Objective An estimated 3.8% of the global population experiences depression, according to the  WHO report. Evidence supports the efficacy of exercise training (EX) for depression; however, its comparative efficacy to conventional, evidence-supported psychotherapies remains understudied. Therefore, we conducted a network meta-analysis to compare the efficacy of exercise training (EX), behavioral activation therapy (BA), cognitive-behavioral therapy (CBT), and non-directive supportive therapy (NDST).
Methods Our search was performed in seven relevant databases (inception to March 10, 2020) and targeted randomized trialsomparing psychological interventions head-to-head and/or to a treatment as usual (TAU) or waitlist (WL) control for the treatment of adults (18 years or older) with depression. Included trials assessed depression using a validated psychometric tool.
Results From 28,716 studies, 133 trials with 14,493 patients (mean age of 45.8 years; 71.9% female) were included. All treatment arms significantly outperformed TAU (standard mean difference [SMD] range, -0.49 to -0.95) and WL (SMD range, -0.80 to -1.26) controls. According to surface under the cumulative ranking (SUCRA) probabilities, BA was mostly likely to have the highest efficacy (1.6), followed by CBT (1.9), EX (2.8), and NDST (3.8). Effect size estimates between BA and CBT (SMD = -0.09, 95% CI = -0.50 to 0.31), BA and EX (-0.22, -0.68 to 0.24), and CBT and EX (-0.12, -0.42 to 0.17) were very small, suggesting comparable treatment effects of BA, CBT, and EX. With individual comparisons of EX, BA, and CBT to NDST, we found small to moderate effect sizes (0.09 to 0.46), suggesting EX, BA, and CBT may equally outperform NDST.
Conclusions Findings provide preliminary yet cautionary support for the clinical use of exercise training for adult depression. High study heterogeneity and lack of sound investigations of exercise must be considered. Continued research is needed to position exercise training as an evidence-based therapy.