- Email: [email protected]
An assessment of treating depression and anxiety with aromatherapy
The International Journal of Aromatherapy (2004) 14, 63–69
The International Journal of
Aromatherapy intl.elsevierhealth.com/journals/ijar
An assessment of treating depression and anxiety with aromatherapy Katie Lemon 22 Perceval Road, Inverness, IV3 5QE, Scotland, UK
KEYWORDS
Summary This investigation studied the effects of aromatherapy in alleviating depression and anxiety. It was an evaluation of the aromatherapy service offered as part of the Surrey Oaklands NHS Trust’s Day Hospital treatment plan. The research was designed to identify if there was a significant difference in perceived levels of anxiety and depression between a control group receiving massage with carrier oil alone and a test group receiving holistically prescribed essential oils diluted in carrier oil during massage. Thirty two subjects suffering from depression and/or anxiety were recruited from both inpatient and predominantly outpatient clients of the hospital. Half were randomly assigned to a control group and the other half to the aromatherapy test group. The test group received six, fortnightly massages lasting for 40 min. The essential oils were selected according to physical and psychological symptoms, e.g. anxiety, depression, headaches and sleep problems. The control group received massage with grape seed carrier oil without the essential oils in an identical environment to the test group. Both groups were monitored by their key worker in one-to-one sessions using the Montgomery-Asberg Depression Rating Scale (MADRS) or the Tyrer Brief Anxiety Scale (TBAS) on a monthly basis until week 12. The clients also completed a Hospital Depression Anxiety Scale (HADS) at the same time intervals. Statistical analysis of the results indicated a significant difference between aromatherapy and control groups. The test group showed a marked improvement in the results of the three questionnaires. c 2004 Elsevier Ltd. All rights reserved.
Aromatherapy; Anxiety; Depression; Psychiatry; Massage; Prescribing
Introduction Lyttle (1988a) states that depression is a disorder in which mood and vitality are lowered to the point of distress. Depression occurring as an unusually prolonged or intense reaction to loss is called reactive or exogenous depression and is classified as neurosis, thus being often called neurotic depression. Particularly severe depression may also arise E-mail address: [email protected].
from within the patient. This type of depression is called endogenous depression and is classified as psychosis, thus being referred to as a psychotic depression. Genetic and biochemical factors play an important part in its development. About one in 10 of the population will suffer from depression and women are twice as likely to be affected as men. Reactive depression is twice as common as endogenous depression and the overall incidence of depression in the UK appears to be rising. Usual treatment may be physical (electroplexy or anti-depressant drugs – tricyclics,
0962-4562/$ - see front matter c 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijat.2004.04.002
64
K. Lemon
monoamine oxidase inhibitors, lithium salts) or non-physical (psychotherapeutic approaches) and the two are often combined. Depression has physical, psychological and social effects and the overall picture is one of loss of drive, vitality, interest and libido with the added problems of delusional thinking and loss of insight in many endogenous attacks (Lyttle, 1988a). Anxiety consists of a blend of physical and psychological responses to threat;be that threat real or imagined. Objective anxiety is a realistic response to perceived danger in the environment and is adaptive in most situations. Neurotic anxiety arises from inner threat generated by conflict in the unconscious. Anxiety is the raw material from which all neuroses are constructed, and neurosis may be regarded as a maladaptive response to anxiety. In some neuroses the individual attempts to reduce anxiety by developing ritualistic techniques (obsessive compulsive neurosis), in others the individual becomes morbidly preoccupied with self (neurotic depression), and in others the anxiety itself predominates (anxiety state). Anxiety states are probably the commonest mental disorders and arise when stress exceeds capacity to cope. Anxiety states may be phobic (related to object or situation) or free-floating (unattached and unexplained). Anxiety states are widespread in their distribution but tend to be commonest in young females. Physical and psychological effects of anxiety vary and cause much psychosocial disruption. Phobias respond favourably to psychological methods of treatment and prognosis is usually good (Lyttle, 1988b). Half of the clients attending the Surrey Oaklands NHS Trust Day Hospital suffered from depression and half suffered from anxiety, or a combination of the two. A previous study carried out by Garnett-Ore (1996) found that aromatherapy could be beneficial in alleviating psychological distress. The object of this investigation was to measure that improve-
Table 1
ment by use of questionnaires, quantify it and statistically analyse whether the difference between the test and control groups was significant or the result of chance.
Essential oils Assessment was made by the aromatherapist as to which essential oils would be most beneficial for the client according to other presenting conditions e.g. headaches, sleep problems. A pilot study prior to the research indicated that a number of essential oils were used most frequently in the Day Hospital setting and so client blends were chosen from this range by the aromatherapist. These essential oils are shown in Table 1. All nine essential oils have been empirically reported to potentially alleviate anxiety and depression.Three top notes, three middle notes and three base notes were selected for inclusion in the study and their claimed effects described in the literature are given below. Bergamot was selected as its light, fresh, citrus fragrance is uplifting to the mind, lifting one out of depression. It can stimulate or sedate the nervous system according to the individual needs, relieving anxiety and calming fears (Lawless, 1994). Clary sage is often described as euphoric it does not always induce such heightened feelings, but it certainly has a deeply relaxing effect, thus helpful in dealing with muscular stress and tension (Davis, 1995). It was also included for treating hormonerelated mood disorders. Another citrus oil, lemon, was included for its tangy, bright fragrance is refreshing and uplifting to the spirit. It also has been found to have a psychologically strengthening effect on usually depressed or fearful patients (Lawless, 1994). Lemon has also been said to boost the immune system and fight infection.
