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Complementary treatments for anxiety: Beyond pharmacotherapy and psychotherapy
Anxiety disorders are the most common psychiatric illnesses in the United States, with a prevalence of nearly 29%.1 These disorders typically are treated with pharmacotherapy, psychotherapy, or a combination of both. Pharmacotherapy for anxiety has evolved considerably during the last 30 years, but medications are not efficacious for or tolerated by all patients. For example, selective serotonin reuptake inhibitors, which are frequently used for treating anxiety, can cause sexual dysfunction,2 weight gain,2 drug interactions,2 coagulopathies,3 and gastrointestinal disturbances.4 Psychotherapeutic techniques, such as cognitive behavioral therapy (CBT) and interpersonal therapy (IPT), are efficacious for mild to moderate anxiety.5-7
In addition to standard pharmacotherapy and psychotherapy, some evidence suggests that complementary therapies, such as yoga, massage, and relaxation techniques, may be beneficial as adjunctive treatments for anxiety. In placebo-controlled trials, several of these complementary therapies have been shown to decrease serum levels of the inflammatory biomarker cortisol. Anxiety is associated with inflammation,8 so therapies that reduce inflammation may help reduce symptoms of anxiety. Here, we describe the results of select positive randomized controlled trials (RCTs) of several complementary interventions for anxiety that might be useful as adjunctive treatments to psychotherapy or pharmacotherapy.
A look at RCTs that measured both anxiety and cortisol
We searched PubMed, Google Scholar, and Scopus to identify RCTs of complementary nonpharmacologic and nonpsychotherapeutic therapies for anxiety published from January 2010 to May 2017. We included only studies that:
- blindly assessed anxiety levels through a validated instrument (the State-Trait Anxiety Inventory [STAI])9
- measured cortisol concentrations before and after treatment.
Evaluating both STAI scores and cortisol levels is useful because doing so gives insight into both the clinical and biological efficacy of the therapies. Studies were excluded if they employed a pharmacologic agent in addition to the approach being evaluated.
We identified 26 studies, of which 14 met the inclusion/exclusion criteria. These studies found beneficial effects for yoga, massage therapy, aromatherapy massage, pet therapy, Qigong, auricular acupressure, reiki touch therapy, acupuncture, music therapy, and relaxation techniques.
Yoga
Yoga has become increasingly popular in the Western world during the last 2 decades.10 There are a variety of yoga practices; common forms include hatha yoga, power yoga, kripalu yoga, and forrest yoga.11
A study of 92 depressed pregnant women monito
Hatha yoga consists of a combination of postural exercises, breathing techniques, relaxation, and meditation. In a 12-week study of 88 postmenopausal women, those who practiced hatha yoga for 75 minutes a day had significantly lower STAI scores compared with women who exercised for 75 minutes a day and those who performed no physical activity.13
Continue to: Massage therapy
Massage therapy
Receiving as little as 15 minutes of back massage has proven to be beneficial for individuals with anxiety. In an RCT conducted in Turkey, 44 caregivers of patients with cancer were assigned to receive a back massage or to rest quietly in a room for 15 minutes once each day for 1 week.14 By the end of the week, compared with those who quietly rested, those who received the back massage had a statistically significant reduction in serum cortisol levels and STAI scores.14
Aromatherapy massage
Aromatherapy is the use of essential oils from plants through distillation.15 The scent of the oils is purported to provide medical benefits. More than 60 essential oils are used therapeutically, including rose, lavender, lemon, and orange.16 These essential oils are frequently used in combination with a massage.
In South Korea, researchers investigated the effects of aromatherapy massage on 25 women who had children diagnosed with attention-deficit/hyperactivity disorder.17 Women assigned to the treatment group received a 40-minute aromatherapy massage using mixed essential oils that contained lavender and geranium twice a week for 4 weeks. Women in the control group received no treatment. Compared with those in the control group, women who received the aromatherapy massages had a statistically significant decrease in STAI scores and salivary cortisol levels. Plasma cortisol was not significantly different between groups.17
Pet therapy
The psychological benefits of animal-assisted therapy were not evident until World War II, when dogs were used to cheer up injured soldiers.18 Today, pet therapy has been used on many inpatient units.19
In a U.S. study, 48 healthy undergraduate students were assigned to a room with a dog, a room with a friend, or a room by themselves.20 All participants were given the Trier Social Stress Test (TSST), a protocol that measures stress by having participants give a speech and perform mental arithmetic in front of an audience.The TSST is known to induce increases in cortisol levels. Although no differences in STAI scores were found among groups, students in the room with the dog had a lower spike in salivary cortisol after the TSST compared with participants who were in a room with a friend or in a room alone.20
Continue to: Qigong
Qigong
In Chinese medicine, Qi is known as a vital life force that flows through the body. The disruption of Qi is hypothesized to contribute to disease.21
Qigong is a medical therapy that focuses on uniting the body, breath, and mind to improve health.21 It consists of rhythmic, choreographed movements used to position the body into postures believed to help direct Qi to specific areas in the body. Qigong also uses sound exercises, in which an individual creates certain syllables while breathing. Six syllables are used, each of which is believed to affect a certain organ.21
Korean researchers randomly assigned 32 healthy men to a Qigong training group or a sham Qigong control group.22 Individuals in the training group performed 25 minutes of sound exercises, 20 minutes of meditation, and 15 minutes of movements. The control group learned the same movements as the experimental group, but without the conscious effort of moving Qi. After 3 sessions, those in the Qigong training group had significantly decreased STAI scores and serum cortisol levels compared with those in the sham group.22
In a different Korean study, researchers randomly assigned 50 participants with elevated distress levels to a Qigong training group or a waitlist control group in which participants called a trainer to describe stressful events.23 After 4 weeks, participants in the Qigong group had significant decreases in STAI scores compared with the control group. However, there were no changes in salivary cortisol levels.23
Auricular acupressure
