Running and exercise for depression

1. Introduction

Version followed: the group exercise option in NICE guideline NG222, Depression in adults: treatment and management (published 29 June 2022, Tables 1 and 2); the supervised group running therapy reported in the MOTAR study (Verhoeven et al., Journal of Affective Disorders 2023; protocol Lever-van Milligen et al., BMC Psychiatry 2019); and the talking-therapist approach to physical activity set out by Thompson and Taylor (University of Plymouth, BMJ Learning module, 2025). Physical-activity screening follows the 2025 PAR-Q+; compulsive-exercise screening follows the Loughborough group's Compulsive Exercise Test. [source: NICE NG222; Verhoeven et al. 2023; Thompson & Taylor 2025]

Running and exercise for depression is not a single manualised therapy with one developer. It is a guideline-recommended treatment option (structured physical activity, often delivered in groups by a trained practitioner) plus a set of behavioural procedures by which a clinician helps a depressed person start, keep up and learn from regular physical activity. NICE lists group exercise among first-line options for less severe depression and also in the table for more severe depression, where options with more therapist contact are to be considered first. [source: NICE NG222, Tables 1–2]

Core idea of change, as the sources state it: regular physical activity may enhance wellbeing, with greater benefit reported outdoors (NICE 1.4.40); trials and reviews report reductions in depressive symptoms comparable in some comparisons to psychotherapy or antidepressants (Cochrane review, Cooney et al. 2013; Noetel et al., BMJ 2024; MOTAR). For the psychotherapist, exercise works as a behavioural intervention: the client acts according to a plan rather than according to mood, gains experiences of competence, control and connection, and these experiences become material for therapy. The behavioural-activation framing is partly [synthesis]; Thompson and Taylor name loss of control, competence and connectedness as barriers that unattainable prescriptions can worsen. [source: NICE NG222; Cooney et al. 2013; Noetel et al. 2024; Thompson & Taylor 2025]

Who delivers what. A psychotherapist can raise, assess, plan, monitor and integrate physical activity within any talking therapy, and can co-facilitate or refer to a group programme. Leading supervised running or exercise sessions (setting intensity, supervising exertion, managing injury) belongs to a qualified exercise professional, physiotherapist or trained running therapist unless the psychotherapist holds that qualification. MOTAR used "qualified staff" and a running therapist or trainer; the exact professional background is not specified in the published report. [source: Verhoeven et al. 2023] [uncertain: the national credential for running therapists in the Netherlands not verified]

2. Framework

There is no developer-defined phase model. The phases below organise what NICE, MOTAR, the PAR-Q+ and Thompson and Taylor describe; the sequence and move-on criteria are [synthesis] unless tagged.

Phase A: Raise and assess (usually within the first one or two sessions).

Goals: introduce physical activity without telling the client what to do; take an activity history; understand capability, opportunity and motivation (COM-B); identify valued activities and daily routines. [source: Thompson & Taylor 2025]
Move on when: the client has expressed some interest, even ambivalent, and you have a picture of past and current activity, routines and obstacles. [synthesis]

Phase B: Safety and suitability screening (before any increase in activity).

Goals: physical-readiness screening (PAR-Q+ or local equivalent), medical clearance where indicated; screen for eating disorders and compulsive exercise; check current suicide risk and severity. [source: PAR-Q+ 2025; Meyer group, Loughborough; NICE NG222]
Move on when: screening is clear, or the client's GP, physician or a qualified exercise professional has advised on safe activity (the PAR-Q+ points to the ePARmed-X+ and a qualified exercise professional when follow-up answers are positive). MOTAR required physician confirmation where somatic contraindications such as serious heart problems were possible. [source: PAR-Q+ 2025; Verhoeven et al. 2023]

Phase C: Shared decision and plan (one session, revisited as needed).

Goals: place exercise among the treatment options the client is choosing between (NICE 1.3.1, 1.3.3, 1.5.2, 1.6.1); agree whether exercise is the main option, an addition to therapy, or a later step; choose format (individual, group programme, community activity) and modality; agree small, realistic first goals. [source: NICE NG222; Thompson & Taylor 2025]
Move on when: there is a written plan with a first step the client rates as achievable. [synthesis]

Phase D: Engagement and active programme.

