Are Depression Guidelines Missing the Evidence for Exercise?

A recent review suggests that depression guidelines do not incorporate evidence for exercise within a stepped-care approach and may be over-reliant on pharmacological treatments.


A new study, published in Translational Behavioral Medicine, reveals that the majority of clinical practice guidelines for the treatment of major depression do not incorporate a stepped care approach and often fail to include physical activity or exercise as a recommended intervention. There is some concern that the variability in guidelines may influence the ability of clinicians to provide adequate care for individuals diagnosed with subthreshold or mild to moderate depression.

“The question of whether evidence for physical activity has been incorporated in an evidence-based way into clinical practice guidelines is a critically important one as guidelines are seen as the gold-standard of evidence-based medicine,” Courtney Hess, a doctoral student in counseling psychology at UMass Boston and the lead author of the review, writes. “As such, they play a major role in decisions about what will (and will not) be covered by insurance companies and government programs, and they have profound consequences for patient care.”

In 2016, the US Preventive Services Task Force recommended a universal depression screening protocol for primary care patients older than 13, with the goal of increasing detection and treatment access. This push has several flaws, including the high rate of false positives on measures such as the PHQ9, which has shown an association with depression diagnosis and antidepressant prescription in patients who do not meet the criteria for major depression. Moreover, antidepressants have been shown to be an ineffective treatment for mild depression, though they are often the primary form of treatment following an MDD diagnosis.

As a result, researchers have suggested stepped care approaches, in which patient treatment begins with a low-burden intervention and only progresses to higher risk steps when there’s no discernable improvement. Several meta-analyses have found that exercise has comparable treatment effects to therapy and antidepressants for depression. In addition, a recent randomized control trial found that neither intensity nor type (yoga, walking or running) of exercise affects the treatment efficacy of physical activity for depression.

The researchers point out that there have been several concerns about the trustworthiness of such guidelines, which are subject to bias and can be used to cement current clinical practices without incorporating new evidence. Treatment guidelines for depression, in particular, are at risk of bias because there are no biomarkers to diagnose or assess treatment effectiveness.

To find current guidelines, the researchers followed PRISMA review standards and utilized the Institute of Medicine’s (IOM) definition of a guideline to create the inclusion criterion. The IOM defines clinical practice guidelines as a statement including recommendations to optimize patient care, which include a systematic review of the evidence as well as an analysis of the benefits and harms of alternative care options. A total of 17 guidelines were selected for this analysis. These guidelines were then assessed on two major domains: the level of recommendation of physical activity as an intervention as well as an assessment of adherence to stepped-approach model.

The review found that four guidelines suggested physical activity as a front-line intervention, four recommended physical activity as sufficient for treatment but not as a front-line intervention, seven gave general support for physical activity, and two did not mention physical activity at all. Further, nine guidelines showed empirical support for their recommendations concerning exercise and seven adhered to a stepped-care model.

“The fact that the majority of the guidelines in the study did not use a stepped approach, together with the wide variation in recommendations, raises concerns about the potential for non-evidenced-based treatment as well as overtreatment,” write Hess and colleagues. “Additionally, almost half of the guidelines did not incorporate evidence for the inclusion or exclusion of physical activity and exercise, thereby raising concerns about the effective translation of current evidence-based research into clinical practice.”

There are several explanations for the variation in depression guidelines. One example is known as “the funding effect,” whereby the influence of financial ties to the industry informs treatment guidelines. This is an especially troubling effect to consider, as groups with commercial ties are less likely to have a methodologist on their panel, and are more likely to recommend more costly, invasive, and industry-friendly interventions.

While there are indeed barriers to treatment implementation for physical activity, such as resistance to exercise from patients, there is no reason to believe this barrier is higher than that of pharmacotherapy. Indeed, antidepressant trials often show nonadherence rates of up to 43%, compared to an average nonadherence rate of 11% for physical activity interventions.

Several methods may be useful in motivating individuals with subthreshold and mild-moderate MDD to engage in physical activity. When the research is presented to doctors and patients indicating that increasing exercise levels is achievable and effective in reducing depressive symptoms it can help to create buy-in. Clinical practice guidelines can be one source of this information.

“Given the likelihood of increased identification of subthreshold and mild to moderate MDD as a result of routine depression screening, and the growing evidence for physical activity and exercise as an evidence-based intervention, there is a need for guideline development groups to incorporate this body of research in future clinical practice guidelines,” the researchers write.

Moreover, there is a need to tailor research to specific populations and specific types of exercise, as well as the need to develop more stringent standards for guidelines and the groups that create them. A stepped-care approach, which considers exercise and physical activity as a potential first-line intervention, can help to decrease the risks of overtreatment and overmedication in the treatment and prevention of mild to moderate and sub-threshold depression.



Hess, C. W., Karter, J., Cosgrove, L., & Hayden, L., (2018). Evidence-based practice: a comparison of International Clinical Practice Guidelines and current research on physical activity for mild to moderate depression. Translational Behavioral Medicine. Advance online publication. doi: 10.1093/tbm/iby092 (Link)


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Gavin Crowell-Williamson
MIA Research News Team: Gavin Crowell-Williamson is a Research Assistant at the University of Washington studying addiction-related suicide prevention. He is interested in researching how to provide opportunities for mental health care in communities that lack access, as well as understanding systemic factors that either facilitate or prevent getting help for mental health. He is currently pursuing a graduate degree in Community Development and Action from Vanderbilt University.


