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ALTERNATIVETHERAPIESjulaug2011VOL.17NO.427AnEvidence-basedIntegrativeCAMModelforDepressioncurrentlyinconclusiveregardingspeciEcgeneticpolymorphisms.11Recenthypothesessuggestthatgenesrelatedtoneuroprotectivetoxictrophicprocessesandtotheoveractivationofthehypothal-micpituitaryadrenalaxisHPAaxismaybeinvolvedinpatho-genesisofMDD.11CurrentevidencesuggeststhattheprimaryriskfactorsinvolvedinMDDareacomplexinterplayinvolvinggenet-icsandexposuretodepressogeniclifeevents.911Earlylifeeventsorproximalstressfuleventsincreasetheriskofanepisodewithtwinstudiesprovidingevidenceoftheeffectofenvironmentalstressorsondepression.12Peoplewithrecurrentdepressiveepisodesandayoungageatonsetpresentwiththegreatestfamilialrisk.13Protectivefactorsareconsideredtobegoodgeneticsbalancedpositivecognitionshealthyinterpersonalrelationsandsocialsupportandspirituality.114CurrentmedicaltreatmentsforMDDprimarilyinvolvesyn-theticantidepressantsegtricyclicsmonoamineoxidaseinhibi-torsMAOIsselectiveserotoninreuptakeinhibitorsSSRIsandpsychologicalinterventionsegcognitivebehavioraltherapyCBTinterpersonaltherapyIPTbehavioraltherapyBT.15MedicaltreatmentguidelinesusuallyinvolveoptionssuchasprovidingcounselingCBTorIPTformilddepressionantide-pressantsandorCBTformoderatedepressionandantidepres-santsandelectroconvulsivetherapyECTandpossiblyhospitaliAationforseveredepression.1617Amoreintegrativemodelconcerningetiologyandtreat-mentofdepressionhasbeenproposedthebiopsychosocialmodelwhichviewsthecausationofdepressionasbeingmulti-factorialwithmanyinterrelatedinfluencesconsideredtobeinvolvedinadepressivedisorderFigure1.18Geneticsandbio-chemistrybiologicalcognitionsandpersonalitytraitspsycho-logicalenvironmentalfactorsenvironmentalandsocialinteractionssociologicalallaffectthelevelofapersonx19svulner-abilitytodevelopingadepressivedisorderwhichiscommonlytriggeredbychronicoracutestressors.ThebiopsychosocialmodelsuitsthecomplementaryandalternativemedicineCAMparadigmwhichtreatspatientsfromax1cwholesystemsx1dapproachregardsallbiologicalsystemsasinterrelatedandFuid-icandviewsdiseasecausationasbeingprofoundlyinFuencedbyacomplexofpsycho-physio-sociologicalfactors.19Astheevidenceindicatesthatdepressioniscommonlyinade-quatelytreated20andthemainstreammedicalapproachofdrugtherapyappearstoonlyachieveErsttreatmentremissioninapprox-imatelyone-thirdofpatients21improvedtreatmentmethodsareurgentlyneeded.Strategiestoimproveoutcomesthathavesupport-iveevidenceincludecombinationapproachessuchascombiningdifferentpharmacotherapiesandorpsychologicaltechniques2223stepped-caremodels24collaborativecrossdisciplinaryapproaches25andenhancedcasemanagement.17Thoughimprovedoutcomesaregenerallyfoundthefinancialcostismuchhigherwiththeseapproachesandinthecaseofaugmentationapproachesaddingadditionalpharmacotherapiestoantidepressantsremissionratesarenotsignificantlyimproved.20Althoughinitialcostsmaybehigherwhensuchintegrativeapproachesareusedthesemaybeoffsetbyfuturesavingsfromincreasedworkproductivityandcom-mensuratelowerdemandsonhealthresources.2426Anintegrativeclinicallyfocusedbiopsychosocialmodeldevelopedfromevidence-basedinterventionsalsomayachievebetteroutcomesthanmono-therapyalone.AsreflectedinCAMpracticeavarietyofinterventionsarecommonlyusedinanintegrativemannertotreathealthconditions.Whereasindividualinterventionsmayhaveevi-denceasmonotherapiescombinationsoftreatmentsaddressingthecausesofdepressedmoodfromtheperspectiveofthebiopsy-chosocialmodelmaybesynergisticallymoreeffectiveinachievinginitialtreatmentresponseandimprovinglong-termremissionofdepressedmood.Thefocusofthisarticleistodetailthecurrentnonpharma-cologicinterventionsforwhichthereisevidenceinthetreatmentofdepressionwithinaclinicalmodel.Pharmaceuticalantidepres-santsarenotevaluatedinthisarticleseeCiprianietal2007andArrolletal2008forreviews.2728AsarecentreviewbyFournieretal2010intheJournalx0ofx0thex0Americanx0Medicalx0AssociationdetailsemergingevidencehasrevealedthatsyntheticantidepressantssuchasSSRIstricyclicsandMAOIsmayhaveaweakeffectagainstdepressivesymptomsinpeoplewithmilderformsofdepression.29Furthermoreclinicalguidelinesoftendonx19tendorseantidepressantsastheprimaryErst-lineinterven-tionformilderformsofMDDandoftenareregardedaswidelyoverprescribed.30ThesedrugsarehoweverefEcaciousagainstmoreseveredepressedmood.Duetothistheproposedmodeloutlinedinthisarticleismoreapplicablefortreatingmild-moderatedepressionorasanadjuvantapproachwithpharmaco-therapiesinmoreseverecasesofMDD.ThoughintegrativepsychiatristsJamesLake31andRobertzuess3233havedevelopedandadvocatedintegrativeclinicalmodelsasearchofthejournalliteraturerevealedonlyonepeer-reviewedpublishedpaperonanintegrativeCAM-basedmodelPoorsocialsupportNeurochemicaldysregulationSedentarylifestyleSubstanceoralcoholabuseStressfullifeeventPoornutritionNegativecognitionsandaffectGeneticsandfamilialfactorsDepressionFIGURE1EtiologicalFactorsandDepression