ORIGINAL ARTICLE
Pilot Study of an Exercise Intervention for Depressive Symptoms
and Associated Cognitive-Behavioral Factors in Young Adults With
Major Depression
Yasmina Nasstasia, MPsych(Clinical),* Amanda L. Baker, PhD, Sean A. Halpin, PhD,*
Terry J. Lewin, BCom(Psych)Hons, Leanne Hides, PhD, Brian J. Kelly, PhD, and Robin Callister, PhD
Abstract: This study assesses the feasibility of integrating motivational
interviewing (MI) with an exercise intervention. It also explores patterns of depres-
sive symptom changes (cognitive, affective, and somatic subscales) and their rela-
tionship to cognitive, behavioral, and immunological factors (interleukin 6, IL-6, a
marker for inflammation) across the exercise intervention. Twelve young adults
(20.8 1.7 years) meeting DSM-IV criteria for major depressive disorder received
a brief MI intervention followed by a 12-week exercise intervention. Assessments
were conducted preintervention, postintervention, throughout the intervention,
and at follow-up. Preliminary results show differential effects of exercise, with
the largest standardized mean improvements for the affective subscale (1.71),
followed by cognitive (1.56) and somatic (1.39) subscales. A significant relation-
ship was observed between increased behavioral activation and lower levels of IL-6.
Despite study limitations, the magnitude of changes suggests that natural remission
of depressive symptoms is an unlikely explanation for the findings. A randomized
controlled trial has commenced to evaluate effectiveness of the intervention.
Key Words: Exercise, depression, cognitive, somatic, affective,
motivational interviewing
(J Nerv Ment Dis 2017;205: 647655)
M ajor depressive disorder (MDD) is increasingly recognized as a
heterogeneous disorder composed of a diverse symptom pro-
file, with cognitive, affective, somatic, and behavioral components
(Harald and Gordon, 2012). Most research has focused on global
changes in depression and is premised on the assumption that symp-
toms contribute in similar proportions toward severity, risk of relapse,
or responsiveness to treatment (Fried and Nesse, 2015; Shafer, 2006).
However, symptom heterogeneity may explain why MDD appears to
respond to a range of treatments (Harald and Gordon, 2012) and
why some patients fail to respond to treatments or recover fully
(Cassano et al., 2009). Recently, there have been calls to investigate
better characterized depressive subtypes (Harald and Gordon, 2012;
Rodgers et al., 2014) including using comprehensive depression
*School of Psychology, and Priority Research Centre for Brain and Mental Health
Research, School of Medicine and Public Health, Faculty of Health, University of
Newcastle, Callaghan, New South Wales; School of Psychology & Counsel-
ling, Institute of Health & Biomedical Innovation, Queensland University of
Technology, Kelvin Grove, Queensland; and Priority Research Centre for
Physical Activity and Nutrition, University of Newcastle, Callaghan, New
South Wales, Australia.
Send reprint requests to Yasmina Nasstasia, MPsych(Clinical), School of Psychology,
University of Newcastle, University Drive, Callaghan, 2308, New South Wales,
Australia. Email: yasmina.nasstasia@newcastle.edu.au.
This study was supported by Hunter Medical Research Institute and Beyond Blue.
Neither funding body had any role in the collection, analysis, or interpretation of
data, or in writing this article. Amanda Baker is supported by an NHMRC
Fellowship, and Leanne Hides is supported by an Australian Research Council
Future Fellowship.
Supplemental digital content is available for this article. Direct URL citations appear in
the printed text and are provided in the HTML and PDF versions of this article on
the journals Web site (www.jonmd.com).
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0022-3018/17/205080647
DOI: 10.1097/NMD.0000000000000611
The Journal of Nervous and Mental Disease Volume 205, Number 8, August 2017
Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.
symptom measures and latent variable techniques such as factor
analysis (Carragher et al., 2009; Shafer, 2006). Specific symptom
domains can then be examined to assess differential benefits from treat-
ment and determine predictors of treatment response (Shafer, 2006).
Exercise as treatment of depression has received increasing attention
with studies documenting beneficial effects (Blumenthal et al., 2012;
Rimer et al., 2012). However, methodological limitations reduce generaliz-
ability of findings (Blumenthal et al., 2007). Less is known about effec-
tiveness of exercise for MDD in young people (Biddle and Asare,
2011). Moreover, the high rates of depression in this age group and
questions surrounding safety of antidepressant medications highlight
the need for efficacious treatment alternatives (Hughes et al., 2009).
Adherence rates for exercise interventions are also problematic.
Approximately 50% of participants discontinue exercise programs
(Herman et al., 2002) and, although comparable to antidepressant trials,
this warrants attention (Dunn et al., 2005). Symptoms associated with
MDD, such as loss of interest and disengagement from usual activ-
ities, can act as additional barriers to exercise participation
(Sherwood et al., 2007).
Higher attrition rates can also weaken the integrity of evi-
dence investigating efficacy of exercise interventions for depression
(Kvam et al., 2016). There is a need to develop exercise interventions
that consider motivational parameters, which could influence engage-
ment and compliance to exercise programs. To this effect, there have
been a number of recommendations by researchers to increase exercise
compliance, including offering supervised exercise sessions by quali-
fied professionals (Stubbs et al., 2016), customizing mode of exercise
based on preferences grounded in each patient's needs and abilities
(Nystrm et al., 2015), and using motivational interviewing (MI) ap-
proaches (Blumenthal et al., 2012). Integrating MI as a prelude to exer-
cise interventions may potentially improve treatment engagement and
enhance intrinsic motivation by helping resolve ambivalence associated
with perceived environmental or symptom barriers to exercise. Re-
search consistently supports the efficacy of MI in modifying a range
of health behaviors (Hettema et al., 2005; Martins and McNeil,
2009). In recent years, MI has also been integrated with cognitive be-
havior therapy (CBT) (Baker et al., 2014b) and lifestyle interventions
(Forsyth et al., 2015) and applied as a treatment engagement strategy
with a range of populations and interventions (Strong et al., 2012).
However, limited research has investigated effectiveness of augmenting
exercise interventions with MI.
Inconsistent rates of response to exercise could also be reflective
of MDD symptom heterogeneity. We have a limited understanding of
the differential effects of exercise on depressive symptom domains,
and this relationship has not been investigated in young adults with
MDD. Exercise helps promote brain health, synaptic growth, and
neurogenesis, particularly within the hippocampus, and facilitates
monoamine neurotransmission not dissimilar to effects observed with
antidepressant medication (Toups et al., 2011). Arguably, these biolog-
ical changes may exert influence across cognitive, affective, and so-
matic symptoms of depression similar to findings reported by Stewart
and Harkness (2012) with antidepressant medication. When only global
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Nasstasia et al. The Journal of Nervous and Mental Disease Volume 205, Number 8, August 2017
symptoms of depression are considered in exercise studies, there is dif-
ficulty in distinguishing between depressive symptom changes and nor-
