Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service Evidence-based Synthesis Program 

An Overview of Complementary and 

Alternative Medicine Therapies for 

Anxiety and Depressive Disorders: 

Supplement to Efficacy of Complementary 

and Alternative Medicine Therapies 

for Posttraumatic Stress Disorder

Department of Veterans Affairs

Health Services Research & Development Service

August 2011

Investigators:

John W. Williams Jr., M.D., M.H.Sc.

Jennifer M. Gierisch, Ph.D.

Jennifer McDuffie, Ph.D.

Jennifer L. Strauss, Ph.D.

Research Associate:

Avishek Nagi, M.S.

Medical Editor:

Liz Wing, M.A.

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center 

Durham Veterans Affairs Healthcare System

Durham, NC

John W Williams Jr., M.D., M.H.Sc, Director
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An Overview of Complementary and Alternative Medicine

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PREFACE

Health Services Research & Development Service’s (HSR&D’s) Evidence-based Synthesis 

Program (ESP) was established to provide timely and accurate syntheses of targeted healthcare 

topics of particular importance to Veterans Affairs (VA) managers and policymakers, as they 

work to improve the health and healthcare of Veterans. The ESP disseminates these reports 

throughout VA.

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help:

• develop clinical policies informed by evidence,

• guide the implementation of effective services to improve patient outcomes and to 

support VA clinical practice guidelines and performance measures, and 

• set the direction for future research to address gaps in clinical knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: Williams JW Jr, Gierisch JM, McDuffie J, Strauss JL, Nagi A. An 

Overview of Complementary and Alternative Medicine Therapies for Anxiety and Depressive 

Disorders: Supplement to Efficacy of Complementary and Alternative Medicine Therapies for 

Posttraumatic Stress Disorder. VA-ESP Project #09-010; 2011.

This report is based on research conducted by the Evidence-based Synthesis 

Program (ESP) Center located at the Durham VA Medical Center, Durham, NC, 

funded by the Department of Veterans Affairs, Veterans Health Administration, 

Office of Research and Development, Health Services Research and Development. 

The findings and conclusions in this document are those of the author(s) who are 

responsible for its contents; the findings and conclusions do not necessarily represent 

the views of the Department of Veterans Affairs or the United States government. 

Therefore, no statement in this article should be construed as an official position of 

the Department of Veterans Affairs. No investigators have any affiliations or financial 

involvement (e.g., employment, consultancies, honoraria, stock ownership or options, 

expert testimony, grants or patents received or pending, or royalties) that conflict with 

material presented in the report.
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An Overview of Complementary and Alternative Medicine

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TABLE OF CONTENTS

ABSTRACT

Background.................................................................................................................................................... 1

Methods......................................................................................................................................................... 1

Key Findings ................................................................................................................................................. 1

INTRODUCTION

Background.................................................................................................................................................... 3

METHODS

Analytic Framework...................................................................................................................................... 5

Search Strategy, Study Selection and Data Abstraction ................................................................................ 6

RESULTS

Literature Search ........................................................................................................................................... 7

Key Question 1: In adults with depressive or anxiety disorders, are mind-body complementary and 

alternative medicine therapies (e.g., acupuncture, yoga, meditation) more efficacious than control for 

PTSD symptoms and health-related quality of life?............................................................................... 7

Key Question 2: In adults with depressive or anxiety disorders, are manipulative and body-based 

complementary and alternative medicine therapies (e.g., spinal manipulation, massage) more 

efficacious than control for PTSD symptoms and health-related quality of life?................................. 10

Key Question 3: In adults with depressive or anxiety disorders, are complementary and alternative 

medicine therapies that are movement-based or involve energy therapies more efficacious than 

control for PTSD and health-related quality of life? ............................................................................ 10

SUMMARY AND DISCUSSION ................................................................................................................ 11

REFERENCES ................................................................................................................................................... 13

FIGURE

Figure 1. Analytic framework........................................................................................................................ 5

APPENDIX A: Search Strategies.............................................................................................................. 16

APPENDIX B: Eligibility Criteria .......................................................................................................... 17

APPENDIX C: Study Quality Assessment – Systematic Reviews ............................................... 18

APPENDIX D: Excluded Studies ............................................................................................................... 20
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ABSTRACT

BACKGROUND

VA is committed to expanding the breadth of posttraumatic stress disorder (PTSD)-related 

services available to Veterans. Since depressive and anxiety disorders share common features 

with PTSD, this report was commissioned to examine the efficacy of complementary and 

alternative medicine (CAM) therapies for the treatment of depressive and anxiety disorders as a 

means to detect treatments that might be applicable to PTSD.

METHODS

The key questions (KQs) were adapted from the parent report, Efficacy of Complementary and 

Alternative Medicine Therapies for Posttraumatic Stress Disorder. We searched MEDLINE®

(via PubMed®) and the Cochrane Database of Systematic Reviews for recent English-language 

systematic reviews (SRs) that examined the literature on mind-body medicine, manipulative and 

body-based practices, and movement or energy therapies, excluding nutritionals, herbal remedies 

and other supplements. To be included, SRs had to be published within the past five years and be 

evaluated as a “fair” or “good” quality. Titles, abstracts, and articles were reviewed in duplicate, 

and relevant data were abstracted by authors trained in the critical analysis of literature.

KEY FINDINGS

We identified five relevant SRs on mind-body CAM therapies, but none on manipulative and 

body-based, movement-based, or energy therapies. Most primary studies were small trials that 

did not provide descriptions of CAM strategies adequate to permit replication. Dose, duration, 

and frequency of interventions sometimes varied widely. Key findings were:

•	 For anxiety disorders, there is limited evidence on the effectiveness of meditation (n = 2 

studies). Studies reported high rates of dropout, suggesting that adherence to meditation 

may be problematic in a clinical setting; therefore, it is difficult to draw conclusions about 

the efficacy of meditation for the treatment of anxiety disorders.