Essential oils most frequently used in the Day Hospital environment
Top notes
Bergamot Lemon Clary sage
Citrus bergamia Citrus limon Salvia sclarea
Middle notes
Lavender Roman chamomile Geranium
Lavandula angustifolia Chamaemelum nobile Pelargonium graveolens
Base notes
Rose otto Sandalwood Jasmine
Rosa damascena Santalum album Jasminum officinalis
An assessment of treating depression and anxiety with aromatherapy The ubiquitous lavender had to be included as it covers a multitude of conditions, but primarily as it is invaluable to those who suffer from widely fluctuating mood states and feelings of emotional instability, including hysteria and manic depression. It also helps to calm feelings of anxiety and assist in getting good nights sleep. Lack of sleep has a profound effect on mood and perception of pain (Lawless, 1994). Roman chamomile has a calming effect on an emotional level and is mildly sedating without being depressive. It is for hyper-sensitive individuals who are deeply affected by emotional upsets, especially those prone to allergies (Lawless, 1994). Geranium is similar to clary sage in that it was selected for its affinity to women’s conditions. It has an excellent regulatory effect on the body including the nervous system. It is soothing yet revitalising (Lawless, 1994). Psychologically, the scent of rose has a powerful effect on the emotions. It is also a mild sedative and anti-depressant, excellent for emotional shock, bereavement and grief (Lawless, 1994). Sandalwood essential oil was also included as a masculine scent as opposed to some of the feminine, floral essential oils. It is beneficial for depression, anxiety and stress-related problems as it has a grounding and opening effect on the psyche. Its heavy scent is gently sedating and antiseptic in nature (Lawless, 1994). Jasmine boosts a person’s sense of self-worth and thus confidence. It is invaluable in treating the lethargy that is associated with depression (Davis, 1995).
Subjects Thirty two clients suffering from depression and/or anxiety were selected from the psychiatric in-patient wards and predominately those attending Surrey Oakland’s NHS Trust’s Day Hospital. Depressed clients were initially assessed by their key worker (either their psychiatric nurse or occupational therapist) using the Montgomery-Asberg Depression Rating Scale (MADRS) for a level above 7 indicating mild to severe depression. Similarly, anxious clients were assessed using the Tyrer Brief Anxiety Scale (TBAS). The cohort was chosen from both sexes, in as wide an age range as possible and included patients with varying degrees of impairment. As the clients were potentially vulnerable, permission was gained from the Hospital’s Ethics Committee and from the clients themselves, who after reading an information sheet, completed a
65
consent form before joining the study. The clients were randomly divided and assigned to either a control group or an aromatherapy test group.
Methods Clients in the test group were seen once a fortnight over a 12-week period at approximately the same time and day. They were welcomed into a warm room and asked to sit down; 5–10 min were spent discussing ailments and changes so as the essential oils could be chosen by the aromatherapist. The blended oil combination would vary from session to session according to presenting problems, but remained from the list of nine frequently used essential oils and at the same dilution rate (4 drops of essential oil in total to 15 ml of carrier oil). Any medication or therapy changes were also asked about and recorded. A tape of gentle music was playing softly throughout – Pantops (Hemi-Sync. Nellysford, VA). The room was warm and dimly lit. Clients in the control group were also received over the same time period and into an identical environment as those of the test group. One to one time was spent by the aromatherapist and client prior to the massage. Both client groups were asked to remove jewellery and undress to expose back, arms and legs. The client then lay face down on an aromatherapy couch and was covered with a bath sheet towel from the buttocks down. Four drops in total of the chosen essential oils were diluted in 15 ml grape seed carrier oil for each client in the test group. The control group were massaged using grape seed oil alone. The full 15 ml of the blend or grape seed oil alone was used for a full body massage using gentle effleurage (large, gentle, and rhythmical stroke) and petrissage (circular movements over a limited area using thumbs or finger tips).
Back Approximately 5 ml of the blend was warmed in the aromatherapist’s hands and then applied to the back using gentle effleurage strokes. Petrissage action was used around the shoulders and sacral areas. The back was then covered with the towel and the legs exposed.
Back of legs The oil blend was applied to the back of both legs. A second towel then covered the leg not receiving
66
K. Lemon
massage at that time. Approximately 212 min massage was given to each leg. Gentle effleurage was directed up the leg towards the heart. Particular attention was made to the calf muscle. If varicose veins or oedema were present, very light pressure was used.
Front of legs The client then turned over whilst remaining covered with a towel from top of legs up. The blend was then applied to the front of legs, and 5 min was spent massaging each leg as before. This time attention was paid to the thigh muscles. The feet were then massaged using a combination of effleurage, then petrissage between tendons leading to toes on the top of the feet, and down the toes, which were then pulled gently. The legs were then covered on completion of the massage.
