A Prospective Study - NCBI

Exercise and Depression in Midlife: A Prospective Study Lisa Cooper-Patrick, MD, MPH, Daniel E. Ford, MD, MPH, Lucy A. Mead, ScM, Patricia P. Chang, MD, and Michael J. Klag, MD, MPH

Introduction

Measurements

It has been suggested that exercise is associated with better mental health. '-3 However, interventional studies have many methodologic problems, including the nonrandom assignment of participants to experimental conditions and the inability to blind participants to a physical activity intervention.3'4 Prospective observational studies have produced contradictory results.57 We hypothesized that (1) physical activity is protective against depression and psychiatric distress and (2) this protective effect is accentuated in vulnerable individuals, specifically those with an "unstable" temperament or with a parental history of depression.

The main independent variable was the frequency of exercising to a sweat during an average week in either 1978 or 1986, abstracted from the Harvard Alumni physical activity questionnaire.9 This questionnaire has been validated in other studies's'2 and has been shown to predict morbidity and mortality.13-16 We also studied change in physical activity between medical school and midlife, categorizing participants as inactive, became active, and remained active. Risk factors for depression were included as covariates in multivariate analyses. Substance abuse was defined as self-reported alcohol/drug abuse or CAGE questionnaire score of 2 or more.'7,18 Socioeconomic status and race are homogeneous in this cohort; they were not included as covariates. Analyses were stratified by three types of temperament assessed in medical school and shown to predict mortality in this cohort: (1) "tension-in," (2) "tension-out," and (3) "stable." 19 Parental history of depression, also used as a stratification variable, was assessed in medical school and during follow-up by annual questionnaire. Incidence of clinical depression from 1979 through December 31, 1993, was defined by self-report on annual morbidity questionnaires and by review of medical records, with the use of Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM-IV) criteria, when possible, and with grief reactions excluded.20 Psychiatric distress was defined as a score of 4 or more on the 20-item General Health Questionnaire administered in 1988.21-23

Methods Study Population The Precursors Study is a longitudinal cohort study of 1337 former medical students from the Johns Hopkins University School of Medicine classes of 1948 through 1964. More than 95% of eligible students were enrolled.8 The study conducts annual follow-up by mailed questionnaires, with 5-year response rates ranging from 87% to 93%. The first analysis assessed the relationship between self-reported physical activity in 1978 and the incidence of clinical depression through 1993. Participants who died before 1978 (n = 61), did not respond to the 1978 questionnaire (n = 465), reported an episode of depression in 1978 or earlier (n = 52), or were lost to follow-up after 1978 (n = 7) were excluded from this analysis, leaving 752 eligible participants. The second analysis assessed the relationship between self-reported physical activity in 1986 and psychiatric distress by the General Health Questionnaire in 1988. Participants who died before 1986 (n = 106), did not respond to the 1986 questionnaire (n = 290), died in 1987 or 1988 (n = 13), did not complete the questionnaire in 1988 (n = 109), or were lost to follow-up (n = 38) were excluded from this analysis, leaving 781 eligible participants.

The authors are with the Division of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Md. Drs Cooper-Patrick, Ford, and Klag are also with the Department of Health Policy and Management, and Drs Klag and Ford are with the Department of Epidemiology, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Md. Requests for reprints should be sent to Lisa Cooper-Patrick, MD, MPH, The Johns Hopkins Precursors Study, 2024 East Monument St, Suite 2-200, Baltimore, MD 21205-2223. This paper was accepted July 9, 1996.

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Analysis To examine the relationship of physical activity in 1978 to the incidence of clinical depression during the subsequent 15 years, Cox proportional hazards models were used. To examine the relationship between physical activity in 1986 and psychiatric distress in 1988, logistic regression analyses were used. For all analyses, two-tailed P values of 55 y Parental history of depression* No Yes Substance abuse No Yes Smoker in 1978** No Yes Physical limitation in 1988 or before* No Yes

243 425 84

32 57 11

181 276 49

74 65 58

62 149 35

26 35 42

662 90

88 12

4353 71

66 79

227 19

34 21

669 83

89 11

447 59

67 71

222 24

33 29

603 123

83 17

420 69

70 56

183 54

30 44

502 192

72 28

352 116

70 60

150 76

30 40

*P < .05; **P < .01; chi-squared test for association with exercise status. aTension-in: uneasy, anxious, with appetite loss and difficulty sleeping when under stress. bTension-out: anxious, angry, with increased activity when under stress. CStable: more self-contained and solid when under stress.

