Anxiety is one of the most common manifestations of psychiatric disorders, and daily stress causes a significant loss in the performance of individuals [1]. Also, depression is a global disease that has infected 350 million people in the world [2]. 
Several studies worldwide have shown that exercise can reduce the severity of anxiety, and after quitting, the anxiety reappears. According to the results of Izard, regular exercise reduces anxiety, and symptoms of anxiety recur with quitting the exercise [3]. 
These meta-analyses had several limitations and potential biases, including unclear search strategies, enrolling a limited number of studies, and the absence of analysis by gender. But their main limitation was their sole study on the effect of exercise on depression, and they did not investigate the effect of meditation. Besides, aerobic exercise was not investigated separately.
Despite the studies that examined the effect of exercise and meditation on depression and anxiety, there was a serious lack of information about the effect of different exercises and meditation on depression and anxiety. Besides, the effect of these methods on depression and anxiety has not been specified by gender. This meta-analysis addressed these gaps.
Major electronic databases, including PubMed, Web of Science, and Embase, were searched until July 2019. Studies addressing the effect of exercise and meditation on depression and anxiety were found. The heterogeneity across studies was investigated by Q-test and I2 statistic. The probability of publication bias was explored using Begg's and Egger's tests. The results were expressed as the Standardized Mean Difference (SMD) with 95% Confidence Intervals (CI) using a random-effects model. 

Information sources and search
Major electronic databases, including PubMed, Web of Science, and Scopus, were searched until October 2018. The reference lists of the included studies were searched, and the study authors were contacted to identify additional studies.
Study selection
We merged search results obtained from different databases using EndNote software and removed duplicate records. Then, two authors (MT, SM) screened titles and abstracts independently to remove irrelevant reports.
Methodological quality
The same two authors (MT, SM) independently assessed the study quality and risk of bias using the Jadad scale method [4] that was used to assess the quality of each study. Furthermore, the criteria of high and low quality of included studies were defined as Jadad score ≤3 and >3, respectively. Disagreements were resolved in pairs of authors by consensus. The five quality criteria were random allocation, method of randomization, blinding, method of blinding, and incomplete outcome data.
Heterogeneity and Reporting Biases
Heterogeneity was explored using Q-test [5], and its quantity was measured using the I2 statistic [6]. The possibility of publication bias was explored using Begg's [7] and Egger's [8] tests. 
Summary Measures
We reported the effect of exercise, aerobic and meditation on depression and anxiety with SMD. Data were analyzed, and the results were reported using a random-effects model [9]. All statistical analyses were performed at a significance level of 0.05 using Stata software, version 11 (Stata Corp, College Station, TX, USA).
Subgroup analysis
Subgroup analyses were performed based on the following items: (a) type of intervention (aerobic, other exercises, and meditation); and (b) gender (female and both).

Synthesis of results
We identified a total of 10015 references in 51 studies involving 3594 participants. Based on the study results and compared to the control group, the SMD estimate of anxiety was -0.7(95%CI: -1.2, -0.19, I2=86.2%, 12 studies) for meditation, -0.9(95%CI: -1.24, -0.57, I2=66.3%, 8 studies) for aerobic, and -1.07 (95%CI: -1.67, -0.46, I2=0.0%, 9 studies) for other exercises (Figure 1).



Also, the SMD estimate of depression was -0.84 (95%CI: -1.26, -0.42, I2=73.4%, 9 studies) for meditation, -0.44 (95%CI: -0.72, -0.17, I2=73.3%, 10 studies) for aerobic, and -1.10 (95%CI: -1.55, -0.65, I2=90.2%, 14 studies) for other exercises (Figure 2).



Publication bias
The possibility of publication bias was explored using the Begg's and Egger's tests and visualized by the funnel plot. Based on Begg's test, there was no evidence of publication bias among studies addressing the effect of meditation on anxiety (P=0.322), aerobic on anxiety (P=0.805), other exercises on anxiety (P=0.677), meditation on depression (P=0.477), aerobic on depression (P=0.714), and other exercises on depression (P=0.803). Besides, according to Egger's test results, there was no evidence of publication bias among studies addressing the effect of meditation on anxiety (P=0.726), aerobic on anxiety (P=0.415), other exercises on anxiety (P=0.219), meditation on depression (P=0.271), aerobic on depression (P=0.773), and other exercises on depression (P=0.428).
Subgroup analysis
The effect of exercise, meditation, and aerobic on depression and anxiety was investigated by gender. Regarding female gender compared to the control group, the SMD estimate of anxiety was -2.61 (95%CI: -2.93, -2.29) for meditation and the SMD estimate of depression was -1.42 (95% CI: -2.09, -0.75) for meditation, -2.21 (95%CI: -3.73,-0.69) for aerobic and was -1.04 (95%CI: -1.98,-0.10). 

