The paper represents a scholar proposal and engages in the investigation on how the exercises and physical activity, in general, affect the health and the state of the patients who have been diagnosed with depression. The study covers such issues as the appliance of exercises when dealing with the consequences of depression. The paper contains various points of view toward the issue of what depression is and how physical exercises are effective in overcoming its essential symptoms. Since depression can have a significant impact on the physical health of people, the majority of scholars believe that both methods – pharmacological and exercise therapies can be effective in the treatment of depression.
Still, many people prefer to use only alternative therapy such as exercising. It is expected to prove that the bigger amount of exercises, specifically outdoors, and the younger the participants, the better effect is to be produced. In the investigation, there will be 231 patients who were diagnosed with depression. They are to be divided into two groups, Exercise One and Exercise Two groups which differ by the setting of physical exercises, specifically, indoor and outdoor
Keywords: depression, physical exercises, consequences, progress, patients.
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Depression has become so common phenomenon in the society that psychiatrists sometimes describe it as a 'completely normal' reaction, which even does not interfere with our daily activities. However, even if this response is normal in the statistical sense regarding the feeling of the majority of people, it cannot be considered as an absolutely healthy state. According to such a definition of normality, depressive tendency and its attendant feelings of alienation and disengagement are considered normal if they cover the majority of people, but only on the condition that the depression is not very severe. The same can be said about the short-sightedness and low back pain that have become so frequent diseases nowadays. Thus, from the point of view of statistics, they can be considered as a normal condition of a modern person.
Depression is known to be extremely different from the usual changes in mood and short-term emotional reactions to problems in everyday life. The inability to interact with the environment distinguishes depression from all other emotional states. A person in dejection re-acquires faith and hope when the situation changes for the better. In particular, the depressed people rise in spirit, when the reason for depression is completely removed.
Moreover, depression can be a serious health disorder, especially if it is delayed and takes a moderate or severe form. Thus, it can result in significant human suffering, as well as poor functioning at work, at school, and in the family. In the worst cases, depression can even lead to suicide. To put an example, there are over one million cases annually, which are characterized by suicide.
The numerous investigations conducted on the essence of depression show that there have already been found various ways to overcome, stop, and even prevent depressive syndrome. Most of the approaches work regardless of the patients' age, financial status, etc. However, the problem is the physical health of a patient. This fact frequently serves as a serious obstacle to further depression treatment. Thus, it is highly important to investigate the role that exercises play in the ways of depression prevention and its treatment in general.
It is widely recognized that effective prevention programs lead to a decrease in the burden of depression. They include targeting programs to prevent child abuse and programs to improve the cognitive and social skills of children and adolescents, as well as their skills in problem-solving. Measures that are intended for parents with behavioral problems may help reduce their depressive symptoms and, thus, improve the outcomes for their children. The similar effect exercise programs can have on elderly people. The purpose of the study is to empirically determine the effects the exercises have on patients with depression.
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The investigation has been created in order to respond to the following questions that represent a great interest and lead to the important value obtaining:
- Is there a connection between a number of exercises, levels of depression, and the time needed to overcome the undesired symptoms?
- How is the exercise program influential on people with depression in terms of their age, gender, and education level?
- What groups of exercises are more effective from the point of view of depression treatment and prevention?
The first hypothesis of the investigation assumes that the bigger amount of exercises are done, the faster depression syndromes are overcome. The second hypothesis states that the younger a person is, the easier he/she undergoes the recovery process. Finally, the third hypothesis of the study consists in the assumption that the constant physical exercises outdoors is more effective when dealing with depression than those ones which are indoors.
Nola Pender’s Health Promotion Model will be used in the study. Basically, this model helps nurses to enhance patient’s well-being by promoting healthy lifestyle changes. The nurse can facilitate those behavior changes to attain a healthier lifestyle. To be specific, Nola Pender’s model utilizes modifications in the person’s behavior, and in the environment to achieve the desired changes (Polit & Back, 2012). As explained by Sakraida, (2014) the Health Promotion model of Nola Pender considers individual characteristics and experiences that influence subsequent health behaviors. Those characteristics are the following: prior related behavior, personal factors, perceived benefits of action, perceived barriers to action, perceived self-efficacy, interpersonal influences, and situational influences.
