WOULDN’T YOU LIKE TO KNOW?
Physical Activity and Depression
by Barbara A. Bushman, Ph.D., FACSM, ACSM-CEP, ACSM-EP, ACSM-CPT
Q:
Is physical activity of any benefit in preventing
or treating depression?
A:
The evidence for physical activity preventing depres-
sion, as well as being used to treat depression, is grow-
ing. Depression is a major health concern worldwide,
including within the United States. Globally, 322 million people
(which equates to 4% of the world’s population) are estimated
to be affected by depression (1). For more information on preva-
lence in the United States, see Box 1.
Treatments for depression include antidepressant medications
and psychotherapy; discussion of these, and other therapies, is be-
yond the scope of this article, and the reader is directed to the list
of resources at the end of the article. A recent report revealed that
approximately 35% of U.S. adults with a major depressive epi-
sode did not receive treatment (2). When considering the high
prevalence of depression, along with situations in which there is
no treatment or there are delays in treatment, the use of exercise
to prevent and to treat mental disorders has been highlighted
as promising (3). Cross-collaborations between exercise science
and mental health professionals are needed to better clarify the
potential benefit of exercise to prevent and treat mental disorders
Volume 23 | Number 5
(3). In addition, other researchers examine what mechanisms are
involved (see Box 2).
At this point, more studies focus on the effect of antidepressant
medications compared with the number of studies that focus on
exercise (3). See Box 3 for some examples of published studies re-
lated to exercise and depression. Even within exercise trials,
“treatment as usual” may be involved and can create challenges
for researchers designing studies to examine effects of exercise.
A randomized controlled trial involves assigning participants into
a treatment group or control group (9). For example, with a med-
ication, the control group would receive a placebo (inert pill)
whereas the treatment group receives the actual medication of in-
terest. With exercise, the ability to “blind” participants to treat-
ment is not possible (i.e., individuals know if they are exercising
or not); finding a true exercise placebo is difficult (9). Within many
studies on depression and exercise, control groups may have a
nonactive intervention or are given the treatment as usual (e.g., re-
ceiving antidepressant medication or psychotherapy). Control
group improvement is common. Because comparison is made
to the control group who often receives standard treatment, exer-
cise effects would need to match or supersede those found in the
placebo/control in order for exercise to be considered a successful
intervention (9).
Even with challenges, research study findings on the poten-
tial role of exercise have been encouraging as noted in several
www.acsm-healthfitness.org 9
WOULDN’T YOU LIKE TO KNOW?

BOX 1. Depression in the United States

According to the National Institute of Mental Health (2): “Major depression is one of the most common mental health disorders
in the United States.” The definition used in the determination of prevalence is based on the Diagnostic and Statistical Manual
of Mental Disorders, 5th edition, including the following (2):
 A period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had
a majority of specified symptoms, such as problems with sleep, eating, energy, concentration, or self-worth.
 No exclusions were made for major depressive episode symptoms caused by medical illness, substance use disorders, or medication.
Prevalence of major depressive episode in U.S. adults is reported to be 7.1%, representing an estimated 17.3 million
individuals (2). The figure shows the overall prevalence as well as prevalence considering sex, age, and race/ethnicity (2).

meta-analyses. The effect of exercise was larger in studies focused
on individuals with major depressive disorder compared with a
moderate effect in studies without this clinical diagnosis (10). Im-
provements were greatest when the exercise was supervised by
exercise professionals (e.g., physical educators, physiotherapists,
exercise physiologists), leading to a notation on “the importance
BOX 2. The relationship between exercise and depression
The relationship between exercise and mental health is
emerging, and within this area of research, scientists are
exploring potential mechanisms of action. Areas of
interest include physiological mechanisms (e.g., action of
endorphins, elevation of body temperature, function of
mitochondria and neuroplasticity, and changes in
serotonin), psychological mechanisms (e.g., distraction or
mental time out, mastery and self-efficacy), and
inflammatory mechanisms (i.e., evidence of a link
between the immune system and the nervous system) (4).
Although well beyond the scope of this article, exploring
the relationship between exercise and mental health is
one of interest and central to understanding direction of
potential causation.
