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Cited by 117Treatment of Major DepressionPhysical Activity and HealthAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Comparative effectiveness of exercise, antidepressants and their combination in treating non-severe depression: a systematic review and network meta-analysis of randomised controlled trials

Open access
Recchia, Francesco, Leung, Chit K, Chin, Edwin C, Fong, Daniel Y, Montero, David, Cheng, Calvin P, Yau, Suk Yu, Siu, Parco M·2022·British Journal of Sports Medicine
DOI 10.1136/bjsports-2022-105964PMC PMC9685718
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Abstract

Objective: To assess the comparative effectiveness of exercise, antidepressants and their combination for alleviating depressive symptoms in adults with non-severe depression. Design: Systematic review and network meta-analysis. Data sources: Embase, MEDLINE, PsycINFO, Cochrane Library, Web of Science, Scopus and SportDiscus. Eligibility criteria: Randomised controlled trials (1990–present) that examined the effectiveness of an exercise, antidepressant or combination intervention against either treatment alone or a control/placebo condition in adults with non-severe depression. Study selection and analysis: Risk of bias, indirectness and the overall confidence in the network were assessed by two independent investigators. A frequentist network meta-analysis was performed to examine postintervention differences in depressive symptom severity between groups. Intervention drop-out was assessed as a measure of treatment acceptability. Results: Twenty-one randomised controlled trials (n=2551) with 25 comparisons were included in the network. There were no differences in treatment effectiveness among the three main interventions (exercise vs antidepressants: standardised mean differences, SMD, −0.12; 95% CI −0.33 to 0.10, combination versus exercise: SMD, 0.00; 95% CI −0.33 to 0.33, combination vs antidepressants: SMD, −0.12; 95% CI −0.40 to 0.16), although all treatments were more beneficial than controls. Exercise interventions had higher drop-out rates than antidepressant interventions (risk ratio 1.31; 95% CI 1.09 to 1.57). Heterogeneity in the network was moderate (τ 2=0.03; I 2=46%). Conclusions: The results suggest no difference between exercise and pharmacological interventions in reducing depressive symptoms in adults with non-severe depression. These findings support the adoption of exercise as an alternative or adjuvant treatment for non-severe depression in adults. Systematic review registration: PROSPERO CRD4202122656.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and network meta-analysis found no difference in effectiveness between exercise, antidepressants, or their combination for reducing depressive symptoms in adults with non-severe depression, though all were superior to controls. Exercise had higher drop-out rates than antidepressants.

Key findings

  • In 21 RCTs (n=2551; 25 comparisons), exercise, antidepressants, and combination treatment did not differ significantly: exercise vs antidepressants SMD −0.12 (95% CI −0.33 to 0.10); combination vs exercise SMD 0.00 (95% CI −0.33 to 0.33); combination vs antidepressants SMD −0.12 (95% CI −0.40 to 0.16).
  • All treatments reduced depressive symptoms versus controls: exercise SMD −0.45 (95% CI −0.67 to −0.23), antidepressants SMD −0.33 (95% CI −0.48 to −0.19), combination SMD −0.45 (95% CI −0.76 to −0.14).
  • Exercise had higher drop-out than antidepressants (RR 1.31; 95% CI 1.09 to 1.57) and controls (RR 1.29; 95% CI 1.03 to 1.61).
  • Network heterogeneity was moderate (τ²=0.03; I²=46.2%), mostly from exercise vs control (Q=15.80; df=4; p=0.003).

Methods

  • Systematic review and frequentist network meta-analysis of RCTs (1990–January 2022) from seven databases, including adults with non-severe depression (major depressive disorder with mild-to-moderate symptoms) and comparing exercise, second-generation antidepressants, combination treatment, or controls.
  • Included 21 RCTs with 2551 participants and 25 pairwise comparisons; primary outcome was depressive symptom severity, secondary outcome was treatment acceptability measured as overall drop-out.
  • Used random-effects netmeta models in R, SMD for continuous outcomes, RR for dichotomous outcomes, P-score ranking, RoB-2 and CINeMA assessments, and sensitivity analyses.

