Physical activity and depressive symptoms in cardiac rehabilitation: Long-term effects of a self-management intervention

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Abstract

Long-term effects of a self-management intervention on physical activity and depressive symptoms were studied in 198 men and women after cardiac rehabilitation in Germany. Participants were randomly assigned to either an intervention group or a standard-care control group. The intervention group received brief self-regulatory skills training that focused on exercise planning strategies. Four and 12 months later, physical exercise levels were half a standard deviation higher in the intervention group. Depressive symptoms 12 months after discharge were almost half a standard deviation lower in the intervention group than in the control group. Mediation analyses were performed to study the potential mechanism that accounted for the reduction in depression. Perceived attainment of exercise goals, but not physical exercise itself, emerged as a mediator between the intervention and the reduction of depressive symptoms. As such attainment of personal goals appears to be of particular importance for lowering depressive symptoms during health–behavior change. Thus, self-management strategies to help patients attain their goals should be part of rehabilitation programs.

Introduction

This study was conducted to examine the effects of a brief intervention on physical exercise and depressive symptoms of cardiac patients in the year following rehabilitation treatment. A theory-guided treatment was designed to improve self-regulatory skills that are supposed to improve exercise maintenance and to lower depressive mood. Particular emphasis lies on the possible mechanisms that translate skills into emotions.

Coronary heart disease (CHD) is mainly caused by modifiable unwholesome lifestyle habits, such as inactivity, smoking, and unhealthy diet (Donker, 2000). Our study focuses on two commonly interrelated risk factors for CHD: physical inactivity and depressive symptoms (Grundy, Pasternak, Greenland, Smith, & Fuster, 1999; Salmon, 2000).

Physical exercise is an essential part of cardiac prevention and rehabilitation programs (Ades, 2001). For cardiac rehabilitation patients, regular aerobic physical activity is associated with lower mortality, lower cardiac relapses, and reduced symptoms (Ades, 2001). Patients with established CHD are recommended to exercise on an individually adapted level of intensity that accommodates the patients’ personal capacity without causing pain or ailment (Williams, 2001).

Approximately 20% of CHD patients report depressive symptoms. Even minor signs of depressive symptoms are related to a worse outcome and a higher risk of mortality in persons who already suffer from CHD (e.g., Frasure-Smith, Lespérance, & Talajic, 1993).

There is compelling evidence that physical activity is associated with lower depressive symptoms and higher positive mood. Prospective studies spanning up to 25 years underscore the beneficial effects of physical exercise on depression (Camacho, Roberts, Lazarus, Kaplan, & Cohen, 1991; Paffenbarger, Lee, & Leung, 1994). The effects of physical exercise on depressive symptoms usually persist even after controlling for sex, age, socioeconomic status, and physical illness (Stephens, 1988).

Possible mechanisms connecting physical exercise with reduced depressive symptoms are not yet well understood. Whereas many of the discussed pathways primarily center on physiological mediators between exercise and depression, in our study we alternatively focus on a cognitive pathway, that is, on subjective goal attainment.

Depressive symptoms and negative affect are often related to perceived failures in goal attainment (Carver & Scheier, 1990). Likewise, success in goal attainment has been found to be positively related to subjective well-being or to the absence of depressive symptoms (e.g., Brunstein, 1993; Emmons, 1996). For example, a study on the effects of cognitive therapy on depression found increased independent goal attainment associated with lowered depressive symptoms in depressed adults (Bieling, Beck, & Brown, 2004). Pomerantz, Saxon, and Oishi (2000) could demonstrate that the positive effect of goal investment on positive emotions was mediated by perceived accomplishment of the respective goals. Furthermore, Nelson and Craighead (1981) established that even goal attainment in laboratory tasks (i.e., tasks with low personal relevance) was negatively related to depressive symptoms when persons attributed their success internally.

The attainment of personal goals is difficult. Thus, self-regulatory skills play a crucial role, especially for complex, effort-demanding, and long-term goals, such as changing one's sedentary lifestyle into a physically active one.

Cardiac rehabilitation patients usually report strong intentions to become physically active on a regular basis (e.g., Johnston, Johnston, Pollard, Kinmonth, & Mant, 2004). Results of longitudinal studies, however, indicate that there is a discrepancy between the intentions and the subsequent behavior of these patients (e.g., Johnston et al., 2004). For example, in the aftermath of cardiac events, patients often initiate lifestyle changes, but they maintain these changes less often (Dusseldorp, Van Elderen, Maes, Meulman, & Kraaij, 1999). This is further supported by studies showing that, for example, attrition in post-rehabilitation physical exercise programs is generally high and increases over time (Moore, Ruland, Pashkow, & Blackburn, 1998). Thus, reporting high intentions might not suffice for actual changes in behavior. This phenomenon is known as intention-behavior gap (Sheeran, 2002).

