physical activity and youth mental health bsphn forum 2018
TRANSCRIPT
Physicalactivityandyouthmentalhealth
ProfessorAlexParker
BrisbaneSouthPHN
YouthHealthForum,Feb2019
Co-investigatorsA/ProfSarahHetrickA/ProfRosiePurcellProfTonyJormProfAndrewMackinnonProfPatMcGorryA/ProfMarioAlvarez-JimenezProfAlisonYungProfDebraRickwood
ProjectManagersConnieMarkulev &VickyRayner
ResearchTherapists&AssistantsDaveena Mawren,JessicaStephens,FayeScanlan,Dr BridgetMoller,ShelleyBaird,DinaEleftheriadis,EmmaBleaney
AcknowledgementsCentremanagers,clinicalleaders,accessteam,receptionandadminstaffatheadspace Sunshine headspaceGlenroyheadspaceCollingwood headspaceCoffsHarbourheadspaceHawthorn headspaceBathurst/OrangeheadspaceTownsville headspaceEdinburghNorthheadspaceIpswich
Alltheyoungpeoplewhoparticipatedinresearchstudies
Health,mentalhealthandphysicalactivity
Evidenceforphysicalactivityinterventionsintreatingdepressioninyoungpeople
Barriersandfacilitatorstoimplementingphysicalactivityinterventions
Integratingphysicalactivityintomentalhealthtreatment(casestudy)
Overview
Hippocrates~450BC
Ifwecouldgiveeveryindividualtherightamountofnourishmentandexercise,
nottoolittleandnottoomuch,
wewouldhavefoundthesafestwaytohealth
Definitions
PhysicalactivityAnybodilymovementproducedbythecontractionofskeletalmusclethatincreasesenergyexpenditureaboveabasallevel.
Physicalactivityincludesexerciseaswellasotheractivitieswhichinvolvebodilymovementandaredoneaspartofplaying,working,activetransportation,housechoresandrecreationalactivities.
ExerciseAsubcategoryofphysicalactivitythatisplanned,structured,repetitive,andpurposiveinthesensethattheimprovementormaintenanceofoneormorecomponentsofphysicalfitnessistheobjective
Globalratesofinactivity
31.1%ofadults
80.3%ofadolescents
Globalestimatesofburdenof
disease
6%coronaryheartdisease
7%type2diabetes
10%breastcancer
10%coloncancer
9%prematuremortality
Physicalinactivityinchildrenandadolescents
Increasedcardio-metabolicrisk
Healthimplicationsofphysicalinactivity
Reducedlifeexpectancycomparedto
generalpopulation
Schizophrenia,bipolar,
schizoaffective,majoraffective
disorders
Mortalityrates2.22timeshigher
10+yearslifelost
Patientfactors
Lowerhelp-seekingfor
physicalhealth
Poorerlifestylebehaviours
Clinicianfactors
Lessmedicalcareandlifestyleinterventions
offeredtothosewithSMI
Mentalhealthimplicationsofphysicalinactivity
Howmuchphysicalactivityisenough?
Currentrecommendationsforphysicalactivity
http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines
Australianguidelines
12-18years
• Atleast60minsmoderate/vigorousexerciseperday
• Muscleandbonestrengtheningactivities3timesperweek
• Reducescreen/TVandsittingtime
18+years
• 30minsmoderateexerciseonmost,preferablyall,days
• 150-300minsmoderateor75-150minsvigorousintensityeachweek
• Musclestrengtheningactivities2timesaweek
• Minimise prolongedperiodsofsitting
Canadian24-hourmovementguidelines
www.csep.ca/en/guidelines/canadian-24-hour-movement-guidelines
DepressionleadingcauseofDALYs
Limitationsofcurrentfirst-linetreatments
Current interventions (CBT, SSRIs) are modestly effective
Many young people do not reach symptomatic or functional improvement after treatment
Many young people do not reach remission after treatment
Need additional therapeutic strategies
Combination treatments may boost treatment effects
Limitations of current first-line treatments
Current interventions (CBT, SSRIs) are modestly effective
Many young people do not reach symptomatic or functional improvement after treatment
Many young people do not reach remission after treatment
Need additional therapeutic strategies
Combination treatments may boost treatment effects
Physicalactivity/exerciseshowspromiseforyoungpeoplewithdepression
Cross-sectionalandlongitudinalstudiesshow
• Morephysicalactivity,lowerdepression
• Higherdepressionsymptoms,lowerphysicalactivity
• Moresedentarybehaviours,higherdepression
Physicalactivitylevels:Australiandata
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
12-17years
18-24years
Sufficientactivity Insufficientactivity
Physicalactivitylevels:Australiandata
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
headspaceYP
12-17years
18-24years
Sufficientactivity Insufficientactivity
Physical activity
Mentalhealth
Mentalhealth
difficulties
Mentalillness
Healthpromotion
UniversalPrevention
IndicatedorTargetedPrevention
Intervention/Treatment
PreventionofComorbidities
MentalhealthcontinuumPhysicalactivityastreatment:metaanalysis
Bailey,A.,etal(2018).PsychologicalMedicine,48(7),1068-1083.
