International Journal of
Mental Health Systems Open Access Hamdani et al. 
International Journal of Mental Health Systems           (2022) 16:31  
https://doi.org/10.1186/s13033-022-00541-y Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31  
https://doi.org/10.1186/s13033-022-00541-y International Journal of
Mental Health Systems © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which 
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the 
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or 
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line 
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory 
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this 
licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​
mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Effectiveness of relaxation techniques 
‘as an active ingredient of psychological 
interventions’ to reduce distress, anxiety 
and depression in adolescents: a systematic 
review and meta‑analysis Syed Usman Hamdani1,2,3*, Zill‑e‑Huma1,2,3, Syeda Wajeeha Zafar1,2, Nadia Suleman1,2, Um‑ul‑Baneen1,2, 
Ahmed Waqas2,3 and Atif Rahman3 Syed Usman Hamdani1,2,3*, Zill‑e‑Huma1,2,3, Syeda Wajeeha Zafar1,2, Nadia Suleman1,2, Um‑u
Ahmed Waqas2,3 and Atif Rahman3 Abstract Background:  Adolescent depression and anxiety are among the leading contributors to health burden worldwide. ‘Relaxation Techniques (RTs)’ are a “set of strategies to improve physiological response to stress” and are frequently 
cited as an active ingredient of trans-diagnostic, psychosocial interventions for scaling-up care for preventing and 
treating these conditions in adolescents. However, there is a little evidence on the effectiveness of ‘relaxation tech‑
niques’ for this age group. Aim:  As a part of the Wellcome Trust’s Active Ingredients commission, we did a systematic review and meta-analysis 
to evaluate the effectiveness of RTs to reduce the symptoms of distress, anxiety and depression in young people, 
aged 14 to 24 years old, globally. Methods:  We searched 10 academic databases to include 65 Randomized Controlled Trials (RCTs) of relaxation-based 
interventions for young people with the symptoms of anxiety and depression. Primary outcomes were reduction in 
symptoms of distress, anxiety and/or depression. We employed the Cochrane risk of bias tool and GRADE (Grading of 
Recommendations, Assessment, Development and Evaluations) guidelines to assess certainty of outcomes pertaining 
to anxiety, depression and distress. Standardized mean difference was estimated using effect size. Results:  The analysis of 65 RCTs with 8009 young people showed that RTs were highly effective in treating anxiety 
(pooled effect size of (Standardized Mean Difference-SMD) − 0.54 (95% CI − 0.69 to − 0.40); moderately effective 
in reducing distress (SMD = − 0.48, 95% CI − 0.71 to − 0.24) and had only a weak effect on improving depression in 
young people (SMD = − 0.28 (95% CI − 0.40% to − 0.15). Face-to-face delivered relaxation techniques yielded higher 
effect size (SMD = − 0.47, 95% CI − 0.64 to − 0.30) compared to online delivery (SMD = − 0.22, 95% CI − 0.48 to 0.04) 
for anxiety. *Correspondence:  syedusmanhamdani@gmail.com 1 Global Institute of Human Development, Shifa Tameer-e-Millat University, 
Islamabad Pakistan ,
ull list of author information is available at the end of the article Description of relaxation techniques g
Depression and anxiety disorders contribute significantly 
to health burden among adolescents worldwide [1, 2]. The published literature reports that most adult men-
tal health problems begin between the ages of 11 and 
18 years, with almost half of the mental health problems 
having started by the age of 14 years [3]. Given the high 
burden of youth mental health problems [4], evidence-
based psychological interventions for prevention and 
treatment of anxiety and depression in adolescents have 
been developed [5, 6]; however, it is not fully understood 
which ‘ingredients’ of these interventions are effective to 
prevent and treat anxiety or depression in adolescents. Identifying their ‘active ingredients’ can help to under-
stand how these interventions work, specifically which 
ingredients of these interventions are more effective to 
reduce or treat anxiety and depression. Unpacking these 
interventions can contribute to improve the provision of 
more personalized treatment for child and adolescent 
mental health problems, globally. Being a low-risk and safe technique, relaxation tech-
niques are frequently cited as an integral component of 
psychological therapies to manage anxiety and reduce 
depression [12]. Relaxation techniques are defined as 
“a set of strategies to improve physiological response to 
stress” [13]. The underlying treatment goal of all relaxa-
tion techniques is to use relaxation to decrease stress or 
anxiety [12]. There are many types of relaxation tech-
niques including progressive muscle relaxation, relaxa-
tion imagery, autogenic training and applied relaxation. These can be administered in many different forms 
such as a standalone psychological intervention or part 
of complex therapy in different settings and context and 
by the very nature of relaxation techniques to improve 
both physiological and psychological responses to 
stress, other forms of treatment such as meditation, 
yoga and tai chi are sometimes classified into the broad 
category of relaxation techniques [14, 15].f A higher treatment effect of relaxation techniques 
compared to other psychological interventions includ-
ing Cognitive Behavioural Therapy (CBT) to improve 
anxiety and depression [16, 17] have been reported in 
the literature. Previous meta-analyses show that among 
all the other types of relaxation therapies, progres-
sive muscle relaxation, relaxation imagery and auto-
genic training are highly effective in reducing anxiety 
and depression in adults [12, 18]. In terms of efficacy 
of relaxation techniques for the specific sub-groups 
of the sample, findings of meta-analysis conducted 
by Manzoni et al. © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which 
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the 
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or 
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line 
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory 
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this 
licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​
mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Page 2 of 17 Conclusion:  Most of the included studies were from High Income Countries (HICs) and had a high risk of bias. Further high-quality studies with low risk of bias, especially from low resource settings are needed to evaluate the 
evidence for effectiveness of RTs as an active ingredient of psychological interventions to reduce the symptoms of 
distress, anxiety and depression in young people. Keywords:  Relaxation techniques, Systematic review, Meta-regression, Anxiety and depression in young people, 
Active ingredients Intervention RCTs where ‘Relaxation Technique(s)’ was used as a stan-
dalone intervention or in combination of other elements 
to reduce the symptoms of distress, anxiety and depres-
sion in young people aged 14–24. All modes of interven-
tion delivery were included (e.g., on-site and technology). Study design We included individual and cluster randomized con-
trolled trials. Description of relaxation techniques [12] showed that in adults there is a 
consistent and significant effect of relaxation exercises 
on anxiety. Moreover, these techniques were found to 
be more effective for young people compared to older 
adults. Another systematic review by Jorm, Morgan & 
Hetrick [18] concluded that relaxation exercises were 
more effective at reducing self-rated depressive symp-
toms than no or minimal treatment; however, this 
systematic review also highlighted the need to review 
the evidence on effectiveness of relaxation techniques 
to manage anxiety and improve depressive symptoms 
in adolescents and to include more rigorous research 
designs such as randomized controlled trials (RCT) in g
y
Recently, mental health research initiatives have 
increasingly focused on developing personalized treat-
ments to improve clinical outcomes by emphasizing the 
need to understand the mechanisms of mental health 
interventions and match these interventions strategies 
to the individual’s needs [7]. There is an urgency and a 
global push for understanding which ingredients of psy-
chological interventions are more effective and for what 
mental health problem and developing more "personal-
ized medicine/interventions," particularly among chil-
dren and adolescents where comparatively little research 
has been undertaken. To find these next generation of 
treatment approaches, specifically to transform how 
mental health problems of adolescents can be under-
