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Original article
State anxiety and subjective well-being responses to
acute bouts of aerobic exercise in patients with
depressive and anxiety disorders
J Knapen,1,2 E Sommerijns,1 D Vancampfort,1,2 P Sienaert,2 G Pieters,2,3 P Haake,2
M Probst,1,2 J Peuskens2,3
1
Faculty of Kinesiology and ABSTRACT increased immediately following 20 minutes of
Rehabilitation Sciences, Objective: Acute aerobic exercise is associated with a cycling performed at 70% of VO2max, whereas
Katholieke Universiteit Leuven, reductions were observed immediately after exer-
Leuven, Belgium; 2 University
reduction in state anxiety and an improvement in
Psychiatric Centre KU Leuven, subjective well-being. The objective of the present study cise at 40% and 60% of VO2max.
Campus Sint-Jozef Kortenberg, was to contrast the effects of aerobic exercise at self- The first objective of the present study was to
Kortenberg, Belgium; 3 Faculty of selected intensity versus prescribed intensity on state compare the changes in state anxiety and sub-
Medicine, Katholieke Universiteit anxiety and subjective well-being (negative affect, jective well-being after a single aerobic exercise
Leuven, Leuven, Belgium
positive well-being and fatigue) in patients with session at self-selected versus prescribed intensity
Correspondence to: depressive and/or anxiety disorders. In addition, the in a sample group of patients with depressive and/
Dr Jan Knapen, Universitair potential impact of heart rate feedback was assessed. or anxiety disorders. Several authors6–9 assume that
Psychiatrisch Centrum KU exercise at preferred intensity is more effective in
Leuven, Campus Kortenberg,
Methods: Nineteen men and 29 women performed three
Leuvensesteenweg S17, 3070 test conditions on a bicycle ergometer during 20 minutes: improving state anxiety and subjective well-being
Kortenberg, Belgium two tests at self-selected intensity; one with and another than exercise at prescribed intensity.
without heart rate feedback, and a third test at the The second objective was to investigate the
Accepted 24 October 2008 prescribed intensity of 50% of the maximal heart rate potential impact of heart rate feedback during an
Published Online First reserve according to Karvonen. Tests were executed in aerobic exercise session on changes in anxiety and
16 November 2008 subjective well-being. Patients with panic disorders
random order. State anxiety and subjective well-being
were evaluated using the state anxiety inventory and the are more sensitive to bodily changes during
subjective exercise experiences scale. physical activity than non-anxious individuals.
Results: After 20 minutes cycling, patients showed They associate normal physiological reactions
significantly decreased state anxiety and negative affect during effort such as tachycardia, hyperventilation
in the three conditions. The magnitude of the reduction and sweating with symptoms that are typical for
did not differ significantly between the three conditions. panic attacks.10–13 In these patients heart rate
Only cycling at self-selected intensity enhanced positive feedback during aerobic exercise has a negative
well-being. Cycling at 50% of the maximal heart rate impact on changes in anxiety and subjective well-
reserve decreased fatigue, whereas cycling at self- being. We investigated whether heart rate feedback
selected intensity increased fatigue. influences response in anxiety and subjective well-
Conclusions: The response in state anxiety and negative being in a sample group of patients with other
affect was unaffected by the type of aerobic exercise. anxiety disorders (eg, generalised anxiety disorder,
Self-selected intensity influenced exercise-induced posttraumatic stress disorder, social anxiety dis-
changes in positive well-being and fatigue in a positive order, obsessive compulsive disorder) and/or
and negative way, respectively. depressive disorders.
