Exercise as a Treatment for Depression: Literature Review

Task 2 PICO Paper

The Healthcare Problem

According to a 2013-2016 U.S data study by the CDC, “One in 12 US adults’ reports having depression, with women twice as likely as men” (

Brody, D., Pratt, L., and Hughes, J., 2018

). When choosing a pertinent, clinical, healthcare problem to focus on for research, my focus went immediately to a colossal, staggering healthcare dilemma that hinders the day to day lives of adults everywhere. This common mental health disorder effects not only your brain and cognitive functioning, but also the mood and physical body as well. It can be as mild as feeling sad and down, and as severe as the inability to move and desire to waste away or end a life. With “50.2% of adults stating that their depression causes difficulty with work, home or social activities”

(Brody, D., et. al 2018)

one could conclude that depression has the potential to flood in and take over one’s whole life. With a staggering statistical probability like 1 in 12, you are likely to have someone in the same space as you every day struggling with depression. Depression can also cause a type of Pain that could be physical or mental, or both. Pain is the 5


vital sign marking its importance in nursing practice. Measuring, empathizing and helping to treat this specific type of Pain is something that Registered Nurses are blessed to having training in. The recognition, observation and clinical significance of depression in patients is significantly important and pertinent to nursing practice and nursing research. The current practice methods for treatment of depression are a plethora of medications, diet and exercise, CAM methods, ECT, cognitive behavioral therapy, and many more. More often than not, as I have observed in my nursing practice, medication as the first line of treatment for depression. Medication can positively alter brain chemistry and neurotransmitters in the brain and immensely fix a patient’s depression, or on the contrary, be a temporary band-aid fix and cause un-wanted side effects that increase depression even more. A change in diet treatment method could also be viewed as something you are putting in your body to cause change, do our clinicians always look at income class for consideration? “15.8% of adults from families living at or below the federal poverty level had depression” (Brody, D., et. al 2018). Exercise is usually encouraged as well, but with the demands of long work hours, commuting, family and children obligations, school and training, and/or social time, how do we squeeze this in and make it a priority? With many other treatment options, but a steadfast, ascending rise in prevalence of this debilitating disease, where do we go with this healthcare problem?

PICO Table

  • How does the use of exercise compare to medication in treating depression in middle aged women?

P (Problem/Patient)

Middle-aged women with Depression (no specific race, ethnicity or social class)

I (Intervention/Indicator)

Exercise (aerobic, endurance, balance, flexibility, strength etc.)

C (Comparison)


O (Outcome)

Reduced or eradicated depression (as evidence by PHQ-9 scale)


  • Depression in middle aged women- 53,764 results
  • Depression and exercise- 93,015 results
  • Exercise as treatment and depression-1,143,240 results
  • Depression and exercise and quantitative research- 25,229 results
  • Women and depression and integrative review- 17,550 results
  • Depression and commentary- 500,625 results
  • Depression and commentary and pilot study- 432,890 results

Types of Articles

During my extensive research I scanned and read through at least 30 different journal and research articles. A difficultly that I encountered during my non-research article search was the rule that there could be no “Methods” section. Almost every single article I thought was a good fit for the topic, ended up having some type of methods section and I had to throw it out. I did up being successful with my search when filtered through and found the “commentary” and “quality improvement” articles to focus. During my search for Research articles I scanned through many systematic and integrative reviews and was careful to shoes an adequate sample size and methods of research. It was a delicate balance of seeing a daunting list of 400,000 results and applying the right keywords and filters to the system, I only used the WGU library search engine for my evidence matrix.

Research and Non-Research Evidence

The first research study was called, “Crawling out of the Cocoon” (Danielsson, L. Louise, Kihlbom, B., & Rosberg, S. 2016) this article explored the intervention of physical therapy for patients suffering from depression. It depicted the patient’s experiences of exercise and what it meant to them and their lives. The qualitative study measured depression levels of participants throughout the study of interviews and physical therapy sessions and resulted in an increase in positive uplifting spirits of the individuals. This article strived to convince the reader that physical exercise in patients who are depressed not only improves physical health but can promote the sense of capability. A sense of self-capability is important to mental health when you think about self-determination and self-efficacy, and self-confidence.

