This article is part of our series on Coping Skills For Depression. In this article like to look at how breathing techniques and breathwork can positively affect conditions such as anxiety and depression.

Introduction: Depression, Anxiety and Breathing
Your Nervous System Explained!
Depression treatment with breath work in the scientific literature
Anxiety treatment with breath work in the scientific literature
A note on stress and cortisol
A breathing technique for easing anxiety, worry, fear or stress
The "Box Technique" or "Square Technique"
A breathing technique for easing depression
The 1/2/3 "Activation Technique"
Summary

Introduction: Depression, Anxiety and Breathing

Depression is a condition which exerts a massive collective toll on humanity. A 2014 Nature article listed depression as being responsible for more "years lost to disability" than any other condition. Anxiety also has a huge impact.

At 76 million years, globally, depression was top of the list. If fact, depression was roughly 50% higher than the next condition, "neck and back pain" at 54 million. Anxiety was also high on the list at 28 million years.

In this meta-study, the reported remission rates for depression treated with pharmaceuticals was roughly 40% after six weeks. There's a desperate need for alternative ways to treat depression and anxiety. Breathwork and breathing techniques may be one of those alternatives.

Taking conscious control of your breathing is one of the quickest and simplest ways to affect your mind and body. Learning how to change your breathing through breathwork will help you control your anxiety and depression. It may also boost your overall mental health, especially if used with mindfulness for depression. Let's dig deeper into managing anxiety and depression through your breath.

If you know me, you'll be expecting a bit of science. Here we go. :-)

Your Nervous System Explained!

Breathing normally automatic, but we can bring it under conscious control.

Let's look at our nervous system for a moment... don't worry, this won't hurt... much! :-)

Our nervous system is split into the central nervous system (the brain and spinal cord) and the peripheral nervous system (everything else!)

After that split, there's another split. The first part is the somatic nervous system (our muscles), which is under conscious control. You can think of it as voluntary control of movement. Examples of using the somatic system would be me typing this right now, someone lifting weights, or if you scratch an itch.

The second part is the autonomic nervous system (our organs), which does things automatically, such as our heart beating for our entire lifetime. We don't even think about it! Our digestive system secretes gastric juices and bile salts without us consciously doing anything. It's impressive how much of us runs on auto-pilot. Perhaps that's why we're happy to let our minds switch to auto-pilot too.

The autonomic nervous system itself is also split into two parts... the sympathetic and parasympathetic parts. You've probably already heard of the sympathetic nervous system because it's responsible for the "flight or fight" response. It diverts energy away from unnecessary activities such as digestion so we can run or fight.

The parasympathetic system, by contrast, is known as the "rest and digest" system. It does the opposite of the sympathetic system. It calms us down, restores energy to the digestive system and relaxes us.

(there's also the enteric part of the autonomic nervous system, which I've omitted for simplicity)

Breathing is one of the few ways we can consciously affect the parasympathetic system to induce relaxation.

Through breathwork we can consciously change our breathing pattern to reduce anxiety and depression.

Depression treatment with breath work in the scientific literature:

An article summarising a scientific study from the Journal of Clinical Psychiatry wrote:

"A breathing-based meditation practice known as Sudarshan Kriya yoga helped alleviate severe depression in people who did not fully respond to antidepressant treatments."

Another study looked at yoga and coherent breathing. They found that people who did yoga each week plus coherent breathing had significant reductions in depression scores.

"During this 12-week intervention of yoga plus coherent breathing, depressive symptoms declined significantly in patients with MDD [major depressive disorder] in both the HDG [high dose group, three classes per week] and LDG [low does group, two classes per week]. Both groups showed comparable compliance and clinical improvements, with more subjects in the HDG exhibiting BDI-II [Beck depression inventory] scores ≤10 at week 12." (my notes in square brackets)

Interestingly, the study's author is quoted as saying,

"While most pharmacologic treatment for depression target monoamine systems, such as serotonin, dopamine and norepinephrine, this intervention targets the parasympathetic and gamma aminobutyric acid system and provides a new avenue for treatment."

If that's the case, breathwork may be useful for treating depression whether or not someone is on anti-depressants. It may function as an augmentation if it works through a different neurotransmitter pathway.

One form of yoga, Sudarshan Kriya Yoga (SKY), was tested against Electroconvulsive Therapy (ECT) and the antidepressant imipramine (IMN). The results were very interesting. While ECT performed best, followed by IMN and then SKY, there was still a huge improvement in patients receiving SKY. The report says...

"Remission (total HRSD score of seven or less) rates at the end of the trial were 93, 73 and 67% in the ECT, IMN and SKY groups, respectively. No clinically significant side effects were observed."

A full two thirds of people had "remission" (a score of seven or less on the Hamilton Rating Scale for Depression) using Sudarshan Kriya Yoga, a specific controlled breathing technique. While the antidepressant score was higher at 73%, and the electroconvulsive score was higher again at 93%, it would seem to me that merely changing breathing patterns should be an initial intervention rather than pharmaceuticals or electroconvulsive therapy.

