Therapeutic Recreation and Depression: A Meta-Analysis of Exercise Interventions

Posted: February 19, 2019 by Starr LaMonde, CTRS

Written by Starr Caruthers, CTRS and Jennifer Chissus, TRS

Individuals with depression may experience feelings of sadness, changes in appetite and/or weight, a change in sleep patterns, unusual psychomotor activity, fatigue, difficulty thinking, concentrating, and making decisions, have feelings of unexplained guilt and/or worthlessness, and thoughts of death or suicide.1   Some physiological theories of depression may include increased norepinephrine levels, decreased aminergic levels, and decreased oxygen consumption.4  Alterations in endorphin levels and serotonin levels may also effect depression in individuals.5

            There are several common medical treatments for depression.  These include medications, electroconvulsive therapy (ECT), cognitive therapy, behavioral therapy, and interpersonal psychotherapy.2   Some common alternative therapies may include phototherapy, herbal therapy, and recreational therapy in the form of exercise.2

              The purpose of this study was to review the literature related to a variety of professions in order to determine the role of physical exercise in reducing depressive behavior among individuals with depression.

Theoretical Framework: 

            Biological and cognitive psychological theories help describe the effects of exercise on the treatment of depressive symptoms.  Biological theory suggests that increasing neurotransmitter deficits provides individuals with numerous psychological benefits.  It has also been found that exercise is able to increase an individual’s number of neurotransmitters.2,5,6   Cognitive theories suggest that the individual is able to decrease symptoms of depression by increasing their body-image, well-being, adaptability, control, sociability, work efficiency and pain tolerance.7  All of these factors are able to be accomplished by initiating some sort of exercise program.   Exercise has the potential to increase mastery, self worth, and self efficacy.5   The exercise intervention is able to increase these cognitions by providing individuals with enhanced perceived capability, which refers to the Social Cognitive Theory presented by Bandura in 1986.5

Literature Review

            Exercise has been identified as a possible intervention for treating symptoms of depression.  There have been a large number of studies and literature on the subject that analyzes what types of exercise bring about changes in mood.  Frequency and duration of exercise has also been researched.2   However, there have been problems regarding reliability and validity of studies due to flawed methodology.13

            Brosse et al conducted a study that analyzed three types of exercise: aerobic, anaerobic, and flexibility exercise.2   Aerobic exercise is described as when oxygen in used to produce energy.2   An example of this type of exercise is running or walking briskly.  Anaerobic exercise is when energy is produced without the use of oxygen.  Weightlifting is an example of this kind of activity.2   Flexibility exercises are meant to increase an individual’s range of motion such as yoga.  Brosse et al found that all of these types of exercises can reduce depressive symptoms and there are many other research articles discussed in this study that show that exercise can significantly improve depression.2

            There are many hypothesized reasons for the effectiveness of exercise.  It has been theorized that central monoamines, such as serotonin, noradrenaline, and dopamine are associated with depression.2   When there is an imbalance in these chemicals it may affect specific regions in the brain related to stress reactivity.  However, studies have not shown that exercise is associated with monoamine levels.  This may be due to the problem of retrieving accurate estimates of CNS levels in humans.2

            Hypothalamic-pituitary-adrenal (HPA) axis functioning has also been associated with depression.  Depressed individuals have higher baseline basal cortisol levels due to hyperactivity of the HPA axis.2   Regulating the HPA axis may reduce depression and also improve an individual’s response to stress.2   Only about half of individuals with depression show HPA axis hyperactivity.2

            β-endorphin is an opioid that has a calming effect on the sympathetic nervous system.  Exercise causes a surge of β-endorphin to be released in the blood stream to provide relief of pain associated with strenuous exercise.2   Studies have indicated that post-exercise individuals have elevated moods and an increase in basal β-endorphin level.  However, these reactions may be short lived.2

Methods

            To carry out this study an analysis of quantitative research was performed.  All articles that were used for this study were peer-reviewed and from scholastic journals.  The researchers focused on finding studies that evaluated whether exercise could be an effective treatment for depression.  Participants that were used ranged from healthy adults to adults with diagnosed major depression.

