Elsevier

Psychiatry Research

Volume 249, March 2017, Pages 102-108
Psychiatry Research

Review article
An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis

https://doi.org/10.1016/j.psychres.2016.12.020Get rights and content

Highlights

  • Previous literature regarding the benefits of exercise for anxiety/ stress disorders is equivocal.

  • Our data suggest that exercise is more effective than control at reducing anxiety symptoms.

  • Given its wider health benefits, exercise should be considered a strategy to improve the health of this population.

Abstract

The literature regarding exercise for people with established anxiety disorders is equivocal. To address this issue, we conducted a systematic review and meta-analysis investigating the benefits of exercise compared to usual treatment or control conditions in people with an anxiety and/or stress-related disorders. Major electronic databases were searched from inception until December/2015 and a random effect meta-analysis conducted. Altogether, six randomized control trials (RCTs) including 262 adults (exercise n=132, 34.74 [9.6] years; control n=130, 37.34 [10.0] years) were included. Exercise significantly decreased anxiety symptoms more than control conditions, with a moderate effect size (Standardized Mean Difference=−0.582, 95%CI −1.0 to −0.76, p=0.02). Our data suggest that exercise is effective in improving anxiety symptoms in people with a current diagnosis of anxiety and/ or stress-related disorders. Taken together with the wider benefits of exercise on wellbeing and cardiovascular health, these findings reinforce exercise as an important treatment option in people with anxiety/stress disorders.

Introduction

Anxiety disorders are pervasive mental health conditions and are currently the leading cause of global years lived with disability (Lopez et al., 2006, Baxter et al., 2014). Anxiety disorders (AD) such as generalized anxiety disorder (GAD), panic disorder (PD), and phobias, as well as closely related stress related disorders such as post-traumatic stress disorder (PTSD), are associated with a considerable range of deleterious impacts upon the individual, including lower quality of life (Mendlowicz and Stein, 2000), comorbid mental illness (Hofmeijer-Sevink et al., 2012) and elevated cardiovascular disease and associated premature mortality (Roest et al., 2012, Batelaan et al., 2016). Moreover, the societal and financial impacts are profound across the Western and Developing World (Chisholm et al., 2016).

Pharmacological agents such as selective serotonin reuptake inhibitors (SSRIs) and various forms of cognitive behavioral therapy (CBT) are the frontline treatments for people with anxiety/stress disorders (Hofmann and Smits, 2008, de Vries et al., 2016). Nevertheless, about a third of patients do not respond to SSRIs and CBT (Hofmann and Smits, 2008, de Vries et al., 2016). In addition, availability of those treatment options is scarce in developing world. In some stances, waiting times for psychotherapy can be lengthy (up to 12 months), resulting in a poor prognosis and more entrenched symptoms.

Exercise might be an alternative for subjects with AD unwilling to initiate medication or psychotherapy, or for subjects from regions where frontline resources are unavailable. There is evidence showing exercise can improve anxiety symptoms in people without established anxiety disorders (Conn, 2010, Herring et al., 2014, Rebar et al., 2015), including those with general chronic illness (Herring et al., 2010). However, the evidence for the anxiolytic effects of exercise in people with a diagnosis anxiety/stress disorders is equivocal and has considerable limitations. To date, one prior meta-analysis has investigated the potential benefits of exercise in people with a diagnosis of AD (Bartley et al., 2013) that concluded, that currently there is insufficient evidence to recommend aerobic exercise for their treatment. However, further investigation is now required due to more recent evidence (Gaudlitz et al., 2015, Powers et al., 2015, Rosenbaum et al., 2015) on the topic and methodological shortcomings with this prior analysis. First, exercise was compared to control conditions with established efficacy for anxiety such as mindfulness and non-aerobic physical activity, thus increasing the likelihood of a type II error. Second, no meta-regression investigated potential mediators despite the significant heterogeneity. Third, no trial with patients with anxiety/stress disorders such as PTSD was reviewed. Overall, the anxiolytic impact of exercise in comparison to usual treatment and the factors which may influence this impact, have yet to be examined. Given also the increased attention to the filed since the implementation of the above review, an update is essential.

We conducted a meta-analysis of exercise RCTs versus control conditions (including treatment as usual/ wait list/ TAU) among people with a diagnosis of an anxiety and/or a stress-related disorder. The specific aims of the current review were: (1) to evaluate the effects of exercise on anxiety symptoms in people with anxiety/stress disorders, (2) to identify moderators through meta-regression analyses, including sample characteristics (gender and age) and exercise intervention variables (length of the trial, frequency, dropout) that could impact the effects of exercise on anxiety symptoms; and (3) to evaluate the magnitude of the symptom reduction in control groups (control group response) of the included trials.

