https://doi.org/10.24095/hpcdp.37.5.

03

Self-management of mood and/or anxiety disorders

through physical activity/exercise
Louise Pelletier, MD (1); Shamila Shanmugasegaram, PhD (1); Scott B. Patten, MD, PhD (2); Alain Demers, PhD (1)

This article has been peer reviewed. Tweet this article

Abstract
Highlights
Introduction: Physical activity/exercise is regarded as an important self-management
strategy for individuals with mental illness. The purpose of this study was to describe • Even though physical activity/exer-
individuals with mood and/or anxiety disorders who were exercising or engaging in cise is effective in decreasing mood
physical activity to help manage their disorders versus those who were not, and the and anxiety symptoms, 51% of
facilitators for and barriers to engaging in physical activity/exercise. those affected by a mood and/or
anxiety disorder do not exercise at
Methods: For this study, we used data from the 2014 Survey on Living with Chronic least once a week on a regular
Diseases in Canada—Mood and Anxiety Disorders Component. Selected respondents basis.
(n  =  2678) were classified according to the frequency with which they exercised: • Canadians with a mood disorder
(1) did not exercise; (2) exercised 1 to 3 times a week; or (3) exercised 4 or more times and those with physical comorbidi-
a week. We performed descriptive and multinomial multiple logistic regression analy- ties were less likely to exercise reg-
ses. Estimates were weighted to represent the Canadian adult household population ularly (at least once a week).
living in the 10 provinces with diagnosed mood and/or anxiety disorders. • The most important factor associ-
ated with engaging in physical
Results: While 51.0% of the Canadians affected were not exercising to help manage activity was to have received advice
their mood and/or anxiety disorders, 23.8% were exercising from 1 to 3 times a week, to do so by a physician or other
and 25.3% were exercising 4 or more times a week. Increasing age and decreasing lev- health professional.
els of education and household income adequacy were associated with increasing prev- • Health professionals play a critical
alence of physical inactivity. Individuals with a mood disorder (with or without anxiety) role in recommending and sup-
and those with physical comorbidities were less likely to exercise regularly. The most porting engagement in physical
important factor associated with engaging in physical activity/exercise was to have activity/exercise, particularly for
received advice to do so by a physician or other health professional. The most fre- those with a mood disorder and
quently cited barriers for not exercising at least once a week were as follows: prevented physical comorbidities.
by physical condition (27.3%), time constraints/too busy (24.1%) and lack of will
power/self-discipline (15.8%).
objectives of self-management are to
Conclusion: Even though physical activity/exercise has been shown beneficial for decrease symptoms, enhance quality of
depression and anxiety symptoms, a large proportion of those with mood and/or anxi- life and prevent relapse or recurrence.3,5
ety disorders did not exercise regularly, particularly those affected by mood disorders
and those with physical comorbidities. It is essential that health professionals recom- Self-management in mental illness can be
mend physical activity/exercise to their patients, discuss barriers and support their used as a complement to conventional
engagement. clinical therapies such as medication and
psychotherapy or as a first-line low-inten-
Keywords: mood disorders, depression, anxiety disorders, physical activity, exercise, sity intervention, especially among indi-
self-management viduals with mild-to-moderate symptoms.6
Among the many self-management inter-
ventions proposed for mood and anxiety
Introduction its use in mental illness is more recent.3 disorders, the most frequently studied
Self-management is defined as the train- include bibliotherapy or computer-based
While self-management has been part of ing, skill acquisition and interventions cognitive behavioural therapy (CBT),7-9
an overall management strategy for chronic through which individuals who suffer herbal therapies,10-12 meditation or relax-
physical conditions such as diabetes, from a disease take care of themselves in ation techniques13-16 and physical activity/
asthma and arthritis for some decades,1,2 order to manage their illness.3,4 The exercise.17-22

Author references:
1. Public Health Agency of Canada, Ottawa, Ontario, Canada
2. Department of Community Health Sciences & Mathison Centre for Mental Health Research & Education, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Correspondence: Louise Pelletier, Public Health Agency of Canada, 785 Carling Avenue, AL 6806A, Ottawa, ON  K1A 0K9; Tel: 613-960-5339; Fax: 613-941-2057;
Email: [email protected]