PAfordepressioninadults:Meta-analysis
Schuch etal(2016)JournalofPsychiatricResearch.2016;77:42-51.
Stubbsetal(2017)PsychiatryResearch;249:102-108
PAforanxietyinadults:Meta-analysis
PAandsuicidalideation
Vancampfort etal(2018)JournalofAffectiveDisorders225,438–448
ExerciseplusCBT/medicationinadultswithMDD
SmallRCTof16adults(Gourgouvelis etalFrontiersinPsychiatry2018:9;37)
8weekintervention
MedicationandgroupCBTplus:
1. 150minutesmoderateexerciseperweek
2. TAUonly
SimpleInterventionsTrial
headspaceSunshineandGlenroy(2008-2013)
174youngmales(40%)andfemales
Meanage17.6years
2x2factorialdesign
• Psychologicalintervention:problemsolvingtherapyorsupportivecounselling
• Physicalactivityintervention:behaviour changeorpsycho-education
Whatdidthephysicalactivityinterventioninvolve?
1. Providingverbalandwrittenpsychoeducation
2. Elicitingideasandbeliefsaboutphysicalactivityandmentalhealth
3. Creatinglistofcostsandbenefits
4. Mappinglevelsofphysicalactivityoverlastfewweeks
5. Providingguidelinesforagegrouptocreateexercisegoalsandbrainstormingrangeofactivities– light,moderate,vigorous
6. Addressingbarrierstoengaginginactivity
7. CompletingSMARTgoalsandweeklyplanner
8. Monitoringrelationshipbetweenphysicalactivity,moodandanxiety
Primaryoutcome:
Selfreportdepressionsymptoms
Proposedmechanismsofactionfordepression
Socialsupport:interactionandincreasednetworks
Distractionfromrumination:shiftfocusfromnegativemoodandnegativethoughts
Behaviouralactivation:increasedengagementinadaptiveactivities;enjoymentandachievement
Self-esteem:confidenceandimprovedcopingwithpsychologicalstress
Self-efficacy:mastery,achievementincreasingperceptionsofcopingorcontrol
Psychologicalhypotheses
Proposedmechanismsofactionfordepression
Endorphins:elevatedplasmalevels
Monoamines:preventionofserotoninandnoradrenalinereuptake
Hippocampal neurogenesis:increaseinBDNFandhippocampalvolume
Aerobic fitness:cardiovascularchanges(egdecreasedcortisol,epinephrine)
Inflammation:increasedIL-6,IL-10;decreasedC-reactiveprotein
Biologicalhypotheses
ClinicianbarrierstoPAinterventions
Notpartofclinicalrole
Concernsitwilldisrupttherapeuticrelationship
Lackoftime
LackofknowledgeandconfidenceinrecommendationsofPA
Beliefthatclientsprefertraditionalpsychologicaltreatments
BeliefthatPAisinsufficientforcomplexpresentations/clinicalneeds
Competingclinicalpriorities
“Thedifficultywas…hewasquiteintenselydepressedatthetime,andhehadsortofhadalotofthingsgoingoninhislife,andhewantedtoshare,usethespacetosharehisexperienceanditjustfeltlikeaninterruption…”
“Itfeltabitartificialattimeskindofgoing“sooknowlet’stalkaboutthephysicalactivitysideofthings”sothatwasabittrickybutotherwisejustgenerallykindofpeoplewhoweren’tveryphysicallyorientated[ummm]itjustmightoffeltlikeitwasn’tquiteamatchforthem…”
“Ithasbeendifficulttoshiftfromtalkingaboutaparticulartraumaandthenallofasuddengohey,we’vegottenminutesleft,whatabouttheexercise?”
Youngpeople
prefertotryothertreatmentsbeforetakingmedicationfordepression
endorseexerciseasahelpfultreatmentfordepression
havefoundexercisebeneficialfortreatingdepression
whohaveengagedinPAinterventionfordepressionreportnoimpactonrelationshipwithclinicianorexpectationsoftherapy
Clinicalroleandtherapeuticrelationship
…whenyoutalkaboutmentalhealth,it’snotjustaboutmentalhealthreally.It’saboutemotionalandsocialhealth,andjustincorporatingphysicalhealth,ithelpseverythingelseout.It’sacircle,it’sabalance.Ithinkbringingitalltogetherjustcomplementsit.