Arms One arm was exposed at a time, and massaged begun with gentle effleurage strokes used from wrist to shoulder. Petrissage was used to the inner forearm, wrist joint, between tendons leading to fingers on the back of the hands, and down the fingers, which were then pulled gently. Both arms were covered on completion.
Top of shoulders and face The towel was folded back down to just below the clavicle. The remainder of the oil was utilised. Effleurage was given around the shoulders to the back of the neck, with petrissage used into the top of the posterior shoulder muscles. Petrissage was applied to the centre of the nape of neck working gradually out towards the ears. Gentle traction was applied to the neck. Effleurage to the neck, as at the start, completed this section. The face was gently massage using effleurage. The client was then allowed to relax for a short time, before getting dressed again. The massage time was allocated as follows: Back Back of legs Front of legs Arms Top of shoulders and face
10 5 10 10 5
min min min min min
Measurements To try to reduce bias from the client or the aromatherapist, assessments were made by the key workers using the MADRS or the TBAS at weeks 0, 4, 8, and 12. The clients also completed a HADS at the same time intervals. The depression rating scale devised by Montgomery and Asberg (1979) has been used for over 20 years. It was used as an assessment tool in this study because it includes 10 commonly occurring symptoms that show the largest change with treatment, and the greatest correlation with overall change, which is an important factor in clinical trials. The questions take into account levels of apparent and reported sadness, feelings or inner tension, affects on sleep and appetite, ability to concentrate and feel, lassitude and thoughts whether pessimistic or suicidal. Each question ranges from 0 to 6. TBAS is described by the authors as a sub-division of the Comprehensive Psychopathological Rating Scale, which allows evaluation of patients other than those with anxiety neurosis (Tyrer et al., 1984). Its pattern is similar to that of the MADRS, which simplified usage. These questions evaluated feelings of inner tension and hostility, hypochondriasis, worrying over trifle issues, phobias, reduced sleep, autonomic disturbances such as palpitations or sweating more, aches and pains (other than an organic cause), separate from muscular tension, which is rated separately. HADS was a questionnaire completed by the client, as it was also important to record how the client felt about the benefits of the treatment. It was designed to measure the perceived severity of emotional disorder. It consisted of 7 anxiety items and 7 depression items and rated each 1–4 (Zigmond and Snaith, 1983). Anxiety questions addressed symptoms such as being frightened, fearing something bad will happen, worry, relaxation, feeling butterflies in stomach, restlessness and panic. Depression questions rated feelings of enjoyment in the present, future and tasks one used to enjoy, feelings of cheerfulness, feeling slowed down, still being able to laugh and see things as funny and interest in one’s own appearance. Medication and therapy changes during the assessment period were also recorded so that benefits could not be attributed to these.
Results Six subjects in the control group dropped out after the first session and their details have been omit-
An assessment of treating depression and anxiety with aromatherapy Table 2
67
The sex, age and oil selection of the test group Sex
Age
Oil selection
1 2 3 4 6 7 8
F F M M M M F
25 35 37 43 24 50 42
9 11 12 13 14 15 16
F F F F F F F
23 37 41 53 39 48 30
Bergamot, chamomile, geranium, lavender, lemon Clary sage, geranium, lavender, rose Chamomile, lavender, lemon, rose Chamomile, geranium, lavender, sandalwood Chamomile, geranium, lemon, sandalwood Jasmine, lavender, lemon, rose, sandalwood Bergamot, chamomile, clary sage, jasmine, lavender, lemon, sandalwood Clary sage, geranium, lavender, lemon, sandalwood, Bergamot, chamomile, lavender, geranium, rose Chamomile, lavender, lemon, rose Chamomile, geranium, jasmine, lemon Clary sage, lavender, geranium, jasmine, lemon Chamomile, clary sage, lemon, rose Bergamot, chamomile, lavender, jasmine, rose
ted from the results. The essential oils chosen by each member of the test group are given in Table 2. After the raw data were collated from the questionnaires taken over the 12-week period, the averages of the results were determined (Tables 2 and 3) and plotted as graphs (Graphs 1 and 2). The two groups (test and control) were then grouped together to rank the differences. Then the totals of the ranks of the test groups gave T. To carry out the calculations, the number of clients in the test group was designated n1 , and the number of clients in the control group was designated n2 . The Mann–Whitney equation T n1 ðn1 þ n2 þ 1Þ=2 z ¼ pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi fn1 n2 ðn1 þ n2 þ 1Þ=12g was applied to give z (Campbell and Machin, 1999). This value was then compared to a table of probability to give U. If U is less than 0.05, the confidence limit of probability, then this indicates Table 3
Average of control results (see Graph 1)
Questionnaire
Time (weeks) 0
4
8
12
MADRS TBAS HA(D) H(A)D
19.8 17.1 14.6 13.3
19.4 17.6 13.3 11.3
18 16.8 13.1 10.3
21.1 21.3 13.7 10.8
Number
10
10
10
10 Graph 1
Average of control results.
