Running Head: EXERCISE THERAPY AS A TREATMENT FOR DEPRESSION
Use of Exercise Therapy and Physiotherapy as Treatment for
Major Depression and Other Mental Disorders
Natalia Redyk
Northeastern University
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EXERCISE THERAPY AS A TREATMENT FOR DEPRESSION
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Abstract
Depression is an important and prevalent disease associated with many risks and comorbid
factors. While most common treatments of major depression include SSRIs, exercise is known
to be a positive influence on depressive symptom prevention. This paper explores how exercise
has been found to have positive and/or preventative effects for depression in various populations,
including the geriatric population, which has been especially focused on in many studies. This
paper examines several studies which suggest that exercise can result in positive outcomes for
patients with major depressive symptoms which are comparable or even improved over the
traditional medication treatment. For example, exercise-based therapy has been found to be
more long-lasting than medication treatment lasting the same period of time. Other studies have
found exercise programs to be ineffectual, although the problems result from the implementation
of the program rather than the exercise itself. Research seems to suggest that exercise therapy is
effective and could be used more widely as a treatment for depression instead of or alongside
with more traditional forms of medication treatment. This paper further explores how exercise
therapy or physiotherapy could be introduced to a treatment plan for depression. Some methods
of introducing exercise therapy to depressive individuals and the benefits of doing so for patients
and for health professionals are discussed, and the importance of exploring and developing this
area through further research is established.
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Use of Exercise Therapy and Physiotherapy as Treatment for
Major Depression and Other Mental Disorders
Depression is an increasingly prevalent chronic psychiatric disorder affecting all
segments of U.S. society. Severe depressive symptoms affect at least 5.4% of the population at
any given point, “is associated with significant disability, comorbidity and mortality,” has low
remission rates, and has a lifetime prevalence of 15-20% (Hoffman et al., 2011). The World
Health Organization (WHO) has found depression to be the leading cause of disability
worldwide (Pratt & Brody, 2008). Major depressive disorder is often comorbid with other types
of mental disorders such as anxiety or personality disorders, and generally leads to impairment in
everyday function, decreased quality of life, risk of suicide, and a greatly increased risk of
coronary heart disease (Panagiotakos et al., 2008). Although depression is a treatable illness, less
than 40% of patients with severe depression initiate contact with a health professional to seek out
treatment for their condition (Pratt & Brody, 2008). This low rate of treatment may be due to a
lack of knowledge about the disorder and treatments available, the stigma of mental illness, lack
of insurance coverage, or general disbelief in the efficacy of treatment. Depression is thus
considered a major health problem and one which the health professional sphere would benefit
from a more thorough understanding of the condition and available treatments. Currently, the
most common treatment for depression is antidepressant medications. However, these are
accompanied with potentially adverse and dangerous side effects which other effective forms of
treatment, such as psychotherapy or exercise therapy, are not associated with. This paper seeks to
explore the effectiveness of exercise therapy in treating depression as compared to
psychopharmaceuticals and the benefits and methods of incorporating exercise therapy into a
treatment plan for depression.
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Most Common Treatments of Depression
The current most common treatments of depression include antidepressant medications
such as SSRIs and SNRIs, cognitive behavioral therapy, and electroconvulsive therapy.
Alternative treatments such as diet and exercise programs are more uncommon and as of now
there has been little research in the area. Major depression has been found to be inversely
correlated with lowered levels of B12 in women and folate in men, which suggests a possible link
between diet and depression (Sanchez-Villegas, Henriquez, Bes-Rastrollo & Doreste, 2006).
However, little else is conclusively known about diet and depression. Although antidepressants
are the most widely used method of treatment for depression, various studies have compared the
efficacy of psychopharmaceuticals to alternative methods such as psychotherapy or exercise
programs, several of which will be highlighted later in this paper.
While antidepressants are the most common treatment, they are also associated with a
wide variety of adverse side effects. Studies investigating the potential and serious side effects of
usage of antidepressants are yet to be completed, and little is known about their safety,
particularly with long-term use. Cary Coupland’s study protocol for a longitudinal cohort study
of the adverse effects of depression medications in adults outlines study methods which would
help to fill in this gap of knowledge and also summarizes the research available. Coupland’s
paper summarizes the results of studies done so far on the adverse effects of antidepressants,
which include increased risks of suicide, myocardial infarction, stroke, fracture, and
gastrointestinal bleeding (Coupland et al., 2013). Limitations to these results do include that
trials have been short-term and often specific only to one type of antidepressants, so while these
studies are not conclusive, they do highlight the dangers of medication treatment being widely
used while so little is still yet known about their long-term effects. Coupland also summarizes
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her earlier study of the safety and risks of antidepressants in individuals aged 65 years and older,
which found that that the adverse effects of selective serotonin reuptake inhibitors (SSRIs) were
comparable to the less “safe” tricyclic antidepressants (TCAs), and sometimes even more
harmful. SSRIs were associated with higher risk of falls and hyponatraemia, and the group of
other antidepressants was associated higher all-cause mortality, attempted suicide/self-harm ,
stroke, fracture, and epilepsy/seizures (Coupland et al., 2011). Antidepressants also include risks
of lethal overdose or development of serotonin syndrome, and they have also been associated
with sexual dysfunction, cognitive impairment, apathy, and sleep disturbances. There are many
implications of these results. The risks of antidepressant medication should be considered when
prescribing treatment; more comprehensive research on antidepressant risks such as Coupland’s
study protocol should be conducted; and alternative treatment methods such as exercise therapy
should be evaluated on their efficacy and safety as compared to pharmaceuticals.
