Physical fitness exercise versus cognitive behavior therapy on reducing the depressive symptoms among community-dwelling elderly adults: A randomized controlled trial

Challenges Establishing the Efficacy of Exercise as an Antidepressant Treatment: A Systematic Review and Meta-Analysis of Control Group Responses in Exercise Randomised Controlled Trials

BACKGROUND

Whilst previous meta-analyses have demonstrated that control group responses (CGRs) can negatively influence antidepressant efficacy, no such meta-analysis exists in exercise randomised controlled trials (RCTs).

OBJECTIVE

The aim of this study was to conduct a systematic review and meta-analysis investigating CGRs and predictors in control groups of exercise RCTs among adults with depression.

METHODS

Three authors acquired RCTs from a previous Cochrane review (2013) and conducted updated searches of major databases from January 2013 to August 2015. We included exercise RCTs that (1) involved adults with major depressive disorder (MDD) or depressive symptoms; (2) measured depressive symptoms pre- and post-intervention using a validated measure [e.g. Hamilton Depression Scale (HAM-D)]; and (3) included a non-active control group. A random effects meta-analysis calculating the standardised mean difference (SMD) together with 95 % confidence intervals (CIs) was employed to determine CGR.

RESULTS

Across 41 studies, 1122 adults with depression were included [mean (SD) age 50 (18) years, 63 % female]. A large CGR of improved depressive symptoms was evident across all studies (SMD -0.920, 95 % CI -1.11 to -0.729). CGRs were elevated across all subgroup analyses, including high quality studies (n = 11, SMD -1.430, 95 % CI -1.771 to -1.090) and MDD participants (n = 18, SMD -1.248, 95 % CI = -1.585 to -0.911). The CGR equated to an improvement of -7.5 points on the HAM-D (95 % CI -10.30 to -4.89). In MDD participants, increasing age moderated a smaller CGR, while the percentage of drop-outs, baseline depressive symptoms and a longer control group duration moderated a larger CGR (i.e. improvement) (p < 0.05).

CONCLUSION

In order to demonstrate effectiveness, exercise has to overcome a powerful CGR of approximately double that reported for antidepressant RCTS.

The effect of physical activity on depressive symptoms and quality of life among elderly nursing home residents: Randomized controlled trial

OBJECTIVES

Physical activity may have positive effects on decreasing anxiety, stress and depression, maintaining mental health and ensuring psychological vitality.This study aimed to determine how a "Physical Activity Program" for elderly people in nursing homes affected their depressive symptoms and quality of life.

METHODS

We included 80 individuals aged >65years (40 in the intervention group, 40 controls) in this experimental, randomized, controlled pretest-posttest study. Besides socio-demographic data, depressive symptoms and quality of life were assessed by standardized procedures (Beck Depression Scale [BDI], SF 36 Quality of Life Questionnaire) before and after a ten-weeks lasting "Physical Activity Program", consisting of 10min warm-up activities, 20 mintes rhythmic exercices, 10min cool-down exercises and a 30 mintes free walking period on four days of the week.

RESULTS

In contast to controls, individuals of the intervention group presented with a significant decrease in the BDI after the "Physical Activity Program". Likewise, eight-subscales and two sub-dimensions of the SF 36 Quality of Life Questionnaire significantly improved only in the experimental group (p<0.05).

CONCLUSIONS

Our results suggest that a structured physical activity program positively impacts depressive symptoms and quality of life in elderly individuals.

Effects of a mutual recovery intervention on mental health in depressed elderly community-dwelling adults: a pilot study

Background

The prevalence of depression in the elderly is growing worldwide, and the population aging in China makes depression a major health problem for the elderly adults and a tremendous burden to the society. Effective interventions should be determined to provide an approach solving the problem and improving the situation. This study examined the effectiveness of a mutual recovery program intervention on depressive symptom, sleep quality, and well-being in community-dwelling elderly adults with depressive symptom in Shanghai.

