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Nephro-Urol Mon. 2017 November; 9(6):e60280.
Published online 2017 September 19.
doi: 10.5812/numonthly.60280.
Research Article
Effects of Aromatherapy Using the Damask Rose Essential Oil on
Depression, Anxiety, and Stress in Hemodialysis Patients: A Clinical
Trial
Alireza Kasra Dehkordi,1Ali Tayebi,2,* Abbas Ebadi,3Hedayat Sahraei,4and Behzad Einollahi5
1MSc in Nursing, Nephrology and Urology Department, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
2PhD Student Nursing, Department of Medical Surgical Nursing, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
3PhD Associate Professor, BehavioralSciences Research Center and Faculty Nursing, Tehran, IR Iran
4PhD Professor in Neuroscience, Neuroscience Research Center, BaqiyatallahUniversity of Medical Sciences, Tehran, IR Iran
5PhD Professor in Nephrology, Nephrology and Urology Department, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
*Corresponding author: Ali Tayebi, Department of Medical Surgical Nursing, Baqiyatallah University of Medical Sciences, Tehran, Iran. Tel: +98-2122289941, Fax: +98-2126127237,
E-mail: tayybi.ali@gmail.com
Received 2016 July 05; Revised 2016 September 21; Accepted 2017 July 09.
Abstract
Background: Depression, anxiety, and stress are very common among hemodialysis patients. The aim of this study was to investi-
gate effects of aromatherapy using the damask rose oil on depression, anxiety, and stress in these patients.
Methods: In a clinical trial that was performed in 2015, 60 patients under hemodialysis treatment were randomly allocated to two
groups of control and intervention each consisting of 30 subjects. The DASS21 scale was used to measure the rates of depression,
anxiety, and stress before and four weeks after intervention. In the intervention group, the patients were asked to inhale the damask
rose oil with a constant density of 2% from a piece of cloth smeared with three drops for an hour. In the control group, only the usual,
standard care was applied.
Results: The comparison of the mean scores before and after the intervention in the two groups showed that after intervention, the
depression, anxiety, and stress scores significantly decreased in the damask rose group (P ≤0.05).
Conclusions: Inhalation aromatherapy using the damask rose oil can decrease depression, anxiety, and stress in hemodialysis pa-
tients.
Keywords: Aromatherapy, Hemodialysis, Depression, Anxiety, Damask Rose Essential Oil
1. Background
Anxiety and depression are among the initial disorders
in end stage renal disease patients (1). On the other hand,
dialysis itself is a process causing stress and anxiety fol-
lowed by several psychological problems (2,3). In such a
way that in some studies, 63.9% of the hemodialysis pa-
tients suffer from anxiety, 60.5% from depression, and 51.7%
from stress. In another study, the rates of depression and
anxiety in patients dialyzed for more than 2.5 years were
62.8% and 83.8%, respectively (4,5). In Knuth’s study, the
prevalence of depression was reported 48% (6).
Depression is an important factor in the reduction of
treatment adherence. Depressed patients’ refusal of co-
operation in treatment increases their medical problems,
endangers their health, and eventually leads to their early
death (7). Moreover, in these patients, many areas of life
quality have displayed significant correlations with men-
tal health. Reduction of mental health in hemodialysis
patients affects their life quality and disturbs their opera-
tions in various respects (8).
Moreover, anxiety prevents from adherence to pro-
posed diets and treatments, and it has negative effects on
self-care and treatment results. Patients with higher social
support and lower anxiety levels enjoy higher levels of self-
care (9). Therefore, maintenance of mental hygiene and
control of anxiety and depression are of great importance
in these patients.
Different non-pharmaceutical methods have been ex-
amined so far as complementary medicine to reduce anx-
iety and depression in diseases and different situations,
which include massage therapy, physical exercises, dry
needling and acupressure, music therapy, aromatherapy,
yoga and tai chi, hypnosis, and prayer therapy (10-18).
