Exercise Gains Momentum as Psychiatric Treatment
Nancy A. Melville Nov 16, 2012, published in MedScape.com
SAN DIEGO, California – The benefits of exercise in nearly every aspect of physical health are well known, but evidence in recent years suggests a unique effect on some psychiatric disorders, prompting mental health clinicians to rethink treatment strategies and to consider the possibility of exercise not just in therapy but as therapy.
“Above and beyond the standard benefits of exercise in healthy living and general well-being, there is strong evidence demonstrating the ability of exercise to in fact treat mental illness and have significant benefits on a neurotrophic, neurobiologic basis,” Douglas Noordsy, MD, told delegates attending Psych Congress 2012: US Psychiatric and Mental Health Congress.
Some of the strongest evidence is seen in depression, where psychiatric benefits from exercise have been shown in some cases to match those achieved with pharmacologic interventions and to persist to prevent remission in the long term.
Dr. Noordsy referenced a study from researchers at Duke University in which 156 patients with major depressive disorder (MDD) were randomly assigned either to aerobic exercise, sertraline therapy (50 mg to 200 mg), or both for 4 months.
The difference in remission rates in the exercise and selective serotonin reuptake inhibitor (SSRI) groups after 4 months were not significant – 60% and 69%, respectively, but at a 10-month follow-up, the exercise group showed a significantly lower relapse rate ( P = .01) ( Psychosom Med 2000;62:633-638).
“The patients who were independently exercising on their own after the treatment period had half the odds for meeting the depression criteria 6 months later compared to patients who didn’t exercise after the 4-month study,” said Dr. Noordsy, an associate professor and director of psychosis services at the Geisel School of Medicine at Dartmouth College, in Hanover, New Hampshire.
A similar study from the same group of researchers 10 years later in a larger sample involving 202 patients assigned to supervised exercise, sertraline therapy (50 mg to 200 mg) or placebo showed remission rates of 46% at 4 months and 66% at the 16-month follow-up across both treatment groups, with no significant greater improvement with SSRIs compared with exercise in predicting MDD remission at 1 year ( Psychosom Med 2011 Feb-Mar;73:127-33; epub 2010 Dec 10).
Other studies have shown equally impressive results in exercise for a variety of populations, including pregnant women with depression, who have a high interest in avoiding medications, people with HIV, and even patients with heart failure, who showed not only a significant reduction in depression related to exercise but also reduced mortality ( Am J Cardiol 2011;107:64-68).
The evidence in relation to anxiety, although not as strong, still suggests a benefit, and the rigors of a cardiovascular workout seem particularly suited to addressing the physiologic effects associated with anxiety, Dr. Noordsy said.
“We know that with anxiety, the heart rate goes up, you start breathing fast, and it kind of snowballs with more anxiety, and that can trigger a panic attack,” he explained.
“So one of the important positive effects of physical exercise is it allows people to become conditioned to having their heart rate and respiratory rate increase when they’re not associated with anxiety, thereby addressing the triggers.”
Evidence is somewhat lacking in the area of bipolar disorder, but patients often have symptoms similar enough to depression to suggest a benefit, Dr. Noordsy said.
“The evidence on depression in bipolar disorder is strong enough that I certainly feel comfortable in talking about exercise as part of [bipolar patients’] management.”
In terms of more serious psychotic disorders such as schizophrenia, evidence is limited on benefits of exercise for the core symptoms of psychosis or cognition. However, several studies have shown improvement in comorbidities and metabolic issues related to antipsychotics that such patients commonly face.
One study of a jogging intervention among 80 inpatients with chronic schizophrenia, in which 40 patients jogged for 40 minutes 3 times a week, depression, anxiety, phobia, and obsessive-compulsive behaviors declined significantly compared with 40 inpatient control participants who were inactive and showed no improvement.
The evidence on the benefits of exercise in cognitive function disorders, such as dementia and Alzheimer’s disease, is much more extensive, with as many as 8 strong studies on dementia alone in the last 3 years showing improvements with activities such as walking and strength training on memory and executive function.
Dr. Noordsy noted one particularly remarkable study in which researchers compared patients with and without the ApoE gene, which is linked strongly to late-onset Alzheimer’s disease.
In the study, patients who were ApoE-negative showed similarly low mean cortical binding potential, related to plaque buildup in the brain, regardless of whether they exercised or not.
But although ApoE-positive individuals (n = 39) had values that were substantially higher, the ApoE-positive patients who exercised (n = 13) had values similar to those who did not carry the gene ( Arch Neurol 2012;69:636-643).
