KAUNAS UNIVERSITY OF MEDICINE
Sigita Saudargienė
EFFECTS OF PHYSICAL EXERCISE
ON TREATMENT OF PATIENTS
WITH SEVERE DEPRESSION
Summary of the Doctoral Dissertation Biomedical Sciences, Nursing (11 B)
The dissertation was prepared in the period 2004–2008 at Institute of
Psychophysiology and Rehabilitation c/o Kaunas University of Medicine and Psychiatric Department of Telšiai District Hospital.
Scientific Supervisor:
Prof. Dr. Habil. Giedrius Varoneckas (Institute of Psychophysiology and Rehabilitation c/o Kaunas University of Medicine, Biomedical Sciences, Nursing – 11 B).
Scientific Consultant:
Dr. Habil. Robertas Bunevičius (Institute of Psychophysiology and Rehabilitation c/o Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B).
The dissertation will be defended at the Nursing research council of Kaunas University of Medicine:
Chairman:
Dr. Jūratė Macijauskienė (Kaunas University of Medicine, Biomedical Sciences, Nursing – 11 B)
Members:
Dr. Virginija Adomaitienė (Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B)
Prof. Dr. Habil. Alfonsas Vainoras (Kaunas University of Medicine, Biomedical Sciences, Nursing – 11 B)
Dr. Vidmantas Alekna (Vilnius University, Biomedical Sciences, Nursing – 11 B) Prof. Dr. Habil. Jonas Poderys (Lithuanian Academy of Physical Education, Biomedical Sciences, Biology – 01 B)
Opponents:
Prof. Dr. Habil. Vita Lesauskaitė (Kaunas University of Medicine, Biomedical Sciences, Nursing – 11 B)
Prof. Dr. Audronius Vilkas (Vilnius Pedagogical University, Social Sciences, Education – 07 S)
The dissertation will be defended at the open session of Nursing research council on the 28th August 2009, at 10 a.m. in the small auditorium of Teaching-Laboratory Building at Kaunas University of Medicine.
Address: Eivenių 4, LT-50009, Kaunas, Lithuania.
The summary of the doctoral dissertation was distributed on 28th July 2009. The dissertation in full text is available in the Library of Kaunas University of Medicine. Address: Eivenių 6, LT–50161 Kaunas, Lithuania.
KAUNO MEDICINOS UNIVERSITETAS
Sigita Saudargienė
FIZINĖS MANKŠTOS POVEIKIS GYDANT
SERGANČIUOSIUS SUNKIA DEPRESIJA
Daktaro disertacijos santrauka Biomedicinos mokslai, slauga (11 B)
Disertacija rengta 2004–2008 metais Kauno medicinos universiteto Psichofiziologijos ir reabilitacijos institute ir Telšių apskrities ligoninės psichiatrijos skyriuje.
Mokslinis vadovas
prof. habil. dr. Giedrius Varoneckas (Kauno medicinos universiteto
psichofiziologijos ir reabilitacijos institutas, biomedicinos mokslai, slauga − 11 B)
Mokslinis konsultantas
habil. dr. Robertas Bunevičius (Kauno medicinos universiteto Psichofiziologijos ir reabilitacijos institutas, biomedicinos mokslai, medicina − 07 B)
Disertacija ginama Kauno medicinos universiteto Slaugos mokslo krypties taryboje:
Pirmininkas
doc. dr. Jūratė Macijauskienė (Kauno medicinos universitetas, biomedicinos mokslai, slauga – 11 B)
Nariai:
doc. dr. Virginija Adomaitienė (Kauno medicinos universitetas, biomedicinos mokslai, medicina – 07 B)
prof. habil. dr. Alfonsas Vainoras (Kauno medicinos universitetas, biomedicinos mokslai, slauga – 11 B)
do. dr. Vidmantas Alekna (Vilniaus universitetas, biomedicinos mokslai, slauga – 11 B)
prof. habil. dr. Jonas Poderys (Lietuvos kūno kultūros akademija, biomedicinos mokslai, biologija – 01 B)
Oponentai:
prof. habil. dr. Vita Lesauskaitė (Kauno medicinos universitetas, biomedicinos mokslai, slauga – 11 B)
prof. dr. Audronius Vilkas (Vilniaus pedagoginis universitetas, socialiniai mokslai, edukologija – 07 S)
Disertacija bus ginama viešame Slaugos krypties tarybos posėdyje 2009 m. rugpjūčio 28 d. 10 val. Kauno medicinos universiteto klinikų Mokomosios laboratorijos korpuse Mažojoje auditorijoje.
Adresas: Eivenių 4, LT-50009 Kaunas, Lietuva.
Disertacijos santrauka išsiuntinėta 2009 m. liepos 28 d.
Disertaciją galima peržiūrėti Kauno medicinos universiteto bibliotekoje. Adresas: Eivenių 6, LT-50161 Kaunas, Lietuva.
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ABBREVATION
∆RRB Maximal heart rate response to AOTAOT Active orthostatic test BDI Beck Depression Inventory CI Confidence interval CNS Central nervous system
GHP General health perception
HADD Hospital Anxiety and Depression Scale, depression
HADN Hospital Anxiety and Depression Scale, anxiety
HFC High frequency component
HR Heart rate
LFC Low frequency component MH Mental heath
P Pain
PF Physical function
PSQI Pittsburgh Sleep Quality index
RE Role limitation due to emotional problems RP Role limitation due to physical problems RRB Maximum heart rate during standing-up
SF Social functioning
SF-36 The Medical Outcomes Study 36 Item Short Form Health Survey VLFC Very low frequency component
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1. INTRODUCTION
Physical exercising and physical fitness has a positive impact on health status because a physical activity is a major element of optimal health and positive emotions (Sallis, 1996; Heath, 1997). In psychiatric patients the physical exercise has many psychological and emotional benefits. It is argued that exercising increases one’s self-confidence as well as provides a feeling of accomplishment and mastery, which in turn may raise an individual’s overall outlook (Van Copennole, 1995). In addition to the increase in self-esteem, exercise can also provide a more grounded perspective on life (Knubben, 2007). However, in the management of patients with severe depression the physical exercise programmes are not involved widely. There are no developed physical exercise programmes based on patient‘s cardiovascular functional status and physical fitness for patients with severe depression. It is not yet clear how and in what way the physical exercise can reduce the severity of symptoms in depressed patients.
The hypothesis of the study was that involvement of physical training programme in the management of severe depression has a positive impact on psychoemotional status, sleep quality and health-related quality of life as well as on cardiovascular function.
The aim of the study was to develop a programme of physical training for patients with severe depression and to assess the impact on psychoemotional status, sleep quality and health-related quality of life as well as on cardiovascular function.
The objectives of the study:
1. To develop a physical training programme for patients with severe depression.
2. To assess the impact of physical training on psychoemotional status, sleep quality, and health-related quality of life in patients with severe depression.
3. To assess the impact of physical training on psychoemotional status, sleep quality and health-related quality of life in relation to the patients’ gender and age.
4. To assess the impact of physical training on cardiovascular function in patients with severe depression
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The scientific novelty of the study.
