More sessions generally produce greater mood benefit.
Supervised group exercise appears more effective than solo activity.
Combination of resistance + aerobic training appears better than aerobic exercise alone.
Indication
Mild to moderate depression.
Subthreshold depressive symptoms.
Can be used as:
sole therapy in appropriate patients
adjunctive therapy with psychological or pharmacological treatment.
Has a moderate effect on reducing depressive symptoms.
Some evidence suggests it may be comparable to psychological or pharmacological treatments in selected mild–moderate cases.
Precautions
Not recommended as sole therapy for severe depression.
Severe depression may reduce motivation, functioning and ability to participate.
Consider medication side effects that may impair exercise, e.g. tricyclic antidepressants causing:
sedation
orthostatic hypotension.
Introduce exercise gradually to reduce injury risk.
Perform cardiovascular risk assessment before starting.
Contraindications / cautions
Use caution in patients with eating disorders such as anorexia nervosa.
Overtraining or fixation on exercise may worsen physical or mental health.
Availability
Walking groups.
Active transport.
Community sport/recreation programs.
Gym programs.
GP practice walking groups.
Exercise physiologist referral.
Medicare rebate may be available for up to 5 allied health sessions under chronic disease management arrangements if depressive symptoms are chronic.
2. Internet-based or computerised CBT
Intervention
Internet-based CBT or computerised CBT.
Structured psychological programs based on CBT principles.
Can be self-guided or clinician-supported depending on the program.
Indication
Depression and anxiety.
Useful for mild–moderate depression and anxiety.
May also be used in moderate–severe depression, depending on risk and support.
Particularly useful for:
rural/remote patients
mobility limitations
patients with limited access to face-to-face therapy.
Clinical relevance
Around 85% of patients with depression have significant anxiety symptoms.
iCBT programs can address both depression and anxiety.
Precautions
Assess risk of self-harm or suicide before recommending.
Not suitable as sole management when urgent, high-risk or complex care is needed.
May not suit patients with:
borderline personality disorder
antisocial personality disorder
substance dependence
severe complexity requiring direct clinician input.
Advise patient to report:
no improvement
worsening depression
worsening anxiety
suicidal ideation.
Availability / Australian resources
MoodGYM.
THIS WAY UP.
Mental Health Online.
MindSpot.
myCompass.
OnTrack.
beyondblue online programs.
eMHPrac resources.
Mindhealthconnect-style online program directories.
Evidence
NHMRC Level 1 evidence.
3. Bibliotherapy for depression
Intervention
Guided self-help using a structured book.
Patient works through the book independently.
GP role is to:
support
motivate
clarify questions
monitor progress
maintain follow-up.
Indication
Mild to moderate depression.
Subthreshold depressive symptoms.
Can be sole or adjunctive therapy.
Best suited to patients who:
have reading age above 12 years
are motivated
have a positive attitude towards self-help.
Not indicated
Severe depression.
Suicidal ideation.
Patients needing more intensive or immediate care.
Depression features
Key symptoms:
persistent sadness or low mood
marked loss of interest or pleasure.
Associated symptoms:
disturbed sleep
fatigue or low energy
guilt or worthlessness
reduced concentration
indecisiveness
psychomotor agitation or slowing
appetite change
suicidal thoughts or acts.
Severity guide
Subthreshold: fewer than five symptoms.
Mild: few symptoms beyond diagnostic threshold; minor functional impairment.
Moderate: symptoms cause some difficulty with everyday activities.
Severe: most symptoms present and marked functional impairment — bibliotherapy alone not appropriate.
Suggested follow-up
Initial consultation:
explain bibliotherapy
set expectations
ensure patient actively chooses this option
create treatment and follow-up plan.
Follow-up at around 2 weeks, ideally 30 minutes.
Discuss barriers, motivation and whether patient finds it acceptable.
Ongoing contact can be face-to-face, phone or email.
Many studies used weekly contact and 3-month follow-up.
Practical tips
Choose books that are:
culturally appropriate
linguistically appropriate
suitable for the patient’s reading level.
GP should be familiar with the recommended book.
Reassure patient this is one option, not dismissal or rejection.
Change plan if not helping.
Evidence
NHMRC Level 1 evidence.
Key takeaway
For mild to moderate depression, consider evidence-based non-drug options:
exercise
iCBT / CCBT
bibliotherapy.
These can be used alone or alongside medication/psychological therapy depending on severity, risk, patient preference and access.
For severe depression, suicidality, high risk, psychosis, bipolar disorder, substance dependence or significant functional impairment, do not rely on self-help or exercise alone; arrange more direct clinical care and safety planning.