Evidence-Based Reviews

CAM for your depressed patient: 6 recommended options

Current Psychiatry. 2009 October;8(10):39-47

References

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4. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosom Med. 2007;69(7):587-596.

5. Dunn AL, Trivedi MH, Kampert JB, et al. Exercise treatment for depression: efficacy and dose response. Am J Prev Med. 2005;28(1):1-8.

6. Legrand F, Heuze JP. Antidepressant effects associated with different exercise conditions in participants with depression: a pilot study. J Sport Exercise Psychol. 2007;29(3):348-364.

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18. Alpert JE, Papakostas G, Mischoulon D, et al. S-adenosyl-L-methionine (SAMe) as an adjunct for resistant major depressive disorder: an open trial following partial or nonresponse to selective serotonin reuptake inhibitors or venlafaxine. J Clin Psychopharmacol. 2004;24(6):661-664.

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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	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

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

Clinical Point

Self-administered CBT learned from reading books has been shown to be an effective treatment for mild-to-moderate depression

A study of 31 patients age >60 with mild-to-moderate depression⁸ 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.