1. Therapeutic Intervention by Physical Exercises in Depression By Afnan Mohammad Al Khateeb Mashael Ghazi Al Sobhi Rehab Abdurrahman Al Harbi Supervised by Ms. Isabelle Devreux A dissertation submitted in partial fulfillment for the Bachelor Degree in Physical Therapy 2008

2. Contents Introduction Depression Methodology Physiological Effects of Physical Exercise on Depression

3. Contents (Cont.) Literature Review Physical Therapist Treatment Approach Results Discussion Conclusion Acknowledgments

4. Introduction

5. - The World Health Organization predicts that by 2020 depression will create the greatest burden of disease in european countries (USDHHS, 1999). - The link between ‘healthy mind and body is not new’ Hippocrates the Greek philosopher recommended exercise as treatment of mental illnesses. 1

6. - The aim of this research is to review the recent literature related to the study of the effects of physical exercise on depression. 2 Aim of the Study

7. Hypothesis - Physical exercise can reduce symptoms of depression and has effective therapeutic effects. 3

8. - The initial study is based on a literature review of all related articles concerning physical therapy and depression since 1990. - The secondary delimitation the study is restricted to a cross sectional screening of the depression in a female student population. 4 Delimitations

9. The study did not include patients referred by the psychologist or psychiatric department. Mental or hormonal disturbances could occur during the assessment or additional stressful events. The study is limited to the short term time frame. 5 Limitations of the Study

10. Limbic System Prefrontal Cortex Depression

11. - Clinical depression is a psychiatric disorder, characterized by a pervasive low mood, loss of interest in usual activities and diminished ability to experience pleasure. 6 Definition of Depression

12. - Persistent sadness. - Insomnia. - Feelings of worthlessness and helplessness. - Thoughts of death or suicide. - Loss of interest or pleasure in hobbies and activities. - Withdrawal from social situations, family and friends. 7 Symptoms of Depression

13. - Genetic Causes: Scientists have not been able to identify a "depression" gene. - Neurochemical Causes: Neurochemical influences of neurotransmitters focus on serotonin and norepinephrine. - The Psychodynamic Causes: Therapists believe the root of all depression lies in the loss of something loved, whether it be a person or an object. - Life Experiences Causes: Such as divorce, financial difficulties and the death of a child or other family member. 8 Causes of Depression

14. - Beck Depression Inventory Scale. -Zung Self-Rating Depression Scale. -Hamilton Rating Scale for Depression. 9 Assessment for Depression

15. Methodology

16. 1- Literature review We reviewed many articles, journals and electronic libraries about our research. 2- Screening study a- Subjects A total of 100 female volunteers, aged between 18 to 22 years, medical students from the King Abdul Aziz University (KAAU), single and free from diseases. 10 Methodology

17. Methodology (Cont.) b- Tools The Beck Depression Inventory was utilized as screening assessment tool for depression. c- Method The questionnaires were randomly distributed to 100 female students of the college of medical technology and collected during the same session. 11

18. Physiological Effects of Physical Exercise on Depression

19. 12 Physiological Effects of Physical Exercise on Depression (Cont.) Sex Appetite Aggression Serotonin (5-HT) Depressed Mood Anxiety Vague aches and pain Irritability Thought process Concentration Interest Motivation Norepinephrine (NE)

20. 1- Sympathetic nervous system is activated. How Exercise Increase the Mood Stabilizers? 13 2- With more strenuous exercise circulating epinephrine and norepinephrine released from the adrenal medulla. (Prentice, 2005)

21. The Mental Effects by Norepinephrine and Serotonin Concentration of norepinephrine neurotransmitters and serotonin in the neurons will increase during exercise and the depressed patient’s mood could improve.

22. There are many theories: 1- Acidosis → ↑ endorphins release. 2- ↑ Circulation →↑↑ endorphins. 15 Supporting Theories of the Exercise Effects on Depression

23. Literature Review

24. Comparative Table of Studies and their Results on Exercise and Depression. ResultsType of Exercise Program Author - Exercises produce larger antidepressant effects. Aerobic exercise program < 9 Ws. Craft, 1997 - Exercise caused a clinically significant drop of depression symptoms. Walking on a treadmill for 30 min. / day for 10 days. Dr. Dimeo, 2001. - Effective as drug therapy in relieving the symptoms of depression. 30 mints. of speed walking 3\ w. Babyak, Hermana, 2000. - Depressive symptoms were reduced almost 50 %. Running 30-min. 3-5 time/week Trivvedi, 2005.

25.  No definitive exercise recommendation for all elements of mental health promotion.  No definitive formula of frequency, intensity and duration.  30 minutes or more of moderate exercise is recommended.  Vigorous exercises are effective in treating depression (Fox,1999). 17 Literature Review

26. Physical Therapist Treatment Approach - Use silence and active listening when interacting with the depressed patient. - Simple, direct sentence should be used. - Avoid asking the depressed patient many questions. - Extra work should not always be requested. - The depressed patient needs care and attention to recover faster. 18

27. Assessment of depression level by the Beck Depression Inventory Scale. History taking. Screening for contraindications. Manual muscle testing. Assessment and monitoring of the exercise within the target heart rate. 19 Protocol of Treatment by Physical Exercises for Depression

28. Exercise Protocol for the Treatment of Mild to Moderate Depression. SessionsWarm upWalkingCyclingRunningWeight liftingCool down 1 st session5 minutes15 minutes5 minutes ـــــــــــــــــــــ 5 minutes 2 nd session5 minutes15 minutes5 minutes ـــــــــــــــــــــ 5 minutes 3 rd session5 minutes10 minutes ـــــــــــــــــــــ 5 minutes 4 th session5 minutes10 minutes ـــــــــــــــــــــ 5 minutes 5 th session5 minutes13minutes5 minutes2 minutes ـــــــــــــــــــــ 5 minutes 6 th session5 minutes13minutes5 minutes2 minutes ـــــــــــــــــــــ 5 minutes 7 th session5 minutes10 minutes5 minutes ـــــــــــــــــــــ 5 minutes 8 th session5 minutes10 minutes5 minutes ـــــــــــــــــــــ 5 minutes 9 th session5 minutes10 minutes5 minutes2 minutes3 minutes5 minutes 10 th session5 minutes10 minutes5 minutes2 minutes3minutes5 minutes 11 th session5 minutes10minutes ـــــــــــــــــــــ 5 minutes 12 th session5 minutes10 minutes ـــــــــــــــــــــ 5 minutes

29. Results

30. Results of the Screening Study 21 The result of the Beck Depression Inventory (BDI) scale that was distributed to 100 female students. All students responded to the questionnaire.

31. There is inverse relationship between severity of depression and physical activity of the students. 22 Results of the Screening Study

32. Discussion

33. - Physical exercise is effective in reducing depressive symptoms. All the previous studies reported good results. - Through the cross sectional screening assessment of the student population in our university we found a 16 % present the symptoms of depression at the time of the screening. - All 16 % of students associated to a sedentary life style. 24

34. Conclusion

35. - We clearly outlined several mechanisms supporting the effects of physical exercise on depression - We resumed the guidelines, precautions and the protocol of management in physical therapy. - There is a high correlation between depression and limited physical activity. - The importance of physical exercises in prevention and treatment of depression. 25 Conclusion

36. Acknowledgments

37. Thanks for: Ms. Isabelle Devreux Dr.Sausan Raheem. Dr.Dua'a Khalifa. Dr. Khaled Mamdooh. Dr. Mohammed Sayim Aldahr.

38. Thank You For Your Attention