Exercise and Mood: not the usual rap
(revised 5/2006)

You've heard it before, exercise is a great for your health, everyone should, etc. etc.    Let's take a different look.

Face it, there must be something very difficult about getting exercise (in the U.S. culture, anyway), because even though everybody knows it's a good thing for you, so few people actually do it!   Thus we'll pay close attention here what makes it hard to do.

And, obviously exercise must be continued, to maintain its benefits.  So the focus here will be on how someone like you, probably pretty doubtful about this whole idea, could practice some sort of sustainable physical activity.  Here are the sections of the following essay: 

Why don't more people exercise?

Here are 3 big reasons:

Most people, by the time they have mood problems they think need treating, have children and/or jobs.  These are essential responsibilities, right?  You can't put your needs ahead of these kinds of needs without serious trouble.  Most people lose out on exercise right there.  They're good, responsible people.  They get their jobs done first, then if there's anything left, which they might take for themselves, they still consider giving it to their kids or their work!  Isn't that how you do it? 

Now of course in the long run those kids and jobs would be better off with a mom or dad who's not troubled by mood problems, and exercise can definitely treat mood problems (evidence below).   But our brains are not designed for long-run type decision making!  This is crucial, and I invite you to read an additional essay about human brains making decisions, but maybe you'll come back for that. 

Most people in the USA have tight schedules (we won't pause here to examine that one).  So most people would have to change their schedule to make room for regular exercise.  Exercise is not the routine thing, it's an extra thing.  There's the second huge reason why it doesn't happen:  people leave their plan for exercise to a repeated decision.  That's like repeatedly deciding to take a medication.  One of those times, taking two minutes to do so will seem less important than something, like getting the kids to school on time, and poof!  medication missed.  And if it requires 30 or 40 minutes, like exercise (in some people's minds; we'll see below how to shoot for 15 minutes), poof again! 

Thirdly, the benefits don't happen right away.  That's another predictable way for human brains to miscalculate, as discussed in the decision-making essay:  something else of more immediate value will win out, even if it's nowhere near as valuable in the long run.  Worse yet, the benefits of exercise are subtle.  So even when they're happening, they're pretty easily missed:  increased strength (how often do you use that?); increased stamina (same problem); better weight control (too many ways to mess that up!); less depression (unless you have other reasons to stay depressed or get depressed again, like stresses or genetics).  And the well-know, undebated benefits like lower heart disease risk and osteoporosis protection are invisible, especially to our decision-making brains. 


Shall we review the benefits?

I wrote a review on this subject 20 years ago.Phelps  Things haven't changed too much since then. [Until March 2005; see the update at the end of this section.]  No doubt about heart benefitse.g.Berlin, and the risk by comparison is tiny.  Even colon cancer e.gSlattery and breast cancere.g.Dorn look like they might be reduced in those who exercise regularly.Freidenreich   There is also no doubt about weight control. Calles-Escandon,(Cochrane)  In the words of a mentor back in my exercise physiology research days, Peter Woode.g.Wood , "those who eat the most are those who weigh the least".   What he meant was, those who eat the most are those who exercise regularly, and despite their eating, in part because of their regular activity, they weigh less on average than sedentary people.  He was a diet researcher as well as distance runner. 

Perhaps even more important, a recent study shows that exercise preferentially reduces abdominal fat.Mayo, Feb 2003  This is important because abdominal fat is closely related to metabolic syndrome, a change in metabolism that can end up having effects on mood and anxiety.   

How about exercise as a treatment for insomnia?  There is limited information on this, somewhat surprisingly.  A recent extensive review of the literature on this topic yielded only one well designed trial, in people over 60.  But that experiment did show positive effects on sleep.Montgomery (Cochrane)  I say surprising because most people believe that if they hiked 20 miles today, they'd sleep very soundly tonight; in other words, most people seem to recognize that physical activity is associated with improved sleep.  We just don't have a lot of data to back that up; though none to the contrary either, as far as I know.  

But the data on exercise and mood have gotten even stronger.  One of the most telling studies was reported recently, in which an exercise program was equal in benefit to routine doses of Zoloft, a common antidepressant.Blumenthal  The Zoloft and the exercise program were tapered off after 4 months; then the researchers tested the participants again, about 8 months after the treatments were stopped.  At that point, the exercise group was doing better than the group that had received Zoloft.Babyak  Exercise appears to affect brain chemistry and brain cells in much the same way, perhaps exactly the same way, as antidepressant medications (increasing the "cell fertilizers" discussed in Part II of the Brain Chemistry of Mood Disorders essay).Ernst  

What about bipolar depression, or bipolar disorder in general? Could exercise act as a "mood stabilizer"? To my knowledge, there is only one small study on this. Although it was just a preliminary inquiry, the results were suggestive of a possible benefit.Ng

Update 3/2005:  And now for the most stunning of all results yet published.  As noted above, the data showing that exercise can actually treat depression has been pretty good for a long while.  But we now know that depression can cause brain shrinkage, and that effective treatments can stop and at least partially reverse that shrinkage (for the full version of this important story, see the Brain Chemistry of Mood Disorders essay; the data on brain shrinkage and the benefits of treatment are in Part II of that story).  So now we can assess just how good a treatment for depression exercise really is:  can it reverse brain shrinkage too?  

