Search tips
Search criteria 


Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Gen Hosp Psychiatry. Author manuscript; available in PMC 2010 July 1.
Published in final edited form as:
PMCID: PMC2752478

The “Inactivity Trap”

In this issue of General Hospital Psychiatry, Roshanaei-Moghaddam, et al. report that baseline depression may be a significant risk factor for the development of a sedentary lifestyle or decreased level of physical exercise. To many, these findings simply document in writing a common clinical observation. One of the well-recognized symptoms of major depression is reduced physical activity, and depressed individuals often report that even previously simple tasks like shopping or going to work seem impossible when they are in the throes of their illness. But in reality, clinicians seldom can determine whether depression or reduced physical activity came first, and either is plausible. In their review of the literature on this topic, Roshanaei-Moghaddam, et al. shed light on one limb of this bidirectional relationship, and their work contributes significantly to the notion that depression can lead to the development of reduced activity and exercise.

It must be pointed out, though, that the conclusion that depression is a risk factor for the development of sedentary lifestyle is by no means iron clad. To truly establish that depression leads to diminished physical activity, one would have to follow a large group of people with constant levels of physical activity over time, some of whom become depressed and some of whom do not. Then, at the onset of depression, the trajectory of physical activity and exercise would have to be compared to the activity levels of matched individuals in the cohort who do not develop depression. Such a study is, of course, not likely ever to be done.

In the absence that type of study, the conclusions of Roshanaei-Moghaddam, et al. might be supported if treatments that specifically affected mood disturbance (and that themselves do not affect motor activity) resulted in greater physical activity as mood improves. The problem is that antidepressant treatments have a range of effects on the brain, and antidepressants themselves may affect psychomotor activity independent of their effect on mood. There is evidence, for example, that even a single dose of a selective serotonin reuptake inhibitor improves motor performance.1-3

Whether the evidence is iron clad or not, in the end the notion that depression leads to reduced physical activity is believable. Indeed, some have suggested that this association is nature's way of protecting an individual when he or she is vulnerable to harm. It has been hypothesized that depression may be “adaptive” and that the condition is an evolutionary trick intended to reduce the activity of an animal that has lost its social status in the group as a result of increasing age, infirmity, or injury.4 The evolutionary adaptation hypothesis suggests that depressed mood leads to diminished physical activity in order to reduce the chances that an animal will be attacked and to decrease the animal's need for food. In physically vulnerable individuals, depression may also provide a survival advantage by leading to social isolation, thereby decreasing the likelihood for conflict with others in the group that may result in harm. The reduced appetite and libido seen in depressed individuals may lead to a lower likelihood of competition with others in the group for resources, and changes in sleep patterns would allow depressed individuals to be more active when other more fit animals are not.

If depression somehow offers a survival advantage to frail individuals, then one would expect depression to be more common as an individual becomes more medically ill or debilitated. In fact, this is the case. The 12-month and lifetime prevalence of major depressive disorder in the community has been reported to be 5.28% (95% confidence interval, 4.98-5.57) and 13.23% (95% confidence interval, 12.64-13.81), respectively.5 However, the prevalence of depression is much higher among those who are physically ill. For example, major depression has been reported in 36.5% of patients over age 60 hospitalized with congestive heart failure,6 and is even higher in those with more severe symptoms.7 Depression has also been reported in more than half of patients with cancer in some studies.8 The more chronic medical conditions an individual has, the greater the likelihood of depression. In one study, compared to a reference group with no chronic medical conditions, the odds ratio of major depression was 2.22, 3.90, and 6.52 for patients with 1, 2 and 3 chronic medical disorders, respectively.9

While it is conceivable that depression may have offered a survival advantage in primitive societies by allowing an individual to survive a period of physical vulnerability, it is hard to view the association of depression and reduced physical activity as anything but problematic in the modern world. Frequent and regular physical exercise decreases all-cause mortality and helps prevent many physical ailments.10 It has been estimated that approximately 12 percent of all mortality in the United States is related to lack of regular physical activity.11 In fact, inadequate physical activity has been documented as an independent risk factor for the premature development of cardiovascular disease,11 and regular physical activity is associated with decreased mortality from heart disease.12 Increased physical activity may aid in smoking cessation,13 helps maintain cognitive function in older adults,14 and decreases the risk of hip fracture.15 It also enhances psychological well-being by improving cognitive function and reducing stress, anxiety and depression.16

