Discuss factors that lead to depression.

Exercise Referral – Case Study 4 Review

Exercise professional within exercise referral and working in an interdisciplinary team

Mental health conditions can affect the way you think, feel and behave that could result feeling bad or worse as any other physical illness (Mind, 2013). The majority of mental health symptoms have been divided into neurotic or psychotic symptoms. Neurotic covers symptoms that are common mental health problems such as depression, anxiety or panic attacks. Whereas the less common come under psychotic symptoms that include hallucinations such as seeing, hearing or feeling things that no one else can (Mental Health Foundation, 2015).

According to the World Health Organization (2016) depression is the direct cause of disability worldwide; it is globally approximated 350 million people of all ages to suffer from depression. Therefore, depression is one of the major contributors to the overall global burden of disease. Through the Health Survey for England (2014), women have demonstrated a common to report mental illness rather than men, with findings of 33% to 19%, the most recurrent mental illness to be diagnosed was depression with a value of 24% women and 13% men. This shows mental illness awareness is highly significant to reduce symptoms and increase quality of life. The economic burden mental illness imposes is substantial this is due to in the years of 2009-10 it has been assessed the economic and social costs for mental health problems was £105 billion pounds. Moreover, mental health is the central cause of absence from work due to illness. For example, in 2007, 70 million sick days were reasoned for poor mental health which resulted a higher unemployment (Faculty of Public Health, 2010).

Public Health England, (2013) assessed lack of physical activity could cause 36,815 premature deaths in England per year, which costs the National Health Service (NHS) £9 billion pounds based on diseases that can be reduced or be prevented through physical activity. Consequently, exercise referral service is required to prescribe and monitor patient’sphysical activity through exercise programmes tailored to the individuals (Pavey et al., 2011). This is to reduce the burden on NHS and strengthen patient’s quality of life. Furthermore, in the interdisciplinary team general practitioners will refer the patient to the exercise referral specialist and recommend a self-help group; this is where the patient has the opportunity to express their feelings (National Institute for Health and Care Excellence, 2016). Additionally National Institute for Health and Care Excellence, (2009) recommended patients with symptoms of mild to moderate depression having counseling in their treatment involves of 6-10 sessions over 8-12 weeks. As an exercise referral specialist a before and after the review of the patient per session can be undertaken, this is to be clear whether the programmes are effectively working or suitable on the patient.

National Institute for Health and Care Excellence, (2015) stated depression is a variety of emotional, cognitive, physical and behavioral symptoms. It is considered by constant low mood or loss of pleasure in majority of activities. The case study shows (see appendix 1) a female aged 47 years old with mild depression, the patient is an early retired school teacher that has limited social life and feels isolated. The patient was physically active up until the death of her husband which was 6 years ago and her weekly average of alcohol is 24 units.

Pathophysiology and medication associated with Depression

Halvorsrud and Kalfoss (2016); Kern et al., (2013) demonstrated depression has been attributed to an internal weakness. The pathophysiology of depression is the change in biochemical neurotransmitters; which are the serotonin and norepinephrine chemicals within the brain that regulate mood and emotions, which go across the synapse and send signals between the right and left of a nerve cell. Therefore due to a disruption in the synaptic the neurotransmitters weaken which result in depression.  Furthermore there are consistent evidence related to the volume loss of the hippocampus, showing untreated depression leads to hippocampal volume loss which results in greater stress sensitivity and therefore increased risk of recurrence (Bondy, 2002; Hasler, 2010). However research has not defined the clear pathophysiology of depression.  Varambally et al., (2013) implicated low brain-derived neurotrophic factor (BDNF) is related into depression. This is because BDNF is a protein for nerve growth, however in depression it has showed to have low BDNF that results in the disturbance for the transmission of the nerve impulse between neurons.

Depression episodes are typically reactive for example activated through significant psychosocial stressors (Halvorsrud and Kalfoss, 2016). According to National Institute of Public Health (2010) to acknowledge whether an individual is depressed the following symptoms must be present as depressed mood or loss of interest in every day. Symptoms of depression could be feeling fatigue or lack of energy, a loss of ability to concentrate weight loss or weight gain, sleep disturbance and reduce interest or pleasure. The patient (appendix 1) shows symptoms of diminished interest of pleasure; due to the individual not having a social life and becoming physically inactive after the bereavement of her husband. This is a common symptom in depression and many experience the symptom, (Beaulieu and Gainetdinov, 2011) showed the association between the lack of dopamine neurotransmitter and depression.
The role of dopamine in the human body is to control the human drive to seek rewards and have the ability to sense pleasure. However depressive individuals may have low dopamine levels and therefore do not drive the sense of pleasure, such as the patient (appendix 1), that does not participate in physical activity anymore due to the death of her husband. As a result of this the patient requires a strategy to become physically active again to raise the dopamine and therefore be able to do daily activities.

