Review Cochrane review: Exercise for depression 2026 Clegg et al

Andy

Andy

Senior Member (Voting rights)

Abstract​

Rationale: Depression is a common cause of morbidity and mortality worldwide. Depression is often treated with antidepressants or psychological therapy, or both, but some people may prefer alternative approaches such as exercise. This review updates one first published in 2008 and last updated in 2013.

Objectives: To determine the effectiveness of exercise in the treatment of depression in adults compared with no intervention, waiting list control or placebo, or where exercise is used as an adjunct to an established treatment that is received by both exercising and non-exercising groups. To determine the effectiveness of exercise compared with other active interventions for depression in adults (psychological therapies, pharmacological treatments or alternative interventions such as light therapy).

Search methods: We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Controlled Trials Register (CCDANCTR) to November 2013. We searched MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials (CENTRAL) from 2013 to November 2023. No date or language restrictions were applied.

Eligibility criteria: We included randomised controlled trials (RCTs) in which exercise was compared to no treatment, inactive treatment or active treatment in adults (aged 18 years and over) with depression. We included trials that randomised individual participants or clusters. We excluded trials of postnatal depression. Two authors independently undertook study selection.

Outcomes: The primary outcome we assessed was a measure of depression or mood at the end of treatment and at any longer-term follow-up. Other outcomes were treatment acceptability, quality of life, cost and adverse events.

Risk of bias: We assessed the risk of bias using the Cochrane risk of bias tool RoB 1. Two authors independently performed the risk of bias assessment.

Synthesis methods: Two authors independently extracted data on outcomes at the end of the trial and end of follow-up (if available). We calculated effect sizes for each trial using Hedges' g method and a mean difference (MD) or standardised mean difference (SMD) for the overall pooled effect for continuous data, and risk ratios for dichotomous data. Where trials used a number of different tools to assess depression, we included only the main outcome measure in our meta-analyses. Where trials provided several 'doses' of exercise, we used data from the largest dose and performed sensitivity analysis using the lower dose.

We performed subgroup analysis to explore the influence of diagnostic method, exercise intensity, number of exercise sessions, type of exercise and type of control (i.e. placebo, no treatment, waiting list, usual care and self monitoring). Through our sensitivity analyses, we explored the influence of study risk of bias.

Included studies: We included 73 RCTs (at least 4985 participants) in the review, 69 of which contributed data to our meta-analyses.

Synthesis of results: For the 57 trials (2189 participants) comparing exercise with no treatment or a control intervention, the pooled SMD for depressive symptoms at the end of treatment was -0.67 (95% confidence interval (CI) -0.82 to -0.52; low-certainty evidence), showing that exercise may result in a reduction in depressive symptoms. When we included only the seven trials (447 participants) with adequate allocation concealment, intention-to-treat analysis and blinded outcome assessment, the pooled SMD was smaller (SMD -0.46, 95% CI -0.88 to -0.04). Pooled data from the nine trials (405 participants) with long-term follow-up provided very uncertain evidence about the effect of exercise on depressive symptoms (SMD -0.53, 95% CI -1.11 to 0.06; very low certainty evidence).

Ten trials (414 participants) compared exercise with psychological therapy, finding there is probably little to no difference in their effect on depressive symptoms at the end of treatment (SMD 0.03, 95% CI -0.16 to 0.23; moderate-certainty evidence). There were similar results at long-term follow-up (SMD -0.11, 95% CI -0.48 to 0.26; 4 studies, 114 participants; low-certainty evidence).

Five trials (330 participants) compared exercise with pharmacological treatment, finding there may be little to no difference in their effect on depressive symptoms at the end of treatment (SMD -0.11, 95% CI -0.33 to 0.10; low-certainty evidence). The evidence was very uncertain at long-term follow-up (SMD -0.40, 95% CI -0.80 to 0.00; 1 study, 58 participants; very low certainty evidence).

There did not appear to be a difference between exercise and other interventions in terms of treatment acceptability, as measured by participants completing the study (moderate to low certainty evidence). Results for the outcome 'quality of life' were inconsistent (low to very low certainty evidence). Adverse events were not common in any comparison, but included musculoskeletal injuries and depression affecting those undertaking exercise, and diarrhoea, sexual dysfunction and fatigue reported by those receiving sertraline. Many trials were affected by multiple sources of bias: randomisation was adequately concealed in only 22 studies, only 31 used intention-to-treat analyses, and only 23 used blinded outcome assessors. Blinding of those receiving and those delivering the interventions is inherently difficult; we judged all studies to be at high risk of performance bias. Many trials used participant self-report rating scales, which have the potential to bias findings.

Authors' conclusions: Exercise may be moderately more effective than a control intervention for reducing symptoms of depression. Exercise appears to be no more or less effective than psychological or pharmacological treatments, though this conclusion is based on a few small trials. Long-term follow-up was rare. The addition of 35 RCTs (at least 2526 participants) to this update has had very little effect on the estimate of the benefit of exercise on symptoms of depression. If further research is to take place, it should focus on improving trial quality, assessing which characteristics of exercise are effective for different people, and exploring health equity.

