Psychology Textbook Chapter 15 Exercise and Physical Activity for Depression

Chapter 15 Exercise and Physical Activity for Depression Brush and Florida State University , USA Please cite as Brush , 2021 ) Exercise and physical activity for depression . In Jones ( Essentials and sport psychology An open access textbook ( Society for Transparency , Openness , and Replication in Kinesiology . Attribution 40 International This content is open access and part of Essentials of Exercise and Sport Psychology An Open Access Textbook . All other content can be accessed at Chapter Overview Depression is a leading cause of global disease burden . Standard treatments include and psychotherapy however , these treatments are not effective for everyone and are associated with several barriers and a substantial side effect profile . There is a need to identify alternative approaches that can be used to treat , or even prevent depression . Exercise and physical activity are two lifestyle behaviors that have been touted for decades as strategies used in the prevention and treatment of depression . The purpose of this chapter is to provide an overview of the scientific evidence supporting the role of these two lifestyle behaviors used in the prevention and treatment of depression . This chapter is organized by first providing insight into the burden of depression , how it is defined and diagnosed , and main treatment approaches . We then outline the scientific evidence for the role of exercise and physical activity in the prevention and treatment of depression . We also discuss plausible neurobiological mechanisms of the relationship and challenges associated with establishing such mechanisms . An overall summary is then provided and outstanding areas of inquiry for future research are highlighted throughout the chapter . For correspondence brush

Chapter 15 Exercise and Physical Activity for Depression Depression Prevalence and Burden Major depressive disorder ( is one of the most common mental illnesses , with point estimates from the Global Burden of Disease Study indicating a mean global prevalence of each year between the years 1990 and 2019 ( Global Burden of Disease Collaborative Network , 2020 ) is a leading cause of disability around the world ( Friedrich , 2017 ) that results in a loss of work productivity and increased morbidity ( et , 2014 Walker et , 2015 ) is also highly recurrent , with about 35 of individuals experiencing an additional episode within the first year of recovery ( et , 2010 ) Even after 15 years following recovery , up to 85 of individuals experience another episode . Therefore , it is unsurprising that often exacts profound suffering and places a staggering burden on individuals , families , and society . Indeed , the total estimated economic burden ( indirect and directs costs attributed to depression ) of people with was US billion in 2010 , with billion in direct costs due to medical and pharmaceutical services directly related to treatment ( et , 2015 ) How is Depression Diagnosed ?

Current diagnostic practices rely on the Diagnostic and Statistical Manual , Fifth Edition ( American Psychiatric Association , 2013 ) and use specific symptoms as indicators of depression to reach a diagnostic threshold . To constitute a diagnosis , an individual must endorse five of nine symptoms that are present for a minimum of weeks and persist for most of the day , nearly every day ( American Psychiatric Association , 2013 ) In terms of symptoms , individuals must endorse at least one of two core criterion symptoms depressed or low mood ( feelings of sadness ) loss of interest or pleasure in almost all typically or previously enjoyable activities ( anhedonia ) An individual must also endorse at least four other symptoms ( a ) significant unintentional change in weight or appetite ( sleep disturbances ( defined as insomnia or hypersomnia ) severe psychomotor agitation ( restlessness ) or retardation observable by others ( slowed speech or movement patterns ) fatigue or low energy ( a sense of worthlessness or excessive guilt ( impaired ability to think or concentrate and make decisions or ( recurrent thoughts of death that include suicidal ideation attempts . Any symptom combination including at least one core criterion symptom and four additional symptoms constitutes a diagnosis . these criteria are also used to inform and issue a diagnosis in the United Kingdom ( National Collaborating Centre for Mental Health and National Institute for Health and Clinical Excellence , 2010 ) Treatments for Depression Clinical practice guidelines recommend the use of pharmacotherapy ( antidepressant drugs ) psychotherapeutic approaches ( therapy ) or a combination of the two as treatments for ( American Psychiatric Association , 2010 American Psychological Guideline Development Panel , 2019 National Collaborating Centre for Mental Health and National Institute for Health and Clinical Excellence , 2010 ) In terms of pharmacotherapy , antidepressant drugs , namely selective serotonin reuptake inhibitors ( are among the most prescribed medications and work by blocking the reuptake of serotonin . Other classes of antidepressant drugs are also prescribed , including serotonin and norepinephrine reuptake inhibitors ( and norepinephrine and dopamine reuptake inhibitors ( all of which work by inhibiting the reuptake of their targeted neurotransmitter ( thereby increasing its availability , and altering their levels in the brain . 339

Brush Despite antidepressant drugs being among the most widely prescribed drugs globally , they are not consistently beneficial . For example , in the Sequenced Treatment Alternatives to Relieve Depression ( STAR ) study , which is the largest depression treatment trial ever conducted and funded by the National Institute of Mental Health , the effectiveness of antidepressant drug treatments was examined among patients with a diagnosis ( age range years ) In both specialty and primary medical care settings , patients were exposed to a tiered approach consisting of four separate treatment levels . The trial was structured such that patients who were unable to achieve as becoming following one level would then move onto the next treatment level , which could consist of either a switch to a different antidepressant drug or a combination of antidepressant drug with psychotherapy . STAR study results indicated that between 28 and 33 of the patients achieved remission following an initial treatment with ( et , 2006 ) After multiple treatment steps , Rush et al . 2006 ) reported a cumulative remission rate of 67 , which was computed by remission rates achieved across all trial stages . As highlighted by ( 2021 ) it is important to note , however , that the actual remission rate is a bit unclear given that a of the available data from the trial resulted in a remission rate of when appropriately accounting for patients who dropped out or relapsed and remained in the trial at the end of the original trial duration ( see , 2011 , 2015 ) Regardless of the true remission rate , many patients were left symptomatic or clinically depressed following the STAR trial , which highlights the variable and limited effectiveness of antidepressant drugs in depression treatment . Furthermore , research has shown that even among patients who achieve remission using antidepressant drug treatment , outcomes are uncertain , as estimates indicate that approximately 40 of remitted patients are likely to relapse within a period ( Keller , 2008 ) The efficacy of antidepressant drugs to treat depression was also examined in a of six studies that evaluated the impact of antidepressant drugs in randomized depression treatment trials approved by the Food and Drug Administration . After individual data from 434 patients receiving antidepressant drugs and 284 patients in placebo groups across six separate trials , et al . 2010 ) found that antidepressant drug efficacy varied as a function of depressive symptom severity . Only patients exhibiting severe symptoms of depression before enrolling in the trial experienced significant treatment reductions in depressive symptoms compared to those in placebo control groups . Antidepressant drugs were no more efficacious in reducing depressive symptoms compared to placebo control for patients experiencing symptom severity before treatment Despite their limited efficacy , there are also several barriers associated with antidepressant drugs , such as costs and a vast side effect profile , including but not limited to nausea , vomiting , diarrhea , dry mouth , constipation , and sexual dysfunction . These side effects are intolerable ( et , 2020 ) and a primary contributor for treatment discontinuation and poor patient compliance ( Lader et , 2004 ) Various forms of psychotherapy , including and behavioral activation , are broadly used to treat and have shown effectiveness in reducing depression ( et , 2013 ) In the largest quantitative review conducted on the topic , et al . 2020 ) assessed whether psychotherapeutic approaches were effective in reducing depression and whether effects differed across the lifespan . The authors compiled data from 366 randomized controlled trials ( and found that psychotherapy was generally effective , resulting in depressive symptom reductions among individuals with clinically diagnosed depression of all ages , with Those interested in learning more about research regarding the use of antidepressant drugs in the treatment of depression should refer to review articles and commentaries by Kirsch et al . 2008 ) Kirsch ( 2014 ) Kirsch ( 2019 ) 2008 ) and Turner et al . 2008 ) 340

