Self-selected intensity exercise in the treatment of major depression: A pragmatic RCT

Exercise as medicine for depressive symptoms? A systematic review and meta-analysis with meta-regression

OBJECTIVE

To estimate the efficacy of exercise on depressive symptoms compared with non-active control groups and to determine the moderating effects of exercise on depression and the presence of publication bias.

DESIGN

Systematic review and meta-analysis with meta-regression.

DATA SOURCES

The Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, Embase, SPORTDiscus, PsycINFO, Scopus and Web of Science were searched without language restrictions from inception to 13 September2022 (PROSPERO registration no CRD42020210651).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials including participants aged 18 years or older with a diagnosis of major depressive disorder or those with depressive symptoms determined by validated screening measures scoring above the threshold value, investigating the effects of an exercise intervention (aerobic and/or resistance exercise) compared with a non-exercising control group.

RESULTS

Forty-one studies, comprising 2264 participants post intervention were included in the meta-analysis demonstrating large effects (standardised mean difference (SMD)=-0.946, 95% CI -1.18 to -0.71) favouring exercise interventions which corresponds to the number needed to treat (NNT)=2 (95% CI 1.68 to 2.59). Large effects were found in studies with individuals with major depressive disorder (SMD=-0.998, 95% CI -1.39 to -0.61, k=20), supervised exercise interventions (SMD=-1.026, 95% CI -1.28 to -0.77, k=40) and moderate effects when analyses were restricted to low risk of bias studies (SMD=-0.666, 95% CI -0.99 to -0.34, k=12, NNT=2.8 (95% CI 1.94 to 5.22)).

CONCLUSION

Exercise is efficacious in treating depression and depressive symptoms and should be offered as an evidence-based treatment option focusing on supervised and group exercise with moderate intensity and aerobic exercise regimes. The small sample sizes of many trials and high heterogeneity in methods should be considered when interpreting the results.

Physical Activity for Cognitive Health: A Model for Intervention Design for People Experiencing Cognitive Concerns and Symptoms of Depression or Anxiety

BACKGROUND

People experiencing cognitive concerns and symptoms of depression or anxiety are at risk for Alzheimer's disease and dementia. We know physical activity can benefit cognition but understanding how to best support engagement is an ongoing challenge. Evidence-based conceptual models of factors underpinning physical activity engagement in target populations can inform intervention tailoring to address this challenge.

OBJECTIVE

This study (part of a pragmatic physical activity implementation trial) aimed to develop a specified model of physical activity engagement in people experiencing depressive or anxiety symptoms and cognitive concerns, to enable optimized dementia risk reduction intervention tailoring.

METHODS

We employed a qualitative design, triangulating data from three sources: semi-structured individual interviews with people experiencing cognitive concerns and mild to moderate depressive or anxiety symptoms; review of published evidence; and the Capability, Opportunity and Motivation system of behavior, an existing behavioral science model. Findings were integrated to develop a contextualized model of mechanisms of action for optimizing engagement.

RESULTS

Twenty-one participants were interviewed, and 24 relevant papers included. Convergent and complementary themes extended understanding of intervention needs. Findings highlighted emotional regulation, capacities to enact intentions despite barriers, and confidence in existing skills as areas of population-specific need that have not previously been emphasized. The final model provides specificity, directionality, and linked approaches for intervention tailoring.

CONCLUSION

This study demonstrated that people experiencing cognitive concerns and symptoms of depression or anxiety require different interventions to improve physical activity engagement. The novel model can enable more precise intervention tailoring, and, ultimately, benefits for a key at-risk population.

Comparing the efficacy of different types of exercise for the treatment and prevention of depression in youths: a systematic review and network meta-analysis

Purpose

Depression disorder is the most commonly diagnosed type of mental illness among youths. Although a plethora of evidence suggests a positive relationship between exercise and lower levels of depression in youths, the findings regarding the variation in magnitude of this relationship are inconclusive with respect to the preventive and therapeutic effects of different types of exercise. This network meta-analysis aimed to determine the best type of exercise for the treatment and prevention of depression in youths.

