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Exercise therapy improves both mental and physical health in patients with
major depression

Article  in  Disability and Rehabilitation · October 2014

DOI: 10.3109/09638288.2014.972579 · Source: PubMed

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ISSN 0963-8288 print/ISSN 1464-5165 online

Disabil Rehabil, Early Online: 1–6

! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.972579

PERSPECTIVE IN REHABILITATION

Exercise therapy improves both mental and physical health in patients

with major depression
Jan Knapen1,2,3, Davy Vancampfort1,4, Yves Moriën3, and Yannick Marchal2,5
1
Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium, 2Huis voor Chronische Zorg, Sint-Truiden, Belgium, 3AZERTIE, Zonhoven,
Belgium, 4Department of Psychomotor Therapy, University Psychiatric Centre KU Leuven, Campus Kortenberg, Kortenberg, Belgium, and
5
Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
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Abstract Keywords
Purpose: to present clinical guidelines for exercise therapy in depressed patients derived from Depressive disorder, metabolic syndrome,
recent meta-analyses. Method: four meta-analyses on effects of physical exercise on mental and physical therapy
physical in depression were analysed. Results: For mild to moderate depression the effect of
exercise may be comparable to antidepressant medication and psychotherapy; for severe History
depression exercise seems to be a valuable complementary therapy to the traditional
treatments. Depression is associated with a high incidence of co-morbid somatic illnesses, Received 11 March 2014
especially cardiovascular diseases, type 2 diabetes and metabolic syndrome. Exercise is Revised 24 September 2014
extremely powerful in preventing and treating these diseases. Physical exercise is an Accepted 30 September 2014
For personal use only.

outstanding opportunity for the treatment of patients who have a mix of mental and physical Published online 24 October 2014
health problems. Exercise therapy also improves body image, patient s coping strategies with
stress, quality of life and independence in activities of daily living in older adults. Conclusions:
Physical therapists should be aware, that several characteristics of major depression (e.g. loss of
interest, motivation and energy, generalised fatigue, a low self-worth and self-confidence, fear
to move, and psychosomatic complaints) and physical health problems interfere with
participation in exercise. Therefore, motivational strategies should be incorporated in exercise
interventions to enhance the patients’ motivation and adherence in exercise programs.

ä Implications for Rehabilitation

 For mild to moderate depression, the effect of exercise may be comparable with
antidepressant medication and psychotherapy; for severe depression, exercise seems to be a
valuable complementary therapy to the traditional treatments.
 Exercise therapy also improves physical health, body image, patient’s coping strategies with
stress, quality of life, and independence in activities of daily living in older adults.
 Motivational strategies should be incorporated in exercise interventions to enhance the
patients’ motivation.

Description of major depression (most symptoms present and interfere with functioning, with or
without psychotic symptoms) [2].
Depression refers to a wide range of mental health problems
Major depression consists of at least one 2-week major
characterized by the absence of a positive effect (a loss of interest
depressive episode [2]. The primary symptom of a major
and enjoyment in ordinary things and experiences), persistent low
depressive episode is either depressed mood or loss of interest
mood, and a range of associated emotional, cognitive, physical,
or pleasure. Additionally, the symptoms must not be clearly
and behavioral symptoms [1]. Severity of depression is classified
attributable to another medical condition or to the physiological
using the Diagnostic and Statistical Manual of Mental Disorders,
effects of a substance. The symptoms cannot be better explained
fifth edition criteria as mild (five or more symptoms with minor
by a range of psychotic, schizophrenic, or delusional disorders.
functional impairment), moderate (symptoms or functional
A major depressive episode is not diagnosed if there has ever been
impairment are between ‘‘mild’’ and ‘‘severe’’), and severe
a manic or hypomanic episode. Symptoms that are clearly
attributable to another medical condition are not counted in the
required five symptoms minimum. Additionally, as with most
psychiatric conditions, the symptoms must cause clinically
Address for correspondence: Jan Knapen, AZERTIE Boddenveldweg
11, 3520 Zonhoven, Belgium. Tel: +32 11 681795. E-mail:
significant distress or impairment in social, occupational, or
[email protected] other important areas of functioning. The following is an
 2 J. Knapen et al. Disabil Rehabil, Early Online: 1–6