stood and addressed, the Welcome Trust, UK launched 
‘Active Ingredients’ initiative with the aim to understand 
the ‘active ingredients (‘building blocks’) of interventions 
for prevention, treatment, rehabilitation and relapse pre-
vention of adolescent anxiety and depression, globally 
[8]. By unpacking these interventions, it aims to provide a 
better understanding of what active ingredients of effec-
tive interventions are; how these active ingredients work; 
through which pathway and for which sub-sample of the 
participants they might best work [9–11]. Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Page 3 of 17 Page 3 of 17 future reviews to ascertain the efficacy of relaxation 
techniques to improve mental health outcomes. Outcome RCTs which reported symptoms of distress, anxiety 
and/or depression as a primary or secondary outcome. Both International Classification of Diseases (ICD)-11 
and Diagnostic and Statistical Manual of Mental Disor-
ders, Fifth Edition, Text Revision (DSM-5TR) criteria of 
diagnoses or symptom severity of distress, anxiety and 
depression, measured on psychometric scales were con-
sidered eligible. Ethics approval As the current paper is a systematic review of literature 
and meta-analysis of de-identified published results, no 
ethical approval to conduct the review was required. Although, relaxation techniques have been increas-
ingly included in the mental health intervention pack-
ages for scaling-up care for adolescent mental health 
globally [19–22] and there is evidence for the feasibility 
and acceptability of relaxation-based interventions with 
children and adolescents, the relative impact of relaxa-
tion based interventions compared with other multiple 
components of interventions (such as psycho-education, 
mobilizing social support) to improve mental health out-
comes in adolescents still has not been fully explored yet 
[3]. Moreover, empirical evidence on the efficacy of these 
interventions to improve child and adolescent mental 
health outcome is required, particularly in Low and Mid-
dle Income Countries (LMICs) [3]. As a part of the Well-
come Trust’s Active Ingredients commission, we studied 
the role of ‘Relaxation Techniques (RTs)’ as an active 
ingredient of mental health interventions to reduce dis-
tress, anxiety and depression in adolescents with symp-
toms of depression and anxiety, globally. Country Cou t y
Studies from all regions were included. y
Studies from all regions were included. Objectives
Th The present systematic review and meta-analysis aimed 
to fill the gap in the literature by evaluating the current 
evidence on the effectiveness of relaxation techniques, 
administered individually or in combination with other 
therapeutic elements, in reducing symptoms of anxiety, 
distress and/or depression in young people, globally. In 
keeping with the staging approach to the classification 
and treatment of mental disorders [23], we included dis-
tress as an outcome measure to evaluate the impact of 
relaxation techniques on distress symptoms in young 
people. The secondary aim of the current review was to 
perform moderator analyses to reveal how intervention 
effect of relaxation techniques may vary across different 
settings and identify the likely conditions under which 
relaxation techniques are effective to reduce symptoms 
of anxiety, distress and/or depression in young people. We studied comparative effectiveness of relaxation tech-
niques across varying delivery models of interventions 
(i.e., electronic vs face-to-face intervention delivery) to 
reduce symptoms of anxiety, distress and/or depression 
in young people. Control Control
All types of control arm were eligible to be included. l types of control arm were eligible to be included Population RCTs focusing on young people (aged 14–24  years, as 
defined by the Wellcome Trust) exhibiting prodromal 
symptoms of depression, anxiety and distress or near cut-
off scores on psychometric scales. Study inclusion criteriah The inclusion criteria were formulated in accord-
ance with the PICO criteria. We included all Rand-
omized Controlled Trials (RCTs) in which relaxation 
technique(s) was used as a standalone intervention or 
in combination with other elements to prevent and 
treat symptoms of anxiety and depression among young 
people aged 14–24. Our inclusion criteria were; Methodsh We excluded studies where; The present review was conducted following the Pre-
ferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines [24]. A protocol for this 
systematic review was agreed with the Wellcome Trust, 
UK as the version of record (see Additional file 2: mate-
rial A). Intervention was conducted with adolescents who were 
chronically ill, requiring in-patient care or were with 
medical comorbidities. Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Page 4 of 17 Search strategy interventions to deconstruct complex interventions to 
identify core components of interventions and the termi-
nologies employed to describe them. First, we identified 
the ‘active ingredients’ of each intervention and type of 
relaxation techniques used in studies, coded each com-
ponent and cross-tabulated studies with each compo-
nent; then we combined these active ingredients with 
other intervention features and dimensions (e.g., theo-
retical underpinning, format, dosage and settings). The 
data on implementation characteristics of the interven-
tions, including measures of intervention fidelity, type of 
delivery agents and their competency assessment, super-
vision and training process and resource provision, was 
also extracted. gy
We searched 10 academic databases including PubMed, 
Cochrane CENTRAL, PsychInfo, Virtual Health Library, 
Scopus Open access, Web of Science all databases (Rus-
sian database), Psycharticles, Psychextra, Proquest Dis-
sertation and thesis (see Table 1 for search strategy). The 
search strategy was pilot tested on PubMed. The actual 
search was conducted between July 7 and July-27, 2020. Four reviewers, working independently from one another, 
reviewed titles and abstracts, followed by full text screen-
ing of eligible studies as per the eligibility criteria. The 
process of title and abstract screening was aided by the 
use of Rayyan software [25]. Furthermore, the references 
of included studies were manually searched and screened 
to identify and include any relevant trials in the review. Discrepancies in the inclusion process were discussed 
and resolved in consultation with the senior authors (UH 
& ZeH). Outcome measures
Th The primary outcome was reduction in the symptom 
scores of anxiety or depression or distress, measured at 
post-intervention, using self-reported, valid and reliable 
psychometric scales that are scored on a continuum [26]. We included outcome data of scales, reported either as 
composite scores (total scores) or subscales wise. To esti-
mate a Standardized Mean Difference (SMD), we calcu-
lated effect size for each listed primary outcome, using 
means and standard deviations. In studies, where no data 
on means and standard deviation was reported, the data 
on binary outcomes and unadjusted statistical effect sizes 
was extracted. Using previously-recommended assump-
tions and formulae [27], these binary outcomes were 
transformed to SMD, based on the assumption that (a) 
continuous measurements follow a logistic distribution 
and (b) the variability of the outcomes is the same in both 
intervention and control groups [28]. For the primary 
endpoint outcome, we used the end point specified in the 
studies. rticipants
(teenage” OR “teenagers” OR “teen” OR “teens” OR “youth” OR “young” “youngster” OR” youngsters” OR “young adult” OR “juvenile” OR “ado‑
lescent” OR “adolescents” OR “adolescence) ns
"psychological relaxation" OR "mental relaxation" OR "physiological relaxation" OR "therapeutic relaxation" OR "relaxation training" OR 
"relaxation technique*" OR breathing OR "slow breathing" OR "deep breathing" OR meditation OR "progressive muscle relaxation" OR 
"imagery" OR "Autogenic training" OR spirituality OR walking OR gardening OR yoga OR "T’ai chi" OR Qigong OR massage OR acu‑
puncture OR "Feldenkrais Method" OR myotherapy OR reflexology OR self-regulation OR autosuggestion OR prayer OR hypnosis OR 
Pranayama OR biofeedback OR music OR art-therapy OR stress-management OR writing OR exercise OR aromatherapy OR hydrotherapy
OR laughing-therapy OR food-therapy OR mindfulness) Participants
(teenage” OR “teenagers” OR “teen” OR “teens” OR “youth” OR “young” “youngster” OR” youngsters” OR “young adult” OR “juvenile” OR “ado‑
lescent” OR “adolescents” OR “adolescence)
Interventions
"psychological relaxation" OR "mental relaxation" OR "physiological relaxation" OR "therapeutic relaxation" OR "relaxation training" OR 
"relaxation technique*" OR breathing OR "slow breathing" OR "deep breathing" OR meditation OR "progressive muscle relaxation" OR 
