5.1 Pharmacological and psychological therapies
Pharmacotherapy with antidepressant medications (see Table 2) and depression-specific psychological therapies (see Box 11) can be effective treatments for depression, either delivered as monotherapy or in combination (Kupfer et al., 2012). Cognitive behavioural therapy (CBT) is empirically supported for mild to moderate depression, and interpersonal psychotherapy can be as effective as CBT in some cases. For those who have had three or more previous depressive episodes, mindfulness-based cognitive therapy has an additive effect. Problem-solving therapy has also been shown to be effective in treating depression. Computer and internet-based therapies are also being developed.
| Class of Drug | Examples | Proposed mechanism of action |
| Selective serotonin reuptake inhibitors (SSRIs) | Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline | Selectively inhibit the reuptake of serotonin |
| Tricyclic antidepressants | Amitriptyline, Desipramine, Doxepin, Imipramine, Maprotiline, Nortriptyline, Protriptyline, Trimipramine | Nonselectively inhibit the reuptake of monoamines, including serotonin, dopamineand noradrenaline |
| Noradrenaline-dopamine reuptake inhibitor | Bupropion | Inhibits the uptake of noradrenaline and dopamine |
| Serotonin modulator | Nefazodone, Trazodone | Primarily antagonises 5-HT2 receptors |
| Serotonin-noradrenaline reuptake inhibitors | Desvenlafaxine, Duloxetine, Venlafaxine | Inhibits the reuptake of serotonin and noradrenaline |
| Noradrenergic and specific serotonergic modulator | Mirtazapine | Primarily antagonises alpha-2 and 5-HT2C receptors |
| Serotonin reuptake inhibitor and 5-HT1A receptor partial agonist | Vilazodone | Potently and selectively inhibits serotonin reuptake and acts as a partial agonist at 5-HT1A receptors |
| MAO inhibitors | Isocarboxazid, Phenylzine, Tranylcypromine, Selegiline | Nonselectively inhibits enzymes (MAO-A and MAO-B) involved in the breakdown of monoamines, including serotonin, dopamineand noradrenaline |
Footnotes
MAO: monoamine oxidase; 5-HT: serotonin (5-hydroxytryptamine).Footnotes
Ketamine, an NMDA receptor antagonist and analgesic/anaesthetic drug, has more recently been investigated as a new form of treatment for severe depression. At the time of writing, a derivative of ketamine (esketamine, marketed as the nasal spray ‘Spravato’) has subsequently been approved by the Food and Drug Administration (FDA) in 2019, for the treatment of severe depression in the United States. Heralded as the first ‘new’ pharmacological treatment for depression in over thirty years, it will be offered to patients who have tried at least two other treatments without success, and will be administered under medical supervision and monitoring, due to its potential for abuse (FDA 2019).Box 11 Psychological therapies for depression
Cognitive-Behavioural Therapy (CBT)
CBTcan help to change negative thinking, to interpret the environment and interactions in a positive way, to recognise factors that may be contributing to the depression and to help change behaviours that may be making the depression worse. Longitudinal formulations such as the 5 ‘Ps’ (predisposing factors, precipitating factors, presenting difficulty, perpetuating factors, protective factors) can be useful.
Interpersonal Therapy (IPT)
IPT is designed to help an individual understand and work through troubled relationships that may cause the depression or make it worse, by exploring major issues that may add to depression, such as grief, or times of upheaval or transition.
Problem-Solving Therapy (PST)
PST can improve an individual’s ability to cope with stressful life experiences, and can be an effective treatment option particularly for older adults with depression. Using a step-by-step process, the individual identifies problems and comes up with pragmatic (realistic) solutions. Typically a ‘short-term’ therapy, PST may be conducted in an individual or group format.