Limitations

  • The paper states that the low number of studies per comparison precluded exploration of heterogeneity and publication bias and may have generated inaccurate between-study heterogeneity estimates.
  • The paper states that control groups were combined into one node, and exercise studies used varied controls, which may have overestimated exercise effects; interventions were also combined into nodes without accounting for differences in antidepressant type/dose/duration or exercise type/frequency/intensity/duration.
  • The paper states that findings apply only to mild-to-moderate depression and cannot be extended to individuals with more severe symptoms; evident from the text, direct exercise–antidepressant evidence came from only three studies.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1136/bjsports-2022-105964

Cites

40 of 40 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 43 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Combined treatment had a similar effect to exercise in reducing depressive symptoms (SMD 0.00; 95% CI −0.33 to 0.33).

    “Exercise had a similar beneficial effect to that of antidepressants (SMD, −0.12; 95% CI −0.33 to 0.10), and the effect of combined treatments was similar to the effect of exercise (SMD, 0.00; 95% CI −0.33 to 0.33) and antidepressants (SMD, −0.12; 95% CI −0.40 to 0.16) alone.”
    • Also stated in: § Results · plain
      “exercise vs antidepressants: standardised mean differences, SMD, −0.12; 95% CI −0.33 to 0.10, combination versus exercise: SMD, 0.00; 95% CI −0.33 to 0.33, combination vs antidepressants: SMD, −0.12; 95% CI −0.40 to 0.16”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Every participant fitting the eligibility criteria could potentially be randomised to any of the treatments compared.
    • The authors state this as an assumption: Heterogeneity was common across the entire network.
  • Findingown data

    Exercise was superior to control in reducing depressive symptoms (SMD −0.45; 95% CI −0.67 to −0.23).

    “At the end of the interventions, exercise (SMD, −0.45; 95% CI −0.67 to −0.23), antidepressants (SMD, −0.33; 95% CI −0.48 to −0.19) and combined treatments (SMD, −0.45; 95% CI −0.76 to −0.14) were superior in reducing depressive symptoms compared with controls (table 2).”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Every participant fitting the eligibility criteria could potentially be randomised to any of the treatments compared.
    • The authors state this as an assumption: Heterogeneity was common across the entire network.
  • Findingown data

    Twenty-one randomised controlled trials (n=2551) with 25 comparisons were included in the network.

    “Twenty-one randomised controlled trials (n=2551) with 25 comparisons were included in the network.”
    • Also stated in: § Study characteristics · plain
      “Overall, 2551 participants in 25 pairwise comparisons were assigned to one of the three treatments and control groups (figure 1).”
    Quote in the paperSubstantial claim
  • Findingown data

    Heterogeneity was mostly caused by the comparison of exercise versus control (Q=15.80; df=4; p=0.003).

    “The network meta-analysis showed that there was moderate heterogeneity (τ2=0.03; I2=46.2%), which was mostly caused by the comparison of exercise versus control (Q=15.80; df=4; p=0.003).”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: Every participant fitting the eligibility criteria could potentially be randomised to any of the treatments compared.
    • The authors state this as an assumption: Heterogeneity was common across the entire network.
  • Findingown data

    Combined treatments were superior to control in reducing depressive symptoms (SMD −0.45; 95% CI −0.76 to −0.14).

    “At the end of the interventions, exercise (SMD, −0.45; 95% CI −0.67 to −0.23), antidepressants (SMD, −0.33; 95% CI −0.48 to −0.19) and combined treatments (SMD, −0.45; 95% CI −0.76 to −0.14) were superior in reducing depressive symptoms compared with controls (table 2).”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Every participant fitting the eligibility criteria could potentially be randomised to any of the treatments compared.
    • The authors state this as an assumption: Heterogeneity was common across the entire network.
  • Classified as probably not a substantial claim. 25
  • May combine two claims. 20

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The duration of the intervention differed among comparisons, with the exercise versus antidepressants comparison having the mean longest intervention (19 weeks) and the antidepressants versus control comparison having the shortest (9 weeks).

    “The duration of the intervention differed among comparisons, with the exercise versus antidepressants comparison having the mean longest intervention (19 weeks), and the antidepressants versus control comparison having the shortest (9 weeks).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The comparison studies included 11 antidepressant versus control comparisons, 6 exercise versus control comparisons, 4 combined treatment versus antidepressant comparisons and 1 combined treatment versus exercise comparison.

