Depression: A Good Workout

It all comes down to lifestyle. Exercise may be especially critical for those with depression.

By Hara Estroff Marano, published on March 01, 2004 - last reviewed on March 23, 2007

Maybe, despite the complex biological links between heart and mind, it all comes down to lifestyle.

"We think exercise is a critical factor in modulating the outcome," says Duke University chief of psychiatry K. Rama Ranga Krishnan. "It works directly and indirectly on a number of factors common to depression and heart disease. It helps depression and it helps cardiac disease." And it does so at many points in paths of both conditions. Adds Emory cardiologist Viola Vaccarino: "Exercise and omega-3 fatty acids are recommended for everyone. But they may be especially critical for those with depression."

Animal studies show that exercise directly alters levels of neurohormones such as norepinephrine in the brain's frontal cortex and in the hippocampus. Both are brain regions involved in circuits of emotion.
Exercise appears to stimulate the vagus nerve, the major channel of the parasympathetic half of the autonomic nervous system. It stabilizes heart function and counterbalances the sympathetic hyperactivity identified in depression. It also improves function of the brain's emotion-sensing network.
By acting on neurohormones that govern the stress response, exercise improves the ability of the body to tolerate stress.
Exercise stimulates production and expression of the nerve growth factor BDNF (brain-derived neurotrophic factor). This protein, elaborated in brain cells, may be the final common pathway by which all antidepressant therapies work. BDNF helps rewire the brain; it induces brain cells to reinforce old connections and to forge new ones, restoring memory and cognitive flexibility to the depressed.
Exercise directly reverses insulin resistance, restoring the body's sensitivity to this important hormone.
Exercise directly burns energy, promoting weight loss.
Studies show that low-intensity exercise boosts immunity and reduces levels of the inflammatory marker C-reactive protein—even in people genetically predisposed to develop cardiovascular disease.
Over the long term, exercise also stimulates the growth of new blood vessels, so-called collateral circulation, boosting the general function of both brain and heart by maximizing delivery of oxygen.
Raising heart rate by exercise delivers more blood to the brain, feeding it nutrients and oxygen that boost mental functions.
Exercise elevates mood by psychological means as well as physiological ones. It changes people's perception of themselves, providing a sense of personal mastery. It also reduces negative thinking.

If there's one person associated with the role of exercise in depression it's James Blumenthal, Ph.D., professor of medical psychology at Duke University. He was one of the first to test aerobic exercise in people with moderate to severe depression. The patients, sedentary men and women over age 50, worked out for 30 minutes three times a week in groups. Their response was compared with that of similarly depressed patients who received either standard therapy with Zoloft or drug and exercise combined.

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Patients in all three groups experienced equally significant reductions in depression symptoms, and remission rates were comparable—60 percent to 65 percent. Surprisingly, combining two effective treatments, drug and exercise, added no benefit. In fact, the only difference among the groups was in speed of response. The medication-alone group began improving within a few weeks; exercisers took a few weeks longer. But the effects of exercise lasted longer. Six months after treatment ended, fewer exercisers had relapsed into depression. Among the patients no longer depressed, only 8 percent of the exercisers relapsed, compared with over 30 percent in the medication group. "That was a big surprise," Blumenthal confides. Contrary to his own expectations, he found that exercise was beneficial against severe depression. "Those with moderate to severe depression responded as well as those with mild depression," he says.

Exercise undertaken to combat depression improves aerobic capacity and cardiovascular fitness, and Blumenthal makes a strong case for aerobic activities such as walking and jogging. "It was a surprise to us but we found that the largest improvements in aerobic capacity correlated with the greatest reductions in depression."

How much exercise is enough?

"Our data show that 30 minutes of aerobic exercise three times a week is sufficient for reducing depressive symptoms," says Blumenthal. That's the minimum recommended for cardiovascular benefit. Patients who responded well to exercise and maintained their regimen had a much smaller risk of relapsing. "We found an inverse relationship between exercise and the risk of relapsing," says Blumenthal. "The more one exercised, the less likely one would see their depressive symptoms return."

That has led him to enunciate what he calls the 50-50 rule. "Exercise was a significant predictor of being free of depression at the end of follow-up," he says. "For every 50 minutes of exercise a week there is a 50 percent decrease in the likelihood of being depressed."