Depression is no respecter of age, gender, race, money or status. But, depression is a much misuderstood condition. Depressed mood is just one of a number of symptoms of depression that can include psychological symptoms (e.g. depressed mood, loss of interest or pleasure, poor memory, being very quiet or agitated and possibly thoughts of death or suicide) and physical symptoms (e.g. poor sleep, mood swings, low appetite, tiredness or loss of energy). In fact, you can be depressed without having a depressed mood.

Most of us experience these feelings every now and again but depression is where the symptoms carry on for weeks or months and interfere with your life

^{Updated 9.11}

• Hide this answer
• Sources for this information

At any one time, about 1 in 20 people have depression, and about 1 in 4 of us will suffer from depression at some time in our lives. Depression is sometimes called MDD (Major Depressive Disorder) to make it clear it isn't just feeling a bit low. Although many people think depression is getting more common, a large study carried out from 1952 to 1992 showed that it hasn't become more common. What has happened is that more people coming forward for treatment rather than suffering (Murphy 2000).

Depression usually shows with a mixture of symptoms. Some can be physical symptoms, such as:

• poor sleep - this can be an early symptom. It can show as taking longer to get to sleep, more waking up, waking early in the morning and, the most important one, not feeling refreshed. Poor sleep can also be an early symptom of depression coming back.

• mood varying throughout the day

• low appetite (sometimes increased appetite)  

• tiredness, slowness or loss of energy

• constipation

• loss of interest in sex  

• loss or gain in weight

• unexplained aches and pains.

Others can be mental health symptoms, such as:

• feeling depressed

• loss of interest or pleasure

• poor memory

• being very quiet or agitated

• returning thoughts of death or suicide

• anxiety

• feelings of worthlessness or guilt.

Social symptoms:

• not doing well at work, school or college
• taking part in fewer social activities and avoiding contact with friends  
• reduced hobbies and interests  
• difficulties in home and family life.

The normal reaction to the death of a loved one doesn't count as depression, unless it goes on for a long time.

Depression can have many consequences e.g. damage to relationships, poor performance at work, self-harm and suicide. Depression can also be bipolar depression and occur as part of bipolar mood disorder and may need different medicines and treatments. Many people with depression also have many symptoms of anxiety.

NICE in the UK has divided depression into 5 grades:

• Subthreshold - where the person has a few symptoms and feels low, but can still carry on OK  

• Mild - where the person has enough symptoms for a diagnosis but can function reasonably well

• Moderate - where the person has a lot of symptoms and are not coping well

• Severe - where the person has a full set of symptoms, can't function and may even suffer some psychotic symptoms too

• Complex - where the symptoms haven't got better to treatment and may have psychosis, other symptoms and problems

^{Updated 4.13}

• Hide this answer
• Sources for this information

Basically, anyone can get depression and it doesn't have to have an obvious cause. However, there are some "risk factors" that make it more likely that someone will get the symptoms of depression. This is not a complete list but some of the main risk factors include:

• Genetics - we seem to inherit the ability to resist depression, and 40-70% people with depression have a close relative who has also had depression

• Anxiety - the genes may overlap between anxiety and depression

• Gender (depresison may be twice as common in females)

• Lack of parental care or childhood sexual abuse

• Social adversity

• Stress (and stress is different for everyone)

• Physical illness, such as kidney disease (5 times the risk), diabetes (much more likely, especially if the diabetes is bad enough to need insulin)

• Poor sleep - it is unclear if poor sleep can make you more likely to get depression or poor sleep is an early symptom. It's probably an early symptom or danger sign, either for getting depression or depression returning.

• Being deficient (not having enough) Vitamin D. The lower your Vitamin D elevls the more chance you have of being depressed. Vitamin D is sometimes called the "Sunshine Vitamin" as it is made for the body by the skin when in direct sunlight. Lack of vitamin D can cause rickets (weak bones), thin bones, fatigue and obesity. And possibly depression, especially if you don't see enough sunlight (Lee 2011). Your levels can be checked by your doctor, and it is possible to have Vitamin D capsules.  

