From the Editor

Studies have shown that exercise is helpful for those with depression. But is one type of exercise better than the others? How much exercise? And what should you tell your patients when they ask?

Michael Noetel (of the University of Queensland) and his co-authors attempt to answer these questions in a new study for The BMJ. They did a systematic review and network meta-analysis, drawing on 218 studies with almost 14  200 participants. “Exercise is an effective treatment for depression, with walking or jogging, yoga, and strength training more effective than other exercises, particularly when intense.” We look at the study, the accompanying editorial, and consider the implications for practice.

And, in the other selection from Psychiatric Services, Ye Zhang Pogue (of RTI International) writes about her advocacy for those with mental illness and her hesitation in disclosing her own diagnosis. In a personal essay, she talks about her aspirations, her fears, and her experiences with discrimination. She calls for a change to corporate culture. “Changing corporate culture will be a slow process, but the cumulative efforts of individuals will make a difference on a systemic level.” Note that this was the most-read paper in any APA journal in 2023.

DG

Selection 1: Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials”

Michael Noetel, Taren Sanders, Daniel Gallardo-Gómez, et al.

The BMJ, 22 February 2024

Major depressive disorder is a leading cause of disability worldwide and has been found to lower life satisfaction more than debt, divorce, and diabetes and to exacerbate comorbidities, including heart disease, anxiety, and cancer… Exercise may be an effective complement or alternative to drugs and psychotherapy. In addition to mental health benefits, exercise also improves a range of physical and cognitive outcomes. Clinical practice guidelines in the US, UK, and Australia recommend physical activity as part of treatment for depression. But these guidelines do not provide clear, consistent recommendations about dose or exercise modality…

Authors of guidelines may find it hard to provide consistent recommendations on the basis of existing mainly pairwise meta-analyses – that is, assessing a specific modality versus a specific comparator in a distinct group of participants. These meta-analyses have come under scrutiny for pooling heterogeneous treatments and heterogenous comparisons leading to ambiguous effect estimates. Reviews also face the opposite problem, excluding exercise treatments such as yoga, tai chi, and qigong because grouping them with strength training might be inappropriate. Overviews of reviews have tried to deal with this problem by combining pairwise meta-analyses on individual treatments. A recent such overview found no differences between exercise modalities…

So begins a paper by Noetel et al.

Here’s what they did:

  • The authors conducted a systematic review and network meta-analysis.
  • They included “any randomised trial with exercise arms for participants meeting clinical cut-offs for major depression.”
  • Studies were drawn from different databases, including Medline.
  • “Screening, data extraction, coding, and risk of bias assessment were performed independently and in duplicate. Bayesian arm based, multilevel network meta-analyses were performed for the primary analyses.” 
  • “Quality of the evidence for each arm was graded using the confidence in network meta-analysis (CINeMA) online tool.”
  • They reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Network Meta-analyses (PRISMA-NMA) guidelines.

Here’s what they found:

  • 218 studies were included with a total of 495 arms and 14 170 participants.
  • Type of exercise. The most effective exercise modalities were walking or jogging (Hedges’ g −0.62), yoga (g −0.55), and strength training (g −0.49). 
  • Gender. Although walking or jogging were effective for men and women, strength training was more effective for women, and yoga, for men.
  • Intensity. “The effects of exercise were proportional to the intensity prescribed.”
  • Bias. “Results appeared robust to publication bias, but only one study met the Cochrane criteria for low risk of bias.”

A few thoughts:

1. This is an impressive study, drawing on much data, and published in a major journal.

2. The findings in two words: exercise worked.

3. The implications? The authors see several, including for establishing new guidelines. “Treatment guidelines may be overly conservative by conditionally recommending exercise as complementary or alternative treatment for patients in whom psychotherapy or pharmacotherapy is either ineffective or unacceptable. Instead, guidelines for depression ought to include prescriptions for exercise and consider adapting the modality to participants’ characteristics and recommending more vigorous intensity exercises.”

4. Should all your patients be dancing? In fact, this form of exercise offered strong results but the authors noted few studies in the area with relatively few participants. 

5. The new Canadian depression guidelines (from CANMAT) will be published in April. Spoiler alert: as was the case with the last update, the authors suggest a big role for exercise in the treatment of depression for those with mild and moderate severity episodes.

6. Dr. Juan Ángel Bellón (of the University of Málaga) writes the accompanying editorial, “Exercise for the treatment of depression.”

“Reasonably effective psychological and drug treatments are available, and in recent years, research has shown that exercise is also effective. Important questions remain, however, about the role of exercise in the treatment of depression, including what type of exercise works best, at what intensity and frequency, in what format (individual or group), and for which patient.”

He notes the major findings. “Walking or jogging, yoga, and strength training appeared to be more effective than other types of exercises. Overall, a dose-response association was found between exercise intensity and greater effectiveness, but even low intensity exercises such as walking and yoga conferred meaningful benefit.”

Juan Ángel Bellón

Dr. Bellón sees important implications. 

