Background
Methods
Search strategy and study selection
Eligibility Criteria
Inclusion Criteria
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1. Study participants were diagnosed with a mental health condition, with primary care being the main source of referral. | |
2. Mental health was the primary reason for referral. | |
3. Studies evaluating ERS, as defined by Pavey et al. [21] | |
o Referral by a primary-care health-care professional to a service designed to increase physical activity or exercise | |
o Physical activity/exercise programme tailored to individual needs | |
o Initial assessment and monitoring throughout the programme | |
4. Studies with any relevant comparator were permitted. | |
5. Studies had to measure one or more of the following | |
o Changes in clinical symptoms of mental health conditions (e.g. depression and anxiety) found or managed in primary care | |
o ERS uptake/adherence rates of individuals referred from primary care for mental health reasons | |
o Impact of ERS on long-term physical activity levels in participants referred from primary care for mental health reasons. |
Data extraction
Quality assessment
Data synthesis
Results
Study selection
Study characteristics
First Author Year Country | Study Type | MH Eligibility Criteria | Mental health condition (% of patients) | Includes Non-MH Referrals (Yes/No) | Comparator(s) | Sample size (ERS/C if applicable) Female % (ERS/C if applicable) | Mean age (± SD) ERS/C if applicable | Outcomes of this review addressed |
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Harrison [27] 2005 United Kingdom | Retrospective data analysis | Participant characteristics: - ≥18 years old - Sedentary Referral reasons: - MH (types not specified) | N/I | Yes | Participants referred for non-MH reasons (took part in same ERS programme) | Sample size = 339 Total female (%) = 60.8 | Total = 51.3 (±12.6) | - Uptake/ Adherence |
Crone [28] 2008 United Kingdom | Retrospective data analysis | Participant characteristics: - N/I Referral reasons: - Depression - Anxiety/ Loss of confidence - Stress/ Tension | Anxiety/loss of confidence = 26% Depression = 61% Stress/tension = 13% | Yes | Participants referred for physical health conditions (took part in same ERS programme) | Sample size = 134 Female (%) = 64 | 42 (±14) | - Uptake/ Adherence |
Chalder [29] 2012 United Kingdom | RCT | Participant characteristics: - 18-69 years old - Have not failed to respond to antidepressants Referral reasons: - Mild/moderate depression | Depression = 100% | No | Control group who received usual care | Sample size = 361 (182/179) Female (%) = 68/65 | 40.9 (±12.5) / 38.8 (±12.7) | - Clinical effectiveness - Uptake/ Adherence - Long-term activity levels |
Murphy [30] 2012 United Kingdom | RCT | Participant characteristics: - >16 years old - Sedentary Referral reasons: - Mild anxiety - Mild depression - Stress | Anxiety = N/I Depression = N/I Stress = N/I | Yes | Control group who received usual care, information leaflet and addresses of local facilities | Sample size = 601 (310/291) - MH only = 79 (41/38) - MH+CHD = 522 (269/253) Female (%) = 65.6/65.5 | Total = 52 (±14.7) | - Clinical effectiveness - Long-term activity levels |
Moore [31] 2013 United Kingdom | RCT | Participant characteristics: - >16 years old - Sedentary Referral reasons: - Mild anxiety - Mild depression - Stress | Anxiety = N/I Depression = N/I Stress = N/I | Yes | Participants referred for coronary heart disease only (took part in same ERS programme) | Sample size = 310 MH: - MH only = 41 - MH+CHD = 269 Total female (%) = 65.6 | Total = 52 (±14.7) | - Uptake/ Adherence |
Forsyth [32] 2015 Australia | RCT | Participant characteristics: - >18 years old Referral reasons: - Depression - Anxiety | Depression only = 46% Anxiety only = 25% Both = 29% | No | Control group received 5-minute phone call every two weeks to assess for any diet or physical activity changes. No advice given | Sample size = 94 (52/42) Female (%) = 73/71 | 43.88 (±14.17)a / 47.33 (±13.45)a | - Clinical effectiveness - Uptake/ Adherence |
