Stress—effective ways to reduce it

Ben Williamson21 Dec 2021 14:50 UTC
78 points
22 comments12 min readEA link

Just in time for the Christmas holidays, often a particularly stressful time of the year, are these practical recommendations for reducing the impact of stress on your wellbeing.

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

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.

Diaphragmatic 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).

Discussion of Secondary Recommendations

Music

Size of effect: 15.27%

Intervention: 10 minutes listening to music with minimal distraction—ideally classical but otherwise personal preference)

That listening to music can be an effective way to relax is likely of little surprise. What is more useful to highlight here are two things. First, that the size of effect from just 10 minutes of listening to music is significant and supported by scientific literature, such as this 2004 meta-analysis of 22 studies. This makes putting on some tunes a valuable strategy comparable to other, more ‘serious’ interventions.

Second, that the effect varies somewhat depending on what music is used. Results are somewhat inconsistent for different groups, but music with a “slower tempo, low pitches… primarily string composition, regular rhythmic patterns, no extreme changes in dynamics, and no lyrics” generally appears best. A loose concept of classical music tends to fit with this, such as Dvorak’s New World Symphony, recommended as an example by the meta-analysis mentioned previously. Beyond classical music, songs that you particularly enjoy appear the next most effective option.

Progressive Muscle Relaxation (PMR)

Size of effect: 14.27%

Intervention: Five minutes of trained PMR practice

Progressive Muscle Relaxation is a relatively simple and easy to learn set of exercises. Individual muscle groups are tensed briefly while breathing in and then swiftly relaxed while breathing out. A simple guide to the practice by the University of Michigan can be found here.

We found a moderate but variable size of effect for PMR on stress, with larger effects appearing to correlate with more frequent and longer practice. Progressive Muscle Relaxation has also been linked to a range of other benefits, including managing anxiety, reducing pain, and increasing general quality of life.

Tea

Size of effect: 13.12%

Intervention: Regular tea consumption (2-4 cups a day), green and/​ or black

Green and black teas all generally contain high levels of L-theanine, which has been linked to reduced anxiety and improved brain function. L-theanine is also the proposed mechanism behind the tea’s stress-reducing effects. While it can be taken separately as a supplement, tea is an effective, simple, and popular source of the amino acid.

High caffeine consumption can promote anxiousness and sensitivity to stress so we recommend moderating black tea consumption with green tea.

Lavender oil

Size of effect: 10.92%

Intervention: Inhaling 2 drops of lavender oil daily

Lavender essential oils are relatively simple and cheap to purchase and appear to have a beneficial effect on levels of perceived stress and blood cortisol. Our research found effect sizes ranging from 4.3% to 20%. Lavender has also been linked to moderate improvements in symptoms of anxiety and sleep quality.

Essential oils can cause contact dermatitis, an allergic skin reaction that tends to produce an itchy, red rash. Inhaling lavender oil, from a bottle or diluted in a small bowl of water, is a simple way of avoiding this.

Nature exposure

Size of effect: 10.78%

Intervention: 20-30 minutes spent in a natural setting (e.g. walking through a park)

Exposure to green spaces tends to produce feelings of relaxation and reduced stress. More generally, regular time in nature has been found to bring wide-ranging benefits to mental health. 20-30 minutes appears to bring the greatest benefit, with diminishing returns on longer periods of time.

While exposure to ‘nature’ sounds brought some benefit, more significant reductions in stress were produced from time spent sitting or walking in parks or woodlands.

Massage

Size of effect: 10.63%

Intervention: 30 minutes of massage, twice a week

Massage appears plausibly beneficial for stress reduction but there is limited research available to assess this. A review of the available literature found single-session effects on salivary cortisol but notes that these effects “may be short-lived and multiple massage treatments do not appear to have a cumulative effect”. There is stronger evidence suggesting beneficial reductions to state anxiety and heart rate, providing a secondary level of evidence that massage may be of some notable benefit in managing stress.

All the studies reviewed were conducted on massage administered by trained professionals, which would make this an expensive intervention to maintain. Untrained massage seems plausibly beneficial but we found a lack of research into its relative effectiveness.

Pets

Size of effect: 10.25%

Intervention: Owning a pet and consistently spending time with them

Pets may form a better buffer to stress than the presence of close friends or spouses, possibly due to an absence of fear of judgement for poor performance. Though we found no studies investigating it, it seems plausible that dog ownership may bring additional benefit by incentivising individuals to spend more time in parks and other green spaces, thereby gaining the benefits of nature exposure discussed above.

