Depression is common. In 2015, about 7 percent of the U.S. adult population—roughly 16 million adults—had at least one bout of depression in the last year, according to figures from the National Institute of Mental Health.
Symptoms can include having sharply decreased energy, a depressed mood, insomnia, loss of appetite, weight loss (or gain), a decline in ability to concentrate, make decisions, or remember; and difficulty functioning normally at work or home.
In this report, we define "depression" as having "major depressive disorder"— the clinical way to describe depression that is persistent, and that causes substantial disruption in your life. To differentiate among the various forms of depression, we often refer to this as "severe depression."
How depression was treated changed markedly in the 1990s and 2000s with the advent of a new class of drugs that included Prozac, Zoloft, Paxil and Celexa. These medicines quickly became the "go-to" treatment for depression.
But later studies showed, and our previous Consumer Reports Best Buy Drugs report on antidepressants found, that between a third and half of people who take an antidepressant don't benefit very much from it—and sometimes not at all.
In addition, studies in the early 2000s found that the newer antidepressants were associated with a heightened risk of suicidal thoughts and attempts among children, adolescents, and young adults.
Non-Drug Treatments May Help
Prescribing of antidepressants remains high, but nondrug treatments have gained renewed attention, particularly as more research on effectiveness has been completed.
Our recommendations are based on two detailed reports, each of which evaluated dozens of studies of depression treatments. Researchers at the RTI International–University of North Carolina Evidence-based Practice Center in Research Triangle Park, NC conducted both studies.
One, published in December 2015, focuses on comparing drug and non-drug treatments for major depression, including cognitive behavioral therapy, psychotherapy (talk therapy), acupuncture, meditation, the over-the-counter supplement St. John's wort, yoga, and exercise.
The second study, used for background purposes, and what we relied upon for earlier CR Best Buy Drug report on antidepressants, focused on research that compares the newer antidepressant drugs. The Agency for Healthcare Research and Quality (AHRQ), a division of the U.S. Department of Health and Human Services, funded both studies.
Best Buy Drug Recommendations
For people with severe depression, consider first trying cognitive behavioral therapy before trying an antidepressant. The evidence suggests CBT works as well and sometimes better and without the risks the medication poses.
That said, with you doctor, you still may wish to either first try an antidepressant or try both therapies at the same time. In that case, among the antidepressants, the evidence suggests the medications are equally effective with some differences in side effects and costs. It can take between four and six weeks to experience an effect.
We did not select a Best Buy drug in this report, but suggest trying the least-expensive options first. Many antidepressants are available at major retail pharmacies for $4 or less for a month's supply.
Depression is not simply unhappiness. Prolonged depression is an illness like heart disease, diabetes, or cancer. Depression can be triggered by external events in a person's life, or arise from biological or chemical changes in the body.
Depression can be periodic, recurrent, or chronic and persistent. Some people have only infrequent bouts, others experience recurrent bouts. And some people suffer chronic, persistent depression.
Also like other diseases, depression can run in families.
Based on the severity of a person's symptoms, depression is usually categorized as mild, moderate, or severe (See Table 1), the degree of a person's impairment, and their level of emotional distress. About a third of people diagnosed with depression have a severe form of the condition, which can be harder to treat.
Symptoms and how severe they are vary from person. If you have five or more of the following symptoms for two weeks or longer, you likely have moderate-to- severe depression, and it's time to make an appointment with your doctor to discuss it..
People who have experienced a traumatic life event may still experience some or many of these symptoms. And they may last weeks or even months. Because of that, determining the difference between what might be called "situational" depression and serious or major depression can be difficult.
Being sad, blue, or unhappy at times is a normal part of life. But being depressed for two weeks or longer usually signals a more serious problem that deserves attention and treatment.
If left untreated, depression limits how much you are able to enjoy life and how productive you are, and for a few people, can even be deadly.
For reasons that are not well understood, people with depression but who don't get treatment are at much higher greater risk of premature death, not only from suicide but from heart disease and a host of other illnesses.
That matters because the issue of who should get treatment—and especially treatment with antidepressants—is not always clear-cut.
There's no standard approach and doctors make the judgment call based on a person's history of depression, how bad their symptoms are, their level of emotional despair, how well they are functioning in life, and possible triggering factors.
Treatment options for the various types and how they compare are discussed below. Note: this report does not discuss bipolar or manic depression; treatment for people with that condition is substantially different than for people who only experience depression, without a "mania" phase.
|"Situational" sadness, grief, or depression||
|Mild to moderate depression||
The information in Table 2. is a general guide and not meant to substitute for a doctor's careful and detailed assessment of your individual circumstances and symptoms. Most family doctors or primary care physicians or general internists can diagnose depression but you may also want to see a specialist such as a psychiatrist, psychotherapist or clinical social worker.
