alternative treatments for depression 1

what else is worth trying besides drugs and talking therapies?

Its important to keep an open mind, but not so open that your brains fall out. attributed to various sources about the author:
James Hawkins is a medical doctor, Chinese trained acupuncturist and accredited cognitive therapist. He chairs the clinical advisory group for Depression Alliance Scotland, the main consumer-led charity working for depression sufferers in Scotland. James was one of the initial group of doctors who set up the BHMA in 1983. He now primarily works through Good Medicine a small Edinburgh-based charity that focuses on helping people with psychological difficulties. Good Medicine tries to use therapies (conventional, complementary and self-help) with better research support before, if necessary, adding in methods that are currently less strongly evidence-based. Good Medicine is also clear that knowledge evolves but the heart of medicine remains constant in the care and sensitivity with which it is practised.

summary:
Depression is the largest single cause of non-fatal disease burden worldwide [1]. It accounts for nearly 12% of total days lived with disability. In December 2004 the National Institute for Clinical Excellence (NICE) published its guideline for doctors on the treatment of depression. A subsequent editorial in the BMJ [2] identified uncertainty about the management of mild or moderate depression as the guidelines central weakness. NICE concluded that there was little current firm evidence that mild to moderate depression is responsive to antidepressant medication or specific psychological treatments. This article looks at emerging research suggesting that treatments involving exercise and sleep should be taken more seriously. Subsequent articles are due to explore the potential value of light, herbs, dietary supplements, self-help books, meditation and other approaches.

physical exercise:
Encouragement to introduce or increase leisure time physical exercise is one of the first interventions that health professionals should consider for depression sufferers. The recent UK Department of Health publication At least five a week: evidence on the impact of physical activity and its relationship to health puts it very clearly People who lead an active lifestyle over several years have a reduced risk of suffering symptoms of clinical depression. Physical activity is effective as a treatment of mild, moderate and severe clinical depression. It may also help people with other mental illnesses [3]. The report goes on to state Physical activity helps people feel better through improvement in mood, reduced anxiety and enhanced self-perceptions. Physical activity can also help people to function better through alleviation of stress, and improved sleep, and in older people through some aspects of cognitive function. More obviously than any other depression treatment, exercise is also hugely helpful for our general health with the DoH report concluding that regular exercise reduces the risk of developing major chronic diseases - such as coronary heart disease, stroke and type 2 diabetes - by up to 50%, and the risk of premature death by 20-30%. A survey of over 300 members of the general public found that physical exercise was rated as the most effective way of improving bad moods [4] and further surveys showed that physically active people feel happier and more satisfied with their lives [5]. Despite all this, 69% of UK adults do not

