What is the National Board for Certified Counsellors?


The National Board for Certified Counsellors, Inc. and Affiliates (NBCC) is an international certifying organisation for professional counsellors in the United States. It is an independent, not-for-profit credentialing organisation based in Greensboro, North Carolina. The purpose of the organisation is to establish and monitor a national certification system for professional counsellors, to identify certified counsellors, and to maintain a register of them.

NBCC has more than 66,000 certified counsellors across the US and in more than 40 countries. Its examinations for professional counsellors are used by all 50 states, the District of Columbia and Puerto Rico to license counsellors.

Brief History

In December 1979, the American Personnel and Guidance Association (APGA) Board of Directors approved a plan to create a generic counsellor certification registry. In February 1982, the APGA President chose the members of the first NBCC Board, and the board’s first meeting was in April 1982. In July 1982, NBCC was incorporated as a not-for-profit entity separate from APGA. The separation ensured an unbiased certification process and an assumption of liability on the part of NBCC.

The NBCC established and now monitors a national certification system, to identify for professionals and the public those counsellors who have voluntarily sought and obtained certification. Unlike other professional mental health entities such as the American Counselling Association (ACA), the American Psychological Association (APA), and the Association for Counsellor Education and Supervision (ACES), NBCC does not have members. Instead, NBCC sets its own policies and procedures for national certification in professional counselling, administers the National Counsellor Examination to applicants, and keeps a register of counsellors who achieve certification.

Since 2001, NBCC has worked to pass legislation adding licensed professional counsellors (LPC) and marriage and family therapists (MFT) to Medicare. Medicare is the largest health care programme in the United States and currently recognises psychiatrists, psychologists, clinical social workers and psychiatric nurses for outpatient mental health services, but does not reimburse LPCs or MFTs for behavioural health services. As a result, a client who sees an LPC or MFT has to immediately cease therapy at the age of 65, when the government mandates that they must leave their health insurance to enrol in Medicare. NBCC believes that this Medicare exclusion of LPCs and MFTs should be removed, because they can play an important role in a functioning mental health system by maximising the capacity of the behavioural health workforce.


The certification programme recognises counsellors who have met predetermined standards in their training, experience, and performance on the National Counsellor Examination for Licensure and Certification (NCE).

National Certified Counsellor (NCC)

NBCC’s flagship certification is the National Certified Counsellor (NCC). The NCC is a generic certification for professional counsellors and does not designate a particular specialty area. Holding an NCC indicates that a counsellor is nationally board certified. There are currently over 63,000 NCCs in the US and many other countries.

The current requirements to become an NCC include:

  • A graduate degree in counselling (or one with a major in counselling) from a regionally accredited college or university.
  • At least 48 semester hours of graduate-level coursework, including at least one course in each of nine specified areas, as well as at least six semester hours of supervised field experience.
  • At least 3,000 hours of post-master’s counselling experience in an applied setting over a minimum of 24 months, 100 of which must be supervised by a qualified supervisor.
  • A passing score on the associated National Counsellor Exam (NCE).

After 01 January 2022, NCC applicants will be required to have a degree from a counsellor education programme accredited by the Council for Accreditation of Counselling and Related Educational Programmes (CACREP), which includes a minimum of 60 semester hours of coursework.

The NCC is the board certification for counsellors. It is not required for supervised or independent practice; it identifies counsellors who have voluntarily sought and met established professional standards, and who continue to fulfil requirements governing continuing education credits and certification renewal. Certification is not a substitute for state-mandated licensure. However, many states use the NCE examination as part of their licensing requirements.

Specialty Certifications

In addition to the NCC, NBCC administers three specialty certifications that each have the NCC credential as a prerequisite, along with other requirements.

  • Certified Clinical Mental Health Counsellor (CCMHC).
  • Master Addictions Counsellor (MAC).
  • National Certified School Counsellor (NCSC).

Affiliates and Divisions

Since its establishment in 1982, NBCC has expanded to include:

  • The Centre for Credentialing & Education (CCE):
    • Created in 1995, CCE provides practitioners and organisations with assessments, business support services, and credentialing in a variety of fields, including counselling supervision, coaching, distance counselling, and human services.
    • CCE manages the Mental Health Facilitator (MHF) programme, which educates community members and leaders in providing basic mental health care and resources to their neighbours, especially in locations where mental health care is difficult to access.
  • NBCC International (NBCC-I):
    • Created in 2003, NBCC-I’s purpose is to promote the counselling profession worldwide.
    • With a focus on cultural sensitivity and understanding, as well as public awareness of the meaning of quality in professional counselling, NBCC-I offers programmes and institutes all over the world. NBCC-I also manages the international portion of the MHF programme.
  • The NBCC Foundation (NBCCF):
    • Created in 2005, NBCCF uses scholarships, fellowships, and capacity-building grants to encourage counsellors and counsellors-in-training to pursue careers as professional counsellors serving high-priority populations.
    • Increasing access to mental health care in rural, military, and minority communities is a major focus for NBCCF.
  • The European Board for Certified Counsellors (EBCC):
    • Created in 2010, EBCC is the hub for NBCC-I’s work in Europe.
    • EBCC provides support for European countries that are developing their own professional counselling efforts.
  • The Professional Counsellor (TPC):
    • Published by NBCC since 2011, TPC is a peer-reviewed, open-access, academic journal.
    • It is published online in a continuous format, and covers a wide range of topics including: mental and behavioural health counselling; school counselling; career counselling; couple, marriage, and family counselling; counselling supervision; theory development; professional counselling ethics; international counselling and multicultural issues; programme applications; and integrative reviews from counselling and related fields.

Mental Health Inequalities in Non-Heterosexuals & Heterosexuals

Research Paper Title

The mental health of lesbian, gay, and bisexual adults compared with heterosexual adults: results of two nationally representative English household probability samples.


Evidence on inequalities in mental health in lesbian, gay, and bisexual people arises primarily from non-random samples.

The aim of this study was to use a probability sample to study change in mental health inequalities between two survey points, 7 years apart; the contribution of minority stress; and whether associations vary by age, gender, childhood sexual abuse, and religious identification.


The researchers analysed data from 10 443 people, in two English population-based surveys (2007 and 2014), on common mental disorder (CMD), hazardous alcohol use, and illicit drug use. Multivariable models were adjusted for age, gender, and economic factors, adding interaction terms for survey year, age, gender, childhood sexual abuse, and religious identification. They explored bullying and discrimination as mediators.


Inequalities in risks of CMD or substance misuse were unchanged between 2007 and 2014. Compared to heterosexuals, bisexual, and lesbian/gay people were more likely to have CMD, particularly bisexual people [adjusted odds ratio (AOR) = 2.86; 95% CI 1.83-4.46], and to report alcohol misuse and illicit drug use. When adjusted for bullying, odds of CMD remained elevated only for bisexual people (AOR = 3.21; 95% CI 1.64-6.30), whilst odds of alcohol and drug misuse were unchanged. When adjusted for discrimination, odds of CMD and alcohol misuse remained elevated only for bisexual people (AOR = 2.91; 95% CI 1.80-4.72; and AOR = 1.63; 95% CI 1.03-2.57 respectively), whilst odds of illicit drug use remained unchanged. There were no interactions with age, gender, childhood sexual abuse, or religious identification.


Mental health inequalities in non-heterosexuals have not narrowed, despite increasing societal acceptance. Bullying and discrimination may help explain the elevated rate of CMD in lesbian women and gay men but not in bisexual people.


Pitman, A., Marston, L., Lewis, G., Semlyen, J., McManus, S. & King, M. (2021) The mental health of lesbian, gay, and bisexual adults compared with heterosexual adults: results of two nationally representative English household probability samples. Psychological Medicine. doi: 10.1017/S0033291721000052. Online ahead of print.

On This Day … 01 March


  • Self-injury Awareness Day.
  • Zero Discrimination Day.

Self-Injury Awareness Day

Self-injury Awareness Day (SIAD) (also known as Self-Harm Awareness Day) is a grassroots annual global awareness event/campaign on 01 March, where on this day, and in the weeks leading up to it and after, some people choose to be more open about their own self-harm, and awareness organisations make special efforts to raise awareness about self-harm and self-injury. Some people wear an orange awareness ribbon, write “LOVE” on their arms, draw a butterfly on their wrists in awareness of “the Butterfly Project” wristband or beaded bracelet to encourage awareness of self-harm. The goal of the people who observe SIAD is to break down the common stereotypes surrounding self-harm and to educate medical professionals about the condition.


Depression and self-harm often go hand-in-hand, though there are many other reasons people self-harm. As many as two million Americans currently engage in self-harm, with methods like cutting, scratching, bruising, and hitting themselves, along with other more harmful methods. It’s said that these behaviours promote feelings of control and help relieve tension, while helping the person express their emotions and escape the numbness that accompanies depression.

SIAD was created to spread awareness and understanding of self-injury, which is often misrepresented and misunderstood in the mainstream. Those who self-harm are often left feeling alone and afraid to reach out for help because they fear they’ll be seen as “crazy.”

