Association Between Physical Activity and Risk of Depression: A Systematic Review and Meta-analysis

Abstract

Importance: Depression is the leading cause of mental health-related disease burden and may be reduced by physical activity, but the dose-response relationship between activity and depression is uncertain.

Objective: To systematically review and meta-analyze the dose-response association between physical activity and incident depression from published prospective studies of adults.

Data sources: PubMed, SCOPUS, Web of Science, PsycINFO, and the reference lists of systematic reviews retrieved by a systematic search up to December 11, 2020, with no language limits. The date of the search was November 12, 2020.

Study selection: We included prospective cohort studies reporting physical activity at 3 or more exposure levels and risk estimates for depression with 3000 or more adults and 3 years or longer of follow-up.

Data extraction and synthesis: Data extraction was completed independently by 2 extractors and cross-checked for errors. A 2-stage random-effects dose-response meta-analysis was used to synthesize data. Study-specific associations were estimated using generalized least-squares regression and the pooled association was estimated by combining the study-specific coefficients using restricted maximum likelihood.

Main outcomes and measures: The outcome of interest was depression, including (1) presence of major depressive disorder indicated by self-report of physician diagnosis, registry data, or diagnostic interviews and (2) elevated depressive symptoms established using validated cutoffs for a depressive screening instrument.

Results: Fifteen studies comprising 191 130 participants and 2 110 588 person-years were included. An inverse curvilinear dose-response association between physical activity and depression was observed, with steeper association gradients at lower activity volumes; heterogeneity was large and significant (I2 = 74%; P < .001). Relative to adults not reporting any activity, those accumulating half the recommended volume of physical activity (4.4 marginal metabolic equivalent task hours per week [mMET-h/wk]) had 18% (95% CI, 13%-23%) lower risk of depression. Adults accumulating the recommended volume of 8.8 mMET hours per week had 25% (95% CI, 18%-32%) lower risk with diminishing potential benefits and higher uncertainty observed beyond that exposure level. There were diminishing additional potential benefits and greater uncertainty at higher volumes of physical activity. Based on an estimate of exposure prevalences among included cohorts, if less active adults had achieved the current physical activity recommendations, 11.5% (95% CI, 7.7%-15.4%) of depression cases could have been prevented.

Conclusions and relevance: This systematic review and meta-analysis of associations between physical activity and depression suggests significant mental health benefits from being physically active, even at levels below the public health recommendations. Health practitioners should therefore encourage any increase in physical activity to improve mental health.

Figure 1.. Association Between Physical Activity and Incidence of Depression

Dark line represents the meta-analytical dose-response curve (constrained to be linear beyond upper knot at 75% of person-years). Shaded area displays 95% CI. Vertical dotted lines indicate knots at the 37.5th and 75th percentiles of person-years. I² = 73.7%; P < .001. Interactive dose-response curves and exposure distributions are available online.

Figure 2.. Associations Between Physical Activity and Incidence of Major Depression and Elevated Depressive Symptoms

Dark lines represent the meta-analytical dose-response curve (constrained to be linear beyond upper knot at 75% of person-years). Shaded area displays 95% CIs. Vertical dotted lines indicate knots at the 37.5th and 75th percentiles of person-years. A, Major depression I² = 54.2%; P = .01. B, Elevated depressive symptoms I² = 81.3%; P < .001.