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Contents Acknowledgements 02

Foreword 03

1. Introduction 041.1 Anupdateontheevidence 041.2 Thepolicycontext 061.3 Exerciseandmentalhealthoutcomes 06

2. The GP survey - Four years on 102.1 Significantstatistics 102.2 Hasmuchchangedoverfouryears? 132.3 Exercise:nowanoption? 132.4 Summary 13

3. Site evaluations 143.1 Overview 143.2 Keyfindingsoftheevaluation 143.3 Runninganexercisescheme-lessonslearned 163.4 Theprojectsites 173.5 Analysisofsitedata 233.6 Exercisereferralschemes:dotheywork? 243.7 Keylearningpoints 28

4. Conclusion 30

5. Key recommendations 31

6. Appendices 33

7. References 44

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AcknowledgementsWewouldliketothankallthesiteswhotookpartinthisstudyandeveryparticipantwhogavetheirtimeandthoughts.WewouldespeciallyliketothankJacquiRyanandMatthewSaundersofFlitwickLeisureCentre;CarrieHolbrookoftheCambridgeStart-UpExerciseReferralSchemeandSiobhanRogers(andpreviouslyCaroleO’Beney)oftheCamdenActiveHealthTeam.

WewouldalsoliketoacknowledgethecontributionofChangingMindsinNorthampton,inparticularJayneShearsandSonyaTerry.

DrRowanMyron,DrCathyStreet,DanRobothamandKarenJamespreparedthisreportfortheMentalHealthFoundation.

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ForewordThisextremelyvaluablefollowupreportfromtheMentalHealthFoundationhighlightsanimportantsubject;thatifmentalhealthcontinuestoberegardedastheCinderellaservice,thenexercisereferralschemeswouldbetheuglysister.

Despiteaprovenandincreasingevidencebasetosupportsuchschemes,muchmoreneedstobedonetopersuadethoseinthehealthserviceoftheirbenefits.AlthoughthenumberofGPswhowouldprescribeexerciseasafirstlinetreatmentformildtomoderatedepressionisincreasing,itisdisappointingthatitremainsatlessthanfivepercent.Allhealthcareprofessionalshaveadutyofcaretopromoteexercise,thereforemuchmoreneedstobedonetoensurethatallwhoworkwithinprimarycarehaveaccesstoexercisereferralschemes.Thereshouldbenopostcodelottery.

Ourownexperienceasadeveloperanddelivererofexercisereferralprogrammesisthatactivity,beitphysicalorcreative,isanimportanttoolwhichshouldbeemployedtohelpindividualssufferingfrommildtomoderatedepression.

Theultimatetestamenttothesuccessofsuchschemesisthenumberswhoremainexercisingandphysicallyactivesincebeingreferred.ExercisereferralschemesmustcontinuetoevolveandflexibilityandvarietyarecrucialtosustaininginterestfromparticipantsandprovidingGPswithadecentpoolofschemestorecommend.Supportedactivityinitsbroadestsenseiswhatcounts,whetherthatisachievedwithinagymenvironmentoroutdoors.

Itishearteningtoreadmanyoftheencouragingcommentsfrompeoplewhoseliveshavebeentransformedbyexercise.Butwordofmouthalonefromthosewhohavecompletedsuchschemesisnotenoughandweapplaudandfullysupportcampaignssuchas‘UpandRunning?’intheirdrivetoraiseawareness.

RosiPrescottChiefExecutiveCentralYMCA

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1. Introduction

“TheextentofanyexerciseIdidbeforetheprogrammewasagentlewalk…nowIgotothegymand Ihavealsostartedtoattendalocalsportsgroup…”

Thereisasubstantialbodyofevidencetoshowthatphysicalexerciseisaneffectivetreatmentforpeoplewithmildtomoderatedepression.In2005MentalHealthFoundationpublishedthereport‘UpandRunning?’,whichhighlightedtheneedtopromoteexercisetherapyfordepressionasarealisticandreadilyavailabletoolforGPsandagenuineoptionthatpatientscouldbothunderstandandchooseforthemselves.

In2006,MentalHealthFoundationreceivedsomefundingfromtheDepartmentofHealthtosupportandevaluateasmallnumberofexercisereferralschemesacrossthecountry.

Thisreportinvestigatesthesuccessesandbarriersinplaceinsitescurrentlyrunningexercisereferralschemesandpresentsthekeyrecommendationsandlessonslearned.ThereportalsorevisitswhatGPscurrentlythinkaboutexercisereferralfouryearsonfromthefirstreport.

1.1 An update on the evidence

Primary Care

Previousstudieshaveindicatedthatphysicalactivityispositivelyrelatedtohealth-relatedqualityoflifeandwell-beingamongpeoplewithmild,moderateandseverementaldistress1.Althoughthephysicalhealthbenefitsofactivityarewelldocumented,evidencesuggeststhatphysicalactivityprovidesmanypsychologicalbenefitsaswell.Onestudy2exploredthepsychologicaleffectsofexerciseonliftingmood.Theinvestigatorsfoundthatpeopleexperiencingmentaldistressgenerallyhadalowlevelofphysicalactivity,theirhierarchicalanalysisoftwogroups(inSerbiaandAmerica)indicatedthatphysicalactivityremainedsignificantlypositivelyassociatedwithmood(evenafteraccountingforindividualvariationsinlevelofexercise).

Afurtherstudy3usedanevidencebasedapproachtodemonstratethatexerciseisnotjustphysicalactivityusedforthepurposeofconditioninganypartofthebody,buthaspositiveeffectsuponwiderphysicalhealth,mentalhealth,diseasepreventionandproductivity.

Intermsofexercisereferralprogrammes,onestudy4investigatedtheeffectivenessofatenweekprimarycareexercisereferralprogrammeonthephysicalself-perceptionandself-worthofolderadults.Theyfoundthatevenmoderatelevelsofattendanceimprovedself-perceptionandselfworth.

Whenlookingspecificallyatexerciseanddepressionasystematicreviewandmeta-analysisconcludedthatexercisemayreducedepressionsymptomsshortterm,butmuchoftheevidenceisinneedofreplicationandmorerobustresearch5.Anotherarticle,whichoverviewedthetreatmentofdepression,concludedthatphysicalactivitymayplayanimportantroleinrelievingdepression6

especiallywhencombinedwithothertreatments.

Intermsofanxietyandexerciseonestudy7foundthatphysicalactivitywasaneffectivetreatmentforanxietyhavingbeneficialeffectsonperceivedlifestresseventsandperceivedself-efficacy.

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Introduction

Anumberofdifferentstudieshavedemonstratedthepositivementalhealthbenefitsofexercisereferralwhilstexploringrecoveryfromaphysicalconditionsuchasstrokeorheartdisease.Oneveryrecentstudyin20098foundthatatenweekexercisereferralprogrammereduceddepressivesymptomsindepressedchronicstrokesurvivors.Theyfoundbothanimmediatepositiveeffect,andalsoalongertermeffectwhentheyfollowedthegroupup6monthslaterwithpatientswhohadparticipatedintheexercisereferralprogramme.Theynotedmodestimprovementsinhealthandwell-beingovertimeandtheyrecommendedthathealthprofessionalsshouldfocusonhelpingstrokesurvivor’smentalhealthrecoveryaswellastheirphysicalrehabilitation.

Secondary Care

Thusfar,theresearchevidencehasbeenfocusseduponexercisereferralinprimarycareformildtomoderateconditions.However,thereisnowanincreasingevidencebasethatexerciseandexercisereferralisappropriateandcanbeusedsuccessfullyinsecondarycaresettings,whetherininstitutionalisedsettingsorinthecommunityforthosewithsevereandenduringmentalhealthproblems.

OnestudywhichtookplaceinAustralia9notedthatintheAustralianhealthsystemthereisagrowingrecognitionandunderstandingoftheinextricableinterrelationshipbetweenphysicalandmentalhealth.Increasinglyinmentalhealthcaresettings,thephysicalhealthofserviceusersisacknowledgedasanissuerequiringurgentaction.Thisissue,theytheorise,isrelatedtonegativesymptomsandthelifestylechoicesofpeoplewithmentalillness.Theyalsonotethatthereisaclearlinkwiththedetrimentalsideeffectsofpsychotropicmedicationswhichcomplicatesthelackofconfidenceorskillinrelationtophysicalhealthmatters.Theauthorsnotethesignificantbenefitsofexerciseonmentalhealthandarguethatmentalhealthnursesandsupportingstaffmustplayanactiveroleinhealthpromotion,primarypreventionandtheearlydetectionandmanagementofphysicalhealthproblemsintheirmentallyunwellclients.

ArecentstudyinEngland10exploredtheuseofaprogrammeofexerciseandsportasasocialsupportformenwithseriousmentalillness.Thestudynotedthatsocialsupportwasimportantintheinitiationandmaintenanceofexerciseandfoundthatinformational,tangible,esteemandemotionalsupportwerebothprovidedforandgivenbyparticipantsthroughexerciseandnotedthatthiselementcouldbeasignificantsupportinanindividual’srecoveryjourney.

Exercisehasalsobeenshowntobeusefulwithininstitutionalisedsettings.Onestudy11investigatedtheimpactofaerobicexerciseontheseverityofsymptomsofPosttraumaticStressDisorder(PTSD)foradolescentsreceivinginpatientcare.Theyfoundthatafifteensessionaerobicexerciseprogrammehadapositiveimpactupontraumasymptoms,reducingsymptomologyandimprovingwellbeing.

Consequently,theresearchevidencebaseforexerciseasanappropriateandeffectivetreatmentformentalhealthisexpanding.

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1.2 The policy context

“Increasingexerciseisthemostcosteffectivewayofimprovingsomeone’shealth.Thereisasound evidencebaseofthebenefitstocardiovascularandpsychologicalhealth.”12

Overthelastdecade,thebenefitsofregularphysicalactivityhavebecomewidelyrecognisedinpreventingchronicdiseaseandpromotinghealthandwell-being,includingbeingendorsedforanumberofspecifichealthconditionsinNationalInstituteforHealthandClinicalExcellence(NIHCE)guidance13.

AreportproducedbytheDepartmentofHealthin200414,notedthatadultswhoarephysicallyactivehaveuptoa50%reducedriskofdevelopingchronicdiseasessuchascoronaryheartdisease,stroke,diabetesandsomecancers.

TheDepartmentofHealthpublishedareportin200515,examiningthebenefitsofphysicalactivityinreducingtherisksofdepression,reducinganxietyandenhancingmoodandself-esteem.Thereisnowagrowingevidencebasethatsupportstheuseofexercisetotacklemildtomoderatedepressionandanxiety.

1.3 Exercise and mental health outcomes

In2005,theMentalHealthFoundationpublishedthefindingsofitsstudyofexerciseasatreatmentoptionfordepression-‘UpandRunning?’16Thiswascommissionedtoexamineavailabletreatmentsformildandmoderatedepressioninprimarycareand,inparticular,tofocusonantidepressantandexercisereferralprescriptions,theiruseandavailability,andhowgeneralpractitionersandpatientsfeelaboutthem.

Thisreportnotesthefollowing:

“Thebenefitstophysicalhealth…ofregularexercisearewellunderstoodandaccepted.Butthebenefits tomentalhealth(reducedanxiety,decreaseddepression,enhancedmood,improvedcognitive functioningandself-worth)havebeenlesswidelyreportedandarelesswell-understoodandaccepted.”

Introduction

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Ithighlightstheconsiderablecostsassociatedwiththewritingofprescriptionsforanti-depressantsinEngland(£397.2millionin2003)andidentifiesthefollowingadvantages:

• Exercise is cost-effective–comparedtopharmacologicalandpsychologicalinterventions, evenstructuredexerciseprogrammescostlessoveranequivalenttimeperiod.

