Facilitated physical activity as a treatment for depressed adults: randomised controlled trial

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2758 (Published 6 June 2012)
Cite this as: BMJ 2012;344:e2758

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Depression has a relapsing course which has not been considered in the study design.

The Treatment of Depression with physical activity (TREAD)[1] study is quite large and well designed. The results of the study got wide media coverage with the main message for the public to the effect that "Exercise Doesn't Treat Depression". This is quite unfortunate in my opinion since there are several aspects that have not been considered in the study design.

Depression is a common condition in Primary Care that typically has a relapsing course. This is important for General Practitioners since they see their patients over an extended period of time. It is equally important to them to cure a current episode as it is to prevent the possible next episode of depression. Effective interventions targeting relapse have the potential to dramatically reduce the point prevalence of the condition.

In this context one might consider the case of Mindfulness Based Cognitive Therapy (MBCT) which has shown to be effective in the relapse prevention of depression in patients who had more than two previous episodes.[2] MBCT which contains components of physical activity is however ineffective during active episodes of depression.[3]

This suggests the following considerations with regard to the present study. Firstly "patients were only eligible to be included in the study if they had a current diagnosis of ICD-10 depressive episode F32".[1] That implies that all patients in the free interval of their recurring condition were excluded from the study. Secondly, the authors state that they "excluded those who had failed to respond previously to antidepressants".[1] That probably means that many severe cases have been excluded.

To conclude the present study shows the ineffectiveness of physical activity in mild cases of depressive episodes while the effectiveness of physical activity for the relapse prevention in severe cases of depression remains an open question and a field for further research. A hasty generalisation that physical activity is ineffective for all cases of depression remains problematic.

1 Chalder M, Wiles NJ, Campbell J, et al. Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. Bmj 2012;344:e2758–e2758.

2 Teasdale JD, Segal ZV, Williams JMG, et al. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology 2000;68:615–23.

3 Piet J, Hougaard E. The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: a systematic review and meta-analysis. Clinical psychology review 2011;31:1032–40.

Competing interests: None declared

Otto Pichlhoefer, General Practitioner

MedUniWien, Währinger Straße 13a, A-1090 Wien

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The rapid responses to this article have been very interesting reading. I am in agreement with many of the points made by correspondents including that the conclusions drawn (by media and authors) seem to overreach the scope of the study. The authors' appear to do the equivalent of 'looking at the floor' as described by Nita Saini in her response about how people with depression start off walking.

This study looked at the effect of the intervention on the CIS-R and the BDI. The results were perhaps predictable but I am not sure the question posed was the one we want the answer to. This maybe one reason for the large number of responses and the media interest.

Sandy Whitelaw is the only correspondant so far to mention mental wellbeing but this is an area that is unexplored by the study which obviously was not set up to capture any potential wider benefits of exercise for people with depression.

Studies that use measurement scales are suitable in some circumstances and make the design of RCTs easier but this study is as notable for what it leaves out as for what it looks at.

Mental wellbeing is a dimension of feeling good and functioning well that is worthy of study in its own right and should not be seen solely as opposite to or the absence of depression (1). So, for instance, just because this intervention did not have a significant effect on BDI does not mean that it did not promote wellbeing which could be of value to the participants.

Exercise is identified as one of the 'five ways to wellbeing'(2) as discussed in the Foresight Report (3). It is an area where evidence is emerging and study is challenging but findings so far should not be dismissed. This is alluded to by other correspondants such as Carol Sinnott and Weber and Murray (11 June responses) who point out that there are all sorts of benefits of exercise; social interaction, structure to the day, taking responsibility etc.

Such factors are complex to look at but rather than continuing to confine ourselves to the foothills of measuring the negative it is high time clinicians, the research community and research funding awarding bodies rose to the challenge of research design that builds understanding of mental health that will have application for both medicine and wider society.