“You could look at these results and rightfully say physical exercise neutralizes your risk for developing Alzheimer’s disease if you’re ApoE positive,” Dr. Noordsy said.
How to Get Patients Moving
Perhaps the biggest caveat with all mental health conditions is how to motivate patients who are struggling with psychiatric disorders to exercise.
Dr. Noordsy offered some key suggestions:
- Start with an assessment: “I start with an assessment of lifetime history of activity and current activity in my baseline assessment template,” Dr. Noordsy said. “I educate the patient on the potential effects of exercise on their disorder and how it fits on the menu of other treatment options.”
- Make clear recommendations: “There is a lot of evidence in areas such as smoking cessation and in the addiction literature showing that a substantial subset of people will respond to very clear recommendations,” he said.
- Offer motivational tools: A behavioral planner, for instance, that allows for goal setting, or connecting a patient with an exercise group can be helpful.
- Consider the patient’s current activity capacity in recommending a regimen: “The general amount of exercise believed to result in a benefit is about 30 to 60 minutes per day, between 3 and 7 days per week.” Some studies have shown strength training to be as beneficial as aerobic activity. For the latter, Dr. Noordsy suggested that one easy method often used in determining maximum heart rate, in general, for people without heart disease or other conditions is to simply subtract their age from 220.
- Help the patient find an activity that works best for them, rather than recommending anything specific, Dr. Noordsy suggested. “Have the patient choose the activity that is right for them.”
- Help guide the patient to educational resources, such as information sources or books. “The book I’ve used the most with patients is John Ratey’s Spark: The Revolutionary New Science of Exercise and the Brain,” Dr. Noordsy recommended. “The book is very scientific and accessible to a lay audience,” he said.
Importantly, discussing the role of exercise in the context of human evolution might be a more effective approach with patients than the standard recommendation to get some exercise.
“Instead of ‘this is something you ought to be doing,’ we might instead say, ‘this is something humans are designed to do, and when we don’t do it, our bodies and brains fall apart’.”
Another important component in helping patients benefit from exercise is simply to improve awareness among clinicians, Dr. Noordsy added.
“We see evidence on the benefits of exercise for psychiatric conditions coming together, and there is a need to increase awareness of this among clinicians as well as reinforce the research community to be taking a more careful look at physical exercise,” he said.
“This may not have as much of an industrial backing as some of the other interventions we use, but I think it’s quite exciting.”
Psych Congress 2012: US Psychiatric and Mental Health Congress. Presented November 9, 2012.
DEPRESSION, SENIORS, AND PHYSICAL ACTIVITY
A group of 1,800 seniors, age 60 or over, participated in a study of depression. All of the participants had some form of depressive disorder.
Treatment were selected by the individual. They included antidepressant medications and/or a brief, structured form of psychotherapy for depression called problem-solving psychotherapy.
The study found that treatment for depression led to considerable improvement in physical functioning.
(Journal of the American Geriatric Society, March 2005)
DEPRESSION, ACTIVITY, CARDIOVASCULAR DISEASE
November 25, 2008 (San Francisco, California) — Researchers who set out to pick apart the bonds that link depression and cardiovascular disease (CVD) say that health behaviors and not complex biological processes largely account for the increased risk of cardiac events in people with depression . Physical inactivity, in particular, likely accounts for the bulk of the risk, Dr Mary A Whooley (VA Medical Center, San Francisco, CA) and colleagues write in the November 26, 2008 issue of the Journal of the American Medical Association.The Heart and Soul Study looked at over 1000 people with stable coronary heart disease, followed for almost five years, measuring depressive symptoms at baseline in relation to subsequent heart failure, MI, stroke, transient ischemic attack, or death.
Whooley explained… “There’s been a lot of interest in physiological consequences of depression, like elevated norepinephrine, elevated cortisol, low heart-rate variability, and platelet activation, but there hasn’t been as much focus on the behavioral mediators, although they certainly have been suggested by previous studies. Surprisingly, we found that the fancy physiological mediators really were not explaining the association and that it seemed to be all about health behaviors.”
According to Whooley, depressed patients were less likely to take their medications as prescribed, less likely to exercise, and more likely to smoke. “And after you accounted for those health behaviors, the association between depression and CVD went away. So we concluded that link between depression and heart disease is largely explained by these health behaviors.”
NEGATIVE THINKING & HEART FAILURE (November, 2008)
Research on heart failure has found that attitude counts for a great deal.
Negative thinking may play a major role in the development of depression in patients with heart failure, new research suggests.
