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Depression



Related Terms
  • Adjustment disorder, antidepressants, antipsychotics, anxiety, atypical depression, bipolar, brain, cocaine, cognitive-behavioral therapy (CBT), computerized tomography (CT), congestive heart failure (CHF), depression, dialysis dementia, dopamine, dysthymic disorder, DSM-IV, ecstasy, electroconvulsive therapy (ECT), encephalitis, extrapyramidal, fatigue, hallucinations, hypomania, interpersonal therapy (IPT), lumbar puncture, magnetic resonance imagining (MRI), major depression, manic-depressive illness, marijuana, meningitis, methamphetamine, neurotransmitter, norepinephrine, positron emission tomography (PET), postpartum mania, premenstrual dysphoric disorder (PMDD), psychotherapy, psychosis, seasonal affective disorder (SAD), serotonin, suicidal, thyroid.

Background
  • Depression or depressive disorder is an illness that involves the body, mood, and thoughts. Depression is considered a mood disorder. Imbalances in three neurotransmitters (brain chemicals), including serotonin, norepinephrine, and dopamine, are linked to depression. Depression affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about life situations. Unlike normal emotional experiences of sadness, loss, or passing mood states, depressive disorders are persistent and can significantly interfere with an individual's thoughts, behavior, mood, activity, and physical health.
  • According to the National Institute of Mental Health (NIMH), depressive disorders affect approximately 18.8 million American adults or about 9.5% of the U.S. population age 18 and older in a given year. This includes major depressive disorder (severe depression), dysthymic disorder (mild to moderate depression), and bipolar disorder (manic-depressive). Among all medical illnesses, major depression is the leading cause of disability in the U.S. and many other developed countries.
  • Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.
  • Children and teenagers can also suffer from depression. Depression in the young is defined as an illness when the feelings of depression persist and interfere with a child or adolescent's ability to function.
  • The American Academy of Child and Adolescent Psychiatry estimates that about 5% of children and adolescents in the general population suffer from depression at any given point in time. Children under stress, who experience loss, or who have trouble with attention, learning, conduct, or anxiety disorders are at a higher risk for depression.

Risk factors and causes
  • Neurotransmitter imbalances: Studies suggest that a low or high level of neurotransmitters such as serotonin, norepinephrine, or dopamine cause depression. Studies have found evidence that a change in the sensitivity of the receptors on nerve cells to these neurotransmitters may be one issue, along with an imbalance in the amounts of neurotransmitters. Balancing neurotransmitters with drug therapy is the current focus for treatment of major depression.
  • Heredity: Researchers have identified several genes that may be involved in bipolar disorder and are looking for genes linked to other types of depression. But not everyone with a family history of depression develops the disorder, and conversely, people with no family history of the disorder can become depressed.
  • Gender: Depression occurs twice as frequently in women as in men, for reasons that are not fully understood. Hormonal changes such as menstrual cycle changes, postpartum period, pre-menopause, pregnancy, childbirth, miscarriage, and menopause are the most likely causes of depression.
  • Although men are less likely to suffer from depression than women, six million men in the United States are affected by the illness. Men are less likely to admit to depression. The rate of suicide in men is four times that of women, though more women attempt it.
  • Stress: Stressful life events, particularly a loss or threatened loss of a loved one or a job, can trigger depression.
  • Medications: Long-term use of certain medications, such as some drugs used to control high blood pressure, sleeping pills, or birth control pills, may cause symptoms of depression in some people.
  • Illnesses: Having a chronic illness, such as heart disease, stroke, diabetes, cancer or Alzheimer's disease, puts an individual at a higher risk of developing depression. Having an underactive thyroid (hypothyroidism), even mildly, also can cause depression. Physical trauma (damage) to the brain can also trigger depression.
  • Personality: Certain personality traits, such as having low self-esteem and being overly dependent, self-critical, pessimistic and easily overwhelmed by stress, can make an individual more vulnerable to depression.
  • Postpartum depression: It is common for mothers to feel a mild form of distress that usually occurs a few days to weeks after giving birth. During this time the woman may have feelings of sadness, anger, anxiety, irritability and incompetence. A more severe form of the baby blues, called postpartum depression, also can affect new mothers.