Formats as published:
- NICE group exercise: a physical activity programme designed specifically for people with depression, including moderate-intensity aerobic exercise, delivered in a group by a trained practitioner, usually more than one session per week over 10 weeks, usually about 8 participants per group. NICE notes it may need adapting for physical health problems, anxiety or shame, needs a considerable time commitment, may benefit physical health and avoids medication side effects. [source: NICE NG222, Table 1]
- MOTAR running therapy: 16 weeks of group-based, supervised outdoor running; a target of two to three sessions a week (at least two group sessions encouraged, with partly home-based running allowed if group attendance was not possible); each session reported as a 10-minute warm-up, 30 minutes of jogging and a 5-minute cool-down; individual heart-rate bands set from a baseline cycle ergometer test, lower in weeks 1–4 and higher from week 5, with heart-rate monitors worn by all participants and checked during sessions. Adherence was defined as attending more than 22 sessions. [source: Verhoeven et al. 2023]
- Within talking therapy: physical activity added to step 2 or step 3 therapy (for example within CBT or behavioural activation) without disrupting planned delivery. [source: Thompson & Taylor 2025]
These figures describe published programmes; they are not instructions for an individual client. Individual intensity and progression are set by the exercise professional or physician.
Move on (to maintenance) when: activity has become a regular part of the week, or the programme ends. [synthesis]

Phase E: Monitoring and review (throughout).

NICE: for less severe depression, reassessment normally within 2 to 4 weeks (1.5.1); if there is no response after 4 to 6 weeks of psychological therapy or combined treatment, review personal, social and adherence factors, then the diagnosis, and reassure that other treatments can be tried (1.9.1–1.9.3). Applying these review points to an exercise programme is [synthesis]. [source: NICE NG222]

Phase F: Maintenance and relapse prevention.

Goals: move from programme to self-sustained or community activity; plan for lapses (illness, injury, holidays, low mood); link to the general relapse-prevention review NICE describes (1.8.1, 1.8.11). [source: NICE NG222] [synthesis for the exercise-specific content]

Typical length: a group programme lasts about 10 weeks per NICE or 16 weeks in MOTAR; integration within psychotherapy follows the length of the therapy itself. [source: NICE NG222; Verhoeven et al. 2023]

3. Guiding principles

Preference and shared decision-making. NICE asks clinicians to support a clear personal preference unless there are concerns about suitability. Practical meaning: offer exercise as one option among others; never make therapy conditional on it. [source: NICE NG222, 1.3, 1.5.2]
Start from what the client already does and values. Ask about past or stopped activity; begin with activities the client feels confident in, such as housework, gardening or walking to the shops. Practical meaning: the first goal comes from the client's life, not from a guideline target. [source: Thompson & Taylor 2025]
Small changes count. Thompson and Taylor stress realistic goals "no matter how small" and note that small changes accumulate. Practical meaning: success is defined by doing the planned step, not by volume. [source: Thompson & Taylor 2025]
Do not lead with guideline targets. Leading with NICE figures or general activity guidelines can feel unattainable. Practical meaning: quote figures only if the client asks, and frame them as population guidance. [source: Thompson & Taylor 2025]
Client ownership (motivational interviewing spirit). Keep discussions client-centred so the client owns decisions and stays in control. Practical meaning: elicit reasons and plans; avoid persuading or prescribing. [source: Thompson & Taylor 2025]
Safety before activity. Physical-readiness screening, medical clearance where indicated, and delay during temporary illness, pregnancy or changed health until advised. Practical meaning: no plan to increase activity until screening is done. [source: PAR-Q+ 2025]
Screen for over-exercise and eating disorders. Compulsive exercise is often an early eating-disorder symptom and one of the last to subside. Practical meaning: never encourage more exercise in a client who shows driven, rigid or compensatory exercise. [source: Loughborough REF impact case study]
Medication decisions stay with the prescriber. NICE advises people to talk with their prescriber before stopping antidepressants (1.4.12). Practical meaning: describe MOTAR only as reported and route all medicine questions to the prescriber. [source: NICE NG222; Verhoeven et al. 2023]
Adapt for physical health, anxiety and shame. NICE names these as reasons to adapt group exercise. Practical meaning: offer private, low-visibility or individual starts and choice of setting. [source: NICE NG222, Table 1]
Act by plan, not by mood. Practical meaning: schedule the activity in advance and treat low motivation as expected, not as a reason to wait. [synthesis, from behavioural-activation practice]
Expect adherence difficulty. In MOTAR, 52% of the running group met the adherence threshold and 15% never started. Practical meaning: plan for non-starting and drop-off from the first session. [source: Verhoeven et al. 2023]
Work alongside exercise professionals. Practical meaning: the psychotherapist owns the psychological work; intensity, technique and injury management belong to the exercise professional or physician. [synthesis]
Keep monitoring mood and risk. Practical meaning: exercise does not replace standard review of symptoms and suicidal ideation. [source: NICE NG222, 1.4.3] [synthesis for application to exercise]
Outdoors and connection are assets. NICE notes greater benefit outdoors. Practical meaning: offer outdoor and social options such as walking groups or green exercise where the client wants them. [source: NICE NG222, 1.4.40; NHS exercise for depression page]

