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A Meta-Meta-Analysis of the effect of physical activity on depression and anxiety in non-clinical adult populations
Abstract
Amidst strong efforts to promote the therapeutic benefits of physical activity for reducing depression and anxiety in clinical populations, little focus has been directed towards the mental health benefits of activity for non-clinical populations. The objective of this meta-meta-analysis was to systematically aggregate and quantify high-quality meta-analytic findings of the effects of physical activity on depression and anxiety for non-clinical populations. A systematic search identified eight meta-analytic outcomes of randomised trials that investigated the effects of physical activity on depression or anxiety. The subsequent meta-meta-analyses were based on a total of 92 studies with 4310 participants for the effect of physical activity on depression and 306 study effects with 10,755 participants for the effect of physical activity on anxiety. Physical activity reduced depression by a medium effect [standardised mean difference (SMD) = −0.50; 95% CI: −0.93 to −0.06] and anxiety by a small effect (SMD = −0.38; 95% CI: −0.66 to −0.11). Neither effect showed significant heterogeneity across metaanalyses. These findings represent a comprehensive body of high-quality evidence that physical activity reduces depression and anxiety in non-clinical populations.
... 14 Individuals who did not engage in physical activity had more depression and anxiety symptoms than those who did, according to a study conducted by Thunyadee et al. 15 A meta-analysis by Rebar et al. reported that regular physical activity has a preventive effect on the development of anxiety disorders. 16 Regarding the role of family caregivers in providing support and care for patients with schizophrenia, as well as the lack of appropriate support and education systems for family caregivers in the health system, interventional and experimental studies are required. Given the limited evidence for physical activity interventions, especially for the effects on caregivers, this randomized controlled study contributes to and expands the literature by identifying 12-week physical activity interventions for caregivers of patients with schizophrenia. ...
... In calculation of the sample size, effect size was taken as 0.73 (Cohen d), 16 power as 0.80, type I margin of error as .05, and the sample size was calculated as 62 (http://danielsoper.com/statcalc3/ calc.aspx?id=47). ...
... Before the study was conducted, the content of the program was designed in line with the relevant literature. 13,14,16 The authors sought expert opinions from 2 faculty members in the psychiatric nursing department who specialized in working with families of patients with schizophrenia, as well as 2 faculty members in the sport science department. The physical activity program was designed to accommodate the ergonomics and physiological structure of the caregiver. ...
Background:
The study aimed to investigate the efficacy of a 12-week physical activity intervention for caregivers of patients with schizophrenia.
Method:
Family caregivers of patients with schizophrenia were recruited and randomized into either a physical activity group (n = 31) or a control group (n = 31). The 12-week "Physical Activity Program" consisted of 10 minutes of warm-up activities as the initial segment, 20 minutes of rhythmic exercises as the activity segment, 10 minutes of cool-down exercises as the final segment, and 40 minutes of free walking. The physical activity program was designed to accommodate the ergonomics and physiological structure of the caregiver. The program consisted of 12 sessions. The Zarit Caregiver Burden Scale and the Beck Depression Inventory were used to the physical activity and control groups before the program's implementation.
Results:
A total of 62 caregivers were randomized to the intervention (n = 31) or control group (n = 31). Postintervention measurement was completed by 61 caregivers, and all the caregivers completed the intervention. Mean scores of Zarit Caregiver Burden Scale score and Beck Depression Inventory score in the physical activity group of caregivers at postintervention, significantly reduced at <.05 level than their mean baseline scores.
Conclusions:
Engagement in a 12-week physical activity intervention can improve the perceived burden of caregiving and symptoms of depression. Future research should examine with larger sample groups, carry out interventions, and apply the physical activity intervention by targeting caregivers, along with different interventions.
... are at higher risk of mental illness later in life and more than 50% who have an episode of major depression experience a recurrence. 7,8 Physical activity (PA) is associated with a reduced risk of depression, [9][10][11] and individuals who are more physically active self-report better levels of mental health. 12,13 PA is a non-pharmacological strategy that may prevent mental health challenges such as experiences of depressive symptoms, and in addition, it supports good mental health. ...
... Specifically, this study highlights the potential to evaluate interventions targeting 24-h movement behavior using self-report data. Thus, reflective of previous studies indicating positive effects of PA on both physical and mental health, 9,10 our findings support that time spent in MVPA relative to other movement behaviors is related to mental health. Participants reported spending 1% of their day in MVPA on average, which is near the 150 min of MVPA per week recommendation detailed in the Canadian public health guidelines. ...
Background
Movement behaviors (i.e., physical activity [PA], sedentary behaviors [SB], sleep) relate to mental health. Although movement behaviors are often analyzed as distinct entities, they are in fact highly inter‐dependent (e.g., if an individual increases sleep, then PA and/or SB must be reduced) and these dependencies should be accounted for in the analysis. We tested whether perceptions of time spent in movement behaviors (i.e., moderate‐to‐vigorous intensity PA [MVPA], light physical activity [LPA], SB, and sleep) related to depressive symptoms and self‐report mental health in young adults using a compositional analysis. We then estimated change in depressive symptoms with reallocation of time across movement behaviors using compositional time‐reallocation models.
Methods
Data were drawn from the longitudinal NDIT dataset. Complete data were available for 770 young adults (Mage = 20.3, 55% females).
Results
The proportion of time spent in MVPA relative to other movement behaviors related to depressive symptoms non‐significantly and to mental health significantly. Reallocating 15 min from MVPA to SB resulted in a significant (0.46 unit) increase in depressive symptoms, and reallocating 15 min of MVPA to LPA was associated with a (0.57) increase in depressive symptoms.
Conclusion
These results indicate the importance of relative time spent in each movement behavior to mental health. Further research should examine these associations over time.
... Also, on days with higher levels of job-related anxiety, employees have been found to show more counterproductive work behavior and less organizational citizenship behavior (Rodell & Judge, 2009). Empirically, physical activity has not yet been linked to job-related anxiety but has been meta-analytically shown to decrease anxiety in general (Rebar et al., 2015). Here, we argue that physical activity immediately before work reduces day-level job-related anxiety. ...
... In general, our study provides new insights into the psychological mechanisms underlying the positive effects of physical activity on employee well-being. Previous studies have found that physical activity tends to reduce stress, anxiety, and depression, and to improve mood, self-esteem, self-efficacy, and cognitive functioning (for reviews, see Calderwood, ten Brummelhuis, et al., 2021;Chang et al., 2012;Rebar et al., 2015). The results of the current study significantly advance theory by showing that physical activity before work benefits employee well-being by shaping how the work situation is interpreted on a day-to-day basis. ...
Previous research has typically conceptualized physical activity as a recovery activity after work that promotes well-being by allowing employees to detach from work and replenish their resources. Here, we aimed to go beyond this framework by proposing a new theoretical model of how physical activity in the morning before work affects employee well-being. Drawing upon the transactional theory of stress, we theorized that physical activity before work shapes employees' appraisal of their upcoming workday which, in turn, affects their well-being. In a preregistered study (N = 269), we utilized a within-person daily experience sampling approach to test our model. Results showed that two types of appraisals are particularly important for explaining the effects of physical activity before work on employee well-being: First, challenge appraisal mediated the effects of physical activity before work on work engagement. Second, we found an indirect effect via threat appraisal of physical activity before work on job-related anxiety. Exploratorily, we found that threat appraisal also mediated the effect of physical activity before work on emotional exhaustion. In conclusion, our results show that physical activity before work is beneficially related to several types of well-being outcomes by increasing challenge appraisal and decreasing threat appraisal. Furthermore, our study advances theoretical understanding on physical activity and work stress by shedding light on the mechanisms underlying the effect of physical activity on employee well-being and showing that physical activity before work benefits well-being by shaping how employees appraise their work situation on a day-to-day basis. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
... Among the benefits evoked by regular physical activity, a plethora of studies showed that physical activity can improve symptoms of anxiety [11] and depression [12,13]. Traditionally, depression and anxiety are treated through pharmacological therapy involving the following: mood stabilizers; antidepressants; anticonvulsants; and atypical antipsychotics [14]. ...
... We also found a negative correlation between habitual physical activity and depressive symptoms. Rebar et al. [12] in a meta-analysis showed a reduction in depression and anxiety as a result of physical activity, even in nonclinical populations. Moreover, some evidence suggests that physical activity has beneficial effects on depression symptoms that are comparable to those of antidepressant treatments [13]. ...
Purposes: To examine the habitual physical activity levels and their relationship with mood disorders (anxious and depressive symptoms) in young healthy adults and evaluated sex differences for these variables. Methods: A total of 297 participants (144 women) answered the following questionnaires: Baecke questionnaire to evaluate habitual physical activity level; State–Trait Anxiety Inventory, to evaluate anxious symptoms; and Beck Depression Inventory, to evaluate depressive symptoms. Results: There was a significant negative correlation between habitual physical activity levels and depressive symptoms (rho = -0.132 “small effect”, p = 0.023), trait anxiety levels (rho = -0.205 “small effect”, p < 0.001), and state anxiety levels (r = -0.216 “small effect”, p < 0.001) of the participants. However, there was no significant difference (p > 0.05) between men and women correlations for all investigated variables. Men presented higher absolute total (p < 0.001, d = 0.549 “medium effect”) and mean (p < 0.001, d = 0.515 “medium effect”) habitual physical activity level, lower trait (p < 0.001, rB = -0.342 “medium effect”) and state (p < 0.001, d = -0.483 “small effect”) anxiety levels, and lower depressive symptoms (p = 0.007, rB = -0.181 “small effect”) than women. Conclusion: Habitual physical activity that is characterized by unstructured pattern seems to be inversely related to mood disorders.
... For example, the Wilderness Therapy Clinical Model argues that wilderness therapy can enhance people's self-confidence, resilience, and positive social interactions (Fernee et al., 2017). Improvement of depressive symptoms might also be achieved through the various forms of moderate to vigorous physical activity that is an inherent part of NBA activities such as rock-climbing, surfing, and backpacking (Catalan-Matamoros et al., 2016;Moreton et al., 2022;Rebar et al., 2015). ...
... The benefits of nature-based activities may be even more pronounced when they involve some degree of physical activity (such as NBA). Individuals who are physically active in nature often report reductions in stress and anxiety, and improvements in attention, mood, and sleep quality (Gladwell et al., 2013;Kaplan, 1995;Lackey et al., 2021;Moreton et al., 2022;Rebar et al., 2015;Shin et al., 2012;Ulrich et al., 1991). The mental health benefits of NBA interventions might also be explained by the satisfaction of basic psychological needs (autonomy, competence, and relatedness) and nature connectedness, which can be strengthened during NBA engagement (Houge Mackenzie et al., 2023). ...
We conducted a systematic review to synthesize evidence of the effect of nature-based adventure (NBA) interventions on depressive symptoms. Our search was conducted in April 2021 and utilized the following databases: MEDLINE (PubMed), PsycINFO, SPORTDiscus, CINAHL, Google Scholar, and Clinicaltrials.gov. Forty-two studies (n = 2,689 participants) with different designs, published between 1979 and 2021, were included. Collectively, results suggest highly variable effects of NBA interventions on depressive symptoms, ranging from reductions in mean depression scores of up to 64% to increases in means scores of up to 18%. Patient adherence to interventions was also variable, and serious adverse events (e.g., leg fractures) did occur. Despite variability across studies, research generally showed that mountain-based and surfing interventions, coupled with other forms of care, may substantially reduce adults' depressive symptoms more than usual care alone or no intervention, highlighting the potential benefits of some NBA activities for individuals experiencing depressive symptoms.
... In addition, the aging process has been found negatively associated with psychological well-being From the other hand, PA practice and correct fitness education could play a relevant role to counteract poor biomarkers commonly associated with aging [3]. Therefore, in older adults, regular exercise practice positively alters depression symptoms, promotes mental health, influencing motor and cognitive skills that may prevent the onset of different mental illnesses and delay mental decay [4][5][6]. ...
Background
Aquatic exercise programs can enhance health and improve functional fitness in older people, while there is limited evidence about the efficacy of aquatic-exercise programs on improving well-being and quality of life.
Aim
The purpose of this study was to determine the effects of a supervised water fitness program on subjective well-being in older women.
Methods
The study group included 166 active older women (> 65 years), divided into water-based (WFG) and land-based (CG) training groups. They filled out 3 questionnaires to assess their amount of physical activity (IPAQ), subjective well-being (PANAS) and mental and physical health status (SF-12).
Results
Results showed that subjective well-being, physical activity level, perceived mental and physical status had higher values in the WFG compared to CG.
Conclusions
We found that older women practicing water fitness tend to have a better subjective physical and mental well-being than those who exercise in a land-based context.
... In this study, emotional, social, and psychological well-being mean scores and MHC-SF total score averages were found to be significantly higher for those who engaged in regular physical activity than for those who did not. Studies have reported that the mental states of individuals who do not have psychiatric problems and who exercise regularly are better than people who do not exercise [24][25][26] . In a different study conducted on healthy adults, a high level of negative correlation was found between physical activity and depression 27 . ...