• Exercise is available–allexceptthoseinverypoorphysicalhealthcantakesome formofexercisewhichmakesitafarmoreavailableoptionthatmanypsychological treatments(highlightedbyavarietyofrecentreportsasbeinginshortsupplyandsubject tolongwaitingtimesontheNHS).

• There are co-incidental benefits-unliketheunpleasantsideeffectsthatcan accompanysomeantidepressantmedications,physicalactivityisrelativelylowrisk. Inaddition,exercisecanbeusedtotreatpatientswithamixofphysicalandmental healthproblems–forexample,itcanleadtohealthiermuscles,bonesandjoints alongsidepromotingasenseofachievementandincreasedself-esteemarisingthrough animprovementinphysicalappearance.(Alackofphysicalfitnessmayinitself beacontributingfactortoaperson’smentalhealthproblems).

• Exercise is a sustainable recovery choice–exerciserequirestheactiveparticipation oftheindividualwhichcanencourageandsupportpeople’sabilitytomakechoicesandwhich canbecontinuedwithoutongoingprofessionalsupervision.Thisisinsharpcontrast tosometreatmentswhichcanreinforcethesenseofbeinga‘passiverecipient’ofcare, whichcanreinforceoneofthecommoncharacteristicsofdepression,thatis,offeelingthat oneisunable,orhaslosttheabilitytomakechoices.

• Exercise promotes social inclusion and is a ‘normalising’ experience –exerciseiswidelyseenassomethingthatisdoneby‘healthy’peopleandassuch, carriesnostigma.Medicationand/orpsychotherapyontheotherhand,areoftendisliked becauseofthestigmaattachedtosuchtreatments.Thefactthatexercisecaneasilybe undertakenalongsideotherpeople,andcanprovideanavenueforsharedcommoninterests, providesanimportantsocialdimensiontotheactivity,whichcanhelptocounterthefeelings ofisolationsooftenexperiencedbypeoplewithdepressionandothermentalhealthproblems.

• Exercise is popular–althoughonlyfewqualitativestudieshavebeenundertaken, peoplewithdepressionarereportedtociteexerciseasbeinganimportant andpositivepartoftheirrecoveryprogramme.Forexample,inasurveyofpeoplewho hadexperiencedmentalhealthdifficultiesbyMindin2001,50%reportingfinding thatexercisehadhelpedthemtorecover.

Introduction

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The‘UpandRunning?’reportalsocitesaDepartmentofHealthfindingthatinanumberofcomparativestudies,physicalactivityhadbeenfoundtobeassuccessfulintreatingdepressionaspsychotherapyandthatintwoothers,ithadbeenfoundtobeassuccessfulintreatingdepressionasmedication.

PossiblepreventativeeffectshavealsobeenreportedinanumberofAmericanstudieswhichsuggestthatrisksofdevelopingdepressionarelowerforthosewhoengageinregularphysicalactivity.

Setagainstthesegenerallypositivefindingshowever,thereportalsohighlightssomeofthekeyfindingsfromsurveyoftwohundredGPswhichgoessomewaytoexplainingwhyexerciseisstillnotoftenthoughtofa‘treatmentoffirstchoice’.Theseinclude:

• Pressure to act–toalleviatethedistressapatientmaybefeeling,GPscanfeelpressuredinto offeringimmediatereliefintheformofmedication(especiallyifthisisrequestedbythepatient).

• Time poverty–thesurveyresultsindicatethatdrugprescriptionratesincreasewith thenumbersofpatientsontheGP’slistwhichmaysuggestthatthoseGPswhoaremore time-pressuredarealsomorelikelytoprescribeanti-depressants.

• Limited alternatives–difficultiesaccessingpsychotherapyorcounsellingprovision (whichcanalsobeexpensive)canresultinGPsoptingfortheimmediatelyavailable optionofprescribinganti-depressants.

• Limited visibility of non-pharmacological and non-psychotherapeutic alternatives –incomparisontothewell-publicisedtrialsofantidepressants,whicharelargelyfundedby thepharmaceuticalindustry,muchlowerlevelsoffundinghavebeenavailableforresearchinto theoutcomesofalternativessuchasexercise;thefindingsoftheresearchthathasbeencarried outalsomaynotreachGPsandotherhealthcaredecision-makers.

• Expediency–findingsfromthe‘UpandRunning?’studysuggestedthatdoctorsareaware ofthestrongplaceboresponseanantidepressantmayproduceandthat,giventhe limitedavailabilityofpreferredalternatives,mayprescribeantidepressantsasanexpedient inthehopeofinducingsucharesponse.

• The dominance of pharmacology–medicationhasbeenthefavouredresponse inprimarycareforsomeconsiderableperiodoftime,aresponsethathasbeenreinforced byextensivepowerfulmarketingbythepharmaceuticalindustry.

Introduction

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Crucially,thereportgoesontonotethatmanyGPsareuncomfortablewiththewaymildormoderatedepressionismanagedinprimarycare,theywouldlikemoreaccesstoalternativetreatmentoptionsandthat,iftheyhadsuchaccess,theirprescribingbehaviourwouldaltersignificantly.

Itsuggeststhatanimportantwayforwardmayliewithexercisetherapywhich,throughdeliveryinanappropriatelysupervisedcontext,couldmakeasignificantdifferencetomanypeoplepresentinginprimarycarewithmildormoderatedepressionby:

• Expanding patient choice and power over their recovery–“depressionisaconditionthat thrivesonperceptionsofpowerlessness,andassuch,anexpansionofchoiceandpowermayitselfhave therapeuticeffects.”

• Helpingpeopletoeffectasustainablelifestylechangethatmaycontinuetosupporttheir mentalandphysicalhealthinthelong-term.

OtheradvantagesincludeempoweringGPsbyprovidingthemwithgreaterscopetoofferholistictreatmentplansand,ultimately,awideruseofexercisetherapycould:

“reducethecostburdenontheNHSprescriptionbudget,bygivingGPsgreaterfreedomtoexplore non-pharmacologicalapproachestotreatment,anddiscouragingpatientswithmildtomoderate depressionfromlong-termdependenceonmedication.”

Introduction

2. The GP survey – Four years on

AspartofthefirstreporttheMentalHealthFoundationsurveyedGPsinNovember2004toexploretheirperceptionsofexercisereferralasaprescription.ThissurveywasrepeatedinNovember2007toexaminewhethertheratesandacceptanceofGPreferraltoexercisehadchangedintheinterveningyears.Anationallyrepresentative,quotacontrolledgroupoftwohundredNHSGPsweresurveyed.ThemajorityofGPssurveyedwerefromEngland,atenthofGPswerefromScotlandandjustunderatenthwerefromWales,3%werefromNorthernIreland.

GPswereaskedabouttheirtreatmentresponsesforpatientswithmildtomoderatedepression.JustunderhalfofGPssaidthattheyprescribeantidepressantmedicationastheirfirsttreatmentresponseandthemajorityofGPsbelievethistobeeffective.Incontrast,thoughoverhalfoftheGPssurveyedbelievedexercisetobeaneffectivetreatment,only4%saidtheywouldrefertoasupervisedprogrammeofexercise.Interestingly,whenaskedabouttheirchoiceoftreatmentforthemselvesiftheybecamedepressed38%ofGPswoulduseantidepressantmedicationastheirfirstchoiceofself-treatmentand18%woulduseasupervisedprogrammeofexercise.

Whenconsideringtalkingtherapytreatments,overathirdofGPswouldreferpatientstosomeformofcounsellingorpsychotherapyastheirfirsttreatmentresponseand10%ofGPswouldrefertheirpatienttocognitivebehaviouraltherapy.

WhenaskedabouttheirthreemostcommontreatmentresponsesforpatientswithmildtomoderatedepressionalmostallGPs(94%)wouldprescribeanti-depressantmedication,thisisinlinewiththefindingsfromthe2004survey(92%).However,21%ofGPssaidtheywouldrefertoasupervisedprogrammeofexerciseand4%woulduseitastheirfirsttreatmentresponse,thisisoverfourtimesmorethantheresponsein2004survey.

Significantly,over40%ofGPsdonothaveaccesstoanexercisereferralscheme.Ofthese,95%saidthattheywouldreferpatientswithmildtomoderatedepressiontoanexercisescheme,iftheyhadaccess.OftheGPswhodidhaveanexercisereferralschemeover80%useditasatreatmentfortheirpatients.

2.1 Statistics

• 45%ofGPsmostcommonlyprescribeantidepressantsastheirfirsttreatmentresponse tomildormoderatedepression.36%ofGPsmostcommonlyrefertosomeform ofcounsellingorpsychotherapyastheirfirsttreatmentresponsetomildormoderatedepression, 10%ofGPsrefertocognitivebehaviouraltherapyastheirfirsttreatmentresponse. 4%ofGPsmostcommonlyrefertoasupervisedprogrammeofexerciseastheirfirsttreatment responsetomildormoderatedepression(Figure2).

• 72%ofGPsbelievethatantidepressantsare‘quiteeffective’,19%believethemtobe ‘veryeffective’.56%ofallGPssurveyedbelievethatasupervisedprogrammeofexercise is‘quiteeffective’inthetreatmentofmildtomoderatedepression,5%believethat itis‘veryeffective’(Figure1).

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Figure 1: GP perceptions of the effectiveness of exercise and antidepressants for patients with mild or moderate depression

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• Whenaskedabouttheirthreemostcommontreatmentresponsesformild tomoderatedepression94%ofGPsprescribeantidepressantmedication,21%ofGPsrefer toasupervisedprogrammeofexercise(Figure2).

Figure 2: GP preferred choices of treatment for patients with mild or moderate depression

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• 38%ofGPsstatedthatiftheybecamedepressedtheywoulduseantidepressantsastheirfirst choiceoftreatment,18%ofGPswoulduseasupervisedprogrammeofexerciseastheirfirst choiceoftreatment.83%ofGPssaidtheywoulduseantidepressantmedicationasoneoftheir topthreetreatmentsforthemselves,43%ofGPssaidtheywoulduseexercise(Figure3).

Figure 3: The treatment strategies that GPs would use if they themselves became depressed

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• 42%ofGPssurveyeddonothaveaccesstoanexercisereferralscheme.

• OftheGPswhodidhaveaccesstoanexercisereferralscheme3%referredtheirpatientstoit ‘veryfrequently’,22%‘fairlyfrequently’,61%‘notveryfrequently’and14%didnotuseitatall.

• 95%ofGPswhodidnothaveaccesstoanexercisereferralschemesaidthatiftheydidthey woulduseitasatreatmentformildtomoderatedepression,15%saidtheywoulduseit ‘veryfrequently’,51%saidtheywoulduseit‘fairlyfrequently’and29%‘notveryfrequently’.

• 70%ofGPssaidthattheywouldusemoresocialprescribing(forexample; bibliotherapy,exercisereferral,self-helpgroupreferral)forcommonmentalhealth problemsiftheyhadtheoption.

• 16%ofGPssaidthatoverthepasttwoyearstheyhadnoticedanincreaseinthenumber ofpatientswithmildormoderatedepressionaskingwhetherexercisewouldbeasuitable treatmentfortheirmentalhealthproblem.

TheGPsurvey-Fouryearson

ThirdchoiceSecondchoiceFirstchoice

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2.2 Has much changed over the last four years?

AntidepressantprescriptionisstillthemostfavouredresponsebyGPswith55%choosingthismethodastheirfirstresponsein2004and45%in2007.Someformofpsychotherapyorcounsellingwaschosenby32%ofGPsastheirfirstresponsein2004,and36%in2007.Lessthan1%ofGPsin2004wouldrefertoasupervisedprogrammeofexerciseastheirfirstresponse,by2007thisfigurehadrisento4%.In2004,41%ofGPsbelievedexercisetobe‘quite’or‘very’effectiveasatreatmentby2007,thisfigurehadrisento61%.

