the runner's high_exercise_depression

A"Review"

The"Runner’s"High:"Can"exercise"help"alleviate"depression?"!

Eissara&Punyapati&

!

Clinical&Question&

Does!exercise!as!part!of!the!treatment!for!depression!improve!depressive!symptoms!in!patients!who!have!

been!diagnosed!with!depression!compared!to!those!who!do!not!undertake!an!exercise!program!as!part!of!

their!treatment?!

&

Introduction&&

Depression! is! classified! under! Depressive!

Disorders! from! the! latest! Diagnostic! and!

Statistical! manual! of! mental! disorders! (APA,!

2013).!Major!depressive!disorder!(MDD)!is!mental!

problem! that! is! characterised! by! absence! of!

positive! affect! and! persistent! low! mood.!

Australian!Institute!of!Health!and!Welfare!quoted!

depression!as! the! fourth! leading!cause!of!disease!

burden! in! Australia.! National! Health! Priority!

Areas!(NHPAs)!have!listed!MDD!as!one!of!the!nine!

diseases! and! conditions! that! significantly! impact!

Australians’! illness! and! wellbeing! (AIHW,! 2013).!

The! effect! of! exercise! training! to! help! combat!

depression! has! been! the! areas! of! interest! for!

researchers.! Past! findings! showed! physical!

activity! as! having! beneficial! effects! as! a!

complementary!treatment!for!depression.!!

Clinical&Bottom&Line&

Aerobic!training!at!maximum!heart!rate!(MHR)!of!

70%R80%! reduced! depression! symptoms!

compared! to! placebo! or! less! intense! exercise.!

However,! physical! training! analysis! showed! the!

overall! reduction! of! depression! in! patients! but!

this! is! not! always! significant.! From! the! chosen!

articles,!it!is!more!viable!for!adults!and!elderly!to!

be! recommended! in! the! exercise! treatment! for!

depression! as! most! studies! were! based! on! the!

mean! age! ranging! from! 35.9! to! 72.5.! More!

research! papers! should! investigate! further! if! the!

patient!presented!with!depression!was!a!child!or!

an!adolescent.!

Most! studies! showed! significant! reduction! in!

depression! scores! (HRSD17,! BDI,! CESRD! and!

BRMS)! for! the! exercised! group! compared! to!

placebo!(Knubben!et.!al.,!2007,!Krogh!et.!al.,!2009,!

Singh!et.!al.,!2001,!Singh!et.!al.,!2005,!Mather!et.!al.,!

2002).!Although,!other!papers!did!not!provide!the!

pRvalue! or! pRvalue! is! >0.05,! exercised! group! still!

showed!to!have!larger!percentage!of!reduction!in!

the!depression!scores! than! the!placebo!(Dunn!et.!

al.,!2005).!This!suggested!that!exercise!does!have!

some! beneficial! effect! on! improving! depressive!

symptoms.!!

As! recommended! in! the!guidelines,! patients!with!

depression! are! recommended! to! be! treat! with! a!

combination! of! antidepressant! and! exercise!

training.!This!is!also!reflected!in!all!of!the!studies!

where! patients! are! on! antidepressants! and!

exercise! intervention! showed! beneficial! results.!

Thus,! it! is! definitely! worthwhile! to! incorporate!

exercise! as! a! complement! intervention! for! DSM!

patient.!!

Most!research!papers!should!be!used!to!consider!

the! final! treatment! for! the! patient! except! for!

(Foley! et.! al.,! 2008).! This! paper! is! lack! of! many!

figures,!data!and!tables!that!makes!inconclusive!to!

draw!conclusion!and!rely!on.!!!!

CHARACTERISTIC)OF)THE)EVIDENCE))

Articles)) Study)design) Participants)) Level)of)Evidence)(Howick'et.'al.,'2011)#

Intervention)) Key)results) Biases))

