What is the optimal treatment approach for depression among surfers?

Treatment of Depression Among Surfers

Cognitive behavioral therapy (CBT) and second-generation antidepressants (SSRIs/SNRIs) are equally effective first-line treatments for depression in surfers, with CBT offering similar response and remission rates while avoiding medication side effects. 1

Primary Treatment Approach

First-Line Options

For surfers with major depressive disorder, initiate treatment with either:

• Cognitive Behavioral Therapy (CBT) as monotherapy, which demonstrates equivalent efficacy to antidepressants with response rates (RR 0.90,95% CI 0.76-1.07) and remission rates (RR 0.98,95% CI 0.73-1.32) that are statistically indistinguishable from pharmacotherapy 1

• Second-generation antidepressants starting with sertraline 50 mg once daily for adults, which can be titrated up to 200 mg/day based on response 2

• Combined therapy (CBT plus medication) shows superior efficacy compared to either monotherapy alone, particularly for chronic or severe depression 3, 4

Leveraging the Surfing Environment

Surf therapy serves as an effective adjunctive intervention that can be integrated into standard treatment protocols 5:

• Active duty service members with MDD who participated in 6 weeks of surf therapy showed significant reductions in depression scores (p < .001) and were more likely to achieve remission at 3-month follow-up compared to land-based activity (p = .015) 5

• Surf therapy promotes mental health through multiple pathways: enhanced self-efficacy, improved interpersonal skills, mentorship formation, and natural environment exposure 6

• Most participants in surf therapy studies received concurrent psychotherapy or pharmacotherapy, indicating surf therapy functions best as an adjunctive rather than standalone intervention 5

Treatment Selection Algorithm

Use a stepped-care model based on symptom severity: 1

Mild to Moderate Depression:

• Start with CBT alone or surf therapy as adjunctive treatment 1, 5
• Consider complementary approaches: exercise (various aerobic activities), omega-3 fatty acids, S-adenosyl-L-methionine (SAMe), or St. John's wort 1, 3

Moderate to Severe Depression:

• Initiate combined therapy (medication plus CBT) 3, 4
• Add surf therapy as adjunctive intervention if accessible 5
• Start sertraline 50 mg daily, assess within 1-2 weeks for suicidal ideation, then at 4 and 8 weeks for symptom relief 4, 2

Factors Favoring Medication:

• Prior positive response to antidepressants 1
• Severe functional impairment 1
• Recurrent or chronic depression (≥2 prior episodes) 4
• Comorbid anxiety requiring prioritization of depressive symptoms 1

Factors Favoring Psychotherapy:

• Patient preference for non-pharmacologic treatment 1
• Concerns about medication side effects (sexual dysfunction, GI symptoms, sleep disturbances affect >60% of patients) 3, 7
• History of medication non-adherence 1

Monitoring and Treatment Adjustment

Assess treatment response using validated instruments (PHQ-9 or HAM-D) at specific intervals: 1, 3

• Week 1-2: Screen for increased suicidal thoughts and behaviors 4
• Week 4: Assess symptom relief, side effects, and treatment satisfaction 1, 4
• Week 8: If minimal improvement despite good adherence, adjust the regimen 1, 4

Treatment modifications at 8 weeks if inadequate response: 1, 4

• Add CBT to medication or vice versa
• Switch to different SSRI/SNRI (no single agent shows superior efficacy; choose based on side effect profile) 4
• Increase medication dose up to maximum (sertraline 200 mg/day) 2
• Intensify surf therapy participation or add individual therapy if in group format 1

Treatment Duration

Continuation and maintenance phases are critical for preventing relapse: 4

• First episode: Continue treatment for 4-9 months after achieving remission 4
• Recurrent depression (≥2 episodes): Maintain treatment for ≥1 year 4
• Chronic depression: Extended maintenance beyond standard recommendations, often requiring treatment duration >9 months 4

Surf-Specific Considerations

Integrate surf therapy into comprehensive treatment plans: 5, 6

• Structure programs with 5-6 weekly sessions over 5-6 weeks 5, 8
• Ensure qualified surf instructors and mental health oversight 9
• Address potential barriers: surf instruction techniques, family engagement, and natural environment challenges (weather, water conditions) 6
• Monitor attendance rates (≥3 sessions needed for therapeutic benefit) 8

Critical Pitfalls to Avoid

Do not use surf therapy as standalone treatment for moderate-to-severe depression - evidence supports only adjunctive use with concurrent psychotherapy or pharmacotherapy 5

Do not delay treatment modification - if no improvement by 8 weeks, waiting longer without adjustment reduces likelihood of eventual remission 1, 4

Do not underdose or discontinue prematurely - up to 70% of patients fail initial treatment, requiring dose optimization or augmentation strategies 3, 7

Monitor closely for suicidal ideation - SSRIs carry increased risk for suicide attempts compared to placebo, particularly in first 1-2 months 4