CoChat
Sign Up
Cited by 707Physical Activity and HealthTreatment of Major DepressionAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials

Open access
Noetel, Michael, Sanders, Taren, Gallardo-Gómez, Daniel, Taylor, Paul, del Pozo Cruz, Borja, van den Hoek, Daniel, Smith, Jordan J, Mahoney, John +10 more·2024·BMJ
DOI 10.1136/bmj-2023-075847PMC PMC10870815
Open this paper in CoChat — free accountOpen PDF

Abstract

Objective: To identify the optimal dose and modality of exercise for treating major depressive disorder, compared with psychotherapy, antidepressants, and control conditions. Design: Systematic review and network meta-analysis. Methods: Screening, data extraction, coding, and risk of bias assessment were performed independently and in duplicate. Bayesian arm based, multilevel network meta-analyses were performed for the primary analyses. Quality of the evidence for each arm was graded using the confidence in network meta-analysis (CINeMA) online tool. Data sources: Cochrane Library, Medline, Embase, SPORTDiscus, and PsycINFO databases. Eligibility criteria for selecting studies: Any randomised trial with exercise arms for participants meeting clinical cut-offs for major depression. Results: 218 unique studies with a total of 495 arms and 14 170 participants were included. Compared with active controls (eg, usual care, placebo tablet), moderate reductions in depression were found for walking or jogging (n=1210, κ=51, Hedges’ g −0.62, 95% credible interval −0.80 to −0.45), yoga (n=1047, κ=33, g −0.55, −0.73 to −0.36), strength training (n=643, κ=22, g −0.49, −0.69 to −0.29), mixed aerobic exercises (n=1286, κ=51, g −0.43, −0.61 to −0.24), and tai chi or qigong (n=343, κ=12, g −0.42, −0.65 to −0.21). The effects of exercise were proportional to the intensity prescribed. Strength training and yoga appeared to be the most acceptable modalities. Results appeared robust to publication bias, but only one study met the Cochrane criteria for low risk of bias. As a result, confidence in accordance with CINeMA was low for walking or jogging and very low for other treatments. Conclusions: Exercise is an effective treatment for depression, with walking or jogging, yoga, and strength training more effective than other exercises, particularly when intense. Yoga and strength training were well tolerated compared with other treatments. Exercise appeared equally effective for people with and without comorbidities and with different baseline levels of depression. To mitigate expectancy effects, future studies could aim to blind participants and staff. These forms of exercise could be considered alongside psychotherapy and antidepressants as core treatments for depression. Systematic review registration: PROSPERO CRD42018118040.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and network meta-analysis of 218 randomised trials found that exercise produces moderate reductions in depression compared with active controls, with walking/jogging, yoga, strength training, and dance among the more effective modalities. Effects appeared proportional to prescribed intensity, but confidence in the evidence was low for walking/jogging and very low for other modalities.

Key findings

  • Across 218 unique studies, 495 arms, and 14,170 participants, exercise reduced depression compared with active controls: dance (n=107, κ=5, Hedges’ g −0.96, 95% credible interval −1.36 to −0.56), walking or jogging (n=1210, κ=51, g −0.63, −0.80 to −0.46), yoga (n=1047, κ=33, g −0.55, −0.73 to −0.36), strength training (n=643, κ=22, g −0.49, −0.69 to −0.29), mixed aerobic exercises (n=1286, κ=51, g −0.43, −0.61 to −0.25), and tai chi or qigong (n=343, κ=12, g −0.42, −0.65 to −0.21).
  • Effects were proportional to prescribed intensity: light physical activity had g −0.58 (−0.82 to −0.33), while vigorous exercise had g −0.74 (−1.10 to −0.38).
  • Strength training (odds ratio 0.55, 95% credible interval 0.31 to 0.99) and yoga (0.57, 0.35 to 0.94) had lower odds of dropout than active control.
  • Confidence in the evidence was low for walking or jogging and very low for other treatments; only one study met Cochrane criteria for low risk of bias.

Methods

  • Systematic review and Bayesian arm-based multilevel network meta-analysis of randomised controlled trials, registered as PROSPERO CRD42018118040 and reported per PRISMA-NMA.
  • Searches covered Cochrane Library, Medline, Embase, SPORTDiscus, and PsycINFO, with no language restrictions; eligible trials included exercise arms for participants meeting clinical cut-offs for major depression.
  • Main analyses used Hedges’ g standardised mean change from baseline, with active controls grouped and waitlist control separated; credibility was assessed with CINeMA, and moderation analyses examined intensity, dose, age, sex, baseline depression, comorbidities, behaviour change techniques, autonomy, and funding.