"imagery" OR "Autogenic training" OR spirituality OR walking OR gardening OR yoga OR "T’ai chi" OR Qigong OR massage OR acu‑
puncture OR "Feldenkrais Method" OR myotherapy OR reflexology OR self-regulation OR autosuggestion OR prayer OR hypnosis OR 
Pranayama OR biofeedback OR music OR art-therapy OR stress-management OR writing OR exercise OR aromatherapy OR hydrotherapy 
OR laughing-therapy OR food-therapy OR mindfulness)
Conditions
(“Depression" OR “depressive disorder” OR “depressive symptoms” OR “depressed” OR “anxiety” OR “anxieties” OR “anxiety symptoms” OR 
“anxiety disorder” OR “anxiety disorders”)
Outcomes
Mental health” OR psychosocial OR “Well-being” OR “self-esteem” OR social OR suicide OR suicidality OR distress OR depress* OR stress OR 
anxiety OR anxious OR emotional OR internaliz* OR externaliz*
Study design
(“Clinical trial” OR intervention OR trial OR “randomized controlled trial” OR RCT OR “cluster randomized control trial”)
Region
N/A Data extraction
I f
ti Information pertaining to the characteristics of the 
study sample and interventions was extracted from 
the included studies. After establishing an adequate 
inter-rater reliability with senior authors across 20% 
of the studies, data was extracted by two reviewers for 
each study. The data from the studies were extracted 
across three broad matrices: (i) study sample (ii) theo-
retical underpinnings and components of interventions 
and (iii) implementation characteristics of interven-
tions. Variables pertaining to the study sample included 
important characteristics such as age of the study sam-
ples, inclusion and exclusion criteria of the studies, and 
outcome measures. Recognizing the fact that several 
complex interventions will utilize relaxation techniques 
as one of many components, we critically reviewed all Table 1  Search strategy of peer-reviewed articles
Condition
Search terms
Participants
(teenage” OR “teenagers” OR “teen” OR “teens” OR “youth” OR “young” “youngster” OR” youngsters” OR “young adult” OR “juvenile” OR “ado‑
lescent” OR “adolescents” OR “adolescence)
Interventions
"psychological relaxation" OR "mental relaxation" OR "physiological relaxation" OR "therapeutic relaxation" OR "relaxation training" OR 
"relaxation technique*" OR breathing OR "slow breathing" OR "deep breathing" OR meditation OR "progressive muscle relaxation" OR 
"imagery" OR "Autogenic training" OR spirituality OR walking OR gardening OR yoga OR "T’ai chi" OR Qigong OR massage OR acu‑
puncture OR "Feldenkrais Method" OR myotherapy OR reflexology OR self-regulation OR autosuggestion OR prayer OR hypnosis OR 
Pranayama OR biofeedback OR music OR art-therapy OR stress-management OR writing OR exercise OR aromatherapy OR hydrotherapy 
OR laughing-therapy OR food-therapy OR mindfulness)
Conditions
(“Depression" OR “depressive disorder” OR “depressive symptoms” OR “depressed” OR “anxiety” OR “anxieties” OR “anxiety symptoms” OR 
“anxiety disorder” OR “anxiety disorders”)
Outcomes
Mental health” OR psychosocial OR “Well-being” OR “self-esteem” OR social OR suicide OR suicidality OR distress OR depress* OR stress OR 
anxiety OR anxious OR emotional OR internaliz* OR externaliz*
Study design
(“Clinical trial” OR intervention OR trial OR “randomized controlled trial” OR RCT OR “cluster randomized control trial”)
Region
N/A Conditions
(“Depression" OR “depressive disorder” OR “depressive symptoms” OR “depressed” OR “anxiety” OR “anxieties” OR “anxiety symptoms” OR 
“anxiety disorder” OR “anxiety disorders”)
O
M
l h
l h”OR
h
i l OR“W ll b i
”OR“
lf
”OR
i l OR
i id OR
i id li
OR di
OR d
* OR
OR Condition
Search terms s
(teenage” OR “teenagers” OR “teen” OR “teens” OR “youth” OR “young” “youngster” OR” youngsters” OR “young adult” OR “juvenile” OR “ado‑
lescent” OR “adolescents” OR “adolescence) ntions
"psychological relaxation" OR "mental relaxation" OR "physiological relaxation" OR "therapeutic relaxation" OR "relaxation training" OR 
"relaxation technique*" OR breathing OR "slow breathing" OR "deep breathing" OR meditation OR "progressive muscle relaxation" OR 
"imagery" OR "Autogenic training" OR spirituality OR walking OR gardening OR yoga OR "T’ai chi" OR Qigong OR massage OR acu‑
puncture OR "Feldenkrais Method" OR myotherapy OR reflexology OR self-regulation OR autosuggestion OR prayer OR hypnosis OR 
Pranayama OR biofeedback OR music OR art-therapy OR stress-management OR writing OR exercise OR aromatherapy OR hydrotherapy 
OR laughing-therapy OR food-therapy OR mindfulness) ealth” OR psychosocial OR “Well-being” OR “self-esteem” OR social OR suicide OR suicidality OR distress OR depress* OR stress O
OR anxious OR emotional OR internaliz* OR externaliz* Study design
(“Clinical trial” OR intervention OR trial OR “randomized controlled trial” OR RCT OR “cluster randomized control trial”)
Region
N/A Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Page 5 of 17 Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Risk of bias and quality of evidence Risk of bias and quality of evidence
Risk of bias among RCTs was assessed using the 
Cochrane tool for risk of bias assessments. GRADE 
(Grading of Recommendations, Assessment, Develop-
ment and Evaluations) evidence criteria was applied to 
grade the certainty of evidence for these interventions. Using GRADE profiling method, the strength of evidence 
for these outcomes was rated from very low to high. i
Interventions in 34/65 (52%) studies were delivered 
in an educational setting (school/colleges/universi-
ties). Relaxation techniques (either as a standalone or 
in combination with other elements) were delivered in 
group format in 57% (37/58) of the studies. Among the 
studies reporting relaxation techniques as a standalone 
intervention, the mean number of sessions was 22.27 
(± 12.48), over 9.55 (± 2.92) weeks. Mean session dura-
tion was 66.5 (± 32.32) minutes. Out of 12 studies, two 
studies did not report program duration; one study was 
of 2  h and one study did not report session duration. The average program duration for multicomponent 
interventions was 7.39 (± 6.35) weeks; average num-
ber of sessions were 9.04 (± 8.40) and average session 
duration was 72.14 min (± 37.61). Among studies using 
multicomponent interventions, nine studies did not 
report program duration; one study was of 2  h, three Interventions’ characteristics Interventions characteristics
Of the 65 studies, 12 (18%) studies reported ‘relaxa-
tion technique/s’ as a standalone intervention to reduce 
symptoms of anxiety, distress and depression in ado-
lescents. The most commonly reported ‘relaxation 
techniques’ in the literature were Progressive Muscle 
Relaxation Techniques-PMR, breathing, exercise, walk-
ing meditation, stretching, relaxation imagery and medi-
tation. In 82% (53/65) of the studies relaxation techniques 
were implemented as an integral component of other 
psychotherapies, multicomponent interventions such as 
Cognitive Behavioural Therapy (CBT), Mindfulness and 
Acceptance and Commitment Therapy (ACT). Other 
components of multicomponent interventions included 
identifying affect, psychoeducation and mindfulness 
exercises. A list of ‘relaxation techniques’ reported in the 
studies are mention in Table 3. The detail on characteris-
tics of included interventions is mentioned in Additional 
file 2: Table S6). i
Subgroup analyses were run when specific subgroups 
(such as theoretical orientation of psychological inter-
ventions, type of delivery agents, dosage density of inter-
vention and type of population) were reported in more 
than 4 studies. We used meta-regression analysis [31] to 
understand the impact of other therapeutic elements of 
interventions employed in included studies compared 
with ‘relaxation techniques’. Meta-regression analysis 
was run when covariates were reported in more than ten 
studies [32, 33]. Study characteristics y
Effect size such as Mean and Standard Deviation (SD) 
was extracted for continuous outcomes and for binary 
outcomes, frequency of events and sample size of inter-
vention and control group was extracted. A series of 
meta-analyses were run, where studies were weighted 
using random effects model and forest plots were gener-
ated exhibiting effect size for each study along with their 
95% confidence intervals. Random effects were applied 
throughout the analyses due to expected clinical, meth-
odological and statistical heterogeneity in the studies. Sensitivity analyses were employed to assess contribution 
of each study especially outliers to the pooled effect size. Publication bias was assessed using Egger’s regression 
statistic, where there were more than ten studies. In addi-
tion, we also visualized Begg’s funnel plot [29]. If there 
was a significant publication bias in reporting of an out-
come, it was adjusted using the Duval & Tweedie’s trim & 
fill method [30].i Of the 65 studies, 56 were from High Income Countries, 