In order to account theoretically for this gap between intentions and behavior, self-regulatory processes following intentions help to initiate and maintain behavior change (Luszczynska & Schwarzer, 2003; Schwarzer, 1992). One self-regulatory skill is planning (Gollwitzer, 1999; Leventhal, Singer, & Jones, 1965; Sniehotta, Schwarzer, Scholz, & Schüz, 2005). Sniehotta et al. (2005) propose the subdivision of planning into action planning and coping planning. Action planning specifies exactly where, when, and how to act (Leventhal et al., 1965). It has consistently been found to predict goal attainment in various domains, including physical activity (Gollwitzer, 1999). Coping planning refers to planning exactly what to do when barriers come into view (e.g., Lippke, Ziegelmann, & Schwarzer, 2004; Sniehotta, Scholz, & Schwarzer, in press). A coping plan might read, “If I want to go running but it is raining heavily, I will go swimming instead.” By linking appropriate coping responses to situational cues of anticipated risk situations, the intended behavior is more likely to be executed despite barriers and obstacles.

Planning is assumed to be useful in fostering behavior change and promoting personal goal attainment. The two distinct planning strategies are hypothesized to bridge the intention-behavior gap. Thus, an intervention facilitating both kinds of planning might not only be able to promote regular physical exercise, but also to lower depressive symptoms via physical exercise and the attainment of a personal physical exercise goal.

Four aims guided this study: First, we examined whether a self-regulatory intervention (action planning and coping planning) can foster maintenance of physical activity levels in the year after cardiac rehabilitation treatment. Second, we hypothesized that the same intervention might lower depressive symptoms within a one-year observation period. Third, we assumed that physical activity would mediate between the intervention effects and later changes in depressive symptoms. And fourth, a second mediational factor for the intervention effect on depressive symptoms was assumed to be the subjective attainment of exercise goals, i.e., if physically active patients believe that they have reached their personal goals they should become less depressed.

Section snippets

Sample and procedure

Participants were 198 patients who took part in a 3-week standard-care cardiac rehabilitation program. In Germany, standard-care cardiac rehabilitation is provided on an inpatient basis. It includes guided exercise sessions at least three–four times a week, such as bicycle ergometer training or power walking, with individualized intensity levels prescribed by a physician. In addition, patients attended courses on preventing CHD risk factors (e.g., balanced nutrition, smoking cessation) as well

Randomization check

Cell sizes of the two experimental groups turned out to be slightly unequal due to the randomization procedure. Participants with odd IDs were consecutively assigned to the intervention group, and those with even IDs to the control group. The IDs were specific for each consultant making initial contacts with patients. The initially unequal group sizes (control group: n=95, intervention group: n=103) were due to consultants seeing an uneven number of patients.

A one-way ANOVA did not reveal any

Discussion

The first two research questions of this study concerned the efficacy of a brief self-regulatory intervention (action planning plus coping planning) in fostering maintenance of physical activity levels after cardiac rehabilitation and lowering depressive symptoms within a one-year observation period. The intervention that combined the planning strategies with a weekly diary positively influenced both risk factors for CHD. Compared to a standard-care treatment, the intervention enhanced physical

References (49)

  • J.C. Brunstein

    Personal goals and subjective well being: A longitudinal study

    Journal of Personality and Social Psychology

    (1993)
  • R.C. Camacho et al.

    Physical activity and depression: Evidence from the Alameda County study

    American Journal of Epidemiology

    (1991)
  • C.S. Carver et al.

    Origins and functions of positive and negative affect: A control-process view

    Psychological Review

    (1990)
  • L. Cooper-Patrick et al.

    Exercise and depression in midlife: A prospective study

    American Journal of Public Health

    (1997)
  • S.L. Dupuis et al.

    An examination of the relationship between psychological well being and depression and leisure activity participation among older adults

    Society and Leisure

    (1995)
  • E. Dusseldorp et al.

    A meta-analysis of psychoeducational programs for coronary heart disease patients

    Health Psychology

    (1999)
  • R.A. Emmons

    Striving and feeling: Personal goals and subjective well being

  • N. Frasure-Smith et al.

    Depression following myocardial infarction: Impact on 6-month survival

    Journal of the American Medical Association

    (1993)
  • P. Gollwitzer

    Implementation intentions. Strong effects of simple plans

    American Psychologist

    (1999)
  • S.M. Grundy et al.

    Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations. A statement of healthcare professionals from the American Heart Association and the American College of Cardiology

    Circulation

    (1999)
  • M. Hautzinger

    Die CES-D Skala: Ein Depressionsmessinstrument für Untersuchungen in der Allgemeinbevölkerung [The CES-D scale: An instrument for the assessment of depression in the normal population]

    Diagnostica

    (1988)
  • D.W. Johnston et al.

    Motivation is not enough: Prediction of risk behavior following diagnosis of coronary heart disease from the theory of planned behavior

    Health Psychology

    (2004)
  • R.S. Lazarus

    Emotion and adaptation

    (1991)
  • H. Leventhal et al.

    Effects of fear and specificity of recommendation upon attitudes and behavior

    Journal of Personality and Social Psychology

    (1965)
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