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Dear Authors,
Thank you for submitting your manuscript to PeerJ.
The Reviewers' comments and suggestions have been adequately addressed; therefore the paper can be accepted for publication.
Kind regards,
Marialaura Di Tella
[# PeerJ Staff Note - this decision was reviewed and approved by Jafri Abdullah, a PeerJ Section Editor covering this Section #]
The reviewer has identified some outstanding issues that should be addressed in your next revision.
1.Basic Reporting
1.1 Language Expression
The manuscript is generally well-written, but some sentences are overly complex (e.g., Lines 77–80: "Mind-body exercises are practices that integrate physical movement with psychological concentration..."). These could be simplified for better readability.
Example of redundancy:
The phrase"It also compares the effects... It also examines..."appears twice in the Abstract (Lines 4–6).
Minor grammatical issues:
Line 80: "Subjectively, mind-body exercises help regulate attention..." → Consider rewording for conciseness (e.g.,"Mind-body exercises regulate attention...").
Line 162 "To reduce heterogeneity and enhance the internal validity..." → Could be streamlined (e.g., "To minimize heterogeneity...").
Suggestion：
Use shorter sentences where possible;
Avoid repetitive phrasing (e.g., "It also..." in the Abstract);
Consider professional editing for minor grammatical refinements.
1.2 Introduction and Background
Strengths:
Clearly establishes the global burden of depression/anxiety (Lines 58–69);
Justifies the focus on mind-body exercises (e.g., cost-effectiveness, physiological benefits like BDNF modulation);
Identifies deficiency in prior research (e.g., inconsistent findings on moderators like exercise type/duration).
Weaknesses:
The rationale for why mind-body exercises (vs. aerobic/resistance training) are particularly effective is underdeveloped.
Some cited studies (e.g., Tian et al., 2024) are mentioned without sufficient context.
Suggestions:
Expand on the mechanistic pathways (e.g., vagal nerve modulation, inflammation reduction) that differentiate mind-body exercises from other interventions.
1.3 Structure and Format
Overall Structure:
Follows PRISMA guidelines well. The "Methods" section is thorough but could be streamlined (e.g., duplicate details in search strategies).
Specific Issues:
Figure 1 (PRISMA Flowchart):Should specify reasons for full-text exclusions (e.g., "n=61 inconsistent interventions").
Subsection redundancy:"Literature Retrieval Strategy" and "Inclusion Criteria" overlap in describing database searches.
Suggestions:
Merge overlapping subsections (e.g., "Literature Retrieval" and "Inclusion/Exclusion Criteria").
Standardize terminology (e.g., "Tai Chi" vs. "Taijiquan").
1.4 Charts and Data
Strengths:
High-quality forest plots (Figures 2–3) and GRADE assessment (Figure 8).
Subgroup analyses (Tables 3–4) are well-presented.
Weaknesses:
Suggestions:
Clarify column headers in Table 1 (e.g., "Baseline severity" should specify measurement scales).
Add a brief interpretation of Egger’s test results (e.g., "No significant publication bias was detected, but small-study effects cannot be ruled out.").
2. Experimental Design
2.1 Research Methods
Strengths:
Rigorous protocol (PRISMA/PROSPERO registration).
Explicit inclusion/exclusion criteria (e.g., only RCTs with passive controls).
Weaknesses:
Exclusion of active controls (Line 164):This may inflate effect sizes. The rationale ("to isolate mind-body exercise effects") is valid but should acknowledge potential bias.
2.2 Data Analysis Methods
Strengths:
Appropriate use of Hedges’ g, random-effects models, and sensitivity analyses.
ubgroup analyses explore key moderators (e.g., exercise type, duration).
Weaknesses:
Heterogeneity Handling:
Depression outcomes had high heterogeneity (I²=89.98%), only partially explained by moderators.
No exploration of meta-regression for continuous moderators (e.g., age, baseline severity as continuous variables).
Suggestions:
Conduct meta-regression for continuous variables (e.g., age, baseline scores).
Discuss possible sources of unexplained heterogeneity (e.g., cultural differences, unmeasured confounders).
4.General Comments
4.1 Innovation and Contribution
Key Contributions:
Identifies dose-response relationships (e.g., Qigong, 31–60 mins, 3x/week for depression).
Highlights baseline severity as a moderator (greater effects in high-severity subgroups).
Strengths:
Comprehensive subgroup analyses.
Adherence to PRISMA enhances transparency.
4.2 Limitations and Improvements
Major Limitations:
1. Self-report bias (Line 536): All outcomes were questionnaire-based.
2. Lack of long-term follow-up (Line 559): No data on sustained effects.
3.Diagnostic heterogeneity (Line 549):Unclear if participants had clinical diagnoses or subthreshold symptoms.
5 .Confidential Notes to the Editor
Overall Evaluation:
The manuscript provides valuable insights but requires minor revisions for clarity and methodological transparency.
Key strengths: Rigorous analysis, clinically relevant findings.
Key concerns: Unexplained heterogeneity, potential effect size inflation.
Recommended Action:
Minor Revisions(address language, methodological justifications, and limitations).
