Deakin Research Online Deakin University s institutional research repository DDeakin Research Online Research Online This is the published version:

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1 Deakin Research Online Deakin University s institutional research repository DDeakin Research Online Research Online This is the published version: Ng, Felicity, Dodd, Seetal, Jacka, Felice, Leslie, Evie and Berk, Michael , Effects of a walking program in the psychiatric in-patient treatment setting: a cohort study., Health promotion journal of Australia, vol. 18, no. 1, pp Available from Deakin Research Online: Reproduced with the kind permission of the copyright owner. Copyright : 2007, Australian Association of Health Promotion Professionals

2 Intervention and Program Evaluation Effects of a walking program in the psychiatric in-patient treatment setting: a cohort study Felicity Ng, Seetal Dodd, Felice N. Jacka, Evie Leslie and Michael Berk Introduction The role of physical activity in the prevention and management of physical illnesses, such as cardiovascular disease and diabetes, is well established. 1 Adults are recommended to accumulate 30 minutes of moderate-intensity physical activity on most, preferably all, days of the week in order to reap health benefits. 2 There is evidence to support parallel benefits of physical activity in mental health, especially in anxiety and depression, 3 which has important treatment and public health implications given the extent of the mental illness burden in our society. 4 Studies investigating the relationship between physical activity and the risk of depression are complicated by methodological limitations, varying definitions of physical activity, and have yielded conflicting results However, there is evidence of physical activity being protective against depression, 7-10 physical inactivity being a risk factor for depression, 10 and for the effectiveness of physical activity in the treatment of depression and anxiety In one study of 23 depressed out-patients, running was found to be as effective as psychotherapy in reducing symptoms over a 12-week period. 12 In another study of 12 patients with moderate to severe major depression, a program of 30 minutes of aerobic exercise per day over 10 days was associated with substantial improvements in Hamilton Rating Scale for Depression scores. 13 There has been reported improvement in depressive symptoms after a single bout of aerobic exercise. 16 On the other hand, physical activity was not shown to have beneficial mood effects in non-depressed individuals. 17,18 In their randomised controlled trial of 156 patients with major depressive disorder that compared the effects of aerobic exercise, sertraline, and both aerobic exercise and sertraline, Babyak et al. found that not only did the three groups showed comparable remission rates after four months of intervention, but the aerobic exercise group had significantly lower relapse rates than the other groups at six-month follow-up. 19 While physical activity has been shown to be effective in Abstract Issue addressed: To assess the effectiveness of a walking program in a psychiatric in-patient unit. Method: In-patients at a private psychiatric unit were offered the opportunity to participate in a daily morning 40- minute walk led by an activity supervisor. After discharge, outcomes for patients who had regularly participated in the walking group (n=35) and patients who had not participated (n=49) were compared for length of stay during their period of admission and Clinical Global Impression Severity (CGI-S) and Depression Anxiety Stress Scales (DASS) scores measured at admission and discharge. This was a retrospective analysis of data collected routinely. Results: There were no significant differences between the two cohorts on most primary outcome measures, including length of stay, DASS scores at admission and at discharge and CGI-S scores at admission. Patients who had not participated in the walking group had a significantly lower score on a single measure, the CGI-S, than patients who had participated (p=0.001). Conclusions: This study showed no evidence that in-patients benefited from participating in the physical activity program. However, this must be interpreted within the confines of a number of study limitations and, as such, the findings can neither support nor refute the effectiveness of physical activities. Key words: Mental health, walking, depression, physical activity, in-patients, outcomes. So what? Health Promotion Journal of Australia 2007;18:39-42 Introducing a program of walking in a psychiatric in-patient setting is a potentially low-cost, low-risk, well-tolerated intervention that may have benefits extending beyond mental health. It is an intervention that seems acceptable to a large proportion of patients, and would benefit from more stringently designed trials to determine its utility in the psychiatric in-patient setting. Health Promotion Journal of Australia 2007 : 18 (1) 39

