Physical exercise and internet-based cognitive-behavioural therapy in the treatment of depression: randomised controlled trial

Wellness Interventions in Psychiatrically Ill Patients: Impact of WILD 5 Wellness, a Five-Domain Mental Health Wellness Intervention on Depression, Anxiety, and Wellness

BACKGROUND: The efficacy of individual wellness interventions are well studied in relation to their respective impacts on psychiatric and mental wellness. To date, there is limited research on programs that incorporate multiple wellness domains and measure psychiatric and wellness markers. AIM: To assess the psychiatric and wellness impact of a nonpharmacologic wellness intervention on subjects receiving psychiatric treatment. METHOD: Forty-one adults with a psychiatric disorder completed the first 30 days of WILD 5 Wellness (Wellness Interventions for Life's Demands), a 90-day self-management mental wellness program that incorporated exercise, mindfulness, sleep, social connectedness, and nutrition. Subjects recorded participation in both workbooks and online surveys. Participants were recruited nationally via online and outpatient clinic advertisements. Wellness and mental health were measured on Days 1 and 30 of the intervention via five instruments: the Patient Health Questionnaire-9 for mood, the Generalized Anxiety Disorder 7-Item Scale for anxiety, the Sleep Condition Indicator for sleep quality, the Sheehan Disability Scale for functionality in psychiatric patients, and the HERO Wellness Scale, which measures happiness, enthusiasm, resilience, optimism, and overall mental wellness. RESULTS: Subjects reported statistically significant improvements across all measures on Day 30. CONCLUSION: The research suggests that this multidomain wellness program may be a valuable adjunct to traditional psychiatric treatment and an accessible tool for all health care providers.

Workplace-Related Interpersonal Group Psychotherapy to Improve Life at Work in Individuals With Major Depressive Disorders: A Randomized Interventional Pilot Study

OBJECTIVES

Individuals suffering from major depressive disorder (MDD) often report workplace-related stress as the major cause of their disorder. Accordingly, workplace-related stress was established as a fifth psychosocial problem area of Interpersonal Psychotherapy (workplace-related Interpersonal Psychotherapy, W-IPT). The aim of the study was to investigate the influence of W-IPT on depressive symptoms and on workplace-related issues in individuals with MDD compared to a treatment-as-usual (TAU) condition.

METHODS

A total of 27 individuals with MDD (mean age = 43 years, 48% males) were randomly assigned either to eight weekly group sessions of W-IPT or to the TAU condition. At baseline, 8 weeks later at the end of the intervention, and 20 weeks later at follow-up, the Hamilton Rating Scale for Depression was conducted. In addition, the participants completed the Beck Depression Inventory, the Work Ability Index (WAI), the Return to Work Attitude (RTW-SE), and the Insomnia Severity Index (ISI).

RESULTS

Symptoms of depression in experts' ratings as well as in self-rated ratings decreased over time, but more so in the W-IPT condition compared to the TAU condition [experts rating: large effect size (d = 1.25) and self-assessment: large effect sizes (d = 0.94)]. The subjective ability to work (WAI) [medium effect size (d = 0.68)], self-efficacy to returning to work RTW-SE [medium effect size (d = 0.57)], and subjective symptoms of insomnia (ISI) [large effect size (d = 1.15)] increased over time, but again more so in the W-IPT condition compared to the TAU condition. The effects of the intervention remained stable from the end of the intervention to follow-up.

CONCLUSIONS

The pattern of results of this pilot study suggests that a newly established fifth IPT focus on workplace-related stress appeared to be particularly efficient in individuals with MDD due to work-related stress in reducing depressive symptoms and reducing sleep complaints as well as in improving occupational outcomes.

Healthy Eating, Physical Activity, and Sleep Hygiene (HEPAS) as the Winning Triad for Sustaining Physical and Mental Health in Patients at Risk for or with Neuropsychiatric Disorders: Considerations for Clinical Practice

Neuropsychiatric disorders stem from gene-environment interaction and their development can be, at least in some cases, prevented by the adoption of healthy and protective lifestyles. Once full blown, neuropsychiatric disorders are prevalent conditions that patients live with a great burden of disability. Indeed, the determinants that increase the affliction of neuropsychiatric disorders are various, with unhealthy lifestyles providing a significant contribution in the interplay between genetic, epigenetic, and environmental factors that ultimately represent the pathophysiological basis of these impairing conditions. On one hand, the adoption of Healthy Eating education, Physical Activity programs, and Sleep hygiene promotion (HEPAS) has the potential to become one of the most suitable interventions to reduce the risk to develop neuropsychiatric disorders, while, on the other hand, its integration with pharmacological and psychological therapies seems to be essential in the overall management of neuropsychiatric disorders in order to reduce the disability and improve the quality of life of affected patients. We present an overview of the current evidence in relation to HEPAS components in the prevention and management of neuropsychiatric disorders and provide suggestions for clinical practice.

Changes in alcohol consumption after treatment for depression: a secondary analysis of the Swedish randomised controlled study REGASSA

OBJECTIVES

Mental health problems and hazardous alcohol consumption often co-exist. Hazardous drinking could have a negative impact on different aspects of health and also negatively influence the effect of mental health treatment. The aims of this study were to examine if alcohol consumption patterns changed after treatment for depression and if the changes differed by treatment arm and patient sex.

METHODS

This study of 540 participants was conducted in a large randomised controlled trial (RCT) that aimed to compare the effect of internet-based cognitive behavioural therapy, physical exercise and treatment as usual on 945 participants with mild-to-moderate depression. Treatment lasted for 12 weeks; alcohol consumption (Alcohol Use Disorder Identification Test (AUDIT)) and depression (Montgomery Åsberg Depression Rating Scale (MADRS)) were assessed at baseline and 12-month follow-up. Changes in alcohol consumption were examined in relation to depression severity, treatment arm and patient sex.

RESULTS

The AUDIT distribution for the entire group remained unchanged after treatment for depression. Hazardous drinkers exhibit decreases in AUDIT scores, although they remained hazardous drinkers according to the cut-off scores. Hazardous drinkers experienced similar improvements in symptoms of depression compared with non-hazardous drinkers, and there was no significant relation between changes in AUDIT score and changes in depression. No differences between treatment arm and patient sex were found.

CONCLUSION

The alcohol consumption did not change, despite treatment effects on depression. Patients with depression should be screened for hazardous drinking habits and offered evidence-based treatment for hazardous alcohol use where this is indicated.

TRIAL REGISTRATION NUMBER

DRKS00008745.

Does stigmatization moderate the association between intention and implementation of learned prevention-strategies at work after a depressive episode? - a cross-sectional pilot study

Background

A depressive episode is a frequent reason for production loss due to long periods of absence at work. To maintain work ability after depression, affected employees need to implement learned coping strategies from interventions at work. Based on the theory of planned behavior, this paper examines how stigmatization relates to the implementation of the learned strategies at the workplace. Further, differences between employees with single or recurrent depressive episode were considered.

Methods

Data of an online survey from 112 participants who returned to work after sick leave because of a depressive episode were analyzed [men = 28 (25%); Age: mean = 42.3, SD = 10.9]. The strategies learned were asked openly, intention and implementation with a questionnaire based on the theory of planned behavior and stigmatization with an adapted version of the German inventory of subjective stigma experience.

Results

Intention is positively (β = .46, p < .001) and anticipated (β = −.18, p = .052) and experienced stigmatization not (β = −.11, p = .27) correlated with implementation. Only anticipated stigmatization moderates the association between intention and implementation (β = .26, p = .003). If individuals report a high intention to implement the learned strategies, stigmatization has no influence on implementation. Under low intention, stigmatization leads to less implementation. Participants with recurrent depressive episodes report higher anticipated stigmatization than participants with a single episode.

Conclusion

When employees return to work after a depressive episode, it is important to address anticipated stigmatization and to develop an organizational culture that helps them to reduce their fear of stigmatization and strengthens their work ability via implementing learned prevention-strategies. The reduction of patient’s anticipated stigmatization should already be considered in the therapy and reduced in cooperation with occupational physicians.

[Exercise for depression treatment. Exercise modalities and types]

The risk of metabolic disorders, including type 2 diabetes and cardiovascular diseases, is increased in depression, there is a decrease in life expectancy by 8-10 years. Pharmacotherapy is the first-line method in the treatment of depression. However, pharmaceutical-related side-effects and resistance to antidepressant pharmacotherapy create serious problems in treatment. Regular exercise not only weakens the symptoms of depression, increases aerobic capacity and muscle strength, but also has a positive effect on comorbid diseases. The purpose of this review is to answer the question, on which parameters of exercise the antidepressant effect depends. The review highlights the results of clinical studies of different types of exercises, intensities and modalities for the treatment of depression over the past 10 years. Because of the contradictory results of the studies, it is impossible to make final conclusions regarding the parameters of exercise. It is possible to say with high probability that in the treatment of depression, moderate and intense aerobic exercises with elements of strength exercises and a variety of coordination exercises more often lead to a positive effect than monotonous exercises with low intensity. It is possible that regular patient adherence to the prescribed exercise regimen is more important than the specific exercise type.