6 studies were from Upper Middle-Income Countries 
and only 1 study was from a Lower- and Middle-Income 
country (i.e., India). In majority of the studies (96%, 
62/65), the study participants were students. Mean age 
of adolescents was 19.09 (± 2.92). In 80% (52/65) of the 
studies, participants were both male and female adoles-
cents. Studies included adolescents with depression (21%, 
14/65), anxiety (9%, 6/65), distress (20%, 13/65), com-
bined symptoms of anxiety, distress and depression (17%, 
11/65) and behavioural problems, academic concerns 
and eating problems (11%, 7/65). In 21% of the stud-
ies (14/65), the condition of the study participants was 
not specified (see Table  2 for the characteristics of the 
included studies). Study selectioni Out-
come measures used to measure distress were Perceived 
Stress Scale (n = 13), Penn State Worry Questionnaire 
(PSWQ) (n = 3), Kessler Perceived Distress Scale (n = 2), 
and General Health Questionnaire (GHQ) (n = 2). Other studies did not report session duration and 11 studies 
did not report session duration. Booster sessions were 
delivered in 3 trials. In 37/65 (57%) studies, relaxation 
interventions (either as a standalone or in combination 
with other elements) were delivered by the specialists. Relaxation based interventions were self-administered 
in 18/65 (28%) studies and the intervention was deliv-
ered online in 4/65 (6%) studies. In 62/65 studies, men-
tal health was reported as a primary outcome. Study selectioni We identified and screened 16,816 records from 10 aca-
demic databases. After removing duplicates, 10,694 stud-
ies were assessed for title and abstract screening. Out 
of these, 10,461 studies were excluded as they did not 
meet the eligibility criteria. Two reviewers independently 
screened 233 full-text articles and included 24 studies for 
meta-analysis. We manually searched and screened the 
references of the primary studies and included 41 more 
studies for meta-analysis. A total of 65 RCTs with 8009 
participants were included in the systematic review and 
meta-analysis. Figure  1 describes the study selection 
process. Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Page 6 of 17 Fig. 1  Study selection process     Fig. 1  Study selection process Anxiety Scale (SCAS) (n = 3), The Spielberger State-Trait 
Anxiety Inventory (STAI) (n = 3), State Trait anxiety 
(STAI) (n = 3), Anxiety Sensitivity Index (n = 3) and Beck 
Anxiety Inventory (BAI) (n = 2). Many studies used sev-
eral other tools for anxiety (n = 20). The outcome meas-
ures used for depression were Beck Depression Inventory 
(BDI) (n = 9), Centre for Epidemiologic Studies Depres-
sion Scale (CES-D) (n = 7), Reynolds’ Adolescent Depres-
sion Scale (RADS) (n = 4), Patient Health Questionnaire 
(PHQ-9) (n = 3), Child Depression Rating Scale Revised 
(CDACR) (n = 3). Moreover, various studies used differ-
ent types of tools to measure depression (n = 12). Out-
come measures used to measure distress were Perceived 
Stress Scale (n = 13), Penn State Worry Questionnaire 
(PSWQ) (n = 3), Kessler Perceived Distress Scale (n = 2), 
and General Health Questionnaire (GHQ) (n = 2). Other Anxiety Scale (SCAS) (n = 3), The Spielberger State-Trait 
Anxiety Inventory (STAI) (n = 3), State Trait anxiety 
(STAI) (n = 3), Anxiety Sensitivity Index (n = 3) and Beck 
Anxiety Inventory (BAI) (n = 2). Many studies used sev-
eral other tools for anxiety (n = 20). The outcome meas-
ures used for depression were Beck Depression Inventory 
(BDI) (n = 9), Centre for Epidemiologic Studies Depres-
sion Scale (CES-D) (n = 7), Reynolds’ Adolescent Depres-
sion Scale (RADS) (n = 4), Patient Health Questionnaire 
(PHQ-9) (n = 3), Child Depression Rating Scale Revised 
(CDACR) (n = 3). Moreover, various studies used differ-
ent types of tools to measure depression (n = 12). Outcomes
ff Different outcome measures were reported to measure 
anxiety, distress and depression in the included studies. In majority of the studies (n = 12) Depression, Anxiety 
and Stress Scale (DASS) was used to measure all three 
outcomes (distress, anxiety and depression). The out-
come measures used for anxiety were Spence Children’s Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Page 7 of 17 Table 2  Characteristics of included studies (N = 65)
Sr. No. Study 
(Author, year
Country
Sample
Trial Des
1
(Caldwell 
et al., 2016)
USA
50
RCT​
2
(Gold et al., 
2017)
Australia
100
cRCT​
3
(Robledo-
Colonia et al., 
2012)
Cali, Colombia
74
RCT​
4
(Harmat et al., 
2008)
Hungary
65
RCT​
5
(Nabkasorn 
et al., 2006)
Thailand
49
RCT​
6
(Putra et al., 
2018)
Indonesia
31
RCT​
7
(MacMahon & 
Gross, 1988)
USA
69
RCT​
8
(Reynolds & 
Coats, 1986)
California
21
RCT​
9
(Roth, 1989)
USA
80
RCT​
10
(Roth & Hol‑
mes, 1987)
UK
57
RCT​
11
(Velasquez 
et al., 2015)
Columbia
125
RCT​
12
(Norris et al., 
1992)
UK
91
RCT​
13
(Walsh et al., 
2016)
USA
64
RCT​
14
(Raes et al., 
2014)
Belgium
335
cRCT​
15
(Sagon et al., 
2018)
USA
103
RCT​
16
(Stasiak et al., 
2014)
New Zealand
34
Pilot RCT
17
(Cui et al., 
2016)
China
120
RCT​
18
(Felver et al., 
2015)
USA
47
RCT​
19
(Khalsa et al., 
2012)
USA
100
RCT​
20
(De Vibe et al., 
2013)
Norway
288
RCT​
21
(De Vibe et al., 
2013; Erogul 
et al., 2014)
New York, USA 57
RCT​
22
(Phang et al., 
2015)
Malaysia
75
RCT​
23
(Scholten 
et al., 2016)
 Netherlands
138
RCT​ Table 2  Characteristics of included studies (N = 65) Table 2  Characteristics of included studies (N = 65)
Sr. No. Outcomes
ff International Journal of Mental Health Systems           (2022) 16:31 Page 8 of 17 Table 2  (continued)
Sr. No. Study 
(Author, year
Country
Sample
Trial De
24
(Grassi et al., 
2011)
Not specified
75
RCT​
25
(Dvořáková 
et al., 2017)
USA
107
Pilot RCT
26
(Vázquez 
et al., 2012)
Spain
133
RCT​
27
(McGrady 
et al., 2012)
USA
105
RCT​
28
(Levin et al., 
2017)
USA
79
RCT​
29
(Blake et al., 
2018)
Australia
123
RCT​
30
(Merry et al., 
2012)
New Zealand
187
RCT​
31
(Seligman 
et al., 2007)
USA
212
RCT​
32
(Kenardy et al., 
2003)
Australia
74
RCT​
33
(Seligman 
et al., 2000)
USA
225
RCT​
34
(Calear et al., 
2009)
Australia
1477
cRCT​
35
(Chen et al., 
2013)
China
60
RCT​
36
(Delgado 
et al., 2010)
Not specified
32
RCT​
37
(Shapiro et al., 
1998)
USA
78
RCT​
38
(Astin, 1997)
USA
28
RCT​
39
(Shearer et al., 
2015)
USA
46
RCT​
40
(Hilyer et al., 
1982)
USA
43
RCT​
41
(Melnyk et al., 
2009)
USA
47
RCT​
42
(Ștefan et al., 
2018)
Romania
46
RCT​
43
(Chiauzzi et al., 
2008)
USA
157
RCT​
44
(Saravanan 
& Kingston, 
2014)
Malaysia
66
RCT​
45
(Fleming et al., 
2012)
New Zealand
30
RCT​
46
(Deckro et al., 
2002)
USA
90
RCT​
47
(Nguyen-Feng 
et al., 2017)
USA
243
RCT​ Table 2  (continued)
Sr. No. Outcomes
ff Study 
(Author, year
Country
Sample
Trial Design
Population
Gender/Age, 
M(SD)
Recruitment 
setting
Relaxation 
Type
Clinical 
outcome
1
(Caldwell 
et al., 2016)
USA
50
RCT​
University 
students
Both, 18–40 
(mean, SD miss‑
ing)
University
Relaxation
Anxiety
2
(Gold et al., 
2017)
Australia
100
cRCT​
School stu‑
dents
Both, 13.84 (0.74) School
Relaxation
Depression
3
(Robledo-
Colonia et al., 
2012)
Cali, Colombia
74
RCT​
Pregnant 
women
Female, 21 (SD 
missing)
Prenatal Care 
Services of 
three Hos‑
pitals
Relaxation
Depression
4
(Harmat et al., 
2008)
Hungary
65
RCT​
University 
students
Both, 22.6 (2.83)
University
Relaxation
Depression
5
(Nabkasorn 
et al., 2006)
Thailand
49
RCT​
Nursing 
students
Female,18.8 (0.7)
Not specified
Relaxation
Depression
6
(Putra et al., 
2018)
Indonesia
31
RCT​
School stu‑
dents
Female,15–17 
(mean, SD miss‑
ing)
School
Relaxation
Depression
7
(MacMahon & 
Gross, 1988)
USA
69
RCT​
Juvenile
Male, 16.3 (SD 
missing)
Juvenile 
detention 
facilities
Relaxation
Depression
8
(Reynolds & 
Coats, 1986)
California
21
RCT​
School stu‑
dents
Both, 15.65 (SD 
missing)
School
Relaxation
Depression and 
anxiety
9
(Roth, 1989)
USA
80
RCT​
College 
students
Both, 20.8 (SD 
missing)
College
Relaxation
Depression and 
anxiety
10
(Roth & Hol‑
mes, 1987)
UK
57
RCT​
College 
students
Both, 18.9 (1.3)
College
Relaxation
Depression and 
anxiety
11
(Velasquez 
et al., 2015)
Columbia
125
RCT​
School age 
children
Not specified
Not specified
Relaxation
Depression and 
anxiety
12
(Norris et al., 
1992)
UK
91
RCT​
School stu‑
dents
Both, 16 (SD 
missing)
School
Relaxation
Depression 
anxiety and 
stress
13
(Walsh et al., 
2016)
USA
64
RCT​
Students
Female, 19.15 
(SD missing)
Not specified
Multicompo‑
nent
Depression
14
(Raes et al., 
2014)
Belgium
335
cRCT​
School stu‑
dents
Both, 13- 20 
(mean, SD miss‑
ing)
School
Multicompo‑
nent
Depression
15
(Sagon et al., 
2018)
USA
103
RCT​
Freshmen 
university 
students
Both, 18.15 (.46)
University
Multicompo‑
nent
Depression
16
(Stasiak et al., 
2014)
New Zealand
34
Pilot RCT​
School stu‑
dents
Both, 13–18 
(mean, SD miss‑
ing)
School
Multicompo‑
nent
Depression
17
(Cui et al., 
2016)
China
120
RCT​
College 
students
Both, 19.42 (1.66) College
