Principles of treating major depression in adults and young people

Manage major depression in adults and young people with psychosocial interventions and, when required, drug treatment. For the approach to treating depression in people with dementia, see here.

At the time that depression is diagnosed, provide psychoeducation to the patient: discuss the diagnosis (including its natural history with and without treatment) with the patient and, if appropriate, their family, carers or significant others; identify acute or chronic stressors that can be addressed with psychosocial interventions; and explain the available treatments, the likelihood of response to treatment and possible adverse effects. Showing support and providing reassurance throughout the depressive episode can lessen feelings of hopelessness and encourage treatment adherence.

Psychoeducation should be accompanied by support to help the patient modify their lifestyle, if necessary. Lifestyle modification can include improving sleep hygiene, undertaking adequate physical activity (see below), consuming a healthy diet (see below), minimising alcohol consumption, reducing stress, and reviewing daily routines and social support.

Exercise is an effective treatment, either alone or as an adjunct to psychosocial interventions or pharmacotherapy for major depression¹.

There is increasing evidence of a relationship between diet and mental health. Adherence to a Mediterranean diet (high intake of vegetables, fruits, nuts, cereals, legumes and fish) has been associated with a decreased risk of depression. Additionally, diets with high levels of processed foods have been found to contribute to depressive symptoms. Depression can influence eating habits. For example, patients with depression may restrict their eating or overeat in response to their symptoms. Hence, in addition to providing advice about the importance of a healthy and balanced diet, it can be helpful to enquire about patients’ specific eating habits and address any issues that may be contributing to their mental health issues².

Implement simple psychosocial interventions in all patients with major depression.

Use a shared decision-making approach when discussing further treatment options (psychological therapies, antidepressants or both) with patients. Specific considerations for treating a young person with major depression are described below.

• In mild major depression, psychological therapies are preferred; antidepressants are not routinely recommended but can be used if psychological therapies are not available or based on patient preference.
• In moderate major depression, either psychological therapies or antidepressants can be used; base initial treatment choice on patient preference. For some patients, concurrent use of psychological therapy and an antidepressant is the most effective management.
• In severe major depression, start treatment with an antidepressant. If the patient is willing and able, start concurrent psychological therapy. Electroconvulsive therapy (ECT) may be considered for some forms of severe depression (eg melancholic depression).
• In psychotic depression, refer the patient for urgent treatment by a psychiatrist, specialist centre or mental health team. For the management of acute behavioural disturbance associated with psychotic depression, see here. Treatment options in adults include combining an antidepressant and antipsychotic, or ECT.
• If catatonic features are present, seek expert advice.

When evaluating treatment options for a young person, also consider:

• there are few data on psychotropic use in young people because young people are poorly represented in clinical trials
• young people are more susceptible to developing activation and suicidal thoughts when starting treatment with an antidepressant; this effect has been most often observed with selective serotonin reuptake inhibitors (SSRIs)
• if pharmacotherapy is used, it should ideally be started by a clinician with expertise in using psychotropics in young people.

The risk of suicide is increased in the early stages of pharmacological treatment, although suicide attempt rates remain lower than before treatment is started. Educate patients and, if appropriate, their family, carers or significant others about the risk of suicide, and monitor patients for suicide risk. For information on assessing suicide risk, see here.

Major depression is predominantly managed in primary care or community settings. However, treatment in hospital may be required for patients³:

• with symptoms of psychosis (eg delusions, hallucinations)
• at significant risk of harm to themselves or others
• at significant risk of suicide or homicide (eg patients with severe postnatal depression at risk of infanticide should be treated in a parent–infant psychiatric unit, if possible)
• with inadequate social supports for their needs
• with a serious chronic medical condition
• who are not adequately attending to self-care (eg not eating or drinking)
• with complicated and treatment-resistant depression.

Home- or community-based support may be an alternative to treatment in hospital in some areas, dependent on the services available.

During remission of major depression, address factors that increase the risk of recurrent episodes, if possible. Educate patients and family, carers or significant others about how to identify early warning signs of a recurrent episode and develop a plan for early intervention. Most patients who have had an episode of major depression will experience more than one episode in their lifetime. If the patient has a recurrence of major depression, see Recurrent major depression in adults and young people for treatment.

Complementary medicines  are commonly used by patients with major depression but their safety, quality and efficacy are not well established.

For considerations in treating a psychiatric disorder, including major depression, in a female of childbearing potential, including advice on contraception, preconception planning and psychotropic use, see here.

For advice on treating perinatal depression (ie antenatal and postnatal depression, depression in partners), see here.