48

E
xercise has a wide range of health
benefits. There is substantial
evidence of the efficacy of regular
physical activity for prevention and
management of diseases such as diabetes,
hypertension, cancer, cardiovascular
disease and osteoporosis [see JCM
2005;4(1):2633]. Associations between
improved mood and exercise have
also been documented, with evidence
in support of the use of exercise in
managing major depressive disorder
(MDD; a diagnostic term used for
clinical depression that does not imply
that the depressive episode is necessarily
severe, e.g. there can be mild MDD).
MDD is a consistently highly prevalent
mental disorder. A 1997 mental health and
well-being profile of over 10,600 Australian
adults observed one-year MDD rates of
3.4% for men and 6.8% for women.
1
The
prevalence of less-severe presentations is
even greater. Over 12% of Australians
are highly distressed at any time, and
another 23% are moderately distressed.
2

Since the lifetime prevalence of MDD
is 1316%
3,4
, the chance of someone
having a depressive disorder at some
point in their life is very high.
By 2020, MDD is predicted to pose
the second-greatest health burden after
cardiovascular disorders, in terms of
quality-adjusted life years.
5
The social cost
of MDD due to loss of productivity, sick
days and treatment amounts to billions
of dollars.
6,7
A consistent research theme
regarding the cost of treating MDD is
that untreated depression yields a greater
socio-economic burden than spending on
prevention and treatment.
7

Remission rates for depression treated
with synthetic antidepressants offer ample
room for improvement, with fewer than
50% of all patients achieving full remission.
8

Poor compliance and significant potential
side-effects are other negative factors of
synthetic antidepressant prescription.
9

With appropriate safeguards, exercise may
provide a relatively safe and effective way
to deal with depression, or may augment
effects of other treatments.
Mechanisms of action
Current evidence on the pathophysiology
of depression supports the monamine
hypothesis, involving serotonin,
norephinephrine and dopamine. Neuro-
endocrinological abnormalities have
Depression
and exercise
With the efficacy of antidepressants under a question
mark, many depressed patients are turning to
commonsense remedies such as exercise.
Increasing activity not only has physical
effects that lift a depressive mood:
it can be fun as well.
li festyle
Complementary Medicine MAY / JUNE 2008 49 MAY / JUNE 2008 Complementary Medicine
Jerome Sarris, BHSc, GradDip(HMed), AdvDip(Nat), AdvDip(Acu), Dip(Nutri), MNHAA, is a
PhD candidate at the School of Medicine, University of Queensland; Prof David J Kavanagh,
PhD, FAPS, is a Clinical Psychologist and holds a research chair at the Institute of Health and
Biomedical Innovation, Queensland University of Technology; Prof Robert Newton, PhD,
is an exercise physiologist and the Foundation Professor in Exercise and Sports Science at
Vario Institute, Edith Cowan University

The Editor thanks Chris Tzar, BSc(HMS), MSc(ExRehab), Accredited Exercise Physiologist
and Lifestyle Clinic Manager, University of NSW, for his peer review of this article
also been documented. Hyperactivity of
HPTA axis and increased serum cortisol
reduces brain-derived neurotrophic
factor, reducing neurogenesis.
10,11
Other
biological factors may include impaired
endogenous opioid function, abnormal
circadian rhythm, changes in GABAergic
and/or glutamatergic transmission, and
cytokine and steroidal alterations.
10,11

Various potentially antidepressant
neurochemical responses are known
to occur as a result of exercise. Animal
models have demonstrated that exercise
increases brain-derived neurotrophic factor,
promoting neurogenesis.
12
Human studies
have documented an increase in circulating
bendorphins after acute exercise,
promoting mood elevation, increased pain
threshold and neurogenesis.
13

Modulation of the HPTA axis also
occurs with physical activity. Exercise can
produce an acute increase in cortisol if the
overload is excessive and/or appropriate
nutritional intake does not accompany the
exercise session. However, long-term effects
of regular exercise may assist in regulating
the HPTA axis and produce a chronic
reduction in cortisol production. Increased
expression of 5HT in the cerebral cortex
of rats has been observed as a result of
exercise and this is theorised to explain
much of the antidepressant effect of
physical activity.
14

Further, certain modes of exercise have
been demonstrated to markedly increase
circulating levels of testosterone in both
men and women, which may also have
a protective effect against depression.
15

