the runner's high_exercise_depression
TRANSCRIPT
A"Review"
The"Runner’s"High:"Can"exercise"help"alleviate"depression?"!
Eissara&Punyapati&
!
Clinical&Question&
Does!exercise!as!part!of!the!treatment!for!depression!improve!depressive!symptoms!in!patients!who!have!
been!diagnosed!with!depression!compared!to!those!who!do!not!undertake!an!exercise!program!as!part!of!
their!treatment?!
&
Introduction&&
Depression! is! classified! under! Depressive!
Disorders! from! the! latest! Diagnostic! and!
Statistical! manual! of! mental! disorders! (APA,!
2013).!Major!depressive!disorder!(MDD)!is!mental!
problem! that! is! characterised! by! absence! of!
positive! affect! and! persistent! low! mood.!
Australian!Institute!of!Health!and!Welfare!quoted!
depression!as! the! fourth! leading!cause!of!disease!
burden! in! Australia.! National! Health! Priority!
Areas!(NHPAs)!have!listed!MDD!as!one!of!the!nine!
diseases! and! conditions! that! significantly! impact!
Australians’! illness! and! wellbeing! (AIHW,! 2013).!
The! effect! of! exercise! training! to! help! combat!
depression! has! been! the! areas! of! interest! for!
researchers.! Past! findings! showed! physical!
activity! as! having! beneficial! effects! as! a!
complementary!treatment!for!depression.!!
Clinical&Bottom&Line&
Aerobic!training!at!maximum!heart!rate!(MHR)!of!
70%R80%! reduced! depression! symptoms!
compared! to! placebo! or! less! intense! exercise.!
However,! physical! training! analysis! showed! the!
overall! reduction! of! depression! in! patients! but!
this! is! not! always! significant.! From! the! chosen!
articles,!it!is!more!viable!for!adults!and!elderly!to!
be! recommended! in! the! exercise! treatment! for!
depression! as! most! studies! were! based! on! the!
mean! age! ranging! from! 35.9! to! 72.5.! More!
research! papers! should! investigate! further! if! the!
patient!presented!with!depression!was!a!child!or!
an!adolescent.!
Most! studies! showed! significant! reduction! in!
depression! scores! (HRSD17,! BDI,! CESRD! and!
BRMS)! for! the! exercised! group! compared! to!
placebo!(Knubben!et.!al.,!2007,!Krogh!et.!al.,!2009,!
Singh!et.!al.,!2001,!Singh!et.!al.,!2005,!Mather!et.!al.,!
2002).!Although,!other!papers!did!not!provide!the!
pRvalue! or! pRvalue! is! >0.05,! exercised! group! still!
showed!to!have!larger!percentage!of!reduction!in!
the!depression!scores! than! the!placebo!(Dunn!et.!
al.,!2005).!This!suggested!that!exercise!does!have!
some! beneficial! effect! on! improving! depressive!
symptoms.!!
As! recommended! in! the!guidelines,! patients!with!
depression! are! recommended! to! be! treat! with! a!
combination! of! antidepressant! and! exercise!
training.!This!is!also!reflected!in!all!of!the!studies!
where! patients! are! on! antidepressants! and!
exercise! intervention! showed! beneficial! results.!
Thus,! it! is! definitely! worthwhile! to! incorporate!
exercise! as! a! complement! intervention! for! DSM!
patient.!!
Most!research!papers!should!be!used!to!consider!
the! final! treatment! for! the! patient! except! for!
(Foley! et.! al.,! 2008).! This! paper! is! lack! of! many!
figures,!data!and!tables!that!makes!inconclusive!to!
draw!conclusion!and!rely!on.!!!!
