Dr. Nicholas Fabiano proved he’s not afraid of controversy when he provocatively titled his editorial in the British Journal of Sports Medicine, “Could not prescribing exercise for depression be psychiatric malpractice?” While Fabiano may not have been making a legal argument, he is convinced that not including physical activity as part of psychiatric treatment is falling short of standard care.

“If we have a treatment that has the same effects as medications or psychotherapy, then we need to offer it to patients,” explains Fabiano, a psychiatry resident and researcher at the University of Ottawa. “If you're not giving patients the full array of options, then I don't think you're truly helping them make an informed decision, and that represents a form of malpractice.”

Fabiano’s editorial sparked considerable debate in medical circles and caught the attention of media outlets worldwide, including The Washington Post and Canada’s National Post. The piece has been picked up by nine news outlets, referenced by hundreds on social media, and helped earn Fabiano recognition as a “rising star” by Brain Medicine, a new neuroscience journal.

The Evidence Is Clear—Implementation Is Not

Fabiano's argument rests on what he describes as “hundreds of randomized controlled trials” demonstrating that exercise produces antidepressant effects comparable to medication and psychotherapy for mild to moderate depression. Population-level studies also show that physically active people are significantly less likely to develop depression in the first place.

“When we put these studies together and compare [them] to our other first-line measures like medications or therapy, the effects from mild to moderate depression are very similar,” Fabiano explains.

His position aligns with a recent comprehensive meta-analysis reaching similar conclusions about exercise's effectiveness as sometimes matching or exceeding pharmaceutical interventions.

Fabiano identifies multiple systemic obstacles preventing widespread adoption of exercise prescription. Chief among them is inadequate physician education. Most medical schools teach that exercise is good for a variety of health indications but fail to equip students with practical knowledge about intensity, progression, adherence strategies, or how to track patient progress.

“People feel ill-equipped to actually transfer that to clinical practice,” he says.

Psychiatrists can’t realistically supervise their patients' exercise programs while maintaining full treatment schedules. This makes collaboration with fitness professionals essential—and Fabiano emphasizes that such partnerships benefit both patients and providers.

“We know, based on the literature, that supervised exercise leads to greater adherence and also greater antidepressant effects,” he explains. “This is very important in the early phases of depression where innate features like lack of motivation, lack of energy, and lack of concentration are defining features of the condition.”