Physical Exercise Tied to a Reduction in Suicide Attempts

Batya Swift Yasgur, MA, LSW

April 14, 2023

Physical exercise is associated with a reduction in suicide attempts, new research suggests.

A meta-analysis of 17 randomized controlled trials (RCTs), which included more than 1000 participants with mental or physical illnesses, showed there was a significant reduction in suicide attempts in participants randomly assigned to receive exercise interventions, compared with inactive controls. However, there were no differences between the exercise and the control groups in suicidal ideation or mortality.

On the other hand, there was also no significant different in dropout rates between those randomly assigned to exercise vs inactive controls, suggesting that people with mental or physical impairments are able to adhere to exercise regimens.

"A common misconception is that patients, particularly those suffering from mental of physical illness, are not willing or motivated enough to participate in an exercise [regimen], and this has led to primary care providers underprescribing exercise to those with mental or physical illness," lead author Nicholas Fabiano, MD, a resident in the Department of Psychiatry at the University of Ottawa, Canada, told Medscape Medical News.

As a result of the study findings, "we recommend that providers do not have apprehension about prescribing exercise to patients with physical or mental illness. Exercise may be an effective way to reduce suicidal behaviors" in these patients, he said.

The study was published online March 4 in the Journal of Affective Disorders.

Physical, Mental Health Strongly Linked

Existing literature has "demonstrated a protective effect of physical activity on suicidal ideation in the general population," but to date here have been no systematic reviews or meta-analyses investigating its impact on suicide-related outcomes in patients with physical or mental illness, the authors write.

"Those with mental or physical illness are at increased risk of suicide, compared to the general population," Fabiano commented.

"We often split up 'mental health' and 'physical health' in medicine; however, I believe that the two are ore on a continuum and a holistic term, such as 'health,' should be used instead," he added.

He noted that mental and physical health are "inexorably intertwined" and those with physical illness are more prone to developing mental illness, whereas those with mental illness are more likely to suffer from a variety of other medical conditions.

"Therefore, when treating those with mental illness, it is also imperative that we bolster one's physical health through easily accessible activities such as exercise," he said.

The goal of the study was to determine whether individuals with "any mental, physical, clinical, or subclinical condition" might benefit from exercise, particularly in relation to suicide-related outcomes. They searched multiple databases from inception to June 2022 to identify RCTs investigating exercise and suicidal ideation in participants with physical or mental conditions.

Of 673 studies, 17 met the inclusion criteria (total of 1021 participants). Participants' mean age was 42.7 years, 82% were female, and 54% were randomly assigned to an exercise intervention.

Most studies (82%) focused on clinical vs subclinical outcomes. Depression was the most commonly included condition (59%). Aerobic exercise (53%) was the most common form of exercise used in the active study groups. This was followed by mind-body exercise and strength training (53%, 17.6%, and 17.6%, respectively). The mean follow-up time was 10 weeks.

Reduced Impulsivity

The researchers found a difference in post-intervention suicidal ideation when they compared exercise participants to all control and inactive control participants (standardized mean difference, –1.09; 95% CI ­–3.08 to 0.90; P = .20, k = 5). However, the difference was not statistically significant.

Similarly, there was no significant difference (P = .60) in suicidal ideation incidence for subgroup analyses that stratified data among participants with depression, sickle cell disease, and suicidality.

All-cause discontinuation also did not significantly differ between participants who were randomly assigned to exercise interventions vs all controls or inactive controls (odds ratio [OR], 0.85; 95% CI, 0.38 - 1.94; P = .86, k = 12 and OR, 0.81; 95% CI, 0.25 - 2.68; P = .70). All-cause discontinuation also did not differ between participants randomized to exercise vs active controls (OR, 0.94; 95% CI, 0.38 - 2.32; P = .79, k = 3).

Likewise, there were nonsignificant differences between participants who underwent aerobic exercise and strength training (P = .20).

However, there were some nonsignificant differences when comparing participants with depression and stress who received the exercise intervention vs controls (P = .46).

There was a significant reduction in suicide attempts in individuals who participated in exercise interventions vs inactive controls (OR, 0.23; 95% CI, 0.09 - 0.67; P = .04, k = 2). On the other hand, there was no significant difference in mortality (P = .70).

Most of the studies (82%) were "at high risk of bias," the authors note. In addition, the analysis was limited because the included studies were "few, underpowered, and heterogeneous."

Fabiano hypothesized that the lack of effect on suicidal ideation or mortality is "likely due to the limited sample size." As additional RCTs are conducted, Fabiano expects to see decreases in both suicidal ideation and suicide attempts."

The findings may "be explained by the ideation-to-action framework, which suggests that the development of suicidal ideation and the progression to suicide attempts are distinct processes with different influential factors," he said.

Increased levels of exercise have been "shown to reduce emotional impulsivity and, as it has been shown that most suicide attempts are characterized by impulsivity and low lethality, we hypothesize that regular exercise serves as a protective factor against suicide attempts," he said.

Not Useful?

Commenting for Medscape Medical News, Fabien Legrand, PhD, a lecturer in clinical psychology, University of Reims Champagne-Ardenne in Reims, France, said that the impact of physical activity is of "particular interest" to him because it is closely linked to his research activity, where he has "been exploring the antidepressant effects of exercise for more than 15 years."

A small pilot study conducted by Legrand and colleagues found rigorous physical activity to be helpful in reducing hopelessness in psychiatric patients, compared with controls. "This result is of particular relevance for suicidal patients since it has long been documented that hopelessness is one of the main triggers of suicide ideation and suicide attempts," he said.

Initially, Legrand "warmly welcomed" the current review and meta-analysis on the exercise and suicide. However, he felt that the paper fell short in accomplishing its intended goal. "After a thorough reading of the paper, I don't think that the information provided can be used in any way," he stated.

"The paper's title — 'Effects of Physical Exercise on Suicidal Ideation and Behavior' — does not do justice to its content, since 9 of the included 17 RCTs did not measure changes in suicidal ideation and/or suicidal behavior following participation in an exercise program," noted Legrand, who was not involved with authorship or the current analysis.

The study was funded by the University of Ottawa, Department of Psychiatry. Fabiano declares no relevant financial relationships. The other authors' disclosures are listed in the original article. Legrand declares no relevant financial relationships.

J Affect Disord. Published online March 4, 2023. Abstract

Batya Swift Yasgur, MA, LSW is a freelance writer with a counseling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).

For more Medscape Psychiatry news, join us on Twitter and Facebook


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.