Effects of Breathing-Relaxation Training Plus Autonomous Sensory Meridian Response on Mood and Depressive Symptoms in Patients With Mild Depression
Article information
Abstract
Objective
To date, the feasibility of autonomous sensory meridian response (ASMR) as a complement to traditional treatments for patients with depression remains unclear. The main objective of this study was to investigate the effects of breathing-relaxation training plus ASMR on mood and depressive symptoms in patients with mild depression.
Methods
A quasi-experimental pre- and post-test design with a non-equivalent control group was used. Forty patients with mild depression were assigned to the experimental group that received breathing-relaxation training plus ASMR or the wait-list control group for a total of 8 training sessions. To assess mood and depressive symptoms, the Korean version of the Profile of Mood State-Brief and the Patient Health Questionnaire-9 were performed.
Results
There was no significant difference in baseline demographic characteristics between both groups. After the 8 training sessions, the experimental group achieved a significantly greater improvement in mood and depressive symptoms with more ASMR experiences compared to the control group.
Conclusion
These findings illustrated the feasibility of ASMR as a complementary tool and breathing-relaxation training plus ASMR might be clinically beneficial to alleviate negative mood and depressive symptoms in patients with mild depression.
INTRODUCTION
Autonomous sensory meridian response (ASMR) is a physiological phenomenon that describes a tingling sensation or a sense of psychological calm induced by certain trigger stimuli [1]. Among various sensory stimuli, auditory stimuli are mainly used as triggers that produce feelings of emotional stability, contentment, or pleasure [2], and tingling is a pleasant tickling sensation experienced intensely in the head and body when listening to a soft rustling sound [3].
A previous study suggested that an ASMR experience was associated with the activation of brain regions related to reward and emotional arousal [4]. Specifically, an electroencephalogram (EEG) study showed that an ASMR experience increased alpha wave activity in the frontal lobe, suggesting a physiological relaxation response to an ASMR experience [5]. On the other hand, another study has indicated that an ASMR experience causes changes in the brain confirmed by decreases in alpha and theta activity. These were changes in areas associated with changes in arousal and focused attention [6]. Taken together, increased emotional regulation or cognitive function could lead to feelings of stability, relaxation, and euphoria [7].
However, it is still unclear how exactly auditory stimuli of ASMR need to be designed to effectively trigger ASMR experiences. To date, it has been reported that naturally occurring sounds, rain, and whispering cound induce a relaxed state, compared to silence [8]. Relaxation could be defined as a state of calmness and lack of anxiety, or a state in which parts of the body, especially muscles, are less tense [7]. In a previous study, 813 participants were shown two ASMR-triggered videos and one non-ASMR-related video to investigate if there was a difference in physiological responses. As a result, participants felt more relaxed, less stressed, and less depressed with reduced heart rate and increased skin conductance levels when presented with ASMR-triggered videos, compared to a non-ASMR video [9]. Accordingly, these effects of ASMR have led to suggestions for its use as an at-home relaxation tool for stress, depression, and chronic pain [10,11].
Irrespective of its severity (mild, moderate, or severe), depression has emerged as a significant risk factor for both mental and physical disorders [12,13]. While mild depression, in particular, has often been overlooked, it is noteworthy that untreated cases have the potential to escalate in severity over time [14]. Furthermore, neglecting mild depression is linked to an elevated risk of developing major depressive disorders [15]. Consequently, there is an urgent need to effectively address the mental health of individuals with mild depression. Specifically, it has been demonstrated independent use of non-pharmacological treatments is effective in addressing mild depression, setting it apart from other stages. Notably, moderate or severe depression necessitates a combination of nonpharmacological and pharmacological treatments, making sole reliance on non-pharmacological treatments less likely to yield positive outcomes. As a result, advocating for non-pharmacological treatments as the primary approach to managing mild depression is recommended [16].
