Just because a thing is true doesn't mean you can apply it. There are vast numbers of active ingredients discovered or developed that are effective in curing many deceases but there aren't "drugs"/pills with it because we haven't found a delivery mechanism for them to be effective where they should in the human body.
Going back to the subject: Have you ever been clinically depressed or dealt with people in that predicament? Getting up from the bed is already a huge win for that day, let alone exercising and doing it consistently and regularly. Even taking medication regularly can be a hit or miss.
So, yeah the prescription is easy to write and thank god it's real and effective, but that's only ~5% of the work.
Exercise is great on the days I can do it, I love going for a walk. But sometimes when I hear that suggestion - I wonder if those people have ever lain in a totally uncomfortable position in bed for 45 minutes because they felt paralyzed, unable to will their muscles to reposition themselves into something more comfortable. From that perspective, even light exercise seems like walking on the moon; merely a thought, not real.
I appreciate your difficulties but have always wondered at our lack of support for preventative measures as a society here in Australia and possibly worldwide.
Would a personal trainer or paid or not training buddy or something of the sort help your motivation?
It's a good question. I could see it working for some people (accountability, companionship) but at least for me, one of my parents is a certified PT and while she has helped a bit, the problem is just more deeply rooted than that unfortunately, at least for me.
Hear, hear. I've fortunately not had to personally deal with depression, but have been around those who have, and "just go to the gym" is right up there with "have you just tried not being sad?" on the list of unactionable plans.
See also: "Why don't more people with ADHD get treatment?" "Because if they were able to initiate and follow through a complex plan of meeting with care providers, arguing with insurance, and having prescriptions filled, they probably wouldn't need it."
Bingo. It took years to get an ADHD diagnosis after severe issues with productivity and executive function.
I finally get a medication to try, and on the way home it falls out of my pocket. Don’t realize till I’m home and go back and find it… smashed in the street, run over by a car. Lol. So yeah, it’s a real struggle.
That just about broke my heart. I can imagine how awful and hopeless I'd feel in that situation, at least as a first reaction. Great. Just I'll just plan on not planning until I can get the doctor to send a new prescription, which they might not do because FDA.
There's a reason I pick up my refills exactly on time, even if I still have some of the old prescription left. That little overlapping buffer gives me great peace of mind.
The healthcare system in the United States is deeply, horribly broken.
Recently, my wife was going to be out of the country about a week-and-a-half. Her prescription for a medicine to manage arthritis would run out at the very beginning of that time. But insurance company policies refused to allow her to fill it even a little bit early. As a result, her only option was to go without the medicine for several days.
Policies should be set by organizations whose primary goal is to provide effective health solutions, not organizations whose primary goal is to minimize costs in order to make a profit.
She could've gone to her provider to discuss adverse side effects. Sometimes they will prescribe a new medication that could be filled immediately.
She could've got a pill cutter and cut the tablets in half, or space out the doses, or otherwise take less than the specified dose for a few weeks.
She could've asked the pharmacist about OTC treatments which could be safely substituted during the gap time.
She could've gone to the emergency room or urgent care in the destination country, and tell the provider "I have run out of medication!" This would be covered by the traveller's insurance that you purchased for the trip.
You sound like you would be a great patient advocate. His wife would have been lucky to have someone like you help navigate that situation, but it would be even better if people didn't need to waste their brainpower coming up with these tips and tricks to work around this fucked up adversarial system in the first place.
The article says that 41% of mental health professionals never recommend exercise. Is it really the case that these 41% have only patients with the severest forms of depression who struggle to get out of bed at all? Or do they have many patients who get out of bed for work and such, and could force themselves to exercise, but don't know that it's worth the hurdle because they haven't been told about the mental health benefits?
I don’t know a single person in my life who thinks exercise isn’t worth it. I think it’s widely known that exercising is one of the best things you can do for your health, but actually making it a habit is extremely hard.
Perhaps I’m atypical, but when my doctor gave me an exercise regimen and told me I must do it in order to treat a joint issue I was having, I found that much easier to maintain than any workout schedule before or since. Knowing it’s good in general is different than confidence it’ll treat some specific problem.
I have depression, clinically treated with SSRIs. My exercise regimen now is 8-10 hours a week of swimming, cycling, and running. I find that the exercise helps lift my mood a lot, but also if I lose my ability to exercise it is far less catastropic to my mental health than if I stop taking the SSRIs.
My exercise volume varies throughout the year because of physical health concerns (sickness, injury, combination of the two), and I notice it and will become mopey, but it's far from the crippling anxiety and depression that sets in if I miss my SSRIs for a few days.
Aren't depressions coming with side-effects like inability to do anything at all? The block is somewhere else to overcome before even thinking about exercise and the brain might have a good reason to block it (e.g. some local energetic/metabolic failure and the brain forcing a "safe mode" to prevent further damage). It's like telling to people with endothelial damage that exercise would do them good when in fact it would cripple them further (e.g. from long covid).
If your brain has a local metabolic failure leading to the inability to replete neurotransmitters, how taking a walk is a solution to your problem? You need to improve energetics first. Or what if some virus/auto-antibody is occupying some receptors in the brain, messing it up? Pushing the brain would likely just exacerbate the underlying failure.
What do you mean exercise isn't treated like real medicine? Doctors have been trying to advocate for people to be more active to help with basically every major health issue for decades. People complain about "ThEy JuSt WaNt To SeLl YoU pIlLs" as if it's not the people who want to solve their health issues by just taking the correct combination of magic pills.
You can be sold exercise too. Physical therapy exists. Personal trainers exist. Gym memberships, gym influencers, gym culture, and gym products all exist. It's not the inability to sell you a product that stops people from exercising.
> What do you mean exercise isn't treated like real medicine?
It's in the article. How doctors actually recommend it (the complaint of many patients that they are only told, or only hear, "exercise more") versus how medical treatments usually provide plans and guidance. Telling people to exercise more (mostly) doesn't help (especially for people already dealing with reduced motivation from a disorder like depression). Clear, actionable guidance, possibly with a monitored program, that's something patients have more chance of following through on.