There are many factors that lead to depression some of the risk factors are stressful events, bereavement, alcohol and drug abuse or family history National Health Service (2015). Through the case study the patient (appendix 1) indicated signs of increased alcohol consumption due to taking up to 24 units per week. However according to the National Health Service (2015) adults are guided not to drink more than 14 units per week. Therefore showing the patient is taking nearly twice as much as she should be consuming weekly. Furthermore Barbosa-Leiker et al., (2014) showed correlation between heavy drinkers and depression, that heavy alcohol individuals had greater chance of suffering major depressive disorder and in risk of cardiovascular diseases.

Papazoglo et al., (2015) demonstrated symptoms through depression such as weight gain could lead to the risk of developing obesity. This is because the brain regulates the homeostasis and mood, if there is an increased amount of protein synthesis (GSK3β) in the hypothalamus this leads to excessive eating. Therefore the insulin and leptin which are major hormones for managing energy, lose the ability to activate the brain, if individuals are consuming more than they should and lead to obesity.

Antidepressant is a prescribed drug that is licensed to treat depression. In appendix 1 the patient has been prescribed Citalopram and Ramipril. A Citalopram is a Selective Serotonin Reuptake Inhibitor (SSRI) that corrects the chemical imbalances in the brain and circulates the serotonin, by relieving the shortage of the substances which make depression feel worthless or sad and reduces depression (Cipriani et al., 2012). The initial starting dose is 20mg per day depending on how mild or major the depression and takes up to 3- 4 weeks or longer for the antidepressant to begin. This shows that Citalopram makes you feel worse before benefitting the system. Furthermore depressive individuals are advised not to withdrawal antidepressant medication this is because there are high chances of side effects reoccurring. As a result when individuals stop taking the drug, they should be advised to decrease the amount of dose they are in taking to minimise the chances of side effects (National Institute for Health Care and Excellence, 2015).

The client is prescribed with Ramipril which is an Angiotensin-Converting Enzyme (ACE) inhibitor, this is given to individuals who have hypertension or at risk of developing. It works by stopping substances in the body that causes blood vessels to tighten, ramipril relaxes the blood vessels and decreases the blood pressure. As a result increases the supply of blood and oxygen to the heart (Joint Formulary Committee, 2014).

Exercise Programme with Critical Appraisal

The National Institute for Health and Care Excellence (2009) reported the recommended guidelines for mild to moderate depressive individuals. The physical activity recommended programme involves a group session exercise class, the dose response covers 3 sessions a week, lasting approximately 45 minutes to an hour and runs over 10-14 weeks. Mather et al., (2002) conducted a 10 week study that was taken twice a week which lasted 45 minutes, the patients were grouped into exercise classes (aerobic, weight bearing and stretches) or educational talks. The study showed 55% achieved higher response from the exercise group compared to the educational group of values p= 0.05.

As a result a 10 week exercise programme should be taken into consideration this is because exercise will show significant reduction in depression. Stanton and Reaburn (2014) recommended the frequency of exercise for depression should be three times a week at a moderate intensity which consists of aerobic exercises. This strengthen the view of the National Institute for Health Care and Excellence, 2009 as they reported the same guidelines. Therefore the exercise programme (appendix 2) dose response will be a consistent of 10+ weeks for the patient, each session will last up to 45 minutes to an hour to recognise effective result as stated in the study and through the recommended guidelines. Additionally through the study the exercise classes consisted of stretched as a result of this the exercise programme (appendix 2) consists of various stretches for the warm up and cool down for the patient. This is because there are  factors to consider for the patient, such as to lengthen the stretching in the warm up and cool down due to the patient being diagnosed with hypertension (appendix 1) as a result of this it will reduce the patient being dizzy, fatigue and injured.

Blumenthal et al., (2007) study indicated aerobic exercise training showed comparable reduction in depression as to depressive medication, with findings demonstrating in supervised exercise achieved 45% to medication 47% in the decrease of depression.

Through appendix 2, shows the patient weekly exercise program. It consist of a range of aerobic exercises such as walking to light jog which could be done within her local area, the dance and swimming’s session will be undertaken in a leisure centre. The purpose of the patient going into group sessions is to socialise therefore meet new people as well as exercise, as a result this will enhance the patient confident and well-being. The resistance exercises are suitable for the patient to undertake at home such as wall press-ups. There will be a one day rest period for the patient and the patient will do half an hour of yoga that will consist of various range of movements.

