Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials
BMJ 2024; 384 doi: https://doi.org/10.1136/bmj-2023-075847 (Published 14 February 2024) Cite this as: BMJ 2024;384:e075847Linked Editorial
Exercise for the treatment of depression
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Dear Editor
A Comprehensive Approach through Evidence-Based Exercise Prescriptions in Primary Care
The study findings (1) have the potential to significantly reshape how primary care physicians approach the prevention and management of depression, especially in terms of prescribing exercise. We strongly believe that these findings can improve the practicality and efficacy of exercise prescriptions within primary care settings.
The study provides compelling evidence supporting the effectiveness of various exercise modalities in alleviating symptoms of depression (1). This empowers primary care physicians to make recommendations grounded in solid evidence, tailored to the unique preferences, abilities, and needs of individual patients.
A diverse range of exercise modalities-such as walking, jogging, strength training, yoga, tai chi, and qigong-emerge as effective interventions for depression in the research (1). This diversity enables primary care physicians to present patients with a variety of options, thereby increasing the likelihood of adherence and success.
Furthermore, the study indicates that certain exercise modalities may be more effective for specific demographic groups or personal characteristics (1). For example, strength training might be more beneficial for women, while yoga could prove more effective for older adults. This underscores the importance of adopting an individualized approach, considering factors like age, sex, preferences, and baseline health status when prescribing exercise.
The study also offers practical recommendations regarding exercise intensity, duration, and frequency based on observed dose-response relationships (1). Primary care physicians can utilize this information to assist patients in developing personalized exercise plans aligned with their capabilities and goals.
Additionally, the research suggests that exercise can complement traditional treatments for depression, such as cognitive-behavioral therapy and pharmacotherapy. Primary care physicians can integrate exercise prescriptions into comprehensive treatment plans, providing patients with holistic approaches to managing depression.
In consultations with patients suspected of depression or other mental well-being issues, primary care physicians can discuss the study's evidence, empowering and engaging patients to participate in exercises. These discussions can lead to shared decision-making regarding exercise prescriptions, considering benefits, risks, and preferences to enhance adherence.
Primary care physicians can play a crucial role in monitoring patients' progress with exercise interventions, offering ongoing support and encouragement. This involves tracking mood changes, addressing adherence barriers, and adjusting exercise prescriptions as needed.
Beyond treating depression, primary care physicians can advocate for physical activity as a preventive measure (2, 3, 4). By encouraging regular exercise as part of a healthy lifestyle, physicians can help reduce the risk of developing depression and improve overall mental health.
It's worth noting that primary care physicians can actively address barriers to exercise in primary care settings, empowering patients to take an active role in their health (2, 3). Providing support, resources, and strategies to overcome obstacles enables patients to make informed choices and adopt healthier lifestyles.
Understanding the unique barriers faced by individual patients allows primary care physicians to tailor exercise recommendations, accordingly, increasing the likelihood of feasibility and sustainability within specific contexts (2, 3, 4).
Addressing barriers fosters trust and rapport between patients and healthcare providers, creating a supportive environment where patients feel comfortable seeking guidance and assistance.
Recognizing the importance of addressing issues that may lead to discontinuation of exercise programs, primary care physicians can proactively intervene, preventing dropout and promoting long-term adherence to exercise interventions. This becomes especially critical after the study's results, given the effectiveness of exercise interventions in managing depression.
The study findings empower primary care physicians to view exercise as a realistic and effective intervention for preventing and managing depression. By integrating evidence-based exercise prescriptions into routine clinical practice, physicians can enhance patient outcomes and contribute to comprehensive mental health care improvements.
REFERENCES:
(1). Noetel M, Sanders T, Gallardo-Gómez D, Taylor P, Del Pozo Cruz B, van den Hoek D, Smith JJ, Mahoney J, Spathis J, Moresi M, Pagano R, Pagano L, Vasconcellos R, Arnott H, Varley B, Parker P, Biddle S, Lonsdale C. Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials. BMJ. 2024 Feb 14;384:e075847. doi: 10.1136/bmj-2023-075847. PMID: 38355154; PMCID: PMC10870815.
(2). Burtscher J, Strasser B, D'Antona G, Millet GP, Burtscher M. How much resistance exercise is beneficial for healthy aging and longevity? J Sport Health Sci. 2023 May;12(3):284-286. doi: 10.1016/j.jshs.2022.11.004. Epub 2022 Nov 7. PMID: 36356853; PMCID: PMC10199130.
(3). Desapriya E, Dhatt A, Gunaratna D, Pike I. Potential of Exercise as a COVID-19 Prevention Strategy. Am J Prev Med. 2023 Jul;65(1):169-170. doi: 10.1016/j.amepre.2023.02.022. PMID: 37344036; PMCID: PMC10277321.