Fair enough, I usually read the comments first before digging into the article, expecting them to be about the article. My comment was more in response to them. Most of the comments (including mine until now) seem to have not read the article at all. That was a mistake on my part.
It should be encouraged but even accounting for side-effects, taking a pill is easy. From personal experience, when I'm heavily depressed, I can barely get out of bed or eat. Forget exercise.
Personal experience: Exercise did not help with my severe depression. Out of sheer desperation, I started exercising and eating way better. My health improved significantly, dropping 75 pounds.. but the depression still remains. I was just as depressed after 6 months of daily walking (3-5mi/day) as I was before. Left the house depressed, returned home depressed.
All that to say, I think IMO exercise can help improve general daily mood, but it did not really do anything for my overall depression.
Exercise helps my ADHD, but it requires quite a bit of sequential cognitive processing to actually get to the point of starting it. Adderall makes this initial part much easier. I expect something parallel is happening in those with depression.
One day, my psychiatrist had brought her new dachshund puppy to work, and she invited me to pick him up. He promptly licked all over my face and then fell asleep in my arms.
I joked to her that puppies beat SSRIs any day of the week, that she should write prescriptions to take to the animal shelter. And it's probably true! Unfortunately, I don't live the kind of life that's compatible with a pet.
Personally, I'm grateful that doctors mostly stay in their lane, although I would hope a good therapist might recommend physical activity to someone who needs it.
And as to what kind of exercise to recommend -- the advice I've heard is that the best kind of exercise to do is what you enjoy and will therefore stick to. Brisk walking three times a week for 20-30 minutes might work great for some people. But if someone finds that a tedious chore, they're probably not going to stick to it.
You have to start somewhere. A full on daily HIIT routine for someone who's struggling to get out of bed is not going to help them much (setting aside risk of injury, they're going to be frustrated and that will set them back too).
I believe forced exercise actually is counterproductive in terms of the facts that exercise usually has on depression, at least in animal models that have looked at the differences in forced versus voluntary exercise. There's a whole literature out there I believe.
Exercise really is a wonder drug. The best of the best!
If only doctors could prescribe it and have people adhere to the prescription.
If only American culture weren't so car-centric and our daily lives involved some natural amount of exercising. We've built a society where only the privileged few can walk or bike to work. It's just too easy these days to barely move in our normal life. Drive to work, drive to the store, drive the kids places... you literally have to specifically schedule exercise (and ironically, many people will drive to the gym to walk on a treadmill).
Classic case of causality inversion. “People in remission of depression have a higher exercise rate” is the much more precise, much less sensationalist and much more honest take current studies.
The studies that show this are generally aggressively biased against people who do physical labor for subsistence and are worn out or exhausted to the point of depression.
If studies showed that African women who walk miles and miles collecting water somehow are less depressed than women with local water, I'll be more sold that exercise does something special..
Has anyone looked into mental health, inflammation and keto? I looked into it a while back and it seemed promising.
I spent a while reading a bunch of papers on it. First of all, keto lowers inflammation. Inflammation harms cognitive function, especially executive function. Also, a bunch of neurological disorders are associated with mitochondrial dysfunction, and keto acts as a "backup" metabolic pathway. (i.e. if your glucose engine is "misfiring", you can burn fat instead, and in some cases that makes the problem go away.)
The trick is adherence. Carbs are very addictive! I was never able to make the diet stick. (Turns out bread is very tasty...)
But from all I've read, it seems like it would help with a bunch of issues I have. So I thought it would be worth mentioning here, in case it helps someone.
> When we look at higher-quality evidence and direct comparisons, exercise performs similarly to, but not dramatically better than, established treatments. Overhyping it risks damaging credibility in this important area of mental health.
I get where he's coming from, but at the same time, if we can achieve even roughly the same result with exercise as with medication, that's a ridiculously huge win. Side effects of antidepressants are usually uncountably many, whereas for exercise it's (just) injuries and it's pretty well understood how to prevent them. Granted depression is a thousand different diseases in a trench coat, but even if we can ameliorate some forms with exercise, that would still make it considerably more available and approachable.
Exercise doesn't need to be complex or intimidating. Starting out with going for a short walk counts as exercise. You could even do it while you have the patient with you on an appointment, go walk out and about with them. Depression is a complex beast and the more tricks we have up our sleeves to fight it, the better.
If you're depressed, trying to make exercise happen can be the hardest thing in the world for some. But for those that it isn't, it could help a lot.
I totally use exercise to keep on top of slightly wobbly mental health.
I heard the practice referred to recently as "Outrunning the darkness", which is glib but kinda describes why I am typically either at work, caring for my kids, or out on a bike.
That said, I very much sympathise be all the accounts by people for whom days are made palatable, and exercise is made possible, by taking prescription medication.
In some places it is. Some people can indeed be "prescribed" (it's not a prescription, it's a referral) exercise and a low-cost arrangement is made with a local gym and appropriate fitness coach. In the UK, such schemes have historically been 12 to 16 weeks and the costs are jointly met by the NHS and the participant (much as with prescribed drugs).
everybody gets paid to recommend pills and other treatment (directly or indirectly). Nobody gets paid to recommend exercise. You can't gate exercise behind a control mechanism and mark it up 1000X production cost.. the list of why goes on and on...
I've always thought the hard cure to depression was to rip the person completely away from their lifestyle and give them an entirely new, physically active job, witness security program style.
1. While it's difficult to put a number on exactly what % of the time this is true, depression is not always, and I would say not often, a situational problem. For almost every depressed person, there's a happy person living the same lifestyle. For literally every happy person, there's a depressed person living the same lifestyle.
2. People with depression often have careers they care about and families they need to support. Even if leaving their lives behind worked, they wouldn't want to do that for the same reason you wouldn't.
> For almost every depressed person, there's a happy person living the same lifestyle. For literally every happy person, there's a depressed person living the same lifestyle.