Auricular acupressure involves applying pressure on certain portions of the auricle (outer ear) to alleviate pain and disease.24 Similar to Qigong, auricular acupressure focuses on reestablishing Qi in the body. Researchers randomly assigned 80 post-caesarean section women in Taiwan to 5 days of auricular acupressure or usual care.25 The women who received auricular acupressure had significantly lower STAI scores and serum cortisol levels compared with women who received routine care.25
Continue to: Reiki touch therapy
Reiki touch therapy
Reiki touch therapy originated in Japan. In this therapy, healers apply a light touch or hover their hands above an individual’s body to help direct energy.26
The effects of reiki touch therapy were recently evaluated in a U.S. study.27 Researchers randomly assigned 37 patients with human immunodeficiency virus to an experimental group that received 30 minutes of reiki touch therapy plus music therapy 6 times a week for 10 weeks, or to a music therapy–only control group. Patients who received reiki touch therapy had a significant decrease in STAI scores. Patients in this group also had a statistically significant drop in salivary cortisol levels after the first week.27
Acupuncture
Acupuncture is the application of needles to specific areas on the body. Acupuncture has been proposed to activate pain receptors, thereby producing an analgesic response.28
Researchers in Brazil randomly assigned 57 lactating women with preterm infants to an experimental group that received acupuncture or to a control group that received sham acupuncture.29 Treatment was administered at 5 points on the ear unilaterally for 5 minutes once a week for 16 months. Custom-made needles that did not actually puncture the skin were used in the sham group; a toothpick was used to create the sensation of needle perforations. STAI scores were reduced in both groups, although there was no statistically significant difference in scores between the acupuncture and sham groups.29
Music therapy
Music has been long believed to have beneficial psychological effects. In Turkey, researchers evaluated the effects of music therapy in 100 oncology patients who received port catheters.30 Patients were randomly assigned to an experimental group that received music therapy throughout the procedure or to a control group that received normal care. Patients who listened to music during port catheter placement had significantly reduced STAI scores and serum cortisol levels compared with those in the control group.30
Continue to: Relaxation techniques
Relaxation techniques
A wide range of relaxation techniques are used for therapeutic purposes. In Switzerland, researchers evaluated the anxiolytic effects of 10 minutes of progressive muscle relaxation and guided imagery in 39 pregnant women.31 Women randomly assigned to progressive muscle relaxation were instructed to systematically tense and then release muscle groups throughout their body in sequential order. Women assigned to the guided imagery intervention were told to imagine a safe place and to think of someone who could confer security and reassurance. The remainder of the women were assigned to a control group, where they sat quietly without any formal instructions. Researchers found that each group had a decrease in STAI scores and salivary cortisol levels immediately after the intervention.31
The relaxation response was first described in 1975 by Herbert Benson, MD, as a deep meditative state characterized by a decrease in tension, heart rate, and breathing rate. Several techniques can induce this state, including hypnosis, progressive muscle relaxation, yoga, and transcendental meditation.32 In a study of 15 healthy older adults (age 65 to 80), researchers randomly assigned participants to a relaxation response training group or to a control group.33 The relaxation response training included meditation, imagery, and relaxation techniques. After 5 weeks, participants who received the relaxation response training had marginally significant decreases in STAI scores compared with those in the control group.33
Consider these therapies as adjuncts
Our review of select positive RCTs (Table12-14,17,20,22,23,25,27,29-31,33) suggests that some nonpharmacologic/nonpsychotherapeutic adjunctive interventions may have beneficial effects for patients who have anxiety. Several of the controlled studies we reviewed demonstrated that these interventions are superior to placebo. The reductions in both anxiety severity as measured by the STAI and cortisol levels suggests that some of these complementary therapies deserve a second look as useful adjuncts to established anxiety treatments.
Bottom Line
A review of select randomized controlled trials suggests that some complementary therapies may be helpful as adjunctive therapy in patients with anxiety. These include yoga, massage therapy, aromatherapy massage, pet therapy, Qigong, auricular acupressure, reiki touch therapy, acupuncture, music therapy, and relaxation techniques.
Related Resources
- Bandelow B, Baldwin D, Abelli M, et al. Biological markers for anxiety disorders, OCD and PTSD: a consensus statement. Part II: neurochemistry, neurophysiology and neurocognition. World J Biol Psychiatry. 2017;18(3):162-214.
- National Institute of Mental Health. Anxiety disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml.
1. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.
2. Masand PS, Gupta S. Long-term side effects of newer-generation antidepressants: SSRIs, venlafaxine, nefazodone, bupropion, and mirtazapine. Ann Clin Psychiatry. 2002;14(3):175-182.
3. Siddiqui R, Gawande S, Shende T, et al. SSRI-induced coagulopathy: is it reality? Therapeutic Advances in Psychopharmacology. 2011;1(6):169-174.
4. Brambilla P, Cipriani A, Hotopf M, et al. Side-effect profile of fluoxetine in comparison with other SSRIs, tricyclic and newer antidepressants: a meta-analysis of clinical trial data. Pharmacopsychiatry. 2005;38(2):69-77.
5. Slomski A. Blended CBT controls anxiety in cancer survivors. JAMA. 2017;318(4):323.
6. Forsell E, Bendix M, Holländare F, et al. Internet delivered cognitive behavior therapy for antenatal depression: a randomised controlled trial. J Affect Disord. 2017;221:56-64.
7. Lilliengren P, Johansson R, Town JM, et al. Intensive Short-Term Dynamic Psychotherapy for generalized anxiety disorder: A pilot effectiveness and process-outcome study. Clin Psychol Psychother. 2017;24(6):1313-1321.
8. Furtado M, Katzman MA. Neuroinflammatory pathways in anxiety, posttraumatic stress, and obsessive compulsive disorders. Psychiatry Res. 2015;229(1-2):37-48.
9. Spielberger CD, Gorsuch RL, Lushene R, et al. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1983.
10. Saper RB, Eisenberg DM, Davis RB, et al. Prevalence and patterns of adult yoga use in the United States: results of a national survey. Altern Ther Health Med. 2004;10(2):44-49.
11. Farmer J. Americanasana. Reviews in American history. 2012;40(1):145-158.
12. Field T, Diego M, Delgado J, et al. Yoga and social support reduce prenatal depression, anxiety and cortisol. J Bodyw Mov Ther: 2013;17(4):397-403.