Throughout this study a variety of databases from the Grand Valley State University (GVSU) library home page were utilized to collect data.  These databases included; FirstSearch with 246 articles, MEDLINE with 5,112 articles, ProQuest with 618 articles, PubMed with 4,698 articles, CINAHL with 1,317 articles, and REHABDATA with 76 articles.  The keywords that were generally used included “depression” and “exercise”.  The four major journals that provided articles for this study were (but not limited to) Perceptual and Motor Skills, The American Psychiatric Association, The Physician and Sports Medicine, and the Handbook of Depression

To perform this analysis 21 articles were used to distinguish whether exercise was a useful in the treatment of depressed individuals.  Articles selected for this study were selected based on methods used by the researchers.  The studies that were selected contained either a control group and a treatment group, or were based on meta-analysis, survey or questionnaire.  All studies used measurement tools that have been tested for both reliability and validity.  Both the ATRA Annual and TRJ were searched manually from 1990 to present, however articles from these publications were not used due to lack of efficacy research examining the use of exercise as a therapeutic recreation intervention in the treatment of individuals with depression.

Results

            While analyzing the 21 articles that were selected a variety of interventions pertaining to exercise were used to evaluate whether exercise significantly lowered depression.  These interventions ranged from aerobic types of exercise such as walking, running, and aerobics, to anaerobic exercise.  An example of anaerobic exercise is weight lifting.  Some of the research studies that were looked at used both aerobic and anaerobic exercises.  Control groups often contained participants who were taking prescribed anti-depressants or no medications at all, and they were not adhering to any structured exercise program.  The outcomes measured were the reduction in levels of depression.

            The studies used a number of evaluative tools that have been tested for both reliability and validity.  These tools include: The Beck Depression Inventory, the Hamilton Rating Scale for Depression, the Brunel University Mood Scale, the Zung Self-Rating Depression Scale, the Anxiety Scale of Zuckerman’s Multiple Affect Adjective Checklist, the Subjective Exercise Experience Scale, the Depressed Adjective Test, the Profile of Mood States, the Ray Auditory Verbal Training Test, Fitts Tennessee Self Concept scale, and Rotter’s Locus of Control Scale.  The scores of these inventories were then analyzed to see if a significant decrease in depression occurred.                         

Discussion

While analyzing the data collected, it became apparent that there is a significant amount of studies that have been completed that indicate that exercise can be used to decrease depressive symptoms, there is little literature in therapeutic recreation journals to support this claim.  And yet, exercise continues to be utilized and promoted by therapeutic recreation professionals within the contest of current mental health practices.  Future research is needed to delineate the role of exercise within the context of therapeutic recreation programs.

A problem that presents itself when exercise is being used as an intervention is adherence.  If a person is unable to adhere to the recommended amount of treatments to obtain psychological benefits, then the treatment of exercise should not be used.  Several studies had issues pertaining to adherence in both treatment and control groups.  There have been studies that analyze characteristics that may make an individual less likely to adhere to this type of treatment.  An example of this type of study is Exercise Therapy for Depression in Middle-Aged and Older Adults.16  Individuals who have high levels of anxiety are more likely to dropout of exercise treatment.16  When interventions are being prescribed, information like this should be kept in mind.  However, there are a number of interventions that can be used to increase an individual’s adherence.  This indicates that exercise can be used if precautions by the practitioner are taken to increase adherence.16

Many of the studies that were found focused on relieving depressive symptoms in individuals that were not diagnosed with major depressive disorder.  Several the participants were defined as healthy.  To further confirm that exercise is a useful intervention, more studies need to be completed on patients that have been diagnosed with major depression.

