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A new study, published in Psychology of Sport & Exercise, investigate factors leading to poor adherence to prescribed exercise as a treatment for depression. The results of the study point to tobacco use, hazardous alcohol use, and inflexibility at work as primary reasons leading to poor adherence to exercise regimes. Understanding these factors may help researches and health care providers develop more effective exercise interventions to meet individual’s needs.
“Exercise has been proposed as an alternative or complementary treatment for depression and has the added benefit of having a positive effect on somatic health,” the researchers led by Björg Helgadóttir at the Karolinska Institute in Stockholm, Sweden, write. “This is especially important as depression is associated with a higher risk of the metabolic syndrome, type 2 diabetes, cardiovascular disease and the associated mortality.”
While the most common treatment for depression is psychopharmacology and psychotherapy, physical exercise has been shown to be a promising treatment and prevention method. Even minimum activity, as little as 15 minutes, three times a week, has been shown to reduce depressive symptoms in older adults.
In Sweden and other countries, health care providers have begun prescribing exercise for physical and chronic disorders such as diabetes and high blood pressure. Momentum, however, is slower when it comes to prescribing exercise regimes for mental health conditions, even with supporting research and public health agency’s recommendations. One reason for the resistance to prescribing exercise for the treatment of depression is the concern that patients will not adhere to the exercise plan.
“Non-adherence to depression treatment regimens is common and associated with worse patient outcomes and a greater likelihood of relapse,” the researchers write. “Adherence to exercise interventions is also suboptimal in depressed patients.”
The majority of studies considering adherence to depression treatment rely on patient self-report, introducing a slew of limitations. A significant weakness is that an individual may lack understanding surrounding reasons behind poor adherence.
“It is important to identify factors associated with poor adherence so that effective exercise interventions can be developed based on individual patient characteristics,” Helgadóttir and colleagues write.
In an attempt to study factors of adherence to prescribed exercise, researches acquired data from 310 adult participants diagnosed with mild to moderate depression in a parallel, single-blind, randomized controlled trial, called the Regassa study. Participants were randomly assigned light, medium, or rigorous exercise and were prescribed 60 minutes of exercise, three times a week, over twelve weeks. Pulse watches were provided to each participant, recording the frequency, duration, and intensity data.
Following weekly check-ins and coaching for the duration of the study, Helgadóttir and colleagues were able to distinguish 40.7% non-adherers (those that attended 0 exercise session), 27.1% sub-adherers (those that attended 1-11 sessions), and 32.3% adherers (those that attended 12+ session) across all exercise intensity groups, noting significant differences between the three.
“Non-adherers were more likely to have a hazardous alcohol consumption, be daily tobacco users and have no flexibility at work,” the researchers noted, adding that tobacco users attended an average of 52% fewer sessions than non-users overall.
Researchers also found that those assigned light exercises were more likely to be adherers while those in the vigorous exercise group were more likely to be non-adherers, calling to mind earlier research suggesting even minimal activity can be useful in reducing depression.
“A surprising yet promising result was that levels of physical activity at baseline did not predict adherence,” they write. “This indicates that even patients who are inactive can adhere and follow an exercise treatment; an argument that could be used to motivate inactive patients doubting their ability to initiate and maintain an exercise regimen.”
These findings provide helpful information toward increased exercise prescriptions for mental health treatment. Improving adherence though prescribing appropriate intensity, identifying risks such as alcohol and tobacco use, and taking into consideration work schedules and workplace flexibility may help develop practical and obtainable exercise regimes. Helgadóttir and colleagues conclude:
“As adherence is consistently related to treatment effectiveness, greater emphasis should be put on how to increase adherence, rather than just improving exercise treatments per se. The three factors we found to be associated with adherence should always be discussed with the patient before deciding on a treatment plan.”
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Helgadóttir, B., Hallgren, M., Kullberg, C. L., & Forsell, Y. (2018). Sticking with it? Factors associated with exercise adherence in people with mild to moderate depression. Psychology of Sport and Exercise, 35, 104-110. (Link)
I can tell you 13 years ago the psychiatrists were telling people to stop exercising, “stop all activities and concentrate on the meds!” When I said no, I was prescribed some drug that had warnings on it that it could cause a person to overheat when exercising.
I guess at least the mental health professionals are starting to learn that exercising is good for you. Congratulations.
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That’s a great point, actually – how many of those in the study were given drugs that made any kind of exercise activity feel incredibly onerous or even dangerous?
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Well, definitely the neuroleptics make exercise, and most everything else, feel onerous.
