Out of the Blue: Six Non-Medication Ways to Relieve Depression (Norton Professional Books) (19 page)

1. The first group was given Zoloft (an antidepressant commonly used to treat depression).

2. The second group was given an exercise intervention. The exercise consisted of a ten-minute warm-up followed by thirty minutes of walking, jogging, or stationary-bicycle riding and a five-minute cool-down.

3. The third group both took Zoloft and did the exercise. This was called the combined condition.

The results of SMILE? At the end of four months, 60 to 70 percent of the participants in all three groups were “vastly improved” or “symptom free.” But where it gets really interesting and surprising is that, at the ten-month follow-up:

•
38 percent of Zoloft condition subjects had recurrence of their depression

•
31 percent of combined condition subjects had recurrence of their depression

•
8 percent of exercise-only condition subjects had recurrence of their depression (and those who had continued to exercise were even less likely as a group to have recurrence of their depression)

In other words, people who exercised were significantly less likely to get depressed again after having been depressed. What’s more, the amount of exercise mattered: Every fifty minutes of exercise per week correlated with a 50-percent drop in depression levels! Why would this be? One might assume that having both medications and exercise would work better than exercise alone. We don’t really know, but one could hypothesize that the way exercise encourages brain cell growth works a bit better than the way antidepressants work and that the medications may have interfered with what the exercise was doing in the brain to create that brain growth. Another possible explanation is that people who exercised felt they had done it all by themselves while those who took medications felt that they hadn’t really done it and attributed the change to the drug. Finally, many people’s depression doesn’t respond to the first antidepressant they are given, and since only Zoloft was used in the drug treatment and combined conditions, results may have been different if various drugs were tried until one was found that worked best for each participant in the study.

Madhukar Trivedi, a psychiatrist with an interest in helping people with “treatment-resistant depression”—that is, those who had been tried on many different antidepressants and other psychotropic medications and still found themselves depressed—decided to do some studies to find out whether these people would respond to exercise as an intervention. In two different studies (Dunn, Trivedi, Kampert, Clark, & Chambliss, 2005; Trivedi, Greer, Grannemann, Chambliss, & Jordan, 2006), he and his colleagues found that:

•
People who participated in moderately intense aerobics such as exercising on a treadmill or stationary bicycle, whether for three or five days per week, experienced a decline in depressive symptoms by an average of 47 percent after twelve weeks.

•
People in the low-intensity exercise groups showed a 30-percent reduction in symptoms.

•
Exercise helped people who were unresponsive to medications.

What I found interesting after reading all these studies was that I personally, after taking up regular and intense exercise, didn’t experience a mood lift, even though I’d lost some weight and gotten more fit. I wondered about this until I read a University of Virginia study that found that exercise had the most profound mood-lifting effect on people who were depressed (Brown, Ramirez, & Taub, 1978). Since I wasn’t depressed when I started exercising, I didn’t experience the mood-lifting effect.

ENOUGH IS ENOUGH

Of course, there is a danger of “overtraining,” or exercising too much (as in anorexia and other compulsive problems). Alberto Salazar, winner of the New York Marathon three years running, reportedly developed severe depression after pushing himself to train more and more. He began taking Prozac. The evidence shows that overexercising (exercising several times a day at training levels at or near maximal) is correlated with depressed moods (Morgan, Brown, Raglin, O’Connor, & Ellickson, 1991).

Suffice it to say that most of us, and of course, almost all depressed people, are not in danger of exercising at this “overexercising” level, but it is worth mentioning as a word of caution.

GETTING DEPRESSED PEOPLE TO GET MOVING

I’ve spent a lot of time going over the research because I wanted to convince you that getting your depressed clients to get moving can help them gain traction and begin to emerge from their deep depressions. I hope I have.

If you are convinced, the next obvious question is, how do you get depressed clients, who often have a hard time getting out of bed, to get up and start moving?

