VOL: 103, ISSUE: 10, PAGE NO: 32-33
Matt Birks, MA, BSc, PGCE, RMN
Senior lecturer in mental health nursing, University of Derby.
Abstract: Birks, M. (2007) The benefits of salsa classes for people with depression. www.nursingtimes.net
Abstract: Birks, M. (2007) The benefits of salsa classes for people with depression. www.nursingtimes.net Aim: This study aimed to further develop on previous studies which have shown a positive benefit of physical exercise on the mood of people diagnosed with mild to moderate depression. Method: Volunteers were assessed using the Becks Depression Inventory and asked to commit to eight one-hour salsa lessons over a nine-week period. Those remaining in the study were reassessed at weeks 4 and 8 to see if their mood had improved. Results: More than half of the participants dropped out of the study by week 4. However, the main reason for this was reported to be difficulty in attending the lunchtime classes. All the remaining participants showed marked improvements in their mood when assessed at week 4 and further improvement at week 8. Conclusion: Although this was a small exploratory study, the improvements suggest that dance may be helpful in improving the mood of people with depression. Further studies are indicated to confirm this and to ascertain whether a choice of class times would reduce the drop-out rate for those attending classes. The World Health Organization (2000) has predicted that by 2020, depression will be the second most common cause of morbidity worldwide. Although the impact of depression on individuals and their families is well documented, reliable estimates of incidence are problematic, due in part to the stigma that still surrounds what is essentially a medical condition. However, an indication of its prevalence is seen in the growth of usage of the term in popular media generally - appropriately or otherwise. Treatment of depressionMost recent research evidence about treatments for depression involve medicalised vs psychological or ‘talking’ interventions (Van der Mauwe and Naude, 2004a; Moore and McLaughlin, 2003; Gillam, 2003). These studies tend to reinforce NICE (2004) guidelines, which advocate cognitive behavioural therapy (CBT) as the approach of choice in treating depression. They state that antidepressants are not recommended for initial treatment of mild depression as the risk-benefit ratio is poor. Guided self-help is the preferred option, but for more moderate depression, up to 12 sessions of CBT are indicated. This can be electronic or in person. Electronic CBT refers to CBT self-help courses which are supplied by some GPs as CD-ROMs and are more immediately accessible than `live` therapists. However, resource limitations, as described by Layard (2006), coupled with the cost of running fully staffed psychotherapy units (not to mention clinical differences in opinion) mean that 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 Mauwe and Naude (2004b), Kirkby (2005), Limb (2005) 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). Edmonds and McGuire (2005) have also noted the benefits exercise to sufferers of chronic fatigue syndrome (CFS). Interestingly, a study by Doyne et al (1987) comparing aerobic with anaerobic exercise obtained little difference in outcomes. This raises the question as to whether the physical activity or the social interaction is the significant factor. Salsa for people with depressionSalsa, which is Spanish for ‘sauce’ is also an energetic dance with several styles. It has its origins in Cuba, where African slaves combined their indigenous music with Latin American rhythms. Today’s salsa music incorporates elements of several dance styles including as mambo and cha cha cha. Sub-styles or varieties include Cuban, Miami and New York Cross-Body Lead (CBL). 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 as a hobby with my professional background as a mental health nurse. I had tried using dance sessions while working as a staff nurse in a psychiatric day hospital and this had proved popular with clients - although no formal study was undertaken to determine its efficacy. Over years of experience as a community mental health nurse, it became empirically evident that many people suffering with depression found it difficult to maintain motivation due to the sometimes-solitary nature of gym-based exercise. In many areas high costs of gym membership or lack of local provision make it difficult for some clients to access facilities. Gyms may also be perceived by some people who lack self-esteem as the preserve of confident and fit people, which will render them an unattractive prospect to those who employ depressogenic assumptions (Beck, 1979). There is a paucity of research into the efficacy of dance as a form of exercise in treating depression. Most studies tend to be designed around more conventional ideas of exercise, such as running, walking and sports. Dance therapy for self-expression is well accepted, but is a very different and more esoteric intervention. An example of this would be Hawkes (2003), who studied transactional analysis in patients learning Argentine tango. Dance has been used to assess and treat motivation (Shen, 2003) and even sexual arousal problems (Hallam-Jones and Wylie, 2001) but there is a dearth of evidence linking its exercise value with the behavioural activation and social support it can offer. The studyThe study sample consisted of 24 volunteers who answered a newspaper appeal. All but two were women, and their ages ranged from 21 to 54 years (mean 37.5). All respondents but two were white British with one of African-Caribbean origin and one of Indian origin. Twenty-two made initial contact by email and two by phone. Three respondents were students and three were staff at the university. The remainder had no prior contact with the university. Five respondents had received previous dance training, but none of these completed the study. None of the respondents 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, 1961; revised ‘Beck II’ version 1996) before entering the study. All had received a formal diagnosis of depression from their GP or other suitably qualified healthcare professional, and all scored 15 or above - one as high as 47. The 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.
