《气味科学中的健康密码》课程教学资源（阅读材料）A Systematic Review on the Anxiolytic Effects of Aromatherapy in People with Anxiety Symptoms

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 17,Number 2,2011,pp.101-108 Review Article Mary Ann Liebert,Inc. D0110.1089/acm.2009.0277 A Systematic Review on the Anxiolytic Effects of Aromatherapy in People with Anxiety Symptoms Yuk-Lan Lee,BSc,Ying Wu,BSc,Hector W.H.Tsang,PhD:Ada Y.Leung,MA:and W.M.Cheung,PhD2 Abstract Purpose:We reviewed studies from 1990 to 2010 on using aromatherapy for people with anxiety or anxiety symptoms and examined their clinical effects. Methods:The review was conducted on available electronic databases to extract journal articles that evaluated the anxiolytic effects of aromatherapy for people with anxiety symptoms. Results:The results were based on 16 randomized controlled trials examining the anxiolytic effects of aroma- therapy among people with anxiety symptoms.Most of the studies indicated positive effects to quell anxiety.No adverse events were reported. Conclusions:It is recommended that aromatherapy could be applied as a complementary therapy for people with anxiety symptoms.Further studies with better quality on methodology should be conducted to identify its clinical effects and the underlying biologic mechanisms. Introduction Unfortunately,the effect is not at all conclusive based on available information.8 ymaend bhvr Recently,a remarkable increase in the use of comple- mentary and alternative medicine(CAM)around the globe is components.About 4%6%of the global population suffer evidenced.Aromatherapy is a commonly used CAM that has from various forms of anxiety disorders with such symptoms long been regarded as a popular means of treatment for as high blood pressure,elevated heart rate,sweating,fatigue, anxiety.It involves the therapeutic use of essential,aromatic unpleasant feeling,tension,irritability,and restlessness.2 If oils,commonly combined with therapeutic massage and untreated,40%50%of the patients would progress to de- excitation of the olfactory system,to induce relaxation and pression and have suicidal thoughts.3 The symptoms bring thus quell certain anxiety symptoms.Aromatherapy is huge negative impact to their families,social,and occupa- claimed to be beneficial to the mental,psychologic,spiritual, tional roles.National statistics show that in the United States, and social aspects,although they are less quantitatively anxiety disorders incurred $46.6 billion direct and indirect measurable.With respect to safety,it is reported that that costs each year,which constituted nearly one third of the aromatherapy is relatively free of adverse effects compared nation's total mental health expenses. with conventional drugs.10 Pharmacologic and psychologic treatments have remained Unlike conventional medicine,the effectiveness of aro- the conventional interventions to treat anxiety disorders for matherapy remains unclear and is still under intensive re- the past 30 years."However,pharmacologic treatment cau- search.To date,there is only one relevant review on ses many side-effects.For example,benzodiazepine,a pop- aromatherapy for depression.Although depression and ular medication with powerful anxiolytic effects,has been anxiety are usually co-occurring,a separate systematic re- well known for its side-effects including sedation,muscle view on the anxiolytic effects of aromatherapy is still needed. relaxation,headache,and ataxia.These side-effects signifi- To date,there has not been a systematic review on the an- cantly reduce adherence of the patients.Another problem is xiolytic effects of aromatherapy.The purpose of the current that some anti-anxiety drugs are potentially addictive.Re- review is to fill the gap by unraveling the effectiveness occurrence of anxiety symptoms will result from removal of of aromatherapy on relieving anxiety symptoms.Based on the drugs.?Psychologic treatment,especially cognitive be- extant literature,the evidence was integrated so as to aid havior therapy,is the main alternative to drug therapy. in gaining a better understanding on the clinical use of 'Neuropsychiatric Rehabilitation Laboratory,Department of Rehabilitation Sciences,The Hong Kong Polytechnic University,Hong Kong. 2Faculty of Education,The University of Hong Kong,Hong Kong. 101

