October 2019 Issue
Focus on Fitness: Exercise and Depression
By Jennifer Van Pelt, MA
Today’s Dietitian
Vol. 21, No. 10, P. 50
Since 1990, the first full week of October has been designated as Mental Illness Awareness Week. On Thursday of that week (October 10, this year), National Depression Screening Day is held. Many mental health organizations and providers take this occasion to increase awareness of mental illnesses, including depression. Affecting more than 300 million individuals of all ages worldwide, depression is the leading cause of disability and a major contributor to the overall global disease burden, according to the World Health Organization.1 Depression commonly is referred to as mild, moderate, or severe. Severe depression is classified clinically as major depressive disorder (MDD) and affects more than 16 million American adults. It’s the leading cause of disability for Americans aged 15 to 44. Major depression is diagnosed when the following symptoms occur for longer than two weeks2:
• feelings of worthlessness, guilt, gloom, or constant worry;
• loss of interest in activities previously enjoyed;
• weight changes;
• sleep difficulties;
• lack of energy;
• problems with concentration and memory; and
• thoughts of self-harm, death, or suicide.
In mild depression, symptoms are noticeable enough to interfere with some normal activities and include irritability, anger, feelings of hopelessness, poor self-esteem, loss of interest in socializing, lack of motivation, and sleep and eating changes. Symptoms of moderate depression are similar but more serious—enough to cause problems with family, work, and social life. According to a recent data brief from the National Center for Health Statistics, approximately 80% of adults with depression reported some problems performing daily tasks due to depression symptoms; 50% reported having difficulties with work, home, or social activities; and 30% reported moderate to extreme difficulty.3
When mild or moderate depression lasts two years or more, persistent depressive disorder (PDD) is diagnosed. PDD affects approximately 3.3 million American adults.2 Depression of any type is more prevalent in women than in men. More than 50% of those with depression have recurrent episodes, and 20% develop chronic depression.2,3
Lifestyle changes—including regular daily exercise—often are recommended as part of treatment for depression. Exercise has been shown to boost endorphin and serotonin levels, which improve mood. Previously, it was thought that vigorous exercise was required, and that this “runner’s high” was a temporary feeling.
However, recent research has shown that regular exercise of any intensity positively affects brain functioning and reduces depression symptom severity. In fact, recent research has shown that exercise improves depression comparable to antidepressants and psychotherapy, and earlier research underestimated the benefits of exercise as a treatment for depression, including MDD.4,5
Scientists haven’t yet fully determined all the neurologic and physiologic effects of exercise that result in symptom improvement in depression—it isn’t just the endorphin release and serotonin boost that contribute to that postexercise high. Neuroscientific studies suggest that exercise may affect the prefrontal cortex, hippocampus, anterior cingulate cortex, and corpus callosum, which are some of the same areas that are targeted by antidepressant medications. Ongoing research suggests that both exercise and antidepressants produce neuromolecular changes in brain structure and functioning. It’s speculated that the effects of exercise on the brain may be longer term, unlike medications, where benefits stop when treatment ends.6
Even though the mechanisms behind exercise and depression aren’t yet fully understood, the benefits of exercise for improving mental health have been known for years and recommended by clinical and government organizations. In 2004, the American Psychological Association summarized published evidence from the 1990s on exercise for depression in its online resources for consumers, calling it a “beneficial antidepressant both immediately and over the long term.”7
The American Psychiatric Association’s 2010 guideline for treating depression noted randomized controlled trials support regular aerobic exercise and resistance training to modestly improve symptoms. In addition, regular exercise also may reduce depression prevalence in the overall population, especially for older adults and those with other medical problems.8,9
The 2018 Physical Activity Guidelines from the Department of Health and Human Services recommends exercise for depression, stating, “Regular physical activity not only reduces the risk of clinical depression but reduces depressive symptoms among people both with and without clinical depression. Physical activity can reduce the severity of those symptoms, whether one has only a few or many.”8
