Treatments for depression
It’s important to get help and the right treatment for depression. There are a range of effective treatments, and you can get better. Start by talking to your GP.
Important things to know about getting treatment for depression:
- Different types of depression respond to different kinds of treatments. You need a thorough check from a health professional before treatment is prescribed.
- Depression can sometimes go away by itself. But left untreated, it may last for many months or get significantly worse. Always seek help early, so you can recover sooner.
- Depending on the nature of your depression, self-help and alternative therapies can be helpful. They can be used alone or combined with physical and psychological treatments.
- Most people who have had depression have been able to seek help and live active, fulfilling lives.
There are three broad categories of treatment for depression:
- self-help and alternative therapies.
Often, a combination of treatments works best. Different types of depression require different treatments. As we are all individuals with different contributing factors, we all respond differently to treatment.
Read more about different types of depression.
Doctors from the Black Dog Institute have recently developed a 'stepped care approach' to treating patients with major depressive disorder. Essentially, it involves managing patients according to how severe their depression is when they first see their doctor.
Care is 'stepped up' if the initial treatment is not providing a sufficient response.
Health professionals and interested people can download, 'Adult depression: A step-by-step approach guide to treatment'. (412KB)
Overview of the 'stepped care approach' developed by doctors and researchers at the Black Dog Institute
Step 1: Mild depression
Patients with mild depression may initially be observed, educated and advised about self-help and lifestyle changes such as exercise, good sleeping patterns, and mood monitoring to help manage their symptoms.
The Black Dog Institute also recommends using eMental Health interventions in conjunction with professional advice, such as:
Step 2: Moderate depression
Patients with moderate depression may also benefit from eMental Health programs mentioned above, and face-to-face psychological or 'talking therapies' such as interpersonal psychotherapy (IPT) and cognitive behaviour therapy (CBT).
This should be combined with self-help therapies and lifestyle changes. In some cases, antidepressants are considered.
Step 3: Severe depression
When patients have depression that's resistant to the treatments mentioned above, or who present initially to their doctor with severe or melancholic depression, they need to get help in conjunction with a psychiatrist.
Severely depressed people may benefit from antidepressant medication and combined treatments, including psychotherapy approaches.
Doctors and health professionals should always consider local public after-hours or crisis services as part of the care team.
Step 4: Severe depression with marked functional impairment
Treatment in hospital may be required when patients have depression with:
- psychotic symptoms
- impaired functioning
- an ineffective response to multiple courses of antidepressants
- life threatening/suicidal thoughts.
Treatment may include electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS).
For relapse prevention
Structured psychotherapy (for example CBT) and antidepressants are both effective in prevention of relapse of depression.
Doctors need to look for any other health conditions that may be present together with depression. When choosing the right antidepressants, they look at the most significant symptoms.
Health professionals and interested people can download, 'Adult depression: A step-by-step approach guide to treatment'. (412KB)
Psychological treatments are sometimes called 'talking therapies'. They can help us change habits in the way we think, and help us cope better with life's challenges. Some are based on one-on-one interactions, others are group-based.
Psychological treatments provide either an alternative to medication, or work alongside medication. They are also useful in helping us stay well once we've recovered from depression.
A thorough assessment is needed to decide on the best combination of treatments for you.
There are a wide range of psychological treatments for depression:
- cognitive behaviour therapy (CBT)
- e-mental health programs (online therapies)
- interpersonal psychotherapy (IPT)
- mindfulness-based cognitive therapy
- positive psychology
- narrative therapy.
Cognitive behaviour therapy (CBT)
When we experience depression, we can have a negative view about ourselves and the world around us. Thinking patterns can become so entrenched that we don't notice errors of judgement caused by thinking in a negative way. It's like we've put a negative filter on our lives.
Cognitive behaviour therapy (CBT) aims to show us how our thinking affects mood. CBT teaches us to think in a less negative way about life and ourselves. It is based on the understanding that thinking negatively is a habit. And, like other bad habits, it can be adjusted. We can re-frame the way we think.
