}</ref><ref name="Zhou_2020">{{cite journal | vauthors = Zhou X, Teng T, Zhang Y, Del Giovane C, Furukawa TA, Weisz JR, Li X, Cuijpers P, Coghill D, Xiang Y, Hetrick SE, Leucht S, Qin M, Barth J, Ravindran AV, Yang L, Curry J, Fan L, Silva SG, Cipriani A, Xie P | display-authors = 6 | title = Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: a systematic review and network meta-analysis | journal = The Lancet. Psychiatry | volume = 7 | issue = 7 | pages = 581–601 | date = July 2020 | pmid = 32563306 | pmc = 7303954 | doi = 10.1016/S2215-0366(20)30137-1 }}</ref><ref name="Boaden_2020">{{cite journal | vauthors = Boaden K, Tomlinson A, Cortese S, Cipriani A | title = Antidepressants in Children and Adolescents: Meta-Review of Efficacy, Tolerability and Suicidality in Acute Treatment | journal = Frontiers in Psychiatry | volume = 11 | pages = 717 | date = 2020-09-02 | pmid = 32982805 | pmc = 7493620 | doi = 10.3389/fpsyt.2020.00717 | doi-access = free }}</ref><ref name="Hetrick_2021">{{cite journal | vauthors = Hetrick SE, McKenzie JE, Bailey AP, Sharma V, Moller CI, Badcock PB, Cox GR, Merry SN, Meader N | display-authors = 6 | title = New generation antidepressants for depression in children and adolescents: a network meta-analysis | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 5 | pages = CD013674 | date = May 2021 | pmid = 34029378 | pmc = 8143444 | doi = 10.1002/14651858.CD013674.pub2 | editor-last = Cochrane Common Mental Disorders Group }}</ref> Sertraline, escitalopram, [[duloxetine]] might also help in reducing symptoms.<ref name="Hetrick_2021" /> In the UK fluoxetine and escitalopram are the only antidepressants recommended for people under the age of 18, though, if a child or adolescent patient is intolerant to fluoxetine, another SSRI may be considered.<ref>{{Cite web |title=Overview {{!}} Depression in children and young people: identification and management {{!}} Guidance {{!}} NICE |url=https://www.nice.org.uk/guidance/ng134 |access-date=2022-11-06 |website=www.nice.org.uk |date=25 June 2019 |archive-date=2022-10-29 |archive-url=https://web.archive.org/web/20221029101150/https://www.nice.org.uk/guidance/ng134/ |url-status=live }}</ref>
Evidence of effectiveness of SSRIs in those with depression complicated by [[dementia]] is lacking.<ref>{{cite journal | vauthors = Nelson JC, Devanand DP | title = A systematic review and meta-analysis of placebo-controlled antidepressant studies in people with depression and dementia | journal = Journal of the American Geriatrics Society | volume = 59 | issue = 4 | pages = 577–585 | date = April 2011 | pmid = 21453380 | doi = 10.1111/j.1532-5415.2011.03355.x | s2cid = 2592434 }}</ref>
Line 57 ⟶ 59:
=== Serotonin norepinephrine reuptake inhibitor ===
[[Venlafaxine]] (Effexor) from the SNRI class may be moderately more effective than SSRIs;<ref>{{cite journal | vauthors = Papakostas GI, Thase ME, Fava M, Nelson JC, Shelton RC | title = Are antidepressant drugs that combine serotonergic and noradrenergic mechanisms of action more effective than the selective serotonin reuptake inhibitors in treating major depressive disorder? A meta-analysis of studies of newer agents | journal = Biological Psychiatry | volume = 62 | issue = 11 | pages = 1217–1227 | date = December 2007 | pmid = 17588546 | doi = 10.1016/j.biopsych.2007.03.027 | s2cid = 45621773 }}</ref> however, it is not recommended as a first-line treatment because of the higher rate of side effects,<ref>{{cite journal | vauthors = Cipriani A, Geddes JR, Barbui C | title = Venlafaxine for major depression | journal = BMJ | volume = 334 | issue = 7587 | pages = 215–216 | date = February 2007 | pmid = 17272528 | pmc = 1790758 | doi = 10.1136/bmj.39098.457720.BE }}</ref> and its use is specifically discouraged in children and adolescents.<ref name="nice.org.uk">{{cite web |url=http://www.nice.org.uk/Guidance/CG28 |title=Depression in children and young people: identification and management in primary, community and secondary care |date=September 2005 |publisher=NHS National Institute for Health and Clinical Excellence |access-date=2008-08-17 |archive-date=2022-10-17 |archive-url=https://web.archive.org/web/20221017025852/http://www.nice.org.uk/guidance/cg28 |url-status=live }}</ref>
=== Tricyclic antidepressant ===
[[Tricyclic antidepressant]]s (TCAs) have
=== Monoamine oxidase inhibitor ===
[[Monoamine oxidase inhibitor]]s, have historically been plagued by questionable efficacy (although early studies used dosages now considered too low) and life-threatening adverse effects. They are still used only rarely, although newer agents of this class ([[Reversible inhibitor of monoamine oxidase A|RIMA]]), with a better side effect profile, have been developed.<ref>{{cite journal | vauthors = Krishnan KR | title = Revisiting monoamine oxidase inhibitors | journal = The Journal of Clinical Psychiatry | volume = 68 | issue = Suppl 8 | pages = 35–41 | year = 2007 | pmid = 17640156 | url = http://article.psychiatrist.com/?ContentType=START&ID=10003141 | access-date = 2008-08-27 | archive-date = 2012-07-07 | archive-url = https://archive.today/20120707213654/http://article.psychiatrist.com/?ContentType=START&ID=10003141 | url-status = live }}</ref>
In older patients TCAs and SSRIs are of the same efficacy.<ref name="Mottram_2006">{{cite journal | vauthors = Mottram P, Wilson K, Strobl J | title = Antidepressants for depressed elderly | journal = The Cochrane Database of Systematic Reviews | volume = 2009 | issue = 1 | pages = CD003491 | date = January 2006 | pmid = 16437456 | pmc = 8406818 | doi = 10.1002/14651858.CD003491.pub2 }}</ref> However, there are differences between TCA related antidepressants and classical TCAs in terms of side effect profiles and withdrawal when compared to SSRIs.<ref name="Mottram_2006" />
