Web-based exercise interventions for patients with depressive and anxiety disorders: a systematic review of randomized controlled trials

Carneiro, Lara; Rosenbaum, Simon; Ward, Philip B.; Clemente, Filipe M.; Ramirez-Campillo, Rodrigo; Monteiro-Júnior, Renato S.; Martins, Alexandre; Afonso, José

doi:10.1590/1516-4446-2021-2026

Lara Carneiro

Departamento de Ciências da Educação Física e Desporto, Universidade da Maia, Castêlo da Maia, Maia, Portugal

Centro de Investigação em Desporto, Saúde e Desenvolvimento Humano (CIDESD), Vila Real, Portugal

https://orcid.org/0000-0002-4385-5290

Simon Rosenbaum

School of Psychiatry, University of New South Wales, New South Wales, Sydney, Australia

Black Dog Institute, Randwick, New South Wales, Australia

https://orcid.org/0000-0002-8984-4941

Philip B. Ward

School of Psychiatry, University of New South Wales, New South Wales, Sydney, Australia

Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia

https://orcid.org/0000-0002-5779-7722

Filipe M. Clemente Correspondence: Filipe M. Clemente, Complexo Desportivo e Lazer Comendador Rui Solheiro, Monte de Prado, Melgaço, 4900-347, Viana do Castelo, Portugal. E-mail: filipe.clemente5@gmail.com

Instituto Politécnico de Viana do Castelo, Escola Superior Desporto e Lazer, Viana do Castelo, Portugal

Instituto de Telecomunicações, Delegação da Covilhã, Lisboa, Portugal

https://orcid.org/0000-0001-9813-2842

Rodrigo Ramirez-Campillo

Departamento de Ciencias de la Actividad Física, Universidad de Los Lagos, Santiago, Chile

Centro de Investigación en Fisiología del Ejercicio, Facultad de Ciencias, Universidad Mayor, Santiago, Chile

https://orcid.org/0000-0003-2035-3279

Renato S. Monteiro-Júnior

Programa de Pós-Graduação em Ciências da Saúde, Universidade Estadual de Montes Claros, Montes Claros, MG, Brazil

https://orcid.org/0000-0002-8472-262X

Alexandre Martins

Centro de Investigação, Formação, Inovação e Intervenção em Desporto, Faculdade de Desporto, Universidade do Porto, Porto, Portugal

https://orcid.org/0000-0001-6379-0378

José Afonso

Centro de Investigação, Formação, Inovação e Intervenção em Desporto, Faculdade de Desporto, Universidade do Porto, Porto, Portugal

https://orcid.org/0000-0002-2038-393X

Correspondence: Filipe M. Clemente, Complexo Desportivo e Lazer Comendador Rui Solheiro, Monte de Prado, Melgaço, 4900-347, Viana do Castelo, Portugal. E-mail: filipe.clemente5@gmail.com

Disclosure The authors report no conflicts of interest.

How to cite this article: Carneiro L, Rosenbaum S, Ward PB, Clemente FM, Ramirez-Campillo R, Monteiro-Júnior RS, et al. Web-based exercise interventions for patients with depressive and anxiety disorders: a systematic review of randomized controlled trials. Braz J Psychiatry. 2021;00:000-000. http://dx.doi.org/10.1590/1516-4446-2021-2026

Departamento de Ciências da Educação Física e Desporto, Universidade da Maia, Castêlo da Maia, Maia, Portugal

Centro de Investigação em Desporto, Saúde e Desenvolvimento Humano (CIDESD), Vila Real, Portugal

School of Psychiatry, University of New South Wales, New South Wales, Sydney, Australia

Black Dog Institute, Randwick, New South Wales, Australia

Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia

Instituto Politécnico de Viana do Castelo, Escola Superior Desporto e Lazer, Viana do Castelo, Portugal

Instituto de Telecomunicações, Delegação da Covilhã, Lisboa, Portugal

Departamento de Ciencias de la Actividad Física, Universidad de Los Lagos, Santiago, Chile

Centro de Investigación en Fisiología del Ejercicio, Facultad de Ciencias, Universidad Mayor, Santiago, Chile

