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November 2009

Milnacipran (Savella)
Milnacipran (Savella) is the third compound to be approved in the United States for the treatment of fibromyalgia syndrome.

Preventing Depression in Adolescents
Current depression in parents negates the positive effects of a group cognitive behavioral prevention program in preventing depression in adolescents.

Anticholinergic Medicines and Cognitive Decline in the Elderly
Anticholinergic medications can impair cognition and memory, especially in elderly patients.

In Brief
Predictors of Mortality in Depressed Patients following Cardiac Events; Disruption of Dopamine Neurotransmission in ADHD

Raising the SSRI Dose: Does It Help?
Selective serotonin reuptake inhibitors (SSRIs) do not appear to have an obvious relationship of dose to likelihood of benefit.

Generic Antidepressants: Bioequivalent?
Generic formulations of antidepressants may not have the same pharmacokinetics and clinical effects as the original brand-name versions.

Lamotrigine in Borderline Personality Disorder
Preliminary research found lamotrigine (Lamictal) superior to placebo in improving symptoms of affective instability and impulsivity in patients with borderline personality disorder.

And a One, and a Two… Exercise for Depression
As an adjunct to medication and psychotherapy or by itself, exercise can be an effective treatment for depression.

And a One, and a Two… Exercise for Depression

November 2009

First-line treatments for uncomplicated major depressive disorder (MDD) of mild to moderate severity are antidepressant medicines and specific forms of psychotherapy.1 Clinical experience and recent research support exercise as a treatment for MDD, a subject reviewed by Sidhu and coauthors.2

The reviewers begin by noting that among adults in the national comorbidity survey, the 60% who exercised regularly reported lower rates of depression and anxiety than people who were less active. In addition, a meta-analysis of 11 randomized controlled trials suggests exercise is an effective treatment for depression. Nonetheless, only 34% of over 9,000 patients in a population-based survey reported that their physicians counseled them about exercise.

Even more than the general population, depressed patients need support and encouragement to initiate and maintain regular exercise routines. The authors urge clinicians to set small, realistic goals for depressed patients, counsel them about exercise as if it were a prescription, and discuss exercise at each visit.

Exercise is important for the mental and physical health of older people. Elderly patients with depression may be less likely to exercise than people who are not depressed. When counseling exercise to an older person, consult with the patient's primary physician.

Exercise alone (without medication) may help people with mild to moderate levels of MDD. The efficacy of aerobic exercise for treating depression appears to follow a "dose"-response relationship; that is, the more energy expended, the greater reduction in depressive symptoms. The public health recommendation of 30 minutes of moderate to vigorous activity all or most days of the week may be the most efficacious regimen for both physical fitness and to combat depression.

Regular physical activity increases cardiorespiratory fitness. When added to medication treatment for depressed patients, exercise often leads to an increased quality of life. The antidepressant benefits from exercise appear to persist over time, presumably as long as exercise is continued. Regular exercise may help to prevent depression in vulnerable patients, and it also might be able to play a role in the treatment of postpartum and late-life depression.

How does exercise improve mood? Possible mechanisms include elevating central nervous system levels of endorphins, salutary alterations in neurotransmitters, increased levels of brain-derived neurotrophic factor (BDNF), reduction of serum cortisol, elevation of body temperature, enhanced self-esteem, distraction from daily stress, and induction of relaxation. A recent study in laboratory mice found that running increased hippocampal BDNF, promoted hippocampal neurogenesis, and improved recognition memory.3

The authors offer some wise and practical recommendations. They suggest that psychiatrists inquire about physical activity at every visit to assess patients' motivation to exercise. Directly addressing fears and negative experiences can help patients overcome these barriers and find creative ways to fit exercise into their lives. Dr Sidhu and coworkers also suggest lifestyle changes in addition to formal exercise programs. For example, encourage patients to take stairs instead of elevators, play with children or pets, or take brisk walks. Patients with physical handicaps can consider stationary bicycles or swimming. Work around the house or in the garden can be fun and relaxing, as well as a means to increase caloric expenditure. The speed of regular walks can be increased and possibly hills added to a flat path. Motivation to exercise can be enhanced by novel routes, walking with friends or family members, or listening to music.

If patients are healthy enough to participate in physical activity, exercise, in addition to medication and psychotherapy, can be part of a comprehensive biopsychosocial treatment for depression. Once a patient is in remission, exercise can be encouraged as part of a healthy lifestyle to enhance physical well-being and to reduce the likelihood of recurrent depression.

1American Psychiatric Association: Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry 2000;157(Suppl 4):1–45.

2Sidhu KS, Vandana P, Balon R: Exercise prescription: A practical, effective therapy for depression. Curr Psychiatr 2009;8:38.

3Lafenetre P, Leske O, Ma-Hvgemeier Z, Haghikia A, Bichler Z, Wahle P, Heumann R: Exercise can rescue recognition memory impairment in a model with reduced adult hippocampal neurogenesis. Front Behav Neurosci, in press.