Depression and paying for pills or exercise

Last night in the Super Tuesday open thread,  Iowa Old Lady  told us about her evening plans:

I go to the gym because it’s supposed to fight my depression, but lately I’ve come to believe that I’m depressed because I have to go and “feel better” part is that I’m so happy it’s over.

This morning I just got out of a meeting with an accountable care organization that is brainstorming on ways to get some of their behavioral health and co-morbidity health and cost risks under better control.  The big suggestion from some of the Primary Care Providers (PCP’s) and master level clinicians was getting some of these individuals into personal training classes to do something fun.  The theory of change was a combination of increased social connectives and increased physical activity will have direct and indirect medical gains which leads to better health, lower pharmacy costs and fewer infrequent but high cost acute events.  Their revenue model is a modified capitation model with gain sharing, they can pay for dance classes, weight lifting classes, gym memberships and yoga instructors without having to justify the expense on a claim.

There is a long history of research that shows moderate exercise is at least as good as common Selective Serotonin Re-uptake Inhibitors (SSRI’s) in managing depression.  The  Atlantic from 2014  has a good summary:

Depression is the most common mental illness—affecting a staggering 25 percent of Americans—but a growing body of research suggests that one of its best cures is cheap and ubiquitous. In 1999, a randomized controlled trial showed that depressed adults who took part in aerobic exercise improved as much as those treated with Zoloft. A 2006 meta-analysis of 11 studies bolstered those findings and recommended that physicians counsel their depressed patients to try it. A 2011 study took this conclusion even further: It looked at 127 depressed people who hadn’t experienced relief from SSRIs, a common type of antidepressant, and found that exercise led 30 percent of them into remission—a result that was as good as, or better than, drugs alone…

this powerful, non-drug treatment hasn’t yet become a mainstream remedy. In a 2009 study, only 40 percent of patients reported being counseled to try exercise at their last physician visit.

Instead, Americans are awash in pills. The use of antidepressants has increased 400 percent between 1988 and 2008. They’re now one of the three most-prescribed categories of drugs, coming in right after painkillers and cholesterol medications.

A gym membership with personal trainers and potentially day by day incentives for people to go to the gym may make a lot of medical sense and even more financial sense.  However under a fee for service model, reducing pharmacy costs because people were able to step down their SSRI dose or eliminate it entirely was probably a net money loser for the PCP.  The doctor had to spend more time initially with the individual and talk through the program, and then there would be fewer follow-up visits to monitor progress and adjust prescriptions.  Instead, it was easier to write a script, mention that exercise is a good thing in the last thirty seconds of the visit, and then schedule a follow-up in three months to see how the new SSRI dose is working for that individual.  A personal trainer could not bill. and the doctor could not collect any of the savings from deferring pharmacy costs.

The incentives change on risk capitation models as the personal trainer still can not bill the insurer directly, but her salary is paid by the provider office.  A personal trainer at $50 to $75  an hour in total costs  is far cheaper than a PCP at $180 to $250 per hour.  That $50 to $75 an hour is paid for by the savings incurred from lower pharmacy spending and fewer acute medical events.  Plus the patients get into better health/wellness.

Things like this is why I am fundamentally optimistic about health care reform in the United States.  This is not genius level work.  It is basic work and rejiggering of incentives to avoid being stupid.  We have several iterations of being less stupid before we actually have to get too smart.

85 replies
  1. 1
    aimai says:

    I read a fascinating article about–Norway? maybe. About how excercise was simply built into the work day, with employers sponsoring not just gyms but ski trips, employee sports teams, and time to go to the gym on a weekly basis. One of the biggest differences is that people were expected to go, enjoy themselves, socialize, and just fully integrate excercise and movement into their entire lives. Rather than,as here, sports and sports socializing being something that starts in school, is in abeyance or becomes purely couch potato-y in adulthood, and then is something somewhat punitive when it is taken up to “correct” years of inactivity.

    I love having a personal trainer, when I have one. But I would love it more if my local gym where someplace where I met my friends.

  2. 2

    @aimai: One of my non-proven thoughts is that the physical structure of the American built environment discourages interaction and discourages casual physical activity where it is just something that you do.

    I remember when I was living in Paris, I was easily walking eight to ten miles a day to go to class, to grab a glass of wine, to get laid, and to basically live an interesting and fulfilling life. And that walking was part of the background of my day instead of something that I had to do. After my time in Paris, I was probably at my lowest age adjusted BMI in a decade despite eating some of the best food I’ve ever had…

  3. 3
    raven says:

    I’ve always been a gym rat being a coaches kid and then having a career in parks and rec for many years. I am relegated to swimming and the exercise bike now since the wheels are shot for hoops or running. I’m fascinated by the folks that have personal trainers and this whole “boot camp” scene that people claim to enjoys much. In running and swimming I always found that the first 5 minute or so were the most difficult but one I hit the groove it was fine. Wish more folks were self-actualized. I’m off to to pool.

  4. 4
    japa21 says:

    It’s actually been known for a long time that physical activity is a natural anti-depressant. Back in my days as a mental health counselor it was something that I was pretty consistent in recommending to my clients.

    However, much depends on the type of depression and the depth of the depression. Depression is a tricky thing to diagnose properly. There is reactive depression where events trigger the depressive episode. Treatment for this is developing better coping mechanisms and developing better abilities to recognize the true impact and seriousness of events.

    At the opposite end of the depression scale is the severe, biologically caused depression. Although physical activity can have an impact, medication is almost always required.

    Sometimes even reactive depression can be severe enough to impede someone from participating in physical activity or even doing normal counseling. In those cases, medication can serve as a brief bridge to help someone get out of the deeper depressive level and to a level where both counseling and physical activity can take over.

