ISSN: 2320-5407 Int. J. Adv. Res.

11(06), 734-744

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/17122
DOI URL: http://dx.doi.org/10.21474/IJAR01/17122

RESEARCH ARTICLE
THE PREVENTIVE POWER OF PHYSICAL ACTIVITY ON DEPRESSION AND ANXIETY: A
NARRATIVE REVIEW

Albinsaleh Abdullah A.1, Alwael Walla M.2 and Alsaad Ali J.3
1. Joint Program of Preventive Medicine, Al-Ahsa, Community Medicine Department, Al-Ahsa Health Cluster,
Saudi Arabia.
2. Department of Physical Education, College of Education, King Faisal University, Al-Ahsa, Saudi Arabia.
3. Department of Clinical Neuroscience, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Background:Effective treatments for depression and anxiety include
Received: 20 April 2023 psychology and medications. It is proposed that one of the tools of self-
Final Accepted: 24 May 2023 care is physical activity (PA), which is an adjuvant treatment that may
Published: June 2023 play a crucial role in managing depression and anxiety, in addition to
promoting a better quality of life (QoL).Through this narrative review,
Key words:-
Physical Activity, Exercise, Yoga, we aim to summarize the latest available evidence and guide our
Mental Disorders, Depression, Anxiety, healthcare colleagues to help anyone suffering from depression and
Prevention anxiety.
Summary:PubMed and Cochrane databases were systematically
searched for relevantstudies published between January 2018 and June
2023 with no language restriction. Systematic reviews were included in
the search. We performed the study selection in 3 stages: initially, we
did screening by conducting an electronic search. Article titles and their
abstracts were then screened. In the second screening stage, we
assessed the full texts. In the last stage, we included studies that met
our eligibility criteria.
Key Messages:Based on most studies examined, we could conclude
that there is an apparent positive effect on depression and anxiety in all
adult age groups, nevertheless, in many physical, mental, and
psychological conditions.We encourage all our colleagues in preventive
medicine, family medicine, and other specialties to prescribe PA as an
adjuvant therapy to prevent or treat patients suffering from depression
and anxiety. In addition, we recommend that public health and
community medicine professionals advocate for PA and draw and
implement strategies to motivate people to include PA as a lifestyle.
There are still gaps in this field, and we recommend further research
and trials to add more to healthcare and science.

Copy Right, IJAR, 2023,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
Mental disorders are clinically significant disturbances in cognition, emotional regulation, or behavior. Furthermore,
there is an association with parts of functioning impairment. Different types of mental disorders exist, including

Corresponding Author:- Albinsaleh Abdullah A. 734

Address:- Joint Program of Preventive Medicine, Al-Ahsa, Community Medicine
Department, Al-Ahsa Health Cluster, Saudi Arabia.
ISSN: 2320-5407 Int. J. Adv. Res. 11(06), 734-744

depression, generalized anxiety disorder (GAD), social anxiety disorder, panic disorder, obsessive-compulsive
disorder (OCD), post-traumatic stress disorder (PTSD), and phobias(1,2).

According to World Health Organization, in 2019, 1 in every eight people had a mental disorder; the most common
are depression and anxiety. Due to the coronavirus disease 2019 (COVID-19) pandemic, the numbers significantly
increased in 2020, 26% and 28% for depression and anxiety, respectively(1).

Effective treatments for depression and anxiety include psychology and medications. It is proposed that one of the
tools of self-care is PA, which is an adjuvant treatment that may play a crucial role in managing depression and
anxiety, in addition to promoting a better QoL(3,4).

Numerous studies have investigated the connection between PA and its impact on depression and anxiety across
different age groups, health conditions, and environments. Our goal with this narrative review is to provide a concise
summary of the most recent findings and assist healthcare professionals in aiding individuals experiencing
depression and anxiety.

