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Perspectives in Psychiatric Care
ISSN 0031-5990
A Pilot Study of the Views of General Practitioners Regarding Exercise for the Treatment of Depression Robert Stanton, BHMSc (Hons), Chris Franck, BMil, BCom (Hons), MCom (I/O Psychology), Peter Reaburn, PhD, and Brenda Happell, PhD Robert Stanton, BHMSc (Hons), is a Research Officer, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; Chris Franck, BMil, BCom (Hons), MCom (I/O Psychology), is Clinical Director, Central Queensland Medicare Local, Rockhampton, Queensland, Australia; Peter Reaburn, PhD, is an Associate Professor of Exercise and Sports Science, Institute for Health and Social Science Research, School of Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia; and Brenda Happell, PhD, is a Professor of Mental Health Nursing, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia.
Search terms: Depression/mood disorder, mental health, physical activity/exercise Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement The authors have no potential, perceived, or real conflict of interests to declare. Funding Central Queensland Medical Local provided in-kind support for this project.
PURPOSE: To investigate the views of general practitioners (GPs) regarding exercise and the treatment of depression. DESIGN AND METHODS: Twenty GPs completed a 25-item survey investigating their knowledge, beliefs, perceived benefits and barriers, and recommendations to patients regarding exercise for the treatment of depression. The exercise habits of the GPs were also recorded. FINDINGS: GPs are positive toward exercise in the treatment of depression despite low levels of confidence in prescribing exercise or limited measurable benefits. Exercise patterns of GPs were not associated with GP exercise prescription habits. PRACTICE IMPLICATIONS: Education, use of support materials and referral schemes, and increasing exercise behavior among GPs may increase the use of exercise as treatment for people with depression.
First Received May 13, 2014; Final Revision received August 4, 2014; Accepted for publication September 5, 2014. doi: 10.1111/ppc.12088
Depression is a debilitating condition impacting upon millions of people worldwide (Lepine & Briley, 2011) and ranks as the most common mental illness presentation to Australian general practitioners (GPs) (Australian Institute of Health and Welfare, 2010). Guidelines for the management of depression include antidepressant therapy, psychological interventions, and lifestyle advice (Ellis, 2004). However, a survey of 151 GPs in Victoria, Australia, reported that more than 80% prescribed medication and almost 90% provided counseling to patients with mild to moderate depression (McGarry, Hegarty, & Gunn, 2005). This trend is consistent with crosssectional analysis of Pharmaceutical Benefits Scheme data showing a 95% increase in antidepressant medication prescriptions between 2001 and 2011 (Stephenson, Karanges, & McGregor, 2013). Recent systematic reviews and meta-analyses have demonstrated the beneficial effects of exercise for people with depression (Cooney et al., 2013; Daley, 2008; Danielsson, Noras, Perspectives in Psychiatric Care 51 (2015) 253–259 © 2014 Wiley Periodicals, Inc.
Waern, & Carlsson, 2013; Rethorst, Wipfli, & Landers, 2009). Unfortunately, the number of high-quality trials is small and the quality and consistency of reporting intervention details is poor. As a result of these inconsistencies, it may be difficult for GPs to find consensus as to how best design an appropriate exercise program for people with depression. To improve the ease of exercise program design, a recent systematic review concluded that a program comparable with that recommended for an apparently healthy population is likely to be effective for people with depression (Stanton & Reaburn, 2013). A recent study of UK-based GPs regarding physical activity and depression (Searle et al., 2012) reported that GPs believed exercise to be an effective adjunct, rather than a firstline therapy such as antidepressant medications or counseling. This is inconsistent with the National Institute for Clinical Excellence (NICE) guidelines for the treatment of depression, which suggest that people with persistent sub253
A Pilot Study of the Views of General Practitioners Regarding Exercise for the Treatment of Depression
threshold or mild to moderate depression may be considered for a low-intensity psychosocial intervention (NICE, 2009). Moreover, while the NICE guidelines provide specific direction on the supervision, delivery, and frequency of exercise, parameters such as intensity and mode of exercise are absent. Thus, the capacity for GPs to prescribe exercise on the basis of the NICE guidelines alone is limited. The exercise-prescribing habits of Australian GPs remain to be fully evaluated. McGarry et al. (2005) reported that from a sample of 151 GPs, 73% surveyed recommended exercise to at least half of their patients with mild to moderate depression. It is unclear if the rates of prescribing exercise are a consequence of the GPs’ lack of knowledge in the area or a lack of confidence in exercise as either a first-line or adjunct therapy. In a population survey undertaken in Queensland, Australia, less than one-quarter of respondents reported receiving exercise prescription during routine GP appointments (Eakin, Brown, Schofield, Mummery, & Reeves, 2007) and a recent study (Robertson, Jepson, Shepherd, & McInnes, 2011) reported that mental illness represented only 7% of all conditions for which physical activity advice was offered by GPs. Unlike the UK, Australian guidelines for the treatment of depression lack detail regarding the prescription of exercise. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) guidelines for the treatment of depression suggest that “adequate exercise” may be of benefit, but no further information is given about what may constitute “adequate” (Ellis, 2004). This may be a result of the lack of substantial support for exercise at the time of publication of these guidelines. When coupled with the barriers to exercise presented by patients, such as physical health comorbidities, medication side effects, and symptoms related to their condition, it is little wonder there are inconsistencies in the recommendation of exercise for people with depression. At present, there are relatively little data pertaining to the exercise prescription practices of Australian GPs for people with depression. No studies have sought to identify the sources of guidance regarding exercise for depression used by GPs, the type, frequency or intensity of exercise prescribed, the benefits reported by patients, or the use of referrals to exercise professionals. Unlike international studies, the relationship between personal exercise practices and the exercise prescription patterns of Australian GPs has not been investigated. Given the potential benefits of exercise for people with depression and the frequency of presentation to GPs, it is prudent to understand the views of GPs regarding the prescription of exercise for people with depression. These data are important in ensuring people with depression are provided with current evidence-based information regarding the role of exercise in their treatment. Therefore, the purpose of this pilot study is to examine the views and practices of regionally based Australian GPs regarding exercise in the treatment of depression. 254
Methods We conducted an anonymous survey of GPs in Central Queensland, Australia, assisted by the Central Queensland Medicare Local (CQML). GPs in the region were invited to complete a survey via direct email from the CQML Chief Executive Officer and via a regular electronic newsletter. The newsletter contained the link to the online survey. To increase our response rate, identical paper-based surveys were delivered to GP clinics with instructions not to complete both the online and paper-based versions of the survey. Survey Design A survey was developed specifically for the purpose of this study with guidance from the Central Queensland University’s Population Research Laboratory and CQML. Items were chosen to answer the research question, yet not generate significant burden for time-poor GPs. The final survey comprised 25 items including Likert-type response, multiple choice, and open-ended response questions. We identified general demographics (gender, age, and working status) knowledge regarding the inclusion of exercise in clinical practice guidelines (four items) and beliefs (five items) regarding exercise for the treatment of depression, recommendation regarding exercise type and exercise intensity, the presence of patient-reported and objectively measured outcomes (10 items), and the GPs’ individual exercise behaviors (three items). The survey took approximately 6 min to complete. Statistical Analysis Frequency responses (N and % of respondents) are reported. The relationship between GPs’ individual exercise behaviors and knowledge, attitudes, and exercise recommendation for patients with depression was identified using the phi statistic. All analyses were performed using the Statistical Package for the Social Sciences (SPSS) Version 19 (SPSS Inc., Chicago, IL, USA). Results Survey Response The survey was available to 220 GPs at the time of data collection. Completed surveys were received from 20 GPs, resulting in a return rate of 9%. Demographics Male GPs comprised 55% (n = 11) of respondents. The mean age of all respondents was 46.4 ± 8.9 years (range 31–67 years). Two respondents reported working in locum positions at the time of the survey. Perspectives in Psychiatric Care 51 (2015) 253–259 © 2014 Wiley Periodicals, Inc.
