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Surveys have demonstrated that complementary medicine use for depression is widespread, although patterns of use vary. A series of systematic reviews provide a summary of the current evidence for acupuncture, aromatherapy and massage, homeopathy, meditation, reflexology, herbal medicine, yoga, and several dietary supplements and relaxation techniques. The quantity and quality of individual studies vary widely, but research interest in complementary therapies is increasing, particularly in herbal and nutritional products. Major questions are still to be answered with respect to the effectiveness and appropriate role of these therapies in the management of depression. Areas for further research and some of the potential challenges to research design are discussed. Finally, several ongoing developments in information provision on this topic are highlighted.
Author Proof
10.1586/ © 2006 Future Drugs Ltd ISSN 1473-7175
Complementary medicine
for depression
Karen Pilkington
, Hagen Rampes and Janet Richardson
Author for correspondence
University of Westminster, School of
Integrated Health, London, UK
Tel.: +44 207 911 5000 ext. 5340
Fax: Fax
acupuncture, aromatherapy,
complementary medicine,
complementary therapies,
depression, herbal medicine,
homeopathy, nutritional
supplements, St Johns wort, yoga
Surveys have demonstrated that complementary medicine use for depression is
widespread, although patterns of use vary. A series of systematic reviews provide a
summary of the current evidence for acupuncture, aromatherapy and massage,
homeopathy, meditation, reflexology, herbal medicine, yoga, and several dietary
supplements and relaxation techniques. The quantity and quality of individual studies vary
widely but research interest in complementary therapies is increasing, particularly in
herbal and nutritional products. Major questions are still to be answered with respect to the
effectiveness and appropriate role of these therapies in the management of depression.
Areas for further research and some of the potential challenges to research design are
discussed. Finally, several ongoing developments in information provision on this topic
are highlighted.
Expert Rev. Neurotherapeutics 6(11), xxx–xxx (2006)
Depression is described as ‘a broad and hetero-
geneous diagnostic grouping, central to which
is depressed mood or loss of pleasure in most
[101]. International classification of
diseases (ICD)-10 uses an agreed list of ten
depressive symptoms and provides a guide for
assessing the severity of an episode based on
the number of symptoms present
[1]. The com-
mon form of major depressive episode is
divided into four groups: mild depression,
moderate depression, severe depression and
severe depression with psychotic symptoms.
Depression is the most common mental disor-
der in community settings and is a major cause
of disability across the world. It is projected to
become the second leading contributor to the
global burden of disease by 2020
[102]. The
condition affects approximately 121 million
people worldwide and is associated with the
loss of 850,000 lives per year. Apart from the
subjective suffering experienced by people who
are depressed, the impact on social and occu-
pational functioning, physical health, and
mortality is substantial.
Several significant limitations to the cur-
rent evidence base on the treatment and man-
agement of depression exist, including
limited long-term outcome data for most
interventions and limited data on outcomes,
generally, for severe depression
[101]. These
result in part from problems with conducting
well-designed randomized, controlled trials,
particularly for service-based and psychologi-
cal interventions. Antidepressants are widely
used but the risk:benefit ratio of these agents
is poor, particularly in mild depression. Tricy-
clic antidepressants have been associated with
poor compliance and toxicity in overdose but
the newer selective serotonin reuptake inhibi-
tors (SSRIs) are not without problems
The recent UK guidelines on depression rec-
ommend that the patients preference and
experience of previous treatment should be
considered when deciding on treatment
This is particularly relevant in individuals
with mild or moderate depression who are
not considered to be at substantial risk of self
harm and for whom a number of different
approaches may be equally effective. For mild
depression, suggested approaches include
watchful waiting, guided self help, computer-
ized cognitive behavioral therapy (CBT),
exercise and brief psychological interven-
tions. However, patients may turn to comple-
mentary therapies due to the side effects of
Complementary medicine
usage in depression
Aromatherapy, massage
& reflexology
Dietary & nutritional
Herbal medicine
Relaxation techniques
Other therapies
Expert commentary
& five-year view
Key issues
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Pilkington, Rampes & Richardson
Expert Rev. Neurotherapeutics 6(11), (2006)
medication, time and effort associated with nonpharmacolog-
ical therapies, lack of response or simply preference for the
complementary approach.
Complementary medicine usage in depression
Complementary medicine has been defined as ‘all such practices
and ideas that are outside the domain of conventional medicine
in several countries and defined by its users as preventing or
treating illness, or promoting health and wellbeing
The boundaries between complementary and conventional
medicine change over time as certain complementary practices
gradually become accepted and new approaches emerge. Con-
siderable diversity exists in the practices currently included
under the term complementary and alternative medicine
(CAM) and there is variation across different cultures and con-
texts. In this article, the focus is primarily on commonly used
therapies, particularly those reported to be used for depression
by patients and the general public.
Depression, along with anxiety and insomnia, is among the
most common reasons for individuals to seek treatment with
complementary therapies in the USA. A large-scale study used
data from a national household telephone survey and
included those reporting psychological distress or mental
health service use, in addition to nondistressed nonusers
Analysis of the 9585 completed interviews indicated a high
rate of use of complementary therapies in adults who met cri-
teria for common psychiatric disorders. A total of 22.4% of
respondents who met the criteria for major depression had
used complementary and alternative medicine during the past
12 months. A more recent US survey of a nationally repre-
sentative sample of 2055 respondents revealed that 7.2%
reported suffering from severe depression
[7]. Of these, 53.6%
reported using complementary and alternative medicine for
treatment in the past 12 months. Therapies most frequently
sought included relaxation techniques, herbal medicine,
imagery and spiritual healing.
A trend towards increasing use of complementary therapies
among people with major depression was demonstrated by a
study conducted in Canada
[8]. Analysis of data from the
National Population Health Surveys indicated that the preva-
lence of use in those with major depression was 7.8% (19.4%
including chiropractic) in 1994–95 and 12.9% (23.8% includ-
ing chiropractic) in 1996–97. An update of this study pub-
lished in 2005 demonstrated that approximately 21% of
respondents with either major depressive disorder or manic
episodes had used natural health products, while the frequency
of conventional mental health service use had not increased
significantly over the previous decade
The situation is similar in Australia: the findings of a recent
postal survey of 6618 randomly selected adults suggested that
self-help strategies including complementary therapies were
very commonly used to cope with depression
[10]. For mild
depression, the therapies used included massage and medita-
tion, while those for moderate depression included aromath-
erapy, St Johns wort, yoga and nutritional supplements.
Relaxation therapy was mentioned in relation to moderate-to-
severe episodes, but no complementary therapies were
reported to be used for severe depression.
Research on complementary medicine
A wide range of research on complementary therapies in depres-
sion has been conducted. Surveys and outcome studies have
been reported but there has also been a move towards the use of
randomized, controlled trials and, subsequently, systematic
reviews and meta-analyses of these trials. While randomized,
controlled trials are feasible in principle, there are a number of
problems in the design of these studies, which discourages their
use in the complementary medicine field
[11]. One argument
against the use of the randomized, controlled trial is the lack of
individualization of treatment inherent in the design, which is
contrary to the philosophy of many therapies. Difficulties also
exist in the identification of appropriate controls or placebos,
most obviously with physical therapies such as yoga, but there is
concern that many of the sham or placebo techniques developed
for use in acupuncture studies may themselves produce an effect
[12,13]. Blinding of patients and caregivers is impossible for many
treatments so that blinding of assessors becomes more crucial in
minimizing the extent of bias introduced during conduct of the
trial. Other considerations include the fact that many comple-
mentary practitioners use a combination of approaches. For
example, an intervention in traditional Chinese medicine
(TCM) may incorporate acupuncture, diet, massage and herbal
treatment. Finally, problems with recruitment have been
encountered as potential participants may be reluctant to enrol
in a study in which there is a possibility that they will not receive
treatment with their chosen therapy.
The evidence presented in this article is based primarily on
systematic reviews identified from searches of a number of
sources. Searches of the Cochrane Database of Systematic
Reviews and the Database of Abstracts of Reviews of Effects
(DARE) were carried out using the following search terms:
(complementary therapies or acupuncture or acupuncture ther-
apy or electroacupuncture or acupressure or aromatherapy or
herb* or phytotherapy or traditional chinese medicine or die-
tary supplement or nutritional supplements or nutritional ther-
apy or health food or naturopathy or massage or reflexology or
relaxation techniques or homeopath* or hypnosis or hypno-
therapy or biofeedback or imagery or meditation or mindful-
ness or mbsr or osteopathy or chiropractic or alexander tech-
nique or Alexander therapy or yoga or music therapy or dance
therapy or Ayurved* or shiatsu or spiritual healing or energ*
healing) and (depression or depressive disorder).