CHARACTERISTIC)OF)THE)EVIDENCE))
Articles)) Study)design) Participants)) Level)of)Evidence)(Howick'et.'al.,'2011)#
Intervention)) Key)results) Biases))
Blument
hal*et.*
al.,*2007*
Radomised#
controlled#
trails,#
prospective#
study#
Patients#
diagnosed#with#
major#
depression.#
Mean#age:#53#
76%#female,#
24%#male#
N#=#202##
#
2# 1. Aerobic#
exercise#at#
home.#
#
2. Aerobic#
exercise##in#
groups#under#
supervised#
environment.#
#
3. Medication#
treatment#
(Sertraline).#
#
4. Placebo#group.#
45mins/session.#
MHR#=#70%O85%#
16#week#
intervention.#
Experimental#groups#
have#higher#rates#of#
remission#compared#to#
placebo.#
HomeObased#exercise:#
40%#
Supervised#exercise:#
45%#
Medication:#47%#
Placebo:#31%##
(p'=#0.057)#
Randomised#group#allocation.##
Placebo#controlled.#
Study#groups#allocation#concealment.##
Similar#N#(in#percentage).#
More#female#than#male#participants#in#
each#groups#and#overall.#Ratio#is#
consistence#between#groups.#
Inclusion#and#exclusion#criteria#were#
mentioned.#
FollowOup#included.#
Blinded#outcome#assessment##
#
Patients#are#aware#of#their#group#
allocation.#
Individuals#who#are#delivering#the#
intervention#are#aware#of#their#group#
allocation.###
NOTE:#
Unknown#exercise#
sessions/week#
#
Unknown#exercise#sessions/week#
Irregular#ratio#of#N#(in#percentage)#of#
different#ethnicity#in#each#group.#Ratio#
is#consistence#between#groups.#
Participants#selfOreported.*
Dunn*et.*
al.,*2005*
Randomised#
2x2#factorial#
design#
Placebo#
controlled#
design.##
Patients#
diagnosed#with#
mild#to#
moderate#
major#
depressive#
disorder#
(MDD).#
Mean#age:#35.9#
75%#female,#
25%#male#
N#=#80#
#
#
2# 4#aerobic#exercises#
(differ#in#total#
energy#expenditure#
and#frequency)#or#
placebo#group.##
Exercised#group:#
1.#Total#energy#
expenditure:##
Low#dose#(LD)#or#
Public#health#dose#
(PHD)#either#3#
days/week#or#5#
days/week)#for#�#≥20#minutes.#
2.#Placebo#group:#(3#
days/week#
flexibility#exercise).#
At#the#end#of#12#week,#
the#results#show#the#
most#reduced#adjusted#
mean#Hamilton#Rating#
Scale#for#Depression#
(HRSD17)#score#for#PHD#
follow#by#LD#and#the#
placebo#group.##
PHD:#47%#of#the#
participants#showed#
improvement.#PHD#
significantly#reduced#
depression#symptoms#
compared#to#LD#and#
placebo'(p=0.04#and#
p=0.03,#respectively).##
LD:#30%#of#the#
participants#showed#
improvement,#no#
Randomised#group#allocation.#
Placebo#controlled.#
Study#groups#allocation#concealment.#*
Similar#N#in#each#exercise#categories#
and#placebo.#
More#female#than#male#participants.#
Inclusion#and#exclusion#criteria#were#
mentioned.#
No#followOup#after#completion#of#the#
study.#
Experienced#research#assistances#
blinded#from#the#group#allocation#
assessed#the#HRSD17#score.#*
Patients#are#aware#of#their#group#
allocation.#
NOTE:#
MHR:#differ#in#
frequency#and#
exercise.#
12#week#
intervention.#
significant#improvement#
compared#to#placebo#
(p=0.88).#
Placebo:#29%#of#the#
participants#showed#
improvement.##
NOTE:#No#significant#
effect#on#exercise#
frequency#by#the#end#of#
week#12.##
Individuals#who#are#delivering#the#
intervention#are#aware#of#their#group#
allocation.###
Irregular#N#of#different#ethnicity#and#
marital#status#in#each#study#groups.#
This#study#was#funded#in#part#by#NIMH#
57031#and#Technogym.##
Foley*et.*
al.,*2008*
Randomised#
controlled#
trail.#
Participants#
were#recruited#
via#referral#
from#a#
psychiatrist#
and#
advertisements#
via#newspaper,#
radio,#
pamphlets#and#
posters.#
Mean#age:#36.5#
Unknown#
participated#
2# 1.#Aerobic#exercise#
(moderate#
intensity).#
2.#Stretching#
exercise#(mildO
intensity).#
30–40#min/session,#
3#times/week.#
NOTE:##
MHR#is#unknown.#
12#week#
intervention.#
Beck#Depression#
Inventory#(BDIOII)#and#
the#MontgomeryOÅsberg#
Depression#Rating#Scale#
