Running through your mind:

Running through your mind:

The potential role of exercise within the mental health and addictions field

Kari Ala-leppilampi, MHSc, PhD. Candidate, PTS, BM, IMWC

MHSc., health promotion/addictions PhD. Candidate, Health & Behavioural Sciences/Addictions,

University of Toronto Research analyst at the Centre for Addiction and Mental Health

CTCRI Project PhACS Project

Director of the Don River Run for Recovery Founder and Chair of the Fitness In Treatment Research and

Advisory Panel (FITRAP) Certified Personal Training Specialist (PTS)

Most importantly perhaps:

A person who happens to manage mental health and addiction issues

Competitive runner and triathlete (BM, IMWC)

Presentation Outline

Mental Health and Physical Exercise Depression Anxiety Schizophrenia

Addictions and Physical Exercise Alcohol misuse

Mental health & Physical Exercise (PE)1. Prevalence and costs of Mental Illness 2. PE & Depression3. PE & Anxiety4. The Potential Mechanisms of PE 5. PE as a natural ‘fit’ within contemporary

practice6. Revisiting pharmacological treatment7. Challenges to implementing PE into practice

Prevalence and Costs Mental Health Disorders In Canada

In a 12 month period:

1/10 Canadians, or about 2.6 million people, report alcohol or illicit drug dependence or one of the five common mental health disorders

Depressing and stressful facts about depression and anxiety: 4.9% report some form of mood disorder (4.5% major depression) 4.7% report some form of anxiety (3% for SAD) and 3% report substance misuse (2.6% for alcohol and 0.7% for illicit drugs)

As many Canadians suffer from major depression as from other leading chronic conditions, including heart disease (5%), diabetes (5%) or a thyroid condition (6%)

In 1998, mental disorders were the third highest source of direct health care costs at $4.7 billion (Statistics Canada, 2003)

Measured mental disorders or substance dependence in the past 12 months

  Total Males Females

  Number % Number % Number %

Major depression 1,120,000 4.5 420,000 3.4 700,000 5.5

Mania disorder 190,000 0.8 90,000 0.7 100,000 0.8

Any mood 1,210,000 4.9 460,000 3.8 750,000 5.9

Panic disorder 400,000 1.6 130,000 1.1 270,000 2.1

Agoraphobia 180,000 0.7 40,000 0.4 140,000 1.1

Social anxiety disorder (Social phobia) 750,000 3.0 310,000 2.6 430,000 3.4

Any anxiety 1,180,000 4.7 440,000 3.6 740,000 5.8

Alcohol dependence 640,000 2.6 470,000 3.8 170,000 1.3

Illicit drugs dependence 170,000 0.7 120,000 1.0 50,000 0.4

Substance dependence 740,000 3.0 540,000 4.4 200,000 1.6

Total - Any measured disorder or substance dependence 2,600,000 10.4 1,190,000 9.7 1,410,000 11.1

Canadian Community Health Survey (Statistics Canada, 2003)

Definitions

Major depressive episode — at least one episode of 2 weeks or more with persistent depressed mood and loss of interest or pleasure in normal activities, accompanied by problems such as decreased energy, changes in sleep and appetite, impaired concentration, and feelings of guilt, hopelessness, or suicidal thoughts.

Manic episode (mania) — at least one period of a week or longer with exaggerated feelings of well-being, energy, and confidence or irritable mood during which a person can lose touch with reality. Symptoms of mania include: flight of ideas or racing thoughts; inflated self-esteem; decreased need for sleep; talkativeness; and irritability.

Definitions (cont’d) Panic disorder — repeated and unexpected attacks of intense fear

and anxiety where at least one of the attacks has been followed by 1 month or more of persistent concern or worry about having another attack or its physiological manifestations such as Palpitations, chest Pain, feelings of smothering or choking, dizziness, sweating, nausea or abdominal distress, trembling, and hot flushes or chills.

Social phobia — persistent, irrational fear of social or performance situations in which the person may be closely watched and judged by others, as in public speaking, eating, or working. The fear is recognized by the person as excessive or unreasonable. The avoidance, anxious distress in these feared situation (s) interferes significantly with the person’s everyday activities.

Agoraphobia — fear and avoidance of being in places or situations from which escape might be difficult, or in which help may not be available. Feared situations include being outside the home alone, being in a crowd or standing in a line, being on a bridge, and traveling in a bus, train or automobile. The situations are avoided or endured with marked distress or with anxiety about having a Panic attack or Panic-like symptoms.

