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1 Can resistance training improve mental health outcomes in older adults? A

2 systematic review and meta-analysis.
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4 Running head: resistance training and mental health

5 Abstract
6 Purpose: This systematic review and meta-analysis aimed to analyze the effects of
7 resistance training (RT) and to compare the different RT prescriptions, sample
8 characteristics, and mental health outcomes (depressive and anxiety symptoms) in older
9 adults. Methods: All studies that were available on 28th April 2023. For the analysis of
10 intervention effects on depressive and anxiety symptoms, standardized mean differences
11 and standard errors were calculated. Meta-analyses using random-effects models,
12 employing robust variance meta-regression for multilevel data structures, with
13 adjustments for small samples. Results: For depressive symptoms, the mean effect was
14 - 0.94 (95%CI: -1.45 - -0.43, P< 0.01, I2= 93.4%), and for anxiety symptoms, the mean
15 effect was -1.33 (95%CI: -2.10 - -0.56, P< 0.01, I 2= 92.3%). The mean effect was -0.51
16 (95%CI: -0.67 - -0.35, P< 0.01, I2= 36.7%) for older adults without mental disorders,
17 and those with mental disorders the mean effect was ES= -2.15 (95%CI: -3.01 - - 1.29,
18 P< 0.01, I2= 91.5%). Conclusion: RT was able to improve mental health outcomes in
19 individuals with and without mental disorders, and some RT characteristics influenced
20 the effect of RT on mental health.
21 Key Words: depression; anxiety; mood; mental illness; strength training; aging.
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27 INTRODUCTION
28 Resistance training (RT) - also called strength training or weight training - is the use of

29 resistance to muscular contraction to build strength, anaerobic endurance, and size of

30 skeletal muscles (Ratamess et al., 2009). RT has been widely recommended for older

31 adults due to its positive influence on overall health and, mainly to counteract the age-

32 related decline in muscle mass and muscular strength (Fragala et al., 2019). Further,

33 beneficial effects of RT have been reported on several health outcomes, including

34 benefits for several cardiometabolic parameters (i.e., reducing glucose, lipoproteins, and

35 inflammatory markers) (Ashton et al., 2020; Mcleod et al., 2019), blood pressure

36 (Abrahin et al., 2021), body fat (Cunha et al., 2021), cardiorespiratory fitness (Hollings

37 et al., 2017), and the central nervous system (Herold et al., 2019).

38 Previous intervention studies investigating the effects of RT on mental health

39 parameters have shown inconsistent results (Ansai and Rebelatto, 2015; Cassilhas et al.,

40 2007; Cunha et al., 2022; Heissel et al., 2023; Huang et al., 2020), despite general

41 trends showing that RT is associated with reduced depressive and anxiety symptoms

42 (Gordon et al., 2017, 2018). Such inconsistent findings might be attributed to the

43 considerable differences concerning RT type (i.e., traditional RT vs home-based, elastic

44 band, or body weight), manipulation of RT-related variables (i.e., weekly frequency,

45 number of sets and exercise, and duration), and characteristics of the sample. For

46 instance, comparable physical outcomes such as muscle mass and muscular strength are

47 strongly influenced by the RT variables (e.g., appropriate selection of intensity of load

48 and/or training volume), and as a consequence, it may be associated with intervention-

49 induced changes in mental health parameters (e.g., depressive and anxiety symptoms)

50 (Shannon et al., 2023).

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51 Thus, a better understanding of the biological processes driving improvements in

52 anxiety and depressive symptoms is necessary to better tailor physical interventions and

53 their prescription (e.g., such as RT variables). Currently, several biological processes

54 might explain the positive influence of RT on depressive and anxiety symptoms (Figure

55 1). In particular, the following biological and social factors might explain the

56 improvements in depression and anxiety in response to RT: (i) body composition

57 (muscle mass, body fat), (ii) physical fitness (muscular strength), (iii) neuroplasticity

58 (e.g. BDNF, changes in hippocampus volume), (iv) neuroendocrine regulation (e.g.

59 HPA and cortisol regulation), (v) oxidative stress (e.g. TRAP, AOPP), (vi)

60 inflammation (e.g. IL-6, TNF-α), and (vii) psychosocial mechanisms (e.g. social

61 connectedness, self-esteem) (De Sousa et al., 2021; Kandola et al., 2019).

62 ***INSERT FIGURE 1***

63 Therefore, testing how the different types and manipulation of RT variables

64 could induce changes in depressive and anxiety symptoms is pivotal to formulating

65 effective intervention strategies, and to the best of our knowledge, although fewer

66 systematic reviews and meta-analyses on the manipulation of different RT variables

67 have been made (Gordon et al., 2017, 2018), there is still very little information about

68 the effects of different RT prescription on depressive and anxiety symptoms, especially

69 in older populations.

