title: a review of literature on treating depression...

Title:

A review of literature on treating depression

using Pilates

Merlyn Mittins

Feb - June 2016 Pretoria

Abstract

Given the amount of research into physical ailments being successfully treated with Pilates this report focuses on mental disorders, more specifically depression being treated using Pilates. This approach to research was in order to satisfy my own interest and personal journey, as Joseph Pilates stated “it is the mind itself that builds the body”. I was diagnosed with depression during the course of 2015 and decided that I wanted to understand what part Pilates played in my recovery, since I have indeed recovered. This review focuses on employing Pilates specifically as an alternate treatment to drugs for clinical depression. To this end my report highlights pertinent facts, relevant studies and goes on to conclude that the evidence supports my own findings; that physical exercise and in particular Pilates can be used as an alternative non-pharmacological therapy to prevent or help in the recovery from depression.

Table of Contents

1. Title: ................................................................................................................................................ 1

2. A review of literature on treating depression ....................................................................................... 1 3. using Pilates ...................................................................................................................................... 1

4. Abstract ............................................................................................................................................. 2

5. Table of Contents ............................................................................................................................... 3

Introduction ......................................................................................................................... ...... 4 6. Depression and anxiety ....................................................................................................................... 5

7. Illustration 1: Brain activity normal and depressed courtesy the Mayo clinic ........................................... 5 8. Table 1 DSM-1V criteria for major depression. ..................................................................................... 6

9. The causal pathways and how exercise effects the brain ....................................................................... 7

10. Illustration 2: Healthy vs. Depressed synapse courtesy the Mayo Clinic .................................................. 8

Exercise is favourable to drugs as a treatment .................................................................... 9 11. Actual study results on exercise and depression ................................................................................ 10

Types of exercise ................................................................................................................ .... 12

Preventative measures ......................................................................................................... .... 13 12. Illustration 3: Brain activity while sedate and then active courtesy University of Illinois ......................... 13

Inactivity of habitual exercisers ........................................................................................... .... 14 13. A Pilates program to treat mild depression ........................................................................................ 14

14. Thank you ...................................................................................................................................... 18 15. References ....................................................................................................................................... 19

16. Appendix: 8 week teaching schedule ................................................................................................. 22

Introduction

Physical fitness is the first requisite of happiness. Our interpretation of physical fitness is the attainment and maintenance of a uniformly developed body with a sound mind fully capable of naturally, easily, and satisfactorily performing our many and varied daily tasks with spontaneous zest and pleasure.

Joseph Pilates

Joseph Pilates guiding philosophy in creating this form of exercise was that the “whole” must be exercised to achieve good health. Pilates is a way of life and a path to total health, holistic rather than a physical fitness program only. Claims for the emotional benefits of exercise date back 2500 years and are rooted in philosophical and religious ideas, only recently has evidence caught up with the claims. The World Health Organization states “Health is a state of complete physical, mental and social well being and not merely the absence of disease or infirmity” (WHO 2006). In the UK the National Health makes recommendations on treatments according to the best evidence, has published a guide on treatment of depression (NHS, 2006) The guide recommends exercise rather than antidepressants in the treatment of mild depression. This research tries to understand the relationship between the mind and the body and the mechanisms by which exercise effects the brain. Firstly this report describes depression and how it effects the brain, then it discuses the possible casual pathways whereby exercise and in particular Pilates physiologically positively changes the chemicals in the brain. The study of particular types of exercise, duration of a session and participation over the course of time all are addressed, and a formula for a Pilates program that addresses the symptoms of depression is put forward. What is evident in the readings is that it is difficult to measure mental disorders as opposed to physical ailments and therefor there is less critical analysis in this field. “In order for man to succeed in life, god gave him two means, education and physical activity. Not separately, one for the soul and the other for the body, but the two together. With these two means men can attain perfection” (Plato, 4th century BC).

http://www.azquotes.com/quote/734868




Depression and anxiety

Everyone is the architect of their own happiness

Joseph Pilates

Depression is defined as a mood state, psychiatric condition and clinical syndrome. The term “depression” is used variously to describe a dysphoric state, a syndrome comprised of a cluster of symptoms, or a clinical disorder (Blumenthal 2002).