exercise at recommended levels [6]. In the general population, regular physical exercise is associated with lower levels of depression and anxiety, even when allowing for sociodemographic factors and self-reported physical disorders. This seems true across all age groups that have been studied. So 8-12 year olds classified as inactive by a teacher or parent were found to be 2.8 to 3.4 times more likely to suffer from depressive symptoms than similarly aged children who were classified as active [7]. Adolescents who increased the frequency of their leisure time physical activity by 1 standard deviation, between two assessments done a couple of years apart, were found to have decreased the level of their depressive symptoms by 0.25 standard deviations [8]. Similarly the 60.3% of a nationally representative sample of over 8,000 US adults ages 15-54 who reported some degree of regular physical activity had a significantly decreased prevalence of current major depression and anxiety disorders. These associations between regular physical activity and lower prevalence of current major depression (OR = 0.75 (0.6,0.94)), panic attacks (OR = 0.73 (0.56, 0.96)), social phobia (OR = 0.65 (0.53, 0.8)), specific phobia (OR = 0.78 (0.63, 0.97)), and agoraphobia (OR = 0.64 (0.43, 0.94)) persisted after adjusting for differences in sociodemographic characteristics, self-reported physical disorders, and comorbid mental disorders. In this study, self-reported frequency of physical activity also showed a dose-response relationship with current mental disorders [9]. Finally a study following up 1,947 community-dwelling adults aged 50-94 for 5 years found that greater physical activity was protective for both current depression (adjusted odds ratio (OR) = 0.90, 95% confidence interval (CI): 0.79, 1.01) and incident depression (adjusted OR = 0.83, 95% CI: 0.73, 0.96). These odds ratios are given after allowing for differences in age, sex, ethnicity, financial strain, chronic conditions, disability, body mass index, alcohol consumption, smoking, and social relations [10]. The Norwegian psychiatrist Egil Martinsen pioneered exercise treatment for depression sufferers. In the mid-1970s physical fitness training was introduced as an integrated part of a comprehensive inpatient treatment programme for depression in his hospital. By the mid1990s Martinsen was already reporting on a dozen studies he had done using exercise in this way [11]. All twelve studies gave encouraging results. It appeared that for mild to moderate depression, programmes involving an hour of exercise three times weekly for six to nine weeks were better than no treatment and as effective as the psychotherapies they were compared with. Aerobic and anaerobic forms of exercise seemed equally helpful [12]. Retrospectively, patients ranked exercise as the most important component of the overall medication, psychotherapy and exercise treatment programme [13]. At follow-up a year after discharge, more than 50% of ex-patients were still exercising regularly. This more active group tended to do better than those who were more sedentary. Interestingly Martinsen reported that a motivated staff is the most important factor in motivating the patients. This latter point seems to have important implications for doctors and other therapists who plan to introduce exercise more into their work with depression sufferers. As with research in virtually all areas of medicine, study designs have improved and research done a number of years ago may now look less convincing. How has Martinsens and other pioneers early work held up when compared to more recent results? On the whole the conclusions have stood up well, but it is a shame that further research has been relatively limited and patchy. No doubt the lack of funding from both commercial and governmental organizations has contributed largely to this state of affairs. Reviews looking at interventions for depression, other than antidepressants and talking therapies, highlight exercise as a leading candidate [14, 15]. Limited evidence suggests exercise may be as effective as medication [16, 17], but rather better evidence suggests it is as effective as psychotherapy [18] for depression. Since cognitive therapy is known to be as good or better than antidepressants [19-21], the fact that four studies have shown exercise is as effective as cognitive therapy for depression [18] makes the evidence supporting exercise as a treatment

for clinical depression much more convincing. Further research shows it is worth considering adding exercise as a treatment for depression sufferers who have not responded adequately to antidepressants [22]. Aerobic and anaerobic forms of exercise currently seem equally helpful in treating depression [23, 24], though aerobic exercise is clearly preferable for its general health benefits [3]. Interestingly there is work showing that immediate short term improvement in mood following an episode of supervised moderate intensity resistance training is predictive of the likely overall mood improvement after a full ten week exercise programme [25]. It has also been found that how well an individual adheres to regular exercise early in a treatment programme gives a good indication as to how well that individual is likely to keep up regular exercise in the longer term [26]. Depression sufferers with higher levels of anxiety and lower levels of life satisfaction have also been reported to be more likely to drop out or have poor outcome with exercise treatment [27]. All these findings though have emerged from just a few research studies and need to be treated as interesting possibilities rather than firmly entrenched facts. As for optimal exercise programme intensity and frequency, a weight training programme for older women was found to be as effective at moderate intensity three times weekly as at high intensity three times weekly [28]. The recent results from Dunn et als dose ranging study on aerobic exercise [29, 30] suggest that exercising aerobically three times weekly is as effective for depression as exercising aerobically five times weekly, however higher intensity exercise produced better results than lower intensity. The higher intensity exercise was 17.5kcal/kg/week which is consistent with general public health recommendations for physical activity. This means that someone intending to use exercise as a form of depression treatment should probably aim for exercise levels as recommended for their general health benefits. Bandolier, the Oxford evidence-based medicine website [31] see www.jr2.ox.ac.uk/bandolier/booth/hliving/startoex.html provides a free downloadable six page handout on how to start and maintain a sensible exercise programme. There is also the superbly positive evidence-based document available from the UK Chief Medical Officer entitled At least five a week: Evidence on the impact of physical activity and its relationship to health. This includes a well referenced six page section on exercise and mental health as well as lots of other useful information. This already mentioned Department of Health (DoH) publication is highly supportive of exercise as both treatment and general improver of mental health. Its recommendation for adults is to take at least 30 minutes of at least moderate intensity aerobic activity at least five days a week. The whole 128 page PDF document is freely downloadable by visiting the DoH website at www.dh.gov.uk/Home/fs/en and then typing At least five a week into the search facility at the top of the page. One can then print out subsections of the document to use as information leaflets. As with virtually all medical and health interventions, it is important to balance enthusiasm with a degree of caution. Artal and Sherman writing in the journal The Physician and Sports Medicine [32] put it well when they state: Physical activity is a useful tool for preventing and easing depression symptoms. When prescribing exercise the complexity and the individual circumstances of each patient must be considered. Hopelessness and fatigue can make physical exertion difficult, and some patients are vulnerable to guilt and self-blame if they fail to carry out a regimen. A feasible, flexible and pleasurable program has the best chance for success. However, depression sufferers adhere to exercise programmes as well as they adhere to other forms of depression treatment, and they can continue to exercise as consistently as non-depressed populations [3]. How are these benefits produced? What are the mechanisms? It seems it is factors associated with being physically active, rather than the fitness itself, which are mainly responsible for improvements in psychological state. The DoH report lists three major processes: Psychosocial mechanisms including improvements in perception of competence or confidence about the body and its capabilities, improved body image, and experiencing a

