From the Editor
“Go for a Run to Beat Depression – It’s Just As Effective As Taking Medication”
– New York Post
“Running could be just as effective at treating depression as medication, scientists find”
– The Independent
Patients often ask what they can do to get better from their depression. Should we be advising them to put on a pair of runners and go for a jog? A new paper published in the Journal of Affective Disorders seems to suggest as much – and it’s caused a bit of media buzz. In the first selection, Josine E. Verhoeven (of Vrije Universiteit Amsterdam) and her co-authors describe this 16-week study that offered 141 people with depression and/or anxiety either a running intervention or medications, and looked at several mental and physical health outcomes. “We showed that while antidepressant medication and running therapy did not statistically significantly differ on mental health outcomes… the interventions had a significantly different and often contrasting impact on several physical health outcomes, with more favorable outcomes for those in the exercise intervention.” We consider the paper and its implications.
In the second selection, Pim Cuijpers (of Vrije Universiteit Amsterdam) and his co-authors discuss climate change and mental health in a new viewpoint for JAMA Psychiatry. Though they note the lack of high-quality research in the area, they argue that it would disproportionately affect low and middle-income nations. They then point a way forward. “There is no doubt that climate change will have a major impact on mental health in the coming decades.”
And in the third selection which is written anonymously, a person with schizophrenia talks about his experiences in a paper for Schizophrenia Bulletin. He tries to empower himself, working to limit side effects and cope with the voices. “My brain disease is incurable, but it is not an excuse for me to be irresponsible or to give up on life.”
Selection 1: “Antidepressants or running therapy: Comparing effects on mental and physical health in patients with depression and anxiety disorders”
Josine E. Verhoeven, Laura K. M. Han, Bianca A. Lever-van Milligen, et al.
Journal of Affective Disorders, May 2023
Depressive and anxiety disorders cause immense suffering by compromising both mental and physical health, and the need for effective treatment strategies continues to be pressing. Antidepressant medication is, next to psychotherapy, considered a standard first-line treatment with moderate effectiveness and sufficient tolerability. However, antidepressants are not effective for all and often associated with side effects. An interesting alternative treatment is exercise therapy. Meta-analyses showed that for mild to moderate depression the effect of exercise interventions is comparable to antidepressant medication and psychotherapy (with largest effects for aerobic exercise with at least moderate intensity, supervised by exercise professionals), while for severe depression exercise interventions seems to be a valuable complementary therapy. For persons with anxiety disorders, exercise interventions also showed similar effectiveness to established treatments, although the number of studies are fewer and of varying quality…
On a biological level, antidepressant and exercise interventions have both shown to impact neurobiological and physiological pathways. For instance, exercise has been shown to reduce oxidative stress, inflammation, cortisol and metabolic syndrome dysregulation. In contrast, some studies showed that selective serotonin re-uptake inhibitors (SSRIs) resulted in increased body weight, parasympathetic tone and inflammatory levels.
So begins a paper by Verhoeven et al.
Here’s what they did:
- Participants were recruited from psychiatric outpatient clinics in the Netherlands who met criteria for a current depressive disorder or an anxiety disorder based on the Composite International Diagnostic Interview.
- Exclusion criteria included exercising more than once a week and having suicidal thoughts.
- “Those without strong preference for treatment allocation were randomly allocated (1:1) to either antidepressant medication or running therapy… Persons who were not willing to be randomized but willing to participate in the study, were allocated to their preferred intervention.” (!)
- “Running therapy consisted of supervised 45-min outdoor running sessions during 16 weeks. The target was to get persons to participate in these exercise sessions two to three times a week.” Participants in the medication group were given escitalopram or sertraline.
- Mental health outcomes: diagnosis status and symptom severity; physical health indicators: heart rate, weight, and blood pressure.
Here’s what they found:
- 240 patients were screened with 141 were willing and eligible to participate.
- Preferences. “22 were willing to be randomized into the antidepressant (n = 9) or the running therapy (n = 13) groups, while 119 participants chose the treatment of their preference: antidepressant (n = 36) or running therapy (n = 83).”
- Illness severity and demographics. The depression severity score (IDS) was higher for the antidepressant group (mean = 46.0) compared to the running therapy group (mean = 40.5). There were more females in the running therapy than in the medication group (60% vs 53%), but similar ages and years of education.
- Remission. Remission rates didn’t differ, 43.3% for the running therapy group and 44.8% for the med group.
- Physical health outcomes. There were differences between the two groups favouring the running therapy: “weight (Cohen’s d = 0.57…), waist circumference (Cohen’s d = 0.44…), systolic (Cohen’s d = 0.45…) and diastolic (Cohen’s d = 0.53…) blood pressure, heart rate (Cohen’s d = 0.36…)…”
- Adherence. 82.2% of participants adhered to the medications but only 52.2% completed more than 22 sessions of exercise.
A few thoughts:
1. This is an interesting study and there are strengths: a reasonable sample size and various measured physical health outcomes. Given the hesitation that some patients have with medication management, the study is practical and relevant.
2. The big findings in a sentence: While mental health outcomes didn’t differ statistically between the medication and running therapy groups, the runners did better with physical health outcomes.
3. But is this study flawed by its design? Few participants were actually randomized. Most opted for one intervention or the other.
4. And because they weren’t randomized, the baseline illness severity differed. More depressed people chose meds – as we would suspect. Does the similar mental health outcomes mean that meds were, in fact, more effective? Gideon Meyerowitz-Katz (of the University of Wollongong) makes that argument in Slate, drawing on data from the supplementary appendix. Again, given the lack of randomization, it’s difficult to draw larger conclusions as some have done in the popular press.
