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CMAJ. 1999 May 4;160(9 Suppl):S46-50.

Lifestyle modifications to prevent and control hypertension. 7. Recommendations on stress management. Canadian Hypertension Society, Canadian Coalition for High Blood Pressure Prevention and Control, Laboratory Centre for Disease Control at Health Canada, Heart and Stroke Foundation of Canada.

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  • 1University of Western Ontario, London.



To provide updated evidence-based recommendations for health care professionals concerning the effects of stress management on the prevention and control of hypertension in otherwise healthy adults (except pregnant women).


Alternatives to stress management include other nonpharmacologic interventions and medical therapy; these options are not mutually exclusive.


The health outcome considered was reduction of blood pressure. There is little evidence to date that stress management prevents death or vascular events. Because of insufficient evidence, no economic outcomes were considered.


A systematic search of the literature (which yielded, among other sources, 3 meta-analyses) was conducted for the period 1966-1997 with the terms essential hypertension, treatment, psychological, behavioural, cognitive, relaxation, mediation, biofeedback and stress management. Other relevant evidence was obtained from the reference lists of the articles identified, from the personal files of the authors and through contacts with experts. The articles were reviewed, classified according to study design and graded according to level of evidence.


A high value was placed on the avoidance of cardiovascular morbidity and premature death caused by uncontrolled hypertension.


The magnitude of the reduction in blood pressure obtained with multicomponent, individualized cognitive behavioural intervention for stress management was comparable in some studies to that obtained with weight loss or drugs; single-component interventions such as biofeedback or relaxation were less effective. The adverse effects of stress-management techniques are minimal, but the cost for effective interventions is substantial, similar initially to drug costs; continuing costs are probably minimal.


(1) In patients with hypertension, the contribution of stress should be considered. (2) For hypertensive patients in whom stress appears to be an important issue, stress management should be considered as an intervention. Individualized cognitive behavioural interventions are more likely to be effective than single-component interventions.


These recommendations were reviewed by all of the sponsoring organizations and by participants in a satellite symposium of the fourth International Conference on Preventive Cardiology. They have not been clinically tested.


The Canadian Hypertension Society, the Canadian Coalition for High Blood Pressure Prevention and Control, the Laboratory Centre for Disease Control at Health Canada, and the Heart and Stroke Foundation of Canada.

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