Methodology:-
PubMed and Cochrane databases were systematically searched for relevant studies published between January 2018
and June 2023 with no language restriction. Systematic reviews were included in the search. We performed the
study selection in 3 stages: initially, we did screening by conducting an electronic search using the following terms:
“(Exercise* OR Physical OR Activit* OR Isometric OR Aerobic OR Training* OR Sport* OR Yoga) AND
(Anxiety OR Depression)”. Article titles and their abstracts were then screened. In the second screening stage, we
assessed the full texts. In the last stage, we included studies that met our eligibility criteria. Table 1 summarizes
these studies.

Review Findings:-
Table 1:- A summary of studies.
Meta Number
Reference Year Main relevant findings
analysis of studies
- An inverse curvilinear association between
incident depression and PA, with more significant
differences in risk at lower exposure levels.
Pearce et al.(5) 2022 Yes 15
- Adults meeting PA recommendations (equivalent
to 2.5 h/wk of brisk walking) had a lower risk of
depression than adults reporting no PA.
- Yoga might be beneficial in the short term for
improving the intensity of anxiety when compared
to untreated controls or active comparators.
Cramer et al.(6) 2018 Yes 8
- No effects were found when only patients with
DSM-diagnosed anxiety disorder were included in
the analyses.
Mind−body exercise tai chi, health qigong, and
Li et al.(7) 2020 Yes 13 yoga can reduce anxiety and depression in Chronic
Obstructive Pulmonary Disease (COPD) patients.
Physical exercise interventions may improve
working memory behavioral measures in adults
Contreras-Osorio et al.(8) 2022 Yes 7
with mild-to-moderate depression compared to
active and passive control conditions.
Performing PA during Covid-19 is associated with
Wolfet al.(9) 2021 No 21
less depression and anxiety.
Kazeminia et al.(10) 2020 Yes 19 Sport significantly reduces anxiety in the elderly.
No significant difference between pharmacological
Recchia et al.(11) 2022 Yes 21 interventions and exercise in reducing depressive
symptoms in adults with non-severe depression.

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- PA interventions may not affect disease‐ related

mental health.
McGettigan et al.(12) 2020 Yes 16 - PA interventions may be beneficial for aerobic
fitness, health‐ related QoL, and cancer‐ related
fatigue, up to six months follow‐ up.
Exercise may be a way to reduce depression and
pain and improve the QoL in adult subjects with
Couto et al.(13) 2022 Yes 18
fibromyalgia. It should be part of the treatment for
this pathology.
Aerobic, resistance and mind-body exercise
demonstrate equivalence impact on depression
Miller et al.(14) 2020 Yes 82 symptoms in older adults aged ≥ 65 years, with
comparably encouraging levels of compliance to
exercise treatment.
The occupation-based intervention (OBI) sports
program was popular in encouraging participation
and engagement with other people. Other programs
Phadsri et al.(15) 2021 No 10
were suggested for combined interventions to
support life satisfaction, social participation, and
QoL.
Findings on the relationship between light intensity
physical activity (LIPA) and mental ill health
indicators were mixed across all age groups.
Felez-Nobrega et al.(16) 2021 No 22
However, there seems to be limited evidence
suggesting that LIPA benefits mental ill health
indicators.
- Exercise effectively improves health-related QoL
and Polycystic ovary syndrome (PCOS) symptom
distress.
Patten et al.(17) 2021 No 15
- Exercise also shows among women with PCOS
efficacy in improving depression and anxiety
symptoms.
- Community-based preventive programs for
depression and anxiety in women had promising
and positive results.
- Cognitive behavioral therapy (CBT) and exercise
Mollarahimi Maleki et were the most effortless yet most effective
2020 No 23
al.(18) interventions to apply.
- Computer and internet-based programs had the
benefit of covering many people simultaneously.
These interventions are cost-effective and feasible
among Iranian women.
Physical exercise training could have an
antidepressant-like effect inpeople living with
human immune deficiency virus/acquired immune
Ibeneme et al.(19) 2022 Yes 13
deficiency syndrome (PLWHA) but did not affect
physical activity level (PAL) and social
participation.
- The effects of web-based exercise interventions
on depression and/or anxiety symptoms are scarce,
Carneiro et al.(20) 2022 No 3
the risk of bias is high, and the quality of the
cumulative results is low.
- Exercise can effectively improve QoL but not
Carraça et al.(21) 2021 Yes 36 reduce depression-related outcomes.
- Most psychological outcomes (i.e., body image,

