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Microsoft word - exercise prescription

EXERCISE PRESCRIPTIONS
Treating Depression with Physical Activity
David is the former director of national projects at Participaction. In 2003, David experienced his first major depression. He suffered a relapse in 2004. One-week into his relapse, David had a severe, and tragic, psychotic episode. Just over a decade ago, Harvard University conducted a study, in partnership with the World Health Organization and the World Bank, that identified major depression as the leading cause of disability (lost years of healthy living) among 15- to 44-year-olds in developed countries. The top 10 illnesses/conditions were: 1. Major depression 2. Alcohol use 3. Road traffic accidents 4. Schizophrenia 5. Self-inflicted injuries 6. Bi-polar disorder 7. Drug use 8. Obsessive-compulsive disorder 9. Osteoarthritis 10. Violence Major depression was also identified as the most debilitating illness/condition by Christopher Murray and Alan Lopez in The Global Burden of Disease (1996). The top 10 were: 1. Major depression 2. Tuberculosis 3. Road traffic accidents 4. Alcohol use 5. Self-inflicted injuries 6. Bi-polar disorder 7. War 8. Violence 9. Schizophrenia 10. Iron-deficiency anaemia Major depression is a widespread disease. One in 10 people will experience a major depression in their lifetime (DePaulo Jr. and Horvitz, 2002). The Global Business and Economic Roundtable on Mental Health estimates that depression and anxiety costs the Canadian economy $33 billion a year (Sharratt, 2006). Seventy-two percent of the people who suffer from depression are in the workforce (DePaulo Jr. and Horvitz, 2002). Depression is emerging as one of the most common disabilities in the workplace (Quan, 2006). According to a study conducted by Desjardins Financial Security, the major stress triggers for adult depression are personal debt, cellphones and wireless devices (continually being accessed before and after work hours), not enough personal and family time, and long work hours. Yet, 60% of employees maintain regular works hours when they are depressed (Beauchesne, 2006). Although most of the people who suffer from depression are in the workforce, there is evidence to suggest that the numbers are growing among children and youth. According to Mary Anne Chambers, the Ontario Minister of Children and Youth Services, 1 in 5 children in the province have a mental health problem. And 11 percent of the students in grades 7 to 12 have "seriously" considered suicide (Urquart, 2006). There is also evidence to suggest that, as the population ages, more adults will experience depression. In some cases, depression will be an isolated disease among older adults. In other cases, it will be associated with aging-related illnesses such as stroke (Lai et al, 2006), Alzheimer's disease (Regan et al, 2005), heart disease and cancer (Hellenberg et al, 2003). Unfortunately, less than one-third of the people who suffer from depression seek help (Cotroneo, 2006). And when they do, most people equate treatment with antidepressant drugs (Breggin, 2000). Between 1992 and 2003, the number of prescriptions for antidepressants in England tripled from 9.9 million to 27.7 million. Over the same period, the cost of antidepressant prescriptions increased from 18.1 million pounds to 395.2 million pounds. This increase coincided with the introduction of a new class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs), which include Prozac, Paxil and Zoloft (Halliwell, 2006). Although antidepressants are effective at treating depression, there can be some severe physical and mental side effects. For example, studies suggest that some antidepressants may, in rare cases, cause violent episodes of psychosis. For example, Donald Schnell, 60, had been taking Paxil for just 48 hours before he shot and killed his wife, his daughter, his granddaughter and himself on February 13, 1998 (Thompson, 2001). Kip Kinkel killed his parents and opened fire at his Springfield, Oregon high school on May 21, 1998. He was, apparently, taking Prozac a few days before the massacre (Breggin, 2000). Eric Harris, one of the shooters at the massacre at Columbine High School in Littleton, Colorado on April 29, 1999, was