Participating Organisations

Many organizations are now getting involved in SIAD. Some of them include:

  • Sociedad Internacional de Autolesión.
  • LifeSIGNS (Self-Injury Guidance & Network Support).
  • Self-Injury Foundation.
  • YoungMinds.
  • ChildLine.
  • The Mix.
  • Adolescent Self-Injury Foundation.
  • Cars for Hope.

Zero Discrimination Day

Zero Discrimination Day is an annual day celebrated by the United Nations (UN) and other international organisations. The day aims to promote equality before the law and in practice throughout all of the member countries of the UN. The day was first celebrated on 01 March 2014, and was launched by UNAIDS Executive Director Michel Sidibé on 27 February of that year with a major event in Beijing.

In February 2017, UNAIDS called on people to “make some noise around zero discrimination, to speak up and prevent discrimination from standing in the way of achieving ambitions, goals and dreams.”

The day is particularly noted by organisations like UNAIDS that combat discrimination against people living with HIV/AIDS. “HIV related stigma and discrimination is pervasive and exists in almost every part of the world including our Liberia”, according to Dr. Ivan F. Camanor, Chairman of the National AIDS Commission of Liberia. The UN Development Programme also paid tribute in 2017 to LGBTI people with HIV/AIDS who face discrimination.

Campaigners in India have used this day to speak out against laws making discrimination against the LGBTI community more likely, especially during the previous campaign to repeal the law (Indian Penal Code, s377) that used to criminalise homosexuality in that country, before that law was overturned by the Indian Supreme Court in September 2018.

In 2015, Armenian Americans in California held a ‘die-in’ on Zero Discrimination Day to remember the victims of the Armenian Genocide.

On This Day … 27 February

People (Births)

People (Deaths)

  • 2012 – Tina Strobos, Dutch physician and psychiatrist (b. 1920).

Roberto Assagioli

Roberto Assagioli (27 February 1888 to 23 August 1974) was an Italian psychiatrist and pioneer in the fields of humanistic and transpersonal psychology. Assagioli founded the psychological movement known as psychosynthesis, which is still being developed today by therapists and psychologists, who practice the psychological methods and techniques he developed. His work, expounded in two books and many monographs published as pamphlets, emphasized the possibility of progressive integration, or synthesis, of the personality.

Assagioli received his first degree in neurology and psychiatry at Istituto di Studii Superiori Pratici e di Perfezionamento, in Florence in 1910. It was during this time he began writing articles that criticised psychoanalysis in which Assagioli argued a more holistic approach.

Once he finished his studies in Italy, Assagioli went to Switzerland, where he was trained in psychiatry at the psychiatric hospital Burghölzli in Zürich. This led to him opening the first psychoanalytic practice in Italy, known as Istituto di Psicosintesi. However, his work in psychoanalysis left him unsatisfied with the field of psychiatry; as a whole, as he felt that psychoanalysis was incomplete.

Tina Strobos

Tina Strobos, née Tineke Buchter (19 May 1920 to 27 February 2012), was a Dutch physician and psychiatrist from Amsterdam, known for her resistance work during World War II. While a young medical student, she worked with her mother and grandmother to rescue more than 100 Jewish refugees as part of the Dutch resistance during the Nazi occupation of the Netherlands. Strobos provided her house as a hiding place for Jews on the run, using a secret attic compartment and warning bell system to keep them safe from sudden police raids. In addition, Strobos smuggled guns and radios for the resistance and forged passports to help refugees escape the country. Despite being arrested and interrogated nine times by the Gestapo, she never betrayed the whereabouts of a Jew.

After the war, Strobos completed her medical degree and became a psychiatrist. She studied under Anna Freud in England. Strobos later emigrated to the United States to study psychiatry under a Fulbright scholarship, and she subsequently settled in New York. She married twice and had three children. Strobos built a career as a family psychiatrist, receiving the Elizabeth Blackwell Medal in 1998 for her medical work, and finally retired from active practice in 2009.

In 1989, Strobos was honoured as Righteous Among the Nations by Yad Vashem for her rescue work. In 2009, she was recognised for her efforts by the Holocaust and Human Rights Education Centre of New York City.

What is a Major Depressive Episode?


A major depressive episode (MDE) is a period characterised by the symptoms of major depressive disorder.

Sufferers primarily have a depressed mood for two weeks or more, and a loss of interest or pleasure in everyday activities, accompanied by other symptoms such as feelings of emptiness, hopelessness, anxiety, worthlessness, guilt and irritability, changes in appetite, problems concentrating, remembering details or making decisions, and thoughts of suicide. Insomnia or hypersomnia, aches, pains, or digestive problems that are resistant to treatment may also be present. The description has been formalized in psychiatric diagnostic criteria such as the DSM-5 and ICD-10.