It worth stressing that the model gives special attention to self-efficacy as a motivational factor to achieve the desired behavior. Pender (2011), in her health promotion manual, explains how the model addresses several aspects that influence the barriers to adopting a more satisfying lifestyle in order to improve the client’s wellbeing. The Pender Health Promotion Model is applicable to our research because it aims to promote physical activity to treat or avoid depression as well as achieve a higher level of overall health condition. The model elaborated is to be applied differently to those patients who applied the medical treatment and physical exercises and those who did not apply the medication. This will stimulate the patients and raise their motivation in overcoming the depressive syndromes.
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In order to have the investigation based on the most recent data found in the field of depression treatment by exercises, there appears a necessity in reviewing literature dedicated to the topic. Before the usage of exercises had been acclaimed to be effective in depression treatment, a number of scholars investigated the other ways to deal with the depression. When conducting the investigation, it will be assumed that taking exercise is a somewhat more effective method for reducing the symptoms of depression than the absence of treatment. Nevertheless, exercising is considered less effective than antidepressants and psychological therapy.
Thus, Zschucke, Gaudlitz, and Strohle (2013) believe that the conservative and traditional approaches to depression treatment are both effective; however, being in unity with exercises, they are likely to bring more benefits. To prove this assumption, Zschucke et al. (2013) compare and contrast the traditional approaches to depression treatment. For instance, psychopharmacology is currently considered the main method of depression treatment. Therefore, there is an essential quantity of antidepressant drugs that have different indications and contraindications.
Moreover, it is often necessary to combine the antidepressants with the drugs of other groups, such as tranquilizers and antipsychotics. When prescribing, a physician takes into consideration not only the particular manifestations of the disease, but also the patient's age, gender, duration of the disease, the patient's individual response to the drug, and the presence or absence of other systemic diseases. This allows a doctor to determine not only the right combination of drugs but also the appropriate dose of these drugs.
Nowadays, depression has become such a common state, because many people pursue unrealistic goals, which are not directly related to basic human needs. In this regard, everyone wants to love and to feel that this love is accepted and returned. Love and care are associated with the outside world and give people a sense of belonging to life. Moreover, the love of others is so important to a person as it promotes the active expression of his/her own love. People do not become depressed when they love: through love, they express themselves, affirm their existence and identity. Since the investigation is dedicated to the exercises, a certain amount of love for the sport is already a great basis for overcoming the syndromes of depression.
Zarashenas, Houshvar, and Tahmasebi (2013) have a strong conviction that the issue of the effective exercise therapy for improving patient’s mental health is closely linked with an assessment of the changes' significance in the course of psychotherapy from the clinical viewpoint. One of the most important results of the study of this issue will be the data on a significant reduction of depression and its syndromes in patients. In addition to this, Zarashenas et al. (2013) believe that it is important to regard the concept of social validity. They assume that it is the main way of clinical relevance evaluation. It is based on statistical methods and concerns two aspects: firstly, how much change occurred is statistically significant; and, secondly, is it possible to speak of normalization, i.e. their compliance with laws and statistical values on a given questionnaire.
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Thompson Coon et al. (2011) and Lacharite-Lemieux, Brunelle, and Dionne (2015) attempted to identify predictors of adverse outcomes of exercise therapy. Lastly, they came to the following conclusions: a particularly high percentage of negative effects was recorded among the patients with obsessive-compulsive disorder – but not among the patients with depressive disorder. This theory will serve as a basis for the investigation.
