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Exercise Prescription Practices to Improve Mental Health

Escobar-Roldan, Ivan D. MD; Babyak, Michael A. PhD; Blumenthal, James A. PhD

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Journal of Psychiatric Practice: July 2021 - Volume 27 - Issue 4 - p 273-282
doi: 10.1097/PRA.0000000000000554
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Abstract

There is growing evidence that higher levels of physical activity (PA) are associated with better mental health.1 Furthermore, interventional studies have shown that PA improves symptoms of a number of psychiatric conditions, ranging from mood disorders to schizophrenia.2–6 Randomized clinical trials have reported similar effect sizes for exercise compared with antidepressant medications or cognitive-behavioral therapy interventions for depression,3,7,8 although the authors of a Cochrane meta-analysis concluded that the findings concerning depression were based mainly on a few small trials.9 Other studies have found reduced psychiatric symptoms associated with PA interventions in severe mental illnesses including schizophrenia5,10 and bipolar disorder.11 There is also evidence from randomized clinical trials that exercise is associated with improvements in cognitive functioning and activities of daily living in patients with dementia,6,12,13 and with improvements in sleep quality and reductions in sleep latency in patients with sleep disorders.14 Encouraging results have also been reported for exercise in patients with alcohol craving and in the achievement of alcohol abstinence.15 In addition, exercise has been found useful when used as an adjunct therapy in bipolar disorder,4,11 obsessive-compulsive disorder,16 and posttraumatic stress disorder.17

Despite this growing body of evidence for the value of PA, little information is available about how these data are being incorporated into clinical practice. The Centers for Disease Control Healthy People 2020 initiative found that, although the number of individuals advised to exercise by their health providers had increased between 2000 and 2010, only 1 in 3 adults in the United States who had seen a physician or other health professional in the past year reported having been advised to exercise in 2010.18 Another study, conducted in the United States in 2014, found that only 37% of patients reported that their mental health providers regularly discussed PA with them.19 The prescription of exercise by medical professionals increases adherence to exercise programs as well as the percentage of patients reaching recommended PA goals20,21 established by such organizations as US Department of Health and Human Services (HHS) and the American College of Sports Medicine (ACSM). However, a study that examined these prescribing practices in Canada found that primary care providers gave written prescriptions for exercise in <10% of appointments.22 In contrast, surveys done in Australia and New Zealand found that 60% to 70% of mental health providers prescribed exercise regularly for some psychiatric conditions.23,24 In the United States, about 50% to 80% of surveyed psychologists reported advising patients to exercise.25,26 Unfortunately, most of these studies of providers’ practices did not differentiate between casually “recommending” PA and formally prescribing exercise (ie, giving specific instructions on type, frequency, duration, and intensity of PA). Assessing the level of detail and quality of the recommendations provided to patients is crucial, especially since these should be in line with national guidelines and the dosing of exercise used in clinical trials.3,7,8 To our knowledge, no study has described or evaluated the exercise prescription practices for mental health conditions among physicians in the United States. Therefore, the goal of this study was to characterize the exercise prescribing practices of health care providers from different subspecialties and to evaluate factors that may influence their prescribing practices.

METHODS

We conducted a cross-sectional survey among faculty and staff in the Departments of Psychiatry, Medicine, and Family Medicine in a large academic tertiary care medical center in the southeastern United States. Participants were invited to participate via general email or through departmental newsletters. Prospective participants were informed that their consent was inferred from completion of the survey. Exemption for written informed consent was obtained from the Institutional Review Board. All data were collected anonymously using Research Electronic Data Capture (REDcap, www.project-redcap.org).

Development of the Survey

The survey (shown in the Appendix) consisted of items that asked about basic demographic information, providers’ exercise prescribing practices, potential facilitators and barriers for exercise prescription, and providers’ personal exercise habits. Items describing exercise prescription practices were based on HHS Physical Activity Guidelines for Americans, the ACSM’s Guidelines for Exercise Testing and Prescription, and ACMS’ Exercise is Medicine fillable prescription form.27,28 The selection of items assessing factors influencing prescription was based on previously published surveys and clinical experience.24,29 Respondents were asked if they specified the frequency, intensity, duration, and type of exercise in their prescriptions, if they followed national guidelines, and if written recommendations were provided to their patients. Participants also were asked to select from a list of factors that could influence exercise prescribing practices and potential barriers that might affect their exercise/PA recommendations.

