Received: 10 March 2018 | Revised: 30 July 2018 | Accepted: 12 August 2018

DOI: 10.1111/ppc.12325

ORIGINAL ARTICLE

Effects of deep breathing in patients with bipolar disorder

Silvia D. Serafim1,2 | Francisco D. R. da Ponte1,2 | Flavia M. Lima1,2 |

Dayane S. Martins2 | Adriane R. Rosa1,2 | Maurício Kunz1,2

1
Postgraduate Program: Psychiatry and
Behavioral Science, Universidade Federal do Abstract
Rio Grande do Sul (UFRGS), Porto Alegre (RS), Purpose: Our aim was to evaluate the effects of deep breathing exercises in subjects
Brazil
2 with bipolar disorder.
Laboratory of Molecular Psychiatry, Hospital
de Clínicas de Porto Alegre (HCPA), Porto Design and Methods: This was an open‐label, uncontrolled clinical trial with three
Alegre, Brazil
assessments: preintervention, postintervention, and follow‐up.
Correspondence Findings: The Hamilton Anxiety Rating Scale, BECK‐A, Hamilton Depression Rating
Mauricio Kunz, Laboratory of Molecular
Scale, and Young Mania Rating Scale had significant preintervention, postinterven-
Psychiatry, Hospital de Clínicas de Porto
Alegre (HCPA), Ramiro Barcelos 2350, Porto tion, and follow‐up differences. The results indicated that the deep breathing protocol
Alegre, RS 90035003, Brazil.
was effective in reducing anxiety levels in patients with bipolar disorder. The deep
Email: [email protected]
breathing protocol has no negative side effects and might be applied to decrease
anxiety symptoms in individuals with bipolar disorder.
Practice implications: The results provide direction for providing quality care that
reduces anxiety levels in patients with bipolar disorder.

KEYWORDS
anxiety, bipolar disorder, deep breathing

1 | INTRODUCTION breathing exercises can be easily learned and practiced. These

exercises affect major anatomical structures and neural pathways
Bipolar disorder (BD) is among the most common psychiatric involved in the regulation of emotion, attention, perception, and
disorders1 and is often accompanied by clinical and psychiatric problem solving.8 Deep breathing increases activation of the
2
comorbidities. Among them, anxiety disorders stand out due to their autonomic parasympathetic nervous system (PNS),9–11 which in-
3
prevalence of 45% in patients with BD, and they are often causing creases neural plasticity and alters information processing, making
functional impairment, even during periods of euthymia.4 According treatment possible for psychological disorders and stress by reducing
to Kauer‐Sant’Anna et al,5 anxiety has a deleterious impact on BD, anxiety, insomnia, and other symptoms.12,13 The benefits of the deep
worsening the patient's quality of life, particularly in the psycholo- breathing technique studied in this study are the following: stabilized
gical domain. Treatment of anxiety disorders in patients with BD is autonomic nervous system, increased heart rate variability, de-
difficult, since antidepressants commonly used in the treatment of creased blood pressure, increased lung function, increased immune
anxiety disorders may induce mania, hypomania, or a mixed state.6 function, increased blood and lymph flow, improved digestion,
Due to this difficulty and lack of other pharmacological treatment improved sleep quality and standards, and increased biopsychosocial
options, adjuvant treatments are being studied for the best manage- well‐being and quality of life.14
ment of anxiety. Patients with BD tend to have increased activity of the
Deep breathing, also called diaphragmatic breathing, is a form of sympathetic nervous system and decreased activity of the
voluntarily controlled breathing in which the patient trains the PNS.15 Knowing that deep breathing results in greater activation
7
increased use of the diaphragm muscle during breathing. Deep of the PNS, it is believed that it is a potential adjunct treatment
breathing is a simple relaxation technique. With adequate training, for BD.

Perspectives in Psychiatric Care. 2018;1–7. wileyonlinelibrary.com/journal/ppc © 2018 Wiley Periodicals, Inc. | 1

2 | SERAFIM ET AL.