Blument

hal*et.*

al.,*2007*

Radomised#

controlled#

trails,#

prospective#

study#

Patients#

diagnosed#with#

major#

depression.#

Mean#age:#53#

76%#female,#

24%#male#

N#=#202##

#

2# 1. Aerobic#

exercise#at#

home.#

#

2. Aerobic#

exercise##in#

groups#under#

supervised#

environment.#

#

3. Medication#

treatment#

(Sertraline).#

#

4. Placebo#group.#

45mins/session.#

MHR#=#70%O85%#

16#week#

intervention.#

Experimental#groups#

have#higher#rates#of#

remission#compared#to#

placebo.#

HomeObased#exercise:#

40%#

Supervised#exercise:#

45%#

Medication:#47%#

Placebo:#31%##

(p'=#0.057)#

Randomised#group#allocation.##

Placebo#controlled.#

Study#groups#allocation#concealment.##

Similar#N#(in#percentage).#

More#female#than#male#participants#in#

each#groups#and#overall.#Ratio#is#

consistence#between#groups.#

Inclusion#and#exclusion#criteria#were#

mentioned.#

FollowOup#included.#

Blinded#outcome#assessment##

#

Patients#are#aware#of#their#group#

allocation.#

Individuals#who#are#delivering#the#

intervention#are#aware#of#their#group#

allocation.###

NOTE:#

Unknown#exercise#

sessions/week#

#

Unknown#exercise#sessions/week#

Irregular#ratio#of#N#(in#percentage)#of#

different#ethnicity#in#each#group.#Ratio#

is#consistence#between#groups.#

Participants#selfOreported.*

Dunn*et.*

al.,*2005*

Randomised#

2x2#factorial#

design#

Placebo#

controlled#

design.##

Patients#

diagnosed#with#

mild#to#

moderate#

major#

depressive#

disorder#

(MDD).#

Mean#age:#35.9#

75%#female,#

25%#male#

N#=#80#

#

#

2# 4#aerobic#exercises#

(differ#in#total#

energy#expenditure#

and#frequency)#or#

placebo#group.##

Exercised#group:#

1.#Total#energy#

expenditure:##

Low#dose#(LD)#or#

Public#health#dose#

(PHD)#either#3#

days/week#or#5#

days/week)#for#�#≥20#minutes.#

2.#Placebo#group:#(3#

days/week#

flexibility#exercise).#

At#the#end#of#12#week,#

the#results#show#the#

most#reduced#adjusted#

mean#Hamilton#Rating#

Scale#for#Depression#

(HRSD17)#score#for#PHD#

follow#by#LD#and#the#

placebo#group.##

PHD:#47%#of#the#

participants#showed#

improvement.#PHD#

significantly#reduced#

depression#symptoms#

compared#to#LD#and#

placebo'(p=0.04#and#

p=0.03,#respectively).##

LD:#30%#of#the#


improvement,#no#

Randomised#group#allocation.#

Placebo#controlled.#

Study#groups#allocation#concealment.#*

Similar#N#in#each#exercise#categories#

and#placebo.#

More#female#than#male#participants.#


mentioned.#

No#followOup#after#completion#of#the#

study.#

Experienced#research#assistances#

blinded#from#the#group#allocation#

assessed#the#HRSD17#score.#*


allocation.#

NOTE:#

MHR:#differ#in#

frequency#and#

exercise.#

12#week#

intervention.#

significant#improvement#

compared#to#placebo#

(p=0.88).#

Placebo:#29%#of#the#


improvement.##

NOTE:#No#significant#

effect#on#exercise#

frequency#by#the#end#of#

week#12.##



allocation.###

Irregular#N#of#different#ethnicity#and#

marital#status#in#each#study#groups.#

This#study#was#funded#in#part#by#NIMH#

57031#and#Technogym.##

Foley*et.*

al.,*2008*

Randomised#

controlled#

trail.#

Participants#

were#recruited#

via#referral#

from#a#

psychiatrist#

and#

advertisements#

via#newspaper,#

radio,#

pamphlets#and#

posters.#

Mean#age:#36.5#

Unknown#

participated#

2# 1.#Aerobic#exercise#

(moderate#

intensity).#

2.#Stretching#

exercise#(mildO

intensity).#

30–40#min/session,#

3#times/week.#

NOTE:##

MHR#is#unknown.#

12#week#

intervention.#

Beck#Depression#

Inventory#(BDIOII)#and#

the#MontgomeryOÅsberg#

Depression#Rating#Scale#

(MADRAS)#were#used#to#

assess#the#patients’#

outcome.##

Both#exercised#and#

stretching#group#showed#

significant#reduction#in#

the#depression#scores#for#

both#method.##

BDI#and#MADRAS:#

positively#correlated#

No#proper#placebo/controlled#group.##

Study#groups#allocation#method#is#

unknown.#

Unknown#participated#gender#ratio.#

Inclusion#and#exclusion#criteria#were.#

Mentioned.#

No#followOup#after#completion#of#study.#


allocation.#



allocation.###

gender#ratio.#

N#=#23#

#

#

#

(r=0.61,#p=0.002).##

NOTE:#

Reduction#of#depression#

score#in#percentage#was#

not#provided.#

#

#

Incomplete#data#collection.#10#out#of#

23#participants#dropped#out#(2/10#in#

aerobic#exercise#and#8/10#in#

stretching).#

Lack#of#original#data#to#support#the#

result#written#in#the#study.#

No#clear#baseline#characteristics.#

Exercise#group#have#longer#

intervention#than#stretching#group#

(10.7#vs.#6.8#weeks).##

Knubben**

et.*al.,*

2007*

Randomised#

controlled#

trials,#

prospective#

study.#

Patients#with#

major#

depression#

who#are#under#

clinical#

antidepressant#

drug#treatment#

Mean#Age#=#

49.5##

55%#female,#

45%#male#

*N#=#38#

2# 1.#Exercised#group:#

Walking#on#a#

treadmill#(80%#

MHR).#

2.#Placebo#group:#

Stretching#and#

relaxing#exercise#

daily.#

30#minutes#daily.###

10#day#

intervention.#

#

Significant#decrease#in#

depression#scores#in#

exercise#group#in#both#

BechORafaelsen#Scale#

(BRMS)##and#Center#for#

Epidemiologic#Studies#

Depression#Scale#(CESOD)#

compared#to#placebo#

