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• Published: 09 January 2023

Effect of breathwork on stress and mental health: A meta-analysis of randomised-controlled trials

• Guy William Fincham 1 ,
• Clara Strauss 1 , 2 ,
• Jesus Montero-Marin 3 , 4 , 5 &
• Kate Cavanagh 1 , 2  

Scientific Reports volume  13 , Article number:  432 ( 2023 ) Cite this article

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Deliberate control of the breath (breathwork) has recently received an unprecedented surge in public interest and breathing techniques have therapeutic potential to improve mental health. Our meta-analysis primarily aimed to evaluate the efficacy of breathwork through examining whether, and to what extent, breathwork interventions were associated with lower levels of self-reported/subjective stress compared to non-breathwork controls. We searched PsycInfo, PubMed, ProQuest, Scopus, Web of Science, ClinicalTrials.gov and ISRCTN up to February 2022, initially identifying 1325 results. The primary outcome self-reported/subjective stress included 12 randomised-controlled trials ( k  = 12) with a total of 785 adult participants. Most studies were deemed as being at moderate risk of bias. The random-effects analysis yielded a significant small-to-medium mean effect size, g  = − 0.35 [95% CI − 0.55, − 0.14], z  = 3.32, p  = 0.0009, showing breathwork was associated with lower levels of stress than control conditions. Heterogeneity was intermediate and approaching significance, χ 2 11  = 19, p  = 0.06, I 2  = 42%. Meta-analyses for secondary outcomes of self-reported/subjective anxiety ( k  = 20) and depressive symptoms ( k  = 18) showed similar significant effect sizes: g  = − 0.32, p  < 0.0001, and g  = − 0.40, p  < 0.0001, respectively. Heterogeneity was moderate and significant for both. Overall, results showed that breathwork may be effective for improving stress and mental health. However, we urge caution and advocate for nuanced research approaches with low risk-of-bias study designs to avoid a miscalibration between hype and evidence.

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Introduction.

Breathwork comprises various practices which encompass regulating the way that one breathes, particularly in order to promote mental, emotional and physical health (Oxford English Dictionary) 1 . These techniques have emerged worldwide with complex historical roots from various traditions such as yoga (i.e., alternate nostril breathing) and Tibetan Buddhism (i.e., vase breathing) along with psychedelic communities (i.e., conscious connected breathing) and scientific/medical researchers and practitioners (i.e., coherent/resonant frequency breathing). Recently, breathwork has been garnering public attention and popularity in the West due to supposed beneficial effects on health and well-being 2 in addition to the breathing-related pathology of covid-19, however it has only been partly investigated by clinical research and psychiatric medical communities.

Slow-paced breathing practices have gained most research attention thus far. Several psychophysiological mechanisms of action are proposed to underpin such techniques: from polyvagal theory and interoception literature 3 along with enteroception, central nervous system effects, and increasing heart-rate variability (HRV) via modulation of the autonomic nervous system (ANS) and increased parasympathetic activity 4 . ANS activity can be measured using HRV, the oscillations in heart rate connected to breathing (i.e., the fluctuation in the interval between successive heart beats) 5 . Fundamentally, as one inhales and exhales, heart rate increases and decreases, respectively. Higher HRV, arising from respiratory sinus arrhythmia 6 , is typically beneficial as it translates into robust responses to changes in breathing and thus a more resilient stress-response system 7 .

Stress-response dysfunction, associated with impaired ANS activity, and low HRV are common in stress, anxiety, and depression 8 , 9 , 10 , 11 , 12 . This may explain why techniques like HRV biofeedback can be helpful 13 , however, it is possible that simply pacing respiration slowly at approximately 5–6 breaths/minute, requiring no monitoring equipment, can elicit similar effects 14 . Polyvagal Theory 3 , for instance, posits that vagal nerves are major channels for bidirectional communication between body and brain. Bodily feedback has profound effects on mental states as 80% of vagus nerve fibres transmit messages from body to brain 15 . Further, the neurovisceral integration model states that high vagal tone is associated with improved health along with emotional and cognitive functioning 16 , 17 . Vagal nerves form the main pathway of the parasympathetic nervous system, and high HRV indicates greater parasympathetic activity 7 .

Modifying breathing alters communication sent from the respiratory system, rapidly influencing brain regions regulating behaviour, thought and emotion 18 . Likewise, respiration may entrain brain electrical activity 19 , with slow breathing resulting in synchrony of brain waves 20 , thereby enabling diverse brain regions to communicate more effectively 21 . It has been observed that adept long-term Buddhist meditation practitioners can achieve states where brain waves are synchronised continuously 22 .

Breathwork and stress

Stress, anxiety and depression have markedly exceeded pre-covid-19 pandemic population norms 23 . Thus, research is needed to address how this can be mitigated 24 . A recent survey based on more than 150,000 interviews in over 100 countries suggested that 40% of adults had experienced stress the day preceding the survey (Gallup, US) 25 . Prior to the pandemic, mental health difficulties were already a significant issue. For instance, stress has been identified by the World Health Organisation as contributing to several non-communicable diseases 26 and a 2014 survey, led in collaboration with Harvard, of over 115 million adults showed that 72% and 60% frequently experienced financial and occupational stress, respectively (Robert Wood Johnson Foundation, US) 27 .

Chronic stress is associated with, and can significantly contribute to, many physical and mental health conditions, from hypertension and cardiovascular disease to anxiety and depression 28 . For common mental health problems such as anxiety and depression, cognitive behavioural therapy (CBT) is widely recommended in treatment guidelines worldwide 29 , 30 , yet many do not recover and waiting times can be long 31 , 32 , in addition to extensive professional training and ongoing supervision being required for therapists. Moreover, such treatment is typically individualised and offered on a one-to-one basis making it resource intensive. The present state of global mental health coupled with the access barriers to psychological therapies requires interventions that are easily accessible and scalable 7 , and manualised practices such as breathwork may meet this remit.

Breathing exercises can be easily taught to both trainers and practitioners, and learned in group settings, increasingly via synchronous and asynchronous methods remotely/online. Therefore, given the need for effective treatments that can be offered at scale with limited resources, interventions focusing on deliberately changing breathing might have significant potential. Indeed, some government public health platforms already recommend deep breathing for stress, anxiety and panic symptoms (NHS and IAPT, UK) 33 , 34 . However, the evidence underlying this recommendation has not been scrutinised in a comprehensive systematic review and meta-analysis and this is the aim of the current study.

Moreover, it is not only slow-paced breathing which may help reduce stress. Fast-paced breathwork may also offer therapeutic benefit as temporary voluntarily induced stress is also known to be beneficial for health and stress resilience. For example, regular physical exercise can improve stress, anxiety and depression levels 35 , along with HRV 36 . Similarly, fast-paced breathing techniques can induce short-term stress that may improve mental health 37 , and have also been shown to volitionally influence the ANS, promoting sympathetic activity 38 . There are countless breathwork techniques—and such variation in their potential modalities and underlying principles warrants exploration.

Review aims

It is important that hype around breathwork is grounded in evidence for efficacy—and effects are not overstated to the public. Whilst some previous reviews of breathwork have been published, it is not possible to conclude the effectiveness of breathwork for stress (nor mental health in general) based on previous meta-analyses, since they have been restricted by certain factors. These include focusing on populations with impaired breathing (i.e., chronic obstructive pulmonary disease—COPD, and Asthma) 39 , 40 , insufficient focus on the breathwork intervention itself (i.e., including interventions where breathwork is combined with several other intervention components) 41 making it hard to elicit separate effects, along with spanning more literature on self-reported/subjective anxiety and depression compared to stress 14 . On the other hand, systematic reviews with narrative syntheses of quantitative data may have overlooked key studies because of too much focus on a specific technique (i.e., slow breathing or diaphragmatic breathing) 4 , 42 , an absence of randomised-controlled trials (RCTs), scanter literature on self-reported/subjective stress compared to self-reported/subjective symptoms of anxiety and depression, along with limited databases 4 , or exclusion of unpublished studies and grey literature (i.e., theses/dissertations) 43 .

Furthermore, in keeping with the participant, intervention, control, outcome and study design (PICOS) framework 44 , there is an absence of examining dose–response correlates with effects and subgroup analyses evaluating differential effects of different breathwork interventions and how they were delivered, what controls were used, effects on populations with differing health statuses and, finally, the psychological outcome measures used. All of these are crucial for an adequate ethical, precautional and practical implementation of breathwork interventions. Accordingly, subgroup analyses were explored to account for these, for the primary outcome of stress. It could be relevant to investigate potential sources of heterogeneity in terms of effects on stress, and this might be related to how some subgroups (such as mental/physical health populations, along with nonclinical/general populations) receive the intervention. Moreover, other subgroups such as the type of breathwork intervention (i.e., slow/fast) and how it is delivered (i.e., online/in-person or individual/group-based), along with the type of comparator (active/inactive control) and outcome measure (questionnaire) used to self-report on stress, may be sources of heterogeneity and thus warrant investigation.

So far, there is no existing meta-analysis of RCTs on the effect of breathwork on psychological stress. Thus, to fill this research gap, the aim of our meta-analysis was to estimate the effect of breathwork in targeting stress. Because prolonged stress can significantly contribute to anxiety and depressive symptoms and there is considerable overlap between them 45 , 46 , we included these two common mental health issues as secondary outcomes, to provide a bigger picture and greater context around the findings on stress. The primary outcome was pre-registered as stress since it is a transdiagnostic variable, relevant in a variety of disorders, and also in people without a diagnosis but suffering from high levels of psychological distress 47 . This makes stress a very interesting target for breathwork-based interventions.

In brief, our research question was the following: do breathwork interventions lead to lower self-reported/subjective stress (primary outcome), anxiety, and depression (secondary outcomes) in comparison to non-breathwork control conditions? We propose this work as a first comprehensive systematic review and meta-analysis exploring the effects of breathwork on stress and mental health, to help lay a solid foundation for the field to grow and evolve in an evidence-based manner.

We focused solely on RCTs reporting psychological measures, to gauge any potential efficacy or effectiveness of breathwork. We also explored sub-analyses for stress outcomes depending on the health status of the study population, technique, and delivery of breathwork, along with types of control groups and stress outcome measures used. Finally, we examined dose–response effects of breathwork on stress.

Pre-registration and search strategy

Our meta-analysis was pre-registered on the international prospective register of systematic reviews PROSPERO (2022 CRD42022296709). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards were applied throughout. We searched published, unpublished, and grey literature in the following five databases: PsycInfo, PubMed, ProQuest, Scopus, and Web of Science, along with two clinical trial registers: ClinicalTrials.gov and ISRCTN. The search was run up to February 2022 for all seven electronic repositories, with no date restrictions, in line with the search criteria pre-registered on Prospero, including keywords such as: breath*, respir*, random*, RCT, and stress (see Online Appendix A for the detailed search). For purposes of feasibility in conducting the search, we maintained our focus on the pre-registered primary outcome, following Cochrane Collaboration guidelines to meet the highest criteria for self-reported/subjective stress outcomes by searching trial registers for unpublished studies. There is limited search functionality on trial registers and time involved in contacting researchers for trial data. Moreover, as mentioned above, some previous reviews have not searched unpublished, grey literature before and there are less data available on breathwork and self-reported/subjective stress, in comparison to self-reported/subjective anxiety and depression. In brief, given our focus on stress (paired with time and resource constraints), we conducted the most robust search possible for the primary outcome whilst secondary outcomes only included published data—and we were explicit about this from pre-registration onwards.

Inclusion and exclusion criteria

Inclusion criteria were that studies: (1) were published in the English language, (2) included a breathwork intervention where breathwork formed 50% or more of the intervention (and home practice/self-practice, if any), (3) were RCTs, (4) included an outcome measure of self-reported/subjective stress, anxiety, or depression, (5) included an adult participant sample 18 + years of age. For the five databases, studies with abstracts that did not include either the primary outcome keyword (stress), or a secondary outcome keyword (anxiety or depression), were excluded. For the two registers, if it was clear from the summary information that trials did not comprise the primary outcome of stress, they were excluded. As mentioned above, stress is a transdiagnostic health variable, relevant across various (clinical and nonclinical) populations and conditions, hence it was our primary interest. Additional rationale included the fact that there is far more limited research literature available on self-reported/subjective stress and breathwork (as opposed to anxiety and depression) and, since this was the primary outcome, because fewer (published) data were available, and to make the secondary search (which was only used in the present study to contextualise findings) more feasible, we used the referred search strategy, as this allowed us to find more information on stress from unpublished sources.

For all electronic repositories, studies with control conditions that comprised components of breathwork were excluded, except for studies which had time-points wherein data were collected before controls participated in breathwork (i.e., crossover RCTs). Only non-breathwork controls were used as post-intervention comparisons. Studies with interventions that comprised of equipment (oronasal or otherwise) which physically altered and/or assisted breathing activity were excluded. Breathwork was operationalised as techniques which involved conscious and volitional control or manipulation of one's breath (depth, pattern, speed or otherwise) through deliberate breathing practices. Interventions that affected breathing as a by-product, e.g., mindfulness, singing, and aerobic exercise, were excluded.

Review strategy and study selection

The first author conducted the search and initial screening against eligibility criteria along with full-text screening. Records were then screened, excluding reports based on review of titles and keywords in abstracts or summary information (for trials), or if the inclusion criteria were not met. Remaining reports were sought for retrieval and the full-text reports assessed for eligibility, before final eligibility decisions were made. Further identification of studies comprised forward and backward citation searching via Google Scholar and reference lists, respectively, of the final reports included from the database/registry search. For inter-rater consistency purposes, one of the authors (JMM) checked a random sample (10% of reports) after duplicates had been removed. Furthermore, where GWF was unsure after full-text screening, they consulted authors KC and CS to come to a collective decision on eligibility. Any discrepancies between authors were resolved by discussion and reaching consensus.

Data extraction

Our primary outcome was self-reported/subjective stress. Secondary outcomes were self-reported/subjective anxiety, depression, and global mental health (where two or more of stress, anxiety and depression were combined into a total measure without providing subscale data). We extracted the following data across the studies’ conditions: sample sizes, means, and standard deviations of outcome scores post-intervention (timepoint 1—T1, where T0 is pre-intervention/baseline) along with at latest follow-up where possible (a true follow-up was classed as when participants no longer received any instruction for the breathwork intervention). Where studies involved crossover designs, the midpoints were categorised as post-intervention (before the control group started the breathwork given initially to the intervention group). For studies which required multiple groups’ mean and standard deviation (M ± SD) scores to be combined, or for just SDs to be calculated, these were calculated in accordance with the Cochrane Collaboration handbook 48 . For example, calculating SDs from Ms and 95% confidence intervals (CIs) or combining multiple groups’ M ± SD scores if two or more groups completed an intervention that involved breathwork (but the study still comprised a non-breathwork control).

Risk of bias and quality assessment

The most recent, revised Cochrane Collaboration’s tool for assessing risk of bias in randomised trials (RoB 2) 49 was used for analysing studies on the primary outcome measure of self-reported/subjective stress. The studies were analysed across the following five domains for the stress outcomes: randomisation process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Each domain produced an algorithmic judgement of “low risk of bias”, “some concerns”, or “high risk of bias”, resulting in an overall risk of bias judgement. For further inter-rater consistency purposes, both JMM and GWF completed bias scoring using RoB 2 on all included studies for stress, with any discrepancies resolved via discussion.

Data synthesis and analysis

To evaluate whether breathwork can effectively lower stress compared to non-breathwork controls and to quantify the estimation we ran a quantitative synthesis meta-analysis using standardised mean differences and a random-effects model. This used aggregate participant data of M ± SD scores on stress outcome measures for intervention and control conditions of each study at post-intervention (T1), along with the groups’ sample sizes. We also conducted a sensitivity analysis by removing one study at a time, to evaluate the robustness of effects. Separate random-effects meta-analyses were run for the secondary outcomes. The software Review Manager (RevMan) version 5.4 50 was used. For the between-group effect sizes (ESs) we computed Hedges’ g , based on the standardised between-group difference at post-intervention considering sampling variance among groups; an ES of 0.2 is classed as small, 0.5 medium and 0.8 large 51 . For each separate outcome, the ESs were calculated via comparison of post-breathwork intervention scores between the conditions. Intention-to-treat data were chosen over per-protocol data where available, since the former provides a more conservative estimate of between-group differences.

Heterogeneity of ESs variance was assessed using Cochran’s Q 52 based on a chi-square distribution ( χ 2 ) and Higgins’ I 2 53 . If χ 2 is significant and an I 2 index value is around 50%, this implies variance may be explained by variables other than breathwork and such statistical heterogeneity is moderate, respectively. A funnel plot was produced to examine publication bias for the primary outcome, and the software R (version 4) 54 was used to explore asymmetry of the funnel plot via the Egger’s test 55 (i.e., correlations between standard error and ESs). Moreover, Rosenthal’s fail-safe N was calculated (to estimate how many further studies yielding zero effect would be required to make the overall ES non-significant for stress) 56 . Kendall's tau-b (τ B ) correlations were used to detect any potential relationships between ESs of breathwork on stress and: estimated total duration of intervention/home practice, total number of intervention/home practice sessions, and intervention/home practice session frequency. If intervention time was not provided by a study (where participants only had home practice), we used the minimum estimated home practice duration (recommended in the study) to gauge the approximate time taken for participants to ‘learn’ the breathwork technique. Minimum recommended duration was used for most conservative estimates, helping account for common attrition found across behavioural studies.

