Evaluating the impact of stress reduction interventions as supportive approach in patients with depressive disorder

INTRODUCTION

Depression is a highly prevalent psychiatric illness marked by a diminished mood or pleasure in usual activities, impaired social and occupational functioning, low energy and occasionally anxiety or suicide risk.¹ Depression disorder is predicted to be among the second leading causes of the global burden of disease at the end of 2030.² Worldwide population living with depression is estimated to be 322 million, which is 4.4% of the total population. Furthermore, prevalence has increased by 18.4% from 2005 to 2015.³ Depressive disorders impair functioning and are often recurrent, making them the leading cause of disability worldwide.⁴

The treatment of depressive disorders faces widespread challenges, including significant gaps in mental health resources, particularly in less developed countries. The treatment coverage for mental illness especially depression continues to be insufficient in several regions worldwide specifically in poor and lower-middle-income nations.

The worldwide treatment gap and coverage in depressive disorder showed that 33% of treatment coverage for mental health services in high-income locations from 2000 to 2019, whereas only 8% in poor and lower-middle-income nations.⁵ Nearly 66.33% of patients with depression disorder reported disability of different severity and an average treatment gap for the major depressive disorder was 79.1% in the Indian population.⁶

Depressive disorder is often considered a type of stress-related disorder.⁷ Accordingly, exposure to adverse life events and the severity of stress display a significant role in the course of major depressive disorders.⁸ Furthermore, much evidence suggests that individuals with depression disorders perceive their lives as more stressful.⁹ World Health Organisation (2021) reported people who experienced adverse life events are more susceptible to depressive disorder. Depression contributes to significant stress and dysfunction, which not only impact an individual’s life circumstances but also perpetuate the condition itself.¹⁰

The most widely used treatment modalities for depression disorder are psychopharmacology, psychological therapies and electroconvulsive therapy. Many patients find it difficult to tolerate antidepressants due to their side effects or other limitations.

Consequently, clinicians and patients prefer nonpharmacological treatments including alternative therapies and psychotherapy. Whereas, in every treatment strategy, it must be possible to use the best combining treatment for better outcomes. The best treatment is the one that has less dropout, fewer side effects and the highest efficacy in recovery.¹¹

The study aimed to identify original research on various stress reduction interventions and their role in supporting approaches for patients with depressive disorders.

METHODS

To obtain relevant articles, Studies were searched using electronic search engines databases from PubMed, Cochrane Library, MEDLINE, Google Scholar electronic database and other sources such as reports, thesis or dissertations using the Medical Subject Heading and keywords (“stress reduction” OR “stress management” OR “stress interventions” OR “stress outcomes”) AND (“patients with depressive disorder” OR “depressive disorder” “depressed patient” OR “depression disorder”).

To find other pertinent studies, the references list of the selected articles was also examined. Based on the objectives of the review, inclusion and exclusion criteria were prepared and selected studies from various databases. Based on that the selected studies were checked for usefulness, clarity and content. Studies were involved in the review if they fulfil the following eligibility criteria.

Inclusion criteria

The review includes studies that focus on reducing stress and depression as a primary or secondary outcome, involving participants diagnosed with depressive disorders. It considers articles with full texts or abstracts available in English and those recommending interventions to alleviate stress and depression.

The included studies employ quantitative methods, such as randomized controlled trials (RCTs), experimental designs and quasi-experimental approaches, examining stress reduction interventions for patients with depressive disorders limited to the year 2014 to 2022. Both individual and group-based interventions are encompassed.

Exclusion criteria

The review excluded studies on depression combined with other medical conditions, such as cancer or diabetes, as well as subjects with other psychiatric disorders or substance abuse. Articles lacking methodological details or focusing on other than stress reduction outcomes were also excluded.

RESULTS

In this literature review, multiple studies were analysed to evaluate the effectiveness of stress reduction interventions in patients with depression disorder. Table no. 1 summarizes the research study including author/ publication year, authors of the study, country, research design, number of participants, treatment type, intervention session, scale and outcome measures. The review consists of five (45.4%) randomized control trials.^13,18,20-22

Six (54.4%) quasi-experimental studies.^12,14-17,19 As per the number of participants concerned, in the RCTs, the total number of patients with depressive disorder ranged from 19 to 171, whereas 23 to 60 in quasi-experimental studies. Out of a total of 11 studies, the majority were done in Egypt (n=3), followed by one study each from India, United states, Iran, Hong Kong, Greece, Thailand, Netherlands and Switzerland (Table 1).^12-18,22

The most commonly employed tools to assess depression and stress were Depression Anxiety Stress Scale (DASS) in six studies, the Perceived Stress Scale (PSS) and Hamilton Depression Rating Scale (HDRS) scale used in three studies, the Beck depression inventory (BDI) in two studies and Patient Health Questionnaire (PHQ-9) used in one study.^12-22

It is noted that relaxation techniques intervention, cognitive behaviour therapy, relaxation techniques intervention, self-awareness, stress management and resilience strategies, music therapy and mindfulness meditation training appear to be more effective for the reduction in stress and depression levels.