- be conducted by trained therapists either in one-on-one therapy sessions or in small groups
- take between 6-10 sessions (the number will vary from person-to-person)
- include 'homework' between sessions (sometimes this is in the form of online mental health programs that are discussed in the next session)
- help you look logically at the evidence for your negative thoughts, and to adjust the way you view the world.
CBT can be used across all ages, from children to the elderly. CBT has been found to be one of the more effective treatments for depression. CBT is generally delivered by a trained psychologist. Talk to your GP about whether this is an option for you.
Many online therapies are based on CBT principles. You can access the free online program myCompass to learn CBT skills for preventing and coping with depression. Visit the myCompass website.
e-Mental health programs
e-Mental health programs (also called e-therapies or online therapies) are therapies and support services that you can access on the internet using your smartphone, tablet or computer. e-Mental health tools can be used in conjunction with a mental health professional or as a stand-alone option.
e-Mental health treatments can help some people experiencing mild to moderate depression or anxiety, and some have been found to be as effective as face-to-face therapy.
e-Mental health treatments are based on face-to-face therapy, positive psychology and behavioural activation. These therapies mainly focus on re-framing thoughts and changing behaviour.
Some psychologists encourage their patients to use e-mental health tools in between face-to-face visits. They can use them to monitor mood improvement, see which treatment modules are effective, and use them as a catalyst for discussion.
e-Mental health programs:
- are available throughout Australia, wherever there is an internet connection
- are anonymous
- can mostly be accessed without a referral
- can be used in conjunction with the work you are doing with your GP, psychologist or counsellor
- are self-paced
- are either free or have a minimal cost.
The e-mental health programs we recommend have been researched, developed and tested in Australia.
e-Mental health treatment programs you could try
myCompass myCompass is an interactive self-help service that aims to promote resilience and wellbeing for all Australians. myCompass was developed by the Black Dog Institute and is based on CBT, interpersonal psychotherapy, problem solving therapy, positive psychology and behavioural activation. myCompass has been proven to be effective in helping people experiencing mild to moderate depression and anxiety.
THIS WAY UP Using CBT principles, the THIS WAY UP clinic offers proven online courses for depression and anxiety.
MoodGYM MoodGYM is a free self-help program to teach CBT skills to people vulnerable to depression and anxiety.
OnTrack OnTrack offers free access to online programs, information, quizzes and advice to support people in achieving mental and physical health and wellbeing.
Some resources for young people
BITE BACK BITE BACK was developed by the Black Dog Institute and is an ever-changing space which aims to improve the wellbeing and mental fitness of 12-18 year olds, based on the principles of positive psychology.
eHeadspace eHeadspace is a confidential, free, anonymous, secure space where 15-25 year olds can chat, email or speak with qualified youth mental health professionals.
ReachOut ReachOut is a mental health website for people under 25.
Youth Beyond Blue Youth Beyond Blue provides mental health education and links to phone support for 12-25 year olds.
Download our e-mental health and depression fact sheet.
Doctors can read our fact sheet on e-mental health.
Interpersonal psychotherapy (IPT)
Our risk of developing depression can often be traced to aspects of social functioning (work, relationships, social roles) and personality. The underlying assumption with interpersonal therapy is that depression and interpersonal problems are interrelated.
The goal of IPT is to help us understand how our vulnerabilities can lead to current depression, or the risk of developing depression in the future.
IPT occurs in three main phases:
- an evaluation of the patient's history
- an exploration of the patient's interpersonal problem areas and the development of a treatment contract
- recognition and consolidation by the patient of what has been learnt and developing ways of identifying and countering depressive symptoms in the future.
Usually 12-16 sessions of interpersonal psychotherapy will be required.
Mindfulness-based cognitive therapy
Mindfulness-based cognitive therapy is an approach to treating depression, adapted from Buddhist meditation principles. It is also useful in preventing depression relapse, and for assisting with mood regulation.
How can mindfulness help with depression?