Researchers at the University of Kentucky, in Lexington, found negative thinking accounts for more than a third of depressive symptoms in patients with heart failure, independent of sociodemographic factors, antidepressant therapy, and severity of heart failure.
“Depression is under diagnosed and under treated in patients with heart failure,” said lead study author Rebecca Dekker. “Given the life-or-death consequences of depression in these patients, we need to do a better job of not only recognizing depression but treating it.”
The study was presented at the American Heart Association 2008 Scientific Sessions, in New Orleans, November 17, 2008.
CDC STUDY ON DEPRESSION (September, 2008)
September 5, 2008 — A new report from the Centers for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics shows that in any 2-week period, 5.4%,of Americans aged 12 years or older, or more than 1 in 20, are depressed.
Hardest hit are women, non-Hispanic blacks, and those in middle age, between 40 and 59 years of age, where rates were higher than among other demographic groups. Americans living below the poverty level were more likely to be depressed than those with higher incomes; rates in this population were 1 in 7.
“Approximately 80% of people with depression reported that their symptoms interfered with their ability to work, maintain a home, and be socially active,” the authors, Laura A. Pratt, PhD, and Debra J. Brody, both from the National Center of Health Statistics, write in their report. “Reflecting the high rate of functional impairment, almost two-thirds of the estimated $83 billion that depression cost the United States in the year 2000 resulted from lowered productivity and workplace absenteeism.”
In addition, they note, 35% of males and 22% of females with depression reported that their symptoms made this kind of functioning very or extremely difficult, and even among those with mild depressive symptoms, more than half reported some difficulty in functioning attributable to their symptoms.
The new report is based on data taken from the National Health and Nutrition Survey 2005 – 2006, the latest installment of the ongoing national cross-section survey of the noninstitutionalized US population aimed at assessing the health and nutrition of Americans. The current numbers, then, do not include institutionalized populations, where rates of depression are even higher, the authors note.
Despite being a treatable condition, only 29% of those with depression reported contact with a mental health professional within the past year, and only 39% of those with severe depression reported such contact, the authors write.
“There are many reasons people with depression do not receive treatment,” they write. “Some do not realize they have an illness that can be treated. Others do not believe that treatment works.” Other barriers include the stigma that surrounds mental illness and mental health treatment, they note, as well as lack of insurance coverage for mental health care.
Overreporting of Problem?
Asked for comment on the findings of the new report, Jack Drescher, MD, from New York Medical College, and a member of the committee for public affairs at the American Psychiatric Association… …suggested… That people are not seeking treatment from mental health professionals is consistent with previous information… “We already know that the majority of people receiving treatment for a psychiatric problem or receiving psychotropic medications are getting them from primary-care doctors,” he noted. The general underutilization of mental health services in general has also been previously shown, “so that people who need treatment might not be getting it is not surprising.”
National Center for Health Statistics Databrief: Depression in the United States Household Population 2005 – 2006. September 2008.
DEPRESSION CAN LEAD TO INFLATED REPORTS OF PHYSICAL SYMPTOMS (October 29, 2009)
Research shows people who feel depressed tend to recall having more physical symptoms than they actually experienced.
Psychologist Jerry Suls, professor and collegiate fellow in the University of Iowa College of Liberal Arts and Sciences, attributes the findings to depressed individuals recalling experiences differently, tending to ruminate over and exaggerate the bad.
Published electronically this month in the journal Psychosomatic Medicine, the study was conducted by investigators in the UI Department of Psychology, the Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP) at the Iowa City VA Medical Center, and the UI College of Nursing.
The 109 study participants, all female, completed baseline surveys to assess their levels of neuroticism and depression. Each day for three weeks, they reported whether they felt 15 common physical symptoms including aches and pains, gastrointestinal and upper-respiratory issues. On the 22nd day, they were asked to remember how often they had experienced each physical symptom in the preceding three weeks. People who scored higher in depression were more likely to overstate the frequency of their past symptoms.
“People who felt depressed made the most errors when asked to remember their physical symptoms,” Suls said. “They tended to exaggerate their experience.”
Past research has indicated that people high in neuroticism, a general disposition that includes negative affects like irritability, sadness, anxiety and fear, are more likely to exaggerate their physical symptom experience. This new study indicates that depression — which can be one component of neuroticism — is more likely the reason.
“For 30 years, the hypothesis has been that neuroticism is behind inflated reports of symptoms. We’re saying no — depression appears to be the big player,” Suls said. “We discovered that people high in neuroticism but low in depression are not likely to misremember symptoms.”
