Progressive muscle relaxation to reduce anxiety before electroconvulsive therapy (ECT)

Abstract

Background

ECT is a well-established treatment modality for severe psychiatric disorders, particularly major depressive disorder and bipolar disorder. It is well-documented that patients experience significant anxiety before treatment, which can adversely affect nursing care and the treatment process. This study aims to determine the effect of progressive muscle relaxation exercises on anxiety levels among patients with bipolar and depressive disorders prior to their first ECT session.

Method

Data for this quasi-experimental study were collected from 30 in-patients with bipolar disorder and depression who received ECT for the first time in the hospital between May 29 and October 29, 2020. Data collection involved an information form, the STAXI State Anxiety Scale, and the Visual Analogue Scale for Anxiety. The data were analyzed using descriptive statistics, the Friedman test, and the Wilcoxon test.

Results

The mean VAS-A score decreased from 4.93 ± 1.88 before PMR to 2.83 ± 1.76 after PMR, and further to 1.43 ± 1.21 after ECT (p < .001). However, STAI-S scores did not show a statistically significant difference before and after PMR (p > .05). Heart rate and respiratory rate also significantly decreased after PMR exercises (p < .05), while oxygen saturation remained unchanged. Prior to the next ECT session, the mean VAS-A score increased to 5.10 ± 1.77, and no significant changes were observed in either physiological parameters or anxiety measures.

Conclusion

While a short-term effect on VAS Anxiety levels was observed following PMR exercises before ECT, patients still exhibited high levels of anxiety before subsequent ECT sessions. Therefore, it is recommended that PMR exercises be performed before each ECT session, and the effects of long-term application should be further investigated. Future studies should employ a randomized controlled design to compare results with a control group.

Clinical trial number

Not applicable.

Background

Electroconvulsive therapy (ECT) is a well-established treatment modality for severe mood disorders, particularly major depressive disorder (MDD) and bipolar disorder. It is recognized for its rapid efficacy, effective and safe treatment especially in cases where patients exhibit treatment resistance to conventional pharmacotherapy and psychotherapy [1, 2]. The efficacy of ECT has been well-documented, with numerous studies indicating that it can lead to rapid and significant improvements in depressive symptoms, especially in treatment-resistant cases [3, 4]. ECT has been shown to achieve remission rates of 50–60% in patients with severe depression, significantly higher than the 10–40% remission rates associated with pharmacological treatments alone [1, 2, 5, 6]. The mechanism of action, while not fully understood, is believed to involve alterations in neurotransmitter levels, neuroplasticity enhancement, and increased brain-derived neurotrophic factor levels following seizure activity induced by ECT [7, 8]. A cohort study by Rovers et al. highlighted that earlier intervention with ECT, rather than waiting until patients have failed multiple treatments, can lead to better outcomes [3]. Research suggested that ECT should not be relegated solely to a treatment of last resort [1, 3].

Nurses play a critical role in the care of patients undergoing electroconvulsive therapy (ECT), particularly in the period leading up to the treatment. Their responsibilities encompass a range of activities aimed at alleviating patient anxiety, providing education, and ensuring patient safety. A systematic review study by Obbels et al. reported that ECT-related anxiety is experienced at a wide rate between 15% and 75% by patients due to the worries about memory impairment or brain injury [10]. Although there is no structural, biochemical, or epidemiological evidence that ECT causes brain injury [9], patients are afraid of experiencing brain injury. The highlighted that reason of clinical importance of ECT-related anxiety, anxiety-reducing interventions is warranted [10]. This multifaceted role is essential for enhancing the overall experience of patients and improving treatment outcomes. One of the primary responsibilities of nurses before ECT is to address and manage patient anxiety. Nurses can help mitigate this anxiety through supportive communication, providing reassurance, and engaging in therapeutic conversations with patients. According to Lonergan et al., patients reported that friendly and supportive staff significantly contributed to a reduction in their anxiety levels before ECT [11]. This highlights the importance of the nurse-patient relationship in fostering a sense of safety and trust. On the other hand, a qualitative meta-synthesis reported that patient experience fear and trauma after ECT treatment [12]. This is ultimately an important finding to reduce the patient’s anxiety before and during ECT and to avoid a negative experience.

