The SIGN draft guideline day on "Non-pharmacological management of mild to moderate depression" last Wednesday continued with two further presentations in this first section on "Lifestyle and Alternative/Complementary Therapies 1".  After the "grade A" recommendations on exercise and St John's Wort given during the first two presentations (covered in the two previous blog posts), the rest of this section felt a bit of an anticlimax.

Alex McMahon, Head of Mental Health Delivery for the Scottish Government, talked about the possible value of "Lifestyle Changes".  The main message was that currently there is no good evidence from randomized controlled trials showing lifestyle interventions impact on depression.  This is very much an area where "absence of proof does not constitute proof of absence".  Factors like unemployment and addiction are extremely likely to be major contributors to low mood and depression.  They should be tackled where possible.

Rob Durham, Senior Lecturer in Clinical Psychology at Dundee University, then talked about various interventions grouped under the heading "Alternative/Complementary Therapies 1".  The take home message was that there is, as yet, little good quality research backing up the value of any of these complementary medicine approaches to treating depression.  I have two bones to pick with this overview.  The major one is that I think SIGN was over-harsh in their dismissal of light therapy for non-seasonal depression.  I cover this more fully in a paper I've already mentioned (Hawkins 2005b).  In this paper I noted that there had been a meta-analysis entitled "The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence" in the American Journal of Psychiatry in April 2005 (Golden, Gaynes et al. 2005) which concluded " ... analysis of randomized, controlled trials suggests that bright light treatment and dawn simulation for seasonal affective disorder and bright light for nonseasonal depression are efficacious, with effect sizes equivalent to those in most antidepressant pharmacotherapy trials."  A Cochrane Collaboration systematic review published the year before (Tuunainen, Kripke et al. 2004) just looked at the value of bright light treatment for nonseasonal depression and concluded "For patients suffering from non-seasonal depression, bright light therapy offers modest though promising antidepressive efficacy, especially when administered during the first week of treatment, in the morning, and as an adjunctive treatment to sleep deprivation responders." As noted in my 2005 paper there were further relevant studies published since these reviews, and most importantly another systematic review published this year (Even, Schroder et al. 2008) which clearly states "Overall, bright light therapy is an excellent candidate for inclusion into the therapeutic inventory available for the treatment of nonseasonal depression today, as adjuvant therapy to antidepressant medication. Future clinical trials of light therapy should distinguish homogenous subgroups of depressed patients in order to evaluate whether light therapy may eventually be considered as stand-alone treatment for specific subgroups of patients with nonseasonal depression."  With three major systematic reviews coming out in favour of light therapy for the treatment of non-seasonal depression - at least as augmentation for antidepressants - I would ask SIGN to review their judgement that the research studies involved are too poor on which to base any recommendation.

