International Journal of Psychophysiology 131 (2018) 96–101

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International Journal of Psychophysiology

journal homepage: www.elsevier.com/locate/ijpsycho

Adding HRV biofeedback to psychotherapy increases heart rate variability T

and improves the treatment of major depressive disorder
⁎
Yoko Tsui Caldwell, Patrick R. Steffen
Brigham Young University, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Heart rate variability (HRV) is a significant marker of health outcomes with decreased HRV predicting increased
Heart rate variability disease risk. HRV is decreased in major depressive disorder (MDD) but existing treatments for depression do not
Major depressive disorder return heart rate variability to normal levels even with successful treatment of depression. Heart rate variability
Biofeedback biofeedback (HRVB) increases heart rate variability but no studies to date have examined whether combining
Psychotherapy
HRVB with psychotherapy improves outcome in MDD treatment. The present study used a randomized con-
trolled design to compare the effects of HRVB combined with psychotherapy on MDD relative to a psychotherapy
treatment as usual group and to a non-depressed control group. The HRVB + psychotherapy group showed a
larger increase in HRV and a larger decrease in depressive symptoms relative to the other groups over a six-week
period, whereas the psychotherapy group only did not improve HRV. Results support the supplementation of
psychotherapy with HRVB in the treatment of MDD.

1. Introduction
Depression is a highly prevalent and debilitating disorder. The
World Health Organization estimates that depression is the third
leading cause of disease burden in the world and will be the leading
cause by the year 2030 (WHO, 2011), with depression severely im-
pacting both psychological and physiological functioning. Heart rate
variability (HRV) in particular, a key marker of parasympathetic
functioning and a potent predictor of physical morbidity and mortality,
significantly decreases as depression progresses (Gorman and Sloan,
2000; Kemp et al., 2010; Kemp et al., 2012; Koschke et al., 2009; Sgoifo
et al., 2015). Unfortunately, even though there are effective treatments
for depression including antidepressants and psychotherapy, HRV re-
mains low even after successful resolution of depressive symptoms
(Kemp et al., 2010). In other words, current treatments improve psy-
chological wellbeing, but do not resolve physiological issues such as
heart rate variability.
Depression rates have increased in recent decades in spite of effec-
tive treatments, and one potential reason for this problem is lack of
recovery in HRV following treatment (Greenberg et al., 2015; Kemp
et al., 2010; Kessler et al., 2012; Kessler et al., 2014; WHO, 2011). HRV
biofeedback (HRVB) reliably increases HRV and may represent a solu-
tion to the HRV recovery problem observed in depression treatment
(Lehrer and Gevirtz, 2014). No studies to date, however, have experi-
mentally tested whether combining HRVB with standard psychotherapy
increases HRV. Therefore, the purpose of the present study was to ex-
perimentally investigate if adding HRVB to psychotherapy, compared to
a treatment as usual psychotherapy group, would increase HRV and
improve the treatment of depression.
Depression impacts all areas of life including mood (e.g. sadness and
feelings of worthlessness), cognition (difficulties concentrating, deci-
sion making), and physiological functioning (e.g., sleep, energy), and as
depression progresses there is a shift in autonomic balance towards
sympathetic dominance and decreased HRV (Holzel et al., 2011; Kemp
et al., 2014a; Kemp et al., 2014b; Koschke et al., 2009). These symp-
toms significantly disrupt daily life and left untreated negatively impact
work, relationships, and physical health. Successful treatments for de-
pression include antidepressants and psychotherapy. Antidepressant
medications are frequently used to help reduce depressive symptoms
and help those afflicted with MDD to recover more quickly (Arroll et al.,
2009; Fournier et al., 2010). Despite the high usage of antidepressants,
findings from several studies suggest that only a third to a half of pa-
tients find antidepressants to be effective, with long term outcomes
being poor (Garcia-Toro et al., 2012; Hughes and Cohen, 2009; Pigott
et al., 2010; Rush et al., 2006). Antidepressant medications do not
improve HRV functioning, and some studies have found that anti-
depressant medications decrease HRV even further (Bassett, 2016;
Gorman and Sloan, 2000; Kemp et al., 2010). Interestingly, Licht et al.
(2010) found that starting antidepressant medication use decreased
HRV and stopping antidepressant medication use increased HRV.