    “The comparison studies included: antidepressants versus controls (n=11), exercise versus controls (n=6), combined treatments versus antidepressants (n=4) and combined treatments versus exercise (n=1).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Control interventions included placebo (n=11), attention control (n=2), stretching (n=2), no intervention (n=1) and wait-list (n=1).

    “Control interventions included placebo (n=11), attention control (n=2), stretching (n=2), no intervention (n=1) and wait-list (n=1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Only 6 and 11 studies comparing exercise and antidepressants to control were found, respectively.

    “To our own surprise, only 6 and 11 studies comparing exercise and antidepressants to control were found, respectively.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    All antidepressant studies used a placebo comparison, while exercise studies used various types of control.

    “While all antidepressant studies used a placebo comparison, exercise studies used various types of control.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Risk of bias was low in 5 studies, moderate in 15 studies and high in 1 study.

    “Risk of bias was determined to be low in 5 studies, moderate in 15 studies and high in 1 study (online supplemental material etable 3).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Participant age, the proportion of women and the outcome measure used were balanced across comparisons.

    “Participant age, the proportion of women and the outcome measure used were balanced across comparisons.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension guidelines for network meta-analyses.

    “This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension guidelines for network meta-analyses23 and was registered in PROSPERO (identifier CRD42021226561).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Transitivity in the network was assessed by visual inspection of study characteristics: mode participant age, mode proportion of women, mean intervention duration and mode depression scale used.

    “We assessed the transitivity in the network by a visual inspection of study characteristics: mode participant age (≥60 or <60), mode proportion of women (≥50% or <50%), mean intervention duration and mode depression scale used.31 32”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [31] source

      Not checked in the free run.

    • cites [32] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Inconsistency in the network was measured with local and global approaches using netsplit and decomp.design functions.

    “We measured inconsistency in the network with local and global approaches using netsplit and decomp.design functions, respectively.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Two authors independently extracted sample sizes, postintervention mean scores of depressive symptoms, SD and number of drop-outs in each study.

    “Two authors independently extracted sample sizes, postintervention mean scores of depressive symptoms, SD and number of drop-outs in each study.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Two independent researchers performed the search using pre-established criteria.

    “Two independent researchers performed the search using pre-established criteria.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The review was registered in PROSPERO (identifier CRD42021226561).

    “This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension guidelines for network meta-analyses23 and was registered in PROSPERO (identifier CRD42021226561).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Sensitivity analyses were performed by excluding studies with high indirectness and risk of bias, studies with participants older than 60, studies with interventions longer than 12 weeks and studies that used an attention/active or passive control comparison.

    “Sensitivity analyses were performed by excluding studies with high indirectness and risk of bias, studies with participants older than 60, studies with interventions longer than 12 weeks and studies that used an attention/active or passive control comparison.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Risk of bias was assessed using the Cochrane risk of bias assessment tool (RoB-2).

    “We assessed risk of bias using the Cochrane risk of bias assessment tool (RoB-2).28”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [28] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The Confidence in Network Meta-Analysis (CINeMA) model was used to assess the confidence of the entire network.

    “We used the Confidence in Network Meta-Analysis (CINeMA) model to assess the confidence of the entire network.29”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Risk of bias, indirectness and the overall confidence in the network were assessed by two independent investigators.

    “Risk of bias, indirectness and the overall confidence in the network were assessed by two independent investigators.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The evidence on the effectiveness of second-generation antidepressants remains controversial because the immediate and short-term benefits may be small and the long-term balance between benefit and harm is poorly understood.

    “However, the evidence on their effectiveness remains controversial because the immediate and short-term benefits may be small and the long-term balance between benefit and harm is poorly understood.7”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S1 (asserted).

    Premisecitation

    The benefits of antidepressants in non-severe depression have been argued to be minimal.

    “Thus, the benefits of antidepressants in non-severe depression have been argued to be minimal.8 11”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [8] source

      Not checked in the free run.

    • cites [11] source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Owing to an insufficient number of studies in each comparison group, subgroup and meta-regression analyses, as well as the assessment of publication bias, could not be performed to explore potential sources of heterogeneity across the network.