In recent decades our level of physical activity has diminished. Lambert (2006) states that the decline of vigorous physical exercise may contribute to the high level of depression in today's society. While sport activity levels have remained stable or increased, activity levels over the course of an average day have declined (Drummond 2013). In the US it was estimated that over the past 50 years occupation related activity levels decreased by more 100 calories (Church 2011). Worldwide sugar consumption has increased by 74 kcal per day in 45 years, of this 80% is from beverages and fast food (Popkin and Nielson 2003). The changes occurring in this modern world over the past 3 decades have coincided with reported increase in many psychiatric problems, including major depression. While some of the increase may be due to better diagnosis contemporary lifestyles might also explain the increase (Drummond 2013).

Illustration 1: Brain activity normal and depressed courtesy the Mayo clinic

Today, depression is considered as one of the most common mental disorders and general problems of human life. The WHO predicts that depression is the fourth major cause of disability in the world, by 2020 it will have moved to 2nd place. Despite its prevalence, depression is often under recognized and under treated (Blumenthal 2002).

Research on major depression has confirmed that it is caused by an array of biopschosocial and lifestyle factors (Drummond 2013) Diet, Exercise and sleep all play a significant mediating role in the development, progression and treatment of this condition.


6For depression to exist the symptoms need to last for 2 weeks or more. Most episodes

last longer if left untreated, with the average episode lasting 6 to 8 months (Mueller TJ, 1996). Major Depression Disorder (MDD) tends to episodic and of those that suffer an episode, the majority will have a re occurrence (Blumenthal 2002).

There is a well established link between depression and negative self evaluation (Leary 1995). (Drummond (2013) further elaborates that negative self evaluations may play a causal role in MDD. It has been hypothesized that effective depression interventions work by improving self evaluations. Exercise, research reveals affects both self-evaluation such as self esteem, body image and physical self worth. Improving the self evaluation during Pilates can then mediate the anti depressive effects.

After reviewing various methods of diagnosing depression, the chosen one for this reviews' basis for diagnosis being the most widely known, and can be self administered, is the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)(American Psychiatric Ass. 1994). These criteria are very similar to those of other commonly used criteria being Research Diagnostic Criteria – RDC and International Classification of diseases – IDC. Given that teachers may encounter symptoms of depression I thought essential to provide criteria for teachers to use in assessment and better recognition.

The DSM-VI criteria for MDD are presented as nine questions on the following Table, of which five or more should be present in a 2 week period.

Table 1 DSM-1V cr i ter ia for major depression .

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for major depressive episode

1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation

made by others (e.g. appears tearful). Note: In children and adolescents, can be irritable mood

2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either

subjective account or observation made by others)

3) significant bodyweight loss when not dieting or bodyweight gain (e.g. a change of more than 5% of bodyweight in a month), or

decrease or increase in appetite nearly every day

4) insomnia or hypersomnia nearly every day

5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or

being slowed down)

6) fatigue or loss of energy nearly every day

7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach

or guilt about being sick)

8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed

by others)

9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a

specific plan for committing suicide

B The symptoms do not meet criteria for a mixed episode

C The symptoms cause clinically significant distress or impairment in social, occupational, or other important

areas of functioning

D The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a

general medical condition (e.g. hypothyroidism)

E The symptoms are not better accounted for by bereavement,

i.e. after the loss of a loved one, the symptoms persist for longer than 2 months or are characterised by marked functional

impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation

Depression is commonly associated with low levels of exercise, in adults an active lifestyle regardless of education, population or physical health is associated with reduced depression. Key symptoms of major depression include changes in appetite, sleep, energy and general motivation levels, all of which would have likely effects on exercise (Drummond 2012).

Estimates of the prevalence of MDD in community based adult samples vary considerably across studies, the lowest ranging from 3.3% in Seoul South Korea to one of the highest 17.1% in the US (Blumenthal 2002) This review found varying stats from 16.5% to one third of all South Africans having depression (http://africacheck.org). The debilitating effects and enormous costs of MDD for both individuals and society have been well documented. In the US in 1990 the estimated indirect costs associated with depression in the workplace and suicide were $43.7billion (Greenberg 1990). Depression and anxiety affect approximately 9.5% of US adults and approximately 8.6% of European adults each year (National Institute of Mental Health 2007). The side effects associated with anti-depressants include weight gain, hyperglycemia, hyperlipidemia, elevated blood pressure and increased risk of suicide (Landers 2011). The side effects together with low treatments rates and undiagnosed symptoms suggest the need for additional treatment options that are accessible, safe, and cost effective. Hassam (2011) reports women are at a greater risk and 1 in 4 women can expect to develop depressive symptoms in their life time, whereas only 1 in 10 men.

The causal pathways and how exercise effects the brain

It’s the mind itself which shapes the body.

