Research

TLC Poster Presentations

Botanov, Y., Keil, K. M., Ilardi, S. S., Scheller, V. K., Sharp, K. L., & Williams, C. L. (2012. Successful Treatment of Depression via Therapeutic Lifestyle Change: Preliminary Controlled-Trial Results. Poster presentation at the annual conference of the Association for Psychological Science, Chicago, IL. (PDF)

Jacobson, J. D., Kenneth, L. A., Stites, B. A., Karwoski, L., Stroupe, N. N., Steidtmann, D. K.,... Ilardi, S. S. (2007).Therapeutic Lifestyle Change for Depression: Results of a Randomized Controlled Trial. Poster presentation at the annual conference of the Association for Behavioral and Cognitive Therapies, Philadelphia, PA. (PDF)

Sleep Hygiene

Sleep problems are a common theme among those suffering from depression. Increased insomnia has been associated with greater levels of depression (Taylor et. al, 2005). However, not only can sleep exacerbate certain depressive symptoms, such as rumination (Thomsen et. al, 2003), but it may also be a risk factor for developing future depressive episodes (Sadeh, 2012). Research suggests that sleep problems may lead to higher rates of relapse in people with recurrent depression and that sleep complaints may precede the series of symptoms that make up the syndrome of major depression (Perlis et. al, 1997).

An initial study by Ford and Kamerow (1989) suggests that individuals who resolve their sleep problems have a decreased risk for depression. As of 2011 the National Sleep Foundation recommends that those with depression should ensure treatment of sleep problems as well as depressive symptoms because alleviating sleep problems can accelerate the rate of recovery from depressive symptoms (Wiebe, Casoff & Gruber, 2012). Through treating the sleep problem, the risk for developing a future episode of depression may be reduced.

Additionally, many people who suffer from depression are on antidepressant medication. However, because of the strong relationship between sleep patterns and depression, those who are currently taking certain medications should be aware of possible side effects that may increase sleep problems. For example, selective serotonin reuptake inhibitors (SSRIs) may increase insomnia symptoms (National Sleep Foundation, 2011) which may inhibit the treatment process. Therefore, it is good to monitor sleep patterns after beginning a new medication (Wiebe et. al, 2012).

Social Support

Researchers have consistently found that social support is good for our minds and bodies. Poor social support is associated with an increased risk of morbidity and mortality across a wide variety of physical illnesses. In addition, lonely individuals have increased levels of stress hormones (Ozbay et al., 2007) and are more prone to poor mental health outcomes (Croezen et al., 2012) than are individuals with healthy social support systems. Specifically, lower levels of social support are significantly associated with increased symptoms of anxiety and depression (Grav et al., 2011). Not only does poor social support worsen depressive symptoms, it also puts one at an increased risk to relapse. High levels of social support have been found to protect against some of the negative outcomes of physical and mental illness. Spending time with positive others also decreases impairment that occurs as a result of depression and increases the likelihood of recovery (Ozbay et al., 2007).

Exercise

The antidepressant benefits of exercise have been well established. For example, one meta-analysis (Stathopoulou, Powers, Berry, Smiths, & Otto, 2006) consisting of 11 randomized controlled trials (RCTs) demonstrated a very large treatment effect for exercise over control conditions. The authors of another review of RCTs (Sjosten & Kivela, 2006) focusing on adults over 60 years of age concluded that exercise interventions may efficiently reduce depression or high levels of depressive symptoms, particularly in the short-term. Knubben et al. (2007) randomized moderately to severely depressed patients who were undergoing standard clinical antidepressant drug treatment to either a walking condition or a placebo stretching/relaxation condition. After 10 days, those in the walking condition had significantly greater reductions in their depression scores than those in the placebo group. Furthermore, more individuals in the walking group had a clinically meaningful response to treatment. Other RCTs comparing exercise to active and placebo treatments for depression have also been conducted with similar positive results (Blumenthal et al., 2007; Brenes et al., 2007). One interesting RCT by Legrand and Heuze (2007) compared the antidepressant effects of low frequency exercise to high frequency exercise and found that those randomized to the high frequency group reported lower depression scores than those randomized to the low frequency group, which suggests that the antidepressant properties of exercise may be dose-dependent.

Several studies have evaluated the effects of exercise on depressive symptoms against alternative treatments for depression, particularly psychotherapy and medication. Craft and Landers (1998) conducted a meta-analysis and found no differences between exercise and psychotherapy or other types of behavioral and pharmacological interventions. In another meta-analysis, exercise was found to be just as effective as cognitive therapy (Lawlor & Hopker, 2001). Response and remission rates with exercise are also comparable to psychological and drug treatments (Dunn, Trivedi, Kampert, & Clark; Blumenthal et al., 2007). Given that several research studies suggest that exercise is a viable treatment for depression, health professionals should consider promoting it to their depressed clientele.

Light Exposure

Prescribed to treat a host of conditions, light therapy (LT), or phototherapy, consists of exposure to daylight or artificial bright light for a determined period of time at a specific time of day. Early intervention research targeted seasonal affective disorder (SAD) with the first published study by Rosenthal and colleagues (1984). A meta-analysis by the American Psychiatric Association Committee on Research on Psychiatric Treatments (Golden et al., 2005), using strict criteria for only the most methodologically sound trials, concluded that LT is superior to placebo in reducing symptoms of seasonal affective disorder, with an effect size of 0.84. In fact, remission rates were found to be nearly three times higher (Odds Ratio of 2.9) among LT patients in comparison with those receiving placebo. Likewise, when limiting their evaluation to the most methodologically sound studies, Golden and colleagues found that LT was an effective stand-alone treatment for nonseasonal depression, with an effect size of 0.53. They also noted that this observed effect size is similar to that of most antidepressant medication trials.

A Cochrane meta-analysis (Tuunainen, Kripke, & Endo, 2004) examining the effect of LT on nonseasonal depression found that treatment response was significantly better in the LT group compared to the control treatment group (18 studies, 505 patients). This finding was mainly due to the significant benefit of short term treatment of seven days or less (12 studies, 367 patient). Medium term treatment did not show any significant superiority of bright light (6 studies, 138 patients). However, due to significant heterogeneity a more conservative statistical model was also employed and the study effects were no longer statistically significant.

Omega-3 Fatty Acid Supplements

Omega-3 is an essential fatty acid, a type of polyunsaturated fatty acid, and is naturally occurring in marine and plant oils. However, humans must acquire omega-3s through their diet and the Western diet is particularly rich in omega-6 fatty acids. A high ratio of omega-6 to omega-3 alters cell properties and increases production of inflammatory mediators. In contrast, omega-3 fatty acids are anti-inflammatory (Simopoulos, 2002). The link between omega-3 fatty acids and depression stems from numerous sources of etiological evidence. Particularly, studies of individuals with depression have found reduced Omega-3 levels (Edwards, Peet, Shay & Horrobin, 1998; Peet, Murphy, Shay, & Horrobin, 1998) and populations that consume higher levels of fish, a rich source of Omega-3s, have lower levels of depression (e.g., Timonen et al., 2004).

The empirical findings on treating depression with omega-3 supplementation have been mixed for numerous reasons. Often, lack of consistency between treatment length, type of omega-3 supplement, and sufficient control has led to incongruent outcomes. Meta-analytic review of omega-3 for depression has found that the therapeutic effect appears to come from omega-3s rich in eicosapentaenoic acid (EPA). Two meta-analyses have shown that Omega-3s comprised of at least 60% EPA show a significant therapeutic effect (Martins, 2009; Sublette, Ellis, Geant & Mann, 2011). However, ignoring the ratio of EPA leads to a fading of a therapeutic effect in meta-analysis (Bloch & Hannestad, 2011).

Anti-Rumination Strategies

The process of rumination, which involves dwelling on negative thoughts and feelings, has been recognized as a key characteristic of depression (Ingram, 1984). Rumination has been linked to many negative outcomes including longer and more severe depressive episodes and impaired motivation, concentration, and thinking (Lyubomirsky & Tkach, 2003). A connection has also been found between rumination and longer recovery time from coronary incidents (Fritz, 1999). A majority of the research investigating how to decrease rumination has studied behavioral activation treatments. Behavioral activation involves moving attention away from ruminative thoughts and toward active engagement with the environment (Dimidjian et al., 2006) and increasing participation in pleasant activities (Mazzucchelli, Kane & Rees, 2009).

Behavioral activation (BA) has been found to be as effective as antidepressant medication, and more effective than cognitive therapy, for reducing depressive symptoms (Dimidjian et al., 2006). BA was also shown to be just as effective as antidepressant medication or cognitive therapy in preventing depression relapse over a two-year follow-up period (Dobson et al., 2008). Individuals are less likely to drop out of BA treatment than cognitive therapy (Cuijpers et al., 2008), and BA has also been found to be effective for treating individuals who have not had success in cognitive therapy (Coffman, Martell, Dimidjian, Gallop, & Hollon, 2007). A recent meta-analysis on BA treatments for depression in adults reviewed 34 studies with 2,055 participants (Mazzucchelli, Kane & Rees, 2009). This meta-analysis found a large effect for BA compared to control groups, and there was no difference between BA and cognitive therapy. The authors of the meta-analysis conclude that BA be considered a “well-established and advantageous alternative to other treatments of depression.”