Methods

A comprehensive search of databases, including PubMed, EMBASE, The Cochrane Library, Web of Science, PsychINFO, ProQuest, Wanfang, and CNKI, was conducted to identify relevant research on exercise interventions for depression in youth populations. The risk of bias in the included studies was evaluated using Cochrane Review Manager 5.4 according to the Cochrane Handbook 5.1.0 Methodological Quality Evaluation Criteria. The network meta-analysis was performed using STATA 15.1 to calculate the standardized mean difference (SMD) of all concerned outcomes. The node-splitting method was used to test the local inconsistency of the network meta-analysis. Funnel plots were used to evaluate the potential impact of bias in this study.

Result

Utilizing data extracted from 58 studies (10 countries, 4,887 participants), we found that for depressed youths, exercise is significantly better than usual care in reducing anxiety (SMD = -0.98, 95% CI [-1.50, -0.45]). For non-depressed youths, exercise is significantly better than usual care in reducing anxiety (SMD = -0.47, 95% CI [ -0.66, -0.29]). In the treatment of depression, resistance exercise (SMD = -1.30, 95% CI [ -1.96, -0.64]), aerobic exercise (SMD = -0.83, 95% CI [-1.10 -0.72]), mixed exercise (SMD = -0.67, 95% CI [-0.99, -0.35]), and mind-body exercise (SMD = -0.61, 95% CI [-0.84, -0.38]) all showed significant efficacy over usual care. For the prevention of depression, resistance exercise (SMD = -1.18, 95% CI [-1.65, -0.71]), aerobic exercise (SMD = -0.72, 95% CI [-0.98, -0.47]), mind-body exercise (SMD = -0.59, 95% CI [-0.93, -0.26]), and mixed exercise (SMD = -1.06, 95% CI [-1.37 to -0.75]) were all significantly effective compared to usual care. According to the test of the surface under the cumulative ranking score (SUCRA), the ranking of exercises for the treatment of depression in depressed youths is as follows: resistance exercise (94.9%) > aerobic exercise (75.1%) > mixed exercise (43.8%) > mind-body exercise (36.2%) > usual care (0%). For the prevention of depression in non-depressed youths, resistance exercise (90.3%) > mixed exercise (81.6%) > aerobic exercise (45.5%) > mind-body exercise (32.6%) > usual care (0%). Resistance exercise thus had the best comprehensive effect on both the treatment and prevention of depression in youths (clusterank value = 1914.04). Subgroup analyses show that a frequency of 3-4 times per week, a duration of 30-60 min, and a length of more than 6 weeks were found to be the most effective interventions for depression (P > 0.001).

Conclusion

This study provides compelling evidence that exercise is a viable intervention for improving depression and anxiety in young individuals. In addition, the study emphasizes the importance of selecting the appropriate type of exercise to optimize treatment and prevention. Specifically, the results suggest that resistance exercise, performed 3-4 times per week, with sessions lasting 30-60 min and a length of more than 6 weeks, yields optimal results for the treatment and prevention of depression in young individuals. These findings have significant implications for clinical practice, particularly given the challenges associated with implementing effective interventions and the economic burden of treating and preventing depression in young people. However, it is worth noting that additional head-to-head studies are necessary to confirm these findings and strengthen the evidence base. Nevertheless, this study provides valuable insights into the role of exercise as a potential treatment and preventative measure for depression in young people.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=374154, identifier: 374154.

The role of exercise in the treatment of depression: biological underpinnings and clinical outcomes

Globally, depression is a leading cause of disability and has remained so for decades. Antidepressant medications have suboptimal outcomes and are too frequently associated with side effects, highlighting the need for alternative treatment options. Although primarily known for its robust physical health benefits, exercise is increasingly recognized for its mental health and antidepressant benefits. Empirical evidence indicates that exercise is effective in treating individuals with depression; however, the mechanisms by which exercise exerts anti-depressant effects are not fully understood. Acute bouts of exercise have been shown to transiently modulate circulating levels of serotonin and norepinephrine, brain-derived neurotrophic factor, and a variety of immuno-inflammatory mechanisms in clinical cohorts with depression. However, exercise training has not been demonstrated to consistently modulate such mechanisms, and evidence linking these putative mechanisms and reductions in depression is lacking. The complexity of the biological underpinnings of depression coupled with the intricate molecular cascade induced by exercise are significant obstacles in the attempt to disentangle exercise's effects on depression. Notwithstanding our limited understanding of these effects, clinical evidence uniformly argues for the use of exercise to treat depression. Regrettably, exercise remains underutilized despite being an accessible, low-cost alternative/adjunctive intervention that can simultaneously reduce depression and improve overall health. To address the gaps in our understanding of the clinical and molecular effects of exercise on depression, we propose a model that leverages systems biology and multidisciplinary team science with a large-scale public health investment. Until the science matches the scale of complexity and burden posed by depression, our ability to advance knowledge and treatment will continue to be plagued by fragmented, irreproducible mechanistic findings and no guidelines for standards of care.