Definitions (cont’d)

Profiled substance dependence within the 12-month period prior to the survey:

Classification as alcohol or illicit drug dependent — based on sets of questions which examine aspects of drug tolerance, (for example, needing more to have an effect), withdrawal, loss of control, and social or physical problems related to alcohol or illicit drug use in daily life. The information collected on these two types of substance dependence provides a profile of behaviours of alcohol and illicit drug use which lead to clinically significant impairment or distress.

Any mental disorder or substance dependence: Respondents were classified as having “Any mental disorder or substance dependence” if the pattern of answers met the criteria for at least one of the five mental disorders or two substance dependencies covered in the survey (i.e. major depressive episode, manic episode, panic disorder, social phobia, agoraphobia, alcohol dependence, or illicit drug dependence).

Mental Health Disorders as a Major and Growing Worldwide Issue

Mental illness, including suicide, ranks second in the burden of disease in established market economies such as U.S. (United States department of Health and Human Services, 1999) and Canada

5/10 leading causes of disability in the world are related to psychiatric disorders

In less than 20 years depression will be the second-leading cause of disability in the world (WHO cited in Statistics Canada, 2003)

Help seeking and Treatment

Less than half (32%) of Canadians with mental health or addiction issues over the past 12 months will seek treatment

Despite higher prevalence rates among young adults (15-24 yrs.), help seeking is even lower within this group as only one quarter seek treatment

Lack of awareness and stigma as major barriers

However, traditional treatment approaches delivered by specialists, or dependence upon health care system in general (Raglin, 1997), unfeasible so a need for multiple options

Traditional treatment generally consists of some form of psychotherapy and/or medication

PE and Depression• Definition

• Epidemiological evidence

• Meta-analysis of interventions

• General Review of key studies

• Exercise compared to traditional treatment

• Exercise prescription

• Key Findings

Depression

A state characterized by lowered mood, loss of capacity to experience pleasure, increased sense of worthlessness, fatigue and pre-occupation with death and suicide (Strawbridge et al., 2002)

Associated with presence of 1 or more chronic diseases as well as disability, including days in bed and days away from normal activities

Major depressive disorder (MDD) has been associated with a 59% increase in mortality risk during a 1 year follow up (Blumenthal, 1999), but only 23% seek treatment and only 10% receive adequate treatment (Dunn, 2005)

Epidemiological Evidence

3 large longitudinal and prospective survey-type studies, which included both men and women from a broad range of ages, provide strong evidence

While one study only included college men, the other two included men and women from a broad range of age categories

Confounding variables were accounted for in these studies but some may have been overlooked

Association does not equal causation!

Farmer et al.(1988)

survey with 1,497 men and women in the U.S.

Women engaging in “little or no” activity twice as likely to develop depression over 8 year period

No significant association for men, but for those men who were depressed at baseline inactivity was a significant predictor of continued depression

Camacho et al. (1991)

Large sample of men and women in California

Low (LA), medium (MA), or high active (HA) in 1965/baseline (B), 9 years later (F1), and 18 years later (F2)

At F1 (1974) :

Relative risk (RR) of developing depression significantly higher for men & women who were LA at B (~1.75)

those who were MA at B also showed lower RR (~1.2) providing some evidence for dose response (Mutrie, 2000)

Camacho et al. (1991) At F2 (1983)

Those LA at B but were active (MA/HA) at F1, had no greater risk of developing depression at F2 than those active at both B & F2 suggesting a potential protective effect (Mutrie, 2000)

No statistically significant difference when considering odds ratios for developing depression in 1983 based upon changes in activity status from B to F1 in four selected categories (L-L, L-H, H-H, H-L)

However, those who relapsed from activity (MA/HA) at F1 to LA at F2, were 1.6 times more likely to develop depression at F3, which was considered a robust finding

Paffenbarger et al. (1994)

Harvard alumni study that followed men only for 23-27 years

3+ hrs. of PE per wk. at B resulted in 27% reduction in risk of developing depression compared to those engaging in less than 1 hr of PE per wk.

