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Exercise for depression

  1. Gary M Cooney1,
  2. Kerry Dwan2,
  3. Carolyn A Greig3,
  4. Debbie A Lawlor4,
  5. Jane Rimer5,
  6. Fiona R Waugh6,
  7. Marion McMurdo7,
  8. Gillian E Mead8,*

Editorial Group: Cochrane Common Mental Disorders Group

Published Online: 12 SEP 2013

Assessed as up-to-date: 13 JUL 2012

DOI: 10.1002/14651858.CD004366.pub6


How to Cite

Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, McMurdo M, Mead GE. Exercise for depression. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD004366. DOI: 10.1002/14651858.CD004366.pub6.

Author Information

  1. 1

    Royal Edinburgh Hospital, NHS Lothian, Division of Psychiatry, Edinburgh, Midlothian, UK

  2. 2

    University of Liverpool, Institute of Child Health, Liverpool, England, UK

  3. 3

    University of Birmingham, Birmingham, UK

  4. 4

    University of Bristol, MRC Centre for Causal Analyses in Translational Epidemiology, School of Social and Community Medicine, Bristol, Avon, UK

  5. 5

    NHS Lothian, University Hospitals Division, Edinburgh, Scotland, UK

  6. 6

    Victoria Hostpital Kirkcaldy, General Surgery, NHS Fife, Kirkcaldy, Fife, UK

  7. 7

    University of Dundee, Centre for Cardiovascular and Lung Biology, Division of Medical Sciences, Dundee, UK

  8. 8

    University of Edinburgh, Centre for Clinical Brain Sciences, Edinburgh, UK

*Gillian E Mead, Centre for Clinical Brain Sciences, University of Edinburgh, Room S1642, Royal Infirmary, Little France Crescent, Edinburgh, EH16 4SA, UK. gillian.e.mead@ed.ac.uk. gmead@staffmail.ed.ac.uk.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 12 SEP 2013

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms

 
Summary of findings for the main comparison. Exercise compared to control for adults with depression

Exercise compared to no intervention or placebo for adults with depression

Patient or population: adults with depression
Settings: any setting
Intervention: Exercise
Comparison: no intervention or placebo

OutcomesIllustrative comparative risks* (95% CI)No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

No intervention or placeboExercise

Symptoms of depression
Different scales
Follow-up: post-treatment
The mean symptoms of depression in the control groups was
0
The mean symptoms of depression in the intervention groups was
0.62 standard deviations lower
(0.81 to 0.42 lower)1
1353
(35 studies)
⊕⊕⊕⊝
moderate2,3,4
SMD -0.62 (95% CI: -0.81 to -0.42).

The effect size was interpreted as 'moderate' (using Cohen's rule of thumb)

Symptoms of depression (long-term)
different scales
The mean symptoms of depression (long-term) in the control groups was
0
The mean symptoms of depression (long-term) in the intervention groups was
0.33 standard deviations lower
(0.63 to 0.03 lower)
377
(8 studies)
⊕⊕⊝⊝
low4,5
SMD -0.33 (95% CI: -0.63 to -0.03).

The effect size was interpreted as 'small' (using Cohen's rule of thumb)

Adverse eventsSee commentSee comment0
(6 studies)
⊕⊕⊕⊝
moderate
Seven trials reported no difference in adverse events between exercise and usual care groups. Dunn 2005 reported increased severity of depressive symptoms (n = 1), chest pain (n = 1) and joint pain/swelling (n = 1); all these participants discontinued exercise. Singh 1997 reported that 1 exerciser was referred to her psychologist at 6 weeks due to increasing suicidality; and musculoskeletal symptoms in 2 participants required adjustment of training regime. Singh 2005

reported adverse events in detail (visits to a health professional, minor illness, muscular pain, chest pain, injuries requiring training adjustment, falls, deaths and hospital days) and found no difference between the groups. Knubben 2007 reported "no negative effects of exercise (muscle pain, tightness or fatigue)"; after the training had finished, 1 person in the placebo group required gastric lavage and 1 person in the exercise group inflicted a superficial cut on her arm. Sims 2009

reported no adverse events or falls in either the exercise or control group. Blumenthal 2007 reported more side effects in the sertraline group (see comparison below) but there was no difference between the exercise and control group. Blumenthal 2012a reported more fatigue and sexual dysfunction in the sertraline group than the exercise group.

Acceptability of treatmentStudy population1363
(29 studies)
⊕⊕⊕⊝
moderate2
RR 1
(95% CI: 0.97 to 1.04)

865 per 1000865 per 1000
(839 to 900)

Quality of lifeThe mean quality of life in the intervention groups was
0 higher
(0 to 0 higher)
0
(4 studies)
See commentThere was no statistically significant differences for the mental (SMD -0.24; 95% CI -0.76 to 0.29). psychological (SMD 0.28; 95% CI -0.29 to 0.86) and social domains (SMD 0.19; 95% CI -0.35 to 0.74). Two studies reported a statistically significant difference for the environment domain favouring exercise (SMD 0.62; 95% CI 0.06 to 1.18) and 4 studies reported a statistically significant difference for the physical domain favouring exercise (SMD 0.45; 95% CI 0.06 to 0.83).

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Effect estimate calculated by re-expressing the SMD on the Hamilton Depression Rating Scale using the control group SD (7) from Blumenthal 2007 (study chosen for being most representative). The SD was multiplied by the pooled SMD to provide the effect estimate on the HDRS.
2 Lack of blinding of outcome assessors probably increased effect sizes and drop-out rates were high. Also sequence generation was considered unclear in 23 studies.
3 I² = 63% and P < 0.00001, indicated moderate levels of heterogeneity
4 Population size is large, effect size is above 0.2 SD, and the 95% CI does not cross the line of no effect.
5 Lack of blinding of outcome assessors probably increased effect sizes and drop-out rates were high. Also sequence generation was considered unclear in 4 studies.

 Summary of findings 2 Exercise compared to psychological treatments for adults with depression

 Summary of findings 3 Exercise compared to bright light therapy for adults with depression

 Summary of findings 4 Exercise compared to pharmacological treatments for adults with depression

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms
 

Description of the condition

Depression refers to a wide range of mental health problems characterised by the absence of a positive affect (a loss of interest and enjoyment in ordinary things and experiences), persistent low mood and a range of associated emotional, cognitive, physical and behavioural symptoms (NICE 2009).

Severity of depression is classified using the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria as mild (five or more symptoms with minor functional impairment), moderate (symptoms or functional impairment are between 'mild' and 'severe') and severe (most symptoms present and interfere with functioning, with or without psychotic symptoms) (NICE 2009). Depression is common, affecting 121 million adults worldwide, and rated as the fourth leading cause of disease burden in 2000 (Moussavi 2007). Depression is an important cause of morbidity and mortality and produces the greatest decrement in health compared with other chronic diseases such as angina or arthritis (Moussavi 2007).

 

Description of the intervention

Depression is commonly treated with antidepressants or psychological therapies or a combination of both. Antidepressants are effective for the treatment of depression in primary care (Arroll 2009). However antidepressants may have adverse side effects, adherence can be poor, and there is a lag time between starting antidepressants and improvements in mood. Psychological treatments are generally free from side effects and are recommended in the UK National Institute for Health and Clinical Excellence (NICE) guidelines (NICE 2009) but some people may not wish to receive psychological therapy due to low expectations of positive outcome or perceived stigma. Psychological therapy also requires sustained motivation and a degree of psychological mindedness in order to be effective. Depression is a well-recognised reason for seeking alternative therapies (Astin 1998). Whilst this may reflect dissatisfaction with conventional treatments, another possibility is that alternative therapies may be more in line with people's own beliefs and philosophies (Astin 1998). There has been increasing interest in the potential role of alternative therapies such as music therapy, light therapy, acupuncture, family therapy, marital therapy, relaxation and exercise for the management of depression.

Exercise is defined as the "planned, structured and repetitive bodily movement done to improve or maintain one or more components of physical fitness" (ACSM 2001). The effect of exercise on depression has been the subject of research for several decades and is believed by a number of researchers and clinicians to be effective in the treatment of depression (Beesley 1997). This reflects an historic perspective on the role of aerobic exercise prescription for depression. For example, a report for the National Service Framework for Mental Health suggested that exercise should be included as a treatment option for people with depression (Donaghy 2000). The NICE guideline for depression recommended structured, supervised exercise programmes, three times a week (45 minutes to one hour) over 10 to 14 weeks, as a low-intensity Step 2 intervention for mild to moderate depression (NICE 2009). A recent guideline published by the Scottish Intercollegiate Guidelines Network (SIGN) for non-pharmaceutical management of depression in adults recommended that structured exercise may be considered as a treatment option for people with depression (graded 'B' relating to the strength of the evidence on which the recommendation was based) (SIGN 2010). Exercise programmes can be offered in the UK through Exercise Referral Systems (DOH 2001). These schemes direct someone to a service offering an assessment of need, development of a tailored physical activity programme, monitoring of progress and follow-up. However, a systematic review of exercise on prescription schemes found limited evidence about their effectiveness and recommended further research (Sorensen 2006), and a further more recent review found that there was still considerable uncertainty about the effectiveness of exercise referral schemes for increasing physical activity, fitness, or health indicators, or whether they are an efficient use of resources for sedentary people (Pavey 2011). A second recent review noted that most trials in this area that have previously been included in systematic reviews recruit participants from outside of health services, making it difficult to assess whether prescribing exercise in a clinical setting (i.e. when a health professional has made a diagnosis of depression) is effective (Krogh 2011). In that review, studies were restricted only to those trials in which participants with a clinical diagnosis of depression were included, and the authors found no evidence of an effect of exercise in these trials (Krogh 2011). NICE concluded that there was insufficient evidence to recommend Exercise Referral Schemes other than as part of research studies to evaluate their effectiveness. Thus, whilst the published guidelines recommend exercise for depression, NICE recommends that Exercise Referral Schemes, to which people with depression are referred, need further evaluation.

This review focuses on exercise defined according to American College of Sports Medicine (ACSM) criteria. Whilst accepting that other forms of bodily movement may be effective, some of these are the subjects of other reviews.

 

How the intervention might work

Observational studies have shown that depression is associated with low levels of physical activity (Smith 2013). Whilst an association between two variables does not necessarily imply causality, there are plausible reasons why physical activity and exercise may improve mood. Exercise may act as a diversion from negative thoughts, and the mastery of a new skill may be important (LePore 1997). Social contact may be part of the mechanism. Craft 2005 found support for self efficacy as the mechanism by which exercise might have an antidepressant effect; people who experienced an improvement in mood following exercise showed higher self efficacy levels at three weeks and nine weeks post-exercise. Self efficacy has been found to be intricately linked with self esteem, which in turn is considered to be one of the strongest predictors of overall, subjective well-being (Diener 1984). Low self esteem is also considered to be closely related to mental illness (Fox 2000). Physical activity may have physiological effects such as changes in endorphin and monoamine levels, or reduction in the levels of the stress hormone cortisol (Chen 2013), all of which may improve mood. Exercise stimulates growth of new nerve cells and release of proteins known to improve health and survival of nerve cells, e.g. brain-derived growth neurotrophic factor (Cotman 2002; Ernst 2005).

 

Why it is important to do this review

Several systematic reviews and meta-analyses (Blake 2009; Carlson 1991; Craft 2013; Krogh 2011; Lawlor 2001; North 1990; Pinquart 2007; Rethorst 2009; Sjosten 2006; Stathopoulou 2006; Sorensen 2006) have looked at the effect of exercise on depression. However, five of these reviews pooled data from a range of study types that included uncontrolled studies and randomised as well as non-randomised controlled trials, and pooled data from trials that compared exercise without treatment with data from trials that compared exercise and other forms of treatment (Blake 2009; Carlson 1991; Craft 2013; North 1990; Pinquart 2007). Two included trials predominantly of older people (Blake 2009; Sjosten 2006). One meta-analysis (Stathopoulou 2006) included only publications from peer-reviewed journals even though it is widely acknowledged that positive trials are more likely to be published than negative or inconclusive trials. The Cochrane Handbook for Systematic Reviews of Interventions recommends comprehensive searching for all trials, including unpublished ones, to avoid bias (Handbook 2011). Two meta-analyses which included assessments of study quality both cautiously concluded that exercise may be effective, but recommended that further well-designed trials are required (Lawlor 2001; Sjosten 2006). One meta-analysis (Rethorst 2009) concluded that exercise is effective as a treatment for depression, but suggested that further conclusive results are necessary for exercise to become a recommended form of treatment. When only studies recruiting participants from a clinical setting were included (i.e. those diagnosed by a health professional as having depression), there is no evidence that exercise is of benefit (Krogh 2011). Another review of walking for depression suggested that walking might be a useful adjunct for depression treatment, and recommended further trials (Robertson 2012).

This review was published in 2001, in the British Medical Journal (Lawlor 2001). It was converted into a Cochrane review in 2009 (Mead 2009), and updated in 2012 (Rimer 2012). Since our last update, we had become aware of new trials that needed to be considered for inclusion, some of which had received considerable press coverage. Furthermore, several suggestions were made by the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) editorial team about how to improve the review, e.g. inclusion of new subgroup analyses and summary of findings tables. The aim of this review is therefore to update the evidence in this area and to improve the methodology since the previous version (Rimer 2012). These changes are described below in Differences between protocol and review.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms

  1. To determine the effectiveness of exercise compared with no treatment (no intervention or control) for depression in adults.
  2. To determine the effectiveness of exercise compared with other interventions (psychological therapies, alternative interventions such as light therapy, pharmacological treatment) for depression in adults.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Randomised controlled trials (RCTs) (including parallel, cluster, or individual, or the first phase of cross-over trials).

We defined a trial as a 'randomised controlled trial' if the allocation of participants to intervention and comparison groups is described as randomised (including terms such as 'randomly', 'random' and 'randomisation').

 

Types of participants

Adult men and women aged 18 and over (with no upper age limit) in any setting, including inpatients.

Studies were included if the participants were defined by the author of the trial as having depression (by any method of diagnosis and with any severity of depression). We excluded trials that randomised people both with and without depression, even if results from the subgroups of participants with depression were reported separately, as we had done in previous versions of the review (Mead 2009; Rimer 2012).

The effects of exercise on depressive symptoms in participants with emotional distress (but not fulfilling a diagnosis of depression) or those who are healthy were not included in this review. We acknowledge that it can sometimes be difficult to distinguish between depression and dysthymia in the 'real world', as there needs to be only two weeks of decreased interest and enjoyment to define depression. However, we were primarily interested in the role of exercise in people with depression, for whom there is substantial morbidity, rather than people with mild, transient episodes of low mood.

Studies that investigated the effect of exercise on anxiety and neurotic disorders, dysthymia (i.e. low mood not fulfilling diagnostic criteria for depression) or postnatal depression were not included in the review.

 

Types of interventions

Exercise was defined as "planned, structured and repetitive bodily movement done to improve or maintain one or more components of physical fitness" (ACSM 2001). The reviews in 2001 (Lawlor 2001) and 2009 (Mead 2009) included any trial where the intervention was defined by the authors as exercise, irrespective of whether it fulfilled this standard definition. For subsequent updates, we agreed with the CCDAN Review Group editorial team that we would use the widely accepted and standardised definition instead (ACSM 2001). This meant that we excluded two trials (Chou 2004; Tsang 2006) that we had included in a previous review , and we also excluded studies that provided advice on how to increase physical activity, that did not fulfil the ACSM definition of exercise. We note however that studies are included irrespective of whether fitness gains were reported or not, and if they were reported, irrespective of whether fitness gains were achieved.

 

Experimental intervention

  • Any type of exercise (as defined above). We excluded studies that measured outcomes immediately before and after a single exercise session, and trials which provided less than a week of exercise.

 

Comparator intervention

  • A 'control' intervention. This included studies in which exercise was compared to no intervention; 'waiting list control', those in which it was compared to an intervention which the authors defined as a placebo; and those in which exercise was used as an adjunct to an established treatment which was received (in an identical way) by participants in both the exercising and non-exercising group, e.g. exercise plus cognitive behavioural therapy (CBT) versus CBT alone.
  • Other type of active treatments, where the aim of the treatment was to improve mood. This includes pharmacological treatments, psychological therapies, or other alternative treatments.

Note that this strategy was the same as that included in the original review (Lawlor 2001).

We excluded studies comparing two different types of exercise with no non-exercising comparison group.

We excluded trials described by the authors as 'combination treatments', where exercise was one component of the 'combination', because we could not disentangle the effect of exercise from the effect of the other components of the intervention.

 

Types of outcome measures

 

Primary outcomes

1. Our primary outcome was a measure of depression or mood at the outcome assessment, either as a continuous measure or as a dichotomous outcome.

Continuous measures of depression were reported using a variety of depression scales, the most common of which were the Beck Depression Inventory (Beck 1961) and the Hamilton Rating Scale for Depression (Hamilton 1960).

In previous versions of the review, where trials used a number of different tools to assess depression, we included the main outcome measure only in the meta-analysis. The main outcome measure was defined using a hierarchy of criteria as follows: identified by the trial authors as the main outcome measure, outcome reported in the abstract, first outcome reported in the Results section.

Where trials used dichotomous data as primary outcomes, and also provided data on continuous outcome measures, we used the data provided in the trial reports for the continuous outcome measure in our meta-analysis. This was because we knew from previous updates that trials generally reported only continuous outcomes.

 

Secondary outcomes

2. Acceptability of treatment, assessed by a) attendance at exercise interventions, and b) the number of participants completing the interventions;
3. Quality of life;
4. Cost;
5. Adverse events, e.g. musculoskeletal pain, fatigue.

In order to better understand the generalisability of exercise for depression, we also extracted data on the number of people screened for inclusion and the number recruited ( Table 1).

 

Timing of outcome assessment

We extracted data at the end of treatment, and also at the end of any longer-term follow-up after the intervention had been stopped.

 

Search methods for identification of studies

 

Electronic searches

We carried out the following electronic searches (Appendix 1; Appendix 2)

  • The Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (all years to 1 March 2013);
  • The Cochrane Central Register of Controlled Trials (CENTRAL) (all years to 2010):
  • MEDLINE (1950 to February 2010);
  • EMBASE (1980 to February 2010);
  • PsycINFO (all years to February 2010);
  • Sports Discus (1975 to 2007).

We searched Current Controlled Trials (May 2008, November 2010 and March 2013) to identify any ongoing trials. We performed an electronic search of ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) in March 2013.

Because the searches for the CDCANCTR register are up-to-date and comprehensive, we were advised by the CCDAN editorial team that it was not necessary to search the other databases.

For a previous version of this review (Mead 2009) we conducted a cited reference search in the Web of Science using the references to all included studies, excluded studies and studies awaiting assessment. This cited reference search was not repeated for subsequent updates.

In order to ensure that the review was as up-to-date as possible when it was submitted for editorial review, we searched the CCDANCTR (up to 1st March 2013) again on 2nd May 2013, , so that we could list potentially eligible studies as ‘Studies awaiting classification’.

 

Searching other resources

For the initial review (Lawlor 2001), the following journals were searched: BMJ, JAMA, Archives of Internal Medicine, New England Journal of Medicine, Journal of the Royal Society of Medicine, Comprehensive Psychiatry, British Journal of Psychiatry, Acta Psychiatrica Scandinavica and British Journal of Sports Medicine.

For the update in 2009 (Mead 2009), we contacted experts, including authors of all included studies and those with at least two publications amongst the excluded studies, to identify any additional unpublished or ongoing studies, authors of significant papers and other experts in the field to ensure identification of all randomised controlled trials (published, unpublished or ongoing).

Due to limitations in available resources for this current update, we did not repeat these handsearches. We limited our contact with authors to those whose trials had been 'ongoing' in the previous version, to enquire whether they had subsequently been published. We also contacted authors to obtain any missing information about trial details. We had planned to do this should any data be missing e.g. standard deviations, although this was not necessary.

We screened the bibliographies of all included articles for additional references.

 

Data collection and analysis

 

Selection of studies

Two review authors (GC and GM) independently screened the citations from the searches, and decided which full texts should be retrieved. They then independently applied inclusion and exclusion criteria, resolving any differences in opinion through discussion. If they could not reach agreement, a third author was available (CG) to decide whether a study should be included or excluded.

For the searches of the CCDANCTR up to 1st March 2013, the Trials Search Co-ordinator checked abstracts, excluded obviously irrelevant ones, and then sent a list of the remaining citations to GM for scrutiny, to be included as 'studies awaiting classification'. 

We created a PRISMA flow diagram to detail the study selection process.

 

Data extraction and management

We extracted data, when available, at the end of treatment and at the end of follow-up.

For this update, two review authors (GC, FW) independently extracted data for our primary and secondary outcomes for each new trial identified. A third review author (GM) extracted data on type of exercise from all the included trials, to enable a fourth author (CG) to categorise intensity of exercise according to ACSM criteria.

Data extracted were participants, interventions, outcome measures, results, the number of people screened, the number randomised, the number allocated to exercise, the number who dropped out of the exercise arm ( Table 1), secondary clinical outcomes, cost and adverse events, and main conclusions. All the review authors used the same structured paper extraction form that had been piloted on two studies. We resolved any discrepancies by referring to the original papers and by discussion.

 

Main comparisons

We undertook the following analyses.

