Dr Nicholas Fabiano Hello, everyone.  My name is Dr Nicholas Fabiano,   and I’m a Psychiatry Resident at the University  of Ottawa, and I’m also a Researcher interested   in the overlap between mental and physical  health. And I’m particularly interested in   lifestyle interventions, so exercise, diet or  sleep, for mental health, and in this video,   we’re going to talk about exercise and  depression in children and adolescents. So,   just to start off, we’ll speak about some of the  epidemiology behind this. So, we know that the   worldwide prevalence of antidepressive disorder  in children and adolescents is about 2.6%.   However, symptoms of depression,  particularly during the COVID-19 pandemic,   had a prevalence of about 25%, so that’s one  in four people, which is quite significant. The next thing that’s important to  really discuss is the presentation   of depression and how do we actually diagnose  it, from the presentation of a Clinician? So,   when we’re looking at depression, we’re looking  for five or more of the following symptoms that   are present during the same two-week period and  represent a change from previous functioning.   And as I go through the list of symptoms  here, the child must display at least one   of the first two symptoms, as well  as some of the rest below that. So, we’re first looking at a depressed mood,  however, in children, this can be presenting more   as an irritable mood, in comparison to the adults.  They may also display reduced interests. So,   this can be a lack of interest in things  that they used to do, such as, exercising,   playing videogames, hanging out with friends. It’s  just a change from their baseline. You may also   recognise sleeping changes, and this can go either  way. This can take the form of sleeping too much,   or too little. There may also be feelings of  excessive guilt or worthlessness. They may also   display low energy, whereby they just don’t  have the energy to, kind of, get tasks done   throughout the day. This may manifest as low  concentration, whereby there’s difficulties at   school with different tasks and focusing. You may also see changes in appetite,   and in children, it’s particularly useful to  look for failure to make expected weight gain,   which can be a sign of depression. You may also  see psychomotor changes, and this is just a fancy   word for someone being either very restless or  feeling very, very slowed down. And the last   part that we look at, which is very important, is  these recurrent thoughts of death or suicide. And   it’s very important to ask, because sometimes  a child may be experiencing these, but not feel   comfortable readily talking about them, so  opening that discussion is very important. Something that leads into this is the topic of  sedentary behaviour, or a fancy word, again,   for just sitting still a lot, because we  know that children spend over 50% of their   waking time in sedentary behaviours, and a  large portion of this is due to screentime.   This can be on the computer, on your phone,  on an iPad, anything where you’re essentially,   sitting down and not moving around a lot.  And the reason why we’re talking about that   in this topic is because we know that there’s  a dose-response relationship between increasing   sedentary behaviour and risk of depression. And  we also know, beyond the mental health detrimental   effects of sedentary behaviour, higher amounts  of this sedentary behaviour are associated with   the following poor health outcomes. So, we see  increased adiposity, poor cardio-metabolic health,   reduced fitness, behavioural conduct issues,  reduced sleep duration, and again, reduced mood. So, that, kind of, segues us into the topic  of exercise, and where can there be benefits   in this realm? And there seems to be a lot more  research in the field of adults in this area,   but we can extend some of those concepts in  the field of child and adolescent psychiatry,   as well, too. So, we know that in adults, exercise  has very similar efficacy to antidepressants and   cognitive behavioural therapy for the treatment  of depression, and these are two of the first-line   options that are primarily used, but we do  need more research in children and adolescents. However, as per the World Health Organization  guidelines, physical activity does confer   benefits for the following different outcomes.  So, we see benefits to physical fitness,   so that could be cardio-respiratory and muscular.  There’s benefits to cardio-metabolic health,   so that’s blood pressure, dyslipidaemia,  glucose and insulin resistance. We also see   reduced adiposity, improved bone health, better  cognitive outcomes, and this can manifest as   better academic performance, or improved executive  function, and we, again, as per the topic of this   discussion, we see benefits to mental health,  particularly reduced symptoms of depression. So, from this, there’s a recent scoping  review of 16 publications that focus   on exercise interventions for mental  disorders in children and adolescents   and found that moderate to vigorous  intensity exercise may be beneficial,   particularly for reducing depression.  And to further this, there’s been a   meta-analysis of four trials that showed  that exercise may reduce depression severity. However, it was supported by  a low certainty of evidence,   and this is due to the fact that a lot of these  trials are very small at this point in time,   and we need larger trials with longer  follow-up to really have definitive   answers. We also know from the research that  there are benefits of exercise for anxiety,   which is important because depression and anxiety  are often very comorbid with one another. So,   treating one, and both, at the same  time is ideally the best outcome. An extension to the topic of exercise and  depression is also the effect of exercise   on suicide, because as we spoke about before,  suicide is something that is very prevalent in   people that are experiencing depression, and  a lot of people that are having these thoughts   that life isn’t worth living, so talking about  it is quite important. And in the adult world,   we know that there is evidence that exercise may  reduce suicide