Depression and Complementary Health Approaches: What the Science Says
Clinical Guidelines, Scientific Literature, Info for Patients:
Depression and Complementary Health Approaches
Omega-3 Fatty Acid Supplementation
At present, it’s uncertain whether omega-3 fatty acid supplementation may be useful for depression. Some studies have shown small effects in adjunctive therapy in patients with a diagnosis of major depressive disorder (MDD) and on depressive patients without a diagnosis of MDD; however, most trials have been adjunctive studies. Controlled trials of omega-3 fatty acids as monotherapy are inconclusive compared to standard antidepressant medicines, and it remains unclear that a mechanism is present to suggest that a pharmacological or biological antidepressant effect exists.
What Does the Research Show?
- A 2015 Cochrane review of 26 randomized controlled trials involving a total of 1,478 participants concluded that there isn’t sufficient high quality evidence to determine the effects of omega-3 polyunsaturated fatty acid as a treatment for major depressive disorder.
- A 2015 double-blind, randomized controlled trial comparing EPA and DHA as monotherapy for MDD in 1,954 participants found that neither EPA-enriched nor DHA-enriched fatty acid supplementation was superior to placebo.
- Omega-3 fatty acid supplements are generally safe and well-tolerated. When side effects do occur, they typically consist of minor gastrointestinal symptoms and fishy aftertaste.
- There is some concern that omega-3 supplements may extend bleeding time. The risk appears to be minimal, and should never be used in patients who take drugs that affect platelet function. It is important to discuss any potential herb-drug interactions with patients if they are considering using omega-3 fatty acids.
- It is uncertain whether people with fish or shellfish allergies can safely consume fish oil supplements and should not be used in such patients.
St. John’s Wort (Hypericum perforatum)
Results of some studies suggest that St. John’s wort (Hypericum perforatum) may have an effect on mild to moderate major depressive disorder (MDD) for a limited number of patients, similar to standard antidepressants, but the evidence is far from definitive. Although some studies have demonstrated a slight efficacy over placebo, others contradict these findings.
The significant herb-drug interactions of St. John’s wort (Hypericum perforatum) are important safety considerations.
What Does the Research Show?
- A 2015 systematic review and network meta-analysis of 66 studies involving 15,161 patients examined whether antidepressants and other agents, including St. John’s wort (Hypericum perforatum), may be more effective than placebo in the primary care setting. The reviewers found that St. John’s wort (Hypericum perforatum), as well as some other agents, showed some positive results, but because the current evidence is limited, conclusions about their place in clinical practice cannot be drawn.
- The 2010 American Psychiatric Association Task Force on Complementary and Alternative Medicine report states that St. John’s wort (Hypericum perforatum) may eventually become a reasonable treatment for mild to moderate major depressive disorder (MDD) for a limited number of individuals, although not all recent studies for the treatment of MDD demonstrated efficacy over placebo. The report also indicates any potential efficacy is only a greater consensus and support from studies in mild to moderate MDD.
- In a 2011 randomized controlled trial examining the treatment of minor depression with St. John’s wort (Hypericum perforatum) or citalopram over the course of 12 weeks, neither St. John’s wort nor citalopram showed any benefit over placebo.
- A 2012 study examined longer-term efficacy of St. John’s wort (Hypericum perforatum) versus sertraline and placebo in patients with major depressive disorder and found that St. John’s wort, sertraline, and placebo produced similar treatment effects over the course of 26 weeks.
- Drug interactions with St. John’s wort (Hypericum perforatum) limit use and are important safety considerations.
- Combining St. John’s wort (Hypericum perforatum) and certain antidepressants can lead to serotonin syndrome, with dangerous symptoms ranging from tremor and diarrhea to very dangerous confusion, muscle stiffness, drop in body temperature, and even death.
- Other side effects of St. John’s wort (Hypericum perforatum) are usually minor and uncommon and may include upset stomach and sensitivity to sunlight. Also, St. John’s wort may worsen feelings of anxiety in some people.
- A rare, but possible side effect of taking St. John’s wort (Hypericum perforatum) is psychosis. Those with certain mental health disorders, such as bipolar disorder, are at risk of experiencing this rare side effect. Therefore, it is important to discuss this potential side effect with patients who are considering using St. John’s wort and encourage discontinuation of the herb if they experience a worsening of symptoms.
- Taking St. John’s wort (Hypericum perforatum) increases the activity of cytochrome P450 3A4 (CYP3A4) enzyme and reduces plasma concentrations and can weaken many prescription medicines, such as:
- Oral contraceptives
- Some HIV drugs including indinavir
- Some chemotherapeutic agents including irinotecan
- Warfarin and other anticoagulants
Current scientific research does not support the use of SAMe for the treatment of depression.
