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Physical exercise and internet-based cognitive–behavioural therapy in the treatment of depression: Randomised controlled trial

  • Mats Hallgren (a1), Martin Kraepelien (a2), Agneta öjehagen (a3), Nils Lindefors (a2), Zangin Zeebari (a1), Viktor Kaldo (a2) and Yvonne Forsell (a1)...

Depression is common and tends to be recurrent. Alternative treatments are needed that are non-stigmatising, accessible and can be prescribed by general medical practitioners.


To compare the effectiveness of three interventions for depression: physical exercise, internet-based cognitive–behavioural therapy (ICBT) and treatment as usual (TAU). A secondary aim was to assess changes in self-rated work capacity.


A total of 946 patients diagnosed with mild to moderate depression were recruited through primary healthcare centres across Sweden and randomly assigned to one of three 12-week interventions (trail registry: KCTR study ID: KT20110063). Patients were reassessed at 3 months (response rate 78%).


Patients in the exercise and ICBT groups reported larger improvements in depressive symptoms compared with TAU. Work capacity improved over time in all three groups (no significant differences).


Exercise and ICBT were more effective than TAU by a general medical practitioner, and both represent promising non-stigmatising treatment alternatives for patients with mild to moderate depression.

Corresponding author
Mats Hallgren, Department of Public Health Sciences, Section for Epidemiology and Public Health Intervention Research (EPHIR), Karolinska Institutet, SE-171 77 Stockholm, Sweden. Email:
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Physical exercise and internet-based cognitive–behavioural therapy in the treatment of depression: Randomised controlled trial

  • Mats Hallgren (a1), Martin Kraepelien (a2), Agneta öjehagen (a3), Nils Lindefors (a2), Zangin Zeebari (a1), Viktor Kaldo (a2) and Yvonne Forsell (a1)...
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Physical exercise and internet CBT in the treatment of depression

Tejaswi Makam, Foundation Year 2 Trainee in Psychiatry, Black Country Partnership NHS Foundation Trust
Nilamadhab Kar, Consultant Psychiatrist, Black Country Partnership NHS Foundation Trust
01 October 2015


We read with interest the article by Hallgren et al [1] on physical exercise and internet CBT (ICBT) in the treatment of depression. The authors report that there was significant improvement in all the three treatment groups: exercise, ICBT, and treatment as usual (TAU) which included counselling with CBT focus; and the mean reduction of depression score was significantly larger in the exercise and ICBT groups compared with the TAU. We wish to discuss a few points in the methodology and analysis of the data.

Around one third of patients were taking SSRIs prior to and during the trial; the authors inform that the results of the subgroup analysis excluding these patients were equivalent to the total sample analyses, although no data was provided. Considering that most patients in their sample were moderately depressed at baseline assessment, these results are particularly meaningful clinically as SSRI plus supportive care have been reported to be more effective than supportive care alone for patients with mild to moderate depression [2]. Therefore, it would be beneficial to expand on the analysis to assess the contribution of antidepressant treatment on the changes to overall depression scores.

Authors mention that a total of 25% of TAU group had no recorded treatment. This suggests this group was heterogeneous in composition. Within the intervention groups, there were many patients who dropped out; and amongst those who attended, the adherence was suboptimal. This happened in spite of more robust mechanisms encouraging adherence in the treatment groups compared to TAU.

It might be useful to highlight whether the treatment from primary care physician and medications provided were free; considering that the interventions in the other groups were.

Authors have suggested quality of life as a more appropriate measure of functional improvement and they have used EQ-5D in the baseline assessment. However changes in quality of life have not been presented in the article.

With these issues, the findings of the study may have to be interpreted cautiously.

1.Hallgren M, Kraepelien M, Öjehagen A, Lindefors N, Zeebari Z, Kaldo V, Forsell Y. Physical exercise and internet-based cognitive-behavioural therapy in the treatment of depression: randomised controlled trial. Br J Psychiatry. 2015 Sep;207(3):227-34.

2.Kendrick T, Chatwin J, Dowrick C, Tylee A, Morriss R, Peveler R, Leese M, McCrone P, Harris T, Moore M, Byng R, Brown G, Barthel S, Mander H, Ring A, Kelly V, Wallace V, Gabbay M, Craig T, Mann A. Randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of selective serotonin reuptake inhibitors plus supportive care, versus supportive care alone, for mild to moderate depression with somatic symptoms in primary care: the THREAD (THREshold for AntiDepressant response) study. Health Technol Assess. 2009 Apr;13(22):iii-iv, ix-xi, 1-159.

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Conflict of interest: None Declared

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