The Therapist’s Guide To Exercise And Mental Health
Exercise is a powerful tool for increasing emotional and physical wellbeing and is an effective evidence-based treatment for many mental health conditions. Unfortunately, many people fail to meet the recommended target of 150 minutes of moderate physical activity per week  and rates of exercise in people suffering from mental health problems are even lower than average : this means that motivating your patients to engage in exercise is a valuable therapeutic skill. In this article we will review the evidence linking exercise and mental health and discuss practical strategies that you can use to motivate your clients to get active.
What is exercise and physical activity?
Physical activity is defined as any movement produced by the skeletal muscles and exercise is defined as a structured form of physical activity that has the intention of improving a health-related outcome . Exercise can be categorized according to the nature of the activity, or the health-related outcome it is intended to improve. For example, resistance exercise increases muscular strength or endurance by applying resistance to bodily motions, whereas aerobic exercise involves our aerobic respiratory system by working at a low intensity over a sustained period of time (e.g. long-distance running).
What does exercise do for the mind and body?
Exercise has been associated with positive effects upon multiple markers of physical and mental wellbeing:
Exercise increases our energy levels. Increased physical activity is associated with reduced feelings of low energy or fatigue . A 2013 meta-analysis found that acute exercise participation enhances feelings of energy  and multiple randomized controlled trials have indicated that increasing physical activity leads to an increase in self-perceived energy compared to non-active controls [6,7].
Exercise leads to better sleep. Many forms of exercise have been demonstrated to be beneficial for improving sleep quality [8,9,10]. Exercise has even been suggested as an alternative or complimentary form of therapy for clients with sleeping problems . Research seems to suggest that doing exercise 4 to 8 hours before bedtime is likely optimal for improving sleep quality, although some exercise at any time of day seems to be beneficial .
Exercise is associated with greater self-esteem. People who take part in regular physical activity tend to have a higher level of physical self-worth, improved body image, and a higher level of self-esteem . Physical activity was also found to be directly and indirectly associated with self-esteem and advocated as an adjunct treatment for adults with lower self-esteem .
Exercise lowers your risk of death. Physical inactivity is estimated to cause 9% of all premature deaths . In the USA, research has suggested that men and women over 50 who change their physical activity status from inactive to active increase their life expectancy by between 1.3 – 3.7 and 1.5 – 3.5 years respectively .
Exercise lowers your risk of ill-health. Regular physical activity is strongly associated with a decreased risk of many physical health conditions such as diabetes, stroke, and cancer [15,13]. Oftentimes, these health-related benefits occur in the absence of weight changes and therefore clients who make little progress in achieving their weight-loss goals should be reminded of the profound impact that exercise can have on their health regardless .
Exercise is associated with improved brain function. Exercise is shown to have a positive association with cognitive performance [17,18]. Exercise has also been found to improve concentration, reduce levels of irritability , and may slow the deterioration in balance and mobility in patients with Alzheimer’s disease .
“Physical activity is one of the most fundamental factors necessary for maintaining health and warding-off risk factors” 
How can exercise help with mental health conditions?
Exercise has been investigated as both a standalone intervention and as part of comprehensive treatment packages for a variety of mental health conditions. When high-quality studies are reviewed the evidence for introducing exercise as an intervention for people struggling with mental health problems is mostly very encouraging. We will review the evidence for the effects of exercise upon a variety of conditions including depression, anxiety, psychosis, addiction, and ADHD.
Exercise and Depression
Depression is a disorder primarily characterized by a low mood and a lack of interest in activities that were previously pleasurable. Depression is the leading cause of disability worldwide, with around 300 million people affected globally . Major depressive disorder (MDD) is associated with an increased likelihood of school dropout, chronic physical diseases, and extended periods off work . Despite the availability of effective treatments for depression, only a minority receive professional help .
Given the impact depression can have upon people’s lives and the extensive costs associated with the disorder, it is encouraging that research consistently finds exercise to be an effective treatment for depression, with a magnitude of effect similar to other established forms of treatment such as CBT and medication[3,23,24]. An additional benefit of exercise is that it is not associated with the side effects and discontinuation problems associated with antidepressant medication, nor is it as costly as psychotherapy.
What is the evidence for encouraging people with depression to exercise?
