Rumination is a core modifiable cognitive risk factor for the onset and maintenance of mood and anxiety disorders. Exercise emerges as a safe, accessible, and scalable non-pharmacological intervention with potential to mitigate rumination and enhance mental health. This review synthesizes evidence on the neurobiological mechanisms and clinical efficacy of exercise interventions for rumination. Evidence suggests that exercise modulates activity in the default mode network and PFC-limbic circuits, and promotes the release of key neurotransmitters and neurotrophic factors. Therapeutic outcomes are influenced by exercise modality, intensity, frequency, and individual differences. Integrating exercise with psychotherapeutic or digital tools could produce synergistic effects. Future research requires large-scale, longitudinal trials to elucidate the underlying mechanisms and optimize personalized intervention strategies. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that Keywords: cognitive regulation, exercise intervention, mental health, neural mechanisms, rumination status released display-pdf yes is-olf no is-manuscript no is-preprint no is-journal-matter no is-scanned no is-retracted no Received 2026 Jan 12; Revised 2026 Feb 21; Accepted 2026 Feb 25; Collection date 2026. 1. Introduction Rumination is a maladaptive cognitive pattern characterized by repetitive and passive focus on negative emotions, personal experiences, and the potential causes and consequences of distress ( Zhu et al., 2025 ). In recent years, exercise has gained attention as a practical, sustainable, and multifaceted non-pharmacological intervention for mental health promotion ( Koffel et al., 2018 ; Fibbins et al., 2018 ; Rimer et al., 2012 ). Regular exercise improves physical health and may also positively influence rumination through mechanisms involving enhanced neuroplasticity, reduced stress reactivity, and improved affect ( Liang et al., 2021 ; Baskerville et al., 2023 ; Liu and Tang, 2024 ; Wang et al., 2025a ). Evidence suggests exercise can regulate rumination directly (e.g., by attenuating ruminative thoughts) and indirectly through mediators like increased psychological resilience and improved emotion regulation ( Wang et al., 2025b ; Guo et al., 2025 ; Liu et al., 2024 ). Reductions in rumination are associated with favorable behavioral outcomes; for instance, exercise may improve sleep quality by alleviating both rumination and depressive symptoms ( Liu et al., 2025 ; Abdollahi et al., 2017 ). 2. Exercise-induced suppression of default mode network activity Exercise can reduce rumination, in part, by attenuating hyperactivity in the default mode network (DMN). Recent evidence demonstrates that rumination is associated with increased functional connectivity between the DMN and the central executive network (CEN) ( Imperatori et al., 2026 ). This heightened connectivity correlates positively with general psychopathology. This finding directly implicates the DMN in ruminative processing and suggests that its interaction with the CEN influences broader mental health. Thus, interventions targeting these connections could directly improve psychological well-being. Infographic illustrating how exercise reduces rumination, highlighting three pathways: intervention parameters (single session versus sustained exercise), individual differences (high rumination, cognitive barriers, individualized support), and social context (social support through group or solo exercise), all leading to reduced rumination shown by a happy brain icon. 5.1. Individual factors: interindividual differences Individual differences significantly moderate the effect of exercise on rumination and mental health, with baseline rumination being a key moderator. Firstly, rumination can itself hinder exercise participation. For instance, negative expectations about physical activity can reduce motivation in children ( Ling et al., 2023 ). This implies that for individuals with high baseline rumination, initial interventions should focus on addressing cognitive barriers, not merely promoting exercise volume. Furthermore, rumination mediates the relationship between physical activity and mental health: exercise reduces rumination, which is associated with fewer internalizing problems ( McLaughlin and Nolen-Hoeksema, 2012 ; Huang et al., 2025 ). Future studies should therefore establish the dose–response relationship between exercise parameters and rumination reduction to guide precise, individualized prescriptions. 5.3. Implementation context: social and environmental factors The efficacy of exercise interventions for reducing rumination is also moderated by their social and environmental context. Group-based and individual exercise operate through distinct psychosocial mechanisms, leading to different outcomes. Group exercise provides interpersonal support and social embeddedness. For those sensitive to social comparison, non-competitive individual or supportive small-group formats may be preferable. Aligning the environment with an individual’s psychosocial profile is essential to maximize the mental health benefits of exercise. 6. Clinical applications and future directions 6.1. Practical application of exercise interventions in patients with depression Exercise is a key non-pharmacological strategy in the clinical management of depression. Evidence shows that physical activity reduces the frequency and intensity of rumination, thereby alleviating depressive symptoms through multiple mechanisms ( Chen et al., 2025 ). In summary, exercise is a viable adjunctive strategy for mental health. Future research requires large-scale, rigorous trials to clarify mechanisms, establish guidelines, and inform clinical implementation. Funding Statement The author(s) declared that financial support was not received for this work and/or its publication.