    I guess my point is, it is difficult to use the term depression as an overarching diagnosis and state one way or another what would be the most effective treatment, not that I am implying you are doing that Richard.

  5. 5
    raven says:

    @Richard Mayhew: We only walk two miles every morning but it seems to help!

  6. 6
    Big Ol Hound says:

    May I suggest that the definition of “depression ” has also caused more of same. Being in a foul mood or upset about about your status in life for a few days a month never was considered unusual until it was decided by some mental health “experts” that we should be happy all the time. No shrinks around small towns as I was growing up. Big diff between clinical depression and not being cheerful all the time.

  7. 7
    BGinCHI says:

    @aimai: I’m in Norway for this whole academic year (on sabbatical, with Mrs. BG on a Fulbright), and I’d say that’s perfectly accurate. This is a country that loves its outdoor exercise, though not necessarily in a crazy, competitive way. Yes, the Norwegians love to race and compete, etc., but its more of a cultural habit to be outdoors for reasons of physical, mental, and, I would say, spiritual health.

    There is a running joke around here. Guy/gal goes to see the doctor about something (anything, really) and the doctor says, Hmm…have you tried hiking in the mountains more? Or guy/gal goes to seek therapy and the therapist says What are you doing here? You need to go for a walk in the mountains.

    Like many such jokes, it’s pretty accurate in terms of how people think here, perhaps to a fault.

  8. 8
    Dewey Crowe says:

    As someone who has suffered from depression for many years, I can share my personal story. After years of being on and off medication and being told by my therapist that exercise may help (I was moderately active but had become quite sedentary as I got older, had kids, etc.), I finally hit the gym….hard!

    But here’s the thing- I lost 40 lbs, got into the best shape of my life at age 50, and people everywhere were complimenting me on how great I looked. And after two years I still felt like crap. What exercising never gave me was the boost in my mood to carry me through the rest of the day. I felt tired whenever I wasn’t at the gym, and additionally I would beat myself up when I missed a workout (I went 4 days a week, so I wasn’t overdoing it).

    I still work out, but I’ve given up hoping that it would be a cure or help me manage my depression. I know I’m just one example, and maybe not the norm, but I would not recommend exercise as an alternative to mental health treatment, but a supplement to it.

  9. 9
    BGinCHI says:

    As a serious cyclist who does group rides 2 or 3 times a week, I’d say this is a terrific way to get exercise, apart from how hideously hard it is. The combo of workout plus social time is ideal.

    If you can just get some friends together and bike somewhere, though, it might be way better than being isolated at the gym.

    I’m amazed more people don’t do this.

  10. 10
    Rafer Janders says:

    @Big Ol Hound:

    No shrinks around small towns as I was growing up.

    Yes, and those small towns were riddled with depression, alcoholism, suicide, abuse, neglect, and untreated mental health disorders.

  11. 11
    Baud says:

    I feel better immediately after exercising, but it doesn’t last long enough.

  12. 12
    Patience says:

    When I was in school (ElHi, college, grad school), and for a short time thereafter, I was very athletic. I played all kinds of sports – field hockey, basketball, softball, ran track, rugby – and was religious about going to practices. It was pretty much always the highlight of my day.

    Today I’m pretty sedentary, for a variety of reasons (lack of money, so no gyms for me; I’m in a neighborhood full of idiots who give me a hard time when I walk, usually about either politics or the machinations of our asshole HOA board) I’m currently the sole breadwinner in our household, so I’m usually on the computer either doing work or looking for more work).

    But I have to say, my No. 1 reason for not exercising is … I just don’t enjoy it. I have NEVER liked working out for its own sake. There were times in the past, back when I had a steady income, that I belonged to a gym – but what made it bearable was picking up my work best friend at 6 a.m. and going to the gym before going to the office. When she couldn’t do it for some reason (a commitment with her daughter’s school, for instance), I rarely went alone.

    I’ve looked, and there are no organized teams/leagues in any sport for women over 40 in my area (and while I’m a pretty fair distance beyond 40, I’m still strong and coordinated). I don’t want a solitary activity – I’ve got too much solitude in my life already.

    Suggestions? Preferably that don’t require cash expenditures?

  13. 13
    Kylroy says:

    @Rafer Janders: Yes, but you didn’t hear about it, and that’s what matters.

  14. 14
    Redshift says:

    @Big Ol Hound: I can’t agree. Professionals know that depression isn’t the same thing as “being unhappy,” it’s only in layman’s terms that both are referred to as “being depressed.” For the most part, the people I hear complaining about people being given “happy pills” are the ones who don’t want to believe that depression is real, and think those with it should just “cheer up.”

  15. 15
    WereBear says:

    @Rafer Janders: Yes, and those small towns were riddled with depression, alcoholism, suicide, abuse, neglect, and untreated mental health disorders.

    Peyton Place

    King’s Row

    Tobacco Road

  16. 16
    WereBear says:

    @Patience: Can you walk somewhere else?

    “Cardio” is becoming recognized as often counter-productive, especially for people who struggle with it. Increases cortisol, stress on joints, etc.

    A weight set pays for itself and can be much more effective in toning and blood sugar control. Lowers that bane of modern life, insulin resistance.

    And you can’t be the only one in this particular boat. Is there a way of doing Craigslist ad or other way of meeting someone like yourself who would like to do some activity but is not up for teams and such? Maybe even someone in your neighborhood? Two or three could fend off unwanted chatters better than one… who looks so lonely!

