Hindawi Evidence-Based Complementary and Alternative Medicine Volume 2017, Article ID 5869315, 21 pages https://doi.org/10.1155/2017/5869315 Review Article The Effectiveness of Aromatherapy for Depressive Symptoms: A Systematic Review DalindaIsabelSánchez-Vidaña,ShirleyPui-ChingNgai,WanjiaHe,JasonKa-WingChow, BensonWui-ManLau,andHectorWing-HongTsang DepartmentofRehabilitationSciences,TheHongKongPolytechnicUniversity,Kowloon,HongKong CorrespondenceshouldbeaddressedtoBensonWui-ManLau;[email protected] Received25August2016;Revised25October2016;Accepted14November2016;Published4January2017 AcademicEditor:ArndtBu¨ssing Copyright©2017DalindaIsabelSa´nchez-Vidan˜aetal. This is an open access article distributed under the Creative Commons AttributionLicense,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkis properlycited. Background.Depressionisoneofthegreatesthealthconcernsaffecting350millionpeopleglobally.Aromatherapyisapopular CAMinterventionchosenbypeoplewithdepression.Duetothegrowingpopularityofaromatherapyforalleviatingdepressive symptoms,in-depthevaluationoftheevidence-basedclinicalefficacyofaromatherapyisurgentlyneeded.Purpose.Thissystematic reviewaimstoprovideananalysisoftheclinicalevidenceontheefficacyofaromatherapyfordepressivesymptomsonanytypeof patients.Methods.Asystematicdatabasesearchwascarriedoutusingpredefinedsearchtermsin5databases:AMED,CINHAL, CCRCT,MEDLINE,andPsycINFO.Outcomemeasuresincludedscalesmeasuringdepressivesymptomslevels.Results.Twelve randomizedcontrolledtrialswereincludedandtwoadministrationmethodsforthearomatherapyinterventionincludinginhaled aromatherapy(5studies)andmassagearomatherapy(7studies)wereidentified.Sevenstudiesshowedimprovementindepressive symptoms.Limitations.Thequalityofhalfofthestudiesincludedislow,andtheadministrationprotocolsamongthestudiesvaried considerably.Differentassessmenttoolswerealsoemployedamongthestudies.Conclusions.Aromatherapyshowedpotentialtobe usedasaneffectivetherapeuticoptionforthereliefofdepressivesymptomsinawidevarietyofsubjects.Particularly,aromatherapy massageshowedtohavemorebeneficialeffectsthaninhalationaromatherapy. 1.Introduction includefeelingsofguilt,sadness,worthlessnessanddesper- ation, inability to experience pleasure, changes in appetite Depression is a life-threatening mood disorder manifested and sleep patterns, lack of energy, poor concentration and as a combination of cognitive and physical symptoms that memory, motor retardation, fatigue, and recurrent suicidal leads to decreased interest in daily life activities [1] which and death ideation which are experienced for more than 2 imposessignificantnegativeimpactonpeople’squalityoflife weeks[1,9,12,13]. andworkperformanceduetodisability,suffering,andhigh Diagnosis of depressive symptoms is carried out using riskofperpetratingself-harm[2,3]. validatedtools[14].Oneoftheoldestandmostwidelyused Depression is reported as the largest health concern in diagnostic tools is the Hamilton Depression Rating Scale the21stcentury[4].About350millionpeoplearecurrently [15] which comprises a clinical-rated and a self-reported sufferingfromdepression[5].Majordepressivedisorderhas assessment. Another tool included the Beck Depression been projected to be the highest cause of years of life lived Inventorythatusesapatientself-reportingtoolofdepressive with disability by 2030 [6, 7]. The prevalence of depression symptoms[14].Thesetoolsdemonstratedhighsensitivityand hasincreaseddramaticallyatagloballevelandonemillion specificity and therefore are the best validated scales used people with depression commit suicide yearly [6, 8, 9]. In for assessing the degree of severity of depressive symptoms USA, an annual economic loss around USD 210 billion is [14,16,17]. associated with depression, which is one of the diseases Nowadays, the first-line treatment for major depressive withhighesteconomicburden[10,11].Depressivesymptoms disorder is antidepressants including monoamine oxidase 2 