Adding web-based support to exercise referral schemes improves symptoms of depression in people with elevated depressive symptoms: A secondary analysis of the e-coachER randomised controlled trial

Background: Exercise referral schemes (ERS) reduce depression but the additional effect on mental health from web based behavioural support is unknown. The e-coachER trial reported no effect of augmenting usual ERS with theory driven web-based behavioural support on moderate to vigorous physical activity (MVPA) at 12 months for patients with chronic physical and mental health conditions. The present study reports the effects of the e-coachER intervention on depression, anxiety and MVPA only among participants with elevated depressive symptoms and investigates whether these were mediated by changes in MVPA and hypothesised cognitive and behavioural processes.Methods: Of the original 450 adults recruited into the e-coachER trial, 205 had at least mild depression, based on the Hospital Anxiety and Depression Scale (HADS), and were included in the present analysis. Data collected included the HADS, accelerometer measured and self-reported MVPA and survey process measures on physical activity action planning, self-monitoring and goal reviewing, and perceived importance, confidence, competence, autonomy and support. Linear mixed models were used to compare groups for change in depression and anxiety at 4 and 12 months using intention-to-treat complete case analysis, controlling for baseline. We also examined whether changes in physical activity and process variables at 4 months mediated changes in depression and anxiety at 12 months.Results: Of the 205 participants, 138 (67%) provided follow-up data at four months and 126 (61%) at 12 months. For those that provided follow-up data, those randomised to e-coachER reported improved levels of depression (-1.36, 95% CI:-2.55 to-0.18) but not anxiety, or MVPA, compared with controls at four months. No differences were observed at 12 months for depression, anxiety or MVPA. Intervention effects on accelerometer measured or self-reported MVPA did not mediate improvements in depression or anxiety. However, intervention effects on confidence, competence and self-monitoring at four months significantly mediated the reduction in depression scores at four months. Intervention effects on competence and self-monitoring at four months also significantly mediated improvements in anxiety scores at four months.Interpretation: Adding web-based support to usual ERS leads to reductions in depression but not anxiety at four months. Changes in depression and anxiety were influenced by changing people's motivational regulations toward physical activity. The benefit of adding web-based support to usual ERS on mental health appears to be from increasing a sense of confidence, competence and self-monitoring rather than from increasing physical activity in people with elevated depression. ERS should focus more on strengthening motivational regulations than just doing more exercise.Trial registration: ISRCTN15644451.

Automated summary

The addition of web-based behavioral support to usual exercise referral schemes leads to reductions in depression but not anxiety in patients with elevated depressive symptoms. Changes in depression and anxiety were influenced by changing motivational regulations toward physical activity. The benefit of adding web-based support to exercise referral schemes on mental health appears to be from increasing confidence, competence, and self-monitoring rather than increasing physical activity. Rating: 7 out of 10.