Clinical Effectiveness of Guided Breathing Exercises in Reducing Anxiety, Stress, and Depression in COVID-19 Patients

doi:10.21203/rs.3.rs-4421915/v1

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Clinical Effectiveness of Guided Breathing Exercises in Reducing Anxiety, Stress, and Depression in COVID-19 Patients

https://doi.org/10.21203/rs.3.rs-4421915/v1

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published 04 Nov, 2024

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The COVID-19 pandemic has led to an increase in the prevalence of anxiety, stress and depression among affected people. This study was conducted with the aim of investigating the clinical effectiveness of guided breathing exercises in reducing anxiety, stress and depression in patients with COVID-19. A quasi-experimental study design was used, involving a sample of COVID-19 patients who underwent guided breathing exercises as a complementary therapy. The Depression Anxiety Stress Scale-21 (DASS-21) questionnaire was administered before and after the intervention to evaluate changes in anxiety, stress, and depression levels. The results of this study demonstrated that clinically guided breathing exercises had a significant effect on reducing anxiety and stress in COVID-19 patients. The intervention significantly reduced anxiety and stress scores (p < 0.001). However, there was no significant reduction in depression scores among patients who participated in guided breathing exercises (p = 0.946). Guided breathing exercises are an effective complementary technique in reducing the level of anxiety and stress in COVID-19 patients. However, more research is needed to investigate alternative or complementary interventions for coping with depression in this population. Nevertheless, guided breathing exercises may provide a worthy non-pharmacological approach to managing psychological distress in COVID-19 patients.

Biological sciences/Physiology

Biological sciences/Psychology

Health sciences/Diseases

COVID-19

Guided breathing exercises

Anxiety

Stress

Depression

Depression Anxiety Stress Scale-21 (DASS-21)

The COVID-19, also known as the new coronavirus, is a respiratory disease caused by the SARS-CoV-2 virus. It was first identified in Wuhan, China in December 2019 and has since spread globally, resulting in a pandemic [1, 2]. The main symptoms include fever, cough and difficulty breathing, although some people may experience mild or no symptoms. The severity of the disease varies, with older people and those with underlying health conditions being more vulnerable to severe disease [3, 4].

Anxiety, stress, and depression have been widely reported among people who have contracted COVID-19. The global pandemic has created an unprecedented level of fear and uncertainty that has significantly affected mental health [5, 6]. Patients with Covid-19 often experience anxiety due to fear of becoming severely ill, being hospitalized, and potentially infecting others. Constant anxiety about one's health and the unknown duration of symptoms or potential long-term effects can contribute to increased anxiety levels [7]. Coping with physical symptoms, isolation, and disruption of daily routines can lead to increased stress levels in COVID-19 patients. Stress related to the pandemic itself, such as financial difficulties, job loss or caregiving responsibilities, exacerbates the situation [8, 9]. Limited ability to participate in regular activities, loss of social support and reduced quality of life can significantly affect a person's psychological well-being [10].

It has been shown that breathing exercises have a positive effect on reducing anxiety, stress and depression in people, including Covid-19 patients. Breathing exercises, such as deep breathing or diaphragmatic breathing, can activate the body's relaxation response, which helps reduce anxiety symptoms [11, 12]. These exercises promote deep breathing and slow breathing, activate the parasympathetic nervous system, and calm the physiological response to stress. In addition, breathing exercises help manage stress and improve coping mechanisms by regulating the body's stress response [13, 14]. By deepening and slowing breathing, people activate a relaxation response that can counteract the effects of the body's stress hormones, such as cortisol. Regular practice of breathing exercises can help people become more resilient to stress, allowing them to better manage challenging situations and reduce the negative impact of stress on mental health [15, 16]. Furthermore, breathing exercises can improve mood and reduce depressive symptoms in COVID-19 patients. Deep breathing increases oxygen supply to the brain and enhances the sense of clarity, focus and alertness [11, 17]. By prolonging the exhalation, people stimulate the vagus nerve, which activates the parasympathetic nervous system and releases feel-good neurotransmitters such as serotonin and endorphins. It can help reduce symptoms of depression and have positive physiological and psychological effects on mood [18].

The described studies and results led to a knowledge gap suggesting that guided breathing exercises may be effective in reducing anxiety, stress, and depression in COVID-19 patients. These studies were limited in number, quality, or scope, and this could lead to uncertainty about the effectiveness of these interventions in this particular population. For example, studies had small sample sizes, lacked control groups, and had methodological flaws that limit the generalizability of these findings. In addition, there were conflicting results or insufficient evidence from previous studies, making this definitive conclusion challenging.