Methods

Recruitment was performed between July 2012 and August 2012. Using a cluster randomized wait-list controlled design, we randomized 6 communities (n = 237) into either the intervention group (3 communities, n = 105) or to a wait-list control group (3 communities, n = 132). All participants met the inclusion criteria for depression, which were defined by The Geriatric Depression Scale (GDS-15). From March to May of 2013, participants in the intervention group underwent a 2-month mutual recovery program intervention. The intervention included seven 90-min, weekly sessions that were based on a standardized self-designed schedule. Depression was used as primary outcome at three measurement moments: baseline (T1), before intervention at 24 weeks (T2), and immediately after intervention at 32 weeks (T3). Well-being and sleep quality were used as the secondary outcomes, and were evaluated based on the WHO-5 Well-being Index (WHO-5) and the Self-administered Sleep Questionnaire (SSQ). Finally, a total of 225 participants who completed all the sessions and the three measurements entered the final analysis. Mixed-model repeated measures ANOVAs were performed to estimate the intervention effects.

Results

There was no significant difference in gender, marriage, age structure, post-work type, and education background between the intervention and control group at baseline. Multivariate ANOVAs showed that there was no significant difference within the groups in terms of sleep, well-being, and depression at baseline and before the intervention. Mixed-model repeated measures ANOVAs detected a group × time interaction on depression, sleep, and well-being and showed a favorable intervention effect within groups immediately after the intervention.

Conclusions

The mutual recovery program could be a creative and effective approach to improve mental health in older community-dwelling adults with depressive symptom.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3930-z) contains supplementary material, which is available to authorized users.

Psychological Treatment of Depression in People Aged 65 Years and Over: A Systematic Review of Efficacy, Safety, and Cost-Effectiveness

Objectives

Depression in elderly people is a major public health concern. As response to antidepressants is often unsatisfactory in this age group, there is a need for evidence-based non-pharmacological treatment options. Our objectives were twofold: firstly, to synthesize published trials evaluating efficacy, safety and cost-effectiveness of psychological treatment of depression in the elderly and secondly, to assess the quality of evidence.

Method

The electronic databases PubMed, EMBASE, Cochrane Library, CINAL, Scopus, and PsycINFO were searched up to 23 May 2016 for randomized controlled trials (RCTs) of psychological treatment for depressive disorders or depressive symptoms in people aged 65 years and over. Two reviewers independently assessed relevant studies for risk of bias. Where appropriate, the results were synthesized in meta-analyses. The quality of the evidence was graded according to GRADE (Grading of Recommendations Assessment, Development and Evaluation).

Results

Twenty-two relevant RCTs were identified, eight of which were excluded from the synthesis due to a high risk of bias. Of the remaining trials, six evaluated problem-solving therapy (PST), five evaluated other forms of cognitive behavioural therapy (CBT), and three evaluated life review/reminiscence therapy. In frail elderly with depressive symptoms, the evidence supported the efficacy of PST, with large but heterogeneous effect sizes compared with treatment as usual. The results for life-review/reminiscence therapy and CBT were also promising, but because of the limited number of trials the quality of evidence was rated as very low. Safety data were not reported in any included trial. The only identified cost-effectiveness study estimated an incremental cost per additional point reduction in Beck Depression Inventory II score for CBT compared with talking control and treatment as usual.

Conclusion

Psychological treatment is a feasible option for frail elderly with depressive symptoms. However, important questions about efficacy, generalizability, safety and cost-effectiveness remain.

