Prescribing Exercise before Medication

Depression is the most common mental illness—affecting a staggering 25 percent of Americans—but a growing body of research suggests that one of its best cures is cheap and ubiquitous. In 1999, a randomized controlled trial showed that depressed adults who took part in aerobic exercise improved as much as those treated with Zoloft. A 2006 meta-analysis of 11 studies bolstered those findings and recommended that physicians counsel their depressed patients to try it. A 2011 study took this conclusion even further: It looked at 127 depressed people who hadn’t experienced relief from SSRIs, a common type of antidepressant, and found that exercise led 30 percent of them into remission—a result that was as good as, or better than, drugs alone.

Percent of patients in each condition six months after treatment. (Psychosomatic Medicine)

Though we don’t know exactly how any antidepressant works, we think exercise combats depression by enhancing endorphins: natural chemicals that act like morphine and other painkillers. There’s also a theory that aerobic activity boosts norepinephrine, a neurotransmitter that plays a role in mood. And like antidepressants, exercise helps the brain grow new neurons.

But this powerful, non-drug treatment hasn’t yet become a mainstream remedy. In a 2009 study, only 40 percent of patients reported being counseled to try exercise at their last physician visit.

Instead, Americans are awash in pills. The use of antidepressants has increased 400 percent between 1988 and 2008. They’re now one of the three most-prescribed categories of drugs, coming in right after painkillers and cholesterol medications.

After 15 years of research on the depression-relieving effects of exercise, why are there still so many people on pills? The answer speaks volumes about our mental-health infrastructure and physician reimbursement system, as well as about how difficult it remains to decipher the nature of depression and what patients want from their doctors.

Jogging as medicine

“I am only a doctor, not a dictator,” insists Madhukar H. Trivedi, a professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas. “I don't tell patients what to do.”

Trivedi is one of the forefathers of the movement to combat melancholy with physical exertion. He’s authored multiple studies on the exercise-depression connection, and workouts are now one of the many weapons in his psychiatric arsenal. But whether any given treatment is right for a particular person is entirely up to that patient, he said.

“I talk about the pros and cons about all the treatment options available—exercise, therapy, and pills,” he said. “If a patient says, ‘I'm not really keen on medication and therapy, I want to use exercise,’ then if it's appropriate, they can try it. But I give them caveats about how they should be monitoring it. I don't say, ‘Go exercise and call me if it doesn't work.’”

Here’s how he goes about this unconventional type of prescription: “People will take the disease and treatment lightly if they know Paxil is coming.”

First, Trivedi must gently raise the idea of exercise as a treatment option—patients often don’t know to ask. (There are no televised pharmaceutical ads for running, he notes.) He then tells patients about the studies, the amount of exercise that would be required, and the heart rate they’d need to reach. Based on a recent study by Trivedi and others, he recommends three to five sessions per week. Each one should last 45 to 60 minutes, and patients should reach 50 to 85 percent of their maximum heart rates.

He and the patient then blueprint a weekly workout schedule together. Not doing enough sessions, he warns, would be like a diabetic person “using insulin only occasionally.” He encourages patients to use FitBits or other monitoring gadgets to track their progress—and to guilt them off the couch.
Trivedi says this approach rests on three key elements. “One, you have to be very clear with patients that just because exercise has been shown to be efficacious, it doesn't work for everyone. Two, the dose of the treatment is very important; you can't just go for a stroll in the park. And three, there has to be a constant vigilance about the monitoring of symptoms. If the treatment is not working, you need to do something.”

That “something” could be adding antidepressants back into the mix—but only if the workouts have truly failed. “People will take the disease and treatment lightly,” he said, “if they know Paxil is coming.” For more of this article go to
http://www.theatlantic.com/health/archive/2014/03/for-depression-prescribing-exercise-before-medication/284587/