  1. Exercise versus 'control' (as defined above).
  2. Exercise versus psychological therapies.
  3. Exercise versus alternative treatments.
  4. Exercise versus pharmacological treatments.

 

Assessment of risk of bias in included studies

The Cochrane Collaboration 'Risk of bias' tool was used to assess risks of bias, according to Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions (Handbook 2011). Two review authors independently extracted data on random sequence generation, allocation concealment, blinding of participants, blinding of those delivering the intervention, blinding of outcome assessors, incomplete outcome data, selective reporting and other potential biases. Each of these domains was categorised as being at high risk of bias, unclear risk of bias or low risk of bias. We resolved any disagreements through discussion.

For concealment of allocation we distinguished between trials that were adequately concealed (central randomisation at a site remote from the study; computerised allocation in which records are in a locked, unreadable file that can be assessed only after entering participant details; the drawing of non-opaque envelopes), inadequately concealed (open lists or tables of random numbers; open computer systems; drawing of non-opaque envelopes) and unclear (no information in report, and the authors either did not respond to requests for information or were unable to provide information).

Trials could only be defined as 'intention-to-treat' if participants were analysed according to the allocated treatment AND if all participants either completed allocated treatments or if missing outcome data were replaced using a recognised statistical method, e.g. last observation carried forward (LOCF).

For blinding we distinguished between trials in which the main outcome was measured by an assessor who was blind to treatment allocation (blind) and those in which the main outcome was measured either by the participants themselves (i.e. self report) or by a non-blinded assessor (not blind).

 

Measures of treatment effect

We undertook a narrative review of all studies and a meta-analysis of those studies with appropriate data. Where trials used a number of different tools to assess depression we included the main outcome measure only in the meta-analysis. The main outcome measure was defined using a hierarchy of criteria as follows: identified by the authors as the main outcome measure; outcome reported in the abstract; first outcome reported in the Results section.

For continuous data where different scales were used, the standardised mean difference (SMD) was calculated and reported with a 95% confidence interval (CI). For dichotomous data the risk ratio was calculated and reported with a 95% CI.

We interpreted the SMDs using the following 'rule of thumb': 0.2 represents a small effect, 0.5 a moderate effect and 0.8 a large effect (Schünemann 2008).

We pooled long-term follow-up data from those trials that reassessed participants long after the interventions had been completed. 'Long after' could mean an assessment at any period of time after the intervention had been completed.

 

Unit of analysis issues

 

Studies with multiple treatment groups

Where trials included a control arm, an exercise arm and an 'established treatment' arm (e.g. CBT, antidepressants), we extracted data on control versus exercise, and exercise versus established treatment. This meant that data from the exercise arm were included in two separate comparisons, in separate univariate analyses.

Where trials compared an established treatment (e.g. CBT, antidepressants) versus exercise versus both the established treatment and exercise, we made two comparisons: (i) established treatment plus exercise versus established treatment alone, and included this in the meta-analysis of treatment versus control; (ii) exercise versus established treatment (e.g. CBT, antidepressants). This means that data from the 'established treatment alone' arm were used in two separate comparisons.

In the review versions in 2001 (Lawlor 2001), 2009 (Mead 2009) and 2012 (Rimer 2012) , for trials which included more than one intensity of exercise, we used the exercise arm with the greatest clinical effect in the review. Similarly, when trials provided more than one type of exercise, we used the type of exercise with the greatest clinical effect. However, because this may overestimate the effect of exercise, we now use the exercise arm which provides the biggest 'dose' of exercise, and performed a sensitivity analysis to explore the effect of using the smallest 'dose'.

 

Cross-over trials

For cross-over trials, we intended to use the first phase of the trial only due to the potential 'carry-over' effect of exercise. To date, we have not included any cross-over trials.

 

Cluster-randomised trials

If cluster-randomised trials were identified and incorrectly analysed using individuals as the unit of analysis, we intended to make corrections using the intracluster correlation coefficient (ICC). If this had not been available, we would have imputed the ICC from similar studies. In fact, we did not find any cluster-RCTs to include.

 

Dealing with missing data

For two previous versions of this review (Lawlor 2001; Mead 2009) we found current contact details of all authors through correspondence addresses in study reports and by searching websites. We contacted all authors by email or post (sending three reminders to non-responders) to establish missing details in the methods and results sections of the written reports and to determine authors' knowledge of, or involvement in, any current work in the area. For the previous update (Rimer 2012) and this current update, we contacted authors only if there were missing data items, or if we needed more detail to decide on whether or not to include the study.

Some trials, in which participants dropped out, reported data from only the remaining participants, so we used these data in our meta-analyses. For trials which attempted to impute data from missing participants (e.g. LOCF for continuous data) we used the imputed values and categorised the trial as 'intention-to-treat.' When we could not obtain information either from the publication or from the authors, we classified the trial as 'not intention-to-treat', and used the data from the available cases in the meta-analysis.

 

Assessment of heterogeneity

We used the Chi² test, together with the I² statistic, to assess heterogeneity.

A P value of 0.1 or less indicates significant heterogeneity when considering Chi². The ranges for I² are:

  • 0% to 40%: might not be important;
  • 30% to 60%: may represent moderate heterogeneity;
  • 50% to 90%: may represent substantial heterogeneity;
  • 75% to 100%: considerable heterogeneity.

Note that the importance of the observed value of I² depends on (i) the magnitude and direction of effects and (ii) the strength of evidence for heterogeneity (e.g. P value from the Chi² test, or a confidence interval for I²) (Handbook 2011).

 

Assessment of reporting biases

We used a funnel plot to explore reporting biases when 10 or more studies were included in the meta-analysis. However, other reasons such as heterogeneity and small study effects also cause asymmetrical funnel plots.

 

Data synthesis

We used a random-effects model based on DerSimonian and Laird's method to calculate the pooled effect size (DerSimonian 1986). We synthesised data from trials where outcome data were collected as soon as the intervention ended, and performed a separate synthesis of data collected weeks or months after the intervention ended, to explore whether any benefits were retained after the intervention had been completed. When performing meta-analyses of complex interventions, decisions need to be made about whether the interventions are sufficiently similar to be combined into a meta-analysis. We included trials that fulfilled the ACSM definition of exercise (ACSM 2001), and combined these data in a meta-analysis.

We created 'Summary of findings' tables for outcomes and graded them accordingly using the GRADE approach (gradepro.org/aboutus.html).

 

Subgroup analysis and investigation of heterogeneity

  1. We explored the effect of different types of exercise (aerobic, resistance exercise or mixed aerobic and resistance) for those trials comparing exercise versus control on outcome, by performing subgroup analyses for the different types of exercise.
  2. This update has for the first time explored the impact of intensity of exercise on outcome, dividing intensity into hard/vigorous or moderate, using ACSM criteria(ACSM 1998).The combination (where possible) of authors' description, compendium of physical activities classification and the ACSM intensity/metabolic equations (MET) cut-offs (in particular the most recent ones which take age into account) were used to categorise intensity (https://sites.google.com/site/compendiumofphysicalactivities/Activity).
  3. This update has for the first time explored the effect of the number of exercise sessions, by extracting data on the length of the exercise programme and the frequency of exercise sessions. We categorised studies by the total number of sessions and then grouped the total number as 0 - 12, 13 - 24, 25 - 36, at least 37.
  4. This update has for the first time explored how the diagnosis of depression at baseline (using a cut-point on a scale, or by psychiatric interview) influenced the effect of exercise on mood at the end of treatment.

 

Sensitivity analysis

We undertook sensitivity analyses to explore how much of the variation between studies comparing exercise to no exercise is explained by between-study differences in:

  1. publication type (peer-reviewed journal, conference abstract/proceedings, doctoral dissertation).
  2. allocation concealment.
  3. intention-to-treat analysis (as defined above).
  4. blinding.

We included only trials at low risk of bias for each of these outcomes in the sensitivity analysis. We then performed a sensitivity analysis, as we had done previously, including trials that were at low risk of bias for three key quality criteria: Allocation concealment, AND intention-to-treat AND blinding.

We also performed a sensitivity analysis using those trials that had several arms, for which we had included the arm with the biggest 'dose' of exercise in the initial analysis. Here we include the arm with the smallest 'dose'.

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms
 

Description of studies

 

Results of the search

The results of searches for the previous updates have already been described in detail (Lawlor 2001; Mead 2009; Rimer 2012).

The 2012 review update (Rimer 2012) included studies identified from searches performed in 2010 and 2011. In 2010 (Rimer 2012), we had identified three ongoing trials (Blumenthal 2012a; McClure 2008; Underwood 2013). Of these, one has been included (Blumenthal 2012a) in this update. One of these was excluded because the intervention was not exercise alone (McClure 2008). The other was excluded because participants did not have to have depression to enter the trial (Underwood 2013); although the trialists reported results from the subgroup with depression at entry, we had previously excluded trials reporting our main outcomes as subgroup analyses. In June 2011, our search of the Cochrane Depression, Anxiety and Neurosis Group Clinical Trials Register (CCDANCTR) identified 45 citations; of which we retrieved full texts for 10 studies. Of these 10 full-text studies, we excluded five (Lolak 2008; Mailey 2010; Oeland 2010; Sneider 2008; Thomson 2010) and five studies (Annesi 2010; Ciocon 2003; Gary 2010; Shahidi 2011; Chalder 2012) were listed as 'awaiting classification' (Rimer 2012); in this current update, two of these have been included (Gary 2010; Shahidi 2011), one has been excluded because further scrutiny led us to conclude that the intervention did not fulfil the definition of 'exercise' (Ciocon 2003), one was excluded because it was a trial of advice to increase physical activity that did not fulfil the ACSM definition of exercise (Chalder 2012) and one was excluded because it was a subgroup analysis from a trial of people with obesity (Annesi 2010).

In September 2012, the searches of the CCDANCTR identified a further 290 citations. Of these, we retrieved full texts for 43 studies: 39 were excluded (Akandere 2011; Arcos-Carmona 2011; Attia 2012; Aylin 2009; Bowden 2012; Chalder 2012; Chan 2011; Chow 2012; Christensen 2012; Clegg 2011; Demiralp 2011; Deslandes 2010; Gutierrez 2012; Hedayati 2012; Immink 2011; Jacobsen 2012; Johansson 2011; Lavretsky 2011; Leibold 2010; Levendoglu 2004; Levinger 2011; Littbrand 2011; Matthews 2011; Midtgaard 2011; Mudge 2008; O'Neil 2011; Ouzouni 2009; Penttinen 2011; Perna 2010; Piette 2011; Robledo Colonia 2012; Roshan 2011; Ruunsunen 2012; Schwarz 2012; Silveira 2010; Songoygard 2012; Trivedi 2011; Whitham 2011; Wipfli 2011); three were included (Hemat-Far 2012; Mota-Pereira 2011; Schuch 2011) and one trial is not yet complete (EFFORT D).

In March 2013, a search of the WHO Clinical Trials Registry Platform identified 188 citations. We sought full texts for 29; of these 29 studies, 23 are listed as ongoing trials (ACTRN12605000475640; ACTRN12612000094875; ACTRN12612000094875; CTR/2012/09/002985; EFFORT D; IRCT201205159763; IRCT2012061910003N1; ISRCTN05673017; NCT00103415; NCT00643695; NCT00931814; NCT01024790; NCT01383811; NCT01401569; NCT01464463; NCT01573130; NCT01573728; NCT01619930; NCT01696201; NCT01763983; NCT01787201; NCT01805479; UMIN000001488). One trial has been completed and is included (Hoffman 2010). Four trials were excluded (Bromby 2010; Lever-van Milligen 2012; NCT00964054; NCT00416221) and one awaits assessment (DEMO II 2012)

Through correspondence with the authors of one study (Blumenthal 2012a), another study by the same group was identified (Blumenthal 2012b); however this reported data from a subgroup with depression and was excluded (as we did for previous trials reporting subgroups).

The search of CCDANCTR up to 1st March 2013 identified 151 records (titles and abstracts). The Trials Search Co-ordinator excluded 89 obviously irrelevant citations. Of the remaining 62 studies, seven were already listed as included or excluded or awaiting assessment, one review author (GM) excluded 46 were excluded as they were obviously irrelevant, and the full text of nine articles were retrieved; one of these was a subsidiary publication for an included study (Hoffman 2010), one had already been excluded (Silveira 2010) and the other seven are listed as ‘awaiting classification' (Aghakhani 2011DEMO II 2012; Gotta 2012; Murphy 2012; Pinniger 2012; Sturm 2012; Martiny 2012).

For this current update, we are therefore including seven new studies (Hemat-Far 2012; Hoffman 2010; Gary 2010; Mota-Pereira 2011; Shahidi 2011; Schuch 2011; Blumenthal 2012a), making a total of 39 included studies (Characteristics of included studies table). For this update, we have excluded a further 54 studies (Characteristics of excluded studies table), giving a total of 175 excluded, listed 23 as ongoing studies (Characteristics of ongoing studies table), and listed seven as awaiting classification (Characteristics of studies awaiting classification table).

See the PRISMA flow diagram for details of the study selection process for this current update (Figure 1).

 FigureFigure 1. Study flow diagram, showing the results of the searches for this current update.

 

Included studies

In our previous update, we identified 32 completed trials.

For this update, we include seven additional trials, recruiting a total of 408 additional participants at randomisation. Of these, 374 participants remained in the trials by the time of outcome analysis (Blumenthal 2012a; Gary 2010; Hemat-Far 2012; Hoffman 2010; Mota-Pereira 2011; Shahidi 2011; Schuch 2011) (see Characteristics of included studies table).

Of the 39 included trials (recruiting 2326 people), 22 were from the USA (Blumenthal 1999; Blumenthal 2007; Blumenthal 2012a; Bonnet 2005; Brenes 2007; Chu 2008; Dunn 2005; Doyne 1987; Epstein 1986; Fetsch 1979; Fremont 1987; Gary 2010; Greist 1979; Hess-Homeier 1981; Hoffman 2010; Klein 1985; McCann 1984; Orth 1979; Reuter 1984; Setaro 1985; Singh 1997; Williams 2008); one was from Canada (McNeil 1991), three from the UK (Mather 2002; Mutrie 1988; Veale 1992), two from Australia (Sims 2009; Singh 2005), two from Iran (Hemat-Far 2012; Shahidi 2011), one from New Zealand (Foley 2008), one from Norway (Martinsen 1985), one from Denmark (Krogh 2009), one from Germany (Knubben 2007), one from Italy (Pilu 2007), one from Russia (Pinchasov 2000), one from Brazil (Schuch 2011), one from Portugal (Mota-Pereira 2011) and one from Thailand (Nabkasorn 2005).

Of these 39 trials, 30 were peer-reviewed papers (Blumenthal 1999; Blumenthal 2007; Blumenthal 2012a; Brenes 2007; Dunn 2005; Doyne 1987; Foley 2008; Fremont 1987; Gary 2010; Greist 1979; Hemat-Far 2012; Hoffman 2010; Klein 1985; Krogh 2009; Knubben 2007; Martinsen 1985; Mather 2002; McCann 1984; McNeil 1991; Mota-Pereira 2011; Nabkasorn 2005; Pilu 2007; Pinchasov 2000; Schuch 2011; Shahidi 2011; Sims 2009; Singh 1997; Singh 2005; Veale 1992; Williams 2008). Seven were doctoral dissertations (Bonnet 2005; Chu 2008; Epstein 1986; Fetsch 1979; Hess-Homeier 1981; Orth 1979; Setaro 1985) and two were published in abstract form only (Mutrie 1988; Reuter 1984).

Of these 39 trials, data from two studies were unsuitable for statistical pooling because they were provided in graphical form only (McCann 1984) or provided no numerical data at all (Greist 1979). One trial (Nabkasorn 2005) provided data in graphical form only which we were able to include after manually converting the graph into mean and standard deviation (SD) values by drawing a horizontal line from the mean and SD on the graph to the vertical axis. Hence, we used data from 37 trials in the meta-analyses.

Five trials (Blumenthal 1999; Blumenthal 2007; Blumenthal 2012a; Krogh 2009; Mather 2002) provided data on whether participants fulfilled diagnostic criteria for depression at the end of the study, as well as depression scales. We used the scale results described in the paper rather than using formulae to convert the dichotomous outcomes to continuous outcomes, to allow inclusion of these trials in the meta-analysis.

Five authors provided further data on their studies (Blumenthal 2012a; Gary 2010; Hoffman 2010; Mota-Pereira 2011; Sims 2009).

 

Design

All included studies were randomised controlled trials (RCTs); further details are provided in the Characteristics of included studies table. There were no cluster-RCTs that fulfilled our inclusion criteria.

Seventeen studies had two arms (Bonnet 2005; Fetsch 1979; Foley 2008; Knubben 2007; Hemat-Far 2012; Hoffman 2010; Martinsen 1985; Mather 2002; Mota-Pereira 2011; Nabkasorn 2005; Pilu 2007; Pinchasov 2000; Reuter 1984; Schuch 2011; Sims 2009; Singh 1997; Veale 1992), 17 had three arms (Blumenthal 1999; Blumenthal 2012a; Brenes 2007; Chu 2008,; Doyne 1987; Epstein 1986; Fremont 1987; Greist 1979; Hess-Homeier 1981; Klein 1985; Krogh 2009; McCann 1984; McNeil 1991; Mutrie 1988; Shahidi 2011; Singh 2005; Williams 2008), three had four arms (Blumenthal 2007; Gary 2010; Orth 1979), one had five arms (four intensities of exercise and control; (Dunn 2005) and one had six arms (cognitive behavioural therapy (CBT) plus aerobic exercise, aerobic exercise only, CBT only, CBT plus non-aerobic exercise, non-aerobic exercise only or no intervention; Setaro 1985).

Of the 17 trials with two arms, exercise was compared with waiting list or usual care in eight trials (Hemat-Far 2012; Hoffman 2010; Mota-Pereira 2011; Nabkasorn 2005; Pilu 2007; Schuch 2011; Sims 2009; Veale 1992), exercise was compared with a placebo intervention (e.g. social activity) in four trials (Knubben 2007; Martinsen 1985; Mather 2002; Singh 1997), exercise was compared with CBT in one trial (Fetsch 1979), two trials compared CBT plus exercise versus CBT alone (Bonnet 2005; Reuter 1984), one trial compared exercise with stretching (Foley 2008) and one trial compared exercise with bright light therapy (Pinchasov 2000).

Of the 17 trials with three arms, one trial compared exercise versus exercise plus sertraline versus sertraline (Blumenthal 1999), one compared exercise versus sertraline versus usual care (Brenes 2007), one compared exercise versus antidepressant (sertraline) versus placebo (Blumenthal 2012a), one compared exercise versus walking versus social conversation (Williams 2008) and three compared exercise versus waiting list versus a placebo intervention (e.g. social activity) (McCann 1984; McNeil 1991; Mutrie 1988). Two compared exercise versus usual care versus CBT (Epstein 1986; Hess-Homeier 1981), one compared exercise versus CBT versus both exercise and CBT (Fremont 1987), one compared exercise versus low-intensity CBT versus high-intensity CBT (Greist 1979), and one compared exercise versus a placebo versus CBT (Klein 1985). One trial compared high-intensity versus low-intensity aerobic exercise versus stretching (Chu 2008), one compared strength versus aerobic versus relaxation training (Krogh 2009), one compared high-intensity resistance training versus low-intensity resistance training versus usual care (Singh 2005), one compared exercise versus yoga versus control (Shahidi 2011) and one compared running versus weight-lifting versus waiting list (Doyne 1987).

Of the three trials with four arms, one compared exercise to three types of control (Orth 1979), one compared home-based exercise versus supervised exercise versus sertraline versus placebo (Blumenthal 2007), and one compared exercise versus combined exercise and CBT versus CBT alone versus usual care (Gary 2010).

 

Participants

Twenty-three trials recruited participants from non-clinical populations (Blumenthal 1999; Blumenthal 2007; Bonnet 2005; Brenes 2007; Dunn 2005; Doyne 1987; Epstein 1986; Fetsch 1979; Fremont 1987; Greist 1979; Hemat-Far 2012; Hess-Homeier 1981; Klein 1985; McCann 1984; McNeil 1991; Nabkasorn 2005; Orth 1979; Pinchasov 2000; Setaro 1985; Shahidi 2011; Singh 1997; Singh 2005; Williams 2008) with most involving recruitment of participants through the media.

Nine trials recruited participants from clinical populations, i.e. hospital inpatients or outpatients (Gary 2010; Knubben 2007; Martinsen 1985; Mota-Pereira 2011; ; Mutrie 1988; Pilu 2007; Reuter 1984; Schuch 2011; Veale 1992).

Seven trials recruited participants from both clinical and non-clinical populations (Blumenthal 2012a; Chu 2008; Foley 2008; Hoffman 2010; Krogh 2009; Mather 2002; Sims 2009).

Of the 23 trials recruiting people from non-clinical populations, diagnosis of depression was by a clinical interview in ten studies (Blumenthal 1999; Blumenthal 2007; Bonnet 2005; Doyne 1987; Dunn 2005; Hemat-Far 2012; Klein 1985; Pinchasov 2000; Singh 1997; Singh 2005). The other 13 studies used a cut-off point on one of several depression scales: Beck Depression Inventory: (Epstein 1986; Fremont 1987; Fetsch 1979; Hess-Homeier 1981; McCann 1984; McNeil 1991); Centre for Epidemiologic Studies Depression Scale (Nabkasorn 2005); Cornell Scale for Depression in Dementia (Williams 2008); Depression Adjective Checklist (Orth 1979); Minnesota Multiple Personality Inventory (Setaro 1985); Patient Health Questionnaire-9 (Brenes 2007); Geriatric Depression Scale (Shahidi 2011); or Symptom Checklist Score (Greist 1979).

