Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. V. Complementary and alternative medicine treatments

100,000 lumens to treat seasonal affective disorder: A proof of concept RCT of Bright, whole-ROom, All-Day (BROAD) light therapy

BACKGROUND

Seasonal affective disorder (SAD) is common and debilitating. The standard of care includes light therapy provided by a light box; however, this treatment is restrictive and only moderately effective. Advances in LED technology enable lighting solutions that emit vastly more light than traditional light boxes. Here, we assess the feasibility of BROAD (Bright, whole-ROom, All-Day) light therapy and get a first estimate for its potential effectiveness.

METHODS

Patients were randomly assigned to a treatment for 4 weeks; either a very brightly illuminated room in their home for at least 6 h per day (BROAD light therapy) or 30 min in front of a standard 10,000 lux SAD light box. Feasibility was assessed by monitoring recruitment, adherence, and side effects. SAD symptoms were measured at baseline and after 2 and 4 weeks, with the Hamilton Depression Rating Scale-Seasonal Affective Disorders 29-items, self-report version.

RESULTS

All 62 patients who started treatment were available at 4-week follow-up and no significant adverse effects were reported. SAD symptoms of both groups improved similarly and considerably, in line with previous results. Exploratory analyses indicate that a higher illuminance (lux) is associated with a larger symptom improvement in the BROAD light therapy group.

CONCLUSIONS

BROAD light therapy is feasible and seems similarly effective as the standard of care while not confining the participants to 30 min in front of a light box. In follow-up trials, BROAD light therapy could be modified for increased illuminance, which would likely improve its effectiveness.

Association between electroconvulsive therapy and depressive disorder from 2012 to 2021: Bibliometric analysis and global trends

Background

Depressive disorder is a chronic mental illness that is vulnerable to relapse, imposes a huge economic burden on society and patients, and is a major global public health problem. Depressive disorders are characterized by depressed mood, decreased energy and interest, and suicidal ideation and behavior in severe cases. They can be treated through pharmacotherapy and psychotherapy or physical treatments such as electroconvulsive therapy (ECT). In patients with suicidal ideation, behavior, or refractory depressive disorder ECT has a faster onset of action and better efficacy than pharmacotherapy. This study used bibliometric and visual analyses to map the current state of global research on ECT for depressive disorder and to predict future research trends in this area.

Materials and methods

A literature search was performed for studies on ECT and depressive disorder in the Web of Science Core Collection (WoSCC) database. All studies considered for this paper were published between 2012 and 2021. Bibliometric and co-occurrence analyses were performed using the CiteSpace software.

Results

In total, 2,184 publications were retrieved. The number of publications on ECT and depressive disorder have been increasing since 2012, with China being a emerging hub with a growing influence in the field. Zafiris J. Daskalakis is the top author in terms of number of publications, and The Journal of ECT is not only the most published journal but also the most co-cited journal in the field. Co-occurrence analysis showed that electroconvulsive therapy, treatment-resistant depression, bipolar disorder, hippocampus, efficacy, and electrode placement are current research hotspots. Molecular biomarkers, neuroimaging predictors, and late-life depression will become research hotspots in the future.

Conclusion

Our analysis made it possible to observe an important growth of the field since 2012, to identify key scientific actors in this growth and to predict hot topics for future research.

Clinician guidelines for the treatment of psychiatric disorders with nutraceuticals and phytoceuticals: The World Federation of Societies of Biological Psychiatry (WFSBP) and Canadian Network for Mood and Anxiety Treatments (CANMAT) Taskforce

OBJECTIVES

The therapeutic use of nutrient-based 'nutraceuticals' and plant-based 'phytoceuticals' for the treatment of mental disorders is common; however, despite recent research progress, there have not been any updated global clinical guidelines since 2015. To address this, the World Federation of Societies of Biological Psychiatry (WFSBP) and the Canadian Network for Mood and Anxiety Disorders (CANMAT) convened an international taskforce involving 31 leading academics and clinicians from 15 countries, between 2019 and 2021. These guidelines are aimed at providing a definitive evidence-informed approach to assist clinicians in making decisions around the use of such agents for major psychiatric disorders. We also provide detail on safety and tolerability, and clinical advice regarding prescription (e.g. indications, dosage), in addition to consideration for use in specialised populations.

METHODS

The methodology was based on the WFSBP guidelines development process. Evidence was assessed based on the WFSBP grading of evidence (and was modified to focus on Grade A level evidence - meta-analysis or two or more RCTs - due to the breadth of data available across all nutraceuticals and phytoceuticals across major psychiatric disorders). The taskforce assessed both the 'level of evidence' (LoE) (i.e. meta-analyses or RCTs) and the assessment of the direction of the evidence, to determine whether the intervention was 'Recommended' (+++), 'Provisionally Recommended' (++), 'Weakly Recommended' (+), 'Not Currently Recommended' (+/-), or 'Not Recommended' (-) for a particular condition. Due to the number of clinical trials now available in the field, we firstly examined the data from our two meta-reviews of meta-analyses (nutraceuticals conducted in 2019, and phytoceuticals in 2020). We then performed a search of additional relevant RCTs and reported on both these data as the primary drivers supporting our clinical recommendations. Lower levels of evidence, including isolated RCTs, open label studies, case studies, preclinical research, and interventions with only traditional or anecdotal use, were not assessed.

RESULTS

Amongst nutraceuticals with Grade A evidence, positive directionality and varying levels of support (recommended, provisionally recommended, or weakly recommended) was found for adjunctive omega-3 fatty acids (+++), vitamin D (+), adjunctive probiotics (++), adjunctive zinc (++), methylfolate (+), and adjunctive s-adenosyl methionine (SAMe) (+) in the treatment of unipolar depression. Monotherapy omega-3 (+/-), folic acid (-), vitamin C (-), tryptophan (+/-), creatine (+/-), inositol (-), magnesium (-), and n-acetyl cysteine (NAC) (+/-) and SAMe (+/-) were not supported for this use. In bipolar disorder, omega-3 had weak support for bipolar depression (+), while NAC was not currently recommended (+/-). NAC was weakly recommended (+) in the treatment of OCD-related disorders; however, no other nutraceutical had sufficient evidence in any anxiety-related disorder. Vitamin D (+), NAC (++), methylfolate (++) were recommended to varying degrees in the treatment of the negative symptoms in schizophrenia, while omega-3 fatty acids were not, although evidence suggests a role for prevention of transition to psychosis in high-risk youth, with potential pre-existing fatty acid deficiency. Micronutrients (+) and vitamin D (+) were weakly supported in the treatment of ADHD, while omega-3 (+/-) and omega-9 fatty acids (-), acetyl L carnitine (-), and zinc (+/-) were not supported. Phytoceuticals with supporting Grade A evidence and positive directionality included St John's wort (+++), saffron (++), curcumin (++), and lavender (+) in the treatment of unipolar depression, while rhodiola use was not supported for use in mood disorders. Ashwagandha (++), galphimia (+), and lavender (++) were modestly supported in the treatment of anxiety disorders, while kava (-) and chamomile (+/-) were not recommended for generalised anxiety disorder. Ginkgo was weakly supported in the adjunctive treatment of negative symptoms of schizophrenia (+), but not supported in the treatment of ADHD (+/-). With respect to safety and tolerability, all interventions were deemed to have varying acceptable levels of safety and tolerability for low-risk over-the-counter use in most circumstances. Quality and standardisation of phytoceuticals was also raised by the taskforce as a key limiting issue for firmer confidence in these agents. Finally, the taskforce noted that such use of nutraceuticals or phytoceuticals be primarily recommended (where supportive evidence exists) adjunctively within a standard medical/health professional care model, especially in cases of more severe mental illness. Some meta-analyses reviewed contained data from heterogenous studies involving poor methodology. Isolated RCTs and other data such as open label or case series were not included, and it is recognised that an absence of data does not imply lack of efficacy.

