Exercise & mental health – is the connection as clear as we think?

Mental health is something that has been historically treated as a separate thing from physical health – a situation that arises from the dualistic idea that the mind (‘you’) and the brain (the physical thing) are somehow independent entities that can and therefore should be discussed separately. This dualistic way of thinking has a number of really useful applications but it’s important to remember that it’s a metaphor, not a literal illustration of reality.

Your mind is the manifested experience provided by your brain, and your brain houses your mind. As such the workings of your mind, and thus the health of it, is directly caused by the physical activity, changes, and states of your brain. The separation of mental and physical health, while being useful for the sake of conversation, is just an extension of the metaphorical separation of brain and mind.

Your mental health IS your physical health because your physical state is what produces your mental health. This is not to say, incidentally, that depression is explained by the monoamine hypothesis, that it arises from a lack of serotonin, because it almost certainly isn’t. That’s beyond the scope of this piece though so if you’re interested finish up here then have a read of THIS.

Thinking of mental health in those terms isn’t just a pointless “I’m smarter than everyone” thing either, because it is the understanding that your mind (thus mental health) isn’t some woo-woo concept based in feelings that underpins the societal acceptance that ‘fixing’ mental ill health is about more than simply pulling yourself up by your bootstraps, getting your shit together, or trying to be more positive.

While it’s rare to see that idea written out explicitly, the understanding that mental health is a real thing is now, thankfully, broadly accepted by society. It’s common for folks to still talk about a stigma surrounding mental illness but honestly I think most of that has now dissipated as illustrated by the fact that, if you asked them, most people would recommend people with mental ill health seek help. They may have differing ideas about what that help looks like, but they generally accept that it’s a problem in a fairly similar way that they would recognise a broken leg as a problem (obviously that’s not everyone, but mental health is now an extremely common talking point, with the reality of it being mentioned in The Houses of Parliament and printed on beer mats).

The fact that mental health is discussed openly (for the most part) and with the weight that it deserves is fantastic, but not only that it’s necessary. According to Mind, 1 in 4 people will experience a mental health problem in their lifetime, and 1 in 6 report a problem in any given week (1). That’s a serious burden, but talking only about the problem isn’t good enough, we need to talk solutions.

Now I’m a nutritionist. I’m not a sociologist, a psychologist, a political scientist or a philosopher and so I’m entirely unqualified to talk about the biopsychosocial, biomedical, sociocultural, political or philosophical cures for mental ill health, but what I CAN discuss within my remit of practice is this: can exercise be beneficial for those with mental illness?

And the answer appears to be yes, though there is a caveat which I’ll throw into the mix at the end of this piece.

According to a review of clinical and experimental evidence written in 2013 by Zschucke and colleagues (2), research has found the following:

Exercise reduces the body’s sensitivity to anxiety, thus reducing both trait and state anxiety (the former is constant, personality-based anxiety, the latter is the amount of anxiety felt during a specific anxiety-causing situation). Both aerobic and anaerobic exercise seem effective, with both being as effective as cognitive/behavioural therapy (CBT), and more effective than other anxiety-reducing activities

These effects also held true when looking at the effect on both state and trait anxiety in adults with intellectual disabilities. Finally, observational data suggests that those with higher reported anxiety engage in less physical activity.

In people with panic disorders the results are mixed. While one study found that either jogging or walking interventions improved anxiety scores in this population, and another found that exercise was as effective as the drug clomipramine, the latter study found that the drug worked faster and adherence rates were much higher in the drug-taking group. In a study comparing CBT to exercise, CBT worked better (though exercise did also reduce symptoms – there was no group doing both)
Exercise seems to reduce social phobia as well as mindfulness-based stress reduction both acutely and at three-month follow up
Though data are limited and of less than ideal quality, a few studies have looked at the effect of exercise in patients with OCD and depression who are currently using selective serotonin reuptake inhibitors – after just six weeks of walking, OCD behaviours and depression scores decreased. Another study combining exercise, CBT and drugs found that post workout scores of anxiety, OCD symptoms and mood improved
By far the most well researched area of mental illness studied in relation to exercise is that of affective (mood) disorders like major depression and bipolar disorder

In terms of the former, studies have looked at:

Exercise vs nothing (placebo, waitlist, no treatment)
Exercise vs other treatments (psychotherapy, drugs, alternative therapies)
Exercise augmented treatment vs normal treatment alone

Overall exercise in these studies seems effective, with exercise being better than no treatment, exercise augmented treatment being better than treatment alone, and exercise alone being as effective as normal treatments including drugs.

However, some caveats need to be raised. When looking at only the most well performed studies the effect size for exercise was small (though it improved when you look at only resistance or mixed training rather than using aerobic training which seems less effective), and exercise seems to be not effective when looking only at middle aged and older adults, whereas sertraline was.

When looking at bipolar disorder things get a little muddier – on one hand some studies have found that despite people with bipolar disorder fatiguing faster than healthy controls, aerobic exercise can decrease stress, depressive, and anxious symptoms. With that said, semi structured interviews researchers have found that those with bipolar disorder report improved mood during depressive phases through exercise, but a potential exacerbation of manic episodes. Recommendations of exercise for those with bipolar should therefore be made with caution and a note of care for the person’s attitude towards exercise at both ends of the mood spectrum.

Exercise is generally positive for those with eating disorders, with it seeming to help control bodyweight, binge frequency and depression scores in those with binge eating disorder, body satisfaction and binge/purging episodes in those with bulimia nervosa, and bone density, emotional stress and obligatory attitudes in those with anorexia nervosa. Of course in bulimia and anorexia nervosa patients exercise needs to be controlled and closely monitored, but provided this is the case it may improve therapy outcomes
Finally, exercise seems to be highly beneficial for age-related mild cognitive impairment, slowing down the rate of decline. It also may delay the onset of dementia and improve some scores of cognitive performance in Alzheimers’ dementia patients

An impressive list, I’m sure you’ll agree! Reading the above it’s not hard to see why ‘those with mental illness should exercise’ is such a common message, but there are problems with this. First of all, as seen above, exercise is not ALWAYS more effective than traditional treatments, and in many areas much more data is needed to confirm what benefit does exist. Those recommending exercise in place of traditional treatments are doing so despite – not because of – the data, or because they are under the misconception that the findings are more reliable than they are. Yes, the above list reads well, but these are just findings up to now which are, in many cases, not conclusive at all due to methodological issues with the studies or simple small sample sizes.

Good results in 12 people doesn’t mean something works in general.

But there’s something else to consider here – treatments are only effective when they are adhered to.

The issues facing those with mental illness do not begin and end with feeling sad, anxious, compelled to engage in a repetitive action, or whatever the specific results of their condition dictate. Rather, mental illness is something that can render a person unable or unwilling to engage in health-promoting activities such as exercise.

You can’t exercise if you can’t get out of bed
You can’t exercise if you’re too afraid to go outside
You can’t exercise if you can’t stop cleaning
And you can’t exercise if you’re terrified of doing so in case it becomes compulsive like it once was

Now to be clear this is not me saying that exercise is a bad recommendation, or even me saying that it’s a bad one for people who feel like those in my examples here. But rather, to finish this short piece, what I am saying is this:

Exercise, alongside recommendations made by a professional (which may or may not include stopping medication in order to exercise, because medication can be important) seems to be highly beneficial for those with mental illness. Even in the populations for whom it does not seem to be effective at improving symptoms, such as middle aged or older adults with major depressive disorder, exercise is not a negative and so due to its other health-related benefits can still be recommended.

However, this recommendation needs to be made compassionately and with the understanding that the ideal amount of exercise in which a person can participate is “what you feel able to do today”. Exercising during periods of mental ill health falls under the bracket of self-care, and while self-care CAN be hitting the gym when it’s quiet, finding a nice place to go for a run, or punching a bag, it can also be staying at home, getting some sleep and maybe trying to eat well.

Having the mindset that “exercise is good and therefore if you’re not doing it you’re somehow failing yourself” leads to those feeling unable to exercise on a given day feeling like a failure, and if there’s one way to make mental illness worse – it’s that.

So if you have a mental illness should you start exercising?

Well yes – but only if you feel up to it today.

References

Mind.org.uk. (2019). How common are mental health problems? | Mind, the mental health charity – help for mental health problems. [online] Available at: https://www.mind.org.uk/information-support/types-of-mental-health-problems/statistics-and-facts-about-mental-health/how-common-are-mental-health-problems/#.XS7gDJNKjVo [Accessed 17 Jul. 2019].
Zschucke, E., Gaudlitz, K. and StrÃ¶hle, A. (2013). Exercise and Physical Activity in Mental Disorders: Clinical and Experimental Evidence. Journal of Preventive Medicine & Public Health, 46 (Suppl 1), pp.S12-S21.