My second research study was a quantitative study of university aged students participating in Epstein’s TARGET exercise therapy as a possible treatment for depression. As stated in the article, Epstein’s “TARGET” therapy stands for: Task (activity), Authority (location of decision-making), Recognition (distributing the rewards), Grouping (selection criteria), Evaluation (performance standards), and Time (learning rhythm). (Cecchini-Estrada, J.-A., Méndez-Giménez, A. et al. 2015). The statically significant conclusion drawn from this study was that there was an improvement of depressive symptoms in all the tested groups related to the physical activity’s interventions. This study went above and beyond the other research studies in that they investigated the long-term effects of the intervention by revisiting the participants 6-months later. The re-assessment revealed that that continuation of the moderate or vigorous exercise learned in the study, further improved the participants depressive symptoms by as much as 10%. (Cecchini-Estrada, J.-A et al. 2015 pp.197). This article supports my PICO intervention of exercise very well.

My first non-research article was a case report from a Clinical Neuroscience Journal that touched on a different, but important side of the topic of depression and its treatment that I felt was relevant to include in my PICO paper. Electroconvulsive therapy has been around for a long time, and throughout my 5 years of clinical practice, I have never seen or witnessed it being used once. This article brings awareness, and a positive outlook to healthcare professionals that may have a negative stigma attached with this type of treatment. The case involved 50-year-old women who had Major Depressive with a side effect of body dysmorphic disorder. (Mahato, R. S., San Gabriel, M., C. P. Longshore, C.T. & Schnur, D. B. 2016 pp. 37). The article had clear aims and objectives with consistent results in the single patient with an individual intervention grouping. In the conclusion of this case report, they did conclude that SSRI medication are the preferred class of treatment, even with patients suffering from body dysmorphic delusions concurrently.

The final non-research article that I used for this paper was an invited commentary from the JAMA Internal Medicine journal; (Kroenke K., 2015,

The role of decision aids in healthcare

). The article began with a staggering fact that Depression is only falls Second to lower back pain in terms of years lived with a disability. And continues to state that the “primary care setting is where the majority of patients with depression first present with their symptoms and where many receive their initial and often only treatment” (Kroenke K., 2015 pp. 1770). Expertise in this study is clearly evident and is pertinent to my PICO in terms of patients making informed decisions about their depression care. The article draws fairly definitive conclusions that chronic conditions like depression often require treatment changes over time, a cumulative education model that is patient centered, might make an informed patient make better decisions and help outcomes.

Evidence Matrix


Journal Name/WGU library

Year of publication

Research Design

Sample Size

Outcomes Variables Measured

Level (1-111)

Quality (A, B, C)

Results/Authors Suggested Conclusions

Danielsson, L. louise, Kihlbom, B., & Rosberg, S


American Physical Therapy Association

February 2016

Qualitative (Research)


Physical therapy interventions for people with depression



Increase people’s feelings of being capable. E.g.: Capable of taking care of one’s health.

Cecchini-Estrada, J.-A., Méndez-Giménez, A.

, Cecchini, C., Moulton, M., & Rodriguez, C

International Journal of Clinical and Health Psychology

May 2015



1,975 preliminary interviews. Final sample size=106

Depressive symptoms and Self-determined motivation



Significant improvement in depressive symptoms observed.

Gordon, B. R., McDowell, C. P., Hallgren, M., Meyer, J. D., Lyons, M., & Herring, M. P.

JAMA Psychiatry-Original Investigation

May 2018

Quantitative (Research)

33 RTCs, and 1877 participants

Exercise frequency, depression scores, intensity, age, baselines.



Resistance exercise training as effective alternative/adjunct therapy for people with depression

Stubbs, B., Koyanagi, A., Schuch, F. B., Firth, J., Rosenbaum, S., Veronese, N., Vancampfort, D. et al.

Acta Psychiatrica Scandinavica

September 2016

Quantitative (Research)

178,867 people ages 18-69

Mobility, pain, cognition, vision, sleep, physical activity, DSMIV



Those with depression are more likely to be older age and female. As well as lower wealth, lower education.

Carvalho e Silva Sales, J., Guedes da Silva Júnior, F. J., Plácido de Brito Vieira, C. et. al.

Journal of Nursing UFPE

May 2016


(mixed, integrative review)

15 studies

Observe, describe and classify the interface of depression, old age and feminism.



Quality of life in aging women and the contribution of low income, spouse loss, social isolation, retirement etc..

Mahato, R. S., San Gabriel, M., C. P. Longshore, C.T. & Schnur, D. B.

Innovations in Clinical Neuroscience

September 2016


(Case study)


ECT use, medication trail and failure, DSM-IV, symptoms of depression and delusions



ECT should be considered more often for treatment for depression. Screening for body dysmorphic disorder should be included as well.

Kroenke, K.

American Medical Association; JAMA Internal Medicine

September 2015

Non-Research (Commentary)

117 clinicians, 303 patients. 115 trials.

Desirable and undesirable outcomes, cost, informed decision making



Encourage self-management, more depression screening, enhance efficiency of patient-centered care.

