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Prescribing Exercise By Dr. Lisa Smalheiser, Psy.D.

Which came first, the chicken or the egg? This question can be similarly applied to the link between exercise and mood symptoms. Research conducted by McKercher and colleagues (2013) found that people who are physically active are less depressed than people who are inactive. Additionally, people who were once active but then stopped suffer from depression more than those who have continued to maintain an active lifestyle. So the question therein lies: Is it that people who are happier to begin with are more physically active or is it the physical activity itself that can decrease, dampen, or remove the depression altogether?

Exercise has been prescribed by general practitioners and primary care physicians for some time now, and we know the general health benefits are countless. Well, why is it then that the mental health field has yet to implement this strategy with psychological and/or psychiatric disorders? Could a lifestyle change help alleviate years’ worth of anxiety and depression symptoms? Research that was published in The American Psychiatric Publishing Textbook of Psychopharmacology (2009) identified regular exercise as a viable alternative to psychopharmacology and a good complementary strategy to implement in conjunction with psychotherapy. This article is not to suggest exercise in place of drugs and therapy. Its purpose is to promote the use of exercise as a means of increasing the effectiveness of those traditional treatments and decrease the likelihood of remission through prescribing a self-administered and self-monitored treatment.

First, let me provide some statistics and rationale for my push for exercise as a promising therapeutic technique to combat troubling mood symptoms. The recovery rates for antidepressants alone are typically slightly below 50 percent (Casacalenda, 2002; Thase, 2001; Thase, 2005; Trivedi, 2011). With the addition of a secondary drug, a further 20 to 30 percent tend to improve (Trivedi, 2011). Medications can not only get expensive, but there can be unwanted side effects associated with them. Since it appears that most people require a concurrent treatment in order to control their depression, why not use exercise as this complementary treatment?

Blumenthal et al. (1999) conducted a study comparing the effects of regular cardiovascular exercise in adults over the age of 50, diagnosed with major depressive disorder, to Zoloft, a commonly prescribed antidepressant. Results demonstrated that the decreased level of depression in participants was equal in both the drug and exercise groups. Moreover, in a follow-up study, they found that the exercise group had a lower level of relapse than the drug group. In 2007, Blumenthal re-explored this phenomenon and discovered similar findings. Patients in the exercise and antidepressant groups did equally as well with respect to rates of remission, and both fared better than patients in the placebo condition. Through both studies, Blumenthal et al. (1999) and Blumenthal (2007), it appears that exercise provides reductions in the symptoms underlying major depressive disorder comparable to that of antidepressant drugs.

Some side effects of exercise include weight control, reduced risk of cardiovascular disease, type-2 diabetes, and some cancers, strengthen bones and muscles, improved ability to do daily activities, increased chances of a longer life span, etc. Those don’t sound too bad to me. Now, with this promising research, we can add improved mood and reduced risk of depressive and anxiety disorders through the use of exercise. Plus, an additional benefit is that exercise, as a form of medicine, isn’t likely to burn a hole in your wallet!

So what is it exactly that is underlying this phenomenon? Some suggest that exercise can alleviate depression by providing individuals with a sense of accomplishment from completing a meaningful activity. Others hypothesize that exercise has positive effects on the brain by normalizing sleep patterns. While several others believe that it is the increase in serotonin from exercise that reduces depression.

Not only have there been notable advancements in the area of exercise and depression, but researchers document encouraging findings in the use of exercise as a means for treating anxiety. Anxiety and exercise share some common characteristics. People who suffer from anxiety typically experience heavy perspiration, dizziness, increased heart rate, in addition to other nervous system actions typical of what are referred to as fight-or-flight sensations. These physical responses, in anxiety prone individuals are typically met with fear. Similarly, when people exercise, the body produces many of these same physical responses, with the difference being the absence of fear. Otto and Smits (2011) hypothesized that exercise may reduce the likelihood that these sensations will result in panic, and instead be associated with safety. After testing this theory, the study results determined that participants who completed the exercise program showed reductions in their sensitivity to anxiety, and Smits likened exercise to a form of exposure therapy.

