Understanding prognostic benefits of exercise and antidepressant therapy for persons with depression and heart disease: the UPBEAT study--rationale, design, and methodological issues

Depression and Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator in Women

INTRODUCTION

Cardiovascular disease remains a major cause of morbidity and premature mortality worldwide. The aim of the present study was to investigate the association of atherosclerotic cardiovascular disease (ASCVD) risk estimator with depression in women undergoing cardiological evaluation.

MATERIAL AND METHOD

Three hundred women undergoing cardiological evaluation completed the Zung Self-Rating Depression Scale (ZSDS) questionnaire which included women's characteristics.

RESULTS

A percentage of 57.4% of our participants exhibited ASCVD risk <5%; while the 18.3% had ASCVD risk between 5% and 7.4%, the 18.3% between 7.5% and 20%, and the remaining 6% > 20%. In terms of depression, 50% of the women had a score of less than 38 (median), according to Zung scale and mean score was 38.4. In addition, 25% of women had a score below 32. These scores indicate low levels of depression in women. Statistically significant higher rates of depression were found in women who were not involved with physical activities (p = 0.030).

CONCLUSIONS

The negative impact of depression on the ASCVD risk could potentially be prevented by modifying individuals' behavior with regard to their engagement in physical activity.

Psychosocial management in cardiac rehabilitation: Current practices, recommendations, and opportunities

Psychosocial management is a core component of outpatient Phase-II cardiac rehabilitation (CR) and includes psychosocial assessment, providing interventions, measuring outcomes, and care coordination. Psychosocial management contributes to the effectiveness of comprehensive CR, but the implementation is not always consistent or clearly described in the literature, in part due to the availability of behavioral health specialists. Patients in CR have many psychosocial needs including anxiety, depression, substance use disorders, sleep problems, psychosocial stress, and cognitive impairment. Behavioral considerations are inherent in many other aspects of CR,such as participation in CR, health behaviors, adherence, and tobacco cessation. Evaluation, or psychosocial assessment, should identify significant issues, record related medications, and incorporate findings in the individual treatment plan. Some patients require further evaluation and treatment by a qualified behavioral health specialist. Psychosocial interventions provided to all patients include patient education, counseling, stress-management, a supportive environment, and exercise. Measuring outcomes entails repeating the psychosocial assessment when patients finish CR and documenting changes. Coordinating care requires understanding available local mental health infrastructure and procedures for making referrals, and may entail identifying additional resources. Interventions provided concurrently with CR to a subset of patients with more extensive needs are typically pharmacotherapy, psychotherapy, or addictions counseling, which are beyond the scope of practice for most CR professionals. The way psychosocial management is implemented suggests clinical and research opportunities. For example, the combined effects of antidepressants and CR on depression and anxiety are not known. A prominent clinical opportunity is to fully implement psychosocial assessment, as required by statute and the core components. This could involve referring patients for whom clinically significant psychosocial concerns are identified during the evaluation for a more thorough assessment by a behavioral health specialist using an appropriate billing model. A research priority is a contemporary description of behavioral health services available to CR programs, including how psychosocial management is implemented. As delivery of CR comes to include more alternative models (e.g., home-based), research is needed on how that affects the delivery of psychosocial management. Increased use of telehealth may broaden clinical opportunities for psychosocial management.

Psychological and pharmacological interventions for depression in patients with coronary artery disease

BACKGROUND

Depression occurs frequently in individuals with coronary artery disease (CAD) and is associated with a poor prognosis.

OBJECTIVES

To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL databases up to August 2020. We also searched three clinical trials registers in September 2021. We examined reference lists of included randomised controlled trials (RCTs) and contacted primary authors. We applied no language restrictions.

SELECTION CRITERIA

We included RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression. Our primary outcomes included depression, mortality, and cardiac events. Secondary outcomes were healthcare costs and utilisation, health-related quality of life, cardiovascular vital signs, biomarkers of platelet activation, electrocardiogram wave parameters, non-cardiac adverse events, and pharmacological side effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the identified papers for inclusion and extracted data from the included studies. We performed random-effects model meta-analyses to compute overall estimates of treatment outcomes.

MAIN RESULTS

Thirty-seven trials fulfilled our inclusion criteria. Psychological interventions may result in a reduction in end-of-treatment depression symptoms compared to controls (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.92 to -0.19, I² = 88%; low certainty evidence; 10 trials; n = 1226). No effect was evident on medium-term depression symptoms one to six months after the end of treatment (SMD -0.20, 95% CI -0.42 to 0.01, I² = 69%; 7 trials; n = 2654). The evidence for long-term depression symptoms and depression response was sparse for this comparison. There is low certainty evidence that psychological interventions may result in little to no difference in end-of-treatment depression remission (odds ratio (OR) 2.02, 95% CI 0.78 to 5.19, I² = 87%; low certainty evidence; 3 trials; n = 862). Based on one to two trials per outcome, no beneficial effects on mortality and cardiac events of psychological interventions versus control were consistently found. The evidence was very uncertain for end-of-treatment effects on all-cause mortality, and data were not reported for end-of-treatment cardiovascular mortality and occurrence of myocardial infarction for this comparison. In the trials examining a head-to-head comparison of varying psychological interventions or clinical management, the evidence regarding the effect on end-of-treatment depression symptoms is very uncertain for: cognitive behavioural therapy compared to supportive stress management; behaviour therapy compared to person-centred therapy; cognitive behavioural therapy and well-being therapy compared to clinical management. There is low certainty evidence from one trial that cognitive behavioural therapy may result in little to no difference in end-of-treatment depression remission compared to supportive stress management (OR 1.81, 95% CI 0.73 to 4.50; low certainty evidence; n = 83). Based on one to two trials per outcome, no beneficial effects on depression remission, depression response, mortality rates, and cardiac events were consistently found in head-to-head comparisons between psychological interventions or clinical management. The review suggests that pharmacological intervention may have a large effect on end-of-treatment depression symptoms (SMD -0.83, 95% CI -1.33 to -0.32, I² = 90%; low certainty evidence; 8 trials; n = 750). Pharmacological interventions probably result in a moderate to large increase in depression remission (OR 2.06, 95% CI 1.47 to 2.89, I² = 0%; moderate certainty evidence; 4 trials; n = 646). We found an effect favouring pharmacological intervention versus placebo on depression response at the end of treatment, though strength of evidence was not rated (OR 2.73, 95% CI 1.65 to 4.54, I² = 62%; 5 trials; n = 891). Based on one to four trials per outcome, no beneficial effects regarding mortality and cardiac events were consistently found for pharmacological versus placebo trials, and the evidence was very uncertain for end-of-treatment effects on all-cause mortality and myocardial infarction. In the trials examining a head-to-head comparison of varying pharmacological agents, the evidence was very uncertain for end-of-treatment effects on depression symptoms. The evidence regarding the effects of different pharmacological agents on depression symptoms at end of treatment is very uncertain for: simvastatin versus atorvastatin; paroxetine versus fluoxetine; and escitalopram versus Bu Xin Qi. No trials were eligible for the comparison of a psychological intervention with a pharmacological intervention.