⁎
Corresponding author.
E-mail address: steffen@byu.edu (P.R. Steffen).

https://doi.org/10.1016/j.ijpsycho.2018.01.001
Received 23 October 2017; Received in revised form 20 December 2017; Accepted 3 January 2018
Available online 05 January 2018
0167-8760/ © 2018 Elsevier B.V. All rights reserved.
Y.T. Caldwell, P.R. Steffen
Psychotherapy also improves depressive symptoms and helps those
afflicted with MDD to recover more quickly (Butler et al., 2006; De
Maat et al., 2007; DeRubeis et al., 2008; Gartlehner et al., 2015; Hollon
et al., 2005). As with antidepressants, psychotherapy has not been
shown to improve HRV in physically healthy MDD individuals, but
there is evidence that psychotherapy improves HRV in patients with
coronary artery disease, at least in those severely depressed (Carney
et al., 2000; Kim et al., 2009). Mindfulness and mindful approaches to
psychotherapy improve HRV in non-depressed individuals, but no stu-
dies to date have shown success with improving HRV in a depressed
sample. In fact, Wheeler et al. (2014), in a study of Mindfulness Based
Cognitive Therapy, found that depressive symptoms improved but HRV
did not change. In two unique studies that combined elements of
mindfulness with CBT, HRV did improve. Kim et al. (2009) studied a
CBT alone versus CBT plus forest meditation and found HRV im-
provement for the combined group but the CBT alone group showed no
changes. In a similar study, combining slow breathing exercises with
CBT improves HRV (Chien et al., 2015). It is noteworthy that slow,
diaphragmatic breathing is a key part of HRVB.
HRVB is a promising intervention that may improve HRV during
depression treatment. HRVB involves learning how to breathe at a re-
sonance frequency rate, typically about 6 breaths per minute.
Individuals with healthy breathing patterns, including athletes, medi-
tators, and Sherpas, spend more time breathing at this resonance rate
(Bernardi et al., 2001a; Bernardi et al., 2001a, 2001b). HRVB training
increases baroreflexes and helps people develop healthier breathing
patterns (Lehrer et al., 2003). HRV is considered an index of adapt-
ability, a measure of the body's ability to balance environmental change
and physiological needs, and the effects of HRVB appear to be at least
partially mediated by improved baroreceptor and parasympathetic
function.
Initial studies examining HRVB as a therapy for depression have
found encouraging results. Karavidas et al. (2007) investigated HRVB as
a standalone treatment for major depressive disorder. They examined
11 participants diagnosed with major depressive disorder with no
control group and found that depressive symptoms decreased and HRV
increased during the course of treatment. At the end of treatment,
however, HRV returned to baseline levels. As with previous research
using anti-depressants and psychotherapy, gains in depression treat-
ment were maintained. In a similar study, Siepmann et al. (2008) in-
vestigated HRVB as a standalone treatment for depression, examining
14 participants diagnosed with depression and also examining 12
healthy volunteers who received HRV, as well as 12 healthy controls
who did nothing. There was no depressed control group, however, so
complete randomization was not achieved. They found that HRVB im-
proved both depressive symptoms and HRV in the depressed group but
not in the healthy groups. Finally, in a study by Zucker et al. (2009) 38
patients with PTSD were randomly assigned to either HRVB or pro-
gressive muscle relaxation. At the end of the four-week study, only the
HRVB group displayed significant decreases in depression and sig-
nificant increases in HRV. Overall, research findings suggest that HRV
has the potential to be an effective adjunctive treatment for depression.
No published studies to date, however, have examined HRVB as an
adjunct to psychotherapy using a randomized controlled design. The
purpose of the present study was to examine HRVB as an adjunct to
psychotherapy in the treatment of major depressive disorder with
participants randomized to treatment groups. We hypothesized that the
HRVB group would show a larger increase in heart rate variability and a
