Transcript Exercise in the Treatment of Depression

Exercise in the Treatment of
Depression
Sean T. Mullendore
Major, USAF, MC
Primary Care Sports Medicine Fellow
Objectives
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Scope of problem
Depression defined
Evidence of exercise to treat depression
Proposed mechanisms of effect
Limitations of evidence/application
Bottom line
Scope of Problem – Depression
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Prevalence between 5-10% of adults in primary
care in U.S.
2-3X have depressive symptoms without DSM-IV
criteria
Women affected 2X as often as men
Depressive disorders are 4th most important
cause of disability worldwide
Mild-moderate major depressive disorder ranks
2nd to ischemic heart dz for years of life lost due
to premature death/disability
Depression – Presentations/Risk
Factors
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Presentations:
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Multiple medical visits
Multiple somatic
complaints
Work/relationship
dysfunction
Sleep disturbance
Volunteered c/o stress
or mood disturbance
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Risk Factors
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Family/personal hx
Chronic medical illness
Major life change
Stressful life event(s)
involving loss
Depression – Screening Tools
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SIGECAPS
Validated instruments as adjuncts to
clinical interview
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Beck Depression Inventory (BDI)
Hamilton Rating Scale for Depression (HAMD)
Quality Improvement for Depression Scale
(QIDS)
Depression Defined
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Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition Text Revision (DSMIV TR)
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5 or more symptoms present during same 2week period
At least 1 symptom either
Depressed mood OR
 Loss of interest/pleasure
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Other Disorders to Consider…
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Dysthymia
Adjustment disorder with depressed mood
Bipolar disorder
Substance abuse
Overtraining/“staleness”
Descriptive & Cross-Sectional Data
Camacho et al, Am J Epidemiol 1991
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Participant activity levels & depressive sxs
measured in 1965, 1974, & 1983
Significant risk for depression at 1974 followup if inactive at baseline
Changes in exercise habits between 19651974 may have changed risk of depression in
1983 (i.e. more active = less depression and
vice versa)
Descriptive & Cross-Sectional Data
Bäckmand et al, Int J Sports Med, 2001
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Male athletes representing Finland from 19201965 with controls classified as healthy at age
20
5 athlete groups: endurance, power/combat,
power/individual, team, shooting
Questionnaires completed in 1985 & 1995
Finding: Referents more depressed than
endurance and team sport athletes
Descriptive & Cross-Sectional Data
Bäckmand et al, Int J Sports Med, 2003
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Former elite male athletes surveyed by
questionnaire in 1985 & 1995
Findings:
 Low levels of physical activity significantly
increased risk of depression
 Increase of 1 MET-unit (hour/day)
statistically decreased risk of depression by
8%
Randomized Controlled Trial
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Blumenthal JA et al, Arch Intern Med , 1999
InfoPOEMs level of evidence 1b
156 depressed older patients randomly assigned to 1 of
3 groups
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Supervised aerobic exercise at 70%-85% of heart rate reserve
for 30 minutes on 3 days per week
Zoloft Rx at 50 mg to 200 mg daily
Both aerobic exercise and Zoloft Rx
Primary outcomes = scores on Hamilton Rating Scale for
Depression (HAM-D) and Beck Depression Inventory
(BDI)
Blumenthal JA et al (Cont’d)
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Findings at 4 months…
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All 3 groups achieved comparable & significant
remission of MDD based on DSM-IV criteria
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60.4% in exercise group
68.8% in Zoloft group
line:
65.5% in exercise + Zoloft group
Bottom
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•Exercise – walking or jogging – at 70%-85% of
 Patients on Zoloft Rx alone responded faster
maximum aerobic intensity is as effective as Zoloft
 Among patients receiving combination tx, those with
therapy
treating
MDD more quickly to exercise
lessinsevere
MDDmild
responded
•Zoloft
had
a faster
initial
response
+ therapy
Zoloft than
those
with more
severe
MDD than
exercise in improvement of MDD symptoms
Systematic Review
Lawlor et al, BMJ, 2001
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Outcomes = mean differences in effect size in
BDI score between exercise & no treatment
and between exercise & cognitive therapy
72 potentially relevant studies; 56 were
excluded from analysis
Lawlor et al (Cont’d)
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Findings…
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Exercise c/w placebo intervention or as
adjunct to standard treatment
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Effect size was significant at -1.1 (-1.5 to -0.6)
 Exercise c/w standard treatments
Limitations…
Bottom
line:size
•Most
studies
Effect
of was
poornot
quality
significant at -0.3 (-0.7 to 0.1)
•Effectiveness
of exercise
in reducingstudies
sxs of were
•When
exercise
placebo/adjunct,
 Aerobic
andc/w
non-aerobic
exercise have similar
depression
cannot
be determined because of a lack
found
to
be
heterogeneous
effect
of good
research
•None
of quality
participants
exercised alone
Best Evidence (so far) – DOSE trial
Dunn et al, Am J Prev Med, 2005
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InfoPOEMs level of evidence 1b
80 adults w/ mild-moderate depression randomly
assigned to 1 of 5 treatment groups
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7 kcal/kg/week (low dose) performed on 3 or 5 days/week
17.5 kcal/kg/week (high dose) performed on 3 or 5
days/week
flexibility exercise control performed on 3 days/week
Subjects exercised individually in rooms under
supervision by laboratory staff
Primary outcome = score on 17-item Hamilton rating
scale for depression (HRSD17)
Dunn et al (Cont’d)
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Findings…
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Adjusted mean HRSD17 scores at 12 weeks
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Reduced 47% for high dose exercisers
Reduced 30% for low dose exercisers
Reduced 29% for controls
No main effect of exercise frequency
Bottom line(s):
 Remission rates at 12 weeks comparable to other
•Bothtreatments
high & low-dose
for MDD aerobic exercise are
effective
in the
treatment
ofdose
mild to
 NNT as
(formonotherapy
clinically relevant
response)
in high
exercise
=5
moderate
MDD
 NNT (for clinically relevant response) in 3 day/week
•Exercising
times per
low dose3 exercise
= 7week is at least as effective
as 5 times per week
