The body of evidence supporting exercise as a treatment for depression and other mood disorders continues to grow. Many psychiatrists and psychologists urge their patients to get more exercise and make other lifestyle changes.
But perhaps no one takes this idea further than District therapist Jane Cibel, a licensed clinical social worker and certified personal trainer who conducts traditional talk therapy while clients walk on a treadmill or crank out dumbbell curls. In an hour-long therapy session, patients get their weekly counseling session along with a high-heart-rate, sweat-inducing workout.
Cibel, 40, works from a large room in the basement of her Foxhall home. One side is a handsome office, complete with comfortable couches, a fireplace, a desk and a wall full of heady books. The other side of the room has a treadmill, a multi-station weight machine, a rack of dumbbells, a Bosu balance ball and a small trampoline.
Mixing the two disciplines offers several benefits, Cibel said: First, by putting clients on a treadmill during therapy, they begin to see, via their physical accomplishments, that they are capable of "self-bettering behavior." In addition, people talk more freely when they're moving: "If you're just sitting and talking, you are not as stimulated as you would be when moving." (She said the workouts are kept at a "challenging conversational pace" so clients can speak without struggling for breath.)
Finally, Cibel seeks to exploit the generalized positive feelings that occur as a result of exercise to help rewire the brain. Exercise is known to increase levels of dopamine, serotonin and norepinephrine, neurotransmitters that affect mood. These are the same brain chemicals whose levels are controlled by such antidepressant medications as Prozac, Paxil and Zoloft. Positive thoughts triggered by exercise-driven higher levels of brain chemicals can help reinforce positive emotions and behaviors, she said.
"You can restructure your brain with exercise," Cibel said.
The theory behind this is known as "neural Darwinism," a concept advanced by 1972 Nobel Prize winner Gerald Edelman, who asserted that people become optimistic or pessimistic based on habits of mind reinforced by specific neural connections.
"Your brain is made of cell clusters, and the thoughts you attend to dictate the connections between clusters," explained Cibel, who has a PhD in social work from the University of Maryland along with certifications in personal training and sports nutrition from the International Fitness Professionals Association. "So if you have a lot of negative thoughts, those [pessimistic] connections are strengthened."
The converse is also true, she said. Positive thoughts, including those derived from the exercise experience, reinforce the positive neural connections.
A typical client will warm up on a treadmill at around 55 to 70 percent of maximum heart rate, do some upper- and lower-body strength training (on machines or with dumbbells), maybe some core training and balance exercises, then more treadmill.
"We're talking the whole time, working things out," Cibel said.
She provides towels, but her office doesn't have a shower. She said she will soon move to quarters where clients may shower and change if they wish.
Let's Go to the Data
Numerous studies in the past decade have shown that exercise lifts mood and can relieve various mental disorders.
The most recent major study, published in the January issue of American Journal of Preventive Medicine, showed that adults aged 20 to 45 with mild to moderate depression who participated in 30-minute aerobic exercise sessions three to five times a week reduced their symptoms by almost 50 percent.
The study, conducted at the University of Texas Southwestern Medical Center in Dallas, involved 80 people divided into five groups. One group performed moderately intense aerobic exercise five days a week, and another group did the same workout three days a week. Two other groups mimicked that schedule but did lower-intensity aerobic activity. The fifth group did 15 to 20 minutes of stretching exercises three days per week.
Participants in both moderately intense groups experienced a decline in depressive symptoms by an average of 47 percent after 12 weeks. Those in the lower-intensity groups showed a 30 percent drop in symptoms, and those in the stretching group averaged a 29 percent decline.
James A. Blumenthal, a professor of medical psychiatry and psychology at Duke University, has studied exercise and mood disorders. He called Cibel's approach "interesting," but he wondered if the exercise would distract a client who was trying to discuss serious issues with a therapist.
Overall, though, he endorses exercise as a treatment for depression. Blumenthal conducted oft-cited studies, published in Archives of Internal Medicine in 1999 and 2000, that treated older adults suffering from a major depressive disorder with 30 minutes of exercise three times a week or the antidepressant Zoloft, or both.
The exercise group showed better improvement in symptoms than the other two groups. Blumenthal said he was not shocked that exercise outperformed Zoloft alone, but was somewhat surprised to see that those who only worked out did better than those who exercised and took Zoloft.
"I don't really know" what might explain that, he said. "Maybe [the exercise-only] people are gaining a sense of self-mastery" without any help from a drug, he said. "I can't help but think that's a part of it."
A 34-year-old woman who has been seeing Cibel since December said she started therapy with "a lot of problems. I've struggled my whole life with being slightly overweight and having body-image issues, and I was ready to do something about it." To protect her privacy, she agreed to be interviewed on the condition that her name not be used.
The woman said she had taken a diagnostic test, which indicated she was "slightly depressed," and her psychologist suggested she go on medication. "But I was not comfortable with that," she said. "I don't like to take drugs."
The client said Cibel's combination therapy has produced a "dramatic turnaround" in six months," she said. "I've lost 23 pounds" -- of a 35-pound loss goal -- "but that is just one part of the whole thing, taking control of my life. This has really worked well for me."
Cibel's sessions have reacquainted the client with fitness. She used to walk every day but in recent years her exercise habit had dropped to at most one workout per week. Her mood declined at the same time.
"Now I try to work out six times a week," aiming for an hour of cardio exercise on most of those days, with weight lifting three days a week, she said. "If I miss a workout, I feel mad at myself. This is very empowering for me, knowing that I turned this around myself."
Some of Cibel's clients have eating disorders; others have a variety of mood disorders, including depression and anxiety. Some see psychiatrists as well, but, Cibel said, only for "medication management" -- i.e., getting prescription drugs, which Cibel is not licensed to prescribe.
"I really work with people on their diet -- eating the right foods, six [small] meals a day, that type of thing -- because it is such a huge part" of feeling good about oneself, she said.
John Ratey, an associate clinical professor of psychiatry at Harvard Medical School and a specialist in mood disorders, said as little as 10 minutes of exercise at 60 percent of one's maximum heart rate -- that is, walking briskly enough to just begin sweating -- "has an effect. [But] the more intense the exercise, the better, especially if you're only going to do short bursts." (Of course, it's not safe to work out intensely until one has achieved a basic level of fitness. And no one should exercise intensely without a doctor's approval.)
With exercise, one begins to see improvements in depression markers after a few weeks, Ratey noted, about as long as it takes antidepressant drugs to begin working in many people. "And we are talking about seriously ill people here -- the clinically depressed. They are responding to exercise."
Asked if there was any population for whom he would not recommend exercise as a component of treatment for a mood disorder, Ratey paused briefly. "No," he said. "I can't think of any."
John Briley is author of the Health section's weekly Moving Crew column and anchor of its bi-weekly live chat on washingtonpost.com.