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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Bentele UU, Meier M, Benz ABE, Denk BF, Dimitroff SJ, Pruessner JC, Unternaehrer E (2021) The impact of maternal care and blood glucose availability on the cortisol stress response in fasted women. J Neural Transm (Vienna).

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Denk B, Dimitroff SJ, Meier M, Benz ABE, Bentele UU, Unternaehrer E, Popovic NF, Gaissmaier W, Pruessner JC (2021) Influence of stress on physiological synchrony in a stressful versus non-stressful group setting. J Neural Transm (Vienna).

Dickerson SS, Kemeny ME (2004) Acute stressors and cortisol responses: a theoretical integration and synthesis of laboratory research. Psychol Bull 130(3):355–391

Fischer S, Schumacher T, Knaevelsrud C, Ehlert U, Schumacher S (2021) Genes and hormones of the hypothalamic-pituitary-adrenal axis in post-traumatic stress disorder. What is their role in symptom expression and treatment response? J Neural Transm (vienna).

Hollmann K, Allgaier K, Hohnecker CS, Lautenbacher H, Bizu V, Nickola M, Wewetzer G, Wewetzer C, Ivarsson T, Skokauskas N, Wolters LH, Skarphedinsson G, Weidle B, de Haan E, Torp NC, Compton SN, Calvo R, Lera-Miguel S, Haigis A, Renner TJ, Conzelmann A (2021) Internet-based cognitive behavioral therapy in children and adolescents with obsessive compulsive disorder: a feasibility study. J Neural Transm.

Ivarsson T, Melin K, Carlsson A, Ljungberg M, Forssell-Aronsson E, Starck G, Skarphedinsson G (2021) Neurochemical properties measured by 1 H magnetic resonance spectroscopy may predict cognitive behaviour therapy outcome in paediatric OCD: a pilot study. J Neural Transm.

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.

Kuhn L, Noack H, Skoluda N, Wagels L, Rohr AK, Schulte C, Eisenkolb S, Nieratschker V, Derntl B, Habel U (2021) The association of the 5-HTTLPR polymorphism and the response to different stressors in healthy males. J Neural Transm (Vienna).

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.

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Rhein C, Hepp T, Kraus O, von Majewski K, Lieb M, Rohleder N, Erim Y (2021) Interleukin-6 secretion upon acute psychosocial stress as a potential predictor of psychotherapy outcome in posttraumatic stress disorder. J Neural Transm (Vienna).

Sattler FA, Nater UM, Mewes R (2021) Gay men’s stress response to a general and a specific social stressor. J Neural Transm (Vienna).

Skoluda N, Piroth I, Gao W, Nater UM (2021) HOME vs. LAB hair samples for the determination of long-term steroid concentrations: a comparison between hair samples collected by laypersons and trained research staff. J Neural Transm (Vienna).

Stoffel M, Abbruzzese E, Rahn S, Bossmann U, Moessner M, Ditzen B (2021) Covariation of psychobiological stress regulation with valence and quantity of social interactions in everyday life: disentangling intra- and interindividual sources of variation. J Neural Transm (Vienna).

Szep A, Skoluda N, Schloss S, Becker K, Pauli-Pott U, Nater UM (2021) The impact of preschool child and maternal attention-deficit/hyperactivity disorder (ADHD) symptoms on mothers’ perceived chronic stress and hair cortisol. J Neural Transm (Vienna).

Vatheuer CC, Vehlen A, von Dawans B, Domes G (2021) Gaze behavior is associated with the cortisol response to acute psychosocial stress in the virtual TSST. J Neural Transm (Vienna).

Wilamowska ZA, Thompson-Hollands J, Fairholme CP, Ellard KK, Farchione TJ, Barlow DH (2010) Conceptual background, development, and preliminary data from the unified protocol for transdiagnostic treatment of emotional disorders. Depress Anxiety 27(10):882–890.

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Nater, U.M. Recent developments in stress and anxiety research. J Neural Transm 128 , 1265–1267 (2021).

