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Interested in Exercise for Treating Depression in Adolescents? Check out the DATE study!

Half Marathon 2019

Common sense, clinical intuition, non-experimental research studies, and most sentient beings all support the likelihood that physical exercise can reduce depressive symptoms.

But, to the best of my knowledge, only one, very small, randomized controlled study of exercise for treating major depressive disorder in youth has ever been conducted. This study was nicknamed the DATE study (the Depression in Adolescence Treated with Exercise study by Hughes, Barnes, Barnes, DeFina, Nakonezny, & Emslie, and published in 2013 in a journal called, Mental Health and Physical Activity).

A brief review of the DATE study provides a glimpse into the potential of exercise as an intervention for treating depression in youth.

The DATE study randomized youth ages 12 – 18 years into an aerobic/cardio group (n = 16) vs. a stretching group (n =14). Although participants exercised independently and were given a variety of exercise alternatives (they could use Wii or Jazzercize, that’s right Jazzercize), both groups were involved in 12 weeks of rigorously monitored three times weekly exercise treatment protocols.

The results were statistically and clinically significant, with the aerobic condition showing remarkably fast responses and achieving a 100% response rate (86% complete depression remission). The stretching group improved more slowly, but also had a significant positive response (67% clinical response rate; 50% complete depression remission).

Now you might be thinking, that sounds pretty good, but how do those results compare with response rates from established medical treatments, like Prozac?

The authors shared that information. They reported that documented response rates in comparable fluoxetine (Prozac) studies with youth, showed, on average, about a 52% (Prozac) and 37% (placebo) response rate. Just to be clear, let’s put those results in order of which treatment looks best:

  1. Aerobic Exercise = 100% response rate
  2. Stretching = 67% response rate
  3. Prozac = 52% response rate
  4. Placebo – 37% response rate

But the authors didn’t stop there.

They noted that although Prozac shows beneficial treatment effects, clients who take Prozac and other antidepressants commonly experience uncomfortable side effects and occasional health-threatening adverse events. How do you suppose the exercise and stretch groups compared?

No big surprise here: They experienced ZERO side effects and ZERO adverse events.

In summary, the DATE study authors reported that, compared to antidepressant medication treatment with adolescents, exercise resulted in (a) a faster response rate, (b) a better response rate, (c) fewer relapses (n = 0) at six and 12 month follow-ups, and (d) zero side effects or adverse events (Hughes et al., 2103).

But here’s the kicker. Who exactly were these researchers?

This is my favorite part. The researchers were extremely high level and prestigious academics who primarily conduct pharmaceutical research. One of them was the guy responsible for the clinical studies that led to FDA approval of Prozac for treating youth with depression (Graham Emslie). The two biggest names on the study have repeatedly been funded by Eli Lilly, GlaxoSmithKline, Pfizer, and many more. The DATE study was funded by NIH.

Sadly, the DATE study hasn’t been replicated. I can’t find any new RCTs on exercise for  depression among adolescents. When I told this to Rita, she just quipped, “That’s probably because the authors were murdered by pharmaceutical companies in some back alley.”

I hope not. Because, to summarize, the DATE study supports the systematic use of exercise in youth with depressive symptoms OVER and INSTEAD OF antidepressants.

Who knew?

Just about everyone.

My Journey to Neuroscience

For the revision of our Counseling and Psychotherapy text, Rita and I are contemplating how to integrate some neuroscience information in a balanced way. Each chapter would include a short section discussing neuroscience as it pertains to each theoretical perspective. This essay is one effort for beginning or framing the discussion.  Check it out (if you like this sort of thing) and let me know your thoughts (if you do that sort of thing).

From Biological Psychiatry to Interpersonal Neurobiology

In 1980, I (John) began my career in mental health services as a recreation therapist in a 22-bed psychiatric hospital. The patients were experiencing severe depression, manic episodes, and psychotic symptoms.

There was a large and intimidating psychiatrist (Dr. M) on the unit. Dr. M was a fan of biological psychiatry. He would smile as I engaged patients in the “Newly-Friend Game” (like the Newly-Wed Game, only better), relaxation groups, bowling nights, and ice cream socials. Occasionally Dr. M cornered me, explaining how my “cute” recreational programs had absolutely no influence on our hospitalized patients’ mental health. He waxed eloquent about brain chemistry. Never mind that the Thorazine and Haldol he prescribed had nasty side effects. Eventually, he claimed, there would be designer drugs that cured mental disorders from the inside out. Everything else was irrelevant.

I had a fresh, new bachelor’s degree in psychology. Dr. M had his M.D. He knew more than I did. Class dismissed. But it’s funny how encountering a condescending attitude can be motivating. I figured there must be a brain chemistry explanation for that too.

The chemical imbalance theory of mental disorders continued its dominance through the 1980s and 90s. Explanations for psychopathology focused on too much dopamine (causing schizophrenia) and not enough norepinephrine or serotonin (causing depression). No one really knew what caused these so-called imbalances, but biogenetic factors were the prime suspects. Although I kept silent with Dr. M, I held tight to my beliefs that social, psychological, and physical experience could be therapeutic.

Evidence slowly rolled in. While teaching a class on developmental counseling, I found a study showing that testosterone levels vary as a function of winning or losing tennis matches (Booth, Shelley, Mazur, Tharp, & Kittok, 1989). My brain (and the chemicals therein) loved this idea. If our testosterone levels could change based on competitive experiences, what other ways might human behavior influence the brain?

In 1998, while perusing research on serotonin and depression, I discovered that treadmill running increased brain serotonin in rats. The researcher described the complexity of the phenomenon:

Lipolysis-elicited release of free fatty acids displaces the binding of tryptophan to albumin and because exercise increases the ratio of circulating free tryptophan to the sum of the concentrations of the amino acids that compete with tryptophan for uptake at the blood-brain barrier level, tryptophan enters markedly in the brain compartment. (Chaoeloff, 1997, p. 58)

But my take-home message was simple: physical exercise might increase serotonin in human brains and also help alleviate depression.

Then neurogenesis came along. Neurogenesis is the creation of new brain cells. It has been long known that during fetal development, cells are created and migrate to specific places in the brain and body where they engage in their specific role and function. Cells that become rods and cones end up in the eyes, while other cells become bone, and still others end up in the cerebral cortex. In the 1980s and 1990s, everyone agreed that that neurogenesis continued during infancy, but most neuroscientists also believed that after early childhood the brain locked down and neurogenesis stopped. In other words, as adults, we only had neuronal pruning (cell death) in our future.

In the late 1980s, neuroscientists began conducting research that shook long-held assumptions about neurogenesis. For example, Jenkins and colleagues housed adult monkeys in cages where the monkeys had to use their middle finger to rotate a disc to get banana pellets. Even after a short time period (1 week) upon autopsy the monkeys had an enlarged region in their motor cortex. The conclusion: Even in adult monkeys, repeated physical behaviors stimulate neurogenesis in the motor cortex. This seemed like common sense. Not only do our brains shape our experiences, but our experiences shape the brain (literally).

As it turns out, neurogenesis slows with age, but it doesn’t stop. It continues throughout the lifespan. New learning stimulates cell birth and growth in the hippocampus (and other areas involving memory processing and storage). The “new brain research” left open the possibility that counseling and psychotherapy has the potential to stimulate neurochemical changes and cell birth in the human brain.

The evidence is no longer slowly rolling in—it’s popping like popcorn. Neuroscience research is as popular as Beyoncé. Whenever more evidence arrives showing how counseling and psychotherapy might be affecting brain functioning, non-medical mental health professionals get giddy. As you might suspect (or already know) occasionally we’re so excited that our statements about the implications and applications of neuroscience are way ahead of the actual scientific evidence. Counseling and psychotherapy practitioners have created new marketing terminology like “brain-based therapy” and “neurocounseling” and “interpersonal neurobiology” despite the lack of clear scientific evidence to support these terms. In some cases the birthing of this new terminology has caused lament within the neuroscience community (Satel & Lillienfeld, 2015).

Where does all this take us? As Dr. M would say, the brain is central to mood and behavior change. But now we know the reverse is also true: mood and behavior are central to brain development and change. If Dr. M were still alive, I might say, “touche” or “voila” or some other fancy and clever retort to show him that he had the directionality wrong—all these years.

But my retort would be incorrect too. The influence goes both directions at once. Even more importantly, we need to acknowledge that the relationships between and among brain structures, neurotransmitters, hormones, other chemicals, and human behaviors are still complex and mysterious. Even though journalists sometimes write with flourish about our ability to peer directly into the brain and see exactly what’s happening, that’s just not true. And to the extent we can “see” what’s happening, it appears that the brain is simultaneously functioning as a whole, as regions, as inter- and intra-cellular processes, and doing all these activities in particular sequences and all at once. Sure, as many mental health professionals will enthusiastically claim, we now know that meditation and interpersonal empathic experiences appear to stimulate the anterior insular cortex (AIC)! But it’s more complicated than that. The following excerpt from the neuroscience literature helps communicate this complexity (Mutschler, Reinbold, Wankerl, Seifritz, & Ball, 2013).

In summary, we argue that the dorsal AIC plays a pivotal role in empathy (similarly as during emotion processing and pain) by integrating sensory stimuli with its salience, possibly via connections to the cingulate cortex. This assumption is also supported by the fact that ALE-findings related to emotion and empathy for pain and also the DGR—which has been associated with cognition—overlap in the dorsal anterior insula, suggesting that these functions share a common neural substrate . . . . As mentioned above we assume that the overall role of the morphometrically identified area in the dorsal AIC related to individual differences in empathy which overlaps the DGR might be involved in integrating information which is relevant for socio-emotional and cognitive processing. Thus, we assume that empathy is not (only) related to a specific “socio-emotional” interaction area, but to a superordinate “domain-general” area, in line with concepts of empathy that include not only social and emotional, but also cognitive aspects . . . . Whether our findings in the dorsal AIC have also a relation to the “von Economo neurons” [VENs, . . .] remains to be determined. VENs have been hypothesized to play are role in social-emotional processing including empathy . . . .

This excerpt should inspire us all to pause with respect for the density and specificity of neuroscience. It should also inspire us to ramp down our expectations. If we just focus on empathy and the insula, we can see many sources of potential error: (a) much of the empathy research focuses on empathy for pain; (b) empathy is hard to measure; (c) it’s possible for a human brain to “light up” with empathy, but for the human to not express or show empathy toward someone else; (d) while empathy is generally considered a positive quality, some people use empathy to manipulate and hurt others; (e) there is brain structural and functional overlap; (f) the role of the VENs is unknown; and on and on. To use an inappropriate metaphor, it’s likely that the particular blend and balance of neurotransmitters (there may be up to 100) and hormones (there are about 50) and other cellular substances in each individual—along with structural variability—is more unique than a fingerprint on a snowflake.

In every chapter of this text Charles Luke (of Tennessee Tech) and I will share a highlight or update on neuroscience research. These highlights and updates will focus not only on the promise and potential of neuroscience to counseling and psychotherapy, but also on its limitations. A focus on limitations is needed because our ability to imagine what’s happening in the brain greatly outpaces neuroscience research. Although it’s tempting (and terribly fun), we shouldn’t let our imagination get too far in front of the science. As Dr. M might have said, “the brain offers us the greatest opportunity and potential to understand, explain, predict, and manage human behavior.” Of course it does; and it always will.



Neuroscience New Year’s Resolutions for 2016

In case you forgot or never knew, 1990 to 2000 was championed as the decade of the brain. You would think one decade would be enough, but judging by how much of a darling neuroscience is in the media, it looks like the brain will be hogging the whole 21st century too. And so in celebration of our perpetually “New Brain Science,” I’m offering six neuroscience-based New Year’s resolutions for 2016

1. For years, the Dali Lama has been advising everyone to develop a “Loving Kindness” meditation practice. Even if his advice doesn’t change the world, having a consistent loving kindness meditation practice can change your brain. Mindfulness meditation strengthens a region in the brain called the insular cortex, an area broadly linked to self-control and good judgment. This makes 2016 a good time to start meditating. We could all use a little more self-control and good judgment.

2. You should sit down for this one. Or stand up. And then sit down again. This is because scientific research supports brain-body connections. Exercise facilitates everything from sleep to sex. If you want a sharper brain for 2016, then stand-up and get walking or stretching or running or lifting or dancing your way to clearer thinking.

3. Last year might have been the year of the gut. There’s been plenty of talk about the “gut” being our second brain. Of course, this isn’t about growing your gut or striving for a dad-bod. It’s all about digestive health. The best way to get your second brain to support your mental health is to feed it whole, fresh foods, probiotics, and fermented foods (like kombucha, sauerkraut, and kimchee), while avoiding the evils of eating highly processed white sugar/white flour.

4. Exercise is great and good sex may be better, but loving and gentle touch is the bomb. Make 2016 the year—not only for consensual hugs and kisses—but also for shoulder and neck and foot massages. You can even put brushing each other’s hair on your “this-just-might-improve-my-mental-health” to-do list.

5. In 2015 sleep research was hot. It’s more obvious than ever that sleep deprivation is generally bad for your brain; it contributes to clinical depression, suicide, accidents, and illness. Finding a way to sleep well in 2016 means turning off your screens at least 30 minutes before bedtime, cutting out the caffeine after 2pm, and establishing a steady personal and family sleep routine. Sleep is the new black.

6. For those of us in the helping professions, the biggest neuroscience news is all about what psychotherapists call empathic listening. Turns out, listening in an effort to understand others grows the brain in ways similar to mindfulness meditation. That means the more you practice listening with empathy, the more you’ll grow that all-important insular cortex . . . and the more you grow your insular cortex, the less likely you are to engage in violent behaviors that threaten the planet. So if you want a more peaceful planet, put empathic listening on your New Year’s resolution list.

There’s one big principle that underlies all of the new brain science: Whatever behaviors you rehearse, practice, or repeat, are likely to strengthen your skills and grow your brain in those particular regions. What this means is that if your goal is to be a couch potato for 2016, you should spend lots of time couch potatoing so you can develop mad skills in that area, with a neurological net to match. On the other hand, if you want a healthy brain and body and awesome friendships and romance in your life, you should engage in the activities listed above—especially the mindfulness meditation and empathic listening—and you’ll grow a brain and skills that just might bring health, love, and peace in 2016.

Note: I submitted this awesome resolution list to a couple newspapers just before the New Year, but only got rejections. And so I decided to submit it to myself and, voila!, it got published right here on my very own blog (smiley face). Please share and pass it on so that all the newspaper editors who keep rejecting my work start feeling the deep regret they deserve.

Outstanding in Field


Non-Drug Options for Dealing with Depression

Evidence supporting the efficacy of antidepressant medications continues to be weak. That doesn’t mean they never work; some individuals with depressive symptoms find them very helpful and that’s okay. But for many, antidepressant meds just don’t work very well . . . there are side effects and less than desirable antidepressant effects. This is why many people wonder: What are some of the best non-drug alternatives for treating symptoms of depression?

Here’s a short list that might be helpful.

1. Counseling or Psychotherapy: Going to a reputable and licensed mental-health professional who offers counseling or psychotherapy for depression can be very helpful. This may include individual, couple, or family therapy.

2. Vigorous aerobic exercise: Consider initiating and maintaining a regular cardiovascular or aerobic exercise schedule. This could involve a specific referral to a personal trainer and/or local fitness center (e.g., YMCA). In a recent small study of adolescents with clinical depression, 100% of the teens in the aerobic exercise group no longer met the diagnostic criteria for depression after receiving several months of exercise treatment.

3. Herbal remedies: Some individuals benefit from taking herbal supplements. In particular, there is evidence that omega-3 fatty acids (fish oil) and St. John’s Wort are effective in reducing depressive symptoms. It’s good to consult with a health-care provider if you’re pursuing this option.

4. Light therapy: Some people describe great benefits from light therapy. Specific information on light therapy boxes is available online and possibly through your physician.

5. Massage therapy: Research indicates some patients with depressive symptoms benefit from massage therapy. A referral to a licensed massage therapy professional is advised.

6. Bibliotherapy: Research indicates that some patients benefit from reading and working with self-help books or workbooks. The Feeling Good Handbook (Burns, 1999) and Mind over Mood (Greenberger and Padesky, 1995) are two self-help books used by many individuals.

7. Post-partum support: There is evidence suggesting that new mothers with depressive symptoms who are closely followed by a public-health nurse, midwife, or other professional experience fewer post-partum depressive symptoms. Additionally, new moms and all individuals suffering from depressive symptoms may benefit from any healthy and positive activities that increase social contact and social support.

8. Mild exercise and physical/social activities: Even if you’re not up to vigorous exercise, you should know that nearly any type of movement is an antidepressant. These activities could include, but not be limited to, yoga, walking, swimming, bowling, hiking, or whatever you can do! In the same exercise study mentioned above, 71% of the teenagers in the mild exercise group experienced a substantial reduction in their symptoms of depression.

9. Other meaningful activities: Never underestimate the healing power of meaningful activities. Activities could include (a) church or spiritual pursuits; (b) charity work; (c) animal caretaking (adopting a pet); and (d) many other activities that might be personally meaningful to you.

The preceding list is adapted from a tip-sheet in our book, “How to Listen so Parents will Talk and Talk so Parents will Listen.” See: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_9?s=books&ie=UTF8&qid=1413432346&sr=1-9
Or: http://lp.wileypub.com/SommersFlanagan/

John and his sister working on their positive emotions.

Peg and John Singing at Pat's Wedding