Tobi [33] 2017 United Kingdom | Retrospective data analysis | Participant characteristics: - Sedentary Referral reasons: - Depression - Anxiety - Stress - Other mental disorders | Anxiety = N/I Depression = N/I Stress = N/I Other mental disorders = N/I | Yes | Participants referred for physical health conditions (took part in same ERS programme) | Sample size = 141 Female (%) = 63.1 | 41.3 (±11.8) | - Uptake/ Adherence |
Avery [34] 2020 United States of America | Retrospective data analysis | Participant characteristics: - War veterans Referral reasons: - Depression - Stress/anxiety - Post-traumatic stress disorder | Depression = 3%a Stress/anxiety = 95%a Post-traumatic stress disorder = 3%a | Yes | Participants referred for physical health conditions (took part in same ERS programme) | Sample size = 149a Female (%) = 70.1% | 58.4 (±14.4)a | - Uptake/ Adherence |
Morgan [35] 2020 United Kingdom | Retrospective data linkage study | Participant characteristics: - >16 years old - Sedentary Referral reasons: - Mild anxiety - Mild depression - Stress | Anxiety = N/I Depression = N/I Stress = N/I | Yes | Participants referred for coronary heart disease only (took part in same ERS programme) | Sample size = 14,632 - MH only = 8603 - MH+CHD = 6029 Total female (%) = 61.65 | Total = 53 (±16.6) | - Uptake/ Adherence |
Study | Length | Type of ERS | Frequency of sessions | Duration of sessions |
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Harrison 2005 [27] | 12 weeks | Leisure centre-based: - Consultations with exercise officer - Access to leisure facilities and supervised exercise sessions | - Access to leisure facilities and exercise sessions throughout (encouraged to attend ≥2 sessions/week - Two consultations (weeks 0, 12) | N/I |
Crone 2008 [28] | 8-12 weeks | Leisure centre-based: - Gym sessions (majority) - Swimming - Circuits - Exercise-to-music classes | Twice a week | N/I |
Chalder 2012 [29] | 32 weeks | Regular face-to-face consultations and telephone calls with physical activity facilitator | Participants organise timing of: - Three face to face consultations - Ten telephone contacts | 30-60 min |
Murphy 2012 [30] | 16 weeks | Leisure centre-based: - Face to face consultations & telephone contact with exercise professional - Access to one to one exercise instruction & group classes | - Access to exercise instruction and classes throughout - Two consultations (weeks 0, 16) - One telephone contact (week 4) | N/I |
Moore 2013 [31] | 16 weeks | Leisure centre-based: - Face to face consultations & telephone contact with exercise professional - Access to one to one exercise instruction & group classes | - Access to exercise instruction and classes throughout - Two consultations (weeks 0, 16) - One telephone contact (week 4) | N/I |
Forsyth 2015 [32] | 12 weeks | Regular face-to-face consultations and telephone calls with dietician/exercise physiologists | Once every two weeks | 30-60 mina |
Tobi 2017 [33] | 20-26 weeks | Leisure centre-based: - Motivational/educational classes - Access to group exercise - Healthy walks - Gym sessions - Swimming/water workouts | N/I | N/I |
Avery 2020 [34] | Lifelong referral | Therapeutic yoga classes in person and via video link with yoga instructor | Up to 8 classes a week | 60 min |
Morgan 2020 [35] | 16 weeks | Leisure centre-based: - Face to face consultations & telephone contact with exercise professional - Access to one to one exercise instruction & group classes | - Access to exercise instruction and classes throughout - Two consultations (weeks 0, 16) - One telephone contact (week 4) | N/I |
Quality assessment
Primary outcomes
Study details | Outcome measure | Outcome assessment timings | Short-term results ERS vs. C | Long-term results ERS vs. C |
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Chalder 2012 [29] Trial | BDI-II | 4, 8, 12 months | 4 months adjusted between group difference in mean BDI-II score = -0.54 (95%CI -3.06 to 1.99) P=0.68 | Combined 4, 8 and 12 months adjusted between group difference in mean BDI-II score = -1.20 (95%CI -3.42 to 1.02) P=0.29 |
Murphy 2012 [30] Trial | HADS | 12 months | Did not assess | HADS depression 12 months adjusted between group difference in HADS depression score = -1.39 (95%CI -2.60 to -0.18) P<0.05 HADS anxiety 12 months adjusted between group difference in HADS anxiety score = -1.56 (95%CI -2.75 to -0.38) P<0.05 |