There is evidence a prominent side-effect of antidepressants, emotional blunting, is confused with a symptom of depression itself. The cited study, according to Professor Linda Gask was:
{{blockquote|'funded by a pharmaceutical company (Servier) and two of its authors are employees of that company', which may bias the results. The study authors' note: "emotional blunting is reported by nearly half of depressed patients on antidepressants and that it appears to be common to all monoaminergic antidepressants not only SSRIs". Additionally, they note: "The OQuESA scores are highly correlated with the HAD depression score; emotional blunting cannot be described simply as a side-effect of antidepressant, but also as a symptom of depression. More emotional blunting is associated with a poorer quality of remission.<ref>{{Cite web
===NMDA antagonists===
Line 74 ⟶ 76:
====Ketamine====
Research on the antidepressant effects of [[Ketamine#Antidepressant use|ketamine]] infusions at subanaesthetic doses has consistently shown rapid (4 to 72 hours) responses from single doses, with substantial improvement in mood in the majority of patients and [[Remission (medicine)|remission]] in some. However, these effects are often short-lived, and attempts to prolong the antidepressant effect with repeated doses and extended ("maintenance") treatment have resulted in only modest success.<ref>{{cite journal | vauthors = Caddy C, Giaroli G, White TP, Shergill SS, Tracy DK | title = Ketamine as the prototype glutamatergic antidepressant: pharmacodynamic actions, and a systematic review and meta-analysis of efficacy | journal = Therapeutic Advances in Psychopharmacology | volume = 4 | issue = 2 | pages = 75–99 | date = April 2014 | pmid = 24688759 | pmc = 3952483 | doi = 10.1177/2045125313507739 }}</ref> A nasal spray formulation of [[esketamine]], sold under the brand name Spravato, gained FDA approval in 2019 for the treatment of treatment-resistant depression when combined with an oral antidepressant.<ref name="Gastaldon 2019">{{cite journal | vauthors = Gastaldon C, Papola D, Ostuzzi G, Barbui C | title = Esketamine for treatment resistant depression: a trick of smoke and mirrors? | journal = Epidemiology and Psychiatric Sciences | volume = 29 | pages = e79 | date = December 2019 | pmid = 31841104 | pmc = 8061126 | doi = 10.1017/s2045796019000751 | publisher = Cambridge University Press (CUP) }}</ref><ref name="U.S. FDA 2020">{{cite web | title=FDA approves new nasal spray medication for treatment-resistant depression; available only at a certified doctor's office or clinic | website=U.S. Food and Drug Administration | date=5 March 2019 | url=https://www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-resistant-depression-available-only-certified | access-date=12 August 2022 | archive-date=23 July 2021 | archive-url=https://web.archive.org/web/20210723022112/https://www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-resistant-depression-available-only-certified | url-status=live }}</ref>
=== Zinc ===
Line 88 ⟶ 90:
It is also possible to use a benzodiazepine as to improve sleep without impairing the antidepressant response specially in patients presenting symptoms of insomnia and disturbed sleep. A randomized controlled trial found that the use of eszopiclone with fluoxetine resulted in a better remission rate.<ref name="Howland 2016 pp. 21–24">{{cite journal | vauthors = Howland RH | title = Oxazepam for the Treatment of Substance Abuse and Depression: Is it Appropriate? | journal = Journal of Psychosocial Nursing and Mental Health Services | volume = 54 | issue = 5 | pages = 21–24 | date = May 2016 | pmid = 27135891 | doi = 10.3928/02793695-20160420-03 | publisher = SLACK, Inc. }}</ref>
Addition of [[atypical antipsychotic]]s when the patient has not responded to an antidepressant is also known to increase the effectiveness of antidepressant drugs, albeit at the cost of more frequent and potentially serious side effects.<ref>{{cite magazine |url=
==== Lithium ====
Lithium has been used to augment antidepressant therapy in those who have failed to respond to antidepressants alone.<ref name="Bschor 2014 pp. 855–862">{{cite journal | vauthors = Bschor T | title = Lithium in the treatment of major depressive disorder | journal = Drugs | volume = 74 | issue = 8 | pages = 855–862 | date = June 2014 | pmid = 24825489 | doi = 10.1007/s40265-014-0220-x | publisher = Springer Science and Business Media LLC | s2cid = 12892550 }}</ref> Furthermore, lithium dramatically decreases the suicide risk in recurrent depression.<ref>{{cite journal | vauthors = Guzzetta F, Tondo L, Centorrino F, Baldessarini RJ | title = Lithium treatment reduces suicide risk in recurrent major depressive disorder | journal = The Journal of Clinical Psychiatry | volume = 68 | issue = 3 | pages = 380–383 | date = March 2007 | pmid = 17388706 | doi = 10.4088/JCP.v68n0304 }}</ref>
According to the results of the STAR-D experiment, the remission rate of lithium for treatment-resistant depression is about 15.9%.<ref name="Shelton Osuntokun Heinloth Corya 2010 pp. 131–161">{{cite journal | vauthors = Shelton RC, Osuntokun O, Heinloth AN, Corya SA | title = Therapeutic options for treatment-resistant depression | journal = CNS Drugs | volume = 24 | issue = 2 | pages = 131–161 | date = February 2010 | pmid = 20088620 | doi = 10.2165/11530280-000000000-00000 | publisher = Springer Science and Business Media LLC | s2cid = 32936223 }}</ref>