    “Owing to an insufficient number of studies in each comparison group, subgroup and meta-regression analyses, as well as the assessment of publication bias, could not be performed to explore potential sources of heterogeneity across the network.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationown data

    These findings support the adoption of exercise as an alternative or adjuvant treatment for non-severe depression in adults.

    “These findings support the adoption of exercise as an alternative or adjuvant treatment for non-severe depression in adults.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Every participant fitting the eligibility criteria could potentially be randomised to any of the treatments compared.
    • The authors state this as an assumption: Heterogeneity was common across the entire network.

  • Classified as probably not a substantial claim.

    Premisereasoning

    The contrasting statements conveyed by international treatment guidelines preclude drawing definitive conclusions regarding the role of exercise as a treatment for non-severe depression.

    “The contrasting statements conveyed by international treatment guidelines preclude drawing definitive conclusions regarding the role of exercise as a treatment for non-severe depression.”
    Quote in the paperSubstantial claim0 of 5 sources checked
    • cites [6] American Psychological Association . Clinical practice guideline for the treatment of depression across three age cohorts. Guideline development panel for the treatment of depressive disorders, 2019. Available: https://www.apa.org/depression-guideline/guideline.pdf

      Not checked in the free run.

    • cites [19] Stubbs, 2018, EPA guidance on physical activity as a treatment for severe mental illness: a meta-review of the evidence and position statement from the European psychiatric association (EPA), supported by the International organization of physical therapists in mental health (IOPTMH), Eur Psychiatry source

      Not checked in the free run.

    • cites [20] source

      Not checked in the free run.

    • cites [21] source

      Not checked in the free run.

    • cites [22] National Institute for Health and Clinical Excellence . Depression in adults: treatment and management NICE; 2022.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Second-generation antidepressant medications are one of the first-line treatments for depression.

    “Currently, second-generation antidepressant medications are one of the first-line treatments for depression.6”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [6] American Psychological Association . Clinical practice guideline for the treatment of depression across three age cohorts. Guideline development panel for the treatment of depressive disorders, 2019. Available: https://www.apa.org/depression-guideline/guideline.pdf

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    The DSM-5 clinical practice guidelines support exercise therapy only when antidepressants or psychotherapy treatments are ineffective or unacceptable.

    “In contrast, the clinical practice guidelines provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) support exercise therapy only when antidepressants or psychotherapy treatments are ineffective or unacceptable.6”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] American Psychological Association . Clinical practice guideline for the treatment of depression across three age cohorts. Guideline development panel for the treatment of depressive disorders, 2019. Available: https://www.apa.org/depression-guideline/guideline.pdf

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Although there is evidence that antidepressants have some beneficial effects on milder forms of depression compared with placebo, concerns over the risk-to-benefit ratio and the availability of alternative treatments raise questions about the appropriateness of pharmacological treatments for non-severe depression.

    “Although there is evidence that antidepressants have some beneficial effects on milder forms of depression compared with placebo,16 concerns over the risk-to-benefit ratio and the availability of alternative treatments raise questions about the appropriateness of pharmacological treatments for non-severe depression.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [16] Cipriani, 2011, Depression in adults: drug and physical treatments, BMJ Clin Evid

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Reluctance to use antidepressants may be found in patients with non-severe symptoms due to low perceived need or effectiveness of the medication and/or social stigmatisation.

    “Reluctance to use antidepressants may also be found in patients with non-severe symptoms due to low perceived need or effectiveness of the medication and/or social stigmatisation.15”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [15] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S1 (asserted).

    Premisecitation

    The European Psychiatric Association report states that there is sufficient data supporting exercise for the management of mild-to-moderate depression.

    “This contradicts the report by the European Psychiatric Association that states that there is sufficient data supporting exercise for the management of mild-to-moderate depression.19”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] Stubbs, 2018, EPA guidance on physical activity as a treatment for severe mental illness: a meta-review of the evidence and position statement from the European psychiatric association (EPA), supported by the International organization of physical therapists in mental health (IOPTMH), Eur Psychiatry source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    The DSM-5 guidelines state that there is a lack of evidence to recommend exercise as an official treatment.