Findings suggest that that inactivity precedes depression (i.e., temporality as one condition of causation)

Study also supported dose response relationship with significant findings in this area

Paffenbarger et al. (1994)

Relative to least active group (expending less than 1000 cal./wk at B

Those expending 1000-2499 cal./wk. at B were 17% less likely to develop depression

Those expending 2500+ cal./wk. at B were 28% less likely to develop depression

Epidemiological evidence (cont’d) Three other community based longitudinal studies were identified

that found that PA was not protective for subsequent depression however:

two of these studies only considered middle age males (Cooper-Patrick et a., 1997; Lennox et al., 1990)

Such results could be attributed to (Weyerer 1992): cultural factors (first foreign study identified) the fact that it only included exercise occurring during sports

(i.e., thus failing to capture activities such as walking or jogging

The fact that it had a much shorter follow up period than the other studies

Epidemiological evidence (cont’d)

The third study, consisting of 1536 men and women from Bavaria did, however, find supportive cross sectional data:

Relative to those who were not active, those who were regularly and occasionally active were 3.5 and 1.5 times less likely to be depressed, also providing some support for a dose response relationship

Meta-analyses of intervention studies Four meta-analyses of PE interventions have provided substantial

evidence based on “effect size” which suggest that exercise does have an anti-depressant effect (Mutrie, 2000)

Other meta-analyses have suggested that results from interventions have been inconsistent and inconclusive due to serious methodological problems (Strawbridge et al., 2002; Lawlor & Hopker, 2001).

However, positive results were also found within one meta analysis of 30 studies focused exclusively on clinical populations (Craft & Landers, 1998) and in contrast, two others which included studies that measured depression as a more transient mood state (Biddle, 2000)

Selected general reviews of intervention studies Given limitations within meta-analytic methods, a

qualitative/narrative discussion of specific intervention studies may be an alternative

Yet, a number of general reviews to date have provided positive, albeit cautious conclusions regarding the anti-depressant effects of PE (Mutrie, 2000)

Selected general reviews (cont’d)

PE can be a beneficial anti-depressant both immediately, as in the case of alleviating transient depressive moods, and in the long term

Even within clinical populations, anti-depressant effects can occur in a relatively short time frame (4-8 weeks) and persist for some time (2 months to 1 year)

Selected general reviews (cont’d)

positive conclusions have been drawn within reviews of studies with clinical populations (Martinsen, 1989,1993,1994; Mutrie, 2000) and sub clinical populations (Biddle, 2000)

PE is most effective in reducing depression in the most physically and psychologically unhealthy individuals at the start of a program

PE is equally effective for both genders, although some evidence suggests that increasing age results in increasing benefit in terms of anti-depressant effects

Selected general reviews (cont’d)

Reviews have shown that both aerobic (e.g., walking, running) and anaerobic (e.g., weightlifting) PE have equivalent reductions in depression within clinical and non-clinical populations

The longer the program and the greater the number of exercise sessions, the greater the antidepressant effect

Selected general reviews (cont’d) The external validity of the relationship between PE and reduced

depression has been suggested by the fact that general reviews have not only arrived at similar conclusions, but have found positive results within studies conducted within various contexts and populations across North America & Europe

Internal validity of this relationship has been reinforced by the most recent review of 10 studies which all had to meet criteria for both clinical depression and methodological rigor

This most recent general review has concluded that there is an adequate case for causation, based on the epidemiological evidence, its review of interventions that met strict criteria regarding clinical depression and methodological rigor and the general criteria for causation (Mutrie, 2000)

While causation has gained some acceptance, others applying similar criteria have been less convinced & others have questioned it on the basis of methodological limitations of existing studies and a lack of evidence for clinical outcomes (Faulkner, 2000).

PE compared to Traditional TreatmentSummary of research findings: RCTs assigning depressed patients to individual

exercise therapy, vs. psychiatric therapy, vs. meditation or yoga, vs. individual antidepressant drug therapy, or vs. combined exercise and drug therapy found: That exercise is just as effective as traditional treatments leading

to equivalent improvements Mixed results whether exercise should be implemented as a

stand alone treatment or an adjunct to psychotherapy and drug treatments, especially among individuals with major depression

PE compared to Traditional TreatmentGreist et al. (1979)

28 unipolar depression (i.e., without melancholic and psychotic features and generally referred to as mild to moderate forms of depression) patients assigned to running therapy, time limited individual psychotherapy or time unlimited psychotherapy

Running group had equivalent reductions in depression at 10 wks., 1mth., & 3 months.

