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Cited by 449Physical Activity and HealthTreatment of Major DepressionAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Exercise as medicine for depressive symptoms? A systematic review and meta-analysis with meta-regression

Open access
Heissel, Andreas, Heinen, Darlene, Brokmeier, Luisa Leonie, Skarabis, Nora, Kangas, Maria, Vancampfort, Davy, Stubbs, Brendon, Firth, Joseph +4 more·2023·British Journal of Sports Medicine
DOI 10.1136/bjsports-2022-106282PMC PMC10423472
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Abstract

Objective: To estimate the efficacy of exercise on depressive symptoms compared with non-active control groups and to determine the moderating effects of exercise on depression and the presence of publication bias. Design: Systematic review and meta-analysis with meta-regression. Data sources: The Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, Embase, SPORTDiscus, PsycINFO, Scopus and Web of Science were searched without language restrictions from inception to 13 September2022 (PROSPERO registration no CRD42020210651). Eligibility criteria for selecting studies: Randomised controlled trials including participants aged 18 years or older with a diagnosis of major depressive disorder or those with depressive symptoms determined by validated screening measures scoring above the threshold value, investigating the effects of an exercise intervention (aerobic and/or resistance exercise) compared with a non-exercising control group. Results: Forty-one studies, comprising 2264 participants post intervention were included in the meta-analysis demonstrating large effects (standardised mean difference (SMD)=−0.946, 95% CI −1.18 to −0.71) favouring exercise interventions which corresponds to the number needed to treat (NNT)=2 (95% CI 1.68 to 2.59). Large effects were found in studies with individuals with major depressive disorder (SMD=−0.998, 95% CI −1.39 to −0.61, k=20), supervised exercise interventions (SMD=−1.026, 95% CI −1.28 to −0.77, k=40) and moderate effects when analyses were restricted to low risk of bias studies (SMD=−0.666, 95% CI −0.99 to −0.34, k=12, NNT=2.8 (95% CI 1.94 to 5.22)). Conclusion: Exercise is efficacious in treating depression and depressive symptoms and should be offered as an evidence-based treatment option focusing on supervised and group exercise with moderate intensity and aerobic exercise regimes. The small sample sizes of many trials and high heterogeneity in methods should be considered when interpreting the results.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and meta-analysis of 41 RCTs found that exercise produced large reductions in depressive symptoms compared with non-exercising controls (SMD −0.946; NNT 2), with moderate effects in low risk-of-bias trials. Exercise should be offered as an evidence-based treatment option, especially supervised and group exercise with moderate intensity and aerobic exercise regimes, though high heterogeneity and small trials limit certainty.

Key findings

  • Pooled data from 41 RCTs and 2264 post-intervention participants showed a large effect favouring exercise: SMD=−0.946 (95% CI −1.18 to −0.71), NNT=2 (95% CI 1.68 to 2.59), with substantial heterogeneity (I²=82.49).
  • Effects remained large in major depressive disorder (SMD=−0.998, k=20) and supervised exercise (SMD=−1.026, k=40), but were moderate when restricted to low risk-of-bias studies (SMD=−0.666, k=12; NNT=2.8, 95% CI 1.94 to 5.22).
  • Aerobic (SMD=−1.156) and resistance exercise (SMD=−1.042) showed large effects, whereas mixed aerobic and resistance training showed smaller effects (SMD=−0.455). Additional improvement over control was −4.70 points on the HAM-D (n=685) and −6.49 points on the BDI (n=275).
  • Meta-regression found shorter trial duration was associated with larger effects in the main analysis (β=0.032, 95% CI 0.01 to 0.09, p=0.032, R²=0.06); in MDD-only analyses, higher antidepressant use in the control group was associated with smaller effects (β=−0.013, 95% CI −0.02 to −0.01, p=0.012, R²=0.28).

