Treating depression places a huge burden on GPs and primary care staff – up to 30 per cent of consultations relate to a mental health problem1, and depression is the most common mental disorder found in community settings.2
For several decades, the standard firstline treatment response to depression in primary care has been medication. However, in recent years, scientists, regulatory bodies and clinical guidelines have questioned the wisdom of prescribing antidepressants in some circumstances, especially to people with mild depression.
As well as troublesome side effects and withdrawal symptoms, research shows that in some people, certain antidepressants can increase the risk of self-harm and suicide.3,4
Guidance for clinicians published by the National Institute For Clinical Excellence in December 2004 states that:
“Antidepressants are not recommended for the initial treatment of mild depression, because the risk-benefit ratio is poor.” 5
This has created a dilemma for many practitioners. Faced every day with people desperate for help, there seem to be few options.
New research by the Mental Health Foundation shows that GPs would like greater access to alternatives, but that there are shortages of, or there are long waiting lists for, psychological treatments.6 According to this research:
57 per cent of GPs believe antidepressants are prescribed too often.
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 done so because a suitable alternative was not available.
However, there is a well-evidenced treatment for depression that is currently underused in primary care. That option is exercise therapy, and it is increasingly available through organised referral schemes.
The following information explains how exercise therapy can help people with depression and answers frequently asked questions about exercise referral schemes.
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There is a substantial body of evidence to show a causal link between physical activity and reduced clinically defined depression7, and comparative studies have demonstrated that exercise can be as effective as medication or psychotherapy.8
Exercise has been associated with:
According to the National Institute For Clinical Excellence:
“For patients with depression, in particular those with mild or moderate depressive disorder, structured and supervised exercise can be an effective intervention that has a clinically significant impact on depressive symptoms.” 10
In view of this, there are several reasons for using exercise therapy as a first-line treatment in primary care:
Exercise has far fewer negative side effects than antidepressants – indeed, it has a number of co-incidental benefits, including reduced risk of heart disease, stroke, high blood pressure, some cancers, type 2 diabetes, osteoporosis and obesity.11
Exercise can be used to treat patients who have a mix of physical and mental health problems – it is a holistic care option.
Exercise is a sustainable behaviour change. Once the exercise habit is learned, it can be integrated to form part of an overall healthy lifestyle.
Exercise does not carry the stigma sometimes associated with medication or counselling.
Exercise is a popular treatment– in one survey, 85 per cent of people with mental health problems who used exercise as a treatment said they found it helpful.12
Exercise can give patients a sense of power over their recovery, which in itself counteracts the feelings of hopelessness often experienced in depression.13
According to the Chief Medical Officer:
“Physical activity is effective in the treatment of clinical depression, and can be as successful as psychotherapy or medication, particularly in the long term.” 14
In its guidelines for treating depression, the National Institute For Clinical Excellence recommends that:
“Patients of all ages should be advised of the benefits of following a structured and supervised exercise programme of typically up to three sessions per week of moderate duration (45 minutes to one hour) for between 10 and 12 weeks. 15
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The first exercise referral schemes were set up in the 1980s, and it is estimated that 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 heart disease, diabetes, obesity, hypertension and other physical conditions which might be improved by taking more exercise.
Schemes can also take referrals for patients with mental health problems, usually depression and anxiety. However, research by the Mental Health Foundation shows that of those GPs who know they have access to an exercise referral scheme, only 15 per cent of these use it ‘very frequently’ or ‘fairly frequently’ for their patients with depression.17
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Exercise referral schemes operate in a variety of forms, often involving a partnership between primary care trusts and local leisure services.
In most cases, the GP or practice nurse can refer patients who fit the referral criteria by filling in a form that is then sent to the scheme’s organisers. The forms are usually straightforward and easy to fill in, asking only for a few details about the patient’s medical history, the reason for referral and their contact details.
Once the patient has been referred, the scheme organisers will make contact with him or her, and arrange an initial consultation with an exercise professional (someone who has been trained specifically in dealing with exercise referral populations). They will make a detailed assessment of their fitness for exercise and develop with them an individual activity plan.
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.
The patient will then be given free or discounted access to a range of leisure facilities for a period of time (usually 3 or 6 months).
These facilities may include:
Throughout the period of the referral, the responsibility for the patient’s exercise programme rests with the scheme. Referral officers will continue to provide support, motivation and advice to the patient throughout the duration of the programme, and there are follow-up interviews at key points to monitor how he or she is getting on.
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Q: My depressed patients are often unfit and lacking in motivation.Will they be able to adhere to a programme of exercise?
A: It is true that exercise therapy requires willingness on the part of the participant. However, treatment completion rates for exercise referral schemes are often much higher than for medication18, and exercise has been found to be one of the most popular treatments among patients.19,20,21
While the Mental Health Foundation believes that all patients ought to be offered exercise referral, no patient should be referred unless they are willing to undertake an exercise programme. Once they have been referred, patients will be given an individually-tailored programme to suit their fitness and motivation levels.
