REVIEW ARTICLE
Relaxation Therapy for Depression
An Updated Meta-analysis
Yong Jia, PhD,* Xiaowei Wang, BSc,† and Yuanjuan Cheng, MD‡
Abstract: We conducted this updated meta-analysis to evaluate the effects of re-
laxation therapy for depression. We searched PubMed, MEDLINE, PsycINFO,
the Cochrane Library, Web of Science, and CINAHL for randomized controlled
trials evaluating the effects of relaxation therapy in patients with depression.
Finally, 14 studies were included in this meta-analysis. The efficacy of the inter-
vention was evaluated using depression scale scores. We found that there was no
Downloaded from http://journals.lww.com/jonmd by BhDMf5ePHKbH4TTImqenVMvFrBEFsYEgJzh4l23busDBegKVK/UPA57GS+Pz7mO3V2SE6OqmMeU= on 10/23/2020
significant difference between the effects of relaxation therapy and psychother-
apy on decreasing self-rated depressive symptoms (standardized mean difference
[SMD] = 0.19; 95% confidence interval [CI], −0.11 to 0.48). In addition, eight
trials compared relaxation therapy with no treatment, waiting list, or minimal
treatment and showed that the relaxation group reported lower levels of
self-reported depression scores postintervention (SMD = −0.57; 95% CI,
−0.98 to −0.15). Therefore, this meta-analysis showed that relaxation might reduce
depressive symptoms, and the effect is not worse than that of psychotherapy.
Key Words: Relaxation therapy, depression, meta-analysis
(J Nerv Ment Dis 2020;208: 319–328)
T he global prevalence of depression is approximately 4.7%. Depres-
sion not only leads to disability but is also the 11th leading cause of
global disease burden, which shows that depression has become a ma-
jor global public health problem (Ferrari et al., 2013). Practice guide-
lines recommend pharmacotherapy and psychotherapy for depression
(American Psychiatric Association, 2000; Ellis, 2004). As the traditional
treatment for depression, pharmacotherapy has been shown to be effec-
tive in treating depression (Felice et al., 2015; Fink, 1981; Kok et al.,
2012). However, medications can lead to adverse effects (Kok, 2013)
and have low acceptability. The effects of psychotherapy for the treatment
of depression have been indicated, and several psychotherapeutic ap-
proaches have been widely used in the treatment of depression, such as
cognitive-behavioral therapy (Cuijpers et al., 2014; DeRubeis et al.,
2005), behavioral activation therapy (Ekers et al., 2014), problem-solving
therapy (Malouff et al., 2007), interpersonal psychotherapy (Cuijpers
et al., 2011), possibly brief psychodynamic therapy (Driessen et al.,
2010, 2015), and nondirective counseling (Cuijpers et al., 2012). How-
ever, psychotherapy requires complex treatment technology and experi-
ence, which leads to a limited number of therapists who can provide
psychological guidance (Jorm et al., 2008). In addition, various other
therapies have been applied to treating depression, including relaxation
therapy (Jorm et al., 2008; Klainin-Yobas et al., 2015), electroconvulsive
therapy (Borisovskaya et al., 2016; Chen et al., 2017), and music therapy
(Aalbers et al., 2017).
*School of Nursing, †School of Public Health, and ‡The Second Hospital, Jilin
University, Changchun, China.
Yong Jia and Xiaowei Wang are co-first authors.
Send reprint requests to Yuanjuan Cheng, MD, The Second Hospital, Jilin University,
No. 218 Ziqiang St, Changchun, Jilin 130021, China. E‐mail:
chengyj2019@163.com.
Supplemental digital content is available for this article. Direct URL citations appear in
the printed text and are provided in the HTML and PDF versions of this article on
the journal’s Web site (www.jonmd.com).
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0022-3018/20/20804–0319
DOI: 10.1097/NMD.0000000000001121
The Journal of Nervous and Mental Disease • Volume 208, Number 4, April 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Although relaxation therapy was once regarded as a placebo or
control treatment, an increasing number of researchers have attempted
to test the validity of relaxation therapy for depression. In particular,
relaxation therapy has been used to treat anxiety disorders and has
been gradually proven to be effective in alleviating symptoms (Kim
and Kim, 2018). Relaxation therapy can relax mood and decrease
stress through progressive muscular relaxation, autogenic training,
and Jacobson's technique or a derivative. Relaxation therapy has been
considered a treatment for depression given its advantages of conve-
nience, simplicity, low cost, and high acceptability (Klainin-Yobas
et al., 2015). A literature review in 2008 conducted a meta-analysis
by retrieving current studies on the treatment of depression with relax-
ation; after extracting data, they found that relaxation was indeed ef-
fective in the treatment of depression, but the effect was not as good
as that of psychotherapy (Jorm et al., 2008). In the past decade, relax-
ation therapy has matured and developed; however, whether the effect
of relaxation therapy on alleviating depressive symptoms has changed
is unclear. With the completion of the latest studies on relaxation for
depression, there is divergence among randomized controlled trials
(RCTs) evaluating the effects of relaxation therapy in patients with de-
pression, but no recent meta-analysis has reviewed these studies. There-
fore, we performed this meta-analysis to review evidence that examined
the effect of relaxation therapy in relieving depressive symptoms to
help patients choose an effective treatment for depression.
METHODS
The protocol of this updated meta-analysis has been registered in
PROSPERO (trial registration number: CRD42018114410).
Identification and Selection of Studies
We searched the PubMed, MEDLINE, PsycINFO, Cochrane
Library, Web of Science, and CINAHL databases for RCTs up to
September 2018 with no restriction on language. We conducted an
updated retrieval on April 1, 2019. We used depression, relaxation,
and RCTs as key words to search these databases. The full search
strategy for the above databases is shown in Appendix 1 in the Sup-
plementary Material (Supplemental Digital Content 1, http://links.
lww.com/JNMD/A96). Two reviewers independently selected the ti-
tles and abstracts of all studies identified from the search based on
the inclusion criteria. Then, two reviewers independently examined
the full text of these studies, verifying inclusion or the reasons for ex-
