Alcohol use disorders (AUDs) are common and problematic in the United States,
representing one of the leading causes of preventable death (Mokdad, Marks, Stroup, & Gerberding, 2004). Despite the development of effective treatments for short-term abstinence, relapse rates are high (Project Match Research Group, 1997), particularly in the first ninety days (Hendershot, Witkiewitz, George, & Marlatt, 2011; Marlatt & Donovan, 2005). Women in particular are more susceptible to physical and psychological health consequences associated with AUDs (Schenker, 1997), particularly depression (Kessler et al., 1997). Additionally, women with AUDs are more likely to use alcohol to cope with negative affect such as depression (Lehavot, Stappenbeck, Luterek, Kaysen, & Simpson, 2014), which is associated with more problematic patterns of use (Cooper, Kuntsche, Levitt, Barber, & Wolf, 2016). Women also have poorer coping strategies (Timko, Finney, & Moos, 2005) and are more likely to relapse due to negative affect and lack of adaptive coping strategies (Walitzer & Dearing, 2006). Given the additional barriers to attending AUD treatment (Brady & Ashley, 2005) and the risk factors for relapse, it is necessary to develop and implement effective, lifestyle-oriented therapeutic techniques that are easily accessible to women in early alcohol recovery. Helping women engage in physical activity (PA) may be one such technique.
PA has been shown to be an effective strategy for managing negative affect such as depression (Kvam, Kleppe, Nordhus, & Hovland, 2016), including when utilized in acute bouts (Bernstein & McNally, 2017; Ensari, Greenlee, Motl, & Petruzzello, 2015). Similarly, PA also decreases alcohol craving (Brown, Prince, Minami, & Abrantes, 2016) even in brief, ten-minute bouts (Ussher, Sampuran, Doshi, West, & Drummond, 2004). Thus, a PA intervention may be an effective way to help women cope with common causes of relapse like negative affect (e.g., depression) and alcohol craving.
Previous research has examined gym-based, in-person, supervised approaches to PA among individuals with AUDs, and have resulted in promising outcomes (Brown et al., 2014; Murphy, Pagano, & Marlatt, 1986; Sinyor, Brown, Rostant, & Seraganian, 1982). However, women in early recovery may not have time or the ability to engage in such activity. Alternatively, lifestyle PA (LPA) approaches (Dunn et al., 1999) that encourage the integration of PA into a daily schedule are adaptable and may be more feasible for women in early recovery.
Activity monitors (e.g., pedometers) have been used as part of LPA interventions to facilitate self-monitoring and goal-setting (Heesch, Dinger, McClary, & Rice, 2005; Lauzon, Chan, Myers, & Tudor-Locke, 2008; Tudor-Locke & Lutes, 2009), which are essential for increasing and maintaining PA (Nigg, Borrelli, Maddock, & Dishman, 2008; Merom et al., 2007). With recent advances in sensor and Bluetooth technologies, new types of activity monitors have emerged and are currently commercially available (e.g., Fitbit). These newer activity monitors can be used in the context of LPA interventions in the same manner as pedometers to facilitate increases in PA.
This study evaluated a Fitbit-supported LPA intervention (LPA+Fitbit) for depressed women in early recovery from AUDs. In this article we describe the intervention—including the content and structure of counseling sessions—and present findings from an initial pilot study. This LPA+Fitbit study evaluated levels of PA, alcohol use, depression, alcohol craving, and using PA to cope in twenty women over the course of twelve weeks. We also report on women’s feedback on the intervention.
Participants were recruited from an alcohol and drug partial (ADP) hospitalization program. ADP is a five- to ten-day program, running 9:00 AM to 3:30 PM, Monday through Friday. During ADP, patients engage in group therapy, individual counseling, medication management, and aftercare planning. ADP treatment is abstinence based and draws on cognitive behavioral relapse prevention strategies. During the first or second day of treatment, female patients with AUDs were approached for study interest. Patients who were interested received information about the study, provided informed consent, and completed a brief, in-person screening. Those appearing to be eligible participated in a baseline structured interview, completed self-report questionnaires, and were medically cleared by a study physician.
Participants were female, between eighteen to sixty-five years of age, currently in alcohol treatment, had elevated depressive symptoms, were inactive, and had access to the Internet. Women who had anorexia, bulimia, psychosis history, current suicidality and/or homicidality, current mania, were pregnant, had a moderate or severe substance use disorder (SUD) other than AUD, or had physical problems that would prevent healthy exercise were excluded. A total of twenty participants were eligible for the study. Participants had a mean age of 39.5 years (SD=10.6, range 22–61), and were primarily Caucasian (85 percent) and non-Latino (90 percent). Over half of women held at least a college degree (55 percent) and two-thirds were employed part-time or more (65 percent).
