Depression: Medication is not working? Try exercise and the internet!

By Dr. Minal Mistry, Psychiatrist
 
WHO and depression
The World Health Organization (WHO) describes depression as the “leading cause of disability worldwide” and as a “major contributor to the overall global burden of disease” (see World Health Organization Fact Sheet below).  WHO highlights that depression is more common in women, can lead to suicide, but “effective treatments” are available.
Regarding treatment, WHO state that:

• There are interrelationships between depression and physical health e.g. cardiovascular disease can lead to depression and vice versa, and recommend “exercise programs.”
• Health care providers may offer psychological treatments and antidepressant medication, but warn that antidepressants can cause adverse effects.

 
Psychosocial treatments for depression
WHO go on further to say that “psychosocial treatments are also effective for mild depression.”  WHO mention therapies such as cognitive behavioural therapy (CBT), interpersonal psychotherapy (IPT), and behaviouraI activation (BA).  I have already written a blog on The Beautiful Space about one of WHO’s recommendations (see my blog on: “Behavioural Activation (BA): The forgotten therapy for Depression.”) 
I have now encountered newly released research that proves that other psychosocial treatments can help depression: enter stage… EXERCISE and ICBT:

• CBT is not always available, may entail long wait times, or people have difficulties in attending sessions due to other commitments or living in isolated areas.  With the rise of the digital age, the internet has become a more attractive model of delivery for CBT that is immediately accessible, hence the popularity of Internet-based CBT (ICBT).

 

• Exercise, as well as improving sleep (see recent The Beautiful Space blog on “sleep problems”), is known to change our biochemistry (e.g. serotonin synthesis), behaviour (e.g. by distraction), and thinking (e.g. gives a sense of mastery) to improve low mood.  Regardless of whether or not one is depressed, our physical and mental health can be improved with exercise.

 
New Swedish randomized controlled trial
Doctors love randomized controlled trials (RCTs)!  We also love the Swedes…and not just for bringing us ABBA and IKEA!  This new study from Sweden, published in the prestigious British Journal of Psychiatry (November 2016), claims to be the first community-based RCT comparing exercise, ICBT, and usual care for depression (see study reference at the end of this blog).  It involved nearly 1000 participants, most of whom were women (73%) with mild to moderate depression, who were followed up over a period of one year.  Impressive, eh?  Even more impressive were the results that I am completely thrilled by:
“The largest treatment effect was obtained at the interim assessment (3 months), when severity had reduced significantly more in the exercise and ICBT groups compared with usual care.”
 
The results of the Swedish study get even better for the long-term outlook:
“Importantly, the long-term follow-up assessment reported in this study adds the observation that the short-term treatment benefits reported previously were maintained 9 months later.”
 
What does this mean?
WHO state that depression results from “a complex interaction of social, psychological and biological factors.”  With this in mind, we must not forget that treatment also requires a biopsychosocial approach.  If we neglect the (now proven) psychosocial elements of treatment, we are ignoring the best scientific evidence to date from Europe.  The authors of this groundbreaking study advocate for light exercise in helping depression, or ICBT for those who are physically limited.

Moreover, there have been recent discussions in the United Kingdom (UK) about medication being the cause of disability.  For instance, the UK recently had an All-Party Parliamentary Group meeting on “Rising Prescriptions, Rising Disability” in May 2016 (see video via blog link below).  This has prompted many professionals to explore non-medication ways to help people with depression.  ICBT and exercise may be very effective, without the side effects of medication, and should be considered amongst the front-runners for improving mild to moderate depression.
 
Declaration of competing interests (!)
The author of this blog would like to declare that he does at least 30 minutes of brisk walking daily; cycling and running in the spring and summer; and skiing and snowshoeing in those cold Canadian winters…brrrr!

Cite this article as:

Minal Mistry (2016) Depression: Medication is not working? Try exercise and internet!.The Beautiful Space-A Journal of Mind, Art and Poetry. December 2016: TBSB108
 
Useful information
 1. World Health Organization fact sheet on Depression (updated April 2016). http://www.who.int/mediacentre/factsheets/fs369/en/
   2. Hallgren M, Helgadottir B, Herring MP et al. Exercise and Internet-based cognitive-behavioural therapy for depression: multicentre randomised controlled trial with 12-month follow-up. British Journal of Psychiatry 2016; 209: 414-420. 
  3. Video of All-Party Parliamentary Group meeting on “Rising Prescriptions, Rising Disability” (May 2016) - see the relevant blog.http://www.adaptationpractice.org/blog/