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Preliminary Results of an Open Label Study of Heart Rate Variability Biofeedback for the Treatment of Major Depression

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Abstract

Major depressive disorder (MDD) is a common mood disorder that can result in significant discomfort as well as interpersonal and functional disability. A growing body of research indicates that autonomic function is altered in depression, as evidenced by impaired baroreflex sensitivity, changes in heart rate, and reduced heart rate variability (HRV). Decreased vagal activity and increased sympathetic arousal have been proposed as major contributors to the increased risk of cardiovascular mortality in participants with MDD, and baroreflex gain is decreased. Study objectives: To assess the feasibility of using HRV biofeedback to treat major depression. Design: This was an open-label study in which all eleven participants received the treatment condition. Participants attended 10 weekly sessions. Questionnaires and physiological data were collected in an orientation (baseline) session and Treatment Sessions 1, 4, 7 and 10. Measurements and results: Significant improvements were noted in the Hamilton Depression Scale (HAM-D) and the Beck Depression Inventory (BDI-II) by Session 4, with concurrent increases in SDNN, standard deviation of normal cardiac interbeat intervals) an electrocardiographic estimate of overall measure of adaptability. SDNN decreased to baseline levels at the end of treatment and at follow-up, but clinically and statistically significant improvement in depression persisted. Main effects for task and session occurred for low frequency range (LF) and SDNN. Increases in these variables also occurred during breathing at one’s resonant frequency, which targets baroreflex function and vagus nerve activity, showing that subjects performed the task correctly Conclusions: HRV biofeedback appears to be a useful adjunctive treatment for the treatment of MDD, associated with large acute increases in HRV and some chronic increases, suggesting increased cardiovagal activity. It is possible that regular exercise of homeostatic reflexes helps depression even when changes in baseline HRV are smaller. A randomized controlled trial is warranted.

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Notes

  1. Reason for termination was relocation.

  2. Within the initial five sessions, one participant was diagnosed with a medical condition; the other participant stated no longer feeling symptomatic and did not feel it was necessary to continue.

  3. Heart rate is influenced by antidepressant medication. Tricyclics routinely increase heart rate by 11% and decreased HRV while some selective serotonin reuptake inhibitors (SSRI) decrease heart rate slightly and increase HRV (Quitkin, Rabkin, Gerald, Davis, & Klein, 2000; Roose, 2003). It would have been inadvisable to have taken individuals off proven medication to test the efficacy of an unproven treatment.

  4. 13 ≥ HAM-D ≤ 22.

  5. Although LF HRV can be influenced by both sympathetic and parasympathetic systems, we interpret the findings as suggesting greater parasympathetic activity, because, during biofeedback, people breathe at a frequency within the LF range. Thus, unique to this procedure, large increases in LF HRV during biofeedback reflect increases in respiratory sinus arrhythmia, hence, increases in vagus nerve traffic, particularly when data are controlled for respiration rate.

References

  • Agelink, Boz, C., Ullrich, H., & Andrich, J. (2002). Relationship between major depression and heart rate variability. Clinical consequences and implications for antidepressive treatment. Psychiatry Research, 113(1–2), 139–149.

    Article  PubMed  Google Scholar 

  • Apelbaum, H. (2001). The effect of emg-biofeedback on female participants’ major depressive disorder. Dissertation Abstracts International: Section B: the Sciences & Engineering, 61(12-B), 6742, US: Univ Microfilms International.

    Google Scholar 

  • Baher, E., Rosenfeld, J. P., & Baher, R. (2001). Clinical use of alpha asymmetry neurofeedback protocol in the treatment of mood disorders: Follow-up study one to five years post-therapy. Journal of Neurotherapy, 4(4), 11–18.

    Article  Google Scholar 

  • Balogh, S., Fitzpatrick, D. F., Hendricks, S. E., & Paige, S. R. (1993). Increases in heart rate variability with successful treatment in patients with major depressive disorder. Psychopharmacology Bulletin, 29(2), 201–206.

    PubMed  Google Scholar 

  • Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for beck depression inventory-ii. San Antonio, TX: Psychological Corporation.

    Google Scholar 

  • Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571.

    PubMed  Google Scholar 

  • Berntson, G. G., Bigger, J. T. J., Eckberg, D. L., Grossman, P., Kaufmann, P. G., Malik, M., et al. (1997). Heart rate variability: Origins, methods, and interpretive caveats. Psychophysiology, 34, 623–648.

    Article  PubMed  Google Scholar 

  • Chambers, A. S., & Allen, J. J. (2002). Vagal tone as an indicator of treatment response in major depression. Psychophysiology, 39(6), 861–864.

    Article  PubMed  Google Scholar 

  • Cohen, S. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillside, New Jersey: Lawrence Erlbaum Associates, Publishers.

