Open Minds is a column that explores your most pressing questions about mental health, with the goal of pushing back on stigma and cutting through the confusion. Send your questions to firstname.lastname@example.org.
I suppose there was a time when people mostly got their psychiatric advice from their psychiatrist. Now we have Google, in which awaits an inexhaustible supply of blogs and Quoras and self-published self-help books, all promising that your anxiety or depression is totally beatable. You must simply learn to discipline your body and mind, and perhaps you'd like to learn about yoga.
The basis for these claims isn't exactly bullshit. Exercise is great for people with compromised mental health, just as it's great for pretty much anyone. The problem begins when people conflate unpleasant symptoms or emotions with chronic, diagnosable disease. If you're healthy but experiencing markers linked to various mental illnesses—fear, sadness, numbness, trouble concentrating, stress—that sucks also and I'm not here to belittle them. But it is important we clarify that what may be sufficient treatment for someone exhibiting those symptoms alone— like exercise—is almost never sufficient for someone with a chronic disease.
"People experience anxiety, no doubt about it, but [most] don't have an anxiety disorder," says Jennifer Payne, an associate professor of psychiatry and behavioral science at Johns Hopkins School of Medicine. "Yoga is fabulous and can be great for anxiety, but it's not going to cure an anxiety disorder."
If someone can center themselves with exercise that is truly fantastic, but it's also how we end up with all these runaway testimonials about overcoming your ADHD by swimming laps every morning. The claims may seem harmless, but they do matter, because people desperate for alternative treatment options will always be vulnerable to fringes of the online "wellness" movement proclaiming Western medicine is for suckers. When the noise reaches that level—discouraging people from taking their medication because they can 'overcome' their condition 'naturally' via exercise—it can become dangerous.
What working out can do is galvanize a depressed person, or give structure to someone learning to control ADHD. Payne notes it can be particularly beneficial for people with anxiety because it helps regulate adrenaline levels. We also know that rerouting nervous, anxious energy into exercise is more effective than trying to ignore it. But Payne cautions that with diagnosed conditions it should always be considered a supplement—never a stand-alone treatment, despite what you heard from the good people of Yahoo! Answers.
A lot of the misinformation floating around the internet isn't intentional; the average person hyping exercise as a cure-all probably believes it. There's no real reason someone without a science background should be expected to know exactly where researchers draw the borders that define an actual disease. Plus, those lines are much blurrier than they are with physical conditions. But mental illnesses exist on a murkier sort of spectrum.
As a kid, and actually still today sometimes now that I think about it, for weeks after I got a new pair of shoes I would diligently make sure everything about them remained symmetrical. If I scuffed one, I scuffed the other to exactly the same degree, and if I overshot that one I'd keep going, sometimes for hours, until eventually I'd balanced them out. Whenever I started up a flight of stairs, I tracked which foot had stepped up first so that the next time I came upon some stairs I could start with the other one. It would only take a few seconds for someone on the internet to read that stuff and conclude that I must have had OCD, rather than just a feature of my personality that leaned in a vaguely OCD direction.
But I don't have OCD. I could always stop when I needed to. I never lost any sleep over it, and it never developed into a problem that got in the way of my life. Were I struggling with something equivalent today, it's quite possible exercise alone could straighten me out. I doubt you'd find anyone living with actual OCD who would say the same.
Payner feels one of the most recurrent labels we've come to carelessly apply is anxiety, which remains the most common psychiatric illness. Another big one is ADHD, which people probably think is the most common psychiatric illness. Hyperactivity and inattention are readily available to pathologize among minors, and it's getting easier all the time for harried parents or incautious doctors to see a kid exhibit those classic symptoms and conclude it must be ADHD, rather than just a feature of their personality.
"[ADHD] is so incredibly overdiagnosed," Payne says. "Everybody and their brother has it, and people will say, 'oh yeah, I have it, and I exercise, and that's all you need.' I think in the true cases, exercise is not going to be a substitute."
Yet more and more reputable sources are making arguments that stop just shy of saying exercise and ADHD medication are the same. If you actually look at the research they're going off of, you'll find that the kids in those studies weren't necessarily diagnosed with ADHD. Rather, many were "at risk" for ADHD due to "ADHD symptoms," "signs of ADHD," "hyperactivity" …you get it. Even experts cited as proponents of exercise-as-ADHD-medication are really only saying it might work, potentially, for a very small minority.
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This doesn't mean that information is dishonest or useless. Lots of those kids just haven't been around long enough to receive what will eventually be their official diagnosis—you cannot psychopathologize a toddler. But the point is that all of this lends credence to the perception that loads of people are running around with these fairly uncommon disorders, and that they can be cured with exercise.
"So many times [overdiagnosis is] frustrating, to know that the patient believes they really do have ADHD and been prescribed a stimulant, and now they believe they have to have it in order to function," said Mark Longsjo, program director for adult psychiatry at McLean SouthEast Hospital. "For [clinically valid] cases, supplemental things—exercise, meditation, yoga—we love introducing those things to our patients; they're wonderful, but evidence-based practice is the key."
Our two proven treatment paths for psychiatric illnesses are medication and therapy. People have messed around with the possibility of a third (electroconvulsive therapy, heat therapy) but we don't currently have one, no matter how many people say running eases their nerves better than medication.
"I'd definitely veer away from saying anything could replace a medicine fully," Longsjo says. "I don't think it's one-for-one with any type of disorder. With [ADHD] in particular…we have to be very careful that the diagnosis has first been obtained by a professional and everything's been thought through."
If it's fairly easy to see signs of ADHD among psychologically healthy children, it's absurdly easy to project any number of illnesses onto healthy adults—symptoms like stress and difficulty concentrating aren't exactly a stretch for most people. Fatigue is a hallmark of clinical depression, but isn't everyone always kind of tired? And for a lot of people, it just sounds more attractive to say they manage their problems with exercise—not pills, maybe not even therapy. But that doesn't reckon with the fact that a lot of the people evangelizing this stuff don't have a serious condition.
Longsjo works in an inpatient unit with people who are suicidally depressed or so crippled by anxiety they struggle with basic functions. He says everyone he sees benefits from 15- to 30-minute sessions of moderate exercise, regardless of their condition. The results are encouraging enough that he and his colleagues went out of their way to install exercise equipment. That still doesn't make it a substitute for anything.
"When a patient says, 'hey, if I do 30 minutes in the gym three times a day that means I don't have to take my Zoloft, right?' [I say] no," Longsjo says. You have to work with your doctor to wean off of a medication, if that's the goal.
Overall, he and Payne land on the same big takeaway: If you have a diagnosable condition for which you're receiving treatment, stick to the plan outlined by the person providing that treatment.
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