A Long Time Coming - The Creation of an Evidence Base for Physical Activity Prescription to Improve Health Outcomes in Bipolar Disorder

Factors that influence participation in physical activity for people with bipolar disorder: a synthesis of qualitative evidence

BACKGROUND

Mental health problems contribute significantly to the overall disease burden worldwide and are major causes of disability, suicide, and ischaemic heart disease. People with bipolar disorder report lower levels of physical activity than the general population, and are at greater risk of chronic health conditions including cardiovascular disease and obesity. These contribute to poor health outcomes. Physical activity has the potential to improve quality of life and physical and mental well-being.

OBJECTIVES

To identify the factors that influence participation in physical activity for people diagnosed with bipolar disorder from the perspectives of service users, carers, service providers, and practitioners to help inform the design and implementation of interventions that promote physical activity.

SEARCH METHODS

We searched MEDLINE, PsycINFO, and eight other databases to March 2021. We also contacted experts in the field, searched the grey literature, and carried out reference checking and citation searching to identify additional studies. There were no language restrictions.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that focused on the experiences and attitudes of service users, carers, service providers, and healthcare professionals towards physical activity for bipolar disorder.

DATA COLLECTION AND ANALYSIS

We extracted data using a data extraction form designed for this review. We assessed methodological limitations using a list of predefined questions. We used the "best fit" framework synthesis based on a revised version of the Health Belief Model to analyse and present the evidence. We assessed methodological limitations using the CASP Qualitative Checklist. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) guidance to assess our confidence in each finding. We examined each finding to identify factors to inform the practice of health and care professionals and the design and development of physical activity interventions for people with bipolar disorder.

MAIN RESULTS

We included 12 studies involving a total of 592 participants (422 participants who contributed qualitative data to an online survey, 170 participants in qualitative research studies). Most studies explored the views and experiences of physical activity of people with experience of bipolar disorder. A number of studies also reported on personal experiences of physical activity components of lifestyle interventions. One study included views from family carers and clinicians. The majority of studies were from high-income countries, with only one study conducted in a middle-income country. Most participants were described as stable and had been living with a diagnosis of bipolar disorder for a number of years. We downgraded our confidence in several of the findings from high confidence to moderate or low confidence, as some findings were based on only small amounts of data, and the findings were based on studies from only a few countries, questioning the relevance of these findings to other settings. We also had very few perspectives of family members, other carers, or health professionals supporting people with bipolar disorder. The studies did not include any findings from service providers about their perspectives on supporting this aspect of care. There were a number of factors that limited people's ability to undertake physical activity. Shame and stigma about one's physical appearance and mental health diagnosis were discussed. Some people felt their sporting skills/competencies had been lost when they left school. Those who had been able to maintain exercise through the transition into adulthood appeared to be more likely to include physical activity in their regular routine. Physical health limits and comorbid health conditions limited activity. This included bipolar medication, being overweight, smoking, alcohol use, poor diet and sleep, and these barriers were linked to negative coping skills. Practical problems included affordability, accessibility, transport links, and the weather. Workplace or health schemes that offered discounts were viewed positively. The lack of opportunity for exercise within inpatient mental health settings was a problem. Facilitating factors included being psychologically stable and ready to adopt new lifestyle behaviours. There were positive benefits of being active outdoors and connecting with nature. Achieving balance, rhythm, and routine helped to support mood management. Fitting physical activity into a regular routine despite fluctuating mood or motivation appeared to be beneficial if practised at the right intensity and pace. Over- or under-exercising could be counterproductive and accelerate depressive or manic moods. Physical activity also helped to provide a structure to people's daily routines and could lead to other positive lifestyle benefits. Monitoring physical or other activities could be an effective way to identify potential triggers or early warning signs. Technology was helpful for some. People who had researched bipolar disorder and had developed a better understanding of the condition showed greater confidence in managing their care or providing care to others. Social support from friends/family or health professionals was an enabling factor, as was finding the right type of exercise, which for many people was walking. Other benefits included making social connections, weight loss, improved quality of life, and better mood regulation. Few people had been told of the benefits of physical activity. Better education and training of health professionals could support a more holistic approach to physical and mental well-being. Involving mental health professionals in the multidisciplinary delivery of physical activity interventions could be beneficial and improve care. Clear guidelines could help people to initiate and incorporate lifestyle changes.

