Bruce Bassi
The beneficial effects of exercise on physical health have been well established since the 1950’s (Morris et al., 1953). Since this time, various long-term prospective studies and meta-analyses have demonstrated the advantageous effects of exercise on cardiovascular health (Oguma and Shinoda-Tagawa, 2004), diabetes (Boule et al., 2004), musculoskeletal health (Wolff et al., 1999), and even improved gastrointestinal motility (Kim and Song, 2014).
Why is Exercise Good for Mental Health?
In addition to physical health, there have been meta-analyses of randomized control trials that have found that individuals who exercise have a clinically significant improvement in depression (Stathopoulou et al., 2006; Rethorst et al., 2009), anxiety (Wipfli et al., 2008), low back pain (Steffens et al., 2016), sleep (Kredlow et al., 2015), chronic fatigue (Larun et al., 2016), and falls (El-Khoury et al., 2013; Gillespie et al., 2012; Michael et al., 2010; Sherrington et al., 2011; Sherrington et al., 2008).
Among individuals who exercise regularly, stopping exercise was associated with increased depression, confusion, anger, aggression and fatigue (Antunes, 2016). Providing an exercise routine would therefore reduce the need for pharmacologic intervention for these symptoms, which would improve overall safety of patients and staff.
In one study, among 4305 participants over 60 years of age, exercise programs have actually been shown to decrease the number of injurious falls by nearly 40% (El-Khoury et al., 2013).
In fact, as a result of multiple sources of evidence, the United States Preventative Services Task Force recommended exercise or physical therapy as an intervention to prevent falls in community-dwelling adults age 65 and older who are at increased risk for falls (Moyer, 2012).
As the benefits of exercise have become well documented scientifically, public health organizations such as the U.S. Surgeon General and the Center for Disease Control have developed recommendations of various amounts of minimal physical activity to obtain attain these health benefits (U.S. Department of Health and Human Services, 1996; Centers for Disease Control, 2008).
An effective way to assist individuals to adhere to guidelines is to provide a quantifiable goal, as well as a low cost, convenient method of measuring activity, such as the commercial pedometer (Tudor-Locke, 2009).
After a number of pedometer-based studies demonstrated that a step count of less than 7,500 steps per day represents sedentary behavior, and more than 10,000 steps was consistent with an active lifestyle (Tudor-Locke and Bassett, 2004), the World Health Organization (WHO) in 2010 released global recommendations that one should reach a minimum of 10,000 steps daily (World Health Organization, 2010).
This is a quantitative goal that individuals can achieve through a combination of physical activities, not just recreational exercise alone, emphasizing that a reduction of sedentary lifestyle can be just as important in attaining these benefits.
What Do Studies Say About Physical Exercise to Treat Mental Health?
nThere are numerous studies demonstrating the effectiveness of pedometers in the primary care setting (Richardson et al., 2008), but in the inpatient setting there are relatively fewer outside of the realm of post-transplant, post-operative and post-stroke care (Shaughnessy et al., 2005; Cumming et al., 2008).
However, there is no reason to believe that exercise in the inpatient mental health setting would not garner the same benefits as the outpatient setting.
The reality is that the majority of our mainstay psychiatric treatments, especially those which might theoretically take weeks to take effect, are presumed to continue upon discharge.
Prescriptions and psychotherapy are personalized to the patient, the same way that an exercise regimen contains self-selected individualized goals based on one’s baseline physical fitness. It is this goal-setting and self-monitoring feedback system of data is what makes pedometers so effective (Tudor-Locke et al., 2009; Lyons and Lewis, 2014).
As more and more studies continue to prove its effectiveness, exercise may become another pillar in the mental health treatment paradigm. The goal is not to have exercise replace pharamacotherapy or psychotherapy, but to instead use it as an adjunctive treatment plan, which has been found to have a lower chance of relapse than pharmacotherapy alone (Babyak, et al., 2000).
Of course, one of the challenges would be to develop a habit forming regimen to realize the long term benefits of exercise. One way that this is already addressed is that cognitive behavioral therapy (CBT), which our psychiatric staff provides, supports out-of-session assignments as part of treatment, in the same manner as adherence to pharmacotherapy or maintenance of sobriety is discussed.
Exercise, which is an evidence-based treatment plan, is consistent with CBT models that promote becoming active such as Behavioral Activation and Wellness and Recovery Action Plans (WRAP); these interventions are introduced during individual and group inpatient clinical interventions with individuals as a method of recovery (Dimidjian et al., 2006; Fukui et al., 2011).
Our current methods for addressing physical inactivity need to be improved. When patients on the psychiatric ward are noticeably sedentary and verbal encouragement is ineffective, the staff restrict the patient’s access to the room.
This method is used to increase physical and social activity, but often leads to sedentary behavior in another location outside of the bedroom, which highlights the need for an alternative option to encourage exercise on the ward.
Using a wearable device such as a Fitbit or Apple Watch, which are highly rated commercial pedometers, would enable individuals to quantify their exercise activity in a manner consistent with WHO guidelines, and encourage a culture which emphasizes positive reinforcement (goal setting) rather than negative reinforcement (room restrictions).
