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NCCIH Clinical Digest

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Anxiety and Complementary Health Approaches: What the Science Says

August 2020

Clinical Guidelines, Scientific Literature, Info for Patients: 
Anxiety and Complementary Health Approaches

Close up of a person's hands while meditating

Mind and Body Approaches

Acupuncture

Although some studies of acupuncture for anxiety have had positive outcomes, in general, many of the studies on acupuncture for anxiety have been of poor methodological quality or not of statistical significance. In addition, because the research is extremely variable (e.g., number and variety of acupuncture points, frequency of sessions, and duration of treatment), it is difficult to draw firm conclusions about potential benefits.

What Does the Research Show?

  • A 2012 review of 32 studies of acupuncture for anxiety found that although there have been some positive outcomes, the generally poor methodological quality, combined with the wide range of outcome measures used, number and variety of points, frequency of sessions, and duration of treatment makes drawing firm conclusions difficult.
  • A 2014 meta-analysis of 14 studies involving 1,034 participants on the efficacy of acupuncture in reducing preoperative anxiety found that acupuncture has a statistically significant effect relative to placebo or non-treatment controls, but the sample size was small. The meta-analysis supports the possibility that acupuncture is superior to placebo for preoperative anxiety.

Safety

  • Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles. Reports of serious adverse events related to acupuncture are rare, but include infections and punctured organs.

Massage Therapy

In some studies massage therapy helped to reduce anxiety for people with cancer or other comorbid medical conditions; however, other studies did not find a statistically significant beneficial effect. Little research has been done on massage for anxiety disorders, and results have been conflicting.

What Does the Research Show?

  • A 2016 Cochrane review of 19 studies involving more than 1,200 participants found some evidence that massage might help with pain and anxiety in cancer patients, but the quality of the evidence was very low (because most studies were small and some may have been biased), and findings were not consistent.
  • 2014 systematic review and meta-analysis of 18 randomized controlled trials involving 950 women with breast cancer did not find any significant effect of massage on anxiety.
  • 2013 randomized controlled trial of 60 cancer patients examined massage therapy for perioperative pain and anxiety in placement of vascular access devices and found that both massage therapy and structured attention proved beneficial for alleviating preoperative anxiety in these patients.
  • 2012 randomized trial involving 152 cardiac surgery patients found that massage therapy significantly reduced the pain, anxiety, and muscular tension and improved relaxation after cardiac surgery.
  • Findings from a 2012 randomized controlled trial of 120 primiparous women with term pregnancy suggest that massage is an effective alternative intervention, decreasing pain and anxiety during labor.

Safety

  • Massage therapy appears to have few risks if it is used appropriately and provided by a trained massage professional.

Mindfulness Meditation

Meditation therapy is commonly used and has been shown to be of small to modest benefit for people with anxiety-related symptoms. There is some evidence that Transcendental Meditation may have a beneficial effect on anxiety. However, there is a lack of studies with adequate statistical power in patients with clinically diagnosed anxiety disorders, which makes it difficult to draw firm conclusions about its efficacy for anxiety disorders.

What Does the Research Show?

  • A 2019 systematic review and meta-analysis of 34 studies found that interventions based on cognitive-behavioral programs, self-reflection, and mindfulness-based approaches produce satisfactory and significant results in relation to the reduction of stress, anxiety, and depression in students.
  • A 2019 meta-analysis involving 862 participants with anxiety disorders or high trait anxiety compared meditation techniques to relaxation therapies and concluded that meditation seems to be slightly more effective than relaxation in the treatment of anxiety. The meta-analysis also found that meditation might also remain more effective at 12-month follow-up.
  • A 2018 randomized controlled trial examined whether a Transcendental Meditation (TM) program could increase EEG brain integration and positive affect, and decrease psychological distress in 96 school district staff. The study found that TM participants had improved brain integration and positive affect and a reduction in psychological distress, including anxiety.
  • A 2018 randomized controlled trial examined the effects of a single, short bout of aerobic exercise (i.e., a brisk walk) or meditation, as well as exercise and meditation combined on state anxiety among 110 young adults. The study found that meditation (vs a brisk walk) may be a preferred method of attenuating anxiety symptomology.
  • 2017 randomized controlled trial involving 57 participants with generalized anxiety disorder found that mindfulness meditation training was associated with a significantly greater decrease in partial work days and decrease in health care utilization.
  • 2014 systematic review and meta-analysis of 47 trials with 3,515 participants found that mindfulness meditation programs had moderate evidence of improved anxiety. The reviewers concluded that clinicians should be aware that meditation programs can result in small to moderate reductions of multiple negative dimensions of psychological stress.