The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have prioritized mental health and psychological support for COVID-19 patients [19]. They have emphasized the importance of implementing evidence-based interventions to deal with anxiety, stress and depression [20]. Several studies have evaluated the effectiveness of different interventions in reducing anxiety, stress and depression in different populations [21, 22]. Guided breathing exercises have shown promising results in reducing psychological distress. These exercises include deep and slow breathing techniques that help activate the parasympathetic nervous system and create a state of relaxation [13, 23].

Despite the existing literature on the effectiveness of guided breathing exercises in reducing psychological distress, limited research has examined patients with COVID-19. These patients present unique challenges such as potential respiratory distress and impaired lung function that may affect the feasibility and safety of certain respiratory techniques [24, 25]. Therefore, it is necessary to study the clinical effectiveness of guided breathing exercises in this specific population. The aim of this study was to clinically evaluate the effectiveness of guided breathing exercises in reducing anxiety, stress and depression in COVID-19 patients.

Study Design

This study was conducted using a randomized controlled trial design. Participants were randomly divided into an intervention group that received guided breathing exercises and a control group that received standard care without guided breathing exercises. The study population included all patients with covid-19 (over 18 years old) hospitalized in the covid-19 respiratory ward of one of Zahedan hospitals in 2019. All methods were performed in accordance with the relevant guidelines and regulations by including a statement in the methods section.

Participants

The participants included hospitalized Covid-19 patients aged 18 and older. The sample size was determined based on the error of the first type 0.05 and the power of the test 0.9 that was 60 participants. After simple sampling, eligible subjects were randomly divided into two groups: intervention (30 patients) and intervention (30 patients) using random block method.

Inclusion and Exclusion Criteria

The criteria for entering the study were: 1) having informed and free consent to participate in the study, 2) not experiencing severe stress in the past 6 months, such as a severe accident, death of a loved one, and divorce, 3) not having a history of long-term use of drugs Psychedelic at least in the last 6 months, 4) having oxygen saturation > 90 and Glasgow Coma Scale (GCS) = 15, 5) Referral patients from January 2019 to December 2019, 6) Patients referred to all hospitals in Zahedan. The exclusion criteria were also 1) unwillingness of patients to continue participating in the study, 2) deterioration of patients' disease conditions.

Sampling

Participants who met inclusion criteria were assigned a random identification number using a computerized randomization list. These numbers were used to determine their allocation to the intervention or control group. A randomized blocking method is used to ensure an equal number of participants in each group. Blocking is usually considered to balance the number of samples assigned to each of the study groups. This feature helps researchers to equalize the number of samples assigned to each of the study groups where intermediate analyzes are required during the sampling process. In this method, the size of all blocks is equal, and in a two-group experiment, eight-piece blocks including four participants in the intervention group and four participants in the control group are randomly selected as AA, BB, AB, and BA.

Outcome Measures

In this study, the stress anxiety depression scale questionnaire (DASS-21) was used to evaluate the levels of anxiety, stress and depression in the participants. This self-report questionnaire contains 21 items, 7 of which evaluate each of these three areas. The DASS-21 questionnaire consists of three components, each subset of which consists of seven questions; the final score of each is obtained through the sum of the scores of the related questions (Table 1). The participants rated the extent to which they experienced specific symptoms in the past week on a Likert scale ranging from 0 (does not apply to me at all) to 3 (applies to me a lot or most of the time). Because the DASS-21 is an abbreviated form of the original scale (42 questions), the final score for each subscale was doubled. Then, using Table 2, the severity of the symptoms was determined [26].

Table 1

) Subscales and related items
Subscales	Items
Depression	3, 5, 10, 16, 17, 21
Anxiety	2, 4, 7, 9, 15, 19, 20
Stress	1, 6, 8, 11, 12, 14, 18

Table 2

) Severity of each subscale
Intensity	Stress	Depression	Anxiety
Normal	0–14	0–9	0–7
Slight	15–18	10–13	8–9
Medium	19–25	14–20	10–14
Severe	26–33	21–27	15–19
Very severe	+ 33	+ 28	+ 20

In this study, the chosen method for measuring anxiety, depression and stress is a standard questionnaire that is used all over the world to assess the level of anxiety, depression and stress. To determine the validity of this questionnaire, Lovibond et al. (1995) declared the validity of the DASS-21 questionnaire as 0.77. Additionally, Lovibond declared the reliability of the DASS-21 questionnaire and its components by Cronbach's alpha method as described in Table 3 (23). In the present study, the validity cited in previous studies has been referred to them. For ensuring reliability, 10 people completed the questionnaire, and Cronbach's alpha was obtained 0.85%, which were excluded from the study [26].