Of these, aromatherapy as a plant therapy method
is considered as one of the branches of alternative and
Copyright © 2017, Nephro-Urology Monthly. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0
International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the
original work is properly cited.
Dehkordi AK et al.
complementary medicine. Investigation of the history of
medicine demonstrates that old civilizations paid great at-
tention to aromatic plants and applied them widely in vari-
ous aspects of life, from religious ceremonies to treatment
and cosmetic purposes (19).
Aromatherapy denotes using essential oils extracted
from plants and flowers for treatment of different diseases.
These oils can be used via inhalation or bathing or during
a massage. The most frequent form of using aromather-
apy is via messages (20). Studies performed demonstrate
efficient anti-anxiety effects of the aromatherapy method,
which has not accompanied by side effects (21,22).
Aromatherapy has been utilized in different fields
such as pregnancy hygiene, pain relief, side effects of
chemotherapy, skin and hair hygiene, wounds treatment,
epileptic fit control, reduction of breathing problems, and
reduction of anxiety and depression (23,24).
In a study performed on dialysis patients, inhalation of
the orange oil has proven effective in reducing hemodialy-
sis patients’ anxiety without significant side effects (25). In
a study performed by Itai examining psychological effects
of aromatherapy on hemodialysis patients, significant ef-
fects on the reduction of anxiety and depression rates were
observed (26). However, some studies have demonstrated
that aromatherapy is not effective in long-term. The re-
sults of Wilkinson’s study demonstrated that aromather-
apy using the message method did not improve the anx-
iety symptoms 10 weeks after intervention, even though
it had positive effects in the second week (27). All meth-
ods of anxiety reduction have their own limitations de-
spite their effectiveness. Of them, inhalation aromather-
apy seems to have fewer limitations and higher applicabil-
ity, and considering the specific conditions and limitations
of hemodialysis patients, should it turn out to be effective,
it can be utilized widely in treatment centers as a simple,
low-cost method.
There are a few studies having examined inhalation
aromatherapy specifically in hemodialysis patients. In
addition, the effectiveness of aromatherapy in hemodial-
ysis patients is controversial. On the other hand, not
all of the studies performed confirm the effectiveness of
this method, and in some studies, aromatherapy has not
shown much effect. The present research was planned to
examine the effects of aromatherapy on depression, anxi-
ety, and stress in hemodialysis patients.
2. Methods
This was a clinical trial conducted with two groups
of control and intervention for two months between May
and June 2014 on patients suffering from end stage renal
disease (ESRD) undergoing treatment with maintenance
hemodialysis. The required sample size was calculated us-
ing Altman’s nomogram considering type I error (α) of 5%,
type II error (β) of 10%, and power of 90% with the stan-
dard deviation of 2 calculated from Valipour et al.’s study
(28). The sample size required in this study was calculated
as 30 people in each group with an attrition rate of 10%.
The population under study included 60 patients undergo-
ing hemodialysis treatment having entered the study from
two dialysis centers in two hospitals in Tehran (Baqiyatal-
lah and Shahid Chamran hospitals). The sampling method
included random allocation to the two groups based on a
draw. Here, the research environment of the two hospitals
was divided based on even/odd days and morning/evening
shifts, and then each day and shift was assigned to one of
the groups under study based on the draw.
ESRD patients with following criteria were included in
the study: being dialyzed three times a week on a regular
basis, undergoing hemodialysis treatment for more than
three months, being literate, not having allergy to aro-
matics, and not having proven problems with the sense of
smell. Patients who missed more than three consecutive
sessions during the intervention period, and those who
have been undergoing treatment by a psychiatrist due to
a mental disorder were excluded.
2.1. Ethical Considerations
The research followed the tenets of the Declaration of
Helsinki. The objectives of the research were explained to
the patients and informed consent was obtained. All pa-
tients took part in this study voluntary. The research was
approved by the ethics committee of Baqiyatallah Univer-
sity of Medical Sciences, Tehran. Iran.
