The Missing Link:
Integrating Physical Activity into
Positive Mental Health Practice
Kelly P. Arbour-Nicitopoulos, PhD.
Postdoctoral Fellow
Department of Kinesiology
McMaster University
Faculty of Physical Education and Health
University of Toronto
Overview
• Background
• Why physical activity promotion?
• Research on physical activity and depression
• Current research and practice gaps
• Concluding thoughts
Physical Inactivity: A Global „Epidemic‟?
Physical Inactivity: A Global „Epidemic‟?
• 4th leading risk factor for
global mortality
– 6% of deaths globally
• Main cause for 21-25%
of breast and colon
cancer, 27% of diabetes,
and ~30% of ischaemic
heart disease burden
(World Health Organization, 2011)
Daily Minutes of Activity for Canadian
Adults (2007-2009)
700
600
500
mins/day
400
300
200
100
0
Sedentary
Light
(Canadian Health Measures Survey; Colley et al., 2011)
*Moderate to
Vigorous
• Only 15% of Canadian adults are
meeting the physical activity
guidelines
– at least 150 minutes of moderate to
vigorous physical activity per week
• Sedentary for ~ 9.5 hours/day!!
(Colley et al., 2011)
Benefits of Physical Activity
Physical Health
Social Health
Psychological Health
Positive Mental Health
• “a state of well-being in which every
individual realizes his or her own potential,
can cope with the normal stresses of life,
can work productively and fruitfully, and is
able to make a contribution to her or his
community.”
(World Health Organization, 2011)
Mental Illness
• Refers collectively to all diagnosable mental
disorders
– “health conditions characterized by
alterations in thinking, mood, or behaviour
associated with distress and/or impaired
functioning”
(USDHHS, 1999)
A Continuum of Mental Health
MENTAL ILLNESS
MENTAL
HEALTH
PROBLEMS
(Lox, Martin Ginis, & Petruzzello, 2010)
POSITIVE MENTAL HEALTH
Finding the
Neck
Three Broad Mechanistic Perspectives
• Biochemical changes
– Increased levels of neurotransmitters (e.g.,
endorphins, serotonin)
• Physiological changes
– Improved cardiovascular and muscle function
• Psychological changes
– social support, autonomy, self-efficacy, body
image, distraction
(Mutrie & Faulkner, 2003)
Physical Activity Promotion in the
Mental Health Field
• Awareness of physical
health needs
– Severe and comorbid health
conditions
• Health care shift from
Illness to wellness
• Service user advocacy
Chronic Disease and Disability in Persons
with Severe Mental Illness
• Higher morbidity and mortality rates for:
• Heart Disease
• Obesity
• Hypertension (High Blood Pressure)
• Diabetes
• Respiratory Diseases
• Cancer
• Infectious Diseases
(Allison et al. 2009; Brown et al., 2000; Hennekens et al., 2005)
Physical Activity Promotion in the
Mental Health Field
• Awareness of physical
health needs
– Severe and comorbid health
conditions
• Health care shift from
Illness to wellness
• Service user advocacy
Integrating „Wellness‟ into Health Care
• Raising awareness
– Patients are interested in their health and want to
change!
• Education and training
– Breaking down „silos of care‟
– Push the „boundaries‟ of care
• Forging collaborations
– “Gateway” to other services and health promotion
programs
(Lines, 2011; McDevitt et al., 2006)
Physical Activity Promotion in the
Mental Health Field
• Awareness of physical
health needs
– Severe and comorbid health
conditions
• Health care shift from
Illness to wellness
• Service user advocacy
Grey‟s Anatomy – April 23rd 2009
Psychiatric Treatment in Canada
Waiting Your Turn: Hospital Waiting Lists in Canada, 2009 Report
www.fraserinstitute.org
Advantages of Physical Activity
• Inexpensive
• No negative side-effects
• Potentially far reaching
• Sustainable recovery choice
• Cost-effective
• Social Inclusion
• Physical health benefits
Exercise-Referral Schemes (ERS) in the UK
• “Referring patients into a recognized system, with
appropriate qualified staff”
• Partnership between health and „exercise‟
professionals
• A first-line treatment for mild to moderate
depression?
(Department of Health, 2001)
Physicians‟ Perceptions of ERS for Treating
Patients with Mild to Moderate Depression?
• Effectiveness of Treatment?
– „quite effective‟: antidepressants (72%) vs.
exercise (56%)
• Preferred Choice of Treatment?
– antidepressants: 45%
– counselling: 36%
– supervised exercise program: 4%
(Mental Health Foundation, 2009)
Can exercise cause a reduction in
depression?
Is there evidence for the
role of physical activity
and exercise in prevention
and treatment of clinically
defined depression?
Risk of Depression: 10 year follow-up
1.8
1.6
1.4
1.2
Risk
1
0.8
0.6
0.4
0.2
0
Low
Mod
Physical Activity at Baseline
(Camacho et al., 1991)
High
Is there evidence for the role of
physical activity and exercise in
prevention and treatment of clinically
defined depression?
• Longitudinal evidence suggests
people who are inactive are two
times more likely to develop
depression later in life
(Camacho et al., 1991)
– Need stronger evidence?
Is there evidence for the role of
physical activity and exercise in
prevention and treatment of clinically
defined depression?
• Experimental Evidence
– At least 28 randomized controlled
trials (RCTs)
– Compiled into a „meta-analysis‟
(Mead et al., 2008)
Exercise causes a reduction in
depression: Experimental Evidence
• Strong experimental evidence that exercise
reduces depressive symptoms in people with
diagnosed depression when compared to no
treatment or placebo
• Moderate evidence when we only consider
trials that have included „blinded‟ outcome
assessments
(Mead et al., 2008)
An example of an RCT
(Blumenthal et al., 1999)
• N = 156, aged 50-77, RCT, 16 weeks
• 3 experimental groups:
– aerobic exercise (EX) only (n = 53)
– anti-depressant medication only (n = 48)
– EX + medication (n = 55)
• Depression scores did not differ between the
groups at 16 weeks; only exercise groups
improved fitness
• Medication alone provided faster response
Depression scores pre and post 16 weeks of
treatment (from Blumenthal et al., 1999) and 6month follow-up (Babyak et al., 2000)
25
20
Depression 15
scores 10
pre
post
6 mth follow up
5
0
medication
EX
combination
Is there evidence that exercise causes a
reduction in depression?
•
•
•
•
Temporal sequence
Strength of association
Experimental evidence
Consistency
Recommendations for Exercise „Prescription‟
• Standard exercise „dose‟ unlikely to exist
• Focus on activities that individuals enjoy doing
– e.g., aerobic and resistance, indoor and outdoor
• Gradual progression towards moderate intensity
• Self-regulation training
–
–
–
–
–
Monitor levels of physical activity
Discuss benefits of exercise
Provide guidance on appropriate activities and goals
Discuss barriers and overcoming them
Discuss ways for preventing/overcoming relapse
Linking Theory with Practice:
The HEalthy Lifestyle Promotion Program
(HELPP) for Women with Schizophrenia
Arbour-Nicitopoulos KP1, Faulkner GE1, Cohn TA2, Golding N2, &
Hsueh R2
1Exercise
2Mental
Psychology Unit, Faculty of Physical Education & Health,
University of Toronto
Health and Metabolism Clinic, Centre for Addiction and Mental
Health
What is HELPP?
• A 6-week physical activity and diet educational
program for obese women with schizophrenia led
by a recreation therapist and registered dietitian
from CAMH
• Participants:
– 29 women diagnosed with schizophrenia or
schizoaffective disorder
– Inpatients (n= 5) and outpatients (n= 24) of
CAMH
HELPP: Program Delivery
• Twice a week for 90 minutes
– 60 minutes of education and skill development
– 30 minutes of physical activity participation
• Setting:
– Integrated Rehabilitation Unit at CAMH- (inpatients only).
– CAMH‟s Queen Street gymnasium (both inpatient and
outpatient participants).
– Meeting room at CAMH‟s Russell Street site (inpatient and
outpatient participants).
– Community-based clinic where outpatient clients met with their
care team on a regular basis.
HELPP: Program Components
Skill Development/Education
Education:
Self-regulatory skills:
–
–
–
–
–
Self-monitoring
Scheduling
Goal-Setting
Breaking Barriers
Relapse Prevention
–
–
–
–
–
Balanced Diet
Physical Activity
Heart Health/Diabetes
Stress Management
Healthy Body Image
Physical Activity: (“Lifestyle” activities)
–
–
–
–
–
Walking
Dance
Circuit Training
Yoga
Home-based Exercise
HELPP: Program Attendance
• 24/29 participants completed the program
• On average, participants attended 8 out of
the 13 sessions
After 6 weeks of the HELPP program,
participants reported…
• Increased satisfied with their appearance and their
level of physical functioning
• Improvements in quality of life
• Greater confidence to eat healthy and to participate in
regular physical activity
• Greater participation in moderate physical activity
• Slight increases in the number of fruits and vegetable
servings and decreases in fatty foods
WHY WAS HELPP SUCCESSFUL?
Interprofessional Collaboration (IPC)
• “Is an interprofessional process of
communication and decision-making that
enables the separate and shared
knowledge and skills of health care
providers to synergistically influence the
patient care provided.”
(Way et. al., 2000)
Our IPC HELPP Team
Program Delivery
Client
Participants
RT/Dietitian/
Nurse
Program Evaluation
Student
Volunteers
RT/Dietitian/
Nurse
Participant
Recruitment
RT/Dietitian/
Nurse
Case
Worker/Members of
Community Support
Team
Behavioural
Researchers
Behavioural
Researchers
Student
Volunteers
Program
Development
Psychiatrist
Client
Participants
RT/Dietitian
Psychiatrist
Practical Implications
Primary/Secondary Care
• Developing skills
„Exercise‟ Professionals
• Developing skills
• Accessing resources in
the community
• Developing
partnerships and
referral opportunities
• Legitimizing the role of
physical activity?
• Making services
accessible
As We Move Forward…
• How can we better foster IPC in the fields of
physical activity and positive mental health?
• How can we develop programs that are:
– Acceptable to clients?
– Feasible?
– Cost-effective?
• How can we facilitate sustainable programs?
Promoting a Culture of Physical Activity
Socio-ecological Model
Address both the individual and environmental
"Coming together is a beginning.
Keeping together is progress.
Working together is success."
-- Henry Ford
References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Allison et al. (2009). Obesity among those with mental disorders: A National Institute of Mental Health
meeting report. American Journal of Preventive Medicine, 36, 341-350.
Babyak et al. (2000). Exercise treatment for major depression. Maintenance of therapeutic benefits at 10
months. Psychosomatic Medicine, 62, 633-8.
Blumenthal et al. (1999). Effects of exercise training on older patients with major depression. Archives of
Internal Medicine, 159, 2349-56.
Brown et al. (2000) Causes of the excess mortality of schizophrenia. British Journal of Psychiatry, 177,
212-217.
Camacho et al. (1991). Physical activity and depression: Evidence from the Alameda County Study. Am J
Epidemiol, 134(2): 220-31.
Colley et al. (2011). Physical activity of Canadian adults: Accelerometer results from the 2007 to 2009
Canadian Health Measures Survey. Statistics Canada Health Reports, 22(1).
Department of Health. Exercise Referral Systems: A National Quality Assurance Framework. A Report for
the National Health Service, UK, 2001.
Hennekens et al. (2005). Schizophrenia and increased risks of cardiovascular disease. American Heart
Journal, 150, 1115-1121.
Lines E. Barriers and Challenges to Health Promotion Initiatives for Persons with Mental Illness. A Report
for the Public Health Agency of Canada, Ottawa, January 2011.
Mead et al. (2008). Exercise for depression. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD004366
Mental Health Foundation. Moving On Up. United Kingdom, 2009.
Mutrie & Faulkner. (2003). Physical activity and mental health. In: Everett T, Donaghy M, Fever S (editors).
Physiotherapy and Occupational Therapy in Mental Health: An evidence based approach. London,
Routledge, 82-97.
Way et. al. Implementation strategies: “Collaboration in primary care – family doctors and nurse
practitioners delivering shared care.” Toronto: Ontario College of Family Physicians; 2000.
World Health Organization. (2011). http://www.who.int/mental_health/en/
Other Useful References
• Schizophrenia
– Gorczynski & Faulkner. Exercise therapy for schizophrenia.
Cochrane Database Syst Rev. October, 2010, Issue 5, Article No.
CD004412.
• Anxiety
– Petruzzello et al.,(1991). A meta-analysis on the anxiety-reducing
effects of acute exercise and chronic exercise: Outcomes and
mechanisms. Sports Medicine, 11, 143-182.
• Positive Mental Health
– McNeely & Courneya. (2010). Exercise programs for cancer-related
fatigue: evidence and clinical guidelines. Journal of the National
Comprehensive Cancer Network, 8, 945-953.
– Sofi et al. (2011). Physical activity and risk of cognitive decline: a
meta-analysis of prospective studies. Journal of Internal Medicine,
269, 107-117.
– Windle et al. (2010). Is exercise effective in promoting well-being in
older age: A systematic review. Aging and Mental Health, 14, 652669.
The Missing Link:
Integrating Physical Activity into
Positive Mental Health Practice
Kelly P. Arbour-Nicitopoulos, PhD.
Email: [email protected]
Department of Kinesiology
McMaster University
Faculty of Physical Education and Health
University of Toronto