Treating Depression with Exercise

I would venture that anyone who knows anything about treating depression has asked this question: why is it, if we know how effective exercise is in treating depression, are so many patients being given medication. Why is America drowning in SSRIs?

Olga Khazan asked the question a few years ago in the Atlantic. Somehow or other, I missed it at the time, but on the grounds of better-late-than-never I report on it now.

Exercise is cheap. It works as well as anything else. Thus, Khazan raises the issue:

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.

And also:

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.

The answer is complex. But, addressing it must begin with an assessment of the financial incentives that cause physicians to prescribe pills:

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.

For physicians there’s no money in exercise. Since psychiatrists are reimbursed on the basis of the number of appointments, a short interview and a prescription pays much better than a long session filled with conversation. It takes time and, sometimes, lengthy conversations to persuade a depressed patient to sign up at the gym. It takes more time and more conversation to persuade him to go, and to keep going.

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.

Talk therapy has increasingly become the province of social workers and psychologists, providers who cannot write prescriptions.

Meanwhile, psychiatrists who take insurance are increasingly less likely to offer talk therapy—or longer appointments of any kind—because licensed social workers and psychologists can offer the same types of sessions at lower rates.

While panic attacks and anxiety disorders do not fall within the category of depression, they can effectively be mitigated by practicing yoga:

When Brittany, a woman who lives in northern Virginia, first began experiencing panic attacks a few months ago, she turned to a series of providers in her insurance network. None of the doctors she saw wanted to discuss anything but drug options, she said.

“They were all just throwing medication at me,” she said. (She asked that I not use her last name). “I said I don’t want medicine, but they didn't want to talk about a long-term therapeutic plan.”

She went through eight different providers before finally finding a psychiatrist who helped her establish a plan to do yoga several times a week to manage her panic disorder. Those psychiatrist appointments are 90 minutes long.

Add to the mix the fact that a large number of prescriptions for psychiatric medication are not written by psychiatrists. The nation has too few psychiatrists, so primary care physicians take up the slack. They do not have the time or the inclination to persuade patients to take up an exercise regimen:

Exacerbating all of this is the fact that there’s a shortage of psychiatrists, and the needs of people with mental health issues are increasingly being addressed by primary-care doctors, who now provide over a third of all mental health-care in the U.S. Sixty-two percent of all antidepressant prescriptions are now written by general practitioners, ob-gyns, and pediatricians.

But general practitioners aren’t always as equipped as psychiatrists to diagnose and treat depression. In 2007, 73 percent of patients who were prescribed an antidepressant were not given psychiatric diagnoses. In other cases, primary care doctors may balk at the idea of prescribing any interventions because they don’t feel they know enough about depression.

And, of course, many patients resist. Exercise takes time. It requires effort. It even requires work… thus, the term: workout. It’s easier to pop a pill:

Some patients claim they can’t make time for the gym, or are adamant that they can’t afford to sleep more than six hours each night. And lawyers who work 16-hour days are not going to sit through long counseling appointments no matter how many peer-reviewed studies you wave at them.

“What do you do? Do you let them walk around depressed?” Salcedo said. “Or do you offer them a treatment that they'll accept? Everyone has to do the thing that works for them.”

And despite its merits, exercise is not nearly as portable or painless as a tablet.

Since depressed patients are often lethargic and are afraid to expend any effort at all, psychiatrists feel obliged to nag them, to keep after them, to become obnoxious proponents of a treatment plan that the culture downplays. In our medical culture, we have been taught that we can take a pill to solve all of our problems. True enough, gyms are crowded. Many people have gotten the message. But, those who are depressed are not first in line when the doors open.

Depressed patients are also more likely than most to feel unmotivated, so even the best-laid exercise treatment plan can be thwarted by a few days of staying in bed for an extra hour.

“Depressed patients have apathy or a lack of energy. Or they have anxiety disorders so they're not going to go to the gym. Or they're afraid to be seen jogging across Monument Avenue,” said Joan Plotkin Han, a staff psychiatrist at Virginia Commonwealth University in Richmond. Still, she pushes it with her more intrepid patients. “I don't want to be that intimidating or threatening, but I'm a nag. And I will nag them.”

Let’s not forget, depression has been classified as a mental illness. Does it make sense that a mental illness can be treated with aerobic conditioning or weight training? It might be true, but many people still believe that a mental problem can only be solved by mental gymnastics.