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GET YOUR PATIENTS OFF THE COUCH: EXERCISE AND MENTAL HEALTH

by William W. Deardorff, Ph.D, ABPP.


4 Credit Hours - $79
Last revised: 11/11/2016

Course content © Copyright 2012 - 2017 by William W. Deardorff, Ph.D, ABPP. All rights reserved.



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Course Outline

 

Introduction

Learning Objectives

The Importance of Physical Activity and Health

Physical Activity and Medical Conditions

Physical Activity and Mental Health

Exercise and Mental Health

Exercise and Depression

Possible Mechanisms for the Exercise-Depression Relationship

Barriers to Treating Depression with Exercise

Exercise as a Treatment for Depression: Summary

Exercise and Anxiety

Exercise as a Treatment for Anxiety: Summary

Physical Activity, Psychological Distress and Well-Being

Physical Activity, Cognitive Function and Dementia

Physical Activity and Sleep

Physical Activity and Other Aspects of Mental Health

From Theory to Practice: Getting Your Patients to Exercise

Enhancing Motivation and Long Term Lifestyle Changes

Conclusions

Resources

References

Introduction

 

As discussed in many extensive review articles, the scientific evidence from prospective cohort studies and randomized controlled trials (RCTs) supports the overall conclusion that regular scan0014150imageparticipation in moderate-to-vigorous physical activity is associated with prevention of mental health problems, improved aspects of mental well-being, and reduced symptoms of several mental health disorders (after onset or during treatment).

 

The information in this course is based on major reviews in addition to other references cited. Three of the most significant reviews are as follows. The first reference is a sub-section on Mental Health and Physical Activity (61 pages) and much of the information in that report is summarized in this course.  As part of the course please review this document (click here for pdf).  The second reference below is very extensive (683 pages) and is an excellent overview of studies of physical activity and health.  It is not required reading for this course, but is accessible in the public domain for those who are interested.  The third reference below is a Cochrane Review.  It is not necessary to review for this course and cannot be accessed in the public domain; however, much of the information contained in the Cochrane Review has been include herein.  In this course, many of the statistics cited have not been references.  All references support the information in this course can be found in the following detailed reviews.

 

Part G: Section 8: Mental Health.  Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services, 2008. (click here if link problems).

 

Physical Activity Guidelines Advisory Committee. Physical

Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services, 2008. (683 pages)

 

Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA. Exercise for depression. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD004366. DOI: 10.1002/14651858.CD004366.pub4.

 

 

Learning Objectives

 

 

List 4 benefits of exercise and mental health

Discuss using exercise to help treat depression

Discuss using exercise to help treat anxiety

List 5 important features of designing an exercise program

 

 

The Importance of Physical Activity for Health

 

Everyone knows that exercise is good for us. Our bodies were designed to move; however, as our society becomes more and more technologically advanced the actual requirement for physical exertion diminishes. You can almost run your entire life while sitting including changing channels on the television, ordering anything you need from the Internet (even running a business), having food delivered to your home, etc.  In industrialized countries, if you don’t want to move around much, you don’t have to in order to survive.  Unfortunately, this sedentary lifestyle has the potential to increase your risk for medical problems, and decrease your quality and length of life.  

 

The recommendations for physical activity (for everyone) have changed over the past several decades.  For instance, in the 1990s the focus of public health recommendations was 3-5 exercise sessions per week (American College of Sports Medicine; ACSM, 1978, 1990). In 1995, the recommendations changed to include physical activity (exercise) of moderate intensity for at least 30 minutes on most if not every day during the week.  The newest guidelines (2011) are much more specific and can be found on the ACSM site along with ACSM Position Papers for exercise related to a myriad of individuals and conditions such as diabetes, older adults, athletes, weight loss, cardiovascular issues, bone health, etc. In general it is suggested that for a healthy adult a program of regular exercise to maintain physical fitness and health should include cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living. The ACSM recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for at least 30 minutes per day, five days per week, for a total of at least 150 min each week.  In addition, vigorous-intensity cardiorespiratory exercise training should be done for at least 20 min per day, 3 days per week. Adults should also perform resistance exercises for each of the major muscle groups, and neuromotor exercise involving balance, agility, and coordination.

 

Crucial to maintaining joint range of movement, completing a series of flexibility exercises for each of the major muscle-tendon groups is recommended. The exercise program should be modified according to an individual's habitual physical activity, physical function, health status, exercise responses, and stated goals. Adults who are unable or unwilling to meet the exercise targets outlined here still can benefit from engaging in amounts of exercise less than recommended. In addition to exercising regularly, there are health benefits in concurrently reducing total time engaged in sedentary pursuits and also by interspersing frequent, short bouts of standing and physical activity between periods of sedentary activity, even in physically active adults.  The ACSM is an excellent website for resources for professionals, patients, and the general public including brochures for patients, current comment fact sheets, and position papers.  These materials address a variety of conditions and are all available for free.  As part of this course, please review the materials on the ACSM website.

 

Physical Activity and Medical Conditions

 

As is well known and accepted by most experts (and everyone else) that physical activity is associated with a myriad of health benefits.  In contrast, physical inactivity can have harmful effects on health and well-being including such things as increased risk for coronary artery disease, diabetes, certain cancers, hypertension, obesity, just to name of few.  Physical inactivity is a major cause of morbidity and mortality.  Compared with those who are physically active, sedentary individuals have substantially increased risk for developing diabetes, heart disease, high blood pressure, and a number of other medical conditions.     The connection between physical activity and health, and physical inactivity and health problems is well-established, well-researched. 

 

The effects of lifestyle modifications including diet and exercise on many chronic medical conditions have shown positive outcomes.  For example, in study after study, diet and exercise programs have been shown to improve the medical status of patients with diabetes including medication reductions, improved control of blood sugars, decreased co-morbid problems and improved quality of life.  Similar finding have been found for patients with cardiovascular prevention and in those with documented disease. Benefits of diet and exercise in this patient population include such things as decreased risk of heart attack, hospitalizations and death.  Examples for other medical conditions are similar.  Overall, we can safely assume that an appropriately designed diet and exercise program can be quite impactful for a variety of medical conditions.

 

Physical Activity and Mental Health

 

Individuals with serious mental illness are at higher risk for premature mortality than the general population.  On average, people with severe mental illness die ten to 15 years earlier than the general population.  Although some of this is due to suicide and accidental death, heart disease is a common reason for excess mortality in this patient population. In addition, rates of co-morbid illness such as hypertension, diabetes, respiratory conditions, and cardiovascular disease are also higher in this patient population. As will be discussed, medical problems are also prevalent in those with mental health issues that do not rise to the level of “serious mental illness.”

 

Although not studied as extensively as the physical activity-health connection, the relationship between physical activity and mental health has also been investigated.  Unfortunately, it appears that this important area has not received much attention in clinical practice.  Research suggests that physical inactivity may be associated with the development of mental disorders.  Several large clinical and epidemiological studies have shown associations between physical activity and symptoms of depression and anxiety in cross-sectional and prospective-longitudinal studies. In addition, exercise is an integral part of many rehabilitation and treatment programs for various medical conditions (e.g. chronic pain, cardiac, etc.).  Improving physical well-being as part of these programs often leads to improved psychological well-being including reduction in depression and anxiety.

 

Poor mental health, including diseases of the central nervous system (CNS), reduces the quality of life and adds a burden on public health. People with anxiety or depression disorders are more likely to have chronic physical conditions.  In fact, depression and dementia were among the 10 leading risk factors of disability-adjusted life expectancy in high-income nations worldwide during 2001. They are projected to rank first and third by the year 2030. In the United States, dementia and other CNS disorders are a leading cause of death, and mental disorders are estimated to account for more than 40% of years lost to disability.

