Aerobic exercise for depressive symptoms, anxiety symptoms and perceived stress in university students: a systematic review and dose–response meta-analysis of randomized controlled trials

Objective To assess the effects of aerobic exercise on depressive symptoms, anxiety symptoms and perceived stress in university students and to identify potential exercise prescription and dose–response patterns. Methods PubMed, Embase, CENTRAL, Web of Science, PsycINFO and SPORTDiscus were searched from inception to August 15, 2026. Eligible studies were English language, peer reviewed RCTs in university students (≥ 18 years) comparing aerobic exercise with a control condition. Random effects meta-analyses used standardized mean differences (SMDs) based on change scores. Subgroup analyses examined baseline depression, intensity, session duration and intervention length. Dose–response associations (METs·min/week) were modelled using restricted cubic splines. Risk of bias was assessed with RoB 2, and publication bias was explored using funnel plots and Egger test. The review was retrospectively registered in PROSPERO (CRD420261473381). Results Fourteen RCTs ( n = 982) were included. Aerobic exercise reduced depressive symptoms (13 RCTs; n = 717; SMD = − 0.88, 95% CI − 1.35 to − 0.41), anxiety symptoms (10 RCTs; n = 579; SMD = − 0.59, 95% CI − 0.92 to − 0.26) and perceived stress (7 RCTs; n = 353; SMD = − 0.68, 95% CI − 1.20 to − 0.16). Exploratory subgroup analyses suggested variations in pooled estimates across exercise characteristics. For depression, sessions < 60 min and interventions ≤ 6 weeks showed more favorable estimates, whereas the ≥ 60 min subgroup showed an unfavorable estimate based on limited evidence. Dose–response modelling identified a U-shaped pattern, with greater estimated improvement observed between 180 and 910 METs·min/week and the lowest point of the fitted curve around 630 METs·min/week. These values represent model-derived estimates with analytical uncertainty rather than definitive thresholds. For anxiety, dose–response modelling indicated greater estimated improvement within 700 to 1,500 METs·min/week, with the lowest point of the fitted curve around 1,500 METs·min/week. Stress reduction was more evident among students with depression at baseline. Egger test suggested possible small-study effects for depression. Conclusion Aerobic exercise may improve depressive symptoms, anxiety symptoms and perceived stress in university students. Short-term programmes with sessions under 60 min may be beneficial, while dose–response findings provide exploratory estimates of exercise patterns associated with greater improvement rather than established prescriptions. Stress reduction may be more evident among higher risk students.