Forsyth 2015 [32] Trial | DASS-21 | 3 months | DASS-21 depression subscale ERS difference from baseline = -2.1 C difference from baseline = -4.0 Between group difference P=0.1 DASS-21 anxiety subscale ERS difference from baseline = -1.4 C difference from baseline = -3.0 Between group difference P=0.08 DASS-21 stress subscale ERS difference from baseline = -1.5 C difference from baseline = -1.8 Between group difference P=0.06 Total DASS-21 scores ERS difference from baseline = -5.1 C difference from baseline = -6.1 Between group difference P=0.04 | Did not assess |
Study details | ERS information | Outcome measure | Results 1. Uptake 2. Adherence | Results in non-MH referrals (if applicable) 1. Uptake 2. Adherence |
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Harrison 2005 [27] Routine practice | 12 weeks leisure centre-based | Attended first appointment | 1. Attended first appointment - MH = 280 (uptake 82.6%) 2. N/I | 1. Attended first appointment - C = 4945 (uptake 78.9%) 2. N/I |
Crone 2008 [28] Routine practice | 8-12 weeks leisure centre-based | Uptake - Attended first session Completed - Attended ≥80% of scheduled sessions | 1. Uptake - MH = 79 (uptake 59.0%) 2. Completed - MH = 29 (adherence 36.7%) | 1. Uptake - C = 1917 (uptake 69.3%) 2. Completed - C = 935 (adherence 48.8%) |
Chalder 2012 [29] Trial | 32 weeks regular face-to-face consultations and telephone calls | Failed to attend - Did not attend first ERS session Received adequate dose - Had ≥5 sessions | 1. Failed to attend - ERS group = 11 (uptake 94.5%) 2. Received adequate dose at 4 months - ERS group = 102 (59.6% adherence) Received adequate dose at 8 months - ERS group = 129 (75.4% adherence) | Did not assess |
Moore 2013 [31] Trial | 16 weeks leisure centre-based | Did not enter Partial attendance (0-16 weeks) Completed | 1. Did not enter - MH = 52 (uptake 83.2%) 2. Partial attendance - MH = 152 Completed - MH = 106 (adherence 41.1%) | 1. Did not enter - C = 109 (uptake 85.8%) Adjusted OR 0.82 (95%CI 0.57 to 1.17) 2. Partial attendance - C = 294 Completed - C = 367 (adherence 55.5%) Adjusted OR 0.57 (95%CI 0.43 to 0.75) |
Forsyth 2015 [32] Trial | 12 weeks regular face-to-face consultations and telephone calls | Declined referral Discontinued participation | 1. Declined referral - ERS group = 9 (uptake 85.2%) 2. Discontinued participation - ERS group = 21 (adherence 59.6%) | Did not assess |
Tobi 2017 [33] Routine practice | 20-26 weeks leisure centre-based | Adherence - Attended ≥80% of scheduled sessions - Two recorded progress assessments | 1. N/I 2. Adherence - MH = 53 (adherence 37.6%) | 1. N/I 2. Adherence - C = 263 (adherence 47.0%) - Between group difference P = 0.04 |
Avery 2020 [34] Routine practice | Unlimited number of in person or video link yoga classes | Follow through/uptake - Attendance at ≥1 yoga class | 1. Uptake - MH = 63 (uptake 42.3%)
Stress/anxiety (42%)
Depression (40%)
Post-traumatic stress disorder (45%)
2. N/I | 1. Uptake - C = 74 (uptake 27.1%) 2. N/I |
Morgan 2020 [35] Routine practice | 16 weeks leisure centre-based | Did not take up Uptake | 1. Uptake - MH only = 4677 (54.4% uptake) - MH+CHD = 3730 (61.9% uptake) - All MH = 8407 (57.5% uptake) 2. N/I | 1. Uptake - C = 10,699 (67.7% uptake) - OR 0.79, 95%CI 0.74 to 0.84 2. N/I |
Study details | Outcome measure | Outcome assessment | Results ERS vs. C |
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Chalder 2012 [29] Trial | MET minutes of physical activity a week - Meeting current exercise guidelines if MET ≥1000 | 4, 8, 12 months | Participants doing ≥1000 MET minutes of physical activity per week (%): 4 months - ERS = 52% - C = 43% 8 months - ERS = 63% - C = 49% 12 months - ERS = 58% - C = 40% Between group difference at 4 months Adjusted OR 1.58 (95%CI 0.94 to 2.66) P = 0.08 Between group difference using combined 4-, 8- and 12-month data Adjusted OR 2.27 (95%CI 1.32 to 3.89) P = 0.003 |
Murphy 2012 [30] Trial | 7-D PAR | 12 months | 12 months adjusted between group difference in 7D-PAR score = OR 1.06 (95%CI 0.73 to 1.55) P>0.05 |