Bouldering psychotherapy is more effective in the treatment of depression than physical exercise alone: results of a multicentre randomised controlled intervention study
Worldwide, only one out of six individuals suffering from depression receives minimally adequate treatment, a finding that reveals a significant therapeutic supply gap in the mental health care system. Besides a lack of therapists and thus long waiting times for a therapy place, a missing belief in the effectiveness of classical psychotherapeutic interventions as well as stigma play a major role when it comes to actively seek help for the treatment of mental problems. Hence, there is a need for novel and complementary treatment options that exceed traditional therapeutic interventions. As such an alternative approach, physical activity has been found to be effective for the treatment of depression. Previous research has found antidepressant effects for various modes of exercise, ranging from endurance and aerobic exercise such as walking, running, and cycling to resistance and strength training. There is further scientific evidence of an association between lowintensity mindfulness-based techniques such as Yoga, Thai Chi, and Qigong, and an improvement in depressive symptoms. With moderate to large effect sizes (Cohen’s d between 0.62 and 0.82), the antidepressant effect of physical exercise has turned out to be comparable to psychotherapy and antidepressant psychopharmaceuticals. Consequently, both the NICE guidelines and the German guidelines for the treatment of depression have included the recommendation to implement physical activity as a complementary therapeutic method in the standard treatment of depression. Though the efficacy of physical activity is widely accepted, it remains largely unclear which mode and intensity of exercise is most promising in alleviating depressive symptoms. While some studies have demonstrated that resistance exercise is superior to aerobic exercise, others have indicated stronger long-term effects of aerobic endurance training compared with strength training. Regarding the intensity of training, the effectiveness of low-intensity yoga-based stretching exercises was found to be comparable to vigorous intensity aerobic training in treating mild to moderate depression. A special mode of exercise that has gained increased attention in clinical practice lately and has already been applied as part of the overall treatment plan in several clinics involves bouldering, which is defined as climbing to moderate heights without the use of ropes or harnesses. Recent research has shown positive effects of climbing/bouldering not only on various health problems but also on mental disorders such as anxiety disorders, ADHD and eating disorders. Several studies have indicated improvements related to climbing/bouldering in a number of domains that are believed to play an important role in the emergence and maintenance of depression, such as cognitive abilities, self-confidence, self-esteem, self-efficacy, and social skills. In line with these findings, there were some first indications that climbing and bouldering are effective in reducing depressive symptoms However, conclusions regarding bouldering as an effective treatment for depression must be drawn with caution because existing studies are often limited by methodological problems such as small sample sizes, the use of unstandardised psychometric measures, no randomisation, or even the absence of any control groups. Our work group conducted a randomised waitlist-controlled pilot study to investigate the effectiveness of an eight-week bouldering psychotherapeutic intervention on depressive symptoms in individuals with depression. Participants in the intervention group showed a significantly greater reduction in depressive symptoms (from a moderate to a mild severity level, Cohen’s d = 0.77) as well as improvements in a number of other mental health outcomes (i.e. anxiety and self-management) compared with the waitlist control group. We controlled for the confounding effect of general physical activity with the use of accelerometres. However, no direct comparison between the bouldering therapy and a proper sports/physical exercise programme (i.e. in the form of a fitness workout) was drawn. To follow up on this idea, the main aim of the current study called StudyKuS (StudieKuS – ‘Klettern und Stimmung’; ‘Climbing and Mood’) was to investigate the effectiveness of a manualised bouldering psychotherapy (BPT), compared with exercise alone, in a large nationwide sample of outpatients with depression. For this purpose, we used an active control group, involving a home-based exercise programme (EP), instead of a waitlist control group. The home-based exercise programme was designed to be an externally supervised opportunity to engage in exercise such as often offered by health insurance providers. We hypothesised that participation at BPT would lead to a significantly greater reduction in depressive symptoms than mere physical activation in the form of the EP. The effect of BPT on other measures of mental health (e.g. self-esteem, coping skills, anxiety) was examined with an exploratory approach. the study at any time. All procedures were approved by the Friedrich-Alexander Universität of Erlangen- Nürnberg Ethics Committee (Ref. 360_16 B).
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