  • Hormones: Women experience depression about twice as much as men, which leads researchers to believe hormonal factors may play a role in the development of depression.
  • Alcohol, smoking, and drug abuse: Abuse of alcohol, cigarettes, and recreational drugs such as cocaine, methamphetamine (crystal meth), ecstasy, and marijuana can lead to depression.
  • Previous depression: More than half of those who experience a single episode of depression will continue to have episodes that occur as frequently as once or even twice a year. Without treatment, the frequency of depressive illness as well as the severity of symptoms tends to increase over time. Left untreated, depression can lead to suicide.

Complications
  • About half of the people who have a first episode of depression will have another episode within 10 years. The risk of further bouts of depression is higher than in someone who has never been depressed.
  • Alcohol and drug abuse are very common among people with depression.
  • Depressive disorder can have devastating effects on relationships as complete isolation and withdrawal during depression are common.
  • Suicide may be a complication of untreated, mistreated, or misdiagnosed depression. Women attempt suicide more often than men do, but men are much more likely to succeed in killing themselves. The rate of suicide is four times greater for men. Men over 70 are the most likely to commit suicide.
  • Calling a local suicide hotline, such as the National Suicide Prevention Lifeline at 1-800-273-8255, can be help for someone thinking of suicide.

Integrative therapies
  • Strong scientific evidence:
  • Music therapy: Music has been referred to as an ancient tool of healing. Many different forms of music intervention have been used to reduce depression and anxiety in a variety of medical conditions and medical procedures. There is evidence that music therapy may increase responsiveness to antidepressant medication. In elderly adults with depression, a home-based program of music therapy may have long-lasting effects for mood enhancement. In depressed adult women, music therapy may lead to reductions in heart rate, respiratory rate, blood pressure, and depressed mood. Music therapy is generally known to be safe.
  • Sage: Sage has long been suggested as a possible therapy for mood enhancement. Several trials provide evidence for this use of sage, even in stressful situations. Additional study is needed to confirm these findings and determine the best dose.
  • Avoid if allergic or hypersensitive to sage species, their constituents, or to members of the Lamiaceae family. Use cautiously with hypertension (high blood pressure). Use sage essential oil or tincture cautiously in patients with epilepsy. Avoid with previous anaphylactic reactions to sage species, their constituents, or to members of the Lamiaceae family. Avoid if pregnant or breastfeeding.
  • St. John's wort: Extracts of St. John's wort (Hypericum perforatum) have been recommended traditionally for a wide range of medical conditions, with the most common modern-day use being the treatment of depression. St. John's wort has been extensively studied in Europe over the last two decades, with more recent research in the United States. Short-term studies (one to three months) suggest that St. John's wort is more effective than placebo (sugar pill), and equally effective as tricyclic antidepressants (TCAs) in the treatment of mild-to-moderate depressive disorder. Comparisons to the more commonly prescribed selective serotonin reuptake inhibitor (SSRI) antidepressants, such as fluoxetine (Prozac®) or sertraline (Zoloft®), are more limited. However, other data suggest that St. John's wort may be just as effective as SSRIs with fewer side effects. Safety concerns exist as with most conventional and complementary therapies. Studies of St. John's wort for severe depression have not provided clear evidence of effectiveness.
  • In published studies, St. John's wort has generally been well tolerated at recommended doses for up to one to three months. The most common adverse effects include gastrointestinal upset, skin reactions, fatigue/sedation, restlessness or anxiety, sexual dysfunction (including impotence), dizziness, headache, and dry mouth. Caution is advised when taking St. John's wort, as numerous adverse effects including many drug interactions are possible. Drug interactions with St. John's wort can have severe consequences. One small study reported elevated thyroid stimulating hormone (TSH) levels to be associated with taking St. John's wort. St. John's wort should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.
  • Good scientific evidence:
  • 5-hydroxytryptophan (5-HTP): Supplement use of 5-HTP may help balance serotonin in the body. Serotonin is the brain chemical associated with sleep, mood, movement, eating and nervousness. While cells outside the brain, such as platelets in the blood and some cells in the intestine, produce and utilize serotonin, all serotonin used by brain cells must be made within the neurons themselves. When serotonin is not properly constructed within the brain, the result can be irritability, aggression, impatience, anxiety and depression. The results of numerous studies in humans suggest that 5-HTP may aid in the treatment of depression. However, it is not known whether 5-HTP is as effective as commonly prescribed antidepressant drugs.
