Research paperEffect of exercise augmentation of cognitive behavioural therapy for the treatment of suicidal ideation and depression
Introduction
Cognitive behavioural therapy (CBT) is one of the most widely used time-limited and effective interventions for treating depression and suicidal ideation (Brown et al., 2016, Charkhandeh et al., 2016, Cristea et al., 2015, Du et al., 2016, Hadjistavropoulos et al., 2016, Newby et al., 2016, Nyström et al., 2015). Depressive disorder is a serious and debilitating mental illness characterized by substantial impairment in functioning, including sleep disruption, reduced appetite, lack of self-care, poor concentration, loss of interest, sadness, decreased physical power, impaired motivation, and feeling of tiredness (World Health Organization, 2015). In Iran, the 12-month prevalence of the depressive disorder ranges from 15% to 25% (Aghakhani et al., 2011). The rate of suicide completion in depressive disorder is 2.1 times greater than that of the general population (Holma et al., 2010). Depression is an important predictor of suicidal ideation and suicide attempts (Walser et al., 2015), and research shows that reducing depression dramatically decreases the severity of suicidal ideation (Mann et al., 2005, Walser et al., 2015).
Suicide represents a global public health problem and contributes annually to 1.4% of the total burden of mental and physical diseases (World Health Organization, 2012). In Iran, suicidal behavior has increased dramatically over the past decades (Abdollahi and Abu Talib, 2015; Abdollahi and Talib, 2015b), with rates of suicide around 6.1/100,000 for Iranian males and 3/100,000 for females (Malakouti et al., 2009). Given that suicidal ideation is an important precursor to suicide (Abdollahi and Talib, 2015a), providing treatment to individuals suffering from suicidal ideation can play an important role in reducing suicide behavior.
CBT may alleviate suicidal ideation and depression by challenging and modifying maladaptive beliefs, increasing behavioural activation, and developing problem-solving skills (Beck and Dozois, 2011). Research suggests that CBT is most effective when delivered in 1–2 treatment sessions per week for 4–12 weeks (Huang et al., 2015, Strachowski et al., 2008).
Recently, exercise has been suggested as an effective means of alleviating a variety of mental health concerns (Asmundson et al., 2013, Nyström et al., 2015). Exercise is defined as planned, structured, and repetitive physical activities to increase the improvement and maintenance of physical fitness (Caspersen et al., 1985). Evidence suggests that while greater depression is associated with lower levels of physical activity, increasing physical activity can decrease depression (Mothes et al., 2014). This view is supported by Reed and Buck (2009), who highlighted the role of regular aerobic exercise in increasing feelings of well-being and suggested that its absence can have detrimental effects on physical and mental health. Exercise contributes to elevating the levels of serotonin, dopamine, and norepinephrine, which may alleviate depressive symptoms (Wright and Cattan, 2009). Recent studies have focused on the possible role of exercise in the management of depression (Harvey et al., 2010, Ström et al., 2013, Teychenne et al., 2008, Tulio et al., 2013) and have shown that it reduces symptoms of depression (Mota-Pereira et al., 2011) and anxiety (Powers et al., 2015). Although these results are promising, few studies have investigated the role of exercise in relation to suicidal ideation (Babiss and Gangwisch, 2009, Gartlehner et al., 2016) and additional studies regarding depression are warranted.
Because it is effective, safe, easily accessible, inexpensive, requires less clinician training to deliver, and carries a low risk of negative side-effects (Wright and Cattan, 2009), exercise could complement conventional approaches to treating suicidal ideation and depression, such as CBT (Cuijpers et al., 2013). Nonetheless, little research has been conducted on assess the effects of exercise in addition to CBT for suicidal ideation as well as depression (Brosse et al., 2002, Huang et al., 2015, Ströhle, 2009). Therefore, the present study was designed to assess the efficacy of CBT augmented with exercise on suicidal ideation and depression in a sample of Iranian individuals.
Section snippets
Participants
Participants included depressed individuals from two psychology clinics in Tehran, Iran. Of the 77 individuals to whom participation in this study was suggested, 70 agreed. Participants had mild (n=29; 41.4%) to moderate (n=41; 58.6%) depression. Demographic characteristics of the participants at pre-intervention are presented in Table 1. We conducted a priori power analyses according to statistical formulae by Röhrig et al. (2010). An α level of 0.05 and β of 0.10 yielded a recruitment goal of
Preliminary analyses
Of the 70 individuals who were randomized, 54 (77.1%) completed the intervention and provided complete data (see Fig. 1). Individuals who completed the intervention reported greater baseline levels of depression (Mdiff=2.77, t (41.58)=3.16, p=0.003) and activities of daily living (Mdiff=1.38, t (68) =3.49, p=0.001), but there were no significant differences in suicidal ideation (Mdiff=0.84, t (68)=1.31, p=0.194) or age (Mdiff=−0.91, t (68)=−0.44, p=0.659). Fisher's exact tests revealed that
Discussion
Considering the findings of the present study, both a combination of exercise and CBT and CBT alone were effective strategies for reducing depression and suicidal ideation. However, the effects of an exercise program adjunct to a CBT program in reducing depressive symptoms and suicidal ideation were greater than the CBT program alone. The results from this study are consistent with previous studies that have demonstrated the effectiveness of exercise as an adjunct to CBT in reducing symptoms of
Ethical standard
The research was conducted in accordance with ethical standards outlined by the Universiti Putra Malaysia.
Human rights and informed consent
All procedures performed with human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards, and informed consent procedures were completed prior to participation.
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