There were more women than men (see Characteristics of included studies table) and mean age ranged from 22 years (Orth 1979) to 87.9 years (Williams 2008).

 

Interventions

Thirty-three trials provided aerobic exercise, of which 16 trials provided running (Blumenthal 1999; Blumenthal 2012a; Doyne 1987; Epstein 1986; Fetsch 1979; Fremont 1987; Greist 1979; Hess-Homeier 1981; Hemat-Far 2012; Klein 1985; McCann 1984; Nabkasorn 2005; Orth 1979; Reuter 1984; Shahidi 2011; Veale 1992), three provided treadmill walking (Blumenthal 2007; Bonnet 2005; Dunn 2005), four provided walking (Gary 2010; Knubben 2007; McNeil 1991; Mota-Pereira 2011), one provided aerobic training with an instructor (Martinsen 1985), one provided aerobic dance (Setaro 1985) and one provided cycling on a stationary bicycle (Pinchasov 2000).

Three studies provided aerobic exercises according to preference (Chu 2008; Hoffman 2010; Schuch 2011) and another provided mixed aerobic and resistance training (Brenes 2007). One study did not specify the type of aerobic exercise provided (Foley 2008).

Two trials compared two different exercise interventions versus control: Krogh 2009 compared resistance training with combination aerobic exercises (including cycling, running, stepping and rowing) and Williams 2008 compared combination walking and strength training and walking alone.

Two trials provided mixed exercise, i.e. endurance, muscle strengthening and stretching (Mather 2002; Mutrie 1988), and four provided resistance training (Pilu 2007; Sims 2009; Singh 1997; Singh 2005).

Seventeen trials (Blumenthal 2007; Blumenthal 2012a; Bonnet 2005; Brenes 2007; Doyne 1987; Dunn 2005; Fremont 1987; Hoffman 2010; Knubben 2007; Mather 2002; McCann 1984; Mutrie 1988; Schuch 2011; Setaro 1985; Sims 2009; Singh 1997; Singh 2005) provided indoor exercise, two trials provided outdoor exercise ( Gary 2010; McNeil 1991) and the remaining trials did not report whether the exercise was indoors or outdoors.

Only one trial stated that unsupervised exercise was provided (Orth 1979). Two trials included both supervised and home-based exercise arms (Blumenthal 2007; Chu 2008). The other trials provided supervised exercise or did not report this information.

Twelve trials provided individual exercises (Blumenthal 2007; Chu 2008; Doyne 1987; Dunn 2005; Greist 1979; Klein 1985; McNeil 1991; Mota-Pereira 2011; Mutrie 1988; Orth 1979; Schuch 2011; Williams 2008), 16 provided group exercises (Blumenthal 1999; Blumenthal 2012a; Brenes 2007; Fetsch 1979; Fremont 1987; Krogh 2009; Mather 2002; McCann 1984; Nabkasorn 2005; Pilu 2007; Setaro 1985; Shahidi 2011; Sims 2009; Singh 1997; Singh 2005; Veale 1992) and the remaining trials did not report this information.

The duration of the intervention ranged from 10 days (Knubben 2007) to 16 weeks (Blumenthal 1999; Blumenthal 2007). Two trials did not state duration: one performed assessments at the end of the intervention at eight months (Pilu 2007) and the other at time of discharge from hospital (Schuch 2011).

The 'control' groups of 'no treatment' or 'placebo' comprised heterogeneous interventions including social conversation, telephone conversations to discuss their general health and relaxation (avoiding muscular contraction). For exercise versus control, there were different types of comparator arm (see  Analysis 5.5). Two compared with a placebo; 17 with no treatment, waiting list, usual care or self management; six compared exercise plus treatment vs treatment; six compared exercise with stretching, meditation or relaxation; and four with 'occupational intervention', health education or casual conversation.

 

Outcomes

 
Depression measurement

Of the 39 trials, 12 reported Beck Depression Inventory (BDI) scores, and 13 reported Hamilton Rating Scale for Depression (HAMD) scores. A variety of other scales were also used.

 
Other clinical endpoints and adverse effects

Several recorded clinical endpoints as well as mood: Blumenthal 2012a, Brenes 2007 and Gary 2010 (physical functioning); Chu 2008 (self efficacy), Foley 2008 (self efficacy, episodic memory and cortisol awakening response), Knubben 2007 (length of hospital stay), Krogh 2009 (absence from work and effect on cognitive ability), Mather 2002 (participant and clinical global impression), Pilu 2007 and Mota-Pereira 2011 (clinical global impression and global assessment of functioning), Sims 2009 (quality of life, stroke impact scale, psychosocial health status and adverse events), Singh 1997 (sickness impact profile), Gary 2010, Hoffman 2010, Schuch 2011, Singh 2005, Pilu 2007 and Brenes 2007 (quality of life), Shahidi 2011 (Life satisfaction scale) and Blumenthal 2012a (cardiovascular biomarkers).

Seven trials systematically recorded and reported adverse events (Blumenthal 2007; Blumenthal 2012a; Dunn 2005; Knubben 2007; Singh 1997; Singh 2005; Sims 2009). No trial provided data on costs.

 
Timing of outcome measures

All our included trials reported mood as a continuous outcome at the end of treatment. Long-term follow-up data beyond the end of the interventions are described for eight trials (ranging from 4 months to 26 months). Fremont 1987 (follow-up at four months), Sims 2009 (follow-up at six months), Klein 1985 (follow-up for nine months), Blumenthal 1999 (follow-up at 10 months Babyak 2000), Krogh 2009 (follow-up at 12 months), Singh 1997 (follow-up at 26 months, reported in Singh 2001), Mather 2002 (follow-up at 34 weeks) and Gary 2010 (follow-up at six months). Hoffman 2010 reported long-term follow-up but we were unable to include this in the meta-analysis due to the way it was reported. The author has been contacted for data.

 

Excluded studies

In this update, a further 54 studies were excluded following review of full text.

In this update, we decided not to list reviews as excluded studies. Additionally some references that were previously classified as excluded studies have been re-classified as additional reports of included studies. As a result there are now a total of 174 excluded studies.

One hundred and twenty-nine publications described randomised trials of exercise; the reasons for excluding these are listed in more detail below:

In 93 trials, participants did not have to have depression (as defined by the authors of the trial) to be eligible for the trial (Abascal 2008; Akandere 2011; Arcos-Carmona 2011; Asbury 2009; Aylin 2009; Badger 2007; Baker 2006; Berke 2007; Blumenthal 2012b; Bosch 2009; Brittle 2009; Burton 2009; Carney 1987; Chen 2009; Christensen 2012; Clegg 2011; Courneya 2007; Demiralp 2011; Dalton 1980; Eby 1985; Elavsky 2007; Ersek 2008; Fox 2007; Gary 2007; Ghroubi 2009; Gottlieb 2009; Gusi 2008; Gutierrez 2012; Haffmans 2006; Hannaford 1988; Haugen 2007; Hembree 2000; Herrera 1994; Hughes 1986; Jacobsen 2012; Johansson 2011; Karlsson 2007; Kerr 2008; Kerse 2010; Kim 2004; Knapen 2006; Kulcu 2007; Kupecz 2001; Lai 2006; Latimer 2004; Lautenschlager 2008; Leppämäki 2002; Levendoglu 2004; Lever-van Milligen 2012; Levinger 2011; Lin 2007; Littbrand 2011; Lolak 2008; Machado 2007; Mailey 2010; Martin 2009; Matthews 2011; Midtgaard 2011; Morey 2003; Motl 2004; Mudge 2008; Mutrie 2007; Neidig 1998; Neuberger 2007; Nguyen 2001; Oeland 2010; Ouzouni 2009; Pakkala 2008; Penttinen 2011; Perna 2010; Rhodes 1980; Robledo Colonia 2012; Ruunsunen 2012; Salminen 2005; Sarsan 2006; Sims 2006; Smith 2008; Songoygard 2012; Stein 1992; Stern 1983; Strömbeck 2007; Sung 2009; Tapps 2009; Thomson 2010; Tomas-Carus 2008; Tsang 2003; Tenorio 1986; Underwood 2013; Weinstein 2007; White 2007; Wilbur 2009; Wipfli 2008; Wipfli 2011).

Ten trials compared two types of exercise with no non-exercising control (Bosscher 1993; NCT00546221; NCT01152086; Legrand 2009; Passmore 2006; Sexton 1989; TREAD 2003; Trivedi 2011; Wieman 1980; Williams 1992).

Three trials reported subgroup analyses of depressed patients, one from a randomised trial of exercise for osteoarthritis (Penninx 2002), one from a cohort of participants enrolled in cardiac rehabilitation following major cardiac events (Milani 2007) and one from a cluster-RCT of exercise in nursing homes (Underwood 2013).

Three trials included only a single bout of exercise (Bartholomew 2005; Bodin 2004; Gustafsson 2009) and one trial provided exercise for only four days (Berlin 2003).

Two trials that recruited women with postnatal depression were excluded (Armstrong 2003; Armstrong 2004).

Five trials provided exercise interventions that did not fulfil the ACSM definition of exercise (Tai-Chi (Chou 2004); Qigong (Tsang 2006; Chow 2012); and yoga (Oretzky 2006; Immink 2011) to waiting list controls.

Seven trials involving adolescents (Beffert 1993; Brown 1992; NCT00964054; Hughes 2009; MacMahon 1988; Rofey 2008; Roshan 2011) were excluded.

Two trials were excluded as they provided exercise counselling, not exercise (Vickers 2009; Chalder 2012).

Three trials were excluded as the intervention was multifaceted (McClure 2008; O'Neil 2011; Sneider 2008).

 

Ongoing studies

There are 23 ongoing studies (IRCT201205159763; NCT01805479; CTR/2012/09/002985; NCT01787201; NCT01619930; NCT01573130; NCT01573728; EFFORT D; NCT01464463; ACTRN12605000475640; UMIN000001488; NCT01763983; ACTRN12612000094875; NCT00103415; ACTRN12609000150246; NCT01696201; ISRCTN05673017; NCT01401569; IRCT2012061910003N1; NCT01024790; NCT01383811; NCT00643695; NCT00931814). One trial (EFFORT D) was identified from the September 2012 search of the CCDANCTR and the remaining 23 were identified from the March 2013 search of the WHO Clinical Trials Registry Platform.

 

Studies awaiting classification

This is a fast-moving field and our searches of CCDANCTR in March 2013 identified seven studies that are awaiting further assessment (Aghakhani 2011DEMO II 2012; Martiny 2012; Murphy 2012; Pinniger 2012; Sturm 2012; Gotta 2012). Initial screening of these studies indicated three of these studies (Martiny 2012; Pinniger 2012; Sturm 2012) could be eligible for inclusion in this review. We plan to update the review, ideally within the year, to include the constantly growing number of relevant studies. See Characteristics of studies awaiting classification for full details.

 

New studies found for this update

We are including seven additional trials, recruiting a total of 408 participants at randomisation. Of these, 374 participants remained in the trials by the time of outcome analysis (Blumenthal 2012a; Hemat-Far 2012; Hoffman 2010; Gary 2010; Mota-Pereira 2011; Shahidi 2011; Schuch 2011). See Characteristics of included studies.

 

Risk of bias in included studies

 

Sequence generation

We categorised 11 trials as being at low risk of bias, one as being at high risk of bias (Hemat-Far 2012), and the rest as being at unclear risk of bias. A graphical representation of the 'Risk of bias' assessment can be seen in Figure 2 and Figure 3. Please see the Characteristics of included studies for the full 'Risk of bias' assessment for each study.

 FigureFigure 2. 'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
 FigureFigure 3. 'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

 

Allocation

Allocation concealment was adequate and therefore at low risk of bias in 14 trials (Blumenthal 2007; Blumenthal 2007; Blumenthal 2012a; Dunn 2005; Hoffman 2010; Knubben 2007; Krogh 2009; Martinsen 1985; Mather 2002; Sims 2009; Singh 1997; Singh 2005; Veale 1992; Williams 2008). For the remaining trials, the risk of bias was rated as unclear or high.

 

Blinding

Twelve trials included blinding of the outcome assessor so were rated as being at low risk of bias (Blumenthal 1999; Blumenthal 2007; Blumenthal 2012a; Brenes 2007; Dunn 2005; Gary 2010; Knubben 2007; Krogh 2009; Mather 2002; Mota-Pereira 2011; Singh 2005; Williams 2008). The rest were categorised as being at unclear or high risk because they used self-reported outcomes.

In exercise trials, participants cannot be blind to the treatment allocation. We were uncertain what effect this would have on bias, so we classified all trials as being at 'unclear' risk of bias. Similarly, for those trials where supervised exercise was provided, the person delivering the intervention could not be blind, so we classified all trials as being at 'unclear' risk of bias (note that not all reported whether exercise was performed with or without supervision).

 

Incomplete outcome data

Fifteen trials performed 'intention-to-treat' (ITT) analyses (Blumenthal 1999; Blumenthal 2007; Blumenthal 2012a; Dunn 2005; Hemat-Far 2012; Hoffman 2010; Krogh 2009; Mather 2002; McNeil 1991; Mota-Pereira 2011; Mutrie 1988; Orth 1979; Pilu 2007; Singh 1997; Schuch 2011), i.e. complete outcome data were reported or, if there were missing outcome data, these were replaced using a recognised statistical method, e.g. last observation carried forward, and participants remained in the group to which they had been allocated. One trial reported data for individual participants (Orth 1979), so by using last observation carried forward we replaced data from the participants who did not complete the trial and included these data in the meta-analysis of ITT trials. One trial reported that the analysis was ITT, because it used a 'worse-case' scenario assumption to replace data from participants who did not complete the trial, but only included 38 of the 39 randomised participants in the analyses, so we classified it as 'not ITT' (Knubben 2007). The remaining studies were classified as being at unclear or high risk of bias. Most trials did not report data from participants who dropped out.

 

Selective reporting

We attempted to identify whether a protocol was available by screening the reference list of the publications. We identified protocols for three trials and checked that all prespecified outcome events were reported, and rated these as being at low risk of bias (Blumenthal 2012a; Dunn 2005; Krogh 2009). We categorised four others trials (Hemat-Far 2012; Hoffman 2010; Mota-Pereira 2011; Shahidi 2011) as being at low risk of bias as we judged that there was sufficient information in the methods to be sure that the trials had reported all their planned outcomes.

 

Other potential sources of bias

On the basis of the first 50 participants, one study (Krogh 2009) changed their sample size calculation based on the observed standard deviation (they had initially calculated they needed a minimum of 186 participants (SD = 6), but for the first 50 participants the SD was 3.9 so they adjusted their sample size calculation to 135 participants). Hemat-Far 2012 told the control group to reduce their activity.

We decided to include data on continuous depression scores in our meta-analysis, rather than depression measured as a dichotomous outcome. This is because we knew from previous updates that very few trials had reported depression as a dichotomous outcome, and we wished to include as many trials as possible in our meta-analysis. For future updates, we will consider whether to perform a separate meta-analysis for trials that measured depression as a dichotomous outcome.

 

Publication bias

Visually our funnel plot appeared to be asymmetrical.

There is evidence of bias (Begg P value = 0.02, Egger P value = 0.002) (funnel plot for  Analysis 1.1, exercise versus control, Figure 4) that might be due to publication bias, to outcome reporting bias or to heterogeneity.

 FigureFigure 4. Funnel plot of comparison: 1 Exercise versus control, outcome: 1.1 Reduction in depression symptoms post-treatment.

 

Effects of interventions

See:  Summary of findings for the main comparison Exercise compared to control for adults with depression;  Summary of findings 2 Exercise compared to psychological treatments for adults with depression;  Summary of findings 3 Exercise compared to bright light therapy for adults with depression;  Summary of findings 4 Exercise compared to pharmacological treatments for adults with depression

We included 37 trials in our meta-analyses. The remaining two trials could not be included for the reasons stated above (Greist 1979; McCann 1984).

 

Comparison 1: Exercise versus 'control'

Thirty-five trials (1356 participants) included a comparison of exercise with a 'control' intervention.

 

Primary outcome measure

 
1.1 Reduction in depression symptom severity
 
Post-treatment

The pooled standardised mean difference (SMD), for the 35 trials, calculated using the random-effects model was -0.62 (95% confidence interval (CI) -0.81 to -0.42) ( Analysis 1.1), indicating a moderate clinical effect in favour of exercise. There was substantial heterogeneity (I² = 63%).

 
End of long-term follow-up

The pooled SMD from the eight trials (Blumenthal 1999; Fremont 1987; Gary 2010; Klein 1985; Krogh 2009; Mather 2002; Sims 2009; Singh 1997) (377 participants) that provided long-term follow-up data found only a small effect in favour of exercise (SMD -0.33, 95% CI -0.63 to -0.03) ( Analysis 1.2). The long-term follow-up data from Blumenthal 1999 were reported in a separate publication (Babyak 2000), and from Singh 1997 in a separate publication (Singh 2001). There was moderate statistical heterogeneity (I² = 49%). Follow-up data from Blumenthal 2007 have been reported according to the proportion who had fully or partially remitted from depression, but continuous mood scores were not reported so we could not include these data in the meta-analysis.

 

Secondary outcome measures

 
1.2a Acceptability of treatment: attendance at exercise

Fourteen trials reported attendance rates for exercise; these were 50.6% for aerobic and 56.2% for strength arm (Krogh 2009), 59% (Mather 2002), 70% (Doyne 1987), 72% (Dunn 2005), 78% (Nabkasorn 2005), 82% (Gary 2010), 91% (Mota-Pereira 2011) 92% (Blumenthal 1999; Blumenthal 2007), 93% (Singh 1997), 94% (Blumenthal 2012a), 97.3% for high-intensity and 99.1% for low-intensity (Chu 2008) and 95% to 100% (Singh 2005). One trial reported the mean number of exercise sessions attended as 5.88 (Hoffman 2010). One trial rescheduled missed visits (McNeil 1991) so participants attended the full course of exercise. As with intensity of exercise, it is difficult to attribute any differences in outcome to differences in attendance rates, because there were other sources of variation in the type of interventions (e.g. duration of intervention, type of exercise) and differences in the methodological quality between trials which might account for differences in outcome.

 
1.2b Acceptability of treatment: completing the intervention or control

We extracted data on the number randomised and completing each trial (see  Table 1). This ranged from 100% completion (Hemat-Far 2012; Mather 2002; McNeil 1991; Mutrie 1988; Pilu 2007; Singh 1997; Schuch 2011) to 42% completion (Doyne 1987). For the exercise intervention, this ranged from 100% completion (Gary 2010; Hemat-Far 2012; Mather 2002; McNeil 1991; Mutrie 1988; Pilu 2007; Singh 1997; Schuch 2011) to 55% completion (Klein 1985).

Twenty-nine studies (1363 participants) reported how many completed the exercise and control arms ( Analysis 1.3). The risk ratio (RR) was 1.00 (95% CI 0.97 to 1.04).

 
1.3. Quality of life

Five trials reported quality of life at the end of treatment (Gary 2010; Hoffman 2010; Schuch 2011; Singh 2005; Pilu 2007). One author provided data regarding the different domains (Gary 2010). One trial reported quality of life at baseline but not at follow-up (Sims 2009).

There were no statistically significant differences for the mental (SMD -0.24; 95% CI -0.76 to 0.29), psychological (SMD 0.28; 95% CI -0.29 to 0.86) and social domains (SMD 0.19; 95% CI -0.35 to 0.74) ( Analysis 1.4). Two studies reported a statistically significant difference for the environment domain favouring exercise (SMD 0.62; 95% CI 0.06 to 1.18) and four studies reported a statistically significant difference for the physical domain favouring exercise (SMD 0.45; 95% CI 0.06 to 0.83).

 
1.4 Cost

No trial reported costs.

 
1.5 Adverse events

Seven trials reported no difference in adverse events between the exercise and usual care groups (Blumenthal 2007; Blumenthal 2012a; Dunn 2005; Knubben 2007; Singh 1997; Singh 2005; Sims 2009). Dunn 2005 reported increased severity of depressive symptoms (n = 1), chest pain (n = 1) and joint pain/swelling (n = 1); all these participants discontinued exercise. Singh 1997 reported that one exerciser was referred to her psychologist at six weeks due to increasing suicidality; and musculoskeletal symptoms in two participants required adjustment of training regime. Singh 2005 reported adverse events in detail (visits to a health professional, minor illness, muscular pain, chest pain, injuries requiring training adjustment, falls, deaths and hospital days) and found no difference between the groups. Knubben 2007 reported "no negative effects of exercise (muscle pain, tightness or fatigue)"; after the training had finished, one person in the placebo group required gastric lavage and one person in the exercise group inflicted a superficial cut in her arm. Sims 2009 reported no adverse events or falls in either the exercise or control groups. Blumenthal 2007 reported more side effects in the sertraline group (see comparison below) but there was no difference between the exercise and control group. Blumenthal 2012a reported more fatigue and sexual dysfunction in the sertraline group than in the exercise group.