We summarized the available evidence for RCT, experimental, and quasi-experimental studies addressing the effect of exercise and meditation on depression and anxiety. Our results suggested that exercise and meditation were significantly associated with depression and anxiety and positively affected them. Also, there was a positive effect of aerobic exercise on depression and anxiety. These effects are seen in women, too. 
The anxiolytic effect of exercise has been mentioned in other studies [3, 10, 11]. Various mechanisms can explain exercise anti-anxiety effects. These mechanisms include physical, physiological, and psychological mechanisms of exercise. From the biological point of view, exercise can have anti-anxiety effects by providing the person with physical fitness [12, 13], affecting the level of nervous transducers [14] and stress hormones involved in anxiety, and reducing the muscle tension [15]. From the psychological point of view, exercise can reduce anxiety with increased activity levels followed by increased positive reinforcement conditioned by a response [16], providing a situation that distorts one's attention from threatening and anxious situations and provides a basis for increasing trust, self-esteem, and self-efficacy [17]. In some studies, the effects of exercise have been studied by aerobic or anaerobic types, which some of these studies have shown that anaerobic exercise is more beneficial [18].
To explain findings on the effect of meditation on reducing anxiety and depression, we can argue that meditation reinforces important brain parts that relate to emotions. Based on this view, like music, yoga, exercise, and study, meditation also brings happiness and relaxation and thus reduces depression [19]. Some studies believe that meditation reduces rumination and malicious behaviors and reduces anxiety [20]. Scientific studies have shown that meditation affects metabolism, the endocrine system, central nervous system, and autoimmune system. The respiration and heart rates and blood pressure decreased, and alpha brain waves increased that these mechanisms reduce anxiety and pain. To prove this mechanism, we can study brain function during meditation with brain holographic imaging and electroencephalography [21].
In explaining the effect of exercise on depression, research into serotonin secretion and depression indicate that exercise and physical activities increase this hormone and reduce depression. Research has proved a significant relationship between the increase in serotonin and depression reduction [22]. Exercise also increases monoamines, including serotonin and dopamine. The increase in these chemical carrier substances leads to a better transfer of neural messages and mood improvement [23].
The Q-test and I2 statistic test indicated heterogeneity among the included studies. The majority of the observed heterogeneity may be attributable to the quality of the studies, variation in population size, sociodemographic characteristics, and potential confounding factors that were not controlled in the studies. However, these statistical tests should be interpreted with caution. The Q-test is likely to have low statistical power when the sample size or the number of studies included in the analysis is small. On the other hand, when the sample size or the number of the studies included is large, the test is more powerful in detecting a small amount of heterogeneity that may be clinically unimportant [24].
In this study, the effect of exercise on decreasing depression and anxiety was more than the effect of meditation. After analyzing the effect of these methods on reducing anxiety and depression by gender, the effect for females was more than both genders. Because few studies have investigated the effect of these methods on men, we could not analyze the effect of exercise and meditation on depression and anxiety for males, so we did not compare males and females.
Our study had a few limitations: (i) we performed subgroup analysis to assess the effect of meditation, aerobic, and other exercises on depression and anxiety by gender. However, the number of studies in subgroups was limited; this may affect the reliability of the results of subgroup analysis. Besides, because of this limitation, we could not make a comparison between men and women. (ii) We attempted to use an SMD estimate. Nonetheless, five studies did not report mean and standard deviation for the control and intervention groups. (iii) Most studies were low-quality, raising the possibility of bias in the included studies.
Despite its limitations, this meta-analysis provided good evidence of the effect of meditation and exercise on depression and anxiety. This study calculated the relationship between these two methods for both diseases; however, previous studies only examined the effects of exercise on depression. Also, the gender effect was studied in this study.
This meta-analysis addressed the effect of meditation, aerobic, and other exercises on anxiety and depression. This study indicates that all three methods have significantly affected depression and anxiety. This finding can help reduce anxiety and depression.

This article is a meta-analysis with no human or animal sample.

This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Searching for resources and computational framework and data analysis: Saeed Mohammadi; Model design and manuscript writing and interpretation: Mojtaba Tashkeh; Supervising the design and participation in the final version of the manuscript: Kamil Zahedi Tajrishi.

The authors declared no conflict of interest.
 

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