13. Jorge MP, Santaella DF, Pontes IM, et al. Hatha Yoga practice decreases menopause symptoms and improves quality of life: a randomized controlled trial. Complement Ther Med. 2016;26:128-135.
14. Pinar R, Afsar F. Back massage to decrease state anxiety, cortisol level, blood pressure, heart rate and increase sleep quality in family caregivers of patients with cancer: a randomised controlled trial. Asian Pac J Cancer Prev. 2015;16(18):8127-8133.
15. Kuriyama H, Watanabe S, Nakaya, et al. Immunological and psychological benefits of aromatherapy massage. Evid Based Complement Alternat Med. 2005;2(2):179-184.
16. Setzer WN. Essential oils and anxiolytic aromatherapy. Nat Prod Commun. 2009;4(9):1305-1316.
17. Wu JJ, Cui Y, Yang YS, et al. Modulatory effects of aromatherapy massage intervention on electroencephalogram, psychological assessments, salivary cortisol and plasma brain-derived neurotrophic factor. Complement Ther Med. 2014;22(3):456-462.
18. Fine A. Forward. In: Fine A, ed. Handbook on animal-assisted therapy-theoretical foundations and guidelines for practice. 3rd ed. Academic Press; 2010:xvii-xviii.
19. Snipelisky D, Burton MC. Canine-assisted therapy in the inpatient setting. South Med J. 2014;107(4):265-273.
20. Polheber JP, Matchock RL. The presence of a dog attenuates cortisol and heart rate in the Trier Social Stress Test compared to human friends. J Behav Med. 2014;37(5):860-867.
21. Liu T, Qiang X, eds. Chinese medical Qigong. Philadelphia, PA: Singing Dragon; 2013:1-100,192,238,511.
22. Lee MS, Kang CW, Lim HJ, et al. Effects of Qi-training on anxiety and plasma concentrations of cortisol, ACTH, and aldosterone: a randomized placebo-controlled pilot study. Stress Health. 2004;20(5):243-248.
23. Hwang EY, Chung SY, Cho JH, et al. Effects of a brief Qigong-based stress reduction program (BQSRP) in a distressed Korean population: a randomized trial. BMC Complement Altern Med. 2013;13:113.
24. Oleson, T. Overview and history of auriculotherapy. In: Auriculotherapy manual: Chinese and Western systems of ear acupuncture. 4th ed. London: Churchill Livingstone; 2014:1.
25. Kuo SY, Tsai SH, Chen SL, et al. Auricular acupressure relieves anxiety and fatigue, and reduces cortisol levels in post-caesarean section women: a single-blind, randomised controlled study. Int J Nurs Stud. 2016;53:17-26.
26. Horan P. Introduction. In: Horan P. Empowerment through reiki: the path to personal and global transformation. 8th ed. Twin Lakes, WI: Lotus Press; 1998:13-15.
27. Bremner MN, Blake BJ, Wagner VD, et al. Effects of reiki with music compared to music only among people living with HIV. J Assoc Nurses AIDS Care. 2016;27(5):635-647.
28. Helmes JM. The basic, clinical, and speculative science of acupuncture. In: Acupuncture energetics: a clinical approach for physicians. Volume 1. Berkeley, CA: Medical Acupuncture Publishers; 1995:19-32.
29. Haddad-Rodrigues M, Spanó Nakano A, Stefanello J, et al. Acupuncture for anxiety in lactating mothers with preterm infants: a randomized controlled trial. Evid Based Complement Alternat Med. 2013;2013:169184. doi: 10.1155/2013/169184.
30. Zengin S, Kabul S, Al B, et al. Effects of music therapy on pain and anxiety in patients undergoing port catheter placement procedure. Complement Ther Med. 2013;21(6):689-696.
31. Urech C, Fink NS, Hoesli I, et al. Effects of relaxation on psychobiological wellbeing during pregnancy: a randomized controlled trial. Psychoneuroendocrinology. 2010;35(9):1348-1355.
32. Goleman D. The relaxation response. In: Mind body medicine: how to use your mind for better health. Yonkers, NY: Consumer Reports; 1993:125-149.
33. Galvin JA, Benson H, Deckro GR, et al. The relaxation response: reducing stress and improving cognition in healthy aging adults. Complement Ther Clin Pract. 2006;12(3):186-191.
Anxiety disorders are the most common psychiatric illnesses in the United States, with a prevalence of nearly 29%.1 These disorders typically are treated with pharmacotherapy, psychotherapy, or a combination of both. Pharmacotherapy for anxiety has evolved considerably during the last 30 years, but medications are not efficacious for or tolerated by all patients. For example, selective serotonin reuptake inhibitors, which are frequently used for treating anxiety, can cause sexual dysfunction,2 weight gain,2 drug interactions,2 coagulopathies,3 and gastrointestinal disturbances.4 Psychotherapeutic techniques, such as cognitive behavioral therapy (CBT) and interpersonal therapy (IPT), are efficacious for mild to moderate anxiety.5-7
In addition to standard pharmacotherapy and psychotherapy, some evidence suggests that complementary therapies, such as yoga, massage, and relaxation techniques, may be beneficial as adjunctive treatments for anxiety. In placebo-controlled trials, several of these complementary therapies have been shown to decrease serum levels of the inflammatory biomarker cortisol. Anxiety is associated with inflammation,8 so therapies that reduce inflammation may help reduce symptoms of anxiety. Here, we describe the results of select positive randomized controlled trials (RCTs) of several complementary interventions for anxiety that might be useful as adjunctive treatments to psychotherapy or pharmacotherapy.
A look at RCTs that measured both anxiety and cortisol
We searched PubMed, Google Scholar, and Scopus to identify RCTs of complementary nonpharmacologic and nonpsychotherapeutic therapies for anxiety published from January 2010 to May 2017. We included only studies that:
- blindly assessed anxiety levels through a validated instrument (the State-Trait Anxiety Inventory [STAI])9
- measured cortisol concentrations before and after treatment.
Evaluating both STAI scores and cortisol levels is useful because doing so gives insight into both the clinical and biological efficacy of the therapies. Studies were excluded if they employed a pharmacologic agent in addition to the approach being evaluated.
