The effect of Tai Chi and Qigong practice on depression and anxiety symptoms: A systematic review and meta-regression analysis of randomized controlled trials

Accepted Manuscript The Effect of Tai Chi and Qigong practice on depression and anxiety symptoms: A systematic review and meta-regression analysis of randomized controlled trials Jianchun Yin, Rodney K. Dishman, Ph.D. PII:

S1755-2966(14)00046-5

DOI:

10.1016/j.mhpa.2014.08.001

Reference:

MHPA 149

To appear in:

Mental Health and Physical Activity

Received Date: 3 June 2014 Revised Date:

6 August 2014

Accepted Date: 6 August 2014

Please cite this article as: Yin, J., Dishman, R.K., The Effect of Tai Chi and Qigong practice on depression and anxiety symptoms: A systematic review and meta-regression analysis of randomized controlled trials, Mental Health and Physical Activity (2014), doi: 10.1016/j.mhpa.2014.08.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Highlights

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Effects were aggregated from thirty-five randomized trials of 2,765 participants Tai Chi and Qigong had small-to-moderate effects on depression and anxiety Higher-quality trials are needed with patients having elevated symptoms

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The Effect of Tai Chi and Qigong Practice on Depression and Anxiety Symptoms: A Systematic Review and Meta-Regression Analysis of

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Randomized Controlled Trials

Jianchun Yin and Rodney K. Dishman

Corresponding author:

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Rod K. Dishman, Ph.D. Department of Kinesiology Ramsey Center 330 River Road University of Georgia Athens, Georgia 30602-6554 [email protected]

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School of Sports and Health, East China Normal University, Ministry of Education, Shanghai, China Department of Kinesiology, University of Georgia, Athens, GA, USA

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Background: We extend findings from previous quantitative reviews of the effects of Tai Chi and Qigong exercises on symptoms of depression and anxiety in randomized controlled trials by examining whether effects varied according to participant characteristics, exposure, or features of research design.

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Methods: Thirty-five articles published before 1 April, 2013 involving 2,765 participants were selected according to PRISMA guidelines. Hedges d effect sizes were calculated and random effects models were used to estimate population variance of the observed effects and its

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moderators using meta-regression analysis.

Results: Tai Chi training reduced depression by a heterogeneous standardized mean effect size 0.36 (95% CI, 0.19 to 0.53); reductions were larger in participants having elevated

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symptoms at baseline. Studies with blinded allocation of participants had smaller effects. The homogeneous mean effect of Qigong on depression was 0.38 (95% CI = 0.25 to 0.51). The heterogeneous mean effect of Tai Chi on anxiety was 0.34 (95% CI = 0.02 to 0.66); reductions were larger when participants were Asian and smaller when they were older. The heterogeneous mean effect of Qigong on anxiety was 0.72 (95% CI = 0.4 to 1.03); reductions

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were inversely related to age and positively related to session duration and weekly frequency. Conclusion: Tai Chi and Qigong exercises have small-to-moderate efficacy for reducing symptoms of depression and anxiety. Higher-quality trials are needed that sample patients

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with elevated symptoms, use blinded allocation to conditions, and standardize Tai Chi and Qigong exposure in order to better determine clinical effectiveness and its modifiers.

Key words: anxiety, depression, meta-analysis, mindful exercise

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ACCEPTED MANUSCRIPT Cumulative results from randomized controlled trials supports that standardized forms of Western exercise training by patients reduces symptoms of depression (Cooney et al., 2013; Herring, Puetz, O'Connor & Dishman , 2012) and anxiety (Herring, O'Connor, &

Dishman, 2010; Ströhle, 2009), which are burdens on public health in the United States and

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Worldwide (Kessler et al., 2003; Kessler, Berglund, Demler, Jin, Merikangas, & Walters, 2005; Lopez et al., 2006). Estimates from the United States, Australia, and Europe indicate that 8-14% of women and 4-9% of men have some form of clinical depression at any point

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in time (Copeland et al., 2004; Kessler et al., 2005; Lehtinen and Jou¬kamaa 1994).

Lifetime prevalence among U.S. adults is 16% for major depression (Kessler et al., 2003) and 29% for any anxiety disorder (Kessler et al., 2005). Depression was among the 10

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leading risk factors of disability-adjusted life years (DALYs) in high-income nations during 2001 (Lopez et al., 2006). It is projected to rank second worldwide by the year 2020 and then first by 2030 (Mathers & Loncar, 2006). Depressive and anxiety disorders accounted for 40% and 15% of DALYs caused by mental and substance use disorders globally in 2010 (Whiteford et al., 2013). In the United States, mental disorders account 6%

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of all health care expenditures; more than half of that comes from depression and anxiety (Mark et al., 2007). Depression is the most costly brain disorder in Europe, accounting for 33% of the total mental health care costs and 1% of the gross domestic product (GDP) or

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total economy of Europe (Sobocki et al., 2006). The evidence from trials of Western exercise has been judged sufficiently strong to recommend the implementation of traditional exercise as an adjuvant to treatment of

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depression (Freeman et al., 2010; Rethorst & Trivedi , 2013) and anxiety (Asmundson et al., 2013). Growing evidence suggests similarly beneficial effects from the use of Eastern, mindful exercises such as Tai Chi and Qigong (Wang, Lee et al., 2013; Wang, Man et al., 2013; Wang et al., 2014), but the size of those effects and whether they vary according to participant characteristics, features of exercise exposure that are modifiable in clinical settings, and features of research design is less clear. Here we report on a comprehensive, systematic review and meta-regression analysis aimed to clarify these questions.

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ACCEPTED MANUSCRIPT Mindful exercise is a special type of physical exercise that adds a focus on state of mind. According to the IDEA Mind–body Fitness Committee (1997–2001), mindful physical exercise is characterized by ‗physical exercise executed with a profound inwardly directed contemplative focus‘ (La Forge, 2005, p. 7). Mindful exercises of

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Chinese Tai Chi and Qigong have gained the attention of practitioners and researchers in Western countries as a therapeutic intervention for improving the psychological well-being of individuals (Tsang, Chan, & Cheung 2008).

