This post covers exercise prescription for those with depression, how much exercise is required and adherence. It contains excerpted content from Clinical Exercise Physiology, Fifth Edition.

Many systematic reviews and meta-analyses have summarized the antidepressant effect of exercise. A meta-review conducted in 2019 concluded across eight individual meta-analyses that exercise reduced depressive symptoms in children, adults, and older adults (1). 

Exercise prescription

An exercise prescription for people with depression will likely differ little from the prescription used for healthy individuals. Clinicians should be aware, however, that several symptoms of depression (e.g., loss of interest, fatigue, low self-confidence) may interfere with participation in exercise, and that comorbidities can further complicate matters.

Training method	Frequency	Intensity	Time (Duration)	Type (Mode)	Progression
Cardiorespiratory	3-5 d/wk	Initially moderate, then increased to 70%-80% of heart rate reserve; as tolerated, train at higher end of heart rate range	30-45 min (progress if necessary)	Gross motor activities such as walking and biking	Begin at lower intensity for markedly deconditioned patients. Gradually progress as tolerated.
Resistance	2 or 3 d/wk	10RM-15RM RPE of 11-15	2 sets per major muscle group; 1 min rest in between sets	Machines, free weights, elastic bands, calisthenics	Increase weight as tolerated to maintain 10-15 reps per set, at an RPE between 11 and 15.
Range of motion	Daily	Within comfort	10-30 s per major joint	Static and proprioceptive or passive stretching	As tolerated

How much exercise?

One question that remains unanswered is the dose of exercise required to obtain an antidepressant effect. Specifically, what frequency, intensity, duration, and type are most beneficial in treating patients with depression? A meta-review of eight meta-analyses of randomised controlled trails (RCTs) of exercise interventions for major depressive disorder (MDD) concluded that moderate- to vigorous-intensity exercise, alone or in combination with resistance exercise, should be prescribed (1). The review reported that the current evidence base for MDD suggests physical activity should be prescribed for a minimum of 90 min/wk for at least 12 wk. It is, however, still suggested that people adopt the global recommendations of 150 min of moderate to vigorous physical activity per week to achieve the optimal cardiorespiratory benefits.

Although achieving the exercise recommendations may be optimal for prevention and treatment, mental health benefits can still be obtained from lower doses. Evidence from reviews of RCTs has shown that short bouts of physical activity (e.g., 10-15 min) can reduce stress and depressive symptoms and improve self-esteem (2). 

Does the domain of physical activity matter? Although physiological mechanisms (e.g., regulation of the HPA axis and reduced inflammation) contribute to the anti-depressive effect of exercise, factors such as enjoyment, autonomous motivation, social interaction, skill mastery, and goal achievement are also likely to influence the relationship. 

Adherence and exercise

Patients with depression may find it more difficult to stay engaged in an exercise program compared with patients who are not depressed, and specific symptoms of depression such as fatigue and a loss of interest in people and activities may interfere with adherence to an exercise regimen.

O’Neal and colleagues (3) have offered recommendations for working with depressed people in a supervised exercise setting. First, they emphasize that nonadherence should be expected. Exercise professionals should avoid judging or blaming the patient for their depression because doing so will likely lead to guilt and a sense of failure that may cause the person to drop out of the exercise program. Instead, when nonadherence occurs, it should be viewed as a learning opportunity. That is, lapses in exercise participation can be used to identify an individual’s unique barriers to adherence. The exercise professional can then help the patient find ways around these obstacles.

In addition, it is important to adopt a patient-centered approach. This includes helping individuals take personal responsibility for exercise prescription, exercise delivery, and monitoring of compliance. There is no one-size-fits-all prescription for physical activity, and the exercise professional should focus on improving self-efficacy, autonomy, and intrinsic motivation. Finally, when working in exercise settings, it is important to be familiar with the symptoms of depression and have some knowledge of treatment options. When depression is identified, the exercise professional should express warmth and empathy toward the patient while taking care to maintain an appropriate clinician–client boundary. Specifically, the exercise professional should not attempt to be the patient’s psychotherapist but should instead have referral sources available.

Learn more about the effects of exercise on depression in Clinical Exercise Physiology, Fifth Edition.

Related books

References

1. Ashdown-Franks G, Firth J, Carney R, Carvalho AF, Hallgren M, Koyanagi A, et al. Exercise as medicine for mental and substance use disorders: A meta-review of the benefits for neuropsychiatric and cognitive outcomes. Sports Med. 2019.
2. Barr-Anderson DJ, AuYoung M, Whitt-Glover MC, Glenn BA, Yancey AK.Integration of short bouts of physical activity into organizational routine a systematic review of the literature. Am J Prev Med. 2011;40(1):76-93.
3. O’Neal HA, Dunn AL, Martinsen EW. Depression and exercise. International Journal of Sport Psychology. 2000.

Header photo by Yogendra Singh