METHODS
Research indicates that acute bouts of exercise are Subjects
associated with reductions in state anxiety. Taylor1 Nineteen male patients (mean age 40.68 years, SD
evaluated in a narrative review of 24 studies the 13.18; mean body weight 75.71 kg, (12.78); mean
effects of single exercise sessions on state anxiety. body mass index 24.43, (4.45); mean resting heart
In 21 (87%) of the studies, acute exercise resulted rate 71.26, (9.67)) and 29 female patients (mean
in a significant reduction in state anxiety. It age 34.61 years, (11.8); mean body weight
appears that acute aerobic exercise is more effective 67.69 kg, (16.49); mean body mass index 24.13,
than weight training.1–4 In acute bouts of aerobic (6.06); mean resting heart rate 71.34, (14.43)) took
exercise, state anxiety reductions last for 2–4 h part in the study. The patients were diagnosed by
after cessation of activity.2 Individuals with high psychiatrists according to the Diagnostic and
state anxiety and unfit subjects show the greatest Statistical Manual for Mental Disorders, 4th
improvement post-exercise. Generally, a reduction edn.14 They had anxiety disorders and/or depressive
in anxiety will be observed after following moder- disorders or a mixed diagnosis, adjustment disorder
ate intense aerobic exercise. Several investigators with mixed anxiety and depressed mood. Most of
noted that high-intensity physical activity (ie, 80% them (90%) received two diagnoses. The symp-
of maximum oxygen consumption; VO2max) is toms of depression and anxiety often overlap as
associated with significant elevations in state most patients diagnosed as having depression have
anxiety.1 A study by Raglin and Wilson5 using co-morbid symptoms of anxiety disorders.
healthy subjects indicated that state anxiety Similarly, it is common that patients diagnosed
756 Br J Sports Med 2009;43:756–759. doi:10.1136/bjsm.2008.052654
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Original article
as having an anxiety disorder also receive a diagnosis of assessed by Cronbach’s alpha coefficients in the present study
depression.15 Therefore, we made no distinction between was 0.96.
patients with depressive or anxiety disorders. The diagnoses Subjective well-being was measured using the subjective
are represented in table 1. All patients were hospitalised in a exercise experiences scale (SEES).18 It consists of three subscales:
cognitive-behavioural treatment unit of a university psychiatric negative affect, positive well-being and fatigue. Each subscale
hospital in Belgium. Patients were excluded if they had panic contains four items, which are scored on a scale from 0 (not at
disorder, bipolar disorder or psychosis. The somatic exclusion all) to 7 (entirely). Higher scores on a subscale indicate a higher
criteria were treatment with beta-blockers and severe cardio- perception for this factor. The SEES represents one of the most
pulmonary diseases. reliable and valid instruments for assessing subjective well-being
in exercise settings.19 The internal consistency in the present
study was 0.90 for the subscales negative stress and positive
Instruments and procedures
well-being and 0.87 for the subscale fatigue.
Patients carried out three submaximal exercise tests on an
The SAI and the SEES were assessed 5 minutes before the
electronically braked bicycle ergometer (Ergo 2000, Ergo-Fit, The
exercise session and 10 minutes after the completion of the
Netherlands), with 3 days between tests. The tests order was
session.
randomly assigned, to control for the influence of previous test(s).
The study procedure was approved by the Ethical Committee
The randomisation lists were generated by an independent
of the Faculty of Medicine of the Katholieke Universiteit Leuven
statistician using the SAS Ranuni random number generator.16
in accordance with the principles of the Declaration of Helsinki.
The first test (test condition A) consisted of cycling during
All participants gave the research coordinator their informed
20 minutes at an intensity of 50% of the estimated maximal
consent.
heart rate reserve according to Karvonen.17 The maximal heart
rate was estimated using the formula (220 2 age). The work
load was automatically adapted to the heart rate, which Statistical analysis
corresponds to 50% of the estimated maximal heart rate reserve. A 3 6 2 (condition 6 time) within-participants repeated-mea-
During this test, the patient received heart rate feedback. The sures analysis of variance (ANOVA) was conducted using the
heart rate was visible on a screen during the whole test. The SAS procedure MIXED20 to test the significance of the pre-post
experimenter asked the individual for heart rate readings at differences between the means. The significance level was set at
baseline and at 2-minute intervals during the test. 0.05 (two-tailed).
