Running through your mind:

1. Running through your mind: The potential role of exercise within the mental health and addictions field

2. Kari Ala-leppilampi, MHSc, PhD. Candidate, PTS, BM, IMWC • MHSc., health promotion/addictions • PhD. Candidate, Health & Behavioural Sciences/Addictions, University of Toronto • Research analyst at the Centre for Addiction and Mental Health • CTCRI Project • PhACS Project • Director of the Don River Run for Recovery • Founder and Chair of the Fitness In Treatment Research and Advisory Panel (FITRAP) • Certified Personal Training Specialist (PTS) • Most importantly perhaps: • A person who happens to manage mental health and addiction issues • Competitive runner and triathlete (BM, IMWC)

3. Presentation Outline • Mental Health and Physical Exercise • Depression • Anxiety • Schizophrenia • Addictions and Physical Exercise • Alcohol misuse

4. Mental health & Physical Exercise (PE) • Prevalence and costs of Mental Illness • PE & Depression • PE & Anxiety • The Potential Mechanisms of PE • PE as a natural ‘fit’ within contemporary practice • Revisiting pharmacological treatment • Challenges to implementing PE into practice

5. Prevalence and Costs Mental Health Disorders In Canada In a 12 month period: • 1/10 Canadians, or about 2.6 million people, report alcohol or illicit drug dependence or one of the five common mental health disorders • Depressing and stressful facts about depression and anxiety: • 4.9% report some form of mood disorder (4.5% major depression) • 4.7% report some form of anxiety (3% for SAD) • and 3% report substance misuse (2.6% for alcohol and 0.7% for illicit drugs) • As many Canadians suffer from major depression as from other leading chronic conditions, including heart disease (5%), diabetes (5%) or a thyroid condition (6%) • In 1998, mental disorders were the third highest source of direct health care costs at $4.7 billion (Statistics Canada, 2003)

6. Canadian Community Health Survey (Statistics Canada, 2003)

7. Definitions • Major depressive episode — at least one episode of 2 weeks or more with persistent depressed mood and loss of interest or pleasure in normal activities, accompanied by problems such as decreased energy, changes in sleep and appetite, impaired concentration, and feelings of guilt, hopelessness, or suicidal thoughts. • Manic episode (mania) — at least one period of a week or longer with exaggerated feelings of well-being, energy, and confidence or irritable mood during which a person can lose touch with reality. Symptoms of mania include: flight of ideas or racing thoughts; inflated self-esteem; decreased need for sleep; talkativeness; and irritability.

8. Definitions (cont’d) • Panic disorder — repeated and unexpected attacks of intense fear and anxiety where at least one of the attacks has been followed by 1 month or more of persistent concern or worry about having another attack or its physiological manifestations such as Palpitations, chest Pain, feelings of smothering or choking, dizziness, sweating, nausea or abdominal distress, trembling, and hot flushes or chills. • Social phobia — persistent, irrational fear of social or performance situations in which the person may be closely watched and judged by others, as in public speaking, eating, or working. The fear is recognized by the person as excessive or unreasonable. The avoidance, anxious distress in these feared situation (s) interferes significantly with the person’s everyday activities. • Agoraphobia — fear and avoidance of being in places or situations from which escape might be difficult, or in which help may not be available. Feared situations include being outside the home alone, being in a crowd or standing in a line, being on a bridge, and traveling in a bus, train or automobile. The situations are avoided or endured with marked distress or with anxiety about having a Panic attack or Panic-like symptoms.

9. Definitions (cont’d) Profiled substance dependence within the 12-month period prior to the survey: • Classification as alcohol or illicit drug dependent — based on sets of questions which examine aspects of drug tolerance, (for example, needing more to have an effect), withdrawal, loss of control, and social or physical problems related to alcohol or illicit drug use in daily life. The information collected on these two types of substance dependence provides a profile of behaviours of alcohol and illicit drug use which lead to clinically significant impairment or distress. • Any mental disorder or substance dependence: Respondents were classified as having “Any mental disorder or substance dependence” if the pattern of answers met the criteria for at least one of the five mental disorders or two substance dependencies covered in the survey (i.e. major depressive episode, manic episode, panic disorder, social phobia, agoraphobia, alcohol dependence, or illicit drug dependence).