In addition, exercise causes the muscles
to bind stress chemicals such as
adrenaline, effectively neutralising their
psychological impact and producing a
more relaxed state of mind.
There are also psychological factors that
may contribute to positive effects of exercise
on depression. Exercise is often a pleasurable
activity, and pleasant activities have long
been known to lift depressive mood.
16

Exercise in groups or sporting teams
provides social interaction that may also be
pleasurable and also provide opportunities
for practical and emotional support.
Further advantages of exercise are
that it avoids attracting social stigma
a significant barrier to treatment
seeking and is highly accessible,
regardless of location.
These features may help to address the
relatively low rate of uptake for depression
treatment in Australia.
2
Regular exercise improves mood
and helps to relieve depression
Exercise increases BDNF,
bendorphins, regulates HPTA
axis and 5HT, decreases cortisol,
increases testosterone and growth
hormone
Higher intensity anabolic and
perhaps aerobic training appear to
have greater antidepressant effects
Exercise programmes should be
tailored to the individuals needs
Depressi on anD exerci se li festyle
49 JANUARY / FEBRUARY 2008 Complementary Medicine 49 MAY / JUNE 2008 Complementary Medicine
Current evidence
Large cross-sectional studies show
associations between greater physical
activity and improved mood and
well-being
17
and several RCTs confirm
its efficacy in managing MDD.
An earlier meta-analysis of 11
treatment-outcome studies of exercise
on the treatment of depression
16

revealed a significant effect in favour
of physical exercise compared with
control conditions (wait list, routine
care, meditation/relaxation or low-level
exercise). A very large average effect size
was obtained (95% CI: 0.921.93),
with all but two studies obtaining better
results from exercise than from control.
However, many of these studies had
significant methodological weaknesses.
17
An example of a recent high-quality
trial is a four-arm RCT, involving 202
adults with diagnosed MDD, that
compared aerobic exercise (supervised or
in the home environment) to sertraline
(Zoloft) and placebo.
18
Supervised exercise
was comparable to sertraline, with 45 per
cent and 47% of participants respectively
achieving remission after four months. The
placebo arm had 31% remission, while
home-based exercise had 40%. However,
the difference between the treatments fell
just short of statistical significance.
A 2006 Cochrane review of exercise in
a child and adolescent population (up to
age 20)
19
found only one study that used
it for treatment of depression. That study
did not find any significantly different
effect from aerobic exercise compared with
no treatment. Five depression-prevention
or general-population studies did obtain
a differential effect from aerobic exercise
or weight training on depressive mood,
but that effect was small (0.66, 95% CI:
1.25 to 0.08) and heterogeneous across
the studies. Overall, the methodological
quality of studies was poor.
In treating postpartum depression,
the limited available evidence supports
physical activity and exercise in
reducing depressive symptoms.
20
Two
Australian pilot studies have evaluated
the antidepressant effect of group
pram walking against control (normal
activity and social support).
20
Significant
differences between groups were
obtained, with the pram walkers having
a substantial reduction on the Edinburgh
Postnatal Depression Scale compared to
control (P<0.01).
A recent systematic review of trials
in older populations
21
found four trials
in people with clinical depression or
dysthymia [Singh, Blumenthal, Mather,
Chou]. Three of these studies [Singh,
Mather, Chou] had a non-exercise
control group, and all found significant
benefits from exercise. The fourth
[Blumenthal] found equivalent effects
to sertraline. All four studies had blind
assessments, and all but one [Chou]
included a follow-up assessment. Results
on community volunteers or hospitalised
patients were less clear, with only five of
nine studies showing significant benefits
from exercise on depressive symptoms.
In summary, the balance of evidence
supports the use of exercise to improve
mood and reduce depressive symptoms,
with stronger effects being seen in
clinical depression. In some trials, the
effect is comparable to that of a synthetic
antidepressant.
What type of exercise: how often
and how hard?
There are two broad categories of
exercise. Aerobic emphasises the
cardiorespiratory system and consists
of continuous movement using large
muscle groups. Examples are cycling,
jogging, and swimming. Anabolic
(resistance training), which emphasises
the neuromuscular system, consists of a
series of sets of exercises, each consisting
of 612 repetitions, that are performed
against resistance. The effects of these
exercise modes on the endocrine and
neural systems varies considerably with
volume of work, intensity of overload and
rest between sets and sessions.
Acute effects of exercise on people with
MDD include an immediate increase in
well-being, vigour and a decrease in tension
compared with people at rest.
22
A small
controlled trial found no significantly
different effects on depression between
aerobic and anabolic exercise.
22
Participants
in both types of exercise showed greater
improvements than a group that waited for
treatment. However, the exercise intensity
level of subjects performing anabolic exercise
was based on 5060% of maximum heart
rate rather than the more usual percentage
of maximum strength. This means that
it is not possible to determine the actual
intensity of the exercise, and so determine
if anabolic was better than aerobic activity.
Other research strongly suggests that
anabolic exercise of high intensity is more
effective than low intensity.
26

