How to Treat Major Depressive Disorder

Feeling sad or down is a normal human emotion. It’s natural to feel negative feelings like sadness or depression when facing a life challenge, such as losing a job, the passing of a loved one, or facing a serious illness. These are usually short-lived and don't interfere with daily living. But when these feelings become persistent, intensify, and interrupt day-to-day life, a mood disorder like major depressive disorder might be present. Major depressive disorder is a serious mental illness that significantly impairs a person's ability to function, causing changes in mood, behavior, appetite, and sleep. Depression is the leading cause of disability, affecting nearly 280 million people worldwide.

Treatment For Depression

When you’re struggling with a debilitating mental illness like depression, recovery can seem impossible. You may find yourself wondering if you can or will ever get better. The good news is, you can. Depression is a treatable condition that is most effective when treatment begins shortly after a diagnosis, however, it's never too late to seek help. Treatment is individualized based on the severity of symptoms, how long you’ve been experiencing symptoms, physical and mental health history, and co-occurring disorders. Treatment options for depression will vary but will usually include a combination of psychotherapy and medication. If you’re also dealing with a chronic illness like MS, Parkinson’s disease, or an eating disorder, in addition to your depression, you may find yourself working with a medical doctor, too.

Psychotherapy for Depression

Psychotherapy was first developed in the early 1900s by Sigmund Freud and became the first method of treating depression. Often referred to as “talk therapy” or simply therapy, it aims to help control, reduce or eliminate troubling feelings and emotions so a person can feel better, increase well-being and provide healing. It involves a person and therapist sitting in a room together and talking through various events, traumas, feelings, emotions, and relationships. Therapists have formal training in a variety of techniques to help people recover from depression. While there are many different types of therapy, research shows there are seven primary therapeutic modalities that are most effective in treating depression. Each of these modalities can be used individually and are often combined to achieve the best outcomes and prevent relapse.

Cognitive Therapy

The negative thoughts you experience with depression can be overwhelming and even have the power to distort your view of reality. Cognitive therapy can be an effective way to challenge and defuse those thoughts. These thoughts are known as automatic thoughts and occur without making a conscious effort. Some of these thoughts may include:

I’m never good enough
I’ll never be happy
I fail at everything

While automatic thoughts may have some truth, like maybe you failed a test once, a person who is depressed exaggerates the thoughts and distorts reality. The goal of cognitive therapy is to recognize and correct automatic negative thoughts so that over time, depressed people can correct false beliefs about themselves. Cognitive therapy works by disassembling and examining several parts of a problem, such as:

The problem as the person perceives it
Thoughts about the problem
Emotions surrounding the problem
Physical feelings around the problem, i.e.; nausea, headache, racing heart
Actions before, during, and after the problem

It’s much easier to manage parts of a problem, rather than dealing with the problem as a whole. Cognitive therapists teach clients the tools they need to make problems more manageable and change the way they think about them. This often requires continuous practice, which is why homework is often assigned in between sessions.

Behavioral Activation

Behavioral activation (BA), a central focus in behavioral therapy, is centered around changing behaviors that affect emotions. A primary symptom of depression is a behavior change, usually marked by an increase in avoidance, withdrawal, and inactivity. Engaging in these types of behaviors can create a cyclical effect and make depression worse. BA attempts to help you identify specific behavior patterns that are making symptoms worse, like isolation, and create specific goals to help reduce behaviors. The goals are in the form of activities that are consistent with things you enjoy doing, help you cultivate qualities you desire, and aim to help you live the life you want. For example, if you want to be a generous person, you may consider goals like volunteering your time, donating monthly to a charity, or allocating time every week to take a friend out for coffee. The main idea behind BA is to help people learn how to positively cope with negative emotions and increase awareness by developing short- and long-term life goals. By increasing activities that generate a positive reward, you’re more likely to continue to engage in positive activities which will help improve your overall mood.

