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Treating Depression with Treating Depression with Physical ActivityPhysical Activity

Caroline R. Richardson, MDCaroline R. Richardson, MDDepartment of Family MedicineDepartment of Family Medicine

VA Health Services Research and VA Health Services Research and Development Center Development Center

Blumenthal et alBlumenthal et alexercise vs. medicationexercise vs. medication

156 men and women 156 men and women Over 50 years oldOver 50 years oldMajor depressive disorder by clinical interview, BDI, Major depressive disorder by clinical interview, BDI,

HAM-DHAM-D

Randomized to – aerobic exercise (n=53),Randomized to – aerobic exercise (n=53), - Zoloft ( n = 48) or - Zoloft ( n = 48) or

- aerobic exercise + Zoloft (n=55)- aerobic exercise + Zoloft (n=55)For 16 weeksFor 16 weeksSource: Blumenthal et al 1999 Archives of Internal Medicine

The Exercise InterventionThe Exercise Intervention

3 supervised exercise sessions / 3 supervised exercise sessions / weekweek

10 minute warm up10 minute warm up 30 minutes walking or jogging at 70 30 minutes walking or jogging at 70

to 85% of heart rate reserve.to 85% of heart rate reserve. 5 minute cool down5 minute cool down

16 weeks16 weeks

Blumenthal’s ResultsBlumenthal’s Results

Blumenthal et al Archives of Internal Medicine 1999:159:2349-2356.

Blumenthal’s ConclusionBlumenthal’s Conclusion

Exercise is as good as Zoloft in the Exercise is as good as Zoloft in the treatment of Depression.treatment of Depression.

Correct ConclusionCorrect Conclusion

Among highly motivated but Among highly motivated but depressed individuals, those who can depressed individuals, those who can successfully participate in a successfully participate in a structured exercise program will structured exercise program will probably significantly decrease their probably significantly decrease their depressive symptoms. depressive symptoms.

Meta-AnalysisMeta-Analysis 14 Randomized Controlled Trials14 Randomized Controlled Trials

All but two studies showed an independent, All but two studies showed an independent, statistically and clinically significant statistically and clinically significant improvement in depressive symptoms.improvement in depressive symptoms.

Effect Size -1.1 (95% CI -1.5 to -0.7)Effect Size -1.1 (95% CI -1.5 to -0.7) Comparing Exercise to No treatment ControlComparing Exercise to No treatment ControlSource: Lawlor, DA BMJ March 2001.Source: Lawlor, DA BMJ March 2001.

100’s of Observational Studies100’s of Observational Studies

People who are not depressed now People who are not depressed now but are physically active now are less but are physically active now are less likely to be depressed in the future.likely to be depressed in the future.

Physical Activity reduces depression Physical Activity reduces depression relapserelapse

College students who were physically College students who were physically active are less likely to become active are less likely to become depressed laterdepressed later

One more point.One more point.

We know that it is hard to start an We know that it is hard to start an exercise program and harder to stick exercise program and harder to stick with it.with it.

How many of our depressed patients How many of our depressed patients successfully initiate and maintain a successfully initiate and maintain a medication program? 20% to 60% medication program? 20% to 60% stop taking med in 1stop taking med in 1stst week. week.

How Can You Help Depressed How Can You Help Depressed Patients Become More ActivePatients Become More Active

Recommend exercise and say that there Recommend exercise and say that there are some clinical trials showing exercise are some clinical trials showing exercise reduces depression symptoms.reduces depression symptoms.

Write out an exercise prescription along Write out an exercise prescription along with the anti-depressant scriptwith the anti-depressant script

Discuss types of exercise, Ways of fitting Discuss types of exercise, Ways of fitting in exercise, How to get startedin exercise, How to get started

PEDOMETERSPEDOMETERS

Count Daily Steps and record on a Count Daily Steps and record on a calendarcalendar

Bring in Calendar to review after one weekBring in Calendar to review after one week Obese patients may not get accurate step Obese patients may not get accurate step

countscounts Caution with 10,000 steps a day target!Caution with 10,000 steps a day target! Wear the pedometer all day every dayWear the pedometer all day every day

Digi-walker SW200 ($20.00)Digi-walker SW200 ($20.00)

Watch out for BiasesWatch out for Biases

Who do we think will not or should Who do we think will not or should not exercisenot exercise• Poor patientsPoor patients• Sick patientsSick patients• Minority GroupsMinority Groups• Older patientsOlder patients• Depressed PatientsDepressed Patients

More Reasons for Depressed More Reasons for Depressed Patients to ExercisePatients to Exercise

Medications for Depression cause Medications for Depression cause weight gain, diabetesweight gain, diabetes

Number 1 cause of death in Number 1 cause of death in depressed patients is still heart depressed patients is still heart disease.disease.

Diabetes is about 2 x as prevalent in Diabetes is about 2 x as prevalent in depressed patients as it is among depressed patients as it is among non-depressed patients.non-depressed patients.

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Slide 4: Blumenthal et al 1999 Archives of Internal MedicineSlide 6: Blumenthal et al Archives of Internal Medicine 1999:159:2349-2356