context: Although very common, depression is often ignored or misdiagnosed and left untreated. Such inattention can be life-threatening; major depression, in particular, has a high suicide rate. If you or a loved one have symptoms of depression, seek help from a qualified health care provider. Many primary care doctors diagnose and treat depression. Screenings for depression are now often part of a routine visit to your doctor. But if your symptoms get significantly worse or do not improve within four to eight weeks of treatment, ask your health care provider for a referral to a psychiatrist for diagnosis and treatment. Clearly, for more severe symptoms -- and always if you have thoughts about death or hurting yourself or someone else -- you should see a psychiatrist as soon as possible. To diagnose depression, your health care provider will ask you questions about your symptoms and family history. You may be asked to fill out a questionnaire about your symptoms. You may be given medical tests to rule out other conditions that may be causing your symptoms, such as nutrient deficiencies, underactive thyroid or hormone levels, or reactions to drugs (either prescription or recreational) and/or alcohol. The stigma depression carries drives many people to hide it, try to tough it out, or misuse alcohol, drugs, or herbal remedies to get relief. To effectively treat depression, it is important to seek care from a health care provider such as your primary care doctor or a licensed mental health professional. Both of these types of providers can help you get a correct diagnosis and develop a treatment plan. Many treatments for depression are available and typically include a combination of psychotherapy and medication. Psychotherapy teaches patients how to overcome negative attitudes and feelings and helps them return to normal activities. Drug therapy is intended to treat symptoms that are thought to result from abnormalities in brain circuits that regulate mood, thinking and behavior. It may take several weeks for an antidepressant to fully work to ease depression symptoms, so it's important to stay on the medication. As with any chronic illness, getting an early medical diagnosis and medical treatment may help reduce the intensity and duration of depression symptoms. It may also reduce the likelihood of a relapse. The group of antidepressants most frequently prescribed today consists of drugs that regulate the chemical serotonin. Known as selective serotonin reuptake inhibitors ( SSRIs), the group includes citalopram ( Celexa), escitalopram oxalate ( Lexapro), fluoxetine ( Prozac), luvoxamine ( Luvox), paroxetine HRI ( Paxil), and sertraline ( Zoloft). Serotonin norepinephrine reuptake inhibitors ( SNRIs) including desvenlafaxine ( Khedezla,), desvenlafaxine succinate ( Pristiq), duloxetine ( Cymbalta), levomilnacipran ( Fetzima), and venlafaxine ( Effexor), also act on serotonin and norepinephrine but in a different way than SSRIs. The drugs vortioxetine ( Trintellix -formerly Brintellix) and vilazodone ( Viibryd) affect the serotonin receptor (like SSRIs) but also affect other receptors related to serotonin function. Other antidepressants include bupropion ( Wellbutrin), a drug that appears to affect dopamine and norepinephrine regulation, and mirtazapine ( Remeron), which increases levels of serotonin and norepinephrine by a different mechanism than SNRIs. For children and adolescents, the SSRIs are among the best-studied and therefore often the drugs of choice. The tricyclic antidepressants ( TCAs), which have been used to treat depression since the 1950s, are another option, although they are apt to have more side effects than the SSRIs. Like all antidepressant drugs, you must take them for a while before they take effect. TCAs include amitriptyline ( Elavil), amoxapine Asendin), desipramine ( Norpramin), doxepin ( Sinequan), imipramine ( Tofranil), nortriptyline ( Aventyl, Pamelor), protriptyline ( Vivactil), and trimipramine ( Surmontil). Because adolescents do not tolerate side effects well and tend to stop taking their medication, TCAs are not recommended for them as first-line treatments. In addition, heart rhythm problems have been seen in children and adolescents taking desipramine, a TCA, so caution should be taken when this medication is prescribed to this population. The third group of antidepressants, the monoamine oxidase inhibitors ( MAOIs), like phenelzine ( Nardil), tranylcypromine ( Parnate) and the skin patch EMSAM, have also proved effective. MAOIs may sometimes work more quickly than the TCAs, but they require avoiding certain foods (such as aged meats and cheeses) and certain other medicines that can also affect serotonin or raise blood pressure. MAOIs are usually prescribed only if the SSRIs and the TCAs or other depression medicines that can be simpler to take fail to bring improvement. Lithium carbonate ( Eskalith), which is a drug commonly used for manic depression, is also sometimes used to treat depression in combination with an antidepressant. Today, atypical antipsychotics have become the most widely prescribed class of medications that are added on to an antidepressant after an incomplete initial response. Three in particular, aripiprazole ( Abilify), brexpiprazole ( Rexulti), or quetiapine ( Seroquel XR), are FDA-approved as add-on therapy for antidepressants, regardless of the presence or absence of psychosis (delusions or hallucinations). However, atypical antipsychotics can have many possible side effects, including weight gain, changes in blood sugar and cholesterol, sedation, and abnormal movements. The nutriceutical l-methylfolate ( Deplin) is a prescription strength form of the B-vitamin,folate, and has shown success in treatment of depression. Referred to as a medical food by the FDA, l-methylfolate helps regulate all three of the brain's monoamine neurotransmitters associated with moods. Side effects include hives, swelling, nausea and bloating. Your health care provider can recommend the best medicine for you. Psychotherapy is an important part of treatment for depression. In cases of mild-to-moderate depression, psychotherapy may be used alone to relieve symptoms. More often, it is used in conjunction with medication to alleviate depression. Commonly used forms of psychotherapy are cognitive, behavioral, and interpersonal