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Mental Health and Physical Activity

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The impact of exercise on Quality of Life within exercise and depression trials:A systematic review

F.B. Schuch*, M.P. Vasconcelos-Moreno, M.P. FleckHospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil, Rua Ramiro Barcelos 2350, Brazil

a r t i c l e i n f o

Article history:Received 12 November 2010Received in revised form15 June 2011Accepted 15 June 2011

Keywords:ExerciseQuality of lifeDepressionSystematic review

* Corresponding author. Hospital de Clinicas de PPsychiatry, Rua Ramiro Barcelos 2350, CEP 90035-903

E-mail addresses: felipe.schuch@ufrgs.br, 00116mirelavasconcelos@yahoo.com.br (M.P. Vasconceloscom.br (M.P. Fleck).

1755-2966/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.mhpa.2011.06.002

Please cite this article in press as: Schuch, F. Breview, Mental Health and Physical Activity (

relationships and relationship to salient features of environment);and includes the (3) presence of positive (e.g., mobility) and absence

a 9-month-follow-up of primary care treatment for depression,

1. Background

Unipolar depression is a highly prevalent condition (around10.4% worldwide) (Andrade et al., 2003) and, according to Princeet al. (2007), about 14% of the global burden of disease is due tothe chronically disabling nature of this condition. Recent studiesalso show that depressive disorders are associated with significantimpairment in Quality of Life (QoL) (Goldney, Fisher, Wilson, &Cheok, 2000; Papakostas et al., 2004, da Rocha, Power, Bushnell,& Fleck, 2009; Skevington & Wright, 2001).

According to the World Health Organization (1995), QoL can bedefined as “the individual’s perception of his or her position in life,within the cultural context and value system he or she lives in, andin relation to his or her goals, expectations, parameters and socialrelations. It is a broad ranging concept affected in a complex way by theperson’s physical health, psychological state, level of independence,social relationships and their relationship to salient features of theirenvironment”. QoL is consequently a broad ranging concept thatis (1) subjective (each individual should evaluate his/her QoL,according to his/her own values, goals and preferences); (2) multi-dimensional (includes many different aspects of life such as physicalhealth, psychological state, level of independence, social

orto Alegre, Departament of, Brazil.507@ufrgs.br (F.B. Schuch),-Moreno), mfleck.voy@terra.

All rights reserved.

., et al., The impact of exercis2011), doi:10.1016/j.mhpa.20

of negative (e.g., pain) dimensions.There is a conceptual controversy in the literature concerning

depression and QoL. Some authors propose that there is an intimaterelationship between these two constructs and even that depressionand QoL could be tautological or redundant measures (Angermeyer,Holzinger, Matschinger, & Stengler-Wenzke, 2002). However, thereis some empirical evidence to suggest that they are differentconstructs. For example, QoL assessed by Quality of Life DepressionScale (QLDS)(McKenna et al., 2001), not severity of depression,was found as a predictive factor for complete remission within

showing that QoL and severity of depression have different predictivevalue (Fleck et al., 2005); (2) there is a gap between QoL improvementand depressive symptoms improvement with antidepressant use inthat a rapid improvement of depressive symptom may precedeimprovements in QoL, showing that those constructs have differentsensitivity-to-change (McCall, Reboussin, & Rapp, 2001); (3) there isonly a moderate correlation among the different QoL domains anddepression (Fleck et al., 1999, 2000; Berlim, Pavanello, Caldieraro, &Fleck, 2005). If those constructs were the same higher correlationcoefficients would be expected. (4) Modern psychometric strategies(like Rasch analysis) have suggested that most items of a QoL instru-ment (WHOQOL-BREF) are not affected by severity of depression,indicating that they are different constructs (da Rocha et al., 2009).

There is a growing literature supporting the importance ofusing QoL and other Patient Report Outcomes (PRO) as a primary orsecondary outcome in clinical trials not only in depression but in allareas of health research (Speight & Barendse, 2010). Also, theassessment of QoL in depression leads to a broader understanding ofpatients, providing the development of a more rational and individ-ualized treatment, considering their preferences, values and goals,not solely determined by clinical judgment (Berlim& Fleck, 2003). Forexample, an antidepressant may relieve depressive symptoms, but atthe same time cause weight gain. From a physician’s perspective, thegoal of depression remission has been achieved. However, froma patient perspective, weight gain could cause distress. Compliance totreatment can be seriously affected if evaluation of the impact ofweight gain is not taken into account by the physician.

