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Cited by 409Physical Activity and HealthTreatment of Major DepressionAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

The DOI matches its Crossref record; 101 of the 101 references it cites were found in a registry or an index; none of the 96 sources its claims cite is checked for support yet.

The Role of Exercise in Management of Mental Health Disorders: An Integrative Review

Open access
Smith, Patrick J., Merwin, Rhonda M.·2021·Annual Review of Medicine
DOI 10.1146/annurev-med-060619-022943PMC PMC8020774
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Abstract

A large and growing body of evidence suggests that physical activity (PA) may hold therapeutic promise in the management of mental health disorders. Most evidence linking PA to mental health outcomes has focused on the effects of aerobic exercise training on depression, although a growing body of work supports the efficacy of both aerobic and resistance exercise paradigms in the treatment of anxiety and post-traumatic stress disorder. Despite abundant evidence linking PA and mental health, use of exercise training as a mental health treatment remains limited due to three important sources of uncertainty: ( a) large individual differences in response to exercise treatment within multiple mental health domains; ( b) the critical importance of sustained PA engagement, not always achieved, for therapeutic benefit; and ( c) disagreement regarding the relative importance of putative therapeutic mechanisms. Our review of treatment data on exercise interventions and mental health outcomes focuses primarily on depression and anxiety within a health neuroscience framework. Within this conceptual framework, neurobiological and behavioral mechanisms may have additiveor synergistic influences on key cognitive and behavioral processes that influence mental health outcomes. We therefore highlight sources of treatment heterogeneity by integrating the critical influences of ( a) neurobiological mechanisms enhancing neuroplasticity and ( b) behavioral learning of self-regulatory skills. Understanding the interrelationships between dynamic neurobiological and behavioral mechanisms may help inform personalized mental health treatments and clarify why, and for whom, exercise improves mental health outcomes. The review concludes with recommendations for future studies leveraging individual differences to refine treatment approaches to optimize mental health benefits.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This integrative review argues that aerobic and resistance exercise training hold therapeutic promise for mental health, especially depression and anxiety, through synergistic neurobiological and behavioral mechanisms. It emphasizes that treatment response is heterogeneous and long-term benefit depends on sustained physical activity engagement.

Key findings

  • Epidemiological evidence links higher physical activity to lower odds of depression (OR = 0.83, 95% CI 0.79–0.88), elevated anxiety symptoms (OR = 0.87, 95% CI 0.77–0.99), and anxiety disorders (OR = 0.66, 95% CI 0.53–0.83).
  • Exercise trials generally show moderate-to-large improvements: aerobic exercise versus no intervention ES = 1.24 and versus conventional control ES = 0.68, but effects decline at follow-up (ES = 0.22); resistance training for depressive symptoms ES = 0.66 (95% CI 0.48–0.83).
  • Exercise as an add-on therapy enhanced conventional outpatient treatment over 2–3 months (ES = −0.79, 95% CI −1.01 to −0.57), and in late-life depression a meta-analysis of nine trials and 1,308 participants found ES = 0.64 (95% CI 0.27–1.01) with significant heterogeneity.
  • Proposed mechanisms include neuroplasticity facilitators such as BDNF, VEGF, and IGF-1; brain network changes in salience, executive control, and default mode networks; and behavioral mechanisms including emotion regulation, cognitive control, self-efficacy (exercise interventions ES = 0.59), and reinforcement/reward.

Methods

  • Design: integrative/narrative review of treatment data on exercise interventions and mental health outcomes, focused primarily on depression and anxiety within a health neuroscience framework.
  • Data: synthesizes epidemiological studies, randomized controlled trials, meta-analyses, neuroimaging/connectivity findings, and behavioral mechanism research, including populations such as adults with depression, late-life depression, anxiety, and other clinical samples.
  • Analysis: conceptual synthesis integrating neurobiological mechanisms (neuroplasticity, growth factors, inflammation, brain networks, neurotransmitters) with behavioral mechanisms (emotion regulation, cognitive control, self-efficacy, reinforcement) to explain heterogeneity and inform personalized treatment.

Limitations

  • The paper explicitly identifies three sources of uncertainty: large individual differences in response to exercise treatment, the critical importance of sustained physical activity engagement for therapeutic benefit, and disagreement regarding the relative importance of putative therapeutic mechanisms.
  • The paper states that there is a lack of explanatory studies delineating for whom and why exercise is beneficial, and notes significant heterogeneity across trials and populations, including some large multisite trials failing to find benefit in late-life depression.
  • Evident from the text: this is an integrative review rather than a systematic review with a described formal search strategy, quality appraisal, or quantitative pooling, so conclusions rely on narrative synthesis across heterogeneous studies.

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

Integrity signals

Registry

Crossref · 10.1146/annurev-med-060619-022943

Cites

101 of 101 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Verification

Claims the paper makes

0 of 96 cited sources checked · 0 supported · 0 flagged

  • Interpretationreasoning

    Physical activity may hold therapeutic promise in the management of mental health disorders.

    “A large and growing body of evidence suggests that physical activity (PA) may hold therapeutic promise in the management of mental health disorders.”
    Quote in the paperSubstantial claim
  • Premisenone given

    A growing body of work supports the efficacy of both aerobic and resistance exercise paradigms in the treatment of anxiety and post-traumatic stress disorder.