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Tai Chi is a traditional martial art that has been practiced in China for many centuries. It emphasizes continuous slow (flowing) movements with small-to-large expressions of motion, unilateral-to-bilateral shifts of body weight, and rotation of the trunk, head and

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extremities, combined with a deep diaphragmatic breathing and relaxation. During these movements, Tai chi practitioners have to control their center of gravity and remain very stable (Lan, Lai, & Chen ,2002 ; Wainapel et al.,2003). Qigong has a more ancient origin than Tai Chi. It is the over-arching, more original discipline that incorporates widely diverse practices designed to cultivate functional integrity and the enhancement of the life

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essence that the Chinese call Qi (Chen, 2003). In typical practice, bodily movements during Qigong generally are more restricted and less strenuous than in Tai Chi, typically including slow, flowing movements coordinated with deep rhythmic breathing and

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meditation during movement. Despite the fact that there are some discrepancies in practicing styles and gestures, Tai Chi and Qigong are both based on principles that are inherent to traditional Chinese medicine (Jahnke, Larke, Rogers, Etnier, & Lin, 2010). The

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fundamental principles of health-oriented Tai Chi and Qigong are mind-body interaction, including a perception of movement and spatial orientation, breathing regulation and tranquility (Esch, Duckstein, Welke, Stefano, & Braun, 2007; Gallagher, 2003). Tai Chi and Qigong have evolved as a form of complementary and alternative medicine used in the treatment of cardiovascular diseases (Yeh, Wang, Wayne, & Phillips, 2009; Pan, Yan, Guo, & Yan, 2013; Lee, Pittler, & Ernst, 2007); cancer (Zhang, Wang, Chen, & Yu ,2013; Soo, Chen, Sancier, & Ernst , 2007), chronic pain (Wang et al., 2010; Lee, Pittler, & Ernst, 2009), osteoarthritis (Wang et al., 2009; Chen & Liu, 2004), and improved balance and fall

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prevention among non-frail older adults (Gillespie et al., 2012; Leung et al., 2011). Several reviews of a small number of randomized controlled trails ( RCT) have suggested that Tai Chi or Qigong have similarly favorable effects on psychological well-being, particularly reduction in symptoms of depression and anxiety (Chi, Jordan, Guo, Xie, & Bai, 2013;

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Tsang, Chan, & Cheung, 2008; Wang et al., 2010; Wang, Lee et al., 2013; Wang, Man et al., 2013).

We located 6 published meta-analytic reviews of the effects of Tai Chi or Qigong on

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depression or anxiety. One review of 17 randomized controlled or non-randomized trials found that Tai Chi reduced depression and anxiety by heterogeneous standardized effects of -0.66 (95% CI= -0.29 to -1.03) and -0.56 (95% CI = 0.31-0.80), respectively (Wang et

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al., 2010). A second meta-analysis of 4 randomized controlled trials judged to be of moderate to high quality of older adults that compared Tai Chi with a waitlist control group reported a small homogeneous standardized effect on depression in older adults (–0.27; 95% CI = –0.52 to –0.02) (Chi , Jordan‐Marsh, Guo, Xie & Bai , 2013). An analysis of three studies of patients with type II diabetes reported small, homogeneous

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standardized effects of Qigong on symptoms of depression (−0.29; 95% CI, −0.58 to 0.00) and anxiety (−0.37;95% CI, −0.66 to 0.08) (Wang, Man et al. , 2013). A fourth systematic review and meta-analysis of 10 RCTs reported larger, heterogeneous

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standardized effects of Qigong exercise on depressive symptoms when compared to waiting-list controls or usual care only (−0.75; 95% CI, −1.44 to −0.06), group newspaper reading (−1.24; 95% CI, −1.64 to −0.84), or walking, stepping and stretching exercises

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(SD= −0.52; 95% CI, −0.85 to −0.19) (Wang, Chan et al., 2013). The fifth meta-analysis (Wang, Lee et al., 2013) was limited to three reports by the same investigators (Wang et al., 2005, 2009, 2010) judged to be of high quality that examined the effect of Tai Chi on depression among arthritis and fibromyalgia patients. The mean reduction in depression measured by the Center for Epidemiological Studies Depression scale was a homogeneous reduction of 6 points on the scale (95% CI of -7 to -5 points) compared to a wellness education and stretching group. Normalized to the population variance of that measure, the effect would approximate .75 SD. The sixth and most recent review of four

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trials (Wang et al., 2014) reported a mostly homogeneous standardized mean reduction in trait anxiety (-0.75; 95% CI, -1.11 to -0.40) after Qigong practice compared to wait-list control groups. Despite their seminal contributions to the growing knowledge base, those reviews did

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not provide a comprehensive review of the cumulative evidence using the same

methodology and did not fully consider how characteristics of participants, features of research design, or modifiable components of participant exposure to treatment might

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modify depression or anxiety outcomes. Therefore, we considered these potentially

modifying factors and conducted a comprehensive, systematic review and meta-regression

symptoms of depression and anxiety.

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analysis of randomized controlled trials to evaluate the effects of Tai Chi and Qigong on

Method

The meta-analysis was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement guidelines (Moher, Liberati, Tetzlaff & Altman, 2009).

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Data source and searches

Articles published before April 1, 2013, were located using searches of Google Scholar, MEDLINE, PsycINFO, PubMed, and Web of Science. The reference lists of

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articles and reviews were also manually searched. The search terms used were: ―Tai Chi‖, ―Tai Chi Chuan‖, ―Tai Chi Chih‖, ―ta'i chi,‖ ―tai ji,‖, ―Tai Ji Quan‖, and "taijiquan‖, ―qigong‖ ,―qi gong‖, ―qi training‖, ―chi gong‖, ―depression‖, ―anxiety‖ ―randomized

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trial‖, and ―randomized controlled trial‖. Study Selection

Inclusion criteria included (1) English language articles, (2) random assignment to

either Tai Chi or Qigong or to an inactive comparison condition (3) a depression or anxiety outcome measured at baseline and during or after Tai Chi or Qigong intervention. Investigations were excluded that (1) used Tai Chi or Qigong as one part of a multicomponent intervention but did not include the additional component (e.g. stress management or health education) in a comparison condition, (2) evaluated an acute session

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of Tai Chi or Qigong, (3) compared Tai Chi with Qigong or their practice with or without mindfulness, (4) compared Tai Chi or Qigong only with a drug or other active treatment, except Western exercise. Figure 1 presents the flow chart of study selection and exclusion. Effect Size Calculation

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Effect sizes were calculated by subtracting the mean change in the comparison

condition from the mean change in the Tai Chi or Qigong condition and dividing the

difference by the pooled standard deviation of baseline scores. Effect sizes were adjusted

