Additional Strategies for Depression,
by Bruce Schaefer, LMT

We all experience periods of sadness -- feeling down for a day or so, but soon our mood turns around and we continue on our journey. However, for nearly 21 million American adults, emotions degenerate into despondency and anguish, are of much longer duration, and often become intense enough to be debilitating. The term "depression" covers a group of mood disorders which include major depressive disorder ("clinical depression"), dysthymia, and bipolar disorder. The actual causes of depression are varied and complex, and involve genetic, environmental, neurobiological, and psychological factors.

In the U.S., major depressive disorder is the leading cause of disability for people 15 to 44 years of age. The World Health Organization estimates that by the year 2020, depression will be the second most prevalent cause of disability for people of all ages.

People with depression will not necessarily experience the same symptoms. Common symptoms of depressive disorders are:

Persistent sad, anxious, or "empty" feelings
Feelings of hopelessness and/or pessimism
Feelings of guilt, worthlessness, and/or helplessness
Irritability, restlessness
Loss of interest in activities or hobbies once pleasurable, including sex
Fatigue and decreased energy
Difficulty concentrating, remembering details, and making decisions
Insomnia, early-morning wakefulness, or excessive sleeping
Overeating or appetite loss
Thoughts of suicide, suicide attempts
Persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.

The number, intensity, duration, and frequency of these symptoms will vary from person to person. When someone has five or more of these symptoms for a period of two weeks or more they may be diagnosed with depression. ("What are the signs and symptoms of depression?" NIMH)

Although treatments for the various forms of depression are available, only half the people who suffer from depression ever seek help.

Antidepressants in the News

Early this year, the effectiveness of antidepressant medications made headlines when The Journal of the American Medical Society (JAMA) published a meta-analysis* titled "Antidepressant Drug Effects and Depression Severity." This report concluded, "The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial." This report has received some criticism because it involved only six studies and only two antidepressant drugs. (Fournier)

On a related note, the National Institute of Mental Health funded the "Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study" which involved 2,876 participants and was conducted over a six-year period (initial results were released in January 2006). Regarding some of the findings of the STAR*D study, Charles B. Nemeroff, M.D., Ph.D. wrote, "... clinical trials have revealed a disappointing rate of remission (in the range of approximately 28% - 45%) in acute monotherapy [treatment with a single drug] trials with SSRIs [Selective Serotonin Reuptake Inhibitors] and SNRIs [Serotonin-Norepinephrine Reuptake Inhibitors]. These results indicate that more than half of depressed patients exhibit either no benefit or only a partial benefit after an adequate trial with the most commonly prescribed agents."

Commenting on the JAMA report published early this year, Peter Roy-Byrne, M.D. wrote, "... this report may create a storm of controversy with few practical solutions... We know patients should pursue nonpharmacologic treatments, but until these are more accessible, things may not change very much." He also adds, "... with so few specialists in effective psychotherapy techniques, access to nonpharmacologic depression treatments is extremely poor in primary care, where most depressed patients are seen."

Massage Therapy -- Benefits Similar in Magnitude to those of Psychotherapy?

In March 2010, the Journal of Clinical Psychiatry published the article "Treatment Effects of Massage Therapy in Depressed People: A Meta-Analysis." The report concluded, "Massage therapy is significantly associated with alleviated depressive symptoms." Studies included in this meta-analysis found that massage therapy had its strongest effects on recipients immediately after their treatment, when recipients experienced a reduction in distress, anxiety, depression, diastolic blood pressure, and cortisol. When multiple sessions of massage therapy were administered, the average recipients within these studies experienced a reduction in depression that was greater than 73% of comparison group participants. The report notes, "... some experts hypothesize that a regular massage therapy schedule may be necessary to maintain the positive effects, while others suggest further research to investigate the persistence of effects after a series of sessions." (Hou)

An even larger, more comprehension meta-analysis concerning the effects massage therapy was conducted at the University of Illinois at Urbana-Champaign. This meta-analysis was drawn from 37 studies to look at the effectiveness of massage therapy on a number of conditions including anxiety, pain, cortisol levels, blood pressure, heart rate, and depression. The report states, "Reductions of trait anxiety and depression were MT's [massage therapy's] largest effects, with a course of treatment providing benefits similar in magnitude to those of psychotherapy." This assertion was based on the comparison of percentages of positive outcomes for participants receiving massage therapy (found in this meta-analysis) and percentages of positive outcomes found in meta-analyses that examined the effectiveness of psychotherapy for the treatment of depression. (Moyer)

Although there are numerous theories to explain the effects of massage therapy, the authors of "A Meta-Analysis of Massage Therapy Research" feel the results of their findings suggest that massage therapy's effect on depression may be due to its influence on body chemistry (such as increasing levels of serotonin -- a neurotransmitter that has an important role in depression and many other behaviors and physiological functions). Another theory they put forth (which has not yet been studied) is that massage therapy treatment and psychotherapy treatment "... may be more similar than previously considered." The authors state, "Substantial evidence suggests that the considerable efficaciousness of psychotherapy results not from any specific ingredient of treatment, but rather from the factors all forms of psychotherapy share... a client who has positive expectations for treatment, a therapist who is warm and has positive regard for the client, and the development of an alliance between the therapist and client..." These same factors can also be applied to massage therapy, though the authors do not suggest that massage therapy's effects are entirely psychological. (Moyer)

Exercise -- a Powerful Intervention for Clinical Depression

In their book, Exercise for Mood and Anxiety Disorders, Michael W. Otto, Ph.D. and Jasper A.J. Smits, Ph.D. state, "... studies show that a program of exercise can be used to treat depression and achieve results that rival those provided by the use of antidepressant medication or psychotherapy." One of these studies concludes, "The meta-analysis of studies of individuals with depression yielded a very large effect size, showing that exercise can be a powerful intervention for clinical depression." (Stathopoulou)

Studies have shown that exercise produces changes of activity in the system of nerve cells that uses serotonin as their neurotransmitter (the same system that is targeted by many antidepressant medications). Exercise may also have the effect of normalizing disrupted sleep cycles (which are often experienced by people with depression).