Evidence-BasedComplementaryandAlternativeMedicine inhibitors, tricyclic antidepressants, and serotonin-norepi- stimulate brain areas directly via the olfactory epithelium nephrine and selective serotonin reuptake inhibitors (SN/ [44, 48]. Essential oils trigger mechanisms in the brain via SSRIs)[13,30,31].Despitethewidevarietyofantidepressants the olfactory system. The mechanism of action of essential available in the market, a significant proportion of patients oils administered by inhalation involves stimulation of the cannot reach full remission or experience side effects [13, olfactory receptors cells in the nasal epithelium, about 25 32, 33]. For instance, it has been reported that nearly 30% million cells, connected to the olfactory bulb. After stim- of the patients do not respond [8]. Side effects includ- ulation, the signal is transmitted to the limbic system and ing nauseas, insomnia, agitation, weight gain, somnolence, hypothalamus in the brain through the olfactory bulb and sexual dysfunction, and cardiovascular adverse events have olfactory tract. Once the signals reach the olfactory cortex, been reported [9, 31, 34]. Another downside of the use release of neurotransmitters, for example, serotonin, takes of antidepressants is the long treatment period needed to placewhichresultsintheexpectedeffectonemotionsrelated experience the beneficial antidepressant effect. Due to the toessentialoiluse[49–51]. ineffectivenessofthetreatmentin somepatientsorintoler- Increasingpopularityofaromatherapyhasbeenreported ability to the side effects, a large number of patients do not intheUKasoneofthemostcommonlyusedCAMtherapies complywiththetreatmentandsearchforothertherapeutic [52]. Due to the increasingpopularityof aromatherapythis options [13, 31, 35]. Hence, increasing number of people modalityofCAMwaschosentocarryoutasystematicreview withdepressivesymptomsexploredothernonpharmacolog- onitseffectiveness[53]. ical interventions including psychotherapy and counseling, Therewasonepublishedsystematicreviewevaluatingthe psychoeducation, exercise, problem solving therapy, guided effectsofaromatherapyforpeoplewithdepressivesymptoms self-help and behavioral activation treatments [36], or even whichincludedstudiesfrom2000to2008[2].Since2009to complementaryandalternativemedicine(CAM)[3,31]. date, 10 new RCT studies have been carried out to evaluate CAMisdefinedasabroadsetofhealingresources,suchas the effectiveness of aromatherapy on depressive symptoms medicalproductsandpractices,fortheprevention,diagnosis, therebyraisingtheneedtoupdatethediscussiononthenew andtreatmentofdiseasesthatfunctionsasacomplementto findingstakingintoaccountalltheevidencereportedupto themainstreammedicinesystem[37].InUSA,about53.6% date on the topic. Therefore, this systematic review aims to ofthepatientssufferingfromdepressionhavereportedtouse provideanupdatedanalysisoftheevidenceoftheefficacyof CAMasanadjuvanttherapyforthetreatmentofdepression aromatherapyfordepressivesymptoms. [31,38].OneoftheCAMoptionsthatpatientswithdepressive symptomschooseisaromatherapy.Aromatherapyisdefined 2.Methods asthetherapeuticuseofplant-derivedconcentratedessences whichareextractedbydistillation[39–41].Aromatherapyis 2.1. Search Strategy. An extensive literature search was car- an inexpensive and noninvasive modality of CAM used to riedoutinthefollowingdatabases:AlliedandComplemen- improvethepsychologicalhealthandwellbeing[40,42,43]. taryMedicineDatabase(AMED),CochraneCentralRegister Essentialoilscontainvolatileorganiccompoundsthatexert ofControlledTrials(CCRCT),CumulativeIndextoNursing a pharmacological effect by penetrating the body by oral, and Allied Health (CINAHL), MEDLINE, and PsycINFO. dermal(aromatherapymassageortopicalapplicationofaro- The predefined search strategy used to obtain the reference matherapy)[44,45],orolfactoryadministration(inhalation list of potential articles in the present study is shown in aromatherapy)[46–48].Theclassificationofessentialoilsis