European Journal of Public Health, Vol. 16, No.

2, 179184
The Author 2005. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/cki159 Advance Access published on August 26, 2005

............................................................................................................

Effects of physical exercise on depression,

neuroendocrine stress hormones and
physiological fitness in adolescent females
with depressive symptoms
Chanudda Nabkasorn1,2, Nobuyuki Miyai1, Anek Sootmongkol3,
Suwanna Junprasert2, Hiroichi Yamamoto1, Mikio Arita4, Kazuhisa Miyashita1

Keywords: adolescents, depression, exercise, female, randomized controlled trial

............................................................................................................
epression is considered a disease that could create a greater
worldwide burden than ischaemic heart disease, cerebrovascular disease or tuberculosis.1 In recent years, depression has
become increasingly more prevalent among adolescent females
on a worldwide scale.2,3 It appears likely that subclinical depression in adolescence is related to depressive episodes, substance
abuse, higher levels of neuroticism, academic underachievement,
unemployment and early parenthood.4,5 Although depression is
a treatable condition, when associated with maladjustment in an
emotionally unstable individual it is a likely cause of suicide.6 It
is therefore suggested that preventive interventions should be
targeted to this group to improve social consequences and
reduce the risk of developing major depression.
Physical exercise has been proposed as a treatment for a
variety of improved states of physiological and psychological
health. A number of experimental and observational studies
have been conducted using samples that included clinically
depressive patients and members of the general population.7,8
However, most of these studies were limited by inadequacies,
such as use of small or heterogeneous groups, poor application

of exercise regimens and deficient assessments.8 There is little

methodologically sound research that has specifically focused
on an adolescent female population. In addition, the endocrinological measurements such as urinary cortisol and catecholamine secretions were widely utilized in the study of
evaluating the levels of psychophysical stress and depression.
Some previous studies have shown a reduction of these stress
hormones in connection with an alleviation of the psychological
state.9,10 Furthermore, in general, depressive persons are physically sedentary in their daily life and have reduced physical work
capacity compared with healthy individuals.6 This indicates that
depressive state is associated with physiological wellbeing and
may predispose an individual to diseases related to physical
inactivity and limited functional capacity.
Accordingly, we designed a randomized controlled trial to
investigate effects of physical exercise on the depressive conditions, neuroendocrine stress hormones and physiological fitness
variables in adolescent female volunteers with non-clinical,
mild-to-moderate depressive symptoms.

.............................................................

Methods

1 Department of Hygiene, School of Medicine, Wakayama Medical

University, Wakayama, Japan
2 Department of Mental Health and Psychiatric Nursing, Faculty of
Nursing, Burapha University, Chonburi, Thailand
3 Department of Physical Education, Faculty of Education, Burapha
University, Chonburi, Thailand
4 Department of Internal Medicine, School of Health and Nursing
Science, Wakayama Medical University, Wakayama, Japan
Correspondence: Nobuyuki Miyai, PhD, Department of Hygiene,
School of Medicine, Wakayama Medical University, PO Box 6418509, 811-1 Kimiidera, Wakayama, Japan, tel./fax: 81 73 4410646,
e-mail: miyain@wakayama-med.ac.jp

Subjects
A total of 266 female volunteers, aged 1820 years, were
recruited from students in the university nursing program in
Chonburi, Thailand. They participated in a screening examination for depressive symptoms by using the Centre for Epidemiologic Studies Depression (CES-D) rating scale.11 Out of all
subjects, cases of depressive state, defined by commonly used
cut-off score of 16, were found in 114 subjects. This subgroup
returned 4 weeks later so that their symptoms and other health

