Doi:10.1080/14038190701395838

Advances in Physiotherapy. 2007; 9: 76 Á88 Exercise can seriously improve your mental health: Fact or fiction? School of Health Sciences, Queen Margaret University, Leith Campus, Edinburgh EH6 8HF, UK AbstractThe World Health Organization predicts that depression will create the second greatest burden of disease by 2020,requiring cost-effective prevention and intervention strategies. The evidence to support the benefits of exercise in offeringprotection from depression and as an intervention in the treatment of mental illness is growing. The literature is reviewedwith 11 prospective longitudinal studies that include measures of physical activity and depression at two or more timepoints showing a protective effect from physical activity. Fifteen randomized controlled trials (RCTs) and three meta-analyses provide evidence that exercise can reduce depression and that it can be as effective as cognitive therapy. FourRCTs report exercise as an intervention in alcohol addiction and two RCTs in the use of illicit drugs. While many of thestudies reviewed have methodological weaknesses, including lack of concealment in randomization, limited use ofintention to treat and blinding, the benefits of exercise far outweigh the risks. Neurobiological and psychologicalexplanations as to why exercise should work are discussed. There is evidence that exercise protects against depression andis an effective intervention and adjunctive intervention for the treatment of mild to moderate depression. Exerciseprovides some health and psychological benefits as an adjunct to treatment in complex mental health problems such asalcohol and drug rehabilitation.
Key words: Alcohol abuse, cognitive Ábehavioural techniques, depression, drug abuse, physical activity addicted to alcohol causing 60 types of disease and195,000 deaths per year in Europe. The impact of Depression affects 121 million people worldwide; alcohol abuse on disability is high accounting for 4.5 however, under-reporting is common and only 25% million disability-adjusted life-years (6). Global receive treatment (1,2). Lack of access to treatment, mortality figures for injecting drug users are esti- particularly in developing countries, is linked to theincreased risk of suicide, which claims 850 million mated to be 13 million; however, mortality figures lives every year and is one of the three highest causes for drug misuse are difficult to assess with many of death in young adults aged 15 Á35 years (3).
deaths recorded as suicide, accidents or HIV related Depression is more common in women and more (7). This paper will not attempt to cover all areas of prevalent in developing countries (4). The World mental health in which exercise can play a role but Health Organization highlights mental illness as a will focus on the globally important areas of depres- public health issue, predicting that depression will create the second highest burden of disease What is causing this global pandemic of mental by 2020 (1). Exercise is a low-cost intervention, health problems? There are many indicators that which has the potential, if effective, to play a have been associated with the rise in mental health significant role in both developed and develop- problems. Mental health is associated with the ing countries in the prevention and treatment of economy of the country, employment levels and quality of housing. War, political conflict and The rise in mental illness is also associated with natural disasters have specific effects on the mental the global increase in the abuse of alcohol and illegal health of societies. At a family and community level, drugs (5). It is estimated that 76.3 million people are mental health is associated with social support, and Correspondence: Marie E. Donaghy, School of Health Sciences, Queen Margaret University, Leith Campus, Edinburgh EH6 8HF, UK.
(Received 6 March 2007; accepted 5 April 2007) ISSN 1403-8196 print/ISSN 1651-1948 online # 2007 Taylor & FrancisDOI: 10.1080/14038190701395838 Exercise can seriously improve your mental health an environment with manageable levels of stress. At Is there sufficient evidence to support the an individual level, mental health is linked to premise that exercise can seriously improve individual coping strategies, lifestyle and life satis- In order to address this question, the literature ondepression was reviewed and is discussed alongside commentary from a published review by the authoron the use of exercise in drug and alcohol rehabilita- Defining mental health is complex the terminology is viewed negatively in the context of mental illness All studies from 1970 onwards were located by and positively in the context of mental well-being.
standard search methods Firstsearch, MEDLINE, Mental health is defined by WHO as a state of well- PsychInfo Embase, SPORTDiscuss, Cinahl, Bando- being in which the individual realizes his or her own lier, Cochrane Database of Systematic Reviews abilities, can cope with the normal stresses of life, (CDSR) and the Social Citation Index. The search can work productively and fruitfully and is able to words ‘‘depression’’, ‘‘dysthymia’’, ‘‘depressive dis- make a contribution to his or her community (8).
