SSRIs (selective serotonin reuptake inhibitors) are often the first choice medications for depression because they have been thought to cause fewer side effects than other medications. Recent data suggests, however, that side effects are more common than originally thought and may have been underestimated in early studies. People with milder symptoms may try psychotherapy (talking with a therapist) first, and only add medication if their symptoms do not improve.

Side effects of SSRIs include stomach upset, diarrhea, agitation and insomnia, sexual side effects, and a number of other less common side effects. SSRIs cannot be taken by individuals who use a certain type of antidepressant called an "MAO inhibitor" (Marplan, Nardil, Parnate, more).

In general, there does not seem to be a big difference in effectiveness among the different SSRIs. Prozac, however, stays in the bloodstream much longer than other SSRIs and, if side effects develop, they can take many weeks to resolve. For example, SSRIs can cause severe panic attacks. When they occur in individuals taking Prozac, panic attacks can last for many weeks, even after the medication is stopped and even if it was only taken at a low dose for a few days. For this reason, other SSRIs are preferable to Prozac (see "Prozac" below).

Recently there has been controversy about whether there are more suicide attempts among individuals who take SSRIs compared to other types of antidepressants, and careful observation is recommended during the first 6 weeks of treatment, particularly for people under the age of 18.

During the past few years, the use of anti-depressants in children has dramatically increased. The rapid increase has caused concern among many experts since there is little known about the long-term effects of these drugs in children. Since anti-depressant side effects and depression/mental health symptoms are often indistinguishable, drug side effects are often confused with new psychiatric symptoms. Because of this, many drug side effects are treated by adding additional anti-depressants (rather than changing the drug that is causing the side effect) so that a significant number of children end up taking 4, 5, or 6 antidepressants. The effects of combining multiple anti-depressants in children is unknown and many experts worry about the potential for multi-drug regimens in children to cause more problems than they solve.

This group of miscellaneous, newer antidepressants are similar in effectiveness to SSRIs (Prozac, Zoloft, etc.) and tricyclic Antidepressants, with the exception of Desyrel, for which findings related to effectiveness are conflicting.

The most common side effect of Desyrel is sleepiness. It can also cause heart troubles and erection problems in men. It is rarely used for depression, because of the sedative side effect, but is used for some people to treat insomnia.

Wellbutrin can cause headaches, seizures, trouble sleeping, and stomach upset. Effexor and Cymbalta cause side effects similar to the SSRIs (Prozac, Zoloft, etc) such as stomach upset, diarrhea, agitation and trouble sleeping, and sexual side effects, etc.

People with milder symptoms may try psychotherapy (talking with a therapist) first and only add medication if their symptoms do not improve.

Recently there has been controversy about whether there are more suicide attempts among individuals who take some of these newer anti-depressants compared to older types of antidepressants, and careful observation is recommended during the first 6 weeks of treatment, particularly for people under the age of 18.

During the past few years, the use of anti-depressants in children has dramatically increased. The rapid increase has caused concern among many experts since there is little known about the long-term effects of these drugs in children. Since anti-depressant side effects and depression/mental health symptoms are often indistinguishable, drug side effects are often confused with new psychiatric symptoms. Because of this, many drug side effects are treated by adding additional anti-depressants (rather than switching to a less problematic drug) so that a significant number of children end up taking 4, 5, or 6 antidepressants. The effects of combining multiple antidepressants in children is entirely unknown and many experts worry about the potential for multi-drug regimens in children to cause more problems than they solve.

The goal of cognitive therapy is to change the depressed person's irrational beliefs and distorted attitudes towards him/herself and others. Cognitive therapy has been well studied in mild to moderate depression. Studies have shown it to be as effective, or nearly as effective as antidepressant medications for people with mild to moderate depression.

No one type of psychological ("talking") therapy has been clearly shown to be better than another.

Behavioral therapy has been shown to be effective in several studies. Studies have also suggested that it is as effective, or nearly as effective as antidepressant medications for people with mild to moderate depression.

No one type of psychological ("talking") therapy has been clearly shown to be better than the others.

Interpersonal therapy helps the depressed person recognize and deal with factors like social isolation, losses, poor social interactions, and life transitions that can impact their depression. In studies, interpersonal therapy has been shown to be as effective as antidepressants in people with mild to moderate depression.

No one type of psychological ("talking") therapy has been clearly shown to be better than the others.

