Exercise for late-life depression? It depends.
Exercise for late-life depression? It depends.
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锻炼可以治疗晚年抑郁症吗？
DOI：
10.1016/s0140-6736(13)60860-0
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发表时间：
2013
期刊：
影响因子：
--
通讯作者：
Steffens,DavidC
中科院分区：
文献类型：
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作者：
Steffens,DavidC
运动能帮助老年抑郁症患者吗？这个问题相当简单，人们会凭直觉得到一个简单的答案：是的。然而，正如马丁·安德伍德和同事们在《柳叶刀》杂志上发表的研究所提醒我们的那样，一些研究人员发现，要证明运动对抑郁症有实际好处是很困难的。安德伍德及其同事进行了一项随机分组对照试验，他们在英格兰78家养老院招募了891名老年居民（65岁或以上）。35家干预院接受了每周两次的居民团体运动课程，沿着工作人员和居民的积极性促进以及工作人员的抑郁意识培训。43个对照家庭只接受了工作人员的抑郁症意识培训。在12个月的研究结束时，干预组和对照组的抑郁评分（用老年抑郁量表-15 [GDS-15]测量）没有差异（GDS-15评分的平均差异为0.13 [95%CI-0.33至0.60]）。老年抑郁症运动试验结果缺乏一致性可能是多因素的起源，与研究样本的异质性有关;干预类型，实施策略和比较条件的差异;以及安慰剂反应的变异性。简单地说，运动和老年抑郁症结果的概念的结合创造了足够的方法复杂性，负面结果成为不可避免的。入选标准似乎对结果有实质性影响。例如，Bridle及其同事2对运动和抑郁严重程度进行了系统回顾，得出结论认为，“对于出现临床意义的抑郁症状的老年人，根据个人能力定制的结构化运动处方将降低抑郁严重程度”。2为了纳入审查，Bridle和同事要求参与者临床抑郁并且至少60岁。这样的标准是典型的老年运动干预试验，往往导致研究样本的个人轻度至中度抑郁症的平均年龄小于75岁，使他们最有代表性的临床抑郁症的年轻老年人。事实上，分析中包括的9项研究中有7项的样本平均年龄小于75岁;另外两项的平均年龄大于82岁（其中一项专注于阿尔茨海默病的抑郁症）。在安德伍德及其同事的研究中，平均年龄为86· 5岁（范围65-107岁）。抗抑郁药试验中的平均年龄是显著的;在75岁以上患者（老年人）的药理学试验中，研究药物在抑郁结局上通常无法与安慰剂分开。[3]另一个关键的方法论问题似乎是抑郁症的严重程度。在中老年人中进行的几项轻度至中度重度抑郁症的药理学试验报告了高安慰剂应答率，这一事件在一项安慰剂对照的运动研究中显示，该研究还包括抗抑郁药。4在60岁以上的成年人中，纳入轻度至中度锡永的个体似乎对显示锻炼的疗效很重要。相比之下，招募老年人样本，随后评估抑郁症症状的严重程度（即，不需要抑郁症测量的最低分数）可能会导致研究表明，运动不能预防或减少抑郁症症状。安德伍德及其同事注意到，无论是在整个队列中，还是在基线时具有临床显著抑郁症的患者中，都没有证据表明对抑郁症症状有有益影响（基线时抑郁症患者6个月时GDS-15评分的平均差异为0· 22 [95.
Does exercise help older depressed adults? This question is rather simple, and one would intuit a simple answer: yes. Yet, as studies such as those reported by Martin Underwood and colleagues1 in The Lancet remind us, some investigators have found it challenging to show an actual benefit on depression from exercise. Underwood and colleagues did a cluster-randomised controlled trial in which they enrolled 891 elderly residents (aged 65 years or older) of 78 care homes in England. 35 intervention homes received twice-weekly group exercise classes for residents, along with ac tivity promotion among staff and residents and depressionawareness training for staff. 43 control homes received only depression-awareness training for staff. At the end of the 12-month study, depression scores (measured with the geriatric depression scale-15 [GDS-15]) did not differ between intervention and control groups (mean difference in GDS-15 score 0· 13 [95% CI–0· 33 to 0· 60]). The absence of consistency of results across trials of exercise in geriatric depression is probably multi factorial in origin, related to heterogeneity of study samples; differences in intervention type, implementation strategy, and comparator condition; and variability in placebo response. Simply stated, the joining of the concepts of exercise and geriatric depression outcomes creates sufficient methodological complexity that negative results become inevitable. Inclusion criteria seem to have a substantial effect on results. For example, a systematic review by Bridle and colleagues2 of exercise and depression severity concluded that “for older people who present with clinically meaningful symptoms of depression, prescribing structured exercise tailored to individual ability will reduce depression severity”. 2 To be included for review, Bridle and colleagues required that participants be clinically depressed and at least 60 years old. Such criteria are typical for geriatric exercise intervention trials and tend to lead to study samples of individuals with mild to moderate depression with a mean age younger than 75 years, making them most representative of clinically depressed younger old people. In fact, seven of nine studies included in the analysis had samples with a mean age of younger than 75 years; two others had mean ages of older than 82 years (one focusing on depression in Alzheimer’s disease). In Underwood and colleagues’ study, the mean age was 86· 5 years (range 65–107). Mean age in antidepressant trials is salient; in pharmacological trials of patients older than 75 years (older old people), study drugs often fail to separate from placebo on depression outcome. 3 Another key methodological issue seems to be severity of depression. Several pharmacological trials of mild to moderate major depression in middle aged and older adults have reported high placebo response rates, an event that was shown in a placebo-controlled study of exercise that also included an antidepressant drug. 4 In adults older than 60 years, inclusion of individuals with mild to moderate depres sion seems to be important to show efficacy of exercise. By contrast, recruitment of samples of older adults that subsequently characterise depression symptom severity (ie, do not require a minimum score on a depression measure for inclusion) might result in studies which show that exercise does not prevent or decrease depression symptoms. Underwood and colleagues noted no evidence of a beneficial effect on depression symptoms, either among the entire cohort or among those with clinically significant depression at baseline (mean difference in GDS-15 score at 6 months in residents depressed at baseline 0· 22 [95 …