Chapter 15 Exercise and Physical Activity for Depression effect sizes . As with antidepressant drugs , psychotherapy is associated with variable success rates , with many individuals often failing to adequately respond or derive antidepressant benefits to psychological treatments ( et , 2005 ) Moreover , there are several barriers to accessing psychotherapy for many individuals . Psychotherapy is costly and its effectiveness depends on some of the following ( a ) availability and accessibility of mental health professionals ( Marcus , 2010 ) characteristics of the mental health professional ( et , 2009 ) the delivery of intervention ( delivered versus versus ) and ( individual preferences . Purpose of the Chapter Given the variable effectiveness and barriers associated with treatments , there is an urgent need to identify alternative strategies or interventions that can be used to treat depression or prevent the occurrence of the disorder altogether . Exercise and physical activity are two lifestyle behaviors that have been touted for decades and even centuries in the management and treatment of depression . For example , ancient physicians and philosophers including Hippocrates ( 460 ) or 600 ) and Hua from the Eastern Han Dynasty ( 25 CE ) recognized the importance of engaging in regular physical activity to maintain health . In particular , Hippocrates , considered by many to have been the first physician to prescribe exercise for a patient suffering from a mental health condition , believed that eating alone will not keep a man well he must also take exercise ( Jones , 1923 229 ) In the context of depression , exercise and physical activity did not gain significant traction in the scientific literature until seminal studies by William Morgan were published in the late to early . For example , Morgan conducted the first observational studies to indicate that patients with depression tended to have lower cardiovascular fitness levels compared to healthy counterparts ( Morgan , 1968 , 1969 Morgan et , 1970 ) These early efforts laid the foundation for decades of work to follow and since then , there has been burgeoning research interest in this area ( see Figure ) which has resulted in substantial progress toward establishing these two lifestyle behaviors as important strategies to ward off depression . Figure Annual Number of Research Publications on the Exercise and Physical Relationship from 2000 1800 1600 1400 co no 600 Publication can 400 200 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 Year Note . The data used to create this figure were adapted from by using the search terms exercise OR physical activity AND depression between the years of 1970 and 2020 . 341

Brush In this chapter , we examine the research evidence related to exercise and physical as prevention and treatment strategies used for depression . We will first summarize the evidence base of exercise and physical activity in the prevention of depression . Then , we will summarize the current evidence on the influence of exercise as a treatment for depression before offering insight into possible neurobiological mechanisms associated with the relationship . We highlight open questions that need to be explored in future research to help elucidate on the exercise , physical activity , and depression relationship throughout the chapter . Before presenting the evidence base , it is important to gain insight into how and depressive symptoms are measured to understand conclusions that can be drawn from the evidence . Photo by from Measurement of Major Depressive Disorder and Depressive Symptoms Depression is characterized by substantial symptom heterogeneity , which makes its assessment difficult . For example , combinations of the nine criteria required for a diagnosis results in 227 unique depressive symptom profiles ( Fried , 2015 ) Furthermore , Fried ( 2017 ) assessed content overlap of the seven most commonly used depression scales in scientific research and found 52 disparate symptoms , with little symptom overlap across instruments . Therefore , it is important to note that measurement of depression is a challenging endeavor because there is no single measure that can account for its complexity . diagnoses are made using clinical interviewing instruments , while depression symptom severity is measured using rating scales . Researchers often combine clinical interviews with rating scales to provide insight into the presence and nature of an individual depression . For the purposes of this chapter , we provide a brief overview of some of the most prevalent diagnostic interviews and rating scales used in research to measure and depressive symptoms . Physical activity is broadly defined as any bodily movement resulting in energy expenditure , while exercise is a subset of physical activity that is performed for the intention of improving or maintaining one or more aspects of physical fitness ( et , 1985 ) 342

Chapter 15 Exercise and Physical Activity for Depression Diagnostic Interviews Structured Clinical Interview for ( The is the most widely used structured diagnostic interview for assessing the disorders ( First et , 2015 ) Clinical psychologists and psychiatrists and other trained mental health professionals use the to assess for the presence of lifetime and current depressive disorders and other psychiatric disorders such as anxiety disorders ( see Chapter 16 et , 2021 ) psychotic disorders ( see Chapter 17 et , 2021 ) substance use disorders , somatic symptom disorders , externalizing disorders and disorders . Research suggests that the has excellent reliability , sensitivity , and specificity for most of the psychological disorders with high prevalence , even when the clinical interview is conducted over the telephone ( et , 2019 ) Due to its popularity , the has been translated into other languages and has been used in a variety of cultures . Mini International Neuropsychiatric Interview ( MINI ) The MINI is a short , structured diagnostic interview developed jointly by in the and Europe that follows diagnostic criteria outlined in the International Classifications of Disease and ( et , 1997 ) The MINI is typically used in research to reduce the amount of time it takes to assess and diagnose depression . Research suggests that the reliability and validity of the MINI is on par with the ( et , 1997 ) The MINI can be conducted within 15 minutes and can serve as a short and accurate assessment of psychopathology . Dimensional Measures of Depressive Symptoms Depressive symptoms have been measured using a variety of rating scales . Three commonly used rating scales of depressive symptoms are described below . These rating scales assess current depressive symptoms severity over a specified time interval and aid in determining whether treatments are effective in reducing depressive symptoms . Beck Depression Inventory , Second Edition ( The assesses the presence of depressive symptoms during a period using 21 items scored on a scale ranging from . Higher scores indicate greater severity of depressive symptoms ( Beck et , 1996 ) A score of 13 or higher on the is generally an indication of the presence of a depressive disorder and the has shown high sensitivity and specificity when utilized as a screening tool ( Lasa et , 2000 ) The has shown good internal consistency and validity across different settings and populations ( Steer et , 1999 , 2000 ) Hamilton Rating Scale for Depression ( The is a reliable assessment of the severity of depressive symptoms using 17 items scored from ( et , 2011 ) A total score is obtained by summing all the items together . The provides categories that indicate the severity of depressive symptoms based on the total score . For example , a total score from indicates normal levels of depressive symptoms , suggests mild depression , suggests moderate depression , and a score 224 indicates severe depression ( Sharp , 2015 ) Center for Studies Depression Scale ( The was originally developed to assess the number and frequency of depressive symptoms in the general population ( 1977 ) The exhibits strong psychometric properties , including high internal consistency and good divergent and convergent validity ( Van Dam , 2011 ) The has also been validated for use in a variety of age groups , including adolescents and 343

