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Evidence-Based Reviews


Exercise for depression: It really does help—here’s how to get patients moving

Physical activity boosts the power of medications and psychotherapy

Vol. 3, No. 6 / June 2004

Ms. H, age 26, is being evaluated for moderate to severe depressive symptoms, including oversleeping and overeating. She has had difficulty adhering to medication in the past and is ambivalent about taking antidepressants. She takes a passive approach to managing her depression, preferring to “wait for it to pass.”

Her psychiatrist prescribes fluoxetine, 20 mg in the morning, and recommends that Ms. H change her coping strategies from napping and snacking to increased physical activity. She encourages Ms. H to think about what activities interest her and to set exercise goals.

Ms. H says she has considered buying exercise equipment (an elliptical machine) and increasing her walking outside. She sets a goal to walk 20 minutes most days and to spend 10 to 15 minutes using the elliptical machine while watching television.

Physical activity’s mental health benefits are less well-known than its well-documented medical benefits—reduced risk of heart disease, hypertension, and diabetes; weight control; bone mass preservation; better sleep, and improved cholesterol levels.1 By encouraging exercise, you can improve patients’ mood, well-being, and quality of life, independent of medication and psychotherapy. In this article, we:

  • explore the relationship between physical activity and mental health
  • compare exercise with medication and psychotherapies for easing depression
  • discuss counseling strategies shown to be effective in helping sedentary patients become more physically active.

Table 1

Why physical activity may improve mental health

  • Changes in neurotransmitters—noradrenaline, serotonin, and dopamine—are associated with improved mood
  • Increased steroid reserves become accessible to counteract stress
  • Exercise reduces tension by lowering resting muscle activity potential
  • Increased body temperature is associated with sedative effects
  • Exercise releases endorphins, neuropeptides that bind to opioid receptors in the brain and have potent analgesic activity


Psychological theories
Physical activity:

  • increases self-efficacy, self esteem, self-sufficiency
  • induces a meditative, relaxed state
  • distracts from daily stress and anxiety
  • provides positive interactions with people and nature
  • is a form of biofeedback that teaches the individual to regulate autonomic activity


Source: References 10 and 11

Mental benefits of exercise

Adults who exercise regularly report lower levels of depressive and anxiety disorders than the overall U.S. population.2 As a therapeutic intervention, exercise has been studied primarily in depressed individuals, although some data also support its efficacy in:

  • reducing anxiety symptoms in panic disorder3
  • reducing disruptive behavior in developmentally disabled patients4
  • alleviating chronic fatigue symptoms5
  • improving body esteem in patients with body image disturbance6
  • increasing function in chronic pain 7
  • reducing urges to smoke and improving smoking abstinence among nicotine-dependent individuals. 8

Why exercise helps. Mechanisms that would explain exercise’s positive effect on mood are not well understood.9 Physiologic and psychological hypotheses have been suggested (Table 1),10,11 and researchers are attempting to elucidate them by using animal models.13

Case report: Feeling more energetic

At follow-up 6 weeks later, Ms. H. reported a substantial reduction in depressive symptoms. She noted increased energy, improved sleep, decreased overeating, higher self-esteem, and greater confidence in her ability to manage her depression.

Exercising also helped structure her day. She noticed that on days she did not exercise she was more likely to take a nap, miss her medication, or feel pessimistic about her depression.

Exercise as an antidepressant

Exercise vs psychotherapy. Exercise has been shown to be more effective at reducing depressive symptoms than no treatment, occupational therapy, cognitive therapy, health seminars, routine care, or meditation. Interventions used in these meta-analyses ranged from nonaerobic exercise training several times a week to 1 hour of supervised running 4 times a week.12 Literature reviews also have concluded that exercise training compares favorably with individual or group psychotherapy and with cognitive therapy for treating depression.7

Exercise vs medication. Exercise training has also been compared with drug therapy in treating depression.

In a randomized, controlled trial, 156 men and women over age 50 with major depression received exercise training, sertraline, or exercise plus sertraline. Subjects in the exercise groups completed 40 minutes of aerobic exercise (biking or brisk walking/ jogging) 3 times a week. Subjects treated with sertraline received 50 to 200 mg/d, depending on response.

After 16 weeks, all three groups were significantly improved, with no clinically or statistically significant differences in depressive symptoms, as measured with the Hamilton Rating Scale for Depression (HRSD) and Beck Depression Inventory.13

In a follow-up study 6 months later,14 the exercise group had significantly lower rates of relapse (defined as HRSD scores >15 and meeting diagnostic criteria) than did the medication group. Combining exercise with medication did not provide an added benefit in preventing relapse.