In late 2018, after reviewing current published evidence, the European Psychiatric Association released a much stronger recommendation for exercise as a “core part of treatment for severe mental illnesses, including major depressive disorder.” Authors of the guideline called for adding physical activity interventions to mainstream treatment of depression and other mental health conditions, including adding exercise facilities and exercise specialists to mental health facilities and insurance reimbursement policies.10
Despite substantial supporting evidence and guideline recommendations, exercise usually isn’t strongly emphasized in treatment plans for those with depression. Or, it’s recommended, but patients can’t follow recommendations. Depression symptoms are common barriers to exercise: Lack of motivation, low self-esteem, and other factors prevent patients from starting and maintaining a regular exercise program. Recent research may help elevate exercise to first-line adjunctive treatment for depression. Researchers have noted that exercise is particularly effective when combined with psychotherapy and suggest that structured programs with group psychotherapy and exercise combined may improve patient adherence to treatment and increase the likelihood that those with depression will establish a fitness routine and continue to exercise regularly.6,10
What type of exercise should you recommend to clients with depression? Evidence analysis for the European Psychiatric Association guideline found that moderate-intensity aerobic exercise done two to three times per week, or combined aerobic and resistance exercise for a total of 150 minutes can relieve depression symptoms.10 Interestingly, the most recent and largest meta-analysis on exercise for depression excluded mind-body exercises such as yoga, tai chi, and qigong—exercises that may be beneficial because they include deep breathing and meditation, two techniques known to improve depression. There’s a large body of evidence supporting mind-body exercise and meditation for depression; I’ve covered those in previous editions of Today’s Dietitian.
In general, the exercise recommendations to help alleviate depression symptoms mirror those for overall health—a mix of aerobic and resistance exercise of at least moderate intensity 150 minutes weekly, plus mind-body exercises for stretching, meditation, and breathing. Group fitness classes provide motivation and socialization opportunities that may help with adherence. Combination psychotherapy and cognitive behavioral therapy/exercise programs for depression treatment may be available to some clients, depending on the mental health services in their geographic area.
Given recent research recommendations for incorporating exercise into depression treatment, look for more combination programs and exercise programs geared specifically toward depression in the near future.
— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.
References
1. Depression. World Health Organization website. https://www.who.int/news-room/fact-sheets/detail/depression. Published March 22, 2018.
2. Facts & statistics. Anxiety and Depression Association of America website. https://adaa.org/about-adaa/press-room/facts-statistics
3. Brody DJ, Pratt LA, Hughes JP; Centers for Disease Control and Prevention. Prevalence of depression among adults aged 20 and over: United States, 2013–2016. https://www.cdc.gov/nchs/products/databriefs/db303.htm. Published February 2018.
4. Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev. 2013;(9):CD004366.
5. Schuch FB, Vancampfort D, Richards J, Rosenbaum S, Ward PB, Stubbs B. Exercise as a treatment for depression: a meta-analysis adjusting for publication bias. J Psychiatr Res. 2016;77:42-51.
6. Gujral S, Aizenstein H, Reynolds CF, Butters MA, Erickson KI. Exercise effects on depression: possible neural mechanisms. Gen Hosp Psychiatry. 2017;49:2-10.
7. Exercise helps keep your psyche fit. American Psychological Association website. https://www.apa.org/research/action/fit. Published May 28, 2004.
8. 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee scientific report. https://health.gov/paguidelines/second-edition/report/pdf/PAG_Advisory_Committee_Report.pdf. Published February 2018.
9. Gelenberg AJ, Freeman MP, Markowitz JC, et al. Practice guideline for the treatment of patients with major depressive disorder. American Psychiatric Association website. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Published October 2010.
10. Stubbs B, Vancampfort D, Hallgren M, et al. EPA guidance on physical activity as a treatment for severe mental illness: a meta-review of the evidence and position statement from the European Psychiatric Association (EPA), supported by the International Organization of Physical Therapists in Mental Health (IOPTMH). Eur Psychiatry. 2018;54:124-144.