mal somatic changes associated with the physiological effects of regular
exercise. Reductions in global symptoms may reflect both improvement
in depression and physiological training effects.
Research shows regular exercise reduces fatigue (Puetz et al., 2006)
and increases energy and quality of sleep (Santos et al., 2007). Theoret-
ically, exercise may target depression by improving somatic symptoms
ahead of cognitive or affective. Given the potential primacy of effects
on somatic symptoms, investigating relative efficacy across depressive
symptom domains and cognitive change variables is important to assess
the veracity of exercise treatment. There is a paucity of research inves-
tigating effects of exercise on cognitive change associated with depres-
sion. Lash (2000) suggests that exercise may have a role in facilitating
cognitive change; for example, a significant decrease in negative auto-
matic thoughts (often associated with depression) was reported after a
brief 25-minute treadmill walking intervention among depressed women.
This finding is consistent with research showing that antidepressant
medications and behavioral therapies can promote cognitive change
(Furlong and Oei, 2002).
Exercise has other biological effects that may help ameliorate
immunological changes associated with depression, including changes
that may be differentially associated with depressive symptom domains
(Duivis et al., 2013). Although higher levels of C-reactive protein, inter-
leukin 1 (IL-1), and interleukin 6 (IL-6) blood markers have been re-
ported among depressed samples (Dowlati et al., 2010; Howren et al.,
2009), inconsistent results may be due to differential associations with
inflammation across depressive symptom subscales (Duivis et al., 2013).
In support of illness behavior theory, somatic depressivelike symptoms,
such as loss of energy, loss of appetite, and sleeping difficulties, may be
precipitated by increased inflammation (Duivis et al., 2013). Prolonged
or repeated therapeutic administration of interferon, an inflammatory cyto-
kine, precipitates MDD in almost 50% of patients (Harrison et al., 2009),
whereas exercise appears to have anti-inflammatory effects (Lopresti
et al., 2013). Increased understanding of the relationship between inflam-
mation and depressive symptom subscales may help elucidate mecha-
nisms of change between depression and inflammation within the
context of exercise interventions.
The Current Study
This preliminary investigation a) assesses the feasibility of using
a newly developed, single-session MI intervention to engage young
adults diagnosed with MDD in a designated exercise intervention;
b) explores effects of the MI/exercise intervention on depressive symp-
toms (cognitive, affective, and somatic), cognitive (negative automatic
thoughts), and behavioral changes (behavioral activation); and c) ex-
plores relationships between change in these symptoms, self-esteem,
and a marker of inflammation (IL-6).
METHODS
Study Design and Intervention Program
A single-session (90-minute) MI intervention Train your mood:
Exercise as treatment was designed and delivered after baseline as-
sessment to all participants. The intervention was manual guided
(Nasstasia et al., 2014) and facilitated by a clinical psychologist (Y.N.)
trained in MI techniques based on the work of Miller and Rollnick
(2013) (manual available upon request). The intervention included build-
ing intrinsic motivation by eliciting goals, exploring the relationship be-
tween exercise and mood, as well as barriers to exercise attendance and
resolving these. An exercise intervention was also designed to be deliv-
ered three times per week, for 1 hour, over 12 weeks in a supervised,
small group format (Callister et al., 2013). The exercise intervention
was progressive and incorporated resistance exercise and aerobic exercise
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with three blocks of varying activities, each 4 weeks long. Key assessment
measures were completed at baseline, postintervention, regularly through-
out the intervention, and at 9-month follow-up.
Participants
Twelve participants volunteered for the study. Inclusion criteria
were being aged 15 to 25 years and meeting Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition (DSM-IV ) criteria for MDD, as
assessed with the Structured Clinical Interview for DSM-IV-TR Disorders
(SCID) Research edition (First et al., 2002). Participants were excluded if
they were pregnant, at imminent risk of suicide, or had concurrent comor-
bidities, including psychosis, mania, eating disorders with overexercising,
or other medical conditions, or were unable to remain in the study re-
gion for the duration of the intervention. Participants were not excluded
if they were receiving current treatment of depression or engaging in
physical activity. The study was approved by the human research ethics
committee (H2012-0114) at the educational institution.
Measures
A sociodemographic, depression treatment history, and medical
comorbidity questionnaire was created for the study and administered
over the telephone, together with the Sitting Time Questionnaire,
as part of the initial screen. The Sitting Time Questionnaire
(Marshall et al., 2010) is a five-item measure that assesses time
spent sitting (hours and minutes) on a weekday and a weekend day
in the following domains: a) traveling to and from places, b) at work,
c) watching television, d) using a computer at home, and e) for lei-
sure. The authors report acceptable reliability and validity, particu-
larly for weekday sitting times (Marshall et al., 2010).
Biological Measures
The biological marker assessed and reported in this study was se-
rum IL-6 concentration. Fasting blood sample was collected between
8:00 a.m. and 10:00 a.m. at baseline and postintervention and stored
at 70C. The IL-6 marker was measured using an ultra-high sensitivity
enzyme-linked, immunosorbent assay. Lower scores indicate lower
levels of inflammation.
Diagnostic Measures and Comorbidity
The SCID (First et al., 2002) was used to determine diagnostic
eligibility and assess comorbidity, with a focus on current and lifetime
episodes of depression, mania, and eating disorders. The SCID was ad-
ministered at baseline by a clinical psychologist (Y.N.) and repeated
12 weeks postintervention. A mental health comorbidities and severity
index was also derived using information from the sociodemographic
questionnaire and SCID assessment (see Table 1).
Self-Report Measures
The Beck Depression Inventory BDI-II (Beck et al., 1996) is a
self-report measure of depression symptoms corresponding to DSM-IV
diagnostic criteria for MDD. It includes 21 items with scores ranging
from 0 to 63. Higher scores reflect greater depression severity. The
BDI-II demonstrates good psychometric properties, with alpha reliability
coefficients exceeding 0.90 in a range of populations (Beck et al., 1988).
Although it is generally agreed that the BDI-II includes cognitive, affec-
tive, and somatic symptoms, these factors tend to be correlated and allo-
cation of items to factors have been variable (Quilty et al., 2010). Here,
we report both the BDI-II global severity score and subscales based on
Beck et al. (1996) original item allocations (see Table 2).
The Automatic Thoughts Questionnaire (ATQ) (Hollon and
Kendall, 1980) consists of 30 self-report items assessing frequency of
negative automatic thoughts. Scores range from 30 to 150, with higher
scores reflecting increased negative cognitions. The ATQ is a widely
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The Journal of Nervous and Mental Disease Volume 205, Number 8, August 2017 Exercise Training for Depression