Data Analysis

Descriptive statistics were used to characterize the sample. Ordered logistic regression was used to evaluate the association of clinical degree and practitioners’ own exercise habits with their recommendations of exercise as therapy. We estimated a separate ordered logistic regression model for each of the prescription practices (items 4, 5, 6, and 7 in the Appendix) as the response variable. In each model, the predictors were sex, age, clinical degree, and providers’ exercise habits (items 1, 2, 3, and 10). For the clinical degree predictor, Psychiatry MDs and Psychiatry residents were collapsed into a single category. In the primary models, the Psychiatry MD category was specified as the reference category in the models. To provide a further perspective on clinical degree as a predictor, we also provided estimates from the same model, but using the Internal Medicine MD specialty as the reference.

RESULTS

Of the 391 providers who were contacted via email and newsletters postings, 185 respondents completed the survey (response rate of 47%). The majority of participants were MDs (Table 1). Almost 60% of providers recommended PA/exercise “often” or “almost always/always” as part of the treatment recommendations for patients with psychiatric conditions; however, only 30% reported that they followed national guidelines, only 24% provided specific exercise instructions, and only 12% reported that they gave patients written recommendations (Fig. 1). Depression (84.9%) and anxiety (69.2%) were the most common indications for an exercise prescription (Table 2), and insufficient knowledge or training (35.7%) was identified as the most common barrier to prescribing exercise (Table 3). Approximately half of the providers reported that they exercised 3 or more times/week, and 90% reported that, ideally, they would like to exercise 3 or more times/week.

TABLE 1 - Demographics Characteristics of the Sample (N=185)
n (%)
Sex
 Female 117 (63.2)
 Male 68 (36.8)
Age (y)
 25-39 111 (60)
 40-64 66 (35.7)
 ≥65 8 (4.3)
Clinical degree
 MD 132 (71.3)
  Psychiatry 50 (27)
  Family Medicine 20 (10.8)
  Internal Medicine 50 (27)
  Combined Medicine and Psychiatry 12 (6.5)
 Other 53 (28.6)
  Psychologist (PsyD or PhD) 40 (21.6)
  Other 13 (7)

FIGURE 1
FIGURE 1:
Exercise prescription practices of surveyed health providers. MH indicates mental health.
TABLE 2 - Conditions in Which Providers Recommended Exercise as Part of the Treatment Plan (N=185)
n (%)
Depression 157 (84.9)
Anxiety disorders 128 (69.2)
Routine care 128 (69.2)
Sleep disorders 120 (64.9)
Substance-related disorders 59 (32.0)
Posttraumatic stress disorder and related disorder 55 (29.7)
Bipolar disorder 53 (28.6)
Cognitive impairment 50 (27)
Other 34 (18.4)
Schizophrenia/psychotic disorders 28 (15.1)
Obsessive-compulsive and related disorders 25 (13.5)

TABLE 3 - Potential Barriers and Facilitators of Exercise Prescription (N=185)
n (%)
Insufficient knowledge or training 66 (35.7)
More likely to prescribe if there is a comorbidity or side effects from psychiatric medication 66 (35.7)
Believe that exercise is beneficial for mental health and prescribe it following clinical practice guidelines 61 (33.0)
Patients are not interested in exercise recommendations 54 (29.2)
Lack of time to include exercise prescription in day-to-day practice 52 (28.1)
Poor adherence to exercise recommendations 51 (27.6)
Patients prefer or expect medication management or psychotherapy 43 (23.2)
More likely to prescribe exercise as an adjunct therapy if the current treatment is not working 27 (14.6)
Physical activity counseling is not a priority 20 (10.8)
Lack of financial incentive/reimbursement for exercise counseling/prescription 9 (4.9)
Exercise prescription should be implemented by an exercise professional 7 (3.8)
Lack of evidence for the effectiveness of exercise for mental health conditions 6 (3.2)
I do not believe that exercise can be an effective treatment for mental health conditions 3 (1.6)