Multicompo‑
nent
Depression
18
(Felver et al., 
2015)
USA
47
RCT​
School stu‑
dents
Both, 15 (SD 
missing)
School
Multicompo‑
nent
Depression
19
(Khalsa et al., 
2012)
USA
100
RCT​
School Stu‑
dents
Both, 16.8 (0.6)
School
Multicompo‑
nent
Stress
20
(De Vibe et al., 
2013)
Norway
288
RCT​
University 
students
Both, 23 (SD 
missing)
University
Multicompo‑
nent
Stress
21
(De Vibe et al., 
2013; Erogul 
et al., 2014)
New York, USA 57
RCT​
Medical 
students
Both, 23.5 (1.7)
College
Multicompo‑
nent
Stress
22
(Phang et al., 
2015)
Malaysia
75
RCT​
Medical 
students
Both, 21.14 
(1.10)
College
Multicompo‑
nent
Stress
23
(Scholten 
et al., 2016)
 Netherlands
138
RCT​
School stu‑
dents
Both, 13.90 (.91)
School
Multicompo‑
nent
Anxiety Population
Gender/Age, 
M(SD)
Recruitment 
setting
Relaxation 
Type
Clinical 
outcome
University 
students
Both, 18–40 
(mean, SD miss‑
ing)
University
Relaxation
Anxiety
School stu‑
dents
Both, 13.84 (0.74) School
Relaxation
Depression
Pregnant 
women
Female, 21 (SD 
missing)
Prenatal Care 
Services of 
three Hos‑
pitals
Relaxation
Depression
University 
students
Both, 22.6 (2.83)
University
Relaxation
Depression
Nursing 
students
Female,18.8 (0.7)
Not specified
Relaxation
Depression
School stu‑
dents
Female,15–17 
(mean, SD miss‑
ing)
School
Relaxation
Depression
Juvenile
Male, 16.3 (SD 
missing)
Juvenile 
detention 
facilities
Relaxation
Depression
School stu‑
dents
Both, 15.65 (SD 
missing)
School
Relaxation
Depression and 
anxiety
College 
students
Both, 20.8 (SD 
missing)
College
Relaxation
Depression and 
anxiety
College 
students
Both, 18.9 (1.3)
College
Relaxation
Depression and 
anxiety
School age 
children
Not specified
Not specified
Relaxation
Depression and 
anxiety
School stu‑
dents
Both, 16 (SD 
missing)
School
Relaxation
Depression 
anxiety and 
stress
Students
Female, 19.15 
(SD missing)
Not specified
Multicompo‑
nent
Depression
School stu‑
dents
Both, 13- 20 
(mean, SD miss‑
ing)
School
Multicompo‑
nent
Depression
Freshmen 
university 
students
Both, 18.15 (.46)
University
Multicompo‑
nent
Depression
School stu‑
dents
Both, 13–18 
(mean, SD miss‑
ing)
School
Multicompo‑
nent
Depression
College 
students
Both, 19.42 (1.66) College
Multicompo‑
nent
Depression
School stu‑
dents
Both, 15 (SD 
missing)
School
Multicompo‑
nent
Depression
School Stu‑
dents
Both, 16.8 (0.6)
School
Multicompo‑
nent
Stress
University 
students
Both, 23 (SD 
missing)
University
Multicompo‑
nent
Stress
Medical 
students
Both, 23.5 (1.7)
College
Multicompo‑
nent
Stress
Medical 
students
Both, 21.14 
(1.10)
College
Multicompo‑
nent
Stress
School stu‑
dents
Both, 13.90 (.91)
School
Multicompo‑
nent
Anxiety Hamdani et al. Outcomes
ff International Journal of Mental Health Systems           (2022) 16:31 Page 9 of 17 Table 2  (continued)
Sr. No. Outcomes
ff Study 
(Author, year
Country
Sample
Trial Design
Population
Gender/Age, 
M(SD)
Recruitment 
setting
Relaxation 
Type
Clinical 
outcome
24
(Grassi et al., 
2011)
Not specified
75
RCT​
University 
students
Female, 
20.86 (1.27)
University
Multicompo‑
nent
Anxiety
25
(Dvořáková 
et al., 2017)
USA
107
Pilot RCT​
College 
students
Both, 18.2 (0.4)
College
Multicompo‑
nent
Depression and 
anxiety
26
(Vázquez 
et al., 2012)
Spain
133
RCT​
University 
students
Both, 23.3 (SD 
missing)
University
Multicompo‑
nent
Depression and 
anxiety
27
(McGrady 
et al., 2012)
USA
105
RCT​
First year 
medical 
students
Both, age not 
specified
Not specified
Multicompo‑
nent
Depression and 
anxiety
28
(Levin et al., 
2017)
USA
79
RCT​
College 
students
Both, 21.61(5.48)
College
Multicompo‑
nent
Depression and 
anxiety
29
(Blake et al., 
2018)
Australia
123
RCT​
School stu‑
dents
Both, 14.48 (SD 
missing)
School
Multicompo‑
nent
Depression and 
anxiety
30
(Merry et al., 
2012)
New Zealand
187
RCT​
School stu‑
dent
Both, 15.6 (SD 
missing)
School
Multicompo‑
nent
Depression and 
anxiety
31
(Seligman 
et al., 2007)
USA
212
RCT​
First year 
undergradu‑
ate students
Both, age not 
specified
College
Multicompo‑
nent
Depression and 
anxiety
32
(Kenardy et al., 
2003)
Australia
74
RCT​
University 
students
Both, 19.92 (4.78) University
Multicompo‑
nent
Depression and 
anxiety
33
(Seligman 
et al., 2000)
USA
225
RCT​
University 
students (1st 
year under-
graduates)
Both, age not 
specified
University
Multicompo‑
nent 
Depression and 
anxiety
34
(Calear et al., 
2009)
Australia
1477
cRCT​
School stu‑
dents
Both, 14.34 
(0.75)
School
Multicompo‑
nent
Depression and 
anxiety
35
(Chen et al., 
2013)
China
60
RCT​
Nursing 
students
Both, 19.5(0.87)
University
Multicompo‑
nent
Depression and 
anxiety
36
(Delgado 
et al., 2010)
Not specified
32
RCT​
University 
students
Female, 18–24 
(mean, SD miss‑
ing)
University
Multicompo‑
nent
Depression and 
anxiety
37
(Shapiro et al., 
1998)
USA
78
RCT​
Medical 
students
Both, age not 
specified
University
Multicompo‑
nent
Depression and 
anxiety
38
(Astin, 1997)
USA
28
RCT​
University 
students
Both, age not 
specified
University
Multicompo‑
nent
Depression and 
anxiety
39
(Shearer et al., 
2015)
USA
46
RCT​
University 
students
Both, age not 
specified
University
Multicompo‑
nent
Depression and 
anxiety
40
(Hilyer et al., 
1982)
USA
43
RCT​
School stu‑
dents
Male, 15–18 
(mean, SD miss‑
ing)
School
Multicompo‑
nent
Depression and 
anxiety
41
(Melnyk et al., 
2009)
USA
47
RCT​
Adolescents
Both, 14–16 
(mean, SD miss‑
ing)
Not specified
Multicompo‑
nent
Depression and 
anxiety
42
(Ștefan et al., 
2018)
Romania
46
RCT​
College 
students
Female, 18.92 
(SD missing)
College
Multicompo‑
nent
Anxiety and 
stress
43
(Chiauzzi et al., 
2008)
USA
157
RCT​
College 
students
Both, 18–24 (SD 
missing)
College
Multicompo‑
nent
Anxiety and 
stress
44
(Saravanan 
& Kingston, 
2014)
Malaysia
66
RCT​
Medical 
students
Both, 19 (1.04)
University
Multicompo‑
nent
Anxiety and 
stress
45
(Fleming et al., 
2012)
New Zealand
30
RCT​
School stu‑
dents
Male, 14.9 (.79)
School
Multicompo‑
nent
Anxiety and 
stress
46
(Deckro et al., 
2002)
USA
90
RCT​
College 
students
Both, 24 (SD 
missing)
College
Multicompo‑
nent
Anxiety and 
stress
47
(Nguyen-Feng 
et al., 2017)
USA
243
RCT​
College 
students
Both, 18–21 
(mean, SD miss‑
ing)
College
Multicompo‑
nent
Depression, 
Anxiety and 
stress n
Population
Gender/Age, 
M(SD)
Recruitment 
setting
Relax
Type
University 
students
Female, 
20.86 (1.27)
University
Multic
nent
College 
students
Both, 18.2 (0.4)
College
Multic
nent
University 
students
Both, 23.3 (SD 
missing)
University
Multic
nent
First year 
medical 
students
Both, age not 
specified
Not specified
Multic
nent
College 
students
Both, 21.61(5.48)
College
Multic
nent
School stu‑
dents
Both, 14.48 (SD 
missing)
School
Multic
nent
School stu‑
dent
Both, 15.6 (SD 
missing)
School
Multic
nent
First year 
undergradu‑
ate students
Both, age not 
specified
College
Multic
nent
University 
students
Both, 19.92 (4.78) University
Multic
nent
University 
students (1st 
year under-
graduates)
Both, age not 
specified
University
Multic
nent 
School stu‑
dents
Both, 14.34 
(0.75)
School
Multic
nent
Nursing 
students
Both, 19.5(0.87)
University
Multic
nent
University 
students
Female, 18–24 
(mean, SD miss‑
ing)
University
Multic
nent
Medical 
students
Both, age not 
specified
University
Multic
nent
University 
students
Both, age not 
specified
University
Multic
nent
University 
students
Both, age not 
specified
University
Multic
nent
School stu‑
dents
Male, 15–18 
(mean, SD miss‑
ing)
School
Multic
nent
Adolescents
Both, 14–16 
(mean, SD miss‑
ing)
Not specified
Multic
nent
College 
students
Female, 18.92 
(SD missing)
College
Multic
nent
College 
students
Both, 18–24 (SD 
missing)
College
Multic
nent
Medical 
students
Both, 19 (1.04)
University
Multic
nent
School stu‑
dents
Male, 14.9 (.79)
School
Multic
nent
College 
students
Both, 24 (SD 
missing)
College
Multic
nent
College 
students
Both, 18–21 
(mean, SD miss‑
ing)
College
Multic
nent Hamdani et al. Outcomes
ff Study 
(Author, year
Country
Sample
Trial Design
Population
Gender/Age, 
M(SD)
Recruitment 
setting
Relaxation 
Type
Clinical 
outcome
48
(Zhang et al., 
2018)
China
62
RCT​
University 
students
Both, 18.41(2.01)
University
Multicompo‑
nent
Depression and 
stress
49
(Bluth et al., 
2016)
North Carolina 
( USA)
23
RCT​
School stu‑
dents
Both, 16.8 (1.3)
School
Multicompo‑
nent
Depression, 
anxiety and 
stress
50
(Flett et al., 
2019)
New Zealand
208
RCT​
University 
students
Not specified, 
20.08(2.8)
University
Multicompo‑
nent
Depression, 
anxiety, and 
stress
51
(Song & 
Lindquist, 
2015)
South Korea
44
RCT​
Undergradu‑
ate nursing 
students
Both, 19.6 (1.7)
Not specified
Multicompo‑
nent
Depression, 
anxiety, and 
stress
52
(Rentala et al., 
2019)
India
209
RCT​
College 
students
Female, 16–19 
(SD missing)
College
Multicompo‑
nent
Depression, 
anxiety and 
stress
53
(Hall et al., 
2018)
China
54
RCT​
University 
students
Both, 22.30 (2.63) University
Multicompo‑
nent
Depression, 