For the first time in Lithuania the programme of physical training for patients with severe depression was developed and evaluated its impact on psychoemotional status, sleep and health related quality of life as well as on cardiovascular function. The involvement of physical training in the management of patients with severe depression demonstrated a positive impact on attenuation of depression and anxiety symptoms and improvement of sleep and health related quality of life. Aerobic exercise can produce substantial improvement in mood of patients with severe depression in a one-month period. For the first time the evaluation of cardiovascular function during the physical training period in patients with severe depression was performed. The results show that improvement of cardiovascular function and increased physical fitness has a positive impact on psychoemotional status, sleep, and health related quality of life in patients with severe depression.
Practical significance.
It was clearly demonstrated that physical exercise training has positive effect not only on patient’s cardiovascular function, but also on psychoemotional status, sleep, and health related quality of life in patients with severe depression. Development and implementation of physical exercise programme might be effective in improving depression in patients with severe depression.
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2. METHODS
Clinical examination was performed by physician-psychiatrist.
Depression and its severity were diagnosed according International Disease Classification 10. Selective serotonin reabsorbtion inhibitors and anxiolytics (mainly benzodiazepines) were included into the standard pharmacological treatment for depression. The drugs were not modified during 1-month period of treatment. The patient examination was performed on the first or second day of patient admission and after 30-day period of in-patient treatment.
Physical exercise training programme containing aerobic moderate
intensity exercises was provided to patients 5 times per week. Duration of every session was 60 min.
Psychoemotional status was tested according Beck Depression Inventory. The BDI measures attitudes and symptoms that are
characteristic of depression, including mood, pessimism, sense of failure, lack of satisfaction, guilt, sense of punishment, self-hate, self accusations, self punitive wishes, crying spells, irritability, social withdrawal, indecisiveness, body image, work inhibition, sleep disturbance, fatigability, loss of appetite, weight loss, somatic preoccupation, and loss of libido. Total scores are sum of 21 item scores. Scores range from low of 0 to high of 63. These researchers interpreted scores of 5-9 as indicating no or minimal depression, 10-18 as indicating mild to moderate depression, 19-29 as indicating moderate to severe depression, 30-63 as indicating severe depression.
Hospital Anxiety and Depression Scale was used for assessment of
psycho-emotional status. This is a self-screening questionnaire for depression and anxiety. It consists of 14 questions, seven for anxiety and seven for depression. Each item is rated on a four-point scale, giving maximum scores of 21 for anxiety and depression. Scores of 11 or more on either subscale are considered to be a significant „case“ of psychological morbidity, while scores of 8–10 represents „borderline“ and 0–7 „normal“. Cronbachs alpha coefficient for anxiety was 0.81, for depression – 0.81.
Pittsburgh Sleep Quality Index (PSQI) was used for assessment of subjective sleep quality. PSQI is a self-rated questionnaire, which assesses
sleep quality and disturbances over a 1-month time interval. Nineteen individual items generate seven component scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction. The
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sum of scores for these seven components yields one global score, with has a range of 0-21; higher scores indicate worse sleep quality. Sleep quality: no sleep complaints – PSQI≤5, episodically sleep disturbances – 5<PSQI≤10, moderate sleep disturbances – 10<PSQI≤15, severe sleep disturbances – 15<PSQI≤21. Cronbach’s alpha coefficient was 0.7.
The Medical Outcomes Study 36 Item Short Form Health Survey (SF-36), translated to Lithuanian language was used to quantify general
health-related quality of life. It consist of 36 items in eight health domains: physical functioning (PF), role limitations due to physical problems (RP), bodily pain (P), general health perceptions (GHP), vitality (VT), social functioning (SF), role limitation due to emotional problems (RE), and general mental health (MH). In addition, the eight scales yield two summary scales of health, relating to physical (the Physical Component Summary (PCS)) and mental (the Mental Component Summary (MCS)) functioning and well-being. All SF-36 scales demonstrated acceptable internal consistency, with Cronbach’s alpha ranging from 0.71 to 0.94, except social functioning scale (Cronbach’s alpha 0.64).
Active orthostatic test (AOT) was performed before and after the
treatment. The rhythmogram (a sequence of RR intervals of ECG) was recorded while the person was lying quietly in supine position for 5 minutes, while standing up, then while standing up for 5 minutes, while the patient was lying down, and when the person was lying for 5 minutes. When the patient was lying down and when he was standing up the arterial blood pressure was measured using Korotkov’s method. The following parameters were analyzed: mean heart rate (HR) frequency, maximal HR frequency during standing-up (RRB), maximal HR response to AOT
(∆RRB), and minimal HR frequency (RRC) during standing-up.
Fig. 2.1. Rhythmographic recording of heart rate during
active orthostatic test
Heart rate power spectrum analysis was used for assessment of autonomic heart rate control which clearly correlates to cardiovascular
RR, ms
RRB
RRC
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function adaptability and physical fitness. HR frequency, total dispersion (σRR), absolute values of very low frequency (VLFC), low frequency (LFC) and high frequency components (HFC) as well as the relative values (NVLFC, NLFC, NHFC) of the same components were measured in the lying position at rest.
Statistical analysis of the data was performed using „Statistica“ and
„SPSS“ software packages. Averages, biases, standard deviations (SD), and dispersion were; reliability of difference of averages between two independent groups was assessed using Student‘s criterion. The difference was considered to be reliable when p≤0.05, the trend of differences was assessed when 0.05≤p<0.1. The relationship of quantitative characteristics was calculated using correlation and regression analysis. χ2 criterion was used to evaluate the frequency of occurring of clinical sings. Pearson’s χ2 criterion was used to asses informative value of the data. The absolute values of HR and circulation parameters during different stages of the sleep reflect physiological reactions in different group of examined individuals rather insufficiently; therefore the changes of these parameters were assessed in relative baseline – based values. Relative changes of HR were calculated considering the level at the baseline to be 100 percent.
3. CONTINGENT
The contingent included 192 patients (average age 45.5 yr., range 20–67 yr.), 68 males (31.8%, average age 45.6 yr. (21–66 yr.) and 131 females (68.2%, average age 45.8 yr. (20–67 yr.)) with severe depression diagnos-ed according to the International Statistical Classification of Diseases and Related Health Problems (10th Revision) criteria. Bipolar affective disorder was diagnosed in 6 patients, first severe depressive episode in 22 patients, and recurrent severe depressive episode in 164 patients.
All patients randomly were distributed into two groups: physical exercise group – 124 patients (37 males, 29.8% and 87 females, 70.2%) and control group – 68 patients (24 males, 35.3% and 44 females, 64.7%). All patients were under standard pharmacological treatment by selective serotonin reuptake inhibitors and benzodiazepines prescribed by physician psychiatrist for the entire period of the study. All patients were examined twice: before the study and 4 weeks after the first examination.
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4. RESULTS AND DISCUSSION
4.1. Development of physical exercise programme for patients with severe depression.
The physical exercise programme for patients with severe depression was developed to increase their level of physical activity, to reduce symptoms of stress, depression, and anxiety and to motivate them for more active life-style. The main reason for this programme is that exercising has positive effects on patient’s body and mind. In support of the psychological benefits, it is argued that exercising increases one’s self-confidence as well as provides a feeling of accomplishment and mastery, which in turn may raise an individual’s overall outlook. Continuous moderate intensity aerobic exercises were employed. It is important to note that prescribed exercises were not difficult to fulfil and they were appealing to the patient.
