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Some mental health interventions feel intuitively right. Exercise for depression is a great example. Of course, people suffering from low mood, poor motivation, lethargy and all of the other symptoms of depression will benefit from a jog around the park and some fresh air, right?
The logical explanation for how this might help is fairly clear as we know that exercise changes our hormone levels, so presumably this would have a positive impact on people with depression, not to mention the distraction that an hour in the gym would no doubt bring to someone who finds himself/herself in a pattern of negative thinking. Surely it must help, right?
The thing is, the history of evidence-based medicine is littered with examples of treatments that felt intuitively right, indeed ones that had significant amounts of evidence supporting their use, which turned out to be useless, or in extreme cases even harmful. Perhaps the best case in recent years is the drug Vioxx, which was prescribed for pain associated with osteoarthritis. It turned out that Vioxx caused cardiovascular events in over 30,000 people, but we did not discover this until high quality randomised trials were conducted that explained what was happening.
![Treat](http://www.thementalelf.net/wp-content/uploads/2013/09/shutterstock_131605295-300x200.jpg)
Using exercise as part of a tailored approach to treating depression will be easier when randomised trials tell us which types of exercise work best
Now, I’m not for a second suggesting that exercise is killing people with depression, but there does seem to be a groundswell of feeling from health professionals, service users and caregivers that it’s a ‘good thing’ and potentially a replacement for the antidepressants and talking treatments that are widely used in this population. However, we need high quality trials before we can show that exercise is as effective at reducing depressive symptoms as drugs and psychotherapies. Furthermore, we need research that investigates what types of exercise are best for different people with different mental health conditions.
Thankfully, the Cochrane Depression, Anxiety and Neurosis Group have updated their 2010 systematic review that looks at this exact subject. They’ve found a whole heap of new evidence that they have combined into a meta-analysis to provide the most bang up to date answer to our questions. Their 2010 review concluded (somewhat disappointingly) that:
Exercise can reduce symptoms of depression, but the effect was small and did not seem to last after participants stopped exercising.
Methods
The reviewers conducted the usual reliable Cochrane search, looking for randomised controlled trials of adults that compared exercise with standard treatment, antidepressants, psychotherapy, placebo or no treatment. They excluded trials of postnatal depression.
Two independent reviewers extracted primary and secondary outcomes data at the end of the trial and the end of follow-up (if available).
They calculated effect sizes for each trial using Hedges’ g method and a standardised mean difference (SMD) for the overall pooled effect, using a random-effects model risk ratio for dichotomous data.
Altogether, they reviewed the results of 39 trials involving 2,326 people diagnosed with depression. The severity of patients’ symptoms was assessed using standard scales of depression.
This systematic review is an update of a Cochrane review published in 2012 (we blogged about it here). The new review included 7 new trials in the qualitative and quantitative (meta-analysis) synthesis.
Results
![Should we be recommending exercise more readily to the 120 million people worldwide who suffer from depression?](http://www.thementalelf.net/wp-content/uploads/2013/09/shutterstock_115975012-300x248.jpg)
Should we be recommending exercise more readily to the 120 million people worldwide who suffer from depression?
- 35 trials (1,356 participants) compared exercise with no treatment or a control intervention:
- the pooled SMD for the primary outcome of depression at the end of treatment was -0.62 (95% confidence interval (CI) -0.81 to -0.42), indicating a moderate clinical effect
- there was moderate heterogeneity (I² = 63%) in this group of trials
- Only 6 trials (464 participants) had adequate allocation concealment, intention-to-treat analysis and blinded outcome assessment:
- the pooled SMD for this outcome was not statistically significant (-0.18, 95% CI -0.47 to 0.11)
- 8 trials (377 participants) provided long-term follow-up data on mood and these found a small effect in favour of exercise (SMD -0.33, 95% CI -0.63 to -0.03)
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7 trials compared exercise with psychotherapy (189 participants), and found no significant difference (SMD -0.03, 95% CI -0.32 to 0.26)
- 4 trials (n = 300) compared exercise with antidepressants and found no significant difference (SMD -0.11, -0.34 to 0.12)
Conclusions
One of the lead authors, Gillian Mead, concluded:
Our review suggested that exercise might have a moderate effect on depression. We can’t tell from currently available evidence which kinds of exercise regimes are most effective or whether the benefits continue after a patient stops their exercise programme.
When we looked only at those trials that we considered to be high quality, the effect of exercise on depression was small and not statistically significant. The evidence base would be strengthened by further large-scale, high quality studies.
![The evidence-base for exercise is growing year on year](http://www.thementalelf.net/wp-content/uploads/2013/09/shutterstock_79912411-200x300.jpg)
The evidence-base for exercise is growing year on year
So this new Cochrane review updates our knowledge about exercise and depression, but it still does not answer the main questions that we have about this intervention in this population. More large RCTs are needed before we can recommend exercise as a replacement for standard depression treatment and more detailed investigations are required so that we can better understand what types of exercise are likely to have the most benefit for different people with depression.
