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

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.

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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.

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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.

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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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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)

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.