Youngperson
ClinicianfacilitatorstoPAinterventions
Professionaldevelopment
AdequateknowledgeregardingPAinterventions
Perceivedself-efficacyforincreasingPAengagementintheirclient
OwnregularengagementinPA
…asatherapistownityourselfanddoityourself,intermsofphysicalactivity,I’magreatbelieverinthatbecausethenyouabsorbit.Clientspickthatup.
It’sabitlikemindfulness.Ifwearenotdoingmindfulnessourselvesastherapists,Ithinkit’sveryhardtoteachitandencourageittotheotherperson.
Clinician
Casestudy:Sarah
24yearoldfemale,livingwithpartnerof4years,post-graduatestudent(commenced2018)
Long-standinghistoryofsocialanxiety(onset12years),withseverityincreasingduringYear11
3-4yearhistoryofco-morbiddepression(severeatassessment)
Significantsocialandvocationalfunctionalimpairment
• Unemployed,notstudying,limitedsocialinteractions(SOFAS55)
Restricted,depressedandanxiousaffect
Minimalquantityofspeech,softvolume,monotonoustone
Slowthoughtstream,monosyllabicanswers
Casestudy:Sarah
Predisposingfactors:parentalseparation;emotionallydistantmother;sisterwithexternalisingproblems;fatherabsentthroughwork;shytemperament
Precipitatingfactors:transitiontosecondaryschool;increaseinpresentingrequirements;critical/hostilemother;difficultymakingnewfriends/sociallyisolated
Perpetuatingfactors:academicachievementsmaskedanxietysymptoms;partner/sisterreinforcingavoidance/safetybehaviours;high-standards/perfectionistictraits;criticalmother;comparisontoothers’successes;schemasofdefectivenessandfailure
Protectivefactors:supportivepartner,sister,father,in-laws;intelligence/academicsuccess;willingnesstoengageintreatment
CBTmodel:Sarah
Thoughts
BehavioursEmotions
I’muselessIcan’tdothisI’mnogoodatanythingIneverdothingsrightEveryone’slifeisbetterthanmine
Avoidance/notleavinghouse/notansweringphoneSocialwithdrawalUnabletoconcentrateDifficultiesmaintainingwork
OverwhelmedanddistressedGuiltyMiserableandsadLackinginconfidence
Clinicalconsiderations:CBTmodel
Formulation driven and linked to presenting issues
Timing of PA– morning to maximise achievement and challenge core beliefs “I’m useless” and “I’m no good at anything”
Intensity of PA – walking to Uni to manage social anxiety
Type of PA – yoga with friend for social support
Thoughts
BehavioursEmotions
Improvedfunctioning
Normalrangeofaffect
Euthymicmood
Normalrate,tone,volumeofspeech,includingspontaneousspeech
Significantcognitiverestructuring
Serviceexample:KeepingtheBodyinMind
KeepingtheBodyinMind:holistic,individualised lifestyleandlifeskillsinterventiontopreventweightgaininFEPyoungpeople
Evaluation:12weekinterventioncomparedtoTAUinEPservice
Intervention:standardEPcare(medication,psychologicaltreatment,casemanagement)plushealthcoaching,dieteticsupportandsupervisedexerciseprescription
SouthEasternSydneyLocalHealthDistrictCurtisetal (2016)EarlyInterventioninPsychiatry10(3):267-276
KeepingtheBodyinMind:Results
0
20
40
60
80
100
KBIM TAU
Weight
Pre Post
21
22
23
24
25
26
27
28
KBIM TAU
BMI
Pre Post
78
80
82
84
86
88
90
92
KBIM TAU
Waistcircumference
Pre Post
p<.001
Sitextimeinteraction:Weight,waist&BMIp<.001
p<.001
p<.001
SouthEasternSydneyLocalHealthDistrictCurtisetal (2016)
Resources
orygen.org.au/Education-Training/Resources-Training/BIYMH
essa.org.au/wp-content/uploads/2017/03/Addressing-the-Physical-Health-of-People-with-Mental-Illness_Final.pdf
exerciseismedicine.com.au
orygen.org.au/Education-Training/Resources-Training/Resources/Free/Research-Bulletins/Physical-activity-interventions
Summary:Clinicalimplications
Physicalactivityisalow-stigma,safe,feasible,acceptableintervention
Someactivityisbetterthannone:mentalhealthbenefits
Preference,tailoring,enjoyment,short-termaffectiveregulationtoenhanceautonomousmotivationandadherence
Behaviour-changestrategies:motivationalenhancement,goal-setting,monitoring,reinforcement,self-rewards
Multi-disciplinaryapproach:medicalandalliedhealthprofessionals,families,carers
Positivesideeffects:improvedphysicalhealth,sleep,stress-reduction,concentration,cognition
Activitylevelsandhealthbehavioursinadolescencearecarriedintoadulthood
Lederman et al, (2017). Australasian Psychiatry, 25(5), 451-455.