therapies. Cognitive therapies challenge the negative thought patterns that accompany depressed moods and teach you new ways to think more positively. Behavior therapies concentrate on changing patterns of behavior. Interpersonal therapies help you examine how relationships affect your moods. Electroconvulsive Therapy ( ECT) ECT involves the application of an electric current through electrodes on the head. These are not felt by the patient, who is asleep under general anesthesia. Although doctors are still uncertain exactly how ECT works, it is thought that by producing a brief seizure, a course of several treatments of ECT conducted over a few weeks can bring about relief from depression. Its techniques have been refined in the past 20 years in order to minimize side effects, such as memory loss, and today ECT is considered to be as safe, or even safer, than many drugs used to treat depression and for some people, more effective. ECT is usually considered after a number of other options have been tried because it may require hospitalization and general anesthesia. It's also considered if rapid results are vital, as with suicidal patients or those who refuse to eat or drink. ECT should not be thought of as a "last resort"; it is extremely effective and may work before other treatments have been tried and failed. Usually given three times a week for two to four weeks, treatments generally involve 6 to 12 sessions and are sometimes followed by a gradual âtaper downâ in frequency over several weeks. Some people benefit from ongoing âmaintenanceâ treatment over longer periods to prevent relapse when medicines alone may be ineffective. Repetitive Transcranial Magnetic Stimulation (r TMS) r TMS, which involves passing strong magnetic currents through the brain, is another option for treating depression. r TMS has been used effectively at times to treat major depression and depression that does not respond to other forms of treatment (treatment-resistant depression). However, to date, studies have not found r TMS to be as effective as ECT. Vagal Nerve Stimulation ( VNS) VNS is used to treat select cases of severe or recurrent, chronic depression that does not respond to at least two antidepressant trials. This surgical treatment involves the use of a pulse generator implanted under the collar bone that sends out pulses of electricity to stimulate the vagus nerve in an attempt to affect the brain's mood centers. It typically takes at least several months for VNS to begin to show a benefit for treating depression. Exercise should be a part of any therapy for depression. It improves blood flow to the brain, elevates mood, and relieves stress. Even if used alone, it can often bring favorable results. Studies show that jogging for 30 minutes three times a week can be as effective as psychotherapy in treating depression. Pick an exercise you like and do it daily, if possible. Any exercise is fine; the more energetic and aerobic, the better. The key is getting your heart rate into the right range for your age for 20-30 minutes three to four times a week. Because symptoms of depression can be exacerbated by nutritional deficiencies, a healthy diet is important. Eat a well-balanced diet. Some people have noticed an improvement of depression symptoms when they eliminated wheat, dairy, alcohol, sugar, and caffeine from their diets. But this is not proven to treat depression. You can try eliminating those foods one at a time from your diet and note whether your depression improves. It may help to keep a symptom diary. Quitting smoking is also advised. As with any alternative or complementary medicine, check with your health care provider before starting it, especially if you are taking other medications or treatments. Several studies show that the herb St. John's Wort is as successful at improving symptoms of mild-to-moderate depression as prescription medications, often with fewer side effects. However, other reports show that the herb isn't any better than placebo (or sugar pill) in treating depression. Although it is considered safe, St. John's Wort can be potentially dangerous if taken with other antidepressants (especially SSRIs), including certain medications used for treating HIV, cyclosporine, a drug used in organ transplant patients, or anticoagulant drugs. It can also interfere with the efficacy of oral contraceptives and medications used for heart disease and seizures. S-adenosyl-methionine ( SAM-e), another herbal remedy, is also sometimes considered to be a useful treatment option for depression, although existing medical studies have not been conclusive about its effectiveness. Although ginkgo biloba is typically used as an "alternative medicine" strategy that might help to improve memory and ease confusion, it has proven in some cases to work better than placebo for the symptoms of depression, and is approved by the German government's Commission E for this purpose. Whatever herbal remedy you may decide to take to treat a medical condition, it is always best to consult your health care provider first. This is especially true if you are taking prescription medications for the same or other conditions. Many mind/body practices can be helpful with depression. Music and dance can lift the spirits and energize the body. Meditation and relaxation techniques, such as progressive muscle relaxation, both stimulate and relax. Other choices include transcendental meditation, visualizations, and the Asian exercise techniques of yoga, tai chi, and qigong. Choose one or two that suit you and practice often. Massage not only relaxes you, it may help reduce your anxiety and depression. When groups of depressed adolescents received massage therapy, their stress hormone levels changed, their brain activity was positively affected and their anxiety and depression eased. Because it has no side effects, massage could be a safe and positive addition to your depression treatment program. However, by itself, massage is not considered to be a proven or evidence-based treatment for depression. The World Health Organization lists depression among the conditions for which acupuncture is effective. Some studies have shown it markedly lessens symptoms of depression. Acupuncture may be a viable alternative from therapy if you are unable to take antidepressants or have not found them helpful.