Aerobic Exercise Training for Depressive Symptom Management in Adults Living With HIV Infection
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10.1177/1055329002250992
ARTICLE
JANAC Vol. 14, No. 2, March/April 2003
Neidig et al. / Aerobic Exercise Training
Aerobic Exercise Training for
Depressive Symptom Management
in Adults Living With HIV Infection
Judith L. Neidig, PhD, RN
Barbara A. Smith, PhD, FAAN
Dale E. Brashers, PhD
Aerobic exercise training may help prevent or prevalence differences have been less pronounced
reduce depressive symptoms experienced by persons when HIV-positive and HIV-negative subpopulations
living with HIV infection. However, the psychological (gay men, intravenous drug users) were compared in
effects of aerobic exercise have not been studied exten- studies including control groups (Lipsitz et al., 1994;
sively. This study evaluated the effects of an aerobic Rosenberger et al., 1993). In the first nationally repre-
exercise training program on self-reported symptoms sentative sample of adults receiving care for HIV
of depression in HIV-infected adults and examined the infection in the United States, more than one third of
convergent validity of two widely used depressive adults screened positive for major depression during
symptom scales. Sixty HIV-infected adults partici- the previous 12 months (Bing et al., 2001).
pated in a randomized, controlled trial of a supervised Although the 1996 probability sample (Bing et al.,
12-week aerobic exercise training program. As com- 2001) predates the widespread use of more highly
pared to study controls, exercise participants showed active antiretroviral therapies, persons living with HIV
reductions in depressive symptoms on all indices, and continue to face considerable psychological chal-
total depressive symptoms scores were highly corre- lenges. Distressing physical symptoms (Bonfanti
lated. Additional study of the psychological effects of et al., 2000; Carr et al., 1998) and considerable psy-
aerobic exercise programs in the target population is chological demands often accompany these lifetime
recommended. regimens (Chesney, Morin, & Sherr, 2000).
Researchers who reported a significant reduction in
Key words: HIV, exercise, depression, symptom depressive symptoms with protease inhibitor
antiretroviral therapies also noted that 46% of patients
Depression is the most common reason for psychiat- continued to have significant levels of depressive
ric evaluation and treatment of persons living with symptoms 1 year after treatment with these more
HIV infection. Researchers have estimated the preva-
Judith L. Neidig, PhD, RN, is the director of the Office of
lence of major depression in HIV-infected persons in Responsible Research Practices at The Ohio State Univer-
clinical settings to be between 22% and 32% (Brown sity, Columbus, Ohio. Barbara A. Smith, PhD, FAAN, is a
et al., 1992; Evans et al., 1998; Ferrando et al., 1998; professor and the Marie L. O’Koren endowed chair in the
Rabkin, 1997; Williams, Rabkin, Remien, Gorman, & School of Nursing at the University of Alabama at Birming-
Ehrhardt, 1991). These estimated rates are approxi- ham. Dale E. Brashers, PhD, is an associate professor in the
mately twice the observed rate in the general commu- Department of Speech Communication at the University of
nity population (Kessler et al., 1994). However, Illinois, Urbana-Champaign, Illinois.