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Background: Regular physical exercise may improve a variety of physiological and psychological factors
in depressive persons. However, there is little experimental evidence to support this assumption for
adolescent populations. We conducted a randomized controlled trial to investigate the effect of physical
exercise on depressive state, the excretions of stress hormones and physiological fitness variables
in adolescent females with depressive symptoms. Methods: Forty-nine female volunteers (aged 18
20 years; mean 18.8 0.7 years) with mild-to-moderate depressive symptoms, as measured by the Centre
for Epidemiologic Studies Depression (CES-D) scale, were randomly assigned to either an exercise regimen
or usual daily activities for 8 weeks. The subjects were then crossed over to the alternate regimen for an
additional 8-week period. The exercise program consisted of five 50-min sessions per week of a group
jogging training at a mild intensity. The variables measured were CES-D rating scale, urinary cortisol and
epinephrine levels, and cardiorespiratory factors at rest and during exercise endurance test. Results: After
the sessions of exercise the CES-D total depressive score showed a significant decrease, whereas no effect
was observed after the period of usual daily activities (ANOVA). Twenty-four hour excretions of cortisol
and epinephrine in urine were reduced due to the exercise regimen. The training group had a significantly reduced resting heart rate and increased peak oxygen uptake and lung capacity. Conclusions: The
findings of this study suggest that a group jogging exercise may be effective in improving depressive state, hormonal response to stress and physiological fitness of adolescent females with depressive
symptoms.

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European Journal of Public Health

conditions could be re-evaluated and eventually confirmed.

Subjects were excluded if they (i) had ever taken any antidepressant medication, (ii) had symptoms or illnesses that limited
physical activity, and (iii) had engaged in regular, vigorous
sports activity during the prior 6 months. After a strict assessment, 62 of 103 participants presented a mild-to-moderate level
of depressive symptoms1214 and had none of the criteria
for exclusion. Consequently, 59 subjects agreed to participate
in a trial of physical exercise and signed a written informed
consent. The protocol was approved by the institutional ethics
committee.

After completion of the baseline assessment, subjects were

randomly divided into two groups (group A, n 28; group B,
n 31) and assigned to a 16-week two-way crossover trial. In
the first phase, group A started an 8-week physical exercise
program, and group B continued a usual daily routine and
served as non-exercising controls. Subjects were then crossed
over to the alternate condition for an additional 8-week period.
The weekly attendance at the exercise regimen was recorded, and
the total number of sessions over the period was calculated.
Throughout the length of two experimental periods, subjects
were instructed to maintain their usual level of physical activities
(with the exception of the above-mentioned exercise period)
and requested to keep records of the daily activities.

Outcome measurements
The main outcome measure was subject report of depressive
symptoms from the CES-D scale. Subjects were required to
complete the scale every 4 weeks during the experimental period.
The CES-D is a self-reported measure of the frequency of 20
depressive symptoms during the past week.11 The scale has been
shown to have valid and reliable psychometric properties when
used for adolescents.2,5 The score of this 20-item self-reported
scale ranges from 0 to 60, and the depressive level is considered
to advance with increasing scores. A cut-off score of 16 has
been used in adults to define cases of depressive state, yet use
of this definition has yielded estimated prevalence of adolescent
depression of more than 50%.1416 Roberts et al. suggested a
cutoff of 24 for adolescent CES-D scores on the basis of
improved ability to detect DSM-defined depression.12 Rushton
et al. created three levels of provability of depression: minimum
(015), mild (1623) and moderate/severe ($24).13 Further,
Garrison et al. proposed a cut-off score of 30 in adolescents
to indicate probable case of major depression.14 From these
reports, we tentatively categorized a mild-to-moderate depressive symptom as score of 1629 for the present analysis.
Twenty-four hour urinary secretions of cortisol and epinephrine were measured to assess psychophysical stress conditions.
Cortisol secretion was collected from the total urine for 24 h.
The calculations were performed using an automatic reagent
dispenser and determined by radioimmunoassay (Cobra autogamma model; Packard Bio Science Co., France). Urine epinephrine was collected for a 24-h period in 10 ml of 6 N HCl,
unless processed at once. The biochemical assays were performed
with liquid chromatography, and the value was determined
using a spectrofluorometer (model FP-777; Jasco Co., USA).
The urine epinephrine and urine cortisol specimens of each
subject were assayed separately in a laboratory. Pulmonary functional and exercise endurance testing were carried out to investigate training-induced improvements in physiological fitness
factors. The lung capacity was measured with a spirometer.
The endurance test was performed on a bicycle ergometer
(MONARD 818E, DIN 32932; Klassea, Sweden) by the multistage YMCA submaximal exercise test protocol. The heart rates
were measured when the subjects were seated at rest for 5 min