Biological, psychological, and social factors are believed to be involved in the cause of depression, although it is still not well understood. Factors like socioeconomic status, life experience, and personality tendencies play a role in the development of depression and may represent increases in risk for developing a MDE. There are many theories as to how depression occurs. One interpretation is that neurotransmitters in the brain are out of balance, and this results in feelings of worthlessness and despair. Magnetic resonance imaging shows that brains of people who have depression look different than the brains of people not exhibiting signs of depression. A family history of depression increases the chance of being diagnosed.

Emotional pain and economic costs are associated with depression. In the United States and Canada, the costs associated with major depression are comparable to those related to heart disease, diabetes, and back problems and are greater than the costs of hypertension. According to the Nordic Journal of Psychiatry, there is a direct correlation between major depressive episode and unemployment.

Treatments for a major depressive episode include psychotherapy and antidepressants, although in more serious cases, hospitalization or intensive outpatient treatment may be required.

Signs and Symptoms

The criteria below are based on the formal DSM-V criteria for a major depressive episode. A diagnosis of major depressive episode requires that the patient has experienced five or more of the symptoms below, and one of the symptoms must be either depressed mood or loss of interest or pleasure (although both are frequently present). These symptoms must be present for at least 2 weeks and represent a change from the patient’s normal behaviour.

Depressed Mood and Loss of Interest (Anhedonia)

Either depressed mood or a loss of interest or pleasure must be present for the diagnosis of a MDE. Depressed mood is the most common symptom seen in major depressive episodes. Interest or pleasure in everyday activities can be decreased; this is referred to as anhedonia. These feelings must be present on an everyday basis for two weeks or longer to meet DSM-V criteria for a MDE. In addition, the person may experience one or more of the following emotions: sadness, emptiness, hopelessness, indifference, anxiety, tearfulness, pessimism, emotional numbness, or irritability. In children and adolescents, a depressed mood often appears more irritable in nature. There may be a loss of interest in or desire for sex, or other activities once found to be pleasant. Friends and family of the depressed person may notice that they have withdrawn from friends, or neglected or quit doing activities that were once a source of enjoyment.


Nearly every day, the person may sleep excessively, known as hypersomnia, or not enough, known as insomnia. Insomnia is the most common type of sleep disturbance for people who are clinically depressed. Symptoms of insomnia include trouble falling asleep, trouble staying asleep, or waking up too early in the morning. Hypersomnia is a less common type of sleep disturbance. It may include sleeping for prolonged periods at night or increased sleeping during the daytime. The sleep may not be restful, and the person may feel sluggish despite many hours of sleep, which may amplify their depressive symptoms and interfere with other aspects of their lives. Hypersomnia is often associated with an atypical depression, as well as seasonal affective disorder.

Feelings of Guilt or Worthlessness

Depressed people may have feelings of guilt that go beyond a normal level or are delusional. These feelings of guilt and/or worthlessness are excessive and inappropriate. MDE’s are notable for a significant, often unrealistic, drop in self-esteem. The guilt and worthlessness experienced in a MDE can range from subtle feelings of guilt to frank delusions or to shame and humiliation. Additionally, self-loathing is common in clinical depression, and can lead to a downward spiral when combined with other symptoms.

Loss of Energy

Persons going through a MDE often have a general lack of energy, as well as fatigue and tiredness, nearly every day for at least 2 weeks. A person may feel tired without having engaged in any physical activity, and day-to-day tasks become increasingly difficult. Job tasks or housework become very tiring, and the patient finds that their work begins to suffer.

Decreased Concentration

Nearly every day, the person may be indecisive or have trouble thinking or concentrating. These issues cause significant difficulty in functioning for those involved in intellectually demanding activities, such as school and work, especially in difficult fields. Depressed people often describe a slowing of thought, inability to concentrate and make decisions, and being easily distracted. In the elderly, the decreased concentration caused by a MDE may present as deficits in memory. This is referred to as pseudodementia and often goes away with treatment. Decreased concentration may be reported by the patient or observed by others.

Change in Eating, Appetite, or Weight

In a major depressive episode, appetite is most often decreased, although a small percentage of people experience an increase in appetite. A person experiencing a depressive episode may have a marked loss or gain of weight (5% of their body weight in one month). A decrease in appetite may result in weight loss that is unintentional or when a person is not dieting. Some people experience an increase in appetite and may gain significant amounts of weight. They may crave certain types of food, such as sweets or carbohydrates. In children, failure to make expected weight gains may be counted towards this criteria. Overeating is often associated with atypical depression.

