Depression is a common mental health condition characterized by persistent low mood, loss of interest, and fatigue, with mild cases causing some difficulties with daily life, moderate cases leading to significant functional impairment, and severe cases involving near-total disruption of daily life, often with suicidal thoughts and/or psychotic symptoms. While psychotherapy and medications are standard treatments, physical activity (PA) is now recognized as an effective intervention for depression [1]. A 2023 meta-analysis found that exercise can significantly reduce depressive symptoms, with effectiveness comparable to first-line treatments such as psychotherapy and medication [2]. Despite its benefits, the practicalities of prescribing PA for depression remain underutilized [3]. Our goal is to develop a practical guide for clinicians who treat depression, informed by the latest evidence, to help prescribe PA effectively (see Table 1 for a summary of recommendations).
| Component | Recommendation | Key Considerations |
|---|---|---|
| Frequency | 3 to 5 sessions per week [10] | Reduce sedentary behaviours or aim for even lower frequencies for beginners. Even 1–2 sessions per week offer some benefits [3]. |
| Intensity | Moderate- to vigorous-intensity PA (e.g., brisk walking, cycling, swimming) [10] | Start with low-intensity PA (e.g., walking or yoga) for patients with severe depression or low energy [3, 13]. |
| Time | 45–60 minutes per session [2, 10] | Shorter sessions (10–30 minutes) are still beneficial, especially for beginners [3, 10]. |
| Type | Aerobic (e.g., walking, running), resistance (e.g., strength training), or mind-body (e.g., yoga) [2, 14] | Tailor PA to patient preferences to improve adherence [3]. |
| Supervision | Supervised or group-based PA enhances adherence and benefits [2, 10] | Encourage patients to join group classes or work with exercise professionals where available [10]. |
| Barriers | Address amotivation, fatigue, and time constraints [3] | Use strategies like the “commit 10” approach to make PA more manageable [3]. |
| Facilitators | Social support, enjoyable activities [17] | Encourage group activities, buddy systems, or outdoor PA for additional benefits [3, 13]. |
| Patient Involvement | Engage patients in decision-making regarding PA type and schedule [3] | Tailor PA programs based on individual preferences, enhancing motivation and adherence [3]. |
| Flexibility | Emphasize flexibility in PA goals [3] | Encourage patients to focus on consistency over perfection, and to avoid viewing missed sessions as failures [3,17]. |
Table 1 Summary of recommendations for prescribing PA for depression
Why physical activity?
PA is any movement that uses energy, while exercise is a planned and structured form of physical activity aimed at improving fitness. PA provides many benefits for mental health. It reduces stress, improves sleep, boosts mood, enhances self-esteem, and has specific antidepressant effects [4]. Upon contraction, muscles release myokines (cytokines and peptides) that mediate communication with other organs to increase brain-derived neurotrophic factor (BDNF) [5]. Studies have demonstrated that PA promotes neuroplasticity through this upregulation of BDNF, which is important for mood regulation [4]. There exists also a bidirectional relationship with depression - PA reduces depressive symptoms, while inactivity is associated with increased depression risk [6]. Given its broad impact on mental and physical health, PA has been included in treatment guidelines for depression as a first-line therapy [1, 7].
Components of an effective physical activity prescription
Prescribing PA involves more than simply encouraging patients to “be active”. Similar to the low adherence rates observed with psychiatric medications - where the CATIE study reported discontinuation rates as high as 74% within 18 months [8] - we must approach PA recommendations with empathy and understanding. Building a collaborative alliance around shared goals is essential for increasing engagement. Like medication adherence, developing PA habits takes time, and patience is key to success. It can take a similar approach that a physician uses to prescribe a medication, which often includes dose, frequency, and route of administration. For PA, a structured approach based on the FITT framework - Frequency, Intensity, Time, and Type - ensures that PA is both effective and sustainable [9].
Frequency – how often one is participating in PA
For optimal outcomes, patients should participate in PA three to five times per week [10]. Regular, consistent activity is key to maximizing the antidepressant effects. For patients unfamiliar with PA or who struggle with motivation, reducing sedentary behaviours (e.g., sitting, watching TV, using a computer) or aiming for even lower PA frequency, such as once a week, can still provide benefits and serve as a starting point. Ultimately, any PA is better than none [3].