4. Intervention inventory

The sources name the procedures below. Step-by-step wording is written for this guide; all example language is illustrative. None of the steps sets an exercise amount, intensity or duration for a client; where published programme figures appear, they are reported facts.

4.1 Raising physical activity

Purpose and when to use: introduce physical activity as a possible part of treatment without prescribing it. Use at assessment, or whenever the client mentions energy, sleep, routine or body. [source: Thompson & Taylor 2025]
Steps:
1. Ask about activity the client used to do and has stopped, and what it gave them.
2. Ask what they do now in an ordinary day (walking to shops, housework, caring, gardening).
3. Reflect any link the client makes between activity and mood; do not supply the link yourself first.
4. Ask permission before giving information; if the client wants it, say briefly that guidelines list physical activity, including group exercise, among treatment options. Do not lead with guideline figures. [source: Thompson & Taylor 2025; NICE NG222]
5. Leave the decision with the client; return to it later if they are not interested.
Example language (illustrative): "Before things got hard, was there anything active you used to do, a sport, walking, dancing, anything?" / "Would it be useful if I said a little about how some people use movement as part of getting through depression? You can tell me if it isn't for you."
Watch for: shame about body, weight or fitness; past injury or illness; a history of sport that ended badly; sudden enthusiasm for intense exercise (see 4.4). Working: the client talks about past activity with some warmth or curiosity, or names an activity themselves.

4.2 Activity history and COM-B assessment

Purpose and when to use: understand capability, opportunity and motivation before planning. Use once interest exists. [source: Thompson & Taylor 2025]
Steps:
1. Capability: what the client feels physically able to do now; health conditions, pain, energy, sleep. Psychological capability: concentration, planning, rumination. [source: Thompson & Taylor 2025]
2. Opportunity: time, caring duties, money, transport, safe places, weather, access to green space, accessible facilities, people to go with. [synthesis]
3. Motivation: what the client values (health, time outside, company, being a role model), what they fear (being watched, failing, getting worse). [synthesis]
4. Map a typical day and week to find realistic slots. [source: Thompson & Taylor 2025]
5. Record a brief summary to use in planning (4.6).
Example language (illustrative): "Let's look at a normal week. Where would there be any room at all, even ten spare minutes?" / "What would make it more likely you'd actually go: someone with you, a set time, being near home?"
Watch for: depressive pessimism that rules out every option (treat as a symptom, not a fact); practical barriers that need social help rather than motivation work. Working: one or two plausible options emerge.

4.3 Physical-readiness screening and medical clearance

Purpose and when to use: identify cardiac and other medical risks before any increase in activity. Use before planning anything beyond the client's current everyday activity. [source: PAR-Q+ 2025]
Steps:
1. Use the PAR-Q+ (PAR-Q+ Collaboration, 2025) or the screening tool your service uses. The PAR-Q+ has seven general yes/no questions covering heart condition or high blood pressure, chest pain (at rest, in daily activity or exercise), dizziness or loss of consciousness in the past year, other chronic conditions, medicines for chronic conditions, recent bone, joint or soft-tissue problems, and whether a doctor has limited activity to medically supervised sessions. It may be photocopied but must be used whole and unchanged. Do not retype or adapt its items. [source: PAR-Q+ 2025]
2. If every answer is no, the form clears the person to become more active, gradually. [source: PAR-Q+ 2025]
3. If any answer is yes, the person completes the follow-up pages. These cover, among others, heart and circulatory conditions, high blood pressure, metabolic conditions, respiratory disease, stroke, cancer, musculoskeletal problems, and mental health problems or learning difficulties. Any further yes directs the person to the ePARmed-X+ and/or a qualified exercise professional, or to their health care provider. [source: PAR-Q+ 2025]
4. Advise delay where the form advises it: temporary illness (until recovered), pregnancy, or changed health (consult a provider first). [source: PAR-Q+ 2025]
5. Write to or ask the client to see their GP or physician where clearance is needed; MOTAR required physician confirmation of somatic contraindications such as serious heart problems. [source: Verhoeven et al. 2023]
6. If the client takes any medicine and asks whether it affects exercise, refer the question to the prescriber or pharmacist; do not answer it yourself. [synthesis]
7. Tell the client which symptoms during activity mean stopping and seeking medical advice (for example chest pain, fainting, severe breathlessness). [synthesis] [uncertain: symptom list not taken from a clinical source]
Example language (illustrative): "Before we plan anything, there's a short health questionnaire that everyone does, whatever their fitness. If anything comes up, we'll check with your GP first." / "That's a yes on the chest pain question, so the next step is your doctor, not a plan. I'll help you set that appointment up."
Watch for: clients minimising symptoms to get started; avoidance of the GP; new symptoms after starting. Working: screening documented, clearance obtained where needed before the plan begins.