Although a classic highly referenced study, would not meet today’s methodological requirements for publication

Klein et al. (1985)

Randomly assigned 74 participants with unipolar depression to individual running therapy individual meditation-relaxation for similar body awareness and

mastery (i.e., minus aerobic aspect) group breathing exercises an yoga for relaxation or semi-structured group therapy with elements of interpersonal

and cognitive therapy

participants in each treatment showed decreased depression at termination

Klein et al. (1985)

Johnsgard (1989)

In general this review of studies concluded that:

“the magnitude of change which results from exercise therapy by itself is as great as that associated with a variety of standard group and individual psychotherapies, some of which, in turn, have been shown to be as effective as antidepressant drug therapy”

Blumenthal et al. (1999)

important and well designed RCT conducted after reviews

In a 4 month study at Duke University, 156 outpatient men and women (aged 50+) with major depressive disorder were assigned to: Aerobic exercise (3 times per wk., 30 min., 70% VO2 max) Antidepressants (Zoloft) Aerobic exercise & antidepressants

all three groups experienced significant improvements which were not significantly different from one another

Blumenthal et al. (2000)

One measure of depression did not vary at 10 months (i.e., 6 months after original 4 month intervention)

A measure of DSM-IV diagnosis for major depressive disorder (MDD) found that the PE only group exhibited lower rates of MDD at 10 months than both the medication and medication and PE group

In the case of those participants in remission after 4 months, those in the PE group were less likely to relapse at 10 months than those in both the medication and surprisingly, the medication and PE group

Conclusion that modest exercise can be an effective treatment for those with MDD and that benefits likely to endure among patients who PE as a regular ongoing life activity

Dunn et al. (2005)

important and well designed RCT conducted after reviews

In a 12 week study, 80 men & women (age = 20-45 yrs.) with MDD were randomized into Run or bike exercise group that met public health dosage (PHD)

recommendations for weekly PE in terms of kcal/kg/week Run or bike exercise group that exercised at less than half of the

PHD One control/placebo group that took part in mild flexibility

exercises

While frequency was also divided into 3 versus 5 times per week in a 2x2 design, it ultimately had no effect on outcomes

Dunn et al. (2005)

PA conducted according to public health recommendations was just as effective in reducing depression amongst those with mild to moderate MDD as traditional treatments such as psychotherapy or medication

PA conducted at less than half of the PHD was no more effective than the control/placebo group

PE compared to Traditional Treatment (cont’d)

Based upon their findings, Dunn et al. (2005) suggested that PE might be used as an effective stand alone treatment for mild to moderate MDD, a position that also seemed to find support in the surprising fact that Blumenthal et al.(2000) did not find that medication provided any additive effect

Despite such findings, reviews suggest that the greatest anti-depressant effects come as a result of using exercise as an adjunct--rather than a stand alone intervention--particularly in the case of those suffering from severe forms of major depression (e.g., psychotic) who are described as still requiring standard treatment (e.g., psychotherapy, medication) and as potentially having less to gain from PA (Morgan, 1997).

Qualitative research: revealing complexitiesRCT research has been criticized for:

Its focus on circumscribed sets of questions/issues related to outcome, rather than process, and to efficacy rather than practical effectiveness

A lack of attention to complex mechanisms and dynamics of change

A reliance upon (motivated) volunteers have been identified as specific weaknesses

A lack of attention on individual and contextual differences

Qualitative research has been presented as a means of addressing these weaknesses

Faulkner & Biddle (2004)

Explored the motives and barriers to PA experienced by clinically depressed participants

examined the role of PA in promoting psychological well-being in the context of the qualitative narrative/story of participants’ lives

Longitudinal case study approach to capture complexities

6 individuals interviewed at five different points over the course of a year—before, during and after a tailored PA intervention--using semi-structured interview

common themes only after presenting overall narratives/stories of three representative typologies of participants

Faulkner & Biddle (2004)

Three representative typologies

1. The initial enthusiast: Terry

2. The slow starter: Laura

3. The regular: Dave

Faulkner & Biddle (2004)

Some general themes: benefits

Lay people develop complex theories regarding the cause and cure of mental health which have important implications in terms of offering a rationale for PA

Individuals not only point to different motivation for participating in PA and different outcomes that may impact upon their mental health, but may give different weights to these

When there is a congruence between outcomes and initial motives, psychological benefits may be more likely

Faulkner & Biddle (2004) Some general themes: barriers

For the most part barriers identified do not differ from those that have been identified in the literature with respect to the general population (e.g., perceived inadequacies, lack of time, motivation, availability)

Lethargy common symptom of depression that sometimes can not be overcome, despite awareness regarding the benefits of PA

Missing PA often accompanied by guilt

Faulkner & Biddle (2004)

Some general themes: life events Life events may influence PA levels as well as mediate any changes

in psychological benefits

Key conclusions Need to consider association between impact of PA and wider

context of peoples lives which entails broader consideration of environmental, interpersonal and intrapersonal factors