One of the advantages to using the commercial pedometer is that it has other valuable features, such as automatic sleep recognition and recording. This addresses an additional flaw in our diagnostic methodology, which is the documentation of patients’ sleep times.
Very often staff cannot determine if a patient is lying in bed awake or asleep. This leads to highly erroneous sleep data recorded in the chart.
Psychiatrists have relied on accurate sleep data as one parameter for monitoring improvement in mania, depression or PTSD symptoms, which is why having accurate data in this regard is important.
Using the watch can monitor sleep time, would be especially helpful for providers. Having more accurate exercise and sleep data would assist providers (psychiatrists, psychotherapists, and nurses) in individualizing patient treatment plans.
Here we have created an article addressing Wearable Devices for Mental Wellness.
How To Develop an Exercise Plan for Your Mental Health?
To develop an individualized exercise plan, fortunately, some authors (Meyer and Broocks, 2000) have already provided guidelines for providers working with patients with psychiatric disorders.
The first step would be to appropriately screen individuals to ensure that they are free of cardiovascular disease, joint disease and other physical limitations. Cardiovascular disease is not, in itself, a contraindication to exercise, but is a sign to proceed with caution.
If there is a prior history of cardiac disease or joint disease, individuals should be medically cleared of these issues, respectively, prior to exercise.
All individuals should be educated on the typical signs and symptoms of myocardial injury, and should be told to inform staff should these occur. The training should be patient-specific, and exercise interventions should be targeted to relevant goals, for example for stress management, or depression management.
To maximize adherence to a treatment regimen and to minimize injury, easier forms of physical activity should be initially targeted. For this reason, we should also consider low impact devices to give individuals other options besides walking.
Staff should be non-judgmental, and supportive of individuals at all levels of intensity. Exercise routines should be encouraged throughout each individual’s hospitalization, to maximize adherence to therapy upon discharge.
In fact, one study has pointed out that passive exercise (such as walking) does not promote self-efficacy in the way that martial arts do, and therefore does not correspond to as much improvement in positive affect or state anxiety (anxiety at the present moment) (Bodin and Martinsen, 2004).
To account for this, staff should be trained to give verbal encouragement and positive reinforcement to individuals who hit their step goal.
Exercise is a helpful distraction, but participants with too many associated ruminations (related to exercise) could show even greater fatigue and consequently exercise even less (Stathopoulou, 2006). Striking the right balance and developing an individualized treatment plan will be important.
When an individual suffers from depression or anxiety, the corresponding action tendencies are passivity and avoidance, respectively (Stathopoulou, 2006).
Exercise would theoretically replace these action tendencies and potentially replace the depression and anxiety with alternate, more positive emotions.
The literature regarding exercise and mental health is promising, and demonstrates that physical activity will eventually become a routine part of our conversations.
Having Fitbit devices will allow both patient and clinician to receive direct, quantitative feedback regarding physical activity and sleep. We believe this would have excellent potential as an adjunct to our current treatments, and provide individuals with a more comprehensive therapeutic plan.
Frequently Asked Questions
What makes an exercise routine an excellent addition to your depression treatment plan?
Exercise is an excellent addition to your depression treatment plan because it can be tailored to your individual needs. It is also natural, low-cost, and has very few drawbacks if done properly. It would also provide structure and routine, reestablishing a sense of control.
How can exercises help depression patients psychologically so they can feel better?
Exercise can help individuals with depression because it leads to increased endorphines, improved sleep, and enhanced self-esteem. Exercise has been found to increase the release of endorphins, which are natural chemicals in the brain that help to relieve pain and improve mood.
Exercise can help to regulate the sleep cycle, which can be disrupted in people with depression. Getting enough sleep is important for overall mental health and can help to reduce symptoms of depression.
Regular exercise can help to improve self-esteem and self-confidence, which can be particularly beneficial for people with depression who may struggle with feelings of worthlessness or low self-esteem.
How can exercises help depression patients socially?
Exercise can help people with depression socially because it provides an opportunity to meet new people. This can be particularly beneficial for people who may feel isolated or lonely.
Going to the gym or participating in group exercise activities can provide a sense of community and belonging. This can be especially important for people who may not have a strong social support network outside of the gym. Participating in group exercise activities can provide an opportunity to learn new skills or techniques from others.
How can exercises help depression patients physically?
Exercise helps people with depression physically because it:
- Reduces inflammation: Depression is associated with chronic inflammation in the body, which can lead to a range of physical health problems. Exercise has been shown to reduce inflammation, which can improve overall physical health.
- Improves Sleep Quality: Depression can disrupt sleep patterns, leading to insomnia or other sleep disorders. Exercise has been shown to improve sleep quality, which can help to reduce symptoms of depression.
- Improves Cardiovascular Health: Exercise can help to improve cardiovascular health by strengthening the heart and reducing the risk of heart disease. This is particularly important for people with depression, who may be at an increased risk of heart disease.