Purpose: Research on mental health emphasizes that psychological state has an effect on eating behavior. These studies suggest that there may be a relationship between mental health continuum and hedonic hunger. This study aimed to examine the relationship between adults’ mental health continuity and hedonic hunger. Method: Participants were 387 adults (65 men and 322 women) without any mental illness. Data was collected by the researcher using the snowball sampling model, via Google Forms. A general questionnaire, food consumption frequency form, Mental Health Continuum Short-Form (MHC-SF) and Power of Food Scale (PFS) were administered. Results: 56.1% of the participants were in normal mental health and 36.4% in well-being. MHC-SF total and sub-factor scores of the participants who did regular physical activity were significantly higher (p<0.05). The PFS total score was higher in women than men. There was a negative, weak, and statistically significant correlation between participants' MHC-SF and PFS total scores (p<0.05). There was a positive, weak and statistically significant correlation between Body Mass Index (BMI) and PFS total scores. There was a positive, weak and statistically significant correlation between PFS score, body weight and BMI. There was a statistically significant negative correlation between all PSF total and sub-factor scores and the frequency of fast-food and chips consumption (p<0.05). Conclusion: Hedonic hunger increased as the mental health continuum decreased. It was determined that the continuity of mental health was higher in individuals who do regular physical activity and in men. As hedonic hunger increased, the frequency of consumption of chips and fast-food products increased.
... En outre, l'AP constitue un facteur de prévention de certains troubles mentaux, et de promotion du bien-être et de la qualité de vie : l'AP contribue à réduire l'anxiété-trait (avec une taille d'effet modérée d = -0.38 ; (Rebar et al., 2015), la dépression (avec une taille d'effet élevée d = -0.50 ; (Ekkekakis, 2015), et à améliorer l'humeur (avec une taille d'effet faible à modérée d = .21; (Wiese, Kuykendall, & Tay, 2018). ...
Cette note de synthèse réalisée en vue de l’obtention de l’Habilitation à Diriger des Recherches vise à retracer les éléments saillants de mes travaux de recherche portant sur la promotion de la motivation à l’École et en contexte sportif, et sur la promotion de la motivation pour l’activité physique (AP) à des fins de santé. Elle est structurée en trois parties :
La première porte sur la promotion de la motivation pour l’AP à des fins de santé. Les
travaux qui s’inscrivent sur cet axe de recherche se sont intéressés à trois mécanismes de promotion de l’AP : des mécanismes cognitifs visant le développement des intentions d’AP, des mécanismes comportementaux visant le développement des capacités d’autorégulation facilitant l’implémentation des intentions, et des mécanismes affectifs visant le développement d’expériences d’AP positives.
La deuxième partie concerne la promotion de la motivation en EPS et en sport. Les travaux menés dans cette perspective, ont consisté à élaborer, tester, et répliquer plusieurs programmes de formation des enseignants et des entraineurs à dessein d’améliorer leur style motivationnel, ainsi que l’engagement et la motivation autonome de leurs élèves/sportifs.
Enfin, la troisième partie s’intéresse à la promotion de la motivation et du bien-être à l’école. Les travaux relatifs à cet axe se sont notamment intéressés au développement des compétences psychosociales des élèves en tant que vecteur de promotion de la motivation et du bien-être. Le projet ProMoBE consistant à combiner des leviers de la promotion de la motivation (i.e., formation au soutien des besoins psychologiques visant l’amélioration du style motivationnel) et des leviers de la promotion du bien-être (i.e., IPP-multi-composantes visant le développement des CPS) représente le coeur de cet axe de recherche.
... [35]. This is because these psychological aspects are important for well-being and can contribute to a sense of purpose, meaning, and satisfaction in life [36,37]. The findings of this study underscore the importance of health policies and programs designed to promote regular physical exercise among older adults, and such interventions could help improve the psychological well-being of older adults and promote their overall quality of life. ...
This study employed the correlational survey model to examine how regular exercise influ-enced life satisfaction, self-esteem, and self-efficacy in men over 65. The study sample included a total
of 215 participants, of whom 110 exercise regularly (for at least 45 min, three times a week), while
105 engaged in no physical exercise. Regular exercisers were found to score significantly higher on
life satisfaction, self-esteem, and self efficacy scales as compared to non exercisers. These scores also
increased significantly with age and prolonged exercise history. A moderate and positive correlation
was detected between Life satisfaction, self-esteem, and self efficacy among regular exercises, while
non-exercisers showed low to moderate correlations. The findings suggest that regular exercise can
enhance life satisfaction, self-esteem, and self-efficacy in the elderly male population. Such effects
appear to be associated with greater age and lifetime exercise history, highlighting the value of regular
physical exercise in improving the quality of life among older adults.
... On the social front, physical exercise works positively towards integration and the development of interaction with other people (e.g., Di Bartolomeo & Papa, 2019). Lastly, it is effective in the prevention and treatment of psychological disorders affecting a person's mental health (e.g., Fox, 1999), by reducing the symptoms of depression and anxiety for example (e.g., Rebar et al., 2015), or enhancing the perception of well-being (Zhang & Chen, 2019). Some studies have also focused on the beneficial effects of physical activity on mental health during the lockdown period. ...
Background: Between March and May 2020, the COVID-19 pandemic led governments to take specific lockdown measures. Investigations have defined obesity as a risk factor for disease severity, but none has addressed the effects of lockdown on psychological well-being and physical activity in this population. The objective of the study was to analyze the evolution (before vs. during lockdown) of well-being and physical activity among French adult women living with overweight or obesity. Methods: 250 women, divided into 5 Body Mass Index (BMI) categories (healthy weight, overweight, obesity I, II or III), provided online information concerning their self-perceived psychological well-being and level of physical activity before and after one month (± 1 week) of lockdown. Results: This study shows that BMI is a factor that is associated with well-being and physical activity. Compared to women with a healthy weight who significantly increased their level of physical activity, those living with overweight or obesity perceived a significant decrease in psychological well-being, positive affect, and physical exercise. Conclusions: This study highlights the importance of taking into account the well-being and active behavior of women living with overweight or obesity during any lockdown period that could occur in future pandemics.
... However, we cannot conclude the direction of these associations (Rebar et al., 2015;Lesser 297 and Nienhuis, 2020; Meyer et al., 2020). In a cross-sectional study of 3,052 US adults, 298 individuals who decreased physical activity had stronger/higher depressive symptoms and 299 stress compared to those who maintained adherence to physical activity. ...
The COVID-19 pandemic had significant impacts on mental health. We examined factors associated with symptoms of depression and anxiety during the COVID-19 pandemic in Kazakhstan. We surveyed 991 adults in Kazakhstan in July 2021 using multistage stratified sampling. Depression and anxiety were measured with the Patient Health Questionnaire-4. We conducted logistic regression to assess associations between depression and anxiety and sociobehavioral factors. Overall, 12.01% reported depressive symptoms and 8.38% anxiety. Higher likelihood of depression was associated with being female (AOR: 1.64; 95% CI [1.05, 2.55]), having experience with COVID-19 in the social environment (AOR: 1.85; 95% CI [1.1–3.14]), experiencing food insecurity (AOR: 1.80; 95% CI [1.11–2.89]), increased family conflict (AOR: 2.43; 95% CI [1.32–4.48]) and impaired healthcare access (AOR: 2.41; 95% CI [1.32–4.41]). Higher likelihood of anxiety was associated with being female (AOR: 3.43; 95% CI [1.91–6.15]), increased family conflict (AOR: 2.22; 95% CI [1.11–4.44]) and impaired healthcare access (AOR: 2.63; 95% CI [1.36–5.12]). Multiple factors were associated with mental health in Kazakhstan during the COVID-19 pandemic. Further research is needed to determine the extent to which these factors and their associated mental health outcomes may persist.
... Greater amounts of energetic play are best for promoting children's health and development (World Health Organization, 2019). Higher intensity activities like running, using a wheelchair, and jumping jacks protect heart health and reduce feelings of anxiety and depression (Helgerud et al., 2007;Rebar et al., 2015). Walking or stretching while standing or seated, however, are good for restoring attention (Bailey et al., 2018). ...
Self-regulation is a critical emergent developmental competency that lays the foundation for children’s later psychosocial health and academic achievement. Recent work indicates that physical activity and energetic play opportunities support children’s self-regulation in the early childhood classroom. Many early childhood programs offer opportunities for children to engage in play, but teachers are rarely seen modeling physically active behaviors and face barriers to integrating opportunities for energetic play with early academic skills. Early childhood educational settings hoping to support children’s self-regulation development can provide multiple opportunities for children to observe teachers modeling physical activity, provide teacher support and scaffolding for physically active learning centers, and engage children in meaningful energetic play while promoting a range of academic skills. This article provides 10 research-based guidelines for supporting children’s self-regulation development through physical activity in early childhood classrooms.
... that is in line with the spirit of 'living' systematic reviews and their meta-analytic extensions 27,28 . This value conflicts with proposals for syntheses to be more selective in the effects they consider 29 , or to synthesize estimates from previous syntheses instead of original effects [30][31][32] . However, this value is motivated by a recognition that knowledge users need syntheses capable of answering a plurality of questions. ...
... Traditionally, research and intervention for depression have focused on the clinical population, but more efforts have been devoted to the reduction of symptoms and risk factors because numerous studies have documented the benefits of early intervention and prevention of depression in subclinical and at-risk populations (Cuijpers et al., 2014;Rebar et al., 2015). ...
Background and Objectives
Depressive symptoms are common in older adults, and often co-occur with other mental health problems. However, knowledge about depressive symptom-domains and their associations with other conditions is limited. This study examined depressive symptom-domains and associations with anxiety, cognition, and loneliness.
Research Design and Methods
A sample of 3795 participants aged 60 years and older were recruited from the community in Hong Kong. They were assessed for depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]), anxiety (Generalized Anxiety Disorder 7-item), loneliness (UCLA 3-item) and cognition (Montreal Cognitive Assessment 5-minute protocol). Summary descriptive statistics were calculated, followed by confirmatory factor analysis (CFA) of PHQ9. Multiple indicators multiple causes (MIMIC) analysis was used to examine the associations between mental health conditions in the general sample and sub-groups based on depressive symptom severity.
Results
A four-factor model based on the Research Domain Criteria (RDoC) showed the best model fit of PHQ-9 (χ2/df = 10.63, RMSEA = 0.05, CFI = 0.96, TLI = 0.93). After adjusting for demographics, four depressive symptom-domains were differentially associated with anxiety, loneliness, and cognition across different depression severity groups. The Negative Valance Systems and Internalizing domain (NVS-I; guilt and self-harm) were consistently associated with anxiety (β=0.45, 0.44) and loneliness (β=0.11, 0.27) regardless of depression severity (at risk/mild vs moderate and more severe, respectively, all p<0.001).
Discussion and Implications
The consistent associations between the NVS-I domain of depression with anxiety and loneliness warrant attention. Simultaneous considerations of depressive symptom-domains and symptom severity are needed for designing more personalized care.
... Por todo lo anterior, el ejercicio está siendo cada vez más justificado como un preventivo predominante para las diferentes enfermedades de la salud pública (Mang, 2013) y mental (Carter, Morres, Meade, & Callaghan, 2016), acrecentando el bienestar de quienes sufren algún trastorno, por lo que es una herramienta clave para disminuir los altos índices de morbilidad en el mundo (Rebar et al., 2015), debido a su efecto terapéutico (Chekroud et al., 2018). ...
El objetivo del presente estudio fue evaluar los síntomas depresivos, por separado y en su conjunto, antes y al mes de concluir un programa de ejercicio físico en pacientes hospitalizados con depresión. Participaron 48 pacientes los cuales fueron divididos en dos grupos (n= 24 farmacológico, y n= 24 fármaco+ ejercicio físico). Como resultado, al comparar entre grupos al mes de llevar a cabo el programa de ejercicio físico junto con el tratamiento farmacológico, el grupo fármaco+ ejercicio físico tuvo puntuaciones significativamente más bajas en el BDI (Msum= 1.0, DTsum= 1.35), en comparación con el grupo que sólo tuvo el tratamiento farmacológico (Msum= 11.08, DTsum= 5.97). En cuanto al ANOVA de medidas repetidas, se evidencia que hubo diferencias significativas en ambos grupos, farmacológico (F (41)= 11.35, p<. 000; ηp 2=. 33; d=. 79) y fármaco+ ejercicio físico (F (41)= 22.81, p<. 000; ηp 2=. 50; d=. 86) debido al factor tiempo. Sin embargo se encuentra un mayor tamaño del efecto en el grupo donde se intervino con ejercicio físico. Como conclusión, este estudio muestra que un programa de ejercicio físico en conjunto con el tratamiento farmacológico, disminuyen la mayoría de la sintomatología depresiva en pacientes hospitalizados. Además, promueve la incorporación del ejercicio como complemento en el manejo de los síntomas de la depresión mayor.
... It stands as a signi cant determinant of health, with adequate levels of physical activity associated with decreased prevalence and incidence of chronic diseases such as obesity, cardiovascular disease, and type 2 diabetes [8][9][10][11][12]. In addition to the direct physiological advantages, physical activity is correlated with enhanced mental health and cognitive function [13,14]. Regular engagement in physical activity has been associated with extended lifespan and reduced mortality risk, presumably due to an amalgamation of the aforementioned bene ts [15][16][17]. ...
Background
Physical activity plays an integral role in promoting health and well-being. Despite its importance, comprehensive studies exploring the influences of socio-demographic factors on physical activity in the Chinese context are relatively scarce. This study aims to investigate the relationship between physical activity and socio-demographic factors such as gender, age, and socioeconomic status, using data from the 2018 China Family Panel Studies (CFPS).
