Were he around today, I could imagine referring one of my patients or a family asking about help for a loved one with depression to Vincenz Priessnitz. But he died in 1851. Priessnitz was a pioneer in alternative medicine, where diet, exercise, and non-medicinal interventions (like hydrotherapy, namely baths with robust currents and minerals added), were provided to people with depressive illness, among other disorders.
Practicing in Austria (in a region that is now part of the Czech Republic), Priessnitz gained fame throughout Europe, the UK, the New World, and as far as New Zealand for curing his patients by combining baths with vigorous exercise, adequate sleep and proper diet. Exercise consisted of long walks in fresh air or sometimes (the season permitting I suppose) walking barefoot in fields of grass.
What do they say? What goes around, comes around? Especially, what we could call 'the walking cure.'
Several recent studies, a mere 150 or more years after his death, validate Priessnitz's contention about exercise. More general support for the medicinal, or health, value of exercise was reported in a review article on 29 studies that showed that attention, memory and speed of mental functions were substantially improved in individuals who engaged in aerobic exercise (1). More specific, anatomic brain volume increases were found in people with schizophrenia who exercised aerobically (2). General mental health has been shown to be associated positively with how vigorous and frequent adults exercise (3).
But my favorite is the work of Drs. Dunn, Trivedi and their colleagues in Texas and Canada who demonstrated the salubrious effects of exercise on depression (4). Before I describe their work, I want to stress, as I have elsewhere, that if you or a loved one has severe depression, or depression with suicidal ideas or loss of reality (called psychotic depression), get thee to a doctor. Alternate treatments like exercise or evidence-based psychotherapies, like cognitive-behavioral and interpersonal therapy, are highly effective for mild to moderate depression but for more severe depressive illness -- which can be life-threatening -- medication is generally needed. When illness is severe, alternate treatments become complementary treatments, which is to say they can add, or complement, the action of medical interventions.
But back to the 'walking cure.' The work of Dunn and Trivedi showed that exercising three or more times a week to the level recommended by the American College of Sports Medicine and other public health consensus reports improved symptoms of depression. They called this the "public health dose" of aerobic activity, which means vigorous exercise (walking, running, stationery bicycle are all good) for at least 30 minutes at a time, several or more times a week. No differences were found between those that exercised three times versus five times a week. But those who did not get the "public health dose" (either because they were in a group that did less exercise or were controls, people who did not engage in the treatment but were monitored as a comparison group) did not have the clear improvements in depression that those that exercised did, judged by significant reduction in symptoms or full remission of their condition.
You don't have to start at the "public health dose." Like with most treatments, wise counsel is to start low and go slow. Begin with short walks, or time on an exercise machine. Do it twice a week, and then get to three or more times. Find the right time for you: some people prefer to exercise in the morning, some in the late afternoon or evening (when our muscles are more warmed up and flexible). Work, school or home schedules, of course, may make it plain enough what times are possible.
How does exercise work? We don't know for sure. Release of neurotransmitters instrumental to mood regulation (like serotonin and norepinephrine) or pain control (like endorphins) may play an important role, or perhaps reductions in stress hormones. The discipline and self-mastery of committing to a task and doing it faithfully helps with self-esteem and self-confidence. We may not know the mysteries of the neurophysiology and neurochemistry of exercise, but we know it works!
What does not work, however, is not exercising. It can be hard to exercise even if you are not depressed. Exercise takes time, and for people not used to it, exercise can produce aches, pains and fatigue. But those 'side-effects', if you will, go away soon -- replaced often by a feeling of well-being, clearer thinking and improvement in mood; some people even lose weight. For people who are depressed, doing almost anything can seem too great a task, or they feel that their condition is hopeless or that they do not deserve to feel better. That is where family and friends come in. Exercise that is done with others, or encouraged and supported by others, is more likely to happen. Priessnitz had a captive population, so if you were at his spa or under his care you got up and walked -- not negotiable if you want to get better, he might have said.
The question for a person with depression, then, is what are you willing to do to feel better, to be able to feel energy and hope again in your life? What do you not only owe yourself, but what do you owe your loved ones, friends and others who rely on you at home, work, school and in your community?
The answer may be old-fashioned, but not out of style.
References
1.Smith, Blumenthal, et al: Psychosomatic Medicine: 72:239-252, 2010
2.Pajonk, Wobrock, et al: Archives of General Psychiatry: 67:133-143, 2010
3.Medical Sciences Sports Exercise: December 1, 2010
4.Dunn, Triveti, et al: American Journal of Preventive Medicine 5:28:1-8, 2005
Originally published in the Huffington Post on February 8, 2011
The opinions expressed herein are solely my own as a psychiatrist and public health advocate.
Visit Dr. Sederer's website at www.askdrlloyd.com -- for questions you want answered, reviews and stories.
Statistics can be chilling: 34,000 people die by their own hands in the U.S. each year (that's a suicide every 15 minutes, nearly twice that of homicides) and more veterans of Iraq and Afghanistan take their lives than die in combat. But it is the emotional agony that precedes the deadly act for the person and the legacy of lifelong pain that follows it for the survivors that haunts the world of those who take their lives.
Few families are spared -- if not death then suicide attempts and the maelstrom they stir. As a doctor, a psychiatrist, who has treated many patients, I had one man who ran away from a hospital on the day I met him, decades ago, and drowned himself in a freezing river. As a clinical administrator of mental health services and medical director of a psychiatric hospital, I know of many people who have taken the ultimate step and ended their lives. But it was a close relative by a former marriage who hung herself many years ago whose memory to this day still sears my mind and stirs doubt about myself and what might have been done.
Ten years ago, a National Strategy for Suicide Prevention (NSSP) was built on the foundation created by Dr. David Satcher, the extraordinary U.S. Surgeon General who had issued a "Call to Action to Prevent Suicide." A common understanding of suicide was established by the NSSP, advocacy efforts begun, public awareness campaigns launched, local and state prevention plans written and commenced; all the best minds and influential people were involved. Shortly thereafter, the then-President George W. Bush ordered the President's New Freedom Commission on Mental Health and its report candidly identified what needed to be done to improve a very broken mental health system in this country.
A very auspicious start. But when we take its measure today, a decade later, we cannot show any evidence that the suicide rate across this country has been reduced. We have not "bent the curve" on self-inflicted death. Preventable deaths continue. We can and have to do better.
While no specific, single preventative intervention or technique has worked we have seen notable instances where an impact was made in reducing death by suicide. Two remarkable examples stand out. One is the "Perfect Depression Care Initiative" that began in 2001 in the Behavioral Health Services Division of the Henry Ford Health System, a large Health Maintenance Organization with 200,000 members operating in southern Michigan and adjacent states. Since 2008, they have achieved the perfection they sought: 10 calendar quarters have now passed where not one person has died from suicide. The second example was by the U.S. Air Force in the mid-90s to prevent suicide among Air Force personnel; this initiative was driven by top leadership in the wake of growing deaths and produced an 80 percent reduction, initially, and a 50 percent reduction over time.
In September 2010, recognizing that 10 years had passed with disappointing national results, Secretary Kathleen Sebelius, Health and Human Services, and Secretary Robert M. Gates, Department of Defense, accompanied by former U.S. Senator Gordon H. Smith (now CEO of the National Association of Broadcasters), the Secretary of the Army, John McHugh, other officials and experts announced a public and private partnership called the National Action Alliance for Suicide Prevention. A second meeting of the Action Alliance met on February 9 to build on the efforts of various workgroups and change the static state of suicide prevention. Many ideas are now in play, so focus, feasibility and leadership will be needed.
What works, then, I ask? Some aspects that pertain to Henry Ford Health and the U.S. Air Force are revealing. What about starting with the setting rather than with any specific intervention to reduce suicide? In other words, first identify an established group to work with. This can be a health plan, a university, a government agency or institution, or a business organization. It can be an organization that has information on all its members, the capacity to reach them all, has clear and committed leadership and is well disposed to innovation. One that can specifically measure what will be done to change practices as well as report on the results while using a quality improvement framework to sustain and enhance any gains that are achieved.
Once the setting, or population is chosen, then is the time to identify specific clinical or social interventions (like depression screening, care paths for the suicidal person or for specific mental disorders, reducing access to weapons, engaging spouses and families, treating alcohol and drug abuse, education campaigns, etc.) that would fit each unique setting (or population).
This approach inverts a customary approach to suicide which begins with an intervention and looks to where it can be implemented. Since no single intervention has been proven effective it may be time to turn the field on its head: Begin by establishing what contexts offer opportunity for getting something done rather than starting with what can be done.
If we can reduce suicidal deaths by 25 percent in the next 10 years, near to 90,000 lives will be saved -- that we know of -- not to mention reductions in serious suicide attempts and the catastrophe that suicidal behavior rains upon a person, family and community. If we can send a man to the moon, we can figure out how to save lives on earth.
Originally published in the Huffington Post on February 16, 2011
The opinions expressed herein are solely my own as a psychiatrist and public health advocate.
Visit Dr. Sederer's website at www.askdrlloyd.com -- for questions you want answered, reviews and stories.
Dr. Antonio Convit awoke suddenly one night unable to sleep. His research findings were running through his mind and alarmed him. He had been studying children with excess weight (overweight and obese) who were developing pre-diabetes (called insulin resistance) and type 2 (non-insulin dependent) diabetes. It is well known that obesity greatly increases the risk of diabetes in children (and adults). But what relation obesity and diabetes have to the mental functioning of the developing brains of children and adolescents has been unchartered territory – exactly where a scientist like Dr. Convit and his research team would want to go.
They began their work studying obese adolescents with type 2 diabetes. They wondered if serious weight gain and diabetes reduced intellectual performance in youth? To answer this critical question, they would test the brain's functioning by measuring intelligence, reading, spelling, vocabulary, reasoning, memory, attention, concentration, and mental efficiency. They would also do imaging of the brain by MRI (Magnetic Resonance Imaging, a scanning technique where the brain can be safely studied) to see if there were reductions in its size or capacity to function, of course factoring in age, that might be related to lower levels of mental performance.
Their results show that the adolescents they studied with type 2 diabetes did more poorly on all the mental performance tests. In addition, these same youth showed smaller brain volume for the entire brain and the frontal lobes, where much of our reasoning occurs. The frontal lobes are also the last part of the brain to mature so it is highly sensitive to change during adolescence. The abnormal findings Dr. Convit found occur more in obese diabetic youth than in (matched) youth who also were obese but did not have diabetes (or pre-diabetes – where the body has developed insulin resistance).
Obesity in youth has tripled in the past 30 years, with 1 in 3 three high school students now overweight or obese in the United States. Ethnic groups show even more disturbing trends with 1 in 2 Hispanic and 4 in 10 African-American youths affected. Obesity is the road to insulin resistance and diabetes, with their well known adverse effects on blood vessels and the heart - which shorten life and erode its quality along the way. What is new, however, is that obese, diabetic youth also have their brainsimpacted and appear to have difficulty learning and succeeding in school.
A survey by the New York City Department of Health and Mental Hygiene (NYC Vital Signs, June 2009, Volume 8, No.1) examined public school children from kindergarten through 8th grade and found nearly 40% overweight or obese. The epidemic of obesity is greater in NYC than it is nationwide, but not by much. The epidemic has spared no one: boys and girls, and all races and ethnicities, with Hispanic youth the most impacted. This NYC survey focused on Body-Mass-Index (BMI, which is a measure that takes weight and height into account) and physical fitness in this age group; it showed that overweight and obese youth (obesity is defined as an BMI equal or greater than 30) had lower levels of fitness and that those more fit did better on tests of English Language Arts (ELA) and Standardized Math tests, both established measures of school performance. The City Health and Mental Hygiene Department recommended, as a result, that parents, schools and health care providers need to help children be fit by engaging in daily physical activity. In addition, the report stressed healthy eating habits, including healthy meals at home, and "don't let your children drink their calories" referring to the way that high calorie, sugary beverages cause weight gain in youth.
Dr. Convit has taken his research findings beyond his laboratory and academic work at the Nathan Kline Institute (a research institute of the NYS Office of Mental Health; disclosure - the Table of Organization of OMH will show this Institute reporting to me) and the New York University Langone Medical Center. He began The BODY Project: Banishing Obesity and Diabetes in Youth. This program is working with adolescent students at two NYC schools, in Manhattan and Brooklyn, to medically screen, engage and help minority youth with excess weight and their families change how they eat, become more physically active, and take care of their health and wellbeing - today and for the future. The BODY Project aims to improve health and brain functioning (and thus school performance) in these youth.
Dr. Convit's work is revealing a gradient where learning difficulties increase as youth go from lean, to obese without insulin resistance, to obese with insulin resistance but not yet diabetic, to those who are obese and have diabetes. It appears that every step beyond being lean means the brain works less well and performance at school can suffer.
This is what I think is waking Dr. Convit up at night. Imagine if there was a way to improve school performance now, not just prevent heart disease years from now? Imagine if success in school, not just a smaller clothing size, awaited adolescents who with direction and support became fitter and shed pounds. Imagine if school test scores increased as BMI scores decreased. I would be restless too if I saw a way by which one third of American high school students, and others even younger, could become more mentally capable, more competitive and more successful. That would be a real wake up call.
Originally published in the Huffington Post on July 27, 2010.
The opinions expressed herein are solely my own as a psychiatrist and public health advocate.
Visit Dr. Sederer's website at www.askdrlloyd.com — for questions you want answered, reviews and stories.