Lastly, subgroup analyses were run for stress, again using a random-effects model. These subsets included: health status of population (physical, nonclinical, or mental health), technique type (fast or slow-paced breathing) and delivery method of the breathwork intervention (individual, group, or a combination of both, and remote (self-help), in-person, or combination) along with the type of control group (active or inactive; in line with Cochrane Collaboration guidelines 48 ), and outcome measure used (scale).

Search results

As shown in Fig.  1 , the search produced 1325 results: 1175 and 150 records from databases and registers, respectively. After duplicates were removed, the titles and abstracts (or summary information for registers) of 679 records were screened. During screening, the eligibility of 11% of reports were decided collectively among GWF, KC, and CS. All studies included by GWF were checked by KC and CS to ensure none were incorrectly included. One particular study 57 that comprised a global mental health measure only had to be excluded as there were insufficient studies to reliably interpret results ( n  < 5) 58 —the only other available was Goldstein et al. 59 (which also included a measure of self-reported/subjective stress). Accordingly, the global mental health secondary outcome was dropped from the analysis.

PRISMA flow diagram showing the identification of eligible studies via databases, registers, and citation searching. Self-reported/subjective stress was the primary outcome for the quantitative synthesis random-effects meta-analysis. Total number of included studies was 26. Trial registries searched primary outcome only.

Further data were required for eight reports; corresponding authors were contacted, and data from four studies were retrieved, but not the remaining half 60 , 61 , 62 , 63 subsequently excluded from the analysis. Thus, a total of 104 reports were screened and 81 were excluded, leaving 23. As a result of citation searching, a further three studies were included. Of the 26 total reports included in the quantitative synthesis meta-analyses, stress comprised 12 studies 59 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 . Secondary outcomes of self-reported/subjective anxiety and depression comprised of 20 studies 64 , 65 , 66 , 67 , 68 , 69 , 70 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 and 18 studies 64 , 65 , 66 , 67 , 69 , 70 , 71 , 72 , 74 , 78 , 79 , 80 , 81 , 82 , 85 , 86 , 87 , 88 , respectively. Please see Online Appendix B for more information on the secondary outcomes.

Summary of findings for stress

In terms of data extraction, all studies provided raw M ± SD scores apart from two 55 , 56 where estimated marginal M ± SDs were given (raw data was requested from corresponding authors but could not be obtained). One study 65 required SDs from Ms and 95% confidence intervals (CIs) provided, both of which were calculated in accordance with Cochrane Collaboration guidelines 48 . Furthermore, another study 70 required two groups’ M ± SD scores (there was one control group and two intervention groups) to be combined and two further studies 64 , 71 involved crossover designs (hence data were extracted at the midpoints of each study before controls started the breathwork intervention). Analyses of follow-up scores were not possible for self-reported/subjective stress as there were insufficient studies for results to be reliably interpreted 58 .

The 12 studies included in the meta-analysis for the primary outcome of stress were completed from 2012 to 2021 (seven, or 60%, were conducted from 2020 onwards). Half of these studies were conducted in the US 59 , 64 , 65 , 66 , 68 , 74 , two in India 71 , 72 , one globally 73 , and one each in: Israel 70 , Turkey 67 , and Canada 69 . The average age was 41.7 (± 8.47) and 75% identified as female, since the largest study 68 was for women only. Attrition rates (after the breathwork intervention began) ranged from 3 to 40%. Participant sample sizes ranged from 10 to 150, with the total number of participants analysed being 785. The number of participants randomised to a breathwork intervention or control condition was 417 and 368, respectively. The minimum total estimated durations of an intervention/home practice ranged from 80 to 5625 min.

Half of the studies comprised physical health, five nonclinical, and one mental health samples. Ten and two studies comprised interventions with a primary focus on slow-paced breathing and fast-paced breathing, respectively. Seven were individual-based interventions, four taught to groups, and one a combination of both modes. Half were remote/self-help interventions, five in-person, and one combination. Seven and five studies had inactive and active control groups, respectively. Eight studies used the perceived stress scale (PSS) 89 , three used the stress subscale from the depression anxiety stress scale (DASS) 90 , and one used the perceived stress questionnaire (PSQ) 91 .

Risk of bias for stress

Risk of bias scoring for the 12 studies on the primary outcome is reported using RoB 2 in Fig.  2 . Three studies’ overall assessment were algorithmically scored as being at high risk of bias, with domain two (deviations from the intended interventions) contributing to most bias. The remaining nine studies’ overall risk of bias were algorithmically scored as having some concerns. Only one study did not disclose how randomisation was conducted. Most of the domains, from randomisation to selection of the reported result, were scored as having some concerns or low risk of bias. We did not find reported adverse events or lasting bad effects directly attributed to breathwork interventions; four studies (six in total including secondary outcome studies) actively reported on this. Nonetheless, regarding safety and tolerability, a small subgroup of participants in Ravindran et al.’s study 71 focusing on fast-paced breathwork in unipolar and bipolar depression reported side effects such as hot flushes, shortness of breath and/or sweating. However, these participants opted to continue the intervention and no participants dropped out of the breathwork group due to adverse effects.

Risk of bias scoring using Cochrane Collaboration’s RoB 2 tool. Green and red colours correspond to low and high risk of bias, respectively. Yellow represents some concerns. D1 Randomisation process, D2 Deviations from the intended interventions, D3 Missing outcome data, D4 Measurement of the outcome, D5 Selection of the reported result.

As shown in Fig.  3 , the random-effects meta-analysis (k  = 12) displayed a small-medium but significant post-intervention between-group ES, g  = − 0.35 [95% CI − 0.55, − 0.14], z  = 3.32, p  = 0.0009, denoting breathwork was associated with lower levels of self-reported/subjective stress at post-intervention than controls. There were insufficient studies including follow-up measures for a meta-analysis. Heterogeneity was moderate but non-significant, χ 2 11  = 19, p  = 0.06, I 2  = 42%. Via removing one individual study at a time, the ES of breathwork on stress ranged from − 0.27 to − 0.39 and remained significant in all cases. Initial visual inspection of the funnel plot in Online Appendix  C suggested some skew due to studies with small samples; however, the Egger’s test was non-significant, z  = 0.03, p  = 0.947, indicating a low chance of publication bias. Fail-safe N  analysis denoted that a further 69 studies yielding zero effect would need to be added to make the overall ES non-significant for stress. On removal of the one potential outlier 67 the ES remained significant but became smaller: − 0.27. On removal of the two studies using estimated marginal M ± SDs, the ES remained significant and became larger: − 0.40.

Forest plot comparing breathwork interventions to non-breathwork control groups on primary outcome of self-reported/subjective stress at post-intervention. Squares and their size represent individual studies and their weight, respectively. Lines through squares are 95% CIs and diamond is the overall effect size with 95% CIs. More negative values denote larger effect of breathwork on self-reported/subjective stress in comparison to control condition. Effect sizes calculated using Hedges’ g . Figure produced using RevMan v5.4.

Subgroup analyses for stress

As displayed by Table 1 , we conducted five sub-analyses for the primary outcome self-reported/subjective stress. There were no significant differential effects between subgroups.

There was a significant effect of breathwork on stress in nonclinical samples, but not in mental (only one study) or physical health populations. Moreover, significant effects were yielded when breathwork was primarily focused on slow-paced breathing (but not for fast-paced breathing), taught to individuals alone, and when taught to groups (but not in combination, which comprised only one study). There were also significant effects of breathwork on stress when the intervention was taught remotely, in-person, and using a combination of these two delivery methods. Significant effects existed for both active and inactive control groups. There were significant effects for studies which used PSS and DASS measures (but not the PSQ, used by only one study).

Heterogeneity was high for studies with physical health samples, slow-paced breathwork, when breathwork was taught to groups and in-person, plus those studies with inactive controls, and when stress was measured by using the DASS, suggesting potential moderating factors that were not accounted for by the subgroup analyses. There was no significant correlation between estimated total duration of breathwork intervention/home practice and ES ( n  = 12) τ B  = − 0.05, p  = 0.418, number of intervention/home practice sessions and ES for stress ( n  = 12) τ B  = − 0.28, p  = 0.107, nor for intervention/home practice session frequency and ES ( n  = 12) τ B  = − 0.17, p  = 0.224.

Breathwork and secondary outcomes

In terms of data extraction, one study 79 had a measure with positively scored anxiety and depression subscales; accordingly, we subtracted the subscale score from the maximum score to reverse the polarity of the measure without changing the magnitude of difference. Another study 88 required two groups’ M ± SD scores to be combined. Analysis of follow-up scores were not possible for secondary outcomes as there were insufficient studies 58 ( n  < 5). Forest plots for the secondary outcomes are reported in Online Appendix  D . Random-effects analysis for anxiety ( k  = 20) showed a significant small-medium between-group ES in favour of breathwork, g  = − 0.32 [95% CI − 0.48, − 0.16], z  = 3.90, p  < 0.0001, with moderate and significant heterogeneity, χ 2 19  = 38.62, p  = 0.005, I 2  = 51%. Sensitivity analysis showed ESs ranging from − 0.29 to − 0.34, significant in all cases. No individual study was responsible for the significant heterogeneity. Random-effects analysis for depression ( k  = 18) displayed a significant small-medium ES in favour of breathwork, g  = − 0.40 [95% CI − 0.58, − 0.22], z  = 4.27, p  < 0.0001, and heterogeneity was moderate and significant, χ 2 17  = 40.5, p  = 0.001, I 2  = 58%. Sensitivity analysis showed ESs ranging from − 0.35 to − 0.44, significant in all cases. On removal of two potential outliers 85 , 88 , the ES remained the same. No single study was responsible for the significant heterogeneity.

We conducted the first comprehensive systematic review and meta-analysis of RCTs on the effect of breathwork on self-reported/subjective stress, analysing 12 studies which comprised a total of 785 participants. Breathwork yielded a significant post-intervention between-group effect of breathwork on stress compared to non-breathwork controls, denoting breathwork was associated with lower levels of stress than controls.

Statistical heterogeneity was moderate but not significant, meaning variance in ESs was likely explained by breathwork rather than other variables, although this non-significance could also be a consequence of the low number of studies included. This small-medium ES should be interpreted in the light of moderate risk of bias overall for the 12 studies. More than half of the studies included in our meta-analysis for stress were completed from 2020 onwards, suggesting a recent emergence of research into breathwork, which may have been accelerated by the covid-19 pandemic. Research on breathwork could be likened to that of meditation, which received an unprecedented surge in scientific exploration two decades ago 92 . We may be at a similar cusp with breathwork and anticipate considerable growth in the field. Given the close ties of breathwork to psychedelic research 93 , which is growing rapidly, this could accelerate growth further.

Regarding subgroup analyses for self-reported/subjective stress, heterogeneity was significant for studies with physical health samples, slow-paced breathwork interventions, inactive control groups, along with studies when breathwork was group-based and in-person. At present, there are too few studies within the sub-analyses to address this issue of statistical heterogeneity. Overall, point estimates were similar and sample sizes were small, hence where results were non-significant, it is unclear whether there was genuinely no effect, or lack of statistical power. Furthermore, no significant differential effects across subgroups were observed, but this could also be the result of the scarce number of studies.

While nonclinical samples showed a significant effect on self-reported/subjective stress outcomes and physical and mental health samples did not, between-subgroup differences were non-significant and the point estimates for these subgroups were similar (ranging from ES = 0.26–0.38). These findings could mean that breathwork is not effective for physical/mental health populations, however, it is also possible that this analysis was underpowered to detect effects given the relatively small number of studies contributing to the subgroups, as we have already mentioned. There were only two studies primarily focused on fast-paced breathwork and stress, insufficient to make a meaningful comparison with the ten studies primarily focused on slow-paced breathwork. Interestingly, delivery modes and styles did not seem to influence the results, which may suggest breathwork can be learned through several different formats. Half of the studies’ interventions were delivered remotely without instructors (self-help), hence breathwork could potentially be widely disseminated and thus accessible and probably scalable. The results were significant for both active and inactive controls, although it would be expected that breathwork would have less effect compared to active controls. This could be due to poor quality of the active controls. Lastly, results were significant for two of three stress outcome measures, most likely due to them being psychometrically well-validated—only one study used the third measure (PSQ).

Concerning dose–response, although associations were in the expected direction, there were no significant correlations between the minimum estimated durations of breathwork intervention/home practice and ES, for all outcomes. This apparent absence of dose–response effects was surprising as increased practice time might be expected to be associated with greater benefit, however compliance to intervention home practice was not reported for many studies and so true dose–response analysis was not possible. Moreover, intention-to-treat analysis data were used for the most conservative estimates of effect. Dhruva et al.’s study 64 included in our meta-analysis specifically investigated dose–response effects, finding a positive relationship between total amount of breathwork intervention/home practice and improvement in quality of life and chemotherapy-associated symptomology—there was a significant decrease in anxiety for each hour increase in breathwork. Alternatively, this could be indicative of breathwork being possibly able to help quickly, as suggested in very recent literature whereby just one session of slow, deep breathing had beneficial effects on anxiety and vagal tone in adults 94 , with vagal tone being measured, albeit indirectly, through HRV 6 . This may be likened to ‘micro dosing’ breathwork, similar to single session mindfulness meditation practices 95 .

The meta-analysis results are largely consistent with and extend upon previous work. For instance, our findings are somewhat in line with Malviya et al.’s recent review which provides some support for breathwork’s effectiveness in alleviating stress 43 . However, this review only included two studies for stress, one of which comprised of both groups incorporating breathing practices (and was thus excluded from our meta-analysis). Hopper et al.’s systematic review on diaphragmatic breathing found just one RCT for stress, however this used physiological measures 42 . Nonetheless, this study showed that the stress hormone cortisol was lower in people undergoing slow-paced breathwork compared to controls 96 . In a different study 38 , participants administered with bacterial endotoxin ( E. coli ) who performed fast-paced breathwork had higher spikes of cortisol compared to non-breathwork controls, during the intervention, but a quicker recovery and stabilisation of cortisol levels after cessation of breathwork. This could be another mechanism of action warranting further investigation.

Breathwork, anxiety and depression

Furthermore, meta-analyses comprising 20 and18 studies run for secondary outcome measures of self-reported/subjective anxiety and depressive symptoms, showed that breathwork interventions also yielded significant small-medium ESs in comparison to controls, favouring breathwork (see Online Appendix  D for results). However, heterogeneity was significant for both outcomes, meaning the variance in ESs may be due to other variables apart from breathwork. Thus, these ESs should be interpreted with caution and need further research. As per Malviya et al.’s review 43 , greater support was offered for breathwork in alleviating anxiety and depressive symptoms (eight studies for both outcomes). The review deemed findings pertaining to the efficacy of breathwork in decreasing anxiety and depression as promising. This was also consistent with Zaccaro et al.’s review findings on slow breathing (15 studies—no RCTs), that had lower self-reported anxiety and depression, possibly linked to increased HRV measured during interventions 4 . Ubolnuar et al.’s review of breathing exercises for COPD found no significant effect on anxiety and depression from a subgroup meta-analysis of two RCTs, however the interventions used for both were singing classes 39 . Nonetheless, a recent meta-analysis by Leyro et al. of 40 RCTs on interventions for anxiety, which comprised a respiratory component (ranging from diaphragmatic breathing to capnometry assisted respiratory training), showed such treatments were associated with significantly lower symptoms of anxiety compared to control groups 41 . Though non-respiratory controls were used, respiratory components did not have to form a significant part of the intervention, thus it is less possible to tease out the effects of such techniques. While some interventions used physically altering equipment such as training of musculature involved in respiration, this might provide further potential for breathwork-related work in clinical conditions.

Comparison to stress-reduction interventions

Through estimating statistically significant differences and 95% CIs among studies 97 , in comparison to interventions for stress, our findings suggest that breathwork might be associated with similar—and non-significantly different—effects. For instance, Heber et al.’s meta-analysis on computer- and online-based stress interventions, including CBT and third-wave CBT (e.g., inclusion of meditation, mindfulness, or acceptance of emotions) compared to controls in adults, found moderate effects on stress, d  = 0.43 [95% CI 0.31, 0.54], anxiety, d  = 0.32 [95% CI 0.17, 0.47], and depression, d  = 0.34 [95% CI 0.21, 0.48] 98 . Each of these effects overlap more than 25% with the width of either interval in our results for breathwork, denoting no indication of a clinically relevant difference between the interventions. Similar meta-analytic findings concerning effects on stress, anxiety and depression have been found for related and more analogous techniques such as mindfulness-based cognitive therapy and stress reduction (MBCT/MBSR) 99 along with self-help (MBSH) 100 . While Pizzoli et al.’s recent post-intervention HRVB meta-analysis (14 published RCTs) 13 found a significant effect on depression, another meta-analysis did not find a significant effect on stress, with the smallest ES being yielded for self-reported stress out of myriad outcomes 14 . Lastly, a meta-analysis of eight meta-analytic outcomes of RCTs on physical activity 99 showed similar significant effects on depression and anxiety. While we are not proposing breathwork as a substitute for other treatments, it could complement other therapeutic interventions, potentially leading to additive effects of such health behaviours.