Methods
Data was derived from the 2018 CFPS, resulting in a final sample size of 21,854 adults, with physical activity as the dependent variable. The International Socio-Economic Index of Occupational Status (ISEI) was used to gauge socioeconomic status. Other incorporated variables included gender, age, community type, marital status, physical health, and mental health. The study employed a logistic regression model considering the dichotomous nature of the dependent variable.
Results
Significant correlations were found between physical activity and gender, age, and socioeconomic status. Men were found to be more likely to engage in physical activity than women, and the likelihood of physical activity increased with age and socioeconomic status. Further, the influence of socioeconomic status on physical activity was found to vary significantly across different genders and age groups, with complex intersections noted among these factors.
Conclusion
The study underscores the need for public health interventions that are mindful of the complex interplay between gender, age, and socioeconomic status in influencing physical activity. Efforts to promote physical activity should focus on bridging the disparities arising from these socio-demographic factors, especially targeting women and individuals from lower socioeconomic classes. Future research should delve into the mechanisms through which these factors intersect and explore other potential influential elements to enhance our understanding of physical activity behavior.
... I 2 =0%, 92 studies, 4310 participants) for depressive symptomology, and SMD=-0.38 (95% CI -0.66 to -0.11) I 2 =4%, 306 studies, 10,755 participants) for anxiety-related symptomology, in non-clinical populations (57) . ...
Associations between fruit and vegetable (FV) consumption and mental health are suggested, largely from observational studies. This systematic review aimed to identify and summarize all published controlled intervention studies investigating the effects of FV consumption on mental health in adults. Four academic databases (Medline, PsychInfo, Pubmed, Web of Science) were searched on 16.09.22, over all years, for studies that: used an intervention design; included fruit and/or vegetable consumption; included an appropriate non-FV-consumption control; used a validated measure of mental health; and were conducted in healthy adults or adults with solely a depressive or anxiety-related condition. Study details were tabulated and combined using meta-analyses. Risk of bias was assessed using the domains of the Cochrane Collaboration. Six studies, enrolling 691 healthy adults, and reporting on one or more mental health outcomes were found. Meta-analyses found small and imprecise effects of FV consumption: Psychological Well-being (4 studies, 289 participants) SMD=0.07 (95% confidence intervals (95%CI) -0.17, 0.30), p=0.58, I2=0%; Depressive Symptomology (3 studies, 271 participants) SMD=-0.15 (95%CI -0.40, 0.10), p=0.23, I2=46%; Anxiety-related Symptomology (4 studies, 298 participants) SMD=-0.15 (95%CI -0.39, 0.08), p=0.20, I2=69%. Some benefit for Psychological Well-being was found in change-from-baseline data: SMD=0.28 (95%CI 0.04, 0.52), p=0.02, I2=0%). Risk of bias was high in many studies. Limitations include the consideration only of published studies, and stem from the studies found. Given the few, limited studies available and the small size of effects, stronger evidence is needed before recommending FV consumption for mental health.
... Young adults also report poorer mental health and higher stress than other age groups [2]. There is substantial evidence that modifiable lifestyle behaviors, specifically physical activity, sedentary behavior, and sleep, can substantially decrease the risk of chronic illnesses such as mental illnesses [3][4][5][6] and cardiovascular diseases [7][8][9][10]. Thus, young adulthood, defined as the age range of 18 to 25 years [11], is a critical time for the development of healthy lifestyle behaviors to prevent chronic diseases. ...
Background:
Recent technological advances allow for the repeated sampling of real-time data in natural settings using electronic ecological momentary assessment (eEMA). These advances are particularly meaningful for investigating physical activity, sedentary behavior, and sleep in young adults who are in a critical life stage for the development of healthy lifestyle behaviors.
Objective:
This study aims to describe the use of eEMA methodologies in physical activity, sedentary behavior, and sleep research in young adults.
Methods:
The PubMed, CINAHL, PsycINFO, Embase, and Web of Science electronic databases were searched through August 2022. Inclusion criteria were use of eEMA; sample of young adults aged 18 to 25 years; at least 1 measurement of physical activity, sedentary behavior, or sleep; English language; and a peer-reviewed report of original research. Study reports were excluded if they were abstracts, protocols, or reviews. The risk of bias assessment was conducted using the National Heart, Lung, and Blood Institute's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Screening, data extraction, and risk of bias assessments were conducted by independent authors, with discrepancies resolved by consensus. Descriptive statistics and narrative synthesis were used to identify overarching patterns within the following categories guided by the Checklist for Reporting Ecological Momentary Assessments Studies: study characteristics, outcomes and measures, eEMA procedures, and compliance.
Results:
The search resulted in 1221 citations with a final sample of 37 reports describing 35 unique studies. Most reports (28/37, 76%) were published in the last 5 years (2017-2022), used observational designs (35/37, 95%), consisted of samples of college students or apprentices (28/35, 80%), and were conducted in the United States (22/37, 60%). The sample sizes ranged from 14 to 1584 young adults. Physical activity was measured more frequently (28/37, 76%) than sleep (16/37, 43%) or sedentary behavior (4/37, 11%). Of the 37 studies, 11 (30%) reports included 2 movement behaviors and no reports included 3 movement behaviors. eEMA was frequently used to measure potential correlates of movement behaviors, such as emotional states or feelings (25/37, 68%), cognitive processes (7/37, 19%), and contextual factors (9/37, 24%). There was wide variability in the implementation and reporting of eEMA procedures, measures, missing data, analysis, and compliance.
Conclusions:
The use of eEMA methodologies in physical activity, sedentary behavior, and sleep research in young adults has greatly increased in recent years; however, reports continue to lack standardized reporting of features unique to the eEMA methodology. Additional areas in need of future research include the use of eEMA with more diverse populations and the incorporation of all 3 movement behaviors within a 24-hour period. The findings are intended to assist investigators in the design, implementation, and reporting of physical activity, sedentary behavior, and sleep research using eEMA in young adults.
Trial registration:
PROSPERO CRD42021279156; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021279156.
... For example, individuals with more social support may perceive stressful situations to be easier to control [32]. Likewise, engagement in group activities has been established to buffer the effects of stress and promote coping mechanisms [11,14,55,70]. An appropriately regulated HPA axis enables humans to adapt to social and physical environments, while HPA dysregulation can lead to anxiety, mood disorders [16,67] and addictive behaviours [10]. ...
Introduction:
Oral contraceptives (OCs) are primarily known for their effects on the reproductive system, but they can also impact the hypothalamic-pituitary-adrenal (HPA) axis. The present study aimed to compare plasma adrenocorticotropic hormone (ACTH) responses to the anticipatory stress of participating in a scientific experiment and venepuncture in OC users versus naturally cycling (NC) women, with a focus on variations throughout the menstrual cycle.
Methods:
We recruited 131 young women (average age 20.5) and obtained blood samples to measure plasma ACTH concentrations immediately after venepuncture and again after 15minutes of group activities designed to facilitate interpersonal attachment and stress-buffering.
Results:
ACTH levels decreased in 70% of all participants throughout the group activities. A two-way repeated measures ANOVA highlighted a significant interaction between time and OC use, indicating differential changes in ACTH levels during social interaction between OC users and NC women. Further, the post-hoc analysis revealed that a period of stress-buffering group activities significantly decreased ACTH levels in NC women during menstrual and secretory phases, but not during the proliferative phase. In contrast, OC users did not display a decrease during group activities, regardless of the phase.
Conclusion:
This study underscores the influence of OC use on stress regulation, demonstrating that OCs not only modulate reproductive functions but also impact ACTH stress reactivity. Additionally, it emphasizes the importance of considering hormonal contraceptive use and menstrual cycle phases when assessing female stress responses.
... Depression is also co-morbid with a range of chronic physical conditions, including type 2 diabetes, hypertension, osteoarthritis, and obesity (Pilling et al., 2009), so promoting physical activity to patients has multiple benefits (Cooney, 2018). For patients with depression, physical activity is an evidence-based intervention, which is just as effective as anti-depressants and psychological therapies, with the added benefit of treating many chronic physical conditions (Cooney et al., 2013;Heissel et al., 2023;Rebar et al., 2015;Stubbs et al., 2017). Physical activity has also been shown to be an effective treatment for anxiety (Heissel et al., 2023). ...
... Furthermore, in the case of physical access to outdoor greenery during the working day, it is necessary to control for the possible confounding effect of physical exercise (i.e., walking), and thus to extract the "pure" effect of greenery. Indeed, it is possible that access to outdoor greenery during the working day boosts employees' physical activity, which in turn contributes to improving their well-being as shown earlier (see for example, Mitchell, 2013;Rebar et al., 2015;Weng & Chiang, 2014). That being said, the important finding of the current research is that the effect of making use of physical access to nature was significant in Study 2 (physical activity in a "greener" outdoor environment), while in Study 1 (physical activity in a "less green" environment) was not. ...
A significant number of studies have been conducted in order to explore the effects of greenery on various aspects of human functioning. However, little is known about how natural elements affect indicators of well-being at work, such as work burnout or work engagement. Two studies (Study 1, winter – Ljubljana, Slovenia; Study 2, spring – Novi Sad, Serbia) were performed in order to: 1) assess the effect of natural elements on work burnout and work engagement in two different seasons (winter and spring); 2) explore if gender moderates the effects of workplace greenery on work burnout and work engagement. The results from Study 1 (winter) showed that, after the exclusion of outliers from the dataset, neither indoor nor outdoor greenery had a significant effect on work engagement and work burnout. Contrary to this, in Study 2 (spring) outdoor greenery exerted a significant effect on both burnout and engagement, while indoor greenery did not. The moderating effect of gender was not clear and further studies on this topic are needed. Thus, the current research extends the existing literature on workplace greenery and demonstrates that natural elements can, to some extent, affect indicators of employee well-being, such as burnout and work engagement.
... However, psychological distress could further transform to health behaviours of university students. Stanton and colleagues (2020) reported a significant relationship between mental health problems (depression, anxiety, and stress) during COVID-19 and behavioural health changes (reduced physical activity participation and sleep quality, tobacco and alcohol misuse, and even self-harming or suicidal thoughts) both independently and collectively as a compound predictorOther researchers also demonstrated the association between emotional distress and actual unhealthy behaviours in general [11][12][13][14]. ...
Abstract
Background
The mental health issues due to COVID-19, such as intolerance of uncertainty (IOU), anxiety, stress, and depression, have attracted extensive attention from researchers. The challenges for Pakistani university students could be worse than developed countries due to the lack of online courses/programs and online mental health support provided by academic institutions. Therefore, the current study aims to assess the intolerance of uncertainty, depression, anxiety, and stress of Pakistani university students after the second wave of COVID-19 and the relationship among these constructs.
Methods
A convenience cross-sectional sampling method was used to collect data from university students in Pakistan between January 2021 and April 2022 via a structured online questionnaire. The Descriptive analysis focused on frequencies, percentages, mean, and standard deviation (SD) were calculated on IOU-12 and DASS-21. Covariance for the research model and confirmatory factor analyses fit indices for the IOU-12 and DASS-21 were analyzed by AMOS statistical packages.
Results
As expected, anxiety, depression, and stress persist among Pakistani university students. On average, they report mild to moderate mental health problems regarding anxiety, depression, stress, and intolerance of uncertainty. Our results indicate a strong positive relationship among the three emotional distress components - anxiety, depression, and stress. However, our results suggest no significant relationship between IOU and the three subcomponents of emotional distress (anxiety, depression, and stress).
Limitations
First, the cross-sectional survey design means we cannot conclude on the causal relations. Second, the self-report questionnaire embeds subjectivity issues. Last, the generalizability of the sample to the whole student population in Pakistan is limited, considering the sampling method.
Conclusion
This study expanded the current knowledge in the psychological health domain (intolerance of uncertainty, anxiety, depression, and stress) due to the COVID-19 pandemic. In practice, higher education institutions should further mitigate university students' mental health issues. For researchers, our findings inspire future studies to delve into the relationship between IOU and mental health issues due to COVID-19 since our findings display contrary evidence for various reasons.
... However, this literature base is limited by the lack of nuanced investigation that considers both types of exercise (i.e., adaptive and compulsive). For example, exercise-based interventions appear to be effective at reducing symptoms of anxiety in both clinical (Stubbs et al., 2017) and non-clinical (Rebar et al., 2015) samples, but whether the exercise was adaptive in nature was not measured or considered in these studies. Further, although Meyer et al. (2011) propose both body dissatisfaction and anxiety as predictors of compulsive exercise, existing research typically investigates only one construct at a time. ...
Objective:
Little is known about psychosocial variables that may be differentially associated with compulsive exercise versus adaptive exercise. The current study simultaneously examined associations of exercise identity, anxiety, and body dissatisfaction with both compulsive and adaptive exercise behaviors and investigated which construct may account for the most unique variance in compulsive and adaptive exercise. Hypotheses were that: 1) body dissatisfaction, anxiety, and exercise identity would be significantly associated with compulsive exercise and 2) exercise identity would be significantly associated with adaptive exercise.
Method:
A total of 446 individuals (50.2 % female) completed reports of compulsive exercise, adaptive exercise, body dissatisfaction, exercise identity, and anxiety via an online survey. Multiple linear regression and dominance analyses were used to test hypotheses.
Results:
Exercise identity, body dissatisfaction, and anxiety were all significantly associated with compulsive exercise. Only exercise identity and anxiety were significantly associated with adaptive exercise. Dominance analyses suggested that exercise identity accounted for the largest proportion of variance in compulsive (Dominance R2 = 0.27) and adaptive exercise (Dominance R2 = 0.45).
