Exercise May Be as Effective as Therapy for Alleviating Depression Symptoms

A new study found no meaningful difference between exercise and psychological therapy in alleviating depressive symptoms.1

When people think of treating depression, they often consider antidepressants or psychological therapy. However, a new meta-analysis suggests exercise may be equally effective, updating reviews from 2008 and 2013.2,3

“This updated review includes 35 additional trials (2526 additional participants), with conclusions that are similar to the previous version of the review,” wrote study investigator Andrew J. Clegg, PhD, from the Applied Health Research Hub at the University of Lancashire in the UK, and colleagues.1

Investigators conducted a meta-analysis of randomized controlled trials (RCTs) to assess the effectiveness of exercise for treating depression, compared with no intervention, waitlist controls, or placebo. The study also compared exercise alone with exercise plus established treatments, including psychological therapies, pharmacological treatments, or alternative interventions such as light therapy. The primary outcome was depressive symptoms at the end of the treatment and long-term follow-up. Secondary outcomes included treatment acceptability, quality of life, cost, and adverse events.

The team searched the Cochrane Depression, Anxiety and Neurosis Review Group’s Controlled Trials Register (CCDANCTR) to November 2013, along with MEDLINE, Embase, PsycINFO and the Cochrane CentralRegister of Controlled Trials (CENTRAL) from 2013 to November 2023. They included participants aged ≥ 18 years and excluded studies on postnatal depression. The review included 73 RCTs (4985 participants), with 69 in the meta-analysis.1

When trials reported multiple exercise “doses,” investigators used the greatest dose for the primary analysis and conducted sensitivity analyses using the lower dose. Subgroup analyses examined the impact of diagnostic method, exercise intensity, number of sessions, exercise modality, and control type.

In 57 trials (n = 2189) comparing exercise with no treatment or control, the pooled standardized mean difference (SMD) for depressive symptoms at the end of treatment was -0.67 (95% confidence interval [CI], -0.82 to -0.52; low-certainty evidence), suggesting excise reduces depressive symptoms. Restricting the analysis to 7 trials (n = 447) with adequate allocation concealment, intention-to-treat analyses, and blinded outcome assessment yielded a smaller effect (SMD −0.46; 95% CI, −0.88 to −0.04). Combined results from 9 trials (n = 405) with extended follow-up provided very uncertain evidence (SMD −0.53, 95% CI −1.11 to 0.06; very low certainty evidence).1

Moreover, 10 trials (n = 414) comparing exercise with psychological therapy found little to no difference in their effect on depressive symptoms at the end of the treatment (SMD 0.03, 95% CI −0.16 to 0.23; moderate-certainty evidence); 4 trials (n = 114) showed minimal difference at the long-term follow up (SMD −0.11, 95% CI -0.48 to 0.26; low uncertainty). Similarly, 5 trials (n = 330) comparing exercise with pharmacological therapy found little to no difference at the end of treatment (SMD −0.11, 95% CI −0.33 to 0.10; low-certainty evidence); 1 study (n = 58) showed very uncertain long-term effects (SMD −0.40, 95% CI −0.80 to 0.00). Exercise and alternative interventions did not differ in treatment acceptability.1

Investigators noted that many trials had multiple biases: only 22 had adequate allocation concealment, 31 used intention-to-treat analyses, and 23 used blinded outcome assessment. Because blinding participants and providers is inherently challenging, all studies were at high risk of performance bias.1

“Despite a degree of uncertainty, some patterns were evident,” investigators wrote. 1“People doing moderate-intensity exercise reported larger benefits when compared with those doing either light or vigorous exercise. The greatest benefit was shown for people who received between 13 and 36 sessions of exercise; this benefit was reduced to a moderate effect for those who undertook fewer sessions or more sessions.”

The team noted uncertainty about the optimal exercise type, though evidence suggests mixed or resistance exercise may outperform aerobic exercise. Moderate exercise appears most beneficial, but light exercise may be better than vigorous.1

Investigators wrote that the review would benefit from more large, high-quality studies with participants clinically diagnosed at baseline, following exercise-only regimens, and receiving post-intervention clinical assessments. Many studies lacked follow-up.1

“A future update of the current review will only be valuable if large-scale and high-quality trials are conducted, and if these trials give consideration to equity issues,” investigators concluded.1

References

1. Clegg AJ, Hill JE, Mullin DS, Harris C, Smith CJ, Lightbody CE, Dwan K, Cooney GM, Mead GE, Watkins CL.Exercise for depression. Cochrane Database of Systematic Reviews. 2026; CD004366. DOI:10.1002/14651858.CD004366.pub7

2. Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA. Exercise for depression. Mead GE, ed. Cochrane Database of Systematic Reviews. Published online July 8, 2009. doi:https://doi.org/10.1002/14651858.cd004366.pub4

3. Rimer J, Dwan K, Lawlor DA, et al. Exercise for depression. The Cochrane Database of Systematic Reviews. 2012;(7):CD004366. doi:https://doi.org/10.1002/14651858.CD004366.pub5