Participants attended the ADP program for an average of 8.45 days (SD=2.72). The participants drank alcohol on 52.6 percent of the previous ninety days at baseline. Although all participants reported elevated depression symptomatology, most women (55 percent) had a diagnosis of major depressive disorder. Only approximately half of participants (55 percent) reported engaging in some sort of regular exercise for ten minutes or more per week at baseline. Only three women (15 percent) had any past experience with wearing a Fitbit device, and no participant was utilizing the Fitbit during the time of recruitment. Two-thirds (75 percent) of participants completed the end-of-treatment assessments.
In-Person Orientation Session
Participants attended an hour-long orientation session with a physical activity study counselor while enrolled in ADP. During this session, the following points were discussed:
Physical and psychological benefits of PA
Utilizing PA as a coping strategy for negative affect or alcohol craving
Strategies for increasing PA
Local free or low-cost PA resources
How to use the Fitbit and its mobile app
Participants began with a 4,500 per day step-count goal, with a goal to increase by five hundred steps per day each week of the program (i.e., ten thousand steps per day at week twelve, which is equivalent to PA recommendations; Tudor-Locke et al., 2004).
PA Counseling Sessions
Following ADP discharge, study counselors called participants for thirty-minute sessions at six times throughout the intervention: weeks one, two, four, six, eight, and ten. During these sessions, counselors and participants reviewed and/or modified step-count goals, discussed barriers to PA, addressed technological issues, discussed PA usage as a coping strategy, and discussed a PA-related topic (Brown et al., 2009) such as using PA to cope, getting and staying motivated, setting goals and seeking support, breaking down PA barriers, getting back on track, and maintaining PA.
Fitbit Activity Tracker
Participants received Fitbit activity trackers that were linked to online accounts the investigators could access in order to provide PA feedback to participants via telephone sessions. Participants monitored their PA via the device, online website, or mobile app. PA counselors, in collaboration with participants, set step-count goals based on PA counseling session decisions.
End of Treatment Assessment
Participants returned to the study site to complete questionnaires and semi-structured interviews after the twelve-week LPA intervention, during which they provided feedback on various aspects of the intervention.
Participants completed the following measures at the baseline timepoint and at the end of treatment:
Structured Clinical Interview for DSM (SCID; First, 2015): assessed psychiatric comorbidity to aid in eligibility determination
Timeline Follow-back for Alcohol (TLFB; Sobell & Sobell, 1992): assessed quantity and frequency of alcohol use. Days of use, percentage of days abstinent, and drinks per drinking day variables were calculated.
Timeline Follow-back for Exercise (Panza, Weinstock, Ash, & Pescatello, 2012): measured days of PA, type of PA, and rate of perceived exertion (RPE; Borg, 1970) of PA, in order to determine if moderate-to-vigorous physical activity (MVPA; Ritchie, 2012) was attained. We calculated average minutes/week of all PA and of MVPA. Participants also reported whether they had utilized PA as a coping strategy for negative affect or craving on the days in which they engaged in PA.
Step counts: Step counts were monitored from the Fitbit website. Average step count per day was calculated based on days when the device was worn eight or more hours.
Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001): assessed nine symptoms of depression
Penn Alcohol Craving Scale (PACS; Flannery, Volpicelli, & Pettinati, 1999): measured five symptoms of alcohol cravings over the previous week
Participants were compensated for their time throughout the course of the intervention with a total of $190 in possible compensation.
Session Attendance and Attrition
On average, women attended 78 percent of telephone counseling sessions (4.7 out of six sessions). We conducted analyses to determine whether baseline characteristics predicted session attendance, and found that neither demographic characteristics, initial PA level, alcohol use, depression, nor craving was associated with attendance at sessions. Additionally, given that several participants dropped out of the study, we repeated analyses to see if any variable predicted attrition and also found no variables of significance.
The following analyses were performed on the fifteen participants who completed the end-of-treatment assessment.
Almost half of women who completed the end-of-treatment assessment (46.7 percent) reported having complete abstinence through the twelve-week study. Over a quarter of women (26.6 percent) reported drinking for three or fewer days. Participants were completely abstinent from alcohol for 95 percent of days during the twelve-week intervention, as compared to 45 percent of days at baseline (t=6.21, p<.01), which is a statistically significant increase in abstinence over time (see Figure 1).
