Remember the choices Peter was considering for managing his depression and stabilising his mood? He has completed research on exercise, St John's wort and acupuncture. We will use these as examples of evaluating the process.
What is the evidence about acupuncture?
What is acupuncture?
The term "acupuncture" describes a family of procedures involving the stimulation of points on the body using a variety of techniques. The acupuncture technique that has been most often studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation. Practised in China and other Asian countries for thousands of years, acupuncture is one of the key components of traditional Chinese medicine.11
Does acupuncture work?
- There is promising preliminary evidence for acupuncture to assist with mild to moderate depression.18
- The quality of the evidence is low overall meaning the findings cannot be relied on.18
Is acupuncture safe?
Acupuncture can cause some bruising14 but it is considered a very safe treatment with serious side effects being very rare. Peter also has to consider that acupuncture involves seeing a practitioner regularly and paying for these treatments.
What is the evidence about exercise?
What is exercise?
Doing regular physical activity is a good way to help prevent or manage mild depression.19, 20 There are many views on how exercise helps people with depression, but it is not yet known which kind of exercise is best or whether the benefits are lost if exercise is stopped. The benefits that can be attained from exercise depend on the amount of exercise that is undertaken. Most studies showing that exercise was helpful used aerobic exercise (such as running or walking), for at least 30 minutes, three times a week, for at least eight weeks.19, 20 However, more research is needed to work out the best type of exercise, how often and for how long it should be done, and whether it is better in a group or individually.
Does exercise work?
- Evidence suggests physical activity is useful for easing major depression symptoms.19, 20 Exercise activities are recommended for continuation and maintenance of depression treatment.
- An exercise program is best designed and tailored to the individual.
- Exercise has many other important health benefits, including reducing the risk of heart disease and cancer. The current recommendation is at least 30 minutes of moderate intensity physical activity on most, and preferably all, days of the week. However, people with depression may find it difficult to get started or get motivated, or continue to exercise on a long-term basis. Compared with people without depression, those with depression generally have lower fitness levels. Exercise may also change levels of chemicals in the brain, such as serotonin, endorphins and stress hormones.
Is exercise safe?
- This is not widely reported in the studies that have been undertaken, but for those that have reported on safety adverse events were uncommon.
- Peter should have a discussion with his general practitioner before starting any new exercise program.
What is the evidence about St John's wort?
What is St John's wort?
St John's wort is a herbal medicine that is taken orally. It has been used in folk medicine for a long time for a range of indications, including depressive disorders. Today, it is a popular remedy for mild depression. Although St John's wort is a herb, it is still an active treatment that has specific chemical effects which are thought to help depression and are similar to how antidepressants like Prozac work.21
Does St John's wort work?
There have been a lot of research studies.21 Many have found St John's wort to be better than placebo and have similar effects to some medications used to treat mild to moderate depression. It works in a similar way to antidepressants like Prozac.
Is St John's wort safe?
- Common side-effects include dry mouth, dizziness, increased sensitivity to sunlight (photosensitivity), gastrointestinal symptoms and fatigue.
- St John's wort is known to interact with some medications and give risk to negative effects, or reduce the effectiveness of medication. St John's wort should not be used in conjunction with antidepressant medication, and contra-indications can occur with warfarin (a blood thinning agent).22
Peter's evaluation of the evidence
Peter summarises the evidence and his objectives at reducing his periods of depression an0d achieve overall more stable mental health, and to feel more involved with maintaining his health.
There is some evidence acupuncture can reduce depression, it appears safe, but the studies cannot be relied on and there needs to be more research.18
There is evidence to suggest exercise is useful for easing mild depression symptoms, and can be used to help alongside depression treatment for major depression.19, 20
There is evidence St John's wort can help with treating mild to moderate depression, but there can be side effects, and it will interact with the depression medication Peter is taking, and the Wafarin for his blood clot.22
How each person balances the evidence gathered with their personal situation, values and beliefs and objectives is unique. This process may change over the course of an illness. What is important to an individual when first diagnosed may change over time.
Each person also needs to consider how much time, money and energy they are able to commit to their treatment choices.
Some individuals may approach their complementary medicine therapy decision in a very scientific and rational manner, while others may feel more comfortable with gut feeling.
Given the evidence about effectiveness and safety, Peter decides to get a formal exercise program organised. He hopes it will make him feel better but also help with achieving his goal of actively being involved with improving his health. Peter decides against acupuncture at this point in time, and will be interested to read and hear about future research. He decides against St John's wort because of the contra-indications and interaction with the medication he is already taking. He also doesn't want to stop taking his medication in the short term. Peter will inform his general practitioner about his decision to exercise.
Recap: How will you decide?
Working with people you trust, use a careful process that helps you evaluate:
- The evidence you found.
- Your comfort with what is known and not known about a therapy.
- The safety of each choice.
- Your priorities.
- Your beliefs, and personal values.
- Your ability to access and use a therapy, including whether you have the resources to support your need.
Moving forward with your decision
Once you have decided on which choices you would like to use, it is time to take action.
- Create a plan to make it happen:
- Outline what you need to do to put your choice into action.
- Follow up with any people whose help you will need to take action on your decision.
- How much time will you need for your choice?
- Think of barriers and make plans to manage them.
- Monitor your progress.
- Notify the people who need to know about your decision.
This module has presented a step wise process of evaluating all factors that are involved in making a decision, including evidence (finding it, as per Module Three) along with your personal objectives goals and beliefs.
- National Center for Complementary and Integrative Health. Acupuncture. (opens in a new window)
- White AR. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupuncture in Medicine. 2004;22(3):122-133
- Smith CA, Hay PPJ, MacPherson H. Acupuncture for depression. Cochrane Database of Systematic Reviews 2010, (opens in a new window) Issue 1. Art. No.: CD004046. DOI: 10.1002/14651858.CD004046.pub3
- Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, McMurdo M, Mead GE. Exercise for depression. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD004366. DOI: 10.1002/14651858.CD004366.pub6
- Mammen G, Faulkner G. Physical activity and the prevention of depression: a systematic review of prospective studies. American Journal of Preventive Medicine. 2013;45(5):649-57.
- Linde K, Berner MM, Kriston L. St John's wort for major depression. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD000448. DOI: 10.1002/14651858.CD000448. pub3
- Borrelli, F., & Izzo, A. A. Herb–Drug Interactions with St John's Wort (Hypericum perforatum): an Update on Clinical Observations. The AAPS Journal. 2009; 11(4), 710–727.