As clinical practice guidelines vary widely in their search strategies and recommendations of complementary and alternative medicine (CAM) for depression, this overview aimed at systematically summarising the level 1 evidence on CAM for patients with a clinical diagnosis of depression.
PubMed, PsycInfo and Central were searched for meta-analyses of randomised controlled clinical trials (RCTs) until 30 June 2018. Outcomes included depression severity, response, remission, relapse and adverse events. The quality of evidence was assessed according to Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) considering the methodological quality of the RCTs and meta-analyses, inconsistency, indirectness, imprecision of the evidence and the potential risk of publication bias.
The literature search revealed 26 meta-analyses conducted between 2002 and 2018 on 1–49 RCTs in major, minor and seasonal depression. In patients with mild to moderate major depression, moderate quality evidence suggested the efficacy of St. John’s wort towards placebo and its comparative effectiveness towards standard antidepressants for the treatment for depression severity and response rates, while St. John’s wort caused significant less adverse events. In patients with recurrent major depression, moderate quality evidence showed that mindfulness-based cognitive therapy was superior to standard antidepressant drug treatment for the prevention of depression relapse. Other CAM evidence was considered as having low or very low quality.
The effects of all but two CAM treatments found in studies on clinical depressed patients based on low to very low quality of evidence. The evidence has to be downgraded mostly due to avoidable methodological flaws of both the original RCTs and meta-analyses not following the Consolidated Standards of Reporting Trials and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Further research is needed.
Strengths and limitations of this study
- This systematic overview included the comprehensive literature search of important complementary and alternative medicine topics defined by the Cochrane Collaboration.
- The inclusion criteria were restricted to meta-analyses of randomised controlled clinical trials (RCTs) of patients with a clinical diagnosis of depression.
- The quality of evidence from meta-analyses was assessed according to Grades of Recommendation, Assessment, Development, and Evaluation.
- There is a possible lack of evidence of newer RCTs, which have not been analysed by the included meta-analyses.
Depression is one of the most prevalent psychiatric disorders, with about 25% of women and 12% of men suffering from at least one depressive episode during their lifetime.1–3 According to the criteria for diagnosis recommended by the American Psychiatric Association (APA), depressive disorders can be distinguished by their degree of severity or duration and are also characterised by a high comorbidity and an increase of psychological strain for the affected person.4 It is evident that a strong comorbid connection to several chronic conditions like addictions,5 neurodegenerative diseases6 7 or different psychiatric diseases8–11 exists. This leads depressive disorders as one of the leading causes of disability worldwide.12
The most commonly used treatments for depression are antidepressants, psychotherapy or a combination of drugs and psychotherapy. While both treatment strategies (alone and in combination) have been shown to be effective,13–15 more recent meta-analyses also found high dropout and low remission rates16–21 as well as clinically significant differences between antidepressant drugs and placebos only for patients at the upper end of the very severely depressed category.22 This may lead patients to search for alternatives. Increasing mainstream use of complementary and alternative medicine (CAM) support this trend, particularly for different physical conditions with comorbid affective disorders.23–27 The NIH defines CAM as therapeutic approaches that are usually not included in conventional Western medicine systems.28 CAM therapies used in combination with conventional care are considered as complementary, those used instead of conventional care as alternative practices. Types of CAM approaches include natural products, such as herbs and dietary supplements (vitamins, minerals and probiotics) and mind and body practices, such as yoga, chiropractic and osteopathic manipulation, meditation, relaxation, acupuncture, tai chi, qi gong and hypnotherapy. Practices of traditional healers from Europe (naturopathy and homeopathy), Asia (Ayurveda and traditional Chinese medicine) and other continents are also classified as CAM.28 While some complementary therapies have become a promising adjunct in the standard treatment of depression,29 30 others are known for their possible side effects or interactions with standard drugs.30 Recent clinical practice guidelines, in addition, vary widely in their search strategies and resulting recommendations for CAM treatments. While the American College of Physicians (ACP),31 the American Psychiatric Association (APA)32 and the Canadian Network for Mood and Anxiety Treatments (CANMAT) guideline33 provide a more comprehensive overview and critical appraisal of CAM treatments, the Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN),34 the National Institute for Health and Care Excellence (NICE),35 and the World Federation of Societies of Biological Psychiatry (WFSBP)36 guidelines mainly focus on St. John’s Wort and light therapy. Possible effects and risks of further CAM therapies are not discussed. Thus, the purpose of this overview is to provide a comprehensive search strategy of relevant CAM terms and systematically summarise the existing level 1 evidence for clinical depression as a basis for further guideline recommendations on the efficacy, effectiveness and safety of CAM therapies.[…]
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