Because of the diversity of different adverse events reported, we decided not to do a meta-analysis of these data.

 

Comparison 2: Exercise versus psychological therapies

 

Primary outcome

 
2.1 Reduction in depression symptom severity
 
Post-treatment

Seven trials (189 participants) provided data comparing exercise with psychological therapies; the SMD was -0.03 (95% CI -0.32 to 0.26) ( Analysis 2.1) indicating no significant difference between the two interventions. No statistical heterogeneity was indicated.

 
End of long-term follow-up

There were insufficient data available for long-term follow-up.

 

Secondary outcomes

 
2.2a Acceptability of treatment: attendance at exercise sessions

One trial reported adherence scores that were calculated based on the number of sessions attended of those prescribed. This trial reported that the adherence rates were 82% for exercise and 72% for CBT (Gary 2010).

 
2.2b Acceptability of treatment: completing the intervention or psychological therapies

For staying in the trial, there were data from four trials (172 participants) ( Analysis 2.2). The risk ratio was 1.08 (95% CI 0.95 to 1.24).

 
2.3. Quality of life

One trial reported changes in the Minnesota Living with Heart Failure Questionnaire, a quality of life measure (Gary 2010). There was no statistically significant difference for the physical domain (MD 0.15; 95% CI: -7.40 to 7.70) or the mental domain (MD -0.09; 95% CI: -9.51 to 9.33) ( Analysis 2.3).

 
2.4 Cost

No trial reported costs.

 
2.5 Adverse events

No data available.

 

Comparison 3: Exercise versus alternative treatments

 

Primary outcome

 
3.1 Reduction in depression symptom severity
 
Post-treatment

One trial found that exercise was superior to bright light therapy in reducing depression symptoms (Pinchasov 2000) (MD -6.40, 95% CI -10.20 to -2.60) ( Analysis 3.1).

 
End of long-term follow-up

There were no data with regard to long-term follow-up.

 

Secondary outcomes

This trial did not report on any of the following outcomes.

 
3.2a Acceptability of treatment: attendance at exercise

 
3.2b Acceptability of treatment: completing the intervention or control

 
3.3. Quality of life

 
3.4 Cost

 
3.5 Adverse events

 

Comparison 4: Exercise versus pharmacological treatments

 

Primary outcome

 
4.1 Reduction in depression symptom severity
 
Post-treatment

For the four trials (298 participants) that compared exercise with pharmacological treatments (Blumenthal 1999; Blumenthal 2007; Blumenthal 2012a; Brenes 2007) the SMD was -0.11 (95% CI -0.34 to 0.12) ( Analysis 4.1), indicating no significant difference between the two interventions. No statistical heterogeneity was indicated.

 
End of long-term follow-up

There were insufficient data available for long-term follow-up.

 

Secondary outcomes

 
4.2a Acceptability of treatment: attendance at exercise

Blumenthal 1999 reported that of those allocated exercise alone, the median number of sessions attended was 89.6%. Of those allocated medication, no participant deviated by more than 5% from the prescribed dose.

 
4.2b Acceptability of treatment: completing the intervention or pharmacological intervention

For remaining in the trial, there were data from three trials (278 participants). The risk ratio was 0.98 (95% CI 0.86 to 1.12) ( Analysis 4.2).

 
4.3. Quality of life

One trial Brenes 2007 reported no difference in change in SF-36 mental health and physical health components between medication and exercise groups ( Analysis 4.3).

 
4.4 Cost

No trial reported costs.

 
4.5 Adverse events

Blumenthal 1999 reported that 3/53 in the exercise group suffered musculoskeletal injuries; injuries in the medication group were not reported.

Blumenthal 2007 collected data on side effects by asking participants to rate a 36-item somatic symptom checklist and reported that "a few patients reported worsening of symptoms"; of the 36 side effects assessed, only one showed a statistically significant group difference (P = 0.03), i.e. that the sertraline group reported worse post-treatment diarrhoea and loose stools.

Blumenthal 2012a assessed 36 side effects; only two showed a significant group difference: 20% of participants receiving sertraline reported worse post-treatment fatigue compared with 2.4% in the exercise group and 26% reported increased sexual problems compared with 2.4% in the exercise group.

 

Subgroup analyses

 

Type of exercise

We explored the influence of the type of exercise (aerobic, mixed or resistance) on outcomes for those trials comparing exercise versus control ( Analysis 5.1). The SMD for aerobic exercise indicated a moderate clinical effect (SMD -0.55, 95% CI -0.77 to -0.34), whilst the SMDs for both mixed exercise (SMD -0.85, 95% CI -1.85 to 0.15) and resistance exercise (SMD -1.03, 95% CI -1.52 to -0.53) indicated large effect sizes, but with wide confidence intervals.

 

Intensity of exercise

We explored the influence of intensity (light/moderate, moderate, moderate/hard, hard, moderate/vigorous, vigorous) on the reduction of depression for those trials comparing exercise versus control ( Analysis 5.2). The SMD for moderate/vigorous intensity (SMD -0.38, 95% CI -1.61 to 0.85) indicated a small effect size, whilst for moderate (SMD -0.64, 95% CI -1.01 to -0.28), moderate/hard (SMD -0.63, 95% CI -1.13 to -0.13) and hard intensity (SMD -0.56, 95% CI -0.93 to -0.20) there was a moderate clinical effect. A large effect size was indicated for vigorous intensity (SMD -0.77, 95% CI -1.30 to -0.24) and light/moderate intensity (SMD -0.83, 95% CI -1.32 to -0.34).

 

Duration and frequency of exercise

We explored the influence of the total number of prescribed exercise sessions (0 - 12, 13 - 24, 25 - 36, 37+ sessions) on the reduction of depression for those trials comparing exercise versus control ( Analysis 5.3). A moderate effect size was observed for 0 - 12 sessions (SMD -0.42, 95% CI -1.26 to 0.43), and 37+ sessions (SMD -0.46, 95% CI -0.69 to -0.23). A large effect size was observed for 13 - 24 sessions (SMD -0.70, 95% CI -1.09 to -0.31) and 25 - 36 sessions (SMD -0.80, 95% CI -1.30 to -0.29).

 

Type of diagnosis

We performed subgroup analyses according to how the diagnosis of depression was made (cut-point on a scale, or clinical interview and proper psychiatric diagnosis) ( Analysis 5.4). There was a moderate effect size for clinical diagnosis of depression (SMD -0.57, 95% CI -0.81 to -0.32) and a cut-point on a scale (SMD -0.67, 95% CI -0.95 to -0.39).

 

Type of control

We categorised controls as a) placebo; b) no treatment (including waiting list); c) exercise plus treatment versus treatment alone; d) stretching, meditation or relaxation; e) 'occupational', including education, occupational therapy. These categorisations were made by one author (KD) on the basis of data extracted at the initial stage of data extraction, and were checked by a second author (GM) ( Analysis 5.5). The largest effect size was when exercise was compared with 'occupational' (SMD -3.67, 95% CI -4.94 to -2.41), and there was no statistically significant effect of exercise when it was compared with 'stretching, meditation or relaxation' (SMD -0.09 (95% CI -0.65 to 0.48).

We considered whether to perform additional subgroup analyses according to supervised versus unsupervised, indoor versus outdoor and individual versus group, and according to the type of control group (in the no-treatment comparison) but we wanted to focus on the main subgroups of interest. Multiple subgroup analyses are generally considered inadvisable.

 

Sensitivity analyses

We conducted sensitivity analyses for the first comparison of exercise versus control to explore the impact of study quality on effect sizes. We have commented on how these sensitivity analyses influence pooled SMD, compared with the pooled SMD for the 35 trials comparing exercise with control (-0.62 (95% CI) -0.81 to -0.42) ( Analysis 1.1).

 

Peer-reviewed journal publications

For the 34 trials (1335 participants) that were reported in peer-reviewed journal publications or doctoral theses, the SMD was -0.59 (95% CI -0.78 to -0.40) ( Analysis 6.1), showing a moderate clinical effect in favour of exercise, which is similar to the pooled SMD for all 35 trials.

 

Published as abstracts/conference proceedings only

The pooled SMD for the one study published as conference abstracts only was -2.00 (95% CI -3.19 to -0.82) ( Analysis 6.2), showing a large effect size in favour of exercise i.e. larger than the pooled SMD for all 35 trials.

 

Allocation concealment

For the 14 trials (829 participants) with adequate allocation concealment and therefore at low risk of bias, the SMD was -0.49 (95% CI -0.75 to -0.24) ( Analysis 6.3), showing a moderate clinical effect in favour of exercise, similar to the pooled SMD for all 35 trials.

 

Use of intention-to-treat analysis

For the 11 trials (567 participants) with intention-to-treat analyses, the SMD was -0.61 (95% CI -1.00 to -0.22) ( Analysis 6.4), showing a moderate clinical effect in favour of exercise, similar to the pooled SMD for all 35 trials.

 

Blinded outcome assessment

For the 12 trials (658 participants) with blinded outcome assessments and therefore at low risk of bias, the SMD was -0.36 (95% CI -0.60 to -0.12) ( Analysis 6.5), showing a small clinical effect in favour of exercise,which is smaller than the pooled SMD for all 35 trials.

 

Allocation concealment and intention-to-treat analysis and blinded outcome assessment

For the six trials (Blumenthal 1999; Blumenthal 2007; Blumenthal 2012a; Dunn 2005; Krogh 2009; Mather 2002) (464 participants) with adequate allocation concealment and intention-to-treat analyses and blinded outcome assessment and therefore at low risk of bias, the SMD was -0.18 (95% CI -0.47 to 0.11) ( Analysis 6.6), i.e. there was a small clinical effect in favour of exercise, which did not reach statistical significance. This is smaller than the pooled SMD for all 35 trials.

 

Sensitivity analyses: including the arm with the smallest dose of exercise for those trials for which we used the arm with the largest dose of exercise in comparison 1

We included the arm with the smallest dose of exercise for 10 trials (Blumenthal 2007; Chu 2008; Doyne 1987; Dunn 2005; Krogh 2009; Mutrie 1988; Orth 1979; Setaro 1985; Singh 2005; Williams 2008) for which we had used the arm with the largest clinical effect in comparison 1 ( Analysis 1.1). The SMD was -0.44 (95% CI -0.55 to -0.33) ( Analysis 6.7), showing a moderate clinical effect in favour of exercise. This is similar to the pooled SMD for all 35 trials.

 

Recruitment and retention of participants

 Table 1 presents data about the feasibility of recruiting and retaining participants both in the trial as a whole and in the exercise intervention in particular. We extracted data, when available, about the number of participants who were considered for inclusion in each trial, although this information was not available for all trials. The trials that did provide these data used different recruitment techniques (ranging from screening of people responding to advertisements to inclusion of those patients who were considered eligible by a referring doctor).

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms
 

Summary of main results

This updated review includes seven additional trials (384 additional participants); conclusions are similar to our previous review (Rimer 2012). The pooled standardised mean difference (SMD), for depression (measured by continuous variable), at the end of treatment, represented a moderate clinical effect. The 'Summary of findings' table suggests that the quality of the evidence is moderate.

There was some variation between studies with respect to attendance rates for exercise as an intervention, suggesting that there may be factors that influence acceptability of exercise among participants.

There was no difference between exercise and psychological therapy or pharmacological treatment on the primary outcome. There are too few data to draw conclusions about the effect of exercise on our secondary outcomes, including risk of harm.

 

Uncertainties

Uncertainties remain regarding how effective exercise is for improving mood in people with depression, primarily due to methodological shortcomings (please see below). Furthermore, if exercise does improve mood in people with depression, we cannot determine the optimum type, frequency and duration of exercise, whether it should be performed supervised or unsupervised, indoors or outdoors, or in a group or alone. There was, however, a suggestion that more sessions have a larger effect on mood than a smaller number of sessions, and that resistance and mixed training were more effective than aerobic training. Adverse events in those allocated to exercise were uncommon, but only a small number of trials reported this outcome. Ideally both the risks and benefits of exercise for depression should be evaluated in future trials. There were no data on costs, so we cannot comment on the cost-effectiveness of exercise for depression. The type of control intervention may influence effect sizes. There was a paucity of data comparing exercise with psychological and pharmacological treatments; the available evidence suggests that exercise is no more effective than either psychological or pharmacological treatments.

 

Overall completeness and applicability of evidence

For this current update, we searched the CCDAN Group's trial register in September 2012, which is an up-to-date and comprehensive source of trials. We also searched the WHO trials portal in March 2013 in order to identify new ongoing trials. We scrutinised reference lists of the new trials identified. Ideally, we would have performed citation reference searches of all included studies, but with the large number of trials now in this review, this was no longer practical. Thus, it is possible that we may have missed some relevant trials. We updated our search of the CCDAN trials register up to 1st March 2013 and identified several studies that may need to be included in our next update. It is notable that in a seven-month period (September 2012 to March 2013), several more potentially eligible completed trials have been published (Characteristics of studies awaiting classification). This demonstrates that exercise for depression is a topic of considerable interest to researchers, and that further updates of this review will be needed, ideally once a year, to ensure that the review is kept as up-to-date as possible.

The results of this review are applicable to adults classified by the trialists as having depression (either by a cut-off score on a depression scale or by having a clinical diagnosis of depression) who were willing to participate in a programme of regular physical exercise, fulfilling the American College of Sports Medicine (ACSM) definition of exercise, within the context of a randomised controlled clinical trial. The trials we included are relevant to the review question. It is possible that only the most motivated of individuals were included in this type of research.

The data we extracted on aspects of feasibility (see  Table 1) suggest that a large number of people need to be screened to identify suitable participants, unless recruiting from a clinical population, e.g. inpatients with depression. Note, though, that there was a wide range in the proportion of those screened who were subsequently randomised; this may be a function of the sampling frame (which may include a range of specifically screened or non-screened potential participants), and interest in being a research participant at a time of low mood, as much as whether potential participants are interested in exercise as a therapy. A substantial number of people dropped out from both the exercise and control programmes, and even those who remained in the trial until the outcome assessments were not able to attend all exercise sessions.

We did not include trials in which advice was given to increase activity. Thus, we excluded a large, high-quality trial (n = 361) in which people with depression in primary care were randomised to usual care or to usual care plus advice from a physical activity facilitator to increase activity (Chalder 2012), which showed no effect of the intervention on mood.

We had previously decided to exclude trials which included people both with and without depression, even if they reported data from a subgroup with depression. Thus, for this update, we excluded a large, high-quality, cluster-randomised trial recruiting 891 residents from 78 nursing homes (Underwood 2013), of whom 375 had baseline Geriatric Depression Scores suggesting depression. At the end of the treatment, there was no difference between the intervention and control group, for people both with and without depression at baseline. For future updates, we will include data from trials that reported subgroups with depression.

If this review had had broader inclusion criteria in relation to the type of intervention, we would have included additional studies, e.g. trials which provide advice to increase activity (e.g. Chalder 2012) and trials of other types of physical activity interventions that do not fulfil the ACSM definition for exercise (e.g. Tai Chi or Qigong, where mental processes are practiced alongside physical activity and may exert an additional or synergistic effect). Arguably, the review could be broader, but we have elected to keep the it more focused, partly to ensure that it remains feasible to update the review on a regular basis, with the resources we have available. The original review questions were conceived more than 10 years ago (Lawlor 2001), and although they are still relevant today, it would be of value to broaden the research questions to include evidence for other modes of physical activity. This could be through a series of related Cochrane reviews. There are already separate reviews of Tai Chi for depression, and we suggest that a review of advice to increase physical activity would be of value.

This review did not attempt to take into account the effects of exercise when the experience is pleasurable and self-determined, though this would have been difficult as such data were not reported in the trials.

There were more women than men in the studies that we included, and there was a wide range in mean ages. We cannot currently make any new recommendations for the effectiveness of exercise referral schemes for depression (DOH 2001; Pavey 2011; Sorensen 2006). One study of the Welsh exercise referral scheme is 'awaiting assessment'. Nor can we be certain about the effect of exercise on other relevant outcomes e.g. quality of life, adverse events or its cost-effectiveness because the majority of trials did not systematically report this information, although our meta-analysis of quality of life suggested that exercise did not significantly improve quality of life compared to control.

We cannot comment about the effect of exercise in people with dysthymia (or sub-clinical depression) and in those without mood disorders, as we explicitly excluded these trials from the review. Future systematic reviews and meta-analyses might include these people, although new reviews would need to ensure that the search strategy was sufficiently comprehensive to identify all relevant trials. We excluded trials of exercise for postnatal depression (as we had done for our previous update).

 

Quality of the evidence

The majority of the trials we included were small and many had methodological weaknesses. We explicitly aimed to determine the influence of study quality, in particular allocation concealment, blinding and intention-to-treat analyses on effect sizes, as we had done in previous review versions (Lawlor 2001; Mead 2009, Rimer 2012). When only those trials with adequate allocation concealment and intention-to-treat analysis and blinded outcome assessors were included, the effect size was clinically small and not statistically significant ( Analysis 6.6).

There was substantial heterogeneity; this might be explained by a number of factors including variation in the control intervention. However, when only high-quality trials were included, the effect size was small and not statistically significant. Of the eight trials (377 participants) that provided long-term follow-up data, there was only a small effect in favour of exercise (SMD -0.33, 95% CI -0.63 to -0.03) at the end of long-term follow-up, This suggests that any benefits of exercise at the end of treatment may be lost over time. Thus, exercise may need to be continued in the longer term to maintain any early benefits. Our summary of findings tables indicate that the quality of evidence is low ('Summary of findings' table 5).

Our subgroup analyses showed that effect sizes were higher for mixed exercise and resistance exercise than for aerobic exercise alone, but confidence intervals were wide ( Analysis 5.1). There were no apparent differences in effect sizes according to intensity of exercise ( Analysis 5.2). Effect sizes were smaller in trials which provided fewer than 12 sessions of exercise ( Analysis 5.3). Effect sizes were not statistically significant when compared with stretching, meditation or relaxation ( Analysis 5.5). Our sensitivity analysis for 'dose' of exercise suggested that a lower dose of exercise was less effective than a higher dose ( Analysis 6.7). Although our subgroup analyses, are simply observational in nature, they are not inconsistent with the current recommendations by NICE (NICE 2009).

We extracted information from the trials about other potential sources of biases, in line with the Cochrane Collaboration 'Risk of bias' tool. In exercise trials, it is generally not possible to blind participants or those delivering the intervention to the treatment allocation. Thus, if the primary outcome is measured by self report, this is an important potential source of bias. When we performed sensitivity analysis by including only those trials with blinded outcome assessors, the effect size was smaller than when these trials were included. This suggests that self report may lead to an overestimate of treatment effect sizes. It is important to note, however, that clinician-rated outcomes (e.g. Hamilton Rating Scale for Depression) may also be subject to clinical interpretation and therefore are not free from bias. For random sequence generation, the risk of bias was unclear for most of the trials. For selective reporting, we categorised risk of bias as unclear for most of the trials, although we did not have the study protocols.

Furthermore, the funnel plot was asymmetrical suggesting small study bias, heterogeneity or outcome reporting bias.

 

Potential biases in the review process

We attempted to avoid bias by ensuring that we had identified all relevant studies through comprehensive systematic searching of the literature and contact with authors of the trials to identify other trials, both published and unpublished. However, we accept that some publication bias is inevitable and this is indicated by the asymmetrical funnel plot. This is likely to lead to an overestimate of effect sizes, because positive trials are more likely to be published than negative trials. The searches for this current update were less extensive than for the initial review in 2001 (Lawlor 2001), but because the CCDAN register of trials is updated regularly from many different sources, we think it is unlikely that we have missed relevant trials.

As noted above, there is considerable interest in the continued development of a robust and accurate evidence base in this field to guide practice and healthcare investment. We are already aware of three recent additional studies that were identified through extensive searches of CCDANCTR. Initial scrutiny of these studies suggests that they would not overturn our conclusions, but they highlight the need to maintain regular updates of this review.

For a previous version of this review (Mead 2009), we made post hoc decisions to exclude trials defined as a 'combination' intervention, a trial in which the exercise intervention lasted only four days (Berlin 2003), and trials of postnatal depression (Armstrong 2003; Armstrong 2004). For the update in 2012, (Rimer 2012), we specified in advance that we would exclude trials that did not fulfil the ACSM criteria (ACSM 2001) for exercise; this meant that we excluded two studies (Chou 2004; Tsang 2006) that had previously been included.

In previous versions of the review, we used data from the arm with the largest clinical effect; this approach could have biased the results in favour of exercise. For this update, we used the largest 'dose' of exercise and performed a sensitivity analyses to determine the effect of using the smaller 'dose' ( Analysis 6.7). This showed that the effect size was slightly smaller for the lower dose than the higher dose (-0.44 for the lower dose and -0.62 for the higher dose). This is consistent with one of the subgroup analyses which showed that fewer than 12 sessions was less effective than a larger number of sessions.

We performed several subgroup analyses, which, by their nature, are simply observational. A variety of control interventions were used. We explored the influence of the type of control intervention ( Analysis 5.5); this suggests that exercise may be no more effective than stretching/meditation or relaxation on mood. When we performed subgroup analysis of high-quality trials only, we categorised the comparator (relaxation) in one of the trials as a control intervention (Krogh 2009), rather than as an active treatment. Had we categorised relaxation as an active treatment,(e.g. Analysis 6.6), exercise would have had a larger clinical effect in the meta-analysis.

