Exercise and depression: better than meds and mindfulness?

Yesterday 20% of my consultations were for depression. Perhaps I  shouldn’t be surprised - the Office of National Statistics reported that in 2022 one in six adults in the UK suffered from moderate to major depression. My last patient was young, early twenties, and this was already his third episode of the disease.  

With all common conditions clinicians have a “spiel” – with depression first I always talk about simple things people can do – staying socially active, limiting alcohol and drug use, trying to do some exercise. In truth all of these feel like a prelude to the main event: talking therapies, antidepressants, or both. But my patient had tried these already – he didn’t get on with CBT, SSRIs didn’t help. The only thing that made a difference for him was going to the gym. So should exercise take a more prominent role in managing depression?

Well, perhaps so. Last week the BMJ published a systematic review and meta-analysis examining the effectiveness of exercise for treating major depressive disorder. The headline result is that exercise is an effective treatment for depression, but what was really surprising was that the treatment effect may be as good or better than antidepressants or talking therapies.

Mention exercise in a consultation though and it’s not uncommon to see a look of horror spread across the face of our patients. Images of sweat bands, heavy breathing and lycra spring to mind and many will assume doing enough exercise to help with their mood is unachievable. 

The really good news from this review is that while it did show a dose response, with more vigorous exercise potentially driving greater gains, you don’t need to run a marathon and low intensity exercise such as walking, yoga or tai chi was also beneficial. 

Engaging with any treatments can be challenging for an individual when they have depression but for those that are interested we can reassure that doing any sort of activity is likely to help – in addition to those already mentioned strength training, jogging and dancing all showed clinically important improvements over active controls. Sports studied are far from exhaustive and there’s a good chance most would help, from football to aqua aerobics to cheese rolling. 

There is no one size fits all. My wife loves running, I can’t stand it. She gets that ‘runner’s high’, I just get sore knees. The key is finding a type of exercise that the person is physically capable of undertaking, willing to engage with and hopefully enjoy. Exercising in green spaces (e.g. parks, forests, meadows) and blue spaces (e.g. lakes, rivers, seas) can further aid mental health, but where these are not easily or safely accessible, indoor exercise also works.

Existing guidelines do highlight exercise as a treatment. For example, NICE recommends physical activity, ideally outdoors, to ‘enhance a sense of wellbeing’ and group exercise as an intervention for both less and more severe depression. “Group exercise” is another concept that can put a lot of people off (and one I suspect many of us have limited ability to directly access for our patients). Thankfully the BMJ shows both individual and group exercise to be effective options.

This new data is not without issues: the quality of studies included was often low and so the confidence in the outcomes is somewhat less than for CBT or antidepressants; the interventions were almost universally less than one year unlike depression which is often very prolonged (although not unlike drug and psychological therapy trials). It also shows that simply counseling people to do exercise is less effective than actively facilitating them to do it, so it’s worth exploring what local options there are to support your patients. Exercise on prescription? Volunteer or council clubs? Parkrun? Do you have access to a social prescriber? They can help with this.

Nevertheless, as the linked editorial says “primary care clinicians can now recommend exercise, psychotherapy or antidepressants as standalone alternatives for adults with mild or moderate depression”. For a condition where the medications can be problematic and talking therapy services are stretched, this is very welcome news.