Prescribing Physical Activity in Mental Health: A Focused review on the latest evidence, recommendations, Challenges, and relevance
Sai Krishna Tikka1 , Shobit Garg2, M. Aleem Siddiqui3
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Physical activity and mental health are intimately linked. Physical ac- tivity has been considered to have a signi cant impact on global mental health, cognitive functions and, well- being and quality of life.1 Global Action Plan on Physical Activity (GAPPA) 2018– 2030 of the World Health Organization (WHO) has envisioned improvements in these “health and well-being” param- eters by improving levels of physical activity.1 Currently, the global rates of “insu cient physical activity” are 27.5% (23.4% for males and 31.7% for females).2 GAPPA aims at achieving 10% and 15% reductions in physical inactivity rates by 2025 and 2030, respectively, for attain- ing the envisioned improvements. The WHO deems physical activity to contrib- ute in achieving 13 of the 17 sustainable development goals (SDGs)—2030.1
Beyond the common supposition that enhancements in mental health by physical activity might be indirect, that
is, improvement in diabetes and car- diovascular disease statuses being the moderator, physical activity has direct bene ts on mental health too. In this focused review, we provide an appraisal
of the latest available evidence on the mental health bene ts of physical activ- ity and speci c recommendations. To understand the biological validity of the evidence and recommendations, we also brie y discuss the science behind the role of exercise and mental health. The
challenges, especially those relevant to the Indian context, and methods to enhance the acceptability of physical activity in our population are also discussed.
Neurobiology of exercise and Mental Health
Although transient, the commonest known immediate mental health bene t of physical activity is what is termed “runner’s high,” which is the experience of euphoria post an endurance run. Ever since it was recognized as a substrate to understand the e ects of exercise on the brain,3 the role of several neural mecha- nisms has been postulated. The role of endorphins and enhanced opioid sig- naling, the endocannabinoids such as anandamide, monoamines—dopamine and serotonin, neurotrophins such as the brain-derived neurotrophic factor (BDNF), and gamma-aminobutyric acid (GABA) have been hypothesized.5 Recently,
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1Dept. of Psychiatry, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India. 2Dept. of Psychiatry, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India. 3Dept. of Psychiatry, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India.
HOW TO CiTe THiS ArTiCle: Tikka SK, Garg S, Siddiqui MA. Prescribing Physical Activity in Mental Health: A Focused Review on the Latest Evidence, Recommendations, Challenges, and Relevance to India. Indian J Psychol Med. 2020;XX:1–7.
Address for correspondence: Sai Krishna Tikka, Dept. of Psychiatry, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099, India. E-mail: cricsai@ gmail.com
Submitted: 19 Oct. 2020 Accepted: 20 Oct. 2020 Published Online: xxxx
Copyright © 2020 Indian Psychiatric Society – South Zonal Branch
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-Commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as speci ed on the SAGE and Open Access pages (https:// us.sagepub.com/en-us/nam/open-access-at-sage).
ACCeSS THiS ArTiCle ONliNe
Website: journals.sagepub.com/home/szj DOI: 10.1177/0253717620972330
Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2020 1
Tikka et al.