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 14, No. 2, March/April 2003, 30-40
DOI: 10.1177/1055329002250992
Copyright © 2003 Association of Nurses in AIDS CareNeidig et al. / Aerobic Exercise Training 31 effective anti-HIV drug regimens (Low-Beer et al., associated with increased sexual risk behavior. How- 2000). One group reported significant levels of depres- ever, Kalichman and Weinhardt (2001) argued this is sive symptoms in 52% of individuals who had not yet not an unexpected finding when the aggregate litera- initiated anti-HIV drug regimens (Low-Beer et al., ture is examined given methodological shortfalls in the 2000). original studies. Because partial adherence to complex With the lengthening course of HIV illness, the pre- HIV drug regimens may lead to drug resistance vention and management of depressive symptoms (Vanhove, Schapiro, Winters, Merigan, & Blaschke, have important personal and public health benefits. 1996) and because prevalence of drug resistance in pri- Although consensus is lacking, some have reported mary HIV infections is increasing (UK Collaborative more rapid immune decline and accelerated mortality Group on Monitoring the Transmission of HIV Drug in persons with HIV infection reporting higher levels Resistance, 2001), additional research into the impact of depressive symptoms (Burack et al., 1993; Mayne, of depression on adherence and sexual risk taking is Vittinghoff, Chesney, Barrett, & Coates, 1996). needed. Depression is also thought to negatively affect quality Effective drug therapy for clinically depressed HIV- of life more than most medical conditions (Hays, infected persons is available (e.g., Rabkin, Wagner, & Wells, Sherbourne, Rogers, & Spritzer, 1995). Among Rabkin, 1999). Selection from among traditional adults with HIV infection, Sherbourne et al. (2000) (tricyclic, selective serotonin reuptake inhibitors) and found that those with symptoms of depression or other alternative agents (dextramphetamine or testosterone probable mood disorders had significantly lower replacement) is often aimed at minimizing cumulative health-related quality-of-life scores than did those side effects of antiretroviral and antidepressant regi- without depression. Suicide ideation is an important mens and time to clinical response. However, despite depressive symptom that must be carefully assessed in available drugs and psychotherapy, depressive symp- persons with HIV infection. Marzuk et al. (1988) dem- toms in this population often are not treated onstrated dramatic reductions in suicide rates in HIV/ (Sambamoorthi, Walkup, Olfson, & Crystal, 2000). AIDS samples. However, as Levine (2001) astutely Providers may view depressive symptoms as a normal commented, the improved HIV/AIDS therapies that component of the underlying HIV disease or HIV ther- have reduced suicide among persons living with HIV apy (Rabkin, 1997). infection have also led to new stressors. Requirements In addition, depressive symptoms consistently cor- for lifetime adherence to complicated therapies and relate with physical symptom reports (Rabkin et al., HIV risk behavior modification (Rabkin & Ferrando, 1997), and the overlap between symptoms of the viral 1997) as well as the need to renegotiate feelings of infection, related neuropsychological symptoms, and hope and new social roles (Brashers et al., 1999) pres- depressive symptoms (e.g., fatigue, poor appetite, ent new challenges for persons once reconciled to a weight loss, trouble concentrating) has made selecting death from HIV/AIDS. a measure of depressive symptoms difficult. Because Beyond the compelling need to manage depressive there is no HIV-disease-specific measure of depres- symptoms to ameliorate personal suffering, effective sion symptoms, many researchers, including those management of depression may also promote HIV studying the largest cohorts (Burack et al., 1993; drug adherence and help to minimize HIV transmis- Mayne et al., 1996; Ostrow et al., 1989), have assessed sion. Depression has been associated with non- depressive symptoms with the Center for Epidemio- adherence to HIV drug regimens (Gordillo, del Amo, logical Studies–Depression Scale (CES-D) (Radloff, Soriano, & Gonzalez-Lahoz, 1999; Singh et al., 1999) 1977). This scale is thought to be less confounded by and may be associated with increased sexual risk physical symptoms (Drebing et al., 1994). On the behaviors, although findings associating negative other hand, a considerable number of researchers (e.g., affect (depression, anxiety, anger) with sexual risk Singh, Squier, Sivek, Wagener, & Yu, 1997) have col- behaviors have been mixed (Kalichman, 1999). In a lected self-reported symptoms of depression within recent meta-analysis, Crepaz and Marks (2001) con- HIV and AIDS studies using the Beck Depression cluded there is little evidence that negative affect is Inventory (BDI). The BDI is a symptom measure
32 JANAC Vol. 14, No. 2, March/April 2003
originally intended as a clinical index of depression Using Profile of Mood State (POMS) scores,
severity (Beck, Ward, Mendelson, Mock, & Erbaugh, LaPerriere and colleagues (1990, 1991) concluded
1961). To overcome symptom confounds, some HIV/ that aerobic exercise training attenuated stressors
AIDS researchers have developed CES-D subscales associated with receipt of an HIV-positive test result.
(Burack et al., 1993; Ostrow et al., 1989), whereas oth- Others (MacArthur et al., 1993) noted a trend to
ers have used the total scale and controlled for symp- improvement on an unspecified mental health ques-
toms during analysis (Lyketsos et al., 1993). This tionnaire, and Lox, McAuley, and Tucker (1995)
inconsistent use of symptom indices, concern about reported improved mood in HIV-infected exercisers as
symptom confounds, and divergent scoring compared to study controls. Wagner, Rabkin, and
approaches have limited interpretation of this body of Rabkin (1998) also reported mood enhancement when
research. exercise was combined with steroid therapy. Overall,
Aerobic exercise training is also associated with these findings have been limited by small samples,
decreased depression in health and chronic illness limited control for disease stage and concomitant
(Dishman, 1985). In HIV-negative persons, regular drugs, variable exercise protocols (Smith et al., 2001),
exercise has been shown to be an effective therapy for and the use of diverse mental health measures.
