Summary of findings 4. Exercise compared to pharmacological treatments for adults with depression.

Exercise compared to antidepressants for adults with depression
Patient or population: adults with depression Settings: Intervention: Exercise Comparison: antidepressants
Outcomes	Illustrative comparative risks* (95% CI)		No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Antidepressants	Exercise
Symptoms of depression		The mean symptoms of depression in the intervention groups was 0.11 standard deviations lower (0.34 lower to 0.12 higher)	300 (4 studies)	⊕⊕⊕⊝ moderate1,2,3	SMD ‐0.11 (95% CI: ‐0.34 to 0.12)
Acceptability of treatment	Study population		278 (3 studies)	⊕⊕⊕⊝ moderate1	RR 0.98 (95% CI: 0.86 to 1.12)
	891 per 1000	873 per 1000 (766 to 997)
Quality of life		The mean quality of life in the intervention groups was 0 higher (0 to 0 higher)	0 (1 study)	⊕⊕⊕⊝ moderate1	One trial, Brenes 2007, reported no difference in change in SF‐36 mental health and physical health components between medication and exercise groups.
Adverse events	See comment	See comment	0 (3 studies)	⊕⊕⊕⊝ moderate1	Blumenthal 1999 reported that 3/53 in exercise group suffered musculoskeletal injuries; injuries in the medication group were not reported. Blumenthal 2007 collected data on side effects by asking participants to rate a 36‐item somatic symptom checklist and reported that "a few patients reported worsening of symptoms"; of the 36 side effects assessed, only 1 showed a statistically significant group difference (P = 0.03), i.e. that the sertraline group reported worse post‐treatment diarrhoea and loose stools. Blumenthal 2012a assessed 36 side effects; only 2 showed a significant group difference: 20% of participants receiving sertraline reported worse post‐treatment fatigue compared with 2.4% in the exercise group and 26% reported increased sexual problems compared with 2.4% in the exercise group.
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.

1 Lack of blinding of outcome assessors probably increased effect sizes and drop‐out rates were high. Also sequence generation was considered unclear in 1 study.
 2 I² = 0% and P = 0.52, indicated no heterogeneity
 ³ The studies included were all relevant to the review question, particularly given that all studies had to meet the criteria of the ACSM definition of exercise.