For years cardiologists and mental health experts have known that depression raises risk for heart attack by 50 percent or more.
But what hasn’t been clear is why depressed people have more heart problems. Does depression cause some biological change that increases risk? Does the inflammatory process that leads to heart disease also trigger depression?
The answer may be far simpler. A new study suggests that people who are depressed are simply less likely to exercise, a finding that explains their dramatically higher risk for heart problems.
Researchers, led by doctors from the Veterans Affairs Medical Center in San Francisco, recruited 1,017 participants with heart disease to track their health and lifestyle habits. As they expected, those patients who had symptoms of depression fared worse. About 10 percent of depressed heart patients had additional heart problems, during the study, compared with 6.7 percent of the other patients. After controlling for other illnesses and the severity of heart disease, the finding translates to a 31 percent higher risk of heart problems among the depressed people, according to the study published this week in the Journal of the American Medical Association.
But once the researchers factored in the effect of exercise, the difference in risk among depressed people disappeared. In the same study, patients who didn’t exercise, whether or not they were depressed, had a 44 percent higher risk of heart problems, after controlling for a variety of factors including medication adherence, smoking and other illnesses.
The findings are important because some earlier studies have suggested a link between antidepressant use and lower heart risk. The explanation may be that patients who take antidepressants start to feel better and take care of themselves, adopting healthy behaviors including exercise. In a study of nearly 2,500 heart-attack patients, published in the Journal of the American Medical Association in June 2003, behavioral therapy to treat depression didn’t change survival rates compared with patients who received regular care. But among about 20 percent of patients in the study who ended up on antidepressants, the risk of dying or suffering a second nonfatal heart attack was 42 percent lower. Another study, called Sadheart (which stands for Sertraline Antidepressant Heart Attack Randomized Trial) showed the death rate from heart-related problems was 20 percent lower among patients taking the drug, although the data weren’t statistically significant.
The research suggests that doctors treating patients for depression should also talk to them about their lifestyle habits, and encourage them to exercise. The findings, say the researchers, suggest that the heart problems associated with depression “could potentially be preventable.”
The evidence that health behaviors fully explain the link between depression and heart disease in this study is convincing, says Dr. Mary A. Whooley, professor of medicine, epidemiology and biostatistics at the University of California, San Francisco. However, she notes the study is limited to older men with stable coronary disease, and as a result, more study is needed of women and other patients with heart disease.
It remains an open question whether the study findings will change the way doctors counsel their patients. “The clinical practice question is a challenging one,” says Dr. Whooley. “It’s easy for us to tell patients to exercise, take their medicines, and refrain from smoking, but actually changing health behaviors is very difficult.”
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From 1 to 25 of 77 Comments
I think we have a real “chicken or egg” situation here.
Individuals suffering with depression never feel like exercising, but exercise helps to reduce the symptoms of depression.
My claim that exercise reduces the symptoms of depression is based upon clinical research and my first hand experience.
A few years back, I discussed some of the depression / exercise research with a client of mine who is strongly involved in the mental health community.
5 months later, we had a pilot program started with some employees of a municipal government.
After a 12 week program of structured personal training fitness session, almost 80% of the participants were in remission.
All had improved drastically.
But it wasn’t easy.
As the trainer, I can honestly say that no one in this group was motivated to exercise.
They all wanted to get better, get back to their pre-depression lives and drop a few pounds in the process.
But their mental health had killed any desire to maintain or optimize their physical health.
It’s no surprise that physical ailments like heart disease go hand in hand with mental health issues like depression.
But which came first?
And does it even matter?
— DRI should send this to the insurance companies who denied me coverage because I take antidepressants, despite the fact that I exercise regularly, have low blood pressure and a low BMI.
— Cathy BrownI love this study!
If only there were a way to convince people how valuable exercise is to their health & well-being.
And isn’t this quote by Dr. Robert Butler apropos?:
“If exercise could be packaged in pill form, it would immediately become the number one anti-aging medicine, as well as the world’s most prescribed pill.”
-Dr. Robert Butler, International Longevity Center at Manhattan’s Mt. Sinai Hospital-
A good friend of mine recently took up regular aerobic exercise & as a newbie she’d be the first to tell you how unbelievable it makes one feel. It’s easy for our co-workers to see the positive effects on her, as well.
It’s almost malpractice for physicians to not put their depressed clients &/or patients with the usual 21st century health risk factors on prescription EXERCISE, don’t you think?
And if robust heart health & an upbeat attitude isn’t enough to convince one to exercise (or to make you glad that you already do) you might be interested in these two nuggets:
Where Did I Leave My Glasses? So How Exactly Is Exercise Going to Help Me Find Them?
http://www.happyhealthylonglife.com/happy_healthy_long_life/2008/03/where-did-i-lea.html
There’s No Way Around It: If You Want to Live Longer You’ve Just Got to Do It! Get Out There & Exercise!
http://www.happyhealthylonglife.com/happy_healthy_long_life/2008/02/theres-no-way-a.html
Happy Healthy Thanksgiving!
— The Healthy Librarian#2 You were probably denied insurance coverage due to increased suicide risk. I would imagine that exercise among depressed patients lessens that risk as well, but am not aware of any such studies.
For those depressed people who have trouble getting motivated, start with deep, slow breathing in a quiet room and add on simple yoga moves while continuing that all-important breathing. Plenty of places on the internet to learn these basic moves if you don’t want to take a class or buy a DVD.
— jackWait, I’m not so sure this is what the article actually says. Unfortunately, I couldn’t get into the full text of the JAMA article, but these issues are more complicated then they are presented as being and associations don’t yield cause. I doubt it’s as simple as saying Depressed people exercise less and that’s why that have more heart disease. For starters, we don’t know from these data if it’s actually those people who exercise less who have less heart disease. Also, the data are based on a questionnaire– maybe depressed people report that they exercise less (it seems to me that depressed people may under-estimate their accomplishments.)
The abstract reads:
“Results A total of 341 cardiovascular events occurred during 4876 person-years of follow-up. The age-adjusted annual rate of cardiovascular events was 10.0% among the 199 participants with depressive symptoms (PHQ score ≥10) and 6.7% among the 818 participants without depressive symptoms (hazard ratio [HR], 1.50; 95% confidence interval, [CI], 1.16-1.95; P = .002). After adjustment for comorbid conditions and disease severity, depressive symptoms were associated with a 31% higher rate of cardiovascular events (HR, 1.31; 95% CI, 1.00-1.71; P = .04). Additional adjustment for potential biological mediators attenuated this association (HR, 1.24; 95% CI, 0.94-1.63; P = .12). After further adjustment for potential behavioral mediators, including physical inactivity, there was no significant association (HR, 1.05; 95% CI, 0.79-1.40; P = .75).”
So I’m a bit hung up on the statement about “additional adjustment for potential biological mediators”– for this sentence alone, I’d like to read the paper.
There were only 199 people in the study with “depressive symptoms” — we don’t even know if they had Major Depression, if they were on or off medications, if they had another psychiatric illness. 10 percent per year had cardiovascular events– (as opposed to 6.7% in the rest of their study group). We’re not talking about a big enough sample to make definitive conclusions about cause and effect.
I need to read the whole article to really comment
— Dinah–Dinah of the Shrink Rap blog
tgcv;b’nimo
— bob/.,mn
Exercise is one of the “front-line” alternative approaches that every MD should at least mention to his or her patients. ‘Spark’ by John Ratey is essential reading in this area (even if it may be a bit hyperbolic). ‘Unstuck’ by James Gordon is another helpful, and credible, guide to alternative approaches to depression.
— greenfrogpeople have this very american idea that exercise means pain and unpleasantness and must be miserable to be good for them. the key is to find exercise that is enjoyable. if it’s not, change to something else. if it’s too hard, start at a lower pace and work into conditioning. if it always remains too hard, then there is another issue, perhaps low thyroid function or a hidden infection, and addressing that aggressively while continuing to do some kind of movement is necessary.
for most out-of-condition people, swimming and yoga are a great place to start. “restorative” yoga classes are simply lower-paced ones that work well for people with chronic illness. “water walking” is very popular with very overweight people who can’t do other movement, and it can be quite a workout all by itself. joining a gym, especially a Y with a noncompetitive family atmosphere, makes it a social thing.
the important thing is to do *something*, anything, and make it become part of one’s daily routine. after a while, one feels *worse* when one doesn’t exercise.
— apple“A new study suggests that people who are depressed are simply less likely to exercise,”
This is bad logical analysis.
Maybe people in bad health are less likely to exercise and more likely to be depressed.
— HSThis finding illustrates how relationships between different phenomena can be both simple and complex, but comments so far have failed to highlight a critical issue that cuts across both depression and heart disease.
Both of these conditions are increasingly linked to inflammatory cascades (pro-inflammatory cytokines which had been called the neurotransmitters of the immune system). Although this notion of cytokine mediation of depression was originally regarded as ridiculous, evidence is accumulating that pro-inflammatory cytokines may play a major role in many if not most depressions.
Additionally, although relentless drug company advertising makes one think that heart disease is all about cholesterol, the evidence is that it’s more about inflammation and about oxidative stress as well (cholesterol has to be oxidized before it can form plaque structures, and again without inflammation on the vessel wall, even oxidized cholesterol doesn’t get you coronary artery disease).
Exercise is one of the most critical ways to reduce both inflammation and oxidative stress, and as an additional benefit, it deepens sleep, and improves a wide variety of nonspecific sleep difficulties associated with stress and poor lifestyle choices, and deepening sleep also looks like it’s one of the best ways to reduce inflammatory tone in the brain and body.
There is no question that our medical system is failing completely in relationship to the central task of prevention, and that our current emphasis (which consists of throwing lots of high-tech treatment at an established and in some cases advanced disease of aging, while spending relatively very little on preventing that disease of aging) is simply not going to work. it’s an approach that guarantees that long-term health care costs are going to continue to spiral out of control, while outcomes are going to continue to be frankly poor relative to how much money we’re spending
I don’t believe that primary care doctors are doing a very good job of in some cases scaring their patients into better lifestyle choices. All the diseases of aging probably derive more from our lifestyle choices and quite secondly from genes, although no doubt many genetic polymorphisms influence whether or not a person can in a sense tolerate an unhealthy lifestyle or not. There is little question that lifelong aerobic exercise is one of the best things you can do for yourself, biologically and psychologically.
— Dr Douglas WattI had a severe bout of depression back in 1999. I exercised my butt off, literally and figuratively, but I couldn’t shake the depression.
Finally, as in the movie “Forrest Gump,” I just stopped exercising. I was in the best shape of my life; but after I stopped exercising my depression lifted.
What this tells me is that using exercise alone (which is what I did) helps you attack the symptom but not the problem of depression itself. I refused to believe I needed medical attention, although I probably could have used some kind of counseling.
In the end, as I said, the depression lifted and I moved on; gained some weight, but overall I realized that my own depression was just a phase I needed to work through.
It’s not the same for others, so don’t get me wrong. My wife suffers from depression and she takes medication and has gained weight and almost refuses to exercise. Her struggle is more severe, but I believe exercise can help. So I’m glad they wrote this article.
— CraigI developed one of the worst depressive periods of my life while exercising 6 days a week! Unfortunately the rest of my life was falling apart and my chemicals got out of whack.
While exercise helps some who are depressed, it’s not a cure all for everyone or a preventative.
— JayEven if exercise isn’t the ultimate answer for a person’s problem, it’s certainly not a bad place to start. It may not be for everyone, but it’s worth a try.
— KatieDitto to #7 (greenfrog’s) book recommendations: Dr. John Ratey’s “Spark” & Dr. James Gordon’s “Unstuck”. Reputable, credible doctors + references (research).
Off topic–but still worth mentioning, Ratey says:
“We all know that exercise makes us feel better, but most of us have no idea why. We assume it’s because we’re burning off stress or reducing muscle tension or boosting endorphins, and we leave it at that. But the real reason we feel so good when we get our blood pumping is that it makes the brain function at its best, and in my view, this benefit of physical activity is far more important—and fascinating—than what it does for the body. Building muscles and conditioning the heart and lungs are essentially side effects. I often tell my patients that the point of exercise is to build and condition the brain.”
— The Healthy LibrarianThe Mayo Clinic web site has two articles on the subject, “Depression and anxiety: Exercise eases symptoms” and “Exercise and depression: A means of self-management”.
I battle depression by going for long walks in a beautiful, woodsy, park reserve.
— JohnJMajor depression is a medical problem of biological origin. For many patients, one of the most difficult manifestation of the disease is a debilitating lack of energy and stamina that should not be mistaken for willful indolence. Antidepressants can sometimes relieve this symptom but in many cases lack of energy remains a struggle even after the patient’s mood improves. When it comes to exercise, the patience and encouragement of friends and family will do far more to help depressed patients than shame and blame.
— MarkAs someone who has battled severe clinical depression for many years, I am always frustrated by those who say, “Just get some exercise. It will make you feel better.” Well, it’s not that simple. If one has severe depression, then one suffers with intense fatigue, low energy, and a loss of drive. Telling someone with severe depression, who can barely get out of bed, to get to a gym, displays a lack of knowledge about this illness. There have been times when I could barely find the energy to walk from my bed to my sofa. Going for a short walk was beyond my capabilities. Getting into a shower, getting dressed, getting out the door - that used all of my strength. Was I “lazy” or “unmotivated”? No. I was just battling an illness that is hard for some to understand. When medications have worked, I have immediately started to get some exercise and the activity that seemed so difficult before then becomes effortless. But, in my personal experience, “just” getting exercise does not help relieve severe depression, anymore than telling a person who can’t swim to “just” swim to shore. So, severe depression may lead to a greater risk of heart disease. But I couldn’t get more exercise to, as they say, “save my life.”
— jlasfYou know what , I am depressed and can not get out of bed . My husband and I have worked all our lives and we both lost our jobs this year , due to both of us being ill . I barely take a shower let alone get out an exercise . All I can think about is mounting bills , having little food , and with the holidays coming up with four small children . What would make me want to exercise there seems no hope left . My health care runs out December 1st , can’t afford my medication , and no one will help . Exercise that is the last thing on alot of people’s mind . Just surviving this horrible time in America is all we and I am sure many others have on our minds . . God help us all .
— AllisonThe problem as always in so many of these studies that look for and appear to find a cause or a cure for one ailment or another is that they offer an ounce of value and a pound of nothing really useful. Call it foolishness. This is the perfect study to prove it.
I will bet that I could also conduct a study that PROVES people who drive new BMWs have a far lower likelihood of being depressed than a comparison group that drives used Mazdas.
PROBLEM SOLVED. Tell depressed individuals to buy themselves a new BMW at once ! Then watch this group’s percentage of depressed individuals drop significantly.
Where do I apply for a research grant !
— AH2We all know how beneficial exercise is to our mental health. Study after study has demonstrated this. It simply goes without saying today that to exercise is to bring strength and calm to our overwhelmed lives.
Would Barack Obama be able to project that dignified calm so many have come to respect were he not in the gym early every morning?
And yet walk through the bleak corridors of our mental health institutions, where the severely depressed are warehoused in scrubbed, brightly lit wings that have the warmth of operating theatres, and you will see many medicated patients shuffling through the day without any access to fitness facilities.
Even sadder is that many of the medical staff will admit that to manage the daily stresses and occasional bouts of depression in their own lives, they run half marathons, or swim laps, or ride their bicycles to work, but that they have never talked to their patients about this or actually tried to find a way to use exercise to help them.
It is disgraceful that not one hospital in North America, which has arguably the most advanced medical system in the world, has ever bothered to build a fitness facility for patients suffering from clinical depression.
But the hourly lineups for medication at nursing stations? You can imagine.
— LonThe medical establishment is slow to acknowledge that there can be a direct effect of the brain on the body. Depression affects hormone levels and nervous activity; these in turn have an effect on disease rates, including heart disease.
Sure, exercise is part of the equation, but depression is a separate risk factor.
The ‘placebo effect’ is a huge hint that we can’t ignore direct influence of the mind on the body. How can we be surprised that depression affects health?
— Josh Mitteldorf“The research suggests that doctors treating patients for depression should also talk to them about their lifestyle habits, and encourage them to exercise.”
Wow, I never realized it was so simple!
I think we should apply this model to a lot of other diseases. For instance, has anybody suggested we tell diabetics that they need to increase their insulin levels? If they would just do that, they’d get better! And how about telling people at-risk for a heart attack to clear out their arteries? That would totally solve the problem. We could even tell people with cancer to just stop growing those silly tumors.
A lack of energy is one of the symptoms of depression. While there may be a complex relationship here - perhaps people who already exercise are at a lower risk for depression - you cannot simply tell a depressed person “get more exercise!” One thing that could be done would be to incorporate a recommendation for regular exercise into existing treatment protocols, introducing the exercise gradually and at a point in treatment where the person will be able to successfully accomplish the task (because, after all, if you’re telling someone with no energy to exercise, it’s just one more thing for them to fail at).
— LauraI find this interesting, because my experience has been just the opposite. I’m a lifelong regular exerciser, and about 18 months ago I entered into a depression so severe that I finally went on antidepressants, which I’m positive saved my life. I had always exercised partly to expend energy in order to diffuse anxiety. As soon as I started the antidepressants, I felt so much better that I didn’t feel the need to exercise myself into exhaustion as a way of taming the anxious energy. Oddly, I didn’t gain any weight. I went off the meds 3 months ago and feel fine, but I still have little desire to exercise to the extent that I did before. A couple mile walk daily is plenty for me now. (For some people, that might be a lot of exercise, but for me, it isn’t, compared to my pre-medication habits.)
— SJSI had always exercised regularly until I became severely depressed at the age of 52. I tried to go for swims or walks (my preferred regimens) and when I did I certainly felt better for it, at least temporarily, but the depression made it hard to move. Also hard to pay bills, clean the house, wash clothes and do all the other things necessary to life. But my psychiatrist and a DBT therapist really encouraged me to exercise, suggested strategies to get me moving, asked me about my exercise every week and with their help I got myself going again.
Morale of the story: there is nothing for depression like regular meetings with concerned therapists. Maybe if they think it will save them the cost of cardiac care, insurance companies will start paying for face-to-face therapy to treat depression.
— Ellenthanks # 14 — i am dealing with both depression and anxiety and have gained 45 pounds in the last two months. i am a strong, gifted athlete that has a history of mental illness. although exercise and medication have helped me escape that claws of these situations, i continue to fall back into them with what seems to me as little choice to do otherwise.
i will try to see the next effort that i make with the exercise as a thing i do for my mind. i am really good about taking my medicine so maybe if i view exercise this way, i will not stop after i have reached certain peaks.
kisses to all of you, thanks for sharing with me and us….
— Gabe