Iftheybecamedepressedthemselves,moreGPsnowthanin2004,wouldtryexercisethemselves.In200440%wouldtrycounselling/psychotherapyfirst,38%wouldtryantidepressantsfirstand11%wouldtryexercisefirst.In2007,38%wouldtryantidepressantsfirst,27%wouldtrycounselling/psychotherapyfirstand18%wouldtryexercisefirst.

2.3 Exercise: now an option?

Intermsofavailabilityofanexercisereferralscheme,thepicturereportedbyGPshasn’tchangedconsiderably.42%ofGPsreportedaccesstoaschemein2004,in2007thisfigurehadrisento49%,stilllessthanhalfofGPssurveyed.25%ofthoseGPswhodohaveaccesswouldrefer‘fairly’or‘very’frequently.Thisisariseoverthefigurereportedin2004of15%.

GPswereaskediftheyhadnoticedanincreaseoverthelasttwoyearsinthenumberofpatientsaskingwhetherexercisewouldbeasuitabletreatmentfortheirmildtomoderatedepression.16%hadnoticedanincrease,80%hadnot.Whenaskediftheywoulddomoresocialprescribing70%ofGPssaidtheywouldliketorefermoreofteniftheyhadtheoption.

2.4 Summary

TheGPssurveyedseemedremarkablyopentotheoptionofexercisereferralandbelieveinitseffectivenessandusehasrisenoverthelastfouryears.MoreGPsinthecurrentsurveythanin2004wouldrefertoasupervisedexercisereferralscheme.Furthermore,manyGPswouldliketohavetheoptiontorefertosuchschemes.Similarlytothepicturerevealedinthepastsurvey,GPsarestillmorelikelytoprescribeantidepressantsthanexercisereferralortalkingtherapies.

GPsweremorelikelytouseexerciseschemesiftheythemselvesbecameill.However,eveninthiscase,GPsaremorelikelytoprescribemedicationastheirfirstchoiceoftreatment.

TheGPsurvey-Fouryearson

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3. Site evaluations

“Makesmefitter,givesmemyownspace,feelgoodafteritandfeellikeIcancopewitheverything…”

(Interviewee,exerciseschemeparticipant)

3.1 Overview

ThissectiondescribesthefindingsoftheevaluationofaselectednumberofexercisereferralschemeswhoparticipatedintheprojectsupportedbytheMentalHealthFoundationwithfundingfromaDepartmentofHealthgrant.

Thecentralfocusofthisevaluationhasbeenondevelopinganin-depthunderstandingoftheexperiencesofindividualsreferredtotheexerciseschemes,thelastingimpactoftheirinvolvementinexerciseactivitiesandtheirperceptionsofanychangeintheirphysicalandmentalwellbeingasaresultoftakingpartinanexerciseprogramme.

QuantitativedataincludedbaselineinformationalreadyroutinelycollectedbythepilotsitesandalsothedistributionoftheRecoveryEvaluationForm(seeAppendixA).Qualitativeinformationwasgatheredfromfocusgroupsandindividualinterviewswithserviceusersandstafffrom2selectedleisure/exercisesettings.Thequalitativedatafromtheotherpilotsitesisoutlinedalongsidethecollationofotherrelevantfeedbackgatheredfromexerciseparticipantsinthesesites.

NationalResearchEthicsCommitteeApprovalforthestudywasgivenbytheRoyalFreeMedicalSchoolResearchEthicsCommitteeinApril2008andtheinformationgatheringcommencedthatmonthandranthroughoutthesummeruntiltheendofSeptember.

3.2 Key findings of the evaluation

Thefindingsfromtheevaluationhighlightarangeofbenefitsforthosetakingpartinexercisereferralschemesandalsothatthereareanumberoffactorstobeborneinmindinsuccessfullydevelopinganddeliveringexercisereferralprogrammes.

Withregardtothebenefitsforthosetakingpart,thefollowingwereidentified:

Physical and psychological benefits:

Nearlyalloftheparticipantsintheevaluationdescribedfeelingphysicallyandpsychologicallybetterasaresultoftakingpartinaprogrammeofexercise,withmanycommentsaboutincreasedconfidence,feelingmoreenergeticandgenerallyfitter.

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Thequotesbelowillustratethecorethemefindings:

“Therehavebeenmanybenefitstomeinattendingthisprogramme.Oversixweeks, Ihavelostweightandmybloodpressureisnowwithinthe‘normal’range…Mymoodhaslifted… Ihadbeenfeelingverylowbeforeattendingthisprogrammeandusingthegymhasdefinitely hadapositiveeffectonmymood…”

And:

“myinstructorhascontributedtothequalityofmylifegreatly –fromcuringanachinghiptocuringtheblues”

Tackling isolation, promoting social inclusion and supporting peer relationships:

Manyofthosewhowereinterviewedlivedaloneandwerequiteisolated;severalhadexperiencedbereavementinrecentyears(apossiblecausalfactorofdepression).

Inthefocusgroupsandindividualinterviews,thesocialbenefits(andthemotivationaleffects)ofjoininganexerciseprogramme,wasaprominenttheme:

“Isufferfromdepressionandhavefoundthattheexerciseclassesreallyhelpedtoimprove mymood.Myphysicalfitnesshasalsoimproved.InthepastIhavebelongedtogyms buthavealwaysstoppedgoingafterawhilebecauseitwashardtomotivatemyself.Ifindgoing toagroupactivityveryenjoyable.Youseethesamepeopleeveryweekandgraduallyget toknowoneanother.Knowingyouaregoingtoseefriendsmakesexerciselessofachoreandmore ofapleasantsocialactivity.Overall,theexerciseclasseshavehelpedmetogetfitter andtoavoidarelapseintoseveredepression.”

Anothermadethefollowingstatement:

“IamnotexaggeratingwhenIsaythatittransformedmylife.IhavetakenpartinactivitiesthatIhad neverdreamedofbeforetheschemeandhavemadenewfriends”

Tackling anxiety and promoting confidence:

Severaloftheintervieweesreportedhowattendanceatanexerciseclasshadhelpedthemtoovercometheirfeelingsofanxietyandfearofleavingtheirhomestogointosocialsituationswithotherpeople.Theydescribedhowwiththeencouragementofsupportiveexerciseinstructors,alongsideasenseofwhatonedescribedasthe“physicalexhilaration”aftercompletingaclass,theyfeltlessanxious:

“IdoknowthatifbeforeasessionIamanxiousorfearful,duringtheworkoutthesefeelings diminishandafterwardsInoticethatIfeelrelaxed,feelIhaveachievedsomethingandthatmy sleepingthatnightisbetter.”

Siteevaluations

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Improved cognitive functioning:

Awidelyreportedimprovementwaspeople’sabilitytoconcentrate,toplanandtocompletetasks.Thereweremanycommentsaboutthewayattendinganexerciseclassgavestructuretotheday,andaboutlookingforwardtotheactivitiesandachievingthegoalssetbytheexerciseinstructors:

“Ithashelpedmetofocusandtoplan.Iamalsostartingtothinkabout newthingsImighttryinthefuture.”

3.3 Running an exercise scheme – lessons learned

Intermsofthedevelopmentofexercisereferralschemes,theevaluationrevealedthatvariousfactorsarecurrentlyimpactingonthesuccessfuldevelopmentoftheschemesincludingfundingconstraintswithinlocalgovernmentand/orprimarycaretrusts.Inaddition,thefindingshighlighttheimportanceofthefollowing:

• Itappearsthatthereisstillquitelimitedawarenessofexercisereferralschemesamongst manywhomightrefer–savefortheoccasional‘champion’GPorpracticenurse –andthatongoingandhigherlevelactivitytopromotethebenefitsofexercisetherapy areneeded,includingadvertisingthroughawiderrangeofvenuessuchaslibraries, furthereducationcollegesandjobcentres.

• Referrerstoexerciseschemesneedtounderstandwhatisonoffersothattheycanpick the“righttimeandtherightactivity”tosuggestaschemetotheirpatients–ifexercise referralschemesarejustroutinelymentionedasapartofahealthconsultation, variousintervieweessuggestedthatpeopleareunlikelytohavetheconfidencetorespond.

• Thereferralprocessitselfisanimportantavenuetoclarifypatients’expectationsandworries aboutanexerciseactivity,whichcaninturncontributetoachangeinattitudesandbeliefsabout exercise.ThisisalsonotedintheearlierevaluationoftheCamdenscheme(oneofthepilot sitesinthisstudy)byMiddlesexUniversitywhereitisconcludedthat:

“Providingpatientswithinformationrelatingtotheactivitiesonoffer,thevenues,andtheclasstimes, enablesthemtoselectanappropriateexerciseclassthatsuitstheirrequirements.Givingpatientsthe freedomofchoiceislikelytofacilitatebehaviourchange…”17

• Individualisedsupporttoengagepeopleinthefirstclassofanexerciseprogramme isessentialiftheyaretoattendpasttheinitialsession.Intwoofthepilotsites,quitehighdrop outratesofpeoplereferredformentalhealthreasonswerereportedanditwassuggested thatalackofconfidenceandfearofnewsocialsituationsweresignificantdeterrents totheirsuccessfulengagementintheprogrammes.

• Itisimportanttohaveamenuofexercisechoicesavailable–notjustgym-basedprogrammes sinceforsomepeoplewithmentalhealthproblems,lessstructuredandmoreopen-ended activitiessuchashealthywalkingschemes,maybemoreappropriate.Ifpossible, ‘taster’sessionsshouldbeofferedtoeasetherouteofaccess.Familiarstaffmembers, whofollowthroughonvariousdifferentactivities,canhelptoencouragepeopletotrynew things.Inaddition,providingaccesspointsintootheractivities,oncetheinitialprogramme ofexerciseiscomplete,iskeytokeepingpeopleactiveandsupportingtheirrecovery.

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• Offeringprogrammesatdifferenttimesoftheday,includingintheearly evening,isrecommendedtotakeaccountofthedifferentcommitments ofthosereferred.Somepeoplemaybein,oroncetheystarttofeelbetterwill bereturningto,employmentsothisshouldbefacilitatedviaflexibletimings.

• Venuesneedtobeaccessiblewithhighqualityandwell-maintained facilities.Variousrespondentstalkedoffeelingputoffbypoorlymaintained andover-crowdedexercisevenues.

• Respondentsintheevaluationemphasisedthatthepaceofexerciseactivityneedstobe tailoredtomeettheneedsoftheindividualsreferred,especiallysincemanypatientswithmental healthneedsmayneverhavetakenpartinastructuredprogrammeofexercisebefore.

• Thesizeofthegrouporexerciseclassisimportant–toosmallandtheopportunitytomake newfriendsandformsocialnetworksislost(orgroupsruntheriskofbeing‘cliquey’), whilstontheotherhand,ifthegroupistoolargethiscanseemdauntingandimpersonal.

• Costisakeyconsiderationformany,withanumberhighlightingthat theavailabilityofdiscountschemesorloyaltycardshadinfluencedtheirdecision tocontinuewithanexerciseactivityoncetheinitialprogrammewascomplete.

3.4 The project sites

“Forpeoplewithforexamplementalhealthproblems,itgivesyoutheencouragementyouneedtoget thetrainersinthebagandgoknowingthattherewillbesomeonetheresupportingyouandotherslike youinthesameboat.It’sbeenanewexperienceformeandapositiveone…”

(Exerciseschemeparticipant)

Fivepilotsiteswereoriginallyselectedforinclusionintheevaluation.Thesewere:Bedfordshire;Camden;Northamptonshire;CambridgeandWirral.Asixth,RedcarandClevelandwaslateraddedtothegroup.