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There is some evidence for the addition of a thyroid hormone, [[triiodothyronine]], in patients with normal thyroid function.<ref>{{cite journal | vauthors = Nierenberg AA, Fava M, Trivedi MH, Wisniewski SR, Thase ME, McGrath PJ, Alpert JE, Warden D, Luther JF, Niederehe G, Lebowitz B, Shores-Wilson K, Rush AJ | display-authors = 6 | title = A comparison of lithium and T(3) augmentation following two failed medication treatments for depression: a STAR*D report | journal = The American Journal of Psychiatry | volume = 163 | issue = 9 | pages = 1519–30; quiz 1665 | date = September 2006 | pmid = 16946176 | doi = 10.1176/appi.ajp.163.9.1519 }}</ref>
For TRD patients,
==== Regulatory status, efficacy and tolerability of adjunctive treatments in depression ====
{| class="wikitable"
|-
! Drug !! [[Medicines and Healthcare products Regulatory Agency|MHRA]] approved as an adjunct?<ref>British National Formulary (BNF) 65. Pharmaceutical Pr; 2013.</ref>!! [[Therapeutic Goods Administration|TGA]] approved as an adjunct?<ref>{{cite web | title = Therapeutic Goods Administration. TGA eBusiness Services [Internet]. | publisher = Australian Government Department of Health and Ageing. | access-date = 13 September 2013 | url = https://www.ebs.tga.gov.au/ | archive-date = 21 April 2013 | archive-url = https://web.archive.org/web/20130421054308/https://www.ebs.tga.gov.au/ | url-status = live }}</ref>!! [[Food and Drug Administration|FDA]] approved as an adjunct?<ref>{{cite web | author = Drugs@FDA | title = FDA Approved Drug Products | access-date = 13 September 2013 | url = http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm | archive-date = 14 August 2012 | archive-url = https://web.archive.org/web/20120814072104/http://www.accessdata.fda.gov/Scripts/cder/DrugsatFDA/index.cfm | url-status = live }}</ref> !! [[Odds ratio|{{abbr|OR|odds ratio}}]] for non-response over antidepressant monotherapy<ref name="Cochrane">{{cite journal | vauthors = Komossa K, Depping AM, Gaudchau A, Kissling W, Leucht S | title = Second-generation antipsychotics for major depressive disorder and dysthymia | journal = The Cochrane Database of Systematic Reviews | issue = 12 | pages = CD008121 | date = December 2010 | pmid = 21154393 | doi = 10.1002/14651858.CD008121.pub2 | veditors = Leucht S }}</ref> !! Mean difference for [[Montgomery–Åsberg Depression Rating Scale|{{abbr|MADRS|Montgomery–Åsberg Depression Rating Scale}}]]<ref name = "Cochrane" /> !! Mean difference for [[Hamilton Rating Scale for Depression|{{abbr|HAM-D|Hamilton Rating Scale for Depression}}]]<ref name = "Cochrane" /> !! [[Odds ratio|{{abbr|OR|odds ratio}}]] for leaving the study early due to any reason<ref name = "Cochrane" /> !! [[Odds ratio|{{abbr|OR|odds ratio}}]] for leaving the study early due to adverse effects<ref name = "Cochrane" /> !! [[Odds ratio|{{abbr|OR|odds ratio}}]] for significant weight gain<ref name = "Cochrane" /> !! Mean difference for weight gain (kg)<ref name = "Cochrane" /> !! [[Odds ratio|{{abbr|OR|odds ratio}}]] for sedation<ref name = "Cochrane" />
|-
| [[Aripiprazole]] || No || No || Yes || 0.48 (0.
|-
| [[Lithium (medication)|Lithium]]<ref>{{cite journal | vauthors = Bauer M, Dopfmer S | title = Lithium augmentation in treatment-resistant depression: meta-analysis of placebo-controlled studies | journal = Journal of Clinical Psychopharmacology | volume = 19 | issue = 5 | pages = 427–434 | date = October 1999 | pmid = 10505584 | doi = 10.1097/00004714-199910000-00006 }}</ref>|| No || No. But listed in the [[Australian Medicines Handbook]] as an accepted use of lithium treatment.<ref>{{cite book | editor = Rossi, S | isbn = 978-0-9805790-9-3 | title = Australian Medicines Handbook | place = Adelaide | publisher = The Australian Medicines Handbook Unit Trust | year = 2013 | edition = 2013 }}</ref> || No || 0.47 (0.27-0.81) || No data || No data || No data || No data || No data || No data || No data
|-
| [[Olanzapine]] || No || No || Yes (in combination with fluoxetine) || 0.70 (0.48, 1.02) ||
|-
| [[Quetiapine]] || Yes || Yes || Yes || 0.66 (0.51, 0.87) ||
|-
| [[Risperidone]] || No || No || No || 0.57 (0.36, 0.89) ||
|}
===Efficacy of medication and psychotherapy===
Antidepressants are [[statistically]] superior to [[placebo]] but their overall effect is low-to-moderate. In that respect they often did not exceed the [[National Institute for Health and Clinical Excellence]] criteria for a "clinically significant" effect. In particular, the effect size was very small for moderate depression but increased with severity, reaching "[[clinical significance]]" for very severe depression.<ref name="Kirsch08">{{cite journal | vauthors = Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT | title = Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration | journal = PLOS Medicine | volume = 5 | issue = 2 | pages = e45 | date = February 2008 | pmid = 18303940 | pmc = 2253608 | doi = 10.1371/journal.pmed.0050045 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R | title = Selective publication of antidepressant trials and its influence on apparent efficacy | journal = The New England Journal of Medicine | volume = 358 | issue = 3 | pages = 252–260 | date = January 2008 | pmid = 18199864 | doi = 10.1056/NEJMsa065779 | doi-access = free }}</ref> These results were consistent with the earlier clinical studies in which only patients with severe depression benefited from either psychotherapy or treatment with an antidepressant, [[imipramine]], more than from the placebo treatment.