Individually tailored internet treatment in routine care: A feasibility study

INTRODUCTION

Disorder-specific internet treatment, based on cognitive-behavioral therapy, has been a part of routine psychiatric care in Sweden since 2007, provided at the Internet Psychiatry Clinic in Stockholm. Individually tailored treatments, with the opportunity to target more than one condition within the same treatment, has since then been evaluated in randomized trials with promising results. To introduce an individually tailored treatment into a clinical setting originally designed for disorder-specific processes creates challenges, such as how to choose the optimal treatment type for each patient.

METHODS

The feasibility of a proposed new routine for assessment and initiation of either a disorder-specific or an individually tailored treatment was tested on patients self-referring to the Internet Psychiatry Clinic during three weeks (N = 66), by exploring the match between comorbid problem areas and patients' preferred treatments with available disorder-specific treatment options, as well as presenting these patients' preferred problem areas to work with in individually tailored treatment, and evaluating any problems with the proposed routine. The feasibility (i.e. satisfaction, credibility, treatment activity, adherence, and preliminary symptom reductions) in the individually tailored treatment were also explored on a smaller subgroup of eight patients.

RESULTS

A majority (65%) of patients screened had at least 2 comorbid problem areas, although 25% of these comorbid patients that where allocated with the help of the proposed routine still initiated disorder-specific treatment. The proposed assessment routine functioned satisfactorily within the up and running internet clinic. The individually tailored treatment was promising regarding satisfaction, credibility, adherence, and preliminary reductions in symptoms. A notable challenge encountered was that the platform was not set up to assist with assessment process or outcome monitoring for individually tailored treatment.

CONCLUSIONS

It seems feasible to combine individually tailored internet treatment and disorder-specific internet treatment within the same internet clinic. The addition of tailored treatment may prove to increase the number of patients included in treatment.

Effects of physical exercise and stress on hippocampal CA1 and dentate gyrus synaptic transmission and long-term potentiation in adolescent and adult Wistar rats

It is commonly recognized that physical exercise positively affects several CNS regions and improves cognitive abilities. For example, exercise is associated with an increase in neurogenesis and facilitation of long-term potentiation in the hippocampus. Conversely, animal models for depression are associated with a decrease in neurogenesis and a reduction of long-term potentiation in the hippocampus. Although exercise could be a viable option in the treatment of some forms of depression, the mechanisms responsible for such improvements have not been elucidated. In this study, we examine hippocampal function using electrophysiological field recordings in CA1 and dentate gyrus to study baseline synaptic transmission and long-term potentiation in adolescent and adult rats prenatally exposed to the glucocorticoid dexamethasone. One group of animals was allowed to run voluntarily for 10 or 21 days using an exercise wheel before the experiments, and the control group was prevented from running (i.e. the exercise wheel was locked). In adult saline-exposed animals, exercise was associated with increased long-term potentiation in the dentate gyrus. Unexpectedly, in dexamethasone-exposed animals, dentate gyrus long-term potentiation was facilitated, whereas long-term potentiation in CA1 was unaffected by prenatal dexamethasone or by 10 or 21 days of voluntary running. Irrespective of age, prenatal dexamethasone and running had limited effects on synaptic transmission and presynaptic release in CA1 and dentate gyrus. In summary, running facilitates dentate gyrus long-term potentiation in adult animals that resembles the effects of prenatal dexamethasone.

EPA guidance on physical activity as a treatment for severe mental illness: a meta-review of the evidence and Position Statement from the European Psychiatric Association (EPA), supported by the International Organization of Physical Therapists in Mental Health (IOPTMH)

Physical activity (PA) may be therapeutic for people with severe mental illness (SMI) who generally have low PA and experience numerous life style-related medical complications. We conducted a meta-review of PA interventions and their impact on health outcomes for people with SMI, including schizophrenia-spectrum disorders, major depressive disorder (MDD) and bipolar disorder. We searched major electronic databases until January 2018 for systematic reviews with/without meta-analysis that investigated PA for any SMI. We rated the quality of studies with the AMSTAR tool, grading the quality of evidence, and identifying gaps, future research needs and clinical practice recommendations. For MDD, consistent evidence indicated that PA can improve depressive symptoms versus control conditions, with effects comparable to those of antidepressants and psychotherapy. PA can also improve cardiorespiratory fitness and quality of life in people with MDD, although the impact on physical health outcomes was limited. There were no differences in adverse events versus control conditions. For MDD, larger effect sizes were seen when PA was delivered at moderate-vigorous intensity and supervised by an exercise specialist. For schizophrenia-spectrum disorders, evidence indicates that aerobic PA can reduce psychiatric symptoms, improves cognition and various subdomains, cardiorespiratory fitness, whilst evidence for the impact on anthropometric measures was inconsistent. There was a paucity of studies investigating PA in bipolar disorder, precluding any definitive recommendations. No cost effectiveness analyses in any SMI condition were identified. We make multiple recommendations to fill existing research gaps and increase the use of PA in routine clinical care aimed at improving psychiatric and medical outcomes.

Childhood adversities, negative life events and outcomes of non-pharmacological treatments for depression in primary care: A secondary analysis of a randomized controlled trial

Non-pharmacological treatments for depression are effective and available in primary care, but useful prognostic factors are lacking. Childhood adversities (CA) and negative recent life events (RLE) increase the risk and severity of depression, though their effect on treatment outcomes remains understudied. Using a sample of 737 adult participants of a multicenter randomized controlled trial receiving physical exercise, internet based cognitive-behavioral therapy or treatment as usual, alone or in combination with antidepressants, this prospective study aimed to determine the impact of CA, RLE and their interaction as predictors of outcomes of non-pharmacological treatments for mild-moderate depression in primary care. Outcomes were depression severity (MADRS score) and response to treatment (≥50% reduction in MADRS score) after three months. Linear regression and modified Poisson regression were used, interaction was assessed with a product term (CA*RLE) and epidemiological measures of interaction. The number of CA and RLE were associated with higher depression severity at follow-up (CA: β = 0.79, 95% CI: 0.14 to 1.44 and RLE: β = 0.52, 95% CI: 0.14 to 0.72) and showed a trend towards lower rates of response to treatment (RR = 0.94, 95% CI: 0.86 to 1.03; and RLE: RR = 0.95, 95% CI: 0.90 to 0.99). Interaction between CA and RLE was not significant for depression severity (β = 0.10, 95% CI: -2.12 to 0.41) nor for response to treatment (RERI = -0.05, 95% CI = -0.33 to 0.24). CA and RLE are associated with worse outcomes of non-pharmacological treatments in primary care. Further studies to identify predictors of outcomes of non-pharmaological treatments for depression are needed.

The effectiveness and cost-effectiveness of e-health interventions for depression and anxiety in primary care: A systematic review and meta-analysis

PURPOSE

Psychological interventions are labor-intensive and expensive, but e-health interventions may support them in primary care. In this study, we systematically reviewed the effectiveness and cost-effectiveness of e-health interventions for depressive and anxiety symptoms and disorders in primary care.

METHODS

We searched MEDLINE, Cochrane library, Embase, and PsychINFO until January 2018, for randomized controlled trials of e-health interventions for depression or anxiety in primary care. Two reviewers independently screened the identified publications, extracted data, and assessed risk of bias using the Cochrane Collaboration's tool.

RESULTS

Out of 3617 publications, we included 14 that compared 33 treatments in 4183 participants. Overall, the methodological quality was poor to fair. The pooled effect size of e-health interventions was small (standardized mean difference = -0.19, 95%CI -0.31 to -0.06) for depression compared to control groups in the short-term, but this was maintained in the long-term (standardized mean difference = -0.22, 95%CI -0.35 to -0.09). Further analysis showed that e-health for depression had a small effect compared to care as usual and a moderate effect compared to waiting lists. One trial on anxiety showed no significant results. Four trials reported on cost-effectiveness.

LIMITATIONS

The trials studied different types of e-health interventions and had several risks of bias. Moreover, only one study was included for anxiety.

CONCLUSIONS

E-health interventions for depression have a small effect in primary care, with a moderate effect compared to waiting lists. The approach also appeared to be cost-effective for depression. However, we found no evidence for its effectiveness for anxiety.