References
1. Warwick Edinburgh Mental Wellbeing Scale http://www.healthscotland.com/understanding/population/Measuring-positiv...
2. Aked J, Marks N, Cordon C, Thompson S. (2008). Connect; Be active; Take notice; Keep learning; Give. Five Ways to Wellbeing. Centre for Wellbeing (new economics foundation) http://neweconomics.org/publications/five-ways-well-being-evidence
3. Foresight Mental Capital and Wellbeing Project (2008). Final Project report – Executive Summary. The Government Office for Science, London. http://www.bis.gov.uk/foresight/our-work/projects/published-projects/men...

Competing interests: None declared

Sarah K Corlett, Public Health Consultant

NHS Lambeth, 1 Lower Marsh, London, SE1 7NT

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Regarding the TREAD (TREAtment of Depression with physical activity) study (1) in which the authors somewhat unexpectedly found negative results on a facilitated physical activity in patients with depression, the following issues should be seriously taken into account before getting to premature recommendation against exercise in this patient population in general. First of all, the severity of depression in this sample may not be generalisable to many patients with this chronic and frequently recurrent clinical condition. The study originally planned to recruit those with depression (as assessed with the International Classification of Diseases, 10th edition) not taking antidepressants or (presumably) taking them for less than eight consecutive weeks at the longest. Further, the study excluded those who had failed to respond previously to antidepressants.

Considering that antidepressants are seriously considered (or indeed frequently indicated) for those with moderate or severe depression and quite a few patients in the real-world actually fail to respond to a single antidepressant trial (2), the results pertain solely to milder forms of the illness for which nonspecific effects are not negligible (that may be exemplified as a well-known placebo effect in a drug comparative study). Further, while a goal of 1000 or more metabolic equivalent of task minutes per week might be too difficult to achieve for those with more severe illness who would have problematic fatigue and loss of goal-directed activities in the first place (note that the study originally aimed to the intensity of physical activity that is recommended for healthy adults), the percentage of those who were active beyond this threshold improved from 28% from baseline to 40-49% at follow-up periods in usual care group, suggesting a nonspecific effect that argues against any differentials between the two groups. Likewise, the use of antidepressants declined from 53 % at four months to 42% at 12 months in this group, which contrasts further from 59% to 35% in intervention group, respectively. While the dose of antidepressants is another problem, those with marked symptoms are unlikely to discontinue from antidepressant treatment within this timeline, again pointing to milder form of the illness.

Moreover, while this study utilized the Beck Depression Inventory (BDI) as the primary outcome measure, a lack of objective measures of depression is a limitation as well as assessments for subjective perspectives other than depression (as assessed with the BDI that gives us a clue on an aspect of the severity (3)) such as quality-of-life, well-being and self-esteem, or those for social functioning. Possible discrepancy of subjective versus objective evaluations is well possible (medicated in part by personality traits), and subjective improvements in mood may well translate into improvements in other subjective domains, or could ideally functioning in the end, the elements of which are all critically relevant for successful treatment of depression.

These issues taken together as well as a relatively large effect implied from a systematic review on this topic (4), the claim that “Clinicians and policy makers should alert people with depression that advice to increase physical activity will not increase their chances of recovery from depression” appears too definitive to argue against a room of exercise in patients with depression. Especially, a potential role of adjunctive, facilitated but realistic physical activity in patients with moderate to severe depression being treated with antidepressants without substantial relief (who may be relatively more resistant to nonspecific effects of an intervention) needs to be further evaluated.

References
1. Chalder M, Wiles NJ, Campbell J, Hollinghurst SP, Haase AM, Taylor AH, et al. Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. BMJ. 2012;344:e2758. doi: 10.1136/bmj.e2758.
2. Warden D, Rush AJ, Trivedi MH, Fava M, Wisniewski SR. The STAR*D Project results: a comprehensive review of findings. Curr Psychiatry Rep. 2007;9(6):449-59.
3. Uher R, Farmer A, Maier W, Rietschel M, Hauser J, Marusic A, et al. Measuring depression: comparison and integration of three scales in the GENDEP study. Psychol Med. 2008;38(2):289-300.
4. Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA. Exercise for depression. Cochrane Database Syst Rev. 2009;(3):CD004366.

