Content uploaded by Jan Knapen
Author content
All content in this area was uploaded by Jan Knapen on Feb 06, 2021
Content may be subject to copyright.
http://informahealthcare.com/dre
ISSN 0963-8288 print/ISSN 1464-5165 online
Disabil Rehabil, Early Online: 1–6
!2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.972579
PERSPECTIVE IN REHABILITATION
Exercise therapy improves both mental and physical health in patients
with major depression
Jan Knapen
1,2,3
, Davy Vancampfort
1,4
, Yves Morie
¨n
3
, and Yannick Marchal
2,5
1
Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium,
2
Huis voor Chronische Zorg, Sint-Truiden, Belgium,
3
AZERTIE, Zonhoven,
Belgium,
4
Department of Psychomotor Therapy, University Psychiatric Centre KU Leuven, Campus Kortenberg, Kortenberg, Belgium, and
5
Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
Abstract
Purpose: to present clinical guidelines for exercise therapy in depressed patients derived from
recent meta-analyses. Method: four meta-analyses on effects of physical exercise on mental and
physical in depression were analysed. Results: For mild to moderate depression the effect of
exercise may be comparable to antidepressant medication and psychotherapy; for severe
depression exercise seems to be a valuable complementary therapy to the traditional
treatments. Depression is associated with a high incidence of co-morbid somatic illnesses,
especially cardiovascular diseases, type 2 diabetes and metabolic syndrome. Exercise is
extremely powerful in preventing and treating these diseases. Physical exercise is an
outstanding opportunity for the treatment of patients who have a mix of mental and physical
health problems. Exercise therapy also improves body image, patient s coping strategies with
stress, quality of life and independence in activities of daily living in older adults. Conclusions:
Physical therapists should be aware, that several characteristics of major depression (e.g. loss of
interest, motivation and energy, generalised fatigue, a low self-worth and self-confidence, fear
to move, and psychosomatic complaints) and physical health problems interfere with
participation in exercise. Therefore, motivational strategies should be incorporated in exercise
interventions to enhance the patients’ motivation and adherence in exercise programs.
äImplications for Rehabilitation
For mild to moderate depression, the effect of exercise may be comparable with
antidepressant medication and psychotherapy; for severe depression, exercise seems to be a
valuable complementary therapy to the traditional treatments.
Exercise therapy also improves physical health, body image, patient’s coping strategies with
stress, quality of life, and independence in activities of daily living in older adults.
Motivational strategies should be incorporated in exercise interventions to enhance the
patients’ motivation.
Keywords
Depressive disorder, metabolic syndrome,
physical therapy
History
Received 11 March 2014
Revised 24 September 2014
Accepted 30 September 2014
Published online 24 October 2014
Description of major depression
Depression refers to a wide range of mental health problems
characterized by the absence of a positive effect (a loss of interest
and enjoyment in ordinary things and experiences), persistent low
mood, and a range of associated emotional, cognitive, physical,
and behavioral symptoms [1]. Severity of depression is classified
using the Diagnostic and Statistical Manual of Mental Disorders,
fifth edition 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) [2].
Major depression consists of at least one 2-week major
depressive episode [2]. The primary symptom of a major
depressive episode is either depressed mood or loss of interest
or pleasure. Additionally, the symptoms must not be clearly
attributable to another medical condition or to the physiological
effects of a substance. The symptoms cannot be better explained
by a range of psychotic, schizophrenic, or delusional disorders.
A major depressive episode is not diagnosed if there has ever been
a manic or hypomanic episode. Symptoms that are clearly
attributable to another medical condition are not counted in the
required five symptoms minimum. Additionally, as with most
psychiatric conditions, the symptoms must cause clinically
significant distress or impairment in social, occupational, or
other important areas of functioning. The following is an
Address for correspondence: Jan Knapen, AZERTIE Boddenveldweg
11, 3520 Zonhoven, Belgium. Tel: +32 11 681795. E-mail:
jan.knapen@faber.kuleuven.be
Disabil Rehabil Downloaded from informahealthcare.com by 87.64.137.204 on 10/26/14
For personal use only.
abbreviated summary of DSM-V symptoms of depression (at least
five are needed for at least 2 weeks for a diagnosis of major
depressive episode). With the exception of suicidal ideation and
weight change, symptoms must be present most of the day, nearly
every day.