Brush young adults ( Roberts et , 1990 ) The has 20 items scored from . A total score is computed by summing all the items together , with possible scores ranging from . Higher scores indicate more symptoms and are weighted by frequency of occurrence during the past week . scores that are at least 16 or greater have been shown to identify individuals at risk for clinical depression ( et , 1997 ) In 2004 , the original was revised by et al . to reflect depressive symptoms more accurately as indicated by the . The ( Center for Depression Scale Revised et , 2004 ) is also 20 items , with each item scored on a scale of . Higher scores reflect greater severity of depressive symptoms . Based on scoring , participants can be categorized into one of five possible depressive categories meets criteria for major depressive episode , probable major depressive episode , possible major depressive episode , depression symptoms , or no clinical significance . An advantage of using the compared to other instruments is that it is free and accessible as a part of the public domain ( see ) Exercise and Physical Activity in the Prevention of Depression The potential for exercise and physical activity to prevent depression has been studied across a number of and prospective epidemiological studies . One of the earliest epidemiological studies to examine the relationship between physical activity levels and depression was conducted when Farmer and colleagues ( 1988 ) analyzed data from the Study ( 1984 ) Farmer et al . 1988 ) looked at the association between depressive symptomatology , as measured by the , and recreational and physical activity levels . Among healthy adults between the ages of 25 and 77 included in analyses , increased depressive symptoms were related to lower levels of recreational physical activity . Interestingly , individuals engaging in recreational physical activity were at almost a elevation in odds of experiencing increased depressive symptoms compared to those engaging in regular recreational physical activity . To determine whether recreational physical activity levels were a unique risk factor for increased depressive symptoms , the authors examined the influence of age , race , education , employment status , reported chronic health conditions , and household income on the relationship . After accounting for these variables , lower recreational physical activity levels still significantly related to increased depressive symptoms . Goodwin ( 2003 ) extended this work by examining the relationship between regular physical activity levels and rates of diagnoses among Americans ( female ) between the ages of 15 and 54 years who participated in the National Survey ( Physical activity levels were assessed using a item that asked participants , How often do you get physical in or in a recreational activity ?

diagnoses were confirmed using a structured interview ( the World Health Organization Composite International Diagnostic Interview ) Goodwin found that regularly active individuals had a reduced likelihood of having a diagnosis compared to those who engaged in lower levels of physical activity . Importantly , this relationship remained significant even after accounting for important variables , such as age , gender , race , marital status , education , and income , suggesting that lower physical activity levels independently confer risk for . There was also a significant relationship between frequency of physical activity and current prevalence of in the sample , such that was least prevalent among individuals who regularly engaged in physical activity ( compared to those who occasionally engaged in physical activity ( those who rarely engaged in physical activity ( and those who never engaged in physical activity ( refers to the amount of exercise or physical activity ( duration , intensity , and frequency ) that results in graded effects . 344

Chapter 15 Exercise and Physical Activity for Depression and colleagues ( 2015 ) examined the relationship between physical activity and depression in a , prospective study of 676 Swedish women ( MagE at baseline in 1974 years ) followed over 32 years ( Depression was measured using interviews and the Depression Rating Scale ( Montgomery , 1979 ) which assesses the presence of symptoms and signs of depression over the past month . Physical activity levels were and measured using the Physical Activity Level Scale ( 1968 ) which indexes an individual physical activity frequency and intensity . Four separate assessments occurred across the study in 1974 , 1992 , 2000 , and 2005 , which allowed the authors to test several hypotheses . First , the authors examined associations and showed that lower physical activity levels were associated with increased depressive symptoms at the baseline assessment in 1974 . Next , the authors were interested in determining whether changes in physical activity levels coincided with changes in depressive symptoms overtime . There was a significant relationship between physical activity levels and depressive symptoms , such that decreasing physical activity levels were associated with increased depressive symptoms over time . Lastly , the authors tested whether the relationship between physical activity and depressive symptoms was bidirectional and wanted to determine whether initial depressive symptoms could predict subsequent physical activity levels . Women reporting increased depressive symptoms at the 1974 baseline assessment reported less engagement in subsequent physical activity at later time points in 1992 and 2000 , but not in 2005 . This study provides evidence for a potential bidirectional relationship between physical activity and depression from a large and sample of women followed over the span of three decades and suggests that physical activity may not only be a risk factor for depression but may also be a consequence of depression . There may be specific aspects of depression that could explain the prediction of lower subsequent physical activity from depressive symptoms . For example , one of the core criterion symptoms of depression is the loss of interest or pleasure in almost all typically or previously enjoyable activities ( anhedonia ) In a study by ( 2012 ) the author examined whether anhedonia was related to physical activity participation levels in a sample of 157 undergraduate students ( Mage years ) Increased anhedonia was associated with lower physical activity levels , providing preliminary support for the notion that anhedonia , rather than other symptoms of depression , may be associated with lower physical activity participation . It is important to be cautious in interpreting these preliminary data . used a normative sample of undergraduate students to examine the relationship between concurrent levels of anhedonia and physical activity . The sample was relatively homogenous in terms of physical and mental health status and was more physically active compared to the general population . Further , the causative nature of the relationship can not be established since the study employed a design . Therefore , these findings are only suggestive , but provide a template for examining specific symptoms of depression ( anhedonia ) and whether they can explain physical activity participation in clinically depressed samples . Other prospective studies have shown significant relationships between physical activity levels and depression . A cohort study of 424 patients with depression ( MagE at baseline years 54 female ) found that higher physical activity levels were associated with lower concurrent depressive symptoms at four separate assessment points spanning 10 years ( Harris et , 2006 ) This evidence corroborates previous findings demonstrating that increased physical activity is associated with a reduced incidence of depression diagnoses and symptoms . The preventive effects of physical activity on depression ( symptoms and diagnoses ) have also been summarized in reviews ( 2013 et , 2008 ) and colleagues ( 2008 ) performed a literature review of observational and interventional research on the relationship between physical activity and depression in adults . The authors were interested in identifying the influence of physical activity characteristics ( dose , domain , and physical activity 345

