Psychiatric Annals

CME Article 

Exercise as a Nonpharmacological Treatment for Depression

Samantha G. Farris, PhD; Ana M. Abrantes, PhD; Lisa A. Uebelacker, PhD; Lauren M. Weinstock, PhD; Cynthia L. Battle, PhD

Abstract

Exercise is an efficacious treatment approach for the prevention and management of depression. In this article, we review the efficacy of aerobic exercise and resistance training in the treatment of depression, including comparative efficacy to pharmacotherapy and psychotherapy. We describe existing exercise interventions for depression and provide recommendations for how to prescribe exercise for the treatment of depression, ways to maximize intervention adherence, and safety considerations. We also review clinical considerations relevant to exercise in a select subset of special circumstances, including bipolar depression, perinatal depression, and depression in the context of chronic pain conditions and substance use disorders. [Psychiatr Ann. 2019;49(1):6–10.]

Abstract

Exercise is an efficacious treatment approach for the prevention and management of depression. In this article, we review the efficacy of aerobic exercise and resistance training in the treatment of depression, including comparative efficacy to pharmacotherapy and psychotherapy. We describe existing exercise interventions for depression and provide recommendations for how to prescribe exercise for the treatment of depression, ways to maximize intervention adherence, and safety considerations. We also review clinical considerations relevant to exercise in a select subset of special circumstances, including bipolar depression, perinatal depression, and depression in the context of chronic pain conditions and substance use disorders. [Psychiatr Ann. 2019;49(1):6–10.]

Exercise is defined as physical activity that is structured and engaged in with the goal of improving or maintaining physical health and includes both cardiovascular exercise and resistance training. Exercise is recommended as a first-line treatment for mild to moderate unipolar depression in the United Kingdom and Canada and recommended as an adjunctive treatment for depression in the United States.1–3

Exercise is an efficacious singular or adjunctive treatment for depression across a range of populations, producing medium to large antidepressant effects compared to control4–7 or no treatment.4,6,8 A meta-analysis of 25 trials7 found that exercise, relative to control intervention, produced an average 4.5-point decrease on the Hamilton Depression Rating Scale and a 6.5-point reduction on the Beck Depression Inventory, which is a large effect size. Some studies have found that exercise's antidepressant effect is smaller when analyses are restricted to only well-designed studies,4,6 although other reports suggest an underestimation of treatment effects due to publication bias.7

The antidepressant effects of exercise do not vary based on patient age or sex.7 Adherence to exercise interventions for people with depression is generally high, with an average of 81.3% compliance8 and a premature termination rate of approximately 15% to 18%.5,9

The effects of exercise on depression are evident in the short term, with mood boost evident immediately after an exercise session; in the long-term, with a regular exercise program, there are sustained improvements in depression.10 These effects are hypothesized to be mediated by several neurobiological processes, including neuroendocrine reactivity, oxidative stress adaptations and increases in cortical activity,10 and psychological processes, like increased social interaction and self-efficacy and distraction from depressogenic thoughts.4

Comparative Efficacy

Aerobic exercise produces antidepressant effects comparable to those of psychotherapy,4–6,11 including cognitive-behavioral therapy.6 Treatment completion rates are higher in aerobic exercise interventions than psychotherapy.6 No published studies have compared anaerobic exercise to psychotherapy for depression.

Aerobic exercise produces comparable antidepressant effects to pharmacotherapy for mild-moderate depression (eg, Beck Depression Inventory scores between 14 and 28),5,6 and treatment completion rates for exercise treatment and pharmacotherapy are similar.6 Aerobic exercise may have a more favorable side-effect profile compared to pharmacotherapies.6 No studies to date have compared anaerobic exercise to pharmacotherapy for depression.