Comparative Effectiveness of Multiple Exercise Interventions in the Treatment of Mental Health Disorders: A Systematic Review and Network Meta-Analysis

BACKGROUND

The efficacy of exercise interventions in the treatment of mental health disorders is well known, but research is lacking on the most efficient exercise type for specific mental health disorders.

OBJECTIVE

The present study aimed to compare and rank the effectiveness of various exercise types in the treatment of mental health disorders.

METHODS

The PubMed, Web of Science, PsycINFO, SPORTDiscus, CINAHL databases, and the Cochrane Central Register of Controlled Trials as well as Google Scholar were searched up to December 2021. We performed pairwise and network meta-analyses as well as meta-regression analyses for mental health disorders in general and each type of mental health disorder, with alterations in symptom severity as the primary outcome.

RESULTS

A total of 6456 participants from 117 randomized controlled trials were surveyed. The multimodal exercise (71%) had the highest probability of being the most efficient exercise for relieving depressive symptoms. While resistance exercise (60%) was more likely to be the most effective treatment for anxiety disorder, patients with post-traumatic stress disorder (PTSD) benefited more from mind-body exercise (52%). Furthermore, resistance exercise (31%) and multimodal exercise (37%) had more beneficial effects in the treatment of the positive and negative symptoms of schizophrenia, respectively. The length of intervention and exercise frequency independently moderated the effects of mind-body exercise on depressive (coefficient = 0.14, p = .03) and negative schizophrenia (coefficient = 0.96, p = .04) symptoms.

CONCLUSION

Multimodal exercise ranked best for treating depressive and negative schizophrenic symptoms, while resistance exercise seemed to be more beneficial for those with anxiety-related and positive schizophrenic symptoms. Mind-body exercise was recommended as the most promising exercise type in the treatment of PTSD. However, the findings should be treated with caution due to potential risk of bias in at least one dimension of assessment and low-to-moderate certainty of evidence. Trial Registration This systematic review was registered in the PROSPERO international prospective register of systematic reviews (CRD42022310237).

Aerobic exercise in severe mental illness: requirements from the perspective of sports medicine

Major depression, bipolar disorder, and schizophrenia are severe mental illnesses. Despite receiving psychopharmacological and psychosocial treatments, about half of patients develop a chronic course with residual cognitive and negative symptoms and have a high risk for cardiovascular disease and reduced life expectancy. Therefore, add-on innovative treatment approaches are needed to improve outcome. Aerobic exercise interventions have been shown to improve global functioning, cognition, and negative and depressive symptoms in these patients. The basic mechanism of these exercise-related changes has been reported to be improved brain plasticity, e.g., increased volume of disease-related brain regions such as the hippocampus. The optimal type, duration, and frequency of exercise have not yet been determined and need to be addressed in supervised physical exercise studies. Because of the low physical activity levels, lack of drive related to negative and depressive symptoms, and high prevalence of cardiovascular comorbidities in patients with severe mental illness, besides aiming to improve symptoms of mental illness, exercise interventions should also aim to increase cardiorespiratory fitness, which they should comprehensively assess by direct measurements of maximal oxygen uptake. Based on the recommendations for developing cardiorespiratory fitness by the American College of Sports Medicine, 150 min moderate-intensity training per week or vigorous-intensity exercise training for 75 min per week are appropriate. Most studies have had relatively short intervention periods, so future studies should focus on long-term adherence to exercise by implementing motivational strategies supported by telemedicine and by identifying and targeting typical barriers to exercise in this patient population.