Limitations

  • The paper states that only one study met Cochrane criteria for low risk of bias, most studies did not blind participants or staff, and confidence was low for walking or jogging and very low for other treatments.
  • The paper notes that publication bias was present, though not enough to nullify effects; risk-of-bias judgements may be too conservative because RoB 1 was used and many studies predated reporting checklists.
  • The paper states that age and sex moderation was at the study level rather than individual level, dance evidence came from few studies with mostly young women, and searches were not designed to systematically capture grey literature or trial registries.

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

Integrity signals

Registry

Crossref · 10.1136/bmj-2023-075847

Cites

64 of 64 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 45 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Compared with active controls, mixed aerobic exercises produced a moderate reduction in depression (Hedges' g about -0.43, 95% credible interval about -0.61 to -0.24).

    “mixed aerobic exercises (n=1286, κ=51, g −0.43, −0.61 to −0.24)”
    • Also stated in: § Synthesis of results · plain
      “mixed aerobic exercises (n=1286, κ=51, g=−0.43, −0.61 to −0.25)”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Exercise interventions can be grouped into homogenous nodes for network meta-analysis.
  • Findingown data

    Aerobic exercise combined with psychotherapy produced a moderate, clinically meaningful reduction in depression compared with active controls (Hedges' g -0.54, 95% credible interval -0.76 to -0.32).

    “or aerobic exercise was combined with psychotherapy (n=404, κ=15, g=−0.54, −0.76 to −0.32)”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Exercise interventions can be grouped into homogenous nodes for network meta-analysis.
  • Findingown data

    Cognitive behaviour therapy alone produced a moderate reduction in depression compared with active controls (Hedges' g -0.55, 95% credible interval -0.75 to -0.37).

    “effects were moderate for cognitive behaviour therapy alone (n=712, κ=20, g=−0.55, −0.75 to −0.37)”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Exercise interventions can be grouped into homogenous nodes for network meta-analysis.
  • Findingown data

    Exercise combined with SSRIs produced a moderate, clinically meaningful reduction in depression compared with active controls (Hedges' g -0.55, 95% credible interval -0.86 to -0.23).

    “Moderate, clinically meaningful effects were also present when exercise was combined with SSRIs (n=268, κ=11, g=−0.55, −0.86 to −0.23)”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Exercise interventions can be grouped into homogenous nodes for network meta-analysis.
  • Findingown data

    Compared with active controls, dance produced a large reduction in depression (Hedges' g -0.96, 95% credible interval -1.36 to -0.56).

    “large reductions in depression were found for dance (n=107, κ=5, Hedges’ g −0.96, 95% credible interval −1.36 to −0.56)”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Exercise interventions can be grouped into homogenous nodes for network meta-analysis.
  • May combine two claims. 40
  • Classified as probably not a substantial claim. 48

  • May combine two claims.

    Findingown data

    The review included 218 unique studies with 495 arms and 14,170 participants.

    “218 unique studies with a total of 495 arms and 14 170 participants were included.”
    • Also stated in: § Study selection · plain
      “A total of 218 unique studies described in 246 reports were included, totalling 495 arms and 14 170 participants.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    There was no indication that participants were likely to relapse within the measurement period; effects remained steady when measured directly after the intervention or up to six months later.

    “We found no indication that participants were likely to relapse within the measurement period (see supplementary file, section S12); effects remained steady when measured either directly after the intervention (g=−0.59, −0.80 to −0.39) or up to six months later (g=−0.63, −0.87 to −0.40).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The global test design-by-treatment interaction model was not statistically significant, supporting the assumption of transitivity.

    “The results of the global test design-by-treatment interaction model were not statistically significant, supporting the assumption of transitivity (χ2=94.92, df=75, P=0.06).”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The network meta-analysis assumes transitivity: the only systematic difference between arms is the treatment, not other confounders.

  • May combine two claims.

    Findingown data

    Evidence of publication bias was found for overall estimates of exercise on depression compared with active controls, although not enough to nullify effects.

