Review articlePhysical activity and sedentary behavior in people with major depressive disorder: A systematic review and meta-analysis
Introduction
People with major depressive disorder (MDD) are at increased risk of premature mortality (Cuijpers et al., 2014) with 10 year lower life expectancy compared to the general population (Laursen et al., 2016). Recent research suggests that cardiovascular and metabolic disease are major factors contributing to this premature mortality (Charlson et al., 2013). In the general population, there is good evidence that physical activity and exercise can attenuate rates of cardiovascular disease and mortality (Naci and Ioannidis, 2013). However, people with MDD experience a range of barriers to engaging in physical activity such as depressive symptoms, higher body mass index, physical co-morbidity and lower self-efficacy (Vancampfort et al., 2015c).
The relationship between physical activity and depression seems to be bidirectional. Depressed people are typically less active (De Moor et al., 2006), whilst lower levels of physical activity increase the risk of depression (Mammen and Faulkner, 2013). In addition, physical activity and exercise (i.e. structured physical activity) can improve depressive symptoms (Schuch et al., 2016a) and quality of life among people with depression (Schuch et al., 2016b, Schuch et al., 2015). Despite the benefits of physical activity for people with depression, it remains unclear how much physical activity people with depression engage in and what influences physical activity participation. While public health physical activity recommendations exist, such as achieving 150 min of moderate to vigorous PA (MVPA) per week (O'Donovan et al., 2010), it remains unclear how many people with MDD achieve this target.
Recently, interest has grown in the importance of preventing prolonged periods of sedentary behavior in order to tackle cardiovascular disease and mortality. Sedentary behavior is defined as an energy expenditure ≤1.5 metabolic equivalents of task (METs), while in a sitting or reclining posture during waking hours (Sedentary Behavior Research, 2012). A large meta-analysis in the general population demonstrated that sedentary behavior is associated with an increased risk of developing cardiovascular disease, type 2 diabetes, cardiovascular and all-cause mortality (Biswas et al., 2015). People with depression are known to experience high levels of diabetes (Vancampfort et al., 2016a, Vancampfort et al., 2015b). However, it remains unclear exactly how much sedentary behavior people with depression engage in.
When considering physical activity and sedentary behavior levels, many studies appear to have relied on self-report questionnaires (SRQ) rather than relying on objective measures such as accelerometers, which provide more accurate measurements (Soundy et al., 2014). Previous meta-analyses in schizophrenia (Stubbs et al., 2016a, Stubbs et al., 2016b) and bipolar disorder (Vancampfort et al., 2016b) have suggested that significant differences in physical activity and sedentary behavior levels exist between self-report and objective measures. It remains unclear if this extends to people with depression. A number of previous narrative reviews have examined the relationship between physical activity and sedentary behavior among people with depression (Hallgren et al., 2016, Lopresti et al., 2013, Teychenne et al., 2008). However, a comprehensive systematic review and meta-analysis of PA and sedentary behavior levels and predictors among people with MDD is lacking.
The aims of the present systematic review were to: (1), establish the mean amount of physical activity and sedentary behavior per day among people with MDD, (2) investigate predictors of physical activity and sedentary behavior through meta-regression analyses, (3) establish the proportion of people with MDD that meet the guideline recommendation of 150 min of MVPA per week (4) explore differences in physical activity and sedentary behavior in people with MDD versus age- and gender matched healthy controls. (5) evaluate differences between physical activity and sedentary behavior measured using SRQs and objective measures..
Section snippets
Methods
This systematic review was conducted according the MOOSE guidelines (Stroup et al., 2000) and the PRISMA statement (Moher et al., 2009).
Search results
The initial search yielded 8103 results. After removal of duplicates and exclusion during the title and abstract level review, 481 full texts remained. Following the application of the eligibility criteria, 24 articles were included (see Fig. 1 for search results). At the full text review stage, seven of 32 research groups contacted provided additional data (see Acknowledgements). Overall, 24 articles, were eligible for inclusion (Appelhans et al., 2012, Belvederi Murri et al., 2015, Bernard et
Total physical activity
Nine studies including 1192 participants with MDD were pooled, and showed that people with MDD spent a total time of 126.0 (95%CI 91.9–160.4) minutes per day engaged in physical activity. There was no evidence of publication bias (Kendall's tau with continuity correction=0.22, P=0.49).