Exercise could potentially influence QoL positively in bothhealthy (Gillison, Skevington, Sato, Standage, & Evangelidou, 2009;Rejeski & Mihalko, 2001; Rejeski, Brawley, & Shumaker, 1996) and

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F.B. Schuch et al. / Mental Health and Physical Activity xxx (2011) 1e62

clinical populations (Ciccolo, Jowers, & Bartholomew, 2004; Knobf,Musanti, & Dorward, 2007, van Tol, Huijsmans, Kroon, Schothorst, &Kwakkel, 2006). Meta-analyses also suggest that exercise couldbe a potential treatment for depression with an effect size inintervention studies ranging from�0.80 to�1.1 (Rethorst, Wipfli, &Landers, 2009). Nevertheless, some authors suggest that morestudies are necessary due to methodological weaknesses present inmany studies (Lawlor & Hopker, 2001; Mead et al., 2009).

There are some studies evaluating the impact of exercise onQoL indepressive patients but no systematic review analyzing these effectshas been published. Given the recent recognition of the need toconsider PRO assessments, including QoL, as a primary or secondaryoutcome in clinical trials (Speight & Barendse, 2010), examining howexercise impacts QoL within exercise interventions for depressionwould be informative. The aim of this study is to analyze (1) theeffects of exercise on QoL of depressed individuals and (2) identifythe presence of possible methodological bias in these studies.

2. Methods

The systematic review was carried out in three stages: (1)literature search; (2) study selection; (3) data extraction.

2.1. Literature search

In order to identify studies for this review, a comprehensivesearch of papers published in English up to May 2010 was carriedout on Medline, PsychINFO and SPORTDISCUS. The keywords weredivided into three groups that were cross checked among (Group 1AND Group 2 AND Group 3).

Group 1: Major Depression, Mood Depression, DepressiveDisorder, Depression.Group 2: Exercise, Physical Activity.Group 3: Quality of Life.

E.g.: (Major Depression AND Exercise AND Quality of life).(Depression AND Physical Activity AND Quality of Life).The relevant articles indicated on the references of the selected

studies were also included in the review.

2.2. Study selection

The articles were selected by one of the reviewers (FBS) andtheir relevance was judged by their title and abstract. The inclusioncriteria were: 1) be written in English; 2) present original data;3) clinically depressed patients; 4) use an exercise-based inter-vention; 5) assess QoL with a validated instrument.

The articles included were read and the studies excluded wherethose that: 1) did not use avalidQoL instrument; 2) used patientswithclinical comorbidities that caused an impact on QoL; 3) used patientswhose psychiatric diagnosiswas something other thanunipolarmajoror minor depression (e.g. bipolar depression, schizophrenia, alcoholand drug abuse); or 4) did not include a control, placebo or a non-treatment group.

2.3. Extraction of data

Two independent reviewers (FBS, MPVM) extracted the dataconcerning the study population, exercise characteristics, QoLinstruments, main results and limitations, and internal validity.Data extraction was standardized as per The Quality of ReportingMeta-Analyses Conference (QUORUM) (Moher et al., 1999).

Internal validity was assessed based on four criteria: 1) presenceof blinded assessment; 2) use of intent-to-treat analysis; 3)

Please cite this article in press as: Schuch, F. B., et al., The impact of exercisreview, Mental Health and Physical Activity (2011), doi:10.1016/j.mhpa.20

presence of randomization; and 4) use of allocation concealment bytwo independent reviewers (FBS, MPVM). Each item was assessedaccording to the following criteria:

1) Blinded assessment:a. Adequate e if testers were blind to treatment allocation.b. Inadequate e if testers were not blind to treatment

allocation.c. Unknown - not clear in text or author failed to respond to

query.2) Use of intent-to-treat analysis:

a. Adequate e if the results were analyzed based on theintention-to-treat strategy.

b. Inadequate e If the results were not analyzed based on theintention-to-treat strategy

3) Randomization:a. Adequate e if treatment allocation was described as

randomized.b. Inadequate e if treatment allocation was not described as

randomized.c. Unknown - not clear in text or author failed to respond to

query.4) Allocation Concealment:

a. Adequate- If allocation concealment was throughi. Central Randomization;ii. Sequential administration of packages pre-coded or

numbered for patients selected for the study;iii. Data generated by computer program containing

encrypted distribution;iv. Envelopes serial numbered and opaque;v. Other ways that appears to offer adequate allocation.

Furthermore, the person responsible for the allocationconcealment should not assess the outcomes.

b. Inadequate- ifi. The sample was chosen by convenience;ii. Non-randomized protocol

c. Unknown - not clear in text or author failed to respond toquery.