    My problem in my suburban Long Island neighborhood was that everyone stopped and wanted to give me rides! Because the only reason for walking is if the car broke down…

  17. 17
    Eric U. says:

    I used to take pills for depression, but they didn’t really work for me. Probably because depression is an early symptom of Parkinsons, which seems to be genetic and all of my male relatives on my father’s side had it. But anyway, I like to exercise, and it does really help me a lot. I don’t feel like I need to take pills.

    Obviously, pills help a lot of people, I’m just not one of them. Same can be said for exercise, it doesn’t necessarily help.

  18. 18
    Eric U. says:

    Depression can certainly be debilitating, and it’s dangerous how we diminish people for seeking help. My retinal specialist used to talk to me like I was a child because I had told them on the intake form that I took anti-depressants. WTF that had to do with having a major flaw on my retina, I have no idea. I have had other medical people treat me the same way for that reason, now I don’t mention previous anti-depressant use. I wish I could get medical care from people that are smart enough to know what is up with physical conditions like depression, but in the interim I’ll have to help out

  19. 19

    Coincidentally, I just got back from the gym and am feeling pretty good.

    A number of older people at the Y have their membership paid by whatever supplementary health insurance policy they buy. There’s a class called Silver Sneakers that gets paid for, and apparently UHC just started paying memberships too.

  20. 20
    Scout211 says:

    I am retired now but worked in the mental health field for 40+ years.

    Changes like you are suggesting (more therapy and lifestyle changes, less medication) may have to come from the insurance industry.

    In my experience, physicians were resistant to methods other than prescriptions. And insurance companies were extremely resistant to something other than a few sessions of cognitive therapy.

    I hope things do change because I have been concerned for years about doctors over-medicating their patients and resisting therapy and lifestyle changes as part of their treatment plans.

    But unfortunately, the insurance industry has a great deal of control over treatment protocols in mental health. And I hope the industry makes these changes for something other than cost control.

    Like maybe, for the good of their insureds.

  21. 21
    p.a. says:

    Don’t forget the only social benefit of America’s retail mall phenomenon: early opening for walkers (some for 6am most by 7- can work for 9 to 5ers). For those days when it’s too hot cold wet etc to go outside. The demographic there can give you advice on Medicare issues ;-)

    My past work schedules allowed both am &pm walks. The am pre-work crowd was generally pleasant and we exchanged greetings when passing. The after-work folks, it was unusual to even get eye contact. Generally just seemed beat down. It’s a feature, not a bug, of how our system has been perverted the last generation or 2.

  22. 22

    @japa21: Thank you for that term “reactive depression”. I’m going to have to do some research.

  23. 23
    Renie says:

    My biggest issue is motivating myself to do something. When you work all day the last thing you feel like doing is exercise. Since I’m not a morning person, no way can I do it before going to work. Can’t even walk to work cuz it’s too far for walking.

  24. 24
    boatboy_srq says:

    @Richard Mayhew:

    After my time in Paris, I was probably at my lowest age adjusted BMI in a decade despite eating some of the best food I’ve ever had…

    This is something that the self-contained, automobile-dependent US lifestyle misses completely. In the US’ rush to the suburbs, and the fixation on motorized personal transport, so much otherwise-normal activity gets lost. All the heavy, otherwise-fattening food Europeans eat gets worked off in daily life: for a US resident to achieve the same s/he needs either a walkable community (a rarity) or hours in a gym every week – a gym that is strictly for exercise and where socializing is frowned upon (in no small part because “socializing” and “flirting” are barely distinguished in the US gym scene, and where “getting hit on at the gym” is an expectation rather than a surprise). One more thing to blame the US’ shame-obsessed founding principles for: exercise, particularly communal exercise, is viewed less as therapeutic and more as an effort to become more attractive, and any interactions in a non-professional venue are viewed through the lens of lechery instead of community.

    This probably goes hand-in-hand with the difficulty trans equality has: the “bathroom” question is so significant to Reichwingers in part because in their minds gyms (where lockers and toilets are fiercely segregated and privacy-rich spaces) are thinly disguised brothels/bathhouses, and interactions with others there are perceived as more sexual than social.

    The trouble with the US exercise model is that it can feed the depression the act of exercising can alleviate. Being surrounded with other people, each one locked in his/her individual personal space complete with headphones and personal TVs on the cardio equipment, inhibited from reaching out for fear of having interaction being mistaken for innuendo and all surrounded with mirrored surfaces which invite often unflattering physical comparisons with one’s fellows, is overwhelming. Conversely, the presumption that someone interacting with you is some form of sexual advance comes all too easy – although the lack of the same reinforces negative body image and lowers self-esteem. The entire gym construct (as expressed in US architecture and society) seems geared toward making people feel bad, even as it is marketed as making people feel good.

  25. 25
    cmorenc says:

    A HUGE factor in whether people are positively vs negatively attuned to physical exercise is how comfortable and familiar they are with the rewards of “pushing through” the initial discomfort and fatigue of attaining a good baseline of healthy conditioning – where they can feel gaining strength and endurance instead of merely soreness and fatigue and begin associating some of the latter with the former, instead of just a disagreeable eat-your-turnips type of experience. People who aren’t accustomed to sustain pushing through that wall long enough to experience the rewards of the other side have difficulty sticking with any exercise regimen.

  26. 26

    @boatboy_srq: I am comparing American gym culture to those pictures of hundreds or thousands of people in Asia doing tai chi in park as a regular part of their day, and it suffers in the comparison. Granted, no one is going to get huge doing tai chi in a park, even if they do it for an hour every day, but they sure as hell are getting in a good stretch and light to moderate calisthenics that most reasonably healthy people could benefit from, and still do daily well into their 60s or 70s. That’s what I need. Regular exercise that isn’t competitive. I realize everyone is different, but for me, competition ruins everything. It can take a pleasant bike ride and turn it into a race where everyone is exhausted and everyone but the winner is miserable at the end.