Specific terms were incorporated to reflect commonly used
therapies and those reported to be used for depression in the
surveys described above. A methodological filter (meta-analy-
sis or systematic review or systematic overview or research
synthesis or medline or pubmed or Cochrane) was added to
the above strategy for searching PubMed. Further searches
for relevant systematic reviews were conducted on the
Cochrane Collaboration Complementary Field website
Author Proof
Complementary medicine for depression
the National Library for Health CAM Specialist Library [104]
and the CAM Evidence OnLine (CAMEOL) database of
systematic reviews
Systematic reviews of a specific therapy focusing on depression
or including randomized, controlled trials of depression were
selected, while reviews focusing primarily on a medical condition
were excluded. Recent randomized, controlled trials were identi-
fied on PubMed using the search term ‘complementary therapies
and depression and random*’ and restricted to articles published
within the past 3 years. A similar search was conducted on the
Cochrane CENTRAL database. Searches were initially
conducted in March 2006 and repeated in August 2006.
Acupuncture involves the stimulation of specific points on the
body using a variety of techniques, the most frequently used
method requiring penetrating the skin at these ‘acupoints’ with
thin, solid, metallic needles. Acupuncture encompasses a spec-
trum of philosophies and techniques, and variation exists
between different ‘schools’ of acupuncture practice or between
individual acupuncturists. The method of treating a particular
condition may therefore vary considerably in terms of the
points chosen, depth and duration of needling, whether needles
are stimulated manually or electrically, and whether additional
therapies are used. TCM acupuncturists use the concept of a
vital force or energy called ‘Qi’ or ‘Chi’ which can be altered by
the stimulation of points located along ‘meridians’ or channels.
A number of methods of diagnosis are used including periph-
eral pulses, the appearance of the tongue, speech, history and
overall impressions of the patient, and these guide the selection
of acupuncture points. Western medical acupuncture is based
primarily on contemporary neurophysiology and anatomy.
Diagnosis is carried out conventionally and therapy is based on
selection of specific trigger points and commonly used formula
A range of adverse events have been reported in relation to
acupuncture, although serious events are rare. Potential haz-
ards such as the transmission of infection (e.g., hepatitis B) and
serious traumatic adverse events (e.g., pneumothorax) are min-
imised through adequate training and the use of safe needling
[15]. The rate of adverse events reported by practi-
tioners has been investigated in two prospective surveys of a
total of over 60,000 consultations
[16,17]. A total of 86 signifi-
cant nonserious adverse events were reported; the most fre-
quently reported being nausea, fainting and dizziness. A survey
of patient reports revealed a higher rate of adverse events
(10.7%), with severe tiredness, pain at the needling site and
headache being the most frequently described events
[18]. How-
ever, the results of this study reinforced the perception that
acupuncture is relatively safe in ‘competent hands’, that is,
those of regulated practitioners. Research interest into the
potential of acupuncture in the management of depression was
generated by early animal experiments. These suggested that
acupuncture accelerated the synthesis and release of serotonin
and norepinephrine in the CNS
Two meta-analyses on acupuncture in depression have
recently been published
[14,20]. The first, published in 2004,
reviewed randomized, controlled trials of acupuncture, elec-
troacupuncture and laser acupuncture
[14]. Seven trials of 517
subjects with generally mild-to-moderate depression met the
inclusion criteria, five of which included a comparison of acu-
puncture and medication, one a comparison against a wait-list
control and one against sham acupuncture. The authors con-
cluded that there was insufficient evidence to determine the
efficacy of acupuncture compared with medication, wait-list
control or sham acupuncture. The second systematic review
also included seven studies, although different inclusion criteria
were used
[20]. The results of this review suggested that the
effect of electroacupuncture may not be significantly different
from that of antidepressants, but there was inconclusive evi-
dence on whether acupuncture has an additive effect when
given as an adjunct to antidepressants. Both reviews concluded
that as the studies were generally small and poorly designed,
further research is needed. There is considerable debate over the
potential for control or placebo techniques to produce an
effect, so future studies may need to address the use of compar-
ative designs using medication, structured psychotherapies or
standard care.
Aromatherapy, massage & reflexology
Aromatherapy ‘involves the use of essential oils (extracts or
essences) from flowers, herbs and trees to promote health and
[106]. These essential oils are extracted by distillation
or cold pressing
[21]. The chemicals comprising essential oils in
plants are considered to have a host of therapeutic properties.
Oils may be inhaled or added to baths but are most frequently
used in combination with massage, the aim of which is to pro-
mote the circulation of blood and lymph and provide relaxation
of muscles, providing both physical and mental benefits
Reflexology is a method of foot (and sometimes hand) massage
in which pressure is applied to reflex zones or areas mapped out
on the feet (or hands). Reflexology is based on the principle
that these zones correspond to parts of the body including the
major organs and glands. It is suggested that stimulation of
these reflex zones provides a method by which many health
problems can be helped. Theories on the mechanism of action
include the suggestion that reflexology stimulates the release of
endorphins and encephalins in the same way as generalized
massage, while other theories relate more closely to those of
Essential oils are potent chemicals, virtually all of which
require dilution before use. Several oils are avoided due to
potential toxic effects and many are avoided during pregnancy
due to lack of information on the possible risks. Safety issues
are related to inappropriate or excessive use, accidental inges-
tion and lack of patch testing in the allergy-prone
[24]. A sound
knowledge of the properties of individual oils is important but,
as with all plant-derived products, the purity and constituents
may vary. Consequently, the pharmacological actions and phar-
macokinetics of many oils and their potential to interact with
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Pilkington, Rampes & Richardson
Expert Rev. Neurotherapeutics 6(11), (2006)
other agents are not well defined [25]. The safety of massage
therapy has been the subject of a systematic review, which con-
cluded that although it is not entirely risk free, serious adverse
events are probably rare and qualified massage therapists were
rarely implicated in the reported problems
A meta-analysis of massage therapy in a number of condi-
tions suggested that improvement of depression and state anxi-
ety were its largest effects and that a course of treatment pro-
vided benefits similar in magnitude to those of psychotherapy
[27]. A recent review focusing specifically on trials in depression
revealed that a series of randomized, controlled trials of massage
therapy have been conducted in a range of groups including
hospitalized children and adolescents with depression, adoles-
cent mothers with depressive symptoms and women with post-
natal depression
[107]. Massage therapy was found to compare
favorably with relaxing activities, such as viewing a videotape,
yoga plus progressive muscular relaxation or no treatment.
Only one small study was located in which aromatherapy was
combined with massage. The trial, which compared individual-
ized aromatherapy massage with massage alone in elderly
patients with anxiety and/or depression, reported promising
results. It was not possible to assess the effects of aromatherapy
alone as the studies of this intervention suffered from use of
inappropriate controls and, for most studies, either methodo-
logical problems were apparent or details of methods were
unreported. Other problems in interpretation of the results
arose from the nature of the intervention, which precludes
blinding of either patient or carer. Attention from the therapist
is also likely to be an important component of the treatment
and further complicates evaluation. A review of reflexology
located several studies reporting the effects of reflexology on
mood or depression in patients with comorbid conditions such
as cancer but there are no published clinical trials focusing
specifically on depressive disorders
Dietary & nutritional supplements
One area of considerable interest in relation to depression is
that of nutritional therapy. Numerous supplements and prod-
ucts are available but six substances have provided a particular
focus for research and have been the subject of one or more
recent systematic reviews. Cochrane reviews of folate, inositol,
tryptophan and 5-hydroxytryptophan (5-HTP) have been
published since 2002
[28–30], a review of trials of omega-3 fatty
acids (O3FA) has been completed
[31], while S-adenosyl-L-
methionine (SAMe) has been the subject of several systematic
Low folate levels are a common finding in psychiatric
patients and have been linked to a poor response to drug ther-
[28]. Inositol is a naturally occurring compound, an isomer
of glucose that is consumed in a range of foods
[29]. Within the
body, its metabolites are involved in the function of neurotrans-
mitters. Like folate, lower than normal levels have been found
in people with depression. The amino acid tryptophan is con-
verted in the body into 5-HTP, which is converted into serot-
onin (5-hydroxytryptamine [5-HT]), a neurotransmitter, the
levels of which are often depleted in depressed patients
[30]. It
has been suggested that O3FA deficiency may also contribute
to depression
[31] while the effect of SAMe has been shown to
be via its influence on serotonin metabolism.
A review of folate in depression included the results of three
trials (total n = 247), two of which assessed the use of folate in
addition to other treatment
[28]. Addition of folate was found
to reduce scores by a further 2.65 points on the Hamilton
Rating Scale for Depression (HAMD) on average (95% confi-
dence interval [CI]: 0.38–4.93). The authors concluded that
the available evidence suggests that folate may have a poten-
tial role as a supplement to other treatment but that it was
unclear if this was the case both for people with normal folate
levels and for those with folate deficiency. The review of inosi-
tol included four studies (n = 141) but the trials did not dem-
onstrate clear evidence either of a therapeutic benefit or of
poor acceptability, and it is unclear whether it is of benefit in
A systematic review of tryptophan and 5-HTP succeeded in
locating a large number of trials in depression but only two tri-
als involving a total of 64 patients were of sufficient quality for
[30]. The results of these studies indicated that both
substances were more effective than placebo at alleviating
depression (Peto odds ratio: 4.1; 95% CI: 1.28–13.15) but the
evidence was inconclusive. The authors concluded that the
clinical usefulness of either substance is currently limited and
further studies of safety are needed.