order’’, ‘‘mild depression’’, ‘‘moderate depression’’ Clinical depression is diagnosed by a cluster of and ‘‘severe depression’’ were combined with ‘‘ex- symptoms that persist for more than 2 weeks.
ercise’’, ‘‘physical activity’’ and ‘‘running’’. To be Symptoms include feelings of unbearable sadness included in the review, a study had to be published and loss of pleasure in association with four or more between 1970 and 2006. The studies had to be of the following: sleep disturbance, lack of energy, longitudinal studies with measures at two or more inability to concentrate, feelings of worthlessness time points, a randomized controlled exercise inter- and thoughts of suicide (9). Addiction to alcohol or vention for a clinically defined population of people illicit substances can be described as an individual with depression, or a meta-analysis of exercise and who experiences multiple serious life problems as a depression. Studies that looked only at the effect of result of prolonged and heavy drinking or illicit exercise on anxiety or neurotic disorders were drug use (7). Physical activity is any movement of the body that results in energy expenditure rising There are numerous quasi-experimental exercise above resting level and includes activities of daily intervention studies and the numbers of those have living, domestic chores, gardening and walking grown exponentially over the last decade; however, (10). Exercise is a subset of PA and is undertaken these have not been included in this review. In total, to improve health or for leisure-time activities 12 prospective longitudinal studies were included, including activities such as swimming, jogging, 11 with positive outcomes supporting the links brisk walking, going to the gym and sports such between regular physical activity, exercise and re- duced risk of mental health problems. Fifteen RCTsprovide evidence of exercise in the treatment of Is exercise important for mental well-being? depression alongside three meta-analyses. In addi-tion, key policy documents in the UK and NICE There are three critical reasons why exercise is guidelines relating to exercise and mental health important for mental well-being. The literature published between 2000 and 2006 were reviewed in reviewed by a panel of experts to produce the UK order to consider the impact of the evidence on National Consensus Statements (11) provides sup- port for; exercise and decreased depression, thestress reduction effects of exercise, the associationof exercise and positive mood, improvement in cognitive function in fit older adults, and positive Eleven prospective longitudinal studies that include effects of exercise on physical self-perceptions and measures of exercise and depression at two or more body image. Research has also found that people time points have demonstrated a positive association who experience mental health benefits from exercise between physical activity and the reduced risk of are more motivated to continue exercising (12). In depression (Table I). This research has been carried addition, exercise and regular physical activity is out by research teams in the USA, Netherlands and known to offer protection in the prevention of Finland using different populations of community obesity, cardiovascular disease, hypertension and dwellers, workers, adults, adolescents and older diabetes. The promotion of exercise thus benefits people. The findings show that people who are both physical and mental health and can be seen as a physically active and exercise regularly are less likely ‘‘win Áwin’’ situation (13).
to be diagnosed with depression in the period Table I. Prospective longitudinal studies that include measures of physical activity and depression at two or more time points demonstratinga protective effect.
Women not engaged in regular activity twice as likely At 9 years, increased risk of depression for men and women who are low active (RR 1.8 men, 1.7 women)compared with high active. At 18 years, ¡activityincreases risk of depression (OR 02.02) Men taking 3 h of sport a week at baseline had 27% ¡ risk of depression compared with men who played lessthan 1 h a week. Evidence of dose Áresponse Those that walked daily and reported more depression at baseline were a third less likely to reportdepression at follow-up (OR 00.38) Increased levels of physical activity provided protec- tion from depression at 5-year follow-up (OR 00.83) From baseline to follow-up, 155 people reported depression associated with decreased amount ofminutes in physical activity and changing from anactive to a sedentary lifestyle (RR 01.62) 3 time points Decrease (1 SD) in physical activity inversely related Depressive symptoms scores decreased after the 6-month intervention, followed by a sustained reduction for 12 and 60 months. Findings similar forboth types of physical activity Strenuous leisure-time activity 1 Á2 times a week reduced risk of depression and emotional exhaustion.