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Vol 37, No 5, May 2017 149 Research, Policy and Practice
Physical activity/exercise is thought to Disorders Component (SLCDC-MA), a 968  with concurrent mood and anxiety
improve depression and anxiety symp- cross-sectional follow-up survey to the disorders). The term “mood and/or anxi-
toms through a number of physiological 2013 Canadian Community Health Survey ety disorders” used throughout this article
mechanisms as well as through its effect (CCHS)—Annual Component. The 2014 refers to those who have self-reported, pro-
on sleep, sense of mastery and social SLCDC-MA was developed by the Public fessionally diagnosed mood disorders only,
interactions.20,23,24 In general, it has been Health Agency of Canada, in collaboration anxiety disorders only, or concurrent mood
shown that an exercise program of at least with Statistics Canada and external and anxiety disorders. Figure 1 illustrates
10 weeks or more, with relatively intense experts, to provide information on the how respondents were selected for the final
physical activity for at least 20 to 30 min- impact and management of mood and/or study sample.
utes at a frequency of 3 to 4 times per anxiety disorders among Canadian adults.
week, is effective for depression and for Respondents aged 18 years and older who Measures
some anxiety disorders.19,24,25 reported having a mood and/or an anxiety
disorder as part of the 2013 CCHS were In the 2014 SLCDC-MA, respondents were
Physical activity/exercise as a treatment eligible to participate in the 2014 SLCDC-MA. asked the following questions to confirm
has consistently been shown to be supe- The 2014 SLCDC-MA surveyed individuals diagnosis of mood and/or anxiety disor-
rior to control interventions and some- living in private dwellings in the 10 Canadian ders: (1) “Do you have a mood disorder
times comparable to mainstream therapies provinces. Full-time members of the such as depression, bipolar disorder,
(e.g. medication or CBT) for mild and Canadian Forces, people living on reserves mania or dysthymia that has been diag-
moderate depression.17-21 A limited num- and other Aboriginal settlements, those nosed by a health professional?” and
ber of studies on the effects of exercise as residing in institutions and residents of (2) “Do you have an anxiety disorder such
a treatment strategy for anxiety disorders certain remote regions and Canada’s three as phobia, obsessive-compulsive disorder,
have shown generally positive effects of territories (Nunavut, Northwest Territories panic disorder that has been diagnosed by
exercise,19,22 but the impact (effect size) is and Yukon) were excluded from the sam- a health professional?” Those who responded
usually smaller than that observed for pling frame. These exclusions represented “yes” to either or both of these questions
depressive symptoms.26 less than 3% of the overall target popula- were included in this study.
tion. The 2014 SLCDC-MA was adminis-
There is a lack of data describing individu- tered by trained personnel via a structured Exercise subgroups
als who engage in or conversely who do not telephone interview (in English or French) Respondents who answered “yes” to the
engage in physical activity/exercise to help during two data collection periods: question “As a result of being diagnosed
manage their mood and/or anxiety disor- November to December 2013 and February with [a mood disorder/an anxiety disorder/a
ders. This is the first study in Canada to to March 2014. The methodology of the mood or anxiety disorder], did you ever
examine the uptake of this strategy in a 2014 SLCDC-MA was described in an ear- exercise or participate in physical activi-
nationally representative sample of people lier publication.27 ties to help manage your [mood disorder/
with mood and/or anxiety disorders living anxiety disorder/mood or anxiety disor-
in the community. This knowledge could Study sample der]?” were subsequently asked “Are you
assist in developing or adapting interven- still doing this?” If the answer was affir-
tions to promote the engagement of physical In the 2013 CCHS, 5875 respondents indi-
mative, they were asked about the fre-
activity/exercise in this population. Thus, cated that they had been diagnosed with a
quency of the activity with the following
the objectives of the present study were mood and/or anxiety disorder by a health
question: “How often do you do this?”
professional and met the eligibility crite-
(1) to describe individuals with mood and/ Possible responses included every day, 4
rion to participate in the 2014 SLCDC-MA.
or anxiety disorders who are currently exer- to 6 times per week, 2 to 3 times per
Of these respondents, 3361 participated in
cising (1 to 3 times a week and 4 or more week, once a week, less than once a week
the 2014 SLCDC-MA and consented to
times a week) versus those who are not and less than once a month. These fre-
share their data with the Public Health
engaging in exercise, in terms of sociodemo- quencies were combined in the following
Agency of Canada (response rate = 68.9%).
graphic and clinical characteristics; three subcategories:
For the purpose of this study, respondents
(2) to determine whether there are associ- who replied “no” to having a mood and/ (1) “No exercise” (included those who
ations between exercise frequency and or anxiety disorder that has been diag- responded “No” to the question “Did you
perceived general and mental health and nosed by a health professional but “yes” ever exercise or participate in physical
life satisfaction; and to having ever been diagnosed were excluded activities to help manage your [mood dis-
(3) to describe facilitators and barriers for from the study (n  =  445). In addition, order/anxiety disorder/mood or anxiety
engaging or not engaging in exercise as a respondents who indicated that they were disorder]?” and those who answered that
means to help manage mood and/or anxi- already engaging in physical activity for they were engaging in exercise less than
ety disorders in the population affected. reasons other than to help manage their once a week or less than once a month);
mood and/or anxiety disorders (n = 238)
(2) “1 to 3 times a week” (combined those
Methods were also excluded from this study since
who reported engaging in physical activ-
physical activity/exercise frequency data
ity/exercise once a week or 2 to 3 times
Data source were not collected from them. A total of
per week); and
2678 Canadians with a mood and/or an
This study was based on data from the anxiety disorder were included in our (3) “4 or more times a week” (included
2014 Survey on Living with Chronic study (1134 with a mood disorder only, those who were exercising 4 to 6 times a
Diseases in Canada—Mood and Anxiety 576 with an anxiety disorder only and week or daily).

