review article a systematic review of biopsychosocial...
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Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineVolume 2013, Article ID 747694, 23 pageshttp://dx.doi.org/10.1155/2013/747694
Review ArticleA Systematic Review of Biopsychosocial TrainingPrograms for the Self-Management of Emotional Stress:Potential Applications for the Military
Cindy Crawford,1 Dawn B. Wallerstedt,1 Raheleh Khorsan,2 Shawn S. Clausen,3
Wayne B. Jonas,1 and Joan A. G. Walter1
1 Samueli Institute, 1737 King Street, Suite 600, Alexandria, VA 22314, USA2 Samueli Institute, 2101 East Coast Highway, Suite 300, Corona Del Mar, CA 92625, USA3Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building 8, Room 5106, Bethesda, MD 20889, USA
Correspondence should be addressed to Cindy Crawford; [email protected]
Received 10 May 2013; Revised 26 June 2013; Accepted 22 July 2013
Academic Editor: Tobias Esch
Copyright © 2013 Cindy Crawford et al.This is an open access article distributed under theCreativeCommonsAttribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Combat-exposed troops and their familymembers are at risk for stress reactions and related disorders.Multimodal biopsychosocialtraining programs incorporating complementary and alternative self-management techniques have the potential to reduce stress-related symptoms and dysfunction. Such training can preempt or attenuate the posttraumatic stress response andmay be effectivelyincorporated into the training cycle for deploying and redeploying troops and their families. A large systematic review wasconducted to survey the literature on multimodal training programs for the self-management of emotional stress. This report isan overview of the randomized controlled trials (RCTs) identified in this systematic review. Select programs such as mindfulness-Based Stress Reduction, Cognitive Behavioral Stress Management, Autogenic Training, Relaxation Response Training, and othermeditation and mind-body skills practices are highlighted, and the feasibility of their implementation within military settings isaddressed.
1. Introduction
Combat-exposed troops and their family members are atrisk for stress reactions and related disorders [1]. Strategiesto enhance psychological resilience among service membersare needed. Providing this training prior to deploymentmight preempt or attenuate the posttraumatic stress response,depression, anxiety, and other consequences of overwhelm-ing stress.
Complementary and alternative medicine (CAM) andintegrative medicine (IM) approaches to self-management ofemotional stress are increasingly utilized within comprehen-sive care models [2]. Surveys have affirmed the widespreaduse of integrative modalities in military populations and set-tings, including Department of Defense (DoD) beneficiaries[3], active duty military [4], and patients using VeteransHealth Administration (VHA) hospitals [5–7].
Multimodal treatment programs, as compared to singlemodality treatments, have emerged as an important optionin the management of stress disorders [8, 9]. Compared totreatment with a single modality, multimodal programs havethe potential to simultaneously address a range of stress reac-tions, both physical andmental, as well as the dynamic natureof the disease process over time. Applied at the populationlevel, the increased variety of modalities potentially has agreater chance of providing viable alternatives for a givenindividual.
The military is already a culture in which self-care is rec-ognized as a vital tool in warfare: adequate nutrition, hydra-tion, and sleep are part of a warrior’s battle kit.Therefore, self-management skills that are delivered asmultimodal programsinvolving CAM/IM may be an ideal option for the militarycommunity to help build resilience, reset the autonomic
2 Evidence-Based Complementary and Alternative Medicine
nervous system, and ease emotional stress. Consequently,in tandem with the mainstreaming of many CAM practicesin the civilian sector, military personnel may seek CAMtherapies to improve their health and well-being, especiallythose CAM therapies that are self-manageable and drugless.
A number of model biopsychosocial training programsexist in the civilian sector [10–13]. Several have adaptedtheir programs to the military [10, 12–14], and a smallernumber have provided training to military personnel [14].However, to date, there has been no comprehensive sys-tematic review of multimodal biopsychosocial programs forthe self-management of stress. The authors posit that theseinterventions could be markedly effective for individuals inhigh-stress environments such as the military.
1.1. Purpose of the Review. A comprehensive systematicreview was conducted to (1) survey multimodal biopsy-chosocial training programs with at least one CAM/IMcomponent for the self-management of emotional stressacross all populations; (2) assess the quantity and quality ofthe research and programs; and (3) characterize the resultsby type of program and strength of evidence on stress-related outcome measures. Due to the massive amount ofthe literature included, the full report of this review will bedetailed in a much larger report, not suitable for detailingin one paper. The purpose of this current report is to (1)focus on those studies that were scored as high quality anddemonstrated statistically significant results between groups(i.e., intervention group versus control or comparison group)on outcomes of emotional stress for controlled trial studydesigns; (2) describe the multimodal programs available andtheir characteristics; (3) describe the results of outcomesrelated to emotional stress; and (4) discuss what the authorsbelieve to be the resource requirements needed to incor-porate these programs into a military setting for servicemembers and their families. The authors have chosen toreport this subset of data since studies assessed as highquality according to internal validity criteria are the leastlikely to have introduced bias, are more likely replicable, andcan be trusted to show a valid effect for the interventionand population being studied [15, 16]. If these studies aregeneralizable to other populations, then it is reasonable toanticipate that an effective program, if implemented in amilitary environment, could show equivalent benefits for thishighly stressed population.
2. Methods
2.1. Concepts and Definitions
2.1.1. Biopsychosocial Model. The biopsychosocial model(abbreviated “BPS”) is a term introduced in 1977 by theAmer-ican psychiatrist George Engel which describes a health careperspective that acknowledges that biological, psychological(which entails thoughts, emotions, and behaviors), and socialfactors all play a significant role in human functioning in thecontext of wellness and illness. It is a term that is often usedto describe the concept of the “mind-body connection” [8].
2.1.2. Complementary and Alternative Medicine (CAM)Modality. CAM is defined at the National Center forComplementary and Alternative Medicine as: any of anumber of “diverse medical and health care systems,practices, and products that are not generally consideredpart of conventional medicine” (http://nccam.nih.gov/).For the purposes of this review, the authors includedonly CAM modalities that also met our criteria for thebiopsychosocial model and self-management technique(http://www.ncbi.nlm.nih.gov/mesh/?term=complementary+therapies) and used definitions of CAM techniques ofbreathing, relaxation, yoga, imagery, hypnosis, and med-itation as described by the National Center for HealthStatistics on the NCCAM website: http://nccam.nih.gov/health/providers/camterms.htm.
2.1.3. Self-Management Technique. Self-management tech-niques are techniques in which skills are used independentlyby an individual without ongoing reliance on a trainer ortherapist. The authors excluded interventions where patientssolely learn and integrate therapies by themselves (such asthrough a book or online material) or ones that are traineror therapist dependent (i.e., psychotherapy that requires atherapist to lead the sessions).
2.1.4. Multimodality Interventions. These interventions aredefined as those ones that have two or more interventions (atleast one of which is CAM modality) that require an initialtraining period with a therapist or trainer in which skills arelearned, all of which can be transferred into self-managementtechniques. The authors only included programs that havemultimodal interventions. An example is a program thatincludes relaxation, exercise, and behavioral techniques toreduce stress. The thought here was that multimodal pro-grams would allow for more of a biopsychosocial approachto treating thewhole person for the complexities of emotionalstress.
2.1.5. Types of Program. Types of programs that the authorsconsidered were those that include training in at least oneself-management multimodal training with the intention toreduce psychological or emotional stress. The program didnot necessarily have to be an existing named program per sebut had to include interventions that could be developed intoa program (e.g., a potential program). The authors includededucational training programs as long as they met thesecriteria.
2.2. Search Strategy. The following electronic databaseswere searched from database inception through February2009 across keywords identified: PUBMED, EmBase,BIOSIS, CINAHL, the entire Cochrane library as wellas the database of abstracts of reviews of effectiveness(DARE), PILOTS, PsycInfo, AMED, ERIC, and DoDBiomedical Research. Gray literature was also searchedfor unpublished trials via the Register of the ControlledTrials databases (http://www.controlled-trials.com/ andhttp://www.clinicaltrials.gov/), NLM catalog, and NCCAM
Evidence-Based Complementary and Alternative Medicine 3
Grantee Publications Database, communicating with iden-tified experts in the field of CAM/IM for additional reportsof studies not included through traditional searching andpearling references of included articles.
2.3. Study Selection. Studies were included if they involved(1) research on a program or potential program; (2) amultimodal intervention incorporating at least one CAMmodality (as defined by NCCAM and detailed by theNational Library of Medicine (NLM) http://nccam.nih.gov/health/providers/camterms.htm; http://www.ncbi.nlm.nih.gov/mesh/?term=complementary+therapies); (3) skillsthat were learned that could be used as self-managementtechniques, after a training period; (4) at least one outcomemeasure of psychological or emotional stress; (5) humansubjects from any clinical or nonclinical population; and(6) were presented in the English language. To encompassthe construct of “psychological or emotional stress,” studieswere included that used outcome measures containing oneof the following keywords: stress, anxiety, post-traumaticstress disorder, coping, resilience, hardiness, burnout, distress,or relaxation at the screening phase. Since all healthy andclinical populations experience stress (although to varyingdegrees), the authors elected not to exclude any populationbased on predefined criteria about their conditions ordiagnoses. This was consistent with the authors’ intent togeneralize about the value of these programs impacting thesymptoms of stress. Thus, all populations, both healthy andclinical (e.g., those with specific conditions or diagnoses),were included as long as the report included a descriptionof emotional stress as defined above. Types of the literatureexcluded from this systematic review, were thought pieces,descriptive reviews or published expert opinions. Theauthors excluded the following interventions: ones in whichindividuals learned and integrated therapies by themselves;those that involved website training, books, or leaflets asthe sole source of the training; pharmacological agents orplacebos; and pet therapy. Cognitive behavioral therapy(CBT) was not defined as a CAM practice by itself but wasincluded when it incorporated another CAM technique,such as deep breathing or relaxation exercises that were thepredominant feature of the program. All programs had toinvolve at least one CAM modality as described above; noadditional medical or psychosocial procedures were includedunless the program integrated those procedures with theCAM modality for the purpose of stress management. SeeBox 1 for the search terms used.