Activity at greater frequencies did not show thisrelationship Mental well-being in later life is associated with 1, 4, 10 years More physical activity was associated with less concurrent depression with physical activitycountering the effects of negative life events ondepression between baseline and follow-up. The findings of the factors (19). This is further supported by the work first prospective study (15) suggest that women who of researchers in the Netherlands (20), who found had engaged in little or no recreational activity were that study participants who became depressed from twice as likely to develop depression when compared baseline to follow-up had changed from an active to with women who had engaged in moderate or high a sedentary lifestyle, and research undertaken in levels of activity. The same protective effect for men Finland (21) with evidence that mental well-being in was not evident. However, for men who were later life is associated with activity, better health and depressed at baseline, inactivity was a predictor of depression at follow-up. The protective factor of A study to determine if changing to a more active physical activity for both men and women was lifestyle would impact on vulnerability to depression demonstrated in a study reported 3 years later was undertaken with formerly sedentary, older (16). The Harvard Alumini (17), one of the largest adults. Study participants were randomly assigned longitudinal studies of its kind, confirms the protec- into 6-month conditions of either walking or low- tive effects of physical activity and the risk reduction intensity resistance/flexibility training. Depressive symptoms scores decreased after the 6-month inter- The evidence for prevention has also been demon- vention, followed by a sustained reduction for 12 and strated in studies of older people. Adults over the age 60 months. The effect was similar for both types of of 65 were followed up for 3 years providing physical activity (22). A study in the Netherlands evidence that daily walking reduced risk of depres- looking at how much exercise was needed to offer sion (18). A further study in the USA with middle- protection found that those with sedentary jobs only aged and older adults found similar protective needed to engage in strenuous physical activity once Exercise can seriously improve your mental health or twice a week to reduce the risk of depression and the Beck Depression Inventory (31); only four of emotional exhaustion (23). Interestingly, higher these studies used additional clinical interview to levels of activity three or more times a week did confirm the presence of depression. Generalizing these studies, which include non-clinical partici- Protective factors of physical activity have also pants, to populations with a clinical diagnosis of been found in adolescents (24). The findings in- depression may be difficult. The most robust in- dicate that a decrease in the frequency of leisure- dicator of the clinical effectiveness of exercise is time activity was inversely related to an increase in whether at follow-up the participants are still de- depressive symptoms. All of these studies have been pressed. The lack of follow-up data a year post- undertaken in communities and the workplace. In a intervention is missing in these studies. Undoubtedly recent study, the relationship between physical there are weaknesses in the methodology to date.
activity and depression was investigated in a clinical While this challenges the evidence, the effect size is sample of 424 initially depressed patients with a 1-, large and consistent across the studies, and this 4- and 10-year follow-up (25). More physical activity should not be ignored. In considering whether was associated with less concurrent depression, with exercise can be an effective intervention for depres- physical activity countering the effects of negative life sion, the potential benefits are far greater than the events on depression. One further longitudinal study potential risks. In addition to the likelihood of the following up 973 medical school students from 1978 mental health benefits, considering intervention until 1993 did not find a link between levels of alongside the evidence for prevention the additional physical activity and associated risk of depression physical benefits to health are an added value from The RCTs reviewed to inform this paper are outlined in Table II (32 Á48); this includes studies published after the most recent meta-regression Sixteen randomized clinical trials (Table II), and analysis (27), including two studies with older adults three meta-analyses demonstrate the effectiveness of (46,47) and a further study reporting dose Áresponse exercise as a treatment or as an adjunct to treatment (48). This area of investigation is still relatively new for people with mild to moderate depression. The with the earliest of these studies undertaken in 1979 most recent of these meta-regression analyses (27) in the USA (32). The findings indicate that running included a systematic review of 14 RCTs; the three times a week for 30 Á45 min over 10 weeks was as effective as time-limited or non-time-limited (28,29). The results demonstrate that exercise re- psychotherapy. Researchers in Norway were the first duces symptoms of depression, standardized mean to demonstrate the effectiveness of a 9-week pro- difference in effect size of (1.1 (95% confidence gramme of aerobic exercise to reduce the symptoms interval, CI (1.5 to (0.6) when compared with a of depression in people hospitalized with depression no treatment group. This is a large effect size (30).