Duetothesmallsizeofsomeoftheexercisereferralschemesintheseareas,andbecauseoneoftheschemeswasonholdwithbudgetaryconstraints,astheevaluationprogressed,thedecisionwastakentofocusonthethreeschemesthatwerefullyoperationalandwereofasufficientsizetogatherquantitativedata.ThesewereBedfordshire(Flitwick),CamdenandCambridge.Overviewsofthesethreeschemes,plusbriefdescriptionsoftheotherthreepilotsitesfollow:

Bedfordshire exercise referral scheme at Flitwick Leisure Centre

Bedfordshirehasbeenrunninganexercisescheme“ActivitiesforHealth”forapproximatelyfouryears,withtheschemeacceptingpatientsfromfourlocalGPpracticesforavarietyofphysicalhealthproblems,notablycardiacproblemsandobesity.TheschemeoperatesoutofthreelocalsiteswiththeFlitwickbasebeingthelongestestablished.

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Alsointhecounty,thelocalPrimaryCareTrust(PCT)supportsavarietyofactivityreferralschemesinBedforditself:therearevariousestablishedhealthywalksschemesandinLutonandDunstableandawell-establishedexercisereferralschemeforcardiacpatients.

InMarch2007,theFlitwickcentrebeganapilotprojectforexercisereferralwithpatientsexperiencingcommonmentalhealthdisordersfromoneoftheGPpracticesaspartoftheNationalPrimaryCareMentalHealthCollaborative.Thescheme,whichdevelopedinresponsetotheevidentmentalhealthneedsamongstthosereferredforprimarilyphysicalhealthreasons,isforpeoplewhoareexperiencingmildtomoderatedepressionandoranxiety.Priortoreferral,patientsareassessedinprimarycareusingtheHospitalAnxietyandDepressionScale(HAD)and,oninduction,afitnesstestisundertakenwhichhelpstoinformtheprogrammeofexercisethatisrecommended.

AlllevelsoffitnessareacceptedatFlitwick,whichoffersarollingprogrammeofgym-basedactivitiesalongwithotheractivitiessuchashealthywalksthatarerunwhentheweatherisappropriate.Pilates,circuitsandaquaaerobicsarealsoavailable.PCTfundingcoveredsometraininginmentalhealthforthetwoleadmembersoftheexercisestaff,who,inadditiontorunningtheactivities,haveplayedakeyroleindisseminatinginformationaboutthepilotprojecttolocalGPpractices.

Thecentrepromotessocialinteractionsbetweenclientsattendingtheexercisegroupsbyprovidingfreerefreshmentsafterthesessionsandoftengroupmemberswillmeettogetherforlunchorasnackintheleisurecentreaftertheirclass.Thecostis£2.50persession,withaconcessionaryrateof£1.25forthosethatarenotinemployment.

Duringtheevaluation,referralstotheexerciseschemecontinuedtobepredominantlyforcardiacandweightlossreasons,withveryfewreferralsformentalhealthissues.Analysisofthereasonsforstoppingattendancesuggestedthatsomepeoplefoundthegym-basedcoursetoostrenuousandtwowereadvisedbytheirGPtostopduetoillness.Inanattempttoencouragemorereferralsofmentalhealthclients,planstoenlistmoreGPpracticeswereagreedin2008;however,amajorissueinfluencingtheseplans,andalsothecurrentrateofreferrals,wasacknowledgedtobeuncertaintyaboutplanstore-developanewleisurecentreonasitemoreinthetowncentre.

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CASE STUDY A

Jamesheardabouthislocalexercisereferralschemethroughthelibraryand,feelingveryunhappyandisolatedasaresultofhisweight,askedhisGPforareferral.Severalweekslater,hemetamemberoftheCountyCouncilfundedexerciseteamwhoplannedwithhimagym-basedprogrammeofclasses.

Jamesdescribedattendingagymforthefirsttimeasverydauntingsinceheisalsopronetopanicattacksinneworunfamiliarsituations.However,becausehewassupportedthroughouttheprogrammebytheexerciseteammemberofstaffwhohadfirstassessedhim,andbecausehejoinedasmallgroupofpeoplewithsimilarproblems,hemanagedtocompletethefirstclassandthenstartedattendingclassesonceaweek.

Astimepassed,Jamesnoticedthathewasgrowinginconfidencetotrynewpiecesofequipmentandthathisstaminawasimproving.Healsoreportedmoresettledsleepandsomeweightloss.Byconcentratingonbreakingthesmallrecordshehadsetforhimself,hefoundthatanyanxietieshehadonthewaytotheclassdidnotescalateintoapanicattackandveryoften,justdisappeared.

Oncompletionoftheeightweekinitialprogramme,Jamesdecidedtojointhegymonapermanentbasis.Heincreasedhisattendancetotwiceweeklyandalsojoinedalocalteamsportsgrouprunbytheexerciseteam.

Camden Exercise Referral Scheme

TheCamdenExercisereferralSchemewasestablishedin2004andhasateamofspecialists–theCamdenActiveHealthTeam–forspecificconditionsanddisorders.Theydelivertheexercisetothosereferredintothescheme.Theschemeisopentopeopleagedeighteenandoverwhohaveoneormoreofthefollowingchronichealthconditions–obesity,diabetes,osteoporosis,coronaryheartdisease,cardiovasculardisease,andchronicobstructivepulmonarydisease.Peoplewithmentalillnesses(neuroticandpsychoticdisorders)andpeopleagedsixtyorolder,whoaresedentaryandatriskoflosingtheirindependence,arealsoeligible.

TheActiveHealthTeam,whoseexerciseleadersareallqualifiedtolevel3ontheRegisterofExerciseProfessionals,acceptsreferralsfromarangeoflocalhealthprofessionalsincludingGPs,practicenurses,physiotherapists,mentalhealthnursesandoccupationaltherapists.Onceareferralhasbeenmade,theindividualwillhavetheirfirstconsultationwithintwoweeksand,atthistime,theteamusethevalidatedoutcomesmonitoringtoolsSF-12andIPACtolookathealthandthelevelofexercise.Thesescalesarecompletedagainattheendofanysessions.Theteamalsorequestinformationaboutanymedicationsapersonmaybeonandanyexerciseimplicationsarisingfromtheircondition.

TheexerciseschemeinCamdenprovidesactivitiessuchasgreengym,sportsgroups,yogaandPilatesandthosereferredtotheschemereceiveaneightweekprogrammefreeofcharge.Thoseconsideredtobeatriskoflosingtheirindependencebecauseofahealthconditionthatlimitstheirabilitytoleavetheirhouse,areofferedone-to-onesessionsintheirhome.Afterthefirstprogramme,participantscanthenchoosetocontinuewithanyclassesoractivitiesthattheyaredoingforthecostof£1.00asessionortojoinalocalgymforaround£16.00amonth.

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AllGPsaresentfeedbackaftertheeightweekprogrammeandthereisfollow-upatninemonths.OperationoftheCamdenschemeduringitsfirstfourteenmonthswasevaluatedbyMiddlesexUniversity,withtheresultsshowing:

• Highratesofcompletionoftheinitialexerciseprogramme.

• Manypatientsreportingimprovedmentalhealthasaresultofparticipation inthescheme,includingincreasedlevelofpositivemood.

• Thatwhilstthereferralswerelimited,referrerstotheschemehadreceived positivefeedbackabouttheschemefromtheirclients.

Thefindingsalsohighlighttheimportanceofusingeasilyaccessiblevenues,withmanyoftheparticipantsexperiencingnegativejourneysonpublictransporttoattendtheexerciseclasses,andfurtherhighlighttheimportanceofhavingfacilitiesthatarelargeenoughandinagoodcondition.Finally,theroleoftheexerciseleaderinsupportingengagementisapparent:

“Patientsstatedthatthefactthattheyhadmetthementalhealthco-ordinatorattheirinitial consultation,andthatthissameco-ordinatorwouldbeinstructingtheclass,madethemfeelmore comfortableaboutattending.Movingintoadifficultclasswheretheydidnotknowanybody wasperceivedas‘difficult’and‘daunting’.”18

CASE STUDY B

Annawasreferredtoherlocalexerciseschemefollowingseveralmonthsoftreatmentfordepressionandanxiety.Shewasinterestedinattendingagroup-basedactivitybecause,althoughshehadajob,thiswasinatownsomemilesawayandshefeltisolatedinherlocalareaandhopedtomeetsomenewpeoplethroughthegroup.

Workingmeantthatsheneededtobeabletoattendtheexerciseactivityintheeveningsbutalsothatshewasquitetired.Havingstartedonagym-basedcourse,shefoundthistoostrenuousandnotaneasywaytogettoknowotherpeoplesochangedtoanaquaaerobicsclasswhichshefoundmorefun.Intime,shealsobegantotakepartinsomeofthehealthywalkswhichwereavailableattheweekend.

Annareportedenjoyingtheactivitiesonofferandthatthemainbenefittoherhasbeenhavingareasonto“getoutandaboutratherthanjustwatchingthetelevisiononmyown”.Shehascontinuedtoexercisehavingcompletedtheinitialprogrammeshewasreferredto.

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Cambridge Exercise Referral Scheme

InCambridge,theexercisereferralschemeiswellestablishedandhasbeenrunningforovertenyears.Therearetwophysicalactivityschemes,whicharerunbyCambridgeCityCouncil’ssportsdevelopmentdepartmentthathaveamentalhealthcomponenttotheirwork,Start-UpandInvigorate.Bothprojectsofferarangeofactivities;however,amajordifferenceisthatInvigorateoperatesmoreatthesecondarylevelandisfocusedonsupportingpeoplewithestablishedmentalhealthproblems,whereasStart-Upisaimedmoreatthosepeoplewithmildandemergingmentalhealthproblems.Forthisreason,onlytheStart-Upschemewasincludedinthisevaluation.

Start-UpisamemberoftheCountyPhysicalActivityandHealthGroupwhichhasrepresentativesfromawiderangeoflocalorganisationsincludingtheNHSCambridgeshire(formerlyCambridgeshirePCT)andlocalauthorities.Whentheschemeoriginallybegan,onlyGPswereabletorefer;however,theintroductionoftheNationalQualityAssuranceFrameworkforExerciseReferralSystemsin2001providedguidanceonalliedhealthprofessionalswhocouldalsoreferandthishasledtoreferralsbeingacceptedfromnurses,physiotherapists,occupationaltherapistsanddieticians.TheStart-Upschemerunspredominantlyfromtwomainleisuresettingswithinthecityandalsoseveralcommunitycentres.

StaffedbyLevel3ExerciseProfessionals,whoundertaketheinitialassessmentandplanningofanindividualtwelveweekexerciseprogramme(includingidentificationofthemostsuitablelocationforapersontouse),theStart-Upschemeoffersavarietyofactivitiesincluding:supervisedgym,swimming,aquamobility,specialistcircuitbasedclasses,exercisetomusic,Pilatesandchair-basedexercise.Thesesessionsareonlyavailabletocurrentorpastexercisereferralclients,andapartfromthosewishingtoengageinahomebasedprogrammetherearenofreeactivitiesprovided.However,viathelocalLeisureCardschemeandthroughnegotiatedservicelevelagreementsamongstprivateproviders,avarietyofdiscountsapply.

AnalysisoftheuptakeoftheStart-Upprogrammesuggeststhattherearearoundthirty-twonewreferralseachmonth,withthethreemostcommonreasonsforreferralbeingmusculoskeletal(includingbackpainandarthritis),obesityanddiabetes.Mentalhealthisaroundthe5-6thmostcommonreason.60%ofthosereferredcompletetheinitialtwelveweekprogramme,manyofthosewhodocompleteaprogrammethencontinuewiththeirchosenactivityorhaverevitalisedconfidencetoengageinsomeotherchoice.OnepopularrouteforthosewhoarereferredformentalhealthreasonsistothenjoinasamemberoftheInvigorateproject.Membershipisfreeand,althoughnoindividualisedandtailoredsupportisoffered(unliketheStart-Upscheme),Invigorateprovidesanarrayofgroup-basedactivity,canbemoreflexibletotheclient,providesawiderchoiceofsportsandischeaperforclientstoattendonalonger-termbasis.

