Depression: Exercise, Internet CBT Deliver Long-term Relief

Megan Brooks

November 21, 2016

Exercise and Internet-based cognitive-behavioral therapy (ICBT) are good options to consider for patients with mild to moderate depression, say the authors of a large randomized controlled study.

Compared with usual care, 12 weeks of prescribed exercise or ICBT provided "clinically relevant" reductions in depression severity that persisted after 1 year, report the researchers.

"While medication and CBT do have an important role in depression treatment, we advocate that physical exercise should become a prioritized treatment option for most patients," first author Mats Hallgren, PhD, from the Karolinska Institute, Stockholm, Sweden, told Medscape Medical News.

The study was published in the November issue of the British Journal of Psychiatry.

Durable Effects

A recent Cochrane review found exercise to be effective in easing depressive symptoms. Recent studies also suggest that ICBT can be as effective in treating mild to moderate depression as face-to-face CBT. Yet evidence regarding their comparative and long-term effectiveness remains scarce, the researchers point out.

They designed their study to quantify and compare the long-term effectiveness of prescribed exercise and clinician-supported ICBT with usual care for patients with mild to moderate depression. Participants included 945 Swedish adults (mean age, 43 years; 73% women) recruited from primary care clinics located throughout Sweden.

They were randomly allocated to 12 weeks of group exercise (three 60-min sessions per week), clinician-supported ICBT, or usual care. ICBT was created by clinical psychologists and involved having the patients work through online modules while being monitored by a supervising psychologist.

The usual-care group received standard treatment for depression at the discretion of their primary care provider. Most patients in the usual-care group received regular face-to-face counseling. Overall, 27% of participants were taking antidepressants during the trial.

Of the 945 patents, 740 (78%) returned the 3-month questionnaire, and 797 (84%) returned the 12-month questionnaire. Patients in all three groups experienced a significant reduction in depression severity from baseline to 3 months and from baseline to 12 months, as assessed by the Montgomery-Åsberg Depression Rating Scale (MADRS).

Table. Change in MADRS Score

Assessment Exercise ICBT Usual Care
Baseline 22.2 21.9 20.8
Interim 3 months 11.3 11.2 13.9
End 12 months 10.8 9.8 11.1


The largest improvements were seen at 3 months, by which time the standardized depression severity scores had fallen more in the exercise group (Hedges' g = 0.57; 95% confidence interval [CI], 0.41 - 0.73) and the ICBT group (g = 0.66, 95% CI, 0.50 - 0.82) compared with the usual-care group. These group differences were maintained at the 12-month follow-up assessment for both exercise (Hedges' g = 0.24; 95% CI, 0.08 - 0.40) and ICBT (Hedges' g = 0.46; 95% CI, 0.31 - 0.62).

There were no between-group differences in the proportion of patients who reduced their initial MADRS score by 50% or more at 12 months (50% in the exercise group and 47% in the usual-care and ICBT groups).

The researchers say a "conservative interpretation" of their findings is that exercise and ICBT are at least equally effective long-term treatments for mild to moderate depression compared with usual care. "The improvements were also clinically relevant. Depression scores reduced in the exercise and ICBT groups from a 'moderate' level at pre-treatment (scores 21.9 - 22.2) to a 'mild' level at post-treatment (11.2 - 11.3) and the study end-point (9.8 - 10.8)," they write.

"Several key messages emerged clearly from our study," Dr Hallgren told Medscape Medical News. "Findings from our robust trial show that exercise, even at low levels of intensity, is more effective in the treatment of mild to moderate depression than usual care by a physician (medication and/or counseling). ICBT is certainly another effective treatment option, which may be especially useful for patients with mobility issues," he explained.

"It is promising," Dr Hallgren added, "that exercise interventions can have positive long-term benefits equal to CBT, the current first-line treatment for depression. Our findings also suggest that people can benefit substantially from light exercises, such as yoga and stretching. Vigorous exercise may not be necessary, or even desirable, for everyone."

Significant Study

This is a "significant" study, Madhukar H. Trivedi, MD, professor of psychiatry and director, Center for Depression Research and Clinical Care, University of Texas Southwestern Medical Center in Dallas, who was not involved in the study, told Medscape Medical News.

"There remains a question in the field about whether exercise alone can be effective. This study was community-based and quite large, again addressing the limitation of previous work that used smaller samples. The long-term nature of the study is another big merit," Dr Trivedi said.

Timothy Carter, PhD, assistant professor of mental health, University of Nottingham, United Kingdom, agrees. "The findings are very encouraging with regards the additional effects of exercise alongside treatment as usual for people experiencing depression," he told Medscape Medical News.

"Of particular importance is the large sample size, a rarity in studies investigating exercise and depression. This gives us confidence in both the size and likelihood of the effect observed. The long-term 12-month follow-up is also critical, as it tells us that exercise can have a lasting positive impact on depression," said Dr Carter, who was not involved in the study.

The study had no commercial funding. The authors have disclosed no relevant financial relationships.

Br J Psychiatry. 2016;209:414-420. Abstract


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