Stress: effective ways to reduce it
Top recommendation: Training in Cognitive Behavioural Therapy (CBT) had twice the effect of the next most effective recommendations, Sudarshan Kriya Yoga and diaphragmatic breathing, plausibly halving markers of stress after 8 weeks of practice.
Personal recommendation: Diaphragmatic breathing is exceptionally easy to learn, can be beneficially practised at almost any time or location, and produces a large reduction in biological markers of stress.
Introduction
Stress is a leading cause of reduced mental health and wellbeing globally. This article reviews the evidence for 15 main interventions addressing the causes of stress and minimising its impact, both in the moment and long-term. We found that Cognitive Behaviour Therapy (CBT), Sudarshan Kriya Yoga (SKY), diaphragmatic breathing, and Mindfulness-Based Stress Reduction (MBSR) can all reduce indicators of stress by more than 25%.
This research is part of a series looking at the most effective ways individuals can improve their wellbeing. Thanks to the EA Infrastructure Fund for funding this project and to the many people who have reached out to discuss ideas and offer feedback on this and previous posts.
Important note: None of the following constitutes professional medical advice. While stress is often a natural part of the human experience, it can also be a symptom of an underlying mental health issue that should take precedent and may require professional support.
Key recommendations
Efforts to tackle stress roughly target one of three areas: its underlying causes; short-term relief, or long-term resilience. Below are two recommendations for better managing stress across each of these three areas, highlighting the interventions with the greatest effect on stress in the literature we reviewed.
Underlying causes
- Cognitive Behavioural Therapy (CBT): take a course in CBT, either online or through an app.
- Reducing key stressors: money, work, and relationships are the three most common causes of stress in the US. Building a financial runway, task management systems, and adopting better strategies for managing difficulties in relationships could all be highly impactful depending on your personal circumstances.
Short-term relief
- Diaphragmatic breathing: practice slow, diaphragmatic breathing at regular intervals and at the onset of stressful situations.
- Listen to music: put away any distractions and listen to some music to relax, either classical or just songs you particularly enjoy.
Long-term resilience
- Mindfulness: try a mindfulness-based stress reduction programme (MBSR), either online or through an app.
- Rhythmic breathing: learn a rhythmic breathing practice, such as Sudarshan Kriya Yoga (SKY), and do this regularly (e.g. twice a week).
A brief(ish) note on methods
This report is the second in a series researching the most effective ways individuals can improve their own wellbeing. The methods and presentation used are a work in progress, aiming to find a balance between maximising the quality of recommendations, the likelihood people will adopt recommendations made, and the number of topics we can provide recommendations on.
The interventions in this article have been ranked here by their size of effect vs. a control condition in the literature we reviewed. We encourage anyone interested to view our evidence table for a more in-depth understanding of how we have produced the recommendations in this article. Effect size scores are presented with each intervention listed in the main discussion section. All references and calculations can be found in the ‘Data’ tab of our evidence table, with studies also linked in the text wherever results are discussed.
Of particular importance to note is that our research is not as comprehensive or rigorous as we would like. There are likely valuable studies that we have missed that would change the effect sizes we found. A compromise has been made between undertaking more in-depth research and covering a wider range of topics given this is currently a pilot project with limited resources.
Many of the topics discussed have a relatively poor quality and quantity of research into their effectiveness, with a large range of measures used to assess their impact on stress. As such, these recommendations are limited by the quality of evidence available and are therefore presented in a spirit of experimentation, or as Scott Alexander describes it, Pascalian Medicine.
In short: don’t take these results as a final word on effectiveness. Try some things and see if they are useful. If they’re not, try something else.
Why stress matters
The impact of stress on health and wellbeing
Put simply (and a little overdramatically), stress could be killing you.
Stress is both directly associated with lower life expectancy, and associated with an increase in unhealthy behaviours that shorten your lifespan, including smoking, alcohol abuse, and reduced exercise. Seven out of ten leading causes of death in the world are directly linked to stress, while as many as 60% of lost working days may be linked to work-related stress.
High levels of stress are also directly associated with lower wellbeing, with the Covid-19 pandemic unsurprisingly appearing to have increased most people’s stress levels.
Eustress and strain
However, stress can also be a positive influence on wellbeing as part of challenges you feel capable of overcoming. In the words of one paper, stress becomes an issue when it is “mismanaged… too intense, or too frequent, or too prolonged”. In this light, negative stress is often referred to as strain and positive stress as eustress.
Eustress is a positive marker of engagement and excitement, linked to beneficial feelings of control, impact and flow. The rest of this article will describe methods for reducing stress, using this general term for simplicity and ease of understanding. However, these interventions are more specifically targeted at creating the conditions to turn challenges into experiences of eustress rather than strain.
Taking stress personally
Stress (or strain) can also be an indicator of an underlying issue in your life that you are avoiding tackling, neatly described elsewhere as an ugh field. A quick perceived stress test can be a useful starting point for assessing your experience and helping to notice an underlying pattern of stress.