Motor Activity

Nearly every day, others may see that the person’s activity level is not normal. People suffering from depression may be overly active (psychomotor agitation) or be very lethargic (psychomotor retardation). Psychomotor agitation is marked by an increase in body activity which may result in restlessness, an inability to sit still, pacing, hand wringing, or fidgeting with clothes or objects. Psychomotor retardation results in a decrease in body activity or thinking. In this case, a depressed person may demonstrate a slowing of thinking, speaking, or body movement. They may speak more softly or say less than usual. To meet diagnostic criteria, changes in motor activity must be so abnormal that it can be observed by others. Personal reports of feeling restless or feeling slow do not count towards the diagnostic criteria.

Thoughts of Death and Suicide

A person going through a MDE may have repeated thoughts about death (other than the fear of dying) or suicide (with or without a plan), or may have made a suicide attempt. The frequency and intensity of thoughts about suicide can range from believing that friends and family would be better off if one were dead, to frequent thoughts about committing suicide (generally related to wishing to stop the emotional pain), to detailed plans about how the suicide would be carried out. Those who are more severely suicidal may have made specific plans and decided upon a day and location for the suicide attempt.

Comorbid Disorders

MDE’s may show comorbidity (association) with other physical and mental health problems. About 20-25% of individuals with a chronic general medical condition will develop major depression. Common comorbid disorders include: eating disorders, substance-related disorders, panic disorder, and obsessive-compulsive disorder. Up to 25% of people who experience a major depressive episode have a pre-existing dysthymic disorder.

Some persons who have a fatal illness or are at the end of their life may experience depression, although this is not universal.


The cause of a MDE is not well understood. However, the mechanism is believed to be a combination of biological, psychological, and social factors. A MDE can often follow an acute stress in someone’s life. Evidence suggests that psychosocial stressors play a larger role in the first 1-2 depressive episodes, while having less influence in later episodes. People who experience a major depressive episode often have other mental health issues.

Other risk factors for a depressive episode include:

  • Family history of a mood disorder;
  • Recent negative life events;
  • Personality (insecure, worried, stress-sensitive, obsessive, unassertive, dependent);
  • Early childhood trauma;
  • Postpartum; and
  • Lack of interpersonal relationships.

One gene by itself has not been linked to depression. Studies show that depression can be passed down in families, but this is believed to be due to a combined effect of genetic and environmental factors. Other medical conditions, like hypothyroidism for example, may cause someone to experience similar symptoms as a MDE, however this would be considered a mood disorder due to a general medical condition, according to the DSM-V.



The two main symptoms in a major depressive episode are a depressed mood or a loss of interest or pleasure. From the list below, one bold symptom and four other symptoms must be present for a diagnosis of MDE. These symptoms must be present for at least 2 weeks and must be causing significant distress or impairment in functioning.

  • Depressed mood.
  • Loss of interest or pleasure.
  • Change in appetite.
  • Change in sleep.
  • Change in body activity (psychomotor changes).
  • Loss of energy.
  • Feelings of worthlessness and excessive or inappropriate guilt.
  • Indecisiveness or a decrease in concentration.
  • Suicidal ideation.

To diagnose a major depressive episode, a trained healthcare provider must make sure that:

  • The symptoms do not meet the criteria for a mixed episode.
  • The symptoms must cause considerable distress or impair functioning at work, in social settings or in other important areas in order to qualify as an episode.
  • The symptoms are not due to the direct physiological effects of a substance (e.g. abuse of a drug or medication) or a general medical condition (e.g. hypothyroidism).


No labs are diagnostic of a depressive episode. But some labs can help rule out general medical conditions that may mimic the symptoms of a depressive episode. Healthcare providers may order some routine blood work, including routine blood chemistry, CBC with differential, thyroid function studies, and Vitamin B12 levels, before making a diagnosis.

Differential Diagnosis

There are other mental health disorders or medical conditions to consider before diagnosing a MDE:

  • Bipolar disorder.
  • Cyclothymic disorder.
  • Disruptive mood dysregulation disorder.
  • Persistent depressive disorder.
  • Anxiety disorder (Generalised anxiety, PTSD, obsessive compulsive disorder).
  • Substance abuse or Substance Use Disorder.
  • Personality disorder with depressive symptoms.
  • Adjustment disorder.
  • Depression due to a general medical condition.
  • Premenstrual dysphoric disorder.


Healthcare providers may screen patients in the general population for depression using a screening tool, such as the Patient Healthcare Questionnaire-2 (PHQ-2). If the PHQ-2 screening is positive for depression, a provider may then administer the PHQ-9. The Geriatric Depression Scale is a screening tool that can be used in the elderly population.