Health Promotion and Chronic Disease Prevention in Canada

Research, Policy and Practice 150 Vol 37, No 5, May 2017
 FIGURE 1
Flowchart illustrating how respondents were identified for the final study sample (n = 2678), 2014 SLCDC-MA

Predetermined exclusions
nexclusions = 1688
Sampling frame (2013 CCHS)
Exclusion criteria:
Ntotal with mood and/or anxiety disorders = 7563 • Being less than 18 years of age
• Being a resident of one of the three territories
• Not having a valid phone number
• Completing CCHS interview by proxy
• Not giving permission to share or link CCHS data

Out-of-scope
nout-of-scope = 994 (707 resolved cases and 287 estimated for unresolved cases)
Sample selected Reasons for being out-of-scope include:

ntotal = 5875 • Being incorrectly classified as having the condition in the CCHS
• Deliberately providing answers in order to be screened out of the survey
• Having emigrated
• Being deceased

Non-response
nnon-response = 1520
Modelled in-scope sample
Reasons for non-response include:
ntotal = 4881 • Not having a valid phone number
• Not agreeing to participate
• Not completing the whole survey
• Not giving permission to share or link CCHS data

Excluded those without a current mood and/or anxiety disorder

nexcluded = 445
Those who responded “no” to the question: “Do you have a mood disorder such as depression,
Final 2014 SLCDC-MA sample bipolar disorder, mania or dysthymia that has been diagnosed by a health professional?” but
responded “yes” to the following question: “Have you ever been diagnosed with a mood disorder
ntotal = 3361
such as depression, bipolar disorder, mania or dysthymia?” were excluded. The same procedure
was performed for those with an anxiety disorder.

Excluded those already doing physical activity/exercise for other reason

nexcluded = 238
2014 SLCDC-MA sample with
a current mood and/or Those who responded “no” to the question “As a result of being diagnosed with [a mood disorder/
anxiety disorder an anxiety disorder/a mood or anxiety disorder], did you ever exercise or participate in physical
activities to help manage your [mood disorder/anxiety disorder/mood or anxiety disorder]?” and
ntotal = 2916 responded “Already doing this for other reasons” to the question “What are the reasons why [you
do not/you no longer/you do not frequently] exercise or participate in physical activity (to help
manage your [mood disorder/anxiety disorder/mood or anxiety disorder])?”

Final study sample

ntotal = 2678

Abbreviations: CCHS, Canadian Community Health Survey; n, unweighted number; SLCDC-MA, Survey on Living with Chronic Diseases in Canada—Mood and Anxiety Component.

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Vol 37, No 5, May 2017 151 Research, Policy and Practice
While “physical activity” refers to any receipt of recommendation to exercise and options, we defined three categories:
activity that contracts muscles, expends the receipt of clinical treatment. “poor health” included those who reported
energy and includes work, household or their health as “fair” or “poor”; “good
leisure activities, “exercise” refers to a The number of physical comorbidities was health” was a category in itself; and “very
planned, structured and repetitive body determined by asking respondents if they good health” included those who reported
movement performed to improve or main- had any of the following conditions diag- their health as “very good” or “excellent.”
tain physical fitness.28 Despite the differ- nosed by a health professional that had Life satisfaction was assessed by asking
ences, these terms were used interchangeably lasted or were expected to last six months respondents how they feel about their life
in the survey questions and we are there- or longer: asthma, chronic obstructive as a whole right now using a scale from 0
fore using them interchangeably in this pulmonary disease, arthritis, back prob- to 10, where 0 was “very dissatisfied” and
paper. In addition, given that we did not lems, bowel disorder/Crohn disease or 10 was “very satisfied.” In our study, sat-
have information on the duration and the colitis, diabetes, heart disease, cancer, isfaction with life was defined as “dissat-
intensity of the physical activity/exercise stroke and Alzheimer disease or any other isfied” (a response of 0–4), “neutral” (5)
dementia. Each reported disease was or “satisfied” (6–10).
sessions, we were not able to directly
relate the observed frequency to the cur- counted as a separate comorbidity and
rent Canadian Physical Activity Guidelines, their summation was categorized in three Statistical analyses
which recommend at least 150 minutes of groups (none, 1–2 and 3+). Receipt of a
clinical recommendation to exercise was To account for sample allocation and sur-
moderate-to-vigorous physical activity per vey design, all estimates were based on
week for adults aged 18 to 64 years.29 determined by asking respondents “Has a
doctor or other health professional ever weighted data using weights generated by
While more physical activity provides Statistics Canada so that the data would
greater health benefits, it is recognized suggested participating in physical activity
be representative of the Canadian popula-
that engaging in amounts below the rec- or exercise to help you manage your
tion aged 18 years and older living in the
ommended levels can still provide some [mood disorder/anxiety disorder/mood or
community, in the 10 provinces, with
health benefits.30 Therefore, we consid- anxiety disorder]?”, with a yes-or-no
mood and/or anxiety disorders. Weights
response format. Receipt of clinical treat-
ered that individuals incorporating physi- were adjusted for exclusions, sample
ment was defined as current use of pre-
cal activity/exercise at least once a week selection, in-scope rates, non-response
scription medications and/or psychological
in their schedule were doing “regular” and permission to share and link.32
counselling as determined by the follow-
physical activity/exercise for the purpose Furthermore, variance estimates (95%
ing questions: “Currently, are you taking
of this study. confidence intervals and coefficients of
any prescription medications for your
variation) were generated using bootstrap
[mood and/or anxiety] disorder?” (response
Sociodemographic and clinical weights provided with the data.33 Only
options: “yes,” “no”); and “In the past
characteristics results with a coefficient of variation less
12 months, did you receive psychological
Sociodemographic variables included age than 33.3% are reported, as per Statistics
counselling to help manage your [mood
(age groups were 18–34, 35–49, 50–64, and Canada guidelines.32
and/or anxiety] disorder?” (response options:
65+ years), sex (female, male), respon- “yes,” “no”). Those who responded “yes”
dent’s level of education (less than second- We performed chi-square analyses to
to either were considered to be receiving
explore the relationships between the
ary school graduation, secondary school clinical treatment.
three physical activity/exercise subgroups
graduation/no post-secondary, some post-
and respondents’ sociodemographic char-
secondary, and post-secondary graduation), Barriers to engaging in exercise acteristics, number of comorbidities, type
household income adequacy quintiles Those respondents who indicated that of disorders, number of years since diag-
(deciles, a derived variable by Statistics they do not or no longer exercise or par- nosis and use of conventional clinical
Canada,* transformed into quintiles), mar- ticipate in physical activity since their treatment, and whether they had received
ital status (single/never married, widowed/ diagnosis were asked to specify the a clinical recommendation to participate
divorced/separated, married/living com- reason(s) why from the following list of in physical activity or exercise.
mon-law), geographic regions (British barriers: “lack of will power/self-discipline,”
Columbia, Prairie region, Ontario, Quebec, “time constraints/too busy,” “prevented We used multinomial multivariate logistic
Atlantic region), place of residence (urban, by physical condition,” “didn’t know it is regression analysis to examine potential
rural), and immigrant and Aboriginal sta- important/recommended,” “too costly/ associations between exercise frequency
tuses (yes, no). financial constraints,” “other” and “no (defined as no exercise, 1–3 times a week,
reason.” 4 times or more a week) and perceived
Clinical characteristics included the type general and mental health, and life satis-
of disorders (mood disorder only, anxiety Health status faction, adjusting for all sociodemographic
disorder only, and concurrent mood and Perceived general health and mental and clinical characteristics found statisti-
anxiety disorders), the number of years health were evaluated using self-reported cally significant in the bivariate analyses.
since diagnosis (0–4, 5–19, and 20+), the general health and mental health ques- It should be noted that the data did not
number of physical comorbidities, the tions. From the five possible response meet the proportional odds assumption