Depressed mood most of the day and nearly every day
Markedly diminished interest or pleasure, in all, or almost
all, activities most of the day, nearly every day.
Significant weight loss or gain when not dieting (i.e. 5% in a
month), or decreased appetite nearly every day. Failure to
make appropriate weight gains is considered in children.
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every day
(observable by others).
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt
(which may be delusional) nearly every day.
Diminished ability to think or concentrate or indecisiveness
nearly every day.
Recurrent thoughts of death, recurrent suicidal ideation
without plan, or a suicide attempt or plan.
Major depression, a big public health problem
Recent epidemiological surveys conducted in general populations
have found that the lifetime prevalence of depression is in the
range of 10–15% [3]. Mood disorders, as defined by the World
Mental Health and the Diagnostic and Statistical Manual of
Mental Disorders, 4th edition, have a 12-month prevalence which
varies from 3% in Japan to over 9% in the US [4]. A recent
American survey found the prevalence of current depression to be
9% and the rate of current major depression to be 3.4% [5].
Several studies of depressive disorders have stressed the import-
ance of the mortality and morbidity associated with depression
[3,6]. The mortality risk for suicide in depressed patients is more
than 20-fold greater than in the general population. Studies have
also shown the importance of depression as a risk factor for
cardiovascular death [7–10]. Greater severity of depressive
symptoms has been found to be associated with significantly
higher risk of all-cause mortality including cardiovascular death
and stroke. Depression increases the risk of decreased workplace
productivity and absenteeism resulting in lowered income or
unemployment.
An analysis of data from the National Co-morbidity Survey
Replication, a US nationally representative household survey,
found that overall impairment was significantly higher for mental
disorders than for chronic medical disorders [11]. Severe func-
tional impairment was reported by 42% persons with mental
disorders and 24% with chronic medical disorders. Treatment,
however, was provided for a significantly lower proportion of
mental (21.4%) than chronic medical (58.2%) disorders.
DALY, disability adjusted life-years, is the sum of life-years
lost due to premature death and years lived with disability
adjusted for severity [12]. It integrates the notions of individual
mortality and disability with global disease prevalence. Using the
DALY, unipolar major depression was classed in 2004, as the
third leading burden of disease or injury cause worldwide for both
sexes, behind lower respiratory infections and diarrheal diseases
[12]. Worldwide projections by the World Health Organization for
the year 2030 identify major depression as the leading cause of
disease burden.
The substantial burden of major depression is due, in part, to
the limited accessibility and effectiveness of treatments, with
data indicating that only 55% of those with a depressive disorder
seek treatment and only 32% receive an efficacious treatment
(psychotherapy or antidepressant medication) [3]. Physical
exercise has been suggested as an efficient complementary
treatment to reduce symptoms of depression since it reduces cost
with drugs and hospitalizations, and may also improve physical
health and physiological stress responses [13,14]. There are
several hypotheses regarding the physiological and psychological
mechanisms by which exercise impacts on mental health, such
as enhancement of the synthesis and liberation of neurotrophic
factors, as well as of cognitive functioning, angiogenesis,
neurogenesis, and plasticity. Moreover, some studies have
shown that physical exercise may improve physical and global
self-esteem, quality of life, coping strategies with stress, and
social contact [15]. Furthermore, it may also contribute to
increased quality of life and independence in activities of daily
living in older adults [14].
Physical exercise as intervention for depression:
findings of two recent meta-analyses
A recent meta-analysis of the Cochrane Collaboration investi-
gated the effectiveness of exercise in the treatment of depression
in adults compared with no treatment or a comparator interven-
tion [13].
This meta-analysis aimed to answer the following questions:
Is exercise more effective than no therapy for reducing
symptoms of depression?
Is exercise more effective than antidepressant medication for
reducing symptoms of depression?
Is exercise more effective than psychological therapies or
other non-medical treatments for depression?
