Depression is a common disabling condition with a prevalence of 4–8%. There is significant morbidity, mortality and huge personal, family and economic costs, including problems of stigma and discrimination. The National Institute for Health and Clinical Excellence (NICE) recently updated[1] its 2004 guidelines[2] on the treatment of depression while the Scottish Intercollegiate Guideline Network (SIGN) is developing a guideline for the non-pharmacological treatment of mild to moderate depression in primary care.[3,4] Since 2004 NICE has recommended a stepped care approach based on the severity, duration, history and impact of the depression. Recommendations for mild depression include active monitoring, guided self help, computerised cognitive behaviour therapy (CBT), exercise and brief psychological interventions such as counselling, problem-solving therapy and brief CBT. Antidepressants are not recommended because the risk–benefit ratio is poor. For moderate depression, CBT, medication or both are options, taking patient preference into account. In severe depression, treatment resistance or recurrent depression, CBT should be offered in combination with medication. Interpersonal therapy (IPT) or couples therapy should also be considered. Further research is needed to address the issues of efficacy, efficiency and acceptability of the stepped care approach. ####Specific psychological interventions #####Cognitive behavioural therapy Now used in a wide range of disorders, CBT developed from the finding that depressed patients had consistently negative views about themselves, the world and the future, which drove unhelpful behaviours and maintained depressed mood. Cognitive behavioural therapy is structured and time-limited, with typically 16–20 one-hour sessions. Treatment goals are agreed and the patient develops a series of skills, which include identifying and challenging negative thoughts, altering unhelpful behaviours and problem solving. Guided discovery is used rather than debate or persuasion. Homework tasks are agreed as the patient practises the therapy in everyday life. The focus of therapy is in the here and now, with background information gathered to help identify dysfunctional beliefs developed earlier in life. These are addressed later in the therapy to reduce vulnerability to further episodes. Cognitive behavioural therapy is as effective as therapeutic doses of antidepressants, with remission rates of around 50%.[5] There is evidence of benefit over treatment as usual, waiting list controls and persistent benefit at two-year follow-up. There is evidence of benefit of combining medication with CBT, although further research is needed. There is also evidence for small group CBT. There are some criticisms of the CBT evidence, including that the median sample size was only 30, only 70% of studies were randomised and only 20% monitored adherence to therapy for CBT.[3] However, with a large number of randomised controlled trials – NICE reviewed 66 – and systematic reviews, the evidence is robust and consistent. Cognitive behavioural therapy is not more effective in the treatment of depression than other systematic psychological therapies, for example IPT or behavioural activation, but there are considerably more studies of CBT and the range of applications is wider, which may explain why the recommendations for CBT are broader. Mindfulness-based CBT has the best evidence in relapse prevention. This group intervention incorporates meditation and helps patients to focus more on the present (focusing on the body, breathing, seeing thoughts as objects of awareness) and less on regrets from the past or worries about the future. #####Interpersonal therapy Interpersonal therapy focuses on the links between the patient’s current interpersonal relationships and symptoms of depression. The goals are to reduce symptoms by learning to cope with or resolve interpersonal problems such as interpersonal conflicts, role transitions, grief and loss and social skills. There is no writing or homework required. Treatment duration is similar to CBT. Interpersonal therapy is as effective as CBT and medication, with fewer studies but of high quality.[2] There is also evidence of benefit over treatment as usual, waiting list controls, placebo and of persistent benefit. Evidence for benefit combined with medication also requires more study. Monthly maintenance IPT sessions can be effective in delaying relapse of depression. #####Couple-focused therapies The couple-focused therapies reviewed by NICE[1] were based on CBT, IPT or behavioural interventions. There is a small body of evidence of equal benefit to individual CBT or IPT and it is an option where relationship factors are relevant. #####Guided self help and computerised CBT Cognitive behavioural therapy and IPT therapists require considerable training and ongoing supervision and are an expensive and currently insufficient resource. The CBT model has lent itself to self help approaches which may be more acceptable to some patients, improve access and make more efficient use of therapists' time. Patients learn skills using books, self help manuals or interactive computer packages. Effect sizes of 0.4–0.8 are found, with greater effectiveness associated with a supportive therapist monitoring and guiding progress.[6] ‘Blue Pages’, a written course of psycho-education with minimal therapist input, and the computerised CBT (cCBT) programme ‘Mood Gym’ were found to be effective in depression.[7] The cCBT package ‘Beating the Blues’ was found to be ‘clinically superior to treatment as usual, at negligible additional cost’.[8] Questions remain for this and similar packages regarding compliance, relapse rates and costs. #####Behavioural activation Behavioural activation and problem-solving therapy are based on CBT techniques and could be delivered by less highly trained therapists. Behavioural activation focuses on an agreed scheduling of activities to encourage patients to approach activities they have been avoiding and also on analysing the function of rumination (going over and over past regrets) that serves as a form of avoidance. There is strong evidence of benefit equal to CBT.