Episode 230: Exercise Compared to Medications or Therapy for Depression
Audio Episode Host: David Puder, MD
Audio Episode Guest: Nicholas Fabiano MD, Brendon Stubbs PhD
Article Authors: Nicholas Fabiano MD, Liam Browning BA, Christopher Campbell, Brendon Stubbs PhD, David Puder MD
Article Reviewers: Erica Vega, MD, Joanie Burns DNP
Corresponding author: David Puder, MD
Psychiatry CME for listening to this activity: 1.75
Other Places to listen: iTunes, Spotify
Date Published: 12/20/2024
Conflicts of interest: Brendon Stubbs is on the Editorial Board of the Journal of Physical Activity and Health, Ageing Research Reviews, Mental Health and Physical Activity, The Journal of Evidence Based Medicine, and The Brazilian Journal of Psychiatry. Brendon has received honorarium from a co-edited book on exercise and mental illness (Elsevier), an associated education course and unrelated advisory work from ASICS and FitXR LTD.
Dr. David Puder and Dr. Nicholas Fabiano have no conflict of interests to report.
Introduction On Exercise For Depression
Exercise benefits both mental and physical health. Specifically, it has demonstrated antidepressant effects, which are often compared to other first-line treatment options such as medications or therapy. In previous episodes, we have explored various aspects of exercise, including exercise as a prescription for depression/anxiety/stress (episode 010), performance enhancement (episode 012), strength training for depression (episode 018), the best exercise program for depression (episode 096), exercise as a drug for mental health and longevity (episode 142), exercise for the brain (episode 165), and the exercise & mental health 2023 update (episode 179).
In today’s episode, we are delighted to welcome two leading experts in exercise and mental health: Nicholas Fabiano, MD and Brendon Stubbs, PhD. Dr. Fabiano is a psychiatry resident at the University of Ottawa and has contributed extensively to research on exercise and mental health, as well as other innovative topics in psychiatry and medicine. Dr Stubbs is recognized as one of the world’s foremost researchers in mental health and neuroscience, ranked among the top 0.1% of researchers in the field. He has authored more than 2,500 studies, influenced global health policies through organizations such as the World Health Organization and the World Psychiatric Association, and influenced various public health campaigns. Dr. Stubbs has been an instrumental force in bringing credibility and legitimacy to the use of exercise as a valuable treatment modality. Together, Dr. Stubbs and Dr. Fabiano bring unparalleled expertise to today’s conversation on exercise and depression.
We hope you enjoy this engaging episode and encourage you to explore the work of Dr. Fabiano and Dr. Stubbs, as well as our previous episodes on exercise and mental health, for further insights into this transformative area of research.
Why Exercise: The Science Behind Its Power To Combat Depression
Physical activity (PA) is any movement that uses energy, while exercise is a planned and structured form of PA aimed at improving fitness. PA provides many benefits for mental health. It reduces stress, improves sleep, boosts mood, enhances self-esteem, and has specific antidepressant effects (Wegner et al., 2014). Upon contraction, muscles release myokines (cytokines and peptides) that mediate communication with other organs to increase brain-derived neurotrophic factor (BDNF) (Oudbier et al., 2022). Studies have demonstrated that PA promotes neuroplasticity through this upregulation of BDNF, which is important for mood regulation (Wegner et al., 2014). There exists also a bidirectional relationship with depression—PA reduces depressive symptoms, while inactivity is associated with increased depression risk (Huang et al., 2020). Given its broad impact on mental and physical health, PA has been included in treatment guidelines for depression as a first-line therapy (Lam et al., 2024).
Public Perception Of Exercise As A Treatment For Depression (Fabiano et al., 2024)
Decades ago, exercise was not a serious treatment option for depression. However, over the last 30 years, the sheer volume of research publications on physical activity, mental health, and well-being has become immense. A recent bibliometric analysis of the literature found 55,353 documents on exercise and mental health published between 1988-2021 (Sabe et al., 2022). In particular, a large-scale umbrella review (including 97 reviews [1039 trials and 128,119 participants]) found that exercise was highly beneficial for improving symptoms of depression, anxiety and distress across a wide range of adult populations, including the general population, people with diagnosed mental health disorders and people with chronic disease (Singh et al., 2023b). Although these findings are certainly valuable, the media misconstrued the evidence stating that, “[E]xercise is around 1.5 times more effective than either medication or cognitive behaviour therapy” (Singh et al., 2023a); this misleading headline has since been widely disseminated to millions across news outlets, podcasts, videos, and blogs. This claim erroneously arose through the comparison of effect sizes from “very low quality” previous systematic reviews of physical activity interventions for mental health (Singh et al., 2023b). Given the overlapping 95% confidence intervals and substantially methodologically superior systematic reviews the authors used as a comparison, they made a more accurate statement that exercise is “comparable to or slightly greater” (in mild symptoms).