The physical exercises programme included three parts: 1) Introductory part (15 min. period); 2) Exercising part (30 min. period); and 3) Relaxation part (15 min. period) (Figure 4.1). The 60 min training session was executed on daily basis.
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Introductory part mainly included deep-breathing exercises, movements of upper body and extremities, tip toes, and knee-bending. Strength training exercises for muscle tension were involved as well.
Exercise programme included exercises to improve body balance, muscle force, and endurance. It starts from exercises with a ball, follows with exercises of body bending, raising the legs and back arch, and finishes with squats, hand swings and exercising on a bicycle.
Relaxation part included deep-breathing exercises.
The physical exercises and aerobic activity, strength or flexibility training all proved to be effective in treating patients with severe depression. This is because the focus of this treatment is not so much on the cardiovascular exercise and the physiological effects it produces, but more important is the physical activity itself and the effects it carries on the mind.
4.2. Impact of physical exercises on patient’s psychoemotional status, sleep, and health related quality of life.
Before physical training programme the level of depression in both groups, physical exercise and control, did not significantly differ according Beck depression scale (36.1 and 36.7 in physical exercise and control groups, respectively) as well as according HAD scale (depression 15.7 and 16.1, anxiety 17.0 and 17.7, respectively) (Table 4.2.1). Pittsburgh sleep quality index in both groups (17.3 and 17.6 respectively) did not differ significantly. Comparison of the SF-36 scales between the groups did not demonstrate significant changes (Table 4.2.1).
After physical exercise programme the level of depression significantly decreased (according Beck depression scale 23.9 and 34.2 in physical exercise and control groups, respectively) as well as according HAD scale (Depression 6.9 and 13.9, anxiety 8.9 and 15.6, respectively), as compared with control group, which did not received the physical training (Table 4.2.1). These results demonstrate positive effect of physical exercises on the psychoemotional status of patients with severe depression. The sleep quality in patients involved in physical exercise programme was much better as compared with the control group patients (8.5 and 16.7, respectively). The SF-36 scales demonstrated also positive changes in the physical exercise group patients (Table 4.2.1).
Significant improvement of psychoemotional status, the level of depress-sion and anxiety symptoms, after 4 weeks of standard
pharmacolo-13
gical treatment in in-patient department was observed in both groups, physical exercise and control ones. However, the level of changes is different in both groups. If symptoms of depression according to Beck depression scale decreased from 36.7 to 34.2 in control group only, the physical exercise group demonstrated more significant improvement – Beck depression scale decreased from 36.1 to 23.9. Changes in HAD scale were more positive in physical exercise group as well (Table 4.2.1).
Table 4.2.1. Characteristics of depression, anxiety, sleep, and health
related quality of life in physical exercise and control group patients with severe depression before and after treatment
Physical exercise group Control group Before treatment (95% CI) After treatment (95% CI) Before treatment (95% CI) After treatment (95% CI) p<0.05 p<0.1 1 2 3 4 BDID 36.1 (35.3–36.9) 23.9 (22.8–24.8) 36.7 (36.0–37.5) 34.2 (33.0–35.5) 1:2; 2:4; 3:4 HADA 17.0 (16.0–17.5) 8.9 (8.6–9.2) 17.7 (17.2–18.3) 15.6 (14.7–16.5) 1:2; 2:4; 3:4 1:3 HADD 15.7 (15.1–16.3) 6.9 (6.5–7.2) 16.1 (15.4–16.8) 13.9 (12.9–15.0) 1:2; 2:4; 3:4 PSQI 17.3 (16.8–17.7) 8.5 (8.1–8.9) 17.6 (17.1–18.2) 16.7 (16.0–17.4) 1:2; 2:4; 3:4 PF (37.7–46.0) 41.9 (73.5–79.5) 76.5 (32.4–42.7) 37.6 (35.5–47.1) 41.3 1:2; 2:4 RP (5.8–16.4) 11.1 (73.9–85.8) 79.8 (2.9–14.7) 8.8 (4.6–19.6) 12.1 1:2; 2:4 RE (–0.41–3.1) 1.3 (64.9–77.6) 71.2 0.0 2.9 (–1.2–7.1) 1:2; 2:4 SF (15.9–21.4) 18.6 (64.0–69.9) 66.9 (11.6–17.5) 14.5 (19.2–27.5) 23.4 1:2; 2:4; 3:4 1:3 P (46.1–54.1) 50.1 (63.3–70.7) 67.0 (41.1–50.4) 45.7 (43.5–52.9) 48.2 1:2; 2:4 MH (17.0–20.3) 18.7 (52.2–57.5) 54.8 (14.9–19.2) 17.1 (19.3–25.0) 22.2 1:2; 2:4; 3:4 VT (6.3–9.4) 7.9 (45.4–51.1) 48.3 (5.0–8.5) 6.8 (10.2–16.4) 13.3 1:2; 2:4; 3:4 GHP (10.4–14.8) 12.6 (38.8–44.2) 41.5 (8.7–14.9) 11.8 (9.3–15.7) 12.5 1:2; 2:4
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Subjective sleep quality statistically significantly improved in the physical exercise group, as compared with the control group (17.3 and 8.5, respectively). In the physical exercise group, the health related quality of sleep was significantly better in all scales of SF-36, while in the physical exercise group the statistically significant improvement was observed in scales of social function, mental health, and energy/vitality, however, in the control group the level of changes was expressed less (Table 4.2.1). Because of that, we analyzed the changes in all questionnaires before and after the treatment in both groups (Table 4.2.2). The level of depression evaluated by Beck depression scale after the treatment in the physical exercise group, as compared with the control one, was 5 time less expressed (–12,2 and –2,6, respectively). Depression and anxiety evaluated by HAD scale after the treatment was less expressed in the physical exercise group, as compared with the control one (Table 4.2.2).
Improvement of subjective sleep quality evaluated by PSQI, was more expressed in the physical exercise group as compared with the control one (–8.8 and –1.0, respectively). Significant changes were observed in SF-36 scale evaluation. If the general health perception score improved by 28.9 in the physical exercise group, then the control group demonstrated only slight improvement by 0.7 score (Table 4.2.2)
Table 4.2.2. The difference in scores before and after treatment in the
physical exercise and control group patients with severe depression
Physical exercise group (95 % СI) Control group (95 % СI) p<0.05 p<0.1 BDID –12.2(–13.0; –11.5) –2.6(–3.7; –1.6) * HADA –8.1(–8.6; –7.6) –2.1(–2.7; –1.5) * HADD –8.9(–9.4; –8.3) –2.1(–2.9; –1.4) * PSQI –8.8(–9.4; –8.2) –1.0(–1.6; –0.32) * PF 34.6(31.2–38.1) 3.7(0.51–7.0) * RP 68.7(61.4–76.1) 3.3(–1.6–8.2) * RE 69.9(63.4–76.4) 2.9(–1.2–7.1) * SF 48.3(44.9–51.7) 8.8(5.3–12.3) * P 16.9(14.0–19.9) 2.4(0.49–4.4) * MH 36.2(32.9–39.4) 5.1(2.6–7.6) * VT 40.4(37.2–43.6) 6.5(3.7–9.3) * GHP 28.9(25.9–31.9) 0.7(–1.6–3.03) *
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The results demonstrate that complementary physical exercise programme during the standard pharmacological treatment significantly improves the psychoemotional status, decreases the level of depression and anxiety as well as improves sleep quality and health related quality of life. It might be supposed that increased physical fitness and improved cardiovascular function have a positive impact on psychoemotional status. Many psychological and emotional benefits of exercise on depression or anxiety was demonstrated by other authors (Paluska, 2000; Bahrke, 1978; Scully, 1998; Yeung, 1996) who stated that during physical exercise the patient paid attention to pain stimulus. Attraction to new stimulus improves patient’s mood (Osei-Tutu, 1998; 2005). Ability to perform new physical exercise, communicate to people is also important element which has a positive influence on patient’s self-esteem and mood. Being physically active gives you a sense of accomplishment. Meeting goals or challenges, no matter how small, can boost self-confidence at times when you need it the most. Exercise can also make you feel better about your appearance and your self-worth. Exercise can shift the focus away from unpleasant thoughts to something more pleasant, such as your surroundings or the music you enjoy listening to while you exercise. Depression and anxiety can lead to an isolation. That, in turn, can worsen your condition. Exercise may give you the chance to meet or socialize with others, even if it's just exchanging a friendly smile or greeting as you walk around your neighbourhood.