Effects sizes were calculated using Cohen’s D (d ¼ M1eM2/sspooled where s spooled ¼ [(s12 þ s22)/2]) method for each studyindividually (Cohen, 1988). According to Cohen (1988) the effectssizes of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8a large effect.

3. Results

The initial search identified 2088 potentially relevant articles.Among these, 1149 were duplicated by the three databases or bydifferent search strategies within the same database and wereexcluded. Out of the 1269, 236 had no original data (e.g. reviews,comments, and letters to editors), 104 were written in a languageother than English, 858 did not use depressed subjects (e.g. patientswith cancer, COPD, AIDS, and others) and 41 had depressed patientsbut not exercise as an intervention.

The thirty studies left were analyzed in detail. Of these,nine articles did not evaluate QoL, 10 evaluated depressivesymptoms in non-clinically depressed subjects, one was a thesisand the paper was not available, two included patients withother non-psychiatric comorbidities, three had not used exclu-sively unipolar depressed subjects (e.g. bipolar disorder, anxietydisorder, healthy patients), and one did not have a control,non-treatment or a placebo group. Four articles were includedin our review at the end of the search (see Fig. 1). Among thesefour studies, one article presents preliminary data (Brenes

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Fig. 1. Flowchart of study selection.

F.B. Schuch et al. / Mental Health and Physical Activity xxx (2011) 1e6 3

et al., 2007) and three present final results (Carta et al., 2008;Singh, Clements, & Fiatarone, 1997a, 2005). Table 1 shows thesummarized results.

3.1. Study population

One study evaluated the QoL of adults (Carta et al., 2008) andthree of older adults (Brenes et al., 2007; Singh et al., 1997a, 2005).The study with adults involved females with a previous

Table 1Summary of studies.

Article Sample Intervention

Singh et al., 1997a Older adults with majoror minor depressionor dysthymia

Strength training, Anaerobic (80% ofmaximum number of repetitions) �Health education, 3 timesa week for 10 weeks

Singh et al., 2005 Older adults with majoror minor depressionor dysthymia

Strength training, anaerobic,high intensity (80% of a maximumnumber of repetitions) � low intens(20% of a maximum numberof repetitions) � general practitionecare, 3 times a week for 8 weeks

Brenes et al., 2007 Older adults withminor depression

Aerobic and anaerobic exercise,60 min per session(intensity unspec� sertraline � usual care,3 times a week for 16 weeks

Carta et al., 2008 Women with majordepression non-responsiveto previouspharmacological treatment

Exercise at stations, aerobic(intensity unspecified) � controlgroup, twice a week for 32 weeks

Please cite this article in press as: Schuch, F. B., et al., The impact of exercisreview, Mental Health and Physical Activity (2011), doi:10.1016/j.mhpa.20

pharmacological treatment without response (Carta et al., 2008)and the studies with elderly persons involved major and minordepressed elderly persons (Singh et al., 1997a, 2005) and exclu-sively minor depressed elderly (Brenes et al., 2007).

3.2. Exercise characteristics

The studies used different types of exercise. Two of them usedanaerobic exercise (Singh et al., 1997a, 2005) and two used aerobicand anaerobic exercise (Brenes et al., 2007; Carta et al., 2008).The intervention period ranged from 8 to 32 weeks and the weeklyfrequency ranged between 2 and 3 times a week. Exercise intensityranged from unspecified by the author to up to 80% of a onemaximum of repetition.

3.3. Quality of Life

The studies assessed QoL using mainly the MOS 36-item short-form health Survey (SF-36)(Ware and Sherbourne, 1992) and theWorld Health Organization Quality of Life Instrument, Brief Version(WHOQOL-BREF)(The WHOQOL Group (1998). Only one studyevaluated QoL as a primary outcome while the other three useddepressive symptoms scales as the primary outcome.

In the physical domain, Singh et al. (1997a) found improvementsin Physical Function (Effect Size ¼ �0.44) and Bodily Pain (EffectSize ¼ �1.17) in one study and in Physical Function (data notshown) and Role Physical (data not shown) in another study (Singhet al., 2005), both using SF-36. One study using the WHOQOL-BREFfound improvements in the Physical Domain (Effect Size ¼ �0.80)(Carta et al., 2008). However, another study did not find anyimprovements on the Physical Health component of the SF-36(Brenes et al., 2007).