(36). All of the studies demonstrated a positive The effect size was found to be significantly greater effect, whether looking at the effectiveness of ex- for studies with a shorter follow-up period and for ercise versus standard treatment or where compared studies only reported in scientific conferences. Ex- with psychotherapy or medication. Exercise appears ercise was also found to be as effective as cognitive Á to be effective whether it is undertaken with adults or behavioural therapy in reducing depression, standar- older adults. The mode of exercise does not seem to dized mean difference in effect (0.3 (95% CI (0.7 be important with studies including weight training, to 0.1). While these are convincing findings of the aerobic exercise, mixed games and exercise. The efficacy of exercise, the authors concluded that the length of treatment has varied with periods of 8 Á effectiveness of exercise in reducing symptoms of depression could not be determined because of the Recent work from researchers in the USA informs lack of good-quality research. The methodological us that exercise has to be equivalent to the public weaknesses in the studies include lack of information health dose to be effective in reducing depression but regarding treatment allocation, only three studies that frequency does not matter (48). This study appeared to have appropriate concealment, and compared frequency of exercise [3 or 5 days per intention-to-treat analysis was only undertaken in week] and total energy expenditure per week [7 kcal/ two studies. In 12 of the studies, the main outcome kg/week ‘‘low dose’’ versus 17.5 kcal/kg/week ‘‘public was measured by self-assessment using a question- health dose’’] in a 12-week protocol. Four aerobic naire. Nine of the studies included non-clinical exercise conditions allowed these comparisons; two populations with most participants being recruited groups exercised on 3 days a week Á one expended through the media and assessed by a cut-off point on 7 kcal/kg/week and the other 17 kcal/kg/week; two other groups exercised on 5 days a week but ex- depression. A well-funded investigation into the pended the same totals of either 7 or 17.5 kcal/kg/ effectiveness and cost-effectiveness of exercise on week. Participants were randomly assigned to one of prescription for people with depression is currently these four groups or to a placebo exercise condition, being undertaken at the University of Bristol (49) which involved stretching exercises on 3 days of the and the team will report their findings in 2011.
Exercise has been shown to be as effective as anti- However, the benefits of exercise are not depressants or exercise plus anti-depressants in reducing depression with the benefits sustained at6 months (44). In this study, participants (n 0156; A systematic review undertaken by the author high- 113 women, mean age 57 years) who were assessed lights the emerging evidence of the impact of as clinically depressed according to DSM-IV criteria exercise in the treatment of people with mental or HDRS 7 were randomized into one of three health problems such as alcohol and drug addictions groups. The 16-week exercise intervention com- (14). Four RCTs (50 Á53) provide some evidence for prised of three 45-min aerobic sessions a week. All the use of exercise as an adjunct in the rehabilitation three groups reduced depression scores at 16 weeks of problem drinkers and two RCTs (57,58) provide and maintained the reduction at 6 months; at evidence for exercise as an adjunct to the rehabilita- 10 months depression rates were lower for the tion from substance misuse (Table III). Of the four exercise group. The participants self-selected to RCTs relating to problem drinkers, only two (52,53) join the study and motivation may have been a had a sufficient sample size to provide conclusive findings. Both of these studies had a high dropout RCTs undertaken with home-dwelling older peo- rate and only one (53) used intention-to-treat ple who were not self-selecting also show a reduction analysis. Both of these studies followed the American in depression from exercise. A 10-week exercise College Sports Medicine guidelines (ACSM) (54) programme was found to be as effective as an on the frequency, duration and intensity of exercise adjunct to antidepressant therapy in reducing de- required in order to develop and maintain aerobic pressive symptoms in older people (46). Patients and strength fitness. Estimated oxygen uptake was (aged 53 Á78 years) were randomized to attend the most commonly used measure of fitness. Various either exercise classes or health education talks for measures were used for psychological outcome, 10 weeks. Results showed that at 10 weeks, a sig- depression, perceived body image and self-esteem.
