Exercise Can Seriously Improve Your Mental Health: Fact or Fiction
Draft 1
Last year £55 million was spent on anti-depressant drugs in Scotland. The number
of prescriptions for these drugs has risen year on year over a 13 year period. We are
now issuing three times more prescriptions with 3.5 million prescriptions issued in
2005. In Scotland we are using 40% more anti-depressants per head of population
than the rest of the UK1.
This startling increase in the use of anti-depressants is reflected in the growing
number of people across the world requiring treatment for a mental health problem.
Such is the growth that WHO predict that by 2020 depression will create the greatest
burden of disease. Mental health is now a serious public health issue. In Scotland
every third or fourth person seen by their GP has a mental health problem.
The plan for the presentation is to explore with you the:
•
Rise in mental ill health
•
Case for exercise
•
Evidence for prevention
•
Evidence for intervention
•
To consider explanations in regard to:
•
How exercise works
•
The interplay between Mind Brain and Body
•
The way forward
What is causing this global pandemic of mental health problems?
Society is rapidly changing, increasingly we are engaging in sedentary work and
leisure activities, more of us drive cars, domestic chores are eased by clever
appliances and many of us spend more time interacting with computers than with
people. As a society we are not engaging in the same levels of physical activity as
our ancestors. This is also reflected in levels of obesity and other diseases
associated with inactivity. Many of us are now leading a sedentary lifestyle.
Reduced physical activity along with other lifestyle factors such as diet, smoking,
alcohol consumption have been linked to our biggest killers cancer, stroke, coronary
heart disease, diabetes, and obesity It is also been linked to reduced psychological
well being and increased feelings of depression and anxiety2
Definitions: Physical activity is any movement of the body that results in energy
expenditure rising above resting level. Exercise is a subset of PA and is undertaken
to improve health or for leisure time activities including swimming, tennis, football.
For simplicity I will use the term exercise to encompass both PA and exercise.
Is exercise important for mental well being?
The link between a ‘healthy mind and body’ is not new. It has been reiterated
over the centuries. Hippocrates the Greek Philosopher (460-377BC) known as the
founding father of medicine recommended exercise as a treatment for mental illness
and reportedly said ‘walking is mans best medicine’.
Joseph Addison, politician and essayist wrote in the Statesman, 12th July 1711
‘Exercise ferments the humors, casts them into their proper channels, throws off
redundancies, and helps nature in those secret distributions, without which the body
cannot subsist in its vigor, nor the soul act with cheerfulness’.
The physiologist, philosopher and founder of American Psychology William James,
who himself succumbed to bouts of depression, wrote in 1899 ‘Muscular vigor will
always be needed to furnish the background of sanity, serenity and cheerfulness to
life, to give moral elasticity to our disposition to round off the wiry edge of our
fretfulness, and make us good-humored and easy of approach’
All of us will have observed and experienced the pleasure and happiness that being
physically active can bring.
From a very early age children show their pleasure in
movement, reaching sitting, crawling, walking. When my grandson James realised
he could hop on one leg he kept repeating this activity delighted in his prowess. We
have all felt pleasure in one or more of these activities; walking in the park, by the
sea or in the forest, climbing a Munro, playing a sport, dancing, swimming,
gardening, some of us even enjoy domestic and DIY chores.
My interest in the ‘mind body link’ began in 1979 when I took up a post as a
physiotherapist working with people with learning disabilities who had been living in
institutional care since birth. I watched how they used repetitive movements such as
rocking, jumping, swaying, as self stimulation. Over the next 7 years working with my
physiotherapy colleagues with adolescent and adult residents we learnt how to
develop their confidence and self esteem through structured exercise activities. This
included developing skills in balance and strength in the gym, cycling, swimming and
horse riding.
Exercise brought them pleasure, laughter and fun, a sense of
achievement.
In 1986 I moved into Psychiatry and began using exercise as an
adjunct to treatment with people with anxiety and depression. The literature from
exercise psychologists was just beginning to emerge.
I met up with Professor
Nanette Mutrie when she returned from the states, Nanette had undertaken research
with women with depression and we started working together in 1987 looking at the
effects of exercise in the rehabilitation of problem drinkers.
Stuart Biddle and Nanette’s book in 19913 was the first UK textbook on exercise
psychology to pull together the scientific evidence of the benefits of exercise in
relation to mental well being. This included evidence for exercise in the treatment of
depression and anxiety and highlighted the early evidence of exercise in the
treatment of addiction.
Is there sufficient evidence to support the premise that exercise can seriously
improve your mental health?
