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Body to mind: physical activity for mental health

Body to mind: physical activity for mental health. Presented by: Louise Daw PARC Consultant Physical Activity Resource Centre louise@ophea.org 519.646.2121. Special thanks to.

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Body to mind: physical activity for mental health

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  1. Body to mind:physical activityfor mental health VISITwww.ophea.net/parc

  2. Presented by: Louise Daw PARC Consultant Physical Activity Resource Centre louise@ophea.org 519.646.2121 VISITwww.ophea.net/parc

  3. Special thanks to Kari Ala-leppilampi, MHSc, PhD candidate, University of TorontoResearch Analyst, Centre for Addiction & Kari Ala-leppilampi, The Mental Health Gym Inc. Personal training for individuals & organizations‘Physical Exercise for Mental Health Issues,Addiction Treatment & Peak Professional PerformanceMental HealthPTS, IMWC, BM VISITwww.ophea.net/parc

  4. The Physical Activity Resource Centre (PARC) PARC is part of the Ontario Health Promotion Resource System (OHPRS) Managed by Ontario Physical Health and Education Association (Ophea) VISITwww.ophea.net/parc

  5. PARC services • Responding to requests for information • Referrals • Consultations – email, phone & face to face • Training to Physical Activity Promoters • Annual Conference • Adaptable Workshops • Quarterly mailings • Theme PARC VISITwww.ophea.net/parc

  6. Join our listserv! Here’s how: http://www.ophea.net/parc/listservsubscription.cfm VISITwww.ophea.net/parc

  7. Outline • Prevalence & cost of mental illness • Why is physical activity a logical “fit”? • The present state of physical activity – research,policy and practice • Promising research findings : depression, anxiety, severe and persistent mental illness • Compelling explanations & practical implications VISITwww.ophea.net/parc

  8. Connection to mental health and physical activity • Prevention of poor mental health • Improvement in mental health • Treatment of mental disorders • Improvement in the quality of life of persons with mental illnesses VISITwww.ophea.net/parc

  9. Prevalence & cost of mental illness A formidable opponent VISITwww.ophea.net/parc

  10. Prevalence of Mental Illness in Canada • ~1/10 people/yr. (2.6 million) presently experience mental illness • rate much higher (18%) among adolescents (15-24 yrs). • 1 in 5 will experience mental illness in their lifetime...those are your odds! (Health Canada) VISITwww.ophea.net/parc

  11. Costs of mental illness • ↓ levels of mental health in general population = ↑ risk for & rates of physical and medical conditions (e.g., stroke, Alzheimer, cancer, obesity) • 5/10 leading causes of death and 5/10 causes of disability worldwide related to MI • 4000 Canadians/yr. commit suicide & 90% with diagnosable mental illness highest amongst adolescents (24% of all deaths) & younger adults (Stats Canada) VISITwww.ophea.net/parc

  12. Costs of mental illness • third highest source of direct health care costs in Canada at $4.7 billion/yr. (Statistics Canada, 2003) • ~75-80% of employee disability claims due to mental illness - fastest growing sector • Canadian economy loses $14.4 and $18.6 billion /yr. in the workplace due to mental illness and substance misuse; total cost $33 billion • burden of disease: MI ranks 2nd in established market economies (e.g., Canada) • contributes more to burden of disease worldwide than all cancers combined VISITwww.ophea.net/parc

  13. Treatment of mental illness in Canada • Psychotherapy & pharmacotherapy • Canada has highest per capita use of psychiatric medications: - overall expenditures risen from $31.4 million (1981) to 543.4 million (2000) to $1.2 billion (2005) VISITwww.ophea.net/parc

  14. Treatment of MI in Canada • treatment for mental illness expensive & often inaccessible (Mood Disorders Society of Canada, 2006) • less than 1/3 of Canadians with mental health or addiction issues will actually seek treatment - accessibility, side effects of drugs - stigma identified as greatest barrier • Need for more accessible, simple and cost effective, long-term options…PHYSICAL ACTIVITY! VISITwww.ophea.net/parc

  15. Why physical activity?: a logical ‘fit’ for policy & practice VISITwww.ophea.net/parc

  16. PA as a good ‘fit’:physical benefit/absence of harm • mentally ill much less active & less physically healthy than general population - contributes to mental illness itself (Mutrie, 2005) • physical activity ↓ risk of several major diseases & physical conditions associated with MI • In case of Phyiscal activity programs for mental illness:-significant physical health benefits (e.g., fitness, strength) shown as quickly as a matter of weeks - greatest benefit often to those with most severe baseline MI - No reported physical or psychological harms negligible risks (injury, dependence) with screening VISITwww.ophea.net/parc