Table1.OnlystudiesinEnglishwereincludedandthesearch basedonthebotanicalclassificationoftheplantfromwhich was carried out by 2 independent authors having a third theessentialoilsareextracted[44].Theuseofchemotypesis author to consult when discrepancy occurred. The present anotherclassificationofessentialoilsbasedonthesubspecies study included randomized clinical trials involving adult of a plant with the same morphological characteristics that subjectsofbothgenders.Therewasnoagerestriction. produces essential oils with different chemical profile, for example, type and quantity of chemical components [45]. 2.2. Inclusion and Exclusion Criteria for Study Selection and Thechemotypedescribesthemaincompoundwithincertain Outcome Measures. The studies included in the present essentialoil[45].Frequently,essentialoilsareusedatdifferent review comprise RCTs with any kind of study design (e.g., concentrations depending on the route of administration: double blind, single blind, and crossover study). No time (1)foraromatherapymassage,1–5%essentialoilisused,(2) restriction on the publishing year was considered for the fororaladministration,8–50%essentialoilisused,and(3) study selection and studies that fulfill the inclusion and concentratedessentialoilisusedininhalationaromatherapy exclusioncriteriauptodatewereincluded.Studiesinwhich [48].However,thedosageanddilutionofessentialoilchosen depressivesymptomswereevaluatedusinganystandardized are not standardized in practice [48]. The most potent assessmenttoolfordepressivesymptomswereincludeddis- and effective administration method is oral administration regardingthetypeofclinicalconditionstudied.Studiesthat in which the components of the essential oil reach the assesseddepressivesymptomsbyanxietyscalesoranyother bloodstream[44].Sinceessentialoilsarelipophilic,theycan assessmentsfordepressivesymptoms,forexample,Profileof easilybecarriedtoallorgansinthebody[44].Ininhalation Mood States rating scale (POMS) or Hospital Anxiety and aromatherapy, the inhaled air containing essential oils can Depression Scale (HADS), were included. Eligible studies notonlyreachthecirculationsystemviathebloodcapillary had to include the use of essential oils administered by network in the nose and the bronchi in the lungs but also inhalation or topical administration. Any study combining Evidence-BasedComplementaryandAlternativeMedicine 3 Table1:Searchtermsanddatabasesearchstrategy. 2.5.QualityAssessment. Thequalityofthestudiesincluded wasassessedusingtheJadadscalewhoseratingcriteriatake ID Diseasesearchterms into account randomization, double blinding, withdrawals, 1 Depress∗ anddropouts[54].ThescoringrangeintheJadadscalegoes 2 Majordepress∗ from0to5inwhichahigherscorerepresentshigherquality 3 Mooddisorder ofthestudy. 4 Depressivedisorder 5 1OR2OR3OR4 3.Results ID RCTsearchterms 6 Controlledclinicaltrial∗ 3.1.DescriptionoftheStudySelectionScheme. Thecombined 7 Random∗controlledtrial∗ databasesearchwascarriedoutfrominceptiontoMay2016 and resulted in 875 studies identified using the predefined 8 6OR7 search terms (Figure 1). After removal of duplicates (𝑛 = ID Aromatherapysearchterms 207), the title of 668 studies was screened. Most of the 9 Aroma studiesexcludedwerenotconcernedwithdepressionand/or 10 Aromatherapy aromatherapy (𝑛 = 552). In addition, 84 studies were 11 Aromatictherapy excluded because they were not RCTs, they were not in 12 Essentialoil∗ English, and/or no depressive symptoms were measured. 