It is imperative that robust science is communicated widely, but this needs to be done in the interest of science and, in this case, patients. As the media is known to play a crucial role in influencing people’s perception and behaviors, it is imperative that dissemination of scientific information is both clear and accurate. Previous research has demonstrated that subtle misinformation in news headlines, such as the claim that exercise is more effective than medication or therapy, can affect readers’ memory, inferential reasoning, and behavioral intentions (Ecker et al., 2014). Further, readers struggle to update their memory in order to correct initial misconceptions, which highlights the importance of factual messaging to the general public (Ecker et al., 2014).
This is particularly important when it is considered that there is already significant stigma surrounding the use of psychotropic medications, such as antidepressants (Sansone & Sansone, 2012). Thus, wide dissemination of the non-evidence-based claim that exercise is 1.5 times better than other first-line treatments may lead to direct harm to vulnerable patients who may delay seeking specialist support, stop taking medications, or stop attending therapy due to such headlines. Prior evidence has demonstrated that a greater delay to treatment of a depressive episode is associated with a reduced response, and may precede development of a treatment-resistant depression (Corey-Lisle et al., 2004). Further, for those already taking an antidepressant medication, abrupt discontinuation, without physician supervision, can lead to withdrawal effects characterised by dizziness, weakness, nausea, headaches, and insomnia, among others. Moreover, media claims often fail to mention that the evidence for exercise in depression lies mostly in the mild to moderate cases, therefore those with severe depression may be experiencing extreme distress warranting immediate medical attention (i.e., due to active suicidal ideation or malnutrition due to severely reduced intake).
What Does The Evidence Actually Show About Exercise And Depression?
Meta-analysis of Exercise for Depression (Heissel et al., 2023)
The objective of this meta-analysis was to estimate the efficacy of exercise on depressive symptoms compared with non-active control groups and to determine the moderating effects of exercise on depression and the presence of publication bias. Randomized controlled trials (RCTs) including participants aged 18 years or older with a diagnosis of major depressive disorder or those with depressive symptoms determined by validated screening measures scoring above the threshold value, investigating the effects of an exercise intervention (aerobic and/or resistance exercise) compared with a non-exercising control group were included. The authors found:
41 studies (2264 participants) were included.
Twenty-one studies assessed depressive symptoms, while MDD was diagnosed in 20 studies.
Percentage of females ranged from 26% to 100%, mean age from 18.8 to 87.9 years.
Only non-active controls “such as usual-care, wait-list control conditions or placebo pills” were included.
“Studies with any other exercise intervention (such as stretching or low-dose exercise) as a comparator were excluded.”
Taking out the low-dose exercise or stretching exercises from this meta-analysis is interesting because these types of studies control for the antidepressant effect of starting an intervention or group activity, allowing for a more accurate assessment of the true effects of exercise. Using studies that compare exercise to waitlist control and non-interventional groups might inflate the effect size of exercise.
Large effects were found in:
All exercise interventions (standardized mean difference (SMD)=−0.946, 95% CI −1.18 to −0.71)
Individuals with major depressive disorder (SMD=−0.998, 95% CI −1.39 to −0.61, k=20)
Supervised exercise interventions (SMD=−1.026, 95% CI −1.28 to −0.77, k=40)
Moderate effects were found in:
Low risk of bias studies (SMD=−0.666, 95% CI −0.99 to −0.34, k=12, NNT=2.8 (95% CI 1.94 to 5.22)).
Based on exercise type:
Aerobic (SMD=−1.156) and resistance training (−1.042) as exercise types showed large effects whereas mixed aerobic and resistance training showed small effects (−0.455).
Meta-regression:
Shorter trials associated with larger effects (β=0.032, 95% CI 0.01 to 0.09, p=0.032, R²=0.06).
In this study they used unstandardized beta, meaning the average number of standard deviations that the dependent variable changed for each unit change (as opposed to each standard deviation change) on the independent variable. In this example, since the unit of the independent variable is in weeks: if a study lasts 10 weeks, compared to 5 weeks, the effect size might be 0.16 units smaller (0.032 × 5 weeks).
Higher antidepressant use by the control group was associated with smaller effects (β=−0.013, 95% CI −0.02 to −0.01, p=0.012, R²=0.28).
Mean change and number needed to treat (NNT):
Mean change of −4.70 points (95% CI −6.25 to −3.15, p<0.001, n=685) on the HAM-D and for the BDI of −6.49 points (95% CI −8.55 to −4.42, p<0.001, n=275).
NNT was 2.0 (95% CI 1.68 to 2.59) for the main-analysis, and 2.8 (95% CI 1.94 to 5.22) for the low risk of bias studies.
For MDD, only the NNT was 1.9 (95% CI 1.49 to 2.99) and 1.6 (95% CI 1.58 to 2.41) in supervision by other professionals/students.