Review Article A Systematic Review on the Anxiolytic Effects of Aromatherapy in People with Anxiety Symptoms Yuk-Lan Lee, BSc,1 Ying Wu, BSc,1 Hector W.H. Tsang, PhD,1 Ada Y. Leung, MA,1 and W.M. Cheung, PhD2 Abstract Purpose: We reviewed studies from 1990 to 2010 on using aromatherapy for people with anxiety or anxiety symptoms and examined their clinical effects. Methods: The review was conducted on available electronic databases to extract journal articles that evaluated the anxiolytic effects of aromatherapy for people with anxiety symptoms. Results: The results were based on 16 randomized controlled trials examining the anxiolytic effects of aroma￾therapy among people with anxiety symptoms. Most of the studies indicated positive effects to quell anxiety. No adverse events were reported. Conclusions: It is recommended that aromatherapy could be applied as a complementary therapy for people with anxiety symptoms. Further studies with better quality on methodology should be conducted to identify its clinical effects and the underlying biologic mechanisms. Introduction Anxiety is a psychologic and physiologic state charac￾terized by cognitive, somatic, emotional, and behavioral components.1 About 4%–6% of the global population suffer from various forms of anxiety disorders with such symptoms as high blood pressure, elevated heart rate, sweating, fatigue, unpleasant feeling, tension, irritability, and restlessness.2 If untreated, 40%–50% of the patients would progress to de￾pression and have suicidal thoughts.3 The symptoms bring huge negative impact to their families, social, and occupa￾tional roles. National statistics show that in the United States, anxiety disorders incurred $46.6 billion direct and indirect costs each year, which constituted nearly one third of the nation’s total mental health expenses.4 Pharmacologic and psychologic treatments have remained the conventional interventions to treat anxiety disorders for the past 30 years.5 However, pharmacologic treatment cau￾ses many side-effects. For example, benzodiazepine, a pop￾ular medication with powerful anxiolytic effects, has been well known for its side-effects including sedation, muscle relaxation, headache, and ataxia.6 These side-effects signifi- cantly reduce adherence of the patients. Another problem is that some anti-anxiety drugs are potentially addictive. Re￾occurrence of anxiety symptoms will result from removal of the drugs.7 Psychologic treatment, especially cognitive be￾havior therapy, is the main alternative to drug therapy.5 Unfortunately, the effect is not at all conclusive based on available information.8 Recently, a remarkable increase in the use of comple￾mentary and alternative medicine (CAM) around the globe is evidenced. Aromatherapy is a commonly used CAM that has long been regarded as a popular means of treatment for anxiety. It involves the therapeutic use of essential, aromatic oils, commonly combined with therapeutic massage and excitation of the olfactory system, to induce relaxation and thus quell certain anxiety symptoms.9 Aromatherapy is claimed to be beneficial to the mental, psychologic, spiritual, and social aspects, although they are less quantitatively measurable. With respect to safety, it is reported that that aromatherapy is relatively free of adverse effects compared with conventional drugs.10 Unlike conventional medicine, the effectiveness of aro￾matherapy remains unclear and is still under intensive re￾search. To date, there is only one relevant review on aromatherapy for depression.11 Although depression and anxiety are usually co-occurring, a separate systematic re￾view on the anxiolytic effects of aromatherapy is still needed. To date, there has not been a systematic review on the an￾xiolytic effects of aromatherapy. The purpose of the current review is to fill the gap by unraveling the effectiveness of aromatherapy on relieving anxiety symptoms. Based on extant literature, the evidence was integrated so as to aid in gaining a better understanding on the clinical use of 1 Neuropsychiatric Rehabilitation Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong. 2 Faculty of Education, The University of Hong Kong, Hong Kong. THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 17, Number 2, 2011, pp. 101–108 ª Mary Ann Liebert, Inc. DOI: 10.1089/acm.2009.0277 101

