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Clinical Review & Education

JAMA Clinical Evidence Synopsis

Exercise for Depression

Gary Cooney, AB, MBChB; Kerry Dwan, PhD; Gillian Mead, FRCP

CLINICAL QUESTION Is exercise an effective treatment for depression?

BOTTOM LINE Exercise is associated with a greater reduction in depression symptoms

compared with no treatment, placebo, or active control interventions, such as relaxation or
meditation. However, analysis of high-quality studies alone suggests only small benefits.

Depression affects more than 121 million people worldwide.1 Al- ing a maximum score of 63. Scores below 10 are considered mini-
though depression is commonly treated with medications or psy- mal depression, whereas scores above 30 indicate severe
chological therapies, some consider exercise as an adjunct or sub- depression.5
stitute treatment. This JAMA Clinical Evidence Synopsis summarizes Exercise was associated with a greater reduction in depres-
an updated Cochrane review2 that assesses whether exercise is as- sion scores compared with control (35 trials; pooled SMD, 0.62
sociated with improvements in depression. [95% CI, 0.81 to 0.42]). This represented a moderate effect,
equivalent to a difference of approximately 5 BDI points. For the
Summary of Findings 15 studies reporting BDI, the mean difference was 5.34 BDI points
Of the 39 trials that fulfilled inclusion criteria, 37 trials provided data (Figure). However, analyzing only the 6 trials with adequate allo-
for meta-analysis; 35 trials (1356 participants) compared exercise cation concealment, intention-to-treat analysis, and blinded out-
with no treatment or a control intervention. Because different de- come assessment (n = 464) showed no association of exercise
pression scales were used, standardized mean difference (SMD) was with improved depression (SMD, 0.18 [95% CI, 0.47 to 0.11];
used to combine data. An SMD of 0.20 represents a small effect, 0.50 BDI, 1.71 [95% CI, 4.47 to 1.05]). Seven trials (n = 189) found no
a moderate effect, and 0.80 a large effect.3 difference between exercise and psychological therapy (SMD,
We converted SMD to the Beck Depression Inventory (BDI) 0.03 [95% CI, 0.32 to 0.26]; BDI, 0.29 [95% CI, 3.04 to
score, using data from a study by Chalder and colleagues4 and 2.47]). Four trials (n = 298) found no difference between exercise
methods described in the Cochrane handbook.3 The BDI, a self- and antidepressant therapy (SMD, 0.11 [95% CI, 0.34 to 0.12];
rated depression scale, includes 21 items, each scored 0 to 3, giv- BDI, 1.05 [95% CI, 3.23 to 1.14]). Subgroup analyses were con-
ducted to examine the association between type of exercise and
whether depression was diagnosed by a clinical interview or a
Evidence Profile depression scale threshold score. The SMD for aerobic exercise
indicated a moderate clinical association (SMD, 0.55 [95% CI,
No. of randomized clinical trials: 39 0.77 to 0.34]; BDI, 5.23 [95% CI, 7.32 to 3.23]). The SMD for
Study years: Published, 1979-2012; conducted, 1978-2010 resistance exercise (SMD, 1.03 [95% CI, 1.52 to 0.53]; BDI,
No. of patients: 2326 9.79 [95% CI, 14.44 to 3.71]) indicated a stronger association.
Men: 637 (31%) Women: 1382 (68%); only 31 trials (2019 partici- However, aerobic and resistance exercise were not directly com-
pants) reported sex pared head-to-head.
Age, mean range: 22-87.9 years There was also a moderate favorable association between ex-
ercise and reduction in depression scores in studies that reached a
Settings: Community, outpatient, inpatient populations
clinical diagnosis of depression by interview (SMD, 0.57 [95% CI,
Countries: Australia, Brazil, Canada, Denmark, Germany, Iran, Italy,
0.81 to 0.32]; BDI, 5.42 [95% CI, 7.70 to 3.04]), as well as stud-
New Zealand, Norway, Portugal, Russia, Thailand, United Kingdom,
United States ies that reached a diagnosis by cutoff point on a scale (SMD, 0.67
[95% CI, 0.95 to 0.39]; BDI, 6.37 [95% CI, 9.03 to 3.71]). Stud-
Comparisons: Exercise vs no treatment or a control intervention
(ie, placebo treatment or an active control treatment, such as medi- ies with long-term follow-up (8 trials; n = 377; duration of follow-
tation or relaxation); exercise vs antidepressants; exercise vs up, 4-26 mo) reported only a small favorable association (SMD, 0.33
psychological therapies [95% CI, 0.63 to 0.03]; BDI, 3.14 [95% CI, 5.99 to 0.29]). Only
Duration of intervention: 4-16 weeks 7 trials reported adverse events. None reported an increase in ad-
Primary outcomes: Clinical diagnosis of depression, Beck Depres- verse events associated with exercise.
sion Inventory score, Hamilton Rating Scale for Depression score,
Geriatric Depression Scale score Discussion
Secondary outcomes: Treatment acceptability, quality of life, adverse This meta-analysis suggests that exercise may have a moderate-
events sized favorable association with depression, but because of risk of
bias, this association may be small. The optimal type, intensity, fre-
quency, and duration of exercise for depression remain unclear.