Conclusion:
Exercise identity emerged as the strongest predictor of both compulsive and adaptive exercise. The simultaneous presence of exercise identity, body dissatisfaction, and anxiety may contribute to high risk for engagement in compulsive exercise. Incorporating exercise identity into established eating disorder preventions and treatments may contribute to the reduction of compulsive exercise behaviors.
... 95% CI: −0.66 to −0.11] and depression [SMD = −0.50; 95% CI: −0.93 to −0.06] [40]. There may be unidentified moderators or mediators, such as gender or dyspnea and functional capacity, respectively, that may impact the relationship between anxiety, depression, and physical activity in COPD. ...
... This has urged clinical and preclinical researchers to take a more active role in exploring therapeutic alternatives. Regular physical activity has been suggested as one of the therapeutic strategies for major depression disorder [4,5]. For instance, several studies have shown that swimming exercises can reduce depression-related symptoms in experimental models [6][7][8][9][10][11]. ...
Increasing evidence shows that higher physical activity such as running and swimming exercises is associated with decreased depression-related symptoms. However, underlying mechanisms are not fully understood. This study aimed to investigate whether oxytocinergic system can mediate the antidepressant effect of swimming exercises in mice. First, male NMRI mice were subjected to swimming training for eight weeks, then animals intraperitoneally received oxytocin antagonist (L-368899) 1hour before behavioral tests. We assessed anhedonia and social behavior and behavioral despair using the sucrose preference test, social interaction test, and tail suspension test. Oxytocin levels in the brain and serum were also measured. The results showed that swimming training decreased anhedonia and behavioral despair, whereas it increased social behavior and oxytocin levels in male mice. On the other hand, a subthreshold dose of oxytocin antagonist treatment in exercised mice prevented the antidepressant effect of swimming exercise via increased anhedonia and behavioral despair and decreased social behavior compared to the swimming training group. However, the blockade of oxytocin receptors did not affect oxytocin levels in exercised mice. Overall, these findings suggest that oxytocinergic system can play a role in mediating the antidepressant-like effect of swimming training in mice.
... 13 Typically, outdoor space is used for physical activity and the mental health benefits of exercise have been well documented. 14,15 Even low levels of physical activity have the potential to improve cardiovascular health, 16,17 increase bone and muscle strength, improve sleep 18 and generate feelings of wellbeing. 19,20 Physical activity can help improve self-esteem which in turn is associated with healthy lifestyle behaviours. ...
Introduction:
Mental health problems are a considerable public health issue and spending time in nature has been promoted as a way to access a range of psychological benefits leading to the development of nature-based interventions for people with severe and enduring mental health problems. Less, however, is understood about the potential benefits and efficacy of day-to-day routine access to outdoor green and blue spaces for mental health service users.
Methods:
Using a mixed-methods design between April and October 2021, we explored the benefits and barriers to spending time outdoors with a purposive sample of mental health service users (N = 11) using qualitative interviews and an online general population survey (N = 1791). Qualitative evidence highlighted the restorative benefits of nature and identified a number of barriers associated with fears around personal safety, social anxiety, fatigue and lack of motivation. COVID-19 had also restricted access to green and blue spaces. Having social contact and support encouraged people to spend time outdoors. In the quantitative survey, self-report and standardised measures (the Patient Health Questionnaire and the Warwick-Edinburgh Wellbeing Scale) were used to assess past and current mental wellbeing.
Findings:
Statistically significant differences were found between wellbeing and the use of green and blue spaces. Those with mental health problems spent time outdoors because they: felt guilty; wanted to reduce their anxiety; or rely on someone for encouragement. Those without mental health problems endorsed more positively framed reasons including relaxation, improving physical health or getting exercise. Barriers for people with mental health problems involved safety concerns, feeling anxious and having a poor self-image. These findings give insight into motivations for an outdoor activity to help inform the design of public mental health interventions.
Conclusion:
Further work is required to improve access and safety to promote the benefits of green and blue spaces for everyone.
Patient or public contribution:
The research team included expert experienced researchers with a mental health service provider (Praxis Care) and they were involved in the development of the research idea, funding application, design, data collection, analysis, writing up and dissemination activities.
Background: There is a considerable insidiousness with innumerable unknowns about how COVID-19 of this magnitude would damage mental health. Depression is highly stigmatized, with high recurrence rates and various complications, although it is exceedingly curable and has a good prognosis. This study aims to determine the prevalence of depression and identify its factors in adolescents (10-19 years old) in Barangay Diwan, Mahayag Municipality, Zamboanga del Sur as a baseline study and reference for family management and government policies.
Method: This study utilized quantitative research of a combined descriptive and analytical design. An initial prevalence study of a 236 sample size than an unmatched case–control of 224 in sample size, 56 cases, and 168 control group. 257 adolescents were selected as participants in the study amongst the total adolescent population of 290 through stratified sampling per purok then purposive random sampling technique. A house-to-house survey was utilized to obtain the sociodemographic profile, Modified Patient Health Questionnaire – 9 (MPHQ-9), and Reason for Depression Questionnaire for Teens (RFD – A). Central tendency measurements and standard deviation distribution were utilized to determine the prevalence of depression among adolescents. Furthermore, a univariate and multivariate logistical regression was utilized to analyze the factors that increase the likelihood of an individual developing depression.
Results: Data revealed 24.12% of positive cases with a depression point prevalence of 213.79 by 2023 in Barangay Diwan, Mahayag. Factors for the likelihood of developing depression were being female (OR: 3.76, 95% CI: 1.29 – 10.93), those with financial difficulty (OR: 11.85, 95% CI: 1.64 – 85.34), family conflict (OR: 37.15, 95% CI: 2.18 – 634.20), being condemned by others (OR: 8.25, 95% CI: 1.35 – 50.52), and treated inappropriately by others (OR: 24.04, 95% CI: 2.98 – 194.37). 67.74% of those with depression have suicidal risk and 64.52% have functional impairment. The study reveals that 99% of adolescents Purok 4, 85% those who have not worked through childhood experiences, 99% have not become the person they set out to be, 77% are not liked by others, 89% are not given the respect they deserve, 90% believe it's due to their nervous system, 93% think it's genetic, and 87% are not active enough have reduced their likelihood of depression symptoms. However, 78% of those focused on negative aspects of life have a weak inferential.
Conclusion: Adolescents are highly susceptible to depression especially in Barangay Diwan with numerous physiological and psychological factors. Thus, this study recommends creating and intensifying detection, treatment, programs, and policies at the family and municipal level as well as diving further into the emotional contagion and health system analysis of depression
The objective of present study was to investigate psychological process of exercise habit from the perspective of habit strength. In study1, undergraduate students and adults answered two kinds of questionnaires assessing habit strength of exercise. The result of exploratory factor analysis showed that habit strength of exercise consisted of four factors following patterned action, negative consequences, automaticity, and cue driven. And patterned action and automaticity were strongly related to current and past involvement in exercise. In study 2, the factor structure of habit strength was compared between exercise and other health related behaviors using same scale. Exercise and walk commuting had similar structure with two factors, whereas smoking and pinball game had a single factor structure. Meanings of two factors were effortless and personality. These findings indicated that the psychological process of exercise habit is featured by decreasing burdens of practice, and increasing personal value for exercise, and we should take into account these features to facilitate habit formation. It also suggest that it could provide a new template for future research on how exercise habits are developed and maintained.
The COVID-19 crisis resulted in a notable decline in the mental and physical well-being of residents in low-cost housing, primarily due to restricted living space and limited access to recreational activities. The significance of neighborhood parks has increased in recent times due to their ability to fulfill outdoor recreational requirements, thereby promoting mental well-being, provided that the attributes of the parks meet the residents' expectations. Thus, the present research examines the characteristics of neighborhood parks that have an impact on the well-being of low-cost housing inhabitants during the period of post-COVID-19 movement limitations. The investigation utilized a qualitative research design consisting of three case studies conducted in low-cost housing areas located in Lembah Pantai, Kuala Lumpur. A purposive sampling technique was employed to select 15 participants for semi-structured interviews. Additionally, observations were carried out at various times and days to enhance the richness of the data. Thematic analysis was conducted on the interviews using ATLAS.ti v22, whereas manual analysis was performed on the field observation photographs. The research determined that the attribute of adaptability holds the highest significance, given its capacity to adjust and assimilate unforeseen disruptions, such as the COVID-19 pandemic. This study is to guide the planning and implementation of neighborhood parks in low-cost housing areas, with a focus on adapting to the post-COVID-19 criteria.
Meta-analysis is a powerful tool in sport and exercise psychology. However, it has a number of pitfalls, and some lead to ill-advised comparisons and overestimation of effects. The impetus for this research note is provided by a recent systematic review of meta-analyses that examined the correlates of sport performance and has fallen foul of some of the pitfalls. Although the systematic review potentially has great value for researchers and practitioners alike, it treats effects from correlational and intervention studies as yielding equivalent information, double-counts multiple studies, and uses an effect size for correlational studies (Cohen’s d ) that provides an extreme contrast of unclear practical relevance. These issues impact interpretability, bias, and usefulness of the findings. This methodological note explains each pitfall and illustrates use of an appropriate equivalent effect size for correlational studies (Mathur and VanderWeele’s d ) to help researchers avoid similar issues in future work.
Background
Hand eczema (HE) is a common dermatological disorder with considerable effect on the health‐related quality of life (HRQoL). The data on mental comorbidities of HE is sparse and mostly studied among selected patient groups.
Objectives
We aimed to investigate symptoms of depression and anxiety in patients with HE in general population.
Methods
Study subjects ( n = 6695) belonging to the Northern Finland Birth Cohort 1966 Study (NFBC1966) responded to an extensive health questionnaire including questions about HE. Depression and anxiety symptoms were evaluated according to the Hopkins Symptom Checklist‐25 (HSCL‐25).
Results
Having ever suffered from HE was reported by 853 (12.8%) study subjects. Symptoms scores of depression were significantly higher among ( n = 172, 20.3%) HE subjects compared with ( n = 884, 15.4%) subjects without HE (Odds ratio [OR] 1.40, 95% confidence interval [CI]: 1.17–1.68, P < 0.001). Correspondingly, symptoms scores of anxiety were also more common among ( n = 90, 10.6%) HE subjects than among ( n = 448, 7.8%) subjects without HE (OR 1.40, 95% CI: 1.10–1.78, P = 0.007). In an adjusted model, the associations remained statistically significant (OR 1.30, 95% CI: 1.08–1.57, P = 0.007 and OR 1.34, 95% CI: 1.04–1.72, P = 0.021, respectively).
Conclusions
Symptoms associated with mental health should be taken into account when managing patients with HE.
Background
Sedentary behavior among university students could negatively affect their mental health.
Objective
The aim of this study was to examine the relationship of mental health (anxiety and depression) and sedentary behavior between gender in Health Degrees at the University of Zaragoza.
Design
Cross-sectional descriptive study.
Participants
Sample of 257 University students who completed an online questionnaire.
Methods
Sedentary behavior was assessed with the SBQ questionnaire. Anxiety and depression were assessed with the GADS questionnaire. The Mann–Whitney U test and multiple linear regression models were used.
Results
In comparison to men, female students with symptoms of anxiety spend more time in total engaged in sedentary behaviors (10.56 ± 4.83) vs. (7.8 ± 3.28; p < 0.001) and mentally-passive sedentary activities [2.24 (1.57) vs. 1.15 (0.90; p < 0.005)]. Female students at risk of depression also spend more hours engaged in mentally-passive sedentary behaviors in comparison to men (8.28 ± 50.70 vs. 1.27 ± 1.02; p = 0.009).
Conclusion
Female students at risk of anxiety and/or depression spend more time engaged in sedentary activities in comparison to male students. The risk of anxiety and depression is associated with the total number of hours a day spent engaged in sedentary behaviors and with mentally passive behaviors, but not mentally active behaviors.
Internationally, there is growing attention on links between social isolation and mental health problems. Here, we use unique Australian longitudinal data to investigate associations between adult men's (n = 507; age M = 29.90, SD = 1.31) social network investments and their concurrent and subsequent mental health problems. In linear regressions, using generalised estimating equations (GEEs), we examined associations between social network investment (time with friends, network size and various activities with friends) and mental health symptoms (depression, anxiety and stress) across five timepoints. Models were adjusted for waves of outcome and potential confounders. Cross-sectionally, each social network investment variable, except for drinking with friends, was negatively associated with depressive symptoms. Men's extended friendship network size and sharing a meal with friends were negatively associated with concurrent anxiety and stress. Time spent and physical activity with friends was also negatively associated with concurrent stress. In longitudinal analyses, after adjusting for prior depressive symptoms, only the number of friends in close and extended networks remained protective against depressive symptoms 1 year later. Results did not differ by fatherhood or relationship status. Programs designed to strengthen men's investment in social networks are recommended to reduce men's depressive symptoms.
Background:
We investigated the association between cardiorespiratory fitness (CRF) and incident use of antidepressants or anxiolytics in the general adult population.
Methods:
A non-exercise prediction model was used to estimate CRF in 32,603 participants in the third wave of the Trøndelag Health Study (HUNT3; 2006-08). Data on first purchase of antidepressants and anxiolytics were obtained from the Norwegian Prescription Database. Cox regression was used to estimate hazard ratios (HRs).
