As many as 1 in 4 people in the UK are thought to experience a mental health issue each year, with the British 7 year survey predicting an average prevalence of 3.3 people with clinical depression per 100 people in the population – yet this number might be higher due to individuals who do not report or come forward. Interestingly, depression with anxiety disorder in combination is much more prevalence, suggesting an overlap in the proclivity of individuals to experience both mental health disorders. Indeed, the World Health Organisation states that depression is the leading cause of ill health and disability worldwide, yet the reluctance to discuss negative mental states in popular society remains. Depression, when defined, is described as a continuing mood disorder which gives persistent feelings of sadness, loss, suicidal thinking, hopelessness and low mood for several months, away from normal mood states which are typically more fleeting. Despite major activism from mental health advocates and charities, women are more likely to be diagnosed with anxiety-related disorders, yet the suicide rate for men is higher than ever before, with suicide ranking as the leading cause of death for men of ages 20-34. It seems a complex range of societal, psychological and behavioural components relate to the differences in the experience of mental health problems amongst men and women, with even transgender individuals experiencing much more prevalence with depression. Below, we evaluate the treatments for depression, and look at the evidence supporting the implementation of these therapies.
The antidepressant drugs that have long been prescribed for depression are commonly of two classes: tricyclic antidepressant’s (TCA’s) and serotonin reuptake inhibitors (SSRI’s). As the name suggests, these medicines work to increase the availability of serotonin in the brain by preventing the reuptake of the compound. Serotonin is an archaic molecule which regulates cognition, arousal, reward and lots of other complex physiological processes in the body and exists in countless animals, all the way to sea creatures and simple invertebrates, suggesting it has been involved in natural life for millions of years. It is thought that serotonin exists in an intrinsic ‘reward system’ in many animals, including humans – whereby processes and behaviours which benefit survival increase the expression of dopamine and serotonin in the organism, giving positive feedback and a ‘feel good’ reward. It is thought that in depressed individuals, the expression of serotonin amongst other neurotransmitters is affected, leading to reductions in normal physiological levels at synapses in the brains of individuals suffering from depression, leading to lower mood, arousal and persisting poor moods. TCA’s and SSRI’s have been implemented many times over the years, with the latter class of antidepressants the current first line pharmaceutical treatment for depression, with medicines such as sertraline, paroxetine and fluoxetine. In individuals who visit their GP with symptoms of moderate to severe depression, the first line treatment is talking therapies and the implementation of talking therapies concurrently, yet it is always down to the patient to evaluate the risks and benefits of these approaches.
Antidepressant medication typically has a good safety profile and is well tolerated by a lot of individuals, but the time to alleviate symptoms of depression is a minimum of 6 weeks. The nature of the medication implicates a complex physiological process which takes time to obtain a good amount of the drug in the blood (known as the half-life). This affects the time it takes for individuals to feel better, with a variety of responses and unknown efficacy in some individuals. In individuals younger than 25 years of age, antidepressant medication comes with a black box warning for risk of increased suicidal ideology and thinking, due to changes in brain chemistry which occur with this medication. Large meta-analyses (the strongest form of review of scientific evidence) have found generally good results with antidepressant medication for general depression and clinical depression, with a range of response times from 12 weeks to 2 years all showing good alleviation of symptoms. However, it is known that depression can be a refractory illness, meaning the link between withdrawal from antidepressant medication and recurrent onset of depressive periods is becoming further investigated. Interestingly, antidepressant medications often work better in greater severity depression, with large meta-analyses finding negligent difference in mild depression in comparison with placebo pills. Medication as an approach for prophylaxis is attractive, as individuals may be helped from a physiological and psychological perspective by utilising dual therapy approaches. The side effects of antidepressants such as fatigue, brain fog, gastrointestinal distress and mood swings typically subside after around 6 weeks yet higher doses preclude individuals to quite substantial sexual side effects such as lack of arousal, inability to maintain erections, dryness and lack of secretions (in females) and low libido. Indeed, the previously reflected notion of mixed approaches to therapy is of interest in a period whereby the over prescription of these medications is a burden on secondary health outcomes and health providers, and other treatments such as talking therapies may play a role in the behavioural aspects of depression.
Talking therapies such as cognitive behavioural therapy (CBT) are techniques used by counsellors and psychologists to challenge unhelpful behaviours and thoughts in patients with depression and other mood disorders. This technique aims to rationalise and challenge patterns of thinking and behaviour to allow self-actualisation and empowerment by the individual to change their outlook. Psychotherapy like CBT uses conceptualisation of the individual’s strengths and weaknesses and identifies areas to work on. For example, an individual may be good at vocalising their issues and problems to friends but may suffer from thinking patterns such as catastrophizing (assuming the worst and thinking of the worst case scenario in situations). By providing social support and a lifeline to talk to, the therapist and individual may work synergistically to work on areas like self-esteem, making friends, changing habits and challenging unhealthy relationships. On the NHS, waiting times for talking therapies can sometimes be long, which can be unsuitable for individuals with severe depression. Therefore, these individuals often are referred straight to antidepressant drugs as an immediate therapy response. However, the treatment of the physiological inadequacies leading to depression can sometimes be redundant without first addressing unhelpful thinking patterns, thus it is often seen that treatment must involve a combination of both of these techniques. In another large analysis with over 100,000 participants, it was found that those with moderate depression experienced equivalent relief with talking therapies and antidepressant medication, strengthening the deployment of these techniques.
The use of antidepressant medication in the United Kingdom may be heavy handed for case of mild depression where talking therapies may prove more effective. However, individuals with severe depressive disorders are good candidates for antidepressant medication in combination with talking therapies. Individuals must be informed of the range of side effects of medication by their clinician as this drastically affects the potential for retainment of treatment and adherence to treatment regimes. Future studies and research should seek to evaluate further the most effective forms of treatment for different forms of depression and the use in different genders, backgrounds and ethnicities. Furthermore, awareness campaigns should warn individuals of the side effects of medications, but stress their relative good tolerance safety profiles for the alleviation of depressive symptoms.