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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> Physical causes are ruled out with a [[Major depressive disorder#Clinical assessment|clinical assessment of depression]] that measures vitamins, minerals, electrolytes, and hormones.<ref name="Parker_2017">{{cite journal | vauthors = Parker GB, Brotchie H, Graham RK | title = Vitamin D and depression | journal = Journal of Affective Disorders | volume = 208 | pages = 56–61 | date = January 2017 | pmid = 27750060 | doi = 10.1016/j.jad.2016.08.082 }}</ref><ref name="Orengo_2004">{{cite journal | vauthors = Orengo CA, Fullerton G, Tan R | title = Male depression: a review of gender concerns and testosterone therapy | journal = Geriatrics | volume = 59 | issue = 10 | pages = 24–30 | date = October 2004 | pmid = 15508552 }}</ref><ref name="Dale_2008">{{cite journal|vauthors=Dale J, Sorour E, Milner G|year=2008|title=Do psychiatrists perform appropriate physical investigations for their patients? A review of current practices in a general psychiatric inpatient and outpatient setting|journal=Journal of Mental Health|volume=17|issue=3|pages=293–98|doi=10.1080/09638230701498325|s2cid=72755878}}</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 | title = The Merck Manual of Diagnosis and Therapy | access-date = 2011-11-09 | archive-date = 2011-11-09 | archive-url = https://web.archive.org/web/20111109210617/http://www.merckmanuals.com/professional/psychiatric_disorders/mood_disorders/depressive_disorders.html#v1028131 | url-status = live }}</ref> Combining psychotherapy and antidepressants may provide a "slight advantage", but antidepressants alone or psychotherapy alone are not significantly different from other treatments, like "active intervention controls". ( e.g., sham acupuncture{{clarify inline|date=April 2023}}) Given an accurate diagnosis of major depressive disorder, in general the type of treatment (psychotherapy and/or antidepressants, alternate or other treatments, or active intervention) is "less important than getting depressed patients involved in an active therapeutic program."<ref name="Khan_2012">{{cite journal | vauthors = Khan A, Faucett J, Lichtenberg P, Kirsch I, Brown WA | title = A systematic review of comparative efficacy of treatments and controls for depression | journal = PLOS ONE | volume = 7 | issue = 7 | pages = e41778 | date = July 30, 2012 | pmid = 22860015 | pmc = 3408478 | doi = 10.1371/journal.pone.0041778 | doi-access = free | bibcode = 2012PLoSO...741778K }}</ref>
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[[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> 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 |access-date=2013-04-30 |archive-date=2012-02-23 |archive-url=https://web.archive.org/web/20120223144433/http://www.ijpsy.com/volumen10/num1/256.html |url-status=live }}</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/ |access-date=2013-04-30 |archive-date=2013-01-22 |archive-url=https://web.archive.org/web/20130122031152/http://contextualpsychology.org/state_of_the_act_evidence |url-status=live }}</ref>
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== 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>
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==== 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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====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.<ref>{{cite journal | vauthors = Levine J, Barak Y, Gonzalves M, Szor H, Elizur A, Kofman O, Belmaker RH | title = Double-blind, controlled trial of inositol treatment of depression | journal = The American Journal of Psychiatry | volume = 152 | issue = 5 | pages = 792–4 | date = May 1995 | pmid = 7726322 | doi = 10.1176/ajp.152.5.792 }}</ref> It was also reported to be reduced in human CSF in depression and found to lead to
==== Magnesium ====
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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}}
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