Anywhere from a quarter to a third of older adults use complementary and alternative medicine (CAM) for late-life depression (LLD). Several CAM approaches have a long history, but the research is either lacking or misunderstood. In this article, we describe the CAM interventions most commonly used for LLD. See the table on page 8 for a quick summary of efficacy levels.

Nutritional supplements

Vitamin B12 and folate

Many researchers have described the association of low vitamin B12 and folate levels with depression in older adults (Petridou ET et al, Aging Ment Health 2016;20(9):965–973). Fewer studies have looked at the effect of supplementing low levels of B12 and folate in LLD, and the research that does exist shows questionable benefit. I routinely check for and treat B12 and folate deficiency since they are associated with neurological symptoms in older adults, but I do not expect treatment of deficiency to help with a patient’s ­depression. 

Vitamin B12 levels are considered to be low below 200 pg/mL, and folate levels are considered to be low below 2 ng/mL. High-dose vitamin B12 supplements (1000–2000 mcg/day) can often compensate for an older adult’s poor absorption, whereas older adults with folate deficiency often require a folic acid supplement of 1–5 mg/day. At this time, routine supplementation of normal levels is not advised. Regardless of folate levels, L-methylfolate 15 mg/day can be considered as an adjunctive treatment in patients who do not respond to antidepressants, especially in patients with obesity or inflammation.

Vitamin D

Similar to vitamin B12 and folate deficiencies, low vitamin D levels (often defined as <50 nmol/L or <20 ng/mL) are associated with LLD (Okereke OI and Singh A, J Affect Disord 2016;198:1–14). However, vitamin D supplementation does not appear to improve or prevent symptoms of depression (Okereke OI et al, JAMA 2020;324(5):471–480). Nonetheless, it is reasonable to check for and correct vitamin D deficiency with the goal of improving a patient’s bone and metabolic health. Vitamin D supplementation may be particularly beneficial in patients prescribed SSRIs, as these medications are associated with a higher risk of osteoporosis in older adults. For most older adults, a supplement of vitamin D3 1000 IU daily can help prevent low vitamin D levels and fractures. 

Omega-3 fatty acids

Omega-3 fatty acids appear to be beneficial for treatment of LLD both as monotherapy and as add-on agents. However, they do not prevent depression (Okereke OI et al, JAMA 2021;326(23):2385–2394). EPA:DHA ­ratios of 3:2 or greater produce the strongest antidepressant effects. I recommend a dose of 1000 mg/day with reputable brands such as OmegaBrite or OmegaVia. I also consider the freshness and source of omega-3 fatty acids, as they have a limited shelf life and lose potency with time.

S-adenosyl-L-methionine (SAMe)

SAMe has many clinical trials supporting its efficacy in the treatment of depression, but not specifically in older adults. SAMe can be used in doses between 800 mg/day and 1600 mg/day, though I recommend starting low and going slow (Sharma A et al, J Clin Psychiatry 2017;78(6):e656–e667). SAMe can cause mild GI distress, anxiety, insomnia, and mania, but it can also benefit bone and joint health. 

St. John’s wort (SJW)

SJW has been largely studied in Europe, and it is approved for the treatment of mild to moderate depression in Germany. Some studies show positive effects of SJW with fewer side effects compared to SSRIs in general adult populations, while other studies are mixed. The available preparations for SJW vary in pharmaceutical quality and likely vary in efficacy as well. Some tested supplements were found to contain none of the active ingredients (hyperforin and hypericin). SJW is an inducer of CYP3A4 and can interact with other medications, including alprazolam, bupropion, certain chemotherapy and immunosuppressive medications, opioids, and warfarin. SJW also increases the risk for serotonin syndrome when taken with serotonergic antidepressants. I ask about SJW when checking for drug interactions. If patients choose to proceed with this medication, I recommend dosing 300 mg three times a day or 450 mg twice daily. 

