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Complementary Therapies for Depression An Overview Edzard Ernst, MD, PhD, FRCP(Edin); Julia I. Rand, MBBS, MSc; Clare Stevinson, BSc, MSc D epression is one of the most common reasons for using complementary and alternative therapies. The aim of this article is to provide an overview of the evidence available on the treatment of depression with complementary therapies. Systematic literature searches were performed using several databases, reference list searching, and inquiry to col- leagues. Data extraction followed a predefined protocol. The amount of rigorous scientific data to sup- port the efficacy of complementary therapies in the treatment of depression is extremely limited. The areas with the most evidence for beneficial effects are exercise, herbal therapy (Hypericum perfora- tum), and, to a lesser extent, acupuncture and relaxation therapies. There is a need for further re- search involving randomized controlled trials into the efficacy of complementary and alternative thera- pies in the treatment of depression. Arch Gen Psychiatry. 1998;55:1026-1032 Depression is a frequently occurring psy- chiatric disorder with a prevalence of ap- proximately 5% in the general popula- tion. 1,2 It is estimated that at least one third of all individuals are likely to experience an episode of depression during their life- time. 3 Depression results in high personal, social, and economic costs through suffer- ing, disability, deliberate self-harm, and health care provision. Despite the availabil- ity of drug and psychotherapeutic treat- ments, much depression remains undiag- nosed or inadequately treated. 4 This state of affairs has stimulated the development of educational campaigns and treatment con- sensus statements. 5,6 Complementary and alternative medi- cine (CAM) is often negatively defined, for example, as “a system of health care which lies for the most part outside the main- stream of conventional medicine.” 7 A more inclusive definition 8 has been adopted by the Cochrane Collaboration: “complementary medicine is diagnosis, treatment, and/or pre- vention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy, or by diversifying the concep- tual frameworks of medicine.” Complementary and alternative therapies (CATs) are popular. In 1991, 34% of the US adult population used at least 1 such therapy for 1 year. 9 This fig- ure has now risen to 40%. 10 Twenty per- cent of those suffering from depression had used an unconventional therapy within the past year. 9 Depression is among the 10 most frequent indications for using CATs, and relaxation, exercise, and herbal rem- edies are the 3 most prevalent CATs tried for this condition. 10 Forty-two percent of 115 Danish psychiatric inpatients had used CATs at least once, with herbal medicine being the most frequent type. 11 Herbal rem- edies, homeopathy, acupuncture, mas- sage, relaxation, and unconventional psy- chotherapeutic approaches have been reported 12 as the most prevalent CATs among psychiatric patients. The response to the question of why people turn toward CAM is as fascinating as it is complex. No simple, uniform an- swer can be identified as the list of moti- vations will vary depending on which (pa- tient) group one asks. Generally speaking, however, people opt for CAM because they want to leave no option untried and look for treatments devoid of adverse effects. 13 Another important reason is that CATs are viewed as less authoritarian and more em- powering, offering more patient con- From the Department of Complementary Medicine, School of Postgraduate Medicine and Health Sciences, University of Exeter, Exeter, England. NEWS AND VIEWS ARCH GEN PSYCHIATRY/ VOL 55, NOV 1998 1026 ©1998 American Medical Association. All rights reserved. Downloaded From: http://archpsyc.jamanetwork.com/ by a Clemson University User on 09/17/2013

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Page 1: Complementary Therapies for Depression

Complementary Therapies for Depression

An Overview

Edzard Ernst, MD, PhD, FRCP(Edin); Julia I. Rand, MBBS, MSc; Clare Stevinson, BSc, MSc