* This derived variable is a distribution of respondents in deciles (ten categories including approximately the same percentage of residents for each province) based on the adjusted ratio of their
total household income to the low-income cut-off corresponding to their household and community size. It provides, for each respondent, a relative measure of their household income to the
household incomes of all other respondents.31

Health Promotion and Chronic Disease Prevention in Canada

Research, Policy and Practice 152 Vol 37, No 5, May 2017
required to use ordinal regression. Stat­ (vs. those who were) were less likely to Discussion
istical significance was determined at the exercise 1 to 3 times a week. When we
p < .05 level. We used SAS Enterprise Guide compared those who exercised 4 or more While regular physical activity/exercise
version 5.1 (SAS Institute Inc., Cary, NC, times a week to those who did not exer- has been shown to improve depression
USA) for the data analyses. cise, individuals’ province or region (e.g. and anxiety symptoms,26 approximately
those living in all other regions vs. in 50% of those diagnosed with these disor-
Results British Columbia), type of disorders and ders in our study did not exercise re­gularly
advice by a health professional remained (i.e. at least once a week), highlighting an
While 51.0% of the Canadians affected
significant. The most important factor opportunity for improvement in the care
were not exercising to help manage their
associated with physical activity/exercise and management of such individuals.
mood and/or anxiety disorders, about half
participation (at any level) was to have had Even though physical activity/exercise is
were exercising at least once a week, with
physical activity or exercise recommended usually considered an adjunct therapy to
23.8% exercising from 1 to 3 times a week
by a health professional. Depending on conventional clinical treatment (medica-
and 25.3% exercising 4 or more times a
the frequency of exercise, those not receiv- tion and/or psychotherapy) in most clini-
week. Furthermore, we found important
ing advice to exercise had approximately cal guidelines,34-36 it could also be used as
differences among those who exercised
3 to 5 times lower odds of using exercise a first-line, low-intensity intervention for
regularly (i.e. at least once a week) and
for self-management than those receiving mild-to-moderate mood and anxiety disor-
those who did not (Table 1). Increasing
ders, along with other self-management
age and decreasing levels of education such advice. Therefore, receiving or not
strategies.6,37,38
and household income were associated receiving advice, based on the point esti-
with increasing frequency of inactivity. mate of the OR, is more strongly associ-
Differences were also observed among the Findings from this study show that
ated with physical activity/exercise than
provinces or regions of residence: while affected Canadians who were less likely to
education, age, province and type of
those from British Columbia (67.6%) engage in physical activity/exercise were
disorder.
were the most active, slightly more than older, less educated, belonged to the low-
50% of individuals from Ontario and the est income quintiles and resided in
Table 3 presents the associations between Ontario and the Atlantic provinces com-
Atlantic and Prairie regions did not exer-
perceived well-being and physical activ- pared to those who engaged. These results
cise regularly.
ity/exercise frequency. In general, individ- are similar to those of the general
uals who did not engage in exercise were Canadian population who are inactive.38
In terms of clinical characteristics, Canadians
more likely to rate their perceived general
with mood disorders (with or without
and mental health as “fair/poor” and to As shown in other studies,39,40 those with
anxiety) and those with physical comor-
bidities were less likely to exercise regu- be dissatisfied with life. However, the physical comorbidities were less likely to
larly. In addition, individuals with a more association between self-reported mental exercise (although this finding disap-
recent diagnosis (< 5 years) or long-term health and physical activity/exercise fre- peared when we adjusted for age and
disease duration (20+ years) were less quency was not statistically significant. other sociodemographic variables). Simi­
likely to exercise. Those who were treated Even after adjusting for sociodemographic larly, physical conditions (along with time
with conventional clinical therapy (medi- and clinical characteristics that could have constraints) were one of the most fre-
cation and/or psychotherapy) were slightly impacted general well-being, the inverse quently cited barriers in our study. While
more likely to exercise 1 to 3 times a association between exercising 1 to 3 times the presence of a physical comorbidity
week; conversely, those with no clinical a week (vs. no exercise) and “fair/poor” may compound the perceived barriers to
treatment were more likely to exercise 4 or or “good” general health (vs. “very good/ engaging in physical activity/exercise, a
more times a week. Finally, another excellent”) and dissatisfaction (vs. satis- few recent reviews have strongly recom-
important factor associated with doing faction) with life remained (Table 4). mended the prescription of physical
physical activity/exercise was having Similarly, after adjustment, those exercis- ac­tivity/exercise for the treatment and
received advice to do so by a doctor or management of a large number of physi-
ing 4 or more times a week were less
other health professional. cal chronic conditions, as long as the type
likely to report “fair/poor” or “good” gen-
and intensity of physical activity/exercise
eral health (vs. “excellent”), “fair/poor”
After we adjusted for all sociodemo- are tailored to the condition.40,41
mental health (vs. “excellent”) and dissat-
graphic and clinical characteristics, we isfaction with life (vs. satisfaction) com-
compared those exercising 1 to 3 times a Although lack of will power/self-­discipline
pared to those not exercising.
week to those who did not exercise was cited as a barrier by only 15% of
(Table  2). Individuals with less than those not engaging in physical activity/
Among those with mood and/or anxiety exercise, it has been shown previously
secondary school education (vs. post-­
secondary diploma), those in the lowest disorders, the most frequently cited barri- that those with depression lack motiva-
income quintiles (Q1–Q3 vs. Q4–Q5), ers to exercising at least once a week were tion and energy in a number of activities,
those with mood disorders with or with- as follows: “prevented by physical condi- particularly those requiring a certain level
out anxiety disorders (vs. those with anxi- tion” (27.3%), “time constraints/too busy” of effort and regularity.42,43 This is sup-
ety only), those who were not advised to (24.1%) and “lack of will power/self-­ ported by our study, which showed that
exercise by a health professional (vs. discipline” (15.8%). Other unspecified those with a mood disorder (with or with-
those who were) and those who were not reasons were mentioned by 25.0%. Cost out a concurrent anxiety disorder) were
treated with conventional clinical therapy was seldom mentioned as a barrier (2.1%). less likely to exercise than those with an