Some respondents were already taking antidepressant medication (Table 1). Although the BDI is over 40 years old, it is still a widely used assessment tool in mental health services, particularly in cognitive behavioural interventions (Marks et al, 2005; Embling, 2002; Wells, 1998). The participants agreed to attend eight one-hour salsa classes at DerbyUniversity on Wednesday afternoons, over a nine-week period, taught by a local salsa teacher. At week 4, those who were still attending the classes were re-assessed using the BDI; all showed notable improvements in their scores. Those still remaining at week 8 were assessed for a third time, and all showed further improvement (Table 1). The only occasions that scores were revealed to the respondents were after the initial assessment (week 0) and the final assessment (week 8). They had no record of the assessment themselves, so that with each subsequent assessment score, they had no previous score to refer to. Unfortunately, the study suffered a high drop-out rate between weeks 1 and 4, when 14 were lost; a further two dropped out before the end. Results and discussionThe results show a significant improvement at each stage of the assessment process for all class members still involved in the study. Some of the participants who were 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 - some at quite an early stage. In some cases, this was due to participants’ difficulty in committing to attend in the daytime, as some participants were attending in their lunch break - 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. One risk with studies of this kind is that working with depressed people can mean working with people who have low energy levels, diminished concentration and low self-esteem, (Norman and Ryrie, 2004). These difficulties may be exacerbated in the short term when struggling to learn a new skill. Part of the study hypothesis was that a small group would provide mutual support as friendships are established. Further studies might consider more providing than one class per week to accelerate this process. For those participants who completed the study and even for those who were assessed at week 4 stage, the results suggest that attending the classes was worthwhile. It was suggested to those who finished that it would be worth maintaining this progress by continuing to attend dance classes run by the same teacher at a venue less than a mile away. It is hoped that they will do so either individually or as a group. ConclusionsSeveral elements of this small study merit further investigation. Physical exercise has been shown to be beneficial to people suffering from 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 minority ethnic participants was noted. However, it is hoped that with the current success of such television programmes as BBC’s Strictly Come Dancing, in which noted sports stars and actors of both sexes and different ethnic backgrounds appear and excel, more people will consider it a worthwhile and acceptable option. The dance class does not have to be salsa - or Latin for that matter. Salsa was chosen simply for convenience and its current popularity. For many people, the thought of taking medication for depression is unappealing, and the rise of alternative and complementary therapies is probably testament to this. Dance classes may be another hitherto 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). As can be seen from Table 1, one participant (V) who showed a very significant improvement was taking antidepressant medication at the same time. The decision to monitor those taking antidepressant medication as a sub-group 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. However, it was noted that more participants who were 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 who were on no medication at all. The high drop-out rate was a concern and further work needs to be undertaken to explore the reasons for this. One possible factor may have been the time the sessions were run (Wednesdays 1.15-2.15). This time was chosen for reasons of availability of the dance teacher and the venue and it was also felt it might enable parents of school-age children to attend. However, feedback from participants who left the study early suggests that those who tried to attend during work lunch breaks found the time awkward, as did those who found childcare a problem generally (the group did break for a week during half-term). Clearly, there is scope for a follow-up study (or several consecutive studies), which could be run at different times of day/week/year, to involve as many participants as possible. Discussions with the dance teacher also revealed that a 10-20% drop-out rate was normal in dance classes generally. Aside from general life and family issues, many people may have unrealistic expectations of the level of practice and work required to achieve what is considered by many dance students a ‘satisfactory’ level of competence. If one couples this tendency with perfectionistic traits (Power and Dalgleish, 2003; Bruch and Bond, 2003), or feelings of low self-worth generally, then the drop-out rates become less surprising. Some participants who were students or staff at the university disclosed feelings of unease over issues of confidentiality, which contributed to at least one dropping out - clearly depression still carries a stigma in the minds of many. Some unease was also evident when we discussed the request of the local TV news studio, which was interested in filming a class - an idea that was quickly rejected. The study has numerous implications for nursing. In searching for alternatives to medication, nurses as well as doctors tend to think initially of psychotherapies. The challenges associated with providing these 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. Coupled with this, debates around the pathologising of clients have led many healthcare providers to consider social prescribing. Nurses may then 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 commercially 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 study for many. 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 coming along nicely too. Special thanks go to Lee Hunter from Absolute Salsa in Derby (www.absolutesalsa.co.uk) and Holly Ryalls from the University of Derby for their teaching skills, good humour and support, without whom, this study would not have happened. Last but certainly not least, thanks go also to everyone who completed the study.
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