Can physical exercise modulate cortisol level in subjects with depression? A systematic review and meta-analysis

Beserra, Ana Heloisa Nascimento; Kameda, Priscila; Deslandes, Andrea Camaz; Schuch, Felipe Barreto; Laks, Jerson; Moraes, Helena Sales de

doi:10.1590/2237-6089-2017-0155

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Review Article • Trends Psychiatry Psychother. 40 (4) • Oct-Dec 2018 • https://doi.org/10.1590/2237-6089-2017-0155 copy

Can physical exercise modulate cortisol level in subjects with depression? A systematic review and meta-analysis

O exercício físico pode modular os níveis de cortisol em indivíduos com depressão? Uma revisão sistemática e metanálise

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

Major depressive disorder (MDD) is a prevalent medical illness that is associated with chronic stress. Patients with MDD can show an imbalance in cortisol levels, which can be restored with the remission of symptoms. Physical exercise training has been used as a tool to promote changes in cortisol levels in healthy individuals. However, it is unknown if exercise can produce the same results in individuals with MDD.

Objective:

To review evidence of cortisol changes after exercise training in individuals with MDD.

Methods:

We conducted a search on PubMed, SciELO, LILACS, ISI Web of Knowledge, Scopus, and PsycInfo databases. Random effects meta-analysis was performed and standardized mean difference (SMD) effect size was calculated. Analyses of forest and funnel plots was conducted using Stata v.11.0 software.

Results:

At first, 463 studies were obtained in the search. After completion of the selection procedure, five articles with seven analyses were included. Type of exercise, frequency of training, cortisol measurement, and type of control group were analyzed. There was a reduction of cortisol levels in the exercise group (SMD = −0.65, 95%CI 1.30-0.01). Moreover, sensitivity analysis and subgroup analyses revealed an effect of type (aerobic exercise) and frequency (five times per week) of exercise on reduction of cortisol levels. However, these results should be interpreted cautiously due to the small number of studies and a substantial heterogeneity among them.

Conclusion:

Physical exercise promotes a reduction in cortisol levels in individuals with MDD. However, this finding can be influenced by type of exercise, weekly frequency, and type of cortisol measurement.