claims of a transcriptional signature for “runner’s high” in the form of microri- bonucleic acid (miRNA) dynamics have also surfaced.4
Overall, three levels of cellular mecha- nisms have been identi ed to underlie the e ects of exercise on the brain: (1) Increases in synthesis and release of various neurotransmitters—monoamines, GABA, etc.—and neurotrophic factors such as BDNF, (2) these increases lead to mito- chondrial biogenesis and consequent protein synthesis within the endoplasmic reticulum, and (3) neurogenesis, angio- genesis, and, therefore, neuroplasticity, which confers preventive and therapeu- tic bene ts to mental health conditions, mainly depression and dementia.5 One important factor fundamental to mito- chondrial biogenesis (second-level cellular mechanism) is the induction of a transcription coactivator—PGC-1a (peroxisome proliferator-activated recep- tor gamma coactivator 1-a).6 PGC-1a is considered as the principal regulator for promoting anti-in ammatory and immunomodulatory e ects implicated in
the positive e ects of exercise in demen- tia and depression.6,7 Depression, like diabetes mellitus, activates the nuclear factor kappa enhancer of activated B cells (NF-kB) signaling pathway, which leads to the release of proin ammatory cyto- kines interleukins 1 and 6 and, the tumor necrosis factor (TNF)-a. Exercise-related regulation of PGC-1a inhibits the NF-kB pathway and therefore helps alleviate depression.7 As the role of neuroin am- mation has been implicated in various other neuropsychiatric illnesses,8,9 similar neurobiological mechanisms may perhaps underlie the e ects of exercise in them as well (see Figure 1 for physi- cal-activity-led cellular events resulting in positive mental health e ects).
Physical Activity for the Prevention and Treatment of Mental Disorders
In those who are otherwise healthy, physical activity promotes sleep, sex, energy, stamina, endurance, self-esteem,
social interactions, and stress relief.10 While e ective in promoting several such positive mental health indicators, convincing evidence is also available for the role of physical activity in prevent- ing dementia and depression and in the adjunctive treatment of depression, anxiety, substance use, and psychotic disorders.
Prevention of Depression
A meta-analysis by Schuch et al.,11 which included 49 prospective studies and a total sample of 2,66,939, found that people with higher levels of physical activity had lower odds of developing depression (adjusted odds ratio = 0.83) compared to those with lower levels; this protection against incident depression was regardless of age and geographical region. Importantly, across all levels of genetic vulnerability, even among indi- viduals at the highest polygenic risk, higher levels of physical activity have been found to be associated with reduced odds of incident depression.12
Physical activity led cellular events resulting in positive mental health e ects5, 7
PGC-1a: Peroxisome proliferator-activated recepoter Gamma Coactivator 1-1a; NF-kB; Nuclear Factor Kappa enhancer of activated B cells; IL-Interleukin; TNF-a: Tumor Necrosis Factor-a
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Prevention of Dementia
With respect to the bene ts of physi- cal activity in preventing dementia, the WHO has made two recommendations: (1) Physical activity should be recom- mended to adults with normal cognition to reduce the risk of cognitive decline (“moderate” quality of evidence and “strong” strength of recommendation), and (2) physical activity may be recom- mended to adults with mild cognitive impairment to reduce the risk of cogni- tive decline (“low” quality of evidence and “conditional” strength of recommen- dation).13,14 These recommendations are based on the assumptions that around one-third of dementia cases are attribut- able to modi able risk factors and that ‘what is good for the heart is considered good for the brain’.13,14
Treatment of Psychiatric
There is highest level of evidence in the form of meta-analyses for the role of physical activity as a treatment strategy in psychiatric disorders. A recent meta-review, a review of meta- analyses, suggests that physical activity as an adjunct is e ective in a range of diagnoses and helps speed up or enhance the bene ts of the rst-line treatment strategies.15 Table 1 lists important assertions from this meta-review and the corresponding number of support- ing meta-analyses. The level of evidence available for treatment e ects of physical activity for depression, schizophrenia, and anxiety disorders is considered as “1a,”16 that is, presence of homogenous sys- tematic reviews according to the Oxford Centre for Evidence-Based-Medicine
(CEBM) levels and accordingly receives a grade A recommendation. Evidence level of “1a” is also available for the positive adjunctive e ect of physical activity in reducing the severity of mild cognitive impairment, Alzheimer’s dementia, sub- stance dependence (alcohol and nicotine), and post-traumatic stress disorder16 and, therefore, also receive grade A recommen- dation. While eating disorders such as anorexia, bulimia, and binge eating dis- order have level “1b” evidence (individual randomized controlled trial (RCT) with a narrow con dence interval), the level of evidence for bipolar disorder and obses- sive-compulsive disorder is only at the levelofcaseseries(level“4”evidence).16
It is obligatory to mention the role of physical activity in treating metabolic syndrome and weight gain, both of which are prominently associated with mental disorders and their treatment. Apart from direct bene ts on psychi- atric symptoms, physical activity also plays an important role in alleviating the transdiagnostic (and across classes of psychotropic drugs) risk for cardiometa- bolic disorders in psychiatry.15 A review by Paley and Johnson17 showed that a moderate amount of evidence is avail- able that indicates that physical activity can indeed reverse metabolic syndrome. A recent meta-analysis also has found that lifestyle interventions that include physical activity can be used for weight reduction in serious mental illnesses.18
exercise Prescription: What
Type of Physical Activity,
Duration, and Frequency?