The effects of component-specific treatment compliance in individually tailored internet-based treatment

The objective of this study was to explore the effects of treatment compliance in a guided individually tailored internet‐based treatment (TAIL) in relation to depression and co‐morbid symptoms. Compliance with the homework in the different treatment components in TAIL, each aimed at a specific condition, was rated for 207 participants by independent assessors. Six subgroups (n = 34–131) were constructed consisting of participants with co‐occurring symptoms of worry, panic, social anxiety, stress, insomnia, or pain. For each group, hierarchical regression was used to investigate whether the total sum of compliance points, Overall Compliance, predicted reductions in depression and in condition‐specific symptoms. Also, in each subgroup, it was tested whether working with specific treatment components, Specific Compliance, predicted reduction of the targeted symptoms. Overall Compliance predicted 15% of the reduction in depression symptoms. For participants with worry, panic, social anxiety, stress, or insomnia, Overall Compliance also predicted symptom reductions in that specific condition. Specific Compliance predicted reduction in the targeted symptoms for participants with social anxiety, stress, and insomnia. Specific Compliance with stress and insomnia components also predicted reductions in depression. Our results strengthen the importance of compliance in internet‐based treatments. Because compliance with stress and insomnia components was particularly important for broad symptom reductions, these conditions should not be ignored when treating patients with co‐morbid symptoms.

Exercise Reduces Salivary Morning Cortisol Levels in Patients with Depression

Purpose of the Study

Cortisol hypersecretion plays a role in depression pathophysiology. Internet-based cognitive behavioural therapy (ICBT) and physical exercise (PE) are new treatment alternatives for depression, and their long-lasting effect on cortisol is unknown. We investigated cortisol level changes after 12 weeks of ICBT, PE or treatment as usual (TAU).

Procedures

The present pre-post repeated measure study analysed data derived from a randomised controlled trial evaluating the effects of 12 weeks' interventions of ICBT, PE and TAU in depressed primary care patients (Sweden 2011-2013) and aimed at prospectively evaluating the within-group effects of ICBT, PE and TAU on diurnal salivary cortisol levels in a small representative subsample (n = 56, 38 and 27, respectively).

Results

We found a marked flattening of the diurnal cortisol slope (p = 0.004) and a reduced cortisol level at awakening (p = 0.017) after 12 weeks of PE treatment. No apparent effects of ICBT or TAU interventions were seen on diurnal cortisol levels.

Conclusions and Message

PE reduced the rate of cortisol level decline across the day in depressed adults. ICBT and TAU treatments had no detectable effects on diurnal cortisol levels. Larger samples are required for the detection and comparison of smaller effects of PE, ICBT and TAU on diurnal cortisol levels.

Individualized Web-Based Exercise for the Treatment of Depression: Randomized Controlled Trial

BACKGROUND

Due to the high prevalence of depressive disorders, it is mandatory to develop therapeutic strategies that provide universal access and require limited financial and human resources. Web-based therapeutic approaches fulfill these conditions.

OBJECTIVE

The objective of our study was to assess the feasibility, acceptability, and efficacy of a supervised, individualized 8-week Web-based exercise intervention conducted for patients with moderate to severe depression.

METHODS

We recruited 20 patients with unipolar depression and randomly assigned them into 2 groups (intervention, exercise program group, n=14, and control, treatment-as-usual group, n=6). At baseline, depressive symptoms were rated via the Quick Inventory of Depressive Symptomatology (QIDS) by patients themselves (QIDS-self-report, QIDS-SR) and by a blinded psychiatrist (QIDS-clinician rating, QIDS-C). In addition, performance diagnostics (lactate analysis, spiroergometry during a treadmill walking test) were conducted. Quality of life was assessed via the Short Form-36 questionnaire (SF-36) and self-efficacy via the General Self-Efficacy scale (GSE). In addition, habitual physical activity (HPA) was determined via the Baecke questionnaire. Participants of the intervention group received exercise schedules once weekly with endurance and strength training instructions. Rating of depressive symptoms was repeated after 6-12 days and 8 weeks; performance diagnostics and the completion of all the questionnaires were repeated after 8 weeks only.

RESULTS

The severity of depression subsided significantly in the intervention group after 8 weeks (median change in QIDS-SR: -5; interquartile range, IQR: -2 to -10), although it was already evident within the first 6-12 days (median change in QIDS-SR: -6; IQR: -2 to -8). During the intervention, participants undertook a median of 75 (IQR: 63 to 98) minutes of endurance training per week or 84% (16 [IQR: 9 to 19] of 19 [IQR: 15 to 21]) recommended endurance units in total. In addition, 9 (IQR: 4 to 12) of 10 (IQR: 8 to 13) recommended strength training exercise units were conducted during the 8 weeks. Performance diagnostics revealed a substantial increase in the maximum output in Watt for the intervention group after 8 weeks. Moreover, the intervention showed a favorable effect on SF-36 items "emotional well-being" and "social functioning" as well as on GSE and HPA scores.

CONCLUSIONS

Our individualized Web-based exercise intervention for moderate to severe depression was highly accepted by the patients and led to a significant and clinically relevant improvement of depressive symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02874833; https://clinicaltrials.gov/ct2/show/NCT02874833 (Archived by WebCite at http://www.webcitation.org/72ZUUR4tE).

Cross-sectional associations of sedentary behaviour and physical activity on depression in Japanese older adults: an isotemporal substitution approach

OBJECTIVES

Reducing sedentary behaviour (SB) and increasing physical activity (PA) have been shown to be associated with decreased depression. However, there are yet few studies examining the potential benefits on older adults' depression, when SB is replaced with PA. This study aimed to examine the associations of objectively assessed SB, light-intensity PA (LPA) and moderate-to-vigorous PA (MVPA) with depression among a sample of Japanese older adults, and to explore impacts of substituting SB with PA on older adults' depression.

DESIGN

Cross-sectional analysis.

SETTING

General community.

PARTICIPANTS

A total of 276 older adults aged 65-85 years living in Japan.

MAIN OUTCOME MEASURES

Three behaviours including the average daily time spent in SB (≤1.5 METs); LPA (>1.5 to <3.0 METs) and MVPA (≥3.0 METs) per day were calculated by accelerometers. Depression was assessed using the Japanese version of the 15-item Geriatric Depression Scale (GDS-15).

RESULTS

Less SB (β=0.129, 95% CI 0.015 to 0.243) and more LPA (β=-0.138, 95% CI -0.265 to -0.011) were found to be significantly and negatively associated with the GDS-15 score in the single-activity model. The isotemporal substitution model found that replacing only 30 min per day of SB with the same amount of LPA to be significantly and negatively associated with the GDS-15 score (β=-0.131, 95% CI -0.260 to -0.002).

CONCLUSIONS

These findings indicated that substituting even small amounts of SB with LPA may contribute to less depression in older adults. Potential favourable effects can be observed for replacing only 30 min per day of SB with LPA.

Computer-Assisted Cognitive-Behavior Therapy in Medical Care Settings

PURPOSE OF REVIEW

We reviewed research on computer-assisted cognitive-behavior therapy (CCBT) performed in medical settings with the goals of assessing the effectiveness of this newer method of treatment delivery, evaluating the need for clinician support of therapeutic computer programs, and making suggestions for future research and clinical implementation.

RECENT FINDINGS

The overall results of randomized, controlled trials suggest that CCBT can be an effective treatment for depression in primary care patients and health care anxiety. Also, it can be a useful component of treatment for somatic conditions including irritable bowel syndrome, diabetes, fibromyalgia, and chronic pain. The amount and type of clinician support needed for maximizing effectiveness remains unclear. CCBT offers promise for overcoming barriers to delivering effective psychotherapy in medical settings. We recommend that next steps for researchers include more definitive studies of the influence of clinician support, investigations focused on implementation in clinical practices, cost-benefit analyses, and use of technological advances.

Cardiorespiratory fitness and response to exercise treatment in depression

BACKGROUND

Exercise improves cardiorespiratory fitness (CRF) and reduces depressive symptoms in people with depression. It is unclear if changes in CRF are a predictor of the antidepressant effect of exercise in people with depression.

AIMS

To investigate whether an increase in CRF is a predictor of depression severity reduction after 12 weeks of exercise (trial registration: DRKS study ID, DRKS00008745).

METHOD

The present study includes participants who took part in vigorous (n = 33), moderate (n = 38) and light (n = 39) intensity exercise and had CRF information (as predicted maximal oxygen uptake, V̇O_2max) collected before and after the intervention. Depression severity was measured with the Montgomery-Åsberg Depression Rating Scale (MADRS). V̇O_2max (L/min) was assessed with the Åstrand-Rhyming submaximal cycle ergometry test. The main analysis was conducted pooling all exercise intensity groups together.

