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From PEKN 1P93 Winter 2014: Group 19: Health Promotion

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[edit] Background

Depression is a mental illness that can affect anyone and causes a constant feeling of sadness, disappointment, and lack of interest, which affects how a person acts, thinks, and feels. Having depression can lead to not only physical problems, but psychological and emotional problems as well. It can affect individuals academically, socially, as well as behaviorally. Depression is very important for individuals to understand because approximately 5.3% of the Canadian population 15 years and over have been diagnosed with symptoms of this sometimes fatal mood disorder. Up to approximately 24% of young adolescents will suffer from an episode of a depressive disorder (Martin, 1996). It affects their daily activities causing some people to feel that life is not worth living. The risk for depression was significantly higher for the physically inactive compared to regular exercise. Physical activity aids in reducing depression by taking your mind off the worries, allowing for more social interaction, and helping you to cope in a healthy way. Approximately 1 in 10 Canadians will experience depression, also previously known as melancholia, in their lifetime and it is important for them to recognize the misconceptions such as shyness, rudeness, and being anti-social, which are involved (Martin, 1996). By bringing awareness of the illness and presenting signs and symptoms, these misconceptions will be properly diagnosed.








[edit] History

Historical documents written by healers, philosophers, and writers throughout the ages point to a long existence of depression as a health problem for human beings, that in early documents was called ‘melancholia’ (Nemade et al, 2009). The earliest use of physical activity as a tool to prevent depression comes as early 480 BC from Greek physician, Herodicus to who strongly advocated for proper diet and physical training for the prevention and treatment of many diseases, including depression (University of Michigan, 2009, 1). Herodicus’ ways of utilizing physical education in disease preventative were evolved by Galen’s development of the ‘laws of health’, which included exercise as a leading contributor to health and disease prevention, as well as utilized is rehabilitation therapies (Michigan, 2009, 1).


Galen’s and Herodicus’ work with natural prevention was quickly over shadow during the Renaissance periods of Enlightenment and Scientific discovery in Europe by new, medicinal practices (Nemade et al., 2007). American –authored medical books from 1800 to 1850 showed a significant increase in the promotion of health and hygiene in correlation to a person’s overall physical and mental health. While early Greek, Babylonian, Chinese and Egyptian civilizations all viewed depression, and mental illness more generally, as a form of demonic possession in which required exorcism techniques of beatings, restrains, and starvation as an attempt at healing, modern medicine now understands how the bodies chemical composition and other environmental factors are the leading cause in the development of depression and other mental illnesses. Current studies of school ages kids prove that there is a direction association between physical activity and a decrease in the appearance of anxiety and depression (Strong et al, 2005).

[edit] Target Audience

The intended participants would be adolescents-teenagers between the ages of eleven-nineteen. This target audience was chosen because according to Hankinet et al. (as cited in Stavrakakis et al., 2013), the potential that physical activity has to reduce depressive symptoms is relevant in adolescence, as it is a time in life that the possibility for depression is at its highest. Specifically, according to Stavrakakis et al. (2013) women benefit more from low intensity activities. It was also found by Jerstad et al. (as cited in Sabiston et al., 2013) that there is a direct relationship between physical activity and depressive symptoms, more commonly seen in adolescents.

[edit] Research

[edit] Linking depression symptom trajectories in adolescence to physical activity and team sports participation in young adults

For more information, see article [1]

Bauman et al. (as cited in Sabiston et al., 2013) stated that depression has been linked with low levels of physical activity in young adults, which is very concerning because not many youth participate in physical activity programs that are associated with health benefits. Motl et al. (as cited in Sabiston et al., 2013) stated that low physical activity levels have also been related to higher depression symptoms. Studies done by Allison et al. (as cited in Sabiston et al., 2013) have also shown that the amount of time that you spend participating in physical activity is associated with lower depressive symptoms, not necessarily the intensity (low, moderate, high). Also, researchers Sabiston et al. (2013) have not yet determined whether the type of physical activity and affects depressive symptoms, such as participating on a sports team. The point of this study was to examine depressive symptom trajectories during the adolescent years as a predictor of physical activity in young adult hood (Sabiston et al., 2013).