larger decrease in depressive symptoms relative to treatment as usual
(TAU) and to a non-depressed control group (CON). We also hypothe-
sized that the effects of group membership on depression change would
be mediated by changes in heart rate variability. To carefully study the
question, we focused on women diagnosed with Major Depressive
Disorder beginning psychotherapy.
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International Journal of Psychophysiology 131 (2018) 96–101
2. Methods
2.1. Participants
A total of 32 female college students ages 18 to 25 were recruited.
Participation was voluntary. Exclusion criteria included an age < 18 or
over 25 years, use of vasoactive medications, cardiovascular disease,
alcohol or drug abuse, any physiological or neurological disorders,
history of electroconvulsive therapy, and head injury.
Of the 32 participants, 21 individuals with MDD were recruited
through the Brigham Young University (BYU) Counseling Center con-
secutively. One participant with MDD was excluded in the study due to
equipment error. In total, 20 participants with MDD participated in the
study. All met diagnostic criteria for MDD, with five reporting a history
of depressive symptoms during their teen years. One of the MDD par-
ticipants reported current use of medication (Prozac); however, she was
in the process of weaning off this medication. MDD participants were
randomized into either an experimental group (n = 10) that received
both HRV biofeedback training and psychotherapy for MDD or a
treatment as usual (TAU) psychotherapy only group (n = 10). Another
11 healthy individuals were recruited through BYU campus as the
control group. One participant from the control group was excluded due
to equipment error. In total, 10 participants remained in the control
group (CON). None met criteria for psychiatric disorders or reported
medication use. Thus, the total sample for data analyses consisted of 20
MDD participants and 10 healthy control participants. These groups did
not differ by age (HRVB ages M = 20.09, SD = 1.81; TAU ages
M = 20.20, SD = 1.47; control ages M = 20.64, SD = 1.29).
2.2. Psychological measures
The MINI International Neuropsychiatric Interview (MINI; Sheehan
et al., 1998) was used in this study. The MINI is one of the most widely
used clinical structured diagnostic interview instrument with adequate
internal consistency (α = 0.66; Sheehan et al., 1998). The MINI was
used during the recruitment stage to ensure all individuals in the HRVB
group and TAU group met criteria for MDD, and all participants from
the CON group did not meet criteria for any disorders listed on the
MINI.
The BDI-II (Beck et al., 1996) was used to examine the severity of
depression symptoms. The total score of the BDI-II is 63 with 4 levels of
cutoff scores. A total score between 0 and 13 indicates “minimal” level
of depression, score between 14 and 19 indicates “mild” level of de-
pression, score between 20 and 28 indicates “moderate” level of de-
pression, and score between 29 and 63 indicates “severe” level of de-
pression. The BDI-II has demonstrated reliability and validity, with
internal consistency ranging from 0.87 to 0.93 (Titov et al., 2011).
2.3. Physiological measures
Physiological data were recorded using a biofeedback system (J&J
Engineering, Poulsbo, WA). Measures of HRV were recorded and ana-
lyzed including the standard deviation of normal-to-normal intervals
(SDNN) between adjacent heartbeats, high frequency (HF) and low
frequency (LF) heart rate variability (HRV), and the ratio between LF
and HF (LF/HF). SDNN is the amount of variability in heartbeat in-
tervals for a given time period; in this study 5-minute time intervals
were used (Vaschillo et al., 2006). Higher values of SDNN represent
higher HRV and are associated with better health outcomes. HF HRV
reflects parasympathetic activity and typically corresponds to the range
between 0.15 and 0.40 Hz (Karavidas et al., 2007; Kemp et al., 2012).
LF HRV is influenced by both the sympathetic and parasympathetic
systems and baroreflex activity and typically corresponds to the range
between 0.05 and 0.15 Hz.
Y.T. Caldwell, P.R. Steffen International Journal of Psychophysiology 131 (2018) 96–101