AUTHORS' CONCLUSIONS

In individuals with CAD and depression, there is low certainty evidence that psychological intervention may result in a reduction in depression symptoms at the end of treatment. There was also low certainty evidence that pharmacological interventions may result in a large reduction of depression symptoms at the end of treatment. Moderate certainty evidence suggests that pharmacological intervention probably results in a moderate to large increase in depression remission at the end of treatment. Evidence on maintenance effects and the durability of these short-term findings is still missing. The evidence for our primary and secondary outcomes, apart from depression symptoms at end of treatment, is still sparse due to the low number of trials per outcome and the heterogeneity of examined populations and interventions. As psychological and pharmacological interventions can seemingly have a large to only a small or no effect on depression, there is a need for research focusing on extracting those approaches able to substantially improve depression in individuals with CAD and depression.

Good, better, best: clinical scenarios for the use of L-methylfolate in patients with MDD

Depression is among the most prevalent mental disorders worldwide, and a substantial proportion of patients do not respond adequately to standard antidepressants. Our understanding of the pathophysiology of depression is no longer limited to the chemical imbalance of neurotransmitters, but also involves the interplay of proinflammatory modulators in the central nervous system, as well as folate metabolism. Additional factors such as stress and metabolic disorders also may contribute. Multiple inflammatory, metabolic, and genetic markers have been identified and may provide critical information to help clinicians individualize treatments for patients to achieve optimal outcomes. Recent advancements in research have clarified underlying causes of depression and have led to possible new avenues for adjunctive treatment. Among these is L-methylfolate, a medical food that is thought to enhance synthesis of monoamines (serotonin, norepinephrine, and dopamine), suppress inflammation, and promote neural health. Clinical studies that assessed supplemental use of L-methylfolate in patients with usual care-resistant depression found that it resulted in improved outcomes. Patients with selective serotonin reuptake inhibitor-resistant depression, and particularly subgroups with biomarkers of inflammation or metabolic disorders or folate metabolism-related genetic polymorphisms (or ≥2 of these factors), had the best responses. Considering this, the goals of this review are to 1) highlight recent advances in the pathophysiology of major depressive disorder as it pertains to folate and associated biomarkers and 2) establish the profiles of patients with depression who could benefit most from supplemental use of L-methylfolate.

Hormonal Function Responses to Moderate Aerobic Exercise in Older Adults with Depression

Background

Poor daily life physical activities among older people were related to depressive mood especially memory loss. In addition to that, the change in physical ability is significantly associated with the score of depression among older age.

Objective

The present study aimed to evaluate the effects of a supervised aerobic training program with moderate intensity for 12 weeks on mood profiles and hormonal levels of the hypothalamus-pituitary-adrenal axis (HPA axis) of older adults.

Methods

A total of 80 individuals of both gender (90 males, 110 females) of ages ranged between 65 and 95 years were recruited for this study. Based upon the profile of mood states (POMS) analysis, the participants were classified into two groups: control group (n=30) and depressive group (n=50). Leisure-time physical activity (LTPA), adrenal hormones such as ACTH, corticosterone (CORT), cortisol, DHEA/S, and cortisol:DHEA/S ratio were measured at baseline and post-intervention of moderate aerobic exercise for 12 weeks.

Results

Older adults with higher depressive scores showed a remarkable change in the level of adrenal hormones compared to control. There was a significant increase in the level of ACTH, CORT, cortisol, and cortisol:DHEA/S ratio, and decrease in DHEA/S. Compared to females, males showed an improvement in depressive mood score along with an increase in LPTA, DHEA/S and decrease in ACTH, CORT, cortisol, cortisol:DHEA/S ratio following 12 weeks of supervised aerobic training, respectively.

Conclusion

The findings of this study showed that 12 weeks of supervised exercise interventions are promising non-drug therapeutic strategies in improving depression among older adults. The potential performance in a psychological state occurs physiologically via optimizing the levels of the hormones of the HPA axis.

Can physical exercise modulate cortisol level in subjects with depression? A systematic review and meta-analysis

INTRODUCTION

Major depressive disorder (MDD) is a prevalent medical illness that is associated with chronic stress. Patients with MDD can show an imbalance in cortisol levels, which can be restored with the remission of symptoms. Physical exercise training has been used as a tool to promote changes in cortisol levels in healthy individuals. However, it is unknown if exercise can produce the same results in individuals with MDD.

OBJECTIVE

To review evidence of cortisol changes after exercise training in individuals with MDD.

METHODS

We conducted a search on PubMed, SciELO, LILACS, ISI Web of Knowledge, Scopus, and PsycInfo databases. Random effects meta-analysis was performed and standardized mean difference (SMD) effect size was calculated. Analyses of forest and funnel plots was conducted using Stata v.11.0 software.

