Baseer Maroof, LCSW · Raleigh, NC · Adults 21+
Treatment & evidence
Good news first: several treatments work. Here’s how they compare and how to pick a starting point.
In short
- Psychotherapy and second-generation antidepressants are both first-line options. Choose together with your clinician.
- Combined therapy plus medication beat either on its own across 101 trials.
- All 21 antidepressants studied beat placebo in a 522-trial network meta-analysis.
- Antidepressants usually take 4–8 weeks to work. Don’t stop one without talking to your prescriber.
Where to start
Where to start
Tap the one that sounds most like you.
Summarises NICE NG222, APA 2019 and the trials below. Your clinician will tailor it.
Therapy
The options with good evidence
APA’s guideline lists behavioural therapy (including activation), cognitive therapy, CBT, interpersonal therapy, mindfulness-based cognitive therapy, psychodynamic therapy and supportive therapy, without ranking one above the others for adults. (APA 2019)
Behavioural activation
Simpler to deliver than full CBT and just as effective in the COBRA trial. How it works → (Richards 2016)
Exercise counts
In 218 trials, walking or jogging, yoga and strength training all reduced depression. The authors suggest using exercise alongside therapy or medication. (Noetel 2024)
Medication
Talk to your doctor before starting, changing or stopping any medication.
What to expect
Second-generation antidepressants (SSRIs, SNRIs, bupropion) are the usual starting point. They take time, usually 4 to 8 weeks, and sleep, appetite and concentration often improve before mood does. (NIMH; APA 2019)
Under 25
Antidepressants carry an FDA boxed warning: in short-term studies, they raised the risk of suicidal thoughts and behaviour in people up to age 24. If you’re 21 to 24, your prescriber should check in closely in the first weeks and after dose changes. (FDA label)
When it isn’t working
If two or more antidepressants haven’t helped, options include esketamine nasal spray (given in a clinic) and brain stimulation such as rTMS or ECT. (NIMH)
The numbers
Reading the numbers
In Cuijpers’ network meta-analysis, therapy alone and medication alone weren’t significantly different from each other, and fewer people dropped out of therapy or combined treatment than out of medication alone. (Cuijpers 2020; Cipriani 2018; Kuyken 2016)
Sources
All sources, linked9 references⌄
- American Psychological Association (2019). Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts. www.apa.org/depression-guideline/guideline.pdf
- National Institute for Health and Care Excellence (2022). Depression in adults: treatment and management (NG222). www.nice.org.uk/guidance/ng222/chapter/Recommendations
- Cuijpers P et al. (2020). A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry, 19(1), 92–107. pmc.ncbi.nlm.nih.gov/articles/PMC6953550/
- Cipriani A et al. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet, 391, 1357–1366. pubmed.ncbi.nlm.nih.gov/29477251/
- Kuyken W et al. (2016). Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: an individual patient data meta-analysis. JAMA Psychiatry, 73(6), 565–574. pubmed.ncbi.nlm.nih.gov/27119968/
- Richards DA et al. (2016). Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial. Lancet, 388, 871–880. pmc.ncbi.nlm.nih.gov/articles/PMC5007415/
- Noetel M et al. (2024). Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials. BMJ, 384, e075847. pmc.ncbi.nlm.nih.gov/articles/PMC10870815/
- National Institute of Mental Health (2024). Depression (brochure). www.nimh.nih.gov/health/publications/depression
- FDA-approved labeling, Suicidality and Antidepressant Drugs boxed warning (DailyMed). dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=137a953b-3c48-405f-86a6-ff778cb7f5f2&type=display
Related on this site