There are numerous implications for Therapeutic Recreation in the mental health field.  Skalko et al indicates that the use of Therapeutic Recreation in psychiatric facilities has and continues to be based upon many behavioral theories discussed within the psychological discipline.29  Biological, cognitive and social-cognitive theories have already been briefly mentioned in this document.  Skalko et al discusses the Behavior/Learning Paradigm, Bio-chemical Paradigm, and Plan and Leisure Theory and explains how these paradigms serve to justify the implementation of TR services.29   The Behavioral/Learning Paradigm is based up on the idea that individuals learn by cause and effect.29  Skalko et al stated that an individual’s behavior and personality is a result of learned action.29  When the intervention of fitness/exercise is applied to a patient that is suffering from mental illness, primarily depression, the patient is able to physically and mentally obtain benefits as discussed in the theoretical framework and findings of this article.  When an individual is able to find relief from their symptoms, they begin to practice exercise/fitness to achieve a greater level of wellness.29  

The Bio-chemical Paradigm discusses the correlation of behavior and changes in neurotransmitters  and other chemicals.29  As discussed previously exercise and fitness programming produces changes in beta-endorphin levels that in turn affect emotional stability.29  Skalko et al states that exercise/fitness is pertinent to many therapeutic recreation programs, therefore the bio-chemical change that occurs during exercise is primary in the treatment of persons with mental illness.29  It has been confirmed by many disciplines that Play and Leisure Theory is relevant to normal growth and development, and numerous skills such as; motor skill development, social skills training, stress management, relaxation, coping skills, self expression, and physical fitness to name a few.29  The development of the skills listed above influences an individual’s thinking, emotional health, and behavior.29 

The benefits of Therapeutic Recreation and the use of fitness in mental health are growing in popularity due to recent efficacy research completed by allied health professions such as (but not limited to) psychology, sports medicine, and nursing.  Research on treating depression with exercise that has been used in this analysis has been obtained from Sports Medicine, Behavior Therapy, Perceptual and Motor Skills, Journal of Consulting and Clinical Psychology, Archives of General Psychology, British Journal of Psychiatry, Health Psychology, Psychology and Aging, The British Journal of Sports Medicine, Advances in Exercise Adherence, the Journal of Sports Medicine and Physical Fitness, the Journal of Gerontology, the Journal of Exercise and Sport Psychology, American Journal of Psychiatry, the Research Quarterly for Exercise and Sport, the Journal of Epidemology, Professional Psychology: Research and Practice, and Medicine & Science in Sport Exercise.  Providing a variety of statistical information will help therapeutic recreation professionals provide exercise programs to patients in various settings, and to individuals in the community.

References

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed.). test revision. Washington, DC: American Psychiatric Association, 2000.

2. Brosse AL, Sheets ES, Lett HS, Blumentthal JA: Exercise and the treatment of clinical depression in adults: Recent findings and future directions. Sports Medicine. 2002; 32(12): 741-760.

3. American Psychiatric Association:  Practice Guideline for the Treatment of Patients with Major Depressive Disorder (2nd ed.). Washington, DC: American Psychiatric Association, 2000.

4. Doyne E, Chambless D, Beutler L: Aerobic exercise as a treatment for depression in women. Behavior Therapy. 1983; 14: 434-440.

5. Annesi J J: Relationship between self-efficacy and changes in rated tension and depression for 9- to 12-yr. –old children enrolled in a 12-wk. after-school physical activity program. Perceptual and Motor Skills. 2004; 99(3): 191-194.

6. Doyne E, Ossip-Klem D, Bowman E, et al.: Running verses weight lifting in the treatment of depression.  Journal of Consulting and Clinical Psychology. 1987; 55(5): 748-754.

7. Ewing J, Scott D, Mendez A,  McBride T:  Effects of aerobic exercise upon affect and cognition. Perceptual and Motor skills. 1984;59: 407-414.

8. Gittin M: Pharmacological treatment of depression.  In Gottlib IH, Hammer CL (Eds.): Handbook of Depression. New York, NY: The Guilford Press, 2002, 360-382

9. Eastman C, Young M, Fogg L, et al.: Bright light treatment of winter depression. Archives of General Psychiatry. 1998; 55: 883-889.

