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Abstract: Background: Depression is one of the leading indications for using Complementary and Alternative Medicine (CAM). This paper reviews the evidence of efficacy of different types of CAM in depression with the aim of identifying the highest level of evidence. Methods: We conducted literature searches restricted to the English language for studies on CAM as monotherapy in depression. All papers were reviewed by two researchers and the evidence was ranked according to a widely referenced hierarchy of evidence. Results: 19 papers formed the final review. We found Grade 1 evidence on the use of St. John''s wort, Tryptophan/5-Hydroxytryptophan, S-adenosyl methionine, Folate, Inositol, Acupuncture and Exercise in Depressive disorders, none of which was conclusively positive. We found RCTs at the Grade 2 level on the use of Saffron (Herbal medicine), Complex Homoeopathy and Relaxation training in Depressive disorders, all of which showed inconclusive results. Other RCTs yielded unequivocally negative results. Studies below this level yielded inconclusive or negative results. Limitations: Searches were restricted to the English language. Our list of CAM approaches may not have been comprehensive. We excluded studies on the use of CAM as an adjunctive treatment and this review aimed to identify only the highest level of evidence. Conclusions: None of the CAM studies show evidence of efficacy in depression according to the hierarchy of evidence. The RCT model and the principles underlying many types of CAM are dissonant, making its application in the evaluation of those types of CAM difficult. The hierarchy of evidence we used has limited utility in grading trials of CAM. [Copyright &y& Elsevier]

Abstract: Background: Depressed and anxious patients often combine complementary and alternative medicine (CAM) therapies with conventional pharmacotherapy to self-treat symptoms. The benefits and risks of such combination strategies have not been fully evaluated. This paper evaluates the risk-benefit profile of CAM augmentation to antidepressants in affective conditions. Methods: PubMed was searched for all available clinical reports published in English up to December 2012. Data were evaluated based on graded levels of evidence for efficacy and safety. Results: Generally, the evidence base is significantly larger for depression than for anxiety disorder. In unipolar depression, there is Level 2 evidence for adjunctive sleep deprivation (SD) and Free and Easy Wanderer Plus (FEWP), and Level 3 for exercise, yoga, light therapy (LT), omega-3 fatty acids, S-adenosylmethionine and tryptophan. In bipolar depression, there is Level 1 evidence for adjunctive omega-3s, Level 2 for SD, and Level 3 for LT and FEWP. In anxiety conditions, exercise augmentation has Level 3 support in generalized anxiety disorder and panic disorder. Though mostly well-tolerated, these therapies can only be recommended as third-line interventions due to the quality of available evidence. Limitations: Overall, the literature is limited. Studies often had methodological weaknesses, with little information on long-term use and on potential drug–CAM interactions. Many CAM studies were not published in English. Conclusions: While several CAM therapies show some evidence of benefit as augmentation in depressive disorders, such evidence is largely lacking in anxiety disorders. The general dearth of adequate safety and tolerability data encourages caution in clinical use. [Copyright &y& Elsevier]

Abstract: A growing number of patients with mood disorders are using complementary and alternative medicine (CAM) interventions. In this paper, we review the published scientific evidence on the benefits and risks of CAM for the treatment of patients with bipolar disorder. Since very few studies of CAM have involved patients with bipolar disorder, most available evidence is derived from trials conducted in patients with major depressive disorder. The use of omega-3 fatty acids has been studied in two controlled studies in bipolar disorder while St. John''s wort (Hypericum perforatum), S-adenosyl-l-methionine (SAMe), and acupuncture have been studied in a series of randomized controlled trials in patients with major depression. Overall, the best evidence supports the use of St. John''s wort for the treatment of mild to moderate depression. SAMe may also be effective for depression. However, both of these products have the potential to induce mania; the extent of this risk needs to be quantified. St. John''s wort can also interact with a variety of medications. Evidence regarding the benefits of omega-3 fatty acids or acupuncture is inconsistent. Data regarding other CAM interventions (e.g., aromatherapy massage, massage therapy, yoga) are almost entirely lacking. In conclusion, better studies are needed before CAM interventions can be recommended to patients with bipolar disorder. In the meantime, patients need to be informed about the possible risks associated with the use of these interventions. [Copyright &y& Elsevier]