Exercise improves physical and psychological quality of life in people with depression: A meta-analysis including the evaluation of control group response

Exercise has established efficacy as an antidepressant in people with depression. However, few meta-analyses have assessed the effects of exercise across different domains of Quality of Life (QoL) in people with depression. Furthermore, there has been no previous meta-analysis of control group response in relation to QoL in exercise trials for depression. Randomized Clinical Trials(RCTs) were initially identified from a Cochrane review, and those including QoL assessments were included in the analysis. Search of major electronic databases were conducted to identify RCTs that compared the exercise effects on QoL versus control condition in people with depression. A random effects meta-analysis was employed to evaluate the Standardized Mean Difference (SMD). Six RCTs were included. Exercise significantly improved physical and psychological domains and overall QoL. Effects on social relationship and environment domains were not significant. No significant control group response was found for any domain or overall QoL. Exercise can be considered as a therapeutic strategy to improve physical and psychological domains and overall QoL of people with depression, with no effect evident across the social and environmental domains. The lack of improvement among control groups reinforces the role of exercise as a treatment for depression with benefits to QoL.

Exercise for depression in older adults: a meta-analysis of randomized controlled trials adjusting for publication bias

OBJECTIVE

To evaluate the antidepressant effects of exercise in older adults, using randomized controlled trial (RCT) data.

METHODS

We conducted a meta-analysis of exercise in older adults, addressing limitations of previous works. RCTs of exercise interventions in older people with depression (≥ 60 years) comparing exercise vs. control were eligible. A random-effects meta-analysis calculating the standardized mean difference (SMD) (95% confidence interval [95%CI]), meta-regressions, and trim, fill, and fail-safe number analyses were conducted.

RESULTS

Eight RCTs were included, representing 138 participants in exercise arms and 129 controls. Exercise had a large and significant effect on depression (SMD = -0.90 [95%CI -0.29 to -1.51]), with a fail-safe number of 71 studies. Significant effects were found for 1) mixed aerobic and anaerobic interventions, 2) at moderate intensity, 3) that were group-based, 4) that utilized mixed supervised and unsupervised formats, and 5) in people without other clinical comorbidities.

CONCLUSION

Adjusting for publication bias increased the beneficial effects of exercise in three subgroup analysis, suggesting that previous meta-analyses have underestimated the benefits of exercise due to publication bias. We advocate that exercise be considered as a routine component of the management of depression in older adults.

Exercise as a treatment for depression: A meta-analysis adjusting for publication bias

The effects of exercise on depression have been a source of contentious debate. Meta-analyses have demonstrated a range of effect sizes. Both inclusion criteria and heterogeneity may influence the effect sizes reported. The extent and influence of publication bias is also unknown. Randomized controlled trials (RCTs) were identified from a recent Cochrane review and searches of major electronic databases from 01/2013 to 08/2015. We included RCTs of exercise interventions in people with depression (including those with a diagnosis of major depressive disorder (MDD) or ratings on depressive symptoms), comparing exercise versus control conditions. A random effects meta-analysis calculating the standardized mean difference (SMD, 95% confidence interval; CI), meta-regressions, trim and fill and fail-safe n analyses were conducted. Twenty-five RCTs were included comparing exercise versus control comparison groups, including 9 examining participants with MDD. Overall, exercise had a large and significant effect on depression (SMD adjusted for publication bias = 1.11 (95% CI 0.79-1.43)) with a fail-safe number of 1057. Most adjusted analyses suggested publication bias led to an underestimated SMD. Larger effects were found for interventions in MDD, utilising aerobic exercise, at moderate and vigorous intensities, in a supervised and unsupervised format. In MDD, larger effects were found for moderate intensity, aerobic exercise, and interventions supervised by exercise professionals. Exercise has a large and significant antidepressant effect in people with depression (including MDD). Previous meta-analyses may have underestimated the benefits of exercise due to publication bias. Our data strongly support the claim that exercise is an evidence-based treatment for depression.

