Top POEMs of 2018: Behavioral Medicine

Top 20 POEMs of 2018

Physical Activity Associated with Reduced Incidence of Depression

Clinical question

Is physical activity at baseline associated with a reduced risk of subsequent incident depression?

Bottom line
This was a large meta-analysis of prospective cohort studies of individuals of all ages without depression at baseline. All of the studies included at least one year of follow-up. People with high physical activity (> 150 minutes per week of at least moderate-intensity activity) were less likely to have subsequent incident depression than those who had low levels of physical activity. Given the large size of the population, the prospective nature of the studies, and the consistency across age groups, the suggestion that exercise is a preventive factor for new onset depression is relatively strong. This is further evidence that exercise is medicine. (LOE = 2a)

Reference
Schuch FB, Vancampfort D, Firth J, et al. Physical activity and incident depression: a meta-analysis of prospective cohort studies. Am J Psychiatry 2018;175(7):631-648.

Study design:Meta-analysis (other)

Funding source:Unknown/not stated

Setting:Various (meta-analysis)

Synopsis
For this meta-analysis of prospective cohort studies the authors included 49 studies without overlapping populations. The studies included a total of 266,939 individuals who were followed up for more than 1.8 million person-years. Men and women were nearly equally represented (47% and 53%, respectively). Studies were included if: the participants were free of depression or threshold depressive symptoms as measured by any of several tools; physical activity was measured (generally with a self-report questionnaire); the study was a prospective cohort design with at least one year of follow-up (average 7.4 years); and the study evaluated incident depression as an outcome (various methods). Higher physical activity was considered to be more than 150 minutes per week of at least moderate-intensity activity, such as brisk walking. People with higher levels of physical activity were less likely to have incident depression (adjusted odds ratio 0.83; 95% CI 0.79 - 0.88; P < .001). Several potential confounders (including age, sex, body mass index, smoking, and baseline [subthreshold] depressive symptoms) were considered and did not significantly change the results. Subgroup analyses by age group (< 18 years, 18 – 65 years, > 65 years) showed no significant differences from the baseline analysis.

Linda Speer, MD
Professor and Chair, Department of Family Medicine
University of Toledo
Toledo, OH

OneThird of Patients with Anxiety Disorder Will Relapse When SSRI/SNRI Treatment Stops

Clinical question
How common is relapse in patients with anxiety disorder following the discontinuation of treatment with an antidepressant?

Bottom line
Discontinuing the antidepressant treatment of patients with anxiety disorders will cause a relapse in almost one third of them. Unfortunately, 1 in 6 patients previously treated successfully will also relapse despite continued treatment. (LOE = 1a-)

Reference
Batelaan NM, Bosman RC, Muntingh A, Scholten WD, Huijbregts KM, van Balkom AJLM. Risk of relapse after antidepressant discontinuation in anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder: systematic review and meta-analysis of relapse prevention trials. BMJ 2017 Sep 13;358:j3927.

Study design:Meta-analysis (randomized controlled trials)

Funding source:Self-funded or unfunded

Setting: Various (meta-analysis)

Synopsis
The authors searched 3 databases, including Cochrane CENTRAL, as well as clinical trial registries, to identify published and unpublished studies of patients with anxiety disorders (panic disorder, agoraphobia, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, or a specific phobia) who responded to antidepressant treatment and were subsequently randomized to either continue antidepressant treatment or be switched to placebo. Two researchers independently selected research for inclusion, abstracted data, and evaluated study quality. The 28 included studies enrolled a total of 5233 patients, and followed them up for 8 weeks to 52 weeks. Relapse occurred in 36.4% of patients who were witched to placebo, but also in 16.4% of patients who continued treatment (odds ratio 3.11; 95% CI 2.48 - 3.89). There was no significant difference in relapse rates based on type of anxiety. The rate of relapse varied across the studies, likely due to the different durations of follow-up. All but 2 of the studies were sponsored by pharmaceutical companies and 6 were previously unpublished; additional unpublished studies were identified but data could not be obtained, increasing the risk of publication bias.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Nonbenzodiazepine Hypnotic Drugs Are Associated with Increased Fractures in Older Adults

Clinical question
Are zolpidem, zopiclone, eszopiclone and zaleplon—nonbenzodiazepine hypnotics that are also known as z-drugs—associated with harms in older adults?

Bottom line
Among 14 studies reporting on harms of taking so-called z-drugs, the data show an association with higher fracture and injury risk. (LOE = 2a-)

Reference
Treves N, Perlman A, Kolenberg Geron L, Asaly A, Matok I. Z-drugs and risk for falls and fractures in older adults: a systematic review and meta-analysis. Age Ageing 2018;47(2):201-208.

Study design:Meta-analysis (other)

Funding source:Self-funded or unfunded

Setting:Various (meta-analysis)

Synopsis
These authors searched 2 databases and a clinical trials registry to identify studies of nonbenzodiazepine hypnotic drugs that included an assessment of fractures, falls, and injuries. These hypnotic drugs—zolpidem (Ambien), zopiclone (Zimovane, Imovane), eszopiclone (Lunesta), and zaleplon (Sonata, Starnoc, and Andante)—are sometimes called z-drugs. The authors also scanned the reference lists of retrieved studies. Their search included randomized trials, as well as observational studies. Two investigators independently determined study eligibility and resolved disagreements by discussion and consensus. Ultimately, they included 14 studies with more than 800,000 patients. All of the studies were observational: 10 studies (> 830,000 patients) reported on fractures, 3 studies (> 19,000 patients) reported on falls, and 2 studies (> 160,000) reported on injuries. Patients taking z-drugs were 1.6 times more likely to experience a fracture (95% CI 1.4 - 1.9), but these data demonstrated high levels of heterogeneity. Patients taking z-drugs were not at a statistically significant increased risk of falls, but these data, too, were quite heterogeneous. Finally, patients taking zolpidem (the only drug studied for differences in injury rates) were twice as likely as those not taking it to have injuries (odds ratio 2.05; 1.95 - 2.15) with no evidence for statistical heterogeneity. The results didn't vary when taking various subgroup analyses into account.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

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