An early study did not find any advantage for combination therapy. Later studies have shown that combination therapy improves symptoms more than either psychotherapy or drugs alone.

Studies have shown that marital and family therapy can reduce symptoms of depression and reduce risk of recurring depression.

Tricyclic antidepressants are very effective for the treatment of depression.

They may cause a slightly higher rate of side effects when compared to SSRIs (Prozac, Zoloft, etc.) and, therefore, are considered a second-line treatment for milder forms of depression. Recent data suggests, however, that SSRI side effects are more common than originally thought and may have been underestimated in early studies.

Side effects of tricyclic Antidepressants include drowsiness, weight gain, abnormal heart rhythms, low blood pressure, dry mouth, constipation, and sexual dysfunction. Desipramine and nortriptyline are newer tricyclic antidepressants that cause fewer side effects.

Tricyclic antidepressants cannot be taken with another type of drug used for mental health conditions, called "MAO inhibitors" (except for certain rare instances) and have interactions with a number of other drugs as well.

People with milder symptoms may try psychotherapy (talking with a therapist) first, and only add medication if their symptoms do not improve.

Bright light therapy has been shown to improve symptoms of depression, particularly in people whose depression is worse in winter months. It is not considered a stand- alone treatment for depression, but is used jointly with other treatments.

With light therapy, a 10,000-lux intensity light box is slanted toward the face for 30 minutes per day. The major side effects are eye strain and insomnia. People usually show improvement within a week, but it can take up to several weeks. Light therapy is not effective for major depression that is present year-round.

MAO inhibitors (Marplan, Nardil, Parnate, more) are as effective as tricyclic antidepressants for treating depression. There does not appear to be a difference in effectiveness among the different MAO inhibitors. Because of the side effects, these drugs are mostly used for people who have failed other treatments or who have special circumstances.

The major problem with these drugs is that they interact with certain foods and medications to raise blood pressure to very dangerous levels ("hypertensive crisis"). A long list of foods and medications must be avoided by people taking MAO inhibitors. Other relatively common side effects include weight gain, blood pressure problems, swelling, and sexual dysfunction.

In general, there does not seem to be a big difference in effectiveness among the different SSRIs. Prozac, however, stays in the bloodstream much longer than other SSRIs and, if side effects develop, they can take many weeks to resolve. For example, SSRIs can cause severe panic attacks. When they occur in individuals taking Prozac, panic attacks can last for many weeks, even after the medication is stopped and even if it was only taken at a low dose for a few days. For this reason, other SSRIs are preferable to Prozac (see "Prozac" below).

One study found that 5% of people taking Prozac developed panic attacks and that the suicide rates among this group was high. Panic attacks typically cause extremely severe symptoms and the authors of the study speculated that the long-lasting nature of the symptoms contributed to the high suicide rate.

The category of "psychodynamic psychotherapy" includes a number of approaches to "talking therapy" that analyze a person's life starting at early childhood to understand how personality and symptoms have been shaped by life experiences.

This type of therapy is typically long-term, and its goals are usually broader than just the improvement of depression symptoms.

Psychodynamic psychotherapy has not been well studied, but some studies indicate that it may not be as helpful for depression as the other types of "talking therapy".

ECT involves applying electric current to the brain. ECT needs to be done in a hospital with the person under general anesthesia. Side effects include short term memory loss. ECT is reserved for people with severe depression that does not improve with medications.

Some studies suggest that St. John's Wort may be effective for the treatment of mild to moderate depression, but the studies have serious flaws and the results are not conclusive. One problem with St. John's Wort is that the preparations are not standardized and the amount of active ingredients in a dose may vary. More studies are needed, using standardized doses, before this treatment can be recommended.

St. John's Wort may interact with other medications. The most common side effects are digestive symptoms, headache, and fatigue. St. John's Wort causes fewer side effects than other antidepressant medications.

The studies that have been done are small and of poor quality. However, all the studies do show positive results for exercise in improving symptoms and reducing relapses.

More research is needed before exercise can be recommended as a treatment for mild to moderate depression.

Although some studies suggest that tricyclic antidepressants may work better for certain types severe depression, SSRIs (Prozac, Paxil, Zoloft, Celexa, Lexapro, Sarafem, more) are often the first choice medications because they may cause fewer side effects. Recent data suggests, however, that SSRI side effects are more common than originally thought and may have been underestimated in early studies.