Programa de Pós-Graduação em Ciências da Saúde, Universidade Estadual de Montes Claros, Montes Claros, MG, Brazil

Centro de Investigação, Formação, Inovação e Intervenção em Desporto, Faculdade de Desporto, Universidade do Porto, Porto, Portugal

Rule	Inclusion criteria	Exclusion criteria
Study type	Original research published in peer-reviewed journals. No limitations on language or publication date.	Conference abstracts Non-peer-reviewed publications Peer-reviewed publications that are not original research
Participants	Participants of any age, sex, or training status: (i) diagnosed with depression according to well-established criteria, such as DSM-5^® American Psychiatric³⁹39. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington: American Psychiatric Publishing; 2013. WHO ICD-11,⁴⁰40. World Health Organization (WHO). International classification of diseases for mortality and morbidity statistics [Internet]. 11th revision. 2018 ]cited 2021 Jul 30]. icd.who.int/browse11/l-m/en icd.who.int/browse11/l-m/en... or previous versions, or presenting with depressive symptoms above clinically established thresholds in validated scales, such as BDI or BDI-II,⁴¹41. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-71. HAM-D,⁴²42. Hamilton M. Rating depressive patients. J Clin Psychiatry. 1980;41:21-4. GDS⁴³43. Yesavage JA. Geriatric depression scale. Psychopharmacol Bull. 1988;24:709-11.; and/or (ii) presenting with anxiety symptoms above clinically established thresholds on a validated rating scale such as BAI⁴⁴44. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56:893-7. or a formal DSM-5^® American Psychiatric³⁹39. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington: American Psychiatric Publishing; 2013. WHO ICD-11,⁴⁰40. World Health Organization (WHO). International classification of diseases for mortality and morbidity statistics [Internet]. 11th revision. 2018 ]cited 2021 Jul 30]. icd.who.int/browse11/l-m/en icd.who.int/browse11/l-m/en... diagnosis of a specific anxiety disorder (e.g., generalized anxiety disorder). Previous versions of the aforementioned scales were acceptable. Participants could have additional conditions (e.g., mental disorders and other comorbidities).	Participants not diagnosed with depression or anxiety or without depressive or anxiety symptoms
Interventions	Web-based (i.e., website-, e-mail- and/or mobile-app-based) exercise interventions, i.e., planned, structured, repetitive, and purposeful physical activity,⁴⁵45. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 1985;100:126-31. such as strength training, balance, endurance, etc., as well as any multimodal exercise program.	Absence of web-based exercise interventions (e.g., in person, telephone-based)
Comparators	Non-exercising controls and/or alternative interventions. Usual care had to be described. When a description was not provided, the authors were contacted.	Absence of comparators Comparators following usual care, if no information could be obtained to describe usual care
Outcomes	Primary outcomes were changes in depressive symptoms and/or anxiety symptoms according to validated scales, scored from baseline to post-intervention. If available, remission rates were considered among primary outcomes. Secondary outcomes consisted of any other effects on performance, health and quality of life. Adverse effects and dropout rates, when reported, were also analyzed.	Primary outcomes of interest not assessed
Study design	Randomized controlled trials (parallel or cross-over).	Non-randomized studies Observational studies Case studies and case series