For many years, the vast majority of people diagnosed with depression were treated with either drugs or psychotherapy, or a combination of the two.
In recent years, however, more treatments have come into use as newer studies have shown the limited effectiveness and drawbacks of antidepressants.
And, as different kinds of talk therapy and alternative medicine techniques have been tried and studied, there has been greater public willingness to try new treatments.
The talk therapies evaluated in this report include cognitive behavioral therapy, interpersonal talk therapy, and so-called psychodynamic psychotherapy.
The alternative medicine techniques evaluated include acupuncture, meditation, and mindfulness-based stress reduction. Over-the-counter supplements include omega-3 fatty acids, S-adenosyl-L-methionine (SAMe), and St. John's Wort (hypericum perforatum).
Physical movement techniques evaluated include yoga and regular exercise.
The antidepressants evaluated are listed in Table 3.
|Generic Name||Brand Name(s)||Available as a Generic?|
|Bupropion||Wellbutrin, Wellbutrin SR, Budeprion SR, Wellbutrin XL||Yes|
|Fluoxetine||Prozac, Prozac Weekly, Sarafem||Yes|
|Fluvoxamine||Luvox, Luvox CR||Yes|
|Paroxetine||Paxil, Paxil CR, Pexeva||Yes|
|Venlafaxine||Effexor, Effexor XR||Yes|
The newer antidepressants—which started with Prozac in 1987—are thought to work by altering levels of chemicals in the brain called neurotransmitters (serotonin, norepinephrine, and dopamine). Most of the drugs listed in Table 3 are called "selective serotonin reuptake inhibitors," or SSRIs for short. As their name implies, they act primarily by affecting the neurotransmitter serotonin.
The other antidepressants we list appear to work by affecting brain levels of one, two, or possibly three neurotransmitters.
Knowing this can help you understand why your doctor may prescribe another antidepressant for you if the first one doesn't work. As a second or third choice, if other newer antidepressants don't work or a combination of them is still ineffective, physicians may also turn to treatments called tricyclic antidepressants—an older class of drugs from the 1950s.
Because the side effects of drowsiness, tremors, sexual dysfunction, and heart problems including sudden death in patients with existing heart problems, tricyclic antidepressants are today not usually prescribed to treat depression.
Our medical consultants suggest trying non-drug or the antidepressant treatments in Table. 3 instead.
The primary, large-scale analysis on which this report is based looked at 44 studies comparing antidepressants with nondrug treatment.
While many of the studies had flaws—for example, very few assessed adverse events or reported information on a person's reported quality of life, and no study by itself could be considered conclusive—some consistent and useful results emerged.
Talk therapy vs. antidepressants
For example, five studies involving a total of 660 patients found that cognitive behavior therapy (CBT) (see box below) had about the same or slightly better effectiveness when compared to taking an antidepressant.
In addition, two studies that compared antidepressants with so-called "third-wave" cognitive behavioral therapy (see box below) yielded similar results.
Studies that compared interpersonal or psychodynamic talk therapy with antidepressants also found quite similar effectiveness, although cognitive behavioral therapy appears to have an edge, and it produced a longer-term recovery more reliably.
Complementary and alternative therapies vs. antidepressants
Studies suggest that about half of patients with depression use some form of alternative or complementary medicine.
But those treatments have been far less prescribed and rigorously studied. As a result, the research comparing antidepressants to alternative treatment is weak—studies are small, or are poorly designed, for example.
Yet, the results from the detailed analysis on which this guide is based strongly suggests that using alternative or complementary treatments may be worth considering.
For example, acupuncture plus an antidepressant provided slightly better results than antidepressants alone. Likewise, taking omega 3 fatty acids and antidepressants at the same time also seemed to produce marginally better results than antidepressants alone.
Notably however, acupuncture and omega 3 fatty acids alone were less effective than antidepressants alone. Similarly, SAM-e alone was less effective than an antidepressant.
Unfortunately, the researchers found no acceptable (well-done) studies comparing yoga or meditation with antidepressants.
How and why alternaitve treatments might help is not well understood. For many people, the "placebo effect" may be the reason. That is, if you believe a treatment—any treatment—will help, it can greatly increase the chances that it will.
That's not necessary a bad thing, and it's always possible that scientists will find the how and why in the future.