  27. 27
    WereBear says:

    @boatboy_srq: The entire gym construct (as expressed in US architecture and society) seems geared toward making people feel bad, even as it is marketed as making people feel good.

    The end game of the marketed society, perhaps?

    When “community” becomes something that is sold to you.

  28. 28
    Jim, Foolish Literalist says:

    I worked with a trainer for a couple of years. He was smart, I trusted him to stop me from hurting myself and he was reasonably personable. After about six months, he was remarking happily, as he did from time to time, that I was so much stronger than when we started, than at the beginning of the month, etc. Since it seemed to mean a lot to him, I managed what I’m told is my transparently fake smile and mouthed something about “yeah, that’s great”. His smile fell and he stared at me for a beat and said, “You really don’t care, do you?” and I told him: I’m only here to avoid type 2 diabetes and having to buy a new wardrobe. He didn’t quite get it but he accepted that we had very different worldviews.

    I like hiking, biking and X country skiing, but those are weather dependent and time-consuming. Swimming is great (hard but effective) but all the pools near me are too crowded. Gyms make this introvert feel claustrophobic. Right now I’m just trying to get back into walking two or three miles a day before the weather becomes (and other circumstances) more cooperative.

    and exercise doesn’t seem to help my mild but persistent depression as much as gaining weight makes it worse

  29. 29
    Luthe says:

    @japa21: I second all of this. While the strategy of encouraging exercise is a good start for those with new onset depression or “mild to moderate” depression, it’s not something that’s going to work for a severe episode or those of us on our fourth or fifth (or tenth or twentieth) year of chronic depression. Sure, it might *help* a little, but it’s not going to replace our need for anti-depressants and therapy.

    This isn’t even touching the people with social anxiety who would balk at the very idea of going to the gym and interacting with that many people, or those who use a significant amount of their willpower for the day just getting out of bed and are lucky to make it as far as the grocery store.

    In short, this is a strategy that will save insurance companies money on a select sub-group of patients, but won’t really change much for the chronically ill ones.

  30. 30
    Trabb's Boy says:

    I am only now coming out of a major depression with the help of inpatient doses of antidepressants. While waiting for them to kick in, my doctor kept pushing exercise and it was hell — yet another thing that I couldn’t do and was being judged on and had to feel guilty about. It nearly made me stop going to the doctor altogether.

    These “wow, it’s so easy” treatment ideas that require extensive work on the part of a patient may help some, but not everyone is able to do the extensive work, given all sorts of life factors. Where the advice does not help, it may cause significant harm. The entire weight loss concept has this flaw as well, with the simple “eat less and exercise more” advice sometimes triggering eating disorders and frequently resulting in stress and lower self-esteem.

    These are two areas where doctors need to listen to the patient about potential side effects.

  31. 31
    Luthe says:

    @WereBear: Too late! Developers and realtors do this already, especially with New Urbanist and retirement communities. I wrote my undergrad thesis on it.

    Modern capitalism and advertising is a game of solutions in search of problems. Happy people don’t buy vacuums or gym memberships or prescription pills. People with dirty floors, bad self-image, and over-hyped medical problems do. And so the marketers convince us we have endless problems so we will buy the products that fix them.

  32. 32
    raven says:

    Nice, this thread helped me swim just a little harder!

  33. 33
    Baud says:

    Happy people don’t buy vacuums

    Wait, what?

  34. 34
    Soprano2 says:

    I found that the key to exercise is finding things you enjoy doing. I do a combination of Zumba and BodyPump classes, yoga once a week and some walking on the weekend. I have done a weight routine in the past, and sometimes I have to use the elliptical, but I hate it when I do that. Listening to podcasts makes it bearable, but if I had to do that all the time I would hate it. I like the community of taking a class, and it also means I have to show up at a certain time so there’s no “well, I can do that tomorrow” kind of rationalizing skipping a workout.

  35. 35
    No One You Know says:

    @Baud: I hear that.

    Depression is a real thing. The two best descriptions I have ever read about how it feels tho the sufferer…not how it looks to the “judger”…are in David Wallace Foster’s Infinite Jest and William Styron’s Darkness Visible. Kate Gombert’s interview with the intern shows something true about the gap between what a clinician is taught to do, and how it feels to be cared for that way. Styron’s first person account of how it’s possible to lose a $25,000 prize at the dinner table while hiding his affliction and explaining away what’s becoming visible to his surprised hosts is another useful window on what it is to be in these shadows.

    I’m hoping Baud! 2016! will be able to elevate these concerns in the platform. Or at least help diagnose communal psychosis in politicsl parties.

  36. 36
    raven says:

    @No One You Know: It’s worth it to read the book Styron’s daughter wrote.

  37. 37
    boatboy_srq says:

    @BGinCHI: There’s a very strong disincentive for cycling from the Reichwing: anything besides one’s very own automobile is to them betrayal of the Ahmurrrcan Dream. Consider how many cycling-specific initiatives that have been rejected or unraveled because someone insisted that bicycles were a Sign of the Socialist Apocalypse.

  38. 38
    satby says:

    I love to walk and used to go frequently when I lived in Chicago. It didn’t keep me from becoming overweight, but now that I live in a very non-walkable rural area I gained much more weight. I’m looking forward to living in a more urban area again, though I probably will have to take walks at 2am to avoid the Florida heat.
    Right now the pneumonia I’ve developed from the cold I had last week thinks it’s walking pneumonia, since I have to keep doing stuff anyway.

