Exercise vs. Drugs for Depression

Exercise vs. Drugs for Depression
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Aerobic exercise interventions found comparable to antidepressant medication in the treatment of patients with major depressive disorder.

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We’ve known for decades that even a single bout of exercise can elevate our mood, but enough to be used as a treatment for major depression? Well, we know physical activity has been associated with decreased symptoms of depression. For example, if you look at a cross-section of 8,000 people across the country, those who exercised regularly were less likely to have a major depression diagnosis.

That’s just a snapshot in time, though. If you look at that study, the researcher openly admits this may be a case of reverse causation. Maybe exercise didn’t cut down on depression; maybe depression cut down on exercise. The reason depression may be associated with low physical activity is that people feel too lousy to get out of bed. What we need is an interventional study, where you take people who already have depression, and randomize them into an exercise intervention and see if they get better. And that’s what we got.

Men and women over 50 with major depression were randomized to either do an aerobic exercise program for four months, or take an antidepressant drug called Zoloft. This is where they started out before, with Hamilton Depression scores up around 18—anything over seven is considered depressed. But within four months, the drug group came down to normal, which is exactly what the drugs are supposed to do. What about the exercise-only group, no drugs? Same powerful effect.

They conclude that an exercise training program may be considered an alternative to antidepressants for treatment of depression in older persons, given that they’ve shown that a group program of aerobic exercise is a feasible and effective treatment for depression, at least for older people.

Not so fast, though. A group program? They had the exercise group folks come in three times a week for a group class. Maybe the only reason the exercise group got better is because they were forced to get out of bed, interact with people—maybe it was the social stimulation, and had nothing to do with the actual exercise. Before you could definitively say that exercise can work just as well as drugs, what you’d like to see is the same study but with an additional group, the same two plus a home exercise group, where they were just told to exercise on their own at home, no extra social interaction. But nothing like that had ever been done, until it was. The largest exercise trial of patients with major depression conducted to date, and not just including older folks, but other adults as well and three different treatment groups this time: a home exercise group in addition to the supervised group exercise and the drug group as before. And they all worked about just as well in terms of forcing the depression into remission.

So we can say with confidence that exercise is comparable to antidepressant medication in the treatment of patients with major depressive disorder.

Putting all the best studies together, the evidence indicates that exercise, at least, has a moderate antidepressant effect, and at best, exercise has a large effect on reductions in depression symptoms and could be categorized as a very useful and powerful intervention. Unfortunately, while studies support the use of exercise as a treatment for depression, exercise is rarely prescribed as a treatment for this common and debilitating problem.

To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video. This is just an approximation of the audio contributed by Katie Schloer.

Please consider volunteering to help out on the site.

Images thanks to Julos via ImageEnvision.

We’ve known for decades that even a single bout of exercise can elevate our mood, but enough to be used as a treatment for major depression? Well, we know physical activity has been associated with decreased symptoms of depression. For example, if you look at a cross-section of 8,000 people across the country, those who exercised regularly were less likely to have a major depression diagnosis.

That’s just a snapshot in time, though. If you look at that study, the researcher openly admits this may be a case of reverse causation. Maybe exercise didn’t cut down on depression; maybe depression cut down on exercise. The reason depression may be associated with low physical activity is that people feel too lousy to get out of bed. What we need is an interventional study, where you take people who already have depression, and randomize them into an exercise intervention and see if they get better. And that’s what we got.

Men and women over 50 with major depression were randomized to either do an aerobic exercise program for four months, or take an antidepressant drug called Zoloft. This is where they started out before, with Hamilton Depression scores up around 18—anything over seven is considered depressed. But within four months, the drug group came down to normal, which is exactly what the drugs are supposed to do. What about the exercise-only group, no drugs? Same powerful effect.

They conclude that an exercise training program may be considered an alternative to antidepressants for treatment of depression in older persons, given that they’ve shown that a group program of aerobic exercise is a feasible and effective treatment for depression, at least for older people.

Not so fast, though. A group program? They had the exercise group folks come in three times a week for a group class. Maybe the only reason the exercise group got better is because they were forced to get out of bed, interact with people—maybe it was the social stimulation, and had nothing to do with the actual exercise. Before you could definitively say that exercise can work just as well as drugs, what you’d like to see is the same study but with an additional group, the same two plus a home exercise group, where they were just told to exercise on their own at home, no extra social interaction. But nothing like that had ever been done, until it was. The largest exercise trial of patients with major depression conducted to date, and not just including older folks, but other adults as well and three different treatment groups this time: a home exercise group in addition to the supervised group exercise and the drug group as before. And they all worked about just as well in terms of forcing the depression into remission.

So we can say with confidence that exercise is comparable to antidepressant medication in the treatment of patients with major depressive disorder.

Putting all the best studies together, the evidence indicates that exercise, at least, has a moderate antidepressant effect, and at best, exercise has a large effect on reductions in depression symptoms and could be categorized as a very useful and powerful intervention. Unfortunately, while studies support the use of exercise as a treatment for depression, exercise is rarely prescribed as a treatment for this common and debilitating problem.

To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video. This is just an approximation of the audio contributed by Katie Schloer.

Please consider volunteering to help out on the site.

Images thanks to Julos via ImageEnvision.

Doctor's Note

Exercise may compare favorably to antidepressant medications as a first-line treatment for mild to moderate depression, but how much is that really saying? How effective are antidepressant drugs in the first place? Stay tuned for my next video: Do Antidepressant Drugs Really Work?

For dietary interventions that may improve mood, see:

Exercise can also help with ADHD (Treating ADHD Without Stimulants) and improve immunity (Preserving Immune Function in Athletes With Nutritional Yeast), not to mention extend our lives (Longer Life Within Walking Distance). But what we eat matters: Paleo Diets May Negate Benefits of Exercise.

If you haven’t yet, you can subscribe to my videos for free by clicking here.

69 responses to “Exercise vs. Drugs for Depression

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  1. Thank you! That’s why I am on my trainer right now. In fact, exercise saved my life during residency. :-)




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  2. On treating depression with “plants”, see The New Yorker article “The Trip Treatment. Research into psychedelics, shut down for decades, is now yielding exciting results.” by MICHAEL POLLAN. Mushrooms!




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    1. See also Dr Bernard’s latest blog entry (PCRM.org, 2/27/15) titled “Foods that Fight Depression.” He was trained as a psychiatrist.




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      1. I’ll read it again and take notes this time. It seems that the article was published years ago yet the author has updated it.




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          1. b00mer: I thought you would be interested to know that I clicked the link and it says that the video is not available because the account has been terminated. Too bad. I was really interested.




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            1. Something funny is happening, I see the same message when I try my embedded link, but when I searched for it on youtube, the account and video are still available. If you search “This Is Life With Lisa Ling Season 1 Episode 5 Jungle Fix” on youtube I think you should be able to see it.




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    1. In both of the exercise studies: 3 times per week (for 16 weeks), 10 minutes of warm-up followed by 30 minutes of walking/jogging while maintaining a heart rate corresponding to 70% to 85% maximum heart rate reserve (as tested at the start of the study), followed by 5 minutes of cool down.




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    2. Just standing on your feet every 30 min and move around for a few minutes already helps, and is probably the easiest thing to do.
      If you watch TV use the commercial time, internet use or games setting an egg timer will help jolt you out of that hyperfocussed but narrowed state of mind.




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  3. I eat healthy and exercise. In fact I exercised outdoors daily and no one had to encourage me. To be frank neither worked for me as the antidote for depression. I wish it did as I’m not too keen on taking meds. What did help was a combination of talk therapy and meds and my own determination to feel better. Partnering with good doctors and medical staff who listen well and treat me as a person and eliminating “unhelpful” help was also key and beneficial to my health and well-being.




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    1. Karen you make a great point. Thanks for sharing your experience. Depression is serious and it is important to know what works for you. Exercise may help, but as you pointed out it is much more complicated than simply going outside and moving. So glad you are getting the right care you deserve!




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  4. I’ve made exercise a daily part of my life since I was a child and yet I suffer from incapacitating major depression disorder. I also eat vegan which doesn’t seem to confer an immunity on me. I was born with Gilbert’s disease which I suspect is the cause of my depression because many other people with the disease report it as one of its symptoms (other common symptoms include lethargy, stomach problems and jaundice, all of which I get from time to time; the disease acts in bouts rather than continuously). Medical doctors diagnose the disease but make no attempt to treat it. Why? I’ve also read that foods high in limonene may help with GIlbert’s. But so far, I’ve had no luck with that.




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    1. Hello. Thanks for sharing your personal story. I have not seen anything ground-breaking on Gilbert’s Syndrome and diet. I have no idea if it an underlying cause of depression. Regardless, not fun to suffer from depression or the other symptoms you are experience. I can empathize with you and others who must endure these symptoms daily. I don’t know why MDs are not treating it and only diagnosing the problem. I’ll ask one of doctors and see if she knows anything. How frustrating for you!

      Joseph




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    2. Medical doctors diagnose but don’t treat the disease because it is considered a benign disease. That means that the disease doesn’t hurt you in the sense of causing serious complications or death. So money is not put into treating a disease that has no serious threat to human life. It would also be very hard to treat because it is a genetic disease and at this time we don’t have the ability to change specific genes for specific genetic abnormalities.
      And if depression is a symptom of the disease the only thing we can do is put in place things that we know help depression such as exercise, eating healthy, and counseling.
      A really good resource for looking up Gilberts disease is http://Www.Emedicine.com and type in Gilberts or unconjugated hyperbilirubinemia in the search engine. I hope this helps.




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    3. Hello! So sorry to hear about all that you’ve been going through :( It sounds like you are doing all the right stuff though! Agree with Hemo about putting things in place that act as a kind of speedbump for depression. Great that you are eating a whole food plant based diet-did you get to see this piece about greens and mood? It’s one of my favorites, and this knowledge also helps me stay motivated to eat dark leafies at least once a day. It is really a commitment ;0, but I’ve noticed an improvement in my own mood since adding daily greens. Also, my first job out of school was in GI at Mayo. We always told our Gilbert’s patients to avoid fasting (to reduce any stress on the liver). Just thought I’d pass that along in case it could be helpful(?)




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      1. I didn’t even think about that part about not fasting regarding the liver and stress. Thanks for the input! I also agree about the daily greens!




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      2. Hi Jen,
        Just for a bit of clarification for “Guest.” What is considered fasting? Should he/she eat small meals all day? Let’s say every 2 hours?




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        1. Hi Veganrunner! Good question. Did a quick check of the literature. No specific time intervals given. So even though “grazing” (eating every 2 hours) intuitively seems like a good idea, I couldn’t find any science to back it up. But in addition to not fasting, as far as meals go, Gilbert’s patients shouldn’t even skip meals. So if running late and planning to skip breakfast or working through lunch, a Gilbert’s patient should carry some food (fresh fruit, veggies, nuts, or seeds for example) with them, so that they never get stuck in a situation of unintentionally making the liver work harder and therefore accidentally increasing bilirubin-which can lead to those jaundice flares.




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  5. A plant based diet combined with an efficient exercise routine dragged us from a depressive slump so we completely agree! Not only does exercise boost your mood, it can also help boost your energy levels. We regularly go for a short gentle run or perform a quick circuits routine to elevate energy levels. It really helps with productivity too – a lunch time jog can fire up your brain ready for afternoon work again. :-)




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  6. Just a note to remember that some people, who try to do all the right things, are helped enormously by medication for depression and anxiety. I am one of them :). Despite years of intense cardio exercise, healthy eating, relaxation and mindfulness practice, I still suffered from terrible anxiety. It took me a long time to try medicine (which I thought was a weakness), but it has changed my life. Today, I still exercise every day, eat well, am a devoted NutritionFacts reader and am grateful every day that medication to help with depression and anxiety exists. :)




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    1. Well said, Grateful. Thanks for sharing. We should never feel “weak” for taking medications that may help with mental health. If anything, feel empowered and strong that you took a stand!

      Best of luck and thanks for your devotion as a NutritionFacts reader! Let us know how we could improve this site.
      Joseph




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    2. I can so relate! After finally “resorting” to medication 10 or more years ago after a life-long battle with disabling depression and anxiety, I had almost forgotten how miserable life was before, until recently when I decided to try to wean off of it. Since I had drastically improved my diet and lifestyle since then, I was hoping to find I could manage without, and had a big ugly surprise in store shortly after stopping. Even though I had gone slowly, I guess it takes some time to clear from your body, and when it did, WOW, I bottomed out! There were so many mental and physical symptoms I thought I was dying at first, because of the delayed reaction I didn’t make the connection right away! I literally couldn’t get off the couch, even using the bathroom was a supreme challenge. And then it finally dawned on me what was going on, and needless to say I relented and took the quarter of the drug I had been maintaining for the longest time. By the next day it was like a miracle, I was expecting weeks! In fact, it actually woke me with the realization that the panic I was expecting didn’t occur, and I was finally able to sleep! Scary stuff! It literally felt as if some alien force had taken over my brain, just so weird and dark! Since I tend to somaticize, it makes it even worse, just a downward spiral! I’ve read of people having success taking certain amino acids and supplements to build up their stores of serotonin, etc., but that is almost as scary as the drug, and I just don’t have the funds for help! I hope I can at least stay at this lesser dose, but I just hate taking pharmaceuticals because we never know the long term side effects and I hate the idea of being so tied to something. But as you and my son say, be thankful that there is something for you that works, not everyone is that lucky!




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  7. Thanks for a great review of the potential contribution of exercise in major depression. What would make the data even more impressive (ideal studies in the real world are hard to come by) is a study with a true non-treated control, no Rx or exercise, as there is a propensity (natural history) for major depression is to improve for most. I realize that with Bipolar (I or II… rapid or slow cycling) and other variant depressions certainly variety exists in improvement rates…but having a ‘natural history’ group (certainly many people/patients resist Rx, Exercise or talk/cognitive approaches) would certainly lend causality (effectiveness of treatments) to improvements offered in your review. I was also struck by the implied resolution (< HAM-D < 7) even with the psychotropic Rx quoted, which also makes me wonder of the role of supportive care over time + the Rx. Thanks for providing peer reviewed data and seeking feedback and discussion. As Family Physician of 40 years the contribution of exercise to the whole lifestyle medicine approach certainly is one of the foundations in reducing a variety of chronic diseases,… thus is an essential to good health. Thanks again for your wonderful work. bcm




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    1. Thankfully there are doctors like you who take into account the importance of lifestyle medicine for their patients! I appreciate your comments. Hopefully more studies will be conducted using better controls, as you mentioned.




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  8. Cardio exercise has been a life saver for me for my depression, especially since side effects from the drugs meant I couldn’t take them and affordable talk therapy (which has worked in the past for me) was not available. It’s best to do it in the mornings so you get the full mood boost throughout your day rather than partially through your sleeping. And despite the fact that there are lots of articles claiming that ANY exercise will help (eg just take a walk around the block) from my experience that is not true. You have to get your heart rate up into the target cardio zone for at least 20 minutes in order for the deep anti-depressive effect (high intensity exercise doubles the release of brain endocannabinoids for example) to occur. After that type of exercise I literally feel like I have a new brain. A great book to help depressed or anxious people get themselves to exercise for life is ‘Exercise for Mood and Anxiety’.




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  9. Interesting research. Re: Gilbert’s Syndrome (it isn’t actually a disease). It is generally considered a benign condition not requiring treatment and, in fact, may actually confer health benefits. It is characterized by a mild increase in bilirubin. Bilirubin is a potent antioxidant so having a little extra floating around may be a good thing. There has, in fact, been research into developing a drug that would elevate bilirubin serum levels. I, myself, have Gilbert’s Syndrome, with a total bili ranging between 1.5-2.0. It is highly unlikely to be the cause of the writer’s depression..




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    1. I suggest that you do a little homework, Doctor. The illness is called both a disease and a syndrome. It was called a disease when I was diagnosed, but later it started to be called a syndrome more frequently, probably because doctors want to minimize it as a problem for whatever reason. It may be that they don’t know how to go about treating it, don’t like the vagueness of the symptoms or don’t want to bother with something that they may not succeed at. But when the whites of your eyes turn orange, your skin turns yellow, you experience excrutiating stomach pain, you have explosive diarrhea, you’re so lethargic or depressed that you can barely get out of bed, your bilirubin levels are sky high-not the mild levels you report, then the thousands of people who are on Gilbert’s forums would beg to differ with the medical establishment as to how benign it is.




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  10. When I interviewed for medical school, the only question I asked was, “Do you have an exercise facility?” This was in 1966, when the term aerobics had not even been coined. Started commuting by bike as a sophomore in college, and continued throughout my professional career. Always kept my bike in my office so my patients knew I practiced what I preached. I called it my pscyle-therapy. Sometimes after a long day in the OR riding home late at night, I thought I must be crazy, but always felt better after the ride.




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  11. Another comment I would make is that healthy lifestyle habits benefit every organ and physiologic process, so it isn’t surprising that exercise improves mental health just as it does physical health. The same holds true for diet. A whole food plant based diet benefits every cell in the body. I liken the human body to a finely-tuned automobile. A car will get you from point A to point B just by filling the fuel tank. You don’t need to wash it, check the tire pressures, or even change the oil. It will still run, but it won’t look good, feel good, or last very long. I try to treat my body as well as I do my Mustang Boss 302. Best tires, best synthetic oil, always immaculate. The anti-aging program for my car is basically the same as it is for my car. Oh, and I exercise it daily.




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  12. This subject really piqued my interest and the thought occurred to me as to what effect exercise might have on BDNF (brain derived neurotrophic facter). BDNF is a substance critical to optimal brain health and function. It is reduced in response to chronic stress and has been found on autopsy to be lower in the brains of depressed individuals than non-depressed ones. All modalities of treatment for depression, including antidepressant medication, transcranial magnetic stimulation, electroconvulsive therapy, and vagal nerve stimulation increase BDNF. And, to my surprise (only because I never looked until now) so does exercise. Fascinating. But, enough research. Time to rumble outta here.




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    1. As one might expect, the process of neurogenesis is controlled by our DNA. A specific gene codes for the production of a protein, brain-derived neurotrophic factor (BDNF) which plays a key role in creating new neurons. Studies reveal decreased BDNF in Alzheimer’s patients, as well as in a variety of neurological conditions including epilepsy, depression, schizophrenia and obsessive-compulsive disorder.

      Fortunately, many of the factors that influence our DNA to produce BDNF factors are under our direct control. The gene that turns on BDNF is activated by a variety of factors including physical exercise, caloric restriction, curcumin and the omega-3 fat, DHA.
      This is a powerful message.

      Dr Perlmutter’s 4 part plan.
      And there was no mention of having butter in coffee or eating a grass fed cow. Thank goodness, I started doing all 4.

      http://www.huffingtonpost.com/dr-david-perlmutter-md/neurogenesis-what-it-mean_b_777163.html




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  13. Looking at the second study, the point estimate for drugs was greatest for depression remission, although the error bars all overlap each other.




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  14. “Patients receiving active treatments tended to have higher remission rates than the placebo controls: supervised exercise = 45%; home-based exercise = 40%; medication = 47%; placebo = 31% (p = .057).”




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  15. From my personal experience, I believe that American’s sedentary ways are a consequence of early stage vascular disease. Before my plant-based transition, exercise was difficult for me even though I was not carrying a lot of extra weight and was only in my mid-thirties. I believe as pre-diabetes and vascular disease slowly progress, Americans get more and more sedentary (exercise intolerance increases) and, most blame it on normal aging. I believe for many it is actually the slow but insidious vascular disease and, for some, vascular disease and diabetes taking its toll. This lack of exercise due to depleted vascular, mitochondria and insulin sensitivity/function puts Americans at risk for depression and mood disorders, along with Alzheimer’s disease.




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  16. I have a feeling we’re not supposed to be sedentary and meant to be active. Moderate cardio work seem to work best personally.
    If I skip it for more than 3 days the lethargy , grumpiness and pessimism sets in.
    Also prior to going whole food, I found that food containing MSG affected my coordination and mood quite badly.




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  17. Unfortunately, this isn’t the case for all depression. I have dealt with chronic depression (2-3 serious bouts per year lasting weeks to months each) for my entire life, and during the most intense period I didn’t have a car, so I rode my bike everywhere. Loads of exercise (10 minutes at a time of high intensity aerobics twice a day, 5 days per week… going to work) and still severely depressed. It’s worth a try, but it’s not a sure-fire cure.




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      1. It’s possible that it’s environmental, but it’s very predictable. It starts every year between mid February and late March. Sometimes it hits again in the summer, and nearly always again around the holidays. It could be that when I’m not depressed, I tend to eat foods that contain heavy metals and when I get depressed, I stop eating those foods and my body clears them out. I haven’t been tracking what I eat for very long. I’ve been focusing on not scheduling critical things around times of the year I know I won’t be at my best, and trying to avoid being bored when it hits… Idle minds are dangerous even in the best of times… Or is that just me? :)




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            1. Your body is probably detoxing some mercury then, it happens for at least 6 months after a removal, you should feel better in few months/years if not you could try some safe chelation therapy like Cutler protocol?




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    1. I cycle everywhere too and I agree that it doesn’t work unless you do crazy mileage and fast. For me, I need to sweat and do intense cardio of some kind, maybe combined with weights or a good swimming session. I work out at home to videos and it works, especially in the morning, it puts my mind in a different gear.




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  18. Depression is a serious and in some cases a life-threatening disease. Sometimes drugs are necessary – and given to the right patient they can be very effective. Keep in mind that antidepressants dont work against dissatisfaction with life.
    On the other hand nature has provided us with some natural substances
    that can help fight depression – eg curcumin – probably due to the anti-inflammatory properties – neurotoxicity and chronic inflammation are likely to play a role in the development of depression. Maybe the true mechanism of action of SSRI is anti-inflammatory properties.




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    1. When I was taking an anti-depressant, it increased the depression to the point I was suicidal 99% of the time! I have since stopped the drug and found a sharp decrease in the symptoms. Now, I choose exercise instead of taking an anti-depressant and find that exercise does help, not always dramatically but sometimes, I just need to get over that “moment in time”.




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  19. You should have talked about the difference between the side effects of the drugs and exercise. How terrible the side effects and the dependency that anti-depressants cause.




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  20. Plant-based diets and exercise can be great for mood disorders. The wisdom of traditional cultures also included fermented foods, antibacterial spices, meditation and other relaxation respnse traditions to create mental and physical well-being. We are just beginning to explore beyond the tip of the iceberg of mood disorders and the bidirectional influence of our gut and brain. Healthy plant based diet with food-based probiotics and prebiotics, meditation, avoiding any food sensititivities, and adequate sunshine may all contribute to a real vs placebo effect to successfully treating both depression and anxiety. Many folks with lactose intolerance, celiac and other food allergies or intolerances attest that eliminating the intolerant food can completely obliterate their anxiety or depression. The gut- brain connection is strong and bidirectional. Meditation can do wonders, particularly, improving mood and lowering blood pressure.




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  21. Hi, thank you for the video. I can relate to this as I get most depressed when stressed and eating poorly only magnifies the vicious circle I get in. Would you be able to comment or make a video on using different Aminos like Inositol or Glutamine with magnesium as treatments?
    Thanks
    Ant




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