    “Evidence of publication bias was found for overall estimates of exercise on depression compared with active controls, although not enough to nullify effects.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Funnel plots showed asymmetry, but the pooled effects remained statistically significant when only including non-significant studies.

    “Funnel plots showed asymmetry, but the result of pooled effects remained statistically significant when only including non-significant studies”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Overall risk of bias for most studies was unclear or high, and effect sizes could include expectancy effects, among other biases.

    “As a result, overall risk of bias for most studies was unclear or high, and effect sizes could include expectancy effects, among other biases.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    Confidence in the effects was low for walking or jogging and very low for other modalities.

    “Overall, walking or jogging had low confidence, with other modalities being very low.”
    • Also stated in: § Results · plain
      “confidence in accordance with CINeMA was low for walking or jogging and very low for other treatments.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Group exercise appeared to moderate effects: overall effects were similar for individual and group exercise, but some interventions were better delivered in groups (yoga) and some individually (strength training, mixed aerobic exercise).

    “Use of group exercise appeared to moderate the effects: although the overall effects were similar for individual (g=−1.10, −1.57 to −0.64) and group exercise (g=−1.16, −1.61 to −0.73), some interventions were better delivered in groups (yoga) and some were better delivered individually (strength training, mixed aerobic exercise”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    In isolation, the most effective exercise modalities were walking or jogging, yoga, strength training, and dancing.

    “In isolation, the most effective exercise modalities were walking or jogging, yoga, strength training, and dancing.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    Our review did not uncover clear causal mechanisms.

    “Our review did not uncover clear causal mechanisms, but the trends in the data are useful for generating hypotheses.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    The benefits from exercise tended to be proportional to the intensity prescribed, with vigorous activity being better.

    “The benefits from exercise tended to be proportional to the intensity prescribed, with vigorous activity being better.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    These interventions do have different effects, with yoga being an intervention with strong effects and stretching being better described as an active control condition.

    “In so doing, we found that these interventions do have different effects, with yoga being an intervention with strong effects and stretching being better described as an active control condition.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Autonomy, as provided in the methods of included studies, predicted effects, but in the opposite direction to our hypotheses: more autonomy was associated with weaker effects.

    “We did find that autonomy, as provided in the methods of included studies, predicted effects, but in the opposite direction to our hypotheses: more autonomy was associated with weaker effects.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Pooled effect sizes decreased when accounting for risk of publication bias, but no degree of publication bias could nullify effects.

    “Specifically, pooled effect sizes decreased when accounting for risk of publication bias, but no degree of publication bias could nullify effects.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Many exercise modalities appear to be effective treatments, particularly walking or jogging, strength training, and yoga, but confidence in many of the findings was low.

    “Many exercise modalities appear to be effective treatments, particularly walking or jogging, strength training, and yoga, but confidence in many of the findings was low.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    Effects appeared proportional to the intensity of exercise prescribed and were stronger for group exercise and interventions with clear prescriptions.

    “Effects appeared proportional to the intensity of exercise prescribed and were stronger for group exercise and interventions with clear prescriptions”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Various exercise modalities are effective (walking, jogging, mixed aerobic exercise, strength training, yoga, tai chi, qigong) and well tolerated (especially strength training and yoga).

    “Various exercise modalities are effective (walking, jogging, mixed aerobic exercise, strength training, yoga, tai chi, qigong) and well tolerated (especially strength training and yoga)”
    Quote in the paperSubstantial claim

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

    Study design and conductnone given

    Screening, data extraction, coding, and risk of bias assessment were performed independently and in duplicate.

    “Screening, data extraction, coding, and risk of bias assessment were performed independently and in duplicate.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Walking or jogging, yoga, and strength training are more effective than other exercises, particularly when intense.

    “with walking or jogging, yoga, and strength training more effective than other exercises, particularly when intense.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The network meta-analysis assumes transitivity: the only systematic difference between arms is the treatment, not other confounders.
    • Rests on an assumption: Exercise interventions can be grouped into homogenous nodes for network meta-analysis.

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

    Study design and conductreasoning

    The analysis strategy was amended after registering the review to better align with new norms established by the Cochrane Comparing Multiple Interventions Methods Group.

    “We amended our analysis strategy after registering our review; these changes were to better align with new norms established by the Cochrane Comparing Multiple Interventions Methods Group.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Yoga and strength training were well tolerated compared with other treatments.

    “Yoga and strength training were well tolerated compared with other treatments.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Exercise appeared equally effective for people with and without comorbidities and with different baseline levels of depression.