That's not super meaningful though. Just because a specific lifestyle doesn't affect every person doesn't mean it doesn't effect some people.
Like you could probably also say for every smoker with lung cancer there is a smoker who didn't develop lung cancer (since risk is only 15% so the majority dont). But smoking is still terrible for you.
> People with depression often have careers they care about and families they need to support. Even if leaving their lives behind worked, they wouldn't want to do that for the same reason you wouldn't.
Depends on what severity of depression we are talking, but there is a very real way that depressed people do leave their families and lives behind by the very nature of the disease.
> rip the person completely away from their lifestyle and give them an entirely new
This is how mental hospitals show results. A hospitalized person is ripped out of their daily non-routine, detoxed, given constant social interactions, and given a lot of structured routines, including sleep/wake, medications, provider visits, meal times, group sessions, and designated free time.
A person who can get with the program, or a person who does not violently kick against the goads, will get increasingly healthier evaluations, because our drugs are working, right?
As evidenced by multiple examples already in this discussion. Food, exercise, willpower, mental health, all examples where randos without a problem feel entirely comfortable preaching to the victims that they just aren't trying hard enough.
I just think the entire idea of "preachiness" about exercise is wrong. When I tell people that they should start using ibuprofen/acetaminophen fixed-dose combinations (you should! They're substantially better at pain relief than anything else in the OTC market) it would be very strange for someone to jump in to announce that they have kidney problems and I have to stop preaching about things that don't work for them.
It's true that there's some people who can't exercise, and we should have sympathy for them.
Alternatively, I smell a business opportunity, as I know some people that deserve depression and misery, and "pay me to dance near them" could be a thing.
I am not gifted at music but my affinity for it and ability to play music is above-average (not hard, most people just don't ever even try) but if I try to dance, somehow where I think each movement should start or end is entirely wrong, like, to such a degree that it's like I'm trying and wonderfully succeeding at doing it wrong.
Somehow, even with the objective criteria of sensors ensuring I am indeed hitting things when I should be, I can even get pretty damn good at something like Dance Dance Revolution, and feel like I'm moving naturally and smoothly while playing it, yet apparently look like I'm having a seizure even as I'm landing "perfects" across the board.
That's how constitutionally incapable of dance (or, if you prefer, how "white") I am.
Learning how to dance well requires floor-length mirrors and a good coach. Pretty much nobody learns it properly on their own. Even dance champions still take regular coaching.
As for being untalented, all that means is it will take you more time to get good at it.
P.S. What you think you are doing while dancing is not what you are actually doing. That's why a coach is necessary.
Much of it comes from the same place. Depression, ADHD, and many others affect our ability to concentrate and plan. When you are in those situations, long term doesn't matter - you are fighting to live in the short term. Part of using medication is helping to get those effects under control so that you can be forwarded looking and disciplined.
Simply saying "exercise more" to someone struggling with mental health is like telling a person who is bleeding to death that they should stop bleeding. Yeah, chances are they really want to, but they don't have control over it in the moment.
And this article is about not saying that, but giving them actionable guidance and (possibly) referring them to programs that can help (like how you might be referred to a nutritionist by your doctor instead of just being told to "eat better").
There’s a good argument for making joining a gym or buying exercise equipment prescription only. A lot of people can injure themselves if they don’t know what they’re doing.
Maybe we could use flock cameras to enforce prescriptions for walking on the sidewalks.
You should require a permit to leave your house, since a lot of deaths and injury happen outside of the house. The permit would generously give you the freedom to go outside for your job + once per week errand run. 1 hr/month leisure excursions permitted with good behaviour.
>Exercise works for depression. So why isn't it treated like real medicine?
Clinical depression is a serious mental illness, it causes great suffering, broken relationships, and far too frequently, death by suicide.
A person suffering to such an extent frequently will seek treatment (if they don't, well we don't generally pursue people with medical conditions) from a trained, licensed professional for evaluation, and the extent to which the patient gets out of the house and interacts with people is part of the assessment. Exercise will be among the suggestions that will be encouraged.
However, you don't need a prescription to exercise, so it's not treated like medicine, but it is recommended. If you are prescribed medication or exercise, if you don't take it or do it, there generally isn't a compliance system that kicks in (unless the courts have become involved)
I've experienced what this guy has experienced. I don't think that's unique. Being an athlete who gets injured and has mental health suffer because they lose their sense of identity and purpose is not anywhere near the same thing as clinical depression. It's a poor term in a way. You can be depressed or feel depressed and those are perfectly legitimate uses of the term, but it's not "depression," not in the same way. It's closer to grief. It's a response to loss.
In any case, I'm not exactly up to date on the state of the art in terms of standard of care, but as far as I understood the role of a psychiatrist, it is specifically to write prescriptions. Exercise is not a controlled substance. You don't need a prescription to do it. Any doctor or even just a clinical therapist, counselor, anyone with a license to listen to you and make recommendations, can recommend exercise. And I'm sure they do. If you make it to a psychiatrist, it's because the less controlled options didn't do the trick.
I'm happy to force depressed people to exercise. Pay me and I'll make you do it. At the same time, I expect to see zero serious requests for this service. That's revealed preference.
Around the internet you can find tons of people griping about GLP-1s, saying "diet and exercise make you lose weight, they have to, the First Law of Thermodynamics, etc. etc. How come doctors don't prescribe those?". And the answer is "diet and exercise are not a cure, they are a proposed treatment plan with a dismal success rate". To treat something as medicine, we want it to work in the real world of fallible humans, not in the imaginary world of perfect regime adherence that internet commenters dream up when they want to get snarky.
It's exactly the same thing here: exercise is not a "cure" for depression, it is a treatment plan that has good odds of success if stuck to, and it is frequently not stuck to. Turns out that depressed people are even less likely than the median person to stick to an exercise plan, and the median person is already pretty fucking bad. So the field gravitates to treatments which are achievable even if imperfect.
The article goes into this not at all, it just closes with some blather about supervised programs and gym access, which is like yelling louder at a fat person to "eat less, dammit!". Good luck with that treatment, I'll take the drugs which work.