D epression is one of the most common reasons for using complementary and alternativetherapies. The aim of this article is to provide an overview of the evidence available onthe treatment of depression with complementary therapies. Systematic literature searcheswere performed using several databases, reference list searching, and inquiry to col-

leagues. Data extraction followed a predefined protocol. The amount of rigorous scientific data to sup-port the efficacy of complementary therapies in the treatment of depression is extremely limited. Theareas with the most evidence for beneficial effects are exercise, herbal therapy (Hypericum perfora-tum), and, to a lesser extent, acupuncture and relaxation therapies. There is a need for further re-search involving randomized controlled trials into the efficacy of complementary and alternative thera-pies in the treatment of depression. Arch Gen Psychiatry. 1998;55:1026-1032

Depression is a frequently occurring psy-chiatric disorder with a prevalence of ap-proximately 5% in the general popula-tion.1,2 It is estimated that at least one thirdof all individuals are likely to experience anepisode of depression during their life-time.3 Depression results in high personal,social, and economic costs through suffer-ing, disability, deliberate self-harm, andhealth care provision. Despite the availabil-ity of drug and psychotherapeutic treat-ments, much depression remains undiag-nosed or inadequately treated.4 This stateof affairs has stimulated the development ofeducational campaigns and treatment con-sensus statements.5,6

Complementary and alternative medi-cine (CAM) is often negatively defined, forexample, as “a system of health care whichlies for the most part outside the main-stream of conventional medicine.”7 A moreinclusive definition8 has been adopted by theCochrane Collaboration: “complementarymedicine is diagnosis, treatment, and/or pre-vention which complements mainstreammedicine by contributing to a commonwhole, by satisfying a demand not met byorthodoxy, or by diversifying the concep-tual frameworks of medicine.”

Complementary and alternativetherapies (CATs) are popular. In 1991,34% of the US adult population used atleast 1 such therapy for 1 year.9 This fig-ure has now risen to 40%.10 Twenty per-cent of those suffering from depression hadused an unconventional therapy within thepast year.9 Depression is among the 10most frequent indications for using CATs,and relaxation, exercise, and herbal rem-edies are the 3 most prevalent CATs triedfor this condition.10 Forty-two percent of115 Danish psychiatric inpatients had usedCATs at least once, with herbal medicinebeing the most frequent type.11 Herbal rem-edies, homeopathy, acupuncture, mas-sage, relaxation, and unconventional psy-chotherapeutic approaches have beenreported12 as the most prevalent CATsamong psychiatric patients.

The response to the question of whypeople turn toward CAM is as fascinatingas it is complex. No simple, uniform an-swer can be identified as the list of moti-vations will vary depending on which (pa-tient) group one asks. Generally speaking,however, people opt for CAM because theywant to leave no option untried and lookfor treatments devoid of adverse effects.13

Another important reason is that CATs areviewed as less authoritarian and more em-powering, offering more patient con-

From the Department of Complementary Medicine, School of Postgraduate Medicineand Health Sciences, University of Exeter, Exeter, England.

NEWS AND VIEWS

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etrol.14 Astin10 found that CAM us-ers are, on average, better educatedand report poorer health than non-users. Interestingly, they do not usu-ally turn to CAM as a result ofbeing dissatisfied with orthodoxmedicine, and only 5% use CAM asa true alternative to conventionalmedicine.

Lay books on CAM15-18 pro-mote a wide range of CATs for de-pression (Table). In view of suchpromotion and CAM’s popularity,the need for more informationarises.21 The aim of this article, there-fore, is to review the published evi-dence regarding the effectiveness ofCAT in the treatment of depres-sion. As we will see, the trial data arealmost invariably burdened with nu-merous limitations. Small samplesize, selection bias, uncertainty aboutthe diagnosis, lack of blinding, lackof adequate outcome measures, fail-ure to control for nonspecific thera-peutic effects, failure to control forconfounders, inadequate duration,and personal belief of the investiga-tor in the treatment are the most fre-quent drawbacks.

