David Downer is the author of www.NordicWalkingStepByStep.com owner of www.NordicWalkingCommunity.com and former publisher of Nordic Walking Magazine.com

 David Downer

Author of the article “Mental Wellbeing and Nordic Walking” is Malcolm Jarvis who was designer and editor of the former online magazine “Nordic Walking Magazine.com”

Malcolm Jarvis

Mental Wellbeing and Nordic Walking 

Foreword
As this article discusses a particular illness, namely „depressive disorder‟ (clinical depression), I feel compelled to give a number of caveats: I am not a medical practitioner but I can approach this topic sympathetically knowing fully what depressive illness feels like. As something I have experienced intermittently throughout my adult life I have taken a keen interest in its causes and treatments – hence this article. Whilst self help is essential I would nonetheless urge anyone who thinks they are suffering from depression and/or anxiety to seek the help of a medical practitioner. Please take care.

Introduction
We all feel depressed or anxious from time to time. Perhaps you are tired and have “got out of bed the wrong side” or you are facing unusual pressures at work. Or maybe you are generally unwell and this has plunged you into a low mood. More seriously however, you will likely experience real sorrow and despondency as a consequence of the loss of employment or following the death of a loved one. All of this experience is part of the human condition and whilst often unpleasant and unwanted we would not normally conclude that these situations require medical intervention; in other words, we would not classify these mood events as an illness. However, for many individuals depression can reach such a level that it becomes debilitating and extremely distressing, so much so that day to day activities can become almost impossible. Depression is a disorder of mood which is virtually incomprehensible to those who have not had the experience and urging a sufferer with the epithet “pull yourself together” is not helpful.
Whilst depression and anxiety are two separate disorders they very often co-occur and studies suggest that over half of the number of individuals who visit their physicians during an episode of depression will also have symptoms of anxiety (comorbidity). However, this complication need not concern us here, as you will see, exercise has been shown to be a broad spectrum form of treatment which can help to ameliorate the effects of both conditions.
The UK charity Mind lists no fewer than 23 symptoms of depressive disorder (or clinical depression) which includes the following: [1]

• Feeling low spirited for much of the time, every day
• Feeling numb, empty and despairing
• Finding it hard to concentrate or make decisions
• Crying a lot
• Feeling helpless
• Distancing yourself from others; not asking for support
• Experiencing a sense of unreality
• Waking up early, having difficulty sleeping, or sleeping more
• Thinking about suicide

• A deficiency in neurotransmitters
• An imbalance between neurotransmitters
• Dysfunction in the nerve receptors themselves

Anti-depressant medication targets neurotransmitters, serotonin in particular, hence there is a class of modern drugs known as Serotonin Re-uptake Inhibitors, or SSRIs (see below).
A more recent focus has been on the neuronal circuitry itself and in particular how neuronal function is regulated by compounds known as neurotrophins. It is thought that a shortage of one of these substances, brain- derived neurotrophic factor or BDNF, plays a significant role in depression.
(There are many complex reasons why brain chemistry can go awry and those readers who wish to learn more about this complex subject might like to look at some of the literature identified in „Resources‟ at the end of the article.)

Magnitude of the Problem
According to figures published by the UK charity the Mental Health Foundation [2] the number of prescriptions written for antidepressants has almost tripled from 9.9 million in 1992 to 27.7 million in 2003. Over this same period the annual cost of prescriptions for antidepressant drugs has risen from £18.1 million to £395.2 million ($26.4 million to $575.8 million). These increases have coincided with the introduction of the new class of drugs known as Selective Serotonin Re-uptake Inhibitors, or SSRIs – see also below. Furthermore, back in 1997 the World Health Organisation (WHO) [3] considered that depression was the second greatest cause of disability in the world. Figures published in 2007 suggest that the burden of depression was comparable with diseases such as angina, asthma and diabetes. According to one report, depression was described as a condition that is “chronic and recurrent in nature, impairs family life, reduces social adjustment, and is a burden on the community”. [4]