Brush setting ) on depression outcomes . There were inverse associations between physical activity and the likelihood of developing depression . Even lower doses of physical activity ( hours of intensity leisure time physical activity per week ) demonstrated a protective effect against developing depression . physical activity was associated with a decreased likelihood of depression , while there was insufficient evidence regarding the role of other physical activity characteristics on depression . In 2013 , the and review aimed to update the findings from et al . by reviewing high quality research , which was determined using criteria from the Critical Appraisal Skills Programme ( see cas ) for prospective studies . and aimed to address three important questions ( a ) do baseline physical activity levels prevent depression ?

is there a specific dose of physical activity that protects against depression ?

and ( do physical activity levels over time impact risk for subsequent depression ?

To address their first question , and ( 2013 ) examined studies including assessments spanning at least two separate time intervals ( range of period years ) among nonclinical community samples of between the ages of 11 and 100 years . of 30 reviewed studies supported the notion that baseline physical activity levels protect against the incidence or onset of subsequent depression . To address their second question , the authors found that engaging in as little as min of daily physical activity could reduce subsequent risk for depression by 10 ( Lucas et , 2011 ) while other research showed that being physically active just or more times per week was associated with a 40 reduced risk for depression ( et , 2006 et , 2009 ) To address their third question , the authors found that engaging in less physical activity over time was associated with an increased risk of developing depression compared to those who either maintained or increased their activity levels over the same time frame . These findings led and to conclude that there was sufficient support for the preventive effects of physical activity on depression , even when physical activity is performed at low levels . A few years later , et al . 2018 ) conducted a of 49 prospective studies that included individuals ( median proportion of males 47 ) with physical activity and depression measurements at baseline and a assessments ( mean period years range of period years ) across studies . The authors found that individuals of all ages ( youths , adults , elderly persons ) who engaged in more physical activity had decreased odds of developing future depression . These findings were observed across geographical regions around the world ( Asia , Europe , North America , and ) and across genders . Exercise programs may also have preventive effects . In 2020 , Hu and colleagues performed a systematic review of eight that comprised a total of 134 individual studies examining the role of exercise interventions in the prevention of depression . In their review , Hu et al . 2020 ) examined the impact of exercise on depression across the lifespan among the general population and found moderate depressive symptom reductions among children , adolescents , adults , and the elderly . Although exercise interventions decreased depressive symptoms among the general population , the authors were unable to examine whether the incidence of could be prevented , as no research has specifically investigated this relationship . A notable finding was that exercise was comparable to higher of exercise in reducing depressive symptoms however , the authors noted that this evidence is of and needs to be investigated further . The evidence highlights the preventive effects of physical activity and exercise on depression and symptoms of depression however , the following questions remain ( a ) does physical activity causally protect decrease risk or ( does depression causally reduce physical activity ?

These two questions formed the basis for an investigation by Choi and colleagues ( 2019 ) To answer these questions , the authors used bidirectional Randomization 346 Chapter 15 Exercise and Physical Activity for Depression ( a genetically informed method for establishing causality in observational studies by testing whether genetic variants in a potential underlying trait ( or risk factor ) are associated with an outcome of interest . In bidirectional , researchers can evaluate whether the underlying trait causes the outcome and vice versa . In the Choi et al . 2019 ) study , the authors performed analysis in one direction ( physical activity to depression ) and then performed the analysis in the opposing direction ( depression to physical activity ) using genetic variants associated with each trait . Choi et al . 2019 ) extracted physical activity and depression data from the Study ( et , 2018 et , 2018 ) to examine relationships between physical activity and depression . Physical activity was assessed using ( and subjective ( report ) assessments and was assessed using structured clinical interviews to make a lifetime diagnosis , checklists , or medical record reviews ( see et , 2018 for details ) When testing the causal pathway of physical activity to depression , the authors found that each unit increase in physical activity was associated with a 26 reduction in risk for developing . This increase in physical activity was reported as being equivalent to replacing time spent engaging in sedentary behaviors ( sitting ) with 15 min of vigorous physical activity , 60 min of moderate physical activity , or a combination of light and more vigorous activities . Notably , this relationship was only evident for the measurements of physical activity , not physical activity , suggesting that measurement artifacts associated with different instruments ( cognitive biases , memory recall bias ) could influence inferences drawn from studies examining the physical relationship . When testing the causal pathway of depression to physical activity , the authors found no associations , regardless of how physical activity was measured . Thus , there seems to be more evidence supporting the causal pathway of physical activity to depression rather than the reverse . That is , physical activity may offer protection against the development of depression and symptoms of depression . Overall , the available evidence indicates that physical activity and exercise are effective strategies for preventing depression . Although some research suggests that the relationship may be bidirectional ( et , 2015 ) the study by Choi and colleagues ( 2019 ) indicates that there may be more robust evidence supporting the preventive role of physical activity on depression . Exercise and Physical Activity in the Treatment of Depression Initial research on exercise as a treatment for depression was conducted in the 19805 and . These findings were first summarized in a quantitative review by North and colleagues ( 1990 ) who found that exercise alleviated depressive symptoms and demonstrated comparable and at times increased traditional treatments ( antidepressant drugs and psychotherapy ) A major limitation of their review was the heterogeneous composition of the patient samples . That is , the review included both nonclinical and clinical samples . Nonetheless , this analysis was the first to quantitatively demonstrate the potential benefits of exercise for reducing depressive symptoms and laid the foundation for growing interest in exercise as a treatment for depression . In the following sections , we outline the evidence examining exercise as a treatment for depression and document the potential utility for exercise to be used either as a or complementary intervention to existing depression treatments . To date , research has examined the effects of exercise on depression using ( acute ) and ( chronic ) interventions . Acute For additional reading on and how it can be used in physical activity studies to strengthen causal inferences , refer to the research by et al . 2017 ) and Choi et al . 2019 ) respectively . Zheng et al . 2017 ) also provide an overview of the different types of studies that can be used to evaluate causality in observational epidemiological studies . 347