70 Previous systematic reviews and meta-analyses analyzed the effects of RT on

71 mental health outcomes (Gordon et al., 2017, 2018). However, some points deserve to

72 be highlighted: a) both studies were conducted some years ago (2017-2018) so an

73 update would be important, b) authors analyzed not only older adults, c), analyses of

74 different training variables could bring more information to the field, d) verify the
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75 effects of different types of RT (i.e., traditional RT vs alternative RT [elastic band

76 exercises, body weight exercises, home-based training), and studies with different

77 control groups were included (i.e., usual care, patient education, and other treatment).

78 Thus, this systematic review and meta-analysis aimed to address this gap in the

79 literature and give an update by summarizing the evidence concerning RT and changes

80 in mental health outcomes (depressive and anxiety symptoms) in older adults. The

81 following three questions were addressed: 1) is RT effective in improving mental health

82 outcomes in older adults? 2) is RT effective in improving mental health parameters in

83 older adults with and without mental disorders?; and 3) can different RT prescriptions

84 influence the adaptation of mental health outcomes?

85 METHODS

86 Protocol and registration

87 This review followed the Preferred Reporting Items for Systematic Reviews and

88 Meta-Analyses guidelines (PRISMA) (Page et al., 2021), and a search protocol was

89 developed and registered in the International Prospective Register of Systematic

90 Reviews (registration number: CRD42022342701).

91 Search strategy

92 The literature search was performed through PubMed/MEDLINE, Web of

93 Science, and Scielo databases. All studies that were available on 28th April 2023.

94 Searches were carried out using the following search syntax: ("Resistance training" OR

95 "Resistance exercise" OR "Strength training" OR "Weight training") AND

96 ("depression" OR "anxiety" OR "Major depressive disorder" OR "Generalized anxiety

97 disorder") AND ("Older people" OR "Aging" OR Elderly). Secondary searches were

98 performed for: (a) screening the reference lists of the included studies, and (b)
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99 conducting forward citation tracking of the included studies through Google Scholar.

100 Search strategy, article screening, data extraction, and quality assessment were done

101 independently and standardized by two authors (PMC and AOW). Disagreements were

102 resolved through discussion.

103 Inclusion Criteria/ Study Selection

104 The established PICOS principle to screen for relevant articles was applied.

105 “PICOS” represents the following categories: participants (P), intervention (I),

106 comparisons (C), outcomes (O), and study design (S) (Liberati et al., 2009).

107 (P) = older adults (≥ 60 years) without restrictions regarding health status and/or

108 pathologies;

109 (I) = studies that had at least one RT alone group (without any other type of

110 exercise and/or treatment);

111 (C) = studies that compared RT alone and the non-active control group (without

112 any intervention, i.e., stretching sessions, classes about any subject, etc..) on depressive

113 and anxiety symptoms;

114 (O) = studies that evaluated depressive and anxiety symptoms, using validated

115 instruments;

116 (S) = randomized controlled trials with chronic studies (e.g., we considered, at

117 least, 4 weeks of intervention).

118 Data extraction

119 The following information from the relevant studies was extracted: (i) first

120 author and year of publication, (ii) population characteristics including age, sex, and

121 health status, (iii) characteristics regarding the intervention (e.g., study design; duration
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122 of intervention, types of resistance training), (iv) depressive and anxiety symptoms

123 measurements (e.g., Geriatric Depression Scale (GDS), Beck Inventory Anxiety (BAI),

124 and (vi) outcomes (e. g., changes in depressive and anxiety symptoms).

125 Quality assessment

126 The methodological quality of the included studies was assessed using the “Tool

127 for the assEsment of Study qualiTy and reporting in EXercise” (TESTEX) checklist

128 (Smart et al., 2015). The checklist has two sections that refer to study quality (items 1–

129 5) and study reporting (items 6–12). Each item on the TESTEX checklist is answered

130 with “yes” if the criteria are satisfied or with a “no” if the criteria are not satisfied (only

131 the answer “yes” is associated with a point). Items 6 and 8 have three and two questions,

132 respectively. The answer “yes” to each of these subquestions is also associated with a

133 point. Therefore, the maximum number of possible points on the checklist is 15. Based

134 on the summary scores, we classified studies as “excellent quality” (12–15 points),

135 “good quality” (9–11 points), “fair quality” (6–8 points), or “poor quality” (<6 points).