A Pilot Study of the Views of General Practitioners Regarding Exercise for the Treatment of Depression
Knowledge and Beliefs Regarding Exercise for the Treatment of Depression Sixty percent of GPs (n = 12) reported being aware of the existence of current clinical practice guidelines for the treatment of depression, with a further 30% (n = 6) being unsure of the current guidelines. Fifty-five percent (n = 9) of respondents who reported being aware of the clinical guidelines for depression management reported the source of the guidelines being the RANZCP, with 25% (n = 5) of respondents citing the Royal Australian College of General Practitioners (RACGP) as the source. Two respondents cited both the RANZCP and the RACGP and one respondent cited another unidentified source.Of those who reported being aware of the current clinical guidelines for the management of depression, 67% (n = 8) reported the inclusion of exercise in the clinical guidelines, with the remaining 33% (n = 4) being unsure. GPs were asked to respond to a series of Likert scale questions regarding exercise and the treatment of depression. Ninety percent of respondents (n = 18) “Strongly agree” or “Agree” that exercise is a worthwhile inclusion in treatment, with a further 10% (n = 2) providing a neutral response (“Neither agree nor disagree”). However, 75% (n = 15) “Strongly agree” or “Agree” that patients with depression are less likely to adhere to an exercise intervention, with 15% (n = 3) providing a neutral response (“Neither agree nor disagree”) and 10% (n = 2) responding with “Disagree.” Forty-five percent of respondents (n = 9) “Strongly agree” or “Agree” they are confident in prescribing exercise to patients with depression, with a further 45% (n = 9) providing a neutral response (“Neither agree nor disagree”). Similarly, 45% of respondents (n = 9) “Strongly agree” or “Agree” they are competent to prescribe exercise to patients with depression, with a further 45% (n = 9) providing a neutral response (“Neither agree nor disagree”). GPs were asked to respond to a series of Likert scale questions regarding the potential benefits of exercise for people with depression. Responses are shown in Table 1. No GP recorded a response of “Disagree” or “Strongly disagree” to any statement.
Exercise Recommendations by GPs All GPs recommended the use of cardiovascular exercise such as walking or cycling for patients with depression. A slightly smaller proportion (70%, n = 14) recommended the use of relaxation exercises including yoga or tai chi. Group exercises such as aerobic classes or dancing were recommended by 50% (n = 10), with 35% (n = 7) recommending resistance exercise. Recommendations regarding the appropriate exercise intensity were examined using the single item: “At what intensity do you recommend your patients with depression to exercise at?” Response options were “Self-selected,” “Low intensity,” “Moderate intensity,” “High intensity,” “I do not prescribe an exercise intensity,” or “Other.” Responses for exercise intensity are shown in Figure 1. Thirty percent (n = 6) of GPs reported positive benefits to patients as determined by improved Kessler K10 score or other measure for patients arising from their recommendation to undertake exercise. The majority of GPs (65%, n = 13) reported being unsure of any benefit. In contrast, 85% (n = 17) of GPs indicated that patients reported some benefit as a result of commencing exercise based on their recommendation, with the remaining 15% of GPs being unsure of any benefit. Referral to an Exercise Specialist Seventy percent (n = 14) of GPs reported referring their patients with depression to an exercise specialist, including accredited exercise physiologists (AEPs) (65%, n = 13), personal trainers (25%, n = 5), strength and conditioning coaches (10%, n = 2), or gymnasium instructors (30%, n = 6). A number of GPs cited multiple referral pathways to exercise specialists. The Medicare-subsidized Enhanced Primary Care referral was the most commonly reported pathway (65%, n = 13). Referrals under Department of Veterans Affairs arrangements were reported by 35% (n = 7) of GPs, with the use of a referral letter reported by 15% (n = 3) of GPs. For patients referred to an exercise professional, 36% (n = 5) of GPs reported positive benefit for patients as determined
Table 1. Beliefs of GPs Regarding the Potential Benefits of Exercise in the Treatment of Depression
Response Potential benefit
Strongly agree
Agree
Neither agree nor disagree
Reduced medication needs Improved fitness Reduction in depressive symptoms Distraction from ruminating thoughts Improved cardiovascular risk profile
15% (3) 35% (7) 20% (4) 25% (5) 45% (9)
55% (11) 60% (12) 65% (12) 70% (14) 25% (9)
30% (6) 5% (1) 5% (1) 5% (1) 30% (6)
Numbers in parentheses are the number of respondents. No respondent recorded a response of “Disagree” or “Strongly disagree” to any statement. GP, general practitioner.
