Effect of non-pharmacological interventions on depression in obese individuals: a network meta-analysis

Background: Although the efficacy of non-pharmacological interventions for individuals with obesity and concurrent depression has been demonstrated, it remains unclear which strategy yields the most favorable outcomes. We conducted a network meta-analysis (NMA) to evaluate the comparative effectiveness of non-pharmacological interventions on depressive symptoms in overweight or obese individuals. Methods: Randomized controlled trials (RCTs) using non-pharmacological interventions were retrieved from Embase, PubMed, Cochrane Library, and Web of Science (up to March 2025). Standardized mean differences (SMD) were used for pooled analyses across depression scales, while mean differences (MD) were applied for single-scale analyses. Interventions were ranked using surface under the cumulative ranking curve (SUCRA) values. All statistical analyses were performed using R4.5.1 and Stata 15. Results: 36 RCTs involving 11,153 participants were included, with 16 non-pharmacological interventions assessed by five depression scales. SUCRA analysis revealed that in the summary data, cognitive behavioral therapy (CBT) ranked higher (77.8%), while group meetings + telephone consultations (GM+TC) ranked lower (23.7%). For Beck Depression Inventory (BDI), CBT (94.9%) ranked higher, while behavioral therapy (BT) (34.4%) ranked lower. For the BDI-II, BT plus lifestyle intervention (BT+LI) (97.6%) ranked higher, while weight management and structured support programs (WMSSP) (2.6%) ranked lower. However, because the BDI-II network was sparse and relied on indirect comparisons, this ranking should be interpreted cautiously. For the Patient Health Questionnaire-9 (PHQ-9), CBT-based combined intervention (CBT-CI) ranked higher (97.9%), while dietary intervention ranked lower (10.2%). In the assessment using the Center for Epidemiologic Studies Depression Scale (CES-D), psychosocial and mind-body interventions (PMBI) (84.5%) ranked higher, while GM+TC (0.5%) ranked lower. For the Hospital Anxiety and Depression Scale (HADS), WMSSP (81.9%) had higher SUCRA values, while the control (24.7%) had lower values. Given the sparse, indirect network for HADS, the confidence in its high SUCRA ranking was limited. Conclusion: CBT appears effective, though overall certainty is limited by methodological concerns across many RCTs. BT+LI shows benefits in BDI-II assessments; PMBI shows effectiveness in CES-D evaluations. In the HADS network, WMSSP had high SUCRA values; however, intergroup differences were not statistically significant. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD420251022091.