However, due to the obvious heterogeneity among the included studies, our results should be interpreted with caution and more high-quality RCTs are expected to confirm this result in the future.

LT and F-fL: conceptualization, visualization, investigation, and writing-original draft. L-zL and C-gF: conceptualization, visualization, and writing — review and editing.

X-cM: investigation and writing — review and editing. Y-xP: formal analysis and writing — review and editing. J-mL and HQ: funding acquisition and writing — review and editing. All authors contributed to the article and approved the submitted version.

This study was supported by the Youth Talent Promotion Project of China Association for Science and Technology no. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers.

Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Krause KR, Chung S, Adewuya AO, Albano AM, Babins-Wagner R, Birkinshaw L, et al.

International consensus on a standard set of outcome measures for child and youth anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder. Lancet Psychiatry. doi: PubMed Abstract CrossRef Full Text Google Scholar.

Twenge JM, Joiner TEUS. Census Bureau-assessed prevalence of anxiety and depressive symptoms in and during the COVID pandemic. Depress Anxiety. Santomauro DF, Herrera AM, Shadid J, Zheng P, Ashbaugh C, Pigott DM. Global prevalence and burden of depressive and anxiety disorders in countries and territories in due to the COVID pandemic.

Altmann H, Stahl ST, Gebara MA, Lenze EJ, Mulsant BH, Blumberger DM, et al. Coprescribed Benzodiazepines in Older Adults Receiving Antidepressants for Anxiety and Depressive Disorders: Association With Treatment Outcomes. J Clin Psychiatry. Malcolm BJ, Tallian K. Essential oil of lavender in anxiety disorders: Ready for prime time?

Ment Health Clin. Cui J, Li M, Wei Y, Li H, He X, Yang Q, et al. Inhalation aromatherapy via brain-targeted nasal delivery: natural volatiles or essential oils on mood disorders. Wang ZJ, Heinbockel T. Essential oils and their constituents targeting the gabaergic system and sodium channels as treatment of neurological diseases.

Zhang N, Yao L. Anxiolytic effect of essential oils and their constituents: a review. J Agric Food Chem. Lizarraga-Valderrama LR. Effects of essential oils on central nervous system: focus on mental health. Phytother Res. Chung YH, Chen SJ, Lee CL, Wu CW, Chang YS. Relaxing Effects of Breathing Pseudotsuga menziesii and Lavandula angustifolia Essential Oils on psychophysiological status in older adults.

Public Health. Yvon Y, Raoelison EG, Razafindrazaka R, Randriantsoa A, Romdhane M, Chabir N, et al. Relation between chemical composition or antioxidant activity and antihypertensive activity for six essential oils.

J Food Sci. Donelli D, Antonelli M, Bellinazzi C, Gensini GF, Firenzuoli F. Effects of lavender on anxiety: a systematic review and meta-analysis.

Kim M, Nam ES, Lee Y, Kang HJ. Effects of lavender on anxiety, depression, and physiological parameters: systematic review and meta-analysis. Asian Nurs Res. Abbasijahromi A, Hojati H, Nikooei S, Jahromi HK, Dowlatkhah HR, Zarean V, et al.

Compare the effect of aromatherapy using lavender and Damask rose essential oils on the level of anxiety and severity of pain following C-section: A double-blinded randomized clinical trial.

J Complement Integr Med. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA statement: an updated guideline for reporting systematic reviews.

Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials.

Nikolakopoulou A, Higgins JPT, Papakonstantinou T, Chaimani A, Del Giovane C, Egger M, et al. CINeMA: an approach for assessing confidence in the results of a network meta-analysis. PLoS Med. Alvarado-García PAA, Soto-Vásquez MR, Rosales-Cerquin LE, Jara-Aguilar DR, Benites SM.

Anxiolytic-like effect of luma chequen essential oil: a pilot study. Phcog J. CrossRef Full Text Google Scholar. Amzajerdi A, Keshavarz M, Montazeri A, Bekhradi R.

Effect of mint aroma on nausea, vomiting and anxiety in pregnant women. J Family Med Prim Care. Babatabar Darzi H, Vahedian-Azimi A, Ghasemi S, Ebadi A, Sathyapalan T, Sahebkar A. The effect of aromatherapy with rose and lavender on anxiety, surgical site pain, and extubation time after open-heart surgery: A double-center randomized controlled trial.

Bahadori H, Amiri MH, Sharafi H, Entezari A. The effect of aromatherapy with damask rose on anxiety, accuracy and job stress in operating room nurses. based med. Bakhsha F, Mazandarani M, Aryaei M, Jafari SY, Bayate H.

Phytochemical and anti-oxidant activity of Lavandula Angustifolia mill. Essential oil on preoperative anxiety in patients undergoing diagnostic curettage. Int J Womens Health Reprod Sci. Beyliklioglu A, Arslan S. Effect of lavender oil on the anxiety of patients before breast surgery.

J PeriAnesthesia Nurs. Eslami J, Ebrahimi A, Darvishi I, Momeni K, Akbarzadeh M. Relaxation effects of aromatherapy intervention on female and male anxiety: a randomized control trial. Shiraz E Medical J. Eslami J, Ebrahimi A, Hosseinkhani A, Khazaei Z, Darvishi I. The effect of aromatherapy using Lavender Lavandula angustifolia Miller and Citrus aurantium L.

extracts to treat anxiety of patients undergoing laparoscopic cholecystectomy: a randomized clinical trial in Iran. Biomed Res Ther. Farzaneh M, Zarean V, Abbasijahromi A, Mohit M, Amirkhani M, Badiyepeymaiejahromi Z, et al.

A randomized controlled trial examining the effect of aromatherapy using the damask rose essential oil on pre-operative anxiety levels. Nephrourol Mon. Fayazi S, Babashahi M, Rezaei M. The effect of inhalation aromatherapy on anxiety level of the patients in preoperative period.

Iran J Nurs Midwifery Res. PubMed Abstract Google Scholar. Rohi Ganji M, Jafari F, Rezaeian S, Abdi H, Farzaei MH, Khatony A.

The effect of inhalation aromatherapy and music therapy on anxiety in patients undergoing shockwave lithotripsy: a randomized controlled clinical trial. Haddadi M, Robat Sarpooshi H, Jaghouri E, Dehnabi A. The effect of aromatherapy with rose essential oil on apparent anxiety in patients with myocardial infarction.

Hamdamian S, Nazarpour S, Simbar M, Hajian S, Mojab F, Talebi A. Effects of aromatherapy with Rosa damascena on nulliparous women's pain and anxiety of labor during first stage of labor. J Integr Med. Hekmatpou D, Pourandish Y, Farahani PV, Parvizrad R. The effect of aromatherapy with orange essential oil on anxiety and pain in patients with fractured limbs admitted to an emergency ward: a randomized clinical trial.

Hu PH, Peng YC, Lin YT, Chang CS, Ou MC. Aromatherapy for reducing colonoscopy related procedural anxiety and physiological parameters: a randomized controlled study. Jirdehi MM, Monfared A, Ghanaei FM, Leyli EK.