  39. 39
    SuperHrefna says:

    @Trabb’s Boy: Oh how I feel you. I’ve suffered from major depression since childhood, and one of the things I know is that I am much more vulnerable to it when I am tired. So while, on a good day exercise helps me a lot, on a bad day it can push me over the edge of tiredness to where the black dogs of depression live. Just this morning I made the decision to get more sleep instead of going to morning yoga and while I *know* this was the right choice for me, today, I still feel anxious about having made the Wrong Decision and ruined everything.

  40. 40
    boatboy_srq says:

    @WereBear: Ah, so you’ve seen One Loudoun, eh? You should SEE the “gym” that’s in that “community”: personal TVs on each cardio machine, a “spa” (for the ladies, natch, so she can get her hair and nails done while he works out) and a kiddie section (daycare for your kids while you work out, so you can focus on YOU! Whodathunk).

  41. 41
    liberal says:

    There is a long history of research that shows moderate exercise is at least as good as common Selective Serotonin Re-uptake Inhibitors (SSRI’s) in managing depression.

    Fact is that SSRIs are only very slightly more effective than placebo; see The Emporer’s New Drugs. Guy even claims the empirical evidence that started the whole “amine hypothesis” is incredibly weak.

    IMHO exercise is important for someone who is depressed, and maybe could even cure an extremely mild case of depression, but is very unlikely to be a stand-alone cure for cases worse than that.

  42. 42
    liberal says:


    Modern capitalism and advertising is a game of solutions in search of problems.

    LOL. That describes about 98% of what Silicon Valley is working on.

  43. 43
    WereBear says:

    @boatboy_srq: I have not seen that, but ones like it.

    Even “journalism” is just a marketing arm now… are you microwaving that kitchen sponge/eating this one weird thing/killing yourself with that burger?

    And… are you hoarding enough gold?

  44. 44
    Steve in the ATL says:

    @Rafer Janders:

    Yes, and those small towns were riddled with depression, alcoholism, suicide, abuse, neglect, and untreated mental health disorders.

    That pretty well describes my mother’s family in the Mississippi Delta. Just add some Southern Gothic to the mix.

  45. 45
    SuperHrefna says:

    @satby: Please take care of that pneumonia, remember it can kill. Is there anyway you can get the rest you need to heal? I know you have all kinds of drama going on but is there anyone you can call in to help you out?

    The thinnest I’ve ever been as an adult was when I lived in Cambridge (UK) which has laughably few buses so I had to walk everywhere. I like walking in towns and cities, it is interesting. When I lived in London I would often walk from my therapist’s office in Bermondsey, along the river and then up to Euston tube station, to get the tube home. It was a real treat. Now I live in the sticks in the USA and don’t walk much at all – lovely windy roads through woodland with no sidewalk or margin for error and drivers racing through like they are in a car commercial. Incredibly dangerous to walk on. A friend came for a stay from Edinburgh, and snorted with disgust that she couldn’t see anyone walking – she walked to the library *once* and then never again, saying she’d never been so frightened on a walk in her life.

  46. 46
    Tinare says:

    @Eric U.: I stopped noting prior bouts of depression in my medical history as well because it seemed to effect the way I was treated. I had an ER doc nearly fail to order tests to check my gallbladder (which, the surgeon who took it out told me was nearly gangrenous by the time I was diagnosed) because they didn’t seem to believe I was really in pain, and when I threw up, the ER doc told me that was just because I was so upset. I was crying because it was the third time that week that I woke up in the middle of the night in unbelieveable pain and the second time that week I went to the ER to be told that nothing was wrong with me. This was after nearly 5 years of this happening to me intermittently and being diagnosed with things like gas and going through GI tests that were all negative. The ER doc finally agreed to order a sonogram and it was done in a tone that let me know he was just doing it to placate me. I totally was treated like an hysterical woman making up pain to get attention or something. What was supposed to be out patient surgery ended up being a three-day hospital stay. Anyway, after that I figure that my struggles with depression are totally on a need to know basis when I deal with medical professionals. If it might effect the thing I’m there to see them about, I tell them, if not, it’s left off.

  47. 47
    gene108 says:

    Americans are awash in pills. The use of antidepressants has increased 400 percent between 1988 and 2008

    SSRI’s only became approved in the 1990’s, if IIRC.

    There were a lot of new classes of drugs for mental illness that got approved in the 1990’s, which might account for the increase, because there finally were products to meet a need.

    @Trabb’s Boy:

    I am only now coming out of a major depression with the help of inpatient doses of antidepressants. While waiting for them to kick in, my doctor kept pushing exercise and it was hell — yet another thing that I couldn’t do and was being judged on and had to feel guilty about. It nearly made me stop going to the doctor altogether.

    These “wow, it’s so easy” treatment ideas that require extensive work on the part of a patient may help some, but not everyone is able to do the extensive work, given all sorts of life factors

    I agree with this.

    There’s only so much a person can manage.

    If someone is mildly depressed maybe it would help, but with major depression it is not a cure all.

    Also anti-depressants can cause massive weight gain, which makes exercise harder.

    When I was committed after a suicide attempt, in 2003, I weighed 145 pounds at 5’7″. I was in O.K. shape. By June 2003 I weighed 165-170 pounds and by January 2004 I weighed 195 pounds. I’m now up to 215 pounds.

    Managing working and not losing my shit is hard enough. Exercise just became another stresser that I was “should do” and was failing at for not doing.

    Part of my problem is that I was in pretty good shape a few years* earlier, and it did help manage my depression, up to a point, but I wasn’t getting back to that level of fitness, which just made me feel more pathetic.

    Exercise can help, but it is not a cure all for people’s depression and can sometimes make people feel worse by causing stress for “failing” to do things correctly or not being as good as other people.