Intervention
Group jogging was used as the major physical exercise. The
subjects were encouraged to join the exercise class, which
consisted of 50-min sessions for 5 days per week for 8 weeks.
Each session began with a 5- to 10-min warm-up, continued
with about 30 min of group-based jogging exercise, and ended
with a 5- to 10-min cool-down. The exercise class was not strictly
supervised, rather, each subject jogged at her own speed. However, each session was attended by physical fitness instructors
who assisted the subjects and ensured that proper exercise
intensity was maintained. The intensity was adjusted to maintain a constant heart rate of less than 50% of the maximal
heart rate reserve, which was calculated by using Karvonens
formula.17

Statistical analyses
All statistical analyses were performed using the SPSS statistical
package 12.0 for Windows (SPSS Software, Inc., Chicago, IL,
USA). Repeated measures ANOVA followed by the Bonferroni
correction for multiple comparisons was applied for normally
distributed parameters, and the Wilcoxon test, for nonparametric parameters. An exploratory factor analysis for the
items of the CES-D scale was conducted to investigate what
common components of the scale more effectively respond to
physical exercise treatment. Data are presented as mean SEM.
The null hypothesis was rejected at P < 0.05 as the level of
significance.

Results
Of the 59 subjects who joined the present trial, five did not
complete the training regimen; three dropped out due to lack
of motivation and two attended less than three sessions per
week. In addition, five subjects who could not maintain the
usual level of physical activity constant in their non-exercising
period were also excluded. Consequently, data analyses were

Figure 1 Changes in the total scores of CES-D scale across

the screening and 16 weeks of experimental periods by groups.
Data are expressed as mean SEM. *P < 0.05,
**P < 0.01 compared with baseline. P < 0.05 compared with
the end of the first phase of experiment

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Study design

and during the last minute of each incremental stage of exercise.

Peak oxygen uptake was estimated on the basis of the heart rate
increments to workloads.
The measurements were performed at the baseline and at
the end of the representative exercise and usual activity periods
of the trial. Exceptions were made for the premenstrual period
and for 2 or 3 days after the initiation of menstruation.

Exercise in depressed adolescent females

181

Table 1 The result of exploratory factor analysis for 20 items CES-D scale in 266 adolescent female volunteers
No.

Contents

F1

F2

F3

F4

Communality

I had trouble keeping my mind on what I was doing

0.659

0.084

0.130

0.197

0.497

I felt depressed

0.544

0.389

0.240

0.245

0.565

I felt that I could not shake off the blues

0.501

0.169

0.199

0.209

0.363

20

I could not get going

0.491

0.397

0.272

0.165

0.500

10

I felt fearful

0.489

0.331

0.139

0.173

0.398

I felt that everything I did was an effort

0.442

0.121

0.274

0.171

0.315

I thought my life had been a failure

0.442

0.406

0.258

0.028

0.428

I felt lonely

0.415

0.336

0.367

0.258

0.486

I was bothered by things that usually dont bother me

0.401

0.087

0.266

0.218

0.287

11

My sleep was restless

0.363

0.126

0.045

0.276

0.226

17

I had crying spells

0.341

0.107

0.115

0.267

0.212

12

I was happy

0.282

0.645

0.104

0.169

0.535

16

I enjoyed life

0.167

0.587

0.254

0.138

0.437

I felt that I was just as good as other people

0.118

0.571

0.154

0.276

0.341

I felt hopeful about the future

0.054

0.429

0.099

0.088

0.205

15

People were unfriendly

0.187

0.222

0.712

0.035

0.593

19

I felt that people disliked me

0.273

0.096

0.659

0.097

0.527

18

I felt sad

0.421

0.403

0.451

0.268

0.615

I did not feel like eating; my appetite was poor

0.065

0.138

0.012

0.535

0.310

I talked less than usual

0.170

0.219

0.245

0.408

0.303

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14

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1

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2

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13

Exploratory factor analysis based on principal factor analysis and varimax rotation was conducted

performed on the 49 subjects (group A, n 21; group B, n 28).

