“If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.” Hippocrates
It is now internationally recognised that exercise is good for you. Everything your grandmother said about fresh air and exercise is true. But it wasn’t only your grandmother. Modern humans tend to think they have a monopoly over knowledge, yet the benefits of regular exercise were first noted by Hippocrates, an early Greek physician and philosopher. Over the past two decades, a growing body of research has supported his clinical opinion, confirming the crucial role a physically active lifestyle plays in maintaining and improving physical health (Bonomi & Westerterp, 2011).
There is a roll call of physical benefits associated with exercise. It can help prevent the development of coronary heart disease, stroke, hypertension, osteoporosis, type 2 diabetes, and breast and colon cancer (Bryan & Katzmarzyk, 2011). It has a general anti-inflammatory effect on the body which may reduce the risk of chronic diseases such as arthritis. Exercise seems to have an anti-ageing benefit, and early and midlife exercise can even decrease the risk of mild cognitive impairment in later life (Ahlskog, 2011). But what are the effects of regular exercise on our psychological health and can we really change thoughts and feelings through physical patterns of activity? The jury is back and while there is still much to learn and methodology issues that need to be addressed, the consensus is that exercise can improve psychological health.
To date, the mainstay of treatment for major depressive disorder (MDD) consists of antidepressant medication and psychological therapies (Treatment Protocol Project, 2004) with varying levels of treatment success. Given the high cost and prevalence of MDD, the development of efficacious, accessible and cost effective treatments is imperative, and innovative, interdisciplinary treatment approaches are required. Exercise or physical activity prescriptions may offer one such opportunity.
Meta analyses of clinical trials have documented a significant improvement in depression with regular exercise (Ahlskog, 2011). Exercise can be an effective treatment for mild and moderate depression. Research suggests that frequency is important, with daily or near daily exercise most beneficial in reducing depressive symptoms. There also appears to be a balancing act between intensity and duration. Higher intensity activities are easier to fit into a busy lifestyle and require a smaller dose, whereas low intensity exercise needs to be maintained for longer time periods to achieve the same benefits (Bruijin & Rhodes, 2011).
Moreover, there is strong evidence suggesting that people who exercise regularly are less likely to develop depression and this appears to be across the age span (Wipfli, Landers, Nagoshi & Ringenbach, 2011).
Exercise appears to have multiple mechanisms of action, including a behavioural activation component (alters daily routine, providing opportunities to interact with others), improvement in appearance and body image, enhancement of self esteem, and an increase in self efficacy via mastery of mind (setting goals) and body (fitness) challenges. Other research suggests that there are specific biological mechanisms which may help to explain the beneficial effects of exercise on depression. Exercise promotes the secretion of neurotransmitters such as serotonin, and stimulates the secretion of endogenous morphines or ‘endorphins’, producing a state of euphoria (Callaghan, 2004). This finding is especially relevant given that not all clients can tolerate antidepressant medication.
Despite this growing body of evidence, it appears that recommendations for exercise in clinical practice are not routine (Treatment Protocol Project, 2004). This is unfortunate and may reflect the fact that few psychologists are comfortable or feel skilled in using exercise as therapy. The other barrier may be concerns over treatment compliance. Exercise does require a certain amount of adjustment, tolerance of physical discomfort and strain, and this may explain why only 25 per cent of adults in western societies exercise at the level needed to achieve health benefits (Sime, 2002; Fuchs, Goehner & Seelig, 2011). It also requires setting aside time to exercise, as there is very little call for incidental exercise compared to the way our great grandparents experienced life. The modern trappings of robotics, computers and technology that have liberated us, have also changed the way we engage with the world. Exercise for its own sake must now be vigorously pursued, fighting against the tide of time pressures, passive entertainment, and family and work commitments.
Many of us are aware of the costs that not exercising has on our physical health, and as we become more aware of the cost to our psychological health we begin to understand that exercise, as Hippocrates once observed, is the foundation on which to build optimal health. However, given that the general population struggle to exercise, how do we prescribe exercise to our clients who are also dealing with the effects of depression? The barriers to exercise are important to acknowledge, however, the reality is that compliance with antidepressant medications and psychological treatments can be equally fraught with difficulties (Sime, 2002).
Exercise offers an opportunity to engage in a non-stigmatising activity that may hold appeal for difficult-to-reach client populations (Mead, et al., 2009) and is associated with fewer side effects. Of course, it is necessary that any existing health concerns should be explored and where appropriate, medical clearance obtained prior to commencing exercise. Beyond this, exercise side effects mostly relate to muscular/skeletal injuries which can be minimised via injury prevention information or referral to a physiotherapist or exercise physiologist (Sime, 2002). Psychologists interested in prescribing exercise for depression are encouraged to read the relevant literature and seek consultation where appropriate.
There are a number of guiding principles to consider when recommending exercise for depression, as well as potential pitfalls to avoid.
Happy exercising everybody!
The principal author can be contacted at Yasmina.Nasstasia@newcastle.edu.au