(MADRAS)#were#used#to#
assess#the#patients’#
outcome.##
Both#exercised#and#
stretching#group#showed#
significant#reduction#in#
the#depression#scores#for#
both#method.##
BDI#and#MADRAS:#
positively#correlated#
No#proper#placebo/controlled#group.##
Study#groups#allocation#method#is#
unknown.#
Unknown#participated#gender#ratio.#
Inclusion#and#exclusion#criteria#were.#
Mentioned.#
No#followOup#after#completion#of#study.#
Patients#are#aware#of#their#group#
allocation.#
Individuals#who#are#delivering#the#
intervention#are#aware#of#their#group#
allocation.###
gender#ratio.#
N#=#23#
#
#
#
(r=0.61,#p=0.002).##
NOTE:#
Reduction#of#depression#
score#in#percentage#was#
not#provided.#
#
#
Incomplete#data#collection.#10#out#of#
23#participants#dropped#out#(2/10#in#
aerobic#exercise#and#8/10#in#
stretching).#
Lack#of#original#data#to#support#the#
result#written#in#the#study.#
No#clear#baseline#characteristics.#
Exercise#group#have#longer#
intervention#than#stretching#group#
(10.7#vs.#6.8#weeks).##
Knubben**
et.*al.,*
2007*
Randomised#
controlled#
trials,#
prospective#
study.#
Patients#with#
major#
depression#
who#are#under#
clinical#
antidepressant#
drug#treatment#
Mean#Age#=#
49.5##
55%#female,#
45%#male#
*N#=#38#
2# 1.#Exercised#group:#
Walking#on#a#
treadmill#(80%#
MHR).#
2.#Placebo#group:#
Stretching#and#
relaxing#exercise#
daily.#
30#minutes#daily.###
10#day#
intervention.#
#
Significant#decrease#in#
depression#scores#in#
exercise#group#in#both#
BechORafaelsen#Scale#
(BRMS)##and#Center#for#
Epidemiologic#Studies#
Depression#Scale#(CESOD)#
compared#to#placebo#
group#respectively:#
BRMS:#36%,#18%;##
CESOD:#41%,#21%;##
P#for#both#=#0.01##
Exercise#group#shows#
Randomized#controlled#trial:#low#risk#
of#bias.#
Study#groups#allocation#concealment.#
Similar#N#in#both#exercise#and#placebo#
groups.#
Similar#age#in#both#genders#
Inclusion#and#exclusion#criteria#were#
mentioned:#low#risk#of#bias.#
2#weeks#followOup#after#the#
experiment.#
A#single#psychologist#who#is#blinded#
from#the#group#allocation#assessed#the#
significant#clinical#
response#to#the#
intervention#by#reducing#
BRMS#score#by#more#
than#6#points#compared#
to#placebo#respectively:#
65%,#22%;#P<0.01##
#
BRMS#score#outcome.#
Patients#are#aware#of#their#group#
allocation.#
Individuals#who#are#delivering#the#
intervention#are#aware#of#their#group#
allocation.###
One#participant#missing#in#the#study#
analysis.#39#were#involved#in#the#
intervention#but#only#38#participants’#
outcome#was#reported.#
Krogh**
et.*al.,*
2009*
Randomised#
controlled#
trail.#
Unipolar#
patients#were#
recruited#from#
general#
practitioners#
and#
psychiatrists.#
Mean#age:#38.9##
73.9%#female,#
26.1%#male#
N=165#
#
2# 1.#Strength#
exercise.#
2.#Aerobic#exercise#
(MHR=70–85%).#
3.#Relaxation#
exercise#(placebo).#
40#minutes,#2O3#
times/week.#
16#week#
intervention.#
HAMOD17#shows#no#
significant#changes#in#
both#stretch#and#aerobic#
exercise#groups#versus#
placebo#group.##
4#months:#P=0.3#
12#months:#P=0.8#
NOTE:#
No#score#change#
percentages#were#
calculated,#as#there#was#
no#significant#P#value.##
Randomized#controlled#trial:#low#risk#
of#bias.#
Study#groups#allocation#concealment.#
Similar#mean#age#in#different#groups.#
More#female#than#male#participants#in#
each#group.#
Inclusion#and#exclusion#criteria#were#
mentioned.#
12#months#followOup#visit.#
Patients#are#aware#of#their#group#
allocation.#
Individuals#who#are#delivering#the#
intervention#are#aware#of#their#group#
allocation.###
Individuals#who#are#delivering#the#
intervention#are#aware#of#their#group#
allocation.###
Similar#N#for#different#ethnicity.#
Singh**et.*
al.,*2001*
Randomized#
controlled#
trial.#
Patients#with#
major#or#minor#
depression#or#
dysthymia#
were#recruited#