Methods

  • Systematic review and random-effects meta-analysis with meta-regression (PROSPERO CRD42020210651), searching CENTRAL, PubMed, MEDLINE, Embase, SPORTDiscus, PsycINFO, Scopus and Web of Science from inception to 13 September 2022 without language restrictions.
  • Included RCTs of adults aged 18 years or older with major depressive disorder/dysthymia or above-threshold depressive symptoms on validated screening measures, comparing aerobic and/or resistance exercise with non-exercising controls.
  • Data were pooled using standardised mean differences (SMD) and 95% CIs with a pre-post correlation of 0.7 on an intention-to-treat basis; heterogeneity was assessed with I², and subgroup analyses, meta-regression, publication-bias tests, trim-and-fill, and NNT calculations were performed.

Limitations

  • The authors state high heterogeneity across studies due to differing control conditions, cultural backgrounds, gender distribution, assessments, and depression severity/diagnosis; many studies had small samples, including 13 with intervention arms of ≤10 participants post-intervention, and some subanalyses lacked power.
  • The authors also state that long-term effects could not be investigated due to missing follow-up data, placebo effects could not be controlled, 6 of 41 studies were pre-2001/pre-CONSORT, and samples were mainly willing, motivated, physically able participants from high-income and upper-middle-income countries, with no studies from Africa.
  • Evident from the text: the main analysis had substantial unexplained heterogeneity (I²=82.49), publication-bias tests were significant (Begg-Mazumdar tau=−0.379, p<0.001; Egger intercept=−2.706, p<0.001), and several subgroup findings relied on very few studies (e.g., light exercise k=2, health education k=3), making those estimates unstable.

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

Integrity signals

Registry

Crossref · 10.1136/bjsports-2022-106282

Cites

85 of 85 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 30 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    In studies with individuals with major depressive disorder, exercise showed a large effect (SMD=−0.998, 95% CI −1.39 to −0.61, k=20).

    “Large effects were found in studies with individuals with major depressive disorder (SMD=−0.998, 95% CI −1.39 to −0.61, k=20)”
    Quote in the paperSubstantial claim
  • Findingown data

    Exercise interventions showed a large effect on depressive symptoms compared with non-active controls (SMD=−0.946, 95% CI −1.18 to −0.71).

    “demonstrating large effects (standardised mean difference (SMD)=−0.946, 95% CI −1.18 to −0.71) favouring exercise interventions”
    • Also stated in: § Main analysis · plain
      “The main analysis of pooled data from 41 studies showed a large effect favouring exercise for a pre-post-correlation of 0.7 (SMD=−0.946, 95% CI −1.18 to −0.71, p<0.001, I2=82.49, p<0.001”
    Quote in the paperSubstantial claim
  • Findingown data

    Visual inspection of the funnel plot did not indicate risk of bias.

    “The visual inspection of the funnel plot (see online supplemental figure 1) did not indicate risk of bias.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Excluding studies with high risk of bias rendered a moderate effect favouring exercise (SMD=−0.717, 95% CI −1.01 to −0.43).

    “Excluding studies with high risk of bias (see online supplemental table 3) rendered a moderate effect favouring exercise intervention (SMD=−0.717, 95% CI −1.01 to −0.43, p<0.001, I2=82.372, p<0.001).”
    Quote in the paperSubstantial claim
  • Findingown data

    Excluding studies with less than 6 weeks of intervention showed a large effect favouring exercise (SMD=−0.959, 95% CI −1.21 to −0.71).

    “Excluding studies with less than 6 weeks of intervention (see online supplemental table 1) showed a large effect favouring exercise intervention (SMD=−0.959, 95% CI −1.21 to −0.71, p<0.001, I2=84.132, p<0.001).”
    Quote in the paperNot a substantial claim
  • May combine two claims. 33
  • Classified as probably not a substantial claim. 23

  • May combine two claims.

    Findingown data

    Publication bias was indicated by Begg-Mazumdar Kendall's Tau (=−0.379, p<0.001) and Egger tests (intercept=−2.706, p<0.001).

    “Publication bias was indicated by Begg-Mazumdar Kendall’s Tau37 (=−0.379, p<0.001 and the Egger38 tests (intercept=−2.706, p<0.001).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The beneficial effect of exercise on depression remained for all subgroups regarding depression classification, risk of bias, group exercise, sample size of the trial and supervision by exercise professionals.