People with stress and anxiety disorders tend to chronically breathe faster and more erratically, yet with increased meditation practice, respiration rate can become gradually slower, potentially translating into better health and mood, along with less autonomic activity 92 . Positive impacts on HRV may partially explain some of the mechanisms behind mindfulness meditation 101 , 102 . However, the above approaches like MBCT/MBSR and HRVB may be less accessible. MBCT/MBSR teacher training takes at least one year while HRVB is routinely taught by a qualified healthcare professional; this is usually a prerequisite and most certified biofeedback therapists are habitually licensed medical providers, including general practitioners, psychiatrists, dentists, nurses, and psychologists 103 . MBCT/MBSR and HRVB therapist training includes theoretical/practical curricula, while breathwork teacher training can be more quickly and easily taught (i.e., over days and weeks) online and remotely to both healthcare professionals and the general population, thus potentially proving cost-effective.

Two of our studies used the only Food and Drug Administration-approved portable electronic biofeedback device, which encourages deep, slow breathing 103 . However, HRV can be improved in the same way (tenfold) by simply breathing at a rate around 5–6 breaths/min 104 and some Zen Buddhist monks have been found to naturally respire around this rate during deep meditation 105 . It may be possible that breathing rate forms a key component of meditation’s known positive effects. Indeed, it has been shown that HRV can be modulated during the practice of meditation 106 . However, a recent meta-analysis on this exact matter found insufficient evidence suggesting mindfulness/meditation led to improvements in vagally mediated HRV, and more well-designed RCTs without high risk of bias are needed to clarify any such contemplative practices’ impact on this physiological metric 107 , along with potential mechanisms related to cortisol.

Traditional mindfulness-based programmes frequently involve meditation requiring observation of the breath, using it as an object of awareness, not voluntary regulation of respiration like in breathwork. Such breath-focus may be a key active ingredient and potential mechanism of action of the former contemplative practices, since highly experienced meditators have been found to breathe at over 1.5 times slower than nonmeditators, during meditation and at rest 108 . This translates into approximately 2000 less daily breaths for the former group of adept meditation practitioners (i.e., around 700,000 less breaths in a year), placing less demand on the ANS 92 . Meditation could also be complementary; voluntary upregulation of HRV through biofeedback may be improved by mental contemplative training 109 . While there is a possibility that it could simply be the cognitive-attentional components of both meditation and breathing practices that explain their effects, observation of the breath (i.e., most practices within mindfulness curricula) versus control of the breath (i.e., breathwork) warrants nuanced investigation.

Strengths, limitations and future directions

Our systematic review searched published, unpublished and grey literature across numerous electronic databases and the meta-analysis comprised several very recent RCTs with well-validated measures of self-reported/subjective stress. However, like most systematic reviews in this field, given the small sample size (likely due to the recent phenomena of breathwork in the West) and moderate risk of bias across the studies included in our meta-analysis, our results should be interpreted cautiously. Future studies exploring breathwork’s effectiveness should aim for research designs with low risk of bias. While this review attempted to bridge the gap and unify both old and new research, future low risk-of-bias studies are now needed in order to draw definitive conclusions of breathwork’s impact on mental health. There were also not enough studies for valuable subgroup comparisons, and therefore we did not identify any potential sources of heterogeneity. Furthermore, secondary outcomes were not scrutinised with the same level of detail as the primary outcome, as they were only used to provide complementary context and a bigger picture around stress and mental health in general.

Our meta-analysis is the first review of breathwork’s impact on self-reported/subjective stress and its therapeutic potential, and combining this quantitative synthesis of psychological effects of breathwork with other syntheses, i.e., of physiological effects 4 , could help build a stronger psychophysiological model of breathwork’s efficacy along with more robust mechanisms of action. Studies could use stress subscales in DASS as standard in addition to the anxiety/depression scales, as this could be important for nonclinical and subclinical populations experiencing stress and allow for direct comparison of effects across clinical/nonclinical populations. Additionally, psychophysiological RCTs combining both subjective and objective measures in line with proposed mechanisms of action (i.e., self-reported stress and ECG HRV/respiration rate measurements) should be conducted, along with further imaging (MRI, EEG, NIRS, etc.) studies on various breathwork techniques (only one fMRI study was available in Zaccaro et al.’s review 4 ). This could help better determine modalities and underlying principles of different breathwork techniques. Though validated scales were used for stress in the meta-analysis, our review lacks objective outcomes, which increases risk of bias further.

Comparison groups promoting observation versus control of the breath could yield interesting findings when exploring any differences between the effects of meditation and breathwork. However, robust scientific methods that align well with current methodological demands on meditation and contemplative psychological science 110 should be implemented. There was also limited scope to report on follow-up effects, hence more studies could include true follow-up timepoints and longitudinal designs, now more common in meditation and contemplative science research. On top of this, there could be cross-cultural differences in response to breathwork (i.e., between Eastern and Western modalities) which could be explored by future research, along with searching non-English language literature. There could also be differences between age categories (including children); this meta-analysis focused solely on adults across a broad age-range. Lastly, more studies should report on adverse events and lasting bad effects, with further research needed to gauge the safety profile of fast-paced breathwork in particular, so it not administered blindly to potentially vulnerable populations.

Clinical implications

For stress, though not many studies monitored home practice/self-practice, engagement with interventions appeared good, none reporting adverse effects directly attributed to breathwork. This suggests breathwork has a high safety profile and slow-paced breathing techniques can be recommended to subclinical populations or those experiencing high stress. However, regarding clinical populations, the findings from our meta-analysis show non-significant effects for mental and physical health populations, hence it could be premature to recommend breathwork in these contexts. If breathwork can indeed provide therapeutic benefit to specific populations, conducting research with strong, low risk-of-bias design is essential to understanding if breathwork is genuinely effective or not. Ethicality should always take centre stage, with first doing no harm being the priority. Nonetheless, in nonclinical settings (excluding those predisposed to mental and physical health conditions), the low cost and risk profiles make breathwork (primarily focused on slow-paced breathing), scalable, with evidence from this meta-analysis that some techniques can potentially be self-learned, not requiring an instructor in real-time. Providing future robust research shows positive effects of breathwork, only then can an evidence-based canon be borne out of breathwork, using standardised and manualised materials for both training and practicing various secular, accessible techniques. However, there is a possibility rigorous research demonstrates that breathwork is not effective. Moreover, precaution must be exercised at all times; clinicians should consider for the individual whether breathwork may exacerbate the symptoms of certain mental and/or physical health conditions (cf. Muskin et al. 111 ).

Conclusions

More accessible therapeutic approaches are needed to reduce, or build resilience to, stress worldwide. While breathwork has become increasingly popular owing to its possible therapeutic potential, there also remains potential for a miscalibration, or mismatch, between hype and evidence. This meta-analysis found significant small-medium effects of breathwork on self-reported/subjective stress, anxiety and depression compared to non-breathwork control conditions. Breathwork could be part of the solution to meeting the need for more accessible approaches, but more research studies with low risk-of-bias designs are now needed to ensure such recommendations are grounded in research evidence. Robust research will enable a better understanding of breathwork’s therapeutic potential, if any. The scientific research community can build on the preliminary evidence provided here and thus, potentially pave the way for effective integration of breathwork into public health.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Acknowledgements

G.W.F. has a doctoral scholarship from—and is a Fellow of—The Ryoichi Sasakawa Young Leaders Fellowship Fund, Sylff Association, Tokyo. J.M.M. has a “Miguel Servet” research contract from the ISCIII (CP21/00080). J.M.M. is grateful to the CIBER of Epidemiology and Public Health (CIBERESP CB22/02/00052; ISCIII) for its support. Authors thank Dr. Patricia L. Gerbarg, M.D., and Dr. Frances Meeten for reading the manuscript and providing feedback prior to submission for publication. Thank you Dr. Daron A. Fincham for proofreading a final copy of the manuscript.

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G.W.F. was responsible for securing funding for the programme of work to which this contributes, conceived the initial idea, and was responsible for leading the meta-analysis. G.W.F. and J.M.M. conducted the literature search. C.S. and K.C. supervised the entire process. G.W.F. conducted the analysis with support from C.S., K.C., and J.M.M. All authors discussed the data and clinical implications of the study. G.W.F. and J.M.M. conducted the risk-of-bias evaluations. G.W.F. drafted the manuscript, with input from C.S., K.C., and J.M.M. All authors read and revised drafts and approved the final manuscript. Each section of the manuscript was discussed among all authors.

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Recent developments in stress and anxiety research

• Published: 01 September 2021
• Volume 128 , pages 1265–1267, ( 2021 )

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• Urs M. Nater 1 , 2  

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Stress and anxiety are virtually omnipresent in today´s society, pervading almost all aspects of our daily lives. While each and every one of us experiences “stress” and/or “anxiety” at least to some extent at times, the phenomena themselves are far from being completely understood. In stress research, scientists are particularly grappling with the conceptual issue of how to define stress, also with regard to delimiting stress from anxiety or negative affectivity in general. Interestingly, there is no unified theory of stress, despite many attempts at defining stress and its characteristics. Consequently, the available literature relies on a variety of different theoretical approaches, though the theories of Lazarus and Folkman ( 1984 ) or McEwen ( 1998 ) are relatively pervasive in the literature. One key issue in conceptualizing stress is that research has not always differentiated between the perception of a stimulus or a situation as a stressor and the subsequent biobehavioral response (often called the “stress response”). This is important, since, for example, psychological factors such as uncontrollability and social evaluation, i.e. factors that may influence how an individual perceives a potentially stressful stimulus or situation, have been identified as characteristics that elicit particularly powerful physiological stressful responses (Dickerson and Kemeny 2004 ). At the core of the physiological stress response is a complex physiological system, which is located in both the central nervous system (CNS) and the body´s periphery. The complexity of this system necessitates a multi-dimensional assessment approach involving variables that adequately reflect all relevant components. It is also important to consider that the experience of stress and its psychobiological correlates do not occur in a vacuum, but are being shaped by numerous contextual factors (e.g. societal and cultural context, work and leisure time, family and dyadic systems, environmental variables, physical fitness, nutritional status, etc.) and dispositional factors (e.g. genetics, personality, resilience, regulatory capacities, self-efficacy, etc.). Thus, a theoretical framework needs to incorporate these factors. In sum, as stress is considered a multi-faceted and inherently multi-dimensional construct, its conceptualization and operationalization needs to reflect this (Nater 2018 ).

The goal of the World Association for Stress Related and Anxiety Disorders (WASAD) is to promote and make available basic and clinical research on stress-related and anxiety disorders. Coinciding with WASAD’s 3rd International Congress held in September 2021 in Vienna, Austria, this journal publishes a Special Issue encompassing state-of-the art research in the field of stress and anxiety. This special issue collects answers to a number of important questions that need to be addressed in current and future research. Among the most relevant issues are (1) the multi-dimensional assessment that arises as a consequence of a multi-faceted consideration of stress and anxiety, with a particular focus on doing so under ecologically valid conditions. Skoluda et al. 2021 (in this issue) argue that hair as an important source of the stress hormone cortisol should not only be taken as a complementary stress biomarker by research staff, but that lay persons could be also trained to collect hair at the study participants’ homes, thus increasing the ecological validity of studies incorporating this important measure; (2) the incongruence between psychological and biological facets of stress and anxiety that has been observed both in laboratory and field research (Campbell and Ehlert 2012 ). Interestingly, there are behavioral constructs that do show relatively high congruence. As shown in the paper of Vatheuer et al. ( 2021 ), gaze behavior while exposed to an acute social stressor correlates with salivary cortisol, thus indicating common underlying mechanisms; (3) the complex dynamics of stress-related measures that may extend over shorter (seconds to minutes), medium (hours and diurnal/circadian fluctuations), and longer (months, seasonal) time periods. In particular, momentary assessment studies are highly qualified to examine short to medium term fluctuations and interactions. In their study employing such a design, Stoffel and colleagues (Stoffel et al. 2021 ) show ecologically valid evidence for direct attenuating effects of social interactions on psychobiological stress. Using an experimental approach, on the other hand, Denk et al. ( 2021 ) examined the phenomenon of physiological synchrony between study participants; they found both cortisol and alpha-amylase physiological synchrony in participants who were in the same group while being exposed to a stressor. Importantly, these processes also unfold over time in relation to other biological systems; al’Absi and colleagues showed in their study (al’Absi et al. 2021 ) the critical role of the endogenous opioid system and its relation to stress-related analgesia; (4) the influence of contextual and dispositional factors on the biological stress response in various target samples (e.g., humans, animals, minorities, children, employees, etc.) both under controlled laboratory conditions and in everyday life environments. In this issue, Sattler and colleagues show evidence that contextual information may only matter to a certain extent, as in their study (Sattler et al. 2021 ), the biological response to a gay-specific social stressor was equally pronounced as the one to a general social stressor in gay men. Genetic information is probably the most widely researched dispositional factor; Kuhn et al. show in their paper (Kuhn et al. 2021 ) that the low expression variant of the serotonin transporter gene serves as a risk factor for increased stress reactivity, thus clearly indicating the important role of dispositional factors in stress processing. An interesting factor combining both aspects of dispositional and contextual information is maternal care; Bentele et al. ( 2021 ) in their study are able to show that there was an effect of maternal care on the amylase stress response, while no such effect was observed for cortisol. In a similar vein, Keijser et al. ( 2021 ) showed in their gene-environment interaction study that the effects of FKBP5, a gene very closely related to HPA axis regulation, and early life stress on depressive symptoms among young adults was moderated by a positive parenting style; and (5) the role of stress and anxiety as transdiagnostic factors in mental disorders, be it as an etiological factor, a variable contributing to symptom maintenance, or as a consequence of the condition itself. Stress, e.g., as a common denominator for a broad variety of psychiatric diagnoses has been extensively discussed, and stress as an etiological factor holds specific significance in the context of transdiagnostic approaches to the conceptualization and treatment of mental disorders (Wilamowska et al. 2010 ). The HPA axis, specifically, is widely known to be dysregulated in various conditions. Fischer et al. ( 2021 ) discuss in their comprehensive review the role of this important stress system in the context of patients with post-traumatic disorder. Specifically focusing on the cortisol awakening response, Rausch and colleagues provide evidence for HPA axis dysregulation in patients diagnosed with borderline personality disorder (Rausch et al. 2021 ). As part of a longitudinal project on ADHD, Szep et al. ( 2021 ) investigated the possible impact of child and maternal ADHD symptoms on mothers’ perceived chronic stress and hair cortisol concentration; although there was no direct association, the findings underline the importance of taking stress-related assessments into consideration in ADHD studies. As the HPA axis is closely interacting with the immune system, Rhein et al. ( 2021 ) examined in their study the predicting role of the cytokine IL-6 on psychotherapy outcome in patients with PTSD, indicating that high reactivity of IL-6 to a stressor at the beginning of the therapy was associated with a negative therapy outcome. The review of Kyunghee Kim et al. ( 2021 ) also demonstrated the critical role of immune pathways in the molecular changes due to antidepressant treatment. As for the therapy, the important role of cognitive-behavioral therapy with its key elements to address both stress and anxiety reduction have been shown in two studies in this special issue, evidencing its successful application in obsessive–compulsive disorder (Ivarsson et al. 2021 ; Hollmann et al. 2021 ). Thus, both stress and anxiety are crucial transdiagnostic factors in various mental disorders, and future research needs elaborate further on their role in etiology, maintenance, and treatment.

In conclusion, a number of important questions are being asked in stress and anxiety research, as has become evident above. The Special Issue on “Recent developments in stress and anxiety research” attempts to answer at least some of the raised questions, and I want to invite you to inspect the individual papers briefly introduced above in more detail.

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Keijser R, Olofsdotter S, Nilsson WK, Åslund C (2021) Three-way interaction effects of early life stress, positive parenting and FKBP5 in the development of depressive symptoms in a general population. J Neural Transm. https://doi.org/10.1007/s00702-021-02405-0

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Kyunghee Kim H, Zai G, Hennings J, Müller DJ, Kloiber S (2021) Changes in RNA expression levels during antidepressant treatment: a systematic review. J Neural Transm. https://doi.org/10.1007/s00702-021-02394-0

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Nater, U.M. Recent developments in stress and anxiety research. J Neural Transm 128 , 1265–1267 (2021). https://doi.org/10.1007/s00702-021-02410-3

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ORIGINAL RESEARCH article

Mindfulness is associated with lower stress and higher work engagement in a large sample of mooc participants.

• 1 Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, TAS, Australia
• 2 Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
• 3 Centre for Consciousness and Contemplative Studies, Monash University, Melbourne, VIC, Australia
• 4 Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia

Objective: This study aimed to understand the associations between mindfulness, perceived stress, and work engagement in a very large sample of English-speaking adults, from 130 different countries. It also aimed to assess participants' self-reported changes following a 6-week mindfulness massive open online course (MOOC).