 

Agreements and disagreements with other studies or reviews

Previous systematic reviews which found that exercise improved depression included uncontrolled trials (Blake 2009; Carlson 1991; Craft 2013; North 1990; Pinquart 2007), so the results of these reviews are probably biased in favour of exercise. Another systematic review (Stathopoulou 2006) which identified trials in peer-reviewed journals only included only eight of the trials which we identified for our review (Doyne 1987; Dunn 2005; Klein 1985; McNeil 1991; Pinchasov 2000; Singh 1997; Singh 2005; Veale 1992), and also included two trials which we had excluded (Bosscher 1993; Sexton 1989). This review (Stathopoulou 2006) found a larger effect size than we did. A further two reviews included mainly older people (Blake 2009; Sjosten 2006), whereas we included participants of all ages (aged 18 and over). Another meta-analysis (Rethorst 2009) concluded that exercise is effective as a treatment for depression, and also found a larger effect size than we did. A narrative review of existing systematic reviews suggested that it would seem appropriate that exercise is recommended in addition to other treatments pending further high-quality trial data (Daley 2008). However, a systematic review that included only studies where participants had a clinical diagnosis of depression according to a healthcare professional found no benefit of exercise (Krogh 2011). Another review of walking for depression suggested that walking might be a useful adjunct for depression treatment, and recommended further trials (Robertson 2012).

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms

 

Implications for practice

Our review suggested that exercise might have a moderate-sized effect on depression, but because of the risks of bias in many of the trials, the effect of exercise may only be small. We cannot be certain what type and intensity of exercise may be effective, and the optimum duration and frequency of a programme of exercise. There are few data on whether any benefits persist after exercise has stopped.

The evidence also suggests that exercise may be as effective as psychological or pharmacological treatments, but the number of trials reporting these comparisons and the number of participants randomised, were both small.

 
Implications for research

A future update of the current review, including results from ongoing trials and those 'awaiting classification', may increase the precision of estimates of effect sizes. Future systematic reviews and meta-analyses could be performed to investigate the effect of exercise on people with dysthymia. 

This review would be strengthened by additional large-scale high-quality studies where all participants at the time of recruitment were diagnosed through clinical interview as having depression, adhered closely to an exercise regimen as a sole intervention and were further assessed through diagnostic clinical interview post-intervention.

It would also be worth considering whether any long-lasting effects of exercise correlated with sustained increases in physical activity over time. Now that we can measure physical activity directly using accelerometers, this would be a feasible piece of research to perform.

There is a paucity of data comparing exercise with psychological treatments and pharmacological treatments. Further trials are needed in this area.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms

An initial review of the effects of exercise in the treatment of depression, in which Professor Debbie Lawlor was the principal investigator, began as part of a training course at the NHS Centre for Reviews and Dissemination, University of York. Dr Stephen Hopker, consultant psychiatrist at Bradford Community Trust, was an investigator in the earlier review and Mr Alan Lui, audit nurse Airedale General Hospital, helped with the protocol development and retrieval of articles. Dr Domenico Scala, Senior House Officer in psychiatry and Lynfield Mount Hospital, Bradford, translated one Italian paper that was excluded from the review. We are grateful to Mr Paul Campbell for contributing to the previous update by providing expertise on depression. Dr Maria Corretge, Specialty Registrar in Geriatric Medicine at St. John's Hospital, West Lothian, translated two papers in Spanish and Portuguese which were subsequently excluded from the 2010 updated review.

We are very grateful to Ms Maureen Harding, Geriatric Medicine, University of Edinburgh, who retrieved articles and provided administrative support. We are also grateful to the Cochrane Depression, Anxiety and Neurosis Group editorial base team for assistance with searches and for advice on the review.

We are also grateful to several authors for providing more information or data for their studies (Elizabeth Wise - Hoffman 2010; Jorge Mota Pereira - Mota-Pereira 2011; Jane Sims - Sims 2009; James Blumenthal - Blumenthal 2012a; Rebecca Gary - Gary 2010).

We are grateful for the support of an NIHR incentive award to help support the update of this review.

CRG Funding Acknowledgement:
The National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Depression, Anxiety and Neurosis Group. 

Disclaimer:
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms
Download statistical data

 
Comparison 1. Exercise versus 'control'

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Reduction in depression symptoms post-treatment351353Std. Mean Difference (IV, Random, 95% CI)-0.62 [-0.81, -0.42]

 2 Reduction in depression symptoms follow-up8377Std. Mean Difference (IV, Random, 95% CI)-0.33 [-0.63, -0.03]

 3 Completed intervention or control291363Risk Ratio (M-H, Random, 95% CI)1.00 [0.97, 1.04]

 4 Quality of life4Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

    4.1 Mental
259Std. Mean Difference (IV, Fixed, 95% CI)-0.24 [-0.76, 0.29]

    4.2 Psychological
256Std. Mean Difference (IV, Fixed, 95% CI)0.28 [-0.29, 0.86]

    4.3 Social
256Std. Mean Difference (IV, Fixed, 95% CI)0.19 [-0.35, 0.74]

    4.4 Environment
256Std. Mean Difference (IV, Fixed, 95% CI)0.62 [0.06, 1.18]

    4.5 Physical
4115Std. Mean Difference (IV, Fixed, 95% CI)0.45 [0.06, 0.83]

 
Comparison 2. Exercise versus psychological therapies

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Reduction in depression symptoms post-treatment7189Std. Mean Difference (IV, Random, 95% CI)-0.03 [-0.32, 0.26]

 2 Completed exercise or pyschological therapies4172Risk Ratio (M-H, Random, 95% CI)1.08 [0.95, 1.24]

 3 Quality of life1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 Physical
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 Mental
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 3. Exercise versus bright light therapy

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Reduction in depression symptoms post-treatment118Mean Difference (IV, Fixed, 95% CI)-6.4 [-10.20, -2.60]

 
Comparison 4. Exercise versus pharmacological treatments

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Reduction in depression symptoms post-treatment4300Std. Mean Difference (IV, Random, 95% CI)-0.11 [-0.34, 0.12]

 2 Completed exercise or antidepressants3278Risk Ratio (M-H, Random, 95% CI)0.98 [0.86, 1.12]

 3 Quality of Life1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    3.1 Mental
125Mean Difference (IV, Fixed, 95% CI)-11.90 [-24.04, 0.24]

    3.2 Physical
125Mean Difference (IV, Fixed, 95% CI)1.30 [-0.67, 3.27]

 
Comparison 5. Reduction in depression symptoms post-treatment: Subgroup analyses

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Exercise vs control subgroup analysis: type of exercise35Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Aerobic exercise
281080Std. Mean Difference (IV, Random, 95% CI)-0.55 [-0.77, -0.34]

    1.2 Mixed exercise
3128Std. Mean Difference (IV, Random, 95% CI)-0.85 [-1.85, 0.15]

    1.3 Resistance exercise
4144Std. Mean Difference (IV, Random, 95% CI)-1.03 [-1.52, -0.53]

 2 Exercise vs control subroup analysis: intensity35Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 light/moderate
376Std. Mean Difference (IV, Random, 95% CI)-0.83 [-1.32, -0.34]

    2.2 moderate
12343Std. Mean Difference (IV, Random, 95% CI)-0.64 [-1.01, -0.28]

    2.3 hard
11595Std. Mean Difference (IV, Random, 95% CI)-0.56 [-0.93, -0.20]

    2.4 vigorous
5230Std. Mean Difference (IV, Random, 95% CI)-0.77 [-1.30, -0.24]

    2.5 Moderate/hard
266Std. Mean Difference (IV, Random, 95% CI)-0.63 [-1.13, -0.13]

    2.6 Moderate/vigorous
242Std. Mean Difference (IV, Random, 95% CI)-0.38 [-1.61, 0.85]

 3 Exercise vs control subroup analysis: number of sessions35Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    3.1 0 - 12 sessions
5195Std. Mean Difference (IV, Random, 95% CI)-0.42 [-1.26, 0.43]

    3.2 13 - 24 sessions
9296Std. Mean Difference (IV, Random, 95% CI)-0.70 [-1.09, -0.31]

    3.3 25 - 36 sessions
8264Std. Mean Difference (IV, Random, 95% CI)-0.80 [-1.30, -0.29]

    3.4 37+ sessions
10524Std. Mean Difference (IV, Random, 95% CI)-0.46 [-0.69, -0.23]

    3.5 unclear
373Std. Mean Difference (IV, Random, 95% CI)-0.89 [-1.39, -0.40]

 4 Exercise vs control subroup analysis: diagnosis of depression35Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    4.1 clinical diagnosis of depression
23967Std. Mean Difference (IV, Random, 95% CI)-0.57 [-0.81, -0.32]

    4.2 depression categorised according to cut points on a scale
11367Std. Mean Difference (IV, Random, 95% CI)-0.67 [-0.95, -0.39]

    4.3 unclear
118Std. Mean Difference (IV, Random, 95% CI)-2.00 [-3.19, -0.82]

 5 Exercise vs control subgroup analysis: type of control351353Mean Difference (IV, Fixed, 95% CI)-1.57 [-1.97, -1.16]

    5.1 placebo
2156Mean Difference (IV, Fixed, 95% CI)-2.66 [-4.58, -0.75]

    5.2 No treatment, waiting list, usual care, self monitoring
17563Mean Difference (IV, Fixed, 95% CI)-4.75 [-5.72, -3.78]

    5.3 exercise plus treatment vs treatment
6225Mean Difference (IV, Fixed, 95% CI)-1.22 [-2.21, -0.23]

    5.4 stretching, meditation or relaxation
6219Mean Difference (IV, Fixed, 95% CI)-0.09 [-0.65, 0.48]

    5.5 occupational intervention, health education, casual conversation
4190Mean Difference (IV, Fixed, 95% CI)-3.67 [-4.94, -2.41]

 
Comparison 6. Exercise versus control: sensitivity analyses

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Reduction in depression symptoms post-treatment: peer-reviewed journal publications and doctoral theses only341335Std. Mean Difference (IV, Random, 95% CI)-0.59 [-0.78, -0.40]

 2 Reduction in depression symptoms post-treatment: studies published as abstracts or conference proceedings only118Std. Mean Difference (IV, Random, 95% CI)-2.00 [-3.19, -0.82]

 3 Reduction in depression symptoms post-treatment: studies with adequate allocation concealment14829Std. Mean Difference (IV, Random, 95% CI)-0.49 [-0.75, -0.24]

 4 Reduction in depression symptoms post-treatment: studies using intention-to-treat analysis11567Std. Mean Difference (IV, Random, 95% CI)-0.61 [1.00, -0.22]

 5 Reduction in depression symptoms post-treatment: studies with blinded outcome assessment12658Std. Mean Difference (IV, Random, 95% CI)-0.36 [-0.60, -0.12]

 6 Reduction in depression symptoms post-treatment: allocation concealment, intention-to-treat, blinded outcome6464Std. Mean Difference (IV, Random, 95% CI)-0.18 [-0.47, 0.11]

 7 Reduction in depression symptoms post-treatment: Lowest dose of exercise351347Std. Mean Difference (IV, Fixed, 95% CI)-0.44 [-0.55, -0.33]

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms
 

Appendix 1. CCDAN searches all years to 1 March 2013

 

The Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR)

The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) maintain two clinical trials registers at their editorial base in Bristol, UK: a references register and a studies based register. The CCDANCTR-References Register contains over 31,500 reports of trials in depression, anxiety and neurosis. Approximately 65% of these references have been tagged to individual, coded trials. The coded trials are held in the CCDANCTR-Studies Register and records are linked between the two registers through the use of unique Study ID tags. Coding of trials is based on the EU-Psi coding manual. Please contact the CCDAN Trials Search Coordinator for further details. Reports of trials for inclusion in the Group's registers are collated from routine (weekly), generic searches of MEDLINE (1950-), EMBASE (1974-) and PsycINFO (1967-); quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL) and review specific searches of additional databases. Reports of trials are also sourced from international trials registers c/o the World Health Organization's trials portal (ICTRP), drug companies, the handsearching of key journals, conference proceedings and other (non-Cochrane) systematic reviews and meta-analyses.

Details of CCDAN's generic search strategies (used to identify RCTs) can be found on the Group's website.

The CCDANCTR was searched all years to 31 March 2013.

The CCDANCTR-Studies Register was searched using the following terms:
Diagnosis =Depressi* or Dysthymi* and Intervention = Exercise

The CCDANCTR-References Register was searched using a more sensitive set of terms to identify additional untagged/uncoded references:
Title/Abstract/Keywords = (depressi* or dysthymi*)
AND
Free-text  = (sport* or exercis* or aerobic* or running or jogging or walk* or hiking or swim* or aquatic* or cycling or bicycl* or ((physical or strength*) and (activit* or educat* or fitness or train*)) or “physical medicine” or ((resistance or weight*) and (train* or lift*)))

Additional searches were conducted on MEDLINE, EMBASE, PsycINFO and CENTRAL (2007 to 2010) by CCDAN’s Trials Search Co-ordinator (TSC) when the CCDANCTR was out of date due to relocation of the Group’s editorial base and a changeover of staff .

 

MEDLINE

OVID MEDLINE (2007 to 2010) was searched using the following terms:
1.     exp Exercise/
2.     exp Exercise Therapy/
3.     exp "Physical Education and Training"/
4.     Physical Fitness/
5.     Physical Exertion/
6.     exp Walking/
7.     Running/ or Jogging/
8.     Swimming/
9.     (cycling or bicycling).tw.
10.   (exercise$ or exercising).tw.
11.   (physical adj3 (education or training)).tw.
12.   or/1-11
13.   Depression/
14.   exp Depressive Disorder/
15.   or/13-14
16.   randomized controlled trial.pt.
17.   controlled clinical trial.pt.
18.   randomly.ab.
19.   trial.ab.
20.   groups.ab.
21.   (control$ adj3 (trial$ or study or studies)).tw.
22.   randomi#ed.ab.
23.   placebo$.ab.
24.   or/16-23
25.   12 and 15 and 24
26.   (2007$ or 2008$ or 2009$ or 2010$).ed,yr.
27.   25 and 26

 

EMBASE

OVID EMBASE (2007 to 2010) was searched using the following terms:
1.     exp exercise/
2.     exp physical activity/
3.     exp sport/
4.     (exercise$ or exercising).tw.
5.     or/1-4
6.     exp depression/
7.     randomized controlled trial/
8.     controlled clinical trial/
9.     major clinical study/
10.   randomization/
11.   placebo/
12.   randomi#ed.ti,ab.
13.   placebo$.tw.
14.   trial.ti,ab.
15.   randomly.ab.
16.   ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$ or dummy)).mp.
17.   (control$ adj3 (trial$ or study or studies$)).tw.
18.   or/6-16
19.   (2007$ or 2008$ or 2009$ or 2010$).em,yr.
20.   5 and 6 and 18 and 19

 

PsycINFO

OVID PsycINFO (2007 to 2010) was searched using the following terms:
1. exp major depression/
2. atypical depression/
3. seasonal affective disorder/
4. (depress$ adj3 (patient$ or symptom$ or disorder$)).ti,ab.
5. or/1-4
6. exp physical activity/
7. exp sports/
8. running/ or walking/
9. (cycling or bicycling).tw.
10. (exercise$ or exercising).tw.
11. (physical adj3 (education or training)).tw.
12. or/6-11
13. treatment effectiveness evaluation/
14. clinical trials/
15. mental health program evaluation/
16. placebo/
17. placebo$.tw.
18. randomly.ab.
19. randomi#ed.tw.
20. trial$.tw.
21. ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$ or dummy)).tw.
22. (control* adj3 (trial* or study or studies)).tw.
23. "2000".md.
24. or/13-23
25. 5 and 12 and 24
26. (2007$ or 2008$ or 2009$ or 2010$).an,up,yr.
27. 25 and 26

 

Cochrane Central Register of Controlled Trials (CENTRAL)

CENTRAL was searched using the following terms:
#1 MeSH descriptor Exercise explode all trees
#2 MeSH descriptor Exercise Therapy explode all trees
#3 MeSH descriptor Physical Education and Training explode all trees
#4 MeSH descriptor Physical Fitness, this term only
#5 MeSH descriptor Physical Exertion, this term only
#6 MeSH descriptor Walking explode all trees
#7 MeSH descriptor Running explode all trees
#8 MeSH descriptor Swimming, this term only
#9 (cycling or bicycling)
#10 (exercise* or exercising)
#11 (physical NEAR/5 (education or training))
#12 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11)
#13 MeSH descriptor Depressive Disorder explode all trees
#14 MeSH descriptor Depression, this term only
#15 (#13 OR #14)
#16 (#12 AND #15)
#17 (#16), from 2007 to 2010
#18 SR-DEPRESSN
#19 HS-DEPRESSN
#20 (#17 AND NOT ( #18 OR #19 ))

 

Appendix 2. Previous search to 2007

The authors searched Ovid MEDLINE and EMBASE, PsycINFO and Sports Discus on the Silver Platter platform, the Cochrane Controlled Trials Register and the Cochrane Database of Systematic Reviews. Details of the search strategy used in MEDLINE are provided below (Lawlor 2001); this search was modified as appropriate for other databases. Appropriate filters were applied to identify randomised controlled trials.

MEDLINE search strategy:
1. exp EXERCISE/
2. exp Exercise Therapy/
3. exp Exertion/
4. exp Physical Fitness/
5. exp Walking/
6. exp Running/
7. exp Swimming/
8. exp Jogging/
9. exp "Physical Education and Training"/
10. exercise$ near aerobic$.tw.
11. train$ near aerobic$.tw.
12. exercise$ near strength$.tw.
13. train$ near strength$.tw.
14. bicycling$.tw.
15. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14
16. exp DEPRESSION/
17. exp Depressive Disorder/
18. exp Dysthymic Disorder/
19. 16 or 17 or 18
20 15 and 19

 

Feedback

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms
 

Concerning the DOSE 2002 trial, 3 November 2009

 

Summary

I recently read [the] review entitled "Exercise for Depression" and would like to point out some errors in your review. First, you stated the following in your review,

"We attempted to extract data on intensity of exercise but this was reported for only a few trials, and there was too much variation in other aspects of the trial methodologies to attribute differences in outcomes to differences exercise intensities. One of the included trials compared four different 'doses' of aerobic exercise (DOSE 2002) and found that high intensity exercise was more effective than low intensity exercise."

In actuality, participants were allowed to self-select intensity and the two factors that were manipulated were frequency of exercise and total energy expenditure. It was the total energy expenditure that seemed to have a great effect on reduction of symptoms when the low dose was compared with the higher dose.

Second, the study is not cited correctly throughout the article and finally I am not sure why the main results paper was not included in this review because it was published in 2005. What was included was our baseline design paper that had no results.
I would like to see this error corrected in the review.

Andrea L. Dunn, PhD

 

Reply

Reply of Dr Gillian Mead, 10 November 2009

The 2005 paper is now cited as well as the 2002 paper.

The purpose of our review was to determine the effectiveness of exercise for depression. Thus we included trials which compared exercise with 'no treatment' and trials which compared exercise to other treatments for depression e.g. CBT.  Our conclusions were that 'It is reasonable to recommend exercise to people with depressive symptoms and to those who fulfil diagnostic criteria for depression....'

I agree... that it would be misleading if people with depression and researchers were given the impression that exercise had to be intense to bring about benefits.  Based on our subgroup analyses, we have stated that 'we cannot give people accurate information about how effective exercise might be, nor can recommendations be made about the relative benefits of aerobic exercise, resistance exercise or mixed exercise, whether group or individual exercises are better, nor about the optimum duration of exercise'.  We then go on to say that further research is required.

[Concerning intensity within the DOSE study] - text has been added for clarification in both the 'Description of studies' and the 'Discussion'.

 

Contributors

Andrea L. Dunn, PhD
Senior Research Scientist
Klein Buendel, Inc.
1667 Cole Boulevard, Suite 225
Golden, CO 80401
(303)-565-4321 (main line)
(303) 565-4320 (fax)
www.kleinbuendel.com

 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms

Last assessed as up-to-date: 13 July 2012.


DateEventDescription

2 May 2013New citation required but conclusions have not changedNew studies incorporated

2 May 2013New search has been performedReview updated



 

History

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms

Protocol first published: Issue 3, 2003
Review first published: Issue 4, 2008


DateEventDescription

12 November 2009Feedback has been incorporatedFeedback received from a trialist received 3 November 2009 concerning the DOSE 2002 study was addressed on 10 November 2009

13 May 2009New citation required but conclusions have not changedIncorrect 'date assessed as up to date' changed from February 2000 to March 2007 (date of last electronic searches). Abstract corrected to reflect true history of searches

13 August 2008New search has been performedThis is an updated version of a previous review published in the BMJ in 2001 and includes several new trials

30 July 2008AmendedConverted to new review format

21 February 2000New citation required and conclusions have changedSubstantive amendment



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms

This review is based on a previously published BMJ review by Debbie Lawlor and Stephen Hopker. For this update, Dr Cooney and Professor Mead scrutinised studies and selected studies for inclusion. Dr Waugh and Dr Cooney performed data extraction, Dr Dwan performed the analysis, Dr Greig categorised intensity of exercise, and assisted with study selection. Professor Mead, Dr Cooney and Dr Dwan wrote the text. The text was read by all authors.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms

Marion McMurdo is co-director of D.D. Developments, a University of Dundee not-for-profit organisation which provides exercise classes for older people.