Computerized literature search-ing without language restrictions wascarried out to identify all random-ized controlled trials (RCTs) relat-ing to CATs used for depression. Thefollowing databases were searched:MEDLINE (literature from 1966-1996), EMBASE (literature from1986-1996), CISCOM (Central-ized Information Service for Com-plementary Medicine; search per-formed in January 1997), and theCochrane Library (accessed March1997 [Issue 1]). A wide range ofsearch terms was used, reflecting thediversity of CATs: acupuncture, af-fective disorders, Alexander tech-nique, alternative medicine, aroma-therapy, art therapy, Bach (flowerremedies), balneology, chiroprac-tic, color therapy, complementarymedicine, depression, depressive dis-orders, energy, essential oils, exer-cise, healing, herbal medicine,hydrotherapy, hypnosis, kinesiol-ogy, laughter, manipulation, mas-sage, music, naturopathy, osteo-pathy, oxygen, polarity, qigong,reflexology, relaxation, therapeu-tic touch, and tragerwork. The ref-erence lists of all articles thus foundwere also searched. Furthermore, in-

quiries were made to colleagues forany further publications and our fileswere searched.

Ideally, only RCTs would be se-lected for this review. However, asthe search revealed that few RCTshave been conducted, less-rigorousstudies are referred to in cases inwhich no RCTs are available. Ar-ticles discussing the following main-stream treatments for depressionwere excluded: cognitive therapy,light therapy for seasonal affectivedisorder, and partial sleep depriva-tion. Articles with no factual datawere also excluded. All studies ad-mitted to this review were read in fullby two of us (E.E. and J.I.R.). Datawere extracted according to a pre-defined checklist. Discrepancieswere settled through discussion.

ACUPUNCTURE

Acupuncture is an ancient Chinesetreatment. Based on the belief that 2types of “energies” flow in “merid-ians” throughout the body and that

an imbalance of these energies con-stitutes illness, acupuncturists insertneedles into points located on merid-ians with the aim of correcting the im-balance and restoring health. West-ern acupuncturists are critical of theseTaoist theories and attribute acupunc-ture’s alleged benefits to neurophysi-ological effects.22 Hence, the puta-tive mechanism for acupuncture indepression is provided through stud-ies23 showing that the level of endor-phins can be increased through nee-dling. Acupuncture is normallycarried out in specialized clinics ei-ther by physicians or (more often)by nonmedically qualified thera-pists (NMQTs). One session wouldtypically last for 20 minutes, and aseries of 6 to 12 treatments may berequired.

Case series24,25 indicate that acu-puncture is promising for treatingdepression. Several uncontrolled26,27

and controlled28 clinical trials pro-vide data in support.

Electroacupuncture appears tohave greater efficacy than tradi-

Therapies Frequently Cited for the Treatment of Depression in Lay Books*

Therapy Description

Acupuncture Therapy usually involving sticking needles into acupoints along“meridians” to restore the body’s flow of “energy.”

Alexander technique Movement therapy to reduce muscular tension, involves retraining ofposture and movement patterns.

Aromatherapy Use of aromatic plant oils, which usually are massaged into the skin.Applied kinesiology Diagnostic and therapeutic technique based on the assumption that muscle

groups are related to distant parts and organs of the body.Autogenic training A form of self-hypnosis involving a series of visual and sensory exercises.Bach flower remedies Treatment with remedies designed by Edward Bach, MB,BS, MRCS, LRCP,

DPH, similar to those of homeopathy.Color therapy The use of different colored light for therapy based on the assumption that

certain colors have specific effects on diseases.Exercise Treatment through different forms of regular physical activity, usually

supervised by a physiotherapist.Healing Also called spiritual or faith healing, healers believe to channel “energy”

from a higher force toward the patient with a view to restore health andwell-being.