CONCLUSIONS

Based on the current data and clinician input, a range of nutraceuticals and phytoceuticals were given either a supportive recommendation or a provisional recommendation across a range of various psychiatric disorders. However several had only a weak endorsement for potential use; for a few it was not possible to reach a clear recommendation direction, largely due to mixed study findings; while some other agents showed no obvious therapeutic benefit and were clearly not recommended for use. It is the intention of these guidelines to inform psychiatric/medical, and health professional practice globally.

The Korean Medication Algorithm Project for Depressive Disorder 2021: Comparisons with Other Treatment Guidelines

The Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) first was published in 2002, and has been revised four times, in 2006, 2012, 2017, and 2021. In this review, we compared recommendations from the recently revised KMAP-DD 2021 to four global clinical practice guidelines (CPGs) for depression published after 2010. The recommendations from the KMAP-DD 2021 were similar to those from other CPGs, although there were some differences. The KMAP-DD 2021 reflected social culture and the healthcare system in Korea and recent evidence about pharmacotherapy for depression, as did other recently published evidence-based guidelines. Despite some intrinsic limitations as an expert consensus-based guideline, the KMAP-DD 2021 can be helpful for Korean psychiatrists making decisions in clinical settings by complementing previously published evidence-based guidelines, especially for some clinical situations lacking evidence from rigorously designed clinical trials.

Therapeutic role of yoga in neuropsychological disorders

Yoga is considered a widely-used approach for health conservation and can be adopted as a treatment modality for a plethora of medical conditions, including neurological and psychological disorders. Hence, we reviewed relevant articles entailing various neurological and psychological disorders and gathered data on how yoga exerts positive impacts on patients with a diverse range of disorders, including its modulatory effects on brain bioelectrical activities, neurotransmitters, and synaptic plasticity. The role of yoga practice as an element of the treatment of several neuropsychological diseases was evaluated based on these findings.

Strange Days: Adult Physical Activity and Mental Health in the First Two Months of the COVID-19 Pandemic

Background: In addition to its physical health benefits, physical activity is increasingly recognized as a means to support mental health. Regular moderate-to-vigorous physical activity (MVPA) is associated with improved mental well-being, reduced likelihood of developing mental illness, and improved symptom management. Despite these benefits, most people fail to achieve minimum recommended levels of MVPA. Population levels of physical activity have further declined since the onset of the COVID-19 pandemic and implementation of public health measures (e.g., shelter-in-place protocols). The potential impact of this decline on mental heath outcomes warrants ongoing investigation. Purpose: To investigate associations between changes in MVPA and mental health (depressive symptoms, anxiety symptoms, and life satisfaction) in adults impacted by the COVID-19 pandemic. Method: Research followed a cross-sectional design. English-speaking adults were invited to complete an online questionnaire. MVPA was assessed retrospectively (before COVID-19) and currently (during COVID-19) with the International Physical Activity Questionnaire. Mental health was assessed with the Patient Health Questionnaire, 9-Item (PHQ-9), the Generalized Anxiety Disorder, 7-Item (GAD-7), and the Satisfaction with Life Scale (SWLS). Regression was used to assess relationships between MVPA and mental health. ANOVA with follow-up tests examined whether participants who differed in mental health status (e.g., no symptoms vs. severe symptoms) differed in their change in MVPA. T-tests were used to examine differences in mental health symptomatology between participants who were sufficiently (i.e., achieving MVPA guidelines of ≥ 150 min/week) vs. insufficiently active. Results: Prior to COVID-19, 68.2% of participants were classified as being sufficiently active, vs. 60.6% during COVID-19. The majority of participants reported experiencing some level of depressive symptoms (62.0%) or anxiety symptoms (53.7%). After controlling for covariates, changes in MVPA accounted for significant variability in the PHQ-9 (7.7%), GAD-7 (2.5%), and SWLS (1.5 %). Participants with clinically significant mental health symptomatology reported greater declines in MVPA than those who reported no symptoms. Conversely, participants who were sufficiently active during COVID-19 reported significantly lower depression and anxiety, and higher life satisfaction. Conclusion: Participants who experienced the greatest declines in MVPA reported relatively greater psychological distress and lower life satisfaction. While preliminary, these findings suggest the importance of maintaining and promoting physical activity during a period of pandemic.

Proposed Neuroimmune Roles of Dimethyl Fumarate, Bupropion, S-Adenosylmethionine, and Vitamin D3 in Affording a Chronically Ill Patient Sustained Relief from Inflammation and Major Depression

We had discussed earlier that, after most of the primary author's multiple sclerosis (MS) symptoms were lessened by prior neuroimmune therapies, use of dimethyl fumarate (DMF) gradually subdued his asthma and urticaria symptoms, as well as his MS-related intercostal cramping; and bupropion supplemented with S-adenosylmethionine (SAMe) and vitamin D3 (vit-D3) helped remit major depression (MD). Furthermore, the same cocktail (bupropion plus supplements), along with previously discussed routines (yoga, meditation, physical exercises, and timely use of medications for other illnesses), continued to subdue MD during new difficulties with craniopharyngioma, which caused bitemporal vision loss; sphenoid sinus infections, which caused cranial nerve-VI (CN6) palsy and diplopia; and through their treatments. Impressed by the benefit the four compounds provided, in this manuscript, we focus on explaining current neuroimmune literature proposals on how: (1) DMF impedes inflammation, oxidative stress, and cell death in CNS and peripheral tissues; (2) Bupropion curbs anxiety, MD, and enhances alertness, libido, and moods; (3) SAMe silences oxidative stress and depression by multiple mechanisms; and (4) Vit-D3 helps brain development and functioning and subdues inflammation. we realize that herein we have reviewed proposed mechanisms of remedies we discovered by literature searches and physician assisted auto-experimentation; and our methods might not work with other patients. We present our experiences so readers are heartened to reflect upon their own observations in peer-reviewed forums and make available a wide body of information for the chronically ill and their physicians to benefit from.

Evidence available for patient-identified priorities in depression research: results of 11 rapid responses

OBJECTIVES

Patient priority setting projects (PPSPs) can reduce research agenda bias. A key element of PPSPs is a review of available literature to determine if the proposed research priorities have been addressed, identify research gaps, recognise opportunities for knowledge translation (KT) and avoid duplication of research efforts. We conducted rapid responses for 11 patient-identified priorities in depression to provide a map of the existing evidence.

DESIGN

Eleven rapid responses.

DATA SOURCES

Single electronic database (PubMed).

ELIGIBILITY CRITERIA

Each rapid response had unique eligibility criteria. For study designs, we used a stepwise inclusion process that started with systematic reviews (SRs) if available, then randomised controlled trials and observational studies as necessary.