clusion. Disagreement was resolved by consulting a third reviewer.
We included studies with the following characteristics:
1. Types of studies: RCTs.
2. Types of participants: Patients with depression. Patients were diag-
nosed by professional psychologists or any diagnostic scale (includ-
ing self-rating scales), such as the ICD-10 and DSM-4 criteria, the
Hamilton Rating Scale for Depression (HRSD), and the Beck De-
pression Inventory (BDI). In addition, patients who suffered from
other diseases and had been diagnosed with depressive disorder or
depressive symptoms were included.
3. Types of interventions: Studies using relaxation techniques, includ-
ing muscle relaxation, progressive muscle relaxation, autogenic
training, and Jacobson's techniques or derivatives, to treat depression
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Jia et al. The Journal of Nervous and Mental Disease • Volume 208, Number 4, April 2020
were included. However, studies combining relaxation therapy with
other treatments for depression were excluded. In addition, we ex-
cluded studies analyzing the effect of other treatments related to re-
laxation in treating depression, including mind body, spiritual
healing, respiratory muscle training, qi gong, directed reverie therapy,
taiji, yoga, massage, music therapy, and balance exercises.
4. Types of outcome measures: Studies that examined other curative
effects (anger, well-being, fatigue, sleep) simultaneously were not
excluded. However, studies that did not evaluate depression or did
not use scales to measure the level of depression were excluded.
Data Extraction and Quality Assessment
Using specifically developed data extraction forms, two reviewers
independently assessed and extracted data from the studies. The follow-
ing information was extracted from each included study: 1) author and
year of publication; 2) method (study design, randomization, double
blinding, concealment allocation, sample size, comparison group, dura-
tion of follow-up); 3) participants' characteristics (age, sex, setting, type
and severity of depression, diagnostic criteria for depression, previous
history of depression, severe adverse events); 4) intervention (who de-
livered, description of relaxation therapy, number of sessions, and other
details); 5) comparison interventions (using similar details as the relax-
ation intervention); and 6) outcome measures (the scales used to mea-
sure depression, the mean scores, and SD at baseline, posttreatment,
and follow-up). Then, two reviewers independently assessed the risk
of bias in the included studies using the four criteria of the risk of bias
assessment tool developed by the Cochrane Collaboration (Higgins et al.,
2011). This tool assesses possible sources of bias in RCTs: 1) the adequate
generation of the allocation sequence; 2) the concealment of the allocation
to conditions; 3) the prevention of knowledge of the allocated interven-
tion; and 4) dealing with incomplete outcome data. The reviewers re-
sponded to all questions to assess the risk of bias in each aspect and
finally gained an overall risk of bias judgment. Any disagreements were
resolved through discussion and consulting a third reviewer.
Outcome Measures
We calculated the difference in reducing depression symptoms
between relaxation therapy and a control condition. We compared the
efficacy of the following control conditions with that of relaxation ther-
apy: 1) waiting list, supportive therapy, problem-solving therapy, counsel-
ing problem-solving therapy, and so on; and 2) other treatments (exercise
therapy, medication). Depressive symptoms were measured on a validated
and reliable depression symptom scale, including self-rated scales and
clinician-rated scales. In addition, depression scale scores were calcu-
lated at three periods: after treatment, short-term follow-up (not exceed-
ing 3 months), and long-term follow-up (more than 3 months). Other
outcomes were regarded as secondary outcomes.
Meta-analyses
Review Manager Software was used for the statistical analyses.
The extracted data were entered into Review Manager V.5.2 software
by one reviewer and independently checked by the other reviewer. Be-
cause different scales were used to measure the same outcomes for the
measures of depressive symptoms, we calculated the standardized mean
difference (SMD) with 95% confidence intervals and then combined
these values for the meta-analysis. We grouped and pooled analyses
according to the time point and depression scales used.
Heterogeneity among studies was measured using the I2 statistic,
which provides a measure of heterogeneity as percentages. We interpreted
these I2 values using the following guidelines: 0% indicated no observed
heterogeneity, 25% suggested low heterogeneity, 50% suggested mod-
erate heterogeneity, and 75% suggested high heterogeneity (Higgins
et al., 2003). If I2 is greater than 25%, we used random-effects models
(Mantel and Haenszel, 1959). Otherwise, we used fixed-effects models.
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To assess reporting bias, we inspected a funnel plot of the pri-
mary outcome measures using Duval and Tweedie's trim and fill proce-
dure (Duval and Tweedie, 2000), which yields an estimate of the effect
size after the publication bias has been taken into account. We also con-
ducted Egger's test of the intercept to quantify the bias captured by the
funnel plot and tested whether it was significant.
The leave-one-out sensitivity analysis was conducted to evaluate
the stability of the outcome. We conducted a sensitivity analysis to test
the impact of the results with respect to the methodological quality
items rated by the Cochrane tool. After excluding studies with lower
methodological quality and studies with a high or unclear risk of bias,
the meta-analysis was repeated. A sensitivity analysis was performed
and presented in a summary table, and we interpreted the reviewed con-
clusions by making comparisons between the two meta-analyses. We also
evaluated the quality of the evidence using GRADE profiler software.
RESULTS
Results of the Search
Using the described strategy, the search identified 7651 studies
(PubMed = 1433, MEDLINE = 1562, PsycINFO = 158, Cochrane
Library = 2827, Web of Science = 1164, CINAHL = 507). After ex-
cluding duplicate studies, we identified 4811 abstracts. We excluded
4644 records by reading titles and abstracts. Subsequently, we identi-
