Exercise and depression
Exercise referral and the treatment of mild or moderate depression
Information for GPs and healthcare practitioners
There is a substantial body of evidence to show a causal link between physical activity and reduced clinically defined depression, and comparative studies have demonstrated that exercise can be as effective as medication or psychotherapy. Treating depression in primary care
available through organised referral schemes. The following pages explain howexercise therapy can help people with depression and answers frequently asked
Treating depression places a huge burden on GPs and primary care staff – up to
questions about exercise referral schemes.
30 per cent of consultations relate to a mental health problem1, and depression isthe most common mental disorder found in community settings.2
The benefits of exercise for treating depression
For several decades, the standard firstline treatment response to depression in
There is a substantial body of evidence to show a causal link between physical
primary care has been medication. However, in recent years, scientists, regulatory
activity and reduced clinically defined depression7, and comparative studies have
bodies and clinical guidelines have questioned the wisdom of prescribing
demonstrated that exercise can be as effective as medication or psychotherapy.8
antidepressants in some circumstances, especially to people with mild depression.
Exercise has been associated with reduced anxiety, decreased depression, enhancedmood, improved self-worth and body image, as well as improved cognitivefunctioning.9 According to the National Institute For Clinical Excellence: “For patients
• As well as troublesome side effects and withdrawal symptoms, research shows
with depression, in particular those with mild or moderate depressive disorder,
that in some people, certain antidepressants can increase the risk of self-harm
structured and supervised exercise can be an effective intervention that has a
clinically significant impact on depressive symptoms.”10
• Guidance for clinicians published by the National Institute For Clinical Excellence
in December 2004 states that: “Antidepressants are not recommended for the
In view of this, there are several reasons for using exercise therapy as a first-line
initial treatment of mild depression, because the risk-benefit ratio is poor.” 5
Exercise has far fewer negative side effects than antidepressants – indeed, it has anumber of co-incidental benefits, including reduced risk of heart disease, stroke,
This has created a dilemma for many practitioners. Faced every day with people
high blood pressure, some cancers, type 2 diabetes, osteoporosis and obesity. 11
desperate for help, there seem to be few options. New research by the Mental
Exercise can be used to treat patients who have a mix of physical and mental
Health Foundation shows that GPs would like greater access to alternatives, but
health problems – it is a holistic care option.
that there are shortages of, or there are long waiting lists for, psychological
Exercise is a sustainable behaviour change. Once the exercise habit is learned,
it can be integrated to form part of an overall healthy lifestyle.
57 per cent of GPs believe antidepressants are prescribed too often.
Exercise does not carry the stigma sometimes associated with medication
78 per cent of GPs have prescribed an antidepressant despite believing that an
alternative approach might have been more appropriate, and 66 per cent have
Exercise is a popular treatment– in one survey, 85 per cent of people with mental
done so because a suitable alternative was not available.
health problems who used exercise as a treatment said they found it helpful.12
However, there is a well-evidenced treatment for depression that is currently
Exercise can give patients a sense of power over their recovery, which in itself
underused in primary care. That option is exercise therapy, and it is increasingly
counteracts the feelings of hopelessness often experienced in depression.13
1 Norwich Union (2004) Health Of The Nation Index
7 Biddle S., Fox K., Boutcher S., Faulkner G. (2000) The Way Forward For Physical Activity
And The Promotion of Psychological Well-Being, in Biddle S., Fox K., Boutcher S. eds (2000)
2 National Institute For Clinical Excellence (2003) Depression, Nice Guideline,
Physical Activity And Psychological Well-Being London: Routledge p155
8 Department of Health (2004) At Least Five A Week: Evidence On The Impact Of Physical Activity
3 Lynch T. (2004) Beyond Prozac: Healing Mental Distress Llangorran: PCCS pp71-2
And Its Relationship To Health, London: Department Of Health p58
4 Healy D., Whitaker C. (2003) Antidepressant And Suicide: Risk-Benefit Conundrums
9 Biddle S., Fox K., Boutcher S. eds (as in no 7) pp154-158
Journal Of Psychiatry And Neuroscience Vol 28 (5) p331
10 National Institute For Clinical Excellence (as in no 2) p72
5 National Institute For Clinical Excellence (2004) CG23 Depression: Management Of Depression
In Primary Care – NICE Guidance London: NHS p5
12 National Schizophrenia Fellowship, Mind, Manic Depression Fellowship (2000) A Question Of
6 Mental Health Foundation (2005) Up And Running? Exercise Therapy And The Treatment
Of Mild Or Moderate Depression In Primary Care London: Mental Health Foundation p18
13 See Mental Health Foundation (as in no 6) p25-27
How does exercise referral work?
