I don't have much knowledge of all the different types of therapy, but I can talk from personal experience. In my own experience I found the following to be true, but of course that could just have been specific to my situation:
1) I did not find the professional psychologists that I went to to be tremendously helpful. Much more useful in my situation were caring, thoughtful individuals who were short on formal training but rich in common sense and life experience. (This type of person used to be called "wise", but that term seems to have gone a bit out of fashion.)
2) Caring, understanding, and supportive relationships were crucial for me. Family, friends, mentors, and role models all served different supportive roles in this regard, and all were important. In fact, the thing that finally did away with my depression was forming the best and closest relationship in my life - namely meeting my wife.
3) There's a big difference between trying to root out the underlying cause of someone's depression vs. doing practical things to alleviate it. I once saw this compared to a patient who comes in with a gaping wound. If you just try to find out the underlying cause without first treating the wound, then the patient will quickly bleed to death. If you bandage the wound without treating the underlying causes then the patient may live a bit longer but they'll still die. The psychologists and counselors I dealt with all tended to focus on underlying causes, and that was definitely important. But what I usually needed was some short-term bandages. Sometimes what I needed was some concrete, practical advice that I could put to immediate use. Or sometimes the best help would have involved a direct intervention on the part of the counselor, such as getting on the phone with some of my mentors / friends and enlisting their help, or arranging with my teachers to see if there was something that could be done in the classroom that could help. But psychologists are often prohibited from doing things like this.
While I agree that depressives should try CBT, I've begun to think some of the enthusiasm is misplaced, especially when contrasted with the scrutiny antidepressants receive. Yvain has written about this before:
The AJP article above is interesting because as far as I know it’s the largest study ever to compare Freudian and cognitive-behavioral therapies. It examined both psychodynamic therapy (a streamlined, shorter-term version of Freudian psychoanalysis) and cognitive behavioral therapy on 341 depressed patients. It found – using a statistic called noninferiority which I don’t entirely understand – that CBT was no better than psychoanalysis. In fact, although the study wasn’t designed to demonstrate this, just by eyeballing it looks like psychoanalysis did nonsignificantly better. The journal’s editorial does a good job putting the result in context.
This follows on the heels of several other studies and meta-analyses finding no significant difference between the two therapies, including, another in depression, yet another in depression, still another in depression, one in generalized anxiety disorder and one in general. This study by meta-analysis celebrity John Ioannidis also seems to incidentally find no difference between psychodynamics and CBT, although that wasn’t quite what it was intended to study and it’s probably underpowered to detect a difference.
In the vein of non-risky interventions, you might also want to add a section on meditation, expressing gratitude (not sure of the citation -- maybe here? -- but I recall the best possible selves intervention mentioned in the paper being ineffective among the depressed), and expressive writing generally.
Thanks for the link to Yvain's article. The meta-analyses that I found comparing the efficacy of CBT and usual therapy didn't show CBT to be superior, with the possible exception of long-term effects. The points that I raise in favor of CBT are the potential for low-cost and the absence of a need to find a therapist who's a good match.
For those who want to try CBT, I've made available Burn's book together with an Anki deck and a Google Form here.
I share Yvain's skepticism, though. Insofar as there are reasons for experimenting with CBT, they seem to mostly derive from the comparatively low health, time and money costs of trying it for a while, and the benefits of using the knowledge gained during that trial period to make a decision about whether to try it for longer.
From the example cards that are shown in Anki:
Front What is the 'jumping to conclusions' form of twisted thinking?
Back You interpret things negatively when there are no facts to support your conclusion.Mind reading: Without checking it out, you arbitrarily conclude that someone is reacting negatively to you.Fortune-telling: You predict that things will turn out badly. Before a test you may tell yourself, "I'm really going to blow it. What if I flunk?" If you're depressed you may tell yourself, "I'll never get better."
That paragraph is too long. It violates minimum information completely. As a result it's hard to judge whether you answer the card directly and the card doesn't work well as an Anki card.
Thank you for your feedback. This material is not that suitable for Ankification because the purpose is to commit the material to procedural rather than declarative memory. My goal was to give users an easy way to be periodically exposed to the relevant techniques, so that they would eventually change the relevant habits and mindset, rather than to memorize the material in the usual way. If you have some concrete suggestions on how to improve the deck, feel free to send them to me.