TABLE 1. Sociodemographic and Health Characteristics at Baseline

Sociodemographic Characteristic N (%) or Mean (SD) Health Characteristic N (%) or Mean (SD)
Age, yr 20.83 (SD 1.70) Alcohol use (past 3 months)
None 1 (8)
Once or twice 3 (25)
Monthly 3 (25)
Weekly 4 (33)
Almost daily or daily 1 (8)
Sex Tobacco use (past 3 months)
Female 9 (75.0) None 9 (75)
Male 3 (25.0) Once or twice 1 (8)
Weekly 1 (8)
Education Weekly sitting time, min 4318 (SD 1185)
Some high school 1 (8.3)
University student 11 (92) Activity levels, min per week
Does not meet guidelines <150 3 (25.0)
Meets guidelines = 150 4 (33.3)
Exceeds guidelines >150 5 (41.7)
Relationship status Weight, kg 68.96 (SD 14.06)
Single 12 (100.0)
Ethnicity Body Mass Index 23.56 (SD 4.25)
Anglo Australian 11 (92)
European 1 (8)
Employment Mental Health Comorbidity and Severity index (05) 3.41 (SD 1.78)
Currently working 7 (58)
Unemployed 1 (8)
Full-time student 4 (33)
A mental health comorbidities and severity index was derived using information from the sociodemographic questionnaire and SCID assessment. This index was
based on the number of self-reported conditions and associated treatments and ranged from 0 (no self-reported problems) to 5 (multiple comorbidities and previous
and current treatment history); for example: 1 point, if they indicated past treatment for depression; 2 points, if they received past counseling and medication for depres-
sion; another point, if they reported current anxiety as a comorbidity; a further point, if they also reported current eating disorders as a comorbidity; and an additional
point if these comorbid conditions involved current medication.

used measure, demonstrating high-internal reliability and a strong cor-
relation with depression severity (Hollon and Kendall, 1980).
The Behavioral Activation for Depression ScaleShort Form
(BADS-SF) (Manos et al., 2011) is a measure of behavioral activation
(activation and avoidance). This nine-item measure has a total score
ranging from 0 to 54, with higher scores representing increased activa-
tion (and less avoidance). The BADS-SF has an internal consistency of
0.82, with demonstrated construct validity and predictive validity
(Manos et al., 2011).
The Single-Item Self-esteem Questionnaire (SISE) (Robins et al.,
2001) is a one-item questionnaire (I have high self-esteem) and is rated
on a five-point Likert scale ranging from 1 (strongly disagree) to 5
(strongly agree). The SISE has high convergent validity with the Rosen-
berg Self-Esteem Scale (Robins et al., 2001).
Procedure
The study was advertised by flyers on University notice boards,
and counseling staff also referred potential participants to the study.
Telephone screening was conducted to identify initial study eligibility.
A face-to-face psychological assessment then determined if they met
current diagnostic criteria for MDD. Before the interview, potential par-
ticipants completed the self-report questionnaires. Eligible participants
subsequently underwent fitness assessments at baseline and 12 weeks.
A blood sample was taken in the week before and after completion of
the exercise intervention. After the MI intervention, participants com-
menced the exercise intervention. The exercise sessions were supervised
by an exercise scientist, and incorporated progressive resistance and aer-
obic exercise with three blocks of varying activities incorporating in-
creasing intensity, each 4 weeks long. Participants were provided with
gym memberships for the duration of the intervention and encouraged
to participate in 30 minutes of physical activity on other days. The
BDI-II, ATQ, and BADS-SF were re-administered during weeks 2, 4,
6, 8, and 10 of the intervention to monitor symptom change. At 12 weeks
postintervention, participants were reassessed by a trained, independent
rater to determine if they still met diagnostic criteria for MDD. Psycho-
logical self-report questionnaires as well as fitness and biological assess-
ments were also repeated. The self-report measures were additionally
repeated 9 months after baseline. At the conclusion of the study, an exit
interview was conducted with the participants by an independent re-
searcher. A $10 reimbursement for each training and assessment session
attended was provided to participants to cover attendance-related costs.
Statistical Analysis
Statistical analyses were conducted using IBM SPSS for win-
dows (Version 22.0; Armonk, NY). To explore the trajectory of symp-
tom change, key outcome measures were repeatedly measured in the
same participant across eight time points: baseline, weeks 2, 4, 6, 8,
10, 12 (postintervention), and 9 months after baseline. Generalized lin-
ear mixed models, specifically generalized estimating equations
(GEEs), were used to examine changes from baseline to follow-up
(see Table S1, http://links.lww.com/JNMD/A22, for further details).
This analysis strategy used all available data for each participant while

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Nasstasia et al. The Journal of Nervous and Mental Disease Volume 205, Number 8, August 2017

TABLE 2. Mean Baseline and Change Scores for Key Self-Report Measures and IL-6

Observed Change From Baseline

Baseline Postintervention Follow-up
(N = 12) (N = 12) (N = 9)
Measure Possible Range Mean (SD) Mean (SD) Mean (SD)
Depression (BDI-II)
Total score 063 32.25 (9.42) 20.33 (10.58) 21.56 (14.07)
Cognitive 027 14.17 (5.78) 8.92 (5.00) 9.78 (7.74)
Affective 021 9.75 (3.36) 6.67 (3.98) 6.89 (4.14)
Somatic 015 8.33 (1.83) 4.75 (3.22) 4.89 (3.55)
Negative thoughts (ATQ) 30150 88.33 (22.72) 34.33 (19.97) 38.89 (35.40)
Activation (BADS-SF) 054 20.00 (5.49) 14.42 (9.61) 14.77 (14.03)
Paired t-test (df )a
Self-esteem (SISE) 15 2.27 (0.91) 0.73 (0.65) 3.73 (10), p = 0.004*
Inflammation (IL-6 pg/ml) 010b 1.50 (0.81) 0.77 (0.87) 2.66 (8), p = 0.029**
Beck et al. (1996) original item allocation included somatic (items: 15, 16, 18, 19, and 20), affective (items: 4, 10, 11, 12, 13, 17, and 21), and cognitive subscales
(items: 1, 2, 3, 5, 6, 7, 8, 9, and 14).
a
For these measures, only before versus after 12-week intervention data were collected.
b
Reference range for healthy populations.
*p < 0.01.
**ptrend < 0.05.