Predictors of Prescribing Practices

The odds of prescribing exercise were 5 to 9 times greater among providers who were regular exercisers compared with their sedentary counterparts, and the recommendations of those who were regular exercisers were considerably more likely to meet national PA guidelines (Table 4). Family medicine physicians were more likely to recommend exercise, provide specific instructions, and meet national PA guidelines compared with internal medicine and psychiatry physicians. Psychologists were more likely to recommend exercise and provide specific instructions compared with internal medicine physicians. Social workers, physician assistants, nurse practitioners, and other health professionals were less likely to follow national guidelines compared with psychiatrists and internal medicine physicians. There were no significant differences in prescribing practices as a function of practitioners’ age or sex.

TABLE 4 - Logistic Regression Analysis of Predictors of Prescribing Practices
Recommends PA as Treatment for Patients With MH Conditions Provides Specific Instructions on PA Provides Written Recommendations for PA Recommendations Follow National Guidelines for PA
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Personal exercise habits (reference group: never exercise)
 Exercise 1-2 times per month 2.6 0.5-13.5 2.6 0.5-13.5 1.6 0.3-1.99 6.8 0.6-67.7
 Exercise 1-2 times per week 3.1 0.6-14.5 3.1 0.6-15.1 1.5 0.3-8.6 8.3 0.9-76.8
 Exercise 3-5 times per week 5.0* 1.0-24.5 5.1* 1.0-24.8 2.5 0.4-8.62 15.8* 1.7-147.7
 Exercise 6 times or more per week 8.9* 1.6-50.2 5.2 0.9-28.9 2.3 0.4-14.8 35.3* 3.4-368.3
Clinical degree (reference group: Internal Medicine MD)
 Family Medicine MD 8.2* 2.9-23.5 6.3* 2.2-17.9 3.3* 1.2-8.6 6.0* 2.1-16.9
 Psychiatry MD 2.2 0.9-5.1 2.3* 1.0-5.4 1.2 0.5-3.0 0.8 0.3-1.8
 Combined Medicine and Psychiatry MD 2.7 0.8-9.2 2.8 0.6-5.6 1.8 0.5-6.3 1.8 0.5-5.7
 Psychologist 4.2* 1.8-9.5 2.5* 1.1-5.5 1.0 0.4-2.3 0.6 0.3-1.4
 Other 2.4 0.7-8.0 1.7 0.5-5.3 1.5 0.5-5.3 0.3* 0.1-0.8
Clinical degree (reference group: psychiatry MD)
 Family Medicine MD 4.6* 1.4-11.5 2.9* 1.0-8.2 2.7 1.0-7.4 7.1* 2.5-20.4
 Internal Medicine MD 0.5 0.2-1.1 0.5 0.2-1.0 0.8 0.4-1.9 1.2 0.6-2.5
 Combined Medicine and Psychiatry MD 1.3 0.4-4.4 1.3 0.4-4.6 1.5 0.4-5.1 2.1 0.6-6.9
 Psychologist 2.0 0.9-4.5 1.1 0.5-2.5 0.8 0.3-2.0 0.7 0.3-1.6
 Other 1.1 0.3-3.9 0.8 0.3-2.5 1.3 0.4-4.5 0.2* 0.1-0.9
CI indicates confidence interval; MH, mental health; OR, odds ratio; PA, physical activity.
*P<0.05.