<ref>{{cite journal | vauthors = Elkin I, Shea MT, Watkins JT, Imber SD, Sotsky SM, Collins JF, Glass DR, Pilkonis PA, Leber WR, Docherty JP | display-authors = 6 | title = National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatments | journal = Archives of General Psychiatry | volume = 46 | issue = 11 | pages = 971–82; discussion 983 | date = November 1989 | pmid = 2684085 | doi = 10.1001/archpsyc.1989.01810110013002 }}</ref><ref>{{cite journal | vauthors = Elkin I, Gibbons RD, Shea MT, Sotsky SM, Watkins JT, Pilkonis PA, Hedeker D | title = Initial severity and differential treatment outcome in the National Institute of Mental Health Treatment of Depression Collaborative Research Program | journal = Journal of Consulting and Clinical Psychology | volume = 63 | issue = 5 | pages = 841–847 | date = October 1995 | pmid = 7593878 | doi = 10.1037/0022-006X.63.5.841 }}</ref><ref>{{cite journal | vauthors = Sotsky SM, Glass DR, Shea MT, Pilkonis PA, Collins JF, Elkin I, Watkins JT, Imber SD, Leber WR, Moyer J | display-authors = 6 | title = Patient predictors of response to psychotherapy and pharmacotherapy: findings in the NIMH Treatment of Depression Collaborative Research Program | journal = The American Journal of Psychiatry | volume = 148 | issue = 8 | pages = 997–1008 | date = August 1991 | pmid = 1853989 | doi = 10.1176/ajp.148.8.997 }}</ref> Despite obtaining similar results, the authors argued about their interpretation. One author concluded that there "seems little evidence to support the prescription of antidepressant medication to any but the most severely depressed patients, unless alternative treatments have failed to provide benefit."<ref name="Kirsch08"/> The other author agreed that "antidepressant 'glass' is far from full" but disagreed "that it is completely empty". He pointed out that the first-line alternative to medication is psychotherapy, which does not have superior efficacy.<ref>{{cite journal | vauthors = Turner EH, Rosenthal R | title = Efficacy of antidepressants | journal = BMJ | volume = 336 | issue = 7643 | pages = 516–517 | date = March 2008 | pmid = 18319297 | pmc = 2265347 | doi = 10.1136/bmj.39510.531597.80 }}</ref>
Antidepressants in general are as effective as psychotherapy for major depression, and this conclusion holds true for both severe and mild forms of MDD.<ref name=Cuijpers>{{cite journal | vauthors = Cuijpers P, van Straten A, van Oppen P, Andersson G | title = Are psychological and pharmacologic interventions equally effective in the treatment of adult depressive disorders? A meta-analysis of comparative studies | journal = The Journal of Clinical Psychiatry | volume = 69 | issue = 11 | pages = e1–e11 | date = November 2008 | pmid = 18945396 | doi = 10.4088/jcp.v69n1102 }}</ref><ref name="uni dep">{{cite journal | vauthors = Imel ZE, Malterer MB, McKay KM, Wampold BE | title = A meta-analysis of psychotherapy and medication in unipolar depression and dysthymia | journal = Journal of Affective Disorders | volume = 110 | issue = 3 | pages = 197–206 | date = October 2008 | pmid = 18456340 | doi = 10.1016/j.jad.2008.03.018 }}</ref> In contrast, medication gives better results for [[dysthymia]].<ref name=Cuijpers/><ref name="uni dep"/> The subgroup of SSRIs may be slightly more efficacious than psychotherapy. On the other hand, significantly more patients drop off from the antidepressant treatment than from psychotherapy, likely because of the side effects of antidepressants.<ref name=Cuijpers/> Successful psychotherapy appears to prevent the recurrence of depression even after it has been terminated or replaced by occasional "booster" sessions. The same degree of prevention can be achieved by continuing antidepressant treatment.<ref name="uni dep"/>
Two studies suggest that the combination of psychotherapy and medication is the most effective way to treat depression in adolescents. Both TADS (Treatment of Adolescents with Depression Study) and TORDIA (Treatment of Resistant Depression in Adolescents) showed very similar results. TADS resulted in 71% of their teen subjects having "much" or "very much" improvement in mood over the 61% with medication alone and 43% with CBT alone.<ref name="EBSCO">{{cite journal | vauthors = Van Voorhees BW, Smith S, Ewigman B | title = Treat depressed teens with medication and psychotherapy | journal = The Journal of Family Practice | volume = 57 | issue = 11 | pages = 735–79a | date = November 2008 | pmid = 19006622 | pmc = 3183842 }}</ref> Similarly, TORDIA showed a 55% improvement with CBT and drugs versus a 41% with drug therapy alone.<ref name="EBSCO"/> However, a more recent meta-analysis of 34 trials of 14 drugs used with children and adolescents found that only fluoxetine produced significant benefit compared to placebo, with a medium-sized effect (standardize mean difference = .5).<ref>{{cite journal | vauthors = Cipriani A, Zhou X, Del Giovane C, Hetrick SE, Qin B, Whittington C, Coghill D, Zhang Y, Hazell P, Leucht S, Cuijpers P, Pu J, Cohen D, Ravindran AV, Liu Y, Michael KD, Yang L, Liu L, Xie P | display-authors = 6 | title = Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis | journal = Lancet | volume = 388 | issue = 10047 | pages = 881–890 | date = August 2016 | pmid = 27289172 | doi = 10.1016/S0140-6736(16)30385-3 | s2cid = 19728203 | hdl = 11380/1279478 | url = https://ora.ox.ac.uk/objects/uuid:e0b5ae23-d562-4348-94b8-84f70b7812c5 | hdl-access = free | access-date = 2020-11-30 | archive-date = 2021-10-27 | archive-url = https://web.archive.org/web/20211027013100/https://ora.ox.ac.uk/objects/uuid:e0b5ae23-d562-4348-94b8-84f70b7812c5 | url-status = live }}</ref>
====Treatment resistance====
The risk factors
===Experimental treatments===
Line 141 ⟶ 143:
====Inositol====
[[Inositol]], a sugar alcohol in fruits, beans, grains and nuts, was found to be significantly better than placebo in treating depression in a double-blind, controlled trial.