We identified 26 studies, of which 14 met the inclusion/exclusion criteria. These studies found beneficial effects for yoga, massage therapy, aromatherapy massage, pet therapy, Qigong, auricular acupressure, reiki touch therapy, acupuncture, music therapy, and relaxation techniques.
Yoga
Yoga has become increasingly popular in the Western world during the last 2 decades.10 There are a variety of yoga practices; common forms include hatha yoga, power yoga, kripalu yoga, and forrest yoga.11
A study of 92 depressed pregnant women monito
Hatha yoga consists of a combination of postural exercises, breathing techniques, relaxation, and meditation. In a 12-week study of 88 postmenopausal women, those who practiced hatha yoga for 75 minutes a day had significantly lower STAI scores compared with women who exercised for 75 minutes a day and those who performed no physical activity.13
Continue to: Massage therapy
Massage therapy
Receiving as little as 15 minutes of back massage has proven to be beneficial for individuals with anxiety. In an RCT conducted in Turkey, 44 caregivers of patients with cancer were assigned to receive a back massage or to rest quietly in a room for 15 minutes once each day for 1 week.14 By the end of the week, compared with those who quietly rested, those who received the back massage had a statistically significant reduction in serum cortisol levels and STAI scores.14
Aromatherapy massage
Aromatherapy is the use of essential oils from plants through distillation.15 The scent of the oils is purported to provide medical benefits. More than 60 essential oils are used therapeutically, including rose, lavender, lemon, and orange.16 These essential oils are frequently used in combination with a massage.
In South Korea, researchers investigated the effects of aromatherapy massage on 25 women who had children diagnosed with attention-deficit/hyperactivity disorder.17 Women assigned to the treatment group received a 40-minute aromatherapy massage using mixed essential oils that contained lavender and geranium twice a week for 4 weeks. Women in the control group received no treatment. Compared with those in the control group, women who received the aromatherapy massages had a statistically significant decrease in STAI scores and salivary cortisol levels. Plasma cortisol was not significantly different between groups.17
Pet therapy
The psychological benefits of animal-assisted therapy were not evident until World War II, when dogs were used to cheer up injured soldiers.18 Today, pet therapy has been used on many inpatient units.19
In a U.S. study, 48 healthy undergraduate students were assigned to a room with a dog, a room with a friend, or a room by themselves.20 All participants were given the Trier Social Stress Test (TSST), a protocol that measures stress by having participants give a speech and perform mental arithmetic in front of an audience.The TSST is known to induce increases in cortisol levels. Although no differences in STAI scores were found among groups, students in the room with the dog had a lower spike in salivary cortisol after the TSST compared with participants who were in a room with a friend or in a room alone.20
Continue to: Qigong
Qigong
In Chinese medicine, Qi is known as a vital life force that flows through the body. The disruption of Qi is hypothesized to contribute to disease.21
Qigong is a medical therapy that focuses on uniting the body, breath, and mind to improve health.21 It consists of rhythmic, choreographed movements used to position the body into postures believed to help direct Qi to specific areas in the body. Qigong also uses sound exercises, in which an individual creates certain syllables while breathing. Six syllables are used, each of which is believed to affect a certain organ.21
Korean researchers randomly assigned 32 healthy men to a Qigong training group or a sham Qigong control group.22 Individuals in the training group performed 25 minutes of sound exercises, 20 minutes of meditation, and 15 minutes of movements. The control group learned the same movements as the experimental group, but without the conscious effort of moving Qi. After 3 sessions, those in the Qigong training group had significantly decreased STAI scores and serum cortisol levels compared with those in the sham group.22
In a different Korean study, researchers randomly assigned 50 participants with elevated distress levels to a Qigong training group or a waitlist control group in which participants called a trainer to describe stressful events.23 After 4 weeks, participants in the Qigong group had significant decreases in STAI scores compared with the control group. However, there were no changes in salivary cortisol levels.23
Auricular acupressure
Auricular acupressure involves applying pressure on certain portions of the auricle (outer ear) to alleviate pain and disease.24 Similar to Qigong, auricular acupressure focuses on reestablishing Qi in the body. Researchers randomly assigned 80 post-caesarean section women in Taiwan to 5 days of auricular acupressure or usual care.25 The women who received auricular acupressure had significantly lower STAI scores and serum cortisol levels compared with women who received routine care.25
Continue to: Reiki touch therapy
Reiki touch therapy
Reiki touch therapy originated in Japan. In this therapy, healers apply a light touch or hover their hands above an individual’s body to help direct energy.26
The effects of reiki touch therapy were recently evaluated in a U.S. study.27 Researchers randomly assigned 37 patients with human immunodeficiency virus to an experimental group that received 30 minutes of reiki touch therapy plus music therapy 6 times a week for 10 weeks, or to a music therapy–only control group. Patients who received reiki touch therapy had a significant decrease in STAI scores. Patients in this group also had a statistically significant drop in salivary cortisol levels after the first week.27
Acupuncture
Acupuncture is the application of needles to specific areas on the body. Acupuncture has been proposed to activate pain receptors, thereby producing an analgesic response.28
Researchers in Brazil randomly assigned 57 lactating women with preterm infants to an experimental group that received acupuncture or to a control group that received sham acupuncture.29 Treatment was administered at 5 points on the ear unilaterally for 5 minutes once a week for 16 months. Custom-made needles that did not actually puncture the skin were used in the sham group; a toothpick was used to create the sensation of needle perforations. STAI scores were reduced in both groups, although there was no statistically significant difference in scores between the acupuncture and sham groups.29
Music therapy
Music has been long believed to have beneficial psychological effects. In Turkey, researchers evaluated the effects of music therapy in 100 oncology patients who received port catheters.30 Patients were randomly assigned to an experimental group that received music therapy throughout the procedure or to a control group that received normal care. Patients who listened to music during port catheter placement had significantly reduced STAI scores and serum cortisol levels compared with those in the control group.30
Continue to: Relaxation techniques
Relaxation techniques
A wide range of relaxation techniques are used for therapeutic purposes. In Switzerland, researchers evaluated the anxiolytic effects of 10 minutes of progressive muscle relaxation and guided imagery in 39 pregnant women.31 Women randomly assigned to progressive muscle relaxation were instructed to systematically tense and then release muscle groups throughout their body in sequential order. Women assigned to the guided imagery intervention were told to imagine a safe place and to think of someone who could confer security and reassurance. The remainder of the women were assigned to a control group, where they sat quietly without any formal instructions. Researchers found that each group had a decrease in STAI scores and salivary cortisol levels immediately after the intervention.31
The relaxation response was first described in 1975 by Herbert Benson, MD, as a deep meditative state characterized by a decrease in tension, heart rate, and breathing rate. Several techniques can induce this state, including hypnosis, progressive muscle relaxation, yoga, and transcendental meditation.32 In a study of 15 healthy older adults (age 65 to 80), researchers randomly assigned participants to a relaxation response training group or to a control group.33 The relaxation response training included meditation, imagery, and relaxation techniques. After 5 weeks, participants who received the relaxation response training had marginally significant decreases in STAI scores compared with those in the control group.33
Consider these therapies as adjuncts
Our review of select positive RCTs (Table12-14,17,20,22,23,25,27,29-31,33) suggests that some nonpharmacologic/nonpsychotherapeutic adjunctive interventions may have beneficial effects for patients who have anxiety. Several of the controlled studies we reviewed demonstrated that these interventions are superior to placebo. The reductions in both anxiety severity as measured by the STAI and cortisol levels suggests that some of these complementary therapies deserve a second look as useful adjuncts to established anxiety treatments.