What Does the Research Show?
- A 2016 Cochrane review of eight randomized controlled trials involving 934 adults concluded that there isn’t enough high quality evidence nor the ability to draw firm conclusions based on that evidence about the effects of SAMe for the treatment of depression.
- Preliminary results from a 2014 randomized controlled trial in a subsample of 144 participants with major depressive disorder (MDD) who received SAMe, escitalopram, or placebo for 12 weeks provided some evidence for the use of SAMe in the treatment of MDD. However, in the parent study, SAMe failed to demonstrate any advantage over placebo for MDD.
- A 2009 review of evidence for SAMe for the treatment of MDD concluded that there is insufficient evidence examining whether the oral preparations of SAMe can be safe or efficacious when used as adjunctive treatment for patients with MDD who are unresponsive to antidepressants.
- Information on the long-term safety of SAMe is limited and inconclusive. However, in one study of alcohol-related liver disease in which participants took SAMe for 2 years, no serious side effects were reported.
- SAMe may decrease the effects of levodopa. It is also possible that SAMe might interact with drugs and dietary supplements that increase levels of serotonin, including some antidepressants, L-tryptophan, and St. John’s wort, but the evidence for such interactions is very limited.
- SAMe promotes the growth of Pneumocystis, a fungus that can cause pneumonia in people with suppressed immune systems. It is possible that taking SAMe might increase the likelihood or severity of Pneumocystis infection in people who are HIV positive and should never be used in these patients.
- Side effects of SAMe appear to be uncommon, and when they do occur they are usually problems such as nausea or digestive upsets.
Data from current scientific research do not support the use of Inositol for the treatment of depression.
What Does the Research Show?
- A 2016 systematic review and meta-analysis of several adjunctive nutraceuticals for depression found no significant benefit over placebo for inositol.
- A 2014 meta-analysis of seven randomized controlled trials (two bipolar studies, one bipolar and major depressive disorder (MDD) study, two MDD studies, and two premenstrual dysphoric disorder (PMDD) studies) involving 242 participants found no significant treatment effect of inositol for depressed patients. However, inositol showed a trend of efficacy of depressive symptoms over placebo in patients with PMDD.
- There is a paucity of data on the safety and side effects of inositol. A 2014 meta-analysis of inositol for depression and anxiety disorders found that inositol marginally caused gastrointestinal upset compared with placebo. A 2011 European review on the safety of inositol had similar findings in that inositol induced gastrointestinal side effects such as nausea, flatus, and diarrhea.
There is some evidence that suggests acupuncture may have provide a modest reduction in symptoms of depression, particularly when compared with no treatment or a control.
What Does the Research Show?
- A 2018 Cochrane review of 64 studies involving a total of 7,104 participants concluded that acupuncture may result in a moderate reduction in the severity of depression when compared with treatment as usual/no treatment, and the use of acupuncture may lead to a small reduction in the severity of depression when compared with a control. Reviewers also concluded that the effects of acupuncture compared with medication and psychological therapy are uncertain because of the low quality of evidence.
- A 2019 meta-analysis of seven trials compared the effectiveness of acupuncture therapy in patients with post-stroke depression and found evidence to support the use of acupuncture for this condition. Subgroup analyses also showed that acupuncture alone resulted in better outcomes than drug therapy in improving depressive symptoms.
- A 2019 systematic review and meta-analysis of 29 studies involving 2,268 participants (22 trials were conducted in China and 7 conducted outside of China) concluded that acupuncture may be a suitable adjunct to usual care and standard antidepressant medication. However, most of the trials included in the review and meta-analysis were at a high risk of bias.
- Relatively few complications from using acupuncture have been reported. Still, complications have resulted from the use of nonsterile needles and improper delivery of treatments.
- When not delivered properly, acupuncture can cause serious adverse effects, including skin infections, punctured organs, pneumothoraces, and injury to the central nervous system.
There is some evidence that music therapy may provide short-term benefits for people with depression.
What Does the Research Show?
- A 2017 Cochrane review of nine studies involving a total of 421 participants (411 of whom were included in the meta-analysis that investigated short-term effects of music therapy for depression) concluded that music therapy provides short-term beneficial effects for people with depression. Reviewers also found that music therapy shows efficacy in decreasing anxiety levels and improving functioning of depressed individuals.
- There are no adverse effects associated with music therapy.
There is some evidence that yoga may be helpful in reducing depressive symptoms.
What Does the Research Show?
- A 2017 Cochrane review of 23 studies (involving 1,272 participants) in people with depressive symptoms (although not necessarily diagnosed with depression), yoga was helpful in reducing symptoms in 14 of the studies.