through#
volunteer#
database.##
Mean#age:#71.3#
63%#female,#
37%#male#
N=32##
#
2# 1.#Weight#lifting#
exercise:#10#weeks#
of#supervised#
exercise,#then#10#
weeks#of#
unsupervised#
exercise#(MHR##
70%#to#80%).#
2.#Placebo#control:#
10#weeks#lecture.##
45#minutes,#3#
times/week#
20#week#
intervention#
Beck#Depression#
Inventory#(BDI)#shows#
significant#reduction#in#
exercise#group#than#
placebo#group#
respectively#in#both#20#
weeks#intervention#and#
26#months#follow#up.#
Intervention#(20#weeks):#
73%,#36%#(P<0.05–.001)##
Follow#up:#33%,#0%#
(P<0.05)#
#
#
Randomized#controlled#trial.#
Study#groups#allocation#concealment.##
Mean#age#in#different#groups#is#
unknown.#
Similar#mean#age#in#different#groups:#
low#risk#of#bias.#
Inclusion#and#exclusion#criteria#were#
mentioned#
26#months#followOup.#
Patients#are#aware#of#their#group#
allocation.#
Individuals#who#are#delivering#the#
intervention#are#aware#of#their#group#
allocation.###
Singh**et.*
al.,*2005*
Randomised#
controlled#
trails.#
#
>60#years#
patients#with#
major#or#minor#
depression#or#
dysthymia#
were#recruited#
through#
volunteer#
database.##
Mean#age:#72.5#
55%#female,#
45%#male#
N=60#
2# 1. Exercise#group:#
High#intensity#
(80%#MHR).#
#
Low#intensity#
(20%#MHR).#
#
2. Placebo#group:#
GP#care.#
60#minutes,#3#
time/week.#
8#week#
intervention.##
Intervention#showed#the#
percentage#reduction#in#
HRSD17#score#by#50%#in#
each#group:##
High#intensity:#61%#
Low#intensity:#29%##
Placebo:#21%#
P=0.03#
NOTE:#
Greatest#relative#change#
in#progressive#resistance#
training#was#for#the#high#
intensity#group#(p=0.05).##
#
Randomized#controlled#trial:#low#risk#
of#bias.#
Study#groups#allocation#concealment.##
Similar#N#in#each#exercise#categories#
and#placebo.#
Similar#mean#age#in#different#groups:#
low#risk#of#bias.#
Similar#N#(in#percentage)#for#each#
gender.#
Inclusion#and#exclusion#criteria#were#
mentioned.#
FollowOup#not#provided.#
Patients#are#aware#of#their#group#
allocation.#
Psychiatrists#who#are#delivering#the#
intervention#in#the#strength#test#were#
not#blinded.##
Psychiatrists#were#blinded#by#all#
assessment#outcomes.#Psychiatrists#
also#find#it#hard#to#guess#group#
allocation#as#the#group#was#divided#
into#2#categories#(exercised#and#
N#=#number#of#participants.##
MHR#=#maximum#heart#rate.
controlled#group#rather#than#3#
groups).***
Psychiatrists#are#blinded#from#the#
group#allocation#during#the#BDI#
assessment#outcome.#
Mather*
et.*al.,*
2002*
###
#
Randomized#
controlled#
trails.#
#
Patients#were#
either#referred#
or#screened#
and#recruited#
via#primary#
care,#
psychiatric#
services#and#
public#
advertisement#
over#a#15O
month#period.#
Mean#age:#65.0#
68.5%#female,#
31.5%#male#
N=86#
2# 1. Exercise#group.##
#
2. Placebo#group:#
health#
education#talk.#
45#minutes,#>2#
times/week.#
Unknown#MHR.#
10#week#
intervention.#
Higher#proportion#of#
participants#in#exercised#
group#showed#30%#
reduction#in#HRSD17.#
Exercise#group:#55%#
Placebo:#33%#
P=0.05#
Randomized#controlled#trial:#low#risk#
of#bias.#
Study#groups#allocation#concealment.##
Inclusion#and#exclusion#criteria#were#
mentioned.#
Study#groups#allocation#concealment.#
N#in#each#groups#were#divided#equally.#
Similar#mean#age#in#both#groups.#
More#female#than#male#participants#in#
exercise#group#only.#
24#weeks#followOup.#
#
1. Spectrum+of+depressive+disorders.++
+
The$ Diagnostic$ and$ Statistical$ Manual$ of$ Mental$
Disorders,$ 5th$ Ed.$ (DSM:V)$ criteria$ is$ commonly$ used$
to$assess$for$major$depressive$episode.$
A.$Five$(or$more)$of$the$following$symptoms$have$been$
present$during$the$same$2:$week$period$and$represent$
a$change$from$previous$functioning;$at$least$one$of$the$
symptoms$is$either$(1)$depressed$mood$or$(2)$ loss$of$
interest$or$pleasure.!
