Methods for treating depression

I don't have much knowledge of all the different types of therapy, but I can talk from personal experience. In my own experience I found the following to be true, but of course that could just have been specific to my situation:

1) I did not find the professional psychologists that I went to to be tremendously helpful. Much more useful in my situation were caring, thoughtful individuals who were short on formal training but rich in common sense and life experience. (This type of person used to be called "wise", but that term seems to have gone a bit out of fashion.)

2) Caring, understanding, and supportive relationships were crucial for me. Family, friends, mentors, and role models all served different supportive roles in this regard, and all were important. In fact, the thing that finally did away with my depression was forming the best and closest relationship in my life - namely meeting my wife.

3) There's a big difference between trying to root out the underlying cause of someone's depression vs. doing practical things to alleviate it. I once saw this compared to a patient who comes in with a gaping wound. If you just try to find out the underlying cause without first treating the wound, then the patient will quickly bleed to death. If you bandage the wound without treating the underlying causes then the patient may live a bit longer but they'll still die. The psychologists and counselors I dealt with all tended to focus on underlying causes, and that was definitely important. But what I usually needed was some short-term bandages. Sometimes what I needed was some concrete, practical advice that I could put to immediate use. Or sometimes the best help would have involved a direct intervention on the part of the counselor, such as getting on the phone with some of my mentors / friends and enlisting their help, or arranging with my teachers to see if there was something that could be done in the classroom that could help. But psychologists are often prohibited from doing things like this.

While I agree that depressives should try CBT, I've begun to think some of the enthusiasm is misplaced, especially when contrasted with the scrutiny antidepressants receive. Yvain has written about this before:

The AJP article above is interesting because as far as I know it’s the largest study ever to compare Freudian and cognitive-behavioral therapies. It examined both psychodynamic therapy (a streamlined, shorter-term version of Freudian psychoanalysis) and cognitive behavioral therapy on 341 depressed patients. It found – using a statistic called noninferiority which I don’t entirely understand – that CBT was no better than psychoanalysis. In fact, although the study wasn’t designed to demonstrate this, just by eyeballing it looks like psychoanalysis did nonsignificantly better. The journal’s editorial does a good job putting the result in context.

This follows on the heels of several other studies and meta-analyses finding no significant difference between the two therapies, including, another in depression, yet another in depression, still another in depression, one in generalized anxiety disorder and one in general. This study by meta-analysis celebrity John Ioannidis also seems to incidentally find no difference between psychodynamics and CBT, although that wasn’t quite what it was intended to study and it’s probably underpowered to detect a difference.

In the vein of non-risky interventions, you might also want to add a section on meditation, expressing gratitude (not sure of the citation -- maybe here? -- but I recall the best possible selves intervention mentioned in the paper being ineffective among the depressed), and expressive writing generally.

Good post! But you're missing a big piece: Chronic depression is often about relationships. Dysfunctional families, shitty childhoods and abusive spouses get a lot of people depressed - and that includes many who do not realize they learned some bad lessons in their childhoods or that they have unacknowledged needs their significant others aren't meeting. Which is unfortunate, because realizing what's wrong about one's relationships can uncover avenues to improvement.

Personally, I call depression "the slavery response" and think it used to be an adaptive response to certain kin group dynamics. If you're depressed (and it isn't iodine deficiency or something), find out who you feel enslaved by and powerless against, and obtain social support in changing that relationship. Getting this right is what psychodynamic therapy has going for itself and what I think helps it compete with the far more scientific CBT people.

Thank you for mentioning that someone to talk to can be as helpful as a therapist, under some circumstances. Anyone can be that someone, too, and maybe do a lot of good. But it takes some skills: You have to be non-judgemental, interested, observant, honest, quiet and let the sharing person come to his or her own conclusions. Those skills are worth having for other purposes, too. (Therapists are almost universally very pleasant people.) But often the most important help you can give is help establish contact to a better helper.

The SSRIs you mention as "newer" antidepressants are likely to soon be eclipsed by NMDA receptor antagonists, which are in the approval pipeline now and seem to be working somewhat better and much faster than current standard of care antidepressants, without increased suicide risk. Since these aren't approved yet, nootropics-minded folk are getting this kind of help outside the health care system and I'm told it is highly effective.

House of Cards by Robyn Dawes argues that there's no evidence that licensed therapists are better at performing therapy than minimally trained laypeople. The evidence therein raises the possibility that one can derive the benefits of seeing a therapist from talking to a friend.

There seems to be evidence that the empathy of the therapist is very important. http://www.nrepp.samhsa.gov/Norcross.aspx#chapter6 (link for the summary of evidence and not for their description of what empathy is) You don't learn to be empathic by sitting 5 years in university psychology lectures but that doesn't mean that there aren't people who are very good at being empathic to which you can go.

It also really import when choosing a therapist that don't just go because they have a credential but because you feel like you have a good connection with them.

The vast majority of exercise studies have their subjects doing arbitrary exercise routines that are generally ineffective at inducing rapid improvement. In addition, I believe the benefits of exercise on mentality accrue over the span of months, not the weeks that most studies are run for.