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anxiety, perceived stress, life satisfaction,

subjective pain, and some context-specific
measures) are poorly studied, and evidence is either
conflicting findings or null exercise effects to allow
solid conclusions to be drawn.
- Positive exercise-induced changes in exercise
self-efficacy and autonomous motivation were
found and, although limited, were relatively
consistent.
- Hatha yoga does not affect anxiety disorders
compared to treatment in control groups.
Vollbehr et al.(22) 2018 Yes 18
- Psychoeducation and hatha yoga showed more
reductions in depression.
PA was generally found to protect against
Kadariya et al.(23) 2019 No 9 depression and improve the sleep quality of older
adults from South and Southeast Asia.
The relationship between active commuting and
Marques et al.(24) 2020 No 7 depression symptoms in adults and older adults is
inconsistent.
-Antidepressant and/or psychotherapy did not
significantly influence coronary artery disease
(CAD) outcomes in the overall population.
- No difference between antidepressant use and
Akosile et al.(25) 2023 No 19
aerobic exercises.
- Patient autonomy in treatment choice is
associated with greater depression treatment
satisfaction, but most studies are underpowered.
Exercise is associated with anxiety reduction
Kelley et al.(26) 2018 Yes 14 among adults with selected types of arthritis and
other rheumatic diseases (AORD).
Among patients with post-covid-19 conditions,
Piva et al.(27) 2023 Yes 8 exercise was more effective than control
interventions to reduce anxiety and depression.
PA performed outdoors in natural environments is
Wicks et al.(28) 2022 Yes 24 more beneficial for psychological outcomes than in
urban environments.
No significant difference between the effects of
outdoor community ambulation and comparison
Bhatia et al.(29) 2022 Yes 5
interventions on walking endurance and depression
scores, with low to very low certainty evidence.
The meta-analysis included only seven randomized
control trials (RCTs); pooled mean estimates
showed connected health interventions were
moderately effective in reducing symptoms of
Gitonga et al.(30) 2022 Yes 37
depression (standardized mean difference (SMD):
−0.226, 95% CI −0.303/−0.149) and anxiety
(SMD: −0.188, 95% CI: 0.279/−0.0963) compared
with usual care.
Reactive rehabilitation for older adults may include
Geohagen et al.(31) 2022 Yes 29 walking programs with behavior change
techniques.
Serious games, including PA, had a significant
Kim et al.(32) 2022 Yes 17
impact on reducing depression in older adults.
- PA can effectively treat mild and moderate
Vancampfort et al.(33) 2020 Yes 18
depression in children, adolescents, and adults, as

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well as severe depression, anxiety disorders, and

psychotic disorders in adults .
- PA can also help reduce the risk of depression
and anxiety, and to a lesser extent, psychosis.
Specific psychological interventions offered during
Exercise-based cardiac rehabilitation (ebCR) may
Albus et al.(34) 2019 Yes 20
contribute to a reduction of depressive symptoms
and cardiac morbidity.
PA can effectively reduce the severity of
Arsh et al.(35) 2023 Yes 17 depressive symptoms in adults with type 2 diabetes
mellitus (T2DM).
Exercise and social engagement indicated more
significant reductions in depressive symptoms in
Giebel et al.(36) 2022 Yes 40
treatment groups as opposed to established forms
of therapies or education, for example.
Traditional Chinese Exercise (TCE) (Tai Chi,
Qigong) may have benefits in alleviating
Zhang Y et al.(37) 2022 Yes 10
depression, anxiety, and drug cravings in drug
rehabilitees.
No significant improvement found meta-analysis
and systematic review regarding TCE on
Zhang Q et al.(38) 2019 Yes 5 depression parameter among older adults wih mild
cognitive imparmentcompared with the control
group.
Mind-body interventions(MBI) such as music
therapy, relaxation therapy, and spiritual therapy
have demonstrated consistent efficacy for
Chu et al.(39) 2021 No 32
indications such as symptoms of anxiety, pain, and
depression across multiple studies in non-chronic
kidney disease (CKD) patients.