Competing interests: None declared

Takefumi Suzuki, staff psychiatrist

Inokashira Hospital, 4-14-1, Kamirenjaku, Mitaka, Tokyo, JAPAN

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Exercise and Depression: Influence of media attention on confidence and use of cost-effective interventions

Authors:
Dr Rod Lambert 1 and Ms Sarah Ferns 2
1 Lecturer, University of East Anglia, Norwich, NR4 7TJ
2 MSc Physiotherapy student, University of East Anglia, NR4 7TJ

We are writing with concern over the recently published article entitled ‘Facilitated physical activity as a treatment for depressed adults: randomised control trial’ (1), and the degree of media attention this has received. We feel that this media coverage is potentially detrimental for two main reasons:

1. That flaws in the study design lead to potential problems of interpretation, that are compounded by the media attention.

Many of the criticisms of previous studies that are discussed in the introduction, apply equally to the reported study. Although a relatively large study, some of the protocol decisions potentially contaminate the reported results, such as the fact that the 'usual care' group were still able to receive 'exercise by prescription', which if provided would dilute the between group differences based on exercise use. The intervention itself provided no direct exercise activity, but used 'motivational interviewing' to encourage participants to engage in physical activity. There was no direct measurement of activity undertaken, either by direct observation or by patient diary data, and therefore the reliability of data is open to interpretation. The use of a 7 day recall diary with 10 minute intervals is open to significant levels of recall bias. The reported results appear to be based more on the effect of contact with the activity coordinator, rather than effects from exercise/physical activity itself. In this way, the study does not in our view meet the requirements from a recent Cochrane review on this subject (2) as a 'methodologically robust trial'.

2. That due to the conflicting nature of the reported findings compared with the majority of other evidence, such attention may reduce the likelihood of people with depression seeking, and healthcare professionals offering, exercise as a possible treatment option, either formally or informally.

We are currently conducting a systematic review of the effects of exercise on depression. Early indications from this are overwhelmingly positive, showing that statistically significant clinical benefits are achieved through direct provision of exercise at preferred intensity (3), and that when structured exercise sessions are provided, this can benefit people with mild to moderate depression (4). The fact that the reported trial (1) does not provide a specific exercise programme, and does not monitor other than by self report (which is at best variable in interpretation), the intensity of the exercise, leads the reported results to be of questionable validity and reliability.

Our fear is that due to this particular article being brought into the public spotlight, patients suffering from depression may no longer consider exercise as a viable treatment option, or may discontinue programmes they may have been given or have adopted. The evidence from well-designed studies (3) and reviews (2), along with evidence of cost-effectiveness of lifestyle-based interventions (5) suggest that we should be maximising the confidence of both professional prescription for, and patient use of, such interventions, and that these should provide specific and supervised exercise programmes (6).

Reference List

(1) Chalder M, Wiles NJ, Campbell J, Hollinghurst SP, Haase AM, Taylor AH, et al. Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. BMJ 2012;344:e2758.

(2) Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA. Exercise for depression. Cochrane Database Syst Rev 2009;(3):CD004366.

(3) Callaghan P, Khalil E, Morres I, Carter T. Pragmatic randomised controlled trial of preferred intensity exercise in women living with depression. BMC Public Health 2011;11:465.

(4) Oeland AM, Laessoe U, Olesen AV, Munk-Jorgensen P. Impact of exercise on patients with depression and anxiety. Nord J Psychiatry 2010 May 4;64(3):210-7.

(5) Lambert RA, Lorgelly P, Harvey I, Poland F. Cost-effectiveness analysis of an occupational therapy-led lifestyle approach and routine general practitioner's care for panic disorder. Soc Psychiatry Psychiatr Epidemiol 2010 Jul;45(7):741-50.

(6) Perraton LG, Kumar S, Machotka Z. Exercise parameters in the treatment of clinical depression: a systematic review of randomized controlled trials. J Eval Clin Pract 2010 Jun;16(3):597-604.

