Evidence-Based Reviews

CAM for your depressed patient: 6 recommended options

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

References

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30. Wang H, Qi H, Wang BS, et al. Is acupuncture beneficial in depression: a meta-analysis of 8 randomized controlled trials? J Affect Disord. 2008;111(2-3):125-134.

31. Smith CA, Hay PPJ. Acupuncture for depression. Cochrane Database Syst Rev. 2005;(2):CD004046.-

An 8-week double-blind study compared EPA, 1 gram daily; fluoxetine, 20 mg/d; or both agents in 60 outpatients with MDD. Response rates—as measured by ≥50% reduction in baseline HDRS scores—were 50% with fluoxetine, 56% with EPA, and 81% with combination therapy.²⁸

Clinical Point

Although PUFAs’ therapeutic effects remain unclear, they appear safe to use as adjuncts if standard treatment is not satisfactory

Conclusion. Questions remain about dosing, ratio of EPA to DHA, patient selection, and baseline blood levels of PUFAs compared with response. PUFAs have a benign side-effect profile, with occasional reports of diarrhea or GI upset. Although their therapeutic effects are being clarified, PUFAs appear safe to recommend as an adjunct treatment if standard care is not satisfactory.

Insufficient evidence

L-tryptophan. It seems reasonable to expect a serotonin precursor to increase serotonin in the CNS and improve depressive symptoms. Of 111 trials on L-tryptophan for depression, however, only 2 met the quality criteria for inclusion in a recent meta-analysis.²⁹ Combining the 2 trials showed L-tryptophan alone and in combination with a tricyclic antidepressant was more effective than placebo for treating depressive disorders in adults.

Conclusion. Very little research continues to test L-tryptophan as a viable CAM for depressive disorder. Its serious side effect of eosinophilia-myalgia syndrome makes clinical use of this agent unlikely.

Acupuncture. Numerous small studies with questionable controls, different needling placements, and poor allocation concealment and blinding limit the ability to draw conclusions about acupuncture for treating depression ( Table 4 ). A recent meta-analysis by Wang et al³⁰ added 2 Chinese trials not included in an earlier review³¹ and found acupuncture significantly reduced depressive symptoms. No consistent differences were detected in response or remission rates, however.

Conclusion. Evidence is methodologically weak, and the use of acupuncture as an alternative or complementary treatment of depression is questionable.

Table 4

Acupuncture: Insufficient evidence of antidepressant effect

Literature review	Methodology	Conclusion
Mukaino et al, 2005	Systematic review of 7 RCTs including 509 patients; compared either manual or electroacupuncture with any control procedure	Inconsistent evidence of manual acupuncture’s effectiveness vs sham; electroacupuncture’s effect may be similar to that of antidepressant medication and merits further study
Leo and Ligot, 2007	Systematic review of 9 RCTs, 5 considered low quality; some focused on very specific populations (ie, hospitalized stroke patients or pregnant depressed patients)	Evidence inconclusive because of study designs and methodologies
Smith and Hay, 2005	Meta-analysis of 7 trials including 517 adults with mild-to-moderate depression; 5 trials (409 participants) compared acupuncture with medication; 2 trials compared acupuncture with wait list or sham acupuncture	No difference between acupuncture and medication; study quality too poor to support acupuncture’s efficacy
Wang et al, 2008	Meta-analysis of 8 small RCTs totalling 477 subjects (256 received active acupuncture, remainder received sham acupuncture); sham acupuncture design, number of acupuncture sessions, and duration varied among studies	Significant reduction in HRSD or BDI scores for acupuncture vs sham, but no significant effect of acupuncture on response or remission rates
BDI: Beck Depression Inventory; HRSD: Hamilton Rating Scale for Depression; RCT: randomized controlled trial
Source: Mukaino Y, Park J, White A, et al. The effectiveness of acupuncture for depression—a systematic review of randomised controlled trials. Acupunct Med. 2005;23(2):70-76. Leo RJ, Ligot JS Jr. A systematic review of randomized controlled trials of acupuncture in the treatment of depression. J Affect Disord. 2007;97(1-3):13-22. Smith CA, Hay PPJ. Acupuncture for depression. Cochrane Database Syst Rev. 2005;(2):CD004046. Wang H, Qi H, Wang BS, et al. Is acupuncture beneficial in depression? A meta-analysis of 8 randomized controlled trials. J Affect Disord. 2008;111(2-3):125-134.

Related resources

National Center for Complementary and Alternative Medicine, National Institutes of Health. http://nccam.nih.gov.
Journal of Alternative and Complementary Medicine. www.liebertpub.com/products/product.aspx?pid=26.
Complementary and alternative medicine. www.nlm.nih.gov/medlineplus/complementaryandalternativemedicine.html.

Drug brand names

Fluoxetine • Prozac
Imipramine • Tofranil
Lithium • Eskalith, Lithobid
Sertraline • Zoloft
Venlafaxine • Effexor

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.