Results:
Each 1- metabolic equivalent of task (MET) increase in CRF was associated with 4 % reduced risk of purchasing antidepressant or anxiolytic medication during follow-up (HR 0.96, 95 % Confidence interval [CI] 0.94-0.98). Compared to the low CRF tertile, participants in intermediate (HR 0.93, 95 % CI 0.87-0.98) and high (HR 0.92, 95 % CI 0.86-0.98) CRF tertiles had reduced risk of medication purchase. Men in intermediate and high CRF tertile had lower risk of medication purchase (intermediate HR 0.87, 95 % CI 0.79-0.96; high HR 0.87, 95 % CI 0.78-0.96). Intermediate and high CRF tertiles were associated with reduced risk of medication use for younger adults (20 to <30 years old; intermediate HR 0.74, 95 % CI 0.61-0.91, high HR 0.78, 95 % CI 0.64-0.95) and middle-aged adults (30 to <65 years old; intermediate HR 0.90, 95 % CI 0.83-0.97, high HR 0.90, 95 % CI 0.84-0.98), but not in older adults (≥65 years old).
Limitations:
Only information about medication purchase and not actual use was available.
Conclusion:
Increased CRF is associated with reduced risk of anxiolytics and antidepressants purchase, with stronger effects for men and younger adults.
Parents and caregivers who participate in regular physical activity have improved physical and mental health and can influence the physical activity behaviors of children in their care. This study aimed to assess the association between psychological distress and physical activity levels of parents/caregivers in New South Wales, Australia during different COVID‐19 restriction periods. A repeat‐cross‐sectional design was adopted. Parents/caregivers involved in a government‐led children's sport and recreation voucher program were recruited to participate in an online survey as part of the program's evaluation. In response to COVID‐19, parents and caregivers' psychological distress and physical activity levels were assessed using validated items. Binary logistic regression models were used to examine the relationship between physical activity and probable mental illness, and differences across different COVID‐19 restriction periods in 2020 and 2021. In 2020, 10,990 parents/caregivers responded to survey questions and in 2021, 17,106 parents/caregivers responded. Parents/caregivers who were physically active on 7 days per week had lower odds of reporting high psychological distress (odds ratio [OR]: 0.40, 95% confidence interval [CIs]: 0.33, 0.49) than parents/caregivers physically active on fewer days per week. In 2020 9.8% of parents/caregivers ( n = 1076) reported high psychological distress, which decreased to 8% in 2021 ( n = 1366). In 2021, parents/caregivers had lower odds of reporting high psychological distress (OR: 0.79, 95% CIs: 0.72, 0.86). Socioeconomic disadvantage negatively impacted psychological distress and physical activity levels. Australian parents and caregivers who reported high psychological distress, during and after COVID‐19 restrictions, were participating in low levels of physical activity. Greater collaboration between the mental health, and sport and recreation sectors is recommended to harness the co‐benefits of physical activity throughout parenthood, particularly in low socioeconomic areas.
هدفت هذه الدراسة المقطعية إلى التعرف على مستوى الرضا عن الحياة ومستوى الرفاهية النفسية لدى ممارسي رياضة مشي الجبال في سلطنة عُمان، كما هدفت إلى التعرف على العلاقة بين الرضا عن الحياة والرفاهية النفسية. ولتحقيق هذه الأهداف طبقت الصورة المصغرة لمقياس وورويك-إدنبره للرفاهية النفسية (SWEMWBS) ومقياس الرضا عن الحياة (SWLS) على عينة من الممارسين المنتظمين لرياضة مشي الجبال في سلطنة عُمان خلال شهر فبراير 2022. وقد تألفت العينة من 157 ممارسًا تراوحت أعمارهم بين 24 – 58 (م = 38.7، ع = 9.1) يمثلون قرابة 40% من مجمل ممارسي هذه الرياضة من الذكور في سلطنة عمان. وقد أظهرت النتائج أن ممارسي رياضة مشي الجبال في سلطنة عمان لديهم مستويات مرتفعة من الرضا عن الحياة ويتمتعون بمستويات عالية من الرفاهية النفسية. وكشفت النتائج أيضا بأن مستوى الرضا عن الحياة يعتبر عاملًا مهمًا في التنبؤ بمستوى الرفاهية النفسية لدى ممارسي رياضة مشي الجبال. وبناء على ما توصلت إليه هذه الدراسة من نتائج، فإنه يوصى بأن تقوم الجهات الرسمية المعنية بتقديم كل الدعم لرياضة مشي الجبال في سلطنة عمان باعتبارها وسيلة لتعزيز الرفاهية النفسية والرضا العام عن الحياة.
Background:
There is evidence for e-Health interventions for full-blown depression. Little is known regarding commonly untreated subthreshold depression in primary care. This randomized controlled multi-centre trial assessed reach and two-year-effects of a proactive e-Health intervention (ActiLife) for patients with subthreshold depression.
Methods:
Primary care and hospital patients were screened for subthreshold depression. Over 6 months, ActiLife participants received three individualized feedback letters and weekly messages promoting self-help strategies against depression, e.g., dealing with unhelpful thoughts or behavioural activation. The primary outcome depressive symptom severity (Patient Health Questionnaire;PHQ-8) and secondary outcomes were assessed 6, 12 and 24 months.
Results:
Of those invited, n = 618(49.2 %) agreed to participate. Of them, 456 completed the baseline interview and were randomized to ActiLife (n = 227) or assessment only (n = 226). Generalised estimation equation analyses adjusting for site, setting and baseline depression revealed that depressive symptom severity declined over time, with no significant group differences at 6 (mean difference = 0.47 points; d = 0.12) and 24 months (mean difference = -0.05 points; d = -0.01). Potential adverse effects were observed at 12 months, with higher depressive symptom severity for ActiLife than control participants (mean difference = 1.33 points; d = 0.35). No significant differences in rates of reliable deterioration or reliable improvement of depressive symptoms were observed. ActiLife increased applied self-help strategies at 6 (mean difference = 0.32; d = 0.27) and 24 months (mean difference = 0.22; d = 0.19), but not at 12 months (mean difference = 0.18; d = 0.15).
Limitations:
Self-report measures and lack of information on patients' mental health treatment.
Discussion:
ActiLife yielded satisfactory reach and increased the use of self-help strategies. Data were inconclusive in terms of depressive symptom changes.
Psychosis research has traditionally focused on vulnerability and the detrimental outcomes of risk exposure. However, there is substantial variability in psychological and functional outcomes for those at risk for psychosis, even among individuals at high risk. Comparatively little work has highlighted the factors associated with resilience and the processes that might avert serious mental illness and promote positive outcomes. In this Review, we first discuss the prevailing risk-based approach to psychosis. We then outline a resilience-based approach by defining multisystemic mental health resilience and considering what constitutes a positive outcome. We examine evidence of biological, psychological, social and environmental protective and promotive factors that might confer resilience in the context of psychosis risk. A greater understanding of the factors and processes implicated in resilience has the potential to inform psychosis intervention and prevention efforts at multiple levels, including individuals, institutions and policy-making.
Background:
Greater depression has been linked to increased smoking rates. However, the mechanisms underlying this association are not fully understood. It is possible that high perceived neighborhood cohesion may serve as one such mechanism given its associations with decreased depression and smoking. Having increased levels of depression likely impacts one's perceptions of neighborhood cohesion, which could lead to further increases in depression and a need to manage these symptoms via cigarette smoking. As a first test of this theory, the current study examined the effect of neighborhood cohesion on the association between depressive symptoms and smoking frequency and quantity among past 30-day cigarette smokers.
Methods:
Participants were 201 combustible cigarette smokers (Mage = 48.33, SD = 11.64; 63.2% female; 68.2% White) who completed self-report measures as part of a larger study of environmental influences on cardiac health.
Results:
Greater depressive symptoms were associated with lower levels of perceived neighborhood cohesion, and there was a significant indirect effect of greater depressive symptoms on heavier smoking through decreased neighborhood cohesion (b = .07, SE = .04, 95% CI [.003, .15]). There was no significant indirect effect for daily smoking.
Conclusion:
These results suggest that neighborhood cohesion is an important contextual factor that serves as one explanatory mechanism for the well-established relationship between depression and smoking quantity. Thus, there may be utility in implementing interventions focused on increasing neighborhood cohesion as a way to decrease smoking behavior.
Physical inactivity is a ubiquitous global issue and is associated with the development of many common and costly chronic conditions. There are many national and international guidelines around physical activity and exercise that consistently recommend that our entire population, from young children to older adults, needs to move more each and every day. Physical activity and exercise plans should include being less sedentary along with a mix of aerobic, resistance, and balance activities throughout the day and week. Recommendations can be tailored by age and comorbidity. The evidence for adoption of regular physical activity is very compelling: reductions in the incidence and improved management of chronic diseases like diabetes, heart disease, certain cancers, mental health issues, and overall improved survival. Successful behavior change can be complex. Addressing knowledge gaps about the importance of physical activity and understanding of individual circumstances, motivators, and barriers is key. Designing physical activity interventions requires thoughtful planning and application of behavior change models appropriate to the setting and population. Once implemented, the effects of the intervention should be evaluated through quantification of fitness measures and physical activity patterns. New technologies can be very helpful in these assessments.KeywordsPhysical activityExerciseFitnessBehavior changePhysical activity guidelinesChronic diseaseMotivationBarriersPhysical activity measurement
OBJECTIVE: To synthesize recent evidence from systematic and comprehensive reviews on the effectiveness of universal and selective child maltreatment prevention interventions, evaluate the methodological quality of the reviews and outcome evaluation studies they are based on, and map the geographical distribution of the evidence. METHODS: A systematic review of reviews was conducted. The quality of the systematic reviews was evaluated with a tool for the assessment of multiple systematic reviews (AMSTAR), and the quality of the outcome evaluations was assessed using indicators of internal validity and of the construct validity of outcome measures. FINDINGS: The review focused on seven main types of interventions: home visiting, parent education, child sex abuse prevention, abusive head trauma prevention, multi-component interventions, media-based interventions, and support and mutual aid groups. Four of the seven - home-visiting, parent education, abusive head trauma prevention and multi-component interventions - show promise in preventing actual child maltreatment. Three of them - home visiting, parent education and child sexual abuse prevention - appear effective in reducing risk factors for child maltreatment, although these conclusions are tentative due to the methodological shortcomings of the reviews and outcome evaluation studies they draw on. An analysis of the geographical distribution of the evidence shows that outcome evaluations of child maltreatment prevention interventions are exceedingly rare in low- and middle-income countries and make up only 0.6% of the total evidence base. CONCLUSION: Evidence for the effectiveness of four of the seven main types of interventions for preventing child maltreatment is promising, although it is weakened by methodological problems and paucity of outcome evaluations from low- and middle-income countries.
This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2013, Issue 12 http://www.thecochranelibrary.com Buprenorphine for treating cancer pain (Protocol)
Implementing theory-based interventions is an effective way to impact physical activity (PA) practice among the population. This meta-analysis aimed to (a) determine the global effect of theory-based randomised controlled trials (RCTs) dedicated to the promotion of PA among adults, (b) measure the actual efficacy of interventions against their theoretical objectives, and (c) compare the efficacy of single- versus combined-theory interventions. A systematic search through databases and review articles was carried out. Our results show that theory-based interventions (n = 82) significantly impact the PA behaviour of participants (d = 0.31, 95% CI [0.24, 0.37]). While moderation analyses revealed no efficacy difference between theories, interventions based on a single theory (d = 0.35; 95% CI [0.26, 0.43]) reported a higher impact on PA behaviour than those based on a combination of theories (d = 0.21; 95% CI [0.11, 0.32]). In spite of the global positive effect of theory-based interventions on PA behaviour, further research is required to better identify the specificities, overlaps or complementarities of the components of interventions based on relevant theories.
Background
To review the prevalence and impact of generalized anxiety disorder (GAD) below the diagnostic threshold and explore its treatment needs in times of scarce healthcare resources.
Methods
A systematic literature search was conducted until January 2013 using PUBMED/MEDLINE, PSYCINFO, EMBASE and reference lists to identify epidemiological studies of subthreshold GAD, i.e. GAD symptoms that do not reach the current thresholds of DSM-III-R, DSM-IV or ICD-10. Quality of all included studies was assessed and median prevalences of subthreshold GAD were calculated for different subpopulations.
Results
Inclusion criteria led to 15 high-quality and 3 low-quality epidemiological studies with a total of 48,214 participants being reviewed. Whilst GAD proved to be a common mental health disorder, the prevalence for subthreshold GAD was twice that for the full syndrome. Subthreshold GAD is typically persistent, causing considerably more suffering and impairment in psychosocial and work functioning, benzodiazepine and primary health care use, than in non-anxious individuals. Subthreshold GAD can also increase the risk of onset and worsen the course of a range of comorbid mental health, pain and somatic disorders; further increasing costs. Results are robust against bias due to low study quality.
Conclusions
Subthreshold GAD is a common, recurrent and impairing disease with verifiable morbidity that claims significant healthcare resources. As such, it should receive additional research and clinical attention.
To determine effects of physical activity on depressive symptoms (primary objective), symptoms of schizophrenia, anthropometric measures, aerobic capacity, and quality of life (secondary objectives) in people with mental illness and explore between-study heterogeneity.
MEDLINE, Cochrane Controlled Trials Register, PsycINFO, CINAHL, Embase, and the Physiotherapy Evidence Database (PEDro) were searched from earliest record to 2013.
