By Yasmina Nasstasia MAPS, School of Psychology, Professor Amanda Baker MAPS, School of Medicine and Public Health, Professor Robin Callister, School of Biomedical Sciences and Pharmacy, and Dr Sean Halpin, School of Psychology, University of Newcastle

“If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.” Hippocrates

It is now internationally recognised that exercise is good for you. Everything your grandmother said about fresh air and exercise is true. But it wasn’t only your grandmother. Modern humans tend to think they have a monopoly over knowledge, yet the benefits of regular exercise were first noted by Hippocrates, an early Greek physician and philosopher. Over the past two decades, a growing body of research has supported his clinical opinion, confirming the crucial role a physically active lifestyle plays in maintaining and improving physical health (Bonomi & Westerterp, 2011).

There is a roll call of physical benefits associated with exercise. It can help prevent the development of coronary heart disease, stroke, hypertension, osteoporosis, type 2 diabetes, and breast and colon cancer (Bryan & Katzmarzyk, 2011). It has a general anti-inflammatory effect on the body which may reduce the risk of chronic diseases such as arthritis. Exercise seems to have an anti-ageing benefit, and early and midlife exercise can even decrease the risk of mild cognitive impairment in later life (Ahlskog, 2011). But what are the effects of regular exercise on our psychological health and can we really change thoughts and feelings through physical patterns of activity? The jury is back and while there is still much to learn and methodology issues that need to be addressed, the consensus is that exercise can improve psychological health.

Exercise and depression

To date, the mainstay of treatment for major depressive disorder (MDD) consists of antidepressant medication and psychological therapies (Treatment Protocol Project, 2004) with varying levels of treatment success. Given the high cost and prevalence of MDD, the development of efficacious, accessible and cost effective treatments is imperative, and innovative, interdisciplinary treatment approaches are required. Exercise or physical activity prescriptions may offer one such opportunity.

Meta analyses of clinical trials have documented a significant improvement in depression with regular exercise (Ahlskog, 2011). Exercise can be an effective treatment for mild and moderate depression. Research suggests that frequency is important, with daily or near daily exercise most beneficial in reducing depressive symptoms. There also appears to be a balancing act between intensity and duration. Higher intensity activities are easier to fit into a busy lifestyle and require a smaller dose, whereas low intensity exercise needs to be maintained for longer time periods to achieve the same benefits (Bruijin & Rhodes, 2011).

Moreover, there is strong evidence suggesting that people who exercise regularly are less likely to develop depression and this appears to be across the age span (Wipfli, Landers, Nagoshi & Ringenbach, 2011).

Exercise appears to have multiple mechanisms of action, including a behavioural activation component (alters daily routine, providing opportunities to interact with others), improvement in appearance and body image, enhancement of self esteem, and an increase in self efficacy via mastery of mind (setting goals) and body (fitness) challenges. Other research suggests that there are specific biological mechanisms which may help to explain the beneficial effects of exercise on depression. Exercise promotes the secretion of neurotransmitters such as serotonin, and stimulates the secretion of endogenous morphines or ‘endorphins’, producing a state of euphoria (Callaghan, 2004). This finding is especially relevant given that not all clients can tolerate antidepressant medication.

Barriers to prescribing exercise in practice

Despite this growing body of evidence, it appears that recommendations for exercise in clinical practice are not routine (Treatment Protocol Project, 2004). This is unfortunate and may reflect the fact that few psychologists are comfortable or feel skilled in using exercise as therapy. The other barrier may be concerns over treatment compliance. Exercise does require a certain amount of adjustment, tolerance of physical discomfort and strain, and this may explain why only 25 per cent of adults in western societies exercise at the level needed to achieve health benefits (Sime, 2002; Fuchs, Goehner & Seelig, 2011). It also requires setting aside time to exercise, as there is very little call for incidental exercise compared to the way our great grandparents experienced life. The modern trappings of robotics, computers and technology that have liberated us, have also changed the way we engage with the world. Exercise for its own sake must now be vigorously pursued, fighting against the tide of time pressures, passive entertainment, and family and work commitments.

Many of us are aware of the costs that not exercising has on our physical health, and as we become more aware of the cost to our psychological health we begin to understand that exercise, as Hippocrates once observed, is the foundation on which to build optimal health. However, given that the general population struggle to exercise, how do we prescribe exercise to our clients who are also dealing with the effects of depression? The barriers to exercise are important to acknowledge, however, the reality is that compliance with antidepressant medications and psychological treatments can be equally fraught with difficulties (Sime, 2002).