Herbalism Treatment of diseases with plants, parts of plants, or plant extracts.Homeopathy Treatment based on the “like cures like” principle, often with highly dilute

remedies.Hypnotherapy Use of hypnosis as an adjunct to medical treatments.Massage Manual stroking of the body surface with a view of relaxing muscles and

mind.Naturopathy Drugless therapy to enhance the body’s own healing powers using the

treatment modalities supplied by nature.Oxygen therapy Treatment with oxygen: several variants exist, eg, injecting oxygen into the

arteries or veins or treating blood with oxygen in vitro before reinjection.Qigong Traditional Chinese regimen involving movements and breathing

techniques with a view of balancing the body’s flow of “energies.”Tragerwork Treatment with gentle rhythmic touch and movement exercises, also

known as psychophysical integration.

*See books by the Burton Goldberg Group,15 McCarthy,16 and Olsen,17 and the article published inReader’s Digest.18 For good introductory text to these treatments see Cassileth19 and Fugh-Berman.20

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tional acupuncture, and the prelimi-nary results29 of a trial comparingstandard electroacupuncture andcomputer-controlled electroacupunc-ture have been published. These in-dicate that the computer-controlledelectroacupuncture treatment pro-duced greater clinical improvementthan electroacupuncture (P<.05) asmeasured by the grading system com-monly used in China for the assess-ment of therapeutic effects.

Two RCTs30,31 compare the ef-fects of electroacupuncture andamitriptyline hydrochloride in de-pressed patients. Patients sufferingfrom depression (defined accordingtoNationalSurveyandCoordinationGroup of Psychiatric Epidemiologystandards) were grouped at randomto receive 5 weeks of therapy witheither electroacupuncture (n=27) orthe tricyclic antidepressant amitrip-tyline hydrochloride (n=20; aver-age daily dose, 142 mg).30 A com-parison of Hamilton DepressionScale scores before and after treat-ment showed a significant reduc-tion (from 29 to 13 and 29 to 14, re-spectively) in the scores for bothgroups (P<.01). At the end of thetreatment period, there was no sta-tistically significant difference be-tween the 2 groups.

An RCT31 involving 241 de-pressed patients compared treat-ment with electroacupuncture oramitriptyline hydrochloride for 6weeks. Hamilton Depression Scalescores showed a significant reduc-tion after treatment in both groups(from 35 to 8 and 35 to 10, respec-tively). There was no significant in-tergroup difference after 6 weeks.Follow-up of 148 patients for 2 to 4years revealed no significant differ-ence in the depression recurrencerate between the 2 groups.

HERBAL MEDICINE

Medical herbalism (also termed phy-totherapy in Europe) is the treat-ment of illness with plants, parts ofplants, or plant extracts. It has a longhistory in all medical cultures, andmany of our modern drugs havebeen derived from botanical sources.Each plant contains a whole array ofcompounds, and it is sometimes dif-ficult to define which and how manyof these contribute to which phar-

macological effect. The mechanismof action can thus be complex, butmay be understood or researched byconventional pharmacological meth-ods. While the general public usu-ally view plant-based medicines asdevoid of adverse effects, this no-tion can be dangerously mislead-ing.32 In continental Europe, phy-totherapy is an integral part ofphysicians’ prescribing. In the UnitedStates and the United Kingdom,herbal medicine is mostly in thehands of NMQTs.

Scattered references33,34 occur inthe ethnobotanical literature toplants used by indigenous peoplesto treat depression. In China, herbalremedies are often used in combi-nation with conventional westerndrug therapy.35 However, only fewtrials, usually of poor methodologi-cal quality, investigate Chineseherbal therapies for depression. Asimilar situation exists in Japanwhere traditional herbal mixtures areused for depression, but their ef-fects have not yet been scientifi-cally tested.36

