Depression and Anxiety Disorders: Benefits of Exercise, Yoga, and Meditation
Depression and Anxiety Disorders: Benefits of Exercise, Yoga, and Meditation
Depression and Anxiety Disorders: Benefits of Exercise, Yoga, and Meditation
Many people with depression or anxiety turn to nonpharmacologic and nonconventional interven-
tions, including exercise, yoga, meditation, tai chi, or qi gong. Meta-analyses and systematic reviews
have shown that these interventions can improve symptoms of depression and anxiety disorders. As
an adjunctive treatment, exercise seems most helpful for treatment-resistant depression, unipolar
depression, and posttraumatic stress disorder. Yoga as monotherapy or adjunctive therapy shows pos-
itive effects, particularly for depression. As an adjunctive therapy, it facilitates treatment of anxiety
disorders, particularly panic disorder. Tai chi and qi gong may be helpful as adjunctive therapies for
depression, but effects are inconsistent. As monotherapy or an adjunctive therapy, mindfulness-based
meditation has positive effects on depression, and its effects can last for six months or more. Although
positive findings are less common in people with anxiety disorders, the evidence supports adjunc-
tive use. There are no apparent negative effects of mindfulness-based interventions, and their general
health benefits justify their use as adjunctive therapy for patients with depression and anxiety disorders.
(Am Fam Physician. 2019;99(10):620-627. Copyright © 2019 American Academy of Family Physicians.)
Depression and anxiety disorders are among be effective for mild to moderate depression, but
the most common psychiatric conditions, with less so for anxiety.2 However, the study designs
an estimated 19.1% of U.S. adults experiencing had methodologic limitations, including lack
anxiety and 10% experiencing depression in the of consistent definitions for exercise type (e.g.,
past year.1 Nearly one-half of people diagnosed aerobic, resistance), controls (e.g., other comple-
with depression will also experience comorbid mentary treatments, waitlist controls), outcome
anxiety. In addition, many will have symptoms measures (e.g., remission, treatment discon-
that are distressing, but that do not meet duration tinuation), defined clinical populations (e.g.,
or intensity criteria to enable a clinical diagnosis. symptoms vs. diagnosed condition), and sample
Complementary and integrative therapies (e.g., recruitment techniques.3 These study differences
exercise, meditation, tai chi, qi gong, yoga) are increase heterogeneity and undermine the ability
often sought by patients experiencing these con- of meta-analyses to demonstrate clear and con-
ditions. This article provides a concise overview sistent effects.
of the evidence on the effectiveness of comple- A Cochrane review on exercise for major
mentary therapies in treating these conditions. depressive disorder concluded that exercise had
a modest positive effect.4 However, when lower-
Exercise quality studies were excluded, there was no effect.
A review of meta-analyses on the effectiveness Similarly, recent meta-analyses and systematic
of exercise for depression and anxiety disorders reviews found moderate positive effects of exer-
noted that aerobic and resistance exercises may cise for depression and anxiety, particularly
CME This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME
Quiz on page 607.
Author disclosure: No relevant financial affiliations.
Patient information: A handout on this topic is available at https://w ww.aafp.org/afp/2010/0415/p987.
html.
620 American
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2019
DEPRESSION AND ANXIETY
SORT:KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating Comments
Exercise can be a modestly beneficial adjunc- B Several systematic reviews and meta-analyses show positive effects
tive treatment option for depressive and anxiety of exercise on depressive5-10 and anxiety disorders,11-13 but the
disorders, especially treatment-resistant depres- strength of these effects varies. General health benefits justify its use
sion, unipolar depression, and posttraumatic as an adjunctive intervention for depression and anxiety disorders.
stress disorder.