Exercise offers an opportunity to engage in a non-stigmatising activity that may hold appeal for difficult-to-reach client populations (Mead, et al., 2009) and is associated with fewer side effects. Of course, it is necessary that any existing health concerns should be explored and where appropriate, medical clearance obtained prior to commencing exercise. Beyond this, exercise side effects mostly relate to muscular/skeletal injuries which can be minimised via injury prevention information or referral to a physiotherapist or exercise physiologist (Sime, 2002). Psychologists interested in prescribing exercise for depression are encouraged to read the relevant literature and seek consultation where appropriate.

Recommendations for psychologists prescribing exercise

EXERCISE PRESCRIPTION GUIDELINES
  • Regular activity is preferred
  • Higher intensity activities may be easier to fit into a busy day
  • Encourage clients to select activities they’ll enjoy
  • Explore barriers using a motivational interviewing approach
  • Encourage clients to set goals and measure progress
  • Adherence is a challenge, so a key role for psychologists is to promote the benefits and increase likelihood of treatment compliance

There are a number of guiding principles to consider when recommending exercise for depression, as well as potential pitfalls to avoid.

  1. A motivational interviewing approach should be incorporated and the term ‘physical activity’ should be used rather than ‘exercise’. Exercise is a loaded term and some people may have had negative experiences which are important to explore along with any positive experiences associated with exercise. 
  2. The potential physical and psychological benefits and risks should be discussed with the client, remembering to manage expectations as some clients may think that improvement can be achieved through a single exercise session. Any health concerns should be explored and clients should check with their physician before commencing an exercise regime (Sime, 2002). Another cautionary note is that in some cases recommending exercise may be counterproductive, particularly if there are significant barriers to undertaking exercise or other psychological issues. For example, if a client is unable to adhere to the program this may be used as another reason for self criticism, adding to any guilt, remorse or self worth issues already being experienced (Sime, 2002). More traditional therapeutic approaches may be beneficial here.  
  3. When recommending exercise, start with incremental goals that are collaboratively developed and discuss potential barriers and strategies to manage these, including planning for relapse.  
  4. Clients should be encouraged to engage in regular exercise activities sufficient to establish and maintain fitness. While research does not point to any one particular type of activity, the general consensus is that it needs to be moderate to vigorous with a regular routine established. Invite clients to set goals and monitor mood states regularly so that they can see if there is an effect on depression. Research suggests helping clients set achievable goals, as well as measuring exercise progress, are important strategies for assisting people to change behaviour. Another important strategy is establishing or linking in with support networks to reinforce exercise goals (Sime, 2002).  
  5. Progress should be reviewed regularly in therapy, remembering that not everyone will have the same benefit, but clients (and you) won’t know what’s possible until it’s been tried (Sime, 2002).

Happy exercising everybody!

The principal author can be contacted at Yasmina.Nasstasia@newcastle.edu.au

References

  • Ahlskog, E.J. (2011). Does vigorous exercise have a neuroprotective effect in Parkinsons disease? Neurology, 19, 288-294.
  • Bonomi, A.G., & Westerterp, K.R. (2011). Advances in physical activity monitoring and lifestyle interventions in obesity: a review. International Journal of Obesity, advance online publication, 17 May 2011; doi:10.1038/ijo.2011.99.       
  • Bruijin, de, G.J & Rhodes, R.E. (2011). Exploring exercise behavior, intention and habit strength relationships. Scandinavian Journal of Medicine and Science in Sports, 21, 482-491.
  • Bryan, S.N., & Katzmarzyk, P.T. (2011). The association between meeting physical activity guidelines and chronic diseases among Canadian adults. Journal of Physical Activity and Health, 8, 10-17.
  • Callaghan, P. (2004). Exercise: A neglected intervention in mental health care. Journal of Psychiatric and Mental Health Care Nursing, 11, 476-483.
  • Fuchs, R., Goehner, W., & Seelig, H. (2011). Long term effects of a psychological group intervention on physical exercise and health: The MoVo concept. Journal of Physical Activity and Health, 8, 794-803.
  • Mead, G.E., Morley, W., Campbell, P., Greig, C.A., McMurdo, M.E.T., & Lawlor, D.A. (2009). Exercise for depression. Mental health and Physical Activity, 2, 95-96.
  • Sime, W. (2002). Guidelines for clinical application of exercise therapy for mental health case studies. In J.L. Van Raalte & B.W. Brewer (Eds.), Exploring sport and exercise psychology (2nd ed.), (pp.225-251). Washington: APA.
  • Treatment Protocol Project (2004). Management of Mental Disorders (4th ed.). Sydney World Health Organization Collaborating Centre for Evidence in Mental Health Policy.
  • Wipfli, B., Landers, D., Nagoshi, S., & Ringenbach, S. (2011). An examination of serotonin and psychological variables in the relationship between exercise and mental health. Scandinavian Journal of Medicine and Science in Sports, 21, 474-481.