10. Mental Health Disorders as a Major and Growing Worldwide Issue • Mental illness, including suicide, ranks second in the burden of disease in established market economies such as U.S. (United States department of Health and Human Services, 1999) and Canada • 5/10 leading causes of disability in the world are related to psychiatric disorders • In less than 20 years depression will be the second-leading cause of disability in the world (WHO cited in Statistics Canada, 2003)

11. Help seeking and Treatment • Less than half (32%) of Canadians with mental health or addiction issues over the past 12 months will seek treatment • Despite higher prevalence rates among young adults (15-24 yrs.), help seeking is even lower within this group as only one quarter seek treatment • Lack of awareness and stigma as major barriers • However, traditional treatment approaches delivered by specialists, or dependence upon health care system in general (Raglin, 1997), unfeasible so a need for multiple options • Traditional treatment generally consists of some form of psychotherapy and/or medication

12. PE and Depression • Definition • Epidemiological evidence • Meta-analysis of interventions • General Review of key studies • Exercise compared to traditional treatment • Exercise prescription • Key Findings

13. Depression • A state characterized by lowered mood, loss of capacity to experience pleasure, increased sense of worthlessness, fatigue and pre-occupation with death and suicide (Strawbridge et al., 2002) • Associated with presence of 1 or more chronic diseases as well as disability, including days in bed and days away from normal activities • Major depressive disorder (MDD) has been associated with a 59% increase in mortality risk during a 1 year follow up (Blumenthal, 1999), but only 23% seek treatment and only 10% receive adequate treatment (Dunn, 2005)

14. Epidemiological Evidence • 3 large longitudinal and prospective survey-type studies, which included both men and women from a broad range of ages, provide strong evidence • While one study only included college men, the other two included men and women from a broad range of age categories • Confounding variables were accounted for in these studies but some may have been overlooked • Association does not equal causation!

15. Farmer et al.(1988) • survey with 1,497 men and women in the U.S. • Women engaging in “little or no” activity twiceas likely to develop depression over 8 year period • No significant association for men, but for those men who were depressed at baseline inactivity was a significant predictor of continued depression

16. Camacho et al. (1991) • Large sample of men and women in California • Low (LA), medium (MA), or high active (HA) in 1965/baseline (B), 9 years later (F1), and 18 years later (F2) • At F1 (1974) : • Relative risk (RR) of developing depression significantly higher for men & women who were LA at B (~1.75) • those who were MA at B also showed lower RR (~1.2) providing some evidence for dose response (Mutrie, 2000)

17. Camacho et al. (1991) • At F2 (1983) • Those LA at B but were active (MA/HA) at F1, had no greater risk of developing depression at F2 than those active at both B & F2 suggesting a potential protective effect (Mutrie, 2000) • No statistically significant difference when considering odds ratios for developing depression in 1983 based upon changes in activity status from B to F1 in four selected categories (L-L, L-H, H-H, H-L) • However, those who relapsed from activity (MA/HA) at F1 to LA at F2, were 1.6 times more likely to develop depression at F3, which was considered a robust finding

18. Paffenbarger et al. (1994) • Harvard alumni study that followed men only for 23-27 years • 3+ hrs. of PE per wk. at B resulted in 27% reduction in risk of developing depression compared to those engaging in less than 1 hr of PE per wk. • Findings suggest that that inactivity precedes depression (i.e., temporality as one condition of causation) • Study also supported dose response relationship with significant findings in this area

19. Paffenbarger et al. (1994) Relative to least active group (expending less than 1000 cal./wk at B • Those expending 1000-2499 cal./wk. at B were 17% less likely to develop depression • Those expending 2500+ cal./wk. at B were 28% less likely to develop depression

20. Epidemiological evidence (cont’d) • Three other community based longitudinal studies were identified that found that PA was not protective for subsequent depression however: • two of these studies only considered middle age males (Cooper-Patrick et a., 1997; Lennox et al., 1990) • Such results could be attributed to (Weyerer 1992): • cultural factors (first foreign study identified) • the fact that it only included exercise occurring during sports (i.e., thus failing to capture activities such as walking or jogging • The fact that it had a much shorter follow up period than the other studies