Yoga is a therapeutic option for depression and B Yoga can be suggested as a monotherapy for depression, but it is pre-
has positive effects in people with anxiety disor- ferred as an adjunctive treatment for depression and anxiety. 22,26,27,31
ders, particularly panic disorder. The optimal frequency and duration are not clear, but studies have
shown symptom reduction with one 60-minute session per week.16,29
Tai chi and qi gong have inconsistent effec- B Tai chi and qi gong have shown inconsistent effects on anxiety and
tiveness as complementary treatments for depression in several small studies. In studies that demonstrate ben-
depression and anxiety. efits, their effect on depressive and anxiety symptoms is small. 34-36
Mindfulness-based interventions are effective B There is limited support for mindfulness-based interventions as a
as adjunctive treatment for depression, with monotherapy for depression or anxiety disorders, although they
positive effects persisting through follow-up. may be effective for preventing relapse or as an adjunctive treat-
Their effects on anxiety disorders also seem to ment. 28,38,44 Until further adequately powered trials are conducted,
be positive. physicians should use caution in recommending these interventions
as a first-line treatment for anxiety or depressive disorders.
A = consistent, good-quality patient-oriented evidence;B = inconsistent or limited-quality patient-oriented evidence;C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://w ww.aafp.
org/afpsort.
treatment-resistant and unipolar depression and systematic reviews and multiple individual stud-
posttraumatic stress disorder (PTSD).5-15 How- ies conclude that yoga is an effective treatment
ever, these effects were not sufficiently reliable for depression.16-23 A systematic review compared
to assure short-term results or stable long-term yoga with other treatments for major depressive
benefits. Adequate trials on the role of interval disorder and found similar benefits for yoga vs.
training are lacking, although there are indica- exercise and yoga vs. medication. This review
tions that the physiologic changes produced by showed that yoga was less effective than electro-
this type of exercise are greater and longer lasting convulsive therapy for the treatment of major
compared with changes from aerobic or resis- depressive disorder, suggesting that yoga would
tance training. not be appropriate for treatment of resistant-
In summary, despite efforts to demonstrate depression for which electroconvulsive ther-
clear replicable positive therapeutic effects of apy is a treatment option.23 However, one study
exercise on depression and anxiety disorders, has shown long-term effectiveness of yoga as an
evidence is lacking (Table 1).5-15 Although there adjunctive treatment for women with persistent
seems to be more support for exercise in depres- depression.24 Yoga also demonstrated effectiveness
sion vs. anxiety disorders, there are physical in relieving depression in the perinatal period,
benefits for both. One analysis specifically rec- but results varied based on the style of yoga.22,25
ommends exercise as an adjunct to medication Exercise-based yoga was not effective in reducing
in people with treatment-resistant depression.5 depressive symptoms in the perinatal period, but
No trials have shown that exercise worsens either integrative styles with stronger emphasis on med-
condition, so it is safe to recommend to patients itation and breath control were effective.26
with the understanding that additional medica- Indications for yoga in the treatment of anx-
tion or psychotherapy may be needed. iety disorders are less clear. A meta-analysis of
hatha yoga (the most common style in the United
Yoga States) found that people with more severe symp-
Yoga is an ancient Eastern practice that combines toms benefitted most.27 However, the overall
physical postures, breath control, and meditation. effect was relatively small, which suggests that
There are several styles that differ in intensity, it is best used as an adjunctive treatment with
duration, and emphasis on each component. Two cognitive behavior therapy, selective serotonin
May 15, 2019 ◆ Volume 99, Number 10 www.aafp.org/afp American Family Physician 621
DEPRESSION AND ANXIETY
TABLE 1
Systematic review of studies of exercise for unipolar or Exercise plus SSRI therapy was more effective than other treatments,
bipolar depression5 especially for treatment-resistant depression
Meta-analysis of 23 RCTs of exercise for unipolar Exercise was generally helpful, particularly in studies of unipolar depres-
depression or depressive symptoms6 sion;positive effects were reduced in studies with validity steps and no
longer present at follow-up
Summary of meta-analyses and systematic reviews of Recommended 30 minutes of supervised aerobic or resistance exercise
complementary and alternative medicine three times per week for mild to moderate MDD, and as adjunctive ther-