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Accepted : 13 August 2021

Published : 01 September 2021

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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

yoga at home

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} Relaxation Techniques

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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  • Published: 03 October 2021

Cognitive–behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies

  • Mutsuhiro Nakao 1 ,
  • Kentaro Shirotsuki 2 &
  • Nagisa Sugaya 3  

BioPsychoSocial Medicine volume  15 , Article number:  16 ( 2021 ) Cite this article

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Cognitive–behavioral therapy (CBT) helps individuals to eliminate avoidant and safety-seeking behaviors that prevent self-correction of faulty beliefs, thereby facilitating stress management to reduce stress-related disorders and enhance mental health. The present review evaluated the effectiveness of CBT in stressful conditions among clinical and general populations, and identified recent advances in CBT-related techniques. A search of the literature for studies conducted during 1987–2021 identified 345 articles relating to biopsychosocial medicine; 154 (45%) were review articles, including 14 systemic reviews, and 53 (15%) were clinical trials including 45 randomized controlled trials. The results of several randomized controlled trials indicated that CBT was effective for a variety of mental problems (e.g., anxiety disorder, attention deficit hypersensitivity disorder, bulimia nervosa, depression, hypochondriasis), physical conditions (e.g., chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, breast cancer), and behavioral problems (e.g., antisocial behaviors, drug abuse, gambling, overweight, smoking), at least in the short term; more follow-up observations are needed to assess the long-term effects of CBT. Mental and physical problems can likely be managed effectively with online CBT or self-help CBT using a mobile app, but these should be applied with care, considering their cost-effectiveness and applicability to a given population.

History of cognitive–behavioral therapy (CBT)

CBT is a type of psychotherapeutic treatment that helps people to identify and change destructive or disturbing thought patterns that have a negative influence on their behavior and emotions [ 1 ]. Under stressful conditions, some individuals tend to feel pessimistic and unable to solve problems. CBT promotes more balanced thinking to improve the ability to cope with stress. The origins of CBT can be traced to the application of learning theory principles, such as classical and operant conditioning, to clinical problems. So-called “first-wave” behavioral therapy was developed in the 1950s [ 2 ]. In the US, Albert Ellis founded rational emotive therapy to help clients modify their irrational thoughts when encountering problematic events, and Aaron Beck employed cognitive therapy for depressed clients using Ellison’s model [ 3 ]. Behavioral therapy and cognitive therapy were later integrated in terms of theory and practice, leading to the emergence of “second-wave” CBT in the 1960s. The first- and second-wave forms of CBT arose via attempts to develop well-specified and rigorous techniques based on empirically validated basic principles [ 4 ]. From the 1960s onward, the dominant psychotherapies worldwide have been second-wave forms of CBT. Recently, however, a third-wave form of CBT has attracted increasing attention, leading to new treatment approaches such as acceptance and commitment therapy, dialectical behavior therapy, mindfulness-based cognitive therapy, functional analytic psychotherapy, and extended behavioral activation; other forms may also exist, although this is subject to conjecture [ 4 ]. In a field of psychosomatic medicine, it has been reported that cognitive restructuring is effective in improving psychosomatic symptoms [ 5 ], exposure therapy is suitable for a variety of anxious disease conditions like panic disorder and agoraphobia [ 6 ], and mindfulness reduces stress-related pain in fibromyalgia [ 7 ]. Several online and personal computer-based CBT programs have also been developed, with or without the support of clinicians; these can also be accessed by tablets or smartphones [ 8 ]. Against this background, this review focused on the effectiveness of CBT with a biopsychosocial approach, and proposed strategies to promote CBT application to both patient and non-patient populations.

Research on CBT

Using “CBT “and “biopsychosocial” as PubMed search terms, 345 studies published between January 1987 and May 2021 were identified (Fig.  1 ); 14 of 154 review articles were systemic reviews, and 45 of 53 clinical trials were randomized controlled trials. Most clinical trials recruited the samples from patient populations in order to assess specific diseases, but some targeted at those from non-patient populations like a working population in order to assessing mind-body conditions relating to sick leave [ 9 ]. The use of biopsychosocial approaches to treat chronic pain is shown to be clinically and economically efficacious [ 10 ]; for example, CBT is effective for chronic low-back pain [ 11 ]. The prevalence of chronic low-back pain, defined as pain lasting for more than 3 months, was reported to be 9% in primary-care settings and 7–29% in community settings [ 12 ]. Chronic low-back pain is not only prevalent, but is a source of significant physical disability, role impairment, and diminished psychological well-being and quality of life [ 11 ]. Interestingly, according to the results of our own study [ 13 ], CBT was effective among hypochondriacal patients without chronic low-back pain, but not in hypochondriacal patients with chronic low-back pain. These group differences did not seem to be due to differences in the baseline levels of hypochondriasis. Although evidence has suggested that both hypochondriasis and chronic low-back pain can be treated effectively with CBT [ 10 , 11 , 14 ], this has not yet been validated. Chronic low-back pain may be associated with a variety of conditions, including anxiety, depression, and somatic disorders such as illness conviction, disease phobia, and bodily preoccupation. The core psychopathology of hypochondriacal chronic low-back pain should be clarified to promote adequate symptom management [ 13 ].