The serotonin level in the brain is decreased in patients with depression, because the gold standard treatment on selective serotonin reuptake inhibitors increases serotonin level. However, an increase of serotonin after physical exercise was demonstrated by Chaouloff (Chaouloff, 1989). These findings might explain the positive effect of exercise on person’s mood and mental health. Aerobic physical exercise improves mood in patients with depression (Dimeo, 2001). These data confirm our results regarding the positive effect of physical exercise programme in patients with severe depression.
4.3. Impact of physical exercise on the level of depression and anxiety in responders and non-responders groups
Impact of physical exercise programme on patient’s psychoemotional status was evaluated according to the changes in scores of Beck depression scale and HAD scale. If the score decreased by 50 percent or more from the baseline level, the patient was included in „responders“ group, if the score
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decreased less than 50 percent – in „non-responders“ group (Table 4.3.1). According Beck depression scale there were no „responders“ in the control group, while in the physical exercise group we found 5.6% of patients in „responders“ group. Thus, in the physical exercise group, as compared with the control one, we observed significantly more „responders“.
According to the HAD depression scale, we observed 70.2% „responders“ and 29.8% „non-responders“ in the physical exercise group and 2.9% „responders“ and 97.1% „non-responders“ in the control group (Table 4.3.1). These results clearly demonstrate very positive effect of physical training on patient’s depression level during 4-week period treatment. The positive effect was observed on patient’s anxiety level too. We observed 41.9% „responders“ and 58.1% „non-responders“ in the physical exercise group and 0.5% and 98.5%, respectively, in the control group.
Table 4.3.1. Responders and non-responders according to the Hospital
Anxiety and Depression scale and Beck depression scale in the physical exercise and the control groups
HADA HADD HADAD BDID
N (%)
Physical exercise group
A) „responders“ 52(41.9%) 87(70.2%) 44(59.5%) 7(5.6%) B) „non-responders“ 72 (58.1%) 37(29.8%) 30(40.5%) 117(94.4%) Control group C) „responders“ 1(0.5%) 2(2.9%) 1(1.5%) 0(0.0%) D) „non-responders“ 67(98.5%) 66(97.1%) 66(98.5%) 68(100%) p<0.05 A:B; B:D; C:D A:B; A:C; B:D; C:D B:D A:B; B:D
4.4. Impact of physical exercise on patient’s psychoemotional status, sleep, and health related quality of life in male and female patients
with severe depression
Patients with severe depression were distributed according to gender. There were 37 males and 87 females in the physical exercise group and 24 males and 44 females in the control group. All groups did not significantly differ according to age. The males, as compared with females, were higher and heavier, but body mass index did not differ significantly between males and females in both groups.
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Before physical training programme the level of depression according to the Beck depression scale did not significantly differ in males and females of both groups, physical exercise and control (Table 4.4.1). According to the HAD scale there was no statistically significant difference in the level of depression and anxiety between males and females in the physical exercise group, but in the control group we observed more expressed depression and anxiety in females than in males (Table 4.4.2).
Table 4.4.1. Characteristics of depression, anxiety, sleep, and health
related quality of life before and after the treatment in physical exercise group patients with severe depression distributed according to gender
Male group Female group Before treatment (95% CI) After treatment (95% CI) Before treatment (95% CI) After treatment (95% CI) p<0.05 p<0.1 1 2 3 4 BDID 35.5 (34.4–36.6) 23.0 (21.1–25.0) 36.3 (35.3–37.3) 24.2 (23.0–25.5) 1:2; 3:4 HADA 17.3 (16.7–18.0) 8.7 (8.1–9.3) 16.9 (16.3–17.5) 9.0 (8.6–9.4) 1:2; 3:4 HADD 15.9 (15.0–16.8) 6.6 (5.9–7.3) 15.6 (14.9–16.4) 7.0 (6.5–7.4) 1:2; 3:4 PSQI 17.9 (17.2–18.5) 8.1 (7.4–8.8) 17.0 (16.4–17.6) 8.6 (8.1–9.1) 1:2; 3:4 1:3 PF (40.6–54.0) 47.3 (78.7–88.4) 85.5 (34.4–44.8) 39.6 (69.9–77.2) 73.6 1:2; 2:4; 3:4 1:3 RP (0.17–17.4) 8.8 (84.6–97.8) 91.2 (5.3–18.8) 12.1 (67.1–82.9) 75.0 1:2; 2:4; 3:4 RE 0.00 85.6 (77.9–93.2) (–0.59–4.4) 1.9 (57.0–73.3) 65.1 1:2; 2:4; 3:4 SF (12.7–18.6) 15.6 (65.4–73.9) 69.7 (16.2–23.6) 19.9 (61.9–69.6) 65.8 1:2; 3:4 P (49.4–61.7) 55.5 (60.8–74.3) 67.6 (42.7–52.8) 47.8 (62.2–71.3) 66.8 1:2; 3:4 1:3 MH (16.7–20.9) 18.8 (56.8–65.8) 61.3 (16.4–20.8) 18.6 (48.9–55.3) 52.1 1:2; 2:4; 3:4 VT (5.0–9.0) 7.0 (49.0–58.0) 53.5 (6.2–10.3) 8.2 (42.4–49.6) 46.0 1:2; 2:4; 3:4 GHP (10.4–17.9) 14.2 (41.0–50.7) 45.9 (9.2–14.6) 11.9 (36.4–42.9) 39.6 1:2; 2:4; 3:4
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Before physical training programme, the Pittsburgh sleep quality index did not differ statistically significantly in males and females of both groups, physical exercise and control, but the males, as compared with females, in the physical exercise group had a tendency (p<0.1) to a higher PSQI score (worse sleep quality). The score of SF-36 scales did not differ significantly between males and females in both groups too (Table 4.4.2).