Relationships are likely to be complex and highly idiosyncratic This does not undermine existing research, but if such complexities

are not incorporated claims such as those regarding the causative role of exercise in alleviating depression could be considered naive

PE and Anxiety

Some definitions

Effects of acute and chronic exercise on stress reactivity

Effects of acute exercise on state anxiety

Effects of chronic exercise on trait anxiety

Some definitions Stress

The whole process by which we perceive and respond to events/”stressors” we appraise as threatening or challenging

May have positive or negative effect on us and our health (Myers, 1986)

Anxiety An unpleasant emotional state reflecting a negative cognitive appraisal

(of a “stressor”) and typified by worry, self doubt apprehension, dread, distress and uneasiness

An emotional response to stressors, including feelings, cognitions, and physiological changes (Spielberger in Hays, 2004)

Measured through physiological indicators, observational methods or self report measures/instruments

Can have serious consequences for health--even amongst otherwise healthy individuals--as a result of impact upon daily functioning (examination failure, accidents, social isolation), contribution to chronic disease (e.g., cardiovascular) and even suicide (Morgan, 1997; Taylor, 2000) State Anxiety: transient condition that can fluctuate rapidly within a

few seconds to a number of minutes Trait Anxiety: a general tendency toward anxiety proneness

Effects of acute & chronic exercise on reactivity to stress Reactivity to stress may be important to consider given its potential

to contribute to fatigue, health conditions (e.g., high blood pressure), and unhealthy behaviours (e.g., smoking, drinking) as coping mechanisms

Both chronic and acute exercise have been shown to reduce short term reactivity to and to enhance recovery from psychosocial stressors e.g., making a public speech after a bout of exercise and short

rest led to less of an increase in systolic and diastolic blood pressure during this typical psycho-social stressor, in comparison to a non-exercising control (Rejeski et al., 1992)

Drawing conclusions regarding chronic exercise has been complicated, however, by the diversity of training programs studied

Effects of acute exercise on state anxiety Change in state anxiety have usually/logically been studied in

context of acute exercise, which generally refers to single sessions of PA

It has been shown that single sessions of PA can result in reductions in trait anxiety and, in particular, that of an aerobic rhythmic type conducted at low to moderate intensity

In contrast, resistance training has not been shown to have an effect (Petruzzello in Hays, 2004; Taylor, 2000)

Evidence has generally suggested that high intensity aerobic exercise has a negligible, or even deleterious impact upon state anxiety, but a well designed study has recently challenged that conclusion (Cox et al., 2004)

Effects of acute exercise on state anxiety Cox et al. (2004)

A study involving 24 active women (18-45 years) randomized into non-exercise group, a moderate PE group (one 60% VO2 max. session) and a high intensity (one 80% VO2 max. session) group

Effects of chronic exercise on trait anxiety

As trait anxiety does not usually change in response to transient stressors, changes in it have generally/logically been studied in response to chronic exercise, which generally refers to longer- term PA programs consisting of multiple sessions

Studies fairly consistently show that a program of chronic exercise will result in reductions in trait anxiety and although there are limited comparisons available, evidence suggests that it may be in the same order as medication-free anxiety treatments (e.g., relaxation training)

Trait anxiety reducing effects are not dependent upon changes in physical fitness although PA appears to have the greatest impact upon trait anxiety when it is at least 10 weeks in duration

Effects of chronic exercise on trait anxiety Chronic exercise has successfully reduced trait anxiety within a

wide variety of clinical and non-clinical settings: and for a diverse range of sub-groups within the population: male and female, active and inactive, healthy and unhealthy (e.g., cardiac rehabilitation, cancer, coronary

obstruction pulmonary disease, cancer), anxious and non-anxious, and within those with a variety of mental disorders including clinical level

anxiety

Despite early recommendations discouraging exercise interventions for those with anxiety related disorder on the basis that it might cause harm as through inducing “panic attacks” (Pitts & McClure 1967) general reviews with clinical populations have concluded no significant health risks or problems have been identified in the research (Morgan, 1997)

Effects of chronic exercise on trait anxiety Broocks et al. (1998) This 10 week study randomly assigned 46 outpatients suffering from

moderate to severe panic disorder with or without agoraphobia to: running medication (Clomipramine) control (placebo pills)

While the medication was superior initially (at 4 wks.), by the end of the study the running was equivalent in terms of its effect on the anxiety measure

