Journal of Psychiatric and Mental Health Nursing, 2016, 23, 37–44

Exercise for adolescents with depression: valued aspects

and perceived change
T. C A R T E R 1 Ph D, I. MORRES2 MSc , J. REPPER3 Ph D & P. C A L L A G H A N 4 Ph D
1 3
Teaching and Research Associate, Director of ImROC (Improving Recovery through Organisational Change),
4
Professor of Mental Health Nursing, School of Health Sciences, University of Nottingham, Nottingham, UK, and
2
Teaching and Research Fellow, Exercise Therapist, Department of Physical Education & Sport Science, University
of Thessaly, Trikala, Greece

Keywords: adolescents, depression, Accessible summary

exercise, experience, well-being
Correspondence:
T. Carter
School of Health Sciences
University of Nottingham
Room D25, Institute of Mental Health
Triumph Road
Nottingham
NG7 2TU
UK
E-mail: timothy.carter@nottingham.ac.uk
Accepted for publication: 10 July 2015
doi: 10.1111/jpm.12261
What is known on the subject?
• There is evidence suggesting that exercise may be effective at reducing depression
in adults and young people; however, there is no research exploring how adoles-
cents with depression experience exercise interventions.
What the paper adds to existing knowledge?
• This study presents the experiences of 26 adolescents with depression who under-
took an innovative preferred intensity exercise programme. Important insights
relating to benefits and aspects of the preferred intensity exercise emerged. Spe-
cifically, the adolescents experienced feelings of improved mood, achievement and
enjoyment, alongside numerous benefits.
What are the implications for practice?
• Given that mental health nurses are in key positions to promote physical exercise
for this target group, this paper suggests that when promoting exercise they should
consider that preferred intensity exercise may provide a series of valuable mental
health benefits without the need for fixed intensity training.

Abstract

Introduction: Despite systematic reviews demonstrating an association between exer-

cise participation and reduced depressive symptoms in young people, there is no
qualitative research exploring the experience of depressed adolescents who have
engaged in an exercise intervention. Aims: To explore the experience of depressed
adolescents who had recently engaged in a preferred intensity exercise interven-
tion. Method: The participants (n = 26) were recruited through health and social
care services, were all in treatment for depression, and were purposefully sampled for
interview following engagement in a preferred intensity exercise intervention, which
was being evaluated via a pragmatic randomized controlled trial. A thematic
approach was undertaken to analyse and organize the data. Results: Numerous
beneficial changes were reported by participants alongside specific aspects of the
intervention that were valued. Discussion and implications: The findings suggest that
preferred intensity exercise can lead to feelings of improved mood, enjoyment and
achievement, alongside benefits that transcend depressive symptom reduction. Con-
sidering mental health nurses are in key positions to promote exercise in this popu-
lation, the current findings provide vital information for this purpose.