[9] The Scottish Intercollegiate Guidelines Network reviewed two meta-analyses involving 22 studies and found an effect size of 0.7–1.2; it plans to recommend behavioural activation. ####Problem-solving therapy This involves helping the patient develop skills to break down problems into manageable tasks. The evidence for problem-solving therapy is less convincing, based on a small number of suitable studies. #####Counselling Counselling involves professional guidance in resolving personal conflicts and emotional problems. The National Institute for Health and Clinical Excellence advises non-directive person-centred models of 6–10 sessions. The evidence base is less developed. The Scottish Intercollegiate Guidelines Network considers that there is sufficient evidence to recommend counselling, but it point out that many of the studies have mixed populations and do not address use in depression specifically. There is evidence that antidepressants act more quickly than counselling. Some studies show no benefit over usual care and others show that benefits are not sustained. In the 2009 guideline NICE suggests counselling only if other low-intensity interventions or group CBT are declined, and recommends that the practitioner should explain ‘uncertainty of effectiveness in depression’. This has proved highly controversial, with some challenging the evidence NICE included to reach its conclusions. #####Psychodynamic therapy There is a greater emphasis on the therapy relationship and the role of unconscious mechanisms in psychodynamic therapy (PDT) than in other interventions. Therapy is non-directive and the patient is not taught specific skills. Instead, the therapist interprets and helps the patient to develop self awareness and understand how patterns from the past are re-enacted in the present. There is some evidence of equal benefit to CBT or medication. However, few studies focus specifically on depression and some categorised PDT with IPT, leading to difficulty interpreting results. The Scottish Intercollegiate Guidelines Network concluded that further good quality randomised controlled trials are needed but recommends PDT in mild to moderate depression. The NICE 2009 guidline recommends PDT for moderate depression where CBT or IPT have not been beneficial or declined but again advises patients be informed about uncertainty of efficacy.[1] Again, these recommendations have proved controversial. #####Psychological interventions with insufficient evidence Psychological interventions with insufficient evidence include music therapy, art therapy, neurolinguistic programming, thought field therapy and emotional freedom therapy. ####Other interventions #####Exercise Supervised, structured exercise programmes are recommended by both NICE and SIGN as an evidence-based effective treatment. Due to some inconsistencies in earlier meta-analyses, the SIGN group carried out a systematic review of the literature and found good-quality evidence for the benefits of exercise in depression, with reduction in depressive symptoms in a range of settings and age groups of equal efficacy to antidepressants (about 45%), with similar drop-out rates (20–40%) and effect persisting for one year.[3] One study showed similar efficacy to CBT. Study limitations included small sample sizes and the use of volunteers who may have higher motivation levels than usual patients. Studies have tried to determine the required ‘dose’ of exercise, with one study finding a minimum of 30–40 minutes three days per week, others a required energy expenditure of 70–80% of heart rate reserve. The National Institute for Health and Clinical Excellence specifies an average of three sessions per week, lasting 45 minutes to one hour over an average of 12 weeks, tailored to the individual to maximise adherence. #####St John’s wort (*Hypericum*) This herbal supplement has been extensively studied,[1] with robust evidence of benefit in mild and moderate depression, with superiority over placebo and no difference or greater efficacy than synthetic antidepressants. St John’s wort is less effective than low-dose antidepressants in severe depression. It appears as acceptable as placebo and more acceptable than tricyclic antidepressants in particular. It is recommended by SIGN in its draft guideline.[3] However, it is not without important side effects and interactions including with the oral contraceptive pill, warfarin and anticonvulsants. There are also issues with the amounts of active ingredients (there are at least ten potential contributors) in different preparations as St John’s wort is not subject to pharmacoregulation. It is important therefore to check if patients are taking St John’s wort and alert them to these issues. In contrast to the draft SIGN recommendations, NICE recommends that practitioners neither prescribe nor advise patients to take St John's wort due to these concerns.[1] No other herbal supplements currently have sufficient evidence of benefit in depression. #####Complementary therapies With as many as 46% of people using some form of complementary therapy in their lifetime, patients with depression are also likely to consider their use. The Scottish Intercollegiate Guidelines Network looked at the evidence for the benefits of homeopathy, acupuncture, yoga, reiki, aromatherapy, reflexology and t'ai chi in depression. It found a paucity of good-quality randomised controlled trials, poor methodology and reporting and insufficient evidence to recommend any of these complementary therapies. ####Special groups #####Co-morbid physical illness The National Institute for Health and Clinical Excellence has developed a separate guideline in this area.[10] A lower threshold for intervention is suggested where depression complicates the care of the physical health problem. Group-based peer support programmes are recommended in addition to the above range of interventions. The provision of psychological therapy as part of general medical care can be effective and may improve acceptability and access to treatments. #####Elderly There is also good evidence for the benefits of psychological treatments for depression in older adults. Further work is needed to clarify whether this is also true for patients with more severe depression and the older old. #####Depression in pregnancy and postnatal period With higher effect sizes and the changing risk–benefit ratio for psychotropic medication in pregnancy and lactation, NICE recommends more rapid access to the standard range of psychological treatments. Non-directive counselling at home and telephone support are also recommended. #####Children and young people There are specific problems with a lack of efficacy for most selective serotonin reuptake inhibitors (SSRIs) in this group. Non-pharmacological interventions are recommended for children and young people regardless of the severity of depression. ####Which therapy for which patient? More research is required to determine which patients may benefit most from which intervention and what treatments to offer if the initial choices are ineffective. The therapeutic alliance, therapist competence and adherence to the treatment model all have significant effects on clinical outcome. Interventions may cause harm. Ongoing supervision for therapists is essential and the issue of therapist competency in real-life practice requires further study. 2009-06-16T10:18:37Z None declared. 109 2009-11-11T00:00:00Z 2009-11-11T00:00:00Z non-pharmacological-management-of-depression 2009-06-22T00:00:00Z

In recent years there has been a growth in interest in non-pharmacological treatments for depression from patients, professionals and government, with concern about the rising use of antidepressants alongside questions about antidepressant efficacy and a stronger evidence base for some non-pharmacological interventions. In this companion article to our popular article on [the pros and cons of SSRI anti-depressants,](http://behindthemedicalheadlines.com/articles/the-pros-and-cons-of-ssri-antidepressants)Consultant psychiatrist Eleanor Halloran looks at the available options.

2009-11-11T11:02:58Z