Teens (860 participants), between the ages of 12.7-20.4, living in Montreal, Canada were told to report their depressive symptoms every 3-4 months while they were in high school (Sabiston et al., 2013). Three years later, they reported engaging in moderate-vigorous physical activity as well as participating on team sports (Sabiston et al., 2013). The results showed that three depression symptom trajectory groups were identified during the teenage years: Low and declining depressive symptom score (group 1; 37.8%), moderate and stable depressive symptom score (group 2; 41.6%), and high increasing depressive symptom score (group 3; 20.6%) (Sabiston et al., 2013). Due to these results, Sabiston et al. (2013) concluded that young adults with high and/or increasing depressive symptoms during their teenage years participate in less moderate physical activity and are less likely to play a team sport compared to the young adults with low depressive symptoms during their teenage years.

Based on the results of this study, Sabiston et al (2013) have come to the conclusion that it is important to examine both the intensity and type of physical activity with results to depressive symptoms. They also state that teens with moderate to high depressive symptoms need to be encouraged to participate in physical activity and a team sport to improve their health (Sabiston et al., 2013).

[edit] Physical activity and depressive symptoms in adolescents: a prospective study

For more information, see article [2]

Rothon et al. (2010) state that the amount of mental illness found amongst adolescents and its capability to last for an extended period of time make it a relevant and important topic to provide research on, specifically the risk and protective factors. Rothon et al. (2010) believe that there are four theories that link physical activity and depression: distraction hypothesis, mastery concept (such as learning a new sport), increased social interaction and improving self-esteem. Rothon et al. (2010) also bring up a good point of those of lower socioeconomic status are more likely to live in an area that is very crowded leaving very limited space for exercise. They also state that those adolescents living in a high crime rated environment may not be allowed to go outside and play because it is unsafe, leading to depressive symptoms of not being able to play (Rothon et al., 2010).

Participants (2,789 students) for this study were taken from 28 schools in east London between the ages of 11-14 years in the year 2010 (Rothon et al., 2010). Three years later, in the year 2013, 2,093 of those students were followed up (Rothon et al., 2010). During their follow-up students were asked to fill out a Short Moods and Feelings Questionnaire, which was used to measure the amount of depressive symptoms each of the students were (Rothon et al., 2010).

Based on the results founded by Rothon et al. (2010), it was found that one hour more of physical activity per week showed a decrease in depressive symptoms by 8% in both males and females. According to Rothon et al. (2010) this study shows that there is an association between physical activity and depressive symptoms.

[edit] Physical Activity and onset of depression in adolescents: A prospective study in the general population cohort TRAILS

For more information, see article [3]

According to Hankinet al. (as cited in Stavrakakis et al., 2013), the potential that physical activity has to reduce depressive symptoms is relevant in adolescence, as it is a time in life that the possibility for depression is at its highest. According to Allison et al., Tao et al., Goldfield et al., Johnson and Taliaferro and Brand et al. (as cited in Stavrakakis et al., 2013) there has been a number of studies that have compared the intensity of physical activity on depressive symptoms on adolescents, and the results vary greatly. Tao et al. (as cited in Stavrakakis et al., 2013) found that light to moderate physical activity protected against various depressive symptoms, but high physical activity played a role in suicide and psychological distress. In contrast, Goldfield et al. (as cited in Stavrakakis et al., 2013) found that high intensity physical activity was associated with reduced symptoms in males, and light to moderate physical activity had no effect. Brand et al. (as cited in Stavrakakis et al., 2013) revealed that athletes who exercised intensely had a lower depressive mood then non-athletes. As stated by Stavrakakis et al. (2013), the main objective of their study was to investigate the frequency, duration, and intensity of physical activity in relation to depressive symptoms in adolescence in relation to how ones depression plays out during adulthood, as well as gender differences within the participants.

As stated by Stavrakakis et al. (2013) 1,396 adolescence ages 11-14 years were assessed on the frequency, duration, and intensity of physical activity they participated in. Depression symptoms were also measure two years later by a series of questions (Stavrakakis et al., 2013). According to in Stavrakakis et al. (2013), the results of this study showed slight improvement in depressive symptoms in adults for those as adolescents participated in physical activity.

Due to the results of this study, Asztalos et al. and Mikkelsen et al. (as cited in Stavrakakis et al., 2013) state that males and females can benefit from different intensities and level of physical activity. According to Stavrakakis et al. (2013), the adults that participated in physical activity during the adolescent’s years (who suffered from depression) and who continued with this physical activity during adulthood, saw less depressive symptoms then those who didn’t. Specifically, according to Stavrakakis et al. (2013) women benefit more from low intensity activities and males benefit more from high intensity activities.