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for small sample size bias (Hedges & Olkin,1985). A decrease in depression or anxiety

among Tai Chi or Qigong participants is indicated by a positive effect. The first and second author independently calculated all effect sizes (intraclass correlation coefficient, ICC-2,

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was .93) and then resolved any discrepancies in effect size results so that both authors were in agreement with all effect sizes and their standard errors included in the analysis. Data Synthesis and Analysis

A random effects model was used to aggregate mean effect size (ES) and to test variation in effects according to moderator variables using SPSS macros ESmean and

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MetaReg (Wilson & Lipsey, 2001). Heterogeneity of mean effects was tested using the Q and I2 (95% CI) statistics (Hedges & Olkin, 1985; Higgins, Thompson, Deeks, & Altman, 2003). Effects were nested within studies, which might systematically differ from each

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other. Therefore, to adjust for between-study variance and correlated effects within studies, a multi-level mixed model linear regression model with robust maximum likelihood estimation was also applied according to standard procedures (Hox, 2010; Cheung, 2008)

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in Mplus 7.1(Muthén & Muthén, 1998-2013). Parameters and their errors were estimated with clustering on study using the Huber-White sandwich estimator to calculate standard errors that are robust to heteroscedasticity and correlated effects (White, 1998; Froot, 1989; Williams, 2000). The number of unpublished or unretrieved studies of null effect that would diminish the significance of observed effects to P>.05 was estimated as fail-safe N+ (Rosenberg, 2005). Funnel plots were graphed and evaluated (Egger et al., 1997) to estimate possible publication bias (Sterne et al, 2011). Selection of Moderators

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there was an empirical or logical rationale why the variable could moderate depression or anxiety responses to Tai chi or Qigong exercise (see Table 1). We divided the moderator into three categories on the basis of participant variables (i.e., pre-exercise depression or

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anxiety levels, illness type), exercise features (i.e., duration or frequency of sessions), or characteristics of research design (timing of assessments, type of comparison group,

whether allocation was blinded, and whether intent-to-treat analysis was used). Each level

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of categorical moderators was coded according to planned contrasts (Rosenthal 1991) (see Tables 2-4). In multi-level models, the effect of each moderator was first tested separately by comparing each conditional model (which included the intercept and the moderator)

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with the unconditional intercept-only model using a likelihood ratio test and the adjusted Bayesian Information Criterion (BIC) (Muthén & Muthén, 1998-2013).

Results

Study characteristics

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Although Tai chi and Qigong share the same principle of traditional Chinese medicine, they are not conventionally viewed by investigators or practitioners as the same type of mindful exercise. So, we conducted separate analyses of Tai Chi and Qigong

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effects. In Tai Chi studies, a total of 36 effects (25 for depression and 11 for anxiety) were retrieved from 20 studies. In Qigong studies, 33 effects (21 for depression and 12 for anxiety) were retrieved from 15 studies. Most effects (53 of 69) were from studies that

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included participants who had a medical condition: cancer (2 effects), cardiovascular disorders (5 effects), chronic obstructive pulmonary disorders (4 effects), fibromyalgia (5 effects), pain- related disorders (4 effects), psychological disorders(14 effects), diabetes (2 effects）neurological disorders(4 effects), osteoarthritis (3effects),cerebral vascular disorders (3 effects),withdrawal symptoms (2 effects), chronic physical illness, not specified (2 effects), obesity (1 effect), rheumatoid arthritis (1 effect), ankylosing spondylitis (1 effects). Primary outcomes in most studies were focused on physical functions or biomarkers related to diseases (e.g., percent of fat, blood pressure, cerebral

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Cumulative samples sizes were 1435 participants in Tai Chi studies and 1330

participants in Qigong studies. Participants‘ mean age was 67.70 ± 11.16 years in Tai chi studies and 53.51 ± 25.1 years in Qigong studies. Tai Chi or Qigong training consisted of

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1-5 sessions per week, 30-120 minutes per session, and 8-48 weeks duration. Adherence to training ranged from 57%-100% of prescribed sessions, when reported. The depression measures used (k=studies) were the Center for Epidemiological Studies Depression Scale

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(k=9), Beck Depression Inventory (k=4), Geriatric Depression Scale (k=4), Profile of Mood States –Depression (k=3), Hamilton Rating Scale-Depression(k=2), Depression Anxiety Stress Scale–Depression (k=2), Symptom Checklist-90-R Depression (k=1)， Quality of Life Questionnaire-Depression (k=1), General Health Questionnaire 60Depression (k=1) , Self -Rating Depression Scale (k=2),Childhood Depression Inventory

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(k=1) and the Cornell Depression Scale (k=1). Anxiety was measured using State-Trait Anxiety Inventory (k=3), Profile of Mood States-Tension/Anxiety (k=2), Depression Anxiety Stress Scale –Anxiety (k=4), General Health Questionnaire 60-Anxiety (k=1),

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Hamilton Rating Scale-Anxiety (k=3), Symptom Checklist-90-R Anxiety (k=1), Self -Rating Anxiety Scale (k=1) and the Quality of Life Questionnaire-Anxiety(k=1). Effects of Tai Chi on depression

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Twenty one of 25 effects (84%) were larger than zero. A forest plot of the

unweighted distribution of effects is presented in Figure 2. The mean effect size was 0.36 (95% CI, 0.19-0.53; Z = 4.12, p < .001) and was heterogeneous across studies, QB (24) = 51.0, p = .001 and I2 = 55% (43%-64%). In the multi-level model (χ2 (2) = 90.9, BIC = 97.4) the mean delta was 0.36 (95% CI = 0.17, 0.54) with non-significant residual variance (.05, SE = .033, z = 1.50, p = .135). The fail-safe number of effects needed to reduce the effect to a null result (N+) was 84. Egger‘s test for bias was significant, t =4.567, p < .001. A funnel plot (not shown) showed possible publication bias with non-significant, negative

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effects from the two largest samples (Fransen et al., 2007; Lam et al., 2012) and the largest, significant effect from the smallest study (Chou et al., 2004). However, the mean effect was 0.38 (95% CI, 0.22-0.54; Z = 4.64, p < .001) and remained heterogeneous (QB (21) = 33.2, p = .04 and I2 = 40% (22%-54%) in a sensitivity analysis, suggesting true heterogeneity

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(Sterne et al., 2011).