Studies of O3FA were included in a review of these sub-
stances in mental health in general
[31]. One trial of O3FA as
primary treatment and three of O3FA as supplementary treat-
ment were assessed. The first study found no benefit,
although there were a number of possible reasons for this
finding. Promising results were reported for supplementary
treatment but it was concluded that additional investigation
of both uses is required.
The superiority of SAMe over placebo in the treatment of
depression was initially reported in 1994
[32]. A systematic
review conducted in 2003 located 47 studies, of which 28
were included in a meta-analysis
[33]. Compared with pla-
cebo, treatment with SAMe was found to be associated with
an improvement of approximately 6 points (95% CI:
2.2–9.0) on the HAMD measured at 3 weeks; a statistically
and clinically significant degree of improvement. Compared
with treatment with conventional antidepressants, treatment
with SAMe was not associated with a statistically significant
difference in outcomes. A more recent review, described as
systematic but including a range of study types, selected 11
studies for inclusion comprising intervention trials, rand-
omized, controlled trials, a controlled trial, a meta-analysis
and two reviews
[34]. A direct comparison of effect sizes based
on the HAMD demonstrated a ‘favorable and significant
between-group effect. However, the authors also highlighted
the fact that all the studies were short term and that ques-
tions remain regarding the mechanism of action and
bioavailability of oral SAMe.
Author Proof
Complementary medicine for depression
Herbal medicine
Many conventional drugs are derived from plants but are gen-
erally administered as the pure chemical, while herbal medicine
involves the same chemical in a plant matrix. This chemical
complexity is thought to provide advantages in terms of synergy
of pharmacological activity, enhanced solubility or bioavailabil-
[35]. However, the complexity and variability of herbs hinder
rigorous research due to multiple variables that need to be con-
sidered when interpreting results. Nevertheless, herbal medi-
cine has received considerable research and clinical interest, not
least in the study of depression. One agent in particular has
been the focus of attention for a number of years: St Johns wort
(Hypericum perforatum) first received attention when there were
indications of its potential effectiveness in the treatment of
depression in the 1980s.
St Johns wort is a flowering plant and a member of the fam-
ily Hypericaceae. It is widely used as a herbal remedy, particu-
larly for self-treatment of depression. The dried above-ground
parts are the active parts of the plant. These contain several
active constituents of which two, hypericin and hyperforin,
are understood to be the most significant
[36]. St Johns wort
extract appears to increase serotonin, norepinephrine and
dopamine content in the brain, possibly owing to inhibition
of their uptake by hyperforin
[37,38]. Hypericin may also con-
tribute to the antidepressant activity, and the mechanism of
action of St Johns wort has yet to be fully understood
However, it does also affect the cytochrome P450 enzyme sys-
tem by inducing the production of these enzymes, so that the
metabolism of many drugs is increased and, consequently,
plasma concentrations of these drugs are reduced
Systematic reviews, meta-analyses and individual trials have
been published regularly over the past 10 years
[40]. Methodol-
ogy within the reviews has varied, resulting in differing esti-
mates of effectiveness, but overall findings have been positive
when compared with placebo for mild-to-moderate depression.
However, the increased attention has not resulted in a com-
pletely clear picture of its effectiveness. Recent, larger trials in
which inclusion criteria are more clearly defined have been less
positive. The current situation can probably be best summed
up by the conclusions of the updated Cochrane review: “Cur-
rent evidence regarding hypericum extracts is inconsistent and
confusing. In patients who meet criteria for major depression,
several recent placebo-controlled trials suggest that the tested
hypericum extracts have minimal beneficial effects while other
trials suggest that hypericum and standard antidepressants have
similar beneficial effects… several specific extracts of St. Johns
wort may be effective for treating mild-to-moderate depression,
although the data are not fully convincing”
The potential variation in the quality and composition of
preparations of St Johns wort also complicates evaluation.
Trials of the effectiveness of St Johns wort against a range of
antidepressants continue and further investigations of the
individual constituents are in progress, but the focus also
appears to be moving to study of its safety. In general, it is rel-
atively safe, although there have been case reports of allergy or
photosensitivity in patients with sensitive skin, and possible
induction of manic episodes in susceptible individuals. The
main safety concern is the potential to reduce the concentra-
tions of other drugs. The list of those drugs likely to be
affected is being constantly extended and caution should be
exercised if considering use with other agents.
Several other herbs have recently been the focus of individual
trials. A series of three trials of saffron (Crocus sativus L.) have
been conducted in patients who met the DSM-IV criteria for
major depression
[42–44]. The first, against placebo, reported a
statistically significant difference in scores on HAMD after
6 weeks
[43]. The remaining trials revealed no significant differ-
ence between saffron and either imipramine
[44] or
[45] and the authors suggest that these initial findings
warrant further research in the form of large-scale trials. A
study of lavender (Lavandula augustifolia Miller) tincture was
conducted in 45 outpatients with major depression (DSM-IV)
and a HAM-D score of at least 18
[45]. After 4 weeks of treat-
ment, the herb was found to be less effective than imipramine,
although the combination was more effective than imipramine
alone. Again, further research is suggested. Individual studies
on Chinese and other Eastern herbal remedies are also reported
but, as with saffron and lavender, these are insufficient in
number for any conclusions to be drawn and, in some cases, a
different diagnostic framework from that in conventional
medicine is used, further complicating interpretation.
Homeopathy is a system of medicine originally developed by
Samuel Hahnemann, a German physician, in the late 18th
Century. It is based on three key principles: the principle of
similars (‘similia similibus curentur’), of infinitesimal dose and
of specificity of the individual
[46]. The approach to treatment
requires selection of remedies that, if given to a healthy person,
would cause symptoms similar to those from which the patient
is suffering. This is believed to stimulate intrinsic healing sys-
tems. The remedy chosen must match the symptom profile and
take into account the ‘constitutional features’ of the individual.
Homeopathic remedies are dilutions of substances that may be
derived from plants, animals or minerals. The approach to dilu-
tion has been the cause of much of the scientific controversy
surrounding homeopathy, since this includes ‘ultra molecular’
dilutions, in which, according to Avogadros Law, it is extremely
unlikely that any molecule of the starting substance persists.
Homeopathic medicines are prepared by a process of serial dilu-
tion with succussion (vigorous shaking) and homeopathic
prescribing may be described as classical, clinical or complex.
Several systematic reviews and meta-analyses have appraised
evidence of the efficacy of homeopathy in a range of
[47–49]. In each case, the evidence appeared positive
overall for homeopathy in relation to placebo but inconclusive
for specific conditions. A more recent meta-analysis concluded
that there was only weak evidence for a specific effect of home-
opathic remedies, suggesting that the clinical effects of home-
opathy are placebo effects
[50]. However, only eight trials of the
Author Proof
Pilkington, Rampes & Richardson
Expert Rev. Neurotherapeutics 6(11), (2006)
110 initially located were considered to be of sufficient quality
and size for analysis. Homeopathic remedies are frequently rec-
ommended in self-help books for depression but a comprehen-
sive search for published and unpublished studies located only
two randomized, controlled trials of homeopathy in depression
[51]. One of these, a feasibility study, demonstrated problems
with recruitment, while the other had significant methodologi-
cal shortcomings. Several uncontrolled and observational stud-
ies reported positive results including high levels of patient sat-
isfaction, but lack of a control group precluded conclusions on
any specific effects of homeopathy. Reported adverse effects
were limited to ‘remedy reactions’ (‘aggravations’) including
temporary worsening of symptoms, symptom shifts and reap-
pearance of old symptoms. These reactions were generally tran-
sient but caused withdrawal of the treatment in one patient.
The overall conclusion was that, owing to reported use of
homeopathy in depression, further research is required. This
should ideally include well-designed, controlled studies, but the
highly individualized nature of much homeopathic treatment
and the specificity of response may require innovative methods
of analysis.