21. Epidemiological evidence (cont’d) • The third study, consisting of 1536 men and women from Bavaria did, however, find supportive cross sectional data: • Relative to those who were not active, those who were regularly and occasionally active were 3.5 and 1.5 times less likely to be depressed, also providing some support for a dose response relationship

22. Meta-analyses of intervention studies • Four meta-analyses of PE interventions have provided substantial evidence based on “effect size” which suggest that exercise does have an anti-depressant effect (Mutrie, 2000) • Other meta-analyses have suggested that results from interventions have been inconsistent and inconclusive due to serious methodological problems (Strawbridge et al., 2002; Lawlor & Hopker, 2001). • However, positive results were also found within one meta analysis of 30 studies focused exclusively on clinical populations (Craft & Landers, 1998) and in contrast, two others which included studies that measured depression as a more transient mood state (Biddle, 2000)

23. Selected general reviews of intervention studies • Given limitations within meta-analytic methods, a qualitative/narrative discussion of specific intervention studies may be an alternative • Yet, a number of general reviews to date have provided positive, albeit cautious conclusions regarding the anti-depressant effects of PE (Mutrie, 2000)

24. Selected general reviews (cont’d) • PE can be a beneficial anti-depressant both immediately, as in the case of alleviating transient depressive moods, and in the long term • Even within clinical populations, anti-depressant effects can occur in a relatively short time frame (4-8 weeks) and persist for some time (2 months to 1 year)

25. Selected general reviews (cont’d) • positive conclusions have been drawn within reviews of studies with clinical populations (Martinsen, 1989,1993,1994; Mutrie, 2000) and sub clinical populations (Biddle, 2000) • PE is most effective in reducing depression in the most physically and psychologically unhealthy individuals at the start of a program • PE is equally effective for both genders, although some evidence suggests that increasing age results in increasing benefit in terms of anti-depressant effects

26. Selected general reviews (cont’d) • Reviews have shown that both aerobic (e.g., walking, running) and anaerobic (e.g., weightlifting) PE have equivalent reductions in depression within clinical and non-clinical populations • The longer the program and the greater the number of exercise sessions, the greater the antidepressant effect

27. Selected general reviews (cont’d) • The external validity of the relationship between PE and reduced depression has been suggested by the fact that general reviews have not only arrived at similar conclusions, but have found positive results within studies conducted within various contexts and populations across North America & Europe • Internal validity of this relationship has been reinforced by the most recent review of 10 studies which all had to meet criteria for both clinical depression and methodological rigor • This most recent general review has concluded that there is an adequate case for causation, based on the epidemiological evidence, its review of interventions that met strict criteria regarding clinical depression and methodological rigor and the general criteria for causation (Mutrie, 2000) • While causation has gained some acceptance, others applying similar criteria have been less convinced & others have questioned it on the basis of methodological limitations of existing studies and a lack of evidence for clinical outcomes (Faulkner, 2000).

28. PE compared to Traditional Treatment Summary of research findings: • RCTs assigning depressed patients to individual exercise therapy, vs. psychiatric therapy, vs. meditation or yoga, vs. individual antidepressant drug therapy, or vs. combined exercise and drug therapy found: • That exercise is just as effective as traditional treatments leading to equivalent improvements • Mixed results whether exercise should be implemented as a stand alone treatment or an adjunct to psychotherapy and drug treatments, especially among individuals with major depression

29. PE compared to Traditional Treatment Greist et al. (1979) • 28 unipolar depression (i.e., without melancholic and psychotic features and generally referred to as mild to moderate forms of depression) patients assigned to running therapy, time limited individual psychotherapy or time unlimited psychotherapy • Running group had equivalent reductions in depression at 10 wks., 1mth., & 3 months. • Although a classic highly referenced study, would not meet today’s methodological requirements for publication

30. Klein et al. (1985) • Randomly assigned 74 participants with unipolar depression to • individual running therapy • individual meditation-relaxation for similar body awareness and mastery (i.e., minus aerobic aspect) • group breathing exercises an yoga for relaxation • or semi-structured group therapy with elements of interpersonal and cognitive therapy • participants in each treatment showed decreased depression at termination

31. Klein et al. (1985)

32. Johnsgard (1989) • In general this review of studies concluded that: “the magnitude of change which results from exercise therapy by itself is as great as that associated with a variety of standard group and individual psychotherapies, some of which, in turn, have been shown to be as effective as antidepressant drug therapy”

