Exercise and Mental Health: An Overview

The following is presentation of an overview of exercise in mental health which I recently gave. Although not specifically, neuropsychologically based nor neuro-rehab specific, some of the content is relevant in working therapeutically within neuro-rehab settings.


Intro to Sedentary Lifestyles

 Society has become increase sedentary

 Work, travel, domestic, leisure activities

 Urbanisation

 Labour saving devices

 Changes to childhood

 All creating a diversion from the physical role we evolved to do



Footnote:

Exercise is the purposeful application of physical activity

Both concepts have application to the promotion of mental health and wellbeing and both have been researched



Plan for Presentation

So….

 We know generally we don’t get enough

 But we know its society’s fault!!

 We know its generally good for us

But…

 What are the mechanisms/how does it work?

 What are the specific psychological effects?

 How effective exactly is it?

 What about exercise and mental illness specifically?

 How much do we need for an effect?

 What are the current exercise dose recommendations?

 What should we do with exercise as clinicians?



Mechanisms

Bio

Serotonin (Barchas & Friedman, 1963)

Endorphine/opioid system (Harber & Sutton, 1984).

Blood circulation/Cerebral blood flow (Dishman, 1995; Martinsen, 1987).

Realignment of circadian rhythm/sleep (Buxton et al., 2003; Youngstedt, 2005)



Psycho

Anxiolytic and mood enhancing qualities (see latter slides)

Accumulative mood improvements (Baekeland, 1970; Conboy, 1994; Mondin et al., 1996)

Increased tolerance to stress (Salmon, 2001)

Increase in self-esteem (Folkins & Sime, 1981; Fox, 2000)

Flow (Csikszentmihaly, 1990)

Distraction (Daley, 2002)

Control of negative thoughts (Morgan, 1985; 1987)

Improved retrieval of positive thoughts (Clark et al., 1983)

Positive rumination (Feldman et al., 2006)

Skill mastery (Lepore, 1997; Mynors-Wallis et al., 2000)

Spiritual/developmental theories



Social

Behavioural Activation/engagement (Jacobsen et al., 1996)

Socialisation (NHS, 2001; Priest, 2007)

Social inclusion (Taylor et al. 1999; DHSE, 1999)

Value of the group more than its constituent parts?

Drug and alcohol avoidance?



The Key Psychological Effects of Exercise:

Anxiolytic Effects

 Low to moderate anxiety reducing effect (Long & van Stavel, 1995; McDonald & Hogdon, 1991; Petruzzello et al., 1991).

 Exercise has an immediate anxiety reducing effect

 Exercise training has been linked to trait measured reductions anxiety

 Exercise sessions can reduce physiological reactivity and enhance recovery from psychosocial stressors

 Main mechanism: it is believed that accumulative experiences of exercise protect people against physiological and cognitive stress and anxiety by reducing sympathoadrenal or pituitary-adrenal responses. Put another way, exercise presents an opportunity to habituate to similar symptoms to that of anxiety (Mills & Ward, 1986).



Antidepressant Effects

 There is large scale, controlled, cross sectional support for a causal link between exercise and decreased depression (Steptoe and Butler, 1997 and Stephens, 1988)

 Meta-analyses have estimated that Beck Depression Inventory (BDI) Scores decrease by between 0.3 and 1.3 of a standard deviation after exercise by controlled comparison (Craft & Landers, 1998; McDonald & Hogden, 1991; North et al., 1990; Lawlor & Hopker, 2001).

 RCT studies have suggested that physical activity can be as successful at treating depression as psychotherapy or medication for mild and moderate levels (Klein, 1985; Mental Health Foundation, 2004; NICE, 2003).

 Potential for treating comorbid depression (HIV, Dementia, CHF, cancer survivors, forensic)



Self-esteem

 Exercise can promote physical self-worth and body image for males and females

 The effect is strongest amongst children and middle-aged adults, and those with lowest self-esteem

 Support for aerobic and resistance (latter acting quicker) (Fox, 2000)



Cognitive Function

 Majority of cross sectional studies show that fit older adults display better cognitive task performance than less fit adults

 Particularly in attention demanding and rapid tasks

 Small improvement in cognitive functioning of older adults who experience improvement in fitness (Boutcher, 2000)

 Slight beneficial & protective (Broe et al. 1990) effect in AD and other dementias but not VaD (Laurin et al. 2005)

 Anecdotal evidence from physical training focus within non-physical sports (darts, snooker, golf)



Mental Illness

 Inconsistent and poorly controlled evidence (Faulkner, 2005)

 Significant impact upon negative symptoms

 Mixed findings with positive symptoms (Helmsey, 1995)

 Potential risks (esp. in mania (Moore 2010), eating disorders (Szasbo 2000) and poly-medication treated patients (Faulkner 2005



Exercise Routine

 Exercise dependence is extremely rare

 Mixed evidence to who benefits most: sedentary individuals with greater potential (Fasting & Gronningsaeter, 1986; Roth & Holmes, 1987; Simons & Birkimer, 1988; Williams & Lord, 1997) or more regular exercisers who value it higher (Steptoe et al. 1997)

 Some evidence has shown that interruption of exercise routine in athletes/seasoned exercisers can lead to physical symptoms, including somatic anxiety and feelings of inability to cope (Loumidis & Wells, 1998).

 Theories of stress may help explain this (Salmon, 2001 Gauvin & Szabo, 1992; Morris et al., 1990)



Single Dose Immediate Effect

 15 minutes is enough to instigate an increase in positive mood, activation and valence, along with an energising effect whilst walking and a calming effect whilst recovering after walking (Ekkekakis et al., 1999; Ekkekakis & Petruzello, 1999; Thayer, 1987).

 Approx. 65% of MHR but inter-individual difference in preference of intensity (Ekkekakis et al., 2005; Rocheleau et al., 2004).

 Salmon (2001) suggests one way exercise may improve mood is that each single dose has an accumulative effect, increasing the likelihood of triggering positive cognitive appraisals, behaviours and social interactions.



Exercise Guidance

 Recommendations vary slightly according to different sources but most agree that greatest improvement to anxiety, depression and mood is caused by rhythmic, aerobic exercises, that use large muscle groups, such as walking, jogging, swimming, and cycling, of moderate and low intensity (between 50% and 75% of Vo2 max heart rate), conducted for 15 to 30 minutes and performed a minimum of three times a week in programs of 10-weeks or longer (Guszkowska, 2004; NICE 2003).

 Exercise in this format is safe but initially aversive enough to present a challenge, whilst also remaining controllable and offering a sense of achievement on completion (Salmon, 2001).



Questions for the clinician?

 How to we best get across the message?

 How far do we push the message?

 Is it our role?

 How do we integrate exercise interventions into our therapeutic work?

 How do we ensure longevity to the interventions?

 How do we incorporate exercise into relapse prevention?

 Should we and do we practice what we preach?