Five investigators (Cindy Crawford, Sasha Knowlton,Raheleh Khorsan, Dawn Wallerstedt, and Shawn Clausen)individually and independently screened all titles andabstracts in duplicate for relevance based on the inclusioncriteria mentioned above. Weekly team meetings were heldbetween all five screeners to resolve any and all disagree-ments.
2.3.1. Quality Assessment and Data Extraction. The method-ological quality of included RCT studies was assessed inde-pendently by four reviewers in duplicate using a modified
version of the Scottish Intercollegiate Guidelines Network(SIGN 50) checklist, a validated and reliable assessmentapproach widely used in the literature [17]. Three of the 10SIGN criteria for assessment of quality were omitted as theydid not apply to our research question (see Table 1). Highquality was defined as a SIGN 50 score equal to + (only 1-2criteria scored as poorly addressed) or ++ (0 criteria scoredas poorly addressed); that is, some or all of the internalvalidity criteria have been fulfilled.Where they have not beenfulfilled, the conclusions of the study were thought unlikelyto very unlikely to alter results [17]. All reviewers were fullytrained in the methodology employed. All conflicts wereresolved through discussion and consensus or by consultingthe senior author. Samueli Institute developed a rulebook toensure objectivity in scoring and reliability between reviewersto improve the often subjective assessments in quality criteriascoring in systematic reviews. As detailed above and inTable 1, the individual criteria were “weighted” to account forthe omission of criteria that did not apply to this body ofliterature.
2.4. Results. The initial search from the full systematic reviewyielded 11,977 citations from database inception throughFebruary 2009, of which 284 reports were deemed suitable tobe included, with 116 being RCT study designs. See Figure 1for the flow diagram of studies throughout the review phases.This current report includes only those that were RCT’s andwere scored as high quality and statistically significant results.Subsequent planned reports will comment on other studydesigns available.
2.5. Types of Programs. The 116 RCT studies from the fullsystematic review were categorized into the following typesof programs: those that have been previously character-ized/named (56 total): Mindfulness-Based Stress Reduction(MBSR), Cognitive Behavioral Stress Management (CBSM),Autogenic Training (AT), Relaxation Response Training(RRT), Stress Inoculation Training (SIT), Anxiety Manage-ment Training (AMT), and Coping Skills Training (CST);and those that have not been previously characterized/named(60 total): yoga and similar meditation-based modalities(including programs that incorporated yoga-type techniquesas the primary intervention) and relaxation and other similarmind-body skills (including programs that used any relax-ation technique, breathing, guided imagery, self-hypnosis,and/or Cognitive Behavioral Therapy (CBT) as the primaryintervention). Table 2 displays the number of RCT studies,categorized by name of program, quality rating (SIGN 50score), and significance level showing between-group differ-ences on stress-related outcome results. Of note, very few ofthe high-quality studies reported negative results. None ofthe studies that used CST, AMT, or SIT as an interventionfit the criteria of high quality; therefore, these will not bereported on further in this report but will be describedin subsequent publications. Detailed descriptions of eachof the 34 studies that were of high quality and yieldedstatistically significant results between groups are displayed inTable 3 anddescribed below. Because the unnamedprograms’
4 Evidence-Based Complementary and Alternative Medicine
(program OR programme OR training OR taught OR learn∗ OR skill∗) AND (stress OR “Stress, Physiological” [Mesh]OR “Stress Disorders, Post-Traumatic” [Mesh] OR “Stress, Psychological” [Mesh] OR “Stress Disorders, Traumatic” [Mesh])AND (psychosocial OR integrat∗ OR “alternative medicine” OR “complementary medicine” OR “alternative therapy” OR“complementary therapy” OR “complementary and alternative medicine” OR “complementary and alternative therapy” ORmind-body OR imagery OR mindfulness OR yoga OR yogic OR biofeedback OR “heart-rate variability” OR “virtual reality”OR breath∗ OR “cognitive restructuring” OR mantr∗ OR acupressure OR “body scan” OR “autogenic training” OR self-careOR self-awareness OR self-management OR Reiki OR massage OR “therapeutic touch” OR holistic OR wholistic OR prayerOR writing OR “movement therapy” OR “dance therapy” OR “narrative medicine” OR self-acupuncture OR qigong OR chiOR qi OR “spiritual healing” OR meditat∗ OR “mental training” OR self-hypnosis OR relax∗ OR EMDR)
Box 1: Search terms used according to MeSH strategy.
Records identified through database searching andother resources (n = 11977)
Records after duplicates removed(n = 11014)
Records screened for inclusion atlevel 1 (n = 11014)
Full-text articles screened foreligibility at level 2 (n = 1591)
Articles included in the review(n = 283) (one being cloned as itconsisted of two studies in one
so 284 reports)
Recordsexcluded
(n = 9423)
Recordsexcluded
(n = 1308)
Reasons for excludingstudies: descriptive
reviews, thoughtpieces, expert opinion,
no outcome usingemotional stress, not amultimodal trainingprogram as defined,
no CAM interventionas defined, and no self-
management skillsattained
116 RCT’s40 CCT’s0 SR/MA’s
96 observational22 descriptive
10 mixed methods
Figure 1: Flowchart of study selection process.
content and heterogeneity varied across studies, the authorsprovide a full description of the program incorporated in eachstudy in Table 3(b).
2.6. Descriptive Overview of Included High-Quality Programs
2.6.1. Mindfulness-Based Stress Reduction (MBSR). Mind-fulness-Based Stress Reduction was developed approxi-mately 30 years ago by Dr. Jon Kabat-Zinn and now hasevolved into a structured group program (http://www.umassmed.edu/cfm/stress/index.aspx). It uses meditation asa tool to cultivate conscious awareness in a nonjudgmen-tal and accepting manner. MBSR has been used to helpindividuals with stress, chronic pain, anxiety, sleep, andheadache, among others [18, 19]. The MBSR course schedulegenerally consists of eight weekly classes and one day-longretreat, including guided instruction on mindfulness medi-tation practices, gentle stretching and mindful yoga, groupdialogue and discussions aimed at enhancing awareness ineveryday life, individually tailored instruction, daily homeassignments, and home practice CDs.
2.6.2. Cognitive Behavioral StressManagement (CBSM). Cog-nitive Behavioral Stress Management is a multimodal pro-gram adapted from a variety of meditation and cognitivebehavioral strategies and has been used for more than 20years by a variety of groups. CBSM has been used tohelp individuals with coping, quality of life, psychologicalwell-being, PTSD, and HIV-related stressors [20]. CBSM isgenerally a ten-week group-based program that combinesrelaxation, imagery, and deep breathing, along with cognitivebehavior therapy, which is designed to help reduce bodilytension, intrusive stressful thoughts, and negative moods andimprove interpersonal communication skills [21].
2.6.3. Autogenic Training (AT). Autogenic Training wasdeveloped by the German psychiatrist Johannes Schultz in1932. The goal of AT is to achieve deep relaxation andreduce stress by teaching the body to respond to verbalcommands “telling” it to relax and control breathing, bloodpressure, heartbeat, and body temperature [22]. It includesstandardized self-suggestion exercises to make the body feelwarm, heavy, and relaxed [23–26].
Evidence-Based Complementary and Alternative Medicine 5
Table 1: Modified SIGN 50 checklist for RCT study design [17].
(a) Section 1: internal validity∗
Item Description1.1 The study addresses appropriate and clearly focused question.1.2 The assignment of subjects to treatment groups is randomized.1.5 The treatment and control groups are similar at the start of the trial.1.7 All relevant outcomes are measured in a standard, valid and reliable way.1.8 What percentage of subjects in each treatment arm dropped out before the study was completed?1.9 All subjects are analyzed in the groups to which they were randomly allocated (intention to treat analysis).1.10 Where the study is carried out at more than one site, results are comparable for all sites.Each item in Section 1 is to be evaluated using these criteria: well covered; adequately addressed; poorly addressed; and not applicable (NA) only forquestion 1.10.∗Note that 1.3, 1.4, and 1.6 SIGN criteria were omitted from our modified version of the SIGN as they did not apply to our research question/population:as there were wide differences in the types of programs assessed. Note that all criteria were weighted according to a revised SIGN quality score as reflectedbelow consistently.
(b) Section 2: overall assessment
How well was the study done to minimize bias? How valid is the study? Score options: ++, +, and − based on the following(modifications to SIGN criteria in italics).
++ All or most of the criteria have been fulfilled. Where they have not been fulfilled, the conclusions of the study are thought“very unlikely” to alter. An article receives this score if there are 0 criteria scored as poorly addressed.
+ Some of the criteria have been fulfilled. Those criteria that have not been fulfilled or not adequately described are thought“unlikely” to alter the conclusions. An article receives this score if 1-2 criteria are scored poorly addressed.
−
Few or no criteria fulfilled. The conclusions of the study are thought “likely or very likely” to alter. An article receives thisscore if more than 2 criteria are scored as poorly addressed.
SIGN 50 network: a guideline developer’s handbook http://www.sign.ac.uk/guidelines/fulltext/50/checklist2.html.
Table 2: Randomized controlled trials (𝑛 = 116) by SIGN score and significance level∗.
SIGN quality rating ++ + − ++ + −
TotalSignificance level∗ 𝑃 < 0.05 𝑃 > 0.05
Mindfulness-Based Stress Reduction (MBSR) 3 4 3 0 2 1 13Cognitive Behavioral Stress Management (CBSM) 2 6 5 0 1 0 14Autogenic Training (AT) 0 3 4 1 1 1 10Relaxation Response Training (RRT) 0 2 1 0 1 1 5Yoga + Similar Meditation Techniques 0 3 8 1 2 1 15Relaxation + Similar Mind-Body Techniques 24 0 4 6 45(1) Cognitive-Behavioral Therapy-Based Programs 1 3(2) Stress-Management Training Programs (SMTP) 0 3(3) Guided Imagery and/or Relaxation, and Breathing Techniques 1 3Coping Skills Training (CST) 0 0 3 0 0 0 3Anxiety Management Training (AMT) 0 0 4 0 0 0 4Stress Inoculation Training (SIT) 0 0 7 0 0 0 7Totals 7 27 59 2 11 10 116∗On stress-related outcomes with keywords: stress, anxiety, post-traumatic stress disorder, coping, resilience, hardiness, burnout, distress, or relaxation.