For specifics on how much exercise is needed to help mood and anxiety disorders, Otto and Smits recommend aerobic activity in sessions of at least 25 minutes, performed 3 to 5 days a week. They caution to start out slowly, allowing yourself several weeks to reach the recommended levels of activity.

Otto and Smits advise, "Using exercise to help manage mood and anxiety disorders does not mean you should ignore other treatment options... Exercise can be considered as a complement to these approaches [psychotherapy and medications] or can be tried on its own. If you don't achieve the results you desire with this [exercise] program, a consultation to consider other treatment approaches is strongly recommended." They also recommend having a medical evaluation with your physician before you embark on any exercise program.

Other Possibilities

In researching additional strategies for depression, I found numerous other treatment theories that may augment one's approach to dealing with depression. A number of these involved diet, such as the role of essential fatty acids (especially omega 3 found in oily fishes), deficiencies in certain trace elements, alcohol consumption, and probiotics. I have not included these approaches because I did not find enough conclusive evidence to support these theories or the specific dietary supplements needed were not easily accessible to the general public. You may wish to research the effects of diet on depression to see if there are theories or approaches that interest you.

In Closing

In no way am I encouraging anyone to discontinue any pharmaceutical or psychotherapy treatments they are currently receiving for depression. Because the nature and causes of depression are so complex and vary from person to person, different treatment approaches will have different results for each individual. I would encourage people to educate themselves, explore additional approaches, monitor the results, and see what works for them.

Notes

* A "meta-analysis" is a quantitative statistical analysis that is applied to separate but similar experiments of different and usually independent researchers and that involves pooling the data and using the pooled data to test the effectiveness of the results. (Merriam-Webster's Medical Dictionary)

Additional Resources

National Instititue of Mental Health
http://www.nimh.nih.gov/health/topics/depression/index.shtml
http://www.nlm.nih.gov/medlineplus/depression.html

Works Cited or Used as Source Material

Fournier, J.C., DeRubueis, R.J., Hollon, S.D., Dimidjian, S., Amsterdam, J.D., Shelton, R.C., Fawcett, J. "Antidepressant Drug Effects and Depression Severity." Journal of American Medical Association 303.1 (Jan. 2010): 5 May 2010 http://jama.ama-assn.org/cgi/content/short/303/1/47.

Hou, W., Chiang, P., Hsu, T., Chiu, S. Yen, Y. "Treatment Effects of Massage Therapy in Depressed People: A Meta-Analysis." Journal of Clinical Psychiatry (Mar. 2010): 5 May 2010 http://article.psychiatrist.com/dao_1-login.asp?ID=10006792&RSID=32284472078530.

Moyer, C., Rounds, J., Hannum, J. "A Meta-Analysis of Massage Therapy Research." Psychological Bulletin 130.1 (2004): 5 May 2010 http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&term=130[volume]%20AND%201[issue]%20AND%203[page]%20AND%202004[pdat].

Nemeroff, Charles B. "Recent Findings in the Pathophysiology of Depression." Focus 6:3-14 (Winter 2008): 5 May 2010 http://focus.psychiatryonline.org/cgi/content/full/6/1/3.

"The Numbers Count: Mental Disorders in America," National Institute of Mental Health 30 Apr. 2010. National Institute of Health. 1 May 2010 http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml.

Otto, M.W., Smits, J.A.J. Exercise for Mood and Anxiety Disorders: Workbook. Oxford: Oxford University Press, 2009.

Roy-Byrne, Peter. "Depression Level and Suitability of Drug Treatment." Journal Watch - Psychiatry 16.3 (Mar. 2010): 5 May 2010 http://psychiatry.jwatch.org/cgi/content/full/2010/201/1.

Stathopoulou, G., Powers, M.B., Berry, A.C., Smits, J.A., Otto, M.W. "Exercise Interventions for Mental Health: A Quantitative and Qualitative Review." Clinical Psychology: Science and Practice 13.2 (May 2006): 6 May 2010 http://www3.interscience.wiley.com/journal/118574385/abstract.

U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Rockville, MD. National Healthcare Quality Report. December 2003 http://www.ahrq.gov/qual/nhqr03/nhqr2003.pdf.

Werner, Ruth. A Massage Therapist's Guide to Pathology. 3rd ed. Philadelphia: Lippincott, 2005

"What are the signs and symptoms of depression?", National Institute of Mental Health 30 Jan. 2009. National Institute of Health. 1 May 2010. http://www.nimh.nih.gov/health/publications/depression/what-are-the-signs-and-symptoms-of-depression.shtml".