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Morwenna KirwanExercise & Behavioural ScientistFilex, 2012

All Stressed Out:Depression and the Role of Exercise

1 million Aust. Adults & 160,000 young people live with depression

1 in 5 females, 1 in 8 males will experience depression in their lifetime

Depressing Facts

depression in their lifetime Leading cause of suicide in Australia 2020 – depression will be 2nd largest global health

problem behind heart disease

A person may be depressed, if for more than two weeksthey have: felt sad, down or miserable most of the time OR lost interest or pleasure in

Depression Diagnosed

pmost of their usual activities AND

Experienced symptoms in at least threeof the following four categories:

Behaviours Thoughts

Stopped going out Not getting things done at work Loss of appetite or binge eating Withdrawn from family and friends Relying on alcohol and sedatives Stopped doing things they enjoyed

I’m a failure It’s my fault Nothing good ever happens to me I’m worthless Life is not worth living

Symptoms of Depression

pp g g y j y Unable to concentrate

Feelings Physical

Overwhelmed Guilty Irritable Frustrated Unhappy Indecisive Disappointed Miserable Sad/tearful

Tired all the time Sick and run down Headaches and muscle pains Churning gut Sleep disturbance Poor appetite/weight loss

Melancholic depression affects <5 % of Western populations severe depression – including low energy, poor concentration,

slowed or agitated movements

Types of Depression

Non-melancholic depression Most common type of depression Affects 1 in 4 women, 1 in 6 men in western world Linked to stressful events in person’s life in conjunction with

personality style

Psychotic depression

Non-specific response of the body to any stimulus that overcomes, or threatens to overcome, the body's ability to maintain homeostasis

Acute stress: temporary – we are capable

Stress

Chronic stress: ongoing hassle - unmanageable

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Response to Chronic Stress

Source: Adapted from Torres & Nowson 2007; Björntorp 2001.

• Depression is generally marked by hyperactivity of the HPA axis

• Exercise regulates the HPA axis response to stress• Not all depressed patients show HPA axis hyper-

Physiological Mechanisms

Not all depressed patients show HPA axis hyperactivity

• Older adults and women show hypo-activity

Use of antidepressants in the Australian population, 1975–2002

New = selective serotonin reuptake inhibitors, moclobemide, venlafaxine, nefazodone, mirtazapine, and reboxetine. Old = tricyclic antidepressants, monoamine oxidase inhibitors, mianserin, and nomifensine.

Selective Serotonin Reuptake Inhibitor Most widely prescribed anti-depressant in Australian & USA Act on serotonin levels -> serotonin helps regulate mood, but it

also plays a role in digestion, pain, sleep, mental clarity, and other bodily functions

SSRI Anti-depressants

other bodily functions. Symptoms improve following 4 to 6 weeks

SSRI names

•Fluoxetine (Prozac) •Fluvoxamine (Luvox) •Sertraline (Zoloft) •Paroxetine (Paxil) •Escitalopram (Lexapro)•Citalopram (Celexa)

• Low brain cell production of serotonin• Lack of receptor sites able to receive serotonin• Inability of serotonin to reach the receptor sites• Shortage of tryptophan chemical from which

Serotonin Imbalance Hypothesis

• Shortage of tryptophan, chemical from which serotonin is made

• Problem: we can’t measure serotonin levels in brain

SSRE – selective serotonin reuptake enhancer

SSRI – selective serotonin reuptake inhibitor

SNRI – selective serotonin norepinephrine reuptake inhibitor

Chemical Imbalance?

NDRI – norepinephrine dopamine reuptake inhibitor

60% Response Rate

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Only 60% of research conducted is published Published trials show anti-depressants more

effective than placebos Unpublished trials (40%) sponsored by drug

Placebo Effect

Unpublished trials (40%) sponsored by drug companies show no difference between drug and placebo

What do we really know? Anti-depressants do work ~ people get better Placebos do work ~ people get better No treatment ~ people stay same or get worst

SSRI antidepressants cause a wide range of side effects. SSRIs commonly make sleep disturbance/insomnia worse

initially, they are associated with improved sleep four to six weeks later

Side-effects of SSRI

Common side effects of SSRI anti-depressants:

•Nausea•Insomnia•Anxiety •Restlessness•Decreased sex drive•Dizziness•Weight gain or loss•Headaches

•Tremors•Sweating•Sleepiness •Fatigue•Dry mouth•Diarrhoea •Constipation

$150 billion industry

• 80% of which comes from patented drugs developed over the last ten years

• 14% of profit is spent on research and development as compared to 31% on marketing and administration.

“Depression is a heterogeneous disorder with a highly variable course, an inconsistent response to treatment, and no established mechanism. ”

Belmaker, R. H, 2008, Major Depressive Disorder, New England Journal of Medicine 358:55-68.

"The magnitude of benefit of anti-depressant medication compared with placebo ... may be minimal or nonexistent, on average, in patients with mild or moderate symptoms.

Magnitude of Effect

For patients with very severe depression, the benefit of medications over placebo is substantial.”

Jay C. Fournier, MA; Robert J. DeRubeis, PhD; Steven D. Hollon, PhD; Sona Dimidjian, PhD; Jay D. Amsterdam, MD; Richard C. Shelton, MD; Jan Fawcett, MD (January 2010). "Antidepressant Drug Effects and Depression Severity". The Journal of the American Medical Association 303 (1): 47–53.

Alternative/adjunct to anti-depressants Equally as effective Benefits are long term Medication alone: 80% relapse within 2 years

Psychotherapy

Medication alone: 80% relapse within 2 years Psychotherapy: 25% relapse within 2 years 6 year mark: medication alone 90% relapse 6 year mark: psychotherapy 60% relapse

10 weeks of psychotherapy - 40% are depression free 6 years later

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• Meta-analysis – 23 trials, 907 participants• Comparing exercise with no treatment or control

group• Outcomes:

Exercise and Depression

Outcomes:• Exercise is more effective in treating depression than no

treatment• Exercise reduces depression symptoms than no

treatment• Exercise is as effective as psychotherapy and anti-

depressant medication

• increase levels of serotonin in the brain• increase endorphins, which are chemicals in the

brain with ‘mood lifting’ properties.• Increasing energy levels

How Exercise Helps Depression

Increasing energy levels• Helping to get a good night’s sleep• Providing distraction from worries and rumination• Providing social support and reducing loneliness if

exercise is done with other people• Increasing a sense of control and self-esteem, by

taking an active role in the individual’s own recovery

• Regeneration of brain cells

• Stress may suppress creation of new brain cells

A ti d t ti l t ti f

Neurogenesis

• Anti-depressants may stimulate creation of new brain cells

• Exercise stimulates new neurons

• Serotonin may be mediator

potential alternative to medication & electroconvulsive therapy painless with no known serious

side effects Based on neuroplasticity

Direct Current Stimulation (DCS)

ability of the brain to change throughout life based on experiences

long term depression weakening between two neurons

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Anti-depressants can cause hypo & hyperglycemia Anti-depressants can stop working Always encourage client to see GP Educate client that there are many types of

Important knowledge for PT

anti-depressants that work in different ways

Going on anti-depressants Up to 4 weeks of side effects: nausea, insomnia, vertigo

Going off anti-depressants Needs to be done gradually under GP supervision Withdrawal effects can be severe and affect ability to

exercise

Best advice for clients: If client is currently taking antidepressants - don’t stop

without consulting GP If client feels they are working, and are happy with results,

id ff t k k t ki th

Important knowledge for PT

side effects are okay ~ keep taking them If client has side effects, consult GP. Don’t stop taking them

– coming off anti-depressants has to be done gradually

No treatment is not a solution

Practice empathy Be aware of the symptoms of depression Always refer clients to GP

Take Home Message

Be a role model Manage your own stress Introduce mindfulness to clients Yoga and meditation

Be an active listener

Meditation/relaxation music from public library www.mindfulness.org.auGuided mindfulness soundtracks

www.actmindfully.com.au

Mindfulness Resources

Information on mindful techniques www.thehappinesstrap.com/Free chapter of book

www.blackdoginstitute.org.auInformation on depression and bipolar disorder

www.beyondblue.org.auInformation on depression, anxiety and related disorders,

available treatments and where to get help

Depression Resources

www.youthbeyondblue.combeyondblue’s website for young people

www.mmha.org.auMental health information for people from culturally diverse

backgroundsGP Referral – Mental Health Care PlanPsychologists – 5 to 10 sessions per year

SSRI• Nausea• Diarrhoea or

constipation

Side-effects of Anti Depressants

Tricyclic (TCAs)• Cardiac arrhythmia• Sedation• Dry mouth

• Insomnia or tiredness• Anxiety or nervousness• Decreased libido and

abnormal ejaculation• Dry mouth

y• Constipation• Nausea• Increased or decreased

appetite• Weight gain

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Monoamine OxidaseInhibitors

• Increased BP• Dizziness

Side-effects of Anti Depressants

Norepinephrine & Serotonin Reuptake Inhibitors• Sedation• Increase blood pressure

N• Headache• Sleep disturbance• Weight gain• Sexual dysfunction• Gastrointestinal disturbances

• Nervousness• Insomnia• Decreased appetite• Constipation or diarrhoea• Abnormal ejaculation

1. Defusion: distancing from and letting go of unhelpful thoughts, beliefs, memories and other cognitions

2. Acceptance: making room for painful feelings, urges and sensations, and allowing them to come and go without a struggle

Benefits of Mindfulness

struggle3. Contact with the present moment: engaging fully with our

here-and-now experience, with an attitude of openness and curiosity

4. Spacious awareness: accessing a spacious sense of self – the observing self: a transcendent aspect that is conscious of thoughts and feelings as passing experiences, but not identified with them.

Practicing mindfulness helps you: to be fully present, here and now to experience unpleasant thoughts and feelings safely to become aware of what you’re avoiding

Benefits of Mindfulness

to become more connected to yourself, to others and to the world around you

to become less judgmental to increase self-awareness to become less disturbed by and less reactive to unpleasant

experiences to learn the distinction between you and your thoughts

Benefits of Mindfulness

Practicing mindfulness helps you: to have more direct contact with the world, rather than

living through your thoughts to learn that everything changes; that thoughts and

f li d lik th thfeelings come and go like the weather to have more balance, less emotional

volatility to experience more calm and

peacefulness to develop self-acceptance and

self-compassion