A Suitable Case for Treatment
Since the mid twentieth century the usual treatment for depression in primary care has been the use of antidepressant medication. In many ways this paralleled the use of minor tranquilizers for the treatment of anxiety and I recall in the 1960‟s when people who were described as “suffering from nerves” were prescribed “Valium” (Diazepam).
Earlier antidepressants were associated with many unpleasant side effects which included sedation, dry mouth, blurred vision, nausea, postural hypotension, weight gain, sweating, tremor and many more. For some, the side effects were distressing and in some respects were more troublesome than the illness being treated. My own experience taught me that these forms of medication (known as Tricyclic antidepressants) actually reinforced the experience of “unwellness” turning the whole episode into a period of pre-occupation. In the late 1980‟s a new antidepressant was introduced, Selective Serotonin Re-uptake Inhibitors, or SSRIs the best known being Prozac (Fluoxetine). The latter quickly became the drug of choice as it was better tolerated than earlier substances and as recently as 2002 there were 22.2 million prescriptions issued in the US alone. However, these drugs are not free from side effects and the British National Formulary lists about 40 possible outcomes. [5] The pharmacological benefits of antidepressants generally take several weeks to have any perceptible effect (it puzzles me why some people consider the use of an SSRI as a recreational drug given the long wait involved). Perhaps the most difficult aspect of some of the SSRIs is discontinuation. Whilst they are not addictive in the sense they create physical or mental dependence, there can be some very unpleasant effects following abrupt cessation and a very gradual tapering off is essential. [6] “Talking therapy” is also quite effective but in the UK there is usually a long wait before a therapist can be seen and many who have depression are usually desperate for a more rapid form of treatment – hence the use of medication as the usual first choice.

An Alternative Therapy
There is another approach to mild or moderate depression which has shown to be effective and that is exercise. A substantial body of research now shows that exercise can be as effective as medication and in the UK the Chief Medical Officer has stated: Physical activity has been shown to be effective in reducing clinical symptoms in those diagnosed as severely, moderately or mildly depressed. Four studies have indicated that physical activity is at least as effective for treating depression as psychotherapy. Two studies have shown that physical activity can be as successful at treating depression as medication. For example, one study has shown that, after 16 weeks, exercise equalled the effect of a standard anti-depressant drug. A follow-up study showed that, after 6 months, those who continued to exercise were more likely to recover than those solely on medication. Physical activity is also a potential alternative for the many patients who do not wish to take medication for depression because of side effects. [7] And his report further states: Physical activity has modest beneficial effects for people with generalised anxiety disorder, phobias, panic attacks and stress disorders. [8] In response to the Chief Medical Officer‟s report the UK National Institute for Clinical Excellence (NICE) now recommends that patients with depression should be advised of the benefits of following a structured and supervised exercise programme as a first line treatment option. It is now thought that exercise stimulates BDNF (see above) and that neurotransmission is also enhanced. Unlike drug interventions, exercise has a more „holistic‟ action on the brain affecting a whole smorgasbord of chemicals including serotonin, norepinephrine, dopamine, acetycholine and others. Furthermore, what used to be thought of as an endorphin rush (the runners high) is now considered might possibly be a consequence of naturally occurring cannabinoids, a substance which resembles those of the active constituent of cannabis. [9] (This might partly explain why exercise can be “addictive”!)
In addition to the more direct chemical effects, exercise also promotes a range of psychological and emotional benefits which can help greatly with both depression and anxiety:

•  A boost in self confidence in meeting the challenges of an exercise regime
• A shift in preoccupation away from your depression whilst exercising – in other words, distraction
• Doing something positive gives a feeling of self management
• Learning a skill, such as Nordic Walking, increases a sense of self efficacy

It was initially thought that exercise had to be vigorous in order to produce the desired psychological benefits. However, current research suggests that moderate exercise is effective and that a daily 30 minute brisk walk is all that is required to show improvements. [10] However, for some depressed individuals, beginning an exercise regime may prove to be an almost impossible task. This is in the nature of the illness and for some just getting out of bed each morning can be a struggle. A combination of drug therapy which is followed later by exercise may be more helpful in these circumstances. A course of Cognitive Behavioural Therapy, or CBT, could then reinforce the regime and eventually hit the condition “with all guns blazing”.

Up a Notch to Ecotherapy
Whilst it has been shown that exercise can both prevent and alleviate the symptoms of depression it is has also been demonstrated that exercise outdoors in a “green” setting can add considerable value. The UK charity Mind recently commissioned the University of Essex to investigate the effects of exercise taken in a natural setting and their report entitled “Ecotherapy” shows encouraging results. The report states: Empirical evidence shows exposure to nature has substantial mental health benefits. Equally, participating in physical activity is known to result in positive physical and mental health outcomes. So, what happens when you combine the two? A number of research projects have been carried out by the University of Essex, involving a total of more than 3,000 people. This research has identified three key benefits from green exercise:

• It improves psychological wellbeing by enhancing mood and self esteem, while reducing feelings of anger, confusion, depression and tension
• It has a wide range of physical benefits
• It facilitates social networking and connectivity [11]

The study also found that exercise indoors was not as beneficial from a psychological point of view. Two walks were compared; one taken in a country park and the other in a shopping mall. The report states: There was significant difference in the overall effect on mood, strongly favouring the outdoor walk.......Overall, the green walk improved mood by an average of 13 per cent whereas measures for the indoor walk show that on average mood was unaffected. [12]
The report concludes with the following message: Ecotherapy is emerging as a clinically valid treatment option for mental distress, and a core component of an adequate public health strategy for mental health......It directly benefits mental health (lowering stress and boosting self esteem), improves physical health (lowering blood pressure and helping to tackle obesity), provides a source of meaning and purpose, helps to develop skills and form social connections. [13] Needless to say, being in a pleasant green environment does not work for everyone:

Oddball: Why don’t you knock it off with them negative waves? Why don’t you dig how beautiful it is out here? Why don’t you say something righteous and hopeful for a change? Moriarty: Crap! Kelly‟s Heroes 1970

Eco-therapeutic Nordic Walking
Thus far I have identified that moderate exercise taken in a green environment, perhaps supported by CBT, can be an effective means of dealing with depression and anxiety. Can the adoption of Nordic Walking as the exercise modality add any further benefit?