2.6.4. Relaxation Response Training (RRT). RelaxationResponse Training is a stress-management approach firstpublished in 1974 by the cardiologist Benson et al. [27].Benson found that meditation was related to general reversalof the sympathetic activation that produces the “stressresponse” (i.e., decreased oxygen consumption, carbondioxide production, respiratory rate, and minute ventilation)
[28]. RRT was originally based on transcendental meditationbut differentiated into its own technique using the followingfour elements to elicit the relaxation response: (1) a mentaldevice (e.g., a sound, word, or phrase repeated silently oraudibly to free one’s self from logical, externally orientedthought); (2) a passive attitude (e.g., not worrying abouthow well one is performing the technique); (3) a decreased
6 Evidence-Based Complementary and Alternative Medicine
muscle tonus (e.g., comfortable, relaxed posture); and (4)a quiet environment with minimal environmental stimuli(e.g., a place of worship) [29].
2.6.5. Yoga + Similar Meditation-Based Skills. This miscel-laneous category included studies that were not “namedprograms” and did not fit into any of the previously charac-terized categories and so were compiled together as a single,distinct category. These interventions met the inclusioncriteria as programs that incorporated at least one yoga-basedor meditation-based element as primary intervention. SeeTable 3(b) for a more complete description of each of theseprograms.
2.6.6. Relaxation + Similar Mind-Body Skills. Another mis-cellaneous category also included studies of programs thatdid not fit into any of the previously named categories.These incorporated at least one relaxation technique (such asprogressive muscle relaxation) combined with other modal-ities such as breathing, guided imagery, and/or Cognitive-Behavioral Therapy (CBT). While all of these studies hadin common that they integrated at least one relaxationtechnique, for ease of discussion, the authors have groupedthem into three subcategories: those that were based ona CBT model, those that were characterized as “Stress-Management Training Programs,” and those that combinedrelaxation with either guided imagery or breathing tech-niques. Cognitive-behavioral therapy is a well-establishedand effective psychotherapy approach for conditions suchas anxiety and depression [62, 63], which assist individ-uals to recognize distorted thoughts, devise strategies toreframe them, and change resultant reactions and behaviors(http://www.nacbt.org/). An example of a CBT programthat incorporates a relaxation component includes sessionson understanding the nature of stress and stress reac-tions, breathing and/or relaxation techniques, and cognitiverestructuring techniques (i.e., self-talk skills to use in stressfulsituations) [51].
Stress-Management Training Programs (SMTPs) incor-porate a number of skills and techniques to assist individualsto attenuate their physiological and psychological reactivityto stressful situations, including problem-solving, assertive-ness training, and coping skills with various relaxation tech-niques, such as breathing and Progressive Muscle Relaxation(PMR). In this review, a program was tagged as “SMTP” onlyif the intervention was described using this term.
Guided imagery (GI) is a relaxation technique thatfocuses on and directs the imagination to produce thera-peutic change (http://www.healthjourneys.com/) and can beadministered by a trained practitioner leading an individualor group session or delivered as a recording. GI frequentlyincludes suggestions for breathing and relaxation, followedby a purposeful directing of the imaginal mind to recreatea relaxing scene with sensory recruitment to enhance amultisensory experience. See Table 3(b) for a more completedescription of these programs.
2.7. Results of the High-Quality Studies Included. Of the 13MBSR studies included, seven high-quality reports (3++ and4+) were found to produce statistically significant effects onoutcomes of distress in 63 rheumatoid arthritis patients [30];perceived stress in 47 undergraduate students [33]; anxietyand perceived stress in 109 cancer patients [34]; anxiety anddistress in 78 premedical students [32]; anxiety in 20 heartdisease patients [31]; distress in 104 premedical students [25];and distress and perceived stress in 103 volunteers with highlevels of perceived stress [26].
Of the 14 CBSM studies included, eight high-qualityreports (2++ and 6+) were found to demonstrate statisticallysignificant effects on outcomes of coping in 387 HIV patients[35]; everyday life stress in 198 heart disease patients [36];anxiety in 104 HIV patients [37]; anxiety in 37 third semestereconomic students [38]; perceived stress in 48 universitystudents [39]; coping and relaxation in 199 breast cancerpatients [40]; anxiety in 199 breast cancer patients [41]; andcoping in 52 HIV patients [42].
Of the 10 AT studies included, three high-quality reports(3+) were found to yield statistically significant effects onoutcomes of anxiety in 93 nursing students with anxiety [44];anxiety in 100 acute myocardial infarction or coronary arterybypass surgery patients [43]; and distress in 56 patients withchronic tension headache [45]. This final study included acombination program consisting of AT and self-hypnosis[45].
Of the five studies on RRT included, two high-qualityreports (2+) were found to have statistically significant out-comes of psychological distress in 128 healthy undergraduateand graduate students (a program involving RRT and CBTtraining) [46] and distress in 80 patients with psychosomaticcomplaints [47].
Included in the yoga or meditation-based category werethree high-quality reports (3+) that were statistically signifi-cant onmeasured outcomes of the study’s reports.These threestudies consisted of yoga, meditation and relaxation, breath-ing or imagery, or a combination of all, which measuredperceived stress in 259 participants who had experienced ahurtful interpersonal experience from which they still feltnegative emotional consequence [48] and two studies onwomenwith breast cancer thatwere statistically significant onoutcomes of trait anxiety stress plus state anxiety according toSTAI (𝑛 = 34) [49] and an integrated yoga program (𝑛 = 98)[50].
In this relaxation-based category, 35 of 45 studies reportedstatistically significant differences in stress-related outcomes;11 (24%) were classified as high quality (++ or +). Fourstudies examined CBT-based programs that incorporatedrelaxation techniques. In a study of 108 patients with severemental illness and PTSD, an eight-session CBT programwithbreathing techniques resulted in significant improvementsin trauma-related cognitions, anxiety, and PTSD symptoms[51]. In another study of 31 chronic schizophrenic inpatients,a 12-hour CBT program with breathing exercises resultedin significant reductions in work-related stress [53]. In athird study, a 60-hour CBT program with qi gong (a medi-tative breathing technique) and relaxation exercises resulted
Evidence-Based Complementary and Alternative Medicine 7
Table3:Ch
aracteris
ticso
fincludedstu
dies
with
high
quality
andsta
tistic
allysig
nificantresultsbetweengrou
pson
stress-related
outcom
es.
(a)Nam
edprograms
Citatio
nPo
pulatio
nInterventio
n/control
Num
bera
ssigned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(between
grou
pdifferences)
Con
clusio
nsQuality
Mindfulness-Based
StressRe
duction(M
BSR)
Pradhanetal.,2007
[30]
63malea
ndfemale
rheumatoidarthritis
patie
nts
Meanage:54
MBS
R/WLC
T31
(7%)/C32
(7%)(a)
2.5h×8w
(20h
+on
e-day
retre
at+
homew
ork)
SCL-90
(revise
d):
psycho
logicald
istress
(𝐹=4.02,56df,𝑃=0.04)at
6mon
ths(d)
Sign
ificant
improvem
entin
psycho
logicald
istressand35%
redu
ctionin
psycho
logicald
istress
amon
gthosetreated
++
Taconetal.,2003
[31]
20wom
enwith
heart
disease
Meanage:T57.3,C
63.6
MBS
R/WLC
T10/C
10;
drop
outs:
10%in
each
grou
p(b)
2h×8w
(16h
+ho
mew
ork
+retre
at)
STAI(statea
nxiety):
F(1,16)
D6.79,𝑃<0.01(d)
Sign
ificant
differences
betweenthe
treatmentand
controlgroup
son
scores
ofanxiety,em
otional
control,andreactiv
ecop
ingin
wom
endiagno
sedwith
heart
disease
+
Shapiro
etal.,1998
[32]
78male/femalem
edical
studentse
xperiencing
stress
Meanage:ND
MBS
R/WLC
T37
(3%)/C41
(9.8%)(b)
2.5h×7w
(17.5
+ho
mew
ork)
SCL-90
(revise
d):
psycho
logicald
istressand
GSI
(𝑃<0.02)a
ndST
AI
anxiety(𝑃<0.05)(d)
Sign
ificantlyredu
cedself-repo
rted
statea
ndtraitanx
ietyandredu
ced
repo
rtso
foverallpsycho
logical
distressinclu
ding
depressio
n,at
term
inationof
interventio
n
+
Oman
etal.,2
008[33]
47un
dergradu
ate
students
Meanage:18–24
MBS
Rcond
ensed/Ea
swaran’s
8-po
intp
rogram
EPP/WLC
MBS
R16
and
EPP16/C
15;7%
totald
ropo
ut(a)
1.5h×8w
(12h
)PS
S:(𝑃<0.05,C
ohen’sd=
0.45)
Sign
ificant
larger
decreasesin
perceivedstr
essinthetreatment
grou
pcomparedto
control,
implying
thatmeditatio
n-based
stressm
anagem
entp
ractices
redu
cestr
essa
mon
gun
dergradu
ates
++
Specae
tal.,2000
[34]
109male/femalec
ancer
outpatientsw
ithvario
usstages
ofdisease
Meanage:T54.9,
C48.9
MBS
Rcond
ensed/WLC
T61
(13%
)/C48
(23%
)(b)
1.5h×7w
(10.5+
homew
ork)
POMS(anx
iety):𝑃<0.001
intre
atmentg
roup
from
time1
totim
e2and
𝑃<0.001betweenthetwo
grou
ps;totalstr
essscore
(t(88)
5–22.80,𝑃<0.01)(d)
Sign
ificant
decreasesinmoo
ddistu
rbance
andstresssymptom
sin
both
malea
ndfemalep
atientsw
ithaw
idev
arietyof
cancer
diagno
ses,
stageso
filln
ess,andages
++
Jain
etal.,2007
[25]
104male/femalem
edical
students,graduate
nursingstu
dents,and
undergradu
ates
tudents
Meanage:25
MBS
Rcond
ensed
(MM)/str
ess
redu
ction
(SR)/con
trolgroup
ND;dropo
uts:
23%,23
participants
(6MM,11S
R,and6controls)
(a)
1.5h×4(6
h+ho
mew
ork
+retre
at)
BSI:distr
essfor
MM
andSR
versus
controlgroup
(𝑃<0.05in
allcases).Eff
ect
sizes
ford
istresswerelarge
forb
othmeditatio
nand
relaxatio
n(C
ohen’sd=1.3
6and0.91,resp.)