 

Exercise and Mental Health

 

The following general questions about physical activity and mental health conditions are addressed in the reviews cited previously, specifically the Mental Health chapter of the Physical Activity Guidelines Advisory Committee Report (2008). For this course, we will use this format to summarize the material.  After each of these issues is discussed, we will discuss suggestions for, and overcome barriers to, implementing an exercise program.  The questions are in Table 1.

 

 

Table 1. Exercise and Mental Health: Important Questions

 

 

  1. Is there an association between physical activity and depression?

 

  1. Is there an association between physical activity and anxiety?

 

  1. Is there an association between physical activity and distress and well-being?

 

  1. Is there an association between physical activity and cognitive function and dementia?

 

  1. Is there an association between physical activity and sleep?

 

  1. Is there an association between physical activity and other aspects of mental health?

 

  1. Is there an association between physical activity and adverse psychological events?

 

 

Exercise and Depression

 

The American Psychiatric Association recognizes 4 types of mood disorders: (1) depression, (2) bipolar or manic-depressive disorder, (3) mood disorders due to a medical condition, and (4) substance-induced mood disorders.

 

Depression includes a mild chronic form, dysthymia, and a more severe form, major depressive disorder. Depression has an annual prevalence of about 8% among women and 4% among men worldwide and in the United States. It is estimated that 17% of the U.S. population will suffer from a major depressive episode at some point in their lifetime. The lifetime rate of depression among adults aged 30 to 60 years is about twice the rate among people older than age 60 years. Research has demonstrated that over the past 20 years, the rate of outpatient treatment for depression in the U.S. has more than tripled.  The vast majority of patients suffering from depression first seek treatment from their primary care providers. As such, it is estimated that the prevalence in primary care settings is three times that in community samples.  The rates for minor depression and dysthymia are even greater, ranging from 5% to 16% of patients. 

 

People have a major depressive episode when they have depressed mood or lose interest or pleasure in normal activities most of the time for at least 2 weeks. Other symptoms include abnormalities in appetite, libido, sleep, energy levels, concentration and, often, suicidal thoughts. In some cases, anxiety and motor agitation can be more prominent symptoms than depressed mood. Also, mood disturbance can be less apparent than other features such as irritability, abuse of alcohol, and worsening of comorbid phobias, obsessions, or preoccupation with physical symptoms. Depression is not considered a major depressive episode if it is caused by grief (less than 2 months), drug abuse or medication, or a medical condition such as hyperthyroidism, heart disease, diabetes, multiple sclerosis, hepatitis, or rheumatoid arthritis. Many older patients with symptoms of depression do not meet the full criteria for major depressive disorder. If they have similar, but fewer, symptoms they may have minor depression, a sub-syndromal form of depression.

 

Research has demonstrated that depressed patients are less physically fit and have diminished physical work capacity on the order of 80% to 90% of age-predicted norms. 

 

Depressed patients treated in primary care settings receive predominately pharmacology intervention with much fewer being referred for adjunctive psychotherapy.   As a result, the majority of these patients are not educated about non-pharmacologic treatment methods for depression including cognitive therapy and exercise.  In addition, even for those who become involved in psychotherapy, a regular exercise regimen is rarely prescribed as part of the treatment.  This is likely due to the lack of knowledge on the part of the practitioner relative to the efficacy of this intervention.

 

Physical Activity and the Onset of Depression

 

Population-based, prospective cohort studies provide substantial evidence that regular physical activity protects against the onset of depression symptoms and major depressive disorder. Evidence is insufficient to draw conclusions about bipolar disorder and other mood disorders.

 

An association between physical activity and reduced symptoms of depression among adults has been generally supported in more than 100 population-based observational studies published since 1995, including nationally representative samples of nearly 190,000 Americans. Most of the studies looked at cross-sectional associations, which indicated that active people on average had nearly 45% lower odds of depression symptoms than did inactive people. In the national samples of Americans, active people had approximately 30% lower odds of depression.

 

Physical Activity Reduces the Symptoms of Depression

 

A great number of studies suggest that exercise training reduces depressive symptoms in clinical and non-clinical groups.  The results of RCTs indicate that participation in physical activity programs reduces depression symptoms in people diagnosed as depressed, healthy adults, and medical patients without psychiatric disorders.

 

In recent studies comparing the effects of exercise to a placebo or to drug therapy or bright light therapy, the reductions, on average, favored exercise over placebo. Symptom reduction after exercise was similar to drug therapy and similar or superior to bright light therapy. Long-term reductions in symptoms were examined in a few studies and were generally favorable after supervised exercise training ended, especially when people maintained regular physical activity. The trial by Dunn and colleagues (2005) was a placebo trial that controlled for social interaction and sunlight exposure (two confounders common in other studies) and reported response and remission rates after exercise training that were 40 to 50% better than placebo.

 

The Effect of the Type of Exercise on Depression

 

It has been established that physical activity can delay or prevent the onset of depression, and it can decrease the symptoms of depression after onset.  However, these studies vary greatly in the type of exercise program that was implemented.  An important question is how much exercise (and of what type) is necessary to obtain the therapeutic benefit.

 

The various studies reviewed used different measures and criteria for defining levels of physical activity, so it is not possible to convert their findings to a standard estimate (e.g., MET-hours or kilocalories per kilogram) of the amount of physical activity at each level. However, about half the prospective cohort studies provided enough information to determine whether active people were meeting existing public health recommendations for participation in moderate or vigorous physical activity. For example moderate-intensity aerobic or endurance physical activity for a minimum of 30 minutes on 5 days per week, or vigorous-intensity aerobic physical activity for a minimum of 20 minutes on 3 days per week.

 

Just a few of the studies will be discussed as examples. Most of the studies reviewed employ walking or jogging programs.  In one study (McNeil et al, 1991), 30 community-based moderately depressed men and women were randomly assigned to an exercise intervention group, a social support group, or a wait-list control group. The exercise intervention consisted of walking 20 to 40 minutes, three times per week for 6 weeks. The authors reported that the exercise program alleviated overall symptoms of depression and was more effective than the other two groups in reducing the somatic symptoms of depression. In another study Dimeo et al. (2001), just 30 minutes of treadmill walking per day for 10 days was sufficient to produce a clinical relevant decrease in depression as objectively measured by the Hamilton Rating Scale for Depression.  Some studies have reported that supervised exercise programs resulted in larger improvements in functional capacity compared to home-based interventions. 

 

Other studies have employed nonaerobic methods and exercise and compared them to aerobic interventions.  For instance, Doyne et al. (1987) compared the efficacy of running with that of weight lifting.  Forty depressed women were randomly assigned to running, weight lifting, or a wait-list control group.  Participants were asked to complete 4 training sessions each week for the 8 week program (supervised). The running exercise consisted of running at 80% of estimated maximum heart rate.  The weight lifting group was at less than 50% of estimated maximum heart rate. Depression was assessed at mid- and post-treatment and at one-, seven-, and 12-months follow-up.  Results indicated that the two exercise groups did not differ in their outcomes, and both resulted in reduced symptoms of depression as measured by the Beck Depression Inventory (11 and 13 point reduction in scores respectively).  The wait list control showed no change (BDI score decreased 0.8).  For the two exercise groups, there was no difference in the percentage of participants that remained non-depressed at one year follow-up 

 

In another study, Martinsen et al. (1989) assessed 90 depressed inpatients who were randomly assigned to aerobic or non-aerobic exercise. The aerobic exercise consisted of jogging or brisk walking at 70% of maximum aerobic capacity.  The non-aerobic exercise consisted of low-intensity strength training, relaxation, coordination, and flexibility training.  The program was for 8 weeks, and participants exercised for 60 minutes, 3 times per week. Both of the groups experienced a significant reduction in depression and there was no difference between the groups.  Based on these and subsequent studies (See the review), it appears that the benefits of exercise for depression can be obtained whether using aerobic or non-aerobic methods.