In the investigation by Thompson Coon et al. (2011), the groups of depressive patients who obtained negative results are characterized by two features. The first is the expressed interpersonal problems and the second one is rather a severe condition at the beginning of the treatment. Having considered the above-revealed features, the researchers conclude that the study of factors, which lead to deterioration of the illness, is an important issue for patients' selection and training of psychotherapists.
Another approach, which, in accordance with Zschucke et al. (2013), is perceived as highly effective, is psychotherapy. The abilities to listen, give advice, and encourage a person are all the high art of a psychiatrist. Generally, psychotherapeutic techniques are based on the attention and support of a patient at a difficult time. Psychotherapy starts with the trust between a doctor and a patient and ends only after the patient’s complete recovery. The result of such a treatment’s long duration is that a patient starts regarding a doctor as not only a healer, but also as an adviser, a teacher, and a friend. A patient appears to know that he/she can get support and advice from a person whom he/she believes, which is the most significant psychotherapeutic effect.
Finally, Zschucke et al. (2013) apply sociotherapy to treat depression. The sociotherapy is based on the idea that the patients need help in solving their social and domestic problems from the people they are surrounded by. If a patient has a loving husband or a wife, caring children, parents, and friends, the problem of depression is less significant. On the contrary, if a patient constantly faces domestic conflicts and social disorders he/she is very difficult to be calmed and set in an optimistic direction.
The practice of usage of physical exercises during the depression treatment has shown the following result: in an appropriate way of usage, the exercises can be equal even to the antidepressants. To illustrate, Belvederi Murr et al. (2015), when investigating the essence of depression, state that almost any form of painful effect can be mitigated by diverting the patient's attention. This technique is particularly effective when dealing with the emotion of sadness.
In the investigators' point of view, firstly, the therapist is supposed to ask the patient to evaluate the intensity of the emotions experienced, and then he should tell the patient to focus on some object and describe it in detail. Thereafter, the patient re-evaluates the intensity of the emotion and usually discovers that his/her mood is improved. Thus, in the case of successful exercise during the session, the patient is given the task to work out this method after the session.
Kelley, Kelley, and Hootman (2015), as well as Lacharite-Lemieux, Brunelle, and Dionne (2015), consider that the emergence of the emotion of sadness should serve as a signal to do some business. It could be a walk, a telephone conversation, or a simple observation of others. At first, the patient is usually not able to escape from his/her grief; however, after systematic training, he/she can already control the appearance of sadness much better.
Thus, one of the essential conclusions, Kelley et al. (2015) provide the reader with, is the fact that depression is sometimes treated much more effectively than many other diseases. However, it should be treated only by a specialist, namely by a psychiatrist. Additionally, it is important that depression is treated in the way of any other disease. Similar to the hypertensive broken mechanism that regulates blood pressure, the depression is a mechanism that regulates the mood.
Kelley et al. (2015) also believe that a patient should be as frank as possible with their doctor: the sincere description of a patient's condition will help a therapist to choose the right treatment. One of the treatments, the authors' state, can be an outpatient setting, without hospitalization. In this case, it is significant to capture the slightest changes in the patient's status and quick reporting on them to the doctor. This cooperative effort (“doctor-patient”) will extremely accelerate the process of being out of this painful condition.
When exploring the essence of the depression, Zhang and Yen (2015) state that regardless of the reasons that caused the depression, the approaches to its treatment can be the same. Consider an example, “the income, race, education, marriage, and employment can cause the depression” (Zhang & Yen, 2015, p. 1552). However, in all these cases the approach to the treatment can be the same – the appliance of exercises, which will remove bad thoughts and gradually lead to mood improvement. Weir (2016) also supports this idea, stating that “exercise... was generally comparable to antidepressants for patients with the major depressive disorder” (Weir, 2016).
