Integrating physical activity into the treatment of depression in adults: A qualitative enquiry
2021; Wiley; Volume: 30; Issue: 3 Linguagem: Inglês
10.1111/hsc.13283
ISSN1365-2524
AutoresKatarzyna Machaczek, Peter Allmark, Nicholas Pollard, Elizabeth Goyder, Mark Shea, Michelle Horspool, Suzanne Lee, Stephanie de‐la‐Haye, Robert Copeland, Scott Weich,
Tópico(s)Eating Disorders and Behaviors
ResumoHealth & Social Care in the CommunityEarly View ORIGINAL ARTICLEOpen Access Integrating physical activity into the treatment of depression in adults: A qualitative enquiry Katarzyna K. Machaczek, Corresponding Author Katarzyna K. Machaczek k.machaczek@shu.ac.uk orcid.org/0000-0001-5308-2407 College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK Correspondence Machaczek K. Karolina, College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK. Email: k.machaczek@shu.ac.ukSearch for more papers by this authorPeter Allmark, Peter Allmark orcid.org/0000-0002-3314-8947 Division of Nursing and Midwifery, Health Sciences School, University of Sheffield, Sheffield, UKSearch for more papers by this authorNicholas Pollard, Nicholas Pollard orcid.org/0000-0003-1995-6902 College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UKSearch for more papers by this authorElizabeth Goyder, Elizabeth Goyder orcid.org/0000-0003-3691-1888 School of Health and Related Research, University of Sheffield, Sheffield, UKSearch for more papers by this authorMark Shea, Mark Shea Sheffield Health & Social Care NHS Foundation Trust, Improving Access to Psychological Therapies Services, Sheffield, UKSearch for more papers by this authorMichelle Horspool, Michelle Horspool orcid.org/0000-0002-3069-6091 Sheffield Health & Social Care NHS Foundation Trust, Sheffield, UKSearch for more papers by this authorSuzanne Lee, Suzanne Lee Public Representative, Sheffield, UKSearch for more papers by this authorStephanie de-la-Haye, Stephanie de-la-Haye Survivors of Depression in Transition, Sheffield, UKSearch for more papers by this authorRobert Copeland, Robert Copeland orcid.org/0000-0002-4147-5876 Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, UKSearch for more papers by this authorScott Weich, Scott Weich orcid.org/0000-0002-7552-7697 School of Health and Related Research, University of Sheffield, Sheffield, UKSearch for more papers by this author Katarzyna K. Machaczek, Corresponding Author Katarzyna K. Machaczek k.machaczek@shu.ac.uk orcid.org/0000-0001-5308-2407 College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK Correspondence Machaczek K. Karolina, College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK. Email: k.machaczek@shu.ac.ukSearch for more papers by this authorPeter Allmark, Peter Allmark orcid.org/0000-0002-3314-8947 Division of Nursing and Midwifery, Health Sciences School, University of Sheffield, Sheffield, UKSearch for more papers by this authorNicholas Pollard, Nicholas Pollard orcid.org/0000-0003-1995-6902 College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UKSearch for more papers by this authorElizabeth Goyder, Elizabeth Goyder orcid.org/0000-0003-3691-1888 School of Health and Related Research, University of Sheffield, Sheffield, UKSearch for more papers by this authorMark Shea, Mark Shea Sheffield Health & Social Care NHS Foundation Trust, Improving Access to Psychological Therapies Services, Sheffield, UKSearch for more papers by this authorMichelle Horspool, Michelle Horspool orcid.org/0000-0002-3069-6091 Sheffield Health & Social Care NHS Foundation Trust, Sheffield, UKSearch for more papers by this authorSuzanne Lee, Suzanne Lee Public Representative, Sheffield, UKSearch for more papers by this authorStephanie de-la-Haye, Stephanie de-la-Haye Survivors of Depression in Transition, Sheffield, UKSearch for more papers by this authorRobert Copeland, Robert Copeland orcid.org/0000-0002-4147-5876 Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, UKSearch for more papers by this authorScott Weich, Scott Weich orcid.org/0000-0002-7552-7697 School of Health and Related Research, University of Sheffield, Sheffield, UKSearch for more papers by this author First published: 13 January 2021 https://doi.org/10.1111/hsc.13283 Funding information: We received funding from the Sheffield Health and Social Care NHS Foundation Trust (reference number: AA4332175) and from the National Institute for Health Research (Research Design Services Yorkshire and the Humber, RDS YH, Public Involvement in Grant Applications Funding Award). AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Abstract Around 246 million people globally suffer from depression. Physical activity (PA) can reduce the risk of depression by 30% and is recognised as an effective treatment for mild-to-moderate depression (MMD). However, a high proportion of patients with MMD are currently inactive