102 LEE ET AL. aromatherapy as a CAM to treat people suffering from in anxiety symptoms were observed in at least one of the anxiety symptoms outcome measures between the study groups Methods Results Literature search Study description Studies used in this review were extracted from MED- The numbers of citations returned from the database LINE,Social Sciences Citation Index,Science Citation In- search were 70,73,and 42 for MEDLINE,SSCI+SCI,and dex,Psyinfo,PsyARTICLES,Journals@Ovid,MD Consult, others(Psyinfo,PsyARTICLES,Journals@Ovid,MD Consult, ScienceDirect,EBSCOHOST,and Handbook of Psychiatry, ScienceDirect,EBSCOHOST,and Handbook of Psychiatry), from 1990 to 2008,using keywords "anxiety disorder," respectively,in March 2010.Fifty-two(52)relevant publica- “anxiety,”"anxious symptom"or"anxiolytic effects'”and tions were extracted for further evaluation.After abstract "aromatherapy","aroma,"or "essence oil."Only English screening at the first stage and full-text screening at the publications were included.Potential titles were retrieved for second stage,16 studies met the inclusion criteria.Figure 1 the second stage of review.The titles and the available ab- summarizes the selection process of the eligible RCTs stracts were then independently reviewed.Neither of the Table 1 summarizes the methods and results of the 16 reviewers was blind to the author name,institution,and/or qualified RCTs.The total number of subjects involved was the journal. 25,377,in which the female-to-male ratio was 24,887:490.The The target was to extract randomized controlled trials age of the participants ranged from 18 to 90 years (RCT)that used aromatherapy as the intervention to relieve (M=47.77).All subjects suffered from obvious anxiety anxiety symptoms that were measured by validated inven- symptoms.Patients receiving palliative care were reported in tories.A study was operationally defined as a RCT in this three studies.16-18 Healthy volunteers with experimentally review if the allocation of participants to treatment and comparison groups was reported to be randomized,the ue sample size was not less than 10 in each arm,the participants cruited different types of clients,including mothers in labor, were aged 18 or older,and anxiety was included as the postpartum mothers,women prepared for surgical abortion, outcome measure.Studies that did not use any type of participants prepared for endoscopy procedure,patients comparison group,were qualitative in nature,and were prepared for dental procedures,patients with cancer during systematic review or meta-analysis were excluded. radiotherapy,nursing students attended for stressful surgical disease examination,patients with cancer with clinically di- Quality assessment agnosed with anxiety/depression,patients with moderate Studies selected based on the above criteria,and methods and severe dementia,patients in hematology transplant unit, were evaluated for methodological vigor.Guidelines set out and patients primarily diagnosed with generalized anxiety by Glasziou et al.12 were followed,and the quality of the disorder.The types of aromatherapy administration in the studies was assessed by reviewing whether they fulfilled the RCTs included aromatherapy massage,inhalation,tablet criteria of control randomization,allocation concealment, intake,and footbath.The intervention duration of aroma- intention to treat,and blindedness.Adequately concealed therapy massage ranged from 20 minutes to 1 hour,and the RCT means that the trial had a clear description of its allo- duration of inhalation ranged from 5 minutes to 1 hour.The cation procedure,central randomization,and allocation from most commonly used essential oil used in these studies was site apart from the study area and/or blinding allocation lavender.17.19,2 procedure.An RCT is considered to have used intention-to- treat analysis if all the randomized participants were ana- Outcomes lyzed with no differences between the treatment allocation before and after application of treatment procedure.13 A Only 14 studies adopted a control group with a compati- study was classified as "single blind"if the outcome measure ble"conventional therapy"or a"placebo,"and the remaining was conducted by an assessor who was blind to the treat- two studies used a control group with"no active treatment." ment allocation while the participants were not blind to the Fourteen(14)studies reported positive findings as to the treatment.A study was classified as "double blind"if both anxiolytic effects of aromatherapy6 while the re the assessor of outcome measure and the participants were maining two studies reported no effect of the aroma- blind to the treatment allocation.A study was considered therapy toward anxiety symptoms.In comparing changes not blind if neither the assessor nor the participants