Light physical activity
Six studies demonstrated that people with MDD spent 139.9 (95%CI 90.6–189.3) minutes per day in light physical activities. Whilst some publication bias was identified (Kendall's tau with continuity correction=0.66, P=0.03) the trim and fill test did not change the values.
Moderate physical activity
Six studies (n=1411) demonstrated that patients with MDD engaged in a mean of 61.3 (95%CI 42.7–79.8) minutes per day in moderate intensity physical activity. There was no publication bias (see Table 2).
Moderate to vigorous physical activity
Eleven studies (n=1778) demonstrated that patients with MDD spent a mean of 37.6 (95%CI 27.4–47.9) minutes per day engaged in moderate to vigorous physical activity. There was no publication bias (see Table 2).
Vigorous physical activity
Seven studies (n=1463) revealed that patients with MDD spent a mean of 5.3 (95%CI 2.5–8.1) minutes per day in vigorous physical activity. There was some publication bias (Kendall's tau with continuity correction=0.47, P=0.04). The amount of vigorous physical activity was unchanged by the trim and fill test.
Sedentary behavior
Across 6 studies, 1057 participants spent 8.5 (95%CI 7.4–9.6) hours per day in sedentary behavior. There was no publication bias (see Table 2).
Sitting time
Across 3 studies, 627 participants spent 3.9 (95%CI 3.5–4.9) hours per day sedentary sitting. There was no publication bias (Table 2).
Proportion of people with MDD who do not meet recommended PA guidelines?
Data from 13 study arms revealed that 67.8% (95%CI 52.1–80.3) of people with depression did not comply with the recommendation of 150 minutes of moderate or vigorous physical activity per week. No publication bias was identified (Kendall's tau with continuity correction=0.25, P=0.24) and the trim and fill test did not change the results.
Total physical activity
People with MDD spent significantly less time in total PA (n=5, SMD=−0.251, 95% CI, −0.3 to −0.1, P<0.001), equating to a mean difference of −11.6 (95% CI −25.7 to 2.6) minutes engaged in physical activities than their non-depressed counterparts (See Fig. 2).
Light and moderate physical activity
There was inadequate data to calculate light and moderate PA differences.
Moderate to vigorous physical activity
People with depression spent significantly less time in moderate to vigorous activities (n=3, SMD=−0.30, 95% CI −0.40 to −0.21, P<0.001), equating to a mean difference of −9.1 (95% CI, −19.7 to −0.8) minutes engaged in moderate to vigorous physical activities than people without depression. (See Fig. 3).
Vigorous physical activity
There was inadequate data to calculate vigorous PA differences.
Sedentary behavior
People with depression spent significantly more time in sedentary behavior (n=5, SMD =0.09, 95% CI 0.01–0.18, P=0.02), equating to a mean difference of −0.2 (95% CI, −19.7 to 0.8) hours in sedentary behavior than their non-depressed counterparts. (See Fig. 4).
Sitting time
There was inadequate data to calculate sitting time differences.
People with MDD meeting recommended PA guidelines
People with MDD were less likely to meet the recommended 150 min of MVPA physical activity per week (n=4, OR=1.5, 95% CI 1.1–2.0, p=0.001).
Discussion
The current meta-analysis is to our knowledge, the first to investigate physical activity and sedentary behavior levels among people with MDD versus controls. Our analyses revealed that during waking hours people with MDD engaged in 139.9 minutes (equivalent to 2.4 hours per day) of light intensity, 61.0 min (1 hour per day) of moderate intensity and about five minutes of vigorous intensity physical activity per day. Moreover, people with MDD spent more than 8 hours per day in sedentary behavior, of
Role of the funding source
BS receives funding from the National Institute for Health Research Collaboration for Leadership in Applied Health Research & Care Funding Scheme. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.
DV is funded by the Research Foundation – Flanders (FWO – Vlaanderen).
Acknowledgements
The authors would like to thank to Dr. Carrol Sinnott, Dr. Chiara da Ronch, Dr. Corrina Rahe, Dr. Jorge Mota-Pereira, Dr. Morgam Strom, Dr. Paquito Bernard, Dr. Patrick Smith and Dr. Peter Carlbring for providing additional data for use in our meta-analyses.
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