Evidence-Based Reviews

CAM for your depressed patient: 6 recommended options

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

References

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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.

Clinical Point

Multiple RCTs have shown consistent superiority of some CAM treatments over comparison conditions

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 al³ 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.

Clinical Point

Yoga’s positive effects suggest that exercise does not have to be aerobic to provide an antidepressant benefit

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

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.