Reference: BMJ. 2024 Feb 14:384:e075847
Practice Point: Exercise is an effective treatment option for depression and should be prescribed routinely.
EBM Pearl: Compared with the traditional pairwise meta-analysis, a network meta-analysis compares multiple interventions simultaneously and can estimate the ranking and hierarchy of interventions.
Among the treatment options for depression, exercise stands out as a potent yet often underutilized intervention. While antidepressants and psychotherapy remain primary strategies, evidence suggests that physical activity can play a pivotal role in alleviating symptoms of depression. But how do we really prescribe exercise for depression? A recent systematic review and network meta-analysis published in the BMJ sought to identify the optimal type, duration, and intensity of exercise for depression and how it compares with traditional therapy.
RCTs of exercise for depression were included. Exercise was defined as “planned, structured and repetitive bodily movement done to improve or maintain one or more components of physical fitness," and included but was not limited to walking, jogging, cycling, dance, strength training, yoga, tai chi, and qigong. Studies with multiple exercise arms, other interventions like medication and psychotherapy as well as active and waitlist controls were included. Data regarding type, frequency, intensity, time, acceptability, and autonomy (choice) of prescription were collected. The primary outcome was the standardized mean change from baseline in depression scores, with effect sizes reported.
Two-hundred-eighteen studies with 495 arms and 14,170 participants were included. Dancing led to the largest reductions in depression of all the treatments compared to active controls. Next most effective, in order of effect, were walking or jogging, yoga, strength training, mixed aerobic exercises, and tai chi or qigong. Moderate reductions in depression were also seen when exercise was combined with SSRIs or psychotherapy. By itself, CBT demonstrated an effect size on par with yoga. SSRIs by themselves were the least effective method studied. Strength training and yoga were seemingly the most acceptable forms of exercise (had the lowest rate of dropouts). In general, higher intensity exercise was associated with stronger outcomes and similar benefits were seen across varying weekly doses, coexisting conditions, and baseline depression severity. Surprisingly, increased patient autonomy in setting the exercise regimen was associated with fewer benefits.
So go ahead, tell your depressed patients to put on their favorite tune and dance it out, or to get into a yoga flow, to start lifting heavy things, or simply go for a walk or a jog. Make your recommendation specific and don’t be afraid to write it down. Overall, we think this is a well-executed systematic review and network meta-analysis. Authors followed PRISMA guidelines and credibility was assessed using CINeMA. Most studies were unblinded, a major limitation, but we recognize that blinding (the participants at least) is simply not feasible for exercise. This study is a good reminder that SSRIs have limited benefits and that providers should take into account lifestyle when evaluating and treating depression. Though starting an exercise regimen may take some motivation (perhaps that’s what good SSRIs are for!) the benefits cannot be overstated.
For more information, see the topic Major Depressive Disorder (MDD) in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Nicole Jensen, MD, Family Physician at WholeHealth Medical. Edited by Alan Ehrlich, MD, FAAFP, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School; Katharine DeGeorge, MD, MS, Senior Deputy Editor at DynaMed and Associate Professor of Family Medicine at the University of Virginia; Dan Randall, MD, MPH, FACP, Deputy Editor at DynaMed; Vincent Lemaitre, PhD, Medical Editor at DynaMed; Hannah Ekeh, MA, Senior Associate Editor at DynaMed; and Jennifer Wallace, BA, Senior Associate Editor at DynaMed.