Commonreasonsgivenfornon-completioninclude‘lackoftime’and‘notenjoying’theactivity–againemphasisingtheimportanceofofferingachoiceofexerciseoptions.

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CASE STUDY C

Followingthedeathofherhusband,Marionbecameincreasinglyisolatedandwithdrawn.Shehadgivenupherjobandwasspendingalotofhertimeasleeporwatchingthetelevision.Shewasreferredtoherlocalexerciseschemewithadiagnosisofdepressionandfollowinganassessmentbytheexerciseco-ordinator,agreedtotryayogacourse.

Marionwasveryfearfulofattendingthefirstyogaclasssinceitwasmanyyearssinceshehaddoneanyexerciseofanytype.However,herworriesrecededwhenshediscoveredthatsheknewseveralofthegroupmemberswhowerealsoinvolvedinsomeother‘lowkey’exerciseactivitiessuchasadancingclass.Theyogagroupwasalsoverysociable,oftengoingforcoffeetogetherafterclass.

Intime,Mariondescribedfeelingmuchmorephysicallyalertandactive.Byhavingsomethingtolookforwardtowhichsheenjoyed,shewasalsolesspreoccupiedwiththoughtsofherhusband.Shebegantothinkaboutreturningtoworkandasafirststeptowardsthis,decidedtovolunteerinherlocalcharityshop.

Northampton, Redcar and Cleveland and Wirral exercise referral scheme

InNorthampton,theexercisereferralschemeisbasedarounda12weekprogrammeofgymbasedactivities,with24GPpracticesbeingaffiliatedtothescheme.Commonmentalhealthproblemsarethesecondhighestreasonforreferral(17%ofreferrals)behindreferralsforobesity(25%).

Theschemeoperatesoutofanumberofdifferentsitesinthecountyandscreening/assessmentattheinitialconsultationiskepttoaminimum.Afteraninitialtwoweekperiodofactivitiesthatarefreeofcharge,pricesarechargedandvarydependingonthelocationandexerciseactivityselected.Allthosereferredforexercisearealsogivenaleisurecardthatentitlesthemtodiscountsonotherfacilities,backedbyadviceandinformationastotherangeofsportingactivitiesavailable.Thereissomeflexibilityintheschemeandpeoplecansometimesbereferredforasecondtimeattheendofthefirstprogramme.

Redcar and Cleveland’shealthywalksschemehasbeenrunningforoverfiveyearsandhasaroundonehundredpeopleonitsregisterandaregularweeklyattendanceofbetweenthirtytofortypeople.Reasonsforreferralvarybutweightproblemsareprominent.Theschemeaimstobeasflexibleaspossibletokeeppaperworktoaminimumand,assuch,onlylimitedhealthinformationiscollectedwhenpeoplejointhescheme.InformationabouttheprogrammeofwalksisdisseminatedonaregularbasisviaalllocalGPspractices,practicenursesandlocalhealthcentres.

Wirraloffersasimilargym-basedschemetotheBedfordprogrammedescribedearlier.ReferralscurrentlycomefromoneGPpractice.

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CASE STUDY D

Samsawhislocalexercisereferralschemeadvertisedinhislocalhealthcentre.Hehadahistoryofdepressionarisingfromatraumaticworkinjurysustainedsomefiveyearspreviouslywhichhadlefthimwithconstantbackpain.Afteraninitialconsultationwiththelocalsportsteam,Samdecidedtotryoneofthesupervisedswimmingexerciseclasses.

Samfoundthattheclassgavehimsomethingtolookforwardtoand,bygraduallyswimmingforlonger,thathisgeneralfitnessimproved.Althoughitdidnotcompletelycurehisbackpain,hereportedfeelingthathisposturehadimproved.Healsofeltless‘low’andpositiveabouthisachievementsintheclass.

Samemphasisedtheneedforwideradvertisingofexercisereferralschemes,pointingoutthatitwasonlybecausehewasalreadyinpainandinneedofhelpfromhisdoctorthathewasinthehealthcentreandthatthisis“missingoutlotsofpeoplewhomightbenefitbutwhohaven’treachedthestageofhavingaseriousmedicalproblem.”

3.5 Analysis of site data

Profile of the respondents

Atotalofforty-oneinitialRecoveryEvaluationForms(REFs)andtwelvefollow-upformswerecompletedfromBedfordshire(Flitwick),CamdenandCambridgeshire.Thesampleisrelativelysmallandacomparativelylimitedamountofquantitativeanalysiswasconducted.Thefollowingprovidesasnapshotoftheserviceuserswhocompletedtheevaluationforms:

Theaverageagewasforty-twoyearsold(range20-72),andthemajorityofpeopletakingpartwerefemale(71%).ArangeofethnicminoritygroupsparticipatedincludingBritish(45%),African(17%),Caribbean(12%),andEuropean(10%).

Regardingtheworkingstatusofparticipants,43%werenotworkingbutintendedtointhefuture,19%werenotworkingandhappywiththat,14%wereworkingfulltime,11%werestudents,and6%wereworkingpart-time.

85%oftheparticipantsreportedbeingonregularmedication,theseincludedFluoxetine,ProzacandClozapine.32%reportedhavingaphysicaldisability.51%werelivingalone,and24%hadcaringresponsibilities.

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Impact of participating in an exercise programme

Theanalysisofthetwelvefollowupevaluationformsallowedaninsightintotheimpactofexerciseparticipation.Itdoesappearthatparticipationinaprogrammedoesbringsomestatisticallysignificantimprovements(onthebasisofserviceuserself-rating)inthefollowingareas:

• Confidenceregardingmakingdecisions.

• Recognitionofearlysignsofbeingunwell.

• Awarenessofwhatittakestokeepwellandhappy.

• Knowingwheretogethelp.

• Feelingthattheirphysicalhealthwasgood.

• Feelingthattheyhadenergyandenthusiasmfortheircurrentactivities.

• Thattheywereencouragedbystafftotrynewthings.

Fromtheanswersgiven,thereappearstobelittledifferencebetweenmenandwomensaveforthefollowingwherewomengavemuchhigherinitial(baseline)scores:

• Feelingthattheirphysicalhealthwasgood.

• Feelingthattheyhadbeenencouragedtomakedecisionsaboutexercise.

Views about the exercise scheme

TheREFformallowsrespondentstoaddadditionalcommentsabouttheexerciseschemeandsomeofthepointsnotedsuggestthatformosttheexperienceoftakingparthadbeenpositive,hadhelpedpeopletoloseweightandtoimprovetheirsenseofcoping.

Severalalsocommentedonlookingforwardtoactivitiesandthattheywerenowabletofocusandtosetthemselvesgoalsforwhattheywantedtoachieve.

3.6 Exercise referral schemes: do they work?

“Theschemehasgotmebackintothegym…Supportfromothersontheschemehasbeenareal boosttomoraleandanimportantfeaturethatshouldbecontinuedinthefuture…”

(ParticipantinFlitwickexerciseprogramme)

Thecurrentdeliveryofexercisereferralschemeswasexploredviaaseriesoffocusgroupmeetingsandindividualinterviews.Inaddition,asmallnumberofinterviewswereundertakenwithlocalstakeholderssuchascommissionerswithinthelocalprimarycaretrustandcountycouncilleisuredepartments.Thesemeetingsgatheredinformationabout:thedifferenttypesofexerciseactivityonoffer;howinformationisdisseminatedaboutschemes;howthosereferredhadheardabouttheirlocalscheme;participantviewsregardingwhattheythoughtworkswellandideasforimprovingthedeliveryofexercisereferralschemes.

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The activities on offer in exercise referral schemes

TherangeofactivitiesthatparticipantsintheCamdenfocusgrouphadbeenreferredtorangedfromgym-basedclassesincludingcircuits,badminton,Pilatesandyogathroughtoaquaaerobics,activewalksandkickboxing.Activitiesweremainlyindoorsandbasedonbookedclasses,thoughsomedrop-intypesofactivitywerealsomentioned.InBedford,agreaterfocusongym-basedactivitieswasapparent.

InbothCamdenandBedford,theimportanceofhavingapproachableandempathetic,well-trainedinstructorswasemphasised:peopletheparticipantsfelttheycouldgettoknow,whoweregoodatassessingpeople’scapabilitiesandskilledinencouragingthemtoworkwithintheirlimits.

Itwasalsonotedthathavingstaffonhandwho“knowwhoyouarebeforeyouturnup”makesjoininganexercisereferralprogrammelessdauntingandvariouscommentswerealsonotedregardingtheimportanceofstaffhavinganunderstandingofmentalhealthsincepeoplecan“gohighorfeelverydownafterwards”(afteranexerciseclass)–andstaffneedtobeabletosupportpeopleappropriatelythoughthis.

The benefits of exercise referral programmes

Alloftheinformantstotheevaluationwereverypositivethattheirparticipationinaprogrammehadarealdifferencetotheirlives.Seeingotherpeoplewasaprominenttheme,alsothathavingaregularplannedactivitywhichwasseenasgivingafocustothedayandareasontogooutintotheirlocalcommunity.Asoneparticipantnoted:

“Thesocialelementissuchabigpartofit…promisingsomeonethatyouwillmeetupwiththemnext week(atthenextclass)isarealmotivator…”

Avarietyofphysicalandpsychologicalbenefitswerealsoidentifiedincluding:

• Exercisegivingyouaboostorwhatonepersoncalleda“naturalhigh”.

• Feelingmentallyandphysicallystronger.

• Becomingmoreconfident(onepersontalkedofhowithadencouraged themtotakeupsomevoluntarywork).

• Weightloss–andalthoughseveralparticipantswereclearthatexercisedoesn’t replacetheneedformedication,itcanreallyhelpwithreducingtheweightgain thatcanresultfromregularmedicationuse.

Theincreaseinconfidenceandthebenefitsarisingfromthiswasfrequentlynotedandiswellillustratedbythefollowing:

“…findingthatIcouldcope–physicallyandmentally–alongwithher(theinstructor’s) encouragement–gavemeconfidence.SoIstarteddoingothersocialandphysicalactivitiestoo…”

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Theentiregroupthoughtthattakingpartinexercisebenefitedyoungandoldandsuggestedthatmoreshouldbedonetoencourageyoungerpeopletotakepart,especiallygiventheconcernsaboutobesityamongyoungpeople.

Intermsofwhetherparticipationinanexerciseprogrammewaslikelytohavealastingimpact,mostthoughtthatitwould–forexample,feedbackquestionnairescompletedbyallparticipantsintheFlitwickprogrammeindicatedthattheyintendedtocontinueusingthegymaftertheendofthetwelveweekcourseandintheCamdenfocusgroup,mostofthegrouphadnotdoneanexerciseprogrammebeforejoiningtheschemeandnearlyallintendedtocontinueattendanceoncetheireightweekprogrammewascomplete.

ItwassuggestedthatthiswasthetypicalpatterninCamden,hencethelongwaitinglist/fullclasses.Again,theimportanceofhavingempatheticstaffrunningtheclasseswasnoted,withthefollowingillustratingthevalueofsuchinput:

“Hisfriendly,professionalandgood-naturedapproachmeantthatIhavefeltconfidentfrom thestart…hehasbeentotallynon-judgemental…whilealsogivingmepositiveandsustained encouragementtobecomemoreactiveinawaythatIwillbeabletosustainwhenIamno longerpartoftheprogramme…”

Externalstakeholdercommentssupportedthesepositiveviewpoints,withtheimportanceofhavingamenuofexerciseoptionsavailableagainbeingnoted,toensurethatdifferentinterests,differentlevelsofphysicalabilityandtheneedforgreaterorlessstructuredprogrammesofexercise,areaddressed.