4.4 Eating-disorder and compulsive-exercise screening

Purpose and when to use: avoid reinforcing driven or compensatory exercise. Use with every client before encouraging exercise, and again if exercise escalates. [source: Loughborough REF impact case study]
Steps:
1. Ask how the client relates to exercise and eating: whether they feel compelled, guilty or anxious when they miss exercise; whether exercise compensates for eating; whether they exercise through injury or illness; rigid rules about amount; secrecy. [synthesis, informed by the Loughborough description of compulsive exercise as multi-dimensional and maintained by specific cognitive factors]
2. Where concern exists, use a validated measure such as the Compulsive Exercise Test (Taranis, Touyz & Meyer, 2011, European Eating Disorders Review), developed at Loughborough University as a screening measure. Do not reproduce its items; obtain it from the published source. [source: Loughborough REF impact case study] [uncertain: CET subscales and cut-off scores not verified]
3. If an eating disorder or compulsive exercise is suspected, do not start an exercise plan; refer for eating-disorder assessment and medical review. Exercise decisions in eating disorders belong to the eating-disorder team. Specialist resources include the Loughborough Eating disorders Activity Programme (LEAP), a cognitive-behavioural programme for compulsive exercise delivered individually or in groups, and the Australian Safe Exercise at Every Stage guideline (second edition, listed by the National Eating Disorders Collaboration). [source: Loughborough REF impact case study; NEDC SEES-2 listing] [uncertain: SEES-2 content not verified]
4. Also screen for body-image distress that a group or running setting could aggravate. [synthesis]
Example language (illustrative): "Some people find exercise starts to feel like a rule they can't break. Has it ever felt like that for you?" / "What happens inside if you miss a planned session?"
Watch for: exercise used to "earn" food; weight-loss goals presented as mood goals; distress at rest days; exercising despite injury; rapid escalation once a running plan starts. Working: client can describe exercise flexibly, and missed sessions cause disappointment rather than guilt or compensation.

4.5 Suicide risk, severity and treatment-choice check

Purpose and when to use: ensure exercise is a suitable option for this episode. Use at assessment and at each review. [source: NICE NG222]
Steps:
1. Assess severity and current suicide risk in line with your service's standard risk-assessment practice; MOTAR excluded people at acute suicidal risk. [source: Verhoeven et al. 2023]
2. For more severe depression, note NICE's advice that options with more therapist contact are considered first; exercise can still be part of a plan. [source: NICE NG222, Table 2]
3. Confirm exercise is the client's preference, not a way to avoid other care they need. [source: NICE NG222, 1.3]
4. Keep monitoring suicidal ideation during any exercise programme; group leaders should know how to reach the clinician. [source: NICE NG222, 1.4.3] [synthesis for the group-leader link]
Example language (illustrative): "Exercise can sit alongside our work, not instead of keeping an eye on how unsafe things feel. Can we keep checking that each time?"
Watch for: hopelessness about failing at exercise; isolated outdoor running as a setting for risk; worsening mood despite activity. Working: risk is stable or lower and is reviewed routinely.