figure 1

Number of articles per year identified by a PubMed search from 1989 to the present

Since 2000, Cochrane reviews have evaluated the effectiveness of CBT for a variety of mental, physical, and behavioral problems. Through a search of the Cochrane Library database up to May 2021 [ 15 ], 124 disease conditions were assessed to clarify the effects of CBT in randomized controlled trials; the major conditions for which CBT showed efficacy are listed in Table  1 . These include a broad range of medical problems such as psychosomatic illnesses (e.g., chronic fatigue syndrome, irritable bowel syndrome, and fibromyalgia), psychiatric disorders (e.g., anxiety, depression, and developmental disability), and socio-behavioral problems (drug abuse, smoking, and problem gambling). For most of these conditions, CBT proved effective in the short term after completion of the randomized controlled trial. Although the number of literature was still limited, some studies have reported significant and long-term treatment effects of CBT on some aspects of mental health like obsessive-compulsive disorder [ 16 ] 1 year after the completion of intervention. Future research should investigate the duration of CBT’s effects and ascertain the optimal treatment intensity, including the number of sessions.

Future directions for CBT application in biopsychosocial domains

In Japan, CBT for mood disorders was first covered under the National Health Insurance (NHI) in 2010, and CBT for the following psychiatric disorders was subsequently added to the NHI scheme: obsessive–compulsive disorder, social anxiety disorder, panic disorder, post-traumatic stress disorder, and bulimia nervosa [ 17 ]. The treatment outcomes and health insurance costs for these six disorders should be analyzed as the first step, for appropriate allocation of medical resources according to disease severity and complexity [ 18 ]. In Japan, health insurance coverage is provided only when physicians apply for remuneration. A system promoting nurse involvement in CBT delivery [ 19 ], as well as shared responsibility between the CBT instructor and certified psychologists (or even a complete shift from physicians to psychologists), has yet to be established. Information and communication technology (ICT) devices may allow CBT delivery to be shared between medical staff and psychologists, in medical, community and self-help settings [ 8 ]. The journal BioPsychoSocial Medicine published 334 relevant articles up to the end of May 2021, 112 (33.5%) of which specifically addressed CBT [ 20 ]. CBT is a hot topic in biopsychosocial medicine, and more research is required to encourage its application to clinical and general populations.

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The study was supported in part by a Research Grant (Kiban C) from the Japanese Ministry of Education, Culture, Sports, Science and Technology.

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Mutsuhiro Nakao

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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, 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.


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: 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.

figure 1

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.

figure 2

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.

figure 3

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 ).


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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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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research paper topics on stress reduction

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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.

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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 ( ).

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 ).

figure 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.


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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Research: Why Breathing Is So Effective at Reducing Stress

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research paper topics on stress reduction

Studies found it outperformed other techniques over both the short and long term.

Anxiety in the workplace is a serious problem. What can you do to stay calm, rational, and productive when dealing with a stressful situation? In several recently published studies, the authors explored the effectiveness of different techniques and found that one method — SKY Breath Meditation — offered the best results for both immediate and long-term stress reduction. This comprehensive series of breathing and meditation exercises engages the parasympathetic nervous system, which is responsible for the body’s “rest and digest” activities, helping you to calm down and think rationally in the face of stress. These simple techniques can help you sustain greater emotional wellbeing and lower your stress levels at work and beyond.