68
K. Lemon that there is a significant difference between the test and control group, which cannot be attributed to chance. U ¼ 0.0455 U ¼ 0.4295 U ¼ 0.0105 U ¼ 0.0031
HA(D): H(A)D: MADRS: TBAS:
The overall results are shown in Table 4.
Discussion
Graph 2
Table 4
As the clients were randomly assigned to the groups there was a disproportionate amount of ‘severely’depressed or anxious clients assigned to the test group, so their initial results averaged higher than the control group. Even so, the final averages show an improvement compared to the control group. The control averages made a slight improvement according to the gradient of the graph. This was to be expected, as massage itself is relaxing and the expectation of the client is to improve and please the aromatherapist. The test group shows a much more dramatic change in the gradient. The final questionnaire was carried out two weeks after the completion of the course of treatment. At this point we noticed an increase in the results as the clients began to ‘act out’ or exhibit to their key workers a possible reluctance in finishing their treatment and a desire to be re-referred to the
Average of test results.
Average of test results (see Graph 2)
Questionnaire
Time (weeks) 0
4
8
12
30 24.6 15.3 12.3 16
23.4 16.8 12.8 11.1 16
15.8 13.5 10.5 9.3 16
18.1 14.6 9.7 8.7 16
Results used in the Mann–Whitney equation HA(D) H(A)D
MADRS
TBAS
n1 ¼ 16 n2 ¼ 10 T ¼ 254 z ¼ 2:00 p ¼ 0:0455
n1 ¼ 14 n2 ¼ 10 T ¼ 220:5 z ¼ 2:66 p ¼ 0:0105
n1 ¼ 14 n2 ¼ 9 T ¼ 215 z ¼ 2:96 p ¼ 0:0031
MADRS TBAS HA(D) H(A)D Number
n1 ¼ 16 n2 ¼ 10 T ¼ 231 z ¼ 0:79 p ¼ 0:4295
An assessment of treating depression and anxiety with aromatherapy service. However, the questionnaires that the clients completed themselves indicate a continuing of improvement in the test group, the reasons for which are unclear. In the control group, the benefits gained are demonstrated by a slight reduction in the patients’perception of anxiety or depression. The test group showed a marked improvement in the results of the three questionnaires in comparison to the control group. The Mann–Whitney U test was used for the analysis as a non-parametric test as the numbers of the groups was less than 20. According to the Mann–Whitney U test all except the H(A)D probability results (or U) were less than 0.05, indicating that there was a significant difference between the control and test groups, which was a result that can be attributed to the treatment and not by chance. The feedback from the clients involved in the test group was also very positive as they found the treatments both beneficial and pleasurable, with a tangible improvement in their quality of life. The overall effects of the aromatherapy treatments were wider ranging than the original investigation parameters were intended to assess. The researcher found the use of essential oils, prescribed for the relief of depression and anxiety, but also blended specifically for the client, addressed other issues such as sleep disturbance and headaches, which the clients also reported had improved. This in turn, had an effect on their perception of their psychological condition. Clients benefited from the physical contact provided in a professional setting. The massage eased muscular aches, pains, tension, soothed, reassured and relaxed. Although this study is a scientific evaluation of a service, the writer believes that such additional information reinforces the health professionals’ holistic role when dealing with people who have needs and problems and who are not ‘just numbers’. It was interesting to note that there was a drop out rate of 33% (6 people) after the first session amongst the control group; perhaps they realised that they were in the control group due to the lack of odour from the massage oil. A follow-up study
69
could use a synthetic fragrance product in the control group (assuming no inherent beneficial effect) and compare against massage with essential oils to ascertain the therapeutic effect of essential oils over a pleasant odour. Clients tended to drop out just before the end of the course of treatment in the test group (18%). An exit interview would have been useful to identify why this happened, so that it could be reduced in the therapy and in any future research. It was concluded that this study has statistically proven that the holistic use of aromatherapy had a beneficial therapeutic effect on clients who were more than mildly depressed or anxious. Further studies would be beneficial using larger numbers of clients for statistical reasons.
Acknowledgements Sincere gratitude to Shirley Price Aromatherapy for the donation of all the essential oils and carrier oil used in this evaluation. Ian Smith, Ewa Wikiel, Dr. Ken Chezinski, and Dr. William Hood for their clinical and statistical advice. Chris Lemon, Frances Fee, Tessa Flora, Jean Palmer, Druid Fleming, Linda Davies, Carol Farrell and George Hogan for completing the endless questionnaires, and most importantly the clients for participating.
References Campbell MJ, Machin D. Statistical Inference Medical Statistics, A Common Sense Approach. Chichester: Wiley; 1999. Davis P. Aromatherapy an A–Z. Saffron Walden: Daniel; 1995. Garnett-Ore L. Aromatherapy within Mental Health Services. Aromatherapist 1996;3(1):17–29. Lawless J. Aromatherapy and the mind. London: Thorsons; 1994. Lyttle J. Depression in mental disorder. Edinburgh: Bailliere Tindall; 1988a. Lyttle J. Anxiety in mental disorder. Edinburgh: Bailliere Tindall; 1988b. Montgomery A, Asberg M. Br J Psychiatry 1979;134:382–9. Tyrer P, Owen RT, Cicchetti DR. J Neurol Neurosurg Psychiatry 1984;47:970–5. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psych Scand 1983;67:361–70.