3 Ng et al. Article controlled trials, physical activities programs in a mental health service are unusual. Burbach 20 suggested that physical activity could be a useful intervention for anxiety and depressive disorders, but that difficulties remain in translating research into clinical programs. Glasgow et al. 21 identified difficulties in program evaluation as a contributing factor to the slow translation of research into practice. Various mechanisms have been proposed to mediate the positive effects of physical activity on mental health, including enhanced monoamines transmission, release of endorphins, distraction from unfavourable stimuli, generation of a sense of self-efficacy, and social interaction inherent in the physical activity itself. 22 Physical activity may be an under-utilised, simple, low-cost measure that not only facilitates psychiatric recovery, but generates cross-benefits in general health and physical comorbidities. Our objective was to conduct a pilot cohort study investigating the effects of a walking program within a psychiatric in-patient setting. Walking was chosen as a suitable physical activity for in-patients as it is one of the most popular forms of adult physical activity, is acceptable to patients, cost-free, and requires no special facilities. Methods All patients admitted to a private acute psychiatric in-patient unit in Geelong, Victoria, Australia, were offered the opportunity to participate in a walking group for the duration of their admission. For those who chose to participate, they were led on a 40-minute walk on weekday mornings by a psychiatric nurse rostered on nursing duty on the day. The group walked in the vicinity of the hospital, which consisted of suburban streets on flat grounds. The walking speed and distance varied according to the physical capabilities of the participants. There were other activities on offer, such as art, music and group therapy programs. None of these alternate activities had a physical activity component. All patients were offered the opportunity to participate in all activities in the program by the nursing staff and their doctors on admission. Written activities programs were distributed to all patients on admission and on a weekly basis, and reminders via whiteboard notices and overhead audio announcements were carried out on each day that activities were scheduled. Patients were free to participate in all, none, or any combination of these activities, which took place in addition to their usual acute psychiatric care. There were no exclusion criteria or randomisation. Data were analysed for patients discharged from the unit between 1 January 2005 and 31 August 2005 who were known to have participated or not participated in the walking program. Only those patients identified by the walking group co-ordinator as having regularly participated or never participated were included. Regular participants were those who participated most days during their period of hospital admission. Individuals who participated in the walking group only occasionally were excluded from the analysis. Details of the patients participation in the walking program were determined by consulting with the walking group co-ordinator. Two clinical rating scales, Clinical Global Impression 23 and Depression Anxiety Stress Scales, 24 were used at the point of admission and discharge. The former is a clinician-rated scale of overall illness status consisting of three items (i.e. severity of illness, global improvement and efficacy index), and the latter is a 42-item self-report measure with depression, anxiety and stress subscales. These are two routine outcome measures used in the hospital and have been shown to be valid and reliable measures of mental illness outcome in the acute hospital setting. Results There were 35 treatment episodes in patients who participated in the walking group and 49 treatment episodes in nonparticipants. Demographics of the participants are given in Table 1. Multiple admissions were common with nine walkers and 12 non-walkers admitted more than once during the study period. The two groups were analysed for difference of means of length of stay, Depression Anxiety Stress Scales (DASS) and Clinical Global Impression Severity of Illness subscale (CGI-S) scores. Results are shown in Table 2. The study was designed as a naturalistic study with no exclusion criteria. The advantage of this was that it allowed assessment of the real-world effectiveness of the intervention. No significant differences between the two groups were observed at admission or discharge on almost all measures used in the study. Nevertheless, participants in the walking group had a significantly worse score on a single measure, the CGI-S, at discharge than non-participants, suggesting that participants in the walking group were more severely ill at discharge than non-participants. Discussion The sample size of 84 admissions is larger than those in previous intervention studies. 