were and improvement between the aromatherapy and control blind to the outcome measure and treatment allocation, groups providing no active interventions,the subjects who respectively.14 received aromatherapy usually showed better outcomes than those in the control groups.However,when comparing the Data synthesis effect of aromatherapy to a conventional treatment or a placebo (e.g.,massage with carrier oil,inactive coated tab- Due to heterogeneity of the study populations,psycho- lets,benzodiazepine,sniff a hair conditioner,music therapy, metric instruments,and intervention trials,quantitative etc.),the results were inconsistent.Seven (7)studies indi- analysis on the effect size was not performed.However, cated that aromatherapy had benefits that were superior to qualitative analysis using the Sjosten method15 was em- conventional therapy or placebo.19-2224,26,27 In contrast,five ployed to classify interventions as having positive,negative, studies17,18,28-30 reported that the therapeutic effects between or no effect as determined by whether significant differences massage group and aromatherapy group were similar.One

aromatherapy as a CAM to treat people suffering from anxiety symptoms. Methods Literature search Studies used in this review were extracted from MED￾LINE, Social Sciences Citation Index, Science Citation In￾dex, Psyinfo, PsyARTICLES, Journals@Ovid, MD Consult, ScienceDirect, EBSCOHOST, and Handbook of Psychiatry, from 1990 to 2008, using keywords ‘‘anxiety disorder,’’ ‘‘anxiety,’’ ‘‘anxious symptom’’ or ‘‘anxiolytic effects’’ and ‘‘aromatherapy’’, ‘‘aroma,’’ or ‘‘essence oil.’’ Only English publications were included. Potential titles were retrieved for the second stage of review. The titles and the available ab￾stracts were then independently reviewed. Neither of the reviewers was blind to the author name, institution, and/or the journal. The target was to extract randomized controlled trials (RCT) that used aromatherapy as the intervention to relieve anxiety symptoms that were measured by validated inven￾tories. A study was operationally defined as a RCT in this review if the allocation of participants to treatment and comparison groups was reported to be randomized, the sample size was not less than 10 in each arm, the participants were aged 18 or older, and anxiety was included as the outcome measure. Studies that did not use any type of comparison group, were qualitative in nature, and were systematic review or meta-analysis were excluded. Quality assessment Studies selected based on the above criteria, and methods were evaluated for methodological vigor. Guidelines set out by Glasziou et al.12 were followed, and the quality of the studies was assessed by reviewing whether they fulfilled the criteria of control randomization, allocation concealment, intention to treat, and blindedness. Adequately concealed RCT means that the trial had a clear description of its allo￾cation procedure, central randomization, and allocation from site apart from the study area and/or blinding allocation procedure. An RCT is considered to have used intention-to￾treat analysis if all the randomized participants were ana￾lyzed with no differences between the treatment allocation before and after application of treatment procedure.13 A study was classified as ‘‘single blind’’ if the outcome measure was conducted by an assessor who was blind to the treat￾ment allocation while the participants were not blind to the treatment. A study was classified as ‘‘double blind’’ if both the assessor of outcome measure and the participants were blind to the treatment allocation. A study was considered not blind if neither the assessor nor the participants were blind to the outcome measure and treatment allocation, respectively.14 Data synthesis Due to heterogeneity of the study populations, psycho￾metric instruments, and intervention trials, quantitative analysis on the effect size was not performed. However, qualitative analysis using the Sjo¨ sten method15 was em￾ployed to classify interventions as having positive, negative, or no effect as determined by whether significant differences in anxiety symptoms were observed in at least one of the outcome measures between the study groups. Results Study description The numbers of citations returned from the database search were 70, 73, and 42 for MEDLINE, SSCIþ SCI, and others (Psyinfo, PsyARTICLES, Journals@Ovid, MD Consult, ScienceDirect, EBSCOHOST, and Handbook of Psychiatry), respectively, in