Therefore, various non-pharmacological techniques have been implemented to manage the mental health of patients with mild depression. Among these techniques, breathing-relaxation training has been widely used to relax [17]. In a previous study, yoga-based breathing training was conducted, resulting in a significant reduction in depression and anxiety [18]. In addition, a non-randomized study reported that a 1-week breathing practice decreased depressive symptoms [19]. In related works, slow and deep breathing techniques rather than fast and shallow were commonly utilized to ameliorate negative mood and depressive symptoms [18,19]. On the other hand, slow and deep breathing can also induce changes in physiology. In a previous study, after controlled breathing, delta power significantly decreased in the fronto-temporal regions with a reduction in negative affect, suggesting that breathing training could change brain activity as well as mental well-being [20]. These findings suggest that breathing training could be beneficial to improve mental health. However, despite these positive findings, breathing-relaxation training alone did not significantly reduce depression [21]. In addition, a randomized trial reported that breathing-relaxation training did not induce a significant effect on relaxation [22]. Taken together, these results suggest that breathing-relaxation training alone has limited benefits for alleviating mood and depressive symptoms.
Considering that ASMR is a tool that can be used for relaxation, it is expected that breathing-relaxation training plus ASMR might have a synergy effect on mood and depressive symptoms in patients with depression. Unfortunately, to date, very little is known about the effects of breathing-relaxation training plus ASMR. Therefore, the purpose of this study was to investigate whether breathing-relaxation training plus ASMR could improve mood and depressive symptoms in patients with mild depression.
METHODS
Design
This study was a quasi-experimental pre- and post-test design with a non-equivalent control group (CG), and all participants were allocated into the experimental group (EG) or the wait-list CG. The EG performed breathing-relaxation training plus ASMR, while CG participated in the same training as the EG after this study. Outcome measures were conducted pre-and post-intervention by a blinded assessor. The study was conducted in accordance with the relevant Japanese regulations and guidelines for human medical research and the Declaration of Helsinki. This study was approved by the Institutional Review Board of Soonchunhyang University (202212-SB-130). Written informed consent was obtained from all subjects.
Subjects
A total of 42 patients with mild depression were recruited from a mental health welfare center in Chungcheongnam-do, South Korea. A total of 46 subjects were screened and 42 were finally selected. The inclusion criteria were as follows: 1) diagnosed with mild depression by a psychiatrist based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2) no change in antidepressant medication from 2 weeks before pre-screening to post-screening, and 3) able to read and respond to questionnaires and able to communicate. The exclusion criteria were as follows: 1) those diagnosed with psychiatric or neurologic disorders other than mild depression, 2) the presence of visual or auditory impairment, 3) the presence of speech and language disorders, and 4) those who participated in any other intervention in the center. All subjects were naive and unpracticed for breathing-relaxation training and ASMR.
The sample size was calculated by using G*Power 3.1.3 (Informer Technologies, Inc., Düsseldorf, Germany). The effect size was set at 0.45, the α error at a probability of 0.05, and the power at 0.80, resulting in a minimum of 20 subjects in each group.
Intervention
The breathing-relaxation training plus ASMR program consisted of 8 sessions, twice a week for 4 weeks, with each session lasting 50 minutes. From the 1st to the 3rd sessions, breathing-relaxation training was performed, from the 4th to the 7th sessions, ASMR training alone was implemented, and the 8th session consisted of both training. The contents of the program were derived from a previous study [23] and are presented in Table 1.
Breathing-relaxation training plus ASMR program
Subjects in the EG received all training sessions in a spacious, well-appointed room designed for comfort and free from sensory distraction. This setting was achieved by closing windows, minimizing noise, and maintaining a visually subdued environment that was neither too bright nor too dark. Prior to training, subjects were directed to power off their cell phones, and they were encouraged to wear breathable, slightly loose-fitting clothing to ensure unrestricted breathing.