13 Fragrance Aftertitlescreening,32studiesremainedforfurtherfulltext 14 Fragrantoil∗ screening. A total number of 20 studies were excluded at this stage, 7 studies did not assess depressive symptoms, 1 15 Scent studywasacommentary,6werenotRCTs,1studyassessed 16 Massagetherapy cologneswhicharenotessentialoils,and5studiescouldnot 17 Medicalmassage beaccessed.Fromthe5studiesthatcouldnotbeaccessed,1 18 Massage studywasnotdetectedasduplicatebeforesinceitappeared 19 9OR10OR11OR12OR13OR14 with a short title in the database search; therefore, only 4 OR15OR16OR17OR18 studies could not be accessed. The abstract of 2 of those 20 5AND8AND19 studies was available while no abstract was available of the ∗Truncationsymbolfordatabasesearch. other2studies.Theauthorsofthose4studieswerecontacted viaemailrequestingthemthefullstudies.Wecouldnotget access to four studies whose title suggested that the studies aromatherapy and massage was included regardless of the could be included in the systematic review. However, the applicationmethodofthemassage.Therewasnorestriction studieswerenorprovidedbytheauthorduetothefollowing inthedurationofthetreatmentandnumberofsessionsused. reasons: the study was still unpublished, the authors did Systematicreviewsandmeta-analysesonaromatherapyand not reply, or the author could not be reached. Therefore, depression, mood disorders, or depressive symptoms were those studies were excluded. A total number of 12 RCTs notincluded. [18–29] that met the inclusion and exclusion criteria were selected. 2.3. Selection of Relevant Studies. After the article search andremovalofduplicates,thetitlesofthearticlesretrieved 3.2.DescriptionoftheSubjects. Detailedinformationonthe in the database search were screened. The abstracts of the subjects is stated in Table 2. The total number of subjects preselected articles were screened to make a selection for from all the studies was 1226 from which 984 were female further analysis. In case of doubt to include any study in (80.3%) and 224 (18.3%) were male participants. The study the second screening, the full article was reviewed. Two conducted by Lemon [23] did not specify the number of independentauthorscarriedoutthesearchandselectionof female and male subjects in the control group; therefore relevant studies for the present review. Disagreement was thegenderof18subjects(1.4%)wasnottakenintoaccount resolvedbydiscussion. in the above mentioned percentages. The mean subject age includedinthestudieswas47withmeanaverageagerange 2.4. Data Extraction. The data extracted included the ref- of21–73.Theparticipantsincludedinthestudiesselectedare erence, type of study, total number of subjects, number of peoplewithcancer(𝑛 = 682),pregnantwomen(𝑛 = 333), subjects per treatment condition, brief description of the women in menopause phase (𝑛 = 90), patients diagnosed subjects,andtheinclusioncriteria.Regardingtheinterven- withdepressionand/oranxiety(𝑛=32),postpartumwomen tion,informationaboutthecomparisongroup,typeofaro- (𝑛 = 28), women whose children were diagnosed with matherapy,durationofthestudy,frequencyofthetreatment, attention deficit/hyperactivity disorder (𝑛 = 25), healthy outcomemeasures,andconclusionwereextractedfromthe female volunteers (𝑛 = 20), and patients diagnosed with selectedstudies. idiopathicenvironmentalintolerance(𝑛=16). 4 Evidence-BasedComplementaryandAlternativeMedicine n Initial search (n=875) o cati AMED (n=8) MEDLINE (n=153) fi nti CCTR (n=616) PsycINFO (n=44) Ide CINAHL (n=54) Duplicates removed (n=207) Number of studies left after elimination of duplicates (n=668) g n Studies excluded after title screening eni (n=636) e cr Studies were excluded for the following reasons: S Remaining studies (i) Not RCT (n=71) after title screening (ii) Not focused on depression (n=494) (n=32) (iii) Depressive symptoms not measured (n=1) (iv) Not focused on aromatherapy (n=58) (v) Not in English (n=12) Studies excluded after full text screening (n=20) Studies were excluded for the following reasons: (i) Depressive symptoms not measured bility Remaftaeinr ifnugll stteuxdties (ii) (Fnul=l s7t)udy not available from which 1 Eligi s(cnre=en1i2n)g was a duplicate study (n=5) (iii) Commentary (n=1) (iv) Not RCT (n=6) (v) Other fragrances different than essential oils used (n=1) ed Studies included in the ud systematic review cl (n=12) n I Figure1:Studyselectionflowchart. 