Overall, the literature suggests that stress reduction interventions are effective in alleviating stress and the severity of depression, while also improving self-efficacy, reducing anxiety and enhancing the quality of life in patients with depressive disorder within a supportive setting (Table 1).

DASS: Depression Anxiety Stress Scale, BDI: Back Depression Inventory, PSS: Perceived Stress Scale, HDRS: Hamilton Depression Rating Scale, PHQ-9: Patient Health Questionnaire. HLPCQ: Healthy Lifestyle and Personal Control Questionnaire, GSFI: Generalized Self-Efficacy Scale, CD-RISC: Connor Davidson Resilience Scale. MADRS: Montgomery-Åsberg Depression Rating Scale, PSQI: Pittsburgh Sleep Quality Index, HADS: Hospital Anxiety and Depression Scale, WHOQOL: World Health Organization Quality of Life. TSST: Trier Social Stress Test. MDD: Major Depressive Disorder. HADS: Hospital Anxiety and Depression Scale. RSES: Rosenberg self-esteem scale. BICAMS: Brief International Assessment of Cognition for Multiple Sclerosis. IPAQ-SF: International Physical Activity Questionnaire Short Form. BSAQ: Bell’s Social Adaptability Questionnaire. PANAS: Positive and Negative Affect Schedule. WSAS: Work and Social Adjustment Scale. Purpose and Personal Growth scales of the Ryff Scales of Psychological Well-Being–short form.

DISCUSSION

Summary of the main result

This review aimed to examine whether stress reduction intervention can be a supportive or complementary approach among patients with depressive disorder. The majority of the existing research evidence on stress reduction among patients with depressive disorder is available in Western studies (90.9%) and very few available in the Indian setting (9.09%) in defined criteria for critical appraisal of this review.^12-22

Stress reduction interventions for depressive disorder

Findings from the meta-analysis revealed elevated levels of stress biomarkers, such as salivary and hair cortisol, in individuals with depressive disorder compared to those without the condition.²³ Patients with depression reported reduced physical activity, increased substance use, poor sleep quality, weight gain, a sedentary lifestyle and inadequate nutrition. These factors disrupt homeostasis and elevate stress levels, posing significant challenges in managing depressive disorder.²⁴ Several measures were used to evaluate the effectiveness of stress reduction interventions in the review.

Effectiveness of cognitive behavior therapy

Two quasi-experimental studies reported that cognitive behavior therapy was effective in reducing stress and depression among depressive patients.^17,19 The cognitive-behavioral nursing intervention (n=45) for outpatients with the first episode of depressive disorder, which included psycho-education, cognitive restructuring, social skills training, problem-solving, anger and stress management and compliance to treatment which was achieved through 9 sessions of CBT nursing intervention and each session for 120 minutes. The participants reported that there was an improvement in cognitive distortions and self-efficacy and also, highly statistically significant differences in levels of stress, depression and anxiety level between before and after CBT nursing intervention.¹⁷ Abbasian et al, examined the efficacy of stress management training through cognitive-behavioral techniques. These interventions delivered 9 sessions on stress awareness, cognitive reconstruction communicative skills self-expression skills anger management skills breathing skills relaxation skills and problem-solving skills. The cognitive-behavioral techniques interventions were effective in decreasing stress, depression and the development of social adaptability.¹⁹

Effectiveness of relaxation techniques intervention

Evidence from a systematic review supported the positive impact of relaxation techniques on depression and stress outcomes in depressive patients. The progressive muscle relaxation, yoga and music intervention had a greater impact and most effectively reduced depression and anxiety and stress.²⁵ Malky et al, conducted eight consecutive weekly sessions, each for 120 minutes on stress management through progressive muscle relaxation and deep breathing exercises among 30 patients with depressive disorder in a hospital setting.