4.6 Collaborative goal setting and activity planning

Purpose and when to use: turn interest into a concrete, achievable first step. Use after screening. [source: Thompson & Taylor 2025]
Steps:
1. Ask the client to choose the activity, starting with something they feel confident in and value. [source: Thompson & Taylor 2025]
2. Agree a goal small enough that the client rates it as very likely to happen this week. [source: Thompson & Taylor 2025] Leave any intensity or progression to the exercise professional or physician.
3. Specify when, where, with whom, and what the client will do if the plan is disrupted (an if-then backup). [synthesis]
4. Write the plan down; the client keeps a copy.
5. Agree how the client will record it (4.9) and when you will review it.
6. Build gradually over weeks, at the client's pace and within any medical advice; Thompson and Taylor stress slow, safe progression, including for people with several long-term conditions. [source: Thompson & Taylor 2025]
Example language (illustrative): "What's a step so small you'd be surprised if you didn't do it?" / "If it's raining on Tuesday, what's plan B?"
Watch for: goals set to please the therapist; all-or-nothing plans; plans tied to weight. Working: the client carries out the planned step most weeks and starts proposing the next one.

4.7 Choosing format, modality and setting

Purpose and when to use: match the form of activity to preference, health and context. Use during planning and when engagement stalls. [source: NICE NG222; Noetel et al. 2024; NHS exercise for depression page]
Steps:
1. Lay out formats: an NICE-style group exercise programme led by a trained practitioner; a supervised running group; exercise on prescription via the GP; community options; or self-directed activity planned in therapy. [source: NICE NG222; NHS page; Verhoeven et al. 2023]
2. Offer modality information neutrally if asked. Noetel et al. (2024) report effects for walking or jogging, yoga, strength training, mixed aerobic exercise and tai chi or qigong, with walking or jogging, yoga and strength training more effective than other forms in their analysis, and strength training and yoga appearing the most acceptable. They rate certainty as low for walking or jogging and very low for the others. Their finding that effects were proportional to prescribed intensity is a research finding, not an instruction for a client. [source: Noetel et al. 2024]
3. Consider setting: outdoors (NICE 1.4.40); green-exercise projects (TCV Green Gym) and walking groups (Ramblers Wellbeing Walks) named by the NHS for people who prefer not to use gyms. [source: NICE NG222; NHS page]
4. Consider group versus individual: NICE notes possible adaptations for anxiety or shame; Thompson and Taylor note that weekly supervised group exercise is unlikely to appeal to most people with depression or anxiety. [source: NICE NG222; Thompson & Taylor 2025]
5. Let the client choose; record the reasons.
Example language (illustrative): "Some people like a group with a leader, some prefer walking on their own with a podcast. Which sounds less hard right now?"
Watch for: choosing the most demanding option to "prove" something; choosing a group despite strong social anxiety without preparation. Working: the client chooses something they want to repeat.

4.8 Barrier analysis and problem-solving

Purpose and when to use: address the depression-specific barriers that stop people starting or continuing. Use in planning and whenever a plan is missed. [source: Thompson & Taylor 2025]
Steps:
1. Name the barriers Thompson and Taylor list: low energy, poor sleep, rumination, low self-esteem and confidence, and loss of control, competence or connectedness. Ask which apply. [source: Thompson & Taylor 2025]
2. For each, generate options with the client: for low energy, schedule at the least-bad time of day; for rumination, choose company, music or attention to surroundings; for confidence, choose a setting with no audience. [synthesis]
3. Separate practical barriers (cost, childcare, transport, safety, access) and link to resources: exercise on prescription via the GP may be free or reduced cost depending on local services. [source: NHS exercise for depression page]
4. Choose one option, test it, review.
5. Avoid unattainable plans, which Thompson and Taylor say can worsen these barriers. [source: Thompson & Taylor 2025]
Example language (illustrative): "When you didn't go on Thursday, what got in the way, tiredness, thoughts, or something practical?" / "What's one thing that would make the hardest part a bit easier?"
Watch for: self-criticism after missed plans; barriers that are actually symptoms needing other treatment (for example severe insomnia). Working: missed sessions lead to problem-solving rather than giving up.