Thus, overcoming depression requires a new skill set. Hence, it is important to understand that happiness is a skill, willpower is a skill, health is also a skill. The skills are needed for a successful relationship and emotional responsiveness. Weir (2016) believes that this happens because practice does not just improve patients' state, but also changes their brains. Such an approach to life is very inspiring and helps adapt much more than the opinion that these qualities are sparingly distributed from birth and from the fate of no escape. Moreover, these skills are significantly needed to cure depression, and will permeate the whole life; and if a patient considers exercise treatment seriously, they can get much more than just recovery.
Thus, following the idea that the exercises can be applied in various cases of depression, Belvederi Murr et al. (2015) found that there are “two types of physical exercises”. The first one is represented by “higher-intensity, progressive aerobic exercises” and the second one is “lower-intensity, non-progressive physical exercises.” According to the authors, the usage of both groups of exercises “could lead to better outcomes in late-life major depression” (Belvederi Murr et al., 2015, p. 235).
Fraser et al. (2015) believe that one more problem of depressed patients is their misconception that accurate medication and psychotherapeutic sessions can quickly eliminate the depression. In the authors' point of view, the treatment process requires the active participation of patients. Firstly, it is difficult and almost impossible, but in time, a patient will feel free to come to the fight, figuratively speaking. A very similar point of view can be found in the investigation by Rezaei, Abdi, Rezaei, Heydarnezhadian, and Jalali (2015). The authors strongly believe that the exercise helps to cheer a patient up, and not just because a patient will be distracted from their own problems, but also due to their increased muscle tone. In detail, active exercises cause the brain to release natural substances, such as endorphins, which are natural equivalents of antidepressants and neuroleptics.
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Along with Belvederi Murr et al. (2015) and Fraser et al. (2015), this idea was also developed by Kerling et al. (2015). The authors believe that it is important to exercise as much as possible in order to increase muscle tone. When swimming in the pool, playing tennis, or digging up the beds at the summer cottage, the patients make their muscles feel the exercise. The stronger these feelings are, the more beneficial it is for the patients' bodies as well as for their mental state. In addition, Kerling et al. (2015) believe that the exercise makes a patient feel better and get a new charge of strength for a further struggle with the depression.
This diagnosis is controversial since people regularly become depressed in response to changes in daylight and time of year. Knapen, Vancampfort, Morien, and Marchal (2014) state that some people suffer from depression on a regular basis: it usually begins in winter and finishes in spring. In the authors' point of view, this can be explained by a lack of exercise, socialization, and, apparently, a lack of sunlight.
In the depressive phase, the patient is sad, anxious, irritable, and socially closed. Moreover, he/she becomes sleepy, gains weight, experiences an acute need for carbohydrates. In accordance with Knapen et al. (2014) and Gartlehner et al. (2015), women tend to suffer from such disorder four times more often than men do. To such a seasonal depression of women, one can also add the premenstrual mood changes women usually suffer from.
Nevertheless, if in winter the patient moves closer to the equator, the symptoms of the seasonal depression usually diminish. The scholars used to think that phototherapy and regular use of powerful fluorescent lighting might help with such disorder; however, more recent studies have failed to prove the usefulness of these techniques. Nevertheless, it will never hurt if sitting quietly in a good light, reading a book or meditating.
Patel, Keogh, Kolt, and Schofield (2013) believe that the main problem is that depressed patients are so absorbed with their gloomy reflections that even do not pay attention to any external stimuli. Yet, the therapist can help the patient to redirect attention through a series of structured exercises, such as daily jogging. After the successful execution of this task, the patient considers themselves unable to concentrate on negative things and usually changes their mind about themselves. When the therapist sees that the patient can easily handle this task, s/he advises them to buy a kitchen timer and practice in the performance of more complex tasks, which will gradually increase the patient’s attention span.
Emotions, which are usually of great importance, are completely free of value judgments. In the point of view of Rethorst et al. (2013), they are expressed automatically, as salivation or withdrawal of a hand from a hot iron. However, the way people express their emotions is of great social and personal value. Generally, people are able to control their emotions to some extent, but if they suddenly start doing that, they are likely to fail. Rethorst et al. (2013) provide an example when an angry man beats his wife and explains it by the necessity to “let the steam off”. Such a “physical exercise”, undoubtedly, has to be substituted with plunging headlong into work, which is assumed socially and psychologically useful. Once again, it is possible to influence the expression of emotions, but decide that some of them should not be experienced is almost an impossible task.