Depression is a treatable illness. Treatments for a MDE may be provided by mental health specialists (i.e. psychologist, psychiatrists, social workers, counsellors, etc.), mental health centres or organisations, hospitals, outpatient clinics, social service agencies, private clinics, peer support groups, clergy, and employee assistance programmes. The treatment plan could include psychotherapy alone, antidepressant medications alone, or a combination of medication and psychotherapy.

For major depressive episodes of severe intensity (multiple symptoms, minimal mood reactivity, severe functional impairment), combined psychotherapy and antidepressant medications are more effective than psychotherapy alone. Meta-analyses suggest that the combination of psychotherapy and antidepressant medications is more effective in treating mild and moderate forms of depression as well, compared to either type of treatment alone. Patients with severe symptoms may require outpatient treatment or hospitalisation.

The treatment of a major depressive episode can be split into 3 phases:

  • Acute phase: the goal of this phase is to resolve the current major depressive episode.
  • Continuation: this phase continues the same treatment from the acute phase for 4-8 months after the depressive episode has resolved and the goal is to prevent relapse.
  • Maintenance: this phase is not necessary for every patient but is often used for patients who have experienced 2-3 or more MDE’s.
    • Treatment may be maintained indefinitely to prevent the occurrence and severity of future episodes.


Psychotherapy, also known as talk therapy, counselling, or psychosocial therapy, is characterised by a patient talking about their condition and mental health issues with a trained therapist. Different types of psychotherapy are used as a treatment for depression. These include cognitive behavioural therapy, interpersonal therapy, dialectical behaviour therapy, acceptance and commitment therapy, and mindfulness techniques. Evidence shows that cognitive behavioural therapy can be as effective as medication in the treatment of a MDE.

Psychotherapy may be the first treatment used for mild to moderate depression, especially when psychosocial stressors are playing a large role. Psychotherapy alone may not be as effective for more severe forms of depression.

Some of the main forms of psychotherapies used for treatment of a major depressive episode along with what makes them unique are included below:

  • Cognitive psychotherapy: focus on patterns of thinking.
  • Interpersonal psychotherapy: focus on relationships, losses, and conflict resolution.
  • Problem-solving psychotherapy: focus on situations and strategies for problem-solving.
  • Psychodynamic psychotherapy: focus on defence mechanisms and coping strategies.


Medications used to treat depression include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), norepinephrine-dopamine reuptake inhibitors (NDRIs), tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and atypical antidepressants such as mirtazapine, which do not fit neatly into any of the other categories. Different antidepressants work better for different individuals. It is often necessary to try several before finding one that works best for a specific patient. Some people may find it necessary to combine medications, which could mean two antidepressants or an antipsychotic medication in addition to an antidepressant. If a person’s close relative has responded well to a certain medication, that treatment will likely work well for him or her. Antidepressant medications are effective in the acute, continuation, and maintenance phases of treatment, as described above.

The treatment benefits of antidepressant medications are often not seen until 1-2 weeks into treatment, with maximum benefits being reached around 4-6 weeks. Most healthcare providers will monitor patients more closely during the acute phase of treatment and continue to monitor at longer intervals in the continuation and maintenance phases.

Sometimes, people stop taking antidepressant medications due to side effects, although side effects often become less severe over time. Suddenly stopping treatment or missing several doses may cause withdrawal-like symptoms. Some studies have shown that antidepressants may increase short-term suicidal thoughts or actions, especially in children, adolescents, and young adults. However, antidepressants are more likely to reduce a person’s risk of suicide in the long run.

Below are listed the main classes of antidepressant medications, some of the most common drugs in each category, and their major side effects:

  • Selective serotonin reuptake inhibitors (citalopram, escitalopram, paroxetine, fluoxetine, sertraline): major side effects include nausea, diarrhoea, and sexual dysfunction.
  • Serotonin and norepinephrine reuptake inhibitors (duloxetine, venlafaxine, desvenlafaxine): major side effects include nausea, diarrhoea, increased heart rate, increased blood pressure, and tremor.
  • Tricyclic antidepressants (amitryptiline, desipramine, doxepin, imipramine, nortriptyline): major side effects include sedation, low blood pressure when moving from sitting to standing (orthostatic hypotension), tremor, and heart issues like conduction delays or arrhythmias.
  • Monoamine oxidase inhibitors (isocarboxazid, phenelzine, selegiline): major side effects include high blood pressure (emergency) if eaten with foods rich in tyramine (e.g. cheeses, some meats, and home-brewed beer), sedation, tremor, and orthostatic hypotension.