In 2016 Felipe Schuch and colleagues published a high-quality meta-analysis in the Journal of Psychiatric Research . A meta-analysis is a ‘study of studies’ and theirs included data from 1487 adults with depression who had taken part in 25 randomized controlled trials. Half of the participants had been randomized to receive ‘non-active control treatment’ (such as a waiting list, usual, care, or placebo pills). The other half of the participants received an exercise intervention which they defined as “planned, structured, repetitive and purposeful physical activity”. Further, the authors adjusted their results to pay more attention to the high-quality studies. They found “large antidepressant effects of exercise on depression when compared to non-active control conditions”. They observed larger effects in outpatients compared to inpatients and when exercise was supervised by qualified exercise professionals, and cautiously observed that moderate or vigorous exercise was more effective than light to moderate exercise. They conclude that “our results provide robust evidence that exercise can be considered an evidence-based treatment for the management of depression.”
Earlier meta-analyses are consistent with Schuch and colleagues’ findings. A 2012 meta-analysis published by the Cochrane foundation showed a moderate effect of exercise on symptoms of depression compared to a waitlist or placebo condition  with the effect size for the exercise intervention found to be of similar magnitude to the effect size for cognitive-behavioral therapy (CBT). They concluded “it is reasonable to recommend exercise to people with depressive symptoms and to those who fulfil diagnostic criteria for depression”.
What type of exercise is most effective for treating depressive symptoms?
Several RCTs have indicated a dose-dependent relationship between exercise and depressive symptoms, suggesting that a moderate to high intensity is most effective. Aerobic, non-aerobic, and resistance training were all found to be helpful [26,27]. This position is tentatively supported by the Schuch (2016) meta-analysis, although other meta-analyses found that a lower intensity aerobic exercise program 3-5 times per week was optimal for mood improvements  and even low intensity exercises such as walking have been shown to have a large and significant effect on depressive symptoms . The take-home messages are that some exercise is much better than none when it comes to depression, more seems to be better, and all types of exercise seem to be effective.
Exercise and Anxiety
Around 1 in 3 Americans will develop an anxiety disorder at some point in their lifetime . Common anxiety-related mental health problems include generalized anxiety disorder (GAD), panic disorder, obsessive compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). There is interesting evidence that exercise can be an effective treatment for anxiety disorders with acute as well as long-term effects. Even in non-clinical populations, physical activity has been shown to reduce symptoms of anxiety . Evidence from epidemiological studies indicates that those who take part in regular physical activity have a reduced likelihood of developing an anxiety disorder [32,33].
Acute effects of exercise upon anxiety
A single bout of aerobic exercise can have a powerful anxiolytic effect [34,35]. In a 2015 study by LeBouthillier and Amundson , forty-one participants were randomized to complete 30 minutes of aerobic exercise or 30 minutes of stretching. They found that participants who completed aerobic exercise, but not those who did stretching, experienced significant reductions in anxiety sensitivity, intolerance of uncertainty, and increases in distress tolerance. Higher levels of trait anxiety sensitivity are associated with the development and maintenance of anxiety disorders, particularly those with a body-focus and so exercise appears to be a promising intervention with immediate effects.
The effects of exercise as a stand-alone treatment for anxiety
A 2017 meta-analysis by Brendon Stubbs and colleagues published in Psychiatry Research  examined the effects of exercise upon anxiety in people with anxiety or stress-related disorders (including panic disorder, PTSD, GAD, and social anxiety). They included data from six high-quality trials totalling 262 adults. Compared to a non-active control condition (e.g. usual care, wait-list, or placebo pills) exercise was associated with a medium effect size. The authors conclude that “exercise should be considered an evidence-based option for anxiety symptoms among people with anxiety / stress related disorders.”
The effects of adding exercise to other treatments for anxiety
The evidence appears to indicate that exercise can be considered a standalone, evidence-based treatment for anxiety [37,38,36]. But what about combining exercise with other medical and psychological treatments? A number of interesting studies have examined exercise as an additive intervention to conventional treatments. One RCT examined how a 12-week exercise program added to usual care would compare to usual care alone for reducing PTSD symptoms in a group of 81 participants, where usual care consisted of psychotherapy, pharmaceutical interventions, and group therapy . Clinically significant improvements were seen in PTSD symptoms (as well as depressive symptoms and physical characteristics) in the exercise intervention group compared to usual care alone. For patients with panic disorder with or without agoraphobia, 8 weeks of aerobic exercise had an additive anxiolytic effect to CBT alone . Across a variety of anxiety disorders (GAD, social anxiety disorder, and panic disorder), similar results have also been observed when walking is added as an intervention to group CBT . Summarizing a systematic review of exercise for anxiety, Javakody and colleagues conclude that “exercise seems to be effective as an adjunctive treatment for anxiety disorders”.
