What is Depression

Standard Treatments for Depression

The usual treatments for depression include a combination of medication and behavioral treatment, such as cognitive behavioral therapy (CBT).

Medication

Antidepressant medications are usually the first option for treatment. Common medications are:

• Selective serotonin reuptake inhibitors (SSRIs)
• Serotonin and norepinephrine reuptake inhibitors (SNRIs)
• Other medications, including tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs)

People with bipolar disorder and other conditions have additional options, including mood stabilizers.

Safety Concerns

• It is very important to recognize that it usually takes 2–4 weeks for antidepressant medication to work.
• You may initially experience side effects when beginning your medication. Do not stop taking your medication if you begin to experience side effects until you have spoken with your doctor. Depending on how long you have been taking medication, withdrawal symptoms can occur if you stop abruptly.

Behavioral Treatments

Although doctors initially prescribe medication to treat depression, psychotherapy is also an option either before, with, or as the next step after drugs. Psychotherapy seeks to help you address some of the issues that are causing your depression.

Therapists can help you in the following ways: ⁶

• Finding methods to cope with stress and unpleasant experiences
• Examining the relationship between your thoughts, emotions, and behaviors to help you understand their impact on one another
• Providing emotional support to help you work through complicated emotions and reactions
• Helping you understand your triggers and warning signs that you are becoming depressed or are beginning to experience adverse symptoms of your depression

There are a variety of types of psychotherapy used to treat depression. A primary example is cognitive behavioral therapy (CBT).

To better understand the process of psychotherapy and to begin looking for a therapist and ways that psychotherapy can help you, please visit: www.nimh.nih.gov/health/topics/psychotherapies/index.shtml

Side Effects and Safety Concerns

Psychotherapy is generally a safe way to address depression when provided by a properly trained and certified therapist. However, it’s important to note that any type of therapy can uncover uncomfortable emotions and potentially lead to increased distress, at least temporarily.

Brain Stimulation Therapies

When other treatments have not worked or have had little impact on your depression, your psychiatrist may recommend brain stimulation therapies. ⁷ These involve using electrical impulses to directly stimulate the brain. You may have heard the term “electroshock therapy.” These treatments are usually reserved for more serious cases of depression. However, some newer brain stimulation devices are less invasive than previous versions and can even be used at home.

If your doctor suggests this type of treatment, make sure to discuss the potential side effects and risks with them. You can also find more information about brain stimulation therapies and their side effects on the National Institute of Mental Health website. If you would like to learn more about brain stimulation therapies and their possible side effects, please visit www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulationtherapies.shtml

Are There Whole Person Health Treatments for Depression?

It is estimated that, when combined, pharmaceutical and behavioral interventions are effective in treating 60–70% of people with depression, and much of this effect is due to simply getting treatment (i.e., the placebo effect). However, pharmaceutical interventions – medication – can have side effects some people cannot tolerate or that may not be safe. For example, some medications are not safe if you are pregnant. Integrating the use of evidence-based whole person health treatments gives you more options, whether you simply want a more holistic approach or conventional forms of treatment do not work or are not wanted.

Below are some whole person health options for treating depression, along with evidence to help you start researching the ones that interest you.

Light Therapy

Light therapy involves sitting in front of a specialized lamp that emits light similar to natural sunlight. It’s often used for seasonal affective disorder (SAD) but may also help clinical depression.

Research shows light therapy has significant benefits for reducing depressive symptoms, with few side effects. Studies have found it
helps improve sleep and depression in older adults as well.

Overall, light therapy is a safe and effective treatment option, especially for seasonal depression.