AUTHORS' CONCLUSIONS

There is very little research focusing on factors that influence participation in physical activity in bipolar disorder. The studies we identified suggest that men and women with bipolar disorder face a range of obstacles and challenges to being active. The evidence also suggests that there are effective ways to promote managed physical activity. The research highlighted the important role that health and care settings, and professionals, can play in assessing individuals' physical health needs and how healthy lifestyles may be promoted. Based on these findings, we have provided a summary of key elements to consider for developing physical activity interventions for bipolar disorder.

Study protocol for a systematic review of evidence for lifestyle interventions targeting smoking, sleep, alcohol/other drug use, physical activity, and healthy diet in people with bipolar disorder

BACKGROUND

People with bipolar disorder (BD) have a mortality gap of up to 20 years compared to the general population. Physical conditions, such as cardiovascular disease (CVD) and cancer, cause the majority of excess deaths in psychiatric populations and are the leading causes of mortality in people with BD. However, comparatively little attention has been paid to reducing the risk of physical conditions in psychiatric populations. Unhealthy lifestyle behaviors are among the potentially modifiable risk factors for a range of commonly comorbid chronic medical conditions, including CVD, diabetes, and obesity. This systematic review will identify and evaluate the available evidence for effective interventions to reduce risk and promote healthy lifestyle behaviors in BD.

METHODS/DESIGN

We will search MEDLINE, Embase, PsychINFO, Cochrane Database of Systematic Reviews, and CINAHL for published research studies (with at least an abstract published in English) that evaluate behavioral or psychosocial interventions to address the following lifestyle factors in people with BD: tobacco use, physical inactivity, unhealthy diet, overweight or obesity, sleep-wake disturbance, and alcohol/other drug use. Primary outcomes for the review will be changes in tobacco use, level of physical activity, diet quality, sleep quality, alcohol use, and illicit drug use. Data on each primary outcome will be synthesized across available studies in that lifestyle area (e.g., tobacco abstinence, cigarettes smoked per day), and panel of research and clinical experts in each of the target lifestyle behaviors and those experienced with clinical and research with individuals with BD will determine how best to represent data related to that primary outcome. Seven members of the systematic review team will extract data, synthesize the evidence, and rate it for quality. Evidence will be synthesized via a narrative description of the behavioral interventions and their effectiveness in improving the healthy lifestyle behaviors in people with BD.

DISCUSSION

The planned review will synthesize and evaluate the available evidence regarding the behavioral or psychosocial treatment of lifestyle-related behaviors in people with BD. From this review, we will identify gaps in our existing knowledge and research evidence about the management of unhealthy lifestyle behaviors in people with BD. We will also identify potential opportunities to address lifestyle behaviors in BD, with a view to reducing the burden of physical ill-health in this population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015019993.

Effects of a single bout of maximal aerobic exercise on BDNF in bipolar disorder: A gender-based response

Acute exercise increases brain-derived neurotrophic factor (BDNF) serum levels in majorly depressed and anxious patients. However, to the best of our knowledge, no study has evaluated the acute effects of exercise on BDNF serum levels in Bipolar Disorder (BD). The objective of the present study was to evaluate the peripheral BDNF serum response to a single maximum session of exercise in BD participants and age- and gender-matched healthy participants. BD participants (n=18) and age- and gender-matched healthy participants (n=18) were recruited to perform a single bout of maximal exercise on a cycle ergometer. Blood samples were collected prior to and immediately after the exercise protocol. There was a significant group effect and a significant group x time x gender interaction. BD participants presented significantly higher BDNF serum levels when compared to their healthy control counterparts. Exercise increases the BDNF levels of BD women, but not men.

Are adults with bipolar disorder active? Objectively measured physical activity and sedentary behavior using accelerometry

BACKGROUND

Little is known about physical activity and sedentary behavior of adults with bipolar disorder (BP). Physical activity and sedentary behaviors may be modifiable factors associated with elevated rates of obesity, diabetes, cardiovascular disease, metabolic syndrome, and mortality in adults with BP.

METHODS

Sixty adult outpatients treated for BP (> 18 yr) wore accelerometers for seven consecutive days. Each minute epoch was assigned an activity level based on the number of counts per minute; sedentary(<100 counts), light(101-1951 counts), or moderate/vigorous(>1952 counts). Adults with BP were matched 1:1 to users and non-users of mental health services (MHS) (NHANES 2003-2004) by gender, closest BMI, and age.

RESULTS

On average, adults with BP wore actigraphs over 17 h/day. The majority of monitoring time (78%) was classified as sedentary (approximately 13.5h/day). Light physical activity accounted for 21% of the monitoring time/day (215 min/day). None achieved 150 min/wk of moderate/vigorous activity as recommended by national guidelines. Adults with BP were significantly less active and more sedentary than MHS users and non-users in NHANES 2003-2004 (p<0.01).

