There is no single best depression treatment that will work first time for everyone. Depression is a complex disease and the therapy needs to be tailored to each person. Often the depression treatment prescribed will depend on the severity of the depression as well as the number of prior therapies the person has had.
In Australia, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) provide recommendations for how depression should be diagnosed and treated. These recommendations are based on the latest scientific evidence as well as on the experience and opinions of expert psychiatrists.
What is considered an effective depression treatment?
How well a treatment works is defined by response and remission. Response is a 50% decrease (improvement) in the score on depression scales. Even though the scores are lower, symptoms are often still present and so the patient may still feel unwell. Remission on the other hand is a measure of how well someone feels. When remission is achieved, a person experiences few, if any, depression symptoms.
Whether a person relapses is also an important measure of how well a treatment works. Relapse is when the depression symptoms return soon after a person enters remission.
What are the different depression treatments?
There are a range of treatments for depression which fall into four main categories:
Psychological therapies are talking-based therapies and can help to change thought patterns and enable people to better handle stress and conflict. Psychological therapies used to treat depression include cognitive behavioural therapy, interpersonal therapy, behavioural therapy and mindfulness-based cognitive therapy. There isn’t any strong evidence to suggest that one type of psychological therapy is better than another type. The type of psychological therapy will be determined by the healthcare professional according to the needs of the patient.
Antidepressants are the most commonly used medications for depression treatment. They help the brain to send and receive signals by increasing the amounts of neurotransmitters. There are different types of antidepressants and they are generally similar in how effective they are at relieving depression. It is important to understand that people respond differently to depression medication, and that each type of depression medication has different side effects.
Antidepressants generally work better in people who haven’t taken them before for the current episode of depression. Approximately 37% of patients will respond to their first antidepressant whereas only 13% of patients will respond to their third antidepressant. Similarly, 49% of people have no or few depression symptoms after the first antidepressant and this declines to 16% by the third.
Transcranial magnetic stimulation (TMS)
Transcranial magnetic stimulation is an effective depression treatment that works by stimulating the prefrontal cortex of the brain which activates the nerve cells in that area and in the limbic system. These are the parts of the brain responsible for emotion, so after repeated stimulation people may feel more positive and motivated. It is a non-invasive and safe procedure with mild side effects. In Australia, TMS is approved to treat depression in people who have already tried two or more different depression medications.
Over 58% of people who have already failed at least two previous treatments will respond to TMS treatment and 37% will experience remission. These treatment-resistant patients are more likely to respond to TMS therapy than to a different depression medication. There are no major side effects for TMS treatment compared to antidepressants or other therapies.
Electroconvulsive therapy (ECT)
Electroconvulsive therapy is where electric currents are passed through the brain. The currents affect the brain’s activity and help to relieve depression symptoms. ECT is an effective treatment for depression, however it is an invasive procedure and can result in short-term memory loss. It is therefore mostly used as a last resort to treat severe forms of depression and after everything else has failed.
How are the different depression treatments used?
The RANZCP guidelines recommend a step-wise approach to treating depression.
- Stop taking any substances that can affect mood
- Introduce lifestyle changes such as improving sleep routine, quitting smoking, increasing exercise and eating a healthy diet
- Psychosocial interventions (e.g. education, support groups)
- Psychological therapy
- Combine medication with psychological therapy if not done already
- Increase the dose of medication and/or add a new medication
How many different depression medications are needed?
Some patients will only need one antidepressant medication to relieve their depression symptoms while others will require more. It is not uncommon for patients to have tried 4 or 5 different antidepressants before they find a treatment that works for them. In around 30% of patients with depression, antidepressants are simply not effective.
One study by Rush et al. found that for each type of antidepressant, the number of people who responded or entered remission decreased and the chance of relapsing increased. For example:
A study by Carpenter et al. in patients who had failed on average 3-4 depression medications, found that 58% of patients responded to transcranial magnetic stimulation (TMS) and 37% entered remission. This makes TMS the best chance of relieving depression symptoms after having tried two or more depression medications.
Are side effects a consideration when determining the best depression treatment for me?
Each depression treatment has different side effects which can impact how well it is tolerated. If a treatment has side effects, it may be harder to complete treatment, which can make the treatment less likely to work. It is important to tell healthcare professionals about any side effects as they may be able to help manage these, adjust the dose or determine whether a different treatment is more suitable.
- Carpenter L et al. Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observations study of acute treatment outcomes in clinical practice. Depression and Anxiety 2012; 29: 587-596.
- Cuijpers P et al. Who benefits from psychotherapies for adult depression? A meta-analytic update of the evidence. Cognitive Behav Ther 2018; DOI: 10.1080/16506073.2017.1420098.
- Husain MM et al. Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a consortium for research in ECT (CORE) report. J Clin Psychiatry 2004; 65:485-491.
- Lampe L et al. Psychological management of unipolar depression. Acta Psychiatrica Scandinavica 2014; 443: 24-37.
- Malhi GS et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust New Zealand J Psych 2015; 49: 1-185.
- Rush AJ et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 2006; 163: 1905–1917.