SSRIs are often combined with other antidepressants (such as tricyclic antidepressants) for treating severe depression.

Side effects caused by SSRIs include stomach upset, diarrhea, agitation and trouble sleeping, sexual side effects, and other rare side effects.

SSRIs cannot be taken with a type of antidepressant called "MAO inhibitors" (Marplan, Nardil, Parnate, more).

In general, there does not seem to be a big difference in effectiveness among the different SSRIs. Prozac, however, stays in the bloodstream much longer than other SSRIs and, if side effects develop, they can take many weeks to resolve. For example, SSRIs can cause severe panic attacks. When they occur in individuals taking Prozac, panic attacks can last for many weeks, even after the medication is stopped and even if it was only taken at a low dose for a few days. For this reason, other SSRIs are preferable to Prozac (see "Prozac" below).

Recently there has been controversy about whether there are more suicide attempts among patient taking SSRIs, compared to other types of antidepressants. People starting to take an SSRI, particularly those under 18, should be watched carefully for the first 4-6 weeks of treatment.

During the past few years, the use of antidepressants in children has dramatically increased. The rapid increase has caused concern among many experts since there is little known about the long-term effects of these drugs in children. Since antidepressant side effects and depression/mental health symptoms are often indistinguishable, drug side effects are often confused with new psychiatric symptoms. Because of this, many drug side effects are treated by adding additional anti-depressants (rather than switching to a less problematic drug) so that a significant number of children end up taking 4, 5, or 6 antidepressants. The effects of combining multiple anti-depressants in children is entirely unknown and many experts worry about the potential for multi-drug regimens in children to cause serious symptoms. Antidepressants can be life-saving when depression is severe, but careful investigation for drug-related side effects is critical to assuring that the benefits of the treatment outweigh the risks.

This group of miscellaneous, newer antidepressants are similar in effectiveness to SSRIs (Prozac, Zoloft, etc.) and tricyclic Antidepressants, with the exception of Desyrel, for which findings related to effectiveness are conflicting.

The most common side effect of Desyrel is sleepiness. It can also cause heart troubles and erection problems in men.

Wellbutrin can cause headaches, seizures, trouble sleeping, and stomach upset. Effexor and Cymbalta cause side effects similar to the SSRIs (Prozac, Zoloft, etc) such as stomach upset, diarrhea, agitation and trouble sleeping, and sexual side effects, etc.

People with milder symptoms may try psychotherapy (talking with a therapist) first and only add medication if their symptoms do not improve.

Recently there has been controversy about whether there are more suicide attempts among individuals who take the newer antidepressants compared to older types of antidepressants, and careful observation is recommended during the first 6 weeks of treatment, particularly for people under the age of 18.

During the past few years, the use of antidepressants in children has dramatically increased. The rapid increase has caused concern among many experts since there is little known about the long-term effects of these drugs in children. Since antidepressant side effects and depression/mental health symptoms are often indistinguishable, drug side effects are often confused with new psychiatric symptoms. Because of this, many drug side effects are treated by adding additional anti-depressants (rather than switching to a less problematic drug) so that a significant number of children end up taking 4, 5, or 6 antidepressants. The effects of combining multiple anti-depressants in children is entirely unknown and many experts worry about the potential for multi-drug regimens in children to cause serious symptoms. Antidepressants can be life-saving when depression is severe, but careful investigation for drug-related side effects is critical to assuring that the benefits of the treatment outweigh the risks.

Several studies have shown positive results for combination therapy. Also, in people who only have a partial response to medication, adding psychotherapy decreases the relapse rate (chance of the depression returning). Studies have not compared the effectiveness of different types of psychotherapy ("talking therapy") for treatment of severe depression.

Some studies have suggested that TCAs are particularly effective for people with severe depression. They are often used in combination with other drugs for severe symptoms. Side effects of TCAs include sedation, weight gain, problems with abnormal heart rhythms and low blood pressure, dry mouth, constipation, and sexual dysfunction. There are differences among the TCAs in terms of side effects with the newer drugs such as desipramine and nortriptyline having fewer side effects. TCAs cannot be taken with MAO Inhibitors and have interactions with a number of other drugs as well.