abbreviated summary of DSM-V symptoms of depression (at least exercise has been suggested as an efficient complementary
five are needed for at least 2 weeks for a diagnosis of major treatment to reduce symptoms of depression since it reduces cost
depressive episode). With the exception of suicidal ideation and with drugs and hospitalizations, and may also improve physical
weight change, symptoms must be present most of the day, nearly health and physiological stress responses [13,14]. There are
every day. several hypotheses regarding the physiological and psychological
Depressed mood most of the day and nearly every day mechanisms by which exercise impacts on mental health, such
 Markedly diminished interest or pleasure, in all, or almost as enhancement of the synthesis and liberation of neurotrophic
all, activities most of the day, nearly every day. factors, as well as of cognitive functioning, angiogenesis,
 Significant weight loss or gain when not dieting (i.e. 5% in a neurogenesis, and plasticity. Moreover, some studies have
month), or decreased appetite nearly every day. Failure to shown that physical exercise may improve physical and global
make appropriate weight gains is considered in children. self-esteem, quality of life, coping strategies with stress, and
 Insomnia or hypersomnia nearly every day. social contact [15]. Furthermore, it may also contribute to
 Psychomotor agitation or retardation nearly every day increased quality of life and independence in activities of daily
(observable by others). living in older adults [14].
 Fatigue or loss of energy nearly every day.
Physical exercise as intervention for depression:
 Feelings of worthlessness or excessive or inappropriate guilt
findings of two recent meta-analyses
(which may be delusional) nearly every day.
 Diminished ability to think or concentrate or indecisiveness A recent meta-analysis of the Cochrane Collaboration investi-
nearly every day. gated the effectiveness of exercise in the treatment of depression
 Recurrent thoughts of death, recurrent suicidal ideation in adults compared with no treatment or a comparator interven-
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without plan, or a suicide attempt or plan. tion [13].

This meta-analysis aimed to answer the following questions:
Major depression, a big public health problem  Is exercise more effective than no therapy for reducing
symptoms of depression?
Recent epidemiological surveys conducted in general populations  Is exercise more effective than antidepressant medication for
have found that the lifetime prevalence of depression is in the reducing symptoms of depression?
range of 10–15% [3]. Mood disorders, as defined by the World  Is exercise more effective than psychological therapies or
Mental Health and the Diagnostic and Statistical Manual of other non-medical treatments for depression?
Mental Disorders, 4th edition, have a 12-month prevalence which  How acceptable to patients is exercise as a treatment for
varies from 3% in Japan to over 9% in the US [4]. A recent depression?
For personal use only.

