Exercise Treatment for Major Depression: …

1 ExerciseTreatmentforMajorDepression:Main tenanceofTherapeuticBenefitat10 MonthsMICHAELBABYAK, PHD, , PHD,STEVEHERMAN, PHD,PARINDAKHATRI, PHD,MURALIDORAISWAMY,MD,KATHLEENMOORE, PHD, , PHD, , PHD, , MDObjective:Thepurposeofthisstudywastoas sessthestatusof156adultvolunteerswithmaj ordepressivedisorder(MDD)6monthsaftercom pletionofastudyinwhichtheywererandomlyas signedtoa4-monthcourseofaerobicexercise, sertralinetherapy, :Thepresenceandseverityofdepressionwerea ssessedbyclinicalinterviewusingtheDiagno sticInterviewScheduleandtheHamiltonRatin gScaleforDepression(HRSD) ,after4monthsoftreatment,and6monthsafter treatmentwasconcluded(ie,after10months). Results:After4monthspatientsinallthreegr oupsexhibitedsignificantimprovement;thep roportionofremittedpartici-pants(ie,thos ewhonolongermetdiagnosticcriteriaforMDDa ndhadanHRSD score!8) ,however,remittedsubjectsintheexercisegr ouphadsignificantlylowerrelapserates(p". )

2 01) sownduringthefollow-upperiodwasassociate dwithareducedprobabilityofdepressiondiag nosisattheendofthatperiod(oddsratio" ,p".0009).Conclusions:Amongindividualswi thMDD,exercisetherapyisfeasibleandisasso ciatedwithsignificanttherapeuticbenefit, : depression , Exercise , "BeckDepressionInventory;DIS"DiagnosticI nterviewSchedule;DSM-IV"DiagnosticandSta tis-ticalManualofMentalDisorders,fourthe dition;HRSD"HamiltonRatingScaleforDepres sion;MDD"majordepressivedisorder;OR"odds ratio;SMILE"StandardMedicalInterventiona ndLong-TermEx-ercise(study).Aerobicexerc isehasbeenprescribedforthetreat-mentofaw iderangeofmedicaldisorders,includingcard iovasculardisease(1,2),hyperlipidemia(3) ,os-teoarthritis(4),fibromyalgia(5),andd iabetes(6).Inaddition,exercisemayhaveanu mberofpsychologicalbenefits(7,8),anditha sbeensuggestedasapotentialtreatmentforav arietyofpsychiatricconditions,espe-ciall ydepression(9,10).

3 Epidemiologicalstudieshaveshownaninverse relationbetweenphysicalactivityandmental health(11,12).Ithasbeenshown,forexample, thatphysicalactivityisinverselyrelatedto depressivesymptoms(12,13)andthatindividu alswhoincreasedtheiractivityovertimewere atnogreaterriskfordepressionthanindividu alswhohadbeenphysicallyactiveallalong(14 ).Moreover, (15 638(2000)0033-3174/00/6205-0633 Copyright 2000bytheAmericanPsychosomaticSocietyMET HODSP articipantsParticipantswerevolunteersage d50yearsandolderwhometDSM-IVcriteriaforM DD(22)andscoredatleast13ontheHRSD(23) ,participantsalsometthefollowingcriteria :1)notcurrentlytakingantidepressantmedic ation;2)notcurrentlyusingothermedication sthatwouldprecludetheirbeingrandomlyassi gnedtoeithermedicationorexerciseconditio ns(eg,quinidineormetoprolol);3)nocurrent problemwithalcoholorsubstancedependence; 4)nomedicalcontraindicationstoexercise(e g,significantorthopedicproblemsorcardiop ulmonarydiseasethatwouldpreventregularae robicexercise);5)noprimaryaxisIpsychiatr icdiagnosisotherthanmajordepression(eg,b ipolardis-orderorpsychosis);6)notimminen tlysuicidal;7)notcurrentlyinpsychotherap ythatwasinitiatedwithinthepastyear;and8) (20).

4 (24).SubjectswereconsideredtomeetDSM-IVc riteriaforMDDiftheyexhibitedeitherpersis tentdepressedmoodorlossofinterestorpleas ureplusthefollowingadditionalsymptoms:sl eepdistur-bance,weightlossorchangeinappe tite,psychomotorretardationoragitation,f atigueorlossofenergy,feelingsofworthless nessorexcessiveguilt,impairedcognitionor concentration,orrecurrentthoughtsofdeath , (23) , (25) ; ,participantswererandomlyassignedtooneof threetreatments:1)exercise2),medi-cation ,or3) (26), ,followedby30 (radialpulse) (Zoloft), (27).Medicationmanagementwasprovidedbyas taffpsychiatrist,whometwitheachpatientat thebeginningofthestudyandduringweeks2,6, 10,14, , usualcare guidelinesformedicationmanagement, ,HRSD,andBDIwerecon-ductedatbaseline,imm ediatelyafterthe4-monthtreatmentperiod,a nd6monthsaftertreatmentended(ie,10months afterstudyentry).Allevaluationswerecondu ctedinthehospitalclinic, (28).