2.4. Procedure
All participants were recruited through the BYU campus and
Counseling Center. Informed consent was given prior to clinical inter-
view. After potential participants signed the informed consent, the MINI
was administered. All psychotherapy participants who met criteria for
MDD were randomized into either the HRVB or TAU group and re-
ceived the standard psychotherapy approach offered at the student
counseling center consisting of Cognitive Behavioral and Acceptance
and Commitment Therapy approaches. Individuals without any psy-
chopathology were assigned into the control group. All participants
from the 2 therapy groups were scheduled for the baseline HRV mea-
surements before or during the first week of therapy.
resonance frequency breathing rate and breathed in phase with their
heart rate for 20 min on each of the visit. A follow-up appointment was
scheduled upon completion of the 5th training session.
2.4.5. Follow-up measurement
Similar to the baseline HRV measurement, participants from the
three groups were asked to fill out an online survey first and then
breathed with their normal breathing rate for 10 min. Data were re-
corded through the biofeedback system. After that, participants were
debriefed. Total time commitment for the follow-up HRV measurement
was approximately 30 min including placing electrodes and instruc-
tions. Hence, the total time commitment for the present study was
approximately 6 weeks.

2.4.1. Baseline measurement 2.5. Analytic strategy

Each participant was asked to abstain from exercising, consuming
caffeinated and tobacco products for 3 h before testing. Participants'
baseline HRV was measured at the BYU Counseling Center. An online
survey which included the BDI-II and demographic information was
administrated. Participants where then instrumented with a respiration
belt directly over the participant's waist for respiration data and ECG
electrodes were placed on each wrist to measure HRV. A ground elec-
trode was put on the left wrist, above the ECG electrode. After all the
sensors were placed, participants were instructed to breathe with their
normal day-to-day breathing rate for 10 min as a baseline measure-
ment. After the baseline recording, all participants from the HRVB
group received their first HRV training session. The TAU and control
groups were scheduled to come back for follow-up measurements.
All data were analyzed using a 3 (HRVB, TAU, control) × 2 (base-
line, 6 week follow-up) repeated measures ANOVA design. Dependent
variables were total BDI-II scores, SDNN, and LF/HF ratio with separate
repeated measure ANOVAs conducted for each dependent variable.
Follow up analyses were conducted to examine the interactions among
the various experimental groups using a post-hoc Tukey test. Effect size
was measured using partial eta squared (η2). The HRV frequency
measures demonstrated skewed distributions, therefore the natural log
transformation was performed on LF, HF, and LF/HF ratio before
analyses were conducted.
3. Results

2.4.2. 1st HRV training 3.1. Baseline comparisons

This training session occurred on the same day immediately fol-
lowing the HRV baseline measurement. The purpose of the first training
session was to demonstrate and teach abdominal breathing. For more
detail on the procedures see Lehrer et al. (2013). In brief, participants
learned diaphragmatic breathing, practicing for 20 min. This breathing
technique set the stage for the following 4-week HRV training sessions.
Upon finishing the first training session, participants were scheduled for
their second visit and reminded to practice diaphragmatic breathing 15
to 20 min a day, 4 to 5 times a week. Additionally, participants received
a weekly e-mail reminding them to practice and their weekly ap-
pointment. The baseline HRV measurement and all of the following
HRV training sessions lasted approximately 30 to 45 min each.
We examined whether combining HRVB with psychotherapy would
improve the treatment of MDD and measures of HRV relative to a TAU
group and a non-depressed control group. At baseline there were sig-
nificant differences in BDI scores as expected, with the HRVB and TAU
groups reporting higher levels of depressive symptoms than the healthy
controls, with no differences between HRVB and TAU groups, F(1, 27)
= 17.13, p < 0.001, partial η2 = 0.56; see Table 1. Both treatment
groups reported mild to moderate level of depression, scoring above the
cutoff for clinically significant levels of distress, with the control group
reporting a minimal level of depression. There were no significant
differences between groups for SDNN (F(1, 27) = 1.51, p = 0.24,

