Physical Activity for People with Bipolar Disorder

What is bipolar disorder?

Bipolar disorder (BD) is a chronic mental health condition characterised by recurring episodes of depression and mania. It is associated with significant impairment in functioning and quality of life. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a manual produced by the American Psychiatric Association (APA), describes depression as feelings of low mood and lethargy, and mania as feelings of elation and overactivity or hypomania – a milder form of mania (Figure 1 and Figure 2).¹ Most people experiencing a manic episode will develop depressive episode in their lifetime.²

Mental stress as a key factor for bipolar disorder development

Koenders and colleagues found recent stressful life events exacerbated mental stress, contributing to the course of BD.³ Patients who experienced stressful life events relapsed into depressive or manic episode more frequently.⁴ Stressful life events such as divorce, disability and employment led to the first hospitalisation due to a manic episode.⁵ The confounder of genetics had a crucial role in first-degree relative suicide and evidence pointed towards a bidirectional relationship, in which stressful events occurred both before and following the episodes.³

Physical Activity for Management Effectiveness

Two systematic reviews on physical activity (PA) and BD reflect a generally sedentary lifestyle among BD patients from the onset.^{6, 7} Generally, PA interventions can prove beneficial (Figure 3).⁸ However, vigorous exercise may worsen mania or hypomania.⁹

Physical Activity and Depression

PA and depressive symptoms have an inverse relationship.^10-12 BD patients experienced lower depressive symptoms on days with physical activities.⁶ In a walking group experiment, BP patients scored lower in the depressive anxiety stress scale and its corresponding subscales of depression, anxiety and stress.¹³ In a study involving exercise, weight loss, wellness and nutrition, BD patients undertook twelve 60-minute group sessions spanning across 14 weeks. The outcomes include reduced depressive symptoms, improving quality of life, higher functioning and reduced weight.^{11, 12}

Physical Activity and Mania

The relationship between PA and manic symptoms are still inconclusive at best.^{11, 14-17} A therapeutic PA intervention through eight walking sessions showed a decrease or no change in mania symptoms among the eight BD patients.¹⁸ However, this intervention was based on an unpublished PhD dissertation. In contrast, a therapeutic exercise intervention involving exercise and nutrition concurred a positive relationship.¹² With manic symptoms typically include high energy and less sleep (Figure 1), patients would naturally have the tendency to participate in more exercises thus agitating their manic symptoms further.⁶

Wright and colleagues discovered that exercise helped people with BD hypomanic symptoms to curb their mood swings and sleep better.¹⁹ Furthermore, the qualitative study found that these exercises provided a calming effect on them. However, for people with BD manic symptoms, the study revealed that the symptoms could exacerbate. Similarly, Uebelacker and colleagues discovered that mindfulness exercises such as yoga could be either helpful or harmful for people with BD manic symptoms, depending on the yoga session’s intensity, duration and the patient’s mood.²⁰ Engaging in calming and low intensity yoga session proved to be beneficial for people with BD manic symptoms. Engaging in high intensity yoga session proved otherwise. Participants were quoted saying, “feeling more depressed when I’m too depressed to actually do it” and “a tendency to be stuck in my head, feeling of isolation, repeating negative mantras”.²⁰ Therefore, the benefits of physical activity on mania is still debatable.

Physical Activity Behaviour of Bipolar Patients

Majority studies associated bipolar patients with a sedentary lifestyle – an absent or irregular PA participation onset.^{6, 7} 78% of the daily PA level of 60 BD adult patients were under the sedentary lifestyle, and no patients met the 150 minutes per week moderate to vigorous activity level under the UK national guidelines.²¹ Similar findings were reported in the US and Brazil adult populations.^{22, 23} Multiple barriers inducing sedentary lifestyle include unemployment, single marital status, lower educational qualification, higher body weight, geographical differences, and the use of pharmacotherapy.²⁴ Geographically, people with BD in Europe are more physically active due to the better mental health support system and facilities as compared to the rest of the world.²⁵ Whereas older people with BD tend to over-rely on pharmacotherapy, with information on the potential benefits of PA and guidance provided by clinicians found lacking.²⁶