==== Magnesium ====
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There is insufficient evidence to determine that [[omega-3 fatty acid]] has any effect on depression.<ref>{{cite journal | vauthors = Appleton KM, Voyias PD, Sallis HM, Dawson S, Ness AR, Churchill R, Perry R | title = Omega-3 fatty acids for depression in adults | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 11 | pages = CD004692 | date = November 2021 | pmid = 34817851 | pmc = 8612309 | doi = 10.1002/14651858.cd004692.pub5 | publisher = Wiley }}</ref> A 2016 review found that if trials with formulations containing mostly [[eicosapentaenoic acid]] (EPA) are separated from trials using formulations containing [[docosahexaenoic acid]] (DHA), it appeared that EPA may have an effect while DHA may not, but there was insufficient evidence to be sure.<ref>{{cite journal | vauthors = Hallahan B, Ryan T, Hibbeln JR, Murray IT, Glynn S, Ramsden CE, SanGiovanni JP, Davis JM | display-authors = 6 | title = Efficacy of omega-3 highly unsaturated fatty acids in the treatment of depression | journal = The British Journal of Psychiatry | volume = 209 | issue = 3 | pages = 192–201 | date = September 2016 | pmid = 27103682 | pmc = 9406129 | doi = 10.1192/bjp.bp.114.160242 | doi-access = free }}</ref>
A 2020 meta-analysis showed that a high dose of omega-3 polyunsaturated fatty acid (>
====Dopamine receptor agonist====
<!--As with all medical information (see [[WP:BMI]] for a definition of medical), this section needs to meet [[WP:MEDRS]]-->
Some research suggests [[Dopamine agonist|dopamine receptor agonists]], most commonly [[pramipexole]], may be effective in treating depression. Studies are few and results are preliminary, however.<ref>{{cite journal | vauthors = Dunlop BW, Nemeroff CB | title = The role of dopamine in the pathophysiology of depression | journal = Archives of General Psychiatry | volume = 64 | issue = 3 | pages = 327–337 | date = March 2007 | pmid = 17339521 | doi = 10.1001/archpsyc.64.3.327 | s2cid = 26550661 }}</ref>
==== N-Acetylcysteine ====
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==== Psilocybin ====
[[Psilocybin]] has been shown in several studies to improve symptoms in people with treatment-resistant depression.<ref name="Daws 2022">{{cite journal | vauthors = Daws RE, Timmermann C, Giribaldi B, Sexton JD, Wall MB, Erritzoe D, Roseman L, Nutt D, Carhart-Harris R | display-authors = 6 | title = Increased global integration in the brain after psilocybin therapy for depression | journal = Nature Medicine | volume = 28 | issue = 4 | pages = 844–851 | date = April 2022 | pmid = 35411074 | doi = 10.1038/s41591-022-01744-z | s2cid = 248099554 | doi-access = free | hdl = 10044/1/95521 | hdl-access = free }}</ref> In 2018 and 2019, the FDA designated psilocybin as a "[[breakthrough therapy]]" for drug-resistant depression and major depressive disorder.<ref name="Marks 2021">{{cite web | vauthors
====St John's wort====
{{Main|St John's wort}}
<!--As with all medical information (see [[WP:BMI]] for a definition of medical), this section needs to meet [[WP:MEDRS]]-->
A 2008 [[Cochrane Collaboration]] [[meta-analysis]] concluded that "The available evidence suggests that the [[hypericum]] extracts tested in the included trials a) are superior to placebo in patients with major depression; b) are similarly effective as standard antidepressants; c) and have fewer [[side effect]]s than standard antidepressants. The association of country of origin and precision with effects sizes complicates the interpretation."<ref name = Linde2008>{{cite journal | vauthors = Linde K, Berner MM, Kriston L | title = St John's wort for major depression | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD000448 | date = October 2008 | volume = 2008 | pmid = 18843608 | pmc = 7032678 | doi = 10.1002/14651858.CD000448.pub3 }}</ref> The United States [[National Center for Complementary and Integrative Health]] advice is that "St. John's wort may help some types of depression, similar to treatment with standard prescription antidepressants, but the evidence is not definitive." and warns that "Combining St. John's wort with certain antidepressants can lead to a potentially life-threatening increase of [[serotonin]], a brain chemical targeted by antidepressants. St. John's wort can also limit the effectiveness of many [[Prescription drug|prescription medicines]]."<ref name = NCCIH>{{cite web
====Rhodiola rosea====
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==== Tryptophan and 5-HTP ====
<!--As with all medical information (see [[WP:BMI]] for a definition of medical), this section needs to meet [[WP:MEDRS]]-->
The [[amino acid]] [[tryptophan]] is converted into [[5-hydroxytryptophan]] (5-HTP) which is subsequently converted into the [[neurotransmitter]] [[serotonin]]. Since serotonin deficiency has been recognized as a possible cause of depression, it has been suggested that consumption of tryptophan or 5-HTP may therefore improve depression symptoms by increasing the level of serotonin in the brain.<ref name="Shaw_2010">{{cite journal | vauthors = Shaw K, Turner J, Del Mar C | title = Tryptophan and 5-hydroxytryptophan for depression | journal = The Cochrane Database of Systematic Reviews | volume = 2010 | issue = 1 | pages = CD003198 | date = 2002 | pmid = 11869656 | doi = 10.1002/14651858.CD003198 | pmc = 8711266 }}</ref> 5-HTP and tryptophan are sold [[over the counter]] in North America, but requires a prescription in Europe. The use of 5-HTP instead of tryptophan bypasses the conversion of tryptophan into 5-HTP by the enzyme [[tryptophan hydroxylase]], which is the rate-limiting step in the synthesis of serotonin, and 5-HTP easily crosses the blood–brain barrier unlike tryptophan, which requires a transporter.<ref name="Iovieno_2011" />