RESULTS

At first, 463 studies were obtained in the search. After completion of the selection procedure, five articles with seven analyses were included. Type of exercise, frequency of training, cortisol measurement, and type of control group were analyzed. There was a reduction of cortisol levels in the exercise group (SMD = -0.65, 95%CI 1.30-0.01). Moreover, sensitivity analysis and subgroup analyses revealed an effect of type (aerobic exercise) and frequency (five times per week) of exercise on reduction of cortisol levels. However, these results should be interpreted cautiously due to the small number of studies and a substantial heterogeneity among them.

CONCLUSION

Physical exercise promotes a reduction in cortisol levels in individuals with MDD. However, this finding can be influenced by type of exercise, weekly frequency, and type of cortisol measurement.

Design and synthesis of 4-benzylpiperidine carboxamides as dual serotonin and norepinephrine reuptake inhibitors

A series of 4-benzylpiperidine carboxamides were designed and synthesized, and tested for their dual (serotonin and norepinephrine) reuptake inhibition. The synthesis of 4-benzylpiperidine carboxamides involved two main steps: amidation and substitution. Derivatives with 3 carbon linker displayed better activity than with 2 carbon linker. 4-Biphenyl- and 2-naphthyl-substituted derivatives 7e and 7j showed greater dual reuptake inhibition than standard drug venlafaxine HCl.

Effects of different types of physical activity on the cognitive functions and attention in older people: A randomized controlled study

This study aimed to evaluate the effects of different types of exercise on cognition. Eighty participants, 32 males and 48 females, aged 66.96 ± 11.73, volunteered for this study. The participants were randomly divided into the four following groups: Resistance Group (RG; n=20), involved in high intensity strength training; Cardiovascular Group (CVG; n=20), involved in high intensity cardiovascular training; Postural Group (PG; n=20) involved in low intensity training, based on postural and balance exercises; and Control Group (CG; n=20). Exercises were performed over the course of 12 weeks. All participants were tested for their cognitive functions pre- and post-intervention using the following neurocognitive tests: the Attentive Matrices Test, Raven's Progressive Matrices, Stroop Color and Word Interference Test, Trail Making Test and Drawing Copy Test. Statistical analysis showed that the CVG group improved significantly in the Attentive Matrices Test and Raven's Progressive Matrices (both p=<0.05), whereas the RG group improved in Drawing Copy Test time (p=<0.05). These results confirm that different types of exercise interventions have unique effects on cognition. Cardiovascular training is effective in improving performance attentive and analytic tasks, whereas resistance training is effective in improving praxis. Further investigation is necessary to evaluate the combination of the two exercise types in order to ascertain if their respective effects can be summated when performed together.

Vagal modulation of resting heart rate in rats: the role of stress, psychosocial factors, and physical exercise

In humans, there are large individual differences in the levels of vagal modulation of resting heart rate (HR). High levels are a recognized index of cardiac health, whereas low levels are considered an important risk factor for cardiovascular morbidity and mortality. Several factors are thought to contribute significantly to this inter-individual variability. While regular physical exercise seems to induce an increase in resting vagal tone, chronic life stress, and psychosocial factors such as negative moods and personality traits appear associated with vagal withdrawal. Preclinical research has been attempting to clarify such relationships and to provide insights into the neurobiological mechanisms underlying vagal tone impairment/enhancement. This paper focuses on rat studies that have explored the effects of stress, psychosocial factors and physical exercise on vagal modulation of resting HR. Results are discussed with regard to: (i) individual differences in resting vagal tone, cardiac stress reactivity and arrhythmia vulnerability; (ii) elucidation of the neurobiological determinants of resting vagal tone.

Exercise for depression

BACKGROUND

Depression is a common and important cause of morbidity and mortality worldwide. Depression is commonly treated with antidepressants and/or psychological therapy, but some people may prefer alternative approaches such as exercise. There are a number of theoretical reasons why exercise may improve depression. This is an update of an earlier review first published in 2009.

OBJECTIVES

To determine the effectiveness of exercise in the treatment of depression in adults compared with no treatment or a comparator intervention.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Controlled Trials Register (CCDANCTR) to 13 July 2012. This register includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years); MEDLINE (1950 to date); EMBASE (1974 to date) and PsycINFO (1967 to date). We also searched www.controlled-trials.com, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. No date or language restrictions were applied to the search.We conducted an additional search of the CCDANCTR up to 1st March 2013 and any potentially eligible trials not already included are listed as 'awaiting classification.'

SELECTION CRITERIA

Randomised controlled trials in which exercise (defined according to American College of Sports Medicine criteria) was compared to standard treatment, no treatment or a placebo treatment, pharmacological treatment, psychological treatment or other active treatment in adults (aged 18 and over) with depression, as defined by trial authors. We included cluster trials and those that randomised individuals. We excluded trials of postnatal depression.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data on primary and secondary outcomes at the end of the trial and end of follow-up (if available). We calculated effect sizes for each trial using Hedges' g method and a standardised mean difference (SMD) for the overall pooled effect, using a random-effects model risk ratio for dichotomous data. Where trials used a number of different tools to assess depression, we included the main outcome measure only in the meta-analysis. Where trials provided several 'doses' of exercise, we used data from the biggest 'dose' of exercise, and performed sensitivity analyses using the lower 'dose'. We performed subgroup analyses to explore the influence of method of diagnosis of depression (diagnostic interview or cut-off point on scale), intensity of exercise and the number of sessions of exercise on effect sizes. Two authors performed the 'Risk of bias' assessments. Our sensitivity analyses explored the influence of study quality on outcome.