 

In more recent studies supporting exercise for depression, Mather (2002) randomly assigned 86 adults diagnosed with depression to one of two groups: an exercise group consisting primarily of weight-bearing exercise lasting 45 minutes, twice weekly for 10 weeks or a control group consisting of just health education. At 10-weeks a significantly higher proportion of the exercise group (58% versus 33%) experienced a greater than a 30% decline in depression according to the Hamilton Rating Scale for Depression.

 

In Blumenthal (2007), 202 patients diagnosed with major depressive disorder were randomly assigned to one of four conditions: supervised exercise consisting of using a treadmill in a group setting, home-based exercise program, anti-depressant medication, or placebo pill.  The outcome measures were remission as defined as no long meeting the criteria for major depressive disorder and have a Hamilton score less than 8.  After four months of treatment, 41% of the participants achieved remission.  Patients receiving active treatments tended to have higher remission rates than the placebo controls.  Remission rates were as follows: supervised exercise (45%); home-based exercise (40%); medication (47%), and placebo (31%).

 

There have been additional studies investigating the effects of exercise either instead of antidepressant medications (as in the Blumenthal study) or adjunctive to them. Multiple studies have demonstrated strong beneficial effects of exercise adjunctive to antidepressant treatment.  In another study previously completed by Blumenthal et al. (1999), 156 moderately depressed patients were randomly assigned to one of three groups: exercise, medication, or exercise and medication.  The exercise group walked or jogged on a treadmill at 70% to 85% of heart rate reserve for 30 minutes, three times per week for 16 weeks.  The medication group received sertraline followed by a psychiatrist with dose adjustments at 2, 6, 10, 14, and 16 weeks.  Those in the combined group received both interventions. Results demonstrated that while the medication worked more quickly to reduce depressive symptoms, there were no significant differences among the treatment groups at 16 weeks.  The percentage of patients in remission at 16 weeks did not differ: exercise (60%); medication (70%); combined (66%). Interestingly, at 10-month follow-up of those that participated in the exercise group had lower rates of depression (70%) than those in the medication group (48%) and combination group (54%).

 

Surprisingly, there has been little in the way of investigating the addition of exercise to psychotherapy (e.g. cognitive therapy) interventions.  The review of Stathopoulou et al. (2006) identified only one study that had investigated this possibility (Fremont and Craighead, 1987).  In that study, patients with mild to moderate depression were randomly assigned to receive either 10 sessions of cognitive therapy, 10 session of CBT combined with running, or 10 sessions of running only.  No significant additive effects for exercise were found relative to CBT. A search of articles related to combining cognitive behavioral treatment (CBT) with exercise for treatment of depression reveals that virtually all the studies are focused on this combined treatment targeting depression and other symptoms related to a medical condition (e.g. cardiac rehabilitation, stroke, fibromyalgia, etc.).  As such, there is a great deal of evidence for the combining exercise and CBT when a medical condition is involved, but not strictly for the treatment of depression.   

 

Many studies have supported the conclusion that there is positive dose-dependent relationship in terms of the effect of the exercise on the improvement in depressive symptoms. The results favored people who met or exceeded recommendations for moderate or vigorous participation compared to active people who did not meet either recommended level. The benefit was not different between vigorous and moderate participation, but it was possible to distinguish moderate from vigorous participation in only a few studies. After adjustment for other risk factors, a similar protective benefit favored participation in moderate to vigorous physical activity compared to levels less than recommended.

 

Perhaps the clearest experimental evidence for a dose-dependent effect of exercise on symptom reduction comes from the dose study by Dunn et al. (2005).  Adults aged 20 to 45 years diagnosed with mild to moderate major depressive disorder expended either 7.0 or 17.5 kilocalories per kilogram per week at a frequency of 3 or 5 days per week or engaged in 3 days per week of stretching exercises as a placebo control. Physician-rated symptoms after 12 weeks demonstrated a reduction of 47% from baseline for the higher dose, compared with 30% for the lower dose and 29% for control.  This was regardless of whether exercise frequency was 3 days or 5 days each week.  In summary, high-intensity exercise provided superior results compared to lower-intensity exercise. Some studies also indicate that supervised exercise program yield better results than home-based.

 

Possible Mechanisms for the Exercise-Depression Relationship

 

Neurophysiologic

 

The area of neurophysiology is constantly changing and new discoveries are being made on almost a daily basis.  The same is true for theories about depression, physical activity and the brain.  Recent imaging studies (See Carek et al., 2011) have demonstrated structural changes associated with early onset depression in the hippocampus, amygdale, striatum, and frontal cortex.  All of these areas are extensively interconnected.  The most consistent finding is that of loss of volume in the hippocampal formation.  This relates to earlier research in the 1990s that demonstrated that new neurons grow in the adult brain as well as the immature brain.  Previously it was thought that all neuronal development (growth) was completed when we are young and one was then set with a “fixed” number of neurons. The findings that new neuron growth can occur (e.g. in the hippocampus) is critical to the newer neurophysiologic theories of recovering from depression.

 

Depression and stress have been researched in using animal models from both a behavioral and neurophysiologic perspective.  In most research paradigm investigating animal models of depression, the animals are put under physical stress (e.g. shock, physical restraint) to create the depressive symptoms. However, newer research has used a “psychosocial stress model” in which the animals are stressed via “social defeat”.  Both types of studies demonstrate that depressive symptoms are created in the animals. 

 

From animal behavioral research using both stress methods, it has been shown that if an animal’s environment is “enriched” (e.g. giving the animal the opportunity to investigate and exercise in its cage), resilience to stress is fostered and depression-like symptoms are alleviated.  The corresponding neurophysiology behind this finding is now being studied. The process of neurogenesis (nerve growth) continues to be researched but it is known that stress (e.g. depression) slows this growth in the hippocampus (diminished volume). In contrast, in animal models, environmental enrichment enhances and promotes neurogenesis in the hippocampus.

 

Research suggests that one important consequence of environmental enrichment is its impact on the function of the body’s stress response system.  Animals in these enriched environments show positive effects on the physiology of stress resilience.  In humans, successful antidepressant treatment is reflected in similar beneficial changes.  Physical exercise and positive psychosocial activity have beneficial effects on depression and stress resilience.  (Schloesser et al., 2010).

 

Brain neurogenesis can be achieved in many ways including positive psychosocial activity, exercise, and antidepressant medication (Carek et al., 2011). Other mechanisms by which exercise specifically is theorized to improve mood include increased levels of endocannabinoids, and changes in the hypothalamopituitary adrenal axis (increased adrenocorticotropic hormone and decreased cortisol production).

 

Psychosocial

 

Exercise has been hypothesized to have many beneficial psychological effects in the alleviation of depression including distraction, improved self-concept, and enhanced self-efficacy.  In reviewing the research it seems these are all likely interrelated.  The distraction hypothesis is simply that exercise “distracts” the individual from worries and depressing thoughts. 

 

As formulated initially by Bandura, self-efficacy is the belief that one possesses the necessary skills to complete a task as well as the confidence that the task can actually be completed with the desired outcome.  Bandura described depressed individuals as often feeling inefficacious to bring about positive desired outcomes in their lives and low efficacy to cope with the symptoms of depression.  This leads to a cycle of negative self-evaluation, negative ruminations, and faulty styles of thinking.  Exercise has been hypothesized as being able to enhance self-efficacy by providing a “mastery experience”.  An increased sense of mastery is associated with improved coping and mood.

 

Although not discussed in the research literature, exercise also provides the opportunity for increased social interaction if prescribed in the proper manner.  As opposed to exercising alone at home, I will often encourage patients to exercise in a social context whether it is at a gym, some type of class, or with an “exercise buddy”.  This forces social contact in conjunction with the exercise and helps with accountability to follow through on the prescription.