The association between PA and depression:

Due to the inverse curvilinear association between PA and depression incidence, the risk is different at lower
exposure levels. Individuals who performed the recommended PA (the equivalent of performing brisk walking 2.5
h/wk.) had less chance of having depression compared to those who did not do PA. This association suggests that
being physically active significantly benefits mental health, even if it is lower than the public health
recommendations; thus, health professionals should encourage an increase in PA to improve mental health(5).

Furthermore, people with a psychiatric disorder will benefit from PA on psychiatric symptoms and physical health;
there is trans-diagnostic scientific evidence proving that. In addition to PA which also improves the quality of sleep
and cardiorespiratory fitness in people with a psychiatric disorder, PA has strong evidence for its beneficial effects
when incorporated with the treatment of mild and moderate depression from childhood to adults, anxiety disorders,
severe depression, and psychotic disorders in adults and reductions in symptoms of ADHD in children)33(.

Comparing PA with medications:

Recchiaet al. (11) conducted the first network meta-analysis to compare and assess the effectiveness of exercise,
antidepressants, and combined treatments on depressive symptoms in adults with non-severe depression. Regarding
those patients, the results suggest no difference between exercise and pharmacological interventions in reducing
depressive symptoms. These findings go along with adopting exercise as an adjuvant or alternative in managing
patients with non-severe depression. Also, results showed that all treatments had similar beneficial effects on
depressive symptoms compared to the controls, but no treatment was superior to another. The acceptability
assessment showed that antidepressant treatments gave fewer intervention drop-outs than exercise.

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PA and individuals with chronic diseases/ conditions:

Li et al.(7) found that among COPD patients, tai chi, health qigong, and yoga can reduce anxiety and depression.
With no adverse reaction, to optimize the treatment of anxiety and depression, medical professionals could combine
mind-body exercise with usual medical care in those patients.

Adults with mild-to-moderate depression could benefit from physical exercise interventions by improving working
memory behavioral measures compared to active and passive control conditions. However, due to the small number
of available high-quality studies need more sound conclusions(8).

Patients with non-advanced colorectal cancer apparently will not benefit from it. Theywere uncertain aboutPA
interventions could improve physical function. PA interventions may not affect disease-related mental health. PA
interventions (up to six months follow-up)may be beneficial for aerobic fitness, fatigue related to their condition,
and health-related QoL(12).

Coutoet al. (13) conclude in their study that exercise may be a way to reduce depression and pain and improve the
QoL in those subjects with fibromyalgia and should be part of the treatment for this disease condition.
Although there is high heterogeneity in the included studies, requiring high-quality RCTs in future studies,
HIV/AIDS individuals can benefit from physical exercise training in a study that showed an antidepressant-like
effect in PLWHA but did not affect PAL and social participation(19).

A systematic review brought a surprising result that suggests that exercise can effectively improve QoL;
unfortunately, it could not reduce depression-related outcomes. In addition, it showed that most psychological
outcomes among adults with overweight or obesity (i.e., anxiety, life satisfaction, subjective pain, body image,
perceived stress, and some context-specific measures) were poorly studied, and evidence either had no exercise
effects to allow solid conclusions to be drawn or the findings were conflicting. Although they found limited
evidence of positive exercise-induced changes in exercise self-efficacy and autonomous motivations, it was
relatively consistent(21).

Nineteen eligible trials were included in this systematic review. It showed that there was no difference between
performing aerobic exercises and the use of antidepressants. In the overall population, psychotherapy and/ or
antidepressant had no significant influence on(CAD) outcomes. There was a negligible effect on depression
outcomes in CAD patients provided by psychological and pharmacological interventions)25(.

Despite a need for further research with well-designed RCTs on this subject. It was concluded that exercise was
associated with anxiety reduction among adults with selected types of AORD)26(.

Across multiple studies in CKD patients, Chuet al.(39) review showed that MBI such as relaxation therapy, spiritual
therapy, and music therapy had consistent efficacy on symptoms of depression, pain, and anxiety. Two studies
investigated yoga therapy for CKD patients; yoga improves overall well-being through physical, mental, and
spiritual practices.