Gillian E Mead developed a course on exercise after stroke which is licensed to Later Life Training. She receives royalty payments from Later Life Training, which are paid into an account at University of Edinburgh to support further research. She personally receives royalties from a book about Exercise and Fitness Training after Stroke. She receives expenses for speaking at conferences on exercise and fatigue after stroke.

Kerry Dwan: none known.

Carolyn A Greig: none known.

Debbie A Lawlor: none known.

Gary Cooney: None known

Jane Rimer: none known.

Fiona Waugh: none known.

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms
 

Internal sources

  • NHS Lothian, University of Edinburgh, UK.

 

External sources

  • National Institute for Health Research, Cochrane Review Incentive Scheme 2012, UK.

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Index terms

For this update, we defined exercise according to the American College of Sports Medicine (ACSM) definition of exercise, rather than the trialist's own definition of exercise. We performed an additional sensitivity analysis to explore the effect of excluding those trials for which we used the arm with the largest clinical effect, rather than the largest 'dose' of exercise.

Changes for this update: we added subgroups, performed a sensitivity analysis for low/high 'dose' of exercise, included more detail in 'included study' table; we decided to include cluster-RCTs, we produced a PRISMA diagram for the results of the searches for update; and we produced a 'Summary of findings' tables.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractResumo
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Feedback
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. Differences between protocol and review
  20. Characteristics of studies
  21. References to studies included in this review
  22. References to studies excluded from this review
  23. References to studies awaiting assessment
  24. References to ongoing studies
  25. Additional references
  26. References to other published versions of this review
Blumenthal 1999 {published data only}
  • Babyak M, Blumenthal JA, Herman S, Khatri P, Doraiswamy M, Moore K, et al. Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Psychosomatic Medicine 2000;62(5):633-8.
  • Blumenthal JA, Babyak MA, Moore KA, Craighead WE, Herman S, Khatri P, et al. Effects of exercise training on older patients with major depression. Archives of Internal Medicine 1999;159(19):2349-56.
  • Herman S, Blumenthal JA, Babyak M, Khatri P, Craighead WE, Krishnan KR, et al. Exercise therapy for depression in middle-aged and older adults: predictors of early dropout and treatment failure. Health Psychology 2002;21(6):533-63.
  • Khatri P, Blumenthal JA, Babyak MA, Craighead WE, Herman S, Baldewitz T, et al. Effects of exercise training on cognitive functioning among depressed older men and women. Journal of Aging and Physical Activity 2001;9:43-57.
Blumenthal 2007 {published data only}
  • Blumenthal JA, Babyak MA, Doraiswamy PM, Watkins L, Hoffman BM, Barbour KA, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosomatic Medicine 2007;69(7):587-96.
  • Hoffman BM, Babyak MA, Craighead WE, Sherwood A, Doraiswamy PM, Coons MJ, et al. Exercise and pharmacotherapy in patients with major depression: one-year follow-up of the SMILE study. Psychosomatic Medicine 2011;73(2):127-33.
Blumenthal 2012a {published data only}
  • Blumenthal J, Sherwood A, Babyak M, Watkins L, Smith PJ, Hoffman B, et al. Exercise and pharmacological treatment of depressive symptoms in patients with coronary heart disease. Journal of the American College of Cardiology 2012;60(12):1053-63.
  • Blumenthal JA, Sherwood A, Rogers SD, Babyak MA, Doraiswamy M, Watkins L, et al. Understanding prognostic benefits of exercise and antidepressant therapy for persons with depression and heart disease: the UPBEAT study-rationale, design, and methodological issues. Clinical Trials 2007;4:548.
Bonnet 2005 {published data only}
  • Bonnet LH. Effects of Aerobic Exercise in Combination with Cognitive Therapy on Self Reported Depression [dissertation]. Hempstead, NY: Hofstra University, 2005.
Brenes 2007 {published data only}
  • Brenes GA, Williamson JD, Messier SP, Rejeski WJ, Pahor M, Ip E, et al. Treatment of minor depression in older adults: a pilot study comparing sertraline and exercise. Aging and Mental Health 2007;11(1):61-8.
Chu 2008 {published data only}
  • Chu IH. Effect of Exercise Intensity During Aerobic Training on Depressive Symptoms in Initially Sedentary Depressed Women [dissertation]. Columbus, OH: The Ohio State University, 2008.
  • Chu IH, Buckworth J, Kirby TE, Emery CF. Effect of exercise intensity on depressive symptoms in women. Mental Health and Physical Activity 2009;2(1):37-43.
Doyne 1987 {published data only}
  • Doyne EJ, Ossip-Klein DJ, Bowman ED, Osborn KM, McDougall-Wilson IB, Neimeyer RA. Running versus weight lifting in the treatment of depression. Journal of Consulting and Clinical Psychology 1987;55(5):748-54.
  • Ossip-Klein DJ, Doyne EJ, Bowman ED, Osborn KM, McDougall-Wilson IB, Neimeyer RA. Effects of running or weight lifting on self-concept in clinically depressed women. Journal of Consulting and Clinical Psychology 1989;7(1):158-61.
Dunn 2005 {published data only}
  • Dunn AL, Trivedi MH. Exercise and depression: meeting standards to establish treatment efficacy. Proceedings of the 63rd Annual Meeting of the American Psychosomatic Society, 2005 March 2-5, Vancouver, Canada. McLean, VA: American Psychosomatic Society, 2005:A19.
  • Dunn AL, Trivedi MH, Kampert JB, Clark CG, Chambliss HO. Exercise treatment for depression: efficacy and dose response. American Journal of Preventive Medicine 2005;28(1):1-8.
  • Dunn AL, Trivedi MH, Kampert JB, Clark CG, Chambliss HO. The DOSE study: a clinical trial to examine efficacy and dose response of exercise as a treatment for depression. Controlled Clinical Trials 2002;23:584-603.
  • Kitzman HE, Trivedi MH, Dunn AL, Galper DI, Kampert JB, Greer TL. The effect of exercise dose on quality of life in depressed adults. Proceedings of the 63rd Annual Meeting of the American Psychosomatic Society, 2005 March 2-5, Vancouver, Canada. McLean, VA: American Psychosomatic Society, 2005:A110.
Epstein 1986 {published data only}
  • Epstein D. Aerobic Activity Versus Group Cognitive Therapy: an Evaluative Study of Contrasting Interventions for the Alleviation of Clinical Depression [dissertation]. Reno: University of Nevada, 1986.
Fetsch 1979 {published data only}
  • Fetsch RJ. A comparison of the psychological effects of running and transactional analysis stroking for the relief of reactive depression in adults [thesis]. Dissertation Abstracts International 1980;40(10-B):4999.
Foley 2008 {published data only}
  • Foley LS, Prapavessis H, Osuch EA, De Pace JA, Murphy BA, Podolinsky NJ. An examination of potential mechanisms for exercise as a treatment for depression: a pilot study. Mental Health and Physical Activity 2008;1(2):69-73.
Fremont 1987 {published data only}
  • Fremont J. The Separate and Combined Effects of Cognitively Based Counseling and Aerobic Exercise for the Treatment of Mild and Moderate Depression [dissertation]. PA, USA: Pennsylvania State University, 1983.
  • Fremont J, Wilcoxon Craighead L. Aerobic exercise and cognitive therapy in the treatment of dysphoric moods. Cognitive Therapy and Research 1987;11:241-51.
Gary 2010 {published data only}
  • Gary RA, Dunbar SB, Higgins MK, Musselman DL, Smith AL. Combined exercise and cognitive behavioral therapy improves outcomes in patients with heart failure. Journal of Psychosomatic Research 2010;69(2):119-31.
Greist 1979 {published data only}
  • Greist JH, Klein MH, Eischens RR, Faris J, Gurman AS, Morgan WP. Running as a treatment for depression. Proceedings of the 131st Annual Meeting of the American Psychiatric Association; 1978 May 8-12; Atlanta, GA. 1978.
  • Greist JH, Klein MH, Eischens RR, Faris J, Gurman AS, Morgan WP. Running as treatment for depression. Comprehensive Psychiatry 1979;20(1):41-54.
  • Greist JH, Klein MH, Eischens RR, Faris J, Gurman AS, Morgan WP. Running through your mind. Journal of Psychosomatic Research 1978;22(4):259-94.
Hemat-Far 2012 {published data only}
  • Hemat-Far A, Shahsavari A, Mousavi SR. Effects of selected aerobic exercises on the depression and concentrations of plasma serotonin in the depressed female students aged 18 to 25. Journal of Applied Research 2012;12(1):47-52.
Hess-Homeier 1981 {published data only}
  • Hess-Homeier MJ. A Comparison of Beck's Cognitive Therapy and Jogging as Treatments for Depression [dissertation]. Missoula: University of Montana, 1981.
Hoffman 2010 {published data only}
  • Hoffman JM, Bell KR, Powell JM, Behr J, Dunn EC, Dikmen S, et al. A randomized controlled trial of exercise to improve mood after traumatic brain injury. American Academy of Physical Medicine and Rehabilitation 2010;2:911-9.
  • Wise ER, Hoffman JM, Powell JM, Bombadier CH, Bell KR. Benefits of exercise maintenance after traumatic brain injury. Archives of Physical Medicine and Rehabilitation 2012;93(8):1319-23.
Klein 1985 {published data only}
  • Klein MH, Greist JH, Gurman RA, Neimeyer RA, Lesser DP, Bushnell NJ. A comparative outcome study of group psychotherapy vs. exercise treatments for depression. International Journal of Mental Health 1985;13:148-77.
Knubben 2007 {published data only}
  • Knubben K, Reischies FM, Adli M, Schlattmann P, Bauer M, Dimeo F. A randomised controlled study on the effects of a short-term endurance training programme in patients with major depression. British Journal of Sports Medicine 2007;41:29-33.
Krogh 2009 {published data only}
  • Krogh J, Nordentoft M, Mohammad-Nezhad M, Westrin A. Growth hormone, prolactin and cortisol response to exercise in patients with depression. Journal of Affective Disorders 2010;125:189-97.
  • Krogh J, Petersen L, Timmermann M, Saltin B, Nordentoft M. Design paper: The DEMO trial: a randomized, parallel-group, observer-blinded clinical trial of aerobic versus non-aerobic versus relaxation training for patients with light to moderate depression [NCT00103415]. Contemporary Clinical Trials 2007;28(1):79-89.
  • Krogh J, Saltin B, Gluud C, Nordentoft M. The DEMO Trial: a randomized, parallel-group, observer-blinded clinical trial of strength versus aerobic versus relaxation training for patients with mild to moderate depression. Journal of Clinical Psychiatry 2009;70(6):790-800.
Martinsen 1985 {published data only}
Mather 2002 {published data only}
  • Mather AS, Rodrigues C, Guthrie MF, McHarg AM, Reid IC, McMurdo MET. Effects of exercise on depressive symptoms in older adults with poorly responsive depressive disorder. British Journal of Psychiatry 2002;180:411-5.
McCann 1984 {published data only}
McNeil 1991 {published data only}
Mota-Pereira 2011 {published data only}
  • Mota-Pereira J, Silverio J, Carvalho S, Ribiero JC, Fonte D, Ramos J. Moderate exercise improves depression parameters in treatment-resistant patients with major depressive disorder. Journal of Psychiatric Research 2011;45:1005-11.
Mutrie 1988 {published data only}
  • Mutrie N. Exercise as a Treatment for Depression within a National Health Service [dissertation]. PA, USA: Pennsylvania State University, 1986.
  • Mutrie N. Exercise as a treatment for moderate depression in the UK National Health Service [abstract]. Proceedings of Sport, Health Psychology and Exercise Symposium, Sports Council and Health Education Authority, London 1988:96-105.
Nabkasorn 2005 {published data only}
  • Nabkasorn C, Miyai N, Sootmongkol A, Junprasert S, Yamamoto H, Arita M, et al. Effects of physical exercise on depression, neuroendocrine stress hormones and physiological fitness in adolescent females with depressive symptoms. European Journal of Public Health 2005;16:179-84.
Orth 1979 {published data only}
  • Orth DK. Clinical Treatments for Depression [dissertation]. Morgantown, WV: West Virginia University, 1979.
Pilu 2007 {published data only}
  • Carta MG, Hardoy MC, Pilu A, Sorba M, Floris AL, Mannu FA, et al. Improving physical quality of life with group physical activity in the adjunctive treatment of major depressive disorder. Clinical Practice and Epidemiology in Mental Health 2008;4:1.
  • Pilu A, Sorba M, Hardoy MC, Floris AL, Mannu F, Seruis ML, et al. Efficacy of physical activity in the adjunctive treatment of major depressive disorders: preliminary results. Clinical Practice and Epidemiology in Mental Health 2007;3(8):doi:10.1186/1745-0179-3-8.
Pinchasov 2000 {published data only}
  • Pinchasov BB, Shurgaja AM, Grischin OV, Putilov AA. Mood and energy regulation in seasonal and non-seasonal depression before and after midday treatment with physical exercise or bright light. Psychiatry Research 2000;94:29-42.
Reuter 1984 {published data only}
  • Reuter M, Mutrie N, Harris DV. Running as an adjunct to counseling in the treatment of depression [unpublished manuscript]. Pennsylvania State University, 1984.
Schuch 2011 {published data only}
  • Schuch FB, Vasconcelos-Moreno MP, Borowsky C, Fleck MP. Exercise and severe depression: preliminary results of an add-on study. Journal of Affective Disorders 2011;133:615-8.
Setaro 1985 {published data only}
  • Setaro JL. Aerobic Exercise and Group Counseling in the Treatment of Anxiety and Depression [dissertation]. Maryland: University of Baltimore, 1985.
Shahidi 2011 {published data only}
  • Shahidi M. Reply to the letter to the editor re Shahidi M, Mojtahed A, Modabbernia a, et al. 2011. Laughter yoga versus group exercise program in elderly depressed women: A randomized controlled trial. Int j geriatr psychiatr 26: 322-327. First things first! Caveats in research on "laughter yoga". International Journal of Geriatric Psychiatry 2012;27(8):875-6.
  • Shahidi M, Mojtahed A, Modabbernia A, Mojtahed M, Shafiabady A, Delavar A, et al. Laughter yoga versus group exercise program in elderly depressed women: a randomized controlled trial. International Journal of Geriatric Psychiatry 2011;26(3):322-7.
Sims 2009 {published data only}
  • Sims J, Galea M, Taylor N, Dodd K, Jespersen S, Joubert L, et al. Regenerate: assessing the feasibility of a strength-training program to enhance the physical and mental health of chronic post stroke patients with depression. International Journal of Geriatric Psychiatry 2009;24(1):76-83.
  • Teoh V, Sims J, Milgrom J. Psychosocial predictors of quality of life following a stroke. Topics in Stroke Rehabilitation 2009;16(2):157-66.
Singh 1997 {published data only}
Singh 2005 {published data only}
  • Singh NA, Stavrions TM, Scarbek Y, Galambos G, Liber C, Fiatorone Singh MA. A randomised controlled trial of high versus low intensity weight training versus general practitioner care for clinical depression in older adults. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 2005;60A:768-76.
Veale 1992 {published data only}
  • Veale D, Le Fevre K, Pantelis C, De Souza V, Mann A, Sargeant A. Aerobic exercise in the adjunctive treatment of depression: a randomized controlled trial. Journal of the Royal Society of Medicine 1992;85(9):541-4.
Williams 2008 {published data only}

