The focus of this paper is to explore the effect exercise has on North American middle-aged women with major depressive disorder. This topic was chosen because I know many people who suffer from depression and I would like to help find ways to cope with the symptoms and aftermath of this heart-wrenching disease. Finding new ways to help cope with depression may decrease the number of suicides. Depression is a huge driving force for people who commit suicide. This issue remains controversial and has been a source of debate for many years. Several scholars claim that exercise can be used to treat depression, while others claim there is no correlation between the two (Coutinho, 2013). He has also argued that the use of exercise to help treat depression is underestimated and providers should really be looking at the benefits exercise could provide. As of right now, the general treatment for depression is based on pharmacological interventions alone, with a slim emphasis on exercise. However, exercise can help to alleviate symptoms, boost a person’s mood, as well as show improvements in depression, anxiety, and self-concept. The effects of exercise on depression can be long-term, which can help to improve quality of life. Exercise can help release feel-good endorphins, take one’s mind off worries, help gain confidence, get more social interaction, and cope in a healthy way (Mayo Clinic, 2017). It would be nice to know if exercise does, in fact, improve depressive symptoms, as this could potentially save millions of lives. The PICO question researched was, “Among North American middle-aged women, does exercise have an impact on the treatment of major depressive disorder”?
Background
Major depressive disorder (MDD) has been around for many decades now. In fact, depression originated in 400 BC, when it was called melancholia (McKay, 2015). Ever since then, depression has impacted the population locally, nationally, and globally. Globally, 322 million people live with major depressive disorder, with 16.1 million of those people living in America (Anxiety and Depression Association of America, 2018). There were no local statistics on it, but I know many people who suffer from depression in Grand Rapids alone. I have family members who suffer from depression, so this topic is very personal to me. I also know people who have committed suicide due to depression. Even those who are not diagnosed with depression can still live with the effects of it. Depression does not discriminate; It affects people of all ages all around the world. Depression screening is a major aspect in hospitals and clinics. Doing a depression screening on each patient is important because many times depression can go unnoticed by caregivers, or even patients themselves. Even in clinic offices, the nurses ask every single patient about depressive symptoms, even if they are just there for a medication refill. It is important to know if a patient is suffering from depression, so the nurses can help them and prevent them from doing harm to themselves. Treating depression can also help prevent other medical conditions from occurring. Depressive patients may shrug off their physical problems and not even realize it, just to find out they have a serious medical condition later on (CADY Wellness Institute, 2016). By treating depression, nurses can reduce the chances of this happening.
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The use of exercise for the treatment of depression is still controversial because several scholars claim that exercise has the same effect as antidepressants, while others say it has no effect on the treatment of depression. There have been countless studies done over the years, some of which will be discussed in this paper. One side of the debate is that exercise can help ease some of the symptoms of depression. The other side of the debate claims there is no correlation between exercise and depression. It is still being looked at today because of how controversial it is. The research gap I ran into with this topic was there were no reliable studies done to evaluate the long-term effectiveness of exercise, as many of the articles focused solely on the short-term effects.
Search Strategies
When I started exploring databases, I selected PubMed first. I typed in “exercise” AND “depression” into the search bar, and it resulted in 15,178 results. I replaced the word “exercise” with “physical activity” and it resulted in 19,996 results. I then typed in “physical activity” OR “depression” and was able to get 874,880 results. When I added the words “North Americans” to my search, the results went down to 158, but the articles were more relevant to my specific population. The next database I chose to look at was ProQuest Central. I first typed in “physical activity” AND “depression” AND “Americans” and was able to obtain 32,746 results. I selected AND instead of OR because I found those articles to be more relevant to my research question. In ProQuest, I replaced “physical activity” with “exercise” and still received 56,721 results. I then went to the American Psychiatric Association and typed in “exercise” AND “depression”. It came up with only five results, one of which actually pertained to my topic. The last database I searched in was ScienceDirect. I searched “depression” AND “exercise” to start out, and I was able to get 115,543 results. The main databases I selected when finding my articles were ProQuest and ScienceDirect because they had the biggest selection of articles to choose from, giving me more options. Many people post about depression on all social media platforms. It is perceived as less severe than other life crises. For example, I had a friend from high school who committed suicide. A couple of my friends and I went on his Twitter page and found one of his tweets that said, “I just need someone to help motivate me”. Another tweet was, “I feel so lonely in this world”. However, many did not take it as serious as it was meant to be, as we just perceived it as him being upset.
Lessons Learned
One lesson I learned when doing my research was the number of results you find are greatly based on the words you use to find the articles. When I used “or”, I had a lot more results that when I used “and”. When I switched “physical activity” to “exercise”, I received less results, but it gave me more of a selection to choose from. As I kept adding more terms specific to my PICO question, the search became more narrow. However, I found articles that were very specific to my question, so it was very helpful.
