For Depression, Prescribing Exercise Before Medication

Aerobic activity has shown to be an effective treatment for many forms of depression. So why are so many people still on antidepressants?
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Joel Ginsberg was a sophomore at a college in Dallas when the social anxiety he had felt throughout his life morphed into an all-consuming hopelessness. He struggled to get out of bed, and even the simplest tasks felt herculean.

“The world lost its color,” he told me. “Nothing interested me; I didn’t have any motivation. There was a lot of self-doubt.”

He thought getting some exercise might help, but it was hard to motivate himself to go to the campus gym.

“So what I did is break it down into mini-steps,” he said. “I would think about just getting to the gym, rather than going for 30 minutes. Once I was at the gym, I would say, ‘I’m just going to get on the treadmill for five minutes.’”

Eventually, he found himself reading novels for long stretches at a time while pedaling away on a stationary bike. Soon, his gym visits became daily. If he skipped one day, his mood would plummet the next.

“It was kind of like a boost,” he said, recalling how exercise helped him break out of his inertia. “It was a shift in mindset that kind of got me over the hump.”

Depression is the most common mental illness—affecting a staggering 25 percent of Americans—but a growing body of research suggests that one of its best cures is cheap and ubiquitous. In 1999, a randomized controlled trial showed that depressed adults who took part in aerobic exercise improved as much as those treated with Zoloft. A 2006 meta-analysis of 11 studies bolstered those findings and recommended that physicians counsel their depressed patients to try it. A 2011 study took this conclusion even further: It looked at 127 depressed people who hadn’t experienced relief from SSRIs, a common type of antidepressant, and found that exercise led 30 percent of them into remission—a result that was as good as, or better than, drugs alone.

Percent of patients in each condition six months after treatment.
(Psychosomatic Medicine)

Though we don’t know exactly how any antidepressant works, we think exercise combats depression by enhancing endorphins: natural chemicals that act like morphine and other painkillers. There’s also a theory that aerobic activity boosts norepinephrine, a neurotransmitter that plays a role in mood. And like antidepressants, exercise helps the brain grow new neurons.

But this powerful, non-drug treatment hasn’t yet become a mainstream remedy. In a 2009 study, only 40 percent of patients reported being counseled to try exercise at their last physician visit.

Instead, Americans are awash in pills. The use of antidepressants has increased 400 percent between 1988 and 2008. They’re now one of the three most-prescribed categories of drugs, coming in right after painkillers and cholesterol medications.

After 15 years of research on the depression-relieving effects of exercise, why are there still so many people on pills? The answer speaks volumes about our mental-health infrastructure and physician reimbursement system, as well as about how difficult it remains to decipher the nature of depression and what patients want from their doctors.

Jogging as medicine

“I am only a doctor, not a dictator,” insists Madhukar H. Trivedi, a professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas. “I don't tell patients what to do.”

Trivedi is one of the forefathers of the movement to combat melancholy with physical exertion. He’s authored multiple studies on the exercise-depression connection, and workouts are now one of the many weapons in his psychiatric arsenal. But whether any given treatment is right for a particular person is entirely up to that patient, he said.

“I talk about the pros and cons about all the treatment options available—exercise, therapy, and pills,” he said. “If a patient says, ‘I'm not really keen on medication and therapy, I want to use exercise,’ then if it's appropriate, they can try it. But I give them caveats about how they should be monitoring it. I don't say, ‘Go exercise and call me if it doesn't work.’”

Here’s how he goes about this unconventional type of prescription:

First, Trivedi must gently raise the idea of exercise as a treatment option—patients often don’t know to ask. (There are no televised pharmaceutical ads for running, he notes.) He then tells patients about the studies, the amount of exercise that would be required, and the heart rate they’d need to reach. Based on a recent study by Trivedi and others, he recommends three to five sessions per week. Each one should last 45 to 60 minutes, and patients should reach 50 to 85 percent of their maximum heart rates.

He and the patient then blueprint a weekly workout schedule together. Not doing enough sessions, he warns, would be like a diabetic person “using insulin only occasionally.” He encourages patients to use FitBits or other monitoring gadgets to track their progress—and to guilt them off the couch.

Trivedi says this approach rests on three key elements. “One, you have to be very clear with patients that just because exercise has been shown to be efficacious, it doesn't work for everyone. Two, the dose of the treatment is very important; you can't just go for a stroll in the park. And three, there has to be a constant vigilance about the monitoring of symptoms. If the treatment is not working, you need to do something.”

That “something” could be adding antidepressants back into the mix—but only if the workouts have truly failed.

“People will take the disease and treatment lightly,” he said, “if they know Paxil is coming.”

The insurance challenge

When it comes to non-drug remedies for depression, exercise is actually just one of several promising options. Over the past few months, research has shown that other common lifestyle adjustments, like meditating or getting more sleep, might also relieve symptoms. Therapy has been shown to work just as well as SSRIs and other medications. In fact, a major JAMA study a few years ago cast doubt on the effectiveness of antidepressants in general, finding that the drugs don't function any better than placebo pills for people with mild or moderate depression.

The half-dozen psychiatrists I interviewed said they’ve started to incorporate non-drug treatments into their plans for depressed patients. But they said they’re only able to do that because they don’t accept insurance. (One of the doctors works for a college system and only sees students.)

That’s because insurers still largely reimburse psychiatrists, like all other doctors, for each appointment—whatever that appointment may entail—rather than for curing a given patient. It takes less time to write a prescription for Zoloft than it does to tease out a patient’s options for sleeping better and breaking a sweat. Fewer moments spent mapping out jogging routes or sleep schedules means being able to squeeze in more patients for medications each day.

“[Psychiatrists] can probably do four medication-management visits in an hour,” said Chuck Ingoglia, a senior vice president at the National Council for Behavioral Health. If they were doing therapy, they might see one person for 50 minutes.”

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Olga Khazan is a staff writer at The Atlantic, where she covers health.

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