MAIN RESULTS

Thirty-nine trials (2326 participants) fulfilled our inclusion criteria, of which 37 provided data for meta-analyses. There were multiple sources of bias in many of the trials; randomisation was adequately concealed in 14 studies, 15 used intention-to-treat analyses and 12 used blinded outcome assessors.For the 35 trials (1356 participants) comparing exercise with no treatment or a control intervention, the pooled SMD for the primary outcome of depression at the end of treatment was -0.62 (95% confidence interval (CI) -0.81 to -0.42), indicating a moderate clinical effect. There was moderate heterogeneity (I² = 63%).When we included only the six trials (464 participants) with adequate allocation concealment, intention-to-treat analysis and blinded outcome assessment, the pooled SMD for this outcome was not statistically significant (-0.18, 95% CI -0.47 to 0.11). Pooled data from the eight trials (377 participants) providing long-term follow-up data on mood found a small effect in favour of exercise (SMD -0.33, 95% CI -0.63 to -0.03).Twenty-nine trials reported acceptability of treatment, three trials reported quality of life, none reported cost, and six reported adverse events.For acceptability of treatment (assessed by number of drop-outs during the intervention), the risk ratio was 1.00 (95% CI 0.97 to 1.04).Seven trials compared exercise with psychological therapy (189 participants), and found no significant difference (SMD -0.03, 95% CI -0.32 to 0.26). Four trials (n = 300) compared exercise with pharmacological treatment and found no significant difference (SMD -0.11, -0.34, 0.12). One trial (n = 18) reported that exercise was more effective than bright light therapy (MD -6.40, 95% CI -10.20 to -2.60).For each trial that was included, two authors independently assessed for sources of bias in accordance with the Cochrane Collaboration 'Risk of bias' tool. In exercise trials, there are inherent difficulties in blinding both those receiving the intervention and those delivering the intervention. Many trials used participant self-report rating scales as a method for post-intervention analysis, which also has the potential to bias findings.

AUTHORS' CONCLUSIONS

Exercise is moderately more effective than a control intervention for reducing symptoms of depression, but analysis of methodologically robust trials only shows a smaller effect in favour of exercise. When compared to psychological or pharmacological therapies, exercise appears to be no more effective, though this conclusion is based on a few small trials.

The effects of physical exercise in schizophrenia and affective disorders

Affective and non-affective psychoses are severe and frequent psychiatric disorders. Amongst others, they not only have a profound impact on affected individuals through their symptomatology, but also regarding cognition, brain structure and function. Cognitive impairment influences patients' quality of life as well as their ability to work and being employed. While exercise therapy has been implemented in the treatment of psychiatric conditions since the days of Kraepelin and Bleuler, the underlying mechanisms have never been systematically studied. Since the early 1990s, studies emerged examining the effect of physical exercise in animal models, revealing stimulation of neurogenesis, synaptogenesis and neurotransmission. Based on that body of work, clinical studies have been carried out in both healthy humans and in patient populations. These studies differ with regard to homogenous study samples, sample size, type and duration of exercise, outcome variables and measurement techniques. Based on their review, we draw conclusions regarding recommendations for future research strategies showing that modern therapeutic approaches should include physical exercise as part of a multimodal intervention programme to improve psychopathology and cognitive symptoms in schizophrenia and affective disorders.

Exercise for depression

BACKGROUND

Depression is a common and important cause of morbidity and mortality worldwide. Depression is commonly treated with antidepressants and/or psychotherapy, but some people may prefer alternative approaches such as exercise. There are a number of theoretical reasons why exercise may improve depression. This is an update of an earlier review first published in 2009.

OBJECTIVES

To determine the effectiveness of exercise in the treatment of depression. Our secondary outcomes included drop-outs from exercise and control groups, costs, quality of life and adverse events.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis (CCDAN) Review Group's Specialised Register (CCDANCTR), CENTRAL, MEDLINE, EMBASE, Sports Discus and PsycINFO for eligible studies (to February 2010). We also searched www.controlled-trials.com in November 2010. The CCDAN Group searched its Specialised Register in June 2011 and potentially eligible trials were listed as 'awaiting assessment'.

SELECTION CRITERIA

Randomised controlled trials in which exercise was compared to standard treatment, no treatment or a placebo treatment in adults (aged 18 and over) with depression, as defined by trial authors. We excluded trials of postnatal depression.

DATA COLLECTION AND ANALYSIS

For this update, two review authors extracted data on outcomes at the end of the trial. We used these data to calculate effect sizes for each trial using Hedges' g method and a standardised mean difference (SMD) for the overall pooled effect, using a random-effects model. Where trials used a number of different tools to assess depression, we included the main outcome measure only in the meta-analysis. We systematically extracted data on adverse effects and two authors performed the 'Risk of bias' assessments.

MAIN RESULTS

Thirty-two trials (1858 participants) fulfilled our inclusion criteria, of which 30 provided data for meta-analyses. Randomisation was adequately concealed in 11 studies, 12 used intention-to-treat analyses and nine used blinded outcome assessors. For the 28 trials (1101 participants) comparing exercise with no treatment or a control intervention, at post-treatment analysis the pooled SMD was -0.67 (95% confidence interval (CI) -0.90 to -0.43), indicating a moderate clinical effect. However, when we included only the four trials (326 participants) with adequate allocation concealment, intention-to-treat analysis and blinded outcome assessment, the pooled SMD was -0.31 (95% CI -0.63 to 0.01) indicating a small effect in favour of exercise. There was no difference in drop-outs between exercise and control groups. Pooled data from the seven trials (373 participants) that provided long-term follow-up data also found a small effect in favour of exercise (SMD -0.39, 95% CI -0.69 to -0.09). Of the six trials comparing exercise with cognitive behavioural therapy (152 participants), the effect of exercise was not significantly different from that of cognitive therapy. There were insufficient data to determine risks, costs and quality of life.Five potentially eligible studies identified by the search of the CCDAN Specialised Register in 2011 are listed as 'awaiting classification' and will be included in the next update of this review.

AUTHORS' CONCLUSIONS

Exercise seems to improve depressive symptoms in people with a diagnosis of depression when compared with no treatment or control intervention, however since analyses of methodologically robust trials show a much smaller effect in favour of exercise, some caution is required in interpreting these results.

Long-chain, n-3 fatty acids and physical activity--independent and interactive associations with cardiac autonomic control

BACKGROUND/OBJECTIVES

Intake of the marine-based, n-3 fatty acids and engagement in physical activity are inversely related to cardiac morbidity and mortality. Among putative mechanisms, both n-3 fatty acids and physical activity may act through modulation of autonomic control of the cardiovascular system. This investigation examined the independent and interactive associations of n-3 fatty acids (eicosapentaenoic and docosahexanenoic acid; EPA, DHA) and physical activity with heart rate variability (HRV).