American survey found the prevalence of current depression to be

9% and the rate of current major depression to be 3.4% [5]. Which studies were included in the review?
Several studies of depressive disorders have stressed the import-
ance of the mortality and morbidity associated with depression The Cochrane research group used search databases to find all
[3,6]. The mortality risk for suicide in depressed patients is more high-quality randomized controlled trials of how effective exer-
than 20-fold greater than in the general population. Studies have cise is for treating depression in adults over 18 years of age. The
also shown the importance of depression as a risk factor for authors searched for studies published up until March 2013.
cardiovascular death [7–10]. Greater severity of depressive All studies had to include adults with a diagnosis of depression,
symptoms has been found to be associated with significantly and the physical activity carried out had to fit criteria to ensure
higher risk of all-cause mortality including cardiovascular death that it met with a definition of ‘‘exercise’’. Thirty-nine studies
and stroke. Depression increases the risk of decreased workplace with a total of 2326 participants were included in the systematic
productivity and absenteeism resulting in lowered income or review.
unemployment. What does the evidence from this review tell us?
An analysis of data from the National Co-morbidity Survey
Replication, a US nationally representative household survey, The authors concluded that exercise is moderately more effective
found that overall impairment was significantly higher for mental than no therapy for reducing symptoms of depression. In addition,
disorders than for chronic medical disorders [11]. Severe func- exercise is no more or less effective than antidepressants for
tional impairment was reported by 42% persons with mental reducing symptoms of depression, although this conclusion is
disorders and 24% with chronic medical disorders. Treatment, based on a small number of studies. Exercise is also no more or
however, was provided for a significantly lower proportion of less effective than psychological therapies for reducing symptoms
mental (21.4%) than chronic medical (58.2%) disorders. of depression, although this conclusion is based on a small
DALY, disability adjusted life-years, is the sum of life-years number of studies. An important observation was that attendance
lost due to premature death and years lived with disability rates for exercise treatments ranged from 50% to 100%.
adjusted for severity [12]. It integrates the notions of individual
Suggestions for further research
mortality and disability with global disease prevalence. Using the
DALY, unipolar major depression was classed in 2004, as the The authors recommend that future research should look into
third leading burden of disease or injury cause worldwide for both detail at what types of exercise could benefit people with
sexes, behind lower respiratory infections and diarrheal diseases depression most. Research should also investigate the optimal
[12]. Worldwide projections by the World Health Organization for dose–response relationship. Further larger trials are needed to
the year 2030 identify major depression as the leading cause of compare the effects of exercise therapy with antidepressants or
disease burden. psychological treatments.
The substantial burden of major depression is due, in part, to Another very recent meta-analysis of 2013 evaluated the effect
the limited accessibility and effectiveness of treatments, with of aerobic and strength training as a treatment for major
data indicating that only 55% of those with a depressive disorder depression, using various aspects such as remission and response
seek treatment and only 32% receive an efficacious treatment to treatment, age, severity of depression, and type of exercise
(psychotherapy or antidepressant medication) [3]. Physical (aerobic training and strength training) [14].
 DOI: 10.3109/09638288.2014.972579 Exercise therapy for depression 3
The following data were collected: total number of patients, processes, oxidative stress, autonomic nervous system dysregula-
age, randomized design, diagnostic criteria, assessment instru- tion, and insulin resistance are all interacting biological mechan-
ments, and the percentage of remission and treatment response. isms that may mediate the association between depression and
The outcome variables were proportion of remission (no symp- metabolic syndrome. Although biological processes might be
toms) and at least 50% reduction of initial depression scores important, background lifestyle, and socioeconomic factors are
(response). probably equally relevant [16]. For example, major depression
The authors concluded that physical exercise moderately increased the odds for developing hyperglycemia and hypertri-
reduces depressive symptoms in major depression patients glyceridemia, which could be due to depression or related changes
(SMD ¼ 0.61). Physical exercise is an efficient alternative treat- in diet and exercise, but which clearly increases the risk for
ment for depression with a 49% increase in the probability of metabolic syndrome.
response to treatment defined as a 50% reduction in initial Conclusion: both major depression and metabolic syndrome
depression scores. Individuals over 60 years of age showed a are associated with increased mortality and morbidity, possibly
higher efficacy than those found in studies with populations below through the association with various medical diseases such as
60 years. cardiovascular disease and diabetes mellitus type 2. Unhealthy
Patients with mild depressive symptoms showed a better lifestyles such as poor diet and lack of physical activity are
treatment response than patients with mild/moderate depressive suggested to be mediating the association between major depres-
symptoms. Aerobic training was more effective than strength sion and metabolic syndrome.
training. In this meta-analysis, the efficacy of exercise in the
treatment of depression was influenced by age and symptom
The role of lifestyle factors
severity. It is reasonable that physical exercise may in some cases
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be considered an alternative to antidepressants for the treatment of Poor diet, physical inactivity, and smoking have long been
mild major depression in older persons. This finding might recognized as key contributors to the high prevalence non-
contribute to decreasing the use of medication and hospitalization communicable diseases, such as cardiovascular disease, type 2
and in promoting independence in activities of daily living in diabetes, metabolic syndrome, and cancer. However, there are
elderly patients. An important limitation of this meta-analysis is, now an increasing number of studies suggesting that the same
however, that the samples of all studies included consisted of modifiable lifestyle behaviors are also risk factors for common
patients with mild or moderate depression. mental disorders, such as major depression. Research on major
depression has confirmed that it is caused by an array of
biopsychosocial and lifestyle factors [18]. Diet and lack of
Major depression and metabolic syndrome
physical exercise are two such influences that play a signifi-
For personal use only.

