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Systematic review
Non-pharmacological treatment of depression: a systematic review and evidence map
  1. Wigdan H Farah1,2,3,
  2. Mouaz Alsawas1,2,3,
  3. Maria Mainou1,
  4. Fares Alahdab1,2,3,
  5. Magdoleen H Farah1,
  6. Ahmed T Ahmed1,2,4,
  7. Essa A Mohamed5,
  8. Jehad Almasri1,2,3,
  9. Michael R Gionfriddo2,6,
  10. Ana Castaneda-Guarderas7,
  11. Khaled Mohammed1,2,3,
  12. Zhen Wang1,2,
  13. Noor Asi1,2,3,
  14. Craig N Sawchuk4,
  15. Mark D Williams4,
  16. Larry J Prokop8,
  17. M Hassan Murad1,2,3,
  18. Annie LeBlanc2
  1. 1Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
  3. 3Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota, USA
  4. 4Division of Integrated Behavioral Health, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
  5. 5Mayo Graduate School, Mayo Clinic, Rochester, Minnesota, USA
  6. 6Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Forty Fort, Pennsylvania, USA
  7. 7Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
  8. 8Mayo Clinic Libraries, Mayo Clinic, Rochester, Pennsylvania, USA
  1. Correspondence to : Dr M Hassan Murad
    , Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; murad.mohammad{at}mayo.edu

Extract

Background The comparative effectiveness of non-pharmacological treatments of depression remains unclear.

Methods We conducted an overview of systematic reviews to identify randomised controlled trials (RCTs) that compared the efficacy and adverse effects of non-pharmacological treatments of depression. We searched multiple electronic databases through February 2016 without language restrictions. Pairs of reviewers determined eligibility, extracted data and assessed risk of bias. Meta-analyses were conducted when appropriate.

Result We included 367 RCTs enrolling ∼20 000 patients treated with 11 treatments leading to 17 unique head-to-head comparisons. Cognitive behavioural therapy, naturopathic therapy, biological interventions and physical activity interventions reduced depression severity as measured using standardised scales. However, the relative efficacy among these non-pharmacological interventions was lacking. The effect of these interventions on clinical response and remission was unclear. Adverse events were lower than antidepressants.

Limitation The quality of evidence was low to moderate due to inconsistency and unclear or high risk of bias, limiting our confidence in findings.

Conclusions Non-pharmacological therapies of depression reduce depression symptoms and should be considered along with antidepressant therapy for the treatment of mild-to-severe depression. A shared decision-making approach is needed to choose between non-pharmacological therapies based on values, preferences, clinical and social context.

https://doi.org/10.1136/ebmed-2016-110522

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    Extract

    Background The comparative effectiveness of non-pharmacological treatments of depression remains unclear.

    Methods We conducted an overview of systematic reviews to identify randomised controlled trials (RCTs) that compared the efficacy and adverse effects of non-pharmacological treatments of depression. We searched multiple electronic databases through February 2016 without language restrictions. Pairs of reviewers determined eligibility, extracted data and assessed risk of bias. Meta-analyses were conducted when appropriate.

    Result We included 367 RCTs enrolling ∼20 000 patients treated with 11 treatments leading to 17 unique head-to-head comparisons. Cognitive behavioural therapy, naturopathic therapy, biological interventions and physical activity interventions reduced depression severity as measured using standardised scales. However, the relative efficacy among these non-pharmacological interventions was lacking. The effect of these interventions on clinical response and remission was unclear. Adverse events were lower than antidepressants.

    Limitation The quality of evidence was low to moderate due to inconsistency and unclear or high risk of bias, limiting our confidence in findings.

    Conclusions Non-pharmacological therapies of depression reduce depression symptoms and should be considered along with antidepressant therapy for the treatment of mild-to-severe depression. A shared decision-making approach is needed to choose between non-pharmacological therapies based on values, preferences, clinical and social context.

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    Footnotes

    • Contributors WHF screened literature, data extraction of the identified studies, carried out data cleaning and statistical analysis and drafted the manuscript. MA, MM and FA screened and data extraction of the identified studies, carried out data cleaning and approved the final version of the manuscript. MHF, ATA, EAM, JA, MRG, AC-G, KM and NA screened and data extraction of the identified studies and approved the final version of the manuscript. CNS and MDW contributed to clinical expertise to the project and approved the final version. ZW approved the final version of the manuscript and contributed a methodological expertise. LJP approved the final version of the manuscript and designed the search strategy. MHM and AL conceived the idea, wrote the protocol, contributed the methodological expertise and approved the final version of the manuscript.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • ▸ Additional material is published online. To view please visit the journal (http://dx.doi.org/10.1136/ebmed-2016-110522).