Meditation has been defined as a ‘conscious mental process that
induces a set of integrated physiological changes termed the
relaxation response
[109]. It has been suggested that meditation
can be divided into cultic and noncultic forms, with the latter
being developed for clinical or research use
[52]. The main dis-
tinction within the latter is between concentrative methods
such as transcendental meditation and insight forms such as
mindfulness techniques, although there is some overlap
between the two. Transcendental meditation was introduced to
the West in the 1960s and involves techniques such as mantras
and focusing on breathing. The aim is to ‘focus attention on an
object and sustain attention until the mind achieves
[53]. Mindfulness meditation, in contrast, places the
emphasis on an awareness of any thoughts or feelings that enter
the mind, or in fact, anything that arises within the field of
awareness. Mindfulness in meditation has been described as
cultivated attention, on purpose, in the present moment and
A recent systematic review of meditation in depression suc-
ceeded in locating only a limited number of studies, including
two studies in which elderly patients suffering from depressive
symptoms were treated with interventions consisting of medita-
tion combined with relaxation
[110]. No evidence was found for
a reduction in measures of depression in this group, while the
sole study located on patients with clinical depression was a
preliminary report with insufficient details for evaluation. It
was concluded that there is a general lack of research in this area
and, consequently, insufficient evidence to draw any conclu-
sions on either the effectiveness of meditation in easing depres-
sion or on the potential for meditation to exacerbate depres-
sion. More evidence exists on complex interventions that
incorporate mindfulness meditation. A systematic review of
mindfulness-based stress reduction (MBSR) in a range of con-
ditions suggested promising results in depression
[55]. Mindful-
ness-based cognitive therapy, which integrates aspects of CBT
with components of MBSR programs, may be useful in pre-
venting relapse among people who have recovered from
depression and is the subject of ongoing research
Yoga originated in Indian culture and consists of a complex sys-
tem of spiritual, moral and physical practices aimed at attaining
self-awareness. Hatha yoga, the system on which much of
Western yoga is based, has three basic components: asanas (pos-
tures), pranayama (breathing exercises) and dhyana (medita-
tion). The postures involve standing, bending, twisting and
balancing the body and, consequently, improve flexibility and
strength. The controlled breathing helps to focus the mind and
achieve relaxation while meditation aims to calm the mind
Several explanations based on Western physiology have been
proposed to account for potential effects of yoga in the treat-
ment of various conditions. These can be summarized as mod-
ulation of autonomic nervous tone and consequent reduction
in sympathetic tone, activation of antagonistic neuromuscular
systems, which may increase the relaxation response in the neu-
romuscular system and stimulation of the limbic system,
primarily by meditation
Five randomized, controlled trials of yoga in depression were
identified in a recent systematic review
[59]. Different forms of
yoga interventions were utilized but rhythmic breathing formed
an important component of the intervention in four trials. All
trials reported positive findings but methodological details were
missing. No adverse effects were reported, with the exception of
fatigue and breathlessness in participants in one study, but par-
ticipants in all the trials were under the age of 50 years. The
review concluded that there were initial indications of poten-
tially beneficial effects of yoga interventions on depressive dis-
orders, although several of the interventions may not be feasible
in those with reduced or impaired mobility. The variation in
interventions, severity of the depression and limited reporting
of trial methodology suggested that the findings be interpreted
with caution. Further investigation of yoga as a therapeutic
intervention was suggested including investigation into which
of the yoga-based interventions is most effective, the levels of
severity of depression likely to respond, and the comparative
effectiveness of anaerobic exercise (such as yoga) and aerobic
exercise. An randomized, controlled trial in which a yoga-based
intervention was used as additive treatment published since the
review was completed and has also reported positive results
Relaxation techniques
A number of other techniques, other than meditation and
yoga, aimed at relaxation are taught in healthcare environ-
ments and can be practised by the individual. Autogenic train-
ing is a form of self-hypnosis involving autosuggestion, which
aims to elicit a psychophysiologically determined relaxation
response. The technique, generally taught by an instructor,
Author Proof
Complementary medicine for depression
requires a set of statements, each of which suggests a specific
autonomic sensation. Guided imagery involves the individual
being guided through a series of thought processes that invoke
and use the senses.
A meta-analysis of the clinical effectiveness of autogenic
training reported the results of separate meta-analyses for differ-
ent disorders
[61]. Positive effects of autogenic training and of
autogenic training versus control in the meta-analysis of at least
three studies were found in a range of conditions including
mild-to-moderate depression/dysthymia. No systematic reviews
of guided imagery have been published recently, although a sys-
tematic review published in 1999 found ‘preliminary evidence
for the effectiveness of guided imagery in the management of
several conditions including depression
[62]. The authors sug-
gested that further studies of the effects of different imagery
language, method of delivery of the intervention and individual
factors that influence its effectiveness would be valuable. Other
relaxation techniques have not been subject to systematic
review, although individual studies have been published includ-
ing a study comparing progressive muscular relaxation with
yoga, which reported positive results
Other therapies
Light therapy was not mentioned in the surveys of complemen-
tary therapy use in depression, although it is an accepted treat-
ment for seasonal affective disorder (SAD), but a number of stud-
ies in non-seasonal depression have been published. A review of
29 studies concluded that there was evidence of ‘modest though
promising antidepressive efficacy…’
[63] but that the results
should be interpreted with caution, as the quality of reporting was
generally poor, there was considerable heterogeneity and adverse
effects were not reported systematically.
The remaining therapies reported to be used by people with
depression have not been the subject of systematic reviews,
although individual studies have been published on dance ther-
apy, music therapy, Reiki and spiritual healing. Little research
has been conducted on Alexander technique, chiropractic or
osteopathy in depression, presumably because these are seen as
more physically or structurally based than psychologically
focused therapies.
Expert commentary & five-year view
The use of complementary therapies for the management of
depression appears to be relatively widespread. A range of ther-
apies is in use with the patterns of use varying possibly due to
differences in accessibility and acceptability. In many cases, use
of a therapy is an alternative to contact with, and treatment by,
a conventional mental health professional and the implications
of this require consideration.
No complementary therapy has an evidence base which com-
pares with those of the antidepressants or CBT
[64]. Well-
designed studies of complementary therapies have been
reported but the majority of studies suffer from small sample
sizes, short follow-up, lack of blinding and little information on
attrition. However, randomized, controlled trials do focus on
specific effects of treatment and the role of nonspecific thera-
peutic effects also needs to be considered. Nonspecific effects
are related to the interpersonal aspects of the consultation and
treatment, and involve expectations, beliefs and behavioral fac-
tors of patients and healthcare providers
[65]. Many of the thera-
pies described previously involve significant interaction
between the patient and practitioner, which may itself contrib-
ute to any measured response to treatment. This aspect is rele-
vant regardless of the condition being treated, but the situation
is more complex in the management of depression where signif-
icant nonspecific effects are also seen with conventional treat-
ment. Therefore, quantification of these effects is a challenge
and complicates the interpretation of the results of studies of
complementary and conventional therapies.
Virtually all the research evidence is confined to mild-to-mod-
erate depression and this may be the appropriate place for com-
plementary therapies. Furthermore, this correlates with the type
of usage reported in the various surveys. However, as Jorm sug-
gests, the research focus needs to broaden to ‘take account of the
public’s more favorable attitudes to some nonstandard treat-
[64] and a number of studies are currently underway in
addition to those already mentioned. A total of 25 studies on
complementary therapies in depressive disorders are currently
funded by the National Centre for Complementary and Alterna-
tive Medicine
[111]. These include trials of acupuncture, aromath-
erapy, St Johns wort and nutritional supplements, but there is
obviously potential for a more intensive program of research.
As a consequence of the lack of an evidence base to date, only
two of the therapies discussed in this review, St Johns wort and
mindfulness-based cognitive therapy, are mentioned in current
UK guidance on the management of depression
[101]. This guid-
ance recommends that although there is evidence that St Johns
wort may be of benefit, it should not be prescribed or its use
advised by health professionals because of uncertainty about dos-
age, variation in preparations and potential serious interactions.
Nevertheless, there is increasing pressure from the public and
patient groups for access to complementary services, and the pro-
file of complementary therapies is being raised by events such as
general public awareness weeks
[112]. Current levels and routes of
access are unclear, but the demand for complementary therapies
has resulted in the planned development of national guidelines
on best practice and establishing a complementary healthcare
service as part of mental health services in the UK
These initiatives are likely to lead to improved access for men-
tal health patients and the potential for closer monitoring of the
acceptability, effectiveness and safety of individual therapies.
Ultimately, the result could be the integration of services, as pro-
posed by Shannon
[66]. However, increased access to and availa-
bility of complementary therapies may not improve the situa-
tion in relation to research evidence, due to continuing
difficulties with recruitment combined with the problems in
conducting rigorous clinical research already outlined. It may
also be a challenge to place some therapies in the conventional
diagnostic framework, resulting in differential acceptance and
integration of the various therapies and approaches.