12,13 However, the present study has some methodological limitations that need to be noted. The subjects were not controlled for demographics, psychiatric diagnoses, physical co-morbidities or baseline levels of physical activity. As most available data links the benefits of physical activity to depression and anxiety, such benefits, if present, may have been diluted by the inclusion of patients with other psychiatric diagnoses in our study. Furthermore, physical co-morbidities and baseline levels of physical fitness may be confounding variables in the patients participation in the walking program, which could also have influenced our results. Second, the lack of randomisation of subjects into the walking and non-walking groups was associated with inherent biases, such as motivational and illness factors. The preference for males over females in the 40 Health Promotion Journal of Australia 2007 : 18 (1)

4 Intervention and Program Evaluation A walking program in the psychiatric setting walking group is unexplained, however it is likely to be a selfselection variable. The inclusion of re-admission data from a number of individuals should also be taken into consideration as factors such as illness severity, treatment resistance and comorbidities may complicate the outcome. Biases intrinsic to the patients self-selection to participate in the walking program and the therapeutic effects of pharmacological and psychological interventions as well as non-physical group activities available in the hospital program may have influenced outcome. Finally, the exclusion of those who participated in the walking program on an irregular basis could have led to an under-estimation of the benefits of physical activity, in view of some evidence suggesting single-dose effects of physical activity. 16 With such limitations in the study, our data cannot support or refute the effectiveness of a walking program as a treatment strategy in acute mental illness. Nevertheless, the lack of differentiation on most outcome measures in the walking intervention group is interesting and may reflect the complexities of psychiatric management, which balances the use of biological and psychosocial interventions. In the acute treatment setting and with varying diagnoses, the potential benefits of regular walking may have been eclipsed by concurrent treatments such as pharmacotherapy or intensive supportive psychotherapy. It is not known what other forms of activity were being undertaken by patients during the program. Because all patients were free to participate in alternative non-physical activities or informal physical activities during their admission, the specificity of walking as an intervention may have been reduced and its effects clouded by the potential benefits of other activities such as pharmacotherapy, ECT, group-based psychotherapy, music therapy or art therapy. The finding of a less favourable CGI-S outcome in participants of the walking program compared with non-participants was unexpected. As there does not seem to be any reasons for walking having a deleterious effect on mental illness outcome, this result is more likely to stem from confounding factors, such as recruitment bias that perhaps favoured the selection of more severely ill patients into the walking cohort. Examples could include patients admitted for situational crises whose clinical status improved over a short period of time, which precluded them from regular participation in group programs, and patients with primarily personality disorders who did not score highly on illness severity scales but whose engagement difficulties likewise prevented their consistent participation in groups. The use of DASS and CGI, which are broad outcome measures, may also have influenced our findings in the failure to capture more specific symptomatic improvements. Dimeo et al. demonstrated that aerobic exercise led to substantial improvement in their sample of depressed patients over a short period of time. 13 Our study has found no beneficial effects of a walking program in a general psychiatric in-patient setting. Further research could assist in clarifying the type and dose of Table 1: Demographics for participants and non-participants in a program offered in a private acute psychiatric care unit. Walkers Non-walkers (n=35 episodes (n=49 episodes requiring requiring treatment) treatment) Gender 23 males 1 male 12 females 48 females Age (years±sd) 45.6 ± ± 16.7 Unspecified mental disorders 2 0 due to brain damage and