Further exemplifying this phenomenon was a study conducted by Smits and colleagues (2011) where subjects were asked to breathe in CO2-enriched air, triggering those same symptoms typical of a panic attack. Of course, all subjects panicked in response. However, the interesting discovery was that those people who reported engaging in regular exercise in their daily lives were less likely to panic in response to the test than those who had lower activity levels. Conclusively, it appears that exercise could help ward off panic attacks by creating a new connection between these fight-or-flight symptoms and safety, rather than fear.

People nowadays are always looking for a quick fix. The good news is that the mood enhancing effects of exercise are almost instantaneous. If people know that exercise is so good for them, why is it so hard to do, and why is it that so few people do it? For the most part, when people are feeling down and depressed, people not only lack energy in general, but it can be hard to want to pick yourself up to do anything, let alone strenuous physical activity. Although the jury is still out there on the right prescription for type and amount of exercise, researchers have found that you don’t have to overdo it, and the type of aerobic activity isn’t as important. The important part is getting up, getting out there, getting moving. Something is better than nothing when it comes to exercise. Next time you go to the gym, don’t only take note of how you feel physically and the image you view in the mirror, but also be cognizant of your mental state at the time. You may find yourself feeling calmer, less anxious, less depressed, more confident, and hopefully, all around, happier.

Although the underlying factors and mechanisms behind this phenomenon have yet to be conclusively determined, one thing is for certain: exercise is not only good for the body, but for the mind too!

References

Alan F.S. & Nemeroff C.B. (2009). The American psychiatric publishing textbook of psychopharmacology. 4th edition. Arlington, VA: American Psychiatric Publishing.

Blumenthal J.A. et al. (1999). Effects of exercise training on older patients with major depression. Arch Intern Med, 159, 2349-2356.

Blumenthal J.A., Babyak M.A., Doraiswamy P.M., Watkins L., Hoffman B.M., Barbour K.A., et al. 2007). Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosomatic Medicine, (69), 587–596.

Casacalenda N., Perry J.C., & Looper K. (2002). Remission in major depressive disorder: A comparison of pharmacotherapy, psychotherapy, and control conditions. American Journal of Psychiatry, 159(8), 1354–1360.

McKercher C., Patton G.C., Schmidt M.D., Venn A.J., Dwyer T., & Sanderson K. (2013). Physical activity and depression symptom profiles in young men and women with major depression. Psychosomatic Medicine, 75(4), 366-374.

Otto, M & Smits, J. (2011). Exercise for mood and anxiety: Proven strategies for overcoming depression and enhancing well-being. Oxford University Press.

Smits A.J., Tart C.D., Rosenfield D., & Zvolensky M.J. (2011). The interplay between physical activity and anxiety sensitivity in fearful responding to carbon dioxide challenge. Psychosomatic Medicine, 73(6), 498-503.

Thase M.E., Entsuah A.R., & Rudolph R.L. (2001). Remission rates during treatment with venlafaxine or selective serotonin reuptake inhibitors. British Journal of Psychiatry, 178, 234–241.

Thase M.E., Haight B.R., Richard N., et al. (2005). Remission rates following antidepressant therapy with bupropion or selective serotonin reuptake inhibitors: A meta-analysis of original data from 7 randomized controlled trials. Journal of Clinical Psychiatry, 66, 974–981.

Trivedi M.H., Greer T.L., Church T.S., Carmody T.J., Grannemann B.D., Galper D.I., Dunn A.L., Earnest C.P., Sunderajan P., Henley S.S., & Blair S.N. (2011). Exercise as an augmentation treatment for nonremitted major depressive disorder: a randomized, parallel dose comparison. Journal of Clinical Psychiatry, 72(5), 677-684.