accounting for individual variation in the intervals between assessment
points. Orthogonal polynomials were used to examine the linear, qua-
dratic, and cubic components of change across assessment points.
Two baseline covariates were included in the model to delineate effects
of physical inactivity (sedentary behavior) and mental health (mental
health severity and comorbidities) on the changes in depression and
key outcome measures. Secondary analyses for the study included
paired sample t-tests, which assessed changes in outcome measures
for self-esteem and IL-6 (both only assessed at two points). Partial corre-
lations were used to explore interrelationships among change scores for
the key outcome measures, baseline sitting, and mental health comorbid-
ities, holding constant lapsed days from baseline assessment to the end of
the intervention (which varied somewhat across individuals). As a partial
control for the number of statistical tests, the significance level was set at
p 0.01, with statistical trends also noted at p 0.05.
RESULTS
Sample Characteristics
Participant sociodemographic and health characteristics at base-
line are presented in Table 1. The average age of participants was 20.8
(SD 1.7) years, with 75.0% female participants. Participants were pre-
dominantly within a healthy body mass index range (mean 23.6 [SD
4.3] kg/m2) and reported an average baseline sitting time of 4318
(SD 1185) minutes each week. Most participants (75.0%) reported that
they met or exceeded the physical activity guidelines as recommended
by the Australian Government Department of Health (2012). Reported
activity ranged from walking only to planned physical activity. Partici-
pants' mean mental health comorbidities and severity index score was
3.4 (SD 1.8), with 91.7% of participants reporting past treatment of de-
pression, including counseling and medication, and 66.7% of partici-
pants self-reporting anxiety problems. Serum IL-6 concentration was
1.49 (SD .81) pg/ml on average at baseline, which is within the ref-
erence range (Ridker et al., 2000).
The left-hand columns of Table 2 show the mean baseline scores
for the key outcome measures. At baseline, participants reported a mean
BDI-II total score of 32.2 (SD 9.4), which falls within the severe range
(Beck et al., 1996). All three of the BDI-II subscales were similarly en-
dorsed (i.e., means around 50% of the maximum score), with partici-
pants reporting cognitive 14.2 (SD 5.8), affective 9.8 (SD 3.4), and
somatic symptoms 8.3 (SD 1.8). Negative automatic thoughts (ATQ)
averaged 88.3 (SD 22.7) at baseline, which is considered to be high
(DeRubeis et al., 1990). Behavioral activation (BADS-SF) was rela-
tively low at baseline averaging 20.0 (SD 5.5). Postintervention, mean
scores on the ATQ and BDI-II returned to levels consistent with nonde-
pressed populations (DeRubeis et al., 1990).
Program Implementation
Retention and Adherence
Twelve participants completed the intervention and were assessed
at 12 weeks (2 weeks postintervention). Adherence to the exercise pro-
gram was measured by the percentage of exercise sessions (out of 36)
attended by participants, which averaged 65.9% (SD 25.1%). Follow-
up data on key psychological self-report measures were also obtained
for nine participants, reflecting a retention rate of 75% at the
9-month follow-up.
MI Fidelity Review and Feasibility
Interview segments were rated by two independent judges
who were both psychologists trained in MI and in the MI treatment
integrity (MITI) code, Version 3.1.1 (Moyers et al., 2010). Average
session duration was 36.9 minutes. All of the MITI global ratings
(evocation, collaboration, autonomy/support, direction, and empathy),
which were rated from 1 (low) to 5 (high), displayed adequate fidelity
to MI principles, with 62.2% of the domains rated as 5 and 33.3% rated
as 4. With respect to the MI behavior counts, the concordance (Cronbach
alpha) ranged from 0.927 for open questions to 0.792 for MI adherence,
and there was comparable concordance for total reflections (0.705), giv-
ing information (0.713), and closed questions (0.722).
At the conclusion of the study, an exit interview was conducted
by an independent researcher with 92.6% (11) of the participants. These

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The Journal of Nervous and Mental Disease Volume 205, Number 8, August 2017
interviews were recorded and summarized. Participants were asked to
comment on the acceptability of the MI and exercise intervention. Partic-
ipant responses were grouped into nine main themes and are summarized
in Table 3. Overall, participants found the MI and exercise intervention
helpful and beneficial. Despite finding the MI session helpful, 54.5%
(6) of the participants indicated that it was too long, with a mean session
duration of 108.86 (SD 15.60) minutes. Support with transition to other
exercise programs was also raised as a potential addition.
Change Profiles From Baseline to Follow-up
The right-hand columns of Table 2 report mean (raw) change
scores for the key outcome measures at postintervention (12 weeks)
and the 9-month follow-up. To more comprehensively explore the pat-
terns of change across study phases in depressive symptoms and the
other cognitive and behavioral measures, GEE analyses were specified
to examine the linear, quadratic, and cubic components of change
across the eight assessment points. Separate analyses were conducted
for each of the key outcome measures, which are summarized in Sup-
plementary Tables S1 (BDI-II depression analyses, http://links.lww.
com/JNMD/A22) and S2 (other analyses, http://links.lww.com/
JNMD/A23). To facilitate comparisons across the measures, standard-
ized change scores from baseline are reported (using the grand SD of
change from baseline for each outcome measure as the denominator),
together with Wald chi-square statistics for each of the components of
change. The trajectories of change are represented graphically
in Figure 1.
Results from the GEE analyses showed a curvilinear improve-
ment over time for each of the key outcome measures (i.e., a significant
linear component and a significant quadratic component), with a slower
rate of improvement across later study phases and peak improvement at
TABLE 3. Summary of Participant Responses to the Exit Interview (N = 11)
Topic Main Themes
A. Motivational discussion 1. Goal setting (N = 8)
2. Facilitator style (N = 5)
3. Barriers/solutions (N = 8)
4. Helpfulness (N = 9) Helped with motivationgood to figure out things that motivate me (e.g., other people)
B. Exercise intervention 5. Format (N = 11)
6. Information/resources (N = 7)
7. Trainer style (N = 7)
C. Overall program 8. Limitations (N = 4)
9. Benefits (N = 9)
After 2 weeks, I realized it works, not just a myth (that exercise can help)
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Exercise Training for Depression
week 10, near the end of the active intervention phase (see Tables S1,
http://links.lww.com/JNMD/A22 and S2, http://links.lww.com/JNMD/
A23). For the BADS-SF in particular, there was also some evidence
for a significant cubic component of change (see Table S2, http://
links.lww.com/JNMD/A23) (i.e., two points of variation), such that
there was a more gradual improvement up to week 8, followed by a
sharp improvement, and then a partial rebound by week 12.
As shown in Figure 1 and Table S1 (http://links.lww.com/
JNMD/A22), standardized changes from baseline on the BDI-II affec-
tive subscale tended to closely parallel changes in BDI-II total scores.
Two weeks into the exercise intervention, somatic symptoms showed
a larger standardized mean improvement (0.99) compared with cogni-
tive symptoms (0.82) and affective symptoms (0.89). However, these
initial differential improvements were not maintained, with affective
symptoms showing the biggest standardized mean improvement postin-
tervention (1.71), followed by cognitive symptoms (1.56) and somatic
symptoms (1.39). This pattern was largely maintained at 9-month
follow-up (see Table S2, http://links.lww.com/JNMD/A23). Two of the
outcome measures were only assessed at baseline and postintervention,
for which paired sample t-tests were conducted (see Table 2). Self-
esteem ratings improved significantly from baseline to postintervention
(p = 0.004), and there was a tendency for inflammation to decrease, based
on serum IL-6 concentration reductions (p = 0.029). At the end of the
study, 75% of participants no longer met SCID diagnostic criteria
for MDD.
In view of the overall findings from the change analyses (e.g.,
peak change around the end of the intervention program, followed by
substantial maintenance of these effects), simple change scores from
baseline to postintervention were regarded as a satisfactory way to char-
acterize each individual's improvement. In the absence of a direct com-
parison group, typical improvement bands have been added to Figure 1.
Examples
Goal setting was useful
Helped me see what I want, need, and how to get there
Helped motivate me
Really listens, felt like she wanted my opinion and valued it
Helped me open up
Made you feel comfortable with helping yourself
Useful/helpful process
Found ways for me to help myself
Used some of the strategiesmade a useful toolbox to motivate myself
Informative/helpful
Discussion was useful but long
Not just me, everybody had depression
Not a lot of group camaraderiepeople attending less as time went on
Would have liked more variety of exercises
Early morning starts were difficult
Free gym membership motivated meI liked having a personal trainer
Would have liked a resource pack with affordable gyms and trainers
Liked fortnightly mood checksthey were like a personal checkup
Accountability to trainerdidn't want to let trainer down
Felt supported by trainer
Would have liked more support from trainer
Extend gym membership at end to help people transition
Would have liked longer exercise sessions/program
Discontinued medication/counseling
Improved energy or fitness
Volume turned down on problems
Program worked together, would recommend it because it helps
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Nasstasia et al. The Journal of Nervous and Mental Disease Volume 205, Number 8, August 2017

FIGURE 1. Trajectory of symptom change from baseline expressed in standardized scores across study phases. Typical improvement bands are based on
data from the 11 group CBT studies reported in Table S5 (http://links.lww.com/JNMD/A26) (1 SD).

