Physical Activity and Mental Health: A

1
Physical Activity and Mental Health A Win-Win
Consideration?

• Guy Faulkner, PhD

guy.faulkner_at_utoronto.ca
2
Health Promotion in the Mental Health Field

• Significant and severe co-morbid conditions
  experienced by people with severe mental
  illnesses that lead to secondary disability and
  premature death
• Philosophical change in health care Illness to
  wellness
• Service user advocacy

3
Overview

• Physical Health Needs
• schizophrenia
• Mental health promotion
• depression
• 3) Reducing Social Exclusion

4
Rate of Obesity (BMI?30) in CAMH Patients
(N268), and General Population
P0.000
P0.000

(Stats Can 98/99, Age 20-64)
Schizophrenia Program 2001/ 02
5
Rate of Diabetes in 162 Patients
onAntipsychotic Medication

Schizophrenia Program 2002
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What we know?

• Cardiovascular disease is the major contributor
  to excess mortality in schizophrenia (e.g., Casey
  Hansen, 2003)
• Physical inactivity is a primary risk factor for
  cardiovascular disease

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Reduction in coronary mortality with
activity/fitness
ACT?
FIT?
Reduction in coronary mortality ()
Activity/Fitness level
Adapted from Blair Connelly, 1996
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Changing Practice?

• All patients should be referred to a structured
  and supervised lifestyle intervention
• Faulkner Cohn, Can J Psychiatry, In press
  July 2006

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Rationale for Physical Activity

• Physical Health Needs
• schizophrenia
• Mental health promotion
• depression
• 3) Reducing Social Exclusion

10
Physical Activity and HealthUK Chief Medical
Officers Report

• At Least Five a Week Evidence on the Impact of
  Physical Activity and its Relationship to Health
  (2004)
• is accessible at
• www.dh.gov.uk/PublicationsAndStatistics/

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Topics

• Physical activity and cardiovascular disease
• Physical activity, overweight and obesity
• Physical activity and diabetes
• Physical activity and musculoskeletal health
• Physical activity, psychological well-being and
  mental illness
• Physical activity and cancer

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Physical activity, psychological well-being and
mental illness

• Ken Fox (Bristol University)
• Guy Faulkner (Exeter University/UofT)
• Stuart Biddle (Loughborough University)
• Nanette Mutrie (Glasgow University)

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Method

• Phase 1 Literature searches
• Phase 2 Appraisal by expert reviewers
• Phase 3 Review Panel appraisal
• Phase 4 Advisory Group
• Phase 5 Re-appraisal by expert reviewers
• Phase 6 International peer review

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Evidence-based approach

• Findings Assimilated
• Existing Reviews
• Meta-analyses

• Modified in light of new
• Epidemiological/ population surveys
• Experimental (controlled trials/RCTs)

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Targets in mental health promotion

• Four avenues for Physical Activity
• Prevention of poor mental health
• Treatment of mental disorders
• Improvement in mental health
• Improvement in quality of life of individuals
  with mental disorder

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Targets in mental health promotion

• Four avenues for Physical Activity
• Prevention and Treatment of mental disorders
• Depression

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is there evidence for a causal link?Hill, A. B.
(1965). The environment and disease Association
or causation? Proceedings of the Royal Society of
Medicine, 58, 295-300.

• temporal sequence
• strength of association
• consistency
• experimental evidence
• dose response

• coherence
• specificity
• biological plausibility

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Evidence for the role of PA and exercise in
prevention and treatment of clinically defined
depression

• Temporal sequencing
• The most critical of the criteria
• for epidemiological data
• cross-sectional data are
• insufficient evidence

19
Relative risk of depression 10 year follow-up
RR
PA at baseline
Camacho et al., 1991
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Temporal sequencing

• There are at least 4 epidemiological studies that
  can demonstrate appropriate temporal sequencing
  for clinical depression.
• Could these findings be explained by
• bias - unlikely large population studies with
  checks made on non-respondents
• confounding- in all studies statistical
  adjustments are made for disability, BMI,
  smoking, alcohol, social status

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Evidence for the role of PA and exercise in
prevention and treatment of clinically defined
depression

• Strength of association
• epidemiological evidence
• suggests a twofold risk of developing
  depression from low activity status or 25
  reduction in risk if active
• evidence from meta-analyses

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EXERCISE CLINICAL DEPRESSION

• Craft Landers (1998)

ESlarge
ESmod
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Lawlor Hopker (2001) The effectiveness of
exercise as an intervention in the management of
depression systematic review and meta-regression
analysis of randomised controlled trials. BMJ,
322, 1-8

• 14 studies met criteria (RCT)
• Compared to no treatment mean ES for exercise
  -1.1 (95 CI -1.5 to -0.6)
• ES similar to that of cognitive therapy
• Mean difference in BDI score -7.3 (95CI -10 to
  -4.6)
• Conclusion The effectiveness of exercise in
  reducing symptoms of depression cannot be
  determined because of lack of good quality
  research on clinical populations with adequate
  follow up. (p1)

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commentary

• The conclusion does not follow the results-
  effect size for reducing symptoms (BDI) is large
• Other researchers have suggested that 5 points on
  the BDI would provide clinical significance
• Need for more rigorous research with longer
  follow up not disputed

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Experimental Evidence

• at least 15 randomised control trials (RCT) of
  clinically defined depression and exercise in
  peer reviewed journals
• all show a positive effect from exercise (both
  aerobic and resistance modes)
• 4 compared exercise to forms of psychotherapy 3
  of them showed the effect of exercise to be equal
  to other psychotherapies and 1 showed enhanced
  effects from exercise
• 1 showed exercise effect similar to medication
• 2 made comparisons to attention-control groups
  and both showed enhanced effect from exercise