RESULTS

For all but one of the rapid responses we identified existing SRs (median 7 SRs per rapid response, range 0-179). There were questions where extensive evidence exists (ie, hundreds of primary studies), yet uncertainties remain. For example, there is evidence supporting the effectiveness of many non-pharmacological interventions (including psychological interventions and exercise) to reduce depressive symptoms. However, targeted research is needed that addresses comparative effectiveness of promising interventions, specific populations of interest (eg, children, minority groups) and adverse effects.

CONCLUSIONS

We identified an extensive body of evidence addressing patient priorities in depression and mapped the results and limitations of existing evidence, areas of uncertainty and general directions for future research. This work can serve as a solid foundation to guide future research in depression and KT activities. Integrated knowledge syntheses bring value to the PPSP process; however, the role of knowledge synthesis in PPSPs and methodological approaches are not well defined at present.

Feasibility of a group-based laughter yoga intervention as an adjunctive treatment for residual symptoms of depression, anxiety and stress in people with depression

BACKGROUND

Laughter Yoga (LY) is a group-based intervention involving simulated laughter, gentle stretching, rhythmic breathing and meditation. There is some limited evidence that LY reduces depressive symptoms over the short term. However, the quality of previous LY studies is poor and none involved working-aged people with a clinical diagnosis of depression. Therefore, this study aimed to investigate the feasibility and potential efficacy of LY for improving residual mood, anxiety and stress symptoms in adults diagnosed with depression.

METHODS

Fifty participants were randomised to the group LY intervention (n = 23) consisting of eight sessions over four weeks, or treatment-as-usual (n = 27). Participants completed the Depression Anxiety Stress Scale and the Short Form 12 item Health Survey at baseline (T0), post-intervention (T1) and at 3 months follow-up (T2). LY participants also completed a Client Satisfaction Questionnaire (CSQ8) at T1 and eleven participated in individual qualitative interviews at T2.

RESULTS

The LY group had statistically greater decreases in depression and improvements in mental health related quality of life compared to the control group from T0 to T1. The CSQ8 scores indicated a favourable level of satisfaction with the LY intervention. The qualitative interviews highlighted aspects of the intervention that were effective and those requiring modification.

LIMITATIONS

Limitations include the small sample size and treatment-as-usual control group.

CONCLUSIONS

A full scale RCT of LY could be feasible if some modifications were made to the protocol/intervention. The intervention may be effective to improve depression and mental health related quality of life immediately post intervention.

Long-term benzodiazepine use in patients taking antidepressants in a public health setting in Brazil: a cross-sectional study

OBJECTIVE

The aims of the study were to investigate the prevalence of long-term use of benzodiazepines in patients taking antidepressants and to identify the risk factors associated with the prolonged use of benzodiazepines.

DESIGN

Cross-sectional study.

SETTING

Public health system in Brazil.

PARTICIPANTS

Outpatients using antidepressants from January 2008 to December 2009 were included. The data were obtained from pharmacy databases and medical records. All individuals in the database were included in the study and were classified into two categories: (1) patients who had not used benzodiazepines combined with antidepressants or had combined the use of antidepressants with benzodiazepines for a short period (up to 4 weeks), and (2) those who used antidepressants plus benzodiazepines for a longer period (more than 4 weeks).

MAIN OUTCOME MEASURE

The outcome measure is prolonged use of benzodiazepines (more than 4 weeks). We conducted a multivariate analysis to identify the factors associated with prolonged use of benzodiazepines.

RESULTS

Forty per cent of the 870 patients evaluated had prolonged use of benzodiazepines (more than 4 weeks). The risk factors associated with prolonged use were age above 35 years (prevalence ratio (PR): 2.18, 95% CI 1.55 to 3.06, P<0.001), female sex (PR: 1.47, 95% CI 1.07 to 2.02, P=0.019), diagnosis at least 3 years prior (PR: 2.1, 95% CI 1.6 to 2.8, P<0.001), use of selective serotonin reuptake inhibitor antidepressants (PR: 1.7, 95% CI 1.3 to 2.2, P<0.001) and having a prescription from a psychiatrist (PR: 6.5, 95% CI 3.2 to 13.2, P<0.001).

CONCLUSIONS

Prolonged use of benzodiazepines occurs more frequently in women, adults diagnosed several years earlier, users of selective serotonin reuptake inhibitor antidepressants and those who received a prescription from a psychiatrist. Education of clinicians, especially with regard to these populations, may decrease the overuse and misuse of benzodiazepines.

The effect of chronotherapy on depressive symptoms. Evidence-based practice

The global prevalence of depression is increasing, along with rates of depression-associated disability and mortality, rendering depressive disorders a major public health issue. Chronotherapy involves a variety of strategies that control exposure to environmental stimuli that influence the biological clock, such as sleep deprivation (SD) or wake therapy (WT), sleep phase advance (SPA), and light and dark therapy (LT, DT). The purpose of this Evidence-Based Practice (EBP) paper is to answer PICOT questions by a review the effectiveness of chronotherapeutics interventions on depressive symptoms with depression and the depressive episode in the course of bipolar disorder. Early studies suggested the effectiveness of LT, SD, and SPA, more recent research has revealed differences in the efficacy of single and combined interventions involving both chronotherapeutic and pharmacological components. This therapy reduced dura­tion of hospitalization, improvement recovery, and reduced for changes in drug prescriptions.

Antipsychotic augmentation for major depressive disorder: A review of clinical practice guidelines

Clinical Practice Guidelines (CPGs) are seen as the gold standard of evidence-based care. Because of their influence, these guidelines can have profound legal and economic effects. Despite their proliferation and influence, the trustworthiness and quality of guidelines have been seriously questioned and they have been implicated as drivers of overtreatment. In the U.S, augmentation with second generation antipsychotics (SGAs) is becoming an increasingly common strategy for treating major depressive disorder (MDD) when initial antidepressant treatment does not result in remission of symptoms. However, there is debate about the evidence for augmentation and whether this strategy is a form of overtreatment. We conducted a systematic search to identify treatment guidelines for MDD. Fourteen international guidelines met inclusion criteria and we reviewed them to determine: 1) if augmentation with SGAs was recommended for patients who did not respond to antidepressant medication; 2) what evidence was cited for the recommendation for or against augmentation; 3) the extent to which the guidelines addressed risk/benefit concerns when making their recommendations. There was significant variation among the CPGs regarding the recommendation to augment with antipsychotic medication for Major Depressive Disorder. Seven guidelines explicitly recommended augmentation with antipsychotics; 1 guideline reviewed the evidence but neither recommended for nor against; 1 guideline did not make a clear recommendation; 2 guidelines explicitly recommended against augmentation; and 3 guidelines did not address augmentation with antipsychotics as a potential treatment strategy. There was wide variation in terms of attention to risk/benefit issues and to the conditions under which augmentation should be considered. The results are discussed in terms of the implications for risk management and informed consent practices.

Seasonal affective disorder and non-seasonal affective disorders: results from the NESDA study

BACKGROUND

Seasonal affective disorder (SAD) is considered to be a subtype of depression.

AIMS

To compare the clinical picture of SAD to non-seasonal affective disorders (non-SADs).

METHOD

Diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) were established in 2185 participants of the Netherlands Study of Depression and Anxiety. The Seasonal Pattern Assessment Questionnaire was administered to diagnose SAD. Symptoms of depression and anxiety were measured with the Inventory of Depressive Symptoms, the Beck Anxiety Inventory and the Fear Questionnaire.