6. Final Suggestion
Decision:Accept with Minor Revisions
Please take extra care to explain the contribution of this review in the light of the other recent reviews on this subject noted by Reviewer 1.
**PeerJ Staff Note:** Please ensure that all review and editorial comments are addressed in a response letter and that any edits or clarifications mentioned in the letter are also inserted into the revised manuscript where appropriate.
**Language Note:** The review process has identified that the English language must be improved. PeerJ can provide language editing services - please contact us at [email protected] for pricing (be sure to provide your manuscript number and title). Alternatively, you should make your own arrangements to improve the language quality and provide details in your response letter. – PeerJ Staff
GENERAL COMMENTS
This manuscript reports a systematic review and meta-analysis of the effects of mind-body exercise RCTs on depression and anxiety. The study shows a thorough review process, including adherence to PRISMA guidelines, clear inclusion and exclusion criteria, independent screening and extraction. Unfortunately, substantial concerns limit its potential for impact in the field. Major concerns include lack of novelty and impact, the decision to meta-analyze outcomes using only papers that compare mind-body exercise with no intervention, sub-group analyses that are underpowered to be confident in their findings.
Basic reporting
• The use of terminology related to mind-body interventions is consistent, though some terms (e.g., ‘negative emotions’) could benefit from further definition or clarification.
• The title references "effectiveness," whereas the manuscript interchangeably uses “efficacy”. These terms carry distinct methodological implications; consistent and accurate usage is critical.
• The rationale for focusing specifically on “mind-body exercise” needs clearer justification and literature support.
• The authors should provide a definition of what mind-body exercise is and why yoga, tai chi, and qigong would qualify as “mind-body” exercises.
• The background would benefit from a concise synthesis of prior meta-analyses on mind-body interventions, clarifying how this review addresses unresolved gaps or methodological limitations in existing evidence.
• In Table 1, the study sample characteristics (e.g., clinical populations such as MDD) are insufficiently detailed.
• Multiple in-text citations erroneously list (e.g., Line 74: “Depressive Disorder (Depression), n.d.”). Ensure all references include accurate information and adhere to journal guidelines.
• One major concern of this study might be novelty. The manuscript fails to sufficiently articulate the unique research gap addressed by this review. Given existing meta-analyses on mind-body interventions for depression and anxiety, the authors must explicitly justify the novel theoretical, methodological, or clinical value of this work. It’s easily identified some recent published meta-analyses regarding the effects of mind-body exercise in depression and anxiety:
– Tian, S., Liang, Z., Qiu, F., Yu, Y., Mou, H., Zhang, G., & Zhang, H. (2024). Optimal modalities and doses of mind–body exercise for depressive symptoms in adults: A systematic review of paired analyses, network analyses and dose–response meta‐analyses. Applied Psychology: Health and Well‐Being, 16(4), 2598-2614.
– Lin, X., Zheng, J., Zhang, Q., & Li, Y. (2024). The effects of mind body exercise on anxiety: a systematic review and meta-analysis of randomized controlled trials. Mental Health and Physical Activity, 100587.
– Zou, L., Yeung, A., Li, C., Wei, G. X., Chen, K. W., Kinser, P. A., ... & Ren, Z. (2018). Effects of meditative movements on major depressive disorder: a systematic review and meta-analysis of randomized controlled trials. Journal of clinical medicine, 7(8), 195.
• Simply reporting the effects on depression and anxiety within one manuscript is not inherently novel for conducting a SR&MA. The authors should provide strong justification which emphasis novelty and significance of current review compared with the previous similar reviews.
• Line 212-213: The authors should specify how/which analysis were conducted for “effect size pooling, subgroup analyses, heterogeneity assessments, and sensitivity evaluations”
• It’s usually unclear whether the authors are describing depressive symptoms in patients with MDD or anxiety, or anxiety in MDD patients?
• How many and which studies were about depression and anxiety should be specified in Results.
• The objective of the review could be more focused. Consider narrowing or specifying the outcome definition for ‘negative emotions’ to improve clarity.
• A common feature of tai chi, qigong, yoga, and other such practices, is the potential of dilution of the more holistic elements, and yoga in particular can be taught in a way that mostly emphasises the physical poses, with little encouragement to engage with them in a “mind-body” way. Without checking to what extent the ingredients and instructions would have encouraged mindful engagement is a thus a limitation and needs to be addressed in the discussion.
• It would be important to investigate the effects of exercise studies by control conditions (active vs passive), and the magnitude of change in outcome can be interpreted differently. Excluding trials with active controls risks inflating effect sizes. However, this review simply omitted the RCTs compared exercise with active controls. Justify this decision and discuss implications.
• Line 387-389: Any supporting literature for the statement “This superior efficacy may be attributed to Qigong’s explicit focus on synchronizing breathing with movement, a feature not commonly emphasized in Tai Chi or yoga instruction”? It also seems contradict to Line 376-377 “These practices integrate movement and breathing control with specific states of consciousness…”
• The conclusions reflect the findings but would benefit from more caution given the limitations of included studies (e.g., small sample sizes, self-reported outcomes). The authors also overstate the clinical implications of their findings from underpowered subgroup analysis.