    “Exercise appeared equally effective for people with and without comorbidities and with different baseline levels of depression.”
    Quote in the paperSubstantial claim

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

    Study design and conductnone given

    Cochrane's risk of bias tool for randomised controlled trials was used.

    “We used Cochrane’s risk of bias tool for randomised controlled trials.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Findings are presented according to the PRISMA-NMA guidelines.

    “Our findings are presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Network Meta-analyses (PRISMA-NMA) guidelines”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Quality of the evidence for each arm was graded using the confidence in network meta-analysis (CINeMA) online tool.

    “Quality of the evidence for each arm was graded using the confidence in network meta-analysis (CINeMA) online tool.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Informative priors based on the distributional parameters of the meta-analytical model were preregistered.

    “We preregistered informative priors based on the distributional parameters of our meta-analytical model.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    All prespecified moderation and sensitivity analyses were performed.

    “All prespecified moderation and sensitivity analyses were performed.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Even taking conservative estimates, practitioners can expect patients to experience clinically significant effects from walking, running, yoga, qigong, strength training, and mixed aerobic exercise.

    “For example, even taking conservative estimates (ie, the least favourable end of the credible interval), practitioners can expect patients to experience clinically significant effects from walking, running, yoga, qigong, strength training, and mixed aerobic exercise.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The observed effect sizes correspond to clinically significant improvements for patients.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    Exercise modalities such as running may satisfy many of the mechanisms, but they are unlikely to directly promote the mindful self-awareness provided by yoga and qigong.

    “Exercise modalities such as running may satisfy many of the mechanisms, but they are unlikely to directly promote the mindful self-awareness provided by yoga and qigong.”
    Quote in the paperNot a substantial claim

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

    Interpretationcitation

    Treatment guidelines may be overly conservative by conditionally recommending exercise as complementary or alternative treatment for patients in whom psychotherapy or pharmacotherapy is either ineffective or unacceptable.

    “Although confidence in many of the results was low, treatment guidelines may be overly conservative by conditionally recommending exercise as complementary or alternative treatment for patients in whom psychotherapy or pharmacotherapy is either ineffective or unacceptable.60”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [60] American Psychological Association. Clinical practice guideline for the treatment of depression across three age cohorts. American Psychological Association; 2019. https://www.apa.org/depression-guideline/

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Meta-analyses have found social interaction, mindfulness or experiential acceptance, increased self-efficacy, immersion in green spaces, neurobiological mechanisms, and acute positive affect to be associated with decreases in depressive symptoms.

    “Meta-analyses have found each of these factors to be associated with decreases in depressive symptoms, but no single treatment covers all mechanisms.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [61] source

      Not checked in the free run.

    • cites [62] source

      Not checked in the free run.

    • cites [33] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    We were able to combine the strengths of various approaches to exercise and to make more nuanced and precise conclusions.

    “As a result, we were able to combine the strengths of various approaches to exercise and to make more nuanced and precise conclusions.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    We used methods that enabled us to separately analyse the effects of these treatment modalities.

    “We used methods that enabled us to separately analyse the effects of these treatment modalities.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    We attribute the stronger effect sizes for some exercise types to the study level data available in a network meta-analysis compared with an overview of reviews and higher power compared with meta-analyses with smaller numbers of included studies.

    “We attribute this to the study level data available in a network meta-analysis compared with an overview of reviews 24 and higher power compared with meta-analyses with smaller numbers of included studies.22 28”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [24] Chaimani A, Caldwell DM, Li T, Higgins JPT, Salanti G. Undertaking network meta-analyses. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al., editors. Cochrane Handbook for Systematic Reviews of Interventions. Cochrane; 2022. www.training.cochrane.org/handbook

      Not checked in the free run.

    • cites [22] source

      Not checked in the free run.

    • cites [28] source

      Not checked in the free run.

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

    Premisecitation

    Overviews of reviews often include heterogeneous studies without having as much control over moderation analyses.

    “They often include heterogeneous studies without having as much control over moderation analyses (eg, Singh et al included studies covering both prevention and treatment13).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Most existing reviews found various treatment modalities to be equally effective.

    “However, most existing reviews found various treatment modalities to be equally effective.13 27”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [13] source

      Not checked in the free run.

    • cites [27] source

      Not checked in the free run.