Randomized controlled trials of adults with a DSM-IV-TR, ICD-10, or clinician-confirmed diagnosis of a mental illness other than dysthymia or eating disorders were selected. Interventions included exercise programs, exercise counseling, lifestyle interventions, tai chi, or physical yoga. Study methodological quality and intervention compliance with American College of Sports Medicine (ACSM) guidelines were also assessed.
Two investigators extracted data. Data were pooled using random-effects meta-analysis. Meta-regression was used to examine sources of between-study heterogeneity.
Thirty-nine eligible trials were identified. The primary meta-analysis found a large effect of physical activity on depressive symptoms (n = 20; standardized mean difference (SMD) = 0.80). The effect size in trial interventions that met ACSM guidelines for aerobic exercise did not differ significantly from those that did not meet these guidelines. The effect for trials with higher methodological quality was smaller than that observed for trials with lower methodological quality (SMD = 0.39 vs 1.35); however, the difference was not statistically significant. A large effect was found for schizophrenia symptoms (SMD = 1.0), a small effect was found for anthropometry (SMD = 0.24), and moderate effects were found for aerobic capacity (SMD = 0.63) and quality of life (SMD = 0.64).
Physical activity reduced depressive symptoms in people with mental illness. Larger effects were seen in studies of poorer methodological quality. Physical activity reduced symptoms of schizophrenia and improved anthropometric measures, aerobic capacity, and quality of life among people with mental illness.
PROSPERO registration #CRD42012002012.
An increasing number of studies have documented the effectiveness of qigong exercise in helping people reduce psychological stress and anxiety, but there is a scarcity of systematic reviews evaluating evidence from randomized controlled trials (RCTs) conducted among healthy subjects.
Thirteen databases were searched for RCTs from their inception through June 2013. Effects of qigong exercise were pooled across trials. Standardized mean differences (SMDs) were calculated for the pooled effects. Heterogeneity was assessed using the I2 test. The risk of bias was assessed using the Cochrane criteria.
Seven RCTs met the inclusion criteria. Two RCTs suggested that qigong exercise immediately relieved anxiety among healthy adults, compared to lecture attendance and structured movements only. Four RCTs suggested qigong exercise relieved anxiety (pooled SMD = -0.75; 95% CI, -1.11 to -0.40), and three RCTs suggested that qigong exercise reduced stress (pooled SMD = -0.88; 95% CI, -1.22 to -0.55) among healthy subjects following one to three months of qigong practice, compared to wait-list controls.
The available evidence suggests that qigong exercise reduces stress and anxiety in healthy adults. However, given the limited number of RCTs and their methodological flaws, further rigorously designed RCTs are needed.
The neuroscience of exercise is a growing research area that is dedicated to furthering our understanding of the effects that exercise has on mental health and athletic performance. The present study examined three specific topics: (1) the relationship between exercise and mental disorders (e.g. major depressive disorder, dementia and Parkinson's disease), (2) the effects of exercise on the mood and mental health of athletes, and (3) the possible neurobiological mechanisms that mediate the effects of exercise. Positive responses to regular physical exercise, such as enhanced functional capacity, increased autonomy and improved self-esteem, are frequently described in the recent literature, and these responses are all good reasons for recommending regular exercise. In addition, physical exercise may improve both mood and adherence to an exercise program in healthy individuals and might modulate both the performance and mental health of athletes. Exercise is associated with the increased synthesis and release of both neurotransmitters and neurotrophic factors, and these increases may be associated with neurogenesis, angiogenesis and neuroplasticity. This review is a call-to-action that urges researchers to consider the importance of understanding the neuroscience of physical exercise and its contributions to sports science.
Although the association between depression and excess mortality has been well established, it is not clear whether this is greater in major depression than in subthreshold depression.
To compare excess mortality in major depression with that in subthreshold depression.
We searched bibliographic databases and included prospective studies in which both major and subthreshold depression were examined at baseline and mortality was measured at follow-up.
A total of 22 studies were included. People with major depression had a somewhat increased chance of dying earlier than people with subthreshold depression but this difference was not significant, although there was a trend (relative risk 1.13, 95% CI 0.98-1.30, P = 0.1). The population attributable fraction was 7% for major depression and an additional 7% for subthreshold depression.
Although excess mortality may be somewhat higher in major than in subthreshold depression, the difference is small and the overall impact on excess mortality is comparable.
Funnel plots, and tests for funnel plot asymmetry, have been widely used to examine bias in the results of meta-analyses. Funnel plot asymmetry should not be equated with publication bias, because it has a number of other possible causes. This article describes how to interpret funnel plot asymmetry, recommends appropriate tests, and explains the implications for choice of meta-analysis modelThe 1997 paper describing the test for funnel plot asymmetry proposed by Egger et al 1 is one of the most cited articles in the history of BMJ.1 Despite the recommendations contained in this and subsequent papers,2 3 funnel plot asymmetry is often, wrongly, equated with publication or other reporting biases. The use and appropriate interpretation of funnel plots and tests for funnel plot asymmetry have been controversial because of questions about statistical validity,4 disputes over appropriate interpretation,3 5 6 and low power of the tests.2This article recommends how to examine and interpret funnel plot asymmetry (also known as small study effects2) in meta-analyses of randomised controlled trials. The recommendations are based on a detailed MEDLINE review of literature published up to 2007 and discussions among methodologists, who extended and adapted guidance previously summarised in the Cochrane Handbook for Systematic Reviews of Interventions.7What is a funnel plot?A funnel plot is a scatter plot of the effect estimates from individual studies against some measure of each study’s size or precision. The standard error of the effect estimate is often chosen as the measure of study size and plotted on the vertical axis8 with a reversed scale that places the larger, most powerful studies towards the top. The effect estimates from smaller studies should scatter more widely at the bottom, with the spread narrowing among larger studies.9 In the absence of bias and between study heterogeneity, the scatter will be due to sampling variation alone and the plot will resemble a symmetrical inverted funnel (fig 1⇓). A triangle centred on a fixed effect summary estimate and extending 1.96 standard errors either side will include about 95% of studies if no bias is present and the fixed effect assumption (that the true treatment effect is the same in each study) is valid. The appendix on bmj.com discusses choice of axis in funnel plots.View larger version:In a new windowDownload as PowerPoint SlideFig 1 Example of symmetrical funnel plot. The outer dashed lines indicate the triangular region within which 95% of studies are expected to lie in the absence of both biases and heterogeneity (fixed effect summary log odds ratio±1.96×standard error of summary log odds ratio). The solid vertical line corresponds to no intervention effectImplications of heterogeneity, reporting bias, and chance Heterogeneity, reporting bias, and chance may all lead to asymmetry or other shapes in funnel plots (box). Funnel plot asymmetry may also be an artefact of the choice of statistics being plotted (see appendix). The presence of any shape in a funnel plot is contingent on the studies having a range of standard errors, since otherwise they would lie on a horizontal line.Box 1: Possible sources of asymmetry in funnel plots (adapted from Egger et al1)Reporting biasesPublication bias: Delayed publication (also known as time lag or pipeline) bias Location biases (eg, language bias, citation bias, multiple publication bias)Selective outcome reportingSelective analysis reportingPoor methodological quality leading to spuriously inflated effects in smaller studiesPoor methodological designInadequate analysisFraudTrue heterogeneitySize of effect differs according to study size (eg, because of differences in the intensity of interventions or in underlying risk between studies of different sizes)ArtefactualIn some circumstances, sampling variation can lead to an association between the intervention effect and its standard errorChanceAsymmetry may occur by chance, which motivates the use of asymmetry testsHeterogeneityStatistical heterogeneity refers to differences between study results beyond those attributable to chance. It may arise because of clinical differences between studies (for example, setting, types of participants, or implementation of the intervention) or methodological differences (such as extent of control over bias). A random effects model is often used to incorporate heterogeneity in meta-analyses. If the heterogeneity fits with the assumptions of this model, a funnel plot will be symmetrical but with additional horizontal scatter. If heterogeneity is large it may overwhelm the sampling error, so that the plot appears cylindrical.Heterogeneity will lead to funnel plot asymmetry if it induces a correlation between study sizes and intervention effects.5 For example, substantial benefit may be seen only in high risk patients, and these may be preferentially included in early, small studies.10 Or the intervention may have been implemented less thoroughly in larger studies, resulting in smaller effect estimates compared with smaller studies.11Figure 2⇓ shows funnel plot asymmetry arising from heterogeneity that is due entirely to there being three distinct subgroups of studies, each with a different intervention effect.12 The separate funnels for each subgroup are symmetrical. Unfortunately, in practice, important sources of heterogeneity are often unknown.View larger version:In a new windowDownload as PowerPoint SlideFig 2 Illustration of funnel plot asymmetry due to heterogeneity, in the form of three distinct subgroups of studies. Funnel plot including all studies (top left) shows clear asymmetry (P<0.001 from Egger test for funnel plot asymmetry). P values for each subgroup are all >0.49.Differences in methodological quality may also cause heterogeneity and lead to funnel plot asymmetry. Smaller studies tend to be conducted and analysed with less methodological rigour than larger studies,13 and trials of lower quality also tend to show larger intervention effects.14 15Reporting biasReporting biases arise when the dissemination of research findings is influenced by the nature and direction of results. Statistically significant “positive” results are more likely to be published, published rapidly, published in English, published more than once, published in high impact journals, and cited by others.16 17 18 19 Data that would lead to negative results may be filtered, manipulated, or presented in such a way that they become positive.14 20 Reporting biases can have three types of consequence for a meta-analysis:A systematic review may fail to locate an eligible study because all information about it is suppressed or hard to find (publication bias) A located study may not provide usable data for the outcome of interest because the study authors did not consider the result sufficiently interesting (selective outcome reporting) A located study may provide biased results for some outcome—for example, by presenting the result with the smallest P value or largest effect estimate after trying several analysis methods (selective analysis reporting).These biases may cause funnel plot asymmetry if statistically significant results suggesting a beneficial effect are more likely to be published than non-significant results. Such asymmetry may be exaggerated if there is a further tendency for smaller studies to be more prone to selective suppression of results than larger studies. This is often assumed to be the case for randomised trials. For instance, it is probably more difficult to make a large study disappear without trace, while a small study can easily be lost in a file drawer.21 The same may apply to specific outcomes—for example, it is difficult not to report on mortality or myocardial infarction if these are outcomes of a large study. Smaller studies have more sampling error in their effect estimates. Thus even though the risk of a false positive significant finding is the same, multiple analyses are more likely to yield a large effect estimate that may seem worth publishing. However, biases may not act this way in real life; funnel plots could be symmetrical even in the presence of publication bias or selective outcome reporting19 22—for example, if the published findings point to effects in different directions but unreported results indicate neither direction. Alternatively, bias may have affected few studies and therefore not cause glaring asymmetry.ChanceThe role of chance is critical for interpretation of funnel plots because most meta-analyses of randomised trials in healthcare contain few studies.2 Investigations of relations across studies in a meta-analysis are seriously prone to false positive findings when there is a small number of studies and heterogeneity across studies,23 and this may affect funnel plot symmetry.Interpreting funnel plot asymmetryAuthors of systematic reviews should distinguish between possible reasons for funnel plot asymmetry (box 1). Knowledge of the intervention, and the circumstances in which it was implemented in different studies, can help identify causes of asymmetry in funnel plots, which should also be interpreted in the context of susceptibility to biases of research in the field of interest. Potential conflicts of interest, whether outcomes and analyses have been standardised, and extent of trial registration may need to be considered. For example, studies of antidepressants generate substantial conflicts of interest because the drugs generate vast sales revenues. Furthermore, there are hundreds of outcome scales, analyses can be very flexible, and trial registration was uncommon until recently.24 Conversely, in a prospective meta-analysis where all data are included and all analyses fully standardised and conducted according to a predetermined protocol, publication or reporting biases cannot exist. Reporting bias is therefore more likely to be a cause of an asymmetric plot in the first situation than in the second.Terrin et al found that researchers were poor at identifying publication bias from funnel plots.5 Including contour lines corresponding to perceived milestones of statistical significance (P=0.01, 0.05, 0.1, etc) may aid visual interpretation.25 If studies seem to be missing in areas of non-significance (fig 3⇓, top) then asymmetry may be due to reporting bias, although other explanations should still be considered. If the supposed missing studies are in areas of higher significance or in a direction likely to be considered desirable to their authors (fig 3⇓, bottom), asymmetry is probably due to factors other than reporting bias. View larger version:In a new windowDownload as PowerPoint SlideFig 3 Contour enhanced funnel plots. In the top diagram there is a suggestion of missing studies in the middle and right of the plot, broadly in the white area of non-significance, making publication bias plausible. In the bottom diagram there is a suggestion of missing studies on the bottom left hand side of the plot. Since most of this area contains regions of high significance, publication bias is unlikely to be the underlying cause of asymmetryStatistical tests for funnel plot asymmetryA test for funnel plot asymmetry (sometimes referred to as a test for small study effects) examines whether the association between estimated intervention effects and a measure of study size is greater than might be expected to occur by chance. These tests typically have low power, so even when a test does not provide evidence of asymmetry, bias cannot be excluded. For outcomes measured on a continuous scale a test based on a weighted linear regression of the effect estimates on their standard