Few Psychiatrists Recommend Exercise for Anxiety Disorders

Nancy A. Melville

April 10, 2018

WASHINGTON — Although short, intensive bouts of exercise and aerobic exercise of longer duration can have significant benefits for patients with anxiety disorders, few psychiatrists take the time to talk about or recommend these effective interventions, new research suggests.

Several studies on exercise were presented here at the Anxiety and Depression Association of America (ADAA) Conference 2018.

In one, 29 psychiatrists and psychiatry residents in Illinois responded anonymously to a survey conducted from November 2015 to February 2016.

"We found that only about 20% of patients being treated for depression received discussion about exercise from their psychiatrist," reported lead author Dawn C. Roberts, PhD, associate professor of psychology at Bradley University, Peoria, Illinois.

Key predictors of not recommending exercise were psychiatrists themselves rarely having time for exercise or spending more days exercising moderately instead of vigorously.

Overall, "psychiatrists discussed exercise with only a limited number of patients and tended to view it as a lower-potency intervention compared to conventional treatments," Roberts told Medscape Medical News.

American Psychiatric Association practice guidelines describe exercise as an efficacious treatment for depression. Roberts speculated that, as opposed to treatment of depression in primary care, psychiatrists may be seeing patients who have more advanced or severe symptoms. As a result, they may be focusing on what they consider treatments that are needed more immediately.

"Psychiatrists may be more occupied with keeping patients out of the hospital in some cases and preventing them from committing suicide. So it's not that they don't think exercise is important, but it just may be a lower priority initially," she said.

She noted that the finding that the amount of exercise a physician engages in himself or herself is predictive of how often they recommend exercise to their patients is a pattern seen well beyond psychiatry. It applies to all physicians in general.

"So maybe the exercise intervention needs to be for the physicians as well," said Dr Roberts.

Aerobic Exercise and OCD

Although some preliminary studies have shown that bouts of exercise can help improve mood and anxiety in patients with obsessive-compulsive disorder (OCD), randomized clinical trials have been lacking, note investigators from another study presented at the meeting.

For this research, 56 patients with OCD (64% women; mean age, 38.8 years) were randomly assigned to receive either 12 weeks of an aerobic exercise program or 12 weeks of health education (control group).

The exercise group participated in weekly supervised aerobic exercise sessions with an exercise physiologist. Exercises included work on treadmills, recumbent bicycles, and elliptical machines.

Aerobic activity was also recommended three to four times independently, with a gradual increase in activity levels. By the end of the intervention, participants were engaging in moderately intense aerobic exercise for up to 150 min.

The health information group received weekly hour-long psychoeducation sessions that included information on exercise and numerous other topics.

The Yale-Brown Obsessive-Compulsive Scale, the Beck Depression Inventory, and the Beck Anxiety Inventory, consisting of single-item Likert-scale questions, were administered before and after each weekly session of either intervention.

Compared with the health education group, the aerobic exercise group showed significantly greater improvements in mood (P < .0001), anxiety (P < .001), and compulsion (P = .01) scores.

Improvements in anxiety increased in a linear fashion over time during the course of the treatment (P = .04).

The one measure for which the exericse group did not show an improvement, either in the effect size or over time, was in regard to obsessions.

"The findings indicate that patients with OCD may be taught to use bouts of aerobic exercise to manage mood, anxiety, and the desire to engage in compulsions 'in the moment' to improve affect and decrease likelihood of engaging in compulsions," coinvestigator Samantha G. Farris, PhD, Alpert Medical School at Brown University, Providence, Rhode Island, told meeting attendees.

Benefits of "Short Bouts"

Another study, which assessed exercise sessions of shorter intensity, focused specifically on symptoms of anxiety sensitivity. This term generally refers to the "fear of fear," or fear of the negative consequences of severe anxiety, such as fainting or having a heart attack. It is seen as a key driving factor in anxiety disorders.

In this study, 63 participants with anxiety sensitivity were randomly assigned to one of three groups. The moderate-intensity, continuous-training group underwent continuous stationary cycling for 50 min. Participants achieved a heart rate of approximately 70% their maximum. The 10-min sprint interval training group also engaged in stationary cycling, but the participants achieved a heart rate of approximately 85% maximum. The third treatment arm consisted of a wait-list control group.

Both exercise groups showed improvements in anxiety sensitivity, as assessed with the Anxiety Sensitivity Index, compared with the wait-list group (P = .035 for short intensity, P = .024 for moderate intensity). The difference in improvements between the short-intensity group and the moderate-intensity group was not significant (P = .65).

In the sprint-interval group, reductions in anxiety sensitivity were significant only in the subscale regarding concerns of physical symptoms from anxiety (P = .04).

Patients in the longer moderate-intensity, continuous-training group only showed significant reductions in the social and cognitive concerns subscales (P = .04 and .03, respectively).

"The trial results suggest the possibility of customizing exercise prescription for anxiety sensitivity-related disorders," said coinvestigator Julia Mason, MA, University of Regina, Saskatchewan, Canada, while presenting the findings.

"They also suggest a possible solution for the problem of anxiety adherence, with a time-efficient strategy for reducing overall anxiety sensitivity," Mason added.

Clinical Successes, Challenges

Recommending exercise of even short intervals can be an effective strategy on many levels, Beth Salcedo, MD, who is president of the ADAA, told Medscape Medical News.

"I often tell patients that 10 minutes daily of getting their heart rate up can benefit their overall medical health. If they can get out there for 10 minutes, it's pretty likely they will do a little more also," she said.

Salcedo is also medical director of the Ross Center for Anxiety and Related Disorders and assistant clinical professor of psychiatry and behavioral sciences at the George Washington University College of Medicine and Health Sciences in Washington, DC.

"Starting with what feels like an easily achievable goal is the first step," she said. "Imagining going to the gym for an hour daily is a huge goal, [but] 10 minutes of walking outside is much more doable."

Salcedo noted that although she discusses exercise with about 95% of her patients, she was not surprised by the low rate of psychiatrist discussions shown in the earlier study.

"Time is always limited in trying to [determine] the diagnosis, get collateral info from other sources, and coordinate with other providers," she said. "It takes a lot of time to explain how exercise can be beneficial and to really educate the patient and convince them to try it."

Exercise is also often not a priority and gets overlooked, Salcedo added. She noted that she has herself faced challenges in introducing exercise into a treatment regimen.

"Over time, I try to have an influence on exercise habits, but I admit that I am often unsuccessful," she said.

Salcedo described one patient who had severe anxiety, secondary depression, an intolerance to multiple medications, and was taking clonazepam (Klonapin, Roche) for anxiety.

"She finally entered into a marathon training program, which provided her regular exercise and a new social support system, and her symptoms fully remitted. She felt great," said Salcedo.

However, "when she backed off on her exercise, her anxiety came back, and she was eventually lost to follow-up. She has influenced me as well."

The study authors have disclosed no relevant financial relationships.

Anxiety and Depression Association of America (ADAA) Conference 2018. Abstract S1-094, 345R, and 315R, presented April 6-7, 2018.

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