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Exercise and depression
Exercise referral and the treatment of mild or moderate depression Information for GPs and healthcare practitioners There is a substantial body of evidence to show a
causal link between physical activity and reduced
clinically defined depression, and comparative
studies have demonstrated that exercise can be as
effective as medication or psychotherapy.
Treating depression in primary care
available through organised referral schemes. The following pages explain howexercise therapy can help people with depression and answers frequently asked Treating depression places a huge burden on GPs and primary care staff – up to questions about exercise referral schemes.
30 per cent of consultations relate to a mental health problem1, and depression isthe most common mental disorder found in community settings.2 The benefits of exercise for treating depression
For several decades, the standard firstline treatment response to depression in There is a substantial body of evidence to show a causal link between physical primary care has been medication. However, in recent years, scientists, regulatory activity and reduced clinically defined depression7, and comparative studies have bodies and clinical guidelines have questioned the wisdom of prescribing demonstrated that exercise can be as effective as medication or psychotherapy.8 antidepressants in some circumstances, especially to people with mild depression.
Exercise has been associated with reduced anxiety, decreased depression, enhancedmood, improved self-worth and body image, as well as improved cognitivefunctioning.9 According to the National Institute For Clinical Excellence: “For patients • As well as troublesome side effects and withdrawal symptoms, research shows with depression, in particular those with mild or moderate depressive disorder, that in some people, certain antidepressants can increase the risk of self-harm structured and supervised exercise can be an effective intervention that has a clinically significant impact on depressive symptoms.”10 • Guidance for clinicians published by the National Institute For Clinical Excellence in December 2004 states that: “Antidepressants are not recommended for the In view of this, there are several reasons for using exercise therapy as a first-line initial treatment of mild depression, because the risk-benefit ratio is poor.” 5 Exercise has far fewer negative side effects than antidepressants – indeed, it has anumber of co-incidental benefits, including reduced risk of heart disease, stroke, This has created a dilemma for many practitioners. Faced every day with people high blood pressure, some cancers, type 2 diabetes, osteoporosis and obesity. 11 desperate for help, there seem to be few options. New research by the Mental Exercise can be used to treat patients who have a mix of physical and mental Health Foundation shows that GPs would like greater access to alternatives, but health problems – it is a holistic care option.
that there are shortages of, or there are long waiting lists for, psychological Exercise is a sustainable behaviour change. Once the exercise habit is learned, it can be integrated to form part of an overall healthy lifestyle.
57 per cent of GPs believe antidepressants are prescribed too often.
Exercise does not carry the stigma sometimes associated with medication 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 Exercise is a popular treatment– in one survey, 85 per cent of people with mental done so because a suitable alternative was not available.
health problems who used exercise as a treatment said they found it helpful.12 However, there is a well-evidenced treatment for depression that is currently Exercise can give patients a sense of power over their recovery, which in itself underused in primary care. That option is exercise therapy, and it is increasingly counteracts the feelings of hopelessness often experienced in depression.13 1 Norwich Union (2004) Health Of The Nation Index 7 Biddle S., Fox K., Boutcher S., Faulkner G. (2000) The Way Forward For Physical Activity http://www.healthofthenation.com/html/focus.htm And The Promotion of Psychological Well-Being, in Biddle S., Fox K., Boutcher S. eds (2000) 2 National Institute For Clinical Excellence (2003) Depression, Nice Guideline, 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 3 Lynch T. (2004) Beyond Prozac: Healing Mental Distress Llangorran: PCCS pp71-2 And Its Relationship To Health, London: Department Of Health p58 4 Healy D., Whitaker C. (2003) Antidepressant And Suicide: Risk-Benefit Conundrums 9 Biddle S., Fox K., Boutcher S. eds (as in no 7) pp154-158 Journal Of Psychiatry And Neuroscience Vol 28 (5) p331 10 National Institute For Clinical Excellence (as in no 2) p72 5 National Institute For Clinical Excellence (2004) CG23 Depression: Management Of Depression In Primary Care – NICE Guidance London: NHS p5 12 National Schizophrenia Fellowship, Mind, Manic Depression Fellowship (2000) A Question Of 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 13 See Mental Health Foundation (as in no 6) p25-27 How does exercise referral work?