Lay books on CAM15-18 claim avariety of plants to be helpful in de-pression, eg, wild oats, lemon balm,ginseng, wood betony, basil, and StJohn’s Wort. Yet, only for St John’sWort (Hypericum perforatum) doesa substantial body of evidence ex-ist. It has recently been reviewed37,38

in English. The meta-analysis byLinde et al38 identified 23 RCTs in-volving a total of 1757 outpatientssuffering from mild to moderate de-pression. Fifteen of these trials wereplacebo controlled, and 8 com-pared H perforatum with orthodoxantidepressants. The overall re-sponder rate ratio showed that H per-foratum was significantly superior toplacebo (2.67; 95% confidence in-terval, 1.78-4.01). H perforatum wasfound to have an efficacy similar tothat of standard antidepressants.Compared with the antidepressantgroups, the H perforatum groups hadlower dropout rates (7.7% vs 4%)and numbers of patients reportingadverse effects (35.9% vs 19.8%). Arecent comparative analysis (C. S.and E. E., unpublished data, June1998) of adverse effects concludedthat “Hypericum seems to be at leastas safe and possibly safer than con-ventional antidepressant drugs.”

EXERCISE

Many categories of physical exer-cise exist, eg, leisure-time and work-related physical activity or singlebout and regular exercise. Theirphysiological responses may differconsiderably. For the purpose of thefollowing discussion, it is helpful todistinguish between regular endur-ance (mostly aerobic) exercise andpower (mostly anaerobic) exercise.For the treatment of depression, ex-ercise can be carried out either un-der supervision (eg, by a physio-therapist) or independently at home.In practice, a combined approach isusually the best.

A large body of evidence39

(.1000 trials) exists relating to ex-ercise and depression and numer-ous reviews40-53 on the topic haverecently been published. A meta-analysis of 80 studies50 (regardlessof their methodological quality) pro-duced an overall mean exercise ef-fect size of −0.53 (range, −3.88 to2.05). This suggests that the depres-sion scores decreased by approxi-mately one half of an SD more in theexercise groups than in the com-parison groups. The antidepres-sant effect occurred with all types ofregular exercise, independent of sexor age, and it increased with the du-ration of therapy. Overall, exercisewas as effective as psychotherapy.

The available evidence sug-gests that any type of exercise alle-viates depression. Martinsen and Ste-phens49 identified 8 experimentalexercise-intervention trials in clini-cally depressed patients, and exer-cise was associated with reductionsin depression scores in all of thestudies. Two further RCTs54,55 wereidentified via our search strategy.In the first study54 moderatelydepressed elderly subjects wererandomly allocated to walkingexercises, social-contact controlcondition, or a waiting-list controlgroup. After 6 weeks, the first 2groups showed a significant de-crease in Beck Depression Inven-tory scores compared with base-line. The second RCT55 involved 124depressed subjects allocated to aero-bic exercise, low-intensity exer-cise, or to a no exercise-interven-tion group. All subjects continuedtheir usual psychiatric treatment. No

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significant difference was found inthe Beck Depression Inventoryscores between the groups after 12weeks. However, the control grouphad been significantly more de-pressed at baseline.

AROMATHERAPY

Aromatherapists (normallyNMQTs)use a combination of gentle mas-sage techniques and essential oilsfrom plants. These oils are thoughtto have specific pharmacological ef-fects after transdermal resorption.One treatment would last about 30minutes, and a series of 6 to 12 treat-ments would usually be recom-mended.

Although aromatherapy isadvocated for improving mood indepression,56 and is perceived ashelpful by some patients,57 there isvery little objective evidence. In asmall pilot study,58 12 depressed menwere exposed to citrus fragrance inthe air and compared with 8 pa-tients who were not exposed to thefragrance. Both groups were takingantidepressants. It was reported thatthe dose of antidepressants in the ex-perimental group could be mark-edly reduced. The study was not ran-domized and involved only a smallnumber of patients with varying doseand type of antidepressants. At pres-ent, it is not possible to draw anyfirm conclusions about the value ofaromatherapy for depression.

DANCE AND MOVEMENTTHERAPY

A dance therapist (usually anNMQT) aims to involve patientsthrough encouragement to expressthemselves in movement and there-fore enhance well-being. Treat-ments can be organized as group ses-sions, adding an additional elementof social interaction. Typically, a ses-sion lasts 30 to 40 minutes, and regu-lar (eg, weekly) repetitions are nor-mally recommended.