Side Effects

There are very few side effects associated with light therapy and most diminish with continued use. Reported side effects include:

• Headaches
• Increased energy, euphoria or mania
• Agitation or irritability
• Nausea
• Eye strain

Evidence

• A systematic review and meta-analysis (summary of studies) of the use of light therapy for patients with non-seasonal depression found that not only does light therapy have minimal side effects, but patients reported significant improvement in depressive symptoms. ⁸
• A study looking at the impact of light therapy on sleep and depression in older adults in long-term care homes found that there was a significant improvement in symptoms of depression among the study’s participants. ⁹

Exercise

Exercise has been shown to improve cognition, mood, emotional regulation, and motor function. It can also increase social interaction (if done with others) and self-efficacy. The Mayo Clinic and other organizations support the use of exercise for symptom management in people with depression.

Side Effects

If you exercise with approval from your physician and supervision of a trainer, side effects are typically minimal. Many adverse effects may decrease as you become more fit and accustomed to your routine. Possible side effects include:

• Fatigue
• Pain and soreness
• Injuries
• Developing exercise obsession

Evidence

• A systematic review of randomized trials of exercise programs found that moderate, supervised aerobic activity three times a week for nine weeks improved depressive symptoms. ¹⁰
• A meta-analysis of randomized controlled trials with a total of 977 participants found that physical exercise is an effective modality for treating depression and is a useful adjunct to pharmaceutical interventions. ¹¹

Yoga

Yoga is a time-tested practice that integrates mind and body techniques. Scientific research has demonstrated its effectiveness for multiple health conditions. It is especially helpful for:

• Reducing stress
• Improving mental health, including depression
• Managing pain from various conditions

Side Effects

Although very rare, certain types of strokes as well as pain from nerve damage have been reported from people practicing yoga. Muscle injury can also occur if not properly done. Minor side effects include:

• Dizziness
• Fatigue
• Weakness
• Nausea
• Heat exhaustion

Evidence

• A randomized controlled study including 38 adults with mild to moderate depression found that an eight-week hatha yoga intervention clinically reduced depression symptoms. ¹²
• A systematic review of randomized controlled trials looking at yoga interventions for depression found that yoga improved depressive symptoms as much as taking an antidepressant drug. ¹³
• A twelve-week mindfulness-based yoga intervention for women with depression found that in comparison to those who participated in a walking group, those in the yoga group reported significantly lower levels of rumination (a frequent symptom of depression). ¹⁴

Mindfulness Meditation

Mindfulness meditation involves consciously controlling your breathing and paying attention to the moment. It can have many different physical and chemical effects, such as a slower heart rate, lower blood pressure, and lower levels of the stress hormone cortisol.

Side Effects

Meditation is widely considered a safe way of addressing physical and mental symptoms, including those of depression. Side effects are rare.

• There have been some reports that engaging in breathwork has worsened symptoms of people with psychiatric problems such as anxiety. If you are attending a breathwork class, please make sure to alert your instructor to any health conditions you have, including depression or anxiety.
• Excessive, rapid breathing can lower your carbon dioxide levels and change the pH of the blood. This may lead to muscle cramps, light-headedness and, on rare occasions, seizures. If you have a seizure disorder, ask your doctor before doing any type of meditation that includes intensive breathwork.

Evidence

• A 2020 study found that a mindfulness-based lifestyle intervention increased neuroplasticity and reduced the severity of major depressive disorder compared to a control group. ¹⁵
• Mindfulness-based psychotherapy showed medium to large effect sizes in improving depressive symptoms compared to usual care without psychotherapy ¹⁶

Acupuncture

Acupuncture is a practice in which a trained specialist stimulates specific points on the skin called acupoints, usually with a needle. This increases the release of chemicals like endorphins (naturally produced pain reducers) in the body and brain. These chemicals may directly impact how you experience pain.

Side Effects

• Slight bleeding and bruising at the acupoint site
• Fainting
• Convulsions
• Pain or soreness at the acupoint site (which may be important for effectiveness)

Evidence

• A meta-analysis of the use of acupuncture in conjunction with antidepressants for treating depression found that the combination was more effective than the use of antidepressants alone. ¹⁷
• A randomized, single-blind, placebo-controlled study looked at the impact of a twelve-week acupuncture intervention on the quality of life of patients with depression. The study found that those in the acupuncture group had significant improvement in eight quality of life domains including physical function, pain, energy, social and emotional function, and mental health. ¹⁸

Music Therapy

Music therapy is a well-recognized clinical intervention that uses music to help people identify and cope with social, cognitive, emotional, or physical concerns.