This study assessed anxiety and depression changes based on different criteria after controlled breathing intervention. It saw improvements in both, with the larger change being in depression.

Anxiety treatment with breath work in the scientific literature:

It's generally thought that anxiety is more obviously related to breathing than depression. A common sign of anxiety or panic attacks is rapid, shallow breathing.

Would learning to control breathing through breathwork lead to improvements in people with anxiety disorder?

Common treatments for anxiety include pharmaceuticals (such as benzodiazepines, selective serotonin reuptake inhibitors[SSRI's], serotonin and noradrenaline reuptake inhibitors [SNRIs], pregabalin) and psychotherapy ("talking therapy").

Some of the drugs cause side effects, and some can't be taken for long. For example, benzodiazepines can become addictive if used for longer than four weeks, so prescriptions in the UK are only for up to two to four weeks.

Psychotherapy can help, but involves dealing with the underlying issues causing anxiety, which can be traumatic for the patient. The American Psychology Association says that,

"Anxiety disorders are very treatable. Most patients who suffer from anxiety are able to reduce or eliminate symptoms after several (or fewer) months of psychotherapy, and many patients notice improvement after just a few sessions."

Of course, there could be significant expense involved with seeing a therapist, especially if months of treatment is needed. It's also necessary for the person with anxiety to be an active part of the process, from it being a "collaborative process" and necessitating that the client and therapist "work together" to "expect to practice their new skills outside of sessions to manage anxiety in situations that might make them uncomfortable".

It could be that taking control of our breathing may be another avenue for treating anxiety. A study on "diaphragmatic breathing relaxation training for reduced anxiety" found that...

"The experimental group achieved significant reductions in Beck Anxiety Inventory scores (p < .05), peripheral temperature (p = .026), heart rate (p = .005), and breathing rate (p = .004) over the 8-week training period. The experimental group further achieved a significant reduction in breathing rate (p < .001)."

Diaphragmatic breathing is belly or abdominal breathing, as opposed to the chest breathing most of us usually do. In the study people were assigned to a course in diaphragmatic breathing relaxation and then practiced twice a day at home.

A note on stress and cortisol

It's interesting to note that breathing deeply slows the release of cortisol.

"In conclusion, diaphragmatic breathing could improve sustained attention, affect, and cortisol levels. This study provided evidence demonstrating the effect of diaphragmatic breathing, a mind-body practice, on mental function, from a health psychology approach, which has important implications for health promotion in healthy individuals." 

The function of cortisol is to prime the body for "fight or flight", so it activates the sympathetic nervous system. Of course, if we need to protect ourselves or run away, the release of cortisol is very welcome.

However, cortisol has a huge negative downside when it's released chronically, over time. In rat models it has been shown to actually kill hippocampal neurons. The hippocampus in one of the few areas of the brain where new neurons form, whereas the rest of the brain generally remodels itself through creating more or fewer synapses between neurons.

"It is commonly accepted that stress may induce brain damage, especially in hippocampal formation, but the mechanisms that cause such damage are not well understood. This paper investigated the impacts of predatory stress on the hippocampus using cat-exposure to rats. // These results indicate that apoptosis may be one of the most important neuropathological mechanisms for cell loss or hippocampal atrophy induced by predatory stress. Meanwhile, significant positive correlation between serum cortisol level and the number of apoptotic cells in CA3 supports that excessive GCs due to predatory stress, is associated with hippocampal cell apoptosis." (my bold)

Another study showed that young rats exposed to social stress still initially formed new neurons, but after a week only a third of the newly formed neurons has survived!

Also researchers have shown that corticosterone (the rat equivalent of human cortisol), directly affects neuronal transmission in the hippocampus:

"The researchers have shown that in one part of the brain, the hippocampus, corticosterone (the equivalent of human cortisol in laboratory rats) modifies the intensity of transmissions made by excitatory synapses(2). "

And to link breathing directly to emotions, this study showed that breathing at a certain rate, or in a certain way, could elicit emotions:

"To our knowledge, this is the first demonstration that the alteration of respiration is sufficient to induce emotion".

Through the effect of reducing stress, breathwork may ease anxiety and depression.

A breathing technique for easing anxiety, worry, fear and stress

Deep breathing techniques are usually recommended for easing anxiety, worry, stress or fear. Instead of breathing shallowly through the chest, it's recommended to breath more deeply and involve the diaphragm and abdomen.

Breathing using the "belly" is thought to promote relaxation by stimulating the vagus nerve, which is important in the parasympathetic nervous system, as this article explains.

"The current article reviews scientific insights in potential health benefits. In particular, we investigate the role of particular breathing techniques (low respiration rate, long exhalations) integral to contemplative activities and show that these techniques are prime candidates in explaining the benefits of ContActs for health and mental health. Furthermore, we provide mechanisms and a neurophysiological model that can explain how respiratory patterns produce these effects; through vagal nerve stimulation." ("ConActs = contemplative activity)

The "Box Technique" or "Square Technique"

Please don't do any breathing exercise if doing so could possibly cause any danger to yourself or others. If you ever feel sick, dizzy or nausea while doing a breathing exercise, return to your normal pattern of breathing until it passes. If it doesn't pass, seek medical attention.