Little scientific evidence isavailable for the role of dance andmovement therapy.59 Only 2 stud-ies60,61 were found, neither involv-ing large numbers or of rigorous de-sign. Twenty hospitalized psychiatricpatients and 20 normal control sub-jects were divided into 4 groups.60

Half of the psychiatric patients andhalf of the controls received 1 danceand movement therapy session, andthe other subjects received no in-tervention. After therapy, only thepsychiatric patients showed a sig-nificant reduction in depression asmeasured by the Multiple Affect Ad-jective Checklist self-rating scale(P,.001). In the second study,61 12inpatients with major depressionwere randomly assigned to move-ment therapy sessions on 7 of 14days. Five of the patients showed areduction in depression scores onmovement therapy days comparedwith days with no therapy (P,.05).Both studies suffer from method-ological limitations. Thus, insuffi-cient evidence exists to assess the ef-fect of dance and movement therapyin depression.

HOMEOPATHY

Homeopathy is based on the “likecures like” principle that suggeststhat a remedy (often, but not al-ways, plant based), which causes cer-tain symptoms in a healthy indi-vidual, can be used as a treatment forpatients presenting with such symp-toms. Furthermore, homeopaths be-lieve that, by “potentizing” (step-wise dilutions combined withvigorous shaking) a remedy, it willget not less, but more, potent. Theyassume that even dilutions devoid ofmolecules of the original remedy willhave powerful clinical effects.62 Ho-meopathy is practiced by both phy-sicians and NMQTs. A first consul-tation will usually last in excess of1 hour.

There is a dearth of investiga-tions into homeopathy for depres-sion. The literature consists mainlyof unsubstantiated treatment sug-gestions or case reports.63,64 The thor-ough review by Kleijnen et al65 anda recent meta-analysis by Linde etal66 of clinical trials of homeopathydetected only 1 study related to de-pression. It67 compared homeo-pathic treatment with diazepam inmixed anxiety and depressive states.This open trial was of low method-ological quality, but produced a re-sult in favor of homeopathy. A work-ing group of the European Unionlocated 377 reports of trials of ho-meopathy, which included no fur-

ther studies in depression.68 Thevalue of homeopathy as a treat-ment of depression is, therefore,presently unknown.

HYPNOTHERAPY

Hypnotherapy is a state of focusedattention or altered consciousness.All current theories of hypnosis areprovisional and incomplete.69 Hyp-notherapy cannot cure disease, butcan be a useful adjunct to conven-tional treatments. Therapy ses-sions vary in length and rate of rep-etitions. Hypnotherapy is practicedboth by physicians and NMQTs.

The literature on the subjectconsists only of anecdotal accountsand case reports.69,70 Our literaturesearches discovered no controlledclinical trials. It has been sug-gested71 that hypnotherapy may fa-cilitate the process of cognitivetherapy by aiding the restructuringof negative thought patterns.Again, this has not been substanti-ated. The value of hypnotherapyfor depression is, therefore, notknown at present.

MASSAGE THERAPY

There are several different forms andtraditions of massage therapy.72 Inthe context of this article, massageuses typically a gentle manual strok-ing technique over the body (usu-ally the back). This has a number ofcomplex physiological and psycho-logical effects, not least of which isrelaxation of both the musculatureand the mind.72 A treatment, usu-ally carried out by an NMQT, wouldnormally last for 20 to 30 minutesand a series of approximately 6 twiceweekly sessions would constitute atypical prescription.

Most publications relating tomassage and depression were foundto consist of anecdotal accounts andcase studies.73,74 A recent review75 ofmassage therapy uncovered only afew controlled trials. An RCT76 al-located 122 intensive care unit pa-tients to receive either massage, mas-sage with 1% lavender (Lavendulavera) oil, or rest periods. Those whoreceived the massage with lavenderoil reported a greater improvementin mood as measured by a self-rating 4-point scale. The study did

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not involve patients with depres-sion, was short-term, and used acrude outcome measure. It is thusnot possible to draw firm conclu-sions from its results.

