Depression Pocket Guide

What Are The Conventional Ways Of Treating Depression?

Conventional treatments for depression include a combination of pharmaceutical, i.e., antidepressant medication, and behavioral/therapeutic interventions, i.e., cognitive behavioral therapy.

Pharmaceutical Interventions

The first option provided to patients to treat depression is usually pharmaceutical, specifically, in the form of an antidepressant.

The most common pharmaceutical interventions used to treat depression are:

• Selective serotonin reuptake inhibitors (SSRIs), which are the most commonly prescribed antidepressant
• Serotonin and norepinephrine reuptake inhibitors (SNRIs)
• Other medications including tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs)

If you have been diagnosed with bipolar depression (also referred to as Bipolar II disorder.), there are
additional pharmaceutical treatments that may be available, including mood stabilizers.

Safety Concerns

• It is very important to recognize that it usually takes 2–4 weeks for antidepressant medication to work.
• You may initially experience side effects when beginning your medication. Do not stop taking your medication if you begin to experience side effects until you have spoken with your doctor. Depending on how long you have been taking medication, withdrawal symptoms can occur if you stop abruptly.

Behavioral/Therapeutic Interventions

Although doctors initially prescribe medication to treat depression, psychotherapy is also an option either before, with, or as the next step after drugs. Psychotherapy seeks to help you address some of the issues that are causing your depression. Therapists can help you in the following ways ^[vi]

:

• Finding methods to cope with stress and unpleasant experiences
• Examining the relationship between your thoughts, emotions, and behaviors to help you understand their impact on one another
• Providing emotional support to help you work through complicated emotions and reactions
• Helping you understand your triggers and warning signs that you are becoming depressed or are beginning to experience adverse symptoms of your depression

There are a variety of types of psychotherapy used to treat depression. A primary example is cognitive behavioral therapy (CBT). To better understand the process of psychotherapy and to begin looking for a therapist and ways that psychotherapy can help you, please visit: https://www.nimh.nih.gov/health/topics/psychotherapies/index.shtml

Side Effects/Safety Concerns

Psychotherapy is widely considered a safe way of addressing depression when delivered by a well-trained certified therapist. Note that any form of therapy can unearth uncomfortable emotions and may cause you to experience increased levels of psychological discomfort.

Brain Stimulation Therapies

When other treatments have not worked or have had little impact on your depression, your psychiatrist may recommend brain stimulation therapies. ^[vii]

Brain stimulation therapies involve actively inserting electrical impulses into the brain. These are usually used in more severe cases of depression, but new devices are emerging that are less invasive than past versions and can be used at home. Talk to your doctor.

If you would like to learn more about brain stimulation therapies and their possible side effects, please visit: https://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml

Are There Integrative Health Approaches To Treating Depression?

It is estimated that, when combined, pharmaceutical and behavioral interventions are effective in treating 60–70% of people with depression, and much of this effect is due to simply getting treatment (i.e., the placebo effect). Additionally, pharmaceutical interventions can sometimes produce adverse effects and cannot be taken by certain patients (such as pregnant women). Integrating the use of evidence-based complementary interventions provides additional options for patients seeking non-drug approaches or for whom conventional forms of treatment do not work or are not wanted.

Light Therapy

In light therapy, you sit in frontof a lamp (usually referred to as a light box) that emits light that is similar to natural sunlight. Light therapy is typically used with people who suffer from seasonal affective disorder (sometimes called winter blues or SAD) but may also be useful for clinical depression. Light emitted from the lamp affects chemicals in the brain linked to mood and sleep.

Side Effects

There are very few side effects associated with light therapy and most diminish with continued use. Reported side effects include:

• Headaches
• Increased energy, euphoria or mania
• Agitation or irritability
• Nausea
• Eye strain

Evidence

• A systematic review and meta-analysis (summary of studies) of the use of light therapy for patients with non-seasonal depression found that not only does light therapy have minimal side effects, but patients reported significant improvement in depressive symptoms. ^[viii]
• A study looking at the impact of light therapy on sleep and depression in older adults in long-term care homes found that there was a significant improvement in symptoms of depression among the study’s participants. ^[ix]

Exercise

Exercise has been shown to improve cognition, mood, emotional regulation, and motor function. The act of exercising can also increase social interaction (if done with others) and self-efficacy. The Mayo Clinic (and other organizations) support the use of exercise for symptom management among people with depression.