  • Caution is advised when taking 5-HTP supplements, as numerous adverse effects including drug interactions are possible. 5-HTP is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.
  • Art therapy: Art therapy enables the expression of inner thoughts or feelings when verbalization is difficult or not possible. It involves the application of a variety of art modalities including drawing, painting, clay and sculpture. Art therapy may be an effective intervention for hospitalized, suicidal adolescents. There is evidence that it can be used to aid in developing a sense of identity and optimism about the future. It may also aid in relaxation and willingness to communicate, and may result in shorter hospitalization.
  • Art therapy may evoke distressing thoughts or feelings. Use under the guidance of a qualified art therapist or other mental health professional. Some forms of art therapy use potentially harmful materials. Only materials known to be safe should be used. Related clean-up materials (like turpentine or mineral spirits) that release potentially toxic fumes should only be used with good ventilation.
  • Dehydroepiandoseterone (DHEA): DHEA is a hormone made in the human body that serves as precursor to male and female sex hormones (androgens and estrogens). The majority of clinical trials investigating the effect of DHEA on depression support its use for this purpose under the guidance of a healthcare provider. Further research is needed to confirm these results.
  • Few side effects are reported when DHEA supplements are taken by mouth in recommended doses. Avoid if allergic to DHEA. Side effects may include fatigue, nasal congestion, headache, acne, or rapid/irregular heartbeats. In women, the most common side effects are abnormal menses, emotional changes, headache, and insomnia. Individuals with a history of abnormal heart rhythms, blood clots or hypercoagulability, and those with a history of liver disease, should avoid DHEA supplements. Patients who are taking antidepressants should avoid DHEA. Avoid with a history of seizures. Use cautiously with adrenal or thyroid disorders or anticoagulants (blood thinners), or drugs, herbs, or supplements for diabetes, heart disease, seizure, or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
  • Hypnotherapy, hypnosis: Hypnosis appears effective in the treatment of psychosomatic disorders. Additional research is needed to support this finding.
  • Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.
  • Music therapy: There is evidence that music therapy may increase responsiveness to antidepressant medication. In elderly adults with depression, a home-based program of music therapy may have long-lasting effects. In depressed adult women, music therapy may lead to reductions in heart rate, respiratory rate, blood pressure, and depressed mood. Music therapy is generally known to be safe.
  • Phenylalanine: In early human study, L-phenylalanine, DL-phenylalanine, and D-phenylalanine were shown to reduce symptoms associated with depression. However, high quality clinical trials are needed for better assessment of the antidepressant effectiveness of various forms of phenylalanine dietary supplements.
  • Use cautiously in patients taking monoamine oxidase inhibitors (MAOIs), or in patients with hypertension, anxiety disorders, psychiatric disorders, or sleep disorders. Avoid in patients with Parkinson's disease or tardive dyskinesia. Avoid in patients with hypersensitivity to phenylalanine or with phenylketonuria (PKU).
  • Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). A broad range of psychotherapies have been shown to be effective for the treatment of mild to moderate depression, ante- and postpartum depression, and depression in children. Although prescription medication is the most effective treatment for bipolar disorder, psychotherapy may help patients take their medication, prevent relapses, and reduce suicidal behavior.
  • Psychotherapy cannot always resolve mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may get worse if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression. Psychotherapy may help with post-partum depression, but is not a substitute for medication that may be needed in severe cases.
  • St. John's wort: Well-designed studies have investigated the effect of St. John's wort on symptoms associated with somatoform disorders. The results suggest St. John's wort may be effective in this population. Further well-designed clinical trials would add to this information and allow recommendations to be made.
  • In published studies, St. John's wort has generally been well tolerated at recommended doses for up to one to three months. The most common adverse effects include gastrointestinal upset, skin reactions, fatigue/sedation, restlessness or anxiety, sexual dysfunction (including impotence), dizziness, headache, and dry mouth. Caution is advised when taking St. John's wort, as numerous adverse effects including many drug interactions are possible. Drug interactions with St. John's wort can have severe consequences. One small study reported elevated thyroid stimulating hormone (TSH) levels to be associated with taking St. John's wort. St. John's wort should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.
  • Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Several human studies support the use of yoga for depression in both children and adults. Although this preliminary research is promising, better studies are needed.
  • Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.
  • Unclear or conflicting scientific evidence:
  • Acupressure, shiatsu: Acupressure, or shiatsu, has been used in China for thousands of years for health and healing. Several studies suggest that acupressure therapy may be effective for depression. Further research is needed.
  • With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. No serious long-term complications have been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.
  • Acupuncture: Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. A small number of studies have sought to compare acupuncture with medications used in depression. More studies are needed on this use.
  • Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (such as asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
  • Aromatherapy: Fragrant oils have been used for thousands of years. Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Preliminary research suggests that lavender (Lavendula officinalis) aromatherapy may be helpful as an adjunct to prescription medications used for depression. Additional research is necessary before a conclusion can be made.
  • Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
  • Ayurveda: Ayurveda, which originated in ancient India over 5,000 years ago, is probably the world's oldest system of natural medicine. Early evidence suggests that a traditional Ayurvedic formula containing extracts of four Indian herbs, Ashvatha, Kapikachu, Dhanvayasa, and Bhuriphali, may have benefits similar to conventional anti-depressant medication. Further studies are needed to confirm the effects of this ayurvedic preparation for mild to moderate depression.
  • Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking.
  • Bach flower remedies: Depression is one of the major uses of Bach flower remedies. Currently, there is a lack of high-quality clinical trials that have investigated the use of Bach flower remedies for major depressive disorder. Higher quality research is needed in this area. Back flower remedies should not be used in lieu of more proven therapies.
  • Chasteberry: There is limited evidence suggesting possible benefits of chasteberry in the alleviation of symptoms of pre-menstrual dysphoric disorder (PMDD). Further evidence is necessary before a conclusion can be drawn.
  • Avoid if allergic or hypersensitive to members of the Vitex (Verbenaceae) family or any chasteberry components. When taken in recommended doses, chasteberry appears to be well tolerated with few side effects. Use cautiously in patients taking oral contraceptives or hormone replacement therapy. Use cautiously with dopamine agonists or antagonists. Avoid with hormone sensitive cancers or conditions (like ovarian cancer or breast cancer). Avoid if pregnant, breastfeeding or if undergoing in vitro fertilization.
  • Chromium: Early studies show that chromium picolinate may improve symptoms of depression in people with atypical depression. Further research is needed before a recommendation can be made.
  • Trivalent chromium appears to be safe because side effects are rare or uncommon. However, hexavalent chromium may be poisonous (toxic). Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, a weakened immune system (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, or stroke or in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.
  • Coleus: Limited studies have assessed the efficacy of coleus in the treatment of depression. High quality clinical trials are warranted.
  • Avoid if allergic or hypersensitive to coleus. Use cautiously with antidepressants, blood pressure drugs, blood-thinners, pain relievers, anticoagulants, blood sugar drugs, bronchodilators, heart drugs (like anti-arrhythmics), drugs dependent on stomach pH (like ketoconazole), thyroid drugs, bladderwrack, garlic, ginkgo, St. John's wort, and other herbs or supplements with similar effects.
  • Creatine: Early research suggests a potential beneficial of creatine supplements in depression. Large, well-designed studies are needed.
  • Avoid if allergic to creatine or with diuretics (like hydrochlorothiazide, furosemide (Lasix®)). Use caution in asthma, diabetes, gout, kidney, liver or muscle problems, stroke or a history of these conditions. Avoid dehydration. Avoid if pregnant or breastfeeding.
  • Feldenkrais method®: Early research revealed improved mood among participants who enrolled in a one-year program that included the Feldenkrais Method®. There is currently a lack of available scientific studies or reports of safety of the Feldenkrais Method®.
  • Folate: Folic acid or folate deficiency has been found among many individuals suffering from depression and has been linked to poor response to antidepressant therapies. Folate supplements have been used for enhancing treatment response to antidepressants. Limited clinical research suggests that folic acid is not effective as a replacement for conventional antidepressant therapy. Blood tests can determine if an individual is low in vitamins such as folic acid.