RESULTS

All exercise intensities improved V̇O_2max in people with depression. Regardless of frequency and intensity of exercise, an increase in post-treatment V̇O_2max was significantly associated with reduced depression severity at follow-up (B = -3.52, 95% CI -6.08 to -0.96); adjusting for intensity of exercise, age and body mass index made the association stronger (B = -3.89, 95% CI -6.53 to -1.26). Similarly, increased V̇O_2max was associated with higher odds (odds ratio = 3.73, 95% CI 1.22-11.43) of exercise treatment response (≥50% reduction in MADRS score) at follow-up.

CONCLUSIONS

Our data suggest that improvements in V̇O_2max predict a greater reduction in depression severity among individuals who were clinically depressed. This finding indicates that improvements in V̇O_2max may be a marker for the underpinning biological pathways for the antidepressant effect of exercise.

DECLARATION OF INTEREST

None.

[Physical activity as therapeutic intervention for depression]

AIM

This article gives a conspectus of the present state of research on the efficiency of exercise as a treatment for patients suffering from depression.

METHODS

A systematic review of articles published between December 1980 and March 2016 was carried out. The review focused on studies that examined the effects of exercise compared to control conditions in the treatment of depression. Extracted and analyzed information from the articles included details about participants, characteristics of exercise and control conditions, assessments, study design and outcomes.

RESULTS

A total of 34 of the 48 studies included in the literature search reported a significant reduction of depressive symptoms due to exercise interventions. There was a trend to reduced depressive symptoms following the exercise interventions in five studies. In nine studies no positive impact of exercise on depression and affective well-being could be detected.

DISCUSSION

This review article shows that physical activity decreases depressive symptoms and increases affective well-being in patients with depressive diseases; therefore, exercise should be recommended as a component of depression treatment within the framework of a multi-dimensional approach.

Cost-effectiveness of internet-based cognitive-behavioural therapy and physical exercise for depression

BACKGROUND

Both internet-based cognitive-behavioural therapy (ICBT) and physical exercise are alternatives to treatment as usual (TAU) in managing mild to moderate depression in primary care.

AIMS

To determine the cost-effectiveness of ICBT and physical exercise compared with TAU in primary care.

METHOD

Economic evaluation of a randomised controlled trial (N = 945) in Sweden. Costs were estimated by a service use questionnaire and used together with the effects on quality-adjusted life-years (QALYs). The primary 3-month healthcare provider perspective in primary care was complemented by a 1-year societal perspective.

RESULTS

The primary analysis showed that incremental cost per QALY gain was €8817 for ICBT and €14 571 for physical exercise compared with TAU. At the established willingness-to-pay threshold of €21 536 (£20 000) per QALY, the probability of ICBT being cost-effective is 90%, and for physical exercise is 76%, compared with TAU.

CONCLUSIONS

From a primary care perspective, both ICBT and physical exercise for depression are likely to be cost-effective compared with TAU.

DECLARATION OF INTEREST

None.

Comparing individually tailored to disorder-specific internet-based cognitive-behavioural therapy: benchmarking study

Disorder-specific internet-based cognitive-behavioural therapy (ICBT) is effective for depression, panic disorder and social anxiety. In this benchmarking study, a new, individually tailored, ICBT programme (TAIL) showed effects on depression (n = 284, d = 1.33) that were non-inferior to disorder-specific ICBT for depression in routine care (n = 2358, d = 1.35). However, the hypotheses that TAIL for individuals with social anxiety or panic disorder is inferior to disorder-specific ICBT could not be rejected (social anxiety: TAIL d = 0.74 versus disorder-specific d = 0.81; panic: TAIL d = 1.11 versus disorder-specific d = 1.47). Our findings strengthen the empirical base for TAIL as an alternative to disorder-specific ICBT for depression.

DECLARATION OF INTEREST

None.

Do guided internet-based interventions result in clinically relevant changes for patients with depression? An individual participant data meta-analysis

Little is known about clinically relevant changes in guided Internet-based interventions for depression. Moreover, methodological and power limitations preclude the identification of patients' groups that may benefit more from these interventions. This study aimed to investigate response rates, remission rates, and their moderators in randomized controlled trials (RCTs) comparing the effect of guided Internet-based interventions for adult depression to control groups using an individual patient data meta-analysis approach. Literature searches in PubMed, Embase, PsycINFO and Cochrane Library resulted in 13,384 abstracts from database inception to January 1, 2016. Twenty-four RCTs (4889 participants) comparing a guided Internet-based intervention with a control group contributed data to the analysis. Missing data were multiply imputed. To examine treatment outcome on response and remission, mixed-effects models with participants nested within studies were used. Response and remission rates were calculated using the Reliable Change Index. The intervention group obtained significantly higher response rates (OR = 2.49, 95% CI 2.17-2.85) and remission rates compared to controls (OR = 2.41, 95% CI 2.07-2.79). The moderator analysis indicated that older participants (OR = 1.01) and native-born participants (1.66) were more likely to respond to treatment compared to younger participants and ethnic minorities respectively. Age (OR = 1.01) and ethnicity (1.73) also moderated the effects of treatment on remission.Moreover, adults with more severe depressive symptoms at baseline were more likely to remit after receiving internet-based treatment (OR = 1.19). Guided Internet-based interventions lead to substantial positive treatment effects on treatment response and remission at post-treatment. Thus, such interventions may complement existing services for depression and potentially reduce the gap between the need and provision of evidence-based treatments.

Association of Efficacy of Resistance Exercise Training With Depressive Symptoms: Meta-analysis and Meta-regression Analysis of Randomized Clinical Trials

IMPORTANCE

The physical benefits of resistance exercise training (RET) are well documented, but less is known regarding the association of RET with mental health outcomes. To date, no quantitative synthesis of the antidepressant effects of RET has been conducted.

OBJECTIVES

To estimate the association of efficacy of RET with depressive symptoms and determine the extent to which logical, theoretical, and/or prior empirical variables are associated with depressive symptoms and whether the association of efficacy of RET with depressive symptoms accounts for variability in the overall effect size.

DATA SOURCES

Articles published before August 2017, located using Google Scholar, MEDLINE, PsycINFO, PubMed, and Web of Science.

STUDY SELECTION

Randomized clinical trials included randomization to RET (n = 947) or a nonactive control condition (n = 930).

DATA EXTRACTION AND SYNTHESIS

Hedges d effect sizes were computed and random-effects models were used for all analyses. Meta-regression was conducted to quantify the potential moderating influence of participant and trial characteristics.

MAIN OUTCOMES AND MEASURES

Randomized clinical trials used validated measures of depressive symptoms assessed at baseline and midintervention and/or postintervention. Four primary moderators were selected a priori to provide focused research hypotheses about variation in effect size: total volume of prescribed RET, whether participants were healthy or physically or mentally ill, whether or not allocation and/or assessment were blinded, and whether or not the RET intervention resulted in a significant improvement in strength.

RESULTS

Fifty-four effects were derived from 33 randomized clinical trials involving 1877 participants. Resistance exercise training was associated with a significant reduction in depressive symptoms with a moderate-sized mean effect ∆ of 0.66 (95% CI, 0.48-0.83; z = 7.35; P < .001). Significant heterogeneity was indicated (total Q = 216.92, df = 53; P < .001; I2 = 76.0% [95% CI, 72.7%-79.0%]), and sampling error accounted for 32.9% of observed variance. The number needed to treat was 4. Total volume of prescribed RET, participant health status, and strength improvements were not significantly associated with the antidepressant effect of RET. However, smaller reductions in depressive symptoms were derived from randomized clinical trials with blinded allocation and/or assessment.

CONCLUSIONS AND RELEVANCE

Resistance exercise training significantly reduced depressive symptoms among adults regardless of health status, total prescribed volume of RET, or significant improvements in strength. Better-quality randomized clinical trials blinding both allocation and assessment and comparing RET with other empirically supported treatments for depressive symptoms are needed.

The association between paternal depressogenic cognitive styles during pregnancy and offspring depressogenic cognitive styles: an 18-year prospective cohort study

BACKGROUND

Preventing the development of depressogenic or negative cognitive styles could also prevent the development of depression, a leading public health problem worldwide. Maternal negative cognitive styles are a modifiable risk factor for the development of negative cognitive styles in offspring. However, evidence on the role of paternal negative cognitive styles is inconclusive and there have only been a few small studies, which may also have lacked statistical power.

METHODS

We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC) to investigate the association between paternal negative cognitive styles, measured when mothers were 18 weeks pregnant, and offspring negative cognitive styles 18 years later (N = 6,123). Associations were calculated using linear regression models, before and after adjustment for confounders including maternal negative cognitive styles. We compared associations before and after controlling for depression in parents and offspring, and used multiple imputation to reduce biases that may have arisen due to missing data.

