Behavioral activation (BA), which generally is included as a component of CBT, has received support as an independent treatment, and may produce therapeutic results similar to CBT11 and PST (which we’ll discuss in a bit).12 The core components of BA are scheduling pleasant activities and increasing the patient’s positive interactions with his or her environment by decreasing avoidance, withdrawal, and inactivity.11 Compared to CBT, BA is easier for clinicians to learn and incorporate into primary care visits, and it may be especially useful as an adjunctive or first-step intervention in outpatient clinics.11 Like CBT, BA can be effective in diverse patient groups13,14 and can be provided using novel delivery modes, such as via the Internet.15
IPT is a supportive, structured, brief therapy (12-16 visits) that focuses on helping patients identify and solve current situation- and relationship-based problems that stem from or contribute to their depression.16 Enhancing the patient’s interpersonal communication—including improving social skills, assertiveness, and appropriate expression of anger—is typically a component of IPT. Like CBT, IPT has been found to be effective for treating depression when administered in person, in group therapy, or via the phone or Internet, and across a broad age range.17-19
PST involves teaching patients a structured problem-solving process to decrease interpersonal strain and improve positive life experiences.20 Patients are taught to define their problem, generate and evaluate multiple solutions for it, implement a plan for the solution, and evaluate the results. In addition to being used to successfully treat adults,4,5 PST has been adapted effectively to treat adolescents16 and older adults.18
Somatic therapies are also an option
Exercise has long been considered a possible depression treatment due to its activity on endorphin, monoamine, and cortisol levels and via increased social and general activity. A 2013 Cochrane review of 39 randomized control trials (RCTs; N=2326) assessed whether exercise was effective for treating depression in adults.21 Thirty-five trials found a moderate effect size when specifically comparing exercise to no treatment or control interventions. The effect size was reduced, however, when analyses were restricted to trials with the highest methodological quality. There was no statistically significant difference when exercise was compared to pharmacologic treatment or psychotherapy.
Although the amount of research is meager, small but statistically significant improvements have also been found for older adults22 and children/adolescents.23 There is no consensus on the type, frequency, or intensity of exercise needed to achieve benefit. However, because nearly all studies for all age groups have found that exercise has no adverse psychological effects and substantial positive physical effects, exercise should be recommended to all patients with depression unless contraindicated.
Yoga (both exercise-based and meditation-based) has been evaluated both as a sole treatment and as an adjunctive treatment for depression. Several studies have supported the impact of yoga, particularly in pregnant women,24 although the evidence for its efficacy is inconsistent, with yoga frequently failing to improve upon the outcome of waitlist control.25 The evidence for meditation and mindfulness is more consistently positive, with these interventions equaling or exceeding “treatment as usual,” other psychotherapies, and antidepressants in numerous RCTs.25
Electroconvulsive therapy (ECT) has a substantial evidence base supporting its efficacy.26 ECT has been used for decades, although stigma, cardiac and memory risks, and risks of anesthesia often limit its use. Benefits of ECT include a rapid response relative to pharmacotherapy (>50% of patients respond by the end of the first week of ECT)27 and a strong response in older patients.28
In repetitive transcranial magnetic stimulation (rTMS), electromagnetic coils are placed on a patient’s head to deliver electromagnetic pulses that stimulate areas of the brain that regulate mood. Although rTMS is not widely available, a growing body of evidence supports its use for treating depression, including a meta-analysis of 34 RCTs that included 1383 patients.29 A multisite RCT (N=190) that was not industry-funded reported a 15% response rate and 60% maintenance of remission at 3 months (NNT=12).30 Although ECT is more effective than rTMS, rTMS appears useful for treatment-resistant depression, and can be used as an adjunctive treatment.29,31
Dietary supplements may be best used as adjuncts
St. John’s wort (Hypericum perforatum), which contains 2 bioactive ingredients (hyperforin and hypericin), has been effectively used to treat depression.32 A 2008 Cochrane review that was limited to high-quality trials involving patients meeting Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria for depression identified 29 trials (N=5489), of which 18 involved comparisons with placebo and 17 with standard antidepressants.33 Patients’ depression was rated mild to moderate in 19 studies and moderate to severe in 9 studies. Trials examined 4 to 12 weeks of treatment with Hypericum extracts. This study (and several published since) provides strong clinical evidence supporting the efficacy of St. John’s wort for mild to moderate depression. There is insufficient evidence for its use for severe major depression.33TABLE 1 contains dosing information for St. John’s wort and other supplements used to treat depression.34-36