Known Benefits of Exercise
Exercise has many known benefits for mental health. A moderate level of exercise having
positive effects on mood, self esteem, and anxiety levels which last for several hours (Raglin,
1990). Exercise also leads to generally improved health outcomes, which has the potential to
reduce the comorbidity and mortality risks of major depressive disorder. The combined
physiological and psychological effects of exercise build a good case for exploring the benefits
of exercise for depressive patients, which a moderate number of studies have done with various
segments of the population. Exercise is one of the less utilized methods of treatment of
depression, although general levels of exercise have been inversely correlated with major
depression. Exercise is increasing in importance for a healthy daily life and has been found to be
comparable to psychotherapy in improving and maintaining mental health. One of the studies
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linking exercise and diminished depression includes a survey-based study of older adults with
depressive symptoms, which found that physical activity is a protective factor for depression in
the geriatric population. The study used a pedometer to accurately achieve and objective
measurement of the level of exercise of over 800 patients 60 years and older. The article further
recommends the encouragement of physical exercise in older adults, positing that there is a
correlation between physical exercise and improved mental outcomes as well as physiological
outcomes (Lee et al., 2014). There have been multiple studies which compare the long-term
efficacy of exercise to that of antidepressant medications for older adults (Blumenthal et al,
1999). Higher intensity exercise has also been found as an effective treatment for depressive
patients with subacute and chronic stroke in a study conducted by physiotherapists (Eng and
Rieme, 2014). In each of these populations, depressive patients have benefited from exercise as a
cotreatment. The question this paper is further seeking to explore is in what methods has
physiotherapy or exercise therapy been evaluated as an effective treatment for depression and
how it has been found to be comparable to other, more common methods of treatment.
Efficacy of Physiotherapy as a General Depression Treatment
There exists a baseline level of studies utilizing physiotherapy as a treatment of
depression, often discussing them as comparable to antidepressant medications. Perhaps the most
comprehensive of the studies available is the SMILE study, a longitudinal study of over 200 men
and women adult volunteers with major depressive disorder (Babyak et al., 2000) . Individuals
were treated with either aerobic exercise therapy (home based or supervised), setraline (an SSRI
medication), a combination of the two, or a placebo. The patients were evaluated at baseline,
after 4 months of treatment, and 150 of the volunteers were evaluated 6 months after their
treatment. In the short-term, all three groups exhibited improvement on a significant level and
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comparable rates of remission of around 40-45%. This was an improvement over placebo
treatment, although the positive placebo response was a remarkably high rate of around 30%,
showing that the patient’s expectations and the structure of the program itself may have a
significant effect on the efficacy of treatment. However, although all groups exhibited significant
improvement after 4 months, the group with exercise therapy exemplified significantly lower
levels of relapse than those with medication 6 months after the treatment programs ended. The
study further showed that self-motivated exercise after the therapy ended further improved
positive outcome rates (Babyak et al., 2000). The findings of the SMILE study lead to a solid
conclusion that exercise therapy has significant therapeutic benefit for patients with major
depressive disorder, especially over an extended period of time; the results of the study suggest
that is at the very least comparable to the effectiveness of medication treatments, if not more
effective in the long term.
There also exist studies which have less conclusive results about the effectiveness of
exercise therapy programs, which may contradict the positive results found by other studies. The
OPERA study comprises of an evaluation of a whole exercise home program intervention for
depression in older care home residents. It evaluated the impact of twice-weekly,
physiotherapist-led exercise classes provided for residents in 78 different care homes in the UK,
and ultimately found that the program had no effect. However, there are a variety of factors
which could contribute to this result. Overall attendance rates were low, and there were wide
variations in data depending on the care home. Staff prioritized safety over encouraging
exercise, most exercise groups only did seated exercises, and few residents actually participated
in the sessions, and even fewer of those who were depressed (Ellard et al., 2014). Thus, this
study only shows that incorporating exercise as a form of treatment may be more successful
EXERCISE THERAPY AS A TREATMENT FOR DEPRESSION
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using different methods and certainly would be more successful among a different population.
