Professional Documents
Culture Documents
(n = 70)
SSCI + SCI (n = 73)
Other Databases (n = 42)
133 publications excluded because they
were not studies of anxiety or animal
studies involved
52 full text articles for further evaluation
16 RCTs included and reviewed
8 publications excluded because there were
no obvious anxiety symptoms in baseline
measurement of the subjects
24 full text articles for further evaluation
28 publications excluded for reasons below:
No control group (n =12)
Literature review (n = 6)
Sample size less than 10 in each arm (n =5)
Not written in English (n = 2)
Qualitative study (n = 1)
No randomization in subject allocation (n = 1)
FIG. 1. Flowchart of randomized
controlled trials (RCTs) selection
process. SSCI, Social Sciences Cita-
tion Index; SCI, Science Citation
Index.
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105
Discussion
Aromatherapy is the most commonly used CAM for
treating anxiety symptoms around the world.
32
Our review
reveals that aromatherapy shows a positive anxiolytic ef-
fect for patients with anxiety symptoms and more impor-
tantly, it is a safe intervention, and no participants in the
studies reported any adverse effects. However, drawing
conclusions on the effectiveness of aromatherapy for re-
lieving anxiety symptoms should be done with care and
caution.
This review shows that there are insufcient clinical trials
examining the effects of aromatherapy among people with
anxiety disorders as the primary illness. All of the 16 studies
in our review in fact examined the effects of aromatherapy
on secondary anxiety symptoms in various types of partici-
pants, including people with cancer, dementia, postpartum
mothers, and healthy volunteers. In addition, the anxiety
levels of the participants differed signicantly from mild to
moderate in the pretests. The effectiveness of aromatherapy
could hardly be compared among participants with different
levels of anxiety. Improvement in anxiety symptoms among
participants with mild anxiety tended to be insignicant. In
contrast, participants with high levels of psychologic distress
responded better to aromatherapy interventions.
17
To im-
prove the quality of research efforts in the future, the level
of severity of anxiety can be raised to moderate or greater in
the recruitment of participants to assure the validity of the
results.
The Spielberger StateTrait Anxiety Inventory, adopted as
the assessment tool on evaluating anxiety levels in eight
studies, was the most commonly used among the 16 studies.
It is reported to be a reliable and valid self-rating assessment
in research and clinical practice.
33
The meta-analysis of
pooled effect size in the current study shows that aroma-
therapy massage has a median treatment effect for anxiety.
However, it should be noted that the pool effect size is ob-
tained from three studies with different essential oils and
treatment duration.
As to the administration of aromatherapy, six studies
employed aromatherapy massage and seven studies used the
method of inhalation. Other modalities such as internal or
oral application and footbath were mentioned in three
studies. Yim et al.
11
and Imura et al.
27
raised the question of
whether the effect was due to the aromatherapy alone or its
interaction effect with massage. In this review, different im-
plementations of aromatherapy have made the effect non-
comparable and undifferentiated. It is obvious that
inhalation involved purely olfactory stimulation, internal
intake involved both olfactory stimulation and body me-
tabolism, and footbath and aromatherapy massage consisted
of olfactory stimulation, somatosensory stimulation, and
tactile stimulation. Four (4) studies made comparisons be-
tween massage and aromatherapy massage. Three (3) of
them stated a tendency for aromatherapy massage to be
slightly more effective than the placebo. One (1) reported
that massage alone had slightly better anxiolytic effect than
aromatherapy massage. However, the differences were
modest and could have been attributed to aws in the study
design. It is therefore important to determine the best mo-
dalities of aromatherapy in future studies. Comparison be-
tween inhalation, aromatherapy massage, oral intake, and a
control group with a compatible conventional treatment/
placebo in future studies will be necessary to rule out the
effects of nonspecic factors and to unify the modalities of
aromatherapy.
The quality of the studies design prevented drawing
rm valid conclusions as to the clinical efcacy of aro-
matherapy. The size of samples varied largely in the
present studies. Except for one study with a large number
of participants (n 23,857), ve studies used only a small
sample size (n 24, n 28, n 34, n36, n 39). Also, the
gender distribution among the participants was uneven,
with the female subjects outnumbering (n24,887) the male
subjects (n490) on the whole (n25,377) among the ve
reviewed studies. The reason is that one of the reviewed
studies with the largest sample size (n23,857) involved
only female subjects who were in fact mothers in labor.
Other than this study, the distribution of gender of other
studies was even. Further research should employ compa-
rable numbers of male and female participants. Studies also
showed signicant differences in the duration of treatment.
One (1) study lasted only 5 minutes, while two studies
lasted 60 minutes. It is uncertain whether the duration of
aromatherapy treatment between studies would have
affected the outcomes. Furthermore, the studies adopted
different types of essential oil. It is unknown whether the
effects were due to a specic essential oil (e.g., lavender,
etc.) or the general properties of various essential oils.
Although our studies were all RCTs in nature, there were
obvious methodological limitations. To provide further evi-
dence for advocating aromatherapy as an effective com-
plementary or alternative treatment to reduce anxiety
symptoms, studies with stricter and more vigorous proce-
dures in allocation concealment and blinding should be
implemented. Compliance to the therapy should be exam-
ined more thoroughly by intention-to-treat analysis.
Notwithstanding the promising therapeutic effects of
aromatherapy, there has not been literature that could
provide a sound biologic rationale for the use of aroma-
therapy as a complementary and alternative intervention.
The psychobiologic mechanism underlying the anxiolytic
effect remains unclear. According to previous research,
34
g-aminobutyric acid (GABA), one of the brain neurotrans-
mitters, has an inhibitory effect upon the nervous system
and hence may be used to calm the overstimulated nervous
system under tension and stress. Previous research ef-
forts
35,36
have suggested that some essential oils (e.g., lav-
ender, etc.) worked similarly to diazepam, which acts as the
agonist of GABA. One of the current authors reviewed
studies
31
also stated that an oral lavender oil capsule, si-
lexan, is as effective as lorazepam, which is a commonly
used benzodiazepine. Some studies
37
hypothesized that the
anxiolytic effects may be due to the retrieval of pleasant
Table 2. Pooled Effect Size of Aromatherapy
Massage Studies with State Anxiety
Inventory Outcome Measure
Study Effect size Pooled effect size
Imura et al.
27
1.617
0.5103
Wilkinson et al.
18
0.0708
Wilkinson et al.
26
0.5030
106 LEE ET AL.
memories by particular smells associated with some essen-
tial oils. The unclear biologic mechanisms explaining how
aromatherapy reduces anxiety symptoms leave room for
further research.
Conclusions
As generally all of the 16 reviewed studies showed a
positive result of aromatherapy on anxiety, it is re-
commended that aromatherapy could be applied as a com-
plementary therapy for people with anxiety symptoms.
Although there is no conclusive evidence to show lasting
effects of aromatherapy for treating anxiety, it may best be
considered as a safe and pleasant intervention for those who
can afford it and are prepared to pay for it.
Disclosure Statement
No competing nancial interests exist.
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Address correspondence to:
Hector W.H. Tsang, PhD
Neuropsychiatric Rehabilitation Laboratory
Department of Rehabilitation Sciences
The Hong Kong Polytechnic University
Hung Hom, Hong Kong
E-mail: rshtsang@inet.polyu.edu.hk
108 LEE ET AL.