    “Subgroup analyses (summarised in table 1) showed that the beneficial effect of exercise on depression remained for all subgroups regarding depression classification, risk of bias, group exercise, the sample size of the trial and supervision by exercise professionals.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Subgroup analyses with health education, light exercise interventions, or unsupervised training showed comparable SMDs but no significant effects.

    “Subgroup analyses with health education, with light exercise interventions, or with unsupervised training only including small numbers of analysed studies showed comparable SMDs but no significant effects.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Limiting analyses to studies with low risk of bias and some concerns revealed similar results but with effect sizes declining from high to moderate for most analyses.

    “Limiting analyses to studies with low risk of bias and some concerns according to ROB 2 reveal similar results but with ESs declining from high to moderate for most analyses”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In meta-regression with studies with low and moderate risk of bias, duration of trials moderated the effect overall (β=0.064, 95% CI 0.01 to 0.126, p=0.04, R2=0.12) and for MDD only (β=0.070, 95% CI 0.01 to 0.14, p=0.034, R2=0.26).

    “A meta-regression with studies with low and moderate risk of bias (see online supplemental table 8) rendered a moderating effect of duration of trials overall (β=0.064, 95% CI 0.01 to 0.126, p=0.04, R²=0.12) as well as for MDD only (β=0.070, 95% CI 0.01 to 0.14, p=0.034, R²=0.26).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Most trial arms (k=30) investigated aerobic exercise detecting large effects followed by resistance training with comparable outcomes.

    “Regarding the type of exercise, most trial arms (k=30) investigated aerobic exercise detecting large effects followed by resistance training with comparable outcomes.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Minimal differences were detected between group and non-group exercise interventions favouring group exercise, with both showing large effects.

    “Minimal differences were detected between group and non-group exercise interventions favouring group exercise, with both showing large effects.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Supervised exercise revealed large effect sizes compared with unsupervised exercise with small effects.

    “Supervised exercise revealed large ESs compared with unsupervised exercise with small effects.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Studies with sample sizes in the intervention arm of less than 25 participants showed large effects (SMD=−0.868 to −1.281), whereas larger samples showed moderate effects (SMD=−0.532).

    “Large effects were also found for studies including sample sizes in the intervention arm of less than 25 participants (SMD=−0.868 to −1.281) whereas larger samples of participants revealed moderate effects (SMD=−0.532).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Only two arms investigated light intensity exercise while 26 and 10 trials applied moderate and vigorous intensity respectively, with all trials evidencing large effects.

    “In terms of the exercise intensity, only two arms investigated light intensity exercise while 26 and 10 trials applied moderate and vigorous intensity respectively, with all trials evidencing large effects.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Focusing solely on diagnosed MDD, significant effects of exercise were found for all subgroup analyses except for light and mixed exercise, unsupervised training and studies with some concern for risk of bias.

    “Focusing on solely diagnosed MDD, significant effects of exercise were found for all subgroup analyses except for light and mixed exercise, unsupervised training and for studies with some concern for risk of bias”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The present findings are based on an additional 17 studies since Schuch et al's review and 4 studies following the most recent meta-analysis by Carneiro et al.

    “Notably, the present findings are based on an additional 17 studies44 45 48 52 53 55 59 62 67–69 71 74 78 79 84 since Schuch et al’s20 review and 445 55 68 74 studies following the most recent meta-analysis by Carneiro et al,17 comprising only 15 studies focusing on different inclusion criteria including medication in treatment and control arm conditions.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Schuch et al 20

      Not checked in the free run.

    • cites Carneiro et al 17

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  • May combine two claims.

    Findingown data

    The NNT was 2 for the main analysis, 2.8 in low risk of bias studies, 1.9 in MDD only, and 1.6 in supervision by other professionals/students.