The International Journal of
Aromatherapy intl.elsevierhealth.com/journals/ijar
An assessment of treating depression and anxiety with aromatherapy Katie Lemon 22 Perceval Road, Inverness, IV3 5QE, Scotland, UK
KEYWORDS
Summary This investigation studied the effects of aromatherapy in alleviating depression and anxiety. It was an evaluation of the aromatherapy service offered as part of the Surrey Oaklands NHS Trust’s Day Hospital treatment plan. The research was designed to identify if there was a significant difference in perceived levels of anxiety and depression between a control group receiving massage with carrier oil alone and a test group receiving holistically prescribed essential oils diluted in carrier oil during massage. Thirty two subjects suffering from depression and/or anxiety were recruited from both inpatient and predominantly outpatient clients of the hospital. Half were randomly assigned to a control group and the other half to the aromatherapy test group. The test group received six, fortnightly massages lasting for 40 min. The essential oils were selected according to physical and psychological symptoms, e.g. anxiety, depression, headaches and sleep problems. The control group received massage with grape seed carrier oil without the essential oils in an identical environment to the test group. Both groups were monitored by their key worker in one-to-one sessions using the Montgomery-Asberg Depression Rating Scale (MADRS) or the Tyrer Brief Anxiety Scale (TBAS) on a monthly basis until week 12. The clients also completed a Hospital Depression Anxiety Scale (HADS) at the same time intervals. Statistical analysis of the results indicated a significant difference between aromatherapy and control groups. The test group showed a marked improvement in the results of the three questionnaires. c 2004 Elsevier Ltd. All rights reserved.
Aromatherapy; Anxiety; Depression; Psychiatry; Massage; Prescribing
Introduction Lyttle (1988a) states that depression is a disorder in which mood and vitality are lowered to the point of distress. Depression occurring as an unusually prolonged or intense reaction to loss is called reactive or exogenous depression and is classified as neurosis, thus being often called neurotic depression. Particularly severe depression may also arise E-mail address: [email protected].
from within the patient. This type of depression is called endogenous depression and is classified as psychosis, thus being referred to as a psychotic depression. Genetic and biochemical factors play an important part in its development. About one in 10 of the population will suffer from depression and women are twice as likely to be affected as men. Reactive depression is twice as common as endogenous depression and the overall incidence of depression in the UK appears to be rising. Usual treatment may be physical (electroplexy or anti-depressant drugs – tricyclics,
0962-4562/$ - see front matter c 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijat.2004.04.002
64
K. Lemon
monoamine oxidase inhibitors, lithium salts) or non-physical (psychotherapeutic approaches) and the two are often combined. Depression has physical, psychological and social effects and the overall picture is one of loss of drive, vitality, interest and libido with the added problems of delusional thinking and loss of insight in many endogenous attacks (Lyttle, 1988a). Anxiety consists of a blend of physical and psychological responses to threat;be that threat real or imagined. Objective anxiety is a realistic response to perceived danger in the environment and is adaptive in most situations. Neurotic anxiety arises from inner threat generated by conflict in the unconscious. Anxiety is the raw material from which all neuroses are constructed, and neurosis may be regarded as a maladaptive response to anxiety. In some neuroses the individual attempts to reduce anxiety by developing ritualistic techniques (obsessive compulsive neurosis), in others the individual becomes morbidly preoccupied with self (neurotic depression), and in others the anxiety itself predominates (anxiety state). Anxiety states are probably the commonest mental disorders and arise when stress exceeds capacity to cope. Anxiety states may be phobic (related to object or situation) or free-floating (unattached and unexplained). Anxiety states are widespread in their distribution but tend to be commonest in young females. Physical and psychological effects of anxiety vary and cause much psychosocial disruption. Phobias respond favourably to psychological methods of treatment and prognosis is usually good (Lyttle, 1988b). Half of the clients attending the Surrey Oaklands NHS Trust Day Hospital suffered from depression and half suffered from anxiety, or a combination of the two. A previous study carried out by Garnett-Ore (1996) found that aromatherapy could be beneficial in alleviating psychological distress. The object of this investigation was to measure that improve-
Table 1
ment by use of questionnaires, quantify it and statistically analyse whether the difference between the test and control groups was significant or the result of chance.
Essential oils Assessment was made by the aromatherapist as to which essential oils would be most beneficial for the client according to other presenting conditions e.g. headaches, sleep problems. A pilot study prior to the research indicated that a number of essential oils were used most frequently in the Day Hospital setting and so client blends were chosen from this range by the aromatherapist. These essential oils are shown in Table 1. All nine essential oils have been empirically reported to potentially alleviate anxiety and depression.Three top notes, three middle notes and three base notes were selected for inclusion in the study and their claimed effects described in the literature are given below. Bergamot was selected as its light, fresh, citrus fragrance is uplifting to the mind, lifting one out of depression. It can stimulate or sedate the nervous system according to the individual needs, relieving anxiety and calming fears (Lawless, 1994). Clary sage is often described as euphoric it does not always induce such heightened feelings, but it certainly has a deeply relaxing effect, thus helpful in dealing with muscular stress and tension (Davis, 1995). It was also included for treating hormonerelated mood disorders. Another citrus oil, lemon, was included for its tangy, bright fragrance is refreshing and uplifting to the spirit. It also has been found to have a psychologically strengthening effect on usually depressed or fearful patients (Lawless, 1994). Lemon has also been said to boost the immune system and fight infection.