On the type, duration, and frequency of physical activity, the WHO has made
recommendations for “health” in general (Table S1a).19 While for children (5–17 years of age), “60 minutes” of moderate to vigorous-intensity physical exercise “daily” is recommended, “150 minutes” of “moderate” or “75 minutes” of “vig- orous” intensity “throughout the week” is recommended for adults (18 years and above) (Table S1b provides the de nition and examples of moderate and vigor- ous-intensity activities). In this section, we discuss recommendations on the type, duration, and frequency of physical activity in mental health.
Prevention of Depression
The meta-analysis by Schuch et al.11 was not able to specify the optimal type of physical activity or the minimum or optimal dosage, due to the wide vari- ation of these factors in the selected studies. A recent study,20 conducted on a sample of 1.2 million individuals, found that the overall current mental health burden was signi cantly lower in those who participated in “any” physical activity than in those who did not. The optimal duration and frequency of phys- ical activity that this study proposes are 45 minutes and 3–5 days a week, respec- tively. The same conclusions were true for those having an earlier diagnosis of depression as well, implying its role in relapse prevention. Intriguingly, the bene ts of physical activity on mental health burden were shown to paradox- ically reduce with an increase in the time or frequency beyond 45 minutes and 5 per week in this study. Another study, which found incident depression to be lower in those involved in phys- ical activity despite the high genetic risk, also suggests that 45 minutes per day of additional physical activity on 5–6 days/week (a total of 4 hours/week) translates to a meaningful reduction in risk of depression.12 Although any phys- ical activity/exercise was better than no exercise, involvement in “popular sports” was much more strongly related to reduced mental health burden.20 In the context of popular sports, Bohr et al.21 studied a sample in excess of 10,000 individuals and found that involvement in contact sports, speci cally football, during adolescence was associated with lower depression scores and suicidal ide- ation during adulthood. Across walking, jogging, running, biking, and low- and
role of Physical Activity as a Treatment Strategy in Various Psychiatric Diagnoses15
Number of Supporting Meta-analyses
Exercise reduces depression in children, adults, older adults
Exercise reduces anxiety symptoms
Exercise e ective as adjunct in reducing positive/negative symptoms of schizophrenia
Exercise improves global cognitive function in schizophre- nia
Exercise improves global cognitive function in children with ADHD
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high-intensity training, there were sig- ni cant correlations with each other in reducing the risk of depression,12 implying any of these activities may be taken up.
Prevention of Dementia
The WHO recommendations for health, in general,19 are valid for the prevention of the cognitive decline in healthy as well as those with mild cognitive impairment. Speci cally, “10 minutes twice a day” of moderate-intensity aerobic physical activities such as cycling, running, taking a pet for a stroll, etc., and resistance training “twice a week” are recom- mended.13-14 Importantly, a proactive lifelong approach is recommended for dementia prevention.14
Treatment of Psychiatric
There is no consensus on what type of physical activity and for what dura- tion or frequency is more e ective in treating psychiatric symptoms, due to heterogeneity regarding the frequency, intensity, type, and time of physical activity in various RCTs. By and large, the majority of RCTs that formed the recommendationsforphysicalactivityin various psychiatric disorders (depression, anxiety, schizophrenia, and attention de cit hyperactivity disorder (ADHD); see Table 1) involve endurance training— running and cycling, 30-minute sessions, 3 times a week, for 8–12 weeks.16 The European Psychiatric Association (EPA), however, has made certain speci c clin- ical practice recommendations on the type, duration, and frequency of physical activity in the treatment for severe mental illnesses (SMI)22:
1. Mild-moderate depression: 2–3 ses- sions per week of 45–60 minutes of moderate-intensity mixed physical activity (i.e., aerobic and/or anaerobic and resistance training).