Depressed persons have approximately a two-fold increased risk cant mediating role in the development, progression, and treat-
of having or developing cardiovascular disease [7–10]. Further, ment of this condition. Poor diet and physical inactivity can
after a cardiovascular event, the risk of onset of depression is influence several physiological pathways associated with
increased, resulting in poorer cardiovascular outcome. The depression.
metabolic syndrome, a constellation of cardiovascular risk factors Growing evidence indicates a role for physical inactivity as a
including (abdominal) obesity, hypertension, dyslipidemia and risk factor for major depression, while exercise has been shown to
hyperglycemia, has been suggested to be one possible pathway be effective in treatment studies [13,14]. There is some evidence
linking depression and cardiovascular disease. that smoking is highly prevalent among mental disorders. Diet
A recent meta-analysis clearly demonstrated that metabolic quality is the most recent area of attention in the lifestyle mental
syndrome occurs frequently in depressed persons [16]. The health research field. A recent review found consistent evidence
authors included 18 publications (n ¼ 5531) with clearly defined that severity of obesity is associated with the relationship between
major depression, all published between 2004 and June 2013. obesity and depression, such that having a BMI that falls within
They reported that 30.5% of individuals with major depression the class III obese category may confer risk of co-morbid
suffered from metabolic syndrome. The relative risk for metabolic depression [19]. Given that a greater severity of obesity is
syndrome was 1.5 times higher for persons with depression associated with greater health risks and physical impairment
compared with general population controls. aligns with research that has found higher levels of physical
Consistent with population studies, the research group found impairment and lower levels of quality of life to be associated
no significant difference between men and women, indicating that with depression [20]. Thus, it seems likely that severity of obesity
both sexes need the same attention and care. In addition, age also may be an important risk factor in determining an individual’s
did not explain differences in prevalence estimates, indicating that risk of developing co-morbid depression.
the high risk for metabolic abnormalities should be a concern While these lifestyle factors are significant in the etiology and
across the lifespan. However, antipsychotic drugs use significantly maintenance of depression, a multitude of other factors influences
(p50.05) explained higher metabolic syndrome prevalence may also be important [18]. These include chronic stress, social
estimates in patients with major depression. influences, mental, and physical effects associated with medical
Another meta-analysis on the bidirectional association diseases, alcohol and other drug use, chronic pain, and even
between depression and metabolic syndrome concluded that exposure to sunlight/vitamin D. They are these influences in
metabolic syndrome is an independent risk factor major depres- combination with a large array of psychological, genetic, and
sion [17]. Individuals with metabolic syndrome have a higher biological factors that often complicate the treatment of depres-
relative risk to develop clinically diagnosed depression sion. Basic interventions comprising attention towards one cause
(OR ¼ 2.18) than individuals without metabolic syndrome. and/or one biochemical mechanism (e.g. targeting a single
The positive bi-directional longitudinal association between neurotransmitter disturbance) makes the goal of remission or
depression and metabolic syndrome means that depression is recovery less likely. This was highlighted in a recent study where
causing metabolic syndrome and vice versa. This association giving simple written recommendations about lifestyle changes
suggests a possible pathophysiologic overlap [17]. More specif- for sleep hygiene, physical activity, diet, and sunlight exposure in
ically, elevated cortisol secretion due to hyperactivity of the addition to antidepressant treatment enhanced compared with
hypothalamic–pituitary–adrenal (HPA) axis, (pro)-inflammatory standard antidepressant treatment alone [21]. Remission/response
 4 J. Knapen et al. Disabil Rehabil, Early Online: 1–6