Moderator analysis. A summary of the univariate moderator results is presented in Table 2. Effect size differed according to baseline depression symptoms and whether

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allocation to trial conditions was concealed. Effects were larger when participants had

elevated depression at trial outset and were smaller in studies that used blinded allocation to conditions (p<0.001). All other univariate depression moderators were non-significant

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(p > .05). In the multi-level model, the level of pre-trial depression symptoms remained positively related to the reduction in symptoms after Tai Chi intervention (beta = .019, SE = .007, z = 2.62, p = .009). Model fit (χ2 (3) = 85.7, BIC = 95.4) was improved compared to the intercept-only model (Δ χ2 (1) = 4.2, p = .040). The residual variance was .032 (SE= .030, z = 1.073, p = .283), indicating that 54% of the variance between effects was

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explained by the conditional model. Effects were also smaller in studies that used blinded allocation (beta = -.276, SE = .054, z = 5.119, p < .001). Mean ES was 0.12 (95% CI = -0.25, 0.50) when allocation to groups was blinded and was 0.43 (95% CI = 0.27, 0.60)

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when allocation was not blinded or not reported. Model fit (χ2 (3) = 83.8, BIC = 93.5) was improved compared to the intercept-only model (Δ χ2 (1) = 5.3, p = .020). The residual variance was .00 (SE= .013, z = .026, p = .980), indicating that all of the variance between

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effects was explained by the conditional model. When both moderators were included in a multiple regression model, blinded

allocation remained inversely related to depression reduction (beta = -.258, SE = .072, z = 3.607, p < .001) and accounted for all of the variance in effects. Baseline depression was not independently related to effect size (beta = .004, SE = .005, z = 0.854, p = .393). Model fit (χ2 (4) = 82.3, BIC = 95.0) was improved compared to the intercept-only model (Δ χ2 (2) = 17.8, p < .001). Effects of Qigong on depression

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Ninety percent (19 of 21) of the depression effect sizes were greater than zero. The mean effect size for depression was 0.38 (95% CI = 0.25, 0.51), Z = 5.7, p < .0001. The effect was homogeneous across studies, QB (20) = 27.1, p = .1326 and I2 = 29% (8%-47%). The

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fail-safe N+ was 223. Egger‘s test for bias was not significant, t =0.476, p = .639, and a

funnel plot (not shown) of the effects was symmetrical and did not present visual evidence of publication bias. In the multi-level model (χ2 (2) = 65.1, BIC = 71.2) the mean delta was

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0.38 (95% CI = 0.25, 0.50) with non-significant variance (.013, SE = .015, z = 0.88, p = .377) between effects. Therefore, no moderator analysis was conducted. Effects of Tai chi on anxiety

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Eight of 11 effects (72.7%) were larger than zero. A forest plot of the unweighted distribution of effects are presented in Figure 4. The mean effect size was 0.34 (95% CI, 0.02-0.66; Z = 2.09, p = .0365) and was heterogeneous across studies, QB (10) = 42.2, p < .0001 and I2 = 79% (71%-84%). In the multi-level model (χ2 (2) = 39.45, BIC = 44) the mean delta was 0.30 (95% CI = -0.09, 0.69) with a nearly significant variance (.194, SE =

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.103, z = 1.89, p = .059) between effects. The fail-safe N+ was 12. Egger‘s test for bias was significant, t =3.969, p = .003, but a funnel plot (not shown) revealed this occurred because of similarly sized studies rather than publication bias (Sterne et al., 2011).

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Moderator analysis. A summary of the univariate moderator results are presented in Table 3. Effect size was related to participants‘ age and race (p<0.001). Anxiety reduction was smaller for older participants (β = -.867, z = 5.418, p < .001. Planned contrasts showed

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that the effects for Asian participants (0.93, 0.042-1.44) were larger than for non-Asian participants (-.025, -.065-0.15). Contrasts for treatment allocation and intent-to-treat analysis were limited to the same studies and thus redundant. In the multi-level model, effects remained smaller for the oldest participants (beta = -.055, SE = .013, z = 4.187, p < .001). Model fit (χ2 (3) = 24.4, BIC = 30.6) was improved compared to the intercept-only model (Δ χ2 (1) = 4.3, p = .039). The residual variance was .008 (SE= .048, z = .0162, p = .871), indicating that nearly all of the variance between effects was explained by the conditional model. The moderating effect of race remained significant (beta = .793, SE =

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.334, z = 2.377, p = .017) and accounted for 69% of the variance between effects. However, model fit (χ2 (3) = 35.2, BIC = 42.3) was not improved compared to the intercept-only model (Δ χ2 (1) = 1.2, p = .174). Effects no longer varied according to allocation blinding (beta = .141, SE = .128, z =

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1.105, p = .269). Model fit (χ2 (3) = 62.9, BIC = 72.1) was worsened compared to the

intercept-only model (Δ χ2 (1) = 11.6, p < .001). When both moderators were included in a multiple regression model, age (beta = -.286, SE = .089, z = 3.21, p = .001) and race (beta = .597, SE = .121, z = 4.93, p < .001) were independently related to variation between

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effect size. Model fit (χ2 (4) = 25.6, BIC = 35.2) was improved compared to the

effects. Effects of Qigong on anxiety

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intercept-only model (Δ χ2 (2) = 6.2, p = .045) and accounted for all the variance between

All 12 effects (100%) were larger than zero. A forest plot of the unweighted distribution of effects is presented in Figure 5. The mean effect size was 0.72 (95% CI, 0.40-1.03; z=4.45, p < .0001) and was heterogeneous across studies, QB (11) = 58.1, p <

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.0001 and I2 = 83% (77%-87%). In the multi-level model (χ2 (2) = 51.6, BIC = 56.6) the mean delta was 0.54 (95% CI = 0.23, 0.86) with a non-significant variance (.150, SE = .094, z = 1.59, p = .113) between effects. The fail-safe N+ was 20. Egger‘s test for bias was

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not significant, t =0.667, p = .522, and a funnel plot (not shown) of effects was symmetrical and did not present visual evidence of publication bias. The mean effect was 0.63 (95% CI, 0.38-0.87; Z = 4.93, p < .001) and remained heterogeneous (QB (9) = 23.3, p = .006 and I2