Group exercise as a treatment may not be the best solution for frail and weak elderly individuals,
but the study neither promotes nor discounts its efficacy in general. The study did not have a
consistent baseline or achieve a high enough level of resident participation to determine whether
or not exercise could have helped the depressive residents. Perhaps a more individually guided,
one-on-one exercise program, similar to therapy in a clinic with a physiotherapist, would be
more effective, especially if it was given as a part of weekly medical treatment. Even with frail
and/or reluctant geriatric patients, individuals could complete a consistently high level of
physical exercise while still staying within their safety boundaries. A study evaluating this type
of physiotherapy programs may find different types of results than the OPERA study.
Although the OPERA study’s limitations keep it from having a conclusive stance on the
efficacy or lack thereof of exercise treatment, there are many other factors which may play in to
whether or not exercise therapy should be pursued as a treatment for depression. The positive
results of exercise therapy do not have lasting effects after treatment has been discontinued;
however, this is no different than the effects of medication therapy. There is a minimal danger of
“overdosing” in home-based exercise and overexerting one’s self, resulting in injuries; however,
this is much less dangerous and less common than an overdose or dependence on
pharmaceuticals. In general, evidence suggests that exercise therapy has less associated risks and
just as much effectiveness as psychopharmaceuticals in treating depression, although there is a
need for more research in order to form a more conclusive opinion.
Conclusions and Future Study
There seems to be enough evidence to show that the health care system could benefit
from utilizing exercise as form of treatment for mental illness, specifically major depression
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disorder (MDD). More links between physical exercise therapy and increased health outcomes
should be established via research studies, and specifically as knowledge of the benefits of
exercise continues to grow, which types of exercises are most effective for mental health
improvement. Studies could also be conducted comparing at-home exercise treatment programs,
group treatment programs, one-on-one exercise programs, and combinations of the three in order
to determine their efficacy in patients with MDD. The efficacy of exercise therapy of different
populations could also begin to be developed, as well as further physiological research into how
exercise affects the brain, and specifically which areas of the brain therapeutic exercise helps to
enrich and develop.
The question remains of what comprises the best way to build an exercise curriculum into
mental health or depression treatment. The role of a PT (and of any health professional) as a
therapist is apparent in their care for the patient as a whole and their commitment to improving
as many aspects of the patient’s quality of life as possible. However, the modus operandi of
physiotherapists generally consist of taking a specific or localized physical issue – such as a
patellar strain, cerebrovascular stroke symptoms, or a hip replacement surgery – and working
along with the patient in a controlled environment in order to improve symptoms or restore as
much function as possible. Depression, as a mental illness usually only treated by
psychotherapists or psychiatrists, is not a condition commonly treated by physical or exercise
therapists. Unless physiotherapist care begins to extend to improving mental health symptoms, a
whole new kind of health professional may be necessary for this form patient care. However,
when symptoms of depression are present with other comorbid factors such as chronic pain
(which accompanies many conditions under a physiotherapist’s scope of care such as rheumatoid
arthritis or lumbar back pain), a physiotherapist can and should address the depression as well as
EXERCISE THERAPY AS A TREATMENT FOR DEPRESSION
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the physical injury. Another method of introducing exercise care is by encouraging
psychotherapists or psychiatrists to converse with a patient about being referred to a physical
therapist instead of prescribing antidepressant medication. Altering sources of treatment from
medication-based to therapy-based practices could reduce the strain on the health system at the
same time as reducing risk factors. Available research suggests that exercise is just as or more
effective than the currently more common form of treatment (medications), and more research
about the relative costs and benefits of the two would help health professionals to make the
decision whether to pursue exercise therapy as a treatment for depression, and perhaps even
other mental health disorders. The physical therapy profession and the health system as a whole
has room to benefit from this expansion of medical boundaries, as well as the patients suffering
from major depressive symptoms who may be reluctant to undergo medication-based treatment
and would benefit from the more individualized, personal, human interaction-based aspects of an
exercise therapy program. Thus, salient further research into the therapeutic effects of exercise
would lead to improved health outcomes and increased benefits to all individuals involved.
Reflective note: I believe that it could use even further revision, but this piece could and should
definitely belong in a professional portfolio of my work. Depression is an incredibly important
health factor which I am very invested in learning more about, and I believe that this paper’s
summary and evaluation of the existing studies about depression and how they may apply in a
clinical physiotherapy setting applies both to my major/future career and potential directions for
developments of the health system as a whole.
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References
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