• Quitting smoking means you are twice as likely than general population to become depressed, especially if the person has history of depression if they quit smoking (Tsoh 2000)

• Taking some medicines or drugs (see next question) 

• Your mother having postnatal depression increases your risk of depression by about 5 times (Murray 2011)

• Having Parkinson’s Disease – at least doubles your chance of depression (Becker 2011)

• Having insomnia - people with insomnia but without depression are over twice as likely to get depression compared to people with no sleep problems (Baglioni 2011)

There are many chemical messengers in the brain. Serotonin, noradrenaline and dopamine are three important ones, and they control mood, drive, emotions and alertness in some parts of the brain. We know that when someone is under some type of stress, a chain reaction can occur in the brain, which results in serotonin, noradrenaline and dopamine being reduced. This results in less mood, less drive, less emotion and less alertness, which are some of the symptoms of depression. Many of the antidepressants boost serotonin, noradrenaline or dopamine.

^{Updated 4.13}

• Hide this answer
• Sources for this information

Because everyone is unique, everyone's symptoms are different. So, it's not always clear what the right diagnosis is. Here is a list of some other possible causes for the symptoms of depression. This is not meant to be a textbook list, just some ideas. Some of these can be very rare indeed. Some of these don't really matter - the person is still depressed and needs treatment, although the cause will also need to be helped or treated. 

• Prescribed medicine-induced - over 200 prescribed medicines have been reported to cause depression e.g. benzodiazepines (e.g. diazepam, lorazepam), anticonvulsants (e.g. levetiracetam, primidone, phenobarbital, zonisamide), heart treatments such as beta-blockers (especially propranolol, but less so with atenolol, nadolol and sotalol; although beta-blockers can cause fatigue which can feel like depression) and calcium-channel blockers (e.g. nifedipine), NSAIDs (for arthritis, but rare), interferons (often used for MS), steroids (especially at higher doses), statins (such as simvastatin, for high cholesterol) and oral contraceptives ["The Pill"].
   With all these, the risk is low and we can't predict it. Lots of people take these medicines and lots of people get depressed. Clearly people can get depressed while taking any of these drugs anyway. What we don’t know always is with a common medicine and a common condition, how many depressions are caused by the medicine and how many would have happened anyway. If you think it might have happened, think about the timeline - did depression appear a few weeks or a month or so after a drug was started, a dose changed, or something stopped? If so, it is certainly possible.
  If it has occurred you should seek medical advice. The options can include:
  · Can carry on and hope the depression goes away
  · Reduce the dose if possible and hope the symptoms go away
  · Stop and try a non-medicine treatment
  · Switch to another medicine treatment
  · Carry on but treat the symptoms of depression
  · Any combination of the above

• Schizophrenia, which tends to have more fragmented (random) thoughts and retarded (dulled) emotions

• Schizoaffective disorder - having schizophrenia and depression at the same time  

• Bipolar depression - almost impossible to be sure early on that the depression isn't part of a bipolar mood disorder. Depression is more likely to be due to Bipolar Mood disorders in someone who has had more depressive episodes, it starts at an earlier age, has lots of anxiety symptoms, and suicide attempts. Unipolar depression is more likely to be the cause in people with agitation, suicidal ideation and irritability ^{[Schaffer 2010]}

• ADHD (Attention Deficit Hyperactivity Disorder) - as a cause of depression

• Substance misuse e.g. drug dependence or addiction, such as alcohol dependence as self-medication (especially if symptoms persist for more than 2 months after stopping), or alcohol, amphetamine, cocaine withdrawal, long-term ecstasy use

• Personality disorders

• Normal bereavement - 1 in 20 (5%) people who have had a loved one die go on to get major depression. In major depression, there is no lightening of the mood, and the person tends to think of themselves as being ill. In normal bereavement, there is a quite natural feeling of "loss" but no "loss of self-esteem" or feelings of worthlessness

• Physical illness e.g. hormones (low thyroid, Addison's Disease, Cushing's Disease, diabetes), infections (hepatitis, AIDS, influenza, post-viral), arthritis, anaemia, brain disease (e.g. Parkinson's, dementia, Multiple Sclerosis, epilepsy, tumours, sleep apnea)

• GAD or Generalised Anxiety Disorder - which tends to have more panic and tension about danger, and more doubt and uncertainty. Depression is more slowed up and sad, with loss of interest and weight loss

• Dementia - depression can sometimes look like dementia e.g. being slowed down and dull. Dementias usually have a very slow onset or a sudden onset, and there are brain changes

• Chronic fatigue syndrome

• Narcolepsy

• Lack of Vitamin D - this can cause tiredness, aches and pains, and generally feeling low. Vitamin D is made by the skin in sunlight. You need 20-30 minutes of sun on your arms and face 2-3 times a week for 6 months a year to keep your Vitamin D levels up.  

