Factors associated with adherence to sports and exercise among outpatients with major depressive disorder

Abstract Introduction Individuals with major depressive disorder (MDD) face more barriers to engagement in sports and exercise interventions. Evaluating clinical and demographic factors associated with adherence to sports and exercise among MDD outpatients could support development of new options and strategies to increase their participation. Methods In a cross-sectional study, 268 depressed outpatients were evaluated (83.51% females; mean age = 50.74 [standard deviation {SD} = 10.39]). Sports and exercise participation were assessed using a question about participation frequency during the previous month. Clinical and demographic factors were evaluated. Linear regression was used to identify predictors of participation in sports and exercise. Results MDD patients with mild symptoms of depression (odds ratio [OR] = 2.42; 95% confidence interval [95%CI] 1.00, 5.88; p = 0.04) and patients with mild to moderate symptoms (OR = 3.96; 95%CI 1.41, 11.15; p = 0.009) were more likely to engage regularly in sports and exercise than patients with more severe depression. Moreover, smoking (OR = 0.23; 95%CI 0.67, 0.80; p = 0.007) and being divorced (OR = 0.22; 95%CI 0.57, 0.86; p = 0.03) were associated with lower rates of engagement in sports and exercise. Conclusion Our findings indicate a significant association between clinical and demographic factors and participation in sports and exercise among MDD outpatients.


Introduction
Major depressive disorder (MDD) is one of the most common mental disorders. Lifetime prevalence is about 16% and it has a chronic course. 1 People with severe mental illness, including MDD, have a life expectancy that is 10 to 17.5 years shorter compared to the general population. [2][3][4] Researchers have consistently reported that these individuals have elevated mortality, presenting high rates of adverse health behaviors, including tobacco smoking, substance use, physical inactivity, and poor diet. 5 About 60% of the increased mortality observed in mental illness patients is due to physical comorbidities, predominantly cardiovascular diseases. 6 In a recent study, Firth et al. reported that individuals with mental disorders have 1.4 to 2.0 times greater risk of cardiometabolic disease than individuals without mental disorders. 7 Moreover, individuals with depression have around 40% greater risk of developing cardiovascular disease, diabetes, metabolic syndrome, hypertension, and obesity than the general population. 7 Along the same lines, previous studies have reported evidence of a bidirectional association between diabetes and depression, 8,9 demonstrating that this comorbidity has a negative impact on lifestyle and quality of life, increasing healthcare costs, and susceptibility to further chronic diseases. 10,11 Regular physical activity (PA) has been recognized as one of the most important healthy behaviors for preventing onset of many chronic diseases or reducing their severity. 7 In people with MDD, exercise (defined as structured and systematic PA) contributes to reductions in depressive symptoms. 12  Classification Criteria. 16 We used the following assessment instruments: The MINI-Plus is administered by trained health professionals. It contains 17 sections to diagnose current or past episodes of psychotic disorders, mood disorders, anxiety disorders, and alcohol and drug use disorders. 17 It also includes a section to classify a Major Depressive Episode as melancholic or non-melancholic according to the DSM criteria.
2) Hamilton Depression Rating Scale (HAM-D). 18 3) Beck Depression Inventory (BDI). 19 4) Sports and Exercise Participation. Sports and exercise participation was assessed using a single question: "On average, how many hours per week did you spend participating in sports or exercise during the last month?" There were five response options: none; one hour or less; between one and two hours; between two and four hours; and more than four hours per week.
The responses none and less than one hour were categorized as physically inactive and all other responses were categorized as physically active.

7) The World Health Organization Quality of Life
Questionnaire-Brief Version (Whoqol-BREF). 25,26 In the present study, the participants were classified into tertiles by their quality-of-life scores.

8) Clinical Global Impression (CGI). 27
Other independent variables were collected on clinical We did not find any significant associations with the other demographic variables (Table 2).    Moreover, it is necessary to understand the history of PA and promote feasible interventions to reduce physical inactivity in order to lower rates of many different types of disease and improve overall health. 35 Finally, given the complexity of factors involved in participation in exercise and sport among patients with MDD and the high rates of physical inactivity observed, it could be helpful to provide support through multidisciplinary teams, including psychiatrists, psychologists, and other health professionals, to engage this population in sports and exercise programs, raising awareness of the importance of being physically active.
One limitation of the present study is the cross-

Conclusion
This study demonstrates that several demographic and clinical factors are associated with physical inactivity in MDD outpatients in middle-income countries (e.g., Brazil). According to these findings, evaluation of clinical and demographic correlates could aid development of better strategies for increasing sports and exercise levels in depressed subjects, helping to decrease depressive symptoms and improve health.