Introduction 

Depression is the most common mental illness affecting older people in the UK and is estimated to impact on the lives of 2.4 million at any given time (MHF 2006a). Older people diagnosed with severe depression are likely to be offered anti-depressants but treatment takes several weeks to be effective and compliance with medication can be poor (Maidment et al. 2002). Psychological therapies are considered an effective treatment option but access to the relevant professional can be problematic (MHF, 2006b). Exercise provides an alternative approach and a recent systematic review found good evidence for its use in the management of depression in the older population (Sjosten & Kivela, 2006). Engaging in regular physical activity is important for older people irrespective of their mental health needs because they are at risk from medical conditions associated with inactivity (Young & Dinan, 2005). Similarly, exercise can help maintain functional independence among the older population at large as even the healthiest individuals lose muscle mass and experience reduced joint flexibility as a consequence of the ageing process (McMurdo, 2000).

An episode of severe depression may result in a hospital admission for a number of weeks. Physical activity levels in psychiatric units are generally very low (Radcliffe & Smith, 2007) and the reduction in older people’s activity levels can place them at risk of losing the ability to function independently upon their return home. However, it is possible that older psychiatric patients could be more active if given the opportunity. Research suggests that adults experiencing mental illness are as motivated to be active as the wider population (Ussher et al, 2007). Therefore, low levels of activity in the hospital environment may partly reflect both the lack of opportunities as well as indicating how unwell the individuals feel. One way of increasing activity levels for depressed older people in hospital is through the provision of structured exercise.

Aims and method

Research Aim: This project set out to explore the way in which older people admitted to hospital with depression experience exercise groups and the manner in which they engage in physical activity once discharged

Study setting: Daisy Hill House is an in-patient facility for older people with mental health needs in Bradford, West Yorkshire. Exercise groups are run by physiotherapy staff five times a week. Sessions last approximately 30 minutes and are conducted to music. Sessions are open to all patients on the ward who wish to attend and are considered well enough to do so by nursing and physiotherapy staff.

Methods: Eleven participants aged 69 to 86 years were purposively selected using exercise group attendance records. All had been admitted to hospital with depression, had attended a minimum of six exercise sessions and had been discharged for at least three months prior to recruitment. Semi-structured interviews were conducted and data analysis undertaken using the Framework Approach (Pope et al, 2000). 

Main findings

Characteristics of Participants: Virtually all participants were found to have an “exercise self schema” (Sorensen, 2006) indicating that they identified themselves as being an active person. Several expressed an awareness of the link between physical activity and mood.

Participants’ experience of hospital based exercise groups: All participants expressed favourable attitudes to the exercise groups and a majority reported that they had been sufficiently motivated to attend without staff persuasion. Perceived physical benefits included improvements in mobility and the opportunity to be active. Individuals identified positive effects on their mood which lasted from between several hours to the remainder of the day. Diversion in the form of adding structure to the day and an enhanced sense of competence arising from the ability to perform the exercises were considered important benefits.

Physical activity and recovery: Participants reported a variety of physical activities that they engaged in once they had left hospital. Re-engagement in physical activity was described in terms of identifiable milestones in the process of recovery. Several participants reported that they were aware of the positive effect that physical activity had on them and had used it in order to lift their mood. However, the theme of becoming more active again was generally described in the context of social interaction with significant relationships strongly influencing activity choice and level of engagement.

Barriers to activity: Physical ill-health was considered as a barrier by most participants. Several reported with resignation that health problems had curtailed their engagement in activity. Others described the effects of recent mental ill-health in terms of lowered confidence levels. Lengthy hospital stays were identified as a factor in reducing participants’ ability to cope at home. Lack of access to a car formed a barrier for some while others suggested that their needs might not be currently met by available services which were perceived as being aimed at the more physically able.

