Mandala-based art interventions for anxiety and depressive symptoms in middle-aged and older adults: a systematic...

Mandala-based art interventions, which encompass structured coloring as well as open-ended drawing or painting, have gained increasing recognition as low-cost, non-pharmacological strategies for emotional regulation. Nevertheless, empirical evidence regarding their effectiveness, particularly among middle-aged and older adults, remains fragmented. To address this gap, the present systematic review and meta-analysis synthesized randomized controlled trials that evaluated the effects of mandala-based art interventions on anxiety and depressive symptoms in individuals aged 55 years or older. A comprehensive literature search was conducted in PubMed, Web of Science, Embase, SinoMed, and Wanfang from database inception to May 1, 2026. Two independent reviewers screened records, extracted data, and assessed risk of bias using the Cochrane risk-of-bias tool version 2. Pooled standardized mean differences (SMDs; Hedges' g) with 95% confidence intervals (CI) were obtained using random-effects models. Nine randomized controlled trials comprising 648 participants met the inclusion criteria. Relative to control conditions, mandala-based art interventions were associated with significantly lower anxiety symptoms (SMD = -0.95, 95% CI: -1.43 to -0.48, p < 0.0001; I ² = 85%) and lower depressive symptoms (SMD = -1.21, 95% CI: -1.86 to -0.56, p = 0.0002; I ² = 84%), although heterogeneity was substantial for both outcomes. Exploratory subgroup analyses by intervention frequency and mandala format were conducted descriptively. These subgroup findings should be interpreted as hypothesis-generating only because of the small number of studies, substantial heterogeneity, and absence of direct randomized comparisons. Sensitivity analyses did not change the direction of the pooled effects, but substantial heterogeneity persisted. The certainty of evidence was very low for both outcomes because of risk of bias, inconsistency, indirectness, imprecision, and the small number of trials. Therefore, the findings should be interpreted as preliminary rather than definitive evidence of clinical effectiveness. More rigorously designed, adequately powered, and transparently reported randomized trials are necessary before definitive clinical recommendations can be formulated.

PROSPERO, CRD420261389239.