Both
MM
andSR
aree
ffectivein
redu
cing
negativ
epsychological
states
andenhancingpo
sitives
tates
ofmindforstudentse
xperiencing
significantd
istress.Th
erew
eren
osig
nificantd
ifferencesb
etween
meditatio
nandrelaxatio
non
distr
esso
vertim
e
+
8 Evidence-Based Complementary and Alternative Medicine
(a)Con
tinued.
Citatio
nPo
pulatio
nInterventio
n/control
Num
bera
ssigned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(between
grou
pdifferences)
Con
clusio
nsQuality
Williamse
tal.,2001
[26]
103male/female
commun
ityvolunteers
with
high
perceived
stress
Meanage:49.2
MBS
Rmod
ified/group
given
educationalm
aterials
onstr
essm
anagem
ent
andreferralto
commun
ityresources
T59
(45%
)/C44
(41%
)(a)
2.5h×8w
(20h
+on
e-day
retre
at)
DSI,SCL
90-R
(GSI).GSI
(betweengrou
panalysis):
postinterventio
nwas
borderlin
esignificant
(𝑃=0.057)a
ndbecame
significantat3-m
onth
follo
wup
(𝑃=0.049)(d)
Sign
ificant
redu
ctions
inperceived
stressa
ndpsycho
logicald
istress
foun
dbo
thbetweengrou
psand
with
intre
atmentg
roup
from
pre-
topo
stintervention
+
Cognitiv
eBehavioralStre
ssManagem
ent(CB
SM)
McC
ainetal.,2008
[35]
387male/femaleH
IV+
individu
als
Meanage:42.2
Cognitiv
ebehavioral
relaxatio
ntraining
(RLX
N)/focusedTai
chitraining
(TCH
I)/spiritual
grow
thgrou
p(SPR
T)/W
LC
Unclear
(overalldrop
out
rate35%)(a)
1.5h×10w
(15h
+ho
mew
ork)
Cop
ingsubscaleof
theD
IS:
𝑃<0.030for
emotion-focusedcoping
;the
RLXN
andTC
HItreatment
grou
psshow
edsig
nificant
totaltreatmenteffectso
ver
thec
ontro
l(d)
Incomparis
onto
WLC
,both
RLXN
andTC
HIg
roup
sless
frequ
ently
used
emotion-focused
coping
strategies.G
enerally,
decreasedem
otion-focusedcoping
canbe
considered
anenhancem
ent
incoping
strategies;how
ever,there
was
noconcurrent
increase
inprob
lem-fo
cusedor
appraisal-focused
coping
,making
interpretatio
nof
thischange
more
tenu
ous
++
Claesson
etal.,2005
[36]
198isc
hemicheart
diseasew
omen
Meanage:T59,C
62CB
SM/usualcare
T101(20.8%)/C
97(11.3
%)(a)
2h×20
(40h
)
ELSS:group
bytim
einteractioneffectfrom
baselin
etofollo
wup
𝑃=0.006(d)
A1-y
earC
BSM
program
desig
ned
specifically
forw
omen
significantly
improved
psycho
logicalw
ell-b
eing
insomea
spectsin
comparis
onto
usualcare
++
Berger
etal.,2008
[37]
104male/female
HIV-in
fected
person
sMeanage:44
CBSM
/stand
ardcare
T53
(34%
)/C51
(18%
)(a)
2h×12w
(24h
+ho
mew
ork)
HADS(anx
iety):changes
from
baselin
eto12
weeks
betweengrou
ps(−2.4
(−4.0–−0.9)𝑃=0.003)
Effectsize:𝑑=0.52for
CBSM
baselin
eto12
mon
ths
onHADSanxiety
CBSM
training
ofHIV-in
fected
person
stakingcA
RTdo
esno
tim
provec
linicalou
tcom
ebut
has
lasting
effectson
quality
oflifea
ndpsycho
logicalw
ell-being
+
Gaabetal.,2006
[38]
37healthy3rdsemester
econ
omicsstudents
Meanage:ND
CBSM
/con
troln
otspecified
4grou
psof
8–10
subjects.
(CBS
Mgrou
ps1and
2:𝑁=18,con
trol
grou
ps3and4:
𝑁=19);
drop
outs:
T28%/C
22%(b)
6h×2d
(12h
+ho
mew
ork)
MES
A:betweengrou
psF
(6,19)
=1.3
0,𝑃=0.3,STA
I(tr
ait)CB
SM=ST
AI(state)
F(2.06/53.59)
Z3.84,
𝑃=0.03.E
ffectsiz
e:state
anxiety𝑓
2
=0.32
CBSM
preventsincreasesin
anxietyandsomaticsymptom
spriortoan
upcomingstr
essora
ndinflu
encesthe
abilityto
exerta
cortiso
lrespo
nsec
orrespon
ding
tothes
ubjectives
tressappraisal
+
Evidence-Based Complementary and Alternative Medicine 9
(a)Con
tinued.
Citatio
nPo
pulatio
nInterventio
n/control
Num
bera
ssigned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(between
grou
pdifferences)
Con
clusio
nsQuality
Gaabetal.,2003
[39]
48males
tudents
Meanage:T24.2,C
24.5
CBSM
/WLC
T24
(unclear)/C
24(unclear)(a)
6h×2d
(12h
+ho
mew
ork)
PSS:grou
pby
time
interactioneffectfrom
baselin
etopo
sttreatment
(t35
=2.57,𝑃<0.02):F
(1/46)
=5.27,𝑃=0.026,
effectsize𝑓2
=0.11
Short,grou
p-based,Cognitiv
eBe
havioralStressManagem
ent
training
redu
cesthe
salivaryfre
ecortiso
lstre
ssrespon
seto
anacute
stressorinhealthymales
ubjects
with
treatmentg
roup
show
inga
redu
ctionin
thelevelof
perceived
stressp
osttreatm
ent
+
Anton
ietal.,2006
[40]
199femaleb
reastcancer
patients(stageIIIor
less)
Meanage:50
CBSM
and
relaxatio
n/cond
ensed
educational
interventio
nor
social
supp
ort
T92
(22%
)/C107
(19%)(b)
2h×10w
(20h
+ho
mew
ork)
MCO
S:betweengrou
pschangesfrom
baselin
eto10
weeksfor
relaxatio
n(𝑃=0.001)a
ndcoping
(𝑃=0.06).Eff
ectsize
Coh
en’sdMCO
Srelaxatio
n=0.86,cop
ing𝑑=0.04
Theinterventionincreased
confi
denceinbeingableto
relaxat
will.Th
erew
asalso
evidence
that
effectsof
theinterventionon
the
vario
usou
tcom
esexam
ined
were
mediatedby
change
inconfi
dence
abou
tbeing
ableto
relax
+
Anton
ietal.,2006
[41]
199female
nonm
etastatic
breast
cancer
patie
ntsa
tstage
IIIo
rbelo
wandsurgery
with
inthep
ast8
weeks
Meanage:50
CBSM
and
relaxatio
n/cond
ensed
educational
interventio
n
T92
(19.5%)/C
107(22.4%
)(b)
2h×10w
(20h
+1-y
ear
follo
wup
)
HADS(anx
iety):Group
effecto
nslo
pe:𝑧=2.71,
𝑃<0.003;C
ohen’sd=0.74.
Affectbalances
cale
(distress):grou
peffecto
nslo
pe:𝑧=2.48,𝑃<0.02;
Coh
en’sd=0.33.G
roup
sdiffera
ttim
e3(𝑧=2.63,
𝑃<0.01;C
ohen’s𝑑=0.43)
Structured,group
-based
cogn
itive
behavior
stressm
anagem
entm
ayam
elioratecancer-related
anxiety
durin
gactiv
emedicaltre
atmentfor
breastcancer
andfor1
year
follo
wingtre
atment
+
Lutgendo
rfetal.,1998
[42]
52HIV
+males
Meanage:36.75
CBSM
and
relaxatio
n/WLC
with
one-daydidacticand
experie
ntialstre
ssmanagem
entp
rogram
T26
(19%)/C26
(30%
)(b)
135m×10w
(22.5h
+ho
mew
ork)
COPE
(60-item
scale)for
coping
:(𝑃<0.05)(d)
Sign
ificantlygreaterimprovem
ent
inactiv
ecop
ingthan
controls.
Group
-based
CBT+
stress
managem
entsignificantly
attenu
ated
anxietyin
HIV-positive
men
+
AutogenicT
raining(AT)
Trzcieniecka-G
reen
andSteptoe,1996
[43]
87men
and13
wom
enadmitted
toho
spita
lsfor
acutem
yocardial
infarctio
n(W
HO
criteria
)orc
oron
ary
artery
bypasssurgery
Meanage:<70
Autogenic
Training
/WLC
T50
(ND)/C50
(ND)(c)
10sessions
(ND)
HAD(anx
iety):grou
pby
timeinteractio
ns𝑃<0.01,
andatfollo
wup𝑃<0.05(d)
Sign
ificant
redu
ctions
inanxietyin
treatmentg
roup
.Stre
ssmanagem
enttrainingmay
lead
toim
provem
entsin
theq
ualityof
life
ofmyocardialinfarctionand
coronary
artery
bypasspatie
nts
+
10 Evidence-Based Complementary and Alternative Medicine
(a)Con
tinued.
Citatio
nPo
pulatio
nInterventio
n/control
Num
bera
ssigned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(between
grou
pdifferences)
Con
clusio
nsQuality
Kanjietal.,2006
[44]
93male/femalen
ursin
gstu
dents
Age
range:19–4
9
Autogenic
Training
/atte
ntion
controlu
singlau
ghter
therapy/tim
econ
trol
with
notre
atment
T32
(34%
)/attention
control30
(20%
)/tim
econtrol31(16%)
(a)
1h×8w
(8h
+ho
mew
ork)
STAI:sta
teanxietybetween
treatmentand
timec
ontro
l(𝑃<0.001)b
etween
treatmentg
roup
and
attentioncontrol
(𝑃<0.005),andbetweenthe
twocontrolgroup
s(𝑃<0.595).Traitanx
iety
betweenthetreatmentand
timec
ontro
lgroup
s(𝑃<0.001)a
ndbetweenthe
treatmentg
roup
andthe
attentioncontrolgroup
(𝑃<0.084)(d)
AutogenicT
rainingissig
nificantly
moree
ffectiveinredu
ctionof
state
andtraitanx
ietie
sthanin
both
otherg
roup
simmediatelyaft
ertre
atment
+
Spinho
venetal.,1992
[45]
56male/femalep
atients
with
tensionheadache
Meanage:36
AutogenicT
raining
andself-hypn
osis
(SH)/WLC
ND(b)
45m×4(3h
+ho
mew
ork
+3bo
osters)
SCL90:psychological
distr
ess𝑃<0.01at
posttreatmentand
levelof
psycho
logicald
istressin
contrastto
thew
aitin
g-list
perio
d(𝑃<0.05).Fo
llow-up
measurementsindicatedthat
therapeutic
improvem
ent
was
maintained(𝑃<0.05).