2432 JAMA June 18, 2014 Volume 311, Number 23

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JAMA Clinical Evidence Synopsis Clinical Review & Education

Figure. Mean Difference in Beck Depression Inventory Score for Exercise
vs Control or Placebo Intervention Most trials were small, and many had methodological weak-
nesses. Recruitment was often not representative of the popula-
Mean Difference Favors Favors Control tion at large.
Study in BDI (95% CI) Exercise or Placebo
Heterogeneity with respect to depression severity occurred both
Singh, 1997 4.00 (5.53 to 2.47)
McNeil, 1991 3.60 (6.55 to 0.65) within studies and between studies. It was not possi-
Chu, 2008 4.78 (8.41 to 1.15) ble to separately assess the association between exercise and de-
Doyne, 1987 7.07 (11.70 to 2.44) pression according to depression severity. Adherence to
Mutrie, 1988 11.94 (16.74 to 7.14)
exercise may be determined by depression severity, but there were
Hoffman, 2010 4.80 (9.80 to 0.20)
Hemat-Far, 2012 6.20 (11.45 to 0.95) insufficient data to assess this. Positive trials are more likely to be
Veale, 1992 3.85 (9.43 to 1.73) published. We cannot exclude the possibility of publication bias.
Fremont, 1987 2.00 (3.71 to 7.71)
Martinsen, 1985 10.70 (16.56 to 4.84)
Reuter, 1984 13.46 (19.37 to 7.55)
Comparison of Findings With Current Practice Guidelines
Hess-Homeier, 1981 6.40 (15.47 to 2.67) The UK National Institute for Health and Clinical Excellence recom-
Epstein, 1986 7.30 (16.62 to 2.02) mends structured exercise, 3 times a week for 10 to 14 weeks, for
Bonnet, 2005 13.96 (3.34 to 24.58) the treatment of mild to moderate depression.6
Foley, 2008 2.82 (13.84 to 8.20)
Overall 5.34 (7.50 to 3.19)
Areas in Need of Future Study
20 10 0 10 20
Mean Difference in BDI (95% CI) Large-scale, high-quality studies are needed to definitively estab-
lish the association of exercise with depression. The optimal type,
BDI indicates Beck Depression Inventory. Only 15 trials used the BDI score. The intensity, and duration of exercise remain unclear. Further trials are
size of the data markers indicates the weight of the study. Meta-analysis used needed comparing exercise with antidepressants and psychologi-
the random-effects method.
cal treatments.

ARTICLE INFORMATION Role of the Sponsor: The sponsor had no role in 2. Cooney GM, Dwan K, Greig CA, et al. Exercise for
Author Affiliations: Division of Psychiatry, Royal the design and conduct of the study; collection, depression. Cochrane Database Syst Rev. 2013;9
Edinburgh Hospital, United Kingdom (Cooney); management, analysis, and interpretation of the (9):CD004366.
Institute of Child Health, University of Liverpool, data; preparation, review, or approval of the 3. Deeks JJ, Higgins JPT, Altman DG, eds. Chapter
United Kingdom (Dwan); Centre for Clinical Brain manuscript; and decision to submit the manuscript 9: analysing data and undertaking meta-analyses.
Sciences, University of Edinburgh, United Kingdom for publication. Accessed May 20,
(Mead). Additional Contributions: We thank Carolyn Greig, 2014.
Corresponding Author: Gary Cooney, AB, MBChB, Debbie Lawlor, Jane Rimer, Fiona Waugh, and 4. Chalder M, Wiles NJ, Campbell J, et al. A
Division of Psychiatry, Royal Edinburgh Hospital, Marion McMurdo, coauthors of the Cochrane pragmatic randomised controlled trial to evaluate
NHS Lothian, Morningside Terrace, Edinburgh, Review on which this synopsis is based. the cost-effectiveness of a physical activity
Midlothian, EH10 5HF, United Kingdom Correction: This article was corrected on October intervention as a treatment for depression. Health
( 15, 2014, to fix an incorrect figure. Technol Assess. 2012;16(10):1-164, iii-iv.
Section Editor: Mary McGrae McDermott, MD, Submissions: We encourage authors to submit 5. Beck AT, Steer RA, Carbin MG. Psychometric
Senior Editor. papers for consideration as a JAMA Clinical properties of the Beck Depression Inventory. Clin
Conflict of Interest Disclosures: All authors have Evidence Synopsis. Please contact Dr McDermott at Psychol Rev. 1988;8(1):77-100.
completed and submitted the ICMJE Form for 6. National Institute for Health and Clinical
Disclosure of Potential Conflicts of Interest and Excellence. Depression: the treatment and
none were reported. REFERENCES management of depression in adults (update). http:
Funding/Support: This work was funded by the 1. Moussavi S, Chatterji S, Verdes E, Tandon A, Patel // Accessed May
National Institute of Health Research Cochrane V, Ustun B. Depression, chronic diseases, and 20, 2014.
Incentive Award. decrements in health. Lancet. 2007;370(9590):
851-858. JAMA June 18, 2014 Volume 311, Number 23 2433

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