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Beyond the cold baths: contemporary applications of cold-water immersion in the treatment of clinical depression and anxiety
Abstract
Cold-water immersion (e.g. adapted cold showers, partial or whole-body immersion, cold swimming) are nowadays increasingly being used as an adjunctive procedure to enhance the effects of primary treatment of various clinical conditions, including depressive and anxiety disorders. This brief article reviews the evidence regarding the beneficial effects of cold-water immersion on clinical depression and anxiety and outlines potential therapeutic mechanisms underlying the intervention. Promising avenues for future research and best practice recommendations are also discussed to improve the clinical effectiveness of cold-water immersion.
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An emerging body of evidence indicates that short-term immersion in cold water facilitates positive affect and reduces negative affect. However, the neural mechanisms underlying these effects remain largely unknown. For the first time, we employed functional magnetic resonance imaging (fMRI) to identify topological clusters of networks coupled with behavioural changes in positive and negative affect after a 5 min cold-water immersion. Perceived changes in positive affect were associated with feeling more active, alert, attentive, proud, and inspired, whilst changes in negative affect reflected reductions in distress and nervousness. The increase in positive affect was supported by a unique component of interacting networks, including the medial prefrontal node of the default mode network, a posterior parietal node of the frontoparietal network, and anterior cingulate and rostral prefrontal parts of the salience network and visual lateral network. This component emerged as a result of a focal effect confined to few connections. Changes in negative affect were associated with a distributed component of interacting networks at a reduced threshold. Affective changes after cold-water immersion occurred independently, supporting the bivalence model of affective processing. Interactions between large-scale networks linked to positive affect indicated the integrative effects of cold-water immersion on brain functioning.
This review is based on a multiple database survey on published literature to determine the effects on health following voluntary exposure to cold-water immersion (CWI) in humans. After a filtering process 104 studies were regarded relevant. Many studies demonstrated significant effects of CWI on various physiological and biochemical parameters. Although some studies were based on established winter swimmers, many were performed on subjects with no previous winter swimming experience or in subjects not involving cold-water swimming, for example, CWI as a post-exercise treatment. Clear conclusions from most studies were hampered by the fact that they were carried out in small groups, often of one gender and with differences in exposure temperature and salt composition of the water. CWI seems to reduce and/or transform body adipose tissue, as well as reduce insulin resistance and improve insulin sensitivity. This may have a protective effect against cardiovascular, obesity and other metabolic diseases and could have prophylactic health effects. Whether winter swimmers as a group are naturally healthier is unclear. Some of the studies indicate that voluntary exposure to cold water has some beneficial health effects. However, without further conclusive studies, the topic will continue to be a subject of debate.
Objectives
The aims of this review were to 1) summarise the breadth and types of research regarding the impact of aquatic exercise on mental health completed to date, 2) provide a clear indication of the intervention type, volume, measurement tools used, and populations best served in relation to this activity and its effectiveness and 3) to identify domains within the literature that can be developed so recommendations can be made for future investigations.
Method
A scoping review was performed under the PRISMA guidelines. A systematic search of Pubmed, SPORTDiscus, PsycInfo and Google Scholar databases was conducted. Studies observing the effect of aquatic exercises on mental health and related parameters were considered for inclusion. The data from the selected studies were then extracted and analysed methodically.
Primary Conditions Measured
Depression, anxiety, mood, self-esteem, and psychological well-being were the primary mental states for which findings could be clearly extracted.
Results
Of the 1635 articles that resulted from the search, 23 articles met all inclusion criteria. Of these, 12 were randomised controlled trials. Cumulatively, the findings of this review trend towards aquatic exercise being effective in generating positive changes in mental health.
Conclusion
Aquatic exercise, specifically winter swimming, leisure swimming, competitive swimming and aquatic aerobics, can be a promising conservative therapy for mental health management. However, it is recommended that further research be conducted to solidify these findings and establish the long-term effects of this intervention on mental health.
Background
An increasing volume of anecdotal and scientific evidence suggests that mood may be enhanced following swimming in cold water. The exact mechanisms responsible are largely unknown, but may include the effects of exercise from swimming and the effects of cold. This study examined the effect on mood following immersion in cold water, where swimming was not the primary activity.