4.9 Self-monitoring of activity and mood

Purpose and when to use: make the link between action and mood visible and support review. Use from the first planned step. [source: Thompson & Taylor 2025]
Steps:
1. Agree a simple record: what was planned, what was done, a brief mood or enjoyment rating before and after, and any obstacle. Thompson and Taylor describe the aim as "skilful and client centred" self-monitoring. [source: Thompson & Taylor 2025]
2. Keep it short and in a format the client uses (paper, phone note, app). [synthesis]
3. Review the record at the start of each session; look for patterns together.
4. Do not set numerical targets; focus on whether the plan happened and what the client noticed. [synthesis]
Example language (illustrative): "Looking at your week, what do you notice about the days you got out compared with the days you didn't?"
Watch for: monitoring becoming obsessive (counting steps, calories, pace, weight) and feeding compulsive patterns (see 4.4); records used for self-punishment. Working: the client draws their own conclusions from the record.

4.10 Delivering or co-facilitating a group exercise or running programme

Purpose and when to use: offer the NICE group exercise option or a running group. Use where a service runs a programme and the client prefers a group. [source: NICE NG222; Verhoeven et al. 2023]
Published structures:
- NICE: a programme designed specifically for people with depression, including moderate-intensity aerobic exercise, delivered in a group of usually about 8 by a trained practitioner, usually more than one session per week over 10 weeks. [source: NICE NG222, Table 1]
- MOTAR: group, supervised, outdoor running over 16 weeks, sessions comprising warm-up, jogging and cool-down, with individual heart-rate bands from a baseline ergometer test and heart-rate monitors used during sessions and to encourage compliance; partly home-based running allowed where attendance was not possible. [source: Verhoeven et al. 2023]
Steps for the psychotherapist:
1. Confirm a qualified leader (exercise professional, physiotherapist or trained running therapist) is responsible for the physical side: screening review, warm-up and cool-down, intensity, technique and injury. [synthesis]
2. Complete screening (4.3, 4.4, 4.5) before referral and share relevant information with consent. [source: PAR-Q+ 2025; Verhoeven et al. 2023]
3. Prepare the client: what a session looks like, that pace is individual, that nobody is expected to keep up with others. [synthesis]
4. If co-facilitating, attend to group process: welcome, names, shared norms about pace and no comparison, a brief check-in on mood, and a closing moment to notice how people feel. [synthesis]
5. Agree with the leader how attendance and concerns (new physical symptoms, deterioration, risk) are passed to the clinician. [synthesis]
6. Use the programme's experiences as material in individual sessions (4.13).
Example language (illustrative): "In this group everyone runs or walks at their own level; the leader sets that individually. Your only job the first time is to turn up." / to the group: "Before we finish, one word for how you feel compared with when you arrived."
Watch for: comparison and shame in the group; exertion beyond the individual's band; injury; non-starting (15% in MOTAR) and early drop-off. Working: regular attendance, emerging group connection, the client describing sessions as something they want to keep. [source for figure: Verhoeven et al. 2023]

4.11 Referral and linking to community activity

Purpose and when to use: connect the client with sustainable, low-cost activity. Use during planning and in maintenance. [source: NHS exercise for depression page]
Steps:
1. Exercise on prescription: many GP practices prescribe exercise for conditions including depression; suggest asking the GP, especially if the client has not exercised for a long time or worries about effects on health. [source: NHS exercise for depression page]
2. Community options named by the NHS: TCV Green Gym, Ramblers Wellbeing Walks, team sports, leisure-centre classes, active travel, fitness advice for wheelchair users. [source: NHS exercise for depression page]
3. Community running: free weekly timed community runs and walks such as parkrun, and beginner running plans such as Couch to 5K, are widely used. [synthesis] [uncertain: not verified]
4. Give the client the information; let them choose; follow up at the next session.
Example language (illustrative): "There's a walking group that meets near you on Saturdays. Would you want to look it up together now?"
Watch for: referral used as a substitute for therapy contact; social anxiety about first attendance (consider a first visit with a friend). Working: the client attends independently.

4.12 Review and outcome monitoring

Purpose and when to use: judge whether exercise is helping and adjust treatment. Use at every session and at formal review points. [source: NICE NG222]
Steps:
1. Review the activity record (4.9) and mood each session.
2. Use the depression measure your service uses at baseline and at review points. [synthesis]
3. Follow NICE review timing: reassessment for less severe depression normally within 2 to 4 weeks (1.5.1); if no response after 4 to 6 weeks of psychological or combined treatment, review personal, social and adherence factors, then diagnosis, and reassure that other treatments can be tried (1.9.1–1.9.3). [source: NICE NG222]
4. If the programme is not helping, revisit the shared decision (4.5): other options, combination, or referral. [source: NICE NG222]
5. Pass on any adverse physical effect (injury, chest symptoms, fainting) to the client's GP or physician. [synthesis]
Example language (illustrative): "Your scores haven't moved much over the last month even though you've been going. Let's think together about what else might help alongside it."
Watch for: attributing non-response to the client's effort; continuing an unhelpful plan out of loyalty. Working: symptom scores fall or functioning improves; the client reports exercise as useful.

