Exercise has a moderate positive impact on depression in people with heart failure

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Chronic diseases and depression often go hand in hand. There is a growing evidence-base that shows how exercise can help reduce depressive symptoms in people with chronic illness and it’s encouraging to see a steady stream of primary research being published in this area.

A new ancillary study published in JAMA examines the effect that aerobic exercise has on depression in people with chronic heart failure. This work builds on an existing randomised controlled trial (the HF-ACTION trial) published back in 2009.

Methods

The researchers randomised 2,322 stable patients treated for heart failure at 82 centres in the US, Canada and France. Patients were included if they had:

  • Left ventricular ejection fraction of 35% or lower
  • Class I to IV heart failure (measured by New York Heart Association criteria)
  • Completed the Beck Depression Inventory II (BDI-II)

28% of the participants had clinically significant depression at baseline.

The study participants were randomised to one of two treatment arms:

  1. Aerobic exercise – patients were given an exercise bike or treadmill, 3 supervised sessions each week for the first 3 months, then unsupervised home-based exercise for the next 9 months
  2. Guideline-based usual care – patients had no formal exercise prescription, just self-management materials and follow-up phone calls

Outcomes of interest were measured at 3 months and 12 months:

  • Depression symptoms
  • All-cause mortality
  • Hospitalisation
  • Cardiovascular and heart failure

Results

  • Looking at all patients – compared with usual care, aerobic exercise significantly reduced depressive symptoms at:
    • 3 months (adjusted mean BDI-II score: 8.95 with exercise vs 9.70 with usual care, p=0.002)
    • 12 months (adjusted mean BDI-II score: 8.86 with exercise vs 9.54 with usual care, p=0.01)
  • Looking just at the subgroup of patients with clinically significant depression – compared with usual care, aerobic exercise significantly reduced depressive symptoms at:
    • 3 months (mean BDI-II score: 16.66 with exercise vs 17.98 with usual care, p=0.04)
    • 12 months (mean BDI-II score: 15.85 with exercise vs 17.34 with usual care, p=0.02)
  • Compared with usual care, aerobic exercise was associated with a lower risk of:
    • All-cause death or hospitalisation (HR 0.89, 95% CI 0.81 to 0.99, p=0.03)
    • Heart failure hospitalisations and deaths (HR 0.85, 95% CI 0.73 to 0.98, p=0.03)
  • Compared with usual care, aerobic exercise had no significant effect on:
    • Cardiovascular hospitalisations and deaths (HR 0.91, 95% CI 0.81 to 1.01, p=0.09)

Conclusions

The authors concluded:

Compared with guideline-based usual care, exercise training resulted in a modest reduction in depressive symptoms, although the clinical significance of this improvement is unknown.

This new research adds to what we already know about treating depression with exercise in chronic disease. Depression is common in people who experience heart failure and unfortunately low mood often reduces the likelihood of people exercising. Future research that helps to improve methods for exercise adherence is badly needed.

Studies in this area tend not to focus on real-life populations (most of the study participants are often young white men with systolic heart failure). We will need to see results such as these (and better) in a population of older people (including women) with some of the comorbidities that are typically seen, before we can say for sure that exercise is an effective intervention for reducing depression in people with heart failure.

It will also be interesting to see additional research that focuses on the place where exercise happens and the relative impact that the method of delivery has on depression. Clearly, home-based exercise interventions will be far cheaper and more popular with patients.

Links

Blumenthal JA, Babyak MA, O’Connor C, Keteyian S, Landzberg J, Howlett J, Kraus W, Gottlieb S, Blackburn G, Swank A, Whellan DJ. Effects of exercise training on depressive symptoms in patients with chronic heart failure: the HF-ACTION randomized trial. JAMA. 2012 Aug 1;308(5):465-74. doi: 10.1001/jama.2012.8720. [PubMed abstract]

O’Connor CM, Whellan DJ, Lee KL, Keteyian SJ, Cooper LS, Ellis SJ, Leifer ES, Kraus WE, Kitzman DW, Blumenthal JA, Rendall DS, Miller NH, Fleg JL, Schulman KA, McKelvie RS, Zannad F, Piña IL; HF-ACTION Investigators. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009 Apr 8;301(14):1439-50. doi: 10.1001/jama.2009.454.

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Andre Tomlin

Andre Tomlin

André Tomlin is an Information Scientist with 20 years experience working in evidence-based healthcare. He's worked in the NHS, for Oxford University and since 2002 as Managing Director of Minervation Ltd, a consultancy company who do clever digital stuff for charities, universities and the public sector. Most recently André has been the driving force behind the Mental Elf and the National Elf Service; an innovative digital platform that helps professionals keep up to date with simple, clear and engaging summaries of evidence-based research. André is a Trustee at the Centre for Mental Health and an Honorary Research Fellow at University College London Division of Psychiatry. He lives in Bristol with his wife, dog and three little elflings.

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