The emotional burden on nurses can be substantial, especially when they are faced with patients who exhibit severe anxiety or distress. This situation can lead to feelings of helplessness among nurses, particularly if they feel inadequately prepared to address the psychological needs of their patients [11, 13]. Moreover, the environment in which ECT is administered can contribute to the challenges faced by nurses. For instance, the post-anesthesia recovery unit can be a stressful setting, especially when patients experience postictal agitation, which can complicate the recovery process. Nurses must be vigilant in monitoring patients for signs of oversedation or respiratory depression, which can be particularly concerning in the context of ECT [14]. This responsibility adds to the overall workload and stress experienced by nursing staff, further compounding the challenges associated with managing patient anxiety.

The stigma surrounding ECT can also influence the dynamics between nurses and patients. Many patients arrive with preconceived notions about ECT, often fueled by societal fears and misconceptions. Nurses are tasked with not only providing care but also educating patients and their families about the treatment, which can be a daunting responsibility, especially in the face of widespread anxiety and misinformation [15]. This educational role is essential for building trust and rapport, yet it can also be a source of stress for nurses who may feel unprepared to address all patient concerns adequately.

This anxiety is not merely transient or superficial—it can negatively impact treatment adherence and patient satisfaction. Understanding the different types of nursing interventions for managing pre-ECT anxiety is therefore crucial. These interventions can be grouped into four main categories: [1] Educational strategies, such as informational brochures or videos, which help demystify the procedure [16]; [2] Therapeutic communication, including supportive conversations and empathy-based engagement that strengthen the therapeutic alliance [11]; [3] Non-pharmacological approaches, such as progressive muscle relaxation or breathing exercises, or lavender essential oil which physiologically counter anxiety [17]; and [4] Pharmacological methods, like the judicious use of anxiolytics when necessary [18]. While ECT can alleviate both depressive and anxiety symptoms over time, the improvement in anxiety symptoms tends to lag behind that of depression [19]. Progressive muscle relaxation (PMR) is a therapeutic technique that can be beneficial for patients undergoing electroconvulsive therapy (ECT) by helping to alleviate anxiety and promote relaxation before the procedure. PMR involves systematically tensing and then relaxing different muscle groups, which can lead to a reduction in physical tension and anxiety levels [20]. Nurses can implement non-pharmacological interventions, such as progressive muscle relaxation (PMR), to help alleviate anxiety and promote relaxation before the procedure. PMR has been shown to effectively reduce stress and anxiety levels in various populations, including patients undergoing medical treatments [21–26] By guiding patients through PMR exercises, nurses can help them achieve a state of relaxation, which may enhance their overall experience of ECT. A study also found that PMR exercise decrease systolic and diastolic blood pressure, pulse rate, and relieves anxiety in patients [27]. The systematic reviews showed that PMR has significant method to reduce anxiety in adults [28], cancer patient [29], also it has significant effect on psychological symptoms on an inpatient psychiatric unit [30]. In the literature review, limited study was found that measured the effect of an anxiety-inducing treatment such as ECT on psychiatric patients. There are numerous methods available for reducing anxiety, but one of the most cost-effective, efficient, and easily accessible options is progressive muscle relaxation (PMR) exercises. The PMR was selected due to the positive results and the easy and cost-free method. Hence, the study was carried out to determine the effect of progressive muscle relaxation exercise on anxiety among patient with bipolar and depressive disorder before the electroconvulsive therapy.

Method

Aim: A quasi-experimental design study was conducted to assess the impact of progressive muscle relaxation exercises on anxiety levels in patients with bipolar disorder and depression prior to undergoing electroconvulsive therapy (ECT).

Research hypotheses

H0

Progressive muscle relaxation exercises have no effect on anxiety levels before ECT.