4.13 Integrating exercise experiences into psychotherapy

Purpose and when to use: use exercise as behavioural experiments and as material for cognitive and emotional work. Use once activity has begun. [source: Thompson & Taylor 2025 note that physical activity can fit within CBT or behavioural activation] [synthesis for the procedures]
Steps:
1. Before an activity, ask the client to predict how they will feel and what will happen; afterwards, compare with what happened. [synthesis]
2. Explore thoughts that arise (for example "I'm too unfit", "everyone is watching") with the methods of your own modality. [synthesis]
3. Notice experiences of competence, control and connection, and link them to the client's goals and values. [source: Thompson & Taylor 2025 name loss of these as barriers] [synthesis]
4. Use attention to the body and surroundings during activity as an alternative to rumination, if this suits the client. [synthesis]
5. Address body image with care; keep the focus on function and mood rather than appearance or weight. [synthesis]
Example language (illustrative): "You expected the walk to be pointless. What actually happened in your mood afterwards?" / "What did it tell you about yourself that you kept going on the hill?"
Watch for: exercise becoming a new arena for perfectionism or self-attack; body-focused distress. Working: the client generalises learning ("I can do things before I feel like it").

4.14 Responding when the client asks about running instead of medication

Purpose and when to use: answer questions about MOTAR or similar findings accurately without advising on medicine. Use when the client raises it. [source: Verhoeven et al. 2023; NICE NG222]
Steps:
1. Describe the study only as reported: in MOTAR, 141 adults with depression or anxiety disorders chose (or a small subgroup was randomised to) 16 weeks of an antidepressant or group running therapy; remission rates were similar (44.8% and 43.3%); the running group showed more favourable physical-health measures, and adherence to running was lower (52.1% versus 82.2%). Only 22 participants were randomised. People taking antidepressants in the previous two weeks were excluded. [source: Verhoeven et al. 2023]
2. Say clearly that decisions about starting, continuing, changing or stopping medicine are made with the prescriber; NICE advises talking with the prescriber before stopping antidepressants (1.4.12). [source: NICE NG222]
3. Offer to help the client prepare questions for the prescriber. [synthesis]
4. Note in the record that the topic was discussed and the client was directed to the prescriber. [synthesis]
Example language (illustrative): "That study compared people starting one or the other; it didn't look at people coming off medication. Whether anything changes with your tablets is something to decide with your prescriber. Shall we write down your questions for them?"
Watch for: stopping medication abruptly; framing exercise as moral superiority over medication; feeling of failure if exercise alone is not enough. Working: the client raises the question with the prescriber and continues exercise as agreed.

4.15 Maintenance and relapse-prevention planning

Purpose and when to use: keep activity going after therapy or a programme ends. Use in the last weeks of therapy or of a group programme. [source: NICE NG222, 1.8] [synthesis for the exercise-specific content]
Steps:
1. Review what the client has learned about activity and mood.
2. Identify early warning signs of relapse, including dropping activity. [synthesis]
3. Plan for predictable lapses (illness, injury, holidays, weather, life events), including how to restart at a smaller step. [synthesis]
4. Link to sustainable community or social options (4.11).
5. Include activity in the general relapse-prevention plan and the reviews NICE describes (1.8.1, 1.8.11). [source: NICE NG222]
Example language (illustrative): "If you stop for a few weeks, what's the smallest way back in?"
Watch for: all-or-nothing thinking about lapses. Working: the client restarts after a lapse without professional prompting.

5. Handling problems

The sources say little about in-session difficulties beyond the barriers Thompson and Taylor list, NICE's adaptation notes and MOTAR's adherence data. Guidance below is [synthesis] unless tagged.