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= 66% (51%-76%) in a sensitivity analysis that excluded a small non-significant effect from the largest sample (Oh et al., 2010) and a large significant effect (d=2.4) from the smallest study (Li et al., 2002), suggesting true heterogeneity (Sterne et al., 2011). Moderator analysis.Several moderators were related to the overall effect, as shown in Table 4. Level of baseline anxiety, age, race, session duration and frequency, and trial length were related to variation in anxiety change. Anxiety reduction was larger when pre-trial anxiety was elevated (β = .76, z = 4.3, p < .001) and smaller for older participants (β = -.80, z = 4.07, p < .001). Anxiety reduction was positively related to session duration

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ACCEPTED MANUSCRIPT (β = .68, z = 3.3, p < .001) and weekly frequency (β = .62, z = 2.9, p = .0037), but was inversely related to the length of the trials (β = -.51, z = 2.1, p = .0329). Contrasts for change in the primary outcome, treatment allocation, and intent-to-treat analysis were limited to the same studies and thus redundant. In the multi-level multiple regression

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model, baseline anxiety (beta = .02, SE = .01, z = 2.1, p = .039), session duration (beta = .003, SE = .001, z = 2.97, p = .003), and weekly frequency (beta = .108, SE = .04, z = 2.5, p = .011) were independently related to anxiety reduction. Model fit (χ2 (5) = 41.2, BIC =

accounted for 99% of the variance between effects.

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Discussion

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53.6) was improved compared to the intercept-only model (Δ χ2 (3) = 14.6, p = .002) and

An American Psychiatric Association Task Force report on complementary and alternative medicine recommended Western exercise training as a potential adjuvant treatment for depressive disorder, but mindful exercises such as Tai chi and Qigong were not considered in the report (Freeman et al., 2010). The effects summarized here indicate

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that Tai Chi and Qigong have favorable, small-to-moderate effects on symptoms of depression and anxiety similar in size to the effects of Western exercise (Herring et al., 2010; Herring et al., 2012) that could be practically meaningful (Norman, Sloan, &

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Wyrwich, 2003). The results here are in accord with other recent experimental trials and literature reviews supporting the fact that mindfulness based physical activities are associated with reduction of depression and anxiety (Uebelacker et al. 2010; Yeung et al.,

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2013, Field, Diego, Delgado, & Medina, 2012). Qigong practice had a strong effect on anxiety symptoms of nearly three-quarters standard deviation. This result is different from a recent meta-analysis that included just three studies of patients with type 2 diabetes and reported a statistically non-significant reduction in anxiety after Qigong practice (-0.37, 95% CI -0.66 to 0.08) (Wang, Man et al., 2013), likely because of sampling bias. Tai Chi and Qigong practice usually involves movements with breathing, visualization and tranquility. (Yang, Hamilton, & Davis 2011 ;Palmer, 2007). All these elements are encouraged in Tai Chi and Qigong practice. An IDEA Mind–body Fitness

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ACCEPTED MANUSCRIPT Committee claimed that mindfulness is the key element of activities such as Tai Chi and

Qigong (La Forge, 1997), rather than perhaps metabolic or neurologic aspects of physical exertion. Because we located only one study that attempted to compare Tai Chi or Qigong with or without mindfulness (Wang, et al., 2007), we could not examine whether Tai Chi

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or Qigong movements alone or with other mindfulness elements are differently beneficial for reducing anxiety and depression. Determining whether mindfulness can be measured or manipulated during or after Tai Chi or Qigong practice presents a methodological

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challenge for understanding neurobiological mechanisms that might explain the

antidepressant and anxiolytic effects of Tai Chi and Qigong, much like past attempts to explain the effects of meditation (Rubia, 2009; Zeidan et al., 2014). Similar to the

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converse hypothesis of distraction, previously put for to explain anxiety reduction after standard Western exercise (Bahrke & Morgan, 1979; Breus & O‘Connor, 1999), future studies will need to exploit the limits of self-reporting of consciousness, brain imaging, and behavioral manipulations that alter states of consciousness (Berkovich-Ohana & Glicksohn, 2014).

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Tai Chi or Qigong practice was excluded from a recent systematic review and meta-analysis of randomized trials that concluded other meditative practices reduce symptoms of depression and anxiety in patients compared to alternative treatments (e.g.,

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progressive muscle relaxation or Western exercise) or non-specific comparison groups (e.g., education or attention-controls) (Goyal et al., 2014). In addition, positive expectations or social interactions may add to effects related to the Tai Chi or Qigong

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intervention. Future studies need to consider the mindfulness elements in the Tai Chi and Qigong exercise to figure out how much of their effects on anxiety or depression depend upon mindfulness, physical exertion, or alternatively, social features of the exercise environment. Not unlike Western exercise groups, social interactions among participants in classes may contribute to benefits. Also both the technical skill and teaching experience of

Tai Chi or Qigong leaders will likely influence participant outcomes and satisfaction, either through better learning or a more effective environment.

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ACCEPTED MANUSCRIPT Although standard Western exercise has shown promise for improvement of symptoms of depression and anxiety and reduction of risk of the onset of major depression (Physical Activity Guidelines Advisory Committee, 2008), very limited evidence exists about biological mechanisms that can explain the effects of physical

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activity or exercise on mental health. It is accepted that the brain and the rest of the

central nervous system regulate moods, emotions, cognitions, sleep, and neurological

functions, and that social and environmental factors interact with genes to regulate the

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brain. Experimental animal studies show that voluntary running activates and produces

adaptations in several aspects of brain neural circuits involved with emotional stress and behaviors that mimic features of human depression, and anxiety. These include

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monoaminegic and neurotrophic systems that are targets of drug treatments for depression and anxiety (Asmundson et al., 2013; Dishman, Berthoud, Booth et al., 2006; Dishman & O‘Connor, 2009; Mattson, 2012). A putative mechanism of physical activity that has been understudied is increased self-esteem, a core feature of psychological adjustment (Herring, O‘Connor, Dishman, 2014).