Proposed Mechanisms of Effect –
Physiological
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Monoamine hypothesis
Regulation of hypothalamic-pituitaryadrenal (HPA) axis
Endorphin hypothesis
Monoamine Hypothesis
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Exercise enhances brain aminergic synaptic
transmission
Animal models show effects on CNS levels of
noradrenaline with exercise
Human models show effects on plasma/urine
levels of monoamines
Limitations:
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Plasma data are poor estimate of CNS amine levels
HPA Axis Imbalance
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HPA axis may be hyperactive in depression
Depressed patients have
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Higher basal cortisol levels
Non-suppression of endogenous cortisol with dexamethasone
administration
Exercise delays HPA axis response to stress (animal
models)
Exercise-trained subjects exhibit hyposensitive HPA axis
response to exercise challenge (human models)
Limitations:
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Not all depressed patients exhibit HPA axis hyperactivity
Endorphin Hypothesis
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Exercise leads to surge of β-endorphin
β-endorphins reduce pain and potentiate
euphoric state
Unclear if β-endorphins directly alter mood state
or indirectly facilitate improved mood through
energy conservation during exercise
Limitations:
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Same as central amine hypothesis (i.e. plasma data
poor estimate of central β-endorphin levels)
Proposed Mechanisms of Effect –
Psychological
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Distraction hypothesis
Self-efficacy theory
Mastery hypothesis
Social interaction
Distraction Hypothesis
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Diversion from unpleasant stimuli or painful
somatic complaints leads to improved affect
following exercise sessions
28 yo female w/ moderate depression, ADHD,
bulimia
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“Although the exercise helps me feel connected to my
body, at the same time, it is also an escape from
everything that is occurring in my life at a particular
time…If I am truly exerting myself, it is not possible
to dwell on anything outside of the present moment.
It is a mental “nap”.”
Self-Efficacy Theory
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Confidence in one’s ability to exercise is
strongly related to one’s actual ability to
perform the behavior
Exercise poses challenging task for
sedentary subject…successfully adopting
regular exercise may produce improved
mood and enhanced ability to handle
events that challenge one’s mental health
Mastery Hypothesis
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Depression may result as response to loss
of control over one’s body
Control of challenging pursuit (e.g.
exercise) instills sense of independence
and success
As exerciser gains mastery of physical
skills, they may take this feeling of control
into everyday life
Social Interaction Theory
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Social relationships and mutual support
provided to one another by co-exercisers
account for beneficial effects of exercise
on mental health
Limitations
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Good, quality research is lacking
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Lack of adequate allocation concealment
Subjects volunteers rather than clinical subjects
Few studies intent-to-treat
Subjects not motivated to exercise screened out
No true control group
If exercise subject to FDA approval, would NOT
receive approval for treatment of depression
Limitations
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Overall long-term adherence to exercise
program is poor at 50%
Simply suggesting/recommending that a
depressed patient begin exercise often
proves futile
Limitations
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When “prescribing” exercise to depressed
patients, consider caveats:
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Anticipate barriers
Keep expectations realistic
Introduce feasible plan
Accentuate pleasurable aspects
State specifics
Encourage adherence
Summary
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True effectiveness of exercise in reducing
symptoms of depression cannot be determined
because of limitations of available research
BUT…
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Exercise may be an effective therapy for mild to
moderate major depressive disorder
Aerobic and non-aerobic exercise appear to have
similar effect
Summary
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Exercising 3 times per week is at least as
effective as 5 times per week
Walking or jogging at 70%-85% of maximal
aerobic intensity is probably as effective as drug
therapy for treating mild depression
Aerobic exercise at a dose consistent with
ACSM/public health recommendations may be
an effective treatment for mild to moderate
depression
References
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4.
Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise
training on older patients with major depression. Arch Intern Med
1999;159:2349-2356.
Dunn AL, Trivedi MH, Kampert JB, Clark CG, Chambliss HO.
Exercise treatment for depression. Efficacy and dose response.
Am J Prev Med 2005;28:1-8.
Herman S, Blumenthal JA, Babyak M, et al. Exercise therapy for
depression in middle-aged and older adults: predictors of early
dropout and treatment failure. Health Psychology
2002;21(6):553-563.
Lawlor DA, Hopker SW. The effectiveness of exercise as an
intervention in the management of depression: systematic review
and meta-regression analysis of randomised controlled trials. BMJ
2001;322:1-8.
References
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Brosse AL, Sheets ES, Lett HS, Blumenthal JA. Exercise and the
treatment of clinical depression in adults, recent findings and
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Paluska SA, Schwenk TL. Physical activity and mental health,
current concepts. Sports Med 2000;29(3):167-180.
Pollock KM. Exercise in treating depression: broadening the
psychotherapist’s role. J Clin Psychol/In Session
2001;57(11):1289-1300.
Scully D, Kremer J, Meade MM, et al. Physical exercise and
psychological well being: a critical review. Br J Sports Med
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Bäckmand H, Kaprio J, Kujala U, Sarna S. Personality and mood of
former elite male athletes – a descriptive study. Int J Sports Med
2001;22:215-221.
References
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14.
Bäckmand H, Kaprio J, Kujala U, Sarna S. Influence of physical
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Dimeo F, Bauer M, Varahram I, et al. Benefits from aerobic
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Kessler et al. The epidemiology of major depressive disorder.
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References
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Camacho TC, Roberts RE, Lazarus NB, et al. Physical activity and
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