- A 2017 systematic review of 7 studies (involving 240 participants) found some evidence of beneficial effects of yoga for major depressive disorder (MDD); however, the reviewers judged the evidence to be insufficient to justify recommending yoga for people with this condition. Problems included the small number of people studied and an inability to compare benefits with risks because of inadequate information on safety.
- Yoga is generally considered a safe form of physical activity for healthy people when performed properly, under the guidance of a qualified instructor. However, as with other types of physical activity, injuries can occur. The most common injuries are sprains and strains. Serious injuries are rare.
- People with health conditions, older adults, and pregnant women may need to avoid or modify some yoga poses and practices.
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- Appleton KM, Sallis HM, Perry R, et al. Omega-3 fatty acids for depression in adults. Cochrane Database Syst Rev. 2015;11:CD004692.
- Armour M, Smith CA, Wang LQ, et al. Acupuncture for depression: A systematic review and meta-analysis. J Clin Med. 2019;8(8):E1140.
- Boyer EW, Shannon M. The serotonin syndrome. New England Journal of Medicine. 2005;352:1112–1120.
- Carlomagno G, Unfer V. Inositol safety: clinical evidences. Eur Rev Med Pharmacol Sci. 2011;15(8):931–936.
- Clauson KA, Santamarina ML, Rutledge JC. Clinically relevant safety issues associated with St. John’s wort product labels. BMC Complementary and Alternative Medicine. 2008; 8:42.
- Cramer H, Anheyer D, Lauche R, et al. A systematic review of yoga for major depressive disorder. J Affect Disord. 2017;213:70-77.
- Cramer H, Lauche R, Klose P, et al. Yoga for improving health-related quality of life, mental health and cancer-related symptoms in women diagnosed with breast cancer. Cochrane Database Syst Rev. 2017;1:CD010802.
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- Freeman MP, Fava M, Lake J, et al. Complementary and alternative medicine in major depressive disorder: the American Psychiatric Association Task Force report. J Clin Psychiatry. 2010;71(6):669–681.
- Galizia I, Oldani L, Macritchie K, et al. S-adenosyl methionine (SAMe) for depression in adults. Cochrane Database Syst Rev. 10:CD011286.
- Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St. John's wort) in major depressive disorder: a randomized controlled trial. Journal of the American Medical Association. 2002;287(14):1807–1814.
- Jorm AF, Morgan AJ, Hetrick SE. Relaxation for depression. Cochrane Database of Systematic Reviews 2008;4:CD007142.
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- Linde K, Berner MM, Kriston L. St John's wort for major depression. Cochrane Database of Systematic Reviews. 2008;4:CD000448.
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- Linde K, Kriston L, Rücker G, et al. Efficacy and acceptability of pharmacological treatments for depressive disorders in primary care: systematic review and network meta-analysis. Ann Fam Med. 2015;13(1):69–79.
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- Mischoulon D, Nierenberg AA, Schettler PJ, et al. A double-blind, randomized controlled clinical trial comparing eicosapentaenoic acid versus docosahexaenoic acid for depression. J Clin Psychiatry. 2015;76(1):54–61.
- Mischoulon D, Price LH, Carpenter LL, et al. A double-blind, randomized, placebo-controlled clinical trial of S-adenosyl-L-methionine (SAMe) versus escitalopram in major depressive disorder. J Clin Psychiatry. 2014;75(4):370–376.
- Montgomery P, Richardson AJ. Omega-3 fatty acids for bipolar disorder. Cochrane Database of Systematic Reviews. 2008;2: CD005169.
- Mukai T, Kishi T, Matsuda Y, et al. A meta-analysis of inositol for depression and anxiety disorders. Hum Psychopharmacol. 2014;29(1):55–63.
- Papakostas GI. Evidence for S-adenosyl-L-methionine (SAM-e) for the treatment of major depressive disorder. J Clin Psychiatry. 2009;70(Suppl 5):18–22.
- Rapaport MH, Nierenberg AA, Howland R, et al. The treatment of minor depression with St. John’s wort or citalopram: failure to show benefit over placebo. J Psychiatr Res. 2011;45(7):931–941.
- Sarris J, Fava M, Schweitzer I, et al. St John's wort (Hypericum perforatum) versus sertraline and placebo in major depressive disorder: continuation data from a 26-week RCT. Pharmacopsychiatry. 2013;45(7):275–278.
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- Taylor MJ, Wilder H, Bhagwagar Z, et al. Inositol for depressive disorders. Cochrane Database of Systematic Reviews. 2004;2:CD004049.
- Zhang XY, Li YX, Liu DL, et al. The effectiveness of acupuncture therapy in patients with post-stroke depression: An updated meta-analysis of randomized controlled trials. Medicine (Baltimore). 2019;98(22):e15894.
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