Intensity – how much energy is expended during PA
The “talk test” is a practical way for patients to measure PA intensity, which is separated into three groups: (1) low intensity (you can talk and sing during the activity), (2) moderate intensity (you can talk but not sing during the activity), and (3) vigorous intensity (you cannot say more than a few words during the activity) [11]. Moderate- to vigorous-intensity PA is recommended for treating depression in adults [10]. However, clinicians should consider the patient’s baseline fitness level and preferences. Further, intensity is related to affect during PA [12], which must be taken into account. For instance, for individuals experiencing severe depressive symptoms (or older individuals), low-intensity activities such as walking or yoga may be more appropriate to start with and still offer mental health benefits [3, 13]. As patients become more comfortable with PA, they can gradually increase the intensity.
Time – how long PA sessions are
Sessions of 45 to 60 minutes are most effective for improving mood and reducing depressive symptoms [2, 10]. However, shorter durations - such as 10- to 30-minute bouts - can still provide meaningful benefits [3, 10]. The emphasis should be on starting with manageable/realistic goals and gradually increasing the duration as patients gain confidence.
Type – aerobic, resistance, or mind-body
All three PA types (and their combinations) have been shown to reduce depressive symptoms [2, 14]. Aerobic activities include walking, swimming, and cycling; resistance training activities include weightlifting or bodyweight exercises; while mind-body activities include yoga, tai chi, and qigong. As people with depression are characterized by strong affective responses [15], clinicians should encourage patients to select enjoyable activities, leading to greater adherence and long-term success [3].
Supervision and support
Supervised PA enhances adherence and amplifies the antidepressant effects of physical activity, particularly in the early stages [2, 10]. Structured group-based PA or individual sessions with an exercise professional, such as a kinesiologist or health coach, provide accountability and motivation, which are particularly important for individuals with depression, who may struggle with fatigue or low motivation [10]. When supervision is not feasible, clinicians can recommend online exercise programs, fitness apps, or community resources that provide structure.
Social interaction during PA can further enhance its mental health benefits. Group activities or buddy systems can reduce feelings of isolation, which are common in depression (particularly among older individuals), and promote a sense of community [2, 3, 7]. For patients who prefer individual activities, encouraging them to engage in outdoor PA may also boost mood and adherence, as exposure to nature has additional benefits for mental health [13].
Overcoming barriers to physical activity
Barriers such as low energy, amotivation, low income, co-morbidities, inexperience with PA, and time constraints are common among individuals with depression and can hinder engagement in PA. Particularly, green space availability is significantly lower in neighbourhoods with increased poverty, limiting access to outdoor physical activity [16]. A scoping review identified these as key obstacles but also highlighted that social support and enjoyable activities can facilitate adherence [17]. One useful strategy is the “commit 10” approach, where patients commit to just 10 minutes of PA, with the option to continue if they feel capable [3]. Further, engaging in small bouts of activity (such as walking the stairs instead of taking the elevator) or setting daily step goals can make PA more feasible for those with limited time. Although these recommendations fall short of the optimal PA threshold according to the FITT framework, they provide manageable/realistic starting points that can reduce the psychological barriers to beginning a new activity, fostering positive associations with PA for patients.
Gradual progression in both the intensity and duration of PA is essential to prevent patients from feeling overwhelmed. Starting with small, achievable goals allows individuals to build confidence and gradually incorporate more PA into their routines. Clinicians should reinforce that any amount of PA is beneficial and that setbacks or missed sessions should not be seen as failures [17]. The therapeutic alliance should be carefully maintained when making recommendations that could evoke feelings of shame if goals aren’t achieved. At the same time, motivational interviewing techniques can be used, where the clinician encourages the patient to express their reasons for change, reflects these reasons back to them, and emphasizes previous successful habits that supported adherence to change [3].
Patient involvement in decision-making
Involving patients in the decision-making process is crucial for long-term adherence. Patients are more likely to be more motivated and stick to a PA plan when they have a say in their activity [3]. Clinicians should ask patients about their preferences, whether they enjoy indoor or outdoor activities, and whether they prefer activities alone or in groups.
Flexibility
PA for depression should be approached with flexibility. Patients with depression may experience fluctuations in mood and energy levels, and they should not feel pressured to meet rigid activity goals if they are unable to. Clinicians should encourage patients to view PA as a flexible, adaptive process and remind them that even small amounts are beneficial [3]. This helps patients maintain a positive mindset toward PA, which is critical for long-term adherence
Conclusion
PA is an effective intervention for depression and should be more widely utilized in clinical practice. A structured, personalized PA prescription - guided by the FITT framework - can significantly reduce depressive symptoms. By involving patients in decision-making and offering flexible, manageable goals, clinicians can help them overcome barriers to PA and integrate it into their lives. With the right support, PA can become a sustainable and empowering treatment for depression.
References
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