Q: In a busy medical practice,won’t referring patients for exercise be very time-consuming?
A: No. The referral process is quick and straightforward, and because exercise therapy involves referring patients to other qualified professionals, it enables GPs and health practitioners to share the burden of managing patients’ care plans.
There may also be incentives for referring – some GPs operating under the 2004 General Medical Services contract may be able to receive points for referring patients to exercise referral schemes.
Q: How does exercise therapy work?
A: There are several theories about why exercise is beneficial to mental health. These are related to:
A: There are several theories about why exercise is beneficial to mental health. These are related to:
biology (exercise leads to an increased release of endorphins and enkephalins)
sociology (attendance enables people to build new relationships)
skillmastery (exercise improves body condition and creates achievable goals)
distraction (exercise creates a diversion from a preoccupation with negative thoughts).22
Also, whereas some treatments can reinforce the sense of being a passive recipient of care, exercise can create a sense of personal robustness, and of being ‘normal’ and ‘healthy’. As an additional treatment response option, it increases the choices open to both patient and prescriber, maximizing the chances of improvement.
Q: Am I responsible if a patient is injured or becomes ill while participating in an exercise referral scheme?
A: No. According to the National Quality Assurance Framework on Exercise Referral Systems:
A: No. According to the National Quality Assurance Framework on Exercise Referral Systems:
“When the individual is specifically referred for exercise by the health practitioner, responsibility for safe and effective management, design and delivery of the exercise programme passes to the exercise and leisure professionals.” 23
The healthcare practitioner’s responsibility is to retain overall clinical responsibility for the patient, and, with the patient’s consent, to transfer relevant medical information to the exercise professional carrying out the assessment. Once this information is received, the responsibility for the patient lies with the scheme’s staff.
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 benefit for depressed patients engaging in exercise therapy.24
Both the Chief Medical Officer and the National Institute For Clinical Excellence have acknowledged the results of these studies in their publications, and the 2004 government white paper, Choosing Health, states that:
“Regular physical activity reduces the risk of depression and has positive benefits for mental health, including reduced anxiety, enhanced mood and self-esteem.” 25
Q: How do I find out more about referral schemes for my patients with depression?
A: Exercise referral schemes are usually delivered through a partnership of primary care organisations and local leisure services.
Although not all GPs have access to a scheme, their numbers are growing. Contact the health promotion team at your local primary care trust to find out about referral schemes in your area and their ability to take patients with depression.
Q: How can I help my patients to understand the treatment?
A: The Mental Health Foundation has produced a leaflet on exercise referral for patients.
References
1 Norwich Union (2004) Health Of The Nation Index
2 National Institute For Clinical Excellence (2003) Depression, Nice Guideline, Second Consultation London: NHS p13
3 Lynch T. (2004) Beyond Prozac: Healing Mental Distress Llangorran: PCCS pp71-2
4 Healy D.,Whitaker C. (2003) Antidepressant And Suicide: Risk-Benefit Conundrums Journal Of Psychiatry And Neuroscience Vol 28 (5) p331
5 National Institute For Clinical Excellence (2004) CG23 Depression: Management Of Depression In Primary Care – NICE Guidance London: NHS p5
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
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)
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 And Its Relationship To Health, London: Department Of Health p58
9 Biddle S., Fox K., Boutcher S. eds (as in no 7) pp154-158
10 National Institute For Clinical Excellence (as in no 2) p72
11 Department of Health (as in no 8) p58
12 National Schizophrenia Fellowship, Mind, Manic Depression Fellowship (2000) A Question Of Choice London: NSF/Mind/MDF p30
13 See Mental Health Foundation (as in no 6) p25-27
14 Department of Health (as in no 8) p58
15 National Institute For Clinical Excellence (as in no 5) p15
16 Mental Health Foundation (as in no 6) p31
17 Mental Health Foundation (as in no 6) p28
18 Mental Health Foundation (as in no 6) p37
19 Mind (2001) Latest Mind Survey Provides Good News: Press Release London
20 National Schizophrenia Fellowship, Mind, Manic Depression Fellowship (2000) A Question Of Choice London: NSF/Mind/MDF p30
21 Martinsen E. (1990) Benefits Of Exercise For The Treatment Of Depression Sports Medicine Vol 9 p388
22 For further discussion see Daley A. (2002) Exercise Therapy And Mental Health In Clinical Populations: Is Exercise Therapy A Worthwhile Intervention? Advances In Psychiatric Treatment
Vol 8 pp262-70, and Artal M. (1998) Exercise Against Depression The Physician And Sports Medicine Vol 26 (10)
23 NHS (2001) Exercise Referral Systems: A National Quality Assurance Framework NHS: London p13
24 Craft L., Perna F. (2004) The Benefits Of Exercise For The Clinically Depressed Primary Care Companion To The Journal of Clinical Psychiatry Vol 6 pp104-111
25 Department of Health (2004) Choosing Health: Making Healthier Choices Easier London: Department Of Health p132
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