These were based on findings from the 11 group cognitive behavioral
studies detailed in supplementary Table S3 (http://links.lww.com/
JNMD/A24); Okumura and Ichikura (2014) reported posttreatment dif-
ferences for these and other studies (see Table S4, http://links.lww.com/
JNMD/A25). We have calculated standardized differences between
baseline and posttreatment for the same studies (see Table S5, http://
links.lww.com/JNMD/A26), which are represented in Figure 1.
Correlates and Predictors of Change
As detailed in Table 4, partial correlations were used to examine
associations with change scores from baseline to postintervention for
selected key outcome measures. These analyses controlled for variation
in the number of days from baseline assessment to the end of the inter-
vention, which was on average 101 (SD 10.7) days. The upper portion
of Table 4 examines partial correlations between selected change scores
and two baseline measures reflecting current mental health and physical
inactivity, as well as associations with exercise session attendance.
None of these associations were statistically significant; however, to
correctly orient readers, higher exercise session attendance tended to
be negatively correlated (r = 0.49) with changes in IL-6 concentration
(i.e., with greater reductions in IL-6, as the change scores were calcu-
lated by subtracting baseline from postintervention).
As shown in the lower portion of Table 4, changes in negative
automatic thoughts (ATQ) tended to parallel changes in BDI-II total
scores (r = 0.66, p = 0.028), due largely to associated changes in the
BDI-II cognitive subscale (r = 0.71, p = 0.014). As expected, changes
in the three BDI-II subscales were also significantly correlated with
changes in BDI-II total scores. Behavioral activation changes were sig-
nificantly negatively correlated with IL-6 changes (r = 0.84,
p = 0.010), indicating that improvements in behavioral activation were
associated with reductions in IL-6.
DISCUSSION
The present study demonstrates the feasibility of an integrated
MI and exercise intervention developed specifically to enhance engage-
ment in an exercise intervention among young adults diagnosed with

TABLE 4. Selected Interrelationships Between Variables: Partial Correlations With Baseline to Postintervention Change Scores for Key Outcome
Measures

Change Scores for Key Outcome Measures (Postintervention Minus Baseline)a

BDI-II Esteem BDI-II BDI-II BDI-II
Variable IL-6 Total ATQ BADS-SF (SISE) Cognitive Subscale Affective Subscale Somatic Subscale
Baseline mental health comorbidity 0.40 0.14 0.03 0.11 0.08 0.03 0.10 0.41
and severity index
Baseline weekly sitting time 0.11 0.04 0.46 0.34 0.29 0.16 0.24 0.54
Attendance index
% of exercise sessions attended 0.49 0.19 0.40 0.42 0.23 0.35 0.06 0.13
Change scores for key outcome measures
IL-6 0.49 0.34 0.84* 0.23 0.23 0.46 0.63
BDI-II total 0.66** 0.01 0.02 0.87* 0.81* 0.67**
ATQ 0.16 0.08 0.71** 0.55 0.12
BADS-SF 0.51 0.10 0.04 0.32
Esteem (SISE) 0.08 0.05 0.20
All partial correlations controlled for the interval between baseline and postintervention.
a
Sample sizes: N = 12 for BDI-II, ATQ, BDI-II affective, somatic, and cognitive; N = 11 for esteem (SISE); and N = 9 for IL-6.
*p < 0.01.
**ptrend < 0.05.