All sessions were implemented by one occupational therapist with 15 years of clinical experience providing occupational therapy to patients with psychiatric disorders. The intervention was confined to in-session activities, and subjects were explicitly advised against practicing breathing-relaxation and ASMR training outside of the scheduled training sessions.
Outcome measures
ASMR scale
The Autonomous sensory meridian response scale (ASMR-15), originally developed by Roberts et al. [24] was translated into Korean and was utilized to measure ASMR-induced experiences [25]. The ASMR-15 consists of four factors: sensation, relaxation, affect, and altered consciousness. It has a self-reported 5-point Likert scale (1: strongly disagree, 2: disagree, 3: neutral, 4: agree, 5: strongly agree) for a total of 15 items, and higher scores indicate more positive ASMR experiences. The internal consistency (Cronbach’s α) of the ASMR-15 was 0.78 for the total score and ranges from 0.72 to 0.82 for each sub-factor [24].
Korean version of the Profile of Mood State-Brief
The Korean version of the Profile of Mood State-Brief (K-POMS-B), translated by Yeun and Shin-Park [26] was used to assess mood disturbance. Its questionnaire consists of a total of 30 items categorized into six domains (tension-anxiety, depression, anger-hostility, fatigue, confusion, and vigor) and is rated on a 5-point Likert scale. A higher score indicates a poor mood state. The internal consistency (Cronbach’s α) was 0.91 [26].
Patient Health Questionnaire-9
The Patient Health Questionnaire-9 (PHQ-9) was conducted to assess depressive symptoms. The PHQ-9 consists of nine items, and subjects responded to symptoms experienced in the past two weeks on a 4-point Likert scale, with a higher total score indicating more severe depressive symptoms. This study used the Korean version of the PHQ-9 [27], and its internal consistency (Cronbach’s α) was 0.95.
Statistical analysis
All data were analyzed using the SPSS 26.0 version (IBM Corp., Armonk, NY, USA). In order to test data normality, the Kolmogorov–Smirnov test was conducted and then the normal distribution of all outcomes was confirmed. The demographical characteristics of the subjects were analyzed using descriptive statistics. A chi-square test and an independent t-test were used to compare the two groups. After the 8 training sessions, to compare outcome measures between both groups, an analysis of covariance (ANCOVA) with pre-test variables as covariates was implemented considering the design of this study. Additionally, an ANCOVA using pre-test variables as covariates is a relatively sophisticated method that additionally estimates the coefficients of pre-test variables and has the advantage of generally having higher power than an independent t-test even though there is no significant difference in a certain variable between groups [28]. Thus, in this study, all outcome measures were analyzed with an ANCOVA using pre-test scores as covariates.
RESULTS
General characteristics of subjects
A subject in each group dropped out; the study population was thus 20 in each group (Figure 1), as these two subjects refused to continue treatment. There were no significant differences in baseline demographic characteristics between both groups (all p>0.05) (Table 2).
Flow diagram of subjects in this study.
General characteristics of participants (N=40)
ASMR experience
After the 8 training sessions, there was a significant difference in the ASMR-15 between both groups (all p<0.05) (Table 3), indicating that subjects in the EG experienced more ASMR than those in the CG. Specifically, all subscales, including sensation, relaxation, affect, and altered consciousness, demonstrated statistically significant differences between both groups.
Comparison of ASMR experience between both groups (N=40)
Mood and depressive symptoms
After the 8 training sessions, there were significant differences in all subscales of the K-POMS-B (all p<0.001) between both groups except for the subscale of vigor (p=0.072) (Table 4). On the other hand, after the 8 training sessions, subjects in the EG achieved a greater improvement in the PHQ-9 (p<0.001) than those in the CG (Table 4). These findings demonstrated that subjects in the EG were in more positive moods and had fewer depressive symptoms than those in the CG.