I personally don't know CBT very well to be able to tell you what the basics of CBT happen to be.
From my own experience in other frameworks I think that having declarative knowledge of what you want to do procedurally is helpful for being able to perform the procedural part. Understanding the basics of a topic well enough to break them down into atomic bits is hard but I don't think that topics like CBT are inherently structured in a way that they can't be reduced to atomic bits.
But if you lack the ability to know the basics of CBT well enough to state them at a atomic level you fortunately aren't out of luck. A straightforward way is to to write Anki cards that ask: "Is A or B the right way?" The learner has to only remember one bit of information to answer the question.
From the start of the book, you could form the card:
Question: Do your moods get created by your thought and attitudes or by external events?
Answer: thoughts and attitudes
I think it's worthwhile to study the basics of CBT. I downloaded the downloaded the ebook. Hopefully I will have a good answer about the basics of CBT at some point in the future.
Good post! But you're missing a big piece: Chronic depression is often about relationships. Dysfunctional families, shitty childhoods and abusive spouses get a lot of people depressed - and that includes many who do not realize they learned some bad lessons in their childhoods or that they have unacknowledged needs their significant others aren't meeting. Which is unfortunate, because realizing what's wrong about one's relationships can uncover avenues to improvement.
Personally, I call depression "the slavery response" and think it used to be an adaptive response to certain kin group dynamics. If you're depressed (and it isn't iodine deficiency or something), find out who you feel enslaved by and powerless against, and obtain social support in changing that relationship. Getting this right is what psychodynamic therapy has going for itself and what I think helps it compete with the far more scientific CBT people.
Thank you for mentioning that someone to talk to can be as helpful as a therapist, under some circumstances. Anyone can be that someone, too, and maybe do a lot of good. But it takes some skills: You have to be non-judgemental, interested, observant, honest, quiet and let the sharing person come to his or her own conclusions. Those skills are worth having for other purposes, too. (Therapists are almost universally very pleasant people.) But often the most important help you can give is help establish contact to a better helper.
The SSRIs you mention as "newer" antidepressants are likely to soon be eclipsed by NMDA receptor antagonists, which are in the approval pipeline now and seem to be working somewhat better and much faster than current standard of care antidepressants, without increased suicide risk. Since these aren't approved yet, nootropics-minded folk are getting this kind of help outside the health care system and I'm told it is highly effective.
The SSRIs you mention as "newer" antidepressants are likely to soon be eclipsed by NMDA receptor antagonists, which are in the approval pipeline now and seem to be working somewhat better and much faster than current standard of care antidepressants, without increased suicide risk.
How strong is the evidence?
There's little doubt NMDA receptor antagonists can cause rapid alleviation of depressive symptoms in a majority of patients who have previously not benefitted much from SSRIs. The effect of a single dose seems to last days, often weeks and sometimes months. Off label use of ketamine is growing because of this.
Now the pharma companies are developing several similar but new (i.e. patentable) substances that they hope have less hallucinatory side-effects, such as lanicemine. Big money is going into this, so the evidence seems to be good enough.
Reddit thread on using DXM for depression. DXM beginner's guide. Doesn't seem that promising, although chronic use at regular cough syrup doses could be interesting?
My impression was that memantine was the safest NMDA antagonist and it doesn't seem to work for depression.
House of Cards by Robyn Dawes argues that there's no evidence that licensed therapists are better at performing therapy than minimally trained laypeople. The evidence therein raises the possibility that one can derive the benefits of seeing a therapist from talking to a friend.
There seems to be evidence that the empathy of the therapist is very important. http://www.nrepp.samhsa.gov/Norcross.aspx#chapter6 (link for the summary of evidence and not for their description of what empathy is) You don't learn to be empathic by sitting 5 years in university psychology lectures but that doesn't mean that there aren't people who are very good at being empathic to which you can go.
It also really import when choosing a therapist that don't just go because they have a credential but because you feel like you have a good connection with them.
The vast majority of exercise studies have their subjects doing arbitrary exercise routines that are generally ineffective at inducing rapid improvement. In addition, I believe the benefits of exercise on mentality accrue over the span of months, not the weeks that most studies are run for.