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

    Premisenone given

    Overviews of reviews have the ability to more easily cover a wider range of participants, interventions, and outcomes, but also risk double counting randomised trials that are included in separate meta-analyses.

    “Overviews of reviews have the ability to more easily cover a wider range of participants, interventions, and outcomes, but also risk double counting randomised trials that are included in separate meta-analyses.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Network meta-analyses revealed the same phenomenon with psychotherapy: some interventions were robustly more effective than others.

    “Network meta-analyses revealed the same phenomenon with psychotherapy: researchers once concluded there was a dodo bird verdict, whereby “everybody has won, and all must have prizes,”67 until network meta-analyses showed some interventions were robustly more effective than others.6 26”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [6] source

      Not checked in the free run.

    • cites [26] source

      Not checked in the free run.

    • cites [67] Hunsley, 2002, Dodo bird, phoenix, or urban legend?, Sci Rev Ment Health Pract

      Not checked in the free run.

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

    Interpretationreasoning

    Our findings are likely related to the larger power in our review (n=14 170) compared with previous reviews (eg, n=2551), and our ability to better account for heterogeneity in exercise prescriptions.

    “Our findings are likely related to the larger power in our review (n=14 170) compared with previous reviews (eg, n=2551),14 and our ability to better account for heterogeneity in exercise prescriptions.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    One explanation for these data is that people with depression benefit from the clear direction and accountability of a standardised prescription.

    “One explanation for these data is that people with depression benefit from the clear direction and accountability of a standardised prescription.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationnone given

    Many forms of exercise potentially contain therapeutic benefits beyond just energy expenditure.

    “Many forms of exercise potentially contain therapeutic benefits beyond just energy expenditure.”
    Quote in the paperNot a substantial claim

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

    Interpretationreasoning

    After choosing something value aligned, autonomy within the trial may not have helpful.

    “After choosing something value aligned, autonomy within the trial may not have helpful.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Previous reviews on those with mild-moderate depression have found similar effects for exercise or SSRIs, or the two combined.

    “Previous reviews on those with mild-moderate depression have found similar effects for exercise or SSRIs, or the two combined.13 14”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [13] source

      Not checked in the free run.

    • cites [14] source

      Not checked in the free run.

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

    Study design and conductreasoning

    The measurement of study drop-out is an imperfect proxy of adherence.

    “We found evidence to suggest good acceptability of yoga and strength training; although the measurement of study drop-out is an imperfect proxy of adherence.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    Participants were likely autonomous when self-selecting into trials with exercise modalities they enjoyed, or those that fit their social circumstances.

    “Alternatively, participants were likely autonomous when self-selecting into trials with exercise modalities they enjoyed, or those that fit their social circumstances.”
    Quote in the paperNot a substantial claim

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

    Study design and conductreasoning

    Our judgement of the autonomy provided in the methods may not reflect how much autonomy support patients actually felt.

    “Our judgement of the autonomy provided in the methods may not reflect how much autonomy support patients actually felt.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    Researchers may have used behaviour change techniques such as feedback or goal setting without explicitly reporting them in the study methods.

    “Alternatively, researchers may have used behaviour change techniques such as feedback or goal setting without explicitly reporting them in the study methods.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    When provided with more freedom, the low self-efficacy that is symptomatic of depression may stop patients from setting an appropriate level of challenge.

    “When provided with more freedom, the low self-efficacy that is symptomatic of depression may stop patients from setting an appropriate level of challenge (eg, they may be less likely to choose vigorous exercise).”
    Quote in the paperSubstantial claim

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

    Interpretationreasoning

    These characteristics of a modality may be more influential than coexisting behaviour change techniques.

    “These characteristics of a modality may be more influential than coexisting behaviour change techniques.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationown data

    Exercise may therefore be considered a viable alternative to drug treatment.

    “Exercise may therefore be considered a viable alternative to drug treatment.”
    Quote in the paperSubstantial claim

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

    Interpretationreasoning

    It may be that the modality explains most of the variance between effects, such that behaviour change techniques did not provide a meaningful contribution.

    “It may be that the modality explains most of the variance between effects, such that behaviour change techniques (eg, presence or absence of feedback) did not provide a meaningful contribution.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Although the confidence in the evidence for exercise is less strong than for cognitive behavioural therapy, the effect sizes seem comparable, so it may be an alternative for patients who prefer not to engage in psychotherapy.

    “Specifically, although the confidence in the evidence for exercise is less strong than for cognitive behavioural therapy, the effect sizes seem comparable, so it may be an alternative for patients who prefer not to engage in psychotherapy.”
    Quote in the paperSubstantial claim

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

    Study design and conductreasoning

    Our risk of bias judgements may be too conservative.

    “Therefore, our risk of bias judgements may be too conservative.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Assessments of bias between the two tools are generally comparable, but the RoB 1 tool can be more conservative when assessing open label studies with subjective assessments.

    “Although assessments of bias between the two tools are generally comparable,71 the RoB 1 tool can be more conservative when assessing open label studies with subjective assessments (eg, unblinded studies with self-reported measures for depression).71”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [71] Richter B, Hemmingsen B. Comparison of the Cochrane risk of bias tool 1 (RoB 1) with the updated Cochrane risk of bias tool 2 (RoB 2). Cochrane; 2021. Report No.: 1. https://community.cochrane.org/sites/default/files/uploads/inline-files/RoB1_2_project_220529_BR%20KK%20formatted.pdf

      Not checked in the free run.

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

    Premisecitation

    Blinding for exercise interventions may be harder than for drugs.

    “Blinding for exercise interventions may be harder than for drugs23; however, future studies could attempt to blind participants and staff to the study’s hypotheses to avoid expectancy effects.69”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] source

      Not checked in the free run.

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

    Study design and conductreasoning

    The studies we found may be subject to a range of experimental biases.

    “The studies we found may be subject to a range of experimental biases.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Our review was able to integrate evidence that directly compared exercise with other treatment modalities such as SSRIs or psychotherapy, while also informing estimates using indirect evidence.

    “Similarly, our review was able to integrate evidence that directly compared exercise with other treatment modalities such as SSRIs or psychotherapy, while also informing estimates using indirect evidence (eg, comparing the relative effects of strength training and SSRIs when tested against a waitlist control).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    The small number of studies, low number of participants, and biases in the study designs prohibits us from recommending dance more strongly.

    “But the small number of studies, low number of participants, and biases in the study designs prohibits us from recommending dance more strongly.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    Before CONSORT, few authors explicitly described how they generated a random sequence.

    “For example, before CONSORT, few authors explicitly described how they generated a random sequence.23”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] source

      Not checked in the free run.

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

    Premisecitation

    Doing so can detect additional eligible studies and reveal the numbers of completed studies that remain unpublished.

    “Doing so can detect additional eligible studies72 and reveal the numbers of completed studies that remain unpublished.73”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [72] Lefebvre C Glanville J Briscoe S . Searching for and selecting studies. In: Higgins JPT Thomas J Chandler J , eds. Cochrane Handbook for Systematic Reviews of Interventions. Cochrane, 2022, www.training.cochrane.org/handbook.

      Not checked in the free run.

    • cites [73] source

      Not checked in the free run.

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

    Study design and conductcitation

    Some of our ratings are for studies published before the proliferation of reporting checklists, so the ratings might be too critical.

    “Some of our ratings are for studies published before the proliferation of reporting checklists, so the ratings might be too critical.23”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] source

      Not checked in the free run.

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

    Study design and conductreasoning

    We planned to use the Cochrane risk of bias (RoB) 1 tool so we could use the most recent Cochrane review of exercise and depression to calibrate our raters, and because RoB 2 had not yet been published.

    “Similarly, we planned to use the Cochrane risk of bias (RoB) 1 tool40 so we could use the most recent Cochrane review of exercise and depression12 to calibrate our raters, and because RoB 2 had not yet been published.70”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [40] source

      Not checked in the free run.

    • cites [12] source

      Not checked in the free run.

    • cites [70] source

      Not checked in the free run.

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

    Study design and conductnone given

    We did not exclude grey literature, but our search strategy was not designed to systematically search grey literature or trial registries.

    “We did not exclude grey literature, but our search strategy was not designed to systematically search grey literature or trial registries.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    In low resource or funding constrained settings, group exercise interventions may provide relatively low cost alternatives for patients with depression and for health systems.

    “In low resource or funding constrained settings, group exercise interventions may provide relatively low cost alternatives for patients with depression and for health systems.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Our review found some interesting moderators by age and sex, but these were at the study level rather than individual level.

    “Our review found some interesting moderators by age and sex, but these were at the study level rather than individual level—that is, rather than being able to determine whether women engaging in a strength intervention benefit more than men, we could only conclude that studies with more women showed larger effects than studies with fewer women.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    Network meta-analyses exist that directly focus on psychotherapy and pharmacotherapy, and these combined for treating depression.

    “Network meta-analyses exist that directly focus on psychotherapy7 and pharmacotherapy,25 and these combined for treating depression.6”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [7] source

      Not checked in the free run.

    • cites [25] source

      Not checked in the free run.

    • cites [6] source

      Not checked in the free run.

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

    Premisecitation

    Globally there has been an attempt to reduce stigma associated with seeking treatment for depression.

    “Globally there has been an attempt to reduce stigma associated with seeking treatment for depression.74”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [74] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationreasoning

    Exercise may support this effort by providing patients with treatment options that carry less stigma.

    “Exercise may support this effort by providing patients with treatment options that carry less stigma.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    The same finding applied to age, where studies on older adults were likely adapted specifically to this age group.

    “The same finding applied to age, where studies on older adults were likely adapted specifically to this age group.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    These between study differences may explain the heterogeneity in the effects of interventions, and confounding means our moderators for age and sex should be interpreted cautiously.

    “These between study differences may explain the heterogeneity in the effects of interventions, and confounding means our moderators for age and sex should be interpreted cautiously.”
    Quote in the paperSubstantial claim

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

    Premisenone given

    Those reviews include more than 500 studies comparing psychological or drug interventions with controls.

    “Those reviews include more than 500 studies comparing psychological or drug interventions with controls.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationcitation

    Doing so may help bridge the gap in treatment coverage by increasing the range of first line options for patients and health systems.

    “Doing so may help bridge the gap in treatment coverage by increasing the range of first line options for patients and health systems.9”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] source

      Not checked in the free run.

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

    Interpretationreasoning

    Our findings support the inclusion of exercise as part of clinical practice guidelines for depression, particularly vigorous intensity exercise.

    “Our findings support the inclusion of exercise as part of clinical practice guidelines for depression, particularly vigorous intensity exercise.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    These studies may have been tailored towards women, so effects may be subject to confounding, as both sex and intervention may have changed.

    “These studies may have been tailored towards women, so effects may be subject to confounding, as both sex and intervention may have changed.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Effective exercise modalities could be considered alongside cognitive behaviour therapy and SSRIs as core treatments for depression.

    “Therefore, effective exercise modalities could be considered alongside those intervention as core treatments for depression.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    The World Health Organization recommends physical activity for everyone, including those with chronic conditions and disabilities.

    “The World Health Organization recommends physical activity for everyone, including those with chronic conditions and disabilities,75 but not everyone can access treatment easily.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [75] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    Many patients may have physical, psychological, or social barriers to participation.

    “Many patients may have physical, psychological, or social barriers to participation.”
    Quote in the paperNot a substantial claim
77 of 77

  • The authors state this as an assumption.

    The network meta-analysis assumes transitivity: the only systematic difference between arms is the treatment, not other confounders.

    “Incoherence provides some evidence the network may violate the assumption of transitivity: that the only systematic difference between arms is the treatment, not other confounders.”
    “The results of the global test design-by-treatment interaction model were not statistically significant, supporting the assumption of transitivity (χ2=94.92, df=75, P=0.06).”

  • The paper relies on this without support.

    Exercise interventions can be grouped into homogenous nodes for network meta-analysis.

    “These trials could be included because network meta-analysis methods allows for the grouping of those interventions into homogenous nodes.”

  • The paper relies on this without support.

    The observed effect sizes correspond to clinically significant improvements for patients.

    “practitioners can expect patients to experience clinically significant effects from walking, running, yoga, qigong, strength training, and mixed aerobic exercise.”
3 of 3

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?

  • Physical activity/exercise, dietary modification, adequate sleep, social interaction, and mindfulness-based meditation have shown treatment efficacy in separate clinical trials of depression.

    “These include physical activity/exercise, dietary modification, adequate sleep and social interaction, as well as mindfulness-based meditation, all of which have shown treatment efficacy in separate clinical trials of depression [4–16].”

    From Personalized machine learning guided intervention for optimizing lifestyle behaviors in depression: a pilot study (2026) · cites this paper as [11]

  • The 6-week iMAP protocols in sleep, exercise, diet, or social connection were grounded in evidence-based intervention protocols for these lifestyle domains in depression.

