Presidential Column

Did You Prescribe Exercise This Week?

By Michael W. Otto, Ph.D.

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Let’s be clear, exercise is a loaded topic for many people. Talking about exercise can evoke memories of successes or failures in athletics in grade-school and beyond: memories of being picked first or last for the kickball team, catching or dropping the fly ball in outfield, or being cheered at the track or running laps as a punishment for not paying attention in gym. Discussion of exercise may also evoke feelings of failure relative to attempts to control weight or shape during the adulthood years. However, the good news is that exercising for mood is a very different undertaking than exercising for fitness (see below), and is deserving of consideration regardless of an individual’s history with exercise or athletics. And of course, clinicians routinely discuss loaded topics and help patients create a fresh frame, so that new opportunities are not overly burdened by past experiences.

I believe it is time for exercise prescriptions to become a regular part of clinical practice. Quite simply, exercise represents an undervalued but surprisingly strong treatment for both major depression and anxiety disorders. Let me burden you with some of the evidence. Meta-analysis of 23 randomized-controlled depression trials showed that exercise offered benefits in the range of large effect sizes over non-active control, and a moderate effect relative to treatment as usual (Kvam et al., 2016). A smaller but still strong literature shows efficacy for exercise for anxiety disorders, with benefits rivaling those for antidepressant medications (see Asmundson et al. 2013). There is also a wealth of evidence that exercise acts as a cognitive enhancer, improving attention, memory, an some executive functions (McMorris & Hale, 2012; Smith et al., 2010), presumably as a result of effects on brain-derived neurotrophic factor (BDNF, Szuhany et al., 2015). Exercise additionally contributes to improved sleep (Kredlow et al., 2015).

In recent years, there has also been an expansion of the precision application of exercise. For example, based on the rapid effects of exercise on anxiety sensitivity (fears of anxiety-related sensations) as well as mood, Smits and colleagues (2016) showed that exercise aids smoking cessation for patients with elevated anxiety sensitivity scores. Likewise, based the effects of exercise on memory enhancement and anxiety reduction, Powers and colleagues (2015) used exercise to enhance exposure therapy in the treatment of posttraumatic stress disorder. Finally, a number of research groups have applied cognitive-enhancing effects of exercise to ameliorate the cognitive deficits associated with schizophrenia (Firth et al., 2017).

There is No Wrong Time to Prescribe Exercise

A recent article in JAMA Psychiatry recommended exercise as an initial intervention in a stepped approach to the treatment of anxiety disorders, prior to referral to cognitive behavior therapy (CBT) or pharmacotherapy (Stein & Craske, 2017).  Exercise has also been shown to be an efficacious adjunctive treatment to either medication or cognitive-behavior therapy (e.g., Merom et al., 2008; Mura et al., 2014), and exercise interventions have been shown to be an efficacious alternative for treatment-resistant depression (e.g., Mota-Pereira et al., 2011). In addition to outpatient applications of exercise, we have also shown that patients in a partial hospital setting are responsive to exercise for mood interventions, particularly if they have a history of previous engagement in exercise (Hearon et al., 2016). In other words, psychosocial therapists are in an excellent position to offer exercise interventions at the initiation of treatment, as an adjunct to ongoing psychotherapy, as a strategy for enhancing cognition or resilience for other interventions, prior to referring for medication, or as an alternative treatment for an individual who has failed to respond to previous interventions.

Getting Used to the Idea of Prescribing Exercise

Exercise interventions fit more readily with therapies that use weekly assignments as part of treatment. Hence, exercise interventions are an obvious fit with behavioral activation treatments for depression as well as exposure-based treatment for anxiety disorders, and fit fairly well with any treatment that relies on active goal setting and monitoring, including value-based, eclectic, or cognitive-behavioral interventions. For more dynamically-oriented treatments, greater consideration will have to be given for how to frame the benefits of and strategies for regular exercise in relation to the overall process of treatment. Admittedly this may be a challenge, but the broad spectrum of efficacy for exercise makes it a tempting tool for a wide range of clinical applications.