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An example of an RCTBlumenthal et al (1999)
Archives of Internal Medicine, 159, 2349-56

• N 156, aged 50-77, RCT, 16 weeks
• Aerobic exercise compared to antidepressant
  medication or combination
• No difference between BDI scores at 16 weeks
  only exercise groups improved fitness
• Medication alone provided faster response

27
BDI scores pre and post 16 weeks of treatment
(from Blumenthal et al, 1999) and 6 month follow
up (Babyak et al, 2000)
28
Additional information on 6 month follow up
(Babyak et al, 2000, Psychosomatic Med,62, 633-8)

• Clinical interviews at 6 months found lower rates
  of depression in the exercise group (30)than in
  the medication (52) and combined groups (55) (p
  .028)
• exercise group had lower relapse rate and
  reported less medication use
• patients who reported that they engaged in
  regular aerobic exercise during the 6-month
  follow-up period were less likely to be
  classified as depressed at the end of that period

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Strength of association

• There is evidence of an association between low
  activity and increased risk of developing
  depression
• There is evidence of a strong association between
  reduction in depression when exercise is an
  intervention

30
Evidence for the role of PA and exercise in
prevention and treatment of clinically defined
depression

• Consistency
• There are 3 longitudinal studies that have not
  found a relationship.
• These have low numbers less than 1,000 and
  questionable measures of physical activity
• Consistent results from largest studies with
  longest follow-up

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is there evidence for a causal linkfor
depression?

• Temporal sequence
• Strength of association
• Experimental evidence
• Consistency

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Whats missing?

• Dose-response
• modest evidence
• should we expect it?
• Conclusion

Coherence

• possible, but not definitive
• conclusion

X/
X
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Judging Causal Links

• Biological plausibility
• possible, but not definitive
• conclusion? /

• Specificity
• depression is not only affected by exercise
• cannot be supported
• necessary condition?
• conclusion? X

X
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Comparisons with other major reviews - the
causality issue

• Landers Arent 2001 It is premature.to state
  with certainty that exercise causes reductions in
  depression
• ONeal et al, 2000 there is insufficient
  evidence to fully describe the relationship
  between exercise and depression
• Dunn et al, 2001 At this point the evidence is
  suggestive but not convincing.
• Mutrie (2000) There is support for a causal
  link

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What did Hill (1965) suggest

• All scientific work is incomplete whether it
  be observational or experimental. All scientific
  work is liable to be upset or modified by
  advancing knowledge. That does not confer upon
  us a freedom to ignore the knowledge we already
  have, or postpone the action that it appears to
  demand at a given time
• P. 12

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Guidelines for treatment of depression (NICE,
2004) 1.4.1.4 Exercise Patients of all ages
with mild depression should be advised of the
benefits of following a structured and supervised
exercise programme of typically up to 3 sessions
per week of moderate duration (45 minutes to 1
hour) for between 10 and 12 weeks. (p.
15/16)

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Is the glass half full or half empty?

• It might not be causalit might just be
  association or even placebo
• the placebo effect is a boon to therapy but the
  bane of research

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Is the glass half full or half empty?

• We dont know why it works
• We know psychotherapy is effective, but we also
  know that different apparently contradictory
  theoretical approaches are approximately equally
  effective in outcome, but very different in
  content (Llewelyn Hardy, 2001)

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Is the glass half full or half empty?

• Need for rigor in experimental research versus
  the need for practical intervention guidance
• Absence or lack of RCTs may be more due to their
  cost and difficulty, or common-sense

Smith Pell BMJ  20033271459-1461 
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Is the glass half full or half empty?

• it might do harm
• no negative effects reported

• It might not work
• there are other health benefits physical
  activity is win-win

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Rationale for Physical Activity

• Physical Health Needs
• schizophrenia
• Mental health promotion
• depression
• 3) Reducing Social Exclusion

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3) Social Exclusion

• Mental health service users are likely to be
  poor, unemployed, living in substandard housing,
  and socially isolated by their experiences of
  stigma discrimination (Sainsbury Centre for
  Mental Health, 2002)
• Sport Physical Activity as a forum for reducing
  isolation increasing normalisation?

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But whats the exercise dosage?

• Unlikely to exist??
• As there is no single mechanism that explains the
  effects of physical activity on mental health
  outcomes, the effects of different modes and
  intensities of exercise are likely to vary,
  depending on peoples subjective experiences of
  the activity and the setting in which it is
  carried out.

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Therefore . . .

• It is therefore recommended that a range of
  different exercise modes and intensities should
  be recommended, based on the individuals
  previous exercise experiences, preferences and
  goals.
• Current recommendations to accumulate 30 minutes
  of moderate intensity activity on 5 or more days
  each week are generally supported in terms of
  their potential for improving psychological
  well-being.

DoH (2004)
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Integration within Mental Health Services

• Frequent contact with service users
• Overcoming mental health specific barriers
• Legitimizing the role of physical activity
• Skills competence an issue
• Developing partnerships and referral opportunities

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Current Practice

• Interventions to increase physical activity are
  feasible and can succeed
• Interventions effective in the general population
  can also be effective for individuals with SMI
• Adherence appears comparable to general population

Richardson, C., Faulkner, G., McDevitt, J.,
Skrinar, G., Hutchinson, D., Piette, J. (2005).
Integrating physical activity into mental health
services for individuals with serious mental
illness. Psychiatric Services.
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Summary

• Physical activity A win-win scenario
• At the population level physical activity to
  promote mental health
• At the service level Assessment promotion of
  physical activity should be considered when
  formulating care plans for mental health service
  users
• Difficult but not impossible