AGING OF THE population and the increased prevalence of chronic diseases among the elderly are major challenges facing our society and medical community. Depression is a significant cause—and consequence—of disability among older individuals. Estimates of the prevalence of mood disorders in the United States range from approximately 5% to 10% of elderly community dwellers^1,2 to 18% of nursing home residents.³ Depressive symptoms are associated with the presence of 1 or more chronic diseases^4,5 as well as disability,² including days in bed and days away from normal activities.⁵ Moreover, major depressive disorder (MDD) has been associated with a 59% increase in mortality risk during a 1-year follow-up.³

Objective: To assess whether patients receiving aerobic exercise training performed either at home or in a supervised group setting achieve reductions in depression comparable to standard antidepressant medication (sertraline) and greater reductions in depression compared to placebo controls. Methods: Between October 2000 and November 2005, we performed a prospective, randomized controlled trial (SMILE study) with allocation concealment and blinded outcome assessment in a tertiary care teaching hospital. A total of 202 adults (153 women; 49 men) diagnosed with major depression were assigned randomly to one of four conditions: supervised exercise in a group setting; home-based exercise; antidepressant medication (sertraline, 50–200 mg daily); or placebo pill for 16 weeks. Patients underwent the structured clinical interview for depression and completed the Hamilton Depression Rating Scale (HAM-D). Results: After 4 months of treatment, 41% of the participants achieved remission, defined as no longer meeting the criteria for major depressive disorder (MDD) and a HAM-D score of <8. Patients receiving active treatments tended to have higher remission rates than the placebo controls: supervised exercise = 45%; home-based exercise = 40%; medication = 47%; placebo = 31% (p = .057). All treatment groups had lower HAM-D scores after treatment; scores for the active treatment groups were not significantly different from the placebo group (p = .23). Conclusions: The efficacy of exercise in patients seems generally comparable with patients receiving antidepressant medication and both tend to be better than the placebo in patients with MDD. Placebo response rates were high, suggesting that a considerable portion of the therapeutic response is determined by patient expectations, ongoing symptom monitoring, attention, and other nonspecific factors. BDI = Beck Depression Inventory; CI = confidence interval; HAM-D = Hamilton Depression Rating Scale; ITT = intention-to-treat; MDD = major depressive disorder; SD = standard deviation; SSRIs = selective serotonin reuptake inhibitors; TSH = thyroid stimulating hormone.

The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7)¹ recommends that lifestyle modifications should be the initial treatment strategy for lowering blood pressure (BP). In addition to advocating weight reduction, physical activity, dietary sodium reduction, and moderation of alcohol consumption, as recommended by earlier guidelines,² JNC-7 endorses the DASH (Dietary Approaches to Stop Hypertension) diet for patients with elevated BP. Evidence supporting the efficacy of this diet comes primarily from the DASH feeding trials, in which a diet high in low-fat dairy products, fruits, and vegetables; lower in fats; and rich in fiber significantly lowered clinic-measured BP with or without sodium reduction.^3-5 The PREMIER study⁶ subsequently demonstrated that the “established”(JNC-6) lifestyle modifications and lifestyle modifications plus the DASH diet (JNC-7) were associated with larger BP reductions compared with “advice only” controls; however, the BP differences between the JNC-7 recommendations and the previously established (JNC-6) treatment recommendations were small (<1 mm Hg) and not statistically significant. Therefore, although the DASH diet has been shown to lower BP in short-term feeding studies, it has not been shown to lower BP independent of other lifestyle changes among free-living individuals. Because the clinical significance of high BP is derived from morbid events that are not directly caused by elevated BP, but rather the associated structural and functional changes in the heart and blood vessels, we also examined changes in cardiovascular biomarkers of risk.

Ischemic heart disease (IHD) is the leading cause of death in the United States and is rapidly becoming the leading cause of death in developing countries around the world.^1,2 Traditional biomedical risk factors do not fully account for the development of IHD or for the triggering of adverse cardiac events. Psychosocial factors are now recognized as playing a significant and independent role in the development of IHD and its complications.^3,4 Consequently, efforts to alter psychosocial risk factors, particularly in the setting of cardiac rehabilitation, have received increased attention. However, the value of modifying psychosocial risk factors to reduce adverse cardiac events remains controversial.^5,6 Several large-scale randomized trials failed to demonstrate an advantage for stress management interventions in reducing cardiac morbidity or mortality,^7,8 but these studies also failed to adequately reduce psychosocial risk factors. Because emotional distress was not successfully reduced, it was not unexpected that medical end points also were not affected.