group#respectively:#

BRMS:#36%,#18%;##

CESOD:#41%,#21%;##

P#for#both#=#0.01##

Exercise#group#shows#

Randomized#controlled#trial:#low#risk#

of#bias.#

Study#groups#allocation#concealment.#

Similar#N#in#both#exercise#and#placebo#

groups.#

Similar#age#in#both#genders#


mentioned:#low#risk#of#bias.#

2#weeks#followOup#after#the#

experiment.#

A#single#psychologist#who#is#blinded#

from#the#group#allocation#assessed#the#

significant#clinical#

response#to#the#

intervention#by#reducing#

BRMS#score#by#more#

than#6#points#compared#

to#placebo#respectively:#

65%,#22%;#P<0.01##

#

BRMS#score#outcome.#


allocation.#



allocation.###

One#participant#missing#in#the#study#

analysis.#39#were#involved#in#the#

intervention#but#only#38#participants’#

outcome#was#reported.#

Krogh**

et.*al.,*

2009*

Randomised#

controlled#

trail.#

Unipolar#

patients#were#

recruited#from#

general#

practitioners#

and#

psychiatrists.#

Mean#age:#38.9##

73.9%#female,#

26.1%#male#

N=165#

#

2# 1.#Strength#

exercise.#

2.#Aerobic#exercise#

(MHR=70–85%).#

3.#Relaxation#

exercise#(placebo).#

40#minutes,#2O3#

times/week.#

16#week#

intervention.#

HAMOD17#shows#no#

significant#changes#in#

both#stretch#and#aerobic#

exercise#groups#versus#

placebo#group.##

4#months:#P=0.3#

12#months:#P=0.8#

NOTE:#

No#score#change#

percentages#were#

calculated,#as#there#was#

no#significant#P#value.##


of#bias.#


Similar#mean#age#in#different#groups.#


each#group.#


mentioned.#

12#months#followOup#visit.#


allocation.#



allocation.###



allocation.###

Similar#N#for#different#ethnicity.#

Singh**et.*

al.,*2001*

Randomized#

controlled#

trial.#

Patients#with#

major#or#minor#

depression#or#

dysthymia#

were#recruited#

through#

volunteer#

database.##

Mean#age:#71.3#

63%#female,#

37%#male#

N=32##

#

2# 1.#Weight#lifting#

exercise:#10#weeks#

of#supervised#

exercise,#then#10#

weeks#of#

unsupervised#

exercise#(MHR##

70%#to#80%).#

2.#Placebo#control:#

10#weeks#lecture.##

45#minutes,#3#

times/week#

20#week#

intervention#

Beck#Depression#

Inventory#(BDI)#shows#

significant#reduction#in#

exercise#group#than#

placebo#group#

respectively#in#both#20#

weeks#intervention#and#

26#months#follow#up.#

Intervention#(20#weeks):#

73%,#36%#(P<0.05–.001)##

Follow#up:#33%,#0%#

(P<0.05)#

#

#

Randomized#controlled#trial.#


Mean#age#in#different#groups#is#

unknown.#

Similar#mean#age#in#different#groups:#

low#risk#of#bias.#


mentioned#

26#months#followOup.#


allocation.#



allocation.###

Singh**et.*

al.,*2005*

Randomised#

controlled#

trails.#

#

>60#years#

patients#with#

major#or#minor#

depression#or#

dysthymia#

were#recruited#

through#

volunteer#

database.##

Mean#age:#72.5#

55%#female,#

45%#male#

N=60#

2# 1. Exercise#group:#

High#intensity#

(80%#MHR).#

#

Low#intensity#

(20%#MHR).#

#

2. Placebo#group:#

GP#care.#

60#minutes,#3#

time/week.#

8#week#

intervention.##

Intervention#showed#the#

percentage#reduction#in#

HRSD17#score#by#50%#in#

each#group:##

High#intensity:#61%#

Low#intensity:#29%##

Placebo:#21%#

P=0.03#

NOTE:#

Greatest#relative#change#

in#progressive#resistance#

training#was#for#the#high#

intensity#group#(p=0.05).##

#


of#bias.#


Similar#N#in#each#exercise#categories#

and#placebo.#

Similar#mean#age#in#different#groups:#

low#risk#of#bias.#

Similar#N#(in#percentage)#for#each#

gender.#


mentioned.#

FollowOup#not#provided.#


allocation.#

Psychiatrists#who#are#delivering#the#

intervention#in#the#strength#test#were#

not#blinded.##

Psychiatrists#were#blinded#by#all#

assessment#outcomes.#Psychiatrists#

also#find#it#hard#to#guess#group#

allocation#as#the#group#was#divided#

into#2#categories#(exercised#and#

N#=#number#of#participants.##

MHR#=#maximum#heart#rate.

controlled#group#rather#than#3#

groups).***

Psychiatrists#are#blinded#from#the#

group#allocation#during#the#BDI#

assessment#outcome.#

Mather*

et.*al.,*

2002*

###

#

Randomized#

controlled#

trails.#

#

Patients#were#

either#referred#

or#screened#

and#recruited#

via#primary#

care,#

psychiatric#

services#and#

public#

advertisement#

over#a#15O

month#period.#

Mean#age:#65.0#

68.5%#female,#

31.5%#male#

N=86#

2# 1. Exercise#group.##

#

2. Placebo#group:#

health#

education#talk.#

45#minutes,#>2#

times/week.#

Unknown#MHR.#

10#week#

intervention.#

Higher#proportion#of#

participants#in#exercised#

group#showed#30%#

reduction#in#HRSD17.#

Exercise#group:#55%#

Placebo:#33%#

P=0.05#


of#bias.#



mentioned.#


N#in#each#groups#were#divided#equally.#

Similar#mean#age#in#both#groups.#


exercise#group#only.#

24#weeks#followOup.#

#

1. Spectrum+of+depressive+disorders.++

+

The$ Diagnostic$ and$ Statistical$ Manual$ of$ Mental$

Disorders,$ 5th$ Ed.$ (DSM:V)$ criteria$ is$ commonly$ used$

to$assess$for$major$depressive$episode.$

A.$Five$(or$more)$of$the$following$symptoms$have$been$

present$during$the$same$2:$week$period$and$represent$

a$change$from$previous$functioning;$at$least$one$of$the$

symptoms$is$either$(1)$depressed$mood$or$(2)$ loss$of$

interest$or$pleasure.!