METHODS

Subjects were 259 healthy 30-54 year-old adults. Serum phospholipid fatty acid composition was employed as a biomarker of dietary n-3 fatty acid exposure. Physical activity based on the Paffenbarger questionnaire was coded as < or ≥ 2000 kcal/week. Standard time-domain (standard deviation of normal-to-normal intervals and root-mean squared of successive differences; SDNN, RMSSD) and frequency domain (high frequency and low frequency power) measures of HRV were derived from resting electrocardiographic recordings.

RESULTS

In linear regression models with covariate adjustment for age, gender and race, greater n-3 fatty acid exposure was associated with greater SDNN and RMSSD, and high physical activity was associated with greater RMSSD. n-3 fatty acid exposure also predicted variation in SDNN, RMSSD, and high-frequency power in interaction with physical activity. Specifically, n-3 fatty acid exposure covaried positively with these three HRV indices only among participants expending 2000 kcal per week or more in physical activity. These latter findings were noted for DHA but not EPA.

CONCLUSIONS

These results suggest that the cardiovascular benefits of n-3 fatty acid consumption may be mediated, in part, by effects on cardiac autonomic control and may be dependent upon concomitant habitual exercise.

How Should We Treat Depression in Patients with Cardiovascular Disease?

Among patients with cardiovascular disease (CVD), depression is highly prevalent and is associated with worse cardiovascular prognosis and lower quality of life. Treatments for depression in CVD patients produce modest, but clinically significant reductions in depressive symptoms and show promise for improving cardiovascular prognosis. While tricyclics should generally be avoided, antidepressants from multiple other classes appear to be safe in cardiac patients. A strategy of engaging patients in choosing medications or psychotherapy and then intensifying treatment to therapeutic goal appears to be more effective at reducing depression than single mode interventions. Recommendations for screening all CVD patients for depression may be premature given increased costs associated with screening and gaps in knowledge about the risk-benefit ratio of depression treatment in mild and moderately depressed patients.

Unipolar depression and the progression of coronary artery disease: toward an integrative model

BACKGROUND

Despite extensive research on the relationship between depression and coronary artery disease (CAD) after an acute coronary syndrome (ACS), causal interpretations are still difficult. This uncertainty has led to much confusion regarding screening and treatment for depression in CAD patients.

METHOD

A critical and conceptual analysis of the pertinent literature, which elaborates the implications of the heterogeneity in symptom pattern, etiology, and course of depression in CAD patients.

RESULTS

We propose an integrative dynamic model of the depression-CAD relationship. The model rests on three core hypotheses: (1) Depression in CAD patients consists of mixtures of two types of depression, denoted as 'cognitive/affective' and 'somatic' depression, each having a somewhat characteristic symptom expression and etiology. (2) Effects of depression on CAD depend on the type and duration of depression. The dynamic aspect of the model indicates that post-ACS depression shifts, when it persists, from a marker of the severity (somatic type) and meaning (cognitive/affective type) of the ACS to a largely indirect causal factor in the progression of CAD. (3) The most plausible pathways mediating the effects of persistent/recurrent depression, irrespective of type, on cardiac prognosis are behavioral and act by making depressed CAD patients more susceptible to other CAD risks. The model offers testable predictions and explanations for a variety of apparently unrelated or inconsistent findings.

CONCLUSION

The proposed model may have potential for integrating findings regarding the depression-CAD relationship, contributing to the clarification of discords on screening and treatment of depression, and guiding future research.

Cognitive and behavioural effects of physical exercise in psychiatric patients

The current review outlines the under-appreciated effects of physical exercise on the course of psychiatric disorders, focussing on recent findings from animal and human research. Several studies have shown that regular physical exercise is significantly beneficial for psychiatric patients both on a biological and a psychological level. Positive effects of controlled exercise include improved metabolic responses, neuro-protection, increased quality of life, and reduced psychopathological symptoms. Studies investigating the effectiveness of various physical training interventions in alleviating severe mental diseases, such as Alzheimer's dementia (AD), schizophrenia (SZ) or major depressive disorder (MDD) indicate that physical exercise can relieve symptoms of depression, psychosis and dementia and more importantly can curtail further progression of these diseases. This review assesses the most effective methods of physical training for specific psychiatric symptoms. Introducing physical exercise in therapeutic regimes would be an innovative approach that could significantly reduce the severity of psychopathological and cognitive symptoms in patients. The positive biological and molecular outcomes associated with physical exercise render it a concrete therapeutic strategy for improving the quality of live and reducing physical illness in psychiatric patients. Therefore, integrating physical activity into a patient's social life may be an effective treatment strategy. Furthermore, exercise might have the potential to be a preventative treatment within the context of multi-modal therapeutic programs.

Psychological and pharmacological interventions for depression in patients with coronary artery disease

BACKGROUND

Depression occurs frequently in patients with coronary artery disease (CAD) and is associated with a poor prognosis.

OBJECTIVES

To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression.

SEARCH STRATEGY

CENTRAL, DARE, HTA and EED on The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ISRCTN Register and CardioSource Registry were searched. Reference lists of included randomised controlled trials (RCTs) were examined and primary authors contacted. No language restrictions were applied.

SELECTION CRITERIA

RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression were included. Primary outcomes were depression, mortality and cardiac events. Secondary outcomes were healthcare costs and health-related quality of life (QoL).

DATA COLLECTION AND ANALYSIS

Two reviewers independently examined the identified papers for inclusion and extracted data from included studies. Random effects model meta-analyses were performed to compute overall estimates of treatment outcomes.

