1 The case for exercise in the promotion of mental health and psychological well-being
Kenneth R. Fox, Stephen H. Boutcher, Guy E. Faulkner and Stuart J.H. Biddle
Exercise and community health
There is now a worldwide acceptance among medical authorities that physical activity is an important element of healthy living (WHO, 1995). Syntheses of studies (Berlin & Colditz, 1990; Powell, Thompson, Caspersen, & Kendrick, 1987) have indicated that sedentary lifestyles carry at least twice the risk of serious disease and premature death. This is on a par with the relative risk of hypertension and hyperlipidemia and not far behind smoking and has led to suggestions that inactivity should be considered the fourth primary risk factor for coronary heart disease and stroke. Sedentary living is also the most prevalent risk factor with around 40% of the middle-aged and elderly population taking part in infrequent or no moderate to vigorous physical activity (Sports Council/HEA, 1992).
The public burden of inactivity is therefore high and activity promotion could provide a cost-effective strategy for public health improvement (Morris, 1994). In the US it has been estimated that inactivity results in one third of all deaths from CHD, colon cancer and diabetes (Powell & Blair, 1994). The strength of the evidence has led to a US Surgeon Generalās Report entitled Physical Activity and Health (1996) calling for nationally driven initiatives to promote physical activity. In the UK, the Health of the Nation Task Force on Physical Activity produced the consultation paper More people, more active, more often (Department of Health, 1994b). Also, the Health Education Authority expert consensus conference was held to determine the recommended amount of activity for health and targets for physical activity promotion (Killoran, Fentem, & Caspersen, 1994). Policy documents and agendas for physical activity promotion were also produced by organisations such as the National Forum for Coronary Heart Disease Prevention (1995).
Since that time, substantial amounts of public funds have been provided through the Health Education Authority to deliver Active for Life, a public media and community support campaign to promote physical activity. This has finished now and in its latter phases had a more specific focus on groups such as young people, women, and ethnic minorities. For instance, a consensus conference, recommendations document and book summarising existing literature (Biddle, Sallis, & Cavill, 1998) has been produced concerning young people and physical activity. A similar campaign has been launched by the Health Education Board for Scotland.
This rapid boom in interest in the role of physical activity in health has not only taken place at the central policy-making level. There have also been significant initiatives at grass roots level since the early 1980s. For example, many schools and local education authorities have been attempting to promote childrenās physical activity through a greater emphasis on health in the curriculum and through schemes to promote walking and cycling to school. Leisure services have teamed up with primary health care units to develop exercise prescription schemes. These mushroomed in the 1990s (see Fox, Biddle, Edmunds, Bowler, & Killoran, 1997) largely in the absence of rigorous evaluation but have thrived because of a general belief in their efficacy and value by patients and personnel. In contrast, the use of exercise in secondary care has been slow and mainly restricted to cardiac rehabilitation. Similarly, commerce and industry in Britain have not mirrored the tremendous growth in corporate wellness programmes seen in the United States.
In summary, developments in the use of exercise as a medium for health promotion have been built on increasingly sound evidence from epidemiological and well-controlled training studies (see HEA, 1995; and Pate et al., 1995, for summaries) as well as a grass roots interest among various groups of professionals. It is clear that the case has been constructed around the impact of exercise on reducing the risk of physical health problems such as CHD, some cancers, obesity, diabetes, and to a lesser extent musculo-skeletal problems such as low back pain and osteoporosis. To date, much less attention has been paid to the contribution of exercise to the prevention and treatment of the increasingly burgeoning problem of mental disorders, illnesses, and general mental malaise.
The mental health problem
The 1995 Health Survey for England showed that 20% of women and 14% of men may have at some time suffered mental illness. It has been estimated that one in seven adults in the UK will suffer some form of psychiatric morbidity at some point in their lifespan. Even among children it has been estimated that up to 20% will suffer mild and 7ā10% moderate to severe mental health problems that hinder normal development (Kurtz, 1992) and there is evidence of a worsening trend, particularly in socially disadvantaged populations (Rutter & Smith, 1995).