Vancampfort et al (2016). Psychiatry Research, 240, 267-271.
INSTITUTE FOR HEALTH AND SPORT
Ifounditeasiertojustsortofclearmyhead,whenthingsweren’treallyfeelingthebest… ifIwasfeelingparticularly
horribleaboutsomething,insteadofsittingthereandhavingacry,andthinkingaboutit,Iwouldjustgoforabitofajog.
AndatleastthenmyheadwasbitclearersothatIcouldthinkeitherabitlessaboutitorjusttorelaxalittlebit.So,mademe
feelalothappier.
Youngpersonwithdepression
References:publications
BaileyA,Hetrick SE,RosenbaumS,PurcellR,ParkerAG.Treatingdepressionwithphysicalactivityinadolescentsandyoungadults:Asystematicreviewandmeta-analysisofrandomised controlledtrials.PsychologicalMedicine2018;48(7):1068-83.
CurtisJ,WatkinsA,RosenbaumS,TeasdaleS,Kalucy M,SamarasK,etal.Evaluatinganindividualizedlifestyleandlifeskillsinterventiontopreventantipsychotic-inducedweightgaininfirst-episodepsychosis.EarlyInterventioninPsychiatry.2016;10(3):267-76.
Fibbins H,WardPB,WatkinsA,CurtisJ,RosenbaumS.Improvingthehealthofmentalhealthstaffthroughexerciseinterventions:Asystematicreview.JournalofMentalHealth.2018;27(2):184-91.
Gourgouvelis J,YielderP,ClarkeST,Behbahani H,MurphyBA.ExerciseLeadstoBetterClinicalOutcomesinThoseReceivingMedicationPlusCognitiveBehavioralTherapyforMajorDepressiveDisorder.FrontiersinPsychiatry.2018;9:37.
LedermanO,Suetani S,StantonR,ChapmanJ,Korman N,RosenbaumS,etal.Embeddingexerciseinterventionsasroutinementalhealthcare:Implementationstrategiesinresidential,inpatientandcommunitysettings.AustralasianPsychiatry.2017;25(5):451-5.
ParkerAG,Hetrick SE,Jorm AF,MacKinnonAJ,YungAR,McGorry PD,etal.Theeffectivenessofsimplepsychologicalandphysicalactivityinterventionsforhighprevalencementalhealthproblemsinyoungpeople:Afactorialrandomised controlledtrial.JournalofAffectiveDisorders.2016;196:200-9.
References:publications
PhysicalHealthPolicyWritingGroup.Physicalchallenge:widerhealthimpactsforyoungpeoplewithamentalillness.Melbourne:Orygen,TheNationalCentreofExcellenceinYouthMentalHealth;2016.
RosenbaumS,TiedemannA,StantonR,ParkerAG,Waterreus A,WardPB.Implementingevidence-basedphysicalactivityinterventionsforpeoplewithmentalillness:anAustralianperspective.AustralasianPsychiatry.2016;24(1):49-54.
Schuch FB,Vancampfort D,RichardsJ,RosenbaumS,WardPB,StubbsB.Exerciseasatreatmentfordepression:Ameta-analysisadjustingforpublicationbias.JournalofPsychiatricResearch.2016;77:42-51.
StubbsB,Vancampfort D,RosenbaumS,FirthJ,Cosco T,VeroneseN,etal.Anexaminationoftheanxiolyticeffectsofexerciseforpeoplewithanxietyandstress-relateddisorders:Ameta-analysis.PsychiatryResearch.2017;249:102-8.
Vancampfort D,Hallgren M,FirthJ,RosenbaumS,Schuch FB,Mugisha J,etal.Physicalactivityandsuicidalideation:Asystematicreviewandmeta-analysis.JournalofAffectiveDisorders.2018;225:438-48.
Vancampfort D,Moens H,Madou H,DeBackerT,Vallons V,Bruyninx P,etal.Autonomousmotivationisassociatedwiththemaintenancestageofbehaviour changeinpeoplewithaffectivedisorders.PsychiatryResearch.2016;240:267-71.
References:websitesandresources
http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines
www.csep.ca/en/guidelines/canadian-24-hour-movement-guidelines
http://www.essa.org.au/wp-content/uploads/2017/03/Addressing-the-Physical-Health-of-People-with-Mental-Illness_Final.pdf
http://www.orygen.org.au/Education-Training/Resources-Training/Resources/Free/Research-Bulletins/Physical-activity-interventions
http://www.exerciseismedicine.com.au
http:www.orygen.org.au/Education-Training/Resources-Training/BIYMH
http://www.movemoresitless.org.au/
http://www.ispah.org
Thankyou
Twitter@alex_gparker
InstituteforHealthandSport
vu.edu.au/research/institute-for-health-sport