Depression

Depression leads to a persistent feeling of sadness and loss of interest. Clinical features include emptiness, low mood, and irritability. Along with changes in body and mind, this can severely impair functioning and, in the worst cases, lead to suicide¹. Due to misconceptions, nearly 60% of individuals with depression do not seek medical help². The condition is characterized by frequent relapses and remissions, often resulting in poor quality of life. Early diagnosis and proper intervention are essential to reduce long-term effects and improve quality of life.

Etiology

The causes of depression are multifactorial and include genetic, social, lifestyle-related, and environmental factors²⁴.

• First-degree relatives of individuals with depression have a threefold increased risk of developing depression themselves.

• Neurodegenerative diseases such as Alzheimer’s and Parkinson’s disease, as well as stroke, MS, epilepsy, cancer, macular degeneration, and chronic pain are associated with increased risk of depression.

• Life events and stress factors often act as triggers.– Prolonged exposure to violence, neglect, abuse, and poverty increases vulnerability to depression⁵.

• Traumatic events such as bereavement, grief, social isolation, financial problems, or caregiving burden are also major risk factors².

Epidemiology

Depression is a widespread disorder affecting more than 264 million people globally¹. The one-year prevalence is about 7%, but varies significantly with age.

• Prevalence among individuals aged 18–29 is three times higher than in those over 60².

• Women have 1.5–3 times higher prevalence than men, beginning as early as adolescence².

• Nearly 800,000 people die annually from suicide, which is the second leading cause of death among 15–29-year-olds¹.

Symptoms

Depression causes loss of interest and pleasure in activities, along with emotional and physical symptoms that affect work and social functioning. The symptom profile ranges from mild to severe and includes⁵:

• Persistent sadness or low mood

• Lack of interest in previously enjoyable activities

• Changes in appetite (weight loss or gain)

• Sleep disturbances or hypersomnia

• Loss of energy or fatigue

• Psychomotor agitation or retardation

• Feelings of worthlessness or guilt

• Difficulty concentrating and indecisiveness

• Suicidal thoughts or plans

For diagnosis, symptoms must last at least two weeks and represent a functional change.

Classification

According to DSM-5, depressive disorders are categorized as follows²:

• Disruptive mood dysregulation disorder

• Major depressive disorder

• Persistent depressive disorder (dysthymia)

• Premenstrual dysphoric disorder

• Depressive disorder due to another medical condition

All of these share common features: low mood, emptiness, or irritability, combined with somatic and cognitive symptoms that impair functioning.

Treatment

Treatment options must be tailored to severity, availability, and patient preferences. The main approaches are:

1. Pharmacological treatment

• SSRIs (Selective Serotonin Reuptake Inhibitors) and TCAs (Tricyclic Antidepressants) are most often used in moderate to severe depression¹.

• Antidepressants are not recommended as first-line treatment for mild depression, and should be used with caution in children and adolescents.

2. Non-pharmacological / psychosocial interventionsEffective in mild depression and as support in more severe cases:

• Cognitive behavioral therapy (CBT)

• Problem-solving therapy (PST)

• Physical activity

• Increased social contact

Physiotherapy in depression

One of the most important roles of a physiotherapist is to be attentive to the signs and symptoms of depression, as well as to conditions that often co-occur with it. If the therapist is sensitive to this, it can be documented in the treatment plan, and the physician can be notified so that the patient receives necessary medical follow-up when needed. When working with patients who are emotionally unstable, it may be crucial to recognize the signals and adapt communication and activities accordingly – with the goal of promoting coping and motivation.

Physiotherapeutic management of depression is based on a holistic approach combining physical activity, psychological support, and patient education⁶. Physical activity has been shown to positively affect mood and mental health by increasing the release of endorphins – the body’s own “happiness hormones”⁷. This makes exercise an important complementary intervention in depression⁶.

Exercise recommendations and adaptations

Exercise recommendations and adaptations

The American College of Sports Medicine recommends a minimum of 150 minutes of moderate-intensity aerobic exercise per week, in addition to strength training twice a week⁸. It is important that activities are enjoyable and sustainable, such as walking, cycling, swimming, or dancing. Studies have shown that regular physical activity can reduce depressive symptoms and improve mental well-being⁹.

Clinical interventions and methods

Physiotherapists can implement a range of adaptations in treatment:

• Relaxation and breathing exercises

• Mindfulness-based interventions

• Patient-tailored exercise guidance⁶

Such approaches can help reduce stress and improve mental health. Physiotherapists may also collaborate with psychologists, general practitioners, or occupational therapists to ensure a comprehensive and multidisciplinary approach. This increases treatment effectiveness by addressing both physical and psychological aspects.

Support, motivation, and education

Physiotherapists also play an important role as supporters. By establishing a safe and positive therapeutic relationship, conditions for treatment motivation and change are strengthened. Patient education on the effects of physical activity and strategies for self-management enables patients to take an active role in their recovery – contributing to long-term improvements in mental health.

Complementary approaches with documented effect

Physiotherapists can also apply principles from:

• Mindfulness¹⁰

• Cognitive behavioral therapy (CBT)¹¹¹²

• Norwegian psychomotor physiotherapy (NPF)¹³

These approaches can be integrated into clinical practice and provide additional reduction in depressive symptoms.

Differential diagnoses in depression (conditions to be considered and excluded):

• Anemia

• Chronic fatigue syndrome

• Dissociative disorders

• Illness anxiety disorder

• Hypoglycemia

• Schizophrenia

• Somatic symptom disorders²

Type of exercise and why it matters

Recent research shows that the type, intensity, and duration of exercise determine how effective it is against depression¹⁴. For example:

• Walking and strength training have shown equal effectiveness in improving depressive symptoms.