effects of mindfulness training on mental health outcomes. Empirical research further indicates that reductions in rumination mediate improvements in symptoms Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts Psy… Behavior therapies use behavioral techniques, including applied behavior analysis (also known as behavior modification), to change maladaptive patterns of behavior to improve emotional responses, cognitions, and interactions with others. Functional analytic psychotherapy is one form of this approach. By nature, behavioral therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behavior ultimately has), probabilistic (viewing behavior as statistically predictable), monistic (rejecting mind-body dualism and treating the person as a unit), and relational (analyzing bidirectional interactions). Cognitive therapy focuses directly on changing the thoughts, in order to improve the emotions and behaviors. Cognitive behavioral therapy attempts to combine the above two approaches, focused on the construction and reconstruction of people's cognitions, emotions and behaviors. Generally in CBT, the therapist, through a wide array of modalities, helps clients assess, recognize and deal with problematic and dysfunctional ways of thinking, emoting and behaving. The concept of "third wave" psychotherapies reflects an influence of Eastern philosophy in clinical psychology, incorporating principles such as meditation into interventions such as mindfulness-based cognitive therapy, acceptance and commitment therapy, and dialectical behavior Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. Numerous types of psychotherapy have been designed either for individual adults, families, or children and adolescents. While large-scale reviews support its benefits, debates continue over the best methods for evaluating outcomes, including the use of randomized controlled trials versus individualized approaches. A 2022 umbrella review of 102 meta-analyses found that effect sizes for both psychotherapies and medications were generally small, leading researchers to recommend a paradigm shift in mental health research. Although many forms of therapy differ in technique, they often produce similar outcomes, leading to theories that common factors—such as the therapeutic relationship—are key drivers of efficacy. In Germany, the practice of psychotherapy for adults is restricted to qualified psychologists and physicians (including psychiatrists) who have completed several years of specialist practical training and certification in psychotherapy. As psychoanalysis, psychodynamic therapy, cognitive behavioral therapy, and systemic therapy meet the requirements of German health insurance companies, mental health professionals regularly opt for one of these four specializations in their postgraduate training. In 1853, Walter Cooper Dendy introduced the term "psycho-therapeia" regarding how physicians might influence the mental states of patients and thus their bodily ailments, for example by creating opposing emotions to promote mental balance. Daniel Hack Tuke cited the term and wrote about "psycho-therapeutics" in 1872 in his book Illustrations of the Influence of the Mind upon the Body in Health and Disease, in which he also proposed making a science of animal magnetism. Contemporary theories of mindfulness-based interventions suggest that reductions in rumination, alongside increases in decentering, emotion regulation, self-compassion, and psychological flexibility, contribute to the beneficial effects of mindfulness training on mental health outcomes. Empirical research further indicates that reductions in rumination mediate improvements in symptoms of depression, anxiety, and psychological distress, highlighting rumination as a key mechanism through which mindfulness-based interventions exert their therapeutic effects. Psychedelic therapy has been compared with the shamanic healing rituals of indigenous people. Researchers identified two main differences: the first is the shamanic belief that multiple realities exist and can be explored through altered states of consciousness, and second the belief that spirits encountered in dreams and visions are real. The charitable initiative Founders Pledge has written a research report on cost-effective giving opportunities for funding psychedelic-assisted mental health treatments. A 2022 umbrella review of 102 meta-analyses found that most effect sizes reported for both psychotherapies and pharmacotherapies, compared to treatment-as-usual or placebo, were small for most disorders and treatments, and concluded that a "paradigm shift in research" was needed to advance the field and improve treatment strategies for mental disorders. One line of research consistently found that supposedly different forms of psychotherapy show similar effectiveness. According to the 2008 edition of The Handbook of Counseling Psychology: "Meta-analyses of psychotherapy studies have consistently demonstrated that there are no substantial differences in outcomes among treatments".

The primary outcome is the change in Ruminative Responses Scale (RRS) scores. Secondary outcomes include changes in depressive symptoms and dopamine D2 receptor availability. This trial will provide neurobiological insights into the dopaminergic mechanisms underlying pathological rumination and explore the therapeutic potential of D2 receptor modulation in this cognitive domain. Revised Detailed Description（Single-Blind Assessor-Blind Version） Background: Pathological rumination is characterized by repetitive, intrusive, and difficult-to-control negative thinking that often persists even after depressive symptoms remit. It has been recognized as a proximal risk factor for the onset, maintenance, and recurrence of major depressive disorder (MDD). Recent meta-analyses and longitudinal studies have confirmed that rumination significantly contributes to poor treatment outcomes and is associated with trait-like persistence across diagnostic and symptomatic states. Rationale: Aripiprazole, a partial dopamine D2 receptor agonist, has shown potential in augmenting antidepressant therapy by improving cognitive control and reducing rumination.