RESULTS

A two-standard deviation increase in paternal negative cognitive style was associated with a 3-point increase in offspring negative cognitive style (95% CI 1.36-4.37). This association remained after adjustment for confounders and was independent of depression in both parents and offspring. The effect size was equivalent to that of maternal negative cognitive style, and was also independent of maternal negative cognitive style.

CONCLUSIONS

Our results suggest that fathers should be included in individual- and family-based interventions designed to prevent the development of depressogenic cognitive styles in adolescent offspring. This could possibly also prevent the development of depression.

Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis

BACKGROUND

A 2010 meta-analysis of internet-delivered CBT (iCBT) RCTs argued 'computer therapy for the anxiety and depressive disorders was effective, acceptable and practical health care' without data on effectiveness or practicality in routine practice.

METHODS

Databases, reviews and meta-analyses were searched for randomised controlled trials of cCBT or iCBT versus a control group (care as usual, waitlist, information control, psychological placebo, pill placebo, etc.) in people who met diagnostic criteria for major depression, panic disorder, social anxiety disorder or generalised anxiety disorder. Number randomised, superiority of treatment versus control (Hedges'g) on primary outcome measure, length of follow-up, follow up outcome, patient adherence and satisfaction/harm were extracted; risk of bias was assessed. A search for studies on effectiveness of iCBT in clinical practice was conducted.

RESULTS

64 trials were identified. The mean effect size (efficacy) was g = 0.80 (NNT 2.34), and benefit was evident across all four disorders. Improvement was maintained at follow-with good acceptability. Research probity was good, and bias risk low. In addition, nine studies comparing iCBT with traditional face-to-face CBT and three comparing iCBT with bibliotherapy were identified. All three modes of treatment delivery appeared equally beneficial. The results of effectiveness studies were congruent with the results of the efficacy trials.

LIMITATIONS

Studies variably measured changes in quality of life and disability, and the lack of comparisons with medications weakens the field.

CONCLUSIONS

The conclusions drawn in the original meta-analysis are now supported: iCBT for the anxiety and depressive disorders is effective, acceptable and practical health care.

Tobacco use does not influence the response to non-pharmacologic depression treatment: A secondary analysis of the Regassa randomized controlled trial

Behavioural interventions show promising results among patients with mild- to moderate depression. However, whether tobacco use moderates the effects of these interventions is not known. In the present study, we examined whether patients suffering from mild-to-moderate depression differed in their response to prescribed physical exercise or internet-based cognitive behavioural therapy (ICBT) according to their current tobacco use. We conducted a secondary analysis of data from 740 participants in a multicentre randomised controlled trial comparing physical exercise, internet-based cognitive behavioural therapy and treatment as usual (Regassa study). Information on current daily tobacco use was self-reported at baseline. Linear and logistic regression were used to examine the treatments' effect (reduction in depression score) in the subgroups of tobacco users (n=154) and non-users (n=586). We found that baseline tobacco use did not significantly moderate the association between treatment type and post-treatment depression severity. Both interventions (exercise and ICBT) resulted in a reduction of depression scores that was similar among non-users and users of tobacco, albeit formally statistically significant only among non-users. Physical exercise on prescription and ICBT can be used in the clinical management of depressed patients, with similar prognostic advantage among tobacco users and non-users.

Improving the Efficiency of Psychotherapy for Depression: Computer-Assisted Versus Standard CBT

OBJECTIVE

The authors evaluated the efficacy and durability of a therapist-supported method for computer-assisted cognitive-behavioral therapy (CCBT) in comparison to standard cognitive-behavioral therapy (CBT).

METHOD

A total of 154 medication-free patients with major depressive disorder seeking treatment at two university clinics were randomly assigned to either 16 weeks of standard CBT (up to 20 sessions of 50 minutes each) or CCBT using the "Good Days Ahead" program. The amount of therapist time in CCBT was planned to be about one-third that in CBT. Outcomes were assessed by independent raters and self-report at baseline, at weeks 8 and 16, and at posttreatment months 3 and 6. The primary test of efficacy was noninferiority on the Hamilton Depression Rating Scale at week 16.

RESULTS

Approximately 80% of the participants completed the 16-week protocol (79% in the CBT group and 82% in the CCBT group). CCBT met a priori criteria for noninferiority to conventional CBT at week 16. The groups did not differ significantly on any measure of psychopathology. Remission rates were similar for the two groups (intent-to-treat rates, 41.6% for the CBT group and 42.9% for the CCBT group). Both groups maintained improvements throughout the follow-up.

CONCLUSIONS

The study findings indicate that a method of CCBT that blends Internet-delivered skill-building modules with about 5 hours of therapeutic contact was noninferior to a conventional course of CBT that provided over 8 additional hours of therapist contact. Future studies should focus on dissemination and optimizing therapist support methods to maximize the public health significance of CCBT.

Novel technology as platform for interventions for caregivers and individuals with severe mental health illnesses: A systematic review

BACKGROUND

Severe mental illnesses (SMIs) have been found to be associated with both increases in morbidity-mortality, need for treatment care in patients themselves, and burden for relatives as caregivers. A growing number of web-based and mobile software applications have appeared that aim to address various barriers with respect to access to care. Our objective was to review and summarize recent advancements in such interventions for caregivers of individuals with a SMI.

METHODS

We conducted a systematic search for papers evaluating interactive mobile or web-based software (using no or only minimal support from a professional) specifically aimed at supporting informal caregivers. We also searched for those supporting patients with SMI so as to not to miss any which might include relatives.

RESULTS

Out of a total of 1673 initial hits, we identified 11 articles reporting on 9 different mobile or web-based software programs. The main result is that none of those studies focused on caregivers, and the ones we identified using mobile or web-based applications were just for patients and not their relatives.

LIMITATIONS

Differentiating between online and offline available software might not always have been totally reliable, and we might have therefore missed some studies.

CONCLUSIONS

In summary, the studies provided evidence that remotely accessible interventions for patients with SMI are feasible and acceptable to patients. No such empirically evaluated program was available for informal caregivers such as relatives. Keeping in mind the influential role of those informal caregivers in the process of treatment and self-management, this is highly relevant for public health. Supporting informal caregivers can improve well-being of both caregivers and patients.

Effects of internet-based cognitive behavioural therapy and physical exercise on sick leave and employment in primary care patients with depression: two subgroup analyses

OBJECTIVES

Depression can negatively impact work capacity, but treatment effects on sick leave and employment are unclear. This study evaluates if internet-based cognitive behavioural therapy (ICBT) or physical exercise (PE), with already reported positive effects on clinical outcome and short-term work ability, has better effects on employment, sick leave and long-term work ability compared with treatment as usual (TAU) for depressed primary care patients (German clinical trials: DRKS00008745).

METHODS

After randomisation and exclusion of patients not relevant for work-related analysis, patients were divided into two subgroups: initially unemployed (total n=118) evaluated on employment, and employed (total n=703) evaluated on long-term sick leave. Secondary outcomes were self-rated work ability and average number of sick days per month evaluated for both subgroups. Assessments (self-reports) were made at baseline and follow-up at 3 and 12 months.

RESULTS

For the initially unemployed subgroup, 52.6% were employed after 1 year (response rate 82%). Both PE (risk ratio (RR)=0.44; 95% CI 0.23 to 0.87) and ICBT (RR=0.37; 95% CI 0.16 to 0.84) showed lower rates compared with TAU after 3 months, but no difference was found after 1 year (PE: RR=0.97; 95% CI 0.69 to 1.57; ICBT: RR=1.23; 95% CI 0.72 to 2.13). For those with initial employment, long-term sick leave (response rate 75%) decreased from 7.8% to 6.5%, but neither PE (RR=1.4; 95% CI 0.52 to 3.74) nor ICBT (RR=0.99; 95% CI 0.39 to 2.46) decreased more than TAU, although a temporary positive effect for PE was found. All groups increased self-rated work ability with no differences found.

CONCLUSIONS

No long-term effects were found for the initially unemployed on employment status or for the initially employed on sick leave. New types of interventions need to be explored.

Exercise Leads to Better Clinical Outcomes in Those Receiving Medication Plus Cognitive Behavioral Therapy for Major Depressive Disorder

OBJECTIVE

The aim of this study is to investigate the effects of exercise as an add-on therapy with antidepressant medication and cognitive behavioral group therapy (CBGT) on treatment outcomes in low-active major depressive disorder (MDD) patients. We also explored whether exercise reduces the residual symptoms of depression, notably cognitive impairment and poor sleep quality, and aimed to identify putative biochemical markers related to treatment response.

METHODS

Sixteen low-active MDD patients were recruited from a mental health day treatment program at a local hospital. Eight medicated patients performed an 8-week exercise intervention in addition to CBGT, and eight medicated patients attended the CBGT only. Twenty-two low-active, healthy participants with no history of mental health illness were also recruited to provide normal healthy values for comparison.

RESULTS

Results showed that exercise resulted in greater reduction in depression symptoms (p = 0.007, d = 2.06), with 75% of the patients showing either a therapeutic response or a complete remission of symptoms vs. 25% of those who did not exercise. In addition, exercise was associated with greater improvements in sleep quality (p = 0.046, d = 1.28) and cognitive function (p = 0.046, d = 1.08). The exercise group also had a significant increase in plasma brain-derived neurotrophic factor (BDNF), p = 0.003, d = 6.46, that was associated with improvements in depression scores (p = 0.002, R² = 0.50) and sleep quality (p = 0.011, R² = 0.38).

CONCLUSION

We provide evidence that exercise as an add-on to conventional antidepressant therapies improved the efficacy of standard treatment interventions. Our results suggest that plasma BDNF levels and sleep quality appear to be good indicators of treatment response and potential biomarkers associated with the clinical recovery of MDD.

Psychiatric In-Patients Are More Likely to Meet Recommended Levels of Health-Enhancing Physical Activity If They Engage in Exercise and Sport Therapy Programs

Background: People with mental disorders engage in sedentary behaviors more often than their healthy counterparts. In Switzerland, nearly all psychiatric hospitals offer structured exercise and sport therapy as part of their standard therapeutic treatment. However, little is known about the degree to which psychiatric patients make use of these treatment offers. The aim of this study is to examine, in a sample of psychiatric in-patients (a) how many participate in the structured exercise and sport therapy programs offered by the clinic, (b) how many engage in exercise and sport activities on an individual basis, and (c) how many meet recommended levels of health-enhancing physical activity during their stay at the clinic. Furthermore, we examine whether those who engage in exercise and sport activities are more likely to meet internationally accepted physical activity recommendations. Methods: 107 psychiatric in-patients (49% women, M_age = 39.9 years) were recruited at three psychiatric clinics in the German-speaking part of Switzerland. All participants were engaged in treatment and received usual care. Based on accelerometer data, participants were classified as either meeting or not meeting physical activity recommendations (≥150 min of moderate-to-vigorous physical activity per week). Participation in structured and individually performed exercise and sport activities was assessed with the Simple Physical Activity Questionnaire. Results: In total, 57% of all patients met physical activity recommendations. 55% participated in structured exercise and sport therapy activities, whereas only 22% of all patients engaged in exercise and sport activities independently. Psychiatric patients were significantly more likely to meet recommended levels of health-enhancing physical activity if they engaged in at least 60 min per week of structured exercise and sport therapy or in at least 30 min of individually performed exercise and sport activity. Conclusions: Given that prolonged immobilization and sedentary behavior have harmful effects on patients' physical and mental well-being, promoting exercise and sport activities is an important endeavor in psychiatric care. Clinics currently succeed in involving between 50 and 60% of all patients in sufficient physical activity. While this is encouraging, more systematic efforts are needed to ensure that all patients get enough physical activity.

Preferences for Depression Treatment Including Internet-Based Interventions: Results From a Large Sample of Primary Care Patients

Background: To date, little is known about treatment preferences for depression concerning new media. This study aims to (1) investigate treatment preferences for depression including internet-based interventions and (2) examine subgroup differences concerning age, gender and severity of depression as well as patient-related factors associated with treatment preferences. Methods: Data were derived from the baseline assessment of the @ktiv-trial. Depression treatment preferences were assessed from n = 641 primary care patients with mild to moderate depression regarding the following treatments: medication, psychotherapy, combined treatment, alternative treatment, talking to friends and family, exercise, self-help literature, and internet-based interventions. Depression severity was specified by GPs according to ICD-10 criteria. Ordinal logistic regression models were conducted to identify associated factors of treatment preferences. Results: Patients had a mean age of 43.9 years (SD = 13.8) and more than two thirds (68.6%) were female. About 43% of patients had mild depression while 57% were diagnosed with moderate depression. The majority of patients reported strong preferences for psychotherapy, talking to friends and family, and exercise. About one in five patients was very likely to consider internet-based interventions in case of depression. Younger patients expressed significantly stronger treatment preferences for psychotherapy and internet-based interventions than older patients. The most salient factors associated with treatment preferences were the patients' education and perceived self-efficacy. Conclusions: Patients with depression report individually different treatment preferences.Our results underline the importance of shared decision-making within primary care. Future studies should investigate treatment preferences for different types of internet-based interventions.

Prediction of treatment outcomes to exercise in patients with nonremitted major depressive disorder

BACKGROUND

Only one-third of patients with major depressive disorder (MDD) achieve remission with initial treatment. Consequently, current clinical practice relies on a "trial-and-error" approach to identify an effective treatment for each patient. The purpose of this report was to determine whether we could identify a set of clinical and biological parameters with potential clinical utility for prescription of exercise for treatment of MDD in a secondary analysis of the Treatment with Exercise Augmentation in Depression (TREAD) trial.

METHODS

Participants with nonremitted MDD were randomized to one of two exercise doses for 12 weeks. Participants were categorized as "remitters" (≤12 on the IDS-C), nonresponders (<30% drop in IDS-C), or neither. The least absolute shrinkage and selection operator (LASSO) and random forests were used to evaluate 30 variables as predictors of both remission and nonresponse. Predictors were used to model treatment outcomes using logistic regression.

RESULTS

Of the 122 participants, 36 were categorized as remitters (29.5%), 56 as nonresponders (45.9%), and 30 as neither (24.6%). Predictors of remission were higher levels of brain-derived neurotrophic factor (BDNF) and IL-1B, greater depressive symptom severity, and higher postexercise positive affect. Predictors of treatment nonresponse were low cardiorespiratory fitness, lower levels of IL-6 and BDNF, and lower postexercise positive affect. Models including these predictors resulted in predictive values greater than 70% (true predicted remitters/all predicted remitters) with specificities greater than 25% (true predicted remitters/all remitters).

CONCLUSIONS

Results indicate feasibility in identifying patients who will either remit or not respond to exercise as a treatment for MDD utilizing a clinical decision model that incorporates multiple patient characteristics.

Long-term effects of exercise at different intensity levels on depression: A randomized controlled trial

Previous research has shown positive effects of exercise on depression but studies have mainly focused on the short-term effects; few have examined the long-term effect, especially with regard to differences in intensity. The aim of this study was to examine the long-term effects of prescribed exercise on depression, performed at three intensity levels. People aged 18-67years with mild to moderate depression (Patient Health Questionnaire-9 score of ≥10) participated in a single-blind, parallel randomized control trial lasting 12weeks (Sweden 2011-2013). Four arms were included: Treatment as usual (TAU, n=310), light (n=106), moderate (n=105) and vigorous exercise (n=99). Severity of depression was measured at baseline, post-treatment and 12-month follow-up using the Montgomery-Åsberg Depression Rating Scale (MADRS). Coefficients (β) and odds ratios were estimated using linear mixed models with time×group interactions. The results showed that at the 12month follow-up the light exercise group had significantly lower depression severity scores than the TAU (-1.9, 95% CI: -3.7, -0.04) and the moderate exercise group (-2.94 95% CI: -5.2, -0.7). The vigorous exercise group had significantly lower scores than the moderate exercise group only (-2.7, 95% CI: -4.9, -0.4). In conclusion, compared to usual care for depression, only light exercise resulted in significantly lower depression severity at 12-month follow-up. Both light and vigorous exercise was more effective than moderate exercise.

TRIAL REGISTRATION

The study was registered with the German Clinical Trial Register (DRKS study ID: DRKS00008745).

Internet delivered cognitive behavior therapy for antenatal depression: A randomised controlled trial

Major depression occurs in 5-10% of pregnancies and is associated with many negative effects for mother and child, yet treatment options are scarce. To our knowledge, this is the first published randomised controlled trial on Internet delivered Cognitive Behavior Therapy (ICBT) for this group.

OBJECTIVE

To test the efficacy of a pregnancy adapted version of an existing 10-week ICBT-program for depression as well as assessing acceptability and adherence DESIGN: Randomised controlled trial.

SETTING

Online and telephone.

POPULATION OR SAMPLE

Self-referred pregnant women (gestational week 10-28 at intake) currently suffering from major depressive disorder.

METHODS

42 pregnant women (gestational week 12-28) with major depression were randomised to either treatment as usual (TAU) provided at their antenatal clinic or to ICBT as an add-on to usual care.

MAIN OUTCOME MEASURES

The primary outcome was depressive symptoms measured with the Montgomery-Åsberg depression rating scale-self report (MADRS-S). The Edinburgh Postnatal Depression Scale and measures of anxiety and sleep were used. Credibility, satisfaction, adherence and utilization were also assessed.