While exercise resulted in significant improvements in measures of agoraphobia, panic and overall psychological health in comparison to the placebo, the medication was ultimately superior to exercise in these areas

Mechanisms that might mediate the impact of PE onmental health

Mechanisms that might mediate the impact of PE on mental health1. Physiological Theories

Endorphins

(Brain) Monoamines

(Stress) Hormones

Thermogenic

2. Anthropological Theory

3. Psychological TheoriesMastery/self efficacy

Social Networks

Self Concept

Physiological Theories Endorphins Endorphins is a general classification label for beta-endorphins, met-

enkephalins, and leu-enkephalins, which all act as both hormones and neurotransmiters

Endorphins are released into the central nervous system in response to stress

Termed the brains morphine for they mimic its structure and display a similar ability to ease pain and ins some cases produce feelings of well being and euphoria

As PE such as endurance running produces a marked increase in endorphins as they been measured from the periphery of the blood-brain barrier—which they have been shown unable to cross-- the findings regarding the relationship that central/brain endorphins might have on psychological outcomes is promising but requires further study

Despite the absence of conclusive evidence regarding the role of endorphins they continue to provide one of the most popularized explanations for how PE might improve psychological outcomes (Leith, 1994; Martinsen, 2002)

Physiological Theories

(Brain) Monoamines PE increases the level of one or more brain monoamines (i.e.,

dopamine, norepinephrine, serotonin), which are neurotransmitters found in the brain, resulting in psychological improvements

e.g., Serotonin promotes feelings of comfort, pleasure and satiety and has been found to be low in the case of depressed individuals. As exercise has been shown to increase serotonin levels, it has been posited that this is the mechanism by which it has resulted in reductions in depression.

Physiological Theories

(Stress) Hormones

epinephrine/adrenaline and cortisol: a vital role in preparing our bodies for action in response to stress and at a more primitive level, the ‘fight or flight’ response

PE decreases the level of epinephrine and cortisol, hormones circulated throughout the body, resulting in reductions in anxiety

Physiological Theories

The Opponent-Process Model Basic assumption is that brain is organized to oppose pleasurable or

aversive emotional processes in an attempt to restore the organism to a level of homeostasis

It does this through an “opponent” process to counter an arousing stimulus

As the negative affect associated with exercise remains constant, the opponent process (e.g., relaxation) becomes increasingly stronger resulting in a positive psychological feeling

While this model has been used to explain the physiological mechanism represented by endorphins (Leith, 1994; Anderson & Sutherland, 2002)

Physiological Theories Thermogenesis Centuries of sauna baths provide anecdotal evidence as to the relaxing

anxiety reducing benefits of heat (Koltyn, 1997) Different conditions that elevate core body temperature, including a shower,

have been studied & associated with lowered measures of muscle tensions, state anxiety & various subjective & physiological correlates of anxiety

As vigorous PA can also lead to an increase in core temperature this, along with other indirect evidence supports a causal link

The fact that changes in body temperature affect physiological structures, systems & chemical reactions lend further support to this hypothesis and also suggest that the chemical mechanisms described earlier might play a role

This hypothesis remains “tenable” (Koltyn, 1997) with a lack of direct evidence for a causal link & significant methodological challenges to achieving it (e.g., controlling core temperature during exercise)

2. Anthropological Theory Humans have been gatherers and hunters—or the hunted-- and

only recently has it been possible for large populations to survive without hard physical work (Martinsen, 2002)

While the negative impacts on physical health have been evident (e.g., increases in obesity and chronic diseases), it is logical to assume that this change may not be good for our mental health as well (Astrand & Rodahl, 1985)

As we stress at our computers and do not have our natural outlets to deal with it (e.g., fight or flight) is this leading to an unhealthy build up of epinephrine and cortisol?

PE is a logical means of compensating for these changes population- level changes in physical activity whose full impact upon psychological health—and society for that matter-- is not yet known: PA has become our “hunting and gathering” and our “fight or flight”

3. Psycho-Social Theories Mastery/self efficacy/(empowerment) Skills & achievement in PE = sense of mastery & self worth in day to

day situations (e.g., client’s story) Common characteristic of mental illness is a sense of not having, or

having lost the ability to make choices and some treatments can reinforce the sense of being a passive recipient of care with implications for the mental illness itself

On the contrary, PA requires active participation and skill development by the individual (e.g., goal setting, social interaction) which may instill confidence in his/her abilities that spill over in terms of his/her perceived ability to deal with their mental illness