© 2015 John Wiley & Sons Ltd 37

T. Carter et al.
Introduction
There is an increasing number of reviews demonstrating an
association between exercise participation and reduced
depressive symptoms in both adults (Cooney et al. 2013)
and young people (Larun et al. 2006, Brown et al. 2013)
through fixed (moderate or high) levels of intensity (e.g.
Dunn et al. 2005, Hughes et al. 2013). Observational
studies in both adults and young people, however, report
that prescribed (fixed) intensity exercise shows less
favourable affective responses and effort perceptions in
comparison to preferred intensity exercise (Rose & Parfitt
2007, Hamlyn-Williams et al. 2014). The above advan-
tages of preferred intensity over prescribed intensity have
successfully been replicated in adult depressed patients by
Callaghan et al. (2011) and Khalil et al. (2012) who
reported higher antidepressant and well-being effects and
lower effort perception and attrition rates for preferred
intensity exercise. However, relevant research in young
people treated for depression remains unaddressed.
Hence, a qualitative exploration is essential in order to
understand views, contextual factors and mediators related
to participation in a preferred intensity exercise pro-
gramme. Such information is likely to have substantial
implications for those supporting adolescents with depres-
sion including nurses who are in key positions to promote
exercise in mental health settings (Callaghan 2004, Happell
et al. 2011), and tend to do so in their day-to-day practice
(Faulkner & Biddle 2002, Happell et al. 2012).
Methods
Aim
The aim of the study was to explore the experience and
impact of a preferred intensity exercise intervention for
adolescents with depression.
Context
This study was situated within a larger pragmatic rando-
mized controlled trial (Carter et al. 2012), whereby adoles-
cents receiving treatment for depression were randomized
to a 12-session preferred intensity exercise intervention
alongside treatment as usual (TAU) or TAU only.
The exercise intervention was embedded within the
context of a pragmatic design (real life settings, minimum
exclusion criteria, etc.) in order to replicate routine practice
conditions (Hotopf 2002). It was implemented twice
weekly for 6 weeks and consisted of a preferred intensity
exercise programme of a group-based (six to eight partici-
pants) circuit training, which involved an interval pattern
38
and comprised eight different exercise stations. The sta-
tions consisted of strengthening exercises including
abdominal and back exercises from the supine and prone
positions, respectively, two medicine ball arm-based exer-
cises from supine position, bouncing, static and dynamic
balance exercises on a trampoline, body weight squat exer-
cise against the wall and stationary cycling. The eighth
exercise-station was an exercise on supine position that
involved a gliding movement of the lower limbs to both
sides of the body with feet held on the ground and knee
joints at >90˚.
Following 5 min of stretching on major muscle groups
in the upper and lower limbs, participants were encouraged
to exercise for 1 min then break for 1 min, this was then
repeated twice more. Subsequently, they exercised for
2 min followed by a break of 1 min; this was then repeated
six times and then gradually increased to nine times by the
third week of the intervention. Stretching for 5 min on
major muscle groups closed the intervention. The total
duration of each session was 1 h (approximately 45 min of
exercise and stretching). A qualified exercise therapist
supervised each session (IM). Two additional staff members
of the project exercised and interacted with participants in
all sessions including the first author (TC). Participants
could choose the order in which they undertook the differ-
ent exercises according to their own preferences. Through-
out the intervention, no pressure was applied to
participants to exercise at higher levels nor was it applied
to participants to attend the sessions.
The mean heart rate (obtained at five time points
throughout each session using heart rate wrist monitors)
across all sessions was 103 (SD = 15), indicating that par-
ticipants were exercising at a low intensity [approximately
50% of the maximum heart rate (220-age)]. Likewise,
mean participant ratings of perceived exertion (taken at
five time points throughout each session) across all sessions
was 10 (SD = 1.5), which corresponds to a ‘light’ perceived
exertion (Borg 1998).
Interviews
Semi-structured interviews underpinned by a topic guide
(Table 1) were conducted by the first author (TC) with
Table 1
Interview topic guide
1. How they describe their experience of the intervention
2. Likes/dislikes of the intervention
3. Barriers to participation
4. Suggestions for improvements in design and delivery
5. Changes/impact of sessions during and after completion
6. Their ideas about why changes were/were not seen
© 2015 John Wiley & Sons Ltd
 Exercise for adolescents with depression

