Effects of Pharmacotherapy on Combat-Related PTSD, Anxiety, and Depression: A Systematic Review and Meta-Regression Analysis.

OBJECTIVES: To estimate the effect of pharmacotherapy on PTSD, anxiety, and depression among combat veterans; to determine whether the effects varied according to patient and intervention characteristics; and to examine differential effects of pharmacotherapy on outcomes. MATERIALS AND METHODS: Google Scholar, PILOTS, PsycINFO, PubMed, and Web of Science databases were searched through November 2014. Searches resulted in eighteen double-blind, placebo controlled trials of 773 combat veterans diagnosed with PTSD and included only validated pre- and post-intervention PTSD and anxiety or depression measures. Authors extracted data on effect sizes, moderators, and study quality. Hedges' d effect sizes were computed and random effects models estimated sampling error and population variance. The Johnson-Neyman procedure identified the critical points in significant interactions to define regions of significance. RESULTS: Pharmacotherapy significantly reduced (Δ, 95%CI) PTSD (0.38, 0.23-0.52), anxiety (0.42, 0.30-0.54), and depressive symptoms (0.52, 0.35-0.70). The effects of SSRIs and tricyclic antidepressants on PTSD were greater than other medications independent of treatment duration. The effect of SSRIs and tricyclic antidepressants were greater than other medications up to 5.2 and 13.6 weeks for anxiety and depression, respectively. The magnitude of the effect of pharmacotherapy on concurrently-measured PTSD, anxiety, and depression did not significantly differ. CONCLUSIONS: Pharmacotherapy reduced PTSD, anxiety, and depressive symptoms in combat veterans. The effects of SSRIs and tricyclic antidepressants were greater for PTSD and occurred quicker for anxiety and depression than other medications.

Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer.

IMPORTANCE: Creative arts therapies (CATs) can reduce anxiety, depression, pain, and fatigue and increase quality of life (QOL) in patients with cancer. However, no systematic review of randomized clinical trials (RCTs) examining the effects of CAT on psychological symptoms among cancer patients has been conducted. OBJECTIVES: To estimate the effect of CAT on psychological symptoms and QOL in cancer patients during treatment and follow-up and to determine whether the effect varied according to patient, intervention, and design characteristics. EVIDENCE REVIEW: We searched ERIC, Google Scholar, MEDLINE, PsycInfo, PubMed, and Web of Science from database inception to January 2012. Studies included RCTs in which cancer patients were randomized to a CAT or control condition and anxiety, depression, pain, fatigue and/or QOL were measured pre- and post-intervention. Twenty-seven studies involving 1576 patients were included. We extracted data on effect sizes, moderators, and study quality. Hedges d effect sizes were computed, and random-effects models were used to estimate sampling error and population variance. FINDINGS: During treatment, CAT significantly reduced anxiety (Δ = 0.28 [95% CI, 0.11-0.44]), depression (Δ = 0.23 [0.05-0.40]), and pain (Δ = 0.54 [0.33-0.75]) and increased QOL (Δ = 0.50 [0.25-0.74]). Pain was significantly reduced during follow-up (Δ = 0.59 [95% CI, 0.42-0.77]). Anxiety reductions were strongest for studies in which (1) a non-CAT therapist administered the intervention compared with studies that used a creative arts therapist and (2) a waiting-list or usual-care comparison was used. Pain reductions were largest during inpatient treatment and for homogeneous cancer groups in outpatient settings; significantly smaller reductions occurred in heterogeneous groups in outpatient settings. CONCLUSIONS AND RELEVANCE: Exposure to CAT can improve anxiety, depression, and pain symptoms and QOL among cancer patients, but this effect is reduced during follow-up.

Differential effects of exercise on cancer-related fatigue during and following treatment: a meta-analysis.