rates reached 60% in the combined treatment group compared disadvantage of requiring the subject’s optimal motivation to
with 10% in the anti-depressant only group. work to ‘‘near exhaustion’’, and require the supervision of a
It might be hypothesized that lifestyle changes will not only physician and the use of expensive equipment. For depressed and
have beneficial mental health benefits in persons with major anxious patients, however, submaximal measures are highly
depression. Since both depressive symptoms and metabolic recommended for the reasons that many patients have poor
syndrome appear to have a two-directional relationship, poor physical health, low levels of fitness and physical self-worth, few
diet and lower physical activity levels might partially mediate the experience with aerobic training, and less energy and motivation
association between depression and metabolic syndrome. When for heavy physical effort [24,25]. Salmon pointed out that,
both conditions are present, additional metabolic disturbances especially in this population, physiological measurements studied
might promote a chronic character of the depressive symptoms. in a laboratory could be influenced due to pre-test anxiety [26].
These are suggestive of a vicious cycle and are indicative of the Patients with an increased trait/state anxiety, for example, might
existence of a specific condition, which might be labeled as fear that maximal aerobic effort will provoke physiological
metabolic depression [18]. Lifestyle interventions for depressed reactions such as hyperventilation, tachycardia, dizziness, or
patients might improve both mental and somatic health status and sweating, which they associate with symptoms of panic attacks
could possibly prevent mechanisms that may mediate the [27]. These clinical considerations usually lead to the application
association between depression and metabolic syndrome [17,22]. of submaximal exercise tests in psychiatric settings. At the
Conclusion: physical exercise and diet have an impact on both University Psychiatric Centre KU Leuven, Campus Sint-Jozef
physical and mental health, and desirable changes in these Kortenberg, the 6-min walk test [28] and the Franz ergocycle test
lifestyle factors can be useful in the prevention and treatment of [24] are most commonly used.
depression and metabolic syndrome. For patients with major depression who often suffer from
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fatigue and low motivation, the rate of perceived exertion during

Evidence-based recommendations for exercise therapy physical activity is an important parameter when designing an
in patients with depression appropriate exercise schedule [24,25]. The fatigue and recovery
time following an effort are not only dependent on physiological
In this last section, we offer some general recommendations for
stressors (intensity, duration, and frequency of the training
physical fitness assessment and exercise prescription, for inven-
stimulus) but also on psychosocial factors. Psychological and
torying perceived barriers and benefits towards exercise partici-
social problems cause considerable stress. Generalized fatigue
pation and propose some strategies for improving patient’s
and lack of energy are typical symptoms of major depression. The
motivation and adherence to an exercise programme.
exercise tolerance of patients is reduced due to the fact that they
are preoccupied with physiological reactions during effort such as
For personal use only.