and the implementation of PA as an adherent treatment for MMD is not well understood. This study contributes to a growing body of research exploring how to support people who are experiencing MMD to increase their PA levels (i.e. initiation and maintenance). It investigated which factors individuals with MMD perceived to be important for integrating PA into the treatment of depression in adults. In-depth interviews were carried out with individuals with MMD (N = 6), and data were analysed using thematic analysis. Two main theories of social capital that of Bourdieu and Putnam informed the discussion of findings. The initiation and maintenance of PA were linked to individual factors including health (i.e. nature of depression; comorbidities); abilities and tastes; socioeconomic status (e.g. financial position) and positive encouragement. In addition, maintenance emerged as dependent upon the choice, enjoyment, and meaningfulness of PA itself, and, for those who engaged in group PA, on social capital. PA interventions need to be personalised. This goes beyond a simple exercise prescription based on functional ability, but instead takes into account the needs, desires and capabilities of the whole person. The nature of MMD, the wider physical and socio-economic context and the social capital that is available to the individual also need to be harnessed. What is known about this topic Physical activity (PA) is effective in treating and preventing mild-to-moderate depression (MMD). The current national guidance highlights the cost-effectiveness of exercise as a component of management of depression. Nonetheless, a large population of patients with MMD are currently inactive. What this paper adds To support individuals with MMD into more physically active lifestyles, interventions need to be personalised beyond a prescription that is based on their physical fitness. Instead, a person's wider physical and social context needs to be given appropriate consideration. This study suggests that, in relation to PA maintenance, a focus on the individual-level motivational theory and/or biomedical factors does not provide sufficient basis for explaining the PA behaviour of those with depression. Capturing social capital perspectives seems to account for a more comprehensive picture of factors that might contribute to PA maintenance. 1 INTRODUCTION Depression is the largest contributor to the global burden of non-communicable disease, with an estimated 246 million cases (World Health Organisation, 2020). Indeed, 4.4% of the world's population have a diagnosis of depression at any one time (World Health Organisation, 2017); of these, the majority will have mild-to-moderate depression (MMD; Shim et al., 2011). In a recent UK cohort, 24% reported current or previous depression (Davis et al., 2018), indicating a high prevalence and demand which healthcare services are failing to meet. Common interventions for MMD, such as psychological therapies, have limited reach: in the UK, three-quarters of those affected do not receive treatment (The Health Foundation, 2020). COVID-19 brings new challenges, including deterioration of mental health (De Quervain et al., 2020). There is, therefore, an urgent need for cost-effective and scalable interventions which can reach a larger number of people. Physical activity (PA) is defined as "any bodily movement produced by skeletal muscles that requires energy expenditure" (World Health Organization, 2018). It encompasses everyday activities (such as walking, housework, do-it-yourself or gardening), work-related activities and traditional exercise forms such as attending a gym, running, dancing or playing sports or active games (Department of Health, 2011). The relationship between depression and PA is reciprocal; depression leads to decreased PA levels, and reduced PA levels exacerbate depression (Da Silva et al., 2012; Mammen & Faulkner, 2013; Teychenne et al., 2008). Physical activity can decrease the risk of depression (Choi et al., 2019, 2020; Schuch et al., 2018), and has been identified as an effective therapy for depression (Brinsley et al., 2020; Schuch et al., 2014). By contrast, inactive individuals have an incidence of depression which is three times higher than the incidence in those who exercise regularly (Weyerer, 1992). PA may be an effective treatment for depression through multiple mechanisms. For example, PA antidepressant effects have been linked to its ability to: (a) upregulate the anti-inflammatory marker interleukin-10 (Euteneuer et al., 2017); (b) reduce the pro-inflammatory marker interleukin-6 (Lavebratt et al., 2017); and (c) reduce the marker of oxidative stress, serum thiobarbituric acid-reactive substances (Schuch et al., 2014). PA also improves self-esteem (Firth et al., 2016), self-efficacy (Haller et al., 2018) and cognitive