Joseph Pilates

Due to the adverse effects, or even harmfulness of drugs in treating depression, professionals are looking for non pharmaceutical, non invasive methods to treat mental disorders. Major depression has a multi-factorial etiology arising from psychological, environmental, genetic and biological factors (Drummond 2013). Research since 2000 has clarified that depression is associated with neurotransmitter imbalances, HPA disturbances, inflammatory pathways, increased oxidative and nitrosative damage (Lopresti et al, 2012).

The strongest evidence of neurotransmitter imbalances in depression comes from the popular use and efficacy of serotonin re-uptake inhibitors (SSRI's) which are thought to alleviate depression by increasing the availability of monoamines, serotonin, dopamine and noradrenaline (Connelly and Thase 2012). Serotonin is a topical hormone and found in mucous membranes of the digestive are and in 95% of the platelets in the central nervous system (Hassam 2011). Serotonin acts as a neurotransmitter, a type of chemical that helps relay signals from brain area to another. Although serotonin is manufactured in the brain, where it performs its functions, 95% of our serotonin supply is found in the digestive area and in blood platelets (Hassam 2011). Seratonin, noradrenaline and dopamine have long been implicated in the aetilogy (the study of the causes of disease) of major depression. Where as early theories that deficits


of these chemicals under lied depressive disorders more current theories emphasis the complexity of the underlying mechanisms including monoamines. Blumenthal's (2002) study goes on to state that evidence mounts to support that exercise affects central monoamine functioning in a manner relevant to MDD. Other studies (Gomez- Merino D, 2001 & Meeusen R, 2001) show that exercise increases extra-cellular serotonin (a particular type of serotonin gene) and 5-HIAA (the main metabolite of serotonin) in brain areas, including the cortex and hippocampus (part of the brain associated with memory and emotions).

Illustration 2: Healthy vs. Depressed synapse courtesy the Mayo Clinic

One of the strategies to increase serotonin and neurotransmitters is exercise (Bahram 2014), which naturally can affect the nervous system. Borzou (2011) reported that a study of a 12 week course of Pilates exercise increases blood serotonin concentrations and reduces depression and also improved social relations. Exercise leads to changes in transcription levels of genes identified in relation to neuronal activity and synaptic structure, which are important in memory processing and further reduces symptoms of depression (Bahram 2014).

The anti-depressant effects of exercise may be due to its capacity to modify monoamine communication (Drummond 2012). Trials provide evidence of exercise and its serotonin-enhancing effects. Untrained participants randomly assigned to an aerobic exercise group experienced greater changes in serum serotonin levels compared to those in a stretching control group (Drummond 2012). Studies such as Chaouloff (1989) did find that exercise is associated with increases in plasma monoamines levels. In addition exercise increased basal free fatty acids and free tryptophan levels, which can increase the rate serotonin is synthesized. Since Depression is associated with an altered monoamine functioning then exercise may affect this pathway.

Stress activates central opioid systems and this accounts for instances of analgesia which is caused by stress. Spontaneous exercise shares these effects, increasing opioid activity, this release is psychologically important to explaining why exercise helps depression and anxiety (Salmon 2001). The belief that regular exercise recruits opioid activation and the popular view that attributes exercise with the release of endorphin's is proven but not simple.

9It is well known (Blumenthal 2002) that exercise leads to a surge of B-endorphin released

into the blood stream to calm sympathetic nervous system and provide analgesic relief from pain associated with strenuous exercise. B-endorphin surges elevates mood and mediates depression.

The effect of exercise on serotonin production and levels, suggests that the exercise itself not just the rewards may be important (Lambert 2006). If research to prevent depression through Pilates exercise is successful then prevention of depression can be added to the numerous other benefits of exercise.

Exercise is favourable to drugs as a treatment

Pilates is complete coordination of body, mind, and spirit. Through Contrology you first purposefully acquire complete control of your own body and then through proper repetition of its exercises you gradually and progressively acquire that natural rhythm and coordination associated with all your subconscious activities.

Joseph Pilates

A good reason for pursuing knowledge of non-pharmacological methods of increasing serotonin arises from the recent and increasing recognition that happiness and well being are important; both as factors protecting against mental and physical disorders and in their own right (Delamothe T, 2005).

One of the values of exercise might be the controllable element. On this basis Salmon (2001) states that to maximize benefit, participants must have the perception that they are in control. Drugs are seen as less controllable than exercise. Correlated with stress controllablity is predictability and this may be the more important property for stress adaption. The routine and predictable nature of a Pilates program would prove critical to receiving the benefits.