Knowing depression has physical symptoms of its own, researchers employed a key control in the study. When looking at the accuracy of symptom recall, they factored out the physical symptoms associated with depression, like changes in sleep and appetite. They also classified participants as depressed or non-depressed based only on the cognitive symptoms of depression, such as sadness and anhedonia, a lack of interest in normally pleasurable activities. Depressed individuals still over-reported physical symptoms.
The topic is important, Suls said, because inflated symptom reports skew the information healthcare providers need to determine the best course of action. Perception of symptoms can also affect the patients’ decisions — such as whether they take time off work, use over-the-counter medications, or see a doctor.
“Depressed individuals and their physicians shouldn’t discount common symptoms because they can indicate serious problems,” Suls said. “However, since we now know that depressed individuals tend to over-remember the frequency of symptoms, it wouldn’t hurt to encourage patients to write down their symptoms as they’re happening. That way the patient and doctor have an accurate record of what has been going on, rather than relying on memory.”
Participants in the studies were in good health overall.
The research was supported by a grant to Suls from the National Institute on Aging. Co-Authors of the paper are M. Bryant Howren, now a post-doctoral fellow with CRIISP at the VA Medical Center in Iowa City, and René Martin, a research health science specialist at CRIISP and an associate professor in the UI College of Nursing. CRIISP is funded through the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development.
Source: University of Iowa
DIET AND DEPRESSION (November 10, 2009)
Patients who consume a diet rich in high-fat dairy products and fried, refined, and sugary foods are at increased risk of developing depression, whereas those whose diet is rich in fish, fruit, and vegetables are at lower risk of developing depression, a new study shows.
Although other research has looked at the relationship between single nutrients and depression, this is the first study to investigate the effect of dietary patterns on depression.
The results suggest that diet should be considered a potential target for the prevention of depressive disorders.
The five-year study defined two dietary patterns — a “whole” food pattern that included a high intake of vegetables, fruits, and fish, and a “processed” food pattern that included a high consumption of desserts, fried foods, processed meat, refined grains, and high-fat dairy products.
“The study can be an argument to help convince patients who have unhealthy eating behaviors that consuming a healthy diet not only controls excess weight but also may lower the risk of depression,” stated the study’s lead author, Dr. Akbaraly. Tasnime N. Akbaraly, PhD completed the study while at the Department of Epidemiology and Public Health, University College, London, United Kingdom.
An important limitation of the study is that the participants were all white civil service office workers, age 35 to 55. There were insufficient people of color who took the survey to compute statistically reliable comparisons among various non-white groupings.
The study was published in the November issue of the British Journal of Psychiatry.
TEENS, TV AND DEPRESSION (February, 2009)
February 5, 2009 — Excess exposure to television in teens has been linked to an increased risk for depression in early adulthood, particularly among young men.
A large longitudinal study from investigators at the University of Pittsburgh, in Pennsylvania, shows that each extra daily hour of television use was associated with an 8% increase in the odds of developing depressive symptoms by young adulthood.
“We looked at the development of depression over a 7-year period and found that the amount of television exposure was significantly associated with the development of depression,” said principal investigator Brian A. Primack, MD.
The study is published in the February issue of Archives of General Psychiatry.
DEPRESSION MAY BE TWICE AS COMMON AS PREVIOUSLY ESTIMATED (June, 2009)
June 2, 2009 — A new prospective Canadian study that analyzed data from a cohort of 7457 subjects has found that the cumulative prevalence of depression over just 7 years is 19.7% — a rate that is twice as high as previous estimates from retrospective data. This finding calls into question the conclusions of previous retrospective studies, which have estimated lifetime prevalence of depression at 10% to 20%.
“The first large-scale epidemiological studies in the 1980s came up with lifetime prevalence estimates of depression that have since been called into question,” said study investigator Scott Patten, MD, PhD, from the University of Calgary, in Alberta.
DEPRESSION IS AS FATAL AS SMOKING (August, 2009)
Research on 61,349 people in Norway has found that the depression and smoking are about equal in increasing a person’s risk for mortality.
August 14, 2009 — Depression is on a par with smoking when it comes to increasing risks for mortality, although anxiety may counteract some of this increased risk, according to a new study.
“We were a bit surprised to find that depression — and not necessarily at a severe level — is associated with mortality at the same strength as smoking,” said lead author Arnstein Mykletun, PhD, from the University of Bergen, Norway. “Perhaps one of the more important new findings is that depression is that strong, even taking into account a lot of potential confounding factors including health status,” he added.