International Journal of Nursing Studies 52 (2015) 15421552

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Physical tness exercise versus cognitive behavior therapy

on reducing the depressive symptoms among
community-dwelling elderly adults: A randomized
controlled trial
Tzu-Ting Huang a,b,*, Chiu-Bi Liu c,1, Yu-Hsia Tsai a,2, Yen-Fan Chin a,3,
Ching-Hsiang Wong a,4
a
School of Nursing, College of Medicine, Chang Gung University, Taiwan
b
Healthy Aging Research Center, Chang Gung University, Taiwan
c
Central Taiwan University of Science and Technology, Taiwan

A R T I C L E I N F O A B S T R A C T

Article history: Background: Depression is a major health problem for community-dwelling elderly adults.
Received 11 July 2014 Since limited resources are available to decrease the high prevalence of depressive
Received in revised form 13 May 2015 symptoms among the elderly adults, improved support for them can be provided if we can
Accepted 14 May 2015
determine which intervention is superior in ridding depressive symptoms.
Objective: To compare the effectiveness of the physical tness exercise program and the
Keywords:
cognitive behavior therapy program on primary (depressive symptoms) and secondary
Elderly adults
outcomes (6-min walk distance, quality of life, and social support) for community-
Depression
Physical tness dwelling elderly adults with depressive symptoms.
Cognitive behavior therapy Design and settings: A prospective randomized control trial was conducted in three
communities in northern Taiwan.
Participants: The elderly adults in the three communities were invited to participate by
mail, phone calls, and posters. There were a total of 57 participants who had depressive
symptoms and all without impaired cognition that participated in this trial. None of the
participants withdrew during the 9 months of follow-up for this study.
Methods: Fifty-seven participants were randomly assigned to one of the three groups: the
physical tness exercise program group, the cognitive behavior therapy (CBT) group, or
the control group. The primary (Geriatric Depression Scale-15, GDS-15), and secondary
outcomes (6-min walk distance, SF-36, and Inventory of Socially Supportive Behaviors

* Corresponding author at: School of Nursing, Healthy Aging Research Center, College of Medicine, Chang Gung University, 259, Wen-Hwa 1st Road,
Kwei-Shan, Tao-Yuan, Taiwan. Tel.: +886 3 2118800x5321; fax: +886 3 2118700.
E-mail addresses: thuang@mail.cgu.edu.tw (T.-T. Huang), yl870124@yahoo.com.tw (C.-B. Liu), yhtsai@mail.cgu.edu.tw (Y.-H. Tsai),
yenfan@mail.cgu.edu.tw (Y.-F. Chin), wong_6019@yahoo.com.tw (C.-H. Wong).
1
Address: Clinical Instructor, Central Taiwan University of Science and Technology, 666, Buzih Road, Beitun District, Taichung City, Taiwan.
Tel.: +866 0982262774.
2
Address: Senior Instructor, School of Nursing, College of Medicine, Chang Gung University, 259, Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan, Taiwan.
Tel.: +886 3 2118800x5184; fax: +886 3 2118700.
3
Address: Assistant Professor, School of Nursing, College of Medicine, Chang Gung University, 259, Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan, Taiwan.
Tel.: +886 3 2118800x5189; fax: +886 3 2118700.
4
Address: Doctoral Candidate, Graduate Institute of Clinical Medical Sciences, Chang Gung University, 259, Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan,
Taiwan. Tel.: +886 3 2118800x5321; fax: +886 3 2118700.

http://dx.doi.org/10.1016/j.ijnurstu.2015.05.013
0020-7489/ 2015 Elsevier Ltd. All rights reserved.
 T.-T. Huang et al. / International Journal of Nursing Studies 52 (2015) 15421552 1543

scales, ISSB) were collected immediately (T2), at 3 months (T3), and at 6 months after the
interventions (T4).
Results: After the interventions, the CBT group participants demonstrated signicantly
lower symptoms of depression (p = 0.009) at T2 and perceived more social support from
those around them (p < 0.001, <0.001 and =0.004, respectively) at three time-point
comparisons than the control group. Moreover, after intervention, participants in the
physical tness exercise program group had decreased GDS-15 scores at three time-point
comparisons (p = 0.003, 0.012 and 0.037, respectively), had a substantially greater 6-min
walk distance (p = 0.023), a better quality of life (p < 0.001), and a better perceived social
support at T2 (p < 0.001).
Conclusions: Immediately after a 12-week intervention, there were signicant decreases
in depressive symptoms and more perceived social support amongst those in the CBT
group. When considering the effectiveness in the decrease of depressive symptoms longer
term, the increase in the 6-min walk distance and raising the patients quality of life,
physical tness exercise program may be a better intervention for elderly adults with
depressive symptoms.
2015 Elsevier Ltd. All rights reserved.