Mindfulness is a form of self-awareness training. It's about being aware of what's happening in the present moment. At the same time, it helps us not to make judgements about whether we like or don't like what we think. Mindfulness involves:
- cultivating our ability to pay attention in the present moment
- disengaging from mental 'clutter' and having a clear mind
- responding rather than reacting to situations (this can improve our decision-making and potential for physical and mental relaxation).
Mindfulness has also been found to have considerable physical health benefits.
How can I access mindfulness-based cognitive therapy?
Mindfulness-based cognitive therapy is usually undertaken in an eight-week group program format. Sometimes psychologists use these techniques in one-on-one therapy sessions depending on their training and experience.
Other mindfulness-based approaches have also been developed that may be used for depression. Therapies such as dialectical behaviour therapy, and acceptance and commitment therapy, also use components of mindfulness in their approach. You can also practice mindfulness at home and in everyday life.
Download our mindfulness for tips and techniques on how to use mindfulness for yourself.
Mindfulness takes practice, and daily sessions can be entered on a daily mood chart.
Positive psychology is an area of psychology that focuses on the conditions that contribute to flourishing or optimal functioning. Positive psychology is not about putting on a happy face all the time. Life can be hard and disappointments and challenges are inevitable.
Scientific research shows that there are some strategies that help us navigate challenges of life more effectively, and enjoy life despite the upsets.
Positive psychology researchers have identified lots of everyday activities that improve wellbeing. These include:
Enhancing pleasure through:
- savouring or giving attention to the experience of pleasure
- absorption, allowing yourself to be totally immersed in something
- seeking out a variety of experiences and spreading pleasurable events out over time rather than repeating the same things.
- practicing mindfulness – giving mindful attention to the present moment through meditation and mindfulness-based therapies
- nurturing relationships – the most fundamental finding from positive psychology is that strong personal relationships have the greatest impact on your satisfaction with life
- identifying and using your strengths – thinking about your personal strengths and how you might use them in your everyday life. Cultivating and using your strengths at work, in family life and in your leisure time.
- seeking out 'flow' experiences – 'flow' is a state of joy, creativity and total involvement. Problems seem to disappear and there is a feeling of transcendence. Some activities that can produce 'flow' are sport, games, music, bushwalking, craft, art and hobbies.
Finding meaning through:
- learning to forgive letting go of anger and resentment
- keeping a gratitude diary
- reflecting on your life and making changes to match your priorities small acts of kindness (giving not only makes you feel good about yourself, it enhances your connection with others).
Psychotherapy is an extended treatment (usually over months or years) where a relationship is built up between the therapist and the patient. The relationship is then used to explore aspects of a person's past in great depth and to show how it has led to the current depression. Understanding this link between past and present (insight) is thought to resolve the depression, and to make a person less vulnerable to becoming depressed again.
Counselling encompasses a broad set of approaches and goals that are essentially aimed at helping us with solving long-standing problems within the family or at work. It is also helpful in addressing sudden major problems (crisis counselling).
Narrative therapy is a form of counselling based on understanding the 'stories' that we use to describe their lives. The therapist listens to how people describe their problems as stories and helps them consider how the stories may restrict them from overcoming their present difficulties.
Narrative therapy sees problems as being separate from people. It assists individuals in recognising the range of skills, beliefs and abilities that they already have (but may not recognise) that they can apply to problems in their lives.
Narrative therapy differs from many therapies in that it puts a major emphasis on identifying people's strengths. It examines where we have mastered situations in the past, and therefore seeks to build resilience rather than focus on shortcomings.
The main physical treatments for depression are:
- drug treatments (medicines)
- electroconvulsive therapy (ECT)
- repetitive transcranial magnetic stimulation (rTMS).
New treatments being trialled at the Black Dog Institute include transcranial direct current stimulation (tDCS), also known as mild brain stimulation (MBS)
Drug treatments (medications) for depression
Your doctor should undertake a thorough consultation before deciding whether medication is a good option for you. Taking medication for depression must be supervised by a doctor.
If medication is prescribed as part of your treatment, your doctor should explain the reason for choosing the medication they've prescribed.