errors is straightforward.1 When outcomes are dichotomous and intervention effects are expressed as odds ratios, this corresponds to an inverse variance weighted linear regression of the log odds ratio on its standard error.2 Unfortunately, there are statistical problems because the standard error of the log odds ratio is mathematically linked to the size of the odds ratio, even in the absence of small study effects.2 4 Many authors have therefore proposed alternative tests (see appendix on bmj.com).4 26 27 28Because it is impossible to know the precise mechanism(s) leading to funnel plot asymmetry, simulation studies (in which tests are evaluated on large numbers of computer generated datasets) are required to evaluate test characteristics. Most have examined a range of assumptions about the extent of reporting bias by selectively removing studies from simulated datasets.26 27 28 After reviewing the results of these studies, and based on theoretical considerations, we formulated recommendations on testing for funnel plot asymmetry (box 2). The appendix describes the proposed tests, explains the reasons that some were not recommended, and discusses funnel plots for intervention effects measured as risk ratios, risk differences, and standardised mean differences. Our recommendations imply that tests for funnel plot asymmetry should be used in only a minority of meta-analyses.29Box 2: Recommendations on testing for funnel plot asymmetryAll types of outcomeAs a rule of thumb, tests for funnel plot asymmetry should not be used when there are fewer than 10 studies in the meta-analysis because test power is usually too low to distinguish chance from real asymmetry. (The lower the power of a test, the higher the proportion of “statistically significant” results in which there is in reality no association between study size and intervention effects). In some situations—for example, when there is substantial heterogeneity—the minimum number of studies may be substantially more than 10Test results should be interpreted in the context of visual inspection of funnel plots— for example, are there studies with markedly different intervention effect estimates or studies that are highly influential in the asymmetry test? Even if an asymmetry test is statistically significant, publication bias can probably be excluded if small studies tend to lead to lower estimates of benefit than larger studies or if there are no studies with significant resultsWhen there is evidence of funnel plot asymmetry, publication bias is only one possible explanation (see box 1)As far as possible, testing strategy should be specified in advance: choice of test may depend on the degree of heterogeneity observed. Applying and reporting many tests is discouraged: if more than one test is used, all test results should be reported Tests for funnel plot asymmetry should not be used if the standard errors of the intervention effect estimates are all similar (the studies are of similar sizes)Continuous outcomes with intervention effects measured as mean differencesThe test proposed by Egger et al may be used to test for funnel plot asymmetry.1 There is no reason to prefer more recently proposed tests, although their relative advantages and disadvantages have not been formally examined. General considerations suggest that the power will be greater than for dichotomous outcomes but that use of the test with substantially fewer than 10 studies would be unwiseDichotomous outcomes with intervention effects measured as odds ratiosThe tests proposed by Harbord et al26 and Peters et al27 avoid the mathematical association between the log odds ratio and its standard error when there is a substantial intervention effect while retaining power compared with alternative tests. However, false positive results may still occur if there is substantial between study heterogeneityIf there is substantial between study heterogeneity (the estimated heterogeneity variance of log odds ratios, τ2, is >0.1) only the arcsine test including random effects, proposed by Rücker et al, has been shown to work reasonably well.28 However, it is slightly conservative in the absence of heterogeneity and its interpretation is less familiar than for other tests because it is based on an arcsine transformation.When τ2 is <0.1, one of the tests proposed by Harbord et al,26 Peters et al,27 or Rücker et al28 can be used. Test performance generally deteriorates as τ2 increases.Funnel plots and meta-analysis modelsFixed and random effects modelsFunnel plots can help guide choice of meta-analysis method. Random effects meta-analyses weight studies relatively more equally than fixed effect analyses by incorporating the between study variance into the denominator of each weight. If effect estimates are related to standard errors (funnel plot asymmetry), the random effects estimate will be pulled more towards findings from smaller studies than the fixed effect estimate will be. Random effects models can thus have undesirable consequences and are not always conservative.30The trials of intravenous magnesium after myocardial infarction provide an extreme example of the differences between fixed and random effects analyses that can arise in the presence of funnel plot asymmetry.31 Beneficial effects on mortality, found in a meta-analysis of small studies,32 were subsequently contradicted when the very large ISIS-4 study found no evidence of benefit.33 A contour enhanced funnel plot (fig 4⇓) gives a clear visual impression of asymmetry, which is confirmed by small P values from the Harbord and Peters tests (P<0.001 and P=0.002 respectively).View larger version:In a new windowDownload as PowerPoint SlideFig 4 Contour enhanced funnel plot for trials of the effect of intravenous magnesium on mortality after myocardial infarctionFigure 5⇓ shows that in a fixed effect analysis ISIS-4 receives 90% of the weight, and there is no evidence of a beneficial effect. However, there is clear evidence of between study heterogeneity (P<0.001, I2=68%), and in a random effects analysis the small studies dominate so that intervention appears beneficial. To interpret the accumulated evidence, it is necessary to make a judgment about the validity or relevance of the combined evidence from the smaller studies compared with that from ISIS-4. The contour enhanced funnel plot suggests that publication bias does not completely explain the asymmetry, since many of the beneficial effects reported from smaller studies were not significant. Plausible explanations for these results are that methodological flaws in the smaller studies, or changes in the standard of care (widespread adoption of treatments such as aspirin, heparin, and thrombolysis), led to apparent beneficial effects of magnesium. This belief was reinforced by the subsequent publication of the MAGIC trial, in which magnesium added to these treatments which also found no evidence of benefit on mortality (odds ratio 1.0, 95% confidence interval 0.8 to 1.1).34View larger version:In a new windowDownload as PowerPoint SlideFig 5 Comparison of fixed and random effects meta-analytical estimates of the effect of intravenous magnesium on mortality after myocardial infarctionWe recommend that when review authors are concerned about funnel plot asymmetry in a meta-analysis with evidence of between study heterogeneity, they should compare the fixed and random effects estimates of the intervention effect. If the random effects estimate is more beneficial, authors should consider whether it is plausible that the intervention is more effective in smaller studies. Formal investigations of heterogeneity of effects may reveal explanations for funnel plot asymmetry, in which case presentation of results should focus on these. If larger studies tend to be methodologically superior to smaller studies, or were conducted in circumstances more typical of the use of the intervention in practice, it may be appropriate to include only larger studies in the meta-analysis.Extrapolation of a funnel plot regression lineAn assumed relation between susceptibility to bias and study size can be exploited by extrapolating within a funnel plot. When funnel plot asymmetry is due to bias rather than substantive heterogeneity, it is usually assumed that results from larger studies are more believable than those from smaller studies because they are less susceptible to methodological flaws or reporting biases. Extrapolating a regression line on a funnel plot to minimum bias (maximum sample size) produces a meta-analytical estimate that can be regarded as corrected for such biases.35 36 37 However, because it is difficult to distinguish between asymmetry due to bias and asymmetry due to heterogeneity or chance, the broad applicability of such approaches is uncertain. Further approaches to adjusting for publication bias are described and discussed in the appendix.DiscussionReporting biases are one of a number of possible explanations for the associations between study size and effect size that are displayed in asymmetric funnel plots. Examining and testing for funnel plot asymmetry, when appropriate, is an important means of addressing bias in meta-analyses, but the multiple causes of asymmetry and limited power of asymmetry tests mean that other ways to address reporting biases are also of importance. Searches of online trial registries can identify unpublished trials, although they do not currently guarantee access to trial protocols and results. When there are no registered but unpublished trials, and the outcome of interest is reported by all trials, restricting meta-analyses to registered trials should preclude publication bias. Recent comparisons of results of published trials with those submitted for regulatory approval have also provided clear evidence of reporting bias.38 39 Methods for dealing with selective reporting of outcomes have been described elsewhere. 40Our recommendations apply to meta-analyses of randomised trials, and their applicability in other contexts such as meta-analyses of epidemiological or diagnostic test studies is unclear.41 The performance of tests for funnel plot asymmetry in these contexts is likely to differ from that in meta-analyses of randomised trials. Further factors, such as confounding and precision of measurements, may cause a relation between study size and effect estimates in observational studies. For example, large studies based on routinely collected data might not fully control confounding compared with smaller, purpose designed studies that collected a wide range of potential confounding variables. Alternatively, larger studies might use self reported exposure levels, which are more error prone, while smaller studies used precise measuring instruments. However, simulation studies have usually not considered such situations. An exception is for diagnostic studies, where large imbalances in group sizes and substantial odds ratios lead to poor performance of some tests: that proposed by Deeks et al was designed for use in this context.4Summary points Inferences on the presence of bias or heterogeneity should consider different causes of funnel plot asymmetry and should not be based on visual inspection of funnel plots aloneThey should be informed by contextual factors, including the plausibility of publication bias as an explanation for the asymmetryTesting for funnel plot asymmetry should follow the recommendations detailed in this articleThe fixed and random effects estimates of the intervention effect should be compared when funnel plot asymmetry exists in a meta-analysis with between study heterogeneityNotesCite this as: BMJ 2011;342:d4002FootnotesContributors: All authors contributed to the drafting and editing of the manuscript. DA, JC, JD, RMH, JPTH, JPAI, DRJ, DM, JP, GR, JACS, AJS and JT contributed to the chapter in the Cochrane Handbook for Systematic Reviews of Interventions on which our recommendations on testing for funnel plot asymmetry are based. JACS will act as guarantor.Funding: Funded in part by the Cochrane Collaboration Bias Methods Group, which receives infrastructure funding as part of a commitment by the Canadian Institutes of Health Research (CIHR) and the Canadian Agency for Drugs and Technologies in Health (CADTH) to fund Canadian based Cochrane entities. This supports dissemination activities, web hosting, travel, training, workshops and a full time coordinator position. JPTH was funded by MRC Grant U.1052.00.011. DGA is supported by Cancer Research UK. GR was supported by a grant from Deutsche Forschungsgemeinschaft (FOR 534 Schw 821/2-2).Competing interests. JC, JJD, SD, RMH, JPAI, DRJ, PM, JP, GR, GS, JACS and AJS are all authors on papers proposing tests for funnel plot asymmetry, but have no commercial interests in the use of these tests. All authors have completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that they have no financial or non-financial interests that may be relevant to the submitted work.Provenance and peer review: Not commissioned; externally peer reviewed.References↵Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ1997;315:629-34.OpenUrlFREE Full Text↵Sterne JAC, Gavaghan D, Egger M. Publication and related bias in meta-analysis: power of statistical tests and prevalence in the literature. J Clin Epidemiol2000;53:1119-29.OpenUrlCrossRefMedlineWeb of Science↵Lau J, Ioannidis JP, Terrin N, Schmid CH, Olkin I. The case of the misleading funnel plot. 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Background
A systematic review is used to investigate the best available evidence of clinical safety and effectiveness of healthcare intervention. This requires methodological rigor in order to minimize bias and random error. The purpose of this study is to assess the quality of systematic reviews or meta-analyses for nursing interventions conducted by Korean researchers.
Methods
We searched electronic databases from 1950 to July 2010, including ovidMEDLINE, ovidEMBASE, and Korean databases, including KoreaMed, Korean Medical Database, and Korean studies Information Service System etc. Two reviewers independently screened and selected all references, and assessed the quality of systematic reviews or meta-analyses using the “Assessment of Multiple Systematic Reviews" (AMSTAR) tool.
Results
Twenty two systematic reviews or meta-analyses were included in this study. The median overall score (out of 11) for included reviews was 5 (range 2–11) and the mean overall score for AMSTAR was 4.7 (95% confidence interval 3.8-5.7). Nine out of 22 reviews were rated as low quality (AMSTAR score 0–4), 11 were rated as moderate quality (AMSTAR score 5–8), and two reviews were categorized as high quality (AMSTAR score 9–11).
Conclusions
The methodological quality of published reviews on nursing interventions conducted by Korean reviewers was assessed as low to moderate. In order to use the best available evidence in clinical decision making, reviewers should conduct systematic reviews or meta- analyses using rigorous research methods.
Behavioural and psychological symptoms of dementia (BPS) include depressive symptoms, anxiety, apathy, sleep problems, irritability, psychosis, wandering, elation and agitation, and are common in the non-demented and demented population.
We have undertaken a systematic review of reviews to give a broad overview of the prevalence, course, biological and psychosocial associations, care and outcomes of BPS in the older or demented population, and highlight limitations and gaps in existing research. Embase and Medline were searched for systematic reviews using search terms for BPS, dementia and ageing.
Thirty-six reviews were identified. Most investigated the prevalence or course of symptoms, while few reviewed the effects of BPS on outcomes and care. BPS were found to occur in non-demented, cognitively impaired and demented people, but reported estimates vary widely. Biological factors associated with BPS in dementia include genetic factors, homocysteine levels and vascular changes. Psychosocial factors increase risk of BPS; however, across studies and between symptoms findings are inconsistent. BPS have been associated with burden of care, caregiver's general health and caregiver depression scores, but findings are limited regarding institutionalisation, quality of life and disease outcome.
Limitations of reviews include a lack of high quality reviews, particularly of BPS other than depression. Limitations of original studies include heterogeneity in study design particularly related to measurement of BPS, level of cognitive impairment, population characteristics and participant recruitment. It is our recommendation that more high quality reviews, including all BPS, and longitudinal studies with larger sample sizes that use frequently cited instruments to measure BPS are undertaken. A better understanding of the risk factors and course of BPS will inform prevention, treatment and management and possibly improve quality of life for the patients and their carers.