3.3.Intervention 3.3.2. Intervention Group. Two administration methods for aromatherapyidentifiedinthestudiesselected includearo- 3.3.1. Control Group. The comparison groups used in the matherapy via inhalation (inhalation aromatherapy, 𝑛 = studies includednointerventiongroup(𝑛 = 6)[20,22,24, 5) [18–22] and aromatherapy with massage (aromatherapy 26, 28, 29], vehicle group (𝑛 = 4, received vehicle such as massage, 𝑛 = 7 plus 1 study from Conrad and Adams, carrieroilorwater)[18,19,21,23],andactivecontrolgroup 2012,whichalsousedinhalationaromatherapy)[19,23–29]. (𝑛=2;usualsupportivecareandcognitivebehaviortherapy, NoRCTstudyincludedinvolvedaromatherapyadministered well known treatments with positive effect on the outcome orally.Detailsoftheinterventionadoptedinthe12included measures)[25,27]. studiesweresummarizedinTable3. Evidence-BasedComplementaryandAlternativeMedicine 5 Baselinescorefordepressivesymptoms Baselinedepressionstatus:oddsratioof29usingHADS. ThebaselinescoreusingtheEdinburghPostnatalDepressionScaleforthecontrolgroupwas15.9and16.1fortheinterventiongroup. Depression-dejectionscalebaselinescoreusingPOMSwas2.7inthecontrolgroupand1.6inthetreatmentgroup. Thedepression-dejectionscalebaselinescoreusingPOMSwasnotprovided,butthechangedifferencebetweenpre-andposttreatmentwasreported.Thechangeindepression-dejectionscorewas−lowerthan1inthetreatmentgroupandstatisticallysignificantwhencomparedtothechangeinthecontrolgroup.DepressiongradebaselineintheEdinburghtestwas6.3inthecontrolgroupand6.1intheinterventiongroup. rn a theselectedstudies. Diagnosticsystems/inclusioncriteria Patientsprescribedwith8ormorefractionsofradiotherapy 0–18-monthpostpartumwomenwithscoresof10orhigheroneithetheEdinburghPostnatalDepressioScaleortheGeneralizedAnxietyDisorderScale 28-week-pregnantwomen,singletonpregnancy Healthyvolunteers Womenbetween18–35years,withpregnancyagebetween38and42weeks,ascoreof12orlessintheEdinburghtest n i ded cts y en participantsinclu Subje Typeofsubject ationaromatherapIndividualswithcancerreceivingradiotherapytreatment Postpartumwom Pregnantwomen Collegestudents Pregnantwomen aracteristicsofthe 𝑛Gender() Inhal Female(150)Male(163) Female(28) Female(13) Female(20) Female(320) h C p e2: ct up rou age Tabl Meansubjeage(range) 65(33–90) 32(25–43) 27.3forthecontrolgro(NA)29.3forthetreatmentg(NA) 20.5 20–30,averageNA of r e b m us nct Totalsubje 313 28 13 20 320 Typeofstudy Placebo-controlledrandomizeddoubleblindRCT Randomizedobservationalpilotstudywithrepeatedmeasures ProspectiveRCT Randomizedcontrolledcrossoverstudy Controlleddouble-blindedRCT Ref. [18] ∗[19] [20] [21] [22] 6 Evidence-BasedComplementaryandAlternativeMedicine Baselinescorefordepressivesymptoms ThebaselineusingtheMontgomery-AsbergDepressionRatingScalewas19.8inthecontrolgroupand30inthetreatmentgroup.ThebaselineusingtheHADSwas14.6and15.3inthecontrolandtreatmentgroup,respectively. BaselinescoreusingHADSwasnotstated.OnlythemedianchangeinHADSwasprovidedbeing0forthe−aromatherapygroup,1.5forthe−massagegroup,0.5forthearomatherapymassagegroup,and0.5forthecontrol. ThebaselinescoreusingtheCenterforEpidemiologicalStudiesDepressionScalewas26.1forthearomatherapygroupand26forthegroupreceivingusualcare(control). DepressionsubscalebaselinescoreusingPOMSwasaround2.8inthecontrolperiod. ThebaselinescoreusingtheEdinburghPostnatalDepressionScaleforthecontrolgroupwas15.9and16.1fortheinterventiongroup. Diagnosticsystems/inclusioncriteria Patientsscoringmorethan7intheMontgomery-AsbergDepressionRatingScaleand/ortheTyrerBriefAnxietyScale Individualswithcancerwithawidevarietyoflevelsofphysicalandpsychologicalsymptoms Patientsdiagnosedwithcancer,aprognosisofmorethan3months,withclinicalanxietyordepression Clinicalexaminationbyaphysicianandscoringabove26formenand30forwomenintheChemicalOdorSensitivityScale0–18-monthpostpartumwomenwithscoresof10orhigheroneithertheEdinburghPostnatalDepressionScaleortheGeneralizedAnxietyDisorderScale ble2:Continued. Subjects Typeofsubject matherapymassage Patientswithdepressionand/oranxiety Individualswithcancer Individualswithcancer