136 Statistical analysis

137 Intervention effects on depressive and anxiety symptoms were calculated using

138 standardized mean differences and standard errors. In each analysis, the effect size (ES)

139 was calculated as the difference between post-test and pre-test scores, divided by the

140 pooled standard deviation, with Hedges’ g adjustment for small sample bias (Borenstein

141 et al., 2009). A random-effects model was used for the meta-analysis, employing robust

142 variance meta-regression for multilevel data structures, with adjustments for small

143 samples (Hedges et al., 2010). Meta-analysis using random-effects models with robust

144 variance meta-regression for multilevel data structures, adjusted for small samples, were

145 used for subgroup sensitivity analyses in relation to the following RT variables: type of
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146 intervention (traditional resistance training vs. training with elastic bands or body

147 weight), weekly frequency (2x vs. 3x), number sets per exercise (≤ 2 vs. 3), duration of

148 the intervention (< 12 weeks vs. ≥ 12 weeks) and the total number of exercises per

149 session (up to 6 vs. 7 or more) as moderators. Separate meta-regressions using the effect

150 sizes were conducted to analyze the depressive and anxiety symptoms separately, as

151 well as studies in participants with and without mental disorders. Heterogeneity was

152 observed through I2 values (Higgins and Thompson, 2002). All analyses were conducted

153 using the JASP statistical package (version 0.17.1) and JAMOVI (version 2.3). Effects

154 were considered significant at p < 0.05. Data are reported as Hedges’ g ES and 95%

155 confidence interval (CI).

156 RESULTS

157 The search process is depicted in Figure 2. A total of 488 search results were

158 initially screened. After excluding the studies based on title, abstract, full text, and those

159 who were excluded due to the inability to perform data extraction (Alves et al., 2013;

160 Cassilhas et al., 2007; Chin A Paw et al., 2004; Huang et al., 2020; Nyberg et al., 2015;

161 Penninx et al., 2002), a total of twenty-one studies were included in the analysis (Ansai

162 and Rebelatto, 2015; Cassilhas et al., 2010; Cavalcante et al., 2022; Cunha et al., 2022;

163 Damush and Damush, 1999; Ferreira et al., 2018; Kekäläinen et al., 2018; Kim et al.,

164 2019; Lima et al., 2019; Lincoln et al., 2011; Martins et al., 2011; Sahin et al., 2018;

165 Sims et al., 2009, 2006; Singh et al., 2005; Singh et al., 1997a, 1997b, 2001; Timonen et

166 al., 2002; Tsutsumi et al., 1998; Zanuso et al., 2012).

167 ***INSERT FIGURE 2***

168 Characteristics of included studies

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169 A total of 968 subjects participated in the studies (RT groups = 538; Control

170 group = 430). The duration of training interventions ranged from 8 weeks to 12 months.

171 The number of sessions per week employed in the studies ranges from 1 to 3, the

172 number of sets was 1-3 per exercise, the number of repetitions was from 6-25, the

173 intensity of load ranged from 20-85% 1RM, exercises numbers ranged from 5-14, and

174 the interval rest between exercises ranged from 1-3 min. The 11 studies employed older

175 adults without mental disorders (Ansai and Rebelatto, 2015; Cassilhas et al., 2010;

176 Cavalcante et al., 2022; Cunha et al., 2022; Damush and Damush, 1999; Kekäläinen et

177 al., 2018; Kim et al., 2019; Martins et al., 2011; Sahin et al., 2018; Tsutsumi et al.,

178 1998; Zanuso et al., 2012) and 10 employed older adults with mental disorders (Ferreira

179 et al., 2018; Lima et al., 2019; Lincoln et al., 2011; Sims et al., 2006, 2009; Singh et al.,

180 1997a, 1997b; Singh et al., 2005; Singh et al., 2001; Timonen et al., 2002).

181 Lastly, eighteen studies performed a traditional RT program (Ansai and

182 Rebelatto, 2015; Cassilhas et al., 2010; Cavalcante et al., 2022; Cunha et al., 2022;

183 Ferreira et al., 2018; Kekäläinen et al., 2018; Lima et al., 2019; Lincoln et al., 2011;

184 Sahin et al., 2018; Sims et al., 2006, 2009; Singh et al., 1997a, 1997b; Singh et al.,

185 2005; Singh et al., 2001; Timonen et al., 2002; Tsutsumi et al., 1998; Zanuso et al.,

186 2012), and three performed an alternative RT program (e.g., elastic band or home-based

187 exercises) (Damush and Damush, 1999; Kim et al., 2019; Martins et al., 2011).

188 Depressive and anxiety symptoms assessment were obtained through several

189 questionnaires (GDS, POMS-SF, ZSDS, BDI, DSM-IV, CES-D, ESES, HADS, BAI,

190 GAD-7, HRSD, State-Trait Anxiety Inventory, Mental Health Index). The studies were

191 summarized in Table 1.