RESULTS

Participants with SAD, participants with a lifetime bipolar disorder and participants with a lifetime comorbid anxiety and depressive disorder scored highest in terms of psychopathology in the past year. The seasonal distribution of major depressive episodes was not different for participants with or without SAD.

CONCLUSIONS

SAD may be a measure of severity of depression with a subjectively perceived worsening of symptoms in the winter months.

DECLARATION OF INTEREST

Y.M. has received research funding and served as a consultant for Royal Philips Electronics NV and The Litebook Company Ltd. W.A.N. has received grants from the Netherlands Organization for Health Research and Development, the European Union, the Stanley Medical Research Institute, Astra Zeneca, Eli Lilly, GlaxoSmithKline and Wyeth; has received honoraria/speaker's fees from Astra Zeneca, Pfizer, Servier and Wyeth; and has served in advisory boards for Astra Zeneca, Pfizer and Servier.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

St John's wort for depression: scoping review about perceptions and use by general practitioners in clinical practice

BACKGROUND

Extracts of Hypericum perforatum, more commonly known as St John's wort (SJW), have good evidence for treating depression. The herb is easily accessible and widely used by consumers, although it has potential for interaction with other medicines. Consumers' use of SJW is often not discussed with their general practitioners (GPs). It is unclear how GPs perceive use of SJW in practice and the implications for consumers and pharmacists.

OBJECTIVE

Explore GPs' perception of SJW use in practice.

METHODS

Scoping review.

KEY FINDINGS

Few studies explore GPs' perceptions of SJW for depression, but they appear to recommend it infrequently, except in Germany. Reasons for limited use in practice include lack of knowledge, particularly regarding which preparations and dosages have trial evidence, and lack of standardisation of active ingredients. Guidelines either do not mention SJW or advise against its use.

CONCLUSIONS

Consumers drive SJW use but often do not disclose to their GPs, which is concerning due to issues about safety. Pharmacists could play an important role here. Improved education about SJW is required for both GPs and consumers, including the need for communication between them and their pharmacists. Lack of adoption of evidence-based therapy for depression should be explored further.

Patients' Experience of Winter Depression and Light Room Treatment

Background. There is a need for more knowledge on the effects of light room treatment in patients with seasonal affective disorder and to explore patients' subjective experience of the disease and the treatment. Methods. This was a descriptive and explorative study applying qualitative content analysis. A purposeful sample of 18 psychiatric outpatients with a major depressive disorder with a seasonal pattern and a pretreatment score ≥12 on the 9-item Montgomery-Åsberg Depression self-rating scale was included (10 women and 8 men, aged 24-65 years). All patients had completed light room treatment (≥7/10 consecutive weekdays). Data was collected two weeks after treatment using a semistructured interview guide. Results. Patients described a clear seasonal pattern and a profound struggle to adapt to seasonal changes during the winter, including deterioration in sleep, daily rhythms, energy level, mood, activity, and cognitive functioning. Everyday life was affected with reduced work capacity, social withdrawal, and disturbed relations with family and friends. The light room treatment resulted in a radical and rapid improvement in all the major symptoms with only mild and transient side effects. Discussion. The results indicate that light room treatment is essential for some patients' ability to cope with seasonal affective disorder.

Treatment of Depression and Anxiety by Naturopathic Physicians: An Observational Study of Naturopathic Medicine Within an Integrated Multidisciplinary Community Health Center

OBJECTIVES

This project was designed to assess the quality of care received by patients with depression and anxiety who were seen by naturopathic physicians in a community health center.

METHODS

The Natural Medicine Quality Improvement Project for the Treatment of Depression and Anxiety (NMQP-DA) was conducted over a 26-month period from December 2009 through February 2012 at HealthPoint, a non-profit, consumer-governed, community health center network located in suburban King County, Washington. A total of 112 patients enrolled in the NMQP-DA, and 60 were seen for two or more visits, thus meeting eligibility criteria for inclusion in the study. The mean number of visits was 3.3. The Patient Health Questionnaire (PHQ-9) depression screener and the Generalized Anxiety Disorder 7-item scale (GAD-7) anxiety screener were the outcome measures.

RESULTS

The overall improvement in symptoms of depression and anxiety was highly significant (p < 0.0001) when comparing the group's average initial screener scores to their average final screener scores for both depression (16.4 vs. 8.6) and anxiety (12.4 vs. 7.2). The response rate, as measured by a 50% decrease in scores, for those with initial scores ≥10 was 58.6% for depression (PHQ-9) and 50% for anxiety (GAD-7).

CONCLUSIONS

This study adds new data to the limited literature on the nature and effectiveness of naturopathic medicine to treat anxiety and depression in the context of an integrative community health center.

Systematic Review of Clinical Practice Guidelines for Failed Antidepressant Treatment Response in Major Depressive Disorder, Dysthymia, and Subthreshold Depression in Adults

OBJECTIVE

This systematic review critically evaluated clinical practice guidelines (CPGs) for treating adults with major depressive disorder, dysthymia, or subthreshold or minor depression for recommendations following inadequate response to first-line treatment with selective serotonin reuptake inhibitors (SSRIs).

METHOD

Searches for CPGs (January 2004 to November 2014) in English included 7 bibliographic databases and grey literature sources using CPG and depression as the keywords. Two raters selected CPGs on depression with a national scope. Data extraction included definitions of adequate response and recommended treatment options. Two raters assessed quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

From 46,908 citations, 3167 were screened at full text. From these 21 CPG were applicable to adults in primary care and outpatient settings. Five CPGs consider patients with dysthymia or subthreshold or minor depression. None provides recommendations for those who do not respond to first-line SSRI treatment. For adults with MDD, most CPGs do not define an "inadequate response" or provide specific suggestions regarding how to choose alternative medications when switching to an alternative antidepressant. There is variability between CPGs in recommending combination strategies. AGREE II ratings for stakeholder involvement in CPG development, editorial independence, and rigor of development are domains in which depression guidelines are often less robust.

CONCLUSIONS

About half of patients with depression require second-line treatment to achieve remission. Consistency and clarity in guidelines for second-line treatment of depression are therefore important for clinicians but lacking in most current guidelines. This may reflect a paucity of primary studies upon which to base conclusions.

The quantity and quality of complementary and alternative medicine clinical practice guidelines on herbal medicines, acupuncture and spinal manipulation: systematic review and assessment using AGREE II

BACKGROUND

Complementary and alternative medicine (CAM) use is often not disclosed by patients, and can be unfamiliar to health care professionals. This may lead to underuse of beneficial CAM therapies, and overuse of other CAM therapies with little proven benefit or known contraindications. No prior research has thoroughly evaluated the credibility of knowledge-based resources. The purpose of this research was to assess the quantity and quality of CAM guidelines.

METHODS

A systematic review was conducted to identify CAM guidelines. MEDLINE, EMBASE and CINAHL were searched in January 2016 from 2003 to 2015. The National Guideline Clearinghouse, National Center for Complementary and Integrative Health web site, and two CAM journals were also searched. Eligible guidelines published in English language by non-profit agencies on herbal medicine, acupuncture, or spinal manipulation for adults with any condition were assessed with the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument.

