Our approach to treating depression
Many different factors can cause depression and unravelling the cause takes time, empathy and expertise. We have extensive experience in providing treatment for depression using a range of approaches, from medication to therapy. We also understand the importance of using other evidence-based approaches like psychoeducation (providing education and support for mental health problems) and lifestyle interventions (such as nutrition or exercise).
We will do our best to support you in this difficult period and we can help you identify the psychiatrist best suited to your needs who will recommend a holistic treatment plan tailored to your unique circumstances and preferences. Our patients typically choose a combination of the following approaches: psychological therapy, medication (if appropriate), nutritional intervention, exercise, or mindfulness and meditation.
There are many evidence-based interventions that can potentially help reduce depressive symptoms in some people, such as using specific high-grade supplements (such as Vitamin B12, Vitamin D or Omega-3 in some cases), repetitive Transcranial Magnetic Stimulation (rTMS) or Vagus nerve stimulation (VNS), just to mention a few. We generally explore these options when the depression has not satisfactorily improved with conventional treatments. In this case we use the term "treatment-resistant depression", which does not mean that the depression will not improve with any treatments, but rather that it has not improved with the treatments we tend to use initially for most people with depression.
Very often, depressive symptoms that haven’t improved with one type of treatment will start to improve when a different approach is used. For example, when depression has not improved with a serotonin antidepressant (such as fluoxetine or sertraline) it may respond to another antidepressant with a different mechanism of action (e.g. venlafaxine, which also works on the noradrenaline receptors in the brain).
What are the symptoms of depression?
Many of our patients are unsure whether they have depression because they don’t always feel sad or low in mood. However, most people don’t realise that depression can affect us in many different ways. Perhaps you, or someone you know, has recently lost interest in doing things or maybe they have felt flat for a while (known as anhedonia). Maybe they are having trouble focusing or making decisions, or maybe they feel guilty, hopeless, or have persistently low self-esteem (which was not the case some time ago, before the depression started). Or it might just be an ‘indefinable feeling that something isn’t quite right’. Any of these could in fact be a sign of depression.
Many people might not realise that depression can affect you just as much physically as it can mentally. Depression can disrupt sleep, by either stopping you from sleeping enough, or it can make you sleep too much. You might lose your appetite and unintentionally start losing weight, or you might start feeling hungry more often and begin gaining weight. Although most people with depression will experience a reduction in their appetite and some form of insomnia, people with a type of depression called atypical depression can experience the opposite: increased appetite and oversleeping. You might also feel tired all the time, or like your arms and legs are too heavy, or you might be fidgety and restless in a way that you did not feel before the depression started.
Depression can come with any combination of symptoms and these symptoms might change over time, or they may even disappear for a few weeks or months before returning. This demonstrates why it's so important to understand your unique set of symptoms and circumstances so that we can provide you with the best treatment plan.
Are there different types of depression?
Due to the complex nature of depression symptoms, there are many different diagnostic labels for different versions of depression. Although these diagnostic labels can be helpful for characterising symptoms, we endeavour to see people as individuals with a unique set of symptoms, life circumstances and personality when formulating a diagnosis and discussing the treatment plan.
Research has shown that people with different types of depression might even respond to different types of medication and therapy differently. This is why it’s so important to carry out a comprehensive assessment, in order to gain as much information as possible about the type of depression. Often, people have symptoms of depression that do not clearly conform to a particular depressive subtype.
Reactive vs clinical depression
A depression that is reactive tends to happen when somebody has been under intense pressure or stress for some time or in response to a specific traumatic event. We also use the terms ‘circumstantial’ or ‘exogenous’ to refer to this type of depression.
When someone develops depressive symptoms without being able to point to a specific trigger as the cause, we tend to refer to this as clinical depression, depression with biological features or endogenous depression (‘endogenous’ is Latin for ‘from within’).
Some people may experience several episodes during their lifetime, and if that is the case we use the term Recurrent Depression. We used to think that this depression was mostly triggered by a genetic predisposition, but research now shows that some external factors (such as a period of intense stress) can also play a significant role in triggering this type of depression.
Typical vs atypical depression
People with depression can even have completely opposite symptoms. For example, those who experience symptoms such as worse mood in the morning, difficulty sleeping (insomnia), loss of appetite and weight loss, tend to have a type of depression that is sometimes named typical depression (sometimes we use the word ‘melancholic’ for this type of depression). In contrast, people who experience worse mood in the evening, struggle with sleeping too much (hypersomnia), increased appetite and weight gain, tend to fall under the diagnosis of atypical depression.