Physical fitness assessment and exercise prescription

palpitations, perspiration, and hyperventilation. These psycho-
Developing an exercise prescription for people with depression logical factors cannot be ignored when developing a well-
differs from the prescription used for healthy individuals. Physical designed fitness program. The evaluation of degree of perceived
therapists should be aware that several characteristics of major exertion can be derived from the psychophysiological concept of
depression (e.g. loss of interest, motivation and energy, general- Borg [29]. The Borg 15 Graded Category Scale and the Borg
ized fatigue, a low self-worth and self-confidence, fear to move, Category Ratio 10 Scale quantify the sensations that the subject
and psychosomatic complaints) and physical health problems experiences during physical effort. The Borg 15 Graded Category
interfere with participation in exercise. Scale has a score range from 6 to 20 (15 grades), and the Borg
Designing well-considered exercise programs for these Category Ratio 10 Scale from 0 to 10 (10 grades). Both scales
patients requires (1) a risk stratification for patients with co- show a linear relationship with heart rate during progressive
morbid somatic disease, (2) an assessment of physical fitness and incrementally exercise (r ¼ 0.94 and r ¼ 0.88, respectively). At the
the perceived exertion during exercise, and (3) an inventory of the University Psychiatric Centre KU Leuven, Campus Sint-Jozef
perceived barriers and benefits towards exercise participation. Kortenberg, we use the Borg Category Ratio 10 Scale because the
longer Borg 15 Graded Category Scale requires a greater
Risk stratification for patients with co-morbid somatic disease differentiation capacity.
Before initial treatment, physical therapists should identify high-
risk individuals, such as patients with a history of cardiovascular Inventorying perceived barriers and benefits
disease or diabetes [23]. These patients should be medically towards exercise participation
cleared before beginning physical activity. For the vast majority
Depressed patients accumulate a lot of barriers for participation in
of people, the risk of sudden cardiac events is, however, minimal,
exercise such as psychosomatic complaints, a low self-worth and
as long as they start at a realistic pace. Low-intensity physical
self-confidence, loss of energy, interest and motivation, general-
activity is related to a low risk. For example, a walking program at
ized fatigue, weak physical fitness and health condition, fear to
light to moderate intensity is safe for most patients. Intensity can
move, overweight and a low feeling of personal control concern-
be increased over time, and the patient and physical therapist
ing own fitness and health, and helplessness and hopelessness
should pay attention to symptoms such as chest pain or shortness
[15,25]. Consequently, it is highly recommended to have a
of breath. Besides, the moderate training stimulus should be
conversation concerning barriers and possible strategies that assist
adapted to the training status and side effects of psychotropic
a patient in overcoming these barriers (e.g. problem solving,
medication (such as constipation, dizziness, dry mouth, nausea,
planning activity, seeking social support) before starting an
sweating, and tremor) [23].
exercise program. Furthermore, giving information regarding both
mental and physical health benefits of regular physical activity
Assessment of physical fitness and the perceived exertion
and determining which benefits are most salient to each patient is
during exercise
essential. For inventorying of perceived barriers and benefits
Direct measurement of maximal oxygen intake by way of a physical therapists may use a decision balance that patients helps
maximal exercise test is the most accurate indicator of cardio- to reflect the relative weighing of the pros and cons of exercise
respiratory fitness [23]. Maximal tests, however, have the participation [30].
 DOI: 10.3109/09638288.2014.972579 Exercise therapy for depression 5
Strategies for improving motivation and adherence initially very small progress), and encourage modification of
to exercise goals as needed.
 Seek support of others such as family and friends.
Strategies could be based on the principles of Motivational
 Use relapse behaviors/strategies: it is important to explain to
Interviewing following Miller and Rollnick [31], and the
patients that relapses are part of the process of change, and
Transtheoretical Model of Behaviour Change [30,32]. This
that responding with guilt, frustration, and self-criticism may
model postulates that exercise behaviour change involves progress
decrease their ability to maintain physical activity. Relapse
through six stages of change: pre-contemplation, contemplation,
prevention strategies such as realistic goals setting, planned
preparation, action, maintenance, and termination.
activity, realistic expectations, identifying and modifying
Initial phase: starting with supervised exercise negative thinking, and focusing on benefits of single exercise
sessions seem to be effective.
 Create exercise programs based on the patient’s current
preferences and expectations, the initial physical fitness
assessment and the measurement of perceived exertion Conclusion
during exercise. Two recent meta-analyses confirm that exercise is an effective
 Draw up an individual plan with the patient taking into treatment for depression. For mild to moderate depression, the
account emotional, cognitive, and physiological components effect of exercise may be comparable with antidepressant
of major depression. medication and psychotherapy; for severe depression, exercise
 Help the patient set realistic and achievable goals which lead seems to be a valuable complementary therapy to the traditional
to success experiences; this generally gives courage to treatments. Exercise therapy also improves physical health (e.g.
Disabil Rehabil Downloaded from informahealthcare.com by 87.64.137.204 on 10/26/14

persevere. metabolic syndrome), body image, patient’s coping strategies

 Adapt the moderate exercise stimulus to the individual’s with stress, quality of life, and independence in activities of daily
health status and physical abilities, age, training status and living in older adults. Motivational strategies should be
exercise history, expectations and goals, side effects of incorporated in exercise interventions to enhance both the
psychotropic medication, exercise tolerance, and perceived patients’ motivation and their long-term adherence to exercise,
exertion. taking into account emotional, cognitive, and physiological
 Follow the program with exercise cards and a logbook and components of depression.
provide regular progress feedback to the patients.
 Avoid between-patient comparisons.
 Emphasize the short-term benefits after single exercise Declaration of interest
For personal use only.

sessions: improvements in mood and state anxiety, stress The authors report that there are no declaration of interest.
level, energy level, distraction of negative thoughts, the
ability to concentrate and focus, and quality of sleep. Many
patients are focused on the distant outcomes, such as weight References
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