When U.S. Marine Corp Officer Jake D.’s vehicle drove over an explosive device in Afghanistan, he looked down to see his legs almost completely severed below the knee. At that moment, he remembered a breathing exercise he had learned in a book for young officers. Thanks to that exercise, he was able to stay calm enough to check on his men, give orders to call for help, tourniquet his own legs, and remember to prop them up before falling unconscious. Later, he was told that had he not done so, he would have bled to death.

research paper topics on stress reduction

  • Emma Seppälä , PhD, is a faculty member at the Yale School of Management, faculty director of the Yale School of Management’s Women’s Leadership Program and author of The Happiness Track . She is also science director of Stanford University’s Center for Compassion and Altruism Research and Education . Follow her work at or on Instagram . emmaseppala
  • Christina Bradley is a doctoral student in the Management & Organizations department at the University of Michigan’s Ross School of Business. Her research focuses on how to talk about emotions at work.
  • Michael R. Goldstein , Ph.D., is a Postdoctoral Research Fellow at Beth Israel Deaconess Medical Center and Harvard Medical School. He is a Licensed Clinical Psychologist and his research examines the physiological mechanisms of mind-body interventions for insomnia.

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New Research Shows Yoga Reduces Stress and Improves Well-Being

Recent research found improvements in depression and anxiety through yoga..

Posted February 16, 2024 | Reviewed by Monica Vilhauer

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  • Studies published in 2024 demonstrate yoga’s positive effects on feelings of well-being.
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Recent world events (including the Covid-19 pandemic, as well as traumatic events worldwide) have undoubtedly increased stress levels in the US, Europe, and across the globe. In addition to traditional counseling, adjunctive and complementary therapies such as yoga may be especially helpful in reducing stress , as well as symptoms of depression and anxiety . Perhaps partially in response to the increased stress levels globally, there appears to be a plethora of recent academic research studies that examine the potential benefits of yoga.

2024 has revealed promising studies demonstrating that yoga may be just such a complementary therapy to assist in improving feelings of well-being, as well as potentially improving sleep quality and social connectedness, among other beneficial effects.

Different Yoga Types for Every Taste

Numerous forms of yoga exist, with a yoga practice for various tastes and preferences. In the West, Hatha Yoga refers to a number of yoga practices which tend to be slower paced and gentle. Restorative Yoga, an even slower-paced yoga, is meant to relax and restore. Then there are more vigorous and athletic types of yoga such as Vinyasa and hot yoga classes. Additionally, yoga varieties extend from yoga practices that hold the positions (called "postures") for longer periods of time (such as Yin Yoga) to the more traditional yogic practices such as Kundalini, which is both physical and spiritual . Fortunately, especially since the Covid-19 pandemic, one need not leave the comfort of one’s living room to practice yoga, as there are various online yoga classes to be found.

Latest Yoga Research: Yoga for Stress Reduction and Improved Mood

Three recent (2024) studies found that yoga significantly reduced feelings of stress and improved feelings of well-being. In a study newly published in the March 2024 issue of Acta Psychologica journal, individuals who practiced a particular yoga focused on yogic breathing called Sudarshan Kriya Yoga (SKY) demonstrated a significant reduction in stress scores following the yoga intervention. Additionally, the individuals practicing this yoga showed increases in social connectedness scores immediately following the yoga intervention and these scores continued to improve with regular yoga practice.

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In February 2024, an online study reported in Frontiers in Public Health revealed that in another form of yoga called Isha yoga, participants reported significantly lower levels of stress and mental distress, as well as higher levels of well-being than individuals who were not practitioners of yoga. Furthermore, the well-being effects of yoga were also examined in the January 2024 issue of the Journal of Health Psychology , which reported on a 6-week randomized controlled trial (RCT), the gold standard of research. In this study, a Kundalini yoga intervention improved participants’ extrinsic affect (ability to express emotions) and their self-compassion, as well as their spiritual well-being.

Additional Recent Yoga Research Backs Up These Findings

Interestingly, the results of these three recent studies have been backed up by additional research published in the last year that examined a large number of yoga studies. The common thread found in a review of various studies was a reduction in symptoms of depression by those practicing yoga. In fact, one study examining older adults during the Covid-19 pandemic found a reduction in depression, anxiety, and stress for those in the experimental (yoga) group. Additionally, they discovered an improvement in their sleep while practicing Hatha yoga. The control group (who did not practice yoga) showed an opposite effect: they had an increase in their depression scores during the study. Additionally, a recent randomized controlled study examining effects of yoga as a complementary therapy for panic disorder also showed positive results in reduction of anxiety and improvement in quality of life.