2. Schizophrenia: 150 minutes/week of moderate to vigorous aerobic exercise.
Further, there are no clear recommen- dations for the use of a speci c type, frequency, or duration of physical activ- ity in reversing psychotropic-related metabolic syndrome and weight gain as well. Higher intensity interval train- ing (HIIT), which include short (about 10 minutes) bursts of vigorous-intensity
activities, is speci cally bene cial in met- abolic syndrome.17
Challenges for the exercise Prescription and Strategies to Tackle
Apart from a variety of reasons such as the physical make-up of the individual, age, gender, and comorbid conditions, such as coronary artery disease and osteo- arthritis, low exercise motivation can be a signi cant hindrance to initiating and maintaining physical activity as a pre- ventive/therapeutic strategy. Therefore, motivational interviewing principles have been recommended to motivate individuals/patients to take up physical activity.15 Moreover, motivational inter- viewing might also help tackle illness factors associated with psychiatric diag- noses, such as anhedonia, lack of energy, and amotivation.23
Due to all these factors, both physical and psychological, one may not readily achieve the recommended intensity, duration, and frequency of physical activity. This is where graded programs will be helpful. ‘Graded’ programs are characterized by “establish- ment of a baseline of achievable exercise or physical activity, followed by a negoti- ated,incrementalincreaseintheduration of time spent physically active, followed by an increase in intensity.”24 Certain ‘aided’ strategies have also been recommen- ded to cross these hurdles. As standard physical activities may be too demand- ing, low-threshold interventions, like step counting using tness trackers, can be used. Absolute moderate-intensity physi- cal activity translates to 3,000 steps in 30 minutes.25 Moderate to vigorous-intensity physical activity constitute 3,000–6,000 steps.26 Important here is to note that the popular recommendation of 10,000 daily steps is speci cally valid in the context of reducing cardiovascular event rates, and this target is associated adversely with the risk of developing osteoarthritis.26 It is also important to mention here that along with osteoarthritis and other musculoskel- etal disorders, the risk of coronary artery disease and the presence of imbalance due to any reason have been identi ed as realistic concerns for promoting physical activity in SMIs.27 Another aided strategy is incorporating physical activity into cog- nitive behavioral strategies like behavioral activation.28 This strategy has been found
to have strong credibility and better completion rates than physical activity alone and is particularly e ective when standard physical activity schedules are deemed monotonous. In fact, behavioral activation, in conjunction with physical activity, has been found to have the poten- tial to reverse immunological alterations in depression, such as increasing the levels of anti-in ammatory cytokine IL-10.29
The EPA22 recommends that phys- ical activity as a treatment in SMI be supervised by an exercise specialist, that is, the physical activity has to be ‘guided’. This has been deemed import- ant for optimal outcomes and better compliance. These may be particularly important in patients with inattention, distractibility, or impulsivity, such as in those with mania or ADHD. The same principle might be used for the use of physical activity in mental health in general, not just for treatment. Apart from graded and aided strategies, we also deem that the physical activity has to be guided, wherever possible, to tackle various challenges.
