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/

How to energize Your Worplace Wellness Program!

I love this story of a colleague who tried to install physical activities in the workplace with mixed success. She gets extra points for enthusiasm! Exercise is good for your mental health.

“We are in the process of lining up some  very bright interns for the 2012 summer. These interns will provide us with brilliant minds and a strong work ethic - allowing us to rapidly launch more and more walk sites.

In preparation for May, we wanted to liven up the office - make it a fun place for our college/med students. Like Google.

While our Intern Planning Sub-Committee on Recreation (IPC-R) had many great ideas, one in particular stuck out to me - a Zip Line. I insisted it was too dangerous for outside the office, so against the (very strong) wishes of the IPC I placed it indoors.

 For those who have been to our office, I installed this 45 foot, 3/8" line of galvanized steel (14,400 lb braking strength) from our lobby to the absolute rear of the main hallway. Due to the lack of any considerable drop, the IPC became concerned with the ability to build speed (now wonder if they were 'playing' with me?). To prove them wrong, I made the incorrect decision to lube the entire cable with mechanic's grease and 85 packets of K-Y that I "borrowed" from the primary care office next door. This decision would not only create the unsafe speed of 27+ miles per hour (dangerous for indoors), but I'm certain made for some emotional prostate exams over the ensuing week.

For additional atmosphere, I'd lined the hallway with all six of our office ficus trees, therefore creating the illusion that our interns would be zipping across the top of the forest canopy. I'd also turned the thermostat up to 92 degrees and had iPods up and down the corridor streaming jungle sounds. (One of our IT guys was sitting in a room off to the side playing bongo drums)

This combination of executive decisions led the IPC to insist I take a couple of test runs, under their observation.

One was all that was needed.

When I felt we were all set, I smiled at our staff (all of whom appeared present), put on my helmet, and double-clipped onto the Zip Line - asking K. if she would push me. She felt B., a former UT middle linebacker (2004-6) in our labor law division, would be more appropriate.  I don't remember much after that.

What the staff shared with me in the ICU is that I made it over the first three trees fine, but not the fourth. This particular ficus upset my balance, spinning me 180 degrees and hurdling me into multiple glass-framed newspaper articles on the east wall of our main hallway.

Unfortunately, I had lost consciousness at this point and was therefore not aware that I needed to unclip. Despite the obstacles, the grease and K-Y allowed me to maintain my speed right into our executive VP's office, which is where his coat-rack lodged between my 7th and 8th ribs (right side), creating the pneumothorax. The intensity of this jarring did release one of the clips sending me into the double-paned window off the back of his office upside down. When I hit the rear wall, it forced release of the final clip and I came straight down cracking my helmet in the process. Looking on the brighter side, I was already unconscious when this occurred, and again, do not remember a thing.

In short, we are now very excited for our 2012 Intern Class and we're in the process of installing a high-quality ping-pong table to keep them entertained. 

Names have been removed but I had to post it!

Too little exercise, too much TV tied to depression

Peposted at http://darkestcloset.blogspot.com/   Posted at http://www.reuters.com/article/2011/11/14/us-depression-exercise-idUSTRE7AD04I20111114

Sun Nov 13, 2011 9:26pm EST

(Reuters) - Older women who got more exercise and less television time were the least likely to be diagnosed with depression, according to a U.S. study of thousands of women -- with physical activity having the biggest impact.

According to findings published in the American Journal of Epidemiology, researchers found that women who reported exercising the most in recent years were about 20 percent less likely to get depression than those who rarely exercised.

On the other hand, the more hours they spent watching TV each week, the more their risk of depression crept up.

"Higher levels of physical activity were associated with lower depression risk," wrote study author Michel Lucas, from the Harvard School of Public Health in Boston.

More time spent being active might boost self-esteem and women's sense of control, as well as the endorphins in their blood, although the study could not prove directly that watching too much television and avoiding exercise caused depression, she added.

The report included close to 50,000 women who filled out surveys every couple of years as part of the U.S. Nurses' Health Study, and covered the years 1992 to 2006.

Participants recorded the amount of time they spent watching TV each week in 1992, and also answered questions about how often they walked, biked, ran and swam between 1992 and 2000.

On the same questionnaires, women reported any new diagnosis of clinical depression or medication taken to treat depression.

The analysis only included women who did not have depression in 1996. Over the next decade, there were 6,500 new cases of depression.

After the researchers accounted for aspects of health and lifestyle linked to depression, including weight, smoking and a range of diseases, exercising the most -- 90 minutes or more each day -- meant women were 20 percent less likely to be diagnosed with depression than those who exercised 10 minutes or less a day.

Women who watched three hours or more of television a day were 13 percent more likely to be diagnosed with depression than those who hardly ever tuned in, but Lucas said at least part of that link might be due to women replacing time they could be exercising with TV watching.

One alternative explanation the researchers brought up is that women might have been experiencing some symptoms of depression before they were diagnosed, leading them to exercise less. A formal diagnosis could have come later.

"Previous studies have suggested that physical activity is associated with a lower risk of depressive symptoms," said Gillian Mead, who studies geriatric medicine at Edinburgh's Royal Infirmary but was not involved in the study.

"(The finding) adds to the growing body of evidence that physical activity is important to maintain brain health," she added in an email to Reuters Health. SOURCE: bit.ly/sQbWMU

(Reporting from New York by Genevra Pittman at Reuters Health; editing by Elaine Lies and Ron Popeski)

http://www.reuters.com/article/2011/11/14/us-depression-exercise-idUSTRE7AD04I20111114