So I took care of a really depressed young female. She'd been through a lot in her young life. Medically. Physically. Emotionally. She was suicidal. Very pleasant. Married with children. And she was on a boat load of psychiatric drugs.
She was also overweight. I spend 30 minutes talking with her about the benefits of exercise. How I believe she could do more for herself for feeling good with exercise than all the psychiatric medications and electroconvulsive therapies combined.
She thanked me for my time and told me she would do it. I think a saw a glimmer of hope in an otherwise severely depressed young female.
The only in-patient doctor (even outpatient for that matter) you will ever find talking to a patient for 30 minutes about the benefits of exercise is a hospitalist.
If you are depressed, you need to exercise. It should be first line therapy, in front of medications. Comparative effectiveness should prove that. It should be required for any insurance to cover any type of antidepressant. Antidepressant medications should be third line, behind exercise and cognitive therapy. Healthy lifestyles does wonders for mental health.
sense a little depression stigma here...maybe her meds are just wrong. Are we back to pull yourself up by the old bootstrap and get over it...all you need is some fresh air and a brisk 30 minute walk? Those neurotransmittors that aren't firing right...to hell with them. And cognitive therapy? There are some scary "therapists" out there.
ReplyDeleteI say readjust her meds so she feels a little better and then she might wanna get up off the couch. Some people just have essential depression just like hypertension or diabetes and to be so simplistic is insulting to people who suffer from it.
As one who is eternally grateful for her antidepressant and had been exercising and going to a therapist prior to starting my medicine, I actually think I might be a better judge than you. Not arguing against exercise..it does help but I think to say that some people aren't hardwired a certain way and could use some chemical assistance is absurd. If your pancreas won't manufacture the insulin you need, you need an external source. Why is brain chemistry different? Exercise will help in control of blood sugars but in type 1, you'd be sol without insulin. It's reasonable to me to think that a certain group of people can benefit from medication. Why is that scientifically dishonest?
ReplyDeleteIs exercise your first line treatment for DKA?
ReplyDeleteMaybe she was the kind of atypical depressed person who looks and feels a bit better after *any* human contact.
ReplyDeleteI'm highly amused that you think someone who is depressed enough to end up in the hospital is going to be able to just up and start exercising by herself.
She was lucky she was hospitalized. We have a dwindling supply of psych beds in our state. I recommend exercise to my primary care clinic patients, depressed or not, and set up a plan with them. It doesn't take a half hour. We talk about what kind of movement they are able to do, what they like to do, how much they are able to do, the benefits of exercise for them related to their health problems, and make a written plan together. Then I have them come back in a month or whatever is appropriate for them and we talk about progress with the exercise plan. Many of them do follow through (or at least tell me they do). I've been recommending yoga a lot lately for people with stiffness or achy joints. You might try it for your back.
ReplyDeleteI can tell you from personal experience that when I was taken to my doctor by my very concerned husband because I could not work, could not get out of bed, could not stop crying, could not stop wishing I would not wake up from sleep, could not stop thinking about ways to kill myself, if my doctor had told me to exercise........well, I don't know which one of us wouldn't be here today, but I can assure you, one of us wouldn't have walked out of that room alive.
ReplyDeleteYou ever look at the side effects of those Happy Pills? Almost makes Cancer Chemo look good...and the increased Suicide Risk with SSRI's?? thats what I want in an anti-depressant... ECT's the way to go, and they do it all civilized now a days, not like in "One Flew over the Cukoo's Nest"
ReplyDeleteThe point is not that exercise alone is a treatment for depression. The point is that many doctors in general rush give pharmacueticals to the exclusion of other therapies. The same point could be made if the harried PCP did not make arragments for cognitive/behavioral therapy which has randomized data supporting it's effectiveness in combination with SSRI's. I do think that Happy is not accurate in stating that only a hospitalist would spend this time discussing exercise with their patients. I have spent a lot of time with breast cancer patients discussing the role of exercise. Exercise has been been shown to reduce the rate of breast cancer recurrence. The mistake a lot of docs make is not making specific recs regarding what type of exercise (do you discuss the advantages of swimming vs. cycling vs. running vs. other). As an avid cyclist I spend a lot of time discussing these options in detail. Happy, keep talking about exercise!!
ReplyDeleteWhoops, before I get flamed, the first sentence in my above note should have read "The point is not that exercise is the ONLY treatment for depression."
ReplyDeleteThe case here doesn't say the patient couldn't get out of bed. My personal experience says that depression and exercise are not incompatible. On the other hand, exercise is a heck of a lot harder for the patient than swallowing pills. I brought this matter up with a pulmonologist when I was diagnosed with OSA. His response was that, yes, exercise would be best but the percent of patients who could make the gains necessary was so small that he didn't bother trying it before CPAP.
ReplyDeleteThe only thing that bothers me with Happy's post is the sense of self-congratulation that's evident in the fact that the patient wanted to try exercise at that time. So what? Motivational speakers and salesmen can induce feelings easily. Do they last?
The real issue with exercise is that there needs to be a financial incentive for people to do it, which means a way for insurance companies to keep tabs on use of gyms, etc. This could work as a private venture if gyms would buy in.
Many depressed people can benefit from exercise. However, suicidal thoughts should not be treated without therapy or medications. Telling someone to "just exercise" who is having suicidal thoughts is reckless.
ReplyDeleteHere is some little academia for you: After the SSRIs were given a blackbox, less was perscribed. Interestingly, when Rxs went down...suicide went up! Hmmmm
http://ajp.psychiatryonline.org/cgi/content/abstract/164/9/1356
I also have more time than I ever did to spend time with people to counsel on lifestyle modification. We're really just not paid to do it. And yet we're some of the most qualified individuals to do so.