Given the more favourable adverse effects and the fact that they are safer even if overdosed, SSRI's are the favoured first line drug for anti depression. But there is a significant minority of first time users (30%-40%) that do not respond favourably. Furthermore a high percentage experience a relapse after discontinuing treatment. Stopping the treatment also has a high occurrence and this may be due to costs attached, social stigma and the concern for the adverse effects (Blumenthal 2002). Pilates has the potential to be an attractive alternative given the reasons that drugs are often discontinued.

Craft and Landers (1998) reported that the length of time being at least 9 weeks, had a 70% effect on depression levels or clinical results, when compared to standard treatment with pharmacological drugs compared favorably with similar benefits. According to Craft and Perna (2004) exercise training was as effective as cognitive therapy.

Landers (2011) states that serotonin may be of the greatest interest because serotonin based drugs are used to treat both depression and anxiety. One function of most anti-depressant drugs is to make more serotonin available for binding cell rectors sites. Research shows that exercise increases serotonin production. There for exercise provides a similar function to taking serotonin as a drug.





10For the brain to maintain balance and a stable mood, regulated serotonin is essential,

depression can be a lack of serotonin in the brain or inefficient serotonin receptors (Hassam 2011). Evidence suggests that serotonin imbalances influence mood in a way that can lead to depression. Possible problems include low brain cell production of serotonin and lack of receptor sites to receive the serotonin that is made (Hassam 2011).

Direct measurement of serotonin binding in the human brain is currently not possible, but indirect measurement may provide an interim solution (Landers 2011). Although results suggest that there is a relationship between blood levels of serotonin and physiological changes in the central serotonin system, a mechanism to support the link remains elusive.

The clearest evidence that physical exercise is enjoyable has emerged when mood is measured before and after regular exercise at a level at which the individual is used to (Salmon 2001). Salmon goes on to describe that exercise that is more intense than the habitual level is less likey to improve mood and indeed may worsen it. This evidence should be used to create an incrementally challenging Pilates program.

Evidence also suggests that exercise is accompanied by an increase in free radicals, resulting in measurable elevations in oxidative stress bio-markers after both aerobic and anaerobic exercise (Bloomer 2004 and 2008). Gomez-Cabrera (2008) report that because exercise results in an up-regulation of powerful antioxidants enzymes that exercise itself could be considered an antioxidant despite generating free radicals.

Actual study results on exercise and depression

Through the Pilates Method of Body Conditioning this unique trinity of a balanced body, mind and spirit can ever be attained. Self-confidence follows.

Joseph Pilates

Pilates breathing capacity improvement results in enhancement of cerebral flow, and greater oxygen and glucose utilization in the brain, accelerating the transfer of blood antioxidant enzyme activities for the rapid elimination of free radicals which then leads to mood improvement and a reduction in depression (Bahram 2014).

The findings of Bayak (2000) suggest that a modest exercise program of 3 times a week for 50 minutes is an effective robust treatment for patients with depression, and that clinical benefits are likely to endure among patients who adopt exercise as a regular ongoing activity.

Although exercise is regarded in most research as a purely physiological stimulus its emotional effects depend intimately on the social and environmental cues but particularly on expectation (Salmon 2001).

Blumenthal and Moore (1999) could show that 16 weeks of group exercise training in older patients with major depression was as effective as antidepressants treatment with setraline. More importantly the relapse rate was significantly lower on the exercise group at only 8% when compared to the drug group rate of 38%. Blumenthal more recently in a 2007 study reported that the efficacy of exercise seemed generally comparable to most anti depressant medication.



11Despite the awareness that regular exercise improves physical health, only 30% of the

the Western world engage in exercise weekly and once started only 50 % continue with their sessions (Brawley & Rogers 1993). Attempts to explain the reluctance to exercise continue to emphasize the psychological reasons in the individual such as lack of motivation, inappropriate health beliefs or lack of control and discipline (Salmon 2001).

Steptoe & Butler (1996) showed vigorous exercise participation was related to lower emotional distress after controlling for social class and health status. Further reported was that after testing 16483 university under grads similar results were reported and lower depression recorded. Milani (1996) studied over 300 women patients having depression due to cardiac problems and after 3 months of aerobic exercise two thirds said the symptoms had either diminished significantly or were resolved. Beniamini and Rubensteins' (1997) study reported more improved results when aerobic exercise was employed compared to flexibility training. Klein et al. (1985) found aerobic exercise to be as effective in reducing depressive symptoms as psychotherapy.