nificantly higher proportion of the exercise group One study found benefits that included improve- (55% compared with 33%) experienced a greater ments in fitness and strength, physical activity levels, than 30% decline in depression. Two studies looked physical self-perceptions and self-worth (53). The at unsupervised exercise as a long-term treatment for perceptions of the study participants in regard to clinical depression in elderly people (42,43). The how their physical fitness and strength had changed authors studied 32 older adults (aged 60 Á84 years) were in line with actual changes. These physical in a 20-week, randomized, controlled trial, with changes and mental awareness of these changes follow-up at 26 months. Exercisers engaged in impact on physical self-worth with a significant 10 weeks of supervised weight-lifting exercise fol- improvement noted at 1 month and 2 months in lowed by 10 weeks of unsupervised exercise. Depres- this study. Physical self-worth has a direct influence sion was significantly reduced at both 20 weeks and on self-esteem. Enhancing self-esteem is critical 26 months of follow-up in exercisers compared with when people are attempting to change behaviour.
controls. In a further study of 60 older adults, high- For some, the exercise programme enabled them to intensity progressive resistance training (80%) was change their lifestyle and get back to doing activities found to be more effective than low-intensity pro- they used to enjoy, e.g. cycling, hill walking, and for gressive resistance training or general practitioner one teenager boxing. An interesting outcome was (GP) care (47). These studies provide some clinical that the study participants did not link the benefits evidence for group exercise lowering depression in from exercise to their addiction problem. There were home-dwelling older people. Like the studies in many quotes similar to this one ‘‘Feeling fitter is adults, the mode of exercise appears to be flexible great I feel less like drinking but that doesn’t mean I with both weight training and aerobic exercise go to the gym instead of drinking, they are very providing sustainable benefits; these studies vary in In the treatment of substance misuse, two studies Undoubtedly further research, which highlights using an RCT design have been published (Table longer periods of follow-up, is required before we III). One of these studies (55) had an insufficient can confirm the causal link between exercise and sample size (n 015 in each group) to have a realistic Table II. Characteristics of randomized controlled studies of exercise for clinically defined depression.
(ii) Relaxation training;(iii) Waiting list control 12 weeks, 1-, 3- and (i) Running with a leader, 12-month follow-up (ii) Weight-lifting 4 )week; Fremont & Craighead, n 049, M, F, recruited Martinsen et al., 1989, n 099, mean age 41 improvements in exercisers.
Depression lower at 20 weeksand 26 months in exercisers.
33% exercisers still weightlifting at 26 months group only had relapsed orused medication.
61% of the high-intensity,29% of the low-intensity, and21% of the GP care group BDI, Beck Depression Inventory; CES, Center for Epidemiological Studies Depression Scale; CIS, Clinical Interview Schedule; DSM-III or IV, Diagnostic and Statistical Manual of MentalDisorders; HRSD, Hamilton Rating Scale; POMS, Profile of Mood States; RDC, Research Diagnostic Criteria; SCL, Symptom Checklist; SDS, Zung Depression Scale; SF-36, MedicalOutcomes Survey Short Form.
Table III. Characteristics of randomized controlled studies on exercise interventions with problem drinkers or other substance abuse.
Gary & Guthrie 1972, n 020, Male only, VO2 max, BDI, STAI, relapserate, drinking behaviour orpsychosocial functioning.
