Breathwork isn’t new; it has a vast and complex history that spans many disciplines and cultures. Yogis and meditators have been practising various forms of breathwork for thousands of years. Psychedelic communities have been experiencing its transformative power since Woodstock, and scientific and medical researchers have studied the breath for well over four decades.
The intense and unprecedented surge in public interest that breathwork has been receiving in the past few years, however, is a new phenomenon. Reflecting this flood of attention, two new studies have already been published in prestigious scientific journals, Nature and Brain Sciences, this year.
The latest study, a meta-analysis of randomised controlled trials titled “Effect of breathwork on Stress and Mental Health”, published in Nature in January, has found that breathwork significantly reduces stress and improves mental health outcomes. The authors of the study say that breathwork could be a part of the solution to meeting the need for more accessible approaches to stress and mental health conditions.
The study’s findings come as welcome news, as traditional approaches to treating stress, anxiety and depression with drugs/cognitive behavioural therapy (CBT) are often unsuccessful, can be expensive and inaccessible, and can come with unwanted drug side effects that make compliance an issue.
Added to that, the global cost of such interventions is absolutely staggering; the financial burden of traditional interventions is predicted to weigh in at USD $56 billion from 2016 to 2030. This means the need to find effective and accessible treatments is pressing.
The present state of global mental health coupled with the access barriers to psychological therapies means a different solution is needed – interventions that are easily accessible and scalable are required to address the scale of the problem. Practices such as breathwork may meet this remit.
Mental health problems such as stress, anxiety and depression have reached epidemic proportions over the last few years, rising in 2020 by 25% globally and causing the World Health Organisation (WHO) to implore world leaders to invest more seriously in mental health.
“Too many people remain unable to get the care and support they need for both pre-existing and newly developed mental health conditions…the situation underscores a chronic global shortage of mental health resources”, says the WHO.
It’s easy to see why, when the WHO’s latest Mental Health Atlas showed that in 2020, governments worldwide spent on average just over 2% of their health budgets on mental health, with many low-income countries reporting having fewer than 1 mental health worker per 100, 000 people.
Stress, anxiety and depression and mental health difficulties were already a significant issue prior to the pandemic, and have skyrocketed globally since then.
“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)” say the authors of the study that was published in Nature.
“Breathing exercises can be easily taught to both trainers and practitioners, and learned in group settings increasingly via synchronous and asynchronous methods remotely/online.”
Another recent study published last month in Brain Sciences, an international, peer-reviewed journal on neuroscience, also highlighted the need for non-drug therapies that can be self-administered and used by large populations, easily and cost effectively. Breathwork meets all of these requirements according to Johannes Egberts, Breathwork Pioneer, Biohacker and co-author of the study:
“Breathwork has been clinically proven to be a safe, effective and accessible therapy. We propose that breathwork could be a fundamental part of the solution to the explosion in stress and related disorders such as anxiety and depression that we are seeing worldwide.
“Given the bi-directional relationship between stress, anxiety, depression and breathing, it’s hard to comprehend why treatments focusing at least in part on the breath are not already gold standard. The breath is the most readily available tool worldwide for anyone alive today”, says Egberts.
THE GROWING BURDEN OF STRESS
The consequences of stress and anxiety can be debilitating and far reaching. A 2019 study entitled the ‘The Global Burden of Disease Study’ calculated that anxiety disorders account for 28.68 million years of healthy life lost due to disability or premature death.
Chronic stress is associated with, and can significantly contribute to, many physical and mental health conditions, from hypertension and cardiovascular disease to insomnia, anxiety and depression. Stress has been identified by the World Health Organisation as contributing to several serious non-communicable diseases,
Since the global pandemic, more people than ever before are experiencing increased levels of stress, anxiety and depression. Stress affects our health, our quality of life, and a Yale study found that chronic stress not only ages us faster but also shortens our lifespan.
The statistics below highlight the significant impact that the pandemic has had on mental health. With rates of stress, anxiety, and depression increasing significantly since the start of the pandemic, the need for accessible and effective interventions to manage these conditions has never been greater.
· A recent survey by Gallup in the US based on more than 150,000 interviews in over 100 countries suggested that 40% of adults had experienced stress the day preceding the survey according to the study.
· According to a survey by the American Psychological Association, stress levels in the US have increased significantly since the start of the pandemic, with 78% of adults reporting that the pandemic has been a significant source of stress in their lives (APA, 2021).
· A study conducted in the UK found that rates of depression and anxiety have doubled since the pandemic began, with one in five adults reporting symptoms of depression compared to one in ten before the pandemic (Mental Health Foundation, 2021).
· A survey by the Kaiser Family Foundation found that over half of US adults reported that their mental health had been negatively impacted by the pandemic, with feelings of loneliness, anxiety, and depression being the most commonly reported issues (KFF, 2021)
· A global survey conducted by Ipsos found that over 60% of people reported feeling more stressed than before the pandemic, with the highest rates of stress being reported in countries such as Mexico, India, and the United States (Ipsos, 2021).
· A study conducted in China found that rates of depression and anxiety were significantly higher among healthcare workers during the pandemic, with approximately 50% of healthcare workers experiencing symptoms of depression and 45% experiencing symptoms of anxiety (Lai et al., 2020).