Nine studies involving a combined 1,517 participants showed St. John's Wort to be about as effective as antidepressants, although the antidepressant doses used in the studies were often lower than those typically recommended. (See here for more on CR's recommendations about St. John's Wort and Omega-3 fatty acids).
Exercise vs. antidepressants
A strong hypothesis exists that exercise can help ease depression via the same mechanisms that permit it to boost mood, a sense of well-being, and general health in people who are not depressed by increasing chemicals called endorphins in their brain and nervous system and increasing blood circulation.
In head-to-head comparisons of exercise alone versus antidepressants alone, antidepressants yielded better results.
But it's worth noting that regular exercise–which has so many other health benefits–was only slightly less effective in relieving depression compared to antidepressants in the few studies that compared them.
Plus, people stuck with exercise more often: many more people who took antidepressants stopped taking them because of side effects and adverse events.
CBT is a form of psychotherapy—usually short-term—that takes a practical, goal-oriented approach to addressing life's problems and the emotional distress they can trigger. Its goal is to change patterns of thinking or behavior that contribute to people's difficulties.
CBT has been in use for decades, and the goal is to treat people with a wide range of mental health problems, most especially anxiety, depression, substance abuse, addiction, and post traumatic stress disorder. There's no consistent way it's practiced and therapists can pick and choose from various techniques including: relaxation, biofeedback, stimulus desensitization, changing disruptive beliefs and attitudes, and goal setting.
Third-wave cognitive behavioral therapies extend traditional cognitive therapy into alternative and holistic medicine. They emphasize promotion of health and well being as well as reducing psychological and emotional symptoms. To an extent, third-wave therapies abandon some tenets of traditional cognitive therapy and embrace holistic concepts such as mindfulness and spirituality. Approaches include:
Acceptance and commitment therapy. This approach uses mindfulness and "behavioral activation" to improve a person's ability to withstand uncomfortable thoughts and feelings.
Dialectic behavior therapy. This approach is used to treat intense emotional reactivity, relationship difficulties and borderline personality disorder.
Metacognitive therapy. This approach emphasizes exploring in depth a person's thoughts and beliefs and how they affect behavior and emotional reactions.
Mindfulness based cognitive therapy. Similar to metacognitive therapy, mindfulness-based cognitive therapy aims to assist people with learning and practicing new ways of experiencing and relating to mental activity, including thoughts and emotions.
The comprehensive analysis on which this guide is based looked at studies that compared antidepressants to each other. It found no antidepressant more effective or superior than any other in relieving symptoms when taken in comparable doses.
Antidepressants are best viewed as moderately effective medicines, with a wide variability of response. In our past CR Best Buy Drug reports, we note only half to 70 percent of the people who take an antidepressant can expect any response. And that response is usually not complete recovery. Rather, the response ranges from a minor to a substantial reduction in symptoms. And other symptoms may linger or wax and wane.
Response is also quite subjective—some people are pleased with any improvement, while others are not satisfied until they feel a substantial reduction in their symptoms.
In studies, roughly 30 to 50 percent of people with moderate to severe depression aren't helped at all with the initial antidepressant treatment.
That said, studies indicate that people respond to antidepressants differently. An antidepressant effective for one person will not necessarily help another person. (That's not uncommon with other drugs, too.)
As a result, if the first treatment with an antidepressant doesn't work for you—or if it causes unacceptable side effects—your doctor may suggest trying another one. CR Best Buy Drugs also suggests that you consider trying a non-drug treatment such as talk therapy or CBT, either in combination with an antidepressant, or on its own, without medication.
The exception is if you and your doctor decide to try another antidepressant because of intolerable or undesirable side effects you had with the first one—assuming you want to continue trying drug treatment at all.
About two-thirds of people who take an antidepressant experience at least one side effect. Many find the side effects so intolerable that they stop taking the medicine. Table 4. lists the most prevalent side effects of antidepressants.
Increases in agitation, anxiety, and thoughts of suicide are among the most worrisome antidepressant side effects.
If you have such symptoms, contact your doctor immediately. Suicide is rare, estimated to occur in approximately 1 in every 8,000 people who take antidepressants. Suicidal thoughts, however, are common, occurring in 1 in every 160 or so. Suicidal thoughts can be a symptom of depression itself, so if you experience those contact your doctor immediately.
Side effects related to one's sex life concern many people who take antidepressants. Since depression itself can make people lose interest in sex, it is important to determine whether it is the antidepressant or the illness that's causing the problem.
If you first experience loss of libido or sexual problems soon after you started taking the drug and you had not had any sexual problems before despite feeling depressed for months, it's likely linked to the drug, and you and your doctor may consider switching you to another antidepressant such as buproprion or a non-drug treatment if the side effects are bothersome.