• According to the Chief Medical Officer: “Physical activity is effective in the treatment Exercise referral schemes operate in a variety of forms, often involving a partnership of clinical depression, and can be as successful as psychotherapy or medication, between primary care trusts and local leisure services.
• In its guidelines for treating depression, the National Institute For Clinical Excellence In most cases, the GP or practice nurse can refer patients who fit the referral criteria recommends that: “Patients of all ages should be advised of the benefits of by filling in a form that is then sent to the scheme’s organisers. The forms are usually following a structured and supervised exercise programme of typically up to three straightforward and easy to fill in, asking only for a few details about the patient’s sessions per week of moderate duration (45 minutes to one hour) for between 10 medical history, the reason for referral and their contact details.
Once the patient has been referred, the scheme organisers will make contact with Using exercise referral schemes for depression
him or her, and arrange an initial consultation with an exercise professional (someonewho has been trained specifically in dealing with exercise referral populations). They The first exercise referral schemes were set up in the 1980s, and it is estimated that will make a detailed assessment of their fitness for exercise and develop with them 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 heartdisease, diabetes, obesity, hypertension and other physical conditions which might be 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.
Schemes can also take referrals for patients with mental health problems, usually The patient will then be given free or discounted access to a range of leisure depression and anxiety. However, research by the Mental Health Foundation shows facilities for a period of time (usually three or six months). These facilities may that of those GPs who know they have access to an exercise referral scheme, include a gym, swimming pool, exercise classes or even options such as yoga, only 15 per cent of these use it ‘very frequently’ or ‘fairly frequently’ for their patients Throughout the period of the referral, the responsibility for the patient’s exerciseprogramme rests with the scheme. Referral officers will continue to provide support,motivation and advice to the patient throughout the duration of the programme, andthere are follow-up interviews at key points to monitor how he or she is getting on.
“Exercise is one of the few forms of treatment that will hit several different disease “It’s had a definite impact on my well-being. I’ve done about 15-20 sessions now, and targets all at once. More and more of my patients have five different conditions I’m getting more positive in myself. I’m actually starting to enjoy it. I still get knackered, when they come to see me – they have diabetes, high blood pressure, obesity, but I’m in a hall with people who’ve had massive strokes and heart attacks, and I think: raised cholesterol, and they’re depressed. By referring them for exercise, you can actually deal with all of those. Plus, you end up with healthier and more engaged Peter Lawler, participant in the South Tyneside exercise referral scheme patients. It’s good for the patient, and it makes my job more enjoyable, rewardingand more likely to be successful.”Professor Colin Bradshaw, GP, South Tyneside 14 Department of Health (as in no 8) p5815 National Institute For Clinical Excellence (as in no 5) p1516 Mental Health Foundation (as in no 6) p3117 Mental Health Foundation (as in no 6) p28 Exercise referral for depression – frequently
Q: Am I responsible if a patient is injured or becomes ill while participating in
asked questions
an exercise referral scheme?
A: No. According to the National Quality Assurance Framework on Exercise Referral
Q: My depressed patients are often unfit and lacking in motivation. Will they be
Systems: “When the individual is specifically referred for exercise by the health able to adhere to a programme of exercise?
practitioner, responsibility for safe and effective management, design and delivery of A: It is true that exercise therapy requires willingness on the part of the participant.
the exercise programme passes to the exercise and leisure professionals.”23 The However, treatment completion rates for exercise referral schemes are often much healthcare practitioner’s responsibility is to retain overall clinical responsibility for the higher than for medication18, and exercise has been found to be one of the most patient, and, with the patient’s consent, to transfer relevant medical information to the popular treatments among patients.19 20 21 While the Mental Health Foundation exercise professional carrying out the assessment. Once this information is received, believes that all patients ought to be offered exercise referral, no patient should be the responsibility for the patient lies with the scheme’s staff.
referred unless they are willing to undertake an exercise programme. Once they havebeen referred, patients will be given an individually-tailored programme to suit their 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
Q: In a busy medical practice, won’t referring patients for exercise be very
benefit for depressed patients engaging in exercise therapy.24 Both the Chief Medical time-consuming?