The authors conclude that exercise is efficacious in treating depression and depressive symptoms and should be offered as an evidence-based treatment option focusing on supervised and group exercise with moderate intensity and aerobic exercise regimes.
Network Meta-analysis: Comparing Exercise To Pharmacological Interventions For Depression (Recchia et al., 2022)
The objective of this network meta-analysis was to assess the comparative effectiveness of exercise, antidepressants, and their combination for alleviating depressive symptoms in adults with non-severe depression. RCTs that examined the effectiveness of an exercise, antidepressant, or combination intervention against either treatment alone or a control/placebo condition in adults with non-severe depression were included. The authors found:
21 RCTs (2551 participants) were included.
Antidepressants versus controls (n=11), exercise versus controls (n=6), combined treatments versus antidepressants (n=4) and combined treatments versus exercise (n=1).
No differences in treatment effectiveness among the three main interventions, although all treatments were more beneficial than controls.
Exercise vs antidepressants: SMD, −0.12; 95% CI −0.33 to 0.10
Combination versus exercise: SMD, 0.00; 95% CI −0.33 to 0.33
Combination vs antidepressants: SMD, −0.12; 95% CI −0.40 to 0.16
Exercise interventions had higher drop-out rates than antidepressant interventions (RR 1.31; 95% CI 1.09 to 1.57)
Despite the greater drop-out rates in the exercise group, the proportion of participants with adverse events was greater in the antidepressant group, with 22% reporting adverse events compared with 9% in the exercise group.
The authors conclude that the results suggest no difference between exercise and pharmacological interventions in reducing depressive symptoms in adults with non-severe depression.
Network Meta-analysis: Optimal Exercise Dose And Modality For Treating Major Depression Compared To Psychotherapy And Antidepressants (Noetel et al., 2024)
The objective of this network meta-analysis was to identify the optimal dose and modality of exercise for treating major depressive disorder, compared with psychotherapy, antidepressants, and control conditions. Any randomized trial with exercise arms for participants meeting clinical cut-offs for major depression were included. The authors found:
218 studies (14170 participants) were included.
Compared with active controls “usual care, placebo tablet, stretching, educational control, and social support,” large reductions in depression were found for:
Dance (n=107, κ=5, Hedges’ g −0.96, 95% credible interval −1.36 to −0.56)
SMDs are usually estimated by Cohen’s d or Hedges’ g. Cohen’s d divides the difference between sample means of a continuous response by the pooled standard deviation, but is subject to non negligible bias for small sample sizes. Hedges’ g removes this bias with a correction factor.
Compared with active controls, moderate reductions in depression were found for:
Walking or jogging (n=1210, κ=51, g −0.63, −0.80 to −0.46)
Yoga (n=1047, κ=33, g=−0.55, −0.73 to −0.36)
Strength training (n=643, κ=22, g=−0.49, −0.69 to −0.29)
Mixed aerobic exercises (n=1286, κ=51, g=−0.43, −0.61 to −0.25)
Tai chi or qigong (n=343, κ=12, g=−0.42, −0.65 to −0.21)
Moderate, clinically meaningful effects were also present when exercise was combined with SSRIs (n=268, κ=11, g=−0.55, −0.86 to −0.23) or aerobic exercise was combined with psychotherapy (n=404, κ=15, g=−0.54, −0.76 to −0.32).
All these treatments were significantly stronger than the standardized minimum clinically important difference compared with active control (g=−0.20), equating to an absolute g value of −1.16.
For acceptability, the odds of participants dropping out of the study were lower for:
Strength training (n=247, direct evidence κ=6, odds ratio 0.55, 95% credible interval 0.31 to 0.99)
Yoga (n=264, κ=5, 0.57, 0.35 to 0.94)
Effects were moderate for cognitive behavior therapy alone (n=712, κ=20, g=−0.55, −0.75 to −0.37) and small for SSRIs (n=432, κ=16, g=−0.26, −0.50 to −0.01) compared with active controls.
Across modalities, a clear dose-response curve was observed for intensity of exercise prescribed.
Use of group exercise appeared to moderate the effects:
Overall effects were similar for individual (g=−1.10, −1.57 to −0.64) and group exercise (g=−1.16, −1.61 to −0.73).
Yoga was better delivered in groups.
Strength training and mixed aerobic exercise were better delivered individually.
The authors concluded that exercise is an effective treatment for depression, with walking or jogging, yoga, and strength training more effective than other exercises, particularly when intense.