• Stopping smoking (although interestingly actually smoking nearly doubles your chances of getting depression; see Pasco 2008)

• Panic disorder

• Seasonal Affective Disorder

Just to confuse matters further, sometimes people have more than one illness (sometimes called "co-morbidity"). For example, if 1 in 10 people get depressed and 1 in 10 people get anxiety, then just by chance 1 in 10 of the depressed people get anxiety as well. However, if you're depressed, you're more likely to be anxious. Co-morbidity means what else the person is more likely to have at the same time. This can make diagnosis more difficult.

• GAD or Generalised Anxiety Disorder

• Dementia

• Psychosis

• Insomnia - caused by the depression

• OCD (Obsessive Compulsive Disorder)

• PTSD (Post-Traumatic Stress Disorder)

• Panic disorder

• Seasonal Affective Disorder

• Social anxiety

^{Updated 10.11}

• Hide this answer
• Sources for this information

Our aim is to try to help people who are taking medication (or should be) get the right medicine, dose and take it regularly for as long as is right. Any medicines should usually be part of the overall treatment, although some people are quite happy just to stick with drugs or talking treatments. It is important to get medicines right (right medicine and dose). If the medicines are right, then everything else can fall into place. If the medicines are wrong, then they may make the symptoms worse.

The list here includes all options and doesn’t say what works and doesn’t. Many may be used in combination. Most herbal and alternative therapies have not really been tested in the same rigorous way the medicines have.

Milder depression:

This is where the person has some symptoms but it doesn’t really affect the person at home and work. Most mild depressions resolve fairly quickly and self-help is all that is needed.

Self-help

• Guided self-help (books and leaflets) and putting talking therapies into action
• Taking any medicines regularly and reliably
• Eating healthily and taking exercise (“exercise to energise”) or being active has been shown to have a modest effect, even helping antidepressants to work (Trivedi 2011)
• Putting help from others into practice
• Biting your tongue when people tell you to pull yourself together

Help from others

• Social support (very important)
• Psychological help (such as problem-solving therapy, brief CBT, relaxation therapy, anxiety management, mindfulness-related therapies and counseling)
• General advice e.g. financial advice
• Alternative therapies such as aromatherapy, hypnosis or hypnotherapy, homeopathy (click for a review of the 25 studies in mental health by Davidson 2011) (treating like with like) can be used in conjunction with (but not relied on to replace) conventional treatments. Acupuncture is used extensively in many countries and may help anxiety, stress and insomnia, but probably doesn't help depression (Andreescu 2011). The evidence for these treatments is not very robust. All of these can be used in conjunction with other therapies. If they work then that is fine and we wouldn’t knock them. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbals etc, and some useful links).

Medicines

• Medicines (such as SSRIs or St. John’s wort may help mild depression)

Major (moderate to severe) depression

Moderate to severe depression is where the symptoms cause the person not to be able to function at home and/or work. It usually needs more treatment as it can be very damaging and distressing for the person and those around them. It goes without saying that suicide is also possible. Suicide hardly ever happens without depression (including with alcohol).

Although there have been some concerns that antidepressants might be a cause of suicide, the overwhelming evidence is the opposite. There are loads of studies showing that the more antidepressants are prescribed, the lower the suicide rate.

Self-help

• Eating healthily and taking exercise (“exercise to energise”) or being active has been shown to have a modest effect
• Guided self-help (books and leaflets) and putting talking therapies into action
• Taking any medicines regularly and reliably
• Not getting too upset when people tell you to pull yourself together  

Help from others (as well as the ideas in the section above)

• ECT (electroconvulsive therapy) for severe depression
• Talking therapies such as CBT may also help, especially if combined with antidepressants. Other psychological help such as problem-solving therapy, brief CBT, relaxation therapy, anxiety management, mindfulness-related therapies and counseling may be useful
• TMS (transcranial magnetic stimulation) may possibly be useful ^{(Janicak 2010)}
• General advice e.g. financial advice
• In some very resistant cases, treatments such as deep brain stimulation (DBS) and vagus nerve stimulation (VNS) can be used.