    “although a growing body of work supports the efficacy of both aerobic and resistance exercise paradigms in the treatment of anxiety and post-traumatic stress disorder.”
    Quote in the paperNot a substantial claim
  • Interpretationreasoning

    Use of exercise training as a mental health treatment remains limited due to disagreement regarding the relative importance of putative therapeutic mechanisms.

    “(c) disagreement regarding the relative importance of putative therapeutic mechanisms.”
    Quote in the paperSubstantial claim
  • Premisecitation

    Higher levels of PA are associated with reduced odds of developing depression (OR = 0.83, 95% CI 0.79-0.88) across age groups.

    “a recent meta-analysis of 49 prospective studies across nearly 267,000 individuals demonstrated that higher levels of PA associated with reduced odds of developing depression [odds ratio (OR) = 0.83, 95% confidence interval (CI) 0.79–0.88] across age groups (2).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [2] source
  • Premisereasoning

    Greater habitual PA may protect against the development of various mental health conditions.

    “Prospective studies focusing on specific mental health conditions have reported similar findings, suggesting that greater habitual PA may protect against the development of various mental health conditions.”
    Quote in the paperSubstantial claim
  • It may state two separate claims as one. 55
  • Probably not a substantial claim. 15

  • It may state two separate claims as one.

    Premisecitation

    Individuals with moderate or low levels of fitness exhibit a 23% and 47% greater risk of developing a mental health problem compared to their highly fit counterparts, with additive benefits of aerobic and resistance exercise.

    “Individuals with moderate or low levels of fitness exhibit a 23% and 47% greater risk of developing a mental health problem when compared to their highly fit counterparts, with additive benefits of aerobic and resistance exercise (6).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [6] source

  • It may state two separate claims as one.

    Premisecitation

    Results from randomized trials of exercise, while generally favorable, have been more mixed than observational findings.

    “Results from randomized trials of exercise, while generally favorable, have been more mixed than observational findings (7–10).”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [7] source
    • cites [8] source
    • cites [9] source
    • cites [10] source

  • It may state two separate claims as one.

    Premisecitation

    PA is prospectively associated with lower odds of developing elevated anxiety symptoms (OR = 0.87, 95% CI 0.77-0.99) and anxiety disorders (OR = 0.66, 95% CI 0.53-0.83).

    “PA also prospectively associated with lower odds of developing elevated anxiety symptoms (OR = 0.87, 95% CI 0.77–0.99) and anxiety disorders (OR = 0.66, 95% CI 0.53–0.83) in a recent meta-analysis of more than 80,000 individuals (3).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3] source

  • It may state two separate claims as one.

    Premisereasoning

    Most evidence suggests that exercise, particularly aerobic training, improves depression- and anxiety-related outcomes compared with attention control conditions, with treatment effect sizes paralleling those for conventional pharmacotherapeutic approaches.

    “Most evidence suggests that exercise, particularly aerobic training, improves depression- and anxiety-related outcomes compared with attention control conditions, with treatment effect sizes paralleling those for conventional pharmacotherapeutic approaches.”
    Quote in the paperSubstantial claim

  • It may state two separate claims as one.

    Premisecitation

    Lower amounts of physical activity or greater amounts of time spent in sedentary behaviors are associated with greater risk of poor mental health.

    “Numerous epidemiological studies have demonstrated that lower amounts of physical activity (PA) or greater amounts of time spent in sedentary behaviors are associated with greater risk of poor mental health.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim. It may be too vague to check against evidence. The paper may give no reason why it holds.

    Interpretationnone given

    Neurobiological and behavioral mechanisms may have additive or synergistic influences on key cognitive and behavioral processes that influence mental health outcomes.

    “Within this conceptual framework, neurobiological and behavioral mechanisms may have additive or synergistic influences on key cognitive and behavioral processes that influence mental health outcomes.”
    Quote in the paperNot a substantial claim

  • It may state two separate claims as one.

    Premisecitation

    Both depression and anxiety are associated with lower volume within DMN (hippocampus) and SN (amygdala and anterior cingulate cortex) brain structures.

    “Both depression and anxiety are associated with lower volume within DMN (hippocampus) and SN (amygdala and anterior cingulate cortex) brain structures (40).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [40] source

  • It may state two separate claims as one.

    Premisecitation

    Growth factors, particularly BDNF, have systemic effects in regulating cellular bioenergetic function, which is disrupted in multiple mental health conditions, making it more difficult to facilitate affective control, cultivate flexible response patterns, or facilitate synaptic plasticity adaptations within supportive neurocircuitry.

    “Growth factors, particularly BDNF, also have systemic effects in regulating cellular bioenergetic function (32), which is disrupted in multiple mental health conditions (33), making it more difficult to facilitate affective control, cultivate flexible response patterns, or facilitate synaptic plasticity adaptations within supportive neurocircuitry (34).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [32] source
    • cites [33] source
    • cites [34] source

  • It may state two separate claims as one.

    Premisecitation

    Exercise improves depressive symptoms (ES = 0.78), with weak dose-response effects (standardized beta = 0.007, p = 0.012).