What is already known about the topic?
 Depression is a major health problem for community-
dwelling elderly adults, but it is often under-diagnosed
and under-treated, since it is often hidden behind
somatic symptoms.
 Both cognitive behavioral and exercise strategies could
reduce depressive symptoms among elders. However, no
study compares the effects of these two interventions
among elderly with depressive symptoms.
What this paper adds
 Both exercise and CBT (cognitive behavior therapy)
interventions, which are group-based, are appropriate
and effective programs for reducing elders depressive
symptoms after a 12-week program.
 If improving physical tness, quality of life, and
maintaining a longer term effect from the intervention
are desired, then the group-based exercise program is
the best choice for community-dwelling elderly adults
with depressive symptoms.
1. Introduction
Depression has an ubiquitous inuence affecting all
ages and both sexes, earning its place as the second most
prominent disease in the world (Ferrari et al., 2013) as well
as one of the leading causes of suffering for the older
adults. Due to the frequent occurrence of somatic
symptoms concealing the disease, depression is often
under-diagnosed and under-treated (Hsieh and Lai, 2005).
Depressive symptoms (DS) are dened as sadness, melan-
choly, or a feeling of hopelessness (Lai, 2002) and include
feelings of sadness that are accompanied by altered mood
and somatic symptoms that are not sufcient in severity to
lead to a diagnosis of clinical depression (Khalil et al.,
2010). The prevalence of DS in community-dwelling
elderly adults is 10.439.3% (Chung, 2008; Ganatra et al.,
2008; Sirey et al., 2008) (in Taiwan, it is 20.331.3%, Chen,
2009; Lyu and Lin, 2000). DS decreases the quality of life
(Akyol et al., 2010; Dekker et al., 2011) and increases the
risk of suicide (Sirey et al., 2008) leading to a higher
mortality rate (Sun et al., 2011).
According to previous research, the two effective
strategies to decrease depression amongst the older adults
include exercise (Shin et al., 2009; Silveira et al., 2010; Sims
et al., 2009) and cognitive behavioral therapy (CBT) (Ekberg
and Lecouteur, 2012; Laidlaw et al., 2008; Strachowski et al.,
2008). Wright and Cattan (2009) advocated for exercise to
decrease depression due to the accessibility and low cost of
the activity, even drawing attention to the fact that exercise
is free from adverse side effects when done sensibly.
Exercise also leads to an increase of neurotransmitters (e.g.,
serotonin, dopamine, and norepinephrine) available in the
brain, which have been diminished by depression (Sharpley,
2013; Wright and Cattan, 2009). A meta-analysis study to
determine the effectiveness of exercise in the treatment of
adult people with a diagnosis of depression by Mead et al.
(2009) targeted 23 trials (907 participants), and found that
the pooled standardized mean difference (SMD) was 0.82
(95% CI (condence interval) 1.12, 0.51), revealing a large
clinical effect. Conversely, when included the three trials
with adequate allocation concealment, intention to treat
analysis, and blinded outcome assessment, the pooled SMD
was 0.42 (95% CI 0.88, 0.03), indicating a moderate and
non-signicant effect. Mead et al. suggested that more
methodologically robust trials should be performed to
obtain more accurate estimates of effect sizes.
CBT is based on Becks (1979) cognitive theory of
depression that posits depression is the result of faulty or
maladaptive cognitive processes. Thus, the combination of
basic behavioral and cognitive principles can change
maladaptive thinking and lead to changes in both behavior
and affect (Hassett and Gevirtz, 2009; Salmon and
Jablonski, 2010). Recent variants of CBT emphasize
changes in ones relationship to maladaptive thinking
rather than changes in the thinking itself (Hayes et al.,
2011).
The effective exercise programs include promoting
cardiorespiratory endurance (Brenes et al., 2007; Resnick
et al., 2008; Shin et al., 2009), muscle strength and
1544 T.-T. Huang et al. / International Journal of Nursing Studies 52 (2015) 15421552
endurance (Brenes et al., 2007; Shin et al., 2009; Sims et al.,
2009), exibility (Shin et al., 2009), and balance (Shin et al.,
2009). The mode of exercise was 23 times a week (Brenes
et al., 2007; Resnick et al., 2008; Sims et al., 2009) for 30
90 min each time (Brenes et al., 2007; Resnick et al., 2008;
Shin et al., 2009) for 816 weeks (Resnick et al., 2008; Shin
et al., 2009; Sims et al., 2009). Moreover, promoting social
interaction (Sims et al., 2009) and integrating some
techniques into the exercise program, such as matching
background music, in a game like fashion (Shin et al., 2009)
could motivate the elderly adults to exercise regularly,
therefore decreasing DS.
There are two strategies of CBT: the cognitive and the
behavioral. In the cognitive aspect, the effective components
consists of monitoring negative thinking and mood shifts,
recognizing wrong thinking and information (Anderson
et al., 2008; Chen et al., 2008; Laidlaw et al., 2008);
understanding the relationship between cognitive ability
and mood (Anderson et al., 2008; Chan et al., 2006; Forsyth
et al., 2010); coping with automatic, evidence-based, or
alternative thinking (Anderson et al., 2008; Chan et al., 2006;
Forsyth et al., 2010), and having a positive self-conception
(Chen et al., 2008). Behavior aspects comprise of developing
a coping strategy (Strachowski et al., 2008), setting up new
goals and activities (Anderson et al., 2008; Chen et al., 2008;
Laidlaw et al., 2008), relaxing techniques and stress
management (Anderson et al., 2008; Strachowski et al.,
2008), promoting communication (Chen et al., 2008), and
improving problem solving techniques (Chen et al., 2008).
CBT was most effective 12 times a week (Strachowski
et al., 2008; Wagner et al., 2006) for 412 weeks (Anderson
et al., 2008; Chen et al., 2008; Wagner et al., 2006).
Furthermore, the previous studies indicated that the better
the therapeutic relationship between facilitators and
participants (Chen et al., 2008; Forsyth et al., 2010; Wagner
et al., 2006), the stronger the motivation of participants
(Strachowski et al., 2008), as well as providing the
therapeutic handout for each session of the CBT (Anderson
et al., 2008) were associated with less depressive symptoms.
Both exercise and CBT programs contribute to the
reduction of DS, however, limited resources are available
to decrease the high prevalence of DS among older adults.
Improved support to the participants with DS can be
provided if we can determine which intervention is
superior in the ridding of DS.