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Vol 37, No 5, May 2017 153 Research, Policy and Practice
 TABLE 1
Sociodemographic and clinical characteristics among Canadians aged 18 years and older with a self-reported mood and/or anxiety disorder
diagnosis by exercise frequency (n = 2678), 2014 SLCDC-MA
Exercised 1 to 3 times Exercised 4+ Chi-square
Did not exercise
Variable Category per week times per week test
% 95% CI % 95% CI % 95% CI p-value
Sex Male 46.4 (40.2–52.6) 25.8 (19.6–32.0) 27.8 (22.2–33.4) .44
Female 48.6 (44.7–52.5) 27.7 (23.9–31.5) 23.6 (20.6–26.7)
Age (years) 18–34 45.0 (38.3–51.6) 28.4 (21.5–35.3) 26.6 (20.1–33.2) .055
35–49 47.2 (40.1–54.3) 32.8 (25.4–40.1) 20.0 (14.8–25.2)
50–64 49.2 (43.8–54.6) 22.5 (17.9–27.2) 28.3 (23.8–32.8)
65+ 52.5 (46.7–58.3) 21.7 (16.8–26.7) 25.8 (20.1–31.5)
Marital status Single, never married 50.3 (43.9–56.7) 24.0 (18.6–29.5) 25.7 (19.8–31.5) .074
Widowed/divorced/separated 51.5 (44.5–58.5) 20.2 (15.2–25.2) 28.3 (22.0–34.7)
Married/living common-law 45.7 (40.8–50.5) 30.6 (25.6–35.6) 23.7 (19.9–27.6)
Respondent’s Less than secondary school 63.4 (55.6–71.1) 16.9a (11.4–22.4) 19.7a (13.4–26.1) .001*
education level Secondary school graduation 52.2 (45.7–58.6) 23.5 (17.7–29.3) 24.3 (18.5–30.1)
Some post-secondary 46.8a (33.2–60.5) 32.3a (18.2–46.4) 20.9a (10.7–31.0)
Post-secondary graduation 42.8 (38.3–47.4) 30.2 (25.4–34.9) 27.0 (23.1–30.9)
Household income Q1–Q2 (lowest) 56.5 (51.6–61.4) 19.1 (15.2–23.1) 24.4 (20.1–28.6) < .001*
adequacy quintiles Q3 (middle) 49.5 (41.7–57.3) 23.6 a
(16.7–30.4) 26.9 (19.9–33.9)
Q4–Q5 (highest) 36.9 (31.6–42.1) 38.3 (32.1–44.6) 24.8 (20.5–29.2)
Immigrant Yes 47.8 (36.1–59.6) 24.5 a
(14.6–34.4) 27.7 a
(17.0–38.4) .80
No 47.9 (44.2–51.5) 27.4 (23.8–31.1) 24.7 (21.9–27.5)
Aboriginal Yes 54.8 (43.6–65.9) 19.9 (10.7–29.2) 25.3a (16.1–34.6) .32
No 47.6 (43.9–51.2) 27.6 (23.9–31.2) 24.9 (21.9–27.9)
Place of residence Rural 49.7 (44.1–55.2) 24.0 (18.5–29.5) 26.4 (21.3–31.4) .52
Urban 47.5 (43.6–51.4) 27.7 (23.8–31.6) 24.8 (21.6–28.1)
Geographic region British Columbia 32.4 (24.2–40.7) 26.3 (18.0–34.6) 41.2 (30.4–52.1) < .001*
Prairie 51.5 (43.6–59.4) 26.4 a
(18.9–34.0) 22.0 (16.4–27.6)
Ontario 50.6 (44.4–56.7) 25.0 (19.3–30.6) 24.5 (19.9–29.0)
Quebec 48.2 (40.3–56.0) 35.3 (27.1–43.5) 16.5 (11.7–21.4)
Atlantic 50.8 (43.4–58.2) 22.5a (15.8–29.2) 26.7 (19.7–33.8)
Physical comorbidities None 43.3 (37.5–49.1) 33.0 (26.6–39.3) 23.7 (19.2–28.3) .004*
(number) 1–2 49.8 (45.1–54.6) 22.3 (18.5–26.0) 27.9 (23.6–32.3)
3+ 54.8 (47.4–62.3) 25.1a (18.1–32.2) 20.0a (14.4–25.6)
Disorder type Mood disorder only 51.8 (47.0–56.6) 22.2 (17.9–26.6) 25.9 (21.6–30.3) .005*
Anxiety disorder only 37.6 (31.0–44.3) 35.5 (27.3–43.6) 26.9 (21.0–32.8)
Concurrent disorders 49.9 (44.1–55.6) 27.2 (21.7–32.7) 22.9 (18.4–27.5)
Time since diagnosis 0–4 51.7 (44.8–58.6) 27.1 (20.8–33.4) 21.2 (16.3–26.1) .008*
(years) 5–19 42.2 (37.2–47.1) 30.6 (25.1–36.1) 27.3 (22.8–31.8)
≥ 20 54.4 (48.4–60.5) 19.9 (15.5–24.3) 25.6 (20.4–30.8)
Clinical treatment Yes 47.5 (43.6–51.3) 29.3 (25.5–33.1) 23.2 (20.3–26.1) .001*
No 49.7 (41.7–57.6) 16.6a (11.2–21.9) 33.8 (25.6–42.0)
PA/exercise advice Yes 37.5 (33.6–41.5) 33.4 (29.0–37.8) 29.1 (25.5–32.7) < .001*
by HP No 70.2 (64.9–75.4) 13.4a (8.8–18.0) 16.4 (12.4–20.4)
Abbreviations: CI, confidence interval; HP, health professional; OR, odds ratio; PA, physical activity; Q, quintile; SLCDC-MA, Survey on Living with Chronic Diseases in Canada—Mood and
Anxiety Disorders Component.
Note: Percentages and 95% CIs are based on weighted data.
a
High sampling variability (coefficient of variation between 16.6 and 33.3%).
* Statistically significant at the p < .05 level.