Side Effects

Music therapy is widely considered a safe way of addressing physical and mental conditions when delivered by a well-trained certified music therapist. Please note that any form of therapy can bring up uncomfortable emotions and may cause you to experience increased levels of psychological discomfort.

Evidence

• A recent meta-analysis, published in the Cochrane Database, of systematic reviews found that music therapy in conjunction with conventional treatments improved depression symptoms and is more effective than only using conventional treatments alone. ¹⁹
• A systematic review and meta‐analysis of randomized, controlled trials looking at the impact of music therapy on elderly patients found that music therapy improved elderly patients’ depression symptoms. ²⁰

Art Therapy

Art therapy is a treatment that uses art as the primary mode of expression and communication. The art therapist uses creativity to help clients achieve personal and treatment-related goals. You create art to convey your feelings about a current or past situation. Art therapy can help people understand, manage and share feelings in ways that language cannot always accomplish. You do not have to be a talented or experienced artist to benefit from art therapy.

Side Effects

Art therapy is widely considered a safe way of addressing physical and mental conditions when facilitated by a well-trained certified art therapist. Any form of therapy can bring up uncomfortable emotions and cause you to experience increased levels of psychological discomfort. Reliving traumatic experiences is difficult. It’s important to handle the process appropriately to avoid making symptoms worse.

Evidence

• A meta-analysis looking at the impact of art therapy on breast cancer patients experiencing depression, anxiety, and fatigue found that those who participated in art therapy interventions had reductions in all three symptoms. ²¹
• A randomized controlled trial evaluating a manually-based art therapy program including 79 adults suffering from moderate to severe depression found that by the end of the study, patients had significant improvements. ²²

Herbs and Supplements

Herbs and supplements involve taking a plant or pill, usually by mouth, to maintain or improve health. The most common herbs and supplements used for depression are:

• St. John’s wort
• Saffron
• Omega-3 fatty acid (fish oil)
• 5-HTP (5-hydroxytryptophan)
• SAMe (S-adenosyl methionine)

Side Effects

• Currently, none of the above supplements are approved by U.S. Food and Drug Administration to treat depression. Their effectiveness and side effects vary, and a comprehensive summary is beyond the scope of this Pocket Guide.
• To learn more about one or more of the above herbs or supplements and their potential side effects, please visit websites from the Mayo Clinic, Operation Safe Supplement, and the FDA. or
• If you are currently taking prescription medications for depression or any other condition, talk with your doctor before taking any supplements. Many supplements can interact with medications and may cause serious side effects.

Cancer and Depression – Whole Person Health Approaches

In 2023, the American Society of Clinical Oncology (ASCO) and the Society for Integrative Oncology (SIO) published updated guidelines recommending several whole person health treatments for anxiety and depression in adults with cancer. ²³

Mindfulness-based interventions received the strongest recommendation for addressing both anxiety and depression symptoms in cancer patients, during and after active treatment. ²³, ²⁴

Yoga was recommended for reducing anxiety symptoms, particularly for breast cancer patients. The recommendation was strong for breast cancer survivors and moderate for other cancer types. ²⁴

Music therapy and other music-based interventions may be offered to adults with cancer to help alleviate depression symptoms during active treatment. Relaxation interventions may be offered to address depression, though the recommendation was stronger for anxiety than for depression. Reflexology during active cancer treatment received a weak recommendation as a strategy for treating depression, and may be effective for some people. ²⁴

After cancer treatment, mindfulness-based interventions were strongly recommended for addressing both anxiety and depression symptoms. Tai chi or qigong practices may be considered to help alleviate depression symptoms after cancer treatment. ²⁴

These recommendations are based on extensive reviews of randomized controlled trials and systematic reviews published between 1990 and 2023. The guidelines aim to provide evidence based guidance for clinicians and patients on integrating these therapies into conventional cancer care to manage psychological symptoms effectively.

