A Walking Cure

Exercise May Treat Depression, and This Doctor Prescribes It

Could the path to emotional health be as simple as a 30-minute weekend walk in the park?

Alen Salerian, medical director of the Washington Psychiatric Center, thinks so. Salerian says he is helping his depressed patients recover not only by administering antidepressant drugs and therapy, but also prescribing a moderate regimen of weekly exercise. And he is now on a mission to spread the message and persuade other doctors to include an exercise program in their treatment of depression.

Salerian describes his approach as "simple," "totally radical" and so obvious that it's "stupid."

While other mental health practitioners concede that Salerian's weekly workout recommendation may be simple (no comments on the stupid part), few are reaching for their prescription pads. Many say it's fine to recommend physical activity to amenable patients. Few think of exercise as a bona fide treatment for mental illness.

"I have never prescribed exercise, nor would I," says Wayne Blackmon, a Washington psychiatrist who treats many patients for depression. "The general nostrum is, 'Being more active is better.' But as a specific treatment modality, there's a lot I'd need to know before I prescribed it to a patient."

Helen Mayberg, a professor of psychiatry and neurology at the University of Toronto, worries that encouraging expectations that exercise can help cure depression "trivializes" a serious illness. "Exercise sounds good," she says, "but where's the data?"

"Over the years, we have heard you must exercise four times, five times a week to get into shape," says Salerian. "I think the average American would be totally surprised to learn that once-a-week exercise might help him."

So would those at the American Heart Association and the American College of Sports Medicine. Both organizations recommend 30 minutes of exercise at least three times per week to achieve some measure of physical fitness. "A single bout of exercise [weekly] is unlikely to drive any real physiological or psychological benefits," says Steven W. Edwards, a sports psychologist and professor at the School of Applied Health and Educational Psychology at Oklahoma State University.

Still, admit Edwards and others, Salerian could be on to something. Depressed people often lead a depressed lifestyle, prone to lethargy, apathy and feelings of isolation, says Robert Carney, a professor of psychiatry at Washington University in St. Louis, who studies the links between exercise, depression and heart disease. Two-thirds of all adults in the United States lead a sedentary lifestyle, according to Paul Salitsky, a professor of exercise science at the University of California, Davis. If Salerian's low-dose exercise prescription helps a depressed person become more active, that could be a "baby step" toward a healthier lifestyle, Edwards says.

Salerian is not suggesting that exercise alone can lift depression. Even someone mildly depressed, he says, would probably find his regimen very difficult absent other steps to recovery. Underlying mental ills have to be treated first, or simultaneously, for an individual to take on an exercise routine as part of a recovery plan.

"My short message for the majority of people is that if you are not exercising, there's always a reason, and that reason is fixable," he says. Not exercising, Salerian believes, is the equivalent of "self-abuse."

Language like that may not win him many friends. But then Salerian, an assistant clinical professor at George Washington University School of Medicine who worked as the medical director of the FBI's Mobile Psychiatric Emergency Response Team (he debriefed agents during the 1993 siege at the Branch Davidian complex in Waco, Tex.), is used to controversy and prides himself on being a risk-taker. At last month's American Psychiatric Association convention, Salerian presented a paper on the use of Marinol (the marijuana derivative used to treat nausea in cancer patients) as an aphrodisiac. He's already prescribing the drug to patients suffering sexual dysfunction as a side effect of antidepressants.

Last year, Salerian found himself in a flap involving Robert Hanssen, the former FBI agent who was sentenced last month to life in prison for years of spying. Salerian treated Hanssen when the spy was first brought into custody. He was fired from the defense team after talking to the press about Hanssen's mental state. Salerian has said Hanssen asked him to go public with some information.

About seven years ago, he says, he had a chance encounter with a 60-year-old runner who claimed to jog just once a week for 15 miles. Salerian considered his own exercise habits -- about seven times a week -- coupled with his 80-hour workweek, and decided the jogger's path to fitness was more efficient. He adopted the schedule himself and about two years ago began to include the regimen in his practice. The 54-year-old Salerian trained for this year's D.C. Marathon -- which he says he completed in five hours and 10 minutes -- by running just once a week for 12 weeks. He started with 30 minutes and gradually increased his time, peaking at just over three hours the week before the race -- not exactly what the marathon books recommend.

Like many doctors, Salerian often recommended that patients exercise three times per week for 30 minutes. Many patients, he says, tried to take his advice, started a routine . . . and quickly gave up. Many felt worse than before they had started. Some said they didn't have the time. Many found the regimen too high a hurdle. "They would get really disgusted with themselves and feel guilty," Salerian says. "That stayed with me."

His once-a-week regimen, he says, is ideal for therapeutic purposes because it lowers expectations for his patients and works on the reward system. "Each week, it gets easier for them." The protocol eliminates guilt and the excuse of time, he says, and patients report that it makes them feel good.

He was so encouraged by his patients' response that he introduced the concept to 12 women who come to his clinic for group therapy. The women, who suffer severe psychiatric and medical problems including high blood pressure, high cholesterol, obesity and diabetes, responded well to 15 minutes of light exercise at the beginning of each group meeting, he says.

Last month, Salerian developed a formal protocol that will work them up to 2 1/2 hours of exercise once a week while closely tracking their blood pressure, heart rate and improvements in mental health.

"Does it work?" Salerian asks. "That's the question."

Psychological journals are loaded with studies done since the 1970s documenting a relationship between exercise and reduced depression, but meta-analyses have concluded that much of that research is flawed.

"No one would doubt that exercise could be helpful" in managing depression, says Michael Blumenfield, professor of psychiatry at New York Medical College. "But psychiatry is an evidence-based specialty. Whether we prescribe exercise will come down to the research, and not fads."

A study that drew much attention when it was released in 1999 came close to establishing the link that Salerian has suggested. But the study also pointed up the complications of connecting exercise and depression relief. In that study, adults diagnosed with mild to severe depression were randomly assigned to groups in which they received the antidepressant Zoloft; exercise only, three times a week; or both. After four months, people in the exercise-only group improved just as much as those who took Zoloft. In a six-month follow-up, the exercise-only group had the lowest relapse rate -- one-third that of the other two groups.

Despite the positive findings, the study's lead author, James Blumenthal, a professor of medical psychology at Duke University in Durham, N.C., is not ready to trade in the Zoloft for a trip to the gym. Participants in his study, he concedes, were receptive to the idea that exercise might help them. They were also encouraged and reminded to exercise, and they developed a social support network that grew from exercising with others. These factors, he says, may have influenced their depression as much as the activity itself.

Why does exercise generally make people feel better? Most likely it's a constellation of reasons, including increased levels of serotonin and other chemicals in the brain, along with lifestyle changes that can result when a person becomes physically active and engaged in the world. No one knows for sure. As Blumenthal says, "If exercise needed FDA approval, it probably wouldn't get it."

Prescribing exercise as an adjunct to traditional psychiatric or psychological therapies is not yet widespread, but that is not necessarily a bad thing, adds Blumenthal. "People are nervous about doing it. Depression is a serious condition with a high mortality rate."

But it's hard to argue with Salerian's minimalist supplement to conventional treatment: Knowing all we know about the benefits of exercise, once a week is probably better than nothing. "What are we talking about?" he asks. "Thirty minutes. What excuse can you have not to do it?"

Cecilia Capuzzi Simon is a Bethesda-based writer and editor.

© 2002 The Washington Post Company

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