As the patient is prescribed Ramipril and Citalopram this comes with many side effects. At the start of the citalopram medication, the side effects comes with low appetite, increase muscle and joint pain, vomiting, lack of sleep and feeling angry. Additionally the client is prescribed Ramipril which is given to those with hypertension, the side effects that come along with Ramipril are vomiting, dizziness, headaches or indigestion. As a result due to medicine being treated for high blood pressure, exercise consideration should be taken into account such as to do a long cool down, this is to reduce the patient’s risk of feeling dizzy (Joint Formulary Committee, 2014).

Screening and Safeguarding

According to British Heart Foundation (2010) individuals with mental illnesses should be examined before and at the end of an exercise session. This is because an exercise referral should report back to the general practitioner. However to recognise if the patient symptoms have increased, then the exercise referral may have to carry out questions from the Hospital Anxiety and Depression Scale (HADS) questionnaire (appendix 3). This may identify if the patient should be referred back to the general practitioner to have a change of dose in the prescription.

To ensure the safety of the client it is essential for an exercise referral to conduct a screening or pre-exercise assessment to monitor the client.


  1. Barbosa-Leiker C, McPherson S, Cameron M J, Jathar R, Roll J and Dyck G D (2014) Depression as a mediator in the Longitudinal Relationship between Psychological Stress and Alcohol use. Journal of Substance, 19 (4) pp. 327-333
  2.    Beaulieu JM and Gainetdinov RR (2011) the Physiology, Signalling, and Pharmacology of Dopamine Receptors. Molecular and Cellular Biology, 63 (1) pp. 182-217
  3. Blumenthal A J, Babyak A M, Doraiswamy P M, Watkins L, Hoffman M B, Barbour A K, Herman S, Craighead W E, Brosse L A, Waugh R, Hinderliter A and Sherwood A, (2007) Exercise and Pharmacotherapy in the Treatment of Major Depressive Disorder. Psychosom Medicine, 67 (7) 587-596
  4. Bondy B, (2002) Pathophysiology of depression and mechanisms of treatment. Clinical Neuroscience, 4 (1) pp. 7-20
  5. British Heart Foundation (2010) A Toolkit for the Design, Implementation and Evaluation of Exercise Referral [Online]. Available from: <http://www.bhfactive.org.uk/exercisereferral> [Assessed 27th April]
  6. Centres for Disease Control and Prevention, (2015) Percieved Exertion (Borg Rating of Perceived Exertion Scale) [Online]. Available from: < http://www.cdc.gov/physicalactivity> [Assessed 27th April 2016]
  7. Cipriani A, Purgato M, Furukawa A T, Trespidi C, Imperadore G, Signorett A, Churchill R, Watanbe N and Barbui C (2012) Citalopram versus other anti-depressive agents for depression. Cochrane Database, 7 pp. 1-285
  8. Dunn L A, Madhukar H, Kampert B J, Clark G C, Chambliss O H, (2005) American Journal of Preventive Medicine, 28 (1) pp. 1-7
  9. Durstine J L, Moore G, Painter P and Roberts S (2009) ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. 3rd ed. United States of America: Human Kinetics
  10.  Faculty of Public Health (2010) Mental Health and Work [Online]. Available from: <http://www.fph.org.uk> [Assessed 1st March 2016]
  11.  Halvorsrud L and Kalfoss M, (2016) Exploring the Quality of Life of Depressed and Non-depressed, home-dwelling, Norwegian Adults. British Journal of Community Nursing, 21 (4) pp. 170-177
  12.  Hasler G, (2010) Pathophysiology of Depression: do we have any solid evidence of interest to clinicians? World Psychiatry, 9 (3) pp. 155-161
  13.  Health Survey England (2014) Work related stress, Anxiety and Depression Statistics [Online]. Available from: <http://www.hse.gov.uk/statistics> [Assessed 1st May 2016]
  14.  Joint Formulary Committee (2014) British National Formulary 68th ed. England: Pharmaceutical Press.
  15.  Louie L (2014) The Effectiveness of Yoga for Depression: A Critical Literature Review. Mental Health Learning, 35 (4) pp. 265-276
  16.  Mather, Rodriguez, Guthrie, McHarg, Reid, McMurdo (2002) Effects of exercise on depressive symptoms in older adults with poorly responsive depressive disorder. Randomised controlled trial. The British Journal of Psychiatry, 180 pp. 411-415
  17.  Mental Health Foundation (2015) Signs and Symptoms [Online]. Available from: <https://www.mentalhealth.org.uk> [Assessed 28th March 2016]
  18.  Mind (2013) Depression[Online]. Available from: <http://www.mind.org.uk/information> [Assessed 28th March 2016]
  19.  Murrock J C and Graor H C, (2014) Effects of Dance on Depressio, Physical Function and Disability in Underserved Adults. Journal of Aging and Physical Activity, 22 (3) pp. 360-386
  20.  National Health Service (2015) Alcohol Units [Online]. Available from: <http://www.nhs.uk/Livewell/alcohol> [Assessed 15th April 2016]
  21.  National Institute for Health and Care Excellence (2015) Depression in adults: Recognition and Management [Online]. Available from: https <http://cks.nice.org.uk/depression> [Assessed 18th March 2016]
  22.  National Institute for Health and Care Excellence (2009) Treating Depression in Adults [Online]. Available from: <https://my.leedsbeckett.ac.uk> [Assessed 5th March]
  23.  Papazoglou K I, Arnaud J, Arieh G, Taouis M, Vacher C (2015) Hippocampul GSK3β as a Molecular Link Between Obesity and Depression. Molecular Neurobiology, 52 (1) pp. 363-374
  24.  Pascoe C M and Bauer E I (2015) A Systematic Review of Randomised Control Trials on the Effects of Yoga on Stress Measures and Mood. Journal of Psychiatric Research, 68 pp. 270-282
  25.  Public Health England (2013) Physical Inactivity [Online]. Available from:<http://www.noo.org.uk/news> [Assessed 5th March 2016]
  26.  Stanton R and Reaburn P (2014) Review: Exercise and the Treatment of Depression: A review of the Exercise Program Variables. Journal of Science and Medicine in Sport, 17 (2) pp. 177-182

