SCOTTSDALE, ARIZ. – Simple, effective, nonpharmacologic therapies can significantly augment pharmacotherapy for patients with treatment-resistant depression, according to Dr. Mark Hyman Rapaport.
More complex complementary approaches are being explored and may hold promise as part of the future of precision medicine, but well-tested strategies can still help many patients, he said.
Speaking at a session focused on treatment-resistant depression at a meeting of the American Society of Clinical Psychopharmacology, Dr. Rapaport, chairman of the department of psychiatry and behavioral sciences and Reunette W. Harris Professor at Emory University, Atlanta, began with the basics.
Citing a recent meta-analysis examining the way in which exercise works as a treatment for depression, Dr. Rapaport said, “looking at the world’s literature in a very thoughtful way, [the meta-analysis] did demonstrate a significant effect for aerobic exercise in decreasing signs and symptoms of depression.” The meta-analysis, he said, found that exercise provided the equivalent of a 5.07-point improvement on the Hamilton Rating Scale for Depression (HAM-D) (P = .0007). “I think it is something we should encourage our patients to use,” he said.
Similarly, though the treatments “have fallen out of favor,” Dr. Rapaport said “meta-analyses clearly demonstrate” a significant effect of bright white light (BL) therapy in seasonal affective disorder, both as monotherapy and in combination with antidepressants. The light should be dosed at 5000 lux or more for 1 hour daily.
Further, said Dr. Rapaport, BL as monotherapy or used in combination with antidepressants, or with sleep deprivation can be moderately effective in treating major depressive disorder. “It’s something to consider. We do not use it; we should use it,” Dr. Rapaport said. For patients with bipolar disorder, BL therapy can effectively augment medication use as well.
Focused, intensive treatment with light and sleep adjustments can be effective in both bipolar depression and treatment-resistant depression, Dr. Rapaport said. This approach, termed “adjunctive triple chronotherapy,” begins with total sleep deprivation for a period of 33-36 hours. Then, the patient receives BL therapy at 5,000 lux for at least 1 hour for 3 consecutive nights. Finally, patients are asked to advance their sleep phase for 3 days so that they sleep from 6 p.m. to 1 a.m. the 1st night, 8 p.m. to 3 a.m. the 2nd night, and 10 p.m. to 5 a.m. the 3rd night.
The triple chronotherapy approach, said Dr. Rapaport, results in a “rapid and sustained response, both in unipolar and bipolar depression, in the studies that have been done to date.”
Massage can effectively improve mood for individuals with depression as well. In a study of HIV-positive individuals with major depressive disorder and on stable medication, those who received weekly massage had a 33% decrease in HAM-D scores, compared with a 12% increase for those receiving light touch, and a 9% decrease for those on a wait list who received neither touch nor massage (P less than .05). The response rate of 40% for those receiving massage also was significantly higher than the 6.3% for those receiving light touch and the 14% for those on the wait list (P less than .05).
Recently completed unpublished work by Dr. Rapaport and his colleagues involving patients with generalized anxiety disorder also showed significantly greater improvement on a self-rating scale for anxiety for those receiving twice-weekly Swedish massage therapy, compared with those receiving light touch.
“Our patients – their symptoms aren’t just what we see on the monitors – they deal with quality of life, they deal with functioning,” said Dr. Rapaport, “so there are many things that we as clinicians need to look at,” he said at the meeting. “The key is this: There’s a slowly increasing but limited data set for [treatment-resistant depression]. We need to find the right treatments for the right subjects. “
The ASCP meeting was formerly known as the New Clinical Drug Evaluation Unit meeting. Dr. Rapaport reported no relevant financial conflicts.
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