This$includes,$but$is$not$limited$to:$
• Depressed$Mood$
• Loss$of$interest/pleasure$in$usual$activities$
• Lack$of$energy$and$decreased$activity$
• Lack$of$self:esteem/self:confidence$
• Sense$of$guilt/worthlessness$$
• Pessimistic$thoughts$
• Insomnia$or$hyperinsomnia$
• Loss$of$appetite$or$unintentional$weight$loss$
• Ideas$or$recurrent$thoughts$of$suicide$
B.$The$symptoms$cause$clinically$significant$distress$or$
impairment$in$social,$occupational$or$other$important$
areas$of$functioning.$$
C.$ The$ symptoms$ are$ not$ due$ to$ the$ direct$
physiological$ effects$ of$ a$ substance$ (e.g.,$ a$ drug$ of$
abuse,$ a$ medication)$ or$ a$ general$ medical$ condition$
(e.g.,$hypothyroidism)$
2. The+ concept+ and+ criteria+ of+ exercise+ and+
researchers’+beliefs.++
World$ health$ organisation$ (WHO)$ and$ Australian$
Medical$ Association$ (AMA)$ both$ physical$ activity$ as$
the$movement$of$the$body$exerted$by$skeletal$muscles$
that$ result$ in$ energy$ consumption.$ Exercise$ is$ a$
subcategory$ of$ physical$ activity$ where$ it$ requires$
“planned,$ structure,$ purposeful$ and$ repetitive”$
movements$ with$ the$ aim$ to$ “maintain$ or$ improve”$
more$ than$ one$ aspect$ of$ the$ individual$ fitness$ (WHO$
2015,$AMA$2015).$$
The$ effect$ of$ exercise$ on$ depression$ has$ gained$ a$
considerable$amount$of$interest$from$researchers$over$
several$decades$(Beesley$et.$al.,$1997)$
It$ is$ noted$ that$ exercise$ may$ give$ a$ sense$ of$ self:
accomplishment$which$this$then$further$enhance$self:
esteem$and$self:confidence$(lidwidge$1980).$It$may$be$
method$of$deviating$negative$thoughts$by$focusing$on$
the$task$at$hand$(LePore$1997).$$
Exercise$may$also$be$ considered$as$a$ complementary$
therapy,$ rather$ than$relying$purely$on$antidepressant$
that$ may$ lead$ to$ unwanted$ side$ effects.$ Physical$
training$ is$ reported$ to$ be$ especially$ beneficial$ in$
severe$depression$(Knapen$2014).$$
$
Changes$in$the$brain$chemical$mediators$levels$such$as$
endorphin,$ monoamine$ or$ reduction$ in$ cortisol$ level$
through$exercise$may$elevate$mood$in$patients$(Chen,$
2013).$ It$ was$ also$ shown$ that$ exercise$ promotes$
better$sleep$and$the$relief$of$chronic$fatigue$(Lidwidge,$
1980).$ Changes$ in$ cellular$ level$ may$ be$ induced$ in$
physically$active$people$that$result$in$protection$from$
stress:induced$depression$(Agudelo$et.$al.,$2014).$
3. General+methodology.+
Currently$ the$ main$ treatment$ for$ depression$ is$
typically$ pharmacological.$ Antidepressants$ are$ the$
first$ choice$ to$ treat$ depressive$ symptoms$ (Boyce$ et.$
Al.,$2001)$
In$ addition$most$ studies$ are$ conducted$ in$ a$ random:
controlled$trial$(RCT),$with$varied$sample$size$that$are$
rather$small,$short$to$no$follow:ups,$common$physical$
training$ as$ aerobic$ exercise$ with$ MHR$ of$ 70%:85%$
and$consist$of$different$age$group$ranging$from$teens,$
adult$and$elderly.$$
The$Royal$Australasian$College$of$General$practitioner$
(RACGP,$2015)$defined$a$ “good$measure$of$moderate$
aerobic$exercise”$as$the$exercised$individual$becoming$
short$of$breadth$but$is$able$to$carry$out$a$conversation$
(RACGP,$2015).$Aerobic$exercise$ is$mostly$selected$as$
a$ method$ of$ investigation$ in$ the$ experimental$ group$
whilst$ for$ placebo$ group,$ stretching$ and/or$ relaxing$
training$were$the$preferred$choice.$$
Participants$ were$ recruited$ from$ variety$ of$ sources$
such$ as$ being$ referred$ from$ the$ GP$ or$ psychiatrist$
(Blumenthal$ et.$ al.,$ 2007,$Dunn$et.$ al.,$ 2005,$ Foley$ et.$
al.,$ 2008,$ Krogh$ et.$ al.,$ 2009,$ Mather$ et.$ al.,$ 2002),$
recruited$from$volunteer$database$(Singh$et.$Al.,$2001,$
Singh$ et.$ Al.,$ 2005),$ recruited$ through$ other$ clinical$
treatments$ (Knubben$ et.$ al.,$ 2007)$ and$ recruited$
through$ advertisements$ such$ as$ newspaper,$ radio,$
pamphlets$and$posters$ (Foley$et.$ al.,$2008,$Mather$et.$
al.,$2002).$$
4. Why+were+the+articles+selected?++
The$research$articles$chosen$have$a$consistence$
methodology$such$as$RCT;$most$involve$aerobic$
exercise$intervention$and$have$a$similar$MHR$(70%:
80%).$The$intervention$period$for$most$studies$
exceeds$the$minimum$requirement$(9$weeks)$for$the$
depression$treatment$(RACGP,$2015).$$The$articles$are$
relatively$recent$and$does$not$exceed$more$that$two$
decades.$Although$mainly$the$mean$age$for$most$
papers$are$skewed$towards$adults$and$elderly,$the$age$
range$for$all$of$studies$covered$a$wide$spectrum.$$
5. Advantages,+ limitations+and+ inconclusiveness+ in+
aerobic+ exercise+ training+ approach+ to+ treat+
depressive+disorders.+
!