Patientsdiagnosedwithidiopathicenvironmentalintolerance Postpartumwomen Ta 𝑛Gender() AroFemale(10inthetreatmentgroup)Male(4inthetreatmentgroup)Noinformationprovidedonthenumberoffemaleandmalesubjectsinthecontrolgroup Female(32),male(10) Female(250),male(38) Female(15),male(1) Female(28) Meansubjectage(range) 32.9(23–53)inthetreatmentgroup 73,(44–85) 52.1;52.8fortheusualcaregroup;and51.5fortheusualcareplusaromatherapygroup 46.1(37.9–54.3) NA of r e b m us nct Totalsubje 32 42 288 16 28 r e Typeofstudy RCT DoubleblindRCT RCT Nonblindedrandomizedcrossovtrial Randomizedobservationalpilotstudywithrepeatedmeasures Ref. [23] [24] [25] [26] ∗[19] Evidence-BasedComplementaryandAlternativeMedicine 7 Baselinescorefordepressivesymptoms Thebaselinescoreinthedepression-dejectionsubscaleofPOMSwas11.2forthearomatherapymassagegroupand13.4forthecontrolgroup. Atbaseline,accordingtotheMenopauseRatingScale,thefrequencyoftheseverityofthedepressivemoodwasreportedasmild(14.9%),moderate(36.8%),severe(20.7%),andverysevere(2.3%).Nodifferencewasfoundamongthegroupsatbaseline.BaselineusingtheBeckDepressionInventorywas8.6inthecontrolgroupand10.8inthetreatmentgroup. etable.NA,notavailable;HADS,Hospital h Diagnosticsystems/inclusioncriteria Patientsdiagnosedforatleastonemonth,whoalsohadatleastapredictedsurvivalof6monthsandscore11ormoreintheHADSforanxietyordepression Woman,agebetween45and60years,withamenorrheaforatleast1year Womenwhosechildrenwerediagnosedwithattentiondeficithyperactivitydisorder studywasincludedinbothcategoriesint e h able2:Continued. Subjects Typeofsubject Individualswithcancer Womenwhoenteredtheirmenopausalperiodnaturally Womenwithchildren erapymassage.Therefore,t T h at m 𝑛Gender() Female(31),male(8) Female(90) Female(25) erapyandaro h Meansubjectage(range)52.5;51.1forthearomatherapygroup;and54forthecognitivebehaviortherapygroup53.70forthecontrolgroup(49.42–57.98),52(47.12–56.88)forthemassagetherapygroup,and53.35(49.01–57.69) 34–48,averageageNA d,inhalationaromatStates. berof weretesteofMood Totalnumsubjects 39 90 25 modalitiesMS,Profile yO apP herale; ofstudy eblindRCT y,botharomatDepressionSc TypeRef. Singl[27] RCT[28] RCT[29] ∗InthisstudAnxietyand 8 Evidence-BasedComplementaryandAlternativeMedicine InthestudycarriedoutbySehhatieetal.[22],acombi- from 1 to 56 sessions [18–21] (Table 3). In one study, the nationofnonpharmacologicalinterventionsforpainreliefin totaldurationoftheexposuretothearomawasnotspecified labor,includingaromatherapy,wasusedintheintervention sincetheinterventionwascarriedoutduringtheactivephase group. The contribution of aromatherapy in the combined of the labor process that pregnant women underwent [22]. interventioncannotbediscriminatedinthisstudy.Therefore, Furthermore,thefrequencyofthetreatmentinthe5studies caution should be taken when discussing the results of this differs greatly. For example, the frequency of treatment in study. the studies varies from once [20, 22], twice [21], and twice a week [19] to daily [18]. The duration of the treatment in 3.4.SelectionofEssentialOils. Essentialoilsweremainlyused theinhalationaromatherapystudiesallowedtheevaluationof pure, diluted, or in a mixture of 2 or more essential oils acuteandlongtermeffectduetothedurationofthetreatment at a particular ratio. The selection of the essential oils used from1-2daysto4–8weeks,respectively. wasdeterminedbythearomatherapist,theeffectonphysical andphysiologicalstates,subject’spreference,orsafetyforuse 3.5.2. Aromatherapy Massage. The types of massage are duringpregnancywhileotherstudiesdidnotmentioninthe performed with standardized protocols [24–27] in which 3 methodology section the rationale behind the essential oils ofthestudies[25–27]didnotdescribetheareasofthebody chosennorspecifythetypeofessentialoilsused.Themost forthedeliveryofthemassagewhileanotherstudyspecified commonlyusedessentialoilswerelavenderin8studies[18– the target body areas to deliver the massage such as back 20,22–24,28,29]. massage[24].Othermassagetargetareaswerealsodescribed