Depression Treatment

Depression is a treatable psychological condition. In everyday speech, every kind of mental distress, from the slightest worry to the most severe mental illness, tends to be called depression. In fact, depression is a state of low mood that does not pass by itself within a short time and harms the person’s daily functioning. A person with depression does not feel well, no longer enjoys things they used to enjoy, and falls into a pessimistic, restless, sorrowful or sad mood. They describe their state as “sad, distressed, grieving, hopeless”, and often say things like “I can’t enjoy anything, I’m depressed” or “there’s no point in living any more”.

There are two broad kinds of depression. Primary depression arises without any underlying physical or mental illness, while secondary depression develops after a physical illness or another mental disorder.

Depression treatment

The most common risk factors

• losing a parent early in life
• substance and alcohol misuse
• anxiety disorders
• low socioeconomic status
• divorce or separation
• unemployment
• previous episodes of depression
• recent major life events and stressors
• personality structure
• a history of sexual or physical mistreatment in childhood
• hormonal changes
• medical illnesses

Types of depressive disorder

Major depression: feeling depressed most of the day, reduced interest in daily activities, loss of pleasure in life and activities, marked weight gain or loss, severe insomnia or difficulty waking, low self-confidence, lack of energy, poor attention and concentration, and similar symptoms. These must last at least two weeks and markedly impair functioning at work, socially or in other areas of life.

Minor depression: symptoms such as sadness, sorrow and loss of pleasure (anhedonia) that are present but not very severe. It can be described as a sub-threshold form of major depression, covering situations in which the number of symptoms and the diagnostic criteria do not meet those for major depression.

Dysthymic disorder: a chronic form of depression. It is milder than major depression, but because it lasts so long it seriously affects quality of life and functioning. It can occur at any age, from childhood to old age. Dysthymia is an insidious form of depression that can stretch over years; the person is often unaware of being depressed, because the symptoms have become woven into their way of life. They may feel dissatisfied with many aspects of life and themselves, yet look for inner satisfaction and solutions outside themselves.

Premenstrual dysphoric disorder: marked emotional swings before menstruation, notable irritability, anger or increased interpersonal conflict, marked low mood and feelings of hopelessness.

Substance-induced depression: low mood, or a marked loss of interest or pleasure in almost all activities, caused by a substance.

With melancholic features: the person generally does not respond to things that would normally bring pleasure. The capacity for pleasure is not only reduced but almost completely lost, and the quality of mood is distinctly different from that seen in depression without melancholic features.

With atypical features: mood remains reactive, so the person can cheer up in response to positive events, and if circumstances are good they may stay out of low mood for long periods. There may be increased appetite, overeating or weight gain, and oversleeping, with daytime naps or night-time sleep adding up to at least ten hours a day.

With seasonal pattern: episodes of depression regularly begin and end at particular times of year, and seasonal episodes outnumber non-seasonal ones over the person’s lifetime. Seasonal episodes are often marked by low energy, oversleeping, overeating, weight gain and craving for carbohydrates.

Symptoms

Symptoms include changes in appetite (usually reduced appetite and weight loss), sleep problems, physical complaints, restlessness, reduced sexual desire and activity, loss of interest in work or activities, feelings of worthlessness, low self-esteem, self-reproach and guilt, slowed thinking, anxiety, pessimism, thoughts of death or suicide attempts.

Psychomotor retardation, a slowing of movement, may be seen. The face looks blank, with deepened lines on the forehead and deep vertical furrows between the eyebrows. The gaze is often fixed, the shoulders drooping, the posture stooped and the head bowed. This may be accompanied by psychomotor agitation: wringing the hands, pulling the hair, being unable to sit still, pacing back and forth. Self-care declines.

Speech is quiet and slow. There is no impairment of consciousness or of orientation to time, place and person. Patients complain of forgetfulness, but this is not a true memory disorder: they cannot gather their thoughts or focus their attention on a particular subject, so they may be unable to read a book or watch television. In very severe depression, auditory hallucinations (hearing voices that are not there) may occur. Thinking is slowed, and answers to questions are delayed and short. Depressed mood dominates emotional life, and nothing brings pleasure. Behaviourally, patients usually complain of tiredness and exhaustion.

How is depression treated?

Psychopharmacotherapy (medication): when necessary, medicines with proven effectiveness are used together with psychotherapy, most often antidepressants. Medication is the preferred approach particularly in moderate and severe depression.