fied 167 studies to download and peruse the full text. After reviewing
the full text, 153 studies were excluded. Of these, 36 studies were ex-
cluded because they were not RCTs, 37 were excluded because the par-
ticipants were not depression patients, 23 were excluded because they did
not use relaxation therapy as an intervention, and 57 were excluded be-
cause they did not use depression scales to measure changes in depres-
sion as an outcome. Finally, 14 studies (Araujo et al., 2016; Carpenter
et al., 2008; Kahn et al., 1990; Krampen, 1997; Krogh et al., 2009;
McCann and Holmes, 1984; McLean and Hakstian, 1979; Murphy et al.,
1995; Pace, 1977; Reynolds and Coats, 1986; Schröder et al., 2013;
Shinozaki et al., 2010; Wilson, 1982; Wood et al., 1996) met the inclusion
criteria and were included in this study. The study selection process of this
meta-analysis is shown in Figure 1.
Characteristics of the Included Studies
The characteristics of the included studies are detailed in Table 1.
As we can see, there are 10 studies (Carpenter et al., 2008; Kahn et al.,
1990; Krampen, 1997; McLean and Hakstian, 1979; Murphy et al.,
1995; Pace, 1977; Reynolds and Coats, 1986; Schröder et al., 2013;
Wilson, 1982; Wood et al., 1996) comparing the effects of relaxation with
psychological treatment for depression. Besides, eight studies (Araujo
et al., 2016; Kahn et al., 1990; Krampen, 1997; McCann and Holmes,
1984; Reynolds and Coats, 1986; Schröder et al., 2013; Shinozaki et al.,
2010; Wilson, 1982) compared the effects of relaxation with no treatment,
waiting list, or minimal treatment for depression. Meanwhile, two studies
(Krogh et al., 2009; McCann and Holmes, 1984) compared the effects of
relaxation with exercise and lifestyle treatments for depression; and two
studies (McLean and Hakstian, 1979; Murphy et al., 1995) compared the
effects of relaxation with pharmacotherapy for depression. The participants
were adults in eight trials (Araujo et al., 2016; Krampen, 1997; Krogh et al.,
2009; McLean and Hakstian, 1979; Murphy et al., 1995; Pace, 1977;
Schröder et al., 2013; Wilson, 1982), adolescents in three trials (Kahn
et al., 1990; Reynolds and Coats, 1986; Wood et al., 1996), any age (i.e.,
age was not restricted) in two trials (Carpenter et al., 2008; Shinozaki
et al., 2010), and undergraduate women in one trial (McCann and
Holmes, 1984). Of the 14 studies, all studies evaluated depression
levels after treatment, five studies (Kahn et al., 1990; McLean and
Hakstian, 1979; Pace, 1977; Reynolds and Coats, 1986; Wood et al.,
1996) evaluated depression levels in the short-term follow-up (not exceed-
ing 3 months), and four studies (Krogh et al., 2009; Schröder et al., 2013;
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The Journal of Nervous and Mental Disease • Volume 208, Number 4, April 2020
FIGURE 1. Flow chart of the study selection process for this review.
Wilson, 1982; Wood et al., 1996) evaluated depression levels in a long-
term follow-up (more than 3 months). All of these studies used self-rated
scales to measure outcomes, and five studies (Araujo et al., 2016;
Kahn et al., 1990; Krogh et al., 2009; Murphy et al., 1995; Reynolds
and Coats, 1986) used clinician-rated scales. The basic information of
each included study is shown in Table 1.
Risk of Bias
The risk of bias in most of the included studies was considerable.
Among the 14 included studies, 12 studies (Araujo et al., 2016; Carpenter
et al., 2008; Kahn et al., 1990; Krogh et al., 2009; McCann and Holmes,
1984; McLean and Hakstian, 1979; Murphy et al., 1995; Reynolds and
Coats, 1986; Schröder et al., 2013; Shinozaki et al., 2010; Wilson, 1982;
Wood et al., 1996) reported a random sequence generation (85.7%),
whereas only two studies (Krogh et al., 2009; Schröder et al., 2013) re-
ported allocation concealment (14.3%). No studies reported blinding of
participants and personnel or blinding of outcome assessment. There
was either no loss to follow-up or the number, and reasons for loss to
follow-up were reported in 12 (Carpenter et al., 2008; Kahn et al., 1990;
Krampen, 1997; Krogh et al., 2009; McCann and Holmes, 1984;
McLean and Hakstian, 1979; Murphy et al., 1995; Pace, 1977; Reynolds
and Coats, 1986; Schröder et al., 2013; Wilson, 1982; Wood et al., 1996)
of the 14 included trials (85.7%). Because relaxation therapy requires the
patient's own involvement, it is difficult to blind participants to the condi-
tions, which was the major source of risk of bias. The summary of the risk
of bias of the individual studies can be observed in Figure 2. We also made
funnel plots to evaluate publication bias, and the outcomes are supplied
© 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Relaxation Therapy for Depression
in Appendix 2 (Supplemental Digital Content 2, http://links.lww.com/
JNMD/A97).
Description of Interventions
Seven studies (McCann and Holmes, 1984; McLean and
Hakstian, 1979; Pace, 1977; Reynolds and Coats, 1986; Schröder et al.,
2013; Wilson, 1982; Wood et al., 1996) used progressive muscle relaxa-
tion, two studies (Krampen, 1997; Shinozaki et al., 2010) used autogenic
training, two studies (Carpenter et al., 2008; Kahn et al., 1990) used
progressive muscle relaxation plus other relaxation treatments includ-
ing autogenic relaxation exercises, imagery, or breathing, and the re-
maining three studies (Araujo et al., 2016; Krogh et al., 2009; Murphy
et al., 1995) applied the Benson relaxation technique, exercises plus
muscle contraction, and Jacobson's technique or a derivative therapy. Re-
garding the length of the intervention, only one study (Araujo et al.,
2016) was less than 1 week, 10 studies (Kahn et al., 1990; Krampen,
1997; McCann and Holmes, 1984; McLean and Hakstian, 1979; Pace,
1977; Reynolds and Coats, 1986; Schröder et al., 2013; Shinozaki
et al., 2010; Wilson, 1982) were between 1 and 10 weeks, three studies
(Carpenter et al., 2008; Krogh et al., 2009; Murphy et al., 1995) were
longer than 10 weeks, and one study (Wood et al., 1996) was unclear
about the study duration.
Effects of Interventions
Relaxation Compared With Psychotherapy
Ten trials (Carpenter et al., 2008; Kahn et al., 1990; Krampen,
1997; McLean and Hakstian, 1979; Murphy et al., 1995; Pace, 1977;
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Jia et al.
TABLE 1. Study Characteristics for Relaxation as an Intervention for Treating Depression