CONTEXT: Exercise-induced improvements in cancer-related fatigue may be moderated differentially in patients during and following treatment. These effects have not been reviewed systematically. In accordance with PRISMA guidelines, the population effect size for exercise training on cancer-related fatigue during and following treatment was estimated and the extent to which the effect is differentiated across the time course of treatment and recovery was determined. EVIDENCE ACQUISITION: Articles published before August 2011 were retrieved using Google Scholar, MEDLINE, PsycINFO, PubMed, and Web of Science databases. Seventy studies involving 4881 cancer patients during or following treatment were selected. Articles included a cancer-related fatigue outcome measured at baseline and post-intervention and randomized allocation to exercise or non-exercise comparison. From August to October 2011, Hedges' d effect sizes were computed, study quality was evaluated, and random effects models were used to estimate sampling error and population variance. EVIDENCE SYNTHESIS: Exercise significantly reduced cancer-related fatigue by a mean effect Δ (95% CI) of 0.32 (0.21, 0.43) and 0.38 (0.21, 0.54) during and following cancer treatment, respectively. During treatment, patients with lower baseline fatigue scores and higher exercise adherence realized the largest improvements. Following treatment, improvements were largest for trials with longer durations between treatment completion and exercise initiation, trials with shorter exercise program lengths, and trials using wait-list comparisons. CONCLUSIONS: Exercise reduces cancer-related fatigue among patients during and following cancer treatment. These effects are moderated differentially over the time course of treatment and recovery. Exercise has a palliative effect in patients during treatment and a recuperative effect post-treatment.

Effect of exercise training on depressive symptoms among patients with a chronic illness: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Physical inactivity and comorbid depressive symptoms are prevalent among patients with a chronic illness. To our knowledge, randomized controlled trials of the effects of exercise training on depressive symptoms among patients with a chronic illness have not been systematically reviewed. We estimated the population effect of exercise training on depressive symptoms and determined whether the effect varied according to patient characteristics and modifiable features of exercise exposure and clinical settings. METHODS: Articles published before June 1, 2011, were located using the Physical Activity Guidelines for Americans Scientific Database, Google Scholar, MEDLINE, PsycINFO, PubMed, and Web of Science. Ninety articles involving 10,534 sedentary patients with a chronic illness were selected. Included articles required (1) randomized allocation to an exercise intervention or nonexercise comparison condition and (2) a depression outcome assessed at baseline and at mid- and/or postintervention. Hedges d effect sizes were computed, study quality was evaluated, and random effects models were used to estimate sampling error and population variance of the observed effects. RESULTS: Exercise training significantly reduced depressive symptoms by a heterogeneous mean effect size delta (Δ) of 0.30 (95% CI, 0.25-0.36). Larger antidepressant effects were obtained when (1) baseline depressive symptoms were higher, (2) patients met recommended physical activity levels, and (3) the trial primary outcome, predominantly function related, was significantly improved among patients having baseline depressive symptoms indicative of mild-to-moderate depression. CONCLUSIONS: Exercise reduces depressive symptoms among patients with a chronic illness. Patients with depressive symptoms indicative of mild-to-moderate depression and for whom exercise training improves function-related outcomes achieve the largest antidepressant effects.

Effects of cycling exercise on vigor, fatigue, and electroencephalographic activity among young adults who report persistent fatigue.

We previously reported that 6 weeks of exercise training had positive effects on feelings of vigor and fatigue among college students who reported persistent fatigue. Here we examined whether transient mood changes after single sessions of exercise would mimic those chronic effects and whether they would be related to changes in brain activity measured by electroencephalography (EEG). Feelings of vigor were higher after both low- and moderate-intensity exercise during Weeks 1, 3, and 6 compared to a control condition. Feelings of fatigue were lower after low-intensity exercise during Weeks 3 and 6. Posterior theta activity accounted for about half the changes in vigor. Studies that manipulate mood, EEG activity, or both during exercise are needed to determine whether EEG changes after exercise are causally linked with mood.

A randomized controlled trial of the effect of aerobic exercise training on feelings of energy and fatigue in sedentary young adults with persistent fatigue.