Concealment!of!randomization:$All$studies$were$
conducted$in$a$RCT$through$allocation$concealment$
with$the$exception$of$one$study$(Foley$et.$al.,$2008).$In$
this$paper$method$of$blinding$allocation$was$no$stated$
and$hence$may$increase$the$bias$risk.$
$$
Blinding:$To$ensure$ low$ level$of$bias$ in$ the$ study,$ in$
most$papers,$researchers$were$blinded;$it$is$obviously$
difficult$to$double:blind$when$the$treatment$was$easily$
observable.$ A$ notable$ exception$ (Singh$ et.$ al.,$ 2005),$
tried$ making$ it$ harder$ for$ assessors$ who$ are$
conducting$the$intervention$to$guess$group$allocation.$
There$ was$ one$ case$ in$ which$ those$ who$ were$
supervising$ the$ intervention$ or$ recording$ the$
outcomes$were$not$blinded$at$all$(Foley$et.$al.,$2008)$
Inclusion! and! exclusion! criteria:$ In$ all$ papers,$
inclusion$ and$ exclusion$ criteria$ were$ mentioned$ in$
detail.$$
Follow! ups$ were$ noted$ in$ most$ studies$ except$ for$
(Dunn$ et.$ al.,$ 2005,$ Foley$ et.$ al.,$ 2008,$ Singh$ et.$ al.,$
2005).$However,$there$are$varied$lengths$of$follow:up$
ranging$ from$ 2$ weeks$ to$ 26$ months.$ The$ longer$ the$
follow$up,$the$more$comprehensive$data$the$study$will$
obtain$ and$ long:term$ benefit$ of$ exercise$ treatment$
may$be$clearly$determined.$$
Many$articles$have$lost$participants$in$their$follow:ups$
(Blumenthal$et.$al.,$2007,$Dunn$et.$al.,$2005,$Singh$et.$
al.,$2005)$but$the$biggest$drop$out$amongst$the$study$
is$40%$(Krogh$et.$al.,$2009).$In$(Knubben$et.$al.,$2007),$
there$is$one$participant$missing$in$the$study$analysis.$
39$were$involved$in$the$intervention$but$only$38$
participants’$outcome$was$reported.$Some$articles$
have$no$lost$to$follow:up$or$drop$out$(Mather$et.$al.,$
2002,$Singh$et.$al.,$2001)$
Patient;reported!outcomes:!Report$of$remission$by$
participants$(Dunn$et.$al.,$2005).!Self:reported$
exercise$frequency$for$home:based$exercises$
(Blumenthal$et.$al.,$2007).$Patients$reported$no$
negative$effects$of$exercise$(Knubben$et.$al.,$2007).$
This$may$increase$the$bias$risk$as$self:report$is$relying$
on$the$honesty$of$their$participants.$$
Length!of!intervention:!All$studies’$period$of$
intervention$follow$the$recommended$length$of$
exercise$training$by$the$RACGP$(RACGP,$2005).$$
Gender!ratio:$$Overall,$it$was$observed$that$there$are$
more$female$participants$that$male$across$most$of$the$
studies$ except$ for$ (Foley$ et.$ al.,$ 2008)$where$ gender$
percentages$ were$ not$ identified.$ Thus$ these$ papers’$
data$ may$ be$ more$ viable$ to$ treatment$ female$ than$
male.!
Funding:$ It$ should$ be$ noted$ that$ some$ studies$
received$ commercial$ funding;$ despite$ claims$ to$ the$
contrary,$ this$ may$ still$ create$ a$ potential$ conflict$ of$
interest$(Dunn$et.$al.,$2005).$
Mean!and!range!of!age:$Mean$age$across$the$papers$
ranges$ from$ 35.9$ to$ 72.5.$ It$ was$ clear$ that$ most$
participants$ were$ either$ adults$ or$ elderly$ thus$ these$
papers$ may$ not$ be$ applicable$ for$ children$ and$
teenagers$with$depression.$Although$the$(Foley$et.$al.,$
2008)$study$covers$a$wide$range$of$age$group$(18:55$
years$ old)$ the$ mean$ age$ still$ lie$ towards$ adult$ and$
elderly.$
Exercise! choice:$ Pure$ aerobic$ exercise$ was$ used$ in$
most$of$the$study$intervention$except$for$(Krogh$et.$al.,$
2009,$ Singh$ et.$ al.,$ 2001).$ As$ support$ by$ the$ RACGP$
guideline,$ it$ is$ recommended$ that$ aerobic$ exercise$
alone$ is$ not$ as$ effective$ a$ treatment$ than$ combining$
aerobic$ and$ resistance$ training.$ This$ may$ limit$ the$
maximum$effectiveness$of$the$exercise$intervention$to$
treat$depression$(RACGP,$2015).$
Selective! outcome! reporting:$ Lack$ of$ supporting$
data$ collection$ was$ observed$ in$ (Foley$ et.$ al.,$ 2008)$
study.$These$were$lack$of$original$data$to$support$the$
result$ written$ in$ the$ study$ and$ no$ clear$ baseline$
characteristics$were$included.$This$makes$it$harder$for$
the$study$to$be$reliable.!