•	 Relaxation and/or breathing retraining show promise as a CAM therapy for panic 

disorders. Evidence, however, is limited.

•	 Acupuncture shows some promise as a CAM therapy for depression, but results were 

mixed. For major depressive disorder (MDD), acupuncture showed greater effects than 

sham control on depressive symptoms but did not improve response or remission rates. It 

did not differ significantly from short-term use of antidepressants. However, for patients 

with post-stroke depression, acupuncture was more effective than short-term use of 

antidepressants. 

•	 Mindfulness-based stress reduction has shown positive effects on anxiety and depressive 

symptoms. However, studies are poor to fair quality.

•	 No included SRs reported effects on health-related quality of life. Reported results 

provided limited data on adverse effects or retention rates. 
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The limitations of the current evidence preclude strong conclusions about specific CAM 

interventions for the treatment of depressive and anxiety disorders. However, limited evidence 

supports the use of meditation, relaxation training and/or breathing retraining, and mindfulnessbased stress reduction for anxiety, as well as acupuncture for depression. This evidence should 

be considered together with the direct data on CAM treatments for PTSD when planning further 

treatment studies.
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INTRODUCTION

Posttraumatic stress disorder (PTSD) is an anxiety disorder, and the disorder most frequently 

associated with combat exposure.1 An anticipated consequence of our troops’ prolonged 

deployments in Iraq and Afghanistan is an increased incidence of PTSD among returning 

Veterans. The VA is committed to providing cutting-edge, evidence-based treatment for all 

Veterans, including those seeking PTSD-related services. Complementary alternative medicine 

(CAM) interventions are widely requested and used by mental health consumers, including 

Veterans and active duty personnel. CAM treatments are perceived to be less invasive and to 

have fewer side effects than traditional therapies and, in some cases, may be more congruent 

with individual treatment preference.2-6 VA is committed to expanding the evidence base and 

breadth of PTSD-related services available to Veterans. To this end, there is growing interest in 

applications of CAM. This evidence report was commissioned to examine the efficacy of CAM 

therapies for the treatment of PTSD. 

The Durham Evidence-based Synthesis Program (ESP) Center completed a systematic review, 

Efficacy of Complementary and Alternative Medicine Therapies for Posttraumatic Stress 

Disorder,

7

 that included studies of patients with PTSD. In response to a preliminary presentation, 

stakeholders and attendees requested the review be extended to other disorders related to, or 

often comorbid with, PTSD. This supplemental report examines CAM therapies for other anxiety 

diagnoses and depression to better ascertain the potential for CAM therapies in the treatment of 

PTSD. 

BACKGROUND

The National Vietnam Veterans Readjustment Study (NVVRS) found that 98.9 percent of 

Veterans with PTSD reached criteria for a lifetime comorbid psychiatric diagnosis, suggesting 

that the co-occurrence of PTSD with other psychiatric diagnoses is a ubiquitous phenomenon.8

Almost half of men (47.9%) and women (48.5%) in the general population with PTSD meet 

criteria for major depressive episode.9

 Of the other anxiety disorders, generalized anxiety 

disorder (GAD) and social phobia are the most likely to co-occur with both PTSD and major 

depressive disorder (MDD).10, 11 Further support for the interrelationship of these disorders is 

the recommendation for Diagnostic and Statistical Manual of Mental Disorders, 5th edition to 

reclassify the “emotional (or internalizing) disorders,” to include GAD, unipolar depression, 

panic disorder, phobic disorders, obsessional states, dysthymic disorders, PTSD and somatoform 

disorders.12 In addition, a shared association with abnormalities in the 5-HT transporter gene 

provides a potential mechanism to explain the clinical observation that antidepressants are 

effective for a variety of anxiety disorders. Since these disorders share symptoms, possible 

causative mechanisms, and common psychological and pharmacologic treatments, it is plausible 

that CAM therapies shown to be effective for depression or an anxiety disorder may be effective 

for PTSD.

CAM refers to a group of healing techniques not traditionally practiced by Western-trained 

physicians but traditionally used in the medical systems of other parts of the world. The National 

Center for Complementary and Alternative Medicine (NCCAM) in the National Institutes of 

Health (NIH) has proposed a classification system for CAM therapies that includes natural 
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products (e.g., dietary supplements, herbal remedies), mind-body medicine (e.g., meditation, 

acupuncture), manipulative and body-based practices (e.g., spinal manipulation, massage), 

whole medical systems (e.g., traditional Chinese or Ayurvedic medicine), and other alternative 

practices (e.g., light or movement therapy). However, our stakeholders desired to maintain 

the same restriction on the definition of CAM as was applied to the original report – exclude 

natural products. Therefore, this supplemental report examines the evidence base for mind-body 

medicine, manipulative and body-based practices, and movement or energy therapies in the 

treatment of depressive disorders and anxiety disorders other than PTSD.
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METHODS

This review was commissioned by the Department of Veterans Affairs’ Evidence-based Synthesis 

Program. The key questions (KQs) were adapted from the original report, which addresed CAM 

treatments in patients with PTSD, to address CAM treatments in patients with depressive or 

anxiety disorders. CAM therapies are classified using categories proposed by the NCCAM, and 

the KQs reflect this classification:

KQ 1: In adults with depressive or anxiety disorders, are mind-body complementary and 

alternative medicine therapies (e.g., acupuncture, yoga, meditation) more efficacious 

than control for PTSD symptoms and quality of life?

KQ 2: In adults with depressive or anxiety disorders, are manipulative and body-based 

complementary and alternative medicine therapies (e.g., spinal manipulation, 

massage) more efficacious than control for PTSD symptoms and quality of life?

KQ 3: In adults with depressive or anxiety disorders, are complementary and alternative 

medicine therapies that are movement-based or involve energy therapies more 

efficacious than control for PTSD symptoms and quality of life? 

ANALYTIC FRAMEWORK

We developed and followed a standard protocol for all steps of this review. Our approach was 

guided by the analytic framework shown in Figure 1.

