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Out Of the Prozac Bottle and Onto the Treadmill: Exercise and Depression

Miss Hoover: “You see class, my lyme disease turned out to be [spells it on the board] psychosomatic.”

Ralph Wiggum: “Does that mean you were crazy?”

Student #2: “No, that means she was faking it.”

Miss Hoover: “No actually, it was a little bit of both.”

-The Simpsons, “Lisa’s Substitute”

Depression and depressive symptoms are common problems in 21st century society. Maybe it’s the global warming, maybe it’s the additives in the Twinkies, maybe it’s the electromagnetic vibrations of our Sony Discmans frying the happy-making part of our brains, but judging from the numbers of people who at some point or another have been on a downer, we are a culture of bummers. This situation is particularly acute in many populations, especially where there are compounding factors such as oppression and social marginalization (I’m sure all you readers of Trans-Health can think of ways in which society has been less than nice to you).

Exercise and DepressionAside from the many elements of social oppression and predisposing physiological factors, the technological good life may also be harshing our buzz. Inactivity, chemical-laden food, stress due to the economic caprice of the so-called free market or idiotic decisions of old white men in suits, and sporadic self-care are increasingly linked to mental health problems. And maybe we’ll also find that extended time spent under fluorescent light is dooming us all to an eventual freakout, or perhaps that’s just the way I feel every time I step into a Wal-Mart.

In any case, the point is that depression, whatever its origins, is something that many of us deal with in our daily lives. One great medical advance is the recognition of depression as a phenomenon which is fundamentally physiological, but which can have complex psychological/social/emotional causes and effects. Of course they still try to medicate the hell out of it, but at least we’ve moved beyond the notion that people suffering from depression should just lighten up. There are many attendant problems with using medication as a treatment for depression, including the lack of awareness of possible underlying conditions (such as negative social stigma), interactions with other drugs that trans people may be taking, and the side effects of the drugs themselves. Compliance with drug regimes is quite poor, and up to about half of people prescribed antidepressant drugs just quit taking them in the first few weeks.(Lawlor, 2002)

Although there is still much that is not known about the role of exercise in a treatment program for depression, and although many of the studies on depression and exercise are of questionable quality, it seems clear from the bulk, or aggregate, of research that exercise has a significant long-term effect in helping to treat depression and depressive symptoms. More importantly, compared to antidepressant medication, there are no negative effects of exercise, and many unexpected benefits. Indeed, exercise may ameliorate many of the types of side effects produced by antidepressants, such as appetite and sleep disruption. It’s all good.

What Kind of Exercise?

First, let me point out that in our sedentary North American culture, people often associate physical exercise with something that you go to a gym to do. Physical exercise is sort of like a chore, you go somewhere else to do it, and it’s generally done with some kind of thing, like a treadmill. So when you see that physical exercise is a good treatment for depression, you may think, “Crap, it’s going to depress me even more if I have to deal with that.” Au contraire, mon frêre, time to expand your mind. Physical exercise could be something formally organized, perhaps a class that you attend at a gym, or it might be more along the lines of physical activity, such as walking the dog, throwing around a Frisbee, mucking about in the garden, or shaking your booty to whatever music you consider bootyshaking. My god, it might even be fun!

However, the clinical evidence does seem to show that some kind of exercise, or activity, plan is crucial to the success of exercise as a treatment. If exercise makes you feel better after doing it, there’s a good chance you didn’t feel all that great starting out. You need to do it even when you didn’t feel like a bouncy Richard Simmons at the beginning. Even the most cheerful of us often find it hard to find time or energy to exercise. Incorporating exercise into one’s schedule usually takes planning and some forethought. Having a workout partner or joining a class often helps, for both moral support and the little extra motivation of having to meet someone. Scheduling the workout, if possible, at the time of day when you feel best can also make a difference. Don’t delude yourself that a 5:30 a.m. run is going to happen if you’re a night owl. Don’t set yourself up for failure. It’ll just compound your negative self-perception. Build on where you know you can succeed.

