Sunday, June 12, 2011

Is it better to prescribe or negotiate?

Engaging patients in their own care means more than just giving them a handout or teaching them how to care for their feet. The tough part is motivating them to stay engaged for the long run. This is especially difficult when they have depression which itself induces dis-engagement from the world.

Exercise is an effective treatment for depression. It is also inexpensive and has positive benefits in other spheres of health such as weight control and heart disease prevention. However, it is notoriously difficult to get depressed patients to start exercising and to keep them engaged. One reason might be that the recommended duration and intensity of exertion can seem daunting. (30 minutes on the treadmill!!!)

A team of researchers from the University of Nottingham just published the intriguing results of a controlled trial in which they compared the effects of exercise of preferred intensity with exercise of prescribed intensity in thirty-eight women living with depression. The women who chose their own level completed more sessions and had better mental AND physical health at the end of the 12 week study.

The study is quite small (only 38 subjects) and may not be the last word on this issue, but the idea certainly warrants further investigation. It suggests that engaging patients in decisions about the dose of the treatment is effective at keeping them in the treatment. And, that's better than getting them on the "right" dose.

Pragmatic randomised controlled trial of preferred intensity exercise in women living with depression. Patrick Callaghan, Elizabeth Khalil, Ioannis Morres, Tim Carter. BMC Public Health 2011; 11:465


  1. I have a couple thoughts here.

    First, the sample sizes aren't that big, which you mentioned. Also, what if the problem in adherence is in the prescription itself?

    Perhaps the recommendations are wrong and when people self-select their RPE, they are more likely to find exercise enjoyable and sustainable. Having been a runner for more than 26 years, I constantly tell people that if they don't enjoy running, they should find another way to exercise that they enjoy. Perhaps this is a simple case of people sticking with something if they enjoy it and finding a mental benefit from the enjoyment. I don't think I'd find any mental benefit to being on a treadmill and being told what to do.

    Also, the RPE between prescribed and self-selected intensity is not very high. Plus, that's a vague way to evaluate effort rather than knowing min and max heart rates and using HR as a method of calculating effort.

    Lastly, in the study itself that is referenced for prescribed exertion levels (reference 10), I don't even see recommendations, but rather self-reported data from subjects no older than 24.

    I'm not saying that the results are incorrect. The conclusions make perfect sense to me. But, the methods leave me wondering.

  2. Yes, I agree - it is just about impossible for the prescriber to know what is the "right" prescription. By working with the patient to figure it out, we may get a much better result.

    Thanks as always for your insights!


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