Therefore, our goal was to verify if a deep breathing protocol is a of the scale, and the result ranges from 0 to 56.17,18 In anxiety
feasible and effective treatment of anxiety in patients with BD. studies, response to the treatment was defined as a ≥ 50% decrease
in HAM‐A, whereas the definition of remission was based on a
score less than or equal to 7 on HAM‐A.19 The BAI is a self‐reported
2 | METHODS
scale consisting of 21 questions, rated on a 4‐point Likert scale, which
referred to the experience of symptoms last week. Scores for the 21
2.1 | Participants
items are summed to produce a single anxiety index, ranging from 0
The Ethics and Research Committee of the Hospital de Clínicas de to 84 points.20 BAI has adequate test‐retest reliability and
Porto Alegre (HCPA) approved the study. Patients were 20 convergent validity.21
outpatients from the Bipolar Disorder Program and the Support
Group for Patients and relatives with BD at the HCPA. Inclusion
2.5 | Quality of life
criteria were patients who had a diagnosis of BD according to the
diagnostic and statistical manual of mental disorders (DSM-5), were The quality of life of each patient was evaluated with the Short‐Form
male or female, were between 18 and 69 years old, had euthymia for Health Survey (SF‐36) that comprises 36 questions and is subdivided
at least 1 month before the assessment confirmed by the Hamilton into eight domains: functional capacity, body pain, vitality, general
Depression Rating Scale (HAM‐D‐17) and Young Mania Rating Scale health, social function, physical and emotional function, and mental
(YMRS) less than or equal to 7, had a stable pharmacological health. The values range from 0 to 100, and larger numbers
treatment for at least 3 months, and had current complaints of represented a better health‐related quality of life.22
anxiety symptoms as evaluated by the attending physician. Patients
who met the inclusion criteria and who gave their written informed
2.6 | Functionality
consent were invited to the preintervention evaluation.
Patients who had obstructive and restrictive respiratory diseases, The Functional Assessment Short Test (FAST) was used to evaluate
patients diagnosed with a clinical contraindication, and patients the functionality of patients in the last 15 days. It consisted of 24
meeting the criteria for acute mania or depression and needed a items that are divided into six areas of functionality: autonomy, work,
modification in their current medication regimen were excluded from cognition, finance, interpersonal relationships, and leisure. The items
the study. were scored on a 4‐point scale, where 0 is no difficulty; 1, few
difficulties; 2, moderate difficulties; and 3, serious difficulties. The
higher the score was, the more serious the difficulties were.23
2.2 | Study design
This was an open‐label, uncontrolled clinical trial with three
2.7 | Biological rhythms
assessments: preintervention, postintervention, and follow‐up.
The biological rhythms of the patients were evaluated through the
Biological Rhythms Interview for Assessment in Neuropsychiatry
2.3 | Assessments
(BRIAN) scale. The BRIAN scale evaluated the regularity of biological
Three evaluations were performed. Initially, a clinical and socio- rhythms in four different domains: sleep, activities, social, and food.
demographic evaluation questionnaire was applied, usually by This scale consists of 21 items, 18 divided into three specific areas:
researchers at the Laboratory of Molecular Psychiatry of the HCPA, sleep/social, activity, and food. Total scores range from 18 to 72, and
and included the structured interview Mini International Neuropsy- higher scores indicated a greater disruption in the biological
chiatric Interview 5.0 for the diagnostic evaluation and scaling of rhythm.24
mood symptomatology (eg, the HAM‐D and the YMRS).
To verify breathing patterns, cirtometry was used, which
2.8 | Satisfaction of the patients with deep
consisted of a set of measurements of the circumferences of the
breathing
thorax and abdomen during respiratory movements and aimed to
quantify thoracoabdominal mobility.16 To evaluate the patient satisfaction with the deep breathing protocol,
the adapted Andrews Face Scale was used with scores varying from 0
to 10, with 0 being totally dissatisfied and 10 being totally satisfied.25
2.4 | Anxiety
Although there is no validation study for the Brazilian population,
The Hamilton Anxiety Rating Scale (HAM‐A) and the Beck Anxiety this scale has been widely used.
Inventory (BAI) were used to assess anxiety symptoms. The HAM‐A
comprises 14 items distributed in two groups: the first group of
2.9 | Physical activity
seven items is related to symptoms of anxious mood, and the second
group of seven items is related to physical symptoms of anxiety. The To evaluate the level of physical activity, the International Physical
total score is obtained by summing the assigned values in all 14 items Activity Questionnaire scale was used, which is an instrument to
SERAFIM ET AL. | 3