Medicines

• Antidepressants are one of the main treatments and can be very effective
• Combining antidepressants with talking therapies can be more effective than either by themselves

  ^{Reviewed 4.13}

• Hide this answer
• Sources for this information

If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or agreements in your area)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again)

The main medicine treatment options in UK are listed below. They are divided into "Main medicines" and "Others".

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.

There is a myth or misconception that antidepressants are "uppers". Amphetamines ("Speed") might be "uppers" but antidepressants aren't. Antidepressants don't increase the effects of positive emotions. What antidepressants seem to do is reduce the way someone reacts to negative emotions and fears. So, they're stopping lows rather than making you high.

Main medicines

BNF Listed:

SSRIs (Selective Serotonin Reuptake Inhibitors)

• Citalopram (Cipramil ®) - standard first-line UK antidepressant
• Escitalopram (Cipralex ®) - the active part of citalopram
• Fluoxetine (Prozac ®) - standard first-line UK antidepressant
• Fluvoxamine (Faverin ®) - one of the first SSRIs but little used these days
• Paroxetine (Seroxat ®) - standard UK antidepressant
• Sertraline (Lustral ®) - standard UK antidepressant

Others

• Agomelatine - new in 2009, and very different  
• Lithium - usually used as a mood stabiliser
• Mianserin - not used much these days
• Duloxetine (Cymbalta ®) - an SNRI, a little like venlafaxine (click here for the Cochrane review from 2012)
• Mirtazapine (Zispin ®) - standard UK antidepressant
• Moclobemide (Manerix ®)
• Reboxetine (Edronax®) - a noradrenaline booster
• Trazodone (Molipaxin ®) - quite sedative
• Tryptophan (Optimax ®) - discontinued in UK in October 2012 but some supplies are still available
• Venlafaxine (Efexor ® and Efexor XL ®) - has quite a few side effects but may be good for more resistant depression

Tricyclic antidepressants (TCAs)

• Amitriptyline
• Clomipramine (Anafranil ®)
• Dosulepin (dothiepin) - not recommended by NICE
• Doxepin
• Imipramine
• Lofepramine - the NICE recommended tricyclic
• Maprotiline (discontinued in UK)
• Nortriptyline
• Trimipramine

Mono-amine oxidase inhibitors (MAOIs)

You would need to go on a special diet if taking these.  

• Isocarboxazid - usually only for more resistant depression
• Phenelzine - usually only for more resistant depression
• Tranylcypromine - usually only for more resistant depression

Others (licensed):

• Quetiapine XL, which was licensed in 2010 as an "add-on" treatment for depression. It can be used with antidepressants where they have not worked fully. It is also used for bipolar depression.

Others:

• Bupropion (Zyban ®) - is available in many countries for smoking cessation but not licensed for depression, although it is used for depression in some countries e.g. USA
• St. John's wort - is not licensed but widely used, seems effective for mild to moderate depression
• Antipsychotics – can help with psychotic symptoms
• Lamotrigine - for bipolar depression only

Depression that doesn't seem to get better with antidepressants can sometimes actually be bipolar depression, as part of a bipolar mood disorder. It might be worth thinking if this could be the cause if the usual antidepressants don't help much.

Sometimes the symptoms of depression can become very severe e.g. when someone tries to kill themselves. This can result in the person becoming very distressed and/or too difficult to cope with and might need to be admitted to hospital. This might then become what is called an "acute psychiatric emergency" or crisis. The treatments for this may need to include some other medicines just to calm the person down and prevent harm to that person, or others. If this happens, follow the link to some information that might help explain what might be going on.

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

Well it isn't true. Sadly, much publicity on this came in 2008 from an American psychologist called Kirsch, now living in Hull. He said that antidepressants don't work unless you're really depressed and that "Depression is not a brain disease, and chemicals don't cure it". He said that nearly all people who get better with "antidepressants" do so because they're given something, not because they're given an effective medicine. And that they would get better whether they're given an "antidepressant" or a sugar pill. This is called the "placebo" effect i.e. the mere act of giving someone something means they're more likely to get better. Kirsch is the only person to point this out, but he did get a huge amount of media coverage.