therapies for MDD 7 apy for moderate to severe MDD
Meta-analysis of 41 studies with participants Significantly large control group response in exercise trials made evaluting
experiencing MDD or subclinical depressive symptoms8 the actual effects of exercise challenging
Meta-analysis of 25 RCTs with participants Removing publication bias, which underestimated effects, increased
experiencing MDD;investigated the effect of positive effects of exercise
publication bias9
Meta-analysis of 35 RCTs with participants experiencing Inclusive analysis showed moderate positive effect for exercise, which was
clinically diagnosed MDD;included trials from China eliminated when trials were limited to low risk of bias
and South America10
Meta-analysis of eight RCTs of exercise for clinically Exercise had moderate positive effects on anxiety but was less effective
diagnosed anxiety 11 than SSRIs;aerobic and nonaerobic exercises were effective
Qualitative review of 12 RCTs and five meta-analyses of Exercise had mild positive effects, but methodologic problems led authors
exercise for clinically diagnosed anxiety or subclinical to withhold recommendation for use in anxiety disorders
anxiety symptoms12
Meta-analysis of six RCTs with participants experiencing Exercise significantly reduced anxiety with moderate effect size;exclusion
clinically diagnosed anxiety disorder and/or stress- of trials for posttraumatic stress disorder eliminated effect
related disorder13
Meta-analysis of seven RCTs with participants No overall effect for aerobic exercise;cognitive behavior therapy or med-
experiencing clinically diagnosed anxiety14 ication was significantly more effective than aerobic exercise;exercise
was more effective than waitlist controls but not other controls;did not
recommend aerobic exercise for anxiety disorders
Meta-analysis and network analysis of MDD15 No differences between exercise and antidepressants or other comple-
mentary and alternative therapies
MDD = major depressive disorder;SSRI = selective serotonin reuptake inhibitor;RCT = randomized controlled trial.
Information from references 5 through 15.
reuptake inhibitors, or other antianxiety medi- was three to 24 weeks, with frequencies varying
cations. Some studies suggest that yoga may be from once per week to daily for 40 to 100 minutes
more effective at reducing anxiety symptoms per session.
compared with no treatment17,19,28-30; however, In summary, yoga can be suggested as a mono-
other studies do not show symptom improve- therapy for depression, but it is preferred as an
ment.16,25 One study showed that yoga as mono- adjunctive treatment for depression and anxiety
therapy or adjunctive therapy is effective in the disorders (Table 2).16-31 The optimal frequency
treatment of panic disorder.29 and duration are unclear, but studies have shown
There is not enough evidence to determine symptom reduction with one 60-minute session
the optimal duration or frequency of yoga. Ini- per week.
tial studies found no difference in reductions of
depression symptoms when yoga was practiced Tai Chi and Qi Gong
once vs. twice per week.21,28 However, more fre- Tai chi and qi gong are mind and body practices
quent sessions are associated with reductions in that combine postures and gentle movements
anxiety symptoms. The duration in most reports with mental focus, breathing, and relaxation.
622 American Family Physician www.aafp.org/afp Volume 99, Number 10 ◆ May 15, 2019
DEPRESSION AND ANXIETY
TABLE 2
RCT of 60 minutes of yoga per week for six weeks vs. Depression scores significantly improved in yoga group compared with
usual treatment (medication with or without therapy) waitlist control;no significant reduction in anxiety scores
in people with symptoms of depression and anxiety16
Three-arm RCT (yoga vs. meditation vs. control) in Depression and anxiety significantly improved in yoga and meditation groups
college students with depression and/or anxiety17 compared with control, but did not significantly differ from each other
RCT of yoga in treatment-naive people with mild to Yoga participants had greater reduction in symptoms compared with
moderate major depressive disorder18 control and were more likely to achieve remission;effect size suggested
significant reduction in symptoms
RCT of yoga in older women with symptoms of Yoga reduced symptoms of depression and anxiety compared with controls
depression and/or anxiety19
RCT of yoga vs. waitlist control in male military veter- Yoga had largest effect on symptoms of hyperarousal and reexperiencing
ans with posttraumatic stress disorder 20 symptoms, and had significant effect on general distress and anxious arousal
Dosing trial assessing differences in symptom reduc- No differences in compliance, rate of response, or remission between
tion between low-dose yoga (two 90-minute sessions high- and low-dose groups immediately after intervention;at 12 weeks,