BACKGROUND: There is growing evidence that chronic exercise is a promising intervention for combating feelings of low energy and fatigue. Although groups with well-defined medical conditions (for example cancer and heart disease) or unexplained fatigue syndromes consistently have reported improved feelings of energy and fatigue after chronic exercise, relatively few exercise training studies have been conducted with people who report persistent fatigue yet neither have a medical condition nor reach diagnostic criteria for an unexplained fatigue syndrome. The purpose of this investigation was to use a randomized controlled design to examine the effects of 6 weeks of chronic exercise training on feelings of energy and fatigue in sedentary, healthy young adults reporting persistent fatigue. METHODS: Thirty-six healthy, young adults who reported persistent feelings of fatigue were randomly assigned to a moderate-intensity exercise, low-intensity exercise or no treatment control group. Participants in each condition then visited the exercise laboratory on 18 occasions over a 6-week period. Exercise laboratory visits occurred 3 days per week. Vigor and fatigue mood state scores were obtained at the beginning of the third exercise session each week for 6 weeks. Aerobic fitness was measured before and after intervention. RESULTS: The effect of 6 weeks of exercise training on feelings of fatigue was dependent on exercise intensity; however, the effect on feelings of energy was similar for both the low- and moderate-intensity conditions. The changes in feelings of energy and fatigue were independent of changes in aerobic fitness. CONCLUSIONS: Six weeks of low and moderate exercise training performed by sedentary adults without a well-defined medical condition or an unexplained fatigue syndrome but reporting persistent feelings of fatigue resulted in similarly beneficial effects on feelings of energy. The effects for symptoms of fatigue were moderated by exercise intensity, and the more favorable outcome was realized with low-intensity exercise. Changes in feelings of energy and fatigue following exercise training were unrelated to changes in aerobic fitness.

The effect of sport concussion on neurocognitive function, self-report symptoms and postural control : a meta-analysis.

Sport concussion is commonly assessed using a battery of tests that evaluate neurocognitive functioning, postural control and self-report symptoms. The degree to which concussion affects each of these measures is unclear. Thus, the purpose of this meta-analysis is to systematically review and quantify the effect of sport concussion on each assessment measure when administered immediately post-injury and in the 2 weeks following injury. PubMed and PsychINFO databases were searched from January 1970 to June 2006, from which 39 were included for review. Studies were selected for review if they included concussed athletes who were evaluated using one of the three assessment measures. One post-morbid assessment must have been completed within 14 days of injury and compared with a baseline measure or control group. Study design, type of neurocognitive assessment, timing of assessment following injury and number of post-concussion assessments were extracted as potential moderators. Sport-related concussion had a large negative effect (mean Delta; 95% confidence interval) on neurocognitive functioning (-0.81; -1.01, -0.60), self-report symptoms (-3.31; -6.35, -0.27) and postural control (-2.56; -6.44, 1.32) in the initial assessment following injury. A reduced, but large effect, was also seen in the 14 days following the initial assessment for neurocognitive functioning (-0.26; -0.46, -0.06), self-report symptoms (-1.09; -2.07, -0.11) and postural control (-1.16; -2.59, 0.27). Our findings demonstrated large effects for each aspect of the assessment battery. These findings support the use of the multifaceted concussion evaluation.

Low-frequency fatigue in individuals with spinal cord injury.

BACKGROUND/OBJECTIVE: This study examined magnitude and recovery of low-frequency fatigue (LFF) in the quadriceps after electrically stimulated contractions in spinal cord-injured (SCI) and able-bodied subjects. SUBJECTS: Nine SCI (ASIA A-C, levels C5-T9, injured 13.6 +/- 12.2 years) and 9 sedentary able-bodied subjects completed this study. METHODS: Fatigue was evoked in 1 thigh, and the nonfatigued leg served as a control. The fatigue test for able-bodied subjects lasted 15 minutes. For SCI, stimulation was adjusted so that the relative drop in force was matched to the able-bodied group. Force was assessed at 20 (P20) and 100 Hz (P100), and the ratio of P20/P100 was used to evaluate LFF in thighs immediately after, at 10, 20, and 60 minutes, and at 2, 4, 6, and 24 hours after a fatigue test. RESULTS: The magnitude of LFF (up to 1 hour after fatigue) was not different between able-bodied and patients with SCI. However, recovery of LFF over 24 hours was greater in able-bodied compared with patients with SCI in both the experimental (P < 0.001) and control legs (P < 0.001). The able-bodied group showed a gradual recovery of LFF over time in the experimental leg, whereas the SCI group did not. CONCLUSIONS: These results show that individuals with SCI are more susceptible to LFF than able-bodied subjects. In SCI, simply assessing LFF produced considerable LFF and accounted for a substantial portion of the response. We propose that muscle injury is causing the dramatic LFF in SCI, and future studies are needed to test whether "fatigue" in SCI is actually confounded by the effects of muscle injury.

The effect of cardiac rehabilitation exercise programs on feelings of energy and fatigue: a meta-analysis of research from 1945 to 2005.