sense of achievement, mastery and self-determination. The report points out that there has been less focus on the social mechanisms of affiliation, interaction and support than is warranted. Biochemical mechanisms including increased circulatory plasma endorphins, norepinephrine and serotonin (which affects sleep, depression and memory). Physiological mechanisms including increased core temperature and cerebral blood flow, reduced muscular tension, and neurotransmitter efficiency. It seems likely that multiple mechanisms combine to produce exercises effects. So what to conclude at the moment about exercise and depression? Having browsed much of the published literature, I think its very important to have exercise as one of the interventions a therapist considers recommending. Exercise, whether aerobic or anaerobic, can be helpful and in some cases very helpful in combating the depression. If the sufferer seems interested in this approach then Artal and Shermans advice to try to find exercise that is feasible, flexible and pleasurable makes very good sense. Giving a handout on exercise like the downloadable one from Bandolier is also likely to be helpful as it contains much very practical advice. Exercise can be prescribed as the sole treatment in some cases of mild to moderate depression, but it seems more sensible to have exercise as one part of a broader treatment package. Beware of making the sufferer feel more depressed by allowing them to aim too high and fail. Small steps and only gradually increasing challenges is likely to be the best way to go. If a patient finds that with certain types of exercise their mood temporarily lifts, this is a good reason to try to incorporate this type of exercise in their overall programme. Similarly if a patient manages to exercise regularly in the first two or three weeks after starting the programme, this is an encouraging indication that they may well be able to continue exercising long term. Lifelong exercise looks a good candidate for a way of reducing the chance of depressive relapse, and it is very clearly helpful for a whole string of other important health outcomes.

sleep:
Sleep is connected with depression in a number of ways. Examples include poor sleep as a possible early warning sign for depression, as a symptom of current depression, as a sideeffect of depression treatment, and as a residual symptom left when depression has not fully cleared [33]. In this article however I will simply look at the potential value of sleep deprivation (sometimes also called wake therapy) as a form of treatment. Following case observations by Schulte in the 1960s, Pflug and Tolle, in 1971, were the first to publish stronger evidence for sleep deprivations possible value [34]. Since then a considerable amount of research has been done on this topic particularly in mainland Europe. A simple Medline search combining depressive disorder and sleep deprivation as keywords yields well over 300 articles. The research tends to involve small numbers of subjects and is often of quite poor design, but it consistently highlights the value of this approach. Sleep deprivation is the only form of antidepressant therapy that has repeatedly been shown to be able to produce a next-day response [35]. If someone with depression avoids sleeping for a whole night they have approximately a 50% chance of feeling at least 30% less depressed the next day [36]. Interestingly, if non-responders try the procedure again they may respond at a second or further attempt [37]. For many people suffering from depression and associated sleep difficulties, the request to avoid sleeping for a night seems rather crazy. Although probably not quite as effective as total sleep deprivation (TSD) [38], partial sleep deprivation later in the night (LPSD) may well be better tolerated and seems more effective than sleep deprivation earlier in the night (EPSD). A major problem with sleep deprivation is that of the 40 to 60% who feel a good deal better the next day, 80% or more will relapse after sleeping. There has therefore understandably been a number of research studies exploring ways of maintaining the mood improvement achievable through this wake therapy. Lead candidates are only going back to a standard nights sleep times in small increments, adding