DETAILS OF THE STUDY
Researchers wanted to investigate the effectiveness of breathwork as an intervention, due to the amount of public attention and popularity it has been amassing lately, and the reported beneficial effects on health and well-being.
They conducted a systematic review and meta-analysis encompassing 12 randomised-controlled trials with a total of 785 adult participants in order to “bridge the gap and unify both old and new research, because although breathwork has been attracting a lot of attention, it has only been partly investigated by clinical research and psychiatric medical communities.”
“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, could help build a stronger psychophysiological model of breathwork’s efficacy along with more robust mechanisms of action.”
It aimed to estimate the effectiveness of breathwork in targeting stress and examined whether breathwork interventions were associated with lower levels of self-reported/subjective stress compared to non-breathwork controls, and if so, to what extent, with secondary outcomes of anxiety and depression.
According to the authors, past studies and meta-analyses on the subject were restricted by factors that included a narrow focusing i.e., on populations with impaired breathing, insufficient focus on the breathwork intervention itself which made it hard to elicit separate effects, along with more focus on anxiety and depression as outcomes, compared to stress – all of which, the authors of this study say, made it impossible to draw conclusions.
Likewise, they say, other systematic reviews may have overlooked key studies because of too much focus on a specific technique (i.e., slow breathing or diaphragmatic breathing), an absence of randomised-controlled trials, scanter literature on self-reported/subjective stress compared to self-reported/subjective symptoms of anxiety and depression, along with limited databases, or exclusion of unpublished studies and grey literature (i.e., theses/dissertations).
Whilst the study highlights the need for further research, due to the presence of bias that is inherent with self-reporting, the findings are substantial and have helped to fill in some of the gaps in our understanding around the applications of breathwork to stress and mental health.
STUDY HIGHLIGHTS PROBLEMS WITH CURRENT PROTOCOLS
Current protocols for the treatment of depression and anxiety usually include a combination of medication and psychotherapy/cognitive behavioural therapy (CBT).
The study showed that these protocols are leaving patients feeling considerably dissatisfied, many patients do not recover and waiting times can be long, in addition to extensive professional training and ongoing supervision being required for therapists. Drug side effects also play a large part in the problem and result in lack of patient compliance, as do issues around cost and accessibility. Added to that, CTB is usually individualised and offered on a one-to-one basis making it resource intensive.
In short, it’s expensive, resource-intensive, inaccessible, and not everyone responds to treatment.
BREATHWORK AS A PART OF THE SOLUTION
Researchers found that breathwork had significant small-medium results in decreasing:
People with stress and anxiety disorders tend to chronically breathe faster and more erratically. Researchers say that slow breathing practices have received most of the attention in research to date and have been shown to be effective in reducing stress and mental health issues.
Several psychophysiological mechanisms of action are proposed to underpin such techniques:
· polyvagal theory
· central nervous system effects
· increasing heart-rate variability (HRV) via modulation of the autonomic nervous system (ANS) and increased parasympathetic activity.
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). As one inhales and exhales, the heart rate increases and decreases, respectively. Higher HRV, arising from respiratory sinus arrhythmia, is typically beneficial as it translates into robust responses to changes in breathing and thus a more resilient stress-response system.
Stress-response dysfunction, associated with impaired ANS activity, and low HRV are common in stress, anxiety, and depression. This may explain why techniques like HRV biofeedback can be helpful, however, it is possible that simply pacing respiration slowly at approximately 5–6 breaths/minute, requiring no monitoring equipment, can elicit similar effects.
Two of the studies in the meta-analysis used the only Food and Drug Administration-approved portable electronic biofeedback device, which encourages deep, slow breathing. However, the study found HRV can be improved in the same way (tenfold) by simply breathing at a rate around 5–6 breaths/min (known as Coherent or Resonant Breathing) and some Zen Buddhist monks have been found to naturally respire around this rate during deep meditation. It may be possible that breathing rate forms a key component of meditation’s known positive effects.
Polyvagal Theory 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. Further, the neurovisceral integration model states that high vagal tone is associated with improved health along with emotional and cognitive functioning.
Vagal nerves form the main pathway of the parasympathetic nervous system, and high HRV indicates greater parasympathetic activity. Findings showed that the cortisol (stress hormone) levels in people undergoing slow breathing practices was lower than in controls.
Modifying breathing alters communication sent from the respiratory system, rapidly influencing brain regions regulating behaviour, thought and emotion. Likewise, respiration may entrain brain electrical activity with slow breathing resulting in synchrony of brain waves thereby enabling diverse brain regions to communicate more effectively. It has been observed that adept long-term Buddhist meditation practitioners can achieve states where brain waves are synchronised continuously.
The study also found that fast-paced breathwork may also offer therapeutic benefit as temporary voluntarily induced stress is also known to be beneficial for health and stress resilience:
The study concludes that breathwork is an effective intervention for treating stress, anxiety and depression. The authors identified countless breathwork techniques—and say that such variation in their potential modalities and underlying principles warrants further research and exploration. They believe that breathwork could complement other therapeutic interventions, potentially leading to additive effects of such health behaviours.