652 www.jonmd.com 2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

The Journal of Nervous and Mental Disease Volume 205, Number 8, August 2017
MDD. Our results show high acceptability among participants and a
strong engagement and retention rate was observed. Feedback from
the exit interview also confirmed the overall value of the MI and exer-
cise intervention. Further, controlling for previous physical inactiv-
ity and mental health severity and comorbidity, our results show
clinically significant reductions in depression, negative automatic
thoughts, and an increase in behavioral activation at the end of the ex-
ercise intervention, with only one quarter of participants still meeting
diagnostic criteria for MDD. These improvements were largely main-
tained at 9-month follow-up. Participants reported significant improve-
ments in self-esteem, and on a biological level, there was a reduction in
inflammation as measured by the serum IL-6 concentration. These
findings support a small body of research documenting the beneficial
effects of exercise for young people with depression (Hughes et al.,
2009) and extend this work by offering a preliminary investigation of
the specific effects of exercise on depressive symptom subscales and
their relationships with cognitive, behavioral, and biological factors.
Differential Effects of Exercise on
Depressive Symptoms
There was a significant pattern of improvement in depression,
and depressive symptom subscales, across the phases of the inter-
vention. Peak improvements across all outcomes were observed at
week 10, and there was early improvement in depressive symptoms
by week 2. These results add to the body of research documenting early
symptom change in the treatment of depression across therapeutic ap-
proaches (Aderka et al., 2012; Baker et al., 2014a; Masterson et al.,
2014). Although the exact reasons for early change are less understood,
these improvements are regarded as a positive indicator of later treat-
ment responsiveness (Kelly et al., 2005).
Given these findings, there may be merit in examining in greater
detail the sequencing of changes in the depressive symptom profile.
Our results show the largest; early improvement was observed in the so-
matic subscale. At week 2, participants reported improvements in en-
ergy and concentration, less tiredness, as well as changes in sleep and
appetite. These early somatic improvements perhaps mobilized change
and may be an early and specific predictor of an exercise responder and
warrant further investigation. Although somatic symptoms continued to
show improvement, by the end of the intervention, the largest improve-
ments were observed in the affective subscale, followed by the cognitive
and somatic subscales. The affective subscale includes symptoms such
as loss of interest and loss of pleasure, core features of depression mechanism of action of exercise (Brosse et al., 2002).
as defined by the DSM-IV-TR (American Psychiatric Association,
2000) and, together with loss of interest in sex, represent key features
of anhedonia (Joiner et al., 2003). Anhedonia, the inability to experi-
ence pleasure, is a key clinical feature associated with depression and
may represent a specific marker of depression (Joiner et al., 2003).
The link between exercise and positive affect is an intense foci of
theoretical discussion and the exact mechanisms are currently unclear
(Ekkekakis, 2003). Research with animal models suggests exercise
may increase dopamine levels (Leventhal, 2012), whereas higher anhe-
donia is associated with lower levels of physical activity indices in col-
lege students (Leventhal, 2012). Similarly, early research suggests that
antidepressant medication, which enhances noradrenergic and dopami-
nergic activity, may be beneficial in treating anhedonia (Nutt et al.,
2007). Exercise may plausibly target anhedonia symptoms within
MDD and enhanced pleasure may act as a potential affective mecha-
nism of exercise (Leventhal, 2012). Exercise may also increase oppor-
tunities for additional reinforcing experiences that target the reward
system. The results of the current study show a significant improvement
in behavioral activation across the phases of the intervention. Activation
can have a delayed effect on mood if the activation (in this case ex-
ercise) needs to be repeated many times over several weeks before
rewards or reinforcements are observed (Folke et al., 2015). This
2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.
Exercise Training for Depression
may help account for the observed pattern of change in activation
in this study with a gradual rate of improvement initially observed
followed by larger successive increases in the second half of the in-
tervention and a small rebound effect when the exercise intervention
concluded. Our findings also showed a steady pattern of improve-
ment in negative automatic thoughts across the phases of the inter-
vention. As depression and, in particular, cognitive symptoms of
depression improved, negative automatic thoughts reduced in frequency.
Relationship Between Depressive Symptoms and
Cognitive, Behavioral, and Biological Factors
To elucidate patterns of change among key variables, we investi-
gated interrelationships among key outcome measures. Our study
found a significant relationship between cognitive symptoms of depres-
sion and negative automatic thoughts. Cognitive depressive symptoms
include self-criticism, guilt, pessimism, and sense of failure. These im-
provements paralleled a reduction in negative automatic thoughts, pro-
viding further evidence of the effectiveness of exercise in producing
cognitive change in depression. However, our study found no signifi-
cant relationship between depression and behavioral activation, and this
is inconsistent with research by Collado et al. (2014). Perhaps our small
sample size reduced the likelihood of statistical significance, reinforc-
ing the need for further investigation and replication in a larger sample.
Reduced levels of systemic inflammation after exercise are a
consistent finding (Sigwalt et al., 2011), also observed in the current
study. Our results showed a significant relationship between increased
behavioral activation and reduced inflammation. There was a sizeable
though nonsignificant relationship between exercise attendance and in-
flammation, highlighting the specificity of activation and exercise in re-
ducing inflammation. Improvements in depression and depressive
symptom subscales were not significantly associated with reductions
in inflammation. However, reductions in inflammation were more
highly correlated with the somatic depressive subscale, although this ef-
fect was not significant. Similarly, any improvements in depression
were not constrained by clinical complexity at baseline. An exercise
dose response relationship with depression was not observed; however,
unrecorded physical activity on nonintervention days may have influ-
enced results and requires further investigation. There were, however,
significant improvements in self-esteem, which is consistent with re-
search showing that exercise can be beneficial in promoting increased
self-esteem (White et al., 2009) and self-esteem may even be a potential
Limitations
This study had several limitations, and as such, the results from
the present study should be interpreted cautiously. First, although high
participant retention was observed, this is a small sample. Another im-
portant limitation is that without a control group it is difficult to know
whether observed changes in depression were caused by exercise or if
symptoms spontaneously remitted. However, the typical improvement
bands displayed in Figure 1 suggest that the magnitude of improvement
observed in the current study cannot solely be accounted for by natural
remission of depression (or other concurrent treatment as usual ef-
fects). Indeed, the improvements observed in the current study are to-
ward the top end of the range of active treatment conditions.
However, it should be noted that, on average, group interventions in
the studies evaluated by Okumura and Ichikura (2014) (and used in Ta-
bles S3 to S5, http://links.lww.com/JNMD/A24, http://links.lww.com/
