Exercise as an Intervention Depends on Both Clinician and Patient Acceptance

Eriksson and Gard (2011) reviewed studies that used physical exercise as an intervention to treat major depression and presented evidence supporting its use for major depression. The current review mirrors findings found in other recent reviews of this topic. In addition, the systematic review conducted by Eriksson and Gard (2011) did an admirable job of emphasizing two issues in the relationship between physical exercise and depression: (1) there is growing evidence that physical exercise is an effective intervention strategy for treating depression and (2) more research is needed in a variety of areas to decipher the important components and dosing of physical exercise in relation to depression. Despite the fact that this review confirms that current work presents valid and quality studies showing that physical exercise has a mood enhancing effect on individuals with depression, exercise has not been routinely prescribed for depression and is not considered a primary ‘treatment option’. Why is this? A variety of reasons can be cited to explain this, but the most important may be that clinicians, themselves, do not agree that exercise is effective for treating depression. Clinicians do not see exercise as appropriately specific to treat depression and therefore consider it of incidental value only. As mentioned by Eriksson and Gard (2011), the research in this area has historically been methodologically flawed which does not garner confidence in the effectiveness of physical exercise. In addition, established efficacy standards have yet to be met by the physical exercise and depression literature (including a lack of sufficient clinical trials). Participants in research may also differ greatly from treatment-seeking individuals. In general, research participants are less severely depressed than treatment-seeking individuals. Also, patients that volunteer to take part in a ‘physical exercise’ treatment program are typically motivated to engage in exercise (or at least are contemplating engaging in exercise); this may not be applicable to individuals who are seeking treatment. Most individuals with depression are not contemplating engaging in exercise, which will affect their motivation levels. This calls into question the generalizability of the results presented in Eriksson and Gard (2011). Finally, there are the practical issues of implementing an exercise program to individuals with depression. These practical issues of implementing exercise as a treatment for depression have various dimensions. First, the ‘dosing’ of exercise is an area that needs more research attention. There has been some work that has demonstrated that a certain level of exercise is necessary for mood-enhancing benefits. However, there is not presently consensus on the dosing regimen for physical exercise. In fact, it is likely that it is not a one-size-fits-all scenario. It will depend on the current level of activity in which an individual participates, which will ultimately affect their exercise ‘prescription’. General practitioners and/or clinical psychologists treat most depression; however these types of clinicians are not trained to prescribe, implement and follow physical exercise interventions and will have difficulty applying physical exercise as the treatment option or even as an adjunctive aspect of treatment. The patients will need specific advice and guidance on beginning physical exercise, more than ‘please begin an exercise program’. Therefore, clinicians specifically trained in implementing physical exercise interventions will need to be involved (e.g. physical therapists and rehabilitation professionals). Furthermore, patients with depression will undoubtedly struggle with adherence to physical exercise. Even physically and emotionally stable individuals struggle with adherence to physical exercise programs, with studies suggesting that less than 50% of those who start a physical exercise program are still engaging in the exercise program beyond six months. There is evidence that individuals with depression may be even less likely to adhere to exercise recommendations. This is probably not surprising, considering that the idea of exercising (especially vigorously) will probably not be appealing to individuals who are hopeless, fatigued, and sad (core symptoms of depression). Therefore, creative and motivational outreach efforts will need to be utilized in order to get and keep the patients with depression moving. Another issue that may affect adherence is the therapeutic response time of mood improvement following exercise. There is evidence that in reaction to acute exercise, individuals with depression will not Correspondence to: Ali A Weinstein, Department of Rehabilitation Science, Center for the Study of Chronic Illness and Disability, George Mason University, 4400 University Drive, MSN 2G7, Fairfax, VA 22030, USA. Email: aweinst2@gmu.edu Weinstein Commentaries