The presence of a pet during a stressful task appears to reduce stress responses, while long-term ownership of pets may also reduce markers of stress compared to people who don’t own pets.

Saffron

Size of effect: 8.98%

Intervention: 30mg saffron extract supplement taken daily

There is limited evidence to suggest that daily supplementation can reduce stress, as well as reduce anxiety and improve sleep quality. Most impressively, there’s plausible evidence to suggest saffron supplementation could be particularly effective in improving symptoms of depression, possibly even on par with some antidepressant medications.

However, it’s important to note that there are non-trivial side effects from excessive saffron supplementation. 30mg is the recommended daily dosage. Examine.com, who provide rigorous nutrition and supplement research, found a daily dosage of 60mg “may increase the risk for hypotension, reduce haemoglobin, increase blood urea, and reduce the concentration of platelets and immune cells, though these effects aren’t usually particularly potent”.

Meditation

Size of effect: 7.35%

Intervention: 10-20 minutes of regular mindfulness meditation

While Mindfulness-Based Stress Reduction appears particularly effective and beneficial, it also requires a significant investment of time and training. More general mindfulness meditation practice appears to still produce a moderate effect on stress levels.

There is a moderate level of evidence supporting the effectiveness of single-session meditation, suggesting that the practice can be a useful tool for in the moment relief and in anticipation of particularly stressful events.

Gratitude Journaling

Size of effect: 3.12%

Intervention: Listing 5 things you are thankful for each day.

There is minimal evidence demonstrating a notable effect of gratitude journaling on stress. This 2016 meta-analysis of 26 studies found significant effects from gratitude journaling on psychological wellbeing but only a small size of effect (0.11) on levels of stress.

Additional recommendations

This review of interventions for reducing stress began with a list of 62 plausibly useful practices. The majority of these suggestions were then discarded due to low evidence of effect, a lack of available evidence or close similarity to a more effective intervention that was included.

However, this was a rough process that may have resulted in useful practices being discarded. In particular, there are several ‘lifestyle’-type interventions that may be valuable in addressing the root causes of stress for certain individuals and therefore of high benefit. This final section briefly summarises some of these suggestions that were discarded ahead of the more in-depth evidence review but may still be of significant value.

Socialising

Spending time with friends and having more friends are both associated with reduced stress, as is physical contact with said friends and/​or partners.

Diet

Caffeine and sugar increase cortisol levels. Reducing your intake if you suffer from chronic high stress seems a simple and valuable action. Ashwagandha, Rhodiola Rosea and chewing gum may all produce small effects in reducing stress.

Time management

High stress can simply be a symptom of trying to do many things in the time you have available. In which case, simply learning to do less—to say no to less important tasks—may be of significant benefit. Alternatively, adopt a task management framework, such as this simplified version of Getting Things Done, and/​or a task tracking programme (Asana, ClickUp)

Leisure

Create more slack. Working hard requires treating time out seriously and protecting it. Vacations appear to reduce stress but only temporarily, consistent leisure appears the more effective solution.

Runway

In as much as it is possible in your circumstances, build a financial runway so you have the resources and flexibility to tackle major causes of stress and to experiment with the kinds of practices listed in this article.

Miscellaneous

Avoid commuting, or at least make it active. Reduce smoking, news consumption, and exposure to bright lights in the evening. Instead, spend more time laughing, being generous, sleeping, and doing easy aerobic exercise.

Combinations

Many of the practices in this article can be done simultaneously, likely increasing the total beneficial effect. Drink tea while listening to music. Walk your dog in the park. Undertake a CBT course while nibbling on dark chocolate.

Final thoughts

Congratulations on reaching the end of this report! If you’ve read this far, you clearly have the discipline and motivation to actually put some of these practices into place. Experimentation is encouraged, mandated even.

The recommendations and sizes of effect above are by no means the final word on these topics but are strongly suggestive of useful things you can do to improve your wellbeing right now. Please take a look at our evidence table if you want to dive deeper into what we’ve recommended and why.

Thanks for reading. Any and all feedback—whether in the comments or privately—is hugely appreciated.

NB: We are currently running a 5-minute survey evaluating our work which we’d greatly appreciate you filling out!

Flashcards

Thanks to the wonderful people at ThoughtSaver, you can now access and save a deck of flashcards tailored to helping you remember the interventions recommended in this article.

Ben Williamson21 Dec 2021 14:50 UTC
78 points
22 comments12 min readEA link