Section snippets

Methods

This systematic review is in line with the PRISMA statement (Moher et al., 2009) and the MOOSE guidelines (Stroup et al., 2000).

Search results

Following the removal of duplicates from the searches, 3999 entries were considered at the title and abstract level. From 62 full texts, six studies (Broocks et al., 1998, Herring et al., 2012, Gaudlitz et al., 2015, Powers et al., 2015, Rosenbaum et al., 2015) had met the inclusion criteria for the meta-analysis. A summary of the search results including reasons for exclusion are presented in Fig. 1.

Characteristics of included trials and participants

Across the 6 studies, 262 adults with anxiety/stress disorders were included, of whom 132 and

Discussion

Our data suggest that exercise should be considered an evidenced-based option for anxiety symptoms among people with anxiety/ stress related disorders. Specifically, when compared to control conditions, exercise has an effect size in the medium range. Whilst these findings suggest that exercise could be considered as an evidence-based treatment form for patients with anxiety disorders, one should note the limited number of reviewed trials (six). In addition, most of these trials were identified

Conclusion

In conclusion, our data suggests that exercise is seen as an effective intervention in improving anxiety symptoms in people with anxiety and stress-related disorders. However, the small number of trials should be considering in the interpretation of these results, and more high quality trials are required. Given the wider benefits of exercise on wellbeing and cardiovascular markers, we suggest that exercise should be considered an important treatment option among this population.

Declaration of interest

None to declare from any author.

Funding

This article received no specific funding.

Acknowledgement

We would like to thank Dr. Dafna Meron for sending us additional data.

References (58)

  • G.A. Alvares et al.

    Autonomic nervous system dysfunction in psychiatric disorders and the impact of psychotropic medications: a systematic review and meta-analysis

    J. Psychiatry Neurosci.: JPN

    (2016)
  • American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders – DSM-IV-TR, 4th...
  • G.J.G. Asmundson et al.

    Let's get physical: a contemporary review of the anxiolytic effects of exercise for anxiety and its disorders

    Depress. Anxiety

    (2013)
  • B. Bandelow et al.

    Efficacy of treatments for anxiety disorders: a meta-analysis

    Int. Clin. Psychopharmacol.

    (2015)
  • N.M. Batelaan et al.

    Anxiety and new onset of cardiovascular disease: critical review and meta-analysis

    Br. J. Psychiatry

    (2016)
  • A.J. Baxter et al.

    Challenging the myth of an "epidemic" of common mental disorders: trends in the global prevalence of anxiety and depression between 1990 and 2010

    Depress. Anxiety

    (2014)
  • C.B. Begg et al.

    Operating characteristics of a rank correlation test for publication bias

    Biometrics

    (1994)
  • C. Bridle et al.

    Effect of exercise on depression severity in older people: systematic review and meta-analysis of randomised controlled trials

    Br. J. Psychiatry

    (2012)
  • A. Broocks et al.

    Comparison of aerobic exercise, clomipramine, and placebo in the treatment of panic disorder

    Am. J. Psychiatry

    (1998)
  • B.M. Byllesby et al.

    An investigation of PTSD's core dimensions and relations with anxiety and depression

    Psychol. Trauma.: Theory, Res., Pract., Policy

    (2016)
  • C.J. Caspersen et al.

    Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research

    Public Health Rep.

    (1985)
  • B.E. Cohen et al.

    State of the Art Review: Depression, Stress, Anxiety, and cardiovascular disease

    Am. J. Hypertens.

    (2015)
  • J. Cohen

    Statistical Power Analysis for the Behavioral Sciences

    (1988)
  • V.S. Conn

    Anxiety outcomes after physical activity interventions: meta-analysis findings

    Nurs. Res.

    (2010)
  • G.M. Cooney et al.

    Exercise for depression

    Cochrane Database Syst. Rev.

    (2013)
  • Y.A. de Vries et al.

    Influence of baseline severity on antidepressant efficacy for anxiety disorders: meta-analysis and meta-regression

    Br. J. Psychiatry

    (2016)
  • S. Duval et al.

    Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis

    Biometrics

    (2000)
  • Egger, M., Davey Smith, G., Schneider, M., Minder, C., 1997. Bias in meta-analysis detected by a simple, graphical...
  • C.E. Garber et al.

    Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise

    Med. Sci. Sports Exerc.

    (2011)
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