Let’s Get Physical: Exercise in the Treatment of Mood and Anxiety Disorders

As the Olympic Winter Games are commencing tomorrow in Sochi, I feel inspired to write about the role of physical activity in mental health. This post will focus specifically on exercise in the treatment of mood and anxiety disorders.

Numerous studies have shown that regular exercise improves mood in people with mild to moderate depression. For those with severe depression or bipolar disorder, exercise alone is rarely sufficient, but exercise can play an adjunct role in helping patients recover and prevent relapse.

We know from Newton’s law of motion that an object at rest stays at rest unless a force acts upon it, and an object in motion stays in motion unless some force makes it stop. The same is true for human bodies. Paradoxically, sedentary people tend to have less energy and active people tend to have more.

Now, of course this begs the question of the chicken or the egg – it is likely that people become sedentary because they have little energy or stay active because they have a surplus. This is true. People seem to have “set points” for activity level just as they do for weight and mood. That being said, physical activity has an almost immediate effect on mood and energy level. Over time, consistent exercise helps to stabilize moods, improve sleep, reduce stress, and enhance motivation to continue moving.

For these reasons, I strongly encourage my patients who suffer from mood disorders or anxiety disorders to exercise regularly. In my opinion, exercise is every bit as important as therapy, medication, and sleep when it comes to mood and anxiety disorders.

As I have emphasized in previous posts, the mind is a series of conscious functions carried out by the brain, and the brain is part of the body. Physical health and mental health are one in the same. Despite what society, popular wisdom, and health insurance companies may tell us, there is no actual difference between a physical illness and a mental one. When you exercise your body, you are exercising your brain.

Unlike therapy or medication, exercise is cheap or even free. Unlike medication, which can have unpleasant or dangerous side effects, exercise is generally safe so long as you do it sensibly and moderately. Unlike therapy, which requires another person and an appointment, exercise can be done alone if you choose at a time that suits your schedule. Unlike therapy, which is typically one-on-one and indoors, exercise can be enjoyed inside or outside with your family, friends, classmates, or teammates.

Numerous times, I have been amazed at how much exercise improves my patients’ mental health. This is especially true for people who have historically been sedentary and embark on a new exercise routine as part of their treatment plan. For example, I am working with a 15-year-old girl whom I’ll call Elsa who suffered from severe depression and crippling anxiety. When I met Elsa last year, she hated exercise and barely had the energy to get out of bed. After months of encouraging her to try different enjoyable physical activities, she finally started biking with her mom and jogging with her neighbor. She is now in full remission from her depression, making excellent progress in tackling her anxiety, and training for her first 5K. She now wakes up at 7:00 am with plenty of energy and really enjoys exercising. I am so proud of her.

One of the more challenging aspects of incorporating exercise into a patient’s treatment plan is that sometimes the mental illness itself is part of the reason why the patient is inactive. Depressed people tend to lose interest in activities they once enjoyed. They feel unmotivated and chronically exhausted. Clearly, it is a challenge for them to do essential things like get dressed and go to school, let alone something “extra” and “optional” like exercise.

For these patients, I use a behavioral technique called behavioral activation. Here’s how it works: we agree upon a small, realistic exercise goal such as walking for 10 minutes three evenings a week. [Elsa’s initial idea was to do the Insanity DVDs she saw on an infomercial. Given that she hadn’t exercised in years, I told her that this idea was, frankly, insane, and I suggested something more moderate.] I have the patient choose an activity they enjoy (or at least one that they don’t hate) and a time of day when they’re likely to follow through (for example, not at 5:00 AM if they aren’t a morning person).

When possible and feasible, I encourage patients to exercise socially by attending a class, joining a sports team, taking lessons, or doing something active outdoors with their families. We make this activity part of their weekly schedule, writing it down (or, often, putting it in their smart phone) as if it were any other appointment or commitment. Most of the time, the patient achieves their initial goal because it is small, realistic, specific, and planned.

Achieving this initial exercise goal creates a feeling of success and personal satisfaction and enhances the person’s motivation to keep going. In addition, they experience a bit of a mood boost from the activity itself. Once the patient achieves the initial exercise goal, it is increased a little bit in frequency or duration.

Using the example above, the patient may walk for 20 minutes during the second week and 30 minutes during the third week. This gradual increase in frequency and duration continues for a number of weeks or months. Eventually, the patient has incorporated regular exercise into her lifestyle. The stress reduction, mood enhancement, and improvement in fitness level enhance her internal motivation to continue exercising.

Anxiety can also interfere with a patient’s plans to exercise. Many people who experience panic attacks are afraid of the physical sensations that result from exercise (rapid breathing, increased heartbeat, sweating), which closely resemble those of a panic attack.

Patients who have social anxiety may shy away from joining sports teams, taking dance classes, or going to gyms because they worry about being judged or making a fool of themselves. For example, Elsa had enjoyed dance classes and swimming in elementary school but later became socially anxious and self-conscious about wearing a leotard or swimsuit in front of her peers. For this reason, she chose to do biking and jogging which did not require such revealing attire. And now, for the record, Elsa does wear a swimsuit with only mild anxiety when she goes to the beach or the pool with her friends. Did I mention how proud of her I am?

For patients with eating disorders, exercise is altogether a different story. That will be the topic of my next blog post.