Martinsen (1985) on the other hand found that a combination of psychotherapy and exercise training was more effective in decreasing depression than combining psychotherapy with occupational therapy. Martinsen also noted that patients with a moderate 15% - 30% increase in oxygen uptake experienced a larger antidepressant effect.

McCann and Holmes randomly assigned 43 women for 10 weeks of either aerobic strenuous exercise or a placebo treatment where they performed relaxation exercises and found that participants in the exercise group depressive symptoms improved significantly while the relaxation groups had little significant change. McNeil (1991) randomly assigned 30 elderly women to one of three treatment conditions: (i) exercise (ii) social contact (iii) wait list control. Patients in the exercise and social contact conditions exhibited significant reductions in depressive symptoms. This distinction then gives credence to classes of Pilates where there are more social interactions.

Claim for the psychological benefits of physical exercise have tended to precede well supported evidence. The emotional effects of exercise remain various and confusing. Results of various studies are for the most part consistent in indicating that exercise training had anti-depressant affects and can be used as a preventative measure. Studies link exercise and positive effects but causality is still not clear. Nevertheless, evidence mounts to suggest that exercise training employs a process which confers enduring resilience to depression and anxiety related mental disorders. Each 50 minute increment in exercise per week was associated with a 50% decrease in the odds of being classified as depressed (Babyak 2000). Further added that feeling less depressed may make it more likely that patients exercise again, then continue to as behavior is rewarded. Babyak (2000) demonstrated the efficacy of a 16 week exercise training program that was comparable to a standard pharmacotherapy 16 week program. In Babyak's (2000) study called SMILE (Standard Medical Intervention and long term Exercise study) the time frame was 16 weeks but current treatment guidelines suggest 6 months or longer (Depression Guideline Panel 1993). This suggests that less duration is still adequate to see results and a reduction in depression.

If exercise is a way of improving emotional state, adherents may be expected to include many who take up exercise because of emotional problems. Reliable evidence is obviously hard to obtain (Salmon 2001).

Types of exercise

There are 3 basic types of exercise

Cardio respiratory or aerobic, which oxygen is metabolized to produce energy

muscular strength and isometric anaerobic, in which energy is provided without the use of inspired oxygen

Flexibility exercise, that is designed to improve range of movement.

A small number of studies compare aerobic to anaerobic exercise. Overall these studies indicate that both types can reduce depressive symptoms. Doyle (1987) reported one difference was that 1 year later the improvements were maintained in the anaerobic group suggesting that this type of exercise had a longer term benefit over aerobic. Martinsen (1989) concurred and also saw both groups of aerobic and anaerobic exerciser reduce depressive symptoms, this study gave a random selection anti depressant drugs as well and added that the results suggest that exercise and medication is no more effective than exercise alone. Blumenthal (1999) randomly assigned 156 middle aged adults with MDD to one of three treatments: (I) aerobic training (ii) standard pharmacotherapy sertraline and (iii) a combination. After 16 weeks of treatment groups did not differ significantly but all reduced depression. At a 6 month follow up individuals who remained with exercise alone exhibited significantly less relapse rates than the other two groups. Interestingly combining exercise with medication conferred no additional advantage over either treatment alone.

To summarise the above studies and to which Lawlor and Hopker (2001) agree, the research suggests that exercise is more effective in treating depression than no treatment and is as effective as psychotherapy and antidepressant medication and in the long term perhaps more beneficial.

The association of exercise with well being may be greater in older than younger people (Ransford & Palisi 1996, Salmon 2001). Relationships between exercise habits and mood measured simultaneously in cross sectional surveys are inherently ambiguous about cause and effect (Salmon 2001). Longitudinal studies have now shown definitively that exercise habits do predict later freedom from depression, even 25 years later (Salmon 2001). Exercise habits could be evidence rather than the basis of successful treatment (Salmon 2001). In reality no single theory can account for the effects of a complex stimuli as exercise (Salmon 2001). Processes such as social integration, self mastery and distraction influence the effects of exercise. Increased social activity is likely to have been a critical feature of exercise in many early studies: solitary exercise did not improve depression (Salmon 2001).

Preventative measures

Physical fitness is the first requisite of happiness. In order to achieve happiness, it is imperative to gain mastery of your body. If at the age of 30 you are stiff and out of shape, you are old. If at 60 you are supple and strong then you are young.