per week plus three home sessions) vs. high-dose yoga high-dose group had more participants in remission
(three 90-minute sessions plus four home sessions)21
Meta-analysis of 12 RCTs of yoga vs. controls22 Moderate short-term effects of yoga compared with usual treatment;
effects are less than or equal to those of relaxation and aerobic exercise;
limited evidence of effect for anxiety
Systematic review of seven RCTs of yoga vs. controls Similar effects between yoga and other evidence-based treatments (e.g.,
for major depressive disorder 23 medication, exercise)
RCT of adjunctive yoga vs. health maintenance control No difference between yoga and control groups;yoga participants were
in people with persistent major depressive disorder 24 more likely to show treatment response at three months
RCT of yoga vs. usual treatment in pregnant women Depression scores significantly improved in both groups, but yoga group
with symptoms of depression and anxiety 25 had greater improvement in negative affect over time;no difference in
anxiety symptom reduction
Meta-analysis of six RCTs of yoga for perinatal Depression was significantly reduced in yoga groups compared with
depression26 controls;integrated yoga interventions significantly lowered prenatal
depression, but exercise-based yoga did not
Meta-analysis of 17 studies of yoga for anxiety 27 Hatha yoga significantly reduced anxiety compared with waitlist controls,
with moderate effect size;effectiveness was associated with total number
of hours practiced
Three-arm RCT (weekly vs. twice-weekly yoga vs. Both yoga groups had significantly reduced symptoms of depression and
waitlist control) in women with depression and/or anxiety compared with control;reductions were similar in yoga groups;
anxiety 28 compliance was greater in yoga group with fewer sessions
RCT of yoga vs. yoga plus cognitive behavior therapy Both groups had significant improvement in panic symptoms, but the com-
in people with panic disorder 29 bination group had nonsignificantly greater improvement
Three-arm RCT (yoga with relaxation vs. integrated Both yoga groups had significant decreases in anxiety compared with con-
yoga vs. nonactive control) in women with anxiety 30 trol, with integrated yoga protocol showing greatest reduction
RCT of yoga vs. usual treatment in women with breast Significant improvement in state and trait anxiety compared with usual
cancer and comorbid anxiety disorder 31 treatment
The movements can be practiced while walking, depression.32,33 However, systematic reviews and
standing, or sitting. Although limited, the litera- meta-analyses have shown variable effectiveness
ture on these practices suggests that tai chi and qi based on the study population and methodologic
gong may be effective in alleviating symptoms of rigor.34,35 One meta-analysis of tai chi’s effect
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DEPRESSION AND ANXIETY
on depression symptoms found greater benefits suggesting that mindfulness-based training was
among studies that included people with more moderately effective in reducing depression and
severe symptoms, but some studies found small anxiety symptoms in pre-post and waitlist con-
overall effects.34 The actual effect on depression trol comparisons, and when compared with other
symptoms is likely small. Similarly, qi gong has a active treatments, including other psychological
small but variable effect on depression. treatments.40 Mindfulness-based training was
Another study showed that tai chi reduces as effective as cognitive behavior therapy, other
anxiety among older adults with anxiety disor- behavioral therapies, and pharmacologic treat-
ders who are receiving medical therapy.36 It found ments. The authors concluded that mindfulness-
that anxiety recurrence rates were significantly based training is an effective treatment for a vari-
lower among those in the tai chi group compared ety of psychological conditions, and was espe-
with the control group (9.09% vs. 42.86%, respec- cially effective in reducing anxiety, depression,
tively). A study investigating a qi gong–based and stress.
stress-reduction program found greater reduc- Not all studies showed immediate benefit. A
tions in state and trait anxiety among partici- meta-analysis of RCTs showed that MBIs were
pants in the treatment group.37 However, these effective in people currently experiencing an epi-
results contradict a meta-analysis of four ran- sode of depression, but not for anxiety.41 It found
domized controlled trials (RCTs) that did not significant postintervention differences between
find qi gong to be beneficial for the reduction of groups of participants with depressive disorders,
anxiety symptoms.35 In summary, there is a small with a large effect size on primary symptom
body of literature showing mixed results for these severity favoring the intervention. Evidence for
interventions. benefit in anxiety was lacking.
