There are currently 100 clinical trials registered on using massage as a treatment.  Six are listed for the indication of depression.  A small minority are focused specifically on treating depression or anxiety, while in many the effects of massage for patients with serious medical conditions are being explored.  Infant massage is also under study for developmental benefits.  The number of randomized trials for verified psychiatric disorders using massage as an intervention are limited to date.

In a recent review of the literature, the data regarding the use massage for the treatment of depression was assessed.  In this meta-analysis, the authors selected clinical trials that measured depressive symptoms across treatment and also utilized at least one control condition for comparison, and included a total of 17 studies in their analysis.  Studies of infant massage and prenatal massage were not included.  Studies were not limited in terms of primary inclusion of participants for the treatment of depression, although depressive symptoms were measured in all studies included.  None of the studies required a diagnosis of major depressive disorder for inclusion.  Control conditions varied across studies and included no intervention, treatment as usual, relaxation exercises, and a video attention control.  Number of sessions in the studies ranged between 1 and 24 massage sessions.  A meta-analysis of the results demonstrated a significant reduction of depressive symptoms with massage compared to control conditions, with all of the studies consistently demonstrating the antidepressant effects of massage.

Fo perinatal depression, massage has been added to psychotherapy with promising results demonstrated for those who receive both psychotherapy and massage compared to those who receive psychotherapy alone (Fields et al, 2009). In a randomized study, 112 pregnant women with verified diagnoses of depression (96% with MDD, 4% with dysthymia) were randomized to interpersonal psychotherapy (IPT) plus massage or IPT alone.  Depressive symptoms were followed with the Center for Epidemiological Studies Depression scale (CES-D).  Saliva samples were collected to measure cortisol levels.  IPT was provided in a group format.  For the group that received massage, massages were given by trained female massage therapists for 20 minutes once weekly.  The group that received IPT plus massage therapy attended significantly more sessions of IPT and had more study completers and had significantly greater improvements on depression and anxiety measures.  Neonatal outcomes did not differ between the two groups.

In another randomized study, women with depression randomized to receive massage from their partners during pregnancy experienced a greater reduction in depressive symptoms compared to those who did not receive massage during pregnancy.  Eighty-eight women with MDD during pregnancy were randomized to receive massage from 20 weeks gestation to 32 weeks gestation.  Assessments occurred at 20 and 32 weeks.  Significant others were trained in massage for the study, and were instructed to give the pregnant women two massages per week for the twelve weeks.  Sixty one women were in the control group, which consisted of standard treatment.  All women were referred to a collaborating psychiatrist, but it was not clear if other treatments were allowed during the study.

Compared to the control group, the group who received massage therapy experienced a greater decrease in depression scores, as well as  lowers rates of low birth weight and prematurity among their newborns.  Infant cortisol levels were also significantly lower in their infants, and their infants scored higher on the Brazelton Neonatal Behavioral Assessment Scales.  Postpartum depression scores were also lower in the group that received massage therapy.

Interestingly, one of most rigorous studies of massage for the treatment of MDD was done by Manber and colleagues, who sought to assess the efficacy of acupuncture for the treatment of antenatal depression.  In pregnant women with verified major depressive episodes, participants were randomly assigned to receive either acupuncture designed to treat depression, a “sham” acupuncture that was not specifically designed to treat depression, or massage therapy.  Although massage was utilized as a control condition for acupuncture, this arm provides data regarding massage as a potential treatment for depression during pregnancy.  Massage was selected as a control due to previously demonstrated short-term mood improvement but lack of established efficacy in the treatment of MDD.

Strengths of this protocol included verified diagnoses of MDD at study entry in women between 12-30 weeks gestation, minimum depression scores of 14 on the Hamilton Rating Scale for Depression, raters assessing outcomes who were blinded to treatment condition, and standardized protocols for massage and acupuncture delivery.  Treatments were provided twice weekly for 4 weeks, then weekly for 4 weeks, with sessions of either acupuncture or massage lasting 25 minutes.  Standardized Swedish massage with specified amount of time provided to back, face, head, neck and shoulders, and feet were provided by massage therapists who were state board certified in massage and trained in the protocol by a senior massage therapist.

The main finding of the study was that among the 150 randomized participants, those who received acupuncture specific for depression had significantly greater reductions in depression scores than those in either control groups (sham acupuncture or massage).   The response rate (>50% decrease on the HAM-D) for specific acupuncture was 63%, and the response rate for massage was 50%.  Response rates were significantly higher for the group receiving specific acupuncture than for the control groups.  Remission rates (final HAM-D scores < 7) were not different between acupuncture specific for depression (34%) and massage (31%).

While the main objective of this study was to test the efficacy of acupuncture, the investigators creatively used massage, another hands-on treatment, as a control condition.  The finding of efficacy with acupuncture is exciting.  However, the study also provides interesting and compelling data regarding massage as an intervention.  A response rate of 50% and remission rate of 31% with a non-pharmacologic, widely available treatment merits follow up.  While it represented a control condition in this study and was not the most efficacious arm, the findings and low risk make future study attractive.  Since in this study there was not a placebo-only condition, it is difficult to assess the specific effects of massage.

At this time, it is unknown how massage may yield antidepressant effects.   It has been postulated to reduce levels of stress hormones, blood pressure, and heart rate by increasing parasympathetic activity, increasing the availability of serotonin, and increasing the production of oxytocin.  The therapeutic alliance or attention may also play a role.

Studies are needed to determine the efficacy of massage therapy for major depressive disorder and anxiety disorders, but at least these studies demonstrate evidence of short-term improvements in mood.  Importantly, massage appears to be a low risk treatment.

Marlene Freeman, MD

Hou WH, Chiang PT, Hsu TY, Chiu SY, Yen YC. Treatment effects of massage therapy in depressed people: a meta-analysis. J Clin Psych 2010; 71:894-901.

Field T, Deeds O, Diego M, Hernandez-Reif M, Gauler A, Sullivan S, Wilson D, Nearing G. Benefits of combining massage therapy with group interpersonal psychotherapy in prenatally depressed women. J Bodyw Mov Ther. 2009; 13(4):297-303.

Field T, Diego M, Hernandez-Reif M, Deeds O, Figueiredo B.  Pregnancy massage reduces prematurity, low birthweight and postpartum depression. Infant Behav Dev 2009;32(4):454-60.

Manber R, Schnyer RN, Lyell D, Chambers AS, Caughey AB, Druzin M, Carlyle E, Celio C, Gress JL, Huang MI, Kalista T, Martin-Okada R, Allen JJ. Acupuncture for depression during pregnancy: a randomized controlled trial. Obstet Gynecol 2010; 115(3):511-20.

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