Dig out your sneakers, unless… Exercise and Bipolar Disorder

Based on the article “’It’s a double edged sword’: A qualitative analysis of the experiences of exercise amongst people with Bipolar Disorder” Wright, K et. al. Journal of affective disorders 136 (2012) 634-642

How many times have you been told that exercise will do you good, that “it works wonders for mental health” or the clincher: “30 minutes of walking a day changed my life”? Reality check: These statements are true… Sorry I did not stumble upon some random article swearing off exercise, I would love that too. I did however read an article which looks more at how exercise influences not mental health in general, but BD specifically. I think this is very relevant since, unlike unipolar depression, it is characterized by “moods swings” which include mania and hypomania. In terms of symptom profile, these two states strongly contrast depression. So okay, let’s look at what Kim Wright and her co-authors have found out.

The research supporting the fact, that regular exercise reduce the risk of physical health problems associated with bipolar disorder, such as diabetes, is overwhelming and it has also been shown to relieve the symptoms of mild to moderate unipolar depression. The benefits when evaluating the impact on mental health in general is overwhelming, some of these include:

• Enhanced self-esteem and the reconstructing of a positive identity
• Increased mental alertness and energy
• Distraction from negative thinking
• A sense of purposeful activity, accomplishment or achievement
• Improved sleep

Studies looking at the impact of regular exercise on BD though, is limited, like really limited! This study was conducted by interviewing 25 participants concerning their view on the relationship between BD and exercise and the data was subjected to qualitative analysis. This study is limited in the sense that it did not take into consideration aspects such as treatment regime, diet and alcohol use. Furthermore, the interviews were completed telephonically. This has an inherent advantage thought since this enabled the study to not be limited to a specific location.

3 main themes appeared during the in-depth interrogative analysis. These were:

1. Regulating exercise for mood regulation
2. Exercise – the double edged sword
3. Bringing structure to chaos

Let us look at them each separately:

1. Regulating exercise for mood regulation.

This theme encapsulates the idea of sticking to an exercise regime despite changing moods as a way to manage mood fluctuation. Some of the participants found that exercise was a useful tool in symptom management. They went as far as to say that it extended the length of euthymic periods and reducing the intensity of hypomanic and depressive episodes. Several participants said that their mood would decrease if they didn’t work-out for a few days. Negative case analysis found one participant who did not find exercising helpful at all. (Author’s note: 1 out of 25 is not enough for you to go chuck out your exercise bike! Keep on reading!) What was highlighted was the role of a support system as well as monitoring and motivation in maintaining regular of exercise.

2. Exercise, the double edged sword

The key finding of this whole study, according to the authors, is that participants viewed exercise as having the potential to be both helpful and harmful. There was a sense that small distinctions between mood states, circumstances, or forms of exercise could play a big role in whether the exercise was a good idea or a bad idea. We will look at the positive and negative effects of exercise during hypomania or mania. One of the participants reported that whilst exercising it initially induced a sense of calm where after it took her slightly higher. It may be that it is more difficult to regulate the intensity of the exercise during hypomania or mania. The analysis highlighted the potential for an “upward spiral” to develop whereby mania leads to increased quantity and intensity of exercise which exacerbates manic symptoms, leading to a spiralling increase in exercise.

Also, half of the participants found that the positive effects of exercise were diminished during extreme episodes of mania or depression. One participant stated that: “if the depression isn’t too severe it can break that cycle and make, you know, the depression lift. It is when I am at either extreme that it is non beneficial”

A suggestion put forward was that the type of exercise should fit the mood state for example during mania “calming down stuff” should be done and “winding up stuff” when you are depressed, essentially “you’ve got to do the opposite of what you feel”

3. Bringing structure to chaos

The majority of the participants suggested that exercise can provide structure to people with BD. An example of this would be that if you exercise the same time every day for the same length of time it can add structure to your daily routine. Secondly the exercise itself can have an inherent rhythm promoting structure. Sports such as running, walking, swimming and cycling were mentioned more often as having a structuring effect than sports like racket or netball which are less likely to permit a repetitive rhythm. In conclusion structured exercise was described as calming, supportive of structured thinking and useful in facilitating mood regulation.

Emphasis was also placed on exercise being a meaningful use of time within a day and that it clarified and settled thinking. The settling down of thinking is hypothesised to be due to reduced neural activity in higher order processing especially in the prefrontal cortex, to compensate for the increased metabolic demands of exercise. This may contribute to the anxiolytic and anti-depressant effect of exercise. It must be mentioned though that there were a few participants that expressed fear that introducing exercise to their life may lead to further chaos by triggering a manic or hypomanic episode. Fear was also expressed relating to depressive episodes: “Sometimes I know with depression that I’m fighting a losing battle and I need to reserve all my energy to get better.”

Recommendations for exercise as an intervention.

A key theme that emerged was that there is a need for flexibility to suit participant interests, fitness and energy levels both between participants and over time. As mentioned before rhythmic exercise that is “steadying” should be considered above competitive exercise. The importance of support was also highlighted again. Support has the potential to motivate during depressive episodes and reign in activity during periods of high mood.

What I think about all of this.

I think it is safe to deduce from this article that regular exercise does more good than harm for those suffering from BD. From having a calming effect during hypomania, to contributing to structure both in routine and thought and relieving the symptoms of mild depression and anxiety. But like with any pill, there are contraindications that should be kept in mind, like the upward spiral effect it can have during a manic episode or the triggering of a higher mood state and the tiring effect during a depressive episode. One should keep in mind that exercise is an adjunctive therapy and cannot replace your psychiatrist and his bag of goodies, like the article found, it didn’t have a positive effect during extreme mood states. Hopefully this article has shed some light on the more specific interactions between exercise and BD. So my dear reader, the ball is in your court, knowledge is power but only if applied…