Running or medication?

One session at the Sports, Medicine and Health Summit 2021 was all about physical activity and sport in the treatment of mental illnesses.

A combination is best

At the Sports, Medicine and Health Summit 2021 (SMHS 2021), one session was called: SMHS meets DGPPN (Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde, German Association for Psychiatry, Psychotherapy and Psychosomatics). It was about physical activity and sport in the treatment of mental illnesses.

Prof. Dr. Andreas Ströhle from the Charité Hospital, Berlin spoke about physical activity and sport in the treatment of depression and anxiety disorders, the two most common mental illnesses with a lifetime prevalence of about 20% each. There are very good examples that mental illnesses can be influenced by exercise. Anxiety, depression, even stress, the reward system - all of these are influenced by physical activity.
Good evidence for exercise against anxiety and depression

For unipolar depression, there is an evidence level of 1A, and an effect size between 0.6 and 0.9.
For anxiety disorders, the field is more inhomogeneous. Overall, there is a very good evidence level of 1A, but for panic agoraphobia, studies do not show a clear superiority over the control group. But this is also known from pharmacotherapy studies, that such results do not question the overall efficacy.

The first good controlled studies on the effectiveness of endurance training come from the USA (Blumenthal et al.).

In a study of older patients with depression, endurance training performed comparably to pharmacotherapy, with sertraline being slightly more effective. What was special about the work, however, was the catamnesis data, in which the ten-month relapse rates were described. The sports group had the lowest relapse rates of 8% compared to either the drug or combination treatment.

The speaker does not want to claim that sport is more effective than pharmacotherapy. The study has not been replicated often enough for that. But it gives an indication of long-term effects of sport in the treatment and prophylaxis of depression.

One problem is the rather low case numbers of studies on sport in psychiatry; pharmaceutical studies usually have higher case numbers.

Even a ten-day endurance training session, as colleagues in Berlin have been able to show, achieved a significant improvement in depressive symptoms. This means that an antidepressant effect can be achieved in a relatively short time - and that is essential for the patients.

Some examples show different aspects of endurance training in depression treatment.

Brazilian colleagues were able to show that severely depressed patients who were treated as inpatients were able to reduce their clinical symptoms more quickly with additional training than with the usual treatment.
Physiological parameters also play a role in depression - the keyword here is metabolic syndrome. Cardiovascular risk factors can also be influenced by endurance training, which also has a positive effect on patients with depression.

Strength training also has comparable effects. And for yoga, there are also indications from meta-analyses of antidepressant efficacy. So it is a matter of offering patients different types of physical activities and sports in order to reach as many patients as possible.

An important aspect from depression research plays a role in guiding interventions: Patients are much less able-bodied than control subjects. This must be taken into account in the requirements so as not to frustrate them. It is important to convey to patients that this can be a typical symptom of depression.

Anxiety disorders and sport

Many studies prove an anxiolytic effect of endurance sports. The first studies date back to the 1970s. These were often uncontrolled studies and case studies. In later randomised controlled trials (Andreas Brooks et al.) in patients with panic disorder, endurance training was compared with a placebo and with clomipramine. The training effect was somewhat weaker, but still significantly effective compared to the placebo. However, a follow-up study did not show a clear superiority of the endurance intervention.

Training as complementary therapy, not as an alternative

For patients with generalised anxiety disorder, there is evidence of efficacy of training, combining endurance and strength training.

In a direct comparison of cognitive behavioural therapy as a first-line treatment for anxiety disorders with endurance training, it is clear that training is not as effective. This needs to be pointed out again and again, the speaker elaborated: "When we consider where training, sport can be used in the treatment of mental illness, it is precisely not in contrast to other forms of therapy, but as a supplement to or in combination with the classic, established, effective therapy strategies."

The combination of endurance training and psychotherapy has been shown to be more effective than monotherapy. Patients with social phobia particularly benefit from this. Patients with panic disorder also had a significantly better follow-up after endurance training in addition to psychotherapy than the control group who completed an exercise-only programme. This indicates that the effectiveness of psychotherapy can be enhanced by endurance training.

Rapid effects also possible

Acute anxiolytic effects can also be shown after individual training interventions, e.g. 30 minutes on the treadmill. Despite increased physical symptoms after the training, the anxiolytic effect was present.

Mechanisms of behavioural activity during exercise