This$includes,$but$is$not$limited$to:$

• Depressed$Mood$

• Loss$of$interest/pleasure$in$usual$activities$

• Lack$of$energy$and$decreased$activity$

• Lack$of$self:esteem/self:confidence$

• Sense$of$guilt/worthlessness$$

• Pessimistic$thoughts$

• Insomnia$or$hyperinsomnia$

• Loss$of$appetite$or$unintentional$weight$loss$

• Ideas$or$recurrent$thoughts$of$suicide$

B.$The$symptoms$cause$clinically$significant$distress$or$

impairment$in$social,$occupational$or$other$important$

areas$of$functioning.$$

C.$ The$ symptoms$ are$ not$ due$ to$ the$ direct$

physiological$ effects$ of$ a$ substance$ (e.g.,$ a$ drug$ of$

abuse,$ a$ medication)$ or$ a$ general$ medical$ condition$

(e.g.,$hypothyroidism)$

2. The+ concept+ and+ criteria+ of+ exercise+ and+

researchers’+beliefs.++

World$ health$ organisation$ (WHO)$ and$ Australian$

Medical$ Association$ (AMA)$ both$ physical$ activity$ as$

the$movement$of$the$body$exerted$by$skeletal$muscles$

that$ result$ in$ energy$ consumption.$ Exercise$ is$ a$

subcategory$ of$ physical$ activity$ where$ it$ requires$

“planned,$ structure,$ purposeful$ and$ repetitive”$

movements$ with$ the$ aim$ to$ “maintain$ or$ improve”$

more$ than$ one$ aspect$ of$ the$ individual$ fitness$ (WHO$

2015,$AMA$2015).$$

The$ effect$ of$ exercise$ on$ depression$ has$ gained$ a$

considerable$amount$of$interest$from$researchers$over$

several$decades$(Beesley$et.$al.,$1997)$

It$ is$ noted$ that$ exercise$ may$ give$ a$ sense$ of$ self:

accomplishment$which$this$then$further$enhance$self:

esteem$and$self:confidence$(lidwidge$1980).$It$may$be$

method$of$deviating$negative$thoughts$by$focusing$on$

the$task$at$hand$(LePore$1997).$$

Exercise$may$also$be$ considered$as$a$ complementary$

therapy,$ rather$ than$relying$purely$on$antidepressant$

that$ may$ lead$ to$ unwanted$ side$ effects.$ Physical$

training$ is$ reported$ to$ be$ especially$ beneficial$ in$

severe$depression$(Knapen$2014).$$

$

Changes$in$the$brain$chemical$mediators$levels$such$as$

endorphin,$ monoamine$ or$ reduction$ in$ cortisol$ level$

through$exercise$may$elevate$mood$in$patients$(Chen,$

2013).$ It$ was$ also$ shown$ that$ exercise$ promotes$

better$sleep$and$the$relief$of$chronic$fatigue$(Lidwidge,$

1980).$ Changes$ in$ cellular$ level$ may$ be$ induced$ in$

physically$active$people$that$result$in$protection$from$

stress:induced$depression$(Agudelo$et.$al.,$2014).$

3. General+methodology.+

Currently$ the$ main$ treatment$ for$ depression$ is$

typically$ pharmacological.$ Antidepressants$ are$ the$

first$ choice$ to$ treat$ depressive$ symptoms$ (Boyce$ et.$

Al.,$2001)$

In$ addition$most$ studies$ are$ conducted$ in$ a$ random:

controlled$trial$(RCT),$with$varied$sample$size$that$are$

rather$small,$short$to$no$follow:ups,$common$physical$

training$ as$ aerobic$ exercise$ with$ MHR$ of$ 70%:85%$

and$consist$of$different$age$group$ranging$from$teens,$

adult$and$elderly.$$

The$Royal$Australasian$College$of$General$practitioner$

(RACGP,$2015)$defined$a$ “good$measure$of$moderate$

aerobic$exercise”$as$the$exercised$individual$becoming$

short$of$breadth$but$is$able$to$carry$out$a$conversation$

(RACGP,$2015).$Aerobic$exercise$ is$mostly$selected$as$

a$ method$ of$ investigation$ in$ the$ experimental$ group$

whilst$ for$ placebo$ group,$ stretching$ and/or$ relaxing$

training$were$the$preferred$choice.$$

Participants$ were$ recruited$ from$ variety$ of$ sources$

such$ as$ being$ referred$ from$ the$ GP$ or$ psychiatrist$

(Blumenthal$ et.$ al.,$ 2007,$Dunn$et.$ al.,$ 2005,$ Foley$ et.$

al.,$ 2008,$ Krogh$ et.$ al.,$ 2009,$ Mather$ et.$ al.,$ 2002),$

recruited$from$volunteer$database$(Singh$et.$Al.,$2001,$

Singh$ et.$ Al.,$ 2005),$ recruited$ through$ other$ clinical$

treatments$ (Knubben$ et.$ al.,$ 2007)$ and$ recruited$

through$ advertisements$ such$ as$ newspaper,$ radio,$

pamphlets$and$posters$ (Foley$et.$ al.,$2008,$Mather$et.$

al.,$2002).$$

4. Why+were+the+articles+selected?++

The$research$articles$chosen$have$a$consistence$

methodology$such$as$RCT;$most$involve$aerobic$

exercise$intervention$and$have$a$similar$MHR$(70%:

80%).$The$intervention$period$for$most$studies$

exceeds$the$minimum$requirement$(9$weeks)$for$the$

depression$treatment$(RACGP,$2015).$$The$articles$are$

relatively$recent$and$does$not$exceed$more$that$two$

decades.$Although$mainly$the$mean$age$for$most$

papers$are$skewed$towards$adults$and$elderly,$the$age$

range$for$all$of$studies$covered$a$wide$spectrum.$$

5. Advantages,+ limitations+and+ inconclusiveness+ in+

aerobic+ exercise+ training+ approach+ to+ treat+

depressive+disorders.+

!

Concealment!of!randomization:$All$studies$were$

conducted$in$a$RCT$through$allocation$concealment$

with$the$exception$of$one$study$(Foley$et.$al.,$2008).$In$

this$paper$method$of$blinding$allocation$was$no$stated$

and$hence$may$increase$the$bias$risk.$

$$

Blinding:$To$ensure$ low$ level$of$bias$ in$ the$ study,$ in$

most$papers,$researchers$were$blinded;$it$is$obviously$

difficult$to$double:blind$when$the$treatment$was$easily$

observable.$ A$ notable$ exception$ (Singh$ et.$ al.,$ 2005),$

tried$ making$ it$ harder$ for$ assessors$ who$ are$

conducting$the$intervention$to$guess$group$allocation.$

There$ was$ one$ case$ in$ which$ those$ who$ were$

supervising$ the$ intervention$ or$ recording$ the$

outcomes$were$not$blinded$at$all$(Foley$et.$al.,$2008)$

Inclusion! and! exclusion! criteria:$ In$ all$ papers,$

inclusion$ and$ exclusion$ criteria$ were$ mentioned$ in$

detail.$$

Follow! ups$ were$ noted$ in$ most$ studies$ except$ for$

(Dunn$ et.$ al.,$ 2005,$ Foley$ et.$ al.,$ 2008,$ Singh$ et.$ al.,$

2005).$However,$there$are$varied$lengths$of$follow:up$

ranging$ from$ 2$ weeks$ to$ 26$ months.$ The$ longer$ the$

follow$up,$the$more$comprehensive$data$the$study$will$

obtain$ and$ long:term$ benefit$ of$ exercise$ treatment$

may$be$clearly$determined.$$

Many$articles$have$lost$participants$in$their$follow:ups$

(Blumenthal$et.$al.,$2007,$Dunn$et.$al.,$2005,$Singh$et.$

al.,$2005)$but$the$biggest$drop$out$amongst$the$study$

is$40%$(Krogh$et.$al.,$2009).$In$(Knubben$et.$al.,$2007),$

there$is$one$participant$missing$in$the$study$analysis.$

39$were$involved$in$the$intervention$but$only$38$

participants’$outcome$was$reported.$Some$articles$

have$no$lost$to$follow:up$or$drop$out$(Mather$et.$al.,$

2002,$Singh$et.$al.,$2001)$

Patient;reported!outcomes:!Report$of$remission$by$

participants$(Dunn$et.$al.,$2005).!Self:reported$

exercise$frequency$for$home:based$exercises$

(Blumenthal$et.$al.,$2007).$Patients$reported$no$

negative$effects$of$exercise$(Knubben$et.$al.,$2007).$

This$may$increase$the$bias$risk$as$self:report$is$relying$

on$the$honesty$of$their$participants.$$

Length!of!intervention:!All$studies’$period$of$

intervention$follow$the$recommended$length$of$

exercise$training$by$the$RACGP$(RACGP,$2005).$$

Gender!ratio:$$Overall,$it$was$observed$that$there$are$

more$female$participants$that$male$across$most$of$the$

studies$ except$ for$ (Foley$ et.$ al.,$ 2008)$where$ gender$

percentages$ were$ not$ identified.$ Thus$ these$ papers’$

data$ may$ be$ more$ viable$ to$ treatment$ female$ than$

male.!