CSQ:𝑃=0.003at
posttreatment(d)
Patie
ntstreated
with
ATor
SHtraining
achieved
mod
erate
redu
ctions
inpsycho
logicaldistress
andshow
edsta
tistic
allysig
nificant
redu
ctions
indistresscomparedto
WLC
+
Evidence-Based Complementary and Alternative Medicine 11(a)Con
tinued.
Citatio
nPo
pulatio
nInterventio
n/control
Num
bera
ssigned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(between
grou
pdifferences)
Con
clusio
nsQuality
Relaxatio
nRe
spon
seTraining
(RRT
)
Deckroetal.,2002
[46]
51men
and77
wom
enstu
dents
Meanage:24
Relaxatio
nRe
spon
seandCB
TTraining
/WLC
T63
(13%
)/C65
(16%
)(b)
1.5h×6(9
h+ho
mew
ork)
GSI
(SCL
-90-R)
(psychologicaldistress);
betweengrou
panalysisfro
mbaselin
etopo
stintervention:
(𝑃=0.018).PS
S:with
ingrou
panalysis:
pre-po
stscores
forintervention
versus
controlgroup
(𝑃=0.008);ST
AIstate
anxiety(𝑃=0.001)(d)
A6-weekRR
andCB
Ttraining
program
significantly
redu
ceself-repo
rted
psycho
logical
distress,anx
iety,and
the
perceptio
nof
stress
+
Hellm
anetal.,1990
[47]
80male/femalep
atients
with
psycho
somatic
complaints
Meanage:37
Relaxatio
nRe
spon
seTraining
/stre
ssmanagem
ent
inform
ationgrou
p
Waystowellness
28/m
ind/bo
dyprogram
27/stre
ssmanagem
ent
info.group
25;
11%total
drop
outs(b)
WTW
and
MBP
:1.5h×
6w(9
h+
homew
ork),
SMG:1.5h×
2(3h)
B-PO
MS:betweengrou
psanalysis-psycho
logical
distr
essfor
both
WTW
and
MBgrou
ps(𝑡=4.02,
𝑃<0.01),ad
eclin
ethatw
assig
nificantly
greaterthanthat
forthe
inform
ationgrou
p(𝑃<0.05)(d)
Atthe6
-mon
thfollo
wup
,patients
intheb
ehavioralm
edicineg
roup
sshow
edsig
nificantly
greater
redu
ctions
invisitstotheH
MO
andin
discom
fortfro
mph
ysical
andpsycho
logicalsym
ptom
sthan
didthep
atientsintheinformation
grou
p
+
(b)Unn
amed
programs
Citatio
nPo
pulatio
nInterventio
n/controlDescriptio
nof
program
Num
ber
assig
ned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(betweengrou
pdifferences)
Con
clusio
nsQuality
Yoga
+SimilarM
editatio
n-Ba
sedSkills
Harris
etal.,
2006
[48]
259male/female
participants
who
had
experie
nced
ahu
rtful
interpersonal
experie
ncefrom
which
they
still
feltnegativ
eem
otional
consequences
Meanage:41.8
Meditatio
nand
imagery/no
treatmentcon
trol
Com
binatio
nof
cogn
itive
restructuring
positivea
ndnegativ
evisu
alizations
and
heart-focused
meditatio
ntechniqu
es.
Timew
asdevotedto
educationabou
tthe
negativ
ehealth
consequences
ofgrud
ge-holding
andun
forgiveness,
cogn
itive
restructuring,and
meditatio
ns/rela
xatio
nexercises.
Exercisesu
sedin
thetrainingwere
principally
tailo
redto
instillandcultivate
amorer
elaxed
state,to
redu
cearou
sal
durin
gther
ecollectionof
interpersonal
grievances,and
toim
provep
artic
ipants’
abilityto
regu
lateem
otions
byconsciou
slyshiftingattentionbetween
negativ
eand
moren
eutralor
positive
thinking
andfeeling
states
T134
(14%)/C125
(18%
)(b)
1.5h×6w
(9h)
PSSperceivedstr
ess
(𝑃<0.001).Eff
ect
size:Coh
en’sDfor
PSS0.66
atpo
sttest
and0.54
atfollo
wup
Sign
ificant
treatment
effectswerefou
ndfor
forgiveness
self-effi
cacy,
forgiveness
generalized
tonew
situatio
ns,and
perceivedstr
ess
+
12 Evidence-Based Complementary and Alternative Medicine
(b)Con
tinued.
Citatio
nPo
pulatio
nInterventio
n/controlDescriptio
nof
program
Num
ber
assig
ned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(betweengrou
pdifferences)
Con
clusio
nsQuality
Nun
esetal.,
2007
[49]
34femaleb
reast
cancer
patie
nts
Meanage:T
54.2,C
50.07
Meditatio
n,relaxatio
n,breathing,and
imagery:relaxatio
nandvisualtherapy
(RVT)/no
interventio
n
Relaxatio
nandvisualizationtherapy
(RVT)
interventio
ninclu
desa
relaxatio
nperio
d(20m
in),in
which
thes
ubjectis
indu
cedto
mentally
createan
imageo
fthed
esire
dob
jectiveo
rresult,inclu
ding
progressivem
uscle
relaxatio
n,guided
imagery,meditatio
n,anddeep
breathing.
Subjectswereg
uidedto
createam
ental
imageinwhich
theirtum
orisattacked
bytheirimmun
esystem
andthen
tovisualizethe
breastcompletely
healed
T20/C
14(0%)(b)
0.5h×24
(12h
+ho
mew
ork)
ISSL,STA
I:with
ingrou
ps(pre-v
ersus
poste
xperim
ental
grou
p):ISSLQ1
𝑃<0.01,Q
2𝑃<0.05,Q
3𝑃<0.001.STA
I(state)𝑃<0.05,trait
𝑃<0.001.Th
epsycho
logicalscores
didno
tchangeo
ver
timeinthec
ontro
lgrou
p(all𝑃>0.05).
Effectsizes:SSL
Q1
.72ISSL
Q2.64ISSL
Q3.70ST
AI(State)
.52ST
AI(Trait).79
RVTiseffectiv
efor
redu
cing
stress,
anxiety,and
depressio
nscores
and
may
improvethe
quality
oflifeo
fcancer
patie
nts
undergoing
radiotherapy
+
Ragh
avendra
etal.,2007
[50]
98femaleb
reast
cancer
outpatients
Meanage:ND
Yoga,breath-
ing/psycho
dynamic
supp
ortiv
e-expressiv
etherapy
with
coping
preparation
Yoga
interventio
nconsisted
ofas
etof
asanas
(posturesd
onew
ithaw
areness),
breathingexercises,pranayam
a(volun
tarilyregu
lated
nostril
breathing),
meditatio
n,andyogicr
elaxation
techniqu
eswith
imagery.Th
esep
ractices
wereb
ased
onprinciples
ofattention
diversion,
mindful
awareness,and
relaxatio
nto
cope
with
day-to-day
stressfulexp
eriences.Th
efirstsessio
nconsisted
ofyogicr
elaxatio
n,meditatio
nusingbreath
awareness,andim
pulse
sof
touchem
anatingfro
mpalm
sand
fingers
orchantin
gamantrafrom
aVedictextfor
30min.Sub
jectsinthey
ogag
roup
were
provided
with
audioandvideocassettes
ofthey
ogam
odules
forh
omep
ractice;
theseh
omes
essio
nssta
rted
with
afew
easy
yoga
postu
res,breathingexercises
andpranayam
a(voluntarily
regu
lated
nostril
breathing),and
yogicr
elaxation
T28/C
34l
(37%
)(b)
YR30
m(.5
h+
homew
ork)
Cou
nseling
1h;
control.5h
STAIstateanxiety
score:between
grou
psanalysis
𝑃<0.001.
Subjectiv
equ
estio
nnaires:
numbero
fdistr
essfu
lsymptom
s𝑃=0.002;sym
ptom
distr
ess:𝑃<0.002
(d)
Therew
asa
significantd
ecreasein
reactiv
eanx
ietysta
tes,
depressio
n,nu
mber
oftre
atment-r
elated
distr
essfu
lsym
ptom
s,severityof
symptom
sanddistr
ess
experie
nced,and
improvem
entin
quality
oflifed
uring
chem
otherapy
inthe
yoga
grou
pas
comparedwith
control
+
Evidence-Based Complementary and Alternative Medicine 13
(b)Con
tinued.
Citatio
nPo
pulatio
nInterventio
n/controlDescriptio
nof
program
Num
ber
assig
ned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(betweengrou
pdifferences)
Con
clusio
nsQuality
Relaxatio
n+SimilarM
ind-Bo
dySkills
Muesere
tal.,
2008
[51]
108severe
mentalilln
ess
male/female
patie
nts
Meanage:44
.21
CBTand
breathing/TA
Uwith
supp
ortiv
ecoun
selin
gas
needed
CBTprogram
forP
TSDinclu
ded8
mod
ules:introdu
ction,
crisisp
lanreview
,psycho
education(sym
ptom
sofP
TSD),
breathingretraining
,psycho-education
(associatedsymptom
sofP
TSD),
cogn
itive
restructuring(com
mon
styles
ofthinking
),cogn
itive
restructuringII
(5ste
psof
cogn
itive
restructuring),
generalizationtraining
,and
term
ination
CBT
program
54(20%
)/tre
at-
mentas
usual(TA
U)
program
54(0%)(a)
ND
PTCI
,BAI,CA
PS:
betweengrou
psanalysisCB
Tversus
TAU(baseline
versus
postintervention):
PTCI𝑃<0.001;
BAI𝑃<0.03,C
APS
Dx𝑃=0.63,C
APS
Dx(>65)𝑃=0.02,
CAPS
Dx(<65)
𝑃=0.18
.Posth
ocanalysis:
subsetwith
severe
PTSD
(CAPS
>65).Eff
ectsizes
for
both
CAPS
-total
increased,fro
m.45
to.59andin
CAPS
-diagn
osis
from
.27to
.40.