[edit] Effects of physical exercise on depression, neuroendocrine stress hormones and physiological fitness in adolescent females with depressive symptoms

[4]

Nabkasorn et al. (2005) stated that regular physical exercise might improve a variety of physiological and psychological factors in depressive people. Nabkasorn et al. (2005) acknowledges that there is little research conducted on the adolescent population, specifically females. Depression has however become more prevalent in females worldwide and therefore there is a need for greater insight (Nabkasorn et. al, 2005). Nabkasorn et al. (2005) also noted that adults who have depression normally show signs of it when then are adolescents, concluding that adolescence is an important time for intervening. The study conducted was a randomized controlled trial to investigate the effect of physical activity on depressive state persons, which the excretions of stress hormones and physiological fitness variables in adolescent females with depressive symptoms (Nabkasorn et al., 2005). Nabkasorn et al. (2005) noted that the release of the stress hormones, cortisol and epinephrine, has a direct effect with psychophysical stress and depression.

The study involved forty-nine female volunteers, aged 18-20 years of age (Nabkasorn et al., 2005). These forty-nine women were classified as having mild-to-moderate depression symptom, as measured by taking a exam from the Centre for Epidemiologic Studies Depression Scale (Nabkasorn et al., 2005). These forty-nine women were then split into two groups, A and B (Nabkasorn et al., 2005). Group A was assigned an 8-week physical exercise program that combined various aerobic exercises (Nabkasorn et al, 2005). Group B was assigned an 8-week standard physical activities program, however with a non-exercise emphasis (Nabkasorn et al., 2005). However, both groups were involved in a mild level group jogging exercise program for the length of study (Nabkasorn et al, 2005). This group based jogging activity allowed for not only physical activity but for social relationships among the participants, which helped the females motivate and push each other to their maximum effort (Nabkasorn et al., 2005). After concluding the 8-week program, both groups switched activities for another 8 weeks (Nabkasorn et al., 2005). Nabkasorn et al. (2005) concluded that twenty-four hour secretion of cortisol and epinephrine in urine were significantly reduced due to exercise routine. The concentration of these hormones in urine have been used as an indicator of sympathetic nerve activity in relation to psychophysical stress and depression (Nabkasorn et al., 2005). In addition to the lower hormone levels, the groups had a significantly reduced resting heart rate and increase peak oxygen uptake and lung capacity (Nabkasorn et al., 2005).

It can be concluded through Nabkasorn et al. (2005) research that regular group-based physical exercise can not only improve physical fitness but also build relationships between the participants. Nabkasorn et al. (2005) believes that more research should be conducted on the adolescent population in order for early detection of depression.

[edit] The association between physical fitness and depressive symptoms among young adults: results of the Northern Finland 1966 birth cohort study

[5]

Studies show that greater amounts of physical activity are commonly related with reduced depressive symptoms (Suija et al., 2013). Suija et al. (2013) looked at how physical fitness, cardiorespiratory fitness muscular fitness, leisure-time physical activity, and other variables all correlate with depressive symptoms specifically in young people. For example, the Netherlands Study of Depression and Anxiety showed that women with depressive disorders had lower handgrip strength then health women (Suija et al., 2013).

Physical testing was conducted by nurses who performed medical examinations on all participants (Suija et al., 2013). Less then 10% of participants were excluded in the study due to various disease or orthopedic problems (Suija et al., 2013). Cardiorespiratory fitness was conducted by a four-minute single leg step test, using heat rate as an indicator of cardiorespiratory fitness (Suija et al., 2013). An average pace rate was 23 steps per minute (Suija et al, 2013). Muscular fitness was measured by trunk extension and maximal isometric handgrip testing (Suija et al., 2013). Trunk extension was tested when the participant was in a prone position, examining the participant’s endurance capacity of the trunk extensor muscled by holding the upper part of the body as long as possible, however not surpassing four minutes (Suija et al., 2013). Maximal isometric handgrip strength of the dominant hand was measured with a hand dynamometer (Suija et al., 2013). Wrist and elbows were extended, allowing the participant to hold the dynamometer the hand beside but not touching their trunk (Suija et al., 2013). Leisure-time physical activity was measure by interviewing the participants on how often they were involved in light to brisk physical activities (Suija et al., 2013). Possible answers were; daily, few times a week, few times a month, or less then a month (Suija et al., 2013). Possible answers for length of activities were; 90 minutes, 60-90 minutes, 40-2o minutes, less then 20 minutes, or not at all (Suija et al, 2013). Other variables that were considered were alcohol intake, obesity, smoking and somatic diseases that have been shown to be associated with depressive symptoms and physical fitness (Suija et al., 2013).