33. Blumenthal et al. (1999) • important and well designed RCT conducted after reviews • In a 4 month study at Duke University, 156 outpatient men and women (aged 50+) with major depressive disorder were assigned to: • Aerobic exercise (3 times per wk., 30 min., 70% VO2 max) • Antidepressants (Zoloft) • Aerobic exercise & antidepressants • all three groups experienced significant improvements which were not significantly different from one another

34. Blumenthal et al. (2000) • One measure of depression did not vary at 10 months (i.e., 6 months after original 4 month intervention) • A measure of DSM-IV diagnosis for major depressive disorder (MDD) found that the PE only group exhibited lower rates of MDD at 10 months than both the medication and medication and PE group • In the case of those participants in remission after 4 months, those in the PE group were less likely to relapse at 10 months than those in both the medication and surprisingly, the medication and PE group • Conclusion that modest exercise can be an effective treatment for those with MDD and that benefits likely to endure among patients who PE as a regular ongoing life activity

35. Dunn et al. (2005) • important and well designed RCT conducted after reviews • In a 12 week study, 80 men & women (age = 20-45 yrs.) with MDD were randomized into • Run or bike exercise group that met public health dosage (PHD) recommendations for weekly PE in terms of kcal/kg/week • Run or bike exercise group that exercised at less than half of the PHD • One control/placebo group that took part in mild flexibility exercises • While frequency was also divided into 3 versus 5 times per week in a 2x2 design, it ultimately had no effect on outcomes

36. Dunn et al. (2005) • PA conducted according to public health recommendations was just as effective in reducing depression amongst those with mild to moderate MDD as traditional treatments such as psychotherapy or medication • PA conducted at less than half of the PHD was no more effective than the control/placebo group

37. PE compared to Traditional Treatment (cont’d) • Based upon their findings, Dunn et al. (2005) suggested that PE might be used as an effective stand alone treatment for mild to moderate MDD, a position that also seemed to find support in the surprising fact that Blumenthal et al.(2000) did not find that medication provided any additive effect • Despite such findings, reviews suggest that the greatest anti-depressant effects come as a result of using exercise as an adjunct--rather than a stand alone intervention--particularly in the case of those suffering from severe forms of major depression (e.g., psychotic) who are described as still requiring standard treatment (e.g., psychotherapy, medication) and as potentially having less to gain from PA (Morgan, 1997).

38. Qualitative research: revealing complexities RCT research has been criticized for: • Its focus on circumscribed sets of questions/issues related to outcome, rather than process, and to efficacy rather than practical effectiveness • A lack of attention to complex mechanisms and dynamics of change • A reliance upon (motivated) volunteers have been identified as specific weaknesses • A lack of attention on individual and contextual differences Qualitative research has been presented as a means of addressing these weaknesses

39. Faulkner & Biddle (2004) • Explored the motives and barriers to PA experienced by clinically depressed participants • examined the role of PA in promoting psychological well-being in the context of the qualitative narrative/story of participants’ lives • Longitudinal case study approach to capture complexities • 6 individuals interviewed at five different points over the course of a year—before, during and after a tailored PA intervention--using semi-structured interview • common themes only after presenting overall narratives/stories of three representative typologies of participants

40. Faulkner & Biddle (2004) • Three representative typologies • The initial enthusiast: Terry • The slow starter: Laura • The regular: Dave

41. Faulkner & Biddle (2004) • Some general themes: benefits • Lay people develop complex theories regarding the cause and cure of mental health which have important implications in terms of offering a rationale for PA • Individuals not only point to different motivation for participating in PA and different outcomes that may impact upon their mental health, but may give different weights to these • When there is a congruence between outcomes and initial motives, psychological benefits may be more likely

42. Faulkner & Biddle (2004) • Some general themes: barriers • For the most part barriers identified do not differ from those that have been identified in the literature with respect to the general population (e.g., perceived inadequacies, lack of time, motivation, availability) • Lethargy common symptom of depression that sometimes can not be overcome, despite awareness regarding the benefits of PA • Missing PA often accompanied by guilt