Effect of aromatherapy with lavender and damask rose extracts on anxiety in endoscopy patients: a randomised trial. Gastrointest Nurs. Jodaki K, Abdi K, Mousavi MS, Mokhtari R, Asayesh H, Vandali V, et al. Effect of rosa damascene aromatherapy on anxiety and sleep quality in cardiac patients: a randomized controlled trial.

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Effect of inhalation aromatherapy on pain, anxiety, comfort, and cortisol levels during trigger point injection. Holist Nurs Pract. Mokhtari R, Ajorpaz NM, abdi K, Golitaleb M. The effects of Rosa damascene aromatherapy on anxiety and sleep quality in burn patients: a randomized clinical trial.

Moradi K, Ashtarian H, Danzima NY, Saeedi H, Bijan B, Akbari F, et al. Essential oil from citrus aurantium alleviates anxiety of patients undergoing coronary angiography: a single-blind, randomized controlled trial.

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Anxiolytic Effect of Citrus aurantium L. on Patients with Chronic Myeloid Leukemia Phytother Res. Rambod M, Rakhshan M, Tohidinik S, Nikoo MH.

The effect of lemon inhalation aromatherapy on blood pressure, electrocardiogram changes, and anxiety in acute myocardial infarction patients: a clinical, multi-centered, assessor-blinded trial design. Reyes MCGM, Reyes MCGM, Ribay KGL, Paragas ED.

Effects of sweet orange aromatherapy on pain and anxiety during needle insertion among patients undergoing hemodialysis: A quasi-experimental study.

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The effect of lavender on anxiety and hemodynamic status before septorhinoplasy and rhinoplasty. Soleimani M, Kashfi LS, Mirmohamadkhani M, Ghods AA. The effect of aromatherapy with peppermint essential oil on anxiety of cardiac patients in emergency department: a placebo-controlled study. Soto-Vasquez MR, Alvarado-Garcia PAA.

Anxiolytic-like effect of Lippia alba essential oil: a randomized, placebo-controlled trial. Complement med res. Stanley PF, Wan LF, Karim RA, A. Randomized prospective placebo-controlled study of the effects of lavender aromatherapy on preoperative anxiety in cataract surgery patients.

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Conclusions: Overview of clinical trials conducted with Citrus aurantium or Citrus sinensis on people with anxiety showed that inhalation or oral administration of Citrus aurantium and inhalation of Citrus sinensis can exert beneficial effects on anxiety; however, because of incomplete accuracy in the reporting of methodology, further more complete clinical studies are warranted.

Abstract Objective: The aim of this review is to analyze preclinical and clinical studies investigating the anxiety effects of Citrus aurantium or Citrus sinensis essential oils EOs. Essential Oil Aromatherapy on Mood States, Parasympathetic Nervous System Activity, and Salivary Cortisol Levels in 41 Healthy Females.

Forsch Komplementmed. Goes TC, Ursulino FR, Almeida-Souza TH, Alves PB, Teixeira-Silva F. Effect of Lemongrass Aroma on Experimental Anxiety in Humans.

Hu PH, Peng YC, Lin YT, Chang CS, Ou MC. Aromatherapy for Reducing Colonoscopy Related Procedural Anxiety and Physiological Parameters: A Randomized Controlled Study.

Choi SY, Kang P, Lee HS, Seol GH. Effects of Inhalation of Essential Oil of Citrus aurantium L. amara on Menopausal Symptoms, Stress, and Estrogen in Postmenopausal Women: A Randomized Controlled Trial.

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ex Tanaka on Mood States and Salivary Chromogranin A as an Endocrinologic Stress Marker. Ueki S, Niinomi K, Takashima Y, et al. Effectiveness of aromatherapy in decreasing maternal anxiety for a sick child undergoing infusion in a paediatric clinic.

Complement Ther Med. Goes TC, Antunes FD, Alves PB, Teixeira-Silva F. Effect of Sweet Orange Aroma on Experimental Anxiety in Humans. Chaves neto G, Braga JEF, Alves MF, et al.

Anxiolytic Effect of Citrus aurantium L. in Crack Users. American Heart Association. More than million Americans have high blood pressure, AHA says. Kim IH, Kim C, Seong K, Hur MH, Lim HM, Lee MS.

Essential Oil Inhalation on Blood Pressure and Salivary Cortisol Levels in Prehypertensive and Hypertensive Subjects. Moss M, Hewitt S, Moss L, Wesnes K.

Modulation of cognitive performance and mood by aromas of peppermint and ylang-ylang. Int J Neurosci. Akpinar B. The effects of olfactory stimuli on scholastic performance. The Irish Journal of Education. Use limited data to select advertising. Create profiles for personalised advertising.

Use profiles to select personalised advertising. Create profiles to personalise content. Use profiles to select personalised content. Measure advertising performance. Measure content performance. Understand audiences through statistics or combinations of data from different sources.

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Management Techniques.

Anxiety was assessed with the Spielberger State-Trait Anxiety Inventory STAI , which is currently the most extensively used inventory for evaluating anxiety levels and consists of two parts, SAI and TAI.

The changes of SAIS and TAIS were used as the primary outcomes to evaluate the therapeutic effects of EOs on anxiety in this study. Pairwise meta-analyses indicated that EOs could effectively reduce SAIS and TAIS.

Further network meta-analyses showed that jasmine was the most effective EO in reducing SAIS, followed by citrus aurantium L.

Vital signs are considered to be important physiological indicators of anxiety indirectly Emotional signals of anxiety are sent from the amygdala and hippocampus of the limbic system to the hypothalamus, activating the hypothalamic-pituitary-adrenocortical HPA axis Moreover, anxiety could cause increased sympathetic excitability, which leads to increased blood pressure, HR and RR.

Herein, vital signs may be helpful in objective assessment of anxiety. Our results found that EOs dramatically reduced SBP and HR, and had a tendency to lower DBP and RR, but were not statistical significance.

Our findings were consistent with previous conventional meta-analyses focusing on EOs for anxiety. Indicating that EOs significantly alleviate anxiety 62 , Additionally, our results further confirmed the results of a previous meta-analysis pooling animal experiments from a clinical perspective Pairwise meta-analyses suggested that EOs had a stronger total therapeutic effect on state anxiety than trait anxiety.

This was consistent with the results of an earlier meta-analysis Moreover, we further found that EOs were effective in reducing state anxiety regardless of the cumulative duration of the intervention. However, EOs could not alleviate trait anxiety when the cumulative intervention time exceeded min, with the largest effect size within 10 min of the intervention time.

Thus, the efficacy of EOs on trait anxiety was more inclined to immediate intervention. The reason for these results may be related to the mechanisms of state anxiety and trait anxiety.

Previous study has shown that state anxiety and trait anxiety are mapped differently in the brain State anxiety is a transient intense emotional state associated with a temporary increase in sympathetic nervous system activity without a specific pathological condition, and it can disappear with the removal of stress or danger Trait anxiety is a personality tendency that remains stable over time It may be associated with different psychopathological conditions and continuous high arousal.

It does not disappear easily when the stress is relieved, and people with high trait anxiety are easy to develop anxiety disorders Therefore, EOs have a more obvious therapeutic effect on state anxiety.

