Physical Activity and Exercise for Prevention and Treatment of Depression

Although we have all heard the medical profession touting the health benefits of physical activity and exercise, most of us don’t engage in this inexpensive health promoting behavior on a regular basis. In addition to preventing chronic medical conditions, growing evidence demonstrates that physical activity and exercise improve mental well-being and have a buffering effect on depression. A review of literature showed that higher levels of baseline physical activity was associated with decreased risk of developing depression in the future (Mammen & Faulkner, 2013). Even low levels of physical activity such as walking less than 150 minutes per week can prevent future depression. Another study demonstrated that individuals who engaged in physical activity for more than 30 minutes a day had a 48% lower risk of being depressed at follow-up compared to individuals who didn’t engage in physical activity (van Gool et al., 2006). Interestingly, the same study also showed that each minute of physical activity was associated with a 1% decreased risk of depressed mood later. Simple activities such as walking, gardening, or bicycling to work at least two hours a week result in lower self-reported symptoms of depression, anxiety, burnout, and perceived stress (Jonsdottir et al., 2010). Emerging evidence from a large population study of 33,908 adults monitored over 11 years suggests that relatively small amount of exercise, as little as one hour per week, protects against future depression (Harvey et al., 2018). This study predicted that at least 12% of new cases of depression could be prevented if all adults participated in at least one hour of exercise each week, including leisure-time exercise such as walking.

In addition to preventing depression, physical activity, especially exercise, offers a powerful non-pharmacological approach to treat depression. A systematic review and meta-analysis published in the British Journal of Sports Medicine that included 41 studies and 2264 participants demonstrated the effectiveness of exercise in treating depression (Heissel et al., 2023). There is also good news for those who have not fully responded to antidepressants alone. Exercise has been shown to improve residual symptoms of depression in people who were initially treated with antidepressants (Trivedi et al., 2011). Translated in simple terms, if the effect of your antidepressant medication appears to have plateaued, and you have reached the maximum dose for that medication, adding exercise may be a good strategy.

How does exercise compare to therapy and antidepressant medications for treating depression? In research studies, the magnitude of difference between an intervention and a control group is measured by effect size, and larger the effect size, greater the magnitude of difference between two the two groups. The effect size for psychotherapy treatment for depression across all ages, after excluding studies that had risk of bias, is 0.51, which is a moderate effect size (Cuijpers et al., 2020). The same number for antidepressant efficacy for depression when compared to placebo ranges from 0.17 to 0.48 (Cipriani et al., 2018). It, therefore, comes as a surprise that a recent meta-analysis, after excluding studies with high risk of bias, showed a large effect size of 0.7 for exercise as a treatment intervention for major depression (Heissel et al., 2023). Although these findings are encouraging and favor the use of exercise as an evidence-based first-line treatment for depression, even better than medications or therapy, a word of caution here is that when exercise is compared to antidepressants for treating depression as opposed to treatment as usual, the effect size drops. Moreover, the well-known placebo effect in antidepressant trials may lead to underestimation the true efficacy of the medications (Cipriani et al., 2018; Heissel et al., 2023). Nevertheless, recent research has clearly established exercise as an effective intervention for treating depression.

In terms of the type of exercise that has the greatest benefit for treating depression, aerobic exercise has the strongest evidence followed by resistance training (Heissel et al., 2023). Surprisingly, combining aerobic exercise and resistance training is not as effective as either of these interventions individually. Other parameters that make exercise more beneficial for treating depression include moderate and vigorous intensity of exercise and exercise done under supervision or in a group setting. An exercise group led by a professional would meet the latter two conditions.

To summarize, while physical activity and exercise prevent depression, moderate to vigorous intensity aerobic exercise and resistance training offer an evidence-based intervention to treat depression. For individuals who are not inclined on trying any form of psychotherapy or antidepressant medication or cannot tolerate medications, exercise may be their first choice for treating depression. Others who may benefit from exercise are individuals who have residual depressive symptoms while being treated with antidepressant medication. In addition, women with mild to moderate depression who are either pregnant or nursing and don’t want to take medications can also benefit from exercise. Before embarking on an exercise program, it would be prudent to check with your primary care provider to see if you are physically healthy to participate in moderate to vigorous intensity of exercise.

To learn more about evidence-based self-management techniques that promote mental health and well-being, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA

REFERENCES

Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y.,…Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. Lancet, 391, 1357-1366.

Cuijpers P., Karyotaki, E., Eckshtain, D., Ng, M. Y., Corteselli, K. A., Norma, H.,…& Weisz, J. R. (2020). Psychotherapy for depression across different age groups: A systematic review and meta-analysis. JAMA Psychiatry, 77(7), 694-702.

Harvey, S. B., Øverland, S., Hatch, S. L., Wessely, S., Mykletun, A., & Hotopf, M. (2018). Exercise and the prevention of depression: results of the HUNT cohort Study. American Journal of Psychiatry, 175(1), 28-36.

Heissel, A., Heinen, D., Brokmeier, L. L., Skarabis, N., Kangas, M., Vancampfort, D.,…Schuch, F. (2023). Exercise as medicine for depressive symptoms? A systematic review and meta-analysis with meta-regression. British Journal of Sports Medicine. Doi:10.1136/bjsports-2022-106282

Jonsdottir, I. H., Rödger, L., Hadzibarjramovic, E., Börjesson, M., & Ahlborg Jr, G. (2010). A prospective study of leisure-time physical activity and mental health in Swedish health care workers and social insurance officers. Preventive Medicine, 51, 373-377.

Mammen, G., & Faulkner, G. (2013). Physical activity and the prevention of depression: a systematic review of prospective studies. American Journal of Preventive Medicine, 45(5), 649-657.

Trivedi, M. H., Greer, T. L., Church, T. S., Carmody, T. J., Grannemann, B. D., Galper, D. I., … & Blair, S. N. (2011). Exercise as an augmentation treatment for nonremitted major depressive disorder: a randomized, parallel dose comparison. Journal of Clinical Psychiatry, 72(5), 677-684.

van Gool, C. H., Kempen, G. I. J. M, Bosma, H., van Boxtel, M. P. J., Jolles, J, & van Eijk, J. T. M. (2006). Associations between lifestyle and depressed mood: longitudinal results from the Maastricht Aging Study. American Journal of Public Health, 97(5), 887-894.