Methods
The Profile of Mood States (POMS) questionnaire was completed by 64 undergraduate students. The following week, 42 participants completed up to 20-min immersion (18ʹ36ʺ ± 1ʹ48ʺ) in cold sea water (13.6°C). Twenty-two participants acted as controls. The POMS was completed immediately following the cold-water immersion by both groups.
Results
The cold-water immersion group showed a significant decrease, with a large effect size, of 15 points from 51 to 36, compared to 2 points in the control group, 42 to 40. Positive sub-scales increased significantly in the cold-water immersion group (Vigour by 1.1, and Esteem-Related Affect by 2.2 points) and negative sub-scales showed significant reductions (Tension by 2.5, Anger 1.25, Depression 2.1, Fatigue 2.2, and Confusion 2.8 points). The control showed no significant change except for depression, which was significantly higher after the period by 1.6 points.
Conclusion
Cold-water immersion is a well-tolerated therapy that is capable of significantly improving mood in young, fit, and healthy individuals. A key aim of this study was to control for the effects of swimming as a mechanism responsible for the improvement in mood which has been shown in previous studies. Thus, the change in mood evidenced in this study was not due to physical activity per se. Consequently, the hypothesis that cold in and of itself can improve mood is supported.
Increased CO2 sensitivity is common in panic disorder (PD) patients. Free divers who are known for their exceptional breathing control have lower CO2 sensitivity due to training effects. This study aimed to investigate the immediate effects of cold facial immersion (CFI), breath holding and CO2 challenges on panic symptoms. Healthy participants and patients with PD were subjected to four experimental conditions in a randomly assigned order. The four conditions were (a) breath-holding (BH), (b) CFI for 30 s, (c) CO2 challenge, and (d) CO2 challenge followed by CFI. Participants completed a battery of psychological measures, and physiological data (heart rate and respiration rate) were collected following each experimental condition. Participants with PD were unable to hold their breath for as long as normal controls; however, this finding was not significant, potentially due to a small sample size. Significant reductions in both physiological and cognitive symptoms of panic were noted in the clinical group following the CFI task. As hypothesized, the CFI task exerted demonstrable anxiolytic effects in the clinical group in this study by reducing heart rate significantly and lessening self-reported symptoms of anxiety and panic. This outcome demonstrates the promise of the CFI task for clinical applications.
We present a transdiagnostic definition of the commonly used, but poorly defined, term emotional disorder. This definition transcends and possibly complements traditional descriptive diagnostic categories, and candidate dimensional models of psychopathology by focusing on putative mechanisms that contribute to the onset and maintenance of disorders characterized primarily by dysfunction in the interpretation and regulation of emotion. We review three intermediate transdiagnostic mechanisms that characterize emotional disorders, such as, but not limited to, anxiety and depressive disorders, and then illustrate how this proposed definition applies to additional diagnoses beyond anxiety and depression. Implications of this new conceptualization of disorders of emotion are then discussed in the context of assessment, treatment, and prevention.
Hydrotherapy is widely used for the treatment and rehabilitation of patients, but it can also be applied to prevent diseases in healthy people. This review investigates the health effects of water immersion, a form of hydrotherapy, and the mechanisms by which the properties of water elicit such an effect. We searched PubMed, EMBASE, Cochrane Library, and CINAHL to identify relevant articles, of which 13 met the inclusion criteria. Various factors of water immersion were investigated in the 13 selected articles, including water temperature, immersion height, and application area. With respect to health effects, warm and cold water immersion affects the cardiovascular and neuromuscular systems, respectively. Nine articles focused on the effects of warm water immersion, explaining its thermal effect in relation to changes in disease-related serum substance levels and hemodynamic changes. While the sample population in most studies comprised young adults, two articles applied partial water immersion to the legs of elderly subjects to assess its effect on sleep. Because the water immersion protocols applied in the 13 articles were inconsistent, the health benefits could not be clearly explained. However, we expect the present findings to be beneficial for providing research guidelines for studies on the application of water immersion.
We present a transdiagnostic definition of the commonly used, but poorly defined, term emotional disorder. This definition transcends and possibly complements traditional descriptive diagnostic categories, and candidate dimensional models of psychopathology by focusing on putative mechanisms that contribute to the onset and maintenance of disorders characterized primarily by dysfunction in the interpretation and regulation of emotion. We review three intermediate transdiagnostic mechanisms that characterize emotional disorders, such as, but not limited to, anxiety and depressive disorders, and then illustrate how this proposed definition applies to additional diagnoses beyond anxiety and depression. Implications of this new conceptualization of disorders of emotion are then discussed in the context of assessment, treatment, and prevention.
