# Exercise as a treatment for anxiety symptoms

This is a critique of Effects of exercise on symptoms of anxiety in primary care patients: A randomized controlled trial produced by Henriksson et al. (2022) and published in the Journal of Affective Disorders.

## What is the background to this research?

Self reports of nervousness or anxiety in the Swedish population has grown from 31% to 42% over the last ten years, while young adults in Sweden are the most at risk of depression compared to other Europeans. Current treatments for these psychological maladies (e.g., cognitive behaviour therapy, medications) are associated with treatment resistance, reactions to medication and poor medication adherence as well as long wait times for CBT. Exercise has increasingly been suggested as a potential treatment of anxiety and depression symptoms, however previous research has yielded mixed results. Exercise was reported as effective in treating symptoms of depression, while other meta-analyses have found mixed results among research and still other studies were let down by poor experimental design. Given the prevalence of these mental health issues, variability in effectiveness of existing treatments and varied results in existing research, Henriksson et al. set out to investigate to what extent exercise might alleviate the symptoms of both anxiety and depression.

## Where is the research from?

This research was a collaboration between people from the University of Gothenburg, Sahlgrenska University Hospital and Angered Hospital of Sweden and Universitätsmedizin Berlin. The primary author, Malin Henriksson, has contributed to other published articles covering anxiety, cognitive ability, mental disorders, affective disorders and cardiovascular fitness. All research and publication processes were carried out by the authors, independent of the financial sponsors including: the Swedish government, county councils, the ALF-agreement (a regulation authority for the provision of medical education and research) and the Region Västra Götland.

## What kind of research was this?

To examine the effect exercise has on anxiety and depressive symptoms of primary care patients, a random, parallel controlled superiority clinical intervention was used. Randomised control trials are considered the best level of evidence which can be used in concert with other evidence to inform clinical practice. To reduce bias in the results, double-blinding was employed.