Compared to monotherapy, exercise is an effective adjunctive treatment for depression, producing small to large treatment effects (eg, standardized mean difference of −0.44 to −1.22).6 In six trials, standard treatment augmented with exercise produced larger antidepressant effects than standard treatment alone.6 Aerobic exercise has been evaluated as a treatment adjunct to psychotherapy, outpatient treatment as usual, and pharmacotherapy; anaerobic exercise has been evaluated as a treatment adjunct to pharmacotherapy.6

Exercise Prescription

Type, Modality, and Location

The most common type of exercise for depression involves aerobic exercise,12,13 via walking or jogging on a treadmill, or a combination of aerobic exercise. Some interventions involve resistance training or a multimodal format.12 Generally, aerobic and resistance training produce comparable antidepressant effects,4,5,14 although aerobic exercise or multimodal approach might produce larger antidepressant effects in samples with subthreshold depression.5,7

Interventions are typically implemented indoors (fitness centers, research laboratories), which is ideal for resistance training and treadmill training because indoor facilities contain specialty fitness equipment. However, these settings can introduce barriers that can undermine exercise for some patients (eg, transportation, social anxiety). Indoor or outdoor walking may be more accessible and feasible for some people. In terms of exercise format, group exercise can increase social support and adherence, whereas individual exercise can be more flexible and feasible for some patients. In the absence of strong consistent evidence of a superior exercise type,12,15 the prescribed exercise type, modality, format, and location may be best determined based on a patient's preference, with the goal of maximizing exercise enjoyment and adherence.

Supervision

Research on exercise interventions for depression almost always include supervised exercise,12,13 and are most commonly supervised by fitness instructors, and to a lesser extent exercise physiologists, students, or a mental health professionals.12 Larger antidepressant effects may result from supervised or partially supervised exercise, relative to unsupervised.7 Additionally, exercise that is supervised by qualified exercise professionals (eg, exercise physiologists) produces larger antidepressant effects than exercise supervised by others.7

Frequency, Intensity, and Duration

The frequency of sessions for the treatment of depression can range from 2 to 7 sessions weekly, but is typically 3 to 4 sessions per week.12,13 The frequency of exercise sessions does not seem to affect the antidepressant effect of exercise.7

Exercise session duration ranges from 30 to 60 minutes,12 with 30 minutes being the most common. Longer exercise bouts are not more “potent” in their antidepressant effect. In fact, sessions longer than 60 minutes produce smaller antidepressant effects than shorter sessions.5 Acute antidepressant effects also result from single exercise sessions as short as 5 minutes in duration.16

The intensity of the exercise interventions for depression ranges widely. For aerobic exercise, prescribed intensity can range from “comfortable pace,” moderate intensity (50%–70% maximum heart rate), to vigorous intensity (eg, 70%–85% maximum heart rate);12 the most common intensity is 60% to 80% maximum heart rate.12 For anaerobic exercise, the prescribed intensity can range from 50% to 70% of maximum heart rate.12 Although antidepressant effects result from any level of exercise intensity, some evidence suggests that interventions using higher intensity produce larger effects;6,7 although vigorous-intensity exercise relative to moderate-intensity may produce more negative affect in response to exercise that could undermine the mood-enhancing effects of exercise.

The duration of the studied exercise interventions for depression range from 8 to 34 weeks,12,13 with 8 weeks being the most common.13 Shorter interventions produce larger antidepressant effects relative to longer interventions (≥8–10 weeks),4,14 which could be due to habituation or leveling off of exercise's antidepressant effect or reflective of other treatment factors (eg, treatment burden). Chronic exercise interventions appear to yield the strongest therapeutic effect in the short-term, whereas longer-term effects are generally very small6 or not observed11,14 compared to control interventions. Capitalizing on the acute antidepressant effects of exercise via engaging in brief bouts of exercise may be one strategy to extend the antidepressant effect of exercise.17