Publicising exercise referral schemes

Fromtheinformationgathered,itdoesappearthatdisseminationofinformationaboutexercisereferralschemesisstillquitepatchyandlimitedeveninareasofthecountrywithwell-establishedschemes.Avarietyofcommentswerenotedtotheeffectthatitwaslargelybyluckor“onthegrapevine”thatpeoplehadheardabouttheirlocalscheme,includingoneparticipantwhodescribedaskingforareferralaftershehadheardaboutanexercisereferralschemeinanotherareaofthecountry.

Furthermore,althoughhalfthegrouphadbeenreferredbytheirGP,mostfeltthatithadbeenmorethroughtheirownsuggestionratherthantheGPbeingproactiveandawareofwhatwasonoffer.Overall,theysuggestedthattherewasnolocalinformationandagenerallackofadvertising.

ThisfindingechoessomeoftheconclusionsreachedbytheCamden(MiddlesexUniversity)evaluationwhichnotes:

“Healthprofessionalsstatedthattheywouldlikemoreinformationaboutwhatpatientsactually getfromthescheme,intermsofactivitiesaswellashealthbenefits.”19

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OnekeysuggestionmadeforimprovingthissituationwasforGPstobeinvitedtovisittheparticipatingexercise/leisurecentrestoseewhatwasavailable.Thismightimprovetheirawarenessandencouragethemtorefermorepatientswhocouldbenefit.

Suggestions for raising awareness of exercise referral schemes

InadditiontotryingtoinvolveGPsmore,informantstotheevaluationmadethefollowingsuggestions:

• Distributionofinformationtothelocaldayhospitalsandvoluntarysector projectsworkinginthementalhealthfield.

• Provisionofinformationtolocalcolleges.

• Targetingoftheadulteducationsector.

• Regulardisseminationofinformationaboutthedifferentclasses andexerciseactivitiesofferedthroughascheme.

Suggestions for improving the delivery of exercise referral schemes

Inbusyareasorthosewithpopularexercisereferralschemes,someparticipantshadexperiencedalongtimebetweenbeingreferredandbeingseenforaninitialassessment.Whilstitwasrecognisedthatthissituationreflectedthehighnumbersofreferrals,itisalsoimportanttoemphasisethatthisreferralprocessisanimportantpartofengagingpeopleinexerciseanditisimportantthattheyarenotkeptwaitingtoolongotherwisethemomentumandconfidencetotakepartcanbelost.AgainthispointwasraisedintheCamdenevaluationwhichnotesthatatimedelaybetweenreferralandconsultationcanresultinpeopleattendingaconsultationbutnotstartinganexerciseprogrammeduetoreducedmotivation.

Likewiseverypopularclassesgetfullupandattendancecanberestrictedand/orpeoplehavetowait.Thisagainemphasisestheneedtohaveamenuofdifferentchoicesavailable.

Theconsistencyofinstructorswasstressed.Insomeschemes,thereareanumberofdifferentinstructors,someofwhomdotheinitialassessmentsandsometherunningofactualclasses.Itwassuggestedthatintermsofmakingpeoplefeelsupportedandcomfortable,whereverpossible,thereshouldbecontinuityofstaffingthroughouttheassessmentsessionandatleastthefirstfewclasses.

Someconfusionwasnotedaboutcomplicateddiscountandpaymentarrangements–theseschemesneedtobeclear,assimpleaspossible,andwellpublicised.

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Finallytherewassomedebateandmixedviewsabouttheuseoftimelimitedprogrammes(forexampleeightortwelveweeks)andaboutwhetherreferralviaahealthprofessionalisreallynecessaryorsimplyservestodetersomepeople.

Severaloftheintervieweesexpressedtheviewthatprogrammesshouldbemoreopen-endedtoallowmoreflexibleattendance,althoughtheyrealisedthatcapacitycouldbeanissueinrunningschemesthisway.Likewise,allowingpeopletoself-refermightencouragepeopletobecomeactiveearlierratherthanwaitingforphysicalorpsychologicalproblemstoreachthepointofrequiringprofessionalidentificationandreferral.

3.7 Key learning points from the evaluation and 2007 GP surveyregarding the development and delivery of exercise referral schemes

InformationgatheredthroughtheGPsurveyandevaluationhashighlightedboththepositiveoutcomesforthosetakingpartinexercisereferralprogrammesandalsosomeofthefactorsthatarecurrentlyrestrictingtheirdevelopmentandwideruse.

Withregardtowhatmaybeimpedingtheuseofexercisereferralschemes,probablythemostimportantfindingisthatover40%ofGPsreportedthattheydonothaveaccesstoaschemeintheirarea.Alongsidethis,18%reportedthatoverthelasttwoyears,theyhadnoticedanincreaseinthenumberofpatientswithmildtomoderatedepressionaskingaboutexerciseasasuitabletreatment,whichwouldsuggestthatpublicawarenessofthebenefitsofexerciseforthismentalhealthdifficultyhasgrown.

Fromtheevaluationdata,itwasapparentthatthebarriersfacingthedevelopmentanduseofexercisereferralschemesincludeamongstotherthings:

• Inconsistentdisseminationofinformationaboutschemesandlimitedknowledgeastowhat isofferedamongstpotentialreferrers.

• Financial/budgetaryconstraints.

• Whereschemesareverypopular,therecanbedelaysinthetimebetweenreferral andassessmentorclassescanbefull(withthegeneralpressureonbudgetsandpremises meaningthatitisdifficulttorunextraclasses).

• Timeconstraints(aprominentreasongivenforthenon-completionofexerciseprogrammes).

Intermsofthebenefitstothosetakingpart,thefollowingpointswerenoted:

• Involvementinanexercisereferralprogrammedoesappeartobring arangeofphysicalandpsychologicalbenefits.

• Engagementinsuchprogrammescanhelptotackletheisolationandsocialexclusionofpeople withmildtomoderatedepressionandtosupporttheformationofnewpeerrelationships.

• Improvedself-confidence,reducedanxietyandagreaterabilitytofocus, setgoalsandcompletetaskswerealsowidelyreported.

Siteevaluations

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Keyfactorsinthesuccessfuldeliveryofexerciseprogrammesincluded:

• Localreferrerswithunderstandingofwhatwasonofferandanabilitytojudge the‘righttime’inaperson’srecoverytosuggestareferraltoanexerciseprogramme.

• Goodlocalinformationaboutwhatisavailable,whatattendanceentailsandwhatthe programmescost,alongsidevariouseffectivedisseminationchannelssuchasGPsurgeries, localhealthcentres,librariesandothercommunitysettings.

• Apromptandclearreferralprocesswithminimumdelaybetweenreferralandinitialassessment.

• Individualisedsupportforthepersonastheyinitiallyengagewiththeprogramme andmotivationalsupportthroughout(highlightedinbothCamdenandCambridge’sevaluations asacrucialfactorinthecompletionofprogrammes).

• Consistencyofsupportthroughouttheassessmentprocessandatleastthefirst fewexerciseclasses.

• Experiencedexerciseleaderswiththeabilitytoempathisewithpeoplereferredformental healthneedsandtoadjustthedeliveryofaprogrammeorindividualexerciseclasstoaccount forvariationsinmood,confidenceandabilitytoconcentrate.

• Havingachoiceofexerciseoptionsavailable(notjustgym-basedoptions)thatspandifferent fitnesslevels,differentinterestsandareofferedatanappropriatepacetotheneedsoftheclient.

• Flexibilityinthetimesofexerciseclassesandvenuesused;withthelatterbeingofahighquality, withgoodlevelsofcleanlinessandagoodsupplyofequipment.

• Schemes/exerciseclassesofareasonablesizetopromotethesocialaspectsofengagement.

• Clearavenuesintootherexerciseactivitiesoncompletionoftheexercisereferralprogramme.

Siteevaluations

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4. Conclusion

Thisreporthasdemonstratedhoweffectiveexercisecanbeasareferraloptionforthosewithmildtomoderatementalhealthdistress.Exercisetherapyispotentiallybothaneffectivetreatmentfordepressionandaneffectivepromotioninterventionfordepressedpeople.Fortheindividual,controlintheirrecoveryjourneyisleftwiththeminanempoweringwayandalsothereareassociatedbenefitstophysicalfitnessandsocialinclusion.

Despiteagrowingawarenessofthebenefitsofexercise,amongsthealthprofessionalsandthepublic,therearesomesignificantbarrierstoovercomeintermsofensuringthatallareasofthecountryofferexercisereferralschemes;thatinformationaboutwhatisavailableismorewidelydisseminated,andthatwhatisprovidedisofhighquality,affordableandrunbyappropriatedtrainedandexperiencedstaff.

Continuityoftheexercisestaffwithinspecificprogrammesisimportantforconfidencebuildingandengagement,alongsidetheavailabilityofindividualisedsupportifthisisneeded–however,financialandtimeconstraintscanmakethisdifficultinsomeschemes.Flexibilityinthetimingsandvarietyofexerciseisalsoneededtomeetthewiderangingneedsofrefereesbutagain,budgetconstraintsmaymakethisdifficulttodeliver.

Onapositivenote,GPsarenowmoreawareofexercisereferralasanoption,withmoreGPsinthecurrentsurveythanin2004reportingthattheywouldrefertoasupervisedexercisereferralschemeandmanyofthosewhodidn’thavetheoptionstatingthattheywouldliketohaveit.

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5. Key recommendations

Thefindingsfromtheevaluationofasmallsampleofexercisereferralschemes,backedbyanupdatednationalsurveyofGPsinEnglandhighlightthatthereiswidespreadsupportforthewiderdevelopmentofexercisereferralschemesandthat:

• Iftheyweremorewidelyavailable,GPswouldrefertothemasakeytreatmentintervention foravarietyofconditionsincludingmildtomoderatedepression.Thiswouldnotonly promotethedeliveryofsupportinmainstream,non-stigmatisingsettingsbutalso mayhelptoreducetheuseofanti-depressantmedicationandtheresultingsignificantnational expenditureonprescriptiondrugs.

• Ifarangeofdifferentactivities,deliveredatvaryingpacesbysupportivestaffempathetic totheneedsofpeoplewithmentalhealthdifficulties,isoffered,peoplewithsuchneedswill notonlyusethembutwillreportpositivehealthandsocialoutcomes,andinmanycases willthensustainsomeformofexerciseactivity.

For the commissioners and referrers to exercise referral schemes:

• Acrossthecountry,theprovisionofexercisereferralschemesvariesandthereisaneedfor PrimaryCareTrusts(PCTs)andcommissionerstosupportthedevelopmentandfunding ofavariedrangeofexerciseactivitiesthatpeoplewithmentalhealthandotherhealthdifficulties canbereferredtobytheGPsandotherhealthprofessionals,ortheycanself-referto.

• Itisimportantthatsuchschemesareeitherfreeorcompetitivelypricedinorder tobeaffordabletothegeneralpopulation.

• Informationaboutwhatisavailable,whereitisbasedandhowpeoplecanaccess theschemeneedstobedisseminatedviathelocalfacilitiesmostfrequentlyused bythegeneralpublicsuchaslibraries,localpharmaciesaswellascommunity healthsettingssuchasGPsurgeriesandhealthcentres.

• Thegatheringofoutcomesmonitoringdataneedstobesupportedinordertofurtherdevelop andstrengthentheevidencebasefortheuseofexercisereferralschemes,whichinturnwillgive supporttothefuturecommissioningofsuchservices.

• GPsandotherhealthprofessionalsinthoseareaswherethereisanexercisereferral schemealreadyoperationalshouldbesupportedinreferringallpatientspresentingmild tomoderatedepressionandshouldnotconsideronlythosewithphysicalconcerns suchasobesityorcoronaryheartdisease.