Methods: Participants in the 6-week MOOC were invited to complete pre-post online surveys. Cross-sectional associations were assessed using univariate linear models, followed by structural equation models to test mediation pathways in baseline data ( N = 16,697). Self-reported changes in mindfulness, stress and engagement following training were assessed using paired t -tests ( n = 2,105).

Results: Each standard deviation unit increase in mindfulness was associated with a 0.52 standard deviation unit decrease in perceived stress, and with 0.06 standard deviation unit increment in work engagement. 73% of the influence of mindfulness on engagement was direct. Following the mindfulness MOOC, participants reported higher mindfulness ( d = 1.16), reduced perceived stress ( d = 1.00) and a small improvement in work engagement ( d = 0.29).

Conclusions: Mindfulness was associated with lower perceived stress and higher work engagement in both cross-sectional and longitudinal analyses. These findings support mindfulness as a potentially protective and modifiable personal resource. The MOOC format offers a low cost, highly accessible means for extending the reach and potential benefits of mindfulness training to large numbers of people.

Introduction

Mindfulness, or intentionally paying attention to current experiences with an open and non-judging attitude, is described as both a skill and as a way of being ( Bishop et al., 2004 ). As a skill, mindfulness can be cultivated through training in both attention and attitude. Training attention takes place formally through regular meditation practice, and informally by intentionally giving attention to present moment internal and external experiences in day-to-day life. Regular and sustained mindfulness practice has been shown to improve attentional control, increase awareness of internal and external experiences and reduce automatic reactivity in emotional, physiological and behavioral domains ( Chambers et al., 2009 ; Creswell and Lindsay, 2014 ; Garland et al., 2017a ). Mindfulness practices also develop attitudinal qualities such as acceptance, openness, curiosity, compassion and non-judging ( Crane et al., 2016 ). The skills and attitudes acquired through practicing mindfulness thus support a way of being that is characterized by intentional attentiveness, awareness and acceptance ( Bishop et al., 2004 ).

Epidemiological research into the relationship between mindfulness and health and performance outcomes is emerging. Mindfulness correlates strongly with lower perceived stress, and moderately with positive subjective wellbeing in a sample of health professionals ( n = 450; Atanes et al., 2015 ) and amongst university students ( n = 135; Palmer and Rodger, 2009 ; n = 85; Zimmaro et al., 2016 ). In a larger sample of community-dwelling Swedish adults mindfulness is associated with lower stress, depression and anxiety, and positive health perceptions ( n = 1000; Bränström et al., 2011 ). Further, cardiovascular health problems associated with elevated stress appear to be ameliorated by higher mindfulness ( Loucks et al., 2015 ; n = 382). These correlational findings collectively support the premise that increasing people's mindfulness may lead to beneficial health and performance outcomes. However, the sample sizes and context-specificity for these studies somewhat limits generalisability. To establish mindfulness as a determinant, or predictor, of lower stress and of positive health and performance at population level requires more evidence from large and more broadly representative population samples. Whether correlates are directly or indirectly attributable to mindfulness should also be investigated.

Intervention research provides support for the hypothesis that increasing mindfulness can lead to health and performance benefits. Controlled studies show participants in mindfulness-based interventions (MBIs) consistently report lower perceived stress following training ( Balconi et al., 2019 ; Colgan et al., 2019 ). Mental health, executive functioning and social behaviors are known to be detrimentally affected by high stress ( Cohen et al., 2019 ), are also shown to consistently improve following mindfulness training ( Gallant, 2016 ; Donald et al., 2019 ). Further, beneficial training effects for resilience ( Joyce et al., 2018 ), cognitive functioning ( Chiesa et al., 2011 ) and work engagement ( Dane and Brummel, 2014 ; Vonderlin et al., 2020 ), indicate mindfulness may be a protective personal resource that can ameliorate the detrimental effects of stress and enhance health and performance.

Based on this collection of promising evidence, mindfulness training is being taken up in many health-related, educational and corporate settings ( Reb and Choi, 2014 ). MBIs for working populations are proposed as a means to foster employee performance, relationships and wellbeing ( Good et al., 2016 ). Work engagement, which comprises vigor, dedication and absorption is of particular interest to employers because it links personal wellbeing factors with work performance ( Schaufeli et al., 2006 ; Burton et al., 2017 ). For example, in corporate environments higher work engagement correlates with outcomes such as task performance, and innovative work behavior ( Gemeda and Lee, 2020 ) and in healthcare it contributes significantly to lowering costs while improving efficiency, quality of care, patient safety, physician satisfaction and retention ( Perreira et al., 2018 ). Correlations between higher mindfulness and greater work engagement have been reported ( Liu et al., 2019 ), however, most workplace-based MBI studies have focused on employee stress, mental health and wellbeing, few report organizational benefits such as performance and engagement ( Bartlett et al., 2019 ).

Traditionally MBIs have been taught in individual or class-based face-to-face formats, and involve didactic and reflective interactions between the course participants and teacher ( Crane et al., 2016 ). This direct and personal interaction allows for questions and real-time discussion to reinforce learning and address any difficulties arising as the participants learn to practice and apply mindfulness skills, including meditation. However, the face-to-face nature of individual or class-based learning presents an accessibility challenge for many people (e.g., West, 2011 ; Bartlett et al., 2016 ). Given restrictions on social gatherings and reports of escalating mental health problems due to the COVID-19 pandemic ( Newby et al., 2020 ), an evidence-based approach to extending the reach and accessibility of potentially protective interventions such as mindfulness training via online delivery is both warranted and pressing.

Translating face-to-face mindfulness courses to an online medium presents an opportunity to reach large numbers of people, while limiting the associated increase in resource demands. Online learning is especially enabling for people who, through isolation or reduced mobility, cannot otherwise access face-to-face courses. It also presents a number of challenges however, including the lack of direct face-to-face interaction between participant and teacher, and the relative isolation of the online learning environment. These factors can limit the feasibility of responding appropriately to learners who are struggling with personal and health-related issues ( Muilenburg and Berge, 2005 ).

Despite these challenges, there is an emerging literature demonstrating that MBIs delivered online can produce similar benefits to those delivered in face-to-face format ( Platt et al., 2014 ). In the mindfulness field two meta-analyses have been published showing positive results for clinical and non-clinical populations following web-based MBIs ( Spijkerman et al., 2016 ; Toivonen et al., 2017 ). Both reviews included MBIs with various formats and sample sizes (n = 13 to n = 257). Neither review found differences between synchronous (delivered in real time using media such as instant messaging platforms, telephone, or videoconferencing) vs. asynchronous (delayed delivery methods such as email or message boards), or facilitated vs. self-directed online formats. However, Spijkerman et al. (2016) noted stronger effects were common from online MBIs when therapist guidance was available for participants.

Recent years have seen growing use of massive open online courses (MOOC) for education and training purposes ( Ebben and Murphy, 2014 ). MOOCs provide an interactive educational infrastructure that supports delivery of online courses to large numbers (e.g., thousands) of participants, commonly with a good deal of heterogeneity. The MOOC platforms generally combine didactic teaching, both in real-time and asynchronously, with peer-to-peer interaction ( Sunar et al., 2017 ). Emerging evidence supports the effectiveness of the MOOC format for delivering health-related behavioral and educational interventions ( Eccleston et al., 2019 ). However, to date there is little or no published evidence of the effectiveness of MBIs delivered using the MOOC format.

Using a very large baseline sample of MWPP-MOOC participants, the first objective of this study was to assess the associations between mindfulness, work engagement and perceived stress and to investigate the extent to which mindfulness influences engagement directly or indirectly (via lowering stress) (Aim 1). The second objective, drawing on pre-post intervention data, was to test the direction and magnitude of changes in mindfulness, stress and work engagement following participation in a MOOC based MBI (Aim 2).

Participants

The Mindfulness for Wellbeing and Peak Performance MOOC (MWPP-MOOC) is housed on the FutureLearn learning platform based in the United Kingdom. The course was in English but open to anyone around the world with the required English language skills and does not cost money to join. Participants self-select to do the course based on their interest in learning about mindfulness and recruitment into the course was via the FutureLearn website or newsletter, organic web search and word of mouth referrals. The platform allows for collection of basic demographic data such as age, gender and country of origin, but not for more personal health information such as mental health history. Participation in the research was optional and additional to course enrolment. Prior to course commencement, MOOC enrollees were invited to read the participant information sheet and provide their consent to having their anonymous data available to the course facilitators for research purposes.

The MWPP-MOOC was developed at Monash University in 2015 ( Hassed and Chambers, 2015 ). FutureLearn is a British digital education platform founded in December 2012 and is jointly owned by The Open University and SEEK Ltd. As of March 2020, FutureLearn included over 250 UK and international partners in university, industry and government sectors. It therefore has a very broad reach for recruiting diverse learners from many countries, ages and educational backgrounds. Between 2015 and 2020, the MWPP-MOOC has run 14 times and enrolled nearly 400,000 participants. When enrolling in the course, participants can opt to complete pre- and post-training surveys, providing data from a large sample of non-clinical adult learners for research purposes.

The MWPP-MOOC is an asynchronous online mindfulness course developed and delivered by medical (CH) and psychological (RC) professionals, each with decades of experience in developing, contextualizing and delivering mindfulness training in educational, workplace and community settings. Both teachers have ongoing positions at a large Australian university where they deliver mindfulness training programs to over 6,500 people per year. The MWPP-MOOC includes up to 3 h of coursework per week, over 6-weeks. The course shares some similarity with the Mindfulness-Based Stress Reduction protocol, but has shorter meditations (5–10 min duration instead of 20–45 min). Weekly topics build progressively on one another and include (1) the formal and informal practice of mindfulness, (2) the role of mindfulness in stress reduction, (3) how it impacts upon work and study performance, (4) the role of mindfulness in self-compassion, communication and relationships, and (5) how to maintain and extend the practice after the end of the course. The MWPP-MOOC includes a variety of media such as short videos, carefully curated open-source articles, links to useful websites and other resources, downloadable guided meditations and quizzes to test knowledge and understanding of key principles. The course structure is detailed in the Supplementary Material .

MPWW-MOOC participants have access to online forums (moderated by CH and RC). The forums are semi-structured, relate to the content presented in that week, and are intended to encourage self-reflective learning, provide answers to questions, create a sense of community, and support learners. The forum moderators also guide communication quality and help learners to seek professional help if necessary. Unsolicited participant reports indicate the forums are a favorite aspect of the MOOC, providing a “live” feel to the course, informal social support and an opportunity to deepen learning.

Weekly feedback videos are another key feature and popular aspect of the MWPP-MOOC. These videos involve the facilitators engaging in informal discussion about key insights, topics and questions arising from that week's forums and further enhance the sense of responsiveness and interactivity between course facilitators and learners. Live engagement with the discussion boards, moderation, feedback videos and surveys closes 6-weeks after the course opens, although learners can retain access to the course materials for a further 2 weeks. Participants in the September 2015 and February 2016 MWPP-MOOCs provided data for the present study.

Trait mindfulness was measured using the Freiburg Mindfulness Inventory (FMI; Walach et al., 2006 ). The FMI is a brief, 14-item, unidimensional measure of trait mindfulness that includes questions about the respondents' attention, attitude and awareness. Response options range from 1 (Rarely) to 4 (Almost always). One item is reverse-scored and responses are then summed for a total score (range 14 to 56). Internal consistency of the baseline FMI data in our sample was good (α = 0.90).

Perceived stress was measured using the Perceived Stress Scale (PSS; Cohen et al., 1983 ). The 10-item PSS was designed for use in community samples and subjectively measures participant appraisals of the degree to which life is stressful (unpredictable, uncontrollable and overloaded) ( Cohen et al., 2007 ). Response options range from 0 (Never) to 4 (Very often) on a 5-point Likert-type scale. This measure is commonly used in MBI research, with strong negative associations between PSS and mindfulness scores (e.g., Manotas et al., 2014 ; Atanes et al., 2015 ; Bartlett et al., 2019 ). The PSS score is calculated by reversing four negatively worded items and then summing responses. Higher scores indicate higher perceived stress (range 0–40). Internal consistency for the PSS-10 in our sample was good (α = 0.89).

The Utrecht Work Engagement Scale (UWES; Schaufeli et al., 2002 ) was used to measure three dimensions of work engagement: vigor, dedication and absorption. Vigor is characterized by mental resilience and high energy levels while working or studying, and one's willingness to put effort into one's work or study. Dedication is characterized by a sense of involvement, significance, inspiration, challenge, enthusiasm, and pride. Absorption is characterized by high engagement with, and absorption in, work. The UWES has also been used previously to measure study engagement ( Schaufeli et al., 2002 ), with an adapted version (UWES-S) subsequently published by the authors. We instructed anyone who identified as a student to consider their experience studying, rather than working, when completing the UWES. The UWES comprises 17 items measured on a 6-point Likert-type scale ranging from 1 (Almost never/A few times a year or less) to 6 (Always/Every day). Mean responses are computed for total and subscale scores (range 1 to 6). Internal consistency for the UWES in our sample was good at whole scale (α = 0.95) and factor level (vigor α = 0.86, dedication α = 0.92, absorption α = 0.86).

Data Analysis

Data were collected at baseline and post-intervention using online surveys (SurveyMonkey) presented via links included in weeks one and six of the MWPP-MOOC. Prior to analyses, data from each of the three measures were standardized to z-scores, to support interpretability of results. Internal consistency for the outcome measures was assessed using Cronbach's alpha coefficient. Correlations between mindfulness (FMI), perceived stress (PSS) and engagement (UWES) data were inspected using Pearson coefficient.

To address Aim 1, Z-scores for each outcome were used to support comparison of the different measures. Univariate linear regression modeling was applied to test the direction and magnitude of cross-sectional associations between self-reported mindfulness, work engagement and stress in the large baseline data set. Graphical model checks were conducted to detect potential violations to model assumptions, including homogeneity of the variance, normality of the residuals and outlier datapoints. Structural equation modeling (SEM) using the product of coefficients method in the ‘lavaan‘ package ( Rosseel, 2012 ) was then applied to estimate the extent to which the relationship between mindfulness and work engagement is mediated by perceived stress.

To address Aim 2 the difference in means from pre- to post-intervention was assessed using paired t-tests. Observations were included only when cases could be linked by IP address at both time points. First completed attempts only were included. To estimate the association between changes in mindfulness following course exposure with perceived stress and work engagement we regressed PSS and UWES scores post-training on FMI post – FMI pre , adjusted for PSS and UWES pre-training. Cohen's d standardized mean difference effect estimates were computed and interpreted in line with recommendations, where an effect of 0.2 is weak, 0.5 moderate and 0.8 or above is strong ( Lakens, 2013 ). We used Harman's single factor test to assess the degree to which common method variance (covariance between scales which can be attributed to the method of data collection) could bias our results ( Fuller et al., 2016 ).

Analyses were conducted using the “Hmisc,” “psych,” and “lavaan” packages ( Rosseel, 2012 ; Revelle, 2019 ; Harrell et al., 2020 ) in the R statistical computing environment ( R Core Team, 2019 ), with significance at α = 0.05.

Sample and Participant Characteristics

In the first two runs of the MWPP-MOOC there were 86,260 registered learners, with 20,331 consenting to research and 16,697 with complete data at baseline. The post-intervention surveys were completed by 4,681 participants, but not all of these cases could be confidently linked between time points. Complete pre-post data were available for 2,105 participants. The age of learners varied from 18 to over 65 years of age. The largest age bracket with 27% of learners was 56–65 years of age. Learners joined from 130 countries with most located in the UK (42%), Australia (22%), the USA (5%), Canada (2%), and Ireland (2%). In terms of gender, 76.4% of participants identified as female.

Mindfulness experience among learners varied with 58% having had no previous experience (academically or professionally) in mindfulness, 26% having taken another course in mindfulness and 11% working in a related field. Participant motivations for registering included dealing with stress or health problems or to improve work/study performance (e.g., efficiency, coping with pressure, reducing errors) and work prospects. Other reasons included pursuing an academic interest in mindfulness, looking for more enjoyment in life, developing retirement interests, wanting to slow down or to enrich relationships.

Aim 1: How Are Mindfulness, Stress, and Work Engagement Related?

Correlations between mindfulness, perceived stress and work engagement were inspected in the large baseline sample ( n = 16,697). The UWES subscales were strongly intercorrelated (all r = 0.81). The FMI data had a moderate sized positive association with UWES data at whole scale ( r = 0.40) and subscale level (vigor r = 0.47; dedication r = 0.36; absorption r = 0.29), and a moderate to strong negative association with PSS data ( r = −0.59). All these correlations were significant ( p < 0.001). A single, unrotated factor explained 32% of covariance between items across all scales.

