Psychiatric Annals

Guest Editorial Free

Finding Solutions for Treating Depression

Louisa G. Sylvia, PhD

We have not solved the challenge of treating depression. Nearly 30% of adolescents and adults are experiencing subthreshold symptoms of depression, which is associated with increased burden of disease and suicide risk.1,2 Moreover, psychopharmacology remains the gold standard of care for depression, but adherence rates can be highly variable. People who are depressed are also more likely to be nonadherent than those who are not depressed. One comprehensive review across 31 studies and 18,245 participants found that patients who are depressed have nonadherence rates 1.76 times that of their counterparts who are not.3 Access to good care for depression can also be difficult.4 For example, it is estimated that only 24.8% of those who are clinically depressed receive minimally adequate treatment.2 These data highlight the need to consider effective and accessible adjunctive treatment modalities to pharmacological treatment for depression.

Evidence-based integrative health modalities, such as exercise, yoga, nutrition, or mindfulness, yield great promise as adjunctive treatments of depression. These modalities can be affordable and easy to access, especially given the growth of online resources. However, they continue to be under-used in clinical practice. A comprehensive search of the international literature from 2003 to 2014 found that these approaches were becoming increasingly popular in the treatment of depression but varied widely in their prescription rates with only 10% to 30% of most clinicians prescribing them for patients who are depressed.5 This is particularly surprising given that they are generally associated with few side effects and practiced widely in the general population.

The under-use of these modalities for the adjunctive treatment of depression is unclear but is likely due to a lack of synthesis of data for each approach and useful recommendations for clinicians. This is particularly true given the exponential increase in research conducted with integrative health modalities in the past decade. To that end, this issue of Psychiatric Annals reviews four promising adjunctive, integrative health modalities for depression: exercise, yoga, mindfulness, and nutrition. The articles review some of the key evidence for each modality as well as offer recommendations for including the approach in one's clinical practice. Importantly, the acceptability of each modality will vary depending on the person; however, sharing some of the evidence and aspects of each modality with your patients may help to guide a discussion with them. Being creative or thinking beyond the standard medications and psychotherapy options for depression may yield substantial improvements in symptoms and the overall quality of life for your patients.


  1. Balázs J, Miklósi M, Keresztény Á, et al. Adolescent subthreshold-depression and anxiety: Psychopathology, functional impairment and increased suicide risk. J Child Psychol Psychiatry. 2013;54(6):670–677. doi:. doi:10.1111/jcpp.12016 [CrossRef]
  2. Topuzoğlu A, Binbay T, Ulaş H, et al. The epidemiology of major depressive disorder and subthreshold depression in Izmir, Turkey: prevalence, socioeconomic differences, impairment and help-seeking. J Affect Disord. 2015;181:78–86. doi:. doi:10.1016/j.jad.2015.04.017 [CrossRef]
  3. Grenard JL, Munjas BA, Adams JL, et al. Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis. J Gen Intern Med. 2011;26(10):1175–1182. doi:. doi:10.1007/s11606-011-1704-y [CrossRef]
  4. Sawada N, Uchida H, Suzuki T, et al. Persistence and compliance to antidepressant treatment in patients with depression: a chart review. BMC Psychiatry. 2009;9:38. doi:. doi:10.1186/1471-244X-9-38 [CrossRef]
  5. Solomon D, Adams J. The use of complementary and alternative medicine in adults with depressive disorders. A critical integrative review. J Affect Disord. 2015;179:101–113. doi:. doi:10.1016/j.jad.2015.03.031 [CrossRef]
Louisa G. Sylvia, Phd

Louisa G. Sylvia, PhD, is an Associate Professor, Massachusetts General Hospital, Harvard Medical School.

Address correspondence to Louisa G. Sylvia, PhD, Department of Psychiatry, Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114-2517; email:

Disclosure: Louisa G. Sylvia receives royalties from New Harbinger Publications, owns stock in Concordant Rater Systems, and is a consultant for United Biosource Corporation and Clinatra.


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