In the Psychological domain, Singh et al. (1997a, 2005) foundimprovements in the Vitality (Effect Size¼�1.15 (1997a) and EffectSize ¼ �0.45 (2005)), Role Emotional (Effect Size ¼ �0.80 (1997a;data not shown in the 2005 study) and Mental Health (EffectSize ¼�0.67 (1997a; data not shown in the 2005 study) sub-scales,while Brenes et al. (2007) found “substantial but not statisticallysignificant” benefits in the Mental Health component using theSF-36. Carta et al. (2008) did not find benefits on the Psychologicaldomain using WHOQOL-BREF.

Regarding other domains, two studies by Singh et al. (1997a,2005) showed improvement in the Social Functioning sub-scale

Instrument Results Limitations

a SF-36 Improvements in Vitality,bodily pain, role emotionaland social functioning

No use of intention-to-treat analysis

ity

r

SF-36 Improvements in PhysicalFunction, Role Physical,Vitality, Social Function,Role Emotional, andMental Health. Significantlygreater effect of highintensity exercise on Vitality.

No use of intention-to-treat analysis

ified)SF-36 Non- significant

improvement in mentalhealth domain.

Small sample;depression self-reported.

WHOQOL-BREF Improvement inPhysical domain.

Small sample; lack ofan intention- to- treatanalysis; unknownallocation concealment;blinded assessment.

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(Effect Size ¼ �1.20 (1997a), data not shown at 2005 study) usingSF-36, but the other two studies did not find any benefits in anyrelated domains (Brenes et al., 2007; Carta et al., 2008). Only onestudy (Carta et al., 2008) used an instrument that assessed theenvironment domain (e.g., How healthy is your physical environ-ment?) and did not find any improvements.

One study (Singh et al., 2005) evaluated low and high intensityexercises and found that high intensity exercises produce morebenefits in the Vitality (Effect Size ¼ �1.0) domain than lowintensity exercises. No other positive or negative effects were foundin the different domains.

One study (Brenes et al., 2007) compared exercise and sertralinewith usual care. Both sertraline and exercise improved the mentalhealth domain of QoL in depressed elderly persons and there wereno significant differences between conditions.

3.4. Internal validity and limitations

The reviewed studies did have methodological weaknesses.Singh et al. (1997a, 2005) did not use an intent-to-treat analysis.Carta et al. (2008) had no information regarding blinded assess-ments or allocation concealment (Table 2). In the studies by Breneset al. (2007) and Carta et al. (2008) studies, the number of partic-ipants involved was small.

4. Discussion

The studies reviewed suggest that exercise has a moderate tolarge positive impact in QoL of unipolar depressed individuals,especially in components related to Physical (ES ranged from�0.44 to �1.17) and Psychological domains (ES ranged from�0.45 to �1.15). However, the small number of studies and meth-odological weaknesses make it difficult to make definitive conclu-sions. Beyond these methodological problems, heterogeneity ofexercise protocols, subjects of study and instruments for assessingQoL limits the possibility of statistical comparisons.

Both anaerobic exercise and combined aerobic and anaerobicexercise had a positive impact on QoL. However, none of the studiesanalyzed the effects of aerobic exercise only. There are presently nostudies comparing aerobic, anaerobic and/or mixed exercises.

Only one study compared different intensities of anaerobicexercises and foundhigh intensity exercises produced benefits in thevitality domain of SF-36when comparedwith low intensityexercise.This data suggests the possible existence of a doseeresponserelationship. However, more studies are needed to confirm thisrelationship in younger adult populations.

Studies have shown that other interventions in depression suchas ECT (Antunes & Fleck, 2009) and pharmacological treatments(Skevington & Wright, 2001) improve QoL of depressed patients.Brenes et al. (2007) compared exercise and sertraline in depressedelders and concluded that both interventions improve QoL withoutany differences between them. This study showed an improvementin objective physical functioning measures in the exercisegroup (e.g. Six-minute walk distance, Four meter walking speed,Chair stand time, and Short Physical Performance Battery), but noimprovement in the physical health domain was observed in any

Table 2Quality assessments of studies.

Article Blindedassessments

Intent-to-treat analysis

Randomization Allocationconcealment

Singh et al., 1997a A B A ASingh et al., 2005 A B A ABrenes et al., 2007 A A A ACarta et al., 2008 C B A C

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group. Nevertheless, the study used a small sample size and theauthors argue that “Although some effect sizes were large, they werenot significant due to the lack of power” (p. 66). More studies withlarger sample size are needed to clarify these differences.