Financial difficulty, breakdowns in important relationships, and harmful work environments are key causes of stress. If any of these things are significant issues in your life, working to solve them directly is likely to be more impactful for your stress levels, and general wellbeing, than any of the main recommendations of this article.
The ‘Additional Recommendations’ section at the bottom of the article covers suggestions for addressing these areas in more depth, along with other ideas that seem of plausibly significant benefit but lack scientific research into their effectiveness.
Discussion of Primary Recommendations
The top 5 most effective interventions reviewed, discussed in order of effect size.
Cognitive Behavioural Therapy (CBT)
Size of effect: 54.26%
Intervention: An 8-week CBT programme, either in-person, online or via an app.
CBT encompasses a wide range of practices that can be tailored to the individual and condition being treated, loosely focussed on disrupting negative patterns of thinking and reframing thoughts on a topic. 8-week courses in CBT produced a 53% reduction in salivary cortisol and a 55.53% reduction in anxiety sensitivity. In addition, two meta-analyses reviewing a total of 84 studies found large effect sizes for CBT across several markers of stress.
Cognitive Behavioural Therapy is also widely used for improving other aspects of mental health. It is a principal recommendation of the UK’s National Institute for Health and Care Excellence (NICE) for several conditions, including depression, anxiety, OCD, and PTSD. Meanwhile, CBT-i (CBT for insomnia) appears a highly effective treatment for improving sleep quality and quantity. Put simply, there is strong evidence that CBT has wide-ranging benefits beyond the reduction of stress.
While the studies reviewed involved in-person, professionally-guided CBT courses, we expect that a large proportion of the positive effect still applies to CBT accessed through an app or online course. Mind Ease, Sanvello, and Bloom all appear accessible and effective apps providing CBT-based guidance.
Sudarshan Kriya Yoga (SKY)
Size of effect: 27.15%
Intervention: Training in a set of yogic breathing exercises
SKY is a set of rhythmic breathing practices based on the principles of pranayama (yogic breathing). Principally taught by the Art of Living Foundation, Sudarshan Kriya Yoga is one of the most widely-studied breath-based relaxation techniques. Assessing its impact on stress specifically, we found evidence for a 35% reduction in Mood and Anxiety Questionnaire (MASQ) scores and a 19% reduction in blood cortisol after around 20 hours of training and practice.
Significant effects from SKY practice have also been found for depression, anxiety, asthma, and hypertension amongst other conditions. Frustratingly, there seems to be little access to good guidance on the practice outside of the classes taught by the Art of Living Foundation, which appear to cost £250 for a 3-day programme. It seems plausible that a similar level of benefit may be derived from other rhythmic breathing practices that are free and relatively easy to learn, such as the Wim Hof Method, but there is currently little or no literature available to assess this.
Diagphragmatic breathing
Size of effect: 27.05%
Intervention: Slow breathing (around 4 breaths per minute) from the diaphragm.
Breathing techniques appear to be one of the most widespread and effective recommendations for managing stress, both for in-the-moment relief during high-stress situations and for longer-term resilience to stressful events. While Sudarshan Kriya Yoga involves a set of trained breathing practices, diaphragmatic breathing offers an appealing ease of learning and implementation.
In the simplest terms, diaphragmatic breathing practices involve a conscious effort to breathe more slowly, deeply, and from the belly rather than the chest. And that’s it, really. The principles can be learned in a few minutes from one of many Youtube videos demonstrating the practice. While the quality of evidence is low, this literature review found plausible additional benefits for general quality of life, anxiety, migraines, and hypertension.
Mindfulness-based stress reduction (MBSR)
Size of effect: 26.81%
Intervention: an 8-10 week course in Mindfulness-Based Stress Reduction.
Another breathing-based technique that produced significant reductions in stress, MBSR can be undertaken for free either online or via an app. The research we reviewed found effect sizes ranging from 21.6% to 30.15% on subjective scores of perceived stress or tension. The first of these studies was conducted with participants using the ‘Calm’ app for at least 10 minutes a day across 8 weeks, suggesting a relatively low-commitment, app-based version of this treatment can still produce significant benefit.
Meanwhile, a 2003 meta-analysis found significant effects for general physical and mental wellbeing, as well as for specific conditions, including depression, anxiety, and pain management.
Dark chocolate
Size of effect: 21.33%
Intervention: 25-50g of dark chocolate, consumed daily.
Somewhat surprisingly, 25-50g of dark chocolate eaten daily appears to produce significant effects on blood and salivary cortisol, major biological markers of heightened stress. Given the low quality and quantity of evidence reviewed, it seems likely that the effects of dark chocolate on stress are overly high. However, given the ease (and enjoyment!) of the practice, daily consumption of moderate amounts of dark chocolate seems an appealing boost to anyone’s defences against high stress.
Specifically, it appears to be the high flavonoid content of most dark chocolate that is responsible for the beneficial effect on stress. Given the high sugar content of many chocolate bars, moderated consumption is unsurprisingly wise. A high percentage of cocoa solids also correlates with low sugar levels (e.g. Lindt Excellence 85%, a personal favourite).
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Read the rest of this report on the EA Forum.
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