Is ashwagandha (Withania somnifera) supplement recommended as an adjunct for depression treatment?

Ashwagandha as Adjunct for Depression Treatment

Ashwagandha (Withania somnifera) is not recommended as an adjunct for depression treatment based on current clinical practice guidelines, which do not include it among evidence-based adjunctive therapies for major depressive disorder.

Guideline-Based Recommendations for Depression Adjunctive Treatment

The American College of Physicians 2016 guideline on major depressive disorder treatment comprehensively reviewed nonpharmacologic and pharmacologic treatments but does not include ashwagandha or other herbal supplements among recommended adjunctive therapies 1. The guideline focuses on:

• Psychological interventions (cognitive behavioral therapy, interpersonal therapy, acceptance and commitment therapy) 1
• Complementary approaches with evidence: omega-3 fatty acids, S-adenosyl-l-methionine (SAMe), St. John's wort, exercise, acupuncture, meditation, and yoga 1
• Second-generation antidepressants as pharmacologic options 1

The WHO guidelines recommend problem-solving treatment as the primary adjunctive therapy for moderate to severe depression when added to ongoing pharmacotherapy, prioritizing non-pharmacologic augmentation 2. Alternative evidence-based psychological options include cognitive behavioral therapy and interpersonal therapy 2.

Why Ashwagandha Is Not Guideline-Recommended

The absence of ashwagandha from major clinical practice guidelines reflects insufficient high-quality evidence in the specific context of major depressive disorder treatment. The 2016 ACP guideline systematically reviewed complementary and alternative medicine treatments but did not identify ashwagandha as having adequate evidence for recommendation 1.

When guidelines address adjunctive treatments for depression, they consistently recommend:

• First-line: Psychological interventions (CBT, problem-solving therapy) 1, 2
• Pharmacologic augmentation: Bupropion SR or aripiprazole if psychological treatment is insufficient 2

Research Evidence on Ashwagandha (Context and Limitations)

While research studies suggest potential benefits, they have significant limitations:

• A 2019 study showed medium effect sizes (0.683-0.686) for depression and anxiety symptoms in patients with schizophrenia, not primary major depressive disorder 3
• A 2011 animal study in rats showed antidepressant effects when combined with imipramine, but this is preclinical evidence 4
• A 2025 animal study demonstrated antidepressant-like effects in adolescent rats with chronic stress, but again this is not human clinical evidence 5
• A 2020 review noted ashwagandha's traditional use for anxiety and stress, with withanolides as active components, but acknowledged the mechanism of action remains unknown 6

These studies do not establish ashwagandha as an evidence-based adjunctive treatment for major depressive disorder in clinical practice.

Evidence-Based Alternatives You Should Use Instead

For Adjunctive Psychological Treatment:

• Problem-solving treatment as first-line adjunct to antidepressants 2
• Cognitive behavioral therapy (including behavioral activation) 2
• Interpersonal therapy if resources and trained providers are available 2

For Pharmacologic Augmentation (if psychological treatment insufficient):

• Bupropion SR: Lower discontinuation rates (12.5%) due to adverse events compared to other options 2
• Aripiprazole: FDA-approved for adjunctive treatment in unipolar depression 2

For Complementary Approaches with Guideline Support:

• Omega-3 fatty acids (EPA and DHA) are mentioned in cardiovascular guidelines for patients with coronary heart disease and depression 1
• Exercise: Minimum 30 minutes of moderate-intensity physical activity on most days 1

Common Pitfalls to Avoid

• Do not substitute unproven supplements for evidence-based adjunctive treatments when managing inadequate response to antidepressants 1, 2
• Do not delay implementation of guideline-recommended psychological interventions (CBT, problem-solving therapy) in favor of trying herbal supplements first 2
• Avoid polypharmacy with unproven agents when evidence-based augmentation strategies exist 2
• Do not wait beyond 8 weeks to adjust ineffective adjunctive treatment—assess response at 4 and 8 weeks using standardized instruments 2

Clinical Decision Algorithm

1. First step: Add evidence-based psychological intervention (problem-solving therapy or CBT) to ongoing antidepressant 2
2. Assess at 4 and 8 weeks using validated instruments 2
3. If insufficient response after 8 weeks: Add pharmacologic augmentation (bupropion SR or aripiprazole) 2
4. Monitor for adverse events and treatment adherence throughout 2

Ashwagandha does not appear in this evidence-based treatment algorithm and should not be recommended as an adjunctive treatment for major depressive disorder in clinical practice.