A lot of us are concerned about more than objecting to GLP-1’s. They’re pretty aggressive as a “treatment” used for weight loss, TONS of people are on it, it’s aggressively marketed in ways that seem rather backwards with what we’ve learned about how to talk about bodies and weight, and we are already seeing concerning GI issues emerging from prolonged usage - which is a given unless someone makes a lifestyle change, which as you said is not a great assumption.
Here are some hits from a search for “studies on GI problems associated with GLP1's.” I have not read them start to finish but it’s a starting point for you to do your own searches off of. I used Kagi, for reference.
Ah, okay, I was thinking you might have run across something more recent. The latest science seems to be going mostly in the opposite direction, saying that with additional data it looks like early concerns about things like pancreatitis (and worse, cancer) were overblown. If there are some newly identified adverse reactions I'm always interested to learn more about them.
I don’t know what exactly this is but it rubs me the wrong way. You say you’re curious and can’t find anything, but then you dismiss all the stuff I linked in minutes as if no valid literature exists yet and you already have a formed opinion. It doesn’t seem like you’re particularly curious and it feels like my time is being wasted by a lack of transparency.
Sorry, wasn't trying to offend. I skimmed the links, and the majority of what I saw was observations that nausea, constipation, and diarrhea remained fairly common side effects even after having been on the medication for a while. That seems pretty mild [0]. I saw a couple mentions of pancreatitis, which is something that seems mostly debunked by now.
The really interesting one out of those was the first one, which showed an actual physical side effect. In rats, not humans, with disclaimers about how hard it is to replicate in humans. I will keep an eye out for more mentions of that effect, for certain.
[0] Okay, I wanted to say more about the nausea thing, because I suppose this might be a controversial hot take ;-). I think the physical punishment dished out by the medication is the only reason many people see continued success. They could eliminate the side effects by eating less, but that was always the problem. If they lower the dose the side effects go away, but without the punishing side effects they start to gain weight.
Or maybe it's just my own demons talking. Can't tell you how many times I've asked myself why I was eating something in spite of knowing it was the wrong answer, that I was not hungry, etc. If I could answer that with reliably action, I wouldn't take tirzepatide. People may look down on me for being unable to tame those demons, but oh well, I do what works for me. I do want to be on the lookout for long term problems that me outweigh the massive improvement in my health that came with losing 100 pounds, however.
> It doesn’t seem like you’re particularly curious and it feels like my time is being wasted by a lack of transparency.
Sorry, I probably just misread your comment as the usual "hey you lazy fat fuckers why don't you just eat less instead of cheat with a pill" moralizing that crops up in these discussions. I don't really think those links you provided a lot of ammunition disproving that, at least not to me.
Fitness is also a huge industry, as is physical therapy, as is the use of therapy for depression. If the medical industry seriously believed that exercise is a marketable treatment for depression, there are known and quite obvious pathways to monetizing it. It's far more likely that they either don't trust these studies, or that they don't think you can convince a large enough group of depressed patients to exercise.
The idea that doctors are not talking about exercise as if it's some big conspiracy to make more money from the top is ridiculous. Any doctor will say that exercise is the best thing you can do for yourself but most people also know that it's super inconvenient and most people don't follow that advice.
If anything, the people making it out to be some big conspiracy against mainstream medicine are doing it more for the money because they're often peddling some alternative medicine or supplements.
Agreed, in general, doctors are not ill-intent. There is also realistically the fact that some doctors know it's a lost cause to advise some common-sense thing that the patient already know very well (for example Obesity, no exercise, stopping drugs like alcohol...) so they probably refrain from doing so, and patients lie a ton to doctors as well.
Well you're lying because working out is like the top recommended cure for depression. My doc begged me to stop taking meds and run again because it worked much better
Just because a thing is true doesn't mean you can apply it. There are vast numbers of active ingredients discovered or developed that are effective in curing many deceases but there aren't "drugs"/pills with it because we haven't found a delivery mechanism for them to be effective where they should in the human body.
Going back to the subject: Have you ever been clinically depressed or dealt with people in that predicament? Getting up from the bed is already a huge win for that day, let alone exercising and doing it consistently and regularly. Even taking medication regularly can be a hit or miss.
So, yeah the prescription is easy to write and thank god it's real and effective, but that's only ~5% of the work.
Exercise is great on the days I can do it, I love going for a walk. But sometimes when I hear that suggestion - I wonder if those people have ever lain in a totally uncomfortable position in bed for 45 minutes because they felt paralyzed, unable to will their muscles to reposition themselves into something more comfortable. From that perspective, even light exercise seems like walking on the moon; merely a thought, not real.
I appreciate your difficulties but have always wondered at our lack of support for preventative measures as a society here in Australia and possibly worldwide.
Would a personal trainer or paid or not training buddy or something of the sort help your motivation?
It's a good question. I could see it working for some people (accountability, companionship) but at least for me, one of my parents is a certified PT and while she has helped a bit, the problem is just more deeply rooted than that unfortunately, at least for me.
But, again, everyone's experiences are different.
Hear, hear. I've fortunately not had to personally deal with depression, but have been around those who have, and "just go to the gym" is right up there with "have you just tried not being sad?" on the list of unactionable plans.
See also: "Why don't more people with ADHD get treatment?" "Because if they were able to initiate and follow through a complex plan of meeting with care providers, arguing with insurance, and having prescriptions filled, they probably wouldn't need it."
Bingo. It took years to get an ADHD diagnosis after severe issues with productivity and executive function.
I finally get a medication to try, and on the way home it falls out of my pocket. Don’t realize till I’m home and go back and find it… smashed in the street, run over by a car. Lol. So yeah, it’s a real struggle.
That just about broke my heart. I can imagine how awful and hopeless I'd feel in that situation, at least as a first reaction. Great. Just I'll just plan on not planning until I can get the doctor to send a new prescription, which they might not do because FDA.
There's a reason I pick up my refills exactly on time, even if I still have some of the old prescription left. That little overlapping buffer gives me great peace of mind.