H1

Progressive muscle relaxation exercises administered to patients before ECT significantly reduce anxiety levels.

H2

Progressive muscle relaxation exercises applied to patients before ECT significantly reduce anxiety levels prior to subsequent ECT sessions.

Design

A quasi-experimental design.

Participation

The study utilized power analysis via the G*Power program to determine the study’s power. With an effect size of 0.60, an alpha level of 0.05, and a sample size of 30, the calculated power (1 - β) was 0.96. Participants were selected from the inpatient psychiatry ward of a training and research hospital, with a sample of 30 patients chosen from 47 who met the research criteria through purposive sampling.

Inclusion criteria included: having received their first ECT treatment, being in a bipolar depressive episode or diagnosed with depression, and being over 18 years of age. Exclusion criteria included having comorbid diseases or communication difficulties that hindered understanding of the progressive muscle relaxation video. 12 patients were excluded due to the second ECT treatment, 5 patients were excluded due to the comorbid diseases.

Based on these criteria, eleven patients who had not received ECT for the first time and six patients with different diagnoses were excluded from the study.

The characteristics of the participating patients are detailed in Table 1.

Table 1.

Patients’ characteristics (N = 30)

		n	%
Gender	Male	11	36.7
	Female	19	63.3
Age	Under 40 years old	13	44.8
	Up to 40 years old	17	55.2
Education Level	Primary school	11	36.7
	Middle school	2	6.7
	High school	13	43.3
	Undergraduate	4	13.3
Marital Statues	Married	19	63.3
	Single	5	16.7
	Divorce/widow	6	20.0
Economic Income	High-income	4	13.3
	Average-income	17	56.7
	Low-income	9	30.0
Medical diagnosis	Bipolar Depressive Disorder	15	50.0
	Depressive Disorder	15	50.0
Psychiatric history in family	Yes	20	66.7
	No	10	33.3
Substance use history	Yes	0	0.0
	No	30	100.0
Experience worries to procedure	Yes	24	82.8
	No	6	20.0
Age Mean	44.66 ± 12.37	Min:28	Max:71

Data collection

Data were collected using an information form to assess patient characteristics, vital signs (including heart rate, respiratory rate, and oxygen saturation), the STAI State Anxiety Scale, and the Visual Analog Scale for Anxiety.

The information form was developed by researchers to evaluate participants’ gender, age, disease information, and vital signs.

The STAI State Anxiety Scale, developed by Spielberger et al. in 1970, provides a reliable and relatively brief self-report measure [31]. In this study, the state anxiety component was utilized to assess tension, nervousness, and worries prior to ECT. The STAI state scale comprises 20 statements rated on a four-point scale, with higher scores indicating greater levels of state anxiety. The lowest possible score is 20, while the highest is 50. The validity and reliability of the scale in Turkish were established by Oner and Le Compte in 1983, with a Cronbach’s alpha coefficient of 0.88 found in this study [32].

The Visual Analog Scale for Anxiety is a widely used tool for measuring anxiety, scored from 0 to 10, allowing patients to quickly self-assess their anxiety levels. This scale has been shown to effectively capture reductions in anxiety [33].

Procedure

The study was conducted in the psychiatry ward of a training and research hospital. ECT sessions were scheduled for Mondays, Wednesdays, and Fridays, during which one-on-one interviews were held in patient rooms. Patients were informed about the study one day prior to their ECT application and were asked to sign a consent form indicating their acceptance of participation.

To ensure that only first-time ECT patients were included, those who had previously undergone ECT were excluded. During the initial interview, patients were informed about the upcoming ECT, the relaxation exercises, and the CD prepared by the Turkish Psychological Association, which provided instructions on performing the relaxation exercises. A personal information form was completed at this time.

Patients rated their anxiety using the VAS-Anxiety scale (0 to 10) and completed the State Anxiety Inventory in a quiet, dimly lit environment, free from other patients. They were then encouraged to sit or lie down in their preferred comfortable position while the researcher measured and recorded their heart rate, oxygen saturation, and respiratory rate. Following this, patients were instructed to close their eyes, relax, and visualize positive outcomes as the progressive relaxation exercises CD, featuring soothing sounds of a stream and verbal guidance, was played. The audio was standardized and played for 30 min while the researcher remained present without intervening.