192 ***INSERT TABLE 1***

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193 Quality assessment

194 Table 2 presents the results of the quality assessment. The average score on the

195 checklist was 10. Four studies were rated as being of excellent methodological quality

196 (Ansai and Rebelatto, 2015; Singh et al., 2005; Singh et al., 1997a, 2001), fifteen as

197 good quality (Cavalcante et al., 2022; Cunha et al., 2022; Damush and Damush, 1999;

198 Ferreira et al., 2018; Kekäläinen et al., 2018; Kim et al., 2019; Lincoln et al., 2011;

199 Sahin et al., 2018; Sims et al., 2009, 2006; Singh et al., 1997a; Timonen et al., 2002;

200 Tsutsumi et al., 1998; Zanuso et al., 2012), and two as fair quality (Cassilhas et al.,

201 2010; Martins et al., 2011). None of the included studies was classified as being of poor

202 methodological quality.

203 ***INSERT TABLE 2***

204 Overall effects of RT on depressive and anxiety symptoms

205 Figure 3 illustrates the subgroup analyses for studies that addressed, depressive

206 symptoms (Panel A), anxiety symptoms (Panel B), and participants without and with

207 mental disorders in Panels C and D, respectively. For depressive symptoms, it involved

208 20 effect sizes from 18 studies, and the mean effect was -0.94 (95%CI: -1.45 - -0.43,

209 P<0.01, I2= 93.4%). As for anxiety (Panel B), 11 effect sizes from nine studies were

210 analyzed, and the mean effect was -1.33 (95%CI: -2.10 - -0.56, P< 0.01, I2= 92.3%).

211 Twenty effect sizes from 15 studies were used to analyze the effects of RT on

212 older individuals without any mental disorders (Panel C). The mean effect was -0.51

213 (95%CI: -0.67 - -0.35, P< 0.01, I2= 36.7%). Further, 11 effect sizes from six studies

214 were analyzed to investigate the effects of RT on depressive and anxiety symptoms in

215 older individuals with some mental disorder (Panel D), and the mean effect observed

216 was -2.15 (95%CI: -3.01 - -1.29, P< 0.01, I2= 91.5%).
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217 ***INSERT FIGURE 3***

218 Subgroup analysis

219 Influence of resistance training variables

220 To determine the influence of the type of intervention and specific training

221 variables on depressive and anxiety symptoms across all studies, RT variables were

222 used as moderators (Table 3). Some RT variables were compared: a) type of

223 intervention (traditional vs alternative); b) weekly frequency (2 vs 3 times); c) set

224 number per exercise (≤ 2 vs 3 sets); d) duration of the intervention (< 12 vs ≥ 12

225 weeks); and e) exercise number per session (≥ 7 vs ≤ 6 exercises). It was found that

226 traditional RT is effective in improving mental health parameters, while alternative RT

227 has no effects. The frequency of 2 times a week was shown not to be effective (ES= -

228 0.36; 95%CI: -0.92 – 0.19), while 3 times showed to be significantly different than 2

229 times per week (ES= -1.22; 95%CI: -1.56 - -0.89; Difference: ES= -0.86; 95%CI: -1.51

230 - -0.21, P<0.009). For the set number per exercise, it was found that 3 sets per exercise

231 were better (ES= -1.40; 95%CI: -1.78 - -1.01) than 2 sets (ES= -0.54; 95%CI: -0.95 - -

232 0.13). Further, the duration of intervention showed different impacts, in that < 12 weeks

233 of intervention (ES= -1.48; 95%CI: -1.91 - -1.04) than ≥ 12 weeks (ES= -0.63; 95%CI: -

234 1.00 - -0.25). Finally, it was observed that less exercise (≤ 6 exercises, ES= -1.40;

235 95%CI: -1.72 - -1.08) was superior to more exercises (≥ 7, ES= -0.26; 95%CI: -0.67 –

236 0.15) for improving mental health outcomes.

237 In the same Table 3, it was analyzed the impact of RT variables but only in

238 studies with participants without mental disorders. The manipulation of RT variables

239 had no meaningful influence, except for the type of RT, in which just traditional RT was

240 effective for promoting benefit (Traditional = ES= -0.55; 95%CI: -0.73 – -0.36 vs

241 Alternative = ES= -0.34; 95%CI: -0.70 – 0.03), and for exercise number that although
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242 both have promoted benefit, less exercise (≤ 6 exercises, ES= -0.69; 95%CI: -0.88 - -

243 0.50) was better than more exercise (≥ 7, ES= -0.28; 95%CI: -0.46 - -0.10). It should be

244 noted that attempts were made to repeat the above analyses for older adults with mental

245 disorders. However, it was not feasible due to the characteristics of the studies.

246 ***INSERT TABLE 3***

247 In the same way, the effect of RT variables just in depressive and anxiety

248 symptoms, individually, was analyzed. (Figure 4).

249 ***INSERT FIGURE 4***

250 DISCUSSION

251 The main findings of this systematic review and meta-analysis were (1) RT is an

252 effective non-pharmacologic strategy for improving mental health outcomes (depressive

253 and anxiety symptoms) in older adults, (2) RT is effective for improving mental health

254 outcomes regardless of health status (with or without mental disorders), and (3) some

255 RT characteristic (traditional vs alternative, number of exercises, frequency, duration,

256 and sets) can influence RT effects on mental health outcomes in older adults.