Side Effects

If you exercise with approval from your physician and the supervision of a trainer, side effects are minimal. Additionally, many of the adverse side effects may decrease as you become more fit and accustomed to your exercise routine. Some possible side effects include:

• Fatigue
• Pain and soreness
• Injuries
• Developing exercise obsession

Evidence

• A systematic review of randomized trials of exercise programs found that moderate, supervised aerobic activity three times a week for nine weeks improved depressive symptoms. ^[x]
• A meta-analysis of randomized control trials with a total of 977 participants found that physical exercise is an effective modality for treating depression and is a useful adjunct to pharmaceutical interventions. ^[xi]

Yoga

Numerous studies attest to the benefits of yoga, a centuries old mind-body practice, on a wide range of health-related conditions—particularly stress, mental health (including depression), and pain management.

Side Effects

Although very rare, certain types of stroke as well as pain from nerve damage have been reported from people practicing yoga. Muscle injury can also occur if not properly done.

Minor side effects include:

• Dizziness
• Fatigue
• Weakness
• Nausea
• Heat exhaustion

Evidence

• A randomized control study including 38 adults with mild to moderate depression found that an eight-week hatha yoga intervention clinically reduced depression symptoms. ^[xii]
• A systematic review of randomized control trials looking at yoga interventions for depression found that yoga improved depressive symptoms as much as taking an antidepressant drug. ^[xiii]
• A twelve-week mindfulness-based yoga intervention for women with depression found that in comparison to those who participated in a walking group, those in the yoga group reported significantly lower levels of rumination (a frequent symptom of depression). ^[xiv]

Mindfulness Meditation

Meditation is a practice that involves consciously exerting control over breathing and attending nonjudgmentally to the present moment. It produces multiple physiological and chemical effects such as decreased heart rate, blood pressure, and cortisol (stress hormone) levels.

Side Effects

Meditation is widely considered a safe way of addressing physical and mental symptoms; side effects are rare.

• Although rare, there have been reports that engaging in breathwork has worsened symptoms of patients with
  psychiatric problems, such as anxiety. If you are attending a breathwork class, please make sure to alert your instructor of any condition you may have.
• Excessive, rapid breathing can drop carbon dioxide levels and change the pH of the blood, causing muscle cramps, light-headedness and, on rare occasions, seizures. If you are susceptible to seizures, consult your doctor before engaging in any type of meditation that includes intensive breathwork.

Evidence

• A meta-analysis of mindfulness-based approaches found they significantly reduce depressive symptoms and concluded that they are a promising approach for treating people suffering from clinical depression. ^[xv]
• A meta-analysis and systematic review looking at mindfulness based cognitive therapy for depression found that those who had had three or more episodes of depression saw a significant reduction in recurrence of episodes. ^[xvi]

Acupuncture

Acupuncture is a practice in which a trained specialist called an acupuncturist stimulates specific points on the skin called acupoints, usually with a needle. Stimulating acupoints increases the release of chemicals like endorphins (naturally-produced pain reducers) in the body and brain. These chemicals may directly impact how a person experiences pain.

Side Effects

• Slight bleeding and bruising at the acupoint site
• Fainting
• Convulsions
• Pain or soreness at the acupoint site (which may be important for effectiveness)

Evidence

• A meta-analysis of the use of acupuncture in conjunction with antidepressants for treating depression found that the combination was more effective than the use of antidepressants alone. ^[xvii]
• A randomized, single-blind, placebo-controlled study looked at the impact of a twelve-week acupuncture intervention on the quality of life of patients with depression. The study found that those in the acupuncture group had significant improvement in eight quality of life domains including physical function, pain, energy, social and emotional function, and mental health. ^[xvii]

Music Therapy

Music therapy is a well-recognized clinical intervention that uses music within a therapeutic process to assist the patient in identifying and dealing with social, cognitive, emotional, or physical concerns.

Side Effects

Music therapy is widely considered a safe way of addressing physical and mental conditions when delivered by a well-trained certified music therapist. Please note that any form of therapy can unearth uncomfortable emotions and may cause you to experience increased levels of psychological discomfort.

