Is the Gym Really As Good as Therapy?
In mid 2018, Neill started feeling uncharacteristically, persistently anxious. He’d just left his full-time job to study for his PhD, and was struggling with the shift. ‘I live on my own, and then I was in an office in a university, studying on my own,’ says Neill, now 43. ‘It was really isolating. I was thinking, “What am I doing here?”’
Fortunately, he knew what he could do to make himself feel better. For the past few years, Neill had been exercising regularly, cycling the 20-odd miles to work a couple of times a week and getting out to his local parkrun on Saturday mornings. His primary motivation had always been fitness. But when his mental health began to decline with the transition to studying, Neill soon realised that being active triggered an immediate improvement.
Fitness became the anchor Neill desperately needed as he adjusted to his new life, loosening the knot of anxiety he felt in the pit of his stomach and lending structure to his days. ‘When I was really struggling, I tried to make that conscious effort to exercise,’ he says. But his habit wasn’t without its downsides. ‘If I didn’t exercise, it almost made my mental health worse: there was that kind of vicious cycle.’
The many benefits of exercise for physical health are, by now, well established and widely known. But it’s only relatively recently that it has started to draw attention for its effects on mental health. Studies have consistently shown that physical activity can boost mood and self-esteem, improve sleep quality and energy, and lower levels of anxiety and stress. Even single ‘doses’ of low-impact movement, such as walking, can produce an immediate and noticeable improvement.
Many of us experienced this for ourselves during the Covid pandemic, when our ‘silly little walks’ (as they were termed on social media) proved a lifeline through lockdowns.
But in the years since, evidence has been mounting to suggest that exercise doesn’t just improve your mental wellbeing in the moment, it can also protect you against the onset of mood disorders such as depression. It may even be a potential cure.
Two recent studies have recommended that exercise should be taken more seriously by clinicians as a treatment for mental health conditions, and even prescribed. The first, published in the British Journal Of Sports Medicine last year found that physical activity was ‘highly beneficial’ for improving symptoms of depression, anxiety and psychological distress.
The second, published in the British Medical Journal this February, went one step further, suggesting that walking, jogging, yoga and strength training could be just as effective at treating major depressive disorder as psychotherapy and antidepressants.
‘Lots of previous reviews showed exercise helps depression, but our review was big enough that we could figure out what exercise works and how much,’ says Michael Noetel, a senior lecturer in psychology at the University of Queensland and the lead author of the study. ‘Some things were surprising. We thought more would be better, but we didn’t find that it was better to do two hours or 20 minutes.’
His findings were widely publicised as a potential breakthrough for the global scourge of depression. The disorder affects an estimated 280 million people worldwide, yet only half of those based in high-income countries receive treatment. Exercise – being readily accessible and seemingly highly effective, with few to no side effects – could be the miracle cure we’ve been searching for.
While Dr Noetel’s findings were promising, he cautions against seeing exercise as a silver bullet, or a replacement for antidepressants or therapy – each have their place in treatment, he says.
Particularly for people with severe depression – when it can be hard to get out of bed, let alone get moving – medication may be necessary to get to the point of being able to consider those other beneficial behaviours. Likewise, therapy more directly targets the negative thought patterns contributing to mood disorders, says Dr Noetel. ‘It looks like there are lots of things coming together to cause depression, from social isolation and living mindlessly to staying inside and feeling like you can’t achieve anything… The good thing is that exercise often targets lots of these at once.’
How Exercise Changes Your Mind
While the science is increasingly persuasive about physical activity as a treatment for depression, we still don’t understand exactly how it works. Dr Noetel’s study did not reveal ‘clear causal mechanisms’ for exercise’s effect on depression.
His and other research suggests that there’s likely more than one at play, depending on factors such as whether you exercise alone or with others, and indoors or in nature. The form of activity – whether it’s raising your heart rate or clearing your head – is also likely relevant.
Yoga, for example, is understood to be beneficial for anxiety in particular. But while even lower-intensity exercise such as walking does make a difference to mental health, studies show that more vigorous activity produces stronger effects. It’s the same for a consistent routine over the odd session.
But more research needs to be done if we’re to truly understand the relationship between exercise and mental health, and consistently harness its benefits, says Jonathan Roiser, a professor of neuroscience and mental health at University College London.
He’s currently leading a large clinical trial into the link between depression and physical activity, which he hopes will result in more conclusive findings than the existing research. Backed by the Wellcome Trust, the study will compare the effects of aerobic exercise on adults with depression, versus those of gentle yoga and stretching.
‘The question we are basically trying to answer is “how does it work?” and “for whom does it work?’’’ Professor Roiser says. Those findings could go on to help to refine the proposed ‘prescription’ of exercise for mental health.
At the moment, ‘It’s actually very difficult to predict, just on the basis of people’s symptom profiles, whether a particular treatment is going to be good for them or not,’ Professor Roiser says. ‘Some people take an antidepressant, and it’s like a miracle drug with a massive reduction in symptoms and hardly any side effects; others find it doesn’t really work for them at all.’
It’s likely the same for exercise, he says. With his careful, controlled clinical trial, Professor Roiser is hoping to gain clarity, not only on how different types of physical activity affect depression, but also whether there are groups of people for whom it might be especially beneficial. ‘We’re actually more interested in these kinds of questions about the biological and psychological processes that are going on to help people get better,’ he says.
Professor Roiser’s working hypothesis is that physical activity can treat depression by changing motivational processes in the brain. A regular exercise regimen helps to build motivation and increase energy; it also works to reduce inflammation (prevalent in people with depression and other mood disorders) and improve the brain’s transmission of dopamine.
One of the most common symptoms of depression is negativity bias, where you focus more on negative thoughts and stimuli than positive ones. Professor Roiser proposes that exercise may help to break that vicious cycle, gradually influencing your brain to register positive experiences and seek out more of them.
Over time, he suggests, this alters people’s psychological processing. ‘They relearn how to engage with the world,’ and then the depressive mindset lifts.
It will be at least three years until Professor Roiser’s study yields ‘a nice big set of data’ and conclusive results, he says. But the preliminary findings from a pilot study strengthen the existing case for exercising for mental health. And, while it’s certainly true that ‘something is better than nothing’, consistency and intensity are relevant if you want to experience those cumulative benefits, and boost the underlying processes, Professor Roiser says.
‘Many people in our studies don’t feel amazing immediately after the session, but these changes – to their inflammation, neurochemistry, interaction with the world – are taking a bit of time to kick in,’ he says. ‘It’s that kind of cumulative change over time, as opposed to the immediate after-effect, that’s important.’
More Isn’t Always Better
The optimal ‘dose’ of exercise for mental health, in fact, seems to be consistent with the NHS guidelines for physical health: about 150 minutes of ‘moderate intensity’ activity every week. That’s indicated by being slightly out of breath, and perhaps breaking a sweat – ‘so it’s more than a brisk walk [for most people]’, says Professor Roiser.
But while the evidence certainly points to more vigorous activity having a stronger effect, that’s not to say it’s the only kind worth doing. A 2018 study of more than 1.2 million US adults, published in The Lancet Psychiatry journal, found that people who did any form of exercise in a month experienced about 1.5 fewer days of poor mental health than those who didn’t.
‘Even relatively light forms of exercise, or relatively low volumes, seem like they can be helpful,’ says Adam Chekroud, one of the study’s co-authors. Team sports recorded the greatest benefits, likely due to the added social element, but walking and even household chores and gardening made a difference.
‘There was this minimum effect, where anything is better than nothing,’ Chekroud says. The ‘sweet spot’ seemed to be 45-minute sessions, three or four times a week. But, perhaps paradoxically, exercising more than five times a week was associated with worse mental health.
‘These are people who are either exercising three hours at a time, or for 24 to 30 days a month – you start to wonder if that’s a symptom of obsession,’ Chekroud says. ‘It starts to get wrapped up around potential body-image issues, or psychological issues.’ At that level of intensity, there’s an added risk of doing physical damage, Chekroud adds. ‘You’re supposed to have rest and recovery.’ All of which suggests that the best exercise routine for mental health, as well as physical health, is one that you enjoy and can maintain indefinitely.
If you’re struggling with feelings of isolation, for example, you might decide to join a cycling club or team sport. Not only does the social element help with accountability, it layers on another mental health boost. And while the benefits of yoga might not be as pronounced as for more intense activity, if you know that you respond well to mindful movement, you might opt to prioritise it.
It’s this sort of personalised, evidence-based advice that Professor Roiser and other researchers hope will be made widely possible by better understanding exercise’s effect on mental health.
Though it’s included in national guidelines for treating depression, it’s rarely prescribed in practice, ‘even though we know it works’, says Professor Roiser. More research into the mechanisms at play could help clinicians and patients alike to take exercise seriously, he suggests, reducing both the burden of mental illness and demand on healthcare services.
At the moment, waiting lists for therapy on the NHS can be many weeks long, but ‘anyone can basically put on their trainers and go for a run’, Professor Roiser says. ‘Due to the very accessible, low-cost nature of physical activity […] I think there’s good potential to improve, at a population level, the mental health profile of the country.’
When Starting is the Hard Part...
The challenge is encouraging uptake. ‘There’s a bit of a stigma for recommending exercise, as doctors can feel like they’re telling their patients to “run from their problems”,’ says Dr Noetel. Indeed, his study found that people with depression did better with structure, oversight and support – and that isn’t always available. ‘It can be expensive to get a trainer or join a group programme.’
For those not already in the habit of exercising, the barriers are even higher. It’s not that people don’t know that it’s good for the mind, says Masha Remskar, a behavioural scientist at the University of Bath, it’s finding the motivation to start. ‘If you went to the doctor and they said, “Just start exercising” – that’s not a fair recommendation, because we know that taking up exercising is much more complex than just popping a pill.’
This, she suggests, is where mindfulness can come into play. While it may not raise the heart rate, developing non-judgmental awareness of one’s thoughts, feelings and experiences has been shown to be highly effective in reducing stress and anxiety, with benefits for mental health.
Now, Remskar’s research has found that a mindfulness practice can not only motivate people to take up exercise in the first place, but that it can also support them to stick with it. ‘What we’ve found is that mindfulness training in itself can actually help build up those psychological strengths that we know people need in order to have a successful exercise habit,’ she says.
While activities such as yoga have a mindfulness component, Remskar’s study found that combining any physical activity with mindfulness training was effective for improving mental health, and ‘possibly more so than either approach alone’.
The study didn’t identify specific mechanisms of change, but Remskar suggests that, by making us more aware of our bodies and experiences, mindfulness connects us with our reasons for exercising, and helps us attune more quickly to the benefits of getting our bodies moving, encouraging us to stick with it. ‘For example, it makes every single run you go on different, and therefore you’re more likely to stay involved.’
Mindfulness training may also help to counter the ‘all-or-nothing’ thinking that’s so often a barrier for people just starting to exercise, and support other habits such as healthy eating, Remskar says. ‘The beautiful thing about it is that those psychological skills are very transferable.’
To her, this is yet further proof of the interconnectedness of mental and physical wellbeing – and the vital importance of exercise for both. ‘Our bodies really were designed to move,’ Remskar says. ‘All of our bodily systems, physical, mental – from the level of the cell to the full organism – rely on us being physically active.’
It’s true that the many benefits of exercise for mental health only underscore the costs of being inactive. Even if you’re not presently struggling with depression or anxiety, the science suggests that making a habit of exercise will be only to your benefit, should your circumstances change.
Remskar likens it to building a protective buffer, ‘so that when you almost inevitably do experience a hard time, you’re better equipped to deal with it – on the physical side and the mental side’.
It could even delay that day. Remskar points to a 2019 Harvard study that found that an average of 35 minutes a day of physical activity significantly reduced the odds of developing depression, even among people who were genetically predisposed. ‘Essentially, they out-exercised – or out-ran, pun intended – their genetic risk for depression,’ she says. ‘I think that’s something that feels really tangible – and empowering.’
Likewise, Dr Noetel says our focus should be on prevention, rather than cure. ‘Sometimes it’s exactly the people who are struggling with something who need to make the change,’ he says. ‘Diet and exercise are hard for all of us, but for people with chronic diseases like diabetes or heart disease, it’s core to the treatment; we need to see depression in a similar light.’
Neill ended up not completing his PhD – the rewards weren’t worth the mental toll, he says. Since 2019, he has also been taking medication for anxiety, which he says helped to relieve the most acute symptoms. But exercise has remained a constant (and even higher) priority now that he’s experienced its mental benefits.
Where he used to sign up to organised bike rides or half-marathons to motivate him to exercise, when Neill’s focus turned to his mental health, ‘it just became more of a routine thing to do’, he says.
These days, he’ll do 30 to 60 minutes on his exercise bike almost daily, and get outdoors for a longer cycle on weekends. While Neill plans to start tapering off his medication in the coming months, he’s intending on keeping up his exercise routine indefinitely.
‘That protective factor, that’s definitely how I look at it now,’ he says. ‘Whether I’m up or down – I get on the bike anyway.’
How to Move for Your Mind
Any movement is better than none, so focus on what you can do. Our pointers will help
Aim for consistency
While a single ‘dose’ of exercise can boost mood, the biggest and most lasting benefits accrue over time. Three to four 45-minute sessions a week is seen as the sweet spot.
Raise the heart rate
Though calming activities (eg, yoga and qigong) reduce anxiety, aerobic activity appears to produce the strongest benefits for mental health. Being slightly breathless and breaking a sweat indicate you’re in the right zone.
Prioritise balance
More isn’t necessarily better. Exercising more than 24 times a month, or for more than an hour at a time, may be correlated with worse mental health.
Find an activity you love
It sounds obvious, but you’re a lot more likely to stick with exercise that you enjoy. Adding a social component, such as playing team sports or exercising with a friend, can help.
Trust the process
It can take weeks or even months for the effects of exercise to kick in. A mindfulness practice such as meditation may help you to attune to those benefits.
Seek more support if you need it
While exercise may be as beneficial for depression as antidepressants and therapy, it shouldn’t be seen as a replacement. Speak to your doctor before changing any course of treatment.
You Might Also Like
