Alternative and Integrative Treatments for Anxiety

Strong scientific evidence:

Kava: Kava kava (Piper methysticum) is a shrub from the South Pacific islands that has been used for centuries to produce calming effects in humans. Studies have found moderate benefit of kava in the treatment of anxiety, and preliminary evidence suggests that kava may be equivalent to benzodiazepine drugs such as diazepam (Valium®). In one human study, kava's effects were reported to be similar to the prescription drug buspirone (Buspar®) used for generalized anxiety disorder (GAD). However, a recent study found no effect in generalized anxiety disorder. The kava supplement should be standardized for best results.

There is concern regarding kava's potential toxicity, based on multiple reports of liver damage in Europe and a number of cases in the United States, including hepatitis, cirrhosis, and liver failure. The U.S. Food and Drug Administration (FDA) has issued warnings to consumers and physicians. Kava should not be used in individuals with pre-existing liver conditions or a history of alcohol or drug abuse. Caution is advised when taking kava as numerous adverse effects including sedation and drug interactions are possible. Kava should not be used if pregnant or breastfeeding.

Music therapy: Music is an ancient tool of healing. Many different forms of music intervention have been used to reduce anxiety in a variety of medical conditions and medical procedures. Most studies have positive findings, although not all do. There is evidence that music interventions help reduce anxiety related to cataract surgery, sigmoidoscopy, bronchoscopy, breast biopsy, cesarean delivery, colonoscopy, esophagogastroduodenoscopy, cardiac catheterization, hospitalized asthmatic patients, psychotherapy, general medical procedures, radiation therapy, treatment for acute myocardial infarction, preparation for surgery, total knee arthroplasty, ventilator-dependence and transurethral resection of the prostate (TURP). Many of these studies have found reduced blood pressure and heart rate as well. A minority of studies found no benefit including studies related to mammogram, ischemic heart disease, pediatric outpatient surgery, and cardiac catheterization. The choice of music may be a factor in outcomes: listening to music of one's preference has been found to be an important consideration. Overall, the evidence favors use of music interventions for anxiety, although more studies are needed to determine what forms work best.

Good scientific evidence:

Aromatherapy: Fragrant oils have been used for thousands of years. Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Several small studies report that lavender essential oil aromatherapy is able to cause reductions in anxiety levels. Additionally, rosemary (Rosmarinus officinalis) essential oil is frequently used in aromatherapy for treatment of a variety of conditions, including anxiety. Early study has shown benefit in reducing stress levels and increasing alertness. More study is needed to draw a firm recommendation. The use of aromatherapy for anxiety disorders needs more research.

Art therapy: Art therapy may enable the expression of inner thoughts or feelings when verbalization is difficult or not possible. Some evidence suggests that creative expression programs in schools involving art therapy may help alleviate problems of self-esteem and can improve social functioning in school age children. However, there is some evidence suggesting that art therapy may not benefit children with PTSD symptoms. Limited evidence suggests that art therapy, in the context of group psychotherapy, may contribute to reduction of symptoms of emotional distress in military personnel receiving mental health treatment.

Hypnosis: Hypnosis is associated with a deep state of relaxation. Several studies support the use of hypnosis to reduce anxiety, particularly prior to dental or medical procedures, or in the management of phobias. Early evidence suggests that these effects may last for up to three years with benefits reported in children and adults.

Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). Psychotherapy, especially cognitive behavioral therapy, may help decrease the symptoms of anxiety disorders when used along with medications, including GAD, OCD, panic disorder, and PTSD.

Relaxation therapy: Clinical studies suggest that relaxation techniques may be beneficial in patients with anxiety, although these approaches do not appear to be as effective as psychotherapy. Numerous human studies report that relaxation techniques (for example using audio tapes or group therapy) may moderately reduce anxiety, particularly in individuals without significant mental illness. Relaxation may be beneficial for phobias such as agoraphobia (fear of crowds), panic disorder, work-related stress, and anxiety due to serious illnesses, prior to medical procedures, or during pregnancy. However, there are many types of relaxation techniques used in studies, and many trials do not clearly describe design or results.

Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Yoga may reduce daily stress and anxiety in healthy people when practiced several times weekly. Several human studies support the use of yoga therapy in the treatment of clinical anxiety disorders, including generalized anxiety and OCD. Available data remains inconclusive, yet thousands of years of effectiveness in India for stress and anxiety must be appreciated.

Unclear or conflicting scientific evidence:

Acupressure: Acupressure, or shiatsu, has been used in China for thousands of years for health and healing. Preliminary clinical trials suggest that acupressure may significantly reduce general and pre-operative anxiety. However, these studies have been small and poorly designed, warranting better-quality research.