10. Schwartz A,  Schwartz R: Depression: Theories and Treatments. New York, NY: Columbia University Press, 1993.

11. Hollon S, Haman K,  Brown L: Cognitive-behavioral treatment of depression. In Gottlib IH, Hammer CL (Eds.): Handbook of Depression. New York, NY: The Guilford Press, 2002, 383-403.

12. Weissman M,  Markowitz J: Interpersonal Psychotherapy for depression. In Gottlib IH, Hammer CL (Eds.): Handbook of Depression. New York, NY: The Guilford Press, 2002, 404-421.

13. Mather A, Rodriguez C, Guthrie M, et al.: Effects of exercise on depressive symptoms in older adults with poorly responsive depressive disorder. British Journal of Psychiatry. 2002; 180: 411-415.

14. Dimeo F, Bauer M, Varahram I, et al.: Benefits from aerobic exercise in patients with major depression: A pilot study. British Journal of Sports Medicine. 2001;35: 114-117.

15. Lane A, Crone-Grant D: Mood changes following exercise. Perceptual and Motor skills. 2002; 94(1): 732-734.

16. Herman S, Blumenthal J, Babyak M, et al.: Exercise therapy for depression in middle-aged and older adults: Predictors of early dropout and treatment failure. Health Psychology. 2002; 21(6): 553-563.

17. McNeil K, LeBlanc E,  Joyner M: The effects of exercise on depressive symptoms in the moderately depressed elderly. Psychology and Aging. 1991; 6(3): 487-488.

18. Martinsen E,  Stephens T: Exercise and mental health in clinical and free-living populations. In Dishman RK (ed.): Advances In Exercise Adherence (55-72). Champaign, IL: Human Kinetics, 1994, 55-72.

19. Kennedy MM,  Newton M:  Effect of exercise intensity on mood in step aerobics. The Journal of Sports Medicine and Physical Fitness. 1997;37: 200-204.

20. Penninx BWJH, Rejeski WJ, Pandya J, et al.: Exercise and depressive symptoms: A comparison of aerobic and resistance exercise effects on emotional and physical function in older persons with high and low depressive symptomatology. Journal of Gerontology. 2002; 57B(2): 124-132.

21. Faulkner G, Biddle SJH: Exercise and depression: Considering variability and contextuality. Journal of Sport and Exercise Psychology. 2004; 26(1): 3-18.

22. Kessler RC, Soukup J, Davis RB, et al.: The use of complementary and alternative therapies to treat anxiety and depression in the United States. American Journal of Psychiatry. 2001; 158(2): 289-294.

23. Blanchard C, Rodgers W, Wilson P, Bell G: Does equating total volume of work between two different exercise conditions matter when examining exercise-induced feeling states? Research Quarterly for Exercise and Sport. 2004; 75(2): 209-215.

24. Strawbridge W, Deleger S, Roberts R, Kaplan G: Physical activity reduces the risk of subsequent depression for older adults. Journal of Epidemology. 2001; 156(4): 328-334.

25. Tkachuk G,  Martin G: Exercise therapy for patients with psychiatric disorder: research and clinical implications. Professional Psychology: Research and Practice, 1999; 30(3): 275-282.

26. Dunn A, Madhuk T,  O’Neal H:  Physical activity dose-response effects on outcomes of depression and anxiety.  Medicine & Science in Sports & Exercise. 2001; 33(6): S587-S597.

27. Williams P,  Lord S:  Predictors of Adherence to a structured program for older women. Psychology and Aging. 1995;10(4): 617-624.

28. Field T, Diego M, Sanders C: Exercise is positively related to adolescents’ relationships and academics. Adolescence. 2001; 36(141): 105-110. 

29. Skalko T, Van Andel G, DeSalvatore G: The benefits of therapeutic recreation in psychiatry. In Coyle CP, Kinney WB, Riley B, Shank J (Eds.): Benefits of Therapeutic Recreation: A Consensus View. Ravensdale, WA: Idyll Arbor, Inc, 1991, 289-352.

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