257 Although there were no statistical differences between the two models of RT

258 (traditional vs alternative), a positive effect of traditional RT on mental health

259 parameters was observed, while there was no effect for alternative RT programs,

260 indicating a possible superiority of the traditional RT prescription. Furthermore, 3x per

261 week, 3 sets per exerciser, fewer exercises per session (≤ 6), and a shorter duration of

262 the intervention (< 12 weeks) showed more efficiency in improving mental health

263 parameters. These results are of great importance since there is still no guideline with

264 specific RT recommendations focusing on mental health parameters.

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265 The present findings were, in part, in agreement with previous studies (Gordon

266 et al., 2017, 2018) showing the positive effects of RT on depressive and anxiety

267 symptoms. Both studies revealed that RT reduces depressive and anxiety symptoms

268 either in healthy or unhealthy people, however, for anxiety, Gordon et. al. (2017) found

269 larger effects in healthy individuals. These results are in contrast to our findings, which

270 showed larger effects for older adults with any mental disorders. Additionally, previous

271 studies did not find a significant difference in RT variables on depressive and anxiety

272 symptoms. On the other hand, in this present study, it was observed that different RT

273 prescriptions can impact the effect of RT on mental health parameters. Some differences

274 between the studies can be highlighted: previous studies analyzed participants of any

275 age and they inserted aerobic exercise in analyses.

276 However, results should be viewed with caution due high heterogeneity that was

277 found, the prescription of RT was very different between them, the sample characteristic

278 was different (healthy vs non-healthy; mental health disorders vs non-mental health

279 disorders), and there was a wide variety of questionnaires used for the measurement of

280 mental health outcomes. The high heterogeneity also was observed in previous studies

281 (Gordon et al., 2017, 2018) Therefore, more studies with more robust experimental

282 designs and more control of RT variables (intensity and volume) are needed.

283 Influence of type and RT variables on mental health outcomes in older adults

284 After analyzing the body evidence about the effect of RT on depressive and

285 anxiety symptoms in older adults, it was tried to carry out analysis verifying possible

286 effects of different volumes and intensities of training, however, due to the

287 characteristics of the studies it was only possible to verify the effect of different weekly
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288 frequencies, the number of exercises, number of sets, duration of the intervention, and

289 type of training.

290 The weekly frequency, number of sets, and number of exercises are variables

291 that are related to the volume of training. Although no studies have been observed

292 comparing frequency, series, and number of exercises on mental health parameters,

293 some others have verified the effects of manipulating these RT variables on outcomes

294 that may be related to mental health, such as inflammatory biomarkers, oxidative stress,

295 and body fat (Cunha et al., 2021; Padilha et al., 2015; Pina et al., 2019). Different

296 prescriptions for these training variables can have different impacts on these outcomes.

297 Thus, studies comparing different RT variables are necessary in order to obtain a more

298 accurate prescription for improving mental health outcomes in older adults to be able to

299 help exercise/physician professionals make a better training prescription for this

300 purpose.

301 Furthermore, it was found that fewer exercises (≤ 6) showed greater benefits for

302 mental health parameters than more exercises (≥ 7). This is very interesting because the

303 current general recommendations for RT recommend 8-10 exercises per session of

304 training (Fragala et al., 2019; Ratamess et al., 2009). It can be speculated that more

305 exercises make the training session longer and this can generate a not-very-good feeling

306 for these individuals, thus not producing good adaptative responses in mental health

307 outcomes in older adults.

308 It was shown that the shorter duration of the intervention seemed to be more

309 effective than the longer one, although both were effective. In the literature, both shorter

310 and longer duration shows benefits in other outcomes (i.e., muscle mass and muscle

311 strength) (Pinto et al., 2014; Radaelli et al., 2014). Based on the present findings, it can
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312 be speculated that positive influences on mental health occur in the early phases of the

313 intervention period and that with the passage of time such influences dissipate.

314 However, studies comparing different time courses are necessary to identify if there is a

315 minimum duration of intervention and how long these benefits last before they reach a

316 plateau.

317 In summary, although there are some differences in the RT prescriptions for

318 improving depressive and anxiety symptoms, the body of evidence showed that this

319 type of exercise with moderate to high volume and intensity is a non-pharmacologic

320 strategy for improving – directly and/or indirectly – depression and anxiety in older

321 adults. In addition, studies on healthy and older adults with mental disorders must be

322 carried out since their health status can impact adaptations to exercise. Our results

323 indicate that people with mental disorders (e.g., depressive symptoms) showed an ES

324 higher (-2.15) than older adults without a mental disorders (ES= -0.51). This shows that

325 people with unfavorable clinical conditions tend to show more pronounced

326 improvements after a period of intervention.

