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Exercise Gains Momentum as Psychiatric Treatment

NancyA.Melville

Nov16,2012

SANDIEGO,CaliforniaThebenefitsofexerciseinnearlyeveryaspectofphysicalhealtharewellknown,but evidenceinrecentyearssuggestsauniqueeffectonsomepsychiatricdisorders,promptingmentalhealthclinicians torethinktreatmentstrategiesandtoconsiderthepossibilityofexercisenotjustintherapybutastherapy. "Aboveandbeyondthestandardbenefitsofexerciseinhealthylivingandgeneralwellbeing,thereisstrongevidence demonstratingtheabilityofexercisetoinfacttreatmentalillnessandhavesignificantbenefitsonaneurotrophic, neurobiologicbasis,"DouglasNoordsy,MD,tolddelegatesattendingPsychCongress2012:USPsychiatricand MentalHealthCongress. Someofthestrongestevidenceisseenindepression,wherepsychiatricbenefitsfromexercisehavebeenshownin somecasestomatchthoseachievedwithpharmacologicinterventionsandtopersisttopreventremissioninthelong term. Dr.NoordsyreferencedastudyfromresearchersatDukeUniversityinwhich156patientswithmajordepressive disorder(MDD)wererandomlyassignedeithertoaerobicexercise,sertralinetherapy(50mgto200mg),orbothfor4 months. Thedifferenceinremissionratesintheexerciseandselectiveserotoninreuptakeinhibitor(SSRI)groupsafter4 monthswerenotsignificant60%and69%,respectively,butata10monthfollowup,theexercisegroupshoweda significantlylowerrelapserate(P=.01)(PsychosomMed200062:633638). "Thepatientswhowereindependentlyexercisingontheirownafterthetreatmentperiodhadhalftheoddsformeeting thedepressioncriteria6monthslatercomparedtopatientswhodidn'texerciseafterthe4monthstudy,"saidDr. Noordsy,anassociateprofessoranddirectorofpsychosisservicesattheGeiselSchoolofMedicineatDartmouth College,inHanover,NewHampshire. Asimilarstudyfromthesamegroupofresearchers10yearslaterinalargersampleinvolving202patientsassigned tosupervisedexercise,sertralinetherapy(50mgto200mg)orplaceboshowedremissionratesof46%at4months and66%atthe16monthfollowupacrossbothtreatmentgroups,withnosignificantgreaterimprovementwithSSRIs comparedwithexerciseinpredictingMDDremissionat1year(PsychosomMed2011FebMar73:12733epub 2010Dec10). Otherstudieshaveshownequallyimpressiveresultsinexerciseforavarietyofpopulations,includingpregnant womenwithdepression,whohaveahighinterestinavoidingmedications,peoplewithHIV,andevenpatientswith heartfailure,whoshowednotonlyasignificantreductionindepressionrelatedtoexercisebutalsoreducedmortality (AmJCardiol2011107:6468). Anxiety Theevidenceinrelationtoanxiety,althoughnotasstrong,stillsuggestsabenefit,andtherigorsofacardiovascular workoutseemparticularlysuitedtoaddressingthephysiologiceffectsassociatedwithanxiety,Dr.Noordsysaid. "Weknowthatwithanxiety,theheartrategoesup,youstartbreathingfast,anditkindofsnowballswithmore anxiety,andthatcantriggerapanicattack,"heexplained. "Sooneoftheimportantpositiveeffectsofphysicalexerciseisitallowspeopletobecomeconditionedtohaving theirheartrateandrespiratoryrateincreasewhenthey'renotassociatedwithanxiety,therebyaddressingthe
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triggers." Evidenceissomewhatlackingintheareaofbipolardisorder,butpatientsoftenhavesymptomssimilarenoughto depressiontosuggestabenefit,Dr.Noordsysaid. "TheevidenceondepressioninbipolardisorderisstrongenoughthatIcertainlyfeelcomfortableintalkingabout exerciseaspartof[bipolarpatients']management." Intermsofmoreseriouspsychoticdisorderssuchasschizophrenia,evidenceislimitedonbenefitsofexercisefor thecoresymptomsofpsychosisorcognition.However,severalstudieshaveshownimprovementincomorbidities andmetabolicissuesrelatedtoantipsychoticsthatsuchpatientscommonlyface. Onestudyofajogginginterventionamong80inpatientswithchronicschizophrenia,inwhich40patientsjoggedfor 40minutes3timesaweek,depression,anxiety,phobia,andobsessivecompulsivebehaviorsdeclinedsignificantly