43. Faulkner & Biddle (2004) • Some general themes: life events • Life events may influence PA levels as well as mediate any changes in psychological benefits • Key conclusions • Need to consider association between impact of PA and wider context of peoples lives which entails broader consideration of environmental, interpersonal and intrapersonal factors • Relationships are likely to be complex and highly idiosyncratic • This does not undermine existing research, but if such complexities are not incorporated claims such as those regarding the causative role of exercise in alleviating depression could be considered naive

44. PE and Anxiety • Some definitions • Effects of acute and chronic exercise on stress reactivity • Effects of acute exercise on state anxiety • Effects of chronic exercise on trait anxiety

45. Some definitions • Stress • The whole process by which we perceive and respond to events/”stressors” we appraise as threatening or challenging • May have positive or negative effect on us and our health (Myers, 1986) • Anxiety • An unpleasant emotional state reflecting a negative cognitive appraisal(of a “stressor”) and typified by worry, self doubt apprehension, dread, distress and uneasiness • An emotional response to stressors, including feelings, cognitions, and physiological changes (Spielberger in Hays, 2004) • Measured through physiological indicators, observational methods or self report measures/instruments • Can have serious consequences for health--even amongst otherwise healthy individuals--as a result of impact upon daily functioning (examination failure, accidents, social isolation), contribution to chronic disease (e.g., cardiovascular) and even suicide (Morgan, 1997; Taylor, 2000) • State Anxiety: transient condition that can fluctuate rapidly within a few seconds to a number of minutes • Trait Anxiety: a general tendency toward anxiety proneness

46. Effects of acute & chronic exercise on reactivity to stress • Reactivity to stress may be important to consider given its potential to contribute to fatigue, health conditions (e.g., high blood pressure), and unhealthy behaviours (e.g., smoking, drinking) as coping mechanisms • Both chronic and acute exercise have been shown to reduce short term reactivity to and to enhance recovery from psychosocial stressors • e.g., making a public speech after a bout of exercise and short rest led to less of an increase in systolic and diastolic blood pressure during this typical psycho-social stressor, in comparison to a non-exercising control (Rejeski et al., 1992) • Drawing conclusions regarding chronic exercise has been complicated, however, by the diversity of training programs studied

47. Effects of acute exercise on state anxiety • Change in state anxiety have usually/logically been studied in context of acute exercise, which generally refers to single sessions of PA • It has been shown that single sessions of PA can result in reductions in trait anxiety and, in particular, that of an aerobic rhythmic type conducted at low to moderate intensity • In contrast, resistance training has not been shown to have an effect (Petruzzello in Hays, 2004; Taylor, 2000) • Evidence has generally suggested that high intensity aerobic exercise has a negligible, or even deleterious impact upon state anxiety, but a well designed study has recently challenged that conclusion (Cox et al., 2004)

48. Effects of acute exercise on state anxiety • Cox et al. (2004) • A study involving 24 active women (18-45 years) randomized into non-exercise group, a moderate PE group (one 60% VO2 max. session) and a high intensity (one 80% VO2 max. session) group

49. Effects of chronic exercise on trait anxiety • As trait anxiety does not usually change in response to transient stressors, changes in it have generally/logically been studied in response to chronic exercise, which generally refers to longer- term PA programs consisting of multiple sessions • Studies fairly consistently show that a program of chronic exercise will result in reductions in trait anxiety and although there are limited comparisons available, evidence suggests that it may be in the same order as medication-free anxiety treatments (e.g., relaxation training) • Trait anxiety reducing effects are not dependent upon changes in physical fitness although PA appears to have the greatest impact upon trait anxiety when it is at least 10 weeks in duration

50. Effects of chronic exercise on trait anxiety • Chronic exercise has successfully reduced trait anxiety within a wide variety of clinical and non-clinical settings: and for a diverse range of sub-groups within the population: • male and female, • active and inactive, • healthy and unhealthy (e.g., cardiac rehabilitation, cancer, coronary obstruction pulmonary disease, cancer), • anxious and non-anxious, and • within those with a variety of mental disorders including clinical level anxiety • Despite early recommendations discouraging exercise interventions for those with anxiety related disorder on the basis that it might cause harm as through inducing “panic attacks” (Pitts & McClure 1967) general reviews with clinical populations have concluded no significant health risks or problems have been identified in the research (Morgan, 1997)