Effect of Breathwork on Stress & Mental Health: Meta‑Analysis of RCTS

Fincham, G. W., Strauss, C., Montero-Marin, J., & Cavanagh, K. (2023). Effect of breathwork on stress and mental health: A meta-analysis of randomised-controlled trials. Scientific Reports, 13(1), 432.

Rationale

This meta-analysis aimed to evaluate the efficacy of breathwork interventions for reducing self-reported stress, anxiety and depression.

The study was motivated by several key factors:

1. Rising global stress levels and mental health concerns, exacerbated by the COVID-19 pandemic (Jia et al., 2020).
2. The need for more accessible and scalable interventions to address stress and common mental health issues (Gerbarg et al., 2019).
3. Growing public interest in breathwork, but a lack of comprehensive synthesis of its effects on psychological outcomes.
4. Previous reviews on breathwork have been limited by factors such as:
   • Focus on populations with impaired breathing (Ubolnuar et al., 2019; Santino et al., 2020).
   • Insufficient focus on breathwork interventions specifically (Leyro et al., 2021).
   • Limited databases searched or exclusion of unpublished studies (Malviya et al., 2022).
5. No existing meta-analysis specifically focused on randomized controlled trials examining breathwork’s effects on psychological stress.

Given these gaps in the literature, this study aimed to provide a comprehensive systematic review and meta-analysis of randomized controlled trials on breathwork interventions for stress, anxiety and depression outcomes.

The primary focus was on stress as a transdiagnostic variable relevant across clinical and non-clinical populations.

Method

This meta-analysis adhered to PRISMA guidelines and was pre-registered on PROSPERO (CRD42022296709).

Databases searched: PsycInfo, PubMed, ProQuest, Scopus, Web of Science, ClinicalTrials.gov, and ISRCTN

The search was conducted up to February 2022 using keywords related to breathwork interventions and psychological outcomes.

• breath*
• respir*
• random*
• RCT
• stress

Inclusion criteria:

• Published in English
• Breathwork intervention comprising ≥50% of total intervention/practice time
• Randomized controlled trial design
• Outcome measure of self-reported stress, anxiety, or depression
• Adult participants (18+ years)

Exclusion criteria:

• Control conditions that included breathwork components
• Interventions using equipment to physically alter/assist breathing
• Interventions affecting breathing as a byproduct (e.g., mindfulness, singing, exercise)

Statistical measures:

• Random-effects meta-analysis using standardized mean differences (Hedges’ g)
• Heterogeneity assessed using Cochran’s Q and I² statistic
• Publication bias examined via funnel plot, Egger’s test, and fail-safe N analysis
• Sensitivity analyses removing individual studies
• Subgroup analyses for potential moderators of stress outcomes
• Kendall’s tau-b correlations to examine dose-response relationships

Results

Primary outcome – Stress:

• 12 RCTs included (785 total participants)
• Significant small-to-medium effect favoring breathwork compared to those in control conditions: g = -0.35 [95% CI -0.55, -0.14], p = 0.0009
• Moderate non-significant heterogeneity: I² = 42%, p = 0.06
• No evidence of publication bias (non-significant Egger’s test)

Subgroup analyses for stress:

The meta-analysis conducted subgroup analyses to examine whether various factors moderated the effects of breathwork on stress outcomes. Specifically, they looked at:

1. Type of breathwork: Slow-paced vs. fast-paced
2. Delivery method: a. Individual vs. group b. Remote vs. in-person
3. Population: Clinical (physical or mental health conditions) vs. non-clinical

The results showed no statistically significant differences between these subgroups. This means that:

1. Both slow-paced and fast-paced breathwork appeared to be similarly effective.
2. Breathwork seemed to work equally well whether delivered individually or in groups.
3. Remote (e.g., online or self-guided) and in-person delivery methods showed comparable effects.
4. The effects were similar across clinical and non-clinical populations.

Secondary outcomes:

The effect sizes for anxiety and depression were similar to, or slightly larger than, the effect size found for stress (g = -0.35).

• Anxiety (20 RCTs): g = -0.32 [95% CI -0.48, -0.16], p < 0.0001
• Depression (18 RCTs): g = -0.40 [95% CI -0.58, -0.22], p < 0.0001
• Moderate significant heterogeneity for both outcomes

Insight

This meta-analysis provides the first comprehensive synthesis of randomized controlled trials examining breathwork interventions for stress and related mental health outcomes.

The findings suggest that breathwork is associated with small-to-medium reductions in self-reported stress, anxiety, and depression compared to control conditions.

These effect sizes are comparable to those found for other stress-reduction interventions like online cognitive behavioral therapy (Heber et al., 2017) and mindfulness-based interventions (Abbott et al., 2014).

This is noteworthy given that breathwork may be more accessible and require less extensive training to implement compared to these other approaches.

The lack of significant differences in subgroup analyses suggests that breathwork may be effective across different populations and delivery formats.

This supports the potential scalability of breathwork interventions. However, the small number of studies in some subgroups limits firm conclusions.

The findings extend previous research by providing a more rigorous and comprehensive analysis focused specifically on breathwork interventions.

While prior reviews have suggested promise for breathwork (e.g., Zaccaro et al., 2018; Malviya et al., 2022), this meta-analysis offers stronger evidence from randomized controlled trials.

Further research is needed to:

1. Conduct larger, high-quality RCTs with low risk of bias
2. Compare different types of breathwork interventions directly
3. Examine long-term effects and optimal “dosing” of breathwork practice
4. Investigate physiological mechanisms (e.g., heart rate variability, cortisol) alongside psychological outcomes
5. Explore potential applications in specific clinical populations

Clinical Implications

The results suggest that breathwork interventions may be a promising approach for reducing stress and improving mental health outcomes.

