Purpose <p>This cross-sectional study examines the association between health literacy (HL) and depressive symptoms among elderly hospitalized patients and investigates the mediating role of intrinsic capacity (IC) and the moderating effects of psychological resilience. The study’s findings will have theoretical and practical implications for mitigating depressive symptoms and fostering healthy aging in this population.</p> Methods <p>Using a convenience sampling method, 1461 elderly hospitalized patients were enrolled in this study. The participants were assessed using the Brief Health Literacy Assessment Scale, the Geriatric Depression Scale (GDS-15), the Intrinsic Capacity Scale, and the CD-10 Psychological Resilience Scale. Spearman’s correlation analysis was used to identify correlations between variables, and a PROCESS model was applied to test for mediating and moderating associations.</p> Results <p>HL was negatively correlated with depressive symptoms (<i>r</i> = − 0.43, <i>p</i> &lt; 0.001), and IC partially mediated this relationship (indirect association = − 0.014, 95%CI: −0.020 − 0.008), accounting for 24.37% of the total association. Psychological resilience moderated the mediation pathway. Specifically, higher resilience attenuated the negative association between IC and depressive symptoms (β = 0.016, <i>p</i> = 0.040) and enhanced the association between HL and IC (β = -0.005, <i>p</i> &lt; 0.001).IC mediated the relationship between health literacy and depressive symptoms in elderly hospitalized patients, while psychological resilience attenuated the positive association of HL with IC and the predictive association of IC with depressive symptoms.</p> Conclusions <p>Our findings underscore the need for clinical attention to elderly hospitalized patients with low HL levels. Interventions targeting the enhancement of IC may effectively alleviate depressive symptoms, thereby promoting mental health and quality of life in this vulnerable population.</p>