Excercise Better Than CBT For Depression

according to a network meta analysis by Noetel et al (2024) published in the BMJ. These authors suggested  ‘those delivering psychotherapy may want to direct some time towards tackling cognitive and behavioural barriers to exercise’. But I suspect that a goodly proportion of CBT therapists already do this routinely as part of Activity Scheduling or Behavioural Activation. It would likely be atypical CBT to have no mention of excercise. This would make the CBT v exercise comparison in the study problematic.

The study reveals an effect size for Excercise about 0.5, but a little higher  for dance. This means that of those in excercise/dance arm the average person did better than about  69% of those who had CBT.  This equates to patients in both arms scoring  say 28 on the BDI initially and an added reduction of 4 points in the excercise/dance compared to the CBT. Is this really meaningful?

I searched in vain to find what proportion of people in each modality recovered from their depression and remained in remission (more than 8 weeks) . The real world significance of the Noetel et al (2024) findings are in doubt. Nevertheless there is a danger that exercise is seized on and promoted as a cheap alternative to CBT.

Outcome in this meta analysis was based on self-report measures and not the ‘gold standard blind diagnostic interview’, suggesting caution in interpreting the results. Further the studies reviewed included those were entry was gained by scoring over 13 on the 2nd version of the Beck Depression Inventory. I have just seen a client who suffered from a DSM-5 defined adjustment disorder with depressed mood for 6 months, who would almost certainly have scored high on the BDI in this period, but never met criteria for primary major depressive disorder.  There was a clear psychosocial stressor that would have been upsetting to most people. The good news is that he was not referred for CBT and his symptoms were not pathologised.

Dr Mike Scott


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