Trait anxiety symptoms could restore to their stable personality characteristics soon, although a short period of EOs stimulation can effectively alleviate them.

Network meta-analyses suggested that that jasmine was the strongest type of EO for reducing SAIS. Contrary to previous studies that suggested that jasmine could only improve nervousness and not reduce symptoms of anxiety and stress 58 , our study found that jasmine significantly improved state anxiety symptoms and thus reduced SAIS.

Pharmacological studies suggested that the mechanisms by which jasmine reduced SAIS may be related to the increase of β wave in the frontal cortex center and left occipital cortex caused by olfactory stimulation However, only one study explored the efficacy of jasmine on anxiety, so the credibility of this result is low and more researches are indispensable to confirm this result.

Considering that there was only one RCT reporting jasmine for anxiety, the results may be highly biased and less credible. ranked first in reducing TAIS. Furthermore, citrus aurantium L. could dramatically reduce the objective indicators reflecting anxiety, including SBP, DBP, and HR.

The anxiolytic activity of citrus aurantium L. was mediated by the serotonergic system 5-HT1A receptor 7 , Interestingly, citrus aurantium L. significantly ameliorated anxiety and did not interfere with physiological levels of melatonin and corticosterone Thus, it could be reasonably inferred that citrus aurantium L.

EO has the greatest benefits in treating anxiety. Previous studies on the treatment of anxiety with lemon EO are still somewhat controversial. An RCT investigating the effect of lemon EO on anxiety during the active phase in primiparas showed that lemon EO had no effect on anxiety However, another multicenter, assessor-blinded trial demonstrated the efficacy of aromatherapy with lemon EO inhalation in relieving anxiety To the best of our knowledge, this study was the first meta-analysis of lemon EO for anxiety.

Our paired meta-analysis confirmed that lemon EO significantly ameliorated trait anxiety, but did not alleviate state anxiety.

Further, our network meta-analysis found that lemon ranked second among all EOs in the aspect of reducing TAIS. The main component of lemon is s-limonene.

The anti-trait anxiety effect of lemon is closely related to the 5-serotonergic pathway, particularly through the 5-HT 1A receptor. In addition, lemon significantly accelerated the metabolic turnover of dopamine DA in the hippocampus and 5-HT in the prefrontal cortex and striatum Current network meta-analyses also found that damask rose was the third most anti-anxiety EO after jasmine and citrus aurantium L.

in reducing SAIS. However, damask rose could not reduce TAIS. This finding was in line with a previous meta-analysis that pooled the studies about damask rose mill on anxiety, indicating that damask rose dramatically decreased state anxiety but had no obvious effect on trait anxiety Damask rose mainly contains isoflavones.

On one hand, isoflavones can directly bind to GABA receptors to reduce anxiety On the other hand, isoflavones inhibit inducible nitric oxide synthase iNOS and then reduce the production of nitric oxide, which regulates the concentration of neurotransmitters such as serotonin, dopamine, norepinephrine and glutamate, and inhibits the activation of soluble guanylate cyclase, which in turn reduces the production of cyclic guanosine monophosphate cGMP , thereby reducing anxiety The number of studies using lavender as an intervention were the largest for both state anxiety and trait anxiety.

Our results indicated that the efficacy of lavender in reducing SAIS and TAIS was comparable. This was consecutive with the results of previous meta-analyses 12 , Researches in pharmacology have found that the anxiolytic effects of lavender are related to the interaction of its monoterpene components such as linalool and linalyl acetate with NMDA receptors.

Additionally, the anxiolytic effect could be partially attributed to its inhibition of serotonin transporter SERT and protection of SH-SY5Y cells from hydrogen peroxide-induced neurotoxicity Results of an RCT using mint intervention in emergency cardiac patients found that mint reduced anxiety and its induced increase in respiratory rate.

In keeping with this, our study indicated that mint could significantly reduce SAIS. Mint affects the hypothalamus by stimulating the olfactory pathway, which reduces the secretion of adrenocorticotropin-releasing hormone, adrenocorticotropin and cortisol, ultimately reducing anxiety 77 , Finally, the results of our study showed that neither geranium nor copaiba could reduce anxiety, and copaiba ranked the worst.

However, the RCTs on geranium and copaiba for anxiety each only one was included, which tends to cause significant heterogeneity, so these results should be interpreted with caution and more studies are needed to confirm these conclusions in the future.

No adverse events were reported in any of the trials, and their safety remains uncertain. EOs gas molecules can be inhaled and then transported to the central nervous system after entering the bloodstream through the lung, or they can cross the neuronal network of the olfactory system and directly reach and act on the corresponding brain areas, causing activation in different brain regions to induce anxiolytic effects 8.

Several studies concluded that EOs appeared to be well tolerated, as inhalation of different doses of EOs did not cause changes or show signs of toxicity In summary, the most effective was jasmine intervention with a cumulative duration of 30 to min for state anxiety, while citrus aurantium L.

intervention with a cumulative duration of 10 min or less were most efficacious for trait anxiety. Nevertheless, combining self-reported SAIS and TAIS with objective indicators, a cumulative intervention of 10 to 30 min with citrus aurantium L.

was optimal, because it reduced not only SAIS and TAIS, but also SBP, DBP, and HR. However, it is worth noting that due to the lack of reports on adverse effects, the studies with EOs included in this study could not be fully used to rank the safety of EOs. This limitation requires special attention in future studies.

The current study has several strengths. We developed rigorous eligibility criteria, conducted a comprehensive search, assessed the risk of bias, addressed key outcomes, performed valuable sensitivity and subgroup analyses, and rated the certainty of the evidence using CINeMA by GRADE criteria.

For the first time, a network meta-analysis was used to compare the differences in efficacy of various types of commonly used EOs, providing clinicians with a rational choice of essential oils for the treatment of anxiety.

However, the study also had a number of limitations. To comprehensively summarize the efficacy of EOs, we included a wide range of interventions that varied in terms of number of interventions, duration, dose, co-morbidities, or causes of anxiety, so that there may be large heterogeneity across trials.

Moreover, most of the trials had a high risk of bias and low or very low quality of evidence. Therefore, the credibility of the results was low and we need to be cautious in interpreting the results.

In addition, the intrinsic characteristics of EOs, such as the species, place of origin, and the intervention procedures of EOs, including extraction method, exposure concentration, method of exposure, duration of exposure, and route of administration, could affect the amount of active ingredients of EOs in the body and thus the efficacy of EOs.

Thus, only by controlling for these variables can the efficacy of EOs for anxiety in different clinical trials be more accurately determined. What's more, more high-quality RCTs that rigorously document the characteristics and intervention procedures of EO, may be needed in the future to improve the reliability of meta-analysis conclusions.

This study confirmed that EOs may be effective in treating anxiety, and citrus aurantium L. appeared to be the most recommended type, as it showed a large effect size in reducing both SAIS and TAIS. However, due to the obvious heterogeneity among the included studies, our results should be interpreted with caution and more high-quality RCTs are expected to confirm this result in the future.

LT and F-fL: conceptualization, visualization, investigation, and writing-original draft. L-zL and C-gF: conceptualization, visualization, and writing — review and editing. X-cM: investigation and writing — review and editing.

