Back in 1999, the American Psychological Association published a report calling exercise “an effective but under-used treatment” for mild to moderate depression. The implied call to action was largely ignored.
Despite continued research supporting the notion that physical activity can help resolve symptoms of depression, mental health professionals have not found practical ways to implement exercise as a standard part of their practice.
Nonetheless, for patients who can adopt exercise programs of their own, physical activity can provide as much help with their symptoms of depression as other more mainstream modes of treatment.
Experts maintain there’s little evidence for the popular notion that exercise produces a rush of endorphins that improve mood, but they’re unclear on how it seems to combat depression.
Some suggest that activity may improve mental health by helping the brain better cope with stress. Others point to a release of chemicals that have been linked to the brain’s mood control center.
But then, researchers can’t really explain how antidepressant drugs work either. And exercise has been shown to be just as affective as medications.
For example, researchers at the University of Texas Southwest Medical Center at Dallas recently showed that a mere 30 minutes of aerobic exercise three to five times a week could cut the incidence of depressive symptoms almost in half.
“The effect you find using aerobic exercise alone in treating clinical depression is similar to what you find with antidepressant medications,” says Dr. Madhukar Trivedi, a professor of psychiatry and director of the school’s mood disorders research program.
“The key is the intensity of the exercise and continuing it for 30 to 35 minutes per day.”
Individuals who were assigned the toughest workout in the study — running on a treadmill or riding a stationary bicycle — reduced their incidence of depressive symptoms by an average of 47 percent over 12 weeks. Those who participated in lower-intensity physical activity showed a 30 percent reduction in symptoms, while those who did stretching and flexibility exercises averaged a 29 percent decline.
“Numerous effective treatments for depression are available, yet many people don’t seek treatment because of the negative social stigma associated with the disease,” Trivedi says. “Exercise may offer a viable treatment alternative, particularly as it can be recommended for most individuals.”
Immediate gains
There’s evidence that even a single workout can result in short-term mood enhancement. Last year, researchers from the University of Texas at Austin recruited 40 patients who had been diagnosed with a major depressive disorder but were not regular exercisers or taking antidepressants.
Half were assigned to rest quietly for 30 minutes, while others were asked to walk on a treadmill for 30 minutes.
“The question was whether an individual bout of exercise would provide benefit or is the mood disturbance in depressed patients so great that a single bout of exercise can’t improve it?” says Dr. John Bartholomew, a professor of kinesiology and health education. “Most research with clinical populations of depressed individuals has instead focused on exercise as a treatment for the underlying disorder. We were looking at improving their mood in the short term.”
Both groups reported less tension, depression, anger and fatigue, but only the exercise group reported feeling good.
Bartholomew stresses that a single session on a treadmill offers only symptomatic relief and just a temporary improvement in mood rather than a change in diagnosis. Still, it’s a better alternative than the approaches many individuals with depression adopt.
“Many people with depression attempt to self-medicate with alcohol, caffeine or tobacco to manage their daily routine,” he says. “Low- to moderate-intensity exercise appears to be an alternate way to manage depression, one that doesn’t come with such negative health consequences.”
Bartholomew acknowledges the challenge mental health professionals face in motivating depressed individuals to exercise. Patients with depression tend to withdraw rather than seek out new activities.
“It’s hard enough to get people who are not depressed to become active,” he says.
Indeed, the Southwest Medical Center researchers screened 1,664 patients with depression before they could find 80 to participate in their study.
“We have to wonder if the idea of exercising vigorously for 30 minutes a day is really that appealing to anergic (lacking energy), disheartened, depressed patients,” Dr. Murray Stein, a professor of psychiatry at the University of California, San Diego, wrote in a commentary on the study in the American Journal of Preventive Medicine.
“The challenges to engaging depressed patients in such a program are sure to be more difficult and will require some creative motivational and outreach efforts to have any chance at success outside of research settings.”
Creating motion
The difficulty for many mental health professionals is that they are trained in the use of antidepressive medication and psychotherapy, not in overseeing exercise regimes. They can suggest exercise, even prescribe exercise, but the burden then falls on patients to follow through.
Dr. Michael Conner, a clinical psychologist in Bend, says he’s taken some of his patients to the gym to show them that exercise doesn’t have to be as complicated as it might seem.
“I’m so convinced of the benefits of exercise that I’m actually putting a gym in a separate room in my office,” he says. “I’m going to introduce people to some very simple exercises, particularly for patients who are afraid to get a gym membership or are intimidated by the equipment or think it’s going to be too difficult.”
Conner tells his patients that physical exercise requires effort and it creates energy, therefore it reduces both emotional and physical fatigue. Loss of energy is a major symptom associated with depression, he says.
“It’s not a promise for everybody,” Conner says. “And that’s what I tell my patients. ‘If you don’t want to be on drugs your whole life, exercise may be the key.’”
He points to a recent Duke University study that compared the benefits of aerobic exercise, psychotropic medication or a combination of the two.
After 412 months of treatment, patients in all three groups were significantly less depressed, and two-thirds no longer met the diagnosis criteria for depression.
But when researchers followed up with the test subjects six months after the study was completed, they found patients in the exercise group were more likely to be partially or fully recovered than those who were in the medication or medication plus exercise groups.
“People who continue to exercise have lower relapse rates,” Conner says.
When patients have other health problems, any sort of pain or joint injury, Conner refers them to a physical therapist to get an assessment of their physical condition and a safe plan for physical activity.
Erik Zamboni, director of Living Well Therapy in Bend and Sunriver who has a doctorate in physical therapy, says despite mounting evidence of the benefit for depressed individuals, the notion is still not accepted enough for most doctors to send their patients to a physical therapist.
“At this point, I’m not seeing a lot of referrals for depression,” he says. “But I think that will become more prevalent in the months and years ahead.”
Zamboni acknowledges that widespread referrals probably won’t happen until insurance companies begin to reimburse for it. And since most insurers won’t cover exercise programs for physical conditions, like obesity and heart disease where the link is much better established, getting coverage for depression might be an uphill battle.
Robin Henderson, a psychologist with Behavioral Health Services at St. Charles Medical Center-Bend, says psychologists are increasingly looking at overall lifestyles of their patients to improve recovery. Recent studies suggest that people with mental illness face life spans 25 to 30 years shorter than normal, in part due to the weight gain and other side effects caused by long-term use of powerful medications.
Patients with mental illness also have disproportionately high smoking rates. Exercise, she says, might be part of a overall lifestyle improvement program that could help offset those difficulties.
Exercise can also help combat insomnia, a common symptom of depression. One study found that 16 weeks of moderate exercise helped individuals with insomnia fall asleep an average of 15 minutes faster and sleep 45 minutes longer.
And exercise provides an alternative for the one-third of patients with depression who don’t respond to medication. With no serious side effects — aside from a potential risk of injury perhaps — patients turning to exercise have little to lose.
By Markian Hawryluk / The Bulletin
Markian Hawryluk can be reached at 617-7814 or mhawryluk@bendbulletin.com