March 2010. Fifty-two (52) relevant publica￾tions were extracted for further evaluation. After abstract screening at the first stage and full-text screening at the second stage, 16 studies met the inclusion criteria. Figure 1 summarizes the selection process of the eligible RCTs. Table 1 summarizes the methods and results of the 16 qualified RCTs. The total number of subjects involved was 25,377, in which the female-to-male ratio was 24,887:490. The age of the participants ranged from 18 to 90 years (M ¼ 47.77). All subjects suffered from obvious anxiety symptoms. Patients receiving palliative care were reported in three studies.16–18 Healthy volunteers with experimentally induced stress were the second most popular client types that were reported in two studies.19,20 Other studies re￾cruited different types of clients, including mothers in labor, postpartum mothers, women prepared for surgical abortion, participants prepared for endoscopy procedure, patients prepared for dental procedures, patients with cancer during radiotherapy, nursing students attended for stressful surgical disease examination, patients with cancer with clinically di￾agnosed with anxiety/depression, patients with moderate and severe dementia, patients in hematology transplant unit, and patients primarily diagnosed with generalized anxiety disorder. The types of aromatherapy administration in the RCTs included aromatherapy massage, inhalation, tablet intake, and footbath. The intervention duration of aroma￾therapy massage ranged from 20 minutes to 1 hour, and the duration of inhalation ranged from 5 minutes to 1 hour. The most commonly used essential oil used in these studies was lavender.17,19,21–25 Outcomes Only 14 studies adopted a control group with a compati￾ble ‘‘conventional therapy’’ or a ‘‘placebo,’’ and the remaining two studies used a control group with ‘‘no active treatment.’’ Fourteen (14) studies reported positive findings as to the anxiolytic effects of aromatherapy;16–22,24,26–31 while the re￾maining two studies23,25 reported no effect of the aroma￾therapy toward anxiety symptoms. In comparing changes and improvement between the aromatherapy and control groups providing no active interventions, the subjects who received aromatherapy usually showed better outcomes than those in the control groups. However, when comparing the effect of aromatherapy to a conventional treatment or a placebo (e.g., massage with carrier oil, inactive coated tab￾lets, benzodiazepine, sniff a hair conditioner, music therapy, etc.), the results were inconsistent. Seven (7) studies indi￾cated that aromatherapy had benefits that were superior to conventional therapy or placebo.19–22,24,26,27 In contrast, five studies17,18,28–30 reported that the therapeutic effects between massage group and aromatherapy group were similar. One 102 LEE ET AL.

ANXIOLYTIC EFFECTS OF AROMATHERAPY 103 185 publications identified MEDLINE®(I=7O) SSCI+SCI(n=73) Other Databases (n =42) 133 publications excluded because they were not studies of anxiety or animal studies involved 52 full text articles for further evaluation 28 publications excluded for reasons below: No control group(n=12) Literature review (n 6) Sample size less than 10 in each arm (n =5) FIG.1.Flowchart of randomized controlled trials (RCTs)selection Not written in English (n=2) process.SSCI,Social Sciences Cita- Qualitative study (n=1) tion Index;SCI,Science Citation Index. No randomization in subject allocation (n=1) 24 full text articles for further evaluation 8 publications excluded because there were no obvious anxiety symptoms in baseline measurement of the subjects 16 RCTs included and reviewed (1)study16reported that the anxiolytic effect of massage with therapists in the studies did not belong to the research team carrier oil only was significantly better than those receiving and did not need to conduct assessments of the subjects in massage with essential oil.One study reported that an oral order to ensure the double-blindedness.Seven(7)of the 16 lavender oil capsule is as effective as lorazepam,a benzodi- studies did not mention whether blinding techniques were azepine,in adults with generalized anxiety disorder.31 applied Intention-to-treat analysis was employed Two (2)studies had follow-up data after the treatment.in 11 studies.4 One (1)study mentioned the high Both of them suggested that no long-term effect was evi- dropout rate due to the long research period.In addition,the denced,and