Exercise As a Prescription for Patients with Depressive Disorders: A Quality Improvement Project
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Exercise As a Prescription for Patients with Depressive Disorders: A Quality Improvement Project

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Purpose: The aim of this evidence-based practice Doctor of Nursing Practice (DNP) project was to increase the rates of provider counseling for physical exercise as a treatment intervention for patients with depressive disorders by (1) implementing a focused educational training program to increase provider knowledge and (2) understanding the factors that impacted utilization of the practice change in the clinical setting to guide process improvement strategies.

Background: Approximately 280 million individuals globally suffer from depressive disorders. In addition, depression remains the 4th leading cause of disabilities, significantly contributing toward the global burden of disease with risk of increased morbidity, mortality, and an overall decreased quality of of life. Psychopharmacology and psychotherapy are considered gold-standards of treatment, though yield unique challenges, including adverse effects, accessibility, or patient financial burden. Research indicates physical activity to be a cost-effective, evidence-based intervention that can benefit mental health whilereducing long-term effects of depressive symptoms. The Centers for Disease Control and Prevention (CDC) physical activity clinical practice guideline recommends 150 minutes of moderate to vigorous physical activity per week for overall mood improvement. Moreover, a large population study of 17,839 adults found that the combination of aerobic and strength exercises was associated with the lowest likelihood of reporting depressive symptoms, followed by aerobic only and strength only, with prevalence ratios 0.26-0.54, 0.36-0.62, and 0.49-0.84. Despite clear benefits, mental health care providers often underutilize physical activity counseling or prescription.

Methods: A mixed quantitative and qualitative approach was used to identify and characterize thereasons Nurse Practitioner (NP) trainees in the UC San Diego Psychiatric NP Training Program adoptedthe interventional training [Physical Activity Counseling to Patient’s with Depressive Disorders] intoclinical practice for delivery with adults diagnosed with depressive disorders served at an outpatientmental health clinic. Phase one consisted of retrospective chart reviews in the Electronic Health Record (EHR) from May – September 2022, followed by brief semi-structured interviews and surveys inFebruary 2023. Utilization of the Evidence Based Practice Attitude Scale (EBPAS) was highlighted within the survey.

Results: Four NP trainees attended the focused educational training with a 100% follow-up response rate. Overall, the training was considered valuable and informative. When comparing pre- versus post-data,there was an increase from 2% to 17% implementation from baseline to two months post educationalintervention, leading to a 750% increase in patients who received exercise counseling. EBPAS resultsidentify high scores in requirement and appeal of training, with a low divergence rating, indicating anoverall positive attitude towards adoption of the training. Conversely, amongst all trainees, there was avast discrepancy between everyone’s self-report of implementation into clinical practice compared towhat was documented, in which time and environment were noted to be the main barriers.

Evaluation: Focused educational training is a favorable approach to encourage mental health providers torecommend exercise to patients with depressive disorders. Future recommendations include a morecomprehensive training program and implementation of time saving strategies to mitigate the existingbarriers that may prevent adoption into clinical practice. Further research is needed to understand the impact of this practice on long term patient outcomes.

Keywords: Prescribing Exercise, Physical Activity, Depression, Attitudes, Mental Health

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