Exercise Referral and Depression Exercise Specialist

Exercise Referral and Depression

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You may have heard anecdotally that exercise is great for ‘boosting your mood’ and that it can be of benefit to people suffering from depression. But did you know that according to the National Institute for Health and Clinical Excellence (NICE) guidance depression is one of the conditions for which patients can be referred to exercise referral schemes?

For more background information about exercise referral schemes, see this article.

What is depression?

Diseases are classified using the ICD – this a diagnostic classification standard used by health professionals and also for research purposes.

The ICD (International Classification of Diseases) classification of depression includes having at least one of the following most days, most of the time for at least 2 weeks: persistent sadness or low mood, loss of interests or pleasure, fatigue or low energy. Other associated symptoms include disturbed sleep, poor concentration or indecisiveness, low self-confidence, poor or increased appetite, suicidal thoughts or acts, agitation or slowing of movements and guilt or self-blame.

Health in depression

According to Mind, one of the leading charities for mental illness in the UK, people with mental health problems are more likely to have a poor diet, smoke or drink excessively and be overweight or obese, which can be a direct side effect of some of the drugs used to treat mental health problems.

People with mental illness are two times more likely to die of heart disease and four times more likely to die of a respiratory disease. For these reasons, the health benefits of increased physical activity for people with mental illness are even more significant compared to the general population.


It is also important to consider that there is an increased prevalence of depression and anxiety among people with other chronic health conditions, which can become so debilitating that it can become more life-limiting than the initial health problem itself.

How exercise can help

Mind state that physical activity can have a number of benefits on mental health including reduced anxiety and happier moods, reduced feelings of stress, clearer thinking, a greater sense of calm and increased self-esteem.

A recent randomised controlled trial published last month examined the levels of a substance in the brain known as ‘brain derived neurotropic factor’ (BDNF), reduced levels of which have been implicated in the pathology of major depressive disorders. The small study (42 patients) had a control group who continued with their regular medication and treatment regimen and a study group who were given an exercise referral in addition to their existing treatment.

The study found that there was a significant increase in levels of BDNF in the group who were prescribed exercise in addition to their existing treatment. Although this study was small, it supports that physical activity is able to act on a known biochemical pathway that contributes to major depressive disorder.


The heterogeneous symptomatology of depression raises the issue that people may react very differently to treatments, medications and exercise plans. It shouldn’t be assumed that because a program has worked amazingly for one individual that it will have the same effects for all others.

From the study data, there are issues in identifying what the ‘optimal dose’ of exercise is as many of the trials measure this differently, ie. with time, energy expenditure, distance. However, some studies have noted that low-intensity exercise may be optimal for up-regulation of BDNF and stimulation of brain plasticity (changes within the brain itself).

Furthermore, one of the most important factors leading to BDNF up-regulation is actually how pleasant the exercise experience perceived as being. This is something to have at the forefront of your mind when drawing up a plan for an individual with depression.

According to the Department of Health “Start Active, Stay Active” report on physical activity for health by the Chief Medical Officers, there is clear evidence that physical activity reduced the risk of cognitive decline in adults and older adults and there is a moderate body of evidence to support that exercise can help to improve sleep, which can be a significant problem in people with depression.


When looking at the diagnostic criteria for depression above, it’s not difficult to notice that a lot of these symptoms may make physical activity more challenging and more demanding, this is something that fitness professionals should be mindful of when training a client with mental illness.

The issue of stigma

Patients with mental health conditions still to do this day face significant stigma from society. People with mental illness report that how others judge them is a significant barrier to them leading a fulfilling, complete and satisfying life. Time to Change found that nine out of ten people with mental illness reported stigma and discrimination that has had a negative impact on their lives.

Personal trainers can help reduce this stigma by educating themselves about mental illness. It is important to construct a gym environment that is welcoming and free from judgement and to approach each person as an individual with an understanding that what they are capable of achieving from one session to the next may fluctuate depending on their mood, how much sleep they are able to achieve and side effects of medication.


  • That there may be variation in how a person with depression can function day to day
  • What works for one person, may not work for another, there is a need to be flexible when making a plan
  • It is of uttermost important to find a type of exercise that the person genuinely enjoys.
  • To create a gym environment that is welcoming and free from stigma and judgement.

If you yourself have been struggling with low mood or other symptoms of depression or anxiety, make an appointment with your GP to talk, they are really well trained to help you and deal with mental illness on a daily basis. The biggest step can often be the first one to reach out for help.


I have compiled a list of excellent, reliable and credible resources to guide personal learning and development on the topic of depression and mental illness:

Mind UK – one of the UKs biggest mental health charities (http://www.mind.org.uk/information-support/a-z-mental-health/

Time to Change – a group that campaign to end mental health stigma – https://www.time-to-change.org.uk/

NHS Choices – mental health section (http://www.nhs.uk/livewell/mentalhealth/Pages/Mentalhealthhome.aspx)

Royal College of Psychiatrists – http://www.rcpsych.ac.uk/healthadvice/problemsdisorders.aspx

About the author

Jennifer Robinson is a London-based medical student who believes health, fitness and nutrition can come together to make us all healthier. She has a BSc in Biomedical Science and frequently writes articles and creates recipes on her personal website.


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