The following lifestyle changes have been shown to be efficacious in the treatment of depression:

* denotes lifestyle changes that have the best evidence of efficacy [11].

There is debate about whether patients with major depression should have pharmacologic therapy initiated in the emergency department. While over 60 % of prescriptions written for antidepressants are written by nonpsychiatrists [11], many emergency providers feel initiation of pharmacotherapy in the ED should only be carried out under the direction of a psychiatrist because of the significant risk of side effects, the long period of time before drugs become effective, and the lack of adequate follow-up.

However, there are some emergency providers who do not have access to an on-call psychiatric specialist and may want to initiate therapy in the emergency setting. When unsure about the need for initiation of pharmacotherapy, there are several decision aids which can be useful. One such aid is the PHQ-9 questionnaire which uses nine questions to come up with a score from 0 to 27 and gives the recommendation to initiate pharmacotherapy for any patient with a score equal to or greater than 15 [12].

When the decision is made to treat the patient, a second-generation antidepressant should be the first-line treatment. First-generation antidepressants (tricyclic antidepressants, monoamine oxidase inhibitors) and second-generation antidepressants (selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, and atypical antidepressants) have been shown to be equally effective, but the side effect profile and overall safety relating to possible overdose make second-generation antidepressants a better option in most cases. Emergency providers should be familiar with these medications and their side effects because depressed patients may ingest these drugs during suicide attempts.