The healthcare system in the United States is deeply, horribly broken.
Recently, my wife was going to be out of the country about a week-and-a-half. Her prescription for a medicine to manage arthritis would run out at the very beginning of that time. But insurance company policies refused to allow her to fill it even a little bit early. As a result, her only option was to go without the medicine for several days.
Policies should be set by organizations whose primary goal is to provide effective health solutions, not organizations whose primary goal is to minimize costs in order to make a profit.
> her only option was to go without the medicine
She could've gone to her provider to discuss adverse side effects. Sometimes they will prescribe a new medication that could be filled immediately.
She could've got a pill cutter and cut the tablets in half, or space out the doses, or otherwise take less than the specified dose for a few weeks.
She could've asked the pharmacist about OTC treatments which could be safely substituted during the gap time.
She could've gone to the emergency room or urgent care in the destination country, and tell the provider "I have run out of medication!" This would be covered by the traveller's insurance that you purchased for the trip.
You sound like you would be a great patient advocate. His wife would have been lucky to have someone like you help navigate that situation, but it would be even better if people didn't need to waste their brainpower coming up with these tips and tricks to work around this fucked up adversarial system in the first place.
The article says that 41% of mental health professionals never recommend exercise. Is it really the case that these 41% have only patients with the severest forms of depression who struggle to get out of bed at all? Or do they have many patients who get out of bed for work and such, and could force themselves to exercise, but don't know that it's worth the hurdle because they haven't been told about the mental health benefits?
I don’t know a single person in my life who thinks exercise isn’t worth it. I think it’s widely known that exercising is one of the best things you can do for your health, but actually making it a habit is extremely hard.
Perhaps I’m atypical, but when my doctor gave me an exercise regimen and told me I must do it in order to treat a joint issue I was having, I found that much easier to maintain than any workout schedule before or since. Knowing it’s good in general is different than confidence it’ll treat some specific problem.
I have depression, clinically treated with SSRIs. My exercise regimen now is 8-10 hours a week of swimming, cycling, and running. I find that the exercise helps lift my mood a lot, but also if I lose my ability to exercise it is far less catastropic to my mental health than if I stop taking the SSRIs.
My exercise volume varies throughout the year because of physical health concerns (sickness, injury, combination of the two), and I notice it and will become mopey, but it's far from the crippling anxiety and depression that sets in if I miss my SSRIs for a few days.
But this is just anecdata, treat accordingly.
Aren't depressions coming with side-effects like inability to do anything at all? The block is somewhere else to overcome before even thinking about exercise and the brain might have a good reason to block it (e.g. some local energetic/metabolic failure and the brain forcing a "safe mode" to prevent further damage). It's like telling to people with endothelial damage that exercise would do them good when in fact it would cripple them further (e.g. from long covid).
> Aren't depressions coming with side-effects like inability to do anything at all?
Severe depression, absolutely. That's also discussed in the article.
Any non hack psych will tell you to go outside and take a walk. Meds are a minimal solution
If your brain has a local metabolic failure leading to the inability to replete neurotransmitters, how taking a walk is a solution to your problem? You need to improve energetics first. Or what if some virus/auto-antibody is occupying some receptors in the brain, messing it up? Pushing the brain would likely just exacerbate the underlying failure.
What do you mean exercise isn't treated like real medicine? Doctors have been trying to advocate for people to be more active to help with basically every major health issue for decades. People complain about "ThEy JuSt WaNt To SeLl YoU pIlLs" as if it's not the people who want to solve their health issues by just taking the correct combination of magic pills.
You can be sold exercise too. Physical therapy exists. Personal trainers exist. Gym memberships, gym influencers, gym culture, and gym products all exist. It's not the inability to sell you a product that stops people from exercising.
> What do you mean exercise isn't treated like real medicine?
It's in the article. How doctors actually recommend it (the complaint of many patients that they are only told, or only hear, "exercise more") versus how medical treatments usually provide plans and guidance. Telling people to exercise more (mostly) doesn't help (especially for people already dealing with reduced motivation from a disorder like depression). Clear, actionable guidance, possibly with a monitored program, that's something patients have more chance of following through on.
Fair enough, I usually read the comments first before digging into the article, expecting them to be about the article. My comment was more in response to them. Most of the comments (including mine until now) seem to have not read the article at all. That was a mistake on my part.
It should be encouraged but even accounting for side-effects, taking a pill is easy. From personal experience, when I'm heavily depressed, I can barely get out of bed or eat. Forget exercise.
You will find your answer in DJ Shadow's "Why Hip Hop Sucks In '96":
https://www.youtube.com/watch?v=yKf40CLF9MU
"It's the money."
Personal experience: Exercise did not help with my severe depression. Out of sheer desperation, I started exercising and eating way better. My health improved significantly, dropping 75 pounds.. but the depression still remains. I was just as depressed after 6 months of daily walking (3-5mi/day) as I was before. Left the house depressed, returned home depressed.
All that to say, I think IMO exercise can help improve general daily mood, but it did not really do anything for my overall depression.
The article addresses this.
Exercise helps my ADHD, but it requires quite a bit of sequential cognitive processing to actually get to the point of starting it. Adderall makes this initial part much easier. I expect something parallel is happening in those with depression.
For me exercising regularly is about as effective as the medication. Eating well and cutting out sugar and coffee helped a bit too.
One day, my psychiatrist had brought her new dachshund puppy to work, and she invited me to pick him up. He promptly licked all over my face and then fell asleep in my arms.
I joked to her that puppies beat SSRIs any day of the week, that she should write prescriptions to take to the animal shelter. And it's probably true! Unfortunately, I don't live the kind of life that's compatible with a pet.
Personally, I'm grateful that doctors mostly stay in their lane, although I would hope a good therapist might recommend physical activity to someone who needs it.
And as to what kind of exercise to recommend -- the advice I've heard is that the best kind of exercise to do is what you enjoy and will therefore stick to. Brisk walking three times a week for 20-30 minutes might work great for some people. But if someone finds that a tedious chore, they're probably not going to stick to it.