Frequently, the investigators of the exercise therapy compare it with the placebo effect. As Knapen et al. (2014) and Gartlehner et al. (2015) mention, it is based on common sense and underlies the phenomenon known as 'spontaneous recovery.' The latter one consists of the idea that depressive patients even with very severe symptoms of anxiety, depression, phobias, etc. are likely to recover within a year or two without any special psychiatric care. It is quite obvious that such a recovery is not 'spontaneous' from the point of view of time. It comes after a certain period, during which the patient is subjected to relying on common sense therapy that frequently includes exercises.
Thus, spontaneous recovery occurs due to a certain placebo-like therapy type and is not based on any scientific theory. Like any placebo, exercise therapy, however, can be very effective, especially when it includes certain important components. Moreover, the common sense therapy and exercise therapy are very similar and even identical to the theoretically developed behavioral therapy.
Gartlehner et al. (2015) believe that the treatment of depression disorders is usually necessary to conduct by the enlightening conversation with the patient. In addition to this, the scholars consider that it is important to inform the patient of the fact that the increment of the overall activity (including physical exercises) generally will lead to an improvement of sleep. To put an example, if a person spends most of the day in a chair or in bed, occasionally falling into slumber, it is unlikely that they will want to sleep at night. If they start to lead a more active lifestyle and will be engaged in some physical activity, it is, certainly, will lead to better sleep at night. However, it is necessary to warn the patient that the exercise cannot be performed immediately before going to bed as it can have a stimulating effect.
Finally, it is possible to conclude from the literature review that the main goal of mental health care of both the present and the past is to connect a mentally ill person with reality. If the gap with reality is very large, the patient is carefully guided in real-time, space, and his/her identity by a therapist, and such a patient’s condition is described as psychopathic. In order to have future studies, it will be appropriate to review in a more detailed way what types of exercise might be the most useful for people with depression, as well as the number and the duration of those activities that are the most useful ones. The investigation will also focus on the previous studies of large clinical trials to find out whether exercise is as effective as antidepressants and psychological treatment.
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The research is designed in such a way that it is aimed at obtaining practical results, which will reflect on the hypothesis and research questions. The research will be based on the widely used multivariate techniques (e.g., MMPI), which have their own advantages and disadvantages. Moreover, a large amount of data will be received, however, a long filling of questionnaires might require much effort from the patient. The main drawback – which is a limitation for the study – is that the multivariate methods are not always sensitive to the short rapid shifts and changes in the patients’ behavior.
Thus, in order to investigate the progress of patients, the questionnaire SCL-90-R will be used. Univariate methods, which will be applied in the investigation, also have their pros and cons. On the one hand, these methods are easy to use, and they assess the dynamics of the use of the statistical methods, but on the other hand, they often have low discriminant validity (for example, questionnaires for depression and anxiety may show a high correlation because of the similarity of symptoms assessed).
When observing the patients with a difficult diagnosis or a need to consider a quality set of symptoms, the investigation will apply the individualized assessment methods. In order to obtain the status of each individual patient, the research will use the widespread scaling method of achieving goals. The client and the therapist release the goals of therapy before the beginning of treatment so that later an independent researcher could evaluate the success of treatment (i.e., 1st goal consists in reducing the weight and scale of kilograms, the 2nd goal is the improvement of mood and the reduction of points on the Beck Depression Inventory).
In summary, the results of studies of the exercise therapy’s effectiveness will be aimed to obtain the answers to the following questions: firstly, whether the exercises are an effective treatment for mental disorders, including depression; secondly, whether the changes after the treatment are significant from the clinical point of view; thirdly, what is the sufficient amount of exercises to be taken; and lastly, whether there are patients who have a negative result of exercises therapy.