participants who had been allocated to the intervention The NVivo qualitative data analysis software; QSR
arm. The interview avoided leading questions and state- International Pty Ltd. Version 10, 2012, was used to organ-
ments with values implicit within them to avoid socially ize and code the data. All interviews were recorded with a
desirable responses (Breakwell 2006). digital recorder and subsequently transcribed verbatim by
All interviews took place either at the participant’s home the first author (TC).
or at a location convenient to them. All interviews took
place within 4 weeks of completion of the exercise
intervention. Ethical approval
The study received ethical approval from National Health
Inclusion criteria and sampling Service Research Ethics Committee (REC) on 18/07/11.
REC reference: 11/EM/0157.
All study participants consented to be interviewed at the
outset of the larger study (Carter et al. 2012), and all those
allocated to the intervention arm of the trial were subse-
Findings
quently invited to be interviewed. All participants met the
following eligibility criteria as defined by the larger trial: In total, 72% (n = 26) of participants who received the
aged between 14–17 years of age; receiving treatment for intervention were interviewed. It was not possible to inter-
depression from mental health services at the time of view participants who did not attend (n = 8) or who
consent; and scoring above a cut-off value on the Chi- dropped out after attending (n = 3) as they were not
ldren’s Depression Inventory 2nd Edition (Kovacs and contactable. However, all of those interviewed attended at
MHS Staff 2011). Importantly, due to the pragmatic nature least five sessions of the intervention with the majority
of the trial, the participants reflected those in routine clini- attending between nine and ten sessions out of a possible
cal practice. As such, alongside low mood/depression, a 12 (see Table 2).
significant number of participants had self-harm injuries Ten themes were generated from the codes and were
and various physical health problems including sciatica, subsequently collapsed into two categories (Table 3). The
chronic low back pain, knee joint injuries or severe explanations and descriptions of the themes are supported
hemicranias. by illustrative quotes from interview participants. All
quotes are anonymized and are referenced by the inte-
rviewee’s identification number.
Analysis
A thematic approach was undertaken to analyse the inter-
view data (Braun & Clarke 2006). In order to implement Table 2
Participant characteristics
an effective and consistent thematic analysis of the data, the
n (%)
following six steps set out by Braun & Clarke (2006) were
Gender
implemented: becoming familiar with the data; generating
Male 5 (19)
initial codes; searching for themes; reviewing themes; defin- Female 21 (81)
ing and naming themes; and producing the report. Age
14 8 (31)
An initial reading of the interview transcripts was under-
15 5 (19)
taken to identify any pertinent emerging concepts. Subse- 16 8 (31)
quently, these concepts were organized to form the basis of 17 5 (19)
a conceptual category scheme. The data were then reread Treatment at time of interview
Counselling 10 (39)
and each sentence coded in correspondence with the cat- CBT 1 (4)
egory scheme. Initially, five transcripts were independently Treated by CAMHS but unknown modality 6 (19)
assessed by two researchers (TC and JR). A comparison No treatment/waiting list 7 (7)
Not reported 3 (12)
was then undertaken and a consensus was reached on the Attendance at sessions
main categories. The data in each category were then ana- <4 0 (0)
lysed for patterns, themes and subcategories, paying par- 5–6 3 (12)
7–8 7 (27)
ticular attention to outliers and contradictory accounts
9–10 11 (42)
given by participants. All of the categories were then con- 11–12 5 (19)
sidered together to arrange them according to the main CAMHS, Child and Adolescent Mental Health Service; CBT, Cognitive
patterns and processes observed. Behavioural Therapy.

