1. Exercise as a Recreational Therapy Treatment for Depression Tim Passmore, Ed.D., CTRS West Virginia Therapeutic Association Annual Conference Oklahoma State University

2. 8 Global Reasons Increased Demand for Outcomes Eliminate poor/unnecessary practice Eliminate poor/unnecessary practice Negotiations between providers & payers Negotiations between providers & payers Accountability Accountability Mean for evaluation of ill (chronically) Mean for evaluation of ill (chronically) Empower consumers Empower consumers Evaluate new service/intervention Evaluate new service/intervention Priority setting & resource allocation Priority setting & resource allocation Set, monitor & improve standards Set, monitor & improve standards (United Kingdom Clearing House on Health Outcomes, 1997) (United Kingdom Clearing House on Health Outcomes, 1997)

3. The Term Recreation Recreational Therapy/Therapeutic Recreation Recreational Therapy/Therapeutic Recreation Often not given similar consideration as Often not given similar consideration as Other allied health profession Other allied health profession Because of the term recreation Because of the term recreation Regulations Regulations Specifically state – don’t not pay or cover Specifically state – don’t not pay or cover Recreation Recreation Diversion Diversion Maintenance Maintenance Comfort Comfort

4. Inpatient Psychiatric Treatment Facilities Section 20.1.2 – Services Expected to Improve the Condition or for Purpose of Diagnosis, A3- 3102.1.A.2, HO-212.1A2 of the Medicare Benefit Policy Manual Chapter 2 Section 20.1.2 – Services Expected to Improve the Condition or for Purpose of Diagnosis, A3- 3102.1.A.2, HO-212.1A2 of the Medicare Benefit Policy Manual Chapter 2 Adjunctive Therapies – Prior to July 2006 Adjunctive Therapies – Prior to July 2006 Recreational Therapy Recreational Therapy Occupational Therapy Occupational Therapy Milieu Therapy Milieu Therapy Specific Wording of RT & OT Specific Wording of RT & OT Replaced with term Therapeutic Activities Replaced with term Therapeutic Activities

5. Inpatient Psychiatric Treatment Facilities “If the only activities prescribed for the patient are primarily diversional in nature, (i.e. to provide some social or recreational outlet for the patient), it will not be regarded as treatment to improve patients’ conditions.” “If the only activities prescribed for the patient are primarily diversional in nature, (i.e. to provide some social or recreational outlet for the patient), it will not be regarded as treatment to improve patients’ conditions.”

6. Inpatient Psychiatric Treatment Facilities Adjunctive Therapies (Recreational Therapy/Activity Therapy) Adjunctive Therapies (Recreational Therapy/Activity Therapy) Expected to improve Expected to improve Psychiatric condition Psychiatric condition Assist with diagnosis Assist with diagnosis Required to Provide Active Treatment Required to Provide Active Treatment Recreational Therapy interventions Recreational Therapy interventions Specific interventions intended to improve psychiatric condition Specific interventions intended to improve psychiatric condition Assist with diagnosis Assist with diagnosis

7. Inpatient Psychiatric Treatment Facilities Therapeutic Recreation – must follow Therapeutic Recreation – must follow Physician ’ s Orders Physician ’ s Orders Assessment Assessment Goals & Objectives Goals & Objectives Treatment Plan Treatment Plan Delivery of Services or Interventions Delivery of Services or Interventions Documentation of Provision of Services/Interventions Documentation of Provision of Services/Interventions Reevaluation Reevaluation Discharge Recommendations & Summary Discharge Recommendations & Summary

8. Outcomes Terminology Effectiveness Effectiveness Effectiveness Research Effectiveness Research Efficacy Efficacy Evidence-based Practice Evidence-based Practice Clinical Importance Clinical Importance

9. Effectiveness/Effectiveness Research Effectiveness Effectiveness How interventions work in typical clinical practice How interventions work in typical clinical practice Effectiveness Research Effectiveness Research Compares practice or interventions Compares practice or interventions

10. Efficacy Efficacy Efficacy Performance of intervention Performance of intervention Controlled study Controlled study

11. Evidence Based Practice Evidence Based Practice Evidence Based Practice Based on best available scientific Based on best available scientific Evidence Evidence Knowledge Knowledge

12. Clinical Importance Important difference in patient Important difference in patient Outcomes Outcomes Health Status Health Status Different from statistical significance Different from statistical significance

13. Outcomes Characteristics Desired outcomes identified Desired outcomes identified Based on setting Based on setting Client need Client need Measurable Measurable Distance Distance Time tolerated Time tolerated ROM ROM Number of Coping Mechanisms Number of Coping Mechanisms Number of Positive Self Comments Number of Positive Self Comments Etc… Etc…

14. Evidence Based Research 1970’s Early Research – Exercise & Depression 1970’s Early Research – Exercise & Depression Reported positive outcomes of exercise & depression levels Reported positive outcomes of exercise & depression levels 1980’s – Researchers – Compared Exercise & a Combination of Exercise & Psychotherapy 1980’s – Researchers – Compared Exercise & a Combination of Exercise & Psychotherapy Combination – greater effect on lowering levels of depression Combination – greater effect on lowering levels of depression