• According to the Chief Medical Officer: “Physical activity is effective in the treatment
Exercise referral schemes operate in a variety of forms, often involving a partnership
of clinical depression, and can be as successful as psychotherapy or medication,
between primary care trusts and local leisure services.
• In its guidelines for treating depression, the National Institute For Clinical Excellence
In most cases, the GP or practice nurse can refer patients who fit the referral criteria
recommends that: “Patients of all ages should be advised of the benefits of
by filling in a form that is then sent to the scheme’s organisers. The forms are usually
following a structured and supervised exercise programme of typically up to three
straightforward and easy to fill in, asking only for a few details about the patient’s
sessions per week of moderate duration (45 minutes to one hour) for between 10
medical history, the reason for referral and their contact details.
Once the patient has been referred, the scheme organisers will make contact with
Using exercise referral schemes for depression
him or her, and arrange an initial consultation with an exercise professional (someonewho has been trained specifically in dealing with exercise referral populations). They
The first exercise referral schemes were set up in the 1980s, and it is estimated that
will make a detailed assessment of their fitness for exercise and develop with them
there are as many as 1300 operating across the UK.16 Many GPs and other healthcare
professionals already refer to the schemes for their patients with coronary heartdisease, diabetes, obesity, hypertension and other physical conditions which might be
Referral officers understand that many patients being referred will not be used to
exercise, and will make sure the plan is appropriate for their fitness levels.
Schemes can also take referrals for patients with mental health problems, usually
The patient will then be given free or discounted access to a range of leisure
depression and anxiety. However, research by the Mental Health Foundation shows
facilities for a period of time (usually three or six months). These facilities may
that of those GPs who know they have access to an exercise referral scheme,
include a gym, swimming pool, exercise classes or even options such as yoga,
only 15 per cent of these use it ‘very frequently’ or ‘fairly frequently’ for their patients
Throughout the period of the referral, the responsibility for the patient’s exerciseprogramme rests with the scheme. Referral officers will continue to provide support,motivation and advice to the patient throughout the duration of the programme, andthere are follow-up interviews at key points to monitor how he or she is getting on.
“Exercise is one of the few forms of treatment that will hit several different disease
“It’s had a definite impact on my well-being. I’ve done about 15-20 sessions now, and
targets all at once. More and more of my patients have five different conditions
I’m getting more positive in myself. I’m actually starting to enjoy it. I still get knackered,
when they come to see me – they have diabetes, high blood pressure, obesity,
but I’m in a hall with people who’ve had massive strokes and heart attacks, and I think:
raised cholesterol, and they’re depressed. By referring them for exercise, you can
actually deal with all of those. Plus, you end up with healthier and more engaged
Peter Lawler, participant in the South Tyneside exercise referral scheme
patients. It’s good for the patient, and it makes my job more enjoyable, rewardingand more likely to be successful.”Professor Colin Bradshaw, GP, South Tyneside
14 Department of Health (as in no 8) p5815 National Institute For Clinical Excellence (as in no 5) p1516 Mental Health Foundation (as in no 6) p3117 Mental Health Foundation (as in no 6) p28
Exercise referral for depression – frequently Q: Am I responsible if a patient is injured or becomes ill while participating in asked questions an exercise referral scheme? A: No. According to the National Quality Assurance Framework on Exercise Referral Q: My depressed patients are often unfit and lacking in motivation. Will they be
Systems: “When the individual is specifically referred for exercise by the health
able to adhere to a programme of exercise?
practitioner, responsibility for safe and effective management, design and delivery of
A: It is true that exercise therapy requires willingness on the part of the participant.
the exercise programme passes to the exercise and leisure professionals.”23 The
However, treatment completion rates for exercise referral schemes are often much
healthcare practitioner’s responsibility is to retain overall clinical responsibility for the
higher than for medication18, and exercise has been found to be one of the most
patient, and, with the patient’s consent, to transfer relevant medical information to the
popular treatments among patients.19 20 21 While the Mental Health Foundation
exercise professional carrying out the assessment. Once this information is received,
believes that all patients ought to be offered exercise referral, no patient should be
the responsibility for the patient lies with the scheme’s staff.