A 2012 literature review concluded that there
Mindfulness-Based Meditation was growing evidence supporting MBIs in the
There is no consensus on a definition of medita- prevention of depression and anxiety relapse.42
tion. However, it is generally agreed that it is a Another study with a two-year follow-up found
form of mental training that requires calming that mindfulness-based cognitive therapy was
the mind with the goal of achieving a state of as effective as subspecialist care in people with
“detached observation.” Meditation approaches recurrent depression, and that it seemed to work
that have been studied in people with depression well when combined with antidepressants.43
and anxiety disorders include mindfulness-based MBIs are typically integrated into a larger ther-
interventions (MBIs), mindfulness-based train- apeutic framework, and it is not clear whether
ing, mindfulness-based stress reduction, and stand-alone MBIs are beneficial without such
mindfulness-based cognitive therapy. Although a framework. A systematic review and meta-
these approaches differ, they all rely on calming analysis of the effects of stand-alone MBIs on
the mind as their core modality. symptoms of anxiety and depression concluded
A recent systematic review and meta-analysis of that these exercises had small to medium effects
MBIs for psychiatric disorders found the clearest on anxiety compared with controls.44 This was
evidence for their use for depression.38 MBIs were the first meta-analysis to show that regular per-
superior to no treatment and other active thera- formance of mindfulness-based approaches is
pies, and equivalent to evidence-based treatments beneficial, even if they are not integrated into a
such as selective serotonin reuptake inhibitors. larger therapeutic framework.
Another meta-analysis that included patients MBIs may be helpful for some subgroups of
with clinically diagnosed anxiety and mood dis- patients with depression and anxiety disorders,
orders showed that MBIs were moderately effec- but results are mixed. One RCT found that mind-
tive in reducing anxiety symptoms and improving fulness-based cognitive therapy reduced symp-
mood.39 Effect sizes were robust and did not seem toms of depression in people with a traumatic
to depend on the number of sessions. Moreover, brain injury.45 A meta-analysis of MBIs in adults
improvements were sustained over an average with PTSD found 10 RCTs that met inclusion
of 27 weeks (median:12 weeks). A systematic criteria.46 Adjunctive mindfulness-based stress
review of 209 studies found effect size estimates reduction, yoga, and a mantra repetition program
624 American Family Physician www.aafp.org/afp Volume 99, Number 10 ◆ May 15, 2019
DEPRESSION AND ANXIETY
improved symptoms of PTSD and depression com- Some studies have evaluated MBIs for treat-
pared with controls, but the findings were based ment of social anxiety disorder 48,49 and panic dis-
on low- to moderate-quality evidence. Effects were order 50 with encouraging results. However, until
positive but not statistically significant for quality adequately powered trials are conducted, clini-
of life and anxiety, and no studies addressed func- cians should use caution in offering these treat-
tional status. An RCT reported that mindfulness- ments as first-line interventions for social anxiety
based stress reduction in veterans resulted in and panic disorders.
a greater decrease in PTSD symptom severity In summary, MBIs seem to be effective for the
compared with present-centered group ther- treatment of depression and anxiety disorders
apy (a standard non–trauma-focused treatment (Table 3).38-45,47,48 Because no data suggest that
for PTSD).47 Although meditation seems to be these interventions cause harm in patients with
effective for PTSD symptoms, more high-quality these conditions, they can be recommended with
studies are needed with samples large enough to the understanding that additional medications or
detect statistical differences in outcomes.46 psychotherapy may be needed.
TABLE 3
Meta-analysis of 39 studies of mindfulness-based Mindfulness-based therapies were moderately effective for improving anxiety
therapies for anxiety and depression39 and mood symptoms in pre-post analyses
Systematic review of mindfulness-based Mindfulness-based therapies showed large and clinically significant effects on
therapies40 anxiety and depression, which were maintained at follow-up
Meta-analysis of RCTs of MBIs for current epi- MBIs significantly improved primary symptom severity in people with depres-
sodes of anxiety or depressive disorder 41 sion (outcomes may be similar to those achieved with group cognitive behavior
therapy);results did not support MBIs for anxiety disorder
Review of mindfulness-based meditation as self- Mindfulness-based meditation may be viable approach to treatment of anxiety
help for anxiety and depression42 and depression, but more rigorous studies are needed
RCT of MBCT for relapse or recurrence of depres- MBCT seemed to work well in combination with antidepressant therapy;com-
sion over two years of follow-up43 bined treatment (MBCT plus medication) may be an effective option for many
people with extensive histories of recurrent depression
Meta-analysis of 18 studies of stand-alone MBIs MBIs had small to medium effects on anxiety and depression compared with
for symptoms of anxiety and depression44 controls
RCT of MBCT vs. control for depression45 MBCT reduced symptoms of depression in people with traumatic brain injury,
as measured by the Beck Depression Inventory II;reduction was maintained at
three-month follow-up
RCT of MBSR vs. person-centered group therapy MBSR group had greater improvement in self-reported severity of posttraumatic
in military veterans with posttraumatic stress stress disorder symptoms during treatment and at two-month follow-up
disorder 47
RCT of MBSR vs. aerobic exercise for social anxi- MBSR and aerobic exercise reduced social anxiety and depression,
ety disorder 48 and increased subjective well-being immediately and at three months
postintervention
MBCT = mindfulness-based cognitive therapy;MBI = mindfulness-based intervention;MBSR = mindfulness-based stress reduction;RCT = random-
ized controlled trial.