Comparing Antidepressants and Running Therapy on Mental and Physical Health Outcomes (Verhoeven et al., 2023)
The objective of this study was to examine the effects of antidepressants versus running therapy on both mental and physical health. According to a partially randomized patient preference design (compares two or more interventions among groups of patients, some of whom choose the intervention they receive), 141 patients with depression and/or anxiety disorder (mean age 38.2 years; 58.2% female; 45 participants received antidepressant medication and 96 underwent running therapy) were randomized or offered preferred 16-week treatment: antidepressant medication (escitalopram or sertraline) or group-based running therapy ≥2 per week. Baseline (T0) and post-treatment assessment at week 16 (T16) included mental (diagnosis status and symptom severity) and physical health indicators (metabolic and immune indicators, heart rate (variability), weight, lung function, hand grip strength, fitness). The authors found:
Intention-to-treat analyses (analyzing the results of RCTs that compares groups based on their initial treatment assignment, rather than the treatment they actually received) showed that remission rates at T16 were comparable (antidepressants: 44.8 %; running: 43.3 %; p=.881)
There was a larger decrease in anxiety symptoms after six weeks in the antidepressant group, which suggests faster improvement on especially anxiety-related symptoms
However, the groups differed significantly on various changes in physical health:
Weight (d=0.57; p=.001)
Waist circumference (d=0.44; p=.011)
Systolic (d=0.45; p=.011) and diastolic (d=0.53; p=.002) blood pressure
Heart rate (d=0.36; p=.033) and heart rate variability (d=0.48; p=.006).
Adherence:
In the antidepressant group, 82.2 % (N=37) of all participants adhered to the medication treatment protocol.
In the running therapy group, 52.1 % (N=50) of participants completed >22 sessions of exercise therapy.
The treatment adherence was significantly higher in the antidepressant group compared to the running therapy group (p<.001).
Limitation: A minority of the participants were willing to be randomized; the running therapy was larger due to greater preference for this intervention (out of 141 participants, 22 were willing to be randomized into the antidepressant [n=9] or the running therapy [n=13] groups, while 119 participants chose the treatment of their preference: antidepressant [n=36] or running therapy [n=83]).
The authors conclude that while the interventions had comparable effects on mental health, running therapy outperformed antidepressants on physical health, due to both larger improvements in the running therapy group as well as larger deterioration in the antidepressant group.
Internet-Based Cognitive Behavioural Therapy Compared to Exercise for Depression (Hallgren et al., 2018)
The objective of this RCT was to compare the effectiveness of exercise, internet-based cognitive behavioral therapy (ICBT), and usual care for depression. A multicentre, three-group parallel, randomized controlled trial was conducted with assessment at 3 months (post-treatment) and 12 months (primary end-point). 740 adults (mean age 43; 73% female; 56 received usual care, 49 received exercise, and 42 received ICBT) with mild to moderate depression aged 18–71 years were recruited from primary healthcare centres located throughout Sweden were included. Participants were randomly assigned to one of three 12-week interventions:
Supervised group exercise:
Patients in the exercise group were further randomized to one of three supervised exercise conditions: light exercise (yoga/stretching classes), moderate exercise (an intermediate aerobics class) and vigorous exercise (a higher-intensity aerobics/bodyweight strength training class).
Patients were requested to complete three 60 min sessions per week for 12 weeks; sessions typically included 5–20 participants.
Clinician-supported ICBT:
Treatment involved the patient working through a self-help manual available online in the form of modules.
Usual care by a physician:
Standard treatment for depression administered by their primary care physician.
In most instances, ‘usual care’ consisted of 45–60 min CBT delivered by an accredited psychologist or counselor.
The authors found:
Mean differences in MADRS score at 12 months were 12.1 (ICBT), 11.4 (exercise) and 9.7 (usual care)
Exercise and ICBT had equivocal effects, which were greater than treatment as usual.
The authors conclude that the long-term treatment effects reported here suggest that prescribed exercise and clinician-supported ICBT should be considered for the treatment of mild to moderate depression in adults.
Exercise as an Add-On Therapy to Medications and CBT for Depression (Gourgouvelis et al., 2018)
The objective of this study was to investigate the effects of exercise as an add-on therapy with antidepressant medication and cognitive behavioral group therapy (CBGT) on treatment outcomes in low-active MDD patients. Sixteen people were recruited; eight medicated patients performed an 8-week exercise intervention in addition to CBGT, and eight medicated patients attended the CBGT only. Twenty-two low-active, healthy participants with no history of mental health illness were also recruited to provide normal healthy values for comparison. The authors found:
Exercise resulted in greater reduction in depression symptoms (p=0.007, d=2.06), with 75% of the patients showing either a therapeutic response or a complete remission of symptoms vs. 25% of those who did not exercise.
Exercise was associated with greater improvements in sleep quality (p=0.046, d=1.28) and cognitive function (p=0.046, d=1.08).
The exercise group also had a significant increase in plasma brain-derived neurotrophic factor (BDNF), p=0.003, d=6.46, that was associated with improvements in depression scores (p=0.002, R2=0.50) and sleep quality (p=0.011, R2=0.38).
R-squared values range from 0 to 1, with 0 indicating the model doesn’t explain any variability and 1 indicating the model explains all variability.