Your doctor will also discuss the risks and benefits, side effects, and how regularly you need check-ups. They can also advise what treatments can work together with the medication, such as psychotherapy, lifestyle changes (e.g. exercise), and other support options.
It's also important to know that not all types of depression need medication. Some respond to lifestyle changes and psychological treatments. It can take time for medication to start working. Do not stop taking medication suddenly without consulting your doctor.
There are three main groups of drugs most likely to be used for depression:
- mood stabilisers
There are a large number of antidepressants. They have a role in treating many types of depression. They vary in how effective they are across the more biological depressive conditions. Common classes of antidepressants, include:
- selective serotonin reuptake inhibitors (SSRIs)
- tricyclics (TCAs)
- irreversible monoamine oxidase inhibitors (MAOIs).
They each work in different ways and have different applications. It's important to find the right antidepressant for each person. If the first antidepressant doesn't work, it is sensible to move to a different kind of antidepressant. For the biological depressive disorders, more broad action antidepressants are usually more effective.
Mood stabilisers reduce the severity and frequency of mood swings. These drugs are important for treating people with bipolar disorder.Common mood stabilisers include:
- lithium carbonate
- sodium valproate
It is important to remember that the antidepressants and mood stabilisers are often necessary both to treat the depression that is occurring now, and to make a relapse in the future less likely.
People sometimes need to continue taking medication for some time after they are feeling better.
These medications are divided into 'minor' or 'major' tranquillisers.
Minor tranquillisers (typically benzodiazepines) are not helpful in depression; they are addictive and can make the depression worse.
Major tranquillisers are very useful for people experiencing psychotic depression or depression that isn't improving with other medications.
Electroconvulsive therapy (ECT)
ECT is a neurostimulation treatment option for difficult-to-treat depression. ECT is a safe procedure with good patient satisfaction.
Doctors at the Black Dog Institute have found ECT to be the 'most effective, proven biological treatment currently available for depression'. ECT has a small but important role in treatment, particularly in cases of:
- severe or treatment-resistant depression and bipolar depression
- psychotic depression
- severe melancholia where there is a high risk of suicide or the patient is too ill to eat, drink or take medications
- life-threatening mania
- severe post-natal depression.
Some new types of ECT, such as ultrabrief pulses (ultrabrief ECT) and bifrontal ECT have been shown to have fewer cognitive side effects than standard ECT.
ECT is not available at Black Dog Institute but is clinically available in public and some private hospitals.
Download our ECT fact sheet.
Repetitive transcranial magnetic stimulation (rTMS)
Studies at the Black Dog Institute indicate that rTMS has antidepressant effects when applied over the frontal areas of the brain.
rTMS is a mild form of brain stimulation. Magnetic fields, generated by a simple coil placed on the head, are used to stimulate a small area of the brain. A session of rTMS takes about 30 minutes; it is typically given over consecutive weekdays for several weeks, on an outpatient basis.
While receiving stimulation, the patient is fully awake. rTMS is usually well tolerated with minimal side effects. There is no anaesthetic and memory is not affected.
When is rTMS used?
rTMS is used to treat depression and can be offered when patients have not responded to antidepressant medication.
It can also be used if patients prefer to try an alternative to medication, or cannot tolerate antidepressant medications due to side effects.
How long does rTMS take to work?
A course of at least 20 sessions over consecutive weekdays is recommended for therapeutic results although patients may notice changes occurring earlier.
Your mental health professional will undertake careful evaluation first to see whether rTMS is a good treatment option.
Download our rTMS fact sheet.
Find out more about the Sydney Neurostimulation Centre at the Black Dog Institute.
Transcranial direct current stimulation (tDCS)
Studies around the world, including a recently completed study at the Black Dog Institute, have found that tDCS has significant antidepressant effects when applied over the frontal areas of the brain.
tDCS is a very mild form of brain stimulation applied continuously for 30 minutes. It is painless and there are no known serious side effects. The treatment is given while the person is awake, unlike ECT that requires a general anaesthetic.
tDCS is a potential treatment for depression, offered as an alternative to antidepressants and ECT.