Progressive muscle relaxation (PMR) procedure

The PMR exercise was administered approximately 30 min before the first electroconvulsive therapy (ECT) session. The intervention lasted for about 20–25 min and was conducted in a quiet, dimly lit room with participants seated or lying down in a comfortable position. The content and structure of the session followed the standardized script authorized by the Turkish Psychological Association, based on the original method developed by Dr. Edmund Jacobson.

The session consisted of a guided relaxation sequence targeting the major muscle groups in the body. Each muscle group (e.g., hands, arms, shoulders, facial muscles, abdomen, back, legs, feet) was sequentially contracted for 7–10 s and then released, while participants were instructed to synchronize muscle release with slow exhalation. Deep breathing and body awareness techniques were integrated throughout the session to enhance the relaxation response. Participants were encouraged to visualize the release of bodily tension and to notice the physical sensations of calmness and heaviness following muscle release.

The entire session was delivered verbally by a trained healthcare provider using a standardized relaxation script. No background music or external stimuli were used. The script emphasized bodily awareness, diaphragmatic breathing, and progressive relaxation from head to toe. Participants were instructed not to cross their arms or legs and to maintain physical stillness during the exercise.

After the CD session, patients were allowed to relax for five minutes before being asked to open their eyes. Vital signs and scales were reassessed and recorded before the nurse accompanied the patient to the ECT room. After ECT, patients were safely returned to their rooms. For subsequent ECT sessions, patients were taken to their rooms 40 min prior, where their vital signs were measured, and the VAS-Anxiety and State Anxiety Inventory were administered again.

Data analysis

Data were analyzed using the SPSS (Statistical Package for the Social Sciences) statistical program. Descriptive analyses were performed to describe participant characteristics Spearman’s rank correlation analysis was performed between scales for convergent validity. A non-parametric statistical test was employed to investigate differences in repeated measurements. The Friedman test was used to analyze repeated measures, with significance assessed using the Wilcoxon test. Results were evaluated at a 95% confidence interval, with p < .05 indicating statistical significance.

Ethical procedure

The study received approval from the scientific research ethics committee of Namık Kemal University Training and Research Hospital (Date: 26.11.2019, Decision No: 13, Protocol No: 2019.216.11.13). The research adhered to the ethical principles outlined in the World Medical Association’s Declaration of Helsinki. Patients participating in the study were informed about the research objectives. Both written and verbal consent were obtained from the patients prior to data collection. Additionally, the patients’ relatives were verbally informed about the research. All patients and their relatives provided their consent for the study to proceed.

Results

The results of the study demonstrated that the application of progressive muscle relaxation exercises prior to electroconvulsive therapy (ECT) had a statistically significant effect on patients’ anxiety levels measured by the Visual Analog Scale (VAS). As shown in Table 2, the mean anxiety level before the relaxation exercise was 4.93, which decreased to 2.83 after the exercise. Following the ECT session, the anxiety level further declined to 1.43. However, prior to the next ECT session, the mean anxiety level increased to 5.10, indicating a peak in anticipatory anxiety before the subsequent treatment session. This change in VAS scores was statistically significant (p < .05). In contrast, no statistically significant difference was observed in the State Anxiety Inventory (SAI) scores before and after the relaxation exercise (p > .05). To assess the convergent validity of the two anxiety measures used in this study, a Spearman’s rank correlation analysis was performed between the STAI-S and VAS scores prior to the application of progressive muscle relaxation. The analysis revealed a moderate, statistically significant positive correlation between the two measures, rho = 0.47, p = .009, indicating that both tools are moderately aligned in measuring anxiety levels in this clinical context.

Table 2.