And while exercise has health benefits for almost all individuals, it seems to be particularly important in improving outcomes in patients with heart disease.17,18 Thus, the relationship between depression and the development of physical inactivity may explain why depression is associated with an increased risk of heart disease mortality among individuals without heart disease at baseline.19 It may also explain why depression has a well-recognized association with increased cardiac and all-cause mortality among patients who have sustained a myocardial infarction.20

In many ways, people with heart disease and depression are the very group who needs to exercise most. The finding that depressed heart disease patients are more prone to physical inactivity than individuals without depression calls to mind the relationship between socioeconomic status and playing the lottery in our society. It is well-established that low-income individuals, those who should be the most cautious with their resources, actually spend a higher percentage of their income on lottery tickets than do wealthier individuals.21 As a result, the poorest in society may sink deeper in a “poverty trap,” further preventing them from improving their financial situations.21

The idea that depression might lead to reduced activity among patients with heart disease suggests the possibility of an analogous “inactivity trap” which causes depressed heart disease patients to sink further into worsening health status. It is the unfortunate result of the bidirectional relationship between depression and inactivity: depression leads to a reduced activity level, and depressive symptoms then become more severe. Berlin, et al.22 randomized individuals who exercised regularly to continued regular exercise or exercise withdrawal. They found that fatigue and somatic depressive symptoms began after a single week of abstinence from exercise and that cognitive-affective symptoms of depression were noted as early as two weeks. If depression leads to reduced physical activity, as Roshanaei-Moghaddam, et al. found, it is highly likely that the reduced activity will, in turn, lead to further depression, and individuals may fall into an inactivity trap from which there is no return.

In summary, Roshanaei-Moghaddam's work helps clarify that depression is a risk factor for the development of reduced physical activity. This adds to previously published studies on the other limb of the bidirectional relationship showing that regular physical activity decreases the risk of depression23 and that cessation of exercise may lead to the development of depressive symptoms.22 Given the numerous health benefits of exercise, extra efforts must be made to urge depressed individuals to become, or remain, physically active and avoid falling into the “inactivity trap.”


Dr. Ziegelstein is supported by grant number R24AT004641 from the National Center for Complementary & Alternative Medicine and by the Miller Family Scholar Program.


Conflict of interest: None

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.