Brush interventions have focused primarily on providing relief of specific symptoms , such as elevating low mood . Chronic interventions have assessed whether exercise can be used to effectively treat or resolve depression ( the disorder ) and reduce total depressive symptom severity . Below , we discuss the evidence related to both types of exercise interventions and their role in the treatment of depression . Photo from The Role of Acute Exercise in the Treatment of Depression Acute ( single bouts ) exercise will not necessarily resolve an individual depressive symptoms , but it has effects on regulating mood and has the potential to manage symptoms associated with depression . For example , Yeung ( 1996 ) reviewed the effects of acute exercise on mood from studies conducted between the years of 1976 and 1995 and found support for acute induced mood benefits among normative , healthy samples . In 2005 , et al . were interested in determining whether these acute mood benefits could generalize to clinical samples . Using a mixed subjects experimental design , the authors examined the impact of a single bout of aerobic exercise on mood and psychological among 40 adults diagnosed with ( Mage years range 25 female ) Twenty participants completed a bout of brisk walking , while the other 20 participants completed a seated rest control condition . Mood and measures were assessed at four separate time points before the condition ( baseline ) post , post , and post . Compared to the control condition , exercise improved psychological and the mood state of vigor at all assessments . Meyer , and colleagues ( examined the impact of acute exercise on mood in a sample of 24 females diagnosed with ( Mage years ) The authors were interested in determining whether mood improvements were influenced by exercise intensity prescription . In a crossover design , participants performed three different exercise and a seated rest control condition on separate days . Exercise consisted of light , 348

Chapter 15 Exercise and Physical Activity for Depression moderate , or hard and were performed at a rating of perceived exertion of 11 , 13 , and 15 , based on the original scale ( Borg , 1998 ) respectively , while the control condition consisted of quiet rest on a stationary bicycle . Compared to the control condition , a single , bout of cycling , regardless of intensity , significantly improved depressed mood at and following exercise cessation . Meyer , et al . 2016 ) examined whether other exercise characteristics , such as a selected , preferred versus prescribed exercise intensity , would influence the mood effects . Using the same study sample as above , the authors had 24 females perform an additional bout of aerobic exercise at a , preferred intensity . Mood outcomes following the preferred exercise intensity were compared to the light , moderate , or hard intensity session that was closest in terms of to the exercise they did during their preferred session ( if the participants exercise at a low intensity during the preferred session , then their response to that session was compared with the response to the during the prescribed session ) Although the prescribed exercise session resulted in slightly favorable effects relative to the , preferred exercise bout , these effects were small and nonsignificant , highlighting that single bouts of aerobic exercise at any intensity may benefit depressed mood for up to and . Taken together , these findings support the idea that acute exercise can influence specific mood states ( depressed mood and vigor ) at least in the , among individuals with . Given that one of the core criterion symptoms of is low or depressed mood , acute exercise may be particularly effective for managing these core symptoms . Additional research has shown that acute exercise impacts other disrupted psychological processes in depression . Acute aerobic exercise can attenuate negative affect among individuals who recovered from ( Mata et , 2013 ) Separate studies have shown that acute aerobic exercise can diminish reactivity to sad stimuli ( Brush , et , 2020 ) and enhance positive emotional reactivity processes ( Brush , et , 2020 ) among adults at risk for developing ( those high in depressive symptoms ) respectively . Therefore , the utility of acute exercise in the treatment of depression may be most evident in the management of symptoms and psychological processes commonly disrupted in depression . Acute exercise may be most effective in managing symptoms of depression while other treatments and their effects can manifest , which can take weeks to months ( et , 2007 , 2016 ) Several questions remain in the acute relationship . The of the mood benefits are not clear . The et al . and the Meyer et al . studies documented benefits anywhere from min , however , whether the effects are sustained beyond is unknown . Studies have primarily assessed aerobic forms of exercise performed for approximately min . Research is needed to determine how long the benefits last , whether they relate to clinical outcomes ( depressive symptom reduction ) and whether other exercise characteristics ( modality and dose ) impact the effects of acute exercise on mood among individuals with clinical depression . Further , it is unknown how acute exercise compares to other brief interventions ( brief behavioral activation treatment for depression et , 2009 et , 2001 , 2011 ) in managing symptoms of depression . Research that addresses these items can In acute exercise studies , the Profile of Mood States ( et , 1971 ) has been the primary instrument used to assess mood in the context of depression , which has its limitations . As highlighted by and ( 2016 ) the POMS was not designed to capture the global construct of mood . Instead , it decomposes mood into six distinct states ( a ) tension ( depression ( anger ( vigor ( fatigue and ( confusion . There are conceivably other mood states that are not being measured by the POMS therefore , when interpreting studies that use the POMS , it is important to note which specific mood states are altered through exercise to draw valid and accurate inferences . Refer to ( 2013 ) and and ( 2016 ) for a discussion on problems associated with using the POMS in exercise psychology research . 349

Brush help push the envelope for the role of acute exercise in the treatment and management of depression . The Role of Chronic Exercise in the Treatment of Depression There is a long history of research examining the effects of chronic ( exercise on depression . Numerous have examined the effects of exercise for individuals with elevated depressive symptoms . There has also been an accompanying rise in the number of and systematic reviews on this topic ( et , 2013 , et , 2016 ) In one of the most widely cited and influential , James and colleagues ( 1999 ) randomized 156 men and women with ( aged 50 years and older ) to one of three conditions ( a ) an aerobic exercise training program , standard antidepressant treatment with ( drug ) or ( combined exercise plus treatment . For the aerobic exercise training program , three , supervised sessions per week were performed over a span of 16 consecutive weeks in a group setting . Participants were prescribed walking or jogging at a vigorous exercise intensity that ranged from 85 of an individual heart rate reserve ( Although participants assigned to the treatment alone experienced a more rapid initial antidepressant response , there were no significant differences in depressive symptom reduction between groups by the end of the trial , indicating that each treatment resulted in reductions in depressive symptoms . Of the 156 patients who entered the trial , of patients in the aerobic exercise training program , of patients in the treatment condition , and of patients in the combined exercise and treatment no longer met criteria for a diagnosis of . The authors examined outcomes following each of the three treatments in a subsequent study that followed these same patients six months . At the visit , participants assigned to the aerobic exercise group displayed significantly lower rates of depression ( compared to the other two treatment groups ( 52 combined exercise plus 55 et , 2000 ) At the time that this study was published and to the present day , this finding has been critically important in providing some of the strongest evidence for aerobic exercise as both a and complementary treatment to standard antidepressant drugs . Notably , the aerobic exercise treatment group experienced lower relapse compared to participants in the other two treatment groups that included antidepressant drugs , providing the first evidence for the use of aerobic exercise to resolve depression over the ( months following the end ) A limitation of this study was the lack of a placebo control group , which does not permit conclusions about the specific effects of each treatment arm . Therefore , and colleagues ( 2007 ) performed a investigation that added a placebo group to their previous study design . In this study , 202 participants ( female ) diagnosed with were randomized to the following groups for 16 consecutive weeks ( a ) aerobic exercise , supervised exercise in a group setting , or ( a placebo pill . After treatment , 41 of the participants achieved remission and all active treatment groups tended to have greater remission rates compared to the placebo pill group ( aerobic exercise 40 supervised exercise in a group setting 45 47 and placebo pill 31 ) These studies have helped establish preliminary support for the efficacy of exercise treatment for . is computed as the difference between an maximal and resting . The American Psychiatric Association periodically updates the to reflect the most current and research literature on psychopathology . The most recent addition ( was released in 2013 . The first version ofthe was released in 1994 . 350