Univariate models ( Table 1 ) showed strong evidence that higher mindfulness was associated with lower perceived stress. Each standard deviation unit increase in mindfulness was associated with a 0.52 standard deviation unit decrease in stress ( p < 0.001), accounting for 34% total variability in PSS data. A single standard deviation unit increase for mindfulness was associated with 0.06 standard deviation unit increment in overall work engagement scores (p <0.001), accounting for 16% variability in UWES. Within the UWES subscales, vigor appears to account for more variation in mindfulness (22%) than dedication (13%) and absorption (8%). Each unit increase in perceived stress predicted a 0.06 unit decrement in overall engagement scores ( p < 0.001), accounting for 13% variability in UWES.

Table 1 . Univariate regression model results of the relationship between mindfulness, stress, and work engagement ( n = 16,697).

The mediation results are presented in Figure 1 . In this cross-sectional path analysis, a unit increase in mindfulness was associated with higher work engagement (β = 0.29, SE = 0.009, Z = 33.16, p < 0.001) and lower perceived stress (β = −0.59, SE = 0.006, Z = −91.19, p < 0.001). While the effect of mindfulness on work engagement was mostly direct (73%), the total effect was partially (27%) mediated via lower perceived stress (β = −0.18, SE = 0.010, Z = −19.00, p < 0.001).

Figure 1 . Mediation path showing direct and indirect effects of mindfulness on work engagement.

Aim 2: Efficacy of the MWPP-MOOC

The summary results for the tests of difference in mean scores from pre- to post-intervention are presented in Table 2 and illustrated in Figure 2 . Following training, participants ( n = 2,105) reported strong effects from baseline for increased mindfulness (difference: 8.41 [95% CI 8.02, 8.79], d = 1.16), and lower perceived stress (difference: 6.18 [95%CI 5.86, 6.50], d = 1.00), and a small increase in work engagement (difference: 0.30 [95% CI 0.24, 0.35], d = 0.29). The UWES sub-scale scores were consistent in the direction of change, with means for vigor (difference: 0.44 [95% CI 0.38, 0.50]), dedication (difference: 0.25 [95% CI 0.19, 0.32]) and absorption (difference: 0.19 [95% CI 0.13, 0.25]) showing improvement at post-intervention.

Table 2 . Future Learn MOOC–results for stress, mindfulness, and work engagement following participation in mindfulness training.

Figure 2 . Difference in means from pre- to post-training for mindfulness, perceived stress, and work engagement. Violin plots show the kernel density of observations at each score on the Y axis reflected along the midline, to illustrate the distribution of scores by timepoint. Error bars are 95% confidence intervals, but because the sample is so large they appear to be super-imposed.

Post-hoc Analyses

Perceived stress following exposure to the MWPP-MOOC (total PSS post ) was decreased by an expected d = −0.48 [95%CI −0.52, −0.44] for each unit increase in mindfulness (FMI post - FMI pre ), p < 0.001, adjusted for pre-intervention PSS scores. Similarly, work engagement following exposure to MWPP-MOOC (mean UWES post ) was increased by an expected d = 0.45 [95% CI 0.41, 0.50] for each unit increase in mindfulness, p < 0.001, adjusted for pre-intervention UWES scores.

To investigate whether the different performance of the UWES dimensions is an artifact of the instrument we inspected the internal consistency data for the whole instrument and at subscale level. Cronbach's test results indicate UWES16 had a poor fit within the absorption subscale, with a considerably lower item:scale correlation (r.cor = 0.44) than the other included items (range r.cor = 0.68–0.86). Whole scale consistency without this item was marginally stronger when it was removed (α = 0.88) than when it was included (α = 0.86). In our longitudinal analyses, all the individual UWES items correlated positively with change in mindfulness, except for the UWES16 item (see Table 3 ). Further, sensitivity analyses showed the difference between pre and post UWES overall scores returned stronger results without UWES16 (difference = 0.34, t = 11.451, p <0.001) than when this item was included (difference = 0.30, t = 10.408, p < 0.001). The same was true at subscale level, with a stronger pre-post difference in the absorption mean when UWES16 was excluded (difference = 0.29; t = 9.19, p < 0.001), than when it was included (difference = 0.19, t = 0.64, p < 0.001).

Table 3 . Test of associations between FMI change and UWES items.

This paper explored cross-sectional relationships between mindfulness, perceived stress and work engagement in a very large sample of self-selecting adult learners from 130 countries. Cross sectional analyses used data from participants enrolled in, but not yet commenced, the MWPP-MOOC (Aim 1). Longitudinal analyses examined observational pre-post changes in the study variables amongst participants who provided data at both timepoints (Aim 2). Results for Aim 1 support mindfulness as a predictor of both stress and work engagement, and that 73% of the effect of mindfulness on work engagement is direct, with the remaining effect mediated by lower perceived stress. Results for Aim 2 supported the findings from Aim 1, with participants reporting higher mindfulness and work engagement and lower stress following mindfulness training.

Is Mindfulness a Predictor of Stress and Engagement?

Each unit increase in mindfulness predicted a 0.52 (standardized) unit decrease in stress. This translates to a seven-point decrease in perceived stress on the non-standardized scale and indicates a strong inverse relationship between mindfulness and stress. This finding is in keeping with, and adds weight to, previous epidemiological evidence from smaller samples and clearly shows higher mindfulness correlates with lower stress ( Palmer and Rodger, 2009 ; Bränström et al., 2011 ; Atanes et al., 2015 ; Zimmaro et al., 2016 ).

Mindfulness was also shown to be moderately and positively correlated with work engagement. The overall UWES score is the average of subscale means: vigor, dedication and absorption. Results of regression analyses showed a unit increase in mindfulness predicted a small but statistically significant increase in overall engagement. Previous research has found a similar pattern when testing the relationship between two mindfulness measures and work engagement ( Kotzé and Nel, 2016 ). However, these authors found the mindfulness instrument used in the present study (FMI; Walach et al., 2006 ) had a weaker relationship with engagement than the Mindful Attention and Awareness Scale (MAAS; Brown and Ryan, 2003 ), and did not include the absorption dimension of the UWES in analyses. Participant comments in the moderated forums of a positive relationship between mindfulness and work engagement was observed whether “work” referred to paid work, study, caring for others, or engagement with hobbies (data not shown). Participants reported being more engaged with the activities in daily life, whatever they happened to be.

Mindfulness may help to improve work engagement because it fosters the ability to self-regulate automatic defensive or avoidant reactions to the distress and challenges that arise in the workplace ( Malinowski and Lim, 2015 ). It helps people disengage or detach from the unhelpful attentional and cognitive patterns that reinforce distress, thus allowing fuller engagement with work and other valued activities in daily life. This is supported by the results of our path analysis, which showed that stress partially mediates the effect of mindfulness on engagement and that the majority of the mindfulness:engagement relationship was direct. Our results indicate it may be the qualities of mindfulness itself, rather than its effects on stress, that predominantly drive increased work engagement.

In previous research, Leroy et al. (2013) found the effects of mindfulness on engagement were mediated by authentic functioning, which is linked to self-awareness and self-regulatory capacities ( Avolio and Gardner, 2005 ). Further, the construct of psychological capital, which is a determinant of work engagement and incorporates hope, optimism, self-efficacy and resilience, has been shown to have a clear positive relationship with mindfulness ( Avey et al., 2008 ). The qualities of mindfulness (attentional control, awareness and acceptance) may therefore yield additional, independent benefits on positive work-related performance outcomes such as engagement.

Higher work engagement was also predicted by lower perceived stress in our cross-sectional analyses. One explanation may be that people who are stressed struggle to engage fully with work. This is well-established in occupational health psychology theory and research ( Hargrove et al., 2011 ; Bakker and Demerouti, 2017 ) and is a key driver of the quest for effective workplace stress management interventions ( Bhui et al., 2012 ). Research has found that stress interferes with working memory capacity, which limits performance ( Ashcraft and Kirk, 2001 ). People who are stressed have difficulty focusing and find themselves getting caught in modes of thinking that perpetuate stress, such as worry and rumination ( Ganster and Rosen, 2013 ). When sustained in this way, stress is known to lead to burnout ( Iacovides et al., 2003 ) and other factors negatively associated with work engagement and performance ( Cooper and Dewe, 2008 ). Our results support the potential of mindfulness training to ameliorate perceived stress and yield independent positive effects on work engagement ( Vonderlin et al., 2020 ).

Post-intervention Changes in Mindfulness, Stress, and Engagement

Changes in mindfulness, perceived stress and work engagement were assessed following the 6-week MWPP-MOOC. Overall, our observational data indicated significant beneficial changes on all three of the studied variables. A strong positive effect was observed in mindfulness following training. This concurs with a wealth of previous research demonstrating that mindfulness training leads to increased trait mindfulness (e.g., Carmody and Baer, 2008 ; Shapiro et al., 2008 ) and that online MBIs can be effective ( Morledge et al., 2013 ; Spijkerman et al., 2016 ; Cavanagh et al., 2018 ). Our findings also provide important early evidence in support of the massive open online course (MOOC) format for reaching a large number of people and teaching mindfulness and associated practices ( Hodge, 2016 ).

The results observed for perceived stress are consistent with a large body of literature that shows mindfulness training, delivered either in person or online, significantly reduces self-reported levels of stress in various populations ( Chiesa and Serretti, 2009 ; Khoury et al., 2013 ; Cavanagh et al., 2018 ; Bartlett et al., 2019 ). The primary mechanisms involved may be improved attentional control and increased acceptance of whatever is experienced, skills that are explicitly taught in mindfulness training ( Creswell and Lindsay, 2014 ). That is, mindfulness encourages one to pay full attention to moment-by-moment experience, rather than becoming caught in worry or rumination. This reduces amygdala activation, thereby reducing overall levels of stress ( Creswell and Lindsay, 2014 ; Taren et al., 2015 ). Research shows that increases in mindfulness tend to precede decreases in perceived stress, suggesting that increased trait mindfulness may mediate the relationship between mindfulness training and stress ( Baer et al., 2012 ). This sequential development of outcomes has been identified previously ( Garland et al., 2017b ) and may explain why stronger associations between stress and mindfulness were found in our cross-sectional analyses, than observed in our longitudinal analyses, where participants' mindfulness skills were newly emergent at the end of training.

Our finding that MWPP-MOOC participants reported higher work engagement after training adds weight to previous research ( Leroy et al., 2013 ; Atkins et al., 2015 ). Statistically significant improvements were observed on all three dimensions of work engagement, with change in vigor clearly the most pronounced effect. The dominance of vigor may be explained by its correspondence with resilience and vitality, two constructs established as positive correlates of mindfulness ( Allen and Kiburz, 2012 ; Smith, 2014 ). Dedication also improved, but not to the same extent as vigor. Dedication is potentially and conceptually associated with mindfulness via attentional control and prosocial acting, however these nomological relationships are not well-studied. Absorption was the dimension of engagement least responsive to mindfulness training. It is feasible the UWES absorption construct, as it is currently assessed, represents an inability to let go of work and focus on other important areas of life.

In an attempt to explain the engagement results, we conducted post-hoc tests that showed one of the items in the absorption subscale (UWES16: “It is difficult to detach myself from my job”) had a poor fit with the other items in the measure. Further, we found stronger pre-post effects for the overall work engagement and absorption subscale without this item. Our findings support the need for careful consideration of including UWES16 in a positively-oriented measure intended to detect healthy work engagement, and associations with positive, adaptive qualities such as mindfulness. For example, mindfulness training cultivates skills that support the regulation of attention, and is evidenced for increasing the ability to detach from absorbing thoughts and to engage more fully with other aspects of one's life ( Malinowski, 2013 ; Li et al., 2018 ). There may be some construct confusion when work engagement is conceptualized as being interested, motivated and on-task while working, but also as an inability to let it go even when one should. Future research should seek to elucidate the difference between absorption, concentration, acceptance and letting go, and how these may likewise have differential effects of work engagement.

Work engagement is an important indicator of employee wellbeing and organizational performance ( Seppälä et al., 2009 ; Xanthopoulou et al., 2009 ) but this construct has been infrequently studied in mindfulness intervention research ( Malinowski and Lim, 2015 ; Bartlett et al., 2019 ). Recent evidence on the face-to-face delivery of MBIs such as MBSR indicate that it can be effective in increasing resilience ( Klatt et al., 2021 ) and work engagement at the same time as reducing burnout ( Lo et al., 2021 ) but it is currently unclear whether similar benefits can be derived from scalable and affordable brief online MBIs. Our findings that mindfulness training is clearly associated with higher engagement—and in particular, patterns of adaptive engagement—thus offer an additional contribution to the literature but further research and different methodology are required to establish whether this relationship is causal. As previously mentioned, work engagement has three dimensions of vigor, dedication and absorption and it commonly has an inverse relationship with burnout. Many of the work-related health benefits of mindfulness are likely because of its ability to reduce burnout as well as other negative outcomes of demanding or insecure work environments like action crises ( Marion-Jetten et al., 2021 ). This interrelationship between burnout and work engagement is important with one review concluding that burnout is more strongly related to health outcomes, whereas work engagement is more strongly related to motivational outcomes ( Bakker et al., 2014 ).

Based on emerging evidence, it behooves companies to introduce training in generic but adaptable skills like mindfulness to reduce burnout, support dealing with work demands and action crises at the same time as enhancing innovative potential and work engagement. The onus of this responsibility must, however, not fall on the shoulders of individual employees alone who may have found themselves working in dysfunctional and unhealthy work environments. It must be a collective responsibility shared by individual workers and employers to cooperatively create healthy workplace practices and culture.

This paper reports procedures and results of two research questions investigating the relationship between mindfulness, stress and work engagement. Our large, heterogeneous sample of adult learners provided sufficient data for us to conclude that high levels of trait mindfulness is likely to predict substantially lower perceived stress and small, beneficial increments in work engagement. Of the three dimensions of work engagement assessed, mindfulness yields the strongest influence on vigor. While stress partially mediates the relationship between mindfulness and work engagement, most of the effect is directly attributable to mindfulness. Further, we found the MWPP-MOOC format to be effective for teaching and learning mindfulness, and that participants reported higher work engagement and lower stress immediately after the program.

Limitations and Future Directions

MOOCs generally tend to have high attrition rates. The high attrition in survey responses between baseline and post-intervention means it is possible that positively biased people provided full data, and that the effect estimates may have been inflated as a result. Further, there was no unique identifying variable to support linking of demographic, pre- and post-intervention data, and to enable participant characteristics to be linked with outcome data for profile analyses. The absence of a unique identifier meant demographic data was not linked with outcome data and several thousand cases could not be confidently matched across time points. The potential for longitudinal analyses on the full data set was not realized.

The degree of covariance between items across all scales was less than the 50% threshold recommended by Harman's test ( Fuller et al., 2016 ). This suggests there was not severe common method variance, although this bias must be acknowledged. However, all findings were theoretically supported, and the use of validated scales provide ex-ante control for common method bias ( Orben and Lakens, 2020 ).

The use of a control group in our longitudinal study, and access to linked demographic and course engagement data would have enabled more rigorous and in-depth analyses and provided greater confidence that observed changes following the MWPP-MOOC could be attributed to participation. For example, adherence to the course's didactic, interaction and practice elements would enable examination of dose-response relationships and identify process variables that may be responsible for differential effects experienced by participants. We did not measure adherence, or the amount and type of mindfulness practice undertaken. This decision was made to minimize participant burden, however future research should include these valuable metrics as adherence has been shown to be an important predictor of outcomes from mindfulness programs ( Carmody and Baer, 2008 , 2009 ; Bowen and Kurz, 2012 ) and that there may be a clear dose/response relationships (e.g., Strohmaier, 2020 ). Finally, follow-up data would be useful to explore the longevity of training effects and help determine a “sensitive window” for effects to diminish, or further develop. Such information would help guide the way future MBIs are delivered online to ensure maximum impact.

Data Availability Statement

The datasets presented in this article are not readily available because at the time of collecting the data ethics approval to make it openly available was not sought or given. Requests to access the datasets should be directed to Craig Hassed, craig.hassed@monash.edu .

Ethics Statement

This study was undertaken in accordance with ethical standards of the Monash University Human Research Ethics Committee (REF: 18105). The manuscript presents no animal studies or identifiable human images. Informed consent was obtained from all participants in the study. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Author Contributions

LB conducted the analyses and drafted the manuscript. M-JB and AB designed the analytic approach, contributed to running the analyses, and interpreting the results, including figures. CH and RC conceived and designed the study and provided the course description and data for analyses. All authors contributed to the final version of the manuscript.

Conflict of Interest

CH and RC are the developers and lead facilitators of the course being evaluated. Neither author receives financial remuneration from either of those roles.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors are all very grateful for the data provided by participants in the Mindfulness for Wellbeing and Peak Performance Massive Open Online Course.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2021.724126/full#supplementary-material

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Keywords: mindfulness, meditation, stress, work engagement, online course

Citation: Bartlett L, Buscot M-J, Bindoff A, Chambers R and Hassed C (2021) Mindfulness Is Associated With Lower Stress and Higher Work Engagement in a Large Sample of MOOC Participants. Front. Psychol. 12:724126. doi: 10.3389/fpsyg.2021.724126

Received: 12 June 2021; Accepted: 16 August 2021; Published: 10 September 2021.