The combination of tricyclic antidepressants (Adapin, Anafranil, Asendin, Aventyl, Elavil, Endep, Norpramin, Pamelor, Sinequan, Surmontil, Tofranil, Vanatrip, Vivactil, more) and SSRIs (Prozac, Zoloft, Paxil, more) has been shown to result in a faster medication response. However, the SSRIs can raise the blood level of the tricyclic antidepressants, thereby causing more side effects.

An MAO inhibitor is occasionally combined with a tricyclic antidepressant for individuals with severe symptoms and poor response to treatment. Because of potential side effects, this combination is not usually recommended unless other methods have been exhausted.

There is little available research on the effectiveness of combining antidepressants for severe depression.

During the past few years, the use of multiple antidepressants, particularly in children, has dramatically increased. The rapid increase has caused concern among many experts since there is little known about the long-term effects of these drugs in children. Since antidepressant side effects and depression/mental health symptoms are often indistinguishable, drug side effects are often confused with new psychiatric symptoms. Because of this, many drug side effects are treated by adding additional antidepressants (rather than switching to a less problematic drug) so that a significant number of individuals end up taking 4, 5, or 6 antidepressants. There is little known about effects of combining multiple antidepressants, particularly in children, and many experts worry about the potential for multi-drug regimens to cause serious side effects. Antidepressants can be life-saving when depression is severe, but careful investigation for drug-related side effects is critical to assuring that the benefits of the treatment outweigh the risks.

Lithium is most commonly used. Lithium requires regular blood tests to monitor blood levels. There is little research on the effectiveness of these types of drug combinations, and there are no clear guidelines on their use.

Because of the side effects of MAOIs (Marplan, Nardil, Parnate, more) they are usually reserved for patients who have failed other treatments. The major problem with these drugs is that they interact with certain foods and with some other medications to raise the patient's blood pressure to very dangerous levels (called a hypertensive crisis). There is a long list of foods and medications that must be avoided by people taking MAOIs. There are other side effects as well including weight gain, blood pressure problems, swelling, and sexual dysfunction.

In general, there does not seem to be a big difference in effectiveness among the different SSRIs. Prozac, however, stays in the bloodstream much longer than other SSRIs and, if side effects develop, they can take many weeks to resolve. For example, SSRIs can cause severe panic attacks. When they occur in individuals taking Prozac, panic attacks can last for many weeks, even after the medication is stopped and even if it was only taken at a low dose for a few days. For this reason, other SSRIs are preferable to Prozac (see "Prozac" below).

One study found that 5% of people taking Prozac developed panic attacks and that the suicide rates among this group was high. Panic attacks typically cause extremely severe symptoms and the authors of the study speculated that the long-lasting nature of the symptoms contributed to the high suicide rate.

The different types of psychotherapy have not been compared to each other for the treatment of severe depression. Thus they are not discussed separately here. For a discussion of the various types of therapy please see the section on mild to moderate depression above.

ECT has the highest response rate of any treatment for depression and should be considered for people with severe depression who: have not responded well to medication; need a rapid response; or are pregnant or have another medical condition that interferes with the use of antidepressant medication. ECT involves applying an electric current to the brain. ECT needs to be performed in a hospital with the person under general anesthesia.

The major side effects include short term memory loss (both being unable to remember recent events that happened just before ECT, and being unable to remember things for a short time after treatment). Usually this memory loss resolves a few weeks after treatment.

ECT cannot be used for some people with serious medical conditions or for people who have brain aneurysms. ECT typically involves a total of 6 to 12 treatments, given every other day.

ECT can be performed on half of the brain or on the whole brain. Giving ECT to only half the brain is less effective but also causes fewer memory problems.

Antipsychotic medications have potentially serious side effects, particularly when used for long periods of time. Side effects include: sleepiness, serious movement disorders, weight gain, digestive system upset, cardiac effects, and many others. These side effects are a serious problem, however, people with psychotic depression are at a high risk for both suicide and relapse and powerful treatments are typically required.

ECT involves applying an electric current to the brain. ECT needs to be performed in a hospital with the person under general anesthesia.

The major side effects include short term memory loss (both being unable to remember recent events - just before ECT, and being unable to remember things for a short time after treatment). Usually this memory loss resolves a few weeks after treatment.

ECT cannot be used for some people with serious medical conditions or for people who have brain aneurysms. ECT typically involves a total of 6 to 12 treatments, given every other day.

ECT can be done on half of the brain or on the whole brain. Giving ECT to only half the brain is less effective but also causes fewer memory problems.