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Health Protocols

Depression

Other Medical Approaches and Emerging Therapies

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a non-pharmacologic means of therapy often employed to relieve depression. CBT is typically initiated if primary treatment with antidepressant medications fail, but it is sometimes used as part of first-line treatment alongside antidepressants.

CBT is centered upon the belief that depression is closely linked with negative thinking (ie, thought patterns that negatively reinforce depressed mood). The goal of CBT is to help the patient recognize and replace negative thinking with more positive, constructive thoughts. CBT has been studied in various settings and has shown efficacy both independently and in combination with other conventional treatment regimens.

A recent review of studies using CBT in treatment-resistant depression found that CBT performed as well as pharmacotherapy when used in conjunction with a primary medication, or in cyclical fashion involving switching from pharmacotherapy to CBT and back again.81 This same review also pointed out that when a patient with treatment-resistant depression switched antidepressants, greater relief was attained when the switch was accompanied by CBT. A 2010 clinical trial revealed that CBT effectively relieved depression and/or anxiety in patients with chronic obstructive pulmonary disease.82

CBT is also effective in young people with depression, and may be preferable over psychotropic drugs for some parents since it lacks harsh side effects. In one trial, CBT was compared to stand-of-care (pharmacotherapy) in children ages 8–15. CBT was superior to pharmacotherapy in several aspects, including patient alliance to treatment. Moreover, CBT may have an overall cost advantage versus pharmacotherapy.83

Life Extension suggests that every patient with depression talk with a qualified healthcare provider about cognitive behavioral therapy as an adjuvant, or alternative to pharmacotherapy.

Physical Activity

Research supports the use of exercise, primarily aerobic or weight training, as a preventive and adjuvant treatment (used in conjunction with medication) of mood disorders and depression. Some studies have found exercise alone is as effective as medication for relieving depression84 and that exercise can reduce depression recurrence rates.85 A recent study looked at 202 adults with major depression who either participated in four months of exercise, took the medication sertraline, or took a placebo. A one-year follow up showed that exercise was as effective as the medication at relieving depression and that exercise during the follow-up period extended the benefits.86

Light Therapy

Research shows morning light therapy from a light-therapy lamp is effective at treating seasonal affective disorder (seasonal depression), and that it is equally or possibly even more effective than antidepressants, in this type of depression.84 A study of 98 patients with seasonal depression illustrated this. Depressed subjects were randomly assigned to eight weeks of therapy with light in the morning (30 minutes, 10,000 lux, and a placebo pill) or 30 minutes of dim light (100 lux and 20 mg of fluoxetine), with both groups experiencing a 67% response rate.87

Light therapy for non-seasonal depression is not well established, although results are promising; light therapy may be more helpful as an adjuvant treatment than as a stand-alone treatment.

Transcranial Magnetic Stimulation

Interestingly, a new procedure called transcranial magnetic stimulation (TMS), which uses magnetic fields to stimulate nerve cells in the brain, is widely researched and showing promising results as a treatment for depression. The FDA has approved TMS for people who have not responded to medication, and it is often compared to the controversial electroconvulsive therapy (ECT). However, it is a possible alternative to ECT, as it is more humane and causes fewer adverse effects.

A recent study of 190 patients with major depression treated with TMS showed a clinically significant improvement in symptoms.88 In a recent review, TMS was concluded to be as effective as cognitive behavioral therapy or pharmacotherapy for relieving depression.89

TMS is becoming more widely available in hospitals and private practices; however, because it is relatively new, it is important to ask how long the treatment has been offered, how many patients have been treated, and what the success rates are.

Dietary Considerations for Depression

Dietary factors should always be addressed when managing depression, as evidence demonstrates that various aspects of diet can affect the disorder.

Individuals with depression may consume too many inflammatory omega-6 fatty acids and saturated fats, so increasing consumption of omega-3's and decreasing consumption of trans-fats, saturated fat, and excess omega-6 fatty acids is recommended.90

Omega-3 fatty acids91 and folate92 both appear to be very important in mood management. Although the role of these nutrients in the diet is important, one should augment the diet with supplements for maximum benefit in addressing symptoms of depression or in trying to prevent a recurrence. As described later in this protocol, omega-3 fatty acids have been shown to decrease susceptibility to depression and may help as an adjuvant therapy. Foods high in omega-3's include deep-water fish such as salmon, mackerel, sardines, and tuna, as well as flax seeds, and some nuts (eg, walnuts).

Evidence suggests that limiting sugar intake to control blood sugar levels is another important approach to depression. This would include addressing hyperglycemia (high blood sugar), hypoglycemia (low blood sugar), or reactive hypoglycemia (low blood sugar that occurs within 4 hours of eating). Reactive hypoglycemia may be more common in people who are not overweight. To address high or low blood sugar, it is important to limit or avoid sugar and refined carbohydrates, eat small meals 4–6 times per day, eat a balance of healthy proteins, fats, and complex carbohydrates, and decrease caffeine. The nutrients magnesium and chromium and practicing relaxation techniques also help manage hypoglycemia.

Evidence also suggests that an anti-inflammatory Mediterranean Diet may help prevent or manage depression.93 A Mediterranean diet, which is rich in omega-3 fatty acids and polyphenolic antioxidants, could serve as a foundation to which targeted dietary supplements are added for maximum response. The diet generally includes good quantities of fish, vegetables, unrefined grains, beans or legumes, fruit, and olive oil. It includes moderate amounts of dairy (mostly cheese and yogurt) and red wine, and limits meats to small portions.

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