I Feel Depressed: Do I Need an Antidepressant?

The World Health Organization states that depression is the leading cause of disability worldwide. Therefore, one common question when people visit their doctors is: “Do I need an antidepressant?” Every individual’s experience with depression is unique, but the following will help you think about some of the general concepts for treating depression.

Definition of Depression

A major depressive disorder is defined by either a depressed mood or loss of interest or pleasure nearly every day, problems with sleep, problems with appetite (usually causing weight loss or gain), low energy, difficulty concentrating, thoughts of worthlessness, or even suicidal thoughts.A related condition, called persistent depressive disorder (or dysthymia), occurs when you have some depressive symptoms over a long period of time (generally defined as two or more years). There are many variations on these themes. For example, some women have depressive disorders more closely associated with their menstrual cycles; others have mood problems more closely associated with substance abuse. For the purpose of this article, we will focus on the general symptoms listed above that are common in most depressive disorders.

Of note, bipolar depression is an important public health issue but will not be discussed here because the medications used to treat bipolar are often very different from those used to treat other types of depression.

Treating “Minor” Depression

Minor depression is generally defined as a depressed mood plus up to three other symptoms (described above) lasting for a minimum of two weeks.

If you do not have suicidal thoughts and your daily life is not impaired by the depression, my general recommendation is that you not start an antidepressant. Alternative approaches may include (depending on the individual) regular exercise, proper nutrition, meditation, yoga, light box therapy (if there is a seasonal component), fish oil, and scheduled social activities.

However, the term “minor” depression can be a true misnomer. The reason this term is misleading is that the definition uses a checklist approach based on the number of symptoms and not on the severity. For example, if there are only two symptoms, such as depressed mood and insomnia, but these symptoms are incredibly intense and cause functional impairment, I can assure you that no patient experiences this as “minor.”

Psychotherapy is generally my first-line treatment for people with minor depression that causes dysfunction in their lives (i.e., problems with work, relationships, etc.) but without suicidality. Randomized control studies have indicated that cognitive behavioral therapy (CBT) in particular can effectively treat minor depression.

Persistent Depressive Disorder and Major Depressive Disorder

For initial treatment of persistent depressive disorder and major depressive disorder, the medical literature strongly supports taking medication in combination with psychotherapy. Taking medication alone can also be helpful, but the combination of therapy and medication is generally most effective.

An indicator that it is time to start a medication is when you are not able to function in some important aspect of your daily life. Depressive symptoms can result in losing your job, impending divorce, or an inability to maintain adequate nutrition. Other indications to start a medication generally include suicidal thoughts, psychotic features (for example, hearing voices that others cannot hear or having delusions), impaired judgment that causes imminent risk of harm, or severe insomnia.

If you and your doctor decide that starting an antidepressant is appropriate for you, antidepressants should generally be initiated at low doses in order to reduce side effects. People with major depression who start antidepressants often have some meaningful improvement within two weeks. However, it often takes six to 12 weeks before you can determine whether an antidepressant will sufficiently relieve symptoms. For people with little or no improvement after taking an antidepressant for four to six weeks, it is generally advisable to talk with your doctor about moving on from that particular antidepressant and trying different options.

General Principles Regarding Starting an Antidepressant

Everybody experiences depression differently. The rule of thumb is that before you start any medication, you need to talk with your doctor about the potential benefits, risks, and alternatives available to you. This includes a discussion of possible side effects from the medication and also of the risks of untreated depression.

The key point is that depression is a medical condition, oftentimes with a strong social and genetic component, that is highly treatable. If you or a loved one is suffering from depression, I strongly recommend that you contact your doctor.