In a five-arm RCT
23
involving 80 adults
with mild-to-moderate MDD, participants
were randomised into one of four exercise
groups, and undertook supervised indoor
treadmill and cycling. These either had
energy expenditures of 7kcal/kg/week or
17.5kcal/kg/week group, and exercised
for either three or five days/week. A
control group undertook 1520 minutes
of stretching. A statistically significant
reduction in depression compared with
control was only found for the groups
engaging in high energy expenditure.
Curiously, no additional benefit was
noted in the group that exercised for five
compared with three days/week.
A high-quality Australian study also
demonstrated an exercise intensity effect
in 60 older adults with depression.
24

High-intensity anabolic exercise (80% of
maximum strength) was discovered to be
substantially more effective in reducing
depressive symptoms than low-intensity
training. A reduction of >50% in
depressive symptoms was achieved in 61%
of the higher-intensity group, compared
to 29% low-intensity group, and 21%
of routine GP-care group (P=0.03).
Interestingly, strength gain was directly
associated with a reduction of depressive
symptoms. That is, those patients
who exhibited the greatest strength
improvement from training produced the
li festyle Depressi on anD exerci se
Complementary Medicine MAY / JUNE 2008 50 50
ACSM and AHA Joint Position Statement on exercise to maintain health
For adults <65 years of age:
Moderately intense cardio 30 minutes a day, five days a week OR
Vigorously intense cardio 20 minutes a day, 3 days a week AND
810 strength-training exercises, 812 repetitions of each exercise twice a week.
For adults >65 or adults aged 5064 with chronic conditions:
Moderately intense aerobic exercise 30 minutes a day, five days a week OR
Vigorously intense aerobic exercise 20 minutes a day, 3 days a week AND
810 strength-training exercises, 1015 repetitions of each exercise 23 times
per week
If you are at risk of falling, perform balance exercises AND have a physical
activity plan.
Recommendations for exercise for managing clinical depression
favour anabolic over aerobic exercise, and the intensity needs to
be moderate to high and performed 23 times a week
best improvement in depression scores.
On current evidence, recommendations
for exercise mode and dosage for the
management of clinical depression favour
anabolic over aerobic exercise. The intensity
needs to moderate to high and performed
23 times per week. Aerobic exercise also
appears beneficial, and should be included
as part of an overall physically active
lifestyle. The American College of Sports
Medicine, in partnership with the American
Heart Associate, has just released updated
recommendations for exercise for adults and
older adults [see box, p 50].
Yoga
There is also some evidence in support of
yoga as a mood-enhancing intervention.
A review by Pilkington et al located five
RCTs using various types of yoga to treat
MDD.
25
While the studies reviewed all
concluded positive results, the studies
were poorly reported. It is worthwhile
highlighting that certain types of yoga may
actually have greater antidepressant effect.
In line with previous studies demonstrating
that stretching has a placebo effect,
higher-intensity yoga with emphasis on
mindfulness potentially will have greater
efficacy than low-intensity, low-focus yoga.
Tai chi
Traditional Chinese medicine (TCM)
recognises and promotes the use of exercise
to address depressive conditions. Depression
in Chinese is called yiyu, referring to Yu
syndrome that translates as not flowing,
entangled or clogged.
26
Two primary
patterns of depression are diagnosed in
TCM: stagnation of liver qi (excess pattern)
and deficiency of qi, blood or kidney jing
(deficient pattern).
27