I often wonder whether "depression" as a blanket term is useful; and whether using it may even be detrimental.

Consider an analogy: diagnosing someone with "pain" isn't very useful. At best you can give painkillers, which only helps temporarily. But there are so many different causes of pain: arthritis, bone fracture, kidney stone, migraine and so on. Different causes require very different treatments. So, you need to be able to identify these causes accurately if you want any hope of curing the patient.

Just the fact that very different people with very different genetics in very different life circumstances experience a similar mental phenomenon called "depression", doesn't necessarily imply they can all be treated the same way. Phenomenological descriptions may be similar, but causally are they similar? A trivial example: a person who's depressed because her husband died would require a different treatment than a PhD student who's depressed because her research isn't progressing.

This is why I'm not too enthusiastic about anti-depressants; they seem akin to painkillers. But the inefficacy of talk therapy makes me wonder whether even experts can tease out the different causes behind depression; or even if they could, whether they can treat them appropriately.

Note: I'm not an expert, so let me know if I'm oversimplifying here.

I think "treating depression" as a framework for dealing with personal problems can be counter productive. For example, sleep quality can affect depression, but if I try to make improvements in my sleeping and see no discernable impact on my depression I am likely to give up and try something else. Instead, if I try to improve my sleep quality independent of any effect on depression I am more likely to be successful. Thinking this way allowed me to actually make a serial set of improvements*, at the end of which I can look back and say "I am less depressed than I was by a large degree" even when individual changes didn't seem impactful.

*Sleep, diet, exercise, socializing, motivation

Edit: I phrased this comment poorly. I am in fact speaking about my own experience and not a hypothetical person.

When it comes to depression, I think it's important to note that it's a symptom and no condition.

Hitting someone on a head in a way that produces a trauma often causes symptoms of depression. That depression might have a completely different optimal treatment method than depression caused by a more psychological issue.

A gluten insensitivity can also produce depressive symptoms.

but this may reflect insufficient commitment on the part of patients who were assigned to use self-help CBT materials.

So? If I'm trying to get over depression, I just want to know if that method works. Not if failure can somehow be attributed to me.

Any given treatment of depression only works for a fraction of depressed people, suggesting that causes of depression may be diverse.

Has there been a study of correlations? What I am aware of is that many studies report quite high failiure rates but I don't know of any study that tries to asses if success or failiure of treatment A predicts success with treatment B. This could give a hint to the nature of depression.

Talk therapy

The mere fact that there is no difference in effect of any one technique or the other is massive evidence that it is not the technique that is benefit but something else, like simply sharing feelings with a person.

The main downside to exercise is that it takes time, but it may be worth it even if the effect size is small if alleviating depression is sufficiently high priority for you.

...Not to mention that it's worth it for benefits outside of treating depression (e.g., physical health).

This understates the capacity for anti-depressants to reduce depression, because placebo treatment is also better than no treatment, and if one antidepressant doesn't work, you can try another one.

I'm not really sure whether that the case. Don't work often doesn't mean that it shows no effect. If you eat a vegetarian diet you will feel different. Different enough that all sorts of people think that becoming a vegetarian will cure all your problems.

Deciding whether the kind of mental state that you get through a anti-depressent is really better is a nontrival task.

I wrote an article listing the evidence for 54 suggested strategies for increasing happiness.

http://happierhuman.com/how-to-be-happy/

In general, my writing is more enthusiastic than the evidence would call for, but alas I must excite my readers and get the pageviews. My interpretation is that although some of the studies (e.g. keeping a gratitude journal improves symptoms of depression) may be flawed, follow 10 of them at the same time, and you'll likely have included something that works. No smoking guns, of course.

If you're interested in supplements w/ less comprehensive scientific support, here's examine.com's depression page (see also). I found inositol to be somewhat efficacious. Someone sent me this depression interventions spreadsheet that has some ideas you didn't discuss like folate supplementation. (Edit: It seems as though some people have genetic conditions that make folate absorption difficult or impossible for them. Note that you'd expect that these people would therefore be especially likely to become depressed from "folate deficiency" (ie folate malabsorption). So maybe take a highly bioavailable form of folate.) There's discussion in this thread about low-dose lithium decreasing the frequency of suicide. I just noticed that some of the amazon.com reviews for lithium are very positive on it decreasing depression.

Edit: I created a find someone to talk to thread.

Edit: Great depression related post.

Apart from peer reviewed research it also useful to know what other people consider helpful. CureTogether has a infografic that list various treatment methods: http://curetogether.com/depression/ig/treatment-effectiveness-vs-popularity

Out of them having a pet is considered by a lot of people a highly effective way to treat depression. I don't think there a cochrane review on it, but I think if you are a lonely nerd who suffers from depression getting a pet might be a very smart move. The pet gives you company in a way that make you feel less alone. Dogs happen to like their owners even if the owner is extremely poor social skills.

Finding flow activities seems to be a good one.

Also - keeping busy?