Reacción a "Physical exercise is similar to psychological therapy for the treatment of depression"

This is a well-conducted Cochrane review, using rigorous methods to identify and analyse the available evidence. However, as the authors note, its conclusions are limited by the quality of the trials it includes. Many of the exercise studies were small and had methodological weaknesses, and when the analysis is restricted to the most robust trials, the apparent benefit of exercise for depression becomes smaller, although still statistically significant. There is some evidence suggesting that exercise may be no less effective than psychological therapy or antidepressant medication, but this conclusion is based on a small number of studies and therefore comes with considerable uncertainty. The review also cannot tell us confidently whether exercise works better for more or less severe depression, whether effectiveness varies by exercise type, or whether people should switch from medication or therapy to exercise alone.

It is also important to note that this review mainly focused on structured, often supervised exercise programmes, which tend to attract motivated volunteers who are willing and able to take part. This limits how well the findings apply to the wider population of people with depression. The review did not include interventions based on exercise advice or behavioural support, which are much more common in routine care. For example, the authors excluded the large UK TREAD trial, in which people with depression in primary care were randomised to usual care or usual care plus support from a physical activity facilitator. This means the findings reflect the effects of organised exercise under trial conditions, rather than the effectiveness of helping people gradually become more active in everyday life in ways that align with their goals and values.

In real-world practice, and in the absence of more pragmatic studies, physical activity is probably best viewed as a helpful option or addition to existing treatments, rather than as a direct replacement for established care. Further high-quality studies that combine behavioural support with routine care settings are still needed.