Table 4.4.2. Characteristics of depression, anxiety, sleep, and health
related quality of life before and after the treatment in the control group of patients with severe depression distributed according to gender
Male group Female group Before treatment (95% CI) After treatment (95% CI) Before treatment (95% CI) After treatment (95% CI) p<0.05 p<0.1 1 2 3 4 BDID 36.8 (35.6–38.0) 33.2 (30.8–35.5) 36.7 (35.8–37.6) 34.8 (33.3–36.3) 1:2; 3:4 HADA 16.8 (15.9–17.6) 13.8 (12.6–14.9) 18.2 (17.5–18.9) 16.6 (15.5–17.7) 1:2; 1:3; 2:4; 3:4 HADD 14.5 (13.5–15.5) 11.7 (10.5–13.0) 16.9 (16.0–17.8) 15.1 (13.7–16.5) 1:2; 1:3; 2:4; 3:4 PSQI 17.3 (16.3–18.3) 16.1 (14.8–17.4) 17.8 (17.1–18.6) 17.0 (16.1–17.8) PF (40.4–52.9) 46.7 (42.3–61.0) 51.7 (25.7–39.5) 32.6 (28.6–42.7) 35.7 1:3; 2:4 RP (–0.90–5.1) 2.1 (–3.5–14.0) 5.2 (3.6–21.4) 12.5 (5.3–26.5) 15.9 1:3 RE 0.0 4.2 (–4.4–12.8) 0.0 2.3 (–2.3–6.8) SF (11.8–20.6) 16.2 (22.1–31.2) 29.6 (9.6–17.6) 13.6 (15.1–24.8) 19.9 1:2; 2:4; 3:4 P (43.1–55.1) 49.1 (42.6–56.5) 49.5 (37.4–50.5) 43.9 (41.0–53.9) 47.5 MH (15.4–22.3) 18.8 (21.3–32.3) 26.8 (13.3–18.8) 16.1 (16.5–22.7) 19.6 1:2; 2:4 3:4 VT (4.7–10.7) 7.7 (12.3–24.0) 18.1 (4.0–8.4) 6.2 (7.2–14.1) 10.7 1:2; 2:4; 3:4 GHP (6.1–12.2) 9.2 (7.5–16.6) 12.1 (8.7–17.7) 13.2 (8.3–17.1) 12.7
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After the physical training programme, the improvement of psychoemotional status was observed in males and females (Table 4.4.2 ). The level of depression evaluated by Beck depression scale decreased at the same level in males and females. Statistically significant differences were observed after the treatment, but not between male and female groups. Depression and anxiety level evaluated by HAD scale before and after the treatment in males and females demonstrated similar changes (Table 4.4.1).
Males and females did not demonstrate significant differences in subjective sleep quality evaluated before and after the treatment, however health related quality of life was better in males, as compared with females (Table 4.4.1). After physical exercise programme, the better general health perception, physical function, role limitation due to physical problems, role limitation due to emotional problems, mental health, and energy/vitality were observed in males, as compared with females. Improvement in social function and pain scales after the treatment was observed in both, males and females.
In control group after the treatment, the level of depression evaluated by Beck depression scale was decreased significantly in both males and in females (Table 4.4.2). However, no significant changes were observed between male and female groups. There were no significant changes between male and female groups before and after the treatment in subjective sleep quality and health related quality of life too.
Analysis of the changes in all questionnaires before and after the treatment in male and female groups did not demonstrate any statistically significant differences (Table 4.4.3).
The level of depression evaluated by the Beck depression scale after the treatment was more expressed in the physical exercise group, in both groups males and females (–12.5 and –12.1, respectively), as compared with ones in the control, (–3.6 and –2.1, respectively). Depression and anxiety evaluated by HAD scale after the treatment was less expressed in the physical exercise group, as compared with the control one (Table 4.4.3). These results demonstrate that the physical activity, but not the sex differences have influence on diminution of depression level during the treatment.
Improvement of subjective sleep quality evaluated by PSQI, was observed in the physical exercise group, as compared with the control one, however more expressed changes were demonstrated in males than females (Table 4.4.3). Dramatical changes were observed in SF-36 scale
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evaluation. If the general health perception score improved by 28.9 in the physical exercise group, the control group demonstrated only slight improvement by 0.7 score (Table 4.4.3)
Table 4.4.3. The difference in scores before and after the treatment in
physical exercise and control groups distributed according to gender
Physical exercise group Control group Males (95 % СI) Females (95 % СI) Males (95 % СI) Females (95 % СI) p<0.05 p<0.1 1 2 3 4 BDID –12.5 (–13.8;–11.2) –12.1 (–13.1;–11.1) –3.6 (–5.7;–1.5) –2.1 (–3.3;–0.97) 1:3; 2:4 HADA –8.6 (–9.5;–7.8) –7.9 (–8.5;–7.3) –3.0 (–4.0;–2.0) –1.6 (–2.4;–0.83) 1:3; 2:4; 3:4 HADD –9.3 (–10.3;–8.4) –8.7 (–9.4;–8.0) –2.7 (–4.1;–1.3) –1.8 (–2.7;–0.90) 1:3; 2:4 PSQI –9.7 (–10.6;–8.9) –8.4 (–9.1;–7.7) –1.2 (–2.2;–0.09) –0.86 (–1.7;–0.03) 1:2; 1:3; 2:4 PF (31.2–41.2)36.2 (29.5–38.5)34.0 (–1.9–11.9)5.0 (–0.48–6.6)3.1 1:3; 2:4 RP (72.2–92.6)82.4 (53.6–72.3)62.9 (–5.8–12.1)3.1 (–2.6–9.4)3.4 1:2; 1:3; 2:4 RE 85.6 (77.9–93.2) 63.2 (54.9–71.5) 4.2 (–4.4–12.8) 2.3 (–2.3–6.9) 1:2; 1:3; 2:4 SF (49.9–58.2)54.1 (41.4–50.3)45.8 (7.1–19.8)13.4 (2.2–10.5)6.3 1:2; 1:3; 2:4 3:4 P (7.9–16.1) 12.0 (15.2–22.8)19.0 (–2.8–3.7)0.46 (1.0–6.0) 3.5 1:2; 1:3; 2:4 MH (37.6–47.4)42.5 (29.4–37.5)33.5 (3.2–12.8)8.0 (0.67–6.4)3.5 1:2; 1:3; 2:4 3:4 VT (42.1–50.9)46.5 (33.7–41.9)37.8 (5.1–15.7)10.4 (1.2–7.6) 4.4 1:2; 1:3; 2:4; 3:4 GHP (26.0–37.4)31.7 (24.1–31.3)27.7 (–1.7–7.5)2.9 (–3.2–2.2)–0.52 1:3; 2:4
The positive changes in SF-36 scale scores after the treatment were observed in both, males and females of physical exercise and control groups. However, these changes in males, as compared with females, were observed expressed more significantly, especially in the physical exercise group. It demonstrates that physical exercise training programme, but not
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the gender differences, has more positive impact on psychoemotional status of patients with severe depression.
6.5. Impact of physical exercise on patient’s psychoemotional status, sleep, and health related quality of life in different age group patients
with severe depression
According to age, patients with severe depression were distributed into the two groups, younger (≤40 yrs) and older (>40 yrs) ones. There were 39 younger persons and 85 older ones in the physical exercise group, and 22 younger and 46 older ones in the control group. Both groups did not significantly differ according to age. The younger group patients, as compared with older ones, were higher and had less weight in both groups. Before physical training programme, the level of depression according to the Beck depression scale and HAD scale did not significantly differ in younger and older patients of both groups, physical exercise and control. In older patients of both groups, physical exercise and control, we observed statistically significantly increase of anxiety level according to the HAD scale and decreased subjective sleep quality. Scores of health related quality of life was more decreased in older patients than in younger ones.