Open access
 
I don’t understand why they even do the analysis when the evidence is so poor. How does it provide any valuable information?

Surely, the recommendation should be that there is no indication for using exercise as a treatment for depression, and that better studies are required if it’s going to be assessed in a research setting.

@Jonathan Edwards am I going mad?
 
Jonathan Edwards said:
Well they were about as damning by faint praise as they could be even if they did say 'may'.
That might get it through peer review but ensure that nobody used it to produce a GRADE-based guideline I suppose.

We probably all went mad long ago.
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Are you saying it wouldn’t get through peer review if they just said there is no evidence because the trials are too poor?
 
This is a very different interpretation than what we see in the ME/CFS review, where the evidence is far worse and the conclusions are almost marketing material. The evidence for ME/CFS is far worse than this and the review, which similarly only includes a small % of published trials, is basically a glowing recommendation compared to this. It shows how you can completely change the 'conclusions' (i.e. interpretation) of a review by simply changing the people and the biases they have. Which is an entirely useless process.
The paper said:
The addition of 35 RCTs (at least 2526 participants) to this update has had very little effect on the estimate of the benefit of exercise on symptoms of depression.
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Especially this. Obviously there have been way more than 35 RCTs, this is just those they chose to include, likely biased towards finding better outcomes (the positive bias towards this being a thing is more than obvious), and yet they admit that they didn't add anything. Which, duh, they're identical, how does doing the same thing dozens, even hundreds of times, yield more useful data?
If further research is to take place, it should focus on improving trial quality, assessing which characteristics of exercise are effective for different people, and exploring health equity.
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Which sidesteps the issue of whether there is even a need for more. It's obvious that this advice is misguided, was never based on any real evidence. This is the best evidence they can come up, and they tried their best to make it positive. So what is the value of more 'research'? Obviously it won't be higher quality, why would it? Assessing the characteristics of exercise is entirely useless, this is exactly what was happening in the 35 RCTs they chose to include since it has long been decided that the evidence is good enough to make it a strong recommendation, and in the many more they excluded. Exploring health equity is just nonsense, they just put this there to keep the wheel spinning.

All of this is up to the funders and regulators who approve studies. They choose to fund and approve an infinite loop of failure where the same thing is tried again and again until it gives the answers they want. It never does, so they just say it anyway. When there is way more than enough to justify shutting the whole thing down, what do they do? Call for more of the exact same, regardless of some pretense about "do it again, but this time good".

Evidence-based medicine, where neither evidence nor medicine matter, and even "based" doesn't really mean anything. A similar review was published last year. It showed similar null results and high bias, how there was never actually anything there. And this isn't even limited to exercise for depression studies, it's literally all of non-pharmaceutical evidence-based medicine that has been revealed to be a complete sham, but it is desired as the future of medicine, and so it will continue scamming the public with junk nonsense.
 
bigthink.com

Exercise works for depression. So why isn't it treated like real medicine?

Exercise should be recommended with the same structure and seriousness as medication, argues Nicholas Fabiano, M.D.
bigthink.com bigthink.com

Exercise works for depression. So why isn’t it treated like real medicine?​

The evidence is clear. We just don’t use it properly.​

by NICHOLAS FABIANO
July 21, 2026
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KEY TAKEAWAYS
  • Exercise can reduce symptoms of depression as effectively as medication or therapy.
  • Most mental health professionals receive no training in exercise and often default to vague suggestions.
  • To be effective, exercise should be recommended with the same structure and seriousness as medication, argues Nicholas Fabiano, M.D.
About the author:
Nicholas Fabiano, M.D., is a psychiatry resident and researcher at the University of Ottawa whose work focuses on lifestyle psychiatry, including the role of exercise, nutrition, and sleep in mental health.
He has authored over 90 publications and is leading the development of the Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) exercise recommendations for major depressive disorder and bipolar disorder.
He was recently named a “Rising Star” in Psychiatry by the journal Brain Medicine and awarded the Association of Chairs of Psychiatry of Canada Annual Research Award.
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Chandelier said:
bigthink.com

Exercise works for depression. So why isn't it treated like real medicine?

Exercise should be recommended with the same structure and seriousness as medication, argues Nicholas Fabiano, M.D.
bigthink.com bigthink.com


KEY TAKEAWAYS
  • Exercise can reduce symptoms of depression as effectively as medication or therapy.
  • Most mental health professionals receive no training in exercise and often default to vague suggestions.
  • To be effective, exercise should be recommended with the same structure and seriousness as medication, argues Nicholas Fabiano, M.D.
About the author:
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This is genuinely funny and bizarre because the evidence is clear as mud, all over the place, and if there's one key takeaway from decades of pushing this into existence, it's that it's the recreational part of recreational exercise that matters the most.

