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Lifestyle modifications


  • For mild depression: Start with non-pharmacological treatment (2): Work on sleep issues, physical activity, deal with anxiety, simple psychological interventions, self improvement programs based on CBT. Structured counselling if non-pharmacological interventions do not have desired effect. Medications may be used if the former interventions have not the desired outcome (2)


  • St. Johns Wort may be effective for mild and moderate depression and may have similar effect as standard treatment with medications and has less side effects. However, the quality of evidence is weaker and long term effects is uncertain. Optimal dose is not known and various brands have different concentration/dose of St. Johns Wort. In addition it interacts with several types of drugs (2)

  • Avoid excess alcohol (1)

  • Eat a healthy diet (1)


  • Prevention: Physically active people have reduced risk of depression compared to physically inactive people (2)

  • Physical activity - 30 min of moderate intensity most days of the week, may reduce symptoms of mild to moderate depression. Both aerob and resistance training are effective (2)

  • Inform the patient about the benefit of a structured exercise program of 45-60 min 3 times a week over about 12 weeks, preferrably with a personal trainer (2)

  • Physical activity may be a useful addition to pharmacological treatment in people not responding satisfactory to medications (2)

  • Both aerobic and resistance exercise are effective in reducing symptoms of depression, but higher intensity is associated with greater improvements, and may have equal or better effect than psychotherapy and pharmacotherapy (3)

  • Possible mechanisms of action: Biological mechanisms, experience of coping, distraction from negative thoughts and emotions, potential social connection during physical activities (2)

  • Biological mechanisms: increased expression of neurotrophic factors, increased availability of  serotonin and norepinephrine, regulation of  hypothalamic–pituitary–adrenal axis activity and reduced systemic inflammation (3)


  • Sleep problems are common in peopel with depression. Cognitive behavioral therapy for insomnia (CBT-I) is recommended for chronic insomnia (2)


  • As far as possible it is recommended to maintain work, social interactions, and thus reduce loneliness, passiveness and depressive rumination (2)


  • Relaxation training may improve symptoms of depression (1, 4)


  • Light therapy may improve symptoms of depression (1)



Evidence Pyramid


Evidence based on guidelines and evidence based Clinical Decision Systems is written in BOLD

Evidence based on meta analysis or systematic reviews is written in BOLD and CURSIVE

Evidence based on randomized controlled trials is written in plain font

Evidence based on observational / cohort studies is written in CURSIVE

Figure: Evidence pyramid

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