By arbitrary exercise I mean exercise that is no where close to in line with the largest systematic reviews on what exercise is effective in creating physiological changes http://ije.oxfordjournals.org/content/early/2011/09/05/ije.dyr112 https://www.ncbi.nlm.nih.gov/pubmed/16287373
It is rare to see any sort of reasoning about exercise selection in an exercise study. When such reasoning is included it usually just cites other exercise studies, which then do not have such reasoning. Example, this study http://archinte.jamanetwork.com/article.aspx?articleid=485159#ref-ioi81361-43
references the methodology of this study http://www.researchgate.net/publication/19819328_Comparison_of_high-_and_low-intensity_exercise_training_early_after_acute_myocardial_infarction/file/d912f50630d8f7c66f.pdf
which provides a very detailed description of what the exercise protocol is, but no explanation of why. If exercise protocol was standard within the exercise research community then you would expect to either see a protocol listed by name or a lot of studies with similar methodologies. Instead we see exercise studies with all sorts of varying exercise protocols, making direct comparison harder, and meta analysis weaker.
With regard to months instead of weeks, this is based on my experience and anecdotal reports of others. A successful instillation of an exercise habit seems to counter feelings of powerlessness to change one's situation which is a large component of many depressions. This seems to fall in line with studies like this, where the term self-concept is used. http://www.amsciepub.com/doi/abs/10.2466/pms.1992.74.1.79
I often wonder whether "depression" as a blanket term is useful; and whether using it may even be detrimental.
Consider an analogy: diagnosing someone with "pain" isn't very useful. At best you can give painkillers, which only helps temporarily. But there are so many different causes of pain: arthritis, bone fracture, kidney stone, migraine and so on. Different causes require very different treatments. So, you need to be able to identify these causes accurately if you want any hope of curing the patient.
Just the fact that very different people with very different genetics in very different life circumstances experience a similar mental phenomenon called "depression", doesn't necessarily imply they can all be treated the same way. Phenomenological descriptions may be similar, but causally are they similar? A trivial example: a person who's depressed because her husband died would require a different treatment than a PhD student who's depressed because her research isn't progressing.
This is why I'm not too enthusiastic about anti-depressants; they seem akin to painkillers. But the inefficacy of talk therapy makes me wonder whether even experts can tease out the different causes behind depression; or even if they could, whether they can treat them appropriately.
Note: I'm not an expert, so let me know if I'm oversimplifying here.
You're oversimplifying.
The medical and therapeutic community has a host of terms for various clusters of conditions and symptoms associated with depression. For some, the approach to treatment is pretty clear: If the person also has severe social anxiety for example, treating the anxiety should also alleviate the depression. For others, the standard is to try therapies until something works. Since even moderate depression shaves off years of life expectancy, it is worth trying a fifth kind of therapy if the previously four didn't do it.
Intense grief over a lost partner is normal, as is anxiety over unsatisfactory work. Severe depression can be a lot worse than either.
Just the fact that very different people with very different genetics in very different life circumstances experience a similar mental phenomenon called "depression", doesn't necessarily imply they can all be treated the same way. Phenomenological descriptions may be similar, but causally are they similar? A trivial example: a person who's depressed because her husband died would require a different treatment than a PhD student who's depressed because her research isn't progressing.
For a given person, some treatments will work while others won't. So yes, there seem to be multiple possible causes. But
This is why I'm not too enthusiastic about anti-depressants; they seem akin to painkillers.
A variety of factors may cause undesirable brain chemistry, but sometimes undesirable brain chemistry might be a part of the default physiology of the individual.
I think "treating depression" as a framework for dealing with personal problems can be counter productive. For example, sleep quality can affect depression, but if I try to make improvements in my sleeping and see no discernable impact on my depression I am likely to give up and try something else. Instead, if I try to improve my sleep quality independent of any effect on depression I am more likely to be successful. Thinking this way allowed me to actually make a serial set of improvements*, at the end of which I can look back and say "I am less depressed than I was by a large degree" even when individual changes didn't seem impactful.
*Sleep, diet, exercise, socializing, motivation
Edit: I phrased this comment poorly. I am in fact speaking about my own experience and not a hypothetical person.
When it comes to depression, I think it's important to note that it's a symptom and no condition.
Hitting someone on a head in a way that produces a trauma often causes symptoms of depression. That depression might have a completely different optimal treatment method than depression caused by a more psychological issue.
A gluten insensitivity can also produce depressive symptoms.