What is Treatment-resistant depression (TRD)?
Some of our patients feel apprehensive when they hear the term ‘treatment-resistant depression' because they think it means that their depressive symptoms can't be treated. However, treatment-resistant depression' (also known as refractory depression) actually refers to depressive symptoms that don't improve after initial treatment, which could mean only taking one course of antidepressants or trying one type of therapy. There is always help available for depression.
Treatment-resistant depression is far more common than people might think, as it can be challenging to choose the best treatment for such a complex illness the first time around. Often, GPs will prescribe a standard serotonin antidepressant (such as citalopram or sertraline) to someone who experiences depression for the first time. Approximately 50% of people with depression will notice an improvement in their symptoms after 6-8 weeks.
Our psychiatrists have successfully treated many patients with treatment-resistant depression, by taking the time to understand the previous history and circumstances leading to these symptoms. It is also important to rule out what hasn't worked so far. Treatment plans are formulated using a wide variety of evidence-based approaches that might involve incorporating therapy or switching to a different type of antidepressant (which work on alternate neurotransmitters and receptors).
Sometimes we find that depressive symptoms can improve after adjusting the nutritional content of our patient's diets or after implementing an exercise plan or other lifestyle changes. In some cases, long-standing symptoms of depression can be related to previously undiagnosed ADHD, and these symptoms of depression often improve once the ADHD is treated.
What is Chronic Depression?
Sometimes depressive symptoms don't fit into any of the above categories. The symptoms may sometimes not be as severe, but they could still have a negative impact on many areas of a person’s life, such as their relationships, work, or academic performance.
Persistent Depressive Disorder, which is also known as dysthymia, occurs when depressive symptoms persist continuously for two years or more.
Postnatal depression is a type of depression that can affect parents (mothers and fathers) after the birth of a child. Postnatal depression can be caused by hormonal or biological changes after pregnancy, stress associated with the pregnancy or birth, or stress associated with parenthood.
Getting help for postnatal depression is important as dealing with depressive symptoms could prevent you from bonding with your child.
Depression and psychosis
Depression with psychotic features, or psychotic depression, is a form of depression that is also accompanied by hallucinations or delusions.
Approximately 20% of people with depression will experience some psychotic symptoms. These symptoms could be related to common depression symptoms, such as hallucinations or delusions related to feelings of guilt, worthlessness, detachment or suicidality. Occasionally, the psychotic symptoms can even be completely unrelated to the depressive symptoms.
Getting help for depression with psychotic features is crucial, as it can be extremely distressing and increase the risk of suicide.
What causes depression?
Depression is a highly complex disorder that is caused by a range of interacting factors. We still don't understand why some people develop depressive symptoms, and others don't.
There are a number of neurotransmitter systems that are known to be involved in depression, including serotonin, dopamine, norepinephrine, glutamate, GABA and acetylcholine. An imbalance in these neurotransmitter systems can lead to depressive symptoms, but we don’t know exactly what causes the imbalance in the first place.
Antidepressants work by rebalancing some of these neurotransmitters, but they also work differently on different people. For example, antidepressants like fluoxetine (Prozac) work by rebalancing the serotonin neurotransmitter system, but they may only work for people who have an imbalance in their serotonin levels. Other antidepressant medications have more of an effect on dopamine or noradrenaline receptors, so they may suit other people better.
Finding the right medication and dosage can be complicated and time-consuming, which is why psychiatrists are needed to prescribe and tweak medications. If someone wishes to take an antidepressant, we will always follow UK guidelines set out by the National Institute for Healthcare and Excellence (NICE) recommending that patients try a selective serotonin reuptake inhibitor (SSRI) first, before trying other types of antidepressants.
Is depression genetic?
Depression has a genetic component, meaning that the risk for developing depression is higher for some individuals based purely on their genetic makeup.
The heritability of depression is estimated to be 37%, with other factors (such as environment) making up the remaining 63% of the risk factors involved in developing depression.
Heritability essentially refers to the percentage of chance that traits (such as eye colour or height) are passed on from our parents and grandparents. Even traits such as height, which is 80% heritable, are still influenced by our environment growing up. For example, we all know the nutritional content of a child's diet can greatly influence how tall they grow.