27.Stanton R, Rosenbaum S, Reaburn P and Happell B (2014) A multidisciplinary approach to aerobic exercise prescription to mental illness. Sport Health, 32 (3) pp. 58-62

  1.  Stults-Kolehmainen A M, Lu T, Ciccolo T J, Barthomew B J, Brontnow L and Sinha R (2016) Higher Chronic Psychological Stress is Associated with Blunted Affective Responses to Strenuous Resistance Exercise: RPE, Pleasure, Pain. Psychology of Sport and Exercise, 22 pp. 27-36
  2.  Swedish National Institute of Public Health (2010) Physical Activity in the Prevention and Treatment of Disease [Online]. Available from: <file:///C:/Users/DELL%20E5530> [Assessed 12th April 2016]
  3.  T G Pavey, A H Taylor, K R Fox, M Hillsdon, N Anoyke, J L Campbell, C Foster, C Green, T Moham, N Mutrie, J Searle, P Trueman, R S Taylor (2011) Effect of Exercise Referral Schemes in Primary Care on Physical Activity and Improving Health Outcomes: Systematic Review and Meta-Analysis. BMJ [Online], 363 (1) November, pp1-14


31.Varambally S, Naveen H G, Rao G M, Thirtalli J, Christopher R and Gangadhar N B (2013) Low Serum Brain-Derived Neurotrophic Factor in Non-Suicidal Out-Patients with Depression: Relation to Depression Scores. Indian Journal of Psychiatry, 55 (3) pp. 397-399

  1. World Health Organisation (2016) Depression [Online]. Available from: <http://www.who.int/mediacentre> [Assessed 1st April 2016]

Patient Information-Appendix 1

Exercise Programme-Appendix 2

 Weekly Exercise Programme


Day Activity
Monday Dance based exercises (leisure club)
Tuesday (check below various resistance training)
Wednesday Walking to light jog

Moderate intensity

Duration: 30 minutes

Thursday Rest day
Friday Swimming (leisure centre-meet new people)

Intensity: 1 hour

Saturday Yoga- rang of movements such as stretching

Intensity: 1 set, 1RM (each exercise)

Duration: 30 minutes

Sunday (check below various resistance training)


  • Stepper
  • Stop watch
  • Music player
  • Lunges

Warm up- Mobility (8-10 repetitions) 15 minutes


Joints Exercise Instructions
Shoulder Shoulder shrugs
  • Maintain the feet, shoulder width apart and face forward
  • Bring the shoulders up and back down
Neck Neck turns
  • Keep feet, shoulder width apart and face forward
  • Turn head left to right
  • Up and down
Elbows Elbow swings
  • Keep the feet, shoulder width apart and face forward
  • Bring the arms parallel to the ground
  • Swing both arms side to side
Spine shoulder blade squeeze
  • Keep feet, shoulder width apart and face forward
  • Bend the arm up and onto the side at the shoulder height
  • Gradually squeeze the shoulder blades together


  • Keep feet, shoulder, hip apart and face forward
  • Squat down, ensure the knees do not go past the toes and the back is straight


Ankle circles Note: If individual is not comfortable balancing, use the wall for support.