Increased dropout inhigh-intensity exercise group 3 weeks, ' 12-week (i) Aerobic and strength exercise; Est. max. VO2, strength and and strength in exercise grouponly ¡ anxiety and depression BP, blood pressure; Est. max. VO2, estimated maximum oxygen consumption; LOC, locus of control; BDI, Beck Depression Inventory; STAI, Speilberger State and Trait anxiety inventory; CDT,Carbohydrate deficiency transferrin blood analysis; PSPP, Physical self-perception profile; CES-D, Centre of Epidemiological Studies Á Depression; SESWS, Standard Evaluation Scale of Withdrawal Symptoms; HAS, Hamilton Anxiety Scale.
chance of showing any significant effects from the two-thirds indicating that it helped to relieve their exercise, neither were the findings analysed on an depression; however, 58% did not know that some intention-to-treat basis, with 35 participants ex- GPs can prescribe exercise. The GP exercise-referral cluded from analysis as they did not complete the schemes introduced in the late 1990s in the UK programme. The other study used an intensive allow people with mental health problems to access programme of Qigong over 10 days, although the exercise facilities in their local community. The analysis indicate a reduction in withdrawal and commissioned report, ‘‘Up and Running’’ Treat- morphine use, the transferability of this type of ment for Mild and Moderate Depression (65), came programme outside of China may be limited (56).
out strongly in favour of advocating exercise as a While these results are interesting the lack of first-line treatment for depression and led to the consistency in the use of outcome measures and production of posters and leaflets for distribution the small number of well designed RCTs limit the through GP surgeries. The findings outlined in the conclusions. However, we can say that there is report, however, suggest that only 5% of the GPs unequivocal support that physical exercise regimens surveyed consider exercise as one of their three most have a positive effect on aerobic fitness and strength common treatment responses compared with 92% if used as an adjunct in alcohol rehabilitation. The who would consider using medication.
link between improvements in self-esteem and ex-ercise with alcohol and drug rehabilitation is at this time equivocal. The evidence for exercise improving abstinence levels or controlled drinking levels isequivocal. The fitness benefits may be important The association between exercise and positive mood for people attempting to change behaviour.
can be explained by physiological and psychological There are no longitudinal studies supporting the explanations. The increased blood flow to the brain use of exercise as prevention in alcohol and drug stimulates the release of naturally occurring mood- addiction. Some large cross-sectional studies of enhancing chemicals known as endorphins; these adolescents have found a negative association be- natural opiates are similar to morphine and have tween substance use and physical activity, whereas been linked to the ‘‘runners high’’. Studies have others have found no relationship, or have shown a demonstrated their presence in blood samples of negative relationship only in females or only in people following exercise (13). This explanation, males. From this evidence, there appears to be a however, remains speculative, as we don’t know if complex relationship between substance abuse and endorphins can cross over the blood Ábrain barrier.
exercise, which is mediated by gender, personality, Animal studies have found that chemicals known to mode of activity and type of drug used (14).
be depleted during depression Á norepinephrine,dopamine and serotonin Á are released duringexercise (66). These neurotransmitters have been associated with elevating mood. Antidepressant In addition to the scientific literature key reports, medication such as Prozac works by boosting these clinical guidelines and policy documents promote chemicals. This may partially explain why exercise the use of exercise for mental health. The United offers protection to depression and is effective as a States Department of Health and Human Services treatment intervention. Exercise is known to increase and the Department of Health (57 Á60) highlight the levels of brain-derived neurotrophic factor (BDNF); links between exercise and mental health promotion.
this substance is associated with enhancing mood The National Institute for Clinical Effectiveness and helping the brain cells survive longer. This may (NICE) guidelines for Depression (61,62) highlights also be linked to improved cognitive function (66). It exercise as an adjunctive treatment for mild and has also been suggested that increased levels of moderate depression. The recent Scottish Executive phenylethylamine, a known stimulant in the brain policy document Delivering for Mental Health (63) occurring during exercise, is linked to the release of highlights exercise within its self-care management dopamine and endorphins, acting as a natural anti- depressant. This has been evidenced by a rise inphenylacetic acid found in urine samples followingexercise (67).