Cognitive-Behavioral Therapy (CBT)

Cognitive-behavioral therapy (CBT) is an evidence-based approach that has been proven to successfully treat depression and significantly decrease relapse rates. The principle behind CBT is that thoughts impact moods (emotions and feelings) and behaviors (actions), and vice versa. This is known as the CBT triangle. For someone with depression, this can look like a negative core belief such as “I’m a failure” which leads to feeling sad or worthless and encourages isolation. The goal of CBT is to correct false beliefs about oneself that can lead to negative moods and behaviors. To do this, CBT implements both cognitive and behavioral strategies that may include:

Recognizing distortions that are causing problems and challenging them
Using problem-solving skills to cope with difficult situations
Facing fears instead of avoiding them
Using role-play to prepare for interactions with others
Learning to calm your mind and relax your body

CBT emphasizes the client's role in their treatment and encourages clients to be their own therapists (when they are ready). Like in cognitive therapy, this requires practice outside of sessions. Homework like thought records, activity scheduling, and mindfulness practice, are often assigned to help clients develop effective coping skills and challenge their problematic thinking, emotions, and behaviors.

Dialectical Behavioral Therapy (DBT)

A specific type of CBT, dialectical behavioral therapy (DBT) focuses on learning to accept uncomfortable and negative behaviors instead of fighting against them. Dialectic is an integration of opposites. By sitting in the uncomfortably of wanting to engage in harmful behavior but refraining from them, therapists can help clients navigate their thoughts and emotions to help them choose the behavior that will help them reach their goals. DBT is broken down into four skill modules to help clients become more aware of, accept, challenge, and change their behaviors and emotions.

Mindfulness

Mindfulness is about being aware of and accepting the present moment. By learning how to stay in the present, you can better notice thoughts and feelings without judgment. In DBT, mindfulness is split into two groups: “what” and “how” skills. The “what” skills teach you what you are focusing on, like the present moment and awareness of emotions, thoughts, and physical sensations. The “how” skills teach you how to be more mindful, like balancing thoughts, using radical acceptance, and taking effective action.

Distress Tolerance

In moments of crisis, it’s hard to remain mindful. Distress tolerance teaches positive coping strategies to help navigate moments of crisis and help keep you from using negative ones. Some positive coping strategies can include distraction from emotions or a situation, self-soothing, or writing a pros and cons list.

Emotion Regulation

When emotions are high, it can feel like there’s no escape. But with a little help from emotion regulation skills, you can manage them. This group of skills helps you deal with primary emotional reactions before they lead to a chain of secondary reactions. The goal is to prevent one emotion from snowballing into several more. Emotion regulation skills can teach you to recognize emotions, overcome barriers to positive emotions, and reduce vulnerability.

Interpersonal Effectiveness

Intense emotions can make it difficult to connect with the world around you. Interpersonal effectiveness skills help you learn how to communicate clearly in times of stress. It combines listening, social, and assertiveness skills to help you manage difficult situations while adhering to your values. DBT uses three types of therapy to help teach these skills, including one-on-one, group training, and phone coaching. To get the most out of DBT it’s important to go through each module at least once, but therapists recommend two or even three full cycles.

Psychodynamic Therapy

Unlike CBT and IPT, psychodynamic therapy focuses on emotional suffering that happened in the past. It assumes that a person is depressed because of unresolved and unconscious conflicts stemming from childhood. In this type of therapy, self-reflection and self-examination are key in understanding why someone might be depressed. By making past, unconscious elements of a person's life part of their present, it can help them understand why they think, act, and feel the way that they do. To do this, therapists may use techniques like free association, which encourages clients to freely talk about whatever they have on their minds. As they do this, patterns of behaviors and feelings from past experiences are brought to the forefront. The role of the therapist is to help the client talk about the difficult and often contradictory feelings associated with past events so they can better handle them in the present. Because the client drives sessions based on past experiences, psychodynamic therapy is less structured compared to other types of therapy and will last longer.

Interpersonal Therapy

People with depression tend to have poor and stressful relationships with loved ones, making their depression worse. The goal of interpersonal therapy (IPT) is to improve communication skills and as a result, improve relationships and self-esteem. A short-term-focused treatment modality, IPT first aims to reduce symptoms by improving social situations by identifying the problems of how individuals interact (or don’t interact) with others. When those problems are brought to light and addressed, a person can start to become more aware of and change their response to situations.