1. Basic Reporting
1)Language Expression
The overall language expression is relatively clear, but some sentences have grammatical problems or are not expressed accurately enough. For example:
a) In the "Background" section, "This systematic review seeks to comprehensively evaluate the efficacy of mind-body exercises in alleviating depression and anxiety, investigate the differential impacts of distinct types of mind-body exercises, and elucidate whether variables such as cycle, duration, and frequency exhibit a dose-response relationship in enhancing mental health outcomes." The word "cycle" is not accurate enough. It is recommended to change it to an “intervention cycle" or "exercise cycle" to clarify whether it refers to the intervention cycle or the exercise cycle.
b) In the "Results" section, "The meta-analysis demonstrated that mind-body exercise significantly alleviates symptoms of depression (Hedges' g = -0.86, 95% CI [-1.24, -0.48], P < 0.001) and anxiety (Hedges' g = -0.38, 95% CI [-0.53, -0.23], P < 0.001)." The tense of the word "alleviates" is not accurate enough. It is recommended to change it to "alleviated" to be consistent with the tense of the research results.
2) Introduction and Background
The introduction section provides relatively sufficient background information, expounding on the prevalence of depression and anxiety disorders and their harm to health. It also mentions the effectiveness of exercise interventions, providing reasonable background support for the development of research. However, some of the cited literature is relatively old. It is recommended to add some relevant recent studies to enhance the timeliness of the background information.
3) Structure and Format
The structure of the paper basically conforms to the standard format of systematic reviews and meta-analyses, including introduction, methods, results, and discussion, etc., with clear levels and coherent logic. However, in the setting of some section titles and subheadings, it can be further optimized to improve readability. For example, "Subgroup analysis for depression" and "Subgroup analysis for anxiety" can be changed to more descriptive titles, such as "Subgroup Analysis of Mind-Body Exercise Interventions for Depression" and "Subgroup Analysis of Mind-Body Exercise Interventions for Anxiety", so that readers can more intuitively understand the content of each part.
4) Charts and Data
The overall quality of the charts is high, and they can clearly display the research results. However, the annotations of some charts are not detailed enough. For example, in "Figure 2 Forest plot of mind-body exercise interventions for depression" and "Figure 3 Forest plot of mind-body exercise interventions for anxiety", the specific meanings and interpretations of the forest plots are not described in detail. It is recommended to supplement detailed explanations of the forest plots, including the calculation method of the effect size, the meaning of the confidence interval, and how to interpret the data points in the graph, etc., so that readers can better understand the research results.
2. Experimental Design
1) Research Methods
The sample selection is relatively reasonable. 15 studies are included, with a total of 1,351 participants. The sample size is relatively large, which can provide certain statistical support for the research results. However, there may be certain limitations in the representativeness of the sample. For example, the research includes studies published from 2010 to 2024. Although it covers recent studies, some early studies may have certain limitations in research design and methodology. In addition, the research did not conduct a detailed stratified analysis of samples from different regions, cultures, and ethnic backgrounds, which may affect the general applicability of the research results. It is recommended to further expand the sample range in subsequent studies and increase the representativeness of samples from different backgrounds to improve the external validity of the research results.
2) Data Analysis Methods
The data analysis methods are relatively comprehensive, using a variety of statistical methods such as meta-analysis, subgroup analysis, sensitivity analysis, and publication bias assessment, which can conduct in-depth analysis and verification of the research results from multiple angles. It is recommended to supplement detailed descriptions of the statistical analysis methods in the methods section, including the selection basis of the random effects model and the fixed effects model, etc., so that readers can better understand the analysis process and result interpretation of the research.
3. Validity of the Findings
1) Reliability of the Results
The research results show that mind-body exercises have a significant alleviating effect on the symptoms of patients with depression and anxiety disorders, and this conclusion is statistically significant (P < 0.001), indicating that the research results have a high degree of reliability. However, there is a certain degree of heterogeneity in the research. For example, in the analysis of the intervention effect on depressive symptoms. Although some explanations for the heterogeneity have been provided through subgroup analysis and sensitivity analysis, some sources of heterogeneity have not been clearly identified. It is recommended to further explore the possible sources of heterogeneity, such as differences in the characteristics of the research objects and the specific implementation details of the intervention measures, etc., to improve accuracy.
4. General Comments
1) Innovation and Contribution of Research
This research systematically evaluates the intervention effect of mind-body exercises on the negative emotions of patients with depression and anxiety disorders and explores the impacts of different factors on the intervention effect, providing relatively comprehensive evidence support for the application of mind-body exercises in the field of mental health interventions. The research results not only provide specific guiding suggestions for clinical practice but also provide an important reference for the development of future related research and have high innovation and academic contribution.
2) Limitations and Improvement Suggestions for the Research
Although the research is relatively rigorous in design and implementation, there are still some limitations. For example, there are certain differences in the standardization of intervention measures and the selection of evaluation tools in the studies included in the research, which may affect the comparability and accuracy of the results; in addition, the research did not conduct a follow-up assessment of the long-term effect of the intervention, making it difficult to determine the long-term impact of mind-body exercises on mental health.
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