Exercise as it relates to Disease/The benefits of exercise on older adults suffering from depression

This is an analysis of the journal article "Effects of Exercise Training on Older Patients with Major Depression" by Dr James A. Blumenthal, et al (1999)

What is the background to this research?
Research shows that around seven million Americans over the age of 65 suffer from depression and the likelihood of this increases with loss of independence (ie hospital patient or care home). Everyone is likely to experience periods of unhappiness over their lifetime, depression however is a serious long term condition defined by a “persistent feeling of sadness and a loss of interest”. It is believed that depression affects 350 million people worldwide. One of the major concerns with older adults and depression is they are less likely to admit to feelings of sadness or grief and therefore their depression may go untreated. Of the seven million Americans over 65 suffering from depression it is believed that about 75% of them do not receive treatment.

While effects can differ slightly depending on the type of depression the main impacts regardless of age are:
 * Lower self-esteem
 * Altered sleep patterns and feelings of fatigue
 * Decreased energy levels
 * Poor concentration
 * Drastic changes in the way you feel throughout the day

Where is the research from?
The study was led by Dr James Blumenthal and conducted by a group of researchers from a number of American universities. The final paper was published in the Archives of Internal Medicine in 1999.

What kind of research was this?
The research was conducted using a short term intervention study.

What did the research involve?
The aim of the study was to assess the effects of exercise on older adults suffering from Major Depressive Disorder (MDD). Volunteers were recruited through media advertisement, flyers and letters sent to medical clinics. These volunteers were then assessed for the presence and severity of their MDD. Eligible subjects then completed a 16 week treatment program.

To be considered eligible for the trial subjects had to score 13 or higher on the Hamilton Rating Scale for Depression (HAM-D) and meet the criteria of the Diagnostic and Statistical Manual of Mental Health Disorders 4th edition (DSM-IV). From the group of volunteers 156 men and women over the age of 50 were considered suitable for the study. The subjects were then randomly assigned to an exercise group, a medication group or combined medication and exercise group for 16 weeks. The exercise conducted during the test was 30 minutes of continuous supervised walking or jogging on a treadmill 3 times a week.

A number of other tests were conducted at the start and end of the 16 week treatment period including:
 * the Beck Depression Inventory (BDI)
 * scores are out of 63 and the higher the number the more severe the depression;
 * a number of self-reported questionnaires relating to mood and attitude; and
 * a symptom-limited graded exercise treadmill test to assess aerobic capacity.

Throughout the trial evaluations of participants were undertaken using a HAM-D and BDI to assess how the treatment was going.

What were the basic results?
At the end of the 16 week trial a significant number of participants were no longer classified as clinically depressed. Results across the three treatments varied slightly with the following percentages of participants from each group no longer considered clinically depressed:
 * 47.2% from the exercise group
 * 56.2% from the medication group
 * 47.3% from the combined group

The average group scores from the assessments used to assess the severity of depression show a significant reduction from the start to the end of the trial.

The regular assessments conducted throughout the treatment period showed a large initial decline in HAM-D and BDI scores and then after this the decline slowed towards the end of the trial.

How did the researchers interpret the results?
Blumenthal and the team of researchers concluded that exercise could be considered as an alternative to medication for the treatment of depression in elderly patients. They did find however there was a quicker initial response to medication but by the end of the 16 weeks exercise was just as effective.

All groups showed a significant reduction in depression based off the HAM-D and BDI scores. However overall there was no real significant difference between the 3 groups at the end of the treatment. The main differences were that the people only receiving medication exhibited the fastest response and people in the combine medication and exercise group responded quicker if they had less severe symptoms of DMM compared to people with more severe symptoms.

Both the exercise and combined group improved aerobic capacity from the start to the end of the trial, with the exercise group increasing by 11% and the combined group increasing by 9%.

What conclusions should be taken away from this research?
Exercise has a positive effect on older patients suffering from MDD. While medication to treat depression will have a much more immediate effect within the first week or two, after this point exercise becomes just as effective a means of reducing depression. A combination of medication and exercise worked better for someone with less severe depression compared to those with more severe depression.

What are the implications of this research?
The results from the trial show a clear relationship between exercise and a reduction in depressive symptoms for an elderly population. The results suggest that the introduction of aerobic exercise in the older population, especially in nursing home and hospital situations, will be beneficial for those suffering or at risk of suffering depression. The relatively low cost of such a program would make it an accessible treatment alternative. This would be an advantage in an older population who may have limited finances to spend on medication. As well as the benefits to treating depression exercise has been linked to many other factors improving quality of life in older adults.