Physical exercise improves quality of life, depressive symptoms, and cognition across chronic brain disorders: a transdiagnostic systematic review and meta-analysis of randomized controlled trials

We performed a meta-analysis to synthesize evidence on the efficacy and safety of physical exercise as an add-on therapeutic intervention for quality of life (QoL), depressive symptoms and cognition across six chronic brain disorders: Alzheimer's disease, Huntington's disease, multiple sclerosis, Parkinson's disease, schizophrenia and unipolar depression. 122 studies ( = k) (n = 7231) were included. Exercise was superior to treatment as usual in improving QoL (k = 64, n = 4334, ES = 0.40, p < 0.0001), depressive symptoms (k = 60, n = 2909, ES = 0.78, p < 0.0001), the cognitive domains attention and working memory (k = 21, n = 1313, ES = 0.24, p < 0.009), executive functioning (k = 14, n = 977, ES = 0.15, p = 0.013), memory (k = 12, n = 994, ES = 0.12, p = 0.038) and psychomotor speed (k = 16, n = 896, ES = 0.23, p = 0.003). Meta-regression showed a dose-response effect for exercise time (min/week) on depressive symptoms (β = 0.007, p = 0.012). 69% of the studies that reported on safety, found no complications. Exercise is an efficacious and safe add-on therapeutic intervention showing a medium-sized effect on QoL and a large effect on mood in patients with chronic brain disorders, with a positive dose-response correlation. Exercise also improved several cognitive domains with small but significant effects.

A Scoping Review of the Relationship between Running and Mental Health

Poor mental health contributes significantly to global morbidity. The evidence regarding physical benefits of running are well-established. However, the mental health impacts of running remain unclear. An overview of the relationship between running and mental health has not been published in the last 30 years. The purpose of this study was to review the literature on the relationship between running and mental health. Our scoping review used combinations of running terms (e.g., Run* and Jog*) and mental health terms (general and condition specific). Databases used were Ovid(Medline), Ovid(Embase), ProQuest and SportDiscus. Quantitative study types reporting on the relationships between running and mental health were included. Database searches identified 16,401 studies; 273 full-texts were analysed with 116 studies included. Overall, studies suggest that running bouts of variable lengths and intensities, and running interventions can improve mood and mental health and that the type of running can lead to differential effects. However, lack of controls and diversity in participant demographics are limitations that need to be addressed. Cross-sectional evidence shows not only a range of associations with mental health but also some associations with adverse mental health (such as exercise addiction). This review identified extensive literature on the relationship between running and mental health.

Dimensions of leisure-time physical activity and risk of depression in the "Seguimiento Universidad de Navarra" (SUN) prospective cohort

BACKGROUND

An inverse association between total leisure-time physical activity (LTPA) and depression has been previously documented in the scientific literature. Our objective was to prospectively assess the association of LTPA with the risk of depression, focusing on several dimensions of LTPA (intensity, duration and type).

METHODS

The SUN (Seguimiento Universidad de Navarra) project is a prospective cohort study formed by Spanish university graduates. A total of 15,488 adults (40.2% men, mean age 37 ± 12 years) initially free of depression were assessed. A report of a validated medical diagnosis of depression or the habitual use of antidepressants (any of both) were considered as incident cases of depression. LTPA was estimated through previously validated self-reported questionnaires. Participants were classified following Physical Activity recommendations from the World Health Organization, and according to the intensity, duration and type of LTPA. Cox proportional hazards regression models were run, adjusted for demographic, lifestyle, and dietary factors, to estimate adjusted hazard ratios (HR) of depression and 95% confidence intervals (CI).

RESULTS

During 163,059 person-years of follow-up we registered 870 incident cases of depression. Participants with higher total LTPA (METs-h/wk) and higher duration of LTPA (hours/wk) exhibited a lower risk of depression HR = 0.84 (95% CI: 0.72-0.99) and HR = 0.83 (0.70-0.99) respectively, whereas intensity of LTPA (MET) did not show any association with depression.

CONCLUSION

Participants with higher LTPA had a lower risk of depression. The inverse association was stronger for total LPTA time than for its intensity. Higher duration of LTPA should be encouraged to prevent depression.