  • Folate appears to be well tolerated in recommended doses. Avoid if allergic or hypersensitive to folate or any of the product ingredients. It is recommended that pregnant women consume 400 micrograms of folate daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.
  • Ginkgo: Preliminary study suggests that ginkgo (Ginkgo biloba) may not be effective for depression and seasonal affective disorder (SAD). Other research in elderly patients with depression shows possible minor benefits. Ginkgo may help in decreasing sexual side effects such as loss of libido in individuals taking antidepressants. Overall, there is not enough evidence to form a clear conclusion. It remains unclear if ginkgo is effective for improving mood in post-menopausal women. Further well-designed research is needed as existing study reports conflicting evidence.
  • Caution is advised when taking ginkgo supplements as numerous adverse effects and drug interactions are possible. Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily. If allergic to mango rind, sumac, poison ivy or oak, or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (such as aspirin or warfarin) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.
  • Ginseng: A review of several studies suggested that ginseng may improve mood in post-menopausal women. Additional studies are needed before a conclusion can be made.
  • Avoid ginseng with a known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.
  • Guarana: Caffeine, the active ingredient in guarana, may have positive effects on mood enhancement. Caffeine may increase alertness and feelings of well-being and improve performance on sustained attention tasks and simulated driving performance. Slow release caffeine consumption has been correlated with a decrease in calmness and an increase in sleep onset latency.
  • Avoid if allergic/hypersensitivite to guarana (Paullinia cupana), caffeine, tannins or species of the Sapindaceae family. Avoid with hypertension, psychological or psychiatric disorders, liver impairment, and arrhythmias. Avoid with other stimulatory agents, especially ephedra. Use cautiously with breast disease, impaired kidney function, diabetes, pre-existing mitral valve prolapse, iron deficiency, gastric or duodenal ulcers, bleeding disorders, glaucoma, or if at risk for osteoporosis. Use cautiously if undergoing electroconvulsive therapy (ECT). Avoid if pregnant or breastfeeding.
  • Healing touch (HT): Preliminary data suggests that a series of healing touch (HT) sessions over time may reduce depression. However, data are insufficient to form definitive conclusions, and studies of better design are needed. HT should not be regarded as a substitute for established medical treatments. Use cautiously if pregnant or breastfeeding.
  • Kundalini yoga: Kundalini yoga is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. It is an elaborate system focused on healing and "purifying" the mind, body, and emotions. There is preliminary evidence that Kundlini yoga practice may be of benefit in depression. More trials are needed to establish whether this is a viable therapy for depression before a recommendation can be made.
  • Avoid exercises that involve stoppage of breath with heart or lung problems, insomnia, or with poor memory or concentration. Avoid certain inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis or cervical spondylitis. Use cautiously with mental disorders as some techniques may cause an altered state of consciousness. Kundalini yoga is considered safe and beneficial for use during pregnancy and lactation when practiced under the guidance of expert instruction. Teachers of yoga are generally not medically qualified and should not be regarded as sources of medical advice for management of clinical conditions.
  • Lavender: Preliminary research suggests that lavender may be helpful as an adjunct to prescription medications for mild-to-moderate depression. Additional research is necessary before a conclusion can be made.
  • Avoid if allergic or hypersensitive to lavender. Avoid with history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.
  • L-carnitine: L-carnitine (also known as acetyl-L-carnitine) is an antioxidant and may help blood flow as well as neurological function. Although the results are promising there is currently insufficient evidence to support the use of acetyl-L-carnitine in the treatment of depression. Well-designed clinical trials with adequate subject number are required.
  • Caution is advised when taking acetyl-L-carnitine supplements as numerous adverse effects including drug interactions are possible. Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.
  • Massage: Various forms of therapeutic superficial tissue manipulation have been practiced for thousands of years across cultures. Massage is relaxing and may decrease stress. There is currently insufficient evidence to determine if massage is beneficial in patients with depression. Additional research is necessary in order to form a scientifically based recommendation.
  • Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery or blood clots. Use cautiously if history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.
  • Meditation: There is currently not enough scientific evidence to suggest the effectiveness of meditation for mood enhancement. Some forms of meditation may prevent relapse in patients who have had bouts of major depression. More studies are needed.
  • Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.