Kirsch has had over 35 papers published based on his analysis of a limited number of studies. These studies were all from before 1999 and are the ones required by the FDA (the American Food and Drugs Administration) to prove a drug works before it can get a "license". The first of his papers was early in the 2000s and the most well known one was in 2008. Unfortunately it seems that some GPs have taken the story at face value, believed the publicity and press releases, and are now less keen on prescribing antidepressants.

This is all very unfortunate. Even the editor of the journal that carried the first article warned readers that the author had chosen studies very selectively and that the statistics were "clearly arguable".

The same data and analysis has been published over 35 times to date by the same author in different forms. And the conclusion every time is that the only effective therapy for patients with depression is CBT (Cognitive Behavioural Therapy). Really? Please read on.

• This author has focused on these 35 short trials (with 5133 patients) and has conveniently ignored everything else published since. For example, there were over 15 similar studies published in 2000 alone. These newer studies clearly show that antidepressants work very well for many (but by no means all) people with depression, and they reduce relapse and distress. In fact, reducing the return of symptoms is their strong point.

• Two other way of doing the statistics (which are just as fair) of the hand-picked data come up with very different results and show a very good response. This is even more so if you include citalopram and sertraline (which are widely used and which Kirsch ignored) and leave out nefazodone (which Kirsch included but was taken off the market many years ago).

• Many people say they like CBT. But it has to be said that the conclusion that CBT is the only effective treatment for depression is not actually proven. If CBT was a medicine, there is not one single study for CBT in depression that would be good enough get it a license. And any medicine needs two studies for a license. People who throw stones shouldn't live in greenhouses!

This one analysis of a carefully chosen selection of old data appears to have been looked at with only one thing in mind. And it got a stunning amount of publicity, far more than one would expect from a rehashed study in an on-line journal. Sadly much of the media hype (top news in the newspapers and BBC) was based on what many have said was a very misleading press release.

You might say that as pharmacists we're biased and say to us "Well, you would say that wouldn't you?". Well, you could say exactly the same to Professor Kirsch, who is of course a Psychologist with an interest in promoting psychological therapies. The difference is that here at C&M we're only interested in making sure that people get better (as indeed are psychologists of course), and that you have a balanced view into both sides of the story before you make a choice. Interestingly I could name you at least 5 Professors of Psychiatry who take antidepressants long-term and who feel much better on them. I'm sure they wouldn't feel like that if they were actually just taking sugar pills. And would be deeply offended if you said that to them too! And of course placebos only work if you think that you have a chance of getting something that works...

What is the most important point is you finding out what works for you, not people taking part in clinical trials. It is quite possible that the cause of the symptoms is a change in circuits in the brain, not just in the nerve endings. Antidepressants may work on one part of the circuit and talking therapies on another part. So the combination may work better, which is what nearly all combination studies show. 

Perhaps we'll leave the last (and funniest) line to someone on the PLOS website (where the paper was published). He points out that since psychological therapies and antidepressants are widely thought to be as effective as each other, then if antidepressants don't work, you can't prove psychological therapies work. So why bother to pay for any treatments? Especially psychologists!

"For this range of disorders, cognitive therapy and antidepressants are generally considered to be about equally effective. Therefore if Kirsch et al are correct there seems little point in spending large sums of money funding psychological treatments when all that is needed for the management of anything but severe depression is the prescription of sugar pills. This startling and economically important conclusion seems to have eluded both authors and editors in their haste to discredit the real experts, depressed people themselves." 

PLOS website

^{Steve Bazire 8.11}

• Hide this answer
• Sources for this information

Download a handy summary chart (PDF format) comparing the main medicines for depression e.g. names, how they work, doses, how long they take to work, some side effects, how long to take and how to stop.

Those lovely people at Depression Alliance in UK also have a "Choice Toolkit" where you can have a different way of looking at antidepressants and making a choice. Go to the What you should know about depression part of the Depression Alliance website.

^{Updated 5.12}

• Hide this answer
• Sources for this information

You should think carefully about taking any chemical that affects the brain. So think carefully before your next cup of tea or coffee!  