taking Luvox at the time of the mass murders (Rappoport, 1999). And Andrea Yates, who drowned her 5 children in a bathtub in Texas, was on twice the recommended maximum limit of Effexor for postpartum depression until a few days before she committed the mass murders (O'Meara, 2001). There are several treatments for depression including antidepressants, bright light therapy, electro convulsive therapy, natural nutritional supplements and, rarely used, vagal nerve stimulation and brain surgery. One of the most common, and effective, treatments is talk therapy (e.g. psychotherapy, cognitive behavioural therapy). There are, however, some potential barriers to talk therapy. Talk therapy sessions can be expensive. And therapy sessions often require a significant, and sometimes ongoing, time commitment (DePaulo Jr. and Horvitz, 2002). One of the least understood treatments for depression is physical activity. Many of the books on depression make little, if any, reference to the benefits of physical activity. Some books simply refer to physical activity as a diversion for depression sufferers. Yet, there is growing evidence to suggest that exercise can be used as an alternative treatment to antidepressants and talk therapy (Kirby, 2005). A study at Eastern Kentucky University demonstrated that physical activity markedly reduces depressive symptoms among older adults (Palmer, 2005). Following a review of 14 studies on exercise and depression, researchers from the department of social medicine at the University of Bristol concluded that the effect of exercise on depression, particularly mild and moderate depression, is similar to that of cognitive therapy (Lawlor and Hopker, 2001). Another study demonstrated that light, moderate and vigorous intensity resistance training and aerobic training can reduce depressive symptoms (Dunn et al, 2001). There is evidence that exercise increases the production of endorphins among individuals, which reduces pain and induces euphoria. This is particularly true for less physically fit individuals. However, there is also evidence to suggest that physical activity does not produce enough endorphins to reduce depressive symptoms (Artal and Sherman, 1998). Research does, however, demonstrate that exercise increases the availability of serotonin - an important brain chemical (neurotransmitter) that contributes to a range of functions including sleep cycles, wake cycles, libido, appetite and mood - at receptor sites in the brain. Physical activity, and the subsequent increase in physical fitness, alters serotonin levels in the brain and leads to improved mood and feelings of well being. Research also indicates that exercise increases body temperature, which may ease depression by preventing the reuptake of serotonin (Lawlor and Hopker, 2001). Exercise also increases concentrated plasma prolactin which influences serotonin release in the brain (Kiive et al, 2004). Physical activity can also have an antidepressant effect by increasing the synthesis of new neurons in the hippocampus of the brain, which reduces depressive symptoms (Ernst et al, 2006). In addition, dopaminergic agents, which counteract the fatigue symptoms of depression caused by increased serotonin activity in certain areas of the brain, are enhanced by physical activity (Marin and Menza, 2005). There is also evidence to suggest that exercise has antidepressant and anxiolytic effects that protect individuals against the harmful consequences of stress (Salmon, 2001). Physical activity can reduce depressive symptoms among children (9- to 12-year-olds), youth (13- to 17-year-olds), adults (18- to 49-year-olds) and older adults (50 years and older): Children Twenty-eight girls and 26 boys (93% African American) between 9 and 12 years of age participated in a 12-week after-school exercise program. The study examined exercise self-efficacy, mood and depression. Significant correlations were found between increased exercise self-efficacy and decreased mood and depression (Annesi, 2004). In another study, Forty-nine 9- to 12-year-old boys and girls were enrolled in a 12-week after-school exercise program. The purpose of the study was to examine the relationships between depression, negative mood, physical activity and self-concept. There was a significant reduction in depression and elevation in mood for the children who participated in moderate-to-vigorous exercise when compared to children in a non-exercise control group. Those in the physical activity group also scored higher on self-concept scores (Annesi, 2005a). The University of Georgia examined the relationship between naturally occurring changes in physical activity and depressive symptoms across a 2-year period among 4,594 adolescent boys and girls. The study discovered that naturally occurring changes in physical activity were negatively related to changes in depressive symptoms, suggesting that an increase in physical activity reduces depression among adolescent boys and girls (Moti et al, 2004). Although studies on adolescents with depression have been limited, there is evidence to suggest that increased aerobic: exercise or strength training can reduce depressive symptoms (Paluska and Schwenk, 2000). A study that assessed the impact of a 12-week exercise program on depressive symptoms demonstrated that physical activity has a beneficial effect on depression among adults (Manger and Motta, 2005). Lane and Lovejoy (2001) reported that exercise does reduce depressive symptoms among adults, particularly those with more severe symptoms of depression. This is particularly true among sedentary adults (Sexton et al, 2001). In another study, adults with depressed mood were put into two groups. The first group (26 adults) participated in a moderate-intensity exercise program for 20 to 30 minutes, 3 times a week, for 10-weeks. The control group (2:4 adults) did not exercise. There was a significant reduction in depressive symptoms among those who exercised when compared to non-exercisers (Annesi, 2005b). In another study involving 12,250 mild to moderate depression sufferers, it was evident that associated medical expenses were significantly lower among depression sufferers who were physically active than inactive sufferers (Wang and Brown, 2004). Adults suffering from low to moderate depression with low physical activity levels are 6 times more likely to become severely depressed than individuals with normal activity levels (Iverson, 2004) Research from the University of Ulster-Jordanstown demonstrated that 3 ten-minute bouts of brisk walking accumulated throughout the day are as effective as 1 continuous bout of equal duration in improving aspects of mood among previously sedentary individuals (Murphy et al, 2002). Exercising in bright lights may also help further reduce depressive symptoms. Eighty working-age adults were divided into a group that exercised in bright light and a group that exercised in normal illumination. Both groups demonstrated a significant reduction in depressive symptoms. However, exercise was significantly more effective at alleviating more severe depressive symptoms when combined with bright-light exposure (Leppamaki et al, 2002). There is also evidence that sports participation can reduce the likelihood of experiencing depression. A study involving 664 former athletes and 500 control subjects demonstrated that sports participation significantly reduces the risk of depression (Backmand et al, 2003). Harvard Medical School investigated the association between women's athletic activity in the college and physician-diagnosed depression in post college years. The sample size was 3,940. The results indicated that women who participate in athletic activities in college or university are significantly less likely to suffer from depression and psychiatric distress after they graduate (Wyshak, 2001). Physical activity is also beneficial at reducing depressive symptoms among adults with physical health illnesses. A study involving 2,078 men and women demonstrated that exercise reduces depressive symptoms among heart disease survivors (Blumentha et al, 2004). A study of 1,260 testicular cancer survivors demonstrated that depressive symptoms are lower among survivors who are physically active than those who are sedentary (Thorsen et al, 2005). Another study demonstrated that individuals with multiple sclerosis show long-term reductions in depressive symptoms and short-term improvements in "vitality" and "body dynamics" if they participate in cognitive behavioural therapy that includes exercise (Tesar et al, 2003). In addition, aerobic exercise training can reduce depressive symptoms, among HTV-infected adults (Neidig et al, 2003). Researchers have also reported that moderate intensity aerobic exercise reduces depressive symptoms among haemodialysis patients (Suh et al, 2002). Several studies have examined depressed women Researchers at the University of Queensland examined the dose-response relationship between self-reported physical activity levels and depressive symptoms. Results demonstrated that physical activity reduces depressive symptoms regardless of the intensity level. However, women who participated in at least 60 minutes of moderate-to -vigorous exercise a week had significantly fewer symptoms of depression than those who were active for less than 1 hour a week (Brown et al, 2005). A study at the University of British Columbia demonstrated that physically inactive women are 15.7 times more likely to be depressed than women who have a normal activity level (Iverson and Thordarson, 2005). In another study, 52 sedentary women participated in a 10-week resistance-training program. Women who had positive feelings about the resistance-training program showed a significantly greater decrease in total mood disturbance, than those who had negative feelings about exercising (Annesi and Westcott, 2004). A study that examined 20 women who had given birth in the last 12-months and were experiencing depression discovered that those who improved their fitness levels through exercise had fewer depressive symptoms than less fit individuals (Armstrong and Edwards, 2003). A study at the University of Tartu demonstrated that women who participate in physical activity 3 times a week have significantly better mental health and less depression than inactive women. Even women who participate in physical activity 1-2 times a week have better mental health (Kull, 2002). A study involving 112 women demonstrated that brisk walking, along with light therapy and vitamins, can be an effective therapy for mild-to-moderately depressed women (Brown et al, 2001). A study at the University of Illinois examined the effects of 2 physical activity modes, walking and low-intensity resistance/flexibility training, on depressive symptoms and physical self-esteem over a 5-year period among older adults. Results suggest that older adults who participate in walking or low-intensity resistance/flexibility training experience sustained reductions in depression symptoms and increases in physical self-esteem (Moti et al, 2005). In a study involving 1,151 older adults, it was reported that daily walking reduces depressive symptoms (Fukukawa et al, 2004). A study at the Royal Prince Alfred Hospital involving 60 older adults demonstrated that high intensity weight training is more effective than low intensity weight training for the treatment of older depressed patients (Singh et al, 2005). The University of Michigan conducted a study that demonstrated that aerobic exercise significantly reduces depressive symptoms among older adults (Penninx et al, 2002). Nine hundred 2nd thirty-two men and 1,097 women between 50 and 89 years of age participated in a study at the University of California San Diego to examine the relationship between regular exercise and depression. Results demonstrated that older adults who exercise 3 or more times a week have less depressed mood than those who are sedentary (Kritz-Silverstein et al, 2001). A study at the University of Jyvaskyla with 1,224 older adults demonstrated that individuals who are physically active have fewer depressive symptoms than those who are sedentary or mobility-disabled (Lampinen and Heikkinen, 2003). An 8-year study involving 663 older adults demonstrated that individuals who decrease their physical activity levels as they age are more likely to report depressive symptoms than older adults who remain active or increase their physical activity levels (Lampinen et al, 2000). According to Hellenberg et al (2003), older women who are in poor physical condition have more depressive symptoms than physically fit older women. A study involving 32 subjects reported that weight training has an antidepressant effect among elderly patients (Singh et al, 2001). There is also evidence that group exercise programs may be more effective at reducing depressive symptoms than home-based activities. A study involving frail older women recuperating from acute illnesses demonstrated that those who participated in a group strength-training program had significant improvements in mood compared to women who participated in home-based exercise programs (Timonen et al, 2002). Research conducted at the University of Dundee demonstrated that older people with poorly responsive depressive disorder would benefit from group exercise programs (Mather et al, 2002). Physical activity can also benefit older adults suffering from aging-related health conditions. A study at University College London with 224 individuals demonstrated that moderate-to-vigorous exercise reduces depressive symptoms among older adults with Alzheimer's disease (Regan et al, 2005). The University of Kansas Medical Center conducted at study that demonstrated that stroke survivors who participate in exercise programs have fewer post stroke depressive symptoms compared to survivors who are not physically active (Lai et al, 2006). A study at :he Public Health Institute demonstrated that physical activity reduces depressive symptoms among older adults, including disabled subjects (Strawbridge et al, 2002). Research indicates that regular exercise can reduce depressive symptoms. There is, however, a need for more clinical trials on depression and physical activity to be conducted before exercise can be recommended as an alternative to more traditional, empirically validated pharmacological and behavioural therapies (Brosse et al, 2002). One of the challenges with researching children and youth is that the warning signs of mental illness, including depression, can be masked by what is generally considered normal adolescent behaviour. Dr. Smitta Thatte, i psychiatrist and the clinical director of youth programs at the Royal Ottawa Hospital, estimates that between 16 and 20 percent of Canadian teenagers have serious mental health illness and many of them go undiagnosed. She states "there is still a stigma that accompanies mental illness and teenagers may be reluctant to step forward and ask for help" (Lofaro, 2006). Evidence suggests that doctors (general practitioners) are the first group of healthcare professionals that depression sufferers contact for treatment. Most doctors, however, are not receptive to promoting physical activity as an alternative to antidepressants or other forms of therapy. Ninety-two percent of doctors use antidepressants as one of their 3 most common treatment responses. Only 5% of doctors promote exercise as one of their 3 most common treatment responses (Halliwell, 2 306). In addition, few psychotherapists promote exercise as part of their treatment (Pollack, 2001). The physical health risks of physical inactivity (eg. premature death, heart disease, obesity, high blood pressure, adult-onset diabetes, osteoporosis, stroke, colon cancer) are accepted by health organizations throughout the world. The benefits of physical activity to mental health (e.g. decreased depression, increased mood, reduced anxiety) are less widely understood and promoted. Considering the worldwide trend towards an increased number of depression sufferers, the high demand on doctors to manage more patients, and the uncertainties being created by the controversies surrounding some popular antidepressants (e.g. SSRIs), there is an opportunity for health promoters to make doctors, healthcare policy makers, patients and the general public aware that exercise can be an effective intervention for treating depression (Halliwell, 2006). If doctors become convinced that physical activity can be an effective treatment for depression, they also need to be convinced that exercise prescription is a specialized profession. Doctors need to build partnerships with physical activity specialists. With the proper guidance and support, depression sufferers could benefit greatly from exercise prescriptions. Annesi, James (2004). Relationship between self-efficacy and changes in "rated tension and depression for 9- to 12-year-olds enrolled in a 12-week after-school physical activity program. Perceptual and Motor Skills. Vol.99. No.l: pgs.191-194. August. Annesi, James and Westcott, Wayne (2004). Relationship offering states after exercise and total mood disturbance over 10-weeks in formerly sedentary women. Perceptual and Motor Skills. Vol.99. No.l: pgs.107-115. August. Annesi, James (2005a). Correlations of depression and total mood disturbance with physical activity and self-concept in preadolescents enrolled in an after-school exercise program. Psychological Reports. Vol.96: pgs.891-898. June. Annesi, James (2005b). Changes in depressed mood associated with 10 weeks of moderate cardiovascular exercise in formerly sedentary adults. Psychological Reports. Vol.96: pgs.855-862. June. Armstrong, Kylie and Edwards, Helen (2003). The effects of exercise and social support on mothers reporting depressive systems: a pilot randomized controlled trial. International Journal of Mental Health Nursing. Vol. 12. No.2: pgs. 130-138. June. Artal, Michal and Sherman, Carl (1998). Exercise against depression. The Physician and Sports Medicine. Vol.26. No. 10. October. Backmand, H.; Kaprio, J.; Kajala. U.; and Sama. S. (2003). Influence of physical activity on depression and anxiety of former athletes. International Journal of Sports Medicine. Vol.21. No.8: pgs.609-619. November. Beauchesne, Eric (2006). The presenteeism' problem: workers who can't call in sick. The Ottawa Citizen. Friday June 2. Blumenthal, James; Babyak, Michael; Carney, Robert; Huber, Marc; Saab, Patrice; Burg, Matthew, Sheps, David; Powell, Lynda; Taylor, C Barr, and Kaufinann, Peter (2004). Exercise, depression, and mortality after myocardial infarction in the ENR1CHD trial. Medicine and Science in Sports and Exercise. Vol.36. No.5: pgs.746-755. May. Breggin, Peter R. (2000). The White House conference on mentaI health. Ethical Human Sciences and Services. Vol.2. No.l. Brosse, Alisha; Sheets, Erin; Lett, Heather, and Blumenthal, James (2002). Exercise and the treatment of clinical depression in adults: recent findings and future directions. Sprats Medicine. Vol.32. No.12: pgs.741-760. Brown, Wendy; Ford, Jessica; Burton, Nicola; Marshall, Alison and Dobson, Annette (2005). Prospective study of physical activity and depressive symptoms in middle-aged women. American Journal of Preventive Medicine. Vol.29. No.4: pgs.265-272. November. Brown, M.; Goldstein-Shirley, J.; Robinson, J.; and Casey, S. (2001). The effects of a multi-modal intervention trial of light, exercise, and vitamins on women's mood. Women and Health. Vol.34. No.3: pgs.93-112. Cotroneo, Christian (2006). Mass online check-up targets mental health. Toronto Star. Tuesday April 4. DePaulo Jr., J. Raymone and Horvitz, Leslie Alan (2002). Understanding depression: what we know and what you can do about it. John Wiley and Sons, Inc. New Jersey, United States. Dunn, A.; Trivedi, M.; and O'Neal, H. (2001). Physical activity) dose-response effects on outcomes of depression and anxiety. Medicine and Science in Sports and Exercise. Vol.33: pgs. S587-597. June. Ernst, Carl; Olson, Andrea; Pinel, John; Lam, Raymond; and Christie, Brian (2006). Antidepressant effects of exercise: evidence for an adult-neurogenesis hypothesis? Journal of Psychiatry and Neuroscience. Vol.31. No.2: pgs.84-92. March. Fukukawa, Yasuyuki; Nakashima, Chiori; Tsuboi, Satomi; Kozakai, Rumi; Doyo, Waturu; Niino, Naoakira; Ando, Fujiko; and Shimokata, Hiroshi (2004). Age differences in the effect of physical activity on depressive symptoms. Psychology and Aging. Vol. 19. No.2: pgs.346-351. June. Halliwell, Ed (2006). Up and running: exercise therapy and the treatment of mild or moderate depression in primary care. Report for the Mental Health Foundation. United Kingdom. Hollenberg, Milton; Haight, Tad; and Tager, Ira B. (2003). Depression decreases cardiorespiratory fitness in older women. Journal of Clinical Epidemiology. Vol.5. No. 11: pgs. 1111-1117. November. Iverson, Grant and Thordarson, Dana (2005). Women with low activity are at increased risk of depression. Psychological Reports. Vol.96. No.l: pgs.133-140. February. Iverson, Grant (2004). Objective assessment of psychomotor retardation in primary care patients with depression. Journal of Behavioral Medicine. Vol.27. No.l: pgs.31-37. February. Kiive, Evelyn; Maaroos, Jaak; Shlik, Jakov; Toru, Innar; and Harro, Jaanus (2004). Growth hormone, cortisol and prolactin responses to physical exercise: higher prolactin response in depressed patients. Progress in Neuro-Psychopharmacology and Biological Psychiatry. Vol.28. No.6: pgs. 1007-1013. September. Kirby, Sharon (2005). The positive effect of exercise as a therapy for clinical depression. Nursing Times. Vol. 101. No. 13: pgs.28-29. March 29-April 4. Kritz-Silverstein, D.; Barrett-Connor, E.; and Corbeau, C. (2001). Cross-sectional and prospective study of exercise and depressed mood in the elderly: the Rancho Bernardo study. American Journal of Epidemiology. Vol. 153. No.6: pgs.596-603. March. Kull, Merike (2002). The relationships between physical activity, health status and psychological well being of fertility-aged women. Scandinavian Journal of Medicine and Science in Sports. Vol.12. No.4: pgs.241-247. August. Lafaro, Tony (2006). Normal behaviour in teens often masks mental illness — doctor: up to 20% of youth go undiagnosed psychiatrist says. The Ottawa Citizen. Thursday June 8. Lai, Sue-Min; Studenski, Stephanie; Richards, Lone; Perera, Subashan; Reker, Dean. Rigler, Sally; and Duncan, Pamela W. (2006). Therapeutic exercise and depressive symptoms after stroke. Journal of the American Geriatrics Society. Vol.54. No.2: pgs.240-270. February. Lampinen, P.; Heikkinen. R.; and Ruoppila, I. (2000). Changes in intensity of physical exercise as predictors of depressive symptoms among older adults: an eight-year follow-up. Preventive Medicine. Vol.30. No.5: pgs.371-380. May. Lampinen, Paivi and Heikkinen, Eino (2003). Reduced mobility and physical activity as predictors of depressive symptoms among community-dwelling older adults: an eight-year follow-up study. Aging-Clinical and Experimental Research. Vol.15. No.3: pgs.205-211. June. Lane, A. and Lovejoy, D. (2001). The effects of exercise on mood changes: the moderating effect of depressed mood. Journal of Sports Medicine and Physical Fitness. Vol.41. No.4: pgs.539-545. December. Lawlor, Debbie and Hopker, Stephen (2001). The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomised controlled trials. Downloaded on March 21, 2006 from bmj.com. Vol.322. March 31. Leppamaki, S.; Partonen; T.; and Lonnqvist, J. (2002). Bright-light exposure combined with physical exercise elevates mood. Journal of Affective Disorders. Vol.72. No.2: pgs. 139-144. November. Manger, Theresa and Motta, Robert (2005). The impact of an exercise program an posttraumatic stress disorder, anxiety, and depression. International Journal of Emergency Medical Health. Mather, Anne; Rodriguez, Cesar, Guthrie, Moyra; McHarg, Anne; Reid, Ian; and McMurdo, Marion (2002). Effects of exercise on depressive symptoms in older adults with poorly responsive depressive disorder: randomized controlled trial. British Journal of Psychiatry. Vol.180: pgs.411-415. May. Moti, Robert; Birnbaum, Amanda; Kubik, Martha; and Disharn, Rod (2004). Naturally occurring changes in physical activity are inversely related to depressive symptoms during early adolescence. Psychosomatic Medicine. Vol.66. No.3: pgs.336-342. May-June. Moti, Robert; Konopack, James; McAuley, Edward; Elavsky, Steriani; Jerome, Gerald; and Marquez, David (2005). Depressive symptoms among older adults: long-term reduction after a physical activity intervention. Journal of Behavioral Medicine. Vol.28. No.4: pgs.385-394. August. Murphy, Marie; Neville, Alan; Neville, Charlotte; Biddle, Stuart; and Hardman, Adrianne (2002). Accumulating brisk walking for fitness, cardiovascular risk, and psychological health. Medicine and Science in Sports and Exercise. Vol.34. No.9: pgs. 1468-1474. September. Murray, Christopher J.L. and Lopez, Alan D. (1996). The Global Burden of Disease. Table 5.4: pg.270. Neidig, Judith; Smith, Barbara; and Brashers, Dale (2003). Aerobic exercise training for depressive symptom management in adults living with HIV infection. Journal of the Association of Nurses in AIDS care. Vol.14. No.2: pgs. 30-40. March-April. OMeara, Kelly Patricia (2001). Did drugs cause mom to drawn her children? Insight Magazine. Palmer, Carol (2005). Exercise as a treatment for depression in elders. Journal of the Academy of Nurse Practitioners. Vol. 17. No.2: pgs.60-66. February. Paluska, S. and Schwenk, T. (2000). Physical activity and mental health: current concepts. Sports