JNMD/A25, and http://links.lww.com/JNMD/A26) were much shorter
in duration, and this may account for some of the differences. Further,
integrating MI with exercise may have promoted engagement and re-
tention; however, this may have been a highly motivated group of par-
ticipants who self-selected for the study. As a group, they may have
had lower rates of anhedonia at baseline when compared with other
www.jonmd.com 653
Nasstasia et al. The Journal of Nervous and Mental Disease Volume 205, Number 8, August 2017
individuals with depression, and this warrants further investigation.
However, it is important to note that participants in the present study re-
ported severe baseline depressive symptoms as assessed by the BDI-II,
including affective symptoms representative of anhedonia. Higher
symptom rates may have had a negative effect on volition, which sug-
gests that the MI intervention may have offered some benefit in ad-
dressing the motivational restraints. Further research is needed to
establish whether the engagement effects observed in this study are at-
tributable to the MI intervention. A randomized controlled trial compar-
ing MI and exercise with exercise only, or with a low intensity
intervention such as brief advice and exercise, would offer a more rig-
orous evaluation of the MI intervention. Similarly, potential group so-
cial interaction effects on the observed improvements in this study,
including biological changes, cannot be discounted. Although research
suggests that both individual and group exercise programs can be ben-
eficial (Stanton and Reaburn, 2014), further research with a placebo,
social interaction arm may help delineate the relative influence of
group effects.
CONCLUSIONS
Our findings suggest that integrating MI with an exercise inter-
vention is feasible and offers tentative insights into the specific effects
of exercise on depressive symptoms, pointing to the veracity of exercise
as an adjunctive treatment option for MDD in young adults. Exercise
appears to ameliorate somatic symptoms early in treatment and exerts
greatest influence in the affective group with potential implications
for mitigating anhedonia. The relationship between behavioral activa-
tion and inflammation also reveals the ability of behavior to influence
biological change and suggests depression is as much a physical disor-
der as it is a psychological one. Furthermore, given the high rates of
MDD comorbidity, exercise interventions may play an important ad-
junctive role in improving depressive symptoms and overall functioning
within a range of mental health disorders. Recent meta-analyses have
highlighted potential benefits of physical exercise for mental health
conditions (Dauwan et al., 2016; Schuch et al., 2016). Dauwan et al.
(2016) concluded that physical exercise can help improve clinical
symptoms and quality of life and reduce depressive symptoms in pa-
tients with schizophrenia. Similarly, Schuch et al. (2016) demonstrated
that exercise is an efficacious treatment for adults with MDD, with pub-
lication bias constraining effect sizes in previous meta-analyses. Further
research is needed to establish the efficacy of exercise in treating MDD
in young people. Identifying differential effects of exercise on depres-
sive symptom domains, with a focus on anhedonia, in the context of a
randomized controlled trial is an important next step, as is adapting
the MI intervention for delivery by personal trainers. This will further
integrate the MI intervention with exercise and help foster a positive
working alliance between the trainer and the participant.
ACKNOWLEDGMENTS
The researchers would like to thank Mrs Adriana Giles for her as-
sistance with the exercise intervention.
DISCLOSURES
The study was funded by Hunter Medical Research Institute and
Beyond Blue.
The authors declare no conflict of interest.
REFERENCES
Aderka IM, Nickerson A, Be HJ, Hofmann SG (2012) Sudden gains during psycho-
logical treatments of anxiety and depression: A meta-analysis. J Consult Clin
Psychol. 80:93101.
American Psychiatric Association (2000) Diagnostic and statistical manual of mental
disorders. Washington, DC: American Psychiatric Association.
654 www.jonmd.com
Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.
Australian Government Department of Health (2012) Australia's Physical Activity and
Sedentary Behaviour Guidelines for Adults (1864 years) olds. Canberra: Com-
monwealth of Australia.
Baker AL, Kavanagh DJ, Kay-Lambkin FJ, Hunt SA, Lewin TJ, Carr VJ, McElduff P
(2014a) Randomized controlled trial of MICBT for co-existing alcohol misuse
and depression: Outcomes to 36-months. J Subst Abuse Treat. 46:281290.
Baker AL, Turner A, Kelly PJ, Spring B, Callister R, Collins CE, Woodcock KL, Kay-
Lambkin FJ, Devir H, Lewin TJ (2014b) Better Health Choices by telephone:
A feasibility trial of improving diet and physical activity in people diagnosed with
psychotic disorders. Psychiatry Res. 220:6370.
Beck A, Steer R, Brown G (1996) Manual for the Beck Depression Inventory-II. San
Antonio, TX: Psychological Corporation.
Beck A, Steer RA, Carbin MG (1988) Psychometric properties of the Beck Depression
Inventory: Twenty-five years of evaluation. Clin Psychol Rev. 8:77100.
Biddle SJ, Asare M (2011) Physical activity and mental health in children and adoles-
cents: A review of reviews. Br J Sports Med. 45:88695.
Blumenthal JA, Babyak MA, Doraiswamy PM, Watkins L, Hoffman BM, Barbour
KA, Herman S, Craighead WE, Brosse AL, Waugh R, Hinderliter A, Sherwood
A (2007) Exercise and pharmacotherapy in the treatment of major depressive dis-
order. Psychosom Med. 69:587596.
Blumenthal JA, Smith PJ, Hoffman BM (2012) Is exercise a viable treatment for de-
pression? ACSM Health Fit J. 16:1421.
Brosse AL, Sheets ES, Lett HS, Blumenthal JA (2002) Exercise and the treatment of
clinical depression in adults. Sports Med. 32:741760.
Callister R, Giles A, Nasstasia Y, Baker A, Halpin S, Hides L, Kelly B (2013) 12-weeks
supervised exercise training is a feasible and efficacious treatment for reducing de-
pression in youth with major depressive disorder. J Sci Med Sport. 16(suppl 1):e16.
Carragher N, Adamson G, Bunting B, McCann S (2009) Subtypes of depression in a
nationally representative sample. J Affect Disord. 113:8899.
Cassano GB, Benvenuti A, Miniati M, Calugi S, Mula M, Maggi L, Rucci P, Fagiolini
A, Perris F, Frank E (2009) The factor structure of lifetime depressive spectrum in
patients with unipolar depression. J Affect Disord. 115:8799.
Collado A, Castillo SD, Maero F, Lejuez CW, Macpherson L (2014) Pilot of the brief be-
havioral activation treatment for depression in latinos with limited english proficiency:
Preliminary evaluation of efficacy and acceptability. Behav Ther. 45:102115.
Dauwan M, Begemann MJ, Heringa SM, Sommer IE (2016) Exercise improves clin-
ical symptoms, quality of life, global functioning, and depression in schizophre-
nia: A systematic review and meta-analysis. Schizophr Bull. 42:588599.
DeRubeis RJ, Evans MD, Hollon SD, Garvey MJ, Grove WM, Tuason VB (1990) How
does cognitive therapy work? Cognitive change and symptom change in cognitive ther-
apy and pharmacotherapy for depression. J Consult Clin Psychol. 58:862869.
Dowlati Y, Herrmann N, Swardfager W, Liu H, Sham L, Reim EK, Lanctt KL (2010)
A meta-analysis of cytokines in major depression. Biol Psychiatry. 67:446457.
Duivis HE, Vogelzangs N, Kupper N, de Jonge P, Penninx BW (2013) Differential as-
sociation of somatic and cognitive symptoms of depression and anxiety with in-
flammation: Findings from the Netherlands Study of Depression and Anxiety
(NESDA). Psychoneuroendocrinology. 38:15731585.
Dunn AL, Trivedi MH, Kampert JB, Clark CG, Chambliss HO (2005) Exercise treat-
ment for depression: Efficacy and dose response. Am J Prev Med. 28:18.
Ekkekakis P (2003) Pleasure and displeasure from the body: Perspectives from exer-
cise. Cognit Emot. 17:213239.
First MB, Spitzer RL, Gibbon M, Williams JBW (2002) Structured clinical interview
for DSM-IV axis I disorders, research version, non-patient edition (SCID-I/NP).
New York: New York State Psychiatric Institute, Biometrics Research.
Folke F, Hursti T, Tungstrm S, Sderberg P, Kanter JW, Kuutmann K, Olofsson H,