There is no research in academia that compares the
effects of these two interventions (exercise and CBT)
among elderly adults with DS. Both interventions in this
study are based on the effective components for decreasing
DS from previous studies. This study aims to compare the
effectiveness of these two group-based interventions on
primary outcomes (DS), and secondary outcomes (physical
tness (6-min walk), quality of life, and social support) of
community-dwelling elderly adults with DS.
2. Methods
2.1. Design
In this prospective randomized control trial, the rst
author used computer-developed randomization tables to
randomly assign subjects to one of the three groups:
physical tness exercise, CBT, or control. The two
intervention groups were conducted over the course of
12 weeks. For the participants that were allocated to the
intervention groups, assessments of the outcomes were
conducted 1 week before the start of the intervention (T1),
3 months (immediately after a 12-week intervention, T2),
6 months (3 months after intervention, T3), and 9 months
(6 months after intervention, T4) after baseline by a
research assistant blinded to their group allocation.
Participants in the control group completed outcome
measures at the same time frame as those in the
intervention groups.
2.2. Participants
The inclusion criteria were the adults had to be 65 years
of age or older, had a score on the Geriatric Depression
Scale-15 (GDS-15) 5 (indicates with depressive mood,
Sheikh and Yesavage, 1986; Nyunt et al., 2009), experi-
enced no cognitive impairment or been diagnosed as
psychiatric illness or depression, the ability to walk
independently for at least 6 m, the ability to speak and
read Chinese, and no participation in another study.
Moreover, none of the participants is under antidepressant
therapy either at starting point or during follow-up.
Cognitive impairment was determined by MMSE scores
(Yeh et al., 2000; illiterate < 16, 6 years education < 21,
and 9 years < 24).
The sample size was determined based on the outcomes
of one previous physical tness exercise (Brenes et al.,
2007) and one CBT (Laidlaw et al., 2008) intervention
study. The two studies compared the effect of the
interventions to the control group in order to assess the
effect the interventions had on reducing depression among
the community-dwelling seniors. G*Power software was
conducted to calculate the sample size. The mean score of
GDS-15 at pre-test and post-test was 12.7 (SD = 3.4) and
7.8 (SD = 4.3), effect size = 1.14 in the study by Brenes et al.
(2007), and 7.60 (SD = 2.70) and 5.00 (SD = 3.71), and effect
size = .70 in the study by Laidlaw et al. (2008). To detect a
between-group difference in GDS-15 scores at 80% power,
a = .05, the total sample should be at least 9 in exercise
group and 18 in CBT group, respectively.
After receiving the list of community-dwelling elderly
adults (>65 years) in the three communities we invited all
of the 637 community-dwelling elderly adults in the three
communities to participate the screening, between June
and July 2011, by mail, phone calls, and posters.
Throughout July and August 2011, we conducted the
screening at the three community centers. There were
479 community-dwelling elderly adults that participated
in the screening. Two well-trained research assistants (RA)
conducted the interview and testing. The inter-rater
reliabilities (Pearson correlation coefcient) between the
RAs were all above 0.90.
Among those who scored 5 on the GDS-15 (n = 137,
28.60%, none of them were diagnosed as depression), 24
(17.52%) were cognitively impaired, 5 (13.51%) were not
able to walk 6 meters independently, 2 (1.46%) no longer
lived in the community, and 49 (35.77%) refused to
 T.-T. Huang et al. / International Journal of Nursing Studies 52 (2015) 15421552
participate in this study. A total of 57 subjects were
recruited for this trial, and none withdrew during the
9 months of study follow-up between September 2011 and
May 2012 (Fig. 1).
2.3. Interventions: the control group
The control group received no extra care, although
participants could use or apply for available services in the
area the same as before their participation in the study.
They received an abridged version of the interventions of
this study after the post-test session.
2.4. Interventions: physical tness exercise approach (PFE)
The three-times/week, 12-week PFE intervention was
aimed to help community-dwelling elderly adults with DS
to develop a regular exercise program. Participants were
encouraged to engage in 150 min/week of exercise by
completing 3  50 min sessions in groups of 24 partici-
pants for promoting social interaction. The intensity of the
exercise was moderate, determined by perceived exertion
ratings of between 12 and 14 on the Borg Scale (Borg,
1998). Participants were led in a simple exercise routine
that included warming up (range of motion [ROM] and
exibility exercises), cardiovascular exercises (walking
with waving or clapping hands, with a duration from 5 min
the rst week to 30 min the 10th week), muscle strength
exercises (for triceps brachii, biceps brachii, quadriceps
femoris, and iliopsoas), and cool down (exibility, ROM,
and deep breathing). Music they enjoyed played in the
background and the exercise was designed like playing a
game. The program followed the recommendations of
the American College of Sports Medicine (ACSM) and the
American Heart Association (AHA) (Haskell et al., 2007).
Participants of this group needed to complete 150 min/
week of exercise for 12 weeks. A trained physical tness
instructor, who has had experiences with elderly adults,
conducted each session.
Fig. 1. Participant enrollment and ow for this randomized trial.
1545
2.5. Interventions: cognitive behavioral therapy (CBT)
approach
In this study, the three phases proposed by Mor and
Haran (2009) were adapted and integrated into the CBT
intervention. The rst phase is often termed behavioral
scheduling or behavioral activation. In this phase,
participants learn to monitor their daily activities and
experiences. Keeping a log of daily activities themselves
enables them to learn to observe the link between their
behavior and their mood. During the second phase, the
focus of therapy shifts to cognitive assessment and
restructuring. First, participants learn to examine their
thought patterns by recording the occurrence of perceived
adverse events and identifying negative feelings as well as
the automatic thoughts elicited by these events. Second,
participants are led through a process of cognitive
restructuring. They learn to ask themselves questions
about their automatic thoughts and beliefs, such as, What