    * I had a major depressive episode after college, which was about 6-7 years earlier, and after I moved and took up a job out of state, one thing I decided to do was jog a lot more than I had and I think that helped improve my mood, but improving mood only gets you so far, without help in changing the destructive inner thoughts that can fuel depression. I went undiagnosed until I went over the edge years later.

  48. 48
    RaflW says:

    I definitely think there is an exercise-depression link. My challenge these days is that I mostly just like winter activities, snowboarding in particular. I struggle to find fun things that I’m willing to do repetitively from May-November.

  49. 49
    Kathleen says:

    @Iowa Old Lady: Yup. I have Silver Sneakers thru Humana Medicare Advantage. i have been going to the Y for about 30 years. and as one prone to depression my workout routine which includes running, strength and spinning has saved my life on many occasions figuratively speaking. I love going to the Y. I have met so many cool people and made great friends.

  50. 50
    Jim, Foolish Literalist says:

    @SuperHrefna: I saw Bill Bryson, American writer who’s lived in England for a few decades, was giving a talk on CSPAN about his time at I think Dartmouth as a Visiting Something. He was literally speechless trying to describe people who would drive half a mile to the gym, then circle the block looking for “good” parking space. I’m sure we’ve all seen variations on the theme.

  51. 51
    a hip hop artist from Idaho (fka Bella Q) says:

    @Eric U.: Among the didactics I present to 4th year psychiatry residents is on stigma. And for them it’s a presentation focused on stigma within the profession. They always report that they’ve experienced it both for their selection of specialty, with suggestions that they should have been “real doctors,” and in the way other docs threat the residents’ patients.

    I encourage them to push back repeatedly and forcefully, reminding other docs that these are physical, medical conditions and patients should be treated with as much care and respect as patients with chronic heart, lung or kidney disease. I could end up in a rant, so I’ll be careful.

    Tomorrow I teach on psychiatry and the law.

  52. 52
    Waldo says:

    @Patience: Get a bike. They are fun, easy on the joints and can get you places too far to walk to. If there’s a bike shop near you, there’s a good chance they will offer group rides. They will also be happy to sell you a bike, but I’ve bought my last two on Craigslist for under $200 and been very happy. I also have a spin bike at home (another Craigslist special), which I can tolerate for about an hour if I have a book to read or something to watch on Netflix. In my old age, I’m finding cycling to be the only workout that doesn’t beat me up. I hear the same is true of swimming, but I haven’t tried it. Good luck.

  53. 53
    gene108 says:


    Have you tried ?

    They have different groups across the country for a variety of things, including fitness. Maybe there’s one in your area?

    I’ve used this before to get out o the house and meet people.

  54. 54
    SuperHrefna says:

    @RaflW: I have the opposite problem, I love to swim and in season I will swim every day, but I only like to swim outside and since I don’t have a poll but do live on the north shore of Long Island, that limits my swimming to June-October when the Sound is warm enough for me. I try to swim at the local gym but it just isn’t the same.

  55. 55
    SuperHrefna says:

    @gene108: I second this suggestion – I recently signed up for after years of thinking about it and I have had some really nice experiences. I have a lot of social anxiety and one thing I like about Meetup is that it lets you learn a bit about the people who will be at the meetup ahead of time so you can learn names, etc, beforehand.

  56. 56
    debit says:

    @BGinCHI: Yep. It’s too bad that there not everyone lives in a place with good biking infrastructure. I’m lucky; Minneapolis is really progressive in that regard.

  57. 57
    a hip hop artist from Idaho (fka Bella Q) says:


  58. 58
    Mom Says I'm Handsome says:

    I’d read the research on SSRI’s being within the same effectivity range as placebos, talk therapy, and exercise, and was pretty down on them — until I had several bouts of reactive depression (mostly caused by divorce & family tension) and started taking them. It took three tries to get the right SSRI, finally settling on Wellbutrin (the sexual side effects of Prozac and Zoloft can be murderous, adding fuel to the depression by making THAT part of life also suck; Wellbutrin works a different neurochemical pathway that leaves your junk alone). Consider this one anecdatum that antidepressants DO work.

    Richard wrote:

    A personal trainer at $50 to $75 an hour in total costs is far cheaper than a PCP at $180 to $250 per hour. That $50 to $75 an hour is paid for by the savings incurred from lower pharmacy spending and fewer acute medical events. Plus the patients get into better health/wellness.

    To which I have say: Sadly, no. Over a six-month period, I’d pay $430 to go the medical route ($250 for a PCP visit and 6 months of meds at $30/mo), whereas the gym would cost SIX times that (twice weekly trainer appointments at $50 — cheap! — would run to $2,600). In the event that a major mental health crisis was averted, I can see how exercise would pay for itself; but for a run-of-the-mill couch potato, it’s cheaper for the potato and The System to write a scrip.

  59. 59
    Hoodie says:

    @boatboy_srq: I think there used to be more of a social dimension to organized exercise in the US. My parents used to tell me about how everyone in their N. St. Louis neighborhood belonged to the Turner Hall (Turnverein), which was kind of a mix of a social club and an exercise club. That was a remnant of German immigration that was destroyed by white flight to the suburbs in the 50’s and 60’s.