 

Barriers to Treating Depression with Exercise

 

The various reviews of literature on exercise for depression (including the meta-analytic reviews), demonstrate positive benefits.  There is now substantial evidence to conclude that exercise is helpful in the treatment of depression. However, moving from research studies (and evidence) to practice, may be somewhat challenging.  The experience of the clinician who treats depression (moderate to major) is that it is often very difficult to activate the individual towards any change in behavior, much less exercising.  By definition, the depressed individual is often not motivated, lacks energy, is apathetic, gives up easily, and is in a general state cognitive, emotional, and physical paralysis. Depression is characterized by low self-worth and confidence, pessimism, and difficulty in problem-solving and making decisions.  The feelings of low self-esteem, helpless and hopelessness add to physical inactivity, social isolation, and anergia.  Given these issues, along with the findings that depressed individuals are less active overall (before and after onset) as compared to those without depression, the task of adding exercise to the treatment regiment is even more daunting. As we all know, even in healthy individuals, beginning and maintaining a regular exercise program is generally not successful. In fact, most gym facilities count on the fact that they can sign up thousand a members for a monthly fee, and only a very small percentage will come regularly, if at all. 

 

Seime and Vickers (2006) at the Mayo Clinic have found that when they attempt to get depressed individuals to exercise, they commonly focus only on the barriers, “leaving them feeling overwhelmed and with little self-efficacy for exercise” (p. 195).  Of course, that is consistent with the negative cognitions of the depressed person (all-or-nothing thinking, minimizing successes, etc.).  To address these problems, the authors implemented an “exercise adherence” program and completed a pilot study.  Depressed patients were enrolled in a worksite fitness center.  One group was also given brief physical activity counseling emphasizing relapse prevention, goal setting, planned activity, identifying and modifying negative thinking, and use of exercise for mood self-management. Patients were interviewed about what they thought were the important elements of the program.  Almost all patients emphasized that the assistance in connecting them with a fitness facility was very important.  Most were intimidated by the thought of it, and likely would not have followed through without very specific and concrete support. In addition the patient desired ongoing personal support for exercise stating that accountability and encouragement were necessary for exercise adherence. 

 

Based on their studies, the authors suggest that an exercise prescription must be individually tailored to the depressed patient.  They suggest asking patients at least the following questions as an initial assessment (See Table 2):

 

 

Table 2. Exercise Assessment Questions

 

 

  • What are your current physical activities?
  • Were you ever more physically active?
  • What did you like about the activity?
  • Did you experience any benefit?
  • What is preventing you from being more physically active?
  • How could you incorporate more physical activity into your life?
  • What would be a realistic first step?  

 

 

Once information is gathered relative to the above, the clinician can help the patient identify resources and a reasonable first step.  Adding activity counseling to your usual treatment methods for depression will require addressing the cognitive barriers one might expect (as discussed above).  Thus, a cognitive behavioral approach for both the depression and exercise implementation works well.  This is similar to what is done to help chronic pain patients gradually increase their activities while managing cognitive distortions that predictably occur (See Evaluation and Treatment of Chronic Pain and Special Issues in Chronic Pain Treatment especially related to designing an exercise program). It is extremely important that the exercise type be at least somewhat appealing to the patient and easily accessible.

 

In my practice working with depression and chronic pain, I find it critical to use a structure approach, based on CBT principles, to successfully integrate exercise into the treatment regimen.  Like any other intervention, patients must use the cognitive restructuring methods to begin and maintain exercising.  In addition to these “internal” coping techniques, behavioral and environmental changes are usually necessary.  If at all possible, I prefer to have patients become involved in some type of structured exercise program.  This might be a class, joining a gym, etc.  The type of program is really dependent on the individual assessment.  I have utilized such programs as the Arthritis Foundation Twinges in the Hinges water exercise program at the YMCA, other community-based exercise programs, yoga classes, Tai Chi, aerobics, and more aggressive exercise recommendations based on the individual case (e.g. depressed athletes who are in need of re-conditioning). 

 

Aside from the structure of the exercise activity, is the accountability to continue (either to someone else or a group).  Although the patient may be accountable to reporting to the clinician about exercise progress, I find it most useful to develop accountability in the patient’s psychosocial environment that will go on long after the formal treatment for depression has concluded.  This accountability might be an “exercise buddy”, family member, structure classes or something similar. On more than one occasion, after discussing the plan with the patient, I have had a family member or friend attend a session or two to develop a joint exercise program.

 

The above describes the best case scenario for getting someone into a regular exercise regimen.  In many cases, the initial intervention may be just having the patient take daily short walks or “anything more than what you are doing now”.  The clinician can then build on this initial beginning.  Providing the patient with the rationale behind the importance of exercise in the treatment of depression (and health) is critical to maintain motivation.

 

I think the biggest pitfall in adding exercise to the treatment of depression is that the clinician does not assign much importance to it.  If one simply suggests, “It would be a good idea to try and get out and take a walk or exercise a little”, then you will likely get very little if any change in physical activity behavior.  This is what commonly occurs in the primary medical care arena.  The physician will simply recommend “exercise more and lose some weight”.  Of course, the follow through is essentially zero.  Your patients will prioritize the component of a multimodal treatment intervention in the same manner that you do whether it be CBT, medications, exercise, or something else.  Any treatment recommendation made in passing (e.g. “try and exercise more”) will be completed “in passing.”     

 

Exercise as a Treatment for Depression: Summary

 

In conclusion, the evidence from prospective cohort studies and RCTs published since 1995 suggests that moderate and high levels of physical activity similarly reduce the odds of developing depression symptoms (and reducing them once they occur) compared to low levels of physical activity exposure, which is nonetheless more protective than inactivity or very low levels of physical activity. The minimal or optimal type or amount of exercise for reducing depression symptoms is not yet known. The following is a summary of what is currently known.  This can be shared with patients to enhance motivation for exercise:

 

Research has demonstrated that depressed patients are less physically fit.

 

Depressed patients treated in primary care setting receive predominately pharmacology intervention with much fewer being referred for adjunctive psychotherapy.   As a result, the majority of these patients are not educated about non-pharmacologic treatment methods for depression including cognitive therapy and exercise.

 

Population-based, prospective cohort studies provide substantial evidence that regular physical activity protects against the onset of depression symptoms and major depressive disorder.

 

A great number of studies suggest that exercise training reduces depressive symptoms in clinical and non-clinical groups. 

 

Based on these and subsequent studies (See the review), it appears that the benefits of exercise for depression can be obtained whether using aerobic or non-aerobic methods.

 

There is a great deal of evidence for the combining of exercise and CBT when a medical condition is involved (e.g. pain, obesity, diabetes, cardiac, hypertension, etc.), but research is limited relative to this combination in the treatment of strictly depression.  However, one might extrapolate similar conclusions.    

 

High-intensity exercise provided superior results compared to lower-intensity exercise. Some studies also indicate that supervised exercise programs yield better results than home-based.

 

While studies support the use of exercise as a treatment for depression, it is rarely prescribed.  If it is prescribed, it is often done in a manner that does NOT insure any type of actual follow through.  Therefore, if you are interested in adding exercise to your treatment regiment for depression, the following general guidelines should include:

 

Discuss the plan with your patient along with the rationale based on the research findings. Providing the patient with resources and concrete information is very important.  There is a lot of information available on the ACSM web site. See also the resources at the end of this course.

 

Before implementing any exercise program recommendation, be sure that the patient has been cleared to engage in increased activity by his or her physician, in writing.  Many people with depression are suffering co-morbid to a medical problem (that you may or may not be aware of).  Medical clearance for the type of exercise program you and your patient develop is of the utmost importance.