Depression
Author Comparisons Sample Demographics Setting Diagnostic Criteria Type and Dosage of Relaxation Measures
Araujo et al. (2016) 1. Benson relaxation RT = 25 18 y or older Hospitalized women EPDS The Benson relaxation technique EPDS
technique C = 25 Male = 0% with high-risk was applied in the intervention

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2. Control group Female = 100% pregnancies group for 5 d
Carpenter et al. (2008) 1. Behavioral therapy BT = 18 Male = 57.9% University-affiliated, DSM-4 Type of relaxation: progressive HRSD, BDI
2. Structured RT = 20 Female = 42.1% community-based muscle relaxation + autogenic
relaxation BTDD = 38.8 (10.4) treatment programs relaxation exercises + visual
intervention REL = 41.2 (10.9) in the New York imagery based on idiographic
City area scenarios of relaxation or
tranquility; 24 weekly sessions
using a structured treatment
manual (20)
Kahn et al. (1990) 1. Cognitive-behavioral CBT = 17 Early adolescent School CDI, RADS, BID Type of relaxation: progressive BID, PH
treatment RT = 17 subjects (ages muscle plus psychoeducation
2. Relaxation treatment SMT = 17 10–14 y) including mental imagery and
3. Self-modeling WLC = 17 Male = 48.5% breathing
treatment Female = 51.5% Length of sessions: 50 min
4. Waiting list control Number of sessions: 12
Length of intervention: 6–8 wk
Krampen (1997) 1. Relaxation therapy RT = 19 Adult Outpatients ICD-10 and German Relaxation: autogenic training Self-rated
2. Psychological therapy PT = 18 Male = 30.9% version of Number of sessions: 10
3. Waiting list control WLC = 14 Female = 69.1% Structured Clinical Length of intervention: 10 wk
Interview for
DSM-3-R
Patient Edition
Krogh et al. (2009) 1. Strength training ST = 55 Aged between 18 Community ICD-10 Relaxation: exercises, muscle HAM-D17,
2. Aerobic training AT = 55 and 55 y contraction MADRS,
3. Relaxation training RT = 55 Male = 26.1% Length of sessions: 1.5 h DSM-4, BDI
Female = 73.9% Number of sessions: 32
Length of intervention: 4 mo
McCann and Holmes (1984) 1. Aerobic exercise AET = 16 Undergraduate women University BDI Relaxation: progressive muscle BDI
treatment p = 15 Male = 0% relaxation
2. Placebo treatment C = 16 Female = 100% Length of sessions: 15–20 min