  1. There should definitely be “a stepped-care approach” because today’s doctors absolutely are “over-reliant on pharmacological treatments.” To the point that the doctors are handing the antidepressants out to non-depressed people, under the incorrect guise that the antidepressants are “safe smoking cessation meds.”

    And, flaws in your “clinical practice guidelines for the treatment of major depression” do result in depression misdiagnoses. According to the DSM definition of depression, one of the symptoms of depression is “Significant weight loss when not dieting.” Despite the reality that “Significant weight loss when not dieting” is also a symptom of starting an exercise regime, as recommended by another doctor.

    But the mental health professionals are too stupid to ask about exercise as a possible reason for recent weight loss. Instead they automatically incorrectly assume “weight loss when not dieting” is a sign of depression, even though it is not. Losing weight makes one feel better, not depressed.

    But this DSM flaw does result in “depression caused by self” misdiagnoses, when one is discussing interpersonal issues regarding bullies, who turned out to be child rapists, according to other medical records.

    But something else that is important to point out is that over 80% of those stigmatized as “depressed” today are actually misdiagnosed child abuse survivors.

    This explains part of why there is all this misdiagnosis of child abuse survivors as depressed.

    And the antidepressants do NOT cure a person of concerns regarding child abuse issues. They don’t cure someone of disgust at 9/11/2001, and the never ending wars that have bankrupted our country since that event. The psychiatric drugs don’t cure people of anything.

    But millions of people have had the adverse effects of the antidepressants misdiagnosed as bipolar, resulting in a completely iatrogenic (NOT “genetic”) bipolar epidemic, just as Whitaker pointed out in “Anatomy.” And this was malpractice on a staggering societal scale because the US “mental health professionals” apparently aren’t intelligent enough to even read their DSM-IV-TR.

    “Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.”

    But what’s good is we do now know that both bipolar and schizophrenia are iatrogenic, not genetic, illnesses that can be created with the psychiatric drugs. Here’s how the antipsychotics create both the negative and positive symptoms of schizophrenia.

    And we do now know all the DSM disorders are “invalid” diagnoses, so the “mental health professionals” should flush their DMS “bibles.”

    And I’m quite certain that having a multibillion dollar, primarily child abuse covering up industry, which is what today’s “mental health industry” actually is. All this psychiatric and psychological aiding and abetting of child rapists has no doubt helped to create the pedogate, child trafficking, and other related satanic pedophile societal crimes that are now filling the internet.

    Perhaps we should get rid of the “invalid,” child rape covering up, iatrogenic illness creating “mental health” industry? Since such a child rape covering up industry is seemingly destroying our world.

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  2. I am just looking at the picture and of all the different ways to exercise jogging has to be the most difficult way of going about it cause IMO it takes alot of push to make yourself go out and do it and has the least amount of positive feedback. Jog to the end of the block now I am tired this sucks… I would rate dirt bike riding as the number one way to exercise as the fun of it creates the positive feedback to continue the activity.

    Like the Mohs scale, the ten minerals of the Mohs scale are talc (measuring 1 on the scale), gypsum, calcite, fluorite, apatite, orthoclase, quartz, topaz, corundum, and diamond (measuring 10 on the scale).

    Dirt biking is diamond and jogging is talc. Every other activity could be set in between.

    Want depressed people to exercise better suggest something fun or they won’t do it.

    Sex is the best exercise but that entire subject is usually left out of discussions on mental health.

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    • I have always wondered about that – if exercise is so good for us, why is it that it’s so damned painful to start with! I suppose in nature we are forced by circumstances to exercise just to survive, so we don’t have a choice about it.

      Good point about sex, too. It’s a particularly excellent sleep aid!

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  3. Of course exercising’s omitted from treatments for depression. Providers don’t make any money from it, unlike antidepressants, which have to be taken for life, being addictive, thereby providing manufacturers with an opportunity for lifetime income from multitudes of users desperate to avoid withdrawal symptoms.

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  4. I have suffered from depression my whole life but I always, always, always feel better when I run. Running does take an effort and it takes awhile to build up time and distance but there are immediate results. There is an app for cell phones that talks you through a beginning running program, it’s the C25K program and it’s free. It’s a walk/run program that anyone can do. Anyone. I quit taking antidepressants several years ago and running has helped me immensely. No therapist ever even suggested running to me. I also know how many people are resistant to the suggestion to exercise when they’re depressed because when you’re depressed you don’t feel like making an effort to do anything, but I’ve found that making an effort to do something healthy always helps me move through my depressive episodes. The Nike slogan “Just Do It” pertains.

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    Bicycle or walk 7 days a week. Swim 3-5 times a week. No depression.
    Any person with health insurance and a “depression diagnosis” should have a bicycle paid for, and a good pair of walking (or running) shoes, also…. But that just makes WAY too much sense!….
    When I read the piece above, I can’t help see a bunch of grossly over-educated idiots, who are too enamored of the trees of their “higher education”, to EVER see the FOREST of LIFE, where healthy people exercise DAILY!
    But the native vegetable of modern America seems to be the couch potato. No wonder so-called “depression” is epidemic! The human body was genetically designed to *exercise* *daily*!

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