Exercise as monotherapy. Some studies have investigated using exercise instead of medication and psychotherapy. Many of these trials, however, were limited by methodologic weaknesses such as nonrandomized samples or lack of appropriate control groups.12

To address the need for higher-quality evidence, the Depression Outcomes Study of Exercise (DOSE) is investigating the dose-continued from page 12 response effects of exercise as monotherapy for major depressive disorder (MDD).5 The 12-week trial included 80 men and women ages 20 to 45 diagnosed with mild-to-moderate MDD using the Structured Clinical Interview for Depression. They were randomly assigned to one of five supervised exercise regimens:

  • 7.0 kcal/kg/week in 3 days/week
  • 7.0 kcal/kg/week in 5 days/week
  • 17.5 kcal/kg/week in 3 days/week
  • 17.5 kcal/kg/week in 5 days/week
  • 3 days/week of stretching and flexibility exercises for 15 to 20 min/session.

Table 2

How much physical activity is recommended for adults?

For physical and mental health

  • 30 minutes or more of moderate-intensity physical activity on most and preferably all days (Centers for Disease Control and Prevention and American College of Sports Medicine)
  • Activity may be spread out over the day—such as in three 10-minute segments
  • Moderate-intensity physical activities include walking briskly, dancing, swimming, orbicycling on level terrain


For weight loss and management

  • 60 minutes of moderate-intensity physical activity daily (Institute of Medicine)


Depressive symptoms were measured with the HRSD and Inventory of Depressive Symptoms (clinician and self-report). Other outcome measures included cardiorespiratory fitness, self-efficacy, and quality of life. Results are being prepared for publication and will likely help clarify the role of physical activity in treating patients with MDD.

Table 3

Why patients don’t exercise: Common barriers they perceive

Practical limitations

  • Lack of time
  • No safe parks, sidewalks, bicycle trails, or walking paths near home or office
  • Inclement weather


Medical limitations

  • Fatigue
  • Recent injury or fear of being injured


Psychological limitations

  • Exercise is ‘boring’ or ‘not enjoyable’
  • Lack of encouragement, support, or companionship from family and friends
  • Lack of confidence in physical skills (low self-efficacy)
  • Lack of self-management skills (setting goals, monitoring progress, rewarding progress toward goals)
  • Feeling self-conscious
  • Feeling discouraged


Source: References 15 and 16

How much exercise is therapeutic?

In the absence of physical activity guidelines specific to mental health, we suggest using standard public health guidelines (Table 2):

  • 30 minutes or more of moderate-intensity physical activity (brisk walking, swimming, dancing, cycling) most days of the week (recommended by the Centers for Disease Control and Prevention and American College of Sports Medicine)1
  • 60 minutes of moderate-intensity physical activity daily for weight loss and maintenance (recommended by the Institute of Medicine). 16

A recent study investigated the effects of exercise duration and intensity on weight loss in overweight, sedentary women. These researchers recommended setting the initial intervention target at 150 minutes or more of moderate-intensity exercise per week and progressing to 60 minutes per day as appropriate.16

Increasing the number of steps taken per day, as measured by a pedometer, also can be beneficial. Encourage patients to obtain a baseline measure of daily steps and to gradually increase toward a moderate goal of 10,000 steps per day.17

Case report: Accentuating the positive

On follow-up, Ms. H was quick to report the many barriers to exercise she had experienced and the times she did not meet her goal. Rather than dwell on shortcomings, the psychiatrist redirected her to examine the many positive actions she had taken to manage her depression.

As she considered how to overcome barriers to exercise, she reported increased confidence that she could stick with her medication and exercise regimen. She continues to exercise regularly and adheres to her fluoxetine. Her depressive symptoms remain well-controlled.

Overcoming barriers to exercise

Patient obstacles. Many patients acknowledge that regular exercise makes them feel physically and emotionally healthier but have difficulty exercising long term. Less than one-half of those who start an exercise program stick with it beyond 6 months.18 Drop-out reasons include injuries, lack of time, and low motivation (Table 3).19,20

Depressive symptoms—fatigue, loss of interest, low self-esteem, feelings of helplessness, and psychomotor retardation—make exercise adherence even more difficult.

Physician obstacles. The U.S. Preventive Services Task Force recommends that physicians advise all patients to increase physical activity, but the national rate of physician counseling about exercise is low. In a population-based survey of more than 9,000 patients, 34% said their physicians counseled them about exercise at their most recent visit within the past year.21

Physician-reported barriers to exercise counseling include:

  • competing demands for limited clinical time
  • perceived ineffectiveness of advice to exercise
  • lack of training and knowledge about exercise counseling and prescription. 22,23

Patients are more likely to become active and continue exercising when their physicians help them set achievable goals.

Project PACE. Physicians can overcome barriers to counseling patients about exercise. Those who participated in Project PACE (Physician-based Assessment and Counseling for Exercise)24 said they felt more confident that they could counsel patients about physical activity in 1 to 5 minutes.

In a controlled study of 212 sedentary adults, patients who received PACE counseling from their physicians significantly increased their minutes of weekly walking compared with a control group. Also, 52% of patients who received PACE counseling adopted some physical activity, compared with 12% of controls. 25

Though modest initial goals are not sufficient for achieving the full benefits of exercise, success with a small goal is a powerful motivator. Rather than giving up, patients feel encouraged and are more likely to set a subsequent, more ambitious goal.