After the physical training programme the improvement of depression level was more expressed in younger group of patients. Subjective sleep quality after the treatment did not differ between younger and older patients in both groups, physical exercise and control, however the better results were observed in the physical exercise group of patients. Health related quality of life after the treatment was better in younger patients in both groups, physical exercise and control.
The changes in all scales before and after the treatment in patients distributed according to the age demonstrate more positive changes in the physical exercise group, as compared with the control one. However, statistically significant differences were observed only in depression and anxiety level evaluated by the HAD scale and sleep quality (Table 4.5.1). The level of depression and anxiety decreased more in younger patients than in older ones of the physical exercise group, while in the control group no significant changes between younger and older patients were observed.
Improvement of subjective sleep quality evaluated by PSQI, was more expressed in younger patients of the physical exercise group, but no
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significant differences between younger and older patients in the control group were observed.
Table 4.5.1. The difference in scores before and after treatment in the
physical exercise and control groups distributed according to age
Physical exercise group Control group ≤40 yrs (95 % СI) >40 yrs (95 % СI) ≤40 yrs (95 % СI) >40 yrs (95 % СI)p<0,05 p<0,1 1 2 3 4 BDID –12.9 (–14.0;–11.7) –11.9 (–12.9;–10.9) –2,6 (–4.5;–0.6) –2.7 (–3.9;–1.4) 1:3; 2:4 HADA –9.1 (–10.1;–8.1) –7.6 (–8.2;–7.1) –2.7 (–4.0;–1.5) –1.8 (–2.5;–1.1) 1:2; 1:3; 2:4 HADD –10.2 (–11.1;–9.3) –8.3 (–8.9;–7.6) –2.2 (–3.4;–0.9) –2.1 (–3.1;–1.1) 1:2; 1:3; 2:4 PSQI –10.0 (–10.0;–11.1) –8.3 (–8.9;–7.6) –1.0 (–2.2; 0.1) –0.93 (–1.7;–0.1) 1:2; 1:3; 2:4 PF (30.9–42.6) 36.8 (29.3–38.0)33.6 (4.0–16.0)10.0 (–2.9–4.4)0.76 1:3; 2:4; 3:4; RP (56.1–84.9) 70.5 (59.3–76.6)67.4 (–5.6–19.2)6.8 (–2.9–6.2)1.6 1:3; 2:4 RE (63.9–86.5) 75.2 (59.4–75.4)67.4 (–4.9–14.0)4.5 (–2.2–6.5)2.2 1:3; 2:4 SF (50.7–62.1) 56.4 (40.5–48.5)44.6 (4.2–19.0)11.6 (3.5–11.4)7.5 1:2; 1:3; 2:4 P (18.1–30.9) 24.5 (10.5–16.5)13.5 (–0.08–6.1)3.0 (–0.4–4.7)2.2 1:2; 1:3; 2:4 MH 44.5 (39.1–50.0) 32.3 (28.5–36.2) 6.5 (1.4–11.7) 4.4 (1.5–7.3) 1:2; 1:3; 2:4 VT (41.2–53.9) 47.6 (33.6–40.6)37.1 (1.2–13.8)7.5 (3.0–9.1)6.1 1:2; 1:3; 2:4 GHP (25.3–38.3) 31.8 (24.3–30.9)27.6 (–3.4–5.8)1.2 (–2.4–3.2)0.43 1:3; 2:4
Health related quality of life was more improved in younger patients (social functioning, pain, mental health, and energy/vitality scores), than in older ones of the physical exercise group, while no significant changes in quality of life were observed between younger and older patients in the control group, except improved physical function score in younger patients.
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The results demonstrate that physical training programme has more positive effect in younger patients than in older ones on improvement of psychoemotional status, sleep, and health related quality of life. Similar results were obtained by Wallace (1992) demonstrating smaller effect of exercise training on mental health in older patients. North (1990) demonstrated the improvement of depression level after physical training in depressed patients with no clinically expressed symptoms which is more characteristic to younger patients.
Our results demonstrate more significant improvement in depression and anxiety level, sleep, and health related quality of life in younger patients of the physical exercise group.
4.6. Impact of physical exercise on cardiovascular function
The physical exercise group, as compared with the control one, did not differ according anthropomorphic data (age, sex, weight and height), psychoemotional status, sleep, and health related quality of life and heart rate variability pattern.
After the exercise treatment the level of depression according to the Beck depression scale and HAD scale was significantly lower in the physical exercise group patients. Subjective sleep quality and health related quality of life in all domains were significantly improved (Table 4.6.1).
Heart rate variability analysis in the physical exercise group patients demonstrate a decrease (p<0.1) of relative VLFC (61.1% and 53.9%, respectively before and after the treatment) and an increase of relative LFC (20.8% and 26.3%, respectively). It might be related to the beginning of restoration of autonomic heart rate control, a decrease of humoral and an increase of sympathetic input into the heart rate control. Maximal heart rate response to active orthostatic test ((∆RRB=24.6% and ∆RRB=27.1%,
p<0.1, before and after treatment, respectively) confirm an increase in parasympathetic heart rate control after the exercise treatment (Table 4.6.1).
In the control group, it was observed significant (p<0.05) decrease of anxiety level as well as sleep quality and health related quality of life in domains of social function and energy/vitality after 4 week period of standard treatment (Table 4.6.1). Depression symptoms demonstrated a tendency (p<0.1) to decrease, while heart rate variability pattern did not changed significantly.
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Table 4.6.1. Characteristics of depression, anxiety, sleep quality, and
quality of life and heart rate variability in the physical exercise and control groups before and after treatment
Physical exercise group Control group Before treatment (95% CI) After treatment (95% CI) Before treatment (95% CI) After treatment (95% CI) p<0,05 p<0,1 1 2 3 4 BDID 36,6 (35.3–37.9) 24.3 (22.5–26.1) 36.7 (35.7–37.7) 35.0 (33.3–36.7) 1:2;2:4 3:4 HADA 18.1 (17.3–18.8) 9.7 (9.0–10.4) 18.5 (17.8–19.2) 16.9 (15.7–18.1) 1:2;2:4;3:4 HADD 17.2 (16.3–18.1) 7.4 (6.7–8.2) 16.9 (15.9–17.9) 15.4 (14.0–16.8) 1:2;2:4 3:4 PSQI 17.9 (17.2–18.6) 9.6 (8.7–10.4) 18.3 (17.6–19.0) 17.5 (16.4–18.5) 1:2;2:4 PF 45.6 (39.6–51.6) 76.6 (71.4–81.8) 38.0 (30.7–45.2) 41.0 (32.6–49.4) 1:2;2:4 RP (5.1–23.9) 14.5 (65.9–88.1) 77.0 (1.1–16.1) 8.57 (3.6–27.8) 15.7 1:2;2:4 RE (–0.67–2.0) 0.67 (48.3–71.6) 60.0 0.00 5.71 (–2.4–13.8) 1:2;2:4 SF (11.2–17.6) 14.4 (57.3–68.0) 62.7 (7.5–16.0) 11.7 (14.7–27.2) 20.9 1:2;2:4; 3:4 P (43.5–59.2) 51.3 (67.8–79.3) 73.6 (39.4–53.3) 46.3 (41.7–56.7) 49.2 1:2;2:4 MH (15.3–20.7) 18.0 (46.6–55.6) 51.1 (12.4–18.2) 15.3 (15.6–23.9) 19.8 1:2;2:4 3:4 VT (3.8–9.2) 6.50 (38.7–49.3) 44.0 (2.5–7.0) 4.71 (5.8–15.1) 10.4 1:2;2:4; 3:4 GHP (12.6–19.2) 15.9 (34.8–43.5) 39.1 (8.7–17.3) 13.0 (6.8–16.1) 11.4 1:2;2:4
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Continue Table 4.6.1.