10 ACSM’s Health & Fitness Journal ®
of adequately trained professionals providing exercise interven-
tions” (10). For clinically depressed adult patients, aerobic exer-
cise improved depression; benefits were found for various
formats (e.g., equipment-based and equipment-free, inside and
outside a hospital, indoors and outdoors, in groups and solo)
and for individuals with differing severity of depressive symp-
toms (11). For nonclinical populations, physical activity had
a significant reductive effect on depression, although this effect
appeared to be weaker than reported for clinical populations who
may have greater severity of depression (12). Another meta-analysis
also concluded that exercise is an effective intervention for depression
(13). This was true when exercise was compared with various
types of controls, but in particular when compared with no inter-
vention. Given the potential wait time for psychotherapy or for
individuals who are not interested in usual care, physical activity
was suggested to be a treatment option.
Thus, lifestyle factors, including physical activity (as well as
nutrition), hold great potential benefit. However, as highlighted
in a 2012 article, “the evidence for the efficacy of physical activity
has not translated into treatment guidelines, and clinical practice
has often neglected physical activity as a therapeutic target … and
lifestyle is usually ignored as a contributing factor to the genesis
and course of depressive illness” (14). When examining the Adult
Depression in Primary Care guidelines, exercise is not listed with
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 BOX 3. Examples of studies related to exercise and depression
Study on the association between exercise and self-reported mental health (5):
Mental health burden was measured with the question, “Now thinking about your mental health, which includes stress,
depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” Thus,
no interviews or standard rating scales were used; perceived mental health condition is the focus. Researchers found exercise
to be associated with a decrease in self-reported mental health burden (approximately 1.5 days per month less); for those with
a previous depression diagnosis, the effect was even greater (approximately 3.75 days per month less) (5). Any type of exercise
appeared to provide benefit, although stronger associations were noted for sports, cycling, and aerobic/gym exercises (5).
U-shaped relationships were found for both duration and frequency. For duration, the lowest mental health burden was
associated with 30 to 60 minutes of exercise; interestingly, exercise durations of over 3 hours were associated with worse
mental health burden than either 45 minutes or no exercise (5). For frequency, the lowest mental health burden was shown for 3
to 5 days per week when compared with fewer or more days per week (5). This was a cross-sectional study and, thus, cannot
answer the question if activity level affects mental health, or if mental health affects one’s activity.
Studies on the amount of exercise to prevent depression:
Various studies have examined the amount of exercise required to prevent depression. A large population cohort study conducted in
Norway revealed a protective benefit of exercise at even 1 hour per week; this included exercise of any intensity (6). In a large
randomized study that compared three intensity levels (light, moderate, and vigorous) to treatment as usual, all exercise options
had improvements in depression scores compared with the standard treatment; all exercise groups as well as the
treatment-as-usual group did see improvement from moderate depression severity to mild (7).
Study examining the effect of physical activity on treatment of depressive symptoms:
Researchers assigned individuals with mild-to-moderate symptoms of depression to a physical activity group (i.e., created a
personalized progressive exercise plan), a behavior activation group (i.e., completed a self-help workbook and engaged in
personally relevant activities such as lunch with a friend), or a control group (nontreatment) (8). Both treatment groups had
reduced depressive symptoms, and the physical activity intervention was able to do so with a lower time commitment
(approximately 184 minutes per week for exercise compared with 439 minutes per week for the behavior activation group) (8).

the evidence-based recommendations, although exercise is in-
cluded within recommendations based on consensus of the group
compiling the guidelines (15): “Exercise has been shown to work
well as monotherapy or adjuvant to medication in moderate
depression.” In addition, long-term benefits as well as use in
prevention are noted as having “a small but growing body
of evidence” (15). To retain benefits, exercise must be main-
tained; individualization is a consideration given the specific
circumstances (15).
The Canadian Network for Mood and Anxiety Treatments
provides guidelines for management of major depressive dis-
order (MDD) in adults (16). Physical activity is reviewed as one
of the “complementary and alternative treatments” (CAM).