Potentially, exercise could improve depression and QoL throughdifferent mechanisms. For example, in the Psychological domain,exercise may improve self-esteem (Craft, 2005), self-efficacy (Craft,2005; Singh et al., 2005) and self-concept (Ossip-Klein et al., 1989)andpromote generalwell-being (Bartholomew,Morrison,&Ciccolo,2005; Galper, Trivedi, Barlow, Dunn, & Kampert, 2006). In thePhysical domain, exercise improves muscular strength and fitness,mobility, and functionality (Penninx et al., 2002), aspects thatare negatively affected by sedentary behavior, which is highlyassociated with depression (Augestad, Slettemoen, & Flanders,2008; Galper et al., 2006; Sanchez-Villegas et al., 2008; Tolmunenet al., 2006). Exercise could also improve sleep quality (Singh,Clements, & Fiatarone, 1997b) and reduce fatigue (Bartholomewet al., 2005; Ko, Yang, & Chiang, 2008; Marin & Menza, 2005) indepressed individuals. Another domain that deserves attention isSocial Relationship. Singhet al. (1997a, 2005) foundbenefits in SocialFunction, but other studies did not find any benefits in this domain.A suggestedhypothesis is thatwhendone inagroupsetting, exercisecould decrease depression through social contact with otherpatients (Veale et al., 1992) although some studies do not supportthis hypothesis (Armstrong & Edwards, 2003; Dunn, Trivedi,Kampert, Clark, & Chambliss, 2005; Legrand & Heuze, 2007; Singh,Clements, & Singh, 2001).

An important gap in the literature is that no study has explicitlyevaluated the relationship between the reduction of depressionsymptoms and improvement in QoL. Carta et al. (2008) founda greater improvement in depressive symptoms compared to QoL,with an ES ¼ �1.4 for depressive symptoms (data retrieved in thePilu et al. (2007) study) and ES ¼ �0.8 for Physical domain.Conversely, Singh et al. (1997a) found greater improvement in QoLin most sub-scales (Vitality ES ¼ �1.15, Bodily Pain ES ¼ 1.17) thandepressive symptoms (ES ¼ �0.52). These findings are consistentwith the concept that they are independent constructs (e.g., daRocha et al., 2009) and that exercise interventions may havea differential impact on each. Future exercise interventions fordepression should include QoL measures to explore this possi-bility. This would enable the evaluation of the impact of symptomrelief on broader dimensions of QoL in line with a patient’s pref-erences and values (Berlim & Fleck, 2003). Mediation analyses(see Cerin, 2010) will be required to unpick how changes indepression and QoL are linked.

The selected articles presented some limitations. Small numberof participants enrolled (Brenes et al., 2007; Carta et al., 2008), lackof intent-to-treat analyses (Singh et al., 1997a, 2005) and unclearinformation about allocation concealment (Carta et al., 2008)are the most important. A higher number of participants enrolledwould increase the statistical power of the studies and also anactive control group would help to avoid a placebo effect. Anintention-to-treat analysis would suggest more conservativeresults. Another limitation in the studies available is that themajority use older adults with low to moderate depression, whichlimits generalization to younger adults, as well as to more severelydepressed patients. Many of these limitations would be overcomeby the inclusion of QoL measures in future exercise and depressiontrials.

We attempted to avoid bias by ensuring that we had identifiedall relevant studies through a comprehensive search of the litera-ture. However, we may have missed relevant studies throughsearching only a limited number of databases and excludingnon-English studies and grey literature. We attempted to obtainfurther information from authors, particularly to clarify

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F.B. Schuch et al. / Mental Health and Physical Activity xxx (2011) 1e6 5

methodological aspects of the trials and to seek further detailregarding results to allow calculation of effect sizes. Unfortunately,for some trials further information could not be obtained. Thismade it impossible to conduct a meta-analysis of the reviewedstudies.

5. Conclusions

Most studies showed improvements in some domains ofQoL primarily in the Physical and Psychological domains of QoLof depressed individuals after treatment with exercise. However,methodological limitations and the small number of studiesweaken the strength of our conclusions. Future exercise anddepression interventions should include QoL measures to evaluatewhether exercise has a differential impact on depression symptomsand QoL, and whether any difference is informative from a clinical,patient, and research perspective.

Founding

This work was supported by FIPE-HCPA(Fundo de incentivo àpesquisa do Hospital de Clinicas de Porto Alegre).

Acknowledgements

Thanks to the research group and graduate degree from theUniversity Hospital of Porto Alegre for their financial support(FIPE), and the editors of Mental Health and Physical Activity.

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