Figure 1. Analytic framework

Examples of interventions:

•	 Mind-body therapies: acupuncture, meditation, yoga, deep-breathing exercises, guided imagery, hypnotherapy, 

progressive relaxation, and tai chi

•	 Manipulative and body-based therapies: spinal manipulation and massage therapy

•	 Movement-based therapies: Feldenkrais method, Alexander technique, Pilates, Rolfing Structural Integration, and 

Trager Psychophysical Integration

•	 Energy therapies: magnet therapy, light therapy, qi gong, Reiki, and healing touch

Randomized controlled trials: KQs 1-3

Mind-body

therapies*

Manipulative and

body-based

therapies*

Movement-based

and energy

therapies*

KQ1 KQ2 KQ3 KQs 1-3

Adverse

effects

Population

Adults with depressive 

or anxiety disorders

Comparators

Usual care,

empirically-based treatments

 Outcomes

• Depressive or anxiety 

symptoms

• Functional status or 

health-related quality 

of life
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SEARCH STRATEGY, STUDY SELECTION AND DATA ABSTRACTION

We searched MEDLINE (via PubMed) and the Cochrane Database of Systematic Reviews 

for recent English-language SRs that evaluated eligible CAM treatments in patients with a 

depressive or anxiety disorder excluding PTSD, which was addressed in the main report. Search 

terms included a validated search filter to identify SRs, terms for eligible CAM treatments, 

and terms for depressive and anxiety disorders. We used the limit terms Publication Date from 

2006/01/01 to 2011/07/01, English, and Humans. Detailed search terms are given in Appendix 

A. The computerized search was supplemented with a focused review of citations. Using 

prespecified inclusion/exclusion criteria, two reviewers assessed the list of titles and abstracts. 

Full-text articles, identified by either reviewer as potentially relevant, were retrieved for further 

review. Each article retrieved was reviewed by two reviewers using the eligibility criteria in 

Appendix B; disagreements were resolved by discussion or by a third reviewer. To be included 

in this report, an SR had to: (1) address one or more eligible CAM treatments in adults with 

a depressive disorder or anxiety disorder (excluding PTSD), (2) be published within the past 

5 years, and (3) be evaluated as a “fair” or “good” quality SR. We used modified Assessment 

of Multiple Systematic Reviews (AMSTAR) criteria to rate the quality of identified reviews 

(Appendix C).13-15 A trained researcher wrote a structured abstract to summarize each review 

narratively; a second reviewer overread the abstract.
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RESULTS

LITERATURE SEARCH

We identified 194 unique SRs from a combined search of MEDLINE (via PubMed with SR 

filter applied, n = 133) and the Cochrane Database of Systematic Reviews (n = 61). Another 

potentially relevant review was identified from citations. Of these, 175 were excluded at the 

title-and-abstract level most often because the population was not adult, the population was 

not diagnosed with a depressive disorder or anxiety disorder other than PTSD, or the active 

intervention was not a form of CAM therapy of interest for this report. 

An additional 15 studies were excluded following a review of the full text of the 20 articles. 

Four of these studies were not SRs,16-19 one was poor quality,20 four primarily reviewed treatment 

interventions that were not the CAM therapies of interest21-24 and six examined populations who 

were not diagnosed with depressive disorders or an anxiety disorder other than PTSD by valid 

criteria; e.g., Diagnostic Statistical Manual of Mental Disorders (DSM).25-30 A table listing these 

studies and their reasons for exclusion is found in Appendix D. In total, five SRs met eligibility 

criteria and are summarized by KQ.

KQ 1: In adults with depressive or anxiety disorders, are mind-body 

complementary and alternative medicine therapies (e.g., acupuncture, 

yoga, meditation) more efficacious than control for PTSD symptoms 

and health-related quality of life?

We identified five relevant SRs, two that assessed CAM therapies for depressive disorders,31, 32

two that assessed CAM therapies for anxiety disorders,33, 34 and one that assessed CAM therapies 

for anxiety or depressive disorders.35 These are summarized below. 

Depressive disorders mind-body CAM therapies:

Wang, 2008. Is acupuncture beneficial in depression: A meta-analysis of 8 randomized 

controlled trials? (Quality rating: Good)

Study summary: The objective of this good-quality report was to synthesize the evidence for the 

benefit of acupuncture as a treatment for depression. To be eligible for inclusion in this review, 

studies had to be randomized clinical trials that compared traditional acupuncture as the active 

intervention with sham acupuncture as the control group in patients with a diagnosis of MDD or 

depressive neurosis by accepted diagnostic criteria. Acupuncture treatment ranged from 10 to 30 

sessions.

Key findings: The authors identified eight small, moderate- to high-quality trials that were 

included in a meta-analysis (n = 477 patients). Outcome measures were the Hamilton Rating 

Scale for Depression or the Beck Depression Inventory. A pooled analysis of the depression 

scores calculated a standardized mean difference (SMD) of -0.65 (95% CI -1.18 to -0.11) 

indicating greater reduction in depressive symptoms among patients randomized to acupuncture. 

However, response rates (≥ 50% reduction in symptoms) and remission rates did not differ 

between active and sham treatments. Six of the eight trials reported response rates for 
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acupuncture compared to sham treatment (RR 1.32; 95% CI 0.83 to 2.10). Remission rates were 

measured in only four of the eight studies, and no significant difference was found between 

groups (RR 1.30, 95% CI 0.57 to 2.95).

Considerations: There was a large degree of heterogeneity (I2 = 67.9 to 84.1%) among the 

studies: high diversity in the number of sessions; the length of the studies’ active treatment 

phase; the type of randomization; and the type of acupuncture – four had individually chosen 

sites while the other four used fixed points. The high heterogeneity decreases confidence in the 

pooled estimate of effect.