Recommended Practice Change

The evidence of all attached journal articles supports the proposal that exercise can be a morally excellent, and satisfactory treatment option for women and all adults suffering from depression. Decision aids could either be used routinely or targeted towards certain patients based on their decisions making preference, sociodemographic characteristics, history of medication intolerance, or prior treatment failures. (Kroenke, K., 2015 pp. 1770). Depression has emerged as one of the psychiatric disorders that affect more female elderly population, characterized by feelings of sadness, dejection, hopelessness, sleep disturbances, lack of appetite and social isolation. (Carvalho e Silva Sales, J., Guedes da Silva Júnior, F. J. et al. 2016 pp. 1841). The integrative review identified the feminization of old age has interface with depression, since in this process low education, longer institutionalization, greater degree of independence for daily activities, retirement, and physical activity may contribute to the onset of depressive symptoms. (Carvalho e Silva Sales, J. et al. 2016 pp.1844). Resistance exercise training significantly reduced depressive symptoms among adults regardless of health status, volume of resistance exercise training or significant improvements in strength. The available empirical evidence supports that exercise as an alternative or adjunctive therapy for depressive symptoms. (Gordon, B. R., McDowell, C. P., Hallgren, M., Meyer, J. D., Lyons, M., & Herring, M. P. 2018 pp. 573). And as the second leading cause of disability in 2010 (Stubbs, B., Koyanagi, A., Schuch, F. B., Firth, J., Rosenbaum, S., Veronese, N., 2016 pp.547), Stubbs also claims from this study that people with depression are more likely to have chronic pain, which impacts upon mobility and is associated with sedentary behavior. Stubbs et al. also concluded from the study that those with depression were significantly more likely to be of older age, female, as well as lower education and wealth. On another note, Electroconvulsive therapy is said to be highly beneficial for medication resistant depression (Mahato, R. S., San Gabriel, M., C. P. Longshore, C.T. & Schnur, D. B. 2016 pp.37). This is directly relatable to my PICO question as the patient was a 50-year-old female with depression, who had tried and failed medication treatment.

Key Stakeholders

Physicians, and prescribing clinicians working in primary care are key stakeholders in this healthcare problem. While day to day life at work is busy, it often just takes minor adjustment of how you plan your day to make time for something more important. Taking time, even a couple minutes to provide patient education about how to manage depression, might make a big difference in someone’s life. Take a minute to weigh some pros and cons of medication with a patient or alternative therapy treatment options based on their lives. State representatives, senators and judges are key stakeholders as well. Funding is needed for more research and more mental health assistance. These are the people who need the awareness of big of an issue depression and the mental health of our communities is, so they can help with change. And finally, Nurses are key stakeholders too. We are the ones at the bedside taking care of patients, nurses must remember to take of the mind too, not just the physical ailments. People are resilient, and strong, and it can be hard to tell when something is wrong, or when someone is crying out for help. It’s important for nurses to have the knowledge of depression and mental health so we can always be assessing and be a key factor in the prevention of further detrimental side effect and comorbidities of depression.

Barriers and Potential Strategies

There are a few important barriers to mention when talking about change in the field of depression and mental health. First is the negative stigma about psychiatric nursing that surrounds nursing students and nurses across the US. As per previous article reviewing for other papers in this course, it was reiterated that the negative stigma that mental health nurses are lazy, neurotic, crazy themselves and don’t do “real nursing” is in fact intact today. Keeping this healthcare field full of nursing staff is key, but the continued stereotype is a barrier. An answer to this barrier might be increasing the amount of time spent teaching mental health during nursing school or increasing the exposure time in the clinical setting during mandatory clinical rotations. Another barrier is lack of accessibility for mental health help. Currently it seems like our Emergency Rooms are full of both acute and chronic psychiatric cases ranging from acute psychosis, to needing medication stabilization for chronic depression, schizophrenia, or other mental health conditions. ER visits can cost thousands of dollars, and repeat visits rack up costs, and take time from other emergent matters. A strategy for assisting in this barrier might be a more preventative, more cost-effective approach, such as opening specialized clinics, walk ins, or urgent care facilities in our communities where patients could get support with their depression or mental health condition, have specialized practitioners and clinicians to assist in treatment.

Indicator to Measure Outcome

As nurses we can use scales and questionnaires to measure levels of depression and depressive symptoms, such as PHQ-9s, CSS-S, Becks Scale etc. Continuing education in the field might lead to nurse leaders taking information and this data to our senators and government personnel who can start change. A decreased level of suicide rates would be secondary indicator of the depression epidemic improving. Measuring trends in what physicians are prescribing to treat depression and seeing an increase in exercise as therapy would be encouraging and promising.