• In cirrhosis, high-intensity interval training (HIIT) is necessary to achieve measurable health effects.

HIIT consists of alternating high and low intensity – such as running and walking – and has shown particularly strong effects on both physical capacity and mental health¹⁴.

Secondary depression

About 40% of all cases of depression are secondary to another disease¹⁵. This means that depression arises as a result of living with a serious or limiting condition. Examples include:

• Stroke (speech difficulties, hemiparesis, emotional changes)

• Heart disease, COPD, rheumatic disorders

• Cancer diagnoses and orthopedic conditions

Here, exercise can be used both to improve physical function and to reduce depressive symptoms – providing a double treatment benefit¹⁵.

Specific examples from research

• In coronary artery disease, strength training provides greater symptom improvement than aerobic training alone¹⁶.

• In breast cancer patients, exercise reduces mortality by 41%, and in prostate cancer patients by as much as 61% with at least three hours of exercise per week¹⁶.

This demonstrates that tailored exercise selection increases both survival and mental health – and should always be considered as part of physiotherapy management.

Safety and stress testing

In serious somatic conditions, such as heart disease or advanced COPD, it is important to perform a stress test before starting training to determine safe intensity¹⁷. If the medical team has set a maximum heart rate limit, the patient must stay below it during activity.

Training should be divided into realistic goals with gradual increases over weeks and months. Example: The first goal is to walk 10 minutes without a break, and eventually to resume leisure activities that bring joy and social contact¹⁷.

Available programs and referrals

In Norway, patients can be referred free of charge to cardiac or pulmonary rehabilitation through their general practitioner. These programs include tailored exercise interventions for both physical and psychological improvement. Private clinics also offer medical exercise and depression-focused rehabilitation⁷.

References

1. WHO. Depression. Available from: https://www.who.int/news-room/fact-sheets/detail/depression (accessed 05.07.2025).

2. Chand SP, Arif H. Depression. [Updated July 26, 2021]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430847/ (accessed 05.07.2025).

3. Therapist Aid. What is Depression? Available from: https://www.youtube.com/watch?v=fWFuQR_Wt4M (accessed 05.07.2025).

4. Better Health. Depression. Available from: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/depression (accessed 05.07.2025).

5. American Psychiatric Association. Depression. Available from: https://www.psychiatry.org/patients-families/depression/what-is-depression (accessed 05.07.2025).

6. Probst M. Physiotherapy and mental health. Clinical Physical Therapy. 2017 May 31;230:59–68.

7. Drannan JD. The relationship between physical exercise and job performance: the mediating effects of subjective health and good mood (Doctoral thesis, Bangkok University).

8. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PD, Bauman A. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1081.

9. Zhao JL, Jiang WT, Wang X, Cai ZD, Liu ZH, Liu GR. Exercise, brain plasticity, and depression. CNS Neurosci Ther. 2020 Sep;26(9):885–95.

10. Goodman CC, Fuller KS. The psychological spiritual impact on health care. In: Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis: Saunders Elsevier; 2009. p. 110–115.

11. Centers for Disease Control and Prevention. Anxiety and Depression. CDC Features. March 13, 2009. Available from: http://www.cdc.gov/Features/dsBRFSS Depression Anxiety/ (accessed 05.07.2025).

12. Goodman CC, Snyder TK. Pain types and viscerogenic pain patterns. In: Differential Diagnosis for Physical Therapists: Screening for Referral. 4th ed. St. Louis: Saunders Elsevier; 2007. p. 153–157.

13. Jacobsen LN, Lassen IS, Friis P, Videbech P, Licht RW. Bodily symptoms in moderate and severe depression. Nord J Psychiatry. 2006;60(4):294–8.

14. Zhang S, Xiang K, Li S, Pan HF. Physical activity and depression in older adults: the knowns and unknowns. Psychiatry Res. 2021 Jan 18:113738. Available from: https://pubmed.ncbi.nlm.nih.gov/33515871/ (accessed 05.07.2025).

15. Harvey SB, Øverland S, Hatch SL, Wessely S, Mykletun A, Hotopf M. Exercise and the prevention of depression: results of the HUNT cohort study. Am J Psychiatry. 2018 Jan 1;175(1):28–36. Available from: https://pubmed.ncbi.nlm.nih.gov/28969440/ (accessed 05.07.2025).

16. van der Windt DJ, Sud V, Zhang H, Tsung A, Huang H. The effects of physical exercise on fatty liver disease. Gene Expr. 2018;18(2):89.

17. Clayton P, Lewis C. The significance of secondary depression. J Affect Disord. 1981;3:25–35.

18. Marzolini S, Oh PI, Brooks D. Effect of combined aerobic and resistance training versus aerobic training alone in individuals with coronary artery disease: a meta-analysis. Eur J Prev Cardiol. 2012 Feb 1;19(1):81–94.

19. Irwin ML, McTiernan A, Manson JE, Thomson CA, Sternfeld B, Stefanick ML, Wactawski-Wende J, Craft L, Lane D, Martin LW, Chlebowski R. Physical activity and survival in postmenopausal women with breast cancer: results from the Women's Health Initiative. Cancer Prev Res. 2011 Apr 1;4(4):522–9.

20. Craft LL, Perna FM. The benefits of exercise for the clinically depressed. Prim Care Companion J Clin Psychiatry. 2004;6(3):104.