Integrating exercise into mental health care: Development of the Exercise and Depression Toolkit

Integrating exercise into mental health care: Development of the Exercise and Depression Toolkit

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By Krista Glowacki, MSc (OT), PhD Candidate, and Guy Faulkner, PhD, Professor, School of Kinesiology, University of British Columbia.

Summary

Depression is a serious illness and one of the leading causes of disability in Canada and globally.

This WellSpring highlights the Exercise and Depression Toolkit, a new evidence-based resource to aid healthcare practitioners in facilitating conversations around exercise as a treatment for depression.

Introduction

Depression is one of the leading causes of disability in Canada and globally.1,2 Depression is a serious illness and can be debilitating with symptoms such as hopelessness, despair, and thoughts of death. It greatly impacts individuals, families, and communities, and it is a significant burden on economies and healthcare systems. There is an urgent need to expand access to effective treatment options for Canadians living with depression.

Exercise is a treatment option that should be considered. Structured exercise programs can significantly reduce depressive symptoms3-5 and improve quality of life6 for individuals with depression. Exercise is a cost-effective health promotion intervention,7 is low risk, and provides various health benefits. However, access to exercise therapy is not yet a standard part of most mental health services in Canada. Reaching that point will take some time. As a starting point, we created the Exercise and Depression Toolkit to help healthcare providers consider exercise as a treatment option with their clients or patients.

Considering exercise as a treatment for depression

Exercise is defined as physical activity that is planned, structured, repetitive, and done for the purposes of improving or maintaining physical fitness or health.8 Due to increasing evidence, depression is the first and only mental health disorder in which exercise is recommended as an evidence-based treatment in clinical guidelines. The Canadian Network for Mood and Anxiety Treatments (CANMAT) now recommends exercise as a stand-alone treatment for mild-moderate Major Depressive Disorder (MDD), and, in combination with other treatments, for moderate-severe MDD.9 This is the first time exercise has been recommended as a stand-alone treatment for depression in Canada.

Now that we know evidence exists to support exercise for reducing depressive symptoms, along with clinical guidelines recommending exercise as a treatment for depression, where do we go from here?

Healthcare providers play an integral role as gatekeepers to any treatment, and those who are currently working with adults with depression are key stakeholders for the start of the integration of exercise as a treatment for depression. Further, adults with depression have identified the importance of social influences, such as help from a health professional, for engaging in exercise and physical activity.10 However, healthcare providers need support to implement clinical guidelines and collaborate with clients when considering exercise as a treatment option.

Developing the Exercise and Depression Toolkit

Our working group developed the Exercise and Depression Toolkit based on the starting point of initial treatment planning with a clinician. The toolkit is for healthcare providers working with adults with depression. This toolkit supplements the CANMAT guidelines and helps healthcare providers integrate guidelines related to exercise and depression into practice. The toolkit was created over four phases: a review of relevant literature, formative interviews, an expert panel meeting, and final toolkit development. A summary will be provided here, but more details about the developmental process is described elsewhere.11 Various stakeholders were involved throughout this process including healthcare providers, adults who have lived experience with depression, researchers, and exercise professionals who have experience working with adults with depression.

Phase one: Review of the literature

Two scoping reviews were completed to help understand behaviour and to inform the content of the toolkit.10,12 The first review was undertaken to understand the barriers and facilitators that adults with depression experience when engaging in physical activity.10 Important barriers identified were lack of motivation, fatigue, and low mood. Important facilitators were others’ attitude, emotional support, and ongoing support for the exercise itself. The second review helped to understand the barriers and facilitators that healthcare providers, who work with adults with mental illness, experience when promoting physical activity in practice.12 Key barriers identified were those of the clients (e.g., symptoms of their clients’ mental illness) and a lack of resources.

Phase two: Interviews with stakeholders

Phone and in-person interviews were conducted with potential end users of the toolkit, including a variety of Canadian healthcare providers who have experience working with adults with depression. Interviews were also conducted with the toolkit’s target population of Canadian adults with a self-reported diagnosis of depression. Interviews identified needs, content, and format preferences for the toolkit. Desired format preferences led to the decision to have the toolkit available online as a downloadable PDF that can either be used online or printed.

Phase three: Expert panel meeting

A multidisciplinary panel of 12 experts (comprised of healthcare providers, adults with depression, exercise professionals, and physical activity and mental health researchers) appraised the evidence from phases one and two to generate content, format, and distribution recommendations for the toolkit.

Phase four: Toolkit development

The toolkit was written and created in collaboration with a graphic designer. This was based on the two scoping reviews,10,12 desired content from the interviews with adults with depression and healthcare providers, and the panel meeting recommendations.

The Exercise and Depression Toolkit

There are three parts to the toolkit (three PDF documents). The first is the Introduction document for healthcare providers who work with adults with depression guided by the second scoping review and the important barriers healthcare providers identified to promoting physical activity.12 This document explains how the toolkit was developed, relevant evidence and literature, and gives instructions and recommendations on how to use the toolkit.

The second part is the Collaboration document and is meant for a clinician and client to use together. More specifically, these pages (1-4) follow the order of a potential collaborative treatment decision-making process. This document includes education pieces for a client, as well as prompts with questions for a healthcare provider to ask and have their client or patient answer. This document is to help guide a conversation for a collaborative person-centered approach to considering the treatment of exercise and the reality of what that might look like for someone with depression.

