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?