  17. Can stop right here! • Sufficient support to implement based on potential for quick physical health benefits, which outweigh harms, for those most in need • might improve mental health, but will likely improve physical health - e.g., perfect ‘one two punch’ to address 1st heart disease) and 2nd (MI) cause of disability and death in the world • could address social injustice terms of addressing existing physical health inequalities VISITwww.ophea.net/parc

  18. PE as a good ‘fit’:accessibility & normalization (vs. stigma) • PE has potential to reach people who do presently have access to or do not wish to access typical treatment - Independent PE, community resources • treatment ends at 5 o’clock but MI doesn’t - running shoes have no office hours & you can take them with you wherever you go • all but the most frail can participate in some way (e.g., walking) • as a normalizing & socially valued option PA may help to overcome the stigma, bridge to treatment or substitute it (e.g., natural recovery) VISITwww.ophea.net/parc

  19. PE as a good ‘fit’: client options & empowerment • expands the limited tx. options available to include several potential activities • In line with people becoming more active players—versus passive recipients—of tx. • ↓ reliance on external resources & ‘experts’ • Can be maintained relatively independently after an initial period of training or supervision VISITwww.ophea.net/parc

  20. PE as a good ‘fit’:addressing problems w/existing treatment • psychotherapy: long time to access & take effect • drug therapy: may be provided & act quickly but - Requires experimentation & (major) side effects - no behavioural changes for long term success - resisted due to ↑ stigma, control & side effects dangers, lethargy, altered state, wt. gain • Can take part in PE now--with no side effects—& adopt as long term behavioural strategy • Any perception of risk must be weighed against alternative lack of psychotherapy and side effects of drugs) • PE shown to be equally if not more effective as drugs or psychotherapy respectively • Pharmacological paradox: PA may improve adherence to medication, offset side effects (e.g., wt. gain) and ultimately reduce reliance upon it VISITwww.ophea.net/parc

  21. PE as a good ‘fit’:feasibility/cost effectiveness • reliance upon expensive MH specialists, drugs & the medical system not feasible so desperate need for more options (Raglin, 1997) • PE can involve minimal cost if use proven activities requiring limited resources & support (e.g., run/walk, swim, bike) • existing PE referral schemes shown to be less expensive option than drugs & particularly psychotherapy (Mental Health Foundation, 2005) - 4-5 times more cost effective (Tkachuk & Martin, 1999) • even more relevant in common case of chronic or relapsing conditions - PE as an independent ongoing form of coping or prevention VISITwww.ophea.net/parc

  22. PE as a good ‘fit’:young people • help seeking drops to ~1/4 amongst adolescents, despite experiencing the highest rates of mental illness • Anxiety in particular, can be addressed effectively before it advances to more difficult case of depression • social acceptability of exercise is greater in younger versus older adults (Biddle & Mutrie, 2008) and young may be even more able-bodied • an ‘ounce of [early] prevention’ VISITwww.ophea.net/parc

  23. PE as a good ‘fit’:the aging • fastest growing segment of population • PE related to reduced rate of future depression & effective treatment for it • PE associated with reduced risk of cognitive decline which has been associated with ↑ depression • highest rates of chronic disease that may be addressed through PE… VISITwww.ophea.net/parc

  24. PE as a good ‘fit’: chronic illness • MI associated with chronic diseases that are increasing in general population (e.g., CHD, hypertension, diabetes, arthritis, various pain conditions) & which might be directly prevented or mitgated by PE • even in treatment of chronic illness PE shown to: - reduce severity of symptoms, reduce - Reduce levels of medication, - counteract losses in functional ability - reduce the [resultant] emotional distress that is associated with poor prognosis • PE may address interlocking medical & psychological issues simultaneously/cost effectively, overcome intervention overload & overcome for initial reluctance to address psychological issues VISITwww.ophea.net/parc

  25. PE as a good ‘fit’: people like it and can stick to it • contrary to common belief, participants have positive perceptions of PE & can stick to it like anyone else • identified as (the most) important part of mental health tx. by clients (Martinsen & Medhus, 1989; Martinsen, 1990; Mental Health Foundation, 2005) • low retention rates still comparable to those in sedentary general population - those with major MI may require more support but basic issues often similar • retention within exercise interventions has been equivalent, and even superior to, medication adherence (Stathopoulou et al., 2006; Mental Health Foundation, 2005) VISITwww.ophea.net/parc