A pragmatic randomised controlled trial of preferred intensity exercise in depressed adult women in the United Kingdom: secondary analysis of individual variability of depression

BACKGROUND

This study is a secondary analysis of the trial by Callaghan et al. (2011), which reported higher antidepressant effects for preferred intensity (n = 19) vs. prescribed intensity (n = 19) exercise of three sessions/week over four weeks in depressed women. In particular, the present study sought to examine whether greater clinically significant individual change/recovery was observed in the preferred compared to the prescribed exercise group.

METHODS

The reliable change index and the C_cutoff score criteria described by Jacobson and Truax (1991) were employed to determine clinical significance. These criteria examined if individual change in depression scores from pre- to post-intervention in the preferred intensity group were statistically significant beyond the standard error of difference derived from the active comparator prescribed group, and subsequently within a normal population range. Patients fulfilling the first or both criteria were classified as improved or recovered, respectively.

RESULTS

Post-intervention depression scores of six patients in the preferred intensity exercise group (32%) demonstrated statistically reliable improvement (p < 0.05) and recovery. Half of this subgroup started as moderately depressed. No patient demonstrated a reliable deterioration in depression. Due to a small sample size, it was impossible to determine whether patients on psychiatric medication or medication-free patients were equally benefited from preferred intensity exercise. Thirteen patients in the preferred intensity group (68%) displayed non-statistically significant change in post-intervention depression scores (p > 0.05), although eight of them showed a non-significant improvement in post-intervention depression scores and three could not technically show an improvement in depression due to floor effects (baseline depression within normal range).

CONCLUSIONS

Preferred intensity exercise of three sessions/week over four weeks led almost a third of the patients to record scores consistent with recovery from depression. Health professionals may consider that short-term preferred intensity exercise provides clinically significant antidepressant effects comparing favourably to exercise on prescription.

Non-Motor Symptoms after One Week of High Cadence Cycling in Parkinson's Disease

The objective was to investigate if high cadence cycling altered non-motor cognition and depression symptoms in individuals with Parkinson's disease (PD) and whether exercise responses were influenced by brain-derived neurotrophic factor (BDNF) Val66Met polymorphism. Individuals with idiopathic PD who were ≥50 years old and free of surgical procedures for PD were recruited. Participants were assigned to either a cycling (n = 20) or control (n = 15) group. The cycling group completed three sessions of high cadence cycling on a custom motorized stationary ergometer. The primary outcome was cognition (attention, executive function, and emotion recognition were assessed via WebNeuro® and global cognition via Montreal Cognitive Assessment). Depression symptoms were assessed via Beck Depression Inventory-II. There was a main effect of time for emotional recognition (p = 0.048), but there were no other changes in cognition or depression symptoms. Regardless of intervention or Val66Met polymorphism, high cadence cycling does not alter cognition or depression symptoms after three sessions in one week.

Moderating Effects of Exercise Duration and Intensity in Neuromuscular vs. Endurance Exercise Interventions for the Treatment of Depression: A Meta-Analytical Review

Background: Exercise training is a beneficial treatment strategy for depression. Previous meta-analytical reviews mainly examined the effect of aerobic exercise on depressive symptoms neglecting comparisons with neuromuscular training and meta-regression considering relevant exercise training prescriptors such as exercise duration, intensity, number of exercise sessions (volume) and frequency. Methods: A structured literature search was conducted in biomedical and psychological databases and study selection was conducted following the PICOS approach. (Randomized) controlled trials that compared supervised neuromuscular or endurance exercise interventions with an inactive control group (CON) in clinically depressed in- or out-patients over 18 years were included. Eligibility and study quality were evaluated by two independent researchers. Standardized mean differences (SMD) for the reduction of depressive symptoms, measured with different evaluation scales (e.g., BDI, HAM-D, PHQ-9, HRSD, MADRS, GDS) were calculated with the adjusted Hedges'g equation as main outcome for the comparison of endurance and neuromuscular exercise interventions vs. CON. Statistical analyses were conducted using a random effects inverse-variance model. Multivariate meta-regression analysis was performed in order to examine the modulating effects of exercise training prescriptors. Results: Twenty seven trials with 1,452 clinically depressed adults were included. 20 out of 27 included trials reached a PEDro score of at least 6, representing high-quality. Irrespective of the exercise mode and study quality, large effects in favor of exercise compared to the control condition were found. Compared to CON, sensitivity analyses revealed a moderate to large effect in favor of endurance exercise [SMD: -0.79 (90% CI: -1.10, -0.48); p < 0.00001, I² = 84%] and a large effect size in favor of neuromuscular exercise [SMD: -1.14 (90 CI: -1.50, -0.78); p < 0.00001, I² = 80%]. These effects decreased to moderate for endurance and remained large for neuromuscular trials when considering studies of high quality, indicating a significant difference (p = 0.04). Multivariate meta- regression revealed that exercise duration in endurance trials and exercise intensity in neuromuscular trials had a significantly moderating effect. Conclusions: Strong neuromuscular exercise interventions can be slightly more effective than endurance exercise interventions. Interestingly, exercise duration and exercise intensity moderated the effect size meaningfully. This result might be used on exercise in depression to increase efficacy.

