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Exercise for Mental Health

DOI:10.4088/PCC.v08n0208a
Authors:
Ashish Sharma
Ashish Sharma
Ashish Sharma
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Vishal Madaan at University of Virginia
Vishal Madaan
Frederick D Petty
Frederick D Petty
Frederick D Petty
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© C
OPYRIGHT
2006 P
HYSICIANS
P
OSTGRADUATE
P
RESS
, I
NC
. © C
OPYRIGHT
2006 P
HYSICIANS
P
OSTGRADUATE
P
RESS
, I
NC
.
L
ETTERS
TO
THE
E
DITOR
Prim Care Companion J Clin Psychiatry 2006;8(2)106
Exercise for Mental Health
Sir: In this era of exponential growth of the “met-
abolic syndrome” and obesity, lifestyle modifications
could be a cost-effective way to improve health and qual-
ity of life. Lifestyle modifications can assume especially
great importance in individuals with serious mental ill-
ness. Many of these individuals are at a high risk of
chronic diseases associated with sedentary behavior and
medication side effects, including diabetes, hyperlipi-
demia, and cardiovascular disease.
1
An essential compo-
nent of lifestyle modification is exercise. The importance
of exercise is not adequately understood or appreciated
by patients and mental health professionals alike. Evi-
dence has suggested that exercise may be an often-
neglected intervention in mental health care.
2
Aerobic exercises, including jogging, swimming,
cycling, walking, gardening, and dancing, have been
proved to reduce anxiety and depression.
3
These im-
provements in mood are proposed to be caused by
exercise-induced increase in blood circulation to the
brain and by an influence on the hypothalamic-pituitary-
adrenal (HPA) axis and, thus, on the physiologic reac-
tivity to stress.
3
This physiologic influence is probably
mediated by the communication of the HPA axis with
several regions of the brain, including the limbic system,
which controls motivation and mood; the amygdala,
which generates fear in response to stress; and the hip-
pocampus, which plays an important part in memory for-
mation as well as in mood and motivation.
Other hypotheses that have been proposed to explain
the beneficial effects of physical activity on mental
health include distraction, self-efficacy, and social inter-
action.
4
While structured group programs can be effective
for individuals with serious mental illness, lifestyle
changes that focus on the accumulation and increase of
moderate-intensity activity throughout the day may be
the most appropriate for most patients.
1
Interestingly, ad-
herence to physical activity interventions in psychiatric
patients appears to be comparable to that in the general
population.
Exercise improves mental health by reducing anxiety,
depression, and negative mood and by improving self-
esteem and cognitive function.
2
Exercise has also been
found to alleviate symptoms such as low self-esteem and
social withdrawal.
3
Exercise is especially important in
patients with schizophrenia since these patients are al-
ready vulnerable to obesity and also because of the addi-
tional risk of weight gain associated with antipsychotic
treatment, especially with the atypical antipsychotics. Pa-
tients suffering from schizophrenia who participated in
a 3-month physical conditioning program showed im-
provements in weight control and reported increased fit-
ness levels, exercise tolerance, reduced blood pressure
levels, increased perceived energy levels, and increased
upper body and hand grip strength levels.
5
Thirty minutes
of exercise of moderate intensity, such as brisk walking
for 3 days a week, is sufficient for these health benefits.
Moreover, these 30 minutes need not to be continuous;
three 10-minute walks are believed to be as equally use-
ful as one 30-minute walk.
Health benefits from regular exercise that should be
emphasized and reinforced by every mental health pro-
fessional to their patients include the following:
1. Improved sleep
2. Increased interest in sex
3. Better endurance
4. Stress relief
5. Improvement in mood
6. Increased energy and stamina
7. Reduced tiredness that can increase mental alertness
8. Weight reduction
9. Reduced cholesterol and improved cardiovascular
fitness
Mental health service providers can thus provide effec-
tive, evidence-based physical activity interventions for in-
dividuals suffering from serious mental illness. Further
studies should be done to understand the impact of combin-
ing such interventions with traditional mental health treat-
ment including psychopharmacology and psychotherapy.
The authors report no financial or other affiliation relevant to
the subject of this letter.