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60
Proporon of respondents
50
40
30
20
10
0 Self-selected
Low
Moderate
High
Don't provide a recommendaon
Other
Figure 1. GP Recommendations for Exercise Intensity (Sum of Responses Is Greater Than 100% as Some GPs Indicated Multiple Responses)
by improved Kessler K10 score or other measure. The vast majority of GPs (64%, n = 9) reported being unsure of any benefit for patients as a result referring to an exercise specialist. In contrast, 79% of GPs indicated that patients report some benefit as a result of commencing exercise based on the exercise specialists’ recommendations, with the remaining 21% of GPs reporting their patients are unsure of any benefit.
significant relationship between GPs meeting the recommended level of weekly exercise and referral to an exercise specialist (ɸ = 0.21, p = .36) or awareness of the inclusion of exercise in the clinical management guidelines for depression (ɸ = 0.18, p = .72).
Barriers to Exercise
Survey Response
To examine the beliefs of GPs regarding possible barriers to the commencement of exercise reported by patients with depression, we presented a list of barriers previously identified by the literature. Multiple responses were allowed and the responses are shown in Table 2.
Although low, the response rate to our survey is comparable to that of other healthcare professionals. Aitken, Power, and Dwyer (2008) reported response rates of between 7.5% and 13.2% to online surveys of Australian medical practitioners. Low response rates to such surveys may be attributable to increased workloads, competing priorities, or disinterest. The failure of our survey to offer an incentive for respondents may also have contributed to the low return rate.
GPs’ Individual Exercise Behaviors Thirteen GPs self-reported meeting the minimum physical activity guidelines of 150 min/week. The self-reported exercise habits of respondents are shown in Table 3. We found no
Discussion
Demographics Our sample is of similar age to that reported by McGarry et al. (2005) and Alexander and Fraser (2008); however, our cohort
Table 2. GPs’ Beliefs Regarding Barriers to Exercise Reported by Patients Barrier
% age of respondents (n)
Lack of time Injury Comorbidities Lack of confidence Lack of resources Low motivation
35 (7) 25 (5) 45 (9) 45 (9) 20 (4) 90 (18)
Numbers in parentheses are the number of respondents. Percentages sum to more than 100% as some respondents indicated multiple responses. GP, general practitioner.
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Table 3. Personal Exercise Habits of GPs Exercise mode
% age of respondents (n)
Cardiovascular exercise (e.g., walking, cycling) Resistance training (e.g., weight training) Relaxation exercise (e.g., yoga, tai chi) Group exercise (aerobic classes, dancing)
85 (17) 20 (4) 15 (3) 15 (3)
Numbers in parentheses are the number of respondents. Percentages sum to more than 100% as some respondents indicated multiple modes of exercise. GP, general practitioner.
Perspectives in Psychiatric Care 51 (2015) 253–259 © 2014 Wiley Periodicals, Inc.
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contains a smaller proportion of male GPs than the study of McGarry et al. The number of GPs working as locums at the time of data collection is not reported in other studies. Knowledge and Beliefs Regarding Exercise for the Treatment of Depression The knowledge and beliefs of GPs regarding the prescription of exercise for the treatment of depression have not been well investigated. In an early study, Lawlor, Keen, and Neal (1999) reported that GPs acknowledge the benefits of physical activity for chronic health conditions including depression; however, they fail to provide the advice in a manner likely to affect population health. In the present study, 67% of respondents reported being aware of the inclusion of exercise in clinical guidelines for the treatment of depression. However, the detail contained in the RANZCP guidelines is insufficient to develop an effect exercise prescription. At present, only the Exercise is Medicine® Fact Sheet on exercise and depression (http://exerciseismedicine.org.au/public/factsheets) offers sufficient detail for evidence-based exercise prescription for people with depression. In the most recent and comprehensive investigation of the views of GPs regarding exercise for patients with depression (Searle et al., 2012), GPs tended to rely on anecdotal rather than scientific evidence for decision-making. Whether this view is representative of all UK-based GPs is questionable given the small sample (n = 5). Nonetheless, it may represent a knowledge gap for GPs regarding an effective, low-cost and non-pharmaceutical treatment option for people with depression. In line with the findings of Searle et al. (2012), our findings indicate that GPs are in strong agreement regarding the benefits of exercise for the treatment of depression. However, a potential limitation of the present survey is the apparent ceiling effect associated with the use of a 5-point Likert scale where no responses appeared in the “Disagree” or “Strongly disagree” categories. While less of a concern for this crosssectional study, future studies that investigate the change in beliefs over time may consider the use of alternate scales such as a 10-point visual analog scale to improve sensitivity. Less than half of the respondents in our survey agree they are either confident or competent to prescribe exercise for people with depression. This appears consistent with the observation that those GPs have a relatively poor awareness of the existence and source of clinical guidelines for the treatment of depression. Moreover, of those who were aware of appropriate guidelines, only two-thirds were aware of the inclusion of exercise in the guidelines. Exercise Recommendations by GPs Exercise was not considered in the study of Alexander and Fraser (2008) as a treatment option for patients with mental Perspectives in Psychiatric Care 51 (2015) 253–259 © 2014 Wiley Periodicals, Inc.
