Day 10 - Exercise is Medicine

Today was the final day of my psychiatry rotation, and as I pumped away on the elliptical tonight, Black and Andreasen's Introductory Textbook of Psychiatry propped awkwardly over the control panel, I got to thinking about how we often under-emphasise the role of physical activity in mental health.

New day, different machine, different book, same multitasking capacity.

A quick search of PubMed reveals a wealth of resources detailing the beneficial effects of physical activity when it comes to mental health. Here are just a few examples:

This article, authored by two Canadian researchers, reports that almost half of all Canadians over the age of 15 are physically inactive. The authors found that physical inactivity was a risk factor a number of common mental disorders.They recommended that clinicians and public health campaigns target individuals and the general population, promoting increased physical activity. Astonishingly, they believe that "A 10% reduction in the rate of physical inactivity would reduce common mental disorders by 167,000 cases, a 25% reduction would result in 389,000 fewer cases." Can you imagine how we could reduce the individual and systems burden of mental health disorders if we practiced and promoted physical activity?

Physical inactivity isn't just a risk factor for developing mental illness, though - it is also a factor in keeping people ill. This small study in Sweden demonstrated that people with mental health issues experienced less stress and anxiety when they engaged in physical activity. The author of this review article concluded that, although more definitive studies are needed, the mental health of patients with schizophrenia benefits from exercise. The authors of this article found that depressed patients who participated in physical activity performed better on measures of cognition; their reaction times were better, and they could generate lists of words more readily than other depressed patients. In other words, the poor brain function observed in depressed people might actually be ameliorated by exercise.

In other words, exercise is protective and a helpful treatment or co-treatment for a number of mental health disorders. I would never say we should throw away our anti-depressants, anti-psychotics, and anxiolytics. We need appropriately-prescribed medications for a number of conditions. But our patients could really benefit if we showed them how important physical activity can be.

Why are we so good at prescribing these?

...but not this?

So why do we so often fail to prescribe physical activity as an adjunct to drugs and therapy?

To be honest, I'm not sure, but I would guess that it has to do with a few factors.

First, I think we worry that our patients will think we are somehow minimizing the nature of their mental health problems if we glibly tell them to go for a walk around the block or a swim in the community pool. But we prescribe exercise for diabetes and cardiovascular disease - two very serious and life-threatening illnesses - so why can't we prescribe it for equally serious mental health disorders? If we communicate to patients the very real benefits of physical activity, there should be no reason for them to feel we are failing to take their problems seriously.

Second, I think we often don't think of physical activity when it comes to treatment. Lunch with drug reps ensures that names like Zoloft and Wellbutrin roll off our tongues, and physical activity doesn't have the same representation as do prescription drugs (though I'm sure that if someone could figure out a way to make money off it, it would suddenly become the most-prescribed intervention!). I think this means we need to educate and re-educate ourselves on the usefulness of exercise as therapy.

Here is a gratuitous shot of my favourite workout shirt post-elliptical to break up the huge blocks of text.

Third, I think we are uncomfortable with prescribing an intervention over which we have very little control. We can give patients medications, observe whether they take them (as in-patients), and require that they continue to see us for prescription renewals (as out-patients), but we can't monitor physical activity in the same way. We have to trust our patients to remain motivated and continue to participate (which is much harder than taking a pill in the morning or before bed!). But this is exactly what we should be doing - granting patients ownership over their own illness and treatment.

Finally, I think we are scared to ask patients to do something we don't always do ourselves. Physicians are people, and people aren't perfect. When life is stressful and schedules are busy, exercise is often the first thing to go; I see it in myself, in the physicians I've worked with, and in my fellow physicians-in-training. And I can understand why it is hard to recommend physical activity if you're not doing it yourself - it feels hypocritical, and (worse yet!) your patient might call you out on your own failure. So maybe it's a good time to accept our own imperfections, and maybe even to lead by example...