aromatherapy did not appear to confer benefit number of subjects recruited for individual studies varied on anxiety. greatly,from 24 to 23,857. Study quality Pooled effect size All studies applied random allocation.Seven of the 16 State Anxiety Inventory (SAl)was commonly used in the studies nevertheless had no clear description on the ran- 16 reviewed studies.Pooled effect size of the outcome mea- domization procedures.Only one study de sure of SAI is conducted from pre-and post-means and scribed the concealment of allocation procedure,but the standard deviations of the control and treatment groups of description was inadequate.Double-blindedness during three studies.18,26,27 Other studies are not included because outcome assessment was described in three studies corresponding authors could not be contacted for further and single-blindedness in six studies.21,222628 The massage information.Pooled effect size is shown in Table 2

(1) study16 reported that the anxiolytic effect of massage with carrier oil only was significantly better than those receiving massage with essential oil. One study reported that an oral lavender oil capsule is as effective as lorazepam, a benzodi￾azepine, in adults with generalized anxiety disorder.31 Two (2) studies26,28 had follow-up data after the treatment. Both of them suggested that no long-term effect was evi￾denced, and aromatherapy did not appear to confer benefit on anxiety. Study quality All studies applied random allocation. Seven of the 16 studies nevertheless had no clear description on the ran￾domization procedures.16,17,19,22,23,25,29 Only one study21 de￾scribed the concealment of allocation procedure, but the description was inadequate. Double-blindedness during outcome assessment was described in three studies20,30,31 and single-blindedness in six studies.21,22,26,28 The massage therapists in the studies did not belong to the research team and did not need to conduct assessments of the subjects in order to ensure the double-blindedness. Seven (7) of the 16 studies did not mention whether blinding techniques were applied.16–19,23,27,29 Intention-to-treat analysis was employed in 11 studies.19–24,26–30 One (1) study16 mentioned the high dropout rate due to the long research period. In addition, the number of subjects recruited for individual studies varied greatly, from 24 to 23,857. Pooled effect size State Anxiety Inventory (SAI) was commonly used in the 16 reviewed studies. Pooled effect size of the outcome mea￾sure of SAI is conducted from pre- and post- means and standard deviations of the control and treatment groups of three studies.18,26,27 Other studies are not included because corresponding authors could not be contacted for further information. Pooled effect size is shown in Table 2. 185 publications identified MEDLINE® (n = 70) SSCI + SCI (n = 73) Other Databases (n = 42) 133 publications excluded because they were not studies of anxiety or animal studies involved 52 full text articles for further evaluation 16 RCTs included and reviewed 8 publications excluded because there were no obvious anxiety symptoms in baseline measurement of the subjects 24 full text articles for further evaluation 28 publications excluded for reasons below: No control group (n =12) Literature review (n = 6) Sample size less than 10 in each arm (n =5) Not written in English (n = 2) Qualitative study (n = 1) No randomization in subject allocation (n = 1) FIG. 1. Flowchart of randomized controlled trials (RCTs) selection process. SSCI, Social Sciences Cita￾tion Index; SCI, Science Citation Index. ANXIOLYTIC EFFECTS OF AROMATHERAPY 103

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Table 1. Summary of Randomized Controlled Trials (RCTs) Using Aromatherapy as Complementary and Alternative Medicine for Treating Anxiety Symptoms Study No. subjects No. control Mean age % Women Country Type of intervention Aromatherapy elements Type of subjects Instrument Type of study Individual/ group Follow-up after intervention Duration Session Burns et al.29 8058 15,799 Not mentioned 100 UK Aroma inhalation/ massage/ foot-bath of essential oil Rose, jasmine, chamomile, eucalyptus, lemon, man￾darin, clary sage, frank￾incense, lav￾ender, and peppermint Mothers pre￾sented in labor Mother’s rating of ef￾fectiveness; out￾come of labor RCT Individual No 8 years 1 Burnett et al.19 1. Rosemary group: 25 2. Lavender group: 23 25 Ranged from 18 to 31 57.53 United States Aroma inhala￾tion Lavender and rosemary Volunteers