5 Subjectswereclassifiedasbeinginfullremis sioniftheynolongermetcriteriaforMDDandha danHRSD score! #6months(ie,atthe6-monthfollow-upvisit). Aclassificationofpartialrecoverywasusedt odesignatesubjectswhodidnotmeetcriteriaf orMDDbutstillexhibitedsignificantdepress ivesymptomsasreflectedbyanHRSD score#7but! ! ,andbeforethecurrentlevelofdepressionwas assessed,participantswereaskedaboutthena tureandextentofanytherapeuticactivityeng agedinduringthefollow-upperiod, :aerobicexercise,weighttraining, ,ifatall,theyengagedinthatparticulartype ofexerciseandtheusualduration(inminutes) (20).Briefly,inten-tion-to-treatanalyses showedthatthegroupshadsim-ilarremissionr ateswithrespecttopresenceorabsenceofcurr entMDD(p".67) , , !8wasaddedtotheclassificationscheme,ther atesofremissionwereagaincomparableforthe threegroups(p".58).Finally, :633 638(2000)mentsforinitiallevelsofdepressi onweremade,thegroupsstilldidnotdifferonH RSD(p".)

6 39)orBDI(p".40) (6-MonthFollow-UpVisit)Follow-upassessme ntswereavailableon133( ) (oneineachgroup) ( Exercise :N"9,17%;medication:N"6,13%;com bination:N"8,15%;p".89). ,self-reporteddepressivesymptoms(ie,BDIs cores)didnotvaryamongpersonsinitiallyass ignedtotheexercise(mean$SE" $ ),medication( $ ),orcombinedexerciseandmedication( $ )groups(p".13).However,wheninter-viewerr atingsinwhichthepresenceofMDDwasdefineda sthepresenceofDSM-IVdiagnosisoranHRSD score#7wereused,itwasfoundthatpartici-pa ntsintheexercisegroupexhibitedlowerrates ofdepression(30%)thanparticipantsintheme dication(52%)andcombinedgroups(55%)(p".0 28). ,participantswerecategorizedasrecovered( noDSM-IVdiagnosisofMDDandanHRSD score!8for#6months),partiallyrecovered(n oDSM-IVdiagnosisofMDDandanHRSD score#7but!15),orrelapsed(presenceofDSM- IVdiagnosisofMDDregardlessofHRSD scoreoranHRSD score!15)(28).

7 Toassesstherelationbetweentreatmentandou tcomeclassification,aproportionaloddsreg ressionmodel,inwhichthethree-leveloutcom e(fullrecovery,partialrecovery,orrelapse )servedasthedependentvariablewithbase-li neHRSD scorespecifiedasacovariate, ,withmedicationasthereferencegroup, ("2(2)" ,p".016).Specifi-cally,participantsinthe exercisegroupweremorelikelythanthoseinth emedicationgrouptobepar-tiallyorfullyrec overedatthe6-monthfollow-upvisit(OR" ,p".01).Incontrast,patientsreceivingcomb inationtherapywerenomorelikelytobecate-g orizedaspartiallyorfullyrecoveredthanwer epa-tientsinthemedicationgroup(OR" ,p".57).Inaddition,only8%ofremittedpatie ntsintheexercisegrouphadrelapsed,compare dwith38%inthemedi-cationgroupand31%inthe combinationgroup( ). ,allpatientswereeducatedaboutMDDandweree ncouragedtocontinuewithsomeformoftreatme ntontheirown, ,48%ofparticipantsinthemedicationgroupin itiatedanexerciseprogramduringthe6-month follow-upperiod(p".)

8 17).Thegroupsdifferedsignificantlyinthen umberofsubjectsusingantidepressantmedica tion,with40%ofsubjectsinthecombinationgr oup,26%inthemedicationgroup,and7%intheex ercisegroupreportingantide-pressantusedu ringthe6-monthfollow-upperiod(p".001).Tw enty-two(16%)oftheparticipantsenteredpsy chotherapyattheendofthe4-monthinterventi on(medication:N"7;combination:N"8;exerci se:N"7;p".99). (6monthsaftertreatment)amongpatientswhow ereremitted(N"83)after4monthsoftreatment inExercise(N"25),Medication(N"29),andCom bination(N"29) , :633 638(2000)or1(nooryes),andexercisewasquan tifiedasthenumberofminutesperweekofaerob icexercise,scaledtoincrementsof1SD(about 50minutes).Age,gender, (seeTable1),adjustingfordepressionlevela tstudyentry,age,gender,andanti-depressan tmedicationuseduringthefollow-uppe-riod( p!.0009).HRSD scoresat4monthsalsowereinverselyrelatedt ominutesofexerciseperweek(% ,p!