Cognitive behavioural therapy: uses behavioural activation and methods drawn from classic behavioural theories. It is one of the most widely practised evidence-based psychotherapies in the world and, like medication, it is similarly effective in achieving remission.

Psychodynamic psychotherapy: influenced by psychoanalytic theories, especially ego psychology, it can adapt flexibly to a wide range of client needs. It aims both to relieve symptoms and to develop insight and awareness.

Supportive psychotherapies: include many techniques, methods and therapy modules. Their main aim is remission, the easing of symptoms; in this sense, as with many psychiatric disorders, they can be considered equivalent to medication. However, remission is not the same as recovery in psychiatric disorders, which is why relapse rates are very high after medication or many supportive psychotherapies.

Psychoanalysis (individual or group): not a method aimed at relief or at removing symptoms, but an in-depth exploration of insight, awareness and personality structure. Working through the phenomena that present as psychiatric disorders at their roots is still possible only with psychoanalytic methods. Because psychoanalysis is a demanding journey, the timing of starting and the person’s readiness are critical; a hasty decision to begin can be traumatic and overwhelming, and the person may drop out. Psychoanalysis is a long-term psychotherapy spread over years. Because the person faces their deepest fears and emotions, depressive mood or anxiety are natural and necessary side effects.

Electroconvulsive therapy (ECT): used in very severe depression, usually when psychotic features are present or there is a risk to life. When used for the right indication, ECT is life-saving in many cases.

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Below you will find a scientific article by Prof. Dr. Ali Keyvan, with references, on the approaches of the main theorists to the treatment of depression.

Theoretical approaches to the treatment of depression

Author: Prof. Dr. Ali Keyvan, Psychiatrist

Abstract

Major depressive disorder (MDD) is one of the most common and most disabling mental disorders in modern societies. Its aetiology is heterogeneous, with symptoms such as low mood, anhedonia, low energy and feelings of worthlessness, and its treatment should reflect this multifaceted nature. This article compares the methods of the theorists and schools that have shaped the history of psychiatry and psychology in treating depression: from the psychopharmacological interventions of biological psychiatry, to the psychoanalytic formulations of Sigmund Freud and Karl Abraham centred on “anger turned inwards”, to Aaron T. Beck’s cognitive behavioural revolution built on the “cognitive triad” and “automatic negative thoughts”, to the interpersonal psychotherapy (IPT) model of Gerald Klerman and Myrna Weissman. Each theory has its own strengths in understanding and treating depression, but the article concludes that the most effective approach in current clinical practice is an integrative model that rationally combines psychotherapy and psychopharmacology, shaped to the individual patient’s needs.

Keywords: depression, psychotherapy, psychopharmacology, psychoanalysis, cognitive behavioural therapy, interpersonal psychotherapy, integrative approach.

An integrative review from psychopharmacology to the schools of psychotherapy

1. Introduction

Depression, sometimes called “the common cold of the mind”, is a serious medical condition that affects people of every age and socio-cultural background. Patients often come to us with similar symptoms (sleeplessness, loss of appetite, hopelessness), but the story behind them is always unique. In one patient depression may be the result of a biological predisposition; in another it may express a traumatic loss, an unresolved interpersonal conflict or an existential crisis of meaning. Reducing depression treatment to a single “correct” method therefore means ignoring the patient’s individuality. An effective clinician needs tools from different theoretical approaches and must be able to use them flexibly according to the patient’s needs.

2. The main theoretical approaches to treatment

2.1. The biological and psychopharmacological model

This model, the foundation of modern psychiatry, sees depression as a disturbance in brain chemistry and neural circuits. The “monoamine hypothesis” of the 1960s proposed that depression results from a deficiency of neurotransmitters such as serotonin, noradrenaline and dopamine in the synapse.

• Method and treatment: the primary treatment in this model is psychopharmacology. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin–noradrenaline reuptake inhibitors (SNRIs) aim to relieve symptoms by increasing the amount of these neurotransmitters in the synapse. In severe and treatment-resistant cases, neurostimulation methods such as electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS) are used. This model plays a vital role especially in correcting the biological symptoms (sleep, appetite, energy) of moderate and severe depression.