How acceptable to patients is exercise as a treatment for
depression?
Which studies were included in the review?
The Cochrane research group used search databases to find all
high-quality randomized controlled trials of how effective exer-
cise is for treating depression in adults over 18 years of age. The
authors searched for studies published up until March 2013.
All studies had to include adults with a diagnosis of depression,
and the physical activity carried out had to fit criteria to ensure
that it met with a definition of ‘‘exercise’’. Thirty-nine studies
with a total of 2326 participants were included in the systematic
review.
What does the evidence from this review tell us?
The authors concluded that exercise is moderately more effective
than no therapy for reducing symptoms of depression. In addition,
exercise is no more or less effective than antidepressants for
reducing symptoms of depression, although this conclusion is
based on a small number of studies. Exercise is also no more or
less effective than psychological therapies for reducing symptoms
of depression, although this conclusion is based on a small
number of studies. An important observation was that attendance
rates for exercise treatments ranged from 50% to 100%.
Suggestions for further research
The authors recommend that future research should look into
detail at what types of exercise could benefit people with
depression most. Research should also investigate the optimal
dose–response relationship. Further larger trials are needed to
compare the effects of exercise therapy with antidepressants or
psychological treatments.
Another very recent meta-analysis of 2013 evaluated the effect
of aerobic and strength training as a treatment for major
depression, using various aspects such as remission and response
to treatment, age, severity of depression, and type of exercise
(aerobic training and strength training) [14].
2J. Knapen et al. Disabil Rehabil, Early Online: 1–6
Disabil Rehabil Downloaded from informahealthcare.com by 87.64.137.204 on 10/26/14
For personal use only.
The following data were collected: total number of patients,
age, randomized design, diagnostic criteria, assessment instru-
ments, and the percentage of remission and treatment response.
The outcome variables were proportion of remission (no symp-
toms) and at least 50% reduction of initial depression scores
(response).
The authors concluded that physical exercise moderately
reduces depressive symptoms in major depression patients
(SMD ¼0.61). Physical exercise is an efficient alternative treat-
ment for depression with a 49% increase in the probability of
response to treatment defined as a 50% reduction in initial
depression scores. Individuals over 60 years of age showed a
higher efficacy than those found in studies with populations below
60 years.
Patients with mild depressive symptoms showed a better
treatment response than patients with mild/moderate depressive
symptoms. Aerobic training was more effective than strength
training. In this meta-analysis, the efficacy of exercise in the
treatment of depression was influenced by age and symptom
severity. It is reasonable that physical exercise may in some cases
be considered an alternative to antidepressants for the treatment of
mild major depression in older persons. This finding might
contribute to decreasing the use of medication and hospitalization
and in promoting independence in activities of daily living in
elderly patients. An important limitation of this meta-analysis is,
however, that the samples of all studies included consisted of
patients with mild or moderate depression.
Major depression and metabolic syndrome
Depressed persons have approximately a two-fold increased risk
of having or developing cardiovascular disease [7–10]. Further,
after a cardiovascular event, the risk of onset of depression is
increased, resulting in poorer cardiovascular outcome. The
metabolic syndrome, a constellation of cardiovascular risk factors
including (abdominal) obesity, hypertension, dyslipidemia and
hyperglycemia, has been suggested to be one possible pathway
linking depression and cardiovascular disease.
A recent meta-analysis clearly demonstrated that metabolic
syndrome occurs frequently in depressed persons [16]. The
authors included 18 publications (n¼5531) with clearly defined
major depression, all published between 2004 and June 2013.
They reported that 30.5% of individuals with major depression
suffered from metabolic syndrome. The relative risk for metabolic
syndrome was 1.5 times higher for persons with depression
compared with general population controls.
Consistent with population studies, the research group found
no significant difference between men and women, indicating that
both sexes need the same attention and care. In addition, age also
did not explain differences in prevalence estimates, indicating that
the high risk for metabolic abnormalities should be a concern
across the lifespan. However, antipsychotic drugs use significantly
(p50.05) explained higher metabolic syndrome prevalence
estimates in patients with major depression.