    Google Scholar 

  • Cowley, D. S., Ha, E. H., & Roy-Byrne, P. P. (1997). Determinants of pharmacologic treatment failure in panic disorder. Journal of Clinical Psychiatry, 58(12), 555–561; quiz 562–553.

    PubMed  Google Scholar 

  • Dalack, G., & Roose, S. P. (1990). Perspectives on the relationship between cardiovascular disease and affective disorders. Journal of Clinical Psychiatry, 51(7), 4–9.

    PubMed  Google Scholar 

  • Eaton, W. W., Kramer, M., Anthony, J. C., Dryman, A., Shapiro, S., & Locke, B. Z. (1989). The incidence of specific dis/dsm-iii mental disorders: Data from the nimh epidemiological catchment area program. Acta Psyc Scand, 79, 163.

    Google Scholar 

  • Eckberg, D. L. (2003). The human respiratory gate. Journal of Physiology, 548(Pt 2), 339–352.

    PubMed  Google Scholar 

  • Eriksson, E. (1999). Serotonin reuptake inhibitors for the treatment of premenstrual dysphoria. International Clinical Psychopharmacology, 14(Suppl. 2), S27–S33.

    PubMed  Google Scholar 

  • Fawcett, J., Scheftner, W., Clark, D., Hedeker, D., Gibbons, R., & Coryell, W. (1987). Clinical predictors of suicide in patients with major affective disorders: A controlled prospective study. American Journal of Psychiatry, 144(1), 35–40.

    PubMed  Google Scholar 

  • First, M. B., Gibbons, M., Spitzer, R. L., & Williams, J. B. W. (1996). User’s guide for the structured clinical interview for dsm-iv axis i disorders-research version (scid-i, version 2.0). New York: Biometrics Research Department.

  • Fitzgerald, P. B., Brown, T. L., Marston, N. A., Daskalakis, Z. J., DeCastella, A., & Kulkarni, J. (2003). Transcranial magnetic stimulation in the treatment of depression: A double-blind, placebo-controlled trial. Archives of General Psychiatry, 60(10), 1002–1008.

    Article  PubMed  Google Scholar 

  • George, M. S., Rush, A. J., Marangell, L. B., Sackeim, H. A., Brannan, S. K., Davis, S. M., et al. (2005). A one-year comparison of vagus nerve stimulation with treatment as usual for treatment-resistant depression. Biological Psychiatry, 58(5), 364–373.

    Article  PubMed  Google Scholar 

  • Glaser, J. K., & Glaser, R. (2002). Depression and immune function: Central pathways to morbidity and mortality. Journal of Psychosomatic Research, 53, 873–876.

    Article  PubMed  Google Scholar 

  • Greenberg, P. E., Stiglin, L. E., Finkelstein, S. N., & Berndt, E. R. (1993). The economic burden of depression in 1990.[comment]. Journal of Clinical Psychiatry, 54(11), 405–418.

    PubMed  Google Scholar 

  • Grippo, A. J., & Johnson, A. K. (2002). Biological mechanisms in the relationship between depression and heart disease. Neuroscience and Biobehavioral Reviews, 26(8), 941–962.

    Article  PubMed  Google Scholar 

  • Grossman, P., Karemaker, J., & Wieling, W. (1991). Prediction of tonic parasympathetic cardiac control using respiratory sinus arrhythmia: The need for respiratory control. Psychophysiology, 28(2), 201–216.

    Article  PubMed  Google Scholar 

  • Hamilton, M. (1960). A rating scale for depression. Journal of Neurological Neurosurgery in Psychiatry, 23, 56–62.

    Article  Google Scholar 

  • Hammond, D. C. (2000). Neurofeedback treatment of depression with the roshi. Journal of Neurotherapy, 4(2), 45–56.

    Article  Google Scholar 

  • Hassett, A. L., Radvanski, D., Vaschillo, E., Vaschillo, B., & Lehrer, P. M. (2004). A trial of heart rate variability biofeedback in fibromyalgia: Proceedings from the sixth world congress on myofascial pain and fibromyalgia. Journal of Musculoskeletal Pain, 12(9), S9.

  • Humphreys, P., & Gevirtz, R. N. (2000). Treatment of recurrent abdominal pain: Components analysis of four treatment protocols. Journal of Pediatric Gastroenterology & Nutrition, 31, 47–51.

    Article  Google Scholar 

  • Khan, A., Brodhead, Kolts, & Brown. (2005). Severity of depressive symptoms and response to antidepressants and placebo in antidepressant trials. Journal of Psychiatric Research, 39, 145–150.

    Article  PubMed  Google Scholar 

  • Khaykin, Y., Dorian, P., Baker, B., Shapiro, C., Sandor, P., Mironov, D., et al. (1998). Autonomic correlates of antidepressant treatment using heart rate variability analysis. Canadian Journal of Psychiatry, 43(2), 183–186.