The second test (test condition B) involved cycling for
20 minutes at a self-selected intensity. The patient could vary RESULTS
the workload, while he/she got heart rate feedback. Changes in state anxiety and subjective well-being
The third test (test condition C) consisted of cycling for The means before and after exercise sessions are presented in
20 minutes at a self-selected intensity without heart rate table 2 and figs 1 and 2.
feedback. During this test, the heart rate on the screen of the
bicycle ergometer was covered. State anxiety
The testing took place at the same time of day in standardised A 3 6 2 (condition 6 time) within-participants repeated-mea-
conditions. Before examination, heart rate at rest was assessed sures ANOVA revealed a significant time main effect, with
after the subject had relaxed on a mat for 5 minutes. The pedal decreased scores over time (F1.47 = 19.59, p,0.001).
frequency was free. In each test condition, SAI scores after exercise were signifi-
State anxiety was assessed by the state anxiety inventory cantly lower than before exercise (F and p values ranged from
(SAI) of Spielberger.18 The range of possible total scores is 20 to F1.92 = 21.81, p,0.001 to F1.92 = 7.44, p,0.001). There were no
80. Higher scores indicate higher levels of anxiety. The SAI has significant differences in response between the three conditions.
been extensively validated and is the most widely used measure
of anxiety in exercise research.2 The internal consistency Subjective well-being
Negative affect
Table 1 Diagnoses The repeated-measures ANOVA revealed a significant time
N
main effect (F1.47 = 13.16, p,0.001). In each test condition,
post-scores were significantly lower than pre-scores (F and
Anxiety disorders
Generalised anxiety disorder 15
Posttraumatic stress disorder 7
Social anxiety disorder 6
Obsessive compulsive disorder 6
Acute stress disorder 3
Anxiety disorder not otherwise specified 8
Depressive disorders
Major depressive disorder recurrent
Moderate 8
Severe 21
Major depressive disorder single episode
Moderate 3
Severe 7
Dysthymic disorder 5
Depressive disorder not otherwise specified 3
Figure 1 State anxiety and negative affect before and after the
Adjustment disorder with mixed anxiety and depressed mood 6
exercise sessions.
Br J Sports Med 2009;43:756–759. doi:10.1136/bjsm.2008.052654 757
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Original article
work load in conditions B and C than in condition A
(t = 22.49, p = 0.0139; t = 22.05, p = 0.0423).
DISCUSSION
Main findings
Results indicated that self-selected and prescribed exercise
intensity at 50% of maximal heart rate reserve are equally
effective in decreasing state anxiety and negative affect. In
contrast to the study of Schmidt et al,11 exclusively using
patients with panic disorders, heart rate feedback did not
influence the response in state anxiety and negative affect.
Only self-selected exercise intensity, with or without heart
rate feedback, improved positive well-being. According to other
investigators,6–8 it was expected that self-determination of
exercise intensity is associated with positive well-being. Our
findings are in accordance with Ekkekakis et al21 and Raedeke.22
Figure 2 Positive well-being and fatigue before and after the exercise
sessions. Those authors indicated that at preferred intensity (self-
determination) the dominant response will be pleasure, in
contrast to prescribed intensity (no or less self-determination).
p values ranged from F1.93 = 10.11, p = 0.002 up to Exercising at 50% of maximal heart rate reserve decreased
F1.93 = 6.59, p = 0.0119). There were no significant differences fatigue, whereas exercising at self-selected intensity increased
in response between the three conditions. fatigue. A plausible explanation for this interaction effect is that
patients performed a higher average work load at self-selected
Positive well-being intensity than at prescribed intensity of 50% of the maximal
The repeated-measures ANOVA showed a significant time main heart rate reserve.
