By Christian Evans, M.A., M.Div.
Oct. 21, 2019

Photo by Jeremy Henderson

One of the benefits of being a (retired) competitive powerlifter is that people come to you for advice about lifting weights. They see you work out in the gym, and probably say to themselves, "That's someone who knows what he is doing. I'll ask him for help." I've had people ask me simple questions like "How do I improve my squat?" to more complex requests like "Would you mind putting together a training plan for me?" I don't mind assisting people in reaching their goals as I know what my limitations are. I can help develop a plan with exercises, sets, and repetitions, but I shouldn't assist with proper movements or form. Those features are best left to a professional trainer.

How is this experience relevant to the Clinician's Corner audience? Two years ago, I wrote a blog about the benefits of exercise and mental health. I reviewed scientific research which shows physical exercise can help to reduce symptoms of depression and I ended with this suggestion:

If you think your patient would benefit from a more active intervention, another suggestion is to create a SMART goal plan centered on exercise. A SMART goal is Specific, Measurable, Achievable, Relevant, and Time-bound. For example, you could create a daily walking plan for a patient who wants to become more active. The plan could be to walk on a treadmill or outside for 45 minutes, three times a week for three months. This is specific (walking), measurable (45 minutes three times a week), achievable (walking outside or inside maximizes opportunities to complete the weekly goal), relevant (patient wants a simple way to become more active), and time-bound (patient commits to three months initially).

Perhaps a patient would like to enter a powerlifting competition, train for a bike race, begin an exercise program or simply pass their next PT test. You could help the patient create a SMART plan and help him or her to monitor, achieve and re-evaluate goals. The plan could include consulting a coach or a trainer if physical training is outside your field of expertise.

However, there is now research showing that, for some mental health providers, there are barriers to prescribing exercise as a treatment for mental health. Researchers in Australia discovered several barriers including patient's severe mental health problems, patient is unwilling, provider lacks time, damage to the therapeutic relationship, and provider does not consider exercise a legitimate treatment. However, researchers also found facilitators for mental health providers to prescribe exercise to their patients. These facilitators included believing that patients would find a prescription of exercise acceptable, patients reporting positive benefits, and the experience/advice/support of other practitioners.

In both studies, the most common barrier to prescribing exercise was a lack of training and knowledge in exercise prescription. Providers didn't know how much exercise to prescribe, were unsure of the benefits of exercise for mental health, and lacked exercise specific training.

Fortunately, the knowledge barrier is relatively easy to overcome. Rather than thinking of prescribing "exercise," think of prescribing "physical activity." Whereas exercise is planned, structured, repetitive, and purposeful, physical activity is any bodily movement produced by skeletal muscles that results in energy expenditure. In other words, think of exercise as a subcategory of physical activity. With this definition in mind, simply recommending and encouraging patients to be more physically active is a good start. The VA/DOD clinical practice guideline for managing depression recommends offering patient education on the benefits of exercise as an adjunct to first-line evidence-based treatments or when patients are unwilling or unable to engage in first-line treatments. The guideline suggests for patients with mild depression who aren't currently undergoing treatment, exercise is an excellent self-management and preventative strategy. Studies have found the type of exercise (e.g., aerobic, strength training) doesn't influence efficacy yet total energy expended positively correlates with symptom improvement.

Providers can read a full summary of the scientific evidence and clinical guidance for exercise for depression in our evidence brief and can find health and fitness resources for their patients from the Human Performance Resources by CHAMP (Consortium for Health and Military Performance).

Mental health providers who are physically active themselves may use their own knowledge and experience to prescribe exercise. Researchers have found providers who exercised regularly themselves were more likely to prescribe daily exercise than providers who did not exercise as regularly. Perhaps this personal experience with the benefits of exercise gives those providers confidence in prescribing exercise. This personal experience is certainly why I felt confident enough to help people asking me for exercise advice.

So if you're a provider who's reluctant to prescribe exercise because you lack training or knowledge, I suggest expanding your definition of exercise to physical activity. And if you're not already physically active yourself, I encourage you to start moving. Exercise has great potential to improve provider mental health, as well.

Mr. Evans is a public health analyst at the Psychological Health Center of Excellence. He has a master's degree in economics and a master of divinity.

The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.