Lack of Evidence in Non-Pharmacological Therapies for Depression

A review of non-pharmacological options for treating MDD found that there was not enough evidence to support their use.

Most non-pharmacological treatments for major depressive disorder are not evidence-based, according to a recent examination of systematic reviews by a group of researchers.

Led by Gerald Gartlehner, PhD, of the Department for Evidence-based Medicine and Clinical Epidemiology at Danube University in Krems, Austria, the team sought to summarize “the evidence on more than 140 pharmacological and non-pharmacological treatment options for major depressive disorder (MDD) and to evaluate the confidence that patients and clinicians can have in the underlying science about their effects.”

Although the authors note that most evidence-based guidelines say that second-generation antidepressants should be a first step therapy, many patients are resistant.

“Patients with depression may prefer non-pharmacological options because antidepressant therapies also come with considerable risk for harms,” they wrote. As many as 63% of patients taking antidepressants, such as selective serotonin reuptake inhibitors, experience adverse events.

Furthermore, patients worry about becoming addicted to antidepressants, and there is some stigma associated with them. The researchers described the non-pharmacological treatment options for depression as being “vast,” and say the Cochrane Depression and Neurosis Group lists 87 interventions. The existence of so many options—many of which are not supported by scientific evidence–presents a challenge to clinicians.

In order to create an overview of the efficacy and possible risks of the various therapies available for MDD, the researchers identified studies published between 2011 to February 2017, detecting 2532 citations, and 19 systematic reviews.

The only treatment with a high strength of evidence was that of second-generation antidepressants, which were compared to 11 non-pharmacological treatments in 3 of the systematic reviews.

Cognitive behavioral therapy (CBT) showed a moderate strength of evidence, and acupuncture, Chinese herbal medicine, exercise, integrative therapies, omega-3 fatty acids, saffron, S-adenosyl-L-methionine (SAMe), and St. John’s Wort all showed a low strength of evidence. Additionally, gan mai da zao and third wave CBT were insufficient.

In the end, the researchers found that only 5 out of the 140 therapies examined in the review were supported by reliable evidence. Among psychological therapies, only CBT can be described as evidence-based, and among the CAM therapies, only St. John’s Wort is supported scientifically.

“For the vast majority of non-pharmacological interventions, either no systematic review evidence was available or the certainty of evidence was severely limited,” the researchers noted.

There were some limitations to this study, the most important being that it only included systematic reviews; there may be random control trials for some interventions that have not been evaluated in a review.

Even with those limitations, the researchers believe that this study could have significant clinical implications, according to the authors. The results “provide patients and clinicians with solid and up-to-date information about which treatment options have (or have not) been evaluated in rigorous systematic reviews.”

In addition, the results reveal a need for future research in order to fill gaps in the scientific literature regarding non-pharmacological interventions for MDD.

“In the end, even in the absence of clearly informative evidence, clinicians and patients need to make decisions. This review provides a framework to guide discussion of the potential options.”

The full review can be found online in the journal BMJ Open.

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