Y-xP: formal analysis and writing — review and editing. J-mL and HQ: funding acquisition and writing — review and editing. All authors contributed to the article and approved the submitted version. This study was supported by the Youth Talent Promotion Project of China Association for Science and Technology no.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers.

Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Krause KR, Chung S, Adewuya AO, Albano AM, Babins-Wagner R, Birkinshaw L, et al.

International consensus on a standard set of outcome measures for child and youth anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder. Lancet Psychiatry.

doi: PubMed Abstract CrossRef Full Text Google Scholar. Twenge JM, Joiner TEUS. Census Bureau-assessed prevalence of anxiety and depressive symptoms in and during the COVID pandemic. Depress Anxiety. Santomauro DF, Herrera AM, Shadid J, Zheng P, Ashbaugh C, Pigott DM. Global prevalence and burden of depressive and anxiety disorders in countries and territories in due to the COVID pandemic.

Altmann H, Stahl ST, Gebara MA, Lenze EJ, Mulsant BH, Blumberger DM, et al. Coprescribed Benzodiazepines in Older Adults Receiving Antidepressants for Anxiety and Depressive Disorders: Association With Treatment Outcomes.

J Clin Psychiatry. Malcolm BJ, Tallian K. Essential oil of lavender in anxiety disorders: Ready for prime time? Ment Health Clin. Cui J, Li M, Wei Y, Li H, He X, Yang Q, et al.

Inhalation aromatherapy via brain-targeted nasal delivery: natural volatiles or essential oils on mood disorders. Wang ZJ, Heinbockel T. Essential oils and their constituents targeting the gabaergic system and sodium channels as treatment of neurological diseases.

Zhang N, Yao L. Anxiolytic effect of essential oils and their constituents: a review. J Agric Food Chem. Lizarraga-Valderrama LR. Effects of essential oils on central nervous system: focus on mental health. Phytother Res.

Chung YH, Chen SJ, Lee CL, Wu CW, Chang YS. Relaxing Effects of Breathing Pseudotsuga menziesii and Lavandula angustifolia Essential Oils on psychophysiological status in older adults.

Public Health. Yvon Y, Raoelison EG, Razafindrazaka R, Randriantsoa A, Romdhane M, Chabir N, et al. Relation between chemical composition or antioxidant activity and antihypertensive activity for six essential oils. J Food Sci.

Donelli D, Antonelli M, Bellinazzi C, Gensini GF, Firenzuoli F. Effects of lavender on anxiety: a systematic review and meta-analysis. Kim M, Nam ES, Lee Y, Kang HJ. Effects of lavender on anxiety, depression, and physiological parameters: systematic review and meta-analysis. Asian Nurs Res.

Abbasijahromi A, Hojati H, Nikooei S, Jahromi HK, Dowlatkhah HR, Zarean V, et al. Compare the effect of aromatherapy using lavender and Damask rose essential oils on the level of anxiety and severity of pain following C-section: A double-blinded randomized clinical trial.

J Complement Integr Med. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA statement: an updated guideline for reporting systematic reviews.

Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. Nikolakopoulou A, Higgins JPT, Papakonstantinou T, Chaimani A, Del Giovane C, Egger M, et al. CINeMA: an approach for assessing confidence in the results of a network meta-analysis.

PLoS Med. Alvarado-García PAA, Soto-Vásquez MR, Rosales-Cerquin LE, Jara-Aguilar DR, Benites SM. Anxiolytic-like effect of luma chequen essential oil: a pilot study. Phcog J.

CrossRef Full Text Google Scholar. Amzajerdi A, Keshavarz M, Montazeri A, Bekhradi R. Effect of mint aroma on nausea, vomiting and anxiety in pregnant women. J Family Med Prim Care. Babatabar Darzi H, Vahedian-Azimi A, Ghasemi S, Ebadi A, Sathyapalan T, Sahebkar A. The effect of aromatherapy with rose and lavender on anxiety, surgical site pain, and extubation time after open-heart surgery: A double-center randomized controlled trial.

Bahadori H, Amiri MH, Sharafi H, Entezari A. The effect of aromatherapy with damask rose on anxiety, accuracy and job stress in operating room nurses. based med.

Bakhsha F, Mazandarani M, Aryaei M, Jafari SY, Bayate H. Phytochemical and anti-oxidant activity of Lavandula Angustifolia mill. Essential oil on preoperative anxiety in patients undergoing diagnostic curettage. Int J Womens Health Reprod Sci. Beyliklioglu A, Arslan S. Effect of lavender oil on the anxiety of patients before breast surgery.

J PeriAnesthesia Nurs. Eslami J, Ebrahimi A, Darvishi I, Momeni K, Akbarzadeh M. Relaxation effects of aromatherapy intervention on female and male anxiety: a randomized control trial.

Shiraz E Medical J. Eslami J, Ebrahimi A, Hosseinkhani A, Khazaei Z, Darvishi I. The effect of aromatherapy using Lavender Lavandula angustifolia Miller and Citrus aurantium L.

extracts to treat anxiety of patients undergoing laparoscopic cholecystectomy: a randomized clinical trial in Iran. Biomed Res Ther. Farzaneh M, Zarean V, Abbasijahromi A, Mohit M, Amirkhani M, Badiyepeymaiejahromi Z, et al.

A randomized controlled trial examining the effect of aromatherapy using the damask rose essential oil on pre-operative anxiety levels.

Nephrourol Mon. Fayazi S, Babashahi M, Rezaei M. The effect of inhalation aromatherapy on anxiety level of the patients in preoperative period. Iran J Nurs Midwifery Res. PubMed Abstract Google Scholar. Rohi Ganji M, Jafari F, Rezaeian S, Abdi H, Farzaei MH, Khatony A.

The effect of inhalation aromatherapy and music therapy on anxiety in patients undergoing shockwave lithotripsy: a randomized controlled clinical trial. Haddadi M, Robat Sarpooshi H, Jaghouri E, Dehnabi A.

The effect of aromatherapy with rose essential oil on apparent anxiety in patients with myocardial infarction. Hamdamian S, Nazarpour S, Simbar M, Hajian S, Mojab F, Talebi A.

Effects of aromatherapy with Rosa damascena on nulliparous women's pain and anxiety of labor during first stage of labor. J Integr Med. Hekmatpou D, Pourandish Y, Farahani PV, Parvizrad R. The effect of aromatherapy with orange essential oil on anxiety and pain in patients with fractured limbs admitted to an emergency ward: a randomized clinical trial.

Hu PH, Peng YC, Lin YT, Chang CS, Ou MC. Aromatherapy for reducing colonoscopy related procedural anxiety and physiological parameters: a randomized controlled study. Jirdehi MM, Monfared A, Ghanaei FM, Leyli EK. Effect of aromatherapy with lavender and damask rose extracts on anxiety in endoscopy patients: a randomised trial.

Gastrointest Nurs. Jodaki K, Abdi K, Mousavi MS, Mokhtari R, Asayesh H, Vandali V, et al. Effect of rosa damascene aromatherapy on anxiety and sleep quality in cardiac patients: a randomized controlled trial.