I know of only one Nordic Walking study which has involved subjects who were diagnosed with depressive disorder and this was carried out at the Department of Polyclinic and Family Medicine at the University of Tartu, Estonia. This particular study did not compare other exercise modalities, nor a control, but it did demonstrate that some of the subjects who took part experienced an improvement in their symptoms. [14] There have been other studies which have examined mood states in individuals and these have compared Nordic Walking with other activities. However, as far as I am aware these particular tests did not involve subjects who were suffering from major depressive disorder. Nonetheless they all showed that Nordic Walking did improve psychological wellbeing.
My personal view is that Nordic Walking can bring additional benefits and my suggestions are as follows:

• It has been suggested that repetitive loading of the limbs provided during running increases the production of BDNF. [15] In Nordic Walking repetitive loading is increased by adding in the pushing action on the poles. Might this enhancement impact further upon the production of BDNF?
• The rhythmical action of walking or running has been shown to produce a “meditative” state in many individuals. With the use of poles the sense of rhythmic action is increased as the hands and arms are engaged strenuously.
• The mastery of “pole technique” rewards the individual with a greater sense of efficacy.
• Nordic Walking gives the individual “more to do” and this additional focus acts as distraction.
• It‟s free and it‟s great fun.

As for me, it‟s an ongoing “experiment”, and so far so good!

References
[1] Stewart, George. (2008 revision) Understanding depression, Mind
[2] Halliwell, Ed. (2005) Up And Running, Mental Health Foundation
[3] O‟Neill, Emer. The Inside Story – The Impact of Depression on Daily Life, Depression Alliance
[4] ibid
[5] Mehta, D.K. (Ed) (2002) British National Formulary, British Medical Association & Royal Pharmaceutical Society of Great Britain
[6] ibid
[7] Donaldson, Sir L. (2004) At least five a week; Evidence on the impact of physical activity and its relationship to health, Department of Health
[8] ibid
[9] Hamilton, A. (ED) (2010) Runners high: a new explanation, www.pponline.co.uk
[10] Martinsen, EW & Raglin SR. (2007) Themed Review: Anxiety/Depression: Lifestyle Medicine Approaches, American Journal of Lifestyle Medicine
[11] Mind (Charity). (2007) Ecotherapy: The green agenda for mental health, Mind
[12] ibid
[13] ibid
[14] Sulja, K., Pechter,U. et al, (2009) Physical Activity of depressed patients and their motivation to exercise: Nordic Walking in family practice, in International Journal of Rehabilitation Research, Lippincot Williams & Wilkins
[15] Vaynman, S. & Gomez-Pinilla, F. (2005) License to Run: Exercise Impacts Functional Plasticity in the Intact and Injured Central Nervous System by Using Neurotrophins, in Neurorehabilition and Neural Repair, Sage
Resources

For readers wishing to learn more I recommend the following publications and website addresses:
Mind (National Association for Mental Health) web: www.mind.org.uk A highly respected UK charity providing an extensive and freely available catalogue of publications online.

“Ecotherapy: The green agenda for mental health” published by Mind. An easy to read 35 page report about the benefits of activity outdoors.

Ratey, J.R. & Hagerman, E. (2008) Spark, How exercise will improve the performance of your brain, Published by Quercus. An approachable account of the role of chemistry in the brain which includes the role of BDNF (the author calls this substance “Miracle-Gro” for the brain).

U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. This huge document can be downloaded free of charge as a PDF document. The Executive Summary is more digestible as the main report runs to almost 500 pages! Web: www.surgeongeneral.gov

Mental Health Foundation – a UK charity taking an integrated approach to mental health. They published the highly influential report “Up and Running” which is available at no cost online. Web: www.mentalhealth.org.uk

Depression Alliance – Another UK charity which has an excellent online service providing guidance about treatment etc. web: www.depressionalliance.org

Wasserman, D (2006) Depression: the facts, Oxford University Press. An approachable text book written for patients, carers and professionals.

Yeung, A., Feldman, G., et al, (2010) Self-Management of Depression. Cambridge University Press. An excellent book discussing the value of self management, including exercise and meditation.