the road to happiness
Numbing grief, an emotional catastrophe or a case of the blahs… I’ve run my way out of all of them. And I bet you have, too. We runners know that the benefits of our sport go far beyond burning fat, boosting fitness and safeguarding health. Running lifts our spirits, calms the mind and feeds the soul. Research dating back to the 1900s has drawn a link between exercise and mental well being, and there are studies to show that physically active people are happier, less anxious, more positive, more stress-resilient and even more pain-tolerant than their sedentary counterparts.
One study, monitoring runners over a 20-year period, found lower levels of anger, depression, confusion and fatigue (measures of mood on the widely-used Profile of Mood States inventory) compared to a sedentary control group, while research from Penn State University found that more physically active people reported greater feelings of excitement and enthusiasm. Exercise also helps to combat anxiety, suggests a meta-analysis from Arizona State University assessing the findings of 49 trials. In fact, exercise was found to be more effective than every other treatment assessed except drug therapy. Side effects included weight loss, firmer muscles and a laundry basket full of sweaty running gear.
But many questions remain about the relationship between exercise and mental health. Can it do more than blow away a bad mood, and actually tackle serious mental health issues like depression? Or do happy people simply to choose to exercise more? ‘Exercise has proven protective benefits for several aspects of mental health in general, and for symptoms of depression in particular – but findings on its curative effects are conflicting,’ says Professor Frank Kruisdijck, a psychiatrist at the Symfora-Meander Centre for Psychiatry in the Netherlands. This question mark over its effectiveness as a treatment for depression is what led Professor Kruisdijck to embark on a year-long study assessing the impact of running on depressive symptoms. The results are pending.
However, in a study published in the British Medical Journal last year, a group of 360 recently-diagnosed depression sufferers were given either ‘standard care’ or standard care plus a physical activity intervention for one year. The result? The exercise group fared no differently from those receiving usual care, spawning headlines such as ‘Depressed? Exercise won't help you,’ and ‘Exercise doesn’t treat depression.’
As a further blow, a Cochrane Review, summarising the findings of 32 studies and published the following month, concluded: ‘Exercise seems to improve depressive symptoms in people with a diagnosis of depression when compared with no treatment or control intervention – however since analyses of methodologically robust trials show a much smaller effect in favour of exercise, some caution is required in interpreting these results.’ Another less-than-resounding endorsement for working up a sweat to lift your mood.
But Professor Stuart Biddle, a sport psychologist in the department of Sport, Exercise and Health Sciences at Loughborough University, is not persuaded. ‘Let’s come down off the fence once and for all and say that exercise undoubtedly improves mental health,’ he says. ‘Do we need further research in this area? Of course. We need to know more about the type of exercise, the dose, the mechanism behind it. But there is a clear and strong association between mental health and physical activity, including a positive effect on depression, stress, low self-esteem and even cognitive function.’
Dr James Blumenthal, a clinical psychologist at Duke University’s Psychology and Neuroscience department, and a prominent researcher in this area, agrees. ‘A number of studies have shown that exercise results in a significant reduction in depressive symptoms in patients who are clinically depressed or who have elevated symptoms of depression,’ he says. ‘But in addition, studies have shown that people who exercise are less likely to develop depression - and that if people stop exercising, they may be more vulnerable to becoming depressed.’
People with mental health problems giving up on exercise, because they’ve read it ‘won’t help’ is a worrying prospect. As is the recent finding by the Mental Health Foundation that while 42 per cent of GPs would try exercise as one of their top three strategies if they became depressed, it’s a top three treatment modality for only 5 per cent of them.
Guidelines worldwide – including those of the World Health Organisation and the National Institute of Clinical Excellence – still recognise the important role physical activity has to play in mental health, says Biddle. ‘And while I accept that many of the scientific studies done thus far haven’t been perfect, the BMJ study had its flaws, too.’
Among the criticisms levelled at it is the contention that the study didn’t really do what it said on the tin – in other words, measure the effects of exercise. No structure or supervision was offered in the exercise intervention – the subjects were simply advised and encouraged to exercise. Nor was the amount of physical activity they did directly monitored or measured – making it difficult to attribute any effect – or lack of effect – to exercise.
Professor John Campbell, one of the researchers, was quoted as saying: ‘This carefully-designed research study has shown that exercise does not appear to be effective in treating depression.’ But this is questionable. What it showed is that the exercise intervention used in the study did not appear to be effective in treating depression. That’s perhaps why its findings are at odds with the experiences of so many people who have suffered from depression and other mental health issues, who have found sanctuary – even salvation – in physical activity.
Harriet Heal and Shona Campbell, founders of Up and Running www.upandrunninginsevenoaks.org.uk a Kent-based running group specifically geared towards women suffering mental health problems, have seen firsthand the difference donning your trainers can make. ‘It seems to be the combination of exercising outdoors with the social and mutually supportive aspect of being with people who have experienced similar problems,’ says Heal, a clinical psychologist.
The group has been going since 2010, and feedback thus far shows that 90 per cent of participants believe it has had a positive impact on their mood and mental health – a full 100% say they would recommend it to others.
‘For women particularly, I suspect, the beneficial effects of social support are really significant,’ says Heal. ‘Research indicates that social support is protective against depression, but of course, when we're depressed we get more socially isolated, which sets up a vicious circle. If accessing your social support network is intertwined with exercising, as it is with Up and Running, the benefits come together.’
That’s not to say the women spend every session talking about their feelings. ‘Sometimes we just have a laugh and a gossip,’ says group coach Shona Campbell. ‘But knowing that you can talk if you want to, in a mutually supportive non-judgemental environment, is reassuring.’ The fact that Campbell, 52, has herself been plagued by the ‘black dog’ since her early teens and frequently draws on her own experiences, also helps banish any stigma surrounding mental health issues. Campbell tells me she discovered running quite by chance. ‘I was 40 years old, and had dabbled in a few different sports, but nothing had ever stuck. Then I was persuaded to join a beginners’ group with a friend,’ she says. ‘I found it really hard to begin with, and I was always at the back, but I persevered, and it gradually got easier. After about six months I suddenly realised that I was running beside – not behind – another runner, and chatting! It was my light bulb moment, when I finally began to think ‘maybe I can do this’.’
A belief in one’s own competency and ability to succeed in a task is known as self-efficacy – and it is an attribute that many depressed people lack. But some experts believe that exercise participation can enhance self efficacy, increasing feelings of mastery and accomplishment, in depressed and non-depressed people alike.
Campbell – now a marathon and half marathon veteran as well as a coach, agrees. ‘You can feel very helpless and powerless and passive when you are depressed,’ she says. ‘Running is the absolute opposite of that – it helps you take back some control and breaks that ‘I can’t’ cycle. I love the fact that if I’m feeling low, I can get off my backside and do something about it.’
Twelve years on, Campbell no longer takes anti-depressant medication, though she says she would if she needed to. ‘I wouldn’t want to offer running as a ‘cure’ for depression,’ she says. ‘Nor would I claim that since I took up running, all my problems have been solved and I’ve never felt depressed - but it is as an extremely helpful tool.’
Ann Brennan, a writer and editor, agrees. Brennan suffered from severe postnatal depression after the birth of her second child. ‘At my worst point I drove my car down the road trying to figure out how to wreck it in a way that would guarantee my death without anybody knowing it was actually suicide,’ she recalls. When she feel pregnant again, 9 years later, she was terrified the same dark cloud would descend. But something had changed since her last pregnancy – Brennan had become a keen marathon runner and triathlete.
‘Being fit gives me strength,’ she says. ‘Not just physical strength, but emotional and mental strength. When I was going through postnatal depression the first time, I had no tools. No safety net. I ended up on medication. But the next time, I was forewarned. I exercised throughout the pregnancy and when my son was born, I began a training regime with the goal of running a marathon before he was eight months old (I ran two, actually). The depression was still there but it was so much more manageable. Running gave me a way to battle the demons. I had those tools. I was able to get through it without the suicidal thoughts and without any medication. That made a world of difference to me.’
Any runner who has had to hang up their trainers for any length of time, due to injury or illness, will be familiar with the dip in mood and irritability that accompany enforced rest. So does the reverse hold true, too? How does exercise fare when it comes to simply boosting mood or combating stress in people not suffering from clinically diagnosed conditions?
Pretty well, suggests research. ‘Even a single bout of exercise can make a difference,’ says Blumenthal. A study from the University of Northern Arizona found as little as 10 minutes was effective in enhancing mood and energy levels in non-depressed people, while a University of Bristol study showed that employees who exercised before work or in their lunch break felt better equipped to handle the challenges and stresses of the day.
But the benefits won’t endure if the exercise regime lapses. Whether your motivation is weight loss, reduced anxiety, a faster 5km or respite from the fog of depression - you have to do it regularly to continue reaping the benefits. ‘Adherence is one of the biggest challenges we face,’ believes Dr John Ratey, associate clinical professor of psychiatry at Harvard Medical School and author of Spark: How exercise will improve the performance of your brain (Quercus). Heal agrees. ‘Anecdotally, I know lots of mental health clients who have participated in an exercise programme, such as a GP referral scheme giving them access to the gym for a given period, but have then let it lapse. So they get some benefits, but these stop as soon as they stop complying with the "treatment”.’
Ratey reports that there’s a move towards positioning exercise differently when it comes to mental health problems. ‘The message is to just think about today, rather than focusing on the long-term effects,’ he explains. ‘Part of the power of exercise is that it puts you in the moment – you’re not thinking about the past or the future. Exercise today and you’ll make today better.’
One problem, says Blumenthal, is that many people do not 'enjoy' exercise – especially initially. ‘They may view it as a means to an end, to feel better or to improve their health,’ he says. ‘But over time, exercise can become an end in itself – they may grow to enjoy it – which is how it becomes a lifelong habit.’ And that’s where factors like where you exercise, what type of exercise you do and who you do it with become important. (See panel, below.)
I’ve heard so many testimonials supporting the powerful effect of exercise on mental health. Snooker player, avid runner and depression sufferer Ronnie O’Sullivan famously said that if he had to give up his snooker cue or his running shoes, it would be the green baize he’d say farewell to – and I know that my running shoes are the first thing I turn to when I need fortification, clarity, solace or escape. So why isn’t science backing up what so many of us instinctively feel is obvious?
‘Effect sizes in scientific studies can be weak for various reasons,’ Biddle says. ‘But something can be clinically meaningful without being statistically significant.’ The BMJ study is a classic example. Contrary to media portrayal, the researchers actually did find that the exercise subjects were ‘slightly less depressed’ by the end of the study – it just wasn’t a statistically significant difference.
Perhaps only a few people feel better as a result of exercise – or everyone feels better, but not by much. Or perhaps people feel better, but not for very long. These are the sort of outcomes that scientifically, might not spell success, but on an individual basis could make a profound difference. ‘Changes in measurable symptoms of depression and anxiety may be small or negligible, but that does not mean someone has not experienced some important changes in wellbeing,’ explains Heal.
Another stumbling block in defining a cause-effect relationship between exercise and improved mental health is the absence of a clear explanation as to how physical activity might exert its effect.
Those much-touted endorphins undoubtedly have a role to play. Once believed to be the sole cause of the runner’s high’, the endorphin theory came into question a few years ago, when it was discovered that while levels of endorphins in the blood increased as part of the body’s stress response to exercise, blood concentration had no relation to levels of endorphins in the brain, thanks to the ‘blood-brain barrier.’ It was only recently that researchers at the University of Bonn found a way of actually measuring endorphins in the brain using PET scans of runners’ brains during a 2-hour run – and it turns out that endorphin levels do rise in response to exercise, elevating mood, masking pain and proffering a feeling of wellbeing.
But endorphins are probably not the only chemicals at work. The ‘monoamine theory’ holds that people suffering depression are low on neurotransmitters called monoamines – including dopamine, norepinephrine and serotonin – these are the neurotransmitters targeted by many anti-depressant drugs. Physical activity, however, can enhance their availability. In fact, in a landmark study conducted by Dr Blumenthal in 2000, a supervised exercise programme was pitted against an anti-depressant called Zoloft over a 16-week trial. One group ran or walked (whatever got them to 70-85% of their aerobic capacity) for 30 minutes three times a week. Another group took the drug, and a third group did both. At the end of the study, all three groups had a significant reduction in symptoms – in fact, half of each group no longer felt depressed at all, leading Blumenthal to conclude that exercise was as effective as medication. Ten months on, though, he found that exercise actually worked better over the long-term in keeping symptoms at bay. ‘Exercise regulates all of the neurotransmitters targeted by antidepressants,’ explains Ratey. ‘It elevates norepinephrine, which wakes up the brain, boosts dopamine, which improves mood and feelings of wellness and the attention system, and raises serotonin - important for mood, impulse control and self esteem. It also helps stave off stress, by counteracting cortisol.’
Endocannabinoids are another likely ingredient in the chemical cocktail that causes physical activity to lift our spirits. Like the drug they derive their name from, endocannabinoids are associated with feelings of wellbeing, a reduction in anxiety and a dulling of sensations of pain (and, yes, an urge to snack). A study at Georgia College and State University found that levels of anandamide, one of the endocannabinoid family, almost doubled in response to 50 minutes of moderate-intensity treadmill running.
It seems we still can’t pinpoint one single cause behind exercise’s ‘feelgood effect’. And we may need to look beyond biochemistry for the full picture. ‘The problem with the strictly biological interpretation is that we lose sight of the fact that the mind, brain and body all influence one another,’ points out Ratey. ‘In addition to feeling good when you exercise, you feel good about yourself, and that has a positive effect that can’t be traced to a particular chemical or area in the brain.’
We’re back to self-efficacy and mastery again. Or how about the notion that, rather than stirring up a biochemical cauldron, exercise simply serves as a distraction from the daily grind? ‘It’s plausible that the time-out exercise gives you away from stress and depressing thoughts has a positive effect on mental health,’ says Biddle. The fact that exercising to music and in the company of others have been shown to be particularly beneficial to mental health offers some support for this theory. But not enough to rule out the other contenders. ‘The likelihood is that it’s a mixture of biology, physiology, psychology and social connectedness – with the factors varying from person to person.’
So the jury remains out with regard to whether exercise can act as either a safeguard for mental health or a cure for mental woes. And if it does work, we don’t really know how – or why. ‘It’s the classic chicken-egg problem that scientists face when correlating physical activity and mood,’ says Ratey. ‘Does it really matter whether you’re less depressed because you exercise or whether you exercise because you’re less depressed? Either way, you feel better.’
Campbell couldn’t agree more. ‘I’m fully aware that the research is inconclusive about the effects of exercise on mental health – but frankly, I don’t give a stuff, because I know it works for me and I’ve seen it work for others. If you don’t try, you’ll never know.’
Dosing up on exercise
We may be a long way from being able to hand out a failsafe exercise prescription that will work for everyone, but a Polish review study found that rhythmic, aerobic exercise using large muscle groups elicited the best improvements in anxiety, depression and mood, in both healthy and clinical populations, regardless of age and gender. Sounds like running should fit the bill. But how much, how hard and how often? Here’s what the research says….
How long?
As little as ten minutes exercise can perk up mood, found research published in the journal Health Psychology, while a 30-minute workout can buffer you against anxiety and emotional stress, found researchers at the University of Maryland last year. ‘For patients with clinical depression, regular exercise (for example, 30 minutes at least 3 times per week) is needed for at least 12-16 weeks to achieve significant improvement,’ adds Blumenthal.
How hard?
‘We generally recommend low- to moderate-intensity exercise for mental health benefits,’ says Biddle. ‘The evidence suggests that during and immediately after high-intensity exercise, mood worsens.’ However, when you finish – after an initial recovery period – there’s a ‘rebound effect’ resulting in a positive mental state. And that could be why anecdotally, many people say they feel better after toughing it out in a really challenging session. ‘I think cardiovascular intensity is key,’ says Heal. ‘Having been off myself with an injury I am very aware that I need intensity to get the mood effects, and other activities I’ve tried don't hit the spot like running.’ A study assessing the effect of exercise intensity on anxiety, published in Psychology and Health, found that low-intensity exercise successfully reduced anxiety, while more intense exercise did not. So perhaps a soothing recovery run is on the cards when your nerves are stewed...
How often? While there are mixed findings regarding how many exercise sessions it takes to have a positive impact on mental health, it seems that you don’t need to be slogging out excessive miles to reap the benefits. A Finnish study of 3,400 men and women found that those who exercised at least 2-3 times a week reported significantly less depression, anger, cynicism and stress than those who exercised less or not at all. Other research suggests it’s not frequency per se that counts but volume. In a study published in the American Journal of Preventive Medicine, a weekly ‘dose’ equal to 17.5 calories per kg of body weight per week was successful in alleviating mild to moderate depression, while a lower weekly expenditure was not. So if you weigh 70kg, you’d need to burn 1225 per week – the equivalent of just a dozen weekly miles... ‘If you follow the national guidelines and aim to exercise for 150 minutes a week, you won’t go far wrong when it comes to physical and mental health,’ believes Biddle.
Where?
The effect of the environment on our mental health – ecopsychology – is a growing area of interest. Research suggests that if our surroundings are pleasant, it can help to enhance the effects of exercise on mental health. For example, a study in 2007 in Psychophysiology found that outdoor running boosted mood better than treadmill running. John Ratey isn’t surprised. ‘Outside, not inside,’ he says firmly. ‘We have an innate need to connect with the natural environment.’ Campbell agrees. ‘Being outside is what hit the nail on the head for me. I’d previously run on treadmills but not had the emotional lift I got being outside.’ But Biddle believes a pleasant built environment can be just as good as an outdoor one – perhaps beauty is in the eye of the beholder.
Who with?
Research suggests that the majority of people are more motivated to exercise in a group, and more likely to stick to exercise if they work out in the company of others. ‘It’s in our nature to want to belong, and be part of a ‘tribe’,’ says Ratey. Campbell agrees. ‘It’s very common to become isolated and withdrawn when we’re depressed – just being with other people can help.’ But it’s key that you feel supported and accepted by the group – a running club that sprints off and leaves you puffing at the back won’t do much to boost self-efficacy.