When do I recommend non-pharmacological options?

Non-pharmacological strategies are appropriate first-line choices for the treatment of mild depression.1 In moderate depression, non-pharmacological options are as effective as antidepressants and guidelines recommend that choice of therapy should be based on patient preference.1

Non-pharmacological options as part of a broader management plan

Recent meta-analyses have demonstrated small but significant advantages of combined treatment over either medicines or psychological treatment alone.2,3 For patients who require antidepressants for moderate and severe depression,1,4,5 consider adding psychological treatment and other non-pharmacological strategies tailored to individual circumstances.3

Which non-pharmacological approaches have increasing evidence?

Non-pharmacological interventions include formal psychological therapies such as cognitive behaviour therapy (CBT) and interpersonal psychotherapy (IPT), as well as less formal supportive therapies such as counselling within primary care, mindfulness-based therapy, behavioural activation and self-help strategies. Lifestyle changes to improve diet, exercise, relaxation and sleeping habits should also be part of a broader management plan. These changes can help prevent relapse after recovery.6,7 This Medicinewise News gives more information on the less formal supportive interventions for managing depression.

A growing role for e-Mental health tools

e-Mental health tools are online resources that deliver mental health information, services and care.8

A growing body of evidence suggests that online psychological treatment tools, based on well-established techniques from CBT and other formal therapy modalities, are effective for mild and moderate depression.8 More research is required to establish the most effective avenues to implement these health tools.8,9

e-Mental health tools can be used as:

  • prevention and early intervention8
  • primary first-line treatment for mild and moderate depression8
  • maintenance or adjunctive treatment to help prevent relapse or complement other treatment, respectively.8

Lifestyle measures and depression

Many lifestyle factors such as exercise, diet, smoking and drinking alcohol are involved in the pathogenesis of depression, yet are given little consideration in the management of depression.6

Exercise

A recent Cochrane review suggests a moderate effect for exercise in reducing symptoms of depression, over no intervention or placebo among patients with any severity of depression.6,10 Exercise appears to elevate mood and boost self-esteem.6

Sleep

There is a bidirectional relationship between sleep and depression. Research has shown that insomnia can increase the risk of depression.6 Sleep disturbance has an impact on mood, cognitive function, and motivation.11 Alleviating sleep disturbance symptoms can motivate patients to engage in other treatments for depression and help with stress management.11

Online cognitive behaviour therapy available in Australia

ProgramTarget  audienceBeacon evidence rating#AccessWebsite link
MoodGYMAll☺☺☺☺☺Free with registrationmoodgym.anu.edu.au
MindspotaAges 18+☺☺☺☺☺Free with registrationmindspot.org.au
e-couchAll☺☺☺Free with registrationecouch.anu.edu.au
This Way Up - Sadness (Depression)bAdults☺☺☺Fee-based with referral from clinicianthiswayup.org.au
myCompassAges 18+☺☺Free with registrationmycompass.org.au

a: Program not rated by Beacon, however Beacon evidence rating tool was used to rate the available evidence.  b: Program is available as self-guide and clinician-guided. #: Reproduced with permission from Beacon.anu.edu.au. The 'Smiley Rating System' is designed to be used by consumers and health practitioners to examine the efficacy of the program.
Beacon Evidence Rating: ☺x5: more than three RTCs. ☺x4: at least three positive RTCs. ☺x3: at least two positive RTCs exist combined with other supportive evidence. ☺x2: one or two RTCs exist.

Managing depression in adolescents and young adults

A combination of psychoeducation and supportive management with the addition of psychological treatment is recommended first line for adolescents (13–18 years) and young adults (19–24 years) who are not at immediate risk of suicidal behaviour.12

Psychoeducation and supportive management involve active listening, empathy, recommending e-Mental health tools, counselling to encourage completion,8 and providing lifestyle advice tailored to suit each individual’s circumstances.12

There is little evidence of CBT and IPT effectiveness in young adults, but robust evidence of these therapies in adults can be extrapolated to young adults aged 18 to 24.12,13

What if CBT and IPT are not enough?