Recommendations. To help patients start exercising, determine how motivated and ready they are. Start by asking them to describe their current activities. Ask if they were ever more active and what they liked about it. Did they experience any benefits? Establish which of increased activity’s benefits—improved sleep, reduced depression, increased energy—would most benefit the patient, based on his or her symptoms.

Discuss barriers to physical activity and encourage problem-solving to overcome them and incorporate physical activity into their lives. Encourage patients to seek support from family, friends, coworkers, and exercise groups.

Help them set realistic, achievable goals. Even a modest 10 minutes of activity has been shown to enhance mood,26 and a 10-minute brisk walk is one-third of the day’s public health guideline. Suggest that patients choose a variety of activities they enjoy.

During follow-up visits, reinforce any progress toward change. When patients’ exercise efforts fall short, explain that the process of becoming more active often includes setbacks. Advise them to seek support and to consider adopting more-achievable goals.

Related resources

  • Getting started. Resources on nutrition and physical activity from the National Center for Chronic Disease Prevention and Health Promotion. www.cdc.gov/nccdphp/dnpa/physical/starting/index.htm
  • Marcus B, Forsyth L. Motivating people to be physically active. Champaign, IL: Human Kinetics, 2002.

Drug brand names

  • Fluoxetine • Prozac
  • Sertraline • Zoloft

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

References

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2. Goodwin RD. Association between physical activity and mental disorders among adults in the United States. Prev Med 2003;36:698-703.

3. Broocks A, Bandelow B, Pekrun G, et al. Comparison of aerobic exercise, clomipramine and placebo in the treatment of panic disorder. Am J Psychiatry 1998;155:603-9.

4. Gabler-Halle D, Halle JW, Chung YB. The effects of aerobic exercise on psychological and behavioral variables of individuals with developmental disabilities. A critical review. Res Dev Disabil 1993;14:359-86.

5. Powell P, Bentall RP, Nye FJ, Edwards RH. Patient education to encourage graded exercise in chronic fatigue syndrome. Br J Psychiatry 2004;184:142-6.

6. Pinto BM, Clark MM, Maruyama NC, Feder SI. Psychological and fitness changes associated with exercise participation among women with breast cancer. Psychooncology 2003;12(2):118-26.

7. Tkachuk GA, Martin GL. Exercise therapy for patients with psychiatric disorders: research and clinical implications. Prof Psychol Res Pract 1999;30:275-82

8. Ussher MH, Taylor AH, West R, McEwen A. Does exercise aid smoking cessation? A systematic review. Addiction 2000;95(2):199-208.

9. Van Hoomissen JD, Chambliss HO, Holmes PV, Dishman RK. Effects of chronic exercise and imipramine on mRNA for BDNF after olfactory bulbectomy in rat. Brain Res 2003;974:228-235.

10. Plante TG, Rodin J. Physical fitness and enhanced psychological health. Curr Psychol Res Rev 1990;9:3-24.

11. Weyerer A, Kupfer B. Physical exercise and psychological health. Sports Med 1994;17(2):108-16.

12. Lawlor DA, Hopker SW. The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomized controlled trials. Br Med J 2001;322:1-8.

13. Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on older adults with major depression. Arch Intern Med 1999;159:2349-56.

14. Babyak M, Blumenthal JA, Herman S, et al. Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Psychosom Med 2000;62:633-8.

15. Dunn AL, Trivedi MH, Kampert JB, et al. The DOSE study: a clinical trial to examine efficacy and dose response of exercise as treatment for depression. Control Clin Trials 2002;23:584-603.

16. Jakicic JM, Marcus BH, Gallagher KI, et al. Effect of exercise duration and intensity on weight loss in overweight, sedentary women. JAMA 2003;290:1323-30.

17. Tudor-Locke C, Bassett DR, Jr. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Med 2004;34(1):1-8.

18. Dishman RK. Compliance/adherence in health-related exercise. Health Psychol 1982;1:237-67.

19. Sallis JF, Hovell MF. Determinants of exercise behavior. Exerc Sport Sci Rev 1990;18:307-30.

20. Heesch KC, Brown DR, Blanton CJ. Perceived barriers to exercise and stage of exercise adoption in older women of different racial/ethnic groups. Women Health 2000;30(4):61-76.

21. Wee CC, McCarthy EP, Davis RB, Phillips RS. Physician counseling about exercise. JAMA 1999;282(16):1583-8.

22. Kennedy MF, Meeuwisse WH. Exercise counseling by family physicians in Canada. Prev Med 2003 Sep;37(3):226-32.

23. Reed BD, Jensen JD, Gorenflo DW. Physicians and exercise promotion. Am J Prev Med 1991;7:410-15.

24. Long BJ, Calfas KJ, Wooten W, et al. A multisite field test of the acceptability of physical activity counseling in primary care: project PACE. Am J Prev Med 1996;12(2):73-81.

25. Calfas KJ, Long BJ, Sallis JF, et al. A controlled trial of physician counseling to promote the adoption of physical activity. Prev Med 1996;25(3):225-33.

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