Study	Sample	Location, funding, and conflicts of interest	Characteristics of the intervention	Characteristics of the comparator(s)
Haller⁶⁴	20 patients (seven male, 13 female) with moderate to severe unipolar depression (45±14 years-old, range 20-65 years old), but otherwise in good health	Single-center, Germany No mention of funding No conflicts of interest declared	n=14 (four male, 10 female) Individualized web-based exercise program. Participants received a HR monitor and four different types of resistance bands, as well as exercise schedules 1x/week with instructions for 8 weeks of endurance (maximum three exercises) and strength training (maximum two exercises). After each week, the patients had to upload their weekly protocol to the platform, and motivational feedback was provided to improve adherence. Once every 2 weeks, a group training session was offered by a sports therapist (only one patient accepted this session). Training goals were individually adapted in the duration and intensity for the following week. Progression in endurance exercise was achieved through increased intensity and/or duration. Progression in strength training was achieved by increasing the number of sets and repetitions or by changing the type of resistance band. Participants had a median of 75 min (IQR: 63 to 98) of endurance and nine (IQR: 4 to 12) of 10 recommended units of strength training per week. In addition, they had four (IQR: 2 to 28) optional, alternative training units, such as relaxing, hiking or yoga.	n=6 (three males, three females) Treatment-as-usual group
Huberty²⁷	90 underactive women (≤ 120 min/week of moderate intensity PA) who experienced a stillbirth within 6 weeks to 24 months and PTSD (IES score ≥ 33), but without severe depression and otherwise healthy Unreported ages (≥ 18 years-old)	Multicenter United States Funded by a grant from the U.S. NIH No conflicts of interest declared	Home-based, online yoga intervention of varying doses for 12 weeks (with follow-up at 20 weeks). The low-dose group (n=30) performed 60 min of exercise per week, while the moderate-dose group (n=30) performed 150 min per week. Participants received study information and directions, a yoga mat, two blocks and one yoga strap. The intervention was provided via email, including 12 videos developed for women who had experienced stillbirth, and 48 videos with yoga exercises. Participants were asked to accompany the yoga videos in a pre-defined order. Both the low-dose and moderate-dose groups had identical poses and sequences in each prescription. Compliance: of the participants that completed the study, only nine of 34 performed > 90% of the prescribed minutes for a minimum of 9 weeks. The low-dose group performed an average of 44 min per week, and the moderate-dose group 77.3 min per week.	“Stretch and tone” control group (n=30), 60 min per week for 12 weeks (follow-up at 20 weeks) Participants received study information and directions, a stretching mat and one resistance band. They also received 12 30-min videos including warm-up, cool-down, stretching, and toning exercises.
Teychenne²³	62 mothers (33.0±3.7 years in CG, 33.6±3.7 in IG) at risk of postnatal depression and insufficiently active	Multicenter Australia Funded by IPAN, Deakin University No conflicts of interest declared	Home-based, multi-component PA for 12 weeks (n=32). Participants received a multi-component program, exercise equipment (treadmill or stationary bicycle), logbook for goal setting and self-monitoring, access to a smartphone web app and an online forum (facilitated by a research assistant with a Ph.D. in behavioral epidemiology). The web app helped design individualized PA programs. Compliance: only 20 subjects (63%) used the web app, most ≤ 2 times per month (57%). Logbook data was only available for 20 participants. Overall, compliance was low.	Control group (usual routine) (n=30)

Study	D1	D2	D3	D4	D5	Global
Haller⁶⁴	Some concerns	Low	Low	Some concerns	Low	Some concerns
Huberty²⁷	Low	High	High	Some concerns	Low	High
Teychenne²³	Low	Low	High	Some concerns	Some concerns	High