RESULTS

The ICBT group had significantly lower levels of depressive symptoms post treatment (p < 0.001, Hedges g =1.21) and were more likely to be responders (i.e. achieve a statistically reliable improvement) (RR = 0.36; p = 0.004). Measures of treatment credibility, satisfaction, utilization, and adherence were comparable to implemented ICBT for depression.

LIMITATIONS

Small sample size and no long-term evaluation.

CONCLUSION

Pregnancy adapted ICBT for antenatal depression is feasible, acceptable and efficacious. These results need to be replicated in larger trials to validate these promising findings.

Internet interventions for depression: new developments

A wide range of Internet interventions, mostly grounded in methods of cognitive behavioral therapy, have been developed and tested for several mental disorders. The evidence to date shows that these interventions are effective in reducing symptoms of depression. Metaanalyses report small-to-medium effect sizes when Internet interventions are delivered as stand-alone self-help interventions (d=0.25-0.36), and medium-to-large effect sizes when delivered as therapist-guided interventions (d=0.58-0.78), both compared with usual care. Only a minority of people suffering from depression receive adequate treatment, and Internet interventions might help bridge the large treatment gap. This review summarizes the current body of evidence and highlights pros and cons of Internet interventions. It also outlines how they could be implemented in mental health care systems and points out unresolved questions, as well as future directions, in this research field.

BDNF Val66Met and childhood adversity on response to physical exercise and internet-based cognitive behavioural therapy in depressed Swedish adults

The genetic effect of Brain-derived neurotrophic factor (BDNF) on treatment response in depression is not consistent in the literature. Childhood adversity is a known risk factor for depression which has been reported to increase depression susceptibility by interacting with BDNF genetic variation. We aimed to explore whether the BDNF variation Val66Met and childhood adversity (CA) predicted the treatment response to a 12-week intervention with physical exercise (PE) or internet-based cognitive behavioural therapy (ICBT) when compared with treatment as usual (TAU). A prospective cohort study nested within a randomised control trial was conducted using data from 547 participants with mild to moderate depression. Depression severity at baseline and follow-up was measured using the Montgomery-Åsberg Depression Rating Scale. Met allele carriers without exposure to CA and current antidepressant use showed higher treatment response to PE than Val homozygotes. There was no evidence to support that BDNF Val66Met or CA alone predicted treatment response to PE and ICBT. The Met carriers had higher serum mature BDNF level. These data suggest that Met allele carriers benefit more from PE treatment but only if they are not exposed to early adversity.

'Work it out': evaluation of a chronic condition self-management program for urban Aboriginal and Torres Strait Islander people, with or at risk of cardiovascular disease

BACKGROUND

Chronic diseases disproportionately burden Aboriginal and Torres Strait Islander people in Australia, with cardiovascular (CV) diseases being the greatest contributor. To improve quality of life and life expectancy for people living with CV disease, secondary prevention strategies such as rehabilitation and self-management programs are critical. However, there is no published evidence examining the effect of chronic condition self-management (CCSM) group programs for Aboriginal and Torres Strait Islander people who have, or are at risk of, CV disease specifically. This study evaluates the Work It Out program for its effect on clinical outcome measures in urban Aboriginal and Torres Strait Islander participants with or at risk of CV disease.

METHODS

This study was underpinned by a conceptual framework based on Aboriginal and Torres Strait Islander community control. Participants had at least one diagnosed CV disease, or at least one CV disease risk factor. Short-term changes in clinical outcome measures over (approximately) 12 weeks were evaluated with a quasi-experimental, pre-post test design, using paired t-tests. Factors contributing to positive changes were tested using general linear models. The outcome measures included blood pressure (mmHg), weight (kg), body mass index (kg/m2), waist and hip circumference (cm), waist to hip ratio (waist cm/hip cm) and six minute walk test (6MWT).

RESULTS

Changes in several clinical outcome measures were detected, either within the entire group (n = 85) or within specific participant sub-groups. Participant's 6MWT distance improved by an average 0.053 km (95% CI: 0.01-0.07 km). The change in distance travelled was influenced by number of social and emotional wellbeing conditions participants presented with. The weight of participants classified with extreme obesity decreased on average by 1.6 kg (95% CI: 0.1-3.0 kg). Participants with high baseline systolic blood pressure demonstrated a mean decrease of 11 mmHg (95% CI: 3.2-18.8 mmHg). Change in blood pressure was influenced by the number of cardiovascular conditions participants experienced.

CONCLUSIONS

Short-term improvements seen in some measures could indicate a trend for improvement in other indicators over the longer term. These results suggest the Work It Out program could be a useful model for cardiovascular rehabilitation and prevention for other urban Aboriginal and Torres Strait Islander populations.

Association of perceived physical health and physical fitness in two Swedish national samples from 1990 and 2015

Perceived health and physical fitness have been shown to correlate, and low levels of either variable increase the risk for future illness and mortality. However, risk factors and their interrelationship may vary between societies and over time. In this study, the associations of physical fitness and perceived health were therefore assessed in two Swedish national samples 25 years apart. Perceived physical health, dichotomized as "good" or "bad," maximal oxygen uptake (VO₂ max), counter movement jump (CMJ), balance (one-legged 60 second stance), and self-reported demographics and lifestyle were recorded in two cross-sectional samples (sample size, number of eligible participants) of Swedish adults, aged 20-65 years, in 1990-1991 (2203, 1365), and 2013-2015 (3357, 422). The odds for good perceived physical health increased by 5% per mL·kg^-1 ·min^-1 of VO₂ max, 3% per cm CMJ height, and decreased by 4% per 1 time of overbalancing, in both samples. Mutually adjusted regression models showed that perceived physical health was best predicted by VO₂ max and chronic illness in 1990 and by age, BMI, and educational level in 2015.

CONCLUSION

Perceived physical health was related to physical fitness in two samples of Swedish adults from 1990 and 2015. However, multivariate and mutually adjusted models indicate that the most important covariates of perceived physical health may have changed from VO₂ max and chronic illness in 1990, to age, BMI, and educational level in 2015.

Positive effects of Individual Cognitive Behavior Therapy for patients with unipolar mood disorders with suicidal ideation in Malaysia: A randomised controlled trial

The aim of this study was to investigate the effectiveness of Individual Cognitive Behavior Therapy (ICBT) in treating patients with mood disorders with suicidal ideation. A total of 69 patients (48 females, 21 males) with the diagnoses above were randomly allocated to either the group of Treatment As Usual (TAU)+ICBT (n=33) or the TAU group (n=36). All participants completed the Beck Depression Inventory (BDI), Beck Scale for Suicide Ideation (BSS), Positive and Negative Suicide Ideation Inventory (PANSI), Beck Hopelessness Scale (BHS), and Depression Anxiety Stress Scale-21 (DASS-21). These questionnaires were administered at pre-treatment, midway through treatment (week 4), post-treatment (week 8), and at follow-ups after three months (week 20) and six months (week 32). Factorial ANOVA results showed that the TAU+ICBT patients improved significantly and at faster rate as compared to the TAU group, which showed improvement only from pre to mid treatment on DASS-D and BHS-T measures. The effect size (Cohen's d), for the TAU+ICBT group showed large effect (1.47) for depressive symptoms and suicidal ideation (1.00). These findings suggest that ICBT used in addition to the TAU, was effective in enhancing treatment outcome of patients with unipolar mood disorders as well as, reducing risk for suicide behavior.

Blended care vs. usual care in the treatment of depressive symptoms and disorders in general practice [BLENDING]: study protocol of a non-inferiority randomized trial

BACKGROUND

The majority of patients with depressive disorders are treated by general practitioners (GPs) and are prescribed antidepressant medication. Patients prefer psychological treatments but they are under-used, mainly due to time constraints and limited accessibility. A promising approach to deliver psychological treatment is blended care, i.e. guided online treatment. However, the cost-effectiveness of blended care formatted as an online psychological treatment supported by the patients' own GP or general practice mental health worker (MHW) in routine primary care is unknown. We aim to demonstrate non-inferiority of blended care compared with usual care in patients with depressive symptoms or a depressive disorder in general practice. Additionally, we will explore the real-time course over the day of emotions and affect, and events within individuals during treatment.

METHODS

This is a pragmatic non-inferiority trial including 300 patients with depressive symptoms, recruited by collaborating GPs and MHWs. After inclusion, participants are randomized to either blended care or usual care in routine general practice. Blended care consists of the 'Act and Feel' treatment: an eight-week web-based program based on behavioral activation with integrated monitoring of depressive symptomatology and automatized feedback. GPs or their MHWs coach the participants through regular face-to-face or telephonic consultations with at least three sessions. Depressive symptomatology, health status, functional impairment, treatment satisfaction, daily activities and resource use are assessed during a follow-up period of 12 months. During treatment, real-time fluctuations in emotions and affect, and daily events will be rated using ecological momentary assessment. The primary outcome is the reduction of depressive symptoms from baseline to three months follow-up. We will conduct intention-to-treat analyses and supplementary per-protocol analyses.