Talking Therapies are very useful for depression, from mild, to moderate to severe. People generally like them and find them comforting and comfortable. There are several different types, including full CBT (Cognitive Behavioural Therapy), brief CBT, IPT (Interpersonal Therapy), problem-solving therapy, relaxation therapy, anxiety management, mindfulness-related therapies and counselling.

Having said that, the main problem is that we can't really prove (in the same way as we can for antidepressants) that they work. Research is expensive and there is always the problem of telling people that they're depressed but that they can't be treated to get a "placebo" group. The most recent analysis of 117 studies suggests that the effects of Talking Therapies in depression are overestimated due to "publication bias" (Cuijpers 2010).

Antidepressants have been shown to work in depression, both for treating depression and stopping it coming back. But of course they don't work for everyone. Probably the biggest advantage for antidepressants is that there is a very good body of evidence that they are most effective for stopping depression returning (Geddes 2003, NNT=3). In fact, antidepressants and talking therapies might work on different parts of depression e.g. boosting serotonin helps reduce the symptoms, and talking therapies help you control and live with them and so cope better. Both of these can reduce the symptoms, but in different ways.

In order to help people get a sense of balance about the usefulness of medicines and talking therapies, especially in depression, please click here for our take on it.

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

This should be discussed with your doctor, as people respond differently. To help you make a decision, it may be useful for you to know that research has shown that:

• for a first episode of major depression, your chances of becoming depressed again are much lower if you keep taking the antidepressant for six months after you have recovered (longer if you have risk factors for becoming depressed again)

• for a second episode, your chances of becoming depressed again are lower if you keep taking the antidepressant for one or two years after you have got better

• for depression that keeps coming back, keeping taking an antidepressant has been shown to have a protective effect for at least five years. Some people say you should have a good reason to stop an antidepressant if you get depression regularly.

  ^{Reviewed 4.13}

• Hide this answer
• Sources for this information

Before going onto another medicine, it is worth trying to get the best out of the first one. There is a danger or risk that switching medicines too quickly means you don’t get the best out of one medicine and perhaps start to search for the “magic bullet”, expecting quicker responses and having less patience. There are no “magic bullets”. Most symptoms have happened over a few months or years, not a few days, so it is perhaps unrealistic to expect them to go over a few days. They are more likely to resolve over weeks or months. If side effects are the main problem, try fiddling with dosage e.g. changing times, splitting, manage side effects etc.

The best thing to do is set out your aims of success in advance and be realistic. If you decide to stop, then that’s your decision, but make sure you consider the chances of becoming unwell again (and consequences of that to yourself and the people close to you).

If you have unipolar depression (i.e. if you haven’t got bipolar mood disorder or manic-depression), you need to get to the therapeutic dose (see the handy chart for these doses). Then give the antidepressant at least 4 weeks for the full effect. The antidepressant effect will probably start in a few days and may start to be noticeable in a week or so but then continues to build up over the next few weeks. In fact, some effects of SSRIs can be seen within 3 hours (e.g. being less alarmed or upset by fearful faces (Murphy 2009).

Generally, no antidepressant seems to work quicker than any other. Having said that, an analysis of all the 15 main studies of mirtazapine shows that people taking mirtazapine have a 74% higher chance of getting better within 2 weeks compared to SSRIs ^{(Thase 2010)}.

If nothing has changed in 4-6 weeks, there is only a slim chance of the antidepressant working, although increasing the dose sometimes helps. If you get some improvement (even if only subtle), then give it about 6-8 weeks before trying to switch. Beware of switching too soon – the STAR*D study in the USA showed that it really is best to get the best out of the first two antidepressants you try, because the chances of getting better goes down with each subsequent medicine.

Whatever you do, if you decide to stop, please do it gradually over at least several months. You’ve got a lot to lose by stopping too quickly and not a lot to lose by taking those few months and not destabilise yourself.

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

There are no easy answers to this and it is a very individual choice. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any not on this list.

Generally just the one antidepressant is best, as many combinations can have interactions and be dangerous (including when switching from one to another). Combining drugs of a similar way of working is usually pointless and may give more side effects. Sometime combining medicines can help reduce side effects.

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE (the National Institute for Health and Clinical Excellence). NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have their own similar bodies (see links below) although they will often adapt NICE guidance to those countries (and vice versa).