References to studies excluded from this review

  1. Top of page
  2. AbstractResumo
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Feedback
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. Differences between protocol and review
  20. Characteristics of studies
  21. References to studies included in this review
  22. References to studies excluded from this review
  23. References to studies awaiting assessment
  24. References to ongoing studies
  25. Additional references
  26. References to other published versions of this review
Abascal 2008 {published data only}
  • Abascal L. The Effect of Depression and Adherence in a Dietary and Physical Activity Intervention for Overweight and Obese Adults [dissertation]. University of California, San Diego and San Diego State University 2008.
Akandere 2011 {published data only}
  • Ankandere M, Demir B. The effect of dance over depression. Collegium Antropologicum 2011;35(3):651-6.
Annesi 2010 {published data only}
  • Annesi JJ, Gorjala S. Association of reduction in waist circumference with normalization of mood in obese women initiating exercise supported by the Coach Approach protocol. Southern Medical Journal 2010;103(6):517-21.
Arcos-Carmona 2011 {published data only}
  • Arcos-Carmona IM, Castro-Sanchez AM, Mataran-Penarrocha GA, Gutierrez-Rubio AB, Ramos-Gonzalez E, Moreno-Lorenzo C. Effects of aerobic exericise program and relaxation techniques on anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia: A randomised controlled trial. Medicina Clinica 2011;137(9):398-401.
Armstrong 2003 {published data only}
Armstrong 2004 {published data only}
Asbury 2009 {published data only}
  • Asbury EA, Kanji N, Ernst E, Barbir M, Collins P. Autogenic training to manage symptomology in women with chest pain and normal coronary arteries. Menopause 2009;16(1):60-5.
Attia 2012 {published data only}
  • Attia E. In the clinic eating disorders. Annals of Internal Medicine 2012;156(7):1-16.
Aylin 2009 {published data only}
  • Aylin K, Arzu D, Sabri S, Handan TE, Ridvan A. The effect of combined resistance and home-based walking exercises in type 2 diabetes patients. International Journal of Diabetes in Developing Countries 2009;29(4):159-65.
Badger 2007 {published data only}
Baker 2006 {published data only}
Bartholomew 2005 {published data only}
  • Bartholomew JB, Morrison D, Ciccolo JT. Effects of acute exercise on mood and well-being in patients with major depressive disorder. Medicine and Science in Sports and Exercise 2005;37:2032-7.
Beffert 1993 {published data only}
  • Beffert JW. Aerobic Exercise as Treatment of Depressive Symptoms in Early Adolescents [dissertation]. University of Northern Colorado 1993.
Berke 2007 {published data only}
Berlin 2003 {published data only}
  • Berlin B, Moul DE, LePage JP, Mogge NL, Sellers DG. The effect of aquatic therapy interventions on patients with depression: a comparison study. Annual in Therapeutic Recreation 2003;12:7-13.
Biddle 1989 {published data only}
Blumenthal 2012b {published data only}
  • Blumenthal JA, Babyak MA, O'Connor C, Keteyian S, Landzberg J, Howlett J, et al. Effects of exercise training on depressive symptoms in patients with chronic heart failure. JAMA 2012;308(5):465-74.
Bodin 2004 {published data only}
  • Bodin T, Martinensen EW. Mood and self-efficacy during acute exercise in clinical depression. A randomised controlled study. Journal of Sport and Exercise Psychology 2004;26:623-33.
Bosch 2009 {published data only}
  • Bosch PR, Traustadóttir T, Howard P, Matt KS. Functional and physiological effects of yoga in women with rheumatoid arthritis: a pilot study. Alternative Therapies in Health and Medicine 2009;15(4):24-31.
Bosscher 1993 {published data only}
  • Bosscher RJ. Running and mixed physical exercises with depressed psychiatric patients. International Journal of Sport Psychology 1993;24:170-84.
Bowden 2012 {published data only}
  • Bowden D, Gaudry C, An SC, Gruzelier J. A comparative randomised controlled trial of the effects of brain wave vibration training, Iyengar yoga, and mindfulness on mood, well-being, and salivary cortisol. Evidence-based Complementary and Alternative Medicine 2012 Dec 15 [Epub ahead of print]. [DOI: 10.1155/2012/234713]
Boyll 1986 {published data only}
  • Boyll JF. The Effects of Active and Passive Electronic Muscle Stimulation on Self-concept, Anxiety and Depression [dissertation]. Flagstaff: Northern Arizona University, 1986.
Brittle 2009 {published data only}
  • Brittle N, Patel S, Wright C, Baral S, Versfeld P, Sackley C. An exploratory cluster randomised controlled trial of group exercise on mobility and depression in care home residents. Clinical Rehabilitation 2009;23:146-54.
Bromby 2010 {published data only}
  • Bromby S, Chandrasekara A. Study of the effect of physical activity on obese/overweight farm men and women on their psychological health and obesity related clinical co-morbidities. Available from http://www.anzctr.org.au/ACTRN12610000827033.aspx (accessed May 2013). [: ACTRN12610000827033]
Broocks 1997 {published data only}
  • Broocks A, Meyer TF, George A, Pekrun G, Hillmer-Vogel U, Hajak G, et al. Value of sports in treatment of psychiatric illness. Psychotherapie, Psychosomatik, Medizinische Psychologie 1997;47(11):379-93.
Brown 1992 {published data only}
Burbach 1997 {published data only}
  • Burbach FR. The efficacy of physical activity interventions within mental health services: anxiety and depressive disorders. Journal of Mental Health 1997;6:543-66.
Burton 2009 {published data only}
  • Burton NW, Pakenham KI, Brown WJ. Evaluating the effectiveness of psychosocial resilience training for heart health, and the added value of promoting physical activity: a cluster randomized trial of the READY program. BMC Public Health 2009;9:427.
Carney 1987 {published data only}
  • Carney RM, Templeton B, Hong BA, Harter HR, Hagberg JM, Schechtman KB, et al. Exercise training reduces depression and increases the performance of pleasant activities in haemodialysis patients. Nephron 1987;47:194-8.
Chalder 2012 {published data only}
  • Baxter H, Winder R, Chalder M, Wright C, Sherlock S, Haase A, et al. Physical activity as a treatment for depression: the TREAD randomised trial protocol. Trials 2010;11:105.
  • Chalder M, Wiles NJ, Campbell J, Hollinghurst SP, Haase AM, Taylor AH, et al. et al. Facilitated physical activity as a treatment for depressed adults: a randomised controlled clinical trial. BMJ 2012;344:e2758.
  • Chalder M, Wiles NJ, Campbell J, Hollinghurst SP, Searle A, Haase AM, et al. A pragmatic randomised controlled trial to evaluate the cost-effectiveness of a physical activity intervention as a treatment for depression: The treating depression with physical activity (TREAD) trial. Health Technology Assessment 2012;16(10):1-164.
  • Haase AM, Taylor AH, Fox KR, Thorp H, Lewis G. Rationale and development of the physical activity counselling intervention for a pragmatic TRial of Exercise and Depression in the UK (TREAD-UK). Mental Health and Physical Activity 2010;3(2):85-91.
  • Searle A, Calnan M, Lewis G, Campbell J, Taylor A, Turner K. Patients' views of physical activity as treatment for depression: a qualitative study. British Journal of General Practice 2011;61(585):149-56.
  • Searle A, Calnan M, Turner KM, Lawlor DA, Campbell J, Chalder M, et al. General Practitioners' beliefs about physical activity for managing depression in primary care [ISRCTN16900744;TREAD UK]. Mental Health and Physical Activity 2012;5(1):13-19.
Chan 2011 {published data only}
  • Chan AS, Cheung M-C, Tsui WJ, Sze SL, Shi D. Dejian mind-body intervention on depressive mood of community-dwelling adults: A randomised controlled trial. Evidence-based Complementary and Alternative Medicine 2011:473961.
Chen 2009 {published data only}
  • Chen KM, Chen MH, Chao HC, Hung HM, Lin HS, Li CH. Sleep quality, depression state, and health status of older adults after silver yoga exercises: cluster randomized trial. International Journal of Nursing Studies 2009;46(2):154-63.
Chou 2004 {published data only}
  • Chou K-L, Lee PWH, Yu ECS, MacFarlane D, Cheng Y-H, Chan SSC, et al. Effect of Tai Chi on depressive symptoms amongst Chinese older patients with depressive disorders: a randomised clinical trial. International Journal of Geriatric Psychiatry 2004;19:1105-7.
Chow 2012 {published data only}
Christensen 2012 {published data only}
  • Christensen SB, Dall CH, Prescott E, Pedersen SS, Gustafsson F. A high-intensity exercise program improves exercise capacity, self-perceived health, anxiety and depression in heart transplant recipients: A randomised, controlled trial. Journal of Heart and Lung Transplantation 2012;31(1):106-7.
Ciocon 2003 {published data only}
  • Ciocon JO, Galindo-Ciocon D. Loneliness and depression in nursing home setting: the effect of a restorative program. International Psychogeriatrics [abstracts from The International Psychogeriatric Association 11th International Congress, Chicago, United States. 17-22 August 2003]. 2003; Vol. 15:S027-04.
Clegg 2011 {published data only}
  • Clegg A, Barber S, Young J, Forster A, Iliffe S. The home-based older people's exercise (HOPE) trial: study protocol for a randomised controlled trial. Trials (Electronic Resource) 2011; Vol. 12, issue 143.
Courneya 2007 {published data only}
  • Courneya KS, Segal RJ, Gelmon K, Reid RD, Mackey JR, Friedenreich CM, et al. Six-month follow-up of patient-related outcomes in a randomized controlled trial of exercise training during breast cancer chemotherapy. Cancer Epidemiology, Biomarkers and Prevention 2007;16(12):2572-8.
Dalton 1980 {published data only}
  • Dalton RB. Effects of Exercise and Vitamin B12 Supplementation on the Depression Scale Scores of a Wheelchair Confined Population [dissertation]. Columbia, MO: University of Missouri, 1981.
Demiralp 2011 {published data only}
  • Demiralp M, Oflaz F. The effect of relaxation training on symptoms of anxiety and depression in patients with breast cancer. TAF Preventive Medicine Bulletin 2011;10(2):165-74.
Deslandes 2010 {published data only}
  • Deslandes AC, Morales H, Alves H, Pompeu FAMS, Silveira, H, Mouta, R, et al. Effect of aerobic training on EEG alpha asymmetry and depressive symptoms in the elderly: A 1-year follow-up study. Brazilian Journal of Medical and Biological Research 2010;43(6):585-92.
DeVaney 1991 {published data only}
  • DeVaney SB. Comparative Effects of Exercise Reduction and Relaxation Training on Type A Behaviour and Dysphoric Mood States in Habitual Aerobic Exercisers [dissertation]. Greensboro: University of North Carolina, 1991.
DiLorenzo 1999 {published data only}
Eby 1985 {published data only}
  • Eby JM. An Investigation into the Effects of Aerobic Exercise on Anxiety and Depression [dissertation]. Toronto, ON: University of Toronto, 1985.
Elavsky 2007 {published data only}
Emery 1990a {published data only}
Emery 1990b {published data only}
Ersek 2008 {published data only}
  • Ersek M, Turner JA, Cain KC, Kemp CA. Results of a randomized controlled trial to examine the efficacy of a chronic pain self-management group for older adults. Pain 2009;138(1):29-40.
Fitzsimmons 2001 {published data only}
  • Fitzsimmons S. Easy rider wheelchair biking: a nursing-recreation therapy clinical trial for the treatment of depression. Journal of Gerontological Nursing 2001;27:14-23.
Fox 2007 {published data only}
  • Fox KR, Stathi A, McKenna J, Davis MG. Physical activity and mental well-being in older people participating in the better ageing project. European Journal of Applied Physiology 2007;100:591-602.
Gary 2007 {published data only}
  • Gary R, Lee SY. Physical function and quality of life in older women with diastolic heart failure: effects of a progressive walking program on sleep patterns. Progress in Cardiovascular Nursing 2007;22:72-80.
Ghroubi 2009 {published data only}
  • Ghroubi S, Elleuch H, Chikh T, Kaffel N, Abid M, Elleuch MH. Physical training combined with dietary measures in the treatment of adult obesity. A comparison of two protocols. Annals of Physical and Rehabilitation Medicine 2009;52:394-413.
Gottlieb 2009 {published data only}
  • Gottlieb SS, Kop WJ, Ellis SJ, Binkley P, Howlett J, O'Connor C, et al. Relation of depression to severity of illness in heart failure (from heart failure and a controlled trial investigating outcomes of exercise training [HF-ACTION]). American Journal of Cardiology 2009;103:1285-9.
Gusi 2008 {published data only}
  • Gusi N, Reyes MC, Gonzalez-Guerrero JL, Herrera E, Garcia JM. Cost-utility of a walking programme for moderately depressed, obese, or overweight elderly women in primary care: a randomised controlled trial. BMC Public Health 2008;8:231.
Gustafsson 2009 {published data only}
  • Gustafsson G, Lira CM, Johansson J, Wisén A, Wohlfart, Ekman R, et al. The acute response of plasma brain-derived neurotrophic factor as a result of exercise in major depressive disorder. Psychiatry Research 2009;169:244-8.
Gutierrez 2012 {published data only}
Haffmans 2006 {published data only}
Hannaford 1988 {published data only}
  • Hannaford CP, Harrell EH, Cox K. Psychophysiological effects of a running program on depression and anxiety in a psychiatric population. Psychological Record 1988;38:37-48.
Haugen 2007 {published data only}
  • Haugen TS, Stavem K. Rehabilitation in a warm versus a colder climate in chronic obstructive pulmonary disease. Journal of Cardiopulmonary Rehabilitation and Prevention 2007;27:50-6.
Hedayati 2012 {published data only}
  • Hedayati SS, Yalamanchili, Finkelstein FO. A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease. Kidney International 2012;81(3):247-55.
Hembree 2000 {published data only}
  • Hembree LD. Exercise and its Effect on Hopelessness and Depression in an Aging Female Population in Eastern Oklahoma [dissertation]. Fayetteville: University of Arkansas, 2001.
Herrera 1994 {published data only}
  • Herrera F. Efficacy of a psychological intervention for depression in patients on haemodialysis [Eficacia de la intervención psicológica en la depresión del paciente en hemodiálisis]. Psiquis 1994;15(4):175-8.
Hughes 1986 {published data only}
Hughes 2009 {published data only}
  • Hughes CW, Trivedi MH, Cleaver J, Greer TL, Emslie GJ, Kennard B, et al. DATE: Depressed adolescents treated with exercise: study rationale and design for a pilot study. Mental Health and Physical Activity 2009;2:76-85.
Immink 2011 {published data only}
  • Immink MA, Hillier SL. Yoga for chronic post-stroke hemiparesis: A pilot randomised controlled trial. International Journal of stroke. 2011; Vol. Abstract of the 22nd Stroke Society of Australasia Annual Scientific Meeting.
Jacobsen 2012 {published data only}
  • Jacobsen P, Phillips K, Jim H, Faul LA, Small B, Meade C, et al. Self-directed stress management and exercise training for cancer chemotherapy patients. Psycho-Oncology (abstracts of the 9th Annual Conference of the American Psychosocial Oncology Society). 2012; Vol. 21:17.
Johansson 2011 {published data only}
  • Johansson M, Hassmen P, Jouper J. Acute effects of Qigong exercise on mood and anxiety. Sport, Exercise and Performance Psychology 2011;15(2):199-207.
Karlsson 2007 {published data only}
  • Karlsson MR, Edström-Plüss C, Held C, Henriksson P, Billing E, Wallén NH. Effects of expanded cardiac rehabilitation on psychosocial status in coronary artery disease with focus on type D characteristics. Journal of Behavioral Medicine 2007;30:253-61.
Kerr 2008 {published data only}
Kerse 2010 {published data only}
  • Kerse N, Hayman KJ, Moyes SA, Peri K, Robinson E, Dowell A, et al. Home-based activity program for older people with depressive symptoms: DeLLITE - a randomized controlled trial. Annals of Family Medicine 2010;8:214-23.
Kim 2004 {published data only}
  • Kim KB, Cohen SM, Oh HK, Sok SR. The effects of meridian exercise on anxiety, depression and self-esteem of female college students in Korea. Holistic Nursing Practice 2004;18:230-4.
Knapen 2003 {published data only}
  • Knapen J, Van De Vliet P, Van Coppenolle H, David A, Peuskens J, Knapen K, et al. The effectiveness of two psychomotor therapy programmes on physical fitness and physical concept in nonpsychotic psychiatric patients: a randomised controlled trial. Clinical Rehabilitation 2003;17:637-47.
Knapen 2006 {published data only}
  • Knapen J, Van Coppenolle H, Peuskens J, Pieters G, Knapen K. Comparison of changes in physical fitness, physical self-concept, global self-esteem, depression and anxiety following two different psychomotor therapy programs in non-psychotic psychiatric inpatients. The Concept of Self in Education, Family and Sports. Nova, 2006:Chapter 4.
Kubesh 2003 {published data only}
  • Kubesch S, Bretschneider V, Freudenmann R, Weiderhammer N, Lehmann M, Spitzer M, et al. Aerobic endurance exercise improves executive function in depressed patients. Journal of Clinical Psychiatry 2003;64:1005-12.
Kulcu 2007 {published data only}
  • Kulcu DG, Kurtais Y, Tur BS, Gülec S, Seckin B. The effect of cardiac rehabilitation on quality of life, anxiety and depression in patients with congestive heart failure. A randomized controlled trial, short-term results. Europa Medicophysica 2007;43:489-97.
Kupecz 2001 {published data only}
  • Kupecz DB. Effects of a Structured Exercise Program in Older Veteran Patients [dissertation]. Greely, CO: University of Northern Colorado, 2001.
Labbe 1988 {published data only}
Lacombe 1988 {published data only}
  • Lacombe JB. The Role of Aerobic Conditioning and Psychosocial Factors in Mediating the Effect of Exercise on Depression [dissertation]. Hempstead, NY: Hofstra University, 1987.
Lai 2006 {published data only}
Latimer 2004 {published data only}
  • Latimer AE, Martin Ginis KA, Hicks AL, McCartney N. An examination of the mechanisms of exercise-induced change in psychological well-being among people with spinal cord injury. Journal of Rehabilitation Research and Development 2004;41(5):643-51.
Lautenschlager 2008 {published data only}
  • Lautenschlager NT, Cox KL, Flicker L, Foster JK, Van Bockxmeer FM, Xiao J, et al. Effect of physical activity on cognitive function in older adults at risk for Alzheimer disease. JAMA 2008;300(9):1027-37.
Lavretsky 2011 {published data only}
  • Lavretsky H, Alstein LL, Olmstead RE, Ercoli LM, Riparetti-Brown M, Cyr NS, et al. Complementary use of tai chi chih augments escitalopram treatment of geriatric depression: A randomized controlled trial. American Journal of Geriatric Psychiatry 2011;19(10):839-50.
Legrand 2009 {published data only}
  • Legrand FD, Mille CR. The effects of 60 minutes of supervised weekly walking (in a single vs. 3-5 session format) on depressive symptoms among older women: findings from a pilot randomized trial. Mental Health and Physical Activity 2009;2:71-5.
Leibold 2010 {published data only}
  • Leibold ML. Activites and adaptive strategies in late life depression: A qualitative study [thesis]. Dissertation Abstracts International: Section B: The Sciences and Engineering 2011; Vol. 71, issue 9-B:5425.
Leppämäki 2002 {published data only}
  • Leppämäki S, Haukka J, Lönnqvist J, Partonen T. Drop-out and mood improvement: a randomised controlled trial with light exposure and physical exercise. BMC Psychiatry 2004;4:22.
  • Leppämäki SJ, Partonen TT, Hurme J, Haukka JK, Lonnqvist JK. Randomised trial of the efficacy of bright-light exposure and aerobic exercise on depressive symptoms and serum lipids. Journal of Clinical Psychiatry 2002;63(4):316-21.
Levendoglu 2004 {published data only}
  • Levendoğlu F, Altintepe L, Okudan N, Uğurlu H, Gökbel H, Tonbul Z, et al. A twelve exercise program improves the psychological status, quality of life and work capcity in hemodialysis patients. Journal of Nephrology 2004;17:826-32.
Lever-van Milligen 2012 {published data only}
  • Lever-van Milligen B. Mood treatment with antidepressants or running (MOTAR). http://www.trialregister.nl/admin/rctview.asp?TC=3460 June 2012. [: NTR 3460]
Levinger 2011 {published data only}
  • Levinger I, Selig S, Goodman C, Jerums G, Stewart A, Hare DL. Resistance training improves depressive symptoms in individuals at high risk for type 2 diabetes. Journal of Strength and Conditioning Research 2011;25(8):2328-33.
Lin 2007 {published data only}
Littbrand 2011 {published data only}
  • Littbrand H, Carlsson M, Lundin-Olsson L, Lindelof N, Haglin L, Gustafson Y, et al. Effect of a high-intensity functional exercise program on functional balance: Preplanned subgroup analyses of a randomized controlled trial in residential care facilities. Journal of the American Geriatrics Society 2011;59(7):1274-82.
Lolak 2008 {published data only}
  • Lolak S, Conors GL, Sherican MJ, Wise TN. Effects of progressive muscle relaxation training on anxiety and depression in patients enrolled in an outpatient pulmonary rehabilitation program. Psychotherapy and Pyschosomatics 2008;77(2):119-25.
Machado 2007 {published data only}
MacMahon 1988 {published data only}
  • MacMahon JR, Gross RT. Physical and psychological effects of aerobic exercise in delinquent adolescent males. American Journal of Diseases of Children 1988;142:1361-6.
Mailey 2010 {published data only}
  • Mailey EL, Wojcicki TR, Moti RW, Hu L, Strauser DR, Collins KD, et al. Internet-delivered physical activity intervention for college students with mental health disorders: a randomised pilot trial. Psychology Health and Medicine 2010;15(6):646-59.
Martin 2009 {published data only}
Martinsen 1988a {published data only}
  • Martinsen EW. Exercise intervention studies in patients with anxiety and depressive disorders. Proceedings of Sport, Health Psychology and Exercise Symposium. London: Sports Council and Health Education Authority, 1988:77-83.
Martinsen 1988b {published data only}
  • Martinsen EW. Comparing aerobic and non-aerobic forms of exercise in the treatment of clinical depression: a randomised trial. Proceedings of Sport, Health Psychology and Exercise Symposium. London: Sports Council and Health Education Authority, 1988:84-95.
Martinsen 1989c {published data only}
  • Martinsen EW. Aerobic exercise in the treatment of nonpsychotic mental disorders: an exploratory study. Nordic Journal of Psychiatry 1989;43:521-9.
Martinsen 1993 {published data only}
  • Martinsen EW. Therapeutic implications of exercise for clinically anxious and depressed patients. International Journal of Sport Psychology 1993;24:185-99.
Matthews 2011 {published data only}
McClure 2008 {published data only}
  • McClure JB, Catz SL, Ludman EJ, Richards J, Riggs K, Grothaus L. Feasibility and acceptability of a multiple risk factor intervention: the Step Up randomized pilot trial. BMC Public Health 2011;11(167):doi:10.1186/1471-2458-11-167.
  • NCT00644995. Step up wellness program for depression, physical inactivity, and smoking. ClinicalTrials.gov (http//www.clinicaltrials.gov) (accessed 2008). [: NCT00644995]
Midtgaard 2011 {published data only}
  • Midtgaard J, Stage M, Moller T, Andersen C, Quist M, Rorth M, et al. Exercise may reduce depression but not anxiety in self-referred cancer patients undergoing chemotherapy. Post-hoc analysis of data from the 'Body & Cancer' trial. Acta Oncologia 2011;50(5):660-9.
Milani 2007 {published data only}
Morey 2003 {published data only}
  • Morey MC, Dubbert PM, Doyle ME, MacAller H, Crowley GM, Kuchibhatla M, et al. From supervised to unsupervised exercise: factors associated with exercise adherence. Journal of Aging and Physical Activity 2003;11(3):351-68.
Motl 2004 {published data only}
  • Motl RW, Konopack JF, McAuley E, Elavasky S, Jerome GJ, Marquez DX. Depressive symptoms among older adults: long-term reduction after a physical activity intervention. Journal of Behavioral Medicine 2005;28(4):384-94.
Mudge 2008 {published data only}
  • Mudge A. The impact of a disease management programme including a supervised exercise programme versus disease management alone on death, readmissions, depression and functional status on patients with a recent hospitalisation for heart failure. Australian New Zealand Clinical Trials Registry 2008.
Munro 1997 {published data only}
Mutrie 2007 {published data only}
  • Mutrie N, Campbell AM, Whyte F, McConnachie A, Emslie C, Lee L, et al. Benefits of supervised group exercise programme for women being treated for early stage breast cancer: pragmatic randomised controlled trial. BMJ 2007;334(7592):517.
NCT00416221 {published data only}
  • NCT00416221. Development and a pilot study of the PACEPRO exercise and mood management program in depressed patients on escitalopram oxalate (Lexapro). http://clinicaltrials.gov/show/NCT00416221 (accessed 2008). [: NCT 00416221]
NCT00546221 {published data only}
  • NCT00546221. Pragmatic randomised controlled trial of a preferred intensity exercise programme to improve physiological and associated psychological, social, and wellbeing outcomes of women living with depression. ClinicalTrials.gov (http://www.clinicaltrials.gov) 2007. [: NCT00546221]
NCT00964054 {published data only}
  • NCT00964054. Adapting exercise treatment for depression to adolescents: a pilot study [NCT00964054]. http://clinicaltrials.gov/show/NCT00964054 (accessed 1 March 2013). [: NCT00964054]
NCT01152086 {published data only}
  • NCT01152086. The effects of regular mountain hiking on hopelessness in chronically suicidal patients. ClinicalTrials.gov (http://www.clinicaltrials.gov) (accessed 1st March 2013). [: NCT01152086]
Neidig 1998 {published data only}
  • Neidig JL. Aerobic Exercise Training: Effects on Depressive Symptoms in HIV Infected Adults (Immune Deficiency, Exercise Training) [dissertation]. Columbus, OH: The Ohio State University, 1998.
  • Neidig JL, Smith BA, Brashers DE. Aerobic exercise training for depressive symptom management in adults living with HIV infection. Journal of Association of Nurses in AIDS Care 2003;14(2):30-40.
  • Smith BA, Neidig JL, Nickel JT, Mitchell GL, Para MF, Fass RJ. Aerobic exercise: effects on parameters related to fatigue, dyspnea, weight and body composition in HIV-infected adults. AIDS 2001;15(6):693-701.
Netz 1994 {published data only}
  • Netz Y, Yaretzki A, Salganik I, Jacob T, Finkeltov B, Argov E. The effect of supervised physical activity on cognitive and affective state of geriatric and psychogeriatric in-patients. Clinical Gerontologist 1994;15(1):47-56.
Neuberger 2007 {published data only}
Nguyen 2001 {published data only}
  • Nguyen HQ, Carrieri-Kohlman V, Demir-Deviren S, Stulbarg MS. Are the improvements in fatigue, vigor and depression sustained with a home walking programme?. Proceedings of the American Thoracic Society 2001 International Conference; May 18-23; San Francisco, California. 2001.
O'Neil 2011 {published data only}
  • O'Neil A, Hawkes AL, Chan B, Sanderson K, Forbes A, Hollingsworth B, et al. A randomised, feasibility trial of a tele-health intervention for Acute Coronary Syndrome patients with depression ('Moodcare') : Study protocol. BMC Cardiovascular Disorders 2011 25th Feb [Epub ahead of print]; Vol. 11, issue 8. [DOI: 10.1186/1471-2261-11-8]
Oeland 2010 {published data only}
  • Oeland AM, Laessoe U, Olesen AV, Munk-Jorgensen P. Impact of exercise on patients with depression and anxiety. Nordic Journal of Pyschiatry 2010;64(3):210-7.
Oretzky 2006 {published data only}
  • Oretzky S. The Effects of Yoga on Elevated Depressive and Somatic Symptoms in Young Adults [dissertation]. California School of Professional Psychology, Alliant International University 2006.
Ouzouni 2009 {published data only}
  • Ouzouni S, Kouidi E, Grekas D, Deligiannis A. Effect of intradialytic exercise training on health-related quality of life indices in haemodialysis patient. Clinical Rehabilitation 2009;23:53-63.
Pakkala 2008 {published data only}
  • Pakkala I, Read S, Leinonen R, Hirvensalo M, Lintunen T, Rantanen T. The effects of physical activity counseling on mood among 75- to 81-year-old people: a randomized controlled trial. Preventive Medicine 2008;46:412-8.
Palmer 2005 {published data only}
Passmore 2006 {published data only}
  • Passmore T, Lane S. Exercise as a treatment for depression: a therapeutic recreation intervention. American Journal of Recreation Therapy 2006;5(3):31-41.
Peacock 2006 {published data only}
  • Peacock J. A feasibility study to analyse the psychosocial benefits of green exercise (GE) in comparison with cognitive behavioural therapy (CBT) with patients with mild to moderate depression. www.controlled-trials.com 2007.
Pelham 1993 {published data only}
  • Pelham TW, Compagna PD, Ritvo PG, Birnnie WA. The effects of exercise therapy on clients in a psychiatric rehabilitation program. Psychosocial Rehabilitation Journal 1993;16(4):75-83.
Penninx 2002 {published data only}
  • Ettinger WH Jr, Burns R, Messier SP, Applegate W, Rejeski WJ, Morgan T, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA 1997;277(1):25-31.
  • Penninx BWJH, Rejeski WJ, Pandya J, Miller ME, Bari MD, Applegate WB, et al. Exercise and depressive symptoms: a comparison on aerobic and resistance exercise effects on emotional and physical function in older persons with high and low depressive symptomatology. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences 2002;57(2):124-32.
Penttinen 2011 {published data only}
Perna 2010 {published data only}
  • Perna FM, Craft L, Freund KM, Skrinar G, Stone M, Kachnic L, et al. The effect of a cognitive behavioral exercise intervention on clinical depression in a multiethnic sample of women with breast cancer: A randomized controlled trial. International Journal of Sport and Exercise Psychology 2010;8(1):36-47.
Perri 1984 {published data only}
  • Perri S 2nd, Temper DL. The effects of an aerobic exercise programme on psychological variables in older adults. International Journal of Aging and Human Development 1984;20(3):1984-5.
Piette 2011 {published data only}
  • Piette JD, Valenstein M, Himle J, Duffy S, Torres T, Vogel M, et al. Clinical complexity and the effectiveness of an intervention for depressed diabetes patients. Chronic Illness 2011;7(4):267-78.
Raglin 1990 {published data only}
Rhodes 1980 {published data only}
  • Rhodes DL. Mens Sana Corpore Sano: A Study of the Effect of Jogging on Depression Anxiety and Self Concept [dissertation]. Durham, NC: Duke University, 1980.
Robledo Colonia 2012 {published data only}
  • Robledo Colonia AF, Sandoval Restrepo N, Mosquera Valderrama YF, Escobar Hurtado C, Ramirez Velez R. Aerobic exercise training during pregnancy reduces depressive symptoms in nulliparous women: a randomised trial. Journal of Physiotherapy 2012;58(1):9-15.
Rofey 2008 {published data only}
  • Rofey DL, Szigethy EM, Noll RB, Dahl RE, Lobst E, Arslanian SA. Cognitive-behavioral therapy for physical and emotional disturbances in adolescents with polycystic ovary syndrome: a pilot study. Journal of Pediatric Psychology 2009;34(2):156-63.
Roshan 2011 {published data only}
  • Roshan VD, Pourasghar M, Mohammadian Z. The efficacy of intermittent walking in water on the rate of MHPG sulfate and the severity of depression. Iranian Journal of Psychiatry 2011;5(2):26-31.
Roth 1987 {published data only}
  • Roth DL, Holmes DS. Influence of aerobic exercise training and relaxation training on physical and psychologic health following stressful life events. Psychosomatic Medicine 1987;49(4):355-65.
Ruunsunen 2012 {published data only}
Salminen 2005 {published data only}
  • Salminen M, Isoaho R, Vahlberg T, Ojanlatva A, Kivela SL. Effects of a health advocacy, counselling, and activation programme on depressive symptoms in older coronary heart disease patients. International Journal of Geriatric Psychiatry 2005;20(6):552-8.
Salmon 2001 {published data only}
Sarsan 2006 {published data only}
Schwarz 2012 {published data only}
  • Schwarz MJ, Hennings A, Riemer S, Stapf T, Selberdinger V, Gil FP, et al. Effect of physical exercise on psychoneuruoimmunological parameters in patients with depression and patients with somatoform disorder. Neurology Psychiatry and Brain Research [abstracts of the 11th Psychoimmunology Expert Meeting]. 2012.
Sexton 1989 {published data only}
Silveira 2010 {published data only}
  • Silveira H, Deslandes AC, De Moraes H, Mouta R, Ribeiro P, Piedade R, et al. Effects of exercise on electrocencephalographic mean frequency in depressed elderly subjects. Neuropsychobiology 2010;61(3):141-7.
Sims 2006 {published data only}
  • Sims J, Hill K, Davidson S, Gunn J, Huang N. Exploring the feasibility of a community-based strength training program for older people with depressive symptoms and its impact on depressive symptoms. BMC Geriatrics 2006;6:18.
Skrinar 2005 {published data only}
  • Skrinar GS, Huxley NA, Hutchinson DS, Menninger E, Glew P. The role of a fitness intervention on people with serious psychiatric disabilities. Psychiatric Rehabilitation Journal 2005;29(2):122-7.
Smith 2008 {published data only}
Sneider 2008 {published data only}
  • Sneider KL, Bodenlos JS, Ma Y, Olendzki B, Oleski J, Merriam P, et al. Design and methods for a randomised clinical trial treating comorbid obesity and major depressive disorder. BMC Pyschiatry 2008;8:77.
Songoygard 2012 {published data only}
Stein 1992 {published data only}
Stern 1983 {published data only}
Strömbeck 2007 {published data only}
Sung 2009 {published data only}
  • Sung K. The effects of 16-week group exercise program on physical function and mental health of elderly Korean women in long-term assisted living facility. Journal of Cardiovascular Nursing 2009;24(5):344-51.
Tapps 2009 {published data only}
  • Tapps T. An Investigation into the Effects of Resistance Exercise Participation on the Perceived Depression Levels of Older Adults Residing in a Long-Term Care Facility Over Time [dissertation]. Oklahoma State University, 2009.
Taylor 1986 {published data only}
  • Taylor CB, Houston Miller N, Ahn DK, Haskell W, DeBusk RF. The effects of exercise training programmes on psychosocial improvement in uncomplicated postmyocardial infarction patients. Journal of Psychosomatic Research 1986;30(5):581-7.
Tenorio 1986 {published data only}
  • Tenorio LM. Effects of Aerobic Exercise on Symptoms of Depression in Women [dissertation]. Denton, TX: Texas Woman's University, 1986.
Thomson 2010 {published data only}
  • Thomson RL, Buckley JD, Lim SS, Noakes M, Clifton PM, Norman RJ, et al. Lifestyle management improves quality of life and depression in overweight and obese women with polycystic ovary syndrome. Fertility and Sterility 2010;94(5):1812-6.
Tomas-Carus 2008 {published data only}
  • Tomas-Carus P, Gusi N, Häkkinen A, Häkkinen K, Leal A, Ortega-Alonso A. Eight months of physical training in warm water improves physical and mental health in women with fibromyalgia: a randomized controlled trial. Journal of Rehabilitation Medicine 2008;40:248-52.
TREAD 2003 {published data only}
  • National Institute of Mental Health (NIMH). Treatment With Exercise Augmentation for Depression (TREAD). ClinicalTrials.gov (http://www.clinicaltrials.gov) 2003. [: NCT00076258]
  • Trivedi MH, Greer TL, Grannemann BD, Church TS, Galper DI, Sunderajan P, et al. TREAD: TReatment with Exercise Augmentation for Depression: study rationale and design. Clinical Trials 2006;3(3):291-305.
Trivedi 2011 {published data only}
  • Trivedi MH, Greer TL, Church TS, Carmody TJ, Grannemann BD, Galper DI, et al. Exercise as an augmentation treatment for nonremitted major depressive disorder: a randomized, parallel dose comparison. Journal of Clinical Psychiatry 2011;72(5):677-84.
Tsang 2003 {published data only}
Tsang 2006 {published data only}
Underwood 2013 {published data only}
  • Ellard DR,  Taylor SJ,  Parsons S,  Thorogood M. The OPERA trial: a protocol for the process evaluation of a randomised trial of an exercise intervention for older people in residential and nursing accommodation. Trials 2011;12:28.
  • Underwood M, Lamb SE, Eldridge S, Sheehan B, Slowther A, Spencer A, et al. Exercise for depression in care home residents: a randomised controlled trial with cost effectiveness analysis (OPERA). Health Technology Assessment May 2013;17(18):1-281.
  • Underwood M, Lamb SE, Eldridge S, Sheehan B, Slowther A-M, Spencer A, et al. Exercise for depression in elderly residents of care homes: a cluster-randomised controlled trial. Lancet 2013;382(9886):41-9.
  • Underwood M,  Eldridge S,  Lamb S,  Potter R,  Sheehan B,  Slowther AM,  et al. The OPERA trial: protocol for a randomised trial of an exercise intervention for older people in residential and nursing accommodation. Trials 2011;12:27.
Van der Merwe 2004 {published data only}
  • Van der Merwe I, Naude S. Exercise and depression: a treatment manual. Health SA Gesondheid 2004;9(4):28-41.
Van de Vliet 2003 {published data only}
  • Van de Vliet P, Onghena P, Knapen J, Fox KR, Probst M, Van Coppenolle H, et al. Assessing the additional impact of fitness training in depressed psychiatric patients receiving multifaceted treatment: a replicated single-subject design. Disability and Rehabilitation 2003;25(24):1344-53.
Vickers 2009 {published data only}
  • Vickers KS, Patten CA, Lewis BA, Clark MM, Ussher M, Ebbert JO, et al. Feasibility of an exercise counseling intervention for depressed women smokers. Nicotine & Tobacco Research 2009;11(8):985-95.
Weinstein 2007 {published data only}
  • Weinstein AA, Deuster PA, Kop WJ. Heart rate variability as a predictor of negative mood symptoms induced by exercise withdrawal. Medicine and Science in Sports and Exercise 2007;39(4):735-41.
Weiss 1989 {published data only}
  • Weiss CR, Jamieson NB. Women, subjective depression, and water exercise. Health Care for Women International 1989;10(1):75-88.
White 2007 {published data only}
  • White PD, Sharpe MC, Chalder T, DeCesare JC, Walwyn R, PACE trial group. Protocol for the PACE trial: a randomised controlled trial of adaptive pacing, cognitive behaviour therapy, and graded exercise as supplements to standardised specialist medical care versus standardised specialist medical care alone for patients with the chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy. BMC Neurology 2007;7:6.
Whitham 2011 {published data only}
  • Whitham EA, Thommi SB, Holtzman NS, Ostacher MM, El-Mallakh RS, Baldassano CF, et al. Rapid cycling and antidepressants: Data from a STEP-BD randomized clinical trial. Bipolar Disorders [abstracts from the 9th International Conference on Bipolar Disorder]. 2011; Vol. 13:s1.
Wieman 1980 {published data only}
  • Wieman JB. Running as a Treatment for Depression: A Theoretical Basis [dissertation]. Fresno, CA: California School of Professional Psychology, 1980.
Wilbur 2009 {published data only}
  • Wilbur J, Zenk S, Wang E, Oh A, McDevitt J, Block D, et al. Neighborhood characteristics, adherence to walking, and depressive symptoms in midlife African American women. Journal of Women's Health 2009;18(8):1201-10.
Williams 1992 {published data only}
  • Williams VL. Acute Mood and EEG Effects of Aerobic Exercise in Depressed and Non-Depressed Adults [dissertation]. Birmingham, AL: The University of Alabama, 1992.
Wipfli 2008 {published data only}
  • Wipfli BM. Serotonin and Psychological Variables in the Relationship Between Exercise and Mental Health [dissertation]. Arizona State University, 2008.
Wipfli 2011 {published data only}