Bottom Line
A review of select randomized controlled trials suggests that some complementary therapies may be helpful as adjunctive therapy in patients with anxiety. These include yoga, massage therapy, aromatherapy massage, pet therapy, Qigong, auricular acupressure, reiki touch therapy, acupuncture, music therapy, and relaxation techniques.
Related Resources
- Bandelow B, Baldwin D, Abelli M, et al. Biological markers for anxiety disorders, OCD and PTSD: a consensus statement. Part II: neurochemistry, neurophysiology and neurocognition. World J Biol Psychiatry. 2017;18(3):162-214.
- National Institute of Mental Health. Anxiety disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml.
Anxiety disorders are the most common psychiatric illnesses in the United States, with a prevalence of nearly 29%.1 These disorders typically are treated with pharmacotherapy, psychotherapy, or a combination of both. Pharmacotherapy for anxiety has evolved considerably during the last 30 years, but medications are not efficacious for or tolerated by all patients. For example, selective serotonin reuptake inhibitors, which are frequently used for treating anxiety, can cause sexual dysfunction,2 weight gain,2 drug interactions,2 coagulopathies,3 and gastrointestinal disturbances.4 Psychotherapeutic techniques, such as cognitive behavioral therapy (CBT) and interpersonal therapy (IPT), are efficacious for mild to moderate anxiety.5-7
In addition to standard pharmacotherapy and psychotherapy, some evidence suggests that complementary therapies, such as yoga, massage, and relaxation techniques, may be beneficial as adjunctive treatments for anxiety. In placebo-controlled trials, several of these complementary therapies have been shown to decrease serum levels of the inflammatory biomarker cortisol. Anxiety is associated with inflammation,8 so therapies that reduce inflammation may help reduce symptoms of anxiety. Here, we describe the results of select positive randomized controlled trials (RCTs) of several complementary interventions for anxiety that might be useful as adjunctive treatments to psychotherapy or pharmacotherapy.
A look at RCTs that measured both anxiety and cortisol
We searched PubMed, Google Scholar, and Scopus to identify RCTs of complementary nonpharmacologic and nonpsychotherapeutic therapies for anxiety published from January 2010 to May 2017. We included only studies that:
- blindly assessed anxiety levels through a validated instrument (the State-Trait Anxiety Inventory [STAI])9
- measured cortisol concentrations before and after treatment.
Evaluating both STAI scores and cortisol levels is useful because doing so gives insight into both the clinical and biological efficacy of the therapies. Studies were excluded if they employed a pharmacologic agent in addition to the approach being evaluated.
We identified 26 studies, of which 14 met the inclusion/exclusion criteria. These studies found beneficial effects for yoga, massage therapy, aromatherapy massage, pet therapy, Qigong, auricular acupressure, reiki touch therapy, acupuncture, music therapy, and relaxation techniques.
Yoga
Yoga has become increasingly popular in the Western world during the last 2 decades.10 There are a variety of yoga practices; common forms include hatha yoga, power yoga, kripalu yoga, and forrest yoga.11
A study of 92 depressed pregnant women monito
Hatha yoga consists of a combination of postural exercises, breathing techniques, relaxation, and meditation. In a 12-week study of 88 postmenopausal women, those who practiced hatha yoga for 75 minutes a day had significantly lower STAI scores compared with women who exercised for 75 minutes a day and those who performed no physical activity.13
Continue to: Massage therapy
Massage therapy
Receiving as little as 15 minutes of back massage has proven to be beneficial for individuals with anxiety. In an RCT conducted in Turkey, 44 caregivers of patients with cancer were assigned to receive a back massage or to rest quietly in a room for 15 minutes once each day for 1 week.14 By the end of the week, compared with those who quietly rested, those who received the back massage had a statistically significant reduction in serum cortisol levels and STAI scores.14
Aromatherapy massage
Aromatherapy is the use of essential oils from plants through distillation.15 The scent of the oils is purported to provide medical benefits. More than 60 essential oils are used therapeutically, including rose, lavender, lemon, and orange.16 These essential oils are frequently used in combination with a massage.
