Depression and the Starting Strength Model
By: David Puder, MD
I recently interviewed Barbell Logic producer Trent Jones about his struggles with depression and anger, and how Starting Strength has helped him in his journey. We also discussed a recent meta analysis on the benefits of strength training for depression.
Prescribing Strength Training for Depression
Trent’s transformation—both physical and emotional, is a great tool for taking control of total health. But, it’s one that most people don’t think about when they think about classic depression.
Most patients that come to me don’t expect me to recommend a weight lifting regimen when they step into my office for psychotherapy and medication management. Of course, medicine and talk therapy are incredibly helpful. Strength training is just one of the tools in my toolbelt for depression, but it’s a very powerful additive force for long-term treatment success.
I wanted to zoom in on the meta-analysis and explain it in more depth for your understanding.
In the recent large meta analysis1, the overall effect size (the amount of change the strength training group had, compared to the control groups) for strength training was 0.66 (95% CI, 0.48-0.83; P< .001). Learning to understand effect size can be very important as it is a common number given in scientific studies, so I will mention a few things here to make sense of this.
Effect size is the difference between treatment and control group, expressed in standard deviation units, where an effect size of 1 means that the treatment arm moved one standard deviation away from the control group. An effect size of 0.8 is a large effect, 0.5 is a moderate effect, and 0.2 is a small effect (Cohen, 1998). It compares two treatments, and looks at how far they move away from each other.
The larger the effect size, the better the treatment.
As a point of reference, a different meta-analysis of 37 psychotherapy studies looking at the treatment of depression found an effect size of 0.73 (Robinson, 1990). Another recent study on antidepressant medications for depression found that the effect size for mild to moderate depression was 0.11 and for severe depression the effect size was 0.17, very severe was 0.47, and most severe (HRSD >27) was 0.81. This means that for mild to moderate depression, medications are not that much better than placebo.
However, placebos are powerful, in and of themselves. A doctor (a trusted individual) giving a medication has a powerful effect, even if the medication does not do anything more than a sugar pill. Further medication studies show that placebos can change the brain—just from the power of belief.
So part of the effect size being smaller until the higher rates of depression is because they are comparing the medication against a placebo. For severe depression I still use medications, therapy, and also continually urge patients to do the Starting Strength program.
In this meta analysis, they also found that total volume of resistance training, participant health status, and previous strength status didn’t really matter. However, sometimes when a group of studies are looked at simultaneously they miss the nuance of well designed individual studies. One study in particular showed the more strength gained the larger reduction in depression.
It didn’t matter how out of shape people were when they started, it only mattered that they started the strength training program—it still helped depression. This is something that as a doctor, I’d rarely say, but: You don’t have to comply fully in order to reap benefits. You don’t have to be an expert lifter to gain benefits.
If you can train even two days a week, you will still get benefits from that.
Nevertheless, the people who gained the most strength had a correlated decrease in depressive symptoms. Basically, the more strength you gain, the more effective it is for treating depression.
The other key is to notice what Trent noticed: exercise and even unregimented, random training isn’t as effective as a systematic lifting program.
On another level, strength training helps patients with developing assertiveness, which increases confidence and happiness. To understand this, we have to talk about anger. We often think anger is a bad feeling, a wrong emotion. But it’s not. Anger has an adaptive function. The primal purpose of anger is so we can protect ourselves, loved ones and overcome obstacles (like being disconnected with a loved one). When we feel anger, hormones like adrenaline result in courage to fight the bear that’s trying to attack us. Or to pay attention to our spouse so we can remove the emotional obstacle between us and feel close to them.
When we feel angry, it may be a message that someone has violated our space, talents or abilities and we need to therefore allow the anger to empower us to put up a boundary. Most often, in our childhoods, demonstrating anger was not acceptable behavior. As we age, we keep that messaging and suppress our anger inwardly, leading to a lack of assertiveness. That lack of assertiveness then can lead to further issues like less respect for ourselves in relationships, which develops from being constantly getting “run over.” Then we tend to misplace our anger—like how Trent wouldn’t confront his boss for overstepping his boundaries, but would go home and throw plates to act out his aggression.
When people start strength training, they are, quite literally, adding stress to their body. But, with a systematic training program, the stress is sequential and leads to adaptation. When we do something difficult, we practice courage. Over time we not only grow strong, but also more competent to meet the huge challenges that life throws our way.
Like Trent, I used to be an athlete in college. When I started medical school, and on into residency, I exercised, but didn’t strength train the way I do now. It has changed my life.
As a psychiatrist, I write prescriptions for medicines for severe mental illness. I prescribe talk therapy to almost everyone as part of the process of overcoming. And I also write a prescription for strength training. In my therapy practice, I’ve personally seen the results of the training on decreasing depression in my patients—it absolutely helps.
The Link between Empathy and Self-Care
Some of my patients who are incredibly empathic also struggle with depression. They are so empathic, so giving, that their schedules often reflect this—they don’t make time for themselves.
Strength training can help, as it did with Trent, to develop assertiveness and even deal with chronic, unresolved anger. Self care through strength training can aid in decreasing depression.
Empaths naturally lean towards being professional therapists, or are life-giving people in their myriad of relationships. As professional caretakers, it’s important to make time in our schedules for ourselves to do things like strength training.
In summary, doing Starting Strength improves brain function and helps in the treatment in depression. Hopefully this is something you can understand and use to inspire yourself, continuing the hard work and also share with others who struggle but don’t have this important, life saving, information.
1 Gordon, B. R., McDowell, C. P., Hallgren, M., Meyer, J. D., Lyons, M., & Herring, M. P. (2018). Association of Efficacy of Resistance Exercise Training With Depressive Symptoms: Meta-analysis and Meta-regression Analysis of Randomized Clinical Trials. JAMA Psychiatry.