Essential oils most frequently used in the Day Hospital environment
Top notes
Bergamot Lemon Clary sage
Citrus bergamia Citrus limon Salvia sclarea
Middle notes
Lavender Roman chamomile Geranium
Lavandula angustifolia Chamaemelum nobile Pelargonium graveolens
Base notes
Rose otto Sandalwood Jasmine
Rosa damascena Santalum album Jasminum officinalis
An assessment of treating depression and anxiety with aromatherapy The ubiquitous lavender had to be included as it covers a multitude of conditions, but primarily as it is invaluable to those who suffer from widely fluctuating mood states and feelings of emotional instability, including hysteria and manic depression. It also helps to calm feelings of anxiety and assist in getting good nights sleep. Lack of sleep has a profound effect on mood and perception of pain (Lawless, 1994). Roman chamomile has a calming effect on an emotional level and is mildly sedating without being depressive. It is for hyper-sensitive individuals who are deeply affected by emotional upsets, especially those prone to allergies (Lawless, 1994). Geranium is similar to clary sage in that it was selected for its affinity to women’s conditions. It has an excellent regulatory effect on the body including the nervous system. It is soothing yet revitalising (Lawless, 1994). Psychologically, the scent of rose has a powerful effect on the emotions. It is also a mild sedative and anti-depressant, excellent for emotional shock, bereavement and grief (Lawless, 1994). Sandalwood essential oil was also included as a masculine scent as opposed to some of the feminine, floral essential oils. It is beneficial for depression, anxiety and stress-related problems as it has a grounding and opening effect on the psyche. Its heavy scent is gently sedating and antiseptic in nature (Lawless, 1994). Jasmine boosts a person’s sense of self-worth and thus confidence. It is invaluable in treating the lethargy that is associated with depression (Davis, 1995).
Subjects Thirty two clients suffering from depression and/or anxiety were selected from the psychiatric in-patient wards and predominately those attending Surrey Oakland’s NHS Trust’s Day Hospital. Depressed clients were initially assessed by their key worker (either their psychiatric nurse or occupational therapist) using the Montgomery-Asberg Depression Rating Scale (MADRS) for a level above 7 indicating mild to severe depression. Similarly, anxious clients were assessed using the Tyrer Brief Anxiety Scale (TBAS). The cohort was chosen from both sexes, in as wide an age range as possible and included patients with varying degrees of impairment. As the clients were potentially vulnerable, permission was gained from the Hospital’s Ethics Committee and from the clients themselves, who after reading an information sheet, completed a
65
consent form before joining the study. The clients were randomly divided and assigned to either a control group or an aromatherapy test group.
Methods Clients in the test group were seen once a fortnight over a 12-week period at approximately the same time and day. They were welcomed into a warm room and asked to sit down; 5–10 min were spent discussing ailments and changes so as the essential oils could be chosen by the aromatherapist. The blended oil combination would vary from session to session according to presenting problems, but remained from the list of nine frequently used essential oils and at the same dilution rate (4 drops of essential oil in total to 15 ml of carrier oil). Any medication or therapy changes were also asked about and recorded. A tape of gentle music was playing softly throughout – Pantops (Hemi-Sync. Nellysford, VA). The room was warm and dimly lit. Clients in the control group were also received over the same time period and into an identical environment as those of the test group. One to one time was spent by the aromatherapist and client prior to the massage. Both client groups were asked to remove jewellery and undress to expose back, arms and legs. The client then lay face down on an aromatherapy couch and was covered with a bath sheet towel from the buttocks down. Four drops in total of the chosen essential oils were diluted in 15 ml grape seed carrier oil for each client in the test group. The control group were massaged using grape seed oil alone. The full 15 ml of the blend or grape seed oil alone was used for a full body massage using gentle effleurage (large, gentle, and rhythmical stroke) and petrissage (circular movements over a limited area using thumbs or finger tips).
Back Approximately 5 ml of the blend was warmed in the aromatherapist’s hands and then applied to the back using gentle effleurage strokes. Petrissage action was used around the shoulders and sacral areas. The back was then covered with the towel and the legs exposed.
Back of legs The oil blend was applied to the back of both legs. A second towel then covered the leg not receiving
66
K. Lemon
massage at that time. Approximately 212 min massage was given to each leg. Gentle effleurage was directed up the leg towards the heart. Particular attention was made to the calf muscle. If varicose veins or oedema were present, very light pressure was used.
Front of legs The client then turned over whilst remaining covered with a towel from top of legs up. The blend was then applied to the front of legs, and 5 min was spent massaging each leg as before. This time attention was paid to the thigh muscles. The feet were then massaged using a combination of effleurage, then petrissage between tendons leading to toes on the top of the feet, and down the toes, which were then pulled gently. The legs were then covered on completion of the massage.