health disorders including depression. This is surprising since the efficacy and acceptance of exercise as a treatment for depression was well demonstrated by that time (Trivedi, Greer, Grannemann, Chambliss, & Jordan, 2006). Therefore, we cannot compare our findings to this earlier study even though some GPs may have prescribed exercise for patients with depression and the role of the AEP was well established. Similar to the present study, Searle et al. (2012) did not determine the frequency of exercise prescription nor the recommended intensity at which exercise should be performed. The findings of the present study suggest that a self-selected exercise intensity is most commonly recommended by GPs for people with depression. This is import since self-selected exercise intensity leads to improved autonomy, results in increased affective responses, and improved postexercise behavioral outcomes, compared to prescribed intensity (Ekkekakis, 2009; Ekkekakis, Parfitt, & Petruzzello, 2011). We also report, however, that GPs encourage cardiovascular exercise, which is consistent with a number of current recommendations (NICE, 2009; Stanton & Reaburn, 2013). In support of Searle et al.’s (2012) notion that GPs may recommend exercise based on anecdotal rather than scientific evidence, 85% of GPs cite patient-reported benefits following the commencement of exercise despite only 36% of GPs reporting any psychometric evidence. The low level of self-reported confidence and competence expressed by GPs regarding the prescription of exercise for people with depression may lead to the low reporting of exercise prescription by GPs in general. Early studies (Eakin et al., 2007) show that almost one-quarter of patients received recommendations regarding exercise from their GPs. More recent data report that approximately 18% of patients receive recommendations regarding exercise from their GPs, mainly for weight management (Robertson et al., 2011). Most recently, data from the “Bettering the Evaluation and Care of Health” initiative suggest that Australian GPs provide recommendations regarding exercise at a rate of 1.3/100 encounters; a rate that has shown a significant decline in the past decade (Britt et al., 2012). Given the demonstrated efficacy of exercise in the treatment of a number of chronic health conditions including depression, and the availability of patient and clinician support materials via the “Exercise is Medicine” program, more clearly needs to be done to encourage the uptake of this valuable treatment option. Referral to an Exercise Specialist Referrals to AEPs ranked as the seventh most common GP referral under Australia’s Medicare-supported program in 2001–2012 (Britt et al., 2012). While both AEPs and GPs are of similar views regarding the value of exercise in the treatment of people with depression, their views regarding the lack of adherence to exercise in people with depression are also 257
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similar. However, evidence shows that adherence to exercise in people with depression is similar to the general population (Arikawa, O’Dougherty, Kaufman, Schmitz, & Kurzer, 2012; Friedenreich et al., 2011) and therefore should not deter clinicians from prescribing exercise to this population. Moreover, a recent systematic review and meta-analysis (Pavey et al., 2011) supports the efficacy of exercise referral schemes in primary care in both increasing physical activity and reducing depression.
The most common barriers to exercise for people with depression reported by GPs were low motivation (90%), comorbidities (45%), and lack of confidence (45%). Of these, only comorbidities are consistent with the current literature. Glover, Ferron, and Whitley (2013) identified medication side effects and condition-related symptoms in addition to comorbidities as self-identified barriers to exercise by people with depression. This disparity between self-identified and perceived barriers to exercise may contribute to the low rates of exercise prescription, referral, and perceived adherence to exercise in people with depression. Therefore, when prescribing exercise to people with depression, identification of individual barriers to exercise and determining strategies to overcome these may be significantly more effective than a generic approach to exercise prescription.
for the treatment of depression are consistent with recent recommendations (Stanton & Reaburn, 2013). However, providing education and support materials for GPs which are easily accessible may improve the perceived confidence and competence of GPs to prescribe exercise for people with depression. Accessing Internet-based resources such as Exercise is Medicine® Australia (http://www.exerciseismedicine.org.au) will be of benefit in this regard. Exercise programs consistent with those for the general population are likely to be beneficial for people with depression. Alternatively, GPs may consider increased use of incentive-based referral programs such as the Medicare Enhanced Primary Care Referral Scheme for referral to AEPs, as this group of health professionals is university trained and industry accredited to develop and deliver exercise interventions for people with mental illness including those with depression. The exercise habits of health professionals are an independent predictor of exercise counseling behavior. Therefore, GPs who are currently inactive should seek to increase their own exercise levels to establish themselves as role models and improve their confidence in exercise prescription. This is especially important for people with depression who are more likely to suffer comorbid physical illness. Taken together, the use of supplementary resources and referral schemes by GPs, and increasing one’s own exercise are likely to increase the use of exercise as medicine in the treatment of people with depression.
GPs’ Individual Exercise Behaviors
Limitations of This Study
The exercise habits of Australian GPs and the relationship with exercise-prescribing behaviors have not been previously investigated. We found no relationship between GPs’ exercise habits and referrals to exercise professionals or awareness of the inclusion of exercise recommendations in depression management guidelines. In contrast, a recent systematic review of intervention and observational studies of physicians’ physical activity counseling habits including exercise prescription (de Quevedo & Lobelo, 2013) showed the healthcare professionals’ exercise habits to be an independent predictor of exercise counseling behavior and that interventions designed to increase a physician’s physical activity have the potential to improve exercise prescription for patients. The lack of a significant relationship in the present study may be a result of the small sample, GP workload, GPs’ own perceived health, or from environmental factors such as climate. More work on this topic specific to Australia is needed.
We acknowledge the small sample is a limitation of the present study and our sample may not be representative of the view of GPs in the region. Larger studies are needed to investigate this further. We also acknowledge we did not investigate the frequency of exercise prescription by GPs and this limits the capacity to examine the relationships between GPs’ knowledge, attitudes, and exercise-prescribing behaviors. We do, however, provide novel data on the knowledge, attitudes, and beliefs of GPs regarding the prescription of exercise for people with depression which has not previously been investigated and is critical to improving the physical health outcomes for this population.
Practice Implications
References
GPs in regional Queensland, Australia, are positive regarding the prescription of exercise for people with depression. In general, the type and intensity of exercise prescribed by GPs
Aitken, C., Power, R., & Dwyer, R. (2008). A very low response rate in an on-line survey of medical practitioners. Australian and New Zealand Journal of Public Health, 32, 288–289.
Barriers to Exercise
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Acknowledgments There are no persons other than the authors who contributed to this study.
Perspectives in Psychiatric Care 51 (2015) 253–259 © 2014 Wiley Periodicals, Inc.