Physical activities

Group-based physical activity ­programs 

Group-based and social aerobic physical activity programs, including walking and swimming groups, are highly effective in treating mild to moderate depression, with an effect size comparable to medication. Exercise has many benefits, such as providing a pleasant distraction, increasing levels of beta-endorphins, and improving quality of sleep, with aerobic activities having the best evidence for benefit. Programs like SilverSneakers allow older adults to participate in group exercise activities with minimal financial cost (https://tools.silversneakers.com/). I recommend a minimum of 150 minutes of physical activity weekly, which translates to a little over 20 minutes of physical activity daily. To overcome restrictions during the pandemic, I suggest taking advantage of online exercise classes. For patients who are concerned about physical limitations, I suggest discussion with their primary care clinician or consultation with a physical therapist.

Yoga

Yoga is a mindful physical exercise that has demonstrated evidence in the treatment for depression in the elderly. It additionally provides benefits to a patient’s physical health, mindfulness, and stress perception. I recommend yoga as a useful and overall beneficial intervention for depressive symptoms. To get started, I recommend Yoga for Seniors (www.tinyurl.com/yd38aapb) or Yoga Alliance (www.tinyurl.com/2d4bh2n3). For patients who prefer home versus group settings, many yoga classes are now offered virtually.

Tai chi

A mind-body exercise, tai chi is a moving meditation with gentle exercises and is considered to be more dynamic than yoga. Similar to yoga, a few studies show that tai chi can benefit depressive symptoms in the elderly. Benefits may be conferred by tai chi’s effects on physical health, as well its meditative quality. Both tai chi and yoga focus on enhancing attention and separating the person’s identification with negative thoughts. People who are experienced practitioners of yoga and tai chi often describe both exercises as promoting a state of “transcendental consciousness.” You can find beginner tai chi classes at community centers and recreation centers like the YMCA, and the Tai Chi for Health Institute ­(https://taichiforhealthinstitute.org/instructors/) lists instructors available to conduct online classes.

Other interventions

Art

Art therapy, which includes techniques such as drawing, painting, and sculpting, allows for self-expression and provides creative satisfaction. There are a few studies supporting the use of art therapy for mild to moderate depression, and I recommend using this approach for patients who are interested in or familiar with art. 

Massage

Massage therapy, which may be combined with aromatherapy, has limited evidence in LLD and can cause physical harm. As it is not regulated, I advise patients to seek out licensed and qualified massage therapists if they’re interested in massage, though I typically do not recommend it as a treatment option for ­depression. 

Music

A few studies support music therapy as an add-on agent in LLD. Active music therapy involves playing an instrument, singing, or dancing. Receptive music therapy involves listening to music based on a patient’s preferences and experiences. Music also provides a way for older adults to express their feelings and can help create a bond between a patient and a clinician. I usually ask about the importance of music in the depressed older adult’s life and encourage reconnecting with music, either as a creator or as a listener. Although many elements of music therapy do not require a music therapist, patients can find trained music therapists through this resource: www.musictherapy.org/about/find/. Sessions generally last between 30 and 60 minutes and can be in person or virtual.

Religion/spirituality

Many older adults prefer to include religion and spirituality in their treatment, particularly in psychotherapy for LLD (Stanley MA et al, Aging Ment Health 2011;15(3):334–343). 

I ask about a person’s previous and current relationship to religion and spirituality before recommending a religion-based approach. A person may use religion to rationalize or universalize negative events, or they might think of these events as a punishment for their sins. These factors can have a positive or negative impact on treatment.

CARLAT VERDICT

Although data are sparse for most complementary and alternative treatments for late life depression, we can be comfortable recommending physical activity as a first-line intervention for all patients. Nutritional supplements may be a consideration in patients preferring natural approaches. SAMe stands out with good evidence and a low risk of drug interactions or side effects. Other interventions, such as art and music therapy, can be considered in interested patients. Although vitamin supplements may not treat depression, correcting deficiencies may positively affect physical health and cognition.