Complementary Therapies for Depression,
Background Research

This paper looks briefly at some of the relevant background research on complementary therapies for depression.  St John’s wort is not well covered – see instead the article ‘St John’s wort, background research’.   This current paper is not a systematic review so some important articles will have been missed out.  Having said this, articles in this field that are intended to be systematic reviews often also miss out relevant research.  This is partly because the definition of what should and what should not be included as a complementary therapy is unclear.

St John's wort and SAMe

There are several interesting reviews of complementary therapies that are particularly relevant for depression [1-9].  The most of recent of these[1] – Werneke et al’s ‘Complementary medicines in psychiatry: review of effectiveness and safety’ –  was published in early 2006.  It concludes that ‘Potentially useful substances include ... St John’s wort and s-adenosylmethionine as antidepressants, and selenium and folate to complement antidepressants.’  St John’s wort is easily available in the UK.  See the sister article ‘St John’s wort, background research’ for more on this somewhat controversial subject.  My impression is that s-adenosylemethionine (SAMe) is not widely used in the UK, despite a recent relatively favourable systematic review[8].  There is also an encouraging paper whose summary is downloadable from the US Agency for Healthcare Research and Quality (AHRQ) at www.ahrq.gov .  Research on oral SAMe has tended to use 1,600 milligrams daily [10].  This makes it a fairly expensive form of treatment and there are also concerns about the quality and content of some available SAMe products [11].  SAMe does however seem well worth researching further.  Possibly it is an agent that we will see more of in the future.

Omega-3s

Werneke et al are fairly dismissive of the helpfulness of fish oils and omega-3 fatty acids in depression.  Their approximately 50 word comment is dramatically dwarfed by the 418 page AHRQ systematic review ‘Effects of omega-3 fatty acids on mental health.’ which is freely downloadable from www.ahrq.gov .  AHRQ also highlight how much more research is needed before it becomes clear how useful the omega-3 fatty acids are.  The more recent paper on omega-3’s for bipolar depression is a small, but further encouraging, step forward[12].  It certainly seems reasonable to encourage some increase in omega-3 intake for the general population, and even more so for those who struggle with depression.  It may also be sensible to encourage some reduction in intake of omega-6 fatty acids as well.  

Selenium

Wernecke et al’s comments about selenium are interesting.  Selenium levels tend to be low across the Scottish and general UK population [13, 14].  Low selenium levels are associated with increased risk of a number of cancers [15, 16], viral infections, reproductive problems and other disorders [13].  There have been several small scale studies suggesting selenium supplementation might be helpful for improving mood [17-21], but a recent larger scale study throws doubt on this suggestion [22].  For general health reasons, it makes sense for people in the UK to take a dietary supplement that contains selenium.  A 200 microgram supplement of selenium as selenium methionine has been used in some research trials.  Care should be taken to avoid too high a selenium intake as this is toxic, but a total daily dose from all sources of up to 450 micrograms per day is probably well within safety limits [23].   At the moment though it is unclear whether or not selenium supplementation will help with mood as well as producing its better documented general health benefits.

Folic Acid

Folic acid supplementation currently looks a better bet for helping with depression.  There is a huge amount of research on folate.  A Medline search using ‘folic acid’ as a keyword turned up 1,000 articles for 2005 alone.  Low folic acid seems to predispose to all kinds of health problems including depression [24-26].  This seems partly to do with some people having a particular genetic vulnerability to such problems [27, 28].  Folic acid does not appear to be an adequate treatment for depression on its own (although it might reduce the risk of developing depression in the first place).  Supplementation may well however improve the response to standard antidepressants and also make maintenance antidepressant treatment more effective [6, 29, 30].  Taking 400-800 micrograms of supplemental folic acid daily seems sensible as too does emphasising folate rich foods in the diet.

Other Dietary Supplements

Further aspects of diet that have been looked at in depression include other B vitamins, chromium, zinc, tryptophan and inositol.  Vitamin B6 may be useful for pre-menopausal women [31], and there is also limited evidence suggesting benefits from vitamin B12 in depression across the general population [32-34].  There is some work on a possible role for chromium supplementation – for example chromium picolinate at 600 micrograms daily – particularly for atypical depression sufferers with high carbohydrate craving [35-38].  Atypical depression is commoner in women than men and it is characterised by symptoms such as swings in mood (mood reactivity), over eating, over sleeping, and weight gain (rather than the poor sleep and loss of appetite often seen in ‘typical depression).  There is some very preliminary work looking at a possible role for zinc [39, 40].  Tryptophan depletion has been used for many years as an experimental inducer of depression [41] and there is a good deal of rather poor quality research suggesting taking tryptophan may be of some use as a depression treatment [42].  Finally a 2004 meta-analysis of inositol treatment for depression showed unclear results [43] but a more recent trial using inositol as an add-on treatment in bipolar depression was somewhat more encouraging [44].

As can be seen from this article so far, many alternative treatments for depression involve dietary supplements.  It has been argued by very well-informed specialists that pretty much everyone should consider taking a general dietary supplement.  To quote: ‘Most people do not consume an optimal amount of all vitamins by diet alone. Pending strong evidence of effectiveness from randomized trials, it appears prudent for all adults to take vitamin supplements.’ [45, 46]  I would add that it is probably also prudent – especially in the UK – to make sure the supplement contains other ingredients such as selenium.

Acupuncture

As for other complementary approaches, there have been several reports that acupuncture is helpful for depression.  Most of this research seems of fairly poor quality and does not control adequately for placebo effects [47-49].  A more recent trial of acupuncture for depression during pregnancy was better controlled and yielded encouraging results [50].  This is particularly encouraging as depression during pregnancy is usually best not treated with antidepressants.  Further research is clearly needed.

Mindfulness-based Cognitive Therapy

Mindfulness-based cognitive therapy (MBCT) has recently been shown to be well worth considering for reducing the chance of depressive relapse in people who have suffered three or more previous episodes of depression [51-54].  Despite being well at the time of treatment, subjects were at clear risk of developing depression again.  Learning this meditation technique in a training group reduced relapse rates by 40-50% over the following 60 weeks as compared with a comparison treatment-as-usual group.  Further studies, including research comparing response rates with credible active-treatment control groups, is well worth pursuing.  One interesting comparison would be with a straightforward relaxation training group.  Although relaxation training as a possible treatment for depression has fallen out of fashion, early results appeared to show some worthwhile benefits [55-58].  It is possible too that hypnotherapy has something worthwhile to offer.  It has been suggested that hypnosis is not a treatment in its own right but more a vehicle for the delivery of other treatments.  Cognitive therapy is a well documented therapy for depression and there is some evidence suggesting that hypnosis can at times boost the effectiveness of cognitive therapy [59, 60].

At present there seems to be very little research evidence supporting the use of other complementary therapies as treatments for depression.  Certain individuals with depression may find that they benefit from therapies such as homoeopathy, massage, manipulation, reflexology, Bach flower remedies, and so on.  Currently, however, there is no good reason for recommending any of these practices as general treatments for those affected by depression.    

Dr James Hawkins, DAS Clinical Advisory Group Member, April 2006. www.goodmedicine.org.uk

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