Funding:$ It$ should$ be$ noted$ that$ some$ studies$

received$ commercial$ funding;$ despite$ claims$ to$ the$

contrary,$ this$ may$ still$ create$ a$ potential$ conflict$ of$

interest$(Dunn$et.$al.,$2005).$

Mean!and!range!of!age:$Mean$age$across$the$papers$

ranges$ from$ 35.9$ to$ 72.5.$ It$ was$ clear$ that$ most$

participants$ were$ either$ adults$ or$ elderly$ thus$ these$

papers$ may$ not$ be$ applicable$ for$ children$ and$

teenagers$with$depression.$Although$the$(Foley$et.$al.,$

2008)$study$covers$a$wide$range$of$age$group$(18:55$

years$ old)$ the$ mean$ age$ still$ lie$ towards$ adult$ and$

elderly.$

Exercise! choice:$ Pure$ aerobic$ exercise$ was$ used$ in$

most$of$the$study$intervention$except$for$(Krogh$et.$al.,$

2009,$ Singh$ et.$ al.,$ 2001).$ As$ support$ by$ the$ RACGP$

guideline,$ it$ is$ recommended$ that$ aerobic$ exercise$

alone$ is$ not$ as$ effective$ a$ treatment$ than$ combining$

aerobic$ and$ resistance$ training.$ This$ may$ limit$ the$

maximum$effectiveness$of$the$exercise$intervention$to$

treat$depression$(RACGP,$2015).$

Selective! outcome! reporting:$ Lack$ of$ supporting$

data$ collection$ was$ observed$ in$ (Foley$ et.$ al.,$ 2008)$

study.$These$were$lack$of$original$data$to$support$the$

result$ written$ in$ the$ study$ and$ no$ clear$ baseline$

characteristics$were$included.$This$makes$it$harder$for$

the$study$to$be$reliable.!

6. Comparison+ of+ Findings+ With+ Current+ Practice+

Guidelines.+

Moderate$ intensity$ exercise$ with$ 55%:70%$ MHR$ is$

recommended$ according$ to$ the$ general$ practice$

guidelines.$This$is$lower$than$the$investigated$studies.$

As$ recommended,$ exercise$ should$ be$ “conducted$ 30:

40$minutes,$three$times$a$week$for$a$minimum$of$nine$

weeks”$(RACGP,$2015).$This$current$practice$guideline$

was$ followed$ by$most$ chosen$ studies$ except$ for$ two$

(Knubben$ et.$ al.,$ 2007,$ Singh$ et.$ al.,$ 2005)$where$ the$

period$of$intervention$does$not$meet$the$minimum.$

$

As$mentioned$ above$most$ studies$were$ conducted$ to$

test$ only$ for$ aerobic$ training$ for$ their$ exercise$

intervention.$Whilst$RACGP$recommended$a$combined$

exercise$of$aerobic$and$resistance$training.$

$

7. Areas+in+need+of+future+study.++

Overall$ aerobic$ exercise$ does$ improve$ depressive$

symptoms,$but$there$also$many$shortcomings$that$has$

to$ be$ dealt$ with.$ The$ chosen$ studies$ provide$ a$ good$

evidence$ for$ exercise$ having$ beneficial$ effects$ on$

depressive$ individuals.$ However,$ the$ range$ of$ mean$

age$is$from$35.9$to$72.5$thus$the$appraised$articles$are$

more$ viable$ for$ adult$ and$ elderly$ patients.$ It$ is$ then$

may$ be$ worthwhile$ explore$ exercise$ impacting$ on$

adolescent$with$depression.$$

Most$ articles$ chose$ aerobic$ training$ as$ their$

intervention$ however,$ this$ type$ of$ exercise$ requires$

whole$ body$ movement$ such$ as$ cycling,$ swimming,$

running$and$walking.$Thus$aerobic$exercise$might$not$

be$ applicable$ to$ all$ individuals$ such$ as$ people$ with$

disability.$ Therefore,$ it$may$ also$ be$ useful$ to$ explore$

anaerobic$ or$ resistance$ exercise$ to$ compare$ the$

beneficial$ effects$with$ aerobic$ training.$ In$ addition$ it$

may$also$be$worthwhile$looking$into$the$best$exercise$

type$ for$ different$ age$ group$ and$mobility$ range$ such$

elderly,$ individual$with$different$types$of$trauma,$and$

people$with$disability.$

In$ this$ review,$ the$ research$ studies$ were$ focused$ on$

patient$who$ are$ diagnosed$with$ depression$ and$ thus$

fulfilled$ the$ DSM:V$ criteria.$ It$ is$ also$ critical$ to$ take$

note$ that$ there$ are$many$more$ individuals$ that$ does$

not$ completely$ fit$ the$ DSM:V$ criteria$ but$ may$ show$

some$ cognitive$ changes.$ It$ is$ then$ should$ exercise$ be$

recommended$to$those$patients?$$

Another$ area$ that$ is$ in$ need$ for$ further$ study$ is$

regards$ to$ individuals$who$are$already$active$or$ elite$

athletes$ who$ were$ diagnosed$ with$ depression.$ What$

would$be$ the$most$viable$ intervention$ for$ them?$Will$

exercise$ intervention$ be$ helpful$ as$ these$ individuals$

are$already$active?$$

Krogh$ et.$ al.,$ 2009$ showed$ a$ significant$ reduction$ in$

depression$scores$for$the$exercised$group$for$the$first$

four$ months$ (p=0.03).$ However,$ p:value$ becomes$

insignificant$ for$ the$ rest$ of$ the$ 12:month$ study$

(p=0.8).$There$ is$ a$need$ for$ further$ research$ into$ the$

long:term$ effectiveness$ of$ exercise$ as$ depression$ can$

often$a$life$long$disorder$(Boyce$et.$al.,$2001)$$

In$the$case$of$contradicting$results,$it$is$always$best$to$

compare$ and$ contrast$ the$ validity$ of$ each$ article$ and$

its$ biases.$ More$ articles$ should$ be$ explored$ before$

coming$ to$ a$ conclusion$ to$ ensure$ that$ a$ wide$

population$on$research$on$exercise$and$depression$are$

covered.$This$also$helps$ to$gauge$ the$majority$results$

or$findings$made$by$other$researchers.$

Aerobic$ training$ at$ maximum$ heart$ rate$ (MHR)$ of$

70%:80%$reduced$depression$symptoms$compared$to$

placebo$ or$ less$ intense$ exercise.$ However,$ physical$

training$ analysis$ showed$ the$ overall$ reduction$ of$

depression$ in$ patients$ but$ this$ is$ not$ always$

significant.$From$the$chosen$articles,$ it$ is$more$viable$

for$ adults$ and$ elderly$ to$ be$ recommended$ in$ the$

exercise$ treatment$ for$ depression$ as$ most$ studies$

were$based$on$the$mean$age$ranging$from$35.9$to$72.5.$

More$research$papers$should$investigate$further$if$the$

patient$ presented$ with$ depression$ was$ a$ child$ or$ an$

adolescent.$

Most$ studies$ showed$ significant$ reduction$ in$

depression$scores$(HRSD17,$BDI,$CES:D$and$BRMS)$for$

the$exercised$group$compared$to$placebo$(Knubben$et.$

al.,$2007,$Krogh$et.$al.,$2009,$Singh$et.$al.,$2001,$Singh$

et.$ al.,$ 2005,$ Mather$ et.$ al.,$ 2002).$ Although,$ other$

papers$did$not$provide$the$p:value$or$p:value$is$>0.05,$

exercised$group$still$showed$to$have$larger$percentage$

of$reduction$in$the$depression$scores$than$the$placebo$

(Dunn$et.$al.,$2005).$This$suggested$that$exercise$does$

have$ some$ beneficial$ effect$ on$ improving$ depressive$

symptoms.$$

As$ recommended$ in$ the$ guidelines,$ patients$ with$

depression$ are$ recommended$ to$ be$ treat$ with$ a$

combination$ of$ antidepressant$ and$ exercise$ training.$

This$ is$ also$ reflected$ in$ all$ of$ the$ studies$ where$

patients$ are$ on$ antidepressants$ and$ exercise$

intervention$ showed$ beneficial$ results.$ Thus,$ it$ is$

definitely$ worthwhile$ to$ incorporate$ exercise$ as$ a$

complement$intervention$for$DSM$patient.$$

Most$ research$papers$ should$be$used$ to$ consider$ the$

final$treatment$for$the$patient$except$for$(Foley$et.$al.,$

2008).$ This$ paper$ is$ lack$ of$ many$ figures,$ data$ and$

tables$that$makes$inconclusive$to$draw$conclusion$and$

rely$on.$$$$

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Palmertz,$M.,$Goiny,$M.,$Martinez:Redondo,$V.,$...$&$

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modulates$kynurenine$metabolism$and$mediates$

resilience$to$stress:induced$

depression.$Cell,$159(1),$33:45.$

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American$Psychiatric$Association$(APA).$

(2013).$Diagnostic!and!Statistical!Manual!of!Mental!

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Australian$Institute$of$Health$and$Welfare$(AIHW).$

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Australian$Medical$Association$(AMA).$(2014).$

Physical$Activity$–$2014.$Retrieved$from$

https://ama.com.au/position:statement/physical:

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Beesley,$S.,$&$Mutrie,$N.$(1997).$Exercise$is$beneficial$

adjunctive$treatment$in$depression.$BMJ:!British!

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Blumenthal,$J.$A.,$Babyak,$M.$A.,$Doraiswamy,$P.$M.,$

Watkins,$L.,$Hoffman,$B.$M.,$Barbour,$K.$A.,$...$&$

Sherwood,$A.$(2007).$Exercise$and$

pharmacotherapy$in$the$treatment$of$major$

depressive$disorder.$Psychosomatic!

medicine,$69(7),$587.$

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Chen$MJ.$(2013).$The$neurobiology$of$depression$and$

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Boyce,$P.,$Harris,$M.,$&$Penrose:Wall,$J.$(2001).$From$

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Project.$Australasian!Psychiatry,$9(4),$332:337.$

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Dunn,$A.$L.,$Trivedi,$M.$H.,$Kampert,$J.$B.,$Clark,$C.$G.,$&$

Chambliss,$H.$O.$(2005).$Exercise$treatment$for$

depression:$efficacy$and$dose$response.American!

journal!of!preventive!medicine,$28(1),$1:8.$

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Foley,$L.$S.,$Prapavessis,$H.,$Osuch,$E.$A.,$De$Pace,$J.$A.,$

Murphy,$B.$A.,$&$Podolinsky,$N.$J.$(2008).$An$

examination$of$potential$mechanisms$for$exercise$

as$a$treatment$for$depression:$a$pilot$study.$Mental!