The most prevalent psychiatric disorder is depression, affecting 5ā10% of the population of most developed countries (Weismann & Klerman, 1992), with some estimates suggesting that 20% of the population will be affected by ādepressive disordersā at one time in their lives (Richards, Musser, & Gerson, 1999). It is more common in the older middle-aged and elderly populations with the result that 20% of consultees in primary care in Britain have recognisable degrees of symptomology (Paykel & Priest, 1992). In addition, more than half with mental health problems seek help from their GP yet GPs have no specialised training in this area (Richards et al., 1999). Treatment is generally through serotoninenhancing pharmaceuticals. Less common is the use of psychotherapy, sometimes incorporating stress management techniques and occasionally exercise.
Such prevalance is not without great cost. The Department of Health (1996) estimated that in 1992ā93, 17% of expenditure in the health services that amounted to more than Ā£5 billion was spent on mental illness and disorders. In 1992, the Office of Health Economics estimated costs of treating depression at Ā£333 million, which included Ā£55 million for drugs, Ā£250 million for hospitalisation, and Ā£28 million for primary care consultations. Wider cost implications were estimated at Ā£6 billion when social services provision, sickness and invalidity benefits, and loss of productivity were included. Cooper and Cartwright (1996) estimated that half of all absenteeism due to sickness is stress related. The Department of Health (1996) estimated that 15% and 26% of days of certified incapacity in men and women respectively were due to mental disorders.
Problems with mental health are also associated with suicide ideation, suicide attempts, and successful suicides, contributing to human distress and further service costs. There are also increasing signs that less than optimal mental well-being is common in the population. The impact of emotional distress, low self-esteem, poor body image, chronic anxiety and stress that is not diagnosed as a clinical disorder has not been possible to estimate. However, it adds to the demands of primary care and social services, is linked to drug abuse problems, alcoholism and increased absenteeism from work. Furthermore, mental well-being is a critical element of quality of life.
Recently, the Department of Health acknowledged the problems of increasing mental illness and poor mental well-being in their White Paper Saving Lives: Our Healthier Nation (1999) and wrote āThe national strategy must reflect more than just the absence of physical disease and be a basis for efforts which acknowledge a more rounded idea of good healthā. The promotion of mental health has been included as one of four health targets in the proposed national health contract so that regional and local strategies will be developed to address the problem. As part of this contract, new primary care groups consisting of multi-professional teams are being established. In promoting mental health, these groups will have to consider a broader range of approaches that can be incorporated within local health improvement programmes.
Physical activity and the promotion of psychological well-being
Although it is clear that the case for exercise in reducing physical illness is well established, there has also been a growing interest in the contribution of exercise to the alleviation of the problems of mental illness. Specifically, there has been increasing consideration of the role of exercise as
- a therapy for the treatment of mental illness and disorders;
- a means of coping and managing mental illness;
- a means of improving quality of life for the mentally ill; and
- a means of preventing the onset of mental health problems.
In addition, there is a growing recognition of a widespread mental malaise in the general public that is expressed as mild depression, low self-esteem, high stress and anxiety and poor coping. This has been accompanied by institutional and cultural reductions in physical activity levels and it has been suggested that increases in exercise participation may have a substantial impact on the incidence of sub-clinical levels of mental ill health among the general public. This has accompanied a greater focus, at the demand of the research councils and National Health Service funding bodies, on the assessment of quality of life and related constructs such as life satisfaction and mental well-being.
These concerns have been reflected in an increasing interest in research and policy concerning exercise and mental health. In 1987 the US National Institute of Mental Health consensus workshop statements regarding the contribution of exercise to mental health were published in a book by Morgan and Goldston (1987). This comprehensive summary of the literature has since been followed and updated by others such as Biddle and Mutrie (1991), Leith (1994) and more recently Morgan (1997), and several published narrative and meta-analytical reviews. There have also been further consensus conferences which have, at least in part, addressed the mental benefits of exercise, the most notable of these being the āPhysical activity, health and well-beingā conference held in Quebec in 1995 (see Biddle, 1995; Blair & Hardman, 1995) and the San Diego conference on adolescence and physical activity (see Sallis & Patrick, 1994). Additionally, in a review of the treatment of depression in primary care services, the Centre for Health Economics (Freemantle et al., 1993) recommended the funding of research into the effectiveness of non-drug therapies, particularly for those who do not respond well to medication.
