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Evidence-Based Reviews


CAM for your depressed patient: 6 recommended options

Vol. 8, No. 10 / October 2009

Comment on this article

Americans with depression turn to complementary and alternative medicine (CAM) more often than conventional psychotherapy or FDA-approved medication. In a nationally representative sample, 54% of respondents with self-reported “severe depression”—including two-thirds of those receiving conventional therapies—reported using CAM during the previous 12 months. 1

Unfortunately, popular acceptance of CAM for depression is disproportionate to the evidence base, which—although growing—remains limited. As a result, your patients may be self-medicating with poorly supported treatments that are unlikely to help them recover from depression.

In reviewing CAM treatments for depression, we found some with enough evidence of positive effect that we feel comfortable recommending them as evidence-based options. These promising, short-term treatments are supported by level 1a or 1b evidence and at least 1 study that demonstrates an ability to induce remission ( Table 1 ). 2

For patients seeking “natural” or nonprescription treatments—or when you wish to augment standard treatments that are not working adequately—you might recommend fatty acids, St. John’s wort, or S-adenosyl-L-methionine (SAMe). Similar recommendations can be made for yoga, exercise, and bibliotherapy, as we discuss here.

Table 1

Evidence these authors required to recommend a CAM treatment

Minimum requirements

Level of evidence

Recommendation

Systematic review showing superiority to placebo or standard treatment
Plus
1 study showing CAM treatment can induce remission

1a +


1b or 2b

A

At least 2 RCTs showing superiority to placebo or standard treatment
Plus
1 study showing CAM treatment can induce remission

1b


1b or 2b

A–

CAM: complementary and alternative medicine; RCT: randomized controlled trial

Source: Reference 2

Reviewing CAM evidence

This article refers to as “alternative” any treatment other than a form of psychotherapy or an FDA-approved medication that substitutes for a standard psychiatric treatment. When used to augment standard psychiatric treatments, these approaches are considered “complementary.”

Our search for evidence on CAM treatments for depressive disorders raised questions about what constitutes acceptable and convincing methodology:

  • Studies often had problems with blinding and suitable placebos. Many were small, with short duration and no long-term follow-up.
  • Comparisons with active treatments that showed no differences were assumed to imply comparability, even though the studies were powered to detect only large differences.

On the other hand, multiple randomized controlled trials (RCTs) have shown consistent superiority of some CAM treatments over comparison conditions.

Applying the evidence. Because CAM use is widespread, be sure to ask psychiatric patients if they are using CAM treatments. If the answer is “yes,” a risk-benefit assessment is needed. Inform patients who are using poorly supported CAM approaches that they could consider better-supported CAM options as well as standard effective antidepressants.

Monitor patients for an adequately prompt positive response to an evidence-based CAM approach that has shown efficacy for their level of depression. As with any treatment, consider other evidence-based options when CAM treatments are inadequate or unsuccessful in achieving remission of depressive symptoms.

Sufficient evidence of efficacy

Yoga. In their systematic review of yoga’s effectiveness for depression, Pilkington et al 3 analyzed 5 RCTs that met 3 criteria:

  • participants had mild to severe depression or depressive disorders
  • yoga or yoga-based exercises alone were used for treatment
  • depression rating scales were used as outcome measures.

They found evidence that yoga can reduce depressive symptoms and induce remission ( Table 2 ). The studies were generally small and of short duration, and depression severity and interventions varied widely. Most participants were young and relatively fit, raising questions about yoga’s applicability to older or less fit patients. Reporting of adverse events was limited, but no safety issues or adverse effects were identified.

Conclusion. Yoga has been studied primarily as an alternative treatment, but its physical health and group participation benefits and lack of side effects make it a suitable complementary treatment as well.