is the evidence for or against my belief? The third phrase
involves two arenas. In the cognitive arena, participants
work on altering core beliefs that may trigger negative
automatic thoughts. In the behavioral arena, they perform
a behavioral analysis of dysfunctional coping mechanisms
and alternative problem-solving strategies.
Our CBT intervention consisted of 12 weekly sessions,
lasting 6080 min in groups of 35 participants. The main
strategy was to restructure misconceptions to promote
positive thinking and behavior. The 12 weekly sessions
covered the following topics: rst phase (Weeks 13:
introduction; breaking free from a depressive life); second
phase (Weeks 47: listening to the evidence of verbal
communication, i.e.: I can think in this way; loving
myself; and my new thinking); and the third phase
(Weeks 812: activating the mind; an enrichment of life; I
can solve the problem, expecting an easier life; and
program review and farewell). Participants in this group
needed to complete all sessions of the CBT intervention. A
trained facilitator, who was a geriatric nurse with nursing
1546 T.-T. Huang et al. / International Journal of Nursing Studies 52 (2015) 15421552
master degree and had completed CBT course, conducted
each session. The facilitator was supervised by respondent
author who is an experienced CBT researcher.
2.6. Primary outcome measures
Depressive symptoms. A short-form GDS that consisted
of 15 questions was the primary outcome measure
(Sheikh and Yesavage, 1986). Scores of 04 are considered
normal; 58 indicates mild depression; 911 indicates
moderate depression; and 1215 indicates severe depres-
sion. The Chinese version of the GDS-15 demonstrates
high reliability (Liao et al., 1995); in this study, the
Cronbachs a is .91.
2.7. Second outcome measures
2.7.1. Physical tness
The 6-min walk test was used to measure cardiorespi-
ratory endurance. We instructed participants to walk back
and forth along a marked 50-m walkway in 6 min. For
safety precautions, a RA accompanied the participants
when the participants were tested.
2.7.2. Quality of life
The SF-36 questionnaire was used to measure quality of
life. This 36-item questionnaire assesses health-related
functions for eight distinct domains, which can be divided
into physical component and mental component scales.
Subsequent to summing the Likert-scaled items in the SF-
36 survey, scores in each scale are standardized so that
they each range from 0 to 100. Higher scores indicated
better level of functioning. The Chinese version of SF-36
demonstrated high reliability of previous studies (Lu et al.,
2003). In this study, the Cronbachs a is .81.87.
2.7.3. Social support
The Chinese version of the Inventory of Socially
Supportive Behaviors scales (ISSB) was used to measure
the perception of social support. The ISSB (Barrera et al.,
1981) was translated and modied by Yeh (1998). The
scale includes 10 items that are used to measure
emotional, informational, instrumental, and appraisal
support. Each item consists of three parts: the provider
of personal support, the perceived frequency of support
(1 = never to 3 = always), and the perceived satisfaction of
support (1 = never to 3 = extreme satisfaction). The total
scores range from 30 to 90. Higher scores indicated an
improved perception of social support. The ISSB Chinese
version has established satisfactory reliability for Taiwans
older adults (Yeh, 1998). The Cronbachs a is .89 in this
study.
2.8. Ethical considerations
Approval for this trial was obtained from the Institu-
tional Review Board of Chang Gung Hospital. Written
informed consent was obtained from each participant;
each participant was assured of condentiality and the
option to decline participation or to withdraw from the
trial at any time without penalty.
2.9. Data analysis
Statistical analyses were conducted using the SPSS
Version 18.0 (SPSS Inc., Chicago, IL, USA). Baseline data for
the experimental and control groups were compared using
x2 tests for categorical variables and KruskalWallis/one-
way analysis of variance (ANOVA) for continuous variables.
Inferential statistics on repeated measures were conducted
using generalized estimating equations (GEEs) to examine
the effectiveness of interventions in improving depressive
symptoms, 6-min walk distance, quality of life, and social
support when compared with the control groups. Relation-
ships between the average scores in above outcome
variables and variables such as time, group, and time
group interaction were explored.
3. Results
3.1. Comparison of three groups at baseline
The majority of participants were female (52.63%), with
6 or fewer years of education (57.89%), married (73.68%),
with religious (75.44%), nancially solvent (73.68%), had
self-awareness, and an overall better health status (68.42%).
The mean age of participants was 76.53 (SD = 5.94); the
mean score for activities of daily living (ADL; Barthel Index)
was 97.89 (SD = 3.89). In terms of demographics, no notable
baseline differences were found between the groups
(Table 1). The three groups were well balanced for baseline
depression as well as for other outcome variables (physical
tness measures, quality of life, and social support)
(Table 2).
3.2. Impact of experimental programs on outcomes
3.2.1. Primary outcomes: depressive symptoms
At T1, all of participants had DS; at T2, there were 11
(57.9%), 11 (61.1%), and 6 (30.0%) participants resulting in
an absence of DS in PFE, CBT, and control groups,
respectively. At T3, 13 (68.4%), 11 (61.1%), and 9 did not
have DS (in the same order as the previous statistic). At T4,
12 (63.24%), 12 (66.7%) and 7 (35.0%) became free of DS.
The results showed that after a 12-week PFE intervention
versus the pretest, when the average GDS-15 score of the
PFE group was 4 points lower; at 3 months after cessation
of the intervention versus the pretest, when the average
score of the PFE group was 4.21 points lower; and at
6 months after cessation of the intervention versus the
pretest, when the average score of the PFE group was
3.84 points lower (Fig. 2A). Results showed a statistically
signicant decrease in GDS-15 scores in the PFE group at
three time-point comparisons (Table 3). However, a
statistically signicant decrease in GDS-15 scores in the
CB group only at T2 comparison: at T2 versus the pretest,
when the average score of the CB group was 3.5 points
lower (Table 4).
3.2.2. Secondary outcomes: physical tness, quality of life,
and social support
As shown in Table 3, the results showed a statistically
signicant increase in 6-min walk distance and total scores
 T.-T. Huang et al. / International Journal of Nursing Studies 52 (2015) 15421552 1547