in three studies [19, 28, 29]. Taavoni et al. [28] focused the 3.4.1. Inhalation Aromatherapy. The essential oils that were massage on the abdomen, thighs, and arms while Wu et al. morecommonlyusedintheinhalationaromatherapystudies [29]focusedontheneck,shoulders,arms,back,andlegswith werelavenderandbergamoteitherasasingleessentialoilor effleurage, friction, petrissage, and vibration at a moderate inamixturewithotheressentialoils[18–20,22–24,28,29]. pressure.InthestudyofConradandAdams[19],theessential Onemixtureoffractionatedessentialoilswasused,butthe oilmixturewasappliedonbothhands(handaromatherapy typeofessentialoilscontainedinthemixturewasnotspeci- massage) using the well m’technique which involves gently fied[18].Inaddition,thepurityofthefractionatedmixture strokingmovementsappliedinasetsequencewithstructured was unknown. Other essential oils utilized were petitgrain strokes, sequence, number, and pressure [45]. The duration [20] and Yuzu [21] essential oil alonewhile cedarwood [18] ofthestudieswas4,8,10,and12weeksand2years.Weekly androseotto[19]wereusedincombinationwithamixture sessionswerecarriedoutinmostofthestudies[19,24,25,27– oflavenderandbergamot,andlavender,respectively. 29];onlyinonestudythefrequencywasonceevery2weeks [26].Thenumberofsessionsperweekalsovariedfromonce 3.4.2.AromatherapyMassage. Asetof20differentessential or twice weekly to once every 2 weeks. The duration of the oil options were used in two of the studies from which the treatments was 15, 30min, and 40min to 1h and the total therapistschosethemostsuitableessentialoilforeachoneof numberofsessionsvariedfrom4and6to8sessions. thesubjects[25,27].However,thetypeofessentialoilsused providedtotheparticipantswasnotspecifiedinthosestudies. 3.6. Outcome Measures. A summary of the outcome mea- On the other hand, in the study conducted by Lemon [23], suresisshowninTable4.Themostfrequentlyusedinstru- theessentialoilsusedwereselectedfromalistof9options mentswereHADSandPOMS[18,20,21,24,26,27]followed andtheauthorspecifiedthetypeofessentialoilusedineach by EPDS which was used in 2 studies [19, 22]. Other subject of the intervention group. The essential oils used in assessment tools include the MADRS [23], MRD [28], BDI theotherstudiescompriselavender,amixtureof2–4different [29],andCES-D[25]. essentialoils,androseottocombinedwithlavender. 3.7.EfficacyofAromatherapy 3.5.AdministrationProtocol 3.7.1.InhalationAromatherapy. Twooutof5studiesevaluat- 3.5.1. Inhalation Aromatherapy. The method of administra- ingtheeffectofinhalationaromatherapyreportedbeneficial tion of inhalation aromatherapy also differed among the effects to improve depressive symptoms in the subjects [19, studies [18–22]. The main differences in the administration 21].ThesubjectsinthestudyofConradandAdams[19]were methodsrelyonthedistancebetweenthearomasourceand postpartum women exposed to two different aromatherapy the subject’s nose. In one study, cotton impregnated with interventions, inhalation aromatherapy and topic applica- essential oil placed in a diffuser was set in the nostrils of tion of aromatherapy, for 8 sessions. At baseline, control the subjects [21]. In the other two studies the source of and treatment groups showed similar levels of depressive aromawasplacedapproximately30cmawayfromthenose symptoms (EPDS: 𝑝 = 0.8). At the end of the study, the of the subjects [18, 20]. In other two studies, the essential treatment group with aromatherapy showed a significant oil was applied to a bib or to a cloth that were worn by reductionofdepressivesymptoms(EPDS:𝑝 = 0.01),butthe the participants [18, 22]. The volume of essential oil used improvement was lesser than using m’technique. The study intheinhalationaromatherapystudiesvariesfrom10𝜇Lto conducted by Matsumoto et al. [21] showed improvements 1mL or 3, 5, or 8 drops. The exposure time to the aroma in negative emotional stress after 2 sessions of 10min on ranged from 5 to 20 minutes, with the number of