Zhang, 2010. The effectiveness and safety of acupuncture therapy in depressive 

disorders: Systematic review and meta-analysis (Quality rating: Fair)

Study summary: The objective of this fair-quality report was to evaluate the effectiveness of 

acupuncture as monotherapy and as an additional therapy for depressive conditions. To be eligible 

for this review, a study needed to be a moderate- to high-quality (Jadad score >3) randomized, 

controlled trial, and patients had to be diagnosed with MDD by accepted diagnostic criteria or poststroke depression (PSD) by neuroimaging verification of brain alteration. Acupuncture treatment 

ranged from 15 to 60 sessions. Control conditions were sham acupuncture (n = 3 MDD; n = 0 

PSD), antidepressant medication (n = 15 MDD; n = 12 PSD) or waitlist (n = 1 MDD; n = 3 PSD). 

Treatment was short term (median = 6 weeks for MDD and 4 weeks for PSD).

Key findings: The review identified 20 trials (n = 1998 patients) on MDD and 15 trials (n = 1680 

patients) on PSD. Most trials were conducted in China. In nine trials of MDD (n = 662 patients), 

there was no significant difference between acupuncture as monotherapy versus antidepressant 

treatment on change in depressive symptoms (mean difference -0.31, 95% CI -0.94 to 1.56) or 

response rates (RR = 1.09, 95% CI = 0.92 to 1.30). Other comparisons, acupuncture versus sham 

acupuncture, waitlist or as adjunctive therapy also did not yield significant differences in response 

rates. There was some evidence in two trials that acupuncture as an adjunct to antidepressant 

treatment improved symptom severity (WMD* = 2.38, 95% CI = 0.62 to 4.12) with low 

heterogeneity (I

2 = 0%), but response rates were not significantly improved. Conversely, for PSD, 

11 trials (n = 708) comparing acupuncture as monotherapy versus antidepressant showed a greater 

response rate for acupuncture (RR† = 1.31, 95% CI = 1.19 to 1.44) with low heterogeneity 

(I

2

 = 0%). Similar effects were obtained for measuring change in symptom severity. Fewer adverse 

effects were found with acupuncture in 21 of 35 trials reporting this information.

Considerations: There was a large degree of heterogeneity (I2 = 68-94%) in most comparisons 

among these trials in the type of acupuncture, the number of acupuncture sessions and the length 

of treatment (4 to 12 weeks). In 27 of 35 trials, the comparator was antidepressant. Only three 

of the eight sham controlled trials evaluated by Wang et al.31 were included in this study. When 

heterogeneity was controlled by removing outliers, results did not change. Given the degree of 

heterogeneity, any conclusion about acupuncture as therapy for MDD must be interpreted with 

caution; however, there is evidence that high-intensity acupuncture may be effective for PSD. 

Finally, most studies were conducted in China and did not provide detailed information about the 

study population; therefore, results may not be applicable to U.S. Veterans.

* Weighted mean difference

†Relative risk
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Hofmann, 2010. The effect of mindfulness-based therapy on anxiety and depression: A 

meta-analytic review (Quality rating: Fair)

Study Summary: The objective of this fair-quality review was to quantitatively synthesize the 

evidence on mindfulness-based therapies (MBT) for the treatment of anxiety or depression. To 

be eligible for this evidence synthesis, studies needed to evaluate mindfulness-based treatment, 

either mindfulness-based cognitive therapy (MBCT) or mindfulness-based stress reduction 

(MBSR) in adults age 18 to 65, with a diagnosable psychological or physical/medical disorder 

and report sufficient data to calculate effect sizes for anxiety and/or depressive outcomes. 

Comparative and noncomparative studies were included.

Key findings: The review included 39 studies (n = 1,140 patients); primary studies were fair to 

poor quality (median quality score = 1 on a 0 to 5 point scale, with 5 being highest quality). Of 

the 39 studies, 16 were controlled studies, and most (n = 11) compared MBT to waitlist or usual 

care; 15 were conducted in patient samples relevant to this summary (anxiety or depressive 

disorder). Across all studies, MBT was associated with improved anxiety symptoms (Hedges 

g 0.63, 95% CI 0.53 to 0.73) and depressive symptoms (Hedges g 0.59, 95% CI 0.51 to 0.66). 

Extensive sensitivity analysis showed similar effects for those treated with MBCT and MBSR, 

controlled and uncontrolled studies, and those reporting intent-to-treat analyses.

Considerations: This review evaluated a highly heterogeneous, poor-quality group of studies. 

Many of the studies used MBCT, a treatment derived from cognitive behavioral therapy and 

considered to be a mainstream therapy. 

Anxiety disorders mind-body CAM therapies:

Krisanaprakornkit, 2006. Meditation therapy for anxiety disorders (Quality rating: Good)

Study summary: The objective of this good-quality report was to synthesize the evidence of 

meditation therapy for the treatment of anxiety disorders. To be eligible for this evidence review, 

studies needed to be randomized, controlled trials of concentrative or mindfulness meditation 

with either an active comparator (i.e., pharmacotherapy, psychological treatments, other 

meditation methods) or no treatment control. 

Key findings: The review identified only two eligible trials,36, 37 both of moderate quality and 

conducted in the U.S. Included studies were too varied to pool results. Raskin36 compared the 

effectiveness of transcendental meditation, muscle biofeedback, and relaxation training (n = 55). 

All three conditions reported significant improvement in anxiety symptoms (F = 7.26; df = 1,27; 

P<0.01), as measured by the Taylor Manifest Anxiety Scale Score. Shannahoff 37 reported on the 

effectiveness of Kundalini yoga versus mindfulness meditation for participants with obsessive 

compulsive disorder (n = 21) and found no significant differences on the primary outcome 

measure (Yale-Brown Obsessive-Compulsive Scale). Two secondary measures, the Perceived 

Stress Scale and Purpose In Life Scale, showed significant differences favoring Kundalini yoga. 

Considerations: Both included studies excluded participants with substance use disorders. 