Table 1
Demographic characteristic at baseline.

Variables PFE group (n = 19) CB group (n = 18) Control group Total p

(n = 20)

Frequency (%) or Frequency (%) or Frequency (%) or Frequency (%) or

mean (SD) mean (SD) mean (SD) mean (SD)

Gender 0.691
Male 8 (42.1) 10 (55.5) 9 (45.0) 27 (47.4)
Female 11 (57.9) 8 (44.4) 11 (55.0) 30 (52.6)
Education (years) 0.493
>6 years 6 (31.6) 8 (44.4) 10 (50.0) 24 (42.1)
6 years 13 (68.4) 10 (55.6) 10 (50.0) 33 (57.9)
Marital 0.648
Married 14 (73.7) 12 (66.7) 16 (80.0) 42 (73.7)
Single 5 (26.3) 6 (33.3) 4 (20.0) 15 (26.3)
Religious 0.365
Yes 16 (84.2) 14 (77.8) 13 (65.0) 43 (75.4)
No 3 (15.8) 4 (22.2) 7 (35.0) 14 (24.6)
Financial 0.438
Enough 12 (63.2) 14 (77.8) 16 (80.0) 42 (73.7)
Not enough 7 (36.8) 4 (22.2) 4 (20.0) 15 (26.3)
Self-awareness health 0.270
Average/better 13 (68.4) 10 (55.6) 16 (80.0) 39 (68.4)
Worse 6 (31.6) 8 (44.4) 4 (20.0) 18 (31.6)
Age 76.42 (5.31) 77.39 (6.09) 75.85 (6.56) 76.53 (5.94) 0.693
ADL 98.16 (2.99) 96.39 (5.37) 99.00 (2.62) 97.89 (3.89) 0.197

Note: ADL, the scores of Barthel Index.

of quality of life in the PFE group only at T2 comparison: at
T2 versus the pretest, when the average score of the PFE
group was 15.37 m longer in walking distance and
15.51 scores higher in quality of life (Fig. 2B and C,
Table 4). However, there was no statistical signicance in
the CB group at three time-point comparisons. The results
showed a statistically signicant increase in ISSB scores in
the PFE group only at T2 comparison: at T2 versus the
pretest, when the average score of the PFE group was
4.84 scores higher in social support (Table 4). However, a
statistically signicant decrease in ISSB in the CB group at
three time-point comparisons: at T2 versus the pretest,
when the average score of the CB group was 5.44 points
higher; at T3 versus the pretest, when the average score of
the CB group was 4.11 points higher; and at T4 versus the
pretest, when the average score of the PFE group was
4.06 points higher (Fig. 2D, Table 4).
4. Discussion
This is the rst trial to compare exercise and CBT
interventions to decrease DS among community-dwelling
elderly adults. After 9-month follow up, there were more
participants without DS in the both two experimental
groups than the control group. When compared with the
impact of experimental program on DS, though the
difference of decrease of GDS-15 scores was non-signi-
cant between the two experimental groups, the effect of
PFE lasted longer than CBT. The effect of PFE on the
decrease of DS lasted for 6 months after the PFE
intervention.
This study provides evidence to support both inter-
ventions as appropriate and effective programs for
reducing DS in community-dwelling older adults after a
12-week program immediately. The results were consis-
tent with previous studies (Resnick et al., 2008; Stra-
chowski et al., 2008). Both of our interventions (exercise
and CBT) were group based and adapted effective
components from previous studies. Exercise may increase
the availability of brain neurotransmitters (e.g., serotonin,
dopamine, and norepinephrine) (Craft and Perna, 2004),
which has a positive impact on physical disability (Brenes
et al., 2007) and relieves the symptoms of depression via
social interaction (Sims et al., 2009). In the case of CBT,

Table 2
Baseline outcome variables by group.