In 1999 Somerset Health Authority commissioned work in the UK bringing renowned
exercise psychologists, psychiatrists and clinical psychologists together to review the
evidence for exercise and psychological well being. The view of those engaged in
this process, including myself, concluded that there was a convincing literature base
to support the role of exercise as strategies for promoting mental health. These
findings include support for; a link between exercise and decreased depression,
anxiolytic and stress reduction effects of exercise, association of exercise and
positive mood, improvement in cognitive function in fit older adults, positive effects of
exercise on physical self perceptions and body image. The research consensus
statements emerging from this forum4 were disseminated through conferences and
publications bringing the evidence to the attention of GP’s and other healthcare
professionals.
Since this time the literature base has grown providing further
scientific evidence from clinical research for exercise as a treatment intervention.
Evidence for prevention
Ten prospective longitudinal studies that include measures of exercise and
depression at two or more time points have demonstrated a positive association
between exercise and psychological well being5. This research has been carried out
by research teams in the USA, Netherlands and Finland using different populations,
including community dwellers, workers, adults, adolescents and older people. The
findings show that people who are physically active and exercise regularly are less
likely to be diagnosed with depression.
Here is an example of one of these studies undertaken by Camacho and colleagues
in the USA (1991) the results show that in the first 9 years the relative risk (RR) of
developing depression was significantly greater for both men and women who were
low active in 1965 (RR 1.8 for men, 1.7 for women) compared to those who were
high active.
Evidence for intervention
16 Randomised clinical trials6, 40+ experimental studies and three meta-analysis
demonstrate the effectiveness of exercise as an adjunct to treatment of people with
mild to moderate depression. The earliest of these studies was undertaken in 1979
By Greist and colleagues in the USA. They found that running three times a week for
30 – 45 minutes over 10 weeks was as effective as time limited or non time limited
psychotherapy, Martinsen and colleagues in Norway in 1985 were the first to
demonstrate the effectiveness of a 9 week programme of aerobic exercises to reduce
the symptoms of depression in people hospitalised with depression.
More recently researchers at Duke University found that a modest exercise
programme of 16 weeks was as effective as medication in the treatment of people
with major depression. (Blumenthal et al 1999, Babyak et al 2000). 156 people aged
50-77 were randomly allocated to one of three groups.
Medication, Exercise or
combined exercise and medication. At 6 month follow up fewer in the exercise group
had relapsed with depression.
Lawlor and Hopker (2001) in a review of 14 of these randomised controlled studies7
found that exercise reduced the symptoms of depression and that it was as effective
as other treatments such as cognitive therapy. The effect size was large -1.1 (95% CI
-1.5 to -0.6).
However they concluded that the effectiveness of exercise could not
be determined due to the lack of good quality research.
Their conclusions have
since been challenged. A well funded investigation into the effectiveness and costeffectiveness of exercise on prescription for people with depression is being led by
Professor Glyn Lewis at the University of Bristol8 and the team will report their
findings in 2011.
However, the benefits of exercise are not limited to the treatment of depression
and anxiety.
In our edited book9 published in 2003 we highlight the emerging evidence of the
impact of exercise in the treatment of people with mental health problems such as
alcohol and drug addictions and enduring mental health problems of a more serious
nature.
My own work includes a multi-site RCT across Scotland10 using exercise as an
adjunctive therapy in the rehabilitation of people with alcohol problems. 117 problem
drinkers were randomly allocated to one of two groups a three week programme of
aerobic and strength exercise followed by a 12 week home based programme with a
5 month follow up or a control group. Physiotherapists in four sites across Scotland
carried out the exercise programme. Benefits included improvements in fitness and
strength, physical activity levels, physical self perceptions and self worth.
What was interesting was that the participants perceptions of how their
physical fitness and strength had changed were in line with actual changes.
Here we can see changes in aerobic fitness (sub max exercise test Astrand Rhyming
Nomogram) at 1 month, 2 month and sustained at 5 months.
In this slide we can see similar changes in how the study participants viewed their
fitness, as measured by the physical self perception profile (Fox and Corbin 1989).
Similar story for changes in strength
These physical changes and mental awareness of these changes impact on physical
self worth with a significant improvement noted at 1 month and 2 months.
Physical self worth has a direct influence on self esteem
Enhancing self esteem is critical when people are attempting to change behaviour.