  • For primary care. “Primary care clinicians can now recommend exercise, psychotherapy, or antidepressants as standalone alternatives for adults with mild or moderate depression. The final choice depends on patient preference and other considerations, including any barriers to access. Clinicians and patients should also take into account the benefits of exercise in preventing or treating chronic conditions such as type 2 diabetes, overweight and obesity, cardiovascular disease, cancer, and cognitive impairment.”
  • For research. “Most of the randomised controlled trials included in this new network meta-analysis were conducted in a highly simulated and standardised context. Therefore, implementation studies (pragmatic randomised controlled trials and observational studies) are needed to evaluate physical activity programmes for people with depression using real world data.”
  • For governments. “Health services and local and national administrations should provide enough resources to make individualised and supervised exercise programmes accessible to the entire population.”

The full editorial can be found here:

https://www.bmj.com/content/384/bmj.q320

7. This study is impressive but there are clear limitations. A systematic review and network meta-analysis builds on existing studies, like a tall building is built on pillars. Here, the pillars are weak: “Results appeared robust to publication bias, but only one study met the Cochrane criteria for low risk of bias. As a result, confidence in accordance with CINeMA was low for walking or jogging and very low for other treatments.” That’s not to second guess the major finding but to imply that the research may evolve with time.

8. Like debates over antidepressants, is the take-away message that exercise is important for the treatment of depression, but the exact type of exercise may be less important? Is patient preference (tied to adherence in past work) ultimately the most relevant factor then? Regardless of your interpretation of the findings, this much is clear: a discussion about treatment for depression should include careful mention of exercise.

The full BMJ paper can be found here:

https://www.bmj.com/content/384/bmj-2023-075847

Selection 2: “Career Aspirations for Individuals with Serious Mental Disorders”

Ye Zhang Pogue

Psychiatric Services, September 2023

‘What is your career aspiration?’ my project director recently asked me.

I was tempted to once again give the professional answer that I usually offer – to publish more academic articles, take leadership roles in projects, and be promoted to a more senior position. However, what I really wanted to say was that I hoped I would never lose my ability to work. Such a comment would sound absurd, however, because I have a stable job, my performance evaluations have been excellent, and I recently received a promotion.

However, career prospects do not appear as bright when bipolar disorder is part of the package. For me, as someone living with this condition, nothing can be taken for granted. I work hard to manage my symptoms and have not had an acute episode for a decade, which has allowed me to finish a Ph.D. focused on behavioral health…

I am an advocate for people with serious mental illness (i.e., those who have schizophrenia, psychosis, bipolar disorder, or other psychiatric conditions with psychotic features), so I do not deliberately conceal my diagnosis. However, in the professional world, when talking to my supervisors, I pretend that I am just an average employee who wants to perform her duty well.

So begins an essay by Pogue.

“I want people to see me as ‘normal,’ as ‘one of us.’” 

She notes that “bipolar disorder is both a stigmatized and a romanticized illness.” And she worries that “everything I do might be mistaken for symptoms of mental illness. Laughing to tears could be seen as hypomania. Complaining about a bad day could be interpreted as depression. Arguing with others may be taken as a sign of relapse.”

She describes the impact of stigma on herself. “Because of stigma, I have become more hypervigilant and less trusting. These are not symptoms of bipolar disorder – they are my responses to the outright discrimination I have endured. Despite past negative experiences, I force myself to be positive and optimistic, as if stigma and discrimination have had no effect on me.”

“A promising career is elusive for me. In the world of advocacy for people with serious mental illness, we talk about employment, jobs, and skills, as well as friendly workplaces and job accommodations. As far as I remember, never once have we talked about careers, let alone aspirations. A career requires some level of continuity, yet serious mental illness is an unpredictable disruptor.”

And she notes the contrast between clinical and career successes. “Clinically, the desired outcome for persons with serious mental illness is remission and a high level of social functioning. Holding a full-time, mainstream, competitive job is like the Holy Grail. I do not know how to move beyond these expectations.”

She provides possible solutions. “Everyone needs a mentor providing understanding and helping one to navigate one’s career.” And she advocates for a change in corporate culture. “Employers could provide time and space for support groups… It could be helpful for these groups to provide evidence-based advice to employees on how to disclose their conditions, if they want to disclose. There could be training to help managers and supervisors understand the lived experience of persons with disabilities, including serious mental disorders.”

Pogue closes on a hopeful note. 

“Understanding and empathy are powerful tools to reduce stigma and to challenge the perception that people with serious mental illnesses are inherently different from ‘normal’ people. I wait for that day in the hope that all of us will have the opportunity to achieve our highest potential.”

A few thoughts:

1. Pogue’s essay is thought-provoking and vulnerable. She is transparent about her reasons for not disclosing her mental illness to her workplace and discusses how societal stigma can become internalized.

2. The comments about self-stigma are moving. “Frequently, I have a strong feeling that I am unable to perform certain tasks, even though I know that I have done similar ones not long ago. It is challenging to fight against these feelings of inadequacy.”

3. She points to possible solutions to decrease workplace stigma and make individuals more comfortable disclosing their mental health diagnoses. We may ask: with fading stigma, are occupational opportunities improving? In a Psychiatry Services paper drawing on US employment data, Frank et al. found: “over the past 20 years, people with serious mental health conditions have been less likely to participate in the labor force in part because the types of jobs they have traditionally held have been disappearing.” Ouch – there is much work to be done.

You can find the Frank et al. paper here:

https://ps.psychiatryonline.org/doi/10.1176/appi.ps.202000243

The full Psych Services paper can be found here:

https://ps.psychiatryonline.org/doi/10.1176/appi.ps.20220633

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.