Safety

  • Meditation is generally considered to be safe for healthy people. However, people with physical limitations may not be able to participate in certain meditative practices involving movement.

Relaxation Techniques

Relaxation techniques may reduce anxiety in individuals with chronic medical problems and those who are having medical procedures. However, research demonstrates that conventional psychotherapy, for individuals with generalized anxiety disorder, may be more effective than relaxation techniques.

What Does the Research Show?

  • 2014 meta-analysis of a total of 41 studies involving 2,132 participants with generalized anxiety disorder found some indications that cognitive-behavioral therapy was more effective than relaxation techniques over the long term.
  • 2016 randomized trial of 236 women undergoing large core breast biopsy found that adjunctive self-hypnotic relaxation decreased procedural pain and anxiety.
  • A 2012 randomized controlled trial of 39 participants with inflammatory bowel disease found that those who received the relaxation-training intervention showed a statistically significant improvement in anxiety levels as compared to the control group.

Safety

  • Relaxation techniques are generally considered safe for healthy people. People with serious physical or mental health problems should discuss relaxation techniques with their health care providers.

Natural Products

Chamomile

There is some research that suggests that a chamomile extract may be helpful for generalized anxiety disorder, but the studies are preliminary, and their findings are not conclusive.

What Does the Research Show?

Safety

  • There have been reports of allergic reactions, including rare cases of anaphylaxis, in people who have consumed or come into contact with chamomile products.
  • People are more likely to experience allergic reactions to chamomile if they’re allergic to related plants such as ragweed, chrysanthemums, marigolds, or daisies.
  • Interactions between chamomile and cyclosporine and warfarin have been reported, and there are theoretical reasons to suspect that chamomile might interact with other drugs as well.

Kava

Kava extract may produce moderately beneficial effects on anxiety symptoms; however, the use of kava supplements has been linked to a risk of severe liver damage.

What Does the Research Show?

  • A 2018 systematic review found that kava may produce short-term improvements for anxiety, but is not a replacement for prolonged anti-anxiety use. The reviewers noted that liver toxicity is especially possible if taken longer than 8 weeks.
  • 2013 randomized controlled trial involving 75 participants with generalized anxiety disorder concluded that standardized kava extract may be a moderately effective short-term option for the treatment of generalized anxiety disorder.

Safety

  • The use of kava supplements has been linked to a risk of severe liver damage, according to the U.S. Food and Drug Administration. However, a 2013 randomized controlled trial of 75 participants who received kava extract over a 6-week period found no significant differences across groups for liver function tests, nor any significant adverse reactions associated with kava administration. Long-term safety studies of kava are needed.
  • Kava has been associated with several cases of dystonia and may interact with several drugs, including drugs used for Parkinson’s disease.

Melatonin

There is some research that suggests melatonin may help reduce anxiety in patients who are about to have surgery and may be as effective as standard treatment with midazolam in reducing preoperative anxiety.

What Does the Research Show?