Taken together, recent research findings indicate yoga may be a promising complementary or integrative therapy for assistance in the reduction of symptoms of depression and anxiety, as well as improvement in feelings of well-being. Additional benefits appear to include increased social connection, improved spiritual well-being and better sleep. As a complement to counseling, yoga holds a great deal of promise in improving well-being and we look forward to seeing further yoga research in the future.

Gamonal-Limcaoco, S., Montero-Mateos, E., Lozano-López, M. T., Maciá-Casas, A., Matías-Fernández, J., & Roncero, C. (2021). Perceived stress in different countries at the beginning of the coronavirus pandemic. The International Journal of Psychiatry in Medicine , 57 (4), 309–322.

Kanchibhotla, D., Harsora, P., & Subramanian, S. (2024). Influence of yogic breathing in increasing social connectedness among Indian adults. Acta Psychologica , 243 , 104164.

Malipeddi, S., Mehrotra, S., John, J. P., & Kutty, B. M. (2024). Practice and proficiency of Isha Yoga for Better Mental Health Outcomes: Insights from a COVID-19 survey. Frontiers in Public Health , 12 .

Brandão T, Martins I, Torres A, Remondes-Costa S. Effect of online Kundalini Yoga mental health of university students during Covid-19 pandemic: A randomized controlled trial. Journal of Health Psychology. 2024;0(0). doi:10.1177/13591053231220710

Wu, Y., Yan, D., & Yang, J. (2023). Effectiveness of Yoga for major depressive disorder: A systematic review and meta-analysis. Frontiers in Psychiatry , 14 .

Baklouti, S., Fekih-Romdhane, F., Guelmami, N., Bonsaksen, T., Baklouti, H., Aloui, A., Masmoudi, L., Souissi, N., & Jarraya, M. (2023). The effect of web-based Hatha Yoga on psychological distress and sleep quality in older adults: A randomized controlled trial. Complementary Therapies in Clinical Practice , 50 , 101715.

Yadla, V. S., NJ, P., Kamarthy, P., & Matti, M. R. (2024). Effect of integrated yoga as an adjuvant to standard care for panic disorder: A randomized control trial study. Cureus .

Tamara Goldsby Ph.D.

Tamara Goldsby, Ph.D. , is a Clinical Research Psychologist affiliated with the University of California, San Diego (UCSD) and a sound healing researcher. Her goal is to bring healing to people on a large scale through her research and writing.

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⭐ Simple & Easy Stress Essay Titles

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  • Trauma-Focused Therapy: Effectiveness on Patients Experiencing PTSD Psychology essay sample: The COVID-19 pandemic and its implications ranked first among the predisposing factors for the unprecedented annual statistics.
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  • The Effectiveness of Occupational Stress Management The focus of this study will be on the experiences of both workers and managers to determine the effectiveness of occupational stress management.
  • The Physiology of Stress: Understanding the Body’s Response Mechanisms
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  • Stress and Physical Health: The Connection to Chronic Diseases
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  • The New Sources of Stress in Modern Society
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  • How Constant Stress Can Trigger Acute Coronary Events
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  • Social Determinants of Stress: The Impact of Socioeconomic Factors
  • The Role of Stress in Obesity and Weight Management
  • Analyzing the Negative Impact of Stress on an Individual’s Health
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  • Influence of Yogic Techniques on Stress Management
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  • Why Group Therapy Improves Symptoms of Posttraumatic Stress?
  • How Cognitive-Behavioral Group Therapy Reduces Stress and Improves the Quality of Life in Patients With Parkinson’s Disease?
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  • Does Music Therapy Reduce Stress?
  • Can Psychology Help With Stress Reduction?
  • How Stress Affects the Human Mind?
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  • Does Stress Affect Students’ Academic Performance? The main goal of this paper is to establish whether being under stress affects a student’s performance to a noticeable extent and how it’s possible to improve academic performance.
  • Can Stress Cause Illness?
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  • How Can You Reduce the Adverse Effects of Stress?
  • How Fear and Stress Shape the Mind?
  • How Does Chronic Stress Affect the Body?
  • How Stress Affects Our Health, Personality, and Relationship With People?
  • How Does Stress Affect Child Development?
  • How Does Job Stress Affect Your Health?
  • How Stress Affects Memory in Adults?
  • How Stress Affects Our Bodies, Minds, and Well Being?

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  • v.8(Spec Iss 4); 2015

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.


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.


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.


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.


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