Competing interests: None declared

Rodney A Lambert, Lecturer

Ms Sarah Ferns

University of East Anglia, Earlham Road, Norwich, NR4 7TJ

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Our paper(1) has generated a great deal of interest and reporting in the media. We would like to respond to these comments and in particular clarify our own interpretation of the data and mention some of the outstanding questions the research did NOT ask.

The study compared a physical activity intervention plus usual care with usual care alone. The intervention did not lead to an improvement in depressive symptoms compared to usual care. As many correspondents have stated, we did not evaluate “exercise” or even “physical activity” but the possible effect of our intervention on depression. That said, our intervention did increase self-reported physical activity levels. We can reasonably conclude that our intervention should not be widely adopted for treating depression.

The next question is whether general practitioners (GPs) should advise their patients with depression to become more physically active? Our argument would be that advice to be physical active alone is unlikely to improve depressive symptoms, after all our more intensive facilitated intervention was ineffective. On the other hand, all of us should be physically active because of the other well described health benefits. GPs should be advising all of us, including those with depression, to be physically active taking individual health and circumstances into account but on average, we would not expect that to improve depressive symptoms.

Many of the rapid responses to the BMJ have pointed out that giving advice to be physically active is not the same as following that advice. What if someone with depression does substantially increase their activity levels? Would this increase in physical activity lead to an improvement in depressive symptoms? Even though our intervention increased physical activity levels, we do not know if there is physical activity of the “right” intensity, duration or frequency that might benefit depression. Comments have advocated both higher intensities (as suggested in the rapid response by Larkin et al) and lower intensities (as suggested by Nita Saini who herself has suffered from depression). We did not choose an intervention in which participants, for example, were given a personal trainer, as this would be very expensive and unlikely to be adopted widely by the NHS. Nor did we choose to use a traditional 12 session “exercise on prescription” scheme at the local sports centre as this does not seem to lead to a sustainable increase in physical activity levels.(2) Our study was a pragmatic trial designed to evaluate an intervention that could be used in addition to usual care in the NHS and allowed individuals choice and autonomy about their physical activity in order to lead to a more sustained change in behaviour.

The patients who took part in this trial were referred by their general practitioners as potentially suitable and had a diagnosis of depressive illness. The current NICE guidelines(3) make a recommendation for “structured” physical activity in mild and moderate depression (Pilling rapid response). However, we could find no evidence within our trial for increased effectiveness in those with less severe symptoms though our statistical power for this subgroup analysis was low. Many people, including participants in the trial,(4) express the opinion that physical activity can improve their mood, though this benefit might be shortlived and a randomised controlled study is giving an “average effect”. There could be subgroups of people who benefit and subgroups who do not – but at present we do not know if such subgroups exist and cannot identify them.

It is clear from much of the response both in the BMJ and the popular media that different commentators were interested in a range of questions, only one of which our study addressed. The “headline” that “exercise is no help for depression” clearly goes beyond our finding. We asked a pragmatic question concerning a feasible intervention that could be used in primary care. There are clearly some outstanding explanatory questions about the possible therapeutic role of physical activity in depression. Nevertheless, given the present state of knowledge, we think that people with depression should be recommended to have treatments such as antidepressants and cognitive behavioural therapy (3) that will on average help to relieve the depressive symptoms. Like all of us, people with depression should also be physically active and who knows – this may help some of the people some of the time.

1. Chalder M, Wiles NJ, Campbell J, Hollinghurst SP, Haase AM, Taylor AH, et al. Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. BMJ. 2012;344:e2758. Epub 2012/06/08.
2. Pavey TG, Anokye N, Taylor AH, Trueman P, Moxham T, Fox KR, et al. Clinical effectiveness and cost-effectiveness of exercise referral schemes. Health Technology Assessment. 2011;15(44):1-254.
3. National Institute of Health and Clinical Excellence. Depression guideline (updated edition). London: The British Psychological Society and The Royal College of Psychiatrists, 2009.
4. Searle A, Calnan M, Lewis G, Campbell J, Taylor A, Turner K. Patients' views of physical activity as treatment for depression: a qualitative study. Br J Gen Pract. 2011;61(585):149-56.