BACKGROUND: Physical activity is a healthful behavior that has promise for combating feelings of low energy and fatigue. Despite evidence suggesting that fatigue is a prodromal symptom of major cardiac events, improvements in feelings of energy and fatigue have largely been ignored by reviewers of cardiac rehabilitation literature who have focused on anxiety, depression and general measures of quality of life. DESIGN: A meta-analytical review. METHODS AND RESULTS: Computer databases were searched from January 1945 to May 2005 to identify relevant literature. A total of 36 studies consisting of 4765 subjects were included. Cardiac rehabilitation exercise programs were consistently associated with increases in energy and decreases in fatigue. The magnitude of the effect was moderately large (mean delta 0.51; 95% confidence interval 0.42-0.61) but was heterogeneous and modified by features of the research design. Comparison of effect sizes in cardiac rehabilitation studies concurrently measuring energy/fatigue, anxiety and depression suggest that exercise-based cardiac rehabilitation programs have larger effects on feelings of energy and fatigue compared with anxiety and depression. CONCLUSION: This review quantifies the potential benefit of cardiac rehabilitation exercise programs on feelings of energy and fatigue, and suggests that cardiac rehabilitation researchers and practitioners may benefit from examining, and perhaps even focusing on, feelings of energy and fatigue as an important outcome variable. A greater understanding of the effect of cardiac rehabilitation exercise programs on feelings of energy and fatigue will be reached when more true experiments are conducted thereby avoiding the primary limitation of the literature reviewed; that is, the frequent use of non-experimental research designs.

Effects of chronic exercise on feelings of energy and fatigue: a quantitative synthesis.

The authors investigated the effect of chronic exercise on feelings of energy and fatigue using meta-analytic techniques. Chronic exercise increased feelings of energy and lessened feelings of fatigue compared with control conditions by a mean effect delta of 0.37. The effect varied according to the presence or absence of a placebo control or whether chronic exercise was completed alone or in combination with an additional therapy. Investigations that used a placebo control and examined chronic exercise alone found no effect of chronic exercise on feelings of energy and fatigue. Certain placebo controls may increase feelings of energy and lessen feelings of fatigue when used with older adults or people with psychological distress. The results highlight the need for research identifying the most useful control conditions for accurately interpreting mental health outcome data obtained in chronic exercise investigations.

Physical activity and feelings of energy and fatigue: epidemiological evidence.

Approximately 20% of adults worldwide report persistent fatigue. Physical activity is a healthful behaviour that has promise for combating feelings of fatigue and low energy. This article summarises the epidemiological literature that examined the association between physical activity and feelings of energy and fatigue. Twelve population-based studies conducted between January 1945 and February 2005 that concurrently measured physical activity and feelings of energy and fatigue were located. All of the studies suggested that there was an association between physical activity and a reduced risk of experiencing feelings of low energy and fatigue when active adults were compared with sedentary peers (odds ratio = 0.61; 95% CI 0.52, 0.72). The effect was heterogeneous and varied according to study design and the energy/fatigue measure used in the study. Because epidemiological comparisons cannot establish direction of causality, standard criteria for evaluating strength of evidence in epidemiological studies (i.e. strength of association, temporal sequence, consistency, dose response and biological plausibility) were used to judge whether the observed association between physical activity and feelings of energy and fatigue suggest causality in the absence of adequate experimental evidence. There was agreement among the studies suggesting a strong, consistent, temporally appropriate dose-response relationship between physical activity and feelings of energy and fatigue. No compelling evidence has confirmed any plausible biological mechanisms that explain the apparent protective effect of physical activity against feelings of low energy and fatigue. Nonetheless, the epidemiological evidence is sufficiently strong to justify better controlled prospective cohort studies and randomised controlled trials.

Chronic physical activity and feelings of energy and fatigue.

This brief review summarizes key epidemiological and experimental evidence concerning relationships between chronic physical activity and feelings of energy (vigor, vitality) and fatigue. The epidemiological studies show a positive association between the amount of typical weekly physical activity reported and the frequency with which people report feeling energetic. The randomized controlled experiments show that 10-20 wk of exercise training is associated with an increase in the frequency and intensity of feelings of energy among fatigued people with medical conditions. The results of longitudinal studies with non-fatigued, healthy adults are mixed. Overtraining by athletes is associated with increased intensity of feelings of fatigue. Additional well-controlled investigations into relationships between physical activity and feelings of energy and fatigue, especially among sedentary and fatigued individuals, are warranted given the available evidence and the importance of these moods to health, work productivity, and quality of life.