  26. PE as a good ‘fit’:public health • troubling trends in physical inactivity in general • holistic (body and mind), positive (e.g., wellness) & preventive (primary or secondary) approach to mental health • logical use of limited PH resources as can have greatest impact on most severely mentally ill & addresses increasing rates of physical & psychological illness simultaneously VISITwww.ophea.net/parc

  27. The present state of PE in the MH system Hurdles to overcome but promising developments VISITwww.ophea.net/parc

  28. Hurdles to overcome • PE still absent &/or viewed as ‘add on/something to do’ vs. integral part of tx. w/special benefits • does not ‘fit’ within existing funding system • not part of academic curriculum • expected resistance within professional establishment threatens knowledge, status, power • too simple • too complex & multifaceted • too experimental (and dangerous!) • too obvious • not walking the talk – role modeling • dualistic thinking still lingers VISITwww.ophea.net/parc

  29. It’s one thing to look after your body, just don’t forget your mind VISITwww.ophea.net/parc

  30. Promising developments • recently embraced by UK gov’t where much of the research has been done- doctors now use exercise as a first line treatment for dep. in special referral scheme • Promising, small group of programs, practitioners & researchers--both in Canada & abroad • growing interest in this area within the public and popularized media • private corporations are also getting into the race… VISITwww.ophea.net/parc

  31. Promising developments • workplace is environment with great number of stressors • ↑ in fitness facilities or subsidies by companies & insurers- Northern Gas Company: 80% fewer sick days amongst those in exercise program - Coca Cola: $500 less in health claims per person in fitness program - employees had more energy, felt better about work, & better able manage time, meet deadlines & interact on days they used company gym (Ratey, 2008) • Such finding also supported by promising findings in the research realm… VISITwww.ophea.net/parc

  32. PE & depression:moving your body to lift your mood “It’s impossible to run and be depressed at the same time” – Johnsgard, 1989 VISITwww.ophea.net/parc

  33. Definition of depression Feelings of sadness, worthlessness, loss of interest in life, lower mood, loss of capacity to experience pleasure, general fatigue etc. May be diagnosed as clinical depression (e.g., DSM-IV criteria) when such feelings interfere with life and ability to function and persist over a long period of time (weeks or months) VISITwww.ophea.net/parc

  34. Prevalence of depression • 5% of Canadians/yr. depressed, comparable to other leading chronic diseases such as heart disease (5%), diabetes (5%) or thyroid condition (5%) • 8% of Canadians will experience major depression in their lifetime…that is your odds! • only 1 in 10 depressed Canadians will actually seek treatment & only about ¼ of those will receive adequate treatment (Dunn, 2005) VISITwww.ophea.net/parc

  35. Cost of depression • associated with presence of 1 or more chronic diseases, disability, days in bed & 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) • depression leads in years lived with disability in world • 4th cause of premature death & disability in world • in <20 yrs., depression will be 2nd leading cause of disability in the world (next to heart disease) VISITwww.ophea.net/parc

  36. PE & depression • Constitutes bulk of research on PE and mental illness • monumental research consensus: there is a causal link between PA and reductions in depression (Biddle, Fox, & Boutcher, 2000; Mental Health Foundation, 2005) • critical mass of studies have supported this consensus by pointing in the same direction on a diversity of related questions… VISITwww.ophea.net/parc

  37. PE & Depression • Are active people less depressed? • Do active people experience less clinical depression? • Can physical inactivity lead to depression? • Can PE prevent depression? • Can PE treat depression? • Can PE compare to traditional treatment? VISITwww.ophea.net/parc

  38. Are active people less(sub-clinically) depressed? • Several large scale cross-sectional population surveys show a negative relationship between a physically active lifestyle and sub-clinicaldepression E.g., study of 3000 adults in NA showed sub-clinical depression to be highest amongst those reporting “little or no activity” (Stephens, 1988) VISITwww.ophea.net/parc

  39. Why is sub-clinical depression even important? • hidden cost to treatment system • Preventive & positive approach- lowering baseline levels = ↓ risk of clinical depression- addressing human cost, even if does not meet criteria VISITwww.ophea.net/parc

  40. Do active people experience less clinical depression? • Several cross-sectional population surveys have shown a negative relationship between PA and clinical depression E.g., in a study of 1536 adults in Bavaria, those who were inactive were 3 times more likely to have clinical depression than those who were regularly active (Weyerer, 1992) VISITwww.ophea.net/parc