How long does tDCS take to work?
The stimulation takes 30 minutes per session, and for therapeutic results the recommended course is every weekday for at least four weeks .tDCS is available through participating in our tDCS research trials.
Download our tDCS fact sheet.
Watch a Channel 9 news report on the Black Dog Institute's tDCS trial.
There are a wide range of self-help measures and alternative therapies that can be useful for some types of depression .They can be used alone or in conjunction with physical treatments (such as antidepressants) or psychological treatments. It can be good to know that there are things you can do for yourself to feel better. Some of these are listed below.
More biological and severe types of depression are unlikely to respond to self-help and alternative therapies alone. However, they are valuable adjuncts to physical treatments.
Self-help and alternative therapies that may be useful for depression include:
- St John’s wort
- massage therapy
- meditation and mindfulness.
It's good to remember that different types of depression respond to different kinds of treatments.
Regular exercise may increase the level of brain serotonin. Serotonin is a neurotransmitter involved in regulating mood, sleep, libido, appetite and other functions. Problems in the serotonin pathways of the brain have been linked to depression. Exercise can also increase the level of endorphins in the brain which have 'mood-lifting' properties.
Regular exercise may alleviate symptoms of depression by:
- increasing energy levels
- improving sleep
- distracting from worries and rumination
- providing social support and reducing loneliness, if exercise is done with other people
- increasing a sense of control and self-esteem, having an active role in our own wellbeing.
Regular exercise can be an effective treatment by itself for mild depression, particularly for people who were previously inactive. Exercise does not need to be extremely vigorous to be helpful for depression – a brisk walk each day can be beneficial.
For more severe melancholic depressions, exercise may be a helpful strategy alongside other treatments (e.g. medication or psychological therapies).
Watch Dr Sam Harvey from the Black Dog Institute discussing exercise and mental health.
There is evidence that omega-3 fatty acids, commonly found in oily fish such as salmon, anchovies, trout, tuna, mackerel and swordfish, play a role in mental wellbeing. This has particularly been in cases of bipolar disorder, but some studies also demonstrate antidepressant properties.
How does omega-3 affect mood?
There are several lines of evidence that suggest that omega-3 consumption may be associated with mood disorders.
Research suggests that omega-3 is related to a number of biological processes that have been found to be associated with brain functioning.
Note that consuming large amounts of some fish may lead to ingestion of contaminants. Download our omega-3 fact sheet for more information.
St John's wort
St John's wort is a herbal remedy for depression. It is a herb with a yellow flower and has many chemical compounds. Some of these compounds are believed to help depression by preventing nerve cells in the brain from reabsorbing the neurotransmitter serotonin. Another way it may work is by reducing levels of a protein involved in the body's immune system functioning.
Studies have shown that St John's wort is an effective antidepressant in cases of people with mild non-melancholic depression. However, it is ineffective for people with biological depression.
St John's wort can have side-effects. Some reports suggest it may have some toxic effects on reproductive functioning. There are other possible problems with St John's wort, including possible interactions with certain medications.
You can download our fact sheet on St John's wort as a treatment for depression for more information.
Yoga is an ancient Indian exercise philosophy that provides a gentle form of exercise and stress management. It consists of postures or 'asanas' that are held for a short period of time and are often synchronised with your breathing. Yoga is very helpful for reducing stress and anxiety, which are often precursors to depression.
A number of studies have shown that yoga breathing exercises are beneficial for depression.
Massage therapy is believed to be helpful for people with depression, although further studies are needed to conclusively demonstrate this.
Massage produces chemical changes in the brain that result in a feeling of relaxation, calm and wellbeing. It also reduces levels of stress hormones, such as adrenalin, cortisol and norepinephrine, which in some people can trigger depression.
Meditation and mindfulness
Mindfulness is a form of self-awareness training adapted from Buddhist mindfulness meditation. Mindfulness is about being in the present moment, without making judgment. It allows us to experience our body and feelings in each moment with acceptance, and helps free us of mental 'clutter'.