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Glover, C. M., Ferron, J. C., & Whitley, R. (2013). Barriers to exercise among people with severe mental illnesses. Psychiatric Rehabilitation Journal, 36, 45–47. doi:10.1037/h0094747 Lawlor, D. A., Keen, S., & Neal, R. D. (1999). Increasing population levels of physical activity through primary care: GPs’ knowledge, attitudes and self-reported practice. Family Practice, 16, 250–254. Lepine, J. P., & Briley, M. (2011). The increasing burden of depression. Neuropsychiatric Disease and Treatment, 7, 3–7. doi:10.2147/ndt.s19617 McGarry, H., Hegarty, K., & Gunn, J. (2005). How do Victorian GPs manage patients with depression? Australian Family Physician, 34, 603–606. National Institute for Health and Clinical Excellence. (2009). Depression: The treatment and management of depression in adults (update). NICE clinical guideline 90. London: Author. Pavey, T. G., Taylor, A. H., Fox, K. R., Hillsdon, M., Anokye, N., Campbell, J. L., . . . Taylor, R. S. (2011). Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: Systematic review and meta-analysis. BMJ (Clinical Research Ed.), 343. doi:10.1136/bmj.d6462 Rethorst, C. D., Wipfli, B. M., & Landers, D. M. (2009). The antidepressive effects of exercise: A meta-analysis of randomized trials. Sports Medicine, 39, 491–511. doi:10.2165/00007256-200939060-00004 Robertson, R., Jepson, R., Shepherd, A., & McInnes, R. (2011). Recommendations by Queensland GPs to be more physically active: Which patients were recommended which activities and what action they took. Australian and New Zealand Journal of Public Health, 35, 537–542. doi:10.1111/j.1753-6405.2011.00779.x Searle, A., Calnan, M., Turner, K. M., Lawlor, D. A., Campbell, J., Chalder, M., & Lewis, G. (2012). General practitioners’ beliefs about physical activity for managing depression in primary care. Mental Health and Physical Activity, 5, 13–19. doi:10.1016/j.mhpa.2011.11.001 Stanton, R., & Reaburn, P. (2013). Exercise and the treatment of depression: A review of the exercise program variables. Journal of Science and Medicine in Sport, 17, 117–182. doi:10.1016/j.jsams.2013.03.010 Stephenson, C. P., Karanges, E., & McGregor, I. S. (2013). Trends in the utilisation of psychotropic medications in Australia from 2000 to 2011. Australian and New Zealand Journal of Psychiatry, 47, 74–87. doi:10.1177/0004867412466595 Trivedi, M. H., Greer, T. L., Grannemann, B. D., Chambliss, H. O., & Jordan, A. N. (2006). Exercise as an augmentation strategy for treatment of major depression. Journal of Psychiatric Practice, 12, 205–213.
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A Pilot Study of the Views of General Practitioners Regarding Exercise for the Treatment of Depression Robert Stanton, BHMSc (Hons), Chris Franck, BMil, BCom (Hons), MCom (I/O Psychology), Peter Reaburn, PhD, and Brenda Happell, PhD Robert Stanton, BHMSc (Hons), is a Research Officer, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia; Chris Franck, BMil, BCom (Hons), MCom (I/O Psychology), is Clinical Director, Central Queensland Medicare Local, Rockhampton, Queensland, Australia; Peter Reaburn, PhD, is an Associate Professor of Exercise and Sports Science, Institute for Health and Social Science Research, School of Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia; and Brenda Happell, PhD, is a Professor of Mental Health Nursing, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation, School of Nursing and Midwifery, Central Queensland University, Rockhampton, Queensland, Australia.
Search terms: Depression/mood disorder, mental health, physical activity/exercise Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement The authors have no potential, perceived, or real conflict of interests to declare. Funding Central Queensland Medical Local provided in-kind support for this project.
PURPOSE: To investigate the views of general practitioners (GPs) regarding exercise and the treatment of depression. DESIGN AND METHODS: Twenty GPs completed a 25-item survey investigating their knowledge, beliefs, perceived benefits and barriers, and recommendations to patients regarding exercise for the treatment of depression. The exercise habits of the GPs were also recorded. FINDINGS: GPs are positive toward exercise in the treatment of depression despite low levels of confidence in prescribing exercise or limited measurable benefits. Exercise patterns of GPs were not associated with GP exercise prescription habits. PRACTICE IMPLICATIONS: Education, use of support materials and referral schemes, and increasing exercise behavior among GPs may increase the use of exercise as treatment for people with depression.
First Received May 13, 2014; Final Revision received August 4, 2014; Accepted for publication September 5, 2014. doi: 10.1111/ppc.12088
Depression is a debilitating condition impacting upon millions of people worldwide (Lepine & Briley, 2011) and ranks as the most common mental illness presentation to Australian general practitioners (GPs) (Australian Institute of Health and Welfare, 2010). Guidelines for the management of depression include antidepressant therapy, psychological interventions, and lifestyle advice (Ellis, 2004). However, a survey of 151 GPs in Victoria, Australia, reported that more than 80% prescribed medication and almost 90% provided counseling to patients with mild to moderate depression (McGarry, Hegarty, & Gunn, 2005). This trend is consistent with crosssectional analysis of Pharmaceutical Benefits Scheme data showing a 95% increase in antidepressant medication prescriptions between 2001 and 2011 (Stephenson, Karanges, & McGregor, 2013). Recent systematic reviews and meta-analyses have demonstrated the beneficial effects of exercise for people with depression (Cooney et al., 2013; Daley, 2008; Danielsson, Noras, Perspectives in Psychiatric Care 51 (2015) 253–259 © 2014 Wiley Periodicals, Inc.
Waern, & Carlsson, 2013; Rethorst, Wipfli, & Landers, 2009). Unfortunately, the number of high-quality trials is small and the quality and consistency of reporting intervention details is poor. As a result of these inconsistencies, it may be difficult for GPs to find consensus as to how best design an appropriate exercise program for people with depression. To improve the ease of exercise program design, a recent systematic review concluded that a program comparable with that recommended for an apparently healthy population is likely to be effective for people with depression (Stanton & Reaburn, 2013). A recent study of UK-based GPs regarding physical activity and depression (Searle et al., 2012) reported that GPs believed exercise to be an effective adjunct, rather than a firstline therapy such as antidepressant medications or counseling. This is inconsistent with the National Institute for Clinical Excellence (NICE) guidelines for the treatment of depression, which suggest that people with persistent sub253