2.2. Psychoanalytic and psychodynamic psychotherapy

Founded on Sigmund Freud’s paper “Mourning and Melancholia” (1917), this approach sees depression as an unresolved grief reaction to a lost object (a person, an ideal, a status and so on).

• Theory: according to Freud, unlike normal mourning, melancholia (depression) involves ambivalent feelings (love and hate) towards the lost object. Because the person cannot accept the feelings of hate, they cannot let the object go; instead they take it into their own ego (introjection). The anger towards the lost object is thus turned against the self. In Freud’s famous phrase, “the shadow of the object fell upon the ego”. The depressed person’s harsh self-criticism, feelings of worthlessness and tendency to self-punishment are really expressions of repressed anger towards the introjected object.

• Treatment: the aim of therapy is to gain insight. Within a safe therapeutic relationship, the therapist helps the patient bring this unconscious anger, disappointment and the underlying experience of loss into awareness and work through it. Analysis of the transference, in which old relationship patterns are re-enacted in the therapy room, is a key tool.

2.3. Cognitive behavioural therapy (CBT)

Developed by Aaron T. Beck in the 1960s, CBT revolutionised the treatment of depression. According to Beck, the problem is not events themselves but how we interpret them.

• Theory: Beck proposed that at the root of depression lies the cognitive triad, negative thinking in three areas:

  1. a negative view of the self (“I’m worthless”, “I’m inadequate”, “I’m unlovable”)

  2. a negative view of the world and experience (“Life is unfair”, “Nothing ever goes right”)

  3. a negative view of the future (“Nothing will ever get better”, “I’ll always be this unhappy”)

  The triad is maintained through cognitive distortions (such as all-or-nothing thinking, overgeneralisation and catastrophising), which in turn stem from rigid, unconditional core beliefs (“schemas”) learned in childhood. The behavioural activation component explains how depressed people’s withdrawal from enjoyable or rewarding activities creates a lack of positive reinforcement that traps them in a vicious circle.

• Treatment: CBT is structured and goal-oriented. Therapist and patient aim to identify automatic negative thoughts, test their validity through Socratic questioning, develop new and more realistic perspectives through behavioural experiments and ultimately change the underlying core beliefs. Behavioural activation assignments encourage the patient to re-engage with life.

2.4. Interpersonal psychotherapy (IPT)

Developed by Gerald Klerman and Myrna Weissman, IPT holds that depression arises in the context of interpersonal relationships and can be treated by resolving problems in those relationships.

• Theory: IPT links depressive symptoms to one of four interpersonal problem areas:

  1. complicated grief: prolonged or frozen grief after the loss of someone close

  2. interpersonal role disputes: conflicting expectations with an important person such as a partner, family member or colleague

  3. role transitions: difficulty adjusting to a new life role such as marriage, divorce, parenthood or retirement

  4. interpersonal deficits: social isolation and chronic difficulty forming or sustaining meaningful relationships

• Treatment: this time-limited therapy (usually 12–16 sessions) focuses on identifying which of these four areas triggered the current depressive episode and on resolving the problems in that area.

3. An integrative approach to treatment planning

In clinical reality, these theories are not rivals but complements. A new mother who has become depressed (“role transition” in IPT), for example, may also think “I’m an inadequate mother” (a “cognitive distortion” in CBT), and this may stem from an unresolved relationship with her own mother (“object relations” in psychodynamic terms). If her symptoms are severe, she may benefit from an SSRI (the “biological model”) to be able to start psychotherapy. Effective treatment requires an integrative approach that sees these layers and plans intervention flexibly according to the patient’s needs.

4. Conclusion

Depression will not disappear at the touch of a magic wand. Its treatment is a multifaceted art and science that respects the complexity of the human psyche. Biological interventions repair the brain’s hardware, while the different schools of psychotherapy address the errors, conflicts and gaps in the mind’s software. As clinicians, our task is to tailor the right combination of treatments for each patient with a tailor’s precision and to show them that hope and recovery are possible.

5. References

• Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive Therapy of Depression. Guilford Press.

• Freud, S. (1917). Mourning and Melancholia. In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. XIV.

• Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, E. S. (1984). Interpersonal Psychotherapy of Depression. Basic Books.

• Frankl, V. E. (1959). Man’s Search for Meaning. Beacon Press.

• American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, 5th Ed., Text Revision (DSM-5-TR).

• Stahl, S. M. (2021). Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. Cambridge University Press.