bright light therapy, and using wake therapy in conjunction with medication. Typical instructions for late sleep deprivation (LPSD) followed by gradual return to standard sleep would run as follows: Go to bed early if you want to, but then get up by 1.00am at the latest. Once youre up, stay up and make sure you do not nap at all during the day. You can go to bed early the next night (from 5.00pm onwards), but then get up at 2.00am. Again stay awake all day, and the next night get up at 3.00am. Continue this process allowing an extra morning hour in bed each subsequent night until the normal get up time is reached. Other authors have had encouraging responses with more rapid sleep phase advance advocating getting up at midnight the first night, 2.00am the second, 4.00am the third and so on [39]. Using these phase advance methods reduces the relapse rate for the 40 to 60% of LPSD responders from 80% to only about 40% [40-42], so approximately 1 in 3 depression sufferers starting this procedure will have made a rapid and sustained response after this treatment. When one realizes that standard antidepressants or psychotherapy typically only achieve a 50 to 60% response rate after a number of weeks [21, 43, 44], this potential rapid 30 to 35% response rate begins to look rather attractive especially as one can add in other therapies to further improve the outcome. Adding bright morning light using a lightbox is another way to help maintain improvements achieved through TSD or LPSD. Getting people who are trying sleep deprivation to use a lightbox providing half an hour or more of 3,000 to10,000 lux between 6.00 and 9.00am for at least a week seems helpful whereas a control condition using 100 to 500 lux seems no better than placebo [45, 46]. Various types of medication also appear to help maintain sleep deprivation improvements. Standard antidepressants [47], lithium [48, 49], and pindolol [50] all seem useful in this situation. There has also been a search for predictors of good response to sleep deprivation. Having a tendency to feel worse in the morning and then a bit better later in the day (diurnal variation) seems associated with better response to TSD/LPSD [51-53]. Bipolar depression either type I or type II seems to be more likely to respond to sleep deprivation than unipolar depression [54]. Sufferers from type I bipolar disorder (formerly known as manic depression) seem more likely to know their diagnosis as they will have had prominent manic symptoms as well as prominent depressions over the years. Sufferers from type II bipolar disorder characterised by hypomania rather than full mania may well not know that this is the form of depression that is troubling them. The Mood Disorder Questionnaire [55] is a useful screening tool in this situation. Hirschfeld has estimated that many people diagnosed with standard unipolar depression may in fact being suffering from bipolar II disorder with its pattern of depression episodes and occasional times of hypomania [56]. Like all treatments, sleep deprivation has potential side-effects. It is understandably likely to produce tiredness. About 5% of people will feel temporarily more depressed [36]. For patients with bipolar disorder there seems to be about a 5% risk of switching into mania and about a 5% risk of switching into hypomania similar rates to those found with standard antidepressant treatment [57, 58]. Obviously therapists recommending sleep deprivation should warn bipolar patients especially about the risk of switching to mania or hypomania and discuss ways of responding to this development if it becomes necessary. Ideally bipolar sufferers should already have discussed with a mental health professional what their first aid response to early signs of mania would be as there is research showing the value of this preparation whether they try sleep deprivation or not [59, 60]. Overall sleep deprivation or wake therapy seems an underused form of treatment that should be made available to more depression sufferers. It has obvious applications in many situations including pregnancy and breastfeeding [61] where antidepressants might not be indicated. Incidentally abbreviated wake therapy, involving just one night of getting up at 1.00am, may also help PMT [62, 63]. Adolescents too seem to respond to this form of treatment though the data is preliminary [64]. There will also be many other situations where it would be welcome to have alternatives to drugs and psychotherapy. Depression sufferers

who are prepared to try wake therapy have a good chance of getting a considerably quicker response than with other forms of treatment [47, 65].

conclusion:
This article started by highlighting how much suffering depression causes. Exercise and wake therapy, two non-drug, non-talking therapy treatments, were then introduced. Wake therapy can be made more helpful by combining it with light or medication or by phasing the return to standard get-up time over a few days. It is an underused way of achieving a rapid and persistent therapeutic response for approximately 1 in 3 depression sufferers. One can improve this response rate further by choosing patients with obvious symptom diurnal variation or a history of bipolar disorder. Exercise, in contrast, is a slower intervention. It is however relevant, in one form or another, for almost all depression sufferers. It is typically viewed positively by the general public. It has remarkably few side-effects and huge numbers of additional positive benefits. Any therapist seeing depression sufferers regularly should be aware of the relevance of exercise and be able to help patients choose forms of exercise that are likely to be personally appropriate for them. Later articles in this series will introduce light, herbs, dietary supplements, self-help books, meditation and other non-drug, non-talking therapy treatments.

a note for depression sufferers:

Information in this article is not a substitute for seeking expert help. If you feel you may be depressed, please see your family doctor or other qualified health professional. You can always show them this article and discuss these treatments with them.

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