Recommendations for Exercise Prescription and Adherence

Symptoms of depression (anhedonia, amotivation, fatigue) may interfere with adoption and maintenance of an exercise program; people who are depressed may also have poor problem-solving abilities to manage emergent barriers. Thus, people with depression may benefit from learning cognitive-behavioral skills with exercise programs (eg, challenging negative thoughts about exercise, goal setting, problem-solving strategies) to address depression-specific barriers to engaging in exercise.18 Example exercise prescriptions are presented in Table 1. We also include a prescription recommendation based on the evidence for the mood-enhancing effects of lifestyle physical activity (LPA), which stresses the integration of brief bouts of activity into the context of daily living.17 LPA intervention can be a good fit for inactive people with depression who may find it less overwhelming to engage in brief bouts of activity within their daily life, relative to structured exercise.

Example Exercise Prescriptions for Depression

Table 1.

Example Exercise Prescriptions for Depression

Special Populations

Bipolar Depression

Depression accounts for much of the symptom morbidity and impairment in bipolar depression (BD). Although treatment guidelines emphasize pharmacotherapy as the first-line treatment for BD, exercise is a promising adjunctive intervention that may have a “dual benefit” for both mood and physical wellness.19 Preliminary trials indicate that exercise produces antidepressant effects in BD.19 Qualitative research further supports the self-reported benefits of exercise on BD mood symptoms, including improvements in hypomanic symptoms.20 Moreover, lifestyle interventions that address nutrition and healthy living in addition to exercise appear to have promising effects on well-being and physical health in BD.21

Given the sensitivity of the behavioral activation system and risk for mania,20,22 there is some concern that exercise could be overly activating for patients with BP, leading to new onset or exacerbation of hypomanic symptoms. Some patients report excessive exercise during hypomanic states,20 which may lead to acceleration of activation and maintenance of mood symptoms; the risk of potential physical injury may also increase. Moreover, heat sensitivity is associated with the use of lithium and other mood-stabilizing agents.23 It is important to monitor the setting, intensity, and time of day to limit risk of heat-related side effects of pharmacotherapy for BD. Until more data are available on exercise in BD, exercise prescriptions should be personalized, flexible, closely supervised, and modified based on patients' current mood state.22 Ensuring that exercise occurs on a consistent schedule may also promote the circadian and social rhythm regularity that is associated with mood stabilization in BP.24 Future research is necessary to determine the efficacy of exercise in BP and to refine exercise recommendations.

Perinatal Depression

Nonpharmacologic treatments frequently appeal to pregnant and postpartum women, given the lack of medication exposure to the fetus or nursing infant. The American College of Obstetrics and Gynecology currently endorses 20 to 30 minutes of moderate-intensity physical activity per day on all or most days in healthy pregnant women.25 Pregnant women are advised to consult with their prenatal care provider prior to initiating an exercise program or if their medical status changes, and to increase activity levels gradually over time. Postpartum women are advised to obtain medical clearance before restarting exercise after childbirth. Although there are some absolute contraindications for prenatal exercise (eg, preeclampsia), most women with uncomplicated pregnancies are encouraged to exercise regularly.25 Benefits of perinatal exercise are numerous, including improved cardiovascular fitness, decreased risk for gestational diabetes and preeclampsia, and improved maternal mood.26

Several randomized controlled trials indicate that postpartum exercise has superior antidepressant effects relative to a control intervention,27 although low adherence may attenuate intervention effects. Exercise during pregnancy also appears to lower the risk of postpartum depression.28 Studies of perinatal exercise interventions used varied exercise formats, including group or individual walking programs, gym-based fitness programs involving cardiovascular and/or resistance training, and home-based programs that use a range of physical activities based on women's interests. Further research is needed to clarify the efficacy of exercise as an intervention for depression during pregnancy and postpartum, as well as optimal intervention format.