Author Proof
Pilkington, Rampes & Richardson
Expert Rev. Neurotherapeutics 6(11), (2006)
Current research highlights the potential of various herbs and
nutritional supplements in the treatment of depression, but
there have been few studies of the safety of therapies other than
St Johns wort. Consequently, there is a need for further evalua-
tion of effectiveness, safety and ultimately dosages. As seen with
St Johns wort, prolonged and intensive examination has not yet
led to a clear picture on effect sizes or safety. This may in part
be due to the range of products that are available and the result-
ing difficulties in assessing products, which vary in both quality
and constituents. In addition, much of the use of herbs and
nutritional supplements is without the knowledge of the health
professional so that patterns of safety and risks of interaction
are unclear. Both concerns will be resolved to a certain extent
by the increasing regulation and monitoring of herbal and
nutritional products. There is a temptation for research efforts
to become increasingly focused on the individual constituents
of herbs. However, this will, direct the approach to treatment
away from herbal medicine and towards a more conventional
approach. The current emphasis on self help and patient treat-
ment preferences provides support for further investigation of
interventions such as yoga and meditation-based programs
through appropriately designed and powered studies. Clarifica-
tion of whether such therapies could be used in treatment or as
an adjunct to standard care may then be achieved. The results
of ongoing studies of therapies such as acupuncture and mas-
sage will also provide a clearer picture of effectiveness and
appropriate use in depressed patients.
At present, one of the most urgent needs is for informa-
tion. The available evidence on a range of complementary
therapies is being identified and presented by a number of
ongoing projects. These include the Blue Pages project in
[114], the CAMEOL project [105], the UK National
Library for Health Complementary and Alternative Medicine
Specialist Library
[104]. A number of relevant systematic
reviews are underway under the auspices of the Cochrane
Collaboration Complementary Medicine Field
[103]. As
knowledge and research progress, these sources have the
potential to provide an authoritative guide to complementary
therapies in depression.
Several of the systematic reviews described and the CAMEOL
database are outcomes of the National Health Service Priorities
Project, which is funded by the UK Department of Health.
The views and opinions expressed are those of the authors and
do not necessarily reflect those of the Department of Health.
Key issues
There is increasing interest in a range of complementary therapies for the treatment of depression, which appears to be driven by
patient and general public demand.
Initial indications are that a number of therapies may have beneficial effects and a role in the management of depression,
particularly in mild depression where the risk:benefit ratio of antidepressants is poor.
Conclusive recommendations on effectiveness and safety are precluded by the lack of an evidence base due to difficulties in study
design and, for some therapies, differing diagnostic frameworks.
Herbal medicines and nutritional supplements are the focus of much of the research interest at present, but interpretation of the
findings of research is complicated by the variation in the products and preparations available.
Further, well-conducted clinical trials are required to assess patient preference, safety and efficacy of complementary therapies in
depression. Studies that focus on exploring specific and nonspecific effects are also required.
Papers of special note have been highlighted as:
• of interest
•• of considerable interest
1 WHO. The ICD-10 Classification of Mental
and Behavioural Disorders. World Health
Organization, Geneva, Switzerland (1992).
2 Martinez C, Rietbrock S, Wise L et al.
Antidepressant treatment and the risk of
fatal and non-fatal self-harm in first episode
depression. Br. Med. J. 330, 389–393
3 Fergusson D, Doucette S, Glass KC et al.
Association between suicide attempts and
selective serotonin reuptake inhibitors:
systematic review of randomised controlled
trials. Br. Med. J. 330, 396–399 (2005).
4 Hammad TA, Laughren T, Racoosin J.
Suicidality in pediatric patients treated with
antidepressant drugs. Arch. Gen. Psychiatry
63, 332–339 (2006).
5 Berman BM. The Cochrane Collaboration
and evidence-based complementary
medicine. J. Altern. Complement. Med. 3(2),
191–194 (1997).
6 Unutzer J, Klap R, Sturm R et al. Mental
disorders and the use of the alternative
medicine: results from a national survey. Am.
J. Psychiatry 157(11), 1851–1857 (2000).
Large-scale survey of use in the USA.
7 Kessler RC, Soukup J, Davis RB et al.
The use of complementary and alternative
therapies to treat anxiety and depression in
the United States. Am. J. Psychiatry 158,
289–294 (2001).
8 Wang J, Patten SB, Russell ML. Alternative
medicine use by individuals with major
depression. Can. J. Psychiatry 46, 528–533
9 Wang J, Patten SB, Williams JV et al.
Help-seeking behaviours of individuals
with mood disorders. Can. J. Psychiatry
50(10), 652–659 (2005).
10 Jorm AF, Griffiths KM, Christensen H,
Parslow RA, Rogers B. Actions taken to
cope with depression at different levels of
severity: a community survey. Psychol. Med.
34, 293–299 (2004).
Survey conducted in Australia providing
a picture of the pattern of use of
complementary and self-help
strategies related to mild through to
severe depression.
Author Proof
Complementary medicine for depression
11 Lewith G, Jonas WB, Walach H. The role
of outcomes research in evaluating
complementary and alternative medicine.
In: Clinical Research in Complementary
Therapies: Principles, Problems and
Solutions. Churchill Livingstone, London,
UK, 29–45 (2002).
12 Dincer F, Linde K. Sham interventions in
randomized clinical trials of acupuncture –
a review. Complement Ther. Med. 11(4),
235–242 (2003).
13 Kaptchuk TJ, Stason WB, Davis RB et al.
Sham device v inert pill: randomised
controlled trial of two placebo treatments.
Br. Med. J. 332(7538), 391–397 (2006).
14 Smith CA, Hay PPJ. Acupuncture for
depression. Cochrane Syst. Rev. 3,
CD004046. John Wiley and Sons.
•• Cochrane review.
15 Cummings M, Reid F. BMAS policy
statements in some controversial areas of
acupuncture practice. Acupunct. Med.
22(3), 134–136 (2004).
16 MacPherson H, Thomas KJ, Walters S et al.
The York acupuncture safety study:
prospective survey of 34,000 treatments by
traditional acupuncturists. Br. Med. J. 323,
486–487 (2001).
17 White A, Hayoe S, Hart A et al. Adverse
events following acupuncture: prospective
survey of 32,000 consultations with doctors
and physiotherapists. Br. Med. J. 323,
485–486 (2001).
18 Macpherson H, Scullion A, Thomas KJ,
Walters S. Patient reports of adverse events
associated with acupuncture treatment: a
prospective national survey. Qual. Saf.
Health Care 13, 349–355 (2004).
19 Han JS. Electroacupuncture: an alternative
to antidepressants for treating affective
diseases. Int. J. Neurosci. 29, 79–92 (1986).
20 Mukaino Y, Park J, White A, Ernst E. The
effectiveness of acupunture for depression –
a systematic review of randomised
controlled trials. Acupunct. Med. 23(2),
70–76 (2005).
•• Recent systematic review for comparison
with the Cochrane review on the
same topic.
21 Tisserand R, Balacs T. Essential oil safety.
Churchill Livingstone, NY, USA (1995)
22 Hallissey S. Aromatherapy and massage. In:
Integrated Cancer Care. Barraclough J (Ed).
Oxford University Press, Oxford, UK
23 Tiran D. Reviewing theories and origins.
In: Clinical Reflexology: A Guide for Health
Professionals. PA Mackereth, D Tiran (Eds).
Churchill Livingstone, London, UK, 5–15
24 Buckle J. ClinicaL Aromatherapy: Essential
Oils in Practice. Second Edition. Churchill
Livingstone, London, UK (2003).
25 Natural standard herb and supplement
handbook: the clinical bottom line.
Basch EM, Ulbricht CE (Eds). Mosby, St
Louis, Missouri, USA (2005).
Comprehensive reference source providing
clinically relevant information
26 Ernst E. The safety of massage therapy.
Rheumatology 42(9), 1101–1106 (2003).
27 Moyer CA, Rounds J, Hannum JW. A meta-
analysis of massage therapy research. Psychol.
Bull. 130(1), 3–18 (2004).
Systematic review on massage for a range
of conditions.
28 Taylor MJ, Carney S, Geddes J, Goodwin
G. Folate for depressive disorders. Cochrane
Syst. Rev. 2, CD003390 (2003).
•• Cochrane review.
29 Taylor MJ, Wilder H, Bhagwagar Z,
Geddes J. Inositol for depressive disorders.
Cochrane Syst. Rev. 1, CD004049 (2004).
•• Cochrane review.
30 Shaw K, Turner J, Del Mar C. Tryptophan
and 5-Hydroxytryptophan for depression.
Cochrane Syst. Rev. 1, CD003198 (2002).
•• Cochrane review.
31 Schachter HM, Kourad K, Merali Z et al.
Effects of omega-3 fatty acids on mental
health. Evid. Rep. Technol. Assess. No. 116.
AHRQ Publication No 05-E022–1. Agency
for Healthcare Research and Quality,
Rockville, MD, USA (2005).
Recent systematic review on omega-3 fatty
acids for a range of conditions including
depression, attention-deficit hyperactivity
disorder and schizophrenia.