  • A 2019 randomized controlled trial found that melatonin showed sufficient anxiolytic effect in patients undergoing dental surgery without affecting cognitive and psychomotor functions.
  • A 2018 randomized clinical trial compared the effects of melatonin and oxazepam in the management of anxiety and insomnia on patients following primary percutaneous coronary intervention (PCI). Results of the study suggest that melatonin may be more effective than oxazepam in improving the sleep quality and anxiety levels of patients with STEMI (ST-Elevation Myocardial Infarction), and it could be considered a new alternative to benzodiazepines in this setting.
  •  A 2017 randomized trial involving 80 children undergoing surgery found that melatonin was as effective as midazolam in reducing children’s anxiety in both preoperative room and at induction of anesthesia.
  • 2015 Cochrane review of 12 studies involving 774 participants found that melatonin compared to placebo, given as premedication, reduced preoperative anxiety (measured 50 to 100 minutes after administration) and may reduce postoperative anxiety (6 hours after surgery). The reviewers also found that melatonin may be equally as effective as standard treatment with midazolam in reducing preoperative anxiety.

Safety

  • Melatonin supplements appear to be safe when used short-term; less is known about long-term safety.

Lavender

Although some studies of lavender preparations for anxiety have shown some therapeutic effects, in general, many of these studies have been of poor methodological quality.

What Does the Research Show?

  • A 2019 systematic review and meta-analysis of a qualitative synthesis of data including 65 randomized controlled trials (7,993 participants) and 25 non-randomized studies (1,200 participants), and a quantitative synthesis of data involving 37 randomized controlled trials (3,964 participants) found that overall, oral administration of lavender essential oil was effective for anxiety, whereas for inhalation there was only an indication of an effect of reasonable size, due to the heterogeneity of available studies. Lavender essential oil administered through massage appeared to be effective, but available studies were not sufficient to determine whether the benefit was due to a specific effect of lavender.
  • A 2018 randomized controlled trial examined the effects of lavender oil aromatherapy on anxiety and sleep quality in 70 patients undergoing chemotherapy and found a significant improvement in anxiety in the lavender group.
  • 2017 meta-analysis of five studies involving 1,165 participants with anxiety diagnoses found Silexan (lavender oil) to be significantly superior to placebo in ameliorating anxiety symptoms independently of diagnosis. The study also found a tendency for greater clinical effect when analyzing separately generalized anxiety disorder patients in comparison with all other diagnosis.

Safety

  • When lavender teas and extracts are taken by mouth, they may cause headache, changes in appetite, and constipation.
  • Using lavender supplements with sedative medications may increase drowsiness.

References

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  • Braun LA, Stanguts C, Casanelia L, et al. Massage therapy for cardiac surgery patients–a randomized trial. J Thorac Cardiovasc Surg. 2012;144(6):1453-1459.
  • Chen KW, Berger CC, Manheimer E, et al. Meditative therapies for reducing anxiety: a systematic review and meta-analysis of randomized controlled trials. Depress Anxiety. 2012;29(7):545-562.
  • Cuijpers P, Sijbrandij M, Koole S, et al. Psychological treatment of generalized anxiety disorder: a meta-analysis. Clin Psychol Rev. 2014;34(2):130-140.
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  • Ghaeli P, Solduzian M, Vejdani S, et al. Comparison of the effects of melatonin and oxazepam on anxiety levels and sleep quality in patients with ST-segment-elevation myocardial infarction following primary percutaneous coronary intervention: A randomized clinical trial. Ann Pharmacother. 2018 Oct;52(10):949-955.
  • González-Valero G, Zurita-Ortega F, Ubago-Jiménez JL, Puertas-Molero P. Use of meditation and cognitive behavioral therapies for the treatment of stress, depression and anxiety in students. A systematic review and meta-analysis. Int J Environ Res Public Health. 2019;16(22):4394.
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  • Mortazavi SH, Khaki S, Moradi R, et al. Effects of massage therapy and presence of attendant on pain, anxiety and satisfaction during labor. Arch Gynecol Obstet. 2012;286(1):19-23.
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