Ekselius L (2015) Behavioral activation in acute inpatient psychiatry: A multiple
baseline evaluation. J Behav Ther Exp Psychiatry. 46:170181.
Forsyth A, Deane FP, Williams P (2015) A lifestyle intervention for primary care
patients with depression and anxiety: A randomised controlled trial. Psychiatry
Res. 230:537544.
2016 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease Volume 205, Number 8, August 2017
Fried EI, Nesse RM (2015) Depression sum-scores don't add up: Why analyzing spe-
cific depression symptoms is essential. BMC Med. 13:1372.
Furlong M, Oei TPS (2002) Changes to automatic thoughts and dysfunctional atti-
tudes in group CBT for depression. Behav Cogn Psychother. 30:351360.
Harald B, Gordon P (2012) Meta-review of depressive subtyping models. J Affect
Disord. 139:126140.
Harrison NA, Brydon L, Walker C, Gray MA, Steptoe A, Critchley HD (2009) Inflam-
mation causes mood changes through alterations in subgenual cingulate activity
and mesolimbic connectivity. Biol Psychiatry. 66:407414.
Herman S, Blumenthal JA, Babyak M, Khatri P, Craighead WE, Krishnan KR,
Doraiswamy PM (2002) Exercise therapy for depression in middle-aged and older
adults: Predictors of early dropout and treatment failure. Health Psychol. 21:
553563.
Hettema J, Steele J, Miller WR (2005) Motivational interviewing. Annu Rev Clin
Psychol. 1:91111.
Hollon S, Kendall P (1980) Cognitive self-statements in depression: Development of
an automatic thoughts questionnaire. Cogn Ther Res. 4:383395.
Howren MB, Lamkin DM, Suls J (2009) Associations of depression with C-reactive
protein, IL-1, and IL-6: A meta-analysis. Psychosom Med. 71:171186.
Hughes CW, Trivedi MH, Cleaver J, Greer TL, Emslie GJ, Kennard B, Dorman S, Bain
T, Dubreuil J, Barnes C (2009) DATE: Depressed adolescents treated with exer-
cise: Study rationale and design for a pilot study. Ment Health Phys Act. 2:7685.
Joiner TE, Brown JS, Metalsky GI (2003) A test of the tripartite model's prediction of
anhedonia's specificity to depression: Patients with major depression versus pa-
tients with schizophrenia. Psychiatry Res. 119:243250.
Kelly MA, Roberts JE, Ciesla JA (2005) Sudden gains in cognitive behavioral treat-
ment for depression: When do they occur and do they matter? Behav Res Ther.
43:703714.
Kvam S, Kleppe CL, Nordhus IH, Hovland A (2016) Exercise as a treatment for de-
pression: A meta-analysis. J Affect Disord. 202:6786.
Lash JM (2000) The effects of acute exercise on cognitions related to depression.
Dissertation Abstracts International: Section B: The Sciences and Engineering.
60(12-B):6371.
Leventhal AM (2012) Relations between anhedonia and physical activity. Am J Health
Behav. 36:860872.
Lopresti AL, Hood SD, Drummond PD (2013) A review of lifestyle factors that con-
tribute to important pathways associated with major depression: Diet, sleep and
exercise. J Affect Disord. 148:1227.
Manos RC, Kanter JW, Luo W (2011) The behavioral activation for depression scale-
short form: Development and validation. Behav Ther. 42:726739.
Marshall AL, Miller YD, Burton NW, Brown WJ (2010) Measuring total and domain-
specific sitting: A study of reliability and validity. Med Sci Sports Exerc. 42:
1094102.
Martins RK, McNeil DW (2009) Review of motivational interviewing in promoting
health behaviors. Clin Psychol Rev. 29:283293.
Masterson C, Ekers D, Gilbody S, Richards D, Toner-Clewes B, McMillan D (2014)
Sudden gains in behavioural activation for depression. Behav Res Ther. 60:3438.
Miller WR, Rollnick S (2013) Motivational interviewing: Helping people change
(3rd ed). New York: Guilford Press.
Moyers TB, Martin T, Manuel JK, Miller WR, Ernst D (2010) Motivational
interviewing treatment integrity 3.1.1: Revised global scales. Albuquerque, NM:
University of New Mexico. Available at: http://casaa.unm.edu/download/mitii3_
1.pdf. Accessed April 10, 2014.
Nasstasia Y, Callister R, Baker A, Halpin S, Hides L, Giles A, Dascombe B, Kelly B,
Lewin T (2014) Skilling up with motivational interviewing: Engagement in per-
sonal training with motivational interviewing: A guide for physical trainers. J Sci
Med Sport. 18(suppl 1):e115.
2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.
Exercise Training for Depression
Nutt D, Demyttenaere K, Janka Z, Aarre T, Bourin M, Canonico PL, Carrasco JL,
Stahl S (2007) The other face of depression, reduced positive affect: The role of
catecholamines in causation and cure. J Psychopharmacol. 21:461471.
Nystrm MBT, Neely G, Hassmn P, Carlbring P (2015) Treating major depression
with physical activity: A systematic overview with recommendations. Cogn Behav
Ther. 44:341352.
Okumura Y, Ichikura K (2014) Efficacy and acceptability of group cognitive behav-
ioral therapy for depression: A systematic review and meta-analysis. J Affect
Disord. 164:155164.
Puetz TW, O'Connor PJ, Dishman RK (2006) Effects of chronic exercise on feelings of
energy and fatigue: A quantitative synthesis. Psychol Bull. 132:866876.
Quilty LC, Zhang KA, Bagby RM (2010) The latent symptom structure of the Beck
Depression InventoryII in outpatients with major depression. Psychol Assess.
22603608.
Ridker PM, Rifai N, Stampfer MJ, Hennekens CH (2000) Plasma concentration of
interleukin-6 and the risk of future myocardial infarction among apparently
healthy men. Circulation. 101:17671772.
Rimer J, Dwan K, Lawlor DA, Greig CA, McMurdo M, Morley W, Mead GE (2012)
Exercise for depression. Cochrane Database Syst Rev. 7:CD004366.
Robins RW, Hendin HM, Trzesniewski KH (2001) Measuring global self-esteem:
Construct validation of a single-item measure and the Rosenberg Self-Esteem
Scale. Pers Soc Psychol Bull. 27:151161.
Rodgers S, Grosse Holtforth M, Mller M, Hengartner MP, Rssler W, Ajdacic-Gross
V (2014) Symptom-based subtypes of depression and their psychosocial corre-
lates: A person-centered approach focusing on the influence of sex. J Affect
Disord. 156:92103.
Santos RV, Tufik S, De Mello MT (2007) Exercise, sleep and cytokines: Is there a re-
lation? Sleep Med Rev. 11:231239.
Schuch FB, Vancampfort D, Richards J, Rosenbaum S, Ward PB, Stubbs B (2016) Ex-
ercise as a treatment for depression: A meta-analysis adjusting for publication bias.
J Psychiatr Res. 77:4251.
Shafer AB (2006) Meta-analysis of the factor structures of four depression question-
naires: Beck, CES-D, Hamilton, and Zung. J Clin Psychol. 62:123146.
Sherwood C, Salkovskis PM, Rimes KA (2007) Help-seeking for depression: The role
of beliefs, attitudes and mood. Behav Cogn Psychother. 35:541544.
Sigwalt AR, Budde H, Helmich I, Glaser V, Ghisoni K, Lanza S, Cadore EL, Lhullier
FL, de Bem AF, Hohl A, de Matos FJ, de Oliveira PA, Prediger RD, Guglielmo
LG, Latini A (2011) Molecular aspects involved in swimming exercise training re-
ducing anhedonia in a rat model of depression. Neuroscience. 192:661674.
Stanton R, Reaburn P (2014) Exercise and the treatment of depression: A review of the
exercise program variables. J Sci Med Sport. 17:177182.
Stewart JG, Harkness KL (2012) Symptom specificity in the acute treatment of Major
Depressive Disorder: A re-analysis of the treatment of depression collaborative re-
search program. J Affect Disord. 137:8797.
Strong DR, Uebelacker L, Schonbrun YC, Durst A, Saritelli J, Fokas K, Abrantes A,
Brown RA, Miller I, Apodaca TR (2012) Development of a brief motivational in-
tervention to facilitate engagement of smoking cessation treatment among inpa-
tient depressed smokers. J Smoking Cessation. 7:411.
Stubbs B, Vancampfort D, Rosenbaum S, Ward PB, Richards J, Soundy A, Veronese
N, Solmi M, Schuch FB (2016) Dropout from exercise randomized controlled
trials among people with depression: A meta-analysis and meta regression.
J Affect Disord. 190:457466.
Toups MS, Greer TL, Kurian BT, Grannemann BD, Carmody TJ, Huebinger R,
Rethorst C, Trivedi MH (2011) Effects of serum Brain Derived Neurotrophic Fac-
tor on exercise augmentation treatment of depression. J Psychiatr Res. 45:
13011306.
White K, Kendrick T, Yardley L (2009) Change in self-esteem, self-efficacy and the
mood dimensions of depression as potential mediators of the physical activity
and depression relationship: Exploring the temporal relation of change. Ment
Health and Phys Act. 2:4452.
www.jonmd.com 655