The research doesn’t seem to show a preference for the type of exercise. Aerobic exercise, such as riding a bike, walking, or running, is the most commonly used exercise modality, simply because it’s easiest for researchers to supervise and teach. Non-aerobic exercise such as weight training is used less frequently, but also seems to show good results. Based on my experience with training clients, I would recommend a program which combines both cardio and weight training. The strength increases and skill development from weight training will combine with the general effects of fitness to produce positive results. Improved insulin sensitivity from building muscle can assist in managing appetite disruptions which are common to depression, and the physical re-shaping of the body, especially for FTMs, can also have positive effects on self-perception. MTF and FTM readers may wish to search the Trans-Health fitness archives for a weight training program that best suits their needs.

Also in my experience, if one is able to manage a relatively higher intensity of cardiovascular exercise then they should do so. Walking feels pleasant to do, but it doesn’t measure up to the endorphin rush of more intense forms of cardio such as hill or stair runs, wind sprints, sprint cycling, or boxing. If you can do so, try incorporating a bit of interval training into your program where you alternate brief bursts of high intensity work with periods of lower intensity work. However, it is important to emphasize that this is not a requirement. There is a chance that people who aren’t big on intense exercise in general aren’t likely to feel better if they push themselves. Other people may take time to work up to a level of fitness where they feel confident and good about working at a higher level. Experiment and see what you enjoy and feel good doing. Don’t use someone else’s ideal workout as a model for yours.

If you think it might be your type of thing (or even if you don’t— otherwise pacifist people are often surprised by how much they enjoy this!), may I also recommend a martial art such as boxing. It’s a great stress reliever, a challenging cardio and strength-endurance workout, and a fun learning experience. It’s hard to feel tense after spending time beating the snot out of a heavy bag. More mellow types may also enjoy yoga, and the mind-body awareness it gives, but personally it’s never chilled me out. I prefer the more active types of stress release such as the high intensity stuff mentioned above.

The main thing is to experiment with the wide variety of physical activities available, find a few that you like, then most importantly, do them regularly and consistently. Plan them into your schedule, and make them a part of your routine. Personally I think of it as not unlike a daily dose of medication or vitamins; it’s something I need regularly to feel good.

How Much Exercise?

One study found that adherence to exercise could predict the ongoing success of treatment. People who were able to stick to a regular program had better results, and in addition, the time spent exercising correlated to the levels of depressive symptoms. More regular exercise equaled fewer symptoms. This study also noted that some of the positive effects of exercise might be due to the social environment of exercising, which is another good reason to bring a friend. (Babyak et al 2000)

Beyond this hypothesis that more exercise (within reasonable limits) is better, it is not clear, however, just how much exercise you need to improve. Given the sedentary nature of the population, probably anything is better than nothing. Likely, people would see the best results from daily activity, which could be something as simple as a 15-minute walk. At minimum, people should probably be active and exercising 3-4 days per week, for at least 20 minutes per session. Greater frequency is probably better than longer duration. In other words, a daily 15-minute exercise session is likely more effective than a couple of hours done only twice weekly.

For the average person, compliance is a problem with exercise; for a person suffering from depression, it’s probably worse. If possible, start an exercise program when you are not in an acute episode, but rather are feeling relatively better and able to cope. Exercise probably won’t help you get out of bed when you’re on a downer, but it might help keep you out of there in the first place, or make your stay there a shorter one.

How to Measure Results

This is a tricky area, and one reason why clinical studies of exercise and depression remain somewhat problematic. First, mood is usually self-reported. Scientists haven’t yet developed a thingy that they can hook up to your brain and observe how you’re feeling. Clinical subjects have to tell the eggheads how they’re feeling, and then the scientists will probably try and quantify this often-non-quantifiable observation. Depending on which scale of measurement is used, studies show different results. The choice of subject population may skew results. Studies rarely include a long term followup.