DISCUSSION

This trial will show whether blended care might be an appropriate treatment strategy for patients with depressive symptoms and depressive disorder in general practice.

TRIAL REGISTRATION

Netherlands Trial Register: NTR4757; 25 August 2014. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4757 . (Archived by WebCite® at http://www.webcitation.org/6mnXNMGef ).

Behavioral activation versus physical activity via the internet: A randomized controlled trial

BACKGROUND

A major problem today is that only about fifty percent of those affected by depression seeks help. One way to reach more sufferers would be by offering easily accessible internet based treatments. The purpose of this study was to compare/evaluate four therapist supported internet administered treatments.

METHOD/RESULTS

Two hundred eighty six participants were included. The treatment period lasted twelve weeks, consisting of the following treatments: 1) physical activity without treatment rational, 2) physical activity with treatment rational, 3) behavioral activation without treatment rational and 4) behavioral activation with treatment rational. All groups (including a control-group) showed a significant decrease in depressive symptoms. When the treatment groups were pooled and compared to the control group, there were significant differences from pretest to posttest (Hedges g_av treatment =1.01, control group =0.47). This held true also when each of the four treatment groups was compared to the control group, with one exception: Physical activity without treatment rationale.

LIMITATIONS

The differences between how many modules the participants completed could indicate that there are other factors than the treatments that caused the symptom reduction, however, the dose-response analysis did not detect any significant differences on account of modules completed.

CONCLUSIONS

The results support the positive effects of internet administered treatments for depression, and highlights the importance of psychoeducation, which tends to affect both the treatment outcome and the probability of remaining in treatment. These aspects need to be considered when developing and conducting new treatments for depression, since they would increase the likelihood of positive treatment outcomes.

Interleukin-6 and depressive symptom severity in response to physical exercise

Elevated IL-6 has been implicated in depression. The anti-inflammatory effects of exercise may be associated with its clinical efficacy for depression. We determined if serum IL-6 levels were altered by 12 weeks of physical exercise, and if IL-6 levels were associated with baseline depression severity and change in depression severity in response to exercise. Data from 116 adults (42.7±11.5y) with mild-to-moderate depression (Patient Health Questionnaire >9) who participated in the physical exercise arm of the Regassa RCT (www.regassa.se) were analyzed. Participants were requested to complete three 60-min exercise sessions weekly for 12 weeks. Blood samples were provided at baseline and post-intervention following an overnight fast and were analyzed for serum levels of IL-6 using ELISA. IL-6 values were logarithm-transformed. Higher baseline serum IL-6 levels were significantly associated with reduced depression severity after exercise. Reduced IL-6 levels following exercise were significantly associated with parallel reductions in depression severity. These findings are consistent with a previously reported association between reduced serum IL-1β levels and reduced depression severity following 12 weeks of physical exercise in 105 depressed adults. Findings support associations between IL-6, depressive symptoms, and exercise response, and provide support for the plausible involvement of IL-6 in the antidepressive effect of exercise.

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.

A critical review of exercise as a treatment for clinically depressed adults: time to get pragmatic

OBJECTIVE

Although considerable evidence supports the efficacy of exercise as an antidepressant treatment, critical reviews informing routine practice and future research directions are scarce.

METHODS

We critically reviewed exercise studies for clinically depressed adults, focussing on the PICOS criteria referred to participants, interventions, comparisons, outcomes, and study designs.

RESULTS

Most studies have not screened their samples for symptom heterogeneity. Also, they have employed heterogeneous exercise interventions and control groups that may lead to an underestimation of the benefits of exercise. In addition, pragmatic trials allowing scalable replication and implementation in routine practice are scarce. Future studies, can consider the research domain criteria as a diagnostic framework, and conduct moderator analyses to identify depressed subgroups with symptomatology and biopsychosocial characteristics associated with differential responses to exercise interventions. The search for biomarkers of the antidepressant responses to exercise should be prioritised. Further, non-physically active comparison groups should be used to minimise treatment cross-overs and thus the underestimation of the effects of exercise interventions. Finally, the use of outcome measures that maintain their validity at low and moderate levels of symptom severity and the development of trials with a pragmatic design are essential.

CONCLUSION

The current evidence base is fraught with methodological considerations that need to be taken into account in order to increase further our understanding on the impact of exercise as medicine in depression. Future research should include moderator analyses, incorporate biomarker assays, use appropriate control and comparison groups, assess outcomes with psychometrically sensitive measures, and prioritise pragmatic trials towards transition to routine practice.

Somebody to lean on: Social relationships predict post-treatment depression severity in adults

Supportive social relationships can help protect against depression, but few studies have examined how social relationships influence the response to depression treatment. We examined longitudinal associations between the availability of social relationships and depression severity following a 12-week intervention. In total, 946 adults aged 18-71 years with mild-to-moderate depression were recruited from primary care centres across Sweden and treated for 12 weeks. The interventions included internet-based cognitive behavioural therapy (ICBT), 'usual care' (CBT or supportive counselling) and exercise. The primary outcome was the change in depression severity. The availability of social relationships were self-rated and based on the Interview Schedule for Social Interaction (ISSI). Prospective associations were explored using and logistic regression models. Participants with greater access to supportive social relationships reported larger improvements in depression compared to those with 'low' availability of relationships (β= -3.95, 95% CI= -5.49, -2.41, p< .01). Binary logistic models indicated a significantly better 'treatment response' (50% score reduction) in those reporting high compared to low availability of relationships (OR= 2.17, 95% CI= 1.40, 3.36, p< .01). Neither gender nor the type of treatment received moderated these effects. In conclusion, social relationships appear to play a key role in recovery from depression.

A randomized trial of aerobic exercise on cognitive control in major depression

OBJECTIVE

The aim of this study was to examine the effects of an 8-week moderate-intensity aerobic exercise training intervention on cognitive control in individuals with major depressive disorder (MDD).

METHODS

Participants with a current diagnosis of MDD (n=30; 21.1±2.0years) were stratified by depressive symptoms and randomized to an 8-week intervention of aerobic exercise (AE) or placebo exercise (PE). AE consisted of three sessions/week of moderate-intensity exercise training while PE consisted of three sessions/week of light-intensity stretching. Cognitive control was assessed pre- and post-treatment using behavioral performance (i.e., reaction time and accuracy) and event-related potentials (i.e., N2 amplitude). Depressive symptoms and rumination were also assessed before and after the intervention.

RESULTS

Compared with PE, the AE treatment arm was associated with an increase in N2 amplitude to incongruent flanker task trials, reflecting an increase in cognitive control processes. Symptoms of depression also decreased after AE although the treatments did not differ in their effects on rumination. Exploratory mediation analysis indicated that changes in N2 amplitude did not mediate pre-to-post treatment reductions in depressive symptoms.

CONCLUSIONS

An 8-week moderate-intensity AE program is associated with improved neural indices of conflict monitoring and reduced depressive symptoms among individuals with MDD.

SIGNIFICANCE

Future research examining the influence of exercise in combination with behavioral and pharmacological treatments for neurocognitive function in MDD is warranted.

Twelve-week physical exercise does not have a long-lasting effect on kynurenines in plasma of depressed patients

BACKGROUND

Physical exercise has well-characterized positive effects on depressive symptoms. The underlying biologic mechanisms are, however, far from established. A recently discovered mechanism has linked the enhanced conversion of kynurenine to kynurenic acid (KYNA) to an increased resilience toward stress-induced depression in mice. The aim of this study was to translate these findings to humans.

MATERIALS AND METHODS

Kynurenine and KYNA levels were measured by high-performance liquid chromatography in plasma samples from 117 patients affected by mild-to-moderate depression before and within a week after a 12-week training period at three different intensities. The patients were part of the Regassa study.

RESULTS

No differences in plasma levels of kynurenine and KYNA or in their ratio could be detected between before and after training. No effect of the intensity group could be observed. No correlation with the improvement in cardiovascular fitness (Åstrand score) or the improvement in mood (Montgomery Åsberg Depression Rating Scale score) could be observed.

LIMITATIONS

As the Regassa study is based on an intention-to-treat protocol, the exact time and the exact intensity of the physical exercise are not known. Analyses of pulse data as well as personal interviews, however, were used to control the exercise protocols. Furthermore, the observations reflect chronic changes.

CONCLUSION

Physical exercise positively affects mood and cardiovascular fitness, but does not lead to long-lasting changes in plasma levels of kynurenine and KYNA in patients affected by mild-to-moderate depression.