1. Pariente J, Loubinoux I, Carel C, Albucher JF, Leger A, Manelfe C, Rascol O, Chollet F. Fluoxetine modulates motor performance and cerebral activation of patients recovering from stroke. Ann Neurol. 2001;50:718–729. [PubMed]
2. Loubinoux I, Pariente J, Boulanouar K, Carel C, Manelfe C, Rascol O, Celsis P, Chollet F. A single dose of the serotonin neurotransmission agonist paroxetine enhances motor output: double-blind, placebo-controlled, fMRI study in healthy subjects. Neuroimage. 2002;15:26–36. [PubMed]
3. Loubinoux I, Tombari D, Pariente J, Gerdelat-Mas A, Franceries X, Cassol E, Rascol O, Pastor J, Chollet F. Modulation of behavior and cortical motor activity in healthy subjects by a chronic administration of a serotonin enhancer. Neuroimage. 2005;27:299–313. [PubMed]
4. Hendrie CA, Pickles AR. Depression as an evolutionary adaptation: implications for the development of preclinical models. Med Hypotheses. 2009;72:342–347. [PubMed]
5. Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005;62:1097–1106. [PubMed]
6. Koenig HG. Depression in hospitalized older patients with congestive heart failure. Gen Hosp Psychiatry. 1998;20:29–43. [PubMed]
7. Freedland KE, Rich MW, Skala JA, Carney RM, Dávila-Román VG, Jaffe AS. Prevalence of depression in hospitalized patients with congestive heart failure. Psychosom Med. 2003;65:119–28. [PubMed]
8. Massie MJ. Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr. 2004;32:57–71. [PubMed]
9. Egede LE. Major depression in individuals with chronic medical disorders: prevalence, correlates and association with health resource utilization, lost productivity and functional disability. Gen Hosp Psychiatry. 2007;29:409–16. [PubMed]
10. Paffenbarger RS, Jr, Hyde RT, Wing AL, Hsieh CC. Physical activity, all-cause mortality, and longevity of college alumni. N Engl JMed. 1986;314:605–613. [PubMed]
11. Powell KE, Thompson PD, Caspersen CJ, Kendrick JS. Physical activity and the incidence of coronary heart disease. Annu Rev Public Health. 1987;8:253–87. [PubMed]
12. Haapanen-Niemi N, Miilunpalo S, Pasanen M, Vuori I, Oja P, Malmberg J. Body mass index, physical inactivity and low level of physical fitness as determinants of all-cause and cardiovascular disease mortality--16 y follow-up of middle-aged and elderly men and women. Int J Obes Relat Metab Disord. 2000;24:1465–1474. [PubMed]
13. Marcus BH, Albrecht AE, King TK, Parisi AF, Pinto BM, Roberts M, Niaura RS, Abrams DB. The efficacy of exercise as an aid for smoking cessation in women: a randomized controlled trial. Arch Intern Med. 1999;159:1229–1234. [PubMed]
14. Weuve J, Kang JH, Manson JE, Breteler MM, Ware JH, Grodstein F. Physical activity, including walking, and cognitive function in older women. JAMA. 2004;292:1454–1461. [PubMed]
15. Feskanich D, Willett W, Colditz G. Walking and leisure-time activity and risk of hip fracture in postmenopausal women. JAMA. 2002;288:2300–2306. [PubMed]
16. Warburton DE, Gledhill N, Quinney A. Musculoskeletal fitness and health. Can J Appl Physiol. 2001;26:217–37. [PubMed]
17. O'Connor CM, Whellan DJ, Lee KL, Keteyian SJ, Cooper LS, Ellis SJ, Leifer ES, Kraus WE, Kitzman DW, Blumenthal JA, Rendall DS, Miller NH, Fleg JL, Schulman KA, McKelvie RS, Zannad F, Piña IL, HF-ACTION Investigators Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301:1439–50. [PMC free article] [PubMed]
18. Flynn KE, Piña IL, Whellan DJ, Lin L, Blumenthal JA, Ellis SJ, Fine LJ, Howlett JG, Keteyian SJ, Kitzman DW, Kraus WE, Miller NH, Schulman KA, Spertus JA, O'Connor CM, Weinfurt KP. Effects of exercise training on health status in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301:1451–9. [PMC free article] [PubMed]
19. Whang W, Kubzansky LD, Kawachi I, Rexrode KM, Kroenke CH, Glynn RJ, Garan H, Albert CM. Depression and risk of sudden cardiac death and coronary heart disease in women: results from the Nurses' Health Study. J Am Coll Cardiol. 2009;53:950–958. [PMC free article] [PubMed]
20. van Melle JP, de Jonge P, Spijkerman TA, Tijssen JG, Ormel J, van Veldhuisen DJ, van den Brink RH, van den Berg MP. Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis. Psychosom Med. 2004;66:814–822. [PubMed]
21. Haisley E, Mostafa R. J Behav Dec Making. Wiley InterScience; 2007. Loewenstein Subjective relative income and lottery ticket purchases. Published online in (
22. Berlin AA, Kop WJ, Deuster PA. Depressive mood symptoms and fatigue after exercise withdrawal: the potential role of decreased fitness. Psychosom Med. 2006;68:224–30. [PubMed]
23. Teychenne M, Ball K, Salmon J. Physical activity and likelihood of depression in adults: a review. Prev Med. 2008;46:397–411. [PubMed]