mild to moderate depression and an efficacious The current study examines the efficacy of aerobic
adjunct for severe depression (Morgan & Goldston, exercise training for the management of depressive
1987; Tkachuk & Martin, 1999). In controlled studies symptoms experienced by adults living with HIV
of clinically depressed patients, aerobic exercise train- infection. The purpose of this study was to (a) deter-
ing has been consistently shown to be more effective mine the impact of participation in a 12-week aerobic
than no treatment or placebo control and to have favor- exercise training program on self-reported depressive
able efficacy when compared to psychotherapy and symptoms and (b) to examine the correlations among
cognitive therapy (Tkachuk & Martin, 1999). As com- participant scores on several widely used measures of
pared to traditional depression treatments, exercise depressive symptoms and depressed mood. The
therapy may be more cost-effective (Greist et al., researchers hypothesized that the experimental group,
1979). As such, aerobic exercise may be a cost- as compared to the study controls, would have
effective way for HIV-positive persons to prevent or improved Week 12 CES-D, BDI, and POMS depres-
reduce mild to moderate symptoms of depression. In sion subscale scores.
light of potential antiretroviral and antidepressant drug
interactions (Rabkin, 1997), exercise may also be an
important drug adjunct for more severely depressed
Method
persons.
Aerobic exercise is one of the most frequently Study data were collected between 1995 and 1998
reported alternative and complementary activities as part of a larger study examining aerobic exercise
used by HIV-infected persons (Greene et al., 1999). training for HIV symptom management (Smith et al.,
Results from small, controlled studies also suggest 2001). Participants were randomly assigned to a 12-
that HIV-infected persons may engage in habitual week aerobic exercise training or to a wait list (main-
moderate-intensity exercise to improve cardiopul- tain usual activity) condition within a pretest/posttest
monary fitness without clinically significant CD4 lym- control group design. The study received prior
phocyte cell decreases (MacArthur, Levine, & Birk, approval by the institutional review board, and
1993; Rigsby, Dishman, Jackson, Maclean, & Raven, informed consent was obtained. Participants were
1992; Smith et al., 2001; Stringer, Berezovskaya, exercise tested in a university health and wellness cen-
O’Brien, Beck, & Casaburi, 1998) or undesired increases ter and mainstreamed for training into university staff
in plasma HIV viral load (Smith et al., 2001; Stringer and patient fitness programs at the same facility. Other
et al., 1998). Mental health outcomes, however, have not procedures were performed at the university’s AIDS
been studied as extensively, and the effects of chronic Clinical Trials Unit (ACTU). A convenience sample of
exercise on depressive symptoms have not been isolated. 60 adults who had laboratory-confirmed HIVNeidig et al. / Aerobic Exercise Training 33
Table 1. Pearson Product-Moment Correlations Between Mean Scale Scores
Week 0 Week 12
CES-D BDI POMS POMS-D CES-D BDI POMS POMS-D
CES-D .93 .71 .79 .83 .93 .71 .90 .86
BDI .71 .81 .76 .70 .71 .89 .78 .67
POMS .79 .76 .90 .93 .90 .78 .91 .91
POMS-D .83 .70 .93 .92 .86 .67 .91 .96
NOTE: CES-D = Center for Epidemiological Studies–Depression Scale; BDI = Beck Depression Inventory; POMS = Profile of Mood State;
POMS-D = POMS depression subscale. Scale reliabilities are in bold.