 

In conjunction with the patient, design a program and will be enjoyable, easy to implement and well within the physical capabilities of the individual.  You want an initial program that is virtually assured of success (these concepts are also discussed in the Chronic Pain Courses).  Be sure to include the concepts of accountability and encouragement in the program.

 

Be prepared to manage the cognitive distortions that will come with beginning an exercise program in someone who is depressed (e.g. “I only walked once this week and it was much less than I wanted”; “I used to be very athletic and now I can’t do anything”; “I tried to sign up at the gym but everyone there is in such good shape”, etc.).

 

Exercise and Anxiety

 

Anxiety is characterized by apprehensive or worrisome thoughts and is typically accompanied by agitation, feelings of tension, and activation of the autonomic nervous system. A distinction is made between transient anxiety symptoms, termed state anxiety, persistent symptoms, termed trait anxiety, and a group of disabling conditions characterized by excessive, chronic anxiety that are known as anxiety disorders. The anxiety disorders, listed from most to least common, are:

 

 

Table 3. Anxiety Disorders

 

 

Specific phobia — an intense fear of an object, place, or situation that poses little or no actual danger.

 

Social phobia — an overwhelming fear of scrutiny and embarrassment in social situations, leading to avoidance of potentially enjoyable activities.

 

Generalized anxiety disorder — recurrent or persistent excessive worry about everyday, routine life events and activities, lasting at least 6 months.

 

Panic disorder — repeated episodes of intense fear and physical symptoms that strike without warning and without an obvious source, often producing fear of being alone or going into public places (agoraphobia) and persistent fear of an attack.

 

Obsessive-compulsive disorder — repeated, unwanted thoughts or compulsive behaviors that seem impossible to stop, typified by repetitive acts or rituals to relieve anxiety.

 

Post–traumatic stress disorder — a delayed or prolonged response (including flashbacks, dreams, insomnia, hypervigilance) to a stressful event or situation (either short- or long-lasting) that was especially threatening or catastrophic.

 

 

Anxiety disorders are common, affecting more than 16 million people in the United States each year (roughly 4% of women and 2% of men). More than 80 million people in the United States at some point in their lives suffer from an anxiety disorder. Anxiety disorders begin at a median age of 15 years, often persist throughout life and are associated with numerous physical and mental co-morbidities, especially depression. People aged 15 to 24 years experience episodes of anxiety about 40% more often than people aged 25 to 54 years, regardless of race. Although less than 30% of those who suffer from anxiety disorders seek treatment, they strain the health care system because of direct psychiatric and nonpsychiatric treatment costs. Additional indirect costs of anxiety disorders are incurred from reduced work productivity.

 

Physical Activity and the Onset of Anxiety Symptoms

 

The association between anxiety and exercise has received comparatively less attention than that of depression.  The majority of studies have examined the transient psychological outcomes of single exercise sessions. In addition, the clinical diversity of anxiety disorders (ranging from a simple phobic to fully developed generalized anxiety) does not allow generalization from studies address one type of anxiety to those addressing other types.  However, the weight of evidence from a small number of nationally representative and population-based cross-sectional and prospective cohort studies supports that regular physical activity protects against the onset of various anxiety disorders and symptoms.

 

Physical Activity Reduces the Symptoms of Anxiety 

 

Many studies of anxiety and exercise have examined temporary psychological benefits after a single exercise session.  A general finding is that state anxiety is significantly reduced following an exercise session both in individuals with normal or elevated levels of anxiety. The reduction in anxiety is statistically significant within approximately 5 to 15 minutes after the cessation of exercise and remains decreased for about 2 to 4 hours following.  At that time, the anxiety gradually returns to pre-exercise levels. The influence of long term exercise programs for trait anxiety (or other types of anxiety) is less consistent.

 

Overall, as discussed in the various reviews, the results of RCTs conducted with medical patients and healthy adults indicate that participation in physical activity programs reduces anxiety symptoms. Since 1995, at least 46 RCTs involving more than 3,550 people have examined the effects of chronic exercise on anxiety symptoms among inactive adults who were healthy or had a medical condition other than anxiety disorders or disabling central nervous system (CNS) disorders including multiple sclerosis, traumatic head injury, stroke or spinal cord injury. The effect of exercise compared to control conditions in reducing anxiety symptoms was 0.38 standard deviations (SD). Outcomes favored exercise in 84% (67 of 80) of the comparisons with control conditions, and 28% (22 of 80) reached statistical significance. In 6 studies that compared moderate-to-vigorous exercise to a placebo-type condition (usually low intensity exercise such as stretching) the effect of moderate-to-vigorous exercise on reducing anxiety symptoms was 0.19 SD. Exercise effects were favorable in 90% (9 of 10) of the placebo-type comparisons, and 30% reached statistical significance. The average study included about 60 people, but a fourth of the studies had less than 40 participants, too few to detect small but possibly meaningful effects.

 

To gain a fuller understanding of these large meta-analytic study results, it is useful to look at few example studies of using exercise as part of a treatment program for anxiety.  According to Carek et al. (2011), several studies have demonstrated that aerobic exercise may be effective in reducing generalized anxiety, similar to the benefit of CBT.  Exercise has been shown to alleviate anxious feelings.  Exercising at 70% to 90% of maximum heart rate for 20 minutes three times per week has shown a significant reduction in anxiety sensitivity.  Anxiety sensitivity is the tendency to respond fearfully to anxiety-related bodily sensation.  Some research suggests that exercise programs produce physical symptoms that are similar to those produced by anxiety sensitivity (increased heart rate, sweating, rapid breathing, etc.).  As such, each time an individual exercises, he or she is being exposed to physical symptoms similar to those of anxiety sensitivity (a type of desensitization model or internal exposure). This model is consistent with another study in which self-reported fears of anxiety sensations, fears of respiratory and cardiovascular symptoms, publically observable anxiety symptoms, and cognitive dyscontrol decreased following a prescribed exercise program.

 

In a study of patients suffering from moderate to severe panic disorder without agoraphobia, the relative efficacy of regular aerobic exercise, psychopharmacology (clomipramine), and pill placebo over a 10-week period (See Stathopoulou et al, 2006 for a review).  The study suggested that those treated with medication improved more quickly than the exercise group.  However, at 10-weeks, there were no differences between the exercise and medication groups, and both were significantly improved over placebo.

 

Using exercise as an adjunctive treatment for anxiety is not without risk and probably relates to the type of anxiety being treated.  In a few studies, exercise was found to induce acute panic attacks or increase subjective anxiety in patients with panic disorders compared to other individuals (see Strohle, 2009 for review).

 

The Effect of the Type of Exercise on Anxiety

 

Limited cross-sectional, observational evidence suggests that the odds of an anxiety disorder may be reduced by higher weekly frequency of exercise bouts. However, there is an absence of evidence from prospective cohort studies or RCTs that examine whether anxiety symptoms vary according to features of physical activity exposure. As such, unlike the guidelines developed for exercise and depression, little is known about the optimal level or type of exercise to address anxiety.

 

Exercise as a Treatment for Anxiety: Summary

 

As can be seen, much less is known about the effect of exercise on anxiety.  Overall, the large review and meta-analytic study suggest a benefit. However, these conclusions must be tempered by the fact that they are based on group data often including a heterogeneous population of individuals with different types of anxiety disorders.  Certainly, the presentation and treatment of specific phobias, social phobia, generalized anxiety disorder, panic disorder, OCD and PTSD are all very different.  Given the vast differences in these disorders, the decision to add exercise to the treatment regimen must be made on a case by case basis.  Also, once it is decided that exercise will be added to the treatment, the program must be individually tailored. 