  • Melatonin: Melatonin has been suggested for the improvement of sleep disturbances in depression, although research is limited in this area. There are several small, brief studies of melatonin in patients with seasonal affective disorder (SAD). This research is not well designed or reported, and further study is necessary before a clear conclusion can be reached.
  • Melatonin is not to be used for extended periods of time. Caution is advised when taking melatonin supplements as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor. Use cautiously with drugs broken down by the liver, sedative drugs (Ambien®), barbiturates, narcotics, antidepressants, alcohol, drugs that increase the risk of bleeding such as warfarin (Coumadin®), non-steroidal anti-inflammatories (ibuprofen or naproxen), drugs that affect blood pressure (atenolol), drugs that lower levels of vitamin B6 in the body (such as birth control pills, hormone replacement therapy, or loop diuretics), diazepam, verapamil, temazepam, somatostatin, drugs that alter blood sugar levels (insulin), caffeine, succinylcholine, methamphetamine, isoniazid or herbs or supplements with similar effects (such as 5-HTP, Ginkgo biloba,garlic, saw palmetto, vitamin B12, chasteberry, arginine, DHEA, and Echinacea).
  • Omega-3 fatty acids, fish oil, alpha-linolenic acid: Essential fatty acids (including omega-3 fatty acids) have many roles in the body, including proper nerve and brain function. There have been several studies on the use of omega-3 fatty acids in depression; however, not enough reliable evidence is available to form a clear conclusion.
  • Omega-3 fatty acids found in fish oils are normally used. It is important to choose quality fish oil supplements, as heavy metals have been reported in some fish oil supplements. The label should say if the product has been tested for heavy metal contamination (such as lead and mercury). Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid, or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/breastfeeding women to a single six-ounce meal per week, and in young children to less than two ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration (FDA) recommends that pregnant/breastfeeding women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat seven ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).
  • Prayer, distant healing: Early study suggests that psychiatric inpatients may benefit from anonymous distant healing intention for depression. Additional research is needed.
  • Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers.
  • Psychotherapy: Telephone-administered cognitive-behavioral therapy may help treat depression for multiple sclerosis patients, although more study is needed in this area. Short-term psychotherapy for psychosomatic conditions may not be as effective as long-term psychotherapy. More research needs to be done to evaluate these approaches. Psychotherapy may help seasonal affective disorder (SAD). Further study is needed to confirm early results.
  • Psychotherapy cannot always resolve mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may get worse if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression. Psychotherapy may help with post-partum depression, but is not a substitute for medication that may be needed in severe cases.
  • Qi gong: Qi gong is a type of Traditional Chinese Medicine (TCM) that is thought to be at least 4,000 years old. Preliminary study shows that Qi gong may be beneficial for relieving stress. Available data remains inconclusive, yet thousands of years of effectiveness in China for stress and anxiety must be appreciated. Qi gong has been studied in elderly patients to assess if it helped with depression in those with chronic physical illnesses. Results were inconclusive, and further research is needed before a recommendation can be made. Qi gong may be used as an adjunct to more proven therapies.
  • Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders. In cases of potentially serious conditions, Qi gong should not be used as the only treatment instead of more proven therapies, and should not delay the time it takes to see an appropriate healthcare provider.
  • Reflexology: Reflexology may provide some benefits to patients suffering from depression. However, results from numerous studies have been inconsistent. Further research is needed.
  • Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.
  • Reiki: Reiki is a Buddhist practice that is approximately 2,500 years old. It is used for stress reduction and relaxation and is administered by "laying on hands" and moving around the "energy" of the body. There is evidence that Reiki may reduce symptoms of depression. Additional research is needed.
  • Reiki is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Use cautiously with psychiatric illnesses.
  • Relaxation therapy: Relaxation therapy includes self-control relaxation, paced respiration, and deep breathing. There is promising early evidence from human trials supporting the use of relaxation to reduce symptoms of depression,although effects appear to be short-lived. Better quality research is necessary before a firm conclusion can be drawn.
  • Avoid with psychiatric disorders such as schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.
  • Riboflavin (Vitamin B2): Riboflavin is a water-soluble vitamin, which is involved in many processes in the body, and is necessary for normal cell function, growth, and energy production. Adequate nutrient supplementation with riboflavin may be required for the maintenance of adequate cognitive function. Treatment with B-vitamins, including riboflavin, has been reported to improve depression in patients taking tricyclic antidepressants.
