One in six Australians will experience an episode of depression at sometime in their lives.
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01 .Introduction


Our sister publication in the US, Consumer Reports, recently surveyed more than 1500 of their members who had sought professional help for depression, anxiety or both.

Key findings

  • Respondents who stuck with talking therapies (psychotherapies) for at least seven sessions reported as much improvement as those who used medication alone.
  • People who used both talking and medication fared even better.

For talking therapies, Consumer Reports found the type of therapist didn’t really matter much – psychologists, social workers and licensed professional counsellors received equal “helpfulness” ratings from those who had undergone talking therapy for depression.

The survey also found that some drugs have an edge over others. People who took medications from the SSRI class of antidepressants reported lower rates of side effects than those taking SNRIs – a newer, often more expensive class of antidepressant.

Respondents also reported they found SSRI treatment at least as helpful as treatment with SNRIs.

Types of depression

In Australia, too, the first-line option for treating depression is to use antidepressant medication and talking (psycho) therapies. The most effective method
depends partly on the type of depression:

  • Melancholic depression is the severe form. Middleaged or elderly people are more prone than young people, and it often strikes out of the blue. Sufferers may wake at 3am and not be able to fall sleep again, despite feeling exhausted all day. Weight loss is common because their appetite can disappear and they may have to force themselves to eat. Their movements may slow, or they may become agitated – pacing or wringing their hands. There’s a total loss of interest and pleasure in activities that used to be fun. Thankfully, melancholic depression responds dramatically to the right kind of treatment, which is usually the more powerful classes of antidepressant. Talking therapy alone is unlikely to be effective, while weaker antidepressants may or may not help.
  • Non-melancholic depression is less severe and much more common. With this form, a person is unhappy most of the time, but their mood may lift occasionally – for example, when distracted by work or socialising. Untreated, it still saps the pleasure from life and damages the ability to work and have successful relationships. People with either kind of depression may often think about death and even attempt suicide. All treatments for non-melancholic depression – including antidepressant medication, St John’s wort (see The Lowdown on St John’s Wort, right) and rates of side effects than those taking SNRIs – a newer, often more expensive class of antidepressant. Respondents also reported they found SSRI treatment at least as helpful as treatment with SNRIs.

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Antidepressants reduce the destruction of serotonin and noradrenaline in the brain. These are “neurotransmitters” – compounds that brain cells use to communicate with each other, especially about matters to do with emotion. They are reduced in the brains of depressed people, which means the brain cannot function normally.

Antidepressants are not addictive and don’t damage the brain, even if taken continuously for many years. In fact, one of their main actions is to encourage the brain to produce more of its own natural “fertiliser” proteins, known as “neurotrophins” (from the Greek neuron, nerve, and trophe, nourishment). Neurotrophins help brain cells repair damage caused by depression. They also support an increase of the number of connections between brain cells back to normal levels. The mind uses these richly connected neural cell networks to think, remember and feel. Interestingly, other treatments such as psychotherapy and exercise also boost neurotrophins to some extent.

  • Tricyclic antidepressants are the most powerful commonly used antidepressants, and also the cheapest. Used since the 1950s, they include nortriptyline (Allegron), amitriptyline (Endep), and dothiepin (Prothiaden, Dothep). They are taken at night because they have a sedative effect and can cause dizziness and falls, especially in the elderly. They’re also dangerous if overdosed on. On the upside, they cause fewer sexual side effects than most of the weaker antidepressants, and also alleviate chronic pain.
  • Selective Serotonin Reuptake Inhibitors (SSRIs) Less effective in severe depression, these are useful in mild depression or anxiety disorders. They include fluoxetine (Prozac, Lovan), sertraline (Zoloft), citalopram (Cipramil) and escitalopram (Lexapro). They’re all equally effective, and their rates of side effects are similar. SSRIs are quite safe in overdose and cause less dizziness in the elderly, but people may have less interest in sex than usual or find it harder to maintain an erection or reach climax (sexual health clinics use them to treat premature ejaculation). SSRIs can cause “fuzzy head” syndrome, meaning people feel less depression but less of everything else as well.
  • Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs) A newer class of antidepressants, these include venlafaxine (Effexor) and duloxetine (Cymbalta). SNRIs have similar side effects to SSRIs and seem to be roughly as effective, although venlafaxine at a high dose can also be effective in more severe depression.
  • Electroconvulsive therapy (ECT) If all else fails, or if the depression is exceptionally severe, ECT can be used. It works in the brain similarly to antidepressants, by restoring the levels of neurotransmitters to normal and boosting the brain’s own neurotrophins – but it does these things much better than tablets and so is more likely to treat an episode of depression successfully. Most people need eight to 12 treatments to get better; these are given two or three times a week under a general anaesthetic. The major disadvantage is that ECT must be carried out in a hospital. Its main side effect is that many people who have ECT do not store new memories well during the course (for example, they may forget particular conversations or forget meals), though this ability quickly returns to normal after the treatment finishes.