Suija et a.l (2013) concluded that high levels of isometric endurance capacity of trunk extensor muscles are linked with low levels of depressive symptoms, as well as the link between handgrip strength and depressive symptoms. Low levels of physical activity levels also had an increase affect on depressive symptoms among young adults (Suija et al., 2013). Suija et al. (2013) intriguingly found there is no significant connotation between measured cardiorespiratory fitness and depressive symptoms. Suija et al. (2013) concluded that physical activity is inversely associated with prevalence of depressive symptoms in young adults.

[edit] Exercise and the treatment of depression: A review of the exercise program variables

[6]

Over the past several years, there is a growing curiosity in how the use of physical activity can be used to treat depression symptoms, however the dosage of how often and how much exercise remains unclear (Stanton and Reaburn, 2013). For example, Chu and et al. (as cited in Stanton and Reaburn, 2013) reported that there was no difference between a high intensity aerobic exercise (65-75%MVO2reserve), low intensity aerobic exercise (40-55%MVO2reserve), or a stretching program in the decrease of depressive symptoms after 10 weeks of training in a group of women with mild to moderate depression. Stanton and Reaburn (2013) examined various randomized controlled trials that looked at how aerobic and non-aerobic exercise affects the reduction of depressive symptoms. Stanton and Reaburn (2013) wanted to investigate the specific does of exercise that a person with depression should be receiving. This would include determining the suitable frequency, intensity, duration and type of exercise difficult levels (Stanton and Reaburn, 2013).

Stanton and Reaburn (2013) resulted in finding 102 randomized controlled trials that were examined for additional research. Training frequency was sufficiently reported in all trails, as well as intensity and duration (Stanton and Reaburn, 2013). The common frequency level was 3.8 sessions per week (Stanton and Reaburn, 2013). The common intensity level was low to moderate levels or at the participant’s preferred intensity (Stanton and Reaburn, 2013). The common duration was around 30-40 minutes in length (Stanton and Reaburn, 2013). Stanton and Reaburn (2013) also noted that intervention durations between 4-12 weeks are effective in reducing depressive symptoms. All of these studies applied treadmill walking either alone, or combined with other forms of aerobic exercise such as cross trainer, stationary cycling, outdoor walking or the participant’s personal preferences (Stanton and Reaburn, 2013). The program that would most likely benefit people with depression would include prescribing the minimum amount of exercise because this will allow them to become more motivated and more encouraged to be active over time (Stanton and Reaburn, 2013).

Stanton and Reaburn (2013) concluding in developing an exercise program, which incorporated all of their studies. This program would be supervised aerobic exercise including indoor or outdoor walking, stationary cycle or cross trainer exercise in either group, individual or combined formats, completed three to four times a week, under low to moderate intensity or at the participant’s preferred intensity, with sessions lasting 30-40 minutes in length and over 4-12 weeks (Stanton and Reaburn, 2013). This exercise regime may in turn help people with depression and allow them to live more active lives (Stanton and Reaburn, 2013).

[edit] Existing Physical Activity Programs

[edit] Heart Foundation Walking Program

The Heart Foundation Walking Program is a program where a person with depression is individualized to include forms of activity that the person is most likely to do, understanding that initially these activities may not be as enjoyable as usual. The aim of this program is to achieve at least 30 minutes of moderate-intensity physical activity on most or all days of the week, which can be accumulated in shorter bouts, such as three 10 minute walks. Although it can be difficult for people with severe depression to increase their physical activity, help is always available from the Heart Foundation professionals.

For more information about this program visit: http://www.heartfoundation.org.au/SiteCollectionDocuments/Physical-activity-and-depression.pdf

[edit] The Little Activity Big Change Program

The Little Activity Big Change Program is designed to promote physical activity and boost self-confidence in teenage girls. This program is run through Brock University, and is open to Big sisters and Little sisters. It promotes physical activity by various indoor and outdoor activities that build teamwork and self-esteem skills.

Image:Changeprogram.jpg

[edit] Minding Our Bodies Project

The Minding Our Bodies Project is in partnership with the Canadian Mental Health Association of Ontario. They serve as a mental health associate to aid with individuals who are suffering with mental health disorders such as depression. Their main incentive is to promote physical activity and healthy eating within the communities of Ontario for people with these illnesses. By promoting this awareness they plan on encouraging social inclusion through multiple programs throughout Ontario. By promoting physical exercise the body naturally releases endorphin's which help chemically regulate the body and promote feelings of happiness.