functioning (Ashdown-Franks et al., 2020). PA can amplify its antidepressant effects through providing opportunities for social engagement and support (Hallgren et al., 2017). With regard to dosage, higher levels of PA are associated with lower risk of developing depression (Schuch et al., 2018). The UK's National Institute for Health and Clinical Excellence (NICE) guideline on treating MMD and persistent subthreshold depression (NICE, 2020) recommends that individuals engage in up to three, 45–60 min PA group sessions per week, over 10–14 weeks. With regard to PA type, aerobic (cardio-respiratory), anaerobic (intense PA of short duration, e.g. muscle strengthening) and activities which improve flexibility and co-ordination (e.g. yoga) have all been found to have positive effects on depression (Bennie et al., 2019; Brinsley et al., 2020; NICE, 2020). Interventions delivered by exercise professions have been found to have larger effect on depression (Schuch et al., 2016). NICE highlights the importance of patients' preferences for PA type(s) (NICE, 2020). Despite being efficacious in the treatment for depression (Morres et al., 2019), it is less well known how to support patients with depression to initiate and sustain PA. This has significant implications for implementation efforts. Exploring the perceptions of individuals with depression on how PA could be implemented into depression management is likely to inform future interventions. Specifically, a greater understanding of what matters most for people with depression will further understanding of how PA can be initiated and sustained in this population. The distinction between PA initiation and maintenance is important here, as the two functions engage different mechanisms and require separate psychological processes and skills (Voils et al., 2014). 2 METHODOLOGY AND METHODS 2.1 Phenomenology This study adopted a descriptive phenomenological approach (Husserl, 1982), which has often been applied in studies on depression where the meaning of tacit experience is little explored and requires analysis (Drew, 2004; Matua & der Wal, 2015). Digitally recorded in-depth interviews with adult individuals who have experienced depression were used to elicit their experiences and perceptions of integrating PA into the treatment of depression. The data would offer insights into the relationship between individual engagement and management of depression in adults. 2.2 Sampling method Purposive sampling was used to maximise the diversity of the sample (Mason, 1996, 2002). The only limits placed on selection were the age of participants (≥18 years) and whether they have been diagnosed with depression by a general practitioner. The maximum number of participants (n = 12) was determined by the study protocol, available funding and having a practical sample with which to conduct an in-depth and thorough study (Mason, 2002). 2.3 Study setting and recruitment Participants were recruited via local mental health charity organisations in a city in the north of England. Charity managers applied the inclusion criteria to identify eligible individuals, who were given a participant information sheet. If they expressed interest in taking part, their contact details were passed to a member of the research team (KM), who then contacted them to provide more information about the study and answer questions. Twelve individuals were invited to participate. Each was given at least 5 days to consider taking part. The most common reasons provided by those who declined were lack of time and interest. One person reported being too unwell to participate. Six participants aged between 38 and 62 were interviewed. Five were women. Two participants were self-employed and working full-time; four were unemployed. All but one participant lived alone. Two participants were previously referred by a health professional to a PA intervention; others were self-referred or else were directed to group PA by third parties (usually peers). All participants were physically active at the time of the interview. 2.4 An interview schedule The interview schedule was based on the aims and objectives of the study. The majority of items on the schedule concerned participants' experiences and perceptions of integrating PA into management of depression. The schedule was piloted on one Patient and Public Representative (SH) and one peer researcher. Prior to testing the schedule was subjected to scrutiny by the ethics review panel. No changes to the schedule were requested. 