What types of exercise are most effective for treating anxiety symptoms?
The anxiolytic effects of exercise have been examined in a number of trials. Interesting questions are “which exercise is most helpful for reducing anxiety?” and “do different anxiety disorders respond to different forms of exercise?”. Evidence addressing these questions is fairly limited. There is growing support for the idea that individuals with panic disorder benefit from aerobic exercise such as running, particularly as an adjunct to psychological therapy . A 2011 study examined the effectiveness of aerobic and resistance exercise for the treatment of GAD and found that both groups had similar reductions in trait anxiety after a 6-week intervention . When looking at the exercise intensity, several RCTs have indicated a benefit of moderate/hard intensity over low intensity exercise on anxiety symptoms [40,44]. A fair summary of the current research is that exercise appears to be helpful for anxiety disorders, but more data is needed to determine which exercise type and intensity is most helpful for each individual condition.
Exercise and psychosis
People diagnosed with psychosis and schizophrenia experience symptoms including hallucinations and delusions. Standard psychiatric treatment for schizophrenia is antipsychotic medication, which is somewhat effective at managing the positive symptoms such as hallucinations and delusions, although it is less effective at treating the negative symptoms such as anhedonia, emotional flattening, and behavioral withdrawal [45,46,3,47]. Antipsychotic medications are also associated with side effects including weight gain, lipid abnormalities, and metabolic syndrome. For these reasons among others, adherence to medication is often poor [47,3].
A growing body of research supports the use of exercise interventions to augment standard treatment and improve negative symptoms in patients with schizophrenia (e.g. [46,48,49,3]). In 2015 Elisa Vera-Garcia and colleagues published a systematic review in Psychiatry Research  which considered the effectiveness of physical therapy interventions within the multi-disciplinary management of schizophrenia. Their review included 13 randomized controlled trials representing 549 participants. Specifically, they looked at studies which included aerobic exercises, strength exercises, relaxation training, body awareness exercises, or a combination of all of these. Their results clearly demonstrate that aerobic, strength exercises and yoga reduce psychiatric symptoms while improving health-related quality of life. They conclude that “There is currently sufficient scientific evidence to conclude that aerobic exercise reduces negative symptomatology and improves cardiorespiratory fitness.” 
Exercise and addiction
There is substantial evidence to suggest that acute exercise participation can reduce cravings, improve withdrawal symptoms, and attenuate triggers in heavy cigarette smokers [51,52,53]. Exercise may also help individuals resist urges to use other substances such as alcohol, high-energy foods, and psychoactive drugs [54,55]. Although evidence supporting the effect of exercise for those with problematic alcohol use appears to be more mixed, with Hallgren and colleagues  reaching the conclusion that “exercise appears not to reduce alcohol consumption but has significant improvements in other health outcomes including depression and physical fitness”.
Attention Deficit/Hyperactivity Disorder and Exercise
Individuals with attention deficit hyperactivity disorder (ADHD) display symptoms of inattention, hyperactivity, and impulsivity and are often treated with a combination of medication and psychosocial interventions. It is one of the most frequently diagnosed neurodevelopmental disorders in school-aged children, with a worldwide prevalence rate of 5.29% . Medication is largely effective at improving behavioral symptoms, executive functioning, and productivity  although it is associated with side effects such as sleep difficulties and mood changes .
In 2016 Ruta Vysniauske and colleagues published a meta-analysis in the Journal of Attention Disorders  exploring the effects of physical exercise on children who met criteria for ADHD. Ten studies with a total of 300 participants were included in the analyses, with the average age of participants being 9.3 years old. Compared to no-exercise conditions they found a significant and medium-sized effect of physical exercise upon functional outcomes in ADHD. Similarly, a 2015 systematic review and meta-analysis published in Child Care Health and Development concluded that “The main cumulative evidence indicates that short‐term aerobic exercise, based on several aerobic intervention formats, seems to be effective for mitigating symptoms such as attention, hyperactivity, impulsivity, anxiety, executive function and social disorders in children with ADHD” .