In South Korea, researchers investigated the effects of aromatherapy massage on 25 women who had children diagnosed with attention-deficit/hyperactivity disorder.17 Women assigned to the treatment group received a 40-minute aromatherapy massage using mixed essential oils that contained lavender and geranium twice a week for 4 weeks. Women in the control group received no treatment. Compared with those in the control group, women who received the aromatherapy massages had a statistically significant decrease in STAI scores and salivary cortisol levels. Plasma cortisol was not significantly different between groups.17
Pet therapy
The psychological benefits of animal-assisted therapy were not evident until World War II, when dogs were used to cheer up injured soldiers.18 Today, pet therapy has been used on many inpatient units.19
In a U.S. study, 48 healthy undergraduate students were assigned to a room with a dog, a room with a friend, or a room by themselves.20 All participants were given the Trier Social Stress Test (TSST), a protocol that measures stress by having participants give a speech and perform mental arithmetic in front of an audience.The TSST is known to induce increases in cortisol levels. Although no differences in STAI scores were found among groups, students in the room with the dog had a lower spike in salivary cortisol after the TSST compared with participants who were in a room with a friend or in a room alone.20
Continue to: Qigong
Qigong
In Chinese medicine, Qi is known as a vital life force that flows through the body. The disruption of Qi is hypothesized to contribute to disease.21
Qigong is a medical therapy that focuses on uniting the body, breath, and mind to improve health.21 It consists of rhythmic, choreographed movements used to position the body into postures believed to help direct Qi to specific areas in the body. Qigong also uses sound exercises, in which an individual creates certain syllables while breathing. Six syllables are used, each of which is believed to affect a certain organ.21
Korean researchers randomly assigned 32 healthy men to a Qigong training group or a sham Qigong control group.22 Individuals in the training group performed 25 minutes of sound exercises, 20 minutes of meditation, and 15 minutes of movements. The control group learned the same movements as the experimental group, but without the conscious effort of moving Qi. After 3 sessions, those in the Qigong training group had significantly decreased STAI scores and serum cortisol levels compared with those in the sham group.22
In a different Korean study, researchers randomly assigned 50 participants with elevated distress levels to a Qigong training group or a waitlist control group in which participants called a trainer to describe stressful events.23 After 4 weeks, participants in the Qigong group had significant decreases in STAI scores compared with the control group. However, there were no changes in salivary cortisol levels.23
Auricular acupressure
Auricular acupressure involves applying pressure on certain portions of the auricle (outer ear) to alleviate pain and disease.24 Similar to Qigong, auricular acupressure focuses on reestablishing Qi in the body. Researchers randomly assigned 80 post-caesarean section women in Taiwan to 5 days of auricular acupressure or usual care.25 The women who received auricular acupressure had significantly lower STAI scores and serum cortisol levels compared with women who received routine care.25
Continue to: Reiki touch therapy
Reiki touch therapy
Reiki touch therapy originated in Japan. In this therapy, healers apply a light touch or hover their hands above an individual’s body to help direct energy.26
The effects of reiki touch therapy were recently evaluated in a U.S. study.27 Researchers randomly assigned 37 patients with human immunodeficiency virus to an experimental group that received 30 minutes of reiki touch therapy plus music therapy 6 times a week for 10 weeks, or to a music therapy–only control group. Patients who received reiki touch therapy had a significant decrease in STAI scores. Patients in this group also had a statistically significant drop in salivary cortisol levels after the first week.27
Acupuncture
Acupuncture is the application of needles to specific areas on the body. Acupuncture has been proposed to activate pain receptors, thereby producing an analgesic response.28
Researchers in Brazil randomly assigned 57 lactating women with preterm infants to an experimental group that received acupuncture or to a control group that received sham acupuncture.29 Treatment was administered at 5 points on the ear unilaterally for 5 minutes once a week for 16 months. Custom-made needles that did not actually puncture the skin were used in the sham group; a toothpick was used to create the sensation of needle perforations. STAI scores were reduced in both groups, although there was no statistically significant difference in scores between the acupuncture and sham groups.29
Music therapy
Music has been long believed to have beneficial psychological effects. In Turkey, researchers evaluated the effects of music therapy in 100 oncology patients who received port catheters.30 Patients were randomly assigned to an experimental group that received music therapy throughout the procedure or to a control group that received normal care. Patients who listened to music during port catheter placement had significantly reduced STAI scores and serum cortisol levels compared with those in the control group.30
Continue to: Relaxation techniques
Relaxation techniques
A wide range of relaxation techniques are used for therapeutic purposes. In Switzerland, researchers evaluated the anxiolytic effects of 10 minutes of progressive muscle relaxation and guided imagery in 39 pregnant women.31 Women randomly assigned to progressive muscle relaxation were instructed to systematically tense and then release muscle groups throughout their body in sequential order. Women assigned to the guided imagery intervention were told to imagine a safe place and to think of someone who could confer security and reassurance. The remainder of the women were assigned to a control group, where they sat quietly without any formal instructions. Researchers found that each group had a decrease in STAI scores and salivary cortisol levels immediately after the intervention.31
The relaxation response was first described in 1975 by Herbert Benson, MD, as a deep meditative state characterized by a decrease in tension, heart rate, and breathing rate. Several techniques can induce this state, including hypnosis, progressive muscle relaxation, yoga, and transcendental meditation.32 In a study of 15 healthy older adults (age 65 to 80), researchers randomly assigned participants to a relaxation response training group or to a control group.33 The relaxation response training included meditation, imagery, and relaxation techniques. After 5 weeks, participants who received the relaxation response training had marginally significant decreases in STAI scores compared with those in the control group.33
Consider these therapies as adjuncts
Our review of select positive RCTs (Table12-14,17,20,22,23,25,27,29-31,33) suggests that some nonpharmacologic/nonpsychotherapeutic adjunctive interventions may have beneficial effects for patients who have anxiety. Several of the controlled studies we reviewed demonstrated that these interventions are superior to placebo. The reductions in both anxiety severity as measured by the STAI and cortisol levels suggests that some of these complementary therapies deserve a second look as useful adjuncts to established anxiety treatments.
Bottom Line
A review of select randomized controlled trials suggests that some complementary therapies may be helpful as adjunctive therapy in patients with anxiety. These include yoga, massage therapy, aromatherapy massage, pet therapy, Qigong, auricular acupressure, reiki touch therapy, acupuncture, music therapy, and relaxation techniques.
Related Resources
- Bandelow B, Baldwin D, Abelli M, et al. Biological markers for anxiety disorders, OCD and PTSD: a consensus statement. Part II: neurochemistry, neurophysiology and neurocognition. World J Biol Psychiatry. 2017;18(3):162-214.
- National Institute of Mental Health. Anxiety disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml.
1. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.
2. Masand PS, Gupta S. Long-term side effects of newer-generation antidepressants: SSRIs, venlafaxine, nefazodone, bupropion, and mirtazapine. Ann Clin Psychiatry. 2002;14(3):175-182.