Alternative Treatments

There are several treatment options that exist for people who have experienced several episodes of major depression or have not responded to several treatments.

Electroconvulsive therapy is a treatment in which a generalised seizure is induced by means of electrical current. The mechanism of action of the treatment is not clearly understood but has been show to be most effective in the most severely depressed patients. For this reason, electroconvulsive therapy is preferred for the most severe forms of depression or depression that has not responded to other treatments, known as refractory depression.

Vagus nerve stimulation is another alternative treatment that has been proven to be effective in the treatment of depression, especially people that have been resistant to four or more treatments. Some of the unique benefits of vagus nerve stimulation include improved neurocognitive function and a sustained clinical response.

Transcranial magnetic stimulation is also an alternative treatment for a major depressive episode. It is a non-invasive treatment that is easily tolerated and shows an antidepressant effect, especially in more typical depression and younger adults.


If left untreated, a typical MDE may last for several months. About 20% of these episodes can last two years or more. About half of depressive episodes end spontaneously. However, even after the MDE is over, 20% to 30% of patients have residual symptoms, which can be distressing and associated with disability. 50% of people will have another major depressive episode after the first. However, the risk of relapse is decreased by taking antidepressant medications for more than 6 months.

Symptoms completely improve in six to eight weeks in 60%-70% of patients. The combination of therapy and antidepressant medications has been shown to improve resolution of symptoms and outcomes of treatment.

Suicide is the 8th leading cause of death in the United States. The risk of suicide is increased during a MDE. However, the risk is even more elevated during the first two phases of treatment. There are several factors associated with an increased risk of suicide, listed below:

  • Greater than 45 years of age;
  • Male;
  • History of suicide attempt or self-injurious behaviours;
  • Family history of suicide or mental illness;
  • Recent severe loss;
  • Poor health;
  • Detailed plan;
  • Inability to accept help;
  • Lack of social support
  • Psychotic features (auditory or visual hallucinations, disorganisation of speech, behaviour, or thought);
  • Alcohol or drug use or comorbid psychiatric disorder; and/or
  • Severe depression.


Estimates of the numbers of people suffering from MDE’s and major depressive disorder (MDD) vary significantly. Overall, 13-20% of people will experience significant depressive symptoms at some point in their life. The overall prevalence of MDD is slightly lower ranging from 3.7-6.7% of people. In their lifetime, 20% to 25% of women, and 7% to 12% of men will suffer a MDE. The peak period of development is between the ages of 25 and 44 years. Onset of major depressive episodes or MDD often occurs to people in their mid-20s, and less often to those over 65. The prevalence of depressive symptoms in the elderly is around 1-2%. Elderly persons in nursing homes may have increased rates, up to 15-25%. African-Americans have higher rates of depressive symptoms compared to other races. Prepubescent girls are affected at a slightly higher rate than prepubescent boys.

In a National Institute of Mental Health study, researchers found that more than 40% of people with post-traumatic stress disorder suffered from depression four months after the traumatic event they experienced.

Women who have recently given birth may be at increased risk for having a major depressive episode. This is referred to as postpartum depression and is a different health condition than the baby blues, a low mood that resolves within 10 days after delivery.

Adolescents, Depression & Low Income Countries

Research Paper Title

Mind the brain gap: The worldwide distribution of neuroimaging research on adolescent depression.


Adolescents comprise one fourth of the world’s population, with about 90% of them living in low- and middle-income countries (LMICs).

The incidence of depression markedly increases during adolescence, making the disorder a leading cause of disease-related disability in this age group.

However, most research on adolescent depression has been performed in high-income countries (HICs).


To ascertain the extent to which this disparity operates in neuroimaging research, a systematic review of the literature was performed.


A total of 148 studies were identified, with neuroimaging data available for 4,729 adolescents with depression.

When stratified by income group, 122 (82%) studies originated from HICs, while 26 (18%) were conducted in LMICs, for a total of 3,705 and 1,024 adolescents with depression respectively.

A positive Spearman rank correlation was observed between country per capita income and sample size (rs=0.673, p = 0.023).


The results support the previous reports showing a large disparity between the number of studies and the adolescent population per world region.

Future research comparing neuroimaging findings across populations from HICs and LMICs may provide unique insights to enhance our understanding of the neurobiological processes underlying the development of depression.


Battel, L., Cunegatto, F., Viduani, A., Fisher, H.L., Kohrt, B.A., Mondelli, V., Swartz, J.R. & Kieling, C. (2021) Mind the brain gap: The worldwide distribution of neuroimaging research on adolescent depression. Neuroimage. doi: 10.1016/j.neuroimage.2021.117865. Online ahead of print.