The average ages of the group A and the group B were 18.7 0.2
and 18.8 0.1 years, respectively. Comparisons of the groups at
baseline revealed no significant differences as for CES-D
depressive score (group A, 20.1 0.9; group B, 18.8 0.7).
In the course of the 40 sessions, the subjects in group A exercised
an average of 31.3 0.6 sessions, and those in group B, 29.5 0.7
sessions.

For the CES-D scale, measuring psychological effects, among

subjects in the group A (training first) the total score decreased
as the results of training (P 0.003) (figure 1). During the
subsequent daily activity phase, it gradually increased but
was still significantly lower than baseline value (P 0.037).
The same result after training was also observed in group B
(P 0.008). No significant changes were observed after the
phase of usual daily routine. An itemized comparison of

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Figure 2 An itemized comparison of the 20 subscale items of CES-D scale between baseline and after the exercise training in both
groups of subjects. Data are expressed as mean SEM. *P < 0.05, **P < 0.01 compared with baseline

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European Journal of Public Health

Table 2 Endocrinological, cardiorespiratory and exercise testing data for both groups during two experiment periods
Variable

Group A (n 21)
Training first
Baseline

Group B (n 28)
Daily activity first
Training

Daily activity

Baseline

Daily activity

Training

Endocrinogical measurements

..............................................................................................................................
Cortisol (mg/day)

93.6 (7.5)

61.8 (8.0)**

74.4 (6.9)*

84.6 (6.4)

82.3 (10.3)

57.0 (8.5)*

Epinephrine (mg/day)

5.92 (0.36)

4.32 (0.28)*

4.85 (0.43)

5.31 (0.34)

6.17 (0.39)

4.14 (0.27)*

..............................................................................................................................
..............................................................................................................................
Physiological fitness factors

..............................................................................................................................
51.6 (2.6)

51.2 (2.4)

50.9 (2.5)

50.4 (0.9)

50.3 (1.0)

49.6 (1.0)

Peak VO (ml/kg/min)

33.6 (1.4)

38.1 (1.2)**

34.3 (1.4)

36.7 (1.5)

34.3 (0.8)

38.9 (0.9)*

116.5 (8.7)

131.6 (5.8)**

117.7 (6.4)

120.9 (7.2)

116.3 (4.9)

136.1 (5.0)*

. . . . . . . . . . .2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workload (watts)

..............................................................................................................................
Lung capacity (l)

1.76 (0.09)

2.00 (0.09)**

1.97 (0.08)

1.81 (0.06)

1.80 (0.07)

2.02 (0.06)*

Heart rates (beats/min)

81.7 (2.1)

78.7 (2.6)**

82.1 (2.2)

80.1 (2.4)

81.2 (1.7)

77.5 (1.5)**

..............................................................................................................................
Values are expressed as mean (SEM)
VO2 oxygen uptake. *P < 0.05, **P < 0.01 compared with baseline; P < 0.05,
training period

the 20 subscale items of CES-D scale between prior and after the
training regimen was conducted (figure 2). A significant
decrease in the score was found for eight items: item 3,
I could not shake off the blues, item 6, I felt depressed,
item 10, I felt fearful, item 11, My sleep was restless, item
14, I felt lonely, item 15, People are unfriendly, item 17, I had
a crying spell and item 18, I felt sad. Table 1 shows the factor
pattern matrix when exploratory factor analysis was applied
to the correlation matrix from the CES-D subscale items in
the original 266 female volunteers. The four common factors
of depression affect (F1), positive affect (F2), relation with
others (F3) and somatic symptoms (F4) were interpreted. The
eight items that had significantly decreased after training were
components in the factor of depressive affect (six items) and of
relation with others (two items).
Table 2 shows measured endocrinological, cardiorespiratory
and exercise testing data obtained at the baseline study and
following the training and daily activity phases. Compared
with the baseline, 24-h urinary cortisol (P 0.003) and epinephrine excretions (P 0.031) for the group A were significantly reduced as a result of training. These hormonal excretions
for the group B did not change after the usual daily routine, but
they were significantly lower after the training period (cortisol,
P 0.012; epinephrine, P 0.040). Following the exercise
training, both groups of subjects had a lower heart rate at
rest when compared with values after the daily activity phase
and at baseline. In addition, training-induced improvements
in cardiorespiratory fitness were significant for both groups,
as indicated by an increase of lung capacity and estimated
peak oxygen uptake, and a higher level of workload during
exercise test. After the daily activity phase, none of the data
differed significantly from baseline values. Mean body weight
did not alter significantly throughout the experimental period.