6. Comparison+ of+ Findings+ With+ Current+ Practice+
Guidelines.+
Moderate$ intensity$ exercise$ with$ 55%:70%$ MHR$ is$
recommended$ according$ to$ the$ general$ practice$
guidelines.$This$is$lower$than$the$investigated$studies.$
As$ recommended,$ exercise$ should$ be$ “conducted$ 30:
40$minutes,$three$times$a$week$for$a$minimum$of$nine$
weeks”$(RACGP,$2015).$This$current$practice$guideline$
was$ followed$ by$most$ chosen$ studies$ except$ for$ two$
(Knubben$ et.$ al.,$ 2007,$ Singh$ et.$ al.,$ 2005)$where$ the$
period$of$intervention$does$not$meet$the$minimum.$
$
As$mentioned$ above$most$ studies$were$ conducted$ to$
test$ only$ for$ aerobic$ training$ for$ their$ exercise$
intervention.$Whilst$RACGP$recommended$a$combined$
exercise$of$aerobic$and$resistance$training.$
$
7. Areas+in+need+of+future+study.++
Overall$ aerobic$ exercise$ does$ improve$ depressive$
symptoms,$but$there$also$many$shortcomings$that$has$
to$ be$ dealt$ with.$ The$ chosen$ studies$ provide$ a$ good$
evidence$ for$ exercise$ having$ beneficial$ effects$ on$
depressive$ individuals.$ However,$ the$ range$ of$ mean$
age$is$from$35.9$to$72.5$thus$the$appraised$articles$are$
more$ viable$ for$ adult$ and$ elderly$ patients.$ It$ is$ then$
may$ be$ worthwhile$ explore$ exercise$ impacting$ on$
adolescent$with$depression.$$
Most$ articles$ chose$ aerobic$ training$ as$ their$
intervention$ however,$ this$ type$ of$ exercise$ requires$
whole$ body$ movement$ such$ as$ cycling,$ swimming,$
running$and$walking.$Thus$aerobic$exercise$might$not$
be$ applicable$ to$ all$ individuals$ such$ as$ people$ with$
disability.$ Therefore,$ it$may$ also$ be$ useful$ to$ explore$
anaerobic$ or$ resistance$ exercise$ to$ compare$ the$
beneficial$ effects$with$ aerobic$ training.$ In$ addition$ it$
may$also$be$worthwhile$looking$into$the$best$exercise$
type$ for$ different$ age$ group$ and$mobility$ range$ such$
elderly,$ individual$with$different$types$of$trauma,$and$
people$with$disability.$
In$ this$ review,$ the$ research$ studies$ were$ focused$ on$
patient$who$ are$ diagnosed$with$ depression$ and$ thus$
fulfilled$ the$ DSM:V$ criteria.$ It$ is$ also$ critical$ to$ take$
note$ that$ there$ are$many$more$ individuals$ that$ does$
not$ completely$ fit$ the$ DSM:V$ criteria$ but$ may$ show$
some$ cognitive$ changes.$ It$ is$ then$ should$ exercise$ be$
recommended$to$those$patients?$$
Another$ area$ that$ is$ in$ need$ for$ further$ study$ is$
regards$ to$ individuals$who$are$already$active$or$ elite$
athletes$ who$ were$ diagnosed$ with$ depression.$ What$
would$be$ the$most$viable$ intervention$ for$ them?$Will$
exercise$ intervention$ be$ helpful$ as$ these$ individuals$
are$already$active?$$
Krogh$ et.$ al.,$ 2009$ showed$ a$ significant$ reduction$ in$
depression$scores$for$the$exercised$group$for$the$first$
four$ months$ (p=0.03).$ However,$ p:value$ becomes$
insignificant$ for$ the$ rest$ of$ the$ 12:month$ study$
(p=0.8).$There$ is$ a$need$ for$ further$ research$ into$ the$
long:term$ effectiveness$ of$ exercise$ as$ depression$ can$
often$a$life$long$disorder$(Boyce$et.$al.,$2001)$$
In$the$case$of$contradicting$results,$it$is$always$best$to$
compare$ and$ contrast$ the$ validity$ of$ each$ article$ and$
its$ biases.$ More$ articles$ should$ be$ explored$ before$
coming$ to$ a$ conclusion$ to$ ensure$ that$ a$ wide$
population$on$research$on$exercise$and$depression$are$
covered.$This$also$helps$ to$gauge$ the$majority$results$
or$findings$made$by$other$researchers.$
Aerobic$ training$ at$ maximum$ heart$ rate$ (MHR)$ of$
70%:80%$reduced$depression$symptoms$compared$to$