PFE group (n = 19) CB group (n = 18) Control group (n = 20) K-W/ANOVA p

Mean (SD) Mean (SD) Mean (SD)

GDS-15 8.63 (3.56) 7.78 (2.29) 7.20 (2.19) 1.370 0.505

6-min walk distancea 258.69 (100.90) 221.19 (100.27) 244.06 (87.71) 0.710 0.496
Quality of life (SF-36)a 60.61 (15.41) 67.14 (11.80) 63.52 (18.67) 0.801 0.454
Physicala 59.20 (16.58) 61.25 (18.35) 60.46 (21.24) 0.056 0.946
Mental 62.01 (18.54) 73.01 (12.43) 66.59 (19.25) 5.200 0.074
ISSBa 63.74 (10.07) 59.89 (11.46) 61.35 (9.38) 0.661 0.520

Note: K-W, KruskalWallis test; GDS-15, Geriatric Depression Scale-15; ISSB, Inventory of Socially Supportive Behaviors.
a
ANOVA.
1548 T.-T. Huang et al. / International Journal of Nursing Studies 52 (2015) 15421552

Fig. 2. (A) GDS-15, (B) 6-min walk distance, (C) SF-36, and (D) ISSB scores stratied by groups over time. Note: PFE, physical tness exercise group; CB,
cognitive behavioral group; T1, baseline; T2, 3 months; T3, 6 months; T4, 9 months; GDS-15, Geriatric Depression Scale-15; ISSB, Inventory of Socially
Supportive Behaviors.

promoting a positive therapeutic relationship (Wagner
et al., 2006), a group-based social interaction (Sims et al.,
2009), a therapeutic handout for each session (Anderson
et al., 2008), and the use of distracting activities (Craft and
Perna, 2004) created a positive inuence on the manage-
ment of depression, which results in a greater reduction in
DS.
However, we came to consensus that the effectiveness
of CBT intervention in our study was only signicant at T2.
There are several possible explanations for this. First, not
all participants in the intervention group maintained their
practice. For example, participants in PFE group maintain
the exercise program (150 min/week moderate intensity)
100% at T2, 63.16% (n = 12) and 47.37% (n = 9) at T3 and T4,
 T.-T. Huang et al. / International Journal of Nursing Studies 52 (2015) 15421552 1549

Table 3
GEE analysis on outcome variables.

Variables B SE 95% Wald CI Wald x2 p

GDS-15
Group (CB)a 0.578 0.694 0.782 to 1.938 0.694 0.405
Group (PFE)a 1.432 0.928 0.387 to 3.250 2.381 0.123
Time 4thb 2.100 0.552 3.182 to 1.018 14.483 <0.001
Time 3rdb 2.450 0.39 3.215 to 1.685 39.393 <0.001
Time 2ndb 2.000 0.367 2.720 to 1.280 29.630 <0.001
Interaction
Group (CB)  Time 4thc 0.900 0.901 2.666 to 0.866 0.998 0.318
Group (CB)  Time 3rdc 0.161 0.894 1.914 to 1.592 0.032 0.857
Group (CB)  Time 2ndc 1.500 0.571 2.619 to 0.381 6.907 0.009
Group (PFE)  Time 4thc 1.742 0.836 3.381 to 0.103 4.340 0.037
Group (PFE)  Time 3rdc 1.761 0.699 3.130 to 0.391 6.351 0.012
Group (PFE)  Time 2ndc 2.000 0.667 3.308 to 0.692 8.984 0.003
6-min walk
Group (CB)a 22.866 30.773 83.179 to 37.448 0.552 0.457
Group (PFE)a 14.631 29.547 43.281 to 72.542 0.245 0.620
Time 4thb 37.305 20.139 76.776 to 2.166 3.431 0.064
Time 3rdb 35.990 20.852 76.859 to 4.879 2.979 0.084
Time 2ndb 13.850 8.667 30.837 to 3.137 2.554 0.110
Interaction
Group (CB)  Time 4thc 19.222 22.163 24.216 to 62.659 0.752 0.386
Group (CB)  Time 3rdc 19.418 23.021 25.703 to 64.538 0.711 0.399
Group (CB)  Time 2ndc 12.972 8.924 4.518 to 30.462 2.113 0.146
Group (PFE)  Time 4thc 43.951 23.687 2.474 to 90.377 3.443 0.064
Group (PFE)  Time 3rdc 38.205 25.099 10.988 to 87.398 2.317 0.128
Group (PFE)  Time 2ndc 29.223 12.847 4.044 to 54.401 5.175 0.023
QOL
Group (CB)a 3.605 4.8295 5.861 to 13.071 0.557 0.455
Group (PFE)a 2.912 5.3293 13.358 to 7.533 0.299 0.585
Time 4thb 5.380 2.5728 0.338 to 10.423 4.373 0.037
Time 3rdb 4.771 2.3823 0.102 to 9.440 4.011 0.045
Time 2ndb 2.824 1.7932 0.690 to 6.339 2.480 0.115
Interaction
Group (CB)  Time 4thc 2.793 4.8550 12.309 to 6.723 0.331 0.565
Group (CB)  Time 3rdc 0.637 3.8478 6.904 to 8.179 0.027 0.869
Group (CB)  Time 2ndc 0.961 3.7633 6.415 to 8.337 0.065 0.798
Group (PFE)  Time 4thc 6.478 4.3635 2.075 to 15.030 2.204 0.138
Group (PFE)  Time 3rdc 5.760 4.4991 3.058 to 14.578 1.639 0.200
Group (PFE)  Time 2ndc 12.684 3.1771 6.457 to 18.911 15.938 <0.001
Social support
Group (CB)a 1.461 3.3152 7.959 to 5.037 0.194 0.659
Group (PFE)a 2.387 3.0378 3.567 to 8.341 0.617 0.432
Time 4thb 0.050 0.9393 1.791 to 1.891 0.003 0.958
Time 3rdb 0.300 0.7972 1.862 to 1.262 0.142 0.707
Time 2ndb 0.250 0.9457 2.104 to 1.604 0.070 0.792
Interaction
Group (CB)  Time 4thc 4.006 1.3744 1.312 to 6.699 8.493 0.004
Group (CB)  Time 3rdc 4.411 1.2535 1.954 to 6.868 12.383 <0.001
Group (CB)  Time 2ndc 5.694 1.1814 3.379 to 8.010 23.233 <0.001
Group (PFE)  Time 4thc 2.003 1.1668 0.284 to 4.290 2.946 0.086
Group (PFE)  Time 3rdc 1.563 1.1782 0.746 to 3.872 1.760 0.185
Group (PFE)  Time 2ndc 5.092 1.1500 2.838 to 7.346 19.608 <0.001