Another meta-analysis on the bidirectional association
between depression and metabolic syndrome concluded that
metabolic syndrome is an independent risk factor major depres-
sion [17]. Individuals with metabolic syndrome have a higher
relative risk to develop clinically diagnosed depression
(OR ¼2.18) than individuals without metabolic syndrome.
The positive bi-directional longitudinal association between
depression and metabolic syndrome means that depression is
causing metabolic syndrome and vice versa. This association
suggests a possible pathophysiologic overlap [17]. More specif-
ically, elevated cortisol secretion due to hyperactivity of the
hypothalamic–pituitary–adrenal (HPA) axis, (pro)-inflammatory
processes, oxidative stress, autonomic nervous system dysregula-
tion, and insulin resistance are all interacting biological mechan-
isms that may mediate the association between depression and
metabolic syndrome. Although biological processes might be
important, background lifestyle, and socioeconomic factors are
probably equally relevant [16]. For example, major depression
increased the odds for developing hyperglycemia and hypertri-
glyceridemia, which could be due to depression or related changes
in diet and exercise, but which clearly increases the risk for
metabolic syndrome.
Conclusion: both major depression and metabolic syndrome
are associated with increased mortality and morbidity, possibly
through the association with various medical diseases such as
cardiovascular disease and diabetes mellitus type 2. Unhealthy
lifestyles such as poor diet and lack of physical activity are
suggested to be mediating the association between major depres-
sion and metabolic syndrome.
The role of lifestyle factors
Poor diet, physical inactivity, and smoking have long been
recognized as key contributors to the high prevalence non-
communicable diseases, such as cardiovascular disease, type 2
diabetes, metabolic syndrome, and cancer. However, there are
now an increasing number of studies suggesting that the same
modifiable lifestyle behaviors are also risk factors for common
mental disorders, such as major depression. Research on major
depression has confirmed that it is caused by an array of
biopsychosocial and lifestyle factors [18]. Diet and lack of
physical exercise are two such influences that play a signifi-
cant mediating role in the development, progression, and treat-
ment of this condition. Poor diet and physical inactivity can
influence several physiological pathways associated with
depression.
Growing evidence indicates a role for physical inactivity as a
risk factor for major depression, while exercise has been shown to
be effective in treatment studies [13,14]. There is some evidence
that smoking is highly prevalent among mental disorders. Diet
quality is the most recent area of attention in the lifestyle mental
health research field. A recent review found consistent evidence
that severity of obesity is associated with the relationship between
obesity and depression, such that having a BMI that falls within
the class III obese category may confer risk of co-morbid
depression [19]. Given that a greater severity of obesity is
associated with greater health risks and physical impairment
aligns with research that has found higher levels of physical
impairment and lower levels of quality of life to be associated
with depression [20]. Thus, it seems likely that severity of obesity
may be an important risk factor in determining an individual’s
risk of developing co-morbid depression.
While these lifestyle factors are significant in the etiology and
maintenance of depression, a multitude of other factors influences
may also be important [18]. These include chronic stress, social
influences, mental, and physical effects associated with medical
diseases, alcohol and other drug use, chronic pain, and even
exposure to sunlight/vitamin D. They are these influences in
combination with a large array of psychological, genetic, and
biological factors that often complicate the treatment of depres-
sion. Basic interventions comprising attention towards one cause
and/or one biochemical mechanism (e.g. targeting a single
neurotransmitter disturbance) makes the goal of remission or
recovery less likely. This was highlighted in a recent study where
giving simple written recommendations about lifestyle changes
for sleep hygiene, physical activity, diet, and sunlight exposure in
addition to antidepressant treatment enhanced compared with
standard antidepressant treatment alone [21]. Remission/response
DOI: 10.3109/09638288.2014.972579 Exercise therapy for depression 3
Disabil Rehabil Downloaded from informahealthcare.com by 87.64.137.204 on 10/26/14
For personal use only.
rates reached 60% in the combined treatment group compared
with 10% in the anti-depressant only group.
It might be hypothesized that lifestyle changes will not only
have beneficial mental health benefits in persons with major
depression. Since both depressive symptoms and metabolic
syndrome appear to have a two-directional relationship, poor
diet and lower physical activity levels might partially mediate the
association between depression and metabolic syndrome. When
both conditions are present, additional metabolic disturbances
might promote a chronic character of the depressive symptoms.
These are suggestive of a vicious cycle and are indicative of the
existence of a specific condition, which might be labeled as
metabolic depression [18]. Lifestyle interventions for depressed
patients might improve both mental and somatic health status and
could possibly prevent mechanisms that may mediate the
association between depression and metabolic syndrome [17,22].
Conclusion: physical exercise and diet have an impact on both
physical and mental health, and desirable changes in these
lifestyle factors can be useful in the prevention and treatment of
depression and metabolic syndrome.
Evidence-based recommendations for exercise therapy
in patients with depression
In this last section, we offer some general recommendations for
physical fitness assessment and exercise prescription, for inven-
torying perceived barriers and benefits towards exercise partici-
pation and propose some strategies for improving patient’s
motivation and adherence to an exercise programme.
Physical fitness assessment and exercise prescription
Developing an exercise prescription for people with depression
differs from the prescription used for healthy individuals. Physical
therapists should be aware that several characteristics of major
depression (e.g. loss of interest, motivation and energy, general-
ized fatigue, a low self-worth and self-confidence, fear to move,
and psychosomatic complaints) and physical health problems
interfere with participation in exercise.
Designing well-considered exercise programs for these
patients requires (1) a risk stratification for patients with co-
morbid somatic disease, (2) an assessment of physical fitness and
the perceived exertion during exercise, and (3) an inventory of the
perceived barriers and benefits towards exercise participation.
Risk stratification for patients with co-morbid somatic disease
Before initial treatment, physical therapists should identify high-
risk individuals, such as patients with a history of cardiovascular
disease or diabetes [23]. These patients should be medically
cleared before beginning physical activity. For the vast majority
of people, the risk of sudden cardiac events is, however, minimal,
as long as they start at a realistic pace. Low-intensity physical
activity is related to a low risk. For example, a walking program at
light to moderate intensity is safe for most patients. Intensity can
be increased over time, and the patient and physical therapist
should pay attention to symptoms such as chest pain or shortness
of breath. Besides, the moderate training stimulus should be
adapted to the training status and side effects of psychotropic
medication (such as constipation, dizziness, dry mouth, nausea,
sweating, and tremor) [23].
Assessment of physical fitness and the perceived exertion
during exercise
Direct measurement of maximal oxygen intake by way of a
maximal exercise test is the most accurate indicator of cardio-
respiratory fitness [23]. Maximal tests, however, have the
disadvantage of requiring the subject’s optimal motivation to
work to ‘‘near exhaustion’’, and require the supervision of a
physician and the use of expensive equipment. For depressed and
anxious patients, however, submaximal measures are highly
recommended for the reasons that many patients have poor
physical health, low levels of fitness and physical self-worth, few
experience with aerobic training, and less energy and motivation
for heavy physical effort [24,25]. Salmon pointed out that,
especially in this population, physiological measurements studied
in a laboratory could be influenced due to pre-test anxiety [26].
Patients with an increased trait/state anxiety, for example, might
fear that maximal aerobic effort will provoke physiological
reactions such as hyperventilation, tachycardia, dizziness, or
sweating, which they associate with symptoms of panic attacks
[27]. These clinical considerations usually lead to the application
of submaximal exercise tests in psychiatric settings. At the
University Psychiatric Centre KU Leuven, Campus Sint-Jozef
Kortenberg, the 6-min walk test [28] and the Franz ergocycle test
[24] are most commonly used.