The authors conclude that exercise as an add-on to conventional antidepressant therapies improved the efficacy of standard treatment interventions.
Multisystem Benefits Of Exercise For Mental And Physical Health
Comorbidity Between Major Depressive Disorder and Physical Diseases (Berk et al., 2023)
Those with common physical diseases (such as cardiovascular diseases, cancer and neurodegenerative disorders) experience significantly elevated rates of MDD, and those with MDD have an increased risk of numerous physical diseases.
This significant comorbidity is associated with worse outcomes, reduced treatment adherence, increased mortality, and greater health care utilization/costs.
The figure below demonstrates the association between MDD and various physical diseases according to Mendelian randomization studies.
One issue we have with this study is that it suggests a unidirectional association between type 2 diabetes mellitus and major depressive disorder. However, other studies highlight the bidirectional relationship between major depressive disorder and both type 1 and type 2 diabetes. For instance, when blood glucose levels are well-controlled, depression scores tend to improve; conversely, when blood glucose levels are poorly controlled, depression screening scores often worsen. Similarly, as major depressive disorder symptoms improve, blood glucose levels also improve, and patients are more likely to adhere to blood glucose monitoring, insulin use, and dietary modifications. By contrast, an escalation in depressive symptoms correlates with a decline in these measures (Bernstein et al., 2013; Corathers et al., 2013; Massengale, 2005; Santos et al., 2015).
Antidepressant Side Effects (Wang et al., 2018)
On top of the aforementioned physical health comorbidities associated with depression, antidepressant medications have several known side effects such as:
Cardiovascular side-effects:
Increased resting heart rate
Decreased heart rate variability
Hypertension
Gastrointestinal side effects:
Constipation
Metabolic:
Weight gain
Sleep:
Increased rapid eye-movement (REM) sleep latency
Insomnia
Musculoskeletal:
Increased risk of fractures
Therefore, although at best there is equivalence of efficacy between exercise interventions and medications or therapy, this does not mean these treatment modalities are all the same in the treatment of depression. Beyond its antidepressant effects, exercise has numerous multisystem benefits, which are often in contrast to the adverse side effects of antidepressant medications (Warburton et al., 2006). As such, exercise has the unique ability to simultaneously bolster one’s mental and physical health. Despite these beneficial multisystem effects and higher adverse events in antidepressant trials, there is a higher drop-out rate for exercise interventions (Recchia et al., 2022). This likely arises from the fact that exercise is physically demanding and more difficult to implement when compared to pharmacological interventions such as antidepressants. This places an onus of responsibility on the healthcare provider to develop an understanding of the benefits of exercise, address barriers, provide clear exercise “prescriptions,” and incorporate behavioral change techniques to increase initiation and adherence.
Optimal Amount of Exercise to Improve Depressive Symptoms (Tian et al., 2024)
The objective of this systematic review and Bayesian model-based network meta-analysis of RCTs was to examine the efficacy of four major types of exercise (aerobic, resistance, mixed, and mind-body) on depression, as well as the dose-response relationship between total and specific exercise and depressive symptoms. People aged 18 years or older with a diagnosis of major depressive disorder, or a depressive symptom score above a threshold as determined by a validated screening measure, implemented one or more exercise therapy groups, and assessments of depressive symptoms at baseline and follow-up were included. The authors found:
Forty-six RCTs (3164 people) were included.
All exercise types improved depressive symptoms:
Aerobic (SMD = -0.93; 95% CI: -1.25 to -0.62)
Mind-body exercise (SMD) = -0.81; 95% CI: -1.19 to -0.42)
Mixed (SMD = -0.77; 95% CI: -1.20 to -0.34)
Resistance exercise (SMD = -0.76; 95% CI: -1.24 to -0.28)
The metabolic equivalent of task (MET) is a measure of the ratio of the rate at which a person expends energy, relative to the mass of that person, while performing some specific physical activity compared to a reference, currently set by convention at an absolute 3.5 mL of oxygen per kg per minute.
The dose-response meta-analysis showed a u-shaped curve between exercise dose and depressive symptoms.
There were different optimal doses, depending on the type of physical activity whereby AE=aerobic, RE=resistance, ME=mixed, and MBE=mind-body.
The minimum effective dose was estimated to be 320 metabolic equivalent (METs) -min per week and the optimal response was 860 METs-min per week.
This is equivalent to 245 min of walking (3.5 METs-min), 140 min of moderate-intensity aerobic exercise (6 METs-min), or 215 min of yoga (4 METs-min) per week.
The authors conclude that clinicians can carefully select the appropriate dose of exercise based on the patient’s individual characteristics and needs, in conjunction with psychological care interventions.
The Physiologic Antidepressant Mechanisms Of Exercise (Hird et al., 2024)
The objective of this review was to propose a novel hypothesis for understanding the antidepressant effects of exercise, centred on motivation, across different levels of explanation. The authors found:
Depression is associated with disruptions to several closely related neural and cognitive processes, including dopamine transmission, fronto-striatal brain activity and connectivity, reward processing and motivation.