2.5 Interviews In-depth interviews (Boyce & Neale, 2006) were digitally recorded between December 2017 and March 2018. One interview was conducted by telephone and five at university premises. Participants were interviewed by the first author, a researcher with experience in interviewing individuals with mental ill health. Before the interviews commenced, participants were put at ease with general introductions and a brief background to the study (Adams & Cox, 2018). They were also provided with details on confidentiality (Adams & Cox, 2018). Interviews lasted from 65 to 100 min (with an average length of 90 min); all were transcribed verbatim. 2.6 Data analysis Interview data were given a thematic analysis (Braun & Clarke, 2006; Merton, 1975) and independently coded by two researchers (KM and PA). Thematic analysis was selected as it is compatible with descriptive phenomenology (Sundler et al., 2019). The data analysis commenced by KM and PA jointly developing an initial coding framework and code units, which were subsequently used to code all interview transcripts. The initial framework was then refined further through integration as coding progressed and new codes emerged from the data. To establish the credibility of the findings, the reliability of the coding was assessed (Tuckett, 2005), through calculating the percentage of matching coding decision made using the final version of the coding framework. The inter-coder agreement ranged between 83% and 93% with a mean score of 88%. Any discrepancies in judgement between the researchers were resolved through discussion. Reflexivity was maintained throughout the data analysis process (Sundler et al., 2019). 3 ETHICS Ethical approval was granted by the Sheffield Hallam University Ethics Committee (ref. 2017-8/HWB-HSC-05). Written informed consent was obtained from participants for the use of evidence from interviews. The ethical principles and practices adhered to were those identified by the U.K. Public and Patient Involvement Advisory Group: NIHR INVOLVE. 4 FINDINGS This section examines the participants' views of features important for the integration of PA into the management of depression, including factors important for PA initiation and maintenance. An overview of the key findings is provided in Table 1. TABLE 1. Key findings Theme Key findings Nature of disorder Depression is a long-term condition (typically, recurrent and relapsing) and any attempt to increase and sustain greater levels of physical activity in this population requires long-term support PA initiatives need to account for the cyclical nature of depression, planning for when people are at their lowest point in the cycle. This also implies the need for flexible schemes Cognitive and psychological consequences of depression (e.g. negative thought patterns) can present a significant barrier for individuals with MMD wishing to increase their PA levels Individual factors Comorbidities, individual abilities and willingness to initiate PA, and their preferences for PA need to be taken into account It is important that individuals are encouraged to choose physical activities which are enjoyable and meaningful to them Individuals should be given an opportunity to choose between mainstream activities and activities designed specifically for individuals with mental ill health Unobtrusiveness and flexibility in allowing people the opportunity to make their own choices are important attributes of such support Social factors Social support plays a significant role in supporting individuals with depression to increase and sustain greater levels of physical activity The importance of a trusted connector in facilitating physical activity initiation and maintenance Feelings of group achievement can reinforce a sense of gain and encourage continuation Socioeconomic factors Inadequate financial resources and fees can be a significant barrier to activity participation. Some individuals may therefore require other types of support, such as help to find a job, before physical activity can be introduced There is critical need for a more holistic, whole-person approach, which takes account of depression, comorbidities, and at the same time looks at the social context in which people live and their community-level socioeconomic status The importance of multiorganisational and multidisciplinary input 4.1 The integration of PA into depression management 4.1.1 Personalisation Participants stressed the importance of personalising the integration of PA into the management of their depression. Personalisation was characterised as encompassing components related to several factors, as set out below. Nature of disorder Narratives indicated that PA initiatives and programmes need careful planning to weave in elements targeting the nature of depression. Participants reported experiencing days when they struggled to get out of bed and engaging in PA would be inconceivable. PA initiatives need to account for the cyclical nature of depression, planning for when people with MMD are at their lowest point in the cycle. All participants thought that an essential component of intervention was being offered PA