In principle, physical activity and
exercise are regarded to move qi and blood,
so alleviating stagnation, and to tonify
qi (lung and spleen), thereby improving
energy and vigour. Excessive or intensive
activity would however be contraindicated
in patterns of marked deficiency, hence
lighter exercise, such as tai chi, would be
commonly recommended in such cases to
gently build vitality. A small study
28
in an
older group of people with depression or
dysthymia obtained significantly greater
reductions in self-reported depression
compared with a wait-list control. Some
larger-scale trials using tai chi are needed to
clarify its impact on clinical depression.
Exercise prescriptions
Caveats exist regarding exercise prescription
for MDD. Depression may be worsened if
the person is unable to meet expectations,
potentially promoting a sense of failure
and guilt. This may be more likely to
occur in severe MDD, especially where
psychomotor retardation, hypersomnia,
somnilescence, marked fatigue or
anhedonia are present. Patients should
be screened for comorbidities, including
cardiovascular disease or musculoskeletal
conditions, prior to initiating an exercise
regime. In these cases, an appropriate
physiological examination before starting a
program is strongly recommended, and an
appropriate allied health professional, e.g.
exercise physiologist, should be involved in
the design and monitoring of the program.
Patients referred by their GP to accredited
exercise physiologists may claim a Medicare
rebate for up to five sessions per year.
Supervision of the exercise may
heighten adherence and exercise
that is social and highly pleasurable
may have augmented impact. Many
exercise modalities are available and
the option/s should be tailored to suit
the individual, taking into account
the severity of the depression, age,
body type, comorbidities and the
availability of equipment, facilities
and exercise specialists. If exercise is to
provide sustained psychological and
physiological benefits, it needs to be
maintained by being incorporated into
the persons routine and lifestyle.
Depressi on anD exerci se li fEsTYlE
continued on page 62
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62 Complementary Medicine MAY / JUNE 2008
holi sti c casebook post-mi i nsomni a holi sti c casebook
insecurity levels. On questioning,
it appeared that he was becoming
increasingly depressed. He stayed at
home brooding about the future
but was also extremely unmotivated
and had become socially withdrawn.
He was fearful of his financial future
but was not taking any of the steps
necessary to try and find a new job.
Using a mental-health measurement
tool, the DM1-10, he had a score of
30 (the maximum possible) and was
prescribed Zoloft but, after consideration,
he declined this medicine.
The mental-health issues seen
now were in many ways just a more
pronounced version of his usual
anxious depression seen over the years
and, as before, it was complementary
to his poor lifestyle choices.
However, he now seemed at a pivotal
juncture in his life in that he had the
opportunity to act on the wake-up call
and proactively change his life behaviours
and habits. However, his tendency
to mope and slide into a vegetative
depression were concerning. The
normal adjustment phase to his changed
health and circumstances were rapidly
becoming a new baseline state for him
from which positive changes were
unlikely, and continued unemployment
and further mental health issues and
cardiac events would be more likely.
A stress echocardiogram revealed
excellent exercise capacity, with
post-exercise echo indicating mild
ischaemia and hypokinesis in the
postero-lateral area, consistent with the
known circumlex obstruction.
conclusion
A thorough assessment of Victors
active biochemistry risk factors
reveals hyperlipidaemia but no other
significant abnormalities. However,
analysis of his lifestyle risk factors
reveals issues relating to diet, smoking,
stress management, anxiety and
depression, so a health management
plan was organised [see p 60].
Follow-up
It has been almost 12 months since Vera
began using the products mentioned, and
still uses two capsules of the fish oil but
one each of the eye-health supplements.
Her optometrist has seen her again,
and she is also under the care of an
ophthalmologist. Both professionals
are impressed that she has managed to
incorporate a routine of supplements
that is easy to maintain long term. Both
healthcare providers and their patient are
looking forward to a bright future.
References
1 SanGiovanni JP, et al. Arch Opthalmol
2007;125(5):6719.
2 National Eye Institute. AREDS Results. URL
www.nei.nih.gov/amd/background.asp.
3 Mares JA, et al. Am J Clin Nutr
2006;84:110722.
4 Tan JSL, et al. Ophthalmol 2008;115:33441.
5 OConnell ED, et al. Am J Clin Nutr
2008;87(3):71222.
6 Tan JS, et al. Br J Ophthalmol 2008;92:50912.
7 Cohen SY. Bull Soc Belgian Opthalmolog
2006;(301):336.
8 Jellin JM. Natural Medicines Comprehensive
Database. URL www.naturaldatabase.com/.
HoListiC CasEBooK
continued from page 56
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LifEstyLE
continued from page 53