How should I approach the management of an adult with mild to moderate depression who prefers psychological therapy over medication?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 16 August 2025Updated: 16 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

For an adult with mild to moderate depression who prefers psychological therapy over medication, the management approach should prioritise their preference within a stepped-care framework ,,.

  • Assessment and Shared Decision-Making:
    • First, confirm the severity of depression. Mild depression is defined as a PHQ-9 score less than 16, while moderate depression is a PHQ-9 score of 16 or more .
    • Develop a treatment plan based on shared decision-making, taking into account the person's wishes, previous treatment experiences, and expectations . Discuss potential benefits, harms, waiting times, and how treatments will be delivered .
  • Recommended Psychological Interventions:
    • For less severe depression, psychological therapies are recommended first-line, and antidepressant treatment is generally not offered first-line unless the person prefers it .
    • Effective and cost-effective first-line psychological options include:
      • Guided self-help: This is often recommended first-line for most people with less severe depression due to its accessibility, pragmatism, and cost-effectiveness .
      • Individual or group Cognitive Behavioural Therapy (CBT) .
      • Individual or group Behavioural Activation (BA) .
    • Other psychological interventions that may be considered, though potentially less cost-effective, include:
      • Counselling: This involves individual sessions focusing on emotional processing and developing coping mechanisms, often useful for people with psychosocial, relationship, or employment problems contributing to their depression .
      • Short-term psychodynamic psychotherapy (STPP): This involves individual sessions focusing on recognising difficult feelings in relationships and identifying repeated patterns . It may be useful for people with emotional and developmental difficulties in relationships .
      • Interpersonal Psychotherapy (IPT): This may be helpful for people with depression associated with interpersonal difficulties, such as adjusting to relationship transitions or loss .
  • Stepped Care Approach:
    • The stepped-care model suggests delivering the least intrusive, most effective, and least resource-intensive treatments first ,. If the person does not benefit from initial interventions, they can be "stepped up" to more intensive treatments ,.
    • For persistent subthreshold depressive symptoms or mild to moderate depression, low-intensity psychosocial interventions and psychological interventions are appropriate for Step 2 . If there's an inadequate response, they may be stepped up to Step 3, which includes high-intensity psychological interventions .
  • General Support and Monitoring:
    • Provide advice on the nature and course of depression, recovery, and sources of information and support (e.g., self-help materials, support groups) .
    • Advise on activities to improve well-being, such as physical activity and maintaining a healthy lifestyle .
    • Offer social support, including for family and carers .
    • If the person has a new episode of less severe depression and does not want treatment or feels symptoms are improving, offer active monitoring with the option to consider treatment at any time .
    • Routine outcome monitoring should be used to assess progress regularly, usually at each contact, using valid scales for symptoms or personal and social functioning .

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