VOL: 103, ISSUE: 10, PAGE NO: 32
Matt Birks, MA, PGCE, BSc, RMN, is senior lecturer in mental health nursing, University of Derby
Salsa is an energetic dance originating from Cuba incorporating elements of several dance styles including mambo an…
Salsa is an energetic dance originating from Cuba incorporating elements of several dance styles including mambo and cha cha cha. It is growing in popularity as a leisure activity in the UK, with salsa clubs opening nationwide.
I decided to study the effects of salsa on people with depression because it combined my personal interest in salsa dancing with my background as a mental health nurse. During my years of experience as a community mental health nurse it became evident that many people with depression found it difficult to maintain motivation with gym-based exercise due to its solitary nature. In many areas, high costs of gym membership or lack of local provision make it difficult for some clients to access facilities. There is a paucity of research into the efficacy of dance as a form of exercise in treating depression.
The study sample consisted of 24 volunteers, aged 21-54 years, who answered a newspaper appeal. All but two were women and all but two were white British, with one of African-Caribbean origin and one of Indian origin. Five respondents had received previous dance training but none of these completed the study. None had an obvious or disclosed physical disability. The respondents were assured of confidentiality before agreeing to participate.
Participants were assessed using the Beck Depression Inventory (BDI) (Beck, 1996) before the study. All had received a formal diagnosis of depression, some were already taking antidepressant medication and all scored 15 or above on the BDI - one as high as 47. Scores for the BDI-II equate as follows:
- 5-9 - normal ups and downs of life;
- 10-18 - mild to moderate depression;
- 19-29 - moderate to severe depression;
- 30-63 - severe depression.
The participants agreed to attend eight one-hour salsa classes at Derby University on Wednesday afternoons over a nine-week period. At week four those who were still attending the classes were reassessed using the BDI; all showed notable improvements. Those remaining at week eight were assessed for a third time, and showed further improvement. The study suffered a high drop-out rate between weeks one and four, when 14 participants were lost; and two more later dropped out.
RESULTS AND DISCUSSION
The results show a significant improvement at each stage of the assessment process for all class members still involved in the study.
Some of those taking antidepressant medication throughout seem to have made the biggest improvements but the numbers were not high enough to draw specific conclusions from this.
One concern is the number of participants who dropped out of the study. In some cases this was due to difficulty in attending daytime classes - further studies providing classes at different times may prove more successful in this respect.However, a greater number of those who completed the study stated that the afternoon classes enabled them to attend more readily, as they did not have to arrange childcare.
Part of the study hypothesis was that a small group would provide mutual support as friendships are established. Further studies might consider providing more than one class per week in order to accelerate this process.
For participants who completed the study and even for those who were assessed at week 4, the results indicate that attending the classes was worthwhile. It was suggested to those who finished that it would be worth continuing to attend dance classes and it is hoped that they will do so, either individually or as a group.
Several elements of this study merit further investigation. Exercise has been shown to be beneficial to people with depression. Behavioural activation in attending these classes may have been further enhanced by a variety of factors - social interaction, shared experience, concentrating on learning a new skill and the confidence this can bring probably all played a part. It would have been preferable had more respondents completed the study, and the reasons for so few completing merit further investigation.
Dance is not for everyone and the low numbers of men, people with physical disabilities and black and minority ethnic participants was noted. However, it is hoped that with the current success of television shows such as BBC’s Strictly Come Dancing more people will consider it an acceptable option. The dance class does not have to be salsa - it was chosen simply for convenience and popularity.
For many people, the thought of taking medication for depression is unappealing, and dance classes may be an unexplored option in this area. At present, only 5% of GPs use exercise as a treatment option for mild to moderate depression, although 42% have access to exercise referral schemes (Halliwell, 2005).
One participant who showed a very significant improvement was taking antidepressants at the time. The decision to monitor those taking antidepressants as a subgroup was taken at the last minute, not only as a general risk assessment along with other prescribed medications but also to identify any possible trends.
Unfortunately, this is impossible to identify with any reliability, due to the small numbers completing the study. It was noted that more participants taking antidepressants dropped out of the study than completed it. Initially, this was thought to be due to possibly higher levels of depression. However, upon examination of the results it can be seen that initial BDI scores are not significantly different from many on no medication at all.
The high drop-out rate was a concern and requires investigation. One possible factor may have been the session time (1.15pm-2.15pm on Wednesdays). This was chosen for reasons of availability of the dance teacher and venue. However, feedback from participants who left the study early suggests that those who tried to attend during lunch breaks from work found the time awkward, as did those who found childcare a problem. Clearly, there is scope for further study at different times. Discussions with the dance teacher also revealed that a 10-20% drop-out rate in dance classes is normal.
- NICE (2004) guidelines advocate cognitive behavioural therapy (CBT) as the approach of choice for treating depression and state that antidepressants are not recommended in the initial treatment of mild depression.
- Due to resource limitations and the cost of running fully staffed psychotherapy units, some researchers have been investigating alternative approaches to treating depression.
- For some time now, the link between exercise and mood has been clear. The bulk of work in this area has been with depressed people. Van der Merwe and Naude (2004), Kirby (2005), Limb (2004) and Palmer (2005) all concur that exercise has a positive effect on mood, while initiatives such as Local Exercise Action Pilots (LEAP) report positive outcomes in participants who initially exhibited symptoms of clinical depression (Department of Health, 2006).
IMPLICATIONS FOR PRACTICE
- In searching for alternatives to medication, nurses as well as doctors tend to think initially of psychotherapies. The challenges associated with providing these therapies are concentrated around access and client suitability.
- Referral is often followed by a prolonged wait for a client to be assessed. If, for whatever reason, the client is felt to be unsuited for the form of therapy on offer, this process may be perceived negatively, thus reinforcing feelings such as low self-worth, or at the very least time spent waiting for nothing. These problems, coupled with debates about the pathologising of clients, have led many healthcare providers to consider social prescribing.
- Nurses may have an alternative source on which to draw for referring clients or, with appropriate training, be able to offer dance classes themselves within the therapeutic setting - with appropriate risk assessment. It cannot be denied that classes such as this are successful only if there is an element of fun involved. The strong probability is that the fun element was a major contributor to the success of the intervention.
- The classes were run by a teacher who had 18 years’ experience of teaching dance, and who had taught internationally and danced competitively. This is a skilled role that nurses would not be able to adopt overnight so, in the majority of cases, the most useful application of the outcome of this study is likely to be referral to existing dance classes.
- At the time of writing, the study has been over for two months. Four of the group who completed it are attending classes on a weekly basis and report no symptoms of depression whatsoever - they report feeling happier, fitter and their dance skills are also improving and progressing.
This article has been double-blind peer-reviewed.