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Brain encephalographic activity is increased during and immediately after a single session of leg cycling exercise (Crabbe & Dishman, 2004), and brain blood flow and oxygenation to the frontal cortex are increased during moderate-to-hard cycling or

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treadmill exercise (Rooks, Thom, McCully, Dishman, 2010). Whether other brain regions involved with emotional and motivational responses are affected by Western Exercise has received little study (Boecker et al., 2008). Similarly, the acute or chronic effects of Tai

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Chi or Qigong practice on brain are unknown and require elucidation to help confirm whether brain neural networks likely activated or quieted during exercise can explain the apparent effects of mindful exercise on depression and anxiety, beyond what might be explained by expectancy or placebo effects (Lindheimer, O‘Connor, & Dishman, 2014). A primary aim here was to examine features of Tai Chi or Qigong exposure, participant variables, and research design features that might be modified to optimize the effect of Tai Chi or Qigong on anxiety and depression. The results showed that Qigong practice lasting up to 6 weeks resulted in significant anxiety-reduction effects compared

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to longer trials. Longer program durations led to favorable Qigong effects on physical and emotional function in women undergoing radiotherapy for breast cancer (Chen, et al., 2013) and depressed elders with chronic illness (Tsang, et al., 2013). Reed and Buck (2009) reviewed 105 studies of Western aerobic exercise and positive affect published

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from 1980 to 2008 and reported a moderate beneficial effect on self-reported affect with the optimal program 3 to 5 times per week. Here, reductions in anxiety after Qigong were

larger when the duration of practice was 90 or more minutes each session or the frequency

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of practice was six days each week. However, we did not find any other Tai Chi or Qigong exercise features that had a moderating effect on anxiety or depression. This finding is limited by the small number of effects in the different levels of these features. Exercise

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intensity, frequency, and duration are key features of Western exercise that determine overall exposure, which has been related to the size of anxiety and depression effects in some reviews (Physical Activity Guidelines Committee, 2008; Reed, & Ones, 2006; Kennedy & Newton,1997; Netz ,Wu, Becker, & Tenenbaum, 2005). We did not find any articles that defined the intensities of Tai Chi or Qigong. The primary reason may be that

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Tai Chi and Qigong practice are comprised of different gestures that are difficult to quantify. Although cardiac pace and oxygen consumption could be monitored by telemetry during mindful exercises, it is not as easy to manipulate or measure the actual

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work done as in typical Western exercises such as cycling or resistance training. Hence, future studies should better study the stimulus properties of Tai Chi and Qigong, particularly as they may influence physical activity participation and its outcomes,

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consistent with prior calls to better understand the impact on health of physical activity types and amounts (Physical Activity Guidelines Advisory Committee, 2008). About 60% of US adults say they do enough exercise to meet public health guidelines (Tucker, Welk, Beyler, 2011), but less than 5% meet guidelines for health or fitness when physical activity is measured objectively (Troiano, Berrigan, Dodd, Masse, Tilert, & McDowell, 2008; Tucker et al., 2011). Estimates from Canada, Norway, and Sweden are similarly low (Colley et al, 2011; Drystad et al., 2014; Hagströmer, Troiano, Sjöström, & Berrigan, 2010). Many efficacy trials report high adherence rates (e.g., 75-85% of the prescribed

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number of sessions in trials lasting six to 24 months), but trials rarely report the extent to which participants who attend also comply with the prescribed intensities and durations of exercise (Miller et al., 2014). Other evidence suggests that up to 7% of individuals exposed to standard Western exercise training may actually experience adverse health outcomes

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(Bouchard et al., 2012). Hence, Tai Chi and Qigong practice may offer a health alternative to people who have trouble adhering or adapting to Western exercise.

In studies of Western exercise, the largest effects of exercise on depressive symptom

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were found when the primary trial outcome was improved among patients with elevated

baseline depression symptoms (Herring, et al., 2012). Here, 53 of 69 effects of Tai Chi or Qigong were from participants having some chronic health problem. However, neither the

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type of illness nor whether the primary trial outcome was improved affected depression or anxiety outcomes. In addition, baseline depression symptoms did not influence outcome size.

Previous studies have suggested that people from different cultures may experience different emotional responses to Tai chi or Qigong (Fischer, Rodriguez ,Vianen, &

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Manstead, 2004; Matsumoto, et al., 2002 ). We located no studies that examined whether different cultural backgrounds of exercisers influenced Tai Chi and Qigong outcomes. Nonetheless, the larger reductions in anxiety after Tai Chi among Asian participants might

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indicate that they were more comfortable doing Tai Chi or have greater expectancies in terms of benefits. However, experience or skill of practitioners were not well described in the studies we reviewed, and we found no studies that compared practitioners with novices.

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However, in the few studies that used Western exercise as the comparison group (Brown, et al.,1995; Frye, et al., 2007; Yeh, et al., 2012; Putiri, et al., 2012; von Trott, et al., 2009; Stephens, et al., 2008; Liu, et al., 2012), 4 effects on depression (mean d = 0.59, P = .051), 3 effects on anxiety (mean d = 0.34, P = .182) after Tai Chi and 4 effects on depression after Qigong (mean d =0.06, P =.713) were larger or similar to the effects of Western exercise. We found no evidence that age modified the effects of Tai Chi, but participants who were under 60 years of age had larger reductions in anxiety after Qigong compared with those over 60 years of age.

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Although double-blind allocation is not feasible in exercise interventions, 18 effects were derived from trials that blinded treatment allocation from investigators. Reductions in depression and anxiety symptoms after Tai Chi were smaller in trials that reported blinded allocation. The 27 of 69 effects (39%) derived from trials that used intent-to-treat analysis

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did not differ from effects of efficacy trials. However studies that reported adverse events had smaller effects on depression after Tai Chi (p=0.0003).However, this finding should be interpreted with caution because only 5 of the 25 depression studies reported adverse

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events.

Several other cautions should be considered when interpreting the strength of the evidence reviewed here. Although key design features such as blinding of treatment

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allocation, whether intent-to-treat analysis was used, and the degree of treatment adherence were unrelated to depression treatment outcomes, those tests of effect moderation were limited by the relatively small number of studies in some moderator levels (e.g., Wang et al., 2014). Other measures of design quality such as method of randomization could not be adequately evaluated in many studies. Most studies sampled

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patients having various chronic illnesses. However, representation in each type of illness was limited to a few studies, precluding a strong test of whether effects of Tai Chi and Qigong differ according to type of illness. Likewise, most studies reported a significant

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improvement in the primary outcome of the study, precluding a strong test of whether such improvements are necessary for improvements in depression and anxiety, as has been shown for the effects of Western exercise on symptoms of depression in patients

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with a chronic illness (Herring et al., 2012). Also, the effects of Tai Chi or Qigong on depression and anxiety may have been confounded in some studies by a common method bias of using self-report measures for primary outcomes. Although length of the trials, which varied widely, was not an independent moderator of effect size, the small number of studies of common length precluded a strong test of whether outcomes depend on exposure to the intervention. Tests of whether acute exposure to Tai Chi and Qigong sessions altered outcomes were similarly limited, especially for Tai Chi where nearly all sessions lasted between 40 and 60 minutes. Additionally, the studies conducted in Eastern

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articles published in English, because the Asian language papers we found had previously

Conclusion

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been judged as having low quality of methods (Wang, Lee et al., 2013).