Never starts ("I'll start when I feel better"). Expected: 15% of MOTAR's running group never started. [source: Verhoeven et al. 2023] Response: explain acting before feeling better as part of the method; shrink the first step until the client rates it as nearly certain; schedule it in session; consider a supported first attendance. [synthesis]
Starts then drops off. In MOTAR, 52.1% of the running group met the adherence threshold. [source: Verhoeven et al. 2023] Response: review the record without blame; identify the point where it stopped; problem-solve the specific barrier (4.8); offer a different format or modality (4.7). [synthesis]
Ambivalence or resistance. Response: return to the client's own reasons; reflect both sides; accept "not now" and revisit later; do not argue for exercise. Client-centred discussion keeps ownership with the client. [source: Thompson & Taylor 2025] [synthesis for the steps]
Overwhelm or unattainable plans. Unattainable plans can worsen low confidence and loss of control. [source: Thompson & Taylor 2025] Response: cut the plan back to one action; remove any target the client did not choose. [synthesis]
Shame, body image or social anxiety in groups. NICE notes group exercise may need adapting for anxiety or shame. [source: NICE NG222, Table 1] Response: offer individual or low-visibility starts, a companion, an introductory visit, or a non-gym setting; address body-related thoughts in therapy; check for an eating disorder. [synthesis]
Physical health problems, pain or injury. Response: pause the plan; send the client to the GP, physiotherapist or exercise professional; adapt only on their advice; keep the psychological work going and plan a return. [source: NICE NG222 (adaptation for physical health problems); PAR-Q+ 2025 (consult a provider when health changes)] [synthesis for the steps]
New chest pain, fainting, palpitations or severe breathlessness reported. Response: advise the client to stop and seek medical assessment promptly; do not resume the plan until cleared. [synthesis] [uncertain: not verified against a clinical source]
Over-exercise, rigid rules or compensatory exercise emerging. Response: stop encouraging exercise; screen (4.4); refer for eating-disorder assessment; inform the exercise leader with consent. Compulsive exercise is linked to longer hospital stays, poorer outcomes and higher relapse in eating disorders. [source: Loughborough REF impact case study] [synthesis for the steps]
Mood worsening or rising suicide risk during the programme. Response: follow standard risk assessment; review treatment choice; options with more therapist contact may be needed (NICE Table 2). Isolated running in remote places is not a safety plan. [source: NICE NG222] [synthesis for the steps]
Client wants to stop or change medication because exercise is helping. Response: do not advise; refer to the prescriber; NICE advises talking with the prescriber before stopping (1.4.12). Describe MOTAR only as reported (4.14). [source: NICE NG222; Verhoeven et al. 2023]
Rupture: client feels pushed or judged about fitness or weight. Response: name and repair it; acknowledge that the suggestion may have felt like criticism; restate that exercise is optional; return to the client's agenda. [synthesis]
Therapist's own exercise values. Response: notice enthusiasm or moralising about fitness in yourself; keep the client's goals central; take this to supervision. [synthesis]
Practical barriers: cost, caring duties, transport, safety, disability. Response: exercise on prescription (possibly free or reduced cost), walking groups, green exercise, active travel, and NHS fitness advice for wheelchair users. [source: NHS exercise for depression page]
Pregnancy or temporary illness. Response: the PAR-Q+ advises delay and consultation with a health care practitioner or the ePARmed-X+ before becoming more active. [source: PAR-Q+ 2025]
Weather, seasons and darkness. Response: indoor or daytime alternatives planned in advance; personal-safety planning for outdoor activity. [synthesis]
Group programme ends and activity stops. Response: plan the transition before the last session (4.15); link to community options (4.11). [synthesis]
Scope of practice. A psychotherapist without exercise qualifications should not set intensities, supervise exertion or treat injury; work alongside qualified professionals and stay within competence. [synthesis]

Sources

Published works cited:

Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, McMurdo M, Mead GE (2013). Exercise for depression. Cochrane Database of Systematic Reviews, Issue 9, CD004366 (details as given in the Mental Elf summary).
Noetel M, Sanders T, Gallardo-Gómez D, et al. (2024). Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials. BMJ 384:e075847.
Verhoeven JE, Han LKM, Lever-van Milligen BA, et al. (2023). Antidepressants or running therapy: comparing effects on mental and physical health in patients with depression and anxiety disorders. Journal of Affective Disorders 329:19–29.
Lever-van Milligen BA, Verhoeven JE, Schmaal L, et al. (2019). The impact of depression and anxiety treatment on biological aging and metabolic stress: study protocol of the Mood treatment with antidepressants or running (MOTAR) study. BMC Psychiatry 19.
Taranis L, Touyz S, Meyer C (2011). Compulsive Exercise Test. European Eating Disorders Review [uncertain: full title and pages not verified].

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