I qualified as a nurse at Brighton University in 1996. I very much enjoy sharing the health, nursing and medical knowledge that I have nurtured over that time, and most importantly I enjoy sharing that knowledge and experience in my capacity as a writer, with clients who utilise my writing services. I have enjoyed a broad spectrum career as a nurse and worked at senior level. My areas of expertise are: Accident & Emergency, Coronary Care, Primary Care and the field of Occupational Health.
Promoting the use and benefits of exercise as an intervention in the treatment of depression for adults of working age
Major depressive disorder has been recently found to be associated with high medical utilisation and more functional impairment than most chronic medical illnesses. Major depression is a common illness among persons in the community, in ambulatory medical clinics, and in inpatient medical care. Studies have estimated that major depression occurs in 2%-4% of persons in the community, in 5%-10% of primary care patients, and 10%-14% of medical inpatients (Katon and Schulberg, 1998).
In recent years much has been written and discussed about the possible benefits exercise has on those suffering from depression. General practitioners (G.P’s) are experiencing a huge strain on their budgets as a direct result of increasing funds being spent on the prescription of medications and other therapies to treat depression.
It is believed that approximately 30% of general practitioner consultations centre on patients suffering from depression. Depression is believed to be the most common mental health disorder in the community setting (NICE, 2003). As a direct result of this, new practices are being trialled to involve patients in exercise as a more effective, and cost saving method of treating depression. Referral-based exercise programmes are being run by the ‘Mental Health Foundation’ and are being rolled out UK wide. It won’t be long before the prescription of exercise for the depressed adult equates to, or over takes the prescription of anti-depressant medication.
The benefits of exercise in the depressed adult have become a popular subject in medical circles. The benefits in many cases exceed those of the benefits of medical treatments such as anti-depressants, primarily because there are no detrimental side-effects to be wary of. Indeed there is also the matter of public perceptions and stigma’s attached to the more conventional treatments for depression. Those requiring the use of drugs or supportive therapies such as counselling often feel embarrassed to be associated with these treatments, however exercise is not deemed to hold any negative social stigma. This theory is supported by The Department of Health (2004), who believe: “Physical activity is effective in the treatment of clinical depression and can be as successful as psychotherapy or medication, particularly in the long term.”
A patient suffering from depression can obtain both physical and psychological benefits from exercise therapy. Physically, it has been proven that exercise releases chemicals in the brain known as ‘endorphins’, these chemicals are known to contribute to an improvement in mood.
The endorphin hypothesis proposes that the effects of acute exercise on psychological wellbeing, in particular ‘euphoria’ is caused by the release and subsequent binding of endogenous opiods, these being release of endorphins to receptor sites in the brain (Steinberg and Sykes, 1985).
Psychologically, a person that becomes involved in exercise, particularly through a programme organised by the G.P, will be privy to involvement in a social group. New relationships can be built and this in itself is a positive achievement for the depressed adult.
Reports by the ‘Mayo Foundation For Medical Education And Research’ suggest that it will take at least 30 minutes of exercise, three to five days per week to significantly improve symptoms of depression. However shorter episodes of activity – as little as 10-15 minutes at a time, can contribute to an improvement of mood in the short term (Vickers-Douglas, 2007)
Theory therefore suggests and has proven that exercise holds many benefits, and very few negative effects. It is therefore the role of the health professional to support these theories and put them into every day clinical practice.
The concept of health promotion has been present in the field of healthcare and medicine for many years. Health promotion schemes have predominantly focused on disease management and prevention in conditions such as heart disease, diabetes and asthma. It is only in recent years that health promotion, both physical and psychological, has been recognised to benefit the mental health patient.
In order to systematically develop and deliver a health promotion model, it has been recognised that the utilisation and guidance of a ‘planning model’ is effective. It is reasonable to conclude that nurses both in the hospital and primary care setting have knowledge of health promotion and its benefit, the problem is that few nurses are given the opportunity, encouragement or guidance to implement the techniques proven to enhance patient care.
According to Tones and Tilford (2001) the chances of a successful outcome in a health promotion programme are significantly improved if a systematic approach is taken. There are several planning models that provide a framework for planning effective health promotion:
The ‘Precede Proceed’ model was established by Green et al in the 1980’s. The aim of the model was to explain health related behaviours and environments, and to design and evaluate the interventions needed to influence both the behaviors and the living conditions that influence them and their consequences (Naidoo and Willis, 2000). This model enforces the need for a voluntary compliance of the health initiative. In the case of engaging a patient in an exercise programme, it is essential that they are willing to participate. Compliance is most effectively and consistently achieved when the client is in full agreement of the task. And understand the aims, objectives and benefits of the outcomes.