There is also evidence to suggest that the motivational symptoms of depression are related to inflammation (Bell et al., 2017).
Inflammation is known to reduce dopamine transmission, which, in turn, is strongly implicated in effort-based decision making for reward; however, aerobic exercise is known to decrease this systemic inflammation.
By reducing inflammation and boosting dopamine transmission, exercise improves “interest-activity” symptoms of depression—namely anhedonia, fatigue and subjective cognitive impairment—by increasing propensity to exert effort.
From this, cognitive impairment in depression may also be conceptualized through an effort-based decision-making framework, which may help to explain the impact of exercise on cognitive impairment.
The Psychological Antidepressant Mechanisms of Exercise
While the physiological mechanisms of exercise in alleviating anhedonia, fatigue, and passivity are increasingly well-characterized, its psychological mechanisms in improving cognitive and emotional symptoms of depression are no less significant.
Among the more commonly understood cognitive symptoms of depression is the persistently negative or conflicting view of the self (Montesano et al., 2017). Therefore, one of the most compelling explanations for exercise’s antidepressant effects lies in its ability to foster a sense of mastery—the belief that one can successfully accomplish tasks and achieve personal goals.
This concept is foundational to Albert Bandura’s work in self-efficacy (1977), which emphasizes the importance of mastery experiences as a key source of self-efficacy. For individuals with depression, who often feel incapable of change and struggle with helplessness, negative self-perception, and diminished agency, exercise provides an opportunity to counter these patterns through incremental and tangible achievements.
In a randomized controlled trial conducted by Craft (2005), 40 women with moderate depression were assigned to either a 9-week aerobic exercise intervention (3 sessions per week) or a control group. Each session involved 30 minutes of treadmill walking or cycling at moderate intensity. The results showed a significant improvement in coping self-efficacy—defined as the belief in one’s ability to manage depressive symptoms—among women in the exercise group compared to controls. Importantly, the coping self-efficacy was strongly correlated with reductions in depressive symptoms (r = −0.79, p < 0.05), suggesting that enhanced self-belief acted as a mediator for mood improvements.
Similarly, a 10-year longitudinal study by Harris and colleagues (2006) investigated the role of physical activity as a coping mechanism in 452 adults with depression. The authors followed this cohort and assessed their physical activity levels, coping, and depression and found that individuals who adopted regular exercise as part of their coping strategies reported greater coping efficacy and experienced significant reductions in depressive symptoms over time. The data indicated that regular exercise contributed not only to immediate self-efficacy gains but also to long-term resilience in managing stress and depressive episodes.
Importantly, constructs of the self, such as self-esteem and self-efficacy, can be viewed both as a global construct and as domain-specific. For example, domains include academic, social, physical, and emotional, within which are even more specific contexts (ability in math, science, baseball, giving a speech), and an individual’s sense of competency in these different areas depends on their prior experience. Some theorists suggest that exercise more tangibly improves physical self-efficacy, whereby these improvements do not easily generalize to improvements in global self-esteem or self-efficacy. While early research suggested minimal global changes in self-esteem following exercise, these two studies of coping efficacy highlight that improvements in self-efficacy are not entirely domain specific.
A meta-analysis by Spence, McGannon, and Poon (2005) lended support to the mastery hypothesis by revealing small but significant improvements in global self-esteem (effect size d = 0.23) following exercise interventions. Importantly, the effect was larger (d = 0.32) when physical fitness improved, suggesting that tangible improvements in fitness, which are probably more likely to improve physical self-efficacy, are key to improving global self-efficacy.
It may be that certain forms of exercise, such as weightlifting, running, and climbing, are particularly effective in promoting mastery because they provide objective feedback on progress. Measurable achievements reinforce the relationship between effort and reward, engaging dopaminergic pathways and further motivating continued participation.
Exercise as a Form of Behavioral Activation
This ties closely to behavioral activation, a therapeutic approach of CBT that encourages engagement in structured, goal-directed activities to counteract the passivity and withdrawal characteristic of depression. Behavioral activation posits that progressively increasing participation in rewarding and meaningful activities provides opportunities for positive reinforcement and habit formation, which can improve mood and disrupt maladaptive cognitive patterns. Surprisingly, there has been only one study published on using exercise as an augment to behavioral activation.
Szuhany and Otto (2020) conducted a randomized pilot trial examining the effects of augmenting behavioral activation with exercise versus stretching in 31 sedentary adults with MDD. Participants completed nine sessions of BA over 12 weeks and were randomized to an additional 30-minute exercise or stretching component immediately following each session.
The exercise group was also encouraged to engage in moderate-intensity aerobic exercise (e.g., brisk walking, cycling) on their own for a total of 150 minutes per week. The stretching group performed light stretching or yoga to control for non-aerobic movement.