anxiety, and 
stress
54
(Hindman 
et al., 2014)
USA
34
RCT​
University 
students
Both, 22.35 (SD 
missing)
University
Multicompo‑
nent
Depression, 
anxiety, and 
stress
55
(Levin et al., 
2019)
USA
39
Pilot trial RCT​ University 
students
Both, 20.51 (2.73) College
Multicompo‑
nent
Depression, 
anxiety, and 
stress
56
(Ellis et al., 
2011)
Australia
26
RCT​
University 
students
Both, 19.67 (1.66) University
Multicompo‑
nent
Depression, 
anxiety, and 
stress
57
(Gallego et al., 
2015)
Spain
53
RCT​
University 
students
Both, 20.07 (SD 
missing)
University
Multicompo‑
nent
Depression, 
anxiety and 
stress
58
(Berger et al., 
1988)
USA
232
RCT​
College 
students
Both, 20 (SD 
missing)
College
Multicompo‑
nent
Depression 
anxiety and 
stress
59
(Van Aubel 
et al., 2020)
Neatherland
55
RCT​
General popu‑
lation
Both, 21.36 
(2.39)
Community
Multicompo‑
nent
Depression and 
Anxiety
60
(Nguyen-Feng 
et al., 2016)
USA
314
RCT​
College 
students
Both, 18–21 
(mean, SD miss‑
ing)
College
Multicompo‑
nent
Depression, 
anxiety and 
stress
61
(Warnecke 
et al., 2011)
Australia
84
RCT​
University 
students
Both, 23.92 (3.2)
University
Multicompo‑
nent
Depression and 
Anxiety
62
(Moir et al., 
2016)
New Zealand
402
RCT​
University 
students
Both, 21 (SD 
missing)
University
Multicompo‑
nent
Depression and 
Anxiety
63
(Nguyen-Feng 
et al., 2019)
USA
382
RCT​
College 
students
Both, 21.3 (SD 
missing)
College
Multicompo‑
nent
Depression and 
Anxiety
64
(Levin et al., 
2016)
USA
234
RCT​
University 
students
Both, 20.51(2.73)
University
Multicompo‑
nent
Depression and 
Anxiety
65
(Hazlett-Ste‑
vens & Oren, 
2017)
USA
92
RCT​
College 
students
Both, 22.1 (4.7)
College
Multicompo‑
nent
Depression and 
Anxiety RCT: Randomized Controlled Trial (RCT); cRCT: Cluster Randomized Controlled Trial Sub‑group and moderator analyses Meta-analysis was conducted with 8009 participants. Effectiveness of relaxation-based interventions in the 
treatment of anxiety was explored in 46 studies, with a 
cumulative sample size of 5234 participants (2486 in 
intervention and 2748 in control arm). Meta-analysis 
with random effects model showed that relaxation tech-
niques were effective to reduce the symptoms of anxi-
ety in adolescents at post-intervention (SMD − 0.386, 
95% CI − 0.52 to − 0.25) (Fig. 2). There was evidence for 
substantial heterogeneity across the studies (I2 = 79.16%, 
t2 = 0.15). No significant changes in pooled effect size 
were observed on sensitivity analysis. Egger’s regression 
statistic was significant (t = 2.32, p = 0.02, see Additional 
file  2: Fig. S5), demonstrating significant publication 
bias in reporting of anxiety outcome. The pooled effect 
size increased after adjusting for the publication bias 
(SMD− 0.54, 95% CI − 0.69 to − 0.40). We did a sub-group and meta-regression analyses to 
evaluate in which settings relaxation techniques work to 
reduce the symptoms of anxiety, distress and/or depres-
sion in adolescents. Anxiety: Subgroup analyses revealed 
that face-to-face, individually delivered, multicomponent 
interventions with a booster session yielded a higher 
effect size to reduce the symptoms of anxiety in ado-
lescents. However, these results were statistically non-
significant (Table 4). Data regarding intervention dosage 
(including number of sessions; duration of sessions and 
overall programme) was provided in 30 studies report-
ing anxiety outcome. To analyse association of dosage 
of intervention with improvement in the symptoms of 
anxiety (effect size) meta-regression analyses were run, 
after removing three of the outlier studies [34–36]. The 
density of intervention dosage explained 44% of the vari-
ation in overall effect size (Table  5) (Additional file  2: 
Figs. S8–S10). Age of participants explained 13% of vari-
ance in anxiety outcome, where age associated inversely 
with effect size (B =  −  0.07, SE = 0.03, p = 0.04). Depres-
sion: Subgroup analyses did not reveal any significant 
subgroup differences based on the mode and format of 
intervention delivery, types of intervention and booster 
sessions for depression outcome (Table 4). A total of 33 
studies reported statistics pertaining to density of dos-
age of interventions. The moderator analysis of the data 
revealed that characteristics of ‘relaxation techniques’ 
(format, dosage, components) did not have any effect to 
reduce the symptoms of depression in adolescents. Sub‑group and moderator analyses Mul-
tivariate meta-regression analyses revealed that 5% of the 
variation in effect size was explained by density of dos-
age of interventions. None of the indicators of the dose 
of interventions reached statistical significance (Table 5, 
Additional file  2: Figs. S11–S13). Age did not yield any 
significant association with effect size, explained only 
4% of variance in the depression outcome (B = -0.04, f
symptoms of depression Depression was reported as an outcome in a total of 50 
studies, with a cumulative sample size of 5732 partici-
pants (2719 in intervention arm and 3013 in control arm). There was small evidence to support relaxation tech-
niques being effective to reduce the symptoms of depres-
sion in adolescents (SMD = − 0.28 (95% CI − 0.40% to 
− 0.15) (Fig. 4). There was a substantial heterogeneity in 
reporting of depression outcome (I2 = 76.82%, t2 = 0.13). The sensitivity analysis did not result in any change in the 
pooled effect size for depression outcome. There was no 
evidence of publication bias (Egger’s regression p = 0.36, 
see Additional file 2: Fig. S7). Control groups studies used different tools to measure distress (n = 3) 
(list of outcome measures used in studies is given in 
Additional file 2: Table S8). studies used different tools to measure distress (n = 3) 
(list of outcome measures used in studies is given in 
Additional file 2: Table S8). g
In the included studies, relaxation techniques were com-
pared with control groups, including wait-list controls 
(n = 16), treatment-as-usual (n = 7), no active interven-
tion (n = 23), placebo control (n = 1) or active controls 
(n = 18). Page 10 of 17 Page 10 of 17 Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Table 3  List of relaxation techniques used in included studies 
(N = 65)
Category of relaxation technique
Progressive Muscle Relaxation (PMR)
Breathing
Exercise
Walk
Stretches
Relaxation (music, art)
Autogenic training
Meditation (sitting, eating, walking) Effect of relaxation‑based interventions to reduce 
symptoms of depression Effect of relaxation‑based interventions to reduce Effect of relaxation‑based interventions to reduce 
symptoms of distress Distress was reported as an outcome in a total of 23 stud-
ies, with a cumulative sample size of 2246 (1122 par-
ticipants in intervention arm and 1124 participants in 
control arm). There was a substantial heterogeneity in 
reporting of this outcome (I2 = 85.08%, t2 = 0.26). Meta-
analysis revealed a moderate effect size in favour of the 
intervention group (SMD = − 0.48, 95% CI − 0.71 to 
− 0.24) (Fig. 3) to reduce the symptoms of distress in ado-
lescents. Removal of outlier studies in sensitivity analyses 
did not reveal any significant changes in the pooled effect 
size for distress outcome. Egger’s regression statistic 
revealed a non-significant publication bias in reporting of 
distress outcome (P = 0.30, see Additional file 2: Fig. S6). Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Page 11 of 17 Fig. 2  Forest plot for anxiety outcome  results remained consistent even after removal of the 
outlier study [36]. Age did not yield any significant asso-
ciation with effect size, explained only 1% of variance to 
reduce the symptoms of distress (B = – 0.03, SE = 0.06, 
p = 0.64). SE = 0.04, p = 0.33). Distress: Subgroup analyses revealed 
that studies with low risk of bias, multicomponent, indi-
vidually delivered face-to-face interventions, with a 
booster dose were more effective in reducing the symp-
toms of distress. Only mode of delivery and booster dose 
were found to be statistically significant (Table 4). Mul-
tivariate regression model pertaining to density of inter-
vention dosage of explained 47% of variation in effect size 
for distress outcome. None of the indicators of dose of 
interventions emerged as a significant predictor in this 
model (Table  5, Additional file  2: Figs. S14–S16). The The results show that active components (i.e., individ-
ual effect of each intervention component) of interven-
tions explained 9% to 25% of variance in heterogeneity 
across studies targeting distress, anxiety, and/or depres-
sion. Highest variance in heterogeneity amongst differ-
ent studies was explained in the interventions targeting Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Page 12 of 17 Fig. 3  Forest plot for distress outcome Fig. 3  Forest plot for distress outcome anxiety as an outcome (25%). Overall, multicomponent 