© 2015 John Wiley & Sons Ltd 39

T. Carter et al.

Table 3 been facilitated in a way that expected a certain level of

Categories and themes
intensity.
Categories Themes
If you told me I had to work at a certain pace, or work
Valued aspects of The importance of choice
really really hard, I wouldn’t come, at all. (MA1)
the intervention
A sense of achievement
Being distracted A shared experience
Feeling clam
Routine Over three quarters of participants highlighted that being
Perceived change Physiological change with other young people who were experiencing similar
Emotional, psychological and
behavioural change
issues and problems was a positive and valued experience.
A cycle of change Some participants felt this shared experience resulted in an
implicit respectful understanding of how to act and
respond towards each other in the group.
Valued aspects of the intervention Because I knew it was other people in the same boat and
it was all to do with mental health I just felt like they
The importance of choice would respect me and they wouldn’t look out for bad
things about me, they would look out for the good
Approximately two-thirds of participants identified that
things. (F1)
having a choice of: (1) attending the intervention sessions;
Participants also reported that just knowing the other
(2) selecting the exercise intensity; and (3) which available
young people in the group had similar difficulties was
exercises to engage with were particularly valued aspects of
comforting.
the intervention.
I just liked kind of getting together with people that
By having the choice of how intensely to exercise
were going through similar things to me and even
allowed them to engage in exercise at a level they felt
though we didn’t speak to each other it was just
manageable.
knowing that I’m not the only one. (C2)
You wasn’t pushed to do what you couldn’t do basically,
Some participants reported this knowledge was positive
so if I was feeling tired or something like that I wasn’t
as they reflected how ‘normal’ the other young people in
going to get pushed to do loads and loads of work if I
the group looked, which seemed to challenge how they
don’t want to. (B5)
viewed themselves.
Similarly, by having the choice of how intensely to exer-
It was nice to know that they were all really normal girls
cise resulted in it being perceived as easy.
and it wasn’t like, I felt more normal and happy, and it
I thought ‘wow’ exercise is supposed to be hard but
made me more confident that other people were going
it’s actually kind of easy so you know the more you do
through the same thing. (A4)
it’s nice to do something easy and be good at it. (A4)
The shared experience also facilitated participants to
Having the choice of exercise intensity allowed them to
share with each other and in some cases offer advice and
exercise at an intensity level congruent with their current
support.
emotional and physical state.
Well I was talking to one of them, I think it was Emma,
I guess like you could push yourself but then you could
and I was telling her a feel a bit down and she asked me
also take it easy that was the good thing about it.
why, and I told her why I was feeling down, I can’t
Because it’s like, if you didn’t have the energy in you
remember why, then she gave me some ways that I could
because you were down and you didn’t want to do
actually try and deal with it. (MA1)
much, you could just take it easy, but if you were deter-
mined then you could push yourself. (MA2)
A sense of achievement
Some participants stated that coupled with having the
choice to stop, not being pressured to continue when they Over half of the participants experienced a sense of
were tired was valued. achievement, typically associated with feeling better about
I liked that it wasn’t sort of pressured, it was more free themselves.
to do what you want, like if it was do that exercise for Yeah, I felt that I had achieved something and then you
2 minutes, but it was more like choose one and then do feel better about yourself and want to do other stuff
it but if you get tired stop and I liked the freedom of it. after that, and you feel better because you think you can
(MA4) do it. (A2)
Some participants stated that they would have Some participants felt a sense of achievement through
responded negatively should the exercise session have their perceived accomplishments at the sessions. With one