Information from references 38 through 45, 47, and 48.
May 15, 2019 ◆ Volume 99, Number 10 www.aafp.org/afp American Family Physician 625
DEPRESSION AND ANXIETY
This article updates a previous article on this topic by 7. Ravindran AV, Balneaves LG, Faulkner G, et al.;CANMAT
Saeed, et al. 2 Depression Work Group. Canadian network for mood and
anxiety treatments (CANMAT) 2016 clinical guidelines for
the management of adults with major depressive disorder:
Data Sources: PubMed searches were completed
section 5. Complementary and alternative medicine treat-
using the key terms anxiety (specific diagnoses),
ments. Can J Psychiatry. 2016;61(9):576-587.
depression (specific diagnoses), yoga, qi gong, tai chi,
8. Stubbs B, Vancampfort D, Rosenbaum S, et al. Challenges
meditation, exercise, and RCT. Also searched were
establishing the efficacy of exercise as an antidepressant
the Cochrane database, Medline, and Sumsearch. treatment:a systematic review and meta-analysis of con-
Search date:November 2018. trol group responses in exercise randomised controlled
trials. Sports Med. 2016;46(5):699-713.
9. Schuch FB, Vancampfort D, Richards J, Rosenbaum S,
The Authors Ward PB, Stubbs B. Exercise as a treatment for depression:
a meta-analysis adjusting for publication bias. J Psychiatr
SY ATEZAZ SAEED, MD, is professor and chairman
Res. 2016;7 7:42-51.
of the Department of Psychiatry and Behavioral
10. Krogh J, Hjorthøj C, Speyer H, Gluud C, Nordentoft M.
Medicine at East Carolina University Brody School
Exercise for patients with major depression:a systematic
of Medicine, Greenville, N.C., and executive direc- review with meta-analysis and trial sequential analysis.
tor of behavioral health service line for Vidant BMJ Open. 2017;7(9):e014820.
Health, Greenville. 1 1. Jayakody K, Gunadasa S, Hosker C. Exercise for anxiety
disorders:systematic review. Br J Sports Med. 2014;48(3):
KARLENE CUNNINGHAM, PhD, is clinical assis- 187-196.
tant professor in the Department of Psychiatry
1 2. Stonerock GL, Hoffman BM, Smith PJ, Blumenthal JA.
and Behavioral Medicine at East Carolina Univer- Exercise as treatment for anxiety:systematic review and
sity Brody School of Medicine. analysis. Ann Behav Med. 2015;49(4):5 42-556.
1 3. Stubbs B, Vancampfort D, Rosenbaum S, et al. An exam-
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Medicine at East Carolina University Brody School chiatry Res. 2017;249:102-108.
of Medicine. 14. Bartley CA, Hay M, Bloch MH. Meta-analysis:aerobic exer-
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Brody School of Medicine, East Carolina Univer- 15. Asher GN, Gartlehner G, Gaynes BN, et al. Comparative
sity, 600 Moye Blvd., Ste. 4E-100, Greenville, NC benefits and harms of complementary and alternative
27834 (e-mail:saeeds@ecu.edu). Reprints are not medicine therapies for initial treatment of major depres-
available from the authors. sive disorder:systematic review and meta-analysis.
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May 15, 2019 ◆ Volume 99, Number 10 www.aafp.org/afp American Family Physician 627