Exercise & Mood Part III - From Science to Action

Originally published Tuesday, February 1, 2011
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There is probably no one word that can sum up what people want in terms of emotional or mental health. Whether it be clients I meet in the clinic with a mood or anxiety disorder or a friend or acquaintance asking for an opinion in a social setting, the theme of the question is common but each one is different. However I think there is one common thread that joins the questions and ONE word that captures 99% of what is ideally sought STABILITY.

Those with recurring depressive episodes or mood swings want mood stability. Others with anxiety, nervousness or worry want calm stability. The frazzled, stressed, workaholics want relaxed stability. For many achieving stability would make them happier, more productive, more sociable and have a better quality of life. I don’t claim that exercise is the only way to achieve stability. There is no panacea. The correct treatment of all of the above situations is an individually tailored combination that could include medications, talk-therapy, lifestyle changes and other components but should ALWAYS include exercise.

Now let’s make the leap from the science we reviewed in the previous blog posts to action. How do we “dose” exercise? What kind of exercise? What time should I exercise? For how long? How do I start and how do keep going?

For an easy reference I will summarize the answer in one sentence then explain the details and the fine tuning will come later. Remember here we are talking about the ‘dosing’ of exercise that changes the biology of the brain and not the number of packs in your Abs! Although that might be a welcome side effect - if you are trying to achieve that talk to a personal trainer. Here we are treating the brain and going after STABILITY. 

Exercise for 30 minutes 6 days a week at a high-impact level. 

That’s it simple, right? Ok ok I know it is not that easy. So let me explain further by breaking it down into 3 rules.

Rule #1 - Exercise: For brain health exercise can be any type that suits you. It does NOT have to be weight-lifting or running on a treadmill. You do NOT have to go to a gym or use a workout DVD. Do any exercise that you enjoy. Swim, run, hike, climb, lift weights, tennis, basketball, soccer, yoga, cycling and on and on. Adapt the exercise to your body if your capacity is limited by physical needs or injuries, but anyone can do some sort of exercise unless you are fully paralyzed. 

Rule #2 - 30 minutes 6 days a week: The bottom-line is that the research shows this is the average of the dose needed for the brain to adapt. Now let’s break this rule down. First reactions are usually - 6 days?! That’s a lot! Yes it is, but we are only asking for 30 minutes. Think about it, how many hours a day do you sit at the internet or TV? 30 minutes is very short. In fact, DON’T do more than 30 minutes (unless you have a routine and have been doing this for years). Doing more will lead to inconsistency and skipping workout days. The science shows it is far better (at least for the brain) to be consistent in exercising most days of the week rather than spending an hour exercising 2 or 3 days a week. In fact, for you gym-goers if you think about it (and research also supports this) if you are spending more than 30 minutes at the gym then your are chatting and resting too much. Thirty minutes makes it harder to come up with excuses such as: There is no time! or I’m too busy! If you work a lot or travel find 30 minutes to do some stretches, pushups, air-squats, jumping jacks etc. 30 focused minutes is all you need, Done! Six days too much? Fine five days is the absolute minimum, but better to aim for 6 so that if you fall short then you have a day to save for later.

Rule # 3 - High Impact: For the scientists reading this that is 16 kcal/kg/week. What?? English please! Ok so here is how I explain high-impact to people: For most of the 30 minutes you are exercising you should be sweating and it should be difficult to speak in complete sentences without needing to catch your breath. This means you work hard for 30 minutes then you are done. Walking doesn’t count unless it meets the criteria above. Commuting does not count! That is your normal energy expenditure. Remember we are trying to change the brain and you can’t do that without effort. 

Last few tips:

• You can exercise anytime in the day that fits your schedule. I find first thing in the morning works best because it is the time of day with the least demands on your schedule. Plus there is evidence this timing may have a more efficient effect than other timings. If it means you have to wake up 30 minutes earlier then do it and just sleep 30 minutes earlier at night. No big deal. But if it doesn’t work just exercise at any time that’s the most important thing. Get it done. 

• You can either start slow and build up to 6 days a week over a number of weeks or just pick a week and start. If you have started and stopped exercise routines in the past you will find this one is easier to maintain because it is more flexible. You can do anything as long as you break a sweat. Jumping rope is great if you don’t have a lot of equipment and can’t go to a gym. Keep telling yourself it’s only 30 minutes and just get up and do it. 

• If you skip days and don’t exercise at least 5 days in a week don’t be discouraged and go back down to zero. Just start again. It is normal to stumble. I do all the time. The important thing is to keep the 30 minutes 6 days a week in your head and keep as close to that as you can. But the closer you are to that ‘dose’ the better the result will be.

Exercise & Mood Part II - New Science

Originally posted Tuesday, January 25, 2011
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The human brain is a complex marvel. There are more than 15 times the number of cells in your brain as there are people on this planet. Every moment of your life countless electro-chemical messages are being sent in your brain (see image) to regulate everything from your hands picking up a coffee to your feet walking out the door; and from your lungs unconsciously drawing in the crisp morning air to your hopes and worries about the coming day.

When patients or acquaintances used to ask me, “What causes mental illness?” I used to give a standard answer that many doctors give today, “There is a chemical imbalance in your brain and that’s what we need to correct with medication.” But as I learned more about the secrets of the brain and realized how little, in fact, we know I changed my answer. “I’m not sure what causes mental illness. It is probably a unique interaction between your genetics, brain chemicals, life experience and other factors.” 