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Research, Policy and Practice 154 Vol 37, No 5, May 2017
 TABLE 2
Adjusted odds ratio of having exercised “1 to 3 times a week” or “4 or more times a week” compared to “did not exercise”
by sociodemographic and clinical characteristics among Canadians aged 18 years and older with a self-reported mood
and/or anxiety disorder diagnosis (n = 2678), 2014 SLCDC-MA

Exercised 1 to 3 Exercised 4+
times per week times per week
Variable (reference) Category vs. did not exercise vs. did not exercise
OR 95% CI p-value OR 95% CI p-value
Sex (female) Male 0.83 (0.54–1.25) .37 1.13 (0.77–1.67) .53
Age (18–34 years) 35–49 years 0.89 (0.51–1.55) .68 0.68 (0.40–1.14) .14
50–64 years 0.69 (0.39–1.22) .20 1.05 (0.61–1.80) .86
65+ years 1.10 (0.57–2.12) .79 1.23 (0.67–2.28) .51
Marital status Single/never married 0.91 (0.55–1.50) .71 1.16 (0.75–1.80) .50
(married/living common-law) Widowed/divorced/separated 0.95 (0.58–1.55) .84 1.43 (0.87–2.35) .16
Respondent’s education level Less than secondary school 0.55 (0.32–0.94) .028* 0.66 (0.40–1.11) .12
(post-secondary graduation) Secondary school graduation 0.84 (0.53–1.34) .46 0.74 (0.49–1.12) .16
Some post-secondary 1.00 (0.45–2.23) .99 0.54 (0.24–1.23) .14
Household income adequacy
Q1–Q2 (lowest) 0.39 (0.25–0.60) < .001* 0.63 (0.42–0.96) .033*
quintiles (Q4–Q5; highest)
Q3 (middle) 0.47 (0.28–0.78) .003* 0.78 (0.48–1.26) .31
Immigrant (no) Yes 0.51 (0.13–2.03) .34 1.56 (0.44–5.49) .49
Aboriginal (no) Yes 0.69 (0.30–1.60) .39 0.94 (0.50–1.77) .84
Place of residence (urban) Rural 0.95 (0.61–1.49) .83 1.08 (0.73–1.58) .71
Geographic region (British
Prairie 0.63 (0.31–1.30) .21 0.36 (0.20–0.68) .001*
Columbia)
Ontario 0.69 (0.37–1.28) .24 0.44 (0.25–0.80) .007*
Quebec 0.84 (0.43–1.65) .61 0.32 (0.17–0.62) < .001*
Atlantic 0.53 (0.27–1.04) .065 0.49 (0.25–0.95) .035*
Physical comorbidities (none) 1–2 0.77 (0.50–1.18) .22 0.87 (0.60–1.26) .47
3+ 0.92 (0.53–1.62) .78 0.70 (0.40–1.21) .20
Disorder type Concurrent disorders 0.51 (0.31–0.83) .007* 0.43 (0.27–0.70) < .001*
(anxiety disorder only) Mood disorder only 0.53 (0.33–0.87) .011* 0.69 (0.45–1.05) .080
Time since diagnosis 0–4 years 0.77 (0.47–1.25) .29 0.74 (0.47–1.14) .17
(5–19 years) ≥ 20 years 0.68 (0.44–1.07) .10 0.80 (0.52–1.22) .30
Clinical treatment (yes) No 0.68 (0.40–1.16) .16 1.63 (1.02–2.61) .043*
PA/exercise advice
No 0.21 (0.15–0.31) < .001* 0.31 (0.22–0.45) < .001*
by HP (yes)
Abbreviations: CI, confidence interval; HP, health professional; OR, odds ratio; PA, physical activity; Q, quintile; SLCDC-MA, Survey on Living with Chronic Diseases in Canada—Mood and
Anxiety Disorders Component.
Note: ORs and 95% CIs are based on weighted data. ORs adjusted for all sociodemographic and clinical characteristics.
* Statistically significant at the p < .05 level.