Evidence

• A recent meta-analysis, published in the Cochrane Database, of systematic reviews found that music therapy in conjunction with conventional treatments improved depression symptoms and is more effective than only using conventional treatments alone. ^[xix]
• A systematic review and meta‐analysis of randomized, controlled trials looking at the impact of music therapy on elderly patients found that music therapy improved elderly patients’ depression symptoms. ^[xx]

Art Therapy

Art therapy is a form of clinical intervention that uses art as the primary mode of expression and communication. The art therapist uses creativity to help achieve personal and treatment-related goals. The patient uses and makes art to convey their feelings at that moment or relating to an experience or past situation. When people are experiencing intense, complex, or confusing emotions, the use of art in a therapeutic setting can help them learn about, manage, and communicate their feelings in ways that language cannot always accomplish. You do not have to be a talented or experienced artist to enjoy the benefits of art therapy.

Side Effects

Art therapy is widely considered a safe way of addressing physical and mental conditions when facilitated by a well-trained certified art therapist. Any form of therapy can unearth uncomfortable emotions and may cause you to experience increased levels of psychological discomfort. Reliving traumatic experiences is difficult and if it isn’t handled correctly, can negatively impact an individual’s psychological and/or physical health.

Evidence

• A meta-analysis looking at the impact of art therapy on breast cancer patients experiencing depression, anxiety, and fatigue found that those who participated in art therapy interventions had reductions in all three symptoms. ^[xi]
• A randomized control trial evaluating a manually-based art therapy program including 79 adults suffering from moderate to severe depression found that by the end of the study, patients had significant improvements. ^[xxii]

Herbs and Supplements

Herbs and supplements involve taking a plant or pill, usually orally, to either maintain or improve an individual’s health. The most commonly used herbs and supplements used to treat depression are:

• St. John’s wort
• Saffron
• Omega-3 fatty acid (fish oil)
• MSM (Methylsulfonylmethane)
• 5-HTP (5-hydroxytryptophan)
• SAMe (S-adenosyl methionine)

Side Effects

• Currently, none of the above herbal supplements are approved by the FDA for the treatment of depression. Their effectiveness and side effects vary, and a comprehensive summary is beyond the scope of this Pocket Guide.
• To learn more about one or more of the above herbs or supplements and their potential side effects, please
  visit: https://www.mayoclinic.org/drugs-supplements or https://www.fda.gov/Food/DietarySupplements/UsingDietarySupplements/default.htm
• If you are currently taking prescription medication to treat your depression, do not begin taking supplements until you have spoken to your physician.

Is There Anything I Can Do To Begin Tackling Depression?

The United States Institute of Mental Health (part of the National Institutes of Health) recommends the following to help immediately address your depression:

• Try to find ways to be active or to get exercise
• Try to prioritize what you do and break up lager tasks into smaller tasks
• Spend time with loved ones and friends who you can trust and are supportive
• If you have an important life decision to make, ask for advice from friends and/or family members you trust or postpone making the decision
• Avoid self-medicating with alcohol or recreational drugs
• Most importantly, try to be easy on yourself and engage in activities that you enjoy
• See your doctor if you think you may be depressed or have symptoms that impact your ability to go about your daily functions

Bottom Line

Conventional therapies work for depression and your doctor or primary care provider will most likely recommend or offer you those treatments first. Usually, you will be offered medications, although, current evidence shows that non-drug approaches like cognitive behavioral therapy (CBT) work just as well with fewer side effects. ^[xxiii] However, your insurance may not cover CBT. If the conventional approaches work and are satisfactory for you, then nothing further may be needed. If they are only partially effective, produce side effects that are unacceptable, or if you prefer a deeper, more comprehensive self-care approach to depression, consider integrative approaches. Many complementary and integrative approaches are safe and effective. For more information visit the National Center for Complementary and Integrative Health at the National Institutes of Health: https://nccih.nih.gov/health/depression.htm.

For a good review of conventional treatments of depression including some comparisons with complementary approaches and exercise, see the guideline published in 2015 by the American College of Physicians: http://annals.org/aim/fullarticle/2490527/nonpharmacologic-versus-pharmacologic-treatment-adult-patients-major-depressive-disorder-clinical.

Talk To Your Doctor And Integrate These Practices

Always let your medical providers know what treatments you are using to improve your health. Never change your medications without consulting your providers. If your doctor does not know about or offer some of the complementary and integrative practices described in this pocket guide, give him or her a copy and ask if you can work with him or her to integrate them alongside the conventional treatment. In this way you are both building a more holistic healthcare process for healing a chronic illness.