By: Astra Manasieva, PhD.
HCPC Counselling Psychologist, MBPsS
Introduction
According to the DSM-V (2013) clinical depression refers to the loss of interest or pleasure in daily activities for more than 2 weeks. It always impacts the feelings, thoughts, behaviour and the mood. People with symptoms of depression experience psychological (thoughts), physical (feelings), and behavioural (mood) issues which are constant and painful almost all the time. By having clinical depression those systems are highly affected and because they are connected with each other, the vicious cycle of a situation without an exit continues to exist until the person is totally exhausted and helpless. It is not only the feeling of sadness and loneliness, it is also the inability to experience positive thoughts and emotions which makes people with depression isolating and being distant towards others, hiding in their own inner world.
Deactivating or decreasing the connection and communication with others and experiencing such negative emotions and thoughts can lead to suicide attempts and self-harming behaviour. Because of those issues, finding different ways of dealing with depression is of a high for people’s psychological and physical wellbeing. Today various clinicians, scientists and service users are trying to find a way out of this “trap”, combining different evidence based approaches by decreasing the symptoms and making the person more adaptive and capable of dealing with their emotions, difficulties and stress in a healthier way. Different guidelines like the NHS, NICE, IAPT, The Mental Health Act etc. suggest various evidence- based models and techniques for overcoming the symptoms. But regardless of the approach, they all have one thing in common – the activation of people’s behaviour by making the person engaged with different exercises and commitments. The aim of this essay is to discuss the effects of different exercises on depression and also to outline some of the positive impacts of exercise on the psychological and psychical wellbeing.
Clinical Depression
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), fifth edition (DSM-V, 2013) and the International Classification of Diseases and Related Health Problems (ICD-10), version 10 (ICD-10, 2010) there are different types of depression: Disruptive Mood Dysregulation Disorder, Major Depressive Disorder, Persistent Depressive Disorder, also called Dysthymia, or mild, moderate and severe depression with different criteria, duration, timing, aetiology and severity of functional impairment.
This impairment must be present for at least two weeks and must represent a change from the person’s daily routine or baseline in his social, occupational, educational and personal life, with specific symptoms that are present nearly every day. Depression is fairly common, affecting about one in ten people at some point during their life (NHS, 2016). The treatment can involve a combination of medication (such as SSRIs) and psychotherapy.
There are different indicators for having this mood disorder, as well as some biological, psychological and social factors that can lead to a depressive episode at some point in people’s lives. Different studies and meta-analyses (Cuijpers and Smit, 2002; Coryel and Young, Carroll, 2006; Seymour, Benning, 2009) suggest that there is a relationship between depression and mortality. Being co morbid with other diagnoses and having a very high impact on our daily activity, clinical depression is one of the most common mood disorders worldwide and one of the top reasons for mortality worldwide. This observation must consider the level of depression, as well as the symptoms in relation to the cognitive system, the affective system and their representations in the behaviour. Being self-destructive in
terms of depression means that the individual is less active and less socially engaged but much more anxious, worried, thoughtful, sad, tearful and melancholic; the less they do, the less they want to do This is of big significance, because when experiencing such strong overwhelming symptoms, levels will decrease and motivation and enthusiasm will go down, making the person more tired, with activity levels that are below their previous performance.
This can also lead to augmentation in the use of alcohol, cigarettes and caffeine, as well as substance misuse. Experiencing guilt and re-thinking the past are inner mechanisms indicating the risk of “tunnel vision” and not-being capable of living in the current moment. This is why when talking about depression the focus is always on the past and not on the future. The levels of enjoyment from life will decrease and the person will regress into the past. This is because of the negative focus and the cognitive distortion that “everything is black” and there is no escape or light, meaning no positive thoughts and experiences, reduced confidence and capability of resolving the personal issues and increasing the negative automatic thoughts and the low mood.
Because of the vicious cycle of those negative thoughts, feelings, behaviour and mood, the only way to get out of it is by changing those systems and breaking the previous model of learned behaviour. If not, those experiences will repeat over and over again – even with different situations, people and circumstances. (Beck, 1991). Breaking the previous ineffective coping strategies and using new ones instead is the focus for lots of psychotherapy treatments and approaches. For example using distractions in the cognitive- activity behavioural therapy, as a new model of behaviour can regulate the emotions, decrease the negative thoughts and gain a better self-image and self-esteem. Exercising in a good way of distracting and keeping the focus on something else, being more self-reflective and engaged. Much research (Gilbert, 2009; Myles, Shafran, 2015; Beck, 1991; Bellow, 2014 etc.) is concentrated on finding the tools and techniques to influence those systems by making the person more adaptive, self-reflective and engaged. This is why by using cognitive behavioural therapy (an evidence based treatment for depression) the focus is on the behavioural activation and the activation of the inner strength using exercise as a baseline for commitment, achievement and motivation.
Exercise and the effects of behavioural activation
Talking about exercise it is very important to describe what exactly this means. In terms of psychotherapy, exercise is every behavioural act that helps the person change his model of behaviour and activates his coping strategies. This could include physical high-energy or low-energy exercises, painting, playing, cooking, participating in different classes, volunteering, writing, reading etc. This could also have an impact on the physical symptoms (sleep problems, muscle retardation or tension, psychomotor agitation, change in appetite, high blood pressure, headache etc.), on the cognitive system (negative thoughts, low motivation and concentration, cognitive dissonance, high frustration levels, lack of focus and cognitive distortions) and on emotional regulation (feelings of anger, fear, guilt, anxiety, loneliness, worthlessness and hopelessness). The reduced willingness of participation in different activities may be explained with those distortions. This is why being depressed can leave the person feeling tired, with lack of interest in the world and with low levels of energy.