ReplyDeleteBut, sadly, as some of your commentators have alluded to, I've been interpreted as saying, "You're a fatass." When in reality I was trying to do my duty to my patient.
If I only cared about my customer... I mean patient satisfaction, I would tell people to keep chugging Pepsi and eating Taco Bell. They know where to find me when they get sick again.
I am not commenting on anything above and will probably repeat some points, but exercise is a valid *adjunct* to other, more "traditional" modalities of therapy. If it keeps their dosage lower, or helps at all, great. If that's all they needed I doubt they'd be suicidal. I'd never suggest it alone without some other form of help, just as *ideally* one shouldn't prescribe antidepressants to someone with MDD without at least a future intent to f/u w/talk therapy.
ReplyDeleteI'll risk an analogy by saying diuretics unquestionably help hypertension, but you wouldn't use them alone in someone with malignant hypertension or hypertensive crisis.
It wasn't lost on me that the point of the post was that you took the time to talk to the patient at length about her psychosocial issues, so I applaud you for taking the time to do that.
John Ratey MD, author of Spark: The Revolutionary New Science of Exercise and the Brain suggests regular physical activity might combat depression and anxiety, saying "In some cases, a regular exercise program works as well as medication typically used to relieve anxiety or mild to moderate depression."
ReplyDelete(Would have cited from PubMed, but that site doesn't work well on this phone.)
Suicidal depression is NOT mild to moderate depression.
ReplyDeleteHoly fu*king sh*t, people.
Um. Speaking as a person who has been severely depressed, when you are THAT down it's impossible to motivate yourself to do something as active as exercise. You can talk to that person until you are blue in the face about the benefits, but chances are the only thing they are ABLE to do is lie on the couch and stare at the ceiling. The depression needs to be treated enough so that she CAN get exercise.
ReplyDeleteYou could always recommend the Poor Womans ECT...AKA..umm y'all know what it is...
ReplyDeleteSeriously, if it wasn't for my daily left handed workout I'd be depressed to...its also a great soporific...
I didn't even know I was depressed until I started taking Lexapro - for anxiety. I felt the edge taken off.
ReplyDeleteIt hasn't been a complete cure. But before the Lexapro, I was biking and playing team sports.
Exercise was exhilerating, but it didn't last for hours. Not for me.
It definitely wasn't a cure-all. Neither was therapy.
I mean when your neurotransmitters aren't doing their job, you need an intervention.
I've actually tried to wean off on my own - against the advice of my doctors. I thought they were to Rx-happy. But it turns out they were right.
The thing is that exercise, especially if you're not used to it, involves pain. And physical pain and depression are responded to by similar neurotransmitters. So, it's very possible that exercise can make things worse if neurotransmitters respond to sore muscles at the same time they're responding to depression.
Exercise is a good thing, but probably not the first line of defense for depression. It takes a lot of courage for people to report depression to their doctors due to stigma. So, I highly doubt too many of you are truly facing mild/moderate cases.
And even those of us who thought we were in temporary depressions related to obvious events - may not realize we are in a deeper depression than we realize.
Too many physicians dismiss the experience of the patient when it comes to depression. But treatment of depression will not progress until you do.
Please tell me that you didn't tell her exercise was BETTER than her meds, or she didn't need her meds.
ReplyDeleteYes, it should be the first line of defense-- when she's still mildly depressed. Once she's suicidal, it will help a great deal, and should 100% be encouraged-- as long as she understands it won't replace her need to find a good mix of medications and continue talk therapy. IF, and ONLY IF, she then finds she is doing well with exercise then a PSYCHIATRIST might want to wean her off the meds, while carefully watching her.
Now, of course, if you did the right thing and told her to exercise while still seeing her therapist and taking her meds, and mentioned that you don't know that exercise will replace her need for medication and only a PSYCHIATRIST will have the experience and knowledge required to guide her, then yay! You did a good thing and hopefully it will turn out that exercise saves her from needing the meds.
But if you didn't... my sister has unipolar depression. She is also morbidly obese. A few months ago she found out online that exercise is the best cure-- and her answer was to stop taking her meds, which depressed people do at the slightest indication. She very quickly spiraled downward, before she even got a chance to exercise. You CANNOT give a person on psychiatric meds a reason to go off them unless you are a PSYCHIATRIST overseeing their care and you are confident that they no longer need the med (or, of course, in the case of bad side effects).
So, Happy, as you are NOT a psychiatrist or even a psychologist, you are NOT qualified to tell a woman that her psychiatric meds are useless unless they are actively causing her PHYSICAL harm, and I really hope that woman lives long enough for her qualified psychiatrist to help her understand that exercise is GOOD, but it may not be ENOUGH, and she needs to continue traditional therapies until they know for sure. Alas, it seems more likely that she heard what you said, thought, "Stupid psychiatrist, I don't need these meds," threw them out, exercised a few times, then spiraled down too quickly to maintain the regime and now believes her psychiatrist doesn't know what he's talking about so won't get real help.
I could have been that woman. I attempted suicide several months ago and was admitted. I'm overweight but haven't always been. I had been feeding my depression, stuffing it down with food. When you are so depressed as to want to end your life, it is a slap in the face to be told to exercise. It would have made me hate myself more. Would that be the first suggestion to a depressed woman who has a great figure, or already exercises. If the doc had told me to start exercising, I would have felt unheard, not taken seriously, and even embarassed as if you were speaking to how I looked and not how I felt.
ReplyDelete