Shannahoff 37 also excluded participants who smoked, had spinal/physical issues (e.g., 

pulmonary disorders, overweight, hypertension, and other cardiovascular issues), or who had 

another primary psychiatric condition (e.g., MDD, bipolar disorder, schizophrenia). Moreover, 

dropout rates were high in both studies (44% for Raskin36 and 33% for Shannahoff 37).
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Sanchez-Meca, 2010. Psychological treatment of panic disorder with or without 

agoraphobia: A meta-analysis (Quality rating: Fair)

Study summary: The objective of this fair-quality report was to analyze the efficacy of 

psychological interventions for the treatment of panic disorder with or without agoraphobia. 

Much of this evidence review focused on non-CAM therapies. Only the CAM-specific results 

(i.e., relaxation and breathing retraining) are summarized here. To be eligible for this evidence 

review, studies met the following criteria: recruited participants with panic disorder with no less 

than five participants, tested psychological treatments only (no adjunctive pharmacotherapy) 

in experimental arm with a nonactive (e.g., waitlist) or active (e.g., pharmacotherapy, other 

psychological treatment) comparator, and published between 1980 and 2006 in French or 

English.

Key findings: Authors identified 42 eligible reports encompassing 65 comparisons. Only three 

included studies were comparisons of relaxation training and/or breathing retraining (total 

participants not reported). Relaxation training and breathing retraining improved measures of 

panic disorder (d+ = 0.862, 95% CI 0.203-1.521) compared to nonactive or active control. 

Considerations: This report provided no details on comparator conditions. Also, much of this 

report is devoted to non-CAM therapies, with only three included studies of CAM-specific 

therapies. Details on the interventions used were sparse. 

KQ 2: In adults with depressive or anxiety disorders, are manipulative 

and body-based complementary and alternative medicine therapies 

(e.g., spinal manipulation, massage) more efficacious than control for 

PTSD symptoms and health-related quality of life?

We found no relevant SRs of good or fair quality. 

KQ 3: In adults with depressive or anxiety disorders, are 

complementary and alternative medicine therapies that are 

movement-based or involve energy therapies more efficacious than 

control for PTSD and health-related quality of life?

We found no relevant SRs of good or fair quality. 
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SUMMARY AND DISCUSSION

We identified five SRs of CAM therapies for depressive and anxiety disorders that were of 

good or fair quality. All five reviews evaluated mind-body CAM therapies (KQ 1). We found no 

synthesized evidence of acceptable quality for manipulative and body-based CAM therapies (KQ 

2) or CAM movement-based or energy therapies (KQ 3). We summarize the findings below:

•	 Overall, few recent good- or fair-quality systematic reviews have evaluated CAM 

therapies of interest for depressive and anxiety disorders.

•	 For anxiety disorders, there is limited evidence on the effectiveness of meditation (n = 2 

studies). Studies reported high rates of dropout, suggesting that adherence to meditation 

may be problematic in a clinical setting. With so few studies of moderate quality and a 

small number of participants completing treatments, it is difficult to draw conclusions 

about the efficacy of meditation for the treatment of anxiety disorders.

•	 Relaxation and/or breathing retraining show promise as a CAM therapy for panic 

disorders; however, evidence is limited.

•	 Acupuncture shows some promise as a CAM therapy for depression; however, results 

were mixed. For MDD, acupuncture showed greater effects than sham control on 

depressive symptoms but did not improve response or remission rates. In a fair-quality 

review, acupuncture did not differ significantly from short-term use of antidepressants. 

For patients with post-stroke depression, acupuncture was more effective than short-term 

use of antidepressants. 

•	 Mindfulness-based stress reduction has shown positive effects on anxiety and depressive 

symptoms; however, studies are poor to fair quality.

•	 Most SR studies evaluated small trials that did not provide adequate descriptions of CAM 

strategies to permit replication. Dose, duration, and frequency of interventions sometimes 

varied widely, which, in turn, influenced estimates of pooled effects. 

•	 No included SRs reported effects on health-related quality of life. Reported results 

provided limited data on adverse effects or retention rates. 

•	 The limitations of the current synthesized evidence preclude strong conclusions about 

specific CAM interventions for the treatment of depressive and anxiety disorders. 

However, limited evidence supports the use of meditation, relaxation training and/or 

breathing retraining, and mindfulness-based stress reduction for anxiety and acupuncture 

for depression.

The available evidence on CAM treatments for anxiety or depression has important limitations 

but identifies a small number of therapies that have at least some evidence of positive effects. 

This evidence should be considered together with the direct data on CAM treatments for PTSD 

when planning further treatment studies. Meditation, relaxation and breathing retraining, 

mindfulness-based stress reduction, and acupuncture showed some limited promise for select 

populations with anxiety or depressive symptoms. In our review of CAM for PTSD,7

 we found 
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moderate evidence for benefits from acupuncture and low-quality evidence for meditation. Thus, 

by broadening our review to include closely related conditions, we have identified two additional 

CAM treatments that should be considered for further evaluation in patients with PTSD.

We did not identify any SRs of good or fair quality that synthesized the evidence for 

manipulative and body-based CAM therapies or CAM movement-based or energy therapies 

for depressive and anxiety disorders. Future studies should seek to summarize the available 

evidence on these CAM modalities; however, a dearth of primary studies may preclude 

synthesis. As noted in the Efficacy of Complementary and Alternative Medicine Therapies for 

Posttraumatic Stress Disorder7

 report, designing rigorous tests of some CAM modalities may 

be difficult since sham procedures that are both truly inert and appear sufficiently similar to the 

active intervention are challenging to devise. Future research may want to test these strategies 

in small exploratory trials if there is a sufficient theoretical rationale for a beneficial treatment 

effect. 
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REFERENCES

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2004;351(1):75-77.

2. Kessler RC, Davis RB, Foster DF, et al. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann. Intern. Med. Aug 21 

2001;135(4):262-268.