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threshold or mild to moderate depression may be considered for a low-intensity psychosocial intervention (NICE, 2009). Moreover, while the NICE guidelines provide specific direction on the supervision, delivery, and frequency of exercise, parameters such as intensity and mode of exercise are absent. Thus, the capacity for GPs to prescribe exercise on the basis of the NICE guidelines alone is limited. The exercise-prescribing habits of Australian GPs remain to be fully evaluated. McGarry et al. (2005) reported that from a sample of 151 GPs, 73% surveyed recommended exercise to at least half of their patients with mild to moderate depression. It is unclear if the rates of prescribing exercise are a consequence of the GPs’ lack of knowledge in the area or a lack of confidence in exercise as either a first-line or adjunct therapy. In a population survey undertaken in Queensland, Australia, less than one-quarter of respondents reported receiving exercise prescription during routine GP appointments (Eakin, Brown, Schofield, Mummery, & Reeves, 2007) and a recent study (Robertson, Jepson, Shepherd, & McInnes, 2011) reported that mental illness represented only 7% of all conditions for which physical activity advice was offered by GPs. Unlike the UK, Australian guidelines for the treatment of depression lack detail regarding the prescription of exercise. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) guidelines for the treatment of depression suggest that “adequate exercise” may be of benefit, but no further information is given about what may constitute “adequate” (Ellis, 2004). This may be a result of the lack of substantial support for exercise at the time of publication of these guidelines. When coupled with the barriers to exercise presented by patients, such as physical health comorbidities, medication side effects, and symptoms related to their condition, it is little wonder there are inconsistencies in the recommendation of exercise for people with depression. At present, there are relatively little data pertaining to the exercise prescription practices of Australian GPs for people with depression. No studies have sought to identify the sources of guidance regarding exercise for depression used by GPs, the type, frequency or intensity of exercise prescribed, the benefits reported by patients, or the use of referrals to exercise professionals. Unlike international studies, the relationship between personal exercise practices and the exercise prescription patterns of Australian GPs has not been investigated. Given the potential benefits of exercise for people with depression and the frequency of presentation to GPs, it is prudent to understand the views of GPs regarding the prescription of exercise for people with depression. These data are important in ensuring people with depression are provided with current evidence-based information regarding the role of exercise in their treatment. Therefore, the purpose of this pilot study is to examine the views and practices of regionally based Australian GPs regarding exercise in the treatment of depression. 254
Methods We conducted an anonymous survey of GPs in Central Queensland, Australia, assisted by the Central Queensland Medicare Local (CQML). GPs in the region were invited to complete a survey via direct email from the CQML Chief Executive Officer and via a regular electronic newsletter. The newsletter contained the link to the online survey. To increase our response rate, identical paper-based surveys were delivered to GP clinics with instructions not to complete both the online and paper-based versions of the survey. Survey Design A survey was developed specifically for the purpose of this study with guidance from the Central Queensland University’s Population Research Laboratory and CQML. Items were chosen to answer the research question, yet not generate significant burden for time-poor GPs. The final survey comprised 25 items including Likert-type response, multiple choice, and open-ended response questions. We identified general demographics (gender, age, and working status) knowledge regarding the inclusion of exercise in clinical practice guidelines (four items) and beliefs (five items) regarding exercise for the treatment of depression, recommendation regarding exercise type and exercise intensity, the presence of patient-reported and objectively measured outcomes (10 items), and the GPs’ individual exercise behaviors (three items). The survey took approximately 6 min to complete. Statistical Analysis Frequency responses (N and % of respondents) are reported. The relationship between GPs’ individual exercise behaviors and knowledge, attitudes, and exercise recommendation for patients with depression was identified using the phi statistic. All analyses were performed using the Statistical Package for the Social Sciences (SPSS) Version 19 (SPSS Inc., Chicago, IL, USA). Results Survey Response The survey was available to 220 GPs at the time of data collection. Completed surveys were received from 20 GPs, resulting in a return rate of 9%. Demographics Male GPs comprised 55% (n = 11) of respondents. The mean age of all respondents was 46.4 ± 8.9 years (range 31–67 years). Two respondents reported working in locum positions at the time of the survey. Perspectives in Psychiatric Care 51 (2015) 253–259 © 2014 Wiley Periodicals, Inc.
A Pilot Study of the Views of General Practitioners Regarding Exercise for the Treatment of Depression
Knowledge and Beliefs Regarding Exercise for the Treatment of Depression Sixty percent of GPs (n = 12) reported being aware of the existence of current clinical practice guidelines for the treatment of depression, with a further 30% (n = 6) being unsure of the current guidelines. Fifty-five percent (n = 9) of respondents who reported being aware of the clinical guidelines for depression management reported the source of the guidelines being the RANZCP, with 25% (n = 5) of respondents citing the Royal Australian College of General Practitioners (RACGP) as the source. Two respondents cited both the RANZCP and the RACGP and one respondent cited another unidentified source.Of those who reported being aware of the current clinical guidelines for the management of depression, 67% (n = 8) reported the inclusion of exercise in the clinical guidelines, with the remaining 33% (n = 4) being unsure. GPs were asked to respond to a series of Likert scale questions regarding exercise and the treatment of depression. Ninety percent of respondents (n = 18) “Strongly agree” or “Agree” that exercise is a worthwhile inclusion in treatment, with a further 10% (n = 2) providing a neutral response (“Neither agree nor disagree”). However, 75% (n = 15) “Strongly agree” or “Agree” that patients with depression are less likely to adhere to an exercise intervention, with 15% (n = 3) providing a neutral response (“Neither agree nor disagree”) and 10% (n = 2) responding with “Disagree.” Forty-five percent of respondents (n = 9) “Strongly agree” or “Agree” they are confident in prescribing exercise to patients with depression, with a further 45% (n = 9) providing a neutral response (“Neither agree nor disagree”). Similarly, 45% of respondents (n = 9) “Strongly agree” or “Agree” they are competent to prescribe exercise to patients with depression, with a further 45% (n = 9) providing a neutral response (“Neither agree nor disagree”). GPs were asked to respond to a series of Likert scale questions regarding the potential benefits of exercise for people with depression. Responses are shown in Table 1. No GP recorded a response of “Disagree” or “Strongly disagree” to any statement.