This is true even in cases of supervised activity, as it is the effort of the individual that will make the program a success and he/she can take credit for maintaining it upon program termination (MHF, 2005)

Put simply PE provides opportunities for a sense of mastery which traditional treatments do not

Proposed mechanisms...(cont’d)

Social networks: support, skills & other social capitalSelf concept Improved physical self worth & perceptions (e.g., body image)

leading to improved global self esteem

Time out or distraction Providing a diversion from negative thoughts or daily stressors and

an alternate focus

Immersion & flow Calming meditative and transcendent state

Improved cognition & clarity for problem solving Supportive findings re: cognition from research with older adults

and children Anecdotal experiential accounts of clarity as

Proposed mechanisms...(cont’d) Immediate structure and immediate goals (even if

temporary)

Spill over into other beneficial health behaviours

Indirect effects on psychological health via improvement in physical health, particularly amongst the aging (Strawbridge, 2002)

Proposed mechanisms...(cont’d)

Some final remarks

In conclusion, despite an impressive amount of research regarding PA and mental health, we are no closer to identifying a clear mechanism or specific set of mechanisms for to explain why PE might have effects on psychological well being

Many of the physiological and psychological mechanisms may operate concurrently and psychological explanations do not dispute physiological explanations (Faulkner, 1999)

It is unlikely that only one mechanism [or set of mechanisms] mediates the psychological effects of exercise (Mutrie, 1997), particularly given individual differences

Mechanisms that might mediate a psychological impact of PE However, greater research and consideration regarding

the mechanisms is still vital for physical activity promotion, exercise prescription and interventions in order to make some generalizations to determine how the mechanisms for one individual (population) may be different than those for another

e.g., It has been posited that the newcomers psychological health may be more influenced by psychological mechanisms (e.g., social support, mastery) for practical reasons (e.g., lack of experience) and as he/she will have yet to experience the physiological adaptations required for benefiting from the physiological mechanisms

The reverse has been suggested in the case of the experienced athlete (or the newcomer who has finally gained experience) who might be more influenced by physiological mechanisms as a result of such adaptation and greater experience

PE as a good ‘fit’ within contemporarypractice

PE as a good ‘fit’ within contemporary practice Physical benefits Reduced risk of several major diseases, healthier muscles, bones and

joints, improved cardiovascular fitness Physical benefits are even more relevant in the case of those with

mental illness, particularly clinical populations, as they are generally much less active and physically unhealthy than the general population which can in fact often contribute to the mental illness itself (Mutrie in MHF, 2005)

Physical benefits in mental health populations in terms of addressing their much higher rates of morbidity and mortality far outweigh the potential risks which have been shown to be negligible even within clinical populations (Mutrie, 2005)

We can stop right there !...potential psychological benefits are just a bonus

PE as a good ‘fit’ within contemporary practice Addressing the central policy/practice issue of stigma Traditional treatment may be disliked or even avoided due to the

stigma it carries with it Exercise viewed as a socially valued activity—for better or worse--

done by healthy ‘normal’ people and, as such, may not only avoid stigma but has the potential to become a very ‘normalizing’ experience “Players also feel a sense of normalcy. Hockey is Canada’s

national sport and people feel like they are participating in something that is valuable in Canada” (McGlynn, 2004)

May promote social inclusion and an improved identity or self concept as a result of being ‘normal’ and ‘healthy’ which may in turn be therapeutic

PE as a good ‘fit’ within contemporary practiceAvailability

All but those in very poor health are able to partake in some form of exercise (MHF, 2005)

Given that it may be self administered this can make it both more (immediately) available and cost effective than traditional treatment...just throw on those sneakers and run out the door!

Feasibility

Can be less effective over an equivalent period of time than pharmacological and psychological interventions even when delivered through a structured program (Mental Health Foundation, 2005) E.g., evaluation of U.K. referral scheme

Can take advantage of existing resources (e.g. running/walking groups) in community thus making it both more cost effective and integrative, particularly given an increasing emphasis upon community based approaches to mental health issues with one some would argue are inadequate resources

PE as a good ‘fit’ within contemporary practice Feasibility (cont’d)

Given the important role of follow-up in chronic cases of mental illness, PA provides a natural and very transition from structured programs to long term follow-up options in the community that do not require expensive psychiatric supervision

Alternatively, PA can serve as a non-stigmatizing form of early intervention that reduces costs associated with the development of much more significant problems

Moreover, as young people are most likely to suffer from mental health issues, to avoid treatment and yet to have relatively higher levels of health, they represent an ideal target population