effect, with higher scores after exercise bouts (F1.47 = 9.30,
p = 0.0038). We observed a significant condition-by-time inter- Limitations of the study
action effect (F2.93 = 3.14, p = 0.0479). The interaction effect In spite of the positive results, the findings of the present study
indicates that the type of exercise condition influenced positive must be interpreted with caution because of some methodolo-
well-being responses. In conditions B and C, post-scores were gical limitations. The major limitation was the absence of a no-
significantly higher than pre-scores (F1.93 = 9.31, p = 0.003; exercise control condition. A future study to contrast the effects
F1.93 = 15.31, p,0.001). There was no significant change in of an acute bout of aerobic exercise with an anxiety-reducing
condition A. relaxation or yoga session will be planned. A second limitation
was the lack of repeated measures post-exercise. Despite state
Fatigue anxiety reductions lasting for 2–4 h after cessation of activity,1
Repeated-measures ANOVA revealed no significant time main only the response 10 minutes after the completion of the
effect. However, the condition-by-time interaction effect was session was assessed. This study did not examine potential
significant (F2.93 = 3.87, p = 0.0242). In condition A, the physiological (eg, increased norepinephrine, serotonin and beta-
fatigue scores after exercise sessions were lower than the scores endorphins, increased parasympathetic activity) and/or psycho-
before exercise. In contrast to conditions B and C, the level of logical mechanisms (eg, increased self-efficacy, distraction, a
fatigue increased after exercise. sense of mastery) that are responsible for the reduced state
anxiety and improved subjective well-being.23 Further research
Comparisons of heart rate at rest, maximal heart and average will be needed to examine putative underlying mechanisms. A
work load final limitation was that the maximal heart rate was not
The heart rate at rest (condition A 71.26, (9.67); condition B measured but estimated by means the formula 220 2 age.17
71.34, (7.43); condition C 70.73, (7.86)) and maximal heart rate
(condition A 134.93, (10.89); condition B 141.83, (21.07); CONCLUSIONS
condition C 140.34, (22.62)) did not differ significantly across In summary, the results indicate that the response in state
the three test conditions. The average work load under anxiety and negative affect is unaffected by self-selected
condition A, B and C was 57.54 (20.03), 65.86 (28.67) and intensity compared with prescribed intensity, and by heart rate
63.88 (26.34) Watts, respectively. Patients performed a higher feedback in a sample group of patients with depressive and/or
Table 2 Means and standard deviations of state anxiety, negative affect, positive well-being and fatigue
before and after the exercise sessions
Condition A n = 48 Condition B n = 48 Condition C n = 48
Before After Before After Before After
State anxiety 45.54 (14.16) 39.23 (16.18) 42.91 (131) 38.98 (11.97) 47.72 (13.22) 41.30 (12.46)
Negative affect 11.25 (6.46) 9.08 (6.43) 9.83 (6.15) 8.10 (5.61) 10.87 (6.13) 9.36 (5.29)
Positive well-being 16.00 (6.2) 16.60 (6.99) 16.13 (6.19) 18.04 (5.99) 15.00 (5.62) 17.23 (5.75)
Fatigue 11.58 (5.75) 10.56 (6.02) 10.31 (5.49) 11.13 (5.29) 11.06 (5.45) 11.77 (4.84)
Results are means (SD). Condition A: 50% of the maximal heart rate reserve. Condition B: self-selected intensity with heart rate
feedback. Condition C: self-selected intensity without heart rate feedback.
758 Br J Sports Med 2009;43:756–759. doi:10.1136/bjsm.2008.052654
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Original article
Ethics approval: The study procedure was approved by the Ethical Committee of the
What is already known on this topic Faculty of Medicine of the Katholieke Universiteit Leuven in accordance with the
principles of the Declaration of Helsinki.
There is growing evidence to show that acute aerobic exercise is Patient consent: Obtained.
associated with a decrease in state anxiety and an improvement
in subjective well-being (negative affect, positive well-being and
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Br J Sports Med 2009;43:756–759. doi:10.1136/bjsm.2008.052654 759
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State anxiety and subjective well-being
responses to acute bouts of aerobic
exercise in patients with depressive and
anxiety disorders
J Knapen, E Sommerijns, D Vancampfort, et al.
Br J Sports Med 2009 43: 756-759 originally published online
November 19, 2008
doi: 10.1136/bjsm.2008.052654
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