3. Siddiqui R, Gawande S, Shende T, et al. SSRI-induced coagulopathy: is it reality? Therapeutic Advances in Psychopharmacology. 2011;1(6):169-174.
4. Brambilla P, Cipriani A, Hotopf M, et al. Side-effect profile of fluoxetine in comparison with other SSRIs, tricyclic and newer antidepressants: a meta-analysis of clinical trial data. Pharmacopsychiatry. 2005;38(2):69-77.
5. Slomski A. Blended CBT controls anxiety in cancer survivors. JAMA. 2017;318(4):323.
6. Forsell E, Bendix M, Holländare F, et al. Internet delivered cognitive behavior therapy for antenatal depression: a randomised controlled trial. J Affect Disord. 2017;221:56-64.
7. Lilliengren P, Johansson R, Town JM, et al. Intensive Short-Term Dynamic Psychotherapy for generalized anxiety disorder: A pilot effectiveness and process-outcome study. Clin Psychol Psychother. 2017;24(6):1313-1321.
8. Furtado M, Katzman MA. Neuroinflammatory pathways in anxiety, posttraumatic stress, and obsessive compulsive disorders. Psychiatry Res. 2015;229(1-2):37-48.
9. Spielberger CD, Gorsuch RL, Lushene R, et al. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1983.
10. Saper RB, Eisenberg DM, Davis RB, et al. Prevalence and patterns of adult yoga use in the United States: results of a national survey. Altern Ther Health Med. 2004;10(2):44-49.
11. Farmer J. Americanasana. Reviews in American history. 2012;40(1):145-158.
12. Field T, Diego M, Delgado J, et al. Yoga and social support reduce prenatal depression, anxiety and cortisol. J Bodyw Mov Ther: 2013;17(4):397-403.
13. Jorge MP, Santaella DF, Pontes IM, et al. Hatha Yoga practice decreases menopause symptoms and improves quality of life: a randomized controlled trial. Complement Ther Med. 2016;26:128-135.
14. Pinar R, Afsar F. Back massage to decrease state anxiety, cortisol level, blood pressure, heart rate and increase sleep quality in family caregivers of patients with cancer: a randomised controlled trial. Asian Pac J Cancer Prev. 2015;16(18):8127-8133.
15. Kuriyama H, Watanabe S, Nakaya, et al. Immunological and psychological benefits of aromatherapy massage. Evid Based Complement Alternat Med. 2005;2(2):179-184.
16. Setzer WN. Essential oils and anxiolytic aromatherapy. Nat Prod Commun. 2009;4(9):1305-1316.
17. Wu JJ, Cui Y, Yang YS, et al. Modulatory effects of aromatherapy massage intervention on electroencephalogram, psychological assessments, salivary cortisol and plasma brain-derived neurotrophic factor. Complement Ther Med. 2014;22(3):456-462.
18. Fine A. Forward. In: Fine A, ed. Handbook on animal-assisted therapy-theoretical foundations and guidelines for practice. 3rd ed. Academic Press; 2010:xvii-xviii.
19. Snipelisky D, Burton MC. Canine-assisted therapy in the inpatient setting. South Med J. 2014;107(4):265-273.
20. Polheber JP, Matchock RL. The presence of a dog attenuates cortisol and heart rate in the Trier Social Stress Test compared to human friends. J Behav Med. 2014;37(5):860-867.
21. Liu T, Qiang X, eds. Chinese medical Qigong. Philadelphia, PA: Singing Dragon; 2013:1-100,192,238,511.
22. Lee MS, Kang CW, Lim HJ, et al. Effects of Qi-training on anxiety and plasma concentrations of cortisol, ACTH, and aldosterone: a randomized placebo-controlled pilot study. Stress Health. 2004;20(5):243-248.
23. Hwang EY, Chung SY, Cho JH, et al. Effects of a brief Qigong-based stress reduction program (BQSRP) in a distressed Korean population: a randomized trial. BMC Complement Altern Med. 2013;13:113.
24. Oleson, T. Overview and history of auriculotherapy. In: Auriculotherapy manual: Chinese and Western systems of ear acupuncture. 4th ed. London: Churchill Livingstone; 2014:1.
25. Kuo SY, Tsai SH, Chen SL, et al. Auricular acupressure relieves anxiety and fatigue, and reduces cortisol levels in post-caesarean section women: a single-blind, randomised controlled study. Int J Nurs Stud. 2016;53:17-26.
26. Horan P. Introduction. In: Horan P. Empowerment through reiki: the path to personal and global transformation. 8th ed. Twin Lakes, WI: Lotus Press; 1998:13-15.
27. Bremner MN, Blake BJ, Wagner VD, et al. Effects of reiki with music compared to music only among people living with HIV. J Assoc Nurses AIDS Care. 2016;27(5):635-647.
28. Helmes JM. The basic, clinical, and speculative science of acupuncture. In: Acupuncture energetics: a clinical approach for physicians. Volume 1. Berkeley, CA: Medical Acupuncture Publishers; 1995:19-32.
29. Haddad-Rodrigues M, Spanó Nakano A, Stefanello J, et al. Acupuncture for anxiety in lactating mothers with preterm infants: a randomized controlled trial. Evid Based Complement Alternat Med. 2013;2013:169184. doi: 10.1155/2013/169184.
30. Zengin S, Kabul S, Al B, et al. Effects of music therapy on pain and anxiety in patients undergoing port catheter placement procedure. Complement Ther Med. 2013;21(6):689-696.
31. Urech C, Fink NS, Hoesli I, et al. Effects of relaxation on psychobiological wellbeing during pregnancy: a randomized controlled trial. Psychoneuroendocrinology. 2010;35(9):1348-1355.
32. Goleman D. The relaxation response. In: Mind body medicine: how to use your mind for better health. Yonkers, NY: Consumer Reports; 1993:125-149.
33. Galvin JA, Benson H, Deckro GR, et al. The relaxation response: reducing stress and improving cognition in healthy aging adults. Complement Ther Clin Pract. 2006;12(3):186-191.
1. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.