Discussion

The frequency of physical activity in sample of White male professionals is much higher than in population-based samples. However, the validity of the exercise measure is supported by its

our

Many interventional studies of vigorexercise training programs have also failed to show a beneficial effect on mental health.2>27 At least two observational studies using population-based male samples have failed to show a protective benefit of exercise for psychiatric distress.5'7 In a sample of medical students, Buchman and colleagues found no relationship between physical activity and depression.28 Most studies showing a relationship between exercise and depression have included such activities as golf and horseback riding, which are strong correlates of higher social status and larger social networks.6'29 ous

association with cardiovascular disease in this cohort.30 The incidence of depression and the prevalence of psychiatric distress in our sample are consistent with other population-based studies.3' Of our clinical depression cases, 86% also reported taking medication or seeing a health professional for their problem (unpublished data by P.P. Chang et al.). Although the long-term effects of

physical activity

on

psychological status

have not been established, moderate levels of regular physical activity do

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TABLE 2-Relative Risk of Depression and Relative Odds of Psychiatric Distress, by Physical Activity: The Precursors Study of Former Medical Students, 1948 through 1964 6. %

Unadjusted

Adjusted

RR of depression by physical activity in 1978 (n = 752)a Sweat weekly 1.27 (0.67, 2.41) 1.11 (0.56, 2.18) 33 No 1.00 67 1.00 Yes Number of sweats* 0 times/week 1.18 (0.53, 2.64) 33 1.45 (0.68, 3.09) 1.08 (0.48, 2.45) 30 1.26 (0.56, 2.80) 1-2 times/week 37 1.00 3 or more times/week 1.00 Change from medical school 0.86 (0.33, 2.24) 32 0.87 (0.34, 2.22) Inactiveb 52 0.66 (0.27,1.65) 0.60 (0.24,1.48) Became activec 1.00 16 1.00 Remained actived

RO of psychiatric distress for physical activity in 1986 (n = 781 )e Sweat weekly 1.16 (0.72,1.76) 35 1.20 (0.80,1.80) No 1.00 65 1.00 Yes Number of sweats* 1.22 (0.77,1.92) 0 times/week 35 1.26 (0.81, 1.98) 1.17 (0.69, 2.00) 22 1.22 (0.72, 2.06) 1-2 times/week 1.00 3 or more times/week 43 1.00 Change from medical school 1.13 (0.55, 2.32) 35 1.18 (0.59, 2.40) Inactiveb 1.19 (0.60, 2.36) 51 1.16 (0.59, 2.29) Became activec 14 1.00 1.00 Remained actived Note. RR = relative risk; RO = relative odds. aAdjusted for gender, age in 1978, smoking status in 1978, and substance abuse prior to depression. blnactive: no sweats weekly in 1978 or 1986, regardless of medical school activity. CBecame active: no or little exercise in medical school, sweat weekly in 1978 or 1986. dRemained active: moderate or much exercise in medical school, sweat weekly in 1978 or 1986. eAdjusted for gender, age in 1986, smoking status in 1986, and substance abuse prior to 1988. *Pfor test of trend = .60 (unadjusted) and 0.94 (adjusted). *Pfor test of trend = .15 (unadjusted) and 0.20 (adjusted).

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

benefit physical health status. 1-16 32.33 Exercise has more physical health benefits, lower costs, and fewer side effects than psychotherapy and pharmacotherapy. Efforts to determine whether exercise is effective in preventing depression and psychiatric distress should continue, especially in vulnerable subgroups, such as individuals with a family history of depression. Any protective effect of physical activity on depression or psychiatric distress is probably small and will require a larger sample size than the present study to measure with confidence. [1

Acknowledgments This work was partially supported by research grants from the National Institute of Mental Health (MH46967), the National Institute on Aging (AGOI 760-13A1 and AGO1760-14S1), and by a Health of the Public Grant from The

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Pew Charitable Trust and The Rockefeller Foundations. Dr Klag is an Established Investigator of the American Heart Association. This paper was presented in part at the 33rd Annual Conference on Cardiovascular Disease Epidemiology, American Heart Association, Santa Fe, NM, March 17, 1993, and at the 13th Mid-Atlantic Regional Meeting of the Society of General Internal Medicine, Philadelphia, PA, March 11, 1994.