    “recent literature syntheses have begun integrating affective and cognitive mechanisms of treatment across samples of patients with neurodegenerative disorders and depression, demonstrating that exercise improves depressive symptoms (ES = 0.78), with weak dose-response effects (standardized beta = 0.007, p = 0.012).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [16] source

  • It may state two separate claims as one.

    Premisecitation

    Evidence for dose-response effects of training is less robust than observational findings; relatively few studies link the degree of improvement with the intensity or duration of training.

    “Interestingly, evidence for dose-response effects of training is less robust than observational findings; relatively few studies link the degree of improvement with the intensity or duration of training (14).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] source

  • It may state two separate claims as one.

    Interpretationcitation

    Training improves neurobiological systems critical for adaptive learning, as well as affective and cognitive control processes, resulting in synergistic improvements in the regulation of both cognitive and affective responses through a 'virtuous circle' of reinforcement.

    “Within this framework (25, 26), training improves neurobiological systems critical for adaptive learning, as well as affective and cognitive control processes, resulting in synergistic improvements in the regulation of both cognitive and affective responses through a “virtuous circle” of reinforcement (27, 28).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [25] source
    • cites [26] source
    • cites [27] source

  • It may state two separate claims as one.

    Premisecitation

    Moderate-intensity training in older adults increases hippocampal volume with dose-response improvements from 6 to 12 months, offsetting normative neurodegenerative changes (1-2% annually), without volumetric increases in other brain regions.

    “Moderate-intensity training in older adults, for example, increases hippocampal volume with dose-response improvements from 6 to 12 months, offsetting normative neurodegenerative changes (1–2% annually), without volumetric increases in other brain regions (47).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [47] source

  • It may state two separate claims as one.

    Premisecitation

    BDNF is increased following aerobic and resistance exercise training and is critical to neurogenesis in the dentate gyrus.

    “BDNF is increased following aerobic (30) and resistance exercise training (31) and is critical to neurogenesis in the dentate gyrus.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [30] source
    • cites [31] source

  • It may state two separate claims as one.

    Interpretationnone given

    Exercise training is beneficial for a broad array of mental health outcomes, although the strength of treatment benefit appears to vary across populations and training modalities.

    “Examination of the literature linking exercise to mental health suggests that exercise training is beneficial for a broad array of mental health outcomes, although the strength of treatment benefit appears to vary across populations and training modalities.”
    Quote in the paperSubstantial claim

  • It may state two separate claims as one.

    Premisecitation

    The subventricular zone and caudate are critical to striatal dopamine function and subcortical white matter pathways.

    “The subventricular zone and caudate are critical to striatal dopamine function and subcortical white matter pathways (29).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] source

  • Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.

    Premisenone given

    Increased neuroplastic capacity is one hypothesized mechanism underlying the mental health benefits of several widely used somatic psychiatric treatment modalities, including selective serotonin reuptake inhibitors and transmagnetic stimulation.

    “Increased neuroplastic capacity is one hypothesized mechanism underlying the mental health benefits of several widely used somatic psychiatric treatment modalities, including selective serotonin reuptake inhibitors and transmagnetic stimulation.”
    Quote in the paperNot a substantial claim

  • It may state two separate claims as one.

    Premisecitation

    The most important factor associating with remission from various mental health conditions is the degree of exercise maintenance over time, regardless of initial intervention assignment, with continued exercise participation demonstrating a threshold of benefit corresponding closely to the American Heart Association's recommended level of activity of 150 min per week.

    “In addition, examination of sustained treatment response over time suggests that the most important factor associating with remission from various mental health conditions is the degree of exercise maintenance over time, regardless of initial intervention assignment, with continued exercise participation demonstrating a threshold of benefit corresponding closely to the American Heart Association’s”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [13] source
    • cites [15] source

  • It may state two separate claims as one.

    Premisecitation

    Exercise training is moderately effective in reducing depressive symptoms in late-life depression (ES = 0.64, 95% CI 0.27-1.01), with significant heterogeneity across studies.

    “Nevertheless, in a recent meta-analysis of nine trials and 1,308 participants, exercise training was found to be moderately effective in reducing depressive symptoms (ES = 0.64, 95% CI 0.27–1.01), with significant heterogeneity across studies (9).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] source

  • It may state two separate claims as one.

    Interpretationreasoning

    Exercise training appears to have a potentially important impact on mental health functioning, comparable to conventional psychotherapeutic and pharmacological approaches; however, the effects vary across patient populations and training modalities, and the long-term mental health benefits appear contingent upon sustained PA engagement.

    “In summary, exercise training appears to have a potentially important impact on mental health functioning, comparable to conventional psychotherapeutic and pharmacological approaches; however, the effects of exercise training vary across patient populations and training modalities, and the long-term mental health benefits appear contingent upon sustained PA engagement.”
    Quote in the paperSubstantial claim

  • It may state two separate claims as one.

    Premisenone given

    The dentate gyrus is essential for the creation and consolidation of new memories and regulation of affect, primarily changing through new gray matter cell growth.

    “The dentate gyrus is essential for the creation and consolidation of new memories and regulation of affect, primarily changing through new gray matter cell growth.”
    Quote in the paperNot a substantial claim

  • It may state two separate claims as one.