  • Avoid if allergic or hypersensitive to riboflavin. Since the amount of riboflavin a human can absorb is limited, riboflavin is generally considered safe. Riboflavin is generally regarded as being safe during pregnancy and breastfeeding. The U.S. recommended dietary allowance (RDA) for riboflavin in pregnant women is higher than for non-pregnant women; the RDA during pregnancy is 1.4 milligrams daily, and 1.6 milligrams during breastfeeding.
  • SAMe: S-adenosylmethionine, or SAMe, is normally formed in the body from the essential amino acid methionine. SAMe supplements are used in depression and mood disorders. SAMe has been studied for use in depression for many decades. However, the majority of trials that have been performed have significant methodological flaws limiting their clinical usefulness. A small number of randomized placebo controlled trials suggest an antidepressant effect that is greater than that observed with placebo. Although some studies have suggested that SAMe has a more rapid onset of action in depression than tricyclic antidepressants (TCAs), it is uncertain whether these effects result in improved patient outcomes. Large randomized placebo controlled trials that compare SAMe to other antidepressants such as Selective Serotonin Reuptake Inhibitors (SSRIs) are needed. Until these trials are available, it is difficult to justify the use of SAMe in patients with depression since there are many effective antidepressants available to this patient population.
  • Caution should be used when taking SAMe supplements as drug interactions are possible. Avoid if allergic or hypersensitive to SAMe. Use cautiously with diabetes and anxiety disorders, or in women in their third trimester of pregnancy. Avoid with bipolar disorder. Avoid during the first trimester of pregnancy or if breastfeeding.
  • St. John's wort: Studies of St. John's wort for severe depressive disorder have not provided clear evidence of effectiveness. Additionally, despite some promising early data, there is currently not enough evidence to recommend St. John's wort for Seasonal Affective Disorder (SAD). Additional study is needed.
  • In published studies, St. John's wort has generally been well tolerated at recommended doses for up to one to three months. The most common adverse effects include gastrointestinal upset, skin reactions, fatigue/sedation, restlessness or anxiety, sexual dysfunction (including impotence), dizziness, headache, and dry mouth. Caution is advised when taking St. John's wort, as numerous adverse effects including many drug interactions are possible. Drug interactions with St. John's wort can have severe consequences. One small study reported elevated thyroid stimulating hormone (TSH) levels to be associated with taking St. John's wort. St. John's wort should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.
  • Tai Chi: Tai chi is a system of movements and positions believed to have developed in 12th Century China. Tai chi techniques aim to address the body and mind as an interconnected system, and are traditionally believed to have mental and physical health benefits to improve posture, balance, flexibility and strength. Preliminary research suggests that tai chi may help alleviate depression. Patients may experience improved mood as a result of tai chi practice. Additional research is needed.
  • Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and in patients with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while practicing tai chi may increase the risk of injury.
  • Therapeutic touch: Therapeutic touch may offer some benefits when used with standard therapies to treat depression. More research is needed.
  • Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.
  • Valerian: There is currently not enough available scientific evidence on the use of valerian for depression.
  • Use with caution if allergic to members of the Valerianaceaefamily. Avoid if driving or operating heavy machinery, as it may cause drowsiness. Avoid with liver disease. Avoid if pregnant or breastfeeding.
  • Vitamin B6 (Pyridoxine): Some research suggests that pyridoxine supplementation alone or in combination with high doses of other B vitamins may help with depression. Pyridoxine helps increase the "calming" neurochemicals serotonin and gamma amino butyric acid (GABA) levels in the blood, possibly benefiting people in dysphoric mental states. Well-designed clinical trials are needed to confirm potential benefit. Vitamin B6 may be found in a multivitamin or a B-complex vitamin supplement.
  • Avoid if sensitive or allergic to any vitamin B6 product ingredients. Some individuals seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Avoid excessive dosing. Vitamin B6 is likely safe when used orally in doses not exceeding the recommended dietary allowance (RDA). The RDA for pregnant women is 1.9 milligrams per day. For relief of severe nausea in early pregnancy, 30-75 milligrams has been used daily. There is some concern that high-dose pyridoxine taken by a pregnant mother can cause seizures in a newborn. The RDA in breastfeeding women is 2 milligrams per day. Use cautiously if pregnant or breastfeeding.