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18. 19.

References 1. Folkins CH, Sime WE. Physical fitness training and mental health. Am Psychol. 1981 ;36:375-389. 2. Plante TG, Rodin J. Physical fitness and enhanced psychological health. Curr Psychol. 1990;9:3-24. 3. Byrne A, Byrne DG. The effect of exercise on depression, anxiety and other mood states: a review. J Psychosom Res. 1993;37: 565-574. 4. Hughes JR. Psychological effects of habitual aerobic exercise: a critical review. Prev Med. 1984;13:66-78. 5. Farmer ME, Locke BZ, Moscicki EK,

Dannenberg AL, Larson DB, Radloff LS. Physical activity and depressive symptoms: the NHANES I epidemiologic follow-up study. Am J Epidemiol. 1988; 128: 1340-1351. Camacho TC, Roberts RE, Lazarus NB, Kaplan GA, Cohen RD. Physical activity and depression: evidence from the Alameda County study. Am J Epidemiol. 1991; 134:220-231. Weyerer S. Physical inactivity and depression in the community: evidence from the Upper Bavarian field study. Int J Sports Med. 1992; 13:492-496. Thomas CB. Observations on some possible precursors of essential hypertension and coronary artery disease. Bull Johns Hopkins Hosp. 195 1;89:419-441. Paffenbarger RS Jr, Wing AL, Hyde RT. Physical activity as an index of heart attack risk in college alumni. Am J Epidemiol. 1978;108: 161-175. Albanes D, Conway JM, Taylor PR, Moe PW, Judd J. Validation and comparison of eight physical activity questionnaires. Epidemiology. 1990;1 :63-71. Washburn RA, Smith KW, Goldfield SRW, McKinlay JB. Reliability and physiologic correlates of the Harvard Alumni Activity Survey in a general population. J Clin Epidemiol. 1991;44:1319-1326. Ainsworth BE, Leon AS, Richardson MT, Jacobs DR, Paffenbarger RS Jr. Accuracy of the College Alumnus physical activity questionnaire. J Clin Epidemiol. 1993;46: 1403-1411. Paffenbarger RS, Hyde RF, Wing AL, Hsieh C. Physical activity, all-cause mortality, and longevity of college alumni. New Engl J Med. 1986;314:605-613. Paffenbarger RS, Wing AL, Hyde RF, Jung DL. Physical activity and incidence of hypertension in college alumni. Am J Epidemiol. 1983; 117:245-257. Lee I, Paffenbarger RS, Hsieh C. Physical activity and risk of developing colorectal cancer among college alumni. J Nati Cancerlnst. 1991;83:1324-1329. Helmrich SP, Ragland DR, Leung RW, Paffenbarger RS. Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus. New Engl J Med. 1991;325: 147-152. Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA. 1984;252: 19051907. Bush B, Shaw S, Cleary P. Screening for alcohol abuse using the CAGE questionnaire. Am J Med. 1987;82:231-235. Graves PL, Mead LA, Wang N, Liang K, Klag MJ. Temperament as a potential predictor of mortality: evidence from a 41-year prospective study. J Behav Med.

1994;17:111-126. 20. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994. 21. Goldberg D, Williams P. A User's Guide to the General Health Questionnaire. Windsor, Berkshire, England: Nfer-Nelson Publishing Co Ltd; 1988. 22. Goldberg DP. The Detection of Psychiatric Illness by Questionnaire: A Technique for the Identification and Assessment of Non-

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23.

24.

25.

26.

psychotic Psychiatric Illness. London, England: Oxford University Press; 1972. Ford DE, Anthony JC, Nestadt JR, Romanoski AJ. The General Health Questionnaire by interview: performance in relation to recent use of health services. Med Care. 1989;27:367-375. De Geus EJC, van Doorien UP, Orlebeke JF. Regular exercise and aerobic fitness in relation to psychological make-up and physiological stress reactivity. Psychosom Med. 1993;55:347-363. Hughes JR, Casal DC, Leon AS. Psychological effects of exercise: a randomized cross-over trial. J Psvchosom Res. 1986;30: 355-360. King AC, Taylor CB, Haskells WL, De-

27.

28.

29. 30.