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US Navy and Marine Corps personnel. BMC Complement Altern Med. 2007;7:16.

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and Alternative Therapies for Posttraumatic Stress Disorder VA-ESP Project #09-010. 2011.

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9. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder 

in the National Comorbidity Survey. Arch. Gen. Psychiatry. Dec 1995;52(12):1048-1060.

10. Brady KT, Clary CM. Affective and anxiety comorbidity in post-traumatic stress disorder 

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11. Dozois DJ, Frewen PA. Specificity of cognitive structure in depression and social phobia: 

a comparison of interpersonal and achievement content. J. Affect. Disord. Feb 2006;90(2-

3):101-109.

12. Goldberg DP, Krueger RF, Andrews G, Hobbs MJ. Emotional disorders: cluster 4 of the proposed meta-structure for DSM-V and ICD-11. Psychol. Med. Dec 2009;39(12):2043-2059.

13. Effectiveness of Continuing Medical Education, Structured Abstract Agency for Healthcare Research and Quality, Rockville, M.D. http://www.ahrp.gov/clinic/tp/cmetp.htm. 

February 2007.

14. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of 

reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet. Nov 27 1999;354(9193):1896-1900.
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15. Shea BJ, Grimshaw JM, Wells GA, et al. Development of AMSTAR: a measurement tool 

to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 

2007;7:10.

16. van der Watt G, Laugharne J, Janca A. Complementary and alternative medicine in the 

treatment of anxiety and depression. Curr Opin Psychiatry. Jan 2008;21(1):37-42.

17. Halbreich U. Systematic reviews of clinical trials of acupuncture as treatment for depression: how systematic and accurate are they? CNS Spectr. Apr 2008;13(4):293-294, 299-300.

18. Uebelacker LA, Epstein-Lubow G, Gaudiano BA, Tremont G, Battle CL, Miller IW. Hatha 

yoga for depression: critical review of the evidence for efficacy, plausible mechanisms of 

action, and directions for future research. J Psychiatr Pract. Jan 2010;16(1):22-33.

19. Teixeira MZ, Guedes CH, Barreto PV, Martins MA. The placebo effect and homeopathy. 

Homeopathy. Apr 2010;99(2):119-129.

20. Even C, Schroder CM, Friedman S, Rouillon F. Efficacy of light therapy in nonseasonal 

depression: a systematic review. J. Affect. Disord. May 2008;108(1-2):11-23.

21. Freeman MP, Mischoulon D, Tedeschini E, et al. Complementary and alternative medicine for major depressive disorder: a meta-analysis of patient characteristics, placeboresponse rates, and treatment outcomes relative to standard antidepressants. J. Clin. 

Psychiatry. Jun 2010;71(6):682-688.

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Cochrane Database of Systematic Reviews. 2010(7). http://www.mrw.interscience.wiley.

com/cochrane/clsysrev/articles/CD008619/frame.html.

23. Thachil AF, Mohan R, Bhugra D. The evidence base of complementary and alternative 

therapies in depression. J. Affect. Disord. Jan 2007;97(1-3):23-35.

24. Tsang HW, Chan EP, Cheung WM. Effects of mindful and non-mindful exercises on people 

with depression: a systematic review. Br. J. Clin. Psychol. Sep 2008;47(Pt 3):303-322.

25. Bohlmeijer E, Prenger R, Taal E, Cuijpers P. The effects of mindfulness-based stress 

reduction therapy on mental health of adults with a chronic medical disease: a meta-analysis. J. Psychosom. Res. Jun 2010;68(6):539-544.

26. Coelho HF, Boddy K, Ernst E. Massage therapy for the treatment of depression: a systematic review. Int. J. Clin. Pract. Feb 2008;62(2):325-333.

27. Hou WH, Chiang PT, Hsu TY, Chiu SY, Yen YC. Treatment effects of massage therapy in 

depressed people: a meta-analysis. J. Clin. Psychiatry. Jul 2010;71(7):894-901.

28. Lee MS, Pittler MH, Ernst E. Effects of reiki in clinical practice: a systematic review of 

randomised clinical trials. Int. J. Clin. Pract. Jun 2008;62(6):947-954.
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29. Meeks TW, Wetherell JL, Irwin MR, Redwine LS, Jeste DV. Complementary and alternative treatments for late-life depression, anxiety, and sleep disturbance: a review of randomized controlled trials. J. Clin. Psychiatry. Oct 2007;68(10):1461-1471.

30. Shih M, Yang YH, Koo M. A meta-analysis of hypnosis in the treatment of depressive 

symptoms: a brief communication. Int. J. Clin. Exp. Hypn. Oct 2009;57(4):431-442.

31. Wang H, Qi H, Wang BS, et al. Is acupuncture beneficial in depression: a meta-analysis 

of 8 randomized controlled trials? J. Affect. Disord. Dec 2008;111(2-3):125-134.

32. Zhang ZJ, Chen HY, Yip KC, Ng R, Wong VT. The effectiveness and safety of acupuncture therapy in depressive disorders: systematic review and meta-analysis. J. Affect. 

Disord. Jul 2010;124(1-2):9-21.

33. Krisanaprakornkit T, Krisanaprakornkit W, Piyavhatkul N, Laopaiboon M. Meditation 

therapy for anxiety disorders. Cochrane Database Syst Rev. 2006(1):CD004998.

34. Sanchez-Meca J, Rosa-Alcazar AI, Marin-Martinez F, Gomez-Conesa A. Psychological 

treatment of panic disorder with or without agoraphobia: a meta-analysis. Clin. Psychol. 

Rev. Feb 2010;30(1):37-50.

35. Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy 

on anxiety and depression: A meta-analytic review. J. Consult. Clin. Psychol. Apr 

2010;78(2):169-183.

36. Raskin M, Bali LR, Peeke HV. Muscle biofeedback and transcendental meditation. A 

controlled evaluation of efficacy in the treatment of chronic anxiety. Arch. Gen. Psychiatry. Jan 1980;37(1):93-97.

