PRACTICE RECOMMENDATIONS
› Recommend cognitive behavioral therapy, interpersonal therapy, or problem-solving therapy for the treatment of depression in patients of all ages. A
› Consider prescribing exercise as a stand-alone or adjunctive treatment for patients with depression. B
› Advise patients who ask about omega-3 fatty acid supplements that formulations with a high eicosapentaenoic acid (EPA) to docosahexaenoic acid (DHA) ratio (2:1) may be a useful “add-on” to their current regimen. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE 1 › Steve J, age 43, comes to your clinic looking uncharacteristically glum. He was recently downsized from his job and misses his former colleagues. His job loss has caused a financial strain for his family, and he admits to crying in the shower when he thinks about how his life has turned out. Mr. J tells you that he’s gotten a part-time job, but he’s already called in sick several times. On those sick days he “stayed in bed all day and slept.” He says that when he does go to work, he rarely interacts with his coworkers and his concentration is poor. He tells you he wakes up early in the morning on most days and cannot return to sleep, despite being “tired all the time.” He denies suicidal ideation. Mr. J has never felt this way before, which is what prompted his visit today, but he thinks it is “weak to take a pill to feel better.”
What nonpharmacologic options can you offer him?
CASE 2 › Kerri S is a 27-year-old mother of 2 who comes to your clinic to establish care. She tells you about a recent recurrence of depressed mood, which she feels is due to the stress of moving to the area. She is experiencing sleep-onset insomnia and concentration lapses. Her appetite is poor (self-reported 8-lb weight loss in 2 months) and she lacks the motivation to engage in her daily activities, saying, “I wouldn’t even get out of bed if my kids didn’t need me.” She notes that she is constantly irritable and has completely lost her sex drive. Unlike her prior depressive episode, she has not had any suicidal thoughts. Mrs. S was previously successfully treated with paroxetine, 20 mg/d, but she is not interested in restarting her medication because she is still breastfeeding her toddler.
Are there evidence-based options for her care that do not include medication?
Major depressive disorder (MDD) is widespread and often disabling, affecting nearly 8% of people ages 12 and older at any given time.1 Thus, it’s crucial to be familiar with the diverse array of evidence-based treatment options from which patients can choose. Although medications are an essential treatment option for patients with severe depression, their value for patients with mild to moderate depression is often limited.2 In addition, when antidepressants aren’t combined with psychosocial interventions, discontinuing them is associated with relapse.3
Fortunately, research has found that certain nonpharmacologic interventions—including psychotherapies, somatic therapies, and dietary supplements—can have either therapeutic or adjunctive benefits for treating depression, and can be provided in ways that are time- and cost-effective. This article reviews the evidence supporting several options in each of these treatment categories.
Evidence backs several types of psychotherapy
Several recent meta-analyses suggest that a variety of psychotherapeutic treatments may hold promise for your patients with depression.4,5 When analyses were limited to larger studies in order to decrease the risk of bias, cognitive behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy (PST) all resulted in moderate to large improvement in depressive symptoms when compared to wait-list controls.4 These findings were echoed in a recent systematic review/meta-analysis that focused on depressed primary care patients. Linde et al5 found that the number needed to treat (NNT) to achieve one response (≥50% reduction in score on a depression scale) using any type of psychotherapy was 10, and the NNT to achieve one remission (scoring below a predefined score on a depression scale) was 15.
Psychotherapy can be effective when provided in individual and group settings,6 as well as via telephone, the Internet, or software programs.7 (For a list of self-help, computerized, and Internet-based resources, see TABLE W1 below.)
CBT has been studied for several decades and there’s strong evidence for its efficacy.6 Recent investigations have suggested that CBT delivered in less resource-intensive modes (such as via computer program, Internet, telephone, or videoconferencing) can be as effective as face-to-face CBT.6,8 CBT has been shown to be helpful for a wide range of patients,6 improves outcomes over standard primary care treatment,9 and provides a useful adjunct to medication in treatment-resistant severe depression.10