40 © 2015 John Wiley & Sons Ltd


participant clarifying that the relative easiness of the exer-
cises contributed to this positive feeling.
. . . because it was easy you felt good about what you
were doing but like if it had been harder then maybe not
so much but I suppose like that was a good aspect about
the exercise is that it’s easy so people feel like they can
do it and that gives them a sense of achievement which
is good. (A4)
Some participants felt achievement simply through the
fact that they had done ‘something’ compared to how
many described typically sedentary lifestyles.
After the session I felt better about myself because I’d
actually gone out and done something. (B2)
Routine
Approximately half of the participants reported that
having a consistent routine of something to do in their lives
was beneficial to them.
So doing it twice a week it just gave you something to
do. It kind of like was more of a plan so it’s kind of like
I’m doing this so I can’t do stuff with you [others]. It was
good because it was dedication even though it was only
not that many sessions. It was enough; it was just good
to have something to do. (C2)
One participant described how the consistency provided
by the intervention was a vehicle for getting used to doing
something and acted as a conduit for further activity.
When you are unhappy you generally don’t have routine
or consistency in anything and everything goes wrong
and in getting sort of a structure and a structure to your
life helps make things easier because you get used to
doing something, and I think helps you to realise that to
get a job you have to have consistency and perhaps gives
consistency in school work and other areas. So I guess it
was like a stepping stone towards doing other things
which was good. (A4)
Being distracted
Approximately one-third of participants reflected that
during the exercise sessions they were able to focus their
attention and distract themselves from other problems and
difficulties.
. . . it was like, you’re exercising to forget, and it really
helped me because if I was stressed out about something,
I’d exercise and be like that’s actually really helped. (D2)
. . . you concentrate on doing the exercises, and then
when you concentrate on doing that you’ve just got
nothing else in your head, so then you’re just doing it
and its calming. (MA2)
© 2015 John Wiley & Sons Ltd
Exercise for adolescents with depression
Feeling healthier
Approximately one-third of the participants described
feeling healthier as a result of taking part in the interven-
tion. Some participants articulated this was associated with
increased confidence, feeling ‘better’ and motivating them
to change.
. . . I was feeling healthier like within myself and I was
thinking I’m going to sort myself out again, another day
to sort myself out. (B3)
It made me feel a bit healthier because I’ve not done
anything in ages and just doing that made me feel more
confident. (D3)
Perceived changes
Physiological change
Sleep
A quarter of participants noticed a sleep improvement
during the intervention period.
I seemed to be asleep, especially the days we were doing
it, I slept like solid hours . . .. . .. in the morning espe-
cially because it was school, I was so awake ready to get
up and get ready, whereas normally I just drag myself
out of bed but because I’d done the exercise the night
before my body was still awake, but I was still sleeping
like decent amounts of sleep. (C2)
Some participants attributed the improved sleep to
feeling more tired, and in one instance a participant found
this led to the discontinuation of hypnotic medication.
Yeah just that ever since I did the project I erm, I took
myself off the sleeping tablets because I felt more tired,
I had to do it gradually because obviously it wasn’t that
easy to just take myself off them, but I did do it and now
I don’t take them at all. (B5)
Energy
Approximately half of the participants experienced an
increase in energy after the exercise sessions. Some partici-
pants reflected on this increase in energy in terms of feeling
more awake and consequently wanting to engage in more
activity.
I wasn’t as tired, I just wasn’t really sleepy. (F3)
It kind of energized me a bit so I’d feel more like less
wanting to sit and do nothing. I felt more awake as well,
which is weird when you talk about exercise. (A1)
Some participants described that this increase in energy
resulted in generally feeling less tired which they attributed
to an improvement in their mood.
If I was like tired or whatever in the day, by the end of
it I wasn’t as tired and felt happy. (A2)
41
T. Carter et al.
Emotional, psychological and behavioural changes
Motivation
Approximately two-thirds of the participants felt an