anxiety disorder only. New types of increase engagement in pleasant and time constraints have been cited as the
approaches and therapies such as motiva- rewarding activities.45,46 main barriers for prescribing physical activ-
tional interviewing44 and behavioural acti- ity/exercise by health professionals,47-50
vation45 may help individuals who lack The advice from a doctor or other health research has shown that family physicians
motivation and energy to initiate and main- are effective in increasing physical activity/
professional to participate in physical activ-
tain new lifestyle behaviours. One of the exercise among primary care patients.47,51
objectives of behavioural activation is to ity/exercise was the most important factor In light of these findings, it is essential that
increase positive reinforcement from the associated with being active at least once a health professionals recommend physical
environment by encouraging individuals to week. Although the lack of knowledge and activity/exercise to their patients with

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Vol 37, No 5, May 2017 155 Research, Policy and Practice
 TABLE 3
Perceived health and life satisfaction status among Canadians aged 18 years and older with a self-reported mood and/or
anxiety disorder diagnosis by physical activity/exercise frequency (n = 2678), 2014 SLCDC-MA

Exercised 1–3 times Exercised 4+ times Chi-square

Did not exercise
Variable Category per week per week test
% 95% CI % 95% CI % 95% CI p-value
Perceived general health Excellent/very good 35.6 (29.8–41.5) 35.6 (28.7–42.5) 28.8 (23.6–34.0) < .001*
Good 50.0 (44.5–55.5) 25.1 (20.7–29.5) 24.9 (20.1–29.7)
  Fair/poor 61.7 (55.5–67.9) 17.9 (13.2–22.6) 20.4 (15.3–25.5)
Perceived mental health Excellent/very good 43.7 (37.9–49.6) 26.2 (20.1–32.3) 30.1 (24.7–35.4) .053
Good 45.7 (40.4–51.1) 30.5 (24.9–36.1) 23.8 (19.4–28.1)
  Fair/poor 54.6 (48.2–60.9) 23.2 (17.4–28.9) 22.3 (17.0–27.6)
Life satisfaction Satisfied 43.3 (39.4–47.2) 30.9 (26.8–35.0) 25.8 (22.6–29.0) < .001*
Neutral 55.6 (45.9–65.3) 17.2 a
(10.6–23.7) 27.2 a
(18.4–36.1)
  Dissatisfied 71.2 (62.4–79.9) 11.0a (6.3–15.7) 17.8a (10.1–25.5)
Abbreviations: CI, confidence interval; SLCDC-MA, Survey on Living with Chronic Diseases in Canada—Mood and Anxiety Disorders Component.
Note: Percentages and 95% CIs are based on weighted data.
a
High sampling variability (coefficient of variation between 16.6 and 33.3%).
* Statistically significant at the p < .05 level.

mood and/or anxiety disorders and sup- by sustaining motivation and adher- conditions and develop strategies to deal
port their engagement. ence.47,52 Simple and practical strategies with the issue of time constraints.
such as prescription of physical activity/
A recent systematic review of studies on exercise and use of pedometers and log- Finally, our study demonstrated an associa-
physical activity/exercise and depression books have also been shown to be help- tion between physical activity/exercise and
suggests the following guidelines for health ful.47,53,54 Most importantly, the primary perceived well-being. Individuals who did
professionals: (1) both aerobic and anaero- not engage in exercise were more likely to
goal is to encourage the patient to be active
bic activity are effective, therefore the report “fair/poor” general health and dis-
(regardless of the type, duration and fre-
choice should be based on patient’s prefer- satisfaction with life compared to those
quency of activity) and to ensure that the
ence; and (2) in terms of duration and fre- who exercised at least once per week, even
quency, sessions should last for at least selected physical activity/exercise is seen after adjusting for all sociodemographic
30  minutes three times a week.52 Partici­ as pleasurable.24,51,52 Lastly, interventions and clinical characteristics that could affect
pation in group activities and regular designed to increase self-management perceived well-being. However, since the
supervision and monitoring appear to through exercise will need to address the 2014 SLCDC-MA is a cross-sectional sur-
increase the chance of successful outcomes barriers presented by comorbid chronic vey, the direction of the association could

