Abstract
Major depression disorder is most commonly treated with antidepressants. However, due to their side effects clinicians seek non-pharmacologic options, and one of these is exercise. The literature on the benefits of exercise for depression is extensive. Nevertheless, two recent reviews focusing on antidepressants vs. other therapies as a basis for clinical practice guidelines recommended mainly antidepressants, excluding exercise as a viable choice for treatment of depression. The aim of this perspective is to analyze the literature exploring the reasons for this discrepancy. Two categories of publications were examined: randomized controlled trials (RCTs) and meta-analyses or systematic reviews. Based on this reassessment, RCTs comparing exercise to antidepressants reported that exercise and antidepressants were equally effective. RCTs comparing exercise combined with antidepressants to antidepressants only reported a significant improvement in depression following exercise as an adjunctive treatment. Almost all the reviews examining exercise vs. other treatments of depression, including antidepressants, support the use of exercise in the treatment of depression, at least as an adjunctive therapy. The two reviews examining pharmacologic vs. non-pharmacologic therapies as a basis for clinical practice guidelines examined limited evidence on exercise vs. antidepressants. In addition, it is possible that academics and health care practitioners are skeptical of viewing exercise as medicine. Maybe, there is a reluctance to accept that changes in lifestyle as opposed to pharmacological treatment can alter biological mechanisms. Longitudinal studies are needed for assessing the effectiveness of exercise in real clinical settings, as well as studies exploring dose-response relationship between exercise and depression.
Highlights
The perception of exercise as medicine has been discussed in relation to health conditions such as cognitive decline (e.g., Nagamatsu et al, 2014), cancer (e.g., Lin et al, 2016), cardiac rehabilitation (e.g., Almodhy et al, 2016), schizophrenia (e.g., Firth et al, 2015), alcohol use disorders (e.g., Hallgren et al, 2017), and all-cause mortality (e.g., Eklund et al, 2016)
Exercise combined with antidepressants vs. antidepressants only – combination comparisons (Table 1) Eleven RCTs compared exercise as an adjunctive treatment to antidepressants – 10 for MDD and one for minor depression (Table 1)
All studies but one (Chalder et al, 2012) informed that patients using exercise as an adjunctive treatment for depression showed a significant depressive improvement after the exercise period, and/or that the proportion of patients with a clinical response was larger for the exercise group than the control
Summary
The perception of exercise as medicine has been discussed in relation to health conditions such as cognitive decline (e.g., Nagamatsu et al, 2014), cancer (e.g., Lin et al, 2016), cardiac rehabilitation (e.g., Almodhy et al, 2016), schizophrenia (e.g., Firth et al, 2015), alcohol use disorders (e.g., Hallgren et al, 2017), and all-cause mortality (e.g., Eklund et al, 2016). When exercise is combined with antidepressants, BDNF levels were found to increase in as little as two days, compared with two weeks with antidepressants alone (Russo-Neustadt et al, 2001) Another mechanism for enhancing neurogenesis is serotonin. It is certain that exercise generates both acute and chronic responses, mainly in hormones, neurotrophines, and inflammation biomarkers (Schuch et al, 2016a) It is, not surprising that quite a few attempts have been made to compare the effects of exercise to other treatments, including drug treatments, in various depressive disorders, MDD. As a collection of RCTs does not reflect a general effect size, meta-analyses, Cochrane reviews and systematic reviews providing an effect size of exercise vs antidepressants in the treatment of depression were examined. The present review investigated: (1) whether comparisons were conducted between exercise and antidepressants (as opposed to exercise vs. all other treatments together, or antidepressants vs. all other treatments together), (2) which RCTs comparing exercise to antidepressants were included in these reviews, (3) which conclusions were drawn from these comparisons, and (4) whether all published RCTs conducting such comparisons were included in the reviews
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