5. The 2013 Cochrane review on exercise and depression found that most studies they reviewed were problematic with issues around bias, randomization, and blinding. They concluded: “Exercise is moderately more effective than a control intervention for reducing symptoms of depression, but analysis of methodologically robust trials only shows a smaller effect in favour of exercise.” That review can be found here:
6. Clinically, this JAD study doesn’t mean that patients should be told to buy runners. But the role of exercise is established for mood disorders with limited downside, and is recommended in both the 2016 CANMAT depression guidelines and the forthcoming 2024 update.
The full JAD study can be found here:
Selection 2: “Climate Change and Mental Health – Time to Act Now”
Pim Cuijpers, Manasi Kumar, Eirini Karyotaki
JAMA Psychiatry, 4 October 2023 Online First
There is no doubt that human activities have caused the earth’s global warming, resulting in extensive and swift changes in the atmosphere, ocean, cryosphere, and biosphere, including rising sea levels, extreme weather events, deforestation, and stress to different ecosystems. These alterations are unparalleled in magnitude over numerous centuries or even thousands of years and may have serious implications for human health, such as kidney function loss, dermatological malignant neoplasms, pregnancy complications, allergies, and cardiovascular and pulmonary morbidity and mortality.
These climate changes also have considerable impact on mental health through several different pathways. First, natural disasters, such as floods, hurricanes, and earthquakes, may directly result in increases in posttraumatic stress disorder, depression, and suicide. Second, gradual changes, such as rising sea levels and temperatures, may slowly disrupt societies and can be associated with more aggression and higher suicide rates. Pollution and greenhouse gases from burning fossil fuels may further exacerbate this effect.
So begins a paper by Cuijpers et al.
The authors focus on three areas.
Limited Research on Climate Events and Mental Health
“[T]here is little high-quality research connecting climate change with mental health. We recently conducted an umbrella review including 13 meta-analyses examining the association of climate events with mental health. We found low-quality evidence for an increased prevalence of symptoms of posttraumatic stress, depression, and anxiety associated with the exposure to climate events. However, the effect sizes differed considerably across studies and not all were significant.”
Climate Change and Inequalities
They suggest that inequities will occur on a national level. “More than 80% of the 1 billion people experiencing mental disorders worldwide live in low- and middle-income countries (LMICs). Many debilitating climate events occur in LMICs, which have the lowest resources to prevent and treat mental disorders, whether or not they are related to climate events. Research on scalable interventions to build up an infrastructure for mental health care in LMICs is essential for reducing the worldwide burden of mental disorders and reducing the psychosocial impact of climate events. Climate events may add to this already high disease burden. If the infrastructure for regular mental health care is not optimal, it will be challenging to handle the additional problems caused by the extreme climate events that present as humanitarian crises.”
They also suggest that some “vulnerable populations” may be more affected, including “individuals who have low income, are older and have disabled children, those who are incarcerated, migrants, and those who misuse substances.”
Climate Events and Emergency Preparedness
“There is already much experience with supporting communities that are struck by adverse events, including floods, hurricanes, and earthquakes… The World Health Organization has developed several brief and scalable interventions for mental health problems and ongoing and severe adversities that can be used in any crisis, including those caused by climate events, and many other interventions have been tested in a growing number of randomized clinical trials. Action plans for emergency preparedness in countries and communities at risk for climate events can build on this growing body…”
They close with a call to action.
A few thoughts:
1. This is a timely paper.
2. Though others have written about climate change and mental health, the authors make a very practical point about scaling up existing crisis-focused interventions.
3. For a Canadian perspective on this issue, Drs. Daniel Rosenbaum and Sarah Levitt (both of the University of Toronto) wrote a Canadian Psychiatric Association position paper, “Mental Health and the Climate Crisis: A Call to Action for Canadian Psychiatrists.” They make eight recommendations. You can find it here:
The full JAMA Psych viewpoint paper can be found here:
Selection 3: “Understanding My Personal Schizophrenia”
Schizophrenia Bulletin, 17 October 2023
Twenty years have passed since I started recovery from my schizophrenia. Those years have taught me many lessons about my diagnosis, and my purpose in life now is to use those learned lessons to help others who have recently been diagnosed. One of the important lessons I have learned over the years is that everyone’s mental health journey is different. We all may have the same symptoms, but those symptoms may vary widely depending on the person.
So begins an essay written anonymously.
He notes that weight gain can be problematic with his medications. “One of the ways I combat that side effect is through intermittent fasting. I have talked to my doctors about fasting and together, we worked out a plan for the hours when I will eat and when I will fast. I have to be mindful and stop eating around 4 PM or 4:30 PM. I know that a little bit of time makes a difference in my situation.”
He discusses the auditory hallucinations. “The voices I hear are usually recognizable from my past. I conclude: Why would past bullies still have a problem with me? It has been twenty years since I last interacted with them. Have they not gone on with their lives? I can talk through these racing thoughts, but they still happen. I try to distract myself from them.”
What works to keep him well? “Accepting my illness, being patient with myself, taking the right medication, and having things to help me distract myself from my personal schizophrenia. All this takes time. When I began taking my meds and they began working, I not only could accept my illness, but I realized what was going on in my brain was in fact schizophrenia. I still did not understand where all those excessive thoughts came from… that takes time.”
And he notes the importance of empowerment. “I have spent many years learning to recognize my symptoms and figuring out what some of my triggers might be. It is hard work to constantly assess what could be triggering symptoms, but in the end, it is empowering to know I do have some control over my mental health journey.”
A few thoughts:
1. This is a personal and moving essay.
2. Though hopeful, he candidly describes the daily struggles of his chronic illness. “I can understand my schizophrenia, but I still deal with the same delusions I had since my twenties.”
3. His focus on empowerment is interesting. Can we do that better with our patients?
The full Schizophrenia Bulletin first person account can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.