A Systematic Study on the Effects of Aerobic Exercises on Depression in Post Remission Maintenance Therapy Phase among College Level Subjects

Introduction

Depression is a psychological state of affairs marked by an inordinate feeling of dejection, quarantine and despair that influences a person’s thoughts, feelings, and activity. This disease impacts a person’s performance in emotional, motor, social, and biological areas, and its severity varies from mild to severe.¹ Depression is an illness that affects both the mind and the body, which is a leading cause of disability, workplace absenteeism, decreased productivity and high suicide rates.² People with depression have poor physical health and experience significant psychiatric, social and cognitive disability. It is also considered as a state of low mood and aversion to activities that can affect a person’s thoughts, behaviour, feelings, and sense of well-being.³ Depression is a disorder of paramount public health importance regarding its prevalence and anguish, nonadaptability, morbidity, and economic burden.^4,5 The World Health Organisation estimated that the total number of people living with depression in the world is 322 million, and nearly half of them live in SouthEast Asian and Western Pacific region. In India, the total cases of depressive disorders were 5,66,75,969 which was 4.5% of the population in 2015. According to a WHO report published in 2014, one person committed suicide every 40 seconds globally, and India accounted for highest estimated number of suicides in the world.⁶

The available antidepressant medications are not very effective in treating depressed patients, as was reported by patient organizations and doctors.⁷ It has been reported that despite antidepressants administration, many depressed patients are still suffering from incapacitating residual symptoms.⁸ Furthermore, follow-up investigations have demonstrated that after antidepressant therapy, the depressed are still presenting multiple residual symptoms and are at a higher risk of relapse or recurrence than patients achieving complete remission after treatment.⁹ In contrast, a better level of functioning and an improved prognosis than nonremitters was found in depressed patients who reach complete remission after treatment.¹⁰ Adequate clinical remission is therefore of great, functional importance for the patient because it seems to be a predictor of long-term stability and a rather good indicator of better psychosocial functioning, which is of utmost importance for assessing the quality of life in depressed patients.¹¹ Remission definition may vary across the literature, and questions arise about the boundaries between complete remission and partial remission, the presence after treatment of residual symptoms, and the return or not to premorbid psychosocial functioning. Partial remission is a time with some improvement of symptoms but not of enough magnitude to achieve full remission and the persistence of some residual symptoms.¹² This state corresponds to a score of 8 to 15 on the Hamilton Rating Scale for Depression (HAM-D17).

In contrast, when the patient becomes almost asymptomatic, full remission is obtained, called clinical improvement. Clinical remission is considered by a score of 7 or less on the HAM-D17 or a score of 1012 or less on the Montgomery Asberg Depression Rating Scale (MADRS). This is a crucial stage in the complete rehabilitation of subjects with depression. Depression is challenging; however, treatment can help to improve the quality of life.¹³ The symptoms can be managed with single or combination treatment. However, it is advisable to combine both, i.e. medical treatments and lifestyle therapies.¹⁴ Antidepressants, antianxiety, or antipsychotic medications can treat depression with benefits and potential risks.¹⁵ Physiotherapist can help in learning skills to manage negative thoughts.¹⁶ Certain activities such as exposure to sunlight can help regulate mood and improve symptoms of depression. Mood enhancing therapy is quite effective in seasonal affective disorders. Exercise is considered to be an excellent tool for managing depression and the link between mental wellness and getting stronger.¹⁷ People who undertake regular physical activity or exercise, even at deficient levels, are less likely to experience symptoms of depression and are less likely to experience future depressive episodes.¹⁸ Exercising raises core body temperature, and it is thought that this temperature change can reach specific regions of the brain.¹⁹ In turn, this might lead to a feeling of relaxation and reduction in muscular tension. Depression has the nasty side-effect of diminishing neurotransmitters (serotonin, dopamine, norepinephrine), and there is a chance that exercise can help restore them. This is a more complicated hypothesis to prove, as the only way to do so involves invasive surgeries. As the name implies, the distraction hypothesis proposes that, during exercise, our attention is diverted away from our problems. Results surrounding this explanation are inconclusive, but the principle remains strong, so exercise demands all of attention and concentration. The common exercises prescribed are participation in functional activities, relaxation exercise, free active exercises to limb, breathing exercises, walking and jogging exercises, aerobic exercises etc.²⁰ It has been observed in several studies that 30 minutes of physical activity, three to five days a week can help diminish the effect of depression.²¹ The production of hormones called endorphins can be increased by aerobic exercise, and thereby it helps in improving the mood.

Therefore, the present study was planned to evaluate the positive impact of aerobic exercises on depression in post-remission maintenance therapy.