Complement Ther Clin Pract. Jokar M, Delam H, Bakhtiari S, Paki S, Askari A, Bazrafshan MR, et al. The Effects of inhalation lavender aromatherapy on postmenopausal women's depression and anxiety: a randomized clinical trial.

JNP-J Nurse Pract. Kasar KS, Yildirim Y, Senuzun Aykar F, Uyar M, Sagin FG, Atay S. Effect of inhalation aromatherapy on pain, anxiety, comfort, and cortisol levels during trigger point injection. Holist Nurs Pract. Mokhtari R, Ajorpaz NM, abdi K, Golitaleb M. The effects of Rosa damascene aromatherapy on anxiety and sleep quality in burn patients: a randomized clinical trial.

Moradi K, Ashtarian H, Danzima NY, Saeedi H, Bijan B, Akbari F, et al. Essential oil from citrus aurantium alleviates anxiety of patients undergoing coronary angiography: a single-blind, randomized controlled trial.

Chin J Integr Med. Moslemi F, Alijaniha F, Naseri M, Kazemnejad A, Charkhkar M, Heidari MR. Citrus aurantium aroma for anxiety in patients with acute coronary syndrome: a double-blind placebo-controlled trial. J Altern Complement Med. Özkaraman A, Dügüm Ö, Yilmaz HÖ, Yeşilbalkan ÖU.

Aromatherapy: The effect of lavender on anxiety and sleep quality in patients treated with chemotherapy. Clin J Oncol Nurs. Pasyar N, Rambod M, Araghi F. The effect of bergamot orange essence on anxiety, salivary cortisol, and alpha amylase in patients prior to laparoscopic cholecystectomy: A controlled trial study.

Pimenta FCF, Alves MF, Pimenta MBF, Melo SAL, de Almeida AAF, Leite JR, et al. Anxiolytic Effect of Citrus aurantium L. on Patients with Chronic Myeloid Leukemia Phytother Res.

Rambod M, Rakhshan M, Tohidinik S, Nikoo MH. The effect of lemon inhalation aromatherapy on blood pressure, electrocardiogram changes, and anxiety in acute myocardial infarction patients: a clinical, multi-centered, assessor-blinded trial design.

Reyes MCGM, Reyes MCGM, Ribay KGL, Paragas ED. Effects of sweet orange aromatherapy on pain and anxiety during needle insertion among patients undergoing hemodialysis: A quasi-experimental study. Nurs Forum. Sahin S, Tokgöz B, Demir G. Effect of lavender aromatherapy on arteriovenous fistula puncture pain and the level of state and trait anxiety in hemodialysis patients: a randomized controlled trial.

Pain Manag Nurs. Saritas SC, Buyukbayram Z, Serin EK, Bilgic Y. Effects of lavender oil intervention before endoscopic retrograde cholangiopancreatography on patients' vital signs, pain and anxiety: A randomized controlled study. Explore-J Sci Heal.

Shirzad M, Nasiri E, Hesamirostami M, Akbari H. The effect of lavender on anxiety and hemodynamic status before septorhinoplasy and rhinoplasty. Soleimani M, Kashfi LS, Mirmohamadkhani M, Ghods AA. The effect of aromatherapy with peppermint essential oil on anxiety of cardiac patients in emergency department: a placebo-controlled study.

Soto-Vasquez MR, Alvarado-Garcia PAA. Anxiolytic-like effect of Lippia alba essential oil: a randomized, placebo-controlled trial. Complement med res. Stanley PF, Wan LF, Karim RA, A.

Randomized prospective placebo-controlled study of the effects of lavender aromatherapy on preoperative anxiety in cataract surgery patients.

J Perianesth Nurs. Tahmasbi H, Abasi E, Zafari M, Hasan P, Abdi H. The association of state anxiety and factors that are related to increased anxiety before coronary angiography.

Google Scholar. Tahmasebi H, Poorkhiz A, Joubari HA. Comparing the aromatherapeutic effects of orange and lavender essential oils on anxiety and physiological indicators in patients undergoing coronary angiography: a clinical trial study.

Med Surg Nurs J. Wen X, Shi J, Tan W, Jiang H, Wang D, Su J, et al. Effects of aromatherapy and music therapy on patients' anxiety during MRI examinations: a randomized controlled trial. Eur Radiol. Fakari FR, Tabatabaeichehr M. Comparing the effect of geranium and orange essential oils on level of anxiety during delivery.

J Mazandaran Univ Med Sci. An aromatherapy remedy with a sweet and spicy aroma, neroli essential oil is sometimes used to ease anxiety. Proponents claim that breathing in the scent of this essential oil sourced from the flowers of the bitter orange tree can help promote calm and stop excessive worrying.

Research on the effects of neroli citrus aurantium L. essential oil is fairly limited. In a study published in Hepato-gastroenterology , for instance, participants inhaled either neroli oil or a control sunflower oil before undergoing a colonoscopy.

Inhalation of neroli is used as a sedative in some health centers outside the United States. A study showed improvement in menopausal symptoms in menopausal women and a decrease in PMS symptoms in university subjects with inhalation of neroli.

A study using olfactory stimuli with lemon found that it improved concentration, mood, and memory in fourth-grade pupils. Lemon essential oil , sourced from the leaves of the lemon plant, have been found in preliminary studies in animals to have sedative and anxiety-reducing properties.

Rich in linalool a compound found in lemons, oranges, basil, mangos, grapes, lavender, and other foods and flowers , practitioners of aromatherapy often use lemon essential oil to relieve stress, improve mood, promote sleep, and ease symptoms of depression.

In the UK, personal aromatherapy inhaler devices have been used in a cancer center to promote relaxation and relieve nausea, with lemon essential oil being one of the most commonly used scents. A scent long used in aromatherapy, Japanese yuzu essential oil is sometimes touted as a natural solution for stress relief.

It's thought that breathing in the citrus fragrance of this essential oil can suppress sympathetic nervous system activity responsible for the body's fight or flight response and, in turn, promote relaxation.

Ten minutes of yuzu scent inhalation was found to decrease salivary chromogranin A an indicator of stress and sympathetic nervous system activity and negative emotional stress, according to a small study.

In a study published in Complementary Therapies in Medicine , inhalation of yuzu essential oil decreased anxiety levels in mothers caring for sick children at a pediatric clinic.

Need to unwind? Preliminary research suggests that breathing in the sweet aroma of orange essential oil may help alleviate your anxiety. A s tud y published in the Journal of Alternative and Complementary Medicine , for instance, found that participants who inhaled sweet orange essential oil did not have an increase in anxiety or tension during an anxiety-inducing situation, unlike those who inhaled a control aroma tea tree oil or a placebo.

Another type of orange essential oil known as bitter orange Citrus aurantium was found to reduce anxiety during a simulated public speaking event, according to a study.

More than million Americans have high blood pressure, a major risk factor for heart disease. Preliminary research also suggests that ylang ylang essential oil a substance long used in aromatherapy may be of some benefit to people with high blood pressure.

For instance, a small study published in found that breathing in the scent of an aromatherapy blend containing ylang ylang essential oil led to a decrease in blood pressure and stress-hormone levels.