Also real funny in that it's true that exercise equals therapy and medication in most cases, because neither are effective. It's also equally effective to "drink 5 glasses of water per day" therapy.
If exercise is genuinely helpful, why isn’t it recommended more often? Exercise is already recommended as a first-line treatment for mild depression in major treatment guidelines.
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It's not recommended enough, but it's commonly recommended as first line treatment. Yeah makes perfect sense. It's just not talked about enough, people are literally silenced from speaking about it, and so on.
There’s a clear disconnect between the evidence, the guidelines, and clinical practice. Imagine sitting across from your psychiatrist after being diagnosed with depression. If they simply said, “Just take this antidepressant,” you’d probably expect much more, such as the specific drug, the dose, how long to take it, and what side effects to watch for. Yet when it comes to exercise, vague advice like “just go work out” is still surprisingly common. Exercise deserves the same level of thought and structure we give to medication.
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What an odd dude. In most cases it really is "just take this antidepressant". What the hell he is even talking about?
One practical way to do this is to use the FITT framework: Frequency, Intensity, Type, and Time. Instead of generic advice, a clinician might recommend something specific, such as: “Start with brisk walking three times a week for 20-30 minutes at an intensity where you can still talk.” This can then be adjusted as the person’s energy and fitness improve.
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That's GET, the most generic common recommendation. He is literally describing the current thing as a new idea that is beyond vague, generic advice and it's the most vague and generic advice possible. What in the hell he is on?
The evidence that exercise helps treat depression is strong. We don’t need more studies to prove it works. What we need now is to start treating it like the legitimate medical intervention that it is.
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No, seriously, what in the hell is this dude talking about? Is this a bit?
 
He was recently named a “Rising Star” in Psychiatry by the journal Brain Medicine
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Getting onto one of those lists all too often seems the kiss of death for your career.

rvallee said:
it's that it's the recreational part of recreational exercise that matters the most.
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Have they ever controlled for the benefits of just getting out of the house, especially into a bit of nature? Genuine question.

rvallee said:
It's also equally effective to "drink 5 glasses of water per day" therapy.
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Don't know about depression specifically, but speaking as long term resident of the steamy tropics, staying well hydrated is sound enough advice for general health, and for some specific conditions, e.g. constipation. It is one of those things with no real downsides (within reason, and if your kidneys are working okay), and some real upsides.

I just follow the rule of thumb about urine colour: If it is clearish to light yellow, you are adequately hydrated. Any darker and you need to start increasing water intake.

One practical way to do this is to use the FITT framework: Frequency, Intensity, Type, and Time. Instead of generic advice, a clinician might recommend something specific, such as: “Start with brisk walking three times a week for 20-30 minutes at an intensity where you can still talk.” This can then be adjusted as the person’s energy and fitness improve.​

I think a lot of what these guys are on about is imposing a system or structure on it all, despite the complete lack of evidence for any relevance in the absence of an actual understanding of what is going wrong underneath it all. The underlying assumption seems to be that patients have just lost the organising or regulating psycho-behavioural principles/narratives in their life, and 'therapy' consists largely of helping them find it again.
 
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rvallee said:
This is a very different interpretation than what we see in the ME/CFS review, where the evidence is far worse and the conclusions are almost marketing material.
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Yes, it is interesting to think about why that was allowed to happen in Cochrane. I assume it is because depression is already safely contained in the mental health box when it comes to insurance claims. A mental health classification for a disability typically reduces payouts on claims substantially - see here
Many insurers apply mental-health exclusions or limited benefit periods
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But ME/CFS teeters on the edge of the "mental health" classification, with no clear pathology to prove someone has it. Hence the interest of insurance medicine interests in ensuring that ME/CFS is a condition that "can be recovered from with the requisite will and a bit of exercise".

I guess too, Cochrane is a sprawling organisation, perhaps those who manage what is published about ME/CFS so tightly can't be everywhere, controlling everything.
 
Sean said:
Getting onto one of those lists all too often seems the kiss of death for your career.
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The scientifically productive part of it at least. Might go on to glittering and well remunerated success at policy advice, book writing, morning TV shows, and keynote speaking.
 
Always always the advice for depression is to get out of bed, and out of the house, force yourself to do things. These things are interacting with people, moving the body, normalcy. Sure, throw in some jogging if you like. Common sense dictates that anything other than lying in bed is beneficial for the depressed person. That is hard enough.

Since suicide risk is always 'hanging' around the depressed person, of course, you are told to be active, take the anti-depressant as prescribed, and you are monitored for worsening symptoms, like suicide ideation (talk of suicide) or if you start to make plans to off yourself, you are interned in a psych facility.

This exercise obsession evidenced by the psychiatrist author, is a limited view. Depression is a very serious condition that must be attacked on all possible fronts.
 
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