## What did the research involve?

Participants were recruited between May 2017 and March 2020, through six primary care facilities, where they had presented to seek help with anxiety and depressive symptoms. Patients between the ages 18 and 65 underwent an initial psychiatric interview asper the Mini International Neuropsychiatric Interview (Swedish version). Those who received a diagnosis of panic syndrome, generalised anxiety, mixed anxiety, depression or non-specific anxiety, 365 people, were offered the opportunity to take part in the study.
Treatment groups were prescribed individualised exercise regimens by a physiotherapist. After a 10 minute warm up, participants engaged in two laps of a circuit, with 45 seconds at each of the12 stations, and 15 seconds break/travel between each finishing off with 5 to 10 minutes cool down. Cardiorespiratory exercises included step-ups, lunges, jump rope, burpees, step touches side-to-side and step touches using a step board. Resistance exercises were squats, prone planks, hip lifts, crunches, row-exercises and push-ups.
Intervention Groups, Treatments and Measurements :
| | | | Measurement Time-frame | Measurement Time-frame | Measurement Time-frame |
| Computer randomised and allocated to groups 1:1:1 n= 223 | Intervention Group | Protocol | Baseline | 12-week Post Intervention | One-year Follow-up |
| Computer randomised and allocated to groups 1:1:1 n= 223 | Low intensity training group n= 48 | 1.5-2.9 METs RPE 10-14 40%-59% HRmax | Mini International Neuropsychiatric Interview Beck Anxiety Inventory (BAI) Montgomery-Asperg Depression Rating Scale (MADRS) Psychoactive Drugs Questionnaire Alcohol Use Disorders Identification Test EuroQol-5 Dimension Questionnaire (EQ-5D) Sick Leave Questionnaire Blood pressure (mmHg) BMI (kg/m²) Weschler Adult Intelligence Scale 4th edition Delis-Kaplan executive Functioning System Åstrand ergometer test (VO2max) Hormones/cytokine blood sampling (S-IGF-1, S-BDNF. S-VEGF, CRP) Muscle strength (single leg 45cm chair rises) | Mini International Neuropsychiatric Interview Beck Anxiety Inventory (BAI) Montgomery-Asperg Depression Rating Scale (MADRS) Psychoactive Drugs Questionnaire Alcohol Use Disorders Identification Test EuroQol-5 Dimension Questionnaire (EQ-5D) Sick Leave Questionnaire Blood pressure (mmHg) BMI (kg/m²) Weschler Adult Intelligence Scale 4th edition Delis-Kaplan executive Functioning System Åstrand ergometer test (VO2max) Hormones/cytokine blood sampling (S-IGF-1, S-BDNF. S-VEGF, CRP) Muscle strength (single leg 45cm chair rises) | Mini International Neuropsychiatric Interview Beck Anxiety Inventory (BAI) Montgomery-Asperg Depression Rating Scale (MADRS) Psychoactive Drugs Questionnaire Alcohol Use Disorders Identification Test EuroQol-5 Dimension Questionnaire (EQ-5D) Sick Leave Questionnaire Blood pressure (mmHg) BMI (kg/m²) Weschler Adult Intelligence Scale 4th edition Delis-Kaplan executive Functioning System Åstrand ergometer test (VO2max) Hormones/cytokine blood sampling (S-IGF-1, S-BDNF. S-VEGF, CRP) Muscle strength (single leg 45cm chair rises) |
| Computer randomised and allocated to groups 1:1:1 n= 223 | Moderate-high intensity training group n= 53 | 3-8.99 METs RPE 12-17 60%-90% HRmax | Mini International Neuropsychiatric Interview Beck Anxiety Inventory (BAI) Montgomery-Asperg Depression Rating Scale (MADRS) Psychoactive Drugs Questionnaire Alcohol Use Disorders Identification Test EuroQol-5 Dimension Questionnaire (EQ-5D) Sick Leave Questionnaire Blood pressure (mmHg) BMI (kg/m²) Weschler Adult Intelligence Scale 4th edition Delis-Kaplan executive Functioning System Åstrand ergometer test (VO2max) Hormones/cytokine blood sampling (S-IGF-1, S-BDNF. S-VEGF, CRP) Muscle strength (single leg 45cm chair rises) | Mini International Neuropsychiatric Interview Beck Anxiety Inventory (BAI) Montgomery-Asperg Depression Rating Scale (MADRS) Psychoactive Drugs Questionnaire Alcohol Use Disorders Identification Test EuroQol-5 Dimension Questionnaire (EQ-5D) Sick Leave Questionnaire Blood pressure (mmHg) BMI (kg/m²) Weschler Adult Intelligence Scale 4th edition Delis-Kaplan executive Functioning System Åstrand ergometer test (VO2max) Hormones/cytokine blood sampling (S-IGF-1, S-BDNF. S-VEGF, CRP) Muscle strength (single leg 45cm chair rises) | Mini International Neuropsychiatric Interview Beck Anxiety Inventory (BAI) Montgomery-Asperg Depression Rating Scale (MADRS) Psychoactive Drugs Questionnaire Alcohol Use Disorders Identification Test EuroQol-5 Dimension Questionnaire (EQ-5D) Sick Leave Questionnaire Blood pressure (mmHg) BMI (kg/m²) Weschler Adult Intelligence Scale 4th edition Delis-Kaplan executive Functioning System Åstrand ergometer test (VO2max) Hormones/cytokine blood sampling (S-IGF-1, S-BDNF. S-VEGF, CRP) Muscle strength (single leg 45cm chair rises) |
| Computer randomised and allocated to groups 1:1:1 n= 223 | Control, non-exercise group n= 52 | One physiotherapist consultation Three month gym pass post-intervention | Mini International Neuropsychiatric Interview Beck Anxiety Inventory (BAI) Montgomery-Asperg Depression Rating Scale (MADRS) Psychoactive Drugs Questionnaire Alcohol Use Disorders Identification Test EuroQol-5 Dimension Questionnaire (EQ-5D) Sick Leave Questionnaire Blood pressure (mmHg) BMI (kg/m²) Weschler Adult Intelligence Scale 4th edition Delis-Kaplan executive Functioning System Åstrand ergometer test (VO2max) Hormones/cytokine blood sampling (S-IGF-1, S-BDNF. S-VEGF, CRP) Muscle strength (single leg 45cm chair rises) | Mini International Neuropsychiatric Interview Beck Anxiety Inventory (BAI) Montgomery-Asperg Depression Rating Scale (MADRS) Psychoactive Drugs Questionnaire Alcohol Use Disorders Identification Test EuroQol-5 Dimension Questionnaire (EQ-5D) Sick Leave Questionnaire Blood pressure (mmHg) BMI (kg/m²) Weschler Adult Intelligence Scale 4th edition Delis-Kaplan executive Functioning System Åstrand ergometer test (VO2max) Hormones/cytokine blood sampling (S-IGF-1, S-BDNF. S-VEGF, CRP) Muscle strength (single leg 45cm chair rises) | Mini International Neuropsychiatric Interview Beck Anxiety Inventory (BAI) Montgomery-Asperg Depression Rating Scale (MADRS) Psychoactive Drugs Questionnaire Alcohol Use Disorders Identification Test EuroQol-5 Dimension Questionnaire (EQ-5D) Sick Leave Questionnaire Blood pressure (mmHg) BMI (kg/m²) Weschler Adult Intelligence Scale 4th edition Delis-Kaplan executive Functioning System Åstrand ergometer test (VO2max) Hormones/cytokine blood sampling (S-IGF-1, S-BDNF. S-VEGF, CRP) Muscle strength (single leg 45cm chair rises) |