    Premisecitation

    Aerobic exercise trials have generally reported moderate to large improvements compared with no intervention (ES = 1.24) or conventional control conditions (ES = 0.68), with improvements comparable to standard psychological or pharmacological approaches.

    “Aerobic exercise trials have generally reported moderate to large improvements compared with no intervention [effect size (ES) = 1.24] or conventional control conditions (ES = 0.68), with improvements comparable to standard psychological or pharmacological approaches.”
    Quote in the paperSubstantial claim

  • It may state two separate claims as one.

    Premisecitation

    Resistance training appears to improve depressive symptoms (ES = 0.66, 95% CI 0.48-0.83), albeit with significant heterogeneity across trials.

    “Although fewer studies have examined resistance training paradigms, existing data suggest that resistance training also appears to improve depressive symptoms (ES = 0.66, 95% CI 0.48–0.83), albeit with significant heterogeneity across trials (10).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [10] source

  • It may state two separate claims as one.

    Premisecitation

    Volumetric changes following exercise training have been most consistently observed in the prefrontal cortex, subcortex, and mesial temporal brain structures, with the most consistent changes in the dentate gyrus.

    “Volumetric changes following exercise training have been most consistently observed in the prefrontal cortex (PFC), subcortex, and mesial temporal brain structures (43), with the most consistent changes in the dentate gyrus (44, 45).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [43] source
    • cites [44] source
    • cites [45] source

  • It may state two separate claims as one.

    Premisenone given

    Individuals with late-life depression are more likely to have cardiovascular disease risk factors, white matter hyperintensities, and comorbid cognitive dysfunction typified by executive function impairments than individuals with an earlier onset of depression.

    “Individuals with LLD are more likely to have cardiovascular disease risk factors, white matter hyperintensities, and comorbid cognitive dysfunction typified by executive function impairments than individuals with an earlier onset of depression.”
    Quote in the paperSubstantial claim

  • It may state two separate claims as one.

    Premisecitation

    The effects of exercise training tend to decline over time and are generally not significant at follow-up (ES = 0.22), with therapeutic benefits only sustained among individuals who continue to exercise following cessation of active treatment.

    “Importantly, the effects of exercise training tend to decline over time and are generally not significant at follow-up (ES = 0.22) (8), with therapeutic benefits only sustained among individuals who continue to exercise following cessation of active treatment (13).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [8] source
    • cites [13] source

  • It may state two separate claims as one.

    Interpretationcitation

    Exercise may facilitate skeletal muscle clearance of kynurenine, suggesting that the comparable effects of exercise and selective serotonin reuptake inhibitors on mental health outcomes may be due to their parallel, neuroprotective effects through kynurenine pathways.

    “Exercise may facilitate skeletal muscle clearance of kynurenine, suggesting that the comparable effects of exercise and selective serotonin reuptake inhibitors on mental health outcomes may be due to their parallel, neuroprotective effects through kynurenine pathways (38).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [38] source

  • It may state two separate claims as one.

    Interpretationreasoning

    Existing evidence linking exercise training to mental health outcomes suggests that exercise has beneficial effects with wide variation, but there is a lack of explanatory studies delineating for whom and why exercise is beneficial.

    “Existing evidence linking exercise training to mental health outcomes suggests that exercise has beneficial effects with wide variation, but there is a lack of explanatory studies delineating for whom and why exercise is beneficial.”
    Quote in the paperSubstantial claim

  • It may state two separate claims as one.

    Premisecitation

    In one of the few exercise trials collecting neuroimaging data from participants with depression, depressive symptoms improved in parallel with increased MTL volume and improved verbal memory, despite a 30% dropout rate and lack of a significant treatment group benefit.

    “In one of the few exercise trials collecting neuroimaging data from participants with depression, depressive symptoms improved in parallel with increased MTL volume and improved verbal memory, despite a 30% dropout rate and lack of a significant treatment group benefit (48).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [48] source

  • It may state two separate claims as one.

    Premisenone given

    Neuroplasticity is increasingly characterized as a central mechanistic component of mental health improvements and is highly influenced by PA.

    “Neuroplasticity is increasingly characterized as a central mechanistic component of mental health improvements and is highly influenced by PA.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds. It may state two separate claims as one.

    Interpretationnone given

    Exercise may potentiate reward salience through increased engagement in personally meaningful or rewarding activities and reward sensitization, or improved fitness.

    “Exercise may also potentiate reward salience through increased engagement in personally meaningful or rewarding activities and reward sensitization, or improved fitness (e.g., feeling more fit, improved body image).”
    Quote in the paperNot a substantial claim

  • It may state two separate claims as one.

    Premisecitation

    The impact of exercise on mood is one of the most widely studied mechanisms linking exercise to mental health, both through acutely enhancing mood and by improving ER during stressful life circumstances.

    “The impact of exercise on mood is one of the most widely studied mechanisms linking exercise to mental health, both through acutely enhancing mood and by improving ER during stressful life circumstances (78).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [78] source

  • It may state two separate claims as one.