infection and met Centers for Disease Control and Pre- not intended as a diagnostic measure of clinical
vention (CDC) disease classifications A2 (asymptom- depression (Radloff, 1977). Respondents rate the fre-
atic, non-AIDS) or B2 (symptomatic, non-AIDS) quency of symptoms experienced in the past week on a
(CDC, 1993) was recruited from the ACTU and the 4-point scale; each item receives a score from 0 to 3,
local community. If participants were taking and total scores range from 0 to 60. Scores greater than
antiretrovirals or antidepressants at screening, regi- 16 indicate a high level of depressive symptoms and
mens were stable for at least 8 weeks. During screen- have good sensitivity in predicting a clinical diagnosis
ing, all participants were examined and cleared medi- of depression (Weissman, Prusoff, & Newberry,
cally by an ACTU physician. 1975). High internal consistency, concurrent validity
Exercisers were required to attend three supervised with self-report and clinical interviews, and construct
1-hour training sessions per week. Trained exercise validity have been established (Radloff, 1977). Reli-
leaders coached participants to exercise a minimum of ability (Cronbach’s alpha = .90) has been established
30 minutes within an individually prescribed target in HIV/AIDS samples (DeGenova, Patton, Jurich, &
heart rate range corresponding to 60% to 80% of maxi- Macdermid, 1994); reliability estimates for adminis-
mum oxygen uptake (VO2 max). Personal trainers trations of the CES-D and other dependent measures in
supervised the exercise sessions conducted in a medi- this sample are reported in bold in Table 1.
cal exercise facility with nurse practitioners, exercise
physiologists, and physicians in attendance. Partici- BDI. The BDI is a self-report depressive symptom
pants chose an aerobic exercise modality from among index that includes 21 items. Participants rate each
treadmill use, stationary biking, and walking. Further symptom on severity, and individual items are scored
details of the inclusion/exclusion criteria, exercise from 0 to 3. Total scores range from 0 to 63, and a score
testing and training protocols, and participant moni- of 9 is thought to be indicative of at least mild depres-
toring are reported elsewhere (Smith et al., 2001). sion. A score of 15 is designated as a possible depres-
sion cutoff in the general population (Beck & Steer,
Measures 1993). Concurrent validity with other measures of
depression, internal consistency, and instrument sta-
Dependent measures were collected at Weeks 0 and bility have been demonstrated (Beck & Steer, 1993);
12. Only exercise participants who completed at least the BDI has been frequently used by researchers
28 of 36 sessions and attended at least 80% of sessions examining the effects of exercise on depression
during the month prior to the graded exercise posttest (Tkachuk & Martin, 1999).
were included in these analyses.
POMS. The POMS is a 65-item instrument measur-
CES-D. The CES-D is a 20-item self-report mea- ing six mood states: tension/anxiety, depression/
sure of symptoms commonly associated with depres- dejection, anger/hostility, fatigue/inertia, confusion/
sion. The scale emphasizes affective distress and was bewilderment, and vigor/activity (McNair, Lorr, &34 JANAC Vol. 14, No. 2, March/April 2003
Droppleman, 1971). Respondents rate the occurrence situations as stressful. Items are scored from 0 to 5,
of adjective items during the past week on a 5-point with higher scores indicating greater perceived stress.
scale from 0 (not at all) to 4 (extremely). With the The PSS 4 is thought adequate when a brief stress mea-
exception of the vigor subscale, higher scores indicate sure is desired (Cohen & Williamson, 1988). In the
a negative mood state. Internal consistency estimates general population, a mean of 4.49 (± 2.96) has been
of 0.90 or greater have been reported for all six mood reported. Both the Social Support Questionnaire–6
scales, and test-retest reliabilities have been estimated (SSQ-6) and the PSS 4 have been used in HIV/AIDS
at 0.65 to 0.74. Construct and predictive validity using samples; estimated reliabilities in this sample ranged
other measures of depression, anxiety, and distress from 0.82 to 0.84.
have been established (McNair, Lorr, & Droppleman,
1992), and excellent reliability for the entire scale and Social support. The SSQ-6 (Sarason, Sarason,
the 15-item depression subscale (Cronbach’s alpha = Shearin, & Pierce, 1987) is a widely used six-item self-
.93) has been reported in HIV samples (e.g., Perkins report that measures perceived access to supportive
et al., 1995). others and individual satisfaction with the perceived
support. Higher scores indicate higher levels of per-
Other Variables ceived access and satisfaction. Across administra-
tions, reliabilities in this sample ranged from 0.77 to
A number of potentially confounding or explana- 0.91 for the number scale and 0.93 to 0.96 for the satis-
tory variables were assessed at Weeks 0 and 12 in the faction scale.
larger exercise study (Smith et al., 2001). These
included measures of physical fitness, physical activ- HIV medical history. When interviewing partici-
ity outside the exercise study, stress, social support, pants about their current medications and other medi-
and HIV-related medical history and self-reported cal history, trained ACTU research nurses used stan-
symptoms. dardized data collection tools that are widely used
across AIDS Clinical Trials Group protocols. Self-
Physical fitness. Aerobic fitness or peak aerobic reported symptoms were assessed using an HIV symp-
power (VO2 max) was measured during graded exer- tom checklist (Smith et al., 2001). Demographics, HIV
cise testing on a motor-driven treadmill. Testing fol- risk behaviors, and other drug use patterns were also
lowed guidelines adapted from American College of self-reported.
