# Exercise as it relates to Disease/The implementation of a short term endurance training to improve patient outcomes from major depression

This is a critique of a particular mode of exercise and its effect on depression. This was carried out by a University of Canberra student for a Health, Disease and Exercise assignment.
The Paper: Knubber, K., Reischies, F., Adli, M., Shlattmann, P., Bauer, M. and Dimeo, F. (2007). A randomised, controlled study on the effects of a short-term endurance training programme in patients with major depression. The British Journal of Sports Medicine, [online] (41), pp. 29–33.

## What is the background to this research?

Depression is a serious illness that affects both a person’s mental and physical health. The World Health Organization (WHO) has defined depression as “a common mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration”. Depression as a disorder is said to be wide spread, as it has been reported to affect around 350 million people worldwide.
Over recent years exercise has been increasingly shown to be highly effective at improving an individual’s mental state. There is ever- increasing interest and support for the use of exercise as a treatment strategy for people suffering from various degrees of depression, with specific regards to people suffering from major depression.
The overall objective of this study was to determine what effect a short-term endurance training protocol had on individuals who had major depression.

## Where is the research from?

This study was conducted in Germany by K Knubben, F M Reischies, M Adli, P Schlattmann, M Bauer, and F Dimeo and was published in the British Journal of Sports Medicine.

## What kind of research was this?

This study was a “prospective, randomized, control study”. This means that the individuals that were assigned to the various groups were assigned randomly by the researchers with the aim of reducing bias. Researchers commonly use this method when they are testing new treatment.
Table 1 Advantages and Disadvantages of RCT.
| Advantages | Disadvantages |
| Greatly reduces experimental bias | Expensive and time consuming method |
| Allows for cause and effect to be explained | Large ethical considerations/restrictions |
| Shown to be the best method of determining efficacy | Limited follow up procedures results in substitute endpoints which may not reflect the true results of the study |
| Allows for specific research questions to be answered. | Researchers typically do not know how much improvement in participants is clinically meaningful however this knowledge is necessary in order to calculate the sample size. |

## What did the research involve?

The research involved taking participants from a group of individuals who had been recently admitted to a university- based hospital. These individuals were currently undergoing treatment as they had recently experienced a severe depressive episode. The selection criteria were based on the individuals having a Bech-Rafaelsen Melancholy Scale (BRMS) score of greater than 12. Once all the participants were selected they were randomly assigned into either the ‘Training Group’ or the ‘Placebo’ group (see table 2 for specifics).
| | Training Group (n=20) | Placebo Group (n=18) |
| Mode of exercise | Endurance training, interval training pattern. Conducted on a treadmill | Light stretching (calves, thighs, back, shoulders, and pectoral muscles.) |
| Time | 5x3min | 20s on 40s off for each muscle group |
| Duration (days) | 10 | 10 |
| Intensity | Dependent on lactate concentration and HR | Not specified (very low intensity) |
| Frequency | 30min a day | 30min a day |
* It is important to note that the exercise protocols were carried out alongside the use of antidepressant medication.

## What were the basic results?

The average age for the patients in the training group was 49(±13), and for the placebo group it was 50(±13). There were 17 male patients and 21 female patients. Patients had a variety of depression diagnoses (including bipolar affective disorder, moderate to severe Depressive episode, moderate to severe Recurrent depressive disorder, moderate to severe Dysthymia, and Persistent affective disorder). They were also taking various antidepressant medications (Tricyclic and tetracyclic antidepressant, Specific serotonin re-uptake inhibitors, Monoaminooxidase inhibitors, Lithium carbonate, Trazodone, Serotonin and noradrenaline re-uptake inhibitors, Noradrenalin re-uptake inhibitors, No pharmacological treatment and Sleep deprivation therapy).
Upon completion of the study it was found that:
* After the 10-day period, the Training (test) group showed a greater reduction in the BRMS scores (36%) when compared to the Placebo (control) group (18%).
* After the 10-day period, the participants’ perception of their depression (measured by their CES-D scores) was greatly reduced in the training (test) group (41%) when compared to the placebo (control) group (21%). These above to findings were found to be statistically significant.
* The training (test) group was found to have a reduced hospital stay compared to the placebo (control) group. However this particular result was determined to be statistically insignificant (P=0.32).