Comparison of mood state and depression symptoms between both groups (N=40)
DISCUSSION
The current study was to investigate the effects of breathing-relaxation training plus ASMR on mood and depressive symptoms in patients with mild depression. After the 8 training sessions, significant differences in mood and depressive symptoms between both groups were found. This finding suggested that breathing-relaxation training plus ASMR would be clinically effective in alleviating negative mood and depressive symptoms, which is consistent with the results of previous studies that have shown positive changes in mood and depressive symptoms with breathing-relaxation training or ASMR [6,9,29]. Even though previous studies did not combine breathing-relaxation training with ASMR, they have consistently reported positive effects of each treatment alone on mood and depressive symptoms. Furthermore, previous studies identified physiological changes that were not investigated in the present study, demonstrating the objective evidence for each intervention [6,9].
Numerous studies have indicated that breathing-relaxation training is beneficial to improve mental health [29-31], which is in line with the findings of this study. Breathing-relaxation training involves concentrating on abdominal or diaphragmatic breathing while feeling the sensations felt in the body without paying attention to anything besides the sensations felt [32]. This process would be helpful to decrease the frequency of negative automatic thoughts, resulting in an increased perceived ability to disengage from negative thoughts [33]. These findings imply that cognitive aspects of breathing might alter cognitive processes associated with depression, providing evidence that breathing-relaxation training could be used as an intervention in patients with depression. Accordingly, breathing control has been utilized extensively to treat depression, anxiety, and other associated mental disorders [31], which is consistent with the results of this study.
However, in contrast, some studies reported that the effects of breathing-relaxation training were not considerable [21,34]. These studies performed breathing-relaxation training for non-clinical populations: coronavirus disease-2019 first-line nurses and healthy children. This discrepancy might be due to the subject’s health status difference. Subjects in most of the studies reporting positive effects of breathing-relaxation training had depressive symptoms, which is consistent with the findings of this study. A previous study indicated that a breathing exercise had no effects on relaxation but in situations when subjects got worried, its effect was improved [22], which further supports this interpretation. Consequently, breathing-relaxation training might work differently depending on the mental health status of individuals given no considerable difference in intervention durations between studies that reported a positive effect and those that did not. Thus, further research is needed to clarify this disparity.
On the other hand, in this study, to maximize the effects of breathing-relaxation training, ASMR was also performed. After the 8 training sessions, the subjects in the EG achieved a greater improvement in the ASMR-15 score, compared to the CG, resulting from an additional ASMR experience from the 4th to the 8th sessions. This ASMR experience might positively affect mood and depressive symptoms in the subjects in the EG. This study used nature sounds, such as rain sounds, as auditory stimuli for ASMR, which is consistent with a previous study using forest sounds of trickling streams, resulting in significant alleviations in negative mood states such as tension, depression, anger, and fatigue [35]. Indeed, an ASMR experience has recently been shown to be effective in mental health, including pleasant emotion inducement [9,23], relaxation inducement [23,36], and anxiety reductions [37]. One of many possible explanations for these positive effects of ASMR might be related to social grooming. Social grooming is a major social activity and is used as a means to create social structures, family, and friendships, and to strengthen bonds [38]. A previous study found that a pleasure response evoked by social grooming is due to the release of oxytocin and endorphins, which can stimulate a sense of calm and peace in individuals [39]. Thus, ASMR-related stimuli can lead to the experience of social grooming, which in turn can induce social bonding responses, leading to relaxation and mood enhancement [23]. Furthermore, a prior study has shown that ASMR experience induces increased arousal and focused attention confirmed by EEG responses. Even though this study did not directly measure the brain signals of subjects, these cognitive aspects of ASMR could positively affect an ability to regulate mood and depressive symptoms [6].
While ASMR has been utilized to improve mental health in a variety of ways, there has been a lack of research combining ASMR with breathing-relaxation training. In this study, the combination of breathing-relaxation training and ASMR was shown to be an appropriate way to achieve relaxation, and the findings were positive in ameliorating negative mood and depressive symptoms. The main advantage of ASMR is that it is inexpensive and easy to use, and it can be easily combined with other training, especially as a mental health-related intervention, which is the main clinical implication of this study.