Discussion
We designed a randomized controlled trial of physical exercise
among adolescent female volunteers with mild-to-moderate
depressive symptoms. The results have demonstrated that a
mild level of group jogging exercise significantly alleviates
the depressive state and reduces the volumes of urine cortisol
and epinephrine excretions, as well as improving physiological
fitness conditions. These findings would lend support to the
assumption that regular physical exercise can promote a variety

P < 0.01 compared with the end of

of psychological and physiological conditions and may be beneficial in the primary care of adolescent females with depressive
symptoms.
It has been shown that most adults who experience recurrent
depression have an initial depressive episode as teenagers,18,19
suggesting that adolescence is an important developmental
period in which to intervene. Recent studies on the treatment
of depression in youth provide evidence supporting the efficacy
of medication20 and psychotherapy.21,22 The effect of exercise on
depression has been the subject of research for several decades
and the available literature is increasing. However, there is little
experimental research that has specifically focused on a sample
of adolescent female population. In addition, some critics have
noted that use of well-controlled and reliable research methods
is largely lacking.7 The present study used a randomized control
group by manipulating of the screening examination and based
on a crossover design. We applied a counterbalancing technique
to ensure that the subjects in different groups were drawn into
the same condition. This technique can help prevent possible
errors that could potentially occur at any period of the randomized controlled trial and come from carryover effects. Therefore,
with the process of counterbalancing and the design itself, the
protocol employed in this study could be considered empirically
a validated treatment that prevailed reliable and confident
results.23
The present study demonstrated a significant decrease in the
CES-D total depressive score after the sessions of physical exercise. In addition, the results from an exploratory factor analysis
in the CES-D 20 items revealed that physical exercise contributed to lowering the scores in items from common components
of depression affect and relation with others but not in
positive affect and somatic symptoms. The lack or loss of
social relationships may be a distinctive feature of depression.
Early studies emphasized that interpersonal problem plays a
major role in the development of depression.24 Furthermore,
the cognitive behavioural change that is experienced with
exercise has been proposed as a psychological mechanism for
its antidepressant effects.25 In this regard, a previous report
has noted minimal changes in the psychological variables for
individuals exercising alone rather than in a group format,26
suggesting the potential importance of the social aspects of
exercise on psychological outcomes. For the current study,
it is possible that a group-based exercise program could provide
a social relationship that would provide support among the

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Body weight (kg)

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Exercise in depressed adolescent females

these subjects were excluded from the data analysis despite their
high level of adherence to the program. This might influence
some of the results from this group obtained after the training.
Thirdly, the study sample was adolescent females with nonclinical, mild-to-moderate levels of depression, and it is thus
possible that the results obtained may not be transferable to
other populations with differences in age, severity of depression,
and social and cultural contexts.
In conclusion, depression is a condition that occurs throughout the general population, being especially prevalent among
adolescent females, and may extend to a large range of outcomes
with negative consequences for health. The present results
have demonstrated that group-based physical exercise program,
which can increase daily physical activity or social relationships
in adolescent female, improve not only the physiological fitness
levels but also the depressive state and the psychophysical
stress condition. Therefore, regular physical exercise is concluded to have a variety of benefits that may help promote
physiological and psychological wellbeing in adolescent females
with depressive symptoms.

Key points
 Does regular physical exercise improve physiological
and psychological factors in adolescent females with
depressive symptoms?
 A group-based jogging program increased the daily
physical activity or social relationships among the
participants.
 Physical exercise for 8 weeks reduced depressive state
and urine cortisol and epinephrine excretions, and
increased cardiorespiratory functions.
 Regular physical exercise may have a variety of benefits
of promoting physiological and psychological wellbeing
in adolescent females.