Second, the choice of how to represent stress or a triggering negative stimulus is interesting. Let’s say you want to study the effects of exercise on alleviating snake phobia. It would be unethical, to say the least, to make your lab rats run on a treadmill while you dangle enraged rattlers in front of their face. The best a researcher can do is provide the subject with things that they think will inspire the stress response, such as a math test. That might provide some clues, but let’s face it, a few calculus problems on a computer is hardly equivalent to a family Thanksgiving dinner for real-world stress levels, even if the scientists don’t give you a calculator. Additionally, there are both acute and long-term effects from a stimulus. This might be the difference between the urge to strangle your creepy Uncle Zeke when he calls you by the wrong name, and the need to spend months lying on your shrink’s couch. By the way, one study on males used losing a motor task to a female as a stressor. Either those researchers seriously lacked a gender consciousness or they were amazingly aware of it; I can’t decide. (Anshel 1996) Physical responses to stress are not always equivalent to psychological responses to stress, though the two certainly intersect. Thus, whether you have a lower resting heart rate while performing physical work doesn’t necessarily mean you’ll also have this lower heart rate while facing old Zeke over the mashed potatoes, although it might mean that if you’re in better shape, you’ll recover faster from the heart rate spike.

Nevertheless, based on the available evidence, we can probably conclude without too much doubt that exercise does improve people’s experiences of depressive symptoms, and mental health in general. This may happen rapidly, within a workout session, and/or it may take longer, perhaps a period of several weeks. Improvement appears to be consistent over time; the longer you stick to it, the better you’re likely to get. In addition to improvements to mood and overall outlook, progress can also be measured in terms of resilience to future crises. So, not only are you likely to feel better after a workout, consistent training may make you better at responding to challenges and problems in the future.

Exercise also appears to help in the treatment of problems related to depression, such as anxiety, as well as the physical manifestation of depression-associated conditions, such as fibromyalgia, chronic fatigue, and panic attacks.

The bottom line is this. While more research on the causes and treatments for depression needs to be done, exercise is still a good choice. Whatever your management program for depression, whether it includes medication, behavioural modification, psychotherapy, or woowoo crystals, exercise should be part of it. There are so many benefits to exercise and so few drawbacks! Many types of exercise are free: go out and walk/run around the block, dance to the radio, run up the stairs of your apartment building, play catch with your favourite child. Other types require only a nominal fee, such as joining a local YMCA or purchasing a secondhand bicycle. Whatever you choose, it should be viewed as therapy and prevention, and should be given an important place in your life. In a world where many of us feel that our bodies are not under our control, exercise can help us feel more productively in control and less alienated from our physical selves. Sometimes, all that stands between us and mutiny by our neurotransmitters is 20 minutes on the Stairmaster. If only other things in life were this simple, cheap, and good for us!

Selected Bibliography

Anshel, M.H. “Effect of Chronic Aerobic Exercise and Progressive Relaxation on Motor Performance and Affect Following Acute Stress”. Behavioral Medicine 21: 186-196 (1996).

Babyak M et al. “Exercise Treatment for Major Depression: Maintenance of Therapeutic Benefit at 10 Months”. Psychosomatic Medicine 62(5):633-8 (September-October 2000).

Brosse AL, Sheets ES, Lett HS, Blumenthal JA. “Exercise and the Treatment of Clinical Depression in Adults: Recent Findings and Future Directions”. Sports Medicine 32(12):741-60 (2002).

Dunn, Andrea L., et al. “The DOSE Study: A Clinical Trial to Examine Efficacy and Dose Response of Exercise as Treatment for Depression”. Controlled Clinical Trials 23(5): 584-603 (October 2002).

Dunn AL, Trivedi MH, O’Neal HA. “Physical Activity Dose-Response Effects on Outcomes of Depression and Anxiety”. Medicine and Science in Sports and Exercise 33(6 Suppl):S587-97 (June 2001).

Fox KR. “The Influence of Physical Activity on Mental Well-Being”. Public Health and Nutrition. 2(3A):411-8 (September 1999).

Lawlor, Debbie A. and Stephen W. Hopker. “The Effectiveness of Exercise as an Intervention in the Management of Depression: Systematic Review and Meta-Regression Analysis of Randomised Controlled Trials”. British Medical Journal 322: 1-8 (March 31, 2002).