• Allhealthprofessionalswhorefertoexercisereferralschemesneedtounderstandandbeable toexplainwhattheseschemescanoffer.ThedevelopmentofcloserworkinglinksbetweenGPs, practicenurses,othercommunitybasedhealthstaffandtheexercisestaffworkinginreferral schemesisrecommended.This,andtheagreementofclearandsimplereferralprotocols, willprovideavenuesfordevelopinganimprovedandsharedknowledgeofwhattheseschemes canoffer,towhomtheyarerelevantandatwhattimeinthecourseofaperson’smental orphysicalillnesstheschemesoughttobeoffered.

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For the providers of exercise referral schemes

• Avarietyofexerciseactivitiesneedtobeonoffer,notonlygym-basedprogrammes, tocaterfordifferentinterestsandlevelsoffitnessandactivity.Theseneedtobeavailable atdifferenttimesofthedayincludingintheearlyevenings.

• Thereneedstobecarefulplanningofsupportintheearlystagesofaperson beginninganexerciseprogramme,andthepacingoftheclass.Thesearebothimportant factorsinthesuccessfulengagementofpeopleintoexercisereferralprogrammes.

• Whereverpossible,schemesshouldaimtooffercontinuityofstaffingthroughanexercise programmeandtheavailabilityofindividualisedsupportwhererequired.

• Staffworkinginexercisereferralschemesneedtodevelopacloserworkingrelationship withthosewhorefertotheirschemes,inordertoshareinformationaboutwhatisonoffer, toprovidefeedbackastotheimpactofprogrammesonthosereferredandtoplantogether thepossiblefutureexerciseneedsofthoseindividualsinthelocalpopulation withmentalandphysicalhealthdifficulties.

For those using exercise referral schemes

• Insupportingthedevelopmentofawiderrangeofexercisereferralschemes, andtheactivitiesonoffer,opportunitiesforthosereferredtoschemestosharetheirviews andsuggestionsforimprovingschemesshouldbeactivelypromoted.

• Someusersofexercisereferralschemesmayalsobeinterestedinhelpingtoplanorrunnew activitiesandshouldbeencouragedtosharethiswishwiththestaffintheirlocalscheme.

Keyrecommendations

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6. Appendices

Appendix A: GP Survey

TheresultscontainedinthisreportarederivedfromaconfidentialquestionnaireplacedbytheMentalHealthFoundationonNOPWorldHealth’s‘GPNet’Service–anonlinesyndicatedmedicalomnibusconductedamongstanationallyrepresentativequota-basedsampleofGeneralPractitioners.Thisweb-basedsurveywasself-completedbyGPsduringNovember2007.TheconfidentialquestionnairewasdesignedandformattedbyNOPWorldHealthwiththeMentalHealthFoundation.

Semi-structuredquestionnairesweresetuponNOPsownserver.Emailinvitationsweresentouttoarandom‘rolling’sampleofapproximately2000GPs,allbeingmembersofDoctors.net.uk’swebcommunity.Fromthispoolofdoctorsanationallyrepresentative,quota-controlledsampleof200NHSGPscompletedthesurveyonline.Thesamplewasquota-basedonthedoctor’squalifyingage(pre-1990and1990onwards)andon11regionstoensurefullnationaldistribution.Eachdoctorwhowassentane-mailinvitationhadtheirownuniqueidentificationnumberhiddenwithinthesurveyURL(whichpreventsasurveybeingcompletedtwiceandallowsforapartlycompletedquestionnairetobefinishedatalaterdate).InadditiontothissurveyPINeachrespondentcouldonlyaccessthesurveyviaDoctors.net.uk’s(DNUK)websiteviatheirownuserIDandpasswordasaDNUKmember.Thuseachparticipatingdoctorhadtopassthroughtwolevelsofsecurityinordertocompletethesurvey.

AlltherespondentswhoparticipatedinthissurveywereGMClistedphysicianswhowerememberofDoctors.net.uk,theUK’sleadingproviderofonlineservicesexclusivelyfordoctors.

Thisonlinesurvey(reproducedinthefollowingpages)wasself-completedbyGPs,allofwhomweremembersofDoctors.net.ukduringtheperiod19th–20thNovember2004inclusive.

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Q1:Whenapatientpresentswithmildormoderatedepression,whatareyourmost commontreatmentresponses?

Pleaseselectuptoamaximumofthreetreatmentresponses,where‘1’=yourmostcommontreatmentresponse,‘2’=yoursecondmostcommontreatmentresponseand‘3’=yourthirdmostcommontreatmentresponse

Mostcommon(1)

2ndmostcommon

(2)

3rdmostcommon

(3)

Prescriptionofantidepressantmedication

Referraltocognitivebehaviouraltherapy

Referraltoanotherformofcounselling/psychotherapy

Referraltoasupervisedprogrammeofexercise

Referraltoalternative/complementarytherapies

Referraltoadietician

Other(pleasespecify)

Q2: Ingeneral,whichdoyoubelievearethemosteffectivestrategiesforpatients presentingwithmildormoderatedepression?

Pleaseselectuptoamaximumofthreestrategies,where’1’=themosteffectivestrategy,‘2’=thesecondmosteffectivestrategyand‘3’=thethirdmosteffectivestrategy

Mostcommon(1)

2ndmostcommon

(2)

3rdmostcommon

(3)

Antidepressantmedication

Cognitivebehaviouraltherapy

Otherformofcounselling/psychotherapy

Asupervisedprogrammeofexercise

Alternative/complementarytherapies

Dietarychanges

Other(pleasespecify)

Appendices

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Q3:Whichoneofthefollowingtermsbestdescribesyouropiniononthegeneral frequencywithwhichantidepressantsareprescribed?

Singleansweronly

Toooften Appropriately Toolittle?

Q4:Ingeneral,howeffectivedoyouconsiderthefollowingformsoftreatment areforpatientswithmildormoderatedepression?

Singleanswerforeachformoftreatment

Notatalleffective

Notveryeffective

Quiteeffective

Veryeffective

Antidepressantmedication

Asupervisedprogrammeofexercise

Q5: Ingeneral,whichoneofthefollowingformsoftreatmentdoyoubelieveismorelikely tohelpsomeonepresentingwithmildormoderatedepression?

Singleansweronly

Antidepressantmedication Asupervisedprogrammeofexercise

Q6: Accordingtothescaleshown,pleaseindicateyourlevelofagreement foreachofthefollowingstatements.

Singleanswerforeachstatement

Stronglydisagree

Disagreeeffective

Agreeeffective

Stronglyagree

Antidepressantmedicationsarenotaseffectiveasthepublicthinkstheyare

Mostpatientswhoaregivenantidepressantswouldbeaslikelytogetbetteriftheywereunknowinglyprescribedaplacebo

Antidepressantsarenotgenerallyeffectiveasatreatmentformildtomoderatedepressionunlessusedaspartofawider,individuallytailoredcarepackage

Appendices

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Q7:Ifothertreatmentresponsestomildormoderatedepression(suchascognitivebehavioural therapies,otherformsofcounselling/psychotherapy,exercisereferralschemes orcomplementarytherapies)weremoreavailabletoyou,whichoneofthefollowing statementswouldbestdescribehowwouldyouprescribeantidepressants?

Singleansweronly

Lessfrequentlythannow

Asfrequentlyasnow,inadditiontoincreasedusageofothertreatmentresponses

Asfrequentlyasnow–butwithoutincreasedusageofothertreatmentresponses

Morefrequentlythannow

Q8:Inthelastthreeyears,haveyouhadcausetoprescribeanantidepressantdespite believingthatanalternativetreatmentmighthavebeenmoreappropriate?

Yes>Q9No>Q10

Q9: Whydidyouprescribeantidepressantsinthis/thesecase(s)?

Pleaseselectallthatapply

Thepatientrequestedaprescriptionforanantidepressant

Suitablealternativetreatment(s)was/werenotavailabletome

Thepatientwasnotwillingtotrythealternative(s)offered

TherewasawaitinglistforsuitablealternativetreatmentsoIprescribed anantidepressanttoprovideanimmediateresponseintheinterim

Other(pleasespecify)

Appendices

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Q10: Ifyoubecamedepressedyourself,whichofthefollowingtreatment strategieswouldyoumostlikelyuse?

Pleaseselectuptoamaximumofthreestrategies,where’1’=yourfirstchoicestrategy,‘2’=yoursecondchoicestrategyand‘3’=yourthirdchoicestrategy.

1stchoice(1) 2ndchoice(2)

3rdchoice(3)

Antidepressantmedication

Cognitivebehaviouraltherapy

Otherformofcounselling/psychotherapy

Aprogrammeofexercise

Alternative/complementarytherapies

Dietarychanges

Other(pleasespecify)

Q11: Ifmoneywerenoobject,whichofthefollowingstrategiesdoyouthinkwould bethemostusefultoimplementinordertoreducetheincidenceofdepressionamongst primarycarepatientsintheUnitedKingdom?

Pleaseselectuptoamaximumoffivestrategies,where‘1’=themostusefulstrategy,‘2’=thesecondmostusefulstrategyetc

Mostuseful(1)

2ndmostuseful(2)

3rdmostuseful(3)

4thmostuseful(4)

5thmostuseful(5)

Longerconsultations

Greateraccesstocognitivebehaviouraltherapy

Greateraccesstootherformsofpsychotherapyandcounselling

Greateraccesstosupervisedexerciseschemes

Greateraccesstocomplementarytherapies

Greaterinvestmentinimprovingpatients’socialsupports–(suchasinimprovedhousing,greateremploymentopportunities,reducingpoverty)

Greaterinvestmentinpublicmentalhealthpromotioncampaigns

Appendices

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Mostuseful(1)

2ndmostuseful(2)

3rdmostuseful(3)

4thmostuseful(4)

5thmostuseful(5)

GreaterinvestmentinGPmentalhealthtraining

Greaterinvestmentinresearchtoevaluateandimproveantidepressantmedication

Greaterinvestmentinresearchtoevaluateandimprovenon-pharmacologicalinterventions,suchascognitivebehaviouraltherapy,otherpsychotherapyandcounselling,diet,exercise,alternative/complementarytherapies)

Other(pleasespecify)

Q12:Doyouhaveaccesstoanexercisereferralschemeforyourpatients?

Yes > Q13

No > Q14

Don’tknow > Q14

Q13:Onaverage,howoften,ifatall,doyouusetheexercisereferralscheme forpatientswithmildormoderatedepression?

Singleansweronly

Veryfrequently > Q16

Fairlyfrequently > Q16

Notveryfrequently > Q15a(1)

Never > Q15a(2)

Q14: Ifanexercisereferralschemewereavailabletoyou,howoften,ifatall, wouldyouconsiderusingitforpatientswithmildormoderatedepression?

Singleansweronly

Veryfrequently > Q16

Fairlyfrequently > Q16

Notveryfrequently > Q15a(1)

Never > Q15a(2)

Appendices

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Q15a(1):Whydo(would)younotusetheexercisereferralschememorefrequently forpatientswithmildormoderatedepression?

or

Q15a(2):Whydo(would)youneverusetheexercisereferralschemeforyour patientswithmildormoderatedepression?

Pleaseselectallthatapply

Iamnotconvincedthatexerciseisaneffectivetreatmentresponse formildormoderatedepression

Idon’t/wouldn’thavetimetoaddexercisereferraltomyprescribingrepertoire

Idon’t/wouldn’twanttobesuedifthepatientinjureshim/herselfbyexercisinginappropriately

Mostofmypatientswithmildormoderatedepressionaren’t/wouldn’tbeeither ableorwillingtocarryoutaprogrammeofexercise

Mostofmypatientswithmildormoderatedepressionexpecttobegiven antidepressantsasatreatmentresponsetodepression

Idonotbelievethataddingexercisereferraltomycurrentrangeoftreatmentresponseswould makeasignificantdifferencetothewell-beingofmypatientswithmildtomoderatedepression

Idon’thaveenoughtrustinexercisereferralschemestohandlemypatientssafelyandeffectively

Itwouldn’toccurtometouseanexercisereferralschemeforpatients withmildtomoderatedepression

TheexercisereferralschemetowhichIhaveaccessdoesnotpermit metoreferpatientswithmildtomoderatedepression

Other(pleasespecify)

Appendices

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Appendix B: Evaluation Form

ThisquestionnairehasbeendesignedtocaptureinformationtoimproveadultexerciseschemesinNorthamptonshireandallinformationisconfidential.