interventions were associated with a better improvement 
in anxiety than relaxation alone, still this effect was statis-
tically non-significant. Certainty of outcomes pertaining to anxiety, depression 
and distress using GRADE (Grading of Recommendations, 
Assessment, Development and Evaluations) framework Certainty of outcomes pertaining to anxiety, depression 
and distress using GRADE (Grading of Recommendations, 
Assessment, Development and Evaluations) framework Assessment, Development and Evaluations) framework
Certainty of outcomes pertaining to anxiety, distress and 
depression reported in the trials was assessed using the 
GRADE guidelines [37]. The certainty for the outcome of 
anxiety was downgraded by three levels to very low for 
serious concerns pertaining to risk of bias in the studies, 
substantial heterogeneity and publication bias in report-
ing of this outcome. The outcomes of distress and depres-
sion were downgraded to low by two levels, due to high 
risk of bias in intervention design and presence of sub-
stantial heterogeneity, explained by clinically heteroge-
neous study samples and interventions (see Additional 
file 2: Table S7). f
The relaxation techniques were found to be moderately 
effective in reducing anxiety and distress in adolescents. This is consistent with the findings of previous reviews 
of relaxation techniques which yielded positive effect of 
relaxation techniques on reducing symptoms of anxiety 
in adults. In a systematic review and meta-analysis of 27 
RCTs, with 1005 adults, Manzoni et al. [12] found that 
relaxation techniques had medium to large effect size 
to reduce the symptoms of anxiety in adults. Similarly, 
Klainin-Yobas [38] reported reduction in the symptoms 
of anxiety among older adults. Our meta-analysis showed that relaxation techniques 
have only a small effect on improving depressive symp-
toms in adolescents. The finding is consistent with the 
findings reported in the literature where the impact of 
relaxation strategies to reduce the symptoms of depres-
sion is not well established [39]. Other psychological 
treatments like Cognitive Behavioural Therapy (CBT) are 
found to be more effective for the treatment of depressive Effect of relaxation‑based interventions to reduce 
symptoms of distress of the studies included in our analysis were conducted in 
an educational setting of High-Income Countries (HICs) 
with adolescents with symptoms of depression and dis-
tress. The results of meta-analysis showed that relaxation 
techniques work across three outcomes (distress, anxiety 
and depression) yielding small to moderate effect sizes. Multicomponent, face-to-face delivered relaxation tech-
niques with a booster dose were more effective.h Discussionh The present systematic review and meta-analysis of 65 
RCTs with 8009 adolescents is the first evidence synthesis 
to review the literature on the effectiveness of ‘relaxation 
techniques’ to reduce the symptoms of anxiety, distress 
and/or depression in young people aged 14–24. Majority Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Page 13 of 17 Fig. 4  Forest plot for depression outcome symptoms, where relaxation techniques can be imple-
mented with mild to moderate depressive symptoms as a 
part of multicomponent therapy [40]. A recent systematic 
review and network meta-analysis of school-based inter-
ventions to prevent anxiety and depression in children 
and adolescents [41] showed that compared with usual 
treatment, mindfulness and relaxation-based universal interventions were effective to reduce symptoms of anxi-
ety in young people; however, no effect of relaxation 
techniques was found on depressive symptoms. y
Although all included interventions varied greatly in 
their dose and types, overall, these interventions were 
more effective to reduce the symptoms of anxiety and dis-
tress and less effective to reduce symptoms of depression Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Page 14 of 17 Table 4  Sub-group analysis
Variable
No. of s
Anxiety
 Risk of bias
  High
40
  Low
6
 Mode of delivery
  Mixed
1
  Onsite
33
  Technology
12
 Format of delivery
  Group
28
  Individual
15
  Mixed
1
 Type of therapy
  Multicomponent
28
  Relaxation only
18
 Booster sessions
  No
37
  Yes
5
 Intervention focus
  Preventive
24
  Treatment
21
  Both
1
Depression
 Risk of bias
  High
40
  Low
10
 Mode of delivery
  Mixed
1
  Onsite
38
  Technology
11
 Format of delivery
  Group
33
  Individual
14
  Mixed
1
 Type of therapy
  Multicomponent
29
  Relaxation only
21
 Booster sessions
  No
42
  Yes
4
 Intervention focus
  Both
1
  Preventive
26
  Treatment
23
Distress
 Risk of bias
  High
19
  Low
4 Table 4  Sub-group analysis
Variable
No. Discussionh International Journal of Mental Health Systems           (2022) 16:31 Page 15 of 17 Table 4  (continued)
Variable
No. of studies
SMD (95% CI)
I2
Q-value
df
p-value
 Mode of delivery
  Mixed
0
− 
  Onsite
16
− 0.62 (− 0.87 to − 0.38)
88.39%
6.28
1
0.01
  Technology
6
− 0.06 (− 0.42 to 0.30)
33.49%
 Format of delivery
  Group
14
− 0.47 (− 0.78 to − 0.17)
64.06%
2.31
2
0.31
  Individual
6
− 0.64 (− 1.08 to − 0.19)
93.72%
  Mixed
2
0.02 (− 0.71 to 0.75)
45.24%
 Type of therapy
  Multicomponent
13
− 0.60 (− 0.90 to − 0.29)
90.07%
1.42
1
0.23
  Relaxation only
10
− 0.30 (− 0.67 to 0.07)
61.69%
 Booster sessions
  No
19
− 0.38 (− 0.64 to − 0.11)
79.86%
3.28
1
0.07
  Yes
4
− 0.96 (− 1.53 to − 0.39)
95.87% adolescents, especially in low resource settings and that 
the relaxation techniques are simple, easy to learn, teach 
and use and can be delivered by health care workers 
across the spectrum (i.e., from non-specialist facilita-
tors in community and primary healthcare settings to a 
mental health specialist). Finding of our review support 
the use of relaxation intervention techniques to address 
non-specific mental health distress according to the 
staged model of illness, which highlights the importance 
of relaxation technique as first level population mental 
health interventions [23, 42]. Because of their poten-
tial for scalability, effectiveness and cost-effectiveness, 
relaxation techniques have been recommended in the 
World Health Organization Mental Health Gap Action 
Programme (WHO mhGAP) intervention guide for the 
management of stress, emotional problems and depres-
sion in adolescents and have been used as an integral 
component of multicomponent psychological interven-
tion packages for adolescent anxiety and depression in 
low resource settings [43]. Discussionh Table 5  Meta-regression analysis showing association between 
anxiety, distress and depression outcome and density of dosage 
of interventions anxiety, distress and depression outcome and density of dosage 
of interventions
Anxiety R2 analog = 44%, Distress R2 analog = 0.47, Depression R2 analog = 0.05
Covariate
Coefficient
Standard error
Z-value
P
Anxiety
 Intercept
− 0.29
0.14
− 2.10
0.04
 Number of sessions
0
0.010
− 0.40
0.69
 Duration of sessions
0
0
− 1.54
0.12
 Duration of pro‑
gramme
0.03
0.03
0.86
0.40
Distress
 Intercept
− 0.48
0.24
− 1.98
0.05
 Number of sessions
0.02
0.01
1.61
0.11
 Duration of sessions
0
0
− 1.46
0.14
 Duration of pro‑
gramme
− 0.01
0.01
− 0.70
0.49
Depression
 Intercept
− 0.015
0.22
− 0.71
0.48
 Number of sessions
− 0.01
0.01
− 0.93
0.35
 Duration of sessions
0
0.0
− 0.66
0.51
 Duration of pro‑
gramme
0
0.01
0.27
0.79 Covariate
Coefficient
Standard error
Z-value
P Discussionh of studies
SMD (95% CI)
I2
Q-value
df
p-value
Anxiety
 Risk of bias
  High
40
− 0.41 (− 0.57 to − 0.26)
80.73
0.64
1
0.43
  Low
6
− 0.25 (− 0.62 to 0.11)
57.36
 Mode of delivery
  Mixed
1
− 0.13 (− 0.87 to 0.62)
0%
3.0
2
0.22
  Onsite
33
− 0.47 (− 0.64 to − 0.30)
83.10%
  Technology
12
− 0.22 (− 0.48 to 0.04)
31.54%
 Format of delivery
  Group
28
− 0.30 (− 0.48 to − 0.11)
48.56%
2.72
2
0.26
  Individual
15
− 0.53 (− 0.77 to − 0.29)
90.84%
  Mixed
1
− 0.13 (− 0.97 to 0.72)
0%
 Type of therapy
  Multicomponent
28
− 0.38 (− 0.56 to − 0.21)
80.59%
0.004
1
0.95
  Relaxation only
18
− 0.39 (− 0.62 to − 0.17)
77.73%
 Booster sessions
  No
37
− 0.38 (− 0.54 to − 0.22)
70.76%
0.90
2
0.34
  Yes
5
− 0.59 (− 1.00 to − 0.18)
94.96%
 Intervention focus
  Preventive
24
− 0.38 (− 0.56 to − 0.19)
74.81%
1.07
2
0.59
  Treatment
21
− 0.42 (− 0.62 to − 0.22)
83.70%
  Both
1
0.25 (− 1.02 to 1.51)
0%
Depression
 Risk of bias
  High
40
− 0.30 (− 0.55 to − 0.16)
77.92%
0.68
1
0.41
  Low
10
− 0.18 (− 0.44 to 0.09)
68.35%
 Mode of delivery
  Mixed
1
− 0.23 (− 1.02 to 0.56)
0
0.15
2
0.93
  Onsite
38
− 0.29 (− 0.44 to − 0.14)
70.79%
  Technology
11
− 0.24 (− 0.49 to 0.02)
57.46%
 Format of delivery
  Group
33
− 0.21 (− 0.37 to − 0.05)
70.65%
1.88
2
0.39
  Individual
14
− 0.41 (− 0.65 to − 0.17)
86.06%
  Mixed
1
− 0.23 (− 1.032 to 0.57)
0%
 Type of therapy
  Multicomponent
29
− 0.26 (− 0.34 to − 0.06)
70.07%
0.14
1
0.71
  Relaxation only
21
− 0.27 (− 0.45 to − 0.08)
83.02%
 Booster sessions
  No
42