The comparison of patients’ anxiety levels before, after progressive muscle exercise and next electroconvulsive treatment (N = 30)

Anxiety Levels	Before PME1		After PME2		Before Next ECT Treatment3		Chi-square	p	Z/p
	Mean	SD	Mean	SD	Mean	SD
VAS-A	4.93	2.24	2.83	2.135	5.10	2.38	49.010	0.000	1 > 2 1 < 3	-4.756/0.000 -1.249/0.212
State-Anxiety	39.03	5.28	38.97	4.32	38.50	5.4	0,222	0,895

†Friedman Test ‡Z: Wilcoxon test, *p < 0,05, VAS-A: Visual Analog Scale - Anxiety PME: Progressive Muscle Exercise, ECT: Electroconvulsive Treatment, SD: Standard Deviation

In terms of physiological indicators, the implementation of progressive muscle relaxation was associated with significant reductions in both heart rate and respiratory rate. As presented in Table 3, both parameters showed statistically significant decreases following the relaxation exercise conducted prior to the ECT session (p < .05). However, no significant change was observed in oxygen saturation levels across the measurement points.

Table 3.

The comparison of patients’ heart, respiratory rates and saturation before, after progressive muscle exercise and next electroconvulsive treatment (N = 30)

Vital Sign	Before PME1		After PME2		Before Next ECT Treatment3		Chi-square†	p	Z/p
	Mean	SD	Mean	SD	Mean	SD
Heart Rate	81,43	10,56	77,20	8,83	82,03	10,57	25,626	0,000	1 > 2 1 < 3	-4,036/0,000 -1,101/0,271
Respiratory Rate	22,13	1,96	21,37	1,83	20,23	0,68	19,568	0,000*	1 > 2 1 > 3	-2,501/0,012 -2,333/0,020
SPO2	98,07%	1,05	98,23%	0,77	98,37%	0,72	2,077	0,558

†Friedman Test ‡Z: Wilcoxon test, PME: Progressive Muscle Exercise, ECT: Electroconvulsive Treatment, SD: Standard Deviation, SPO₂: Saturation of peripheral oxygen, *p < 0,05

These findings suggest that while progressive muscle relaxation effectively reduces subjective anxiety levels and physiological arousal in the immediate pre-ECT period, its effects may not be sustained, as anxiety tends to rise again prior to subsequent treatments. Additionally, the relaxation exercise did not significantly affect state anxiety scores, highlighting the possible need for repeated or complementary interventions to maintain its anxiolytic effects.

Discussion

This study aimed to evaluate the effect of muscle relaxation exercises on patients’ anxiety levels before ECT. Anxiety levels were assessed using both the state anxiety scale and the visual analog scale, alongside vital signs such as pulse, respiration, and oxygen saturation. The findings indicated that progressive relaxation exercises had a short-term effect on anxiety, respiration, and pulse as measured by the visual analog scale. The relationship between vital signs and anxiety levels was also noted. However, no significant changes were observed in state anxiety levels, nor were there any notable differences in patients’ findings before the next ECT treatment.

According to the study’s hypothesis, the application of progressive muscle relaxation was expected to reduce anxiety before ECT, with this effect not persisting into the next ECT session. While significant short-term changes in anxiety were observed, the lack of effect on state anxiety raised questions for the researchers. The state anxiety score reflects anxiety related to the current situation, and given that the highest score on the scale is 50, it can be inferred that patients experienced above-average anxiety before ECT (39.03–38.50). The visual analog scale indicated a medium level of anxiety, with patients scoring an average of 4.93. The visual analog scale is widely recognized for its reliability and ease of use. Studies have suggested that the VAS-A scale can serve as a rapid diagnostic tool, as a correlation exists between the two scales [34–36]. The observed discrepancy between the significant reduction in anxiety levels measured by the Visual Analog Scale (VAS) and the non-significant change in the State-Trait Anxiety Inventory (STAI) scores may be attributed to several methodological and conceptual differences between the two instruments. VAS is a unidimensional, momentary self-report tool that captures the individual’s subjective perception of anxiety at a specific point in time. The Visual Analog Scale for Anxiety (VAS-A) is an ideal tool for assessing state-dependent changes in anxiety in clinical patients, especially when there are restrictions such as limited time for completing questionnaires, due to its strong correlation with the State-Trait Anxiety Inventory-State (STAI-S). It is highly sensitive to immediate interventions and often reflects transient emotional fluctuations [33, 37, 38]. In contrast, the STAI—particularly the State subscale—assesses a broader range of cognitive-affective symptoms associated with anxiety, requiring deeper processing and a more stable emotional shift to register meaningful change [31]. Additionally, STAI’s format involves multiple Likert-type items, which may be less responsive to single-session interventions compared to the more immediate and intuitive VAS. This psychometric divergence may explain why the PMR intervention, while effective in reducing physiological arousal and perceived tension in the short term, was insufficient to produce significant change on the more complex and cognitively loaded STAI. While differences were noted in the visual analog scale, no differences were found in the State Anxiety scores, suggesting that patients may respond more readily to the visual analog scale.