A gluten insensitivity can also produce depressive symptoms.
Interesting. Do you have references for this?
Unfortunately it's knowledge that I acquired orally.
I quick googling for signs of gluten insensitivity however reveals:
So you're feeling tired and headachy, and your digestive system is off (and has been for what seems like forever). Maybe you have some other symptoms: a rash, dandruff, a feeling that you're operating in a depressed and disorganized manner, or are just in a fog.
Mayo clinic writes:
Wheat sensitivity symptoms also may include headaches, rashes, "brain fog," or fatigue.
They don't use the word depression but I think a person who happens to have those symptoms scores on the Hamilton scale.
Okay, thanks! I'll probably check into it further myself. I've trained myself to be skeptical of gluten-related claims, only cause it's become the placebo of choice in some circles recently. This sounds pretty plausible, though.
but this may reflect insufficient commitment on the part of patients who were assigned to use self-help CBT materials.
So? If I'm trying to get over depression, I just want to know if that method works. Not if failure can somehow be attributed to me.
This is not exactly true. If it is difficult to motivate yourself to do something, this is a massive problem of the intervention as motivation is exactly the thing depressed people lack.
My thinking was that you can choose to be one of the people who is sufficiently committed, though I acknowledge that this may not be realistic. I just added "If you're sufficiently committed, the expected benefits that you stand to gain from self-help CBT."
I interpreted that bit as "If you're the kind of person who is able to do this kind of thing, then self-administered CBT is a great idea."
Any given treatment of depression only works for a fraction of depressed people, suggesting that causes of depression may be diverse.
Has there been a study of correlations? What I am aware of is that many studies report quite high failiure rates but I don't know of any study that tries to asses if success or failiure of treatment A predicts success with treatment B. This could give a hint to the nature of depression.
Talk therapy
The mere fact that there is no difference in effect of any one technique or the other is massive evidence that it is not the technique that is benefit but something else, like simply sharing feelings with a person.
The mere fact that there is no difference in effect of any one technique or the other is massive evidence that it is not the technique that is benefit but something else, like simply sharing feelings with a person.
False. It is evidence the difference between talk therapy and CBT is largely philosophical.
The various "types" of therapy liberally steal from each other what works. For example, in treating phobias, CBT methods are so obviously beneficial that the users of other techniques would be utter fools not use them. Therapists sometimes modify and often rename what they steal - schema therapy, for example, is a CBTish rebranding of classical psychodynamic methods. And so on.
I do think simply sharing feelings (and especially the effort of putting feelings into words) does much, maybe even most, of the good. But the lack of difference in the effect of techniques is not evidence of that.
I do think simply sharing feelings (and especially the effort of putting feelings into words) does much, maybe even most, of the good.
For my own part, I think paying attention to feelings (and more generally to mental and physical states) does most of the good of this sort of therapy. But yeah, talking about stuff explicitly is one of the more reliable ways most people have of directing their attention.
Has there been a study of correlations? What I am aware of is that many studies report quite high failiure rates but I don't know of any study that tries to asses if success or failiure of treatment A predicts success with treatment B. This could give a hint to the nature of depression.
This is a very good question that I don't know the answer to. Anecdotally, it seems that people try X, find that it doesn't work, then try Y, and find that it does work.
The mere fact that there is no difference in effect of any one technique or the other is massive evidence that it is not the technique that is benefit but something else, like simply sharing feelings with a person.
One would have to look at the details regarding what's meant by "no difference in effect." It could be that the error bars around the effect size of each are really large and overlap to such an extent that there's a ~50% chance that intervention X is better and a ~50% chance that intervention Y is better, and that this gets labelled "no difference in effect" even though it could be that there's a big difference in actual effect size.
The main downside to exercise is that it takes time, but it may be worth it even if the effect size is small if alleviating depression is sufficiently high priority for you.
...Not to mention that it's worth it for benefits outside of treating depression (e.g., physical health).
This understates the capacity for anti-depressants to reduce depression, because placebo treatment is also better than no treatment, and if one antidepressant doesn't work, you can try another one.
I'm not really sure whether that the case. Don't work often doesn't mean that it shows no effect. If you eat a vegetarian diet you will feel different. Different enough that all sorts of people think that becoming a vegetarian will cure all your problems.
Deciding whether the kind of mental state that you get through a anti-depressent is really better is a nontrival task.