2.4.3. 2nd HRV training Table 1

The purpose of the second training session was to determine each Descriptive information by experimental group.
participants' resonance frequency breathing rate, i.e. the rate that cre-
HRVB + TAU TAU Controls F p
ates the greatest oscillations in HR (Lehrer and Gevirtz, 2014). At the (n = 10) (n = 10) (n = 10)
beginning of this training session, all participants were instructed to do Mean (SD) Mean (SD) Mean (SD)
diaphragmatic breathing for 3 min then breathed at different rates,
from 6.5 down to 4.5 breathes per minute (see Vaschillo et al., 2006) BDI
Baseline 24.9 (11.7) 17.7 (7.1) 3.7 (4.0) 17.13 0.001
with a change of 0.5 stepped down each time. Each rate of breathing 6 weeks 12.0 (10.5) 12.1 (5.5) 2.5 (3.3) 5.99 0.007
lasted for 2 min and HRV data was recorded for each breathing rate. Difference 12.9 (12.1) 5.6 (5.8) 1.2 (1.6) 5.76 0.008
Participants followed a visual pacer on a computer screen at their SDNN
corresponding respiratory rate. Participants' resonance frequency Baseline 42.9 (23.1) 50.0 (12.13) 56.7 (16.5) 1.51 0.24
6 weeks 60.3 (26.5) 48.5 (10.2) 56.3 (17.9) 0.96 0.40
breathing rate was determined by the highest LF spike, which was
Difference 17.4 (9.7) − 1.5 (9.5) −0.4 (16.3) 7.47 0.003
generated from the J&J program. Once participants' optimal breathing LF
rate was determined, they were instructed to practice with a visual Baseline 2.9 (0.5) 2.9 (0.3) 3.1 (0.3) 1.32 0.28
pacer corresponding to their optimal breathing rate for another 3 min. 6 weeks 3.2 (0.4) 2.8 (0.4) 3.2 (0.4) 3.54 0.04
Upon completion, participants were scheduled for three weekly 20 min Difference − 0.3 (0.5) 0.1 (0.2) −0.1 (0.2) 3.03 0.07
HF
HRV training sessions. They were also instructed to practice 4 to 5 times Baseline 2.7 (0.6) 3.0 (0.4) 3.0 (0.4) 1.05 0.36
a week for three weeks, between 15 and 20 min a day by using visual 6 weeks 2.6 (0.6) 2.8 (0.5) 2.8 (0.5) 0.66 0.53
guides that could be downloaded from the internet for free. Difference 0.1 (0.5) 0.2 (0.3) 0.2 (0.3) 0.10 0.90
LF/HF ratio
Baseline 1.1 (0.2) 1.0 (0.2) 1.1 (0.2) 1.22 0.31
2.4.4. 3rd, 4th and 5th HRV training
6 weeks 1.3 (0.3) 1.0 (0.2) 1.2 (0.2) 3.86 0.03
These three training sessions aimed to fine tune and target partici- Difference − 0.2 (0.2) − 0.03 (0.1) −0.1 (0.2) 2.86 0.08
pants' resonance frequency breathing rate. Participants practiced their