Unless, as was true in my case, you were massively over “medicated.” Then you’re made not just “psychotic,” via anticholinergic toxidrome, but also “hyperactive.” Yet you still sleep way too much.
Based upon my experience and research, I think the antipsychotic induced “hyperactivity” would most likely be described psychiatrically as “akathisia.”
I did find exercising possible and helpful in getting some of the inner angst out when dealing with “akathisia.” It wasn’t easy, however.
And as we know, drug withdrawal also results in making a person “hyperactive.” However, this was more of a euphoric “hyperactive” feeling. This type of “hyperactivity” would more likely be psychiatrically described as “mania.”
But definitely I exercised a ton while dealing with my drug withdrawal induced super sensitivity mania.
The moral of my personal experience is that very slowly weaning people (over years) off the drugs – encouraging a lot of exercise / dance / gardening etc. – while one’s brain heals itself from the neurotoxic poisonings and drug withdrawal induced mania. That is likely the best way to help those stigmatized as “mentally ill” actually heal.
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One thing I note here is the concept of “adherence,” which is a short step from “compliance.” I’d be interested to know if there was any attempt to identify the person’s perception of internal and/or external barriers to exercise, including past bad experiences, perceived lack of time, joint or other pain that makes exercising uncomfortable, lack of understanding of how to gradually build up to higher levels of exercise, etc. I’d be willing to bet that getting to know the person and their perception of what exercising will be like for them would lead to more people choosing to participate.
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Didn’t read your comment til after I’d written mine, Steve. Great minds think alike 🙂
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Indeed!
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They forgot something! Did they had money to spend!? And Walking, hiking cycling is not so lovely living in a bad neighbourhood (in the slums or Ghetto’s!)at 8 p.m and not very safe!
In the article wasn’t telling what kind of exercise they did or getting offered! In indoor exercise centre’s it could be difficult to dangerous from if you’re a not passing trans (like me!) or be there will be traumatic if in the Zumba class! everybody go to the right and me going to the other side! so you don’t make not many friends!
Or maybe they just did not like the kind of exercise! Going to a gym or ballet studio I experienced as torture! But when offering horseback riding on a good horse (with good I mean a sport/competition horse, who hates when other are faster! I used to ride on an angel /satan horse! The sweetest in the stable and on low speed! while running/racing or jumping! it was the devil himself!
I have no money for it because of losing my job! With “Wotan” I could ride to the end of the multiversum!
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Excellent points! Context is vital in any of these “studies,” yet context is almost always ignored or minimized.
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Want to understand why a particular person isn’t more physically active? Well, here’s a novel approach: ask them open-ended questions, like 1) whether they’d want to be more physically active, 2) what physical activities they already enjoy doing, and whether there are new ones they’d like to try, 3) have they cut back on (or stopped doing) physical activities they used to do more of, and why/how did that happen. Then actually listen to them when they tell you.
For a lot of people, “exercise” is a turn-off: Folks who were bullied in gym class or on sports teams. Folks who were always made to feel at odds with their own body because it is “too fat.” Folks who fear injuring themselves and compromising what mobility they still have left. But there are usually some physical activities that people do enjoy, and others they might/would enjoy if they had whatever support they need to pursue them. To swim, you need access to a pool and appropriate swimwear. Given that, you can do it independently, but other activities require someone to be your “spotter,” (think lifting weights or climbing rocks).
Maybe if they were less concerned with getting people to “adhere to” or “comply with” imposed directions, they could begin to listen. Tell me I’m going to jog, or tell me I’m signed up to play soccer and I will tell you to go fuck yourself. But put on some disco or ’80s pop without trying to impose an agenda on me, and just watch my body dance! Because it wants to move like that, and I enjoy the way it feels, even if it leaves me sweaty, breathless and spent.
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Good advice, Lavender Sage. What a concept … listen to the client, and respond in a mutually respectful and logical manner.
But the “invalid” DSM “bible,” and the training that the “mental health” workers are “professionals,” thus above their clients, tends to prevent the “mental health” workers from behaving in either a logical or mutually respectful manner.
But I agree, lots of dancing helped save me, too. Glad I ignored that bad psychological advice to turn off my favorite music.
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Exercise can be a snap if you find a way to do as a routine where you don’t have to drop what you’re doing to go to the track or the pool or the gym. Can you cycle to the store or to your appointments? Have you got enough time for tai chi before you go about your day ( I pick that because it doesn’t involve violent movement)? Notice that routine activities are a part of your “non-program” instead of separate activities where everything has to stop for you to perform exercises.
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Yup. Rode my bike to work for decades. It was an easy way to work in exercise without it being a chore.