-Exercise could be done, sitting, standing or with the support of the wall

  • Feet, shoulder width apart and face forward
  • Keep the left leg stationary on the ground
  • With the right foot, bring the toe facing forward and rotate the ankle
  • Change leg to complete


Preparatory Stretches: 8-10 seconds

Name of muscle Diagram Instructions
  • raise the right arm up
  • position the arm over the head
  • using the left hand, grip hold of the right elbow
  • pull the elbow downward to stretch
  • repeat with the opposite arm


  • At start, stand straight
  • Bring the arms in front, gripping onto one another
  • Lift the arms slightly, ensuring they stretch through the back
Quadriceps   Note: If individual is not comfortable balancing, use the wall for support.

  • Keep the left foot stationery
  • Bend the right knee and pull the right foot heel toward the bottom, until there is a stretch in the thigh
  • Rotate leg to complete the stretch


  Note: If individual is not comfortable balancing, use the wall for support.

  • Keep the right leg stationery
  • With the left leg, step slightly forward
  • Bend the right knee, keep the weight onto the knee
  • Rotate leg to complete
Gastrocnemius   Note: If individual is not comfortable balancing, use the wall for support.

  • Position the legs far in front of the other
  • Ensure the back heel is flat on the floor
  • Bend the front leg, ensuring back leg is straight
  • Rotate leg to complete



Main 20 minutes

Exercise Instructions
Dance-based cardio This is exercise is a dance based cardio, it is a creative and fun idea to use to get the client moving. (music required)

  • To begin with march on the spot (repeat 10)
  • Come forward five and back five (repeat 7)
  • Repeat all at the same time (spot, front, back) (repeat 7)
  • Side step to right side and raise arm over the head, repeat with left side (repeat 7)
  • Repeat forward, back, side to side (repeat 5 times)
  • Carry on marching on the spot
  • A half turn and clap to the side (right/left)
  • Full turn and clap in the middle
Wall squats
  • To begin with keep your feet shoulder and hip apart
  • Place the ball on your back against the wall
  • Bend your knees, using the ball slide your knees down until they reached 90 degrees

1 set, 8 repetitions  

Wall press ups
  • Feet shoulder width apart, lean body forward and place palms flat against the wall (shoulder height distance)
  • Bend the elbow and lower the upper body towards the wall
  • Keep feet flat on the floor
  • Down for 2, up for 2

Repeat 8 times, rest and then repeat again (2 sets)

Wall lunges
  • Using the wall to support balance, stand 2 feet away from the wall, place your hands on the wall on the side
  • Place your right foot out and left behind, aligned
  • Bend front leg at 90 degrees, placing your knee above the ankle and the knee behind not touching the ground
  • Ensuring the upper body is upright
  • Alternative: use dumbbells to increase the intensity

Repeat on each leg 10 times, 1 set

Stepper (1 minute)
  • Place your feet in front of the stepper
  • Place one foot in the centre of the stepper and then place the other foot
  • Keep repeating
  • Moderate and quick

1 set, 1 minute

Post-workout Stretches (15-30 seconds) 12 minutes

Muscles Diagram Instructions
  • Position laying on the floor
  • Bend left knee
  • Raise the right knee up, but slightly flexed
  • Use your hands to place them on the thighs or calves to continue the stretch
  • Repeat with other leg, to complete
Erector spine
  • Position laying on the floor
  • Bend knees, pull both of the knees towards the shoulder
  • Make sure they stretch but at a comfortable position
Gastrocnemius Note: If individual is not comfortable balancing, use the wall for support.

  • Position the legs far, in front of the other
  • Ensure the back heel is flat on the floor
  • Bend the front leg, ensuring back leg is straight
  • Rotate leg to complete
  • raise the right arm up
  • position the arm over the head
  • using the left hand, grip hold of the right elbow
  • pull the elbow downward to stretch
  • repeat with the opposite arm

PAR-Q Questionnaire-Appendix 3






























Hospital Anxiety and Depression Scale (HADS)-Appendix 4

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