Mechanisms by Which Exercise May Influence Mental Health
So we know that exercise can be an effective way of improving mental health, but why is it effective? A useful way of understanding why is to systematically consider the biopsychosocial factors.
Biological mechanisms by which exercise improves mental health
There are several biological pathways by which exercise may improve mental health. These include:
- Brain Derived Neurotrophic Factor (BDNF). BDNF is a protein that is thought to play a role in neurogenesis, neuroprotection, synaptic transmission , and is an important component in the extinction of fear . Exercise has been shown to increase resting BDNF levels with aerobic exercise leading to greater increases than resistance exercise .
- Increased stress tolerance. Exercise is thought to decrease activity of the sympathetic nervous system and activity in the hypothalamic-pituitary-adrenal (HPA) axis . The effect of this is that individuals are less reactive to stress and are therefore thought to be more resilient to daily stressors.
- Inflammation. There are a number of theories which posit that depression in some individuals is underpinned by inflammation which results in ‘sickness behaviors’ [65,66]. Aerobic exercise can be used to reduce inflammation in both the periphery and the brain  and “Exercise is a promising intervention for the prevention and treatment of various diseases characterized by chronic inflammation” .
- Endorphins / endocannabinoids. Traditionally the mood changes resulting from aerobic exercise such as running have been attributed to the increase in endorphins . However, more recent research suggests that endocannabinoids (eCBs) could largely explain the anxiolytic and analgesic effects of aerobic exercise . eCBs bind to the same cannabinoid receptors as the psychoactive component in cannabis or marijuana, therefore making the term ‘runners high’ somewhat appropriate .
Psychological mechanisms by which exercise improves mental health
There are several psychological pathways by which exercise may improve mental health. These include:
- Exercise promotes a sense of mastery and achievement. Depression is a state of inertia and people who are depressed tend to have lower than usual levels of activity and achievement. Physical activity is a behavioral ‘antidote’: patients increase their activity levels with the resulting opportunity to increase self-mastery and sense of achievement.
- Exercise assists the expenditure of anxious energy. Anxiety is characterized by avoidance and an overactive ‘fight or flight’ response. When the sympathetic nervous system is activated during a state of anxiety, the body gears up to expend energy by fighting or running away. Exercise is a safe and socially acceptable way of expending this energy in order for the parasympathetic nervous system to activate and bring the body back to a relaxed state.
- Exercise promotes development of improved self-esteem. Exercise can lead to an improved body image, body satisfaction or acceptance through a perceived increase in physical competence and ability in different aspects of fitness. All of which can positively influence self-esteem or self-estimation and promote a sense of autonomy and control [71,11].
Social mechanisms by which exercise improves mental health
There are several social pathways by which exercise may improve mental health. These include:
- opportunities to mix with other people through engagement in social activities such as exercise classes or running clubs;
- improved sense of belonging and significance through relationships with exercise leaders or others in the exercise group .
- increased social skills, social interest, and social communication resulting from group exercise .
What are the benefits of using exercise as a treatment for mental health conditions?
Exercise comes with a number of benefits when compared with other interventions for mental health difficulties:
- Exercise can be low-cost. Exercise does not come with the considerable costs associated with psychological or medical treatments. “The evidence reveals that especially brief exercise training counselling is an efficient, effective, and cost-effective means to increase physical activity… and to bring considerable clinical benefits to various patient groups.” 
- Exercise leads to physical health benefits. Exercise comes with a host of other beneficial effects and can often mitigate some of the adverse side effects of medication. These benefits include a lower risk of death and many non-communicable diseases such as cancer, stroke, and coronary heart disease.
- Exercise can be done independently by clients. Exercise interventions do not require expert medical assistance and can be performed alone, with friends, or a qualified exercise professional. Some patients may feel empowered when they understand that they have the capacity to improve their mental health difficulties with physical exercise.
- Exercise is non-stigmatizing. Some people may feel embarrassed about receiving therapy or medication for mental health problems but “exercise does not carry the same stigma as psychotherapy or medications; indeed most people are proud to say they exercise” 
- Exercise has social benefits. Physical activity can be a social activity. Group exercise therapy and classes can provide clients with a means of ongoing group interaction and represents a form of exposure therapy for those with social anxiety disorder.
Innovative ways of integrating physical exercise into psychological treatment plans
A number of studies have integrated exercise into psychological treatment programmes. Some innovative uses of exercise as an additive intervention are worth reviewing.