Methods

Study design and procedure:

Pre-Post experimental study design was used with depressive subjects completing the self-reported Beck Depression Inventory (BDI) scale to evaluate the depression level, SF-36 scale to assess the quality of life prior and after intervention. The inclusion criteria such as depressive disorder subjects diagnosed by physician, male and female subjects of age range between 18 to 25 years and also subjects who were willing to participate in the study were considered. The exclusion criteria included subjects who were non-ambulatory or with severe depressive disorder, subjects with major cardiorespiratory and orthopaedic illness that would contraindicate exercise, subjects with contraindications to aerobic exercise (treadmill, cycling, jogging exercise etc.) as stated by American college of sports medicine.

Also subjects received a standard history, physical examination and special tests like 6-min walk test (6-MWT) to measure the functional capacity of the systems such as pulmonary and cardiovascular, systemic circulation, peripheral circulation, blood, neuromuscular units and muscle metabolism by physiotherapist. Instructions were given to subjects to perform quickly and properly. The participants had received training in daily exercise therapy for the medication-plus exercise group. The therapy consisted of a 5-minutes warm-up, 15 minutes of stationary running, and a 10-minute cooldown, that was convenient and economical for all the participants regardless of gender or location and within guidelines on exercise. Participants were advised not to perform any other exercise beyond usual daily activities. Participant’s vital signs, including pulse and heart rate were monitored during the exercise and the intensity of exercise was adjusted to keep within the target heart rate zone. Exercise sessions were reviewed by a physiotherapist at every follow-up. Follow-up was done at 6 weeks intervals for 12 weeks. (Figure 1).

Pre-Post control study design - Subjects performed deep breathing exercises -10 repetitions for a session with 10 seconds hold time. Slow rhythmic active full range of motion (ROM) exercises for both upper limb and lower limb joints and trunk with 10 repetitions for session were performed. It also had 2 to 3 minutes of rest time between exercises.²⁰ Symptomatic physiotherapy treatment for muscle pain was done by 10 minutes moist heat therapy. Subjects were advised to carry out their normal daily activities. Subjects were taught to maintain an upright posture. The above program was done with the same dosage of 30 minutes per session, three times a week for 12 weeks. After three months of the above interventions, the subjects in both the groups were assessed for the study outcome measures, i.e., Depression by Beck Depression Inventory (BDI), Physical Fitness (Aerobic Capacity) by 6-min walk test (6-MWT) and Quality of Life by SF-36 and the same were noted. (Figure 2).

The collected data were subjected to statistical analysis and hypothesis testing. This study was approved by Institutional Ethical Committee (Topic Registration Number: MVSTOCP/IEC/28-109-2018).

Study participants and sampling

Simple alternate sampling was used for selecting the samples in two different groups. Each group included 15 subjects within the age group of 18-25 years with history of depressive disorder. In both the groups, subjects received continuous maintenance dosage of medication as prescribed by the physician in discussion with investigator to keep consistency in dosage of medication and also received aerobic exercises. Subjects with cardiorespiratory and orthopaedic illness, comorbid psychiatric illness and major depressive or dysthymic disorder conditions were excluded.

Study instruments and measures

Physiotherapy gymnasium, stopwatch, treadmill / bicycle, data collection sheet, pen, pencil and paper, informed consent form, BDI, 6-MWT, Quality of life by SF-36. Permission was taken from respective institutions.

Measurement of study outcome measures Beck Depression Inventory (BDI)

Beck Depression Inventory (BDI) was used to determine depression level. BDI was a 21-question multiple-choice self-reported inventory, one of the most widely used method for measuring depression severity.

Physical Fitness (Aerobic Capacity) by 6-min walk test (6-MWT)

The 6-min walk test (6-MWT) was a practical, simple test that requires a 100-ft hallway but no exercise equipment or advanced training for physiotherapists is needed. In six minutes, the test measures the distance that a patient can quickly walk on a flat, hard surface. During exercise, the global and integrated responses of all the systems were recorded. The functional capacity of the systems such as pulmonary and cardiovascular, systemic circulation, peripheral circulation, blood, neuromuscular units and muscle metabolism was assessed with 6-MWT.

Quality of Life by SF-36

A generic questionnaire about the quality of life was assessed using SF-36. There were 36 questions grouped in eight separate multi-item scales that covered the domains such as physical functioning (10 items), role limitations due to physical problems (4 items), body pain (4 items), general health perception (5 items), vitality (4 items), social functioning (2 items), role limitations due to emotional problems (3 items) and mental health (5 items). The majority of the scales were scored on three to six-point categorical scales with different anchor points, whereas the response choices in the role functioning scales were dichotomous. There were 0-100 scales set, and questions were summated and transformed, indicating higher scores with better quality of life.