  • Vitamin D: In limited available study, vitamin D was found to be better than light therapy in the treatment of seasonal affective disorder (SAD). Further studies are necessary to confirm these findings.
  • Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.
  • Fair negative scientific evidence:
  • Psychotherapy: Several studies suggest that patients with psychotic depression are probably not good candidates for psychotherapy and that medication remains the optimal treatment. More research is needed to determine how psychotherapy may be of benefit in psychotic depression.
  • Psychotherapy cannot always resolve mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may get worse if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression. Psychotherapy may help with post-partum depression, but is not a substitute for medication that may be needed in severe cases.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Types of depression
  • Major depression: This type of depression lasts more than two weeks. Symptoms may include overwhelming feelings of sadness and grief, loss of interest or pleasure in activities usually enjoyed, and feelings of worthlessness or guilt. This type of depression may result in poor sleep, a change in appetite, severe fatigue and difficulty concentrating. Severe depression may increase the risk of suicide.
  • Atypical depression: Individuals with atypical depression, as opposed to major depression, experience improved mood when something good happens. In addition, two of the following symptoms occur to have atypical depression: an increase in appetite or weight gain (as opposed to the reduced appetite or weight loss of "typical" depression), excessive sleeping (as opposed to insomnia), leaden paralysis (a severe form of fatigue or tiredness), and sensitivity to rejection.
  • Dysthymia: Dysthymia is a less severe depression (mild to moderate) than major but a more chronic form of depression. Signs and symptoms usually are not disabling, and periods of mild depression can alternate with short periods of feeling normal. Having dysthymia places an individual at an increased risk of major depression. To be considered having dysthymia, the first two years of depressed mood cannot include any episodes of major depression. In addition, no underlying cause of depressed mood, such as a general medical condition (PMS, menopause, or coronary heart disease) or substance abuse may be present. The symptoms of dysthymia and the associated signs of depression cause significant distress or impairment in social, occupational, and other important areas of functioning. When a major depressive episode occurs on top of dysthymia, healthcare professionals may refer to the resultant condition as double depression.
  • Adjustment disorders: Having a loved one die, losing a job, or receiving a diagnosis of cancer or another disease can cause an individual to feel tense, sad, overwhelmed, or angry. Eventually, most people come to terms with the lasting consequences of life stresses, but some do not; this is called an adjustment disorder. Adjustment disorders are forms of depression that occur when the response to a stressful event or situation causes signs and symptoms of depression. Some people develop an adjustment disorder in response to a single event such as a parent or spouse dying. In others, it stems from a combination of stressors. Adjustment disorders can be acute (lasting less than six months) or chronic (lasting longer). Doctors classify adjustment disorders based on the primary signs and symptoms of depression.
  • Bipolar disorder: Having recurrent episodes of depression and elation (mania) is characteristic of bipolar disorder. Because this condition involves emotions at both extremes (poles), it's called bipolar disorder or manic-depressive disorder. Mania affects judgment, causing individuals to make unwise decisions. Some people have bursts of increased creativity and productivity during the manic phase. The number of episodes at either extreme may not be equal. Some people may have several episodes of depression before having another manic phase, or vice versa.
  • Seasonal affective disorder: Seasonal affective disorder (SAD) is a pattern of depression related to changes in seasons and a lack of exposure to sunlight. SAD usually occurs in winter. It may cause headaches, irritability and a low energy level. SAD is not a chronic (long term) depressive disorder.
  • Postpartum depression: According to the American College of Obstetricians and Gynecologists, about 10% of new moms experience postpartum depression, a more severe form of depression that can develop within the first six months after giving birth. For women with postpartum depression, feelings such as sadness, anxiety and restlessness can be so strong that they interfere with daily tasks. Rarely, a more extreme form of depression known as postpartum psychosis can develop. Symptoms of this psychosis include a fear of harming oneself or one's baby, confusion and disorientation, hallucinations and delusions, and paranoia.
  • Premenstrual dysphoric disorder (PMDD): PMDD occurs when depressive symptoms, such as crying, tiredness, and sadness, occur one week prior to menstruation and disappear after menstruation.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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