Mindfulness helps us stop getting caught up in thinking about the past or worrying about the future. Mindfulness can change the way our brain and nervous system function. It can allow our parasympathetic nervous system to take over and place us in a state of rest, healing and restoration.
Mindfulness has been adapted for use in treatment of depression, especially preventing relapse and for assisting with mood regulation.
For more information download our mindfulness fact sheet.
The symptoms of depression or anxiety that occur in childbearing women can be similar to those that occur at other times of life.
However, choices for treatment may differ during pregnancy or when a woman is breastfeeding.
Treatment options include counselling, psychological therapies and medications
It’s important to treat depression and anxiety as early as possible because these conditions not only cause distress for the mother, but can also influence her ability to cope with her baby, and affect their developing relationship.
Partners and young children can also feel stressed when a parent is anxious or depressed.
Types of treatment will vary with the nature and severity of the symptoms, and the type of depression.
Psychological therapies and counselling
These are appropriate and sufficient for many women where there are stresses from life events, relationship disturbances, or personality patterns contributing to the difficulties of coping with a newborn baby.
Sometimes there is a problem related to the baby that is causing distress such as difficulty settling or excessive crying.
In these cases, practical help, advice on coping methods, and psychological support may be sufficient to help settle the distress for both mother and baby.
Severity of symptoms sometimes make it necessary for medication to be used as part of the treatment.
Wherever possible, doctors try to avoid the use of medication that might affect the developing foetus or the breastfeeding infant.
A consultation with your GP or psychiatrist will help you to obtain advice about management of your symptoms including the best types of treatment.
Some physical illnesses are sometimes accompanied by symptoms of depressed mood
A medical examination may be required to detect these, for example, thyroid disease and anaemia. See your doctor if you think you might have a medical condition that may be associated with depression.
These treatments are supportive, educational and aim to give a woman and her partner some understanding and acceptance of the causes for the depression.
It’s important to ask questions rather than worry in silence
There are some situations where depression is triggered by unnecessary worrying, lack of information, or incorrect beliefs about a situation.
Doctors, midwives, child and family health nurses, and parent educators all play a part in providing information for new and prospective parents.
They have lots of information about pregnancy and normal behaviours of newborn babies. They can also correct misinformation.
When symptoms persist despite reassurances and the provision of correct information, other treatment approaches can be considered.
Psychological or counselling treatment
There are also various counselling approaches such as cognitive behaviour therapy (CBT) and interpersonal therapy (IPT) that can teach women skills to deal with situations that trigger or increase distress.
- can be delivered individually or in groups and usually take place weekly for 6-12 sessions
- might be provided by a doctor, psychologist, social worker, midwife or nurse trained in these methods
- involving a mother and baby together, or with both parents together.
Couples counselling can be also be useful for problems in the parents’ relationship including communication problems and sexual difficulties.
For women with long-standing problems arising in childhood, there are other forms of psychotherapies that require longer-term treatment.
Always talk to your doctor before taking any medication whilst pregnant or breastfeeding
If you are taking prescribed medications and plan to become pregnant, discuss your plans with your doctor before discontinuing your medication.
This is to ensure that you don’t experience adverse withdrawal effects or a relapse of the condition being treated.
The use of medications in the perinatal period is usually avoided because of the risks of exposure for the foetus and breastfeeding infant. However, in some cases it may be necessary for expectant mothers to commence or remain on medications under strict medical supervision.
However, decisions about the use of medication involve weighing up of risks against the benefits for each woman.
Your doctor will take into account the type of depression and the severity of the symptoms when prescribing medication.
In some situations, under medical guidance, it’s better to treat the symptoms using medication to shorten the period of distress.
A mother who is seriously depressed or anxious will find it difficult to be emotionally available for her baby. This can interfere with the developing relationship between the mother and infant. This means that early and effective treatment of serious depression, including medication if necessary, is vital to the wellbeing of mother and baby.