    “The NNT for the main-analysis was 2, while it was 2.8 in the low risk of bias studies, 1.9 in MDD only and 1.6 in supervision by other professionals/students.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    For the main analyses, 95% CIs were documented for exercise conditions comprising moderate intensity, aerobic exercise, group exercise, and supervised exercise (ranging between 26 and 41 included studies).

    “for the main analyses, 95% CIs were documented for exercise conditions comprising moderate intensity, aerobic exercise, group exercise and supervised exercise (ranging between 26 and 41 included studies)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Exercise showed an additional decline over control conditions of −4.70 points on the HAM-D in 16 studies and −6.49 on the BDI in eight studies.

    “exercise showed an additional declining effect over control conditions of −4.70 points in the HAM-D as a diagnostic clinician measure in 16 studies and −6.49 in the BDI in eight studies”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    The included studies in the current and former reviews consisted of samples meeting trial inclusion criteria: individuals willing, motivated, and physically able to take part in the exercise regimen, and excluded individuals with diagnoses for which exercise may pose a risk.

    “the studies included in the current and former reviews consisted of samples which met the trial inclusion criteria comprising individuals that were willing, motivated and physically able to take part in the exercise regimen (eg, assessed by the Physical Activity Readiness Questionnaire91) and excluded individuals with diagnoses that exercise may pose a risk”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [91] source

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  • May combine two claims.

    Findingown data

    The included studies were mainly conducted in high-income and upper-middle income countries; no study was identified from the African continent.

    “the included studies were mainly conducted in high-income and upper-middle income countries, for example, no study was identified from the African continent.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Studies with larger sample sizes showed smaller but still moderate effects.

    “studies with larger samples sizes showed smaller but still moderate effects.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Five investigators judged article eligibility with disagreements resolved through discussion.

    “Five investigators (NS/ LLB, DH, FS, AH) judged article eligibility with any disagreements resolved through discussion.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Publication bias was assessed with visual inspection of funnel plots, Begg-Mazumdar Kendall's tau and Egger bias test.

    “Publication bias was assessed with visual inspection of funnel plots and with the Begg-Mazumdar Kendall’s tau37 and Egger bias test.38”
    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 conductcitation

    The PRISMA Statement (updated version) and PERSiST guidance were followed.

    “The PRISMA Statement was followed23 in its updated version24 additionally considering the PERSiST guidance (implementing PRISMA in Exercise, Rehabilitation, Sport medicine and SporTs science).25”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Selected studies were assessed by three independent authors for overall risk of bias using the revised Cochrane risk-of-bias tool for randomised trials (RoB2).

    “Selected studies were assessed by three independent authors (NS/ LLB, DH) given an overall estimation of risk of bias (ie, low risk, some concerns or high risk) according to the revised Cochrane risk-of-bias tool for randomised trials (RoB2).33”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    All results were calculated on an intention-to-treat basis.

    “All results were calculated on an intention-to-treat basis.”
    Quote in the paperSubstantial claim

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

    Study design and conductnone given

    Meta-regression assumptions were tested in JASP.

    “Meta-regression assumptions were tested in JASP.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    This systematic review and meta-analysis was registered in PROSPERO with protocol number CRD42020210651.

    “PROSPERO registration no CRD42020210651”
    • Also stated in: § Search strategy and selection criteria · plain
      “This systematic review and meta-analysis was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the protocol number CRD42020210651.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    All manuscripts were reviewed by at least two independent reviewers.

    “All manuscripts were reviewed by at least two independent reviewers.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    Sensitivity analyses with pre-post correlations of 0.6 and 0.8 were calculated.

    “Sensitivity analyses with pre-post-correlations of 0.6 and 0.8 were calculated to investigate changes in effect with less or more conservative values.”
    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

    Three reviewers independently determined potentially eligible articles using titles and abstracts, then applied eligibility criteria after full texts, with consensus.

    “Three reviewers (NS/LLB, DH) independently determined potentially eligible articles meeting the inclusion criteria using the titles and abstracts. Three independent reviewers (NS/LLB, DH) then applied the eligibility criteria after obtaining the full texts and generated a final list of included articles through consensus.”
    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 conductown data

    Data extraction was done by three reviewers independently using a systematic extraction form.