Find the guidelines at the American Society for Clinical Oncology, which also publishes guidelines on cancer and other symptoms and side effects such as pain and fatigue.

Is There Anything I Can Do To Begin Tackling Depression?

The United States Institute of Mental Health (part of the National Institutes of Health) recommends the following to help immediately address your depression:

• Try to find ways to be active or to get exercise.
• Try to prioritize what you do and break up larger tasks into smaller tasks.
• Spend time with trusted, supportive loved ones and friends.
• If you have an important life decision to make, ask for advice from friends or family members you trust, or postpone the decision until you feel better.
• Avoid self-medicating with alcohol or recreational drugs.
• Most importantly, try to be easy on yourself and engage in activities that you enjoy.
• See your doctor if you think you may be depressed or have symptoms that impact your ability to go about your daily functions.

Bottom Line

Conventional therapies work for depression, and your doctor or primary care provider will most likely recommend or offer you those treatments first. Usually you will be offered medications, although, current evidence shows that non-drug approaches like cognitive behavioral therapy (CBT) work just as well with fewer side effects. ²⁵

If the conventional approaches work and are satisfactory for you, then nothing further may be needed. If they are only partly effective, produce side effects that are unacceptable, or if you prefer a whole person health approach, consider some of the approaches above. Many of these whole health approaches are safe and effective. For more information visit the National Center for Complementary and Integrative Health at the National Institutes of Health.

For a good review of conventional treatments of depression, including some comparisons with complementary approaches and exercise, see the 2023 American College of Physicians guidelines.

Researchers are still studying some new therapies that may help. Coverage for these is limited and it’s critical to talk to your doctor about whether there is enough evidence for you to explore it. These include ketamine, psychedelics, and some brain stimulation techniques.

Talk To Your Doctor about Whole Health for Depression

Always let your medical providers know what treatments you are using to improve your health. Never change your medications without consulting your providers. If your doctor does not know about or offer some of the whole health practices described in this pocket guide, give him or her a copy and ask if you can include them along with conventional treatment.

