Exercise as medicine: An evidence-based treatment for depression

What is the evidence?
Depression is among the most common of medical disorders, resulting in significant lifetime costs to patients and society. Exciting research over the last decade has shown regular exercise to be an effective treatment for depression. A recent meta-analysis demonstrates that regular physical activity in moderately severe depression can be as effective as antidepressants or cognitive therapy.[1,2] Current research focuses on determining what types of exercise and the number and duration of exercise sessions required to achieve the greatest antidepressant effect.

The database on exercise in treating depression is increasingly robust:
•    The recommended Canadian standard continues to be 150 minutes per week (i.e., 30 minutes per day, 5 times per week) of moderate physical activity to receive health benefits from exercise, yet 85% of Canadians are currently not meeting this minimum. 
•    Exercise has a large antidepressant effect compared to inactivity.
•    Physician counseling or offering an exercise prescription has a high dropout rate compared to exercise with the supervision of an exercise professional.
•    While most studies support moderate to vigorous intensity exercise as having an antidepressant effect, a recent controlled trial showed efficacy at all intensity levels and suggests patients should self-select their preferred method of exercise, as it may increase enjoyment and improve adherence.[3]
•    Larger effects are found in outpatient settings in the absence of other psychiatric illness (e.g., substance use disorder) and with the supervision of an exercise professional.
•    Both aerobic and mixed aerobic/anaerobic exercises are effective first-line treatments for depression. Yoga is currently considered a second-line treatment.

What resources are available in BC?

Jumpstep 
Jumpstep is a 12-week treatment program for depression developed collaboratively between the Mood Disorders Association of BC and the Centre for Hip Health and Mobility. It is currently delivered by the Mood Disorders Association of BC in conjunction with the Greater Vancouver YMCA. In each 2-hour weekly session, the first hour is devoted to physical activity, including outdoor walks, gym floor exercises, cardio workouts, etc., facilitated by an exercise therapist. The second hour, conducted by a psychiatrist, uses the format of a shared medical appointment (group medical visit) to help patients set short- and long-term fitness goals, examine barriers that might prevent sustained participation in regular physical activity, and understand the relationship between depression, exercise, medications, and other forms of treatment. The program has demonstrated high consumer satisfaction, increased activity level, and decreased depression and anxiety.[4] With support from the Vancouver Foundation, a detailed manual is available outlining the steps and resources required to offer a Jumpstep program in any BC community.

Jumpstep for Teens
A pilot project funded by the Canucks for Kids Foundation and the BC Healthy Living Alliance will be offered in winter 2017 using the Jumpstep model to treat teenage depression with exercise.

BCCA United 
A collaborative pilot project with the BC Cancer Agency, the Mood Disorders Association of BC, and the Greater Vancouver YMCA has created a team sport–based exercise intervention for people with or recovering from cancer. The program will combine successes seen in Jumpstep with those seen in the Vancouver Street Soccer League, a soccer league for men and women affected by or at risk of homelessness. The league’s players have demonstrated remarkable changes in physical and mental health, including decreased substance use.

Conclusion
There are many reasons why well-intentioned words from physicians to “just get more exercise and you will feel better” typically fall on deaf ears in patients with depression. Focused programs that provide support to patients are key, and the programs noted above are a small start. Further uptake throughout the province and country should be our mandate. In the proper setting exercise can be an intervention without medication-like side effects in the armamentarium of effective treatments for depression.
—Ronald A. Remick, MD, FRCPC
Doctors of BC Athletics and Recreation Committee, Medical Director, Psychiatric Clinics at MDABC 
—Anush Evans, MD
Resident, UBC Department of Psychiatry 
—Alan Bates, MD, PhD, FRCPC 
Consultant Psychiatrist, Psychiatric Clinics at MDABC, Provincial Practice Leader for Psychiatry, BC Cancer Agency

Walk With Your Doc this spring 
Spring is approaching and so is Move for Health Day on 10 May. During that week (7–14 May) we invite our patients to go for a Walk With Your Doc. As 2017 is Canada’s 150th birthday, we have been challenged to hold 150 Walk With Your Doc events in BC this year. We continue to grow our collaborative efforts for this event, and this year we are working with the Physiotherapy Association of BC and the BC Recreation and Parks Association. For more information visit http://walkwithyourdoc.ca/about.
—Ron Wilson, MD
Chair, Doctors of BC Athletics and Recreation Committe

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This article is the opinion of the authors and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Cooney GM, Dwan K, Greig CA, et al. Exercise for depression (Review). Cochrane Database Syst Rev 2013:(9):CD004366.
2.    Schuch FB, Vancampfort D, Richards J, et al. Exercise as a treatment for depression: a meta-analysis adjusting for publication bias. J Psychiatr Res. 2016;77:42-51.
3.    Helgadóttir B, Hallgren M, Ekblom Ö, Forsell Y. Training fast or slow? Exercise for depression: A randomized controlled trial. Prev Med 2016;91:123-131.
4.    Adams DJ, Remick RA, Davis JC, et al. Exercise as medicine—the use of group medical visits to promote physical activity and treat chronic moderate depression: A preliminary 14-week pre-post study. BMJ Open Sport Exerc Med 2015;1:e000036.