For more information about this program visit: http://www.mindingourbodies.ca/

[edit] Yoga Therapy

Yoga therapy is a gentle, calming, and soothing exercise, which will help a person raise their self-esteem. The yoga therapy instructors encourage their participants to focus on breathing, concentration, smooth movements and positive images which will in turn help them to think much more positively.

For more information about this program visit: http://yogafordepression.com/simple-practice-for-anxiety-depression/

[edit] Healthy U

An existing physical activity program is called Healthy U. Healthy U was developed as a public information and education campaign in 2002 to support and encourage Albertans to lead healthier lifestyles by providing them with access to information on healthy eating and active living (Government of Alberta, 2014). The 2012-2014 campaign supports parents and their children up to 12 years old to make healthier choices that will develop healthy habits that will last a lifetime (Government of Alberta, 2014). The goals for Healthy U are to encourage and support Albertans to become more physically active and eating healthier; to increase the number of Albertans who are physically active; and to increase the number of Albertans who eat a balanced diet following the Alberta Nutrition guidelines (Government of Alberta, 2014).

For more information about this program visit: http://www.healthyalberta.com/425.htm

[edit] Child and Family Clinic Run Group Therapy Program

The Child and Family Clinic Run Group Therapy Program of the Credit Valley Hospital is a teen "running" group therapy/research program that was designed to evaluate the impact of regular exercise on self-concept, as well as symptoms of depression and anxiety (McGann, 2014). The "learn to run" group runs over a 12 week period with the teens running as a group twice a week concluding with a 5 or 10 km community run (McGann, 2014). Participants are asked to keep a runners log and the group has a parent-teen component where stress in their relationship is pre- and post-evaluated (McGann, 2014).

For more information about this program visit: http://www.mindingourbodies.ca/program_directory/child_family_clinic_run_group_therapy_program

[edit] Best Practice Activity Suggestions

[edit] Yoga

The gentle movements, concentration and self-focus from yoga are extremely beneficial to those suffering from depression. Yoga is said to produce the brain chemical serotonin, a chemical believed to be lacking in those with depression. (Krans, 2013)

A relaxing yoga routine to help stress and depression: https://www.youtube.com/watch?v=Mqiqq3mutCQ

[edit] Team Sports

Sabiston et al. (2013) suggested teens (12.7-20.4) showing moderate to high depressive symptoms should participate in a team sport to improve their health. This can help motivate the individual to take part in activity and feel included, improving one's self-esteem.

[edit] Resistance Training

Resistance training has been compared to aerobic exercises in its effects on depression. Both aerobic and non-aerobic (resistance-training) exercises showed a significant reduction in depressive symptoms. This would be good for individuals who may not like participating in aerobic exercises as much or for a change from aerobic exercises. (Craft, 2004).

[edit] Swimming

Berger et al. (1983) conducted a study, based on the short-term influence of swimming on participants' mood. They assumed that three things would occur during the study: 1) Swimmers would report greater mood changes when tested before and after exercising, 2) The effects of swimming on mood would be similar to those reported for running, and 3) Intermediate swimmers would report greater pre-, post-swimming changes in mood than beginners. According to Berger et al. (1983), self-selected swimmers reported really "feeling better," both beginner and intermediate swimmers showed enchanted moods, mood changes accompanying exercise occurred in a "normal" population, and that there are gender differences in mood, but not in the amount of mood change, associated with swimming. Therefore, it was concluded that swimming is a best practice activity suggestion, because it has been proven that swimming decreases levels of depression.

[edit] Exercise Suggestions

Research suggests that regular exercise may be effective in preventing depression and that regular exercise alters brain chemistry, which leads to improved mood and feelings of wellbeing (Better Health Channel, 2012). The Better Health Channel (2012) suggests some ways that you can use exercise to help manage depression. The following suggestions include exercising two to five times per week; making the length of each exercise session at least 30 minutes; asking a family member or friend to be an exercise partner, as lack of motivation is one of the key characteristics of depression; and trying to live a more active lifestyle by using the stairs instead of elevators or escalators when possible (Better Health Channel, 2012).

[edit] Future Directions

Health promotion of depression, through physical exercise, would benefit from more research in many ways. According to Byrne, A. and Byrne, D.G. (1993), different types of exercise programs may have different implications for the anti-depressant, anti-anxiety and mood elevating effects of exercise and specific versus non-specific effects must be tested. In future work, the exercise program being studied should be carefully documented, controlled and measured. Future directions must also involve adequate fitness assessment techniques that complement the needs and sophistication of the study (Bryne & Byrne, 1993, p.571). Careful documentation of the specific psychological change produced by exercise treatment and a more careful selection of subjects is also necessary in future research (Bryne & Bryne, 1993, p.572). In future research, there is a clear need for an increase in the number of controlled experimental studies with study designs and methods described in sufficient detail to allow replication of past work so that confirmation of results can be achieved (Bryne & Bryne, 1993, p.572).