Mather AS et al. “Effects of Exercise on Depressive Symptoms in Older Adults with Poorly Responsive Depressive Disorder: A Randomised Controlled Trial”. British Journal of Psychiatry 180: 411-415 (May 2002).

Moore KA, Blumenthal JA. “Exercise Training as an Alternative Treatment for Depression Among Older Adults”. Altern Ther Health Med. 4(1): 48-56 (January 1998).

Paluska SA, Schwenk TL. “Physical Activity and Mental Health: Current Concepts”. Sports Medicine 29(3):167-80 (March 2000).

Salmon, Peter. “Effects of Physical Exercise on Anxiety, Depression, and Sensitivity to Stress: A Unifying Theory.” Clinical Psychology Review 21(1): 33-61 (February 2001).

Singh NA, Clements KM, Singh MA. “The Efficacy of Exercise as a Long-term Antidepressant in Elderly Subjects: A Randomized, Controlled Trial”. J Gerontol A Biol Sci Med Sci. 56(8):M497-504 (August 2001).

3 thoughts on “Out Of the Prozac Bottle and Onto the Treadmill: Exercise and Depression”

  1. I can attest to the absolute fact that exercise is just as good, if not better, for controlling the symptoms of depression and anxiety than medication.

    I had a panic attack out of the blue about 15 years ago. I thought I was having a heart attack. I thought I was going to die. All I could really think about was my four year-old daughter and what her life was going to be like without me in it. Would she remember me?

    I got to the hospital, and I was pushed to the front of the line because of my symptoms. They gave me a battery of tests. When I got to the stress test, it got interesting.

    I had a panic attack while I was on the treadmill. I could see a regular, towering spike on my EKG (it was almost off the top of the screen). As I pushed harder, though, that spike shrank. When I pushed as hard as the doctors would allow me, that spike was all but gone, normalized and swallowed up in the jaggedness that represents a busy heart.

    They told me I was having a panic attack. They gave me medication that made me feel like a zombie. After three days of that, I stopped taking it. I remembered the normalization of my EKG spike and decided to try intense cardio as a way to control my attacks.

    As I said, it’s been 15 years. Have I had a panic attack since then? You bet. Did I think I was going to die? A couple of times. Have I been on any drugs for my anxiety? Nope. The cardio works sufficiently well for me.

    Why does it work? Here’s my best guess: Panic attacks are typically associated with tachycardia, which is a sometimes dangerous condition in which the heart beats irregularly and very fast. This condition can be exacerbated by having a minor nerve bundle on the heart that competes for heartbeat cadence. When it does manage to inflect on the main nerve bundle, all hell breaks loose.

    Whether it’s simply a really fast heartbeat or fast and irregular, doing something to shock the heart can reset the cadence. I have found that really cold water or ice applied to the neck does this very nicely. If I do happen to have a panic attack, this is what I do. And it does work.

    My point is that the exercise itself is placing stress on the heart. Good stress. This stress helps to normalize the heartbeat by resetting any irregularities. Exercise has a bonus feature over the ice, however: it strengthens the heart and makes the cadence itself more regular, thereby diminishing the probability of panic attacks.

    My advice to anyone who is suffering from depression, anxiety, or panic attacks is to give this a try. Please do NOT stop taking your medication, though! Tell your doctor what you plan to do, and see what he or she thinks about it first. Your doctor might decide to create a plan to wean you from your medication as you progress in your exercise regimen.

    One final note: I have worked out while having a panic attack. But there is a difference between prudent and foolish here. If the panic attack is mild, cardio can erase it. If you have tachycardia with the panic attack, grab a bag of ice, go lay down, and place the ice on your neck for a while. Don’t work out if the panic attack is bad.

  2. I 100% agree with this article. I have been transitioning for 4 years now. I started exercising day 1 because I had to…I had to get my health under control otherwise my doctor would not allow or assist with medical transitioning. I reversed diabetes, slowed potential cardiac problems, and turned back the clock on potential strokes. Today I workout 7 days per week with the 7th as a yoga/deep stretch but when done properly it is a workout of its own. Just not high intensity. I have still had my downs but the recovery is so much easier with fitness involved.


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