327 Although there are few controversial results, RT can be a good tool for the

328 prevention and treatment of these mental disorders (depression and anxiety). More

329 studies in this field are still warranted for a better understanding of how RT can

330 influence mental health parameters in older adults and what would be a better

331 prescription (or whether there is a better one!). Further research with better control of

332 RT variables and comparing protocols with different volumes, intensities, and structures

333 of RT are still warranted.

334 CONCLUSIONS
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335 RT is an effective non-pharmacologic strategy for reducing depressive and

336 anxiety symptoms in older adults. Further, RT was able to improve mental health

337 outcomes in individuals with and without mental disorders. Specific characteristics

338 (type of RT, weekly frequency, number of sets, duration of intervention, and the number

339 of exercises) influenced the effect of RT on mental health.

340 Acknowledgment

341 P.M.C. is supported by the São Paulo Research Foundation (FAPESP) with a

342 postdoctoral fellowship (FAPESP process: 2021/01318-0).

343 Conflicts of Interest

344 The authors have no conflicts of interest to declare.

345

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454 depressive symptoms in elderly people with Parkinson disease: A controlled

455 randomized study. Scand. J. Med. Sci. Sports 1–11.
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477 Shamseer, L., Tetzlaff, J.M., Akl, E.A., Brennan, S.E., Chou, R., Glanville, J.,
478 Grimshaw, J.M., Hróbjartsson, A., Lalu, M.M., Li, T., Loder, E.W., Mayo-Wilson,
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481 updated guideline for reporting systematic reviews. Syst. Rev. 10, 89.
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484 W.B., Pahor, M., 2002. Exercise and depressive symptoms: a comparison of
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485 aerobic and resistance exercise effects on emotional and physical function in older
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492 Pinto, R.S., Correa, C.S., Radaelli, R., Cadore, E.L., Brown, L.E., Bottaro, M., 2014.
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495 9567-2

496 Radaelli, R., Botton, C.E., Wilhelm, E.N., Bottaro, M., Brown, L.E., Lacerda, F., Gaya,
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529 2005. A randomized controlled trial of high versus low intensity weight training
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540 https://doi.org/10.1097/XEB.0000000000000020

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545 Comparison of high and moderate intensity of strength training on mood and
546 anxiety in older adults. Percept. Mot. Skills 87, 1003–1011.
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547 https://doi.org/10.2466/pms.1998.87.3.1003

548 Zanuso, S., Sieverdes, J.C., Smith, N., Carraro, A., Bergamin, M., 2012. The effect of a
549 strength training program on affect, mood, anxiety, and strength performance in
550 older individuals. Int. J. Sport Psychol. 43, 53–66.
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551 LIST OF FIGURES LEGEND

552 Figure 1. Scheme of possible mechanisms that may be associated with RT and mental
553 health outcomes.
554 Figure 2. Flow diagram of the search process.
555 Figure 3. In panel A, the forest plot of the effects of resistance training on depressive
556 symptoms is presented, while in panel B, the effects are related to anxiety symptoms.
557 Panel C is the forest plot of the effects of RT in participants without mental disorders,
558 and Panel D is for participants with mental disorders. Data are presented as mean ± 95%
559 CI. RE, randomized effect.
560 Figure 4. Impact of RT variables in Depressive and Anxiety symptoms, separately.
561 Data are presented as mean ± 95% CI.
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Table 1. Characteristics of the included studies (n = 21).
Studies Sample Duration Types of RT RT program Tools Effects
(weeks/ (yes/no)
Characteristics N months)
Ansai et al., 2015 Non-disease older RT = 23 16 weeks Traditional 3x/week; 10-12 RM; 6 exercises; 1 min GDS NO
women, ≥ 80 years Control = 23 RT interval rest between sets
Cassilhas et al., 2010 Non-disease older RT = 20 24 weeks Traditional 3x/week; 2 sets of 8 reps (50-80% RM); 6 State-Trait YES
men, 65-75 years old Control = 23 RT exercises; 1:30 min interval rest between sets Anxiety
Inventory
Cavalcante et al., Non-disease older RT = 18 12 weeks Traditional 3x/week; 3 sets of 10-15 RM; 7 exercises; 1- GDS-15 NO
2022 adults of both sexes, Control = 22 RT 1:30 min interval rest between sets and 2-3
≥65 years min between exercises
Cunha et al., 2021 Non-disease older RT = 41 12 weeks Supervised, 3x/week; 3 sets of 8-12 reps; 8 exercises; 1 to GDS, BAI YES
women, ≥ 60 years Control = 35 traditional 2 min interval rest between sets
RT
Damush et al., 1999 Non-disease older RT = 33 8 weeks Elastic 2x/week; 1 set of maximum repetition; 7 Mental Health NO
women, > 60 years Control = 29 resistance exercises; 90-sec interval rest between sets Index
old exercise
Ferreira et al., 2018 Older adults of both RT = 18 6 months Supervised, 2x/week; 2 sets of 10 reps; 6 exercises; 1 to 2 BAI YES
sexes, Parkison's Control = 17 traditional min interval rest between sets
disease, > 60 years RT
old
Kekäläinen et al., Non-disease older RT = 81 9 months traditional 1-3x/week; 8-9 exercises; BDI-II YES
2018 adults of both sexes, Control = 23 RT
65-75 years old
Kim et al., 2019 Non-disease older RT = 11 24 weeks Body weight 3x/week, 2-3 sets GDS NO
women, 67-81 years Control = 10 resistance
old exercises
Lincoln et al., 2011 Older adults of both RT = 29 16 weeks traditional 3x/week; 3 sets of 8 reps; 5 exercises; 60-80% GDS YES
sexes, Diabetics, > 60 Control = 29 RT RM
years
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50