Many would argue that we shouldn’t be thinking about exercise as a replacement for standard treatments such as antidepressants or psychotherapy, but that it should be recommended as an add-on for patients who are willing and able. Indeed, this is very much the thrust of existing guidance.
Exercise is defined by the American College of Sports Medicine as the “planned, structured and repetitive bodily movement done to improve or maintain one or more components of physical fitness”. The most recent NICE depression guideline recommends structured, supervised exercise programmes, 3 times a week (45 minutes to one hour) over 10 to 14 weeks, as a low-intensity intervention for mild to moderate depression (NICE, 2009).
Limitations
The overall quality of the evidence included in this new review was mixed. There were multiple sources of bias in many of the included trials; randomisation was adequately concealed in 14 studies, 15 used intention-to-treat analyses and 12 used blinded outcome assessors.
It’s not straightforward to conduct research in this area. It’s hard to conceal which patients have been allocated to treatment groups, and which have been allocated to control or no treatment groups. It’s obviously hard to blind the patients and therapists to the intervention they are receiving (there’s no sugar pill equivalent for exercise). Some studies use participant self-report rating scales as a method for post-intervention analysis, but this also has the potential to bias findings.
Links
Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, McMurdo M, Mead GE. Exercise for depression. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD004366. DOI: 10.1002/14651858.CD004366.pub6.
New but is it better? Vioxx – Testing Treatments website, accessed 9 Sep 2013.
Depression: the treatment and management of depression in adults (update). NICE Clinical Guideline 90, Oct 2009.
Previous Mental Elf blogs on exercise and depression include:
- Physical activity a promising treatment for depression in children and young people, but more research is needed, 8 Mar 2013
- Structured exercise reduces depression in older people, according to new systematic review, 6 Sep 2012
- New Cochrane review shows that exercise helps with depression, but more research is needed, 12 Jul 2012
- Here is the evidence for exercising if you are depressed, 11 Jun 2012
- ‘Exercise doesn’t help with depression’ – have the headline writers got it wrong again? 7 Jun 2012
What kind of exercise is best for depression? New Cochrane review says we need more trials before we can be su… http://t.co/mxGjFGBDl9
@Mental_Elf one cure does not fit all one day they might realise that
@Mental_Elf I’m not sure one will emerge as most effective. For me it’s cycling & walking, for a friend it’s rowing & running.
Great blog from @Mental_Elf on updated #CochraneEvidence on exercise for #depression. http://t.co/Kdx0xBdLEg
@Mental_Elf for me martial arts are good. Get rid of anger and frustration as well as focusing the mind through meditation.
@Mental_Elf What’s the evidence for NICE guidelines of low-intensity exercise — as opposed to mid to high intensity exercise?
Should we be recommending exercise more readily to the 120 million people worldwide who suffer from depression? http://t.co/ZJWgxlAI6c
What kind of exercise is best for depression? Please share your experiences: http://www.thementalelf.net/?p=6823
RT @Mental_Elf: Pls RT @MindCharity What kind of exercise is best for depression? Please share your experiences: http://t.co/ZJWgxlAI6c
Excellent piece on what we (don’t) know about which types of exercise work for depression by @Mental_Elf: http://t.co/kNKEDYrvik
@PeteEtchells @Mental_Elf Telling people to ‘go for a walk’ is all to common ;) Can be good, but it’s not a ‘treatment plan’
RT @Mental_Elf: Pls RT @exerciseworks What kind of exercise is best for depression? Please share your experiences: http://t.co/ZJWgxlAI6c
What kind of exercise is best for depression? http://t.co/1ki1tLKzF3 http://t.co/lGKsRdeZ2z
Exercise and depression: far from straightforward, far from certain http://t.co/bd24Lz01WS
“@Mental_Elf:What kind of exercise is best for depression? Please share your experiences: http://t.co/FWILIEOSHT” @worton1 @GarethSharman
Exercise & depression. via @anandamide http://t.co/WBPrwC4HRF New Cochrane review says we “need more trials” – is it ever different?
What kind of exercise is best for #depression? @Mental_Elf wants to hear your views: http://t.co/lQQptE3n15
RT @Mental_Elf: Pls RT @BPSOfficial What kind of exercise is best for depression? Please share your experiences: http://t.co/ZJWgxlAI6c
@andretomlin from @Minervation blogs about the updated Cochrane systematic review on #exercise for #depression http://t.co/ZJWgxlAI6c
@cochranecollab conclude that “exercise might have a moderate effect on depression”, but more research is needed http://t.co/ZJWgxlAI6c
RT @Mental_Elf: Pls RT @rcpsych What kind of exercise is best for depression? Please share your experiences: http://t.co/ZJWgxlAI6c
Many people with depression extol the virtues of exercise, but how long will it take for the research to catch up? http://t.co/ZJWgxlAI6c
@Mental_Elf will they ever catch up? Should exercise classes be available on prescription from doctors for mental health sufferers?