The guidelines point out that “… for most patients with MDD,
evidence-based pharmacological treatments and/or psychological
treatments should be considered ahead of CAM treatments be-
cause of a generally larger evidence base and often better quality
evidence for efficacy” (16). Encouragingly, the evidence for exer-
cise in the treatment of MDD is presented at a level 1 (top level of
evidence). Exercise is recommended as a first-line monotherapy
for mild to moderate MDD (16). Because of limited long-term
data and other issues, exercise is recommended as a second-line
adjunctive treatment of moderate to severe MDD (16).
When considering exercise type, most research has focused
on aerobic-based programs. Suggestions include durations of
30 minutes or more with a frequency of 3 days per week, for
at least 8 weeks (17), as well as 30 to 40 minutes with a frequency
of 3–4 days per week at a low to moderate intensity, or
participant-selected intensity (18). The National Institute for
Health and Care Excellence suggests the following recommen-
dations for individuals with persistent subthreshold symptoms
or mild to moderate depression: group settings with a competent
BOX 4. Physical Activity Guidelines for Americans,
2nd edition, key guidelines for adults (20)
 Adults should move more and sit less throughout the day.
Some physical activity is better than none. Adults who
sit less and do any amount of moderate to vigorous
physical activity gain some health benefits.
 For substantial health benefits, adults should do at least
150 minutes (2 hours and 30 minutes) to 300 minutes
(5 hours) a week of moderate-intensity, or 75 minutes
(1 hour and 15 minutes) to 150 minutes (2 hours and
30 minutes) a week of vigorous-intensity aerobic physical
activity, or an equivalent combination of moderate- and
vigorous-intensity aerobic activity. Preferably, aerobic
activity should be spread throughout the week.
 Additional health benefits are gained by engaging in
physical activity beyond the equivalent of 300 minutes
(5 hours) of moderate-intensity physical activity a week.
 Adults also should do muscle-strengthening activities
of moderate or greater intensity and that involve all major
muscle groups on two or more days a week, as these
activities provide additional health benefits.

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WOULDN’T YOU LIKE TO KNOW?
BOX 5. Move Your Way poster (link: https://health.gov/paguidelines/moveyourway/materials/PAG_MYW_Adult_
Poster1.pdf)
practitioner, and typically three sessions per week, 45 to
60 minutes in length, over a 10- to 14-week period (19). Limited
research has been done related to resistance training; one review
suggested equal effectiveness between “aerobic and anaerobic”
although calling for future research to examine effectiveness of
different anaerobic training programs (e.g., level of resistance,
repetition, rest) (17).
12 ACSM’s Health & Fitness Journal ®
Well-established health benefits can be reaped for those who
are regularly active (20). This is relevant given a report that in-
dividuals with major depression die 10 years earlier than those
without depression (21). Physical activity has the potential to
help with treating symptoms of depression while also promoting
overall health, thus reducing mortality (21). When developing
an exercise program, design considerations include 1) risk
September/October 2019
 BOX 6. Promoting adherence
Adherence is key; examples of various behavioral skills
and strategies include the following (25):
 Use positive cues to be more active and remove cues that
cause inactivity.
 Set a realistic goal that gives direction and motivation.
 Find ways to make exercise rewarding with positive
reinforcement.
 Recruit social support.
 Identify resources in the environment that support activity.
 Develop a plan to deal with barriers or interruptions in
exercise plans.
stratification given the incidence of chronic disease (e.g., cardio-
vascular disease, type 2 diabetes, metabolic syndrome), 2) fitness
assessment and exercise perceived exertion, and 3) examination
of perceived barriers and benefits of exercise, along with discus-
sion of strategies for success (22).
Based on a review of the scientific literature, the Physical
Activity Guidelines Advisory Committee Scientific Report high-
lights the value of physical activity (23): “Regular physical activ-
ity not only reduces the risk of clinical depression but reduces
depressive symptoms among people both with and without clin-
ical depression. Physical activity can reduce the severity of those
symptoms whether one has only a few or many.” The committee
concluded that greater amounts of physical activity have the po-
tential to reduce the risk of developing depression and that there
is a dose-response relationship for depressive symptoms (i.e., that
relationship observed at low levels of exercise increases as exer-
cise levels increase) (23). The report underscores the value of ex-
ercise: “Engaging in more than 30 minutes per day of activity
reduced the odds of experiencing depression by 48 percent.”