Considerations for Exercise-for-Mood Prescriptions

Based on the broader literature and treatment resources (e.g., Hearon et al., 2016; Otto & Smits, 2011; Smits & Otto, 2009; for Division 12 CE on this topic by Dr. Smits see https://www.div12.org/webinar-recordings-non-members/), a number of principles for exercise-for-mood prescriptions include:

  • Exercise for mood is different. Exercise for weight control, shape, or health is a difficult endeavor, requiring months of regular workouts to achieve initial goals. Unlike the delayed contingencies that define exercise-for-health/shape goals, exercise for mood effects occur much earlier. Indeed, many mood effects from exercise are felt within 30 minutes of workout completion.
  • Target moderate intensity exercise. High intensity exercise (including interval training) can be a great way to build muscle and burn fat, but it is also a great way to hate exercise. Pleasure during exercise predicts the amount of future exercise, and pleasure takes a nosedive with higher-intensity workouts. Moderate intensity exercise is clearly enough to confer mood benefits (e.g., walking at a quick pace). If you can talk comfortably while you are exercising, you are at a moderate or lower level. The most common exercise prescriptions for mood target 4 episodes of 40-minute exercise per week.
  • Target fun. A crucial part of the exercise prescription is finding an exercise that sounds fun. If your patient chooses walking, then the discussion should be about where, when, and with whom to walk for the best views and the best company.  If your patient was a competitive swimmer in college, then picking any exercise but for swimming may be the best way to provide a fresh and enjoyable exercise experience (and one that is free from perfectionistic expectations or intensive performance demands based on a long history of training).
  • Starting Off. Initiation of exercise is always a stepwise process targeted to the level of fitness of the individual. Although regular exercise routinely reduces cardiac risk, the nature and intensity of exercise needs to be matched to the current level of risk. Exercise approval by the patient’s primary care physician helps facilitate this process. Contraindications to exercise include when it is used as an exclusive emotional regulations strategy, or as a calorie neutralization strategy in eating disorders.
  • Remove barriers and cue exercise. Few people complete a planned exercise if they have trouble finding their left sneaker. Exercising before going home (where the couch is waiting), keeping exercise gear in a prominent location, putting a “do this for your mood” card in your shoe, scheduling exercise with a friend, posting exercise goals on the fridge – these are all good strategies for establishing an exercise program.
  • Monitor benefits. Low moods can demotivate adaptive actions, and so the application of exercise for mood takes some training. Mood disruption becomes the reason to exercise rather than a reason to avoid exercise. I like the adage, “skipping a workout when your mood is low is like specifically not taking an aspirin when you have a headache.”
  • Combine motivations. Music, audiobooks, time with a friend – these are all excellent motivators to combine with exercise to make the experience more pleasant.
  • Consider attention. “My left knee hurts” is a poor attentional focus for a walk or run. Learning to direct attention to the most pleasant aspects of an exercise experience is an emergent and valuable skill. For therapists who provide mindfulness training, mindful exercise is an excellent therapeutic goal.
  • Attend to Self-Talk. Exercise can provide great training to avoid perfectionistic expectations about performance, and even a chance to become good at being bad at something (a pre-requisite to enjoy anything new in adulthood). Also, exercise provides a great way to practice saying “good job” to oneself after completing a planned effort.

Closing Comments

I have gotten all the way to the conclusion of this article focusing on the mental health benefits of exercise–improved mood and wellbeing, reducing anxiety, greater anxiety-related resilience, enhanced cognition, and improved sleep—while delaying mention of the obvious: regular exercise also has powerful effects on physical health and longevity. By helping people focus on the contingent and timely mood benefits of exercise, rather than the important but delayed physical health outcomes, psychologist may have a powerful role in bringing more people to this mood-enhancing and life-giving intervention. Have you prescribed exercise this week?