F I G U R E 1 Deep breathing protocol. BRIAN, Biological Rhythms Interview for Assessment in Neuropsychia try; FAST, Functional
Assessment Short Test; HAM‐D, Hamilton Depression Rating Scale; SF‐36, Short‐Form Health Survey; YMRS, Young Mania Rating Scale

estimate the level of habitual practice of activity. It is composed of performed. In the fifth session, patients performed the deep
eight open‐ended questions and estimates the time spent per week in breathing exercises and were also given written instructions on the
different aspects of physical activity (eg, moderate physical activity, deep breathing techniques for further practice at home. The patient
vigorous walking, and physical exertion) and physical inactivity was seen for the final follow‐up assessment and evaluation (Figure 1).
(sitting position). It classifies the patient into a number of categories,
including sedentary (patient does not perform any regular activity for
2.12 | Statistical analysis
10 continuous minutes) and irregularly active (one that performs
physical activity but at a level insufficient to be classified as active Statistical analyses were performed in R (https://www.Rproject.org/).
because it does not comply with the recommendations regarding Descriptive statistics were collected from clinical and demographic
frequency or duration). Irregularly active is divided into two data. The means (with standard deviation) and frequencies (numbers
subgroups: irregularly active B (someone who did not meet any of or percentages) were used to describe the characteristics of the
the criteria of the recommendations regarding frequency or duration) sample.
and irregularly active A (someone who meets at least one of the To test the effect of the intervention, the “easyanova” package
criteria of the recommendations regarding the frequency (5 days/ was used.29 The comparison of the preintervention, postintervention,
week) or duration (150 min/wk) of the activity. It also ranks people as and follow‐up evaluations was performed by analysis of variance of
active (ie, the patient fulfilled the recommendations of vigorous the following variables: HAM‐D, YMRS, FAST, HAM‐A, BAI,
activity ≥ 3 days/wk and ≥20 min/session, or moderate activity or SF‐36, and BRIAN. The Scott–Knott test was performed to compare
walking, ≥5 days/wk and ≥30 min/session or 5 days/wk and the means of the variables that presented significant differences in
≥150 min/week [walk + moderate + vigorous]) and very active (pa- ANOVA (P < 0.05). The breathing pattern, because it was a
tient met the recommendations of vigorous activity, ≥5 days/wk and categorical variable, was analyzed in an organizational tree model,
≥30 min/session, vigorous activity ≥ 3 days/wk ≥ 20 min/session + using the "rpart" package,30 and the significance of the intervention
moderate activity and/or walking ≥5 days/wk and ≥30 min/ was obtained by the chi‐square test with the package “stats” (native
session).26 R package). The χ2 test was applied when the dependent and
independent variables were categorical, by comparing the group
variances and between groups.31
2.10 | Estimated intellectual functioning (IQ)
The graphs for the presentation of the results were produced
Estimated IQ was assessed with two subtests from the Wechsler with the package "ggplot2".32
Abbreviated Scale of Intelligence: Vocabulary and Matrix Rea-
soning.27,28
3 | RESULTS
2.11 | Intervention
Twenty patients were asked to participate in the study and
The deep breathing protocol was performed at the Clinical Research completed the preintervention evaluation, but 14 patients completed
Center of Hospital de Clínicas de Porto Alegre. The protocol the protocol, as three of the patients dropped out of the study due to
comprised seven sessions that lasted between 30 and 60 minutes, logistical issues and three were excluded from the study because
and during these weekly, individualized sessions, the patient was they did not meet all the inclusion criteria. Of the 20 patients who
guided by the same physiotherapist throughout the protocol. In the performed the first evaluation, 14 patients (70%) were female. The
first session, the preintervention assessment was performed, and mean age was 42.80 (±12.06) years. Thirteen patients (65%) were
information about the deep breathing was shared. During the second sedentary, five patients (25%) were irregularly active A, and two
session, the patient was shown how to perform deep breathing. In patients (10%) were irregularly active B and so remained in the
the third and fourth sessions, the deep breathing training was subsequent assessments. The other data can be seen in Table 1.
4 | SERAFIM ET AL.

T A B L E 1 Demographic and clinical characteristics of participants The comparisons of preintervention, postintervention, and

Characteristic N % follow‐up measures are shown in Table 2.

There were statistically significant improvements postinterven-
Sex
Male 6 30 tion on the HAM‐A (P < 0.001); eight patients (57.14%) had a
Female 14 70 remission of anxiety symptoms, five patients (35.71%) had a response
Age (years) but did not reach remission, and one patient (7.15%) had no response
Mean (SD) 42.80 (12.06) to the intervention. There was also a significant improvement in the
Bipolar disorder subtype BAI score (P < 0.001) and they remained better at follow‐up,
Bipolar I disorder 19 95 demonstrating the efficacy of the adjuvant anxiety treatment
Bipolar II disorder 1 5 technique in BD patients.
Social support The HAM‐D and YMRS scores were statistically significantly
Yes 15 75 lower at postintervention and follow‐up, demonstrating a decrease in
No 5 15 the subsyndromal symptoms of BD.
Race The FAST and the BRIAN did not show statistically significant
Caucasian 17 85
differences at postintervention (P = 0.8574 and 0.292, respectively).
Non‐Caucasian 3 15
The quality of life scale, the SF‐36, had significant preintervention,
QI
postintervention, and follow‐up differences only in the General
Mean (SD) 88.91 (13.81)
Health Status domain, and there were no differences in the other
Schooling (years)
domains (Table 2).
Mean (SD) 11.65 (4.15)
≤8 4 20 The organization tree model calculated the probabilities for each
9–11 6 30 type of respiratory pattern (ie, apical, diaphragmatic, and mixed) at
≥12 10 50 each time of evaluation—preintervention, postintervention, and
follow‐up. These results are presented in Figure 2.
In Figure 3, it was possible to verify the score of each patient
On the satisfaction scale, for the patients who completed the study, in the HAM‐A and BAI scales, observe the improvement of the
13 of the 14 patients (92.86%) were very satisfied with the protocol, and symptoms of anxiety during the postintervention, and observe
one patient (7.43%) was satisfied with the protocol for deep breathing. that the results were maintained at the follow‐up assessment.

T A B L E 2 Mean scores on outcome measures at preintervention, postintervention, and follow‐up assessment