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of NICE guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments
• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound guidance (although these are sometimes controversial). They are, however, only "guidelines", so are not rigid instructions.

When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website:

• Full guideline (very long and detailed, often several hundred pages, for anorak healthcare professionals only)
• Official guideline (usually 10-30 pages, the summary version for healthcare professionals)
• Quick reference guideline for healthcare professionals (usually only a couple of pages)
• User-friendly summary for service users, carers and the general public

These should then be reviewed, usually about 4-5 years or sooner if more information becomes available.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments.

• NICE has produced several guidelines that include depression. These include the depression guidelines; depression in children and young people; depression in people with a chronic physical health problems; and Common mental health disorders, Identification and pathways to care.
• Scottish Intercollegiate Guidelines Network (SIGN), where there is a guideline on the non-pharmaceutical management of depression (January 2010) and a guideline on postnatal depression (updated March 2012)
• Northern Ireland

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based on their own experiences as well as what the published papers say, rather than just what the published studies say). These will have been produced for healthcare professionals by such bodies as BAP (British Association for Psychopharmacology).

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

Use the resources below to find out more information about depression. Please note that this is not an exhaustive list. We welcome your feedback on resources that you think should be listed here.

If you want a more in-depth read, you could no better than visit the BAP (British Association for Psychopharmacology) public web pages, where there are some fairly scientific articles, including about antidepressants so click here, to get there.

Mental Health Ireland has a great links page on this extensive site

Your Mental Health Ireland, with a young person’s page as well

The British Association for Psychopharmacology has a BAP public area, which has loads of interesting articles, some mentioning bipolar disorder.

The Big White Wall is a 16+ safe, anonymous web-based service for people experiencing emotional or psychological distress provided entirely online. Professionally staffed 24/7 it offers a wide range of services for improving mental wellbeing including tests, peer support, individual and group therapies, articles, tips and creative self expression. Simply click on the link to learn more, or to join for £2.00 a week.

^{Updated 12.12}

Resources

• Depression Alliance

  
  Depression Alliance is one of the leading UK organisations trying to improve the care of depression. They have a document called "Daring to choose", which has some key needs for depression, plus a website called whatyoushouldknowaboutdepression, which has a helpful guide on choosing your own treatment and antidepressant by John Donoghue.
  

• Depression leaflet

  Read the leaflet on the Royal College of Psychiatrists website.

  Source: Royal College of Psychiatrists

  The Royal College of Psychiatrists is the professional and educational body for psychiatrists in the United Kingdom and the Republic of Ireland.

  Address: 17, Belgrave Square, London, SW1X 8PG

  Email: mailto:Royal%20College%20of%20Psychiatrists%3Crcpsych@rcpsych.ac.uk%3E?subject=Message%20from%20Choice%20and%20medication%20website

  Website: http://www.rcpsych.ac.uk/

  Credit: Royal College of Psychiatrists

• Depression: a leaflet for carers and professionals working with people with depression

  Download the leaflet from the Royal College of Psychiatrists.

  Credit: Royal College of Psychiatrists

• Computerised cognitive behaviour therapy for depression and anxiety

  Evidence based technology appraisal from NICE recommend the options of psychological therapies and drugs for serious mental illness. NICE guidelines on depression state "cognitive -behavioural therapy should be offered as it is of equal effectiveness to anti-depressants".

  Credit: National Institute for Health and Clinical Excellence (NICE)

• Evidence-based guidelines for treating depressive disorders with antidepressants

  Download the revision of the 2000 British Association for Psychopharmacology (BAP) guidelines (PDF 491 KB) from http://www.bap.org.uk/.

  Credit: British Association for Psychopharmacology

• The Depression Report: A New Deal for Depression and Anxiety Disorders

  This report also known as the Layard Report recommends increasing access to psychological therapies, especially Computerised Behavioural Therapies (CBT) in order to help alleviate the suffering of people with mental health problems.

  Credit: Professor Lord Richard Layard, Centre for Economic Performance's Mental Health Policy group, London School of Economics

• More to depression

A 2011 survey on choice in antidepressants can be found at: http://www.moretodepression.co.uk/.

^{Updated 7.12} 

• Hide this answer
• Sources for this information