According to the NHS (2016), regular exercise can boost mood, and is especially useful for people with mild to moderate depression. It is important to choose something that the person enjoys, otherwise – it will be hard to find the motivation to do it regularly (NHS, 2016). Even 15 minutes exercise a day can clear the mind and relax the body. NHS advises that any exercise is better than none, this is why they give activity guidelines for adults from 19 until 64 years old and for 65 and over. There are also exercises on prescription from the GPs for people who are not sure what type of activity they should join or for those who have not exercised for a long time.
The National Institute for Health and Care Excellence (NICE) recommends for people with depression to participate in about three sessions of physical exercises a week for 45 up to 60 minutes for over 10 to 14 weeks (NICE, 2016). By making this commitment, the motivation as well as the cognitive system will have a goal that must be achieved. Starting with easier exercises like walking, cycling, shopping, doing housework etc., the person will be motivated to continue, will have a goal and will see a real achievement from it. This can also be a trigger for including other activities which are more difficult, like yoga, meditation, joining fitness classes or volunteering. This will reduce the stress levels and the frustration. It could also make the individual more connected with others, which is the opposite of the desire for isolation and hiding from the world by depression. Connecting with others will increase the self-confidence and self-esteem, and will break the vicious cycle of negative thoughts and emotions. By setting a goal such as starting exercise and by making this a new model of behaviour, low mood will improve and the depression symptoms will decrease (Beck, 1991; McKay, Wood and Brantley, 2007).
An article by the Mayo Clinic (2014) gives an interesting point of view on the positive effects of exercise on depression and anxiety. The article outlines the improvement of psychological wellbeing and the decrease of depressive symptoms after starting physical exercises. Some of them are the releasing of eurotransmitters, endorphins and endocannabinoids – also known as the feel-good chemical. Endorphins and endocannabinoids also trigger a positive sense and feeling in the body similar to morphine. This can also explain their impact on the perception of pain (analgesic) and the sedative effect. Some theories also examine nor epinephrine as a neurotransmitter which has a direct impact on the mood by improving it.
Some other advantages are: the increasing of temperature, which has a calming effect; the increasing of acetylcholine, serotonin, nor epinephrine and dopamine, which are responsible for the improvement of the memory, movement and the regulation of sleep, appetite and mood; the decreasing of blood pressure, which has an increasing effect on energy levels and a reduction in the number of negative thoughts, which can improve concentration and focus and also interaction with others. The same result was found in a review of studies starting in 1981 from the Harvard University (Harvard.edu, 2009). This shows that with regular exercise, the symptoms mild to moderate depression can be improved. There has been evidence that it may also play a supporting role in treating severe (major) depression (Kaplan and Sadock, 2002).
Giving an account of the intensity the symptoms, the duration of the depression and the level of exercise – meaning high-energy such as aerobic exercise or resistance training (i.e., weekly expenditure of at least 17.5 kcal per kg) or low-energy exercises such as meditation or yoga (i.e., weekly expenditure of 7 kcal per kg or less) – a classification between the various types of exercises nd their effect must be made. Evidence shows the relationship between high-energy exercises and the decreasing of clinical symptoms by all types of depression (Saeed, Antonacci and Bloch, 2010), but to have a more lasting result, a combination of medication and psychotherapy must be considered.
Systematic evidence reviews and other subsequent studies showed that aerobic, dancing, climbing, cycling and other high-energy activities have a positive effect on people with mild to moderate depression. Exercise like regular yoga, tai chi and mindfulness have an effective intervention for all kinds of depression treatment as well. This could be explained by the focus not on the past, but on the current moment and situation, but also on the social support involved in practicing such activities. This, with the appropriate medical and therapy treatment, can have a beneficial effect on people with clinical depression. All of the above, with an individual approach and psychotherapy, can lead to a healthier way of dealing with the symptoms, and to using a new, more effective way of problem solving with advantages not only for overcoming clinical depression, but also for the managing of daily issues, difficulties and stressors.
Conclusion
Clinical Depression is one of the most painful and isolating mental health issues. Worldwide, people are suffering and isolating themselves from the outer world, in a vicious cycle of negative emotions, thoughts and behaviours. By seeking support and being aware of the possible treatments, this cycle can be broken. Activating the coping mechanisms, learning new ways of dealing with the issues, and gaining a different overview with several other perspectives and options can decrease the symptoms and prevent relapse. Exercises, no matter if they are high-energy or low-energy, are a way of dealing with and overcoming depression.
By engaging in pleasurable activities that function as a distraction from the negative thoughts and emotions and making them routine, the person can overcome their difficulties and learn how to deal with them in a healthier way. This is why exercise is now commonly considered as a non-traditional method of treatment for depression, which in combination with psychotherapy and pharmaceutical treatment provides evidence for improving the psychological wellbeing and for preventing from a future relapse.
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Professional Title:
I offer short-term counselling which provides a safe, caring and confidential space to explore what’s going on in your life – be that a particular issue or a general sense that things are not quite as you’d like them to be. It is also a creative partnership between us, where we can work together to explore both what is troubling you and your potential in life and to support you to find a sense of freedom to be your true self.
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Ian is a state registered Physiotherapist but also holds an additional degree in Sport and Exercise Science (human biomechanics) as well advanced diplomas in Sports Therapy and Sports Massage. He has been treating for 25 years and is one of only a handful of people in the country registered to all four professions. In addition to treating he also teaches and assesses for industry providers.