MAIN RESULTS

The database search identified 3,253 references. Sixteen trials fulfilled the inclusion criteria. Psychological interventions show a small beneficial effect on depression compared to usual care (range of SMD of depression scores across trials and time frames: -0.81;0.12). Based on one trial per outcome, no beneficial effects on mortality rates, cardiac events, cardiovascular hospitalizations and QoL were found, except for the psychosocial dimension of QoL. Furthermore, no differences on treatment outcomes were found between the varying psychological approaches. The review provides evidence of a small beneficial effect of pharmacological interventions with selective serotonin reuptake inhibitors (SSRIs) compared to placebo on depression outcomes (pooled SMD of short term depression change scores: -0.24 [-0.38,-0.09]; pooled OR of short term depression remission: 1.80 [1.18,2.74]). Based on one to three trials per outcome, no beneficial effects regarding mortality, cardiac events and QoL were found. Hospitalization rates (pooled OR of three trials: 0.58 [0.39,0.85] and emergency room visits (OR of one trial: 0.58 [0.34,1.00]) were reduced in trials of pharmacological interventions compared to placebo. No evidence of a superior effect of Paroxetine (SSRI) versus Nortriptyline (TCA) regarding depression outcomes was found in one trial.

AUTHORS' CONCLUSIONS

Psychological interventions and pharmacological interventions with SSRIs may have a small yet clinically meaningful effect on depression outcomes in CAD patients. No beneficial effects on the reduction of mortality rates and cardiac events were found. Overall, however, the evidence is sparse due to the low number of high quality trials per outcome and the heterogeneity of examined populations and interventions.

Accuracy and prognostic value of American Heart Association: recommended depression screening in patients with coronary heart disease: data from the Heart and Soul Study

BACKGROUND- In 2008, the American Heart Association (AHA) recommended a 2-step screening method, consisting of the 2-item Patient Health Questionnaire (PHQ-2) followed by the 9-item Patient Health Questionnaire (PHQ-9), for identifying depression in cardiovascular patients. The accuracy and prognostic value of this screening method have not been evaluated. METHODS AND RESULTS- We administered the 2-step AHA-recommended screening algorithm to 1024 patients with stable coronary heart disease and calculated sensitivity and specificity against a gold standard interview for major depressive disorder. Subsequent cardiovascular events (myocardial infarction, stroke, transient ischemic attack, heart failure, or death) were determined during a mean of 6.27 ± 2.11 years of follow-up. The AHA-recommended screening method had high specificity (0.91; 95% confidence interval, 0.89 to 0.93) but low sensitivity (0.52; 95% confidence interval, 0.46 to 0.59) for a diagnosis of major depressive disorder. Participants who screened positive on the AHA depression protocol had a 55% greater risk of events than those who screened negative (age-adjusted hazard ratio, 1.55; 95% confidence interval, 1.21 to 1.97; P=0.0005). After adjustment for age, sex, body mass index, history of myocardial infarction, hypertension, diabetes, heart failure, and high-density lipoprotein levels, screening positive remained associated with a 41% greater rate of cardiovascular events (hazard ratio, 1.41; 95% confidence interval, 1.10 to 1.81; P=0.008). CONCLUSIONS- Among outpatients with stable coronary heart disease, the AHA-recommended depression screening protocol is highly specific for depression and identifies patients at risk for adverse cardiovascular outcomes.

Exercise-based cardiac rehabilitation for coronary heart disease

BACKGROUND

The burden of coronary heart disease (CHD) worldwide is one of great concern to patients and healthcare agencies alike. Exercise-based cardiac rehabilitation aims to restore patients with heart disease to health.

OBJECTIVES

To determine the effectiveness of exercise-based cardiac rehabilitation (exercise training alone or in combination with psychosocial or educational interventions) on mortality, morbidity and health-related quality of life of patients with CHD.

SEARCH STRATEGY

RCTs have been identified by searching CENTRAL, HTA, and DARE (using The Cochrane Library Issue 4, 2009), as well as MEDLINE (1950 to December 2009), EMBASE (1980 to December 2009), CINAHL (1982 to December 2009), and Science Citation Index Expanded (1900 to December 2009).

SELECTION CRITERIA

Men and women of all ages who have had myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA), or who have angina pectoris or coronary artery disease defined by angiography.

DATA COLLECTION AND ANALYSIS

Studies were selected and data extracted independently by two reviewers. Authors were contacted where possible to obtain missing information.

MAIN RESULTS

This systematic review has allowed analysis of 47 studies randomising 10,794 patients to exercise-based cardiac rehabilitation or usual care. In medium to longer term (i.e. 12 or more months follow-up) exercise-based cardiac rehabilitation reduced overall and cardiovascular mortality [RR 0.87 (95% CI 0.75, 0.99) and 0.74 (95% CI 0.63, 0.87), respectively], and hospital admissions [RR 0.69 (95% CI 0.51, 0.93)] in the shorter term (< 12 months follow-up) with no evidence of heterogeneity of effect across trials. Cardiac rehabilitation did not reduce the risk of total MI, CABG or PTCA. Given both the heterogeneity in outcome measures and methods of reporting findings, a meta-analysis was not undertaken for health-related quality of life. In seven out of 10 trials reporting health-related quality of life using validated measures was there evidence of a significantly higher level of quality of life with exercise-based cardiac rehabilitation than usual care.

AUTHORS' CONCLUSIONS

Exercise-based cardiac rehabilitation is effective in reducing total and cardiovascular mortality (in medium to longer term studies) and hospital admissions (in shorter term studies) but not total MI or revascularisation (CABG or PTCA). Despite inclusion of more recent trials, the population studied in this review is still predominantly male, middle aged and low risk. Therefore, well-designed, and adequately reported RCTs in groups of CHD patients more representative of usual clinical practice are still needed. These trials should include validated health-related quality of life outcome measures, need to explicitly report clinical events including hospital admission, and assess costs and cost-effectiveness.

[Effectiveness of physical exercise in psychiatry: a therapeutic approach?]