Sure enough, this has been shown to occur, only in one small study so far, but getting these results by accident is not very likely.  The study uses just the kind of rigorous design that makes this likely to be a "real" finding.  Comparing older folks (average age of 67) who were physically active versus those who were less active, a research team from the University of Illinois found that the active elders had better mental skills and memory, and even that their brains were more active as well.Colcombe  But then they did the crucial follow-up test:  they divided a group of elders into two groups, one which participated in an aerobic exercise program, and one which did not.  In research which has been presented but not yet published, they have found that the group which exercised increased their brain size compared to the sedentary control group, in the brain regions known to shrink when people have mood problems.   Extrapolating just slighly from these results, we now have preliminary evidence that exercise, like other effective antidepressants, can reverse brain shrinkage.  Why, you might wonder, would anyone take a medication to treat depression, when exercise, with all its other health benefits, can work as well--even at the level of helping the brain re-grow?    

Update 2012: early data, only in rats so far, suggest that exercise can reverse the negative brain effects of a high-fat diet, and perhaps even prevent Alzheimer's. 

Could you do this?
The main "no" must be coming from your head.   Name some physical limitation and you could find somebody somewhere who's got that limitation too but has overcome it somehow.  So we're really dealing with motivation and time/money/other-resources barriers here.

Of course motivation is not a depressed person's strength, right?  If you have depression, you know:  cooking dinner is hard enough.  And look, how many people who aren't depressed exercise regularly?  (people's self-report, which is surely exaggerated -- wouldn't you?-- says that about 5 in 10 Americans who aren't depressed still don't do anything regularly).  So if they can't, or at least don't, why should someone -- including you -- expect that you can?

Ah, but there's a trick here, one you might be able to use.   "Motivation" may not really be necessary!  "Motivation" is a feeling, right?  An inclination, a state of energy and willingness.  Yet people act differently than they feel, all the time, right?   I feel like yelling at my kid, but I choose to wait, calm down a little, and speak softly but firmly.  

So, maybe it's not motivation you need to look for.  Maybe it's the ability to do something different than what you "feel like".  Now even that is a problem for a lot of people, and more so for people with mood problems!  Being less "impulsive", being more deliberate about your choices, can be very hard, especially when your emotions have too much hold on you.  So, if you're going to explain to someone why you "can't" exercise, in my view you really ought to be admitting to them and to yourself that you're not really able right now to direct your own behavior very well. 

Since that's the case for very, very few people, I hope you're with me still, and I hope you're wondering just what really is the limiting factor for you.  I hope you might be concluding that you can, but that you don't.

And for those of you who are so depressed you're certain it's the depression that's holding you back, and that no one who feels as badly as you do would exercise (or benefit from it), you should read these testimonials from depressed women who've used exercise as a treatment even when their depression is at its worst.  

Yes, but I don't
You're in a big club there!  Like about 50% at least of the U.S. population.  So what could you do?  Please, stop right there, stop thinking about exercise (huh?).  Stop thinking about exercise in the way you've thought of it before.  You didn't do it that way, so stop thinking about it! 

Let's think of it a different way.  This way is called SUSTAINABILITY.  If we're really serious about this exercise business as a health thing, we ought to be thinking very long term.  So, something you might do for a while, but then completely abandon, nah. Let's look for something so simple and easy you could almost put it in there with brushing your teeth (you are still doing that? One reader pointed out to me that when depression is really bad, even brushing teeth can go by the wayside. So if it's that bad, you have company. And its time to start doing it anyway despite how you feel.)

So let's think about what kind of physical activity you could do repeatedly for a long time and not skip very often. Unless you're an exercise fan already, in my view there aren't too many of these.  In my view, the one that wins over everything else by a long shot is....brace yourself.... going with a friend.... nearly every day...... for a short walk.  Notice the friend part.  That's almost as important as the "walk" part!  Your friend will be out there when you're not really "feeling like it", but she or he will be waiting on you.  That's a better motivator for most humans than their own health benefits (there's that essay on human decision making again, if you haven't been there yet). 

Don't tell anybody! 
Most people can still walk.  Walking has the absolute best record for easy access.  The Harvard Bipolar Program leader, Dr. Sachs, says "here's your exercise program:  go to the door, look at your watch.  Walk 7.5 minutes in any direction, then turn around and walk home.  Do that 5 days a week at least."  And that's it.  As I recall he calculated the average American would lose 5 pounds a year doing that, as opposed to gaining about that for the average sedentary person. 

(There is the usual recommendation that people over 40-45 have an evaluation by their doctor before starting an exercise program, so if you're really going to do that, see your doctor.  It seems a bit ironic to me that I have to warn you about walking, but this is America, there are lawyers everywhere...Ok, true, my dad was a lawyer). 