    Google Scholar 

  • Kocsis, J. H. (2003). Pharmacotherapy for chronic depression. Journal of Clinical Psychology, 59(8), 885–892.

    Article  PubMed  Google Scholar 

  • Krittayaphong, R., Cascio, W., Light, K., Sheffield, D., Golden, R., Finkel, J., et al. (1997). Heart rate variability in patients with coronary artery disease: Differences in patients with higher and lower depression scores. Psyhosomatic Medicine, 59, 231–235.

    Google Scholar 

  • La Rovere, M. T., Mortara, A., Pinna, G. D., & Bernardi, L. (Eds.). (1995). Baroreflex sensitivity and heart rate variability in the assessment of the autonomic nervous system. Armonkm, New York: Futura Publishing Company, Inc.

    Google Scholar 

  • Lehrer, S. M. H., Mayne, T., Isenberg, S., Lasoski, A., Carlson, V., et al. (1997). Relationship between changes in emg and respiratory sinus arrhythmia in a study of relaxation therapy for asthma. Applied Psychophysiology & Biofeedback, 22(3), 183–191.

    Article  Google Scholar 

  • Lehrer, P. M., Vaschillo, E., & Vaschillo, B. (2000). Resonant frequency biofeedback training to increase cardiac variability: Rationale and manual for training. Applied Psychophysiology & Biofeedback, 25(3), 177–191.

    Article  Google Scholar 

  • Lehrer, P. M., Vaschillo, E., Vaschillo, B., Lu, S. E., Eckberg, D. L., Edelberg, R., et al. (2003a). Heart rate variability biofeedback increases baroreflex gain and peak expiratory flow. Psychosomatic Medicine, 65(5), 796–805.

    Article  PubMed  Google Scholar 

  • Lehrer, P. M., Vaschillo, E., Vaschillo, B., Lu, S. E., Eckberg, D. L., Edelberg, R., et al. (2003b). Heart rate variability biofeedback increases baroreflex gain and peak expiratory flow. Psychosomatic Medicine, 65(5), 796–805.

    Article  PubMed  Google Scholar 

  • Malik, M., Bigger, J. T., Camm, J. A., Kleiger, R. E., Malliani, A., Moss, A. J., et al. (1996). Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Task force of the european society of cardiology and the north american society of pacing and electrophysiology. European Heart Journal, 17(3), 354–381.

    Google Scholar 

  • McCraty, R., Atkinson, M., & Tomasino, D. (2003). Impact of a workplace stress reduction program on blood pressure and emotional health in hypertensive employees. The Journal of Complementary and Alternative Medicine, 9, 355–369.

    Article  Google Scholar 

  • McGrady, A. (1994). Effects of group relaxation training and thermal biofeedback on blood pressure and related physiological and psychological variables in essential hypertension. Biofeedback & Self Regulation, 19(1), 51–66.

    Article  Google Scholar 

  • Murray, C. J. L., & Lopez, A. D. (1996). The global burden of disease: A comprehensive assessment of mortality and disability from disease, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard University Press.

    Google Scholar 

  • Nahas, Z., Marangell, L. B., Husain, M. M., Rush, A. J., Sackeim, H. A., Lisanby, S. H., et al. (2005). Two-year outcome of vagus nerve stimulation (vns) for treatment of major depressive episodes. Journal of Clinical Psychiatry, 66(9), 1097–1104.

    Article  PubMed  Google Scholar 

  • Peniston, E. G., Hughes, R. B., & Kulkosky, P. J. (1986). Emg biofeedback-assisted relaxation training in the treatment of reactive depression in chronic pain patients. Psychological Record, 36(4), 471–481.

    Google Scholar 

  • Quitkin, F. M., Rabkin, J. G., Gerald, J., Davis, J. M., & Klein, D. F. (2000). Validity of clinical trials of antidepressants. American Journal of Psychiatry, 157(3), 327–337.

    Article  PubMed  Google Scholar 

  • Rechlin, T., Weis, M., Spitzer, A., & Kaschka, W. P. (1994). Are affective disorders associated with alterations of heart rate variability? Journal of Affective Disorders, 32(4), 271–275.

    Article  PubMed  Google Scholar 

  • Robins, E. (Ed.). (1986). Completed suicide. Baltimore, MD: Williams & Williams.

    Google Scholar 

  • Rockstroh, B., Elbert, T., Birbaumer, N., Wolf, P., Duchting-Roth, A., Reker, M., et al. (1993). Cortical self-regulation in patients with epilepsies. Epilepsy Research, 14(1), 63–72.

    Article  PubMed  Google Scholar 

  • Roose, S. P. (2003). Treatment of depression in patients with heart disease. Society of Biological Psychiatry, 54, 262–268.