at the right time: …and I know for me personally, if someone said to me when I am very low physically, mentally, and said, oh you can get down to the gym, you know, I would have told them where to go (Participant 2, Female, Age 45). The narratives highlighted the challenge presented by the nature of depression as a cyclical long-term condition with varying symptoms, e.g. some people feel stuck and do not eat, whereas others feel constantly anxious; many withdraw from people and activities: The main thing when somebody is depressed is to withdraw. The first trigger is, I won't go, I won't meet with my friends, I will cancel that appointment, and to withdraw from everything. And even if you know that this will make you feel better, you keep postponing it, you are not doing it (Participant 5, Male, Age 62). Such responses reveal negative thought patterns linked to withdrawal, with some participants reporting significant hurdles to beginning PA. Individual factors – Health, abilities, tastes and PA preferences Participants stressed the importance of taking into account comorbid mental and physical health conditions associated with depression, which could limit individuals' capability: Quite often people have a dual diagnosis of mental and physical illness, it's not just one or the other, there are multiple things (Participant 3, Female, Age 38). Individual abilities and willingness to initiate PA were linked to setting realistic and accessible goals. The narratives provided evidence that effective PA encouragement, including professional advice and referral mechanisms, should be flexible to enable people to find their own starting point: I think helping people change small things would be more helpful than asking them to go to the gym three times a week… (Participant 3, Female, Age 38). Participants expressed activity preferences such as walking, swimming or yoga: There might be other activities. Things like yoga, mindful walking, which aren't traditionally seen as exercise… Like Tai Chi, for example… it isn't cardiovascular, but it's about movement and about mindfulness… (Participant 4, Female, Age 42). Another participant strongly dismissed walking groups as a personal option; implying that initial uptake of PA may hinge directly on prior (perhaps stereotypical) perceptions of the appropriateness of various forms of PA: I don't know whether there are things like that [walking groups] where I live, there probably are, but I see them as for older people, churchgoers or ramblers (Participant 4, Female, Age 42). Other preferences for participation in PA could be grouped as mainstream activities and activities designed specifically for individuals with mental ill health. Participants who preferred mainstream activities appeared to require support to overcome barriers to initiating or re-establishing physical activities but did not seem to require the support of healthcare practitioners. They did not want others to know that they had mental health problems, which was attributable to fear of being stigmatised. They wanted to feel that they are engaging in an activity that is 'normal/typical' for their peers rather than being part of formal agencies. The nature of some PA, such as exercising in the gym, was regarded as a barrier: It's just my opinion, but I feel gyms are quite anti-social. It's like you've got to go on treadmill for ten minutes, then you've got to do that for ten minutes. You know, if you play tennis, even if you're doing it in an inside environment, you're with other people and you've got social aspects, it boosts your mood as well (Participant 4, Female, Age 42). Two participants were concerned about their body image and reported feeling too self-conscious to go to the gym. One participant worried that she would stand out because of a lack of stamina. As a whole, participants felt that it was imperative that people are encouraged to choose activities that are enjoyable and meaningful to them. Social factors Having a trusted connector (a peer, community support worker, healthcare practitioner or others) to support someone to be more active was identified as a desirable and helpful factor in relation to PA initiation and maintenance: …helping people to do that exercise, very slowly, gradually working through it (Participant 4, Female, Age 42). Unobtrusiveness and flexibility in allowing people the opportunity to make their own PA choices were important attributes of such support: There is a balance between a bit of support and a bullying text (Participant 5, Male, Age 62). Attempts to facilitate an increase in and sustainment of PA in people with MMD were identified as requiring long-term support; with change towards increasing PA levels being gradual and slow, with inevitable setbacks: For the majority of people, it's going to be a very staggered, with a few