References

1. World Health Organization. (2018, March 22). Depression. Retrieved from http://www.who.int/news-room/fact-sheets/detail/depression
2. Friedrich, M. (2017). Depression Is the Leading Cause of Disability Around the World. JAMA, 317(15) pp:1517.
3. World Health Organization. (2018, March 22). Depression. Retrieved from http://www.who.int/news-room/fact-sheets/detail/depression
4. Al-Harbi, K. S. (2012). Treatment-resistant depression: therapeutic trends, challenges, and future directions. Patient Preference and Adherence, 6 pp: 369–388.
5. World Health Organization. (2018). Suicide Data. Retrieved from http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/.
6. National Institute of Mental Health. (2016, November). Psychotherapies. Retrieved from https://www.nimh.nih.gov/health/topics/psychotherapies/index.shtml.
7. National Institute of Mental Health. (2016, June). Brain Stimulation Therapies. Retrieved from https://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml.
8. Perera, S., Eisen, R., Bhatt, M., Bhatnagar, N., de Souza, R., Thabane, L., & Samaan, Z. (2016). Light therapy for non-seasonal depression: systematic review and meta-analysis. BJPsych Open, 2(2) pp: 116–126.
9. Wu, M.C., Sung, H.C., Lee, W.L., & Smith, G.D. (2015). The effects of light therapy on depression and sleep disruption in older adults in a long-term care facility. International Journal of Nursing Practice 21(5) pp: 653-9.
10. Stanton, R., & Reaburn P. (2014). Exercise and the treatment of depression: a review of the exercise program variables. Journal of Science and Medicine in Sport 17(2): pp. 177-82.
11. Kvam, S., Lykkedrang, C., Kleppe, I., Nordhus, H., & Hovland, A. (2016). Exercise as a treatment for depression: A meta-analysis. Journal of Affective Disorders, 202: pp. 67-86.
12. Prathikanti, S., Rivera, R., Cochran, A., Tungol, J. G., Fayazmanesh, N., & Weinmann, E. (2017). Treating major depression with yoga: A prospective, randomized, controlled pilot trial. PLoS ONE, 12(3).
13. Cramer, H., Anheyer, D., Lauche, R, & Dobos, G. (2017).A systematic review of yoga for major depressive disorder. Journal of Affective Disorders, 213 pp: 70-77.
14. Schuver, K.J. & Lewis, B.A. (2016). Mindfulness-based yoga intervention for women with depression. Complementary Therapies in Medicine, 26 pp:85-91.
15. Zhao, F. Y., Xu, P., Zheng, Z., et al. (2023). Managing depression with complementary and alternative medicine therapies: a scientometric analysis and visualization of research activities. Frontiers in psychiatry, 14, 1288346. https://doi.org/10.3389/fpsyt.2023.1288346
16. Piet, J., & Hougaard, E. (2011). The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: a systematic review and meta-analysis. Clinical Psychology Review, 31(6): pp:1032-40.
17. Chan, Y.Y., Lo, W.Y., Yang, S.N., Chen, Y.H., & Lin, J.G. (2015). The benefit of combined acupuncture and antidepressant medication for depression: A systematic review and meta-analysis. Journal of Affective Disorders, 176: pp:106-17.
18. Fan, L., Fu, W., Chen, Z., Xu, N., Liu, J., Lü, A., Su, S., Wu, T., & Ou, A. (2016). Curative effect of acupuncture on quality of life in patient with depression: a clinical randomized single-blind placebo-controlled study. Journal of Traditional Chinese Medicine, 36(2) pp: 151-159.
19. Aalbers, S., Fusar‐Poli, L., Freeman, R.E., Spreen, M., Ket, J.C.F., Vink, A.C., Maratos, A., Crawford, M., Chen, X.J., & Gold, C. (2017). Music therapy for depression. Cochrane Database of Systematic Reviews, 11.
20. Zhao, K., Bai, Z.G., Bo, A., & Chi, I. (2016). A systematic review and metaanalysis of music therapy for the older adults with depression. International Journal of Geriatric Psychiatry, 31(11): pp. 1188-1198.
21. Tang, Y., Fu, F., Gao, H., Shen, L., Chi, I., & Bai, Z. (2018). Art therapy for anxiety, depression, and fatigue in females with breast cancer: A systematic review. Journal of Psychosocial Oncology. Advance online publication.
22. Blomdahl, C., Guregård, S., Rusner, M., & Wijk, H. (2018). A manual-based phenomenological art therapy for individuals diagnosed with moderate to severe depression (PATd): A randomized controlled study. Psychiatric Rehabilitation Journal, 41(3): pp.169-182.
23. Carlson, L. E., Ismaila, N., Addington, E. L., et al. (2023). Integrative oncology care of symptoms of anxiety and depression in adults with cancer: Society for Integrative Oncology-ASCO Guideline. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 41(28), 4562–4591. https://doi.org/10.1200/JCO.23.00857
24. Bradt J. Integrative approaches to managing symptoms of anxiety and depression in adults with cancer. ASCO Post, March 25, 2024. Available at https://ascopost.com/issues/march-25-2024/integrative-approaches-tomanaging-symptoms-of-anxiety-and-depression-in-adults-with-cancer/ Accessed October 30, 2024.
25. Qaseem, A., Owens, D. K., Etxeandia-Ikobaltzeta, I., et al. (2023). Nonpharmacologic and Pharmacologic Treatments of adults in the acute phase of major depressive disorder: A living clinical guideline from the American College of Physicians. Annals of internal medicine, 176(2), 239–252. https://doi.org/10.7326/M22-2056