Can physical activity protect against depression and
anxiety during the COVID-19 pandemic? A rapid
Sebastian Wolf ( firstname.lastname@example.org )
University of Tuebingen
University of Tuebingen
University of Tuebingen
University of Tuebingen
University of Heidelberg
University of Tuebingen
Felipe Barreto Schuch
Federal University of Santa Maria
Keywords: physical activity, covid-19, depression, anxiety, review
License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read
The Covid-19 pandemic is affecting the entire world population. During the rst spread, most governments
have implemented quarantine and strict social distancing procedures. Similar measures during recent
pandemics resulted in an increase in post-traumatic stress, anxiety and depression symptoms. The
development of novel interventions to mitigate the mental health burden are of outmost importance. In this
rapid review, we aimed to provide a systematic overview of the literature with regard to associations between
physical activity (PA) and depression and anxiety during the COVID-19 pandemic. We searched major
databases (PubMed, EMBASE, Sportdiscus, Web of Science) and preprint servers (MedRxivs, SportRxiv,
ResearchGate and Google scholar), for relevant papers up to 25/07/2020. We identied a total of 21
observational studies (4 longitudinal, one cross-sectional with retrospective analysis and 16 cross-sectional),
including information of 42,293 (age range = 6-70 years, median female = 68%) participants from 5
continents. The early evidence suggests that people who performed PA on a regular basis with higher
volume and frequency and kept the PA routines stable, showed less symptoms of depression and anxiety.
For instance, those reporting a higher total time spent in moderate to vigorous PA had 12% to 32% lower
chances of presenting depressive symptoms and 15% to 34% of presenting anxiety. In order to maintain PA
routines during Covid-19, specic volitional and motivational skills might be paramount to overcome Covid-
19 specic barriers. Particularly, web-based technologies could be an accessible way to increase motivation
and volition for PA and maintain daily PA routines.
The Covid-19 pandemic increased symptoms of anxiety and depression symptoms. Those reporting a
higher total time spent in moderate to vigorous physical activity, had 12% to 32% lower chances of
presenting depressive symptoms and 15% to 34% of presenting anxiety.
The promotion of physical activity habits and routines might be a cost-effective and comprehensive
worldwide applicable strategy to overcome the severe gap between people in need and people receiving
mental health care, especially in low-income countries with even non-existing mental health supplies.
Web-based technologies might be promising tools to increase motivation and volition for PA and
maintain daily physical activity routines even under pandemic-specic barriers. However, there is a clear
need for more systematic research for effectively and safely usable apps or web-based programs to
prevent psychiatric disorders through physical activity.
With 23,057,288 conrmed cases all over the world (up to August 23th, 2020) , COVID-19 is a global public
health emergency. The World Health Organization (WHO) has issued recommendations to implement social
distancing measures for the general public as well as quarantining procedures, for people infected with the
Quarantine and social distancing measures had already been enforced during earlier pandemics, such as the
2003 outbreak of SARS and the 2014 outbreak of Ebola . Studies on the effects of these measures have
reported increased symptoms of anxiety, post-traumatic-stress, and depressive disorders, as well as a 30%
increase in suicide rates in populations impacted by these measures [3, 4]. These ndings are being
replicated during the Covid-19 pandemic with multiple studies reporting an increased prevalence of
depression and anxiety [e.g. 5, 6-9].
Notably psychiatric disorders result in a considerable burden of disease, accounting for 6.7% of overall
disability-adjusted life years  and being attributable to 14.3% of death worldwide . Despite the high
burden of psychiatric disorders, there is a severe gap between people in need and people receiving mental
health care . This general treatment gap is especially severe in low- and middle-income countries, where
76% to 85% of people with mental disorders do not receive any treatment . The latest WHO “mental
health Atlas” indicates that only 95,6 out of 100 000 depressed cases worldwide receive any professional
mental health care, whereas the treatment prevalence in high-income countries is 16-times higher compared
to low-income countries . Although there is no current global data available, the treatment gap is
assumed to be much higher during or after the Covid-19 pandemic. Access to general mental health care
might be restricted for several reasons, including supply priorities that being focused on Covid-19 infections,
medication shortages, prohibition of face-to-face psychotherapeutic sessions of psychological treatment,
closing of inpatient facilities to mention only some reasons.
To mitigate the negative mental health consequences of pandemics, evidence suggests that policymakers
should ensure quarantine measures to be as short as possible, to provide adequate general supplies for
basic needs, give people as much information as possible and strengthen social support and
communication among people affected by the pandemic . A recently published position paper on research
priorities for mental health science regarding COVID-19  demands the interdisciplinary development of
novel interventions to protect mental wellbeing by mechanistically based approaches to strengthen altruism
and prosocial behavior. Among others, physical activity (PA) interventions are highlighted as a promising
approach. PA is dened as any bodily movement produced by skeletal muscles that results in energy
expenditure and exercise is dened as PA, that is planned, structured, and repetitive, with the primary aim to
improve or maintain physical tness . International PA guidelines recommend 150 minutes of moderate
or 75 minutes of vigorous intensity PA per week for optimal physical and mental health benets . Indeed,
in pre-pandemic times PA has been identied as a protective factor against incident depression  and
anxiety . However decreased levels of PA were observed in the general population in multiple countries
during the pandemic [e.g. 20, 21, 9]. This rapid systematic review aims to outline current evidence regarding
the associations of PA and exercise with depression and anxiety during the Covid-19 pandemic.
In this rapid review, we sought for observational studies examining the associations of PA and depression
and anxiety during the COVID-19 pandemic. inclusion criteria were: 1) Observational studies in any
population, including cross-sectional and longitudinal designs. Longitudinal studies could be either
prospective or retrospective; 2) Studies have tested the association, of PA with depression or anxiety, using
linear or logistic regressions; 3) depression and anxiety were assessed using validated screening or
diagnostic tools. We excluded opinion pieces, systematic reviews, and studies addressing other viruses.
We searched the electronic databases PubMed, EMBASE, Sportdiscus, and Web of Science using the
following strategy: (physical activity OR exercise OR sport) AND (coronavirus OR sars-cov-2 OR COVID* OR
severe acute respiratory syndrome OR pandemic) AND (depression OR anxiety OR mental health). Preprints
were searched in MedRxiv, SportRxiv, and Scielo preprints using the following strategy: "(physical activity OR
exercise) AND (coronavirus OR sars-cov-2 OR COVID* OR severe acute respiratory syndrome OR pandemic)".
Additional hand searches were performed on COVID-19 platform on ResearchGate and Google scholar.
Searches were made by an experienced reviewer (FS) on 29th July, 2020. Study selection was conducted in
three steps: 1) duplicates removal; 2) screening at the title and abstract level; and 3) assessment based on
full-text. The selection was made by one reviewer (FS). Data extraction of selected studies was then
performed by three researchers (FS, BS, SW). Data extracted were: Author and year, country of the included
sample, study design, sample size, age group of the sample included, when possible, mean or range of age
sample, % of women, instrument/question used to assess PA levels, instruments used to assess depression
and anxiety, publication type and statistical outcomes (regression standardized beta coecients and odd’s
ratios). If they were indicated in the report, fully adjusted coecients and odd’s ratios were extracted. As
studies included in this review used very heterogeneous statistical approaches, a meta-analysis could not be
conducted. Instead, we summarized the evidence and presented effect sizes (betas and odds ratios (OR))
with condence intervals and indicated signicant associations between PA and depression or anxiety,
separately (see table 2). In case the study just reported the unstandardized betas, we requested the
standardized betas by email. If standardized effects could not be obtained, unstandardized effects were
presented and indicated. The risk of bias of individual studies was assessed using the National Institutes of
Health (NIH) study quality assessment tool for observational cohort and cross-sectional studies . The
NIH tool assessment is composed by 14 questions the risk of potential selection bias, information bias
measurement bias or confounding bias. There are 3 options (yes, no, other) for each question. Each “no” or
“other” is suggestive of the presence of some risk of bias. Questions #6 (exposure prior outcome), #7
(sucient time to see an effect), #10 (repeated exposure assessment), and #13 (follow-up rate) were
disregarded for cross-sectional studies. Due to the self-reported nature of the assessments, question #12
(blinding of outcome assessors) was also disregarded for all studies.
Searches on PubMed, EMBASE, Sportdiscus, and Web of science resulted in 592 potentially relevant studies.
Preprint databases identied additional 572 potentially relevant studies. A ow-chart of the selection
process is provided in gure 1. Of the identied studies, 21 studies meet the criteria [9, 23-34, 5, 35-37, 6, 38-
40]. Four studies had a prospective longitudinal design [26, 29, 39, 36], one was a cross-sectional study with
a retrospective measure of the exposure factor (henceforth treated as retrospective) , and 16 were cross-
sectional studies [9, 23-25, 27, 29-35, 37, 6, 38, 40, 28, 41]. A total of 7 studies were conducted in Asia [24, 25,
27, 30, 33, 39, 40], 6 in Europe [9, 26, 31, 32, 35, 36], 3 in South America [28, 29, 6], 3 in North America [23, 34,
5], one in Oceania  and one study included a multinational sample .
Data form a total of 42,293 (median = 68% of women) participants were included. Only one study was
exclusively composed by older adults (over 50 years), 4 were in children, adolescents, or young adults, while
13 studies were in adults (over 18). Only 7 studies used validated measures to assess PA levels. A wide
range of scales to measure depression or anxiety were used, the most used scales being the Beck
Depression and Anxiety inventory and the DASS-21. Most studies (n=14) were not per-reviewed (pre-prints).
A summary of studies is provided in Table 1.
Results are summarized and presented in table 2. Out of 9 studies reporting analyses on the association
between the overall volume of PA and depression, 6 studies showed that more PA is signicantly associated
with less depression symptoms [23, 25, 32, 33, 35, 37], and 3 out of 8 studies investigating the association
between the overall volume of PA and anxiety symptoms showed that more PA is signicantly associated
with less anxiety symptoms [25, 32, 35]. 3 out of 5 studies reported higher frequencies of PA to be
signicantly associated with less depression [27, 29, 36] and 2 out of 4 studies to be signicantly associated
with less anxiety [27, 29]. One study showed that vigorous but not moderate PA is signicantly associated
with less depression and anxiety symptoms  and another study indicated that light and vigorous PA is
signicantly correlated with less depression, but moderate intensity was not . Out of 5 studies assessing
an association between regular and guideline-consistent PA less depression and anxiety symptoms, two
studies demonstrate that regular PA (compared to not regular) is signicantly associated with less
depression and anxiety symptoms [27, 30] and 1 study demonstrated that guideline conforming moderate to
vigorous PA is associated with lower odds of depression and anxiety . 5 out of 6 studies showed that a
decreasing PA during the pandemic was signicantly associated with more depression symptoms [9, 27, 5,
38, 40] and 3 out of 6 studies showed that a decrease in PA was signicantly associated with more anxiety
symptoms [9, 27, 38]. 1 study reported that an increase in PA was associated with less depressive symptoms
The risk of bias of individual studies is presented in table 2. All studies clearly dened their research
questions and used valid tools to assess main outcomes. Among the cross-sectional studies, 11 (68.75%)
studies did not report the participation rate or included less than 50% of eligible participants, and 13
(81.25%) did not use valid tools to assess the exposure measure. A total of 3 out of 5 (60%) longitudinal
studies are in risk of bias in the evaluating the denition of the study population, the participation rate, the
validity of the exposure measure and in the retention of the sample.
The present study is, to the best of our knowledge, the rst study to summarize the evidence on the
associations of PA with depression and anxiety during the COVID-19 pandemic. The majority of studies
included in the present review showed that those who performed PA on a regular basis with higher volume
and frequency and kept the PA routines stable, showed less symptoms of depression and anxiety. There was
consistent evidence that those who could not keep their PA routine stable during the pandemic showed more
depression and anxiety symptoms [9, 27, 5, 38-40]. However, the association was more consistent regarding
depressive compared to anxiety symptoms. Those reporting a higher total time spent in moderate to
vigorous PA had 12% to 32% lower chances of presenting depressive symptoms and 15% to 34% of
presenting anxiety. These ndings are in line with results of recent meta-analyses showing that those with
higher PA levels were 17% less likely of developing depression  and 26% less likely to develop anxiety
, independently of the the COVID-19 pandemic.
Indeed, the found reduction of PA behavior during COVID-19 specic conditions is highly expected. For
example, due to social distancing, exercising in a group setting was limited or completely prohibited.
However high social support is associated with more engagement in PA . Indeed, social support was one
of the strongest factors associated with adherence to PA in effective exercise interventions . Furthermore,
the COVID-19 pandemic impaired opportunities to be physically active due to the closure of sports clubs,
gyms, or common indoor and outdoor places for PA. While some people were still allowed to do exercises
like jogging on the streets, others were not . In general, a lack of sporting opportunities seems to be
associated with reduced PA . Further negative consequences of the pandemic such as nancial
insecurities might have caused stress in individuals and stress, in turn, may differentially impact individuals’
level of PA. Whereas habitually active individuals might even increase their level of PA, those who had not
yet integrated exercise as a part of daily life, reduce their level of PA . Thus, habitually active individuals
might have built PA-related health competence and learned to utilize PA as a strategy to cope with negative
feelings, such as stress, that may arise with sudden adaptions [47, 48]. Therefore, in order to prevent an
increase in psychiatric disorders during the current or further pandemics, factors that facilitate the
integration of PA into daily life routines, such as motivational and volitional skills, need to be identied and
encouraged [49, 50]. One of the best ways to promote motivation and volition is the application of behavior
change techniques (BCTs) . During the COVID-19 pandemic, some BCTs appear to be particularly
important for the maintenance of regular PA. For instance, the knowledge about the benets of PA on
symptoms that accompany lock-down procedures, such as lowered mood or anxiety [2-4]. Furthermore,
individuals need the strong ability of coping planning to anticipate barriers that could discourage them to
engage in PA (e.g., closed facilities) and nd strategies to overcome them (e.g., engage in home training).
A web-based tool, e.g. a smartphone application could be a low-threshold and cost-effective option to train,
supervise, apply, and adopt such BCTs, especially in terms of COVID-19. First empirical evidence showed
preliminary ecacy of apps in promoting PA. Users of such apps are more likely to meet recommendations
on PA than non-users [52-54]. Furthermore, a meta-analysis showed that Internet-delivered interventions,
which are able to use different BCTs, were effective in increasing PA . A major advantage of such web-
based tools is the possibility to overcome some of the COVID-19 specic barriers. For instance, it is possible
to become physically active online with friends or a virtual community, which might work against the lack of
social support. In addition, limited sporting opportunities may be expanded through tness technology and
the provision of structured programs, as they can be used both indoors (e.g. through tness videos) and
outdoors (e.g. through running apps) and therefore be adapted to the specic situation.
Most of the studies included in this review used cross-sectional research designs. A causal nature of these
associations therefore remains unclear. There are notably differences in effect sizes which point at a high
heterogeneity of the effects. Several studies further showed methodological shortcomings, e.g. not reporting
the participation rate, including less than 50% of eligible participants, no validated tools to assess PA and
failure to report standardized coecients. Heterogeneity in research designs and statistical analyses
hindered meta-analytic approaches, which would have provided a more sophisticated overall effect
estimate. Finally, several included studies were published as preprints and are currently in review processes
for nal publications. It is therefore planned to update this review in the future.
Conclusions, Future Research Directions And Implications
This rapid review shows promising evidence that higher volume and frequency of PA and the keeping of
regular PA habits during the Covid-19 pandemic is associated with less symptoms of depression and
anxiety. For instance, those reporting a higher total time spent in moderate to vigorous PA had 12% to 32%
lower chances of presenting depressive symptoms and 15% to 34% of presenting anxiety. Thus, the
promotion of PA habits and routines might be a cost-effective and comprehensive worldwide applicable
strategy to overcome the severe gap between people in need and people receiving mental health care,
especially in low-income countries with even non-existing mental health supplies. Particularly, web-based
technologies, could be an easily accessible way to increase motivation and volition for PA and maintain
daily PA routines even under pandemic-specic barriers. However only very few apps or websites have been
tested in RCTs with high methodological standards . Thus, there is a clear need for more systematic
research for effectively and safely usable apps or web-based programs to prevent psychiatric disorders
Funding. No funding has been received for the conduct of this review and preparation of this manuscript.
Conict of Interest. All authors declare that they have no conict of interest.
Availability of data and material. Data sharing not applicable to this article as no datasets were generated or
analyzed during the current study.
Author Contributions. SW and FS devised the project and the main conceptual ideas. FS
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. Characteristics of included studies
Author Country Design TypeN age
Bauer et al.,
pre-print 3,700 adults
(M = 33.13)
78.6 BSA-F PHQ-9; GAD-7
Callow et al.,
1,046 older adults
80 PASE GDS; GAS
Chen et al.,
(R = 6-15)
48.7 NR DSRS-C;
Chen et al.,
pre-print 474 adults
(R = 20-70)
51.3 Single item
Cheval et al.,
pre-print 110 adults
(M = 43)
68 IPAQ PROMIS
Deng et al.,
pre-print 1,607 adolescents/
35.2 Multiple items
pre-print 1,460 adults
(M = 32.9)
72.87 Single item
pre-print 360 adults
(M = 37.9)
68.8 Multiple items
Fu et al.,
1,242 adults (NR) 69.7 NR PHQ-9; GAD-7
Fullana et al.,
5,545 adults (M =
73 NR PHQ-9; GAD-7
Jacob et al.,
902 adults (NR) 63.8 Multiple items
Khan et al.,
pre-print 505 adolescents/
37.3 NR DASS-21
Lebel et al.,
pre-print 1,987 adults
(M = 32.4)
100 Multiple items
Meyer et al.,
pre-print 3,052 adults (NR) 62 Multiple items
Moreira et al.,
pre-print 1,280 adults
(M = 37.1)
79.8 Single item
Gómez et al.,
pre-print 1,056 adults
(M = 32.1)
67.6 NR DASS-21
Plomecka et Multiple (12Cross- pre-print 12,817adults (NR) 72.3 NR BDI
al., 2020 countries) sectional
Schuch et al.,
937 adults (NR) 72.3 Multiple items
(M = 50.5)
67 AAS DASS-21
Zhang et al.,
(M = 20.7)
62.1 IPAQ DASS-21
Zheng et al.,
pre-print 1,620 children/
(M = 10.1)
47.8 Single item
AAS = Active Australia Survey; BASF-F = The Physical Activity Exercise, and Sport
Questionnaire; DASS-21 = Depression and anxiety scale 21 items; DSRS-C = Depression Self-Rating Scale for
Children; EPDS = Edinburgh Depression Scale; FDI = Filgueira depression inventory; GAD-7 = Generalized
Anxiety Screener 7; GAS = geriatric anxiety scale; GDS = geriatric depression scale; IPAQ = International
physical activity questionnaire; M = Mean; MH = mental health; n = number of participants; NR = not
reported; PA = physical activity; PAVS = physical activity vital sign; PASE = Physical activity scale for the
eldery; PHQ-9 = patient health questionnaire 9; PROMIS = Patient-Reported Outcomes Measurement
Information System; R = Range; SASC = Social Anxiety Scale for Children; SCARED = Screen for Child
Anxiety Related Disorders; SSTAI = The Spielberg State and Trait Anxiety Inventory
Main results of multiple linear and logistic regressions analyzing the association of physical activity
or exercise with symptoms of depression or anxiety in the included studies
Author Predictor Depressive Symptoms Anxiety Symptoms
Bauer et al., 2020 EX (minutes/week) 0.00# (NR;
Callow et al., 2020 PA (PASE score) -0.22***
Chen et al., 2020b EX (hours/day) 0.68*
Cheval et al., 2020 PA (minutes/day) NR# (NR;
Jacob et al., 2020 EX (minutes/day) 0.88° (0.8;
Khan et al., 2020 EX (any amount;
Ref.: No EX)
Moreira et al., 2020 EX (hours) -1.17° (NR;
Plomencka et al.,
EX (> 15 min/day;
Ref.: ≤ 15 min/day, <60
(NR; NR) NR# (NR;
EX (≥60 min/day;
Ref.: ≤ 15 min/day)
Schuch et al., 2020 PA (minutes/day; per 10
Deng et al., 2020 EX (> 1 to 2 times/week; Ref: <
Filgueiras & Stultz-
EX (frequency/week) -2.68**
Fullana et al., 2020 EX (Unclear) 0.93 (NR;
EX (1-2 times/week; Ref.: No
EX (3-5 times/week; Ref.: No
EX (6-7 times/week; Ref.: No
Filgueiras & Stultz-
EX (frequency/week) NR# (NR;
Callow et al., 2020 light PA (PASE score) 0.12** (NR;
moderate PA (PASE score) -0.01 (NR;
vigorous PA (PASE score) 0.09* (NR;
Schuch et al., 2020 vigorous PA (minutes/day) -0.19*
moderate PA (minutes/day) 0.00 (-0.09;
Chen et al.,2020a EX (regular; 0.37 (NR;
Ref.: not regular)
Deng et al., 2020 EX (regular; -0.2***
Ref.: not regular)
Fu et al., 2020 EX (not regular; 1.71***
Lebel et al., 2020 EX (guideline conforming; Ref.:
not guideline conforming)
Schuch et al., 2020 PA (≥ 30 minutes/day; Ref.: <
Bauer et al., 2020 EX (less; equal; more)3-0.08***
Deng et al., 2020 EX (no change; Ref.: large
EX (little change; Ref.: large
Filgueiras et al.,
EX (none, increase, decrease) NR# (NR;
Meyer et al., 2020 PA (increased; Ref.: maintained
PA (decreased; Ref.: maintained
PA (maintained low; Ref.:
Stanton et al., 2020 PA (negative change; Ref.: no
Zhang et al., 2020 PA (per 100 MET increase) -0.04*
Zheng et al., 2020 PA (decrease vs. no
AOR = adjusted odd's ratio; EX = Exercise; MET = metabolic equivalent of tasks; NR = not
reported; OR = Odd's ratio; PA = physical activity; PASE = Physical activity scale for the elderly; Ref. =
*p < 0.05; **p < 0.01; ***p<0.001; °signicant association, p-value not reported; #no signicant association,
p-value not reported
1unstandardized regression coecient
2Odd's Ratio calculated from case counts
3Post-Hoc analysis revealed that a decrease in exercise was signicantly associated with less depression
compared to stable exercise and increase. No other comparison reached signicance
. Risk of bias assessment (NIHM tool for observational studies)
Items 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Bauer et al., 2020 YYY YY- - Y Y -Y- - Y
Callow et al., 2020 YYY YY- - Y Y -Y- - Y
Chen et al., 2020a Y N NR N Y - - N N -Y- - N
Chen et al., 2020b Y Y N N Y - - Y N -Y- - Y
Deng et al., 2020 Y Y Y Y N - - Y N -Y- - N
Filgueiras & Stultz-Kolehmainen, 2020a Y N NR Y Y - - Y N -Y- - Y
Fu et al., 2020 Y Y NR Y Y - - N N -Y- - Y
Fullana et al., 2020 Y Y NR Y N - - N N -Y- - Y
Jacob et al., 2020 Y Y NR Y Y - - Y N -Y- - Y
Khan et al., 2020 Y N NR Y Y - - N N -Y- - Y
Lebel et al., 2020 Y Y NR Y Y - - N N -Y- - Y
Moreira et al,. 2020 Y Y NR Y Y - - N N -Y- - Y
Plomecka et al., 2020 YYY YY- - Y N Y Y
Schuch et al., 2020 Y Y NR Y Y Y N -Y- - Y
Stanton et al., 2020 Y Y NR Y Y - - N Y -Y- - Y
Zheng et al., 2020 Y Y Y Y N - - N N -Y- - Y
Cheval et al., 2020 Y N Y Y Y Y Y Y Y Y Y -Y NR
Filgueiras & Stultz-Kolehmainen, 2020B Y N NR Y Y Y Y Y N Y Y -N Y
Meyer et al., 2020 Y Y Y Y Y N Y Y N N Y -NA Y
Planchuelo-Gómez et al., 2020 Y Y NR Y N Y Y Y NR Y Y -N Y
Zhang et al., 2020 Y N NR Y Y Y Y Y Y Y Y -Y NR
PRISMA ow-chart of the screening and selection of studies.