The mean improvement in depression and stress before and after intervention programs was found to be significant at p<0.05.¹⁵ A randomized control trial by Evgenia et al, on 69 participants with major depression received 8 sessions of Pythagorean self-awareness intervention.

The intervention group had significantly greater reductions in depression with a moderate effect size and stress with a low effect size.¹⁸ The other randomized control trial by Bressington Deniel et al, evaluated Group-based laughter yoga reduces depression but the findings contradicted, that the intervention does not produce any significant improvement in stress levels among depressive patients.¹³

Effectiveness of mindfulness training techniques

Studies indicate that practicing mindfulness can be effective in individuals experiencing less stress, depression severity and anxiety. M. Atia et al, evaluated the efficacy of hospitalized depressed patients using 8 weekly sessions consisting of mindfulness training body scan, mindfulness, mindfulness breathing, practicing, mindfulness meditation, mindfulness eating and meditation.

Differences favoring the participants were found positive effects in reducing stress, anxiety level and depression levels in individuals with depression disorder.¹² Whereas, a randomized control trial conducted on 171 patients with depression revealed that Mindful Yoga Intervention showed no significant improvements in depression symptoms, MDD diagnosis rates or quality of life, except for an indirect effect on self-compassion compared to treatments as usual group.²²

Stress management and resiliency training

Seshadri, et al, described the impact of stress management and resiliency training on resilience, stress and depression levels in depressive patients. A total of 8 sessions of SMART therapy each for 75-90 minutes. The study concluded, there was a significant improvement in resilience, reduction in stress and improvement in depression in the participants.¹⁶

Other stress reduction interventions

The complementary therapy initiated by a psychiatric nurse with relaxation interventions, socialization, yoga intervention, sleep enhancement interventions, breath focus body scan, drug compliance and follow-up demonstrated a significant reduction in stress levels and sleep deprivation.¹⁴ A RCT by Gerber et al, used an aerobic exercise for 6 weeks of the intervention consisting of engaging in coordination and stretching activities for all major muscle groups among the depressive patients.

Standardized stretching and mobility program for the control group with 3 months of follow-up. These interventions were effective in reducing Depressive symptom severity and stress level from baseline to post-intervention but no significant difference at p<0.05 level of significance.²¹ Another RCTs more Gaewlai et al, 2018 used Active group music therapy in a hospital setting for 1.5 hours in each session for 7 weeks. Active group music therapy was effective in reducing the perceived stress and depression score.²⁰

Other psychological impacts of stress reduction interventions

The stress reduction interventions play a significant role in terms of the development of social adaptability (p<0.001) and reduction of anxiety among patients with depression While laughter yoga intervention had statistically greater improvement in mental health-related quality of life (p=0.034) in post-intervention.^13,15,19 Furthermore, Mindfulness training intervention showed a significant reduction in the mean anxiety score of 16.6±2.42, at p>0.001.¹²

A smart intervention showed primarily significant improvement in resilience (mean resilience score=61.1, p=0.03).¹⁶ Whereas, sleep quality and healthy lifestyle showed improvement as contributed by holistic stress reduction interventions.¹⁸ While nurse-initiated complementary therapy interventions reveal a statistically significant difference in sleep quality score the difference is 2.84 (t=4.85p=0.001).¹⁴ While music therapy interventions improve sleep quality and quality of life (p=0.010 and 0.008, respectively).²⁰ Although, changes in depression severity were not associated with variations in the cortisol response.²¹ The self-efficacy showed a significant difference in post-intervention as an impact of stress reduction interventions in patients with depression disorder.¹⁷

This review has some limitations. First, this review involved only published literature in the English language. Second, regarding the intervention, the review included stress reduction interventions related to stress and depression among patients with depressive disorder. Third, the small sample size of intervention studies. Therefore, it may limit the representativeness of and generalizability among patients with depressive disorder Yet, stress reduction interventions are of most importance in depressive disorder, due to the strong association between stress and depression in patients with depression disorder.

CONCLUSION

The review shows consistent and significant efficacy of stress reduction intervention (relaxation techniques interventions, mindfulness, cognitive behavioral therapy, self-awareness interventions, complementary therapy, laughter yoga interventions, active music therapy and aerobic exercise etc) in reducing stress, depression and other outcomes in patients with depressive disorder. The health professionals may blend stress management intervention into standard care for patients with depressive disorder in clinical settings and policymakers consider this while preparing health care policy.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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