The comparable effect sizes to other established interventions, combined with the potential accessibility and scalability of breathwork, make it an attractive option for public health initiatives.

For clinical psychology practice, breathwork could potentially be integrated as a complementary technique alongside other evidence-based treatments.

The findings that breathwork was effective across different delivery formats (individual/group, remote/in-person) suggest flexibility in how it could be implemented in various clinical settings.

However, the limitations of the current evidence base mean that caution is warranted in widespread implementation.

More high-quality research is needed to establish the efficacy and safety of breathwork interventions, particularly for clinical populations.

Variables that may influence the results include:

1. Type and “dose” of breathwork practice
2. Individual differences in breathing patterns or physiology
3. Comorbid physical or mental health conditions
4. Cultural factors and prior experience with breathwork or related practices
5. Motivation and adherence to practice

The potential mechanisms of action for breathwork (e.g., effects on autonomic nervous system regulation, interoception, cognitive processes) warrant further investigation to optimize interventions and identify who may benefit most.

Strengths

• Comprehensive search strategy including multiple databases and unpublished studies
• Focus on randomized controlled trials only
• Pre-registration of the review protocol
• Adherence to PRISMA guidelines
• Assessment of risk of bias using the Cochrane RoB 2 tool
• Multiple subgroup and sensitivity analyses
• Examination of publication bias
• Calculation of fail-safe N to assess robustness of findings

Limitations

• Moderate risk of bias in many included studies
• Small number of studies for some subgroup analyses, limiting statistical power
• Lack of long-term follow-up data in most studies
• Heterogeneity in breathwork interventions and control conditions
• Focus on self-report measures only, lacking physiological outcomes
• Inclusion of English-language studies only
• Limited data on adverse effects or contraindications

References

Primary reference

Fincham, G. W., Strauss, C., Montero-Marin, J., & Cavanagh, K. (2023). Effect of breathwork on stress and mental health: A meta-analysis of randomised-controlled trials. Scientific Reports, 13(1), 432.

Other references

Abbott, R. A., Whear, R., Rodgers, L. R., Bethel, A., Thompson Coon, J., Kuyken, W., … & Dickens, C. (2014). Effectiveness of mindfulness-based stress reduction and mindfulness based cognitive therapy in vascular disease: A systematic review and meta-analysis of randomised controlled trials. Journal of Psychosomatic Research, 76(5), 341-351.

Gerbarg, P. L., Brown, R. P., Streeter, C. C., Katzman, M., & Vermani, M. (2019). Breath practices for survivor and caregiver stress, depression, and post-traumatic stress disorder: Connection, co-regulation, compassion. OBM Integrative and Complementary Medicine, 4(3), 1-1.

Heber, E., Ebert, D. D., Lehr, D., Cuijpers, P., Berking, M., Nobis, S., & Riper, H. (2017). The benefit of web-and computer-based interventions for stress: A systematic review and meta-analysis. Journal of Medical Internet Research, 19(2), e5774.

Jia, R., Ayling, K., Chalder, T., Massey, A., Broadbent, E., Coupland, C., & Vedhara, K. (2020). Mental health in the UK during the COVID-19 pandemic: Cross-sectional analyses from a community cohort study. BMJ Open, 10(9), e040620.

Leyro, T. M., Buckman, J. F., Bates, M. E., & Walshe, T. (2021). Respiratory therapy for the treatment of anxiety: Meta-analytic review and regression. Clinical Psychology Review, 84, 101980.

Malviya, S., Meredith, P., Zupan, B., & Kerley, L. (2022). Identifying alternative mental health interventions: A systematic review of randomized controlled trials of chanting and breathwork. Journal of Spirituality in Mental Health, 24(2), 191-233.

Santino, T. A., Chaves, G. S. S., Freitas, D. A., Fregonezi, G. A. F., & Mendonça, K. (2020). Breathing exercises for adults with asthma. Cochrane Database of Systematic Reviews, (3).

Ubolnuar, N., Tantisuwat, A., Thaveeratitham, P., Lertmaharit, S., Kruapanich, C., & Mathiyakom, W. (2019). Effects of breathing exercises in patients with chronic obstructive pulmonary disease: Systematic review and meta-analysis. Annals of Rehabilitation Medicine, 43(4), 509.

Zaccaro, A., Piarulli, A., Laurino, M., Garbella, E., Menicucci, D., Neri, B., & Gemignani, A. (2018). How breath-control can change your life: A systematic review on psycho-physiological correlates of slow breathing. Frontiers in Human Neuroscience, 12, 353.

Keep Learning

Socratic questions for a college class to discuss this paper:

1. How might the mechanisms of action differ between slow-paced and fast-paced breathwork techniques? What physiological and psychological processes could be involved?
2. Given the comparable effect sizes to other stress-reduction interventions, what unique advantages or disadvantages might breathwork have in real-world implementation?
3. How might cultural factors influence the acceptability and effectiveness of breathwork interventions in different populations?
4. What ethical considerations should be taken into account when researching or implementing breathwork interventions, particularly for clinical populations?
5. How could technology be leveraged to enhance the delivery and study of breathwork interventions? What are potential benefits and drawbacks of tech-based approaches?
6. How might individual differences in physiology or psychology moderate the effects of breathwork? What factors should be considered in personalizing interventions?
7. How might the effects of breathwork interventions differ across the lifespan, from children to older adults?