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• Physical activity will remain ‘overlooked’ in the treatment of depression and anxiety until we focus our research on people referred to mental health services.
  Frank R. Burbach
  Published on: 6 March 2023

• Published on: 6 March 2023

  Physical activity will remain ‘overlooked’ in the treatment of depression and anxiety until we focus our research on people referred to mental health services.

  • Frank R. Burbach, Consultant Clinical Psychologist University of Exeter

  Singh and colleagues’ comprehensive systematic review of meta-analyses (97 reviews of 1039 trials including 128,119 participants) confirms that ‘physical activity (PA) is highly beneficial for improving symptoms of depression, anxiety and psychological distress’ with ‘effect size reductions in symptoms of depression (−0.43) and anxiety (−0.42) comparable to or slightly greater than those observed for psychotherapy and pharmacotherapy’.
  This finding has important clinical implications and the authors conclude that PA should be included in public health guidelines as a mainstay approach (i.e. not just as an adjunct to psychological therapy and medication). They also recognise that ‘while the benefit of exercise for depression and anxiety is generally recognised, it is often overlooked in the management of these conditions’ .

  Despite these really impressive results and their important clinical implications, it is unfortunate that the Singh et al review is unlikely to make a significant difference to clinical practice. There are many reasons why physical activity is not used as a first-line intervention for depression and other mental health problems, but one of the problems is that the field has not really addressed an issue I highlighted in a review of the field a quarter of a century ago. The evidence that PA can be an effective stand-alone or adjunctive intervention for a range of mental health problems is diluted amongst the public health/ mental wellbeing st...

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  Singh and colleagues’ comprehensive systematic review of meta-analyses (97 reviews of 1039 trials including 128,119 participants) confirms that ‘physical activity (PA) is highly beneficial for improving symptoms of depression, anxiety and psychological distress’ with ‘effect size reductions in symptoms of depression (−0.43) and anxiety (−0.42) comparable to or slightly greater than those observed for psychotherapy and pharmacotherapy’.
  This finding has important clinical implications and the authors conclude that PA should be included in public health guidelines as a mainstay approach (i.e. not just as an adjunct to psychological therapy and medication). They also recognise that ‘while the benefit of exercise for depression and anxiety is generally recognised, it is often overlooked in the management of these conditions’ .

  Despite these really impressive results and their important clinical implications, it is unfortunate that the Singh et al review is unlikely to make a significant difference to clinical practice. There are many reasons why physical activity is not used as a first-line intervention for depression and other mental health problems, but one of the problems is that the field has not really addressed an issue I highlighted in a review of the field a quarter of a century ago. The evidence that PA can be an effective stand-alone or adjunctive intervention for a range of mental health problems is diluted amongst the public health/ mental wellbeing studies focusing on lifestyle/ general health/ quality of life outcomes. What we need are effectively powered randomised controlled trials of carefully designed PA interventions compared to medication and psychological therapy in primary and secondary care clinical populations. It is important to note that, similar to the Singh et al. review, the Cochrane review ‘Exercise for depression’ (Cooney et al., 2013) included a preponderance of trials with non-clinical populations (23 out of the 39 trials included in the review).
  Nonetheless, it is encouraging to see that the 2022 update of the NICE Guideline for Depression in adults (NG222) now includes the following:
  ‘Advise people that doing any form of physical activity on a regular basis (for example, walking, jogging, swimming, dance, gardening) could help enhance their sense of wellbeing. The benefits can be greater if this activity is outdoors.’

  The Singh et al. review has implications for future research (e.g. neuromolecular mechanisms by which PA appears to improve depression) and clinical practice (e.g. resistance exercise was most effective for depression, while Yoga and other mind–body exercises were most effective for anxiety).

  Research should not focus on neuroscience alone, however, as the mechanism responsible for the relationship between physical activity and mental health is complex and lies in a combination of biological, psychological and social factors (Biddle & Mutrie, 2001). The field therefore would also benefit from in-depth qualitative studies. A good example is a study by Crone et al. (2005) of people referred to ‘exercise prescription’ schemes, which demonstrated the importance of contextual factors such as social network, environment, culture and social support. However, this study also concluded that PA referral schemes appeared to be better suited to the needs of physical- than mental- health patients. This points to the need to research which factors encourage people referred for different mental health problems to engage with, and benefit from, different types of physical activity. Motivational factors may be unique to an individual, but we may find that a physical activity intervention that optimises the ‘therapeutic ingredients’ will have the best outcomes; for example, a specialist PA activity which is provided within a setting which maximises both social support and interaction with nature.

  REFERENCES
  Burbach, F. R. (1997). The efficacy of physical activity interventions within mental health services: Anxiety and depressive disorders. Journal of Mental Health, 6(6), 543-566.
  Cooney, G. M., Dwan, K., Greig, C. A., Lawlor, D. A., Rimer, J., Waugh, F. R., ... & Mead, G. E. (2013). Exercise for depression. Cochrane database of systematic reviews, (9).
  Crone, D., Smith, A., & Gough, B. (2005). “I feel totally alive, totally happy and totally at one”: A psycho-social explanation of the physical activity and mental health relationship from the experiences of participants on exercise referral schemes. Health Education Research, 20(5), 600–611.
  Biddle, S. J. H., & Mutrie, N. (2001). Psychology of physical activity determinants, well-being and interventions.Routledge: London.
  Singh, B., Olds, T., Curtis, R., Dumuid, D., Virgara, R., Watson, A., ... & Maher, C. (2023). Effectiveness of physical activity interventions for improving depression, anxiety and distress: an overview of systematic reviews. British Journal of Sports Medicine.

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  Conflict of Interest:
  None declared.

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