Ms. H, age 26, is being evaluated for moderate to severe depressive symptoms, including oversleeping and overeating. She has had difficulty adhering to medication in the past and is ambivalent about taking antidepressants. She takes a passive approach to managing her depression, preferring to “wait for it to pass.”
Her psychiatrist prescribes fluoxetine, 20 mg in the morning, and recommends that Ms. H change her coping strategies from napping and snacking to increased physical activity. She encourages Ms. H to think about what activities interest her and to set exercise goals.
Ms. H says she has considered buying exercise equipment (an elliptical machine) and increasing her walking outside. She sets a goal to walk 20 minutes most days and to spend 10 to 15 minutes using the elliptical machine while watching television.
Physical activity’s mental health benefits are less well-known than its well-documented medical benefits—reduced risk of heart disease, hypertension, and diabetes; weight control; bone mass preservation; better sleep, and improved cholesterol levels.1 By encouraging exercise, you can improve patients’ mood, well-being, and quality of life, independent of medication and psychotherapy. In this article, we:
- explore the relationship between physical activity and mental health
- compare exercise with medication and psychotherapies for easing depression
- discuss counseling strategies shown to be effective in helping sedentary patients become more physically active.
Why physical activity may improve mental health
| Psychological theories |
|Source: References 10 and 11|
Mental benefits of exercise
Adults who exercise regularly report lower levels of depressive and anxiety disorders than the overall U.S. population.2 As a therapeutic intervention, exercise has been studied primarily in depressed individuals, although some data also support its efficacy in:
- reducing anxiety symptoms in panic disorder3
- reducing disruptive behavior in developmentally disabled patients4
- alleviating chronic fatigue symptoms5
- improving body esteem in patients with body image disturbance6
- increasing function in chronic pain7
- reducing urges to smoke and improving smoking abstinence among nicotine-dependent individuals.8
Why exercise helps. Mechanisms that would explain exercise’s positive effect on mood are not well understood.9 Physiologic and psychological hypotheses have been suggested (Table 1),10,11 and researchers are attempting to elucidate them by using animal models.13
Case report: Feeling more energetic
At follow-up 6 weeks later, Ms. H. reported a substantial reduction in depressive symptoms. She noted increased energy, improved sleep, decreased overeating, higher self-esteem, and greater confidence in her ability to manage her depression.
Exercising also helped structure her day. She noticed that on days she did not exercise she was more likely to take a nap, miss her medication, or feel pessimistic about her depression.
Exercise as an antidepressant
Exercise vs psychotherapy. Exercise has been shown to be more effective at reducing depressive symptoms than no treatment, occupational therapy, cognitive therapy, health seminars, routine care, or meditation. Interventions used in these meta-analyses ranged from nonaerobic exercise training several times a week to 1 hour of supervised running 4 times a week.12 Literature reviews also have concluded that exercise training compares favorably with individual or group psychotherapy and with cognitive therapy for treating depression.7
Exercise vs medication. Exercise training has also been compared with drug therapy in treating depression.
In a randomized, controlled trial, 156 men and women over age 50 with major depression received exercise training, sertraline, or exercise plus sertraline. Subjects in the exercise groups completed 40 minutes of aerobic exercise (biking or brisk walking/ jogging) 3 times a week. Subjects treated with sertraline received 50 to 200 mg/d, depending on response.
After 16 weeks, all three groups were significantly improved, with no clinically or statistically significant differences in depressive symptoms, as measured with the Hamilton Rating Scale for Depression (HRSD) and Beck Depression Inventory.13
In a follow-up study 6 months later,14 the exercise group had significantly lower rates of relapse (defined as HRSD scores >15 and meeting diagnostic criteria) than did the medication group. Combining exercise with medication did not provide an added benefit in preventing relapse.
Exercise as monotherapy. Some studies have investigated using exercise instead of medication and psychotherapy. Many of these trials, however, were limited by methodologic weaknesses such as nonrandomized samples or lack of appropriate control groups.12