The Art and Science of Fitness | Movement and mental health: The link is clear

While the statistics may be shocking, one important study was published on March 3 that makes answering this question a whole lot clearer. Research published in the British Journal of Sports Medicine, Effectiveness of physical activity interventions for improving depression, anxiety and distress: an overview of systematic reviews, compiled an extensive base of evidence regarding the effects of physical activity and exercise on depression, anxiety and psychological distress.

The compilation reviewed and synthesised data from studies which looked at three groups of people: Healthy adults, people with mental health disorders (such as depression, anxiety and psychological stress), and people with various chronic diseases (which include people with cancer, cardiovascular diseases, kidney diseases, and strokes).

Many people with diagnosed depression and anxiety have comorbidities such as hypertension, diabetes, osteoarthritis, and fatigue among others — and suffer from the presence of two or more diseases or medical conditions at once. Further, people with chronic medical conditions such as cancer, cardiovascular diseases, kidney diseases, and stroke tend to have mental health conditions such as depression, anxiety, and psychological distress, among other conditions. However, in both cases, becoming physically active and changing one’s lifestyle isn’t the top prescription.

Despite the role of lifestyle management, including exercise, sleep and nutrition, in practice, pharmacotherapy (medicines given by psychiatrists) and psychotherapy (psychology counselling or psychoanalysis) are considered the first line of treatment. This is despite national guidelines in several countries recommending physical activity as a critical pillar in treatment. For instance, in the United States, the American Psychological Association Clinical Practice Guidelines recommends psychotherapy or pharmacotherapy as the initial treatment approach, with lifestyle approaches considered a “complementary alternative treatment” in case the former is “ineffective”. Clubbing exercise with acupuncture and terming it “alternative” is that its thought is not backed by any evidence. In Australia, however, lifestyle management is recommended as the first-line treatment approach. Despite this, pharmacotherapy is often provided first.

Dr Ben Singh and his colleagues at the University of South Australia, who authored the study, recognised that numerous earlier studies have shown the beneficial effects of exercise and physical activity in treating depression, anxiety and psychological distress. Physical activity has also shown better effects and is advantageous in terms of cost, side effects and ancillary health benefits. I will admit to you, dear reader, that I have read many of these studies over the years. I thought I knew all that there was to know about the role of exercise in mental health but also was disillusioned by the approaches chosen and did not believe that anything could change in the field. When I read this compilation which synthesised enormous amounts of data (1,039 trials and 128,119 participants), I was in for a surprise. And this is why I wanted to share this crucial study with you.

Here is why.

Despite the evidence surrounding the impact of physical activity, it has not been widely adopted therapeutically — leading to my sense of frustration. It is often overlooked in the management of these conditions and deemed ineffective and unacceptable. Patients are also responsible for this situation as they are resistant to making exercise and activity an integral part of their treatment. Further, doctors and therapists are not excited about these modalities despite the data staring at them.

This is also because there aren’t any set prescriptions and dosages like medicine or frequency of counselling sessions, making it difficult to quantify its effects. Importantly, exercise doesn’t work like a magic pill for such conditions. It takes time, patience and expertise, which, unfortunately, our training in medical and psychology colleges do a poor job of. We are barely introduced to the role of exercise in any conditions. Our textbooks have exercise and lifestyle changes mentioned at the top of management, but we simply aren’t trained in the details, and hence, we overlook them. And if we overlook them, they aren’t given their importance. It is a vicious wheel that keeps on turning. Effectively, we don’t bother mentioning exercise in almost any medical conditions, leave alone mental health.

Dr Singh and his colleagues were keen to change that. Hence they searched twelve electronic databases for eligible studies published until January 1, 2022. The authors reviewed 97 review papers, which included 1,039 research trials and had a total of 1,28,119 participants, ages ranging from 29 to 86 years.

What about the duration and intensity of exercise?

They found that doing 150 minutes each week of various types of physical activities — whether they were aerobic (walking or running), strength training, yoga or others — are 1.5 times more effective in reducing the symptoms of depression, anxiety and psychological distress, compared to usual care, ie medications or cognitive behavioural therapy. Further, people who exercised for six to twelve weeks had the greatest benefits, as compared to those who stuck with exercises for a lesser duration.

Most doctors and psychologists are apprehensive about recommending higher-intensity workouts for any medical condition, but they were associated with greater improvement for those with depression and anxiety. And contrary to popular belief in the exercise medicine fraternity, longer duration interventions, ie longer than 60 minutes had smaller effects as compared to shorter periods of exercise, which are more beneficial.

Dr Singh added, “The greatest benefits (as self-reported by the participants) were seen in people with depression, pregnant and postpartum women, apparently healthy individuals and individuals diagnosed with HIV or kidney disease.”

Unfortunately, in India, we don’t even have a public health policy for physical activity during pregnancy, which I plan to change with the help of experts in the field. The same is the case for a lot of other medical conditions.

So why does exercise work in mental health-related conditions?

It’s common knowledge today that exercise leads to the release of endorphins and dopamine in the brain. But there is also irisin, an “exercise hormone” that is manufactured in our muscles when we are physically active to an optimal level. It gets released into the bloodstream and goes on to stimulate the brain’s reward system, making it reach a state of tranquillity. These together improve our mood and reduce our stress levels. When the same happens over a longer period, there is a change in the brain that helps make the mood changes more permanent, reduce inflammation, and boost immunity. Exercising regularly gradually increases one’s pain threshold, which further improves confidence. And then when we sleep, we are able to sleep a lot better and get up fresh the next morning to face the world — a challenge for those suffering from depression, they simply don’t get up fresh. And the vicious circle carries on.

Dr Singh concluded: “It is likely that the beneficial effects of physical activity on depression and anxiety are due to a combination of various psychological, neurophysiological and social mechanisms. Different modes of physical activity stimulate different physiological and psychosocial effects, and this was supported by our findings, eg, resistance exercise had the largest effects on depression, while Yoga and other mind-body exercises were most effective for reducing anxiety. Physical activity improves depression through various neuromolecular mechanisms including increased expression of neurotrophic factors, increased availability of serotonin and norepinephrine, regulation of hypothalamic-pituitary-adrenal axis activity and reduced systemic inflammation. Therefore, low-intensity PA (physical activity) may be insufficient for stimulating the neurological and hormonal changes that are associated with larger improvements in depression and anxiety.”

Unfortunately, despite the plethora of evidence in favour of exercise being better than other treatment modalities for depression, anxiety and so on, it is not given its due.

There is a caveat here that Dr Singh and his colleagues acknowledge. In cases of severe depression, anxiety and psychological distress, Dr Singh admits to the limitation of the review, for it focuses on mild to moderate depression, and not severe depression.

For this, I reached out to Dr Anurag Mishra, a psychiatrist, psychoanalyst and founder of the Livonics Institute of Integrated Learning and Research.

He said, “The challenge with physical activities of any sort is that the person is confronted with their deepest infantile fears like imploding, exploding, drowning, choking, falling and so on. These are the fears that interrogators exploit with torture techniques — like waterboarding, in which water is poured over a cloth covering the face, causing the person to experience the sensation of drowning. In the case of fasting, it exposes us to the fear of dying of hunger and thirst. However, once we start to master them, our tolerance for anxiety increases. The biggest problem in all our lives is us, no one else. Once people overcome these fears and become comfortable with themselves by facing fears head-on and mastering them, they can put it all into action. In this case, physical activity and exercise. People with mild to moderate symptoms of mental health tend to do well but when it comes to severe depression and advanced mental conditions, these fears are an even bigger challenge and we need the help of medication, counselling, coaching and so on to help them deal with their fears to get them started.”

Be it mental health or physical health, the debate isn’t, or rather shouldn’t be, about one treatment modality versus another. It should be about what works best for the patient. For that, my medical colleagues need to understand the human being across the table from them. We need to put ourselves in their shoes and make a decision with them and not for them.

As for the person suffering from mental health problems in isolation, or along with physical medical conditions, it’s about taking control while learning to let go, which seems like an oxymoron, but it isn’t. All you can do is put in your best effort while proactively taking action.

Doctors, councillors, coaches and therapists are all on your team, but you need to be the one in the driver’s seat. Whether it be the degree of intensity, duration or frequency of exercise and physical activity, it’s all relative. Gradually, build it up. You just need to do a bit more than what you did yesterday. Don’t consider it a rat race because the only person you’re competing with is who you were yesterday. There will be good days and bad days. Don’t let them excite or irritate you. Just be on the journey to be a better you.

And as Dr Singh so rightly says, “Exercise shouldn’t be viewed as a ‘nice to have’ option. It is a powerful and accessible tool for managing mental health conditions — and the best part is, it’s free and comes with plenty of additional health benefits.“

At the end of the day, the idea is to get moving, one step at a time.

Keep miling and smiling.

Dr Rajat Chauhan (drrajatchauhan.com) is the author of The Pain Handbook: A non-surgical way to managing back, neck and knee pain; MoveMint Medicine: Your Journey to Peak Health and La Ultra: cOuch to 5, 11 & 22 kms in 100 days

He writes a weekly column, exclusively for HT Premium readers, that breaks down the science of movement and exercise.

The views expressed are personal