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An Evaluation of Physical Activity as a Treatment of Mental Illnesses

To what extent is physical activity an effective treatment for mental illnesses when employed as

the individual controlled intervention or in addition to traditional therapy methods?

Focus Area: Psychology

Date of Submission: 1/22/2018

Word Count: 3454

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Table of Contents

● Abstract……………………………………………………………... P. 3

● Charité – Universitätsmedizin Berlin Analysis…..………………. P. 4

● Anxiety Disorders………………………………………………….. P. 5

● Affective Disorders……………………………………………….... P. 7

● Major Depressive Disorder………………………………………... P. 10

● Conclusion………………………………………………….............. P. 13

● References………………………………………………………….. P.15
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Abstract

The aim of this research paper is to evaluate the effectiveness of physical activity as a

treatment for various mental illnesses when employed as a treatment method either in

addition to traditional therapy methods or as the sole interventional treatment. The objective

of the paper will be to answer the question, does the intervention of physical activity help reduce

the symptoms associated with mental disorders? This paper will attempt to support the

hypothesis that the intervention will have a positive impact and reduce the symptoms. The paper

will begin by giving a general outline of the effects of a physical activity intervention on a variety

of mental illnesses as determined by a meta-analysis conducted by the Charité –

Universitätsmedizin Berlin clinic. Once the effects have been outlined, the search criteria set forth

by Charité will be evaluated, determining whether their criteria yielded research trials that would

provide credible data. Once the credibility of the reviews has been established, there will be a focus

on major depressive disorder (MDD) and the effectiveness of physical activity and the impact of

its absence. The effect on MDD will be determined using a meta-analysis conducted by Cochrane

that researched the effects of exercise on depression. The meta-analysis includes thirty-nine trials

which add up to a total of 2326 participants, but the trials will be criticized regarding their approach

to the research question in groups of similar rather than individually. Based on the analysis of the

trials set forth by the Cochrane review, I reached the conclusion that exercise has shown a moderate

effect on the treatment of depression, however because of the risk of bias seen by the majority of

the trials, it is probable that the effect is much less significant. It is also supported that exercise is

just as effective as traditional psychological treatment programs, however the evidence is limited.
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Charité – Universitätsmedizin Berlin Analysis

The purpose of the research review published by Charité is to summarize several studies

conducted to determine the impact of exercise interventions in patients with a variety of mental

illnesses (Zschucke, 2013). To yield clinical studies relevant to their research questions, the

Charité team used the search engines PubMed, Medline, and Web of Science to generate a list of

reviews (Gaudlitz, 2013). The search engines used by the team are well-respected databases that

contain biomedical literature that is curated by professional peers to guarantee their scientific

accuracy. One of the primary research methods, PubMed, is an access portal that connects users

seeking medical journals, articles, and reviews to the MEDLINE data hub which is maintained by

the United States National Library of Medicine (NLM, 2018). The credibility of the search engine

gives me reassurance that the reviews and studies cited by the Charité review have been properly

vetted and therefore will not skew the results of the data analysis. An issue found with their

selection of trials was that they thought they did a comprehensive search, part of their criteria was

to find trials between the years of 1970 and 2012 (Gaudlitz, 2013). If it were possible to alter the

time period being searched, a time frame between the years 1995 and 2012 for trials would be

more reliable due to the recent significant growth that has taken place in the methodology of

conducting trials. As I will explore later in my paper when the analysis of the Cochrane review

begins, a major issue with the clinical trials is that a large majority failed to properly eliminate bias

(Lawlor, 2013). Based on the trials presented, it seems that the relatively younger trials have a

better understanding of being able to eliminate bias, thus requiring the alteration of the search

criteria regarding the age of the trials. The Charité team used only intervention studies using

physical activity as either a sole or combined treatment in addition to including only reviews
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matching the same criteria. The authors of the review categorized the illnesses in groups of similar

nature rather randomly assort the mental disorders being studied and analyzed.

The mental disorders studied by the Charité team are categorized into the following groupings:

- Anxiety Disorders

- Obsessive Compulsive Disorder

- Affective Disorders

- Eating Disorders

- Substance Disorders

- Schizophrenia/Psychosis

- Dementia/Mild Cognitive Impairment

Due to space constraints and for the sake of staying focused on my original research

question, I will be focusing on two of the seven listed groups to ensure a thorough analysis. The

research done by the Charité review regarding anxiety disorders and affective disorders will be

further analyzed (Zschucke, 2003).

Anxiety Disorders

Patients diagnosed with anxiety disorders face relentless anxiety everyday leading

to social issues, difficulty accomplishing everyday tasks, and making life decisions seem more

serious than they are (NIH, 2018). The class of anxiety disorders is further classified into different

disorders based on the type of anxiety faced such as Generalized Anxiety Disorder vs Panic

Disorder (NIH, 2018). Certain risk factors are more significant than others, such as family history

of mental disorders, having recently experienced a traumatic life event such as a death, and

exposure to stressful situations as a child (NIH, 2018). The current consensus on treating or helping
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reduce the symptoms of anxiety disorders is a treatment plan which employs a combination of

psychotherapy and medication (NIH, 2018). Psychotherapy is “talk therapy”, a method that is

found successful in the management of stress because it allows for clear communication of fears

and issues between the patient and therapist, allowing the therapist to target specific problems. In

addition to psychotherapy, stress management is an important tool to help patients suffering from

anxiety calm themselves down and be able to regain a balance in their life. Physical activity can

be a significant help because it provides a safe and healthy stress management solution. Often

when people have stress and feel overwhelmed they will go on a run to clear their mind

(Lewinsohn, 1994). For this reason, it is believed physical activity can provide a healthy outlet and

therefore make a difference in the anxiety that patients face. The Charité team identified a

mechanism of action in treating anxiety disorders as the reduction of anxiety sensitivity as a result

of the intervention of physical activity (Zschucke, 2013). It was found that subjects who had a

higher anxiety sensitivity level reported a lower level of physical activity compared to patients

with lower anxiety sensitivity (Gaudlitz, 2013). This correlation makes sense as physical activity

is a proven stress management method as well it allows for social interaction. The social interaction

aspect is supported as patients with low levels of physical activity reported a higher level of

perceived social barriers (Gaudlitz, 2013). It was unclear as to what was defined as physical

activity, and what the duration and intensity of the exercises were across the trials. Once I was able

to access the results clinical trials included in the Charité study, I found that the two types of

interventions studied were classified as acute and chronic treatments. It was not differentiated

between these two in the final conclusions because after analyzing the clinical and non-clinical

sample results it was found that both methods were successful in reducing state and trait anxiety

(Petruzzello, 1997). It was found that when the effect of both aerobic and anaerobic physical
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activity were compared to the effect of cognitive therapy, they were just as effective as each other

(Wipfli, 2008). Because of the social interaction factor previously mentioned, it was seen that

across the trials patients with social phobia responded best to the exercise intervention and

demonstrated the greatest reductions in anxiety levels (Merom, 2008). This reduction was

measured in self-reported levels of social anxiety, levels of general depression, and follow-ups

conducted three months post-intervention (Jazaieri, 2012). Patients in the generalized anxiety

disorder (GAD) group also showed promising results when those compared in the wait list control

were compared against those performing resistance exercise and aerobic exercise (Herring,2011).

In the intervention groups there was a reduction in the worry symptoms typically associated with

GAD as well as a reduction in anxiety-tension levels (Herring, 2011). From the results of the

meta-analysis I can conclude that in the case of anxiety disorders, the intervention of physical

activity has beneficial effects, shown by the reduction in symptoms of anxiety associated with

the various disorders analyzed.

Affective Disorders

Affective disorders, also referred to as mood disorders, are mental disorders that deal with

the emotional well-being of patients. The most prominent disorders classified under the DSM-5

grouping of affective disorders are major depression and bipolar disorder (NCBI). Though

depression is often associated with feeling sad or unmotivated, the issue is much larger than

unhappy feelings for a short period of time. For major depressive disorder (MDD) to be clinically

diagnosed, symptoms must persist for at least two continuous weeks to ensure the symptoms are

not merely feelings of unhappiness (NCBI). 40.5% of the disabilities caused by mental illnesses

in the world are accounted for by depressive disorders, and yet this proportion is underrepresented

as many people refuse to seek help and be clinically diagnosed (Whiteford, 2013). The symptoms
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of depression include a general loss of interest and pleasure in once enjoyable activities, feelings

of constant guilt, and low motivation (Mental Health Foundation, 2018). Bipolar disorder is a

combination of both depressive and mania episodes, resulting in a dangerous mental condition if

not treated properly (Legg, 2017). While major depressive disorder has a set of tests such as self-

reported feelings and self-reporting questions, bipolar disorder is much harder to diagnosis. Like

all mental disorders, family medical history is evaluated to rule out other disorders or even show

a family link to bipolar disorder. Professionals turn to the Diagnostic and Statistical Manual of

Mental Disorders (DSM) to provide the most accurate diagnosis of bipolar disorder (Legg, 2017).

Now that the class of affective disorders has been outlined, the Charité review will be used to

analyze the results for bipolar disorder and then use the Cochrane Review to do an in-depth

evaluation of the results for major depressive disorder (MDD).

A 2007 clinical study aimed to research the link between bipolar illness and physical

endurance used a group of 24 adults to determine whether the presence of bipolar disorder lowered

cardiovascular health (Shah, 2007). Prior to this study, the link between cardiovascular diseases

and bipolar disease had been linked, as bipolar patients were 2-3 times were likely to have

cardiovascular issues than the rest of the population (Shah). Using two groups of patients being

exposed to treadmill running, Shah was able to conclude that the bipolar subjects had a

significantly reduced exercise tolerance than the control group however both displayed normal

cardiac function. The significance of this trial is that it shows an existing problem within the

bipolar community, which is that they are lacking physical endurance but have normal cardiac

functions. Therefore researchers have identified a characteristic of bipolar patients that may have

an effect on the bipolar disorder in patients. Studies following Shah’s trial found that physical

intervention methods did not place a strenuous demand on patients, but rather correlated to an
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overall decrease in stress, depressive, and anxious symptoms, all of which are linked to bipolar

disorder (Edenfield, Dodd). These studies support the idea that bipolar patients are physically able

to exercise without negatively impacting cardiac function while also reducing their own bipolar

symptoms after exposure to physical activity interventions. Aside from the benefits, a potential

issue exists with the intervention of physical activity. Since bipolar disorder is characterized by

both episodes of depression and mania, it may be that the physical activity is only alleviating the

symptoms of the depressive episodes. Wright referred to the physical exercise intervention as a

“double-edged sword” for the same reason, as the sudden influx of exercise may inadvertently

intensify the manic symptoms of bipolar patients (Wright, 2012). Therefore because of this serious

issue, I feel that there more research must be done in the field of bipolar disorder before the

intervention of physical activity can be advocated for as an alternative to traditional treatment

through medication. Though the intervention of exercise has shown the ability to manage the

mood fluctuations associated with the depressive side of bipolar disorder, that is only half of

the issue and we cannot ignore the risk of intensifying manic episodes.

Major Depressive Disorder

Major depressive disorder (MDD), commonly referred to as depression, is a medical illness

that affects the emotional well-being and brain chemistry of those afflicted by the condition

(Belmaker, 2008). Depression often alters the way one thinks, behaves, and acts. Clinically

diagnosed depression is associated with feelings of hopelessness and general loss of interest in

activities, in many cases being accompanied by irrational thoughts of self-harm and/or suicide

(Kendler, 2000). The condition can lead to various emotional issues as well as physical problems

arising from the mental toll it takes. In serious cases, major depressive disorder can hinder
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individuals from living their normal life because it disables them from working and interacting

with friends and family (Kendler, 2000). Depression is estimated to affect one in 15 adults (6.7%)

in any given year, however this estimate relies on the number of diagnosed major depressive

disorder cases (Kessler, 2003). Often those with depression fail to be diagnosed either out of social

pressure or denial. The most common symptoms of depression coincide with behavior associated

with sadness or grief, however symptoms must last a minimum of two weeks for a diagnosis of

depression. Symptoms include but are not limited to change in appetite, trouble sleeping or

excessive sleeping, feeling worthless, and loss of interest in previously enjoyed activities.

Depression can appear at any time, but on average, first appears during the late teens to mid-20s

(Kessler, 2003). Women are more likely than men to experience depression. Some studies show

that 33% of women will experience a major depressive episode in their lifetime (Kendler, 2000).

There are certain factors that cause an increased risk for depression in individuals, just like

any other medical condition. Biochemistry has a role in the onset of depression because it deals

with the chemistry of our brain (Fendrich, 1990). Depression can either be increased or hindered

by chemical signals in the brain. Depression can run and be prevalent in families, therefore genetics

play a role. The significance of genetics has been proven as it has been seen that an identical twin

with diagnosed depression correlates with the other twin of having a 70% of also experiencing

depression at one point in their lifetime. Related to brain chemistry, another factor for depression

is personality (Fendrich, 1990). A person’s disposition can make them more or less vulnerable to

the illness. For example, those with self-esteem issues and sensitive to stress are more likely to

experience depression as the symptoms are related to their general attitude. Another significant

factor is the environment to which the individual is constantly exposed to. Those who witness
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more violence, neglect, or abuse tend to be more vulnerable to episodes of depression and a long

term diagnosis (Lewinsohn, 1994).

The Cochrane review is a meta-analysis of 39 studies with the purpose of answering

questions regarding the effectiveness of the intervention of physical activity in the treatment of

major depressive disorder. The Cochrane review utilities the same databases as the Charité review

to find their trials, therefore it is not necessary to re-evaluate the same sources and we can assume

the credibility of the data. Because of the large number of trials, there are variations in both

methodology and the reporting of results. For example, the approach to randomization varied

across the trials. Of the 39 trials, 14 of them properly concealed randomization in the trial, 15 of

them used intention-to-treat analyses, and 12 of them assessed the results blind (Cooney.2013).

The issue with the trials using different outcome measurers is that once the data is pooled, it is

difficult to differentiate as to whether bias affected the data or not. Another issue is that the trials

used different conditions. While 35 of the trials compared the intervention of physical activity with

no treatment or another control intervention such as medication, the other four trials did not share

a similar control group. To analyze the data as a singular number rather than differentiate between

the different results reporting across the trials, the review authors calculated the respective results

of the trials as a standardized mean difference (SMD). This way, the results could all be reported

as a singular number that was comparable to the other trials. Also this allows the authors to group

similar trials and report a singular number to measure the effect of their methodology (Cooney,

2013). For example, the 35 trials previously mentioned (1356 participants) demonstrated the

positive impact of physical activity as a treatment method since their pooled standardized mean

difference at the end of treatment was -.62, a reduction in depression symptoms comparable to

moderate clinical effects. Seven of the trials decided to compare physical activity as the sole
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treatment method, using psychological therapy as the control group. The issue with this method is

that the researchers are assuming that the psychological therapy is making a positive impact on the

patients, which invalidates the data if that is not true. However in these seven trials the reported

SMD was -0.003, an effect difference so small that it does not have any significance. Based on the

results of these trials it is inefficient to replace typical psychological therapy with physical activity

as the primary treatment method, however it supports the idea that exercise is just as effective

because of social interaction factor and the brain chemicals such as endorphins released. Some

researchers may argue that pharmacological treatments are the most effective solutions to clinical

depression, but four of the 39 trials provided disagree with this claim (Cooney, 2013). Four trials,

accounting for 300 patients of the population, compared the effectiveness of physical activity

versus pharmacological treatment (medication). The SMD of the pooled results was -0.11,

signifying a very small effect difference between the two treatments. Based on this SMD we can

conclude that medicating patients to treat major depressive disorder is not the most effective

method, and should be avoided because of the side effects. Psychiatrists should advocate for

physical activity for treatment instead of medication because the effect difference is not big enough

to have be significant. However because of the small population pool of 300 I believe more trials

must be conducted to confirm the effectiveness of exercise in comparison to medication. Based

on the results reviewed by Cochrane, it is supported that physical activity as a treatment is

just as effective as psychological or pharmacological therapies, however there is a need for

more clinical trials to be completely sure.

Conclusion

Based on both the Cochrane meta-analysis and the Charité review, I was able to support

my hypothesis that the intervention of physical activity has a positive effect on patients diagnosed
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with mental disorders. However, I believe that more research and trials must be conducted which

will increase the population pool of patients as well as try to eliminate confounding variables. I

think it is crucial to follow up results a couple months from the end of treatment, especially in the

case of bipolar disorder, to ensure the results were not mis-reported or short lived as part of a

maniac episode. The tricky part of measuring the degree of a mental illness is that the symptoms

are presented in different ways in patients, and there is no singular factor for researchers to measure

and compare. Regardless of this, I believe if researchers continue to experiment with varying

exercise plans, such as weekly running versus yoga sessions, they will be able to determine which

level of intensity is best suited for each mental disorder. As a result of this research paper I have

become much more sensitive to the nature of mental disorders in addition to learning about the

enormous benefits associated with exercising. As a year-round athlete I appreciate the time I have

for exercising much more because I realize that it is a major stress management method for me.
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Works Cited

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U.S. National Library of Medicine, 12 Sept. 2013,

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Med Sci. 2011;180(2):319–325. https://www.ncbi.nlm.nih.gov/pubmed/21076975

Dodd S,The effects of physical activity in the acute treatment of bipolar disorder: a pilot study.

Ng F, Dodd S, Berk M J Affect Disord. 2007 Aug; 101(1-3):259-62.

https://www.ncbi.nlm.nih.gov/pubmed/17182104/

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Disorders., U.S. National Library of Medicine, Dec. 2007,

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Wright, 'It's a double edged sword': a qualitative analysis of the experiences of exercise amongst

people with Bipolar Disorder. Wright K, Armstrong T, Taylor A, Dean S J Affect Disord.

2012 Feb; 136(3):634-42. https://www.ncbi.nlm.nih.gov/pubmed/22100131/

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