Interestingly, some genes can also be turned 'on and off', based on environmental cues and stressors (a process called epigenetics). Essentially, what this means is that our DNA and gene expression can change over time, leading to changes in our biology and behaviour. Just as the nutrients we eat in our childhood influence the genes controlling our height, the food we eat day to day can also affect depressive symptoms. Our DNA is actually changing all the time based on our environmental exposure, which could include everything from hobbies and relationships, to exercise habits and sleep schedules.
Can inflammation cause depression?
Not many people realise that chronic inflammation is associated with depressive symptoms and approximately 30% of patients with depression have increased inflammation. Inflammation is a normal biological response to stress and it can cause sickness behaviours, such as brain fog, fatigue, changes in appetite and social withdrawal. These sickness behaviours are actually an evolutionary response to infection, such as a cold or the flu. However, in our modern environment our body can respond to stress in the same way as it would to an infection, by increasing inflammation and inducing sickness behaviours. Scientists believe that over time this chronic inflammation can lead to depression.
Physical health conditions such as diabetes, hypertension, heart disease and autoimmune diseases all increase inflammation, which can then increase the risk of developing depression. This explains why there is such a high comorbidity between depression and other inflammatory conditions.
New research is now investigating whether therapeutic treatments that reduce inflammation could also help to improve depressive symptoms. This may explain why lifestyle interventions targeted at improving nutrition, exercise and sleep are so effective at improving depressive symptoms, because ultimately they all reduce chronic inflammation.
It is important to remember that not everyone with depression will have increased inflammation, it only occurs in a proportion of patients. Nevertheless, there is no harm in trying different lifestyle interventions that may reduce inflammation, as they will improve your health regardless. Prior to starting any treatment for your depression symptoms, you should always seek help from a healthcare professional as they will be able to advise on the best form of treatment for you.
We suggest embedding the following video (instead of just linking to it) https://www.youtube.com/watch?v=iw7b0-yTnT0&t=35s
Two specific subtypes of depression are believed to have opposite inflammatory processes underlying their symptoms.
Melancholic or typical depression usually involves symptoms such as difficulty sleeping (insomnia), loss of appetite and weight loss. In contrast, some people find they begin sleeping too much (hypersomnia), have an increased appetite and gain weight. These symptoms fall under the diagnosis of atypical depression. People with melancholic depression tend to have an increased stress response, characterised by high levels of the stress hormone cortisol. This may explain why they have difficulty sleeping and a low appetite. It may also explain why they usually feel worse in the morning, as the body’s natural stress response peaks in the morning (in the hour after awakening).
On the other hand, people with atypical depression tend to have much higher levels of peripheral inflammation and lower levels of cortisol, which could explain why they tend to sleep more and eat more. Atypical depression is also a risk factor for weight gain and metabolic conditions.
Loss of appetite or weight loss
Difficulty sleeping or staying asleep
Loss of emotion or responsiveness
Mood worse in the morning
Increased appetite or weight gain
Increased need for sleep and fatigue
Increased emotional sensitivity
Mood worse in the evening
Can nutritional interventions improve depression?
Depression has been associated with a host of nutritional deficiencies and imbalances. Some of these include:
- Iron, Vitamin D, Vitamin B12 and magnesium deficiency
- Imbalance in Omega 3 and Omega 6
- Thyroid issues related to diet
- Hormonal imbalances or menopause exacerbated by poor diet (link to women’s health page)
- Imbalanced gut microbiome (ideally link to a blog article on this)
Environmental and social factors
It is common knowledge that traumatic events or major life changes can trigger depression, this could include major accidents or illnesses, loss of employment or death of a loved one.
Some people recover in a matter of weeks from these events, while others may go on to develop depression as a result. The reason for this is that the traumatic event or major life change triggers a stress response, which can then disrupt biological mechanisms (neurotransmitters, cortisol, inflammatory processes) that control mood and behaviour.
However, not many people realise that low levels of continuous stress can also trigger a biological stress response in the same way. As the stress seems less severe and is ongoing, people don’t always take it as seriously as a major life event. Examples of this could include burnout from work, breakdown of relationships with a partner or family members or chronic illness.
- Patterns of thinking (cognitive biases)
- Learnt behaviours (behavioural tendencies)
- Relationship difficulties (attachment style)
Is it normal to feel depressed during the COVID-19 pandemic?
