Abstract
With more than 340 million recorded cases worldwide, depression is one of the most common psychological disorders today. Women are at a high risk for developing depression, especially during menopause because their hormone levels fluctuate and personality traits may worsen vasomotor symptoms associated with menopause. However, besides biological and psychological factors, lifestyle factors are important determinants of depression symptoms in middle-aged women, and modifying those factors is associated with significant improvements in depression symptoms. For example, transitioning from a sedentary lifestyle into a physically active lifestyle can reduce depression moods and improve the quality of life. The purpose of this paper is to propose a 6-week workout program for middle-aged women. The program consists of both aerobic and anaerobic exercises because both types of exercises were associated with improved depression symptoms while only anaerobic exercises can improve muscle strength, which preserves stability and balance in later stages of life. It is expected that following the program can improve depression symptoms in middle-aged women.
Keywords: depression, exercise, middle-aged women, menopause
Depression is one of the most common psychological disorders today with more than 340 million recorded cases worldwide, and it is generally more prevalent in women than in men (Azar, Ball, Salmon, & Cleland, 2008). It is estimated that up to 47 percent of women in menopause will experience depression (Gallicchio, Schilling, Miller, Zacur, & Flaws, 2007). Although biological and psychological factors have important roles in determining predisposition to depression, they only define predispositions while lifestyle factors determine whether the individual will actually suffer from depression symptoms.
Even though pharmacotherapy and psychotherapy are the most common forms of therapy for depression, but antidepressant therapy usually has low adherence rates and potentially results in adverse events while psychotherapy is often dismissed today in favor of alternative treatment choices (Mead et al., 2009). Although the cost and risks of exercise therapy have not been established, exercise results in significant improvements of depression symptoms and is considered as effective as cognitive therapy (Mead, 2009).
The purpose of this paper is to propose an exercise program for middle-aged women to help them reduce depression symptoms. The term middle-aged refers to women between the ages of 45 and 55, and they were chosen as the target population because they are the most vulnerable to depression symptoms because of the fluctuations in hormones caused by the menopause (Elavsky & McAuley, 2009). The proposed exercise program for reducing depression symptoms in middle-aged women is a 6-week exercise program that incorporates both aerobic and anaerobic movements. The length of the program, frequency, and levels of physical activity used to design the program were determined by analyzing findings from previous studies that reported significant improvements in depression symptoms among intervention group participants.
Literature Review
Studies found that women are two times more likely to experience depression than men, with the onset being a possibility from adolescents to adulthood (Azar et al., 2008). It is not exactly clear why that difference is pronounced because a wide range of biological factors (e.g. hormones or genes) and personality factors (e.g. ruminative processes or chronic mental stress) can be considered responsible for it, so it is not possible to isolate a single factor or a group of factors as the causes of high depression prevalence in women.
For example, some women may experience depressed moods because of hormonal changes that occur during menopause, which indicates that hormones play an important role in determining depression outcomes (Elavsky & McAuley, 2009). However, the study by Gallicchio et al. (2007) found that there are no relationships between hormone levels and depression symptoms, and their finding is consistent with most studies on the topic, but not with all of them. Because the symptoms of depression or physical discomfort during menopause are not universal for all women, it is not possible to dismiss personality factors.
Personality factors, such as anxiety traits or neuroticism, determine attention bias and cognitive processes, so middle-aged women with those factors will more likely perceive their menopause as difficult and consequently experience psychosomatic issues (Elavsky & McAuley, 2009). However, personality factors cannot be used to predict whether middle-aged women will experience depression because the quantity of vasomotor symptoms associated with negative personality traits have been identified as indicators for depression symptoms (Gallicchio et al., 2007). Therefore, lifestyle variables, such as smoking or lack of physical activity, are better indicators of depression than personality factors, so modifications in lifestyle habits is expected to (Gallicchio et al., 2007).