Exercise Recommendations by GPs All GPs recommended the use of cardiovascular exercise such as walking or cycling for patients with depression. A slightly smaller proportion (70%, n = 14) recommended the use of relaxation exercises including yoga or tai chi. Group exercises such as aerobic classes or dancing were recommended by 50% (n = 10), with 35% (n = 7) recommending resistance exercise. Recommendations regarding the appropriate exercise intensity were examined using the single item: “At what intensity do you recommend your patients with depression to exercise at?” Response options were “Self-selected,” “Low intensity,” “Moderate intensity,” “High intensity,” “I do not prescribe an exercise intensity,” or “Other.” Responses for exercise intensity are shown in Figure 1. Thirty percent (n = 6) of GPs reported positive benefits to patients as determined by improved Kessler K10 score or other measure for patients arising from their recommendation to undertake exercise. The majority of GPs (65%, n = 13) reported being unsure of any benefit. In contrast, 85% (n = 17) of GPs indicated that patients reported some benefit as a result of commencing exercise based on their recommendation, with the remaining 15% of GPs being unsure of any benefit. Referral to an Exercise Specialist Seventy percent (n = 14) of GPs reported referring their patients with depression to an exercise specialist, including accredited exercise physiologists (AEPs) (65%, n = 13), personal trainers (25%, n = 5), strength and conditioning coaches (10%, n = 2), or gymnasium instructors (30%, n = 6). A number of GPs cited multiple referral pathways to exercise specialists. The Medicare-subsidized Enhanced Primary Care referral was the most commonly reported pathway (65%, n = 13). Referrals under Department of Veterans Affairs arrangements were reported by 35% (n = 7) of GPs, with the use of a referral letter reported by 15% (n = 3) of GPs. For patients referred to an exercise professional, 36% (n = 5) of GPs reported positive benefit for patients as determined
Table 1. Beliefs of GPs Regarding the Potential Benefits of Exercise in the Treatment of Depression
Response Potential benefit
Strongly agree
Agree
Neither agree nor disagree
Reduced medication needs Improved fitness Reduction in depressive symptoms Distraction from ruminating thoughts Improved cardiovascular risk profile
15% (3) 35% (7) 20% (4) 25% (5) 45% (9)
55% (11) 60% (12) 65% (12) 70% (14) 25% (9)
30% (6) 5% (1) 5% (1) 5% (1) 30% (6)
Numbers in parentheses are the number of respondents. No respondent recorded a response of “Disagree” or “Strongly disagree” to any statement. GP, general practitioner.
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60
Proporon of respondents
50
40
30
20
10
0 Self-selected
Low
Moderate
High
Don't provide a recommendaon
Other
Figure 1. GP Recommendations for Exercise Intensity (Sum of Responses Is Greater Than 100% as Some GPs Indicated Multiple Responses)
by improved Kessler K10 score or other measure. The vast majority of GPs (64%, n = 9) reported being unsure of any benefit for patients as a result referring to an exercise specialist. In contrast, 79% of GPs indicated that patients report some benefit as a result of commencing exercise based on the exercise specialists’ recommendations, with the remaining 21% of GPs reporting their patients are unsure of any benefit.
significant relationship between GPs meeting the recommended level of weekly exercise and referral to an exercise specialist (ɸ = 0.21, p = .36) or awareness of the inclusion of exercise in the clinical management guidelines for depression (ɸ = 0.18, p = .72).
Barriers to Exercise
Survey Response
To examine the beliefs of GPs regarding possible barriers to the commencement of exercise reported by patients with depression, we presented a list of barriers previously identified by the literature. Multiple responses were allowed and the responses are shown in Table 2.
Although low, the response rate to our survey is comparable to that of other healthcare professionals. Aitken, Power, and Dwyer (2008) reported response rates of between 7.5% and 13.2% to online surveys of Australian medical practitioners. Low response rates to such surveys may be attributable to increased workloads, competing priorities, or disinterest. The failure of our survey to offer an incentive for respondents may also have contributed to the low return rate.
GPs’ Individual Exercise Behaviors Thirteen GPs self-reported meeting the minimum physical activity guidelines of 150 min/week. The self-reported exercise habits of respondents are shown in Table 3. We found no
Discussion
Demographics Our sample is of similar age to that reported by McGarry et al. (2005) and Alexander and Fraser (2008); however, our cohort
Table 2. GPs’ Beliefs Regarding Barriers to Exercise Reported by Patients Barrier
% age of respondents (n)
Lack of time Injury Comorbidities Lack of confidence Lack of resources Low motivation
35 (7) 25 (5) 45 (9) 45 (9) 20 (4) 90 (18)
Numbers in parentheses are the number of respondents. Percentages sum to more than 100% as some respondents indicated multiple responses. GP, general practitioner.
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Table 3. Personal Exercise Habits of GPs Exercise mode
% age of respondents (n)
Cardiovascular exercise (e.g., walking, cycling) Resistance training (e.g., weight training) Relaxation exercise (e.g., yoga, tai chi) Group exercise (aerobic classes, dancing)
85 (17) 20 (4) 15 (3) 15 (3)
Numbers in parentheses are the number of respondents. Percentages sum to more than 100% as some respondents indicated multiple modes of exercise. GP, general practitioner.
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contains a smaller proportion of male GPs than the study of McGarry et al. The number of GPs working as locums at the time of data collection is not reported in other studies. Knowledge and Beliefs Regarding Exercise for the Treatment of Depression The knowledge and beliefs of GPs regarding the prescription of exercise for the treatment of depression have not been well investigated. In an early study, Lawlor, Keen, and Neal (1999) reported that GPs acknowledge the benefits of physical activity for chronic health conditions including depression; however, they fail to provide the advice in a manner likely to affect population health. In the present study, 67% of respondents reported being aware of the inclusion of exercise in clinical guidelines for the treatment of depression. However, the detail contained in the RANZCP guidelines is insufficient to develop an effect exercise prescription. At present, only the Exercise is Medicine® Fact Sheet on exercise and depression (http://exerciseismedicine.org.au/public/factsheets) offers sufficient detail for evidence-based exercise prescription for people with depression. In the most recent and comprehensive investigation of the views of GPs regarding exercise for patients with depression (Searle et al., 2012), GPs tended to rely on anecdotal rather than scientific evidence for decision-making. Whether this view is representative of all UK-based GPs is questionable given the small sample (n = 5). Nonetheless, it may represent a knowledge gap for GPs regarding an effective, low-cost and non-pharmaceutical treatment option for people with depression. In line with the findings of Searle et al. (2012), our findings indicate that GPs are in strong agreement regarding the benefits of exercise for the treatment of depression. However, a potential limitation of the present survey is the apparent ceiling effect associated with the use of a 5-point Likert scale where no responses appeared in the “Disagree” or “Strongly disagree” categories. While less of a concern for this crosssectional study, future studies that investigate the change in beliefs over time may consider the use of alternate scales such as a 10-point visual analog scale to improve sensitivity. Less than half of the respondents in our survey agree they are either confident or competent to prescribe exercise for people with depression. This appears consistent with the observation that those GPs have a relatively poor awareness of the existence and source of clinical guidelines for the treatment of depression. Moreover, of those who were aware of appropriate guidelines, only two-thirds were aware of the inclusion of exercise in the guidelines. Exercise Recommendations by GPs Exercise was not considered in the study of Alexander and Fraser (2008) as a treatment option for patients with mental Perspectives in Psychiatric Care 51 (2015) 253–259 © 2014 Wiley Periodicals, Inc.