dysfunction and to physical disease Mental and behavioural disorders 7 4 due to use of alcohol Schizoaffective disorder 2 2 Bipolar disorder 1 9 Depressive episode Recurrent depression 2 10 Generalised anxiety disorder 2 0 Mixed anxiety and depression 0 5 Obsessive compulsive disorder 0 5 Reaction to severe stress 1 0 Post-traumatic stress disorder 0 1 Dissociative disorder 1 0 Unspecified puerperal mental disorder 0 1 Borderline personality disorder 0 1 Table 2: Treatment outcomes for participants and non-participants in a program offered in a private acute psychiatric care unit. Admission Discharge Significance (mean±sd) (mean±sd) Length of stay (days) ± NS Walkers (n=35) Length of stay (days) ± Non-walkers (n=49) DASS depression ± ±14.90 NS DASS depression ± ±11.43 DASS anxiety ± ±12.22 NS DASS anxiety ± ±10.32 DASS stress ± ± NS DASS stress ± ± CGI-S 4.52 ± ± 1.03 NS at Walkers (n=25) admission p=0.001 CGI-S 4.42 ± ± 1.03 at discharge Non-walkers (n=40) Health Promotion Journal of Australia 2007 : 18 (1) 41

5 Ng et al. Author: third page, second col, first para, abbreviation ECT. Is this electro-convulsive therapy? Please spell out. Author: please provide fax number for contact details. Article physical activity beneficial for mental health, benefits in various psychiatric diagnoses, and its role in the management of mental illness, whether in an acute or maintenance/preventive setting. This may assist in a more specific use of particular types of physical activities in targeted patient groups in the clinical setting. Conclusion This study investigates the impact of a walking program as a clinical intervention in an acute psychiatric unit and finds that there is no evidence to suggest that patients have benefited from participation in the program. Indeed, the study found that participants in the walking group had worse outcomes than non-participants on a single measure, the CGI-S. However, this may be caused by recruitment bias as participants were not randomised to the two groups. Nevertheless, this study does not replicate recent studies showing that physical activity is beneficial for mental health 7-15 and suggests that benefits shown in other studies do not translate into advantages for patient outcomes by simply introducing a walking program into the psychiatric in-patient setting. Randomised, controlled trials are required to clarify the role, if any, of particular physical activity programs in the in-patient treatment of mental illness. The amount and type of activity that may be beneficial requires clarification. This study does demonstrate that the introduction of a walking program into a psychiatric in-patient unit is feasible and well received, thus further enhancing the attractiveness of using physical activity programs in the therapeutic setting. Statement of interest The authors have no conflict of interest with any commercial or other association in connection with the submitted article. Acknowledgement We would like to thank the National Health and Medical Research Council for its financial support for this research (Project Grant No ). References 1. Physical Activity and Health: A Report of the US Surgeon General. Atlanta (GA): US Department of Health and Human Services, Centers for Disease Control and Prevention, National Centre for Chronic Disease Prevention and Health Promotion; Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. J Am Med Assoc. 1995;273(5): Bauman AE. Updating the evidence that physical activity is good for health: an epidemiological review J Sci Med Sport. 2004;7Suppl 1: Henderson S, Andrews G, Hall W. Australia s mental health: an overview of the general population survey. Aust N Z J Psychiatry. 2000;34(2): Weyerer S. Physical inactivity and depression in the community. 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Manual for the Depression Anxiety Stress Scales. 2nd ed. Sydney (AUST): Psychology Foundation; Authors Felicity Ng, Department of Clinical and Biomedical Sciences: Barwon Health, University of Melbourne, Victoria, and the Geelong Clinic, Victoria Seetal Dodd and Felice N. Jacka, Department of Clinical and Biomedical Sciences: Barwon Health, University of Melbourne, Victoria Evie Leslie, School of Health and Social Development, Deakin University, Victoria, and Department of Human Services (Barwon-South Western Region) Partnership, Victoria Michael Berk, Department of Clinical and Biomedical Sciences: Barwon Health, University of Melbourne, Victoria; Orygen Research Centre, Victoria; the Geelong Clinic, Victoria; and Mental Health Research Institute, Victoria Correspondence Dr Seetal Dodd, Department of Clinical and Biomedical Sciences: Barwon Health, Swanston Centre, PO Box 281, Geelong, Victoria. Ph: (03) TO COME; fax: (03) ; seetald@barwonhealth.org.au 42 Health Promotion Journal of Australia 2007 : 18 (1)