Sports Medicine (ACSM) (2000) standards for exer-
cise testing and was done in a controlled laboratory Data management and analysis. Investigators
setting by staff members experienced with exercise reviewed case record forms for missing and aberrant
testing in clinical populations. data. Data were quality controlled using standard
ACTU procedures and were analyzed using SPSS for
Physical activity. General physical activity (during Windows computer program (SPSS 10.0) with an
the prior 2 weeks) was measured at baseline and at alpha level of .05 specified prospectively. Chi-square
Week 12 using an adaptation of an instrument origi- analyses or two-tailed Fisher’s exact tests and
nally designed by Paffenbarger, Wing, and Hyde univariate analysis of variance (ANOVA) models were
(1978). Participants in both groups were asked to used to assess pretreatment group equivalence. Means
report the number of hours they spent in light, moder- and standard deviations were calculated, and distribu-
ate, or vigorous activity. These data were desired to tions were examined for all dependent variables. Anal-
identify changes in moderate or vigorous nontraining ysis of covariance (ANCOVA) procedures were used
physical activity that might influence study outcomes. to assess between-group changes after treatment using
pretest measures as the covariate. Finally, Pearson
Stress. The Perceived Stress Scale 4 (PSS 4) product-moment coefficients were used to describe
(Cohen, Kamarck, & Mermelstein, 1983) measures the relationships between mean scores on dependent
the degree to which an individual appraises life measures.Neidig et al. / Aerobic Exercise Training 35
Table 2. Baseline Participant Characteristics Table 3. Baseline Depressive Symptoms/Mood State Scores
Sample Exercise Control Sample Exercise Control
(n = 60) (n = 30) (n = 30) (n = 60) (n = 30) (n = 30)
n % n % n % Center for
Female 8 13 4 13 4 13 Epidemiological
Black 11 18 9 30 2 7 Studies–Depression
Male-Sex-Male 49 82 23 77 26 87 Scale
Heterosexual 8 13 4 13 4 13 Range 0 to 45 0 to 45 0 to 35
Intravenous drug use 3 5 2 7 1 3 Mean 13.2 ± 11.2 12.3 ± 11.8 14.1 ± 10.7
Employed 42 70 19 63 23 77 Score 0-14 39 (65%) 22 (73%) 17 (57%)
College or degree 38 63 19 63 19 63 Score 16-60 21 (35%) 8 (27%) 13 (43%)
Income36 JANAC Vol. 14, No. 2, March/April 2003
Table 4. Comparison of Baseline Exercise Participant At both administrations, mean CES-D and BDI
Characteristics scores were highly correlated (r = .71, p = .05).
Completers Noncompleters Pearson product-moment correlations among mean
(n = 18) (n = 12) CES-D, BDI, and scores for the sample are shown in
n % n % Table 1.
Female 0 0 4 33
African American 2 11 7 58
Male-Sex-Male 16 89 7 58 Discussion and Implications
Heterosexual 0 0 4 13 for Research and Practice
Intravenous drug use 1 6 1 8
Employed 11 61 8 67
College or degree 14 78 5 42 This is thought to be the first report on the effects of
IncomeNeidig et al. / Aerobic Exercise Training 37
Table 5. Group Means and Analysis of Covariance
Exercise Control
Week 0 Week 12 Week 0 Week 12 F p
Center for Epidemiological Studies–Depression Scale
n 30 18 30 30
M ± SD 12.3 ± 11.8 7.2 ± 7.1 14.1 ± 10.7 14.1 ± 11.3 5.16 .028*
Beck Depression Inventory
n 30 18 29 30
M ± SD 8.6 ± 6.0 5.6 ± 6.3 8.9 ± 5.9 8.7 ± 7.1 3.61 .064
Profile of Mood State
n 30 18 30 30
Total (M ± SD) 34.0 ± 39.3 12.2 ± 28.3 31.5 ± 32.7 32.3 ± 40.0 7.04 .011
Depression 10.9 ± 11.8 6.1 ± 8.9 10.9 ± 8.5 10.9 ± 11.2 4.27 .045*
NOTE: Significance indicated with an asterisk.