32 Bressa GM. S-adenosyl-l-methionine
(SAMe) as antidepressant: meta-analysis of
clinical studies. Acta Neurol. Scand.
154(Suppl.), 7–14 (1994).
33 Hardy ML, Coulter I, Morton SC et al.
S-adenosyl-L-methionine for treatment of
depression, osteoarthritis, and liver disease.
Evid. Rep. Technol. Assess. 64(Summ.), 1–3
34 Williams AL, Girard C, Jui D, Sabina A, Katz
DL. S-adenosylmethionine (SAMe) as
treatment for depression: a systematic review.
Clin. Invest. Med. 28(3), 132–139 (2005).
35 Mills S, Bone K. Principles of herbal
pharmacology. In: Principles and Practice of
Phytotherapy: Modern Herbal Medicine.
Churchill Livingston, London, UK, 22–79
36 Natural Medicines Comprehensive Database.
Fifth edition. Jellin JM, Gregory PJ (Eds).
Therapeutic Research Faculty, Stockton,
CA, USA (2003).
Comprehensive reference source on
herbal products.
37 Calapai G, Crupi A, Firenzuoli F et al.
Serotonin, norepinephrine and dopamine
involvement in the antidepressant action of
Hypericum perforatum. Pharmacopsychiatry
34(2), 45–49 (2001).
38 Zanoli P. Role of hyperforin in the
pharmacological activities of St. Johns
Wort. CNS Drug Rev. 10, 203–218 (2004).
39 Mennini T, Gobbi M. The antidepressant
mechanism of Hypericum perforatum. Life
Sci. 75, 1021–1027 (2004).
40 Pilkington K, Boshnakova A, Richardson J.
St Johns wort for depression: time for a
different perspective? Complement. Ther.
Med. (2006) (In Press).
•• Review of systematic reviews of
effectiveness and safety providing an
outline of the variation in methods
and results.
41 Linde K, Mulrow CD, Berner M, Egger M.
St Johns Wort for depression. Cochrane
Syst. Rev. 3, CD000448 (2005).
•• Cochrane review.
42 Akhondzadeh S, Tahmacebi-Pour N,
Noorbala AA et al. Crocus sativus L. in the
treatment of mild to moderate depression: a
double-blind, randomized and placebo-
controlled trial. Phytother. Res. 19(2),
148–151 (2005).
43 Akhondzadeh S, Fallah-Pour H, Afkham K,
Jamshidi AH, Khalighi-Cigaroudi F.
Comparison of Crocus sativus L. and
imipramine in the treatment of mild to
moderate depression: a pilot double-blind
randomized trial. BMC Complement.
Altern. Med. 4, 12 (2004).
44 Noorbala AA, Akhondzadeh S,
Tahmacebi-Pour N, Jamshidi AH.
Hydro-alcoholic extract of Crocus sativus L.
versus fluoxetine in the treatment of mild to
moderate depression: a double-blind,
randomized pilot trial. J. Ethnopharmacol.
97(2), 281–284 (2005).
45 Akhondzadeh S, Kashani L, Fotouhi A et al.
Comparison of Lavandula angustifolia Mill.
tincture and imipramine in the treatment
of mild to moderate depression: a double-
blind, randomized trial. Prog.
Neuropsychopharmacol. Biol. Psychiatry
27(1), 123–127 (2003).
46 Freeman LW. Homeopathy: like cures like.
In: Complementary and Alternative
Medicine: An Evidence-based Approach.
Mosby, Missouri, USA, 345–360 (2001).
47 Kleijnen J, Knipschild P, ter Riet G.
Clinical trials of homeopathy. Br. Med. J.
302, 316–323 (1991).
Author Proof
Pilkington, Rampes & Richardson
Expert Rev. Neurotherapeutics 6(11), (2006)
48 Linde K, Clausius N, Ramirez G et al. Are
the clinical effects of homoeopathy placebo
effects? A meta-analysis of placebo-
controlled trials. Lancet 350, 834–843
49 Cucherat M, Haugh MC, Gooch M,
Boissel JP. Evidence of clinical efficacy of
homeopathy: a meta-analysis of clinical
trials. Eur. J. Clin. Pharmacol. 56, 27–33
50 Shang A, Huwiler-Müntener K, Nartey L et
al. Are the clinical effects of homoeopathy
placebo effects? Comparative study of
placebo-controlled trials of homoeopathy
and allopathy. Lancet 366, 726–732
51 Pilkington K, Kirkwood G, Rampes H,
Fisher P, Richardson J. Homeopathy for
depression: a systematic review of the
research evidence. Homeopathy 94,
153–163 (2005).
Recent review providing a discussion of
the type of research evidence available.
52 Canter PH. The therapeutic effects of
meditation. (Editorial). Br. Med. J. 326,
1049–1050 (2003).
53 Krisanaprakornkit T, Krisanaprakornkit W,
Piyavhatkul N, Laopaiboon M. Meditation
therapy for anxiety disorders. Cochrane
Syst.Rev. 1, CD004998 (2006).
54 Kabat-Zinn J. Bringing mindfulness to
medicine. Interview by Karolyn A. Gazella.
Altern. Ther. Health Med. 11(3), 56–64
55 Grossman P, Niemann L, Schmidt S,
Walach H. Mindfulness-based stress
reduction and health benefits. A meta-
analysis. J. Psychosom. Res. 57(1), 35–43
Systematic review of MBSR for a range
of conditions.
56 Teasdale J, Segal Z, Williams J,
Ridgeway V, Soulsby J, Lau M. Prevention
of relapse/recurrence in major depression
by mindfulness-based cognitive therapy.
J. Consult. Clin. Psychol. 68, 615–623
Well-designed trial demonstrating the
effectiveness in patients who had a history
of three or more episodes of depression.
57 Ma SH, Teasdale JD. Mindfulness-based
cognitive therapy for depression: replication
and exploration of differential relapse
prevention effects. J. Consult. Clin. Psychol.
72(1), 31–40 (2004).
58 Riley D. Hatha yoga and the treatment of
illness (commentary). Altern. Ther. Health
Med. 10(2), 20–21 (2004).
59 Pilkington K, Kirkwood G, Rampes H,
Richardson J. Yoga for depression: the
research evidence. J. Affect. Disord. 89(1–3),
13–24 (2005).
•• Recent systematic review summarising the
results of randomized controlled trials of
several yoga-based interventions.
60 Sharma VK, Das S, Mondal S, Goswampi
U, Gandhi A. Effect of Sahaj Yoga on
depressive disorders. Indian J. Physiol.
Pharmacol. 49(4), 462–468 (2005).
61 Stetter F, Kupper S. Autogenic training: a
meta-analysis of clinical outcome studies.
Appl. Psychophysiol. Biofeedback 27(1),
45–98 (2002).
Comprehensive review of
autogenic training.
62 Eller LS. Guided imagery interventions for
symptom management. Annu. Rev. Nurs.
Res. 17, 57–84 (1999).
63 Tuunainen A, Kripke DF, Endo T. Light
therapy for non-seasonal depression.
Cochrane Database of Systematic Reviews
2004, Issue 2. Art. No.: CD004050. DOI:
•• Cochrane review.
64 Jorm AF, Christensen H, Griffiths KM,
Rodgers B. Effectiveness of complementary
and self-help treatments for depression.
Med. J. Aust. 176(Suppl.), S84–S96 (2002).
•• Provides brief summaries of the evidence
on a wide range of therapies.
65 Kirsch I. The placebo effect in
complementary medicine. In: Clinical
Research in Complementary Therapies. Lewith
G, Jonas W, Walach H (Eds). Churchill
Livingstone, Edinburgh, UK (2002).
Discussion of the placebo effect and its
particular relevance to depression.
66 Shannon S. Synthesis. In: Handbook of
Complementary and Alternative Therapies in
Mental Health. Scott S (Ed.). Academic
Press, London, UK, 541–557 (2002).
101 NICE. Depression: management of
depression in primary and secondary care.
Clinical Guideline 23. Developed by the
National Collaborating Centre for Mental
Health. National Institute for Clinical
Excellence, London, UK (2004)
102 WHO. Depression. World Health
Organisation, Geneva (2006)
103 Cochrane Collaboration Complementary
Medicine Field. University of Maryland.
Accessed Aug 2006
104 National Library for Health Specialist
Library for Complementary and Alternative
Medicine. National electronic Library for
Accessed Aug 2006
105 CAMEOL (Complementary and
Alternative Medicine Evidence OnLine)
database. Research Council for
Complementary Medicine/University of
Accessed Aug 2006
106 NCCAM (National Centre for
Complementary and Alternative
Medicine). What is Complementary and
Alternative Medicine (CAM)? Definitions.
Accessed 31 March 2006
107 Pilkington K, Kirkwood G, Rampes H,
Richardson J. Aromatherapy and massage
for depression: a systematic review.
