Full length articleInvestigation of associations between recurrence of major depressive disorder and spinal posture alignment: A quantitative cross-sectional study
Introduction
Major depressive disorder (MDD) is a serious health problem and will be the second leading worldwide disease burden by 2030 [1]. According to the Diagnostic and Statistical Manual of Mental Disorders Edition IV-Text Revised (DSM-IV-TR), MDD comprises diminished interest in all/most activities, depressed mood for most of the day, insomnia or sleeping too much, psychomotor retardation, loss of energy, diminished concentration ability, and recurrent thoughts of death [2]. MDD is more common in women than men and is highly recurrent [3].
Individuals who suffer from a first depressive episode have a 40%–60% chance of experiencing a subsequent episode. Individuals with two previous episodes have approximately a 60% chance of a further episode, and for individuals with three episodes the risk is as high as 90% [4], [5], [6].
The physical symptoms of depression include psychomotor delay, fatigue, diminished energy, and pain. Depressed patients demonstrate alterations in their motor and cognitive functioning, which can affect adaptation to variations in the everyday environment. Motor retardation is a prominent clinical feature of major depression [7], and depressed individuals tend to have slower gait, slumped posture, and less steadiness when walking than normal individuals [8], [9].
Correct upright posture is an important health marker [10]; some deviations in body posture can be unsightly and can adversely affect muscular efficiency [11]. Posture may be defined as the composition of the positioning of all body segments at a given point in time [12]. Intrinsic and extrinsic factors that can influence posture include heredity, socioeconomic level, and emotional factors [13]. Posture can reflect biomechanical aspects of the body such as misalignment, shortening, and pain, but also reflects emotional state through non-verbal communication [14], [15]. When an individual cannot express their feelings using facial gestures, posture becomes an ideal vehicle for bodily expression. [16]. Postural assessment can be an important clinical diagnostic tool in therapeutic practice, useful for comparing and verifying the efficacy of interventions such as physical exercise [17]. Clinical use of postural assessment includes physiotherapeutic assessment of body posture and psychological and psychiatric assessment of body language. One study showed that reduced walking speed and slumped posture unambiguously characterized the gait patterns of sad and depressed individuals [9]. Static body posture is a reliable source of emotional information and can indicate how emotion is expressed through the body [16]. In addition to motor impairment and gait, poor posture is associated with MDD. Therefore, postural assessment is clinically relevant and may reflect both physical aspects and emotional expression [18].
One study of athletes and non-athletic male students found no relationship between depression and thoracic kyphosis [19]. In contrast, another study [20] reported a positive relationship between increased angle of curvature of kyphosis and depressive symptoms in students. A relationship between low self-esteem and elevated thoracic kyphosis has also been documented [21].
Rosário et al. [22] investigated the association between depression and body posture in 40 women, in the absence of neurological, psychiatric, or musculoskeletal disorders. Relationships were found between depression scores and the angle of Tales (a scoliosis marker); current depression and inclination of the head and shoulders; chronic depression and shoulder protraction. Evidence therefore suggests that depression and sadness may change posture.
Previous studies have suffered from methodological limitations, such as the use of non-clinical samples and symptom scales, instead of DSM-IV-TR criteria [19], [20], [22]. A previous quantitative study by our group over a 10-week period assessed body posture in 34 MDD patients and compared it with that of 37 healthy controls. Posture was assessed during a depressive episode using digital photographs of the subjects. Postural changes during depressive episodes included significant increases in anterior head flexion, increased thoracic kyphosis, a trend toward pelvic retroversion, and an increase in scapular distance. All these interfere with the proper functioning of skeletal muscles. During symptom remission, the posture of the patients with depression was similar to the control group. In addition to consequences such as pain, tension, and shortness of breath, such posture alterations are often observed in MDD, and characterize a “depressive posture.” The findings demonstrated both emotional and physical negative impacts of depression [18].
Findings on body posture and depression are promising but sparse. There is a shortage of investigations into the effects of recurrent depressive episodes and symptom severity on static body posture in MDD patients. MDD involves a range of physical symptoms, such as psychomotor retardation and pain; therefore, it is relevant to assess postural misalignment and its consequences. The purpose of this study was to identify associations between recurrent episodes of MDD, severity of depressive symptoms, and spinal posture alignment.
Section snippets
Patient sample
Of 136 consecutive MDD outpatients presenting at the Mood Disorders Unit (PROGRUDA) of the Institute and Department of Psychiatry of Clinics Hospital of the University of São Paulo Medical School (IPq-HC-FMUSP), 72 patients (53 women, 19 men; mean age, 42.4 ± 9.1 years; range: 18–60 years) met all the criteria and were recruited to the study.
Inclusion and exclusion criteria
Adult participants (men and women, aged 18–65 years) had to fulfill the DSM-IV-TR [2] and Structured Clinical Interview for DSM-IV-TR (SCID) [23] criteria for
Results
Of the 72 patients, 41 were diagnosed with a recurrent MDD episode and assigned to the RE group, and 31 were diagnosed with a single MDD episode and assigned to the SE group. No between-group difference was observed for BMI, age, age at onset, and sex (Table 2). Depression severity was more severe in the RE group than in the SE group. Table 2 shows the number of recurrences in the RE group.
Of the 41 RE subjects, 21 were diagnosed with severe depressive episodes, 17 with moderate, and 3 with
Discussion
The main study purpose was to identify associations between recurrent episodes of MDD, depression severity, and spinal posture alignment. We observed that the recurrence of depressive episodes is associated with postural misalignment.
Canales et al. [18] showed that patients with MDD presented with postural misalignment during a depressive episode (e.g., marked head flexion, scapular abduction, pelvic retroversion, greater thoracic kyphosis), which improved during symptom remission. In agreement
Limitations
One study limitation was the small sample size. A further limitation was locating the anatomical points for placement of markers. However, a tutorial on point location was carefully followed to avert possible placement errors [25].
Although the same appraiser evaluated the posture during the morning, which we assumed would minimize the effects of natural intraindividual postural changes that occur throughout the day, body posture does vary throughout the day; therefore, this was a limitation. In
Conclusion
This study revealed associations between recurrent episodes of MDD, depression severity, and spinal posture alignment. Recurrent depressive patients had greater postural misalignment than single MDD episode patients, and severity of depressive symptoms was associated with kyphosis. These findings demonstrate that depression is a multifactorial disorder, which affects motor and gait patterns and body posture.
Conflict of interest
The authors have no conflicts of interest to report.
Ethical approval
Ethical approval was granted by the Ethics Committee of the Clinical Hospital, School of Medicine of the University of Sao Paulo, Brazil (process: 1127/05) and procedures were conducted according to the Declaration of Helsinki. All participants signed an informed consent form.
Funding
The authors report that there was no direct source of funding for the study.
Acknowledgments
We would like to thank the members of Mood Disorders Unit (PROGRUDA) for their work, as well as the volunteers for their collaboration.
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