Best Practices for "Prescribing" Exercise to Patients With Major Depressive Disorder


In this podcast, Steering Commitment Member Rakesh Jain, MD, MPH, answers pressing questions about the addictive potential of gamma-aminobutyric acid (GABA) agonist interventions, how exercise can help patients with major depressive disorder (MDD), and best practices for clinicians wishing to “prescribe” exercise to their patients.

Saundra Jain, MA, PsyD, LPC, Adjunct Clinical Affiliate, University of Texas at Austin School of Nursing, moderates the session.

Listen to Part 2 of this fascinating Q&A here!

Dr Saundra Jain: Well welcome everyone to what is our last Q&A session of the day. I have to tell you it is hard to believe that we're almost at the end of day 2. Hey Rakesh. Nice to see you.

Dr Rakesh Jain: Nice to see you too. And hello to all of my dear colleagues online.

Dr Saundra Jain: Well, I want you to know we have some great questions, so I suggest we just get going. All right. I'm looking. The number 1 most popular up voted question from our attendees is this:  with GABA agonist interventions, don't I need to worry about addictions the same way that I have to with [benzodiazepines] (benzos) and Z drugs?

Dr Rakesh Jain: 

Very good question. It is a possibility that some of our new [γ-Aminobutyric acid] (GABA) interventions might also be scheduled. That's a real possibility though I'm not sure that'll necessarily happen. Let's remember that just because it's GABA doesn't automatically mean that they would have an equal propensity for addiction, or diversion, or euphoria, whatever. Some of the newer agents that I talked about in my presentation are not necessarily just synaptic GABA, but also extra synaptic GABA agonists. So time will tell. I suspect they will get a scheduling, but I do think the diversion potential could be potentially less. So stay tuned on that very important issue.

Dr Saundra Jain: That's very good news. Rakesh, I know that we share a huge interest in exercise and its impact on our patients, particularly their outcomes. So clinicians are interested. How can exercise help patients with major depression?

Dr Rakesh Jain: So exercise, if it was a prescription medication, most likely all of us would be required by law to give it to our patients. It really is in many ways, a perfect poly pill. And there are many, many multiple mechanisms of action through which exercise works. And we should not only talk about it now Saundra, but we should also make sure we convey to our patients. So here they are.

There is clear evidence exercising, which of course is a behavioral activation technique in itself, sets off a psychological cascade of a feeling of competence and which leads therefore to the person with depression, who's avoiding other things, engaging in it. In other words, there's a behavioral aspect to it, but then there's also the psychological aspect and the biological aspect to it. So even though we keep calling it exercise, which we do with muscles below the neck, there is a very clear and immediate effect on serotonin and tryptophan trafficking. And those neurotransmitters Saundra, as you know, are deeply involved in mood regulation.

And then finally, this is perhaps the reason why exercise may be the near perfect antidepressant we havel, exercise also has a very strong impact on endocannabinoid signaling in the brain. That's a big deal because not only is exercise an antidepressant, the evidence is very clear on it. It also is one of the few interventions that actually improves mood beyond just normal. In other words, not mania or hypomania, but it brings with it a sense of wellness. It brings with a sense of optimism and enthusiasm. It almost seems like a double intervention for mood. So those are the biopsychosocial elements that pretty demonstratively have been shown to make exercise a true antidepressant, not just if you will, a lifestyle management intervention.

Dr Saundra Jain: I like that distinction. Another thing that is oftentimes asked of us that I wonder if you might speak a bit about is this: that when we're working with patients who suffer from major depression and we're offering this really effective intervention exercise, what do we do when our patient is just not motivated, does not have the energy to actually put that prescription into play?

Dr Rakesh Jain: Yeah. Yeah. And we want to be careful not to actually harm people with our prescriptions. So if someone feels less competent and feels like they are letting themselves down by not following our advice, that of course is a boomerang effect. It actually harms the patient. We never want to do that. That's why patient selection is important and it is best not to offer exercise immediately. Perhaps keep it in reserve in patients with melancholic depression. They are too depleted of energy and motivation and the severity of the depression, that it's okay to discuss it, but perhaps to remind them, there will be a time and a place to do it.

But having said that, I think there are so many people with mild to moderate depression who could and will benefit from physical exercise. But because we clinicians don't actually offer them direction, which we'll talk about in just a moment, that we don't offer them a true prescriptive approach to exercise. All they hear is us telling them, go out and exercise and that's it. We would never do that, would we, if we were to prescribe an antidepressant. If you were to prescribe insulin to a patient with diabetes, I don't think you would tell them, make sure you pick up insulin and I will see you in a month. You would actually give them formal advice.

So in fact, you and I developed this Sandra, maybe 15 years ago, we developed the following acronym that to be fit, you have to FID, "F-I-D.” And I would recommend to my colleagues listening in, write that down, if you could, or type that into your computer, “F-I-D.” And here's the evidence on exercise: frequency, intensity, and duration, “F-I-D.” The frequency we are going to request of our patients with depression to maximally benefit from exercise is going to be 5 times a week or more. So they're looking for high frequency. But the intensity doesn't have to be particularly high. Anything from moderate on up is just perfectly effective. And what does moderate mean? Patients often ask. And I say, if you can talk while you're exercising without having to catch your breath, you probably want to increase the intensity a little bit to not only get cardiovascular benefit, but also brain health benefit. And then finally, duration. And this is the best news I can share with all of our patients with depression. Only 20 minutes per day is plenty to get the full effect.

Now I hope you noticed and so did our colleagues that this was highly prescriptive and prescriptive approaches in recommending exercise are ideal. Everything I shared so far Sandra is not based just on guesswork. You and I have done plenty of studies to actually demonstrate its effectiveness, but the Cochrane database, the Cochrane database twice looked at the global evidence, the worldwide evidence for what kind of, and how much exercise actually works and FID, “F-I-D” principles absolutely work.

Dr Saundra Jain: Yeah. And as you're talking about that Rakesh, I'm remembering just from our research, that one of the ways that we were really able to engage people who were maybe new to exercise, hadn't really been doing any kind of formalized exercise practice that when we would ask for 30 minutes, even though the recommendation is 20 for major depression, you always ask for a little bit more hoping that you get that sweet spot of 20. We learned that we could break that down into two 15 minute segments, three 10 minute segments, and our experience with almost 500 people having completed these studies over the last 10 years is that that was just a more spacious way to approach this other than saying, this is what you must do. That little bit of flexibility and control in what they were doing really seemed to make a difference.

Dr Rakesh Jain: Yeah. And exercise is probably the fastest working antidepressant we have ever discovered. So because our topic today was RADs—rapid acting antidepressants—if you're interested in RADs, you have to be interested in physical exercise.

Dr Saundra Jain:

 Great point.


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