References
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Rushton JL, Forcier M, Schectman RM. Epidemiology of depressive

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participants, enhancing the motivation and adherence to the

program and possibly contributing to relatively high rates of
participation. The psychological benefits from exercise are likely
to be mediated not only by exercise itself but also by a variety of
sources. Other factors such as increased self-efficacy, mastery
and distraction associated with participating in physical activity,
may be responsible for alleviating symptoms of depression.
Another important result of our study is the significant reduction in the 24-h urine cortisol and epinephrine secretions after
the exercise regimen. The concentration of urine epinephrine
has been used as an indicator of sympathetic nerve activity in the
study of psychophysical stress and depression.27,28 It has been
shown that increased depressive mood state is associated with
stressful events, which influence the relationship between autonomic nervous system, endocrine system and immune system.8
Physical exercise appears to reduce urine epinephrine as a result
of the attenuation of sympathetic nervous tension. In our results, this assumption might be supported by the reduction in the
resting heart rate observed after training, indicating a decrease
of the sympathetically mediated cardiovascular response to
psychophysical stress. Such neuroendocrine action has been
considered a plausible mechanism to explain the effects of exercise on mood and depression.28 Likewise, the urine cortisol
concentration was lowered significantly from its level at baseline.
This result is consistent with those of investigators who have
demonstrated a reduction of cortisol secretion accompanying
an alleviation of the psychological state.9,10,29 Hypothalamicpituitary-adrenal (HPA) activation produces elevations of
cortisol by the pituitary gland, which secretes the adrenocorticotropic hormone, which in turn, has an effect on the adrenal
cortex, releasing corticosteroids. A previous report suggests
that physical exercise may reduce cortisol concentrations as a
tranquilizing effect of exercise.30 Although the mechanisms
mediating the beneficial effects of exercise on a depressive status
are still not clear, the reduction in the subjects neuromuscular
hyperactivity in the HPA axis may play a role in some part of
the antidepressant effects of regular exercise.
After exercise, the participants did increase their levels of
physiological fitness, as indexed by an increase of peak oxygen
uptake or improved performance on the cycle ergometer. It has
been demonstrated that depressive persons have significantly
lower physical work capacity than individuals from the general
population and that the reduced fitness levels are mainly due to
their poor physical activity in daily life.6 This evidence suggests
that depressive state is associated with physiological wellbeing
and may predispose an individual to diseases related to physical
inactivity and limited functional capacity. In fact, most epidemiological studies addressing this issue have revealed that
depression may lead to the development of cardiovascular disease through its association with the metabolic syndrome.31,32
Therefore, it is possible that physical exercise can be efficacious
in reducing the risk of such diseases as well as in promoting
psychological health by an increase of daily physical activity and
improvements in cardiorespiratory function.
Some limitations of the present study should be taken into
consideration. First, the study is limited by the inability to use a
structured psychiatric interview to follow-up the adolescents
that were identified by CES-D as having depressive symptoms.
The CES-D self-reporting scale is a questionnaire widely used
as a screening tool, especially in primary care and outpatient
settings, but it represents symptoms during the past week and
may include more transient or temporary symptoms than other
measures. However, at least in this screening procedure, we
assessed depressive state of subjects twice with an interval of
4 weeks so as to carefully identify a sample with depressive
symptoms. Secondly, five subjects from the group that received
exercise training first were allowed to participate in a physical
exercise class again during the period when no exercise was
scheduled. Because of the strict criteria applied to this study,

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European Journal of Public Health

11 Radloff LS. The CES-D scale: a self-report depression scale for research in the
general population. Appl Psychol Meas 1977;1:385401.
12 Roberts RE, Lewinsohn PM, Seeley JR. Screening for adolescent depression:
a comparison of depression scales. J Am Acad Child Adolesc Psychiatry
1991;30:5866.
13 Rushton JL, Forcier M, Schectman RM. Epidemiology of depressive
symptoms in the National Longitudinal Study of Adolescent Health.
J Am Acad Child Adolesc Psychiatry 2002;41:199205.
14 Garrison CZ, Addy CL, Jackson KL, et al. The CES-D as a screen for
depression and other psychiatric disorders in adolescents. J Am Acad Child
Adolesc Psychiatry 1991;30:63641.
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Received 1 September 2004, accepted 7 June 2005

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