INTRODUCTION

There is a general belief that physical activity and exercise have positive effects on mood and anxiety. Intervention studies describe an anxiolytic and antidepressive effect of exercise in healthy subjects and patients. However, the majority of published studies have substantial methodological inconsistencies. Our review of the literature showed the importance of distinguishing three items in studies regarding efficacy of physical exercise in psychiatry: operationalisation of concepts (duration, frequency, intensity, type of exercise), the type of disorder, the diagnosis, and exploratory hypotheses. The aim of this article is to demonstrate that physical exercise in the psychiatry department contributes to the improvement of the mental health of in-hospital patients.

METHODS

Sociodemographical data, the diagnosis and the physical exercise (duration, distance, type and frequency) of 283 in-hospital patients in the psychiatry department were listed. Physical exercise (cycling, long walks, short walks, soft and hard gymnastics) included in a database has been proposed to patients for many years in this hospital. After their hospitalisation, the members of the medical staff (20 persons) evaluated the patients on a visual analogic scale from 1 to 10 related to the improvement of their mental health. No experimental manipulation was made.

SUBJECTS

One hundred and twenty-eight men, mean age: 45.67 years (± 13.59) exhibited the following disorders: major depressive disorder (117), anxious disorders (25), alcoholic addiction (85), toxicomania (10), psychotic decompensation (33), bipolar disorder (3) and others (10). Patients practised at least one exercise during their hospitalisation, mean duration of 15.93 (± 9.18) working days. The frequency of physical exercises per patient was 5.65 (± 6.20). The improvement of each patient was evaluated around six times (6.16 ± 3.83). The average amelioration score for all the patients was close to 50% (4.99 ± 1.65).

RESULTS

Correlations between the improvement of mental health and participation in physical exercises were all significant (frequency: r=0.228; P<0.001; duration: r=0.236; P<0.001; distance: r=0.201, P=0.001). In comparison with psychotic patients, drug addiction and alcoholic, depressive patients showed greater interest in physical exercise. This is similar for anxious disorders. According to the results, two groups were created regarding their improvement (cut out point: 5.08). We observed that patients suffering from major depression considerably improved thanks to physical exercise (P=0.048), spent more time practising (P=0.037) and walked or cycled greater distances (P=0.038). Finally, cycling (frequency: P=0.008; distance: P=0.016; duration: P=0.011) and "hard" gymnastics were the physical exercises which optimized the results.

DISCUSSION

Physical exercise is correlated with the improvement of mental health. The practice of physical exercise depends on the mental disorder. People suffering from major depressive disorder benefit more from physical exercise than other groups. Cycling and "hard" gymnastics are both exercises to be proposed in every programme.

CONCLUSION

To practice physical exercise during hospitalisation in a psychiatric department has a positive influence on the symptomatology, and contributes to the improvement of mental health.

Management of depression in patients with coronary heart disease: association, mechanisms, and treatment implications for depressed cardiac patients

IMPORTANCE OF THE FIELD

Coronary heart disease (CHD) and depression are two leading causes of death and disability in the United States and worldwide. Depression is especially common in cardiac patients, and there is growing evidence that depression is a risk factor for fatal and nonfatal events in CHD patients.

AREAS COVERED IN THIS REVIEW

This paper reviews current literature of depression as a risk factor for CHD along with pharmacologic and non-pharmacologic treatments for depression in cardiac patients.

WHAT THE READER WILL GAIN

Readers will gain knowledge about the importance of depression as a CHD risk factor and learn the results of efforts to treat depressed CHD patients.

TAKE HOME MESSAGE

Although randomized clinical trials (RCTs) of medication and non-pharmacologic therapies have not demonstrated that treating depression improves survival, there is evidence that treating depressed patients can reduce depressive symptoms and improve quality of life. Additional RCTs are needed, including evaluation of non-pharmacologic therapies such as exercise, to examine the effects of treatment of depression on medical and psychosocial outcomes.

Selective serotonin reuptake inhibitors provide significant lower re-hospitalization rates in patients recovering from acute coronary syndromes: evidence from a meta-analysis

Depression is an independent negative prognostic factor in patients with acute coronary syndromes (ACS), yet it is unclear if its treatment is beneficial after ACS. We sought to compare, through a meta-analytic process, antidepressant therapy with selective serotonin reuptake inhibitors (SSRIs) versus control treatment in patients with recent ACS. BioMedCentral, CENTRAL, ISI Web of Science, PsycInfo, and PubMed were searched for pertinent studies (November 2008). We selected studies with randomized allocation to antidepressant drug versus control in patients with acute or recent ACS reported as intention-to-treat. Exclusion criteria were: duplicate publication, regimen of antidepressant drug <4 weeks, follow-up <6 weeks or incomplete follow up, or a lack of clear/reproducible results. Changes from the baseline to the follow-up in depression score, major adverse cardiac events (MACE - including death, myocardial infarction, and repeat revascularization), and hospitalizations were pooled with random or fixed-effect methods. Five randomized trials (801 patients) were included. Fifteen studies were excluded because they were unpublished, ongoing, or duplicates. Subjects treated with antidepressant medications did not show, after a median of six months, a significant improvement in depression symptoms, although there was a trend for a reduction in depression scores. Besides, subjects treated with antidepressant medications showed a significantly lower rate of re-hospitalizations from all causes (risk difference (RD) = 14% (95% confidence interval: 5-23%), p = 0.001). Therapy with antidepressants was notably safe, with similar rates of adverse events, including MACE, death, myocardial infarction, or repeat revascularization (all p > 0.05). Treatment with SSRIs in patients recovering from ACS is associated with significant lower re-hospitalization rates. These data suggest that antidepressant therapy with SSRIs, given its efficacy and safety, should be routinely considered in patients with a recent ACS and depression symptoms.

Differential associations between specific depressive symptoms and cardiovascular prognosis in patients with stable coronary heart disease

OBJECTIVES

The purpose of this research was to evaluate the relationship between cognitive and somatic depressive symptoms and cardiovascular prognosis.

BACKGROUND

Depression in patients with stable coronary heart disease (CHD) is associated with poor cardiac prognosis. Whether certain depressive symptoms are more cardiotoxic than others is unknown.