Exercise. Extensive literature has examined the relationship between exercise and depression. We identified 7 reviews published between 1993 and 2008 ( Table 3 ). All supported positive effects of exercise except for patients age <20. In a later RCT, the efficacy of aerobic exercise and antidepressant medication did not differ significantly in 202 adults with major depressive disorder (MDD). Remission rates were:

  • 45% with supervised exercise
  • 40% with home-based exercise
  • 47% with sertraline, 50 to 200 mg/d
  • 31% with placebo. 4

Table 2

5 RCTs of yoga’s effectiveness in treating depression

RCT

Interventions

Conclusion

Broota and Dhir, 1990

Yoga and PMR vs control

Yoga and PMR were more effective than control, with yoga more effective than PMR

Khumar et al, 1993

Shavasana yoga vs no intervention

College students with severe depression improved during and after yoga treatment

Janakiramaiah et al, 2000

SKY vs ECT vs imipramine

Reductions in BDI scores for all 3 groups; ECT > SKY or imipramine, SKY=imipramine

Rohini et al, 2000

Full SKY vs partial SKY

30 individuals with MDD improved with either therapy, but results were not statistically significant

Woolery, 2004

Iyengar yoga vs wait list

28 mildly depressed individuals benefitted from yoga, as measured by BDI scores at midpoint and throughout treatment

BDI: Beck Depression Inventory; ECT: electroconvulsive therapy; MDD: major depressive disorder; PMR: progressive muscle relaxation; RCT: randomized controlled trial; SKY: Sudarshan Kriya yoga

Source:
Broota A, Dhir R. Efficacy of two relaxation techniques in depression. Journal of Personality and Clinical Studies. 1990;6(1):83-90.
Khumar SS, Kaur P, Kaur S. Effectiveness of Shavasana on depression among university students. Indian J Clin Psychol. 1993;20(2):82-87.
Janakiramaiah N, Gangadhar BN, Naga Venkatesha Murthy PJ, et al. Antidepressant efficacy of Sudarshan Kriya yoga (SKY) in melancholia: a randomized comparison with electroconvulsive therapy (ECT) and imipramine. J Affect Disord. 2000;57(1-3):255-259.
Rohini V, Pandey RS, Janakiramaiah N, et al. A comparative study of full and partial Sudarshan Kriya yoga (SKY) in major depressive disorder. NIMHANS Journal. 2000;18(1):53-57.
Woolery A, Myers H, Sternlieb B, et al. A yoga intervention for young adults with elevated symptoms of depression. Altern Ther Health Med. 2004;10(2):60-63.

Table 3

Evidence of the antidepressant effect of exercise

Literature review

Methodology

Conclusion

Byrne and Byrne, 1993

13 studies, clinical samples, measured changes in depressed mood

90% of studies reported beneficial effects, especially in clinical populations

Scully et al, 1998

4 literature reviews, 1 monograph, 1 study

Positive relationship of physical activity and depression in healthy and clinical samples, increased over time

Lawlor and Hopker, 2001

14 RCTs from 1966 to 1999 with depression as an outcome

Significant methodologic weaknesses, but exercise effect > no treatment and=cognitive therapy

Dunn et al, 2001

Examined dose effect in 37 studies; subjects diagnosed with depressive disorders, mild-to-moderate symptoms, and no medical comorbidity

Only level B and C evidence; positive effects with exercise from light to heavy intensity; aerobic=nonaerobic; improvement may or may not be related to improved fitness

Brosse et al, 2002

12 RCTs from 1979 to 1999

Significant methodologic limitations, but authors concluded evidence supports a positive effect of exercise in healthy and clinical populations

Larun et al, 2006

4 RCTs in children and youth age <20

Exercise effect same as no intervention, low-intensity relaxation, or psychosocial intervention

Barbour et al, 2007

2 meta-analyses, 1 RCT, 2 studies

Positive effect; high-energy was optimal dose; aerobic=nonaerobic; improvement may or may not be related to improved fitness

