Depression: Is Medication Really Necessary?

by Dr Gordon Wong, Specialist in Psychiatry

MBBS (HK), MRCPsych, FHKCPsych, FHKAM (Psychiatry), MSocSc (Couns)(South Australia), DCPsyc RCP&S (Irel), DFM (HKCFP), Dip Med (CUHK), PGDipClinDerm (QMUL)

Some years ago, I went on a hike with some friends. There was a guy who talked about how he did not believe people with depression should take medication. He believed that depression would be gone by going on a hike or watching a film. Unfortunately, over the years, I have heard several other people making the same comments. I would like to address this topic in this article.

For non pathological low mood or mild depression, going out more does in fact help to alleviate mood. This is called 'behavioural activation'. Do you recall a time when someone suggests going to the cinema, but you are not so keen? You go anyway, and you find yourself enjoying the film and the company so much? This is how behavioural activation works. Once an activity is set in motion, it gains momentum and helps with lifting the mood.

However, going out or doing more exercise does not work by itself on moderate or severe depression. In these cases, the neurotransmitters in the brain are not balanced, most commonly lacking in serotonin. The chemical imbalance does not normalise just by behavioural activation alone. Medication treatment is needed to help restore balance in the brain, giving you more space to breathe and cope with the demands of life.

There are many types of antidepressants, for example tricyclic antidepressants (such as amitriptyline), selective serotonin reuptake inhibitor (such as fluoxetine and sertraline), noradrenergic and specific serotonergic antidepressant (such as mirtazapine) and serotonin-norepinephrine reuptake inhibitor (such as venlafaxine). These medications have been shown to work, but they may not work for everybody. In case one particular type does not work for one person, doctors can always use another type of medication.

As for side effects, a web search almost always generate a scary list of side effects longer than a phone book. Fortunately, most of these side effects are very rare. If side effects occur, most of them are mild and tend to disappear after a few days of taking the medication. Remember to tell your doctor if side effects do occur, so the doctor can adjust the medication treatment plan accordingly.

Psychotherapy (talking therapies) are indicated for treatment of moderate depression, either by itself or in combination with medication treatment. There are many types of psychotherapies that are scientifically proven to be effective in treating depression, such as cognitive behavioural therapy, mindfulness, acceptance and commitment therapy and hypnotherapy.

For the most severe cases of depression, people may become psychotic. For example, I have encountered cases who deluded that their windpipes rotted and hence could not breathe (despite the fact that she was clearly breathing). Another woman believed that her intestines disappeared and hence she refused to eat, for fear of food clogging up in her chest. Another man hallucinated and saw flies and maggots in his food when there weren't any. In these severe cases, both medication treatments and psychological treatments are needed. Other treatments such as electroconvulsive therapy may be considered as well.

In summary, the treatment of depression depends on the severity of the depression. For mild cases, medication may not be needed, while for severe cases it is much needed. The above treatment methods are by no means exhaustive. Consult a professional for advice if you find yourself or people around you having symptoms of depression.