placebo$ or$ less$ intense$ exercise.$ However,$ physical$
training$ analysis$ showed$ the$ overall$ reduction$ of$
depression$ in$ patients$ but$ this$ is$ not$ always$
significant.$From$the$chosen$articles,$ it$ is$more$viable$
for$ adults$ and$ elderly$ to$ be$ recommended$ in$ the$
exercise$ treatment$ for$ depression$ as$ most$ studies$
were$based$on$the$mean$age$ranging$from$35.9$to$72.5.$
More$research$papers$should$investigate$further$if$the$
patient$ presented$ with$ depression$ was$ a$ child$ or$ an$
adolescent.$
Most$ studies$ showed$ significant$ reduction$ in$
depression$scores$(HRSD17,$BDI,$CES:D$and$BRMS)$for$
the$exercised$group$compared$to$placebo$(Knubben$et.$
al.,$2007,$Krogh$et.$al.,$2009,$Singh$et.$al.,$2001,$Singh$
et.$ al.,$ 2005,$ Mather$ et.$ al.,$ 2002).$ Although,$ other$
papers$did$not$provide$the$p:value$or$p:value$is$>0.05,$
exercised$group$still$showed$to$have$larger$percentage$
of$reduction$in$the$depression$scores$than$the$placebo$
(Dunn$et.$al.,$2005).$This$suggested$that$exercise$does$
have$ some$ beneficial$ effect$ on$ improving$ depressive$
symptoms.$$
As$ recommended$ in$ the$ guidelines,$ patients$ with$
depression$ are$ recommended$ to$ be$ treat$ with$ a$
combination$ of$ antidepressant$ and$ exercise$ training.$
This$ is$ also$ reflected$ in$ all$ of$ the$ studies$ where$
patients$ are$ on$ antidepressants$ and$ exercise$
intervention$ showed$ beneficial$ results.$ Thus,$ it$ is$
definitely$ worthwhile$ to$ incorporate$ exercise$ as$ a$
complement$intervention$for$DSM$patient.$$
Most$ research$papers$ should$be$used$ to$ consider$ the$
final$treatment$for$the$patient$except$for$(Foley$et.$al.,$
2008).$ This$ paper$ is$ lack$ of$ many$ figures,$ data$ and$
tables$that$makes$inconclusive$to$draw$conclusion$and$
rely$on.$$$$
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Singh,$N.$A.,$Stavrinos,$T.$M.,$Scarbek,$Y.,$Galambos,$G.,$
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controlled$trial$of$high$versus$low$intensity$weight$
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World$Health$Organisation$(WHO).$(2015).$Physical$
Activity.$Retrieved$from$
http://www.who.int/dietphysicalactivity/pa/en/$
$
Howick,!J.,!Chalmers,!I.,!Glasziou,!P.,!Greenhalgh,!T.,!
Heneghan,!C.,!Liberati,!A.,!Ivan!Moschetti,!Phillips,!B.,!
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2011$Levels$of$Evidence.$Retrieved$from$
http://www.cebm.net/index.aspx?o=5653$
!
A!P!P!E!N!D!I!C!E!S!MEDLINE+
Ovid$MEDLINE$was$searched$using$the$following$terms:$
1. exp$depression/$
2. exp$exercise/$
3. exp$therapy/$
4. exp$randomized/$$
5. exp$controlled$trial/$
$
$
+
+
+
+
OXFORD+JOURNALS+
Oxford$Journals$was$searched$using$the$following$terms:$$
1. Effect$
2. Exercise$
3. Depression$
$
!
!
!
!
!
!
!
!
!
!
!
SPINGERLINK+
SPINGERLINK$was$searched$using$the$following$terms:$$
1. Exp$Treat/$
2. Exp$Physical$exercise/$
3. Exp$treat/$
4. Exp$Depression/$
$
$
$
$
$
$
$
$
!
!
!
!
ScienceDirect+
ScienceDirect$was$searched$using$the$following$terms:$$
3. Effect$
4. Exercise$
5. Depression$
6. Depressive$Disorder$$
7. Physical$$
$
$
$
$
!
!
!
!
MEDLINE+
1,835$articles$were$retrieved$in$the$search.$Out$of$those,$3$articles$were$finally$selected$for$appraisal.$$
Oxford+Journals++
22$articles$were$retrieved$in$this$search.$Out$of$those,$2$articles$were$finally$selected$for$appraisal.$
ScienceDirect+
68$articles$were$retrieved$in$the$search.$Out$of$those,$3$articles$were$finally$selected$for$appraisal.$
SPRINGERLINK+
384$articles$were$retrieved$in$the$search.$Out$of$those,$1$article$was$finally$selected$for$appraisal.$