Don't tell anybody.  You don't need any additional pressure or anybody you'd want to "show who's boss" should they start having hopeful expectations of you.  You know what I mean?  Tell your wife you've started an exercise program and she'll be watching to see if you're still doing it.  If you're not, she's liable to make some comment, or give you some look (what, you know that look?) And now your resentment at her telling you what to do is going to come out by, whoops, not getting the walk in today.  Doggonit, nobody's going to tell you what to do, etc. etc.. 

So, just say you're going to go for a little walk and be back in about 15 minutes.  That will do for now. 

(Later you can look at strength training, adding something focused less on aerobic and more on a broader view of "fitness". But the first thing to do is get moving: simple and sustainable first. You don't ever have to do anything more than walking, if you want to be better off than you are now.)

Pay yourself first.

There's a book series out there on how to be a rich businessman, entitled "Rich Dad, Poor Dad".  Too bad it doesn't pay a little more attention to the social consequences of trying to be rich.  A friend told me to read it but I can't seem to quite get the hang of it. 

Anyway, there is a striking idea in there: "Pay yourself first".  It says, don't put your money in savings after you've paid the electric bill, the gas bill, the insurance bill, etc.  Put the money in first!  But, you say, what if you're out of money at the end of the month and can't pay those basic bills?  Ah, he says, doing it this way will show you:  either you need to reduce your expenses, or make more money -- but either way, the most important step for your future has already been taken (the saving, that is...).  

Interesting idea; sure made me think, it's so opposite from the usual, responsible way of approaching money.  Note that the key idea is:  make the future such a priority that it gets top position.  Assume that otherwise, the daily stuff will be so much more obvious to you -- after all, there's that bill from the gas company right there on the table -- that you will risk, every month, not being able to invest "in your own future".  

Well, you can see how that applies here:  if everybody else's needs get taken care of before you take care of "investing in your own (health, in this case) future", then every day there's a risk that your long-term needs will be pushed to the bottom of the list, behind that long list of more obvious, more immediate needs.  Isn't that pretty close to just what happens to you?  What would happen if you "paid yourself first"?  Aren't all of those other needs, even your kids', less important in the long run than your physical and emotional good health?  (e.g. you can't really help them so well if your boat is sinking, right?)

Shall we measure?  weight? waist? miles?

Why don't we measure what's really important first, then you can measure anything else you want -- as long as it doesn't make something worse to do so!  Right, so what does Dr. Phelps think is "really important" to measure?  Why, mood and energy of course (typical doctor:  my disease is more important than your disease...).  

So, I recommend you use some measure of mood (that's the simplest example; there are many to choose from; here's how to score it) before you use some measure of weight, or inches.  Let's keep the spotlight on what really matters and see if this exercise business really does anything.  After all, I'm the evidence-based treatment psychiatrist.   I should be able to give up when you produce the evidence that in your case, sure enough, after a month of getting at least the 15 minutes described above, at least 5 days a week -- there's been no improvement in your mood or energy.  I'd say that was a fair trial, just like we'd give an antidepressant.  

You can even use my mood chart for this, which you'll note I modified to include a column for exercise, alongside any other medications you're taking.  

Practicing the preaching

Yes, I do what I say -- most of the time.  Though I take breaks from time to time on writing down what I do, I do something nearly every day.  Here's my (Excel) exercise log, charting in early 2004 and resuming late May 2004.   You're welcome to use the format if you like it -- pretty simple.  An example of the charting:

Exercise Log 1= walk 2= fast walk, easy bike, tap practice   3= tap wkout,jog 4= run, singles
  Activity 1       Activity 2      
Date Day Type Intensity Duration Score Type Intensity Duration Score Sum
1/8 nordic track 3 30 90 Tap 2 50 100 190
1/9 run 3 25 75       0 75
1/10 (Salem)     0       0 0
1/11 sick     0       0 0
1/12 sick     0       0 0
1/13 sick     0       0 0
1/14 tennis dbls 2 60 120 Tap 3 15 45 165
1/15 run 4 20 80 Tap 2 50 100 180
1/16 run 4 20 80       0 80
1/17 bike 2 20 40 kayak 2 50 100 140
1/18 walk 1 60 60       0 60
1/19 bike 2.5 20 50 kayak 2 90 180 230
1/20 ?     0       0 0
1/21 nordic track 3 30 90 Tap 2 30 60 150
1/22 nordic track 3 30 90 Tap 2 50 100 190
1/23 run 4 25 100 Weights 3 10 30 130
1/24 Fri ?     0         0
1/25 Sat climb 4 10 40 Tennis 4 60 240 280
1/26 Sun bike 2 20 40 Tennis 4 60 240 280
1/27 Mon run 3 30 90       0 90
1/28 Tues run 3 20 60       0 60
1/29 Wed ski 2 180 360       0 360
1/30 Thurs ski 2 180 360       0 360
1/31 Fri ski 2 180 360       0 360