It is easier to encourage a patient to take a tablet once a day, than it is to expect them to go for a 30 minute walk. The latter requires effort, and in the depressed patient, low mood, lack of motivation and general lethargy can hinder the acceptance of such a health promotion concept. Therefore a strong health promotion approach is required in order to ‘sell’ the concept and benefits to a patient that is already consumed by negative thoughts.
Ewles and Simnet (2003) developed a clear, formatted approach to delivering health promotion. The plan was delivered in seven clear stages:
- Identification of needs and priorities
- Set aims and objectives
- Decide on the best way of achieving the aims
- Identify resources
- Plan evaluation methods
- Set an action plan
- Action and implement the plan – evaluate
This plan, as with many others can be used in the planning and implementation of any type of treatment plans for the patients in any health care environment. This model merely provides a framework on which to structure a more detailed plan. The model does not relate in any particular way to the concept of exercise in the depressed patient, nor could it be obviously or usefully be applied. It is my belief that focus need to be made on models that relate to the mental health setting to enable health professionals to follow the same guidelines. This way there will be greater unity and more effective compliance and success of the project or task.
The ‘Health Belief Model’ (HBM) was first developed in the 1950’s by social psychologists Hochbaum, Rosenstock and Kegels.
The HBM is based on the understanding that a person will take a health-related action if that person feels:
- That a negative health condition can be avoided.
- Has a positive expectation that by taking a recommended action, he/she will avoid a negative health condition.
- Believes that he/she can successfully take a recommended health action.
This model provides the patient with guidelines and incentives as to outcomes and aims from following the model. Even seventy years ago, health promotion models had similar aims and objectives to those being utilised in healthcare today.
It would appear that health promotion models have been around for centuries, yet creating one that healthcare professionals use uniformly would be impossible, as everyone works within a different clinical area, and certain models apply more or less so.
The important thing is that a model is used at all. Models create a foundation for health professionals to work on, and be able to substantiate reasons for their actions.
According to O’Donnell, health promotion is the science and art of helping people change their lifestyle to move towards a state of optimal health. Optimal health is defined as an equal balance between physical, emotional, spiritual, social and intellectual health. Lifestyle changes can be facilitated through a combination of efforts to enhance awareness, change behaviour and create environments that support good health practices (O’Donnell, 1989).
If a well defined and useable model encompassing all of the above considerations is used for the delivery of health promotion, the acceptance and absorbance of the information given will be much higher. The benefits of planning models are that they provide a basic template which can be used in any health care arena, be it mental health, paediatrics or general nursing.
A health promotion approach must be decided upon, and using a well known model clearly defines the intention behind the choice of model. Dependant on the planning model used a further more detailed approach must be considered. This being which approach best suits the client.
Downie et al (1990) developed a three tier health promotion approach which encompasses three key areas for consideration when planning a health related initiative. The model makes reference to ‘health promotion’, ‘health prevention’ and ‘health protection’ which illustrates that consideration for combined health issues can be utilised when using this model. It is then possible to gain greater client compliance if they can understand that all of their health needs are being taken into account.
The truth is that both medicine and health promotion have a scientific basis, and both deal with prescriptions for improving the quality of life. The differences are between perspectives: the individual and the societal; the negative and the positive; the curative and the preventive; the reductivist and the holistic (Downie et al, 1996)
In particular, this model aims to prevent ill-health and enhance positive health, a concept that a client suffering any condition would comprehend. It is my belief that this model provides the clearest framework by which to deliver a health initiative, particularly in the scenario of promoting an exercise initiative in the adult rehabilitation setting.
Health and the maintenance of health, is a concept that is often only adopted when a person has acquired a health problem. To encourage a mental health client whom is suffering from depression to embark on a regular prescription of exercise is no easy task.
Practically, for the working aged client suffering from depression, consideration needs to be taken as to the ease to which exercise can be incorporated into their routine. To enable the three tier approach developed by Downie et al, it is essential that each individual client situation can be placed neatly into the framework template.
The World Health Organisation (WHO) suggests that at present, the field of health promotion lacks the appropriate infrastructure to develop expertise in health promotion evaluation research (WHO, 1998). In essence this statement is true, however if healthcare professionals are encouraged to select, plan, implement and evaluate the current ‘key’ health promotion models available, then a degree of feedback can be gained, thus developing a level of expertise on the subject. This will in turn encourage other health care professionals to use models, based on the reflective studies available.