DISCUSSION

Almost 60% of providers who responded to our survey indicated that they regularly recommend exercise or PA to their patients with mental health conditions and a very high proportion of the providers recommended exercise in depression (84.9%), the condition for which there is the most evidence.3,7,8 Our findings are consistent with previous surveys, which have generally shown that exercise is considered a valid therapeutic intervention for treating psychiatric conditions.23–26 However, we also found that only a small proportion of respondents (24%) provided detailed recommendations or exercise prescriptions and instruction as to the type, frequency, duration, and intensity of exercise. The absence of these concrete recommendations is crucial in evaluating the quality of the recommendations and the clinical impact they may have. Most national guidelines, at the minimum, emphasize the intensity and duration of PA necessary to have a physiological and clinical impact. Likewise, clinical trials that have reported positive effects of exercise on psychiatric conditions used a specific “dose” of exercise.3,7,8 For example, the Depression Outcomes Study of Exercise (DOSE) examined different components of the exercise prescription for patients with major depressive disorder and found that a 17.5 kcal/kg/week dose, consistent with public health recommendations for PA, reduced depressive symptoms significantly compared with a 7.0 kcal/kg/week dose.30 The Duke Standard Medical Intervention and Long-term Exercise (SMILE) studies3,31 examined the effects of sertraline and exercise in patients with major depressive disorder. In the first study, supervised exercise 3 times/week achieved benefits comparable to sertraline after 4 months of treatment. However, in the absence of a control group, it was impossible to attribute the benefits to the treatment.31 In a subsequent study comparing home-based and supervised exercise with sertraline and a placebo, patients receiving active treatments had reduced depressive symptoms and tended to have higher remission rates compared with the placebo controls.3 In the SMILE studies, patients engaged in a typical cardiac rehabilitation exercise protocol: patients in the aerobic exercise groups had sessions 3 times a week that began with a 10-minute warm-up of walking followed by 30 minutes of walking or jogging on a treadmill at a moderate intensity (equivalent to 70% to 85% maximum heart rate reserve) and concluded with 5 minutes of cool-down exercises. Exercisers had comparable improvements in depressive symptoms compared with those participants on sertraline, and both the sertraline and exercise groups achieved greater improvements compared with the placebo controls. In addition, the exercisers achieved greater improvements in aerobic fitness and functional capacity.

Clinical Implications

Despite the physical and mental health benefits of exercise in patients with mental health issues, exercise is seldom prescribed with the same degree of precision as are medications. Respondents to our survey cited insufficient knowledge or training as the most common potential barrier to prescribing exercise for patients with mental health conditions, consistent with a recent review on this topic.32 Wider dissemination of information about the effects of exercise on mental illness and the inclusion in training curriculums of exercise physiology, clinical guidelines, and available resources for exercise prescription, such as ACSM’s Exercise is Medicine initiative, may help address these issues and facilitate standardization of prescription practices.33

Previous reports concerning the association of providers’ personal exercise habits with their exercise prescription practices have been mixed. For example, Radovic et al23 reported that there was no significant relationship between clinician exercise levels and clinician rates of exercise prescription for adolescent depression, and Stanton et al34 found that the exercise practices of general practitioners were not associated with their prescribing practices for depression, although the sample of only 20 respondents was insufficient to draw any definitive conclusions. In contrast, on the basis of a survey of a sample of 325 respondents, Way et al24 reported that mental health practitioners who exercised regularly prescribed exercise for mental health more regularly than nonexercisers. Similarly, on the basis of a survey of 236 psychologists, Burton et al35 reported that regular exercise was significantly associated with providing activity advice and counseling. In our survey, we found that the odds of prescribing exercise for psychiatric conditions and providing more detailed and specific exercise recommendations were 5 to 9 times higher among providers who reported exercising regularly than among those who did not. Health professionals who exercise regularly may be more familiar with exercise issues that are likely to be faced by their patients, may be more confident in the perceived value of exercise, and may feel more competent in prescribing exercise, suggesting that promoting exercise among health practitioners, in addition to self-care benefits, may have an indirect beneficial effect on their patients by leading the providers to encourage their patients to exercise too.

We found modest evidence for differences in prescribing practices among different subspecialties. Differences in prescription practices according to medicine specialty or type of provider may be explained by differences in practice setting; for example, having a predominately inpatient versus outpatient practice may influence prescribing practices. Outpatients may receive more detailed exercise prescriptions, but this may be a result of outpatients having less severe medical conditions and psychopathology and greater flexibility with regard to prescribing components such as exercise intensity and duration.