    Premisereasoning

    During exercise, individuals experience these sensations in a nonthreatening context, in which aversive interoceptive cues are not only expected but may be indicative of effective engagement.

    “During exercise, individuals experience these sensations in a nonthreatening context, in which aversive interoceptive cues are not only expected but may be indicative of effective engagement.”
    Quote in the paperSubstantial claim

  • It may state two separate claims as one.

    Premisecitation

    Preliminary evidence suggests similar improvements following resistance training, with participants exhibiting improvements in PFC white matter volume and executive functioning.

    “Notably, preliminary evidence suggests similar improvements following resistance training, with participants exhibiting improvements in PFC white matter volume and executive functioning (52).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [52] source

  • It may state two separate claims as one.

    Premisecitation

    Altered connectivity in DMN and ECN is associated with poorer treatment outcomes and greater cognitive dysfunction among adults with depression.

    “Similar findings have been reported for mood improvements (61), with altered connectivity in DMN and ECN associating with poorer treatment outcomes and greater cognitive dysfunction among adults with depression (62).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [61] source
    • cites [62] source

  • It may state two separate claims as one.

    Premisecitation

    Neurobehavioral improvements following exercise are largest in executive functions, which are preferentially impacted by dopaminergic disruption.

    “This assertion is supported by large amounts of indirect evidence suggesting that neurobehavioral improvements following exercise are largest in executive functions (17, 18), which are preferentially impacted by dopaminergic disruption.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [17] source
    • cites [18] source

  • It may state two separate claims as one.

    Premisecitation

    A 12-month aerobic exercise program among older adults enhanced ECN and DMN connectivity, with corresponding improvements in executive function.

    “Voss and colleagues, for example, found that a 12-month aerobic exercise program among older adults enhanced ECN and DMN connectivity, with corresponding improvements in executive function (57).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [57] Voss MW, 2010, Front. Aging Neurosci.

  • It may state two separate claims as one.

    Premisecitation

    Higher intensity of aerobic training increased plasma 5-HT levels, which associated with improved response inhibition.

    “with at least one prior trial demonstrating that higher intensity of aerobic training increased plasma 5-HT levels, which associated with improved response inhibition (69).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [69] source

  • It may state two separate claims as one.

    Premisecitation

    Parallel cognitive improvements are observed across heterogeneous populations with dysfunctional dopaminergic/norepinephrine functioning, including Parkinson's disease, attention-deficit/hyperactivity disorder, and bipolar disorder, with exercise-related increases in dopamine production.

    “In addition, parallel cognitive improvements are observed across heterogeneous populations with dysfunctional dopaminergic/norepinephrine functioning, including Parkinson’s disease (63), attention-deficit/hyperactivity disorder (64, 65), and bipolar disorder (66), with exercise-related increases in dopamine production (67).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [63] source
    • cites [64] source
    • cites [65] source

  • Probably not a substantial claim. The paper’s conclusions may not depend on it.

    Premisecitation

    Many psychological disorders result from cumulative or catastrophic failures of goal pursuits.

    “According to SST, many psychological disorders result from cumulative or catastrophic failures of goal pursuits (72).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [72] source

  • It may state two separate claims as one.

    Premisecitation

    Acute exercise enhances efficiency within the DMN and improves functional modulation between networks, as indicated by enhanced ability of SN and ECN brain regions to selectively and adaptively inhibit DMN functioning, with parallel improvements in behavioral markers of cognitive control.

    “Acute exercise, for example, has been shown to enhance efficiency within the DMN and improve functional modulation between networks, as indicated by enhanced ability of SN and ECN brain regions to selectively and adaptively inhibit DMN functioning (53), with parallel improvements in behavioral markers of cognitive control (54).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [53] source
    • cites [54] source

  • It may state two separate claims as one.

    Interpretationreasoning

    Enhanced production and synthesis of monoamines is a critical component of improved affect regulation and cognitive control, both of which enhance self-regulation.

    “Taken together, these data suggest that enhanced production and synthesis of monoamines is a critical component of improved affect regulation and cognitive control, both of which enhance self-regulation.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim. The paper’s conclusions may not depend on it.

    Premisecitation

    Self-systems theory is superior to conventional therapeutic approaches among depressed adults with self-regulatory deficits.

    “SST has most widely been used in depression, where it is superior to conventional therapeutic approaches among depressed adults with self-regulatory deficits (71).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [71] source

  • It may state two separate claims as one.

    Premisecitation

    During a 10- to 12-year follow-up examination of participants in the LOOK-AHEAD diabetes trial, the lifestyle intervention group demonstrated a 28% lower white matter hyperintensity volume, compared to only a 9% lower ventricle volume.

    “Similarly, during a 10- to 12-year follow-up examination of participants in the LOOK-AHEAD diabetes trial, the lifestyle intervention group demonstrated an impressive 28% lower white matter hyperintensity volume, compared to only a 9% lower ventricle volume (50).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [50] source

  • Probably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.

    Premisenone given

    Self-regulation includes emotion regulation and cognitive control, which are transdiagnostic mechanisms of change.

    “While self-regulation is vast, it includes ER and cognitive control, which are transdiagnostic mechanisms of change.”
    Quote in the paperNot a substantial claim

  • It may state two separate claims as one.