Limited studies measure physical performance based on motor functions. Vancampfort and colleagues had patients participated in a walking intervention programme.²⁷ Key findings include participants having shorter walking distance, lower PA level and more musculoskeletal pain as compared to the control group. In another study, participants underwent a physical fitness test covering flexibility, speed, endurance and strength. Participants’ explosive power and speed of legs movement had diminished.²⁸ A potential barrier is the elevated increased risk for chronic pain suffered by BD patients, which might have accelerated their musculoskeletal pain primarily in their lower limbs.²⁹

Only two studies focused on adolescents’ PA level.^{14, 30} Both studies found that adolescents with BD had less tolerance for high intensity exercises than their control groups. Jewell and colleagues observed that the adolescents with BD generally participated in less PAs.¹⁴ Psychological traits – such as unusual coping styles, irregular sleeping patterns and a volatile self‐esteem³¹ – that are found in adolescents with BD could potentially discourage them in participating in PAs. More studies on adolescents should be conducted to provide a more comprehensive understanding.

Physical Activity / Exercise Promotion

PA/exercise programmes for BD based on empirical data are inconclusive. Also, existing interventions focused on only one condition of the BD – either depression or mania.⁷ Designing an all-round PA programme for BD is challenging due to the existing polarising outcomes of PA on manic symptoms.^{11, 12} Additionally, the PA variables such as exercise intensity, targeted muscle groups and progression level must be fully considered as the incidence of recurring musculoskeletal pain is high among the BD population.²⁹

Especially with the high incidence of substance abuse among people with BD³², PA programmes can help to focus on mental resilience and overall sense of wellbeing.³³ People with BD would be meaningfully occupied through their exercise participation and the post-exercise positive mood might help in getting their minds away from mood-type distractions such as substance abuse.³⁴

Considering the potential effects of exercise stimulating further manic symptoms as discussed earlier,²⁰ an individualised physical activity/exercise programme with consultation from experts is needed. The hypothesised outcomes of the neurological and psychological mechanisms of exercises (i.e., positive mood, higher functioning, increased eustress, and better self-management) can provide the theoretical foundation for the design of physical activity/exercise programmes.

Individualised Physical Activity / Exercise Programme

A collaboration between the patient, doctor and physical health experts is required for a more effective individualised programme. A personalised plan would consider risk factors such as genetics, mental stress, substance abuse, age (Figure 4), employment type (Figure 5) and existing treatment (Figure 6), among others – the guidance and provision of doctor and health experts become a necessity. For instance, patients who suffer from a more frequent bout of manic attack would be best not to engage in vigorous physical activities.⁹ At the same time, low intensity activity such as yoga could also prove detrimental depending on the mood state of the patient.²⁰ Thus, a comprehensive individualised programme would have to be co-designed by the stakeholders that could include a self-report checklist and corresponding options of physical activities that best suit the needs of the patients at that moment and in the long run.

The shared decision-making between the stakeholders has shown to improve the intended physical health outcomes.³⁵ When patients are involved in designing their programme, the sense of empowerment and autonomy is accorded to them, invoking a more identified regulation of motivation. Additionally, with the doctor and health experts getting the patient’s feedback on the types of physical activities to prescribe, the patient’s self-efficacy can be enhanced when the activities chosen are within the patient’s comfort zone.³⁶

Conclusion

Existing evidence points towards BD adult patients leading a sedentary life, which is associated with more comorbidity (e.g. obesity, stroke, heart disease, type 2 diabetes, poor musculoskeletal health), diminishing quality of life, worse functioning and increasing depressive symptoms.^{6, 7} These findings concurred with other psychosis studies.^{37, 38} However, more studies with BD children and adolescents are required.

Exercise is associated with improved quality of life, better functioning and reduced depressive symptoms. However, mixed findings for exercise impact on mania were discovered. Exercise can be integrated into psychotherapy treatments to further increase participants’ self-esteem and adherence towards the treatments. Additionally, an individualised physical activity/exercise programme can be an effective adjunctive treatment to pharmacotherapy and psychotherapy. As literature for exercise in BD is scarce, findings are extrapolated from unipolar literature, theory and clinical practices.⁷ Thus, further research is required for evidence-based effects of exercise for BD on BD symptomatology.

References

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