sessions healthy volunteers. The TMD score (𝑝 < 0.001) and the Evidence-BasedComplementaryandAlternativeMedicine 9 r bens mo nuessi 56 8 1 2 1 als otof T Durationpersession 15–20min 15min 5min 10min(sessionsseparatedinintervalsaround2.6days) Durationoftheactivephaseoflabor Treatmentfrequency Daily Twiceaweek Once Twice Once dintheselectedstudies. Administrationmethod 3dropsofoilappliedtoabibwornduringtheadministrationofthetreatment 8dropsofoilappliedtoacottonpad.Subjectswereinstructedtosmellthecottonpadfor15min 5dropsofoilappliedonafilterplacedinadiffuser 𝜇10Loilinacottonpadusedinadiffusersetinthesubject’snostrils ×1010cmclothimpregnatedwith1mL20%lavenderessentialoilwhichwasattachedtothemother’sbreastatthebeginningoftheactivephase.Thearomatherapyinterventionwascombinedwithothernonpharmacologicalinterventions e s andprotocolsu protocolDurationofthestudyromatherapy 8weeks 4weeks 1day 2days Duringlabor escriptionoftheinterventions Interventionand Typeofessentialoilused Inhalationa(i)Fractionatedoilsofunknownpuritydiluted1:3incarrieroil(ii)Mixtureoflavender,bergamot,andcedarwood(2:1:1)(i)0.25roseottoessentialoiland0.75lavender,2%dilutionoftheessentialoilmixture(i)Lavender(ii)Petitgrain(iii)Bergamot (i)Yuzu (i)20%lavenderessentialoil D Table3: Treatmentgroup(s)𝑛() (i)Carrieroilwithfractionatedlow(NA)gradeessentialoil(ii)Pureessentialoil(NA) (i)2%dilutionofamixtureofessentialoils(6) (i)Pureessentialoil(7) (i)Pureessentialoil(20) (i)Nonpharmacologicalmethodsforpainreliefoflaborincludingshowering,beinginuprightposition,aromatherapy,andsoftmusicwithoutwords(160) Comparisongroup𝑛() Controlwithsweetalmondcold-pressedpurevegetableoilwithnofragrance(NA) Control,jojobaoil(14) Control,nointervention(6) Control,water(20) Controlgroupwhichdidnotreceiveanynonpharmacologicalmethodforpainreliefoflabor(160) e c n e Refer [18] ∗[19] [20] [21] [22] 10 Evidence-BasedComplementaryandAlternativeMedicine Totalnumberofsessions 6 4 4 4 8 Upto8sessionsin10weeks 8 n ationessio min min h h min h min Durers 40 30 1 1 15 1 30 p Treatmentfrequency Onceafortnight Weekly Weekly Everytwoweeks Twiceaweek Weekly Twiceaweek Administrationmethod 15mLgrapeseedcarrieroilwith(4drops)orwithoutessentialoilsappliedinafullbodymassageusinggentleeffleurageandpetrissage Backmassage Standardizedmassageagreedbythetherapists Standardizedmassageontheback,shoulders,arms,hands,lowerlegs,andfeetusing20–30mLmassageoil TopicapplicationoftheoilorlotiononbothhandswithgentlestrokesofhomogeneouspressureandspeedStandardizedmassagecombinedwithtreatmentasusual(routinesupport)Massageintheabdomen,tights,andarmsusingmassageoilcontainingessentialoilsorodorlessliquidpetrolatum.Massagewasappliedwithclockwisecircularmovementsandlightpressure ontinued. rotocolDurationofthestudypymassage 12weeks 2years 10weeks 8weeks 4weeks 2years 4weeks C p a Table3: Interventionand Typeofessentialoilused Aromather(i)9essentialoils(bergamot,lemonclarysage,lavender,romanchamomile,geranium,roseotto,sandalwood,andjasmine).Acombinationofessentialoilschosenbythearomatherapistoneachtreatmentsession(16) (i)1%lavenderessentialoildilutedinsweetalmondoil (i)20essentialoils (i)1%massageoilcontainingmelissa,juniper,androsemaryessentialoilsmixedintojojobaoil(1:2:2ratio) (i)0.25roseottoessentialoiland0.75lavender,2%dilutionoftheessentialoilmixture (i)20essentialoils (i)3%oilmixturecontaininglavender,geranium,rose,androsemary(4:2:1:1ratio)inalmondandeveningprimroseoil Treatmentgroup(s)𝑛() (i)Dilutedessentialoil(16) (i)Aromatherapymassage(16)(ii)Massagewithinertcarrieroil(13)(i)Usualsupportivecareandaromatherapymassage (i)Aromatherapymassage (i)2%dilutionofamixtureofessentialoils(8) (i)Aromatherapymassage(20) (i)Aromatherapymassage(30)(ii)Massage(30) e Comparisongroup𝑛() Control,grapeseedoil(16) Control,nointervention(13) Usualsupportivecar Control,nointervention Control,essentialoilblendunscentedwhitelotion(14) Cognitivebehaviortherapy(19) Control,nointervention(30) e c n e Refer [23] [24] [25] [26] ∗[19] [27] [28]