Lima et al., 2019 Older adults of both RT = 17 20 weeks traditional 2x/week; 2 sets of 8-12 reps; 5 exercises; 1-2 HAM-D17 YES
sexes, Parkison's Control = 16 RT min interval rest between sets and exercises
disease, > 60 years
old
Martins et al., 2011 Non-diseases older RT = 23 16 weeks Elastic band 1-3 sets; 8-15 reps; 8 exercises; 3 min rest POMS-SF NO
adults of both sexes, Control = 31 and interval between sets and exercises
65-95 years old callisthenic
resistance
exercise
Sahin et al., 2018 Non-diseases older RT = 32 8 weeks Traditional 3x/week; 1 sets of 6-10 reps (40-70% RM); 6 GDS YES
adults of both sexes, Control = 16 RT exercises
≥ 65 years old
Sims et al., 2006 Older adults of both RT = 14 10 weeks Traditional 3x/week; 3 sets of 8 reps (80% RM) GDS NO
sexes, Depression, ≥ Control = 18 RT
65 years old
Sims et al., 2009 Older adults of both RT = 23 10 weeks Traditional 2x/week; 3 sets of 8-10 reps (80% RM), 6 CES-D YES
sexes, Stroke, Control = 20 RT exercises
Depression,
Singh et al., 1997a Older adults of both RT = 15 10 weeks Traditional 3x/week; 3 sets of 8 reps (80%RM; 5 BDI, GDS YES
sexes, Depression, ≥ Control = 13 RT exercises
60 years
Singh et al., 1997b Older adults of both RT = 17 10 weeks Traditional 3x/week; 3 sets of 8 reps (80%RM; 6 BDI, HRSD, YES
sexes, Depression, ≥ Control = 15 RT exercises GDS, DSM-IV
60 years
Singh et al., 2001 Older adults of both RT = 15 26 months Traditional 3x/week; 3 sets of 8 reps (80%RM; 5 BDI YES
sexes, Depression, ≥ Control = 14 RT exercises
60 years
Singh et al., 2005 Older adults of both RT = 40 8 weeks Traditional 3x/week; 3 sets of 8 reps (20-80%RM; 6 HRSD, GDS YES
sexes, Depression, ≥ Control = 20 RT exercises
60 years
Timonen et al., 2002 Older women, Any RT = 34 10 weeks Traditional 2x/week; 2 sets of 15 reps; 6 exercises ZSDS YES
diseases, ≥ 75 Control = 34 RT
Tsutsumi et al., 1998 Non-diseases older RT = 24 12 weeks Traditional 3x/week; 2 sets of 8-16 reps (55-85% RM); 6 POMS-SF, YES
women, ≥ 60 years Control = 12 RT exercises State-Trait
old Anxiety
Inventory
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52

Zanuso et al., 2012 Non-diseases older RT = 10 12 weeks Traditional 2 sets of 10 reps (55-85% RM); 8 exercises POMS, TAI NO
adults of both sexes, Control = 10 RT
≥ 65 years old
Note: GDS = Geriatric Depression scale; POMS-SF = Profile of Mood States; TAI = Trait Anxiety Inventory; ZSDS = Zung Self-Rating Depression Scale-test; BDI = Beck
Depression Inventory; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders IV; CES-D = Centre for Epidemiologic Studies for Depression scale; ESES = Exercise
Self-Efficacy Scale; HADS = Hospital Anxiety and Depression Scale; BAI = Beck Anxiety Inventory; GAD-7 = Generalized Anxiety Disorder-7 scale; HRSD= Hamilton Rating
Scale of Depression.
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Table 2. Quality assessment using the TESTEX checklist.