Walking Sessions

The easiest way to get your clients moving is to do “walking sessions” with them. Instead of sitting in an office or hospital room conducting your interview or intervention, get the person up and walking (outside if weather permits, to add the “nature effect” to the mix) as you talk and listen. Any movement, even walking, can help people combat the decline in brain cells that may accompany depression and perhaps encourage the growth of new brain cells.

Once, after I gave a talk on this subject, a member of the audience approached me with this story. This person had attended a lecture by one of the original developers of the new class of antidepressants called SSRIs when they were first being studied. The scientists said that when they were testing the effectiveness of the new medications, they cast around for a placebo condition that was an active intervention, in addition to the “sugar pills” usually used. The researchers decided they would have a nurse or an aide come to the patient’s hospital room and manually move the depressed patient’s arms and legs for fifteen minutes each day. The medications beat the sugar pills handily, but the researchers were astounded to discover that the manual movement condition also handily beat the effectiveness of the SSRIs. They were mystified by this result, but after reading this chapter, you surely aren’t. Any physical movement can help.

Baby Steps

Another way to get depressed people moving is to start slowly, with small steps. Get them to walk from their bed to the bathroom. Have them move from their chair to the kitchen. Have them walk one time around the block. Two times around the block. Take a bike ride to the store. Dance to one song. Play one active video game. Go to the post office. Clean out one messy drawer. Start small and add tiny increases gradually. Baby steps, Bob, baby steps.

The Solution-Oriented Method

Another way to get depressed people moving is to find out how they have done any difficult thing in their life or since they have been depressed and use that as a model for exercising or moving. For example, I had a freelancer client who had pushed himself to finish a challenging work project as he began to be depressed. He had been depressed previously and recognized the signs of an impending depressive episode. This project would bring in a lot of money, and he knew he would need it since he wouldn’t be very productive while he was depressed.

I asked him how he was able to get himself to do this project despite being dragged down by the depression, and he said, “I set daily goals. I built in times for resting and retreating. I enlisted my best friend to talk to me every day for accountability and grousing.”

After I convinced him that exercising could be helpful in alleviating his depression, he put the exact same structure in place to help himself start exercising and increase his activity level. He set daily goals, built in rest days and times, and enlisted his friend to play the same supportive role he had for the work project.

The Buddy System

When I began to exercise regularly, I found it helpful to exercise with my fiancée. If she was feeling unmotivated one particular day or it was cold and rainy outside, I would pull her along with my energy, and she would do the same for me on days when I was less motivated. This is the “buddy system”: partnering with another person or a group to help stay on track with your exercise plans.

Have your client find another person or a group of people who are willing to walk, run, or do whatever exercise he’s planning to do, and then have him enlist that person or group as his buddy or buddies.

Gamifying Exercise

There are software programs, devices, and apps that can help you make a game with achievement levels that can be tracked. Since depressed people seem to have problems with motivation and games are good at releasing dopamine, the brain’s reward and motivational chemical, gamifying exercise activities can be helpful.

Linking Exercise to Motivation

People seem to have two types of motivation: away from and toward. Harness one or both of these to help your clients get moving and active.

For example, when I began to exercise regularly and more intensively, I had two motivations: I wanted to keep my brain alive and healthy so I could continue to be a lifelong learner (that’s the “toward” motivation), and I also had grown dissatisfied with my growing midlife tummy (the “away from” motivation). Find similar motivations with your depressed client and link them to exercising. Perhaps your client wants to be better for his daughter’s wedding (a “toward” motivation) or he doesn’t want to keep feeling this sense of dread and inability (an “away from” motivation).

HOW MUCH EXERCISE?

It’s difficult to prescribe an exact amount of exercise because each person is an individual, but some general recommendations have emerged from the research:

1. For relief of depression, do aerobic exercise three times a week for at least twenty minutes at 50 to 70 percent of your maximum heart rate.