REFERENCES
1. Richardson CR, Faulkner G, McDevitt J, et al. Integrating
physical activity into mental health services for persons with
serious mental illness. Psychiatr Serv 2005;56:324–331
2. Callaghan P. Exercise: a neglected intervention in mental health
care? J Psychiatr Ment Health Nurs 2004;11:476–483
3. Guszkowska M. Effects of exercise on anxiety, depression and
mood [in Polish]. Psychiatr Pol 2004;38:611–620
4. Peluso MA, Andrade LH. Physical activity and mental health:
the association between exercise and mood. Clinics 2005;60:
61–70
5. Fogarty M, Happell B, Pinikahana J. The benefits of an
exercise program for people with schizophrenia: a pilot study.
Psychiatr Rehabil J 2004;28:173–176
Ashish Sharma, M.D.
University of Nebraska Medical Center
Vishal Madaan, M.D.
Creighton University/
University of Nebraska Medical Center
Frederick D. Petty, M.D., Ph.D.
Omaha VA Medical Center
Omaha, Nebraska
Citalopram Treatment for Inappropriate Sexual
Behavior in a Cognitively Impaired Patient
Sir: Sexual inappropriateness and hypersexuality can
be defined as vigorous sexual drive or other sexually
related problems that interfere with normal activities of
daily living, or sexual behavior that is pursued at inappro-
priate times. By definition, such behavior is persistent,
uninhibited, and directed against oneself or toward unwill-
ing partners. Inappropriate sexual behavior encompasses a
range of behavior, including suggestive language, flirta-
tion, fondling, removing one’s clothing, and masturbating
in public. The rates of sexual disinhibition reported in the
literature in people diagnosed with Alzheimer’s disease liv-
ing both in the community and in residential care range
from 2.9% to 8%.
1
These behaviors may result from mental
and physical illnesses, alone or in combination.
2
Work has been done as to how hospital and nursing
home staff should respond to these behaviors and guide
© C
OPYRIGHT
2006 P
HYSICIANS
P
OSTGRADUATE
P
RESS
, I
NC
. © C
OPYRIGHT
2006 P
HYSICIANS
P
OSTGRADUATE
P
RESS
, I
NC
.
LETTERS TO THE EDITOR
Prim Care Companion J Clin Psychiatry 2006;8(2) 107
the development of management strategies and care plans. Most
researchers agree that behavioral, psychological, and environ-
mental interventions are preferable to the risks of pharmacol-
ogy.
1
However, Harris and Wier,
3
in a review of the literature,
found that, in many cases, pharmacologic treatment is often
the preferred first-line treatment for hypersexual behavior be-
cause of its ease of administration, perceived efficacy, and de-
creased use of staff time. Numerous medications have been
tried for the treatment of such behaviors, but there are no con-
vincing data supporting the use of a particular medication. Be-
cause most evidence is in the form of case reports, data are also
lacking regarding the advantage of any medication over placebo
or in comparison with other medications.
Some preliminary reports indicate that selective serotonin
reuptake inhibitors (SSRIs) might be effective in controlling
such behaviors.
4,5
The reason for their effectiveness has yet
to be established, but the effectiveness could be due to their
antiobsessive and antilibidinal effects. To our knowledge, no
case reports have been published on the use of citalopram for
such behaviors. We report successful use of citalopram in the
treatment of inappropriate sexual behavior in a cognitively im-
paired adult with a history of bipolar disorder.
Case report. Mr. A, a 54-year-old man with a long history
of bipolar disorder and recent onset of cognitive deficits due to
Parkinson’s disease, had been displaying inappropriate sexual
behavior on and off for the last 5 years. This problem had re-
cently become worse and had necessitated multiple hospital ad-
missions. At the time of this admission, he was on a regimen
that included lamotrigine, clozapine, aripiprazole, ziprasidone,
and olanzapine. Once he was admitted, all of his psychotropic
medications except clozapine were stopped and lithium 150 mg
b.i.d. was initiated; after a few days, clozapine was stopped as
well.