RESULTS

From 3,126 unique search results, 17 guidelines (two herbal medicine, three acupuncture, four spinal manipulation, eight mixed CAM therapies) published in 2003 or later and relevant to several clinical conditions were eligible. Scaled domain percentages from highest to lowest were clarity of presentation (85.3 %), scope and purpose (83.3 %), rigour of development (61.2 %), editorial independence (60.1 %), stakeholder involvement (52.0 %) and applicability (20.7 %). Quality varied within and across guidelines. None of the 17 guidelines were recommended by both appraisers; 14 were recommended as Yes or Yes with modifications.

CONCLUSIONS

Guidelines that scored well could be used by patients and health care professionals as the basis for discussion about the use of these CAM therapies. In future updates, guidelines that achieved variable or lower scores could be improved according to specifications in the AGREE II instrument, and with insight from a large number of resources that are available to support guideline development and implementation. Future research should identify CAM therapies other than those reviewed here for which guidelines are available. Research is also needed on the safety and effectiveness of CAM therapies.

Conflict of Interest Policies and Industry Relationships of Guideline Development Group Members: A Cross-Sectional Study of Clinical Practice Guidelines for Depression

Because of increased attention to the issue of trustworthiness of clinical practice guidelines, it may be that both transparency and management of industry associations of guideline development groups (GDGs) have improved. The purpose of the present study was to assess a) the disclosure requirements of GDGs in a cross-section of guidelines for major depression; and, b) the extent and type of conflicts of panel members. Treatment guidelines for major depression were identified and searched for conflict of interest policies and disclosure statements. Multi-modal screens for undeclared conflicts were also conducted. Fourteen guidelines with a total of 172 panel members were included in the analysis. Eleven of the 14 guidelines (78%) had a stated conflict of interest policy or disclosure statement, although the policies varied widely. Most (57%) of the guidelines were developed by panels that had members with industry financial ties to drug companies that manufacture antidepressant medication. However, only a minority of total panel members (18%) had such conflicts of interest. Drug company speakers bureau participation was the most common type of conflict. Although some progress has been made, organizations that develop guidelines should continue to work toward greater transparency and minimization of financial conflicts of interest.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 5. Complementary and Alternative Medicine Treatments

BACKGROUND

The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals.

METHODS

Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. "Complementary and Alternative Medicine Treatments" is the fifth of six sections of the 2016 guidelines.

RESULTS

Evidence-informed responses were developed for 12 questions for 2 broad categories of complementary and alternative medicine (CAM) interventions: 1) physical and meditative treatments (light therapy, sleep deprivation, exercise, yoga, and acupuncture) and 2) natural health products (St. John's wort, omega-3 fatty acids; S-adenosyl-L-methionine [SAM-e], dehydroepiandrosterone, folate, Crocus sativus, and others). Recommendations were based on available data on efficacy, tolerability, and safety.

CONCLUSIONS

For MDD of mild to moderate severity, exercise, light therapy, St. John's wort, omega-3 fatty acids, SAM-e, and yoga are recommended as first- or second-line treatments. Adjunctive exercise and adjunctive St. John's wort are second-line recommendations for moderate to severe MDD. Other physical treatments and natural health products have less evidence but may be considered as third-line treatments. CAM treatments are generally well tolerated. Caveats include methodological limitations of studies and paucity of data on long-term outcomes and drug interactions.

Effectiveness of bright light therapy on depressive symptoms in older adults with non-seasonal depression: a systematic review protocol

REVIEW QUESTION

What is the effectiveness of bright light therapy (BLT) on depressive symptoms in older adults with non-seasonal depression?

REVIEW OBJECTIVE

The review objective is to determine the current evidence related to the effectiveness of BLT on depressive symptoms in older adults with non-seasonal depression.

Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond

OBJECTIVES

To provide health care professionals in Canada with the basic knowledge and tools to provide nutrition guidance to women through their lifecycle.

OUTCOMES

Optimal nutrition through the female lifecycle was evaluated, with specific focus on adolescence, pre-conception, pregnancy, postpartum, menopause, and beyond. The guideline begins with an overview of guidance for all women, followed by chapters that examine the evidence and provide recommendations for the promotion of healthy nutrition and body weight at each life stage. Nutrients of special concern and other considerations unique to each life stage are discussed in each chapter.

EVIDENCE

Published literature, governmental and health agency reports, clinical practice guidelines, grey literature, and textbook sources were used in supporting the recommendations made in this document.

VALUES

The quality of evidence was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care. CHAPTER 2: GENERAL FEMALE NUTRITION: Summary Statements Recommendations CHAPTER 3: ADOLESCENCE NUTRITION: Summary Statements Recommendations CHAPTER 4: PRE-CONCEPTUAL NUTRITION: Summary Statement Recommendations CHAPTER 5: NUTRITION IN PREGNANCY: Summary Statements Recommendations CHAPTER 6: POSTPARTUM NUTRITION AND LACTATION: Summary Statements Recommendations CHAPTER 7: NUTRITION DURING MENOPAUSE AND BEYOND: Summary Statement Recommendations.

Deconstructing Diabetes and Depression: Clinical Context, Treatment Strategies, and New Directions

Depression and diabetes are common, chronic, and frequently comorbid diseases that contribute substantially to global disability and mortality. Their relationship is bidirectional: depression increases the risk of developing type 2 diabetes mellitus (T2DM), and diabetes increases the risk of depression. Unhealthy lifestyles and poor self-care by patients with depression contribute to the increased T2DM risk. The psychosocial burden of a diabetes diagnosis and its eventual complications predispose diabetic patients to depressive symptoms. Neuroendocrine alterations and inflammation may underlie the increased risk of T2DM in depression but are also proposed as common causative factors for both illnesses. Screening for depression is essential in T2DM, and vice versa. Selective serotonin reuptake inhibitors effectively treat depression of patients with diabetes and positively influence glycemic control. Psychological interventions are effective for depressive symptoms, but their effect on glycemic control varies. Novel depression interventions targeting inflammation or insulin resistance underscore the common biological underpinnings of mood and metabolism.

[Other therapeutic strategies]

Non-selective and irreversible MAOI have become as third or fourth-line strategy for the management of treatment-resistant depression. Non-selective and irreversible MAOI requires careful monitoring of drug interactions and dietary restrictions. Nutritional supplements such as omega-3 have been found to produce beneficial effects in the management of treatment-resistant depression when administered in combination with the ongoing antidepressant treatment. The glutamate antagonist ketamine has been found to produce beneficial effects in the management of treatment-resistant depression while administered alone. Dopamine and/or norepinephrine agonists, such as methylphenidate, modafinil or pramipexole, have been found to produce beneficial effects in the management of treatment-resistant depression when administered in combination with the ongoing antidepressant treatment.

Bright white light therapy in depression: A critical review of the evidence

BACKGROUND

Light therapy is an accepted treatment option, at least for seasonal affective disorder (SAD). Our aim was to critically evaluate treatment effects of bright white light (BWL) on the depressive symptoms in both SAD and non-seasonal depression.

METHODS

The systematic review was performed according to the PRISMA guidelines. PubMed, Embase, and PsycINFO were searched (December 1974 through June 2014) for randomized controlled trials published in peer-reviewed journals. Study quality was assessed with a checklist developed by the Swedish Council on Technology Assessment in Health Care. Only studies with high or medium quality were used in the meta-analyses.

