Re: Facilitated physical activity as a treatment for depressed adults: randomised controlled trial
Exercise and Depression: Influence of media attention on confidence and use of cost-effective interventions
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).
(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: No competing interests