# Exercise as it relates to Disease/Exercise and major depression in older patients
## What is the background to this research?

Major depressive disorder, also known as clinical depression is a syndrome that involves extremely low moods and a decreased interest in activities that a person would normally enjoy. Depression is an extreme disability that effects approximately 5-10% of elderly people in the United States of America. This disorder effects many people and their everyday life and signs and symptoms of this illness include;
* general discontent
* mood swings
* extreme sadness
* fatigue
* social isolation
* irritability
* lack of concentration
* suicidal thoughts
This study focuses on the effects of major depressive disorder in older adults and the benefits of exercise training. The background to this research is to see whether a regular aerobic exercise program can reduce symptoms of major depressive disorder (MDD) in older patients compared to standard medication (antidepressants - sertraline) for 16 weeks. Antidepressants are the most common treatment for MDD but can also induce negative side effects that can reduce an individual's quality of life which is why the study looks at aerobic exercise being a preventative measure.

## Where is the research from?

The research was conducted in America with older adult groups. The authors who conducted the research are from the Departments of Psychiatry and Behavioural Sciences and the Department of Psychology, University of California-San Diego. This can create limitations as the study only looks at how exercise impacts major depressive disorder in individuals in America only opposed to other countries.

## What kind of research was this?

This investigation is a randomised control trial (RCT) study where individuals were randomly assigned to a particular group to complete the 16 week study. These groups included;
* Aerobic exercise only
* Antidepressants only
* Combination of exercise and antidepressants
A limitation to this is that there is no control group that did not participate in any treatment which prevents the researchers from witnessing any spontaneous recoveries.
Other studies on this topic also show that the evidence of exercise has a significant effect on reducing the symptoms of depression. A controlled study on the effects of aerobic exercise on depression in the British Medical Journal by Martinsen EW also shows that exercise has a significant impact on reducing the symptoms of depression. The results of this study showed that the patients involved had reduced depression scores among the group who participated in exercise. These results were a similar outcome to the results on the article relating to major depression in older patients by Blumenthal JA. Another study by John B. Bartholomew looking at the effects of acute exercise on mood and well-being in patients with major depressive disorder shows that exercise had a greater effect than rest. Both mood and well-being improved following exercise helping reduce the symptoms of major depressive disorder.

## What did the research involve?

150 patients aged 50-77 years participated in an exercise program over 16 weeks. Subjects underwent evaluations of the severity of MDD using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and Hamilton Rating Scale of Depression (HAM-D) and Beck Depression Inventory (BDI) scores before and after treatment. After the completion of these pre-assessments, each participant was assigned to 1 of 3 treatment groups; medication, exercise and a combination of medication and exercise. For 16 weeks the patients participated in aerobic exercise to see whether it would be beneficial for depressive symptoms. The limitations to the measures taken are that the evaluations are self-reported and is a questionnaire so patients may not have answered accurately.
This methodology was the best approach as the study showed that the impact of aerobic exercise in older patients had a successful outcome and provided evidence that exercise can be as beneficial as antidepressant medication which is indicated in the results section.

## What were the basic results?

After 16 weeks of treatment, growth curve models showed that there was a significant reduction in depressive symptoms for all 3 groups. Patients that were taking antidepressant medication showed the fastest initial response compared to patients in the other groups. Individuals with depressive symptoms that were less severe showed a rapid response than those who suffered with major depressive disorder. The exercise group, medication group and the combination group no longer met the criteria for major depressive disorder. These results were according to the clinician who was unaware of the patient’s group status and were also assessed using HAM-D and BDI. The results also support that an aerobic exercise program is an effective treatment of MDD in older adults and also showed that individual's who exercised in the study also achieved a small improvement in their aerobic capacity. It is still unknown whether different outcomes and results would have occurred if the duration of treatment was longer than 16 weeks and whether the treatment effects will be effective over time.
| Group Category | HAM-D Score Before | HAM-D Score After |
| Medication | 18 | 8 |
| Exercise Treatment Group | 17.5 | 8.5 |
| Combination | 18 | 9.5 |
| Group Category | BDI Score Before | BDI Score After |
| Medication | 23 | 9 |
| Exercise Treatment Group | 21 | 10 |
| Combination | 23 | 11 |