PFE, physical tness exercise; CB, cognitive behavioral; CON, control group.
a
Reference group, control group.
b
Reference group, time (1st).
c
Reference group, group (CON)  Time (1st).

respectively. But, we do not know the compliance rate of
practicing of cognitive and behavior strategies, since we
could not operationally dene the effectiveness of the CBT
intervention for much of it was introspection. Second, both
of the interventions in this study are group based, which
increases the participants social interactions during the
12-week programs in both of the intervention groups to
help relieve the DS (Sims et al., 2009). However, during the
follow-up period, the social interaction decreased, thus the
effectiveness of our intervention could not be maintained.
This result was most prominent in the CBT group due to the
groups frequent socializing during the intervention
therefore when the intervention ended, the amount of
social interaction decreased dramatically. Further, as seen
in the descriptive data, participants in the control group
had lower DS at the three posttests than at T1. These
results are consistent with several studies (Brittle et al.,
2009; Duarte et al., 2009; Durmus et al., 2009). The placebo
1550 T.-T. Huang et al. / International Journal of Nursing Studies 52 (2015) 15421552

Table 4
Comparison of training gains in outcome variables by group.

Variable PFE group1 (n = 19) CB group2 (n = 18) Control group3 (n = 20) K-W test p Post hoc
Mean (SD) Mean (SD) Mean (SD)

DS (GDS-15)
T2-T1 4.00 (2.49) 3.50 (1.95) 2.00 (1.69) 8.91 0.012 1, 2 > 3
T3-T1 4.21 (2.59) 2.61 (3.51) 2.45 (1.79) 4.26 0.119
T4-T1 3.84 (2.81) 3.00 (3.12) 2.10 (2.53) 3.21 0.201
6-min walk distance
T2-T1 15.37 (42.47) 0.87 (8.90) 13.85 (39.76) 7.91 0.019 1 > 2, 3
T3-T1 2.21 (62.56) 16.57 (40.16) 35.99 (95.68) 3.35 0.187
T4-T1 6.65 (55.85) 18.08 (38.42) 37.31 (92.40) 4.68 0.096
Quality of life
T2-T1 15.51 (11.75) 3.79 (14.37) 2.82 (8.23) 10.79 0.005 1 > 2, 3
T3-T1 10.53 (17.09) 5.41 (13.01) 4.77 (10.93) 2.04 0.360
T4-T1 11.86 (15.78) 2.59 (17.71) 5.38 (11.80) 3.41 0.182
Physical
T2-T1 15.01 (11.93) 4.33 (17.64) 2.75 (8.96) 9.71 0.008 1>3
T3-T1 9.96 (21.18) 8.47 (15.12) 6.21 (14.71) 1.95 0.378
T4-T1 12.29 (17.76) 4.64 (26.01) 6.36 (15.28) 1.49 0.474
Mental
T2-T1 16.02 (16.08) 3.24 (16.76) 2.89 (12.09) 6.93 0.031 1>3
T3-T1 11.12 (18.49) 2.34 (14.99) 3.32 (11.42) 2.74 0.254
T4-T1 11.44 (18.33) 0.534 (18.68) 4.39 (13.39) 3.91 0.142
Social support (ISSB)
T2-T1 4.84 (2.93) 5.44 (2.99) 0.25 (4.34) 20.43 <0.001 1, 2 > 3
T3-T1 1.26 (3.89) 4.11 (4.46) 0.30 (3.65) 9.07 0.011 2 > 1, 3
T4-T1 2.05 (3.10) 4.06 (4.34) 0.05 (4.31) 9.86 0.007 1, 2 > 3