> Start with brisk walking three times a week for 20-30 minutes at an intensity where you can still talk.
When people talk about exercise as a treatment for depression, i never imagined they meant such small amounts.
You have to start somewhere. A full on daily HIIT routine for someone who's struggling to get out of bed is not going to help them much (setting aside risk of injury, they're going to be frustrated and that will set them back too).
I understand that, but regardless there is presumably an exercise amount threshold you need to clear in order to get the anti-depression effects.
And yet even that little exercise produces significant differences in outcome compared to doing less.
I believe forced exercise actually is counterproductive in terms of the facts that exercise usually has on depression, at least in animal models that have looked at the differences in forced versus voluntary exercise. There's a whole literature out there I believe.
Exercise really is a wonder drug. The best of the best!
If only doctors could prescribe it and have people adhere to the prescription.
If only American culture weren't so car-centric and our daily lives involved some natural amount of exercising. We've built a society where only the privileged few can walk or bike to work. It's just too easy these days to barely move in our normal life. Drive to work, drive to the store, drive the kids places... you literally have to specifically schedule exercise (and ironically, many people will drive to the gym to walk on a treadmill).
There are simple things that add up:
Skip the elevator and take the stairs.
Park at the far end of the parking lot, not next to the door.
When I run errands, I park at a central location and walk to the various destinations.
When I meet a friend or associate, instead of meeting at a restaurant, I propose meeting at a nice area and have a walk & talk.
It adds up.
Classic case of causality inversion. “People in remission of depression have a higher exercise rate” is the much more precise, much less sensationalist and much more honest take current studies.
The studies that show this are generally aggressively biased against people who do physical labor for subsistence and are worn out or exhausted to the point of depression.
If studies showed that African women who walk miles and miles collecting water somehow are less depressed than women with local water, I'll be more sold that exercise does something special..
Has anyone looked into mental health, inflammation and keto? I looked into it a while back and it seemed promising.
I spent a while reading a bunch of papers on it. First of all, keto lowers inflammation. Inflammation harms cognitive function, especially executive function. Also, a bunch of neurological disorders are associated with mitochondrial dysfunction, and keto acts as a "backup" metabolic pathway. (i.e. if your glucose engine is "misfiring", you can burn fat instead, and in some cases that makes the problem go away.)
The trick is adherence. Carbs are very addictive! I was never able to make the diet stick. (Turns out bread is very tasty...)
But from all I've read, it seems like it would help with a bunch of issues I have. So I thought it would be worth mentioning here, in case it helps someone.
> When we look at higher-quality evidence and direct comparisons, exercise performs similarly to, but not dramatically better than, established treatments. Overhyping it risks damaging credibility in this important area of mental health.
I get where he's coming from, but at the same time, if we can achieve even roughly the same result with exercise as with medication, that's a ridiculously huge win. Side effects of antidepressants are usually uncountably many, whereas for exercise it's (just) injuries and it's pretty well understood how to prevent them. Granted depression is a thousand different diseases in a trench coat, but even if we can ameliorate some forms with exercise, that would still make it considerably more available and approachable.
Exercise doesn't need to be complex or intimidating. Starting out with going for a short walk counts as exercise. You could even do it while you have the patient with you on an appointment, go walk out and about with them. Depression is a complex beast and the more tricks we have up our sleeves to fight it, the better.
If you're depressed, trying to make exercise happen can be the hardest thing in the world for some. But for those that it isn't, it could help a lot.
The problem is that most people will reach for a pill before they will exercise, when given the choice.
I totally use exercise to keep on top of slightly wobbly mental health.
I heard the practice referred to recently as "Outrunning the darkness", which is glib but kinda describes why I am typically either at work, caring for my kids, or out on a bike.
That said, I very much sympathise be all the accounts by people for whom days are made palatable, and exercise is made possible, by taking prescription medication.
Has anyone's doctor ever not ask them if they exercise during a checkup?
Every checkup for me has started with "what is you diet and exercise like?"
In some places it is. Some people can indeed be "prescribed" (it's not a prescription, it's a referral) exercise and a low-cost arrangement is made with a local gym and appropriate fitness coach. In the UK, such schemes have historically been 12 to 16 weeks and the costs are jointly met by the NHS and the participant (much as with prescribed drugs).
everybody gets paid to recommend pills and other treatment (directly or indirectly). Nobody gets paid to recommend exercise. You can't gate exercise behind a control mechanism and mark it up 1000X production cost.. the list of why goes on and on...
I've always thought the hard cure to depression was to rip the person completely away from their lifestyle and give them an entirely new, physically active job, witness security program style.
1. While it's difficult to put a number on exactly what % of the time this is true, depression is not always, and I would say not often, a situational problem. For almost every depressed person, there's a happy person living the same lifestyle. For literally every happy person, there's a depressed person living the same lifestyle.
2. People with depression often have careers they care about and families they need to support. Even if leaving their lives behind worked, they wouldn't want to do that for the same reason you wouldn't.
> For almost every depressed person, there's a happy person living the same lifestyle. For literally every happy person, there's a depressed person living the same lifestyle.
That's not super meaningful though. Just because a specific lifestyle doesn't affect every person doesn't mean it doesn't effect some people.
Like you could probably also say for every smoker with lung cancer there is a smoker who didn't develop lung cancer (since risk is only 15% so the majority dont). But smoking is still terrible for you.
> People with depression often have careers they care about and families they need to support. Even if leaving their lives behind worked, they wouldn't want to do that for the same reason you wouldn't.
Depends on what severity of depression we are talking, but there is a very real way that depressed people do leave their families and lives behind by the very nature of the disease.
> rip the person completely away from their lifestyle and give them an entirely new
This is how mental hospitals show results. A hospitalized person is ripped out of their daily non-routine, detoxed, given constant social interactions, and given a lot of structured routines, including sleep/wake, medications, provider visits, meal times, group sessions, and designated free time.