blips, you know, the ladder thing, coming down, going up again and everything else and having to work with that (Participant 3, Female, Age 38). Given these challenges to starting PA for those with MMD, a positive encouragement to boost self-efficacy (the belief that one can perform the behaviour) was thought to play a particularly important role in creating the atmosphere, motivation and environment in which to sustain engagement: A few kind words of encouragement, even when you are underperforming, can make a difference… the opposite is also true (Participant 5, Male, Age 62). Participants discussed the reasons why they might find PA meaningful and worthwhile; in some cases, it might be the sociability of the activity, and the possibility of finding new friends and networks: …it's not just about getting your heart rate going and its benefits… you might meet some people you've never met before… (Participant 3, Female, Age 38).I was isolated… but you can build relationships, even if it's only 'see you next week' and you look forward to seeing them next week, and you get suggestions about going to a gardening group or another group… and slowly… you aren't isolated (Participant 6, Female, 43). The narratives suggested some fluidity in terms of preferences for group or lone activities, indicating that the two should not be seen as a binary choice but depended on individuals' moods and preferences on a given day: I may want to go and join a class, or I may go on my own, it depends on my mood (Participant 5, Male, Age 62). For individuals who reported that PA helped them overcome isolation, improved their social interactions and helped them bond with others, the positive effects of PA seemed to evolve organically through spending time together and sharing experiences. Despite the major initial barrier concerning fear of social interaction, participants in group-based PA found emotional connections and a strong sense of duty and responsibility towards others were crucial to the maintenance of their engagement: I always felt uncomfortable as I don't mix easily. I met the woman who did bowling and… it has been my saviour. I can mix with people without talking to them, not because I am antisocial, but I play the game and I am concentrated and I do not think about my troubles …Sometimes I enjoy bowling and sometimes I do not, but I go… If I would do it just for me, I could easily not do it, but if I'm doing it for the team, I would be there, because I do not want to let them down… (Participant 1, Female, Age 48). Additionally, feelings of group achievement seemed to reinforce a sense of gain and encourage continuation. Participants discussed how PA might help to combat depression through links to other activities and outcomes, such as providing practical support for conservation work or gardening, which in addition to providing physical enjoyment and spending time with others offers skill-building experiences: …To say actually, to go down into, I don't know the woods etc. and do some conservation work that's chopping down bushes or whatever, it is exercise. That's physical activity. But at the same time, it is different. I'm going down to do my eco-therapy, I am doing stuff, I am socialising, I am with people (Participant 3, Female, Age 38). Activities such as hobbies done in groups, including reading or a range of craft activities such as knitting, were also identified as useful for those who might not be able because of poor physical health to engage in more physically demanding modes of PA. These activities seem low in physical demand but require individuals to get out of the house. Additionally, they involve social bonding and are associated with the psychological benefits of interacting with others: For some people where they are just being able to get out, get on the bus, go to somewhere and maybe do an activity, I don't know, maybe a craft for instance or something like that… (Participant 3, Female, Age 38). Socioeconomic and other factors Inadequate financial resources and fees were identified as a significant barrier to activity participation: We can't sort of say well go there but you've got to pay… (Participant 2, Female, Age 45). Financial considerations and fees also featured among reasons for not joining the gym. Two participants thought that purchasing a gym membership would likely increase their general anxiety, and they may experience prevarication due to anxiety at the point of leaving the house to go to the gym: I'm physically active, but I don't go to gyms and I can't sort of commit to big things like that. That would be just me, I'd feel too much pressure, or I'd probably feel anxious about I've got a gym membership, so I feel under pressure that I need to go to the gym (Participant 2, Female, Age 45). Sometimes
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