Both groups demonstrated significant improvements in depressive symptoms (MADRS: d=1.19; BDI-II: d=1.16), functional impairment (d=0.87), and quality of life (d=1.06) over the course of treatment. However, the exercise group showed greater improvements in perceived stress and distress intolerance, with medium-to-large effect sizes (d ≈ 0.70–1.01). Participants who engaged in more exercise (regardless of group assignment) experienced faster and larger reductions in depressive symptoms.
While the literature describing the psychological mechanism of exercise’s antidepressant effects is limited, there is plenty of reason to believe exercise can be used as a tool to challenge a patient’s understanding of themselves in a way that compliments therapy.
How To Prescribe Exercise For Depression: A Practical Guide For Clinicians (Zhou et al., 2024)
Components of an Effective Physical Activity Prescription for Mental Health
Prescribing physical activity involves more than simply encouraging patients to “be active.” Similar to the low adherence rates observed with psychiatric medications—where the CATIE study reported discontinuation rates as high as 74% within 18 months (Swartz et al., 2007) —we must approach physical activity recommendations utilizing an empathic and understanding approach. Building a collaborative alliance around shared goals is essential for increasing engagement. Like medication adherence, developing PA habits takes time, and patience is key to success. It can take a similar approach that a physician uses to prescribe a medication, which often includes dose, frequency, and route of administration. For PA, a structured approach based on the FITT framework—Frequency, Intensity, Time, and Type—ensures that PA is both effective and sustainable.
Frequency—how often one is participating in PA. For optimal outcomes, patients should participate in PA three to five times per week. Regular, consistent activity is key to maximizing the antidepressant effects. For patients unfamiliar with PA or who struggle with motivation, reducing sedentary behaviors (e.g., sitting, watching TV, using a computer) or aiming for even lower PA frequency, such as once a week, can still provide benefits and serve as a starting point. Ultimately, any PA is better than none.
Intensity—How Much Energy is Expended During PA. The “talk test” is a practical way for patients to measure PA intensity, which is separated into three groups: (1) low intensity (you can talk and sing during the activity), (2) moderate intensity (you can talk but not sing during the activity), and (3) vigorous intensity (you cannot say more than a few words during the activity). Moderate- to vigorous-intensity PA is recommended for treating depression in adults. However, the patient’s baseline fitness level and preferences help to determine the initial plan. Additionally, intensity influences affect during physical activity (PA) and plays a key role in planning. For individuals with severe depressive symptoms or older adults, starting with low-intensity activities like walking or yoga may be more suitable and still provide mental health benefits. As patients become more comfortable with PA, they can gradually increase the intensity.
Time—how long PA sessions are. Sessions of 45 to 60 minutes are most effective for improving mood and reducing depressive symptoms. However, shorter durations—such as 10- to 30-minute bouts—can still provide meaningful benefits. The emphasis should be on starting with manageable/realistic goals and gradually increasing the duration as patients gain confidence.
Type—aerobic, resistance, or mind-body. All three PA types (and their combinations) have been shown to reduce depressive symptoms. Aerobic activities include walking, swimming, and cycling; resistance training activities include weightlifting or bodyweight exercises; while mind-body activities include yoga, tai chi, and qigong. As people with depression are characterized by strong affective responses, clinicians should encourage patients to select enjoyable activities, leading to greater adherence and long-term success.
Supervision and Support for Enhancing Exercise Benefits
Supervised PA enhances adherence and amplifies the antidepressant effects of physical activity, particularly in the early stages. Structured group-based PA or individual sessions with an exercise professional, such as a kinesiologist or health coach, provide accountability and motivation, which are particularly important for individuals with depression, who may struggle with fatigue or low motivation. When supervision is not feasible, clinicians can recommend online exercise programs, fitness apps, or community resources that provide structure.
Social interaction during PA can further enhance its mental health benefits. Group activities or buddy systems can reduce feelings of isolation, which are common in depression (particularly among older individuals), and promote a sense of community. For patients who prefer individual activities, encouraging them to engage in outdoor PA may also boost mood and adherence, as exposure to nature has additional benefits for mental health (Bettmann et al., 2024).
Overcoming Barriers To Physical Activity
Barriers such as low energy, lack of motivation, low income, comorbidities, inexperience with PA, and time constraints are common among individuals with depression and can hinder engagement in PA. Particularly, green space availability is significantly lower in neighbourhoods with increased poverty, limiting access to outdoor physical activity. A scoping review identified these as key obstacles but also highlighted that social support and enjoyable activities can facilitate adherence. One useful strategy is the “commit 10” approach, where patients commit to just 10 minutes of PA, with the option to continue if they feel capable. Further, engaging in small bouts of activity (such as walking the stairs instead of taking the elevator) or setting daily step goals can make PA more feasible for those with limited time. Although these recommendations fall short of the optimal PA threshold according to the FITT framework, they provide manageable/realistic starting points that can reduce the psychological barriers to beginning a new activity, fostering positive associations with PA for patients.
