Exercise for the treatment of depression

According to the World Health Organization, more than 300 million people worldwide suffer from depression.1 Even after recovering from a major depressive episode, there is a high rate of recurrence and, in some cases, a tendency to become chronic.2 Depression significantly reduces the quality of life for affected individuals and their families.3 More than 700,000 people die by suicide each year worldwide.1 Additionally, mortality rates from other physical diseases such as diabetes, heart disease, and cancer increase by 50% when the affected person is depressed.Four People with depression may have difficulty finding employment, and for those who are employed, depression is associated with lower productivity, higher rates of absenteeism, and increased risk of unemployment.Five All of these emotional, quality of life, work-related and economic impacts affect not only individuals and their families, but also the efficiency of health services, businesses and society in general. Furthermore, this effect increased from 1990 to 2019,3 And during the COVID-19 pandemic, the prevalence of depressive disorders increased by almost 28%.6

Although quite effective psychological and pharmacological treatments are available,7 In recent years, research has shown that exercise is also effective.8 But when it comes to the role of exercise in the treatment of depression, what kind of exercise, at what intensity and frequency, in what form (individual or group), and for which patients, etc. , important questions remain.

In the linked paper, Noetel and colleagues (doi:10.1136/bmj-2023-075847) report a network meta-analysis of randomized controlled trials that answers some of these questions.9 Walking, jogging, yoga, and strength training appear to be more effective than other types of exercise. Overall, there was a dose-response relationship between exercise intensity and improved efficacy, although low-intensity exercise such as walking and yoga also had meaningful benefits. Conversely, the authors found no association between exercise effectiveness and baseline depression severity. In general, with the exception of yoga, group exercise was no more effective than individual exercise. Strength training, a combination of aerobic exercise and strength training, was more effective for individuals than for groups. The effect size for exercise was similar to that for cognitive behavioral therapy, but the quality of evidence supporting such therapy was higher. The effects of exercise appeared to be better than antidepressants, but combining exercise and antidepressants improved the effects of the drugs.

Noetel et al.'s network meta-analysis included 218 randomized controlled trials with a total of 14,170 participants from multiple countries, but participants from African countries were underrepresented. Other limitations include the low quality of the evidence and the scarcity of randomized controlled trials with long-term (>1 year) follow-up.

Primary care clinicians can now recommend exercise, psychotherapy, or antidepressants as sole alternatives for adults with mild or moderate depression. The final choice will depend on patient preference and other considerations such as access barriers. Clinicians and patients should also consider the benefits of exercise in preventing or treating chronic diseases such as type 2 diabetes, overweight and obesity, cardiovascular disease, cancer, and cognitive impairment. Notably, physical exercise has also been shown to help prevent depression.Ten For adults with severe or treatment-resistant depression, currently available evidence supports treatment that combines psychotherapy and pharmacotherapy.7

People with depression often experience symptoms such as fatigue, low energy, and decreased motivation, so it can be difficult to exercise regularly. Most of the randomized controlled trials included in this new network meta-analysis were conducted in highly simulated and standardized settings. Therefore, implementation studies (pragmatic randomized controlled trials and observational studies) are needed to evaluate physical activity programs for patients with depression using real-world data. Many people don't have access to exercise facilities or live in areas where it's unsafe to walk or jog.

Health services and local and national governments must provide sufficient resources to make personalized and supervised exercise programs available to the entire population. For example, the European Union, through her NextGenerationEU fund, is working to promote the movement across its member states.11 Using these funds and their own funds, the Spanish government and the government of Andalusia, Spain, recently launched a program to work with primary care to prescribe personalized physical exercise programs supervised by sports specialists. The program promotes citizen participation and promotes physical activity by recommending health assets in the areas where citizens live.12