Keywords:
Physical activity; depression; cortisol; HPA axis; exercise

Study	Sample characteristics	MD characteristics	Clinical diagnosis	Exercise type	Exercise methodology	Exercise intensity	Cortisol analysis	Cortisol measurement	Results
Foley et al.²⁵25. Foley LS, Prapavessis H, Osuch EA, De Pace JA, Murphy BA, Podolinsky NJ. An examination of potential mechanisms for exercise as a treatment for depression: A pilot study. Ment Health Phys Activity. 2008:69-73.	IG1 (n = 8), 18-55 years, male and female CG (n = 5), 18-55 years, male and female	IG1: BDI-II 21.40±4.33 MADRS 28.80±9.86 IG2: BDI-II 20.00±7.08 MADRS 28.69±8.59	DSM-IV	IG1: aerobic IG2: stretching	3 days per week, 30/40 minutes (6 and 12 weeks)	IG1: moderate IG2: mild	Saliva	Cortisol awakening response: awakening (T1), 30-minute post awakening (T2) and before bed (T3).	Cortisol: ↓ IG1 DS: ↓ IG1
Nabkasorn et al.²⁶26. Nabkasorn C, Miyai N, Sootmongkol A, Junprasert S, Yamamoto H, Arita M, et al. Effects of physical exercise on depression, neuroendocrine stress hormones and physiological fitness in adolescent females with depressive symptoms. Eur J Public Health. 2006;16:179-84.	IG1 (n = 21), 18.7±0.2 years, female CG (n = 28), 18.8±0.1 years, female	IG1: CES-D 20.1±0.9 IG2: CES-D 18.8±0.7	None	IG1: jogging then usual routine IG2: usual routine then jogging	IG1: 5 days per week, 50 minutes (8 weeks) IG2: 8 weeks	Mild; constant HR of less than 50% of the HR reserve	Urine	24 hours of excretions	Cortisol: ↓ after exercise for IG1 DS: ↓ after exercise for IG1 and IG2
Krogh et al.29	IG1 (n = 29), 42.4±9.5 years, male and female IG2 (n = 31), 39.3±9.8 years, male and female CG (n = 28), 36.0±9.8 years, male and female	IG1: HAM-D 17.6±3.5 IG2: HAM-D 18.4±4.2 CG: HAM-D 15.6±3.4	ICD-10	IG1: strength IG2: aerobic CG: relaxation	2 days per week, 60 minutes (16 weeks)	IG1: 50% of RM then 75% of RM IG2: % HR maximum from 70 to 90%	Plasma	Baseline (T1), post-intervention (T2)	Cortisol: NS DS: NS
Carneiro et al.³⁰30. Carneiro LS, Mota MP, Vieira-Coelho MA, Alves RC, Fonseca AM, Vasconcelos-Raposo J. Monoamines and cortisol as potential mediators of the relationship between exercise and depressive symptoms. Eur Arch Psychiatry Clin Neurosci. 2017;267:117-21.	IG (n = 9), 18-65 years, female CG (n = 10), 18-65 years, female	No scales	ICD-10	IG: aerobic CG: no exercise	3 days per week, 45/50 minutes (16 weeks)	Average intensity, 72% HR maximum	Plasma	Baseline (T1) and after 16 weeks (T2)	Cortisol: NS DS: -
Prakhinkit et al.³⁷37. Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions. Chichester: Wiley; 2008.	IG1 (n = 13), 74.8±1.7 years, female IG2 (n = 14), 74.0±1.9, female CG (n = 13), 81.0±1.7, female	IG1: GDS 17.3±1.0 IG2: GDS 16.8±0.9 CG: GDS 17.9±0.7	None	IG1: traditional walking IG2: walking meditation CG: sedentary group	P1 (IG1 and IG2): 3 days per week, 20 minutes (weeks 1-6) P2 (IG1 and IG2): 3 days per week, 30 minutes (weeks 7-12)	P1 (IG1 and IG2): mild (20-39% HR reserve) P2 (IG1 and IG2): moderate (40-50% HR reserve)	Plasma	After 8 hours of overnight fasting	Cortisol: ↓ IG2 DS: ↓ IG2

Analysis		SMD	95°CI	p	Heterogeneity	I²2. Gomez R, Fleming S, Keller J, Flores J, Kenna H, DeBattista C, et al. The neuropsychological profile of psychotic major depression and its relation to cortisol. Biol Psychiatry. 2006;60:472-8. p
Main analysis (all trials)		-0.65	-1.30 to 0.01	0.054	82.7	<0.001
Main analysis (four trials)		-0.64	-1.17 to −0.10	0.019	28.7	0.240
Aerobic x strength
	Aerobic	-0.76	-1.55 to 0.03	0.059	83.9	<0.001
	Strength	-0.05	-0.57 to 0.47	0.842	–	–
5, 3 or 2 times per week
	5 times per week	-2.18	-2.90 to −1.47	<0.001	–	–
	3 times per week	-0.64	-1.17 to −0.10	0.019	28.7	0.240
	2 times per week	0.05	-0.32 to 0.41	0.793	0.0	0.590
Saliva × plasma × urine
	Saliva	-0.88	-2.00 to 0.30	0.143	–	–
	Plasma	-0.26	-0.71 to 0.18	0.249	53.8	0.070
	Urine	-2.18	-2.90 to −1.47	<0.001	–	–
Control group types
	Active treatment	-0.05	-0.46 to 0.35	0.795	19.2	0.290
	No treatment	-0.99	-1.95 to −0.04	0.042	82.4	<0.001

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E-mail: trends@aprs.org.br

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[1] Correspondence: Ana Beserra Av. Venceslau Braz, 71, fundos, Botafogo 22290-140 - Rio de Janeiro, RJ - Brazil Tel.: +55 (21) 39385546 E-mail: biomedica.anabeserra@gmail.com