Preintervention Postintervention Follow‐up

Mean SD Mean SD Mean SD Statistic

a b b
HAM‐A 24.43 ± 7.84 7.57 ± 3.61 7.21 ± 4.82 <0.001
BAI 24.93a ± 13.99 10.07b ± 7.04 9.50b ± 7.46 <0.001
a b b
HAM‐D 7.14 ± 5.36 1.86 ± 1.56 1.50 ± 1.99 <0.001
a b b
YMRS 1.79 ± 1.48 0.86 ± 1.23 0.57 ± 0.76 0.0271
FAST 25.14 ± 14.39 24.57 ± 12.35 22.64 ± 10.34 0.8574
BRIAN 35.57 ± 8.71 33.07 ± 6.16 31.29 ± 6.45 0.2972
SF‐36
Physical functioning 67.50 ± 19.68 79.64 ± 19.76 73.57 ± 15.24 0.2162
Bodily pain 44.64 ± 38.20 66.07 ± 36.17 55.36 ± 31.28 0.2876
b a a
General health 41.64 ± 25.99 66.07 ± 24.52 61.93 ± 23.55 0.0281
Vitality 62.00 ± 13.53 62.26 ± 15.24 65.50 ± 18.26 0.8088
Social functioning 52.86 ± 19.39 53.21 ± 15.14 56.78 ± 14.22 0.7835
Mental health 63.39 ± 27.93 68.93 ± 30.49 62.50 ± 27.73 0.8151
Role–physical 45.22 ± 42.57 61.90 ± 46.88 61.88 ± 38.91 0.5007
Role–emotional 56.86 ± 17.62 68.57 ± 15.60 69.93 ± 16.35 0.0840

Abbreviations: BRIAN, Biological Rhythms Interview for Assessment in Neuropsychia try; FAST, Functional Assessment Short Test; HAM‐D, Hamilton
Depression Rating Scale; SF‐36, Short‐Form Health Survey; YMRS, Young Mania Rating Scale.
a,b
Means followed by the superscript letters did not differ according to Scott–Knott test at 5% significance.
SERAFIM ET AL. | 5

FIGURE 2 Breathing pattern: preintervention, postintervention, and follow‐up assessment

F I G U R E 3 HAM‐A and BAI preintervention , postintervention, and follow‐up assessment. HAM‐A, Hamilton Anxiety Rating Scale; BAI, Beck
Anxiety Inventory

4 | D IS C U S S IO N is necessary to study the efficacy of therapies in patients with

subsyndromal symptoms, as well as to design interventions (pharma-
This was a pilot study of a specific protocol for patients with BD, cological and psychosocial) to attenuate this type of symptomatology.
offered as an adjuvant treatment to treat anxiety. Our findings Decreasing the subsyndromal symptoms also decreases the chances
showed that this brief intervention produced changes in the HAM‐A of the patient having a new episode. Thus, we have deep breathing as
and BAI scales, indicating that anxiety symptoms decreased an important adjuvant treatment for patients with BD, and due to its
significantly in these patients, corroborating studies by Brown, simplicity, it is possible to include it in psychoeducation protocols.
et al8 and Chen et al (2016)33 stated that deep breathing decreased All patients were able to learn and replicate the deep breathing
anxiety levels. It is noteworthy that the improvement was maintained technique without difficulties. There was a change in the preinter-
in the follow‐up evaluation performed one month after the end of the vention breathing pattern, which was initially apical, to the
intervention, and we concluded that the technique was an effective diaphragmatic pattern in the postintervention and maintained
and lasting adjuvant anxiety treatment in patients with BD. through the follow‐up assessments. This is an easy protocol that
It was verified that the technique statistically reduced the scores has no need for specific material or support from the therapist, has
on the HAM‐D and YMRS scales, easing the subsyndromal symptoms no cost and is easy to understand by the patient, and this study
of BD. Subchondromic symptoms, especially depressive symptoms, proves that the protocol is feasible. Quality of life improved
have an impact on psychosocial functioning and neurocognition34,35 statistically only in the General Health Status domain, contrasting
in patients with BD. Treating subsyndromal depressive symptoms is with the results of Tsai et al38 that deep breathing improved the
an unresolved issue in psychiatry that represents an obstacle in mental health domain in patients undergoing hemodialysis. The
36 37
restoring normal patient functioning. According to Grande et al, it inconsistent results may not be due to the short intervention period,
6 | SERAFIM ET AL.

because in the Tsai et al38 study, the protocol lasted 8 weeks. In R E F E R E N CE S

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