    Exercise needs to be fun, like Richard’s chasing wine and nookie in Paris. Another factor in the reduction of exercise in the US might be the fetishization of competition, which is probably related to why gyms are all about looking good and not fun and health. I think one thing that works against a lot of kids is that schools and leagues are largely captured by ultracompetitive kids, parents and coaches, which deters a lot of noncompetitive kids from participating in sports. My kid is 6’5″ and wanted to play football, but his high school requires practice 5 days a week and a full summer camp. There really is nothing comparable to intramural sports in any high school I’m aware of. It’s ridiculous, he wants to be able to do things other than study, practice and sleep. It was a blessing in disguise that he didn’t want to make that commitment to football, given the risks of football, but he tried lacrosse for year and found that it, too, was dominated by competitiveness. He ended up hating a lot of the guys he played with, who often are assholes to (i.e., impatient with) guys that don’t have 8 years of youth league experience. I heard a guy from MLPA the other day complaining about how kids are getting ruined by too much and too intense youth play, and that a lot of real talent doesn’t make it into MLB because it costs too much to participate in youth league ball.

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    muddy says:

    That horrible auto-play ad from is back on the site. Alain took it away recently, not sure why it re-appeared today. It makes my browser refresh repeatedly.

    I know, ad-blocker, but for some reason I can’t get it to deal with this.

  61. 61
    Origuy says:

    I do Scottish country dancing at least once a week. It’s a social folk dance, a little like square dancing. It’s pretty vigorous, though, and there’s a fair bit of hopping, which can be tough on the knees. English country dance or contra dancing is a little easier on the body. All three forms can have fairly complex patterns; following the geometry of the dances has been shown to keep the mind healthy, too.

    I also do orienteering, which is competitive navigation with map and compass. Generally there are various lengths of courses for different levels of physical and technical ability. I know several people in their 70s who compete regularly.

  62. 62
    sacrablue says:

    I think for many people depression is linked to anxiety disorders as well. Getting that person to interact at a gym or in a yoga class would only cause more anxiety, therefore deeper depression, overeating, more anxiety, etc. The problem just gets worse and the patient is too anxious to seek treatment. Welcome to my nightmare.

  63. 63

    @Mom Says I’m Handsome: This was a discussion on the provider side with no member cost sharing (the members in question blew through their cost sharing requirements by February 1st).

  64. 64
    I'mNotSureWhoIWantToBeYet says:

    @satby: :-( Get well soon!

    I got hit with my annual/biennial sinus infection yesterday. I’m hoping to keep it out of my lungs this time…

    Hang in there everyone.


  65. 65
    Mom Says I'm Handsome says:

    @Richard Mayhew: But somebody’s got to pay the gym and the trainer, right? The expenses are what they are; is the provider saying, “We’ll cover doctors and pills, but not wellness”? Are there available plans (or plans in the works) that would provide excellent coverage for preventive care, such as gyms & trainers, nutrionists, chiropractic & massage, and meditation? Cuz THAT would be ground-breaking.

  66. 66
    I'mNotSureWhoIWantToBeYet says:

    @Tinare: That’s so horrible! I’m sorry. Thank you for sharing your experience.

    Too many physicians form instant opinions of patients and then only do what’s necessary to confirm their suspicions. I’m sure it’s very common for women in particular to suffer such things. :-(

    My FIL had several medical issues including very bad scoliosis as a child. He lived with us when he was in his late 80s. One of his docs was someone who had a very gruff bedside manner that I argued with a couple of times. He made some remark once about whether we were sure his pneumonia should be treated because “just look at him”. (Yeah, he looked like hell, but his doctors had expected that he wouldn’t live past his 50s and he was still fighting and enjoying life.) The doc also seemed to not know the difference between life expectancy at birth and life expectancy at 85… He was a good doc technically, but it took far too much aggravation to overcome his bias sometimes.

    Hang in there.


  67. 67
    Diana says:

    Surprised to see no-one has mentioned meditation yet.

    I’ve always been a runner, and while running made me feel good for a while, it didn’t prevent a depressive episode when my stepmother convinced my father he didn’t need to see his kids from his first marriage (yes, I had an evil stepmother, I can’t believe the cliche but it really happened, I swear). After taking antidepressants for a couple of years, I injured my ankle and turned to yoga when I couldn’t run.

    The yoga made me fee so good that I decided to try to see if I couldn’t get off the drugs by doing more yoga. So far it’s been working. I’ve tried to analyze why, and I think that it’s not just the exercise: it’s also the community (I go to a yoga studio where people say “Om” and “the light in me bows to the light in you” and every class has a dharma talk, not a yoga class at a gym), the personal attention from the yoga instructors, the knowledge that I’ll be seeing friends or at least friendly faces that day whenever I go to the yoga studio, and the meditation, which my yoga studio considers part of the practice and encourages via meditation workshops.

    Now on the occasional day when I find myself starting to slip into dysfunctional thoughts, I’ll take a quiet twenty minutes, shut the door and turn off the phone, and meditate. (I’ve also managed to figure out how to do this at work.) I come out of it feeling refreshed and better than I ever did on the drugs.

    I also live in a walkable neighborhood in a walkable city, which helps as well. Not sure how I would scale my experience to a nonwalkable neighborhood that had only gyms, but I’d recommend meditation training for anyone who’s interested.

  68. 68
    Mary says:

    @japa21: Yes! This is such an important point. For me, exercise helps, but only when it’s used in conjunction with medication. By itself it’s useless. In fact, my sister, who is similarly situated, developed a problem with compulsive exercise at the same time that she had her first major depressive episode. So for her exercise was essentially a symptom of her depression/anxiety.

  69. 69
    Lurking Canadian says:

    I have come to the conclusion that in my own personal neuro-physiology, I need the exercise in order to have any serotonin at all, the re-uptake of which can then be inhibited by the junk.

    One or the other alone doesn’t get the job done.

  70. 70
    chopper says:

    @Richard Mayhew:

    it’s true overall for america but not every part. when i lived in NYC i walked an average of 6 miles a day, almost every day. carrying kids, groceries, you name it.