[edit] External Links

Bell Let’s Talk: http://letstalk.bell.ca/en/

Canadian Mental Health Association: http://www.cmha.ca

Mental Health Helpline: http://www.mentalhealthhelpline.ca

Mental Health Commission of Canada: http://www.mentalhealthcommission.ca

Teen Mental Health: http://teenmentalhealth.org

Teen Health: http://teenshealth.org/teen/your_mind/

Kids Help Phone: https://www.kidshelpphone.ca/Teens/InfoBooth/Emotional-Health/Depression.aspx

[edit] Notes and References


Berger, B.G., & Owen, D.R. (1983). Mood Alteration with Swimming - Swimmers Really Do "Feel Better." Psychosomatic Medicine, 45(5), 425-433.

Better Health Channel. (2012, March). Depression and Exercise.

Byrne, A. & Byrne, D.G. (1993). The Effect of Exercise on Depression, Anxiety and Other Mood States: A Review. Journal of Psychosematic Research, 37, 565-574.

Craft, L., & Perna, F. (2004). The Benefits of Exercise for the Clinically Depressed. The Primary Care Companion to the Journal of Clinical Psychiatry. 6(3): 104-111.

Government of Alberta. (2014). Healthy U.

Krans, B., & Krucik, G. (2010). Yoga and Depression. Depression.

Martin, G. (1996). Depression in Teenagers. Current Therapeutics, 37(6), 1-5.

McGann, D. (2014). Child & Family Clinic Run Group Therapy Program. Canadian Mental Health Association: Minding Our Bodies.

Nabkasorn, C., Miyai, N., Sootmongkol, A., Junprasert, S., Yamamoto, H., Arita, M., & Miyashita, K. (2006). Effects of physical exercise on depression, neuroendocrine stress hormones and physiological fitness in adolescent females with depressive symptoms. European Journal Of Public Health, 16(2), 179-184. doi:10.1093/eurpub/cki159

Nemade, R., Reiss, N., & Dombeck, M. (2007). Depression: Major depression & unipolar varieties. Historical Understandings of Depression. Retrieved from: http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=12995

Rothon, C., Edwards, P., Bhui, K., Viner, R., Taylor, S. and Stanfeld, S. (2010). Physical activity and depressive symptoms in adolescents: a prospective study. BMC Med. 8:32.

Sabiston, C., O’Loughlin, E., Brunet, J., Chaiton, M., Low, N., Barnett, T., and O’Loughlin, J. (2013). Linking depression symptom trajectories in adolescence to physical activity and team sports participation in young adults. Preventative Medicine. 56: 95-98

Stanton, R., & Reaburn, P. (2014). Exercise and the treatment of depression: A review of the exercise program variables. Journal Of Science & Medicine In Sport, 17(2), 177-182.

Stavrakakis, N., Roest, A., Verhulst, F., Ormel, J., Jonge, P. and Oldehinkel, A. (2013). Physical Activity and onset of depression in adolescents: A prospective study in the general population cohort TRAILS. Journal of Psychiatric Research. 47: 1304-1308.

Strong, W., Malina, R., Blimkie, C., Daniels, S.,Dishman, Rodney., Gutin, B., Hergenroeder, A., Must, Aviva., Nixon, Patricia., Pivarnik, J., Rowlan, T., Trost, S., & Trudeau, F. (2005). Evidence Based Physical Activity for School-age Youth. The Journal of Pediatrics, 146(6), 732-737.

Suija, K., Timonen, M., Suviola, M., Jokelainen, J., Järvelin, M., & Tammelin, T. (2013). The association between physical fitness and depressive symptoms among young adults: results of the Northern Finland 1966 birth cohort study. BMC Public Health, 13(1), 1-7. doi:10.1186/1471-2458-13-535nton, R., & Reaburn, P. (2014). Exercise and the treatment of depression: A review of the exercise program variables. Journal Of Science & Medicine In Sport, 17(2), 177-182.

University of Michigan. (2009). Reading #2: Origins of exercise physiology. Exercise physiology. 10. Accessed from: www.umich.edu/-exphysio/mvs110lecture/…/Reading2History.doc

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