BACKGROUND: Past episodes of depressive or anxiety disorders and subthreshold symptoms have both been reported to predict the occurrence of depressive or anxiety disorders. It is unclear to what extent the two factors interact or predict these disorders independently. AIMS: To examine the extent to which history, subthreshold symptoms and their combination predict the occurrence of depressive (major depressive disorder, dysthymia) or anxiety disorders (social phobia, panic disorder, agoraphobia, generalised anxiety disorder) over a 2-year period. METHOD: This was a prospective cohort study with 1167 participants: the Netherlands Study of Depression and Anxiety. Anxiety and depressive disorders were determined with the Composite International Diagnostic Interview, subthreshold symptoms were determined with the Inventory of Depressive Symptomatology-Self Report and the Beck Anxiety Inventory. RESULTS: Occurrence of depressive disorder was best predicted by a combination of a history of depression and subthreshold symptoms, followed by either one alone. Occurrence of anxiety disorder was best predicted by both a combination of a history of anxiety disorder and subthreshold symptoms and a combination of a history of depression and subthreshold symptoms, followed by any subthreshold symptoms or a history of any disorder alone. CONCLUSIONS: A history and subthreshold symptoms independently predicted the subsequent occurrence of depressive or anxiety disorder. Together these two characteristics provide reasonable discriminative value. Whereas anxiety predicted the occurrence of an anxiety disorder only, depression predicted the occurrence of both depressive and anxiety disorders.
School-based interventions are thought to be the most universally applicable and effective way to counteract low physical activity (PA) and fitness although there is controversy about the optimal strategy to intervene.
The objective of this review was to summarise recent reviews that aimed to increase PA or fitness in youth and carry out a systematic review of new intervention studies.
Relevant systematic reviews and original controlled and randomised controlled school-based trials with a PA or fitness outcome measure, a duration of ≥12 weeks, a sufficient quality and involvement of a healthy population aged 6-18 years that were published from 2007 to 2010 were included. Results In these reviews, 47-65% of trials were found to be effective. The effect was mostly seen in school-related PA while effects outside school were often not observed or assessed.
The school-based application of multicomponent intervention strategies was the most consistent, promising strategy, while controversy existed regarding the effectiveness of family involvement, focus on healthy populations at increased risk or duration and intensity of the intervention. All 20 trials in the review update showed a positive effect on in-school, out-of-school or overall PA, and 6 of 11 studies showed an increase in fitness. Taking into consideration both assessment quality and public health relevance, multicomponent approaches in children including family components showed the highest level of evidence for increasing overall PA. This review confirms the public health potential of high quality, school-based PA interventions for increasing PA and possibly fitness in healthy youth.
Past episodes of depressive or anxiety disorders and subthreshold symptoms have both been reported to predict the occurrence of depressive or anxiety disorders. It is unclear to what extent the two factors interact or predict these disorders independently.
To examine the extent to which history, subthreshold symptoms and their combination predict the occurrence of depressive (major depressive disorder, dysthymia) or anxiety disorders (social phobia, panic disorder, agoraphobia, generalised anxiety disorder) over a 2-year period.
This was a prospective cohort study with 1167 participants: the Netherlands Study of Depression and Anxiety. Anxiety and depressive disorders were determined with the Composite International Diagnostic Interview, subthreshold symptoms were determined with the Inventory of Depressive Symptomatology-Self Report and the Beck Anxiety Inventory.
Occurrence of depressive disorder was best predicted by a combination of a history of depression and subthreshold symptoms, followed by either one alone. Occurrence of anxiety disorder was best predicted by both a combination of a history of anxiety disorder and subthreshold symptoms and a combination of a history of depression and subthreshold symptoms, followed by any subthreshold symptoms or a history of any disorder alone.
A history and subthreshold symptoms independently predicted the subsequent occurrence of depressive or anxiety disorder. Together these two characteristics provide reasonable discriminative value. Whereas anxiety predicted the occurrence of an anxiety disorder only, depression predicted the occurrence of both depressive and anxiety disorders.
To develop more efficient programmes for promoting dietary and/or physical activity change (in order to prevent type 2 diabetes) it is critical to ensure that the intervention components and characteristics most strongly associated with effectiveness are included. The aim of this systematic review of reviews was to identify intervention components that are associated with increased change in diet and/or physical activity in individuals at risk of type 2 diabetes.
MEDLINE, EMBASE, CINAHL, PsycInfo, and the Cochrane Library were searched for systematic reviews of interventions targeting diet and/or physical activity in adults at risk of developing type 2 diabetes from 1998 to 2008. Two reviewers independently selected reviews and rated methodological quality. Individual analyses from reviews relating effectiveness to intervention components were extracted, graded for evidence quality and summarised.
Of 3856 identified articles, 30 met the inclusion criteria and 129 analyses related intervention components to effectiveness. These included causal analyses (based on randomisation of participants to different intervention conditions) and associative analyses (e.g. meta-regression). Overall, interventions produced clinically meaningful weight loss (3-5 kg at 12 months; 2-3 kg at 36 months) and increased physical activity (30-60 mins/week of moderate activity at 12-18 months). Based on causal analyses, intervention effectiveness was increased by engaging social support, targeting both diet and physical activity, and using well-defined/established behaviour change techniques. Increased effectiveness was also associated with increased contact frequency and using a specific cluster of "self-regulatory" behaviour change techniques (e.g. goal-setting, self-monitoring). No clear relationships were found between effectiveness and intervention setting, delivery mode, study population or delivery provider. Evidence on long-term effectiveness suggested the need for greater consideration of behaviour maintenance strategies.
This comprehensive review of reviews identifies specific components which are associated with increased effectiveness in interventions to promote change in diet and/or physical activity. To maximise the efficiency of programmes for diabetes prevention, practitioners and commissioning organisations should consider including these components.
depression remains a major public health problem that is most often evaluated and treated in primary care settings. The objective of this study was to examine the prevalence, treatment, and control of depressive symptoms in a national data sample using a common primary care screening tool for depression.
we analyzed a sample of adults (n = 4836) from 2005 to 2008 National Health and Nutrition Examination Survey data. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9) to determine the overall prevalence, rates of treatment, and antidepressant control of mild, moderate, moderately severe, and severe depressive symptoms.
of the sample, 20.1% reported significant depressive symptoms (PHQ-9) score, ≥ 5), the majority of whom had mild depressive symptoms (PHQ-9) score, 5-9). Even among individuals with severe depressive symptoms, a large percentage (36.9%) received no treatment from a mental health professional or with antidepressant medication. Of those taking antidepressants, 26.4% reported mild depressive symptoms and 18.8% had moderate, moderately severe, or severe depressive symptoms.
despite greater awareness and treatment of depression in primary care settings, the prevalence of depressive symptoms remains high, treatment levels remain low, and control of depressive symptoms are suboptimal. Primary care providers need to continue to focus their efforts on diagnosing and effectively treating this important disease.
Results of reliability and agreement studies are intended to provide information about the amount of error inherent in any diagnosis, score, or measurement. The level of reliability and agreement among users of scales, instruments, or classifications is widely unknown. Therefore, there is a need for rigorously conducted interrater and intrarater reliability and agreement studies. Information about sample selection, study design, and statistical analysis is often incomplete. Because of inadequate reporting, interpretation and synthesis of study results are often difficult. Widely accepted criteria, standards, or guidelines for reporting reliability and agreement in the health care and medical field are lacking. The objective was to develop guidelines for reporting reliability and agreement studies.
Eight experts in reliability and agreement investigation developed guidelines for reporting.
Fifteen issues that should be addressed when reliability and agreement are reported are proposed. The issues correspond to the headings usually used in publications.
The proposed guidelines intend to improve the quality of reporting.
To assess the effectiveness of exercise in adults with clinical depression.
The databases CINAHL, Embase, Cochrane Database of Systematic reviews, Cochrane Controlled Trials Register, MEDLINE, and PsycINFO were searched (1806-2008) using medical subject headings (MeSH) and text word terms depression, depressive disorder and exercise, aerobic, non-aerobic, physical activity, physical fitness, walk*, jog*, run*, bicycling, swim*, strength, and resistance.
Randomized trials including adults with clinical depression according to any diagnostic system were included.
Two investigators evaluated trials using a prepiloted structured form.
Thirteen trials were identified that fulfilled the inclusion criteria. Eight had adequate allocation concealment, 6 had a blinded outcome, and 5 used intention-to-treat analyses. The pooled standardized mean difference (SMD) calculated using a random-effects model was -0.40 (95% CI, -0.66 to -0.14), with evidence of heterogeneity between trials (I(2) = 57.2%, P = .005). There was an inverse association between duration of intervention and the magnitude of the association of exercise with depression (P = .002). No other characteristics were related to between-study heterogeneity. Pooled analysis of 5 trials with long-term follow-up (ie, that examined outcomes beyond the end of the intervention) suggested no long-term benefit (SMD, -0.01; 95% CI, -0.28 to 0.26), with no strong evidence of heterogeneity in this pooled analysis (I(2) = 23.4%, P = .27). There was no strong statistical evidence for small study bias (P > .27). Only 3 studies were assessed as high quality (adequately concealed random allocation, blinded outcome assessment, and intention-to-treat analysis). When we pooled results from these, the estimated beneficial effect of exercise was more modest (SMD, -0.19; 95% CI, -0.70 to 0.31) than the pooled result for all 13 studies, with no strong evidence of benefit.
Our results suggest a short-term effect of exercise on depression: on average, depression scores 0.4 of a standard deviation lower in clinically depressed patients randomly assigned to an exercise intervention at the end of that intervention compared to those randomly assigned to a none exercise group. There is little evidence of a long-term beneficial effect of exercise in patients with clinical depression.
The metafor package provides functions for conducting meta-analyses in R. The package includes functions for fitting the meta-analytic fixed- and random-effects models and allows for the inclusion of moderators variables (study-level covariates) in these models. Meta-regression analyses with continuous and categorical moderators can be conducted in this way. Functions for the Mantel-Haenszel and Peto's one-step method for meta-analyses of 2 x 2 table data are also available. Finally, the package provides various plot functions (for example, for forest, funnel, and radial plots) and functions for assessing the model fit, for obtaining case diagnostics, and for tests of publication bias.
Several World Health Organisation reports over recent years have highlighted the high incidence of chronic diseases such as diabetes, coronary heart disease and cancer. Contributory factors include unhealthy diets, alcohol and tobacco use and sedentary lifestyles. This paper reports the findings of a review of reviews of behavioural change interventions to reduce unhealthy behaviours or promote healthy behaviours. We included six different health-related behaviours in the review: healthy eating, physical exercise, smoking, alcohol misuse, sexual risk taking (in young people) and illicit drug use. We excluded reviews which focussed on pharmacological treatments or those which required intensive treatments (e.g. for drug or alcohol dependency).
The Cochrane Library, Database of Abstracts of Reviews of Effectiveness (DARE) and several Ovid databases were searched for systematic reviews of interventions for the six behaviours (updated search 2008). Two reviewers applied the inclusion criteria, extracted data and assessed the quality of the reviews. The results were discussed in a narrative synthesis.
We included 103 reviews published between 1995 and 2008. The focus of interventions varied, but those targeting specific individuals were generally designed to change an existing behaviour (e.g. cigarette smoking, alcohol misuse), whilst those aimed at the general population or groups such as school children were designed to promote positive behaviours (e.g. healthy eating). Almost 50% (n = 48) of the reviews focussed on smoking (either prevention or cessation). Interventions that were most effective across a range of health behaviours included physician advice or individual counselling, and workplace- and school-based activities. Mass media campaigns and legislative interventions also showed small to moderate effects in changing health behaviours.Generally, the evidence related to short-term effects rather than sustained/longer-term impact and there was a relative lack of evidence on how best to address inequalities.
Despite limitations of the review of reviews approach, it is encouraging that there are interventions that are effective in achieving behavioural change. Further emphasis in both primary studies and secondary analysis (e.g. systematic reviews) should be placed on assessing the differential effectiveness of interventions across different population subgroups to ensure that health inequalities are addressed.
Mental disorders are common, and they are a significant contributor to disability in the community. There is growing interest in the effectiveness of exercise interventions for improving mental and physical health in individuals with mental disorders. This paper reviews the evidence for the benefits of exercise for mental health problems and provides some practical recommendations for patients and clinical exercise professionals. Exercise appears most effective for depressive disorders and may also improve mental well-being and physical health in individuals with serious mental disorders. There is limited research on the optimal type and dose of exercise suitable for individuals with mental disorders. It is recommended that exercise dose should meet minimum public health guidelines for maintaining health. Higher doses may have stronger effects on mental health, but may be more difficult to implement in practice. Exercise programs should be adapted to accommodate individual circumstances and preferences and to minimize barriers to exercise medicine.
Several meta-analyses examining the effects of exercise on depression have been criticized for including studies of poor methodological integrity. More recent meta-analyses addressed the most common criticism by including only randomized control trials; however, these analyses suffer from incomplete literature searches and lack of moderating variable analyses. Using a more extensive search procedure, the current meta-analysis examines the effects of exercise on depressive symptoms in 58 randomized trials (n = 2982). An overall effect size of −0.80 indicates participants in the exercise treatment had significantly lower depression scores than those receiving the control treatment. This 3/4 SD advantage represents level 1, Grade A evidence for the effects of exercise upon depression. Analysis of moderating variables examined the influence of population characteristics, exercise characteristics and methodological characteristics. Examination of clinical significance in 16 trials with clinically depressed patients found 9 of 16 exercise treatment groups were classified as ‘recovered’ at post-treatment, with another three groups classified as ‘improved’. Analysis showed dropout rates for the exercise treatment were similar to those found in psychotherapeutic and drug interventions.