In a well-conducted RCT,77,78

72 hospitalized children and ado-lescents, half with adjustment dis-order and half with depression,either received 30-minute backmassages (n=52) daily for 5 days orwatched a relaxing video (n=20)for the same period. Profile ofmood states depression scores weresignificantly lower immediatelyafter massage compared with pre-treatment values (P=.005). In addi-tion, the premassage profile ofmood states scores significantlydeclined during the 5-day treat-ment period (P=.01), and the mas-sage group was less depressed thanthe control group at the end ofthe study. Because of the smallsample size and the short treat-ment period, the data are insuffi-cient to judge the value of mas-sage for depression.

MUSIC THERAPY

Music therapy is the active or pas-sive use of music to promote healthand well-being. During treatment,patients perform music or listen tomusic carefully chosen and super-vised by a trained music therapist(usually an NMQT). The type of mu-sic will depend on the personalityand condition of the patient.

A limited amount of work re-lates to the effects of music therapyon depression.79 The results of an ob-servational study80 using psychody-namic music therapy methods withdepressed inpatients suggest thatthere may be a beneficial effect. OneRCT81 involved 30 elderly patients(aged 61-86 years) with depres-sion. They were randomly allo-cated to either a home-based musictherapy program, a self-adminis-tered music therapy program, or anonintervention waiting list (con-trol group). After 8 weeks, the Ge-riatric Depression Scale scores of the2 music groups were significantlybetter than those of the controlgroup (P,.05). There is a need forfurther trials with larger numbers todetermine whether this result can bereplicated.

RELAXATION THERAPY

Relaxation therapy is an umbrellaterm for several techniques prima-rily aimed at decreasing physical andmental tension. Such treatments mayinclude elements of meditation,yoga, and other mind-body thera-pies. They would normally be car-ried out by NMQTs.

Three RCTs82-84 investigatingthe effects of relaxation therapy werefound. In the first study, 30 psychi-atric outpatients with depression, alltaking medication, were random-ized to 3 groups.82 Two of the groupswere given different forms of relax-ation therapy during 3 days, whilethe third group acted as a control.Compared with controls, both re-laxation-therapy groups showed asignificant improvement in symp-tom scores (P,.05). However, asymptom score list was used that hadnot been validated, the sample sizewas small, and the treatment pe-riod short.

In an RCT83 involving 37 mod-erately depressed patients assignedto cognitive behavior therapy, re-laxation therapy, or tricyclic anti-depressants, the first 2 interven-tions resulted in significantly bettermean Beck Depression Inventoryscores than the pharmacologicaltreatment (P,.01). The resultsshould be viewed with caution be-cause of the small sample size, lackof control for the nonspecific ef-fects of attention from profession-als, and reported noncompliancewith the medication regime.

An RCT84 in 30 moderately de-pressed adolescents showed that re-laxation training or cognitive behav-ior therapy resulted in a greaterimprovement than no interven-tion. Again, the sample size wassmall and there was no control fornonspecific effects.

On balance, therefore, relax-ation treatments are promising, butfurther research and replications arerequired.

CONCLUSIONS

Because of the nature of the evi-dence relating to CAM and depres-sion, a qualitative overview seemedpreferable to a systematic review.Collectively, the above data sug-

gest that exercise and H perforatumare effective symptomatic treat-ments for mild to moderate depres-sion. The evidence for acupunc-ture, massage, and relaxation ispromising, but not compelling.