Physical exercise group Control group Before treatment (95% CI) After treatment (95% CI) Before treatment (95% CI) After treatment (95% CI) p<0,05 p<0,1 1 2 3 4 RR, ms 749 (718–780) 776 (739–813) 742 (705–779) 739 (702–777) HR, bpm 81.7 (78.3–85.1) 79.4 (75.8–83.0) 82.4 (78.5–86.3) 82.6 (78.8–86.4) systolic BP, mmHg 122 (117–127) 121 (118–125) 126 (120–132) 128 (122–134) 2:4 diastolic BP, mmHg 77.8 (74.9–80.7) 76.6 (74.6–78.7) 73.4 (74.5–82.3) 79.6 (77.5–81.7) 2:4 RA, ms (29.3–38.1) 36.7 (31.0–41.1)36.0 (24.4–32.5) 28.5 (22.3–30.0) 26.1 2:4 1:3 σRR, ms (30.7–38.2) 34.5 (29.8–38.2)34.0 (26.0–33.5) 29.8 (24.1–31.7) 27.9 2:4 1:3 VLFC, ms 26.7 (23.4–30.0) 24.6 (21.1–28.0) 23.0 (19.8–26.3) 21.7 (18.4–24.9) LFC, ms 14.8 (12.6–17.1) 17.1 (14.7–19.6) 12.6 (10.1–14.8) 12.3 (10.3–14.3) 2:4 HFC,ms 13.1 (11.5–14.7) 14.0 (12.1–15.9) 12.1 (10.2–13.9) 11.0 (9.2–12.8) 2:4 NVLFC, % 61.0 (56.2–65.8) 53.9 (49.0–58.9) 61.2 (55.7–66.8) 60.9 (55.5–66.3) 1:2 2:4 NLFC, % 20.8 (17.3–24.4) 26.3 (22.7–29.9) 18.7 (15.3–22.0) 20.1 (16.7–23.6) 1:2;2:4 NHFC, % 18.1 (14.7–21.5) 19.8 (16.1–23.4) 20.1 (15.0–25.1) 18.9 (13.6–24.3) RRB, ms 560 (538–582) 562 (538–586) 578 (543–614) 572 (532–613) 1:2 ∆RRB, ms 189 (167–211) 214 (191–238) 164 (139–188) 167 (143–191) 2:4 1:2 ∆RRB, % 24.6 (22.2–27.0) 27.1 (25.0–29.2) 22.0 (19.0–25.1) 22.8 (19.6–25.9) 2:4 RRC, ms 657 (624–689) 683 (642–724) 653 (616–691) 658 (612–703)
The decrease of depression and anxiety after 4-week period significantly differs in the physical exercise and control groups. The difference was two and half time more expressed in the physical exercise group (HADD 17.2
and 7.4; HADN 18.1 and 9.7, before and after the treatment, respectively),
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16.9, respectively). These results demonstrate a positive impact of physical exercise on the treatment in patients with severe depression.
The both groups, physical exercise and control ones, were distributed according to the presence of somatic symptoms.
Before the treatment in the physical exercise group, patients with somatic symptoms demonstrated statistically significantly larger weight (average 79.8 kg) than patients without somatic symptoms (71.3 kg). However, the level of depression, anxiety, sleep quality, and health related quality of life did not differ between groups. Patients with somatic symptoms, as compared with patients without ones, were characterized by increased relative VLFC (66.1% and 56.4%, in patients with and without somatic symptoms, respectively) and decreased relative HFC (13.7% and 22.2, in patients with and without somatic symptoms, respectively) at the same heart rate frequency (81 bpm and 82 bpm, respectively). It demonstrates depressed baseline autonomic heart rate control in patients with somatic symptoms.
The same tendency was observed in the control group of patients. Parasympathetic heart rate control was decreased in patients with somatic symptoms (VLFC 54.2% and 67.2%, p<0.05, in patients with and without somatic symptoms, respectively; HFC 27.2% and 14.1%, p<0.05, respectively).
In the physical exercise group a decrease of depression, anxiety, sleep quality and health related quality of life was observed in patients without somatic symptoms as well as in patients with somatic symptoms. However, the heart rate variability pattern was different in both groups. Maximal heart rate response to the active orthostatic test statistically significantly increased after 4 weeks of training in the physical exercise group patients without somatic symptoms, however it did not changed significantly in patients with somatic symptoms (Figure 4.6.1)
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*p<0.1
Fig. 4.6.1. Maximal heart rate response to active the orthostatic test
before and after treatment in the physical exercise group patients distributed according the prevalence of somatic symptoms
These data clearly demonstrate that physical exercise training added to the standard treatment has a positive effect not only on psychoemotional status, but also on physical fitness which is determined by cardiovascular function status in patients with severe depression. The strong relation between physical fitness and cardiovascular functional status was demonstrated using maximal heart rate response, which mainly depends on modifications of the parasympathetic heart rate control during the active orthostatic test (Buchheit, 2007; Zhemaityte, Kepezenas, 1998, Varoneckas, Žemaitytė, 1996; Žemaitytė, 1997). Recently heart rate variability was employed in psychosomatic medicine for evaluation of parasympathetic and sympathetic input into autonomic control (Ritz, 2006).
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Improvement of heart rate variability characteristics indicates that the parasympathetic control was observed in the physical exercise patient group only. They demonstrated an increased parasympathetic and a decreased sympathetic input into autonomic heart rate control. Our results are in line with findings that severe depression might be a factor decreasing baroreflex sensitivity and autonomic control (Watkins, 1999; Lehofer, 1997; Weinstein; 2007). Because of that, physical training restores autonomic control, improves cardiovascular functional status and physical fitness in patients with severe depression and decreases depression and anxiety as well as improves sleep quality and health related quality of life. However, somatic symptoms in severe depression patients reduce impact of physical training on psychoemotional status and physical fitness what might be explained by a decreased energy and activity in these patients or by short period of physical exercises.
In conclusion, the physical training added to the standard antidepressant treatment improves not only psychoemotional status, but also physical fitness and autonomic heart rate control in patients with severe depression. Optimal physical exercises have benefits for cardiovascular function as well as for depression and anxiety coping with stress, quality of sleep and health related quality of life.
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5. CONCLUSIONS
1. The physical exercise programme consisting daily aerobic exercises of moderate intensity and duration in patients with severe depression substantially decreased symptoms of depression and anxiety and improved sleep and health related quality of life as well as cardiovascular function.