Competing interests: None declared

Glyn Lewis, Professor of Psychiatric Epidemiology

John Campbell, Anne Haase, Debbie Lawlor, Ken Fox, Adrian Taylor, Tim Peters, Mel Chalder, Alan Montgomery and on behalf of all co-authors

University of Bristol, School of Social and Community Medicine, Oakfield House, Oakfield Grove, Bristol BS8 2BN

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My response is aimed more at BMJ's advertisement of this study in their email alert

'Exercise is good for depression, right? Wrong, according to this study... So we have no evidence to support advising depressed patients to exercise. And advising exercise may increase a depressed person’s sense of failure and guilt if they cannot follow the advice'.

The study found exercise did not improve depression. Does this mean we should not recommend exercise to people who are depressed? I would argue that the other benefits of exercise to cardiovascular health etc, would by far outweigh the theoretical downside of 'sense of failure and guilt' if they fail to achieve their goals.

Even if exercise does not help, the beneficial side effects of activity are vast. As GPs we must be mindful of the patient as a whole. They may be depressed, but they are still subject to the long term health risks caused by inactivity like everyone else.

My point is simply a reminder that even if the evidence does not support advising exercise for depression it certainly does not mean we should not be advising exercise to people who are depressed!

'

Competing interests: None declared

CRAIG J SHERIDAN, GPCTS ST2

Ipswich Hospital, Heath Rd, IP45PD

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In response to Larkin and colleagues, who ask if the media coverage of the findings of this paper are supported by the trial, and to others concerned at the media interpretation of this work, we wish to clarify that the BMJ did not issue a press release for this paper. A press release was issued by the University of Bristol and is available on their website (http://www.bris.ac.uk/news/2012/8529.html ). We have invited the University of Bristol to respond.

There was a short delay, however, in the BMJ posting the paper online after the embargo was lifted so journalists were unable to access the full paper immediately. We recognise that this may have inadvertently contributed to miscommunication of the study findings. While an email alert, sent to a closed list of those who have registered with the BMJ, may have been misleading, it included a direct link to the paper.

Competing interests: None declared

Domhnall MacAuley, Editor (Primary Care)

BMJ, BMA House, London WC1H9JR

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Many of the respondents have already commented on this interesting study on technical grounds and the media portrayal of its findings. As clinicians, we expect the researchers to be more careful and cautious when they said1, “Clinicians and policy makers should alert people with depression that advice to increase physical activity will not increase their chances of recovery from depression”

The BMJ is one of the most influential journals in the field of medicines and has its following in whole of the world.

Without going into the details of the robustness of the study or the correctness of the interpretation, it is also our duty to be aware of the potential effects on the audience. A study 2 about the efficacy of antidepressants resulted in editorials in the serious and respectable newspaper3 questioning the use of antidepressants, thus raising the anxiety among a sizable proportion of depressed patients in Pakistan. The fact is that public is largely ignorant of the complexities of research. Therefore, media and public report, interpret and perceive things from their own angle and perspective. However, it is not just Pakistan.

In this week’s Lancet4 , Richard Horton commented that “Many scientists and doctors will have hoped that wider coverage of medical science in the media, better science education in schools, and greater access to scientific findings through the Internet would have improved the public's understanding of research. But, maybe these assumptions are unreasonable. The idea of a scientifically engaged society is still a distant dream”, highlighting the same issue in the developed world where awareness, education and access to information is far better than most of the developing world. This situation demands extra responsibility on medical profession.

It is very important that we must give the right information to our patients, but it is equally important that we should weigh the pros and cones of our statement on the ‘whole person’ in a wider society. For example, in this part of the world where diabetes is touching to an extent of an epidemic5, the prevalence of depression is very high. The present study comes up with different findings from the previous ones and its conclusions are still being questioned, will such categorical statements be helpful for patients? We know that obesity, diabetes, hypertension and cardiovascular illnesses are increasing all over the world. We also know that antidepressants cause weight gain. In this background, should we really “alert”. Wouldn’t a careful statement like “although our study does not confirm the previous findings but given the additional benefits of exercise in reducing the risks of many physical illnesses that may indirectly reduce the future risks of episodes of depression, the clinicians should continue to follow the guidelines of NICE until the matter is settled” be more helpful?