On This Day … 26 February

People (Births)

People (Deaths)

  • 1930 – Mary Whiton Calkins, American philosopher and psychologist (b. 1863).
  • 1969 – Karl Jaspers, German-Swiss psychiatrist and philosopher (b. 1883).

Emile Coue

Émile Coué de la Châtaigneraie (26 February 1857 to 02 July 1926) was a French psychologist and pharmacist who introduced a popular method of psychotherapy and self-improvement based on optimistic autosuggestion.

Considered by Charles Baudouin to represent a second Nancy School, Coué treated many patients in groups and free of charge.

Sandie Shaw

Sandie Shaw, MBE (born Sandra Ann Goodrich; 26 February 1947) is an English singer. One of the most successful British female singers of the 1960s, she had three UK number one singles with “(There’s) Always Something There to Remind Me” (1964), “Long Live Love” (1965) and “Puppet on a String” (1967). With “Puppet on a String”, she became the first British entry to win the Eurovision Song Contest. She returned to the UK top 40, for the first time in 15 years, with her 1984 cover of the Smiths song “Hand in Glove”. Shaw announced her retirement from the music industry in 2013.

Mary Whiton Calkins

Mary Whiton Calkins (30 March 1863 to 26 February 1930) was an American philosopher and psychologist. As a psychologist, she taught at Wellesley College for many years and conducted research on dreams and memory. Calkins was the first woman to become president of the American Psychological Association and the American Philosophical Association.

Karl Jaspers

Karl Theodor Jaspers 23 February 1883 to 26 February 1969) was a German-Swiss psychiatrist and philosopher who had a strong influence on modern theology, psychiatry, and philosophy. After being trained in and practicing psychiatry, Jaspers turned to philosophical inquiry and attempted to discover an innovative philosophical system. He was often viewed as a major exponent of existentialism in Germany, though he did not accept the label.

Book: A New Understanding of ADHD in Children and Adults

Book Title:

A New Understanding of ADHD in Children and Adults – Executive Function Impairments

Author(s): Thomas E. Brown.

Year: 2013.

Edition: First (1st).

Publisher: Routledge.

Type(s): Hardcover, Paperback, and eBook/Kindle.


For over 100 years, ADHD has been seen as essentially a behaviour disorder. Recent scientific research has developed a new paradigm which recognizes ADHD as a developmental disorder of the cognitive management system of the brain, its executive functions. This cutting-edge book pulls together key ideas of this new understanding of ADHD, explaining them and describing in understandable language scientific research that supports this new model. It addresses questions like:

  • Why can those with ADHD focus very well on some tasks while having great difficulty in focusing on other tasks they recognize as important?
  • How does brain development and functioning of persons with ADHD differ from others?
  • How do impairments of ADHD change from childhood through adolescence and in adulthood?
  • What treatments help to improve ADHD impairments? How do they work? Are they safe?
  • Why do those with ADHD have additional emotional, cognitive, and learning disorders more often than most others?
  • What commonly-held assumptions about ADHD have now been proven wrong by scientific research?

Psychiatrists, psychologists, social workers, and other medical and mental health professionals, as well as those affected by ADHD and their families, will find this to be am insightful and invaluable resource.

Book: Understanding, Diagnosing, and Treating ADHD in Children and Adolescents – An Integrative Approach

Book Title:

Understanding, Diagnosing, and Treating ADHD in Children and Adolescents – An Integrative Approach.

Author(s): James A. Incorvaia, Bonnie S. Mark-Goldstein, and Donald Tessmer (Editors).

Year: 1999.

Edition: First (1st).

Publisher: Jason Aronson, Inc.

Type(s): Hardcover and eBook.


When it comes to Attention Deficit/Hyperactivity Disorder, which is too often a cavalier diagnosis of first resort, clinicians can benefit from the range of responsible views on assessment and treatment proffered here. If doctors, therapists, and school personnel were to have only one resource to consult to fully understand AD/HD the problems and the solutions this collection of authoritative perspectives assembled by Doctors Incorvaia, Mark-Goldstein, and Tessmer should be it.

Book: The ADHD Parenting Handbook

Book Title:

The ADHD Parenting Handbook – Practical Advice for Parents from Parents.

Author(s): Colleen Alexander-Roberts.

Year: 2006.

Edition: Second (2nd).

Publisher: Taylor Trade Publishing.

Type(s): eBook/Kindle.


Practical advice for parents from parents, and proven techniques for raising hyperactive children without losing your temper.