Alternative Therapies In Health And Medicine

Table 1 Major Evidence of Nonpharmaceutical Treatments of Depression, continued
Intervention Mechanisms of Action* Key Evidence† Summary of Results
Cognitive
behavioral
therapy;
Interpersonal
skills;
Psychoeducation
Enhances neuronal plasticity;
modulation of limbic brain
center activity; increased serotonin
and GABAergic effects;
brain imaging shows posttreatment
activity in temporal
lobe, hippocampal, and cingulated
areas
Psychological Techniques (Major Interventions)
Meta-analyses and
reviews:
Cuijpers 2008 118 ;
Bell 2009 77 ;
Donker 2009 70 ;
Wolf 2008 17
RCTs consistently show psychological
interventions to be
effective in reducing depression;
evidence supports the
longer term effects carry on
after treatment is ceased
Evidence
Level Comment
A
Important intervention for
depression with a psychological
or external life stressor
trigger. Referral may be
required to qualified psychologists
in higher levels of
depression or pronounced
distress
Level A: meta-analyses or 2 or more RCTS with positive results; Level B: more than 2 RCTS, mainly positive results; Level C: nonreplicated RCT or mixed evidence
from several RCTs. Abbreviations: HPA, hypothalamic-pituitary-adrenal; SJW, St John’s wort; MDD, major depressive disorder; RCT, randomized controlled trial;
HDRS: Hamilton Rating Scale for Depression; NMDA, N-Methyl-D-aspartate; GABA, γ-Aminobutyric acid; CVD, cardiovascular disease; 5-HTP, 5-hydroxytryptophan;
MAOI, monoamine oxidase inhibitors; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant. *See article text for references. †First author
of study included.
and the enhancement of cell membrane fluidity. 50-52
The use of acupuncture to treat depressive disorders has
been documented in traditional Chinese medical texts. 53 Reviews
and meta-analyses of small randomized controlled trials indicate
that acupuncture can significantly reduce the severity of depression
on the Hamilton Depression Rating Scale (HDRS) 54 or Beck
Depression Inventory (BDI). 55 Significant effects on reducing
depression occurred compared to nonspecific or sham acupuncture
or massage, while equivocal efficacy compared to tricyclic
antidepressants also was revealed. It should be noted that not all
studies are positive and that the poor methodology used in many
studies preclude acupuncture as having a higher level of evidence.
Further, due to methodological challenges (eg, blinding
and a strong placebo effect from sham acupuncture points), it
often is difficult to draw definitive conclusions. Acupuncture has
been documented to interact with opioid pathways, and substances
that modulate these pathways have been shown to have
antidepressant activity. 56 Other possible antidepressant mechanisms
of action include increased release of serotonin and norepinephrine
and cortisol modulation. 57
Lifestyle. General lifestyle advice should focus on encouraging
a balance between meaningful work, adequate rest and sleep,
moderate exercise, positive social interaction, and pleasurable
hobbies. Dietary programs designed to treat depression have not
been rigorously evaluated to date; however, cross-sectional studies
by Akbaraly et al 58 and Jacka et al 59 have revealed that a healthy
diet rich in complex carbohydrates, fruits and vegetables, and
lean meats and low in processed foods reduces the risk of depression.
Although evidence supporting specific nutritional advice is
currently lacking, a basic balanced diet including foods rich in a
spectrum of nutrients can be recommended. Among important
nutrients for neurochemical function, adequate folate consumption
is vital. Folate is involved with the methylation pathways in
the “one-carbon” cycle, responsible for the metabolism and synthesis
or various monoamines, and notability involved with the
synthesis of SAMe. 41 Higher rates of folate deficiency have been
found in people with depressive disorders compared to their nondepressed
counterparts. 60,61 Foods rich in omega-3, L-tryptophan,
B and C vitamins, zinc, and magnesium are recommended, as
they are necessary for the production of neurotransmitters and
for neuronal communication. 62 These include whole grains (zinc,
magnesium, B vitamins) lean meat (zinc, magnesium, protein, eg,
tryptophan), deep-sea fish (essential fatty acids), green leafy vegetables
(vitamin C, folate), colored berries (vitamin C, antioxidant
phenolic compounds), and nuts (monounsaturated fats, vitamin
E, zinc, magnesium). 63 A strong causal link between substance or
alcohol abuse/dependence and MDD has been established, and
depression, in turn, increases the risk of substance and alcohol
misuse. 64,65 In such cases, supportive advice on curtailing the use
of alcohol or recreational drugs and/or referral to an appropriate
treatment program can be provided.
Increasing physical activity is advised if the patient has a
sedentary lifestyle and is especially indicated in cases of obesity.
Associations between greater physical activity and improved
mood and well-being have been documented. 66,67 As is indicated
in Table 1, many RCTs have revealed that exercise is effective in
reducing symptoms of depression, with meta-analyses of clinical
studies of exercise showing a significant effect in favor of
physical exercise compared with control conditions (routine
care, waitlist, meditation/relaxation, or low-intensity
exercise). 68 Evidence also exists for the use of yoga to reduce
depression and improve mood, with several RCTs revealing
mostly positive results. 69 The methodologies were, however,
commonly poorly reported, and therefore these interventions
cannot currently be considered as “gold-standard” grade
A–level evidence. The biological antidepressant effects of exercise
include a beneficial modulation of the HPA-axis, increased
expression of 5-HTP, and increased levels of circulating testosterone
(which may have a protective effect against
depression). 67,68
An Evidence-based Integrative CAM Model for Depression
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