The other, smaller, bone I would pick with SIGN over this section is the absence of any mention of sleep interventions.  This could be seen as falling into two areas.  One is paying attention to the well known and complex inter-relationships between sleep and depression with insomnia being, at different times, " ... a precursor, symptom, residual symptom, or side effect of depression or its treatment" (Fava 2004; Buysse, Angst et al. 2008).  Treatment with sleeping pills may well simply increase the risk of precipitating depression (Kripke 2007).  Psychotherapeutic approaches to insomnia can however be more helpful (Manber, Edinger et al. 2008).  Possibly some brief mention of this field as being of potential interest might be worthwhile.  The other sleep area that might be worth noting is the use of therapeutic sleep deprivation (sometimes called "wake therapy").  In an article published in 2005 (Hawkins 2005a), I wrote "Following case observations by Schulte in the 1960's, Pflug and Tolle were the first to publish stronger evidence for sleep deprivation's possible value (Pflug and Tolle 1971).  Since then a considerable amount of research has been done on this topic particularly in mainland Europe.  A simple Medline search combining ‘depressive disorder' and ‘sleep deprivation' as keywords yields well over 300 articles.  The research tends to involve small numbers of subjects and is often of quite poor design, but it consistently highlights the value of this approach.  Sleep deprivation is the only form of antidepressant therapy that has repeatedly been shown to be able to produce a next-day response (Ringel and Szuba 2001).   If someone with depression avoids sleeping for a whole night they have approximately a 50% chance of feeling at least 30% less depressed the next day (Giedke and Schwarzler 2002).  Interestingly, if non-responders try the procedure again they may respond at a second or further attempt (Wiegand, Lauer et al. 2001).  For many people suffering from depression and associated sleep difficulties, the request to avoid sleeping for a night seems rather crazy.  Although probably not quite as effective as total sleep deprivation (TSD) (Giedke, Klingberg et al. 2003), partial sleep deprivation later in the night (LPSD) may well be better tolerated and seems more effective than sleep deprivation earlier in the night (EPSD).  A major problem with sleep deprivation is that of the 40 to 60% who feel a good deal better the next day, 80% or more will relapse after sleeping.  There has therefore understandably been a number of research studies exploring ways of maintaining the mood improvement achievable through this ‘wake therapy'.  Lead candidates are only going back to a standard night's sleep times in small increments, adding bright light therapy, and using wake therapy in conjunction with medication."  The quality of the research studies tends to be fairly poor, but searching PubMed today with the keywords "depressive disorder" AND "sleep deprivation" pulls up 357 citations - many are irrelevant to sleep deprivation therapy, but many are relevant.  Again, I think brief mention that this field is of potential interest seems sensible in a major review of the literature on non-pharmacological approaches to depression management.    

Buysse, D. J., J. Angst, et al. (2008). "Prevalence, course, and comorbidity of insomnia and depression in young adults." Sleep 31(4): 473-80.  [PubMed]
 Even, C., C. M. Schroder, et al. (2008). "Efficacy of light therapy in nonseasonal depression: a systematic review." J Affect Disord 108(1-2): 11-23.  [PubMed]
Fava, M. (2004). "Daytime sleepiness and insomnia as correlates of depression." J Clin Psychiatry 65 Suppl 16: 27-32.  [PubMed] 
Giedke, H., S. Klingberg, et al. (2003). "Direct comparison of total sleep deprivation and late partial sleep deprivation in the treatment of major depression." J Affect Disord 76(1-3): 85-93. [PubMed]
 Golden, R. N., B. N. Gaynes, et al. (2005). "The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence." Am J Psychiatry 162(4): 656-62.  [PubMed]
 Hawkins, J. (2005a). "Alternative treatments for depression 1: exercise and 'wake' therapy." Journal of Holistic Healthcare 2(2): 9-15.  [Free Full Text]
Hawkins, J. (2005b). "Alternative treatments for depression 2: light and St. John's wort." Journal of Holistic Healthcare 2(4): 19-26.  [Free Full Text]
Kripke, D. F. (2007). "Greater incidence of depression with hypnotic use than with placebo." BMC Psychiatry 7: 42.  [PubMed] 
Manber, R., J. D. Edinger, et al. (2008). "Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia." Sleep 31(4): 489-95.  [PubMed]
 Pflug, B. and R. Tolle (1971). "Disturbance of the 24-hour rhythm in endogenous depression and the treatment of endogenous depression by sleep deprivation." Int Pharmacopsychiatry 6(3): 187-96.   [PubMed]
 Ringel, B. L. and M. P. Szuba (2001). "Potential mechanisms of the sleep therapies for depression." Depress Anxiety 14(1): 29-36.  [PubMed] 
Tuunainen, A., D. F. Kripke, et al. (2004). "Light therapy for non-seasonal depression." Cochrane Database Syst Rev(2): CD004050.  [PubMed] 
Wiegand, M. H., C. J. Lauer, et al. (2001). "Patterns of response to repeated total sleep deprivations in depression." J Affect Disord 64(2-3): 257-60.  [PubMed]