The Current Situation on Major Depressive Disorder in China: Research on Mechanisms and Clinical Practice

Depression is the most disabling disorder worldwide that accounts for the highest proportion of global burden attributable to mental disorders. Major depressive disorder (MDD) is characterized by deep sadness, reduced energy, vegetative nervous system dysregulation, cognitive dysfunction, and even a high suicidal tendency. Although other treatment choices are available, antidepressant medication is the front-line treatment option for MDD. Regarding clinical efficacy, only ~50% of patients respond to frontline antidepressants, and <33% obtain remission. Currently, objective indexes to guide clinical decisions are still lacking. Furthermore, knowledge about the neurobiological mechanisms underlying discrepant antidepressant outcomes is still also fragmentary. In the present review, we discuss the current research progress and clinical opinions on MDD in China.

Predictors of depressive symptoms following the Great East Japan earthquake: A prospective study

We sought to investigate prospectively the association between exposure to disaster (the 2011 East Japan Earthquake) and change in depressive symptoms among community-dwelling older adult survivors. We used two waves of data from the Japan Gerontological Evaluation Study (JAGES), an ongoing population-based, prospective cohort study in Japan. A unique feature of our study was the availability of information about mental health status pre-dating the disaster. Our sample comprised community-dwelling survivors aged 65 and older, who responded to surveys in 2010 (i.e. one year before the disaster) and in 2013 (n = 3464). We categorized disaster exposure according to three types of experiences: loss of family/friends, property damage, and disruption in access to medical service. Our main outcome was change in depressive symptoms, measured by the 15-item geriatric depression scale (GDS). Among the participants, 917 (26.5%) reported losing a family member to the disaster, while a further 537 (15.5%) reported losing a friend. More than half of the participants reported some damage to their homes. After adjusting for demographics and baseline mental health, people whose homes were completely destroyed had significantly elevated depressive symptom scores three years later (+1.22 points, 95%CI: 0.80, 1.64, p < 0.0001). Disruption of psychiatric care was also associated with change in GDS scores (+2.51 points, 95%CI: 1.28, 3.74, p < 0.0001). By contrast, loss of family/friends was no longer associated with GDS after 3 years; +0.18 points (95%CI: -0.018, 0.37, p = 0.08) for loss of family, and -0.045 points (95%CI: -0.28, 0.19, p = 0.71) for loss of friends. Three years after the disaster, survivors of the 2011 earthquake and tsunami appeared to have recovered from loss of loved ones. By contrast, property loss and disruption of psychiatry care were associated with persistent adverse impact on mental health.

Incidence and Prognostic Significance of Depressive Symptoms in Peripheral Artery Disease

Background

We compared the incidence of depression, defined by a Geriatric Depression Score (GDS) ≥6, between people with versus without peripheral artery disease (PAD). We determined whether depressive symptoms were associated with increased mortality in people with and without PAD.

Methods and Results

Nine hundred and fifty‐one PAD patients and 478 non‐PAD patients were recruited from Chicago medical centers and followed prospectively. At baseline and annually, participants completed the GDS (0–15 scale, score ≥6=depression) and 6‐minute walk. Cause of death was confirmed with death certificates. The prevalence of a GDS ≥6 at baseline was 186/951 (19.6%) among PAD versus 63/478 (13.2%) among non‐PAD participants (P=0.003). During a mean follow‐up of 2.7±1.2 years, 122/712 (17.1%) of participants with PAD versus 51/403 (12.7%) without PAD developed a GDS ≥6 (P=0.047). Adjusting for age, sex, race, comorbidities, and other confounders, PAD participants had an increased rate of developing a GDS ≥6 compared to non‐PAD participants (hazard ratio=1.54 (95% CI=1.05–2.25, P=0.026). This association was not statistically significant after adjusting for 6‐minute walk (P=0.258). Among PAD participants, a baseline GDS ≥6 was associated with increased all‐cause mortality, adjusting for confounders (hazard ratio=1.57, 95% CI=1.12–2.21, P=0.009). This association was not significant after adjusting for 6‐minute walk (P=0.224).