− 0.31 (− 0.47 to − 0.19)
78.64%
1.75
1
0.19
  Yes
4
− 0.03 (− 0.45 to 0.39)
67.58%
 Intervention focus
  Both
1
− 0.13 (− 1.36 to 1.10)
0%
0.65
2
0.72
  Preventive
26
− 0.32 (− 0.49 to − 0.15)
79.92%
  Treatment
23
− 0.23 (− 0.41 to − 0.15)
74.10% SMD (95% CI)
I2
Q-value
df
p-value
− 0.41 (− 0.57 to − 0.26)
80.73
0.64
1
0.43
− 0.25 (− 0.62 to 0.11)
57.36
− 0.13 (− 0.87 to 0.62)
0%
3.0
2
0.22
− 0.47 (− 0.64 to − 0.30)
83.10%
− 0.22 (− 0.48 to 0.04)
31.54%
− 0.30 (− 0.48 to − 0.11)
48.56%
2.72
2
0.26
− 0.53 (− 0.77 to − 0.29)
90.84%
− 0.13 (− 0.97 to 0.72)
0%
− 0.38 (− 0.56 to − 0.21)
80.59%
0.004
1
0.95
− 0.39 (− 0.62 to − 0.17)
77.73%
− 0.38 (− 0.54 to − 0.22)
70.76%
0.90
2
0.34
− 0.59 (− 1.00 to − 0.18)
94.96%
− 0.38 (− 0.56 to − 0.19)
74.81%
1.07
2
0.59
− 0.42 (− 0.62 to − 0.22)
83.70%
0.25 (− 1.02 to 1.51)
0%
− 0.30 (− 0.55 to − 0.16)
77.92%
0.68
1
0.41
− 0.18 (− 0.44 to 0.09)
68.35%
− 0.23 (− 1.02 to 0.56)
0
0.15
2
0.93
− 0.29 (− 0.44 to − 0.14)
70.79%
− 0.24 (− 0.49 to 0.02)
57.46%
− 0.21 (− 0.37 to − 0.05)
70.65%
1.88
2
0.39
− 0.41 (− 0.65 to − 0.17)
86.06%
− 0.23 (− 1.032 to 0.57)
0%
− 0.26 (− 0.34 to − 0.06)
70.07%
0.14
1
0.71
− 0.27 (− 0.45 to − 0.08)
83.02%
− 0.31 (− 0.47 to − 0.19)
78.64%
1.75
1
0.19
− 0.03 (− 0.45 to 0.39)
67.58%
− 0.13 (− 1.36 to 1.10)
0%
0.65
2
0.72
− 0.32 (− 0.49 to − 0.15)
79.92%
− 0.23 (− 0.41 to − 0.15)
74.10%
− 0.43 (− 0.68 to − 0.17)
86.23%
0.85
1
0.36
− 0.71 (− 1.25 to − 0.16)
0% Hamdani et al. Anxiety R2 analog = 44%, Distress R2 analog = 0.47, Depression R2 analog = 0.05 RTs: Relaxation Techniques; RCTs: Randomized Controlled Trials; GRADE: Grad‑
ing of Recommendations, Assessment, Development and Evaluations; SMD: 
Standardized Mean Difference; HIC: High Income Countries; CBT: Cognitive 
Behavioural Therapy; LMICs: Low- and Middle-Income Countries; PRISMA: 
Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PICOS: 
Population, Intervention, Control, Outcome, Study Design; ICD: International 
Classification of Diseases; DSM: Diagnostic and Statistical Manual of Mental 
Disorders; SD: Standard Deviation; PMR: Progressive Muscle Relaxation Strengths and limitations of this reviewhi In the light of this evidence, we recom-
mend that future studies should develop and test sim-
ple and easy to follow interventions for adolescents and 
provide detailed description of interventions using the 
standard intervention reporting guidelines [45]. Techniques; CBT: Cognitive Behavioural Therapy; ACT​: Acceptance and Com‑
mitment Therapy; DASS: Depression, Anxiety and Stress Scale; SCAS: Spence 
Children’s Anxiety Scale; BAI: Beck Anxiety Inventory; BDI: Beck Depression 
Inventory; RADS: Reynolds’ Adolescent Depression Scale; CDACR​: Child 
Depression Rating Scale Revised; PSWQ: Penn State Worry Questionnaire; 
GHQ: General Health Questionnaire; WHO mhGAP: World Health Organization 
Mental Health Gap Action Programme. Strengths and limitations of this reviewhi The findings of the present review should be interpreted 
in the context of following limitations. Firstly, the major-
ity of the studies included in our analysis were conducted 
in educational settings of High-Income Countries (HIC), 
with only one study from a low- and middle-income 
country. Moreover, the studies included in this review 
had a high risk of bias, where the certainty of outcomes 
for depression, anxiety and distress was low. Further 
high-quality research, both from high- and low-income 
countries is needed to ascertain the evidence generated 
from the current review. Secondly, most of the included 
interventions were heterogeneous in their makeup and in adolescents. In this review, age of the participants was 
inversely related with reduction of anxiety symptoms. These findings are in line with what Manzoni et al. [12] 
reported, where relaxation techniques had more benefi-
cial effects to treat anxiety in young people compared to 
older people. p
p
The findings of this review may be of clinical impor-
tance given that there is a lack of evidence-based psy-
chosocial interventions for anxiety and depression in Hamdani et al. International Journal of Mental Health Systems           (2022) 16:31 Page 16 of 17 Page 16 of 17 did not effectively define their individual therapeutic 
components (“active ingredients”). Not many of these 
interventions were manualized to aid in reproducibil-
ity and implementation. Moreover, we did not observe 
a lot of variance in number of sessions delivered across 
the interventions; therefore, regression analyses did not 
predict dose response relationship. Also, studies did 
not clearly state whether RTs were delivered by trained 
healthcare workers or untrained. Such information could 
provide comparative effectiveness of delivering RTs by 
trained versus not trained healthcare workers and might 
have implications on the scale-up of such intervention 
strategy, especially in low resource settings. Addition-
ally, the heterogeneity in the design of the included inter-
ventions contributed to high risk of bias. This is similar 
to the previous systematic review and meta-analysis of 
relaxation techniques [12] where significant heterogene-
ity was observed in relaxation approaches, study partici-
pants and outcome measures. Studies show that simple 
and easy to follow interventions result in better quality of 
intervention delivery, which matters more than the “dose 
density” of an intervention to produce the desired clinical 
outcomes [44]. Availability of data and materials Availability of data and materials
Not applicable. Acknowledgements This systematic review and meta-analysis was conducted as part of the 
Wellcome Trust Mental Health Priority Area special commission on core com‑
ponents in youth anxiety and depression. Funding g
This work was financially supported by the Wellcome Trust, UK Mental Health 
Priority Area special commission on core components in youth anxiety and 
depression. Author contributions SUH conceived the study, participated in the design, data collection, and 
analysis of the data and drafted the manuscript. ZeH conceived the study, 
participated in the design, data collection and analysis of the data and drafted 
the manuscript. SWZ participated in the data collection and analysis of the 
data and drafted the manuscript. NS participated in the data collection and 
analysis of the data and drafted the manuscript. UB participated in the data 
collection and analysis of the data and drafted the manuscript. AW partici‑
pated in the analysis of the data and drafted the manuscript. AR conceived 
the study, participated in the design and data analysis of the data and drafted 
the manuscript. All authors read and approved the final manuscript. Abbreviations
RT R l
ti
T Received: 10 February 2022   Accepted: 6 June 2022 Received: 10 February 2022   Accepted: 6 June 2022 The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s13033-​022-​00541-y. The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s13033-​022-​00541-y. The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s13033-​022-​00541-y. Additional file 1. Protocol_systematic_review_meta_analysis_ 
relaxation_techniques. Additional file 1. Protocol_systematic_review_meta_analysis_ 
relaxation_techniques. Additional file 2. Supplementary_results. Additional file 2. Supplementary_results. Consent for publication
Not applicable. Consent for publication
Not applicable. Competing interests The authors declare that they have no competing interests. Author details 1 Global Institute of Human Development, Shifa Tameer-e-Millat University, 
Islamabad, Pakistan. 2 Human Development Research Foundation (HDRF), Raw‑
alpindi, Pakistan. 3 Institute of Population Health, Department of Primary Care 
and Mental Health, University of Liverpool, Liverpool, UK. 1.	
Erskine HE, Baxter AJ, Patton G, Moffitt TE, Patel V, Whiteford HA, et al. The 
global coverage of prevalence data for mental disorders in children and 
adolescents. Epidemiol Psychiatric Sci. 2017;26(4):395–402. Declarations Ethics approval and consent to participate
Not applicable. Conclusionshi This is the first systematic review and meta-analysis of 
literature to evaluate the evidence on the effectiveness of 
relaxation techniques as an active ingredient to improve 
anxiety, distress and depression in adolescents. Given the 
potential for relaxation techniques to be scalable, effec-
tive and cost-effective in decreasing symptoms of anxiety, 
distress and improving depressive symptoms in adoles-
cents; clinicians, practitioners, adolescent mental health 
experts, policy makers and academics may consider 
implementation of relaxation techniques with adoles-
cents for potentially significant impact at-scale. However, 
further high-quality studies with low risk of bias, espe-
cially from low resource settings are needed to ascertain 
the evidence for the effectiveness of these highly used 
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