All of these advantages in relation to accessibility and feasibility are all the more urgent given increasing mental illness and the growing inability that traditional services will have to cope

PE as a good fit within contemporary practice Empowerment

PA is also consistent with the increase emphasis upon empowering mental health consumers, on the grounds of both treatment effectiveness and as a matter of social principle: it allows them to take much greater control of their treatment rather than having to rely solely upon professionals or medications

PA may also be viewed as part of a general move toward offering individuals with greater options for dealing with multi-faceted mental health issues—requiring multiple modes of intervention-- a move which may be viewed as both enhancing the effectiveness of treatment and empowering individuals by virtue of choice

PE as a good ‘fit’ within contemporary practice Because people like it!

Contrary to popular beliefs that people with mental illness will be resistant to exercise, people with mental illness frequently cite exercise as being an important and positive aspect of their treatment (MHF, 2005)

A very prominent researcher has also found this to be a consistent finding with a review of studies (Martinsen,1995) and has suggested that exercise is viewed as a rewarding experience with a positive nature relative to the common prohibitions of preventive medicine (Martinsen,1993)

PE as a good ‘fit’ within contemporary practice Because people like it!

One survey of people with mental health difficulties found that 50% felt that exercise had helped them recover (Mind, 2001)

One survey reported that 85% of those who used exercise as a treatment found it helpful to them, which was the highest positive response for any non medical intervention (NSF, 2000)

The majority of participants with schizophrenia who have undertaken exercise or a sport program have valued its role (Faulkner, 1999)

Martinsen (1995) found that mental health patients described PA as “the most important element in the comprehensive treatment programs” he studied, ranking it above traditional forms of psychotherapy, milieu therapy and medication”

PE as a good ‘fit’ within contemporary practice Because people can stick to it!

Retention rates for PE amongst those with mental health issue is similar to that for other groups in the general population (Martinsen, 1993) and in some studies have been higher than that for traditional therapies (Ritvo in Pelham, 1990)

Most surprisingly, retention rates for PE amongst those with mental health issues are often much higher than that for medication (MHF, 2005)

Completion rates of ~ 60-80% have been reported in the case of mental health programs incorporating PA, although retention has varied across studies (MHF, 2005; Dunn et al., 2005)

One researcher suggested that the majority of his patients continue to exercise upon program termination (Martinsen, 1993), although long term engagement remains an important question mark as no conclusive information was identified in this regard

PE as a good ‘fit’ within contemporary practice

Because people like it and can stick to it!

“There is no reason to believe that individuals with schizophrenia and ‘normal’ sedentary members of the population differ widely in their attitudes to exercise. Perceived and actual barriers to exercise participation and adherence may differ in degree but the desire to increase or maintain activity levels for those inclined probably does not” (Faulkner, 1999)

The real and perceived challenges may be magnified, but so too may be the real and perceived benefits

PE as a good ‘fit’ within contemporary practice Revisiting psychiatric medication

Most frequently used treatment for major depression As many as 30-35% of patients do not respond to pharmacological

treatment for their depression May induce unwanted and even dangerous side effects that can

impair patients quality of life and reduce compliance. Even for those who show improvement, significant risk of relapse

within one year of pharmacological treatment termination (Blumenthal, 1999)

The development, sale and prescription drugs continues to grow at an exponential rate while exercise—which has been shown to have comparable effectiveness—receives far less attention in practice

PE as a good ‘fit’ within contemporary practice Revisiting psychiatric medication

While medications carry significant risk of unpleasant—and perhaps even dangerous—side effects, physical activity has relatively low risks which are outweighed in terms of side effects in the form of improved physical and potentially mental health

The negative side effects of PA are very limited, even in clinical populations, and with few exceptions are of the same nature and magnitude as those found in other groups (Broocks et al., 1998)

No serious complications to the combination of physical exercise and psychotropic medication has been published (Morgan, 1997)

PA provides an effective option for those who simply will not take psychiatric medication

PE as a good ‘fit’ within contemporary practice Enhances traditional treatment

Improvements in medication adherence quality of psychotherapeutic sessions after exercise (e.g., mood,

cognition, receptivity) Metaphors Fits within CBT ex.., reattribution w/anxious clients

The (lack of) ‘fit’ within actual practice Presently ad hoc Lack of referral (but U.K.) Continued dualism Does not fit into existing psychological theory Not viewed as part of the job of psychology Threatens existing knowledge and power structures

within psychology