Anti-depressants, Anxiety and Aerobics: The physical activity prescription

A report by RMPBS partner, Health Policy Solutions. 
For other stories from Health Policy Solutions and additional news, visit 
RMPBS Reports.
By Molly Maher

Getting to yoga class is not always easy for Diane Sieg.

“There are days I’d much rather hide my head than exercise or do anything else,” she said.

But for the public speaker, author and coach, physical activity is a balancing force in her life.

“I’ve always been involved in health and fitness because of my own issues around depression,” she said. “I learned at a very young age that moving makes me feel much better.”

Her background led her to develop a life-balance approach that includes consistent physical activity, like practicing yoga no matter how difficult it can be.

“It’s a hard road because people who don’t feel good don’t want to move,” she said. “We all have to remember what it is that keeps us going and moving in the right direction.”

She now brings this approach to coach clients of the Wellness Treatment Center, where people with depression, anxiety and other mental health issues are led through a six-step program based on the research of Dr. Stephen Ilardi, associate professor of clinical psychology at the University of Kansas.

Should we live more like our ancestors?

When Stephen Ilardi was majoring in math and economics as an undergraduate at Emory University, psychology was not on his radar.

Then, while volunteering at a psychiatric hospital, his curiosity led him to non-degree classes and eventually to graduate school at Duke University, where his interests shifted to the “bigger picture issue of depression.”

The big picture is bleak, with increasingly high incidence of depression and inconsistent results from anti-depressant medication.

Dr. Ilardi’s six part depression cure

    • Intensive physical activity
    • Increased Omega-3 intake

Lowers inflammation that can lead to neurotransmitter suppression

    • Bright light exposure

Leads to cascade of reactions that increase dopamine- and serotonin-based activity, like those of antidepressants

    • Healthier sleep habits
    • Enhanced social connectedness

“More face time, less Facebook.”

    • Mindfulness about rumination

The dwelling on negative thoughts is psychologically toxic for patients.[/sidebarContent]

“We have an epidemic that is burgeoning throughout most of the industrialized world and nothing we are doing seems to be making much of a dent,” he said.

This depression epidemic, which Ilardi notes is the single leading cause of medical related disability in the United States, is not a result of modern society’s higher self-awareness or of a culture of excessive complaining, he said.

Rather, it is at least partially a result of the disconnect between modern society and our hunter-gatherer past.

“There’s arguably been no selection pressure in post-agrarian society,” he said. “[Modern society] is badly adapted to post-industrial 21st-century life.”

He and his research team set out to answer the question: Is it possible to create a successful depression treatment that returns some of these protective hunter-gatherer habits to an individual?

Once he’d identified that question, Ilardi said six different protocols quickly emerged as “robustly supportive” of good mental health. Among these is intensive physical activity.

Participants in his six-part program typically work out with a trainer, which Ilardi says can give them the extra motivation a person with depression needs.

Although sometimes participants may “feel like crap when they first start,” Ilardi said they usually feel better after a few consistent workouts.

“Virtually all of our patients have reported they actually begin to see some benefit,” he said.

Teen physical activity may lower chance of chronic depression

Dr. Andrea Dunn, senior scientist at Klein Buendel, a communications firm in Golden, first studied the effects of exercise on neurochemistry and depression by observing wheel-running rats in 1987.

One research project addressed the results of different exercise doses on depression using methods similar to those used to study prescription drug treatments. The results showed that the dosage did not have as much effect as the frequency: exercise three times or more per week produced a positive response, whether it was a low or high dose of activity. The low dosage measured was the public health dose recommended by the American College of Sports Medicine.

Today, Dunn is conducting a study funded by the National Institute of Mental Health. The subjects are Denver-area teens and the objective is to determine ways to treat their depression before it becomes a chronic problem: DOSE (Depressions Outcome Study of Exercise) for Teens.

Dunn said typically depression begins in childhood or adolescence and patients wait four to five years on average to seek treatment. If a person suffers two or more episodes of depression, it likely will recur – if only episodically — for a lifetime.

Dunn’s study will include participants 12 to 21 years old who are not currently in counseling, though there are exceptions for those on anti-depressants.

The goal is to include 20 to 25 young people who will exercise regularly for 12 weeks. Researchers will use interviews and the Hamilton 17 Rating Scale for Depression to measure the level of symptoms throughout the process.

How physical activity treats and prevents depression

Exercise is generally accepted as a good thing for most people. It has been linked to lower risks of diabetes, cancer and Alzheimer’s.

Resources 

If you or someone you know is having thoughts of suicide, call your local hotline.

The Depression Center offers consultations, second opinions and therapy sessions. Call (303) 724-3300.

See your family physician or therapist if you are concerned you may have depression or before beginning any new exercise practice.

Though casual enthusiasts long have claimed that there is a mysterious connection between exercise and happiness — the runners’ high, for example — more and more work like that of Dunn and Ilardi is drawing scientific connections between physical activity and mental health, particularly in treatment for depression and anxiety.

Dr. MacAndrew Jack, a faculty member in the Contemplative Counseling Psychology department  at Naropa University in Boulder, said that not only does exercise, even moderate levels like walking, activate reward endorphins that make you feel good, it also helps create a mind-body connection that leads to increased mental well-being.

“What’s going on in your mind is much more related to your body while you’re exercising,” he said, though he notes that the strength of the connection may vary. It may be less powerful when a person is on a Stairmaster watching CNN, for example, than if he is fully preoccupied with physical activity.

Jack, who researches breathing patterns and their expression of and influence on our emotional life, said that the limbic sensors connection to breath regulation are also connected to emotional sectors. Breathing becomes more entrained during exercise, which increases harmony in the brain, he said.

Jack also cited the ability of exercise to broaden a person’s perspective. Dunn said that depression causes a very narrow focus, something exercise expands.

Exercise helps induce nerve growth factors associated with mood and memory, and it encourages the release of endocannabinoids that can cross the blood-brain barrier, perhaps contributing to a “runners’ high,” Dunn said.

Similarly, Dr. Neil Weiner, the director of clinical services at the Depression Center at the University of Colorado Anschutz Medical Campus, attributes some of the psychiatric value of exercise to its effect on the hippocampus, where growth there increases the connectedness of neurons.

He adds that exercise often leads to other antidepressant results, like increased self-confidence and a sense of mindfulness.

Trends in physical activity as treatment in health care field

Research has found direct, positive results in lifestyle- and physical activity-based treatment programs.

Ilardi says the participants in his research, who represent a population with severe, chronic and treatment-resistant depression, have had about a 75 percent response rate.

Sieg said Ilardi’s plan has worked impressively at the Wellness Treatment Center, which is open to anyone interested in improving his quality of life.

“As long as they follow, they get better,” she said. “I’ve been amazed at the results.”

At the end of her 12-week study on adults, Dunn saw the participants’ scores on the Hamilton Rating Scale for Depression  drop a mean of 47 percent.

Dunn said that recently – after 25 years in the field — she has seen increased acceptance of the connection between physical activity and mental health.

“Trying to gain credibility with the psychiatric community, to have more respect from them…it’s taken a long time,” she said. “It seems sort of ridiculous, because the two are so inextricably linked.”

Weiner pointed out that the Cochrane Review, an industry standard for quality research, reviewed all studies related to physical activity and depression up until 2010. It showed that the majority of studies met basic research standards and their aggregate success rates were quite high, however only two studies met rigorous research standards, and their results were much lower.

No matter the status of research, Weiner says most therapists with extensive education around depression believe in the benefits of exercise.

Meanwhile, Ilardi has seen practical application of his research. He knows of least five treatment centers that use his protocols to treat depression, and more are reaching out to integrate it into their preexisting programs, a sign that there is recognition of alternative treatments for mental health issues.

“I think I’ve seen among psychotherapists a feeling of great openness when they hear me talk about the actual research and the potential for a lifestyle-based approach to depression,” he said. “Many feel empowered.”

Ilardi is married to a nurse practitioner in a psychiatric private practice. She integrates some lifestyle-based approaches, Ilardi said, but at least every other week she jokingly says, “You’re ruining my practice.”

Often her patients want to try something like his six guidelines before taking medication. If the exercise program is successful, her patients will need only one follow-up appointment and seek no further treatment.

He said his wife will make more from a session where she prescribes medication than from one where she does not. For her, the choice to use lifestyle approaches gives greater client satisfaction, making up for these economic factors.

In a prescription-based practice, “It’s crazy to adopt a lifestyle approach to depression,” Ilardi said.

Weiner said that the Depression Center regularly provides psychotherapy and behavioral activation therapy side by side.

Sometimes they are used in coordination with anti-depressants, and sometimes the therapies may not include strict exercise. Rather they may focus on mindfulness techniques, socialization or simple movement, like getting up to get the mail daily.

Patients need to understand that mild to moderate depression can have equal response rates from psychotherapy or behavioral therapy as from antidepressants, Weiner said.

“Patients should be educated about the facts of psychotherapy, of cognitive behavioral therapy,” he said. “We give the patients a choice.”

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