Medicine. Vol.29. No.3: pgs.167-180. March. Penninx, Brenda; Rejeski, W Jack; Pandya, Jasma; Miller, Michael; Di Bari, Mauro; Applegate, William; and Pahor, Marco (2002). Exercise and depressive symptoms: a comparison of aerobic and resistance exercise effects on emotional and physical function in older persons with high and low depressive symptomatology. Journals of Gerontology Series B-Psychological Sciences and Social Sciences. Vol.57. No.2: pgs. P124-132. March. Pollock, K. (2001). Exercise in treating depression: broadening the psychotherapist's role. Journal of Clinical Psychology. Vol.57. No.ll: pgs.1289-1300. November. Quan, Jennifer (2006). The overlooked illness: practical advice on how employers can identify and manage workplace depression. Canadian Healthcare Manager. February. Rappoport, Jon (1999). School violence: the psychiatric drug connection. The Truth Seeker Foundation. San Diego, California. Regan, Ciaran; Katona, Cornelius; Walker, Zuzana; and Livingston, Gill (2005). Relationship of exercise and other risk factors to depression of Alzheimer's disease; the LASER-AD study. International Journal of Geriatric Psychiatry. Vol.20. No.3: pgs.261-268. March. Salmon, P. (2001). Effects of physical exercise on anxiety, depression, and sensitivity to stress: a unifying theory. Clinical Psychological Review. Vol.21. No.l: pgs.33-61. February. Sexton, H.; Sogaard, A.; and Olstad, R. (2001). How are mood and exercise related? Results from the Finnntark study. Social Psychiatry and Psychiatric Epidemiology. Vol.36. No.7: pgs.348-353. July. Sharratt, Anna (2006). Stick it to stigma. Canadian Business. Jan 30-Feb 12: pgs.55-56. Singh, N.; Clements, K.; and Singh, M. (2001). The efficacy of exercise as a long-term antidepressant in elderly subjects: a randomized, controlled trial. Journals of Gerontology Series A-Biological Sciences and Medical Sciences. Vol.56. No.8: pgs.M497-504. August. Singh, Nalin; Stavrinos, Theodora; Scarbek, Yvonne; Galambos, Gany; Liber, Cas; and Fiatarone Singh, Maria (2005). A randomized controlled trial of high versus low intensity -weight training versus general practitioner care for clinical depression in older adults. Journals of Gerontology Series A-Biological Sciences and Medical Sciences. Vol.60. No.6: pgs.768-776. June. Strawbridge, William; Deleger, Stephane; Roberts, Robert; and Kaplan, George (2002). Physical activity reduces the risk of subsequent depression for older adults. American Journal of Epidemiology. Vol. 156. No.4: pgs.328-334. August. Suh, Mi Rye; Jung, Hae Hyuk; Kim, Soon Bae; Park, Jung Sik; and Yang, Won Seok (2002). Effects of regular exercise on anxiety, depression, and quality of life in maintenance haemodialysis patients. Renal Failure. Vol.24. No.3: pgs.337-345. May. Tesar, N.; Baumhacki, U.; Kopp, M.; and Gunther, V. (2003). Effects of psychological group therapy in patients with multiple sclerosis. Acta Neurologica Scandinavica. Vol.107. No.6: pgs.394-399. June. Thompson, Anne (2001). Paxil maker held liable in murder/suicide. Lawyers Weekly Inc. Thorson, Lene; Nystad, Wenche; Stigum, Hein; Dahl, Olav; Klepp, Olbjom; Bemnes, Roy, Wist, Erik; and Fossa, Sophie (2005). The association between self-reported physical activity and prevalence of depression and anxiety disorder in long-term survivors of testicular cancer and men in a general population sample. Supportive Care in Cancer. Vol.13. No.8: pgs.637-646. August. Timonen, L.; Rantanen,T.; Timonen,T.; and Sulkava, R. (2002). Effects of group-based exercise program on the mood state of frail older women after discharge from hospital. International Journal of Geriatric Psychiatry. Vol.17. No. 12: pgs. 1106-1 111. December. Urquhart, Ian (2006). Kids need easy access to mental health treatment. Toronto Star. Wednesday May 10. Wang, Guijing and Brown, David (2004). Impact of physical activity on medical expenditures among adults downhearted and blue. American Journal of Human Behavior. Vol.28. No.3: pgs.208-217. May-June. Wyshak, G. (2001). Women's college physical activity and self-reports of physician-diagnosed depression and of current symptoms of psychiatric distress. Journal of Women's Health and Gender-Based Medicine. Vol.10. No.4: pgs.363-370. May.

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