While it's too soon to recommend ylang ylang essential oil for blood pressure control, incorporating aromatherapy with ylang ylang into your self-care routine might offer stress-reducing benefits that could enhance your overall health. Although ylang-ylang can be relaxing, don't use it before an exam.

One study comparing ylang-ylang aroma with peppermint aroma found that while peppermint enhanced memory, ylang-ylang caused calmness but impaired memory and lengthened processing speed. An aromatherapy oil with a sweet, woody scent, frankincense essential oil is sometimes used to unwind and ease stress.

Typically sourced from the resin of the boswellia tree, frankincense essential oil is also said to alleviate anxiety. So far, research on the stress-relieving effects of frankincense essential oil is very limited. While there's currently a lack of scientific support for the claim that frankincense can fight stress, it's possible that using this essential oil in combination with relaxing oils like lavender, rose , and orange drops of the oil onto a cloth or tissue could help you calm down.

When using essential oils, make sure to combine the oil with a carrier oil such as jojoba, sweet almond, or avocado , before applying it to your skin or adding it to your bath. You can also use an aromatherapy diffuser or vaporizer, or sprinkle a few drops of the oil onto a cloth or tissue and then breathe in its aroma.

Despite aromatherapy's long history of use, there is still a lack of large-scale clinical trials exploring the effects of aromatherapy on anxiety. While an essential oil combined with a carrier oil and massaged into your skin or added to a bath may help you unwind after a stressful day, consult your healthcare provider before using essential oils for any condition.

While nearly everyone experiences stress every now and then, it's important to watch out for signs of an anxiety disorder. If you're experiencing symptoms like a near-constant presence of worry or tension, difficulty concentrating, and sleep disruption, or have other symptoms that concern you, be sure to talk to your healthcare provider.

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Bergamot Citrus bergamia Essential Oil Inhalation Improves Positive Feelings in the Waiting Room of a Mental Health Treatment Center: A Pilot Study. Phytother Res.

Watanabe E, Kuchta K, Kimura M, Rauwald HW, Kamei T, Imanishi J. Essential Oil Aromatherapy on Mood States, Parasympathetic Nervous System Activity, and Salivary Cortisol Levels in 41 Healthy Females.

Forsch Komplementmed. Goes TC, Ursulino FR, Almeida-Souza TH, Alves PB, Teixeira-Silva F. Effect of Lemongrass Aroma on Experimental Anxiety in Humans. Hu PH, Peng YC, Lin YT, Chang CS, Ou MC. Aromatherapy for Reducing Colonoscopy Related Procedural Anxiety and Physiological Parameters: A Randomized Controlled Study.

Choi SY, Kang P, Lee HS, Seol GH. Effects of Inhalation of Essential Oil of Citrus aurantium L. amara on Menopausal Symptoms, Stress, and Estrogen in Postmenopausal Women: A Randomized Controlled Trial. Evid Based Complement Alternat Med. Dyer J, Cleary L, Ragsdale-Lowe M, McNeill S, Osland C.

The use of aromasticks at a cancer centre: a retrospective audit. Complement Ther Clin Pract. Matsumoto T, Asakura H, Hayashi T.

Effects of Olfactory Stimulation from the Fragrance of the Japanese Citrus Fruit Yuzu Citrus junos Sieb. ex Tanaka on Mood States and Salivary Chromogranin A as an Endocrinologic Stress Marker. Ueki S, Niinomi K, Takashima Y, et al.

Effectiveness of aromatherapy in decreasing maternal anxiety for a sick child undergoing infusion in a paediatric clinic. Complement Ther Med.

Goes TC, Antunes FD, Alves PB, Teixeira-Silva F. Effect of Sweet Orange Aroma on Experimental Anxiety in Humans. Chaves neto G, Braga JEF, Alves MF, et al. Anxiolytic Effect of Citrus aurantium L. in Crack Users. American Heart Association.

More than million Americans have high blood pressure, AHA says.

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Inhale slowly and deeply for minutes. Adults: Add 60 drops to 10ml of carrier oil for local application to shoulders and back of neck.

Start with the lower dosage and increase if well tolerated and if symptoms persist. Adults: Add drops to a full bath. Scatter the drops of the essential oil into a full bath and swish the water gently so that the oil forms a film on the top of it. Alternatively, mix the essential oil with the same amount of shampoo before adding it to the bath.

For prolonged use, consult a health care practitioner. WARNINGS Keep out of reach of children. Alleviate symptoms of mild anxiety such as restlessness and nervousness by inducing relaxation.

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Formulation guarantee. diffuser guarantee. Close Shipping Please allow business days to process and pack your order. Boxes, Rural, remote areas, and Territories may take additional days. The consistency model and the inconsistency model were applied to evaluate the hypothesis of overall consistency between networks in the meta-analysis.

Then the deviance information criteria DIC of the two models were compared, and the model with the lower DIC value was selected.

A consistent model was accepted when there were no inconsistencies. Due to there were closed-loop structures between interventions, we conducted a loop inconsistency test to determine the existence of inconsistency according to the inconsistency factor IF value.

A WMD of 0. The Higgins I-squared I 2 index was used to estimate the potential heterogeneity. Random effects models were chosen to compare treatment efficacy considering the clinical and methodological heterogeneity between studies. To rank the interventions, the probability of each intervention being ranked first, second, etc was calculated.

The efficacy of each intervention was also ranked by calculating the surface under the cumulative ranking curve SUCRA. In view of the significant heterogeneity, exploratory subgroup analyses were conducted based on type of EO, country, cause of anxiety, and accumulative duration of intervention for SAIS, TAIS, SBP, DBP, HR, and RR.

Meta-regression analyses were performed based on the accumulative duration of intervention, baseline SAIS and baseline TAIS.

Potential publication bias was evaluated by visual assessment of funnel plots. Conventional pairwise meta-analyses were performed by STATA version Network meta-analyses were conducted using R version 4. Network pictures were created to visualize network geometry and node connectivity.

The screening process of a PRISMA study flow diagram was shown in Figure 1. Two hundred and eighty-eight articles were potentially eligible records whose full text was reviewed.

Finally, 44 articles were included in present review 14 , 18 — Figure 1. Flow diagram of study identification, screening, eligibility assessment, and inclusion. The second highest number of trials was conducted in Turkey, with eight. The EOs involved lavender, Rosa rugosa Thunb. damask rose , Citrus citrus aurantium L.

Greene lippia alba , Mentha haplocalyx Briq. mint , Citrus limon L. lemon , Eucalyptus citriodora Hook. lippia citriodora , Pelargonium hortorum Bailey geranium , Jasminum sambac L. jasmine , and Balsam capivi, jesuits'resin copaiba. Fourteen trials explored the effects of EOs on operation-related anxiety, while 12 trials about the invasive examinations induced anxiety.

Overall, 44 studies involving 3, anxiety patients 1, patients in EOs group and patients in control group were included 14 , 18 — The detailed characteristics of the studies included in this review were listed in Table 1. As shown in Figures 2 , 3 , all included trials were assessed for risk of bias RoB 2.