Our survey focused on exercise as a treatment for mental health conditions. However, there is also evidence supporting the prescription of exercise in more than 2 dozen medical conditions ranging from osteoarthritis to pulmonary disease and cancer,2 with some recent studies examining the appropriate exercise dose needed for clinical impact.36,37 Many mental health providers have training in techniques such as motivational interviewing and cognitive-behavioral therapy to promote patients’ adoption of exercise in their daily lives.

Limitations

We performed a survey that relied on volunteer health care providers. While over 391 providers were contacted, fewer than half responded (response rate of 47%). However, we surveyed a broad range of health providers from a number of different specialties with diverse demographic characteristics, suggesting that the sample is representative of the clinical workforce that treats patients with mental health conditions in the context of the study. The clinicians who volunteered were also all affiliated with a single large academic tertiary care medical center; hence the sample may not be representative of health care providers more generally. Also, considering that we relied on provider self-report, response bias or recall bias may have affected our findings.38 In addition, our survey covered a range of factors that could affect prescribing practices, but there may have been other considerations that affect prescribing practices that we did not assess. Finally, participants were asked if they included exercise as part of their treatment plans for patients with mental health conditions; however, we did not explore if exercise was prescribed primarily to reduce psychiatric symptoms or to improve general well-being or physical health.

CONCLUSIONS

Exercise is widely considered to be an important health behavior to improve both physical and mental well-being. Yet, only a small proportion of health providers provide exercise recommendations consistent with national guidelines. Insufficient knowledge and training were considered the most common barriers to exercise prescription and the differences in prescription practices among clinicians from different specialties suggest the need to include exercise prescription in school curriculums and in clinical practice training, as well as wider distribution of exercise prescription guidelines.