2.2. Measurement Tools and Method
Personal information including age, gender, weight,
marital status, previous dialysis, and education was col-
lected using demographic questionnaires. Depression,
anxiety, and stress levels were measured using the DASS21
scale. In the case of patients who needed help in filling out
the questionnaire (such as those with vision problems),
the questionnaire was read and the patients’ responses
were recorded with no judgments or changes.
The DASS-21 scale for depression, anxiety, and stress was
developed in 1995 by Lovibond and Lovibond (29). This
scale comes in two versions. The short version contains 21
items evaluating each of the mental constructs including
depression, anxiety, and stress using 7 different items. The
long version contains 42 items, where each mental factor
or construct is measured by 14 items. The validity and reli-
ability of this tool have been proven in different studies in-
cluding Iranian studies (30-33). In Iran, this questionnaire
2Nephro-Urol Mon. 2017; 9(6):e60280.
Dehkordi AK et al.
was examined by Samani and Joukar, who reported the
test-retest validity for the depression, anxiety, and stress
scales as 0.80, 0.76, and 0.77, respectively, and Cronbach’s
alpha for the depression, anxiety, and stress scales as 0.81,
0.74, and 0.78, respectively (34). Each of the subscales of
DASS contains 7 questions, and the final score of each sub-
scale is obtained by summing the scores of the relevant
questions. Each question is scored from zero (not at all true
about me) to 3 (completely true about me). The depression
subscale includes questions 3, 5, 10, 13, 16, 17, and 21, the anx-
iety subscale includes questions 2, 4, 7, 9, 15, 19, and 20, and
the stress subscale includes questions 1, 6, 8, 11, 12, 14, and
18.
2.3. Interventions
After collecting the initial information, the interven-
tion began. Here, once the patient was connected to the
dialysis machine, a piece of cloth smeared with three drops
of the damask rose oil with a constant density of 2% was at-
tached to the patient’s collar, and the patient was asked to
breathe normally. The intervention was decided to last an
hour. In the control group, only the usual care was taken.
After a month, the patients’ depression, anxiety, and stress
levels were measured again using the DASS21 scale.
2.4. Statistical Tests
After the data collection, the statistical calculations
were performed using chi-square test and independent t-
test in SPSS software version 20. P values less than 0.05 were
considered statistically significant.
3. Results
In this study, 4 patients were excluded due to hospital-
ization in the intensive care unit, missing more than three
sessions, and transfer to another center. Finally, 56 patients
(28 in each group) completed the study. 36 (64.3%) partici-
pants were men, and 53 (94.6%) were married. The mean
age of the control group was 58.2 ±12.6, and the mean age
of the intervention group was 58.9 ±13.4, which were not
statistically different. Our data showed that the distribu-
tion of the demographic variables in the two groups was
homogeneous (Table 1).
The DASS21 scale scores demonstrated high prevalence
of depression, anxiety, and stress in the patients under
study. After the intervention, a significant reduction was
observed in the DASS scale scores of the damask rose group,
while the scores of the control group did not show a signif-
icant difference. Moreover, among the three variables of
depression, anxiety, and stress, the highest reduction was
related to the variable stress, which showed a reduction of
Table 1. Baseline Characteristics of Hemodialysis Patients in Intervention and Con-
trol Groups
Parameter Hemodialysis Groups Chi-Square Test
Damask Rose Control
Sex P = 1.00
Male 18 (64.3) 18 (64.3)
Female 10 (35.7) 10 (35.7)
Marital status P = 0.55
Married 26 (92.9) 27 (96.4)
Single 2 (7.1) 1 (3.6)
previous dialysis, y P = 0.36
< 1 6 (21.4) 12 (42.9)
1 - 2 5(17.9) 3 (10.7)
2 - 3 5 (17.9) 3(10.7)
> 3 12 (42.9) 10 (35.7)
Education P = 0.14
Primary 14(50) 16 (57.1)
Secondary 8 (28.6) 2 (7.1)
College or
university
6 (21.4) 10 (35.7)
5.7 ±4.9. Comparison of the mean scores of the DASS vari-
ables of the two groups before and after the intervention
also showed a significant difference (Table 2).