Exercise for patients with major depression: a systematic review with meta-analysis and trial sequential analysis

OBJECTIVES

To assess the benefits and harms of exercise in patients with depression.

DESIGN

Systematic review DATA SOURCES: Bibliographical databases were searched until 20 June 2017.

ELIGIBILITY CRITERIA AND OUTCOMES

Eligible trials were randomised clinical trials assessing the effect of exercise in participants diagnosed with depression. Primary outcomes were depression severity, lack of remission and serious adverse events (eg, suicide) assessed at the end of the intervention. Secondary outcomes were quality of life and adverse events such as injuries, as well as assessment of depression severity and lack of remission during follow-up after the intervention.

RESULTS

Thirty-five trials enrolling 2498 participants were included. The effect of exercise versus control on depression severity was -0.66 standardised mean difference (SMD) (95% CI -0.86 to -0.46; p<0.001; grading of recommendations assessment, development and evaluation (GRADE): very low quality). Restricting this analysis to the four trials that seemed less affected of bias, the effect vanished into -0.11 SMD (-0.41 to 0.18; p=0.45; GRADE: low quality). Exercise decreased the relative risk of no remission to 0.78 (0.68 to 0.90; p<0.001; GRADE: very low quality). Restricting this analysis to the two trials that seemed less affected of bias, the effect vanished into 0.95 (0.74 to 1.23; p=0.78). Trial sequential analysis excluded random error when all trials were analysed, but not if focusing on trials less affected of bias. Subgroup analyses found that trial size and intervention duration were inversely associated with effect size for both depression severity and lack of remission. There was no significant effect of exercise on secondary outcomes.

CONCLUSIONS

Trials with less risk of bias suggested no antidepressant effects of exercise and there were no significant effects of exercise on quality of life, depression severity or lack of remission during follow-up. Data for serious adverse events and adverse events were scarce not allowing conclusions for these outcomes.

SYSTEMATIC REVIEW REGISTRATION

The protocol was published in the journal Systematic Reviews: 2015; 4:40.

Physical activity and exercise attenuate neuroinflammation in neurological diseases

Major depressive disorder (MDD), schizophrenia (SCH), Alzheimer's disease (AD), and Parkinson's disease (PD) are devastating neurological disorders, which increasingly contribute to global morbidity and mortality. Although the pathogenic mechanisms of these conditions are quite diverse, chronic neuroinflammation is one underlying feature shared by all these diseases. Even though the specific root causes of these diseases remain to be identified, evidence indicates that the observed neuroinflammation is initiated by unique pathological features associated with each specific disease. If the initial acute inflammation is not resolved, a chronic neuroinflammatory state develops and ultimately contributes to disease progression. Chronic neuroinflammation is characterized by adverse and non-specific activation of glial cells, which can lead to collateral damage of nearby neurons and other glia. This misdirected neuroinflammatory response is hypothesized to contribute to neuropathology in MDD, SCH, AD, and PD. Physical activity (PA), which is critical for maintenance of whole body and brain health, may also beneficially modify neuroimmune responses. Since PA has neuroimmune-modifying properties, and the common underlying feature of MDD, SCH, AD, and PD is chronic neuroinflammation, we hypothesize that PA could minimize brain diseases by modifying glia-mediated neuroinflammation. This review highlights current evidence supporting the disease-altering potential of PA and exercise through modifications of neuroimmune responses, specifically in MDD, SCH, AD and PD.