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Do have long them patients the money for it!? fees, sports clothes insurance, do they have to travel having not a car!? Maybe you want to hike the Appalachian trail, but are not allowed from the social worker, legal presentation, the mental prison, you are allowed, but no gear and money and so on!
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What causes people to stop exercising during and after a mental crisis IMO:
– isolation and anxiety means you can’t get out and it’s only by yourself anyway.
– drugs plus condition cause a couldn’t-care-less mindset where the future is irrelevant.
– drugs slow you down , make you fat, and make exercise much harder.
– psychiatrist on-the-hoof brainwaves such as “don’t do anything you might fail at” and “don’t mix with other mental health patients”.
– “mental hospital patients don’t appear to exercise, so it can’t be any good”
– psychiatrists discourage psychosocial exercise projects – because they work.
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For me it wasn’t any of those that prevented me exercising. I wasn’t “prescribed” an exercise regimen though.
1 – Exercise makes me feel bad.
2 – When I am depressed, *standing up* is hard work.
I’m sure exercise is worthwhile, but I also think it simply isn’t as easy as that. I also know that lots of people will look at my first point and have no comprehension of that statement!
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whatever—-if you want some help you do three things…
you eat healthy….and you do healthy physical activity…
and you stay away from sugar…there all kinds of reasons why
people don’t do this… but the fact is these behaviors are crucial…
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Hmmm. Good physical health is conducive to good “mental health” apparently. Perhaps it is there that we should put our focus. Living a physically unhealthy (sic) lifestyle can get you a psychiatric label.
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Everyone knows that since stone age!
maybe they think not for the future because they have not one! or it seems worse than hell
They lost hope for a nice life! A nice house with a garden, a dog and a tree and of course a nice new car and so on! And hope already means Expecting a beautiful life like from a middle-class live without worrying to pay the bills this month! Do I have a job tomorrow or doing jail time, getting killed by a gang and so on! They know: the American dream is just a dream! Waking up in the slums!
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I was prescribed excercise by my doctor. I’ve been taking the scripts to the pharmacy and watching ehile the pharmacist does 20 push ups, 20 sit ups and 20 star jumps. My depression isn’t any better but the pharmacist tells me he is losing weight lol.
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“Prescribed exercise” is almost as ludicrous and oxymoronic as “forced voluntary”. And that “30 mins. 3x week” is LAME…. EVERYBODY should walk, swim, bicycle, yoga, etc., whatever, EVERYDAY, for a MINIMUM of 30 – 60 minutes. To start. That Psychs EVER advised against “exercise” only further proves that psychs are quacks. And no, you don’t need to pump iron, or run marathons, or do “vigorous” exercise. Walk 1/2 an hour, then turn around and walk back. Hey, if your life isn’t worth ONE hour out of 24, maybe we’d all be better off without you?….. OOOOH! Strong language alert! Relax, kids, that’s called a “rhetorical question”. Google it.
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Maybe people hate walking in the area because in there block on every corner is a gang or pimp! Waling in the area of Lauterbrunnen, Swiss is XTC, but also could kill you! example: as a moron low lander though glacier is Ice thus white! that below the gravel and stones where I walked on was a real big glacier with covered holes from 40 feet! And nature doesn’t care! Youre just food for others!
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At the risk of repeating myself:
While healthy diets and exercise can protect against many health problems, this may be an example of correlation rather than causation.
There is ample evidence that social class is a major determinant of health. Those who are better off socially and financially eat better, exercise more, experience less stress, and enjoy better health.
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What’s your heart age?
https://www.nhs.uk/conditions/nhs-health-check/check-your-heart-age-tool/
It helps to know your cholesterol levels and blood pressure.
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A a study for this?
its hard to maintain any sort of exercise regime when you are feeling relatively well given all the competing demands on time and energy – exercise or any sort of behavioural activation is the opposite of what it means to be depressed – add in the side effects of various prescribed drugs, a job that sucks the life force out of you, zero community, relative poverty etc and really is it surprising that its hard?
surely ‘treating depression’ is just focusing on a set of symptoms while leaving the causes and many others besides lurking.
I wonder has anyone had any experience with the power threat meaning framework? seems to be an attempt to recontextualise people after all the so called treatments seek to reduce the irreducible to an internal issue amenable to change via will power
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I read about a survey conducted that showed not only does exercise work better than Zoloft alone but better than Zoloft and exercise combined. Meaning, perhaps, exercise can be hindered by SSRI’s.
i feel better after 20-25 minutes low impact exercise but it hurts like crazy while I do it. I’m still messed up. 😛
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