The third part of the toolkit is the Action Materials. These materials are client handouts for the healthcare provider to distribute, and they may be used independently or in collaboration with the provider. These handouts are strategies or actions that an individual can take to help overcome barriers to engaging in physical activity or exercise. This part of the toolkit has five handouts. The first is a Mood and Activity Diary for an individual to track their physical activity and mood throughout a week. The second is SMART goal setting to help set goals around exercise and physical activity. The third is a Weekly Schedule to assist with planning a week of activity. The fourth is Individuals with Lived Experience, which has quotes from Canadian adults about their positive experiences with exercise. The final handout provides Positive Statements to help an individual write encouraging, personal sayings about engaging in activity and exercise. Other existing behaviour change resources such as the Centre for Active Living’s Physical Activity Counselling Toolkit could also be used in tandem with the Exercise and Depression Toolkit.

The toolkit is available for free at: www.exerciseanddepression.ca. To download the toolkit, registration will be required to track the professional designation of individuals accessing the site and how they found out about the toolkit. A final optional question will request contact details for those interested in providing feedback on the toolkit one month after download. The website’s news blog will include relevant knowledge translation activities related to the toolkit.

Practical implications

We acknowledge that exercise programming and the option to refer to an exercise professional will vary across Canada, and this may pose as a challenge. However, the toolkit gives healthcare providers an evidence-based resource to use in practice to guide and facilitate conversations in considering exercise as a treatment for depression. The toolkit will also help healthcare providers to have general discussions around physical activity promotion. For adults with depression, the toolkit is intended to increase awareness and knowledge of recommendations around exercise as a treatment for depression, and to provide behavioural strategies to overcome barriers to engaging in exercise. We believe that this toolkit is a starting point in helping healthcare professionals integrate evidence-based guidelines into practice and to integrate exercise into health service delivery to improve the lives of the many Canadians living with depression.

Acknowledgements and funding

Thank you to all of our participants who contributed their invaluable time and knowledge to inform the development of the Exercise and Depression Toolkit. This project was funded by a Canadian Institutes of Health Research (CIHR) Foundation Award granted to Dr. Guy Faulkner.


About the Authors

Krista Glowacki s a PhD Candidate at the University of British Columbia in the Population Physical Activity Lab. Her research interests include the relationship between physical activity and mental health. Krista also works as a clinical occupational therapist with adults with mental illness in Vancouver, BC.

Guy Faulkner, PhD, is a Professor in the School of Kinesiology at the University of British Columbia . He is also the primary investigator of the Population Physical Activity Lab and his research broadly looks at the development and evaluation of physical activity interventions and health at a population level. Guy is also a Canadian Institutes of Health Research-Public Health Agency of Canada (CIHR-PHAC) Chair in Applied Public Health.


References

  1. Mental Health Commission of Canada. Making the case for investing in mental health. https://www.mentalhealthcommission.ca/sites/default/files/2016-06/Investing_in_Mental_Health_FINAL_Version_ENG.pdf. Published March 2017. Accessed July 29, 2019.
  2. World Health Organization. Mental disorders: depression. World Health Organization. https://www.who.int/mental_health/management/depression/en/. Updated April 2017. Accessed July 29, 2019.
  3. Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev. 2013(9):CD004366. doi: 10.1002/14651858.CD004366.pub6.
  4. Krogh J, Hjorthoj C, Speyer H, Gluud C, Nordentoft M. Exercise for patients with major depression: a systematic review with meta-analysis and trial sequential analysis. BMJ Open. 2017;7(9):e014820. doi: 10.1136/bmjopen-2016-014820.
  5. Morres ID, Hatzigeorgiadis A, Stathi A, et al. Aerobic exercise for adult patients with major depressive disorder in mental health services: a systematic review and meta-analysis. Depress Anxiety. 2019;36(1):39-53. doi: 10.1002/da.22842.
  6. Schuch FB, Vancampfort D, Rosenbaum S, Richards J, Ward PB, Stubbs B. Exercise improves physical and psychological quality of life in people with depression: a meta-analysis including the evaluation of control group response. Psychiatry Res. 2016;241:47-54. doi: 10.1016/j.psychres.2016.04.054.
  7. Abu-Omar K, Rutten A, Burlacu I, Schatzlein V, Messing S, Suhrcke M. The cost-effectiveness of physical activity interventions: a systematic review of reviews. Prev Med Rep. 2017;8:72-78. doi: 10.1016/j.pmedr.2017.08.006.
  8. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 1985;100(2):126-131.
  9. Ravindran AV, Balneaves LG, Faulkner G, et al. Canadian network for mood and anxiety treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 5. complementary and alternative medicine treatments. Can J Psychiatry. 2016;61(9):576-587. doi: 10.1177/0706743716660290.
  10. Glowacki K, Duncan MJ, Gainforth H, Faulkner G. Barriers and facilitators to physical activity and exercise among adults with depression: a scoping review. Mental Health and Physical Activity. 2017;13:108-119. doi: 10.1016/j.mhpa.2017.10.001.
  11. Glowacki K, Arbour-Nicitopoulos K, Burrows M, et al. It’s more than just a referral: development of an evidence-informed exercise and depression toolkit. Mental Health and Physical Activity. 2019; in press.
  12. Glowacki K, Weatherson K, Faulkner G. Barriers and facilitators to health care providers’ promotion of physical activity for individuals with mental illness: a scoping review. Mental Health and Physical Activity. 2019;16:152-168. doi: 10.1016/j.mhpa.2018.10.006.

September 2019, Volume 30, No. 09


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