For some the exercise programme enabled them to change their lifestyle and get
back to doing activities they used to enjoy, e.g. cycling, hill walking, and for one
teenager boxing. An interesting outcome was that the study participants did not link
the benefits from exercise to their addiction problem.
similar to this one
There were many quotes
“Feeling fitter is great I feel less like drinking but that doesn’t
mean I go to the gym instead of drinking. They are very different things”
Mind Body Link
This led me to consider how we can reinforce the link between the feelings and the
emotions associated with the exercise, e.g. feeling invigorated, elated, to the physical
changes, e.g. increased strength and fitness. Although this is likely to be different
from the feelings and emotions associated with taking alcohol and drugs it has the
potential to counter unwanted cravings. Helping people recognize the way their
behaviour influences their emotions, their physiological response and their
thoughts is important in reinforcing this Mind-Body link. This can be facilitated
by using cognitive behavioural techniques such as keeping a diary which details: the
exercise context e.g a brisk 30 minute walk, a description of the emotion this elicited
e.g. feeling invigorated and some rating of its strength and what thoughts were
elicited during and immediately after the walk.
Michael Ussher, a research clinical psychologist at St Georges in London and I
designed a study with OT’s applying cognitive behavioural techniques within the
exercise programme11. The study with problem drinkers and drug abusers looked at
the impact of a 6 week programme which combined exercise, counselling, discussion
and advice on levels of exercise, goal attainment and integration into the community.
The intervention included structured exercise and lifestyle activity, goal setting and
keeping a diary.
The outcomes of this study reinforced the importance of
establishing the motivation of individuals, setting their individual goals and using a
diary to monitor positive and negative emotions.
Michael and I published a review of exercise as a therapeutic adjunct in the treatment
of alcohol and drug addiction in this book12 (Donaghy and Ussher 2005).
We
conclude that while the research evidence is limited in quality and quantity
the
benefits far outweigh the risks and for some people exercise has enabled them to
change their behaviour to a healthier lifestyle.
There is also tentative evidence on the role of exercise for people with enduring
mental health problems, benefits include alleviating negative symptoms such as
depression, low self esteem and social withdrawal.
Guy Faulkener in Toronto
University has been one of the leading lights in this field.
Ros Johnstone, Dr Kath
Nicol and myself are currently looking at barriers to engaging in exercise for this
group to inform how best to facilitate exercise programmes.
From working and
speaking with people with serious mental illness of a long standing nature we are
aware how the body can change with long term drug use, weight gain, loss of
mobility, rigidity in gait, we need to understand how these changes along with the
effects from the drugs themselves impacts on confidence to begin exercising.
Jenny Roe a PhD student at Herriot Watt University recently completed a very
interesting pilot study with the Be Active Stay Active (BASA) walking group in Alva.
This is a group with excellent user involvement led by the occupational therapist and
physiotherapist for people with enduring mental illness. Jenny met several times with
the group going on different walks looking at the impact of the environment when
walking in different locations, rural, lakeside and forest. The findings suggest that
walking in a group can increase feelings of energetic arousal and control and that the
forest walk created the strongest effect.
In addition to the scientific literature key reports, clinical guidelines and policy
documents promote the use of exercise for mental health13.
The United States
Department of Health and Human Services (1999) and the Department of Health
(2001 and 2004) highlight the links between exercise and mental health promotion.
The National Institute for Clinical Effectiveness (NICE) guidelines for Depression
published in 2004 highlight exercise as an adjunctive treatment for mild and
moderate depression. The Scottish Executive Delivering for Mental Health (2006)
highlights exercise within its self-care management programme, in addition surveys
have been undertaken seeking the opinions of people with mental health problems.
There is sufficient evidence to state that exercise can improve your mental
health. Participation in regular exercise can reduce the risk of common mental
heath disorders. Exercise can be used as a treatment or adjunct to treatment
for common and enduring mental illness and addiction.
Do people with mental health problems want to exercise?
In 2001 a survey by the charity Mind14 found that 83% of people with mental health
problems looked to exercise to lift their mood or to reduce stress with two thirds
indicating that it helped to relieve their depression however 58% did not know that
some GP’s can prescribe exercise. The GP exercise referral schemes introduced in
the late 1990’s allow people with mental health problems to access exercise facilities
in their local community. The commissioned report ‘Up and Running’ Treatment for
Mild and Moderate Depression by the Mental Health Foundation15 in 2005 came out
strongly in favour of advocating exercise as a first line treatment for depression and
led to the production of information sheets on prescribing exercise for GP’s and
posters and leaflets for distribution through GP surgeries. The findings outlined in
the report however, suggest that only 10 of the 200 GP’s (5%) surveyed consider
exercise as one of their 3 most common treatment responses compared to 92% who
considered medication as one of their 3 most common treatment responses for mild
to moderate depression. Of those surveyed only 42% had access to an exercise
referral scheme. Where exercise referral schemes have been used they have been
successful.