Reduced risk of depression was observed for even lower levels
of activity (less than 150 minutes per week), with larger effects as-
sociated with more activity (23). When compared with cognitive
behavioral therapy or antidepression medication, physical activ-
ity has been found to be as effective as these commonly used
treatments (23). When developing a plan, intensity level should
be regulated to promote adherence, with additional interven-
tions and support potentially needed for more vigorous-intensity
exercise (23).
The Physical Activity Guidelines for Americans, 2nd edition, recog-
nizes reduced risk of depression and reduced risk of depressed
mood with habitual physical activity, including this encouraging
statement (20): “Engaging in regular physical activity reduces
the risk of developing depression in children and adults and
can improve many of the symptoms experienced by people with
depression.” The key guidelines for adults are shown in Box 4
(these are for all adults, not specifically for those with depres-
sion); an example of a poster available from the Move Your
Way campaign is shown in Box 5 and includes “better mood”
within the highlights (24).
Volume 23 | Number 5
As with any exercise prescription, individualization is key.
Studies related to specific exercise programs reflect aspects of
the Physical Activity Guidelines, and thus including aerobic
and resistance exercises may be considered for future goals re-
garding physical activity. A gradual increase in physical activity
over time is recommended (25). As with traditional treatments
for depression, improvements in depression usually take time
(i.e., several weeks to months) (25). To promote adherence, var-
ious behavioral skills and strategies may be helpful (see Box 6).
SUMMARY
Traditional treatments for depression include antidepressant
medications and psychotherapy, among others. Physical activity
and exercise also have shown promise in reducing the risk of de-
veloping depression and in helping with depressive symptoms.
Future research is needed to examine program variables (e.g.,
type of exercise, duration, and level of supervision) that are
most effective.
RESOURCES
Overview:
• Risk factors, treatment and therapies, and free booklets and
brochures: https://www.nimh.nih.gov/health/topics/
depression/index.shtml
• Background, treatment/therapies, and additional informa-
tion: https://medlineplus.gov/depression.html
• Background, treatment, and support: https://www.nami.
org/Learn-More/Mental-Health-Conditions/Depression
• Background: https://adaa.org/
Mental illness assistance:
• Help for mental illness: https://www.nimh.nih.gov/
health/find-help/index.shtml
• Help for mental illness: https://www.mentalhealth.gov/
get-help
• National helpline: https://www.samhsa.gov/find-help/
national-helpline
Depression screening:
• Depression screening: https://medlineplus.gov/lab-tests/
depression-screening/
• Depression screening tool: https://www.myhealth.va.gov/
mhv-portal-web/web/myhealthevet/depression-screening
Downloadable brochures:
• https://www.nimh.nih.gov/health/publications/
depression-listing.shtml
• https://adaa.org/about-adaa/request-publications
Exercise and fitness-related information:
www.acsm-healthfitness.org 13
WOULDN’T YOU LIKE TO KNOW?
• https://www.nami.org/Blogs/NAMI-Blog/May-2016/
Exercise-for-Mental-Health-8-Keys-to-Get-and-Stay
• https://www.nami.org/Blogs/NAMI-Blog/February-
2018/How-Dogs-Can-Help-with-Depression
• https://www.nami.org/Blogs/NAMI-Blog/July-2016/
Top-10-Fitness-Motivation-Tips
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Disclosure: The author declares no conflict of interest and does
not have any financial disclosures.
Barbara A. Bushman, Ph.D., FACSM,
ACSM-CEP, ACSM-EP, ACSM-CPT, is a pro-
fessor at Missouri State University. She holds
four ACSM certifications: Program Director,
Clinical Exercise Physiologist, Exercise Physi-
ologist, and Personal Trainer. Dr. Bushman
has authored papers related to menopause,
factors influencing exercise participation, and
deep-water run training; she authored ACSM’s Action Plan
for Menopause (Human Kinetics, 2005), edited both the
first and second editions of ACSM’s Complete Guide to
Fitness and Health (Human Kinetics, 2011 and 2017), and
promotes health/fitness at www.Facebook.com/FitnessID.
September/October 2019