Officer and the National Institute For Clinical Excellence have acknowledged the A: No. The referral process is quick and straightforward, and because exercise therapy
results of these studies in their publications, and the 2004 government white paper, involves referring patients to other qualified professionals, it enables GPs and health Choosing Health, states that: “Regular physical activity reduces the risk of depression practitioners to share the burden of managing patients’ care plans. There may also be and has positive benefits for mental health, including reduced anxiety, enhanced incentives for referring – some GPs operating under the 2004 General Medical Services contract may be able to receive points for referring patients to exercisereferral schemes.
Q: How do I find out more about referral schemes for my patients
with depression?
Q: How does exercise therapy work?
A: Exercise referral schemes are usually delivered through a partnership of primary
A: There are several theories about why exercise is beneficial to mental health. These
care organisations and local leisure services. Although not all GPs have access to a are related to biology (exercise leads to an increased release of endorphins and scheme, their numbers are growing. Contact the health promotion team at your local enkephalins), sociology (attendance enables people to build new relationships), skill- primary care trust to find out about referral schemes in your area and their ability to mastery (exercise improves body condition and creates achievable goals), and distraction (exercise creates a diversion from a preoccupation with negativethoughts).22 Also, whereas some treatments can reinforce the sense of being a passive Q: How can I help my patients to understand the treatment?
recipient of care, exercise can create a sense of personal robustness, and of being A: The Mental Health Foundation has produced a leaflet on exercise referral for
‘normal’ and ‘healthy’. As an additional treatment response option, it increases the patients. Email mhf@mhf.org.uk to order copies of the patient leaflet. A charge will choices open to both patient and prescriber, maximizing the chances of improvement.
be levied to cover postage costs when placing bulk orders.
18 Mental Health Foundation (as in no 6) p3719 Mind (2001) Latest Mind Survey Provides Good News: Press Release London: www.mind.org.uk 20 National Schizophrenia Fellowship, Mind, Manic Depression Fellowship (2000) A Question Of 21 Martinsen E. (1990) Benefits Of Exercise For The Treatment Of Depression Sports Medicine 23 NHS (2001) Exercise Referral Systems: A National Quality Assurance Framework NHS: 22 For further discussion see Daley A. (2002) Exercise Therapy And Mental Health In Clinical 24 Craft L., Perna F. (2004) The Benefits Of Exercise For The Clinically Depressed Primary Care Populations: Is Exercise Therapy A Worthwhile Intervention? Advances In Psychiatric Treatment Companion To The Journal of Clinical Psychiatry Vol 6 pp104-111 Vol 8 pp262-70, and Artal M. (1998) Exercise Against Depression The Physician And Sports 25 Department of Health (2004) Choosing Health: Making Healthier Choices Easier London: About the Mental Health Foundation
Founded in 1949, the Mental Health Foundation is the leading UK charity working in mental
health and learning disabilities.
We are unique in the way we work. We bring together teams that undertake research,develop services, design training, influence policy and raise public awareness within oneorganisation. We are keen to tackle difficult issues and try different approaches, many ofthem led by service users themselves. We use our findings to promote survival, recoveryand prevention. We do this by working with statutory and voluntary organisations,from GP practices to primary schools. We enable them to provide better help for peoplewith mental health problems or learning disabilities, and promote mental well-being.
We also work to influence policy, including Government at the highest levels. And we useour knowledge to raise awareness and to help tackle stigma attached to mental illness andlearning disabilities. We reach millions of people every year through our media work,information booklets and online services.
The Mental Health Foundation recommends that GPs with access to exercise referralschemes should offer all patients presenting with mild or moderate depression theopportunity for referral to that scheme as part of their treatment plan.
Published by the Mental Health Foundation, June 2005
For more information about the benefits of using exercise as a treatment for mild or
moderate depression, please visit www.mentalhealth.org.uk. To order a copy of the Mental
Health Foundation report UP AND RUNNING? Exercise therapy and the treatment of mild
or moderate depression in primary care, to order additional copies of this booklet or copies of
our patients leaflet please email mhf@mhf.org.uk
Sea Containers House, 20 Upper Ground, London SE1 9QB
Tel: 020 7803 1100 Fax: 020 7803 1101
www. mentalhealth.org.uk
Registered charity No: 801130 The Mental Health Foundation

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