2. For maximum brain growth and learning, exercise six times a week for fifty minutes at 50 to 70 percent of your maximum heart rate.

3. Learn something new in the next twenty-four hours. Stretch yourself by doing or learning something slightly beyond your comfort zone.

This last recommendation alludes to the fact that new brain cell growth by itself isn’t sufficient. In order to use those new brain cells and have them be of benefit, the person must learn something by stretching himself and repeating these new ideas, behaviors, perceptions, or understandings until they are grooved into his brain and neurology. This is akin to repeating muscular exercises or dance steps over time. The new learning tends to become easier and smoother as the nervous system and brain create new pathways and associations out of the new cells.

A SHOCKING AND SURPRISING POSSIBILITY: ECT

When I first starting reading about exercise, I was surprised to learn the explanation for why exercising works to build muscle and improve health. As you run, tiny fractures occur in the bones in your legs. The body’s immune system notices the damage and sends repair substances that rebuild your bones stronger than before. Lifting heavy weights creates tiny tears in your muscles, and a similar rebuilding process happens that ends up making bigger muscles.

Now I tell you this to introduce what might be a surprising possibility for relieving depression. Although it has a bad reputation because of the primitive way it was initially done and how movies such as
The Snake Pit
and
One Flew Over the Cuckoo’s Nest
and books have portrayed it as a brutal procedure, electro-shock therapy (now called ECT or electroconvulsive therapy) may have a similar effect on the brain. It was done in a more barbaric manner when it was first performed, but now it’s done under sedation and in a much less traumatizing and more controlled way. However, most people haven’t updated their images.

Just as the body rebuilds the bones and muscles after exercise, it may be that after the ECT session, the brain and body mobilize to repair the damage done by the induced seizure and in fact build new brain cells. Of course, this procedure is for extreme, intractable cases of depression, but I wanted to include it here to open up the possibility that you might consider it or recommend it for people who haven’t responded to any other interventions and are still terribly, perhaps suicidally, depressed.

I had a friend in such a state, and when I suggested she consider ECT, she replied, “I would rather die than sink that low.” Indeed, she was in danger of dying several times during the course of her serious depression. I was saddened by her unwillingness to consider ECT. She had a cartoonish, dated image of the procedure and would rather die than update that image.

I recommend you go to the web and watch a very moving presentation by renowned surgeon and writer Sherwin Nuland, whose life was saved by ECT. You can find it at http://www.youtube.com/watch?v=oEZrAGdZ1i8.

I once had a client with intractable depression. Medications would work for him somewhat and for some time, but then stop working. He was in danger of killing himself during the times when his medications and therapy weren’t helping, which often lasted quite a while. He finally heard about and opted for ECT and found that it shifted him rapidly out of his depression. He did have some short-term memory loss, but considering that the other option was dying, he thought it was a good bargain.

So, what I am suggesting here is that when someone isn’t responding to any available methods of treatment, ECT is a last-ditch alternative that can work. Do some more research on this option if you have a client who has been “treatment resistant.” Although most of us who are therapists can’t provide this treatment directly, we may be in a position to educate our clients and help persuade someone in dire straits to consider this option.

I’m far from an expert in this area, but, as you may have discerned, I have a “possibility-oriented” point of view. As long as interventions aren’t disrespectful or permanently harmful, and if they have the possibility of helping someone who is suffering deeply and in danger of giving up on himself and on life, I’m willing to consider them. I hope you and your clients will take a similarly open stance toward this much-maligned treatment.

RUTS VERSUS GRAVES

Here’s another take on the correlation between brain plasticity and depression.

There is good news and bad news about the recent discovery that the brain can change all through life, that is, that the brain and nervous system are plastic. The good news is that the brain can change if you stretch and challenge it and provide it with the raw material to grow new brain cells (activity, new stimulation, and the right foods). The bad news is that the brain tends to get grooved when we do or experience the same stuff over and over again. And it’s difficult to get out of that groove.