Author's reply to the Letter to the Editor "Exercise is medicine for depression: Even if the "pill" is small" of Hallgren, Stubbs and Vancampfort

In their letter, Hallgren, Vancampfort and Stubbs supported our claims1 that more systematic efforts are required to increase physical activity and cardiorespiratory fitness in psychiatric settings, and to better utilize the potential of exercise as a treatment in psychiatric care. They also shared our view that behavior skill training may be a promising avenue to increase exercise adherence. In this respect, Mota-Pereira et al (2011) showed that regular and moderately intensive walking improved symptoms of depression in treatment-resistant patients with major depressive disorders. Specifically, they employed both supervised and non-supervised techniques. The latter consisted of reminders to exercise by placing sports shoes by the front door, leaving a note on the main door or using cell phone reminders with a specific ringtone. Further, “social enhancers” were employed; patients were encouraged by and involved family members, in order to both remind them to be physically active and to exercise together with them. We hold that such pragmatic tricks are more efficient, compared to simply advising patients to increase their cardiorespiratory fitness levels. Further, we claim that “cardiorespiratory fitness” seems to be a rather academic, intellectual and “bulky” concept, which may be difficult to translate to patients in a comprehensible form (How does cardiorespiratory fitness feel, and what should I do to improve it?). Accordingly, we claim that the “next generation” of exercise interventions targeting patients with major depressive disorders should take into account which environmental, social and above all cognitive-emotional processes might boost and stabilize the social and cognitive determinants of exercise regulation. As a result of this, questions arise as to why it seems so difficult, even for people without psychiatric diagnoses, to maintain regular exercise regimes, resulting in the fact that physical inactivity is among the main causes of both somatic and psychiatric diseases worldwide. We thank Hallgren, Vancampfort and Stubbs for their appreciatory comments and for sharing their own ideas. Hallgren et al complemented our perspectives with several important points, which we would like to comment on.