The benefits of breathwork are numerous and supported by research. Physically, it can help balance blood pressure (Abbott et al., 2019), improve sleep quality (Wells et al., 2018), enhance respiratory function, boost the immune system, and reduce stress hormones. Emotionally, breathwork can decrease symptoms of depression and anxiety (Jerath et al., 2015), improve mental focus, reduce addictive behaviors, promote emotional healing, and enhance overall well-being.  Unlike casual deep breaths, breathwork involves structured patterns and practices that can influence our nervous system, promoting relaxation and reducing stress (Brown & Gerbarg, 2005). Research suggests that breathwork may also aid in emotional regulation, trauma recovery, and even pain management (Emerson et al., 2009).

Effect of breathwork on stress and mental health: A meta-analysis of randomized-controlled trials

Abstract:

Deliberate control of the breath (breathwork) has recently received an unprecedented surge in public interest and breathing techniques have therapeutic potential to improve mental health. Our meta-analysis primarily aimed to evaluate the efficacy of breathwork through examining whether, and to what extent, breathwork interventions were associated with lower levels of self-reported/subjective stress compared to non-breathwork controls. We searched PsycInfo, PubMed, ProQuest, Scopus, Web of Science, ClinicalTrials.gov and ISRCTN up to February 2022, initially identifying 1325 results. The primary outcome self-reported/subjective stress included 12 randomized-controlled trials (k = 12) with a total of 785 adult participants. Most studies were deemed as being at moderate risk of bias. The random-effects analysis yielded a significant small-to-medium mean effect size, g = − 0.35 [95% CI − 0.55, − 0.14], z = 3.32, p = 0.0009, showing breathwork was associated with lower levels of stress than control conditions. Heterogeneity was intermediate and approaching significance, χ²₁₁ = 19, p = 0.06, I² = 42%. Meta-analyses for secondary outcomes of self-reported/subjective anxiety (k = 20) and depressive symptoms (k = 18) showed similar significant effect sizes: g = − 0.32, p < 0.0001, and g = − 0.40, p < 0.0001, respectively. Heterogeneity was moderate and significant for both. Overall, results showed that breathwork may be effective for improving stress and mental health. 

Introduction:

Breathwork comprises various practices which encompass regulating the way that one breathes, particularly in order to promote mental, emotional and physical health (Oxford English Dictionary)¹. These techniques have emerged worldwide with complex historical roots from various traditions such as yoga (i.e., alternate nostril breathing) and Tibetan Buddhism (i.e., vase breathing) along with psychedelic communities (i.e., conscious connected breathing) and scientific/medical researchers and practitioners (i.e., coherent/resonant frequency breathing). Recently, breathwork has been garnering public attention and popularity in the West due to supposed beneficial effects on health and well-being² in addition to the breathing-related pathology of covid-19, however it has only been partly investigated by clinical research and psychiatric medical communities.

Slow-paced breathing practices have gained most research attention thus far. Several psychophysiological mechanisms of action are proposed to underpin such techniques: from polyvagal theory and enteroception literature³ along with enteroception, central nervous system effects, and increasing heart-rate variability (HRV) via modulation of the autonomic nervous system (ANS) and increased parasympathetic activity⁴. ANS activity can be measured using HRV, the oscillations in heart rate connected to breathing (i.e., the fluctuation in the interval between successive heart beats)⁵. Fundamentally, as one inhales and exhales, heart rate increases and decreases, respectively. Higher HRV, arising from respiratory sinus arrhythmia⁶, is typically beneficial as it translates into robust responses to changes in breathing and thus a more resilient stress-response system⁷.

Stress-response dysfunction, associated with impaired ANS activity, and low HRV are common in stress, anxiety, and depression^8–12. This may explain why techniques like HRV biofeedback can be helpful¹³, however, it is possible that simply pacing respiration slowly at approximately 5–6 breaths/minute, requiring no monitoring equipment, can elicit similar effects¹⁴. Polyvagal Theory³, for instance, posits that vagal nerves are major channels for bidirectional communication between body and brain. Bodily feedback has profound effects on mental states as 80% of vagus nerve fibres transmit messages from body to brain¹⁵. Further, the neurovisceral integration model states that high vagal tone is associated with improved health along with emotional and cognitive functioning^16,17. Vagal nerves form the main pathway of the parasympathetic nervous system, and high HRV indicates greater parasympathetic activity⁷.

Modifying breathing alters communication sent from the respiratory system, rapidly influencing brain regions regulating behavior, thought and emotion¹⁸. Likewise, respiration may entrain brain electrical activity¹⁹, with slow breathing resulting in synchrony of brain waves²⁰, thereby enabling diverse brain regions to communicate more effectively²¹. It has been observed that adept long-term Buddhist meditation practitioners can achieve states where brain waves are synchronized continuously²².

Breathwork and stress

Stress, anxiety and depression have markedly exceeded pre-covid-19 pandemic population norms²³. Thus, research is needed to address how this can be mitigated²⁴. A recent survey based on more than 150,000 interviews in over 100 countries suggested that 40% of adults had experienced stress the day preceding the survey (Gallup, US)²⁵. Prior to the pandemic, mental health difficulties were already a significant issue. For instance, stress has been identified by the World Health Organization as contributing to several non-communicable diseases²⁶ and a 2014 survey, led in collaboration with Harvard, of over 115 million adults showed that 72% and 60% frequently experienced financial and occupational stress, respectively (Robert Wood Johnson Foundation, US)²⁷.

Chronic stress is associated with, and can significantly contribute to, many physical and mental health conditions, from hypertension and cardiovascular disease to anxiety and depression²⁸. For common mental health problems such as anxiety and depression, cognitive behavioral therapy (CBT) is widely recommended in treatment guidelines worldwide^29,30, yet many do not recover and waiting times can be long^31,32, in addition to extensive professional training and ongoing supervision being required for therapists. Moreover, such treatment is typically individualized and offered on a one-to-one basis making it resource intensive. The present state of global mental health coupled with the access barriers to psychological therapies requires interventions that are easily accessible and scalable⁷, and manualized practices such as breathwork may meet this remit.

Breathing exercises can be easily taught to both trainers and practitioners, and learned in group settings, increasingly via synchronous and asynchronous methods remotely/online. Therefore, given the need for effective treatments that can be offered at scale with limited resources, interventions focusing on deliberately changing breathing might have significant potential. Indeed, some government public health platforms already recommend deep breathing for stress, anxiety and panic symptoms (NHS and IAPT, UK)^33,34. However, the evidence underlying this recommendation has not been scrutinized in a comprehensive systematic review and meta-analysis and this is the aim of the current study.

Moreover, it is not only slow-paced breathing which may help reduce stress. Fast-paced breathwork may also offer therapeutic benefit as temporary voluntarily induced stress is also known to be beneficial for health and stress resilience. For example, regular physical exercise can improve stress, anxiety and depression levels³⁵, along with HRV³⁶. Similarly, fast-paced breathing techniques can induce short-term stress that may improve mental health³⁷, and have also been shown to volitionally influence the ANS, promoting sympathetic activity³⁸. There are countless breathwork techniques—and such variation in their potential modalities and underlying principles warrants exploration.

References: Abbott R, et al. (2019). Effect of Prolonged Manual Therapy-Directed at the Thoracic Spine and Ribs in a Patient with Adhesive Capsulitis: A Case Report. Journal of Orthopedic & Sports Physical Therapy, 49(5), 312–321.