Acupuncture and electroacu-puncture can stimulate the synthe-sis and release of the monoaminesserotonin and noradrenaline-norepinephrine in animals.85 This isthe postulated mechanism for theperceived beneficial effect of acu-puncture in depression. The evi-dence available on the efficacy ofelectroacupuncture in the treat-ment of depression has mainly comefrom 1 research group at the Insti-tute of Mental Health, Beijing, China.The limited number of RCTs sug-gest a beneficial effect of a similarmagnitude to that produced by ami-triptyline hydrochloride. Electroacu-puncture is reported to producefewer and less-severe adverse ef-fects than standard antidepres-sants. However, there is a need forthe results to be replicated in rigor-ously designed RCTs using clear di-agnostic criteria for patient entry,specified randomization proce-dures, and control for nonspecific re-sponses resulting from the time andattention received during the acu-puncture therapy.

Despite the potential of plantextracts as psychoactive substances,H perforatum is the only herb that hasbeen investigated rigorously. The re-sults show promising effects in pa-tients with mild to moderate depres-sion. However, they need to befollowed up by further studies withmore clearly defined diagnosticgroups, groups of patients with ma-jor depression, standardized prepa-rations, trials longer than 8 weeks,and comparison with antidepres-sant doses within the normal thera-peutic range.86,87 H perforatum is as-sociated with a markedly betteradverse effect profile than standardantidepressants.88 This could lead tobetter compliance, quality of life, andefficacy.

The results of exercise-in-tervention studies indicate that thereis an overall association between ex-ercise and reduction in the symp-toms of mild to moderate depres-sion. However, many studies sufferfrom significant methodological

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flaws that make it difficult to drawfirm conclusions.46 Many of the in-vestigations are not of RCT design,involve only small numbers of sub-jects, are not controlled for the non-specific effects of exercise, such asattention from trainers and social in-teraction where a group is in-volved, do not give full details of theexercise intervention, and use a va-riety of mainly self-reporting depres-sion scales without objective blindedassessment. As with other CATs, itis unclear how long the antidepres-sive effects (if any) would persist.

A number of mechanisms bywhich exercise may improve moodhave been proposed.41,46 These in-clude physiological effects, such aschanges in endorphin and mono-amine levels; psychological effects,such as subject expectation, diver-sion from stressful stimuli, the ef-fects of receiving attention, im-proved self-image, and feelings ofcontrol; and sociological factors,such as the benefits of social inter-action and support. Although somelongitudinal epidemiological evi-dence89,90 indicates that there may bea strong link between exercise anda reduction in depression levels, itis necessary to investigate this pos-sibility further via high quality RCTs.

Few clinical studies are avail-able regarding the effectiveness ofother CATs in the treatment of de-pression. The data that do exist aregenerally of poor methodologicalquality. There are some indicationsthat aromatherapy, massage, musictherapy, and relaxation techniquesmay be of value. These areas thuswarrant further investigation. Nodata exist regarding the efficacy ofother therapies such as Alexandertechnique, Bach flower remedies,color therapy, kinesiology, natu-ropathy, polarity, tragerwork,qigong, and reflexology.

In CAM, there is heated de-bate about which research meth-ods might be appropriate. Someclaim that this area of medicine is sodifferent that it defies standard re-search methods. This, however, hasrepeatedly been demonstrated to bewrong (as shown by White et al91

and Vickers et al92). Clearly, the op-timal method has to be chosen ac-cording to the research question andnot to some vague ideological un-

derpinning. If the question relates totesting the efficacy of a given treat-ment for depression, the RCT is un-questionably the design option thatbest excludes bias (eg, as summa-rized by Ernst,93 Sibbald and Ro-land,94 and Ernst95).

In conclusion, apart from H per-foratum and exercise, little rigor-ous scientific evidence exists regard-ing the effectiveness of CATs indepression. In view of the public’sdemand for CAT, investigation ofthese therapeutic options by well-designed RCTs is important.

Accepted for publication July 23, 1998.Reprints: Edzard Ernst, MD,

PhD, FRCP (Edin), Department ofComplementary Medicine, School ofPostgraduate Medicine and Health Sci-ences, University of Exeter, 25 Victo-ria Park Rd, Exeter EX2 4NT, Eng-land (e-mail: [email protected]).

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