References to studies awaiting assessment

  1. Top of page
  2. AbstractResumo
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Feedback
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. Differences between protocol and review
  20. Characteristics of studies
  21. References to studies included in this review
  22. References to studies excluded from this review
  23. References to studies awaiting assessment
  24. References to ongoing studies
  25. Additional references
  26. References to other published versions of this review
Aghakhani 2011 {published data only}
  • Aghakhani N, Sharif F, Khademvatan K, Rahbar N, Eghtedar S, Shojaei Motlagh V. The reduction in anxiety and depression by education of patients with myocardial infarction. International Cardiovascular Research Journal 2011;5(2):66-8.
DEMO II 2012 {published data only}
  • Krogh J, Videbech P, Thomsen C, Gluud C, Nordentoft M. DEMO-II Trial. Aerobic exercise versus stretching exercise in patients with major depression - a randomised clinical trial. PLoS ONE 2012;7(10):e48316.
Gotta 2012 {published data only}
  • Gotta G. Sex differences and the effects of exercise on depression and executive dysfunctioning in older adults (thesis). Dissertation Abstracts International: Section B: The Sciences and Engineering 2012;72(10-B):6385.
Martiny 2012 {published data only}
  • Martiny K, Refsgaard E, Lund V, Lunde M, Sorensen L, Thougaard B, et al. A 9-week randomised trial comparing a chronotherapeutic intervention (wake and light therapy) to exercise in major depressive disorder patients treated with duloxetine. Journal of Clinical Pyschiatry 2012;73(9):1234-42.
Murphy 2012 {published data only}
  • Murphy SM, Edwards RT, Williams N, Raisanen L, Moore G, Linck P, et al. An evaluation of the effectiveness and cost effectiveness of the National Exercise Referral Scheme in Wales, UK: a randomised controlled trial of a public health policy initiative. Journal of Epidemiology and Community Health 2012;66(8):745-53.
Pinniger 2012 {published data only}
  • Pinniger R, Brown RF, Thorsteinssona EB, McKinley P. Argentine tango dance compared to mindfulness meditation and a waiting-list control: a randomised trial for treating depression. Complementary Therapies in Medicine 2012;20(6):377-84.
Sturm 2012 {published data only}

References to ongoing studies

  1. Top of page
  2. AbstractResumo
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Feedback
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. Differences between protocol and review
  20. Characteristics of studies
  21. References to studies included in this review
  22. References to studies excluded from this review
  23. References to studies awaiting assessment
  24. References to ongoing studies
  25. Additional references
  26. References to other published versions of this review
ACTRN12605000475640 {published data only}
  • ACTRN12605000475640. Does a home-based physical activity programme improve function and depressive symptomatology in older primary care patients: a randomised controlled trial. [Australian New Zealand Clinical Trials Registry] www.anzctr.org.au/ACTRN12605000475640.aspx (accessed 1 March 2013).
ACTRN12609000150246 {published data only}
  • ACTRN12609000150246. Promoting physical activity to improve the outcome of depression in later life (ACTIVEDEP). www.anzctr.org.au/ACTRN12609000150246.aspx ) (accessed 1 March 2013.
ACTRN12612000094875 {published data only}
  • ACTRN12612000094875. A randomised controlled trial to improve depression in family carers through a physical activity intervention: IMPACCT Study. www.anzctr.org.au/ACTRN12612000094875.aspx (accessed 1 March 2013).
CTR/2012/09/002985 {published data only}
  • CTR/2012/09/002985. Effect of sprint interval training on depression: a randomized controlled trial [Clinical Trials Registry - India]. www.ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=5224 (accessed 1 March 2013).
EFFORT D {published data only}
  • Kruisdijk FR, Hendriksen IJM, Tak ECPM, Beekman ATF, Hopman-Rock M. Effect of running therapy on depression (EFFORT-D). Design of a randomised controlled trial in adult patients. BMC Public Health 2012;12:50. [: NTR1894]
IRCT201205159763 {published data only}
  • IRCT201205159763N1. The effect of regular exercise on the depression of hemodialysis patients. www.irct.ir/searchresult.php?id=9763&number=1 (accessed 1 March 2013). [: IRCT201205159763N1]
IRCT2012061910003N1 {published data only}
  • IRCT2012061910003N1. A comparative study of the efficiency of group cognitive- behavioral therapy with aerobic exercise in treating of major depression. www/irct.ir/searchresult.php?id=10065&number=1 (accessed 1 March 2013).
ISRCTN05673017 {published data only}
  • ISRCTN05673017. Psycho-education physical exercise effects: does treating subsyndromal depression improve depression- and diabetes-related outcomes? [PEPEE]. isrctn.org/ISRCTN05673017 (accessed 1 March 2013).
NCT00103415 {published data only}
  • NCT00103415. Trial investigating the effect of different exercise forms on depression. ClinicalTrials.gov/show/NCT00103415 (accessed 1 March 2013).
NCT00643695 {published data only}
  • NCT00643695. Efficacy of an Exercise Intervention to Decrease Depressive Symptoms in Veterans With Hepatitis C. ClinicalTrials.gov/show/NCT00643695 (accessed 1 March 2013).
NCT00931814 {published data only}
  • NCT00931814. Effects of exercise on depression symptoms, physical function, and quality of life in community-dwelling elderly. ClinicalTrials.gov/show/NCT00931814 (accessed 1 March 2013).
NCT01024790 {published data only}
  • NCT01024790. Exercise study to help patients who have type 2 diabetes and depression. ClinicalTrials.gov/show/NCT01024790 (accessed 1 March 2013).
NCT01383811 {published data only}
  • NCT01383811. Clinical and neuroendocrine/metabolic benefits of exercise in treatment resistant depression (TRD): a feasibility study. ClinicalTrials.gov/ct2/show/NCT01383811 (accessed 1 March 2013).
NCT01401569 {published data only}
  • NCT01401569. Efficacy of exercise and counseling intervention on relapse in smokers with depressive disorders STOB-ACTIV [NXR 01401569]. http://clinicaltrials.gov/show/NCT01401569.
NCT01464463 {published data only}
  • NCT01464463. The impact of psychological interventions (with and without wxercise) on psychometric and immunological measures in patients With major depression. ClinicalTrials.gov/show/NCT01464463 (accessed 1 March 2013).
NCT01573130 {published data only}
  • NCT01573130. An internet-administered, therapist-supported physical exercise program for the treatment of depression. ClinicalTrials.gov/show/NCT01573130 (accessed 1 March 2013).
NCT01573728 {published data only}
  • NCT01573728. Role of exercise in depression in middle aged and older adults. ClinicalTrials.gov/slow/NCT01573728 (accessed 1 March 2013).
NCT01619930 {published data only}
  • NCT01619930. The effects of behavioural activation and physical exercise on depression. ClinicalTrials.gov/show/NCT01619930 (accessed 1 March 2013).
NCT01696201 {published data only}
  • NCT01696201. Effect of a supervised exercise program during whole pregnancy on outcomes and level of depression. ClinicalTrials.gov/show/NCT01696201 (accessed 1 March 2013).
NCT01763983 {published data only}
  • NCT01763983. Effects of cognitive behaviour therapy and exercise on depression and cognitive deficits in multiple sclerosis. ClinicalTrials.gov/show/NCT01763983 (accessed 1 March 2013).
NCT01787201 {published data only}
  • NCT01787201. The effects of exercise on depression symptoms using levels of neurotransmitters and EEG as markers. ClinicalTrials.gov/show/NCT01787201 (accessed 1 March 2013).
NCT01805479 {published data only}
  • NCT01805479. Exercise therapy in depressed traumatic brain injury survivors. ClinicalTrials.gov/show/NCT01805479 (accessed 1 March 2013).
UMIN000001488 {published data only}
  • UMIN000001488. A randomised controlled trial of exercise class for older persons with mild depression. www.umin.ac.jp/ctr/index.htm (accessed 1 March 2013).

Additional references

  1. Top of page
  2. AbstractResumo
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Feedback
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. Differences between protocol and review
  20. Characteristics of studies
  21. References to studies included in this review
  22. References to studies excluded from this review
  23. References to studies awaiting assessment
  24. References to ongoing studies
  25. Additional references
  26. References to other published versions of this review
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