Note: K-W, KruskalWallis test; post hoc, MannWhitney test; 1, PFE group, 2, CB group, and 3, Control group; GDS-15, Geriatric Depression Scale-15; ISSB,
Inventory of Socially Supportive Behaviors; T1, baseline; T2, 3 months after baseline (after a 12-week intervention); T3, 6 months after baseline (3 months
after intervention); T4, 9 months after baseline (6 months after intervention).

effect may accompany and enhance the effectiveness of
medical interventions with demonstrated specic treat-
ment efcacy. Moreover, the communicative interaction of
practitioners with patients, both verbal and nonverbal,
may produce placebo effects even without the use of
discrete treatments by giving the patients a feeling of
assurance (Miller et al., 2009). Additionally, Duarte et al.
(2009) found that patients in a control group received
much less structured psychological care but were provided
with emotional support and general guidelines about the
treatment, which may lessen their DS.
At T2, the participants in the PFE group had better 6-
min walk distances (cardiorespiratory endurance), which
is consistent with the ndings of De Moraes et al.
(2012). Performing large muscle, dynamic, moderate-to-
high intensity exercise improves the aerobic capability of
respiratory, cardiovascular, and tissue systems (ACSM,
2014). Exercise for older adults can increase their
cardiorespiratory endurance, reserve capacities, and there-
fore maintain the ability to perform normal activities in
daily life (Demura et al., 2005).
In regards to changes in quality of life, participants in
the PFE group had more improvement in quality of life at
T2, which is consistent with several studies (Brenes et al.,
2007; Heydarnejad and Dehkordi, 2010; Sato et al., 2009).
Quality of life is related to body structure, mental status,
and societal roles (Acree et al., 2006). Exercise may lead to
improvement in body strength and endurance (ACSM,
2014), increase in brain neurotransmitters (Craft and
Perna, 2004), and in older adults improves physical and
mental function to promote their quality of life.
Finally, the results for social support at all post-tests
revealed that participants of both experimental groups
perceived more social support than those in the compari-
son group, which is consistent with a previous report that
proved social support was positively associated with
physical activity of older rural women (Plonczynski
et al., 2008). This effect may have been due to the fact
that both of the interventions are group-based, which
would increase the probability of social interaction
amongst the elderly adults (Armstrong and Edward,
2003) and provide group support, the opportunity to learn
from others, test beliefs, express opinions and attitudes,
practice adaptive social behavior (Gelder et al., 2005), as
well as experience a sense of belonging (Garcia et al.,
2005). During the program, we provided several types of
social support: tangible support (setting, time, and
instruments), information support (CBT and exercise),
and emotional support (paying attention, listening, and
caring).
This study has several limitations. First, participants
were recruited from three communities in northern
Taiwan with a relatively better health status. Considering
the safety and the feasibility of interventions, we excluded
the elderly with cognitive impairment and those without
independent walking abilities. Thus, the effects of this
intervention program can only be generalized to those
cognitively intact and walking independently elderly.
Secondly, in this study, depression is the primary
outcome variable; therefore, we estimated the sample
size based on the data by Brenes et al. (2007) and Laidlaw
et al. (2008). For examining the effects of our interventions
 T.-T. Huang et al. / International Journal of Nursing Studies 52 (2015) 15421552
on secondary outcomes, more participants may be needed.
Thirdly, the participants were studied over a relatively
short period. To examine the long-term effectiveness of the
intervention, a longer longitudinal design is needed.
Fourthly, both interventions are group-based. The effect
of decreased depression in this study may come from the
social aspect of the two interventions. Further study may
compare the effectiveness one-on-one and group-based
exercise and CBT interventions among community-dwell-
ing elderly subjects with DS. Lastly, for maintaining the
effects from the intervention, further research could aim to
either motivate the elderly participants in intervention
groups to maintain these intervention practices (either
exercise or CBT) and incorporate them into their daily lives,
or to manage the placebo effects among some participants
in the control group.
5. Conclusions
To the extent of our knowledge, this is the rst trial to
compare the impact of exercise to CBT interventions in
order to decrease DS with community-dwelling elderly
subjects. We found that both of the 12-week interventions
could decrease DS and improve the perception of social
support among the participants. Moreover, participants in
the exercise group decreased their depressive symptoms
longer time, and improved their physical tness and
quality of life. To boost the longer-term effectiveness of
interventions, some interventions may be added, e.g.,
social resources (experts, community centers, and physical
activity-related associations) to develop a self-help group
or to maintain participants motivation to engage in
exercise, positive thinking, stress management, and social
interaction. These groups may also help elderly adults to
support each other as a part of their daily routine. The two
interventions lessen DS by different mechanisms so we
suggest that, in future research, the two interventions be
combined and tested for DS decrease.
Acknowledgment
We would like to thank all the study participants for
sharing their experiences.
Conict of interest: None declared.
Funding: This work was supported by the Chang Gung
University, Taiwan under Grant EMRPD1C0291.
Ethical approval: Approval for this trial was obtained
from the Institutional Review Board of Chang Gung
Hospital. IRB No. 99-2089B.
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