Subsetwith
mild
-mod
erate
PTSD
(CAPS<65)
Thee
ffectsiz
esdecreasedto
.12and
.10,respectively
Find
ings
suggestthat
clientswith
severe
mentalilln
essa
ndPT
SDcanbenefit
from
CBTand
breathing,despite
severe
symptom
s,suicidalthinking
,psycho
sis,and
vulnerabilityto
hospita
lizations
++
Heidenetal.,
2007
[52]
75male/female
patie
ntso
nsic
kleavefor
atleast
50%of
thetim
eforstre
ss-rela
ted
diagno
ses
Meanage:44
CBTandrelaxatio
ntechniqu
es/physic
alactiv
ity/usualcare
Cognitiv
einterventionfocusedon
education,
qigong
andrelaxatio
ntechniqu
es,cop
ingskills,andstr
ess
managem
entexercise
s.Participantsin
the
physicalactiv
itygrou
pwereo
ffered
exercise
sessions.Partic
ipantschosea
nexercise
(e.g.,streng
thtraining
,sw
imming,aerobics,orw
alking
)in
consultatio
nwith
theg
roup
leader.
Duringtheintervention,
each
participant
kept
adiary
oftheirp
hysic
alexercise
CBT28
(28%
)/ph
ys.
23(4.3%)/con-
trol24
(8.3%)(a)
3h×2×10
w(60h
+ho
mew
ork)
BQ:betweengrou
ps(F
(2,61)=3.9,
𝑃=0.024).By
6mon
thsthe
differences
weren
otsig
nificant𝑃=0.062
(d)
CBTgrou
predu
ced
theirb
urn-ou
tratings
comparedwith
the
controlgroup
bythe
endof
the
interventio
n.At
follo
wup
,these
differences
faded
+
14 Evidence-Based Complementary and Alternative Medicine
(b)Con
tinued.
Citatio
nPo
pulatio
nInterventio
n/controlDescriptio
nof
program
Num
ber
assig
ned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(betweengrou
pdifferences)
Con
clusio
nsQuality
Leee
tal.,2006
[53]
31male/female
patie
ntsw
ithchronic
schizoph
renia
who
engagedin
level4
or5of
thec
enter’s
part
timep
aidjob
program
Meanage:34.9
CBTand
breathing/WLC
Thew
ork-relatedstr
essm
anagem
ent
program
inclu
dedshortlectureso
nthe
influ
enceso
fstre
sson
cogn
ition
,em
otion,
andbehavior;instructio
nin
the
techniqu
esof
hand
lingnegativ
eemotions
andstr
ess(e.g
.,deep
breathing,str
ut(w
alking
prou
dly),and
exercise)a
ndem
otionalintelligence.Severalsessions
wered
evoted
tocommun
ication,
skills
training
,assertiv
enesstraining,and
prob
lem-solving
skillstraining.Finally,
metho
dsdealingwith
work-relatedcrise
swerep
resented
andpractic
ed
31total
Only2
drop
out
total(b)
1h×12w(12h
+ho
mew
ork)
WSQ
P:between
grou
psanalysisfro
mfirstto
second
testingperio
d(12
weeks):totalW
SQP
stressscore
𝑃=0.0039.Poo
ling
datafro
mbo
th12-w
eektre
atment
perio
ds,treatment
effectfor
thec
hange
intotalW
SQP
scores
(𝑃=0.0034).
Effectsize:𝑟=0.49
Work-relatedstr
ess
managem
entp
rogram
hadlarges
hort-te
rmpo
sitivee
ffectso
npatie
nts’perceived
work-relatedstr
ess.
Thesefi
ndings
supp
ortp
roviding
thistype
ofprogram
toem
ployed
patie
nts
with
schizoph
renia
+
Kroener-Herwig
andDenecke,
2002
[54]
85ou
tof175
who
metthe
inclu
sion
criteria
,male/female
pediatric
headache
patie
nts
Meanage:12.1
CBTandrelaxatio
n(TG)/self-help(SH)
controlgroup
follo
wingthes
ame
program
except
that
treatmentd
one
throug
htheu
seof
amanual/W
LC
Maintopics
TG:sessio
n1isa
nintro
ductionto
thetrainingas
wellas
educationabou
theadache.Session2
dedicatedto
thea
cquisitionof
progressiver
elaxationtechniqu
es.Sessio
n3intro
ducedthep
erceptionof
stress
symptom
s,ther
oleo
fstre
ssregarding
headache
andho
wto
cope
with
stress.
Session4intro
ducedthec
hildrento
the
significance
ofdysfu
nctio
naland
functio
nalcognitio
nsregardingstr
ess
andheadache.Sessio
n5explainedthe
roleof
attentionon
pain
experie
ncea
ndintro
ducedpo
sitiveimageryas
means
todistractattentionfro
mpain
andattain
arelaxedstate.In
Session6,selfassertive
behavior
was
them
aintopic.Session7
offered
amod
elforg
eneralprob
lem
solving.Session8gave
asum
maryof
all
skills.
TG30/SH
35/W
LC20
Dropo
ut:
12%(unclear
asto
which
grou
ps)(b)
1.5h×8w
(12h
)
The“coping
with
stress”subscaleof
thes
tress
questio
nnaire:T
GandSH
comparedto
WLC
overall
(𝑃=0.032)(d)
Thee
fficiencies
ofthe
twotraining
form
ats
aren
early
identic
al.
Both
grou
pssig
nificantly
redu
ced
stressa
scom
paredto
theW
LC.Th
egroup
form
at,because
ofits
bette
racceptance,is
recommendedfor
practic
aluse
+
Evidence-Based Complementary and Alternative Medicine 15
(b)Con
tinued.
Citatio
nPo
pulatio
nInterventio
n/controlDescriptio
nof
program
Num
ber
assig
ned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(betweengrou
pdifferences)
Con
clusio
nsQuality
Pruitt,
1992
[55]
81male/female
USarmy
employees
Age
range:21–6
5
SMTP
with
relaxatio
n/control
grou
pwith
delayed
classattend
ance
atthee
ndof
testing
perio
d
Thes
tressmanagem
entcou
rseinthe“
Fit
toWin”p
rogram
consisted
ofstr
ategies
involvingstr
essa
warenessa
ndprinciples
ofho
mem
anagem
ent,environm
ental
mod
ificatio
n,andassertiveness,as
wellas
multip
lemetho
dsof
relaxatio
n.Anaudio
cassetteof
relaxatio
nstr
ategiesw
asavailablefor
homep
ractice
T31/C
33;
drop
outs:
ND(b)
ND
STAI:pretestto
posttestb
etween
grou
psF(1,61)=
1.32𝑃=0.254
SCL-90:pretestto
posttestb
etween
grou
psF(1,62)
=5.21𝑃=0.026(d)
Therew
asno
statisticallysig
nificant
differenceb
etween
grou
psforstate
anxiety.Th
elackof
significance
isprim
arily
dueto
improvem
entsin
the
controlgroup
mem
bersalso
participatingin
the
overallw
ellness
program.Th
erew
asa
significanto
verall
improvem
entfor
the
combinedgrou
psin
relatio
nto
allfou
rvaria
bles
(stre
ss-rela
ted
physicalsymptom
s,perceptio
nof
anxiety,
andsysto
licand
diastolic
bloo
dpressure).Th
ereis
benefit
tothis
program
with
overall
lowcost
+
Singer
etal.,
1988
[56]
36male/female
parentso
fchild
renwith
severe
hand
icaps
Meanage:ND
SMTP
with
relaxatio
n/control
Lectures,dem
onstratio
ns,and
discussio
nfocusedon
self-mon
itorin
gof
stressa
ndph
ysiologicalreactions
tostr
ess,muscle
relaxatio
n,andrestructuring/mod
ifying
cogn
itive
disto
rtions
relatedto
stress
T18/C
18;
drop
outs:
ND(b)
2h×8w
(16h
)
STAI:analysisof
covaria
nce
(con
trolling
preintervention
scores)stateand
traitanx
ietyF(1,34)
=5.98,𝑃=0.02(d)
Thetreatmentg
roup
improved
significantly
onmeasureso
fdepressio
nand
anxiety
+
16 Evidence-Based Complementary and Alternative Medicine(b)Con
tinued.
Citatio
nPo
pulatio
nInterventio
n/controlDescriptio
nof
program
Num
ber
assig
ned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(betweengrou
pdifferences)
Con
clusio
nsQuality
deJong
and
Emmelkamp,
2000
[57]
155
males/fe
males
recruited
throug
hem
ployers
Meanage:38
SMTP
with
relaxatio
n(different
grou
psof
workers)/a
ssessm
ent
ofon
lycontrol
grou
p
TheS
MTprogram
taug
htparticipantsa
varie
tyof
activ
ecop
ingstr
ategies
coverin
gthefollowingelem
ents:
(a)
progressivem
uscle
relaxatio
n,(b)
prob
lem-solving
training
,(c)
assertivenessskills
training
,and
(d)
raising
awarenesso
find
ividualstre
ssors,
stressreactions,cop
ingsty
leor
styles
,and
(un)healthylifestyle.
Attheo
utseto
feach
session,
anou
tlinedagenda
was
provided.