TABLE 4
Adjusted odds ratio of having exercised “1 to 3 times a week” or “4 or more times a week” compared to “did not exercise” by perceived
health and life satisfaction status among Canadians aged 18 years and older with a self-reported mood and/or anxiety disorder diagnosis
(n = 2678), 2014 SLCDC-MA

Exercised 1–3 Exercised 4 +

times per week times per week
Variable (reference) Category vs. did not exercise vs. did not exercise
OR 95% CI p-value OR 95% CI p-value
Perceived general health Fair/poor 0.33 (0.19–0.56) < .001* 0.40 (0.25–0.64) < .001*
(excellent/very good) Good 0.50 (0.32–0.77) .002* 0.59 (0.40–0.88) .010*
Perceived mental health Fair/poor 0.69 (0.41–1.15) .15 0.57 (0.37–0.90) .015*
(excellent/very good) Good 0.96 (0.62–1.49) .85 0.71 (0.49–1.04) .078
Satisfaction about life Dissatisfied 0.29 (0.16–0.50) < .001* 0.46 (0.25–0.83) .011*
(satisfied) Neutral 0.53 (0.31–0.93) .027* 0.87 (0.54–1.41) .58
Abbreviations: CI, confidence interval; OR, odds ratio; SLCDC-MA, Survey on Living with Chronic Diseases in Canada—Mood and Anxiety Disorders Component.
Notes: ORs and 95% CIs are based on weighted data. ORs adjusted for: sex, age, marital status, education, household income, region, comorbidity, diagnosis type, clinical management and
advice by health professional.
* Statistically significant at the p < .05 level.

Health Promotion and Chronic Disease Prevention in Canada

Research, Policy and Practice 156 Vol 37, No 5, May 2017
not be determined and we were not able to symptoms in addition to many other health 4. Bodenheimer T, Lorig K, Holman H,
assess whether respondents reported better benefits such as increasing overall wellness Grumbach K. Patient self-manage-
health and life satisfaction because they and preventing or mitigating other chronic ment of chronic disease in primary
were engaging in exercise, or alternatively, diseases, its uptake was challenging for at care. JAMA. 2002;288(19):2469-75.
whether they were exercising because they least 50% of those affected by these disor-
5. Health Council of Canada. Self-
felt better. Also, it is interesting to note that ders in our study. Individuals who were
management support for Canadians
there were no major differences in terms of more likely not to exercise shared many of
with chronic health conditions: a
well-being among those reporting exercis- the sociodemographic characteristics also
focus for primary health care. Toronto
ing 1 to 3 times a week versus 4 or more observed in the general population. Engaging
(ON): Health Council of Canada;
times a week. This may reflect the fact that in physical activity/exercise was particu-
2012. 64 p.
the psychological (e.g. self-esteem, self- larly difficult for those affected by a mood
efficacy) and social impact of engaging in disorder and those with physical comor- 6. National Institute for Health and
physical activity/exercise are as important bidities, although exercise may be particu- Clinical Excellence. Common mental
larly important for these individuals. health disorders: identification and
as its physiological effects.52
pathways to care. London (UK):
The most important factor associated with National Institute for Health and
Strengths and limitations
exercising was the recommendation by a Clinical Excellence; 2011 [Clinical
The 2014 SLCDC-MA is the only national doctor or other health professional. Health Guideline CG123]. 55 p.
survey to have collected detailed informa- practitioners play a critical role in recom-
7. Spek V, Cuijpers P, Nyklícek I, Riper
tion on the experiences of a large sample of mending physical activity/exercise and
H, Keyzer J, Pop V. Internet-based
supporting its engagement, particularly for
Canadians with a diagnosed mood and/or cognitive behaviour therapy for
those with a mood disorder and physical
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comorbidities.
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Acknowledgements
8. Gellatly J, Bower P, Hennessy S,
clinical characteristics, perceived well-being The authors would like to thank Siobhan Richards D, Gilbody S, Lovell K.
and reported barriers. O’Donnell for her thorough review. Scott B. What makes self-help interventions
Patten is a Senior Health Scholar with effective in the management of
This study has a few limitations that war- Alberta Innovates, Health Solutions. No depressive symptoms? Meta-analysis
rant mentioning. First, the 2014 SLCDC-MA external financial or material support was and meta-regression. Psychol Med.
had a lower response rate (68.9%) com- obtained for this study. 2007;37(9):1217-28.
pared to previous cycles (75%–83%).55,56
This phenomenon has been observed in Conflicts of interest 9. Lewis C, Pearce J, Bisson JI. Efficacy,
other health surveys, both nationally and cost-effectiveness and acceptability of
internationally.57 While this may introduce The authors declare no conflict of interest. self-help interventions for anxiety
disorders: systematic review. Br J
bias due to non-response, it should be
noted that Statistics Canada made adjust- Authors’ contributions Psychiatry. 2012;200(1):15-21.
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Louise Pelletier (LP), Alain Demers (AD)
excluded or did not respond to the survey.32 sus placebo for treating anxiety.
and Shamila Shanmugasegaram (SS) con-
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ceptualized the study, AD analyzed the
duration and intensity of physical activity/ (1):CD003383.
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