METHODS

In the Heart and Soul Study, 1,019 patients with stable CHD were assessed using the Patient Health Questionnaire to determine the presence of the 9 depressive symptoms included in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition. The mean age of the patients was 67 years, and 82% were men. A comparison was made on a new cardiovascular event (myocardial infarction, stroke, transient ischemic attack, or congestive heart failure) or death (mean follow-up duration 6.1 +/- 2.0 years) on the basis of cognitive and somatic sum scores and for patients with or without each of those specific depressive symptoms. Demographic characteristics, cardiac risk factors, and cardiac medications were controlled for.

RESULTS

After adjustment for demographic data and cardiac risk factors, each somatic symptom was associated with 14% greater risk for events (hazard ratio [HR]: 1.14; 95% confidence interval [CI]: 1.05 to 1.24; p = 0.002). Fatigue (HR: 1.34; 95% CI: 1.07 to 1.67; p = 0.01), appetite problems (HR: 1.46; 95% CI: 1.12 to 1.91; p = 0.005), and sleeping difficulties (HR: 1.26; 95% CI: 1.00 to 1.58; p = 0.05) were most strongly predictive of cardiovascular events. In contrast, cognitive symptoms (HR: 1.08; 95% CI: 0.99 to 1.17; p = 0.09) were not significantly associated with cardiovascular events.

CONCLUSIONS

In patients with stable CHD, somatic symptoms of depression were more strongly predictive of cardiovascular events than cognitive symptoms, although the CIs surrounding these estimates had substantial overlap. These findings are highly consistent with those of previous studies. Further research is needed to understand the pathophysiological processes by which somatic depressive symptoms contribute to prognosis in patients with CHD.

Combined exercise and cognitive behavioral therapy improves outcomes in patients with heart failure

OBJECTIVE

The purpose of this study is to compare the effectiveness of a combined 12-week home-based exercise (EX)/cognitive behavioral therapy (CBT) program (n=18) with CBT alone (n=19), EX alone (n=20), and with usual care (UC, n=17) in stable New York Heart Association Class II to III heart failure (HF) patients diagnosed with depression.

METHODS

Depressive symptom severity [Hamilton Rating Scale for Depression (HAM-D)], physical function [6-min walk test (6MWT)], and health-related quality of life (HRQOL) (Minnesota Living with Heart Failure Questionnaire) were evaluated at baseline (T1), after the 12-week intervention/control (T2), and following a 3-month telephone follow-up (T3). A repeated measures analysis of variance was used to determine group differences. Depression severity was dichotomized as minor (HAM-D, 11-14) and moderate-to-major depression (HAM-D, >/=15), and group intervention and control responses were also evaluated on that basis.

RESULTS

The greatest reduction in HAM-D scores over time occurred in the EX/CBT group (-10.4) followed by CBT (-9.6), EX (-7.3), and UC (-6.2), but none were statistically significant. The combined group showed a significant increase in 6-min walk distance at 24 weeks (F=13.5, P<.001). Among all groups with moderate-to-major depression, only those in CBT/EX had sustained lower HAM-D scores at 12 and 24 weeks, 6MWT distances were significantly greater at 12 (P=.018) and 24 (P=.013) weeks, and the greatest improvement in HRQOL also occurred.

CONCLUSIONS

Interventions designed to improve both physical and psychological symptoms may provide the best method for optimizing functioning and enhancing HRQOL in patients with HF.

Long-term secondary prevention programs after cardiac rehabilitation for the reduction of future cardiovascular events: focus on regular physical activity

Cardiac rehabilitation/secondary prevention programs are recognized as integral to the comprehensive care of patients with coronary heart disease, and as such are recommended in most contemporary clinical practice guidelines. The interventions are aimed at reducing disability, optimizing cardiovascular risk reduction by drug therapy and promoting healthy behavior. Healthy lifestyle habits must be recognized as capable of substantially reducing the risk for cardiovascular events in patients with coronary heart disease. This review highlights the recommended components of cardiac rehabilitation/secondary prevention programs, with special emphasis on regular physical activity.

Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease

CONTEXT

Depressive symptoms predict adverse cardiovascular outcomes in patients with coronary heart disease, but the mechanisms responsible for this association are unknown.

OBJECTIVE

To determine why depressive symptoms are associated with an increased risk of cardiovascular events.

DESIGN AND PARTICIPANTS

The Heart and Soul Study is a prospective cohort study of 1017 outpatients with stable coronary heart disease followed up for a mean (SD) of 4.8 (1.4) years.

SETTING

Participants were recruited between September 11, 2000, and December 20, 2002, from 12 outpatient clinics in the San Francisco Bay Area and were followed up to January 12, 2008.

MAIN OUTCOME MEASURES

Baseline depressive symptoms were assessed using the Patient Health Questionnaire (PHQ). We used proportional hazards models to evaluate the extent to which the association of depressive symptoms with subsequent cardiovascular events (heart failure, myocardial infarction, stroke, transient ischemic attack, or death) was explained by baseline disease severity and potential biological or behavioral mediators.

RESULTS

A total of 341 cardiovascular events occurred during 4876 person-years of follow-up. The age-adjusted annual rate of cardiovascular events was 10.0% among the 199 participants with depressive symptoms (PHQ score > or = 10) and 6.7% among the 818 participants without depressive symptoms (hazard ratio [HR], 1.50; 95% confidence interval, [CI], 1.16-1.95; P = .002). After adjustment for comorbid conditions and disease severity, depressive symptoms were associated with a 31% higher rate of cardiovascular events (HR, 1.31; 95% CI, 1.00-1.71; P = .04). Additional adjustment for potential biological mediators attenuated this association (HR, 1.24; 95% CI, 0.94-1.63; P = .12). After further adjustment for potential behavioral mediators, including physical inactivity, there was no significant association (HR, 1.05; 95% CI, 0.79-1.40; P = .75).

CONCLUSION

In this sample of outpatients with coronary heart disease, the association between depressive symptoms and adverse cardiovascular events was largely explained by behavioral factors, particularly physical inactivity.