Arms One arm was exposed at a time, and massaged begun with gentle effleurage strokes used from wrist to shoulder. Petrissage was used to the inner forearm, wrist joint, between tendons leading to fingers on the back of the hands, and down the fingers, which were then pulled gently. Both arms were covered on completion.
Top of shoulders and face The towel was folded back down to just below the clavicle. The remainder of the oil was utilised. Effleurage was given around the shoulders to the back of the neck, with petrissage used into the top of the posterior shoulder muscles. Petrissage was applied to the centre of the nape of neck working gradually out towards the ears. Gentle traction was applied to the neck. Effleurage to the neck, as at the start, completed this section. The face was gently massage using effleurage. The client was then allowed to relax for a short time, before getting dressed again. The massage time was allocated as follows: Back Back of legs Front of legs Arms Top of shoulders and face
10 5 10 10 5
min min min min min
Measurements To try to reduce bias from the client or the aromatherapist, assessments were made by the key workers using the MADRS or the TBAS at weeks 0, 4, 8, and 12. The clients also completed a HADS at the same time intervals. The depression rating scale devised by Montgomery and Asberg (1979) has been used for over 20 years. It was used as an assessment tool in this study because it includes 10 commonly occurring symptoms that show the largest change with treatment, and the greatest correlation with overall change, which is an important factor in clinical trials. The questions take into account levels of apparent and reported sadness, feelings or inner tension, affects on sleep and appetite, ability to concentrate and feel, lassitude and thoughts whether pessimistic or suicidal. Each question ranges from 0 to 6. TBAS is described by the authors as a sub-division of the Comprehensive Psychopathological Rating Scale, which allows evaluation of patients other than those with anxiety neurosis (Tyrer et al., 1984). Its pattern is similar to that of the MADRS, which simplified usage. These questions evaluated feelings of inner tension and hostility, hypochondriasis, worrying over trifle issues, phobias, reduced sleep, autonomic disturbances such as palpitations or sweating more, aches and pains (other than an organic cause), separate from muscular tension, which is rated separately. HADS was a questionnaire completed by the client, as it was also important to record how the client felt about the benefits of the treatment. It was designed to measure the perceived severity of emotional disorder. It consisted of 7 anxiety items and 7 depression items and rated each 1–4 (Zigmond and Snaith, 1983). Anxiety questions addressed symptoms such as being frightened, fearing something bad will happen, worry, relaxation, feeling butterflies in stomach, restlessness and panic. Depression questions rated feelings of enjoyment in the present, future and tasks one used to enjoy, feelings of cheerfulness, feeling slowed down, still being able to laugh and see things as funny and interest in one’s own appearance. Medication and therapy changes during the assessment period were also recorded so that benefits could not be attributed to these.
Results Six subjects in the control group dropped out after the first session and their details have been omit-
An assessment of treating depression and anxiety with aromatherapy Table 2
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The sex, age and oil selection of the test group Sex
Age
Oil selection
1 2 3 4 6 7 8
F F M M M M F
25 35 37 43 24 50 42
9 11 12 13 14 15 16
F F F F F F F
23 37 41 53 39 48 30
Bergamot, chamomile, geranium, lavender, lemon Clary sage, geranium, lavender, rose Chamomile, lavender, lemon, rose Chamomile, geranium, lavender, sandalwood Chamomile, geranium, lemon, sandalwood Jasmine, lavender, lemon, rose, sandalwood Bergamot, chamomile, clary sage, jasmine, lavender, lemon, sandalwood Clary sage, geranium, lavender, lemon, sandalwood, Bergamot, chamomile, lavender, geranium, rose Chamomile, lavender, lemon, rose Chamomile, geranium, jasmine, lemon Clary sage, lavender, geranium, jasmine, lemon Chamomile, clary sage, lemon, rose Bergamot, chamomile, lavender, jasmine, rose
ted from the results. The essential oils chosen by each member of the test group are given in Table 2. After the raw data were collated from the questionnaires taken over the 12-week period, the averages of the results were determined (Tables 2 and 3) and plotted as graphs (Graphs 1 and 2). The two groups (test and control) were then grouped together to rank the differences. Then the totals of the ranks of the test groups gave T. To carry out the calculations, the number of clients in the test group was designated n1 , and the number of clients in the control group was designated n2 . The Mann–Whitney equation T n1 ðn1 þ n2 þ 1Þ=2 z ¼ pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi fn1 n2 ðn1 þ n2 þ 1Þ=12g was applied to give z (Campbell and Machin, 1999). This value was then compared to a table of probability to give U. If U is less than 0.05, the confidence limit of probability, then this indicates Table 3
Average of control results (see Graph 1)
Questionnaire
Time (weeks) 0
4
8
12
MADRS TBAS HA(D) H(A)D
19.8 17.1 14.6 13.3
19.4 17.6 13.3 11.3
18 16.8 13.1 10.3
21.1 21.3 13.7 10.8
Number
10
10
10
10 Graph 1
Average of control results.
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K. Lemon that there is a significant difference between the test and control group, which cannot be attributed to chance. U ¼ 0.0455 U ¼ 0.4295 U ¼ 0.0105 U ¼ 0.0031
HA(D): H(A)D: MADRS: TBAS:
The overall results are shown in Table 4.