The cumulative evidence tentatively supports that the practice of Tai chi or Qigong is accompanied by small-to-moderately sized antidepressant and anxiolytic effects. However,

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more studies of high methodological rigor are needed to discount sources of design and

sampling bias and provide stronger tests of whether effects differ according to participant

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characteristics and Tai Chi or Qigong exposure such as those suggested here.

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pilot trial. Journal of Sport and Health Science. 2,104-108

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cellular immunity in post-surgical non-small cell lung cancer survivors: A randomized

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ACCEPTED MANUSCRIPT Table 1 definition for levels of moderator Effect Moderator

Levels

Participant Variables >50 <50

Health

Sample was healthy Sample included patients with a chronic illness Patients with physical illness Patients with psychosomatic /neurologic illness <30 30-60 >60 Age not specified

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Illness type

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T-score

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Age (yr)

Sample ≥60% Asian Sample <60% Asian

Country

Eastern country Western country

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Race

Tai Chi or Qigong features

1-20 21-40 41-60 >60min

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Session duration (min)

Program length (weeks)

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

1-6 6-12 12-24 >24 weeks

Frequency sessions/week) 1 2 3 4 ≥5 Features of research design

34

ACCEPTED MANUSCRIPT Timing of effect

Mid: effect was evaluated at the midpoint of trial Post: effect was calculated after trial ended Control: the comparison condition involved no treatment or usual care or wait-list participate in the intervention Placebo and other treatment: the comparison group was a placebo, drug therapy, or minimal intervention control Western exercise: the comparison group was a form of aerobic or resistance exercise training standardized according to recommended guidelines for fitness

Primary outcome

Primary outcome of the study changed significantly Primary outcome of the study did not change

Allocation

Evaluators of depression or anxiety symptoms were blinded to allocation group Not reported

Intent-to-treat

Effects were tested using intent-to-treat analysis Effects were tested using only participants who completed the trial

Adverse events

Incidents of adverse events reported No adverse events reported

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SC

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Comparison type

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

35

ACCEPTED MANUSCRIPT Table 2 summary of univariate moderator analysis for Tai Chi effects on depression Effect moderator

Contrast weight

Number of effects

Mean (95% CI)

Contrast p-value

p=0.0280

Participant characteristics

>50

14

0.40 (0.15-0.64)

≤50

11

0.31 (0.07-0.56)

7

0.35 (0.15-0.55)

18

0.38 (0.15-0.61)

Health status Non-patients

1

Patients

-1

Age (yrs) 4

0.55 (0.14-0.96)

>60

14

0.33 (0.10-0.55)

Not reported

7

0.33 (-0.02-0.65)

p=0.2387

Session duration (min)

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Race

p=0.8480

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30-60

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Baseline symptoms (T-score)

<45

1

-0.01(-0.26-0.24)

22

0.40 (0.21-0.60)

Asian

1

6

Non-Asian

-1/2

6

Not reported

-1/2

11

0.27 (0.07-0.47)

2

0.27(-0.11-0.66)

Mixed race

0.37 (-0.17-0.90)

45-60

1

90

-1

2

0.27 (-0.12-0.66)

8-12

1

16

0.42 (0.15-0.69)

14-16

-1/2

4

0.48 (0.18-0.77)

-1/2

3

0.15 (-0.10-0.40)

2

0.27 (-0.12-0.66)

1/2

3

0.36 (0.02-0.70)

1/2

12

0.39 (0.15-0.64)

-1/2

9

0.40 (0.03-0.76)

-1/2

1

-0.01 (-0.26-0.24)

1

2

0.28 (-0.08-0.63)

23

0.37 (0.19-0.56)

24-48 Not reported

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Trial length (weeks)

p=0.5516

0.47 (0.33-0.61)

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Tai chi exposure

p=.9304

p=0.2250

Frequency (days/week) 1 2 3 5

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p= 0.2718

Features of research design Timing of effect evaluation Mid-point Post

-1

p=0.7628

Comparison type No-treatment control

1

17

0.41 (0.25-0.57)

Western exercise

-1/2

5

0.41 (-0.05-0.87)

p=0.1007

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ACCEPTED MANUSCRIPT Placebo or other treatment

-1/2

3

-0.10 (-0.77-0.58)

Significant change

1

19

0.38 (0.18-0.58)

No change

-1

6

0.29 (-0.04-0.63)

Blinded

1

5

0.12 (-0.25-0.50)

Not blinded

-1/2

4

0.39 (0.10-0.68)

Not reported

-1/2

16

0.44 (0.24-0.63)

Yes

1

8

0.35 (0.01-0.68)

No

-1

17

0.38 (0.19-0.56)

1

5

0.005(-0.17-0.18) p=0.0003

Primary outcome p=0.7431

Allocation

Yes

p=0.4321

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Adverse event

p<0.0003

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Intent-to-treat analysis

-1 /2

6

0.32(0.06-0.57)

Not reported

-1/2

14

0.47(0.30-0.63)

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No

Baseline symptoms, age, session duration, frequency, trial length shown as categorical for descriptive purposes but were

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analyzed as ordinal variables

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37

ACCEPTED MANUSCRIPT

Table 3 Summary of univariate moderator analysis for Tai Chi effects on anxiety Effect moderator

Contrast weight

Number of effects

Mean (95% CI)

Contrast p-value

p=0.5659

Baseline symptoms (T-score) >50

1

9

0.26 (-0.08-0.61)

≤50

-1

2

0.71 (0.04-1.40)

Non-patients

1

5

0.20 (-0.23-0.64)

Patients

-1

6

0.45 (-0.224-0.9141)

2

1.16 (0.82-1.50)

-0.02 (-0.22-0.17)

Health status

SC

-1/2

>60

1

6

Not reported

-1/2

3

Asian

1

3

Non-Asian

-1/2

2

Not reported

-1/2

6

Race

Tai chi exposure

p=0.4293

p<.0001

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Age (yrs) 50-60

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Participant characteristics

0.54 (0.20-0.89)