Chapter 15 Exercise and Physical Activity for Depression There has been a longstanding interest in determining the presence of a relationship between exercise and reductions in depressive symptoms ( 2013 ) In 2000 , a scientific symposium sponsored by Health Canada and the Centers for Disease Control and Prevention was held to determine whether a relationship exists between physical activity and multiple outcomes , including depression . At the time , experts indicated that aerobic exercise programs lasting at least weeks were consistently associated with depressive symptom reductions comparable in magnitude to those observed following antidepressant drug treatment however , they noted that there was insufficient evidence to make definitive conclusions regarding a relationship between exercise and depression . Dunn et al . 2005 ) conducted the first designed specifically to assess the relationship of exercise for depression . Dunn et al . randomized 80 patients with depression severity to two different doses of aerobic exercise ( low dose or , public health dose ) performed at two different frequencies ( three or five days per week ) or to an placebo group of flexibility training . Exercise intensity was selected by participants assigned to the exercise conditions . There was a significant effect . A greater depressive symptom reduction ( 47 decrease in score ) was observed patients in the group compared to the ( 30 decrease in score ) and stretching control groups ( 29 decrease in score ) Further , the treatment response following the prescription was comparable to depressive symptom reductions that are typically observed following other depression treatments , including antidepressant drugs and . Additional evidence supporting a relationship was examined in a study examining the effects of a exercise training program on depression among women ( Chu et , 2009 ) The authors randomized women with high levels of depressive symptoms to a or intensity aerobic exercise condition or to a stretching program for 10 weeks . Participants in the aerobic exercise groups met for one min supervised session and then were asked to complete four additional unsupervised exercise sessions during the week . During the unsupervised sessions , participants in the exercise groups were permitted to choose their preferred mode of aerobic exercise , such as aerobic dancing , walking , or biking . This approach may have served to enhance motivation and adherence to exercise , since participants were afforded greater autonomy in their own exercise . All three groups demonstrated a significant reduction in depressive symptoms at the end of the intervention . After controlling for depressive symptoms ( as measured by the ) depressive symptoms were significantly lower following the intervention for the aerobic exercise group compared to the and stretching groups , suggesting a potential response effect that favors higher aerobic exercise intensity prescriptions for depressive symptom reduction . and colleagues ( 2011 ) extended these findings by showing that aerobic exercise training can also be effective as an augmentation or complementary treatment for patients with resistant depression . The authors enrolled patients who failed to achieve remission following at least six weeks of treatment with and prescribed one of two exercise doses to patients a low dose ( or high dose ( 16 ) Among 126 men and women , those assigned to the higher dose of exercise showed a trend for increased remission rates compared to participants who were assigned to the lower dose of exercise ( for the group compared to for the group ) Higher doses of aerobic exercise may more effectively treat depression and be a viable augmentation strategy for patients with depression who have failed to respond to antidepressant drugs . The low dose prescription is equivalent to approximately 45 min of intensity exercise per week , while the high dose prescription is equivalent to approximately 180 min of intensity exercise per week . 351

Brush It is important to note that the authors found that those assigned to the lower exercise exhibited better adherence rates compared to those assigned to the higher dose . This suggests that lower doses of intensity aerobic exercise may be more tolerable and acceptable for individuals with depression aiming to begin an aerobic exercise program . Most of the work on the effects of exercise as a treatment for depression has focused on the effectiveness of aerobic exercise . Indeed , a that findings across 25 ( weeks range of length weeks ) indicated large reductions in depressive symptoms following exercise compared to nonactive interventions ( et , 2016 ) The extent to which other exercise have utility in the treatment of depression has received less attention . Resistance exercise training is known for its many health benefits , especially for increasing muscular strength , muscle mass , endurance , power ( Department of Health and Human Services , 2008 ) Research has also examined the potential antidepressant effects of resistance exercise training . Singh et al . 1997 ) assessed whether 10 weeks of resistance exercise training significantly reduced depression among 32 older adults over the age of 60 years ( Mage years ) with diagnosed depression or Intervention groups consisted of a supervised , intensity resistance exercise training program performed three times per week or an group . Participants in the resistance exercise group performed upper and lower body exercises for three sets of eight repetitions at 80 of an individual maximum ( Following the intervention , participants in the resistance exercise group reported a 59 reduction in depressive symptoms compared to a 26 reduction in the group . Participants were encouraged to continue their resistance exercise regimen at least twice weekly for another ten weeks upon completing the intervention . After this period , 73 of the participants in the resistance exercise group achieved remission , while only 36 of the participants achieved remission ( Singh et , 2001 ) This evidence served as preliminary support for the antidepressant effects of resistance exercise in both shorter and longer periods of time . Similar to the aerobic exercise literature , Singh and colleagues were interested in examining potential effects of resistance exercise training on depressive symptoms . In a subsequent study , the authors randomly assigned 60 older adults between the ages of 60 and 85 to a high ( 80 of ) low ( 20 of ) or comparator condition for eight weeks ( Singh et , 2005 ) resistance exercise training resulted in larger antidepressant effects compared to the and comparator groups . Interestingly , the authors examined the proportion of individuals who adequately responded to treatment , which was defined as a 50 reduction in the score from . The results revealed a 61 response rate in the group compared to 29 and 21 in the and groups , respectively . This evidence suggests that resistance exercise training may not only reduce depression , but higher may be more effective . Noting that the majority of conducted on the exercise and depression relationship has focused on aerobic forms of exercise , Gordon and colleagues ( 2018 ) aimed to address One included in the , et al . 2016 ) did not report the trial length . Therefore , the mean and range of trial lengths reported include that were included in the authors . is no longer considered a diagnosis in the . It was removed from the Edition ( IV ) and replaced by persistent depressive disorder . Minor depression was considered a Depressive Disorder Not Otherwise Specified in the . 11 Resistance exercise training intensity is often based off an individual , which is defined as the maximal amount of weight an individual can lift in a single repetition ( et , 2011 ) 352