    “Moreover, the DSM-5 guidelines state that there is a lack of evidence to recommend exercise as an official treatment.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] American Psychological Association . Clinical practice guideline for the treatment of depression across three age cohorts. Guideline development panel for the treatment of depressive disorders, 2019. Available: https://www.apa.org/depression-guideline/guideline.pdf

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Lifestyle interventional strategies incorporating diet, sleep and physical activity have been recognised as protective treatments for depression.

    “Recently, lifestyle interventional strategies incorporating diet, sleep and physical activity have been recognised as protective treatments for depression.17 18”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [17] Opie, 2021, Designing lifestyle interventions for common mental disorders: what can we learn from diabetes prevention programs?, Nutrients source

      Not checked in the free run.

    • cites [18] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    Our findings align with recommendations from European, Canadian, Australian and UK treatment guidelines supporting exercise as an alternative treatment for non-severe depression.

    “Our findings align with the recommendations provided by European, Canadian, Australian and UK treatment guidelines supporting the use of exercise as an alternative treatment for non-severe depression.19–22”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [19] Stubbs, 2018, EPA guidance on physical activity as a treatment for severe mental illness: a meta-review of the evidence and position statement from the European psychiatric association (EPA), supported by the International organization of physical therapists in mental health (IOPTMH), Eur Psychiatry source

      Not checked in the free run.

    • cites [20] source

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    • cites [21] source

      Not checked in the free run.

    • cites [22] National Institute for Health and Clinical Excellence . Depression in adults: treatment and management NICE; 2022.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Gartlehner et al compared pharmacological versus non-pharmacological treatments using only direct evidence.

    “Gartlehner et al 34 compared pharmacological versus non-pharmacological treatments, but only direct evidence was analysed.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Gartlehner et al 34

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Gartlehner et al's analysis included two exercise studies and concluded there was insufficient evidence to promote exercise as a depression treatment.

    “This resulted in the inclusion of two exercise studies and with the conclusion that there was insufficient evidence to promote exercise as a depression treatment.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Gartlehner et al 34

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Using exercise as an adjunctive treatment to pharmacotherapy may counterbalance side effects associated with antidepressant use and promote faster recovery.

    “Our findings do not support the synergistic effects of exercise and antidepressants; however, considering the various health benefits of physical exercise, using exercise as an adjunctive treatment to pharmacotherapy may counterbalance the side effects that are often associated with antidepressant use and promote a faster recovery.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The low number of studies limited the interpretation of the findings, which need to be corroborated by further research.

    “This limited the interpretation of our findings, which need to be corroborated by further research.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Antidepressant treatments are associated with greater adverse effects, higher costs and social stigma.

    “On the other hand, antidepressant treatments are associated with greater adverse effects, higher costs and social stigma.14”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] Sansone, 2012, Antidepressant adherence: are patients taking their medications?, Innov Clin Neurosci

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Both exercise and antidepressant interventions have limitations in securing treatment adherence.

    “Clearly, both interventions have limitations in securing treatment adherence.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Overall drop-out is a valid measure of treatment acceptability.

  • May combine two claims.

    Interpretationown data

    The effect of exercise might have been overestimated and needs to be validated by additional high-quality studies.

    “Although our sensitivity analyses found no considerable changes in study effects after excluding studies with an active or passive control comparison, the effect of exercise might have been overestimated and needs to be validated by additional high-quality studies.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Differences within antidepressant and exercise interventions might have affected the overall heterogeneity of the network.

    “These differences might have affected the overall heterogeneity of the network.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Antidepressant studies vary by type, dose and duration of antidepressant used, and exercise studies vary by type, frequency, intensity and duration of the training sessions.

  • May combine two claims.

    Study design and conductown data

    The overall low number of studies available for each comparison precluded exploration of potential sources of heterogeneity and publication bias, and may have generated inaccurate estimates of between-study heterogeneity.

    “First, the overall low number of studies available for each comparison precluded us to explore potential sources of heterogeneity and publication bias, and may have generated inaccurate estimates of between-study heterogeneity.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Cipriani et al analysed over 500 antidepressant studies and found that 89% only recruited participants with moderate-to-severe symptoms (mean Hamilton Rating Scale score of 25.7).