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3. No treatment Number of sessions: 40
Length of intervention: 10 wk
McLean and Hakstian (1979) 1. Psychotherapy PT = 51 Between 20 and 60 y Community DACL Type of relaxation: progressive BDI
2. Relaxation therapy RT = 48 Male = 28% MMPI muscle relaxation
3. Behavior therapy BT = 44 Female = 72% BDI Length of sessions: 1 h
4. Drug therapy DT = 53 Number of sessions: 10
Length of intervention: 10 wk
Murphy et al. (1995) 1. Relaxation therapy RT = 14 Between 18 and 60 y Community BDI, HRSD Type of relaxation: Jacobson or BDI,
2. Cognitive-behavior CBT = 11 Male = 29.7% derivative HRSD-17
therapy DT = 12 Female = 70.3% Length of sessions: 50 min
3. Antidepressants (plus 20 min relaxation
tape daily)
Number of sessions: max of 20
Length of intervention: 16 wk

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The Journal of Nervous and Mental Disease • Volume 208, Number 4, April 2020
 Pace (1977) 1. Relaxation therapy RT = 6 Aged 20 to 55 y University BDI Type of relaxation: progressive BDI
2. Sensory awareness SAT = 6 Male = 0% muscle relaxation
training CET = 6 Female = 100% Length of sessions: 1 h
3. Cognitive-emotional Number of sessions: 7
therapy Length of intervention: 3.5 wk
Pace (1977) 1. Relaxation therapy RT = 8 Aged 20 to 55 y University BDI Type of relaxation: progressive BDI
2. Task assignment TA = 8 Male = 0% muscle relaxation
3. Client-oriented therapy COT = 8 Female = 100% Length of sessions: 1 h
4. Waiting list control Number of sessions: 7
Length of intervention: 3.5 wk
Reynolds and Coats (1986) 1. Cognitive-behavioral CBT = 9 Adolescents (mean School BDI Type of relaxation: progressive BDI, BID,
treatment RT = 11 overall age: 15.65 y) muscle relaxation RADS
2. Relaxation training WLC = 10 Male = 36.7% Length of sessions: 50 min
3. Waiting list control Female = 63.3% Number of sessions: 10
Length of intervention: 5 wk
Schröder et al. (2013) 1. Cognitive-behavioral CBT = 49 18 y of age or older Outpatients International Type of relaxation: progressive HADS-D
therapy RT = 41 Male = 23.1% Diagnostic muscle relaxation
2. Progressive muscle WLC = 44 Female = 76.9% Checklists for Length of sessions: 90 min
relaxation DSM-4 (IDCL) Number of sessions: 8
3. Waiting list control Length of intervention: 8 wk

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Shinozaki et al. (2010)
Wilson (1982)
1. Autogenic training AT = 11 (sample 1 = 32.8 ± Outpatients SDS Type of relaxation: autogenic SDS
2. Control therapy C = 10 2.8 sample training
2 = 30.3 ± 15.4) Length of sessions: 30–40 min
Male = 47.6% Number of sessions: 8
Female = 52.4% Length of intervention: 8 wk
1. Psychological therapy + PT = 9 Aged between 20 Community BDI Type of relaxation: progressive BDI
placebo (task assignment) RT = 11 and 55 y muscle relaxation
2. Relaxation + placebo C = 12 Male = 34.4% Length of sessions: 1 h (40 min
3. Minimal contact + placebo Female = 65.6% spent on relaxation), 30-min
daily practice encouraged
Number of sessions: 7
Length of intervention: 2 mo
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Wood et al. (1996) 1. Brief cognitive-behavior CBT = 26 Aged 9 through 17 y Unclear; might assume MFQ Type of relaxation: progressive MFQ
therapy RT = 27 Male = 31.25% outpatient at the muscle relaxation
2. Relaxation training Female = 68.75% children's hospital Length of sessions: unclear
where they Number of sessions: 5–8
were recruited Length of intervention: unclear
AT indicates aerobic training; AET, aerobic exercise treatment; BID, the Bellevue Index of Depression; BT, behavioral therapy; C, control group; CBT, cognitive-behavioral treatment; CDI, Children's Depres-