There are ambitious attempts to develop an “exercise pill,” which may be prescribed to individuals, especially the elderly, who are incapable of the minimum required physical activity that will reap cognitive bene ts. Very recently, Horowitz et al.30 conducted an animal experiment in which the glyco- sylphosphatidylinositol (GPI)—speci c phospholipase D1 (Gpld1) rich plasma, extracted from young mice soon after exercise and found to be correlated with improved cognitive functions, was trans- ferred to old mice and found signi cant cognitive bene ts. Moreover, whole- body vibration exercise is already being studied as a replacement for physical activity in certain health conditions.31
relevance to india
The Government of India launched the “Fit India” movement, with the slogan “Get Fitter. Healthier. Happier,” in August 2019.32 This movement has been based on the premise that Indians are far more physically inactive than the global population. In India, 54.4% (41% of males and 59.6% of females) are phys- ically “inactive”33; these rates are two times the global rates of “insu cient physical activity.”2 The rates of physical inactivity in Indian children (aged 11–17
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years), that is, 73.9%, was better than the corresponding global rates of 81.0%.34 However, it has been found that the rates of “no recreational physical activity” in India increases as the age increases (86.7% in 20–29 years to 95.9% in >65 years).33 The “Fit India” campaign adapts the recommendations from WHO and recommends 30–60 minutes per day of physical activity.
Albeit a smaller number of available studies, evidence from India too supports the recommendations for the use of phys- ical activity in various mental illnesses. Recently, a review of Indian studies (both cross-sectional and interventional)35 on the role of physical activity in mental health found physical activity to improve clinical outcomes in both common and severe mental disorders. On the spe- ci c kind of physical activity and in the context of popular and contact sports being better in terms of lesser rates of mental health burden, depression, and suicidal ideation,20,21 indigenous sports like kabaddi might be recommended. In India, popular sports might vary from region to region, and the “Fit India” pro- vides the list of these popular sports.32
Coming to the challenges, “lack of time,” and “lack of motivation” are the most important factors a ecting the lack of physical activity in India.36 These factors might be held responsible for the “staggering” di erence between Indian and global levels of physical inac- tivity.2,33 Understandably, the inability to nd time for physical activity is due to the busy work schedule for those in job/business. However, women who are homemakers too nd it di cult to nd the time. Although household chores are considered moderate-intensity physical activity, it is important to assert that the recommended duration of physical activity in the “mental health prescription” should be “over and above” the usual routine activity. Therefore, the recommended use of motivational interviewing principles to motivate indi- viduals/patients to nd time and take up physical activity15 becomes very import- ant in Indian clients.
Cultural and family values also con- tribute to the low levels of physical activity in Indians. In general, “encour- agement from signi cant others” in the family is the strongest sociocultural
determinants of higher levels of physi- cal activity.37 For Indians, especially girls and women, this determinant is not available to a large extent36 due to cul- tural sanctions (this has been depicted in the Bollywood movie “Dangal”). In this context, family-oriented physical activity interventions where parents are invited to encourage and play with children have been proposed for improv- ing physical activity levels in children.38 Further, most physical activity in Indian children happens in the context of school (including transportation), and only 30% of families have been found to par- ticipate with children in any physical activity.39 More parents should be moti- vated to involve children in out-of-school physical activities. The National Health Portal, India, identi es “fewer opportu- nities for access to safe places” and “fear of violence and crime in outdoor areas” as factors discouraging physical activity among Indians.40 Apart from the cultural and family factors, these issues also lead to a lack of “encouragement from sig- ni cant others,” especially for women. Hence ensuring the safety of outdoor parks and grounds is very important.