Guidelines recommend use of antidepressants for moderate and severe depression where psychological strategies have been unsuccessful, patient has no access to psychological strategies, patient refuses such treatment, or depressive symptoms are severe or life-threatening.12

A large RCT showed that combining CBT and an antidepressant reduced suicidal thinking and depressive symptoms compared to placebo.12

Fluoxetine is recommended in adolescents12 as it is the only antidepressant where the benefits outweigh the risks in this patient population.14
CBT can be added to selective serotonin reuptake inhibitor (SSRI) treatment to reduce the risk of suicidal thinking and improve functioning in severe depression.1,12

Enhancing clinical outcomes through shared decision-making

Involving patients in decision-making improves outcomes of depression and can result in higher probability of symptom improvement over an 18-month period.15 Providing detailed information, including consumer resources and written information can promote long-term adherence.15

The management plan should have:

  • agreed management strategies and treatment trial periods.
  • patient mental status assessment, including risk of self harm, suicide or harm to others.13
  • details of endpoints or specific target symptoms (eg, improvement in mood as documented in a mood diary), assessment of benefit and review points (details on monitoring or assessing patient outcomes via questionnaires or mobile apps that can track patient progress).

Expert reviewer

Dr Jan Orman, GP Facilitator, Black Dog Institute

References

  1. Psychotropic Expert Group. Therapeutic guidelines: psychotropic. Version 7. Melbourne: Therapeutic Guidelines Limited: 2013. [TG Online] (accessed 16 September 2015).
  2. Cuijpers P, Andersson G, Donker T, et al. Psychological treatment of depression: results of a series of meta-analyses. Nord J Psychiatry 2011;65:354-64. [PubMed].
  3. Picardi A and Gaetano P. Psychotherapy of mood disorders. Clin Pract Epidemiol Ment Health 2014;10:140-58. [PubMed].
  4. Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol 2015;29:459-525. [PubMed].
  5. Royal Australian College of General Practitioners. Medical care of older persons in residential aged care facilities South Melbourne: Royal Australian College of General Practitioners, 2006. [Online] (accessed 9 September 2015).
  6. Sarris J, O'Neil A, Coulson CE, et al. Lifestyle medicine for depression. BMC Psychiatry 2014;14:107. [PubMed].
  7. Hoffman BM, Babyak MA, Craighead WE, et al. Exercise and pharmacotherapy in patients with major depression: one-year follow-up of the SMILE study. Psychosom Med 2011;73:127-33. [PubMed].
  8. Royal Australian College of General Practitioners. e-Mental health: A guide for GPs. Melbourne: The Royal Australian College of General Practitioners, 2015. [Online] (accessed 30 September 2015).
  9. Arnberg FK, Linton SJ, Hultcrantz M, et al. Internet-delivered psychological treatments for mood and anxiety disorders: a systematic review of their efficacy, safety, and cost-effectiveness. PLoS One 2014;9:e98118. [PubMed].
  10. Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev 2013;9:CD004366. [PubMed]..
  11. Skeffington P. Quality of lifestyle: Building the foundations for better mental health Australian Psychological Society Limited, 2013. [Online] (accessed 7 October 2015).
  12. beyondblue. Clinical practice guidelines:Depression in adolescents and young adults. 2011. [Online] (accessed 16 September 2015).
  13. Purcell R, Ryan S, Scantan F, et al. A guide to what works for depression in young people. 2nd ed. beyondblue: Melbourne, 2013.
  14. National Institute for Health and Clinical Excellence. Depression in children and young people: identification and management. UK: NICE 2005. [Online] (accessed 4 November 2015).
  15. Clever SL, Ford DE, Rubenstein LV, et al. Primary care patients' involvement in decision-making is associated with improvement in depression. Med Care 2006;44:398-405. [PubMed].