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sion Inventory; CET, cognitive-emotional therapy; COT, client-oriented therapy; DACL, depression adjective check list; DT, drug therapy or antidepressants; EPDS, Edinburgh Postnatal Depression Scale; HADS-
D, Hospital Anxiety and Depression Scale for Depression; HAM-D17, 17-item Hamilton Rating Scale for Depression; MADRS, Montgomery-Åsberg Depression Rating Scale; MFQ, mood and feelings ques-
tionnaire; MMPI, Minnesota Multiphasic Personality Inventory Depression Scale; P, placebo treatment; PT, psychotherapy; RADS, Reynolds Adolescent Depression Scale; RT, relaxation therapy; ST, strength
training; SAT, Sensory Awareness Training; SDS, Self-Reported Depression Scale; SMT, self-modeling treatment; TA, task assignment; WLC, waiting list control.

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Relaxation Therapy for Depression
Jia et al. The Journal of Nervous and Mental Disease • Volume 208, Number 4, April 2020
FIGURE 2. The summary of the risk of bias of the individual studies.
Reynolds and Coats, 1986; Schröder et al., 2013; Wilson, 1982; Wood
et al., 1996) compared relaxation with psychotherapy, and the results
from all studies could be pooled. For the 11 studies that used self-rated
scales, all 11 studies had postintervention data (SMD = 0.19; 95%
confidence interval [CI], −0.11 to 0.48) (Fig. 3A), five studies (Kahn
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et al., 1990; McLean and Hakstian, 1979; Pace, 1977; Reynolds and
Coats, 1986; Wood et al., 1996) had data over a short-term follow-up
(SMD = 0.29; 95% CI, −0.12 to 0.70) (Fig. 3B), and only three studies
(Schröder et al., 2013; Wilson, 1982; Wood et al., 1996) had data over
a long-term follow-up (SMD = −0.01; 95% CI, −0.29 to 0.27) (Fig. 3C).
For the clinician-rated scales, four studies (Carpenter et al., 2008; Kahn
et al., 1990; Murphy et al., 1995; Reynolds and Coats, 1986) had postin-
tervention data (SMD = 0.16; 95% CI, −0.24 to 0.57) (Fig. 3D), and only
one study (Reynolds and Coats, 1986) had data over a short-term follow-
up (SMD = 0.81; 95% CI, −0.39 to 2.01) (Fig. 3E). In conclusion, there
was no significant difference between the effects of relaxation therapy
and psychotherapy on depression. The outcomes of relaxation com-
pared with psychological treatment can be observed in Figure 3.
Relaxation Compared With No Treatment, Waiting List, or
Minimal Treatment
Eight trials (Araujo et al., 2016; Kahn et al., 1990; Krampen, 1997;
McCann and Holmes, 1984; Reynolds and Coats, 1986; Schröder et al.,
2013; Shinozaki et al., 2010; Wilson, 1982) compared relaxation with
no treatment, waiting list, or minimal treatment; these trials showed that
the relaxation group reported lower levels of self-reported depression
scores at postintervention (SMD = −0.57; 95% CI, −0.98 to −0.15)
(Fig. 4A). At follow-up, two trials (Kahn et al., 1990; Reynolds
FIGURE 3. Forest plots of comparison 1: Relaxation versus
psychotherapy. A, Depression scores: self-rated post intervention.
B, Depression scores: self-rated follow-up (short-term). C, Depression
scores: self-rated follow-up (long-term). D, Depression scores:
clinician-rated post intervention. E, Depression scores: clinician-rated
follow-up (short-term).
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The Journal of Nervous and Mental Disease • Volume 208, Number 4, April 2020 Relaxation Therapy for Depression

FIGURE 4. Forest plots of comparison 2: Relaxation versus waiting list, no treatment, placebo, or minimal treatment. A, Depression scores: self-rated
postintervention. B, Depression scores: self-rated follow-up (short-term). C, Depression scores: self-rated follow-up (long-term). D, Depression scores:
clinician-rated postintervention. E, Depression scores: clinician-rated follow-up (short-term).