RESULTS

Eight studies of SAD and two studies of non-seasonal depression met inclusion and quality criteria. Effects on SAD were estimated in two meta-analyses. In the first, week by week, BWL reached statistical significance only at two and three weeks of treatment (Standardized Mean Difference, SMD: -0.50 (-CI 0.94, -0.05); -0.31 (-0.59, -0.03) respectively). The second meta-analysis, of endpoint data only, showed a SMD of -0.54 (CI: -0.95, -0.13), which indicates an advantage for BWL. No meta-analysis was performed for non-seasonal depression due to heterogeneity between studies.

LIMITATIONS

This analysis is restricted to short-term effects of BWL measured as mean changes in scores derived from SIGH-SAD, SIGH-SAD self-report, or HDRS rating scales.

CONCLUSIONS

Most studies of BWL have considerable methodological problems, and the results of published meta-analyses are highly dependent on the study selection. Even though quality criteria are introduced in the selection procedures of studies, when the results are carefully scrutinized, the evidence is not unequivocal.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders. part 2: maintenance treatment of major depressive disorder-update 2015

These guidelines for the treatment of unipolar depressive disorders systematically review available evidence pertaining to the biological treatment of patients with major depression and produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians assessing and treating patients with these conditions. The relevant data have been extracted primarily from various treatment guidelines and panels for depressive disorders, as well as from meta-analyses/reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into five levels of evidence (CE A-F) and five levels of recommendation grades (RG 1-5). This second part of the WFSBP guidelines on depressive disorders covers the management of the maintenance phase treatment, and is primarily concerned with the biological treatment (including pharmacological and hormonal medications, electroconvulsive therapy and other brain stimulation treatments) of adults and also, albeit to a lesser extent, children, adolescents and older adults.

A call to action: exercise as treatment for patients with mental illness

Mental illness affects the lives of a significant number of Australians. In addition to pharmacological and psychological interventions, exercise has demonstrated benefits for people with mental illness including symptom reduction, improved cardiovascular risk profile and improved physical capacity. Unfortunately, evidence shows that clinician-delivered exercise advice is not routinely offered. This is despite patient acceptability for exercise. This article summarises the recent evidence supporting the prescription of exercise for people with mental illness and offers a model incorporating basic exercise prescription, and referral pathways for specialised advice. Current exercise prescription patterns for people with mental illness may not meet patient expectations; therefore, clinicians should consider exercise referral schemes to increase the accessibility of interventions for people with a mental illness.

Efficacy and acceptability of pharmacological treatments for depressive disorders in primary care: systematic review and network meta-analysis

PURPOSE

The purpose of this study was to investigate whether antidepressants are more effective than placebo in the primary care setting, and whether there are differences between substance classes regarding efficacy and acceptability.

METHODS

We conducted literature searches in MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and PsycINFO up to December 2013. Randomized trials in depressed adults treated by primary care physicians were included in the review. We performed both conventional pairwise meta-analysis and network meta-analysis combining direct and indirect evidence. Main outcome measures were response and study discontinuation due to adverse effects.

RESULTS

A total of 66 studies with 15,161 patients met the inclusion criteria. In network meta-analysis, tricyclic and tetracyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), a serotonin-noradrenaline reuptake inhibitor (SNRI; venlafaxine), a low-dose serotonin antagonist and reuptake inhibitor (SARI; trazodone) and hypericum extracts were found to be significantly superior to placebo, with estimated odds ratios between 1.69 and 2.03. There were no statistically significant differences between these drug classes. Reversible inhibitors of monoaminoxidase A (rMAO-As) and hypericum extracts were associated with significantly fewer dropouts because of adverse effects compared with TCAs, SSRIs, the SNRI, a noradrenaline reuptake inhibitor (NRI), and noradrenergic and specific serotonergic antidepressant agents (NaSSAs).

CONCLUSIONS

Compared with other drugs, TCAs and SSRIs have the most solid evidence base for being effective in the primary care setting, but the effect size compared with placebo is relatively small. Further agents (hypericum, rMAO-As, SNRI, NRI, NaSSAs, SARI) showed some positive results, but limitations of the currently available evidence makes a clear recommendation on their place in clinical practice difficult.

Optimizing the management of depression: primary care experience

This article is intended to identify some of the most important challenges faced by family physicians when treating MDD and to provide practical solutions. Key issues, reviewed from a primary care view point will include: treating to remission (and not just response), identification of high-risk groups, diagnosis, acute treatment approaches (including pharmacotherapy and the management of related side effects), the use of psychotherapy and somatic therapies, assessment of the adequacy of treatment including the assessment of remission, response measurement, optimal follow-up care throughout the phase of treatment, the key components of patient education and strategies for partial/limited response to the first-line antidepressant (switching, augmentation and combination strategies), how to provide support for improved treatment adherence, and approaches to prevent the recurrence of depressive episodes.

Wake-promoting pharmacotherapy for psychiatric disorders

Medications promoting wakefulness are currently used in psychopharmacology in different contexts and with different objectives. In particular, they may be used for the treatment of syndromes that primarily show significant impairment in alertness/wakefulness (e.g., excessive sleepiness and other sleep disorders) as well as for the symptomatic treatment of different neuropsychiatric disorders that, in turn, are not exclusively characterized by sleep-wake disturbances (like mood disorders, for instance). In addition, several psychotropic compounds, including some antipsychotics, mood stabilizers, antidepressants, and anxiolytics have well-established sedating side effects that may go beyond the therapeutic target and require the symptomatic use of wake-promoting agents. Even though such a clinical scenario reflects millions of individuals affected (alterations of wakefulness have a prevalence rate of 20-43% in the general population), relatively few pharmacotherapies are available, mainly including compounds with psychostimulating effects, such as methylphenidate, modafinil, and armodafinil and some amphetaminic agents. In light of their side effects and potential for abuse, such compounds have received FDA approval only for a limited number of psychiatric disorders. Nonetheless, their clinical application has recently become more widespread, including attention deficit hyperactivity disorder, narcolepsy, treatment-resistant depression, bipolar disorder, shift work sleep disorder, schizophrenia, and addictions. Wake-promoting agents have different mechanisms of action, peculiar clinical strengths and specific limitations, with novel drugs in the field under extensive investigation. The present review is aimed to provide an updated overview of the aforementioned compounds as well as investigational drugs in the field, in terms of mechanism of action, indications and use in clinical practice.

Transcranial bright light treatment via the ear canals in seasonal affective disorder: a randomized, double-blind dose-response study

BACKGROUND

Bright light treatment is effective for seasonal affective disorder (SAD), although the mechanisms of action are still unknown. We investigated whether transcranial bright light via the ear canals has an antidepressant effect in the treatment of SAD.

METHODS

During the four-week study period, 89 patients (67 females; 22 males, aged 22-65, mean ± SD age: 43.2 ± 10.9 years) suffering from SAD were randomized to receive a 12-min daily dose of photic energy of one of three intensities (1 lumen/0.72 mW/cm(2); 4 lumens/2.881 mW/cm(2); 9 lumens/6.482 mW/cm(2)) via the ear canals. The light was produced using light-emitting diodes. The severity of depressive symptoms was assessed with the Hamilton Depression Rating Scale - Seasonal Affective Disorder (SIGH-SAD), the Hamilton Anxiety Rating Scale (HAMA), and the Beck Depression Inventory (BDI). Cognitive performance was measured by the Trail Making Test (TMT). The within-group and between-group changes in these variables throughout the study were analysed with a repeated measures analysis of variance (ANOVA), whereas gender differences at baseline within the light groups were analysed using Student's t-tests.