Agend
asinclu
dedtheoretic
allectures,
exercises(i.e.,relaxatio
nand
prob
lem-solving
exercisesa
ndbehavioral
roleplay
with
otherg
roup
mem
bers),and
homew
orkassig
nments
SMTp
sy53
(11%
)/SM
Tpara
51(14
%)/con-
trols51
(20%
)(b)
2.5h×8w
(20h
+ho
mew
ork)
GHQforg
eneral
distr
essa
ndST
AI
(trait):
difference
betweenthe
interventio
nand
controlfor
both
measures
𝑃<0.05(d)
Results
show
favorablee
ffectso
fthe
SMTprogram
both
inthes
hortterm
andat
6-mon
thfollo
wup
.Re
sults
show
edno
serio
usdifferences
ineffectiv
enessb
etween
trainers.Itisa
rgued
that,tobe
effectiv
e,theS
MTprogram
does
notn
ecessarily
have
tobe
givenby
clinicalp
sychologists
onlybu
tmay
inste
adbe
givenby
individu
alsfrom
otherp
rofessional
orientations
+
Blum
enthal
etal.,2005
[58]
134isc
hemic
heartd
isease
(IHD)p
atients
Meanage:63
Relaxatio
nand
imagery(SM)/
exercise
only/usual
care
3keycompo
nentstostressmanagem
ent
(SM)training:educationin
which
participantswerep
rovidedinform
ation
abou
tIHDandmyocardialischemia,
structure
andfunctio
nof
theh
eart,
tradition
alris
kfactors,andem
otional
stress.Second
,patientsu
nderwentskills
training
,involving
instr
uctio
nin
specific
skillstoredu
cethea
ffective,behavioral,
cogn
itive,and
physiologicalcom
ponents
ofstress.Th
erapeutic
techniqu
esinclu
ded
graded
task
assig
nments,m
onito
ring
irrationalautom
aticthou
ghts,
and
generatin
galternativeinterpretations
ofsituatio
nsor
unrealisticthou
ghtp
atterns.
Patie
ntsinstructedin
progressivem
uscle
relaxatio
nandim
agerytechniqu
es,along
with
training
inassertiveness,prob
lem
solving,andtim
emanagem
ent.
Role-playing
also
was
used.Th
ird,group
interactionandsocialsupp
ortw
ere
encouraged
SM44
(5%)/exer-
cise
48(8%)/usual
care
42(9.5%)(a)
1.5h×16w
(24h
)
STAIg
eneral
anxiety:𝑃=0.22for
exercise
andSM
versus
usualcare
after
treatmentand
the2
4-item
GHQto
assesspsychiatric
symptom
sand
generald
istress
𝑃=0.02fore
xercise
andstr
ess
managem
entversus
usualcare(d)
Forp
atientsw
ithstableIH
D,exercise
andstr
ess
managem
enttraining
redu
cedem
otional
distr
essa
ndim
proved
markersof
cardiovascular
risk
morethanusual
medicalcare
alon
e
++
Evidence-Based Complementary and Alternative Medicine 17
(b)Con
tinued.
Citatio
nPo
pulatio
nInterventio
n/controlDescriptio
nof
program
Num
ber
assig
ned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(betweengrou
pdifferences)
Con
clusio
nsQuality
Bridge
etal.,
1988
[59]
161fem
ales
with
breastcancer
stage
IorIIa
fter
firstsessionof
six-w
eekcourse
ofradiotherapy
Meanages:R
&I
53,R
51,con
trol
54
Relaxatio
n,breathing,and
imagery/relaxatio
n/controlgroup
Both
treatmentg
roup
s(relaxatio
nand
relaxatio
nplus
imagery)
weretaughta
relaxatio
ntechniqu
ewhich
byap
rocess
ofdirectconcentrationfocusessensory
awarenesso
nas
erieso
find
ividual
muscle
grou
ps.Th
esep
atientsw
erea
lsogiveninstr
uctio
nsford
iaph
ragm
atic
breathing,which
slowsrespiratio
n,indu
cesa
calm
ersta
te,and
redu
ces
tension.
Inadditio
nto
theb
reathing
and
relaxatio
n,each
patie
ntin
ther
elaxation
plus
imagerygrou
pwas
taug
htto
imagine
apeacefulscene
ofhero
wnchoice
asa
means
ofenhancingther
elaxatio
n.
Unclear;13%
total
drop
outb
0.5h×6w
(3h
+ho
mew
ork)
Theitem
“relaxed”is
partof
thes
ubscale
fortensio
nin
the
POMS:𝑃=0.025.
TheL
eeds
general
scales
fora
nxiety
anddepressio
nshow
edno
significantchanges
over
thes
ixweeks
oftre
atment(d)
Atthee
ndof
the
study
perio
dthe
wom
entrainedin
relaxatio
nplus
imagerywerem
ore
relaxedthan
those
trainedin
relaxatio
non
ly,who
inturn
were
morer
elaxed
than
thec
ontro
ls.Patie
ntsw
ithearly
breastcancer
benefit
from
relaxatio
ntraining
+
Fuku
ietal.,
2000
[60]
50femaleb
reast
cancer
patie
nts
Meanage:T
52.6,C
54.3
Relaxatio
nand
imagery/WLC
Them
odelconsisted
ofthese
compo
nents:(1)h
ealth
education;
(2)
Cop
ingSkillsT
raining;(3)stre
ssmanagem
ent;and(4)p
sychosocial
supp
ort.In
theh
ealth
education
compo
nent,m
edicalandpsycho
logic
inform
ationspecifictobreastcarcinom
awas
presented.In
thec
opingskills
compo
nent,the
patie
ntsw
eretaughtto
utilize
thea
ctive-cogn
itive
and
activ
e-behavioralcoping
metho
dswhen
they
encoun
teredspecificp
roblem
srelatedto
having
cancer.Inthes
tress
managem
entcom
ponent,theywere
taug
htrelaxatio
nexercises,inclu
ding
progressivem
uscle
relaxatio
n(PMR)
follo
wed
bygu
ided
imagery(G
I).
Psycho
logics
uppo
rtwas
offered
bythe
staff
throug
hout
theintervention,
and
with
in-group
supp
ortw
asprovided
bythep
atientsthemselves
T25
(8%)/C
25(8%)(b)
1.5h×6w
(9h
+hom
ework)
POMS
(tension/anxiety):
𝑃=0.03(between
grou
ps),𝑃=0.15
(group×tim
ebaselin
e,6weeks,6
mos
follo
wup
)HADS(anx
iety)
𝑃=0.40between
grou
ps,𝑃=0.98
(group×tim
ebaselin
e,6weeks,6
mos
follo
wup
)(d)
Assessm
ento
fthe
effecto
npsycho
logicald
istress
indicatedas
ignificant
decrease
intotal
moo
ddistu
rbance
ontheP
OMSover
the
study
perio
d
+
18 Evidence-Based Complementary and Alternative Medicine
(b)Con
tinued.
Citatio
nPo
pulatio
nInterventio
n/controlDescriptio
nof
program
Num
ber
assig
ned
(dropo
ut%)
Totald
ose
Stressou
tcom
es(betweengrou
pdifferences)
Con
clusio
nsQuality
Deffenbacher
etal.,1979
[61]
69male/female
studentsw
hoscored
inthe
upper15%
ileon
thed
ebilitatin
gscaleo
fthe
achievem
ent
anxietyscale
Meanage:ND
Relaxatio
nand
breathinginterven-
tions/W
LC/no
treatment
expectancy
control
Relaxatio
nas
self-controlinvolving
discrim
inationtraining
,rela
xatio
ntraining
,app
licationtraining
,and
guided
practic
einrelaxatio
nprocedures.
Mod
ified
desensitizatio
ninvolved
learning
relaxatio
nas
acop
ingskill,
relaxatio
nas
self-control,andho
mew
ork
from
relaxatio
nskillslearned,a
scene
presentatio
nmeant
torelaxthep
atient
Relaxatio
n17
(0%)/mod
.desensitiza-
tion17
(12%
)/con-
trol17
(17%
)/WLC
18(0%)(b)
50m×7(5.83h
)+ho
mew
ork
AAT
D(debilitatin
ganxiety)
andAAT
F(fa
cilitatinganxiety):
posttestand
follo
wup
between
grou
psandtwo
controlgroup
s𝑃<0.001;TAI:
betweengrou
psat
posttest𝑃<0.05
andatfollo
wup
𝑃<0.001(d)
Group
sgiven
relaxatio
nas
self-controland
mod
ified
desensitizatio
nbo
threpo
rted
significantly
lessd
ebilitatin
gtest
anxietyand
significantly
more
facilitatingtest
anxietythan
controls.
Relaxatio
nas
self-controlgroup
show
edredu
ctionand
maintenance
onbo
thmeasureso
fno
ntargetedanxiety
relativ
etothec
ontro
ls
+
Tables
3(a)
and3(b)
have
been
split
accordingto
thosep
rogram
sthatcon
sisto
f“named”p
rogram
sand
thosethatcon
sisto
f“un
-nam
edprograms.”
Becausethe
un-nam
edprogramsc
onsisto
fsom
etim
esmultip
leactiv
ities
andareh
eterogeneous
across,the
authorsh
aveincludedthep
rogram
descrip
tionto
complem
enttho
secategorie
sofstudies.
AAT
D:achievementanx
ietytest(debilitatin
ganxiety);A
ATF:achievem
entanx
ietytest(fa
cilitatinganxiety);B
AI:Be
ckanxietyinventory;B-PO
MS:bipo
larp
rofileo
fmoo
dstates;B
SI:brie
fsym
ptom
inventory;
CAPS
:clin
icianadministered
PTSD
scale;BQ
:Shirom-M
elam
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Evidence-Based Complementary and Alternative Medicine 19
in significantly less burnout in 75 individuals with stress-related conditions [52]. In the fourth study, 85 pediatricheadache patients who completed a 12-hour CBT programincorporating progressive muscle relaxation had significantimprovements in coping with stress [54]. Three studiescharacterized their intervention as an SMTP plus relaxationtechniques. In one study of 81 US Army employees stationedat the Pentagon, an SMTP that combined multiple relaxationtechniques resulted in significant reductions in distress butnot anxiety [55]. A second study which implemented a 16-hour SMTP with PMR in 36 parents of children with severephysical disabilities resulted in significant reductions in bothstate and trait anxiety [56]. A third study using a 20-hourSMTP program with PMR resulted in decreases in distressand trait anxiety in 155 police, hospital, and school employees[57].
