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Comparative efficacy of green exercise versus indoor exercise for depression and anxiety: a systematic review and
Yun Liang1, Da-Yuan Wei1, Su Min1
1Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Background:
Physical activity is a proven intervention for depression and anxiety, but the optimal environment for exercising remains debated. While "green exercise" (in nature) is theorized to offer superior mental health benefits to indoor exercise, a comprehensive quantitative ranking of these modalities against a no-exercise control is lacking. We aimed to determine the comparative efficacy of green exercise, indoor exercise, and control conditions for improving mental health outcomes.
Methods:
We conducted a systematic review and network meta-analysis of randomized controlled trials (RCTs). We searched PubMed, Embase, Web of Science, and CENTRAL from inception to December 2024 for RCTs comparing at least two of the following: green exercise, indoor exercise, or a no-exercise/standard care control group in adults. The primary outcome was a composite measure of mental health, including symptoms of depression, anxiety, and psychological distress. A random-effects network meta-analysis was performed to calculate standardized mean differences (SMDs) and rank the interventions using P-scores. The protocol was registered with PROSPERO (CRD420261279222).
Results:
Fifteen RCTs involving 809 participants were included. The network of evidence formed a closed three-node loop. Compared to control, green exercise showed a large and statistically significant effect on improving mental health (SMD = -0.96, 95% CI: -1.66 to -0.25). Indoor Exercise showed a small, non-significant beneficial trend (SMD = -0.21, 95% CI: -1.08 to 0.67). In direct comparison, green exercise was significantly superior to indoor exercise (SMD = -0.75, 95% CI: -1.32 to -0.18). Ranking analysis confirmed green exercise as the most effective intervention with near certainty (p-score = 0.99). The superior effect of green exercise was maintained in a subgroup analysis of clinical populations.
Conclusion:
Green exercise is a highly effective intervention for improving mental health, demonstrating benefits significantly greater than both indoor exercise and no-exercise control conditions. These findings strongly support the integration of nature-based physical activity into clinical practice and public health strategies for mental wellness.
Systematic Review Registration:
PROSPERO, CRD420261279222.
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