## What were the basic results?

Compared to the control group, both exercise groups displayed significant reduction in anxiety symptoms from initial assessments. While the control group showed reductions in symptoms, the exercise groups showed a significantly greater mean reduction in symptoms, corresponding to five points on the BAI. All groups also showed reductions in depression scores on the MADRS, however, the exercise groups show a significantly greater reduction in depressive symptoms compared to the control group.
The researchers concluded that exercise is an effective treatment for reducing symptoms of anxiety, however there were no indication of any important differences between low-intensity or moderate-high intensity exercise.

## What conclusions can we take from this research?

Despite two adverse events during the intervention (a participant developed symptoms of fatigue and exhaustion disorder, screening of which was included in all subsequent screenings; a separate participant herniated their L5-S1 disc shortly after a training session which was found to be unrelated to the research), both low- and moderate/high-intensity exercise are presented as efficacious treatments for the symptoms of not only anxiety, but also depression in those who are not already exercising regularly.
The researchers acknowledge the lack of dose response may have been due to the fact that participants, who had dealt with symptoms long term and had no established exercise routine, would probably have responded to any level of exercise, explaining why the low-intensity protocol was also able to show benefits. However, earlier evidence suggests there are variations in treatment response depending on exercise intensity and mode, such that aerobic exercise may not relieve anxiety symptoms and resistance training can provide small to moderate improvements in anxiety symptoms. A future line of enquiry might look into the role of endorphins in reducing anxiety symptoms, as high intensity interval training has been associated with endogenous opioid release, affecting brain regions responsible for pain, mood and affective (mood) states, and may offer an alternative explanation for symptom relief.
Because neither cardiorespiratory fitness (VO2max) nor muscle strength were associated with improvements in symptoms, the researchers suggested that the intrinsic social support provide by other participants and the physiotherapist may account for the changes. Or, an increase of circulating insulin-like growth factor 1, which is associated with neuro-plasticity could explain the improvements in symptomatology.
The use of self-reports, which, in the case of depression, have been reported to under-estimate patients true experience, suggests this study may not give a clear indication of the effects of exercise.

## Practical advice

Due to its affordability and ability to improve multiple domains of health, exercise and physical activity is highly recommended. While small lifestyle changes, such walking to the shops or cycling to work, are easily implemented, engaging in a 12-week exercise program may need deeper consideration.
If you have not engaged in regular physical activity recently, or have health concerns that may make taking up exercise difficult you may want to consult a physician or accredited exercise professional before attempting higher intensities of exercise.
To find an accredited exercise professional in Australia, visit the Exercise and Sport Science Australia website: essa.org.au/find-aep/
If you are looking to use exercise to treat anxiety or depression, consult a Psychologist by visiting the Australian Psychological Society website: https://psychology.org.au/find-a-psychologist

## Further information/resources

* To read more about the benefits of exercise visit Health Direct at: https://www.healthdirect.gov.au/exercise-and-mental-health
If you require support now you can call:
* Lifeline. Phone: 13 11 14
* Beyond Blue. Phone: 1300 22 4636