0.93 (0.42-1.44)

p= 0.0002

-0.25 (-0.65-0.15) 0.23 (-0.02-0.47)

40-60

TE D

Exercise session duration (min) 11

0.34 (-0.21-0.66)

7

0.33 (-0.13-0.78)

4

0.37 (-0.01-0.74)

-1/2

1

0.32 (-0.36-1.00)

-1/2

3

0.03 (-0.22-0.28)

1

7

0.49 (0.15-0.97)

11

0.34 (0.21-0.66)

Program length (weeks) 7-12

1

13-24

-1

EP

Frequency (days/week) 1 2 3

AC C

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

p=0.8766

p=.2830

Features of research design Timing of effect evaluation Post

Comparison type

No-treatment control

1

7

0.39 (-0.09-0.86)

Western exercise

-1/2

3

0.35 (-0.16-0.85)

Placebo or other treatment

-1/2

1

0.17(-0.36-0.39)

Significant change

1

9

0.39 (0.20-0.76)

No change

-1

2

0.07 (-0.36-0.49)

p=0.7151

Primary outcome p=0.4715

38

ACCEPTED MANUSCRIPT Allocation Blinded

1

2

0.06 (-0.21-0.34)

Not blinded

-1/2

3

-0.10 (-0.52-0.32)

Not reported

-1/2

6

0.65 (0.23-1.08)

Yes

1

2

0.06 (-0.21-0.34)

No

-1

9

0.41 (0.01-0.81)

1

2

0.06(-0.21-0.34)

p=0.3428

Intent-to-treat analysis

Yes No

-1 /2

3

-0.20(-0.51-0.11)

Not reported

-1/2

6

0.79(0.56-1.02)

p=0.3428

RI PT

Adverse event

p=0.3428

SC

Baseline symptoms, age, session duration, frequency, trial length shown as categorical for descriptive purposes but were

EP

TE D

M AN U

analyzed as ordinal variables

AC C

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

39

ACCEPTED MANUSCRIPT Table 4 Summary of univariate moderator analysis for Qigong effects on anxiety Effect moderator

Contrast weight

Number of effects

Mean (95% CI)

Contrast p-value

p <0.0001

Participant characteristics >50

1

10

0.77 (0.46-0.75)

≤50

-1

2

0.50 (-0.03-1.04)

Non-patients

1

2

0.24 (-0.10-0.58)

Patients

-1

10

0.82 (0.45-1.18)

1

5

1.27 (0.70-1.83)

>60

-1/2

3

0.37 (0.01-0.73)

Not reported

-1/2

4

0.36 (0.13-0.59)

Asian

1

6

Non-Asian

-1/2

1

Not reported

-1/2

5

Health status

30-60

Exercise session duration (min)

0.41 (0.22-0.59)

1.27 (0.70-1.83)

1

45-60

-1/2

4

0.48 (0.26-0.70)

90-150

1

7

0.91 (0.36-1.47)

4

1.47 (0.92-2.01)

TE D

-1/2

0.48 (-0.04-1.01)

1

7-12

-1/2

6

0.31 (0.14-0.48)

-1/2

2

0.50 (-0.03-1.04)

-1/2

2

0.24 (-0.10-0.58)

-1/2

2

0.25 (-0.02-0.52)

1/2

2

0.50 (-0.03-1.04)

1/2

6

1.11 (0.59-1.64)

EP

1-6

13-24

p= 0.0271

0.17 (-0.14-0.48)

20

Program length (weeks)

p=0.0088

M AN U

Race

Qigong exposure

p=0.1744

SC

Age (yrs)

RI PT

Baseline symptoms (T-score)

p=0.009

p=0.0329

Frequency (days/week) 1 2 3 5

AC C

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

p=0.0037

Features of research design Timing of effect evaluation Mid

1

4

0.99 (0.10-1.87)

Post

-1

8

0.59 (0.31-0.87)

No-treatment control

1

8

0.69 (0.31-1.07)

Western exercise

-1/2

1

0.23 (-0.21-0.68)

Placebo or other treatment

-1/2

3

0.96 (0.67-1.26)

p=0.3208

Comparison type p=0.7526

40

ACCEPTED MANUSCRIPT Primary outcome Significant change

1

10

0.77 (0.39-1.14)

No change

-1

2

0.50 (-0.03-1.04)

p=0.5576

Blinded

1

2

0.50 (-0.03-1.04)

Not blinded

-1/2

7

0.91 (0.36-1.47)

Not reported

-1/2

3

0.46 (0.19-0.73)

Yes

1

7

0.97 (0.45-1.48)

No

-1

5

0.38 (0.16-0.60)

Yes

1

1

0.17 (-0.84-1.18) p=0.2673

Not reported

-1

11

0.77 (0.44-1.10)

Allocation

p=0.0722

SC

Adverse event

p=0.5576

RI PT

Intent-to-treat analysis

M AN U

Baseline symptoms, age, session duration, frequency, trial length shown as categorical for descriptive purposes but were

EP

TE D

analyzed as ordinal variables

AC C

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

41

ACCEPTED MANUSCRIPT Figure Captions Figure 1. flow chart showing selection of randomized controlled trials (RCT). Figure 2 .Forest plot of effects of Tai Chi on depression.

Figure 4. Forest plot of effects of Qigong on depression.

EP

TE D

M AN U

SC

Figure 5. Forest plot of effects of Qigong on anxiety.

RI PT

Figure 3. Forest plot of effects of Tai Chi on anxiety.

AC C

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

Figure 1

ACCEPTED MANUSCRIPT 1

RI PT

Figure 1 flow chart showing selection of randomized controlled trials (RCT). 294 Articles excluded (title and

database and manual search

abstract review, not a RCT)

SC

343 Articles identified via electronic

5 Excluded because acute session of exercise

M AN U

1 Excluded because compared with or without mindfulness when performing exercise

49 RCTS for full text evaluation

2 Excluded because Tai Chi or Qigong was one part of a multicomponent intervention

15 Qigong studies

or other treatment except Western exercise)

Tai Chi on depression (19 studies yielded effects)

Tai Chi on anxiety (7studies yielded effects)

AC C

EP

35 Studies included in meta-analysis

6 Excluded because comparison was with drug

TE D

20 Tai Chi studies

Qigong on depression (12 studies yielded effects)

Qigong on anxiety (7 studies yielded effects)

Figure 2

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

Figure 3

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

Figure 4

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

Figure 5

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT