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Complementary Therapies for Clinical Depression: an Overview of Systematic Reviews

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Complementary Therapies for Clinical Depression: an Overview of Systematic Reviews Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-028527 on 5 August 2019. Downloaded from Complementary therapies for clinical depression: an overview of systematic reviews Heidemarie Haller, Dennis Anheyer, Holger Cramer, Gustav Dobos To cite: Haller H, Anheyer D, ABSTRACT Strengths and limitations of this study Cramer H, et al. Complementary Objectives As clinical practice guidelines vary widely therapies for clinical in their search strategies and recommendations of ► This systematic overview included the comprehen- depression: an overview of complementary and alternative medicine (CAM) for systematic reviews. BMJ Open sive literature search of important complementa- depression, this overview aimed at systematically 2019;9:e028527. doi:10.1136/ ry and alternative medicine topics defined by the summarising the level 1 evidence on CAM for patients with bmjopen-2018-028527 Cochrane Collaboration. a clinical diagnosis of depression. ► The inclusion criteria were restricted to meta-anal- ► Prepublication history and Methods PubMed, PsycInfo and Central were searched yses of randomised controlled clinical trials (RCTs) additional material for this for meta-analyses of randomised controlled clinical trials of patients with a clinical diagnosis of depression. paper are available online. To (RCTs) until 30 June 2018. Outcomes included depression view these files, please visit ► The quality of evidence from meta-analyses was severity, response, remission, relapse and adverse events. the journal online (http:// dx. doi. assessed according to Grades of Recommendation, The quality of evidence was assessed according to org/ 10. 1136/ bmjopen- 2018- Assessment, Development, and Evaluation. Grades of Recommendation, Assessment, Development, 028527). ► There is a possible lack of evidence of newer RCTs, and Evaluation (GRADE) considering the methodological which have not been analysed by the included Received 12 December 2018 quality of the RCTs and meta-analyses, inconsistency, meta-analyses. Revised 18 June 2019 indirectness, imprecision of the evidence and the potential Accepted 08 July 2019 risk of publication bias. Results The literature search revealed 26 meta-analyses be distinguished by their degree of severity or conducted between 2002 and 2018 on 1–49 RCTs in duration and are also characterised by a high major, minor and seasonal depression. In patients with comorbidity and an increase of psychological mild to moderate major depression, moderate quality strain for the affected person.4 It is evident evidence suggested the efficacy of St. John’s wort towards http://bmjopen.bmj.com/ placebo and its comparative effectiveness towards that a strong comorbid connection to several 5 standard antidepressants for the treatment for depression chronic conditions like addictions, neurode- 6 7 severity and response rates, while St. John’s wort generative diseases or different psychiatric caused significant less adverse events. In patients with diseases8–11 exists. This leads depressive disor- recurrent major depression, moderate quality evidence ders as one of the leading causes of disability showed that mindfulness-based cognitive therapy was worldwide.12 superior to standard antidepressant drug treatment for the The most commonly used treatments prevention of depression relapse. Other CAM evidence was for depression are antidepressants, psycho- on September 28, 2021 by guest. Protected copyright. considered as having low or very low quality. therapy or a combination of drugs and Conclusions The effects of all but two CAM treatments psychotherapy. While both treatment strat- found in studies on clinical depressed patients based on egies (alone and in combination) have low to very low quality of evidence. The evidence has to 13–15 be downgraded mostly due to avoidable methodological been shown to be effective, more recent flaws of both the original RCTs and meta-analyses not meta-analyses also found high dropout and 16–21 © Author(s) (or their following the Consolidated Standards of Reporting Trials low remission rates as well as clinically employer(s)) 2019. Re-use and Preferred Reporting Items for Systematic Reviews and significant differences between antidepres- permitted under CC BY-NC. No Meta-Analyses guidelines. Further research is needed. sant drugs and placebos only for patients at commercial re-use. See rights the upper end of the very severely depressed and permissions. Published by 22 BMJ. category. This may lead patients to search INTRODUCTION Department of Internal and for alternatives. Increasing mainstream use Integrative Medicine, Evang. Depression is one of the most prevalent of complementary and alternative medicine Kliniken Essen-Mitte, Faculty of psychiatric disorders, with about 25% of (CAM) support this trend, particularly for Medicine, Universitat Duisburg- women and 12% of men suffering from at different physical conditions with comorbid Essen, Essen, Germany least one depressive episode during their life- affective disorders.23–27 The NIH defines CAM 1–3 Correspondence to time. According to the criteria for diagnosis as therapeutic approaches that are usually not Dr Heidemarie Haller; recommended by the American Psychiatric included in conventional Western medicine h. haller@ kem- med. com Association (APA), depressive disorders can systems.28 CAM therapies used in combination Haller H, et al. BMJ Open 2019;9:e028527. doi:10.1136/bmjopen-2018-028527 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-028527 on 5 August 2019. Downloaded from with conventional care are considered as complementary, if separate meta-analyses for the included RCTs were those used instead of conventional care as alternative performed. practices. Types of CAM approaches include natural prod- ► Types of participants: only reviews of patients with ucts, such as herbs and dietary supplements (vitamins, a diagnosis of major depression or dysthymia were minerals and probiotics) and mind and body practices, eligible as well as reviews including patients/general such as yoga, chiropractic and osteopathic manipulation, population samples with mild depressive symp- meditation, relaxation, acupuncture, tai chi, qi gong toms above a clinical cut-off or seasonal patterns. and hypnotherapy. Practices of traditional healers from In contrast, reviews studying depressive symptoms Europe (naturopathy and homeopathy), Asia (Ayurveda within specific subpopulations of substance-induced and traditional Chinese medicine) and other continents or demented patients, secondary depression due to 28 are also classified as CAM. While some complementary another medical condition (eg, poststroke, cancer therapies have become a promising adjunct in the stan- or pain patients), bipolar disorders, or females with 29 30 dard treatment of depression, others are known for premenstrual dysphoric disorder or postpartum their possible side effects or interactions with standard depression were excluded. Further restrictions 30 drugs. Recent clinical practice guidelines, in addition, regarding the diagnostic criteria or procedures, vary widely in their search strategies and resulting recom- regarding age, gender, duration of the condition or mendations for CAM treatments. While the American 31 symptom intensity were not applied. College of Physicians (ACP), the American Psychiatric ► Types of interventions: reviews investigating the Association (APA)32 and the Canadian Network for Mood 33 effectiveness and/or safety of a single, adjunctive or and Anxiety Treatments (CANMAT) guideline provide combined CAM treatment were included. For the a more comprehensive overview and critical appraisal of classification of CAM treatments the definition of CAM treatments, the Deutsche Gesellschaft für Psychi- the US National Institutes of Health40 was followed. atrie und Psychotherapie, Psychosomatik und Nerven- CAM interventions have to be compared against treat- heilkunde (DGPPN),34 the National Institute for Health ment as usual (TAU)/waiting list, placebo/sham or and Care Excellence (NICE),35 and the World Federation standard medical care. of Societies of Biological Psychiatry (WFSBP)36 guide- ► Types of outcomes: reviews were eligible if they lines mainly focus on St. John’s Wort and light therapy. assessed at least one measure of effectiveness such as Possible effects and risks of further CAM therapies are severity of depressive symptoms, response rate (gener- not discussed. Thus, the purpose of this overview is to ally defined as a 50% decrease in depression scores provide a comprehensive search strategy of relevant CAM after a period of up to 12 weeks of treatment),31 remis- terms and systematically summarise the existing level sion rate (generally defined as a period of up to 12 1 evidence for clinical depression as a basis for further weeks during which a patient is asymptomatic or has http://bmjopen.bmj.com/ guideline recommendations on the efficacy, effectiveness 41 and safety of CAM therapies. only few symptoms to a very mild degree), relapse rates and/or a measure of safety such as number of adverse events (AEs), drug interactions or numbers needed to harm for study withdrawal due to side METHODS effects. This systematic overview of reviews was conducted in accor- dance with the Preferred Reporting Items for Systematic Search strategy 37 38 Reviews and Meta-Analyses (PRISMA) guidelines and on September 28, 2021 by guest. Protected copyright. 39 Electronic literature was systematically searched via the recommendations of the Cochrane Collaboration.
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