RESULTS

Patients in all three groups showed significant decreases in their BDI, HAMA, and SIGH-SAD scores. Response rates, i.e., an at least 50% decrease of symptoms as measured by the BDI, were 74%-79% in the three treatment groups. Corresponding variations for the SIGH-SAD and the HAMA were 35-45% and 47-62%, respectively. No intensity-based dose-response relationships in the improvement of anxiety and depressive symptoms or cognitive performance between treatment groups were observed. Approximately one in four patients experienced mild adverse effects, of which the most common were headache, insomnia, and nausea.

CONCLUSIONS

These results suggests that transcranial bright light treatment may have antidepressant and anxiolytic effect in SAD patients, as both self- and psychiatrist-rated depressive and anxiety symptoms decreased in all treatment groups. These improvements are comparable to findings of earlier bright light studies that used conventional devices. The lack of dose response may be due to a saturation effect above a certain light intensity threshold. Further studies on the effects of transcranial bright light with an adequate placebo condition are needed.

TRIAL REGISTRATION

NCT01293409, ClinicalTrials.gov.

Plurality of anxiety and depression alteration mechanism by oleanolic acid

Our study sought to evaluate the anxiolytic and antidepressant activities of oleanolic acid as well as the neural mechanisms involved. Animal models such as barbiturate sleep-induction, light-dark box, elevated plus maze, forced swimming test, tail suspension test and open field test were conducted. Male Albino Swiss mice were treated orally with vehicle 10 mL/kg, fluoxetine 20 mg/kg, imipramine 15 mg/kg, diazepam 1 mg/kg or oleanolic acid 5-40 mg/kg. Pretreatment (intraperitoneal) of animals with pentylenetetrazole (PTZ) 20 mg/kg, 1-(2-methoxyphenyl)-4-[4- (2-phthalimido) butyl]piperazine hydrobromide (NAN-190) 0.5 mg/kg, p-chlorophenylalanine methyl ester (PCPA) 100 mg/kg or α-methyl-p-tyrosine (AMPT) 100 mg/kg, WAY100635 (WAY) 0.3 mg/kg, prazosin (PRAZ) 1 mg/kg, yohimbine 2 mg/kg as well as monoamine oxidase assay and hippocampal brain-derived neurotrophic factor (BDNF) quantification were carried out. Oleanolic acid potentiated the hypnotic effect of barbiturate and demonstrated an anxiolytic effect in both the light-dark box and elevated plus maze. This effect was not reversed by PTZ. Acute and/or chronic oral treatment of mice with oleanolic acid (5-20 mg/kg) elicited an antidepressant effect in the forced swimming test and the tail suspension test without interfering with the locomotor activity. The antidepressant effect of oleanolic acid was attenuated by NAN-190, AMPT, PCPA, WAY and PRAZ. Although monoamine oxidase activity remained unaltered by oleanolic acid, chronic administration of oleanolic acid augmented hippocampal BDNF level. These findings demonstrate multiple mechanisms of the anxiolytic and antidepressant effect of oleanolic acid.

The influence of Hatha yoga as an add-on treatment in major depression on hypothalamic-pituitary-adrenal-axis activity: a randomized trial

OBJECTIVES

The impact of Hatha yoga as add-on treatment to quetiapine fumarate extended release (QXR) or escitalopram (ESC) in depressed patients on hypothalamic-pituitary-adrenal (HPA) axis activity was assessed.

METHODS

60 inpatients suffering from major depressive disorder (MDD) according to DSM-IV were randomized for a 5 week treatment with Yoga or not (control group) and with either QXR (300 mg/day) or ESC (10 mg/day). Serial dexamethasone/corticotropin releasing hormone (DEX/CRH) tests were performed to assess HPA axis function. The Hamilton Depression Rating Scale (21-HAMD) was used weekly.

RESULTS

A more pronounced down regulation of the HPA axis activity due to yoga could not be detected. The stepwise long term cortisol reduction was seen in both medication groups, irrespectively of yoga add-on treatment. In addition, cortisol improvers in week 1 of therapy (reduction in cortisol peak value within the DEX/CRH test) reached significant greater amelioration of depressive symptoms after 5 weeks.

CONCLUSIONS

Our results suggest that antidepressant agents down regulate HPA axis function to a greater extent than additional Hatha yoga treatment. Moreover, an early reduction of HPA system hyperactivity after one week of pharmacological treatment seems to raise the possibility of a favorable treatment response.

Modeling mental health information preferences during the early adult years: a discrete choice conjoint experiment

Although most young adults with mood and anxiety disorders do not seek treatment, those who are better informed about mental health problems are more likely to use services. The authors used conjoint analysis to model strategies for providing information about anxiety and depression to young adults. Participants (N = 1,035) completed 17 choice tasks presenting combinations of 15 four-level attributes of a mental health information strategy. Latent class analysis yielded 3 segments. The virtual segment (28.7%) preferred working independently on the Internet to obtain information recommended by young adults who had experienced anxiety or depression. Self-assessment options and links to service providers were more important to this segment. Conventional participants (30.1%) preferred books or pamphlets recommended by a doctor, endorsed by mental health professionals, and used with a doctor's support. They would devote more time to information acquisition but were less likely to use Internet social networking options. Brief sources of information were more important to the low interest segment (41.2%). All segments preferred information about alternative ways to reduce anxiety or depression rather than psychological approaches or medication. Maximizing the use of information requires active and passive approaches delivered through old-media (e.g., books) and new-media (e.g., Internet) channels.

Winter depression and diabetes

Depression is a common and often harmful disorder, which is frequently associated with the winter season. Research has shown a link between type 2 diabetes mellitus and depression. Furthermore, diabetics with depression have a higher rate of adverse outcomes. Little has been published regarding the seasonality of depression in diabetics. The case report described in this article concerns a 65-year-old woman with type 2 diabetes and a history of winter depression. Current evidence-based management options are reviewed.

Complementary and alternative therapies as add-on to pharmacotherapy for mood and anxiety disorders: a systematic review

BACKGROUND

Depressed and anxious patients often combine complementary and alternative medicine (CAM) therapies with conventional pharmacotherapy to self-treat symptoms. The benefits and risks of such combination strategies have not been fully evaluated. This paper evaluates the risk-benefit profile of CAM augmentation to antidepressants in affective conditions.

METHODS

PubMed was searched for all available clinical reports published in English up to December 2012. Data were evaluated based on graded levels of evidence for efficacy and safety.

RESULTS

Generally, the evidence base is significantly larger for depression than for anxiety disorder. In unipolar depression, there is Level 2 evidence for adjunctive sleep deprivation (SD) and Free and Easy Wanderer Plus (FEWP), and Level 3 for exercise, yoga, light therapy (LT), omega-3 fatty acids, S-adenosylmethionine and tryptophan. In bipolar depression, there is Level 1 evidence for adjunctive omega-3s, Level 2 for SD, and Level 3 for LT and FEWP. In anxiety conditions, exercise augmentation has Level 3 support in generalized anxiety disorder and panic disorder. Though mostly well-tolerated, these therapies can only be recommended as third-line interventions due to the quality of available evidence.