Small studies have been performed using 5-HTP and tryptophan as adjunctive therapy in addition to standard treatment for depression. While some studies had positive results, they were criticized for having methodological flaws, and a more recent study did not find sustained benefit from their use.<ref name="Ravindran">{{cite journal | vauthors = Ravindran AV, da Silva TL | title = Complementary and alternative therapies as add-on to pharmacotherapy for mood and anxiety disorders: a systematic review | journal = Journal of Affective Disorders | volume = 150 | issue = 3 | pages = 707–719 | date = September 2013 | pmid = 23769610 | doi = 10.1016/j.jad.2013.05.042 }}</ref> The safety of these medications has not been well studied.<ref name="Shaw_2010" />
==Medical devices==
A variety of medical devices are in use or under consideration for treatment of depression including devices that offer electroconvulsive therapy, [[vagus nerve stimulation]], [[repetitive transcranial magnetic stimulation]], and [[cranial electrotherapy stimulation]]. The use of such devices in the United States requires approval by the U.S. [[Food and Drug Administration]] (FDA) after field trials. In 2010 an FDA advisory panel considered the question of how such field trials should be managed. Factors considered were whether drugs had been effective, how many different drugs had been tried, and what tolerance for suicides should be in field trials.<ref>{{cite web | url = http://www.medpagetoday.com/Psychiatry/Depression/22648 |
===Electroconvulsive therapy===
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In 2004, a meta-analytic review paper found in terms of efficacy, "a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus [[placebo]], ECT versus antidepressants in general, ECT versus tricyclics and ECT versus [[monoamine oxidase inhibitor]]s."<ref name="pmid15087991">{{cite journal | vauthors = Pagnin D, de Queiroz V, Pini S, Cassano GB | title = Efficacy of ECT in depression: a meta-analytic review | journal = The Journal of ECT | volume = 20 | issue = 1 | pages = 13–20 | year = 2004 | pmid = 15087991 | doi = 10.1097/00124509-200403000-00004| s2cid = 25843283 }}</ref>
[[Electroconvulsive therapy]] (ECT) is a standard [[psychiatry|psychiatric]] treatment in which [[seizure]]s are electrically induced in patients to provide relief from psychiatric illnesses.<ref name="Rudorfer">{{cite book | vauthors = Rudorfer MV, Henry ME, Sackeim HA | date = 2003 | chapter-url = http://media.wiley.com/assets/138/93/UK_Tasman_Chap92.pdf | chapter = Electroconvulsive therapy | veditors = Tasman A, Kay J, Lieberman JA | title = Psychiatry | edition = Second | location = Chichester | publisher = John Wiley & Sons Ltd | pages = 1865–1901 | access-date = 2013-11-03 | archive-date = 2007-08-10 | archive-url = https://web.archive.org/web/20070810172506/http://media.wiley.com/assets/138/93/UK_Tasman_Chap92.pdf | url-status = live }}</ref>{{rp|1880}}
A round of ECT is effective for about 50% of people with treatment-resistant major depressive disorder, whether it is unipolar or [[Bipolar II disorder|bipolar]].<ref name=Dierckx>{{cite journal | vauthors = Dierckx B, Heijnen WT, van den Broek WW, Birkenhäger TK | title = Efficacy of electroconvulsive therapy in bipolar versus unipolar major depression: a meta-analysis | journal = Bipolar Disorders | volume = 14 | issue = 2 | pages = 146–50 | date = March 2012 | pmid = 22420590 | doi = 10.1111/j.1399-5618.2012.00997.x | s2cid = 44280002 }}</ref> Follow-up treatment is still poorly studied, but about half of people who respond relapse with twelve months.<ref name=Jelovac2013Rev>{{cite journal | vauthors = Jelovac A, Kolshus E, McLoughlin DM | title = Relapse following successful electroconvulsive therapy for major depression: a meta-analysis | journal = Neuropsychopharmacology | volume = 38 | issue = 12 | pages = 2467–74 | date = November 2013 | pmid = 23774532 | pmc = 3799066 | doi = 10.1038/npp.2013.149 }}</ref>
Aside from effects in the brain, the general physical risks of ECT are similar to those of brief [[general anesthesia]].<ref name="SG">{{cite book | author = Surgeon General | date = 1999 | url = http://www.surgeongeneral.gov/library/mentalhealth/home.html | title = Mental Health: A Report of the Surgeon General | chapter = Chapter 4 | access-date = 2015-01-07 | archive-date = 2007-01-12 | archive-url = https://web.archive.org/web/20070112012907/http://www.surgeongeneral.gov/library/mentalhealth/home.html | url-status = live }}</ref>{{rp|259}} Immediately following treatment, the most common adverse effects are confusion and memory loss.<ref name=FDA2011rev/><ref name="APA2001guideline">{{cite book |
A usual course of ECT involves multiple administrations, typically given two or three times per week until the patient no longer has symptoms
ECT appears to work in the short term via an [[anticonvulsant]] effect mostly in the [[frontal lobes]], and longer term via [[neurotrophic]] effects primarily in the [[medial temporal lobe]].<ref name=Abbott2014>{{cite journal | vauthors = Abbott CC, Gallegos P, Rediske N, Lemke NT, Quinn DK | title = A review of longitudinal electroconvulsive therapy: neuroimaging investigations | journal = Journal of Geriatric Psychiatry and Neurology | volume = 27 | issue = 1 | pages = 33–46 | date = March 2014 | pmid = 24381234 | pmc = 6624835 | doi = 10.1177/0891988713516542 }}</ref>
===Deep brain stimulation===
The support for the use of [[deep brain stimulation]] in [[treatment-resistant depression]] comes from a handful of case studies, and this treatment is still in a very early investigational stage.<ref name="APS">{{cite journal | vauthors = Marangell LB, Martinez M, Jurdi RA, Zboyan H | title = Neurostimulation therapies in depression: a review of new modalities | journal = Acta Psychiatrica Scandinavica | volume = 116 | issue = 3 | pages = 174–81 | date = September 2007 | pmid = 17655558 | doi = 10.1111/j.1600-0447.2007.01033.x | s2cid = 38081703 }}</ref>
===Repetitive transcranial magnetic stimulation===
[[Transcranial magnetic stimulation]] (TMS) or [[deep transcranial magnetic stimulation]] is a noninvasive method used to stimulate small regions of the brain.