2. There was no difference in the effectiveness of attenuation of the level of depression between males and women. However, the statistically significant improvement of subjective sleep quality and health related quality of life was observed in males, as compared with women. The reduction of severity of depression and anxiety symptoms and the improvement of subjective sleep quality and health related quality of life was observed in the patient group which underwent the physical exercise programme, especially in the younger patient group.
3. In patients with severe depression the improvement of cardiovascular function during the physical exercise programme was related to the restoration of the autonomic heart rate control, especially parasympathetic one, clearly demonstrated by the modifications of the heart rate variability – decreased very low frequency component and increased high frequency component of heart rate power spectrum as well as increased maximal heart rate response to the active orthostatic test.
4. Physical exercises reduce the severity of depression and anxiety symptoms, subjective sleep quality and health related quality of life in severe depression patients with somatic symptoms. However, it did not have an impact on the cardiovascular function.
6. PRACTICAL RECOMMENDATIONS
Implementation of the physical exercise programme into daily clinical practice has a positive effect on the treatment of patients with severe depression, improvement of coping with environment, social integration, and quality of life.
Optimal physical exercises improve physical fitness and functional cardiovascular reserve in patients with severe depression. More attention should be paid for involvement of patients with somatic symptoms into the physical exercise programme.
Developed physical exercise programme for patients with severe depression might be effectively employed in psychiatric hospitals and out-patient departments.
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7. LIST OF THE AUTOR‘S PUBLICATIONS
1. Saudargienė S, Raškauskienė N, Varoneckas G. Fizinės mankštos efektas depresija sergančių moterų klinikinei būklei, miego ir gyvenimo kokybei. Sveikatos mokslai. 2007;4(17):1081-85.
2. Saudargienė S, Podlipskytė A, Varoneckas G. Fizinės mankštos poveikis sergančiųjų depresija širdies ir kraujagyslių funkcinei būklei, miego ir gyvenimo kokybei. Sveikatos mokslai. 2008;5(59):1880-86. 3. Saudargienė S, Varoneckas G, Podlipskytė A, Bunevičius R. Fizinės
mankštos įtaka nerimo simptomams, nuotaikai, miegui ir su sveikata susijusiai gyvenimo kokybei, gydant sunkų depresijos epizodą.
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SANTRAUKA
Įvadas. Pastaruoju metu didėja mokslininkų susidomėjimas fizine veikla
ir sportu nes, fizinė veikla yra svarbus optimalios sveikatos bei teigiamų emocijų elementas. Fizinė veikla yra svarbi ir psichikos sutrikimų turintiems asmenims. Ji ne tik gerina fizinį pajėgumą, bet ir palengvina naujų įgūdžių įsisavinimą, dalijimąsi problemomis ir ypatingais interesais, leidžia pasiekti geresnę fizinę formą, geresnį savęs vertinimą, kurti strategijas kasdienių problemų sprendimui. Fizinė mankšta pripažįstama veiksminga fizinės ir psichosocialinės sveikatos pagerinimo priemonė.kuri gali padėti žmonėms tiesiog jaustis gerai. Sumažinti individualią depresijos išsivystymo riziką ir sušvelninti depresijos simptomus.
Darbo tikslas – sudaryti fizinės mankštos programą ir įvertinti jos
efektyvumą depresija sergančiųjų asmenų psichinei būklei. miego bei gyvenimo kokybei ir autonominiam širdies ritmo reguliavimui.
Uždaviniai :
1. Sudaryti fizinės mankštos programą sergančiųjų depresija gydymui. 2. Įvertinti fizinės mankštos poveikį sergančiųjų depresija psichinei
būklei. miego ir su sveikata susijusiai gyvenimo kokybei.
3. Įvertinti fizinės mankštos efektyvumą psichinei būklei, miego ir gyvenimo kokybei, priklausomai nuo paciento lyties ir amžiaus.
4. Įvertinti fizinės mankštos poveikį kardiovaskulinei funkcijai.
Tyrimo kontingentas ir metodai. Tiriamąjį kontingentą sudarė 192
Telšių apskrities ligoninės psichiatrijos skyriaus pacientai (amžiaus vidurkis 45,5 m., intervalas 20–67 metai), atvykę stacionariniam depresijos gydymui. Tiriamieji atsitiktinės atrankos būdu buvo suskirstyti į fizinės mankštos ir kontrolinę grupes. Fizinės mankštos grupė keturias savaites dalyvavo mankštos užsiėmimuose, o kontrolinė grupė buvo gydoma įprastai, nedalyvaujant jokioje papildomoje fizinėje veikloje. Abi grupės buvo gydomos medikamentais. Pacientai buvo tiriami pirmąją gydymo dieną ir po 30 dienų.
Psichinė būklė buvo vertinta naudojant Becko depresijos (BDI) ir HAD (Hospital Anxiety and Depresion Scale) skales, miego kokybė – Pitsburgo miego kybės indeksą, su sveikata susijusi gyvenimo kokybė – SF-36 klausimyną, širdies ir kraujagyslių sistemos funkcinė būklė – aktyvios ortostazės mėginį.
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Išvados:
1. Sudaryta fizinės mankštos programa iš aerobinio pobūdžio vidutinio intensyvumo ir trukmės kasdieninių fizinių pratimų, kurios taikymas sergantiesiems sunkia depresija mažina depresijos ir nerimo simptomus bei gerina subjektyvią miego ir su sveikata susijusią gyvenimo kokybę, o taip pat širdies ir kraujagyslių sistemos funkcinę būklę.
2. Žymesnis depresijos, nerimo, miego ir gyvenimo kokybės rodiklių gerėjimas gydymo metu stebimas fizinės mankštos grupėje jaunesnių asmenų tarpe. Lytis neturi esminės įtakos depresijos lygio mažėjimui, tačiau subjektyvi miego kokybė ir su sveikata susijusi gyvenimo kokybė fizinės mankštos poveikyje statistiškai reikšmingai labiau gerėja vyrams nei moterims.
3. Sergantiesiems sunkia depresija be somatikos simptomų fizinė mankšta gerina širdies ir kraujagyslių sistemos funkcinę būklę, ką nusako autonominio širdies ritmo reguliavimo atsigavimas, ypač parasimpatinis, ir pagerėjęs širdies ritmo variabilumas – sumažėjusi labai lėtų dažnumų komponentė ir padidėjusi aukštų dažnumų komponentė, o taip pat pagerėjusi maksimali širdies ritmo reakcija aktyvaus ortostatinio mėginio metu.
4. Sergantiesiems sunkia depresija su somatikos simptomais fizinė mankšta mažina depresijos ir nerimo simptomus, subjektyvią miego ir su sveikata susijusią gyvenimo kokybę, tačiau negerina širdies ir kraujagyslių sistemos funkcinės būklės.
AUTHOR CV
Sigita Saudargiene graduated from Lithuanian Academy of Physical Education with the Master degree in Rehabilitation and Nursing in 2002. She worked in rehabilitation of mental patients at the Telsiai Mental Health Center and Department of Psychiatry at the Telsiai District Hospital from 2000 to 2006. In 2004, Saudargiene became a Ph.D. student at Kaunas Medical University (Biomedical Sciences, B11 (Nursing)). Currently, she works as a Director of Center of Medical & Financial Information since 2006 and a Doctor at Plunge District of Local Administration.
