Treatment for depression

How treatment is chosen

In England, NHS treatment for depression is based on the NICE guideline Depression in adults: treatment and management (NG222), published in 2022. Services elsewhere in the UK use similar approaches.

NICE recommends that you and your clinician choose treatment together. The discussion should cover what each option involves, its benefits and downsides, and your own preferences and past experience of treatment.

Treatment usually builds step by step. People start with the option that suits their situation best, and treatment is reviewed and changed if it is not helping. This is often called a stepped approach.

The biggest factor is how severe your depression is. NICE groups depression into less severe (subthreshold symptoms and mild depression) and more severe (moderate and severe depression). The symptoms page explains how severity is judged.

Less severe depression

For a new episode of less severe depression, NICE lists these options in order of how clinically effective and cost-effective its committee judged them to be, taking practical factors into account:

1. guided self-help
2. group cognitive behavioural therapy (CBT)
3. group behavioural activation (BA)
4. individual CBT
5. individual BA
6. group exercise
7. group mindfulness and meditation
8. interpersonal psychotherapy (IPT)
9. selective serotonin reuptake inhibitors (SSRIs), a type of antidepressant
10. counselling
11. short-term psychodynamic psychotherapy

NICE says antidepressants should not routinely be offered as the first treatment for less severe depression, unless that is the person’s preference.

For mild symptoms, the NHS says a GP may also suggest waiting a short time to see whether things improve on their own, with a review after 2 to 4 weeks.

More severe depression

For a new episode of more severe depression, NICE lists, again in order:

1. a combination of individual CBT and an antidepressant
2. individual CBT
3. individual BA
4. antidepressant medication
5. individual problem-solving
6. counselling
7. short-term psychodynamic psychotherapy
8. interpersonal psychotherapy (IPT)
9. guided self-help
10. group exercise

The NHS notes that a combination of an antidepressant and CBT usually works better than having just one. If depression is severe or you are at risk, you may be referred to a specialist mental health team.

Guided self-help

Guided self-help uses structured materials, such as a workbook or online course based on CBT, with support from a trained practitioner. The practitioner checks in, helps you use the materials and reviews your progress. It is often the first option offered by NHS Talking Therapies for milder depression.

CBT and behavioural activation

Cognitive behavioural therapy (CBT) is a talking therapy that helps you change how you think and act. You look at difficult situations and at the thoughts, feelings and behaviours linked to them, then try out new ways of responding. The NHS says people usually have between 5 and 15 sessions, and practising between sessions is an important part of it.

Behavioural activation (BA) focuses on what you do. Depression tends to make people withdraw, which makes mood worse. BA helps you gradually build back activities that give you a sense of enjoyment, achievement or connection, even before you feel like doing them. Self-help for depression describes a simple version you can start now.

Other talking therapies

• Interpersonal psychotherapy (IPT) looks at how relationships, conflicts, losses and life changes connect with your mood.
• Counselling gives you space to talk through what is troubling you with a trained counsellor.
• Short-term psychodynamic psychotherapy explores how past experiences and patterns may be affecting you now.
• Problem-solving therapy helps you break practical problems into steps and work through them.

Group exercise

NICE includes group exercise as a treatment option. It describes this as a group physical activity programme, led by a trained practitioner, using moderate-intensity aerobic exercise. The NHS says these programmes usually involve more than one session a week over about 10 weeks.

Many GP surgeries can refer people to local exercise schemes. The NHS page on exercise for depression has more on getting started.

Medication

Antidepressants can help many people, particularly with more severe depression. They usually take 1 to 2 weeks to start having an effect, and up to 8 weeks to work fully. People are usually advised to keep taking them for at least 6 months after they feel better, to lower the risk of depression returning.

NICE recommends reviewing how well treatment is working within 2 to 4 weeks of starting. For people aged 18 to 25, or at increased risk of suicide, NICE recommends a review 1 week after starting or increasing the dose.

The antidepressants page covers types, side effects and how to stop safely.

NHS Talking Therapies

NHS Talking Therapies services in England offer free psychological treatment for depression and anxiety. Options include guided self-help, CBT, counselling, interpersonal therapy, couples therapy and mindfulness-based cognitive therapy.

You can refer yourself online without seeing a GP. The NHS says you need to live in England and be 18 or over (16 or 17 in some areas). Sessions can be in person, by phone or video, or as an online course. The NHS notes that waits can be several weeks or months, so it is worth referring early.

In Scotland, Wales and Northern Ireland, ask your GP or local health board about talking therapy.

If treatment isn’t working

Not everyone improves with the first treatment. The NHS says you may need to try 2 or more treatments before you find one that works. That is common and not a failure.

NICE recommends first looking at why treatment may not be working, including:

• whether you have been able to take medication as prescribed, or attend sessions
• side effects that made treatment hard to continue
• personal, social or practical problems holding back recovery
• physical health conditions or other mental health conditions

If depression still has not responded, NICE says the diagnosis should be reviewed, including the possibility of other conditions. Options then include:

• after therapy alone: switching to a different therapy, adding an SSRI, or switching to an SSRI
• after medication alone: adding group exercise, switching to therapy, increasing the dose or changing the antidepressant, or moving to combined therapy and medication
• after combined treatment: changing the therapy, changing or increasing the antidepressant, or adding another medicine

Some of these steps, such as combining medicines or using lithium, are usually guided by a psychiatrist. For depression that has not responded to several treatments, a specialist may also discuss options such as brain stimulation treatments.

If you have tried two or more treatments without much improvement, it is reasonable to ask your GP about a specialist opinion. See seeing a psychiatrist.