Treatment | MGH Depression Clinical and Research Program

Many different treatment options for depression are now available, including medication, psychotherapy, natural and alternative therapies, and neurotherapeutics. Sometimes a combination of treatment approaches is recommended. A skilled healthcare professional can help with depression treatment decisions.

Medication

Antidepressant treatment is often successful in treating depression, particularly moderate to severe depression. Antidepressants affect brain chemicals called neurotransmitters, as well as other aspects of brain function, such as neurogenesis (the development of new nerve cells). Many types of antidepressants are available to treat depression. The most common types are:

Selective Serotonin Reuptake Inhibitors (SSRIs), thought to modulate serotonin levels in the brain. Some common SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro).
Serotonin and norepinephrine reuptake inhibitors (SNRIs), a class of antidepressant that is similar to SSRIs but that also modulates levels of norepinephrine. Examples of SNRIs are duloxetine (Cymbalta), venlafaxine (Effexor), desvenlafaxine (Pristiq), and levomilnacipran (Fetzima).
Atypical antidepressants are medications that work in somewhat unique ways, often involving serotonin and norepinephrine, and that don’t fit into other categories. Examples of atypical antidepressants include bupropion (Wellbutrin), mirtazapine (Remeron), trazodone (Deseryl), vilazodone (Viibryd), and vortioxetine (Brintellix).
Tricyclic antidepressants (TCAs) were among the first antidepressant classes developed. Though effective, they tend to cause potentially more serious side effects than SSRIs or SNRIs and are usually only prescribed if other medications have been tried first. Examples include imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Pamelor), and clomipramine (Anafranil).
Monoamine oxidase inhibitors (MAOIs), also among the first antidepressant classes, may be prescribed if other medications haven’t worked. They are effective but can have serious side effects, including interactions with certain foods or other medication. Patients taking MAOIs are required to maintain a strict diet avoiding aged and fermented foods and must avoid some common medications, like over-the-counter decongestants such as pseudoephedrine (Sudafed) and certain pain medications like meperidine (Demerol). Phenelzine (Nardil), tranylcypromine (Parnate), and the selegiline transdermal patch (Emsam) are examples of MAOIs.

Overall, all antidepressants are similarly effective, although some may offer additional benefits. For example:

Depression that is complicated by chronic pain is generally more responsive to serotonin norepineprhine reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs) than other classes
An individual who is trying to quit smoking and who is depressed may obtain more benefit from bupropion (Wellbutrin, also called Zyban)
If significant insomnia and loss of appetite are among the symptoms of depression that are being experienced, mirtazapine (Remeron) or trazodone (Deseryl) may be most helpful

Side effects

Side effects caused by medication are common but most of them are mild and many side effects disappear over the first days or weeks of treatment. Some side effects, like severe agitation, are uncommon but serious and require immediate attention.

Effectiveness

Antidepressants work only if they are taken daily. Most antidepressants begin working after 2 to 4 weeks, and their full effect may not be felt until 8-12 weeks. Sometimes it is necessary to start with a low dose, then steadily increase it based on how it affects the individual.

About 30% of depressed individuals taking their first antidepressant experience a full return to health, also called “remission.” Another 20-40% improve noticeably but continue to have some symptoms, also called “response without remission” or having “residual symptoms.”

Options may include trying another antidepressant, trying a combination of medications, or adding other treatments such as psychotherapy, complementary and integrative treatments such as yoga, or neurostimulation such as electroconvulsive therapy or transcranial magnetic stimulation. It is always important for your doctor to re-evaluate your diagnosis and to help you address conditions that may interfere with optimal response, such as poor diet or heavy alcohol use.

To safely stop taking an antidepressant, talk with a doctor first. Many antidepressants need to be tapered slowly and require medical guidance to prevent significant side effects, such as muscle aches, nausea, or worsening depression.

To learn about medication treatment options available in our studies, please contact us.

Psychotherapy

Psychotherapy is the process of reviewing symptoms, problems, and experiences with a trained clinician and developing new ways of thinking and coping. It is sometimes referred to as talk therapy.

Psychotherapy is a highly effective treatment for depression. For moderate to severe depression, or depression that has been recurrent, a combination of psychotherapy and medication may be the most effective approach for treating the depression and for maintaining good mental health after the depression has resolved.

A number of different psychotherapy approaches are available to treat depression, including cognitive behavioral therapy (CBT), interpersonal therapy (IPT), problem solving therapy (PST), acceptance and commitment therapy (ACT), and psychodynamic therapy. Some forms of psychotherapy may be pursued in individual sessions or in groups (group therapy). Increasingly, many psychotherapists have expert training that allows them to offer a range of approaches that are tailored to the specific needs of an individual.

To learn about psychotherapy treatment options available in our studies, please contact us.

Natural and alternative therapies

Many promising natural medication therapies are being explored as potential treatments for depression. Researchers at the DCRP and elsewhere have investigated Omega 3 fatty acids (fish oils), S-Adenosyl Methionine (SAMe), L-Methylfolate (Deplin), and St. John’s Wort (hypericum).

Because we still don’t know enough about their safety or effectiveness, individuals who use natural medication therapies should do so under a doctor’s supervision. Also, as with medications and psychotherapy, a physician can also monitor progress and adjust treatment if the depression persists.

Alternative therapies that do not involve medication are also being studied as potential treatments for depression, including:

Movement therapies, such as Tai Chi, Qigong, and yoga
Novel device-based therapies like low-field magnetic stimulation (LFMS), transcranial laser therapy (TLT), and cranial electrotherapy stimulation (CES)

To learn about natural and alternative treatment options available in our studies, please contact us.

Neurotherapeutics

Electroconvulsive therapy (ECT) was one of the earliest treatments for depression. It has been steadily refined over the years and is still in use today, particularly for severe depression that has not responded to medications or psychotherapy. Individuals who are candidates for ECT usually have a detailed consultation and complete medical work-up and an opportunity to review all risks and benefits.

ECT is conducted while a patient is under general anesthesia; it electrically stimulates the brain. Each treatment session lasts only minutes but most individuals require 6-12 treatments, typically spaced 2-3 days apart, over a series of weeks. Treatments may be applied to one side of the brain (unilateral) or both (bilateral). Side effects include temporary headaches and confusion, potential memory problems, and reactions to the anesthetic agents. Although it is more invasive than most other forms of depression treatment, ECT has been life-saving, with rates of response that are generally higher than for medications or psychotherapy alone. More recently, other forms of neurostimulation have been developed, including repetitive transcranial stimulation (rTMS), vagal nerve stimulation (VNS), and deep brain stimulation (DBS). Much remains to be learned about these newer forms of neurostimulation, but they offer promise for individuals for whom other treatments are ineffective or poorly tolerated.

To learn about neurotherapeutic treatment options available in our studies, please contact us.