Complementary and Alternative Medicine
Evidence Online (CAMEOL) Database.
Accessed 7 Apr 2006
•• Recent systematic review comparing the
evidence for aromatherapy, massage and
combined therapy.
108 Pilkington K, Kirkwood G, Rampes H,
Richardson J. Reflexology for depression: a
systematic review. Complementary and
Alternative Medicine Evidence Online
(CAMEOL) Database. (2006)
Accessed 7 Apr 2006
109 NCCAM . Mind-Body Medicine: An
Overview. (2005)
Accessed 25 Aug 2005
110 Kirkwood G, Rampes H, Richardson J,
Pilkington K. Meditation for depression: a
systematic review. Complementary and
Alternative Medicine Evidence Online
(CAMEOL) Database (2005)
Accessed 7 Apr 2006
111 NCCAM (National Centre for
Complementary and Alternative
Medicine).National Institutes of Health.
Accessed Apr 2006
112 Depression Alliance.
Accessed Apr 2006
Author Proof
Complementary medicine for depression
113 Prince of Wales’s Foundation for Integrated
Health. Unity in Diversity:
Complementary healthcare in mental
health services.
Accessed Apr 2006
114 BluePages Depression Information.
The Centre for Mental Health Research,
The Australian National University.
Accessed 7 Apr 2006
•Karen Pilkington, BPharm, DipInfSci, MSc
Project Manager/Senior Research Fellow
(NHSP/CAMEOL Project) and Project Adviser
to the NLH CAM Specialist Library, University
of Westminster, School of Integrated Health,
London, UK
Tel.: +44 207 911 5000 ext. 5340
Fax: Fax
Hagen Rampes
, BSc, MBChB, FRCPsych
Consultant Psychiatrist, Barnet, Enfield &
Haringey Mental Health NHS Trust, Northwest
Community Mental Health Team, Edgware,
Middlesex, UK
Tel.: +44 208 951 2142
Fax: Fax
Janet Richardson
, BSc(hons), PhD, RN, CPsychol
Reader in Nursing and Health Studies,
University of Plymouth, Faculty of Health and
Social Work, Portland Square, Drake Circus,
Plymouth PL4 8AA, UK
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... Большинство клинических исследований у людей на сегодняшний день сфокусировано на антидепрессивных свойствах экстракта зверобоя. Так, в ряде систематических обзоров литературы и метаанализов была подтверждена эффективность экстракта зверобоя в лечении легкой и умеренной депрессии [14] . В рандомизированном клиническом исследовании экстракта зверобоя при соматоформных расстройствах, сопровождающихся высоким уровнем тревоги [15] , был показан значительный положительный эффект экстракта зверобоя по сравнению с плацебо в уменьшении соматической и психической тревоги, общего балла тревожности и выраженности симптомов соматоформного расстройства. ...
... Большинство клинических исследований у людей на сегодняшний день сфокусировано на антидепрессивных свойствах экстракта зверобоя. Так, в ряде систематических обзоров литературы и метаанализов была подтверждена эффективность экстракта зверобоя в лечении легкой и умеренной депрессии[14]. В рандомизированном клиническом исследовании экстракта зверобоя при соматоформных расстройствах, сопровождающихся высоким уровнем тревоги[15], был показан значительный положительный эффект экстракта зверобоя по сравнению с плацебо в уменьшении соматической и психической тревоги, общего балла тревожности и выраженности симптомов соматоформного расстройства. ...
... (3) Slow action: For many of these drugs, it takes several weeks to achieve their clinical efficacy. Hence, there is a growing interest in complementary and alternative medicine (CAM) among depression patients, with the general belief that " Natural is better " (Pilkington et al., 2006; Sarris and Kavanagh, 2009). Examples of plants with confirmed anti-depression effects include Akebiae quinata (Zhou et al., 2010), Albizzia julibrissin (Kim et al., 2007) and Bupleurum falcatum (Kwon et al., 2010). ...
... The findings indicate the potential use of these strategies in the behavioural activation of depressed undergraduates. Although there is comparatively less evidence for strategies such as relaxation exercises, yoga and meditation [48][49][50], these were highly endorsed by both the undergraduates and mental health experts. Indian undergraduates have also endorsed such methods, with their endorsement of these being higher than endorsements by American undergraduates [51]. ...
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Background: Research examining the depression literacy of undergraduates in non-western developing countries is limited. This study explores this among undergraduates in Sri Lanka. Methods: A total of 4671 undergraduates responded to a survey presenting a vignette of a depressed undergraduate. They were asked to identify the problem, describe their intended help-seeking actions if affected by it and rate the helpfulness of a range of help-providers and interventions for dealing with it. Mental health experts also rated these options, providing a benchmark for assessing the undergraduates' responses. Results: Only 17.4 % of undergraduates recognised depression, but this was significantly lower among those responding in Sinhala compared to English (3.5 vs 36.8 %). More undergraduates indicated intentions of seeking informal help, such as from friends and parents, than from professionals, such as psychiatrists and counsellors. However, a majority rated all these help-providers as 'helpful', aligning with expert opinion. Other options recommended by experts and rated as 'helpful' by a large proportion of undergraduates included counselling/psychological therapy and self-help strategies such as doing enjoyable activities and meditation/yoga/relaxation exercises. However, a low proportion of undergraduates rated "western medicine to improve mood" as 'helpful', deviating from expert opinion. Although not endorsed by experts, undergraduates indicated intentions of using religious strategies, highly endorsing these as 'helpful'. Labelling the problem as depression and using mental health-related labels were both associated with higher odds of endorsing professional help, with the label 'depression' associated with endorsing a wider range of professional options. Conclusions: The recognition rate of depression might be associated with the language used to label it. These undergraduates' knowledge about the use of medication for depression needs improvement. Health promotion interventions for depressed undergraduates must be designed in light of the prevalent socio-cultural backdrop, such as the undergraduates' high endorsement of informal and culturally relevant help-seeking. Improving their ability to recognise the problem as being mental health-related might trigger their use of professional options of help.
... [11] However, major questions regarding the effectiveness and appropriate role of Homoeopathy in the management of depression are still unanswered. [12] There is a lack of high quality clinical trials and incorporation of preference arms or uncontrolled observational studies have been suggested to be methodologically suitable for further studies in this direction. [13] Systemic reviews of randomised placebo-controlled studies with homoeopathic treatment in psychiatry do not preclude the possibility of some benefit. ...
Objective: To evaluate the role of homoeopathic medicines in the management of depressive episodes. Material and Methods: A prospective, non-comparative, open-label observational study was carried out from October 2005 to September 2010, by the Central Council for Research in Homoeopathy (CCRH) (India), at - the Central Research Institute CRI (H), Kottayam. Patients who were 20-60 years of age, suffering from mood disorders were screened for inclusion and exclusion criteria. Homoeopathic medicines were prescribed in 30, 200 and 1M potencies, after repertorising the symptoms and signs and final consultation with the Materia Medica. The internationally accepted scales - Hamilton Depression Rating Scale (HDRS), Beck Depression Inventory (BDI) and Clinical Global Impression (CGI) - were used to assess the symptoms at each visit and measure the outcome. The follow up of 12 months included six months of observation period. Analysis was done as per the intention-to-treat (ITT) principle using SPSS version 20. Results: Eighty-three patients (35 males and 48 females), who fulfilled the inclusion and exclusion criteria were enrolled in the study. Out of these, 67 patients completed the follow-up, 16 patients did not attend the Outpatient Department (OPD) for varying periods. The ITT principle was applied for the analysis considering their last observations. A statistically significant ( P = 0.0001, P t -test, was observed. The mean scores at baseline and at end were 17.98 ± 4.9 and 5.8 ± 5.9, respectively . Statistically significant differences were also observed in the BDI and CGI scales. The most frequently used medicines were: Natrum muriaticum (n = 18), Arsenicum album (n = 12), Pulsatilla nigricans (n = 11), Lycopodium clavatum (n = 7) and Phosphorus ( n = 6). Conclusion: A course of six months of homoeopathic treatment is associated with significant benefits in patients suffering from depressive episodes, as measured by HDRS. Further controlled studies are needed to assess the efficacy .
Objective: Previous research suggests that online positive psychology interventions (PPI) are frequently used by individuals with symptoms of depression. We aimed to investigate differences in the way depressed and nondepressed users react to the content of an existing online PPI, originally designed for the general public. Method: In a retrospective online survey, we assessed discontinuation parameters, aspects of satisfaction with the program, and negative reactions among users of an online PPI. Results: Bivariate and multivariate analyses showed that, overall, reactions between depressed and nondepressed individuals were similar. Differences were observed concerning reasons for using and for discontinuing the program, the perception of exercises, and negative reactions. Conclusions: Although satisfaction with the program was high, it did not seem to fully meet users' expectations and might be more difficult to complete during episodes of depression. Implications of this study for the adaptation of online PPIs addressing depressed individuals are discussed.