They also found that Pilates improves the individual's physical strength and well-being through low-impact exercise
combining gentle stretching and deep breathing. Although more studies were required to confirm the efficacy of this
intervention, it has shown that among CKD patients, there is a promising result in improving anxiety and depressive
symptoms(39).

Interestingly, a study showed that among T2DM patients, PA reduced the severity of depressive symptoms;
however, PA had no significant effect on improving glycemic control in adults with both conditions. Moreover, PA
in high-income and low- and middle-income countries (LMICs) could be a suitable adjuvant to other methods in
managing depression in T2DM)35(.

Zhang Yet al.(37) found in their study that there may be benefits from performing Tai Chi and Qigong which are
both traditional Chinese exercises, in alleviating symptoms of depression, anxiety, and drug cravings in drug
rehabilitees .

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The effect of several types of PA:

A study about yoga for anxiety by Cramer et al. (6)concluded that there could be a short-term improvement in the
intensity of anxiety compared to those active comparators or untreated controls. However, they found no effects
when only DSM-diagnosed anxiety disorder patients were included in their analyses. Furthermore, with the caution
that only 3 RCTs reported safety-related data, the application of yoga was not associated with any increase in injury
or anxiety symptoms.

Contrary to the previous study, another meta-analysis showed that hatha yoga did not affect form of mood and
anxiety disorders compared to treatment as usual or active control groups. However, there is a limited ability to draw
firm conclusions to support this claim due to the heterogeneity and low quality of most of the included studies.
However, there is a need for more high-quality studies in this field because they found that hatha yoga had more
reduction in depression compared to psychoeducation(22).

Four OBI sport and exercise programs (animal-assisted therapy (AAT), sport or exercise program(SEP), religious
activity (RA), and behavioral change program and health education (BCPHE)) demonstrated visible behavioral
changes in social participation and engagement with others. All of these interventions reported a decrease in
depressive symptoms. Four intervention programs illustrated life satisfaction (skill-building program, SEP, peer
support, and group-based activity), but only clinical psychotherapy group promoted the QoL. On these bases, AAT,
SEP, and BCPHE are recommended. Integrating treatment with flexibility to cover more benefits in reducing
depression, promoting social participation,and contributing to life satisfaction and QoL is recommended for other
programs(15).

Felez-Nobregaet al. (16)found that due to the limited evidence that suggests LIPA has benefits on mental ill health
indicators, the relationship between LIPA and mental ill health indicators was mixed across different age groups. In
addition, it is proven that there are benefits on several mental health indicators, and performing regular MVPA
should be encouraged first. However, because MVPA is less feasible for older people or frail populations, LIPA
might be a better approach to foster a physically active lifestyle in those vulnerable groups.

Carneiroet al. (20)could not propose any recommendations based on the high risk of bias, and the quality of the
results was low. The effects of web-based exercise interventions on depression and/or anxiety symptoms were
insufficient.

Active commuting could improve daily PA levels related to depression symptoms. Thus, it could be speculated that
active commuting could be related to depression. A systematic review by Marqueset al.(24) showed an inconsistent
relationship between active commuting and depression symptoms in adults and older adults. For the most part, out
of seven studies, five studies showed no significant relationship between active commuting and depression
symptoms. However, only two found beneficial effects of active commuting on depression symptoms.

Albuset al. (34)concluded that despite considerable uncertainty under which conditions these ebCR interventions to
deploy their best effects, bearing that in mind, the results of this study showed that specific psychological
interventions offered might contribute to a reduction of depressive symptoms and cardiac morbidity.

Contrary to the findings of Zhang Y et al. (37), a systematic review and meta-analysis did not find any significant
improvement in depression parameters compared with that in the control group. They explain such insignificant
findings by several factors, such as a small number of eligible trials, insufficient sample size, intervention regimens,
different adopted TCE styles and the short follow-up periods for the participants(38).

Old age andPA:

Kazeminiaet al. (10)found that among the elderly age group, sports significantly reduce anxiety. Based on that, as
part of the elderly care program, a regular exercise program can be introduced .