Reviewed by:

Copyright © 2021 Bartlett, Buscot, Bindoff, Chambers and Hassed. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Craig Hassed, craig.hassed@monash.edu

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Stress Management: Concept, Approaches, and Analysis

International Journal of Management, Technology, and Social Sciences (IJMTS), 8(4), 213-222. ISSN: 2581-6012. (2023)

9 Pages Posted: 6 Mar 2024 Last revised: 27 Mar 2024

Ganapathi P.

Muthayammal Engineering College

P. S. Aithal

Poornaprajna College

Kanchana D.

Arignar Anna Government Arts College

Date Written: November 30, 2023

Purpose: Enhance well-being; acquire adaptive decision-making skills; Relationship breakdown, mental health enhancement, and unemployment problem-solving are all focus areas. Design/Methodology/Approach: Secondary data for this study came from a wide range of places, such as case studies, books, periodicals, journals, articles, and online searches. Findings/Results: Stress has many facets, both in terms of its causes and its effects. It’s more of a personal journey than a general truth to determine what helps you cope with pressure. The client will be taught techniques for dealing with everyday and unexpected tension sources. Cognitive and behavioral strategies are helpful for stress management. Mindfulness-based stress reduction therapies have received much research and attention recently. Due to its association with numerous diseases, stress management is paramount. Outcome: The outcomes include the concept of stress management, various stages of stress and how to overcome the stress, the causes and effects of individual stress, the management of stress effectively through the use of cognitive behavioral techniques, and how to use mindfulness-based interventions for stress management. Originality/Values: This research sheds light on the many sources of stress in the lives of humans, including but not limited to increased workload, increased risk of physical and mental illness, and strategies for coping with stress at different levels. How one chooses to spend one’s life determines the particular sources of stress that they will face.

Keywords: Stress Management, individual and social life, stressors, personality, and cognitive behavioral.

Suggested Citation: Suggested Citation

Muthayammal Engineering College ( email )

P. s. aithal (contact author), poornaprajna college ( email ).

Poornaprajna Institute of Management Udupi District Karnataka India +919343348392 (Phone)

HOME PAGE: http://www.pim.ac.in

Arignar Anna Government Arts College ( email )

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Clinical & Counseling Psychology eJournal

Mindfulness meditation: A research-proven way to reduce stress

Mindfulness meditation can improve both mental and physical health.

• Mindfulness
• Mental Health

People have been meditating for thousands of years, often as part of a spiritual practice. But in more recent years, mindfulness has become a popular way to help people manage their stress and improve their overall well-being — and a wealth of research shows it’s effective. Psychologists have found that mindfulness meditation changes our brain and biology in positive ways, improving mental and physical health.

What is mindfulness meditation?

Meditation can be defined in many ways. But a simple way to think of it is training your attention  to achieve a mental state of calm concentration and positive emotions.

Mindfulness is one of the most popular meditation techniques. It has two main parts: attention and acceptance.

The attention piece is about tuning into your experiences to focus on what's happening in the present moment. It typically involves directing your awareness to your breath, your thoughts, the physical sensations in your body and the feelings you are experiencing. The acceptance piece involves observing those feelings and sensations without judgment. Instead of responding or reacting to those thoughts or feelings, you aim to note them and let them go.

Mindfulness classes and mindfulness-based therapies provide the tools to put those concepts into practice. Such programs might include breathing exercises, yoga and guided lessons to help you become aware of your body sensations, thoughts and feelings.

Much of the research on mindfulness has focused on two types of interventions:

• Mindfulness-based stress reduction (MBSR) is a therapeutic intervention that involves weekly group classes and daily mindfulness exercises to practice at home, over an 8-week period. MBSR teaches people how to increase mindfulness through yoga and meditation.
• Mindfulness-based cognitive therapy (MBCT) is a therapeutic intervention that combines elements of MBSR and cognitive behavioral therapy (CBT) to treat people with depression.

Researchers reviewed more than 200 studies of mindfulness among healthy people and found mindfulness-based therapy was especially effective for  reducing stress, anxiety and depression . Mindfulness can also help treat people with specific problems including depression, pain, smoking and addiction . Some of the most promising research has looked at people with depression. Several studies have found, for example, that MBCT can significantly reduce relapse in people who have had previous episodes of major depression . What's more, mindfulness-based interventions can  improve physical health , too. For example, mindfulness may  reduce pain, fatigue and stress in people with chronic pain . Other studies have found preliminary evidence that mindfulness might  boost the immune system and help people recover more quickly from cold or flu.

How mindfulness works

How could simply tuning into your thoughts and feelings lead to so many positive outcomes throughout the body? Researchers believe the benefits of mindfulness are related to its ability to dial down the body's response to stress.

Chronic stress can impair the body's immune system and make many other health problems worse. By lowering the stress response, mindfulness may have downstream effects throughout the body.

Psychological scientists have found that mindfulness influences  two different stress pathways in the brain , changing brain structures and activity in regions associated with  attention and emotion regulation . Scientists are also beginning to understand which elements of mindfulness are responsible for its beneficial effects. In a review of meditation studies, psychology researchers found strong evidence that people who received MBCT were less  likely to react with negative thoughts or unhelpful emotional reactions in times of stress . They also found moderate evidence that people who participated in MBCT or MBSR were better able to focus on the present and less likely to worry and to think about a negative thought or experience over and over.

[ Related:  6 mental health tips psychologists use]

How to get started

Ready to give it a try? Learning mindfulness is easier than ever. Mindfulness classes and interventions are widely available in settings including yoga centers, athletic clubs, hospitals and clinics, though the classes can vary in their approach. Find a therapist trained in MBSR or MBCT — interventions that have the most evidence of benefits.

A number of mindfulness-based interventions are now available online or through smartphone apps as well, although more long-term research is needed to explore how they affect the body and the brain. Still, early studies have found that  online mindfulness-based interventions can have a positive effect on mental health .

It can take a little while for mindfulness meditation to feel natural and to become a part of your regular routine. But with practice, you may discover a powerful tool for relieving stress and improving well-being.

Thanks to psychologists J. David Creswell, PhD, and Bassam Khoury, PhD, who assisted with this article.

The Meeting of Meditative Disciplines and Western Psychology: A Mutually Enriching Dialogue Walsh, et. al., American Psychologist 2006

Mindfulness-Based Therapy: A Comprehensive Meta-Analysis Khoury, B., et. al. Clinical Psychology Review, 2013

Mindfulness-Based Interventions for Psychiatric Disorders: A Systematic Review and Meta-Analysis Goldberg, S.B., et. al. Clinical Psychology Review, 2018

Mindfulness Interventions Creswell, J.D., Annual Review of Psychology, 2017

Mindfulness Training and Physical Health: Mechanisms and Outcomes Creswell, J.D., et. al.,  Psychosomatic Medicine, 2019

Mindfulness and Cognitive–Behavioral Interventions for Chronic Pain: Differential Effects on Daily Pain Reactivity and Stress Reactivity Davis, M.C., et. al., Journal of Consulting and Clinical Psychology, 2015

Mindfulness Meditation and The Immune System: A Systematic Review of Randomized Controlled Trials Black, D.S., et. al. Annals of the New York Academy of Sciences, 2016

Meditation or Exercise for Preventing Acute Respiratory Infection: A Randomized Controlled Trial Barrett, B., et. al., Annals of Family Medicine, 2012

The Neuroscience of Mindfulness Meditation Tan, Y.-Y., et. al., Nature Reviews Neuroscience, 2015

How Do Mindfulness-Based Cognitive Therapy and Mindfulness-Based Stress Reduction Improve Mental Health and Wellbeing? A Systematic Review and Meta-Analysis of Mediation Studies Gu, J., et. al. Clinical Psychology Review, 2015

Effectiveness of Online Mindfulness-Based Interventions in Improving Mental Health: A Review and Meta-Analysis of Randomised Controlled Trials Spijkerman, M.P.J., et. al., Clinical Psychology Review, 2016

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Mind and Body Approaches for Stress and Anxiety: What the Science Says

Clinical Guidelines, Scientific Literature, Info for Patients:  Mind and Body Approaches for Stress and Anxiety

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Relaxation techniques may be helpful in managing a variety of stress-related health conditions, including anxiety associated with ongoing health problems and in those who are having medical procedures. Evidence suggests that relaxation techniques may also provide some benefit for symptoms of post-traumatic stress disorder (PTSD) and may help reduce occupational stress in health care workers. For some of these conditions, relaxation techniques are used as an adjunct to other forms of treatment.

What Does the Research Show?

• Biofeedback for anxiety and depression in children. A 2018 systematic review included 9 studies—278 participants total—on biofeedback for anxiety and depression in children and adolescents with long-term physical conditions such as chronic pain, asthma, cancer, and headache. The review found that, although biofeedback appears promising, at this point it can’t be recommended for clinical use in place of or in addition to current treatments. 
• Heart rate variability biofeedback. A 2017 meta-analysis looked at 24 studies—484 participants total—on heart rate variability (HRV) biofeedback and general stress and anxiety. The meta-analysis found that HRV biofeedback is helpful for reducing self-reported stress and anxiety, and the researchers saw it as a promising approach with further development of wearable devices such as a fitness tracker.
• Progressive muscle relaxation. A 2015 systematic review , which included two studies on progressive muscle relaxation in adults older than 60 years of age, with a total of 275 participants, found that progressive muscle relaxation was promising for reducing anxiety and depression. The positive effects for depression were maintained 14 weeks after treatment.
• PTSD. A 2018 meta-analysis of 50 studies involving 2,801 participants found that relaxation therapy seemed to be less effective than cognitive behavioral therapy for PTSD and obsessive-compulsive disorder. No difference was found between relaxation therapy and cognitive behavioral therapy for other anxiety disorders, including generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobias. The review noted, however, that most studies had a high risk of bias, and there was a small number of studies for some of the individual disorders.
• Anxiety in people with cancer. In the 2023 joint guideline issued by the Society for Integrative Oncology and the American Society for Clinical Oncology on integrative oncology care of symptoms of anxiety and depression in adults with cancer, relaxation therapies may be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate). 
• Relaxation techniques are generally considered safe for healthy people. In most research studies, there have been no reported negative side effects. However, occasionally, people report negative experiences such as increased anxiety, intrusive thoughts, or fear of losing control. 
• There have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain psychiatric conditions, or with a history of abuse or trauma. 

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A range of research has examined the relationship between exercise and depression. Results from a much smaller body of research suggest that exercise may also affect stress and anxiety symptoms. Even less certain is the role of yoga, tai chi, and qigong—for these and other psychological factors. But there is some limited evidence that yoga, as an adjunctive therapy, may be helpful for people with anxiety symptoms.

• Yoga for children and adolescents. Findings from a 2021 meta-analysis and systematic review of 10 trials involving a total of 1,244 adolescents suggest a potential beneficial effect of tai chi and qigong on reducing anxiety and depression symptoms, and reducing cortisol level in adolescents. However, nonsignificant effects were found for stress, mood, and self-esteem. A  2020 systematic review  of 27 studies involving the effects of yoga on children and adolescents with varying health statuses, and with varying intervention characteristics, found that in studies assessing anxiety and depression, 58 percent showed reductions in both symptoms, while 25 percent showed reductions in anxiety only. Additionally, 70 percent of studies included in the review that assessed anxiety alone showed improvements. However, the reviewers noted that the studies included in the review were of weak-to-moderate methodological quality. 
• Yoga, tai chi, and qigong for anxiety. A  2019 review  concluded that yoga as an adjunctive therapy facilitates treatment of anxiety disorders, particularly panic disorder. The review also found that tai chi and qigong may be helpful as adjunctive therapies for depression, but effects are inconsistent.
• Yoga for anxiety. A  2021 randomized controlled trial examined whether Kundalini yoga and cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) were each more effective than a control condition (stress education) and whether yoga was inferior to CBT for the treatment GAD. The trial found that Kundalini yoga was more efficacious for generalized anxiety disorder than the control, but the results support CBT remaining first-line treatment. A  2018 systematic review and meta-analysis  of 8 studies of yoga for anxiety (involving 319 participants with anxiety disorders or elevated levels of anxiety) found evidence that yoga might have short-term benefits in reducing the intensity of anxiety. However, when only people with diagnosed anxiety disorders were included in the analysis, there was no benefit. 
• Yoga is generally considered a safe form of physical activity for healthy people when performed properly, under the guidance of a qualified instructor. However, as with other forms of physical activity, injuries can occur. The most common injuries are sprains and strains. Serious injuries are rare. The risk of injury associated with yoga is lower than that for higher impact physical activities.
• Older people may need to be particularly cautious when practicing yoga. The rate of yoga-related injuries treated in emergency departments is higher in people age 65 and older than in younger adults.

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Some research suggests that practicing meditation may reduce blood pressure, anxiety and depression, and insomnia.

• Mindfulness-based stress reduction. A  2023 randomized controlled trial involving 208 participants found that mindfulness-based stress reduction (MBSR) is noninferior to escitalopram, a commonly used first-line psychopharmacologic treatment for anxiety disorders. A  2021 randomized controlled trial of 108 adults with generalized social anxiety disorder found that cognitive behavioral group therapy and MBSR may be effective treatments with long-term benefits for patients with social anxiety networks that recruit cognitive and attention-regulation brain networks. The researchers noted that cognitive behavioral therapy and MBSR may both enhance reappraisal and acceptance emotion regulation strategies.
• Mindfulness-based meditation. A  2019 review  concluded that as monotherapy or an adjunctive therapy, mindfulness-based meditation has positive effects on depression, and its effects can last for 6 months or more. Although positive findings are less common in people with anxiety disorders, the evidence supports adjunctive use. A 2019 analysis of 29 studies (3,274 total participants) showed that use of mindfulness-based practices among people with cancer significantly reduced psychological distress, fatigue, sleep disturbance, pain, and symptoms of anxiety and depression. However, most of the participants were women with breast cancer, so the effects may not be similar for other populations or other types of cancer. A  2014 meta-analysis  of 47 trials in 3,515 participants suggests that mindfulness meditation programs show moderate evidence of improving anxiety and depression. But the researchers found no evidence that meditation changed health-related behaviors affected by stress, such as substance abuse and sleep.
• Mindfulness-based programs for workplace stress. A  2018 systematic review and meta-analysis  of nine studies examined mindfulness-based programs with an employee sample, which targeted workplace stress or work engagement, and measured a physiological outcome. The review found that mindfulness-based interventions may be a promising avenue for improving physiological indices of stress. 
• Meditation is generally considered to be safe for healthy people.
• A 2019 review found no apparent negative effects of mindfulness-based interventions and concluded that their general health benefits justify their use as adjunctive therapy for patients with anxiety disorders.

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Hypnosis has been studied for anxiety related to medical or dental procedures. Some studies have had promising results, but the overall evidence is not conclusive.

• A  2022 systematic review and meta-analysis of 19 trials found positive effects of hypnotherapy for reducing dental anxiety and fear during dental treatment. However, the reviewers noted that despite positive effects of hypnotic interventions in the systematic review, the results of the meta-analysis are very heterogeneous. 
• The 2023 joint guideline issued by the Society for Integrative Oncology and the American Society for Clinical Oncology recommends that hypnosis may be offered to people with cancer to improve anxiety symptoms during cancer-related diagnostic and treatment procedures (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
• Hypnosis is a safe technique when practiced by a trained, experienced, licensed health care provider.