The remaining 16 studies were at low risk of bias 14 , 19 , 21 , 26 , 28 , 34 , 39 — 41 , 47 , 49 , 52 , 53 , 56 , 57 , 60 , with all assessed domains in these studies being at low risk. Forty-four trials 50 study arms , including 3, anxiety patients 1, patients in EOs group vs.

Figure 4. Direct pairwise random-effects meta-analyses of SAIS. SAIS, State Anxiety Inventory scores. A total of 14 studies 17 study arms , including anxiety patients patients in EOs group vs. Figure 5. Direct pairwise random-effects meta-analyses of TAIS.

TAIS, Trait Anxiety Inventory scores. The effects of EOs on DBP and RR were also evaluated. Figure 6. Direct pairwise random-effects meta-analyses of vital signs. A Systolic blood pressure SBP ; B Diastolic blood pressure DBP ; C Heart rate HR ; D Respiratory rate RR.

The network consisted of 38 studies with two arms and 6 studies with three arms reporting on 10 different EOs 20 arms on lavender , 11 damask rose , 9 citrus aurantium L. The network formed by the direct comparisons between different interventions was shown in Figure 7A. Figure 7. Network meta-analysis of available comparisons between 10 essential oils and the control.

A State Anxiety Inventory scores SAIS ; B Trait Anxiety Inventory scores TAIS. Line width is proportional to the number of trials that included each pair of treatments direct comparisons. Circle size is proportional to the total number of participants for each treatment in the network.

The effect sizes for the differences between all EOs were presented in league table Table 2. Second only to jasmine is citrus aurantium L. Figure 8. Network meta-analysis for comparisons with the control group of SAIS A and TAIS B.

SAIS, State Anxiety Inventory scores; TAIS, Trait Anxiety Inventory scores. As shown in Table 3 , the SUCRA indicated that jasmine was the best ranked intervention with a SUCRA of The control intervention had the lowest SUCRA of Figure 9.

SUCRA figure of SAIS A and TAIS B. Figure Ranking probability plot of SAIS A and TAIS B. There are 3 loops were formed between the pairwise comparisons, and the loop inconsistency test indicated that there was no significant loop inconsistency Table 4.

However, the overall heterogeneity remained high This network consisted of 14 RCTs, including 11 studies with two arms and 3 studies with three arms, involving 7 different EOs 7 lavender , 3 damask rose , two arms each on citrus aurantium L.

and lippia alba , one arm each on lippia citriodora, lemon , and copaiba , and 17 arms were control groups. The most applied EO was lavender. The network formed by the direct comparisons between different interventions was shown in Figure 7B.

The effect sizes for the differences between all EOs on TAIS were presented in league table Table 2. Citrus aurantium L.

As shown in Table 3 , the SUCRA indicated that citrus aurantium L. was the highest ranked intervention with a SUCRA of Subgroup analyses stratified by type of EOs, country, causes of anxiety, and cumulative duration of intervention were performed Supplementary Table S5 and Figure S5.

According to the results of subgroups by types of EOs, most EOs could significantly reduce SAIS, TAIS, SBP, DBP, HR or RR. However, citrus aurantium L. With respect to the country, studies from Iran, Peru, and Turkey found that EOs could significantly reduce SAIS and TAIS.

Studies in Brazil and Philippines have only reported that EOs reduced SAIS. EOs were poorly efficacious in delivery-related anxiety, failing to reduce TAIS, SBP, DBP, HR, and RR. Table 5. Meta-regression of weighted mean difference according to cumulative duration of intervention.

Additionally, the exclusion of small studies did not generate a reduction in heterogeneity Supplementary Figure S6A. Interestingly, in the sensitivity analyses to test the effect of smaller sample sizes on the overall weighted mean, studies using the Trait Anxiety Inventory as an evaluator showed the same effect size trends as the State Anxiety Inventory.

The exclusion of small studies did not decrease the heterogeneity Supplementary Figure S6B. Supplementary Figure S7 presented the funnel plot of the publication bias.

The distribution of most dots in the figure was relatively symmetrical and uniform, indicating little evidence of publication bias. CINeMA application was used to conduct GRADE judgments. The therapeutic effect of EO on anxiety was measured by SAI inventory, twenty-six of comparisons were judged to be low rating, with twenty-nine very low comparisons while measured by TAI inventory, eighteen of comparisons were judged as low rating, with ten very low comparisons Supplementary Tables S3.

To the best of our knowledge, this was the first study about different EOs for treating anxiety using Bayesian network meta-analysis. Anxiety was assessed with the Spielberger State-Trait Anxiety Inventory STAI , which is currently the most extensively used inventory for evaluating anxiety levels and consists of two parts, SAI and TAI.

The changes of SAIS and TAIS were used as the primary outcomes to evaluate the therapeutic effects of EOs on anxiety in this study.

Pairwise meta-analyses indicated that EOs could effectively reduce SAIS and TAIS. Further network meta-analyses showed that jasmine was the most effective EO in reducing SAIS, followed by citrus aurantium L. Vital signs are considered to be important physiological indicators of anxiety indirectly Emotional signals of anxiety are sent from the amygdala and hippocampus of the limbic system to the hypothalamus, activating the hypothalamic-pituitary-adrenocortical HPA axis Moreover, anxiety could cause increased sympathetic excitability, which leads to increased blood pressure, HR and RR.

Herein, vital signs may be helpful in objective assessment of anxiety. Our results found that EOs dramatically reduced SBP and HR, and had a tendency to lower DBP and RR, but were not statistical significance. Our findings were consistent with previous conventional meta-analyses focusing on EOs for anxiety.

Indicating that EOs significantly alleviate anxiety 62 , Additionally, our results further confirmed the results of a previous meta-analysis pooling animal experiments from a clinical perspective Pairwise meta-analyses suggested that EOs had a stronger total therapeutic effect on state anxiety than trait anxiety.

This was consistent with the results of an earlier meta-analysis Moreover, we further found that EOs were effective in reducing state anxiety regardless of the cumulative duration of the intervention.

However, EOs could not alleviate trait anxiety when the cumulative intervention time exceeded min, with the largest effect size within 10 min of the intervention time. Thus, the efficacy of EOs on trait anxiety was more inclined to immediate intervention.

The reason for these results may be related to the mechanisms of state anxiety and trait anxiety. Previous study has shown that state anxiety and trait anxiety are mapped differently in the brain State anxiety is a transient intense emotional state associated with a temporary increase in sympathetic nervous system activity without a specific pathological condition, and it can disappear with the removal of stress or danger Trait anxiety is a personality tendency that remains stable over time It may be associated with different psychopathological conditions and continuous high arousal.

It does not disappear easily when the stress is relieved, and people with high trait anxiety are easy to develop anxiety disorders Therefore, EOs have a more obvious therapeutic effect on state anxiety. Trait anxiety symptoms could restore to their stable personality characteristics soon, although a short period of EOs stimulation can effectively alleviate them.

Network meta-analyses suggested that that jasmine was the strongest type of EO for reducing SAIS. Contrary to previous studies that suggested that jasmine could only improve nervousness and not reduce symptoms of anxiety and stress 58 , our study found that jasmine significantly improved state anxiety symptoms and thus reduced SAIS.