with labora￾tory- in￾duced stress Profile of Mood States & heart rate RCT Individual No 10 minutes Not men- tioned Fujii et al.22 14 14 78 67.86 Japan Aroma inhala￾tion oil Lavender Patients with moderate and severe dementia Neuropsychiatric Inventory—NPI (structured interview with caregiver) RCT Individual No 1 hour 84 sessions Graham et al.25 1. Carrier oil with fractionated oils group: 111 2. Carrier oil group: 111 3. Pure essential oils group: 111 65 47.92 Australia Mildly to mod￾erately anx￾ious patients with cancer during ra￾diotherapy Lavender, bergamot, and cedar￾wood Essential oils of lavender, bergamot, and cedar￾wood Hospital Anxiety and Depression scale – HADS; Somatic and Psychological Health Report￾SPHERE RCT Group No Not men￾tioned 1 Imura et al.27 16 20 31.9 100 Japan Aromatherapy massage Neroli and lavender Postpartum mother STAI-StateAnxiety In- ventory Quasi- experi￾mental study Individual No 30 minutes Not men￾tioned Kennedy et al.20 24 received 3 separate single doses separated by a 7-day washout period 23.48 50 UK Aroma tablet intake M. officinalis and V. offici￾nalis Melissa officina￾lis and Va￾leriana offici￾na STAI-StateAnxiety In- ventory RCT Group No 5 study days separated by 7 days washout period 5 Kutlu et al.21 50 45 20.51 73.68 Turkey Aroma inhala- tion Lavender fragrance Nursing stu- dents who attended the stressful surgical dis￾ease exami￾nation STAI–State Anxiety Inventory RCT Group No 60 minutes 1 Kyle16 1. Massage with essen￾tial oil group: 15 2. Aroma stone with essential oil group:10 12 Not mentioned 100 UK Aromatherapy massage/ aromastone Santalum album oil Palliative care patients STAI–State Anxiety Inventory RCT Individual No 4 weeks 4 Lehrner et al.24 1. Lavender group: 48 2. Orange odor group: 50 3. Music group: 49 51 40.5 50 Austria Aroma inhala￾tion/music therapy Orange oil and lavender oil Patients wait￾ing for den￾tal proce￾dures STAI-State Anxiety Inventory Mehrdi- mensionale Befindlichkeitsfra￾gebogen–MDBF RCT Group No Not men- tioned Not men- tioned (continued) 104

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Table 1. (Continued) Study No. subjects No. control Mean age % Women Country Type of intervention Aromatherapy elements Type of subjects Instrument Type of study Individual/ group Follow-up after intervention Duration Session Muzzarelli et al.23 61 57 52 50 United States Aroma inhala￾tion Lavender oil 5 minutes STAI–State Anxiety Inventory RCT Individual No 5 minutes Not men- tioned Soden et al.17 1. Massage with essen￾tial oil and an inert car￾rier oil group: 16 2. Massage with an in￾ert carrier oil group: 13 13 Ranged from 44 to 85 76.19 UK Aromatherapy massage Lavender es￾sential oil Patients with specialist palliative care unit Hospital Anxiety and Depression–HAD RCT Individual No 30 minutes 4 Stringer et al.28 1. Aromather￾apy massage: 13 2. Massage with Base oil: 13 13 Ranged from 19 to 70 58.97 UK Aromatherapy massage Varied from 40 oil blends Patients in the Hematology Transplant unit 1. Serum cortisol and prolactin levels 2. Quality of Life (EORTC QLQ– C30) 3. Semistructured interview 4. Therapist’s ses￾sional diary RCT Individual Yes (fol￾low-up ½ hourly for 2 hours and at 24 hours) 20 minutes, the whole experi￾ment took 24 hours 1 Wiebe30 36 30 26.5 100 Canada Aroma inhala￾tion Vetivert, ber- gamot, and geranium oil Women wait￾ing for sur￾gical abor￾tions with preoperative anxiety Verbal Anxiety Scale RCT Group No 10 minutes Not men￾tioned Wilkinson et al.18 43 44 53.5 89.66 UK Aromatherapy massage Roman chamo- mile essen￾tial oil (% was not mentioned) Palliative care patients 1. State–Trait Anxiety Inventory 2. Rotterdam Symp￾tom Checklist 3. Semistructured questionnaire RCT Individual No 3 weeks Not men￾tioned Wilkinson et al.26 144 144 52.1 86.81 UK Aromatherapy massage Not specified (20 essential oil) Cancer patients 1. State anxiety in￾ventory 2. Center for Epide￾miological Stu￾dies–depression 3. Quality of life (EORTC) RCT Individual Yes 4 weeks 4 Woelk et al.31 40 37 Not mentioned 76.6 Germany Aroma tablet intake Lavender Patients pri- marily diag￾nosis of generalized anxiety dis￾order 1. Hamilton Anxiety Rating Scale 2. Self-rating Anxiety Scale 3. Peen Sate Worry Questionnaire 4. SF-36 Health Sur￾vey Questionnaire 5. Clinical Global Impressions of se￾verity of disorder 6. Sleep diary RCT Group No 6 weeks Not men￾tioned EORTC, European Organization for Research on the Treatment of Cancer; QLQ-C30, Quality of Life Questionnaire—C30. 105