Antidepressants in pregnancy and after childbirth
Our knowledge about the safety of antidepressant medication in pregnancy and whilst breastfeeding is improving.
Some antidepressant medications are relatively safe for use in pregnancy and most are safe during breastfeeding. Your doctor will know which are the safest medications for use at these times.
In breastfeeding, 1-5% of the drug passes into breastmilk. Some babies may show withdrawal effects from SSRIs and may need medical supervision for a short time.
Antidepressant medications can also be useful in the treatment of anxiety symptoms.
For more information contact MotherSafe and we recommend Overcoming the Baby Blues by Professor Gordon Parker, Kerrie Eyers and Professor Philip Boyce.
Treating teen depression
The following information is intended for health professionals and relates to the treatment of unipolar depression in adolescents.
Treating depression in adolescents requires a multi-modal approach that takes into account the adolescent's context in terms of their age, their family circumstances, as well as their social and educational settings.
Antidepressant drugs are considered along with other management strategies, but are only indicated as first-line treatment in adolescents with a melancholic depression.
- Prevalence of depression in adolescents worldwide is 1–2% annually.
- Recurrence rates are high: 50–70% within five years.
- Onset of depression in early adolescence has a poorer prognosis.
- Despite adequate drug treatment, 20% of adolescents with depression don't improve in the short term, highlighting the need for more comprehensive management planning, combining psychological and pharmacological treatment.
General approach to management
- engage the teenager and establish rapport
- explain confidentiality to the teenager and parent/guardian, including empathic explanation of the need to involve others in the young person's care, especially when depressed, if they are self-harming or feeling suicidal
- consider both the diagnosis of depression and the type of depression, remembering that depression can present differently in young people for example as irritability, behaviour problems, and school refusal
- assess risk of harm
- consider co-morbid conditions
- treat depression in parents if present
- in non-melancholic depression, initially try simple non-specific psychosocial strategies such as:
- psychoeducation of the teenager and their parents
- developing problem solving skills
- anxiety management
- dealing with conflict
- sleep hygiene
- liaising with schoolscognitive behaviour therapy (CBT) and interpersonal psychotherapy (IPT)
- try omega-3 (1-2 g/day) or, in non-melancholic depression, St John's wort (remember this acts on serotonin metabolism and can cause a serotonin syndrome. It also interacts with many other medications such as the contraceptive pill).
The use of antidepressants
Antidepressants are prescribed when there is inadequate response to non-pharmacological management.
Please note: Adolescents prescribed antidepressant medication require close follow-up during the first few weeks to monitor any increase in suicidal or externalised aggressive behaviours.
Although at present no antidepressant drugs are approved by the TGA for use in young people, medications with a long half-life such as fluoxetine are generally preferred as missed doses are less problematic. Start with half the recommended dose and increase the dose if there is no response – and no significant side-effects – after 1-4 weeks.
If required, gradually keep increasing the dose in increments as tolerated to the maximum dose recommended by the manufacturer.
SSRIs such as escitalopram (start at 10 mg) and sertraline (start at 25 mg) are alternative choices.
If no response:
- review the diagnosis and examine possible factors that may prevent improvement (e.g. nonadherence, family conflict, abuse, substance use) and address these appropriately
- add or continue CBT or IPT
- refer for specialist opinion.
Educate patients about the rationale for introducing medication, side-effects, not stopping medication suddenly or without consulting a medical practitioner.
Tricyclics should not be used in adolescents as they are generally ineffective and highly toxic in overdose. Avoid concurrent use of benzodiazepines.
Side effects may include:
- increasing agitation – this is dose-related and may improve by reducing the dose
- 'manic switch'
- increased risk of suicidal ideation in first weeks after commencement of therapy, but overall, the benefits of antidepressants are considered greater than the risks of suicide attempts.
Make sure to:
- monitor thoroughly and regularly, particularly during the first few weeks of medication
- keep assessing for suicidal risk – risk keeps changing with time monitor side-effects
- if the patient's response is good, maintain medication for at least nine months.