	Primary outcomes^† † Primary outcomes: changes in depressive and/or anxiety symptoms and/or remission rates. (pre-post values)		Secondary outcomes^‡ ‡ Secondary outcomes: any other effects on performance, health, or quality of life.
Study	Intervention	Comparator(s)	Intervention vs. comparator(s)	Main conclusions
Haller⁶⁴	Mean ± SD QIDS-SR: pre = 16±3. Median change 5 (IQR: 2 to 10)^§ § The graphs presented by the authors consisted of median and IQR, which were not converted into means and SDs since the graphs suggested a highly skewed distribution. QIDS-C: pre = 14±3. Median change 5 (IQR: 2 to 7)	Mean ± SD QIDS-SR: 17±4 QIDS-C: 15±1	= Lactate threshold ↑ Spiroergometry during treadmill walking test in IG ↑ Quality of life (SF-36) in IG↑ GSE in IG ↑ HPA (Baecke Questionnaire) in IG Dropouts: 3 of 14 (21%) in IG; no dropouts in CG. Side effects: minor orthopedic problems in four cases in the IG	Depressive symptoms did not differ between IG and CG (ANCOVA). However, IG improved in several physiological and psychological parameters.
Huberty²⁷	Means (95%CI) Low-dose IG PTSD through IES-R: pre = 43.16 (35.77-50.55); post = 24.53 (16.72-32.34); follow-up = 23.03 (13.86-32.20). Anxiety through STAI: pre = 91.38 (82.78-99.98); post = 87.80 (80.72-94.89); follow-up = 88.17 (81.60-94.75). Depression through PHQ-9: pre = 12.67 (9.23-16.11); post = 6.46 (3.50-9.42); follow-up = 6.38 (3.57-9.19). Moderate-dose IGIES-R: pre = 45.99 (39.30-52.68); post = 20.38 (13.31-27.45); follow-up = 23.39 (15.08-31.69), STAI: pre = 86.68 (79.36-94.01); post = 86.06 (80.03- 92.09); follow-up = 82.36 (76.76-87.95). PHQ-9: pre = 9.27 (6.28-12.26); post = 6.31 (3.74-8.89); follow-up = 7.11 (4.66-9.56).	Means (95%CI) IES-R: pre = 45.75 (36.81-54.69); post = 36.57 (26.22-45.12); follow-up = 29.67 (18.57-40.77). STAI: pre = 90.67 (80.80-100.55); post = 88.77 (80.63-96.00); follow-up = 85.19 (77.65-92.74) PHQ-9: pre = 13.15 (9.14-17.17); post = 12.56 (9.10-16.02); follow-up = 11.21 (7.92-14.49).	PGS in IG Self-Compassion Scale ERQ MAAS PSQI ↑ Subjective health (SF-12) in moderate-dose IG. Dropouts: 42 of 90 (46.7%). Low-dose IG: 12 of 30 (40%). Moderate-dose IG: 14 of 30 (46.7%). CG: 16 of 30 (53.3%). Side effects: no adverse effects were reported, although eight participants reported discomfort (muscle soreness, wrist/knee discomfort).	Significant decreases in depression levels in both IGs compared to CG. IES-R decreased over the trial, although equally in all groups. For most outcomes, the changes were not statistically significant.
Teychenne²³	Mean ± SD Depressive symptoms through EPDS: pre = 12.1±3.8; post = 6.0±4.3. Anxiety symptoms through GAD-7: pre = 8.2±4.6; post = 4.3±4.2.	Mean ± SD EPDS: pre = 12.6±3.9; post = 7.4±3.6. GAD-7: pre = 6.8±2.4; post = 4.2±2.9.	↑ Self-reported PA in IG Self-reported sedentary behavior ↓ Accelerometer-assessed PA in IG Accelerometer-assessed sedentary behavior Pittsburgh Sleep Quality Index Dietary intake PA self-efficacy scale Side effects: the authors reported no side/adverse effects. Dropouts: 1 of 32 in IG, 5 of 30 in CG.	Despite some improvements in secondary outcomes, there was no evidence of any beneficial effects in depressive or anxiety symptoms in IG compared to CG.

Outcomes^† † Outcomes were grouped as their assessments were not different.	Study design	Risk of bias in individual studies	Publication bias	Inconsistency	Indirectness	Imprecision	Quality of evidence	Recommendation
Anxiety and depression symptoms	3 RCTs and 172 participants	Moderate to high^‡ ‡ Detailed assessments in Table 2.	No information, due to reduced number of studies	High^§ § Because the outcomes were continuous variables, high heterogeneity was expected. Heterogeneity also emerged from very distinct study designs, interventions, and comparators.	High^\|\| \|\| Due to heterogeneity of the populations and symptom severity.	High^¶ ¶ Small sample sizes and overlapping results suggest current knowledge is very imprecise.	Low	No recommendation can be provided on the basis of existing data.

[1] Correspondence: Filipe M. Clemente, Complexo Desportivo e Lazer Comendador Rui Solheiro, Monte de Prado, Melgaço, 4900-347, Viana do Castelo, Portugal. E-mail: filipe.clemente5@gmail.com

Brasil

Brasil

Web-based exercise interventions for patients with depressive and anxiety disorders: a systematic review of randomized controlled trials

Objective:

Methods:

Results:

Conclusion:

Registration number: