Exercise therapy improves both mental and physical health in patients with major depression. Although several characteristics of the disease (eg, loss of interest or lack of pleasure) interfere with participation, motivational strategies incorporated into exercise interventions can promote adherence [Knapen J et al. Disabil Rehabil. 2014].

Kirk Bergmark, APN, PMHCNS-BC, Palos Medical Group, Palos Heights, Illinois, USA, addressed how exercise can be successfully integrated into the treatment plans of patients with depression using evidence-based recommendations and connections with health and fitness facilities.

Mr Bergmark reports that exercise increases levels of the same neurotransmitters targeted by antidepressants: norepinephrine, dopamine, and serotonin. Optimal levels of norepinephrine stimulate a sense of well-being. Dopamine is associated with the reward system of the brain, and serotonin is associated with regulating mood, appetite, and sleep.

Improved transmission of dopamine and norepinephrine together strengthens compliance with prescribed physical activity in patients with depression and residual fatigue [Stenman E, Lilja A. Med Hypotheses. 2013]. Exercise may also benefit the brain by enhancing neural plasticity [Silverman MN, Deuster PA. Interface Focus. 2014] and expression of growth factors, such as the brain-derived neurotrophic factor [Phillips C et al. Front Cell Neurosci. 2014].

A substantial body of evidence supports the value of exercise in the treatment of people with depression [Stanton R, Happell BM. Issues Ment Health Nurs. 2013]. Mr Bergmark's prescription calls for 45 minutes to 1 hour of aerobic activity (eg, walking, running, swimming, or cycling) for a minimum of 3 to 5 days a week. Intensity should be low to moderate to start, with an increase to a moderate level over time.

Collaborative arrangements with a health and fitness center willing to support prescription recommendations and provide incentives (eg, a free 1-week pass) and follow-up (eg, ongoing assessment) can help patients start exercising. Use of evidence-based counseling can promote behavior change and adherence.

Motivational interviewing, a form of collaborative conversation in which clinicians elicit and explore a patient's own reasons for change, is an empirically supported counseling style that strengthens a patient's own motivation and resolve [Zuckoff A. Surg Obes Relat Dis. 2012]. Rather than telling patients what to do and how to do it, clinicians invite them to share the doubts, reasons, and concerns that make them uncertain that they are ready to change. By understanding and accepting those reasons, they can then ask patients to explain why they might want to change, the potential benefits as they see them, and how adherence would be consistent with what they care about or value most.

In the context of motivational interviewing, it becomes possible to elicit a commitment to change, which, in turn, predicts new behavior [Amrhein PC et al. J Consult Clin Psychol. 2003]. Ultimately, the decision to exercise despite depression is a byproduct of a clinician-patient partnership, a relationship based on trust. It is an alliance that encourages and supports a patient's choice to adopt a lifestyle that serves his or her own best interests.