Exercise and internet-based cognitive-behavioural therapy for depression: multicentre randomised controlled trial with 12-month follow-up.
Evidence-based treatment of depression continues to grow, but successful treatment and maintenance of treatment response remains limited.



To compare the effectiveness of exercise, internet-based cognitive-behavioural therapy (ICBT) and usual care for depression.



A multicentre, three-group parallel, randomised controlled trial was conducted with assessment at 3 months (post-treatment) and 12 months (primary end-point). Outcome assessors were masked to group allocation. Computer-generated allocation was performed externally in blocks of 36 and the ratio of participants per group was 1:1:1. In total, 945 adults with mild to moderate depression aged 18-71 years were recruited from primary healthcare centres located throughout Sweden. Participants were randomly assigned to one of three 12-week interventions: supervised group exercise, clinician-supported ICBT or usual care by a physician. The primary outcome was depression severity assessed by the Montgomery-Åsberg Depression Rating Scale (MADRS).



The response rate at 12-month follow-up was 84%. Depression severity reduced significantly in all three treatment groups in a quadratic trend over time. Mean differences in MADRS score at 12 months were 12.1 (ICBT), 11.4 (exercise) and 9.7 (usual care). At the primary end-point the group × time interaction was significant for both exercise and ICBT. Effect sizes for both interventions were small to moderate.



The long-term treatment effects reported here suggest that prescribed exercise and clinician-supported ICBT should be considered for the treatment of mild to moderate depression in adults.
Mats Hallgren, PhD, Division of Epidemiology and Public Health Intervention Research (EPHIR), Department of Public Health Sciences, Karolinska Institute; Björg Helgadóttir, MSc, Department of Public Health Sciences, Karolinska Institute, Solna, Sweden; Matthew P. Herring, PhD, Department of Physical Education and Sport Sciences, and Health Research Institute, University of Limerick, Ireland; Zangin Zeebari, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden; Nils Lindefors, MD, PhD, Viktor Kaldo, PhD, Department of Clinical Neuroscience, Karolinska Institute, Huddinge, Sweden; AgnetaÖjehagen, PhD, Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden; Yvonne Forsell, MD, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden Mats.hallgren@ki.se.
Mats
M
Hallgren
Mats Hallgren, PhD, Division of Epidemiology and Public Health Intervention Research (EPHIR), Department of Public Health Sciences, Karolinska Institute; Björg Helgadóttir, MSc, Department of Public Health Sciences, Karolinska Institute, Solna, Sweden; Matthew P. Herring, PhD, Department of Physical Education and Sport Sciences, and Health Research Institute, University of Limerick, Ireland; Zangin Zeebari, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden; Nils Lindefors, MD, PhD, Viktor Kaldo, PhD, Department of Clinical Neuroscience, Karolinska Institute, Huddinge, Sweden; AgnetaÖjehagen, PhD, Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden; Yvonne Forsell, MD, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden.
Björg
B
Helgadóttir
Mats Hallgren, PhD, Division of Epidemiology and Public Health Intervention Research (EPHIR), Department of Public Health Sciences, Karolinska Institute; Björg Helgadóttir, MSc, Department of Public Health Sciences, Karolinska Institute, Solna, Sweden; Matthew P. Herring, PhD, Department of Physical Education and Sport Sciences, and Health Research Institute, University of Limerick, Ireland; Zangin Zeebari, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden; Nils Lindefors, MD, PhD, Viktor Kaldo, PhD, Department of Clinical Neuroscience, Karolinska Institute, Huddinge, Sweden; AgnetaÖjehagen, PhD, Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden; Yvonne Forsell, MD, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden.
Matthew P
MP
Herring
Mats Hallgren, PhD, Division of Epidemiology and Public Health Intervention Research (EPHIR), Department of Public Health Sciences, Karolinska Institute; Björg Helgadóttir, MSc, Department of Public Health Sciences, Karolinska Institute, Solna, Sweden; Matthew P. Herring, PhD, Department of Physical Education and Sport Sciences, and Health Research Institute, University of Limerick, Ireland; Zangin Zeebari, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden; Nils Lindefors, MD, PhD, Viktor Kaldo, PhD, Department of Clinical Neuroscience, Karolinska Institute, Huddinge, Sweden; AgnetaÖjehagen, PhD, Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden; Yvonne Forsell, MD, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden.
Zangin
Z
Zeebari
Mats Hallgren, PhD, Division of Epidemiology and Public Health Intervention Research (EPHIR), Department of Public Health Sciences, Karolinska Institute; Björg Helgadóttir, MSc, Department of Public Health Sciences, Karolinska Institute, Solna, Sweden; Matthew P. Herring, PhD, Department of Physical Education and Sport Sciences, and Health Research Institute, University of Limerick, Ireland; Zangin Zeebari, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden; Nils Lindefors, MD, PhD, Viktor Kaldo, PhD, Department of Clinical Neuroscience, Karolinska Institute, Huddinge, Sweden; AgnetaÖjehagen, PhD, Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden; Yvonne Forsell, MD, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden.
Nils
N
Lindefors
Mats Hallgren, PhD, Division of Epidemiology and Public Health Intervention Research (EPHIR), Department of Public Health Sciences, Karolinska Institute; Björg Helgadóttir, MSc, Department of Public Health Sciences, Karolinska Institute, Solna, Sweden; Matthew P. Herring, PhD, Department of Physical Education and Sport Sciences, and Health Research Institute, University of Limerick, Ireland; Zangin Zeebari, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden; Nils Lindefors, MD, PhD, Viktor Kaldo, PhD, Department of Clinical Neuroscience, Karolinska Institute, Huddinge, Sweden; AgnetaÖjehagen, PhD, Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden; Yvonne Forsell, MD, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden.
Viktor
V
Kaldo
Mats Hallgren, PhD, Division of Epidemiology and Public Health Intervention Research (EPHIR), Department of Public Health Sciences, Karolinska Institute; Björg Helgadóttir, MSc, Department of Public Health Sciences, Karolinska Institute, Solna, Sweden; Matthew P. Herring, PhD, Department of Physical Education and Sport Sciences, and Health Research Institute, University of Limerick, Ireland; Zangin Zeebari, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden; Nils Lindefors, MD, PhD, Viktor Kaldo, PhD, Department of Clinical Neuroscience, Karolinska Institute, Huddinge, Sweden; AgnetaÖjehagen, PhD, Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden; Yvonne Forsell, MD, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden.
Agneta
A
Öjehagen
Mats Hallgren, PhD, Division of Epidemiology and Public Health Intervention Research (EPHIR), Department of Public Health Sciences, Karolinska Institute; Björg Helgadóttir, MSc, Department of Public Health Sciences, Karolinska Institute, Solna, Sweden; Matthew P. Herring, PhD, Department of Physical Education and Sport Sciences, and Health Research Institute, University of Limerick, Ireland; Zangin Zeebari, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden; Nils Lindefors, MD, PhD, Viktor Kaldo, PhD, Department of Clinical Neuroscience, Karolinska Institute, Huddinge, Sweden; AgnetaÖjehagen, PhD, Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden; Yvonne Forsell, MD, PhD, Department of Public Health Sciences, EPHIR, Karolinska Institute, Solna, Sweden.
Yvonne
Y
Forsell
D000293:Adolescent; D000328:Adult; D000368:Aged; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003863:Depression / Q000628:therapy*; D005081:Exercise Therapy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D020407:Internet; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012720:Severity of Illness Index; D055815:Young Adult