Table 3

) Components of stress-anxiety-depression questionnaire and their alpha coefficients
Component	Cronbach's alpha coefficients
Depression	0.89
Anxiety	0.84
Stress	0.82
Stress - Anxiety - Depression	0.83

Procedure

The participants were divided into an intervention group that received guided breathing exercises and a control group that received standard care without guided breathing exercises. The participants of the intervention group were given breathing exercises on the first day, and during the four days, the exercises were performed with supervision. Then the questionnaire was completed again by two control and intervention groups. First, the patients took 10 deep breaths per hour using an incentive spirometer and held their breath for about 2 to 3 seconds. Exhalation was done slowly and passively. The air was blown with pursed lips. They coughed at least five times after exhaling and during exhalation. Finally, they rested for 30 seconds after each cough.

Statistical Analysis

Descriptive statistics was performed to summarize the characteristics of the study population. Student's t-test was used to compare the mean scores of anxiety, stress, and depression between the two groups. Chi-square test was also employed to compare the proportions of participants with different severity levels of anxiety, stress, and depression. Data analysis was conducted using SPSS version 21 software and two-sided P values < 0.05 were considered statistically significant.

Ethical Considerations

Before starting the study, ethical approval was obtained. The current study was approved in 2019 by the Research Ethical Committee. Furthermore, the study has been registered with the code number IR.ZAMUS.REC.1402.185. In addition, informed consent was obtained from all participants and they had the right to withdraw from the study at any time without any negative consequences. Participants' confidentiality and privacy were protected and data were securely stored and analyzed.

In the present study, 60 patients with COVID-19 were in two groups of 30. The mean age in the intervention group was 54.1±16.4 and in the control group was 58.23±14.9. Chi-square and accurate Fisher age test results (p = 0.843), gender (p = 0.443), education level (p = 0.843), marital status (p = 0.630), underlying disease (p = 0.197), occupation (p = 0.925) have been shown in Table 4. Moreover, the mean scores of anxiety before and after the intervention in the intervention and control groups have been described in Table 5. Based on the table the mean and standard deviation of the scores before and after intervention in study group was 14.86±2.06 and 8.44±1.12, respectively. Additionally, the mean and standard deviation of the scores before and after intervention in control group was 15.87±2.69 and 15.67±3.01, respectively (Table 5). Moreover, the mean scores of anxiety before and after the intervention in the intervention and control groups have been described in Table 5. The mean scores of stress before and after intervention in the study group was 15.13±2.87 and 8.55±1.63, respectively (Table 6). The mean scores of stress before and after intervention in the control group also was 15.13±2.87 and 8.55±1.63, respectively (Table 6). In addition, the mean scores of depression before and after intervention in the study and control groups have been shown in Table 7. The mean scores of stress before and after intervention in the study group was 14.58±2.32 and 14.31±2.17, respectively (Table 7). The mean scores of stress before and after intervention in the control group also was 14.35±2.81 and 14.23±2.68, respectively (Table 7).

Table 4

) Demographic characteristics of patients with COVID-19
Variable		Intervention group No/percentage	Control group No/percentage	Chi-square test result
Gender	Female	15 (50%)	20 (66%)	X ²=1.09 p = 0.443
Gender	Male	15 (50%)	10 (34%)	X ²=1.09 p = 0.443
Marital status	Married	12 (40%)	14 (46%)	X ²=1.73 p = 0.630
	Single	8 (25%)	7 (23%)
	Divorced	8 (25%)	5 (16%)
	Spouse decease	4 (12%)	3 (10%)
Underlying disease	Renal	4 (12%)	2 (6%)	X ²=6.28 p = 0.197
	Cardiac	3 (10%)	4 (12%)
	Pulmonary	8 (25%)	10 (34%)
	More than one disease	13 (43%)	13 (43%)
	Other	2 (6%)	1 (3%)
Job status	Government employee	12 (40%)	13 (43%)	X ²=0.19 p = 0.925
	Unemployed	10 (33%)	8 (25%)
	Self-employment	8 (26%)	9 (30%)

Table 5

) Mean scores of anxiety before and after the intervention in the intervention and control groups
Groups	Mean± standard deviation before intervention	Mean± standard deviation after intervention	Mean± standard deviation of variations	Paired t-test
Study group	14.86±2.06	8.44±1.12	-6.42±0.94	T = 7.058 DF-59 p < 0.001
Control group	15.87±2.69	15.67±3.01	-0.2±0.02	T = 1.01 DF-59 p = 0.315
Independent T-test	T = 1.620 DF-59 p = 0.274	T = 12.144 DF-59 P = 0.001	T = 0.68 DF-59 p < 0.001