Purpose:
The aim of this study was to determine the cumulative effect of a routine (hot-to-) cold shower on sickness, quality of life and work productivity.
Methods:
Between January and March 2015, 3018 participants between 18 and 65 years without severe comorbidity and no routine experience of cold showering were randomized (1:1:1:1) to a (hot-to-) cold shower for 30, 60, 90 seconds or a control group during 30 consecutive days followed by 60 days of showering cold at their own discretion for the intervention groups. The primary outcome was illness days and related sickness absence from work. Secondary outcomes were quality of life, work productivity, anxiety, thermal sensation and adverse reactions.
Results:
79% of participants in the interventions groups completed the 30 consecutive days protocol. A negative binomial regression model showed a 29% reduction in sickness absence for (hot-to-) cold shower regimen compared to the control group (incident rate ratio: 0.71, P = 0.003). For illness days there was no significant group effect. No related serious advents events were reported.
Conclusion:
A routine (hot-to-) cold shower resulted in a statistical reduction of self-reported sickness absence but not illness days in adults without severe comorbidity.
Trial registration:
Netherlands National Trial Register NTR5183.
Rheumatism has been treated using whole-body cryotherapy (WBCT) since the 1970s. The aim of this study was to assess the efficacy of WBCT as an experimental, adjunctive method of treating depressive and anxiety disorders.
A control (n=34) and a study group (n=26), both consisting of outpatients 18-65 years old with depressive and anxiety disorders (ICD-10), received standard psychopharmacotherapy. The study group was additionally treated with a series of 15 daily visits to a cryogenic chamber (2-3 min, from -160 degrees C to -110 degrees C). The Hamilton's depression rating scale (HDRS) and Hamilton's anxiety rating scale (HARS) were used as the outcome measures.
After three weeks, a decrease of at least 50% from the baseline HDRS-17 scores in 34.6% of the study group and 2.9% of the control group and a decrease of at least 50% from the baseline HARS score in 46.2% of the study group and in none of the control group were noted.
These findings, despite such limitations as a small sample size, suggest a possible role for WBCT as a short-term adjuvant treatment for mood and anxiety disorders.
In the early nineteenth century, physicians designed the first manufactured showers for the purpose of curing the insane. Sustained falls of cold water were prescribed to cool hot, inflamed brains, and to instil fear to tame impetuous wills. By the middle of the century showers had appeared in both asylums and prisons, but shower-related deaths led to their decline. Rather than being abandoned, however, the shower was transformed by the use of warm water to economically wash the skins of prison and asylum populations. In stark contrast to an involuntary, deliberately unpleasant treatment, by the end of the century the shower was a desirable product for the improvement of personal hygiene and population health.
Depression is a debilitating mood disorder that is among the top causes of disability worldwide. It can be characterized by a set of somatic, emotional, and behavioral symptoms, one of which is a high risk of suicide. This work presents a hypothesis that depression may be caused by the convergence of two factors: (A) A lifestyle that lacks certain physiological stressors that have been experienced by primates through millions of years of evolution, such as brief changes in body temperature (e.g. cold swim), and this lack of "thermal exercise" may cause inadequate functioning of the brain. (B) Genetic makeup that predisposes an individual to be affected by the above condition more seriously than other people. To test the hypothesis, an approach to treating depression is proposed that consists of adapted cold showers (20 °C, 2-3 min, preceded by a 5-min gradual adaptation to make the procedure less shocking) performed once or twice daily. The proposed duration of treatment is several weeks to several months. The following evidence appears to support the hypothesis: Exposure to cold is known to activate the sympathetic nervous system and increase the blood level of beta-endorphin and noradrenaline and to increase synaptic release of noradrenaline in the brain as well. Additionally, due to the high density of cold receptors in the skin, a cold shower is expected to send an overwhelming amount of electrical impulses from peripheral nerve endings to the brain, which could result in an anti-depressive effect. Practical testing by a statistically insignificant number of people, who did not have sufficient symptoms to be diagnosed with depression, showed that the cold hydrotherapy can relieve depressive symptoms rather effectively. The therapy was also found to have a significant analgesic effect and it does not appear to have noticeable side effects or cause dependence. In conclusion, wider and more rigorous studies would be needed to test the validity of the hypothesis.