Even though this study revealed the promising use of breathing-relaxation training plus ASMR to alleviate mood and depressive symptoms, there are limitations to be addressed. Firstly, no experiments were conducted to identify physiological indicators. In a previous study on breathing-relaxation training, physiological variables such as EEG, heart rate variability, and respiratory sinus arrhythmia have been studied to confirm physiological changes according to breathing-relaxation training [8], but our experimental environment was not conducive to physiological approaches. Future studies might attempt to use physiological approaches to establish further evidence and provide personalized intervention. Secondly, the stimuli used to trigger ASMR in this study consisted of auditory stimuli only. In addition, the auditory stimuli were chosen to be predominantly nature sounds, leaving open the question of whether the breadth of the ASMR experience, including the intensity of the tingling sensation, was captured for auditory stimuli other than nature sounds. Thirdly, since the subjects in this study were patients with mild depression, it is unclear whether breathing-relaxation training plus ASMR would be effective for patients with moderate or severe depression. Fourthly, since this study investigated only the short-term effects of breathing-relaxation training plus ASMR, its long-term effects also need to be revealed. Fifthly, in this study, both breathing-relaxation training and ASMR were utilized, making it challenging to distinctly attribute the clinical effects observed solely to one training technique. Future studies should specifically explore the effects breathing-relaxation training plus ASMR by comparing it with breathing-relaxation training alone to investigate the efficacy of breathing-relaxation training alone and to determine whether ASMR could enhance the outcomes of breathing-relaxation training. Finally, there were inherent limitations to this study design. Thus, randomized controlled trials are needed to compare the effects of breathing-relaxation training plus ASMR, breathing-relaxation training alone, and traditional treatments for patients with depression. In the future, it is necessary to investigate the long-term effects of personalized breathing-relaxation training plus ASMR with a variety of ASMR-triggered stimuli. In addition, physiological studies need to be conducted to ensure more objective evidence that breathing-relaxation training plus ASMR could induce physiological changes as well as changes in neuropsychological assessments. Furthermore, it is necessary to implement an algorithm capable of collecting individual subject responses and providing personalized training difficulty using such as long short-term memory. Subsequently, the feasibility of maximizing breathing-relaxation training plus ASMR needs to be verified, allowing for personalized training tailored to individual responses.
In conclusion, to our best knowledge, this study was the first to report the effects of breathing-relaxation training plus ASMR on mood and depressive symptoms in patients with mild depression. Breathing-relaxation training plus ASMR, an inexpensive and easily accessible way, could be used for patients with depression in clinical or non-clinical settings. In particular, ASMR has the potential to be easily combined with a variety of mental health-related treatments to induce synergistic effects. Future follow-up studies are required to confirm whether the effects of breathing-relaxation training plus a variety of types of ASMR could be associated with physiological changes in patients with depression.
Notes
Availability of Data and Material
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
Conflicts of Interest
The authors have no potential conflicts of interest to disclose.
Author Contributions
Conceptualization: Yong-Sup Kim, Jin-Hyuck Park. Data curation: Yong-Sup Kim. Formal analysis: Yong-Sup Kim. Funding acquisition: Jin-Hyuck Park. Investigation: Yong-Sup Kim. Methodology: Yong-Sup Kim, Jin-Hyuck Park. Project administration: Jin-Hyuck Park. Resources: Jin-Hyuck Park. Software: Yong-Sup Kim, Jin-Hyuck Park. Supervision: Jin-Hyuck Park. Validation: Jin-Hyuck Park. Visualization: Yong-Sup Kim. Writing—original draft: Yong-Sup Kim. Writing—review & editing: Jin-Hyuck Park.
Funding Statement
This work was supported by the Soonchunhyang University Research Fund. This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by Ministry of Education (no. 2021R1I1A3041487).
Acknowledgements
The authors would like to thank all subjects.