Table 6

) Mean scores of stress before and after the intervention in the intervention and control groups
Groups	Mean± standard deviation before intervention	Mean± standard deviation after intervention	Mean± standard deviation of variations	Paired t-test
Study group	15.13±2.87	8.55±1.63	-6.58±1.24	T = 7.096 DF-59 p < 0.001
Control group	15.45±2.30	15.00±2.05	-0.45±0.25	T = 1.52 DF-59 p = 0.242
Independent T-test	T = 0.476 DF-59 p = 0.636	T = 11.673 DF-59 p < 0.001	T = 11.737 DF-59 p < 0.001

Table 7

) Mean scores of depression before and after the intervention in the intervention and control groups
Groups	Mean± standard deviation before intervention	Mean± standard deviation after intervention	Mean± standard deviation of variations	Paired t-test
Study group	14.58±2.32	14.31±2.17	-0.27±0.15	T = 1.529 DF-59 P = 0.132
Control group	14.35±2.81	14.23±2.68	-0.12±0.13	T = 0.568 DF-59 p = 0.454
Independent T-test	T = 0.357 DF-59 p = 0.722	T = 0.068 DF-59 p = 0.946	T = 1.993 DF-59 p = 0.163

The study aimed to investigate the clinical effectiveness of guided breathing exercises in reducing anxiety, stress, and depression in COVID-19 patients. The study included a total of 60 patients, divided into two groups of 30. The results showed the anxiety and stress of patients with COVID-19 in the study group after the intervention was reported less than before, while there was no significant difference in the control group. Based on the results, breathing exercises can be effective in reducing the anxiety and stress of patients with covid-19. But the results showed that breathing exercises had no significant affect the depression of COVID − 19 patients in the intervention and control groups.

The results of this study showed that there is no significant difference between the intervention group and the control group in terms of age, sex, education level, marital status, underlying disease, and occupation. This indicated that the two groups were initially comparable. In terms of anxiety, the average score before the intervention was 14.86 in the intervention group and 15.87 in the control group. After the intervention, the average scores in the intervention group decreased to 8.44 and in the control group to 15.67. This demonstrated that guided breathing exercises were effective in reducing anxiety in the intervention group. Similarly, the mean pre-intervention stress scores in both intervention and control groups was 15.13. After the intervention, the average scores in the intervention group decreased to 8.55 and remained constant in the control group. This indicated that guided breathing exercises were effective in reducing stress in the intervention group but not in the control group. In terms of depression, the average scores before the intervention were 14.58 in the intervention group and 14.35 in the control group. After the intervention, the average scores in the intervention group decreased to 14.31 and in the control group to 14.23. This revealed that guided breathing exercises did not have a significant effect on reducing depression in both groups.

Mahendru et al. reported that meditation and breathing exercises on depression level (P < 0.001), stress level (P = 0.004) and sleep quality (difficulty falling asleep (P = 0.007), difficulty staying asleep (0.004) (P = 0.003) and feeling after waking up in the morning (P = 0.003) had a statistically significant effect. Although in their study, the positive effect of the intervention on the level of anxiety of patients in isolation was also observed, this difference was not statistically significant (P = 0.528). They concluded that meditation and breathing exercises have positive effects on depression, stress level and sleep quality in patients with COVID − 19 who are in severe institutional isolation [11]. The results of the present study were in accordance with the results obtained from their study in terms of reducing the amount of stress, and in terms of reducing the amount of depression, the results of their study did not confirm the results obtained from this study.

Additionally, Kepenek-Varol et al. reported that the fear of covid-19 scale, the Hamilton Anxiety Rating Scale, and the Pittsburgh Sleep Quality Index were significantly improved compared to the control group, with large effect sizes (0.135, 0.313, and 0.200, respectively). Although the EQ-5D-3L index and the EQ-5D-3L visual analog scale were not statistically significantly different compared to the control group, a small effect size was observed for the difference between the two groups (0.056 and 0.013, respectively). They found breathing and relaxation exercises to be an effective and practical approach to reducing anxiety and increasing sleep quality during the COVID-19 pandemic [27]. The results obtained from their study confirmed the results of the present study.