## References

* ↑ Henriksson, M., Wall, A., Nyberg, J., Adiels, M., Lundin, K., Bergh, Y., Eggertsen, R., Danielsson, L., Kuhn, H. G., Westerlund, M., David Åberg, N., Waern, M., & Åberg, M. (2022). Effects of exercise on symptoms of anxiety in primary care patients: A randomized controlled trial. Journal of Affective Disorders, 297, 26–34.
* ↑ Folkhälsomyndigheten: Public Health Agency of Sweden (2022, February 10). Mental Health. https://www.folkhalsomyndigheten.se/the-public-health-agency-of-sweden/living-conditions-and-lifestyle/mental-health/#:~:text=Over%20the%20last%20decade%20self,percent%20are%20perceiving%20severe%20symptoms.
* ↑ Eurofound (2019). Inequalities in the access of young people to information and support services, Publications Office of the European Union, Luxembourg.
* ↑ Garakani, A., Murrough, J.W., Freire, R.C., Thom, R.P., Larkin, K., Buono, F.D., Iosifescu, D.V., 2020. Pharmacotherapy of anxiety disorders: current and emerging treatment options. Front. Psychiatry 11, 595584. https://doi.org/10.3389/ fpsyt.2020.595584.
* ↑ Ravindran, L.N., Stein, M.B., 2010. The pharmacologic treatment of anxiety disorders: a review of progress. J. Clin. Psychiatry 71, 839–854. https://doi.org/10.4088/ JCP.10r06218blu.
* ↑ Kvam, S., Kleppe, C.L., Nordhus, I.H., Hovland, A., 2016. Exercise as a treatment for depression: a meta-analysis. J. Affect. Disord. 202, 67–86. https://doi.org/10.1016/ j.jad.2016.03.063.
* ↑ Schuch, F.B., Vancampfort, D., Firth, J., Rosenbaum, S., Ward, P.B., Silva, E.S., Hallgren, M., Ponce De Leon, A., Dunn, A.L., Deslandes, A.C., Fleck, M.P., Carvalho, A.F., Stubbs, B., 2018. Physical activity and incident depression: a meta- analysis of prospective cohort studies. Am. J. Psychiatry 175, 631–648. https://doi. org/10.1176/appi.ajp.2018.17111194.
* ↑ Ashdown-Franks, G., Firth, J., Carney, R., Carvalho, A.F., Hallgren, M., Koyanagi, A., Rosenbaum, S., Schuch, F.B., Smith, L., Solmi, M., Vancampfort, D., Stubbs, B., 2020. Exercise as medicine for mental and substance use disorders: a meta-review of the benefits for neuropsychiatric and cognitive outcomes. Sports Med. 50, 151–170. https://doi.org/10.1007/s40279-019-01187-6.
* ↑ Aylett, E., Small, N., Bower, P., 2018. Exercise in the treatment of clinical anxiety in general practice - a systematic review and meta-analysis. BMC Health Serv. Res. 18, 559. https://doi.org/10.1186/s12913-018-3313-5.
* ↑ ResearchGate (date unknown) Malin Henriksson's research works | University of Gothenburg, Göteborg. Retrieved August 27, 2022, from https://www.researchgate.net/scientific-contributions/Malin-Henriksson-2097551779
* ↑ Hartvigsson, K. (2022). National and regional alf agreements. Retrieved August 27, 2022, from https://ki.se/en/about/national-and-regional-alf-agreements
* ↑ Nyberg, J., Henriksson, M., Åberg, N.D., Wall, A., Eggertsen, R., Westerlund, M., Danielsson, L., Kuhn, H.G., Waern, M., Åberg, M., 2019. Effects of exercise on symptoms of anxiety, cognitive ability and sick leave in patients with anxiety disorders in primary care: Study protocol for PHYSBI, a randomized controlled trial. BMC Psychiatry 19, 172. https://doi.org/10.1186/s12888-019-2169-5.
* ↑ Del Mar, C., Hoffman, T., Glaziou, P. (2013). Information needs, asking questions, and some basics of research studies. In editors.Hoffmann, T., Bennett, S., & Del, M. C. B. (Eds.) Evidence-based practice across the health professions - e-book.(pp 27-29). Elsevier Australia.
* ↑ Aylett, E., Small, N., & Bower, P. (2018). Exercise in the treatment of clinical anxiety in general practice - a systematic review and meta-analysis. BMC Health Services Research, 18(1), 559–559. https://doi.org/10.1186/s12913-018-3313-5
* ↑ Bartley, C. A., Hay, M., & Bloch, M. H. (2013). Meta-analysis: Aerobic exercise for the treatment of anxiety disorders. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 45, 34–39. https://doi.org/10.1016/j.pnpbp.2013.04.016
* ↑ Gordon, B. R., McDowell, C. P., Lyons, M., & Herring, M. P. (2017). The Effects of Resistance Exercise Training on Anxiety: A Meta-Analysis and Meta-Regression Analysis of Randomized Controlled Trials. Sports Medicine (Auckland), 47(12), 2521–2532. https://doi.org/10.1007/s40279-017-0769-0
* ↑ Saanijoki, T., Tuominen, L., Tuulari, J. J., Nummenmaa, L., Arponen, E., Kalliokoski, K., & Hirvonen, J. (2018). Opioid Release after High-Intensity Interval Training in Healthy Human Subjects. Neuropsychopharmacology (New York, N.Y.), 43(2), 246–254. https://doi.org/10.1038/npp.2017.148
* ↑ Hunt, M., Auriemma, J., & Cashaw, A. (2003) Self-Report Bias and Underreporting of Depression on the BDI-II. Journal of Personality Assessment, 80:1, 26-30, DOI: 10.1207/S15327752JPA8001_10