98
Y.T. Caldwell, P.R. Steffen
30
25
Beck Depression Inventory
20
HRV+TAU
15 TAU
CON
10
5 45
0 40
Week 1 baseline Week 6 follow-up
Fig. 1. Effects of HRV + TAU, TAU, and control groups on Beck Depression Inventory
scores at baseline and at 6-week follow-up.
partial η2 = 0.10; see Table 1), log LF (F(1, 27) = 1.32, p = 0.28,
partial η2 = 0.09; see Table 1), log HF (F(1, 27) = 1.05, p = 0.36,
partial η2 = 0.073; see Table 1), and log LF/log HF ratio (F(2, 27)
= 1.22, p = 0.31, partial η2 = 0.08; see Table 1) at baseline. Therefore,
groups did not significantly differ on measures of HRV at baseline.
3.2. Post-treatment comparisons
Our first research question addressed the impact of HRVB combined
with psychotherapy on depressive symptoms over time. Overall, de-
pressive symptoms decreased over the course of the experiment as
evidenced by a significant main effect of time in the ANOVA for BDI
total score, F(2, 27) = 21.34, p < 0.001, partial η2 = 44. This main
effect was qualified by a significant group × time interaction, F(2, 27)
= 5.76, p < 0.01, partial η2 = 0.30. Relative to baseline, the HRVB
group showed the largest decline (Mbaseline = 24.9; Mfollow-up = 12.0;
see Fig. 1), with depression level dropping from a moderate to minimal
level. The TAU group's depression scores slightly shifted from a mild to
minimal depression level at the follow-up time point while the health
controls' depression scores remained at the minimal level (TAU: total
BDI-II scores Mbaseline = 17.7; Mfollow-up = 12.10; control total BDI-II
scores Mbaseline = 3.7; Mfollow-up = 2.5). The TAU group, however, did
not differ significantly in depression change scores from the control
group.
Our second research question addressed the impact of HRVB com-
bined with psychotherapy on measures of HRV over time. Overall,
SDNN, HF, and the LF/HF ratio changed significantly over time (but not
LF) as evidenced by significant main effects of time in the ANOVAs for
SDNN, F(2, 27) = 5.291, p = 0.03, partial η2 = 0.164; HF, F(2, 27)
= 4.29, p < 0.05, partial η2 = 0.14; and LF/HF, F(2, 27) = 11.13,
p = 0.002, partial η2 = 0.29. For LF, the ANOVA results approached
significance with F(2, 27) = 3.11, p = 0.09, partial η2 = 0.10. These
main effects were qualified by a significant group × time interaction
for SDNN, F(2, 27) = 7.469, p = 0.003, partial η2 = 0.356, with the
results approaching significance for LF, (2, 27) = 3.03, p = 0.07, par-
tial η2 = 0.18, and the LF/HF ratio, F(2, 27) = 2.86, p = 0.08, partial
η2 = 0.175, with these changes being driven by the HRVB group. The
HRVB group had a 17-point increase on SDNN from baseline to the
follow-up time point (Mbaseline = 42.9; Mfollow-up = 60.3; p = 0.002),
whereas the TAU and control groups displayed minimal changes (see
Fig. 2).
Our third research question examined whether changes in HRV
would account for the relationship between experimental group and
depressive symptoms. To conduct the Sobel Test for the significance of
mediation, two regression analyses were first run to obtain the un-
standardized beta weights and associated standard errors. Regression
analyses examining the relationship between experimental group and
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International Journal of Psychophysiology 131 (2018) 96–101
65
60
55
HRV+TAU
SDNN
TAU
50 CON
Week 1 baseline Week 6 follow-up
Fig. 2. Effects of HRV + TAU, TAU, and control groups SDNN (HRV) at baseline and at 6-
week follow-up.
SDNN change found a significant relationship, p < 0.005, B = 8.911,
SE B = 2.907. Regression analyses examining the relationship SDNN
change and BDI change also found a significant relationship, p = 0.03,
B = 0.24, SE B = 0.104. The Sobel test statistic was 1.84 with a one-
tailed p = 0.03 indicating that mediation occurred. It appears there-
fore, that the depressive symptom improvement seen in the HRVB
group was partially driven by improvements in HRV (SDNN).
4. Discussion
Traditional interventions for MDD, such as antidepressants and
psychotherapy, do not improve HRV even after successful reduction of
depressive symptoms (Kemp et al., 2010; Kim et al., 2009; Licht et al.,
2010). HRVB improves HRV and has shown promise as a treatment for
depression (Karavidas et al., 2007; Siepmann et al., 2008; Zucker et al.,
2009). We hypothesized that combining HRVB with psychotherapy