In another study by Espinoza-Bravo et al. in a within-group comparison, the functional training group showed improvements in fatigue, functional capacity, and perceived stress, while the aerobic training group improved perceived stress. There was no significant difference in the effect between groups for the studied variables. A significant difference was observed in the overall patient impact change scale in favor of the functional training group compared to the aerobic training group, and the quality of life reached the minimum clinically important difference for both groups. Both remote rehabilitation exercise methods are effective in improving stress symptoms and quality of life in patients with prolonged covid-19. Based their results, for improving fatigue and functional performance, functional exercise indicated more promising results [28]. The results obtained from the present study were similar to the results of their study.

Breathing exercises have been shown to be effective in reducing anxiety, stress and depression in various populations, including covid-19 patients. These exercises mainly focus on breathing control and promoting relaxation, which can have a positive effect on mental health [13, 29]. Anxiety is a common mental health problem experienced by Covid-19 patients as they face uncertainty, fear of illness and often isolation. Breathing exercises can help reduce anxiety symptoms by activating the body's relaxation response [30]. Deep breathing techniques, such as diaphragmatic breathing or abdominal breathing, help lower heart rate, lower blood pressure, and reduce the production of stress hormones such as cortisol [28]. Additionally, COVID-19 patients may experience high levels of stress due to physical symptoms of the virus, health concerns, financial strain, and social isolation. Breathing exercises can relieve the stress response by activating the body's relaxation response [24]. Techniques such as box breathing or alternating nostril breathing can help regulate the autonomic nervous system, balance stress hormones, and create a sense of relaxation. In addition, COVID-19 patients may also experience depressive symptoms such as low mood, lack of energy, and feelings of hopelessness [5]. Breathing exercises can improve mood and reduce symptoms of depression by increasing the production of endorphins, which are neurotransmitters associated with feeling good [29].

The results demonstrated that breathing exercises including deep breathing, effective coughing, and the use of motivational spirometry device are more effective in reducing anxiety and stress in COVID-19 patients. In general, these results revealed that guided breathing exercises can be effective in reducing anxiety and stress in COVID-19 patients. However, they may not have a significant effect on reducing depression. Further research with larger sample sizes and longer follow-up periods is needed to confirm these results and explore the potential benefits of guided breathing exercises in managing mental health symptoms in COVID-19 patients. Although breathing exercises can be helpful in reducing anxiety, stress, and depression, they cannot replace treatment for severe mental disorders.

This study found that guided respiratory exercises can be an effective intervention to reduce anxiety and stress in COVID-19 patients. The results demonstrated that the inclusion of these exercises in the clinical care of COVID-19 patients may improve their psychological well-being during the epidemic. The considerable reduction of anxiety and stress scores among patients involved in guided respiratory exercises showed the potential benefits of this intervention. This shows that patient education and guidance through appropriate respiratory techniques can effectively reduce some of the psychological disorders that COVID-19 patients experience. However, there was no significant decrease in depression scores among patients involved in guided respiratory exercises. This indicates that although these exercises may be effective for anxiety and stress, they may not have the same effect on depression in COVID-19 patients. Extra or alternative interventions may be necessary to relieve depression in this population. Further research is needed to investigate the long-term effects of guided respiratory exercises and their impact on other consequences of mental health in COVID-19 patients. Furthermore, the examination of the potential mechanisms in which respiratory exercises guided by them may provide valuable insights for the development of targeted interventions for different aspects of mental health in this population.

Limitations

Like other research studies, the present study has limitations as follows:

This research was conducted only in one center. If it is performed in a multi-center way, it can have better results.

The time of the study and reporting of data is based on the time of the research. This study was conducted over a year. The samples were collected during peak and off-peak times, and no distinction was made in data reporting between throughout this period.

Ethics statement

The current study was approved in 2015 by the Research Ethical Committee. Furthermore, the study has been registered with the code number IR.ZAMUS.REC.1402.185.

Author contribution statement

All authors listed have significantly contributed to the development and the writing of this article.

Funding statement

The study was financially supported by Zahedan University of Medical Sciences.

Data availability statement

Data is provided within the manuscript

Competing interest statement

The authors declare that have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.

Acknowledgment

The authors thank Zahedan University of Medical Sciences and the management of Ali-Ibn-Abitaleb Hospital for their cooperation and coordination within the department for the successful implementation of the research.

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No competing interests reported.

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Clinical Effectiveness of Guided Breathing Exercises in Reducing Anxiety, Stress, and Depression in COVID-19 Patients

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Abstract

Introduction

Methods

Study Design

Participants

Inclusion and Exclusion Criteria

Sampling

Outcome Measures

Procedure

Statistical Analysis

Ethical Considerations

Results

Discussion

Conclusion

Limitations

Declarations

References

Additional Declarations

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