Exercise matched therapy and antidepressants for easing depression

Depression is a leading cause of ill health worldwide, and while antidepressants and psychological therapy are the standard treatments, many people prefer or want to add alternatives such as exercise. Whether exercise genuinely treats depression, rather than simply lifting mood in people who were going to improve anyway, has been debated for decades. This Cochrane review, first published in 2008 and last updated in 2013, returned to the question with a decade of new trials to see whether the answer had changed.

The reviewers searched major databases up to November 2023 for randomised controlled trials comparing exercise with no treatment, inactive controls or active treatments in adults with depression. They included 73 trials with at least 4985 participants, 69 of which contributed data to the pooled analyses. Depression or mood at the end of treatment was the primary outcome, with acceptability, quality of life, cost and adverse events also assessed. They ran subgroup analyses on exercise intensity, type and dose, and sensitivity analyses on trial quality.

Across 57 trials with 2189 participants, exercise produced a moderate reduction in depressive symptoms compared with no treatment or a control, though the evidence was low certainty. In the seven strictest trials, with 447 participants, the effect was smaller. Ten trials with 414 participants found probably little to no difference between exercise and psychological therapy, and five trials with 330 participants found the same against medication. Long-term follow-up data were rare and very uncertain. Adverse events were uncommon, and dropout rates suggested exercise was as acceptable as the alternatives.

Adding 35 new trials with at least 2526 participants barely moved the estimate from previous versions of this review, which suggests the finding is stable: exercise helps, moderately, and roughly on a par with standard treatments in the small trials that compared them directly. The persistent weaknesses are also stable: trials cannot blind participants to whether they exercised, many relied on self-reported symptoms, and few followed people long term. Which types, doses and intensities of exercise work best for whom remains an open question the authors say future research should prioritise.

For anyone weighing options for low mood, this is a reason to take exercise seriously as more than a feel-good add-on: across a large body of trials it moderately reduced depressive symptoms and held its own against therapy and medication in direct comparisons. The honest reading is that the benefit is real but probably smaller than the headline numbers suggest, since the strictest trials found less. It is information to bring to a conversation about treatment, not a substitute for one.