Research on anxiety reduction during ECT is limited. A literature review revealed few studies on the effectiveness of progressive relaxation exercises in alleviating anxiety before ECT. Although progressive muscle relaxation (PMR) exercises significantly reduced VAS scores and physiological indicators, no statistically significant change was observed in the State-Trait Anxiety Inventory (STAI) scores. One possible explanation for this outcome may be the single-session nature of the intervention, which may have been insufficient to influence the deeper cognitive-affective components of anxiety. Previous studies have demonstrated that repeated or more prolonged PMR interventions can significantly reduce anxiety among patients undergoing electroconvulsive therapy. In a study by Mahmoud et al. (2019) involving psychiatric patients, progressive relaxation exercises performed before ECT resulted in a statistically significant difference in state anxiety levels in the experimental group [39]. The difference in results may be attributed to the fact that two theory sessions and four progressive relaxation sessions were conducted in that study, suggesting that repeated practice may yield different outcomes. In contrast, our study provided only a single progressive muscle relaxation exercise guided by a psychiatric nurse before ECT.

Another study that combined music, imagery (thoughts of health and hope), and relaxation techniques, conducted by a music therapist, found that the application of “Ahir Bhairav” raga (Indian Music) 20 min before ECT had a significant effect compared to the control group [40]. A review by Obells et al. (2017) examined nine studies aimed at preventing anxiety before ECT, with only six demonstrating effectiveness. Various methods, including medication, music, emotional support, and aquarium therapy, were employed, but no significant differences were observed in anxiety levels among patients who listened to different types of music or received emotional support. However, anxiety levels decreased in patients who were provided with brochures, accompanied by relatives in the waiting room, or given low-dose sedation (propofol). The findings suggest that combining relaxation methods with other interventions may yield more effective results [10].

In a study by Barker et al. (2003), a significant decrease in visual analog scale anxiety levels was observed in patients in rooms with aquariums compared to those without. Information provision has also been shown to reduce anxiety levels in patients with mood disorders, particularly when delivered face-to-face by a psychiatric nurse, compared to multimedia training [41].

When examining respiratory averages, it was noted that after progressive relaxation exercises and before the next ECT statistically significant difference was observed. Although the heart rate showed differences only after progressive relaxation exercises. There is no changing observed in heart rate before the next ECT. The significant reductions in heart rate and respiratory rate observed following the application of progressive muscle relaxation suggest that the intervention had a calming effect on the autonomic nervous system. These physiological markers are considered reliable objective indicators of stress reduction, supporting the interpretation that even a single session of PMR prior to ECT can help mitigate the somatic manifestations of anxiety. Future studies could investigate whether repeated or prolonged use of PMR before ECT further enhances these physiological benefits. This highlights the importance of further research on biofeedback related to vital signs.

The visual analog scale scores indicated a significant difference in patients’ anxiety levels before and after the progressive relaxation exercise, with the lowest scores recorded after ECT. However, anxiety levels increased again before the next ECT.