Pooled RCT results show that each type of exercise mode, resistance, aerobic, and mind-body, demonstrate
equivalence in mitigating symptoms of depression in older adults ≥ 65 years; thus, it is encouraged to prescribe
exercise to this age group presenting with depression(14).

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In addition, Kadariyaet al. (23) concluded in their study that among older adults from South and Southeast Asia, PA
had general protective effects against depression and improved sleep quality.

Regardless of the study setting, serious games had a beneficial effect on reducing depression in older adults. In
addition, serious games that included PA significantly reduced depression. Besides, for more substantial evidence of
the effectiveness of challenging games for depression in older adults, high-quality RCTs are necessary(32).

Women's health and PA:

A study showed that exercise effectively improves PCOS symptom distress and health-related QoL. Furthermore,
exercise among women with PCOS, showed some efficacy for improving symptoms of depression and anxiety.
However, conclusions could not be made about the impact of exercise intervention characteristics due to the notable
heterogeneity of the included studies)17(.

In community-based preventive programs for depression and anxiety in Iranian women, they had encouraging and
positive results. Although exercise and CBT are the most effortless, they are already the most effective interventions
to be used; moreover, they are feasible and cost-effective among women. Due to the advantages of Internet-based
and computer programs, they could cover many people simultaneously)18(.

Outdoor PA:
Wickset al.(28) concluded in their study that compared with urban environments, performing PA outdoors in natural
environments has more benefit for different psychological effects. They explain that various effect sizes may be by
differing processes through which participants gain psychological benefits during PA while outdoors in nature.

A systematic review and meta-analysis explored the effects of PA through ambulation interventions in older adults.
Unfortunately, with a low level of evidence, there was no significant difference between the effects of outdoor
community ambulation compared to interventions on walking endurance and depression assessment and other
outcomes that could not be pooled in the meta-analysis. Further studies are warranted to explore such associations in
this field(29).

Community-based PA:
Among older adults, reactive rehabilitation may include walking intervention with behavior change techniques.
Future research should address the potential benefit of a walking program for proactive populations and address
mobility-related anxiety as a barrier to outdoor mobility for both proactive and reactive populations(31).

Depression was the most reported outcome measure; exercise and social engagement led to more significant
reductions in depressive symptoms in treatment groups among older adults who are in low- and middle-income
countries, compared to other forms of treatment or education, for example. Unfortunately, Giebelet al. (36)could not
give a clear conclusion because the same meta-analysis approach did not assess the outcomes of the included
studies.

The pandemic and PA:

Wolfet al. (9) found in their study that performing PA during the Covid-19 pandemic was associated with less
anxiety and depression. Specific motivational and encouraging skills might be supreme to overcoming the
pandemic's barriers and maintaining PA routines. Web-based technologies might be the way to increase motivation
for daily PA and to maintain helpful routines.

The results of a study showed that in comparison to control interventions to reduce the severity of anxiety and
depression, exercise had more effect; thus, it could be a valuable strategy for patients with post-Covid-19
conditions(27).

Conclusion:-
Our work tried to provide and summarize the latest available evidence regarding PA and its impact on depression
and anxiety in adults. Based on most studies examined, we could conclude that there is an apparent positive effect
on depression and anxiety in all adult age groups, nevertheless, in many physical, mental, and psychological
conditions. Many of the included studies gave clear evidence that supports our statement, but a few still need to be
determined due to difficulties after including studies in their analyses. We encourage all our colleagues in preventive

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medicine, family medicine, and other specialties to prescribe PA or a suitable and feasible exercise as an adjuvant
therapy to prevent or treat patients suffering from depression and anxiety. In addition, we recommend that public
health and community medicine professionals advocate for PA and draw and implement strategies to motivate
people to include PA as a lifestyle. There are still gaps in this field, and we recommend further research and trials to
add more to healthcare and science.

Statement of Ethics
This study is exempted from ethics committee approval because it is based on reviewing previously published
literature.

Conflict of Interest
All authors declare no conflicts of interest.

Funding
The authors did not receive any specific funding for this research work.

Author Contributions
All authors contributed equally.

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