Problem-Solving Therapy

When you're struggling with depression, it’s often difficult to cope with everyday life stressors. Stress can take a heavy toll on your health, especially your mental health. Problem-solving therapy (PST) aims to help people with depression identify and manage their stressors. This therapy teaches people several affective, cognitive, and behavioral tools to help them adapt and adjust to life problems. With real-time application, PST can help clients train their brains to overcome barriers that include the way they react and attempt to solve problems. In a typical session, there are five steps in which a therapist will help clients solve problems:

Identify stressors
Brainstorm realistic solutions
Select the most effective solution
Develop and implement an action plan
Assess the effectiveness of their attempt to problem-solve

In addition to these steps, therapists will teach clients specific skills on how to cope with depression, role-play scenarios, and practice communication skills. Most types of therapy start with 1 to 2 sessions weekly and might be a combination of individual, family, and group therapy. Sessions typically last for 50 minutes, though it's common for sessions to extend up to one hour. The type of therapy will dictate how long you can expect to be in treatment. CBT, for example, is a short-term treatment that usually lasts for 12 to 16 weeks but can go longer depending on the level of care needed. Other research shows that it typically takes 15 to 20 sessions for 50% of people to feel improvement.

Medications Used for Treating Depression

During the early 1950s, researchers found that two medications used to treat physical illnesses also improved the moods of patients who had previously been diagnosed with depression. These drugs affected a group of neurotransmitters called monoamines, introducing the chemical imbalance theory where there are too few or too many neurotransmitters in the brain. Researchers found that the most effective antidepressants acted upon serotonin and noradrenaline. Antidepressants are commonly used to treat both acute and non-acute (chronic) major depressive disorder. There are two primary classes of antidepressants called selective serotonin reuptake inhibitors and serotonin and noradrenaline reuptake inhibitors that are used to reduce symptoms of depression. The type of medication your doctor chooses for you will depend on your symptoms, intensity, medical history, and how long you have been depressed.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are usually the first choice of medication to treat depression because they have fewer side effects than most other types of depression. Serotonin is a neurotransmitter that is responsible for mood and emotions and can help with sleep and digestion. Once the neurotransmitter carries a message from one cell to another, it is reabsorbed by the nerve cells. This is known as reuptake. SSRIs work by blocking reuptake, making more serotonin available to pass along more messages to other nerve cells. Research shows that high serotonin levels in the brain are linked to elevated mood and increased feelings of happiness. SSRIs are taken in tablet form, starting with the lowest dose necessary to improve symptoms. Some common but mild side effects include:

Feeling agitated, shaky, or nervous
Nausea
Headaches
Dizziness
Blurred vision
Low sex drive

Serotonin and Noradrenaline Reuptake Inhibitors (SNRI)

Serotonin and noradrenaline reuptake inhibitors work similarly to SSRIs by affecting neurotransmitters in the brain and preventing the reuptake of serotonin and noradrenaline. Noradrenaline, also known as norepinephrine, is a neurotransmitter in the brain that is responsible for mobilizing the brain for action, regulating energy, and improving attentiveness. Low levels of norepinephrine are associated with low energy, poor ability to concentrate, and decreased cognitive ability. By blocking the reuptake of noradrenaline, levels in the brain increase and can improve these symptoms. Like SSRIs, SNRIs are also taken in tablet form and at the lowest dose possible. Some common side effects of SNRIs include:

Tiredness
Insomnia
Nausea
Dry /moth
Changes in appetite

Other Medications

Some other less common types of medications include tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). These were some of the first types of antidepressants developed, but due to more severe side effects, new antidepressants are used more often. Antidepressants must be taken as prescribed for at least 4 to 6 weeks before their full effects begin to take place. During this time, you should be closely monitored by your psychiatrist to look out for unwanted side effects and determine the effectiveness of the medication. It is normal to feel mild side effects at first, but if side effects worsen it may be a sign to try a different medication.

Recovery From Depression

While there is no absolute cure for depression, a combination of therapy and medication can help you recover from depression. In a recent study, researchers found that of 1,500 people with MDD who received treatment, 70.6% of them came into remission. No matter where you are in your MDD diagnosis, know you are not alone in your illness. There are over 63,000 members at PatientsLikeMe who have depression. Join the conversation to learn more about depression and what others are doing to treat and manage their condition.