Study 1 2 3 4 5 6a 6b 6c 7 8a 8b 9 10 11 12 Total
score

Ansai et al. 1 1 1 1 0 1 0 1 1 1 1 1 0 1 1 12
2013
Cassilhas et al. 1 0 0 0 0 1 0 0 0 1 1 0 1 1 1 7
2010
Cunha et al. 1 1 1 1 0 0 0 0 0 1 1 1 1 1 1 10
2021
Cavalcante et 1 1 1 1 0 0 0 0 1 1 1 1 0 1 1 10
al. 2022
Damush et al. 1 0 1 1 0 1 0 1 0 1 1 1 0 1 1 10
1999
Ferreira et al. 1 1 1 1 0 1 0 1 0 1 1 1 0 1 1 11
2018
Kekäläinen et 1 1 1 1 1 1 0 1 1 1 1 0 0 0 1 11
al. 2018
Kim et al. 2019 1 1 1 1 0 0 0 1 1 1 1 1 0 1 1 11
Lima et al. 1 0 1 1 0 0 0 1 0 1 1 1 0 1 1 9
2019
Lincoln et al. 1 1 1 1 1 0 1 0 0 1 1 1 0 1 1 11
2011
Martins et al. 1 0 1 1 0 0 0 1 0 1 1 1 0 0 0 7
2011
Sahin et al. 1 0 1 1 1 0 0 1 0 1 1 1 1 1 1 11
2018
Sims et al. 2006 1 1 1 1 0 0 0 1 0 1 1 1 0 1 1 10
Sims et al. 2009 1 0 1 1 0 0 0 1 1 1 1 0 0 1 1 9
Singh et al. 1 1 1 1 0 1 0 1 0 1 1 1 0 1 1 11
1997a
Singh et al. 1 1 1 1 0 1 1 1 0 1 1 1 0 1 1 12
1997b
Singh et al. 1 1 1 1 0 1 1 1 0 1 1 1 1 1 1 13
2001
Singh et al. 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 13
2005
Timonen et al. 1 0 1 1 0 1 0 1 0 1 1 1 0 1 1 10
2002
Tsutsumi et al. 1 0 1 1 0 0 0 1 0 1 1 1 0 1 1 9
1998
Zanuso et al. 1 0 1 1 0 0 0 1 0 1 1 1 0 1 1 9
2012
Note: 1 = criteria met; 0 = criteria not met.
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Table 3. Impact of RT variables in all studies and just with participants without mental disorders.
All studies Participants without a mental disorder.
RT variables ES 95%CI P-value Diamond Ratio I2 (%) ES 95%CI P-value Diamond Ratio I2 (%)
Traditional vs Alternative
Traditional -1.10 -1.41; -0.79 <0.001 2.76 -0.55 -0.73; -0.36 <0.001 1.45
Alternative -0.37 -1.15; 0.42 0.359 1.00 92.6 -0.34 -0.70; 0.03 0.069 1.00 37.0
Difference -0.73 -1.57; 0.11 0.089 -0.21 -0.62; 0.20 0.322
Weekly frequency
2x per week -0.36 -0.92; 0.19 0.198 1.09 -0.40 -0.69; -0.10 0.009 1.14
3x per week -1.22 -1.56; -0.89 <0.001 2.92 91.8 -0.56 -0.76; -0.35 <0.001 1.44 34.9
Difference -0.86 -1.51; -0.21 0.009 -0.16 -0.52; 0.20 0.381
Sets number per exercise
2 or fewer sets -0.54 -0.95; -0.13 0.009 1.30 -0.51 -0.71; -0.31 <0.001 1.30
3 sets -1.40 -1.78; -1.01 <0.001 3.20 91.2 -0.49 -0.79; -0.20 0.001 1.51 39.9
Difference -0.86 -1.42; -0.29 0.003 0.02 -0.35; 0.38 0.934
Duration of intervention
< 12 weeks -1.48 -1.91; -1.04 <0.001 3.41 -0.41 -0.76; -0.06 0.021 3.41
≥ 12 weeks -0.63 -1.00; -0.25 0.001 1.59 91.6 -0.53 -0.72; -0.34 <0.001 1.59 38.2
Difference 0.85 0.28; 1.42 0.004 -0.12 -0.52; 0.27 0.542
Exercise number per session
≥7 -0.26 -0.67; 0.15 0.209 1.00 -0.28 -0.46; -0.10 0.002 1.00
≤6 -1.40 -1.72; -1.08 <0.001 2.72 91.2 -0.69 -0.88; -0.50 <0.001 1.29 21.5
Difference -1.14 -1.66; -0.62 <0.001 0.41 0.15; 0.67 0.002
Note: ES= effect size; 95%CI= confidence interval.
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602 Figure 2.

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Panel A – Depressive Symptoms Panel B – Anxiety Symptoms

Panel C- Participants without mental disorder Panel D- Participants with a mental disorder

Figure 3.
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622 Figure 4.
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630 Figure 1.