    “This was also reflected in a comprehensive network meta-analysis by Cipriani et al,41 who analysed over 500 antidepressant studies and found that 89% only recruited participants with moderate-to-severe symptoms (mean Hamilton Rating Scale score of 25.7).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Cipriani et al,41

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    This study examined the comparative effectiveness of exercise and antidepressants in mild-to-moderate depression, but did not explore the potential benefits of exercise in individuals with more severe symptoms.

    “Third, this study examined the comparative effectiveness of exercise and antidepressants in mild-to-moderate depression, but did not explore the potential benefits of exercise in individuals with more severe symptoms.”
    Quote in the paperSubstantial claim
41 of 41

  • The authors state this as an assumption.

    Every participant fitting the eligibility criteria could potentially be randomised to any of the treatments compared.

    “We presumed that every participant fitting our eligibility criteria could potentially be randomised to any of the treatments compared.”

  • The authors state this as an assumption.

    Heterogeneity was common across the entire network.

    “It was assumed that heterogeneity was common across the entire network.”

  • The paper relies on this without support.

    No prior network meta-analysis has comparatively assessed the effectiveness of exercise, antidepressants and combined treatments on depressive symptoms in adults with non-severe depression.

    “This is the first network meta-analysis to comparatively assess the effectiveness of exercise, antidepressants and combined treatments on depressive symptoms in adults with non-severe depression.”

  • The authors state this as an assumption.

    The transitivity assumption holds in the network meta-analysis.

    “Compared with Cipriani et al, our study had tighter inclusion criteria to ensure that the transitivity assumption was not violated.”

  • The paper relies on this without support.

    Antidepressant studies vary by type, dose and duration of antidepressant used, and exercise studies vary by type, frequency, intensity and duration of the training sessions.

    “Yet, antidepressant studies can vary by type, dose and duration of antidepressant used, whereas exercise studies can vary by type, frequency, intensity and duration of the training sessions.”

  • The paper relies on this without support.

    Overall drop-out is a valid measure of treatment acceptability.

    “In our study, we used overall drop-out as a measure of treatment acceptability.”
6 of 6

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Each contradiction between two passages listed here was confirmed by an independent check.

  • PROSPERO registration numbers differ

    Minor

    The abstract and Methods give different registration identifiers; the Methods identifier has an additional final digit.

1 of 1

Cites

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Research works printed but not linked: 2

  1. American College of Sports Medicine . ACSM’s guidelines for exercise testing and prescription. Lippincott Williams & Wilkins, 2000.
  2. Gartlehner GHR , Reichenpfader U , Kaminski A . Drug class review: second-generation antidepressants. update 5; 2011.

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Authors
Recchia, F., Leung, C. K., Chin, E. C., Fong, D. Y., Montero, D., Cheng, C. P., Yau, S. Y., & Siu, P. M.
Affiliations
  • University of Hong Kong (HK)
  • Hong Kong Polytechnic University (HK)
Corresponding author
Siu, Parco M
ORCID
Venue
British Journal of Sports Medicine
Publisher
BMJ
Published
2022-09-16
Volume
56
Issue
23
Pages
1375-1380
ISSN
  • 0306-3674 (ISSN-L)
  • 1473-0480
DOI
10.1136/bjsports-2022-105964
PMC
PMC9685718
OpenAlex
W4296072841
Cited by
117
References
40
Citations by year
2026: 31 · 2025: 35 · 2024: 37 · 2023: 14
FWCI
3.09
Type
journal article
Language
en
Open access
Licence
Locations
  • British Journal of Sports Medicine (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
Funders
  • Health and Medical Research Fund (17182461)
  • The University of Hong Kong (Seed Fund for Basic Research)
Topics
  • Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
  • Health Sciences › Medicine › Physiology › Physical Activity and Health
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
exercise therapy, antidepressants, combination therapy, depression severity, treatment effectiveness, treatment acceptability, dropout rates
MeSH terms
Network Meta-Analysis, Network Meta-Analysis as Topic, Adult, Antidepressive Agents, Depression, Humans, Exercise, Randomized Controlled Trials as Topic, Treatment Outcome

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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