    Article  Google Scholar 

  • Ross, D. C., Quitkin, F. M., & Klein, D. F. (2002). A typological model for estimation of drug and placebo effects in depression. Journal of Clinical Psychopharmacology, 22(4), 414–418.

    Article  PubMed  Google Scholar 

  • Rounsaville, B., Carroll, K., & Onken, L. (2001). A stage model of behavior therapies research: Getting started and moving on from stage i. Clinical Psychology: Science and Practice, 8, 133–142.

    Article  Google Scholar 

  • Rush, A. J., George, M. S., Sackeim, H. A., Marangell, L. B., Husain, M. M., Giller, C., Nahas, Z., et al. (2000). Vagus nerve stimulation(vns) for treatment-resistant depression: A multicenter study. Biological Psychiatry, 47, 276–286.

    Article  PubMed  Google Scholar 

  • Rush, A. J., Sackeim, H. A., Marangell, L. B., George, M. S., Brannan, S. K., Davis, S. M., et al. (2005). Effects of 12 months of vagus nerve stimulation in treatment-resistant depression: A naturalistic study. Biological Psychiatry, 58(5), 355–363.

    Article  PubMed  Google Scholar 

  • Sackeim, H. A., Keilp, J. G., Rush, A. J., George, M. S., Marangell, L. B., Dormer, J. S., et al. (2001). The effects of vagus nerve stimulation on cognitive performance in patients with treatment-resistant depression. Neuropsychiatry, Neuropsychology, & Behavioral Neurology, 14(1), 53–62.

    Google Scholar 

  • Sackeim, H. A., Rush, A. J., George, M. S., Marangell, L. B., Husain, M. M., Nahas, Z., et al. (2001). Vagus nerve stimulation (vns) for treatment-resistant depression: Efficacy, side effects, and predictors of outcome. Neuropsychopharmacology, 25(5), 713–728.

    Article  PubMed  Google Scholar 

  • Schwartz, S., Anderson, E., & van de Borne, P. M. D. P. (1992). Autonomic nervous system and sudden cardiac death. Experimental basis and clinical observations for post myocardial infarction risk stratification. Circulation, 85, 177–191.

    Google Scholar 

  • Siever, L., & Davis, K. (1994). Overview. Towards a dysregulation hypothesis of depression. American Journal of Psychiatry, 142, 1017–1031.

    Google Scholar 

  • Steer, R. A., & Clark, D. A. (1997). Psychometric characteristics of the beck depression inventory-ii with college students. Measures Evaluating Counseling Deviations, 30, 128–136.

    Google Scholar 

  • Stein, P. K., Carney, R. M., Freedland, K. E., Skala, J. A., Jaffe, A. S., Kleiger, R. E., et al. (2000). Severe depression is associated with markedly reduced heart rate variability in patients with stable coronary heart disease. Journal of Psychosomatic Research, 48, 493–500.

    Article  PubMed  Google Scholar 

  • Team, R. D. C. (2005). R: A language and environment for statistical computing. Vienna, Austria.

  • Thase, M. E., Ninan, P. T. (2002). New goals in the treament of depression: Moving toward recovery. Psychopharmacology Bulletin, 36(2).

  • Uhlmann, C., & Froscher, W. (2001). Biofeedback treatment in patients with refractory epilepsy: Changes in depression and control orientation. Seizures, 10, 34–38.

    Article  Google Scholar 

  • Vaschillo, E., Lehrer, P., Rishe, N., & Konstantinov, M. (2002). Heart rate variability biofeedback as a method for assessing baroreflex function: A preliminary study of resonance in the cardiovascular system. Applied Psychophysiology & Biofeedback, 27(1), 1–27.

    Article  Google Scholar 

  • Veith, R., Lewis, N., & Linares, O. (1994). Sympathetic nervous system acitivity in major depression. Archives of General Psychiatry, 51, 411–422.

    PubMed  Google Scholar 

  • Yeragani, Rao, K. A., Smitha, M. R., Pohl, R. B., Balon, R., & Srinivasan, K. (2002). Diminished chaos of heart rate time series in patients with major depression. Biological Psychiatry, 51(9), 733–744.

    Article  PubMed  Google Scholar 

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Acknowledgments

These authors wish to thank Erin Arnold for her help in data analysis; and the Department of Psychiatry at the University of Medicine and Dentistry and NIH P20 MH074634 support (Multiple Unexplained Physical Symptoms in Primary Care Research Center).

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Correspondence to Maria Katsamanis Karavidas.

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Karavidas, M.K., Lehrer, P.M., Vaschillo, E. et al. Preliminary Results of an Open Label Study of Heart Rate Variability Biofeedback for the Treatment of Major Depression. Appl Psychophysiol Biofeedback 32, 19–30 (2007). https://doi.org/10.1007/s10484-006-9029-z

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  • DOI: https://doi.org/10.1007/s10484-006-9029-z

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