TMS was approved by the FDA for treatment-resistant [[major depressive disorder]] in 2008<ref name="Melkerson">{{cite web|url=http://www.accessdata.fda.gov/cdrh_docs/pdf8/K083538.pdf|date=2008-12-16|access-date=2010-07-16
The response rate is about 29% for TRD patients.<ref name="Cheng Li Tsai 2021 pp. 333–349">{{cite book |
=== Vagus nerve stimulation ===
[[Vagus nerve stimulation]] (VNS) uses an implanted electrode and generator to deliver electrical pulses to the vagus nerve, one of the primary nerves emanating from the brain. It is an approved therapy for treatment-resistant depression in the EU and US and is sometimes used as an adjunct to existing antidepressant treatment. The support for this method comes mainly from open-label trials, which indicate that several months may be required to see a benefit.<ref name="APS"/> The only large double-blind trial conducted lasted only 10 weeks and yielded inconclusive results; VNS failed to show superiority over a sham treatment on the primary efficacy outcome, but the results were more favorable for one of the secondary outcomes. The authors concluded "This study did not yield definitive evidence of short-term efficacy for adjunctive VNS in treatment-resistant depression."<ref>{{cite journal | vauthors = Rush AJ, Marangell LB, Sackeim HA, George MS, Brannan SK, Davis SM, Howland R, Kling MA, Rittberg BR, Burke WJ, Rapaport MH, Zajecka J, Nierenberg AA, Husain MM, Ginsberg D, Cooke RG | title = Vagus nerve stimulation for treatment-resistant depression: a randomized, controlled acute phase trial | journal = Biological Psychiatry | volume = 58 | issue = 5 | pages = 347–54 | date = September 2005 | pmid = 16139580 | doi = 10.1016/j.biopsych.2005.05.025 | s2cid = 22066326 | url = http://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1069&context=veterans | access-date = 2019-07-14 | archive-date = 2019-02-27 | archive-url = https://web.archive.org/web/20190227104329/http://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1069&context=veterans | url-status = live }}</ref>
=== Cranial electrotherapy stimulation ===
A 2014 Cochrane review found insufficient evidence to determine whether or not [[Cranial electrotherapy stimulation]] with alternating current is safe and effective for treating depression.<ref name=Kavirajan>{{cite journal | vauthors = Kavirajan HC, Lueck K, Chuang K | title = Alternating current cranial electrotherapy stimulation (CES) for depression | journal = The Cochrane Database of Systematic Reviews | volume =
=== Transcranial direct current stimulation ===
A 2016 meta-analysis of [[Transcranial direct-current stimulation|transcranial direct current stimulation]] (tDCS) reported some efficacy of tDCS in the treatment of acute depressive disorder with moderate effect size, and low efficacy in treatment-resistant depression, and that use of 2
== Other treatments ==
===Bright light therapy===
{{Main|Seasonal affective disorder}}
[[File:Bright light lamp.jpg|thumb|200px|right|Bright light therapy is sometimes used to treat depression, especially in its [[seasonal affective disorder|seasonal form]].]]
A meta-analysis of bright [[light therapy]] commissioned by the [[American Psychiatric Association]] found a significant reduction in depression symptom severity associated with bright light treatment.
===Exercise===
[[File:Soccer football informal in Manipur India cropped.jpg|thumb|Physical exercise is one recommended way to manage mild depression, such as by playing [[soccer]].]]
The 2013 Cochrane Collaboration review on [[physical exercise]] for depression noted that, based upon limited evidence, it is moderately more effective than a control intervention and comparable to psychological or antidepressant drug therapies. Smaller effects were seen in more methodologically rigorous studies.<ref name="Cochrane exercise depression">{{cite journal | vauthors = Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, McMurdo M, Mead GE | display-authors = 6 | title = Exercise for depression | journal = The Cochrane Database of Systematic Reviews | volume = 2013 | issue = 9 | pages = CD004366 | date = September 2013 | pmid = 24026850 | doi = 10.1002/14651858.CD004366.pub6 | pmc = 9721454 | quote = Exercise is moderately more effective than a control intervention for reducing symptoms of depression, but analysis of methodologically robust trials only shows a smaller effect in favour of exercise. When compared to psychological or pharmacological therapies, exercise appears to be no more effective, though this conclusion is based on a few small trials. }}</ref> Three subsequent 2014 systematic reviews that included the Cochrane review in their analysis concluded with similar findings: one indicated that physical exercise is effective as an [[wikt:adjunct treatment|adjunct treatment]] with antidepressant medication;<ref name="Exercise MDD antidepressant">{{cite journal | vauthors = Mura G, Moro MF, Patten SB, Carta MG | title = Exercise as an add-on strategy for the treatment of major depressive disorder: a systematic review | journal = CNS Spectrums | volume = 19 | issue = 6 | pages = 496–508 | date = December 2014 | pmid = 24589012 | doi = 10.1017/S1092852913000953 | quote = Considered overall, the studies included in the present review showed a strong effectiveness of exercise combined with antidepressants. ... Conclusions<br /> This is the first review to have focused on exercise as an add-on strategy in the treatment of MDD. Our findings corroborate some previous observations that were based on few studies and which were difficult to generalize.<sup>41,51,73,92,93</sup> Given the results of the present article, it seems that exercise might be an effective strategy to enhance the antidepressant effect of medication treatments. Moreover, we hypothesize that the main role of exercise on treatment-resistant depression is in inducing neurogenesis by increasing BDNF expression, as was demonstrated by several recent studies. | s2cid = 32304140 }}</ref> the other two indicated that physical exercise has marked antidepressant effects and recommended the inclusion of physical activity as an adjunct treatment for mild–moderate depression<ref name="Exercise depression intervention">{{cite journal | vauthors = Josefsson T, Lindwall M, Archer T | title = Physical exercise intervention in depressive disorders: meta-analysis and systematic review | journal = Scandinavian Journal of Medicine & Science in Sports | volume = 24 | issue = 2 | pages = 259–272 | date = April 2014 | pmid = 23362828 | doi = 10.1111/sms.12050 | quote = Physical activity has also become increasingly and firmly associated with improvements in mental health and psychological well-being (Mutrie, 2000; Landers & Arent, 2007). In particular, exercise is believed to be effective in preventing depression and also to significantly reduce depressive symptoms in clinical as well as in nonclinical populations (O'Neal et al., 2000; Landers & Arent, 2007). Several correlational studies show that exercise is negatively related to depressive symptoms (e.g., Galper et al., 2006; Hassmén et al., 2000). Moreover, a considerably large number of intervention studies have by now investigated the effect of various exercise programs on depression and the vast majority of them indicate that exercise significantly reduces depression (e.g., Blumenthal et al., 2007; Martinsen et al., 1985; Singh et al., 1997). ... To date, it is not possible to determine exactly how effective exercise is in reducing depression symptoms in clinical and nonclinical depressed populations, respectively. However, the results from the present meta-analysis as well as from seven earlier meta-analyses (North et al., 1990; Craft & Landers, 1998; Lawlor & Hopker, 2001; Stathopoulou et al., 2006; Mead et al., 2009; Rethorst et al., 2009; Krogh et al., 2011) indicate that exercise has a moderate to large antidepressant effect. Some meta-analytic results (e.g., Rethorst et al., 2009) suggest that exercise may be even more efficacious for clinically depressed people. ... In short, our final conclusion is that exercise may well be recommended for people with mild and moderate depression who are willing, motivated, and physically healthy enough to engage in such a program. | s2cid = 29351791 | doi-access = free }}</ref> and mental illness in general. These studies also found smaller effect sizes in more methodologically rigorous studies.<ref name="Physical activity intervention">{{cite journal | vauthors = Rosenbaum S, Tiedemann A, Sherrington C, Curtis J, Ward PB | title = Physical activity interventions for people with mental illness: a systematic review and meta-analysis | journal = The Journal of Clinical Psychiatry | volume = 75 | issue = 9 | pages = 964–974 | date = September 2014 | pmid = 24813261 | doi = 10.4088/JCP.13r08765 | quote = This systematic review and meta-analysis found that physical activity reduced depressive symptoms among people with a psychiatric illness.