Deciding whether the kind of mental state that you get through a anti-depressent is really better is a nontrival task.
Can you flesh this out?
I wrote an article listing the evidence for 54 suggested strategies for increasing happiness.
http://happierhuman.com/how-to-be-happy/
In general, my writing is more enthusiastic than the evidence would call for, but alas I must excite my readers and get the pageviews. My interpretation is that although some of the studies (e.g. keeping a gratitude journal improves symptoms of depression) may be flawed, follow 10 of them at the same time, and you'll likely have included something that works. No smoking guns, of course.
The majority of the things you name as most effective are basically impossible to implement for a seriously depressed person.
'my writing is more enthusiastic than the evidence would call for, but alas I must excite my readers and get the pageviews'
For my money, that's just contemptible. And there's no 'must' about it: you can, and probably should, stop doing that, even if it means you get less pageviews.
If you're interested in supplements w/ less comprehensive scientific support, here's examine.com's depression page (see also). I found inositol to be somewhat efficacious. Someone sent me this depression interventions spreadsheet that has some ideas you didn't discuss like folate supplementation. (Edit: It seems as though some people have genetic conditions that make folate absorption difficult or impossible for them. Note that you'd expect that these people would therefore be especially likely to become depressed from "folate deficiency" (ie folate malabsorption). So maybe take a highly bioavailable form of folate.) There's discussion in this thread about low-dose lithium decreasing the frequency of suicide. I just noticed that some of the amazon.com reviews for lithium are very positive on it decreasing depression.
Edit: I created a find someone to talk to thread.
Apart from peer reviewed research it also useful to know what other people consider helpful. CureTogether has a infografic that list various treatment methods: http://curetogether.com/depression/ig/treatment-effectiveness-vs-popularity
Out of them having a pet is considered by a lot of people a highly effective way to treat depression. I don't think there a cochrane review on it, but I think if you are a lonely nerd who suffers from depression getting a pet might be a very smart move. The pet gives you company in a way that make you feel less alone. Dogs happen to like their owners even if the owner is extremely poor social skills.
Strikes me as pretty risky, though. If it doesn't work, you're still stuck with an animal to care for, which can be difficult if you're really motivation-sapped and have trouble doing anything. This is especially problematic for high-maintenance pets like dogs.
If it doesn't work, you're still stuck with an animal to care for, which can be difficult if you're really motivation-sapped and have trouble doing anything.
Having something to care for creates motivation. A dog will bug you if you don't care enough for him and if he's stronger willed than you are, he just might get you to take action instead of doing nothing by looking at you with a sad face.
It easy to give your friends an excuse why you want to stay at home. When you however have a dog who looks at you and expects you to care for it the dog won't take any bullshit excuses.
It also an animal. Having a dog die because you don't care enough for it is tragic but less tragic than committing suicide because you took the wrong antidepressant.
If you really fail to develop a relationship with the animal you can also give it away.
Also, pets trigger oxytocin release.
A dog usually also "forces" you to exercise moderately by walking it and exercising while depressed is notoriously difficult to follow through on.
I vaguely remember reading a study that found talking to your dog gave the same result as talking to a therapist, (indicating that talking is more important than having someone listen) but I can't find the link at the moment, maybe I misremember.
Owning a dog is not the only option either, I have fairly regularly lent out some of mine to friends and family going through a rough patch with good results.
I suspect it depends on severity and cause though. If the depression is bad enough you may need chemicals just to get you to a level where you can benefit from other treatment.
Dog library needs to be a thing. Looking around on google it seems this program exists in some places.
"Keeping busy" is based mainly on my personal experience and from what I've heard other people say. But in the book Flow: The Psychology of Optimal Experience (which I didn't cite because I assume you're familiar with it), it's suggested based on self-reports on subjective wellbeing that people are, on average, happier while at work than they are in their leisure time - even though they don't feel as if this is the case.
In Stumbling on Happiness, Daniel Gilbert also suggests that when making decisions about the future, we rely on our own speculations of how we'll feel less than on the reviews of those with experience. This isn't a way of treating depression as much as it is a way of making decisions better at keeping our future selves happy.
I tend to disagree with the idea that a depressed individual should seek flow activities.