Appendix

REFERENCES

1. Dunn AL, Jewell JS. The effect of exercise on mental health. Curr Sports Med Rep. 2010;9:202–207.
2. Pedersen BK, Saltin B. Exercise as medicine—evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015;25(suppl 3):1–72.
3. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosom Med. 2007;69:587–596.
4. Ng F, Dodd S, Berk M. The effects of physical activity in the acute treatment of bipolar disorder: a pilot study. J Affect Disord. 2007;101:259–262.
5. Scheewe T, Backx F, Takken T, et al. Exercise therapy improves mental and physical health in schizophrenia: a randomised controlled trial. Acta Psychiatr Scand. 2013;127:464–473.
6. Steinberg M, Leoutsakos JMS, Podewils LJ, et al. Evaluation of a home-based exercise program in the treatment of Alzheimer’s disease: the Maximizing Independence in Dementia (MIND) Study. Int J Geriatr Psychiatry. 2009;24:680–685.
7. Ekkekakis P, Murri MB. Exercise as antidepressant treatment: time for the transition from trials to clinic? Gen Hosp Psychiatry. 2017;49:A1–A5.
8. Fremont J, Craighead LW. Aerobic exercise and cognitive therapy in the treatment of dysphoric moods. Cogn Ther Res. 1987;11:241–251.
9. Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev. 2013;9:CD004366.
10. Gorczynski P, Faulkner G. Exercise therapy for schizophrenia. Cochrane Database Syst Rev. 2010;5:CD004412.
11. Melo MC, Daher Ede F, Albuquerque SG, et al. Exercise in bipolar patients: a systematic review. J Affect Disord. 2016;198:32–38.
12. Coelho FGdM, Andrade LP, Pedroso RV, et al. Multimodal exercise intervention improves frontal cognitive functions and gait in Alzheimer’s disease: a controlled trial. Geriatr Gerontol Int. 2013;13:198–203.
13. Forbes D, Forbes SC, Blake CM, et al. Exercise programs for people with dementia. Cochrane Database Syst Rev. 2015;4:CD006489.
14. Yang PY, Ho KH, Chen HC, et al. Exercise training improves sleep quality in middle-aged and older adults with sleep problems: a systematic review. J Physiother. 2012;58:157–163.
15. Giesen ES, Deimel H, Bloch W. Clinical exercise interventions in alcohol use disorders: a systematic review. J Subst Abuse Treat. 2015;52:1–9.
16. Rector NA, Richter MA, Lerman B, et al. A pilot test of the additive benefits of physical exercise to CBT for OCD. Cogn Behav Ther. 2015;44:328–340.
17. Powers MB, Medina JL, Burns S, et al. Exercise augmentation of exposure therapy for PTSD: rationale and pilot efficacy data. Cogn Behav Ther. 2015;44:314–327.
18. Barnes PM, Schoenborn CA. Trends in adults receiving a recommendation for exercise or other physical activity from a physician or other health professional. NCHS Data Brief. 2012;86:1–8.
19. Janney CA, Brzoznowski KF, Richardson CR, et al. Moving towards wellness: physical activity practices, perspectives, and preferences of users of outpatient mental health service. Gen Hosp Psychiatry. 2017;49:63–66.
20. Kallings LV, Leijon ME, Kowalski J, et al. Self-reported adherence: a method for evaluating prescribed physical activity in primary health care patients. J Phys Act Health. 2009;6:483–492.
21. Sorensen JB, Skovgaard T, Puggaard L. Exercise on prescription in general practice: a systematic review. Scand J Prim Health Care. 2006;24:69–74.
22. O’Brien MW, Shields CA, Oh PI, et al. Health care provider confidence and exercise prescription practices of Exercise is Medicine Canada workshop attendees. Appl Physiol Nutr Metab. 2017;42:384–890.
23. Radovic S, Melvin GA, Gordon MS. Clinician perspectives and practices regarding the use of exercise in the treatment of adolescent depression. J Sports Sci. 2018;36:1371–1377.
24. Way K, Kannis-Dymand L, Lastella M, et al. Mental health practitioners’ reported barriers to prescription of exercise for mental health consumers. Ment Health Phys Act. 2018;14:52–60.
25. Wendt SJ. Smoking cessation and exercise promotion counseling in psychologists who practice psychotherapy. Am J Health Promot. 2005;19:339–345.
26. Burks RJ, Keeley SM. Exercise and diet therapy: psychotherapists’ beliefs and practices. Prof Psychol Res Pr. 1989;20:62–64.
27. Riebe D, Ehrman JK, Liguori G, et al. ACSM’s Guidelines for Exercise Testing and Prescription. Philadelphia, PA: Wolters Kluwer; 2018.
28. Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320:2020–2028.
29. Stanton R, Happell B, Reaburn P. The development of a questionnaire to investigate the views of health professionals regarding exercise for the treatment of mental illness. Ment Health Phys Act. 2014;7:177–182.
30. Dunn AL, Trivedi MH, Kampert JB, et al. Exercise treatment for depression: efficacy and dose response. Am J Prev Med. 2005;28:1–8.
31. Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on older patients with major depression. Arch Intern Med. 1999;159:2349–2356.
32. Glowacki K, Weatherson K, Faulkner G. Barriers and facilitators to health care providers’ promotion of physical activity for individuals with mental illness: a scoping review. Ment Health Phys Act. 2019;16:152–168.
33. Dacey ML, Kennedy MA, Polak R, et al. Physical activity counseling in medical school education: a systematic review. Med Educ Online. 2014;19:24325.
34. Stanton R, Franck C, Reaburn P, et al. A pilot study of the views of general practitioners regarding exercise for the treatment of depression. Perspect Psychiatr Care. 2015;51:253–259.
35. Burton NW, Pakenham KI, Brown WJ. Are psychologists willing and able to promote physical activity as part of psychological treatment? Int J Behav Med. 2010;17:287–297.
36. Wasfy MM, Baggish AL. Exercise dose in clinical practice. Circulation. 2016;133:2297–2313.
37. Zubin Maslov P, Schulman A, Lavie CJ, et al. Personalized exercise dose prescription. Eur Heart J. 2018;39:2346–2355.
38. Coughlan M, Cronin P, Ryan F. Survey research: process and limitations. Int J Ther Rehabil. 2009;16:9–15.
Keywords:

exercise prescription; physical activity; clinical practice; psychiatric care; mental health

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