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More than 80 percent of people with major depression can be treated successfully with psychotherapy, medical therapy or a combination of both, according to the National Institute of Mental Health (NIMH). However, up to 50 percent may not respond to initial treatment trials, and require medication changes, addition of different medications, or testing and/or second opinions regarding diagnosis.

The treatment options available for depression are varied and should be individualized. Mild depression may respond well to psychotherapy alone, whereas moderate to severe depression typically requires medication treatment (e.g., antidepressants). The outcome of treatment is generally best with a combination of psychotherapy and medication. During treatment, the patient's mood will likely improve gradually, after a slight delay for the treatment to begin working, with the patient feeling a little better each day.

Forms of psychotherapy that may be effective in the treatment of major depression include:

• Cognitive behavioral therapy. Attempts to change negative patterns of thought or behavior that are associated with depression and teach patients to achieve more satisfaction and rewards from their own actions.
  
  
• Interpersonal therapy. Focuses on the patient's personal relationships and the problems in these relationships that cause or worsen depression. A form of interpersonal therapy, family therapy, involves the entire family and may be particularly helpful when there are specific family-related stresses.
  
  
• Psychodynamic therapy. Focuses on resolving the conflict in a patient's feelings, such as the desire for praise coupled with feelings of worthlessness. This therapy is often reserved until symptoms are significantly improved.

Medications for major depression offer relief of symptoms over a period of time. The primary medications for this disorder are antidepressants, and may include:

• Selective serotonin reuptake inhibitors (SSRIs). These newer antidepressants increase the level of serotonin in the brain.
  
  
• Tricyclic antidepressants (TCAs). Alter the levels of several chemicals in the brain.
  
  
• Monoamine oxidase inhibitors (MAOIs). The first antidepressants used, although less commonly used today because of their side effects.
  
  
• Serotonin and norepinephrine reuptake inhibitors (SNRIs). Affect several brain chemicals and may be effective in cases where other antidepressants are not.

Antidepressants typically take several weeks for full effects and are generally taken for at least a year, or even lifelong, to prevent recurrence. Patients should be aware that a physician may need to adjust the dosage or change medications to achieve the best results with minimal side effects. Generally, a first episode of major depression responding to medication should continue medication for a year. A second episode should prompt a closer look at family history and the amount of disability experienced in the illness to decide whether it is reasonable to stop medication after three years. A third episode should almost always result in a recommendation for continuation of antidepressants for a lifetime. In addition, the U.S. Food and Drug Administration (FDA) has advised that antidepressants may increase the risk of suicidal thinking in some patients and all people being treated with them should be monitored closely for unusual changes in thoughts and behavior.

Other medications may be used in combination with antidepressants in some cases. These are generally not effective when taken alone for major depression. Anti-anxiety drugs and mood stabilizers are among the most commonly used medications combined with antidepressants for major depression. When the patient has psychotic symptoms, antipsychotics may be used. Stimulants, such as amphetamines, are not usually effective with antidepressants, but may be used under close monitoring in medically ill patients or when the sedative side effects of a medication that is working well interferes with functioning.

Herbal and dietary supplements such as St. John's wort may also be used to treat major depression, although their effectiveness has not been established. It is important for patients to speak with a physician before taking any herbal or other supplement because many supplements cause serious drug interactions or have other serious side effects. For instance, St. John's wort has been shown to induce mania in people with bipolar disorder. There is also considerable variation in the amount of active ingredient in herbal supplements, so that one bottle may not cause problems, but another may cause a significant negative reaction.

Exercise, particularly aerobic activity, has been shown to have positive antidepressant effects in individuals with mild to moderate depression. Patients are generally encouraged to at least try to exercise. Some patients may also benefit from approaches such as meditation, journaling, music therapy or art therapy.

In some cases, electroconvulsive therapy (ECT) may be recommended by a physician to treat severe depression, when medications are ineffective or the illness has symptoms that are life threatening. ECT is a treatment in which electrical current is used to cause a brief convulsive pattern in the patient's brain.

For some people, major depression may not be preventable. A healthy lifestyle that includes a balanced diet, exercise and strong social and interpersonal connections may help. People who have experienced major depression and recognize the return of their symptoms can seek help immediately to minimize their effect.