The Department of Health in England has identified that people who use mental health services, in particular those with diagnosis of schizophrenia or bipolar disorder, are at increased risk of coronary heart disease, diabetes, infections, respiratory disease and greater levels of obesity [1
]. Additionally, it is reported that they are almost twice as likely to die from coronary heart disease and up to four times as likely to die from respiratory disorder as those in the general population [2
]. Consequently, the Department of Health launched a national initiative to improve the physical health of people with mental illness with an aim to promote activity for all [4
The numerous physical benefits of exercise have been well evidenced throughout the years and are abundant in health promotion literature in G.P surgerys, leisure centres and gymnasiums. Engaging in exercise is associated with reducing the risk of developing heart disease, stroke, cancer, type 2 diabetes and obesity and promoting musculoskeletal health [4
]. It improves the poor physical health that leads to morbidity and early deaths in mentally ill populations.
There is a breadth of evidence suggesting that exercise also has positive effects on mental health. Generally it has been found that exercise can have a positive impact on mood, self esteem and self worth [5
]. Importantly, it has also been shown to be effective at reducing symptoms of depression and anxiety, this has been evidenced in both the general population [6
] and in adult clinical populations [9
]. Although the evidence is scarce there are some studies investigating the association of exercise on mental health, in particular on depression in young people.
Drawing on evidence from a national school based study looking into depression and suicidal ideation of adolescents it was found that higher levels of depression were associated with lower levels of sport participation. After controlling for covariates it was reported that participation in sports reduced the odds of suffering from depression by 25% [11
]. Similar reports have been found from longitudinal data; in a 6 Year study of 496 adolescent students, in which assessments of physical activity and depression scores were taken at 1-year intervals, baseline physical activity predicted fewer depressive symptoms over time [12
]. This finding is supported by longitudinal studies [13
Experimental data is scarce in the literature and results are mixed; In an RCT comparing participants receiving 24 sessions of aerobic activities of moderate intensity compared to a light contact placebo group and a non-treatment control group, participants in the intervention group improved on measures of self-esteem relative to the control group, however no differences were shown on depression scores [15
]. Conversely, in an RCT in which 66 Hispanic students were randomised to an intervention group consisting of moderate intensity aerobic exercise or a control group of low intensity physical activity over a 6 week period, depression scores were significantly lower post intervention in the intervention group [16
Although there are a wealth of studies testing the association between exercise and mental health in young people in the general population, there is little data on its association in clinical populations, i.e. those seeking treatment for mental health issues. In a systematic review of clinical trials up to 2005 [17
] only three trials were found to have investigated the effect of exercise on this population [18
]. All three studies reported no significant difference between depression scores in the intervention and control groups. However, two of the studies were reported to be of low quality and one was rated as moderate; all three studies had relatively small sample sizes. More recently there have been two studies investigating the effects of exercise on young people in a clinical population with slightly more positive results. In a single measures design study, 15 female participants meeting the Diagnostic & Statistical Manual for Mental Disorders IV (DSM-IV) criteria for Post-Traumatic Stress Disorder (PTSD) undertook an aerobic exercise programme for 40 minutes 3 times a week for12 weeks. Significant reduction in depression scores were reported from baseline to mid intervention and post intervention. However, a significant increase in depression scores was reported at 1 month follow up when comparing post intervention to 1 month. The authors conclude that aerobic training may be an effective intervention for childhood PTSD symptom reduction. However, increase in depression scores at 1 month follow up suggests that reduction in depression is not maintained when exercise ceases [21
]. Another single case repeated measures study using 12 female participants (aged 14-17) receiving treatment from a PTSD treatment centre in which participants undertook 25 minute sessions of moderate intensity aerobic exercise 3 times a week for 5 weeks reported that 2 of the 8 participants who demonstrated stable depression scores at baseline showed significant reduction in depression scores post intervention. Importantly, both studies had inadequate sample sizes and no control group and one had a large variance in the type of physical activity participants undertook.
In summary, it is clear that there is potential for exercise to have an effect on depression scores in young adults with depression, however to the authors' best knowledge there has been no well designed RCT's with sufficient statistical power investigating this issue. Furthermore, it is felt that encouraging young people to exercise at levels recommended by national guidelines, or as prescribed by the researcher may be unrealistic for young people with mental health difficulties. The researchers' previous work among young people suggests that interventions tailored to young people's preferred intensity may improve their motivation for exercise and reduce attrition rates and lead to improved mental health outcomes, increase self-esteem and overall quality of life. Therefore, a specially designed programme with exercise at a preferred intensity has the potential to improve health outcomes in young people.
1. To determine the effectiveness of a preferred intensity exercise programme on the mental health outcomes of young people with depression.
2. To examine the acceptability of a preferred intensity exercise programme to young people with depression
3. To determine the cost effectiveness of a preferred intensity exercise programme for young people with depression.
It is hypothesised that exercise of preferred intensity will significantly lower depression scores, increase quality of life, reduce incidents of self harm and be more cost-effective than treatment as usual.