Table 5: APA’s Guidelines for the Treatment of Depression Modality
Recommendation
For adults with depression for whom psychotherapy or pharmacotherapy is either ineffective or unacceptable, the panel suggests the following options: If neither is acceptable or available, the panel suggests:
• Exercise monotherapy • St. John’s wort monotherapy
Conditional recommendation for use
• Bright light therapy • Yoga • If considering adjunctive
Conditional recommendation for use
treatments, the panel suggests adding acupuncture to antidepressant medication.
There is insufficient evidence to recommend:
• Tai Chi • Acupuncture monotherapy • Combination of second-
Insufficient evidence for a recommendation (p. 19)
generation antidepressants and omega-3 fatty acids
• S-adenosyl methionine monotherapy • Combination of second-
generation antidepressants and exercise
From American Psychological Association’s “Guideline for the Treatment of Depression” (2019, p. 15). Exercise
With a symptom remission rate 22% than usual treatment (Murri et al., 2019), exercise has been found to be a strong evidence-based component when integrated into a holistic treatment plan for people experiencing symptoms of depression. When treatment planning, Heissel et al.’s (2023) research recommends supervised and group aerobic exercise of moderate intensity. St. John’s Wort Some clients may want to use herbal medications to treat depression. The use of St. John’s wort has a long history, especially in Europe, to treat mild depression. However, the National Center for Complementary and Integrative Health (2020) warns consumers that research supporting the use of St. John’s wort for treatment of depression is not conclusive and that it may have serious side effects. St. John’s wort has demonstrated greater effectiveness than placebo and effectiveness similar to standard antidepressant medication for people experiencing mild and moderate depression. It may also be helpful for menopausal and somatic symptoms. Research supports safety for usage up to 12 weeks. Research is yet inconclusive for treatment beyond 12 weeks or treatment of severe depressive symptoms. Side effects of using St. John’s wort are increased sensitivity to light, anxiety, dry mouth, dizziness, gastrointestinal problems, fatigue, headache, and sexual dysfunction. Of note, St. John’s wort may interfere with the effectiveness of other medications, including critical medications such as cyclosporine (prevents rejection of transplanted organs), birth control pills, blood thinners, statins, and some heart, HIV, and cancer medications. Using St. John’s wort as an adjunctive treatment to antidepressant medication may increase the risk of serotonin syndrome (National Center for Complementary and Integrative Health, 2020). Sunlight Typically considered for depressive symptoms triggered by shorter, darker days, including seasonal affective disorder (SAD), meta-analyses support at least a modest benefit of light therapy for the treatment of nonseasonal depression when compared to placebo (Pjrek et al., 2020). Exposure to sunlight has been found to lessen symptoms of depression through several modes of action, including the production of beta-endorphins; anchoring the circadian cycle; production of anti-inflammatory protein cytokine, vitamin
Exercise has been found to be generally helpful for the treatment of mild to moderate depression when compared to medication or psychotherapy. Exercise for people with more severe symptoms, as well as dysthymia, atypical depression, seasonal depression, bipolar depression, postnatal depression, and premenstrual dysphoric disorder (PMDD) is also effective (Shaphe & Chahal, 2020). Exercise is less likely to be helpful for those with suicidal ideation, psychosis, mania, hospitalizations, surgery, or changes in antidepressant medication within the last month, and/or medical issues that complicate or limit movement (Kinser et al., 2013). Although we may think of the “runner’s high” or benefits on sleep (Harvard Health, 2020), biological, psychosocial, and environmental models offer insight into the multifaceted impact of depression on exercise (Shaphe & Chahal, 2020). Biological effects of exercise include the increase of norepinephrine, serotonin, brain-derived neurotrophic factor (BDNF), endorphins, endocannabinoids, and the decrease of cortisol, TNF-α, IL-1ß, IL-6, adrenocorticotropic hormone (ACTH). The psychosocial model looks at the impact of exercise on depressive symptoms mediated by the positive factors of a sense of mastery, social interaction, and distraction. Exercise may be most beneficial for people with mild to moderate depression under the age of 20 or over the age of 40, females, and people with higher educational and physical well-being status with less physical training experience (Shaphe & Chahal, 2020). Generally considered an adjunct to traditional antidepressant therapies, recent research supported exercise as helpful as antidepressant medication, with fewer side effects and positive health benefits. Research by Verhoeven et al. (2023) compared the effects of running therapy to those taking antidepressant medication (escitalopram) for a 16-week trial. People in the running group two to three times a week in 45-minute supervised groups. Results supported the success of both antidepressant medication and running on symptoms of depression and anxiety (both at approximately 44% improvement), while the running group also saw improvements in weight, waist size, and blood pressure (Verhoeven et al., 2023).
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