Although this second answer sounds less certain and may seem like it is not instilling hope, I believe that being honest about the complexity of the problem leads to a better acceptance of the need for a variety of treatments. This diversity often means needing an individually-tailored combination of more than one medication rather than the myth (as the research now shows) that using less medications is always better. But it also means that medications alone are NOT enough. Talk-therapy is also essential even if in the simplest of supportive listening techniques. But even using both medications and talk-therapy is NOT enough. Other health-promoting treatments are needed and in the field of mental health, physical exercise is often overlooked or given passing praise. 

The truth is that exercise CHANGES the brain. It causes surges of brain chemicals linked to the treatment of depression and other mental illnesses. Brain messengers like noradrenaline, serotonin and dopamine. It promotes a sense of well-being and relaxation through stimulating cannabinoid-like brain receptors. That’s right for those of you who are re-reading that last sentence this is the brain’s “natural cannabis” without the ill effects of marijuana! (of course it is a little more complicated than that but that’s the short version). If you have heard of the ‘runner’s high’ it may be linked to this cannabis-like signalling system. Exercise also strengths the body’s anti-oxidant and anti-inflammation system. This is important because new research is linking several mental illnesses to inflammation and oxidative stress. Finally exercise can promote the health of brain cells so that they can live longer, stay healthier and regenerate. Of course beyond the biological effects physical exercise is a form of activation behaviourally and socially- both important in treatment. 

So I hope you are now thinking, “I’m convinced tell me what to do!” I will discuss the dosing, timing and type of exercise in the next post.

Exercise & Mood Part I - Tears and Smiles

Originally published Tuesday, January 18, 2011
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“I can’t remember the last time I felt..” I looked up from my notes as she paused over the word as if expecting a mirage to fade into the desert, “You felt?” I said. “..happy,” she said, “.. it feels weird to say that word you know?” I took in the gravity of what she was telling me for a moment and returned her gaze quietly. Then I smiled and for the first time since I had met Alicia about nine months ago she smiled back. Not the half-smile that came with a greeting, fading away no sooner than having appeared, but a full, sustained, toothy smile. A smile that humbled me. 

I had first met Alicia last March when she had been referred by her family doctor. She described a life-long struggle with episodes of deep and disabling sadness and sorrow with no clear relation to any ‘triggering’ events in her life such as a break-up or financial troubles. Over the years the recurrence and length of these depressive spells had become faster and longer; so that now she had been living with a two year long depression that was unbroken by more than a few hours of normalcy. She had become overweight and despite perceiving herself as attractive in the past she now saw herself as unappealing and ugly. As a consequence of her depression she had socially isolated herself and lost touch with many of her friends. In short she was feeling miserable and hopeless. 

“Well,” I said to her at that time, “You have come to the right place!” You see I was feeling emboldened and self-righteous  because I had picked up on a clue in her history that previous health-care providers had missed. When Alicia was younger and she felt ‘better’ in between storms of depression she was in fact doing ‘too better’. She had what we call hypomania - mini episodes of over-the-top happiness bordering on irritability accompanied by faster pace of thoughts and speech and by impulsive pleasure-seeking behavior. Alicia had not improved in the past when doctors gave her anti-depressants because she did NOT have depression! She had Bipolar Disorder (previously known as Manic-Depression). And so armed with this new knowledge I put together a plan with her to start treatment with ‘mood-stabilizing’ rather than anti-depressant medications. Little did I know that I had already missed part of her treatment.

Over the next 3 months Alicia gradually began to improve. Her crying spells subsided, she started eating more regularly and her sleeping improved, and she felt she could concentrate better on her tasks. Overall she described a 60-70% improvement. But the remaining percentage was a big deal because Alicia still did not feel ‘happy’ and she wondered aloud if the best she could get to was to feel ‘not sad’. I kept trying different strategies over the next few months with medications and talk-therapy but we could not break across that elusive happiness barrier. 

At this point it occurred to me that in my zeal for helping her get better I had taken on all the work myself and she had become a passive player in her recovery. In fact, that was just the tip of the iceberg because as an extension I had relied solely on the miracles of modern medicine and had not helped her enable her own body’s natural healing potential. I was ashamed I had let pride get to my head but better late then never I thought.

The next time Alicia came in to see me I shared with her this line of thinking. She was a little confused, “..I’m not a psychiatrist.. How can I treat myself?” I then explained how certain “doses” of physical exercise can change the brain (more on this in next blog entry) and lead to healing. She had her doubts, but we put together a plan, she would take up an exercise routine for 30 minutes 5 days a week and I would follow up with her every on her progress. We didn’t change her medications and stayed with the ones that had gotten her 2/3 of the way to full recovery.

It was hard to get started those first few weeks, but once she had exercised for 5 days in a row she was hooked. She reported little incremental changes - her energy improving, her sleep cycle becoming more regular, her concentration better than it had been for years. And after about 4 months of this, in a small office on the 9th floor of Toronto Western Hospital with miserable freezing rain outside, she smiled and her eyes welled with tears. Happy ones.

-- More on the biological effects of exercise on the brain and using the right ‘dose’ of exercise in an upcoming post. 

*Alicia is a pseudonym and a character drawn from a compound of multiple patients that have allowed me to serve them.