Gradual progression in both the intensity and duration of PA is essential to prevent patients from feeling overwhelmed. Starting with small, achievable goals allows individuals to build confidence and gradually incorporate more PA into their routines. Clinicians can emphasize that any amount of physical activity (PA) is beneficial and that setbacks or missed sessions are not failures. It is important to maintain the therapeutic alliance when making recommendations, especially to avoid evoking feelings of shame if goals are not met. At the same time, motivational interviewing techniques can be used, where the clinician encourages the patient to express their reasons for change, reflects these reasons back to them, and emphasizes previous successful habits that supported adherence to change.
Patient Involvement in Decision-Making Enhances Exercise Adherence
Involving patients in the decision-making process is crucial for long-term adherence. Patients are likely to be more motivated and maintain a PA plan when they have a say in their activity–inventory patient preferences, whether they enjoy indoor or outdoor activities, and whether they prefer activities alone or in groups.
Flexibility in Exercise Regimen Supports Adherence
Approaching physical activity (PA) for depression with flexibility is important. Patients with depression often experience fluctuations in mood and energy levels, and rigid activity goals may not always be achievable. Clinicians can encourage patients to view PA as a flexible, adaptive process and remind them that even small amounts provide benefits. This approach helps foster a positive mindset toward PA, supporting long-term adherence.
Conclusion
Depression is a complex mental illness with devastating impacts. As such, it is vital for clinicians to consider and utilize all available treatment approaches. Exercise stands out as a unique and evidence-based intervention that addresses both mental and physical health needs simultaneously. As highlighted in today’s episode, research demonstrates that exercise is effective both as a standalone treatment and in conjunction with antidepressant medications and psychotherapy.
When prescribing exercise, clinicians should prioritize aerobic and resistance exercises, which are associated with the best outcomes. Moreover, an optimal exercise dose is approximately 860 MET-minutes/week (e.g., 245 minutes of walking or 140 minutes of moderate-intensity exercise). Tailoring exercise to the patient’s needs using the FITT framework (Frequency, Intensity, Time, and Type), flexibility in exercise regimens, supervised exercise programs, and strategies like the “commit 10” approach can further enhance adherence and long-term success. Ultimately, by integrating exercise into a patient’s treatment regimen for depression, clinicians can promote an effective, patient-centered approach to psychiatric care that has broad benefits for both mind and body.
Previous Episodes To Explore:
Sensorium Part 3: Exercise as a Prescription for Depression, Anxiety, Chronic Stress (like Diabetes) and Sensorium (episode 010): Exercise, especially strength training, improves cognitive function, mental health, and overall resilience. It reduces depressive symptoms, enhances brain plasticity, lowers the risk of dementia, and counteracts stress while also improving physical health markers like muscle strength, insulin sensitivity, and cardiovascular health. High-intensity training shows particularly strong benefits for mood, vitality, and cognitive function.
Performance Enhancement with Dr. MaryEllen Eller (episode 012): A discussion about the benefits of learning how to consciously modulate your internal sympathetic state as the key to unlocking optimal performance.
Prescribing Strength Training for Depression (episode 018): A discussion about how strength training can decrease depression and help people deal with anger and develop confidence and assertiveness. Resources are provided to help formulate a simple strength training program.
The Best Exercise Program For Depression (episode 096): A review of recent studies on strength training, exercise, and depression, highlighting the effectiveness of strength training both as a treatment for depression and as a protective measure against its onset. Also discussed: how aerobic training compares with high-intensity interval training (HIIT) in addressing depressive symptoms and practical ways to incorporate these findings into clinical practice.
Exercise as a Drug for Mental Health and Longevity (episode 142): Dr. Puder speaks with Dr. Stephen Seiler about the connection between mental health and physical activity. Physical activity has been shown to reduce stress reactivity and reduce all cause mortality. Physical activity also results in decreased psychosocial stress.
Exercise for the Brain (episode 165): A deep dive into the pathophysiology behind positive effects of exercise and the concept of contracting skeletal muscle behaving as an endocrine organ.
Exercise & Mental Health 2023 Update (episode 179): An in depth discussion on the extensive research available on the benefits of exercise for the brain and pathophysiology as it pertains to dementia, skeletal muscle mass, exercise as a mental health treatment, and cardiorespiratory fitness and its relationship to all-cause mortality.
5 Factors and Domains of Psychiatric Care (episode 207): The 5-factor approach to holistic, patient-centered psychiatric care recognizes each individual’s unique physiological and psychological makeup. It focuses on four modifiable environmental factors—therapy, sleep, activity, and nutrition—to enhance well-being, with the option of adding medication as a fifth factor.
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