Is it better for them to exercise alone or in a group? Please explain why?
It depends on the individual. You should decide which you enjoy more, and which allows for more sustainable exercise habits. If one is very isolated due to depression, it might be a good idea to overcome this by seeking social support.
Connecting with others is one of the most effective ways to combat loneliness of depression. Reach out to friends, family members, or support groups.
How can they organize exercising groups in their neighborhood or community if they don’t feel motivated to exercise alone?
Inquire at your local gym or YMCA about groups in your neighborhood that meet for group exercise. Your city, county, or religious organization may also have a community gym that is more likely than a commercial gym to have group meetings.
• Any other credible resources (videos, books, organizations, foundations, societies, social media groups, etc) that encourage and help people living with depression to exercise, that you’d recommend for people living with depression?
– Search youtube for home exercises that you can follow
– Search Google locally for nearby gyms
– Make a playlist that you can listen to while exercising
– Here are my tips on how to incorporate an exercise routine: https://www.youtube.com/watch?v=Z_SE9P50CTk
Why do people living with depression find it hard to exercise?
- Lack of Motivation: Depression can sap a person’s energy and motivation, making it hard to find the drive to exercise.
- Negative self-talk: Depressed individuals often experience negative self-talk and feelings of worthlessness, which can lead to a lack of confidence in their ability to exercise.
- Physical Symptoms: Depression can cause physical symptoms such as fatigue, sleep disturbance, and body aches, making it uncomfortable to engage in physical activity.
- Time Constraints: Many individuals living with depression may struggle to find the time to exercise due to work, family, or other responsibilities.
What should people living with depression consider before they start exercising?
- Speak to your physician to make sure you don’t exacerbate any medical problem.
- Develop reasonable, reachable goals with your therapist.
- Start slowly, and be proud of yourself for small gains.
How can people living with depression motivate themselves to exercise daily?
- If you can’t hit your goals, make your goals smaller. For example, if you are struggling to get out to walk, make your goal to just put on your walking shoes one day.
- Remind yourself that even a little bit is better than nothing.
- Don’t think of the walking as a chore that someone told you to do, but find something you intrinsically appreciate about walking – the fresh air, nature, checking out birds, trees, new scenery, or clearing your mind, etc.
- Find a friend who you can walk with.
What are some exercises they can do easily in the bedroom if they don’t feel motivated to step out?
There are a variety of callisthenic videos on YouTube that are completely free. You can start a video and then just follow along. Also, cerebellar exercises for balance are found to help with focus and concentration. You can search for these which are also free, and require no exercise equipment.
What are some exercises they can do easily even if they don’t feel motivated to do them?
Motivation is fickle. It comes and goes in waves, depending on your mood, stress, and other factors going on around you. That’s why you need to find other ways to accomplish your goals when motivation alone is not enough.
One way is to make goals smaller so you feel a sense of achievement; it’s easy to want to keep the ball rolling if you met some small goals already.
Secondly, you want to make it easier to accomplish your goals. If your goal is to do 5 pushups a day, make a reminder at a time of day that you would feel like doing pushups. Clear a space where you could do the pushups.
Lastly, make your exercises fun. Do whatever excites you. Turn it into a game. Do whatever you feel like doing and make a goal to do that consistently.
Are there any calisthenic youtube videos you’d recommend personally?
https://www.youtube.com/watch?v=IeGrTqW5lek
How can the calisthenics exercises help the patient?
Calisthenics can help with strength building, improving flexibility, and promoting cardiovascular health.
When an individual suffers from depression or anxiety, the corresponding action tendencies are passivity and avoidance, respectively (Stathopoulou, 2006).
Exercise would theoretically replace these action tendencies and potentially replace the depression and anxiety with alternate, more positive emotions.
How often should they do it in a day/week/month?
The CDC and ASCM would recommend at least 150 minutes per week of Zone 2 cardio. More on that here: https://revolutionrd.com/zone-2-cardio/
How long should they do the exercise when they start?
It depends on the individual. The main goal should be to start to feel a sense of accomplishment. Therefore when starting off, set an attainable goal and just try to reach that goal, whatever it may be.
Don’t compare yourself to others online; set a goal for yourself only. Once you reach that goal, try to maintain it for at least 4 weeks to make it a habit.
What can they do to make the exercise more effective in fighting the depression?
One study has pointed out that passive exercise (such as walking) does not promote self-efficacy in the way that martial arts do, and therefore does not correspond to as much improvement in mood symptoms (Bodin and Martinsen, 2004).
Therefore to promote gains in self-efficacy with passive exercise, try to give yourself more positive encouragement after achieving your goals.
What precautions should they take while exercising to prevent injuries?
- Speak to your physician to make sure you don’t exacerbate any medical problem such as cardiovascular disease or musculoskeletal issues.
- Develop reasonable, reachable goals of mild to moderate exercise, rather than starting off with intense exercise right away. It’s ok to have some of your initial goals to be stretching and improving flexibility to make sure you feel comfortable with your body before starting exercise.