health disorders including depression. This is surprising since the efficacy and acceptance of exercise as a treatment for depression was well demonstrated by that time (Trivedi, Greer, Grannemann, Chambliss, & Jordan, 2006). Therefore, we cannot compare our findings to this earlier study even though some GPs may have prescribed exercise for patients with depression and the role of the AEP was well established. Similar to the present study, Searle et al. (2012) did not determine the frequency of exercise prescription nor the recommended intensity at which exercise should be performed. The findings of the present study suggest that a self-selected exercise intensity is most commonly recommended by GPs for people with depression. This is import since self-selected exercise intensity leads to improved autonomy, results in increased affective responses, and improved postexercise behavioral outcomes, compared to prescribed intensity (Ekkekakis, 2009; Ekkekakis, Parfitt, & Petruzzello, 2011). We also report, however, that GPs encourage cardiovascular exercise, which is consistent with a number of current recommendations (NICE, 2009; Stanton & Reaburn, 2013). In support of Searle et al.’s (2012) notion that GPs may recommend exercise based on anecdotal rather than scientific evidence, 85% of GPs cite patient-reported benefits following the commencement of exercise despite only 36% of GPs reporting any psychometric evidence. The low level of self-reported confidence and competence expressed by GPs regarding the prescription of exercise for people with depression may lead to the low reporting of exercise prescription by GPs in general. Early studies (Eakin et al., 2007) show that almost one-quarter of patients received recommendations regarding exercise from their GPs. More recent data report that approximately 18% of patients receive recommendations regarding exercise from their GPs, mainly for weight management (Robertson et al., 2011). Most recently, data from the “Bettering the Evaluation and Care of Health” initiative suggest that Australian GPs provide recommendations regarding exercise at a rate of 1.3/100 encounters; a rate that has shown a significant decline in the past decade (Britt et al., 2012). Given the demonstrated efficacy of exercise in the treatment of a number of chronic health conditions including depression, and the availability of patient and clinician support materials via the “Exercise is Medicine” program, more clearly needs to be done to encourage the uptake of this valuable treatment option. Referral to an Exercise Specialist Referrals to AEPs ranked as the seventh most common GP referral under Australia’s Medicare-supported program in 2001–2012 (Britt et al., 2012). While both AEPs and GPs are of similar views regarding the value of exercise in the treatment of people with depression, their views regarding the lack of adherence to exercise in people with depression are also 257
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similar. However, evidence shows that adherence to exercise in people with depression is similar to the general population (Arikawa, O’Dougherty, Kaufman, Schmitz, & Kurzer, 2012; Friedenreich et al., 2011) and therefore should not deter clinicians from prescribing exercise to this population. Moreover, a recent systematic review and meta-analysis (Pavey et al., 2011) supports the efficacy of exercise referral schemes in primary care in both increasing physical activity and reducing depression.
The most common barriers to exercise for people with depression reported by GPs were low motivation (90%), comorbidities (45%), and lack of confidence (45%). Of these, only comorbidities are consistent with the current literature. Glover, Ferron, and Whitley (2013) identified medication side effects and condition-related symptoms in addition to comorbidities as self-identified barriers to exercise by people with depression. This disparity between self-identified and perceived barriers to exercise may contribute to the low rates of exercise prescription, referral, and perceived adherence to exercise in people with depression. Therefore, when prescribing exercise to people with depression, identification of individual barriers to exercise and determining strategies to overcome these may be significantly more effective than a generic approach to exercise prescription.
for the treatment of depression are consistent with recent recommendations (Stanton & Reaburn, 2013). However, providing education and support materials for GPs which are easily accessible may improve the perceived confidence and competence of GPs to prescribe exercise for people with depression. Accessing Internet-based resources such as Exercise is Medicine® Australia (http://www.exerciseismedicine.org.au) will be of benefit in this regard. Exercise programs consistent with those for the general population are likely to be beneficial for people with depression. Alternatively, GPs may consider increased use of incentive-based referral programs such as the Medicare Enhanced Primary Care Referral Scheme for referral to AEPs, as this group of health professionals is university trained and industry accredited to develop and deliver exercise interventions for people with mental illness including those with depression. The exercise habits of health professionals are an independent predictor of exercise counseling behavior. Therefore, GPs who are currently inactive should seek to increase their own exercise levels to establish themselves as role models and improve their confidence in exercise prescription. This is especially important for people with depression who are more likely to suffer comorbid physical illness. Taken together, the use of supplementary resources and referral schemes by GPs, and increasing one’s own exercise are likely to increase the use of exercise as medicine in the treatment of people with depression.
GPs’ Individual Exercise Behaviors
Limitations of This Study
The exercise habits of Australian GPs and the relationship with exercise-prescribing behaviors have not been previously investigated. We found no relationship between GPs’ exercise habits and referrals to exercise professionals or awareness of the inclusion of exercise recommendations in depression management guidelines. In contrast, a recent systematic review of intervention and observational studies of physicians’ physical activity counseling habits including exercise prescription (de Quevedo & Lobelo, 2013) showed the healthcare professionals’ exercise habits to be an independent predictor of exercise counseling behavior and that interventions designed to increase a physician’s physical activity have the potential to improve exercise prescription for patients. The lack of a significant relationship in the present study may be a result of the small sample, GP workload, GPs’ own perceived health, or from environmental factors such as climate. More work on this topic specific to Australia is needed.
We acknowledge the small sample is a limitation of the present study and our sample may not be representative of the view of GPs in the region. Larger studies are needed to investigate this further. We also acknowledge we did not investigate the frequency of exercise prescription by GPs and this limits the capacity to examine the relationships between GPs’ knowledge, attitudes, and exercise-prescribing behaviors. We do, however, provide novel data on the knowledge, attitudes, and beliefs of GPs regarding the prescription of exercise for people with depression which has not previously been investigated and is critical to improving the physical health outcomes for this population.
Practice Implications
References
GPs in regional Queensland, Australia, are positive regarding the prescription of exercise for people with depression. In general, the type and intensity of exercise prescribed by GPs
Aitken, C., Power, R., & Dwyer, R. (2008). A very low response rate in an on-line survey of medical practitioners. Australian and New Zealand Journal of Public Health, 32, 288–289.
Barriers to Exercise
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Acknowledgments There are no persons other than the authors who contributed to this study.
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