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Title

A systematic review on the anxiolytic effects of


aromatherapy in people with anxiety symptoms
Author(s) Lee, YL; Wu, Y; Tsang, HWH; Leung, AY; Cheung, WM
Citation
Journal Of Alternative And Complementary Medicine,
2011, v. 17 n. 2, p. 101-108
Issue Date 2011
URL http://hdl.handle.net/10722/139791
Rights
This is a copy of an article published in the Journal of
Alternative & Complementary Medicine 2011 copyright
Mary Ann Liebert, Inc.; Journal of Alternative &
Complementary Medicine is available online at:
http://www.liebertonline.com.
Review Article
A Systematic Review on the Anxiolytic Effects
of Aromatherapy in People with Anxiety Symptoms
Yuk-Lan Lee, BSc,
1
Ying Wu, BSc,
1
Hector W.H. Tsang, PhD,
1
Ada Y. Leung, MA,
1
and W.M. Cheung, PhD
2
Abstract
Purpose: We reviewed studies from 1990 to 2010 on using aromatherapy for people with anxiety or anxiety
symptoms and examined their clinical effects.
Methods: The review was conducted on available electronic databases to extract journal articles that evaluated
the anxiolytic effects of aromatherapy for people with anxiety symptoms.
Results: The results were based on 16 randomized controlled trials examining the anxiolytic effects of aroma-
therapy among people with anxiety symptoms. Most of the studies indicated positive effects to quell anxiety. No
adverse events were reported.
Conclusions: It is recommended that aromatherapy could be applied as a complementary therapy for people
with anxiety symptoms. Further studies with better quality on methodology should be conducted to identify its
clinical effects and the underlying biologic mechanisms.
Introduction
A
nxiety is a psychologic and physiologic state charac-
terized by cognitive, somatic, emotional, and behavioral
components.
1
About 4%6% of the global population suffer
from various forms of anxiety disorders with such symptoms
as high blood pressure, elevated heart rate, sweating, fatigue,
unpleasant feeling, tension, irritability, and restlessness.
2
If
untreated, 40%50% of the patients would progress to de-
pression and have suicidal thoughts.
3
The symptoms bring
huge negative impact to their families, social, and occupa-
tional roles. National statistics show that in the United States,
anxiety disorders incurred $46.6 billion direct and indirect
costs each year, which constituted nearly one third of the
nations total mental health expenses.
4
Pharmacologic and psychologic treatments have remained
the conventional interventions to treat anxiety disorders for
the past 30 years.
5
However, pharmacologic treatment cau-
ses many side-effects. For example, benzodiazepine, a pop-
ular medication with powerful anxiolytic effects, has been
well known for its side-effects including sedation, muscle
relaxation, headache, and ataxia.
6
These side-effects signi-
cantly reduce adherence of the patients. Another problem is
that some anti-anxiety drugs are potentially addictive. Re-
occurrence of anxiety symptoms will result from removal of
the drugs.
7
Psychologic treatment, especially cognitive be-
havior therapy, is the main alternative to drug therapy.
5
Unfortunately, the effect is not at all conclusive based on
available information.
8
Recently, a remarkable increase in the use of comple-
mentary and alternative medicine (CAM) around the globe is
evidenced. Aromatherapy is a commonly used CAM that has
long been regarded as a popular means of treatment for
anxiety. It involves the therapeutic use of essential, aromatic
oils, commonly combined with therapeutic massage and
excitation of the olfactory system, to induce relaxation and
thus quell certain anxiety symptoms.
9
Aromatherapy is
claimed to be benecial to the mental, psychologic, spiritual,
and social aspects, although they are less quantitatively
measurable. With respect to safety, it is reported that that
aromatherapy is relatively free of adverse effects compared
with conventional drugs.
10
Unlike conventional medicine, the effectiveness of aro-
matherapy remains unclear and is still under intensive re-
search. To date, there is only one relevant review on
aromatherapy for depression.
11
Although depression and
anxiety are usually co-occurring, a separate systematic re-
view on the anxiolytic effects of aromatherapy is still needed.
To date, there has not been a systematic review on the an-
xiolytic effects of aromatherapy. The purpose of the current
review is to ll the gap by unraveling the effectiveness
of aromatherapy on relieving anxiety symptoms. Based on
extant literature, the evidence was integrated so as to aid
in gaining a better understanding on the clinical use of
1
Neuropsychiatric Rehabilitation Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong.
2
Faculty of Education, The University of Hong Kong, Hong Kong.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 17, Number 2, 2011, pp. 101108
Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2009.0277
101
aromatherapy as a CAM to treat people suffering from
anxiety symptoms.
Methods
Literature search
Studies used in this review were extracted from MED-
LINE