Results

The collected data were subjected to standard statistical analysis, i.e. mean, standard deviation and further analysis was carried out by ‘t’ test and chi-square test. The subjects in Group A showed a significant decrease in depression by BDI (.000), a significant increase in physical fitness (Aerobic Capacity) by 6-MWT (.000) and a significant improvement in Quality of Life (QOL) by SF36 [p values of .000 (PF), .000 (RP), .000 (BP), .000 (GH), .000 (VT), .000 (SF), .000 (RE) .000 (MH)] following 12 weeks of aerobic exercise on depression in the post-remission maintenance phase of college-level subjects (Figure 3).

In gender analysis, it was observed that there was no statistically significant difference in the proportion of male and female study participants between Group A and Group B (Figure 4).

The study on depression in post-remission maintenance phase of college-level subjects is given in Figure 5.

The studied results were positively co-relating to findings (Figure 6).

Discussion

The subjects in Group B showed a significant decrease in depression by BDI (.000), a significant increase in physical fitness (Aerobic Capacity) by 6-MWT (.000) and a significant improvement in Quality of Life (QOL) by SF36 [p values of .000 (PF), .000 (RP), .000 (BP), .000 (GH), .000 (VT), .000 (SF), .000 (RE) .000 (MH)] following 12 weeks of conventional physiotherapy on depression in the post-remission maintenance phase of college-level subjects. The comparison of effects of interventions between Group A with B had shown that Group A (Aerobic Exercise) had a significant decrease in depression by BDI (0.000), a significant increase in physical fitness (Aerobic Capacity) by 6-MWT (0.000) and a significant improvement in Quality of Life (QOL) by SF36 [p values of 0.000 (PF), 0.000 (RP), 0.000 (BP), 0.000 (GH), 0.000 (VT), 0.000 (SF), 0.000 (RE) 0.000 (MH)] over the Group B (conventional physiotherapy) following 12 weeks of respective interventions on depression in the post-remission maintenance phase of college-level subjects. In this study, no conclusion concerning trends was drawn. The statistical analysis of age had a p-value of 1.000, which was not significant, and this implied that the subjects in Group A and Group B were well matched with respect to age. The mean age in this study was found to be 24.33, and that was nearer to the study conducted “The Effect of Aerobic Exercise in the Maintenance Treatment of Depression” by P. Majumder and the mean age was found to be 29.6 years.

The subjects in Group A showed a significant decrease in depression by BDI (.000), a significant increase in physical fitness (Aerobic Capacity) by 6-MWT (.000) and a significant positive improvement in Quality of Life (QOL) by SF36 [p values of .000 (PF), .000 (RP), .000 (BP), .000 (GH), .000 (VT), .000 (SF), .000 (RE) .000 (MH)] following 12 weeks of aerobic exercise on depression in post-remission maintenance phase of college-level subjects. The studied results that were positively co-relating to findings of this study are as follows: The subjects in Group B showed a significant decrease in depression by BDI (.000), a significant increase in physical fitness (Aerobic Capacity) by 6MWT (.000) and a significant positive improvement in Quality of Life (QOL) by SF36 [p values of .000 (PF), .000 (RP), .000 (BP), .000 (GH), .000 (VT), .000 (SF), .000 (RE) .000 (MH)] following 12 weeks of conventional physiotherapy on depression in postremission maintenance phase of college-level subjects (Figure 5). The studied results that were positively co-relating to findings of the present study were those conducted by De Zeeuw et al., (2010),12 Jaswinder Kaur et al., (2013),13 and Mats Hallgren et al., (2016).19 The comparison of effects of treatments between Group A and B had shown that Group A (Aerobic Exercise) demonstrated a significant decrease in depression by BDI (.000), a significant increase in physical fitness (Aerobic Capacity) by 6-MWT (0.000) and a significant improvement in Quality of Life (QOL) by SF36 [p values of 0.000 (PF), 0.000 (RP), 0.000 (BP), 0.000 (GH), 0.000 (VT), 0.000 (SF), 0.000 (RE) 0.000 (MH)] over Group B (conventional physiotherapy) following 12 weeks of respective interventions on depression in the post-remission maintenance phase of college-level subjects.

The subjects who were non-ambulatory or with severe depressive disorder, or with major cardiorespiratory and orthopaedic illness that would contraindicate exercise were not included in the study. Besides this, subjects with contraindications to aerobic exercise were not fit for the study. These were the major limitations observed in the study.

Take home message: After the post remission period of depression, regular aerobic exercises can decrease depression significantly and lead to positive improvement in quality of life.

Conclusion

The findings of the present study indicated that Group A, i.e. subjects receiving aerobic exercises had shown a significant decrease in depression by BDI, increase in physical fitness (Aerobic Capacity) by 6-MWT and improvement in QOL by SF-36. Hence this study accepted the alternate hypothesis and rejected the null hypothesis. Therefore, it can be suggested that aerobic exercises can decrease depression significantly.