The effectiveness of exercise for treating depression in middle-aged women has been proven, and its results can even be as effective as pharmacotherapy and psychotherapy (as cited in Azar et al., 2008). As a general rule, physical activity is effective for regulating depression in women, but it should also be considered a preventive measure that can be effective when implemented early in life. A longitudinal study by Wyshak (2001) found that women who had been physically active in their young adulthood will show fewer depression symptoms when they reach middle-age than women who had not been physically active.
Aerobic Exercises
Aerobic exercise refers to low-intensity workouts. For example, one study used a 1 hour gentle stretching program and recorded a significant improvement in the depression scores among women in the intervention group (as cited in Azar et al., 2008). Balkin, Tietjen‐Smith, Caldwell, and Shen (2007) found that adhering to aerobic classes for 6-weeks can significantly reduce depression symptoms.
A study by Babyak et al. (2000) used three exercise sessions per week, which consisted of a 10-minute warm-up, 30-minute aerobic activity (i.e. cycling, brisk walking, or jogging) while maintaining the heart rate between 70 and 85 percent of heart rate reserve, and 5-minute cool down exercises. The aerobic exercise studies range from 6-week to 3-month interventions, but there is no indication that longer exercise program will reduce depression symptoms even further (Azar et al., 2008), which means 6-week aerobic programs are sufficient for improving depression symptoms.
Anaerobic Exercises
While aerobic exercises proved effective in several studies for reducing depression symptoms, studies that used anaerobic exercises for their intervention groups usually showed contradictory findings, but it is important to note that the anaerobic exercise studies reviewed by Azar et al. (2008) did not assess or report physical adherence rates among participants.
A review systematic review by Lawlor and Hopker (2001) showed that studies analyzing the effectiveness of aerobic exercises and studies investigating the effectiveness of anaerobic exercises for reducing depression showed similar effectiveness for both protocols. A review by A. Byrne and D. Byrne (1993) found that although researchers mainly focus on investigating the implications of aerobic exercise for mental health, anaerobic exercises proved to be equally effective. Overall, there appears to be no significant difference between anaerobic and aerobic physical activity in terms of improving depression symptoms, but participant adherence and social support may play an important role as well in determining the effectiveness of exercise programs.
Exercise Intervention Program Design
The exercise program proposed in Table 1 is designed for middle-aged women. The program assumes they do not suffer from physical disorders, such as cardiovascular disorders or joint issues, that may cause adverse events or the inability to perform exercises presented in the program. Because both aerobic and anaerobic exercises were associated with reduced depression symptoms, both types of exercises were incorporated in the program
In order to regulate the intensity of the exercise program, the participants must first determine their resting heart rate and maximum heart rate. They can measure their maximum heart rate after running on a treadmill. By deducting their resting heart rate from the maximum heart rate, they will obtain their heart rate reserve. The aerobic exercises need to be performed while maintaining heart rate at 70 percent of their heart rate reserve.
Program Objective
The objective of the exercise program is to reduce depression symptoms, which can be measured by several scales designed to assess depressive symptoms. A review of eight studies by Azar et al. (2008) showed that six of the eight studies used reliable questionnaires, such as the Beck Depression Inventory 13-item (BDI-13), Rand Mental Health Inventory (RMHI-5), Zung Depression Scale, Edinburgh Postnatal Depression Scale (EDPS), and the Center for Epidemiologic Studies Depression scale 10-item (CES-D 10).
However, the proposed questionnaire for measuring baseline depression symptoms and depression symptoms after the intervention is the Beck Depression Inventory for Primary Care (BDI-PC), which includes only seven items from the original questionnaire and has a binary outcome with the cutoff score = 4. Compared to the standard BDI questionnaire’s internal consistency (Cronbach’s alpha = 0.91), the internal consistency of the BDI-PC is slightly lower (Cronbach’s alpha = 0.85), but it is still high and indicates good internal consistency, which means the test is reliable.