increase in motivation in three areas: being sociable; engag-
ing in education; and making positive changes.
If I came home, I’d be different, I don’t know I would
just want to be more talkative with my family and
maybe want to see my friends and just want to do more.
(D3)
Participants typically stated such increased motivation
was in contrast to how they were previously.
Normally when I come in a Just go straight up stairs, so
I was talking to my mum and dad, like coming in here
and talking to my mum and that and watching tele
down here for a bit and doing other things. (C1)
Some participants noticed that the increased socializa-
tion taking place between themselves and their parents had
resulted in improved communication in general with their
parents.
I think my mum kind of opened up more to me, because
she was like, before she was very closed off and she didn’t
really know how to approach me about it, but because I
was happy she kind of felt a bit more like, oh I can talk to
you about it now because I didn’t want to upset you
before. So we have started talking loads, because I never
used to tell her anything but now I do. (C2)
An increase in motivation towards engaging in home-
work and attending school was also experienced by some.
I wouldn’t kind of just come and sit down I would feel
like I wanted to kind of do things rather than just. . . .
Like I’d come home and do work or something, which I
never really did before. (A1)
I don’t know it just kind of motivated me, because I was
in a good mood, I’d think positively and then I’d kind of
think more positively about things and it would make
me want to try and go into school and try harder and
things like that. (D3)
Some participants noticed enhanced motivation to
actively engage in activities that would have further posi-
tive personal impact.
I think just the dramatic change from being so upset and
depressed to feeling really happy all the time it just made
me want to turn everything around and just that little
spark of making me feel happy just kind of set me off
feeling happy and I wanted to carry that on so I just
wanted to do more. (D3)
Mood
Approximately two-thirds of participants experienced
mood improvement both during and since completion of
the intervention.
42
It just made me feel a lot happier, probably from the
third or fourth session, I just felt a lot happier, like when
I came home after I was just in a really good mood. (F3)
Some participants found that their mood improvement
extended beyond the evening of the sessions and was sus-
tained for days afterwards.
Knowing I had something to do I had something to
focus on during the day and I kept telling myself that
because it made me happier if I was sad the night before
then I thought well if I go through the session then I’d be
happy the next day and the next day after that. I don’t
know it just kept me happy knowing that was going to
happen. (D2)
Self-efficacy
Half of the participants reported a general improvement in
self-efficacy, with others noticing improvements in self-
efficacy relating to exercising, joining groups and dealing
with friends.
I think I have become more confident as well. (F1)
Researcher: In what way?
Because I’m not as anxious around my friends now, I
can just be more calm and I’m not really bothered of
what people have to say or what they have to think
anymore. (F1)
Interestingly, some participants experienced an improve-
ment in self-efficacy in different areas of their lives includ-
ing; re-engaging with college, dealing with situations, and
successfully engaging with their school homework.
I felt that I had achieved something and then you feel
better about yourself and want to do other stuff after
that, and you feel better because you think you can do it.
Whereas if you don’t you kind of doubt yourself, like I
could do my homework but I doubt I’ll be able to do it.
After the exercise it was like, my homework’s probably
easy, I’ll look on the internet and see what it means. (A2)
Exercise habits and perception
Approximately half of the participants noticed a change in
their attitude towards exercise; from a difficult and unap-
pealing behaviour to achievable and enjoyable. Some par-
ticipants also stated changes in their exercise habits since
completion of the intervention.
Yeah, it definitely spurred me on to do exercise cos I
thought wow exercise is supposed to be hard but it’s
actually kind of easy so you know the more you do it’s
nice to do something easy and be good at it. (A4)
Having the choice of exercises was reported to poten-
tially underpin this change in attitude towards exercise.
Well I used to think what’s the point, I stopped doing
P.E. But when I started doing that it made me realise it
© 2015 John Wiley & Sons Ltd
 Exercise for adolescents with depression

