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Complementary therapies for depression

Depression is one of the top five conditions for which people turn to complementary and alternative therapies, such as herbal treatments, exercise, relaxation or meditation exercises, and acupuncture. Of the complementary approaches that have been tested in scientific trials, some show better results than others.

Many people don't tell their doctors what alternative therapies they're using, but it is important to do so. Sometimes a complementary treatment has a problematic interaction with a medication your doctor is prescribing for you. Also, your doctor may be able to offer advice about that particular alternative therapy.

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Herbs and supplements

It wasn't long ago that no one had heard of St. John's wort, let alone SAMe. But now, many people are trying supplements for their depression. But before you try any treatment, be sure to ask: Does it work, and is it safe?

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St. John's wort

St. John's wort is the most popular herbal treatment for depression. However, it may be useful only when a person's depression is not too severe. An analysis of several trials on St. John's wort and depression published in the Annals of Internal Medicine in 2002 concluded that the herb seems effective for mild to moderate depression, working as well as the older tricyclic antidepressants such as imipramine. A three-year trial sponsored by the National Institutes of Health (NIH) and published in the Journal of the American Medical Association in 2002 found that St. John's wort was not helpful for more serious depression. And results from studies that compare it with mainstream antidepressant medications vary widely.

The exact mechanism by which St. John's wort works isn't known yet, but the herb appears to enhance serotonin levels, much like Prozac does. It also seems to affect two other key neurotransmitters, dopamine and norepinephrine. Whether this neurotransmitter triple-header suffices to explain the herb's mood-lifting abilities or whether another mechanism is at work remains less clear.

One appeal of St. John's wort is its apparently mild side effects. While some people report problems such as dry mouth, dizziness, confusion, sensitivity to sunlight, or constipation or other gastrointestinal discomforts, very few find them onerous enough to stop taking it. The proportion of those who do stop using it (roughly 2%) compares favorably with the far larger percentages of people who switch or stop taking conventional antidepressants because of side effects. Although these figures are hard to interpret because of a variable that is tough to measure: The motivations and dynamics involved with the self-prescribing of an herbal medication are quite different from those of accepting a prescription from a physician.

It would also be a mistake to regard St. John's wort as entirely benign because it's an herbal remedy. St. John's wort can affect the action of quite a few drugs, including the anti-clotting drug warfarin (Coumadin), the AIDS drug indinavir (Crixivan), and birth control pills. There is a possibility, too, of bad interactions with antidepressant drugs such as monoamine oxidase inhibitors (MAOIs) and serotonin reuptake inhibitors (SSRIs) that affect serotonin transmission. Before taking St. John's wort or any other natural remedy, check with your doctor or a pharmacist about potentially dangerous interactions.

A number of questions about St. John's wort still remain. Despite getting more attention from the scientific community in the past decade, the body of evidence is still limited. It is unclear how long its effects last or how high the depression recurrence rate is. There are few guidelines about proper dosing. Until research provides more data, it may make more sense to turn to one of the many better-tested treatments for depression (see "Medications used for depression and bipolar disorder").

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SAMe

Another supplement for depression that has been in the news is S-adenosyl-L-methionine (SAMe), which is made from an amino acid found in the body. SAMe may be of some benefit for depression, either alone or in combination with another antidepressant. Unfortunately there are very few systematic reviews of its effectiveness available and very little controlled research. More study is needed, and before taking SAMe, it is safest to talk to your doctor first.

Thus far, reported side effects from SAMe have been few. One important exception is that some individuals with bipolar disorder have become manic after taking SAMe. SAMe's most common side effects are headaches, insomnia, jitteriness, and loose stools.

Another problem with SAMe, as with many supplements, is determining the right dose. Doses used in studies have varied from 400 mg to 1,600 mg per day. It's also expensive — about $1 for a 200-mg tablet — and not covered by health insurance.

Since SAMe has not been studied as well as standard antidepressants, it's best to opt for an antidepressant that's been better tested.

