Peter is aged 67. He is married, has two sons and three grandchildren. He has recently retired from a long and demanding career in teaching. Over recent years he was diagnosed with mild to moderate depression. He consulted with his general practitioner who prescribed an anti-depressant called Prozac or fluoxetine. His depression is quite well managed; he will have months of no depression and then all of a sudden symptoms re-appear. Last year he developed a blood clot in his leg, and was prescribed a blood thinner or anti-coagulant called Warfarin. He is now retired and has more time on his hands. Peter is keen to focus on improving his health and is considering other ways to manage his depression and stabilise his mood.
Defining your situation clarifies the overall context of your decision. What are the key facts, important information, and concerns that are relevant to your decision? What questions do you have about your situation?
Peter has discussed his thoughts with his wife and sons. He is also reading some articles about other ways to help manage his depression.
Sometimes you have specific options to consider or you may have different options to choose from. Other times, you may want to explore what your choices could be based on your own goals.
Think about the alternatives, strategies and options relating to what you could do. Start to gather the information you will need to evaluate your choices. At this stage it is useful to consider:
- What do you already know about your healthcare choices?
- What questions do you have about your healthcare choices?
One of your options is to consider continuing with your depression medication. You do not have to use complementary medicine.
What are Peter's choices?
From Peter's readings and advice from his family, Peter knows he has several choices. Peter believes that St John's Wort, exercise or acupuncture may be good for his situation.
When making decisions about complementary medicine, it is important to understand what you hope to achieve by using each therapy.
Key questions to ask when clarifying your objectives:
- Why do you want to use complementary medicine?
- What outcome are you hoping to achieve? For example improving your mood.
- What is the objective of your choice at this point in time?
To make sure your objectives are clear, consider using SMART to develop them.
- Specific: make them precise. What exactly does it look like?
- Measureable: how would you know you achieved your goal?
- Attainable: is your goal realistic and possible?
- Relevant: is this an important issue for you to focus on?
- Timebound: give your objective a timeframe.
Peter has two specific objectives for using complementary medicine:
- Reduce his periods of depression and achieve more stable mental health overall.
- To feel more involved with maintaining his health and wellbeing.
People around you like family, friends and health professionals can help you:
- Find or provide additional information about your healthcare choices.
- Discuss your options and goals.
- Support you in making your decision.
What are their roles and responsibilities? Think about whether:
- They should just be informed of your decision or if you want their support in implementing it.
- You want their input when analysing the choices, but not in making the decision.
- You want particular individuals to be involved in the decision you are currently facing.
Who are Peter's people that will be involved in Peter's decision-making?
- General practitioner
- Complementary medicine or exercise practitioner
- Close friends
How well does each choice you are considering achieve your healthcare goals? Asking the following questions will help:
- What is the current evidence and is this complementary therapy relevant to me?
- Is this complementary medicine or therapy safe and are there side effects?
- Will this medicine or therapy interact with any medication that I am taking right now?
- What are my values, beliefs and hopes around this choice?
Evaluation pros and cons
When investigating the pros and cons of a treatment consider the following:
- Your overall goals, the potential benefits and risks, and what is known about the treatment
- The impact on your quality of life, relationships and overall health
- Your personal values and goals
- Your ability to commit to a treatment
- Time, cost and energy involved with the treatment
Evaluating evidence to help your decision
Because there can be complex, contradictory or missing information, evidence about the effectiveness and safety can assist your decision-making.
Scenario 1: it works and it is safe
- You have discussed the information with your general practitioner for your particular situation.
- There is some credible evidence that complementary medicine therapy might work for your goal, and that it is likely that it is safe to use.
- If it seems okay for your situation, you can consider using it.
- Inform your healthcare provider of use, and monitor its effects on you.
- It can be helpful to make a plan together with your healthcare provider on how to monitor for side effects, and to discuss the safety of the information. Your healthcare provider is the best person to provide advice that is tailored just for you as they know your full medical history.
Scenario 2: it may not work, but it is safe
- There is some credible evidence that the complementary medicine therapy is safe to use in your situation.
- There is conflicting information or little information about whether the therapy works in your situation.
- Based on the discussion with your healthcare provider, you may consider using it.
- If you use it, you should be clear about possible side effects that could occur, and you should work with your healthcare provider to monitor all effects on you.
Scenario 3: it works but, it may not be safe
- There is some credible evidence that the complementary medicine therapy might work in your situation.
- There is conflicting information or little information about the safety of the therapy in your situation.
- Based on the discussion with your healthcare provider, you may choose to consider using it, but make sure you are aware of the possible side effects and monitor your response closely with your healthcare provider.
Scenario 4: it may not work and it may not be safe
- There is conflicting information or little information that the complementary medicine therapy may work and is safe in your situation.
- Because this therapy may harm you, and there is nothing to suggest it will help you, it is not recommended you try this therapy.
- Talk with your healthcare provider about complementary medicine (or conventional medicine) options with better evidence that fit with your complementary medicine objectives. It may be a good time to review all your options. For example, if the change in your mood is not adequate, your healthcare provider may recommend other options.
Evaluation of Peter's choices
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
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.
- British Acupuncture Council (opens in a new window)
- Cochrane (opens in a new window)
- Arnica gel (opens in a new window)
- St Johns Wort (opens in a new window)
- Exercise (opens in a new window)