St John's Wort

Clinical trials have found St John’s wort improves symptoms more effectively than a placebo for people with mild to moderate depression over a period of one to three months. More than half the people treated with St John’s wort experienced improved mood after this period. It’s also been found to work just as well as tricyclic antidepressants and SSRIs in some cases.

However, most of these studies didn’t compare the same St John’s wort pills. Instead, there was a lot of variation in what dosage the pills contained and how they were made – which could well explain the large variation in how well it worked in different studies. Also, the studies tended to be short – usually less than six weeks – so long-term effectiveness isn’t known. While side effects tended to be milder than for conventional antidepressants, most studies did not look properly at them. The most common appear to be stomach problems (feeling sick or having diarrhoea), dizziness or confusion, tiredness and a dry mouth. People in some studies also said St John’s wort gave them headaches or reduced their enjoyment of sex.

The biggest issue with St John’s wort is that it interferes with other medications, including contraceptive pills, simvastatin, triptans, anti-epileptics, warfarin, some HIV drugs and other antidepressants. Always let your GP or specialist know if you’re taking St John’s wort.

Talking therapies offer two advantages over medications: no side effects from drugs, and tools you can use for the long term. There are three main psychotherapies used in Australia:

  • Cognitive behavioural therapy (CBT) is the most accessible. Many psychologists and some psychiatrists perform it in individual or group sessions, usually weekly for about 12 weeks. The focus is on learning to spot negative thoughts as they occur, and changing to a more realistic way of thinking. The therapist may also help the person unearth and challenge any deepseated negative assumptions they may have about themselves and the world. There is homework with each session and, by the end of treatment, the person should have learned some valuable skills to apply later in life, ideally to prevent further depressive episodes.
  • Interpersonal psychotherapy (IPT) also requires about 12 sessions. There are fewer trained practitioners in Australia than for CBT, but it is equally effective. It works on the premise that interpersonal problems may either be causing the depression or preventing it from getting better. The therapist helps the person identify one or two problems that are making their life difficult and learn techniques such as improving communication skills or actively expanding one’s social life to address them.
  • Longer-term analytic psychotherapy was famously used by Sigmund Freud in the 1930s. It is still popular today and involves one or more sessions per week, often for years, delving into the past – especially childhood – to find reasons for problems in the present. It’s very challenging work for both the patient and the therapist, and less useful for simple depression in an otherwise well-adjusted person. It is more helpful when significant childhood problems have resulted in chronic unhappiness and instability.

Both CBT and IPT have been proven to be as effective as antidepressants for mild to moderate depression. For the more severe melancholic form of the illness, they remain useful after the person has recovered enough, with the help of a powerful antidepressant, to be able to think clearly.

Other solutions

Exercise, relaxation techniques, yoga and meditation can all help alleviate depression, but motivation can be a big stumbling block as it’s hard for many people to make themselves exercise regularly, even when well. For a depressed person – who’s feeling lethargic and unmotivated, with black thoughts that sap the will – it’s even harder. However, because exercise boosts serotonin levels and neurotrophins and improves self-esteem, vigorous physical exercise about five times a week can greatly improve mild or moderate depression.

04.How to get treatment and other contacts


Most people first see their GP, who can prescribe the appropriate medication and may also be trained in psychotherapy. Your GP can also refer you to a psychologist; visits attract a Medicare rebate for the first 12 sessions in a calendar year, making it reasonably affordable.

If treatment doesn’t progress well, or if the depression seems particularly severe, many GPs will refer patients to a psychiatrist – a medical specialist who treats mental illness. This attracts a Medicare rebate, but not a rebate from private health funds. Both psychiatrists and psychologists can charge more than the Medicare fee if they choose – sometimes considerably more – so ask how much the gap payment will be when booking an appointment.

There are free psychiatric and psychological services available through community mental health centres, and referrals are not necessary. They offer appointments with psychiatrists (or sometimes doctors training to be psychiatrists) or psychologists, following an initial assessment. Contact your local or state mental health service; your local hospital or GP can also direct you to your nearest community mental health service.

More information

Black Dog Institute:
Beyond Blue:
Blue Pages: 

Help and advice

ACT: Mental Health Triage Service, 1800 629 354
NSW:, (02) 9391 9000
Qld:, (07) 3328 9506
Tas: Mental Health Services Helpline, 1800 332 388
NT: Department of Health and Families Mental Health Unit, (08) 8999 2553
SA:, 1800 643 854
Vic: Mental Health Advice Line, 1300 280 737
WA:, (08) 9222 4222

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