Acupuncture: Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. Several studies have reported benefits in anxiety disorders, but the studies have been small and poorly designed, leaving the scientific evidence on acupuncture use in anxiety inconclusive.

Bacopa: Bacopa (Bacopa monnieri) is commonly called "brahmi" and is used in the Ayurvedic system of medicine in India. Although bacopa is traditionally used for anxiety, high-quality clinical trials are lacking. The one weak study below found some evidence that bacopa reduces clinical anxiety. However, more independent research is needed. Caution is advised when taking bacopa supplements as numerous adverse effects including heart palpitations are possible.

Gotu kola: In the traditional Indian system of Ayurvedic medicine, gotu kola is said to develop the crown chakra, the energy center at the top of the head, and to balance the right and left hemispheres of the brain. It has traditionally been used by yogis as a food for meditation. Animal research has demonstrated anxiolytic (anxiety reducing) properties of gotu kola, but human studies are lacking. A single randomized trial assessing the effects of gotu kola on startle responses in healthy (non-anxious) individuals has reported some benefits. These preliminary findings are promising, although further research should be performed. Gotu kola is not related to the cola nut, and does not contain caffeine. Gotu kola is generally reported as safe when used in humans for short term use.

Guided imagery: Guided imagery may include a number of techniques, such as metaphor, story telling, fantasy, game playing, dream interpretation, drawing, visualization, active imagination, or direct suggestion using imagery. Therapeutic guided imagery may be used to help patients relax and focus on images associated with personal issues they are confronting. Initial evidence suggests that guided imagery relaxation audiotapes may reduce anxiety after surgeries, and may improve healing. More studies are needed.

Healing touch (HT): Preliminary data from an uncontrolled trial suggests HT may help reduce symptoms of PTSD in women. More studies are needed.

Lemon balm: Preliminary human evidence has been published that supports the use of lemon balm (Melissa officinalis) for anxiety. In a large case series that included 1,599 patients with symptoms of anxiety, a combination of lemon balm and valerian (Valeriana officinalis) was found to improve symptoms of anxiety, including nervousness, fatigue, and sleep disturbances in over 90% of the patients. Although only mild side effects were reported, caution is advised when taking lemon balm supplements as numerous adverse effects including drowsiness and drug interactions are possible.

Massage: Various forms of therapeutic superficial tissue manipulation have been practiced for thousands of years across cultures. Several human trials have assessed the effects of massage in patients with anxiety, including those with cancer or chronic illnesses, hospitalized for psychiatric disorders, pre-operative anxiety (anxious about themselves or for family members having surgery), dementia, multiple sclerosis, before/during medical procedures, depressed adolescent mothers, women with premenstrual syndrome, patients with fibromyalgia and in elderly institutionalized patients. Additional research is necessary in order to form a scientifically based recommendation.

Meditation: Various forms of meditation, including mindfulness, transcendental meditation®, and "meditation-based stress reduction programs" have been studied for their effects on anxiety. Better studies are needed.

Qi gong: Qi gong is a type of Traditional Chinese Medicine (TCM) that is thought to be at least 4,000 years old. Preliminary study shows that Qi gong may be beneficial for relieving stress. Available data remains inconclusive, yet thousands of years of effectiveness in China for stress and anxiety must be appreciated.

Reflexology: Reflexology involves the application of manual pressure to specific points or areas of the feet that are believed to correspond to other parts of the body. There is preliminary evidence that reflexology may be useful for relaxation and to decrease anxiety. However, it is not clear that reflexology is equivalent or superior to massage or other types of physical manipulation. Better research is needed in this area.

Therapeutic touch: Results of different studies do not agree with each other, and therefore it is currently unclear if therapeutic touch is a useful anxiety treatment. Some trials report benefits, while others find no effects. Also, there is early evidence that therapeutic touch may reduce anxiety in children with life-threatening illnesses, reduce stress in teenagers with psychiatric disease, and help relax premature infants. Most studies have not been well designed, and better research is necessary in order to draw firm conclusions.

Valerian: Valerian (Valeriana officinalis) has traditionally been used for sleep improvement and for stress and anxiety. Studies have generally been of poor methodological quality, and several have used valerian in combination with other herbs, such as passion flower (Passiflora incarnata), lemon balm (Melissa officinalis), and St. John's wort (Hypericum perforatum). Studies report that valerian is generally well tolerated for up to four to six weeks in recommended doses. Caution is advised when taking valerian supplements as numerous adverse effects including drowsiness, sedation, and drug interactions are possible. Do not use valerian if pregnant or breastfeeding.

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