would improve HRV relative to a treatment as usual (TAU) psy-
chotherapy group and a healthy control group. We found that HRVB
plus psychotherapy led to greater increases in HRV and greater de-
creases in depressive symptoms for patients with MDD relative to the
TAU and non-MDD controls, with increased HRV partially accounting
for the depression change. These findings support the supplementation
of traditional psychotherapy with HRVB as a method to reverse the
negative effects of depression on HRV.
These findings extend current knowledge in two ways. First, a
randomized controlled design allows direct comparisons to be made
between HRVB + TAU and TAU only groups. Analyzing what HRVB
contributes above and beyond traditional psychotherapy builds on
previous studies which did not randomize across experimental groups,
instead using within-subject designs (Karavidas et al., 2007; Siepmann
et al., 2008). Second, examining HRVB as an adjunct to psychotherapy
allows us to explore how HRV may be improved supplementing stan-
dard therapeutic approaches to MDD. It appears that combining HRVB
with psychotherapy has the potential to significantly improve therapy
outcomes as well as improve HRV over time.
We note two key implications of these findings. First, psychotherapy
participants show increased levels of physiological stress and stress
response compared to matched controls during lab based stressors
(Steffen et al., 2014), and increased physiological response to stress at
baseline predicts worse psychotherapy outcomes in depressed patients
(Ehrenthal et al., 2010). This heightened stress physiology may explain
why HRV does not increase following effective anti-depressant and
psychotherapy treatments for depression. In other words, effective
treatment of depression might not reduce stress physiology which
contributes to decreased HRV. Therefore, addressing physiology as well
as psychology may increase psychotherapy effectiveness, and com-
bining HRVB with psychotherapy may significantly improve depression
Y.T. Caldwell, P.R. Steffen
outcomes as well as HRV outcomes.
Second, a significant number of psychotherapy clients quit therapy
early, with the modal number of psychotherapy sessions being one
(Gibbons et al., 2011). Reducing stress during the early phase of
therapy may increase the likelihood of continuing. That is, if clients
experience early stress reduction they may have increased motivation
to continue and have more confidence that therapy will work for them.
And given that the prevalence of depression has increased in recent
decades, more needs to be done to increase the efficacy of available
interventions (Greenberg et al., 2015; Kessler et al., 2012; WHO, 2011).
Supplementing traditional approaches to depression (anti-depressants,
psychotherapy) with HRVB may improve treatment adherence and re-
verse the troubling trend observed in depression prevalence (Steffen
et al., 2017).
There are several limitations to the current study. The sample in-
cluded only college aged women between the ages of 18 and 25. It is not
clear how these results would apply to men and those in older age
groups. Additionally, although the study was randomized, there was a
nonsignificant trend for the HRVB + TAU group having higher de-
pressive symptoms at baseline and therefore had more opportunity for
change to occur. HRVB was not studied in combination with anti-
depressants so it is not clear if the same results would be found in this
context. We also did not have an HRVB group alone so it is not possible
to establish whether the psychotherapy component added anything to
the HRVB. Future studies could build off of the present study by ex-
amining men and older age groups to see if similar results are found.
In conclusion, supplementing psychotherapy with HRVB led to in-
creased HRV and decreased depressive symptoms relative to psy-
chotherapy alone and healthy control groups. Because antidepressants
and psychotherapy alone do not improve HRV following successful
depression treatment, HRVB shows promise as a therapeutic adjunct to
standard treatments. Given the high prevalence of depression and its
negative impact on people and society, more needs to be done to im-
prove treatment. Including HRVB in depression treatment has the po-
tential to improve both psychological and physiological outcomes.
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