and Coats, 1986) had short-term follow-up data still showing a lower
self-rated score in the relaxation group (SMD = −0.74; 95% CI,
−1.34 to −0.15) (Fig. 4B). Only one trial (Wilson, 1982) had long-term
follow-up data, and that study did not show a difference between relax-
ation and control conditions (SMD = −0.39; 95% CI, −1.24 to 0.45)
(Fig. 4C). For the clinician-rated depression scores, two trials (Kahn
et al., 1990; Reynolds and Coats, 1986) had postintervention data
(SMD = −1.35; 95% CI, −3.06 to 0.37) (Fig. 4D), and only one trial
(Reynolds and Coats, 1986) had data over a short-term follow-up
(SMD = −1.41; 95% CI, −2.59 to −0.22) (Fig. 4E). The relaxation in-
tervention showed advantages postintervention and during short-term
follow-up using self-rated scales compared with no treatment, waiting
list, or minimal treatment. Therefore, it might be argued that relaxation
therapy was more effective than no treatment, waiting list, or minimal
treatment in treating depression. The outcomes of the relaxation treat-
ment compared with no treatment, waiting list, or minimal treatment
can be observed in Figure 4.
1979; Murphy et al., 1995) compared relaxation with pharmacotherapy.
Although the number of studies was limited, we pooled the data and
conducted a meta-analysis and found no significant difference in the
effects of relaxation therapy on depression compared with exercise
and medication. The outcomes of relaxation compared with other treat-
ments are provided in Appendix 3 (Supplemental Digital Content
3, http://links.lww.com/JNMD/A98).
Sensitivity Analyses
We conducted a sensitivity analysis among the primary out-
comes, which included 10 studies comparing relaxation to psychother-
apy and eight studies comparing relaxation to no treatment, waiting list,
or minimal treatment. Finally, we found that the outcomes were gener-
ally stable, although they fluctuated slightly. The details of the sensitiv-
ity analysis are shown in Table 2.

Quality of the Evidence

Relaxation Compared With Other Treatments We evaluated the quality of the evidence for our outcomes,
Two trials (Krogh et al., 2009; McCann and Holmes, 1984) com- which showed moderate quality, low quality, and even very low quality
pared relaxation with exercise, and two trials (McLean and Hakstian, of evidence. The details for evaluating the quality of the evidence are

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Jia et al. The Journal of Nervous and Mental Disease • Volume 208, Number 4, April 2020

TABLE 2. Sensitivity Analyses

Study Name Pooled SMD Lower Limit Upper Limit Z-Value p-Value
Relaxation versus waiting list, no treatment, Araujo et al. (2016) −0.43 −0.82 −0.05 2.21 0.03
placebo, or minimal treatment (self-rated, Kahn et al. (1990) −0.50 −0.95 −0.05 2.19 0.03
postintervention) Krampen (1997) −0.60 −1.08 −0.12 2.45 0.01
McCann and Holmes (1984) −0.58 −1.05 −0.10 2.38 0.02
Reynolds and Coats (1986) −0.48 −0.89 −0.07 2.29 0.02
Schröder et al. (2013) −0.67 −1.11 −0.23 3.00 0.003
Shinozaki et al. (2010) −0.63 −1.08 −0.17 2.67 0.008
Wilson (1982) −0.66 −1.10 −0.23 2.99 0.003
Relaxation versus psychological treatment Carpenter et al. (2008) 0.25 −0.04 0.55 1.70 0.09
(self-rated, postintervention) Kahn et al. (1990) 0.14 −0.19 0.46 0.83 0.41
Krampen (1997) 0.17 −0.16 0.50 1.00 0.32
McLean and Hakstian (1979) 0.11 −0.20 0.42 0.71 0.48
Murphy et al. (1995) 0.22 −0.10 0.53 1.34 0.48
Pace (1977) 0.26 −0.01 0.53 1.91 0.06
Pace (1977) 0.23 −0.08 0.53 1.46 0.14
Reynolds and Coats (1986) 0.20 −0.11 0.52 1.28 0.20
Schröder et al. (2013) 0.18 −0.16 0.53 1.03 0.30
Wilson (1982) 0.16 −0.16 0.48 0.98 0.33
Wood et al. (1996) 0.12 −0.18 0.42 0.76 0.45