 

Physical Activity, Psychological Distress and Well-Being

 

Psychological distress is a risk factor for psychiatric disorders and coronary heart disease, and it is negatively associated with quality of life. Conversely, a feeling of well-being can reduce psychiatric risk and is an important feature of high life quality and health. People frequently experience feelings of distress during the normal course of living and during challenging life events, including chronic medical conditions. Thus, it is important to understand the association between physical activity and feelings of distress or well-being because they bear not only on disease risk but also on overall mental health. Measures in this area are not uniform, but most studies have used a scale that assessed the presence of distress (e.g., combined symptoms of anxiety and depression or perceived stress) or the absence of distress (e.g., well-being or positive mental health). Findings of physical activity studies have not differed when measures of distress or well-being were used, so the following results apply regardless of the direction of odds (i.e. decrease in distress or increase in well-being).

 

Physical Activity and Feelings of Distress or Well-being

 

The available evidence from prospective cohort studies indicates a small-to-moderate association that favors people who are physically active. The association between physical activity and reduced feelings of distress or enhanced well-being among adults was virtually unstudied in large groups of people before 1995. Since then, more than 30 population-based observational studies have been published, including nationally representative samples of more than 175,000 Americans. Most of the studies looked at cross-sectional associations, which indicated that active people on average had more than a 30% lower odds of feeling of distress or 30% higher odds of enhanced well-being than did inactive people. In the national samples of Americans, the odds favored active people by approximately 25%.

 

Thirteen studies of adults in Australia, Canada, Denmark, England, Netherlands, Scotland, Wales, and 3 studies of Americans used a prospective cohort design. In those studies, the average odds of reduced feelings of distress or of enhanced well-being favored active people by about 30% compared with inactive people, without adjustments for risk factors. After adjustment for risk factors, such as age, sex, race, education, social class, occupation, income, smoking, alcohol use, substance abuse, chronic health conditions, disability, marital status, life events, job stress, and social support, the odds still favored active people by nearly 20%. About 80% of the comparisons (58 of 70) favored active adults, but half the results did not reach statistical significance, often because of too small sample sizes. The average number of people for each comparison was approximately 1,300 people, but a fourth of the comparisons had 700 people or less.

 

Type of Exercise and Well-being

 

Population-based studies indicate that participation in either moderate or a high level of physical activity is associated with reduced feelings of distress or enhanced well-being, when compared with inactivity or very low physical activity exposure. The minimal or optimal type or amount of exercise for reducing feelings of distress or enhancing feelings of well-being are not yet known, but it appears that an increase in physical fitness is not required.

 

Physical Activity, Cognitive Function and Dementia

 

Cognition can be conceptualized as processes involved in selecting, manipulating, and storing information derived from experiences and how these processes guide behavior. Cognitive abilities are functional properties of the individual that are not directly observed but are inferred from behavior. Researchers in the disciplines of psychometrics, cognitive psychology, and neuropsychology have developed more than 400 tests designed to assess specific types of mental processing. They range from those designed to evaluate specific processes (e.g., working memory, information-processing speed, inhibition) to those that assess global mental functioning involving multiple processes. Assessment methods include those designed specifically to evaluate the effects of injury and degenerative disease on cognitive function and those designed to evaluate individual differences in healthy individuals. The multidimensionality of cognitive function and the diversity of assessment methods present a special challenge for the interpretation of the evidence about the effect of physical activity and exercise on cognitive function.

 

Physical Activity and Onset of Age-related Decline in Cognitive Function

 

Although the exact biologic basis is unknown, Alzheimer’s disease (AD) is a neurodegenerative disease characterized by the formation of beta-amyloid plaques, neuronal loss in the hippocampus, reduced cholinergic function and cognitive deterioration.  Both environmental and genetic factors are thought to influence onset of the disease. Among one of the most important lifestyle changes associated with AD prevention is exercise (see Deslandes et al., 2009 for a review). Several studies have reported an association between physical activity and reduced incidence of dementia or cognitive deterioration.  According to the large review studies, the weight of the available evidence from prospective cohort studies supports the conclusion that physical activity delays the incidence of dementia and the onset cognitive decline associated with aging.

 

The studies varied considerably in sample size, methods used to assess participant’s physical activity level and mental function, and the duration between baseline and follow-up measurements. In general, most studies with sample sizes greater than 1,000 individuals report that physical activity delays the onset of cognitive decline or dementia. The results of studies conducted with smaller numbers of participants are inconsistent. The lack of agreement among the studies reviewed may be explained, at least in part, in terms of statistical power. An alternative explanation for the inconsistencies among the results of these studies is the confounding influence of cognitive stimulation derived while engaged in physical activities. In studies that report a relation between physical activity and delayed onset of dementia, the effects were detected using both clinical assessments and standardized measures of cognitive function. Further, early-life, mid-life, and current levels of physical activity all appear to postpone symptoms of dementia. Thus, although exercise does not prevent dementia, it may be associated with a delay in its onset, perhaps by maintaining a higher level of cognitive function for physically active adults than less physically active individuals as they age.

 

Physical activity and Reducing Symptoms Associated with Alzheimer’s Disease or Other Dementias 

 

Evidence from RCTs of healthy older adults and people with Alzheimer’s disease or other dementias support that regular participation in physical activity improves aspects of cognitive function or reduces symptoms of dementia.

 

Although individuals with dementia benefit cognitively from participation in exercise training, it is not clear whether physical activity ameliorates symptoms of dementia or simply maintains the level of cognitive function for those who are active. In several experiments, differences in cognitive function and information-processing performance in older adults assigned to physical activity or control conditions was due to the degradation of performance by inactive individuals. Further, although relatively short-term exercise programs demonstrate improvements on older adults’ cognitive function, the durability of the effect remains to be determined.

 

Physical Activity and Sleep

 

Nearly one-third of the adult population in the United States experiences insomnia every year, and each year 50 to 70 million Americans experience some effects on their health from sleep disorders, sleep deprivation, and excessive daytime sleepiness (134). The financial cost is approximately $65 billion, $50 billion of which represents costs to industry from lost productivity. Approximately 70 sleep disorders exist, the most studied of which are insomnia and obstructive sleep apnea. Many neurological disorders are associated with poor sleep, and poor sleep itself can have important health-related outcomes. Only about 5% to 20% of people who suffer sleep disturbances will seek help from a primary care physician, and many will purchase over-the-counter sleep aids.

 

Exercise and the Onset of Insomnia or Other Sleep Problems

 

A small number of observational, population-based studies provide initial evidence supporting a positive association of regular participation in physical activity with lower odds of disrupted or insufficient sleep, including sleep apnea. The weight of the evidence from a small number of RCTs supports the conclusion that regular participation in physical activity has favorable effects on sleep quality and is a useful component of good sleep hygiene.

 

Six RCTs, all published since 1995, show positive and large effects (more than 1 SD) of exercise training on symptoms of poor sleep and self-rated sleep quality. Acute aerobic exercise of varying intensities elicits small to moderate improvements (approximately 4 to 13 minutes) in several features of objectively measured sleep quality, including increases in time spent in slow-wave sleep, total sleep time, and latency for rapid eye movement (REM) sleep, and a decrease in REM sleep among normal sleepers. The effects for total sleep time are larger when the exercise lasts more than an hour but do not vary according to people’s fitness levels or the intensity of the exercise. The effects of a single exercise session on the sleep of people with sleep disorders are not known. The long-term effects of exercise on objective measures of sleep among poor sleepers have not been studied much, and the results of a few RCTs and quasi-experimental studies of nursing home residents or patients with sleep apnea have been mixed.

 

Physical Activity and Other Aspects of Mental Health

 

Physical activity and exercise may have the potential to reduce the onset or progression of central nervous system disorders other than dementia that contribute to disability and mortality risk, such as multiple sclerosis and Parkinson’s disease. They also may reduce the adverse impact of these disorders on quality of life. However, too few prospective cohort studies and RCTs have been conducted to allow conclusions about the protective effects of physical activity for CNS diseases other than Alzheimer’s disease and other dementias.