This sort of a careful approach could have avoided misquotations and misperceptions by the media and public.

1. Chalder M, Wiles NJ, Campbell J, Hollinghurst SP, Haase AM, Taylor AH, et al. Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. BMJ 2012;344:e2758.
2. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 2008; 5: e45.

3. http:// Dawn.com March 02, 2008

4. http://dx.doi.org/10.1016/S0140-6736(12)60948-9, 14 June 2012.

5. Priya Shetty, India’s diabetes time bomb S14 | NATURE | VOL 485 | 17 MAY 2012

Competing interests: None declared

Muhammad Naim Siddiqi, Consultant Psychiatrist

Saleha Sami

Sindh Institute of Urology and Transplant, Karachi, Pakistan

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Reactions to this trial have been depressing! Given the high quality of the research, and the consistency of its results with other rigorously conducted research, it's hard not to ponder on the reaction at least as much as the trial.

It's far from easy to tease out exercise and depression in a rigorous way. So it's no surprise that we've been exposed to the results of so much highly biased research on the subject. The results from less rigorous research have aligned with so many people's desires for options to encourage people - not to mention strongly held beliefs about exercise and its virtuousness.

It's one of the key problems of health care generally: that people are so much more of critical of research they don't like the results of, than they are of the things they want most earnestly to be true. If only the reverse were true, we could avoid a great deal of harm.

But back to this trial. This is depression we're talking about, and while it's nice if people can do something towards their own recovery, if it's a very hard thing to do at the best of times (never mind the worst of times), the potential for people to blame themselves over not doing it could be high. Not to mention the potential for others to be reinforced in "pull your socks up" judgmentalism. Care is called for. Chalder et al have tackled an important question in a rigorous manner. Thanks!

***I've expressed my opinion about some aspects of this in a guest blog (& cartoon) at Scientific American: http://blogs.scientificamerican.com/guest-blog/2012/06/13/holy-sacred-co...

Competing interests: None declared

Hilda Bastian, Editor & researcher

http://statistically-funny.blogspot.com, Washington DC USA

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The study realized by Melanie Chalder et al1 suggested that advice and encouragement to increase physical activity is not an effective strategy for reducing symptoms of depression due to its lack of effectiveness as an adjunct treatment.

Although of high relevance, the study showed important limitations, since main parameters of physical training were not controlled. Several reviews, systematic reviews and meta-analysis articles have concluded that previous studies had showed several methodological limitations, such as lack of control of training parameters (e.g. intensity, frequency, and duration of exercise), diagnostic of depression, evaluation of remission and response to treatment, sample size and pharmacological treatment2-5 Unfortunately, the present study perpetuates several methodological flaws, especially in exercise prescription. One study published in 2005 showed that weekly energy expenditure is a determinant factor on efficacy of exercise on depression6. Depressive patients with energetic expenditure of 7 kcal/Kg/week showed lower response to treatment than patients with energetic expenditure of 17.5 kcal/kg/week. In addition, Singh et al7 verified that strength training of 80% 1MR (one maximum repetition) intensity promoted higher reduction of depressive symptoms than 20% 1MR. Obviously, there is a huge difference between advice to increase physical activity and supervised exercise with intensity and duration monitored.

To evaluate physical conditioning before starting a physical exercise program is important to determine exercise doses at the beginning and the dose-response to treatment. In the present study, physiological parameters were not used to determine this intensity. Moreover, energy expenditure evaluations might be not reliable if analyzed by questionnaires. Due to impossibility of using direct evaluation of energy expenditure, equations of American College of Sports and Medicine should have been used. Finally, it is important to comment that control group had practiced physical exercise before starting the experiment.

