Treating mild depression

Evra Taylor Levy and Eddy Lang, Special to the Gazette
Published: Friday, December 21

It's no secret that the holidays and transition into a new year spell depression for many people experiencing loneliness, difficult life events or loss. With this, our end-of-the-year edition of Healthwatch, we bring you an uplifting study that looks at a way of beating some kinds of depression without medication.

Worldwide, depression is the leading cause of years lived with disability. During their lifetime, about five to 12 per cent of men and 10 to 25 per cent of women will have at least one major depressive episode. Interestingly, mood disorders often begin in adolescence, making early diagnosis especially important to offset years of unhappy, impaired living. Additionally, Canadian winters mean reduced sunlight and shorter days, which have been implicated in an increased prevalence of depression at this time of the year.

Symptoms of depression
It has been reported that half of the people who have clinical depression don't know it, so recognizing its symptoms is essential and the first step toward treatment. While not a complete list, symptoms include: persistent sadness; pessimism; feelings of guilt; loss of interest and pleasure in activities; helplessness or hopelessness; difficulty concentrating; insomnia or oversleeping; apathy; anxiety; thoughts of suicide or death.

The study found that home-based exercise was as good as a group workout in dealing with depression, but the people in supervised sessions ended up more aerobically fit.
Peter Martin / Gazette File Photo

Depression has become so ubiquitous that stalwarts who in the past would not have dreamed of admitting to the condition are now openly discussing their struggle with it. The bad news is the incidence of depression in North America has skyrocketed; the good news is that the stigma of having depression has somewhat lessened.
Clinical depression - as opposed to "feeling down," from which someone can more easily spring back - can be triggered by life events, but is also a physical disease caused by changes in brain chemistry and function. Many people are familiar with the effects of reduced serotonin levels in the brain (serotonin is one of the chemicals that affects mood); in addition, "serotonin reuptake" - the ability of the brain to effectively use the serotonin - is often impaired.

Researching the effects of exercise
On the bright side, exercise has, in some camps, been promoted as an aid for depression. Because no single treatment is effective for everyone and side effects from medication are not uncommon, the scientific community has been interested in exploring alternative therapies for its treatment. Numerous studies conducted in the 1980s and '90s looked at the effectiveness of aerobic exercise and resistance training, but these studies were plagued with problems that rendered them less than reliable. A major issue involved the lack of a placebo comparison group in many of the studies.
Clinical depression is known to have a high and variable rate of placebo responsiveness - that is, patients with depression show improvement if simply given a sugar pill. But placebo use is a two-edged sword in this kind of research.
On the one hand, in order to accurately measure the effect of a new medication in comparison with other interventions, it's important that the powerful effects that can be created by the expectation of benefit, attention by healthcare providers or simply the effect of time (i.e. placebo effects), be equal in the groups being compared. Without a placebo, patients in the comparison group can feel like they are being treated differently, and often are, thus muddying measures of benefit: was it the new drug or a placebo effect?
On the other hand, if some of the patients are receiving placebo, in a sense they are not getting any treatment at all and this can be viewed as unethical research since effective treatments do exist.

The study
Exercise and pharmacotherapy in the treatment of major depressive disorder by James A. Blumenthal et al. Journal of Psychosomatic Medicine, Sept. 17, 2007.

What were the specific problems with earlier research examining the value of exercise as a treatment for clinical depression?
In addition to problems with the lack of a placebo group in older studies, the benefits were noted in the context of supervised group exercise sessions. This created the possibility that it wasn't the effects of the exercise that were beneficial but the social support that came with meeting regularly for training that eased the depressive symptoms.

What question did the study try to answer?
The researchers recruited more than 200 patients with mild or moderate depression; it was deemed too risky and unethical to recruit patients with severe depression who would be at higher risk of suicide. There were four distinct comparison groups:

  • Patients who were given a home exercise program to follow.
  • Those who participated in supervised exercise sessions.
  • Patients receiving the standard antidepressant medication, sertraline (sold as Zoloft)
  • A group receiving no treatment other than placebo.

The patients in the exercise groups were instructed to engage in three 45-minute workouts per week, with the focus on a 30-minute aerobic session, a 10-minute warm-up and a five-minute cool down.
The results were reported as the percentage of patients with mild to moderate depression as measured with questionnaires, whose symptoms and ability to function improved; a great enough improvement was deemed a remission. Also examined were changes in exercise capacity at the end of the four-month study period.
All the patients were followed quite closely and met with a psychiatrist on several occasions.

So, how does exercise compare to medication in the treatment of mild to moderate depression?
Although this was a small study, the findings suggest that exercise might be as good as medication in this context. The rates of remission were in the 40 to 50 per cent range for both kinds of exercise programs as well as for the medication. The placebo group responded more modestly, though not all that differently, with 31 per cent meeting the criteria for remission at the end of the study.

Which works better, a home-based program or a supervised program?
They seem fairly equivalent but, interestingly, those in the supervised program logged more exercise sessions than those in the home-based group. They probably pushed themselves harder since they showed better aerobic fitness by the end of the study.

What's the take-home lesson?
This study jibes with the previous research, and brain chemistry research suggests that exercise offers definite mood-lifting properties, in addition to so many other benefits. One should bear in mind that while this study showed a benefit, patients in this study were generally eager to take part in this research. While they showed modest benefit, the same may not hold true for the majority of patients who battle depression.
Major clinical depression is a serious condition and best available evidence supports the idea that exercise can be beneficial and might even reduce or eliminate the need for antidepressant medication. However, it could be a grave mistake to forgo or stop these medications if they are being recommended to you by your family physician or mental health professional.

We wish to thank John Young, Associate Director, Adult Psychiatry Clinic, University of California at San Francisco and Jesper Krogh, Department of Psychiatry, Bispebjerg University Hospital, Copenhagen, Denmark for their input in this column.

Our objective with HealthWatch is to bring to you the latest medical news offering help and hope to aid you on your journey toward optimal health. We wish all our readers a happy - and healthy - holiday season and new year.
The material provided in HealthWatch is designed for general educational purposes only and does not pertain to individual cases. The information included should not replace necessary medical consultations with your own doctor or medical professional.

Additional resources:
Ami-Québec (Action on Mental Illness) offers information, resources and support groups in Quebec:
National Alliance for the Mentally Ill

Rate your risk for depression
Diagnosis of depression is the first step toward treatment. Here's a quiz that might help you decide whether or not you have clinical depression. If you suspect you do, don't be embarrassed or afraid to seek help.
Could you be depressed?
Depression affects people differently. Some people cry a lot and feel sad. Others seem angry, irritable or anxious. For others, depression shows itself in vague physical problems like constipation, muscle aches and headaches. Take a minute to think about how you have felt over the past two weeks. Which of these statements describe you? Feeling five or more of these symptoms in the same two-week period indicates that you might be at risk for clinical depression. A discussion with your physician is recommended.

    1. I feel sad or down most of the time.

    2. I've lost interest in the activities I used to enjoy.

    3. I feel tired almost every day.

    4. I have problems sleeping. I'm either sleeping too much or staying awake at night.

    5. My appetite has changed. I'm not eating enough, or I'm eating too much.

    6. I have trouble concentrating.

    7. My friends say I'm acting different. I'm either anxious and restless or lethargic.

    8. I feel worthless or hopeless.

    9. I'm having frequent headaches, stomach problems, muscle pain, or back problems.

    10. I find myself thinking a lot about dying.


© The Gazette (Montreal) 2007