Discussion

This study set out to explore the experience of depressed older people when engaging in exercise and found that older people can be highly motivated to be active despite being admitted to hospital due to lowered mood. This is significant as activity levels within the older population are generally very low (DOH, 2003) and depression is thought to severely limit one’s ability to perform any task (Craft & Landers, 1998). This study confirms that older people are aware of the benefits of physical activity and value the opportunity to engage in exercise groups. It should be remembered that activity is not embraced by all and even the most committed individuals reported struggling with the barriers associated with low mood. Nevertheless, some older people do find exercise useful and this study indicates that the psycho-social effects of exercise groups such as diversion and competence may be particularly significant.

On discharge, people in the study were able to perform self-directed activities such as walking in order to manage their mood. However, it is apparent that the motivation to be active involved more than a desire to feel better. Older people recovering from depression appear to care more about regaining independence and returning to normality than engaging in well rehearsed activities in order to lift their mood. For people who have been active all their life the resumption of activity after illness represents an attempt to regain a sense of self. By seeking the views of older service users with a recent history of mental illness this study has addressed a gap in the literature.

Ill-health is a widely reported barrier to being physically active in the literature (Crombie et al, 2005). Similarly, expressing a sense of resignation about declining activity levels by older people in the wide population has been reported elsewhere (Stead et al, 1997). For some older people the value that they attach to being active is outweighed by the insurmountable physical and social obstacles they face and they have come to accept the ‘inevitable’ reduction in their activity levels.  

Conclusions

The findings from this study support the use of exercise groups for older people admitted to hospital with depression. Community based interventions designed to promote physical activity in older people recovering from mental illness are most likely to be effective if they address individually identified functional goals and take into account the social needs of the older service users. Future research in this field must acknowledge the significance of personal factors if it is to make a useful contribution to the mental health needs of the older population.

References

Craft L & Landers D (1998) The Effect of Exercise on Clinical Depression and Depression resulting from Mental Illness: A Meta analysis. Journal of Sport and Exercise Psychology, 20 339-357.

Crombie I, Irvine L, Williams B et al. (2004) Why older people do not participate in leisure time physical activity: a survey of activity levels, beliefs and deterrents Age and Ageing, 33 (3) 287-292.

Department of Health (2003) Health Survey for England 1994-2003. London, Department of Health.

Maidment R, Livingston G, Katona C (2002) ”Just keep taking the tablets”. Adherence to anti-depressant treatment in older people in primary care. International Journal of Geriatric Psychiatry, 17 (8) 752-757.

McMurdo M (2000) A healthy old age: realistic or futile goal. BMJ, 321 (7269) 1149-1151.

Mental Health Foundation (2006a) Promoting mental health and well-being in later life. A first report from the UK inquiry into mental health and well-being in later life. London, Mental Health Foundation.

Mental Health Foundation (2006b) We need to talk. The case for psychological therapy on the NHS. London, Mental Health Foundation.

Pope C, Zeibland, S Mays N (2000) Qualitative research in health care. Analysing qualitative data. BMJ, 320 114-6.

Radcliffe J & Smith R (2007) Acute in-patient psychiatry: how patients spend their time on acute psychiatric wards. Psychiatric Bulletin, 31 167-170.

Richardson C, Faulkner G, McDevitt J et al. (2005) Integrating Physical activity Into Mental Health Services for Persons With Serious Mental Illness. Psychiatric Services 56 324-331.

Sjosten N & Kivela S-L (2006) The effects of physical exercise on depressive symptoms among the aged: a systematic review. International Journal of Geriatric Psychiatry, 21 410-418.

Stead M, Wimbush E, Eadie D et al. (1997) A Qualitative study of older people’s perception of ageing and exercise: the implications for health promotion. Health Promotion International, 19 (3) 379-387.

Ussher M, Stanbury L, Cheeseman V et al. (2007) Physical activity preferences and perceived barriers to activity among persons with severe mental illness in the United Kingdom. Psychiatric Services, 58 (3) 405-408.

Young A & Dinan S (2005) Activity in later life. BMJ, 330, 189-192.