attempts, and it’s hypothesised   to be due to reduced impulsivity. However,  we don’t have the same data right now in   children and adolescents, but it’s important  that we get research moving in that field. So, a question you might have been asking  yourself is, you know, why does exercise have   these antidepressant effects? And there’s a lot of  different hypotheses in terms of what’s going on,   and I thought it would be helpful just to  review some of the literature in that area. So,   we know that exercise leads to increased brain  volumes, so that’s changes in the hippocampus,   the anterior cingulate cortex, and the prefrontal  cortex. We also know that exercise upregulates   numerous neurotransmitters, so namely serotonin,  norepinephrine, brain-derived neurotrophic factor   and the endocannabinoid system. It also leads  to a resolution of autonomic system dysfunction,   and a reduction in the systemic inflammatory  response. So, by going through all these   mechanisms, this is really how we’re grasping how  exercise has some of those antidepressant effects. So, from this, it’s great that  we’ve now spoken about, you know,   the treatment effects of exercise, some of the  mechanisms behind it, but what recommendations   can we make to the patient sitting in front  of us? Some people find it useful to frame   this using the FITT Framework. It makes it almost  like you’re prescribing a medication to a patient,   but in the form of exercise. And FITT stands for  F-I-T-T, and what each of those components are is,   F is for frequency, so that is how many times is  that person being prescribed to exercise per week?   I is the intensity, so how hard is that person  going when they’re exercising? That can be light,   moderate or vigorous. The Type is the type of  the exercise, so that could be something like   aerobic, which is running, strength, which is  something like weightlifting, or mind/body,   which would be something like yoga. And Time is  how much time is invested per exercise session? And as I was going through some of those  parameters, you’re probably wondering,   how does someone measure intensity? What does  light, moderate or vigorous really mean? Now,   there are many ways, and you can get quite  technical in terms of what the intensity is,   but I think it’s important to give  a practical examper – example for a   patient to be able to apply, and that’s  something called the ‘talk test’. So,   you can simply explain that if you can talk  and sing without huffing and puffing at all,   you’re probably exercising at a very light  level. If you can comfortably talk, but you   don’t have enough of that air capacity to, kind  of, sing and be very calm when you’re exercising,   you’re probably exercising at a moderate  intensity level. And if you can’t say more than   a few words without grasping for breath, you’re  probably exercising at a vigorous intensity. So, from this, the World Health Organization has  made guidelines for children and adolescents aged   five to 17 in terms of what exercise could be  the most beneficial for them beyond just mental   health. And the recommendations for this stand at  that children and adolescents should do at least   an average of 60 minutes per day, on at least  three days per week of moderate to vigorous,   mostly aerobic, physical activity. And something  that we know, as well, that’s quite important,   is that young people’s attitude towards physical  activity as a treatment option is generally quite   positive, which means that they’re quite accepting  and willing to try exercise as a treatment option,   which is very important. And the acceptance of  exercise as a treatment option was predicted by   higher motivation, fewer perceived barriers  and more perceived benefits to exercise,   which highlights the importance of education  for this age group, as well, too. But beyond   just the guidelines that we discussed, it’s  important to have a few good practice tips,   because realistically, not everyone’s  going to perfectly meet the guidelines,   and it’s hard for a lot of people, for  many different reasons. So, if not meeting   the recommendations, doing some physical  activity will benefit their health overall. So, it’s also important to have a strategy  in terms of how to start physical activity.   I think it’s unrealistic for someone who hasn’t  been doing any exercise at all to be starting to   do 60 minutes per day, three days per week. So,  it’s more realistic to start small amounts of   physical activity and gradually increase the  frequency, intensity and duration over time,   and this can be really done by the FITT  principle that we just previously discussed,   whereby you track how many times per week  they’re doing it, what intensity they’re doing   and what type of exercise, and the important  thing is doing something that they enjoy. So, again, it’s important that – to provide  all children and adolescents with safe and   equitable opportunities and encouragement  to participate in exercise that, again,   is enjoyable, because this leads to better  adherence. And there’s research to back this,   that shows that essentially, positive affect  during the exercise, meaning that the patient   is enjoying the exercise, leads to subsequent  positive affect thereafter, with longstanding   benefits. And to simplify that, it pretty  much it says, if you enjoy what you’re doing,   you’re going to feel better afterwards. And  essentially, just emphasising that point that   you want to make sure that the child is able  to do something that they do really enjoy. And the last point that I wanted  to discuss, before closing off,   is that medications and therapy  can be used at the same time.   Sometimes people think that if exercise is  used as a treatment option, it’s removed   from medications or psychotherapy, which is  traditionally more of the first-line options,   but there’s likely a synergistic effect when  you’re – we’re using all of them together,   and it’s best to use all the tools that  we have available to help people in need. So, thank you for listening. I hope this  talk was helpful, and please reach out   to me with any further questions, and I’d  be more than happy to address. Thank you.