can be fun if you can choose what you want to do rather

than being told what to do. (A3)
Some participants became more physically active in
general in order to prolong the mood improvement they
had experienced.
I’ve done three races for life and I’m going to do more
things like that and I’m walking a lot more and I don’t
know, I just really liked it and I think I’m going to go to
a gym when I’m older and stuff to really improve my
mood. (D2)

Social behaviour Figure 1

Approximately a quarter of participants described a change
in their social behaviour during the intervention period.
Some participants noticed they were ‘nicer’ to people, and
not ‘lashing out’ as often, both in the school setting with
friends and teachers, and at home with the family.
I think I was a lot nicer to my mum and sister, because
I felt a bit like that I was thinking about it more, and
also thinking about my actions, because I would nor-
mally lash out at people and I didn’t do that around my
friends either, it was really good, like with my mood and
stuff at school as well. (D2)
Some participants linked this change with feeling calmer
both after the exercise sessions and throughout the inter-
vention period.
I guess afterwards I was more calmed down, and I was
just more calmed down and I could deal with situations
more. (MA2)
Cycle of change
Some participants noticed that the various beneficial
changes they experienced appeared to be influential in the
development of further beneficial changes, with some sug-
gesting a cyclical nature to these developments.
Because I was less tired my school work went up a bit
and I was concentrating more because it kind of made
me a bit more worn out and then I got a good night’s
sleep so I was ready for the morning and then when I’m
ready for the morning, I’m not as grumpy and that sets
my day off well, and that makes my school work good
and then I’m happy about that, and then when I get
home I’m in a good mood because I have had a good day
at school so it goes on like that, from just one good
sleep. (F1)
Discussion and implications for practice
In the absence of previous qualitative studies exploring the
experience of preferred intensity exercise of adolescents
with depression, the current work contributes to new
Cycle of change
Figure 2
Vicious cycle [adapted from Verduyn et al. (2009)]
knowledge in this area. It suggests that adolescents with
depression may experience significant beneficial changes
following engagement in consistent, preferred intensity
exercise. While research in both adults and adolescents is
underpinned by biochemical theories that assert an inter-
play of relevant physiological factors (e.g. energy expendi-
ture, heart rate, etc.) and prescribed (fixed) intensities with
depression symptom improvement (Dunn et al. 2005,
Hughes et al. 2013), in our study, adolescents with depres-
sion reported benefits that appeared to be independent
from such factors as they preferred to exercise at low
intensity. Some of these benefits seemed to be expressed as
a cycle of change. Specifically, the initial benefits reported
by participants appeared to lead on to further benefits.
Such changes seem to correspond with improved overall
well-being and even appear to extend to improved social
networks.
A conceptual diagram of the cycle of change is presented
in Fig. 1. It is not suggested that all the participants experi-
enced all the changes, or that the changes occurred in any
particular order. However, in line with one of the funda-
mental concepts underling a cognitive behavioural
approach to mental health (Fig. 2) it is proposed that the
intervention potentially interrupted the vicious cycle that is

© 2015 John Wiley & Sons Ltd 43

T. Carter et al.

argued to maintain depression (Verduyn et al. 2009). In
doing so, further changes likely took place, e.g. improved
confidence, increased activity, and improved sleep.
By providing participants with the opportunity to
choose the intensity and the exercises to engage with,
it was found that they felt a sense of achievement,
enjoyed the experience and they were able to temper their
efforts to align with their mood and motivation at the
time. This allowed them to continue to participate at
impressively high rates, especially since they had the
freedom to reduce or stop their activity without conse-
quence (critical feedback or judgement). Participants
reported this was in contrast to physical education classes
at school, where they were typically asked to meet fixed
levels of intensity exercise and were subject to expecta-
tions and judgement, and would subsequently disengage
as a result.
It is acknowledged that the positive findings may be a
result of the increased therapeutic contact received by par-
ticipants through attending the exercise sessions. However,
participants did not typically highlight this as a valued
aspect of the intervention, and although it potentially con-
tributed to some of the reported benefits, it is unlikely to
have accounted substantially to them.
The findings of the current study challenge the tradi-
tional biochemical approach that exercise should be under-
taken at specific (prescribed) intensities for set amounts of
time in order to bring about benefits. Rather, adolescents
are able to effectively exercise at their own preferred inten-
sity (low) while at the same time finding the experience
palatable and enjoyable. The findings also suggest that
preferred intensity exercise leads to numerous self-reported
beneficial physical and psychological changes. An addi-
tional merit to our findings is given by the fact that a
significant number of our participants showed a heavy
clinical profile (e.g. receiving ongoing medical treatment
for self-harm injuries during their participation in the exer-
cise programme).
Mental health nurses are well placed to promote physi-
cal exercise (Callaghan 2004, Happell et al. 2011), espe-
cially for young people receiving treatment from Child and
Adolescent Mental Health Services in the United Kingdom.
Preferred intensity exercise appears to be a promising strat-
egy that stimulates a series of benefits. As such, this study
enables nurses involved in the treatment of adolescents
with depression the platform to promote preferred intensity
exercise and to articulate some of the benefits that may be
experienced.

