Journal Club Samir Patel, MD MPH · Journal Club Samir Patel, MD MPH 03/08/2013 Common Associated...
Transcript of Journal Club Samir Patel, MD MPH · Journal Club Samir Patel, MD MPH 03/08/2013 Common Associated...
Journal Club
Samir Patel, MD MPH
03/08/2013
CommonCommon
Associated with negative outcomes
Inadequately treated
Problems with medication
h i l i iCan physical activity can ameliorate depressive symptoms?y p
Bridle C, Spanjers K, Patel S, Atherton NM, Lamb SE. Effect of exercise on depression severity in older people: systematic review and meta‐analysis p y p p y yof randomised controlled trials. British Journal of Psychiatry 2012; 201(3): 180‐185.
i ld d l i h…in older adults with depression, structured exercise with mixed elements of endurance and strength training reduced depressionreduced depression severity after three to 12 months of follow‐up.
1. Is the clinical question clearly focused with
dregard to:
The population?
The intervention?The intervention?
The outcome measures?
Wh t i th ff t fWhat is the effect of exercise on depression severity among older persons with clinically significant symptoms of depression?depression?
Does treatment effect vary according to depression criteria, clinician‐diagnosedclinician diagnosed depression vs. symptom checklist threshold?
2. Are the criteria for selection of the studies to be included in the review in accordancereview in accordance with:
The specifications of the foregoing questions in regard to populations, interventions andinterventions and results?
The type of research d h ll bdesign that will be chosen?
Older people (≥60 y)
A clinically valid method of assessing depressionof assessing depression
Exercise interventions Body movement activity
Planned/structured
Specified frequency/duration/intensityq y/ / y
Any control
Depression as outcome at follow‐up (≥3 m)
RCTs
Is the literature search method clearly specified?
Is there high probability
• 2 reviewers extracted data• Until Jan 2011• 20 databases usedIs there high probability
that some relevant studies may have been omitted?
• Bibliographies of included papers screened
• MeSH terms and text termsomitted?• MeSH terms and text terms related to exercise, depression, age
Flow diagram of study selection.a.
Bridle C et al. BJP 2012;201:180-185
©2012 by The Royal College of Psychiatrists
4. Have the identified studies been evaluated for methodological quality?quality?
• Independent assessment by 2 authorsauthors
• Cochrane risk of bias tool• low, medium or high
5. Was the methodological gquality evaluation carried out by more than one person
Yes
than one person independently, and the degree of agreement b hbetween them established? None reported
1. Clinical question focused enough? Yesg
2. Are criteria for selection of the studies in accordance to previous question? Yesto previous question? Yes
3. Is the literature search method clear and h ti ? Yexhaustive? Yes
4. Is methodological quality of the included studies evaluated? Yes
5. Is this carried out by more than one personsthan one persons independently? Yes the degree of agreement between them established?between them established? No
Mean difference in outcome measure was standardized for each trial (SMD)( ) Hedge’s g
Heterogeneity between i ltrials I2
Meta‐analysis performedMeta analysis performed using random effects model
Stratified analysis
Sensitivity analyses Sensitivity analyses
Were the resultsWere the results consistent from one study to another?
Trial‐level data, effect estimates and forest plots for depression severity.
Bridle C et al. BJP 2012;201:180-185
©2012 by The Royal College of Psychiatrists
What were the overall results of the review?results of the review?
How precise were the results?
Strengths Weakness
Pre‐specified protocol
C h i h
?publication bias
Moderate risk of biasComprehensive search
Public health implications
Moderate risk of bias
Outpatients
68% participated
In older people with clinically meaningful symptoms of depressionsymptoms of depression, structured exercise with mixed elements of endurance and strength training reduced depression severity. p y
The evidence for 3‐D training, i.e., Tai Chi and Qi Gong, was insufficient.
Are my patients similar toAre my patients similar to the patients included in the original studies?
Many are
Older
ComorbiditiesComorbidities
What about medications?
Is the intervention feasible in my setting?
I can certainly refer someone
Availability
QualityQuality
$$
Transportationp
Have all the clinically relevant results been k i id i ?taken into consideration?
Harm/Risks?
Functional status Functional status
Socialization
Do the benefits outweigh the potential harm?
Individual decision Individual decision.
Longer term follow up
For prescreened ppatients, they probably do
In depressed elderly a mix ofIn depressed elderly, a mix of endurance and strength exercise routine reduced depression severity after 3 to p y12 months of follow‐up.
High quality review
Minimized biasMinimized bias
7/9 trial were adequate quality, sensitivity analyses did not change the outcomechange the outcome.
Long‐term effects?
F i l i ? Functional impact?
Effectiveness in real world?
MOA?