Methods
Setting
GMVs were conducted in a meeting room and a small gym located at the Centre for Hip Health & Mobility (University of British Columbia (UBC); Vancouver, British Columbia, Canada).
Participants
We recruited participants (>18 years) from British Columbia's Lower Mainland (Vancouver), primarily through the regional Mood Disorders Association of British Columbia (MDABC) office and local mental health support organisations such as the Canadian Mental Health Association (CMHA). The inclusion criteria were a confirmed diagnosis (RAR) of MDD, chronic or bipolar 2 disorder (depression) via Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IVR) criteria. Chronic was defined as having symptoms for more than 2 years. No structured diagnostic interview was completed, but the psychiatrist making the diagnosis (RAR) had significant experience in the assessment, treatment and research work with mood and anxiety disorders. Respondents were excluded from participation if they had active psychotic symptoms or a primary active diagnosis of substance abuse. Recruitment responses are reported in figure 1.
All patients were screened with the Physical Activity Readiness Questionnaire (PAR-Q). Any patient who scored 1 (yes) or more were questioned further and their family physician was contacted, the details of the programme and the PA expectations of participants were explained to the family physician, and we requested a written note from the physician that their patient's concomitant medical condition was not an exclusion to participating in our programme. Researchers prepared a list of appropriate, available and affordable resources and counselling services, which they handed to every participant at the start of the intervention.
Ethics approval was obtained from UBC's Behavioural Research Ethics Board obtained and each participant provided written informed consent.
Study design
We conducted weekly 2 h GMVs over 14 weeks along with additional weekly 45 min gentle hatha yoga classes for 11 weeks (weeks 3–14 due to availability of yoga therapist). The study used a pre/post (14 weeks) design.
A psychiatrist (RAR) and an exercise therapist co-led each GMV, which combined specific medical advice, medication management, open discussion of patient concerns, a targeted educational component to guide participants’ self-management or ‘patient activation’ around PA, as well as a PA component.
Thematic content for the 14 weekly group discussions was based on Steven Blair's successful study, Project Active4 and subsequent book, Active Living Every Day.31 Blair et al's book provided a tested, reliable, relevant and accessible framework around which to structure an intervention.
The view behind our intervention was to support individuals in feeling highly responsible for their health and thus, transform them from being the passive receivers of a healthcare provider's advice and recommendations to proactively seeking out strategies and tools that would further their own well-being.
The 2 h session was divided into three sections:
Group check in/out; enter patients weekly step count into database; review and outline the day's group programme—20 min;
Group discussion, regarding selected topics including psychiatric issues—50 min;
PA component—50 min.
During the PA component, participants went for a group walk on alternate weeks, emphasising that 150 min weekly of moderate activity (eg, brisk walking) was all that is necessary to obtain the medical benefits offered by regular PA. On alternate weeks, participants stayed in the gym and were taught techniques and exercises that they could employ in their everyday lives to become more physically active without having to attend special classes, set aside time, or make concerted efforts to ‘exercise’ (eg, in one session, called ‘commercial exercises’, participants were given a series of brief (<5 min) upper and lower body activities they could do in their home during a television commercial in lieu of sitting still, eating a snack, etc). We also wanted to provide participants with tools and a framework that would help sustain them through the drops in motivation, interest and energy that accompany the low cycles of any fitness regime.
Group exercises included aerobic training of cardiorespiratory functioning, circuit training with simple tasks, for example, ergometer bicycling, resistance bands, light weightlifting, stepping, ball work and walking on treadmill, and an introduction to high-intensity interval training. A certified yoga therapist taught the gentle hatha yoga classes. We recorded participant attendance at each group visit/yoga class.
The ideal group size for any therapeutic intervention is considered 6–12 people.32 Accordingly, we split our population into two sections each week whereby one group of 6–10 participants did the 50 min PA component while the other group did the 50 min GMV; and then the two groups were reversed during the subsequent 50 min time block. The participants were randomised each week, so that all participants interacted with each other over the 14-week programme.
During the GMVs, a similar format was used:
A reciting of our refrain about the benefits of PA (see online supplementary appendix A) followed by a brief interesting study in recent exercise research (eg, How much weight will you gain over the Christmas holidays according to research studies? Is sweating important when you exercise? Etc)—5–10 min;
Reviewing each patient's weekly short-term goals (eg, increase from two 20 min walks to three 30 min walks per week)—15 min;
Develop long-term goals for when step-by-step ends (eg, 30 000 ‘steps’ on step counter per week)—10 min;
A group activity dealing with ‘resistance’ to exercise was initiated (eg, divide into groups of three, pick an envelope out of the hat and give counterarguments to what is written inside the envelope (eg, I am too tired to exercise today)—15 min.
Participants were requested to commit to
Recording their daily steps with a pedometer (Fitbit Zip (http://www.fitbit.com); San Francisco, California, USA);
Completing a paper evaluation of each weekly session.
Subsidised parking or public transit tickets were provided to participants who requested them.
Descriptive variables
Demographic data included gender, age, weight (kg), height (m), hips (cm), waist (cm) and body mass index (BMI).
Height (m): wall-mounted stadiometer (Rosscraft Inc, White Rock, British Columbia, Canada) using standard techniques;
Weight (kg): electronic scale (Seca Model 242, Hanover, Maryland, USA) with their feet together. Weight was recorded to nearest 0.1 kg. For height and weight, duplicate measures are taken unless measures differed by±0.4 cm (height) or ±0.2 kg (weight), when a third measure was taken. BMI was calculated as weight/height2;
Waist circumference (cm): we use a flexible steel tape (Rosscraft Inc). We obtained two measures during minimal respiration and recorded to the nearest 0.1 cm. We performed a third measure if the difference between the first two measures was greater than 0.2 cm. We used the mean of 2 and the median of 3 measurements for analysis of all measures.
Primary outcome measures
Physical activity—PA levels were measured by ‘steps’ (SenseWear accelerometer; http://sensewear.bodymedia.com, Pittsburgh, Pennsylvania, USA). Participants were instructed in how to use the SenseWear armband (SWA), which they were to wear for 7 days. SenseWear tracked total number of steps and average energy expenditure (EE; kcal/min; 3233). ‘Steps’ were measured at baseline, 14 weeks, and 3 and 6 months postintervention.
Depression—We tracked depression, using the Patient Health Questionnaire (PHQ-9) at baseline, 14 weeks, and 3 and 6 months postintervention. The PHQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression.33 ,34
Anxiety—Anxiety was measured at baseline, 14 weeks, and 3 and 6 months postintervention using the Generalised Anxiety Disorder 7-item (GAD-7) scale. The GAD-7 has a sensitivity of 89% and a specificity of 82% for GAD.35 ,36
Secondary outcome measures
Participants also completed the International Physical Activity Questionnaire (IPAQ) long form,37 a version of the Physical Activity Enjoyment Scale (PACES)38 adapted by Marcus and Forsyth,39 the Physical Activity Confidence (Self-Efficacy) questionnaire,39the Decisional Balance (perceived barriers of and to PA), Social Support (family/friends; levels of support), and Outcome Expectations for Exercise (perceived benefits).39 Once again these measurements were obtained at baseline, 14 weeks, and 3 and 6 months postintervention
Statistical analysis
All variables are not normally distributed, except weight and BMI; therefore, we used a non-parametric test (Wilcoxon ranked-sum) for all data, except weight and BMI (t test assuming unequal variances (heteroscedastic)), which were normally distributed. We used α=0.05 as the measure of statistical significance. Dropouts were not included in the postintervention analysis.