The immediate effect of the progressive relaxation exercise was evident, as patients experienced the lowest anxiety levels due to sedation after ECT, yet the heightened anxiety levels before the next ECT suggest that progressive muscle relaxation has a transient effect. While the present study provides preliminary evidence on the short-term effects of a single-session PMR intervention, future research should explore the potential for sustained benefits through repeated or longitudinal applications. Repeated PMR prior to each ECT session may result in greater and more durable reductions in anxiety and physiological arousal. Moreover, it is important to consider that individual-level factors—such as baseline anxiety severity, patients’ expectations of ECT, and concurrent use of psychotropic medications—may have influenced the intervention’s effectiveness. These variables were not controlled for in the present study due to its limited scope, but future randomized controlled trials should incorporate them as potential moderators or covariates to obtain a more nuanced understanding of PMR’s efficacy.

Limitations

The study faced several limitations. Due to the COVID-19 pandemic, a control group could not be included because of reduced hospitalizations. The sample was selected from one University Training and Research Hospital which may limit the generalizability of the findings to other hospitals. Self-reported data may have introduced response biases. Although the quasi-experimental design provided initial insight into the short-term effects of PMR on pre-ECT anxiety, the absence of a control group limits causal inference. Future studies should consider alternative analytical methods—such as self-controlled case series (SCCS) designs—that allow for within-subject comparisons while controlling for time-invariant confounders. Despite conducting an a priori power analysis to determine sample adequacy, the relatively small sample size may limit the generalizability and robustness of the findings. Moreover, although the VAS and STAI-S are validated instruments, their sensitivity in capturing subtle, short-term changes in anxiety during acute clinical procedures such as ECT may be limited. Future research should consider employing additional validated measures and larger sample sizes to enhance construct validity and statistical power. The other limitation of this study is the lack of data on the clinical severity of depressive or manic symptoms. Although patients were diagnosed with major depressive disorder or bipolar disorder according to clinical evaluation, no standardized symptom severity scale was administered. Future studies should consider including validated tools to assess symptom severity to allow for more detailed subgroup analyses and generalizability of findings. However, a strength of the study was the inclusion of patients undergoing ECT for the first time.

Conclusion & clinical implications for practice

The results of this research indicate that progressive relaxation exercises performed before ECT effectively influence pulse and respiratory averages and significantly reduce anxiety as measured by the VAS. However, they did not impact state anxiety levels. The long-term effects of these exercises were limited, as they did not affect patients’ anxiety levels before subsequent ECT sessions, only providing immediate relief on the visual scale.

One of the responsibilities of psychiatric nurses is to ensure patient comfort in clinical settings. The findings suggest that implementing progressive relaxation exercises before ECT can help patients undergo the procedure with reduced anxiety. This method is low-cost and easily self-administered, making it suitable for psychiatric clinics. Given the relationship between vital signs and anxiety, it is crucial to incorporate these exercises before ECT in clinical practice. Progressive relaxation exercises should be performed before each ECT session to enhance their effectiveness in alleviating anxiety. Additionally, nurses should adopt and monitor these exercises post-discharge to help patients manage anxiety in various aspects of their lives.

Author contributions

GÖ: Design the study, theoretical framework, data collection, performed the procedure, discuss the findings. ÖS: Design the study, theoretical framework, analyzed the data, discuss the findings, draft manuscript.

Funding

There is no funding.

Data availability

The datasets used and/or analyzed in the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study received approval from the scientific research ethics committee of Namık Kemal University Training and Research Hospital (Date: 26.11.2019, Decision No: 13, Protocol No: 2019.216.11.13). The research adhered to the ethical principles outlined in the World Medical Association’s Declaration of Helsinki. Patients participating in the study were informed about the research objectives. Both written and verbal consent were obtained from the patients prior to data collection. Additionally, the patients’ relatives were verbally informed about the research. All patients and their relatives provided their consent for the study to proceed.

Informed consent

Written informed consent for publication was obtained from the patients and relatives.

Competing interests

The authors declare no competing interests.