LIMITATIONS

Majority of the participants were relatively asymptomatic with most (87%) having no more than mild depressive symptoms and none experiencing severe manic symptoms. The sedating effects of medications on physical activity were not investigated.

CONCLUSION

From clinical perspectives, these findings justify physical activity interventions targeting adults with BP as a possible means to improve their physical and mental health and to reduce the elevated risk of commonly observed medical comorbidities in this high-risk population.

A review of physical activity correlates in patients with bipolar disorder

BACKGROUND

Existing studies do suggest that physical activity interventions may be feasible and have a role in promoting mental and physical health in patients with bipolar disorder. The present review evaluates systematically quantitative studies of correlates of physical activity in patients with bipolar disorder.

METHODS

We searched EMBASE, PsycINFO, PubMed, and CINAHL from their inception, combining the medical subject headings 'bipolar disorder' or 'mania' or 'manic depression' with 'physical activity' or 'physical inactivity' or 'exercise'.

RESULTS

Out of 40 potentially eligible studies, 11 papers evaluating 26 correlates were included. Correlates that were associated with lower physical activity participation were lower self-efficacy, presence of medical co-morbidity, lower educational status and social isolation. Less consistent variables associated with lower physical activity participation included higher BMI, older age, financial strains, not being connected to a health care service, and minority ethnicity. A larger study sample size was related to a higher proportion of significant associations (p=0.04). Current gaps in literature which need to be examined more in detail are the role of psychiatric symptoms, environmental and policy-level factors.

LIMITATIONS

The diversity of physical activity measures and subject samples prevented us to perform a meta-analysis.

CONCLUSIONS

All significant correlates should be confirmed in prospective studies and interventions to improve the modifiable variables should be developed and evaluated. The reviewed data also demonstrate that validation studies on physical activity measurements are highly needed.

The projected effect of increasing physical activity on reducing the prevalence of common mental disorders among Canadian men and women: a national population-based community study

OBJECTIVE

Little quantitative research has been conducted on the effect of physical activity (PA) modification on the prevalence of mental disorders in a nationally representative sample. We aimed to provide quantitative evidence regarding the potential effectiveness of PA in the management of mental disorders.

METHODS

We used data from the national Canadian Community Health Survey of Mental Health and Well-being (CCHS 1.2) designed to represent the approximately the 25 million national community population aged 15 years and over in 2002.

RESULTS

Around 1 in 10 Canadians reported a 12-month mental disorder. Women reported more mood and anxiety disorders, men more substance dependence. Almost half of Canadians were physically inactive. After adjusting for covariates, physical inactivity was a significant risk factor for common mental disorders, except manic episode. Approximately 780,000 cases nationally are attributable to physical inactivity. A 10% reduction in the rate of physical inactivity would reduce common mental disorders by 167,000 cases, a 25% reduction would result in 389,000 fewer cases. PA was more beneficial for men.

CONCLUSIONS

Clinicians and public health campaigns targeting individual patients and general populations can improve patients' symptoms and prevent a significant proportion of future mental disorders by increasing the amount of PA.

Impact of exercise on affective responses in female adolescents with type I diabetes

BACKGROUND

Adolescent is a time of profound biologic, intellectual, psychological, and socioeconomic change that they will face a crisis. Therefore, compatibility may be exposed to many hazards, such as depression, anxiety, and other emotional problems. Nevertheless, a planned regular exercise enhances physical and mental health of adolescent female with diabetes. The aim of this study was to determine the effect of exercise on emotional reactions of female adolescents with type I diabetes.

MATERIALS AND METHODS

This study was a quasi-experimental research conducted in Endocrine and Metabolism Research Centre. A total of 72 patients were randomly allocated in the two groups. The intervention group did aerobic exercise for 45 minutes, while the control group did not aerobic exercise. Data were collected using a Symptom Checklist (SCL)-90 questionnaire. Data were analyzed and using descriptive and inferential statistics methods and SPSS software.

RESULTS

The results showed that the mean score for physical symptoms, depression, obsession-compulsion, interpersonal sensitivity, aggression, phobia, paranoid ideation, psychosis, and anxiety in the test group significantly decreased after intervention than before intervention. The average score in the control group did not differ. The average total score of emotional reactions in the test group after the intervention decreased before the intervention significantly (P = 0.001). However, in the control group, the mean scores did not differ (P = 0.97).

CONCLUSION

The findings showed that regular exercise is effective on affective responses of adolescent females with type I diabetes.