Chapter 15 Exercise and Physical Activity for Depression this gap in the literature by performing the first quantitative review of the effects of resistance exercise training on depression . Gordon et combined effects from 33 , which included a total of participants , and found that resistance exercise training resulted in a reduction in depressive symptoms , regardless of characteristics . It is important to note that this combined findings from studies that included both normative and clinical samples . When examining only those with clinical levels of depression ( at least depressive symptoms ) the resistance exercise training had even larger antidepressant effects compared to those with subclinical depression . There was no specific impact of type of resistance exercise training protocol on depression outcomes . Collectively , the evidence generally supports the notion that both aerobic and resistance forms of exercise are effective treatments for depression . This has been shown in studies examining exercise training as a or complementary treatment to other treatments , namely antidepressant drugs . The antidepressant effects of exercise are at least as comparable to antidepressant drug treatments and over the long run , there is evidence to suggest that exercise may result in more favorable reductions in depressive symptoms and disorders compared to antidepressant drugs ( et , 2000 ) It is important , however , for future studies to continue to examine the impact of exercise on depression to fully understand how long effects are sustained . Most of the research to date has been conducted in adults with depression , while the impact of exercise training in other populations that are substantially impacted by depression , including children and adolescents , is less clear . Future studies are needed in other vulnerable populations to determine whether effects are generalizable . Overall , exercise should play an important role in the treatment of depression as a complementary treatment . Plausible Neurobiological Mechanisms of the Antidepressant Effect Establishing neurobiological mechanisms of the antidepressant effects of exercise has historically been challenging . Depression is characterized by substantial heterogeneity estimates indicate that anywhere from 119 ( Park et , 2017 ) to 681 ( et , 2018 ) to even ( Fried , 2015 ) unique combinations of depressive symptoms could meet diagnostic criteria . Research attempting to explain the mechanistic effects of exercise on depression often struggle to accommodate for the diverse symptom profiles and presentations across individuals , which makes it difficult to design studies aimed at establishing the mechanisms implicated in the antidepressant effects of exercise . In addition to the heterogeneity , exercise is associated with a wide range of neurobiological effects ( see et , 2006 for an extensive overview ) When considering these factors , it is unsurprising that our general understanding of the mechanisms underlying the antidepressant effects of exercise is unclear . It is likely that exercise improves mood and other specific symptoms in the term and reduces depression in the through numerous mechanisms because of its wide range of effects . Indeed , experts have proposed several neurobiological mechanisms ( et , 2019 , et , 2016 ) In this section , we provide a very brief overview of some of the neurobiological mechanisms that have been assessed in acute and chronic exercise studies . We only focus on neurobiological mechanisms that are hypothesized to be implicated in the of depression and have been studied in relation to changes in depressed mood or depressive symptoms . Neurobiological Mechanisms Studied in the Context of Acute Exercise In a series of secondary data analyses , Meyer and colleagues were interested in exploring potential neurobiological mechanisms implicated in the benefits exercise . In three separate reports , Meyer and colleagues examined whether serum concentrations of neurotrophic factor ( Meyer , et , and related lipids ( Meyer et 353

Brush , 2019 ) and ( Perez et , 2020 ) could be altered by acute bouts of aerobic exercise and whether alterations were associated with acute changes in mood states . In each of these studies , blood was drawn before and within 10 min after each condition to determine changes in , and related lipids , and . Specific descriptions related to each analysis are outlined below . In Meyer , et al . 24 women with performed 20 min of aerobic exercise at light , moderate , and hard exercise participants also completed a quiet rest condition . While acute exercise significantly improved depressed mood and increased levels regardless of exercise intensity , these findings do not explain the mechanism , as authors failed to observe a relation between changes in depressed mood and levels . In Meyer et al . 2019 ) 17 women with exercised for at a ( prescribed exercise intensity equivalent to a of 13 ) or , of aerobic exercise ( chosen exercise intensity range ) aerobic exercise significantly increased levels ( and a related lipid ( Most notably , changes in and were associated with changes in mood states , suggesting that and related lipids may contribute to the effects of acute exercise in . No such relationships were observed following the , preferred intensity of aerobic exercise . Differences in findings may be attributed to the substantial variability in how participants selected and performed their preferred exercise intensity , with some individuals exercising at lower than others ( see wide range of above ) This suggests that lower of exercise may not be sufficient to induce changes in the system , or alternatively , other mechanisms might be at play . In 2020 , Perez et al . examined whether serum concentrations of ( ILs ) and and tumor necrosis ( could be altered by a bout of aerobic exercise . Participants completed the same experimental conditions as the Meyer , et al . study . Perez and colleagues found that hard exercise increased , and among 19 women with , while the light and moderate exercise failed to modulate these inflammatory markers . The authors also examined whether changes in each of these inflammatory markers related to changes in depressed mood but failed to find any significant relationships . The authors hypothesized that there is a possibility that acute increases in inflammatory markers following hard exercise could have potential for prompting chronic inflammatory adaptations however , limited conclusions can be drawn from these studies with studies needed to test this possibility . Other limitations of these data include the secondary nature of the analyses , as well as the relatively small samples including only women . In addition to this empirical evidence , and colleagues ( 2016 ) propose other plausible neurobiological mechanisms that may be modulated by acute exercise , including increased levels of atrial peptide , brain peptide , and growth hormone however , currently , there is a dearth of evidence to make strong conclusions about neurobiological mechanisms sensitive to change through acute exercise in depression . Neurobiological Mechanisms Studied in the Context of Chronic Exercise Chronic exercise studies have examined potential neurobiological mechanisms associated with the antidepressant effects of exercise . These studies have focused on assessing whether changes in specific neurobiological mechanisms are associated with depressive symptom change in response to exercise treatment . To date , chronic exercise studies have focused mostly on oxidative stress markers , and inflammatory markers . In et al . 2014 ) the authors conducted a evaluating the effects of exercise as an on treatment to on substances ( and among 26 severely depressed . Fifteen individuals were randomized to an exercise plus 354