Joseph Pilates

Exercise provides a diversion from negative and obsessive thoughts and feelings (Hassam 2011). Perhaps exercise also allows the individual more freedom to eat and drink as they wish, this leads to greater pleasure and freedom. Women who participated in at least 60 minutes of moderate to vigorous Pilates exercise a week had fewer symptoms of depression than those active less than 1 hour a week (Hassam 2011).

Strawbridge (et al 2002) studied 1900 older adult subjects to conclude the protective effect of physical activity on the development of depression. Strohle (2007) sampled adolescents and young adults and concluded that regular exercise lowed the incidents of mental disorders, even 4 years later.

Illustration 3: Brain activity while sedate and then active courtesy University of Illinois

A study on data of 4000 men and women over 20 years of age confirmed that those that spent less time in moderate physical exercise were more likely to have or to acquire depression (Song 2012). Studies have consistently found that more active individuals report lower depression scores than more sedentary individuals. Also regular exercise is associated with lower depression scores (Blumenthal 2002).




Positive moods are an important predictor of health and longevity Danner and Snowden (2001) found that in a study those people who rated in the lowest 25% for positive emotions died on average 10 years earlier than their happier top 25%.

Inactivity of habitual exercisers

It has been shown that physical activity is inversely related to depressive symptoms and that individuals who increased their activity over time were at no greater risk for depression than individuals who had been physically active all along (Babyak 2000). Individuals who had been physically active in the past but who become inactive were 1.5 times more likely to get depressed than those who consistently maintained a level of activity. Salmon (2001) found that there was a gradual increase in the symptoms of depression and anxiety over 2 weeks after the cessation of regular running.

Physical inactivity may also be associated with the development of mental disorders (Goodwin 2003). Exercise is an integral part in the treatment and rehabilitation of many medical conditions. Improving physical well being may also improve psychological well being.

A study at the University of British Columbia demonstrated that physically inactive women were 15 times more likely to be depressed than women that exercised. Women that had a positive feelings towards the training showed significantly greater results than those with negative feelings towards exercise (Hassam 2011).

Most available data accounts that aerobic exercise is positive when performed at an individuals habitual level and although strenuous exercise improves mood in regular exercisers it worsens for non exercisers. The simple explanation is non exercisers mood worsens and the implications for the attempts to start non exercisers exercising. It is possible that people who exercise do so because they experience exertion positively (Salmon 2001).

A Pilates program to treat mild depression

Moreover, such a body freed from nervous tension and over-fatigue is the ideal shelter provided by nature for housing a well-balanced mind that is always fully capable of successfully meeting all of the complex problems of modern living.

Joseph Pilates

One of the most cost effective and easiest approaches to treating depression is through exercise. Pilates remains one of the best methods since all age groups can participate. Research supports that physical exercise is one of the most important strategies to maintain physical well being and mental health, preventing and reducing symptoms. Physical exercise implies regular, leisure time but a structured program whereas physical activity is daily tasks that arise from occupation or domestic acts. Recommendations for physical exercise have increased from 3 to 5 sessions in the 1990's to 30 minutes every day since 2000 (NHS 2006).




15Moderate intensity activities are more successful than vigorous programs (Dishman and

Buckwort, 1996) and sessions that target specific of individual needs were more successful than generic (Strecher et al, 2002). The questions Pilates trainers ask before a session are very important to the individual, specifically targeting their needs and making allowances and modifications. Dishman (1997) reported that across a number of samples that only 50% of individuals who initiate an exercise training program complete it. The factors that influence this are attitudes towards the value and importance of exercise, perceived behavior control or how easy or difficult it is, self efficacy or how successfully it can be done, early exercise experiences and recent involvement in physical activity, knowledge about fitness, perceived support and encouragement. Pilates is seen now as an approachable form of exercise and more widely known and more understood, people perceive that they will be able to try to do the exercises. TM or Trans-theoretical Model take the above factors and integrate them. TM postulates that people move back and forth through 5 stages of change:

1. pre-contemplation

2. contemplation

3. preparation

4. action

5. maintenance

before establishing stable behaviour. The processes of change were the mechanisms that that move a person through the stages, reinforcement, support, helping relationships, self evaluation.

Yang (2015) found reduced symptoms of depression in only one session per week that consisted of 10 minute warm up of Yoga exercises followed by 40 minute Pilates over a 12 week period. Studies do confirm that exercise and in particular Pilates is good for all ages, different body types and levels of fitness. It is reported that Pilates sessions of 3 per week for 50 to 60 minutes is considered effective and safe to train (Bahram 2014).