References

Asmundson, G. J., Fetzner, M. G., Deboer, L. B., Powers, M. B., Otto, M. W., & Smits, J. A. (2013). Let’s get physical: a contemporary review of the anxiolytic effects of exercise for anxiety and its disorders. Depress Anxiety, 30(4), 362-373. doi: 10.1002/da.22043

Firth, J., Stubbs, B., Rosenbaum, S., Vancampfort, D., Malchow, B., Schuch, F., . . . Yung, A. R. (2017). aerobic exercise improves cognitive functioning in people with schizophrenia: A systematic review and meta-analysis. Schizophr Bull, 43(3), 546-556).

Hearon, B. A., Beard, C., Kopeski, L. M., Smits, J. A., Otto, M. W., & Bjorgvinsson, T. (2016). Attending to timely contingencies: promoting physical activity uptake among adults with serious mental illness with an exercise-for-mood vs. an exercise-for-fitness prescription. Behav Med, 1-8.

Kredlow, M. A., Capozzoli, M. C., Hearon, B. A., Calkins, A. W., Otto, M. W. (2015). The effects of physical activity on sleep: a meta-analytic review. J Behav Med, 38(3), 427-49.

Kvam, S., Kleppe, C. L., Nordhus, I. H., & Hovland, A. (2016). Exercise as a treatment for depression: A meta-analysis. J Affect Disord, 202, 67-86.

McMorris, T., & Hale, B. J. (2012). Differential effects of differing intensities of acute exercise on speed and accuracy of cognition: a meta-analytical investigation. Brain Cogn, 80(3), 338-351.

Merom, D., Phongsavan, P., Wagner, R., Chey, T., Marnane, C., Steel, Z., . . . Bauman, A. (2008). Promoting walking as an adjunct intervention to group cognitive behavioral therapy for anxiety disorders–a pilot group randomized trial. J Anxiety Disord, 22(6), 959-968.

Mura, G., Moro, M. F., Patten, S. B., & Carta, M. G. (2014). Exercise as an add-on strategy for the treatment of major depressive disorder: a systematic review. CNS Spectr, 19(6), 496-508.

Mota-Pereira, J., Carvalho, S., Silverio, J., Fonte, D., Pizarro, A., Teixeira, J., . . . Ramos, J. (2011). Moderate physical exercise and quality of life in patients with treatment-resistant major depressive disorder. J Psychiatr Res, 45(12), 1657-1659.

Otto, M. W., & Smits, J. A. (2011). Exercise for Mood and Anxiety: Proven Strategies for Overcoming Depression and Enhancing Well-Being. New York, NY: Oxford University Press.

Powers, M. B., Medina, J. L., Burns, S., Kauffman, B. Y., Monfils, M., Asmundson, G. J., . . . Smits, J. A. (2015). Exercise augmentation of exposure therapy for PTSD: Rationale and pilot efficacy data. Cogn Behav Ther, 44(4), 314-327.

Smith, P. J., Blumenthal, J. A., Hoffman, B. M., Cooper, H., Strauman, T. A., Welsh-Bohmer, K., . . . Sherwood, A. (2010). Aerobic exercise and neurocognitive performance: a meta-analytic review of randomized controlled trials. Psychosom Med, 72(3), 239-252.

Smits, J. A. J., & Otto, M. W. (2009). Exercise for mood and anxiety disorders (Therapist guide). New York: Oxford University Press.

Smits, J. A., Zvolensky, M. J., Davis, M. L., Rosenfield, D., Marcus, B. H., Church, T. S., . . . Baird, S. O. (2016). The efficacy of vigorous-intensity exercise as an aid to smoking cessation in adults with high anxiety sensitivity: A randomized controlled trial. Psychosom Med, 78(3), 354-364.

Stein, M. B., & Craske, M. G. (2017). Treating anxiety in 2017: Optimizing care to improve outcomes. JAMA. Jul 5. [Epub ahead of print]

Szuhany, K. L., Bugatti, M., & Otto, M. W. (2015). A meta-analytic review of the effects of exercise on brain-derived neurotrophic factor. J Psychiatr Res, 60, 56-64.