Chapter 15 Exercise and Physical Activity for Depression usual condition , while the other 11 participants were allocated to a comparator condition . Participants performing the exercise completed a dose three times per week throughout their hospitalization stay . Across the hospitalization stay ( exercise participants days control participants days ) participants in the exercise group performed total sessions . Serum levels increased for the exercise group , while no effects were found for serum levels , indicating that may be a potential neurobiological mechanism implicated in the antidepressant effects of exercise for participants with depression . It was unclear from this study whether change in was associated with changes in depressive symptom improvements . these patients were also receiving which consisted of antidepressant drugs electroconvulsive therapy . It is possible that exercise may impact serum levels when combined with other forms of treatment . Future studies specifically designed to test whether is a neurobiological mechanism of the effects of exercise for depression are needed . and colleagues ( 2017 ) examined whether serum levels could be altered by 12 weeks of exercise and whether changes corresponded to changes in depressive symptoms . In their study , 116 patients ( age range years ) completed light ( 48 ) moderate ( 36 ) and vigorous ( 32 ) exercise conditions for three exercise sessions over 12 weeks . Reductions in levels were associated with depressive symptom reductions , indicating that may be a potential mechanism of the antidepressant effects of a chronic exercise training program . The authors did not examine other inflammatory markers or mechanisms . It remains unknown whether other mechanisms could also account for the effects . These studies suggest that there may be a role of specific oxidative stress and inflammatory markers in the antidepressant effects of exercise training . Overall , the available data for neurobiological mechanisms of the antidepressant effects are too premature to make any definitive conclusions . Conclusion is a prevalent and burdensome mental illness that significantly impacts individuals of all age groups across the globe . Antidepressant drugs and psychotherapeutic approaches are treatments for however , these treatments are associated with several barriers , have variable effectiveness , and have vast side effect profiles . Exercise and physical activity are two lifestyle behaviors that can be used to effectively prevent and treat depression . and longitudinal research indicates that engaging in regular physical activity is associated with a diminished risk of current and future depression . Even engaging in small amounts of physical activity can reduce an individual risk for depression . A large body of evidence has examined exercise programs in the treatment of depression . Acute exercise has shown to exert powerful effects on mood and other disrupted psychological processes in depression , which may have implications for using exercise as a strategy to help alleviate or manage symptoms ( low mood or deficits in positive or negative affect ) in the short run . In the term , treatment studies have shown that aerobic and resistance forms of exercise training result in effect sizes in depressive symptom reduction ( Gordon et , 2018 , et , 2016 ) Establishing neurobiological mechanisms of the antidepressant effects of exercise has been challenging due to the heterogeneous nature of depression and the wide range of neurobiological effects of exercise , but several mechanisms have been proposed and tested . In conclusion , research suggests that consistent physical activity can reduce the risk of developing depression and acute and chronic exercise treatment programs are efficacious in improving mood and symptoms of depression . 355

Brush Learning Exercises issue a diagnosis of based on the presence of at least five symptoms that are present over the same time period . According to the Diagnostic and Statistical Manual , Fifth Edition ( of the American Psychiatric Association ( 2013 ) which two symptoms are required for a diagnosis ?

Do both symptoms need to be present in order to be issued a diagnosis ?

Identify the remaining symptoms that may also be present to constitute a diagnosis . Can physical activity be useful in protecting against the development of depression or does depression reduce physical activity levels ?

What evidence is there to support your answer ?

Can exercise be used to treat depression ?

What evidence is there to support your answer ?

How does exercise compare with antidepressant drugs in the treatment of depression ?

What are the depression outcomes of either treatment ?

Does a specific dose of exercise elicit larger antidepressant effects compared to other doses of exercise ?

Use the available evidence to support your answer . Most treatment studies examining the effects of exercise on depression have focused on aerobic forms of exercise . Does resistance exercise have utility in the treatment of depression ?

Use evidence to support your answer . Several neurobiological mechanisms have been proposed to underlie the antidepressant effects of exercise . Identify at least two mechanisms that change in response to exercise . Indicate the dosage of exercise that was used in terms of type , frequency , intensity , and duration . A friend of yours knows that you are taking a class in sport and exercise psychology . They have recently been issued a diagnosis and are currently considering different treatment options . Your friend wants you to share your insights on how to manage and alleviate their depression . Based on the evidence outlined in this chapter , provide insight into different treatment options in terms of treatment outcomes and efficacy in reducing depression over the . Which treatment would you recommend ?

What type of exercise can individuals do in the versus to manage and reduce their depression ?

Use scientific evidence to support your answer . 356 Chapter 15 Exercise and Physical Activity for Depression Further Reading For practical recommendations and advice for using exercise and physical activity in the treatment of depression , readers are encouraged to refer to primers by and ( 2013 ) and et al . 2020 ) Readers interested in understanding the wide range of potential neurobiological mechanisms implicated in the antidepressant effects of exercise and physical activity in the prevention and treatment of depression should refer to the , et al . 2016 ) and et al . 2019 ) reviews . References , Gordon , Hen , Nestler , 2018 ) Treatment resistant depression A , systems biology approach . Neuroscience Reviews , 84 , American Psychiatric Association . 2010 ) Practice the treatment with major depressive disorder . American Psychiatric Association . 2013 ) Diagnostic and statistical manual disorders ( American Psychological Guideline Development Panel . 2019 ) Clinical practice guidelines for the treatment of depression across three age cohorts . American Psychological Association . Herman , Khatri , Moore , 2000 ) Exercise treatment for major depression Maintenance of therapeutic benefit at 10 months . Psychosomatic Medicine , 62 ( Morrison , 2005 ) Effects of acute exercise on mood and being in patients with major depressive disorder . Medicine Science in Sports Exercise , 37 ( 12 ) Beck , Steer , Brown , 1996 ) Beck depression . van den , 2006 ) Can strenuous leisure time physical activity prevent psychological complaints in a working population ?

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Brush Brush , Miller , Alderman , 2020 ) Aerobic exercise enhances positive emotional reactivity in individuals with depressive symptoms Evidence from neural responses to reward and emotional content . Mental Health and , 19 , Brush , Alderman , 2020 ) Acute aerobic exercise increases respiratory sinus reactivity and recovery to a sad film among individuals at risk for depression . international Journal of Psychophysiology , 156 , Yang , 2017 ) Inference in psychiatry via association to causal pathway ?

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