Exercise in the treatment of PTSD
A 2018 study by Van Woudenberg and colleagues, published in the European Journal of Psychotraumatology  integrated physical exercise sessions into a treatment program for PTSD. Notable features include:
- Three hundred and forty-seven individuals with PTSD were invited to attend and intensive 8-day treatment program over 2 weeks (4 days per-week).
- Psychological treatment consisted of prolonged exposure (PE) in the morning and EMDR therapy in the afternoon. Daily physical exercise sessions were also offered alongside an evening psycho-education program. The physical activity on offer included walking, badminton, archery, and for physically impaired patients, table tennis. Patients were instructed to choose their own exercise intensity level.
- At the end of the study 82.9% of patients reported clinically significant improvements in their PTSD symptoms and over half (54.9%) no longer met criteria for PTSD.
- The authors concluded that their results show “that an intensive treatment format combining PE, EMDR, physical activity, and psycho-education is a potentially effective and safe treatment alternative for patients suffering from severe PTSD, complex trauma histories, and multiple comorbidities”.
Exercise in the treatment of PTSD
A 2016 study by Rosenbaum and colleagues published in Acta Psychiatrica Scandinavica  augmented usual care for PTSD with exercise:
- The researchers allocated forty-two patients to usual care alone and thirty-nine patients to usual care with an exercise intervention.
- Usual care consisted of psychotherapy, pharmaceutical interventions and group therapy and treatment length was around 3 weeks for an in-patient group and several months for the larger out-patient group. The exercise intervention consisted of a weekly supervised exercise session, two unsupervised home-based sessions, and individualized daily step count targets using a pedometer for 12 weeks
- Compared to the usual care group the exercise group demonstrated an additional moderate and significant reduction in PTSD symptoms. Large and significant reductions in waist circumference and depressive symptoms were also observed in the exercise group compared to the non-active controls.
- The researchers concluded that “the findings of the current controlled trial provide support for the use of structured exercise as an augmentation strategy for the treatment of people with PTSD.”
Exercise in the treatment of binge eating disorders
In 2004 Fossati and colleagues published a study comparing a traditional cognitive behavioral approach for treating binge eating disorders with the addition of a nutritional and physical activity program .
- Sixty-one women who met criteria for binge eating disorder were split into three groups: 13 in a traditional CBT group, 23 in a nutritional-CBT group, and 25 women in a nutritional-CBT with physical activity group.
- The CBT consisted of 12 weekly 90-minutes sessions which included the use of daily food records, the creation of eating schedules, and cognitive restructuring. The nutritional-CBT group received nutritional education designed to reduce the amount of fat consumed alongside the CBT treatment. Those in the physical activity group were also given physical activity recommendations such as taking the stairs instead of the elevator and advised to plan 30 minutes of structured activity three times per week, every week.
- They found that the addition of physical activity and nutritional education to CBT led to the greatest reductions in eating disorder scores, and that participants in these groups lost significantly more weight than the other two approaches. The largest reductions in measures of anxiety and depression were also observed in the physical activity group.
Practical ways that therapists can integrate exercise into their psychological treatments
Exercise is a helpful and evidence-based intervention for anxiety, depression, and as an augmentation therapy for a range of other disorders. There are lots of helpful ways that psychological therapists can recommend and integrate exercise into their client’s treatment programs.
Increase client’s motivation to exercise
Exercise takes effort and some of the gains are not immediate. It is helpful to build your client’s motivation to begin exercising, and to persist despite the short-term discomfort that can result. Some ways to increase your client’s motivation to exercise include:
- Provide information. Provide clear information about the physical and mental health benefits of exercise, particularly written information. There is evidence from multiple research studies that “exercise prescription or motivational messages in printed form or by computer are more effective than face-to-face counselling alone” 
- Think about goals and values. Discuss your patient’s short, medium, and long-term goals and values. A useful acronym to remember when goal-setting is SMART: are the goals specific, measurable, achievable, realistic, and time bound? Is being physically and mentally healthy consistent with their values? Helping your patients to remind themselves of their values is a proven approach to help them ‘stay on course’.
- Monitoring progress. Exercise is Medicine (EIM), a global health initiative urges health-care providers to assess their patients’ level of physical activity at every clinical visit. “The more often a provider discusses physical activity with their patient, the more likely that person is to both recall such advice and to engage in regular physical activity. . Record whether tasks are being attempted, whether goals are being met, and monitor current physical activity levels. A useful framework for assessing your clients current physical activity levels is the Physical Activity Vital Sign (PAVS).