Four-high quality studies implemented GI or breathingexercises with other relaxation techniques, and in each casethe results were mixed: some stress-related outcome mea-sures showed statistically significant differences, while othersdid not. In a study of 134 ischemic heart disease patients, a24-hour program combining GI with Coping Skills Trainingand PMR resulted in significant reductions in distress butnot in anxiety [58]. A second study implemented a nine-hour program of GI with Coping Skills Training and PMRin 50 breast cancer patients and found a decrease in anxietyas measured by the Profile of Mood States (POMS) but notby the Hamilton Anxiety and Depression Scale (HADS) [60].The third study used three hours of GI with breathing andrelaxation exercises in 161 breast cancer patients undergoingradiotherapy; while tension scores on the POMS lessenedsignificantly, the Leeds anxiety differences were nonsignifi-cant [59]. The fourth study that used relaxation, breathing,and desensitization techniques in highly anxious psychologystudents produced statistically significant reductions in test-taking anxiety [61].
2.8. Resource Requirements of Named Multimodal Programs.In this section, the authors provide a subjective assessmentof the resource requirements for these programs, based onthe descriptive data collected: information describing theamount of time required for individual and practitioneror trainer involvement, facility and equipment needed, andestimated cost ranges. Because the unnamed programs wereheterogeneous with regard to time for training and contentinvolved in each session, the authors elected not to reporton resource requirements for these. In determining whatresources would potentially be required during the trainingphase for the named programs (see Figure 2(a)), the authorsconsidered this as the period of time when a program wasinitially instituted and would require a trainer or instructorto teach self-management skills to participants. Since datawas collected on the “dose” of the program training (i.e., theactual number of hours per week× number of weeks inwhichthe program was delivered), the authors then categorized theamount of training time needed as minimal (less than 10hours on average) or extensive (greater than 10 hours). Basedon this information, the authors then estimated the amount
of practitioner or trainer involvement required to teach theseskills. Programs like MBSR and CBSM require substan-tially more specialized training of and sustained practitionerinvolvement, compared to interventions like AT and RRTwhich can be more quickly learned by participants. Using thedescriptions of the intervention extracted from the data, theauthors then codified facility requirements (i.e., an estimateof how much space is needed to learn the techniques),whether any equipment is necessary to learn the skills, andcosts associated with the training (based on internet searchesof the described programs). The authors present a similarassessment for the self-practice requirements (i.e., once theindividual is fully trained and able to practice on his/herown) in Figure 2(b). Compared to conventional therapies, theresource requirements for both training and self-practice areall overall likely minimal. Once fully trained, service mem-bers should be able to practice these skills easily in any setting,with minimal time required, no equipment necessary, andat virtually no additional cost. While the main focus of thisreview was to report on the effectiveness of these multimodalprograms in impacting emotional stress, the authors haveadditionally provided information about estimated resourcerequirements for military leadership and program managersin order to guide their decision making about the feasibilityof integrating such programs into military settings. Whetherthese programs could be implemented “as is” or if theywould need to be modified or adapted is not an assessmentthe authors have made, as only those in decision-makingpositions are able to definitively decide such feasibility issues.
3. Discussion
The programs described in this report have potential ben-efits for service members and their families. Since theyprimarily involve self-management skills, they can becomeself-empowering to the individual and can be used inany environment, with minimal time needed. This may beespecially helpful to the population of individuals that arelikely to refuse, delay, or feel stigmatized by conventionaltherapies. They are cost-effective strategies to prevent ormanage stressors. Since they are multimodal, they may offergreater appeal than single-modality programs.There are veryfew to no adverse effects from these self-management skillswhen properly learned and practiced.
Although there are reviews in the literature to describerelevant programs that address specific issues (PTSD,resilience) in service member populations [64, 65], this com-prehensive systematic review globally reviewed the literatureon biopsychosocial multimodal programs, extracted the oneswith high methodological quality and statistically significantreductions in stress (and similar keywords), and presentedthese results with estimated resource requirements. Becauseof this comprehensive approach, promising programs thathave a strong evidence base,most ofwhichwere not evaluatedin military populations, were able to be identified. Thisinformation is important for learning approaches that couldbe applied in these populations, especially since there is so
20 Evidence-Based Complementary and Alternative Medicine
Extensive
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Figure 2: (a) Training requirements and (b) self-practice requirements.
little research on these topics in military populations. Thisdata could potentially aid military leaders who are lookingfor evidence-based programs to reduce psychological stressand help guide their decision making about implementingthese programs as described, or tailoring the needs of servicemembers.
A fundamental problem associated with initial efforts tolaunch effective mind-body programs in practice is the lim-ited evidence base to guide program choice. While evidence-based approaches may be desirable, such evidence is scarce.Even if evidence is available, the basic steps of program plan-ning may lead conscientious planners to programs that havenot been evaluated for their effectiveness. With this paper,the authors hope to stimulate thinking about translatingthis best evidence synthesis into practice, in order to makeheadway into the prevention and treatment of stress-relatedillness. The message to service members and their familymembers who are struggling with stress-related conditions isthat they can change the way their body and mind react tostress by changing their thoughts, emotions, and behaviors.To the leadership, that is, understandably wary of makingdecisions without the proper evidentiary support, the authorsoffer the results of this comprehensive systematic review,demonstrating some promising directions, preliminary evi-dence of effectiveness for stress-related outcomes across allpopulations, and basic characterizations and descriptions ofsome of the self-care, skills training programs.The goals wereto demystify them and to illustrate that many of them involveminimal cost and training time.
TheUSmilitary success at shifting the combat focus fromresponse to IED attacks in theater to better IED detectionand armor to prevent injuries, termed “left of boom” [66]can serve as a powerful model for the mitigation of combatstress-related issues. A similar commitment to changing theparadigm from treatment of combat-related PTSD after it hasbeen diagnosed to empowerment of troops and their familiesto take control over their physiologic and psychological
responses to stress through skills training would represent atrue shift to “left of PTSD” [67, 68].
3.1. Limitations of the Review. The authors of this compre-hensive systematic review were only interested in assessingand reporting on the stress-related outcomes reported in thearticles; whether they were primary or secondary outcomeswas irrelevant to the review. Because of this, the authorsdid not paint the whole picture of each study capturedand may have missed important elements of the originalauthors’ intent. It was chosen to capture only those studiesthat reported on stress using the following terms: stress,anxiety, posttraumatic stress disorder, coping, resilience, har-diness, burnout, distress, or relaxation. The authors derivedthese terms by assessing the literature and consulting withsubject matter experts. The authors acknowledge that thisis most likely not a comprehensive and exhaustive list ofall emotional stress-related terms, and the search may havemissed pertinent studies that would have fit the inclusioncriteria using other similarly related terms for stress.
Another limitation is that this review only includedmultimodal programs. The authors felt that these programswould include the dimensions of the BPS model and wouldhave broader appeal by not focusing all efforts on onetechnique (e.g., yoga). As a result, any studies involving asingle modality (i.e., only yoga, meditation, relaxation, orimagery) were excluded at the screening phase. The authorsand colleagues are currently assessing the literature of single-modal mind-body approaches in a more focused populationrelating to the military.
The authors only included those studies that have beenpublished in the English language. While some systematicreviews consider the inclusion of only English-language stud-ies as a limitation; doing so does not seriously compromisethe outcome or implication for the majority of interventionsand claims [69]. There has been some debate over this in theliterature.The amount of effort and expense to include studies
Evidence-Based Complementary and Alternative Medicine 21
that have not been translated into the English language isa challenge to methodologists since the translator needsto be proficient in scientific language, able to understandthe systematic review methodology, and be involved fromthe protocol development phase to clearly understand howto accurately code each review. The majority of systematicreviews, because of this challenge, only include the literaturethat is available in the English language.
The authors excluded all biofeedback studies during thereview phase because it was decided that these were not trulyself-management techniques; one would have to rely on thedevice during practice.Other programs, such as those learnedthrough the internet or books, were excluded on this basis aswell.
In this report, the authors have only described thosestudies that were of high quality and which reported statis-tically significant results between groups in controlled trialdesigns because of the interest in sharing only those that theauthors felt confident in the estimate of the effect comparedto a control group. Thus, excluded from this report werethose programs that showed only within-group differences.Finally, quality assessment was based solely on internalvalidity criteria (the likelihood that the observed effects aredue to bias) and did not take into account external validity(the likelihood that observed effects would occur outside thesetting, i.e., generalizability), which is not usually assessedwhen evaluating quality in systematic review.Had the authorsassessed external validity, the number of low-quality studiesmay have been decreased, allowingmore studies to be shared.Future studies in the field should evaluate not only bias butalso generalizability when assessing quality criteria.
4. Conclusion
The objective of this paper was to provide a descriptiveoverview and quantitative synthesis of information on multi-modal programs that might be used for the self-managementof emotional stress in our military communities and toconsider this body of research as a guide to next steps in theresearch on implementation in military populations. MBSR,CBSM, AT, RRT, yoga plus similar meditation-based skills,and relaxation practices are the types of approaches emergingin the literature as the most promising for their benefitsand ease of implementation in different settings. Imple-menting these identified training programs into militarysettings appears highly feasible, considering that resourcerequirements are minimal.
Conflict of Interests
None of the authors have any conflict of interests to reportbased on this project, including financial interests, consultant,institutional or other relationships that might lead to bias ora conflict of interests.
Acknowledgments
Theauthors would like to acknowledge Sasha Knowlton,MD,Matthew Fritts, MPH, PMP, E-424 RYT, and Viviane Enslein
for their contributions to the project. Oral presentationwas done by C. Crawford, D. Wallerstedt, and R. Khorsan.Biopsychosocial training programs for the self-managementof emotional Stress: potential applications for the Mili-tary Armed Forces Health Protection Conference AFHPC,Hampton, VA, March 24, 2011. This project was funded bythe US Army Medical Research Acquisition Activity, 820Chandler Street, Fort Detrick, MD Award no. W81XWH-08-1-0408 through Telemedicine and Advanced TechnologyResearch Command (TATRC). The views, opinions, and/orfindings contained in this report are those of the author(s)and should not be construed as an official department of theArmy position, policy, or decision unless so designated byother documentation.
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Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Disease Markers
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BioMed Research International
OncologyJournal of
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Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Oxidative Medicine and Cellular Longevity
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
PPAR Research
The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014
Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Journal of
ObesityJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Computational and Mathematical Methods in Medicine
OphthalmologyJournal of
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Diabetes ResearchJournal of
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Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Research and TreatmentAIDS
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Gastroenterology Research and Practice
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Parkinson’s Disease
Evidence-Based Complementary and Alternative Medicine
Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com