Recent studies have cast serious doubt on the effectiveness of antidepressant drugs for at least some psychological disorders. In January, an analysis of six large antidepressant trials published in The Journal of the American Medical Association found that neither an older drug called Tofranil (imipramine) nor the newer drug Paxil (paroxetine) was significantly more effective than a placebo in people with mild to moderate depression. While the researchers of this reanalysis of existing studies—called a meta-analysis—only looked at two drugs, newspapers were quick to extend the findings to all types of antidepressants.

It should be no surprise then that the number of people exploring non-pharmaceutical solutions for depression and anxiety only continues to grow. What’s not clear, however, is which complementary and alternative medicines (CAMs) actually work, and when it is best to try them.

Just as we are demanding more rigor in the study of prescription drugs for psychological disorders, more and more researchers are exploring the strength of the evidence for CAMs in these same conditions. Unfortunately, while there are dozens of well-controlled studies of pharmaceutical interventions and psychotherapy, researchers have sometimes struggled to find even one controlled study of many CAMs. Nevertheless, there are data on some alternative treatments, and researchers such as Sy Atezaz Saeed, MD, a professor and chair of the department of psychiatric medicine from East Carolina University in Greenville, North Carolina, have been crunching the numbers.

Saeed describes himself as a proponent of a movement called evidenced based medicine, where all types of medicine are put to the same standard to measure their efficacy. “If you just do a Google search, you’ll find that there are thousands and thousands of remedies that have been pushed at one time or other as being effective for anxiety and depression,” he explains. “The purpose of our endeavor was to look at the evidence and ask, ‘What does and doesn’t work?’”

Saeed and his colleagues have published two reviews of popular CAMs in recent years, and he is open to using certain CAMs in his own practice, provided that his patients understand the risks and the benefits. While some CAMs are relatively free of side effects, others are not. What’s more, since supplements are not regulated in North America, it’s not always possible to know for sure whether the herbs and supplements you’ve purchased at the local health food store actually has the amount of active ingredient that is stated on the bottle.

At the end of the day, people with depression and anxiety need to be informed patients, whether they go the traditional route or explore alternative therapies.

Successful Supplements

When Saeed looked over the research on popular substances promoted as treatments for depression and anxiety, his first challenge was making sure that the studies confirmed whether, and how much, a person was depressed or anxious. “Anxiety and depression are not uncommon human emotions, and not everyone who feels anxious or depressed necessarily has an anxiety or depressive disorder,” Saeed says. “Some of the studies that we found did not really differentiate between anxiety or depression as a frame of mind, as opposed to anxiety or depression as a disorder.”

In a review published in Current Psychiatry in January 2009, Saeed and his colleagues considered the evidence for several common supplements and found studies supporting the use of at least three of them: St. John’s wort, S-adenosylmethionine (SAM-e) and omega-3 fatty acids, as are commonly found in fish oil.

In the Current Psychiatry article, Saeed’s team found while some studies showed no benefit for any of the three treatments compared with a placebo, a sufficient number of studies for each compound did demonstrate efficacy compared with a placebo for depression. Data on each drug for anxiety were not covered.

It’s important to pause for a moment before hitting the health food store and then telling your psychiatrist, “Goodbye.” If you want to try an alternative medicine, Saeed recommends, then you should still be followed by a psychiatrist and you should hold the treatment to the same standards as you would a typical antidepressant. “The usual approach is that if within four to six weeks there’s absolutely no change, we can wait another two weeks. But if there’s no change, then we need to [switch treatments].”

Saeed says that it’s also important to monitor for side effects, which do exist despite the popular misconception that if something is “natural” then it can’t possibly be harmful. Drug interactions are another potential problem, especially for St. John’s wort, which can interfere with the blood levels of a host of common drugs.

There are two other factors to consider when it comes to alternative medications: cost and quality. The cost of supplements can add up, and they are not usually covered by health insurance. Quality is also an issue. In 1998, The Los Angeles Times sent out samples from 10 different brands of St. John’s wort to an independent laboratory. They found that the actual dose of hypericin, the active ingredient, varied widely from what was stated on the bottle. One brand had as little as 30 percent of the recommended dose, while another had 140 percent. Moreover, a recent report by the U.S. government accountability office found traces of heavy metals in a number of common over-the-counter supplements.

Get Moving, Breathing and Reading

For people who’d rather not pop a pill or capsule of any kind, Saeed’s team found that a couple of activities might be helpful with at least mild-to-moderate depression, and possibly anxiety as well. These include physical exercise and yoga.

There’s a significant amount of evidence showing exercise fights depression. In fact, recent studies suggest that while low-impact exercise like walking can be helpful, it is strenuous exercise that really packs an antidepressant punch. “The interesting thing with exercise is that it turns out there is clearly a dose-related response,” Saeed says. “There is research now pointing out that exercise needs to be high energy and rigorous to get the antidepressant response.”

People who choose to try exercise, as opposed to an herb or supplement, can have their progress monitored by a psychotherapist rather than a psychiatrist, Saeed says, adding that lab tests are generally not needed. However, some people, particularly those with existing heart problems, need to be careful about strenuous physical activity, and everyone should check with their health care provider before starting a new exercise program.

While studies of yoga have been less rigorous than those involving aerobic exercise, there are data showing that yoga can help ease depressive symptoms and even lead to remission of depression in some people. Most people in the studies conducted so far have been young and relatively fit, so Saeed and his colleagues raised caution about generalizing these findings to everyone. As with exercise, however, there are no significant side effects, and provided that someone is being followed by a trained mental health professional, it is a worthwhile option.

Meditation of varying types as well as guidance from self-help books—usually oriented toward cognitive behavior therapy concepts—also have shown favorable effects for depression and anxiety in some studies, when added to commonly used therapies.

A Final Follow-up

Saeed acknowledges that many people are frustrated with the standard options for treating depression and anxiety. They fear side effects and don’t know what to make of the recent studies calling the efficacy of antidepressants into question. They’re seeking alternatives that seem safe and natural. In his practice, Saeed is willing to work with people who want to explore the alternative options mentioned here, but he encourages them to do so with the guidance of a supportive professional.

“I would make sure that they understand [the potential risks and benefits],” he says. “If they understand these aspects, and they still say, ‘I want to try this,’ then I would say, ‘OK. Just make sure that you are being followed up.’”