Clin Psychopharmacol Neurosci 2019; 17(2): 222-232  
Heart Rate Variability Biofeedback Increased Autonomic Activation and Improved Symptoms of Depression and Insomnia among Patients with Major Depression Disorder
I-Mei Lin1,2,*, Sheng-Yu Fan3,*, Cheng-Fang Yen4,5, Yi-Chun Yeh4,5, Tze‐Chun Tang4,6, Mei-Feng Huang4,5, Tai-Ling Liu4,5, Peng-Wei Wang4,5, Huang-Chi Lin4,5, Hsin-Yi Tsai1,4, Yu-Che Tsai1
1Department of Psychology, College of Humanities and Social Sciences, Kaohsiung Medical University, Departments of 2Medical Research and 4Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung City, 3Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan City, 5Graduate Institute of Medicine and Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, 6Dr. Tang’s Psychiatric Clinic and Mind Center, Kaohsiung City, Taiwan
Correspondence to: Yu-Che Tsai, PhD, Department of Psychology, College of Humanities and Social Sciences, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung City 807, Taiwan
Tel: +886-73215422 ext. 838, Fax: +886-73233716, E-mail:
*These authors contributed equally to this study as co-first authors.
Received: April 11, 2018; Revised: June 3, 2018; Accepted: June 15, 2018; Published online: May 31, 2019.
© The Korean College of Neuropsychopharmacology. All rights reserved.

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Objective: Autonomic imbalance is considered a psychopathological mechanism underlying major depressive disorder (MDD). Heart rate variability (HRV) is an index for autonomic activation. Poor sleep quality is common among patients with MDD. HRV biofeedback (BF) has been used for regulating autonomic balance among patients with physical illness and mental disorders. The purpose of present study was to examine the effects of HRV-BF on depressive symptoms, sleep quality, pre-sleep arousal, and HRV indices, in patients with MDD and insomnia.
Methods: In this case-controlled study, patients with MDD and Pittsburgh Sleep Quality Index (PSQI) score higher than 6 were recruited. The HRV-BF group received weekly 60-minute protocol for 6 weeks, and the control group who have matched the age and sex received medical care only. All participants were assessed on Beck Depression Inventory-II, Back Anxiety Inventory, PSQI, and Pre-Sleep Arousal Scale. Breathing rates and electrocardiography were also performed under resting state at pre-testing, and post-testing conditions and for the HRV-BF group, also at 1-month follow-up.
Results: In the HRV-BF group, symptoms of depression and anxiety, sleep quality, and pre-sleep arousal were significantly improved, and increased HRV indices, compared with the control group. Moreover, in the HRV-BF group, significantly improved symptoms of depression and anxiety, decreased breathing rates, and increased HRV indices were detected at post-testing and at 1-month follow-up, compared with pre-testing values.
Conclusion: This study confirmed that HRV-BF is a useful psychosocial intervention for improving autonomic balance, baroreflex, and symptoms of depression and insomnia in MDD patients.
Keywords: Heart rate variability biofeedback; Major depressive disorder; Insomnia.

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