    “Data extraction was done by three reviewers (NS/ LLB, DH) independently. A systematic extraction form was used for each article to collect the following data:”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Cipriani et al found medication to be more effective in comparison to placebo with Odds ratio of 2.13 indicating a small effect size of d=0.417.

    “while in terms of antidepressant efficacy, Cipriani et al 86 found medication to be more effective in comparison to placebo with Odds ratio of 2.13 indicating a small ES of d=0.417.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Cipriani et al 86

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

    Premisecitation

    A recent meta-analysis by Cuijpers et al found a moderate effect size for psychotherapy treatment for depression across all age groups (g=0.75), and also when solely including studies with low risk of bias (g=0.51).

    “A recent meta-analysis of Cuijpers et al 85 found a moderate ES for psychotherapy treatment for depression across all age groups (g=0.75), and also when solely including studies with low risk of bias (g=0.51)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Cuijpers et al 85

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

    Premisecitation

    An earlier meta-analysis by Schuch et al was based on 25 studies including 1487 participants and revealed high heterogeneity of I2 82.10%.

    “These results extend the findings from an earlier meta-analysis of Schuch et al 20 (based on 25 studies including 1487 participants, revealing high heterogeneity of I2 82.10%).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Schuch et al 20

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Meta-regressions indicated a moderating effect of trial duration favouring shorter interventions and remained robust in meta-regressions without studies of high risk of bias.

    “Meta-regressions indicated a moderating effect of trial duration favouring shorter interventions and remained robust in meta-regressions without studies of high risk of bias.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The positive effect of exercise remained significant regardless of risk of bias, depression classification, exercise type, group setting, type of supervision or sample size.

    “specifically, the positive effect of exercise remained significant regardless of risk of bias, depression classification, exercise type, group setting, type of supervision or sample size.”
    Quote in the paperSubstantial claim

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

    Study design and conductreasoning

    A further study was excluded because participants were offered internet-guided text modules on becoming more physically active but no actual exercise intervention was administered.

    “A further study was also excluded because participants were offered internet guided text modules on how to become more physically active but no actual exercise intervention was administered.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    The current review excluded 13 of the 35 trials in Cooney et al.'s Cochrane meta-analysis because their control groups received psychotherapy or pharmacotherapy, their exercise groups received exercise combined with another therapy or no therapy, or participants did not meet criteria for depression.

    “the current review excluded 13 of these studies as groups were labelled as either ‘controls’ (ie, they received psychotherapy or pharmacotherapy) or groups labelled as ‘exercise’ groups (ie, they received a combination of exercise and another form of therapy or no therapy at all) or participants did not meet criteria for depression”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [21] Cooney, 2013, Exercise for depression, Cochrane Database Syst Rev

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    A cause for concern has been raised in several reviews that exercise does not have a significant effect when restricted to 'low risk of bias' randomised controlled trials.

    “Importantly, a cause for concern has been raised in several reviews that exercise does not have a significant effect when restricted to ‘low risk of bias’ randomised controlled trials (RCTs).18 21”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites 18 21

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    Premisecitation

    About two thirds of adults with depression do not receive adequate treatment.

    “Importantly, about two thirds of adults with depression do not receive adequate treatment.13”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] source

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  • Classified as probably not a substantial claim.

    Premisecitation

    Even light intensity exercise can exert antidepressant effects.

    “This creates the potential for bias22 as even light intensity exercise can exert antidepressant effects.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [22] Ekkekakis, 2015, Honey, I shrunk the pooled SMD! guide to critical appraisal of systematic reviews and meta-analyses using the Cochrane review on exercise for depression as example, Mental Health and Physical Activity source

      Not checked in the free run.

  • May combine two claims.

    Interpretationnone given

    Former published meta-analyses in this field included a notable proportion of trials with questionable intervention or control group conditions, resulting in an inability to detect the effect of exercise per se.