  71. 71
    Mnemosyne says:

    @Mom Says I’m Handsome:

    If I can be a pedant for a moment, Wellbutrin isn’t an SSRI — it works on dopamine, not serotonin.

    There’s an interesting theory right now that what’s currently called “atypical depression” or “dysthymia” is closely tied to ADHD. It’s also been shown pretty clearly that ADHD is helped with regular exercise. So I’m now wondering how many of the patients who are clearly helped by exercise actually have an underlying disorder that causes depression rather than a true mood disorder.

  72. 72
    chopper says:

    i lift at the gym three or so times a week, but luckily i don’t find it too hard to motivate myself to go since it’s so close to my house. the hard part is staying there for a full hour.

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    Mike in DC says:

    Diet, exercise, proper sleep, sunlight, socialization, defeating negative self talk , and meds as needed. Depression is a beast, but it can be coped with.

  74. 74
    Mnemosyne says:

    Also, too, for people who have some social anxiety but think they might benefit from group support, I like Fitocracy. It gives you virtual support with your group (like we have here) but doesn’t require you to actually talk face-to-face with people. It’s a little like Facebook, but for exercise.

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    Gelfling545 says:

    @Patience: I hate working out. On the other hand, I love going to my Taoist Tai Chi club 2 or 3 times a week. (Sometimes it kicks up to 4 when outdoor Tai Chi season hits. ) It doesn’t feel like working out but I feel better & am healthier than I was when I was 10 years younger. If there’s a TTCc near you give it a look.

  76. 76
    Mnemosyne says:

    Also, three, most recent studies seem to indicate that the thing that works best for most types of mental illness — including schizophrenia — is ongoing therapy. Medication is a helpful tool, but without therapy, it’s like giving someone a hammer but no nails or wood and demanding that they build a birdhouse.

  77. 77
    shortribs says:

    I have a family member with life long depression, took her a decade to find the right combination of doctor and drugs and she made great progress, fell into a good rhythm and was generally happy. Like everything it comes and goes and last time she started to hit bottom she bought a bike and started riding every day. No changes to to drugs, therapy or anything else but the exercise and weight loss combination (one of the drug side effect was weight gain) really helped her maintain a sense of stability. Depression is a constant battle and non-stop tweaking of the type of therapy, the kinds of drugs, lifestyle choices, the people you hang out with, etc. are all required.

  78. 78
    LongHairedWeirdo says:

    Um. Exercise is wonderful for depression for most people. But…
    If you have fibromyalgia, or chronic fatigue, or some heart conditions, or some other conditions, you might feel okay while exercising, and feel like total crap later.

    With some other conditions, you might not feel good exercising – and you might write it off as being out of shape.

    The way I understand it, if you exercise to the point that you can hold a conversation (so, you’re not huffing and puffing, gasping for air), but feel like your body is really doing some work, you might ache from over-used muscles for a few days, but after about 2 weeks, you should generally feel better for having exercised, and if you don’t – there could be a problem.

    (So says the guy with a mystery fatigue condition.)

  79. 79
    Aleta says:

    @Mnemosyne:A bit off topic, but I’ve been meaning to ask you :
    Re: “There’s an interesting theory right now that what’s currently called “atypical depression” or “dysthymia” is closely tied to ADHD. ”
    In your research/reading, have you seen much on ADHD and aging. or on ADHD and anxiety? My mom seemed to have resemblances to both ADHD and extreme social anxiety, and also to depression and/or bipolar, and/or atypical depr, But once she got into her 80s it was all written off to aging. There must be some direction in research toward looking at this by now? In trying to better understand, sometimes I find myself trying to sort out between it all.

    On the exercise thing, she was literally transformed after swimming whenever she was living close to a lake or pond.

  80. 80
    Brinks Truck Driver says:

    @Patience: running groups often have a good community and are cheap or free, but aren’t always good at offering an option for people getting into shape, Maybe check out meetup for some type of walking group?

  81. 81
    fuckwit says:

    Please no. They’ll literally take my SNRI’s from my cold dead fingers. I would not be alive without them.

    I tried exercise, didn’t work. I tried religion, new age spiritualism, sex, weed, psychedelics, alcohol, career changes, massage, acupuncture, hypnosis, meditation, yoga, all of it, didn’t work. Over a period of three decades. I was in hell.

    One can lift oneself by one’s bootstraps if one has feet. If one has no feet, one needs prosthetic ones. Yeah they’re expensive, but they are saving my life and I’d for real be dead without them.

    Please let this not get traction; it seems like yet another way for the insurance industry to get away with denying claims to people who are suffering and need help.

  82. 82
    Ohio Mom says:

    @p.a.: The mall near me redid the floors last year and made them very glossy. They look slippery and like an invitation to breaking a hip, I’m convinced they did that to scare away the mall walkers, of which there were legions. Can’t be the hip happening place with all those geezers shuffling about (note, a lot of them walk pretty briskly in their new balance sneaks).

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    No One You Know says:

    @raven: I’ll look for it. Thank you!

  84. 84
    No One You Know says:

    @Aleta: I realize this wasn’t addressed to me, but this is very close to me. I have been diagnosed with all of these. Dysthymia is also tired to Aspergers. Glad you brought up the topic! :-)

  85. 85
    Mom Says I'm Handsome says:

    @Mnemosyne: Pedantry accepted; you are perfectly correct that Wellbutrin operates on a different chemical pathway.

    Back in the early ’90’s my therapist diagnosed me with dysthymia (literally, “broken soul”) because it was a sufficiently vague diagnosis that kept the insurance company paying for my weekly sessions. I’m going to check out how the condition has morphed over time.

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