Chronic Pain

Depression is often comorbid with chronic pain. Although patients may cite chronic pain as a reason why they cannot exercise, exercise is recommended in many chronic pain conditions, such as chronic low back pain29 and osteoarthritis.30 In fact, exercise may serve to improve pain-related outcomes in addition to conferring other mental and physical health benefits.29,30 Many patients with pain have a fear of movement or a fear of increasing pain, possibly because of the patient's belief that pain signals more “damage” to an existing injury or pain site. Thus, it may be difficult for these patients to initiate a new exercise program. Clinicians can help patients to overcome fears by providing education about chronic pain including the fact that research has shown that exercise is indicated or at least not harmful for their pain condition. Patients may start with low intensity, short-duration exercise training, and then slowly but steadily increase the intensity/duration over time.

Substance Use Disorders

Substance use disorders (SUDs) are highly prevalent in people with depression, and due to safety concerns, those with severe SUDs are often excluded from exercise intervention studies. Importantly, however, aerobic exercise has antidepressant effects in people with SUDs and may have a dual benefit of also aiding in abstinence and relapse prevention.31,32 Supervised, moderate-intensity aerobic exercise interventions tested as adjuncts to existing addiction treatments have been most often studied. However, adherence to exercise interventions in people with SUD is often low,32 and theoretically, adherence may be even lower in patients with comorbid depression and SUD. Thus, strategies described above to address depression-specific barriers to exercise may prove fruitful with this population.32

Safety Considerations

The incidence of adverse events from exercise interventions in depression is low.6 Although the absolute risk is low, vigorous-intensity exercise may increase the relative risk of sudden cardiac death or acute myocardial infarction in some people.33 This is balanced with the cardio-protective effects of a sustained exercise program. The American College of Sports Medicine provides guidelines for who should receive medical clearance prior to engaging in a new exercise program.33 Healthy people with no cardiovascular, metabolic, or renal disease, and no symptoms suggestive of these diseases may engage in exercise without medical clearance. People with known disease may require medical clearance, depending on whether they are currently symptomatic and based on current activity levels. Perinatal women without complications are encouraged to exercise regularly but should consult with providers prior to initiating a new exercise regimen. People with severe depression should prioritize standard depression treatment prior to engaging in an exercise program. Those with mild to moderate depression enrolled in exercise programs would benefit from monitoring by mental health providers to address any clinical deterioration. A less severe risk of exercise is musculoskeletal injury, which is lower risk in lower-intensity exercise and with appropriate warm-up, cool-down, and increasing intensity gradually.

Conclusions

Growing literature documents the efficacy of exercise in the treatment of depression, as a stand-alone or adjunctive treatment. More research is needed to establish the efficacy of exercise for treating depression in certain subpopulations as well as the optimal format of exercise interventions.

References

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Example Exercise Prescriptions for Depression

■ Three sessions per week for 30 minutes at 60%–80% heart rate maximum with mode of exercise determined based on individual preference for 8 weeks conducted in a group or individual format with supervision9

■ Three to four session per week for 30–40 minutes at low-moderate intensity or based on patient preference of any aerobic exercise for 9 weeks conducted in a group or individual format and supervised by trained personnel10

■ Lifestyle physical activity: incorporating brief bouts (eg 5 minutes) of exercise of any intensity throughout the day to accumulate 30 minutes of total activity most days per week

Authors

Samantha G. Farris, PhD, is an Assistant Professor, Department of Psychology, Rutgers University. Ana M. Abrantes, PhD, is a Professor, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University. Lisa A. Uebelacker, PhD, is an Associate Professor, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University. Lauren M. Weinstock, PhD, is an Associate Professor, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University. Cynthia L. Battle, PhD, is an Associate Professor, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University.

Address correspondence to Samantha G. Farris, PhD, Department of Psychology, Rutgers University, 53 Avenue East, Piscataway, NJ 08854; email: samantha.farris@rutgers.edu.

Disclosure: Lisa A. Uebelacker discloses that her spouse receives a salary from Abbvie Pharmacueticals. The remaining authors have no relevant financial relationships to disclose.

10.3928/00485713-20181204-01

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