References
Borg G. (1998) Borg’s Perceived Exertion and
Pain Scales. Human Kinetic Publishers, Cham-
paign, IL.
Braun V. & Clarke V. (2006) Using thematic analy-
sis in psychology. Qualitative Research in Psy-
chology 3, 77–101.
Breakwell G.M. (2006) Interviewing methods.
In: Research Methods in Psychology (eds
Breakwell, G.M., Hammond, S., Fife-Schaw,
C., et al.), pp. 232–253. Sage, London.
Brown H.E., Pearson N., Braithwaite R.E., et al.
(2013) Physical activity interventions and
depression in children and adolescents: a sys-
tematic review and meta-analysis. Sports Medi-
cine 43, 195–206.
Callaghan P. (2004) Exercise: a neglected interven-
tion in mental health care? Journal of Psychiat-
ric and Mental Health Nursing 11, 476–
483.
Callaghan P., Khalil E., Morres I., et al. (2011)
Pragmatic randomised controlled trial of pre-
ferred intensity exercise in women living with
depression. BMC Public Health 11, 465.
Carter T., Callaghan P., Khalil E., et al. (2012) The
effectiveness of a preferred intensity exercise
programme on the mental health outcomes of
young people with depression: a sequential
mixed methods evaluation. BMC Public Health
12, 187.
Cooney G.M., Dwan K., Greig C.A., et al. (2013)
Exercise for depression. Cochrane Database of
Systematic Reviews (9), Cd004366.
Dunn A.L., Trivedi M.H., Kampert J.B., et al.
(2005) Exercise treatment for depression: effi-
cacy and dose response. American Journal of
Preventative Medicine. 28, 1–8.
Faulkner G. & Biddle S. (2002) Mental health
nursing and the promotion of physical activity.
Journal of Psychiatric and Mental Health
Nursing 9, 659–665.
Hamlyn-Williams C., Freeman P. & Parfitt G.
(2014) Acute affective responses to prescribed
and self-selected exercise sessions in adolescent
girls: an observational study. BMC Sports
Science, Medicine and Rehabilitation 6, 35.
Happell B., Platania-Phung C. & Scott D. (2011)
Placing physical activity in mental health care: a
leadership role for mental health nurses. Inter-
national Journal of Mental Health Nursing 20,
310–318.
Happell B., Scott D., Platania-Phung C., et al.
(2012) Nurses’ views on physical activity for
people with serious mental illness. Mental
Health and Physical Activity 5, 4–12.
Hotopf M. (2002) The pragmatic randomised con-
trolled trial. Advances in Psychiatric Treatment
8, 326–333.
Hughes C.W., Barnes S., Barnes C., et al. (2013)
Depressed Adolescents Treated with Exercise
(DATE): a pilot randomized controlled trial to
test feasibility and establish preliminary effect
sizes. Mental Health and Physical Activity 6,
119–131.
Khalil E., Callaghan P., Carter T., et al. (2012)
Pragmatic randomised controlled trial of an
exercise programme to improve wellbeing out-
comes in women with depression: findings from
the qualitative component. Psychology (Savan-
nah, Ga.) 3, 979–986.
Kovacs M. & MHS Staff (2011) Children’s
Depression Inventory 2nd Edition (CDI 2).
Technical Manual. Multi-Health Systems,
Toronto, Canada.
Larun L., Nordheim L.V., Ekeland E., et al. (2006)
Exercise in prevention and treatment of anxiety
and depression among children and young
people. Cochrane Database Of Systematic
Reviews (Online) 3, CD004691.
Rose E.A. & Parfitt G. (2007) A quantitative
analysis and qualitative explanation of the indi-
vidual differences in affective responses to pre-
scribed and self-selected exercise intensities.
J Sport Exerc Psychol 29, 281–309.
Verduyn C., Rogers J. & Wood A. (2009)
Depression. Cognitive Behavior Therapy with
Children and Young People. Routledge, East
Sussex.

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