Indeed, when I raised up the notion of Flow with my therapist (treatment for depressed moods and anxiety), she was familiar with it but observed that the basic elements of flow : concentration, accurate and adaptive sense of challenge, internal motivation... were the first victims of depression and that I should not expect to get into flow states before I got those back !
Many people struggle with depression, and I've been trying to formulate some general advice for treating it as a part of my work for Cognito Mentoring. I'm hesitant to write about the subject on account of lacking professional expertise, and so am especially interested in getting feedback on my thinking on the subject. I've written up some tentative thoughts below. The reader being addressed is somebody who's struggling with depression, with a special focus on high school students.
The research on the efficacy of different depression treatments is only moderately strong. I'm not confident in my remarks below: they reflect an attempt to come to the best conclusion possible with the evidence available.
According to The empirical status of cognitive-behavioral therapy: A review of meta-analyses, there's a strong base of evidence that CBT has a large effect of reducing depression on average. There's evidence that the benefits extend beyond the duration of the treatment. Studies generally seem to show that CBT is as effective as antidepressants at reducing depression (some find that CBT is more effective, but the evidence is unclear).
CBT has the advantage that one can learn to do the exercises on one's own, without the expense of a therapist or a psychiatrist. The evidence for the efficacy of self-help CBT materials is weaker than the evidence for the efficacy of therapist-administered CBT, but this may reflect insufficient commitment on the part of patients who were assigned to use self-help CBT materials. The clinical effectiveness of CBT-based guided self-help interventions for anxiety and depressive disorders: A systematic review finds that for self-selected users of self-help CBT materials, the treatment was efficacious (though the quality of the studies was not high). If you're sufficiently committed, the expected benefits that you stand to gain from self-help CBT may be enhanced substantially.
A book for learning CBT on your own is Feeling Good: The New Mood Therapy by David Burns.
It's widely believed that exercise alleviates depression. There's an intuitive basis for thinking this: exercise often gives one a runner's high.
In the Cochrane review Exercise for depression, the authors find that on average, studies show a moderate-sized effect, but that when one restricts consideration to the highest quality studies, one sees a significantly smaller effect, suggesting that the efficacy of exercise for treating depression may be overstated.
The main downside to exercise is that it takes time, but it may be worth it even if the effect size is small if alleviating depression is sufficiently high priority for you.
Talk therapy has been shown to reduce depression on average. However:
House of Cards by Robyn Dawes argues that there's no evidence that licensed therapists are better at performing therapy than minimally trained laypeople. The evidence therein raises the possibility that one can derive the benefits of seeing a therapist from talking to a friend.
This requires that one has a friend who
Some reasons to think that talking with a friend may not carry the full benefits of talking with a therapist are
Depending on the friend and on the nature of help that you need, these factors may be non-issues, but they're worth considering when deciding between seeing a therapist and talking with a friend.
If your depression is seasonal in nature, you may benefit from light therapy. According to The Efficacy of Light Therapy in the Treatment of Mood Disorders: A Review and Meta-Analysis of the Evidence
Randomized, controlled trials suggests that bright light treatment and dawn simulation for seasonal affective disorder and bright light for nonseasonal depression are efficacious, with effect sizes equivalent to those in most antidepressant pharmacotherapy trials.
The Cochrane review Light therapy for non-seasonal depression finds that even for non-seasonal depression, light therapy reduces depression on average, though the effect is modest.
The Cochrane review Newer generation antidepressants for depressive disorders in children and adolescents found that antidepressants increased recover rates from 38.0% to 44.8% (over a specified duration) relative to a placebo. This understates the capacity for anti-depressants to reduce depression, because placebo treatment is also better than no treatment, and if one antidepressant doesn't work, you can try another one.
If you're an adolescent, the case for using an antidepressant is weakened by the fact that antidepressants are thought to increase the risk of suicide in adolescents. Some evidence for this comes from the Cochrane review above, which found that antidepressants increased suicide rates by 58%. The Food and Drug Administration requires that manufacturers of antidepressants include a warning that antidepressants can increase the risk of suicide in children, adolescents and adults under age 25. See antidepressants and suicide risk for more information. The size of the increased risk in "absolute" terms varies from person to person, because some people are more likely to commit suicide than others. But in a given case, the increased risk of suicide may not be worth the potential benefits.
If you're under 25 years old, particularly if you're an adolescent, it seems reasonable to try other methods of treatment before considering antidepressants.