- Correct misperceptions. Take the time to understand how your patient thinks about the relationship between exercise and energy and correct any misperceptions. Some patients think about exercise according to a ‘resource depletion’ model, a bit like liquid in a cup: they think that exercise will deplete their resources, leaving them less to do other things. Although intuitively appealing this metaphor is wrong, it is more helpful to think of exercise as being like an elastic band in a child’s toy: exercise ‘winds up’ the elastic band storing more energy in it. This approach is supported by the research – exercising regularly leads people to have more energy 
- Use technology. Some clients may find that integrating technologies such as pedometers, smart watches, and smart phone applications is helpful for them. Wearable technologies represent affordable and accessible ways to constantly remind clients about the importance of regular exercise and applications can help increase levels of physical activity through healthy competition and effective monitoring (e.g. Strava and MyFitnessPal).
- Don’t underestimate your motivational role. Engaging in psychological therapy is often a time when clients are motivated to change and receptive to new ideas. Having a therapist be interested in their experience of exercise and being willing to check-in, monitor, and explore difficulties can be extremely motivating. Also consider your position as a role model, “If we are going to talk the talk, then we must consistently walk the walk. When our patients observe us adhering to longevity enhancing health behaviors they are much more likely to do the same.” 
Identify barriers to exercise and help your clients to overcome them
Clinicians are used to working with their patient’s ‘barriers to change’ in therapy. When trying to help clients to engage in beneficial exercise it can be helpful to conceptualize ‘barriers to engaging in exercise’ as being similar to ‘barriers to completing homework tasks’. Interventions to help your patients overcome their barriers to exercise include:
- Make the implicit explicit. Make sure to discuss your client’s potential barriers to change, or potential barriers to integrating exercise into their lives. Forearmed is forewarned!
- Take a collaborative approach. Making life changes can be difficult, and change can be met with resistance. It is helpful to ‘sit alongside’ clients and to collaboratively problem-solve ways of making exercise fit into their lives.
- Think about obstacles. Try to consider practical obstacles (location, equipment), financial obstacles (money for the gym), and psychological obstacles (too anxious to leave the house, worried about being ‘the fat person’ in the gym, worried about people looking at me).
- Set reasonable ‘no-fail’ expectations. Some clients have rigid or black-and-white views about success and failure. The research appears to indicate that any exercise is better than none, and so any moves towards integrating exercise should be encouraged and rewarded. “Individuals should be informed that 30 minutes of moderate-intensity physical activity on most days of the week is a target and not a threshold required for achieving health benefits” 
|Barriers to exercise||Ways to overcome the barrier|
|Lack of knowledge||Understand client’s position on physical health and how important it is to them
Provide psychoeducation about physical and mental health benefits of exercise
|Lack of motivation||Information / education
Motivational interviewing techniques
Discussion of personal responsibility for health and wellbeing
|Lack of time||Prioritization of exercise
Activity scheduling – put activity in the diary, make choices about which activities are most important
Exercise while watching TV
|Financial restraints||Exercise at home
Take up walking / running
Use an off-peak gym membership
|Body image / self-consciousness||Join a single-sex gym
Attend single-sex exercise classes
Start by exercising at home
|Fatigue||Educate about physical vs. mental fatigue
Reinforce the idea that physical exercise will give you more energy
|Injury||Exercise non-injured areas
Take up low-impact exercise such as swimming
|Laziness||Join a club or class to increase motivation
Schedule and commit
Exercise with a friend and commit to each other
|Negative past experiences||Choose different activities
Take part in fun and motivating classes which focus on enjoyment rather than outcome
|Boredom||Mix it up, try different exercises
‘Gamify’ exercise with fitness tracking apps
Exercise with a friend
|Weather||Have different activities for different conditions
Join a gym
“Ultimately the key to motivating patients to exercise is to help them understand why exercise will benefit them. If they understand why exercise will benefit them, then most patients will find the means to do it.” 
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APA reference for this article
Jeavons, M. (2019). The therapist’s guide to exercise and mental health. Psychology Tools. Retrieved on [date], from https://www.psychologytools.com/articles/the-therapists-guide-to-exercise-and-mental-health/