A study by Steer, Cavalieri, Leonard, and Beck (1999) showed that sex, age, and ethnicity do not impact the reliability of the BDI-PC test, but more importantly, the presence of medical conditions also does not affect the test results. Because the original BDI scale includes questions regarding physical symptoms, such as sleep quality, it may result in a wrong interpretation of the results. For example, poor sleep quality for middle-aged women would increase their depression score on the original BDI scale when those problems might be related to other menopausal issues, such as fatigue or hot flashes.
The only limitation is that the BDI-PC test was developed for screening primary care patients for depressions rather than making an accurate diagnosis. However, the tool is simple, reliable, and easy to use, so it should prove to be an effective instrument for measuring progress for women following the proposed exercise program. More importantly, it eliminates errors related to items regarding physical symptoms, which can skew the results because of the possible presence of physical illness, fatigue, or vasomotor issues in menopausal women.
Judging by previous studies, it is expected that the proposed exercise program will be effective in terms of improving depression symptoms, but implementing the exercise program alone may have a significant limitation. A study by R. Oman and K. Oman (2003) found that women with worse depression symptoms usually lacked social support, which indicates the possibility of lower perceptions of commitment and control, resulting in low adherence rates. The study by Kerse et al. (2010) also showed that elderly people with severe depression symptoms showed a significant improvement through social visits alone, without any goal setting or physical activity interventions. Although the exercise program alone is considered sufficient for improving depression symptoms, interventions aimed at enhancing problem solving and coping strategies for women with depression symptoms could improve adherence rates to the program. Nevertheless, it is expected that those who adhere to the entire program for six weeks will decrease their depression scores on the BDI-PC below 4 points.
Rationale
Even though both aerobic physical activity and high resistance training were associated with reductions in depression system, this program is designed for middle-aged and menopausal women, so it is therefore structured as an aerobic exercise plan for the first two weeks. With the increase in age, women will have more predispositions to aging-related disorders, such as hypertension and other cardiovascular conditions, which could mean their aerobic metabolism capacity is reduced, and their cardiovascular system will not cope well with high-intensity workouts.
The introduction of high resistance training in menopausal and middle-aged women who have been living a sedentary lifestyle was associated with the higher risk for vasomotor symptoms, such as hot flashes, because of drastic increases in core temperature (Elavsky & McAuley, 2009). Even though the exact physiological mechanisms behind the vasomotor symptoms associated with menopause in middle-aged women are unclear, those potential adverse events suggest that low levels of physical activity should aim to increase aerobic performance in middle-aged women before they attempt anaerobic exercises.
The anaerobic exercises were included in the program because they were also identified as effective exercises for reducing depression symptoms, but they are much more convenient because they take less time to perform and produce the same effects in terms of improving depression symptoms. In addition, resistance training exercises improve strength and stability, which is are important determinants of quality of life in later stages of life-span development, while also developing the aerobic metabolism by activating it to help the muscles recover from lactic acidosis (McGruff & Little, 2008).
The program was designed for a 6-week period. Even though Babyak et al. (2000) consider a 16-week exercise program equally effective as pharmacotherapy for depression, there is significant evidence that shorter 6-week exercise programs are effective for improving depression symptoms (Balkin et al., 2007). If the program is too long, it is possible to expect lower adherence rates, especially because depression mood is associated with a lower perception of commitment. For example, it was found that women who engaged in short workouts of up to 30 minutes in length for 24 months did not show any improvements in vasomotor symptoms or depression scores (as cited in Lee & Kim, 2008). That is why six weeks is considered a sufficient amount of time to achieve a significant improvement in depression symptoms.
Finally, there was no dose-response relationship in any previous study regarding the effects of physical activity on depression, which means even irregular physical activity can result in the reduction of depression symptoms (Azar et al., 2008). A cross-sectional study by Lee and Kim (2008) found that women who exercised three times per week or more had lower menopausal vasomotor symptoms and depression. However, because of the cross-sectional study design, no specific interventions were used and the variables were obtained exclusively through self-reported measures. Nevertheless, this exercise program proposal assumes the frequency of exercising three times per week is both effective and safe in the beginning. In weeks 4-6, the frequency is adjusted to two times per week because high-resistance training requires more time for muscle tissue to repair than anaerobic training (McGruff & Little, 2008).