Health!and!Physical!Activity,1(2),$69:73.$

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Knapen,$J.,$Vancampfort,$D.,$Moriën,$Y.,$&$Marchal,$Y.$

(2014).$Exercise$therapy$improves$both$mental$

and$physical$health$in$patients$with$major$

depression.$Disability!&!Rehabilitation,$(0),1:6.$

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Knubben,$K.,$Reischies,$F.$M.,$Adli,$M.,$Schlattmann,$P.,$

Bauer,$M.,$&$Dimeo,$F.$(2007).$A$randomised,$

controlled$study$on$the$effects$of$a$short:term$

endurance$training$programme$in$patients$with$

major$depression.$British!journal!of!sports!

medicine,$41(1),$29:33.$

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Krogh,$J.,$Saltin,$B.,$Gluud,$C.,$&$Nordentoft,$M.$(2009).$

The$DEMO$trial:$a$randomized,$parallel:group,$

observer:blinded$clinical$trial$of$strength$versus$

aerobic$versus$relaxation$training$for$patients$with$

mild$to$moderate$depression.The!Journal!of!clinical!

psychiatry,$(70),$790:800.$

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Ledwidge,$B.$(1980).$Run$for$your$mind:$Aerobic$

exercise$as$a$means$of$alleviating$anxiety$and$

depression.$Canadian!Journal!of!Behavioural!

Science/Revue!canadienne!des!sciences!du!

comportement,$12(2),$126.$

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Lepore,$S.$J.$(1997).$Expressive$writing$moderates$the$

relation$between$intrusive$thoughts$and$

depressive$symptoms.$Journal!of!personality!and!

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Mather,$A.$S.,$Rodriguez,$C.,$Guthrie,$M.$F.,$McHARG,$A.$

M.,$Reid,$I.$C.,$&$McMURDO,$M.$E.$(2002).$Effects$of$

exercise$on$depressive$symptoms$in$older$adults$

with$poorly$responsive$depressive$disorder$

Randomised$controlled$trial.The!British!Journal!of!

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The$Royal$Australian$College$of$General$Practitioners$

(RACGP).$(2015).$Exercise:$depression.$Retrieved$

from$http://www.racgp.org.au/your:

practice/guidelines/handi/interventions/mental:

health/exercise:for:depression/$

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Singh,$N.$A.,$Clements,$K.$M.,$&$Singh,$M.$A.$F.$(2001).$

The$efficacy$of$exercise$as$a$long:term$

antidepressant$in$elderly$subjects$a$randomized,$

controlled$trial.$The!Journals!of!Gerontology!Series!

A:!Biological!Sciences!and!Medical!Sciences,$56(8),$

M497:M504.$

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Singh,$N.$A.,$Stavrinos,$T.$M.,$Scarbek,$Y.,$Galambos,$G.,$

Liber,$C.,$&$Singh,$M.$A.$F.$(2005).$A$randomized$

controlled$trial$of$high$versus$low$intensity$weight$

training$versus$general$practitioner$care$for$

clinical$depression$in$older$adults.The!Journals!of!

Gerontology!Series!A:!Biological!Sciences!and!

Medical!Sciences,$60(6),$768:776.$

$

World$Health$Organisation$(WHO).$(2015).$Physical$

Activity.$Retrieved$from$

http://www.who.int/dietphysicalactivity/pa/en/$

$

Howick,!J.,!Chalmers,!I.,!Glasziou,!P.,!Greenhalgh,!T.,!

Heneghan,!C.,!Liberati,!A.,!Ivan!Moschetti,!Phillips,!B.,!

Thornton,!H.,!Goddard,!O.,!&!Hodgkinson,!M.!Centre!

of!Evidence9based!Medicine.!(2011).!The$Oxford$

2011$Levels$of$Evidence.$Retrieved$from$

http://www.cebm.net/index.aspx?o=5653$

!

A!P!P!E!N!D!I!C!E!S!MEDLINE+

Ovid$MEDLINE$was$searched$using$the$following$terms:$

1. exp$depression/$

2. exp$exercise/$

3. exp$therapy/$

4. exp$randomized/$$

5. exp$controlled$trial/$

$

$

+

+

+

+

OXFORD+JOURNALS+

Oxford$Journals$was$searched$using$the$following$terms:$$

1. Effect$

2. Exercise$

3. Depression$

$

!

!

!

!

!

!

!

!

!

!

!

SPINGERLINK+

SPINGERLINK$was$searched$using$the$following$terms:$$

1. Exp$Treat/$

2. Exp$Physical$exercise/$

3. Exp$treat/$

4. Exp$Depression/$

$

$

$

$

$

$

$

$

!

!

!

!

ScienceDirect+

ScienceDirect$was$searched$using$the$following$terms:$$

3. Effect$

4. Exercise$

5. Depression$

6. Depressive$Disorder$$

7. Physical$$

$

$

$

$

!

!

!

!

MEDLINE+

1,835$articles$were$retrieved$in$the$search.$Out$of$those,$3$articles$were$finally$selected$for$appraisal.$$

Oxford+Journals++

22$articles$were$retrieved$in$this$search.$Out$of$those,$2$articles$were$finally$selected$for$appraisal.$

ScienceDirect+

68$articles$were$retrieved$in$the$search.$Out$of$those,$3$articles$were$finally$selected$for$appraisal.$

SPRINGERLINK+

384$articles$were$retrieved$in$the$search.$Out$of$those,$1$article$was$finally$selected$for$appraisal.$

the runner's high_exercise_depression

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