, Social Sciences Citation Index, Science Citation In-


dex, Psyinfo, PsyARTICLES, Journals@Ovid, MD Consult,
ScienceDirect, EBSCOHOST, and Handbook of Psychiatry,
from 1990 to 2008, using keywords anxiety disorder,
anxiety, anxious symptom or anxiolytic effects and
aromatherapy, aroma, or essence oil. Only English
publications were included. Potential titles were retrieved for
the second stage of review. The titles and the available ab-
stracts were then independently reviewed. Neither of the
reviewers was blind to the author name, institution, and/or
the journal.
The target was to extract randomized controlled trials
(RCT) that used aromatherapy as the intervention to relieve
anxiety symptoms that were measured by validated inven-
tories. A study was operationally dened as a RCT in this
review if the allocation of participants to treatment and
comparison groups was reported to be randomized, the
sample size was not less than 10 in each arm, the participants
were aged 18 or older, and anxiety was included as the
outcome measure. Studies that did not use any type of
comparison group, were qualitative in nature, and were
systematic review or meta-analysis were excluded.
Quality assessment
Studies selected based on the above criteria, and methods
were evaluated for methodological vigor. Guidelines set out
by Glasziou et al.
12
were followed, and the quality of the
studies was assessed by reviewing whether they fullled the
criteria of control randomization, allocation concealment,
intention to treat, and blindedness. Adequately concealed
RCT means that the trial had a clear description of its allo-
cation procedure, central randomization, and allocation from
site apart from the study area and/or blinding allocation
procedure. An RCT is considered to have used intention-to-
treat analysis if all the randomized participants were ana-
lyzed with no differences between the treatment allocation
before and after application of treatment procedure.
13
A
study was classied as single blind if the outcome measure
was conducted by an assessor who was blind to the treat-
ment allocation while the participants were not blind to the
treatment. A study was classied as double blind if both
the assessor of outcome measure and the participants were
blind to the treatment allocation. A study was considered
not blind if neither the assessor nor the participants were
blind to the outcome measure and treatment allocation,
respectively.
14
Data synthesis
Due to heterogeneity of the study populations, psycho-
metric instruments, and intervention trials, quantitative
analysis on the effect size was not performed. However,
qualitative analysis using the Sjo sten method
15
was em-
ployed to classify interventions as having positive, negative,
or no effect as determined by whether signicant differences
in anxiety symptoms were observed in at least one of the
outcome measures between the study groups.
Results
Study description
The numbers of citations returned from the database
search were 70, 73, and 42 for MEDLINE, SSCI SCI, and
others (Psyinfo, PsyARTICLES, Journals@Ovid, MD Consult,
ScienceDirect, EBSCOHOST, and Handbook of Psychiatry),
respectively, in March 2010. Fifty-two (52) relevant publica-
tions were extracted for further evaluation. After abstract
screening at the rst stage and full-text screening at the
second stage, 16 studies met the inclusion criteria. Figure 1
summarizes the selection process of the eligible RCTs.
Table 1 summarizes the methods and results of the 16
qualied RCTs. The total number of subjects involved was
25,377, in which the female-to-male ratio was 24,887:490. The
age of the participants ranged from 18 to 90 years
(M47.77). All subjects suffered from obvious anxiety
symptoms. Patients receiving palliative care were reported in
three studies.
1618
Healthy volunteers with experimentally
induced stress were the second most popular client types
that were reported in two studies.
19,20
Other studies re-
cruited different types of clients, including mothers in labor,