referred unless they are willing to undertake an exercise programme. Once they havebeen referred, patients will be given an individually-tailored programme to suit their
Q: Is there a strong enough evidence base for exercise therapy as a treatment for depression? A: Yes. The overwhelming majority of studies carried out have shown a positive Q: In a busy medical practice, won’t referring patients for exercise be very
benefit for depressed patients engaging in exercise therapy.24 Both the Chief Medical
Officer and the National Institute For Clinical Excellence have acknowledged the
A: No. The referral process is quick and straightforward, and because exercise therapy
results of these studies in their publications, and the 2004 government white paper,
involves referring patients to other qualified professionals, it enables GPs and health
Choosing Health, states that: “Regular physical activity reduces the risk of depression
practitioners to share the burden of managing patients’ care plans. There may also be
and has positive benefits for mental health, including reduced anxiety, enhanced
incentives for referring – some GPs operating under the 2004 General Medical
Services contract may be able to receive points for referring patients to exercisereferral schemes. Q: How do I find out more about referral schemes for my patients with depression? Q: How does exercise therapy work? A: Exercise referral schemes are usually delivered through a partnership of primary A: There are several theories about why exercise is beneficial to mental health. These
care organisations and local leisure services. Although not all GPs have access to a
are related to biology (exercise leads to an increased release of endorphins and
scheme, their numbers are growing. Contact the health promotion team at your local
enkephalins), sociology (attendance enables people to build new relationships), skill-
primary care trust to find out about referral schemes in your area and their ability to
mastery (exercise improves body condition and creates achievable goals), and
distraction (exercise creates a diversion from a preoccupation with negativethoughts).22 Also, whereas some treatments can reinforce the sense of being a passive
Q: How can I help my patients to understand the treatment?
recipient of care, exercise can create a sense of personal robustness, and of being
A: The Mental Health Foundation has produced a leaflet on exercise referral for
‘normal’ and ‘healthy’. As an additional treatment response option, it increases the
patients. Email [email protected] to order copies of the patient leaflet. A charge will
choices open to both patient and prescriber, maximizing the chances of improvement.
be levied to cover postage costs when placing bulk orders.
18 Mental Health Foundation (as in no 6) p3719 Mind (2001) Latest Mind Survey Provides Good News: Press Release London: www.mind.org.uk 20 National Schizophrenia Fellowship, Mind, Manic Depression Fellowship (2000) A Question Of
21 Martinsen E. (1990) Benefits Of Exercise For The Treatment Of Depression Sports Medicine
23 NHS (2001) Exercise Referral Systems: A National Quality Assurance Framework NHS:
22 For further discussion see Daley A. (2002) Exercise Therapy And Mental Health In Clinical
24 Craft L., Perna F. (2004) The Benefits Of Exercise For The Clinically Depressed Primary Care
Populations: Is Exercise Therapy A Worthwhile Intervention? Advances In Psychiatric Treatment
Companion To The Journal of Clinical Psychiatry Vol 6 pp104-111
Vol 8 pp262-70, and Artal M. (1998) Exercise Against Depression The Physician And Sports
25 Department of Health (2004) Choosing Health: Making Healthier Choices Easier London:
About the Mental Health Foundation Founded in 1949, the Mental Health Foundation is the leading UK charity working in mental health and learning disabilities.
We are unique in the way we work. We bring together teams that undertake research,develop services, design training, influence policy and raise public awareness within oneorganisation. We are keen to tackle difficult issues and try different approaches, many ofthem led by service users themselves. We use our findings to promote survival, recoveryand prevention. We do this by working with statutory and voluntary organisations,from GP practices to primary schools. We enable them to provide better help for peoplewith mental health problems or learning disabilities, and promote mental well-being.
We also work to influence policy, including Government at the highest levels. And we useour knowledge to raise awareness and to help tackle stigma attached to mental illness andlearning disabilities. We reach millions of people every year through our media work,information booklets and online services.
The Mental Health Foundation recommends that GPs with access to exercise referralschemes should offer all patients presenting with mild or moderate depression theopportunity for referral to that scheme as part of their treatment plan. Published by the Mental Health Foundation, June 2005 For more information about the benefits of using exercise as a treatment for mild or moderate depression, please visit www.mentalhealth.org.uk. To order a copy of the Mental Health Foundation report UP AND RUNNING? Exercise therapy and the treatment of mild or moderate depression in primary care, to order additional copies of this booklet or copies of our patients leaflet please email [email protected]
Sea Containers House, 20 Upper Ground, London SE1 9QB Tel: 020 7803 1100 Fax: 020 7803 1101 www. mentalhealth.org.uk Registered charity No: 801130 The Mental Health Foundation
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