For patients with major depression who often suffer from
fatigue and low motivation, the rate of perceived exertion during
physical activity is an important parameter when designing an
appropriate exercise schedule [24,25]. The fatigue and recovery
time following an effort are not only dependent on physiological
stressors (intensity, duration, and frequency of the training
stimulus) but also on psychosocial factors. Psychological and
social problems cause considerable stress. Generalized fatigue
and lack of energy are typical symptoms of major depression. The
exercise tolerance of patients is reduced due to the fact that they
are preoccupied with physiological reactions during effort such as
palpitations, perspiration, and hyperventilation. These psycho-
logical factors cannot be ignored when developing a well-
designed fitness program. The evaluation of degree of perceived
exertion can be derived from the psychophysiological concept of
Borg [29]. The Borg 15 Graded Category Scale and the Borg
Category Ratio 10 Scale quantify the sensations that the subject
experiences during physical effort. The Borg 15 Graded Category
Scale has a score range from 6 to 20 (15 grades), and the Borg
Category Ratio 10 Scale from 0 to 10 (10 grades). Both scales
show a linear relationship with heart rate during progressive
incrementally exercise (r¼0.94 and r¼0.88, respectively). At the
University Psychiatric Centre KU Leuven, Campus Sint-Jozef
Kortenberg, we use the Borg Category Ratio 10 Scale because the
longer Borg 15 Graded Category Scale requires a greater
differentiation capacity.
Inventorying perceived barriers and benefits
towards exercise participation
Depressed patients accumulate a lot of barriers for participation in
exercise such as psychosomatic complaints, a low self-worth and
self-confidence, loss of energy, interest and motivation, general-
ized fatigue, weak physical fitness and health condition, fear to
move, overweight and a low feeling of personal control concern-
ing own fitness and health, and helplessness and hopelessness
[15,25]. Consequently, it is highly recommended to have a
conversation concerning barriers and possible strategies that assist
a patient in overcoming these barriers (e.g. problem solving,
planning activity, seeking social support) before starting an
exercise program. Furthermore, giving information regarding both
mental and physical health benefits of regular physical activity
and determining which benefits are most salient to each patient is
essential. For inventorying of perceived barriers and benefits
physical therapists may use a decision balance that patients helps
to reflect the relative weighing of the pros and cons of exercise
participation [30].
4J. Knapen et al. Disabil Rehabil, Early Online: 1–6
Disabil Rehabil Downloaded from informahealthcare.com by 87.64.137.204 on 10/26/14
For personal use only.
Strategies for improving motivation and adherence
to exercise
Strategies could be based on the principles of Motivational
Interviewing following Miller and Rollnick [31], and the
Transtheoretical Model of Behaviour Change [30,32]. This
model postulates that exercise behaviour change involves progress
through six stages of change: pre-contemplation, contemplation,
preparation, action, maintenance, and termination.
Initial phase: starting with supervised exercise
Create exercise programs based on the patient’s current
preferences and expectations, the initial physical fitness
assessment and the measurement of perceived exertion
during exercise.
Draw up an individual plan with the patient taking into
account emotional, cognitive, and physiological components
of major depression.
Help the patient set realistic and achievable goals which lead
to success experiences; this generally gives courage to
persevere.
Adapt the moderate exercise stimulus to the individual’s
health status and physical abilities, age, training status and
exercise history, expectations and goals, side effects of
psychotropic medication, exercise tolerance, and perceived
exertion.
Follow the program with exercise cards and a logbook and
provide regular progress feedback to the patients.
Avoid between-patient comparisons.
Emphasize the short-term benefits after single exercise
sessions: improvements in mood and state anxiety, stress
level, energy level, distraction of negative thoughts, the
ability to concentrate and focus, and quality of sleep. Many
patients are focused on the distant outcomes, such as weight
loss and improved self-worth, so emphasizing short-term
benefits can help patients adhere exercise participation.
Empathy, validation, praise, and encouragement are neces-
sary during all phases but especially when patients struggle
with ambivalence and doubt their ability to accomplish the
change.
Second phase: maintaining supervised exercise
Focus on perceived fitness gains, achievement of personal
goals, mastery experiences, and sense of control over the
body and its functioning.
Use cognitive-behavioral strategies such as self-monitoring,
stimulus cuing, goal-setting, and contracting.
Once patients begin to feel better as a result of exercise, they
are eager to continue their exercise if the therapist can help
them attribute their improved mood to the exercise regimen.
Improved mood as a result of increased physical activity may
be obvious to the therapist, but the connection is not always
obvious to the patient. Exercise can give patients a sense of
power over their recovery, which in itself counteracts the
feelings of hopelessness often experienced in depression.
Self-determined motivation towards exercise is very import-
ant and results in adaptive exercise-related behaviors, cog-
nitions, and physical self-evaluations. Therefore, it is
important to make physical activity as self-determined as
possible by focusing on the positive experiences of the
activity itself, as well as helping to develop an identity of a
physical active person.
Third phase: follow-up after supervised exercise
Follow-up contact is very important: discuss problem solving
around barriers, reinforce all progress toward change (even if
initially very small progress), and encourage modification of
goals as needed.
Seek support of others such as family and friends.
Use relapse behaviors/strategies: it is important to explain to
patients that relapses are part of the process of change, and
that responding with guilt, frustration, and self-criticism may
decrease their ability to maintain physical activity. Relapse
prevention strategies such as realistic goals setting, planned
activity, realistic expectations, identifying and modifying
negative thinking, and focusing on benefits of single exercise
sessions seem to be effective.
Conclusion
Two recent meta-analyses confirm that exercise is an effective
treatment for depression. For mild to moderate depression, the
effect of exercise may be comparable with antidepressant
medication and psychotherapy; for severe depression, exercise
seems to be a valuable complementary therapy to the traditional
treatments. Exercise therapy also improves physical health (e.g.
metabolic syndrome), body image, patient’s coping strategies
with stress, quality of life, and independence in activities of daily
living in older adults. Motivational strategies should be
incorporated in exercise interventions to enhance both the
patients’ motivation and their long-term adherence to exercise,
taking into account emotional, cognitive, and physiological
components of depression.
Declaration of interest
The authors report that there are no declaration of interest.
References
1. National Institute for Health and Clinical Excellence. Depression:
the treatment and management of depression in adults (update).
London: National Institute for Health and Clinical Excellence; 2009.
2. American Psychiatric Association. Diagnostic and statistical manual
of mental disorders. 5th ed. Arlington, VA: American Psychiatric
Publishing; 2013.
3. Le
´pine J, Briley M. The increasing burden of depression.
Neuropsychiatr Dis Treat 2011;7:3–7.
4. Demyttenaere K, Bruffaerts R, Posada-Villa J, et al. Prevalence,
severity, and unmet need for treatment of mental disorders in the
World Health Organization World Mental Health Surveys. JAMA
2004;291:2581–90.
5. Centers for Disease Control and Prevention. Current depression
among adults – United States, 2006 and 2008. Morb Mortal Wkly
Rep 2010;59:1229–35.
6. Osby U, Brandt L, Correia N, et al. Excess mortality in bipolar and
unipolar disorder in Sweden. Arch Gen Psychiatry 2001;58:844–50.
7. Whang W, Kubzansky LD, Kawachi I, et al. Depression and risk of
sudden cardiac death and coronary heart disease in women: results
from the Nurses’ Health Study. J Am Coll Cardiol 2009;53:950–8.
8. Lett H, Blumenthal J, Babyak M, et al. Depression as a risk factor
for coronary artery disease: evidence, mechanisms, and treatment.
Psychosom Med 2004;66:305–15.
9. Penninx BW, Beekman AT, Honig A, et al. Depression and cardiac
mortality: results from a community-based longitudinal study. Arch
Gen Psychiatry 2001;58:221–7.
10. Rugulies R. Depression as a predictor for coronary heart disease.
A review and meta-analysis. Am J Prev Med 2002;23:51–61.
11. Druss BG, Hwang I, Petukhova M, et al. Impairment in role
functioning in mental and chronic medical disorders in the United
States: results from the National Comorbidity Survey Replication.
Mol Psychiatry 2009;14:728–37.
12. World Health Organization. The global burden of disease: 2004
update. Geneva: World Health Organization Press; 2004.
13. Cooney GM, Dwan K, Greig CA, et al. Exercise for depression.
Cochrane Database of Systematic Reviews 2013, Issue 9. Oxford:
Cochrane Collaboration 2013.