    “Description of each 6-week iMAP in either sleep/ exercise/ diet/ social connection domain is provided in Supplementary Methods section S.5 and is grounded in evidence-based intervention protocols in these lifestyle domains in the context of depression [5, 6, 8, 11, 16, 68–70].”

    From Personalized machine learning guided intervention for optimizing lifestyle behaviors in depression: a pilot study (2026) · cites this paper as [11]

  • Lifestyle targeted behavioral interventions in depression have typically shown small-to-medium effect sizes of ~0.3-0.5, while the placebo effect of behavioral interventions is even smaller ~0.2 in RCTs.

    “Lifestyle targeted behavioral interventions in depression have typically shown small-to-medium effect sizes of ~0.3–0.5 [4–16], while the placebo effect of behavioral interventions are even smaller ~0.2 in RCTs [101, 102].”

    From Personalized machine learning guided intervention for optimizing lifestyle behaviors in depression: a pilot study (2026) · cites this paper as [11]

Cites

Flagged first, then by citations

Research works printed but not linked: 6

  1. National Collaborating Centre for Mental Health (UK). Depression: The Treatment and Management of Depression in Adults (Updated Edition). Leicester (UK): British Psychological Society; https://www.ncbi.nlm.nih.gov/pubmed/22132433
  2. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. Third Edition. Washington, DC: American Psychiatric Association; 2010. 87 p. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd-1410197717630.pdf
  3. 10.2307/20056429 · DOI
  4. Veritas Health Innovation. Covidence systematic review software. Melbourne, Australia; 2023. www.covidence.org
  5. Chu IH . Effect of exercise intensity during aerobic training on depressive symptoms in initially sedentary depressed women. Dissertation Abstracts International B: Sciences and Engineering 2018;78(11-B(E)).
  6. Hunsley, 2002, Dodo bird, phoenix, or urban legend?, Sci Rev Ment Health Pract, 1, 11

Cited by

Sorted by citations

Related

Authors
Noetel, M., Sanders, T., Gallardo-Gómez, D., Taylor, P., del Pozo Cruz, B., van den Hoek, D., Smith, J. J., Mahoney, J., Spathis, J., Moresi, M., Pagano, R., Pagano, L., Vasconcellos, R., Arnott, H., Varley, B., Parker, P., Biddle, S., & Lonsdale, C.
Affiliations
  • The University of Queensland (AU)
  • Australian Catholic University (AU)
  • Department of Physical Education and Sport, University of Seville, Seville, Spain
  • Department of Clinical Biomechanics and Sports Science, University of Southern Denmark, Odense, Denmark
  • School of Health and Behavioural Sciences, University of the Sunshine Coast, Petrie, QLD, Australia
  • University of Newcastle Australia (AU)
  • Macquarie University (AU)
  • The University of Sydney (AU)
  • University of Southern Queensland (AU)
Corresponding author
Noetel, Michael
ORCID
Venue
BMJ
Publisher
BMJ
Published
2024-02-14
Volume
384
Pages
e075847
ISSN
1756-1833 (ISSN-L)
DOI
10.1136/bmj-2023-075847
PMC
PMC10870815
OpenAlex
W4391847428
Cited by
707
References
64
Citations by year
2026: 303 · 2025: 286 · 2024: 118
FWCI
40.18
Type
journal article
Language
en
Update notices
correction (2024-05-28)
Open access
Licence
Locations
  • BMJ (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • Jyväskylä University Digital Archive (University of Jyväskylä) (submittedVersion, cc-by-nc)
  • RODIN (Universidad de Cádiz) (submittedVersion, cc-by-nc-nd)
  • University of Southern Denmark Research Portal (University of Southern Denmark) (submittedVersion, cc-by-nc)
  • HighWire Press Open Archive (submittedVersion)
  • UNSWorks (University of New South Wales, Sydney, Australia) (submittedVersion, cc-by-nc)
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 therapy, major depressive disorder, exercise dose-response, walking and jogging, yoga, resistance training, Tai Chi, qigong, aerobic exercise, antidepressants, psychotherapy, treatment acceptability, comorbidities, expectancy effects, publication bias, risk of bias assessment
MeSH terms
Antidepressive Agents, Major Depressive Disorder, Exercise Therapy, Humans, Psychotherapy, Yoga, 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.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review