Do people with mental health problems want to Explanations from psychology suggest links be- tween exercise and physical self-perceptions such as A survey by the charity Mind (64) found that 83% of body image, physical self-worth and self-esteem people with mental health problems looked to (12). The findings from the Mind survey support exercise to lift their mood or to reduce stress with this explanation, with 50% stating that exercise Exercise can seriously improve your mental health boosted their self-esteem. Planning and undertaking In summing up, exercise increases the blood flow exercise allows setting and achieving goals, skill to the brain. It stimulates the circuits in the sub- development, building self-confidence and it may cortex resulting in increased heart rate, increased also provide a mechanism for social support if levels of cortisol and adrenaline. Regular exercise exercising with others. The anxiety reduction effects changes these pre-set circuits modifying the response of exercise have been linked to improved cardiovas- to stress. This in turn lays down new associations in cular fitness reducing reactivity to and recovery from the cerebral cortex, which influences our thoughts, how we interpret situations, how we interact with It has recently been suggested that exercise can our environment and the people within it. Through influence brain plasticity and bring about changes by this mechanism of adaptation, regular exercise has facilitating neurogenerative, neuroadaptive and neu- the potential to influence other health behaviours roprotective processes (68). Currently the mechan- such as alcohol and drug addiction, smoking and ism for this is not well understood but metabolic and chemical pathways among the brain, spinal cord and It has been argued that the benefits of exercise and muscles offer plausible testable mechanisms. While mental health are likely to be best explained by an agreeing with this, the author would argue that we integrated theory that takes account of the biochem- have ignored the importance of emotions and feel- ical physiological, psychological explanations (71).
ings and their role in neuroadaptation. The human In doing so, the importance of the brain circuitry genome (the totality of our chromosomes) cannot involved in emotions and feelings should not be account for the entire structure of the brain but it ignored. The mind Ábody link is important in all of helps set the circuits in the older part of the brain (69). This part of the brain, which includes the brainstem, hypothalamus, limbic system and amygdala, is So are we really taking this evidence on board pre-set for survival ensuring we continue breathing, regulating our heartbeat and balancing our metabo-lism. Although pre-set, these circuits adapt with Firstly, GPs need to shift their views about choosing experience, ensuring that we can adjust to different exercise as a treatment option. In the UK, only 5% environments across our lifespan. From early child- prescribed exercise as one of their three most hood, we learn about social conventions and ethical common treatments for depression, compared with rules. These layers of new facts and experiences 92% who would prescribe anti-depressants (64).
shape our behaviour leading to desirable decision- Why is this? Perhaps the idea that something as making strategies, increasing our chances of survival.
complex as the ‘‘mind’’ can be treated by something Studies have shown that we have reward circuits in as simple as ‘‘exercise’’ is difficult for GPs, health- the brain linked to the limbic system. Rewarding care professionals and the public to accept. The experiences release dopamine telling the brain ‘‘to do 17th-century Cartesian view that the mind and body it again’’ (70). Memories associated with rewarding are separate entities may still pervade medicine today experiences are laid down in the cerebral cortex and (69), resulting in the psychological consequences of are triggered by certain cues, which stimulate the disease being disregarded. There is a need to recurrence of the behaviour. Thus the brain adapts consider how exercise and the associated changes over time to new experiences that are repeated. The in the body relating to fitness and strength influence sub-cortex or evolutionary part of the brain keeps us our emotions and feelings the somatopsychic re- alive and helps us shape and change our behaviour as sponse. By considering this response alongside and when required (69). The cerebral cortex enables the psychosomatic response, knowledge of how us to reason, make decisions, build and store knowl- exercise can seriously impact on mental health may edge. Our emotions and feelings are like a river with information continually flowing to ensure a con-certed effort.
Recent research highlights how repeated abuse of illicit drugs or alcohol lays down memories that are There is a need to heighten awareness of GPs, difficult to diminish (70). These memories are physiotherapists, occupational therapists and exer- triggered by cues associated with drug taking or cise specialists on the benefits of exercise for people drinking, increasing risk of relapse in addicts.
with mental health problems. We need to consider Changing behaviour requires new pleasurable ex- the training needs of those who deliver exercise periences to be repeated over time in order to rewire programmes in the community at outpatients clinics the circuits. Exercise has the potential to play a key and exercise-referral schemes. At this time, we do not know the optimum strategy to engage people with depression or addiction problems into exercise.
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