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• Carlson LE, Ismaila N, Addington EL, et al.  Integrative oncology care of symptoms of anxiety and depression in adults with cancer: Society for Integrative Oncology-ASCO guideline .  Journal of Clinical Oncology.  2023;41(28):4562-4591. 
• Chugh-Gupta N, Baldassarre FG, Vrkljan BH.  A systematic review of yoga for state anxiety: considerations for occupational therapy . C anadian Journal of Occupational Therapy . 2013;80(3):150-170.
• Cillessen L, Johannsen M, Speckens AEM, et al . Mindfulness-based interventions for psychological and physical health outcomes in cancer patients and survivors: a systematic review and meta-analysis of randomized controlled trials .  Psychooncology . 2019;28(12):2257-2269. 
• Cramer H, Lauche R, Anheyer D, et al.  Yoga for anxiety: a systematic review and meta-analysis of randomized controlled trials .  Depress Anxiety . 2018;35(9):830-843.
• Goessl VC, Curtiss JE, Hofmann SG.  The effect of heart rate variability of biofeedback training on stress and anxiety: a meta-analysis .  Psychological Medicine . 2017;47(15):2578-2586.
• Goldin PR, Thurston M, Allende S, et al . Evaluation of cognitive behavioral therapy vs mindfulness meditation in brain changes during reappraisal and acceptance among patients with social anxiety disorder: a randomized clinical trial .  JAMA Psychiatry . 2021;78(10):1134-1142.
• Goyal M, Singh S, Sibinga EMS, et al.  Meditation programs for psychological stress and well-being: a systematic review and meta-analysis.   JAMA Internal Medicine . 2014;174(3):357-368.
• Greenlee H, Balneaves LG, Carlson LE, et al.  Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer .  Journal of the National Cancer Institute Monographs.  2014;50:346-358.
• Heckenberg RA, Eddy P, Kent S, et al.  Do workplace-based mindfulness meditation programs improve physiological indices of stress? A systematic review and meta-analysis .  Journal of Psychosomatic Research.  2018;114:62-71.
• Hoge EA, Bui E, Mete M, et al.  Mindfulness-based stress reduction vs escitalopram for the treatment of adults with anxiety disorders: a randomized clinical trial .  JAMA Psychiatry . 2023;80(1):13-21.
• James-Palmer A, Anderson EZ, Zucker L, et al. Yoga as an intervention for the reduction of symptoms of anxiety and depression in children and adolescents: a systematic review .  Frontiers in Pediatrics . 2020;8:78.
• Liu X, Li R, Cui J, et al.  The effects of tai chi and qigong exercise on psychological status in adolescents: a systematic review and meta-analysis .  Frontiers in Psychology . 2021;12:746975.
• Klainin-Yobas P, Oo WN, Suzanne Yew PY, et al.  Effects of relaxation interventions on depression and anxiety among older adults: a systematic review .  Aging and Mental Health . 2015;19(12):1043-1055.
• Montero-Marin J, Garcia-Campayo J, López-Montoyo A, et al.  Is cognitive-behavioural therapy more effective than relaxation therapy in the treatment of anxiety disorders? A meta-analysis .  Psychological Medicine . 2018;48(9):1427-1436.
• Saeed SA, Cunningham K, Bloch RM.  Depression and anxiety disorders: benefits of exercise, yoga, and meditation .  American Family Physician . 2019;99(10):620-627.
• Simon NM, Hofmann SG, Rosenfield D, et al.  Efficacy of yoga vs cognitive behavioral therapy vs stress education for the treatment of generalized anxiety disorder: a randomized clinical trial .  JAMA Psychiatry . 2021;78(1):13-20.
• Thabrew H, Ruppeldt P, Sollers JJ 3rd.  Systematic review of biofeedback interventions for addressing anxiety and depression in children and adolescents with long-term physical conditions .  Applied Psychophysiology and Biofeedback . 2018;43(3):179-192.
• Wolf TG, Schläppi S, Benz CI, et al.  Efficacy of hypnosis on dental anxiety and phobia: a systematic review and meta-analysis .  Brain Sciences . 2022;12(5):521.

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• Research article
• Open access
• Published: 15 April 2020

Practice of stress management behaviors and associated factors among undergraduate students of Mekelle University, Ethiopia: a cross-sectional study

• Gebrezabher Niguse Hailu 1  

BMC Psychiatry volume  20 , Article number:  162 ( 2020 ) Cite this article

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Stress is one of the top five threats to academic performance among college students globally. Consequently, students decrease in academic performance, learning ability and retention. However, no study has assessed the practice of stress management behaviors and associated factors among college students in Ethiopia. So the purpose of this study was to assess the practice of stress management behaviors and associated factors among undergraduate university students at Mekelle University, Tigray, Ethiopia, 2019.

A cross-sectional study was conducted on 633 study participants at Mekelle University from November 2018 to July 2019. Bivariate analysis was used to determine the association between the independent variable and the outcome variable at p  < 0.25 significance level. Significant variables were selected for multivariate analysis.

The study found that the practice of stress management behaviors among undergraduate Mekelle university students was found as 367(58%) poor and 266(42%) good. The study also indicated that sex, year of education, monthly income, self-efficacy status, and social support status were significant predictors of stress management behaviors of college students.

This study found that the majority of the students had poor practice of stress management behaviors.

Peer Review reports

Stress is the physical and emotional adaptive response to an external situation that results in physical, psychological and behavioral deviations [ 1 ]. Stress can be roughly subdivided into the effects and mechanisms of chronic and acute stress [ 2 ]. Chronic psychological stress in early life and adulthood has been demonstrated to result in maladaptive changes in both the HPA-axis and the sympathetic nervous system. Acute and time-limited stressors seem to result in adaptive redistribution of all major leukocyte subpopulations [ 2 ].

Stress management behaviors are defined as behaviors people often use in the face of stress /or trauma to help manage painful or difficult emotions [ 3 ]. Stress management behaviors include sleeping 6–8 h each night, Make an effort to monitor emotional changes, Use adequate responses to unreasonable issues, Make schedules and set priorities, Make an effort to determine the source of each stress that occurs, Make an effort to spend time daily for muscle relaxation, Concentrate on pleasant thoughts at bedtime, Feel content and peace with yourself [ 4 ]. Practicing those behaviors are very important in helping people adjust to stressful events while helping them maintain their emotional wellbeing [ 3 ].

University students are a special group of people that are enduring a critical transitory period in which they are going from adolescence to adulthood and can be one of the most stressful times in a person’s life [ 5 ]. According to the American College Health Association’s National College Health Assessment, stress is one of the top five threats to academic performance among college students [ 6 ]. For instance, stress is a serious problem in college student populations across the United States [ 7 ].

I have searched literatures regarding stress among college students worldwide. For instance, among Malaysian university students, stress was observed among 36% of the respondents [ 8 ]. Another study reported that 43% of Hong Kong students were suffered from academic stress [ 9 ]. In western countries and other Middle Eastern countries, including 70% in Jordan [ 10 ], 83.9% in Australia [ 11 ]. Furthermore, based on a large nationally representative study the prevalence of stress among college students in Ethiopia was 40.9% [ 12 ].

Several studies have shown that socio-demographic characteristics and psychosocial factors like social support, health value and perceived self-efficacy were known to predict stress management behaviors [ 13 , 14 , 15 , 16 , 17 ].

Although the prevalence of stress among college students is studied in many countries including Ethiopia, the practice of stress management behaviors which is very important in promoting the health of college students is not studied in Ethiopia. Therefore this study aimed to assess the practice of stress management behaviors and associated factors among undergraduate students at Mekelle University.

The study was conducted at Mekelle university colleges from November 2018 to July 2019 in Mekelle city, Tigray, Ethiopia. Mekelle University is a higher education and training public institution located in Mekelle city, Tigray at a distance of 783 Kilometers from the Ethiopian capital ( http://www.mu.edu.et/ ).

A cross-sectional study was conducted on 633 study participants. Students who were ill (unable to attend class due to illness), infield work and withdrawal were not included in the study.

The actual sample size (n) was computed by single population proportion formula [n = [(Za/2)2*P (1 − P)]/d2] by assuming 95% confidence level of Za/2 = 1.96, margin of error 5%, proportion (p) of 50% and the final sample size was estimated to be 633. A 1.5 design effect was used by considering the multistage sampling technique and assuming that there was no as such big variations among the students included in the study.

Multi-stage random sampling was used. Three colleges (College of health science, college of business and Economics and College of Natural and Computational Science) were selected from a total of the seven Colleges from Mekelle University using a simple random sampling technique in which proportional sample allocation was considered from each college.

Data were collected using a self-administered questionnaire by trained research assistants at the classes.

The questionnaire has three sections. The first section contained questions on demographic characteristics of the study participants. The second section contained questions to assess the practice of stress management of the students. The tool to assess the practice of stress management behaviors for college students was developed by Walker, Sechrist, and Pender [ 4 ]. The third section consisted of questions for factors associated with stress management of the students divided into four sub-domains, including health value used to assess the value participants place on their health [ 18 ]. The second subdomain is self-efficacy designed to assess optimistic self-beliefs to cope with a variety of difficult demands in life [ 19 ] and was adapted by Yesilay et al. [ 20 ]. The third subdomain is perceived social support measures three sources of support: family, friends, and significant others [ 21 ] and was adapted by Eker et al. [ 22 ]. The fourth subscale is perceived stress measures respondents’ evaluation of the stressfulness of situations in the past month of their lives [ 23 ] and was adapted by Örücü and Demir [ 24 ].

The entered data were edited, checked visually for its completeness and the response was coded and entered by Epi-data manager version 4.2 for windows and exported to SPSS version 21.0 for statistical analysis.

Bivariate analysis was used to determine the association between the independent variable and the outcome variable. Variables that were significant at p  < 0.25 with the outcome variable were selected for multivariable analysis. And odds ratio with 95% confidence level was computed and p -value <= 0.05 was described as a significant association.

Operational definition

Good stress management behavior:.

Students score above or equal to the mean score.

Poor stress management behavior:

Students score below the mean score [ 4 ].

Seciodemographic characteristics

Among the total 633 study participants, 389(61.5%) were males, of those 204(32.2%) had poor stress management behavior. The Median age of the respondents was 20.00 (IQR = ±3). More ever, this result showed that 320(50.6%) of the students came from rural areas, 215(34%) of them had poor stress management behavior.

The result revealed that 363(57.35%) of the study participants were 2nd and 3rd year students, of them 195 (30.8%) had poor stress management.

This result indicated that 502 (79.3%) of the participants were in the monthly support category of > = 300 ETB with a median income of 300.00 ETB (IQR = ±500), from those, 273(43.1%) students had poor stress management behavior (Table  1 ).

Status of practice of stress management behaviors of under graduate students at Mekelle University, Ethiopia

Psychosocial factors

This result indicated that 352 (55.6%) of the students had a high health value status of them 215 (34%) had good stress management behavior. It also showed that 162 (25.6%) of the students had poor perceived self-efficacy, from those 31(4.9%) had a good practice of stress management behavior. Moreover, the result showed that 432(68.2%) of the study participants had poor social support status of them 116(18.3%) had a good practice of stress management behavior (Table  1 ).

Practice of stress management behaviors

The result showed that the majority (49.8%) of the students were sometimes made an effort to spend time daily for muscle relaxation. Whereas only 28(4.4%) students were routinely concentrated on pleasant thoughts at bedtime.

According to this result, only 169(26.7%) of the students were often made an effort to determine the source of stress that occurs. It also revealed that the majority (40.1%) of the students were never made an effort to monitor their emotional changes. Similarly, the result indicated that the majority (42.5%) of the students were never made schedules and set priorities.

The result revealed that only 68(10.7%) of the students routinely slept 6–8 h each night. More ever, the result showed that the majority (34.4%) of the students were sometimes used adequate responses to unreasonable issues (Table  2 ).

Status of the practice of stress management behaviors

The result revealed that the practice of stress management behaviors among regular undergraduate Mekelle university students was found as 367(58%) poor and 266(42%) good. (Fig  1 )

Factors associated with stress management behaviors

In the bivariate analysis sex, college, year of education, student’s monthly income’, perceived-self efficacy, perceived social support and perceived stress were significantly associated with stress management behavior at p < =0.25. Whereas in the multivariate analysis sex, year of education, student’s monthly income’, perceived-self efficacy and perceived social support were significantly associated with stress management behavior at p < =0.05.

Male students were 3.244 times more likely to have good practice stress management behaviors than female students (AOR: 3.244, CI: [1.934–5.439]). Students who were in the age category of less than 20 years were 70% less to have a good practice of stress management behaviors than students with the age of greater or equal to 20 year (AOR: 0.300, CI:[0.146–0.618]).

Students who had monthly income less than300 ETB were 64.4% less to have a good practice of stress management behaviors than students with monthly income greater or equal to 300 ETB (AOR: 0.356, CI:[0.187–0.678]).

Students who had poor self- efficacy status were 70.3% less to have a good practice of stress management behaviors than students with good self-efficacy status (AOR: 0.297, CI:[0.159–0.554]). Students who had poor social support were 70.5% less to have a good practice of stress management behaviors than students with good social support status (AOR: 0.295[0.155–0.560]) (Table  3 ).

The present study showed that the practice of stress management behaviors among regular undergraduate students was 367(58%) poor and 266(42%) good. The study indicated that sex, year of education, student’s monthly income, social support status, and perceived-self efficacy status were significant predictors of stress management behaviors of students.

The current study revealed that male students were more likely to have good practice of stress management behaviors than female students. This finding is contradictory with previous studies conducted in the USA [ 13 , 25 ], where female students were showed better practice of stress management behaviors than male students. This difference might be due to socioeconomic and measurement tool differences.

The current study indicated that students with monthly income less than 300 ETB were less likely to have good practice of stress management behaviors than students with monthly income greater than or equal to 300 ETB. This is congruent with the recently published book which argues a better understanding of our relationship with money (income). The book said “the people with more money are, on average, happier than the people with less money. They have less to worry about because they are not worried about where they are going to get food or money for their accommodation or whatever the following week, and this has a positive effect on their health” [ 26 ].

The present study found that first-year students were less likely to have good practice of stress management behaviors than senior students. This finding is similar to previous findings from Japan [ 27 ], China [ 28 ] and Ghana [ 29 ]. This might be because freshman students may encounter a multitude of stressors, some of which they may have dealt with in high school and others that may be a new experience for them. With so many new experiences, responsibilities, social settings, and demands on their time. As a first-time, incoming college freshman, experiencing life as an adult and acclimating to the numerous and varied types of demands placed on them can be a truly overwhelming experience. It can also lead to unhealthy amounts of stress. A report by the Anxiety and Depression Association of America found that 80% of freshman students frequently or sometimes experience daily stress [ 30 ].

The current study showed that students with poor self-efficacy status were less likely to have good practice of stress management behaviors. This is congruent with the previous study that has demonstrated quite convincingly that possessing high levels of self-efficacy acts to decrease people’s potential for experiencing negative stress feelings by increasing their sense of being in control of the situations they encounter [ 14 ]. More ever this study found that students with poor social support were less likely to have a good practice of stress management behaviors. This finding is similar to previous studies that found good social support, whether from a trusted group or valued individual, has shown to reduce the psychological and physiological consequences of stress, and may enhance immune function [ 15 , 16 , 17 ].

Ethics approval and consent to participate

Ethical clearance and approval obtained from the institutional review board of Mekelle University. Moreover, before conducting the study, the purpose and objective of the study were described to the study participants and written informed consent was obtained. The study participants were informed as they have full right to discontinue during the interview. Subject confidentiality and any special data security requirements were maintained and assured by not exposing the patient’s name and information.

Limitation of the study

There is limited literature regarding stress management behaviors and associated factors. There is no similar study done in Ethiopia previously. More ever, using a self-administered questionnaire, the respondents might not pay full attention to it/read it properly.

This study found that the majority of the students had poor practice of stress management behaviors. The study also found that sex, year of education, student’s monthly income, social support status, and perceived-self efficacy status were significant predictors of stress management behaviors of the students.

Availability of data and materials

The datasets used during the current study is available from the corresponding author on reasonable request.

Abbreviations

Adjusted Odd Ratio

College of Business& Economics

College of health sciences

Confidence interval

College of natural and computational sciences

Crud odds ratio

Ethiopian birr

Master of Sciences

United States of America

United kingdom

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Hailu, G.N. Practice of stress management behaviors and associated factors among undergraduate students of Mekelle University, Ethiopia: a cross-sectional study. BMC Psychiatry 20 , 162 (2020). https://doi.org/10.1186/s12888-020-02574-4

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New McGovern study supports ‘social good’ as a cognitive approach to deal with highly stressful events.

Research has shown that emergency personnel are at elevated risk for mental health challenges like post-traumatic stress disorder. A new MIT study shows that a cognitive strategy focused on social good may be effective in helping people cope with distressing events.

A new strategy to cope with emotional stress

by Rubina Veerakone | June 25, 2024 June 26, 2024

Categories: Cognitive Neuroscience , John Gabrieli

Some people, especially those in public service, perform admirable feats—healthcare workers fighting to keep patients alive or a first responder arriving at the scene of a car crash. But the emotional weight can become a mental burden. Research has shown that emergency personnel are at elevated risk for mental health challenges like post-traumatic stress disorder. How can people undergo such stressful experiences and also maintain their well-being?

A new study from the McGovern Institute reveals that a cognitive strategy focused on social good may be effective in helping people cope with distressing events. The research team found that the approach was comparable to another well-established emotion regulation strategy, unlocking a new tool for dealing with highly adverse situations.

“How you think can improve how you feel.” – John Gabrieli

“This research suggests that the social good approach might be particularly useful in improving well-being for those constantly exposed to emotionally taxing events,” says John Gabrieli , the Grover Hermann Professor of Health Sciences and Technology and a professor of brain and cognitive sciences at MIT, who is a senior author of the paper.

The study, published today in PLOS ONE , is the first to examine the efficacy of this cognitive strategy. Nancy Tsai, a postdoctoral research scientist in Gabrieli’s lab at the McGovern Institute, is the lead author of the paper.

Emotion regulation tools

Emotion regulation is the ability to mentally reframe how we experience emotions—a skill critical to maintaining good mental health. Doing so can make one feel better when dealing with adverse events, and emotion regulation has been shown to boost emotional, social, cognitive, and physiological outcomes across the lifespan.

One emotion regulation strategy is “distancing,” where a person copes with a negative event by imagining it as happening far away, a long time ago, or from a third-person perspective. Distancing has been well-documented as a useful cognitive tool, but it may be less effective in certain situations, especially ones that are socially charged—like a firefighter rescuing a family from a burning home. Rather than distancing themselves, a person may instead be forced to engage directly with the situation.