 

Benefits of physical activity may also extend to other aspects of mental health that are less directly linked to disability and mortality risks but are important contributors to overall quality of life, such as self-esteem and feelings of energy/fatigue. Sufficient evidence exists to encourage more study in these areas, but presently not enough studies are available to draw conclusions about how the effects of physical activity or exercise might differ according to types of people or types and amounts of physical activity.

 

Self-Esteem

 

Enhanced self-esteem has significance for mental health because it conveys a feeling of value or self-worth and it is a generalized indicator of psychological adjustment and health risk. A meta-analysis of about 50, mostly small, RCTs of various types of exercise reported an average increase in self-esteem of about 0.25 SD among adults. Self-esteem is increased among adults when physical fitness is increased. However, because features of physical activity exposure were not associated with self-esteem outcomes in the studies, it is difficult to conclude that fitness influences self-esteem independently of other diverse aspects of the studies’ methods, social contexts, and participant expectations of benefit. Nonetheless, larger gains in self-esteem can be expected for individuals with low initial levels, and for whom physical attributes have a relatively high value as a part of global self-concept.

 

From Theory to Practice: Getting your Patients to Exercise

 

If you read the course carefully, along with the adjunctive materials, you should be firmly convinced that some type of exercise is good for everyone (including therapists!).  In the course, we discussed the importance of physical activity and depression (and other mental health issues), and some ideas about “getting your patients off the couch”.  These are general guidelines that can be applied to any situation in which exercise will be added to a treatment regimen.  In addition, there are a great many resources available to help patients begin and maintain an exercise program (for instance the Physical Activity Guidelines for Americans).

 

The following will focus on practical methods for “getting your patients off the couch”.  For anyone, getting started and continuing an exercise program can be a challenging yet rewarding undertaking. However, the statistics for the general population are not encouraging.  Fifty percent of those who begin an exercise program will drop out within six months. But, the therapist can act as a “behavioral coach” to help increase the chances of your patient getting started and continuing with exercise, long after the therapy has finished. To do this, you can help your patients implement various techniques to improve adherence to an exercise “lifestyle” once it is established. (these work for therapists as well).

 

The following are some general ideas for a process of adding exercise to a psychotherapy intervention.  These have to be flexible depending upon the patient’s situation, etc.

 

Get Medical Clearance, Guidelines and Restrictions 

 

The very first task is to be sure your patient has been seen by his or her physician and given the OK to participate in exercise.  If your patient does not have a physician, then that may be the initial focus of this type of intervention.  As a psychotherapist, you are the “behavioral” expert in terms of adding exercise to your treatment regimen.  Of course, the behavioral aspect of an exercise program is the most important part.   The medical aspect is critical since you may have a wide variety of patients with mental health issues that are at different levels of physical status (and exercise ability).  An athlete who is depressed over a relationship loss and has stopped exercising altogether will be much different than an elderly woman who is depressed and physically inactive. In the first case, your exercise intervention may be getting him back to running 6 miles a day, just to start. In the second case, it may be walking around the block with a neighbor. 

 

Designing the Program

 

Like many other behavioral programs, you can think in terms of who, what when, where, why, and how often (not necessarily in that order). The following are ideas for the general process of designing an exercise program for patients.  There are also resources at the end of the course.

 

Involve the patient (“Who”).  For any psychotherapy or intervention or behavioral program, the patient should be involved in all aspects.  The therapist who simply prescribes “I want you to exercise more if it’s OK with your doctor” is doomed to fail.  This is commonly what a primary care physician will recommend (of course, this is within a 5-10 minute office visit), and it doesn’t work.    Adding exercise to your treatment requires as much focus as any other intervention.  This will include such things as: educating the person about the importance of exercise as part of the treatment, discuss and agree on goals (small steps), determine a starting point, determine how to assess progress, decide how to determine when to proceed to the next “stage”, etc.  The important thing is to get started.  As one of my colleagues says when discussing projects “you can’t create a McDonalds until you make the first hamburger”.

 

The importance of exercise (“Why”). The first part of designing any exercise program from a behavioral perspective is educating your patient about the importance of exercise in general, and as part of your psychotherapy intervention and for general health.  If they don’t believe it has value, they will not do it.  Of course, your patients will take cues from you in terms of assigning importance to the recommendation (e.g. “Do you exercise regularly”, etc.).  In this case, telling them “Do as I say, not as I do” will likely work against the intervention.   If your patient has a particular medical problem (aside from the mental health issue), discussing the benefits for exercise for both (physical and mental) is important. I will often do this with the chronic pain patients I treat.  The exercise will help with both the pain AND the depression.  

 

Determine “where” the exercise will occur. Some people find it more convenient to exercise at home. Others may find they have fewer distractions at an exercise facility. In many cases there may not be an option. For instance, many issues can prevent someone from even have the option to go to a gym (physical status, transportation, cost). All of these must be taken into account in terms of where the exercise will occur.  Help your patient decide (and commit) to a place to exercise.  If the individual chooses to exercise at a gym, the first “homework” assignment is to get a membership.  Be sure and discuss picking one that is nearby since a person is less likely to exercise at a club that is further away.  You might also want to have your patient look at several prior to making a decision.  Be sure the gym has equipment and facilities appropriate to your patient’s needs (have them research it).  If you are recommending the “Twinges in the Hinges” water program done in a pool which is a low level group exercise class and your patient joins the local “Power Lifting Gold’s Gym” there will be problems.

 

Make the exercise fun and convenient (“what”). The “what” aspect of the equation is choosing an exercise that provides the physical needs while also being enjoyable and convenient.  If your patient hates water and running, suggesting swimming laps or jogging is not going to work.  The “what” aspect does not need to be a formal exercise regimen.   It might be a sporting involvement (e.g. tennis, golf, etc.) or something else (a class versus individual).  In building the behavioral plan behind the exercise program, discuss these issues with your patient in detail. You might include questions like, What types of exercise have you enjoyed in the past?; How often did you do this exercise?; Did you generally exercise with a friend or alone?; What made you keep going with the exercise?, etc. 

 

Once the type of exercise is agreed upon, the aspects of just getting started are important.  Any behaviorist will tell you that you want to design a program that is “rigged for success”.  Therefore, the first few workouts should be brief and well within the person’s abilities. In fact, with some patients, I have had them just go to the gym even without exercise, just as a first step.  Once the patient starts exercising, gradually have the patient increase the duration and intensity of the program until the desired level is obtained. Again, you are always working within the bounds of physician recommendations and restrictions.  A method for gradually increasing exercise (exercising to quota) is discussed in the Evaluation and Treatment of Chronic Pain course.

 

“When” to exercise.  Another important aspect of the program is “when” to exercise.  If you simply help your patient design an exercise program and you both agree that it will be done “three times per week”, the actual compliance rate will be low.  It is preferable to have the exercise regimen a regular part of the person’s schedule (e.g. M, W, F at 8 AM before work). 

 

Working out with a partner (another “who”).  It can often be useful to have an “exercise buddy” or to join a class.  When working out with a partner have the patient try to choose someone with a similar fitness level. If the patient is just getting back to exercise, working with an experienced partner will be frustrating and increase the likelihood of discontinuing. Studies have demonstrated individuals are less likely to continue their program if they exercise at higher intensities too soon. Likewise, long workouts are also associated with higher dropout rates.