Accordingly, either in terms of clinical or non-clinical conditions, exercise may offer substantial potential alone or as an adjunct in improving the mental well-being of many individuals. There are five important benefits that are associated with the potential use of exercise in such a role. First, exercise is cheap. Second, exercise carries negligible deleterious side-effects. Third, exercise can be self-sustaining in that it can be maintained by the individual once the basic skills have been learnt (Martinsen, 1993). Fourth, given that many common non-drug treatments, such as cognitive behavioural therapy, can be expensive and often in short supply (Mutrie, this book), there is much to commend other strategies. The need for treatment in psychiatry can never be fully met by health professionals. Promoting exercise could reach a broader audience of individuals who cannot access therapy or would prefer not to use medication. Greater time and effort could also be targeted at more acute and complex cases by mental health services. Finally, given the inherent physical benefits, exercise should be promoted regardless of any impact on mental health. In particular, the physical health needs of psychiatric clients are poorly served (McCarrick, Manderscheid, Bertolucci, Goldman, & Tessler (1986). These benefits have important implications for the quality of life of many individuals as well as the financial burden imposed on the NHS by mental ill health.
In some countries, the evidence for exercise and mental health has already been accepted and formalised into delivery systems. In Belgium, for instance, psychomotor therapy to treat depression and anxiety is now established in the health system. Unfortunately, in the UK it remains unusual for mental health services to use exercise as a therapy or preventive medium. Furthermore, the case for exercise and its potential to improve the general mental well-being of the population and prevent mental illness has either not been widely publicised or seen as a priority by health services, a situation paralleled in the US, where exercise is also not a more popular treatment option despite the supportive evidence (Tkachuk & Martin, 1999). One reason for this lack of recognition may be the ineffective diffusion of such research to other health professionals, which this book seeks to rectify.
Purposes of this book
Somerset Health Authority (SHA) has commissioned this series of papers. SHA through its appointed officers and the Somerset Physical Activity Group are already committed to physical activity promotion. Notably they have developed the first recognition/accreditation and scientific advisory system for exercise prescription in the UK. SHA has also seen the potential for exercise in the promotion of mental as well as physical health and already has promotion and research projects underway. They saw a need to update and summarise existing evidence for the case of exercise and mental health enhancement. This is particularly timely in the light of the recent Department of Health White Paper (DoH, 1999) that has targeted mental health as one of four key health outcomes in the national health contract. In relation to mental health, exercise is specifically suggested as a strategy that āpeopleā can participate in for improving mental health.
The purpose of these chapters is therefore to provide an updated overview of the case for exercise and the promotion of psychological well-being. Leading researchers have been recruited to produce chapters on the effects of exercise on anxiety and stress, depression, mood and affect, self-perceptions including self-esteem, cognitive performance and also the negative effects of exercise on psychological well-being. Attention has been directed at (a) treating mental illness and disorders, and (b) enhancing psychological well-being in the general public. Priority has been given to evidence from randomised controlled trials, large scale epidemiological studies, and meta-analytic reviews. Authors have been asked to summarise their findings in tables and closing sections featuring āwhat we knowā and āwhat we need to knowā statements. A closing chapter draws together key findings and implications for further research and practice.
Throughout, attention has been paid to the relevance of findings to health service commissioners and providers and every effort has been made to present the information in familiar terminology. The Consensus statements that were adapted from this work have been supported by professional and governing bodies such as the BPS (British Psychology Society), BASES (British Association of Sport and Exercise Sciences) and Exercise England. The strong evidence base exists! It is hoped that this resource will be valuable for practitioners in āmaking the caseā for physical activity and mental health at a local and national level.
In closing, it is important to acknowledge a range of other conditions for which exercise has bee...
