How to Prescribe Exercise for Anxiety, Depression, or Psychological Distress

A recent overview of 97 systematic reviews, encompassing 1,039 trials, and 128,119 participants, found that physical activity can reduce “mild-to-moderate symptoms of depression, anxiety, and psychological distress compared to usual care across all populations.”¹ The reviewers concluded that “physical activity should be a mainstay approach” in the management of these common mental health conditions.

Here, Jeff Junig, MD, PhD, a psychiatrist and addictionologist in private practice in Wisconsin, provides a sample dialogue that clinicians treating mental health can use to help motivate their patients to exercise and improve outcomes, even when they are uninterested. This dialogue can be downloaded and printed.

Patient: My anxiety has been horrible. I was thinking you could give me a prescription for Xanax or something similar to help me deal with it?

Clinician: I understand what you’re saying. So much has changed over the past few years, and I know you’ve gone through some hard times. I want to help you, and I don’t want to take an approach that could make things worse.

Patient: How could you make it worse?

Clinician: Some medications commonly prescribed for anxiety, such as the one you mentioned, can worsen anxiety symptoms in some individuals. This class of drugs works on receptors for a brain chemical called GABA. They work well for a week or so, but they block attention and, in higher doses, coordination – so you may be impaired when they are in effect, similar to how alcohol affects the body.

GABA agonists can be valuable in the right situation, for example, when used short-term or intermittently. Some people can take medication like Xanax once or twice per month for their worst episodes of anxiety, although others might find it hard to control that type of medication. GABA agonists including benzodiazepines are also commonly used to provide sedation and amnesia in operating rooms.

But when used daily for more than a few weeks, benzodiazepines change the way your body responds to GABA, so that chemical does not work as well at relieving anxiety. So after a short time, the anxiety may get worse and some people end up taking the drug just to avoid a type of withdrawal that feels like severe anxiety. Today, there are better classes of medications, such as SSRIs. They reduce obsessive negative thoughts but do not impair the person. But I’d like to recommend something else for you.

Patient: So, what do you recommend?

Clinician: I always remind people that they were designed by evolution over millions of years, so your own brain chemistry is designed perfectly. We have different challenges though, and we no longer live like we used to.

Patient: What do you mean?

Clinician: We used to get more exercise for one thing. Exercise builds confidence, which is a good antidote for anxiety. It releases endorphins – our natural opioids – that boost both mood and energy levels.

Patient: I just feel so tired all the time.

Clinician: That’s the challenge. I promise that you will feel more energetic, the more exercise you do. But yes, there is an initial “hump” to get past. I try to exercise every day and I notice, when I walk across the parking lot, that some days I want to jog or skip because that energy feels so good.

Patient: I just don’t have time for that.

Clinician: I hear you. I started looking at what I was doing all day. The time I spent watching some rerun, doing nothing – I realized that I had the time, but I was wasting it.

Patient: I can’t get away from the kids.

Clinician: Yes, that’s hard. Those are tough years to get free time. Sometimes it works if you take an extra 30 minutes before or after work, after you drop off the kids. I have patients who find really creative ways to exercise, such as going up and down the staircase at work or home a few times.

Some people try to work it into their schedule, such as walking to a lunch place or coffee shop that is a little farther away, or parking farther away.

If you don’t have young kids, though, I think the best idea is to set aside some time for yourself. Maybe your neighborhood has hills that make it the perfect workout place.

Patient: I tried to exercise a few years ago and then I went through a depression. I stopped doing it.

Clinician: I know – that’s hard. From where I sit, it seems that all of the things people believe they need when they are depressed are actually more likely to keep them depressed. People feel like they need to withdraw and rest. But honestly, the way out of depression is to try to keep moving, keep people around, and avoid lying in bed or in front of the TV

Exercise works best if a person already has a routine going. If you just started exercising, keeping it up during a depression would be hard. But if you are doing it at the same time every day, you would be more likely to keep it going. That would probably make the depression shorter, and less severe.

Patient: I’ll think about it. What did you say about prescribing me something?

Clinician: Oh yes – let’s spend a moment on the different options. On the exercise thing though, what do you think you could do later today or tomorrow to get something started?

Patient: Ugh. I don’t know, I suppose I could take a walk.

Clinician: It works best if you get your heart rate up, higher than normal. You don’t need to go all out, but you want to do something that gets you breathing a little harder and raises your heart rate.

[Clinical Note: If the patient has a cardiovascular condition, it’s important to address safe exercise during the conversation.]

Patient: I guess I could walk from our house down the long hill to the south, maybe do a loop. Then come back up the hill.

Clinician: Wow, that actually sounds nice! Try it out. I want to hear how it went next time we talk and whether you could keep doing it. After that last hill, it would be best to do an easy walk for 5 to 10 minutes around the yard, on flatter ground, until your breathing returns to normal.