The box deep breathing technique is very simple and can be quickly implemented either for yourself, or to instruct someone else such as someone having an anxiety attack or panic attack.

The basic method consists of breathing in while counting to four, holding the breath while counting to four, breathing out while counting to four, then holding again for a count of four. That counts as one "box" or "square" which can be repeated as many times as necessary to create relief from the anxiety, stress, worry, fear or panic.

• 1: Breathe in while counting to four
• 2: Hold while counting to four
• 3: Breathe out while counting to four
• 4: Hold while counting to four
• (repeat four times)

It's recommended to alter the Box technique to suit your own feelings of what works best for you. A few suggestions would be to lengthen the pause steps, to lengthen the exhalation step relative to the inhalation step, or to do the Box to a completely different count such as five, six or seven.

It has been shown that inhalation stimulates the sympathetic nervous system and exhalation stimulates the parasympathetic system. Hence, doing a longer out-breath may directly increase the relaxation aspect of deep breathing.

"Inhalation stimulates the sympathetic nervous system, while exhalation stimulates the parasympathetic nervous system." (source)

The main point of the Box technique is to focus the mind on the breathing and so distract it from any other sensory inputs which may be disturbing it and causing or maintaining the panic attack, and reduce the number of breaths per minute from a rapid, shallow, chest-centered and anxiety-generating breathing pattern to a slower, more relaxed and deeper breathing which stimulates the vagus nerve and the parasympathetic nervous system and thereby relaxes the person.

"In sum, experimental slowing of respiration seems to shift the balance between SNS and PNS activity towards the latter." (source)

A breathing technique for easing depression

Depression is a complex condition. It's generally thought that it's an adaptation to stress, whereby chronic activation of the sympathetic nervous system (the "flight or fight" response) results in the body no longer being able to respond to the stressful stimulus and effectively shutting down. The concept of shutting down aligns with the presentation of depression which is that the person is relatively refractory to stimuli, lethargic, avoidant of social interaction, lacking motivation, has low mood and often sadness, guilt and a lack of enjoyment of life.

One way to tackle low mood or depression is to stimulate the body through exercise or active breathing. While the person may not feel like doing either, exercise causes an increase in breathing rate and heart rate which releases endorphins and can help lift their mood.

A study which compared "supervised exercise", "home-based exercise", "medication" and "placebo" for 16 weeks found that:

"The efficacy of exercise in patients seems generally comparable with patients receiving antidepressant medication and both tend to be better than the placebo in patients with MDD." (my bold, MDD = Major Depressive Disorder)

It's interesting to look at the rates of remission after 16 weeks:

• supervised exercise = 45%;
• home-based exercise = 40%;
• medication = 47%;
• placebo = 31%

Note that 31% of people gained remission purely through taking a placebo pill for 16 weeks! That shows the power of the mind, and how important its role is in treating mental health conditions.

It's also interesting that the effect of exercise was generally comparable to medication!

A similar study by the same primary author tested "exercise" against "anti-depressant" and a group who did both "anti-depressant and exercise". While the anti-depressant group saw improvements earlier than the exercise group, at 16 weeks there was not difference between the groups. Exercise alone was as effective as anti-depressants or both.

The 1/2/3 "Activation Technique"

This is another simple breathing technique. While I've listed this one as for depression and the Box Technique as for anxiety, there's no reason why you cant use both or either, depending on which technique you think works for you:

• 1: Breathe in as quickly as you can through your nose
• 2: Purse your lips
• 3: Breathe out through your mouth with pressure.

Sometimes depression can make it hard to want to do anything, even if it's going to be beneficial. Fortunately, breathing work can be done sat on the couch or lying in bed.

Once you know what to do, you can pretty much do either exercise at any time. Simply making the decision to try one is a positive. You can build on that positive by actually trying one and seeing how you feel afterwards. It costs nothing but a few minutes of your time.

Summary

Breath work can be very helpful for people with anxiety and depression. Both anxiety and depression are unwanted "mal-adaptions" to the natural stress response. Instead of priming the body for "flight or fight" and then returning to baseline, people with anxiety stay in a state of hyperarousal, ready to ward off any incoming threat. Depression looks nothing like anxiety, but it's also based on not being able to effectively turn on and off the stress response. Unlike anxiety, depression is the shutdown of the system due to chronic activation causing a "burn out" which leaves the person unable to interact normally with their environment.

In this article we looked at two different breathing techniques, the Box or Square technique and the 1/2/3 Activation technique. I listed one under "anxiety" and one under "depression". However, the two aren't mutually exclusive. It's possible to use whichever one works for you and also to adapt them to get the most benefit from them. Both techniques result in fewer breaths per minute and should increase your relaxation and sense of wellbeing.