    Premisecitation

    Specific behavioral mechanisms linking exercise interventions to mental health include self-regulatory skills specific to affect regulation and cognition, which could influence mental health directly and through increased self-efficacy.

    “Specific behavioral mechanisms linking exercise interventions to mental health include self-regulatory skills specific to affect regulation (61, 74) (e.g., tolerating and modulating arousal) and cognition (75) (e.g., exerting cognitive control over behavior, sustaining attention, and flexibly shifting attention and behavioral responses to match environmental demands) (76), which could influence”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [61] source
    • cites [74] source
    • cites [75] source

  • It may state two separate claims as one.

    Interpretationreasoning

    This may form new associations with anxiety and increase capacity to tolerate interoceptive sensations while inhibiting avoidance/escape responses.

    “This may form new associations with anxiety and increase capacity to tolerate interoceptive sensations while inhibiting avoidance/escape responses.”
    Quote in the paperSubstantial claim

  • It may state two separate claims as one.

    Premisenone given

    Difficulties in ER are associated with mental health problems and improvements in ER correspond with better mental health.

    “A significant literature indicates that difficulties in ER are associated with mental health problems and that improvements in ER correspond with better mental health.”
    Quote in the paperNot a substantial claim

  • It may state two separate claims as one.

    Premisecitation

    Exercise training appears to have preferentially favorable effects on executive functions and connectivity within ECN brain areas.

    “As noted above, exercise training appears to have preferentially favorable effects on executive functions (76) and connectivity within ECN brain areas (57).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [76] source
    • cites [57] Voss MW, 2010, Front. Aging Neurosci.

  • Probably not a substantial claim. The paper’s conclusions may not depend on it.

    Premisecitation

    There is an extensive literature on increasing reinforcers/reward as a treatment mechanism of depression through behavioral activation.

    “There is an extensive literature on increasing reinforcers/reward as a treatment mechanism of depression through behavioral activation (97).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [97] source

  • Probably not a substantial claim. It may be too vague to check against evidence.

    Interpretationreasoning

    By clearly specifying both neurobiological and behavioral mechanisms linking exercise to improved mental health, it may be possible to optimize treatment effects and personalize training approaches for maximal benefit.

    “By clearly specifying both neurobiological and behavioral mechanisms linking exercise to improved mental health, it may be possible to optimize treatment effects and personalize training approaches for maximal benefit.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.

    Interpretationreasoning

    Exercise training programs may increase the ability to direct and sustain attention to the present, particularly if exercises are sufficiently difficult.

    “Exercise training programs may increase the ability to direct and sustain attention to the present, particularly if exercises are sufficiently difficult.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Effective engagement in an exercise activity requires full attention to the task and awareness of a narrowed set of stimuli.

  • It may state two separate claims as one.

    Premisecitation

    Focusing on goal-directed behaviors enhances top-down activation within the ventromedial PFC and ventral striatum, as well as downregulating insular and amygdala activation during stressful activities.

    “Focusing on goal-directed behaviors has been shown to enhance top-down activation within the ventromedial PFC and ventral striatum, as well as downregulating insular and amygdala activation during stressful activities (98).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [98] source

  • It may state two separate claims as one.

    Premisecitation

    In several mental health conditions, difficulties include poor set-shifting abilities, selective attention, and distractibility.

    “Difficulties include poor set-shifting abilities (i.e., difficulty switching between tasks or altering behavior in response to feedback) (88), selective attention, and distractibility.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [88] source

  • Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.

    Interpretationreasoning

    These behavioral mechanisms may change in tandem with neurobiological-mediated decreases in the saliency of some stimuli and potentiation of reward.

    “These behavioral mechanisms may change in tandem with neurobiological-mediated decreases in the saliency of some stimuli (described above) and potentiation of reward, as detailed below.”
    Quote in the paperNot a substantial claim

  • It may state two separate claims as one.

    Interpretationcitation

    When these strategies are utilized in behavioral trials among individuals with mental health conditions, they likely play an active therapeutic role and may partially explain treatment improvements.

    “When these strategies are utilized in behavioral trials among individuals with mental health conditions, they likely play an active therapeutic role and may partially explain treatment improvements (87).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [87] source

  • It may state two separate claims as one.

    Premisecitation

    Individuals accustomed to habitual PA show improved reward system functioning compared to sedentary counterparts, a relationship that does not appear to differ based on physical fitness.

    “Individuals accustomed to habitual PA also show improved reward system functioning compared to sedentary counterparts, a relationship that does not appear to differ based on physical fitness (100).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [100] source

  • It may state two separate claims as one.

    Interpretationcitation

    Poorer cognitive control is likely to present barriers both for initial acquisition of self-regulatory skills for PA engagement and utilization of these skills for maintenance over time.

    “Notably, poorer cognitive control is also a robust predictor of inadequate PA maintenance (28, 93), suggesting that poorer cognitive control is likely to present barriers both for initial acquisition of self-regulatory skills for PA engagement and utilization of these skills for maintenance over time.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [28] source
    • cites [93] source

  • Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it.

    Interpretationreasoning

    Interventions cultivating these skill sets may therefore offer opportunities for experiential practice of clinically relevant skill domains in the service of exercise titration and maintenance.

    “Interventions cultivating these skill sets may therefore offer opportunities for experiential practice of clinically relevant skill domains in the service of exercise titration and maintenance.”
    Quote in the paperNot a substantial claim

  • It may state two separate claims as one.

    Premisecitation

    Exercise self-efficacy is associated with improved body image and physical quality of life.

    “Greater engagement in PA has been shown to increase exercise self-efficacy (73), associated with improved body image and physical quality of life, and increases the likelihood of sustained PA maintenance over time (94).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [73] source

  • It may state two separate claims as one.

    Premisecitation

    Cognitive flexibility is a putative treatment mechanism of mindfulness-based stress reduction, which has been shown to increase resting-state connectivity within ECN brain areas following training.

    “For example, cognitive flexibility is a putative treatment mechanism of mindfulness-based stress reduction, which has been shown to increase resting-state connectivity within ECN brain areas following training (92).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [92] source

  • Probably not a substantial claim. It may be too vague to check against evidence. The paper may give no reason why it holds.

    Interpretationreasoning

    These factors likely work in synergy, creating a "virtuous cycle" to predict long-term effects of exercise on mental health.

    “These factors likely work in synergy, creating a “virtuous cycle” to predict long-term effects of exercise on mental health.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim. The paper’s conclusions may not depend on it.

    Interpretationreasoning

    Many of the domains reviewed above align closely with key conceptual elements of improved self-efficacy, including monitoring of performance accomplishments, behavioral modeling, social persuasion, and adaptive interpretation of physiological states.

    “In addition, many of the domains reviewed above align closely with key conceptual elements of improved self-efficacy, including monitoring of performance accomplishments, behavioral modeling, social persuasion, and adaptive interpretation of physiological states.”
    Quote in the paperNot a substantial claim

  • It may state two separate claims as one.

    Interpretationcitation

    Exercise might decrease affective reactivity/saliency of food cues, increasing ability to control impulses or regulate eating behavior.

    “Taken together, this work suggests that exercise might decrease affective reactivity/saliency of food cues, increasing ability to control impulses or regulate eating behavior.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim. It may be too vague to check against evidence. It may state two separate claims as one.

    Interpretationreasoning

    Both neurobiological markers of neuroplasticity and behavioral markers of self-regulatory function hold relevance in the development of future exercise training paradigms.

    “As reviewed above, both neurobiological markers of neuroplasticity and behavioral markers of self-regulatory function hold relevance in the development of future exercise training paradigms.”
    Quote in the paperNot a substantial claim

  • It may state two separate claims as one.

    Interpretationreasoning

    Behavioral activation often includes exercise or other forms of PA and may therefore both increase opportunities for positive reinforcement and cultivate realistic expectations regarding loss and reward, both of which may improve mental health.

    “Behavioral activation often includes exercise or other forms of PA and may therefore both increase opportunities for positive reinforcement and cultivate realistic expectations regarding loss and reward, both of which may improve mental health.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: A poverty of reinforcement or adaptive reward may lead to increased negative affect (e.g., depression) or the development of maladaptive behavior patterns to increase positive feelings (e.g., substance abuse).

  • Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds. It may state two separate claims as one.

    Interpretationreasoning

    Increased modulation of food responses may also have broader implications for cultivating impulse control and self-regulatory capacity, which holds importance for reduced substance use risk, behavioral impulsivity, and overall improvements in mental health functioning.

    “Increased modulation of food responses may also have broader implications for cultivating impulse control and self-regulatory capacity, which holds importance for reduced substance use risk, behavioral impulsivity, and overall improvements in mental health functioning.”
    Quote in the paperNot a substantial claim
66 of 66

  • The paper relies on this without support.

    The brain’s capacity for neurobiological remodeling within key neurocircuitry is impaired across many heterogeneous mental health conditions, declines with age, and may be inhibited by several age-related systemic processes.

    “The brain’s capacity for neurobiological remodeling within key neurocircuitry is a critical element of adaptive learning, is impaired across many heterogeneous mental health conditions, declines with age, and may be inhibited by several age-related systemic processes.”

  • The paper relies on this without support.

    Adaptive learning is a critical element of mental health improvements following behavioral interventions.

    “Adaptive learning, in turn, is a critical element of mental health improvements following behavioral interventions.”

  • The paper relies on this without support.

    Exercise is one of the few behavioral processes that appears to increase neuroplasticity.

    “Exercise is one of the few behavioral processes that appears to increase neuroplasticity.”

  • The paper relies on this without support.

    Several key systemic factors must be present to facilitate neuroplastic changes, all of which are modifiable through exercise training: neurotrophins, intact cerebral metabolic function, low neuroinflammation, and sleep.

    “Several key systemic factors must be present to facilitate neuroplastic changes, all of which are modifiable through exercise training. Briefly, these include neurotrophins, intact cerebral metabolic function, low neuroinflammation, and sleep.”

  • The paper relies on this without support.

    Effective behavioral engagement and self-monitoring are frequently impaired in individuals with depression and anxiety.

    “As detailed below, effective behavioral engagement and self-monitoring are frequently impaired in individuals with depression and anxiety.”