2. Masand PS, Gupta S. Long-term side effects of newer-generation antidepressants: SSRIs, venlafaxine, nefazodone, bupropion, and mirtazapine. Ann Clin Psychiatry. 2002;14(3):175-182.
3. Siddiqui R, Gawande S, Shende T, et al. SSRI-induced coagulopathy: is it reality? Therapeutic Advances in Psychopharmacology. 2011;1(6):169-174.
4. Brambilla P, Cipriani A, Hotopf M, et al. Side-effect profile of fluoxetine in comparison with other SSRIs, tricyclic and newer antidepressants: a meta-analysis of clinical trial data. Pharmacopsychiatry. 2005;38(2):69-77.
5. Slomski A. Blended CBT controls anxiety in cancer survivors. JAMA. 2017;318(4):323.
6. Forsell E, Bendix M, Holländare F, et al. Internet delivered cognitive behavior therapy for antenatal depression: a randomised controlled trial. J Affect Disord. 2017;221:56-64.
7. Lilliengren P, Johansson R, Town JM, et al. Intensive Short-Term Dynamic Psychotherapy for generalized anxiety disorder: A pilot effectiveness and process-outcome study. Clin Psychol Psychother. 2017;24(6):1313-1321.
8. Furtado M, Katzman MA. Neuroinflammatory pathways in anxiety, posttraumatic stress, and obsessive compulsive disorders. Psychiatry Res. 2015;229(1-2):37-48.
9. Spielberger CD, Gorsuch RL, Lushene R, et al. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1983.
10. Saper RB, Eisenberg DM, Davis RB, et al. Prevalence and patterns of adult yoga use in the United States: results of a national survey. Altern Ther Health Med. 2004;10(2):44-49.
11. Farmer J. Americanasana. Reviews in American history. 2012;40(1):145-158.
12. Field T, Diego M, Delgado J, et al. Yoga and social support reduce prenatal depression, anxiety and cortisol. J Bodyw Mov Ther: 2013;17(4):397-403.
13. Jorge MP, Santaella DF, Pontes IM, et al. Hatha Yoga practice decreases menopause symptoms and improves quality of life: a randomized controlled trial. Complement Ther Med. 2016;26:128-135.
14. Pinar R, Afsar F. Back massage to decrease state anxiety, cortisol level, blood pressure, heart rate and increase sleep quality in family caregivers of patients with cancer: a randomised controlled trial. Asian Pac J Cancer Prev. 2015;16(18):8127-8133.
15. Kuriyama H, Watanabe S, Nakaya, et al. Immunological and psychological benefits of aromatherapy massage. Evid Based Complement Alternat Med. 2005;2(2):179-184.
16. Setzer WN. Essential oils and anxiolytic aromatherapy. Nat Prod Commun. 2009;4(9):1305-1316.
17. Wu JJ, Cui Y, Yang YS, et al. Modulatory effects of aromatherapy massage intervention on electroencephalogram, psychological assessments, salivary cortisol and plasma brain-derived neurotrophic factor. Complement Ther Med. 2014;22(3):456-462.
18. Fine A. Forward. In: Fine A, ed. Handbook on animal-assisted therapy-theoretical foundations and guidelines for practice. 3rd ed. Academic Press; 2010:xvii-xviii.
19. Snipelisky D, Burton MC. Canine-assisted therapy in the inpatient setting. South Med J. 2014;107(4):265-273.
20. Polheber JP, Matchock RL. The presence of a dog attenuates cortisol and heart rate in the Trier Social Stress Test compared to human friends. J Behav Med. 2014;37(5):860-867.
21. Liu T, Qiang X, eds. Chinese medical Qigong. Philadelphia, PA: Singing Dragon; 2013:1-100,192,238,511.
22. Lee MS, Kang CW, Lim HJ, et al. Effects of Qi-training on anxiety and plasma concentrations of cortisol, ACTH, and aldosterone: a randomized placebo-controlled pilot study. Stress Health. 2004;20(5):243-248.
23. Hwang EY, Chung SY, Cho JH, et al. Effects of a brief Qigong-based stress reduction program (BQSRP) in a distressed Korean population: a randomized trial. BMC Complement Altern Med. 2013;13:113.
24. Oleson, T. Overview and history of auriculotherapy. In: Auriculotherapy manual: Chinese and Western systems of ear acupuncture. 4th ed. London: Churchill Livingstone; 2014:1.
25. Kuo SY, Tsai SH, Chen SL, et al. Auricular acupressure relieves anxiety and fatigue, and reduces cortisol levels in post-caesarean section women: a single-blind, randomised controlled study. Int J Nurs Stud. 2016;53:17-26.
26. Horan P. Introduction. In: Horan P. Empowerment through reiki: the path to personal and global transformation. 8th ed. Twin Lakes, WI: Lotus Press; 1998:13-15.
27. Bremner MN, Blake BJ, Wagner VD, et al. Effects of reiki with music compared to music only among people living with HIV. J Assoc Nurses AIDS Care. 2016;27(5):635-647.
28. Helmes JM. The basic, clinical, and speculative science of acupuncture. In: Acupuncture energetics: a clinical approach for physicians. Volume 1. Berkeley, CA: Medical Acupuncture Publishers; 1995:19-32.
29. Haddad-Rodrigues M, Spanó Nakano A, Stefanello J, et al. Acupuncture for anxiety in lactating mothers with preterm infants: a randomized controlled trial. Evid Based Complement Alternat Med. 2013;2013:169184. doi: 10.1155/2013/169184.
30. Zengin S, Kabul S, Al B, et al. Effects of music therapy on pain and anxiety in patients undergoing port catheter placement procedure. Complement Ther Med. 2013;21(6):689-696.
31. Urech C, Fink NS, Hoesli I, et al. Effects of relaxation on psychobiological wellbeing during pregnancy: a randomized controlled trial. Psychoneuroendocrinology. 2010;35(9):1348-1355.
32. Goleman D. The relaxation response. In: Mind body medicine: how to use your mind for better health. Yonkers, NY: Consumer Reports; 1993:125-149.
33. Galvin JA, Benson H, Deckro GR, et al. The relaxation response: reducing stress and improving cognition in healthy aging adults. Complement Ther Clin Pract. 2006;12(3):186-191.