A person who can get with the program, or a person who does not violently kick against the goads, will get increasingly healthier evaluations, because our drugs are working, right?
Exercise helps symptoms of depression. Yay!
Also, when fat people eat less they lose weight.
As with any intervention, the devil is in the details. The author doesn't really provide any.
If the fix was easy we wouldn't need doctors to provide it.
More importantly - the cost of the medical assistance to help someone get out of the house and physically train is much more expensive than a drug.
If you want to prescribe exercise for someone with this level of depression, you need to prescribe someone to remove the barriers to exercise.
Surprisingly I've found some stigma attached to it - because people can get "preachy" about exercise I guess.
As evidenced by multiple examples already in this discussion. Food, exercise, willpower, mental health, all examples where randos without a problem feel entirely comfortable preaching to the victims that they just aren't trying hard enough.
I just think the entire idea of "preachiness" about exercise is wrong. When I tell people that they should start using ibuprofen/acetaminophen fixed-dose combinations (you should! They're substantially better at pain relief than anything else in the OTC market) it would be very strange for someone to jump in to announce that they have kidney problems and I have to stop preaching about things that don't work for them.
It's true that there's some people who can't exercise, and we should have sympathy for them.
Placebo also works so why aren't healing crystals and essential oils treated like real medicine?
I remember reading that Dancing blows aware meds and exercise. So why isn't that treated like real medicine?
For some of us, attempting to dance causes greater amounts of depression in those nearby than it cures in us.
Well, then it is not your problem anymore.
Alternatively, I smell a business opportunity, as I know some people that deserve depression and misery, and "pay me to dance near them" could be a thing.
Eh, more like cringe. They'll get over it. You'll also get better.
> Eh, more like cringe.
Yeah, true.
> They'll get over it.
Has not been my experience.
> You'll also get better.
Ditto.
I am not gifted at music but my affinity for it and ability to play music is above-average (not hard, most people just don't ever even try) but if I try to dance, somehow where I think each movement should start or end is entirely wrong, like, to such a degree that it's like I'm trying and wonderfully succeeding at doing it wrong.
Somehow, even with the objective criteria of sensors ensuring I am indeed hitting things when I should be, I can even get pretty damn good at something like Dance Dance Revolution, and feel like I'm moving naturally and smoothly while playing it, yet apparently look like I'm having a seizure even as I'm landing "perfects" across the board.
That's how constitutionally incapable of dance (or, if you prefer, how "white") I am.
Learning how to dance well requires floor-length mirrors and a good coach. Pretty much nobody learns it properly on their own. Even dance champions still take regular coaching.
As for being untalented, all that means is it will take you more time to get good at it.
P.S. What you think you are doing while dancing is not what you are actually doing. That's why a coach is necessary.
People do not discipline.
Bipolar disorder patients were able to adhere to ketogenic diet with great outcomes [1] (diet adherence for bipolar disorder was 95%).
[1] https://www.youtube.com/watch?v=PBsjhpphowI - 18:20 and on.
Why do we not treat this as an ill?
Much of it comes from the same place. Depression, ADHD, and many others affect our ability to concentrate and plan. When you are in those situations, long term doesn't matter - you are fighting to live in the short term. Part of using medication is helping to get those effects under control so that you can be forwarded looking and disciplined.
Simply saying "exercise more" to someone struggling with mental health is like telling a person who is bleeding to death that they should stop bleeding. Yeah, chances are they really want to, but they don't have control over it in the moment.
> Simply saying "exercise more"
And this article is about not saying that, but giving them actionable guidance and (possibly) referring them to programs that can help (like how you might be referred to a nutritionist by your doctor instead of just being told to "eat better").
[dead]
There’s a good argument for making joining a gym or buying exercise equipment prescription only. A lot of people can injure themselves if they don’t know what they’re doing.
Maybe we could use flock cameras to enforce prescriptions for walking on the sidewalks.
> buying exercise equipment prescription only
Like eyeglasses for near-sighted people. Obviously prescriptions should never be needed for far-sighted people. Only for near-sighted people.
You should require a permit to leave your house, since a lot of deaths and injury happen outside of the house. The permit would generously give you the freedom to go outside for your job + once per week errand run. 1 hr/month leisure excursions permitted with good behaviour.
You know, for your safety.
Can you help me understand? Why does safety have to be all or nothing?
Isn't the alternative that people get hurt or die? And we want to prevent that?
Every decision has a cost as well as a benefit.
Exercise is to medicine, what sex is to psychology.
Mr dr tells me every visit I need more exercise.
I’ve heard people give that as a reason for wanting a new doctor.
>Exercise works for depression. So why isn't it treated like real medicine?
Clinical depression is a serious mental illness, it causes great suffering, broken relationships, and far too frequently, death by suicide.
A person suffering to such an extent frequently will seek treatment (if they don't, well we don't generally pursue people with medical conditions) from a trained, licensed professional for evaluation, and the extent to which the patient gets out of the house and interacts with people is part of the assessment. Exercise will be among the suggestions that will be encouraged.
However, you don't need a prescription to exercise, so it's not treated like medicine, but it is recommended. If you are prescribed medication or exercise, if you don't take it or do it, there generally isn't a compliance system that kicks in (unless the courts have become involved)
I've experienced what this guy has experienced. I don't think that's unique. Being an athlete who gets injured and has mental health suffer because they lose their sense of identity and purpose is not anywhere near the same thing as clinical depression. It's a poor term in a way. You can be depressed or feel depressed and those are perfectly legitimate uses of the term, but it's not "depression," not in the same way. It's closer to grief. It's a response to loss.
In any case, I'm not exactly up to date on the state of the art in terms of standard of care, but as far as I understood the role of a psychiatrist, it is specifically to write prescriptions. Exercise is not a controlled substance. You don't need a prescription to do it. Any doctor or even just a clinical therapist, counselor, anyone with a license to listen to you and make recommendations, can recommend exercise. And I'm sure they do. If you make it to a psychiatrist, it's because the less controlled options didn't do the trick.