Relatively minor side effects that usually go away in time or are short-lived:
|More serious side effects that can be annoying or dangerous:
Talk with your doctor about the difference between antidepressants in terms of side effects. This may well be the most important factor in your choice. Table 5 summarizes the evidence on the rate at which people stopped taking each antidepressant because of side effects. The table also has comments on some of the strengths and problems with each drug.
|Generic name||Brand name||% of people who stopped drug due to side effects1||Comments/safety notes2|
Source: Derived from Comparative Effectiveness of Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression. Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jan. Report No.: 07-EHC007-EF. AHRQ Comparative Effectiveness Reviews.
The researchers also looked at people who switched depression treatments after their first treatment wasn't effective.
For example, people may switch antidepressants. Also, people who were not helped from psychotherapy or cognitive behavioral therapy may try an antidepressant, or vice versa.
And people may quit taking an antidepressant and try an alternative medical intervention. Doctors often refer to the new treatment as "second-step" therapy.
Research results are mixed for treatment switches and second-step treatment. For example, two comparisons of people who tried a second drug after the first one didn't work—involving 1,123 patients—found that no particular drug used as a second-step worked any better than any other—in other words, there was no best "next step" antidepressant medication.
Another small study involving 122 patients who were switched to a different antidepressant or to CBT also found no difference in response. And researchers have been unable to prove any benefit for patients who switched from an antidepressant to an alternative medicine technique such as acupuncture.
But studies have shown that when second-step treatment combined two types of treatments instead of replacing one with another, results improved for some patients.
Switching to another antidepressant, switching to cognitive therapy, and augmenting an initial treatment with a particular medication or cognitive therapy are all good choices.
If you are prescribed an antidepressant, we advise discussing the following with your doctor:
Cost may be a factor in your decision about depression treatment.
Check with your insurance company about coverage of talk therapy like CBT. Under most plans, weekly sessions for up to a few months are covered. But many plans limit the payment for each session, compelling people to pay half the cost or more.
Many people today pay out of pocket for therapy—in large part because therapists don't accept coverage. And, some may prefer to keep this part of their medical care private.
Shorter-term talk therapies such as cognitive behavioral therapy have become more popular in part because insurance coverage may be offered for 8 to 12 sessions. A single CBT session typically costs $180 to $250. You'll want to try at least 8 sessions before you decide whether CBT is working or not.
In addition, one recent study found that patients diagnosed with depression had success with internet-based self-guided CBT.
Alternative treatments such as acupuncture are often not covered by insurance.
All but three of the antidepressants on the market today are available as less expensive generics. A month's supply of a generic antidepressant typically costs between $ to $25 at your local pharmacy. But a month's supply can cost as little as $4 at chain discount stores such as Costco, Kroger, Sam's Club, and Walmart. In some cases, a three-month's supply at these stores cost $10 to $15.
Some pharmacy chains compete with these prices, but may require a membership fee to participate. Also, check the details carefully to make sure your drug and dose are covered.
Be mindful that some doctors may want to try newer drugs, and pharmaceutical companies promote and advertise them heavily in medical journals (and sometimes to consumers via magazines and TV). But there is no indication that any antidepressant is more likely to work than any other, nor does research show is there any indication that currently available generic and brand antidepressants medications differ in effectiveness.
Be especially cautious if your doctor offers you a free sample of an antidepressant that they happen to have in their office. While getting a medication for free may be tempting, the drug is almost certainly brand name. And your doctor won't supply you with free samples for long.
This guide to the treatment of depression is based on two detailed reports, each of which evaluated dozens of studies of depression treatments. Researchers at the RTI International–University of North Carolina Evidence-based Practice Center in Research Triangle Park, NC conducted both studies.
One, published in December 2015, focuses on comparing drug and non-drug treatments for major depression, including cognitive behavioral therapy, psychotherapy (talk therapy), acupuncture, meditation, the over-the-counter supplement St. John's wort, yoga, and exercise. RTI International–University of North Carolina Evidence-based Practice Center's full review is available here. (This is a long and technical document written for physicians).
The second study, used for background purposes, and what we relied upon for earlier CR Best Buy Drug report on Antidepressants, focused on research that compares the newer antidepressant drugs. The Agency for Healthcare Research and Quality (AHRQ), a division of the U.S. Department of Health and Human Services, funded both studies.
A consultant to Consumer Reports Best Buy Drugs is a member of the Pacific Northwest Evidenced-based Practice Center research team, which has no financial interest in any pharmaceutical company or product.
These materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multi-state settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).