## What conclusions can we take from this research?

A regular exercise program could possibly be an alternative treatment option to antidepressants in older adults. Antidepressants may result in a quicker initial response but participating in an exercise program can have a similar response. Exercise had the same effect in reducing depression symptoms among those older adults with major depressive disorder. This can also be compared to the levels that were achieved in other clinical trials of depression using the antidepressant, sertraline.
The findings in this study are similar to a recent study looking at the same topic. A study by F. Dimeo looking at the benefits of aerobic exercise in patients with major depression represents that there was a substantial improvement in some patients that participated in the study. The severity of depressive symptoms reduced dramatically over the course of the study and indicates that aerobic exercise could be an appropriate and safe option for individuals.

## Practical advice

Implications that can be taken from this study is that participating in regular aerobic exercise can be beneficial especially to the older population.
Readers should know more about the risks involved before taking this practical advice especially in terms of anti-depressant medication as there are severe risks that can negatively impact an individual's well-being https://www.health.harvard.edu/newsletter_article/what-are-the-real-risks-of-antidepressants. Risks of taking antidepressants include;
* Headaches/migraines
* Nausea
* Joint and muscle pain
* Irritability
* Anxiety
* Crying spells
* Worsened depressive symptoms
If an individual experiences these symptoms they should see a doctor immediately. Experiencing these symptoms will reduce the chance of participating in exercise significantly which can then be detrimental to the individual's mental health and well-being, increasing symptoms of depression. If an individual is suffering from major depressive disorder, they should consult their general practitioner about antidepressant medication and which one is most suitable for the individual and get advice about starting an exercise program and how this will benefit them in the future.
Further readings that interested readers may benefit from;
* https://www.sciencedirect.com/science/article/pii/S0749379704002417
* https://www.tandfonline.com/doi/pdf/10.3109/09638288.2014.972579?needAccess=true
* https://www.ncbi.nlm.nih.gov/pmc/articles/PMC474733/pdf/i1523-5998-6-3-104.pdf
* https://www.beyondblue.org.au/the-facts/depression
Websites that provide further information and support to groups related to this study are linked below;
* https://www.beyondblue.org.au/the-facts/depression/treatments-for-depression
* https://www.blackdoginstitute.org.au/clinical-resources/depression/treatment
* https://blackdoginstitute.org.au/docs/default-source/factsheets/exercise_depression.pdf

## References

* ↑ Rush AJ. The varied clinical presentations of major depression disorder. The Journal of clinical psychiatry. 2007.
* 1 2 3 4 5 6 7 8 9 10 Blumenthal JA, Babyak MA, Moore KA, Craighead WE, Herman S, Khatri P, et al. Effects of exercise training on older patients with major depression. Archives of internal medicine. 1999;159(19):2349-56.
* ↑ Costello CG. Symptoms of depression: Wiley New York; 1993.
* ↑ Martinsen EW, Medhus A, Sandvik L. Effects of aerobic exercise on depression: a controlled study. British medical journal (Clinical research ed). 1985;291(6488):109
* 1 2 Bartholomew JB, Morrison D, Ciccolo JT. Effects of acute exercise on mood and well-being in patients with major depressive disorder. Medicine & Science in Sports & Exercise. 2005;37(12):2032-7
* ↑ Bech P, Rasmussen N-A, Olsen LR, Noerholm V, Abildgaard W. The sensitivity and specificity of the Major Depression Inventory, using the Present State Examination as the index of diagnostic validity. Journal of affective disorders. 2001;66(2-3):159-64
* ↑ Dimeo F, Bauer M, Varahram I, Proest G, Halter U. Benefits from aerobic exercise in patients with major depression: a pilot study. British journal of sports medicine. 2001;35(2):114-7