and no Black women completed the randomized exer- club or gym. Some sessions were very crowded, but at
cise intervention. Individuals who were lost from the other times, exercise participants worked out individu-
study were often among the working poor and reported ally. Although this and all studies of exercise must nec-
abrupt changes in employment, unreliable transporta- essarily use convenience samples, some may contend
tion, and increased family responsibilities as reasons that exercise participants were more motivated to per-
for premature study discontinuation. Most exercisers form because they were research participants. Some
who completed the study were Caucasian men who participants may have been motivated to continue in
reported homosexual or bisexual HIV risk factors, and the exercise program longer than they might have if
all had CD4 cell counts ranging from 200 to 500/mm3. they had not been involved in a research study.
Researchers should budget for personnel and services Findings of psychological benefit should also be
that support participant retention in future exercise interpreted cautiously because the study attracted few
studies. Transportation, child care, and other services participants with high levels of depressive symptoms.
may be needed to retain less economically advantaged Because 65% to 80% of participants had normal
participants. depressive symptom scores at baseline, it is difficult to
Although it would have been ideal to exclude per- evaluate the clinical relevance of these findings. Few
sons taking antidepressants, only persons on stable exercise studies have reported pretest BDI and posttest
drug regimens were enrolled in this study. The use of BDI data; however, the magnitude of CES-D symptom
randomization did balance groups on antidepressant reduction we observed in this study is comparable to
use and should have also controlled for disparate life that observed by Chesney, Folkman, and Chambers
events, depressive symptoms that may have spontane- (1996) following a coping effectiveness training pro-
ously remitted, and differences in concurrent psycho- gram. Moreover, any symptom improvement is desir-
therapy. Because social reinforcement may ameliorate able as even low symptom burden represents distress
depression, the addition of an attention-only control and suffering. Preventing or reducing depressive
group may have helped us to examine the influence of symptom burden over the lengthening course of
social interactions. However, it is worth noting that chronic HIV infection may be very important for
this study’s exercise intervention did not use a group adherence and quality of life.
format, as was the case in LaPerriere and colleagues’ As depressive symptom measures, both self-report
(1991) trial. Moreover, in this sample, exercisers did measures worked well, and scores were highly corre-
not differ significantly from control participants on lated providing evidence of convergent validity (r =
perceived social support. Although exercisers had per- .71). The finding that the CES-D and BDI have conver-
sonal supervision during each session, the exercise gent validity should help readers better integrate the
facility was similar to the “real-life” setting of a health findings of prior studies that used one of these38 JANAC Vol. 14, No. 2, March/April 2003
symptom measures. These study findings also provide Henry, Melroe, Huebsch, Kopaczewski, & Simpson,
preliminary support for using the POMS depression 1998) will lead to renewed enthusiasm for exercise
subscale as a measure of depressed mood in HIV- training among some persons on anti-HIV drug regi-
infected persons. mens. Nurses may find the current HIV treatment
Symptom management is an essential but often environment may present excellent opportunities to
neglected component of HIV care. Because persons encourage health-promoting behaviors that include
living with HIV infection often experience depressive regular physical activity.
symptoms over the course of their chronic HIV illness,
these symptoms warrant systematic study to deter-
mine the best management strategies. This study pro-
Acknowledgments
vides preliminary evidence that a program of moder-
ately intense aerobic exercise might be an effective This research was funded by the National Institutes
approach to preventing or reducing prevalent symp- of Health, National Institute of Nursing Research (NR
toms of depression in persons with HIV infection. 03974), the National Institute of Allergy and Infec-
Additional research is needed to determine whether tious Diseases (Adult AIDS Clinical Trials Group,
exercise can benefit HIV-infected persons with signifi- A125924), and The Ohio State University College of
cantly higher levels of depressive symptoms. Future Nursing. The authors gratefully acknowledge the
researchers should also consider including a social efforts of the study participants and thank Michael
attention control group (in addition to a no-treatment McDonald, Dylan Wessman, Jeremy Johnson, the
control group). ACTU staff, and Dr. Jennie Nickel for their important
The differential loss of participants from the exer- contributions. In remembrance we also acknowledge
cise treatment group reinforces the general finding that Dr. Robert J. Fass for his encouragement and thought-
exercise adherence is very difficult for many people. In ful manuscript reviews.
general, a 50% drop-out rate within 6 months of start-
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