I'm happy to force depressed people to exercise. Pay me and I'll make you do it. At the same time, I expect to see zero serious requests for this service. That's revealed preference.
Around the internet you can find tons of people griping about GLP-1s, saying "diet and exercise make you lose weight, they have to, the First Law of Thermodynamics, etc. etc. How come doctors don't prescribe those?". And the answer is "diet and exercise are not a cure, they are a proposed treatment plan with a dismal success rate". To treat something as medicine, we want it to work in the real world of fallible humans, not in the imaginary world of perfect regime adherence that internet commenters dream up when they want to get snarky.
It's exactly the same thing here: exercise is not a "cure" for depression, it is a treatment plan that has good odds of success if stuck to, and it is frequently not stuck to. Turns out that depressed people are even less likely than the median person to stick to an exercise plan, and the median person is already pretty fucking bad. So the field gravitates to treatments which are achievable even if imperfect.
The article goes into this not at all, it just closes with some blather about supervised programs and gym access, which is like yelling louder at a fat person to "eat less, dammit!". Good luck with that treatment, I'll take the drugs which work.
When I took up jogging, I had to force myself to. After a year of that, I suddenly realized I was looking forward to running and began to enjoy it.
I had taken up jogging before, but never stuck with it for very long.
I had an operation a couple years ago, and the surgeon told me I could not jog for six weeks. It was hard to wait that long :-)
A lot of us are concerned about more than objecting to GLP-1’s. They’re pretty aggressive as a “treatment” used for weight loss, TONS of people are on it, it’s aggressively marketed in ways that seem rather backwards with what we’ve learned about how to talk about bodies and weight, and we are already seeing concerning GI issues emerging from prolonged usage - which is a given unless someone makes a lifestyle change, which as you said is not a great assumption.
> we are already seeing concerning GI issues emerging from prolonged usage
Could you elaborate? I have been looking for a scientific discussion on that topic and coming up with not much.
Here are some hits from a search for “studies on GI problems associated with GLP1's.” I have not read them start to finish but it’s a starting point for you to do your own searches off of. I used Kagi, for reference.
https://pmc.ncbi.nlm.nih.gov/articles/PMC10213739/
https://www.mayoclinicproceedings.org/article/S0025-6196(25)...
https://www.ncbi.nlm.nih.gov/books/NBK551568/
https://pmc.ncbi.nlm.nih.gov/articles/PMC9821052/
https://www.nature.com/articles/s41366-025-01859-6
Ah, okay, I was thinking you might have run across something more recent. The latest science seems to be going mostly in the opposite direction, saying that with additional data it looks like early concerns about things like pancreatitis (and worse, cancer) were overblown. If there are some newly identified adverse reactions I'm always interested to learn more about them.
I don’t know what exactly this is but it rubs me the wrong way. You say you’re curious and can’t find anything, but then you dismiss all the stuff I linked in minutes as if no valid literature exists yet and you already have a formed opinion. It doesn’t seem like you’re particularly curious and it feels like my time is being wasted by a lack of transparency.
Sorry, wasn't trying to offend. I skimmed the links, and the majority of what I saw was observations that nausea, constipation, and diarrhea remained fairly common side effects even after having been on the medication for a while. That seems pretty mild [0]. I saw a couple mentions of pancreatitis, which is something that seems mostly debunked by now.
The really interesting one out of those was the first one, which showed an actual physical side effect. In rats, not humans, with disclaimers about how hard it is to replicate in humans. I will keep an eye out for more mentions of that effect, for certain.
[0] Okay, I wanted to say more about the nausea thing, because I suppose this might be a controversial hot take ;-). I think the physical punishment dished out by the medication is the only reason many people see continued success. They could eliminate the side effects by eating less, but that was always the problem. If they lower the dose the side effects go away, but without the punishing side effects they start to gain weight.
Or maybe it's just my own demons talking. Can't tell you how many times I've asked myself why I was eating something in spite of knowing it was the wrong answer, that I was not hungry, etc. If I could answer that with reliably action, I wouldn't take tirzepatide. People may look down on me for being unable to tame those demons, but oh well, I do what works for me. I do want to be on the lookout for long term problems that me outweigh the massive improvement in my health that came with losing 100 pounds, however.
> It doesn’t seem like you’re particularly curious and it feels like my time is being wasted by a lack of transparency.
Sorry, I probably just misread your comment as the usual "hey you lazy fat fuckers why don't you just eat less instead of cheat with a pill" moralizing that crops up in these discussions. I don't really think those links you provided a lot of ammunition disproving that, at least not to me.
I mean one thing is that exercise is good for your general health, so maybe there's a reluctance to tie it to specific conditions like depression.
Because exercise is free and 'real medicine' for depression is a $25b industry
Fitness is also a huge industry, as is physical therapy, as is the use of therapy for depression. If the medical industry seriously believed that exercise is a marketable treatment for depression, there are known and quite obvious pathways to monetizing it. It's far more likely that they either don't trust these studies, or that they don't think you can convince a large enough group of depressed patients to exercise.
The idea that doctors are not talking about exercise as if it's some big conspiracy to make more money from the top is ridiculous. Any doctor will say that exercise is the best thing you can do for yourself but most people also know that it's super inconvenient and most people don't follow that advice.
If anything, the people making it out to be some big conspiracy against mainstream medicine are doing it more for the money because they're often peddling some alternative medicine or supplements.
Also it’s really hard to start exercising if you’re already depressed.
Agreed, in general, doctors are not ill-intent. There is also realistically the fact that some doctors know it's a lost cause to advise some common-sense thing that the patient already know very well (for example Obesity, no exercise, stopping drugs like alcohol...) so they probably refrain from doing so, and patients lie a ton to doctors as well.
It's also because exercise requires exertion, which is effortful, and most people who need the exercise would rather spend money to not have to exert.
Does it pain me to say it? Nah, I'm numb :-/
Well you're lying because working out is like the top recommended cure for depression. My doc begged me to stop taking meds and run again because it worked much better