Review and meta-analysis suggests breathwork may be effective for improving stress and mental health

By Nidhi Saha, BDSReviewed by Danielle Ellis, B.Sc.Jan 13 2023

The findings of a study published in Scientific Reports suggest that practicing breathing exercises helps decrease stress and improve mental health. 

Background 

Breathwork practices date back to ancient times, as evidenced in yoga (India), vase breathing (Tibet), and Tai chi (China). Its benefits on spiritual, mental, and physical health and well-being have been conveyed through generations.

Currently, breathwork is also advocated by medical practitioners and researchers and is steadily gaining popularity, especially in developed nations. The beneficial therapeutic effects of breathwork practice have become more widely known since the coronavirus disease 2019 (COVID-19) outbreak and as the associated respiratory ill-effects emerged. Despite its well-known benefits, breathwork has been inadequately investigated by the scientific community.

The World Health Organization (WHO) identifies stress as a major factor contributing to non-communicable diseases leading to several mental health issues (like anxiety and depression) and physical ailments (like hypertension).

Cognitive behavioral therapy (CBT) has been widely recommended and accepted as a treatment option for such mental disorders. However, it does not offer a definitive cure and necessitates prolonged treatment and counseling under a trained therapist.

Breathwork training can be easily and remotely imparted, online or offline, making it significantly economical and accessible.

Scientists have described multiple mechanisms instrumental in the beneficial effects of practicing slow-paced breathing. These include central nervous system (CNS) pacification, polyvagal theory, interoception and enteroception, increased heart rate variability through autonomic nervous system (ANS) modulation, and heightened parasympathetic action. 

Stress, depression, and anxiety impair ANS activity and lower HRV. Breath modification alters the neurological signals sent by the respiratory system, influencing parts of the brain that regulate thoughts, emotions, and behavior.

Additionally, slow-paced breathing synchronizes brain waves, improving communication between different parts of the brain. Meanwhile, fast-paced breathing voluntarily induces transient stress, which aids in improving stress resilience.

Current evidence proposes that one session of slow-paced deep breathing benefits the vagal tone (measured through HRV) and attenuates anxiety in adults. Hence, breathwork can be compared to mindfulness and meditation practices. Meditation and breathing 5-6 breaths/minute improves HRV.

This is comparable to the electronic biofeedback device approved by the Food and Drug Administration (FDA). A ten-fold greater effect can be achieved by practicing meditation and breathwork.

About the study

This article reviewed various impacts of breath alteration on subjective stress levels and compared them to non-breathwork controls. The study also examined the dose-response effects of breath alteration on stress.

This study solely focused on randomized control trials (RCTs). It entailed sub-analyses of the study population and controls based on their health status, breathwork technique, delivery, and the outcome measures employed. The dose-response effect on stress was evaluated. 

A systematic search was conducted through PubMed, PsycInfo, Scopus, Web of Science, and ProQuest databases and the clinical trial registers – ISRCTN and ClinicalTrials.gov. The meta-analysis included 12 RCTs (with 785 adults) until February 2022. 

Findings

The result of the meta-analysis yielded a significant association between breathwork intervention and lower stress levels compared to the controls. Despite the insufficient data availability, the outcomes of the included studies seemed consistent. 

Further, the nonclinical samples also depicted similar results, excepting those with mental and physical health issues. The benefits on stress were noteworthy after slow-paced breathing intervention when taught alone rather than when imparted in groups. In addition, the benefits of the fast-paced breathing intervention were also mild in comparison. 

The technique seemed to be efficacious whether taught in-person, remotely or both. The findings depicted a high safety profile of breathwork interventions––slow-paced breathing. Hence, it can be prescribed to individuals experiencing high stress levels and populations with subclinical stress. 

Of note, the interventional technique and mode-of-delivery of breathing alterations did not impact outcomes. Thus, its various modalities can be effective. Another advantage was that breathwork showed attenuated stress in the inactive and active controls. Hence, the intervention can be deemed accessible and somewhat universal.  

Conclusions 

These results showed significant improvements in self-reported anxiety, depression, and stress in individuals practicing breathwork compared to non-breathwork control populations.

Although breathwork is a popular therapeutic approach to mitigate stress, more studies are warranted to differentiate between the "hype and evidence" and better understand breath alterations' therapeutic potential.

This study provides preliminary evidence for further research on breathwork before incorporating it into routine practice for improving public health.