Mr. A continued to be disorganized and was making sexually
inappropriate comments and touching female staff members,
which progressed to making inappropriate comments toward
male peers and staff members. This behavior had not responded
to the numerous antipsychotic medications he was taking at the
time of this admission. Estrogen, which has been considered ef-
fective in reducing inappropriate sexual behavior, seemed only
to have attenuated this behavior and caused the patient to de-
velop gynecomastia, which was unacceptable to him and his
family.
Mr. A was difficult to interview; he was disorganized and ex-
tremely distractible. During his lucid periods when he had more
insight, however, he would talk about thoughts of a sexual na-
ture that he was unable to get rid of despite identifying them as
improper. Neither could he control the urges to touch female
companions or make comments of a sexual nature.
After the behavior had been observed by the treatment team
for about a month, during which time trials to manage the
patient behaviorally had failed, treatment with citalopram
20 mg/day was started. Five days after the start of citalopram,
Mr. A’s inappropriate sexual behavior started to disappear. Two
weeks into therapy, although he remained somewhat disorga-
nized in his thoughts, the sexual inappropriateness had disap-
peared. No side effects were reported by the patient or noted by
the treatment team. There were no concomitant medication
changes.
In this case, we postulate that the sexually disinhibited be-
havior was caused by obsessive thoughts and resulted in com-
pulsive behavior. One can speculate that the beneficial effects
of SSRIs on these behaviors can at least partially be explained
by the effectiveness of this class of medications in treating
obsessive-compulsive spectrum disorders. Another possibility
is that, in some patients, SSRIs might have the side effect of di-
minishing libido. However, it has also been reported that SSRIs
cause disinhibition of libido.
6
Of note, this particular patient has Parkinson’s disease, a
frequent cause of such behavior. Interestingly in our case, such
behavior could not have been related to dopaminergic treatment
since no such treatment was used. This finding raises the pos-
sibility that some of the inappropriate sexual behavior that pa-
tients with Parkinson’s disease display is not the result of
dopaminergic drugs but rather may be a consequence of demen-
tia which itself often accompanies this disease.
SSRIs—in our case, citalopram—might be of use in treating
inappropriate sexual behavior. Controlled trials are needed to
establish the efficacy of these agents in treating such behavior.
If efficacy is established, further investigation to clarify why
these medications are so effective is warranted.
The authors report no financial or other affiliation relevant to the
subject of this letter.
REFERENCES
1. Higgins A, Barker P, Begley CM. Hypersexuality and dementia:
dealing with inappropriate sexual expression. Br J Nurs 2004;13:
1330–1334
2. Lesser JM, Hughes SV, Jemelka JR, et al. Sexually inappropriate
behaviors: assessment necessitates careful medical and psychological
evaluation and sensitivity. Geriatrics 2005;60:34–37
3. Harris L, Wier M. Inappropriate sexual behaviour in dementia:
a review of the treatment literature. Sex Disabil 1998;16:205–217
4. Levitsky AM, Owens NJ. Pharmacologic treatment of hypersexuality
and paraphilias in nursing home residents. J Am Geriatr Soc 1999;
47:231–234
5. Lothstein LM, Fogg-Waberski J, Reynolds P. Risk management and
treatment of sexual disinhibition in geriatric patients. Conn Med
1997;61:609–618
6. Greil W, Horvath A, Sassim N, et al. Disinhibition of libido:
an adverse effect of SSRI? J Affect Disord 2001;62:225–228
Irakli Mania, M.D.
Harun Evcimen, M.D.
Maju Mathews, M.D., M.R.C.Psych.