Summary and Conclusion
Biological factors and personality factors can be significant determinants for depression in middle-aged women, but lifestyle factors are the most reliable indicators of middle-age depression associated with menopause that can be modified to alleviate depression symptoms. One of those factors is physical activity. The 6-week exercise program presented in this paper is designed for physically inactive middle-aged women with depression symptoms. The first three weeks are designed to increase aerobic capacity because acute training may worsen vasomotor symptoms associated with menopause. Once aerobic capacity increases, tissue recovery from anaerobic training will become faster, so the last three weeks of the program introduce anaerobic exercises, which improve both depression symptoms and muscle tone.
References
Azar, D., Ball, K., Salmon, J., & Cleland, V. (2008). The association between physical activity and depressive symptoms in young women: A review. Mental Health and Physical Activity, 1(2), 82-88.
Babyak, M., Blumenthal, J. A., Herman, S., Khatri, P., Doraiswamy, M., Moore, K., & Krishnan, K. R. (2000). Exercise treatment for major depression: Maintenance of therapeutic benefit at 10 months. Psychosomatic Medicine, 62(5), 633-638.
Balkin, R. S., Tietjen‐Smith, T., Caldwell, C., & Shen, Y. P. (2007). The utilization of exercise to decrease depressive symptoms in young adult women. AdultSpan Journal, 6(1), 30-35.
Byrne, A., & Byrne, D. G. (1993). The effect of exercise on depression, anxiety and other mood states: A review. Journal of Psychosomatic Research, 37(6), 565-574.
Elavsky, S., & McAuley, E. (2009). Personality, menopausal symptoms, and physical activity outcomes in middle-aged women. Personality and Individual Differences, 46(2), 123-128.
Gallicchio, L., Schilling, C., Miller, S. R., Zacur, H., & Flaws, J. A. (2007). Correlates of depressive symptoms among women undergoing the menopausal transition. Journal of Psychosomatic Research, 63(3), 263-268.
Kerse, N., Hayman, K. J., Moyes, S. A., Peri, K., Robinson, E., Dowell, A., & Arroll, B. (2010). Home-based activity program for older people with depressive symptoms: DeLLITE–a randomized controlled trial. The Annals of Family Medicine, 8(3), 214-223.
Lawlor, D. A., & Hopker, S. W. (2001). The effectiveness of exercise as an intervention in the management of depression: Systematic review and meta-regression analysis of randomised controlled trials. BMJ: British Medical Journal, 322(7289), 763-767.
Lee, Y., & Kim, H. (2008). Relationships between menopausal symptoms, depression, and exercise in middle-aged women: A cross-sectional survey. International Journal of Nursing Studies, 45(12), 1816-1822.
McGruff, D., & Little, J. (2008). Body by science: A research based program for strength training, body building, and complete fitness in 12 minutes a week. New York, NY: McGraw-Hill.
Mead, G. E., Morley, W., Campbell, P., Greig, C. A., McMurdo, M., & Lawlor, D. A. (2009). Exercise for depression. Mental Health and Physical Activity, 2, 95-96.
Oman, R. F., & Oman, K. K. (2003). A case-control study of psychosocial and aerobic exercise factors in women with symptoms of depression. The Journal of Psychology, 137(4), 338-350.
Steer, R. A., Cavalieri, T. A., Leonard, D. M., & Beck, A. T. (1999). Use of the Beck Depression Inventory for Primary Care to screen for major depression disorders. General Hospital Psychiatry, 21(2), 106-111.
Wyshak, G. (2001). Women's college physical activity and self-reports of physician-diagnosed depression and of current symptoms of psychiatric distress. Journal of Women's Health & GenderBased Medicine, 10(4), 363-370.