Accumulating studies have shown that a traditional Chinese decoction Chaihu-Shugan-San produced the antidepressant-like effects in rodents including in perimenopausal. Previous studies and our preliminary study indicated that saikosaponin A, one of the main constituents of Chaihu-Shugan-San, enhanced brain-derived neurotrophic factor (BDNF) expression in rats. Herein, this study aimed to evaluate the antidepressant-like effects of saikosaponin A in perimenopausal rats exposed to chronic unpredictable mild stress (CUMS). The sucrose preference test, novelty-suppressed feeding test and forced swimming test were performed after administration of saikosaponin A for 4 weeks. Serum corticotrophin-releasing hormone (CRH), adrenocorticotropic hormone (ACTH) and corticosterone levels, as well as hypothalamus CRH and hippocampal glucocorticoid receptor were measured. In addition, pro-inflammatory cytokines such as interleukin-1beta (IL-1β), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) in the hippocampus were detected for evaluation of the neuroinflammation. Further, BDNF levels and its receptor TrkB were also determined. Our results indicated that four-week treatment with saikosaponin A increased sucrose preference, decreased latency to feed in the novelty-suppressed feeding test and reduced the immobility time in the forced swimming test. In addition, saikosaponin A restored the dsyregulation of HPA axis and neuroinflammation in rats exposed to CUMS. Moreover, saikosaponin A promoted BDNF-TrkB signaling in the hippocampus. This study demonstrates that saikosaponin A produced the antidepressant-like effects in rats, which may be mediated by restoration of neuroendocrine, neuroinflammation and neurotrophic systems in the hippocampus during perimenopausal.
Introduction Western biomedicine approaches healing as related to either the body or the mind, as if they were in isolation from each other. In this conception, illness is external, following a disease-oriented model. In contrast, Eastern medicine views the mind and body as unified and approaches healing as an internal process. As we adopt Eastern medicine into Western society, alternative practices to address both physical and mental health problems are becoming widely employed. These “non-traditional practices,” from the perspective of conventional Western biomedicine, have been termed complementary and alternative medicine (CAM). CAM is typically divided into two broad categories: complementary medicine – approaches used along with conventional biomedicine – and alternative medicine – approaches used instead of conventional biomedicine. CAM approaches are diverse and abundant, and they are grouped by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health into four general domains: (1) mind-body medicine, (2) biologically based practices, (3) manipulative and body-based practices, and (4) energy medicine. Kessler and colleagues (2001) found that people with anxiety and depressive disorders use CAM therapies more frequently than conventional mental health therapies. Almost nine out of ten patients with self-defined “anxiety attacks” seen by a psychiatrist also use some type of complementary and alternative therapy to treat their anxiety.
Background: The first childbirth experience is an exceptionally anxious event for couples. Caregivers have pointed to increased psychological and physical anxiety during labor pains. Aromatherapy has been cited by many articles in the literature for its ability to mitigate the psychosomatic symptoms of labor and improve physical and psychological well-being. Purpose: This study was designed to evaluate the effectiveness of essential oil massage in improving the overall condition of women in the intra-natal period during labor. Methods: This study applied a quasi-experimental design and purposive sampling method. Fifty-two participants were recruited from a teaching hospital in eastern Taiwan and assigned randomly to experiment (n=26) and control groups (n=26). Participants in the experiment group received massage with essential oils and participants in the control group received massage with carrier oils. The duration of massage in these two groups was 15 minutes in total. Data were collected four times, as follows: (1) before the massage, (2) immediately after the massage, (3) 30 minutes after the massage, and (4) 60 minutes after the massage. The visual analogue scale of anxiety and Philips M1165A biophysical monitor were employed to measure heartbeat, blood pressure, and blood oxygen saturation in participants. Results: Findings showed that, 30 minutes after receiving massage with essential oils, the experiment group reported significantly less anxiety and had significantly increased oxygen saturation and decreased diastolic pressure levels as compared with the control group. Applying massage with essential oils can decrease labor anxiety levels during firsttime labor. Researchers found no significant differences in other physiological indicators between the two groups. Conclusions: The results from this study support massage with essential oils as an alternative approach to relieving anxiety in women in the intra-natal period during labor.
The root bark of Morus alba is commonly used as an alternative medicine due to its numerous health benefits in humans. However, the antidepressant effects of various active components from M. alba have not been fully elucidated. In this study, we aimed to determine whether sanggenon G, an active compound isolated from the root bark of M. alba, exhibited antidepressant-like activity in rats subjected to forced swim test (FST)-induced depression. Acute treatment of rats with sanggenon G (30 mg/kg, i.p.) significantly reduced immobility time and increased swimming time without any significant change in climbing. Rats treated with sanggenon G also exhibited a decrease in the limbic hypothalamic-pituitary-adrenal (HPA) axis response to the FST, as indicated by attenuation of the corticosterone response and decreased c-Fos immunoreactivity in the hypothalamic paraventricular nucleus (PVN). In addition, the antidepressant-like effects of sanggenon G were significantly inhibited by WAY100635 (1 mg/kg, i.p.; a selective 5-HT1A receptor antagonist), but not SCH23390 (0.05 mg/kg, i.p.; a dopamine D1 receptor antagonist). Our findings suggested that the antidepressant-like effects of sanggenon G were mediated by an interaction with the serotonergic system. Further studies are needed to evaluate the potential of sanggenon G as an alternative therapeutic approach for the treatment of depression.
Acupuncture, one of the most popular complementary therapies, is best known for its ability to provide pain relief. Accumulating evidence suggests that acupuncture may also be beneficial in depression, although its effectiveness remains uncertain in this condition. We conducted a meta-analysis of randomized trials in which the effects of acupuncture combined with antidepressant medications were compared with those of antidepressant medications alone in adults with a diagnosed depressive disorder. Thirteen randomized controlled trials involving 1046 subjects were included in the meta-analysis. Our results confirmed that the pooled standardized mean difference of the 'endpoint scores of the 17-item Hamilton rating scale for depression' was -3.74 (95% CI, -4.77 to -2.70, p<0.001) in week 1 and -2.52 (95% CI, -4.12 to -0.92; p<0.01) in week 6, indicating a significant difference in favor of acupuncture combined with selective serotonin reuptake inhibitors (SSRIs). Moreover, therapeutic response rates were statistically significantly different between the two groups (risk ratio [RR], 1.23; 95% CI, 1.10 to 1.39; p<0.001; I(2)=68%) in favor of the combined treatment group. This systematic review and meta-analysis suggest that acupuncture combined with antidepressant medication is effective, has an early onset of action, safe and well-tolerated over the first 6-week treatment period. Moreover, this treatment combination appears to result in greater therapeutic efficacy than SSRI therapy alone. More high-quality randomized clinical trials are needed to evaluate the clinical benefit and long-term effectiveness of acupuncture in the treatment of depression. Copyright © 2015. Published by Elsevier B.V.
The authoritative and comprehensive modern textbook on western herbal medicine - now in its second edition This long-awaited second edition of Principles and Practice of Phytotherapy covers all major aspects of herbal medicine from fundamental concepts, traditional use and scientific research through to safety, effective dosage and clinical applications. Written by herbal practitioners with active experience in clinical practice, education, manufacturing and research, the textbook is both practical and evidence based. The focus, always, is on the importance of tailoring the treatment to the individual case. New insights are given into the herbal management of approxiately 100 modern ailments, including some of the most challenging medical conditions, such as asthma, inflammatory bowel disease and other complex autoimmune and inflammatory conditions, and there is vibrant discussion around the contribution of phytotherapy in general to modern health issues, including health ageing. Fully referenced throughout, with more than 10, 000 citations, the book is a core resource for students and practitioners of phytotherapy and naturopathy and will be of value to all healthcare professionals - pharmacists, doctors, nurses - with an interest in herbal therapeutics.
A basic principle of systems theory explains that systems interact and influence each other in a complex manner. This defines an open system. It exists in a web of interconnected relationships that exchange information, food, energy, etc. All existing models of biological systems presuppose that they function as open systems. On the other hand, a closed system has no active exchange of materials (chemicals, information, energy) with the outside. Whether it is spiritual healing or process work, acupuncture or Ayurveda, all incorporates a premise of body–mind–spirit interaction (an open system) and the constant sustaining relationship that human being have with its complex environment. The prevailing paradigm of science has built itself on the precision and exactness of the pure sciences such as chemistry and physics. This precision and exactness has provided humans much in the way of useful knowledge and technology. Any area of health care that uses a closed systems model tends to develop more precision, exactness, and technology. This chapter introduces synthesis that involves combining separate elements into an integrated whole. The goal is to make human being whole again. To accomplish this, good, wisdom and knowledge must be balanced. It is also needed to fully accept the open-system quality of human experience and reevaluate scientific research designs.