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ALTERNATIVETHERAPIESjulaug2011VOL.17NO.431AnEvidence-basedIntegrativeCAMModelforDepressionandtheenhancementofcellmembraneHuidity.50-52TheuseofacupuncturetotreatdepressivedisordershasbeendocumentedintraditionalChinesemedicaltexts.53Reviewsandmeta-analysesofsmallrandomizedcontrolledtrialsindicatethatacupuncturecansigniGcantlyreducetheseverityofdepres-sionontheHamiltonDepressionRatingScaleHDRS54orBeckDepressionInventoryBDI.55SignificanteffectsonreducingdepressionoccurredcomparedtononspeciGcorshamacupunc-tureormassagewhileequivocalefGcacycomparedtotricyclicantidepressantsalsowasrevealed.Itshouldbenotedthatnotallstudiesarepositiveandthatthepoormethodologyusedinmanystudiesprecludeacupunctureashavingahigherlevelofevi-dence.FurtherduetomethodologicalchallengesegblindingandastrongplaceboeffectfromshamacupuncturepointsitoftenisdifGculttodrawdeGnitiveconclusions.Acupuncturehasbeendocumentedtointeractwithopioidpathwaysandsub-stancesthatmodulatethesepathwayshavebeenshowntohaveantidepressantactivity.56Otherpossibleantidepressantmecha-nismsofactionincludeincreasedreleaseofserotoninandnor-epinephrineandcortisolmodulation.57Lifestyle.Generallifestyleadviceshouldfocusonencourag-ingabalancebetweenmeaningfulworkadequaterestandsleepmoderateexercisepositivesocialinteractionandpleasurablehobbies.Dietaryprogramsdesignedtotreatdepressionhavenotbeenrigorouslyevaluatedtodatehowevercross-sectionalstudiesbyAkbaralyetal58andJackaetal59haverevealedthatahealthydietrichincomplexcarbohydratesfruitsandvegetablesandleanmeatsandlowinprocessedfoodsreducestheriskofdepres-sion.AlthoughevidencesupportingspeciGcnutritionaladviceiscurrentlylackingabasicbalanceddietincludingfoodsrichinaspectrumofnutrientscanberecommended.Amongimportantnutrientsforneurochemicalfunctionadequatefolateconsump-tionisvital.Folateisinvolvedwiththemethylationpathwaysinthex1cone-carbonx1dcycleresponsibleforthemetabolismandsyn-thesisorvariousmonoaminesandnotabilityinvolvedwiththesynthesisofSAMe.41HigherratesoffolatedeGciencyhavebeenfoundinpeoplewithdepressivedisorderscomparedtotheirnon-depressedcounterparts.6061Foodsrichinomega-3L-tryptophanBandCvitaminszincandmagnesiumarerecommendedastheyarenecessaryfortheproductionofneurotransmittersandforneuronalcommunication.62TheseincludewholegrainszincmagnesiumBvitaminsleanmeatzincmagnesiumproteinegtryptophandeep-seaGshessentialfattyacidsgreenleafyvege-tablesvitaminCfolatecoloredberriesvitaminCantioxidantphenoliccompoundsandnutsmonounsaturatedfatsvitaminEzincmagnesium.63AstrongcausallinkbetweensubstanceoralcoholabusedependenceandMDDhasbeenestablishedanddepressioninturnincreasestheriskofsubstanceandalcoholmisuse.6465Insuchcasessupportiveadviceoncurtailingtheuseofalcoholorrecreationaldrugsandorreferraltoanappropriatetreatmentprogramcanbeprovided.Increasingphysicalactivityisadvisedifthepatienthasasedentarylifestyleandisespeciallyindicatedincasesofobesi-ty.Associationsbetweengreaterphysicalactivityandimprovedmoodandwell-beinghavebeendocumented.6667AsisindicatedinTable1manyRCTshaverevealedthatexerciseiseffectiveinreducingsymptomsofdepressionwithmeta-analysesofclini-calstudiesofexerciseshowingasigniGcanteffectinfavorofphysicalexercisecomparedwithcontrolconditionsroutinecarewaitlistmeditationrelaxationorlow-intensityexercise.68EvidencealsoexistsfortheuseofyogatoreducedepressionandimprovemoodwithseveralRCTsrevealingmostlypositiveresults.69Themethodologieswerehowevercommonlypoorlyreportedandthereforetheseinterventionscannotcurrentlybeconsideredasx1cgold-standardx1dgradeAx13levelevidence.Thebiologicalantidepressanteffectsofexer-ciseincludeabeneGcialmodulationoftheHPA-axisincreasedexpressionof5-HTPandincreasedlevelsofcirculatingtestos-teronewhichmayhaveaprotectiveeffectagainstdepression.6768TABLE1MajorEvidenceofNonpharmaceuticalTreatmentsofDepressioncontinuedInterventionMechanismsx0ofx0ActionKeyx0EvidenceSummaryx0ofx0x0Resultsx0Evidencex0Levelx0CommentPsychologicalx0Techniquesx0MajorInterventionsCognitivebehavioraltherapyInterpersonalskillsPsychoeducationEnhancesneuronalplasticitymodulationoflimbicbraincenteractivityincreasedsero-toninandGABAergiceffectsbrainimagingshowspost-treatmentactivityintemporallobehippocampalandcingu-latedareasMeta-analysesandreviewsCuijpers2008118Bell200977Donker200970Wolf200817RCTsconsistentlyshowpsy-chologicalinterventionstobeeffectiveinreducingdepres-sionevidencesupportsthelongertermeffectscarryonaftertreatmentisceasedAImportantinterventionfordepressionwithapsycho-logicalorexternallifestres-sortrigger.ReferralmayberequiredtoqualiGedpsy-chologistsinhigherlevelsofdepressionorpronounceddistressLevelAmeta-analysesor2ormoreRCTSwithpositiveresultsLevelBmorethan2RCTSmainlypositiveresultsLevelCnonreplicatedRCTormixedevidencefromseveralRCTs.AbbreviationsHPAhypothalamic-pituitary-adrenalSJWStJohnx19swortMDDmajordepressivedisorderRCTrandomizedcontrolledtrialHDRSHamiltonRatingScaleforDepressionNMDAN-Methyl-D-aspartateGABA-AminobutyricacidCVDcardiovasculardisease5-HTP5-hydroxytrypto-phanMAOImonoamineoxidaseinhibitorsSSRIselectiveserotoninreuptakeinhibitorTCAtricyclicantidepressant.Seearticletextforreferences.Firstauthorofstudyincluded.