Bush RF. Influence of regular aerobic exercise on psychological health. Health Psychol. 1989;8:305-324. Moses J, Steptoe A, Mathews A, Edwards S. The effects of exercise training on mental well-being in the normal population: a controlled trial. J Psvchosom Res. 1989;33:47-61. Buchman BP, Sallis JF, Criqui MH, Dimsdale JE, Kaplan RM. Physical activity, physical fitness, and psychological characteristics of medical students. J Psychosom Res. 1991 ;35: 197-208. Ross CE, Hayes D. Exercise and psychologic well-being in the community. Am J Epidemiol. 1988; 127:762-77 1. Deckers JW, Klag MJ, Seidler AJ, Mead

LA. Association of youthful and midlife physical activity with subsequent development of cardiovascular disease. Circulation. 1990;82:258. 31. Robins LN, Regier DA, eds. Psychiatric Disorders in America: The Epidemiologic CatchmentArea Study. New York, NY: The Free Press; 1991. 32. Leon AS, Connett J, Jacobs DR, Rauramaa R. Leisure-time physical activity levels and risk of coronary heart disease and death: the multiple risk factor intervention trial. JAMA. 1987;258:2388-2395. 33. Cummings SR, Kelsey JL, Nevitt MD, O'Dowd KJ. Epidemiology of osteoporosis and osteoporotic fractures. Epidemiol Rev. 1985;7:178-208.

Composite Cardiovascular Risk Outcomes of a Work-Site Intervention Trial Michelle K. Gomel, PhD, Brian Oldenburg, PhD, Judy M. Simpson, PhD, Marilyn Chilvers, MAppStat, and Neville Owen, PhD

~~~~~~~~~~~~~~~~~~.. . ..... 12 month. s Rsu"'.. .Oer .

......

Introduction

Most work-site multiple risk factor intervention trials have used single outt jthe ond..i.ions. Sta .,......''. '''..... *.ve come measures to assess intervention effects. Of six large randomized trials, three have demonstrated significant reducdardized . scores. decreased for tions in at least one risk factor after intervention.'-5 However, single risk facon' temlilloitcfction tor outcomes may not reflect the overall effect of intervention, because change in one risk factor may be accompanied by behavl6ral counseling relativeto hel negative or positive changes in other risk factors. Furthermore, small positive changes in individual risk factors may only be detected when the information *f all ther oaditioiuW from each is combined into a summary measure. In fact, this may be the reason Coclsins Bhaioalcon why some trials failed to find an effect. This paper reports a reanalysis of the risk thae to.coronaly heart diseasechage in *elig proucslare main results presented in an earlier paper5; composite outcomes were used to take into account the extent and direction of 7. .~~~~~ ~ ~ ~ ~~~~~~~~~~~~~~~~change occurring for each risk factor outcome. Two composite outcome mease 1997e;e8i itrestions' sures were used, not for the purpose of 673-n (Amolmhy Pub.1feaL comparison but because each had particular advantages for combining the single 676)...:*M}. :1i8F..671. outcome measures used in this trial. * ; ; i&

...............................:..

domly assigned to one of four interventions. The methodology and interventions have been described previously in detail.5 All participants received a risk factor assessment and feedback at baseline, as well as at 3, 6, and 12 months after the initial assessment. Participants in the health risk assessment condition (n = 130) received the risk factor assessment only. Participants in the risk factor education condition (n = 82) received information on risk factors, an educational resource manual, and videos.

*.

co

Methods Twenty-eight ambulance stations in metropolitan Sydney, Australia, were ran-

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At the time this paper was written, Michelle K. Gomel was with the Department of Psychological Medicine, University of Sydney, Sydney, New South Wales, Australia. She is now with the Division of Mental Health and Prevention of Substance Abuse, World Health Organization, Geneva, Switzerland. Brian Oldenburg is with the School of Public Health, Queensland University of Technology, Queensland, Brisbane, Australia. Judy M. Simpson is with the Department of Public Health, University of Sydney. Marilyn Chilvers is with the Department of Statistics, Macquarie University, Sydney. Neville Owen is with the School of Human Movement, Deakin University, Melbourne, Victoria, Australia. Requests for reprints should be sent to Michelle K. Gomel, PhD, Division of Mental Health and Prevention of Substance Abuse, World Health Organization, 20 Ave Appia, CH- 121 1 Geneva 27, Switzerland. This paper was accepted September 6, 1996. Editor's Note. See related annotation by Heitjan (p548) in this issue.

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