Depression Treatment: Treating Depression the Old-Fashioned Way

Were he around today, I could imagine referring one of my patients or a family asking about help for a loved one with depression to Vincenz Priessnitz. But he died in 1851. Priessnitz was a pioneer in alternative medicine, where diet, exercise, and non-medicinal interventions (like hydrotherapy, namely baths with robust currents and minerals added), were provided to people with depressive illness, among other disorders.

Practicing in Austria (in a region that is now part of the Czech Republic), Priessnitz gained fame throughout Europe, the UK, the New World, and as far as New Zealand for curing his patients by combining baths with vigorous exercise, adequate sleep and proper diet. Exercise consisted of long walks in fresh air or sometimes (the season permitting I suppose) walking barefoot in fields of grass.

What do they say? What goes around, comes around? Especially, what we could call 'the walking cure.'

Several recent studies, a mere 150 or more years after his death, validate Priessnitz's contention about exercise. More general support for the medicinal, or health, value of exercise was reported in a review article on 29 studies that showed that attention, memory and speed of mental functions were substantially improved in individuals who engaged in aerobic exercise (1). More specific, anatomic brain volume increases were found in people with schizophrenia who exercised aerobically (2). General mental health has been shown to be associated positively with how vigorous and frequent adults exercise (3).

But my favorite is the work of Drs. Dunn, Trivedi and their colleagues in Texas and Canada who demonstrated the salubrious effects of exercise on depression (4). Before I describe their work, I want to stress, as I have elsewhere, that if you or a loved one has severe depression, or depression with suicidal ideas or loss of reality (called psychotic depression), get thee to a doctor. Alternate treatments like exercise or evidence-based psychotherapies, like cognitive-behavioral and interpersonal therapy, are highly effective for mild to moderate depression but for more severe depressive illness -- which can be life-threatening -- medication is generally needed. When illness is severe, alternate treatments become complementary treatments, which is to say they can add, or complement, the action of medical interventions.

But back to the 'walking cure.' The work of Dunn and Trivedi showed that exercising three or more times a week to the level recommended by the American College of Sports Medicine and other public health consensus reports improved symptoms of depression. They called this the "public health dose" of aerobic activity, which means vigorous exercise (walking, running, stationery bicycle are all good) for at least 30 minutes at a time, several or more times a week. No differences were found between those that exercised three times versus five times a week. But those who did not get the "public health dose" (either because they were in a group that did less exercise or were controls, people who did not engage in the treatment but were monitored as a comparison group) did not have the clear improvements in depression that those that exercised did, judged by significant reduction in symptoms or full remission of their condition.

You don't have to start at the "public health dose." Like with most treatments, wise counsel is to start low and go slow. Begin with short walks, or time on an exercise machine. Do it twice a week, and then get to three or more times. Find the right time for you: some people prefer to exercise in the morning, some in the late afternoon or evening (when our muscles are more warmed up and flexible). Work, school or home schedules, of course, may make it plain enough what times are possible.

How does exercise work? We don't know for sure. Release of neurotransmitters instrumental to mood regulation (like serotonin and norepinephrine) or pain control (like endorphins) may play an important role, or perhaps reductions in stress hormones. The discipline and self-mastery of committing to a task and doing it faithfully helps with self-esteem and self-confidence. We may not know the mysteries of the neurophysiology and neurochemistry of exercise, but we know it works!

What does not work, however, is not exercising. It can be hard to exercise even if you are not depressed. Exercise takes time, and for people not used to it can produce aches, pains and fatigue. But those 'side-effects', if you will, go away soon -- replaced often by a feeling of well being, clearer thinking and improvement in mood; some people even lose weight. For people who are depressed, doing almost anything can seem too great a task, or they feel that their condition is hopeless or that they do not deserve to feel better. That is where family and friends come in. Exercise that is done with others, or encouraged and supported by others, is more likely to happen. Priessnitz had a captive population, so if you were at his spa or under his care you got up and walked -- not negotiable if you want to get better, he might have said.

The question for a person with depression, then, is what are you willing to do to feel better, to be able to feel energy and hope again in your life? What do you not only owe yourself, but what do you owe your loved ones, friends and others who rely on you at home, work, school and in your community?

The answer may be old-fashioned, but not out of style.

1. Smith, Blumenthal, et al: Psychosomatic Medicine: 72:239-252, 2010
2. Pajonk, Wobrock, et al: Archives of General Psychiatry: 67:133-143, 2010
3. Medical Sciences Sports Exercise: December 1, 2010
4. Dunn, Triveti, et al: American Journal of Preventive Medicine 5:28:1-8, 2005

The opinions expressed herein are solely my own as a psychiatrist and public health advocate.

Dr. Sederer receives no support from any pharmaceutical or device company.

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