The repetition of exercise produced tolerance based on Salmon (2001) that explains although exercise could initially be unpleasant could acquire positive motivational properties because it reinforced positive out comes. One of the positive psychological benefits of systematic exercise is the development of a sense of personal mastery and positive self regard, which Babyak (2000) reported may have a role to play in reducing depression related effects.

The effects of physical activity stimulate a complex system and trigger a succession of events which result in a higher resilience against mental disorders. If prevention is better than cure, the research supports exercise as not only preventative but also a cure.

Based on this research my Pilates program would cater for depression with the following guild lines:

Join a mat class to incorporate the interactive social element, one on one was not as effective for depression symptoms.

If the person is new to Pilates then it will be vital to start with fundamental exercises and because the research shows that perception is paramount to make sure people feel capable of the exercises. If a person has done Pilates before then advancing incrementally through to intermediate without compromising their confidence.

3 sessions a week for a person with no other physical exercise regime or 2 for an individual who participates in other physical exercise or who has high physical activity due to domestic or job situations. NB with a sensitivity to understanding that even 1 session will see results and better to continue rather than have a client give up because 2 or 3 sessions becomes onerous.

The duration would be an hour, and made up of 10 minutes warm up, 35 minutes exercise, 10 minutes of stretching and a cool down and quiet meditation at the end of the session for a further 5 minutes. The evidence suggested that a combination of flexibility, stretching and exertion was most efficient and what make Pilates unique.

Continual realistic self assessment and establishment of goals, self esteem and self confidence were seen to be negative while an individual has depression. It would be essential to help a person to be realist and positive about their body and goals.

Keep it fun and inject humour always.

The tables in the appendix refer to a 8 week teaching schedule.

Further studies

Every moment of our life can be the beginning of great things.

Joseph Pilates

A major priority for further research is not whether exercise helps with various disorders and disease, since this is now proven, but what type of exercise, how often, and what duration and at what level of intensity is optimal.

Sonstroem (1998) reported that exercise results in an increase of physical self concept and self esteem, there for may help to alleviate depression and anxiety. Both self concept and self esteem have been shown to be positively related to participation in exercise. Self efficacy may mediate the relationship between exercise, anxiety and depression. The link between the psychological mechanisms of exercise is primarily correlational, the chemical behavior of the mind is these feelings is what needs to be studied.


Although people may prefer to exercise on their own rather than be supervised, few studies have examined unsupervised exercise, which takes more effort and discipline. By studying the difference the impact of the social support could be seen. Further studies of the effects of the exercise and interactions during exercise may further support its use as an alternative effective treatment.

The effect of non-pharmacological interventions on brain serotonin and the implications of increased serotonin for mood and behaviour need further research. Young (2007) argues that the amount of money that is used on research into drugs is far greater that in research into non-pharmacological methods and the magnitude of the discrepancy is neither in tune with the wishes of the public nor optimal for the progress in prevention and treatment of mental disorders.

Thank you

Physical exercise changes as its cultural significance changes (Salmon 2001). Joseph Pilates didn't see the surge in uptake of his exercise philosophy but perhaps culture has now caught up with his thinking. We are viewing our life styles is a more holistic way and the increase in take-up of Pilates is a refection of our new attitude.

Thank you to Theo, my fellow class mats, teachers and staff and to all those I came into contact with because of my new found passion.

References

1. American Psychiatric Ass. Diagnostic and Statistical manual of Mental disorders. 1994 4th ed. Washington DC.

2. Babyak M, PhD, Blumenthal J, PhD, et al, Exercise Treatment for Major Depression: Maintenance of Therapeutic Benefit at 10 months. Psychosomatic Medicine, 2000, 62 (pp 633-638)

3. Baharm ME, Pourvaghar MJ, Effect of 12 weeks of Pilates exercise on improvement of symptoms in elderly women with mild depression. International journal of Sport Studies 2014, Vol 4 (11) (pp 1409 - 1414)

4. Bloomer RJ, Golfarb AH, Anaerobic exercise and oxidative stress: a review. Canadian Journal Appl. Physiol 2004 Vol, 29 (pp 245 – 263)

5. Bloomer RJ, The effects of exercise on oxidative stress bio-markers. Advanced Clinical Chem, 2008, Vol 29. (pp 245- 263)

6. Blumenthal J, PhD, Sheets ES, Exercise and the Treatment of Clinical Depression in Adults. Sports Medicine, Feb 2002; 32 (12)

7. Blumenthal JA, Babyak M, Moore KA, et al, Effects of exercise training on patients with major depression. 1999 Arch International Medicine 159 (pp 2349 – 2356)