 

Set realistic goals related to long term lifestyle changes. Help your patient set both behavioral and outcome goals. A behavioral goal might be exercising on weekdays at 7 P.M. for 30 minutes. Examples of outcome goals include losing 10 pounds in 2 months, improving one’s mood, or some other physical goal related to the exercise.  It is important to focus initially on achieving the behavior goals since the patient will have much more control in achieving this type of goal. In fact, the outcome goals may or may not be mentioned or discussed initially, depending upon the situation.  The exercise plan (compliance, barriers, etc.) should be evaluated at every follow-up visit.  The patient will prioritize exercise only to the degree that you do.

 

Enhancing Motivation and Long Term Lifestyle Changes

 

Initially your patient may (or may not) be very motivated to stick to the program. It is not unusual for one’s motivation to wax and wane. To help get your patient through the difficult times, consider the following ideas.  The goal is not only getting your patient to exercise regularly, but also increase the chances that the healthy behavior will continue long after the psychotherapy has concluded.

 

Behavioral contracting. After the initial exercise program has been developed with your patient, write it down (in simple terms).  Some aspects of the program, and compliance and goals, can be posted where they are in view for the patient to see every day (e.g. refrigerator, mirror, date book, etc.). The nature of the contract, how much is shared with others, etc., is unique to the individual patient and situation.

 

Teach strategies for managing problems.  This is just like any other cognitive behavioral intervention.  Anticipate what will occur, predict it, and then develop a plan to manage it.  Tell your patient that if he or she does not feel like working out on a particular day, complete a very short, light workout instead (or some other equivalent substitute). Quite often, after getting ready and warming up, a person will find enough motivation to push through and complete a full workout. If your patient missed a scheduled workout, realize not all is lost. Teach your patient to “Forgive yourself and reevaluate your behavioral plan”. Teach your patient to adjust one’s strategies to prevent future drop outs and recommit to the program. Develop a back-up plan in case of unforeseen circumstances. As your patient progresses, continue to analyze any obstacles to the regular exercise program and implement strategies to overcome these barriers.

 

Perform a variety of exercises and activities. Engaging in exercise can be done in a variety of ways, in addition to the structured approach (not instead of).  Recommend that your patient engage in such utilitarian activities such as walking to the store, walking the dog, or catching up on yard work. Encourage patients to try new physical and exercise activities that they might enjoy. Always help your patient investigate other resources such as a company wellness incentive program, fitness facilities, or corporate sports competitions.

 

Utilize social support. Behaviorists will tell you that accountability works great for behavior change.  Being accountable might include such things as finding an exercise partner, hiring a personal trainer, or exercising in a group setting. A training partner or exercise instructor can provide feedback, assistance, and motivation. Participate in physical activities with a spouse, family, or friends. Encourage patients to be creative with their exercise program.

 

Public commitment.  Another technique that increases the chances of success includes public commitment to the desired behavior change.  Encourage your patients to share their goals with those close to them or others that are likely to ask about progress. Patients can also ask others for support. Have patient explain to others that they have set aside a particular time to exercise to potentially minimize future conflicts or misunderstandings. This will also help those close to the patient understand the importance of the exercise goals and the time that has been set aside. 

 

Monitor progress. In many cases, having your patient record activity and progress in an exercise diary or log can be very valuable. In this technology age, these are available as applications for computers and/or smart phones, etc.

 

Professional guidance. Depending on the patient’s resources, an exercise professional (physical therapist, trainer) can help in terms of designing a program, accountability, monitoring progress, etc. Regular fitness tests can objectively measure the effectiveness of one’s program. A fitness professional can help the patient decide how to monitor progress in a way that is most compatible with the fitness goals.

 

 

Certainly, every idea outlined in this course need not be implemented either immediately or at all.  Be sure to design the behavioral aspects of the exercise program with the full input and commitment of the patient.  Start out slow and choose strategies and ensure initial success. 

 

Conclusions

 

The vast literature over the past several decades has established that exercise is beneficial for mental health. This includes prevention and treatment.  Unfortunately, it is rarely recommended as part of a comprehensive mental health treatment (the focus being primarily on cognitive and pharmacology approaches).  Adding exercise to one’s treatment “toolbox” is straight forward and effective.  The importance of exercise has been summed up nicely by The American College of Sports Medicine in their exercise position paper (Garber et al., 2011, p. 1348):

 

The ACSM recommends a comprehensive program of exercise including cardiorespiratory, resistance, flexibility, and neuromotor exercise of sufficient volume and quality as outlined in this document for apparently healthy adults of all ages. Reducing total time spent in sedentary pursuits and interspersing short bouts of physical activity and standing between periods of sedentary activity should be a goal for all adults, irrespective of their exercise habits. Exercise performed in this manner improves physical and mental health and/or fitness in most persons. However, a program of exercise that does not include all exercise components or achieves less than the recommended volumes (intensity, duration, and frequency) of exercise is likely to have benefit, particularly in habitually inactive persons. The exercise prescription is best adjusted according to individual responses because of the considerable individual variability in the response to a program of exercise. Exercise is beneficial only if a person engages in it. To this end, focusing on individual preferences and enjoyment and incorporating health behavior theory and behavior change strategies into exercise counseling and programs can enhance adoption and short-term maintenance of regular exercise, and these form an essential component of exercise counseling and programs.

 

Resources

 

Baxter, J. (2011). Manage Your Depression Through Exercise: The Motivation You Need to Start and Maintain an Exercise Program. Northbranch, MN: Sunrise River Press.

 

Johnsgard, K. (2004). Conquering Depression and Anxiety through Exercise. Amherst, New York: Prometheus Books.

 

Otto, M. and Smits, J. (2011). Exercise for Mood and Anxiety: Proven Strategies for Overcoming Depression and Enhancing Well-Being. New York: Oxford Press.

 

References

 

Blumenthal et al. (2007). Exercise and pharmacotherapy in the treatment of major depressive disorder.  Psychosomatic Medicine, 69, 587-596.

 

Blumenthal et al. (1999). Effects of exercise training on older patients with major depression. Arc Internal Medicine, 159, 2349-2356.

 

Carek et al. (2011). Exercise for the treatment of depression and anxiety. International Journal of Psychiatry in Medicine, 41, 15-28.

 

Craft, L.L. and Perna, F.M. (2004). The benefits of exercise for the clinically depressed.  Journal of Clinical Psychiatry, 6, 104-111.

 

Deslandes et al. (2009). Exercise and mental health: Many reasons to move. Neuropsychobiology, 59, 191-198.

 

Dimeo et al. (2001). Benefits of aerobic exercise in patients with major depression: a pilot study. British Journal of Sports Medicine, 35, 114-117.

 

Doyne et al. (1987). Running versus weight lifting in the treatment of depression.  Journal of Consulting and Clinical Psychology, 55, 748-754.

 

Dunn et al. (2005). Exercise treatment for depression: efficacy and dose response. American Journal of Preventative Medicine, 28, 1-8.

 

Eakin et al. (2000). Review of primary care-based physical activity intervention studies: Effectiveness and implications for practice and future research. Journal of Family Practice, 49, 158-168.

 

Fremont, J. and Craighead, L.W. (1987). Aerobic exercise and cognitive therapy in the treatment of dysphoric moods. Cognitive Therapy and Research, 11, 241-251.

 

Garber et al. (2011). Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults: Guidance for Prescribing Exercise. Medicine and Science in Sports and Medicine, 1334-1359.

 

Martinsen, E.W. (2008). Physical activity in the prevention and treatment of anxiety and depression. Nord J Psychiatry, 62, 25-29.

 

Martinsen et al. (1989). Physical fitness level in patients with anxiety and depressive disorders. International Journal of Sports Medicine, 10, 58-62.

 

Mather et al. (2002). Effects of exercise on depressive symptoms in older adults with poorly responsive depressive disorder: Randomized controlled trial.  British J. of Psychiatry, 180, 411-415.

 

McNeil et al. (1991). The effect of exercise on depressive symptoms in the moderately elderly. Psychology of Aging, 6, 487-488.

 

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