Evidence-Based Reviews

Exercise prescription: A practical, effective therapy for depression

Current Psychiatry. 2009 June;8(6):39-51

References

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No subjects received medication. Women in the exercise support program were less likely to have high scores on the Edinburgh Postnatal Depression Scale, compared with controls. Women who exercised also reported a greater sense of well-being. Differences between the 2 groups were not statistically significant at 4 weeks post partum but achieved significance at 5 months.¹⁷

Depressive symptoms may exacerbate fatigue in postpartum women.¹⁸ A study of 88 women with postpartum depression showed the benefits of a home-based exercise program on physical and mental fatigue.¹⁹ This finding may be important because fatigue often is associated with treatment-resistant depression and may increase the likelihood of relapse in women with postpartum depression.²⁰

Clinical Point

Aerobic exercise may reduce depressive symptoms in a dose-response relationship

Late-life depression. Exercise can benefit the depressed elderly as well. In a 10-week randomized, controlled trial²¹ of volunteers age ≥60 with major or minor depression or dysthymia, progressive resistance training (PRT) significantly reduced depression, as measured by the Beck Depression Inventory (BDI) and HRSD. PRT also improved quality of life, vitality, social functioning, and emotional well-being when compared with a control group (Box 2).

A dose-response relationship of exercise for treating late-life depression was shown in a blinded, controlled trial²² of 60 community-dwelling, depressed subjects age >60. These patients were randomly assigned to high-intensity PRT, low-intensity PRT, or standard care by a general practitioner (GP). A ≥50% reduction in HRSD score was achieved by:

61% of the high-intensity PRT group
29% of the low-intensity PRT group
21% of the GP care group.

Sleep quality improved in all participants, with the greatest relative change in the high-intensity PRT group.

Exercise vs psychotherapy. The benefits of exercise may be comparable or superior to those of cognitive or group psychotherapy.^23,24 This may be good news for patients such as Mrs. S who lack time or financial resources for regular psychotherapy.

Adjunctive exercise

In depressed patients, exercise may increase the perceived quality of life when combined with medication. This was demonstrated in a randomized, 32-week naturalistic study of 30 women, age 40 to 60, with treatment-resistant MDD.²⁵ The 10 women who received various antidepressants plus physical exercise showed significantly greater long-term improvement in depression symptoms, as measured by the HRSD and Global Assessment of Functioning (GAF) scores, compared with 20 women who received pharmacotherapy alone.²⁶ Study limitations included the absence of a placebo arm, small sample size, and inclusion of subjects with comorbid anxiety disorders.

Group aerobic exercise programs can be an effective and feasible treatment for depression, particularly for older adults. In a controlled trial,²⁷ 156 men and women age >50 with MDD were randomly assigned to 3 groups: a program of aerobic exercise; sertraline, ≤200 mg/d; or exercise plus sertraline. HRSD and BDI scores before and after treatment were the primary outcome measures. Secondary measures included aerobic capacity, life satisfaction, self-esteem, anxiety, and dysfunctional cognitions. After 16 weeks of treatment, similar percentages of patients in each group no longer met DSM-IV-TR criteria for MDD:

60.4% of patients in the exercise-only group
68.8% of patients in the medication-only group
65.5% of patients receiving exercise plus medication.

Depression severity appeared to predict the rate of response to the different treatments. Patients who received medication alone seemed to have the most rapid response to treatment. Patients with less severe depression appeared to respond more quickly to exercise plus medication than those with more severe depression.

Long-term benefits

Because depression is a chronic, relapsing illness, any treatment will be widely accepted only if its benefits are long-term. A study of aerobic exercise in 156 adults age ≥50 with MDD²⁸ found that benefits were sustained for >6 months.

Participants were randomly assigned to 4 months of aerobic exercise; sertraline, ≤200 mg/d; or a combination of exercise and sertraline. Aerobic exercise consisted of 30 minutes of brisk walking and jogging on a treadmill, with training ranges equivalent to 70% to 85% of individuals’ maximum heart rate. Appropriate warm-up and cool-down sessions of 5 to 10 minutes were included.

Depressive symptoms improved significantly from baseline in all 3 groups—as assessed by clinical interview, HRSD, and BDI—and after 4 months a comparable number in each group no longer met diagnostic criteria for MDD. When subjects were reassessed 6 months later, the exercisers had significantly lower relapse rates than those receiving medication (P=.01). Those who continued to exercise also were less likely to meet MDD criteria at the end of the 10-month study.

Box 3

5 ways to help depressed patients start and maintain an exercise program

Ask about physical activity at every visit to gauge motivation to exercise

Discuss benefits of exercise for depression and other ailments, and use motivational interviewing techniques when appropriate

Screen for barriers to an exercise routine, and discuss strategies to overcome barriers

Recommend exercise as a prescription, rather than simply advice, because adherence may be greater

Encourage patients to increase physical activity each day, participate in exercise support groups, and seek support from coworkers, family, and friends