===Meditation===
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A 2017 cochrane systematic review found that music therapy added to the usual treatment of depression gives better outcome than the usual treatment alone: "The effect size translates to a difference of 9.8 points on the HAM-D". It also found that there is no significant difference between active and receptive music therapy comparing depression outcome. It is also important to note that music therapy is not associated with more or fewer adverse events than treatment as usual.<ref name="Aalbers Fusar-Poli Freeman Spreen p.">{{cite journal | vauthors = Aalbers S, Fusar-Poli L, Freeman RE, Spreen M, Ket JC, Vink AC, Maratos A, Crawford M, Chen XJ, Gold C | display-authors = 6 | title = Music therapy for depression | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | issue = 11 | pages = CD004517 | date = November 2017 | pmid = 29144545 | pmc = 6486188 | doi = 10.1002/14651858.cd004517.pub3 | publisher = Wiley }}</ref>
=== Occupational therapy ===
'''Occupational therapy''' ('''OT''') is a [[healthcare]] profession that involves the use of assessment and intervention to develop, recover, or maintain the meaningful activities, or ''occupations'', of individuals, groups, or communities.<ref>{{Cite web |title=What is Occupational Therapy |url=https://www.caot.ca/site/aboutot/whatisot?nav=sidebar |access-date=2017-05-24 |publisher=Canadian Association of Occupational Therapists {{!}} Association canadienne des ergothérapeutes |archive-date=2017-06-06 |archive-url=https://web.archive.org/web/20170606091141/http://caot.ca/site/aboutot/whatisot?nav=sidebar |url-status=live }}</ref> It is an independent health profession sometimes categorized as an [[Allied health professions|allied health profession]] and consists of [[occupational therapists]] (OTs) and occupational therapy assistants (OTAs).<ref>{{Cite web |title=What is Occupational Therapy |url=https://www.caot.ca/site/aboutot/whatisot?nav=sidebar |access-date=2017-05-24 |publisher=Canadian Association of Occupational Therapists {{!}} Association canadienne des ergothérapeutes |archive-date=2017-06-06 |archive-url=https://web.archive.org/web/20170606091141/http://caot.ca/site/aboutot/whatisot?nav=sidebar |url-status=live }}</ref> A person with depression may experience interruptions in sleep, difficulty completing self-care tasks, decreased motivation to participate in leisure activities, decreased concentration for school or job related work, and avoidance of social interactions. Occupational therapy practitioners possess the educational knowledge base in mental health and can contribute to the efforts in mental health promotion, prevention, and intervention.
Winston Churchill is a famous example of someone who treated his depression by occupying himself with work and other productive activities. Out of office, Churchill was prone to depression (his "black dog") as he sensed his political talents being wasted and time passing him by – in all such times, writing provided the antidote.<ref>{{cite book |last=Jenkins |first=Roy |author-link=Roy Jenkins |title=Churchill |year=2001 |publisher=Macmillan Press |location=London |isbn=978-03-30488-05-1 |page=466, 819 |url=https://archive.org/details/churchill0000jenk/mode/2up |url-access=registration}}</ref>
===Sleep===
Depression is sometimes associated with [[insomnia]]
===Smoking cessation===
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===Total/partial sleep deprivation===
{{main|Wake therapy}}
[[Sleep deprivation]] (skipping a night's sleep) has been found to improve symptoms of depression in
=== Shared Care ===
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Trials are investigating whether [[botulinum toxin]], when used to make a person appear to frown less, stops negative [[Facial feedback hypothesis|feedback from the face]] and affects depression.<ref>{{cite journal | vauthors = Schulze J, Neumann I, Magid M, Finzi E, Sinke C, Wollmer MA, Krüger TH | title = Botulinum toxin for the management of depression: An updated review of the evidence and meta-analysis | journal = Journal of Psychiatric Research | volume = 135 | pages = 332–340 | date = March 2021 | pmid = 33578275 | doi = 10.1016/j.jpsychires.2021.01.016 | s2cid = 231911095 }}</ref>
[[Psilocybin]] may have a beneficial role in the treatment of depression.<ref>{{cite journal | vauthors = Goldberg SB, Pace BT, Nicholas CR, Raison CL, Hutson PR | title = The experimental effects of psilocybin on symptoms of anxiety and depression: A meta-analysis | journal = Psychiatry Research | volume = 284 | pages = 112749 | date = February 2020 | pmid = 31931272 | doi = 10.1016/j.psychres.2020.112749 | s2cid = 209527316 }}</ref><ref>{{cite journal | vauthors = Vargas AS, Luís Â, Barroso M, Gallardo E, Pereira L | title = Psilocybin as a New Approach to Treat Depression and Anxiety in the Context of Life-Threatening Diseases-A Systematic Review and Meta-Analysis of Clinical Trials | journal = Biomedicines | volume = 8 | issue = 9 | page = 331 | date = September 2020 | pmid = 32899469 | pmc = 7554922 | doi = 10.3390/biomedicines8090331 | doi-access = free }}</ref>
A 2019 meta-analysis found that [[hypnotherapy]] may be an effective way of alleviating the symptoms of depression.<ref>{{cite journal | vauthors = Milling LS, Valentine KE, McCarley HS, LoStimolo LM | title = A Meta-Analysis of Hypnotic Interventions for Depression Symptoms: High Hopes for Hypnosis? | journal = The American Journal of Clinical Hypnosis | volume = 61 | issue = 3 | pages = 227–243 | date = January 2019 | pmid = 34874235 | doi = 10.1080/00029157.2018.1489777 | s2cid = 149965049 }}</ref>
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== External links ==
* {{Commons category-inline|Treatment of depression}}
{{Public health}}
[[Category:Treatment of depression| ]]
[[Category:Treatment of bipolar disorder]]
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