Discussion
Graph 2
Table 4
As the clients were randomly assigned to the groups there was a disproportionate amount of ‘severely’depressed or anxious clients assigned to the test group, so their initial results averaged higher than the control group. Even so, the final averages show an improvement compared to the control group. The control averages made a slight improvement according to the gradient of the graph. This was to be expected, as massage itself is relaxing and the expectation of the client is to improve and please the aromatherapist. The test group shows a much more dramatic change in the gradient. The final questionnaire was carried out two weeks after the completion of the course of treatment. At this point we noticed an increase in the results as the clients began to ‘act out’ or exhibit to their key workers a possible reluctance in finishing their treatment and a desire to be re-referred to the
Average of test results.
Average of test results (see Graph 2)
Questionnaire
Time (weeks) 0
4
8
12
30 24.6 15.3 12.3 16
23.4 16.8 12.8 11.1 16
15.8 13.5 10.5 9.3 16
18.1 14.6 9.7 8.7 16
Results used in the Mann–Whitney equation HA(D) H(A)D
MADRS
TBAS
n1 ¼ 16 n2 ¼ 10 T ¼ 254 z ¼ 2:00 p ¼ 0:0455
n1 ¼ 14 n2 ¼ 10 T ¼ 220:5 z ¼ 2:66 p ¼ 0:0105
n1 ¼ 14 n2 ¼ 9 T ¼ 215 z ¼ 2:96 p ¼ 0:0031
MADRS TBAS HA(D) H(A)D Number
n1 ¼ 16 n2 ¼ 10 T ¼ 231 z ¼ 0:79 p ¼ 0:4295
An assessment of treating depression and anxiety with aromatherapy service. However, the questionnaires that the clients completed themselves indicate a continuing of improvement in the test group, the reasons for which are unclear. In the control group, the benefits gained are demonstrated by a slight reduction in the patients’perception of anxiety or depression. The test group showed a marked improvement in the results of the three questionnaires in comparison to the control group. The Mann–Whitney U test was used for the analysis as a non-parametric test as the numbers of the groups was less than 20. According to the Mann–Whitney U test all except the H(A)D probability results (or U) were less than 0.05, indicating that there was a significant difference between the control and test groups, which was a result that can be attributed to the treatment and not by chance. The feedback from the clients involved in the test group was also very positive as they found the treatments both beneficial and pleasurable, with a tangible improvement in their quality of life. The overall effects of the aromatherapy treatments were wider ranging than the original investigation parameters were intended to assess. The researcher found the use of essential oils, prescribed for the relief of depression and anxiety, but also blended specifically for the client, addressed other issues such as sleep disturbance and headaches, which the clients also reported had improved. This in turn, had an effect on their perception of their psychological condition. Clients benefited from the physical contact provided in a professional setting. The massage eased muscular aches, pains, tension, soothed, reassured and relaxed. Although this study is a scientific evaluation of a service, the writer believes that such additional information reinforces the health professionals’ holistic role when dealing with people who have needs and problems and who are not ‘just numbers’. It was interesting to note that there was a drop out rate of 33% (6 people) after the first session amongst the control group; perhaps they realised that they were in the control group due to the lack of odour from the massage oil. A follow-up study
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could use a synthetic fragrance product in the control group (assuming no inherent beneficial effect) and compare against massage with essential oils to ascertain the therapeutic effect of essential oils over a pleasant odour. Clients tended to drop out just before the end of the course of treatment in the test group (18%). An exit interview would have been useful to identify why this happened, so that it could be reduced in the therapy and in any future research. It was concluded that this study has statistically proven that the holistic use of aromatherapy had a beneficial therapeutic effect on clients who were more than mildly depressed or anxious. Further studies would be beneficial using larger numbers of clients for statistical reasons.
Acknowledgements Sincere gratitude to Shirley Price Aromatherapy for the donation of all the essential oils and carrier oil used in this evaluation. Ian Smith, Ewa Wikiel, Dr. Ken Chezinski, and Dr. William Hood for their clinical and statistical advice. Chris Lemon, Frances Fee, Tessa Flora, Jean Palmer, Druid Fleming, Linda Davies, Carol Farrell and George Hogan for completing the endless questionnaires, and most importantly the clients for participating.
References Campbell MJ, Machin D. Statistical Inference Medical Statistics, A Common Sense Approach. Chichester: Wiley; 1999. Davis P. Aromatherapy an A–Z. Saffron Walden: Daniel; 1995. Garnett-Ore L. Aromatherapy within Mental Health Services. Aromatherapist 1996;3(1):17–29. Lawless J. Aromatherapy and the mind. London: Thorsons; 1994. Lyttle J. Depression in mental disorder. Edinburgh: Bailliere Tindall; 1988a. Lyttle J. Anxiety in mental disorder. Edinburgh: Bailliere Tindall; 1988b. Montgomery A, Asberg M. Br J Psychiatry 1979;134:382–9. Tyrer P, Owen RT, Cicchetti DR. J Neurol Neurosurg Psychiatry 1984;47:970–5. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psych Scand 1983;67:361–70.