RCT: randomized controlled trial

Source:
Byrne AE, Byrne DG. The effect of exercise on depression, anxiety and other mood states: A review. J Psychosom Res. 1993;37(6):565-574.
Scully D, Kremer J, Meade MM, et al. Physical exercise and psychological well being: a critical review. Br J Sports Med. 1998;32(2):111-120.
Lawlor DA, Hopker SW. The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomised controlled trials. BMJ. 2001;322(7289):763-767.
Dunn AL, Trivedi MH, O’Neal HA. Physical activity dose-response effects on outcomes of depression and anxiety. Med Sci Sports Exerc. 2001;33(6):S587.
Brosse AL, Sheets ES, Lett HS, et al. Exercise and the treatment of clinical depression in adults: recent findings and future directions. Sports Med. 2002;32(12):741-760.
Larun L, Nordheim LV, Ekeland E, et al. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev. 2006;3:CD004691.
Barbour KA, Edenfield TM, Blumenthal JA. Exercise as a treatment for depression and other psychiatric disorders: a review. J Cardiopulm Rehabil Prev. 2007;27(6):359-367.

Conclusion. Evidence supports exercise for short-term treatment of mild or moderate depression in adults. Studies tend to be small and brief, to enroll young physically -sound patients, and to include little follow-up. Studies of subjects age <20 are limited, of poor quality, and indicate no effect.

At least 2 studies suggest that high-energy exercise and aerobic or resistance training provide greater reductions in depressive symptoms than exercises such as walking. 5,6 Yoga’s positive effects suggest, however, that an aerobic effect is not necessary for an antidepressant benefit.

Exercise has not been adequately tested as a complementary treatment but likely is safe for most psychiatric patients. Perspiration and dehydration might alter therapeutic blood levels of lithium or other medications. Advise patients to drink water before, during, and after exercise and to avoid outdoor exercise in extreme temperatures. More vigorous monitoring might be indicated in specific cases.

Tailor exercise programs to individual needs, considering the patient’s age and health status. Refer a patient with a known heart problem or increased cardiovascular risk to his or her physician for selective exercise testing.

Bibliotherapy—reading self-help books, usually about cognitive-behavioral approaches to depressive disorders—has been relatively well studied. A recent meta-analysis examined 29 studies with pre-post designs. Group differences in the 17 controlled studies yielded a large effect size of 0.77. Participants who read the materials benefitted similarly whether they met in groups or applied the information on their own. Older adults tended to be less depressed at baseline and made smaller treatment gains. 7

A study of 31 patients age >60 with mild-to-moderate depression 8 compared 16 sessions of professionally administered cognitive-behavioral therapy (CBT) with self-administered cognitive therapy learned from reading a book. 9 Both groups showed greater improvement in depressive symptoms compared with a control group. Subjects in the CBT group did somewhat better during the trial, but at 3-month follow-up most patients in both treatment groups no longer met diagnostic criteria for MDD.

Conclusion. Evidence supports bibliotherapy as an effective treatment for mild-to-moderate depression. No convincing data support its use as a complementary treatment, but it poses virtually no risk.

St. John’s wort (Hypericum perforatum) has been extensively studied for depressive disorders, with 29 RCTs in a meta-analysis of MDD trials through July 2008. 10 Another meta-analysis compared St. John’s wort with selective serotonin reuptake inhibitors (SSRIs) in 13 studies through June 2008. 11 These and most RCTs have found St. John’s wort significantly more effective than placebo in reducing depressive symptoms.

Data selected from double-blind RCTs totaling 217 patients with mild depression [Hamilton Depression Rating Scale (HDRS) scores <20] showed that St. John’s wort standardized extract WS5570 induced significantly higher remission rates than placebo. 12 Studies routinely show that treating MDD with St. John’s wort is comparable to using tricyclic or SSRI antidepressants.

Side effects with St. John’s wort generally are no different than with placebo and significantly less than with comparison treatments. Even so, using St. John’s wort instead of SSRIs for MDD remains controversial.

Studies vs SSRIs. Many of the favorable St. John’s wort trials were conducted in Europe, particularly in Germany. Two large RCTs conducted in the United States reported that the St. John’s wort standardized extract LI-160 was not more effective than placebo, but neither could be clearly interpreted as negative for St. John’s wort:

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