    “This summary reveals that a notable methodological limitation based on the former published meta-analyses in this field, included a proportion of trials with questionable intervention or control group conditions, which resulted in the inability to detect the effect of exercise per se (while excluding other forms of interventions).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Excluding trials with active comparators or combined interventions isolates the effect of exercise per se.

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

    Premisecitation

    Some meta-analyses found moderate, weak or no effects of exercise while others reported large effects.

    “However, some of these meta-analyses18 21 found moderate, weak or no effects of exercise while others reported large effects.17 19 20”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites 18 21

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    • cites 17 19 20

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

    Premisecitation

    Exercise has been recommended as an adjunct treatment for depression by both the WHO and NICE guidelines.

    “Exercise has been recommended as an adjunct treatment for depression by both the WHO15 and National Institute for Health and Care Excellence (NICE) guidelines.16”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [15] World Health Organization . WHO guidelines on physical activity and sedentary behaviour. 2020.

      Not checked in the free run.

    • cites [16] National Institute for Health and Care Excellence . Depression: the treatment and management of depression in adults. 2018. Available: https://www.nice.org.uk/guidance/cg90/ [Accessed 6 Nov 2021].

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    The current review used the RoB2 risk of bias tool and included a greater number of low risk of bias trials (11) than Krogh et al.'s meta-analysis (4).

    “we used the current risk of bias tool (RoB2) and included a greater number of low risk of bias trials compared with Krogh et al’s18 meta-analysis (11 vs 4).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] Krogh, 2017, Exercise for patients with major depression: a systematic review with meta-analysis and trial sequential analysis, BMJ Open source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    If 100 people were in each of the control and exercise groups, 20 participants in the control group and 54 in the exercise group for the main analysis, and 43 in the exercise group for the low risk of bias studies, can be expected to have favourable outcomes.

    “if 100 people were each in the control and the exercise group, 20 participants in the control and 54 in the exercise group for the main analysis and 43 in the exercise group for the low risk of bias studies, analyses can be expected to have favourable outcomes.89”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [89] Magnusson K . Interpreting cohen’s d effect size. 2021. Available: https://rpsychologist.com/cohend/ [Accessed 3 Dec 2021].

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Earlier trials published before 2001 might not reflect current standards and/or feature incomplete reporting of methodological details introduced with CONSORT, increasing scope in biased risk assessments and heterogeneity.

    “This means that these earlier trials might not reflect the current standards and/or feature incomplete reporting of methodological details that was introduced with the CONSORT guidelines and checklist, therefore increasing scope in biased risk assessments and heterogeneity.22 90”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [22] Ekkekakis, 2015, Honey, I shrunk the pooled SMD! guide to critical appraisal of systematic reviews and meta-analyses using the Cochrane review on exercise for depression as example, Mental Health and Physical Activity source

      Not checked in the free run.

    • cites [90] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The effect of exercise is comparable to recent meta-analyses of psychotherapy (NNT 2.5 main, 3.5 low risk of bias) and medication (NNT 4.3).

    “This effect is comparable to recent meta-analyses with psychotherapy revealing a NNT of 2.5 for the main analyses and 3.5 in the low risk of bias studies and for medication of 4.3.85 86”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [85] Cuijpers, 2020, Psychotherapy for depression across different age groups: a systematic review and meta-analysis, JAMA Psychiatry source

      Not checked in the free run.

    • cites [86] Cipriani, 2018, Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis, Focus (Am Psychiatr Publ)

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    The findings from this review represent the most up-to-date and comprehensive meta-analysis of the available evidence.

    “The findings from this review represent the most up to date and comprehensive meta-analysis of the available evidence”
    Quote in the paperNot a substantial claim

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

    Interpretationnone given

    High heterogeneity among included studies can stem from different control group conditions, cultural backgrounds, gender distribution, variable forms of assessments, and diagnosis of depression severity or MDD.

    “We acknowledge that limitations lie in the high heterogeneity of the included studies that can stem from different control group conditions, cultural backgrounds, gender distribution, variable forms of assessments and diagnosis of depression severity or MDD.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationown data

    These outcomes provide adequate evidence to support the recommendation that exercise has utility in treating depression based on the aforementioned conditions.