37. Shannahoff-Khalsa DS, Ray LE, Levine S, Gallen CC, Schwartz BJ, Sidorowich JJ. 

Randomized controlled trial of yogic meditation techniques for patients with obsessivecompulsive disorder. CNS Spectr. Dec 1999;4(12):34-47.
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APPENDIX A. Search Strategies

Step Goal Terms Result

1 Anxiety Terms (generalized[tiab] AND anxiety[tiab] AND disorder[tiab]) OR 

“generalized anxiety disorder” OR ”generalised anxiety disorder”[tiab] 

OR “panic disorder”[tiab] OR “panic disorder”[mesh] OR “phobic 

disorders”[Mesh] OR agoraphobia[Mesh] OR “obsessive-compulsive 

disorder”[Mesh] OR “stress disorders, traumatic, acute”[mesh] OR 

“anxiety disorder NOS”[tiab] OR (“Adjustment Disorder”[tiab] AND 

anxiety[tiab]) OR “adjustment disorders/therapy”[mesh]

27999

2 Depression terms Depressive disorder[Mesh] OR “subsyndromal depression”[tiab] OR 

“subthreshold depression”[tiab] OR “minor depression”[tiab]

68923

3 Interventions Acupuncture Therapy[Mesh:noexpl] OR Acupuncture Analgesia[Mesh] 

OR Acupuncture, Ear[Mesh] OR Electroacupuncture[Mesh] OR 

Acupuncture[Mesh] OR Acupressure[Mesh] OR Auriculotherapy[Mesh] 

OR acupuncture[All Fields] OR (acupuncture[All Fields] AND 

therapy[All Fields]) OR (acupuncture therapy[All Fields]) OR 

acupressure[All Fields] OR auriculotherapy[All Fields] OR MindBody Therapies[Mesh:noexpl] OR Breathing Exercises[Mesh] 

OR Hypnosis[Mesh] OR Imagery (Psychotherapy)[Mesh] OR 

Meditation[Mesh] OR Mental Healing[Mesh] OR Relaxation 

Therapy[Mesh] OR Tai Ji[Mesh] OR Therapeutic Touch[Mesh] OR 

Yoga[Mesh] OR Mind-Body Relations, Metaphysical[Mesh] OR 

breath[All Fields] OR breath[All Fields:expl] OR Complementary 

Therapies[Mesh:noexpl] OR Holistic Health[Mesh] OR Medicine, 

East Asian Traditional[Mesh] OR Reflexotherapy[Mesh] OR Spiritual 

Therapies[Mesh] OR acoustics[MeSH] OR acoustics[All Fields] 

OR acoustic[All Fields] OR aromatherapy [MeSH] OR sensory[All 

Fields] OR aromatherapy[All Fields] OR art[MeSH] OR art[All 

Fields] OR colour[All Fields] OR color[MeSH] OR color[All Fields] 

OR dance[All Fields] OR music[MeSH] OR music[All Fields] OR 

play and playthings[MeSH] OR (play AND playthings[All Fields]) OR 

play and playthings[All Fields] OR play[All Fields] OR sensory art 

therapies[MeSH] OR reflexotherapy[All Fields] OR craniosacral[All 

Fields] OR magnet[All Fields] OR light[MeSH ] OR light[All Fields] 

OR feldenkrais [Tiab] OR Alexander[Tiab] OR pilates[All Fields] OR 

trager[All Fields] OR movement therapeutic[All Fields] OR movement 

therapies[All Fields] OR movement therapy[All Fields] OR healers[All 

Fields] OR energy[All Fields] OR therapeutic touch[MeSH] OR 

(therapeutic[All Fields] AND touch[All Fields]) OR therapeutic touch[All 

Fields] OR reiki[All Fields]) OR ayurvedic[All Fields]

1689320

3 Study designs Cochrane Database Syst Rev [TA] OR search[Title/Abstract] OR 

meta-analysis[Publication Type] OR MEDLINE[Title/abstract] 

OR (systematic[Title/Abstract] AND review[Title/Abstract]) OR 

Systematic[sb]

271733

4 Combine results 

and apply limits

(#1 OR #2) AND #3 AND #4

LIMITS: English and Human and Years 2006-7/1/2011

133
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APPENDIX B. Eligibility Criteria

Study 

characteristic Inclusion criteria Exclusion criteria

Study design Fair- or good-quality systematic review Non-English language publication

Non-peer-reviewed publication

Population Adults ≥ 19 diagnosed with depressive disorder or 

anxiety 

Depressive disorders could include: major depressive 

disorder, dysthymia, depressive disorder NOS, minor 

or subthreshold depression

Anxiety disorders could include: generalized anxiety 

disorder, panic disorder, obsessive compulsive 

disorder, phobic disorders, acute stress disorder, 

anxiety disorder NOS, adjustment disorder with 

anxiety or mixed anxiety-depression

Seasonal affective disorder

Post-partum depressive disorder

Post traumatic stress disorder

Interventions Any of the following eligible treatments:

•	 Mind-body therapies: acupuncture, meditation, 

yoga, deep-breathing exercises, guided imagery, 

hypnotherapy, progressive relaxation, and tai chi

•	 Manipulative and body-based therapies: spinal 

manipulation and massage therapy

•	 Movement-based therapies: Feldenkrais method, 

Alexander technique, Pilates, Rolfing Structural 

Integration, and Trager Psychophysical Integration

•	 Energy therapies: magnet therapy, light therapy, qi 

gong, Reiki, and healing touch

Interventions used in a continuation 

or maintenance phase

Dietary supplements

Standard psychotherapies 

(e.g., prolonged exposure) and 

extensions of these therapies 

(e.g., mindfulness-based cognitive 

therapy)

Relaxation used as a control arm or 

reported without describing the key 

components

Biofeedback

Comparators Studies comparing an eligible treatment to a 

control condition such as usual care (including no 

treatment), supportive therapy, attention control, sham 

intervention, or a waitlist 

Studies comparing an eligible treatment to an 

empirically based treatment, prolonged exposure, 

cognitive processing therapy, or antidepressant 

medication

None

Outcomes Change in level of depressive or anxiety symptoms 

(i.e., on self-report and/or clinician-administered 

measures, including remission rates) or change in 

quality of life (i.e., functional status and health-related 

quality of life)

Reported at ≥ 6 weeks after treatment initiation

None

Setting Patients recruited from community or outpatient 

mental health or general medical settings 

None.