Pharmacological studies suggested that the mechanisms by which jasmine reduced SAIS may be related to the increase of β wave in the frontal cortex center and left occipital cortex caused by olfactory stimulation However, only one study explored the efficacy of jasmine on anxiety, so the credibility of this result is low and more researches are indispensable to confirm this result.

Considering that there was only one RCT reporting jasmine for anxiety, the results may be highly biased and less credible. ranked first in reducing TAIS. Furthermore, citrus aurantium L. could dramatically reduce the objective indicators reflecting anxiety, including SBP, DBP, and HR.

The anxiolytic activity of citrus aurantium L. was mediated by the serotonergic system 5-HT1A receptor 7 , Interestingly, citrus aurantium L.

significantly ameliorated anxiety and did not interfere with physiological levels of melatonin and corticosterone Thus, it could be reasonably inferred that citrus aurantium L. EO has the greatest benefits in treating anxiety. Previous studies on the treatment of anxiety with lemon EO are still somewhat controversial.

An RCT investigating the effect of lemon EO on anxiety during the active phase in primiparas showed that lemon EO had no effect on anxiety However, another multicenter, assessor-blinded trial demonstrated the efficacy of aromatherapy with lemon EO inhalation in relieving anxiety To the best of our knowledge, this study was the first meta-analysis of lemon EO for anxiety.

Our paired meta-analysis confirmed that lemon EO significantly ameliorated trait anxiety, but did not alleviate state anxiety. Further, our network meta-analysis found that lemon ranked second among all EOs in the aspect of reducing TAIS.

The main component of lemon is s-limonene. The anti-trait anxiety effect of lemon is closely related to the 5-serotonergic pathway, particularly through the 5-HT 1A receptor. In addition, lemon significantly accelerated the metabolic turnover of dopamine DA in the hippocampus and 5-HT in the prefrontal cortex and striatum Current network meta-analyses also found that damask rose was the third most anti-anxiety EO after jasmine and citrus aurantium L.

in reducing SAIS. However, damask rose could not reduce TAIS. This finding was in line with a previous meta-analysis that pooled the studies about damask rose mill on anxiety, indicating that damask rose dramatically decreased state anxiety but had no obvious effect on trait anxiety Damask rose mainly contains isoflavones.

On one hand, isoflavones can directly bind to GABA receptors to reduce anxiety On the other hand, isoflavones inhibit inducible nitric oxide synthase iNOS and then reduce the production of nitric oxide, which regulates the concentration of neurotransmitters such as serotonin, dopamine, norepinephrine and glutamate, and inhibits the activation of soluble guanylate cyclase, which in turn reduces the production of cyclic guanosine monophosphate cGMP , thereby reducing anxiety The number of studies using lavender as an intervention were the largest for both state anxiety and trait anxiety.

Our results indicated that the efficacy of lavender in reducing SAIS and TAIS was comparable. This was consecutive with the results of previous meta-analyses 12 , Researches in pharmacology have found that the anxiolytic effects of lavender are related to the interaction of its monoterpene components such as linalool and linalyl acetate with NMDA receptors.

Additionally, the anxiolytic effect could be partially attributed to its inhibition of serotonin transporter SERT and protection of SH-SY5Y cells from hydrogen peroxide-induced neurotoxicity Results of an RCT using mint intervention in emergency cardiac patients found that mint reduced anxiety and its induced increase in respiratory rate.

In keeping with this, our study indicated that mint could significantly reduce SAIS. Mint affects the hypothalamus by stimulating the olfactory pathway, which reduces the secretion of adrenocorticotropin-releasing hormone, adrenocorticotropin and cortisol, ultimately reducing anxiety 77 , Finally, the results of our study showed that neither geranium nor copaiba could reduce anxiety, and copaiba ranked the worst.

However, the RCTs on geranium and copaiba for anxiety each only one was included, which tends to cause significant heterogeneity, so these results should be interpreted with caution and more studies are needed to confirm these conclusions in the future.

No adverse events were reported in any of the trials, and their safety remains uncertain. EOs gas molecules can be inhaled and then transported to the central nervous system after entering the bloodstream through the lung, or they can cross the neuronal network of the olfactory system and directly reach and act on the corresponding brain areas, causing activation in different brain regions to induce anxiolytic effects 8.

Several studies concluded that EOs appeared to be well tolerated, as inhalation of different doses of EOs did not cause changes or show signs of toxicity In summary, the most effective was jasmine intervention with a cumulative duration of 30 to min for state anxiety, while citrus aurantium L.

intervention with a cumulative duration of 10 min or less were most efficacious for trait anxiety. Nevertheless, combining self-reported SAIS and TAIS with objective indicators, a cumulative intervention of 10 to 30 min with citrus aurantium L.

was optimal, because it reduced not only SAIS and TAIS, but also SBP, DBP, and HR. However, it is worth noting that due to the lack of reports on adverse effects, the studies with EOs included in this study could not be fully used to rank the safety of EOs.

This limitation requires special attention in future studies. The current study has several strengths. We developed rigorous eligibility criteria, conducted a comprehensive search, assessed the risk of bias, addressed key outcomes, performed valuable sensitivity and subgroup analyses, and rated the certainty of the evidence using CINeMA by GRADE criteria.

For the first time, a network meta-analysis was used to compare the differences in efficacy of various types of commonly used EOs, providing clinicians with a rational choice of essential oils for the treatment of anxiety. However, the study also had a number of limitations.

To comprehensively summarize the efficacy of EOs, we included a wide range of interventions that varied in terms of number of interventions, duration, dose, co-morbidities, or causes of anxiety, so that there may be large heterogeneity across trials. Moreover, most of the trials had a high risk of bias and low or very low quality of evidence.

Therefore, the credibility of the results was low and we need to be cautious in interpreting the results. In addition, the intrinsic characteristics of EOs, such as the species, place of origin, and the intervention procedures of EOs, including extraction method, exposure concentration, method of exposure, duration of exposure, and route of administration, could affect the amount of active ingredients of EOs in the body and thus the efficacy of EOs.

Thus, only by controlling for these variables can the efficacy of EOs for anxiety in different clinical trials be more accurately determined. What's more, more high-quality RCTs that rigorously document the characteristics and intervention procedures of EO, may be needed in the future to improve the reliability of meta-analysis conclusions.

This study confirmed that EOs may be effective in treating anxiety, and citrus aurantium L. appeared to be the most recommended type, as it showed a large effect size in reducing both SAIS and TAIS. However, due to the obvious heterogeneity among the included studies, our results should be interpreted with caution and more high-quality RCTs are expected to confirm this result in the future.

LT and F-fL: conceptualization, visualization, investigation, and writing-original draft. L-zL and C-gF: conceptualization, visualization, and writing — review and editing. X-cM: investigation and writing — review and editing. Y-xP: formal analysis and writing — review and editing. J-mL and HQ: funding acquisition and writing — review and editing.

All authors contributed to the article and approved the submitted version. This study was supported by the Youth Talent Promotion Project of China Association for Science and Technology no.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers.

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