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1. Akhondzadeh S, Jafari S, Raisi F, et al. Clinical trial of adjunctive celecoxib treatment in patients with major depression: a double blind and placebo controlled trial. Depress Anxiety. 2009;26(7):607-611.
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Comments

Benton and colleagues³ published an impressive paper in Annals of Clinical Psychiatry wherein they demonstrated that coronary heart disease influenced survival curves in patients with depression versus patients without depression.

Looking further, Lespérance and colleagues⁴ examined post-MI patients in a hospital who were screened for depression with the Beck Depression Inventory (BDI). The initial depression score was shown to correlate with long-term survival post-MI.

A British study by Surtees and colleagues⁵ demonstrated an increased risk for ischemic heart disease in patients with major depression wherein almost 20,000 patients were studied. The findings were quite interesting. Patients who were currently depressed had the highest risk for ischemic heart disease and those who were depressed within the past 12 months also had elevated risk, but those who had suffered previously but had been in remission for 12 months or greater had no elevated risk from baseline. This challenges us as clinicians to diagnose and treat depression aggressively.

Whereas the data demonstrating this association between depression and cardiovascular illness is so numerous that we could go on for hours, I will present for your consideration one last study. Frasure-Smith and colleagues⁶ evaluated depressive symptoms as measured by BDI scores as well as C-reactive protein levels. These results again demonstrated that both depression levels as well as inflammatory cytokine levels were negatively associated with cardiac survival in a two-year study of 741 patients with acute coronary syndrome.

It is hoped that this discussion will further stimulate us as clinicians to appreciate the strong association between depression and cardiovascular illnesses. We as clinicians should be diligent in screening patients for depression when they present wtih cardiovascular disease and vice versa.

—Jon W. Draud, MD, MS

References

Comments

2/6/2010 Jon W. Draud, MD, MS

RE: Louise Andrew Yes CRP levels have been widely studied in non-depressed pts and many do believe there is a correlation btwn depression and inflammation....see Dr. Raison's posting this week on this site...Thanks.

There appears to be an additional benefit seen in animal studies—modulation of the hypothalamic-pituitary-adrenal (HPA) axis, which as we know, is crucial in stress management. If you are interested in reading more on the HPA axis modulation in animal models, I recommend two specific articles from Fediuc et al.³ and Droste et al.⁴

There is a wealth of experimental and clinical data revealing positive effects on both the brain and mood in humans. Interestingly, exercise also appears to have a strong anti-inflammatory effect, which is an extra benefit to the individual with depression who exercises, as depression appears to have a large inflammatory component to it. Two studies worth reviewing to examine this experimental data in humans who exercise are from Pereira et al.¹ and Pedersen and Febbraio.⁵

The clinical trials data are actually quite impressive. Let’s first examine a few individual studies, and then we will examine data from a meta-analysis.

One of the more impressive studies published relatively recently was conducted by Dunn et al.⁶ Their data revealed that exercise as a therapy in patients with major depression was quite effective, but only if the patient exercised fairly rigorously and with regular frequency. Blumenthal and colleagues at Duke University published a study in 1999,⁷ and then a follow-up study in 2007,⁸ that compared the benefits of exercise with an established antidepressant. Exercise was nearly as effective as the antidepressant. Even more impressive, Blumenthal’s studies revealed that exercise was effective in mildly as well as severely depressed patients. It also revealed that both supervised and home-based exercise were effective as depression interventions.

Now, a meta-analysis by Mead and colleagues⁹ looked at this data recently and it revealed some very interesting facts. It showed that exercise is effective in the young and old, male and female, and that regular exercise over weeks to months is more effective than infrequent exercise and both aerobic and resistance training are helpful. I highly recommend you read this article.

In summary, it’s time to start thinking about exercise as both a treatment for depression as well as an “add-on” recommendation for patients who are already on antidepressant medications. Exercise appears to have a positive biopsychosocial impact on our patients who suffer from depression.

Clearly, a challenge in clinical practice is how to get patient adherence with our exercise recommendations. You perhaps have faced this situation in your practice as well. It appears that the use of structured, supervised exercise is helpful, as is the use of exercise logs to motivate/monitor our patients with depression. I have attached a copy of an exercise log I use in my practice—you are welcome to download and use it, click here. Let our community of clinicians know how it worked for you!            

I invite your comments and questions. The learning experience will be richer if we communicate. I look forward to your postings on the topic of exercise and mood disorders.

—Rakesh Jain, MD, MPH

References

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Comments

2/1/2010 Rakesh Jain, MD

RE: Judy NP Your point is well understood and I too have encountered exactly the same difficulties you are reporting. It is indeed the patient who most needs to exercise who frequently is the toughest to motivate. Here are some tips that have worked for me. Ask for 'baby step' changes. Asking for large changes frequently backfires. I am often asking for 5 minute walks per day, but on a daily basis. I am frequently asking them to not exercise alone, but with a family member to act as a motivator. I am asking for the tinniest changes the patient can make, but ask them to not go back to old behaviors. This patient approach has proven to be far more successful than my usual, older behavior of wanting dramatic changes right now! Please consider this approach and report back to this group what success you might have had! - Rakesh Jain, MD

2/1/2010 Rakesh Jain, MD

RE: Kristy Cameron I am so delighted that people with your background and training are wanting to connect with mental health professionals! We mental health professionals have the same issues as you - we frequently have limited access to people we can refer our patients for the kind of help you can give them! So, you writing on this blog clearly reveals that we all need better networking. I suggest you drop a letter to your area psychiatrists and primary care physicians and let the know of your existence and your professional interests in helping patients through the use of exercise. If you can, even go by and visit them briefly! Such contact are important. Another thing you might consider dong is contacting your local mental health support groups and volunteer to do brief presentation on yourself, your background, and how exercise might help a number of individuals. Good luck! Keep all of us posted on your progress! - Rakesh Jain,MD

2/1/2010 Rakesh Jain, MD

Re: Jenny Kim RPh I completely agree with a number of things you have said in your eloquent support of exercise. Yes, its a important issue that we clinicians need to discuss with our patients. And yes, its a positive intervention for patients with both psychiatric and physical disorders (or both at the same time). I also strongly endorse your use of exercise not only for treatment, but prevention. And finally, in strong agreement with you, intertwining all avaialble treatment options will indeed be most rewarding for patients and clinicians alike. Thanks for your very wise and perceptive comments. - Rakesh Jain, MD