Non-pharmacological treatment of depression: a systematic review and evidence map.
BACKGROUND
The comparative effectiveness of non-pharmacological treatments of depression remains unclear.


METHODS
We conducted an overview of systematic reviews to identify randomised controlled trials (RCTs) that compared the efficacy and adverse effects of non-pharmacological treatments of depression. We searched multiple electronic databases through February 2016 without language restrictions. Pairs of reviewers determined eligibility, extracted data and assessed risk of bias. Meta-analyses were conducted when appropriate.


RESULTS
We included 367 RCTs enrolling ∼20 000 patients treated with 11 treatments leading to 17 unique head-to-head comparisons. Cognitive behavioural therapy, naturopathic therapy, biological interventions and physical activity interventions reduced depression severity as measured using standardised scales. However, the relative efficacy among these non-pharmacological interventions was lacking. The effect of these interventions on clinical response and remission was unclear. Adverse events were lower than antidepressants.


CONCLUSIONS
The quality of evidence was low to moderate due to inconsistency and unclear or high risk of bias, limiting our confidence in findings.


CONCLUSIONS
Non-pharmacological therapies of depression reduce depression symptoms and should be considered along with antidepressant therapy for the treatment of mild-to-severe depression. A shared decision-making approach is needed to choose between non-pharmacological therapies based on values, preferences, clinical and social context.
Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.|Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.|Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Wigdan H
WH
Farah
Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.|Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.|Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Mouaz
M
Alsawas
Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.
Maria
M
Mainou
Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.|Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.|Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Fares
F
Alahdab
Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.
Magdoleen H
MH
Farah
Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.|Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.|Division of Integrated Behavioral Health, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA.
Ahmed T
AT
Ahmed
Mayo Graduate School, Mayo Clinic, Rochester, Minnesota, USA.
Essa A
EA
Mohamed
Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.|Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.|Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Jehad
J
Almasri
Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.|Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Forty Fort, Pennsylvania, USA.
Michael R
MR
Gionfriddo
Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Ana
A
Castaneda-Guarderas
Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.|Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.|Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Khaled
K
Mohammed
Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.|Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.
Zhen
Z
Wang
Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.|Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.|Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Noor
N
Asi
Division of Integrated Behavioral Health, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA.
Craig N
CN
Sawchuk
Division of Integrated Behavioral Health, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA.
Mark D
MD
Williams
Mayo Clinic Libraries, Mayo Clinic, Rochester, Pennsylvania, USA.
Larry J
LJ
Prokop
Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.|Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.|Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota, USA.
M Hassan
MH
Murad
Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA.
Annie
A
LeBlanc
D000928:Antidepressive Agents; D015928:Cognitive Behavioral Therapy; D003863:Depression / Q000628:therapy*; D003865:Major Depressive Disorder / Q000628:therapy*; D006801:Humans; D011613:Psychotherapy; D016032:Randomized Controlled Trials as Topic
D000928:Antidepressive Agents