Physical Activity and Utilizing PA to Cope
Participants had a 73 percent increase in their step counts from baseline to the end of treatment, increasing from 5,290 to 9,174 steps/day on average (t=2.81, p=0.01, dz=0.85). Participants reported a significant increase in the duration of weekly PA per week as measured by all PA (see Figure 2; t=4.50, p<.01). However, their rates of higher-intensity PA did not increase significantly (t=.80, p=.44). Participants reported more than a five-fold increase in days during which they used PA to cope with depression or alcohol craving, an increase of 2.90 (SD=5.98) days to 15.67 (16.96) days (t=2.49, p=.03). Of note, 100 percent of participants reported using PA to cope on at least one occasion by the end of treatment.
Depression and Craving
Reports of depression significantly decreased from baseline to the end of treatment (see Figure 3; t=-4.07, p<0.01). Additionally, participants reported a reduction in their alcohol cravings over time (see Figure 4; t=-1.70, p=.11).
Results from this study provide preliminary evidence that a LPA+Fitbit intervention, in conjunction with self-monitoring and feedback from a Fitbit device, can be effective and be feasibly delivered as an adjunctive treatment in the context of early recovery for depressed women with AUDs. In qualitative interviews performed at the end of treatment, women reported appreciating the accountability that the Fitbit and the counseling provided. They reported feeling supported and motivated by the LPA+Fitbit intervention, particularly with the immediate feedback that Fitbit provides via display of step count and acknowledgement of reaching PA goals. Women reported that that they enjoyed challenging themselves and measuring their progress. And, perhaps most importantly, women reported that they learned to cope with the difficulties of early alcohol recovery by using PA to help decrease depression and craving in the moment.
Despite few women having experience with activity devices or Fitbits, very few technical difficulties were reported, even among participants who had little experience with smartphone apps. Women reported monitoring step counts multiple times per day through the Fitbit device and app. Women also remained engaged in the intervention; attendance rates at phone counseling sessions were high and 75 percent of women were still engaged in the intervention by the end of treatment. As such, Fitbit may be a feasible option to support LPA interventions for individuals with a range of technological expertise.
The increase in PA observed throughout the course of the intervention could not only help improve emotional health and alcohol use outcomes, but can also help reduce the risk for negative physical health outcomes that alcohol-dependent women disproportionately face (Schenker, 1997). Findings that women increased overall PA (e.g., lifestyle activities plus bouts of physical activity) but not MVPA (i.e., higher-intensity bouts of physical activity) highlight the importance of introducing exercise in a different way—not just as a gym-based activity, but also as a lifestyle. We encouraged women to increase levels of PA in creative ways, such as parking farther away, walking to the store, or doing chores (such as laundry) that require physical exertion.
Given the parallel reductions in depression, it is possible that our LPA+Fitbit intervention served as a mechanism by which behavioral activation could improve mood (Sturmey, 2009). As has been found in other populations (Meyer, Koltyn, Stegner, Kim, & Cook, 2016), increasing PA is related to significant improvements in mental health outcomes, including depression. Notably, women reported utilizing PA to cope with negative affect and craving. Future randomized controlled trials, where LPA+Fitbit can be compared to a control condition, will help determine the extent to which mental health improvements are a result of increases in PA specifically.
This study has several limitations that should be noted. Of critical importance is that the current study was a preliminary pilot evaluation of the LPA+Fitbit intervention. As such, results must be interpreted with caution. Given the small sample size, the intervention should be tested in a larger sample to evaluate whether results can generalize to other depressed women with AUDs across various treatment settings. Additionally, as mentioned, there was no control condition in this study. Lastly, given that many of our measures were self-reported, it is possible that participants’ responses were biased or inaccurate.
Summary and Conclusion
Among women with depression and AUDs, a LPA intervention that incorporates Fitbit is a promising adjunct to standard aftercare—one that may be cost effective and easily implementable across varied treatment settings. These results provide preliminary support to the burgeoning field of PA and addiction research literature. Future research, which is currently being conducted, should examine the impact of the LPA+Fitbit intervention compared to an intervention that does not incorporate PA.
Acknowledgements: This work was supported by a grant funded by the National Institute of Alcohol Abuse and Alcoholism (NIAAA; R34 AA024038; PI: Ana M. Abrantes, PhD).
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Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:
Abrantes, A. M., Blevins, C. E., Battle, C. L., Read, J. P., Gordon, A. L., & Stein, M. D. (2017). Developing a Fitbit-supported lifestyle physical activity intervention for depressed alcohol-dependent women. Journal of Substance Abuse Treatment, 80, 88–97.