Recently, the COVID-19 pandemic has been a major cause of continuous stress for so many of us. As time goes on, many people are struggling to cope with the uncertainty it has triggered in all aspects of our lives. Many people who have never experienced depression before are starting to experience depression symptoms for the first time in their lives. Although this is a completely normal reaction to a global pandemic, it can still help to speak to a psychiatrist about these symptoms so that you can prevent them from getting worse and find ways to cope with this new form of stress.
Should I see a psychiatrist, a psychologist or a therapist for depression?
You can choose if you’d prefer to use a psychiatrist or a psychologist (or therapist), or both. It is not uncommon for people to have support from both of these professions, since they offer unique benefits as a result of their specific training.
- A psychiatrist is a medical doctor who can provide both psychological therapy and medication, as well as referrals to psychologists if needed. Psychiatry can have a reputation for solely focusing on medication to treat symptoms. We strongly advocate taking a personalised approach to treatment using psychological therapies (psychotherapy), psychoeducation, diet and lifestyle interventions, and using medication only when it is required.
- A psychologist is someone with extensive training in psychological function. In much the same way that medical doctors choose which area to specialise in, such as choosing to be a heart surgeon or a kidney specialist, a psychologist will also choose a specific area of expertise. There are many types of psychologist, for example there are social psychologists, occupational psychologists and clinical psychologists, to name a few. Clinical psychologists are the psychologists that deal with the treatment of mental health problems, they have specialised experience and intensive training often using approaches such as cognitive-behavioural therapy. Psychologists are not medical doctors, but have a doctorate, also known as a PhD. This means they may be termed a ‘doctor,’ which can be confusing. In fact, anyone who has completed a PhD will have the option to call themselves a ‘doctor.’ This does not necessarily mean that they are a medical doctor, and medical doctors, by contrast, do not have to complete a PhD to be referred to as a ‘doctor.’
- A therapist is a mental health professional who does not necessarily have a doctorate, but has training in specific mental health difficulties. ‘Therapist’ is a generic term used to describe anyone who helps people on a professional level, with their mental health struggles. Therapists are subject to their specific governing bodies depending on which school of therapy they have trained under. Unlike psychologists and psychiatrists, who are subject to the governance of the GMC and HPCP, respectively. Some may choose to see a therapist instead of a clinical psychologist because they would like to use strategies outside of the clinical psychologist’s remit. For example, a therapist could be trained in any discipline, from biodynamic to Human Givens therapy, whereas a clinical psychologist tends to be exclusively trained in the use of cognitive behavioural therapy (CBT).
What is the best treatment for depression?
Every individual will have a unique set of symptoms and circumstances contributing to their depressive symptoms. We take the approach that ideally the treatment for depression should be as much as possible tailored to the person’s preferences and circumstances. The goal is, whenever possible, to identify the cause of your symptoms, to restore a state of health. We will design a personalised treatment plan for you that may combine any of the following evidence-based approaches:
Psychotherapy (psychological therapy or talking therapies)
- Cognitive behavioural therapy (CBT)
- Psychodynamic therapy
- Psychoanalytic therapy
- Interpersonal therapy
- Family and couple therapy (systemic therapy)
Medication (if required)
Antidepressants such as SSRIs, SNRIs, atypical and tricyclic antidepressants, MAOIs
Other medications such as mood stabilisers, ketamine, and many more
Diet and lifestyle interventions
It is undeniable that diet and lifestyle interventions can bring about positive changes to mental health. In fact the more we research it, the more we find the link between diet and mental health, here is a fascinating Ted Talk from 2014 on just this topic. However, before you dive into a new dietary regime it is important to highlight that these changes are best made under the care of a professional, such as a dietician or nutritionist. While we encourage you to take a proactive approach to make positive lifestyle changes, it is important to be aware that there are many unsupported claims about dietary and lifestyle interventions.
There are certain interventions that are popular alternative treatments and may yield significant benefits and symptom relief. The following is a list of low risk interventions that could be tried, but always under the guidance of a healthcare professional:
- Exercise - you may find this interview helpful
- Diets such as the ketogenic diet, intermittent fasting and the Mediterranean diet all have promising but sparsely researched results for treating psychiatric disorders. It is important to work alongside a dietician or nutritionist before making dramatic changes to your diet
- Probiotics and supplements can be helpful, but only after you have undergone the necessary testing to identify deficiencies
- SAD lamps can be beneficial for those who benefit from bright light therapy. You can learn more about SAD light therapy here
- Meditation and mindfulness
- Music and art therapy