Conclusions

People with PAD have a higher incidence of depressive symptoms than people without PAD. In PAD, depressive symptoms are associated with increased all‐cause and cardiovascular mortality. These associations are explained in part by poorer 6‐minute walk among people with PAD and among depressed people with PAD, respectively.

Dropout from exercise randomized controlled trials among people with depression: A meta-analysis and meta regression

OBJECTIVE

Exercise has established efficacy in improving depressive symptoms. Dropouts from randomized controlled trials (RCT's) pose a threat to the validity of this evidence base, with dropout rates varying across studies. We conducted a systematic review and meta-analysis to investigate the prevalence and predictors of dropout rates among adults with depression participating in exercise RCT's.

METHOD

Three authors identified RCT's from a recent Cochrane review and conducted updated searches of major electronic databases from 01/2013 to 08/2015. We included RCT's of exercise interventions in people with depression (including major depressive disorder (MDD) and depressive symptoms) that reported dropout rates. A random effects meta-analysis and meta regression were conducted.

RESULTS

Overall, 40 RCT's were included reporting dropout rates across 52 exercise interventions including 1720 people with depression (49.1 years (range=19-76 years), 72% female (range=0-100)). The trim and fill adjusted prevalence of dropout across all studies was 18.1% (95%CI=15.0-21.8%) and 17.2% (95%CI=13.5-21.7, N=31) in MDD only. In MDD participants, higher baseline depressive symptoms (β=0.0409, 95%CI=0.0809-0.0009, P=0.04) predicted greater dropout, whilst supervised interventions delivered by physiotherapists (β=-1.2029, 95%CI=-2.0967 to -0.3091, p=0.008) and exercise physiologists (β=-1.3396, 95%CI=-2.4478 to -0.2313, p=0.01) predicted lower dropout. A comparative meta-analysis (N=29) established dropout was lower in exercise than control conditions (OR=0.642, 95%CI=0.43-0.95, p=0.02).

CONCLUSIONS

Exercise is well tolerated by people with depression and drop out in RCT's is lower than control conditions. Thus, exercise is a feasible treatment, in particular when delivered by healthcare professionals with specific training in exercise prescription.

Effects of a Social Welfare Program for Health Promotion on Cardiovascular Risk Factors

Background

Socioeconomic status is closely associated with an individual’s health status. However, there are few studies examining the role of exercise-training as part of a community-based social welfare program in socially vulnerable groups. Given this, our aim was to measure whether long-term exercise training as a social welfare program affects the prevalence of depressive symptoms, metabolic syndrome and peripheral blood vessel condition among participants with low household income.

Methods

Twenty-nine adults and twenty-two older adults were recruited into this study with non-radomized, pre/post-test design. The subjects underwent a combined training consisting of aerobic and muscle strengthening exercises for 6 months or more. Depressive symptoms were evaluated using the Beck Depression Inventory and the Korean version of Geriatric Depression Scale. Metabolic syndrome was defined according to the International Diabetes Federation criteria. Blood vessel condition was assessed using non-invasive accelerated photoplethysmograph.

Results

Mean skeletal muscle mass increased after exercise-training, but body mass index and percent body fat were unchanged. Overall age-specific physical fitness and performance increased markedly among both adult and elderly subjects, respectively. The proportion of depressive symptoms was significantly reduced by 33% after exercise-training among all participants. The prevalence of individuals having metabolic syndrome was significantly reduced by 19.6% and the number of individual components of metabolic syndrome decreased after the exercise intervention. Among components of metabolic syndrome, waist circumference, HDL cholesterol and systolic blood pressure significantly improved. In addition, the proportions of moderate and severe arteriosclerotic progression significantly decreased.

Conclusion

Long-term exercise-training as a social welfare program is beneficial for health promotion and effective in simultaneously improving psychological and physiological health status in a low income population. This suggests that the development and expansion of an exercise intervention as a health-promoting welfare program are needed to address the inequality of exercise participation among socially vulnerable groups.