provided in Appendix 4 (Supplemental Digital Content 4, http://links.
lww.com/JNMD/A99).
DISCUSSION
Primary Findings and Interpretations
Our meta-analysis systematically reviewed currently available
articles and included 14 studies with 978 patients. The efficacy of relax-
ation therapy for depression was superior to that of no treatment,
waiting list, or minimal treatment but was not superior to psychother-
apy. However, given the risk of bias and the GRADE assessments, we
could not make definitive conclusions based on the current evidence.
Furthermore, the methodological quality and the overall strength of ev-
idence were low, suggesting that any estimate of effect is very uncertain.
The heterogeneity analysis indicated high heterogeneity. This finding
was likely due to the low-quality methodologies and small sample sizes.
Relaxation Compared With Psychotherapy
Despite its limitations, psychotherapy remains a classic treat-
ment for depression, and there is no doubt about its effectiveness
(Cuijpers et al., 2011; Cuijpers et al., 2012; Cuijpers et al., 2014;
DeRubeis et al., 2005; Driessen et al., 2010; Driessen et al., 2015;
Ekers et al., 2014; Malouff et al., 2007). Therefore, we compared the ef-
fect of relaxation on depression to psychotherapy. Relaxation therapy
has been suggested to be effective in treating depression, but not as ef-
fective as psychotherapy (Jorm et al., 2008). To our surprise, the results
of this updated meta-analysis suggested that there was no difference be-
tween relaxation therapy and psychotherapy in alleviating self-rated and
clinician-rated depressive symptoms either after the intervention or
at follow-up.
To determine the reasons for the different results, we first com-
pared the studies included in these two meta-studies. First, we found
that two new studies (Carpenter et al., 2008; Schröder et al., 2013) were
included in this updated meta-analysis, both of which showed that there
was no significant difference between the efficacy of relaxation therapy
and psychotherapy in treating depression. Therefore, we have
conducted a thorough understanding and analysis of the content of
these two included studies. We found that the relaxation therapy applied
in a recent trial (Carpenter et al., 2008) was different from that applied
in others, and the effect of the relaxation was more significant. Three
relaxation strategies were used in this trial: progressive muscle relaxa-
tion, autogenic relaxation exercises, and visual imagery; conversely,
only progressive muscle relaxation was applied in most other studies.
This finding suggested that relaxation became more effective in treating
depression, which may have resulted from the development and wide-
spread use of relaxation therapy. Second, RCTs have recently been
widely used in this research area because of their high reliability, and
we only included RCTs, whereas quasi-RCTs were also included in that
original meta-analysis. As we know, the results of RCTs are more reli-
able, which may suggest that the reliability and quality of our updated
meta-analysis are higher. Lastly, we conducted a sensitivity analysis
and found that the outcomes of our studies were stable; conversely, no
sensitivity analysis was performed in the other meta-analysis. Taking
these three reasons into account, we can conclude that our outcomes
are reliable and that there is indeed no difference in depressive symp-
toms alleviated by relaxation compared with psychotherapy. Moreover,
the effect of relaxation therapy on depression was more significant with
the development of relaxation therapy. Psychotherapy has been shown
to have definite effects on depression (Cuijpers et al., 2010) and has be-
come one of the most commonly used treatments for depression, but
complex treatment technology limits the application of psychotherapy
for depression. Relaxation is well accepted by participants (Jorm
et al., 2008) and does not require complex psychological techniques.
Therefore, relaxation therapy might be used as an alternative to psycho-
therapy to reduce depressive symptoms and improve attendance; fur-
thermore, it might be used in combination with psychotherapy to
improve the effect and acceptability.
Relaxation Compared With No Treatment, Waiting List, or
Minimal Treatment
As we expected, the results of this updated meta-analysis con-
firmed that relaxation therapy was more effective at reducing self-rated
depressive symptoms than no treatment, waiting list, or minimal

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The Journal of Nervous and Mental Disease • Volume 208, Number 4, April 2020
treatment (eight studies, 292 participants). However, there was no
significant difference in reducing clinician-rated depressive symptoms
between the relaxation and no treatment, waiting list, or minimal treat-
ment conditions. This finding may be due to the small quantity and ex-
cessive heterogeneity among the studies with data that could be pooled.
We could not account for this high heterogeneity. This result is consis-
tent with that of another meta-analysis (Jorm et al., 2008), and the effect
is also similar. Relaxation therapy was shown to be effective in reducing
self-reported depressive symptoms compared with no treatment or waiting
list or minimal treatment. However, given the limited number of related
studies, it is uncertain whether relaxation therapy is indeed valid in re-
ducing clinician-rated depressive symptoms, and further verification
is necessary.
Relaxation Compared With Other Treatments
In addition, in this updated meta-analysis, there was no differ-
ence in the reduction in depressive symptoms between relaxation and
therapy with medication or exercise. This same conclusion was reached
in the original meta-analysis (Jorm et al., 2008). However, because of
the limited number of comparisons that have been conducted in this
respect, no definitive conclusion can be drawn, and further research
should be conducted.
Strengths and Limitations
However, there are still some limitations in this meta-analysis.
Given the characteristics of relaxation interventions, blinding is impos-
sible, and only two trials definitely applied allocation concealment,
which may have decreased the quality of the research. Second, in most
studies included in our analysis, self-rated depression was used as the
primary outcome instead of clinician-rated depression. Taking these
two factors into account, we wonder whether there is performance bias
in the included studies.
CONCLUSIONS
This updated meta-analysis provides evidence to support the
viewpoint that relaxation might reduce depressive symptoms and that
the outcomes are no worse than those of psychotherapy. Given its sim-
plicity and acceptability, relaxation therapy may be used as a treatment
or adjuvant therapy for depression.
DISCLOSURE
The authors declare no conflict of interest.
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