Previous clinical trials have already demonstrated that supervised exercise is effective on depressive treatment through control group with social contact, analysis of intention to treatment and comparisons among type, duration, and intensity of exercises. In addition, recent researches from our laboratory have showed better response and remission after exercise through subjective scales and cortical activity changes measured by electroencephalogram4 8.

Another potential influence in these findings was the evaluation of depressive symptoms by mail, since inadequate answers might have been chosen. The authors should have used both self-evaluations (e.g., BDI) and scales administered by health care professional (e.g., HRDS, MADRS). Finally, there is a wide range of age in the groups and the study has poor control criteria concerning to diagnostic exclusion. It means that the methodology is not reliable, since elderly patients and young adults, as well bipolar and psychotic patients can show different responses when exercise is included as an additional treatment.

In addition to clinical evidence, several studies have shown that physical exercise increases neurotrophic factors, neurogenesis, angiogenesis, synaptogenesis, mitochondrial biogenesis, neuroprotection, neuroplasticity, and reduce oxidative stress9. Thus, the conclusion of Chalder et al1 is, at least , polemic and questionable. Moreover, the message reproduced by media was mistaken, since the present study has not investigated the effect of physical exercise, but the effect of advice and encouragement to increase physical activity.

The above reviewed evidence illustrates the benefits of physical training on depression and methodological questions should be resolved in future randomized and controlled studies.

• Heitor Silveira
Email: hsilveira@hotmail.com
Center for Alzheimer’s disease and Related Disorders, Institute of Psychiatry, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.
Neuroscience Exercise Laboratory – LaNEx (PPGCEE/UGF), Rio de Janeiro, Brazil
• Helena Moraes
• Eduardo Matta Mello Portugal
• Andrea Deslandes (Corresponding Author)
Email: camazdeslandes@gmail.com

1. Chalder M, Wiles NJ, Campbell J, Hollinghurst SP, Haase AM, Taylor AH, et al. Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. BMJ 2012;344:e2758.
2. Stathopoulou G, Powers MB, Berry AC, A.J. J, Smits JA, Otto MW. Exercise Interventions for Mental Health: A Quantitative and Qualitative Review. Clinical Psychology: Science and Practice 2006;13(2):179-93.
3. Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA. Exercise for depression. Cochrane Database Syst Rev 2009(3):CD004366.
4. Deslandes AC, Moraes H, Alves H, Pompeu FA, Silveira H, Mouta R, et al. Effect of aerobic training on EEG alpha asymmetry and depressive symptoms in the elderly: a 1-year follow-up study. Braz J Med Biol Res 2010;43(6):585-92.
5. Krogh J, Nordentoft M, Sterne JA, Lawlor DA. The effect of exercise in clinically depressed adults: systematic review and meta-analysis of randomized controlled trials. J Clin Psychiatry 2011;72(4):529-38.
6. Dunn AL, Trivedi MH, Kampert JB, Clark CG, Chambliss HO. Exercise treatment for depression: efficacy and dose response. Am J Prev Med 2005;28(1):1-8.
7. Singh NA, Stavrinos TM, Scarbek Y, Galambos G, Liber C, Fiatarone Singh MA. A randomized controlled trial of high versus low intensity weight training versus general practitioner care for clinical depression in older adults. J Gerontol A Biol Sci Med Sci 2005;60(6):768-76.
8. Silveira H, Deslandes AC, de Moraes H, Mouta R, Ribeiro P, Piedade R, et al. Effects of exercise on electroencephalographic mean frequency in depressed elderly subjects. Neuropsychobiology 2010;61(3):141-7.
9. Dishman RK, Berthoud HR, Booth FW, Cotman CW, Edgerton VR, Fleshner MR, et al. Neurobiology of exercise. Obesity (Silver Spring) 2006;14(3):345-56.

Competing interests: None declared

Heitor Silveira Silveira, Research

Helena Moraes, Eduardo Matta Mello Portugal, Andrea Deslandes

Institute of Psychiatry, Federal University of Rio de Janeiro, Street marquesa de santos, 5/702 - laranjeiras Zip code: 2222-080 Rio de Janeiro, RJ

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