@Mental_Elf yes it has been disappointing to see no effect in RCTs for depression and smoking cessation
We’ve had a great response to our #exercise & #depression blog. Tell us what kind of exercise you think works best http://t.co/ZJWgxlAI6c
@Mental_Elf I’ve always considered Martial arts to be perfect for depression – the mental discipline and mindfulness are perfect for therapy
Does exercise help combat depression? Seems the evidence isn’t in: http://t.co/f3SgN3C33I Another great post from @Mental_Elf
@edmsykes @Mental_Elf I’ve been a geniue pig this summer and intense cardio exercising is having a profound affect on my well being.
@MrSlider good review on exercise and depression, worth a read. http://t.co/tCOR1aBuv4
In case you missed it: What kind of exercise is best for depression? New Cochrane review says we need more research http://t.co/ZJWgxlAI6c
@Mental_Elf when you are deeply depressed at the virtual catatonic stage, exercise is not going to work.
@Mental_Elf Exercise is a loaded word nowadays so perhaps time to reframe. Dancing/walking/cycling/swimming whatever gets the motor moving..
@Mental_Elf Thank goodness @jackmcme said that- I can barely move let alone workout when at my lowest
@Mental_Elf Exercise won’t do it alone, but I advocate line dancing.
@cochranecollab have published an update of their #exercise and #depression review today. Read our summary here: http://t.co/ZJWgxlAI6c
Mental Elf: What kind of exercise is best for depression? New Cochrane review says we need more trials before we… http://t.co/XG5ZbUaol8
From @Mental_Elf What kind of exercise is best for #depression? New Cochrane review says we need more trials http://t.co/tSgsGIQ5j9
Exercise helps for depression but its effects are small and not well researched yet… #bipolar @Mental_Elf http://t.co/AsGfsTUgPl
New Cochrane Review says we need more evidence to determine whether exercise combats depression http://t.co/JybhftklCe via @Mental_Elf
V.accessible summary by @Mental_Elf of new @cochranecollab sys review of effects of exercise on depression: http://t.co/3xijdQdnZf
Should we bin the pills, do away with psychotherapy for depression, and exercise instead? @Mental_Elf says not yet http://t.co/gwTFRxQE7f
MT: “Should we bin the pills&psychotherapy for depression, and exercise instead? @Mental_Elf says not yet http://t.co/DGxzaupK3R” Thoughts?
What kind of exercise best for depression? Cochrane says we need more trials before we can be sure http://t.co/RmUbuyGt7O via @sharethis
What kind of exercise is best New Cochrane review says we need more trials before we can be sure – The Mental Elf http://t.co/FQawEpIz1q
Our most popular blog this week: What kind of exercise is best for depression? http://t.co/ZJWgxlAI6c #exercise #depression
@Mental_Elf Yoga is pretty good for helping with depression
@Mental_Elf
I love a swim, the one exercise that leaves you clean and non sweaty.
Many people with #depression extol the virtues of exercise, but how long will it take for the research to catch up? http://t.co/5A6wiAqnnO
Given the difficulty of accounting for response bias in exercise trials, the reliance on subjective outcome measures, and the finding that “when we looked only at those trials that we considered to be high quality, the effect of exercise on depression was small and not statistically significant”, it seems difficult to justify the routine promotion of exercise as a treatment to those suffering with depression. It may help some, but it is also a task which requires considerable work from patients – indeed, if equivalent effort needed to be made by paid medical staff, I think it is rather less likely exercise would be so casually prescribed.
We need more good *qualitative* studies. Very few of these studies seem to ask the patients themselves what it is that *they* find useful (beyond simple depression scale type instruments). The NICE recommendation (structured, supervised exercise programmes, 3 times a week (45 minutes to one hour) over 10-14 weeks) is all very well, but I suspect it is rarely prescribed. In my experience, patients are simply told to “get more exercise”. I find that exercise tends to set off my ruminatory thinking, so finding something more appropriate is a challenge. I’d also like to know whether this particular intervention is contraindicated in some way, and it is not actually the exercise that is useful, but the structured nature of programme that helps in this case: ie, would doing *any activity* under supervision 3 times a week for about an hour produce a similar result?
RCTs are great for pills and simple interventions. We need to find a better way of assessing more complex interventions, or at least learn much more about placebo effects, since “how I feel about this intervention” is a crucial part of all studies of psychological well-being.
When I was depressed I hated myself, in order to punish myself I used to do some exercise – thus guaranteeing that my depression would be far worse the next day (I thought I deserved to suffer for being such an awful person)
Only really started to recover when I stopped exercise and started doing small things that completely occupied my mind and therefore stopped the rumination.
The best exercise is the one you enjoy and can stick to. Some people like walking/running, others like group classes or team sports.
Good to have up to date information- keep it rolling Mental Elf!
There’s a bunch of good stuff about this Cochrane review on the Cochrane summaries website: http://summaries.cochrane.org/CD004366/exercise-for-depression
This includes coverage of the research on the BBC, in the Huffington Post and on other major news sites.
I have recently had an depression,mental illness,& taking mediation from my doctor as i was doing exercise an have a pain knee joints as I am 49 years old an I want to know what is the best exercise that I can change