8. Blumenthal, JA, Michael A, et al, Exercise and pharmacotherapy in the treatment of major depression disorder. 2007 Psychosom Med Vol 69 (pp 587 - 596)

9. Borzou S, Arasto S et al, The effects of Aerobic Exercise on the quality of life of the elderly. Journal of Aging 2011, Vol 19 (pp 47 - 51)

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Appendix: 8 week teaching schedule

Mat Exercise Mat Exercise Cadillac Exercise

Foot work Foot work Foot work series

Abdominal work Hundred prep Abdominal work Rol l up with RUB

Hip work Hip work Bas ic leg series

Spinal Articulation

Stretches Stretches

Side Spl i t Si tting back

Sitting forward

Arm Work

Arm Work Triceps prone Leg work Single leg series

butterfly

Leg work Hamstring curl Back extension Prone 1

Hip opener

Side s tretch

Back extension Swan bas ic

Week 1 x 2 sessions

Reformer Exercise

Wunda Chair Exercise

Week 2 x 2 sessions

Ladder Barrel Exercise

Warm up/ Foundation

rol l down, pelvic curl

spine twist, chest l i ft +

chest l i ft with rotation

Warm up/ Foundation




Foot work series

Supine leg series

Spinal Articulation

Standing hamstring

s tretch

Gluts , Hamstrings ,

Adductors , hip flexors

Full Body Integration F/I


Scooter knee s tretch group

Reverse knee s tretch

Arms s tanding series

Side arm kneel ing

Lateral flexion/ Rotation


Mat Exercise Mat Exercise

Foot work Foot work

Chest l i ft

Hip work

Stretches Hip work

Arm Work Stretches

Leg work

Arm Work

Side over prep Leg work Jumping series

swan prep

Week 3 x 2 sessions

Reformer Exercise



Week 4 x 2 sessions

Reformer Exercise

Step Barrel Exercise

Warm up/ Foundation


spine twis t, chest l i ft + chest l i ft

with rotation

Warm up/ Foundation


spine twis t, chest l i ft + chest l i ft

with rotation

Seated foot work series

Supine foot work series

Abdominal work

Standing & reverse pike

Abdominal work

Supine leg series

Reach us ing pole

Spinal Articulation

Overhead s tretch

Shoulder s tretch 1 & 2

Supine leg series


Round & flat back knee

s tretch group

Spinal Articulation

Arms supine series

Shoulder s tretch lying

s ide

Single leg skating


s tomach massage

series

Hamstring curl

Arms kneel ing series


Back extension


Spine twis t supine

Back extension

swan dive prep


Foot work Hip opener Foot work

Hundred

Hip work Hip work

Stretches Stretches Kneel ing lunge

Up s tretch 1

Arm Work Elephant

Frog back Arm Work

Leg work Leg work forward lunge

frog front Mermaid

Side l i ft

Week 5 x 2 sessions

Cadillac Exercise


Week 6 x 2 sessions

Reformer Exercise


Warm up/ Foundation


spine twis t, chest l i ft +


Warm up/ Foundation


spine twis t, chest l i ft +


Foot work series

Abdominal work

Warm up series

Abdominal work

Single leg series

extended frog and reverse

Spinal Articulation

Monkey origina l

Spinal Articulation

bottom l i ft plus

extens ions

Shoulder s tretch


Thigh s tretch with RUB


Tricep press & shrugs

Arm s i tting series

Leg press s tanding


Side kneel ing s tretch


Back extension

back extens ion s ingle arm

Back extension

swan on the floor


Foot work Foot work

Abdominal work Abdominal work

teaser Hip work

Hip work short spine

tower prep Stretches

Stretches

Arm Work

saw Leg work

Arm Work

Leg work squats Back extension

Back extension Prone 1 & 2

Week 7 x 2 sessions

Cadillac Exercise


Week 8 x 2 sessions

Reformer Exercise



Warm up/ Foundation




Warm up/ Foundation




Foot work series

Seated foot work series

Rol l up with RUB

Standing & s i tting pike

Supine leg series

Bas ic leg series

Spinal Articulation

Spinal Articulation

Shoulder s tretch 1 & 2

Gluts , Hamstrings ,

Adductors , hip flexors


Up stretch 1 & 2


cat s tretch kneel ing

Side arm kneel ing

series

Single leg skating

s i tting s ide prep

Hamstring curl

shoulder adduction

double arm


s ide over on box

pul l ing s traps 1 & 2


s ide l i ft with ptb

title: a review of literature on treating depression...

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