“In these cases, the ‘social good’ approach may be a powerful alternative,” says Tsai. “When a person uses the social good method, they view a negative situation as an opportunity to help others or prevent further harm.” For example, a firefighter experiencing emotional distress might focus on the fact that their work enables them to save lives. The idea had yet to be backed by scientific investigation, so Tsai and her team, alongside Gabrieli, saw an opportunity to rigorously probe this strategy.

A novel study

The MIT researchers recruited a cohort of adults and had them complete a questionnaire to gather information including demographics, personality traits, and current well-being, as well as how they regulated their emotions and dealt with stress. The cohort was randomly split into two groups: a distancing group and a social good group. In the online study, each group was shown a series of images that were either neutral (such as fruit) or contained highly aversive content (such as bodily injury). Participants were fully informed of the types of images they might see and could opt out of the study at any time.

Each group was asked to use their assigned cognitive strategy to respond to half of the negative images. For example, while looking at a distressing image, a person in the distancing group could have imagined that it was a screenshot from a movie. Conversely, a subject in the social good group might have responded to the image by envisioning that they were a first responder saving people from harm. For the other half of the negative images, participants were asked to only look at them and pay close attention to their emotions. The researchers asked the participants how they felt after each image was shown.

Social good as a potent strategy

The MIT team found that distancing and social good approaches helped diminish negative emotions. Participants reported feeling better when they used these strategies after viewing adverse content compared to when they did not and stated that both strategies were easy to implement.

The results also revealed that, overall, distancing yielded a stronger effect. Importantly, however, Tsai and Gabrieli believe that this study offers compelling evidence for social good as a powerful method better suited to situations when people cannot distance themselves, like rescuing someone from a car crash, “Which is more probable for people in the real world,” notes Tsai. Moreover, the team discovered that people who most successfully used the social good approach were more likely to view stress as enhancing rather than debilitating. Tsai says this link may point to psychological mechanisms that underlie both emotion regulation and how people respond to stress.

“The social good approach may be a potent strategy to combat the immense emotional demands of certain professions.” – John Gabrieli

Additionally, the results showed that older adults used the cognitive strategies more effectively than younger adults. The team suspects that this is probably because, as prior research has shown, older adults are more adept at regulating their emotions likely due to having greater life experiences. The authors note that successful emotion regulation also requires cognitive flexibility, or having a malleable mindset to adapt well to different situations.

“This is not to say that people, such as physicians, should reframe their emotions to the point where they fully detach themselves from negative situations,” says Gabrieli. “But our study shows that the social good approach may be a potent strategy to combat the immense emotional demands of certain professions.”

The MIT team says that future studies are needed to further validate this work, and that such research is promising in that it can uncover new cognitive tools to equip individuals to take care of themselves as they bravely assume the challenge of taking care of others.

Paper: "Social good reappraisal as a novel and effective emotion regulation strategy"

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A review of the effectiveness of stress management skills training on academic vitality and psychological well-being of college students

P alborzkouh.

* Exceptional Children Psychology, Islamic Azad University, Central Tehran Branch, Iran

** General Psychology, Islamic Azad University, South Tehran Branch, Iran

*** General Psychology, Humanities and Social Sciences Faculty, Paradise University, Gillan Branch, Iran

**** General Psychology, Islamic Azad University, Science and Research Branch, Tehran, Iran

F Shahgholy Ghahfarokhi

***** Clinical Psychology, Islamic Azad University, Science and Research Branch Branch, Isfahan, Iran

Objective: Carrying out the appropriate psychological interventions to improve vitality and mental well-being is critical. The study was carried out to review the effectiveness of stress management training on the academic life and mental well-being of the students of Shahed University.

Methodology: The method used was quasi-experimental with a pretest-posttest plan and control group. Therefore, a total of 40 students of Shahed University of Tehran were selected by a convenience sampling method and were organized into two groups: experimental and control group. Both groups were pretested by using an academic vitality inventory and an 84-question psychological well-being inventory. Then, the experimental group received stress management skills training for ten sessions, and the control group did not receive any intervention. Next, both groups were post-tested, and the data were analyzed with SPSS-21 software by using descriptive and inferential statistical methods.

Findings: The findings showed that the stress management skills training significantly contributed to promoting the academic vitality and psychological well-being of students (p < 0.001).

Conclusions: It was concluded from this research that teaching the methods for dealing with stress was an effective strategy to help students exposed to high stress and pressure, and this was due to its high efficiency, especially when it was held in groups, had a small cost, and it was accepted by the individuals.

Introduction

Challenges during education create sources of stress for students, and put their health at risk, in a way that affects their learning abilities [ 1 ]. Therefore, paying attention to the factors that could have a positive impact on the agreeableness and could increase the positive psychological states, and as a result, the physical and psychological health of the students was of great importance.

Among the important factors that affect people’s ability to adapt to the stresses of studying era is academic vitality [ 2 ]. Academic vitality means an adaptive response to various challenges and barriers experienced during education [ 3 ]. When a person does things spontaneously, does not feel not only frustrated and tired, but also constantly feels the strength and increased energy, and overall has a sense of inner vitality [ 2 ]. Therefore, the academic life has a relationship with the individual’s adaptation to the various situations of the academic period, feelings of self-efficacy and empowerment in the face of challenges, experiencing less anxiety and depression, a sense of responsibility in dealing with the academic tasks and better academic success [ 3 ]. Despite the high importance of academic vitality in the successful confrontation with the challenging academic period, the literature review of the studies managed in Iran showed that few studies were performed on the factors promoting this important variable. Therefore, an attempt to address this research gap increased the need for the current study.

Another important positive psychological state in students is the psychological well-being. The psychological well-being factor is defined as a person’s real talents growth and has six components that are the purpose in life, positive relations with others, personal growth, self-acceptance, autonomy, and environmental mastery [ 4 ]. The purpose in life means having a purpose and direction in life and pursuing them [ 5 ]. Positive relations with the others mean having warm, satisfactory relations along with confidence and empathy [ 6 ]. Personal growth means having a sense of continuous growth and the capacity for it and having an increased sense of efficacy and wisdom [ 4 ]. Self-acceptance means having a positive attitude towards oneself and accepting the various aspects of oneself [ 6 ]. Autonomy means the feeling of self-determination, independence, and self-assessment against personal criteria [ 4 ]. Moreover, environmental mastery means a sense of competence and the ability to manage the complex environment around [ 5 ].

However, one of the most significant parts affecting the psychological health and well-being of individuals is life skills training [ 7 ]. Life skills’ training is critical for students, in a way that on this basis, many universities have started to teach life skills and stress management skills to improve the physical and psychological health of their students in the recent years [ 8 ]. The main objective of the World Health Organization regarding the creation of a life skills plan is in the field of psychological health. Therefore, different societies throughout the world try to promote the implementation and evaluation of the programs training in life skills. It focuses on the growth of mental abilities such as problem-solving, coping with emotions, self-awareness, social harmony, and stress management among children, teenagers, and even adults [ 9 ]. From the life skills, training in stress management skills is critical, because students need to deal effectively with stressful issues and factors. Accordingly, it was thought that teaching stress management skills is very efficient in improving the students’ positive psychological states, in particular, their vitality and mental well-being. Therefore, this study examined the effectiveness of the stress management skills training on the academic life and psychological well-being among Shahed University students.

Methodology

The study was quasi-experimental with a pretest-posttest. The analytical community of the study included all the students of Shahed University of Tehran in the fall of 2015, who were selected with a convenience method. For the calculation of the sample size, the appropriate sample size in experimental studies was of 15 people for each group [ 10 ]. At first, the sample size of 15 individuals was selected for each group. Then, to increase the statistical power and to manage the possible decrease in the number of participants, the sample size of 20 individuals (n = 20) was considered for each group. The sampling was voluntary non-random from among all the students studying at Shahed University. The inclusion criteria included an informed consent and the willingness to participate in the research, the ability to take part in the sessions and to collaborate in carrying out assignments, willingness to cooperate in completing the instruments, and the age range of 18 to 35 years. The exclusion criteria included the lack of desire to participate in the sessions and the absence to more than three courses in the preparation method, the lack of the ability to participate in the sessions, lack of cooperation in carrying out assignments, and receiving any training or psychological therapy that was not part of the program of this research.

The procedure of the study was that from all the students studying at Shahed University, a number was non-randomly and voluntarily selected, and if they met the inclusion criteria, they were randomly assigned to two groups: experimental and control. At the beginning and before starting the study, an informed consent was obtained from all of them to uphold moral considerations, through informing them of the aim of the study and the impact of such studies in improving their psychological status. Then, all the information of the participants were collected, and they were assured that the information would remain confidential by the researcher. Then, the experimental group received group stress management training for ten sessions, and the control group did not receive any intervention. In the end, both groups were post-tested. The protocol of stress management training sessions is presented in Table 1 .

Protocol of stress management skills training sessions

The instruments used in the study included a demographic sample page, an academic vitality questionnaire, and a psychological well-being scale (PWBS-18).

Demographic sample page: The demographic sample page included age, gender, educational level, and marital status. The sample page was prepared and evaluated by the researchers of the study.

Academic vitality questionnaire: This questionnaire was developed by Dehqanizadeh MH, Hosseinchari M (2012) [ 3 ], based on the academic vitality scale of Martin AJ, Marsh HW (2006) [ 15 ], which had four items. After various implementations of the items of the questionnaire, the final version was rewritten, and the result was that the revised version had ten items. Then the items above were again examined in a preliminary study on a sample including 186 high school students, who were chosen by using a cluster random sampling, and their psychometric properties were examined. The results of the examination showed that the obtained Cronbach’s alpha coefficient, by removing [ 3 ] item number 8, was 0.80 and the retest coefficient was 0.73. Also, the range of correlation of the elements with the total score was between 0.51 and 0.68. These results indicated that the items had a satisfactory internal consistency and stability.

Psychological well-being scale (SPWB): Riffe’s mental well-being scale [ 11 ] was made up of 84 questions in Likert’s 7-degree scale (from “strongly disagree” to “agree strongly”). It was a self-report questionnaire, which measured six components of the psychological well-being, including purpose in life, positive relations with others, personal growth, self-acceptance, autonomy, and environmental mastery. The internal consistency coefficients for the components of this questionnaire were obtained from 0.83 to 0.91. In Mohammadpour and Joshanloo research (2014) [ 6 ], the reliability coefficient of this scale with Cronbach’s alpha method for the psychological well-being scale obtained was 0.81. Also, for the subscales of the test including self-compliance, environmental mastery, personal growth and development, link with others, the goal in life, and self-acceptance were obtained at 0.60, 0.64, 0.54, 0.58, 0.65, and 0.61, respectively. A study performed by Kafka and Kozma (2002) was conducted to verify the validity of the items of the Riffe’s psychological well-being scale. The findings showed that there was a high correlation between this scale and the subjective well-being scale (SWB) and the satisfaction with life scale (SWLS). In the present study, the reliability coefficient with Cronbach’s alpha method for the psychological well-being scale obtained was 0.81. Also, for the subscales of the test, including self-compliance, environmental mastery, personal growth and development, relations with others, the goal in life, and self-acceptance were obtained at 0.60, 0.64, 0.54, 0.58, 0.65, and 0.61, respectively.

The SPSS-20 software was used for data analysis. The statistical method used for the data analysis of the research on the level of descriptive statistics was mean, standard deviation, frequency, and frequency percentage indexes, and on the inferential statistics, univariate and multivariate analysis of covariance model were used.

Findings of the research

The demographic properties of the sample present in the study are presented in Table 2 .

Demographic characteristics of the subjects

As presented in Table 1 , the largest frequency of participation belonged to the participants in the age range of 21 to 25 with 14 individuals (35%) and the lowest frequency of individuals in the range of 18 to 20 years, with six individuals (15%). In addition, the mean age of the participants was 24.85, and the standard deviation was 4.41. The other information about the demographic properties of the present sample is provided in Table 2

As shown in Table 3 , the mean scores of purpose in life, positive relations with others, personal growth, self-acceptance, autonomy, environmental mastery, total score of psychological well-being, and academic vitality of posttest were increased in the test group as associated with the control group.

Descriptive stats of academic vitality and psychological well-being scores of the two groups divided by the pretest and posttest

As shown in Table 4 , the null hypothesis of the equality of variances of the two groups in the academic vitality and psychological well-being with all its components was confirmed. It meant that the variances of the two clusters in the population were equal and had no significant difference for the academic vitality and the psychological well-being variable with all its components. Thus, given the compliance with the Levene assumption, the analysis of covariance of the results of the hypothesis of the research were permitted.

Results of Levene test for the examination of the consistency of variances of academic vitality and psychological well-being variables with its components in the posttest stage

As shown in Table 5 , the significance level of all the tests (p < 0.001) indicated that there was a significant difference between the two groups at least in one of the dependent variables (academic vitality and psychological well-being with its components). And, according to the eta square, 0.89 percent of the differences observed among individuals were associated with the effect of the independent variable, which was the intervention method (stress management skills training). On the other hand, given that the statistical power was 0.95, which was higher than 0.80, the sample size was acceptable for the research. The results related to significant differences in any of the dependent variables are listed below.

Results of multivariate analysis of covariance on the scores of posttest with the control of pretest in the academic vitality and psychological well-being variable with its components

According to Table 6 , the significance level was p < 0.001, the hypothesis of the difference between the academic vitality and the psychological well-being with its components in the two groups was confirmed. It stated that 0.54, 0.25, 0.52, 0.64, 0.60, 0.59, 0.45 and 0.81 percent change in the academic vitality, individuals’ purpose in life, positive relations with others, personal growth, self-acceptance, autonomy, environmental mastery, and psychological well-being scores were due to the independent variable (stress management skills training). Therefore, it could be said that stress management skills training increased the academic vitality and the psychological well-being and all of its components.

The results of multivariate analysis of covariance to assess the impact of stress management skills training on the level of psychological well-being and its components in the posttest stage

Discussion and conclusions

Given the aim of this study, which was to examine the effectiveness of stress management skills training on the academic vitality and psychological well-being of the students of Shahed University, the results of the univariate and multivariate analysis of covariance showed that stress management skills training had a significant impact on increasing the academic vitality and psychological well-being. The findings indicated that the stress management skills training had a major impact on increasing the academic life. It was consistent with different studies of Habibi M (2015), Pakdaman A, Ganji K, Ahmadzadeh M (2012), Shirbim Z, Sudani M, Shafi-Abadi A (2008) [ 12 - 14 ].

In explaining their similar finding, Pakdaman A, Ganji K, Ahmadzadeh M (2012) [ 13 ] also stated that life skills training helped in the improvement of the academic conditions of the subjects. In addition, this was because of this training, with growing different skills of the students, helping the students know their strengths and weaknesses, and overall, help the individuals move from weaknesses and skill deficits to capable and strong skills. Therefore, this could provide the students with better educational conditions [ 14 ]. In explaining their similar finding, Shafi-Abadi (2008) stated that teaching life skills, including stress management skills, are one of the ways to improve the mental health of the individuals of the community and to prevent harms. In fact, these teachings protected the health and mental hygiene of the society and protected it against diseases, disabilities, and disturbances in human relations. As a result, the feeling of security and solidarity increased among the members of the society, and then their senses of happiness, vitality, and health increased.

The findings showed that stress management skills’ training has a significant impact on the psychological well-being. It was consistent with the multiple studies of Qadiri-Bahramabadi F, Mikaeli-Manee F (2015), Qanbari N, Habibi M, Shams-Aldini S (2013), Alavi-Arjmand N, Kashaninia Z, Hosseini MA, Reza-Soltani P (2012), Chubforushzadeh A, Kalantari M, Molavi H (2009) [ 16 - 19 ].

In explaining their similar findings, Qadiri-Bahramabadi F, Mikaeli-Manee F (2015) [ 16 ] stated that facing numerous stresses required teaching and learning of appropriate stress management skills. In other words, during stress, individuals must know the necessary coping skills to reduce the effects of stress, and if the pressure was managed and the effective coping skills were applied, the person would be able to get along better with the needs and challenges of his/ her life. Therefore, the intervention of stress management led to the formation of good feelings about oneself, as well as a positive performance in the stable world. It created interest and motivation in people’s lives as well as increasing the self-confidence of the individuals. As a result, it increased the psychological well-being.

In explaining their similar finding, Qanbari N, Habibi M, Shams-Aldini S (2013) [ 17 ] stated that with the help of multiple strategies to manage stress such as relaxation, and muscular relaxation, stress and anxiety could be reduced. The individuals identified the somatic symptoms, and with mastering the ways to acquire relaxation, which was inconsistent with stress, reduced their anxiety and unpleasant feelings, thus increasing the psychological well-being. Also, in explaining their similar finding, Chubforushzadeh A, Kalantari M, Molavi H (2009) [ 19 ], stated that stress management treatments make multiple changes in the individual’s beliefs, feelings, and behaviors. Therefore, improving the individual’s evaluations and coping skills, and the provided practices to integrate the learned separations with real life situations could lead to a decrease in the perceived stress and an increase in the psychological well-being.

Acknowledgement

The authors would like to thank the venerable authorities of Shahed University of Tehran for their assistance. Also, the authors would like to thank all the participants in the study.