As Downie et al also suggest, there are two types of evaluation in health promotion. Firstly there is the evaluation that involves assessing the activity in terms of specific aims or objectives. In reality this is the assessment/evaluation phase of the health promotion project and focuses on what has been achieved. The second evaluation is related to measuring the chosen activity against a standard, it too deals with assessment/evaluation but the crux of this evaluation is to focus on how the intervention was achieved? (Downie et al, 1996). In the case of implementing exercise regimes for the depressed adult, the implementation is not complex it simply requires the nursing team to incorporate exercise into the daily routine of the rehabilitation facility. By offering encouragement and motivational techniques, it is likely that individuals will conform, particularly if they see no harm attached to the action. Evaluation of this is not complicated. Did clients participate as required? Did the client believe they benefited from the exercise plan? Would they participate again in the future? If a positive response is gained from this then the health promotion initiative has been a success.
For the purpose of long term mental health rehabilitation, it is my belief that this model once again serves a pivotal purpose in not only addressing the mental health needs of the client, but the physical and social needs also. It is by far the preferred model for the planning, implementation and evaluation of patient exercise programmes as it encompasses a ‘wider picture’ of health needs. In addition, effective, planned evaluation of an implemented health promotion plan offers tangible evidence of what has been achieved and thereby offers nurses confidence and satisfaction in relation to their health promotion role (Kiger, 1995).
In light of the crippling cost implications of the nations declining mental health, the concept of exercise as a therapeutic method that provides a marked improvement, notably in the depressed adult, must be acknowledged.
Researching and determining suitable health promotion models, to assist the application of such care initiatives is definitely a positive step forward for mental health caregivers. It is however not clear whether exercise alone can substitute other treatments for depression, and therefore it would be unwise for health care providers to replace existing care unless it can be proven that they are no longer required.
Exercise, as a treatment for depression in the working adult should continue to be trialled, particularly in those suffering mild and moderate levels of depression. Equal importance must be placed on who is delivering the exercise regimen to the client. Health and fitness establishments do not tend to employ staff with specific mental health knowledge.
With the rise in referrals from primary care practitioners to leisure and health centres, a greater level of bespoke training is being given to staff to ensure that assessment and exercise regimes are being agreed following detailed assessments of each client that has been referred. Most of the information about the client and their needs is passed on to the leisure facility at the time of initial referral.
When appropriate referrals, effective implementation of exercise programmes, and equally efficient supplementary care is provided by mental health teams, the benefits of exercise for the depressed client will certainly continue to increase. Where revolutions in treatment medications and therapies have occurred over centuries, simple exercise plans will remain just that, simple and uncomplicated, without the risk of undesirable side effects. Providing ongoing patient monitoring is offered, at regular intervals, primary care practitioners will continue to see positive outcomes from the exercise referral schemes, involving improvement in patient symptoms, and less money being spent on other, possibly less effective therapies.
1. Department of Health (2004) ‘At least five a week: Evidence on The Impact of Physical Activity and its Relationship to Health’. London, DOH, P.58
2. Downie, R.S, Fyfe, C, and Tannahill, A (1990) ‘Health promotion models and values’. Oxford, England: Oxford University Press.
3. Hochbaum, Rosenstock and Kegels (1950’s) – ‘Health Promotion Model’ [Online] http://www.tcw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communication/Health_Belief_Model.doc/ [Accessed 15.2.08]
4. Katon, W & Shulberg, H (1998) –‘ Epidemiology of Depression in Primary Care’ [Online] http://www.ncbi.nlm.nih.gov/pubmed/1505745 [Accessed 15.02.2008]
5. Kiger A.M (1995) ‘Teaching for Health’, 2nd Edition. Churchill Livingstone, Edinburgh.
6. NICE (2003) ‘Depression – NICE guidelines’, Second consultation, London: NHS p.13
7. Nidoo J, and Willis J (2000) ‘Health Promotion. Foundations for practice’ (2nd edition) Edinburgh. Bailliere Tindall
8. O’Donnell M.P (1989) ‘Definition of Health Promotion’ Part 3, Expanding the definition. American Journal of health Promotion, 3,3,5.
9. Steinberg, H. & Sykes, E. A. (1985) Exercise therapy and mental health in clinical populations: is exercise therapy a worthwhile intervention? [Online] http://apt.rcpsych.org/cgi/content/full/8/4/262 [Accessed 15.02.2008]
10. Tones, K and Tilford, S (2001) Health Promotion: Effectiveness, efficiency and equity’. (Third Edition) Cheltenham, Nelson Thornes.
11. Vickers-Douglas, Dr (2007) ‘Mayo Foundation For medical Education and Research [Online] http://www.mayoclinic.com/health/depression-and- exercise/MH00043 [Accessed 14.02.2008]
12. Whitehead, D (2001) – ‘Stage Planning Model A stage programme model of health education/health promotion practice’. Journal of Advanced Nursing. 36,2,311-320.
13. World Health Organisation (1998) ‘Health Promotion Evaluation: Recommendations to Policymakers’. Report of the WHO European Working Group on Health Promotion. WHO, Copenhagen