  • The paper relies on this without support.

    Conventional exercise training programs teach participants to identify and implement SMART goals to optimize exercise participation and maintenance.

    “Conventional exercise training programs teach participants to identify and implement goals that are specific, measurable, achievable, realistic, and timely (SMART goals), in order to optimize exercise participation and maintenance.”

  • The paper relies on this without support.

    Through setting SMART goals, striving toward them, and evaluating iterative progress, participants cultivate realistic expectations for themselves and internalize a sense of behavioral control.

    “Through the process of setting SMART goals, striving toward them, and evaluating iterative progress, participants cultivate realistic expectations for themselves and internalize a sense of behavioral control.”

  • The paper relies on this without support.

    Realistic goal setting and attainment contribute to emotion regulation by increasing self-mastery, increasing agency, and establishing new, positive associations with self-concept.

    “Realistic goal setting and attainment also contribute to ER by increasing self-mastery, increasing agency, and establishing new, positive associations with self-concept.”

  • The paper relies on this without support.

    Self-monitoring may build a greater capacity to identify and repeat effective behaviors and to identify maladaptive behavioral patterns.

    “The process of self-monitoring (tracking behavior and its consequences) may also build a greater capacity to identify and repeat behaviors that are effective, as well as identifying maladaptive behavioral patterns.”

  • The paper relies on this without support.

    Sustained attention and vigilance are impaired across many mental health conditions, particularly in depression, where patients have difficulties sustaining engagement toward goal-directed targets over prolonged periods.

    “Sustained attention and vigilance are also impaired across many mental health conditions, particularly in depression, where patients have difficulties sustaining engagement toward goal-directed targets over prolonged periods of time.”

  • The paper relies on this without support.

    Competing cognitive processes, such as rumination or excessive worry, may divert attention away from effective task performance and increase emotional suffering.

    “Competing cognitive processes, such as rumination or excessive worry, may divert attention away from effective task performance and increase emotional suffering.”

  • The paper relies on this without support.

    Effective engagement in an exercise activity requires full attention to the task and awareness of a narrowed set of stimuli.

    “In this case, effective engagement in the activity requires full attention to the task and awareness of a narrowed set of stimuli (e.g., one’s breathing and ability to pace breathing).”

  • The paper relies on this without support.

    A poverty of reinforcement or adaptive reward may lead to increased negative affect (e.g., depression) or the development of maladaptive behavior patterns to increase positive feelings (e.g., substance abuse).

    “A poverty of reinforcement or adaptive reward may lead to increased negative affect (e.g., depression) or the development of maladaptive behavior patterns to increase positive feelings (e.g., substance abuse).”

  • The paper relies on this without support.

    Newer CBTs, such as Acceptance and Commitment Therapy, link behavioral activation specifically to personal values, which may function to augment its reinforcement value or function as an establishing operation, and/or help sustain activity engagement.

    “Newer CBTs, such as Acceptance and Commitment Therapy, link behavioral activation specifically to personal values, which may function to augment its reinforcement value or function as an establishing operation, and/or help sustain activity engagement.”

  • The paper relies on this without support.

    Dysfunctional reward sensitivity is a core feature increasing the risk of depression and serves as a key barrier to implementation of many therapeutic interventions.

    “Dysfunctional reward sensitivity is a core feature increasing the risk of depression and serves as a key barrier to implementation of many therapeutic interventions.”

  • The paper relies on this without support.

    Several newer CBTs teach mindfulness to decrease engagement in unproductive mental activities and improve capacity to be in the present moment.

    “Several newer CBTs teach mindfulness to decrease engagement in unproductive mental activities and improve capacity to be in the present moment.”
16 of 16

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Citations

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Research works printed but not linked: 1

  1. Voss MW, 2010, Front. Aging Neurosci., 2, 32

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Metadata

Authors
Smith, P. J., & Merwin, R. M.
Affiliations
  • Duke University (US)
  • Department of Psychiatry and Behavioral Sciences,
ORCID
Venue
Annual Review of Medicine
Publisher
Annual Reviews
Published
2021-01-27
Volume
72
Issue
1
Pages
45-62
ISSN
  • 0066-4219 (ISSN-L)
  • 1545-326X
DOI
10.1146/annurev-med-060619-022943
PMC
PMC8020774
OpenAlex
W3108397702
Semantic Scholar
9d060f58ee734ebfe0ffeedb76c1765864aa04e5
Cited by
360
References
101
Citations by year
2026: 81 · 2025: 121 · 2024: 83 · 2023: 45 · 2022: 25 · 2021: 5
FWCI
2.39
Type
journal article
Language
en
Open access
Locations
  • Annual Review of Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health
  • National Heart, Lung, and Blood Institute (R01HL130237)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Physical Activity and Health
  • Health Sciences › Medicine › Pharmacology (medical) › Treatment of Major Depression
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
physical activity, mental illness, depression, anxiety, post-traumatic stress disorder, aerobic exercise, resistance training, neuroplasticity, self-regulation, individual differences, treatment effect heterogeneity, exercise adherence, personalized treatment
MeSH terms
Mental Disorders, Exercise Therapy, Humans, Mental Health, Psychotherapy, Quality of Life, Exercise

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