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Exercise

Can a few laps around the block actually solve your emotional problems? Probably not, but a regular exercise program might help. A review of studies stretching back to 1981 concluded that regular exercise can improve mood in people with mild to moderate depression. It also may play a supporting role in treating severe depression.

Another study, published in the Archives of Internal Medicine in 1999, divided 156 men and women with depression into three groups. One group took part in an aerobic exercise program, another took the SSRI sertraline (Zoloft), and a third did both. At the 16-week mark, depression had eased in all three groups. About 60%–70% of the people in all three groups could no longer be classed as having major depression. In fact, group scores on two rating scales of depression were essentially the same. This suggests that for those who need or wish to avoid drugs, exercise might be an acceptable substitute for antidepressants. Keep in mind, though, that the swiftest response occurred in the group taking antidepressants, and that it can be difficult to stay motivated to exercise when you're depressed.

A follow-up to that study found that exercise's effects lasted longer than those of antidepressants. Researchers checked in with 133 of the original patients six months after the first study ended. They found that the people who exercised regularly after completing the study, regardless of which treatment they were on originally, were less likely to relapse into depression.

A study published in 2005 found that walking fast for about 35 minutes a day five times a week or 60 minutes a day three times a week had a significant influence on mild to moderate depression symptoms. Walking fast for only 15 minutes a day five times a week or doing stretching exercises three times a week did not help as much. (These exercise lengths were calculated for someone who weighs about 150 pounds. If you weigh more, longer exercise times apply, while the opposite is true if you weigh less than 150 pounds.)

How does exercise relieve depression? For many years, experts have known that exercise enhances the action of endorphins, chemicals that circulate throughout the body. But it turns out the advantages go beyond the endorphin effect. Exercise helps your brain function better. Nerve cells are more robust and they make better connections with one another. Recently, scientists have observed similar changes in the brain related to exercise as observed in the brains of people taking an antidepressant.

Besides lifting your mood, regular exercise offers other health benefits, such as lowering blood pressure, protecting against heart disease and cancer, and boosting self-esteem. How often or intensely you need to exercise to alleviate depression is not clear, but for general health, experts advise getting half an hour to an hour of moderate exercise, such as brisk walking, on all or most days of the week. It's most important to pick a level of exercise that you feel you can sustain. Every bit of extra exercise you get is potentially helpful.

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Meditation

Meditation is a systematic method of regulating your attention, often through focusing on your breathing, a phrase, or an image. It may include calmly dismissing distracting thoughts and feelings while sitting in a relaxed position with your eyes closed.

Meditation is used to relieve stress and elicit the relaxation response, a state of profound rest and release. Some experts believe that by regularly practicing techniques that evoke the relaxation response, such as meditation, you can help your body erase the cumulative effects of stress, which has been linked to health problems such as high blood pressure, heart disease, a weakened immune system, and asthma. As noted earlier, there appears to be a link between stress and depression (see "Hormones and the HPA axis").

Studies have found that meditation can help prevent relapse in people who have had three or more episodes of depression. For example, in one study, while 78% of depressed people given normal treatment for depression relapsed in the following year, only 36% of those people who got meditation training in addition to regular treatment did. For people with fewer than three episodes of depression, meditation has not been found to be as effective.

There is evidence that meditation has distinct effects on the brain. In one study, researchers measured brain electrical activity before, immediately after, and four months after a two-month course in mindfulness meditation. They found persistent increased activity on the left side of the prefrontal cortex, which is associated with joyful and serene emotions.

Another goal of meditation is to facilitate personal change — much the same goal as psychotherapy. Some therapists, particularly those in the cognitive behavioral field, have incorporated meditation techniques into therapy, either as part of the session or as homework for patients to do on their own. If meditation appeals to you, ask your therapist about how best to use it. Going to a class or listening to a meditation tape may be a good first step. In addition, try the meditation exercises listed below.

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Review Date: 2008-04-01

Harvard Medical School does not endorse products or services.