Another lesson I learned was some of the results only contain an abstract, so they do not have much information with them. I disregarded those articles because they did not provide me with the information I needed. There is an option on ProQuest that allows you to choose “full text”, so I did that to make sure it did not include just abstracts. This allowed me to find quality journal articles with enough information.
A third lesson I learned was that reading the summarized article can be very helpful. I would often feel like I found a good article just by the title, but when I selected it, it did not pertain to my topic. Reading the abstract saved me some time, as I knew right away which articles I could discard.
One last lesson I learned was to not judge an article based on its title. I found a few articles that contained the words “literature review” in the title, but they were not actually literature reviews. I also found an article that consisted of a “qualitative review” in the title, but it was actually a quantitative review. This taught me that it is important to analyze what I am reading to make sure the information is consistent with the title.
State of Evidence
Literature Review
A literature review is a paper written by a scholar, including current knowledge on a particular topic. Sharpe’s literature review, containing 25 articles, examined the correlation between clinical depression and physical activity, specifically focusing on women (Sharpe, 2016). She emphasized how clinical depression is more prevalent in women than men, but the reason is unclear. Insufficient physical activity can be associated with depressive symptoms. Some depressive symptoms including reduced enjoyment levels and interest, decreased mood, fatigue, and reduced energy make it hard to find motivation to engage in physical activity. These barriers should be addressed in the clinical setting, so nurses can help patients work around them by developing an exercise regimen specific to each patient. More research is needed to determine how to encourage women to engage in physical activity.
In another literature review by Anderson and colleagues (2015), 31 articles were reviewed to determine the current findings of the relationship between physical activity and major depressive disorder. Several of the scholars they examined concluded that exercise does improve depressive symptoms and should be utilized. “It has been found that physically active adults have been shown to have 30% lower odds of developing depression” (Anderson, 2015, p.3). This is an alarming statistic that medical professionals should take into consideration when treating their patients.
Meta-analysis
A meta-analysis is a way of combining data from multiple studies by means of a statistical procedure. Coutinho and colleagues (2013) wrote a meta-analysis based on 10 different articles and looked at the different interventions in each one. Their study was over a 12-month period where they reviewed 1,288 articles, eliminating the ones that did not meet their standards. Strength and aerobic training (swimming, dancing, hiking, etc.) did not have a significant difference, so they decided to combine the data. They looked at different aspects that included the type of exercise, the weekly frequency, the duration of the intervention, and the intensity of the exercise (Coutinho, 2013). Some articles they found were ones that discussed the effects of exercise alone, while others evaluated the use of exercise combined with medications. Both aerobic training and strength training played a role in reducing the depressive symptoms. In the article, they concluded that exercise could be used in the place of antidepressants to reduce hospital visits and the use of medications. They concluded that physical exercise, mainly aerobic training, helped improve depressive symptoms, and therefore, helped treat it (Coutinho, 2013). They also discovered that age and symptom severity played a role in the results.
In a different meta-analysis, Richards (2106) was interested in looking at the mean change in depressive symptoms. He focused his research on randomized control trials. Initially, there were 819 potentially relevant articles, with only 25 articles meeting the criteria in the end. The participants in the study were limited to only those with major depressive disorder. He came to the conclusion that there is evidence that exercise can be considered an evidence-based treatment for the management of depression.
Qualitative Research and Social Media
Qualitative research is exploratory in nature and provides insights into a problem. The first qualitative article I found was one in which Danielsson and colleagues (2016) interviewed 13 people who participated in aerobic exercise which was guided by physical therapy. This article specifically focused on the patients’ perspectives because the authors believe that is an important aspect. The participants had to have a diagnosis of Major Depressive Disorder and be willing to participate in the exercise regimen. In the interviews, they asked open-ended questions focusing on direct and indirect changes, previous experiences of exercise, views on exercise during depression, and barriers and facilitators. The interviews all lasted between 29 and 65 minutes. After comparing all of the results and doing some research, Danielsson and colleagues (2016) came to the conclusion, “Exercise in a physical therapy context can improve the patients' perceptions of their physical ability and create a sense of liveliness, improving their depressed state.”
The second study from Busch (2016), consisted of a survey that was given to 102 individuals, in which 50% of them were female. There were barriers within the study which included fatigue, mood, and lack of motivation. However, both genders were interested in an exercise program for depression. Overall, the participants prefer an exercise regimen that is coached, 30-60 minutes in length, occur multiple times per week, is provided in the patient’s home and is offered on the individual level (Busch, 2016).