Department of Psychiatry
Drexel University College of Medicine
Philadelphia, Pennsylvania
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Relationship Between O2 Saturation Values, Functional Mobility, Physical Activity Levels and Quality of Life in Older People
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Introduction: Aging is an inevitable, complex and multifactorial process that leads to a set of physiological, biochemical and biomechanical changes. The present study aims to evaluate the relationship between peripheral oxygen saturation values, functional mobility, physical activity levels and quality of life in elderly people. Materials and methods: Cross-sectional study, with a sample (n = 48) of elderly people. Characterisation data, oxygen saturation values, functional mobility, physical activity levels, and quality of life were collected. Results: There were statistically significant differences (p ≤ 0.05) between the SpO2 values of subjects aged 65–79 years (96.3 ± 1.8%) versus those aged ≥ 80 years (94.6 ± 2.7%); and between those who reported mobility problems (94.6 ± 2.6) and those who did not (96.5 ± 1.6). We also observed a moderate positive correlation (r = 0.437) between SpO2 values and the mean number of steps recorded during 4 days and a moderate negative correlation (r = −487) with the times recorded in TUG. No statistically significant correlations were found between QoL and SpO2 levels. Conclusions: A decrease in SpO2 values was observed with age progression, and subjects with lower values had worse functional mobility and lowered physical activity levels. QoL is influenced by a wide range of internal and external conditions may explain the lack of significant correlations with SpO2. Even so, of the four QoL domains analysed, the physical domain showed the highest correlation coefficient.
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Hypersexuality and dementia: Dealing with inappropriate sexual expression
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Full-text available
Sexuality is always a difficult and challenging issue for nurses to address with older patients. This is particularly the case in relation to responding to incidents of hypersexuality or inappropriate sexual expression as a result of dementia. Although research suggests that hypersexuality is a rare occurrence, when it happens it has the potential to jeopardize the quality of life of all concerned. The focus of this article is on exploring the literature on hypersexuality in people with dementia in the residential care setting. Information and principles of care are offered that may help nurses respond in a sensitive manner that protects the rights, dignity and autonomy of all concerned.
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Exercise: a neglected intervention in mental health care?
Article
This paper reports the results of a literature review examining the effects of exercise on mental health and well-being. Throughout history many societies, ancient and modern, have used exercise as a means of preventing disease, and promoting health and well-being. There is evidence that exercise is beneficial for mental health; it reduces anxiety, depression, and negative mood, and improves self-esteem and cognitive functioning. Exercise is also associated with improvements in the quality of life of those living with Schizophrenia. However, exercise is seldom recognized by mainstream mental health services as an effective intervention in the care and treatment of mental health problems. There is evidence to suggest that exercise may be a neglected intervention in mental health care.
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Exercise: A neglected intervention in mental health care?
Article
This paper reports the results of a literature review examining the effects of exercise on mental health and well-being. Throughout history many societies, ancient and modern, have used exercise as a means of preventing disease, and promoting health and well-being. There is evidence that exercise is beneficial for mental health; it reduces anxiety, depression, and negative mood, and improves self-esteem and cognitive functioning. Exercise is also associated with improvements in the quality of life of those living with Schizophrenia. However, exercise is seldom recognized by mainstream mental health services as an effective intervention in the care and treatment of mental health problems. There is evidence to suggest that exercise may be a neglected intervention in mental health care.
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Inappropriate Sexual Behavior in Dementia: A Review of the Treatment Literature
Article
  • Sep 1998
Research concerning the treatment of sexually inappropriate behavior in individuals with dementia, and information concerning the treatment of those problems is not abundant. The reasons for this relative neglect are many, but the discomfort caregivers feel in discussing sexual difficulties and the cultural bias of ageism undoubtedly contribute. This manuscript reviews the literature concerning sexually inappropriate behavior in demented individuals. Behavioral and pharmacological treatment approaches are explored, and recommendations and guidelines offered by other researchers are described. Caregiver stress and other potentially serious results that can accrue from sexually indiscreet behavior is investigated, and cautions regarding provider inattention to this issue are voiced.
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Risk management and treatment of sexual disinhibition in geriatric patients
Article
Upwards of 7% of cognitively impaired elderly are reported to exhibit sexually disinhibited behaviors. These behaviors may be the result of either a chronic history of sexual disinhibition, regression, or sequel to a stroke, surgical intervention, vascular insult, blow to the head, or cardiac event in which observed cognitive deterioration is the acute symptom. Elderly patients who are sexually disinhibited may exhibit a behavior that makes it difficult to manage them at home or in a nursing home. A review of the treatment of sexual disinhibition with neurohormones is presented; guidelines for assessing risk and risk management are proposed; and a five-year study with 39 geriatric out patients with cognitive impairment and sexual disinhibitions reviewed. Case examples of sexual aggressives are followed by treatment recommendations in which an algorithm is presented. The treatment algorithm recommends beginning selective serotonin reuptake inhibitors medication before considering estrogen (preferably a patch) or antiandrogen therapy. The estrogen patch led to excellent treatment results in elderly demented men with sexual disinhibition. Elderly demented patients who are sexually disinhibited may be managed successfully with neurohormones if SSRI medication proves unsuccessful.
