Ex-professional cyclist Tyler Hamilton (in the news again recently, which you will know unless you were asleep for 60 minutes) claimed in 2009 that his second positive test for doping (DHEA) was the result of his taking a herbal remedy to counter longstanding depression (Bonnie Ford of ESPN as usual does an excellent job of summarising here). Hamilton is not the only professional cyclist to have suffered from depression during or after their career, and I have often wondered about the relationship between training workload as a cyclist and mental health. I recently read two blog posts about depression by active cyclists (Scientist, you’re a failure & Drugs and Mental Healthcare) and this got me thinking about how exercise and mental health interact. In this post I write about my own experiences, share some academic research on the topic, and speculate a bit about depression and cycling in general. I am not a mental health professional (although I am an academic working in the area of empirical psychology) so please take my words with this in mind.
My current training load (if you can call it that) is circumscribed by my role as a parent, partner and academic: I tend to ride once or twice a week, and rarely ride longer than about 60-80 km in a day: most times a ride is 40 km: it is, however, very hilly here so the rides include plenty of variation, and for strength work I have some monster climbs that are easily supplemented with a child on a child seat or a child-stoked tandem. I rarely do intervals, and do most of my riding outside, not on a trainer. This was not always the case: until not long ago I was riding around 100-250 km per week (sometimes further), including interval sessions. Most of my riding at this peak was aimed at building endurance and some degree of speed (I am not naturally fast) to make randonneur events more comfortable and enjoyable, were social rides with my partner, or took the form of randonneur events themselves. Every year for four years my partner and I holidayed in France, conquering big climbs, including the Spandelles (but also some you would be more familiar with). Our bible was altigraph (more on this another day).
I have a family history of depression including bipolar disorder, suicide and clinical depression. Until quite recently I managed my own depression without having to visit a doctor, counsellor or therapist. Although I have taken non-prescription drugs, and still drink alcohol, it is cycling that has often seemed to offer some control over my mood (among other things). Like many suffering from underlying long-term depression, I have learnt when to rest: physical insults (colds and flu in particular) often trigger depressive episodes and need to be watched out for. Since having had Epstein-Barr in my twenties, I have not recovered as well from physical stresses, and I ignore physical illness at my peril, however minor it may seem to others. This means that cycling is both a source of relief, and a danger to me, but it was only recently that this was highlighted to me.
Following the death of my father, I have had two more serious episodes. The first lasted about six weeks and although I was off work, I received some very good help from a counsellor, and was able to rationalise my illness as a response to grief. The second was much more serious, and (if I am to believe the professionals and friends that helped me) mainly triggered by workplace stress. I recovered from this episode and have been ‘well’ since: I took six months off work, received counselling, and spent about two months taking citalopram, an oft-prescribed SSRI in the UK with side-effects I will never forget.
I spent a lot of time in doctors’ offices, but it was an interview with my workplace occupational health practitioner which gave me pause for thought regarding cycling as a kind of self-medication: she reviewed a range of obvious factors in my life which might have impacted on my mental health and was very keen to advise me to moderate my exercise regimen. At the time I only had one child, and had just begun to regain some time to ride, and saw this as a positive influence on my mood.
Since her intervention I have become more aware of the tightrope I walk in relation to cycling: it does make me feel good more often than not, but I have also had experiences before, during and after rides where I have had quite extreme negative episodes which do not seem to be coincidental. Sometimes the stress of getting ready to go out on a ride seems to be a trigger (not being able to find my pump or glasses; realising that the bike I want to use is unroadworthy or unsuitable for the weather); sometimes I have had to stop by the side of the road, completely numb; and sometimes after a ride I have felt like I never want to ride again. I know what the bonk feels like, and I know that these feelings, although sometimes brought about by exertion (or its anticipation) are different.
Cycling (among other forms of exercise) is often seen as a way of rising one’s spirits, a source of pleasure, even an ecstatic pursuit. Indeed, some make big claims for cycling as a way of combating depression:
Since one way to decrease stress, and perhaps even to decrease depression, is to exercise, the cycling community needs information about depression to be able to detect it and when necessary, refer people for appropriate treatment when cycling is not enough.
Nierenberg and Ostacher see their in their article for VeloNews as educative, and never suggest that cycling itself might play a role in instigating or worsening depressive episodes. They even suggest that a sudden reduction in training workload might be factor in triggering depression. Nierenberg and Ostacher are only telling half the story here. Although there is indeed much research that suggests exercise can be an effective part of treatment or prophylaxis for depression (see e.g., Dunn et al, 2005 for a classic controlled study), and anecdotal evidence for this abounds, two systematic reviews (Lawlor and Hopker, 2001; Larun et al, 2006) have found the evidence-base pretty weak, even for the general population, so we should not get to too excited yet about exercise being a magic bullet.
More importantly though, most studies look at the response of untrained people, not at recreational or competitive cyclists (as my partner was quick to point out when I discussed this with her). Indeed, one paper’s abstract (Martensen, 1990) notes that:
In general, depressed patients are physically sedentary. They have reduced physical work capacity but normal pulmonary function compared with the general population. This indicates that the reduced fitness level is caused by physical inactivity and is a strong argument for integrating physical fitness training into comprehensive treatment programmes for depression.
For trained, active cyclists the relationship between mental health and quantity and quality of exercise is undoubtedly more complex. As Nierenberg and Ostacher remind us, competitive cycling itself can be source of stress, although they downplay the double-edged nature of physiological stress: it makes us feel better and builds strength and endurance, but in excess leads to abnormal immune response, chronic fatigue, mood disturbance, and injury. It has even been suggested (Armstrong and van Heest, 2002) that overtraining syndrome (OTS) is so close to clinical depression that it might respond well to the same medications.
Hence it is possible that for athletes suffering from depression, less exercise might be the answer, and not more. It is also possible that within a culture where drugs are regularly used to combat the effects of excessive training or racing load (to maintain hematocrit, for example, or testosterone levels) athletes turn to off-prescription SSRIs or other anti-depressants when they become depressed, or are self-medicating with alcohol or cocaine, rather than changing their workload or getting the psychotherapeutic help that they need. At least two high-profile professional cyclists who seem to have taken this path have ended up dead, and Jesus Manzano, ex-Kelme, is better placed than I to place anti-depressants in this rather grim context:
The drugs lead you to other addictions. The anti-depressants almost automatically accompany other doping treatments. I took up to 8 pills of prozac a day when I was racing… …Prozac cuts the appetite, keeps you in another world, a world where you’re not afraid of what you’re doing. You’re no longer afraid to inject yourself with all the crap. It takes you to a world where you don’t ask any more questions especially you don’t ask your doctor questions either or your sporting director. Then there are periods where you must stop doping you feel like superman. Then one day all of the sudden it stops and you become dramatically depressed. Look at Pantani, Vandenbroucke and all the others we don’t even talk about. They are numerous other cyclists and former cyclists that are addicted to cocaine, heroin and other medications. It’s not just in the world of cycling.
I don’t race, and no-one is stupid enough to pay me to ride, but I know that for me, exercise is not a simple cure for depression, nor even for feeling unhappy. It can lift mood, but it can also contribute to the problem. The key here is to aim for what a psychobiologist would call ‘optimal arousal': do enough to make you feel good, and know when to rest. Seems like commonsense, but having sometimes gone over the edge, maybe I needed reminding…