Client Number:

Name of exercise service

Today’s date

Baseline or follow-up

Foreachofthefollowingquestionspleasecircleoneoftheanswersaccordingtohowyoufeel

SA=StronglyAgree A=Agree N=Neutral D=Disagree SD=StronglyDisagree

1 IhavegoalsIamworkingtoachieve SA A N D SD

2 Ihaveenergyandenthusiasmformycurrentactivities SA A N D SD

3 Ifeelhopefulaboutmyfuture SA A N D SD

4 Iamawareofmypersonalskills,talentsandstrengths SA A N D SD

5 IfeelconfidentinmakingmyowndecisionsaboutwhatIwant

SA A N D SD

6 IhaveconfidencethatIcancopeifsituationsbecomedifficult

SA A N D SD

7 IcanrecognisetheearlysignsifIambecomingunwell SA A N D SD

8 I’mawareofwhatittakestokeepmewellandhappy SA A N D SD

9 IknowwheretogethelpifIneedit SA A N D SD

10 Myphysicalhealthisgood SA A N D SD

11 IamhappywithwhereIlive SA A N D SD

12 Icanmanagemycurrentfinancialsituation SA A N D SD

13 Ihaveagoodsocialnetworkandstrongfriendships SA A N D SD

14 IamabletopracticeanyspiritualorreligiousbeliefsImayhave

SA A N D SD

15 Thereismeaningfulactivityinmylife(ahobby,aninterestIenjoy)

SA A N D SD

16 Ifeelsupportedbymyfamily SA A N D SD

The exercise service you receive:

17 Ifeellistenedtobythestaff SA A N D SD

18 Theserviceprovidesmewithinformationregardingthebenefitsofexerciseonmyemotionalwell-being

SA A N D SD

19 Iamencouragedtomakethedecisionsaboutmyexerciseprogram

SA A N D SD

20 Thestaffareawareofmyemotionalstrengths SA A N D SD

Appendices

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21 Thestaffencouragemetotrynewthings SA A N D SD

22 IcanattendtheservicewhenIneedto SA A N D SD

23 Theserviceisimportantingivingmehopeforthefuture SA A N D SD

Please only answer Questions 25 & 26 if you have completed your exercise program

24. Wouldyourecommendtheexerciseprogramyouhavejustattendedtoafriend?

Yes No Don’tKnow

25.Wouldyouaccessotherexerciseprogramsinthefuture?

Yes No Don’tKnow

About you. Please fill out the in the following as best describes you.

26.Gender: Male Female

27.Ageinyears:

28.IsEnglishyour1stlanguage: Yes No

29.Ethnicity:

Pleaseonlytickonebox,ifyourethnicityisnotstatedinthecategoriesbelow,thenpleasewriteitinthe‘other’box.

White Mixed Asian/AsianBritish

Black/BlackBritish

Chinese/otherethnicgroup

British WhiteandBlackCaribbean Indian Caribbean Chinese

Irish WhiteandBlackAfrican Pakistani African

WhiteandAsian BangladeshiOther

30.Doyoulivealone? Yes No

31.Doyouhavecarerresponsibilities? Yes No

32. Doyouhaveanyphysicaldisabilities? Yes No

IfYes,pleasestate:…………………………………………………………………………………

33. Areyouonanyprescribedmedication? Yes No

IfYes,pleasestate:…………………………………………………………………………………

Appendices

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34.Areyoureceivinganyothertypeofsupportforyouremotionaland/ormentalwell-being?

Yes No

IfYes,pleasestate:

35. Employment&Education:

Iamworkingfulltime Iamnotworking,butseemyselfworkinginthefuture

Iamworkingparttime Iattendcollegeoraneducationalprogramme

Iamdoingvoluntarywork Iamnotworkingandamhappywithmylife

36. Inwhatwaysdoyouthinktheexercisehashelpedyou?

Appendices

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Appendix C: Project information sheet

An evaluation of Exercise on Referral schemes in selected areas of England

Version 1, February 14th 2008 Protocol reference: 08/H0720/26

Participantinformationform(shortversion)DRAFT

AcrosstheUK,therehasbeenaconsiderablegrowthofexercisereferralsschemes,ofteninresponsetothegreaterawarenessandevidencewenowhaveofthebenefitsofexercisenotonlyinpromotinggoodphysicalhealthbutalsogoodmentalhealthandwell-being.

TheMentalHealthFoundation,anationalmentalhealthcharity,hasbeenfollowingthisissueforsomeyears.ItisworkingwithpeopleinbothhealthandexerciseservicestochampionthedevelopmentofexercisereferralschemeswherebyhealthprofessionalssuchasGPscanrefertheirpatients,inparticularthosewhomayhavemildtomoderatedepression,toanexercisescheme.

Thisprojectiscalled‘UpandRunning?’andasapartofthework,thecharityisgatheringinformationaboutdifferentexercisereferralschemes–howtheywork,whattheyoffer,howmuchtheycharge,howmanypeopleareusingthemandwhetherthepeopletakingpartfeelthattheyarehelpful.

In(nameofarea),anexercisereferralschemehasbeenrunningforsomeyears/hasjustbeensetup(textwillbedeleteddependingonwhatapplies)andstaffintheschemewillbehelpingtheMentalHealthFoundationbysendingsomeinformationaboutwhattheyoffer.Thiswillincludesomeofthefigurestheyroutinelycollectabouthowmanypeopleusetheexerciseclasses,whorefersthemandthefeedbackpeoplegiveabouttheexerciseactivitytheyhavetakenpartin.Itwillnotbepossibletoidentifyanyindividualsfromthisinformationwhichwillbeusedforareportdescribinghowexercisereferralschemesarebeingrunandhowwelltheywork.

Theinvolvementof(nameofarea)shouldnotinanywayaffecthowtheexerciseactivitiesareoffered,andasbefore,thecompletionofanyself-reportingformsbyanyonetakingpartinanexerciseactivityisentirelyvoluntary.However,ifyouhaveanyquestionsorconcernsabouttheexercisevenueyouattendbeinginvolvedinthe‘UpandRunning?’project,youarewelcometocontacttheFoundation’sinvestigatorXXXXonXXXXwhowillbehappytoexplainmoreabouttheproject.

Appendices

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7. References

1. Biddle,S.J,&Mutrie,N(2001)Psychologyofphysicalactivity:Determinants,well-beingandinterventions.

2. McCormick,B,Frey,G,Lee,C,Chun,S,Sibthorp,J,Gajic,T,Stamatovic-Gajic,B&Maksimovich,M.(2008)Predictingtransitory moodfromphysicalactivitylevelamongpeoplewithseverementalillnessintwocultures.TheInternationalJournalofSocial Psychiatry,vol54(6),527-38.

3. Deihl,J&Choi,H(2008)Exercise:thedataonitsroleinhealth,mentalhealth,diseasepreventionandproductivity. PrimaryCare,vol35(4),803-16.

4. Taylor,A&Fox,K(2005)EffectivenessofaPrimaryCareExerciseReferralInterventionforChangingPhysicalSelf-Perceptionsover 9months.HealthPsychology,vol24(1),11-21.

5. Lawler,D&Hopker,S(2001)Theeffectivenessofexerciseasaninterventioninthemanagementofdepression:systematic reviewandmeta-regressionanalysisofrandomisedcontrolledtrials.BritishMedicalJournal,vol322,763-767.

6. Sutherland,J,Sutherland,S&Hoehns,J(2003)Achievingthebestoutcomeintreatmentofdepression.TheJournalofFamily Practice,vol52(3),201-209.

7. Ma,W,Lane,H&Laffrey,S(2008)AmodeltestingfactorsthatinfluencephysicalactivityforTaiwaneseadultswithanxiety. ResearchinNursing&Health,Vol31(5),476-489

8. Sims,J,Galea,M,Taylor,N,Dodd,K,Jespersen,S,Joubert,L,Joubert,J.(2009)Regenerate:assessingthefeasibilityofastrength- trainingprogramtoenhancethephysicalandmentalhealthofchronicpoststrokepatientswithdepression.International JournalofGeriatricPsychiatry.Vol24(1)76-83.

9. Wand,T&Murray,L(2008)Let’sgetphysical.InternationalJournalofMentalHealthNursing.Vol17(5),363-9.

10. Carless,D&Douglas,K(2008)SocialSupportforandThroughExerciseandSportinaSampleofMenwithSeriousMentalIllness. IssuesinMentalHealthNursing,vol29(11),1179-1199.

11. Diaz,A&Motta,R(2008)Theeffectsofanaerobicexerciseprogramonposttraumaticstressdisordersymptomseverityin adolescents.InternalJournalofEmergencyMentalHealth,vol10(1),49-60.

12. NorthamptonshireCountyStandardProtocolDecember2007

13. NationalInstituteforClinicalExcellence.ClinicalGuideline23:depression:managementofdepressioninprimary andsecondarycare.London:NICE.

14. DepartmentofHealth(2004)Atleastfiveaweek:Evidenceontheimpactofphysicalactivityanditsrelationshiptohealth

15. DepartmentofHealth(2005)ChoosingActivity:Aphysicalactivityactionplan.

16. MentalHealthFoundation(2005)UpandRunning?Exercisetherapyandthetreatmentofmildormoderate depressioninprimarycare.

17. Stathi,A;Milton,K.andRiddoch,C.(2006)EvaluationoftheLondonBoroughofCamdenExerciseReferralScheme MiddlesexUniversity,LondonSportInstitute

18. Stathi,A;Milton,K.andRiddoch,C.(2006)EvaluationoftheLondonBoroughofCamdenExerciseReferralScheme. MiddlesexUniversityLondonSportInstitute.

19. Stathietal(2006)OpCit

Registeredcharitynumber(England)801130(Scotland)SC039714©MentalHealthFoundation2009 ISBN978-1-906162-36-8

www.mentalhealth.org.uk

Mental Health Foundation9thFloor,SeaContainersHouse20UpperGroundLondon,SE19QB02078031100mhf@mhf.org.uk

Scotland OfficeMerchantsHouse30GeorgeSquareGlasgow,G21EG01415720125scotland@mhf.org.uk

Foundedin1949,theMentalHealthFoundationistheleadingUKcharityworkinginmentalhealthandlearningdisabilities.

Weareuniqueinthewaywework.Webringtogetherteamsthatundertakeresearch,developservices,designtraining,influencepolicyandraisepublicawarenesswithinoneorganisation.Wearekeentotackledifficultissuesandtrydifferentapproaches,manyofthemledbyserviceusersthemselves.Weuseourfindingstopromotesurvival,recoveryandprevention.Wedothisbyworkingwithstatutoryandvoluntaryorganisations,fromGPpracticestoprimaryschools.Weenablethemtoprovidebetterhelpforpeoplewithmentalhealthproblemsorlearningdisabilities,andpromotementalwell-being.

Wealsoworktoinfluencepolicy,includingGovernmentatthehighestlevels.Weuseourknowledgetoraiseawarenessandtohelptacklestigmaattachedtomentalillnessandlearningdisabilities.Wereachmillionsofpeopleeveryyearthroughourmediawork,informationbookletsandonlineservices.Wecanonlycontinueourworkwiththesupportofmanyindividuals,charitabletrustsandcompanies.Ifyouwouldliketomakeadonation,pleasecalluson02078031121.

Visitwww.mentalhealth.org.ukforfreeinformationonarangeofmentalhealthissuesforpolicy,professionalandpublicaudiences,andfreematerialstoraiseawarenessabouthowpeoplecanlookaftertheirmentalhealth.