comparedwith40inpatientcontrolparticipantswhowereinactiveandshowednoimprovement. DementiaPrevention Theevidenceonthebenefitsofexerciseincognitivefunctiondisorders,suchasdementiaandAlzheimer'sdisease, ismuchmoreextensive,withasmanyas8strongstudiesondementiaaloneinthelast3yearsshowing improvementswithactivitiessuchaswalkingandstrengthtrainingonmemoryandexecutivefunction. Dr.Noordsynotedoneparticularlyremarkablestudyinwhichresearcherscomparedpatientswithandwithoutthe ApoEgene,whichislinkedstronglytolateonsetAlzheimer'sdisease. Inthestudy,patientswhowereApoEnegativeshowedsimilarlylowmeancorticalbindingpotential,relatedtoplaque buildupinthebrain,regardlessofwhethertheyexercisedornot. ButalthoughApoEpositiveindividuals(n=39)hadvaluesthatweresubstantiallyhigher,theApoEpositivepatients whoexercised(n=13)hadvaluessimilartothosewhodidnotcarrythegene(ArchNeurol201269:636643). "YoucouldlookattheseresultsandrightfullysayphysicalexerciseneutralizesyourriskfordevelopingAlzheimer's diseaseifyou'reApoEpositive,"Dr.Noordsysaid. HowtoGetPatientsMoving Perhapsthebiggestcaveatwithallmentalhealthconditionsishowtomotivatepatientswhoarestrugglingwith psychiatricdisorderstoexercise. Dr.Noordsyofferedsomekeysuggestions: Startwithanassessment:"Istartwithanassessmentoflifetimehistoryofactivityandcurrentactivityinmy baselineassessmenttemplate,"Dr.Noordsysaid."Ieducatethepatientonthepotentialeffectsofexercise ontheirdisorderandhowitfitsonthemenuofothertreatmentoptions." Makeclearrecommendations:"Thereisalotofevidenceinareassuchassmokingcessationandinthe addictionliteratureshowingthatasubstantialsubsetofpeoplewillrespondtoveryclearrecommendations," hesaid. Offermotivationaltools:Abehavioralplanner,forinstance,thatallowsforgoalsetting,orconnectingapatient withanexercisegroupcanbehelpful. Considerthepatient'scurrentactivitycapacityinrecommendingaregimen:"Thegeneralamountofexercise
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believedtoresultinabenefitisabout30to60minutesperday,between3and7daysperweek."Some studieshaveshownstrengthtrainingtobeasbeneficialasaerobicactivity.Forthelatter,Dr.Noordsy suggestedthatoneeasymethodoftenusedindeterminingmaximumheartrate,ingeneral,forpeoplewithout heartdiseaseorotherconditionsistosimplysubtracttheiragefrom220. Helpthepatientfindanactivitythatworksbestforthem,ratherthanrecommendinganythingspecific,Dr. Noordsysuggested."Havethepatientchoosetheactivitythatisrightforthem." Helpguidethepatienttoeducationalresources,suchasinformationsourcesorbooks."ThebookI'veused themostwithpatientsisJohnRatey'sSpark:TheRevolutionaryNewScienceofExerciseandtheBrain,"Dr. Noordsyrecommended."Thebookisveryscientificandaccessibletoalayaudience,"hesaid. Importantly,discussingtheroleofexerciseinthecontextofhumanevolutionmightbeamoreeffectiveapproach withpatientsthanthestandardrecommendationtogetsomeexercise. "Insteadof'thisissomethingyououghttobedoing,'wemightinsteadsay,'thisissomethinghumansaredesigned todo,andwhenwedon'tdoit,ourbodiesandbrainsfallapart'." Anotherimportantcomponentinhelpingpatientsbenefitfromexerciseissimplytoimproveawarenessamong clinicians,Dr.Noordsyadded. "Weseeevidenceonthebenefitsofexerciseforpsychiatricconditionscomingtogether,andthereisaneedto increaseawarenessofthisamongcliniciansaswellasreinforcetheresearchcommunitytobetakingamorecareful lookatphysicalexercise,"hesaid. "Thismaynothaveasmuchofanindustrialbackingassomeoftheotherinterventionsweuse,butIthinkit'squite exciting." PsychCongress2012:USPsychiatricandMentalHealthCongress.PresentedNovember9,2012.

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Citethisarticle:ExerciseGainsMomentumasPsychiatricTreatment.Medscape.Nov16,2012.

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