Abbreviations: DSM = Diagnostic and Statistical Manual of Mental Disorders, VA = Veterans Affairs 
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APPENDIX C. Study Quality Assessment – Systematic

Reviews*

For reviews, first determine whether it is a systematic review (SR). To be a systematic review, it 

must include a methods section that describes: (1) a search strategy, and (2) an a priori approach to 

synthesizing the data. For reviews determined to meet the SR criteria, assess methodological quality.

General instructions: 

Step 1: Grade each of the criteria listed below as “Yes,” “No,” “Can’t tell” or “Not 

Applicable”. Factors to consider when making an assessment are listed under each 

criterion. Where appropriate (particularly when assigning a “No,” or “Can’t tell” score), 

please provide a brief rationale for your decision (in parentheses).

1. Is a focused clinical question clearly stated?

At a minimum, the question should be developed a priori and should clearly identify 

population and outcomes. The study question does not have to be in PICO (Population, 

Intervention, Comparisons, Outcomes) format.

2. Are the search methods used to identify relevant studies clearly described? 

Search methods described in enough detail to permit replication. (The report must include 

years and databases used. Key words and/or MeSH terms must be stated and where feasible 

the search strategy should be provided.)

3. Was a comprehensive literature search performed? 

At least two electronic sources should be searched. Electronic searches should be 

supplemented by consulting: reviews, textbooks, specialized registers, or experts in the field 

and by reviewing the references in the studies found. (OK to limit to key studies.)

4. Are the inclusion/exclusion criteria used to screen primary studies clearly described? 

Inclusion/exclusion criteria described in enough detail to permit replication.

5. Was there duplicate study selection and data extraction?

Did two or more raters make inclusion/exclusion decisions, abstract data, and assess study 

quality – either independently or with one rater over-reading the first raters result?

Was an appropriate method used to resolve disagreements (e.g., a consensus procedure)?

6. Were the characteristics of the included studies provided?

In an aggregated form such as a table, data from the original studies should be provided on 

the participants, interventions and outcomes. The ranges of characteristics in all the studies 

analyzed (e.g., age, race, sex, relevant socioeconomic data, disease status, duration, severity 

or other diseases) should be reported.

7. Was the scientific quality of the included studies assessed and documented?

A priori methods of assessment should be provided and criteria used to assess study quality 

specified in enough detail to permit replication.
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8. Were the methods used to combine the findings of studies appropriate?

For pooled results, an accepted quantitative method of pooling should be used (i.e., more 

than simple addition; e.g., random-effects or fixed-effect model). For pooled results, a 

qualitative and quantitative assessment of homogeneity (Cochran’s Q and/or I

2

) should be 

performed.

9. Was the scientific quality of the included studies used appropriately in formulating 

conclusions?

The results of the methodological rigor and scientific quality should be considered in the 

analysis (e.g. subgroup analyses) and the conclusions of the review, and explicitly stated in 

formulating recommendations.

10. Was publication bias assessed?

Publication bias tested using funnel plots, test statistics (e.g., Egger’s regression test), and/or 

search of trials registry for unpublished studies.

11. Was the conflict of interest stated?

Potential sources of support should be clearly acknowledged in both the systematic review 

and the included studies.

12. Are the stated conclusions supported by the data presented?

Step 2: Rate the overall quality of the SR as “Good,” “Fair,” or “Poor” using the guidance 

below. 

Good = After considering items 1 to 11, item 12 is rated “Yes” with no important limitations. 

This means that few of the items 1 to 11 are rated “No,” and none of the limitations are thought 

to decrease the validity of the conclusions.

Fair = After considering items 1 to 11, item 12 is rated “Yes,” but with at least some important 

limitations. This means that enough of the items 1 to 11 are rated “No” to introduce some 

uncertainty about the validity of the conclusions.

Poor = After considering items 1 to 11, item 12 is rated “No.” This means that several of items 1 

to 11 are rated “No,” introducing serious uncertainty about the validity of the conclusions.

* Adapted from:

1. Effectiveness of Continuing Medical Education, Structured Abstract. February 2007. Agency for Healthcare Research 

and Quality, Rockville, MD. http://www.ahrq.gov/clinic/tp/cmetp.htm

2. Moher D, Cook DJ, Eastwood S et al. Improving the quality of reports of meta-analyses of randomized controlled 

trials: The QUOROM statement. Lancet 1999;354:1896-900.

3. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, Porter A, Tugwell P, Moher D, Bouter LM. 

Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC 

Medical Research Methodology 2007;7:10.
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APPENDIX D: EXCLUDED STUDIES 

All studies listed were reviewed in their full-text version and excluded for the reason indicated.

Reference Design Intervention Population Poor

 not SR not eligible not primary quality SR

 CAM depression 

 treatment or anxiety

Bohlmeijer_2010_EN2000 X

Coelho_2008_EN1926 X

Even_2008_EN1920 X

Freeman_2010_EN2003 X

Halbreich_2008_EN1936 X

Hou_2010_EN1992 X

Lee_2008_EN1937 X

Li_2010_EN2066 X

Meeks_2007_EN1921 X

Shih_2009_EN1990 X

Teixeira_2010_EN1998 X

Thachil_2007_EN1894 X

Tsang_2008_EN1930 X

Uebelacker_2010_EN1986 X

van_der_Watt_2008_EN1932 X