postpartum mothers, women prepared for surgical abortion,
participants prepared for endoscopy procedure, patients
prepared for dental procedures, patients with cancer during
radiotherapy, nursing students attended for stressful surgical
disease examination, patients with cancer with clinically di-
agnosed with anxiety/depression, patients with moderate
and severe dementia, patients in hematology transplant unit,
and patients primarily diagnosed with generalized anxiety
disorder. The types of aromatherapy administration in the
RCTs included aromatherapy massage, inhalation, tablet
intake, and footbath. The intervention duration of aroma-
therapy massage ranged from 20 minutes to 1 hour, and the
duration of inhalation ranged from 5 minutes to 1 hour. The
most commonly used essential oil used in these studies was
lavender.
17,19,2125
Outcomes
Only 14 studies adopted a control group with a compati-
ble conventional therapy or a placebo, and the remaining
two studies used a control group with no active treatment.
Fourteen (14) studies reported positive ndings as to the
anxiolytic effects of aromatherapy;
1622,24,2631
while the re-
maining two studies
23,25
reported no effect of the aroma-
therapy toward anxiety symptoms. In comparing changes
and improvement between the aromatherapy and control
groups providing no active interventions, the subjects who
received aromatherapy usually showed better outcomes than
those in the control groups. However, when comparing the
effect of aromatherapy to a conventional treatment or a
placebo (e.g., massage with carrier oil, inactive coated tab-
lets, benzodiazepine, sniff a hair conditioner, music therapy,
etc.), the results were inconsistent. Seven (7) studies indi-
cated that aromatherapy had benets that were superior to
conventional therapy or placebo.
1922,24,26,27
In contrast, ve
studies
17,18,2830
reported that the therapeutic effects between
massage group and aromatherapy group were similar. One
102 LEE ET AL.
(1) study
16
reported that the anxiolytic effect of massage with
carrier oil only was signicantly better than those receiving
massage with essential oil. One study reported that an oral
lavender oil capsule is as effective as lorazepam, a benzodi-
azepine, in adults with generalized anxiety disorder.
31
Two (2) studies
26,28
had follow-up data after the treatment.
Both of them suggested that no long-term effect was evi-
denced, and aromatherapy did not appear to confer benet
on anxiety.
Study quality
All studies applied random allocation. Seven of the 16
studies nevertheless had no clear description on the ran-
domization procedures.
16,17,19,22,23,25,29
Only one study
21
de-
scribed the concealment of allocation procedure, but the
description was inadequate. Double-blindedness during
outcome assessment was described in three studies
20,30,31
and single-blindedness in six studies.
21,22,26,28
The massage
therapists in the studies did not belong to the research team
and did not need to conduct assessments of the subjects in
order to ensure the double-blindedness. Seven (7) of the 16
studies did not mention whether blinding techniques were
applied.
1619,23,27,29
Intention-to-treat analysis was employed
in 11 studies.
1924,2630
One (1) study
16
mentioned the high
dropout rate due to the long research period. In addition, the
number of subjects recruited for individual studies varied
greatly, from 24 to 23,857.
Pooled effect size
State Anxiety Inventory (SAI) was commonly used in the
16 reviewed studies. Pooled effect size of the outcome mea-
sure of SAI is conducted from pre- and post- means and
standard deviations of the control and treatment groups of
three studies.
18,26,27
Other studies are not included because
corresponding authors could not be contacted for further
information. Pooled effect size is shown in Table 2.
185 publications identified
MEDLINE

(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.
ANXIOLYTIC EFFECTS OF AROMATHERAPY 103
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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.