How does exercise help in preventing and alleviating mental health problems?
Several explanations have been put forward. The association between exercise,
positive mood and affect can be explained by physiological and psychological
explanations.
The increased blood flow to the brain stimulates the release of naturally occurring
mood enhancing chemicals known as endorphins, these natural opiates are similar to
morphine and have been linked to the ‘runners high’. Studies have demonstrated
their presence in blood samples of people following exercise. This explanation
however remains speculative as we don’t know if endorphins can cross over the
blood brain barrier.
Animal studies have found that chemicals known to be depleted during depression,
norepinephrine, dopamine and serotonin are released during exercise. These
neurotransmitters have been associated with elevating mood. Antidepressant
medication such as Prozac works by boosting these chemicals. This may partially
explain why exercise offers protection to depression and is effective as a treatment
intervention.
Exercise is known to increase levels of brain derived neurotrophic factor (BDNF) this
substance is associated with enhancing mood and helping the brain cells survive
longer this may also be linked to improved cognitive function.
It has also been
suggested that increased levels of Phenylethylamine a known stimulant in the brain
occuring during exercise is linked to the release of dopamine and endorphins acting
as a natural anti-depressant. This has been evidenced by a rise in Phenylacetic acid
found in urine samples following exercise.
Explanations from psychology research suggests links between exercise and
physical self perceptions such as body image, physical self worth and self esteem,
the findings from the Mind survey (2001) supports this explanation with 50% stating
that exercise boosted their self-esteem.
Planning and undertaking exercise allows setting and achieving goals, skill
development, building self-confidence and it may also provide a mechanism for
social support if exercising with others. The anxiety reduction effects of exercise
have been linked to improved cardiovascular fitness reducing reactivity to and
recovery from psychosocial stressors.
Rod Dishman (2006) in a recent paper16 suggests that exercise can influence brain
plasticity and bring about changes by facilitating neurogenerative, neuroadaptive and
neuroprotective processes. He emphasises that the mechanism for this is not well
understood but metabolic and chemical pathways among the brain, spinal cord and
muscles offer plausible testable mechanisms. While I agree with this I would argue
that we have ignored the importance of emotions and feelings and their role in
neuroadaptation.
Like Rod I believe the brain can be changed through experience.
The human
genome (the totality of our chromosomes) cannot account for the entire structure of
the brain but it helps set the circuits in the older part of the brain. This part of the
brain which includes the brain stem, hypothalamus, limbic system and amygdala is
pre-set for survival ensuring we continue breathing, regulating our heartbeat,
balancing our metabolism. Although pre-set these circuits adapt with experience
ensuring that we can adjust to different environments across our lifespan.
From
early childhood we learn about social conventions and ethical rules. These layers of
new facts and experiences shape our behaviour leading to desirable decision making
strategies, increasing our chances of survival.
Studies have shown that we have reward circuits in the brain linked to the limbic
system. Rewarding experiences release dopamine telling the brain ‘to do it again’.
Memories associated with rewarding experiences are laid down in the cerebral cortex
and are triggered by certain cues which stimulate the recurrence of the behaviour.
Thus the brain adapts over time to new experiences that are repeated. The subcortex or old brain keeps us alive and helps us shape and change our behaviour as
and when required. The cerebral cortex enables us to reason, make decisions, build
and store knowledge. Our emotions and feelings are like a river with information
continually flowing to ensure a concerted effort.
The Harvard Mental Health letter January 200717 reports on new research which
highlights how repeated abuse of illicit drugs or alcohol lays down memories that are
difficult to diminish. These memories are triggered by cues associated with drug
taking or drinking increasing risk of relapse in addicts. Changing behaviour requires
new pleasurable experiences to be repeated over time in order to rewire the circuits.
Exercise can play a key role in this rewiring.
How do we define emotions?
Emotions are pre-set automatic responses in our body that can be observed in our
behaviour, such as laughing and crying.
William James wrote that we cannot
describe our emotions without using references about the body. When we describe
love we talk about our heart racing, tingling, arousal. Similarly fear, we describe as
goose bumps, tensing of the muscles clenching of the fist.
Hearing a familiar piece
of music may trigger emotions such as crying or laughing depending on the
memories associated with the music. Feelings can be described as the interpretation
of these changes linking body state – the emotion - to cognition. ‘Feelings let us
monitor the body during an emotional state’. Thinking enables us to interpret the
situation.