    “These outcomes provide adequate evidence to support the recommendation that exercise has utility in treating depression based on the aforementioned conditions.”
    Quote in the paperNot a substantial claim
49 of 49

  • The paper relies on this without support.

    A large volume of studies has been published within the last 5 years, requiring an updated meta-analysis on the antidepressant effects of exercise.

    “However, a large volume of studies has been published within the last 5 years, requiring an updated meta-analysis on the antidepressant effects of exercise, while addressing the shortcomings of previous reviews.”

  • The paper relies on this without support.

    Non-inferiority trials indicate that exercise is non-inferior to current first line treatments.

    “Non-inferiority trials indicate that exercise is non-inferior to current first line treatments, and evidence that exercise is effective at long-term follow-ups are needed to clarify the identified evidence gaps.”

  • The paper relies on this without support.

    Excluding trials with active comparators or combined interventions isolates the effect of exercise per se.

    “which resulted in the inability to detect the effect of exercise per se (while excluding other forms of interventions).”

  • The paper relies on this without support.

    Comparing exercise treatment groups only with non-exercising control groups isolates the effect of exercise per se.

    “To reduce risk of bias, we compared exercise treatment groups with non-exercising control groups only.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

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

  • Trial-duration meta-regression coefficient differs from the table

    Minor

    The results text reports β=0.032 for trial duration in the main analysis, while table 2 reports β=0.047 for the same moderator and analysis.

  • Low-risk-of-bias trial count differs from the table

    Minor

    The discussion says this review included 11 low-risk-of-bias trials, but table 1 and the risk-of-bias results both report 12.

  • Abstract and methods give different database lists

    Minor

    The abstract lists Scopus and Web of Science among the databases searched, but the methods' stated list of databases searched omits both.

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. American Psychiatric Association . Diagnostic and statistical manual of mental disorders (DSM IV). American Psychiatric Press, 2000.
  2. 10.2307/20056429 · DOI

Cited by

Sorted by citations

Related

Authors
Heissel, A., Heinen, D., Brokmeier, L. L., Skarabis, N., Kangas, M., Vancampfort, D., Stubbs, B., Firth, J., Ward, P. B., Rosenbaum, S., Hallgren, M., & Schuch, F.
Affiliations
  • University of Potsdam (DE)
  • Macquarie University (AU)
  • KU Leuven (BE)
  • King's College London (GB)
  • Greater Manchester Mental Health NHS Foundation Trust (GB)
  • UNSW Sydney (AU)
  • Karolinska Institutet (SE)
  • Universidade Federal do Rio de Janeiro (BR)
Corresponding author
Heissel, Andreas
ORCID
Venue
British Journal of Sports Medicine
Publisher
BMJ
Published
2023-02-01
Volume
57
Issue
16
Pages
1049-1057
ISSN
  • 0306-3674 (ISSN-L)
  • 1473-0480
DOI
10.1136/bjsports-2022-106282
PMC
PMC10423472
OpenAlex
W4319022775
Cited by
449
References
85
Citations by year
2026: 132 · 2025: 144 · 2024: 126 · 2023: 47
FWCI
16.02
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)
  • Lirias (KU Leuven) (acceptedVersion, cc-by-nc)
  • Lirias (KU Leuven) (submittedVersion, cc-by-nc)
  • Figshare (submittedVersion, cc-by-nc)
  • HighWire Press Open Archive (submittedVersion)
  • Research Explorer (The University of Manchester) (submittedVersion, cc-by-nc)
Funders
National Institute for Health and Care Research (NIHR301206)
Topics
  • Health Sciences › Medicine › Physiology › Physical Activity and Health
  • Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
exercise medicine, depressive symptoms, major depressive disorder, aerobic exercise, resistance training, supervised exercise, group exercise, publication bias, risk of bias
MeSH terms
Depression, Depressive Disorder, Major, Major Depressive Disorder, Exercise Therapy, Humans, Exercise

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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