Quantitative Research
Quantitative research is done by collecting data from different sources and analyzing it in a structured way. This may include clinical trials, randomized control trials, experiments, or surveys. In a quantitative study by Helgadottir and colleagues (2016), a single-blind, randomized control trial which lasted 12 weeks was conducted. Measurements were observed at baseline and post-treatment. There were 4 different treatment groups: vigorous exercise, moderate exercise, light exercise, and treatment as usual. There were 620 American participants in the study, ranging from age 18-67 years old, with the majority being women. Participants had to have a score greater than 10 on the Depression Patient Health Questionnaire (PHQ-9) to be considered for the trial. The light exercise consisted of yoga, moderate exercise consisted of aerobic conditioning, and vigorous exercise consisted of aerobic conditioning. Treatment as usual consisted of either cognitive-behavioral therapy or counseling sessions. In the end, the authors concluded that there were no differences between the groups; any level of exercise is effective in treating mild to moderate depression (Helgadottir, 2016). All of the exercise intensity levels had lower depression severity levels than the treatment as usual group.
In a similar study conducted by Cangin and colleagues (2018), data from four surveys was collected, in which there were 3,935 women and 3,419 men who participated in the study. Fewer women exercised on a daily basis than men, whereas fewer men were clinically depressed. This study was interesting because it was one of the few to have at least 1,000 participants. In conclusion of this study, a regimen that consisted of exercise for at least 150 minutes a week of moderate-intensity proved to decrease depressive symptoms in the participants. An equivalent to this would be 75 minutes of vigorous activity a week.
Clinical Guidelines
Clinical guidelines are statements with intentions to optimize patient care by including knowledgeable recommendations. In one clinical guideline I reviewed, the American College of Physicians (2016) compared the use of second-generation antipsychotics (SGA) with exercise. Sertraline, a common SGA, has adverse effects that could lead to its discontinuation, while exercise does not have any adverse effects. This is a major aspect they looked at since adverse effects can be overwhelming and discouraging. Overall, the recommendation is to use exercise or cognitive-behavioral therapy to treat middle-aged women with major depressive disorder, over the use of second-generation antipsychotics alone (American College of Physicians, 2016). They claimed that patients should exercise at least two times a week with moderate intensity (running, bicycling, dancing, etc.). The use of physical activity in the treatment of depression was associated with positive outcomes.
In another clinical guideline by Thompson (2018), there are new guidelines set in place for patients with depression in the hospital. These guidelines discuss how any amount of exercise at all can improve depressive symptoms, and it can all be done in 1-2 days. It does not have to be drawn out throughout the week. Something as simple as climbing a flight of stairs can even provide health benefits. This was interesting because this was the only article found that concluded this.
Recommendations
Clinical Recommendations
One clinical recommendation I would make is to have the nurse talk to an exercise specialist who can help create an exercise regimen specific to each patient with major depressive disorder. The nurse can write down the weekly plan and give it to the patient, so he or she is able to take it home. The nurse could also provide music recommendations for the patient, as research above has indicated that this keeps the patient engaged. Collaborating with an exercise specialist will ensure the best exercise regimen is created for each patient (Coutinho, 2016). Information on gyms near the patient’s home may also be helpful so they know their options of where to go.
Another clinical recommendation I would make is to encourage any patient with major depressive disorder to exercise at least fifteen minutes on a daily basis and keep a log of it. This could help improve their moods and release those endorphins that I mentioned above. Keeping a log would help keep the patient on track and see what improvements could be made. It will also help to get in a routine. Also, setting them up with an exercise partner may help motivate them more than a doctor would. They can then push each other and hold each other accountable for sticking to their goals.
Research Methodology Recommendations
One research methodology recommendation I would make is to look at how much exercise is needed to reach and maintain a therapeutic level. Also, researchers should look at how often the exercise is needed. There was only one article that addressed these aspects and the conclusions were vague. A lot of the articles concluded that exercise does improve depressive symptoms, but there was lack of evidence to determine how much and how often it is needed. Participants could be divided into different groups based on the level of intensity of the physical activity and how often they exercise.
Another research methodology recommendation I would make is to observe participants over a longer period of time. Most of the articles examined participants over a 6-week period, which does not address the long-term effects of exercise. There should be trials that last at least six months, so the improvements or setbacks can be compared to the baselines.
Conclusion
The effect of exercise on depression has a clear impact on the nursing community. Nurses are in contact with depressed patients on a daily basis, whether that is their presenting complaint or not. If nurses can provide patients with ways to reduce their depressive symptoms, that can help both the nurse and the patient. It also has an impact on nursing because it is a nurse’s responsibility to make sure patients are safe and not a danger to oneself or the community. If an exercise can decrease the chances of depression-induced suicide, a nurse is potentially saving that person’s life.
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