  41. Can a lack of PE lead to depression? • From association toward causation: prospective surveys • In a recent review 8 out of 11 prospective surveys have shown that lower PA measured at some prior date (2-30 yrs. earlier) is associated w/ higherrates of clinical depression at follow-up • E.g., In a study of 1500 U.S. residents: - women with “little or no” activity at baseline twice as likely to develop depression over 8 year period - No stat. sign. association for men, but inactivity was a significant predictor of cont’d depression (Farmer et al., 1988) VISITwww.ophea.net/parc

  42. Can PE prevent depression? • A protective role for PA is supported by the weight of the evidence (Biddle & Mutrie, 2008) and particularly multi-point prospective surveys: • E.g., A landmark study of 6000 California residents originally interviewed at baseline (B) in 1965 • 9 yrs. later (F1):- Low activity (LA) at B = higher risk of depression • But 20 yrs. later (F2):-LA at B but moderate/high activity (MA/HA) at F1 = same risk of depression as those MA/HA at both B & F2...protectiveeffect!- MA/HA at F1 to LA at F2 = significant increase in depression VISITwww.ophea.net/parc

  43. Does more PE = more protection? • In prospective surveys, higher levels of PA consistently associated w/ lower risks of clinical depression (Biddle & Mutrie, 2008) • E.g., Study followed men for 23-27 years • Relative to least active group (expending less than 1000 cal./wk at B):- 1000-2499 cal./wk. at B = 17% less likely to develop depression- 2500+ cal./wk. at B were 28% less likely to develop depression (Paffenbarger et al.,1994) VISITwww.ophea.net/parc

  44. Can PE treat depression? • number of reviews and meta analysis (i.e., quantitative synthesis’) of exercise intervention studies show that PA: - is a very effective treatment for clinical depression, particularly for moderate-severe forms (vs. mild-moderate) - results in less substantial but still significant reductions in sub-clinical depression (Biddle & Mutrie, 2008) • greatest impact on depression amongst those with lowest initial levels of physical & psychological health (North et al., 1990) • research on uni-polar (not manic) depression/ bipolar disorder VISITwww.ophea.net/parc

  45. Can PE compare to traditional treatment? • One meta analysis & reviews of exercise interventions have suggested they can be at least as effective as traditional treatment: • E.g., “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”(Johnsgard,1989) VISITwww.ophea.net/parc

  46. PA vs. psychotherapy E.g., Klein et al. (1985) VISITwww.ophea.net/parc

  47. PA vs. medication E.g., Blumenthal et al. (1999) • In landmark study, 156 outpatients with MDD randomized to: 1) (aerobic) exercise b) drugs (SSRI: Zoloft); c) combined treatment.: exercise & drugs At the end of the 4 month intervention: • significant & equivalent reductions in depression (and remission) in all groups, despite the more immediate initial impact of drug treatment At 6 month followup: • lower rate of depression amongst exercisers in comparison to drug & combination treatment groups • amongst treatment remitters, exercisers had lower rates of relapse than those in drug or combined treatment groups VISITwww.ophea.net/parc

  48. PE as a monotherapy or complimentary • PE can clearly serve as a stand alone treatment for depression—and as some studies would suggest anxiety– versus combining it with traditional treatment such as drugs and/or psychotherapy • Ongoing support as adjunct might be explained by: - caution particularly in case of more severe or complicated cases - the aggregate evidence to date - medication to simply get going - talking therapy to ultimately get at underlying issues or cognitions that aren’t necessarily going to go away - a lack of integration thus far between psychotherapy and PE within research despite some in practice… VISITwww.ophea.net/parc

  49. Enhancing psychotherapy: PE as a team player? • enhanced mood & malleability • logical extension of cognitive benefits, life lessons, metaphors • Integral part of therapy or therapeutic encounters for depression or anxiety • compelling support in clinical accounts: Side by side conversation (in contrast to face-to-face therapy) seems to elicit more candor; the movement together with the informal nature of the activity, seems to break down the barriers & facilitate greater emotional release (Kendzierski & Johnson, 1993) VISITwww.ophea.net/parc

  50. Is there a PA ‘dosage’?: • No firm answer as patient/condition specific: “some exercise is good, more is better (to a point)” (Ratey, 2008) • 2 key studies support this & do provide general guidance: • Study 1: High int. (80% max load) PRT led to sign. & subst. red’n in clinical dep. among older randomized adults(>60 yrs.) whereas low int. (20% maximum load) did not, in comparison to ctls: 61%, 29% & 21% respectively (Singh et al., 2005) VISITwww.ophea.net/parc

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