Yoga and Physical Activity
India being the land of yoga, its role as a means of physical activity in mental health needs a special mention. Given the lack of motivation for e ort and the relatively lesser e orts needed in yoga,41 it can be an alternate means for physical activity for Indian clients. In fact, most Indian studies evaluating the e cacy of physical activity in psychi- atric disorders involve yoga programs as a comparator (rather vice versa).35 Reviewing and comparing these two strategies, Govindaraj et al.42 show that yoga is equal to or superior to exercise in most outcomes, not only related to mental health but also general health, including cardiovascular, reproduc- tive, musculoskeletal, endocrine, etc. In fact, a recent review by Mohanty et al.43 recommends the compendium of physical activities to add a separate cat- egory for energy expenditure by yoga; they found that yoga, in terms of energy expenditure, is equivalent to moderate intensity physical activity. The review by Govindaraj et al.,42 however, points to the common but inaccurate notion
that “yoga is a form of exercise” and lists important di erences between them that are mainly attributable to yoga, which includes “emphasis on breath reg- ulation, mindfulness during practice, the importance given to the maintenance of postures and di erential e ects on the body and the brain.” We suggest studies examining preventive and therapeutic physical activity schedules to combine yoga and other customary forms of physical activity to assess whether the bene ts are additive.
The Conundrum of COViD-19 Pandemic—relevance to Mental Health and Physical Activity
Any discussion during the current times is incomplete without mentioning the relevance in the context of the COVID- 19 pandemic. The pandemic has had an alarming e ect on global mental health. Therefore, maintaining ade- quate levels of physical activity may be bene cial during these times. However, pandemic-led restrictions, such as social isolation and compulsory donning of face masks when outdoors, have badly a ected the routine modes of physical activities too. The WHO’s campaign “healthy at home”44 has recommended certain strategies to remain physically active and maintain recommended levels of physical activity. These are walking up and down the stairs; stretching exer- cises, dancing to music, and seeking more ideas and resources online. Online strategies such as eMotion—an online Intervention using behavioral activation and physical activity for persons with depression,45 might be useful and need to be assessed systematically. Intriguingly, the pandemic-led restrictions have led to negative mental health consequences in sportspersons too, due to detrain- ing. Minimalistic physical training in the form of plyometric exercises ( jump training) and tele-workouts, as well as maintaining social connectedness, which is akin to behavioral activation, have been recommended to deal with them.46
Various strategies and corresponding challenges that they aim to tackle in improving physical activity outcomes are presented in Table 2.
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Suggested Strategies for improving Physical Activity Outcomes
3 4 5
• Low exercise motivation • Where lack of time is considered a hindrance • Illness factors such as anhedonia, lack of energy and amotivation • To improve family participation and encouragement
• Comorbid physical conditions—coronary artery disease and osteoarthritis • Imbalance, which may be due to e ect of psychotropic • Low exercise motivation
• Low exercise motivation • Comorbid conditions due to which standard physical activities may be deemed too demanding
• Low adherence due to monotonous nature of the schedule • Illness factors such as anhedonia, lack of energy and amotivation
• Low adherence due to any reason • Severe mental illnesses • To improve family participation and encouragement
Yoga and minimalistic training
• Low exercise motivation • Comorbid conditions due to which standard physical activities may be deemed too demanding • Lack of opportunity for outdoor activities
With the rates of physical inactivity in India being two times that of the global rates, achieving the proposed 15% reduc- tion in these rates by 2030 will be a huge challenge. Prescribing physical activity for mental health by we mental health professionals might contribute signi – cantly in achieving the goals set by the GAPPA. The adjunctive role of physical activity in the prevention and treatment of various mental health conditions has gathered signi cant positive evidence. Therefore, including physical activity in our prescription might help bring down the rates of the current prevalence of mental illnesses in India, which, too, pose an immense challenge. An import- ant by-product of enhancing our skills in the implementation of physical activity, exercise, and sports in the prevention and treatment of mental disorders might as well see the growth of a subspecialty in our discipline—sports psychiatry.16
The review presented in this article was presented by Dr Sai Krishna Tikka during a webinar cum panel discussion titled “Nutrition, Exercise and Mental Health” on August 1, 2020 organized by the Tele Arogya Webinar Series Team in association with the Indian Psychiatric Society–Karnataka Chapter.
Declaration of Conflicting Interests
The authors declared no potential con icts of interest with respect to the research, authorship, and/or publication of this article.
The authors received no nancial support for the research, authorship, and/or publication of this article.
Supplementalmaterialfor this article is avail- able online.
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