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Pharmacologic Treatment of Hypersexuality and Paraphilias in Nursing Home Residents
Article
  • Mar 1999
To discuss the pharmacologic options for treatment of hypersexuality or paraphilias in nursing home residents. A MEDLINE search was conducted for English-language articles published over the past 20 years and was supplemented by a search of bibliographies of relevant articles. Case reports of pharmacologic treatment of hypersexual or paraphilic behavior were selected only if the patient receiving treatment was an older person and/or cognitively impaired. Case reports were grouped according to the class of the pharmacologic agent used (antiandrogens, estrogens, GnRH analogues, or serotonergic drugs). Each case report was evaluated for pharmacologic agent administered, route of administration, duration of therapy, therapeutic response, and incidence of side effects. Nursing home residents who display hypersexual or paraphilic behavior are extremely difficult to manage. Before initiating pharmacotherapy to control unwanted sexual behaviors, the current drug regimen should be evaluated carefully for drugs that may be causing or exacerbating the behavior. Case reports suggest that antiandrogens, estrogens, GnRH analogues, and serotonergic medications may be useful when other methods have failed. Controlled comparative trials of these agents are needed to establish their efficacy clearly.
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Disinhibition of libido: An adverse effect of SSRI?
Article
The article focuses on adverse drug reactions (ADR) to selective serotonin reuptake inhibitors (SSRI) concerning libido and sexual behaviour: cases of disinhibition of libido observed at the Psychiatric Hospital of Kilchberg near Zurich are described. Within the scope of a drug safety program, the physicians of the hospital are regularly asked about severe and unexpected events under drug treatment. During remission of depression, five outpatients noticed an increase of libido experienced as strange to them, i.e. preoccupation with sexual thoughts, first appearance of promiscuity, of unsafe sexual intercourse, and of excessive pursuit of pornography, respectively, during administration, change in dose or discontinuation of SSRI. The case studies suggest that SSRI treatment might be associated with increase and disinhibition of libido. The phenomena are discussed as a "selective switch" into partly manic symptomatology or an induction of mixed states with prevailing sexual symptoms.
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Effects of exercise on anxiety, depression and mood
Article
This article reviews the studies on the effects of physical activity on the emotional states--anxiety, depression and mood. The meta-analyses of correlational and experimental studies reveal positive effects of exercise, in healthy people and in clinical populations (also in patients with emotional disorders) regardless of gender and age. The benefits are significant especially in subjects with an elevated level of anxiety and depression because of more room for possible change. The most improvements are caused by rhythmic, aerobic exercises, using of large muscle groups (jogging, swimming, cycling, walking), of moderate and low intensity. They should be conducted for 15 to 30 minutes and performed a minimum of three times a week in programs of 10-weeks or longer. The results confirm the acute effect of exercise i.e. the reductions in anxiety and depression after single sessions of exercise. The changes in anxiety, depression and mood states after exercise are explained most frequently by the endorphin and monoamine hypotheses. Exercise may also increase body temperature, blood circulation in the brain and impact on hypothalamic-pituitary-adrenal axis and physiological reactivity to stress. The possible psychological mechanisms include improvement of self-efficacy, distraction and cognitive dissonance.
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The Benefits of an Exercise Program for People with Schizophrenia: A Pilot Study.
Article
  • Feb 2004
While the benefits of physical fitness have been extensively documented, there is a paucity of literature examining the impact of an exercise program on people experiencing a mental illness. An exploratory study was conducted with six patients diagnosed with schizophrenia who participated in a 3-month physical conditioning program. The findings suggest that most participants increased their physical strength and endurance and exhibited improvements in weight control and flexibility. The majority of patients reported increased fitness levels, exercise tolerance, reduced blood pressure levels, perceived energy levels and upper body and hand grip strength levels.
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