Thus the body informs the mind of what is happening as a result of
biological reactions to imminent threats. For example walking home alone you see
something that senses danger. This danger triggers an emotional response in the
body preparing it to fight or flee and at the same time the brain is assessing the risks
and level of danger, as you are deciding what action to take your body is highly
prepared, muscles, nerves, release of adrenaline, you react.
Early pre-set emotions are called primary emotions as we develop we build
secondary emotions these are the ones that are meaningful to us as individuals,
such as associations between love, smells, images, music. Our secondary emotions
refine our emotional responses to things that give us pleasure however they also can
be responsible for associations linked to fears resulting in phobias and anxiety,
negative personal experiences linking to depression. Our secondary emotions allow
us to trigger an emotional response by thinking about a particular pleasant or
unpleasant situation or visualising an event. Our general mood state, happy sad
indifferent reflects our emotions, cognitions, neural circuitry, experience, and the
biochemical changes associated with them.
As we can see feelings are complex biological and sociological structures and there
is a need to understand the context in which they operate and how they impact on
any treatment intervention. We need to understand the links between Mind and Body
in any intervention but particularly where we are trying to change lifestyle behaviour
such as engaging in and maintaining exercise regimens.
In summing up this argument exercise increases the blood flow to the brain.
It
stimulates the circuits in the older part of the brain resulting in physiological
responses, increased heart rate, increased levels of cortisol and adrenaline. Regular
exercise changes these pre-set circuits modifying the response to stress. This in turn
lays down new associations in the cerebral cortex which influences our thoughts,
how we interpret situations, how we interact with our environment and the people
within it.
Through this mechanism of adaptation, regular exercise has the potential
to influence other health behaviours such as alcohol and drug addiction, smoking and
diet.
La Forge (1995)18 has argued that the benefits of exercise and mental health are
likely to be best explained by an integrated theory that takes account of the
biochemical physiological, psychological explanations. I am stressing the importance
of the brain circuitry involved in emotions and feelings.
The mind body link is
important in all of these explanations.
So are we really taking this evidence on board and what can we do to influence
change?
Firstly, GPs need to shift their views about choosing exercise as a treatment option.
Only 5% prescribed exercise as one of their three most common treatments for
depression, compared to 92% who would prescribe anti-depressants.
Why is this?
Perhaps the idea that something as complex as the ‘mind’ can be treated by
something as simple as ‘exercise’ is difficult for GPs, health care professionals and
the public to accept.
Despite scientific advances in our understanding of how the brain works and the
inter-relationship between emotion, behaviour, mental and physical well being we
still seem to be treating and thinking of the mind and body as separate entities.
Why is this?
Descartes error
‘Cogito ergo sum’ ‘I think, therefore I am’
René Descartes the French philosopher imagined thinking as an activity quite
separate from the body he talked about this in his Principles of Philosophy published
in 1644. Descartes considered the mind- the thinking thing (res cogitans) as
separate from the non thinking body with its mechanical parts (res extensa)19.
He goes on to say “this me that is to say the soul by which I am what I am is entirely
distinct from my body” This view was not entirely new as it was a strongly held belief
in Christian faith at that time.
The Cartesian view influenced the development of medicine from the 17th Century
and pervades both practice and research to this day. This has resulted in the
psychological consequences of disease often being disregarded. I consider that it
has stifled our thinking about the impact of behaviour on the mind, such as the
effects from participation in exercise, despite the growth in psychology over the last
century.
What do we need to do?
We need to encourage discussion about the mind body links and how exercise and
the associated changes in the body relating to fitness and strength influence how we
think and feel the Somatopsychic response. Most of us are familiar with the
Psychosomatic response how our thoughts and feelings affect our body. By
understanding these links our knowledge of how exercise can seriously impact on
mental health will become evident.
The public, GPs and health care workers need to be convinced about the mental
health benefits of exercise. We need a high profile person, possibly a celebrity with
personal experience of mental health problems who could champion the cause. We
need to increase the exercise referral scheme. Provide training in cognitive
behavioural techniques for physiotherapists occupational therapists and exercise
specialists to ensure that health professionals and exercise specialists are skilled in
helping people with mental health problems to start exercising, develop their
motivation and keep them exercising.
The Scottish Executive announced in December last year that they will spend an
additional 2.5 million on psychological therapies to reduce the drugs bill20. One
million pounds would seriously increase the number of exercise referral schemes and
provide appropriate training.
Fact - exercise can seriously improve your mental health! Make a start now.
And finally…… “ To love what you do and feel it matters – how could anything be
more fun”
Graham (1986)
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