Is Exercise as Good as Medicine? - Coach Tip Tuesday

Endurance athletes and exercise enthusiasts alike have long praised movement and sport for how good it makes them feel.  I’m sure all of us endurance athletes have had non-athletes say something similar to the following over the years: “I only run when I’m being chased” or “You’re crazy for doing a triathlon” or “Why would you ride a bike for that long?”

But those of us who have been endurance athletes - even if it’s just been for a relatively short amount of time - understand that there is something about maintaining a regular movement practice that changes something in us for the better.  But what exactly changes in us, and why do we have such strong (positive) feelings when we sustain a regular exercise practice?

First-Hand Experience of Exercise as Medicine

More than 12 years ago, I started volunteering with a non-profit organization called Team Red, White & Blue (more commonly known as Team RWB).  Team RWB was originally founded as a way to help veterans returning from serving in Operation Iraqi Freedom and Operation Enduring Freedom to reintegrate into civilian life and to connect them with their communities. When it was founded, one of the main mechanisms Team RWB used to facilitate this process of reconnection was group runs.  Recognizing the powerful combination of exercise and social connection, since the organization’s founding in 2010, Team RWB has moved beyond just running to leverage a wide variety of movement practices and group gatherings to help connect veterans of all ages and all periods of time served with civilians and their communities at-large.

So many veterans who have served the United States of America have been diagnosed with Post-Traumatic Stress Disorder, more commonly referred to as PTSD.  According to the Mayo Clinic, PTSD is “a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it.  Symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event.”  Team RWB recognized that movement and exercise helped veterans struggling with PTSD and encouraged them to leverage the combination of exercise and community engagement to help them manage their symptoms both acutely and over the long-term.

Over the many years that I have been involved with Team RWB, I have witnessed exercise’s positive impact on mental health first-hand.  And the benefits are not just limited to veterans diagnosed with PTSD;  I have seen how it helps anyone - veterans and civilians alike - who is experiencing depression to manage their symptoms and to start to feel better.  Furthermore, I saw how exercise helped so many people feel good both mentally and physically.

On a personal level, exercise has helped me manage the ups and downs that come with living one’s life.  Many years ago, one of my very first running partners, Ed Griffin-Nolan, said to me, “Many marathoners are born out of grief.”  I’ve never forgotten that, especially because I’ve seen it play out as true time and time again over the years.  Through grief, sadness, joy, heartbreak, celebrations, trauma, and joy, movement has been there for me through it all.  Very specifically, exercise has helped me navigate the periods of grief, sadness, heartbreak, and trauma and manage my emotions as I figured out how to navigate those chapters of my life.

2021 was - beyond a shadow of a doubt - the hardest, saddest, and worst year of my life to date.  Having been an endurance athlete for well over a decade at that point and having been a coach for close to a decade then, I was well aware of the power of exercise and movement.  That being said, it was during this time that I came to fully appreciate how powerful exercise really is in terms of helping me manage the overwhelming emotional load I was carrying that year.  There were periods of time that I felt so down and awful that getting off the couch to go to the kitchen - much less getting in a workout - seemed utterly impossible.  But bit by bit, I got myself moving, even if it was just for the teeniest, tiniest amount of time.  Those efforts snowballed (in a positive way), and by the end of the year, I was convinced that exercise was just as impactful and effective - if not more so - than pharmaceuticals when it came to managing the symptoms of depression and managing mental health.  How I felt mentally at the end of 2021 was noticeably different from how I had been feeling in mid-2021.

Should Exercise Be Prescribed as Treatment for Depression and Other Mental Health Concerns?

Recent reviews of randomized control trials (more commonly referred to as RCTs) and meta-analyses and systemic reviews explored whether this anecdotal sentiment that I and so many endurance athletes have expressed - that exercise is just as powerful as pharmaceutical  medicine - was rooted in evidence.  What these reviews found was both interesting and affirming.

The researchers found that exercise is equally as effective as antidepressants.  When RCTs compared exercise + antidepressants to the use of antidepressants alone, a significant improvement in depression symptoms was only observed after exercise was added as an adjunctive treatment to the antidepressants.  In short: The researchers concluded that the anecdotal experience of athletes and exercise enthusiasts alike was confirmed: Exercise is just as effective as medicine, and that it is a catalyst often needed for pharmaceutical antidepressants to have a measurable effect.

The conundrum facing humans (and therefore athletes) experiencing depression or symptoms of poor mental health is this (and is the same as what I shared that I experienced above): When you are in a depression down cycle or feeling poorly mentally, getting out of bed in the morning can feel like a monumental and impossible task.  Therefore, getting in a workout feels like climbing a mountain taller than Mount Everest.  So even though people may completely intellectually understand that exercise is good for them, getting them to actually do said exercise may be a really big ask.

If Movement is Medicine, Why Aren’t More Practitioners Prescribing It?

If exercise is so powerful and transformative, why aren’t more doctors and therapists prescribing exercise as a viable treatment to people experiencing depression?  There probably isn’t a clear, definitive answer here that applies to all situations and practitioners, but I have several hypotheses.  First and foremost, exercise is not tangible.  It’s not a pill you can take, and therefore to a society that has become accustomed to popping any number of pills (whether it be pain relievers, antibiotics, antacids, etc.) when they are experiencing a medical issue, an intangible such as exercise doesn’t necessarily feel like a solution to a medical issue.  (And yes, depression and mental health are medical issues, despite the stigma that still surrounds them.)  It’s kind of like when you go to the doctor when you’re physically sick and the prescription is to rest, drink fluids, and be patient.  That’s a frustrating “lack” of a solution for a lot of people; they want something they can take and just feel better after taking.

I think that there’s a massive hesitation among many, many people to accept that lifestyle changes - such as integrating a movement practice into one’s life - can alter biological mechanisms in the human body (such as those that would be required to be altered to resolve depression or mental health challenges).  In some ways - paradoxically perhaps since exercise can be something hard to do - prescribing a lifestyle change such as exercise to help treat and resolve a deep and complex issue such as depression seems too “simple” to be an actual solution.  However, just because something is simple does not mean that it is easy.

Second, as discussed earlier, exercising or getting in a workout requires actual action on the part of a person.  And doing anything actionable when experiencing depression can feel nearly impossible.  That being said, American distance runner Shalane Flanagan said something years ago that has always stuck with me: “Mood follows action.  You don’t need to feel good to get going.  You need to get going to give yourself a chance to feel good.”  This has become a nudge of advice that I have given to countless athletes who I’ve coached over the years.  Once we actually get going, that can give us the momentum boost we need to start a snowball effect.  But we need to take that first - albeit very hard - step.  

Whatever the hesitation to accept this as true may be, both anecdotal and research-based evidence demonstrates the clear and powerful correlation between exercise and improvements in mental health.  One reason is that aerobic exercise promotes neuroplasticity, thereby reducing the neuron atrophy that occurs in the hippocampus region of the brain in depressed people.  Neuroplasticity is the ability of the brain to form and reorganize the connections between nerve cells in response to learning, experience or injury.  Neuron atrophy is the loss of brain cells and the connections between them; researchers have learned that individuals experiencing depression have physical changes like this to their hippocampus. The hippocampus is a small part of the human brain that is part of the limbic system, which is a group of brain structures that regulate our emotions, memories, autonomic behaviors (such as heart rate, breathing, and sweating), and smells.  The hippocampus is connected to and works with the amygdala, which is the brain’s processing center for emotions.  As you can see, neuron atrophy in these structures of the brain impacts a lot of important functions and how we feel.

In fact, it was found that exercise not only reduces this neuron atrophy, but facilitates neurogenesis.  Neurogenesis is the process by which new neurons are formed in the brain.  Brain-Derived Neurotrophic Factor (BDNF) - a protein found in the brain that supports survival of existing neurons and encourages growth and differentiation of new neurons and connections between them (called synapses) - increases when people take antidepressants.  In short, BDNF is known to facilitate neurogenesis.  Even more interestingly, studies have shown that BDNF increases in as little as two days when people leverage a combination of antidepressants and exercise.  When taking antidepressants alone ((without exercise as an adjunctive treatment), it takes much longer to see increases in BDNF (around two weeks).  For all of these reasons, researchers have concluded that exercise (by itself) can be prescribed as a treatment for depression; they also concluded that exercise can be prescribed alongside pharmacological antidepressants.

What Kind of Exercise is Best?

Though research has shown a clear correlation between exercise and positive mental health outcomes, the research is much less clear about what kind of exercise facilitates this.  This is partially because there are not many - if any - studies that have specifically focused on this exact topic.  That being said, I’ve learned over the years that the best exercise is the one that works best for you.

In a practical sense, this means that whatever movement practice resonates with you can (and likely will!) bestow the positive benefits of exercise upon you.  So whether it’s running, cycling, hiking, yoga, weight training, group fitness classes, swimming, skiing, basketball, baseball, or any other movement practice, find the modality that works best for you.  That’s what you are most likely to do consistently and frequently, and consistency is one of the most important elements required to see benefits from and progress from any kind of movement practice.

It should be noted that there is a lot of evidence that demonstrates that combining exercise with social connection and/or being outside (bonus points if you do something that checks all three of these boxes!) has a profoundly positive effect on mental health.  I saw this in action via all of the outdoor group outings and workouts I’ve done over the years both as part of Team RWB and as an athlete and coach.  Being outside by itself has been shown to reduce depression symptoms by a whopping 61% and to lower the overall risk of depression for those not currently experiencing it.  So no matter what the exercise is, if you’re doing it outside and/or with other people, the mental health benefits are very real.

The Bottom Line

Research is now clearly showing what so many in the endurance sports world have known to be true for a long time: Movement is medicine.  If you are currently struggling or ever find yourself struggling with depression or poor mental health in the future, consider what Shalane Flanagan said: Mood follows action.  Get yourself to engage in movement - any type of movement - and see if it doesn’t help you to feel better.  Even if it’s “only” a small bit better, that small bit is powerful and can grow…if you give it the chance to.

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Sources:

Netz, Yael. (2017). “Is the Comparison between Exercise and Pharmacologic Treatment of Depression in the Clinical Practice Guideline of the American College of Physicians Evidence-Based?”

Perlmutter, David, and Austin Perlmutter. Brain Wash: Detox Your Mind for Clearer Thinking, Deeper Relationships, and Lasting Happiness. Little, Brown Spark, 2020.

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