## What conclusions can we take from this research?

The study stated that antidepressant medication has a latency period of several weeks. Therefore, determining a means of exercise- based treatment that is focused around a short period of time is vitally important in effectively treating people suffering from severe depression. The research showed that endurance exercise regimes lead to fast and effective improvements for participants suffering from depression. Other more recent research into exercise and its effects on depression have also shown this positive association. However, there are numerous inconsistencies across these studies regarding the “mechanism of action, type of exercise, intensity and frequency of exercise” that is required to achieve the best and most effective results. Therefore, the next logical step forward would be to design a study that improves interdisciplinary communication which would then allow for us to come closer to determining a standardised exercise program/regime to improve patients’ wellbeing from various degrees of depression.

## Practical advice

As exercise has been found to be effective in reducing the symptoms of depression it has been recommended by numerous researchers that exercise be prescribed as a formal means of treatment by medical professionals. This can be prescribed as either a stand-alone treatment or in conjunction with antidepressant medication, as is what occurred in this study.

## Further information/resources

For further information regarding exercise and its effect on depression please read the information below:
* Exercise and Depression: http://www.blackdoginstitute.org.au/docs/ExerciseandDepression.pdf
* Depression Explained and how to get started: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/depression-and-exercise
* Further background reading (exercise and depression): http://www.health.harvard.edu/mind-and-mood/exercise-and-depression-report-excerpt

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 The Paper: Knubber, K., Reischies, F., Adli, M., Shlattmann, P., Bauer, M. and Dimeo, F. (2007). A randomised, controlled study on the effects of a short-term endurance training programme in patients with major depression. The British Journal of Sports Medicine, [online] (41), pp.29-33.
* ↑ World Federation for Mental Health, (2012). Depression: A Global Crisis. [online] World Health Organisation.
* ↑ World Health Organization. (2015). Depression. [online].
* 1 2 Dunn, A. and Jewell, J. (2010). The Effect of Exercise on Mental Health. Current Sports Medicine Reports, 9(4), pp.202-207.
* 1 2 Wolff, E., Gaudlitz, K., von Lindenberger, B., Plag, J., Heinz, A. and Ströhle, A. (2011). Exercise and physical activity in mental disorders. Eur Arch Psychiatry Clin Neurosci, 261(S2), pp.186-191.
* 1 2 3 Eriksson, S. and Gard, G. (2011). Physical exercise and depression. Physical Therapy Reviews, 16(4), pp.261-268.
* 1 2 1. Mead, G., Morley, W., Campbell, P., Greig, C., McMurdo, M. and Lawlor, D. (2009). Exercise for depression. Mental Health and Physical Activity, 2(2), pp.95-96.
* 1 2 1. Het Rot, M., Collins, K. and Fitterling, H. (2009). Physical Exercise and Depression. Mount Sinai Journal of Medicine, 76(2), pp.204-214.
* 1 2 Medical Publishing Internet, Kent W. The advantages and disadvantages of observational and randomised controlled trials in evaluating new interventions in medicine.: Educational article [Internet]. Version 1. Clinical Sciences. 2011 June 9.
* ↑ Levin K. Study design VII. Randomised controlled trials. Evidence-Based Dentistry. 2007;8(1):22-23.
* ↑ 1. Bech P, Rafaelsen OJ. The Melancholia-Scale: development, consistency, validity and utility. In: Satorius N, Ban TA, eds. Assessment of depression. Berlin: Springer, 1986:259–69.
* ↑ 1. Daley, A. (2008). Exercise and Depression: A Review of Reviews. J Clin Psychol Med Settings, 15(2), pp.140-147