Exercise Prescription for Major Depressive Disorder
SAN DIEGO—In a presentation at Psych Congress, Chad Rethorst, PhD, advised clinicians on how to talk about exercise with their patients. He also took the time to answer some questions about best practices.
How do you go about prescribing exercise?
There are data saying exercise is effective in treating depression, but we see that clinicians aren’t prescribing exercise very often compared with other treatments. One possibility is they don’t know about the treatment.. really we try to break it down very simply into the FIT principle, which stands for Frequency, Intensity, Time, and Type of exercise.
We’ve found that the recommendations for the general population, which is 150 minute of moderate intensity exercise per week, is about what is effective in treatment of depression. That breaks down to approximately 30 minutes 5 times a week.
Moderate intensity can be measured with a heart rate monitors, which is technical and not the most practical, but it’s approximately 60% to 75% of your maximum heart rate. Practically speaking, we tell people that they should work at an intensity at which they can still hold a conversation.
I like to tell people that if they run with their headphones and they’re listening to music and can still sing along with the music, they’re probably not working hard enough. However, if they’re not able to talk while exercising, then they’re probably above that level of moderate intensity.
How do you communicate your recommendations to patients?
It’s definitely a conversation. The biggest challenge in prescribing exercise, not only in people with depression but in the general population, is getting people to do the exercise. We want to find activities the patient enjoys doing. If we made everyone enter the program to train for a marathon, many people would not like that.
Part of the conversation is about what activities the patient likes to do and in what setting do they prefer to do them. It’s important to take all those preferences into consideration and still fit them into that FITT principle.
In addition, there’s research showing that if patients actually leave with a written prescription for exercise they’re much more likely to engage in the activity.
What if clinicians think patients won’t adhere and it’s not worth trying exercise?
With any treatment, there are individual differences in adherence. I think that with any treatment you’re providing, you have to take patient preference into consideration. Just some people are unwilling to exercise, others are unwilling to take a medication or engage in psychotherapy. You have to take that into account, but you have to be able to give the right tools to patients who are interested in exercising.
If patients leaving your talk could change only one thing, what would you want that to be?
We’re making a big push to encourage clinicians to at least ask about physical activity. I think it’s not only important to think about not only about the mental health benefits of exercise, but also about the physical benefits. Physical activity should be viewed as a vital sign for every clinician to check.
It’s also important to emphasize that even though 150 minutes of exercise is the goal, patients aren’t going to go from 0 to 150 overnight. It’s important to encourage small changes in behavior to get them active over time.
The American College of sports Medicine has been specifically looking at how we can screen for exercise. They have a questionnaire with 2 questions: how many days are you engaging in physical activity, and on those days how many minutes are you
They’re also working to set up a referral network, so clinicians can refer patients to people on to someone who has specific expertise in exercise. Hopefully people are at least getting a base knowledge so they can start that conversation of encouraging a patient to be more active.
When does adherence stop and are there strategies for addressing that?
We see that adherence gradually declines for about 6 months. If someone is adherent for the first 6 months, it’s likely they’ll continue to be adherent. If someone becomes nonadherent, it’s revisiting that conversation about barriers and the problems they’re encouraging and helping them troubleshoot and come up with solutions to those problems.
Any advice for how to manage time and still talk about exercise with patients?
Having some conversation is better than having none. It may be as simple as asking the questions and articulating the goal, which can be a 30-second conversation. Time is important, but let’s have that conversation and write a prescription. If you have more time, you could always extend the conversation.