9 001). (standardizedOR" ,p".002);however,minutesofexerciseperwee kremainedasignificantpredictorofdepressi vestatuswithlittlechangeintheeffectsize( standardizedOR" ,p".010).DISCUSSIONR esultsofthisrelativelylarge, (20), , , ,theoppositewasthecase, ,ifanything, antimedication sentimentamongsomestudyparticipants, , , , ,lessself-confirmingattributionforone Iwasdedi-catedandworkedhardwiththeexerci seprogram;itwasn teasy,butIbeatthisdepression, patientsmightincorporatethebeliefthat Itookanantidepressantandgotbetter. Thepossibilitieshereareinteresting, , , ,however,thataftercontrollingforposttrea tmentde-pressionlevel, (no/yes) (&50min/wk) . :633 638(2000) :Feelinglessdepressedmaymakeitmorelikely thatpatientswillcontinuetoexercise, ,whichweintroducedinouroriginalreport(20 ),isthatthebenefitsoftheexerciseprogramm aybeattributable,atleastinpart, ,however,becausecontinuationofexercisedu ringthefollow-upperiodgenerallytookplace inanindi-vidual,ratherthanagroup, , (48%) ,only26%ofpatientsinthemedicationgroupch osetocontinuepharmacotherapy,andonly6% prescribed byaclinicianwillbeacceptedandcompliedwit htothesameextentaswhenitissoughtoutandad optedonone crossover ,thefindingthatself-reportedexercise,ind ependentoftheoriginaltreat-mentgroup, ,althoughweusedtheintention-to-treatprin cipleinconductingouranal-yses,15% , (medication,psychotherapy,andexercise).

10 Duringthefollow-upperiod,participantswer eassessedsolelybyself-report, ,however, ,theuseofdiariesorpillcountswouldhavecon veyedexpectationsthatcouldhaveinfluenced subject (albeitblindedtoinitialtreat-mentgroupas signment), , ,thepresentfindingssug-gestthatamodestex erciseprogram(eg,threetimesperweekwith30 minutesat70%ofmaximumheartratereserveeac htime)isaneffective,robusttreatmentforpa tientswithmajordepressionwhoarepositivel yin-clinedtoparticipateinitandthatclinic albenefitsareparticularlylikelytoendurea mongpatientswhoadoptexerciseasaregular, ,HL43028,HL49572, ,PhD,KarenMallow,MA,andDeniseDeBruycker, BA,fortheirassistanceinexercisetestingan dtraining, ConnorGT,BurlingJE,YusufS,GoldhaberSZ,Ol msteadEM,PaffenbargerRS, ;80:234 ,GuyattGH,FischerME, ;260:945 ,WeltmanA,GlassGV, ;15:393 ,Kashikar-ZuckS,OpiteckJ,HageE,Dalrymple L, ;24:279 ,StilesTC, :633 638(2000) ;25:77 ,KoivistoVA,DeibertD,FeligP, ;301:1200 , ;154:497 , ;36:373 , ;5:263 ,McCullaghP, ;18:379 ,LockeBZ,MoscickiEK,DannenbergAL,LarsonD B, ;28:1340 ;17:35 ,MosbacherBJ, ;27:69 ,RobertsRE,LazarusNB,KaplanGA, ;134:220 ,WilliamsRS,NeedelsTL, ;44:529 , ;20:41 ,LeBlancEM, ;6:487 ,MedhusA, ;291 ,HoffertA, ;30:324 ,BabyakMA,MooreKA,CraigheadWA,HermanS,Kh atriP,WaughR,NapolitanoMA,DoraiswamiPM, ;159:2349 ,AgencyforHealthCarePolicyandResearch; :AmericanPsychiatricAssociation; ;45:742 ,HelzerJE,CroughanJ, :itshistory,characteris-tics, ;38:381 ,WardCH,MendelsohnM,MockJ, ;35:837 ,KentalaK, (Finn)1957;35:307 ,ShrivastavaR,MendelsJ,CohnJB,FabreLF,Cl aghornJL,DessainEC,ItilTM, , ;51(SupplB):28 ,PrienRF,JarrettRB,KellerMB,KupferDJ,Lav oriPW,RushAJ, :remission,recovery,relapse.