Table2. Changes in the DASS21 Scale Scores Before and After Intervention
Stage Hemodialysis Groups T Test
Damask Rose Control
Before
Depression 8.2 ±6.6 7.4±6.9 P = 0.63
Anxiety 6.2 ±4.5 8.1 ±6.2 P = 0.21
Stress 11.2 ±5.9 9.6 ±6.5 P= 0.34
After
Depression 5.1 ±4.5 7.4 ±7.3 P = 0.16
Anxiety 3.1 ±3.8 7.5 ±6.5 P = 0.004
Stress 5.5 ±4.6 9.6 ±7.4 P = 0.01
The differences between the
means
Depression -3.1 ±4.2 0.0 ±2.6 P = 0.002
Anxiety -3.1 ±3.4 -0.6 ±2.9 P = 0.006
Stress -5.7 ±4.4 0.0 ±3.9 P = 0.000
Nephro-Urol Mon. 2017; 9(6):e60280. 3
Dehkordi AK et al.
4. Discussion
The aim of this study was to examine the effects of in-
halation aromatherapy using the damask rose essential
oil on depression, anxiety, and stress in hemodialysis pa-
tients. Our data demonstrated that the differences be-
tween the mean depression, anxiety, and stress scores be-
fore and after intervention were significant in patients
who inhaled the damask rose aroma, as compared to those
of the control group. Of these, the variable stress showed
the highest reduction. Moreover, comparison of the mean
anxiety and stress raw scores showed a significant reduc-
tion in the damask rose group, but the depression raw
score after the intervention did not statistically differ, al-
though it decreased slightly. This appears logical and ac-
ceptable considering the nature and intensity of depres-
sion in hemodialysis patients and the lengthy treatment
of depression. However, comparison of the differences be-
tween the mean scores of this variable before and after the
intervention also demonstrated a significant difference.
Studies that have investigated the effects of inhalation
aromatherapy on dialysis patients are limited. In a study
by Kanani et al., effectiveness of the orange aroma in anx-
iety rates in hemodialysis patients was examined (25). In
this study, the patients’ state anxiety rate decreased from
46.9 ±9.7 before intervention to 35.9 ±8.7 after interven-
tion, which is in accordance with the results of our study.
Itai also examined the effects of inhalation aromather-
apy on dialysis patients (26). Only 14 women participated
in his study utilizing Hamilton anxiety and stress measure-
ment scales. He examined his sample in three conditions:
ordinary environment, odorless environment (using de-
odorants), and environment containing lavender and hiba
aromas, and concluded that using the aromatic conditions
significantly reduced the patients’ depression and anxiety.
Mirzaei also investigated effects of lavender oil inhala-
tion on anxiety rate (35) and reported results that are in ac-
cordance with our results.
The results of Graham’s study are contrary to ours. He
utilized inhalation aromatherapy on patients undergoing
radiotherapy using lavender,bergamot, and cedarwood es-
sential oils. He eventually found inhalation aromatherapy
non-effective in reduction of anxiety and depression in pa-
tients undergoing radiotherapy (36). Therefore, it is sug-
gested that more studies be performed in this area with
higher sample sizes and intervention periods.
4.1. Conclusions
The present study showed that depression, anxiety, and
stress are very common among hemodialysis patients, and
inhalation aromatherapy using the damask rose oil signifi-
cantly reduces depression, anxiety, and stress rates in these
patients.
Acknowledgments
This article was extracted from a master’s thesis at
Baqiyatallah Nursery College. We hereby thank and ap-
preciate the nephrology research center and neuroscience
research center, which provided us with a part of the ex-
penses of this research, and all of the dear patients who
participated in this research.
Footnote
Conflict of Interests: None declared.
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