In accordance with a recent meta-analysis of major works about the prevention of depression, the risk of depression can be reduced by 19-26% depending on the type of prophylaxis (Silveira et al., 2013). The main target groups for large-scale selective prevention will consist of adolescents, pregnant and recently given birth women, diabetics, and the elderly people. The results of the analysis of the literature and our own clinical experience will help unite theory and empirical approach. 231 patients will be examined at the age of 60 with depression of varying degrees.
The number of patients chosen will be selected by means of the random method. A questionnaire to find out the reduction/increase of a level of depression and the symptoms which go along when exercising will be used. In addition to this, the social and economic status of the patients will be taken into consideration in order to evaluate their ability to take exercise in their free time. The number of males is 115 while the number of females is 116.
Complex clinical psychodiagnostic and neuropsychological studies will be conducted in order to identify cognitive and depressive disorders and their quantitative and qualitative assessment, followed by exercises. The patients will be divided into two groups, Exercise One group and Exercise Two group: the first group will be an outdoor one while the second group will be an indoor one. The use of the proposed approach to the treatment will reduce the time of selection of regimens.
The 60+-year-old patients, who obtained the depressive disorder syndrome in the course of their life due to the inappropriate living conditions and stressful situations, will be engaged in the investigation. Moreover, the above-mentioned patients are people with a high level of literacy and proficiency in English.
The patients who appeared to have physical limitations in exercising are regarded as the exclusion criteria.
Using a test to answer the research questions, with set at = 0.05, with a power = 0.80, a medium effect size = 0.40, we need 99 subjects in each group, for a total of 198 subjects. Test with power 0.80 is considered powerful. Thus, we will be able to reduce the risk of type II errors (false negative). The strength of the effect will be understood as the percentile average of the test of the Exercise One group. It will be relative to the average of the test Exercise Two group (an average degree of patient differences).
Thus, the strength of the effect of 0.0 means that the average of the Exercise One matches the 50th percentile of the Exercise Two group (i.e., 50% of the subjects in the Exercise Two group has a variable value not larger than the average Exercise One group). The strength of the effect of 1.7 means that 95.5% of the subjects in the Exercise Two group has a variable value not larger than the average of Exercise One group. The strength of the effect can also be interpreted as a percentage disjointness field value of both Exercise One and Exercise Two groups.
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Thus, the force effect of 0.8 means that:
- 47.4% of the tested values of the two groups do not overlap;
- the average of the Exercise One group by 0.8 standard deviations is above the average of the Exercise Two group;
- Exercise One group's average patient has a better result than the 79% of the Exercise Two group.
Data Collection Procedures
Before the patients are engaged in the investigation, they will be informed about the methods and possible results of the study. The participants will be supposed to give their confirmation on taking part in the investigation. The personal information they will provide in the questionnaires will be processed within 48 hours and will be regarded as confidential data.
The meta-analysis procedure will take into account the reliability of the study with a low effect size indicator and a small number of people in the group, resulting in a total revaluation of the therapy effect. However, even with a strict selection of studies presented above,
there is an average effect size regarding exercises in the broadest sense of the word, which includes a variety of methods of physical training.
The study will not directly address the questions of comparative (ideal) effectiveness of any sense of depression analysis since that is considered insufficient. This demonstrates the need to observe caution when evaluating a meta-analysis of findings without the first critical study of research included in it. Moreover, if based only on indirect, mixed multiple comparisons, the estimates of the relative effectiveness of exercise therapy can be poorly defined.
That is why the methods of investigation are versatile and may vary from patient to patient – this is done in order to investigate the real effect of the exercises on a person. In addition, the results of meta-analyses, carried out on the basis of the research studies with the apparent lack of sensitivity analyzes, cannot be used to criticize the treatment guidelines. Finally, some data sets may not meet the requirements allowing for of confirmation the results of the meta-analysis.