Depression Treatment: Therapy, Medication, and What Works Best

You may have just been told you have depression, or you may suspect it after weeks of low mood, poor sleep, and losing interest in things you used to enjoy. It is normal to wonder what comes next. The good news is that depression is treatable, and there is strong research on what helps. This guide explains the main options and how clinicians choose between them.

What depression is

Depression (major depressive disorder) is a medical condition that affects mood, thinking, sleep, energy, and the body. It is more than sadness. To meet the medical definition, a person has several symptoms most of the day, nearly every day, for at least 2 weeks [5]. At least one of these must be low mood or loss of interest or pleasure.

Other common symptoms include:

• Changes in sleep, either too little or too much
• Changes in appetite or weight
• Low energy and tiredness
• Trouble concentrating or making decisions
• Feeling worthless or guilty
• Moving or speaking more slowly, or feeling restless
• Thoughts of death or suicide

Depression has many causes. Genes, stress, life events, medical illness, some medications, and substance use can all play a part. It is not a personal weakness.

The main treatment options

Talking therapy

Psychotherapy (talking therapy) is a structured treatment with a trained therapist. The best studied types include:

• Cognitive behavioural therapy (CBT): learning to notice and change unhelpful thoughts and habits
• Behavioural activation: planning activities that bring a sense of pleasure or achievement
• Interpersonal therapy (IPT): working on relationships and life changes
• Problem-solving therapy: breaking problems into steps you can act on

Therapy can be one-on-one, in a group, online, or through guided self-help programs.

Antidepressant medication

Antidepressants are medications that act on brain chemical systems linked to mood. Common types include SSRIs (selective serotonin reuptake inhibitors, such as sertraline and escitalopram), SNRIs (serotonin and norepinephrine reuptake inhibitors, such as venlafaxine and duloxetine), bupropion, mirtazapine, and vortioxetine. A large 2018 analysis of 522 trials found that all 21 antidepressants studied worked better than placebo for adults with major depression [3]. The differences between drugs were mostly modest, so side effects and personal factors often guide the choice.

Lifestyle supports

Regular physical activity, steady sleep routines, and reducing alcohol can help. Canadian guidelines list exercise as a reasonable option for mild depression and as an add-on for more severe depression [1]. These supports work best alongside, not instead of, care for moderate or severe depression.

What your doctor looks at

Clinicians match the treatment to how severe the depression is, your history, and your preferences. Here is what the major guidelines say.

How severity shapes the plan

• Canadian guidance from CANMAT (Canadian Network for Mood and Anxiety Treatments, 2023) lists psychological treatment and antidepressant medication as first-line choices for moderate to severe depression [1].
• For milder depression, CANMAT suggests options such as therapy, guided self-help, or exercise before medication [1].
• The UK NICE guideline (NG222) recommends that for less severe depression, people start with options such as guided self-help, group CBT, or behavioural activation, and that medication is not routinely the first choice unless the person prefers it [2].
• For more severe depression, NICE says a combination of individual CBT and an antidepressant is among the most effective options [2].

Combined treatment

A 2020 analysis of over 100 trials found that combining therapy and medication worked better on average than either one alone for adult depression [4]. Therapy alone and medication alone had broadly similar results to each other.

Measuring progress

Your clinician may use a questionnaire such as the PHQ-9 at the start and at follow-up visits. This helps track change over time. Guidelines expect some improvement within about 2 to 4 weeks of starting medication, with full benefit taking longer [1]. If there is little or no change after an adequate trial, your clinician may adjust the dose, switch, or add a treatment.

How long treatment lasts

• CANMAT recommends continuing an antidepressant for 6 to 12 months after symptoms go away [1].
• People with repeated episodes or other risk factors may benefit from 2 years or longer [1].
• NICE advises discussing the benefits of continuing for at least 6 months after remission, and planning any stop carefully [2].

Canada and US differences

Canadian (CANMAT) and US care follow similar principles. The US does not have one national depression treatment guideline that everyone uses, so US clinicians often draw on several sources, including professional society guidelines and FDA drug labels. Access to publicly funded therapy also differs between provinces and states.

Other treatments for hard-to-treat depression

If two or more medications have not worked well, clinicians may consider:

• Adding a second medication, such as an antipsychotic used at low dose or another antidepressant
• Repetitive transcranial magnetic stimulation (rTMS), a non-invasive brain stimulation treatment
• Esketamine nasal spray, used under supervision in a clinic
• Electroconvulsive therapy (ECT), which is very effective for severe depression and is done under anesthesia

These are usually managed with help from a psychiatrist.

Questions to ask your clinician

• How severe is my depression, and how did you measure it?
• What are the pros and cons of therapy, medication, or both for me?
• How can I find a therapist, and what does it cost where I live?
• If I start medication, what side effects should I watch for?
• When will we check whether the treatment is working?
• What should I do if I feel worse or have thoughts of self-harm?
• How long do you expect I will need treatment?

When to get care quickly

Get help right away if you have thoughts of suicide or harming yourself, if you have a plan, or if you cannot keep yourself safe. In Canada and the US, you can call or text 988 at any time to reach a suicide crisis line. If you are in immediate danger, call 911 or go to the nearest emergency department.

Also seek urgent care if you have not been able to eat, drink, or care for yourself, or if you hear or see things others do not.

Bottom line

Depression is common and treatable. For milder depression, therapy, guided self-help, and exercise are good starting points. For moderate to severe depression, therapy and antidepressants both work, and using both together works best on average. Treatment usually continues for months after you feel better, and your clinician should check your progress early and often.

Primary AI can show you the guideline and study sources behind this topic in plain language, so you can bring better questions to your appointment.