DOI: 10.3109/09638288.2014.972579 Exercise therapy for depression 5
Disabil Rehabil Downloaded from informahealthcare.com by 87.64.137.204 on 10/26/14
For personal use only.
14. Silveira H, Moraes H, Oliveira N, et al. Physical exercise and
clinically depressed patients: a systematic review and meta-analysis.
Neuropsychobiology 2013;67:61–8.
15. Knapen J, Van de Vliet P, Van Coppenolle H, et al. Comparison of
changes in physical self-concept, global self-esteem, depression and
anxiety following two different psychomotor therapy programs in
non-psychotic psychiatric inpatients. Psychother Psychosom 2005;
74:353–61.
16. Vancampfort D, Correll C, Wampers M, et al. Metabolic syndrome
and metabolic abnormalities in patients with major depressive
disorder: a meta-analysis of prevalences and moderating variables.
Psychol Med 2013;21:1–12.
17. Pan A, Keum N, Okereke O, et al. Bidirectional association
between depression and metabolic syndrome: a systematic review
and meta-analysis of epidemiological studies. Diabetes Care 2012;35:
1171–80.
18. Lopresti AL, Hood SD, Drummond PD. A review of lifestyle factors
that contribute to important pathways associated with major depres-
sion: diet, sleep and exercise. J Affect Disord 2013;148:12–27.
19. Preiss K, Brennan L, Clarke D. Obesity comorbidity: a systematic
review of variables associated with the relationship between obesity
and depression. Obes Rev 2013;14:906–18.
20. Guh DP, Zhang W, Bansback N, et al. The incidence of co-
morbidities related to obesity and overweight: a systematic review
and meta-analysis. BMC Public Health 2009;25:88.
21. Garcia-Toro M, Ibarra O, Gili M, et al. Four hygienic-dietary
recommendations as add-on treatment in depression: a randomized-
controlled trial. J Affect Disord 2012;140:200–3.
22. Zoeller R. Physical activity: depression, anxiety, physical activity,
and cardiovascular disease: what’s the connection? Am J Lifestyle
Med 2007;1:175–80.
23. American College of Sports Medicine. ACSM’s guidelines for
exercise testing and prescription. 8th ed. Baltimore: Lippincott
Williams & Wilkins; 2010.
24. Knapen J, Van de Vliet P, Van Coppenolle H, et al. Evaluation of
cardio-respiratory fitness and perceived exertion for patients with
depressive and anxiety disorders: a study on reliability. Disabil
Rehabil 2003;25:1312–15.
25. Knapen J, Van de Vliet P, Van Coppenolle H, et al. Improvements in
physical fitness of non-psychotic psychiatric patients following
psychomotor therapy programs. J Sports Med Phys Fitness 2003;43:
513–22.
26. Salmon P. Effects of physical exercise on anxiety, depression, and
sensitivity to stress: a unifying theory. Clin Psychol Rev 2001;21:
33–61.
27. Stro
¨hle A, Graetz B, Scheel M, et al. The acute antipanic
and anxiolytic activity of aerobic exercise in patients with panic
disorder and healthy control subjects. J Psychiatr Res 2009;43:
1013–17.
28. Vancampfort D, Probst M, Maurissen K, et al. Reliability, minimal
detectable changes, practice effects and correlates of the six-minute
walk test in patients with schizophrenia. Psychiatry Res 2011;187:
62–7.
29. Borg G. Borg’s perceived exertion and pain scales. Champaign, IL:
Human Kinetics; 1998.
30. Marshall S, Biddle S. The transtheoretical model of behavior
change: a meta-analysis of applications to physical activity and
exercise. Ann Behav Med 2001;23:229–46.
31. Miller W, Rollnick S. Motivational interviewing: preparing people
for change. New York: Guilford Press; 2002.
32. Prochaska J, Velicer W. The transtheoretical model of health
behavior changes. Am J Health Promot 1997;12:38–45.
6J. Knapen et al. Disabil Rehabil, Early Online: 1–6
Disabil Rehabil Downloaded from informahealthcare.com by 87.64.137.204 on 10/26/14
For personal use only.