15. Evidence Based Research 1980’s Research 1980’s Research Compared counseling & aerobic exercise Compared counseling & aerobic exercise Aerobic exercise had greater effect on depression levels Aerobic exercise had greater effect on depression levels Later Studies Later Studies Compared exercise & exercise in combination with pharmacotherapy & pharmacotherapy alone Compared exercise & exercise in combination with pharmacotherapy & pharmacotherapy alone Exercise alone was found to be as effective as combination or pharmacotherapy alone Exercise alone was found to be as effective as combination or pharmacotherapy alone

16. Evidence Based Research Current Studies – Last 10 Years Support earlier studies Support earlier studies Individuals who exercise after diagnosis of depression Individuals who exercise after diagnosis of depression Report decreasing levels of depression Report decreasing levels of depression Maintains lower levels of depression Maintains lower levels of depression Studies Comparing pharmacotherapy with exercise Studies Comparing pharmacotherapy with exercise Indicate exercise elicits similar outcomes as medication Indicate exercise elicits similar outcomes as medication

17. Diagnosis Depression Depression Dysthymia Dysthymia Persistent depression that has symptoms such as fatigue, low self-esteem, insomnia, and appetite disturbances but is not severe enough to amount to a psychosis Persistent depression that has symptoms such as fatigue, low self-esteem, insomnia, and appetite disturbances but is not severe enough to amount to a psychosis

18. Intervention Exercise Aerobic Type Aerobic Type Treadmill Treadmill Stationary bike Stationary bike 10 minute warm-up 10 minute warm-up 45 minutes 45 minutes 60% to 70% of Target Heart Rate 60% to 70% of Target Heart Rate Goal of aerobic type Goal of aerobic type

19. Intervention Exercise Resistive Resistive Free Weights Free Weights Exercise Machines Exercise Machines Exercise Bands Exercise Bands Weight appropriate Weight appropriate 3 sets 3 sets Weight appropriate for prescribed repetitions Weight appropriate for prescribed repetitions 10 repetitions each set 10 repetitions each set

20. Exercise Routines 2 types 2 types Aerobic type Aerobic type Combined aerobic type & resistive Combined aerobic type & resistive 3 X’s per week 3 X’s per week 10 to 15 minute warm-up period 10 to 15 minute warm-up period 45 minutes 45 minutes

21. Discharge Recommendations Continue Exercise Routine Continue Exercise Routine Locate post discharge facility to exercise Locate post discharge facility to exercise Commercial Commercial Senior Citizen Center Senior Citizen Center Community Center Community Center Exercise Facility Exercise Facility Exercise in the community/at home Exercise in the community/at home Not recommended – due to Not recommended – due to Isolation Isolation Reasons causing diagnosis Reasons causing diagnosis

22. Data & Analysis 21 patients 21 patients 11 assigned to combined exercise group 11 assigned to combined exercise group 10 assigned to aerobic type exercise group 10 assigned to aerobic type exercise group Completed Beck Depression Inventory at Completed Beck Depression Inventory at Admission Admission Discharge Discharge 6 week post discharge 6 week post discharge 12 week post discharge 12 week post discharge

23. Instrument Beck Depression Inventory Scale Scale Measures reported levels of depression Measures reported levels of depression 0 to 63 0 to 63 See next slide See next slide

24. Instrument Beck Depression Inventory Below 4 = Possible denial of depression Below 4 = Possible denial of depression Faking Faking Below usual scores Below usual scores 05 - 09 Considered normal 05 - 09 Considered normal 10 - 18 Mild to Moderate depression 10 - 18 Mild to Moderate depression 19 - 29 Moderate to Severe depression 19 - 29 Moderate to Severe depression 30 - 63 Severe Depression 30 - 63 Severe Depression Over 40 Significantly above severe depression Over 40 Significantly above severe depression Suggests possible exaggeration of depression Suggests possible exaggeration of depression Possibly characteristic of borderline personality disorders. Significant levels of depression are still possible (Groth-Marnat, 1990). Possibly characteristic of borderline personality disorders. Significant levels of depression are still possible (Groth-Marnat, 1990).

25. Results

26. Results Admission 90% of the 11 Combined Subjects 90% of the 11 Combined Subjects Scored in range of clinical depression Scored in range of clinical depression 100% of the 10 Aerobic Subjects 100% of the 10 Aerobic Subjects Scored in the ranges of clinical depression Scored in the ranges of clinical depression

27. Results Discharge 80% of Combined Group 80% of Combined Group No presences of depression No presences of depression Two had scores of 17 Two had scores of 17 Had decreases in depression scores of 31 points & 19 points Had decreases in depression scores of 31 points & 19 points 100% of Aerobic Group 100% of Aerobic Group No presences of depression No presences of depression

28. Results 6 Week Post Discharge Between groups Between groups No significant difference No significant difference In adherence In adherence In depression scores In depression scores Both Groups Both Groups Significant difference – between those who continued & those who did not Significant difference – between those who continued & those who did not

29. Results 12 Week Post Discharge Between Groups Between Groups No significant difference No significant difference In adherence In adherence In depression scores In depression scores Both Groups Both Groups Significant difference – between those who continued & those who did not Significant difference – between those who continued & those who did not

30. Contact Information Participate in Research Tim Passmore, Ed.D., CTRS Assistant Professor School of Applied Health & Educational Psychology - Leisure Studies Program Oklahoma State University (405) 744-1811 tim.passmore@okstate.edu