Evidence-Based Reviews

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

Current Psychiatry. 2004 June;3(6):10-20

Physical activity boosts the power of medications and psychotherapy

References

1. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273(5):402-7.

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.

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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.

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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.

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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 pain⁷
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