LIMITATIONS

Overall, the literature is limited. Studies often had methodological weaknesses, with little information on long-term use and on potential drug-CAM interactions. Many CAM studies were not published in English.

CONCLUSIONS

While several CAM therapies show some evidence of benefit as augmentation in depressive disorders, such evidence is largely lacking in anxiety disorders. The general dearth of adequate safety and tolerability data encourages caution in clinical use.

An integrative group therapy model for depression and anxiety in later life

Research shows that elderly patients are fully capable of benefiting from psychotherapy, and often prefer this non-pharmacological treatment option. Further, there is consensus among geriatric clinicians and researchers that a group format for psychotherapy is likely especially helpful for the elderly. In this paper, we describe a unique group therapy program for elderly patients referred to a community outpatient setting for depression and/or anxiety. This integrated group therapy program, unlike existing programs, combines a more structured cognitive-behavior therapy (CBT) with a more process-oriented interpersonal therapy (IPT), specifically targeting the coexistence of depression and anxiety in the elderly. We present two cases of prototypical patients benefiting from the program, and also provide preliminary empirical support for the effectiveness of this group program.

Getting depression clinical practice guidelines right: time for change?

OBJECTIVE

As part of a series of papers ['Chronobiology of mood disorders' Malhi & Kuiper. Acta Psychiatr Scand 2013;128(Suppl. 444):2-15; and 'It's time we managed depression: The emerging role of chronobiology' Malhi et al. Acta Psychiatr Scand 2013;128(Suppl. 444):1] examining chronobiology in the context of depression, this article examines recent western clinical practice guidelines (CPGs) for the treatment of depression with respect to the recommendations they make, in particular as regards chronobiological treatments, and briefly considers the implications of their methodology and approach.

METHOD

Five international treatment guidelines, which had been published in the past 5 years, were identified, representing North American and European views. Chosen guidelines were reviewed by the authors, and the relevant recommendations were distributed for discussion and subsequent synthesis.

RESULTS

Most current guidelines do not address chronobiology in detail. Chronotherapeutic recommendations are tentative, although agomelatine is considered as an option for major depression and bright light therapy for seasonal affective disorder. Sleep deprivation is not routinely recommended.

CONCLUSION

Recommendations are limited by the lack of reliable therapeutic markers for chronotherapeutics. Current evidence supports use of light therapy in seasonal depression, but in non-seasonal depression there is insufficient evidence to support reliance on chronotherapeutics over existing treatment modalities.

Interventions (other than pharmacological, psychosocial or psychological) for treating antenatal depression

BACKGROUND

A meta-analysis of 21 studies suggests the mean prevalence rate for depression across the antenatal period is 10.7%, ranging from 7.4% in the first trimester to a high of 12.8% in the second trimester. Due to maternal treatment preferences and potential concerns about fetal and infant health outcomes, diverse non-pharmacological treatment options are needed.

OBJECTIVES

To assess the effect of interventions other than pharmacological, psychosocial, or psychological interventions compared with usual antepartum care in the treatment of antenatal depression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2013), scanned secondary references and contacted experts in the field to identify other published or unpublished trials.

SELECTION CRITERIA

All published and unpublished randomised controlled trials of acceptable quality evaluating non-pharmacological/psychosocial/psychological interventions to treat antenatal depression.

DATA COLLECTION AND ANALYSIS

Both review authors participated in the evaluation of methodological quality and data extraction. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

MAIN RESULTS

Six trials were included involving 402 women from the United States, Switzerland, and Taiwan. For most comparisons a single trial contributed data and there were few statistically significant differences between control and intervention groups.In a trial with 38 women maternal massage compared with non-specific acupuncture (control group) did not significantly decrease the number of women with clinical depression or depressive symptomatology immediately post-treatment (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.25 to 2.53; mean difference (MD) -2.30, 95% CI -6.51 to 1.91 respectively). In another trial with 88 women there was no difference in treatment response or depression remission rates in women receiving maternal massage compared with those receiving non-specific acupuncture (RR 1.33, 95% CI 0.82 to 2.18; RR 1.14, 95% CI 0.59 to 2.19 respectively).In a trial with 35 women acupuncture specifically treating symptoms of depression, compared with non-specific acupuncture, did not significantly decrease the number of women with clinical depression or depressive symptomatology immediately post-treatment (RR 0.47, 95% CI 0.11 to 2.13; MD -3.00, 95% CI -8.10 to 2.10). However, women who received depression-specific acupuncture were more likely to respond to treatment compared with those receiving non-specific acupuncture (RR 1.68, 95% CI 1.06 to 2.66).In a trial with 149 women, maternal massage by a woman's significant other, compared with standard care, significantly decreased the number of women with depressive symptomatology immediately post-treatment (MD -6.70, 95% CI -9.77 to -3.63). Further, women receiving bright light therapy had a significantly greater change in their mean depression scores over the five weeks of treatment than those receiving a dim light placebo (one trial, n = 27; MD -4.80, 95% CI -8.39 to -1.21). However, they were not more likely to have a treatment response or experience a higher remission rate (RR 1.79, 95% CI 0.90 to 3.56; RR 1.89, 95% CI 0.81 to 4.42).Lastly, two trials examined the treatment effect of omega-3 oils. Women receiving omega-3 had a significantly lower mean depression score following eight weeks of treatment than those receiving a placebo (one trial, n = 33; MD -4.70, 95% CI -7.82 to -1.58). Conversely, in a smaller trial (21 women) there was no significant difference in the change in mean depression scores for women receiving omega-3 and those receiving a placebo (MD 0.36, 95% CI -0.17 to 0.89), and women who received omega-3 were no more likely to respond to treatment (RR 2.26, 95% CI 0.78 to 6.49) or have higher remission rates (RR 2.12, 95% CI 0.51 to 8.84). Women in the placebo group were just as likely to report a side effect as those in the omega-3 group (RR 1.12, 95% CI 0.56 to 2.27).

AUTHORS' CONCLUSIONS

The evidence is inconclusive to allow us to make any recommendations for depression-specific acupuncture, maternal massage, bright light therapy, and omega-3 fatty acids for the treatment of antenatal depression. The included trials were too small with non-generalisable samples, to make any recommendations.

Bupropion for the treatment of seasonal affective disorder

INTRODUCTION

Seasonal affective disorder (SAD) is a psychiatric illness with recurring depressive episodes during particular seasons, mostly winter. Bupropion is effective in the preventive treatment of SAD and is probably also effective in the acute treatment of SAD.

AREAS COVERED

This review covers the pharmacokinetics and pharmacodynamics of bupropion. The authors also evaluate bupropion's clinical efficacy as well as its safety and tolerability.

EXPERT OPINION

Bupropion is available in an immediate release formulation, as well as a sustained release formulation and an extended release (XR) formulation. The XR formulation is recommended for SAD due to its ease of use and is the only formulation currently used as a therapy. Due to the predictable nature of SAD, the use of bupropion XR is considered a relevant treatment option. Bupropion's efficacy is shown in three trials that started in autumn at a time when SAD symptoms were not yet present although treatment effects were relatively small compared with a placebo. Bupropion was also shown to have efficacy in an open-label study. That being said, in order to reach definitive conclusions about its efficacy with acute treatment of SAD, more placebo-controlled trials are needed.