(4). Warburton DE, Nicol CW, Bredin SS. 2006. Health benefits of physical activity: The evidence. CMAJ 174: 801–809.
Competing interests: No competing interests
Dear Editor,
It is unfortunate that there is no comparison of exercise vs SSRIs + CBT, which, in ideal world, would be the standard of care for depressed patients. I'm wondering if the authors have this information but have not published it?
Thank you.
Ester Cela
Competing interests: No competing interests
Dear Editor,
Noetel and colleagues have conducted a timely and important network meta-analysis of randomised controlled trials on the effect of exercise for depression (1). This work included 218 unique studies with 14170 participants and concluded that exercise is an effective treatment for depression, with the antidepressant effects being proportional to the intensity of exercise. Further, specific modalities of exercise such as walking, jogging, yoga and strength training were found to be more effective than other exercise. These findings are in keeping with a recent systematic review of randomised controlled trials by Heissel and colleagues, including 41 studies and 2264 participants, which found large effects (standardised mean difference = −0.946, 95% CI −1.18 to −0.71) favouring exercise interventions with a number needed to treat of 2 (95% CI 1.68 to 2.59) (2).
These findings build upon the literature highlighting exercise as an effective treatment for depression, with effects comparable to psychotherapy and pharmacotherapy. In Canada, the antidepressant effects of exercise have been incorporated into the current Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical Guidelines for the Management of Adults with Major Depressive Disorder, highlighting exercise as an appropriate first-line monotherapy for mild to moderate major depressive disorder (3).
Recurrent thoughts of death, suicidal ideation or suicide attempt are commonly seen in depression and place a person at higher risk of death due to suicide. As per a global burden of disease study from 2016, there has been an estimated 6.7% increase in the total number of deaths due to suicide, indicating a need to find effective methods for prevention (4). Currently, the literature regarding the effects of exercise on suicide is inconclusive, with two recent systematic reviews indicating that exercise may decrease suicide attempts, however no clear association was delineated between suicidal ideation or death due to suicide (5,6).
The current network meta-analysis by Noetel and colleagues used scales such as the Beck Depression Inventory and Hamilton Depression Rating Scale, which include measures of suicide (1). It would be of value if additional analyses could be conducted using these suicide measures to also determine the effect of exercise on suicide in those with depression. If possible, the optimal dose and modality of exercise could be delineated to minimise suicide among those with depression which would be of utmost importance.
References
1. Noetel M, Sanders T, Gallardo-Gómez D, Taylor P, Cruz B del P, Hoek D van den, et al. Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials. BMJ. 2024 Feb 14;384:e075847.
2. Heissel A, Heinen D, Brokmeier LL, Skarabis N, Kangas M, Vancampfort D, et al. Exercise as medicine for depressive symptoms? A systematic review and meta-analysis with meta-regression. Br J Sports Med. 2023 Aug 1;57(16):1049–57.
3. Ravindran AV, Balneaves LG, Faulkner G, Ortiz A, McIntosh D, Morehouse RL, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 5. Complementary and Alternative Medicine Treatments. Can J Psychiatry Rev Can Psychiatr. 2016 Sep;61(9):576–87.
4. Naghavi M. Global, regional, and national burden of suicide mortality 1990 to 2016: systematic analysis for the Global Burden of Disease Study 2016. BMJ. 2019 Feb 6;364:l94.
5. Fabiano N, Gupta A, Fiedorowicz JG, Firth J, Stubbs B, Vancampfort D, et al. The effect of exercise on suicidal ideation and behaviors: A systematic review and meta-analysis of randomized controlled trials. J Affect Disord. 2023 Jun 1;330:355–66.
6. Fabiano N, Gupta A, Wong S, Tran J, Mohammad IY, Bal S, et al. Physical activity, suicidal ideation, suicide attempt and death among individuals with mental or other medical disorders: A systematic review of observational studies. Neurosci Biobehav Rev. 2024 Jan 20;158:105547.
Competing interests: No competing interests
Promoting Mental Well-being Through Exercise: Insights from 'Mens sana in corpore sano'
Dear Editor,
The Latin phrase "Mens sana in corpore sano," meaning "a healthy mind in a healthy body," encapsulates the interconnectedness of physical and mental well-being. While not prescribing specific exercise routines, it underscores the importance of maintaining physical fitness for mental health.
Noetel et al.'s study reinforces this concept, highlighting exercise as a promising intervention for depression. Various activities like walking, yoga, and strength training have shown efficacy in reducing symptoms. Tailoring exercise to individuals, considering intensity, is crucial. Recommendations advocate for regular exercise, aiming for at least 3-5 sessions weekly, each lasting 30 minutes of moderate-intensity activity. Ultimately, accumulating 150 minutes weekly can enhance mental health. Integrating exercise into treatment plans presents a holistic approach to depression management.
Competing interests: No competing interests