What is the effectiveness of stress interventions for men: a systematic review

2.1 Search strategy

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement [10]. The completed PRISMA 2020 Checklist is provided in Supplementary material 1. The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 17 January 2023 (Registration ID CRD42023392091). Although literature searches were completed prior to registration, the protocol was registered before completion of study screening, data extraction, quality appraisal and synthesis. No substantive changes were made to the eligibility criteria, search strategy or review methodology following registration.

The PICO (Patient/Population/Problem, Intervention, Comparison/Control and Outcome) framework informed the development of the research question and search strategy [10]. A systematic search was undertaken by the first author (EBa) in Allied and Complementary Medicine Database (AMED), Excerpta Medica Database (EMBASE), Excerpta Medica Care (EMCARE) and Health Management Information Consortium (HMIC), British Nursing Index (BNI) and Psychological Information Database (PsycINFO), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDical Literature Analysis and Retrieval System Online (MEDLINE), and PubMed for peer-reviewed journal articles published up to 14 December 2022.

Search terms included combinations of stress, burnout, men, male, masculinity, intervention, programme, support, management, efficacy, effectiveness, and outcome measures. Full search strategies are provided in the Supplementary material 2.

An updated surveillance search was conducted across PubMed, MEDLINE, PsycINFO, and EMBASE using the original search strategy and eligibility criteria to identify studies published between 15 December 2022 and 27 July 2026. This yielded 792 records, of which 10 articles underwent full-text review.

2.2 Eligibility criteria, study selection, screening, data extraction and quality

Studies were eligible for inclusion if they involved healthy adult males with elevated stress, evaluated a stress-management intervention, and reported outcomes demonstrating a change in stress from baseline. Mixed-sex studies were eligible if male-specific outcomes or separate analyses for male participants were reported.

Studies were excluded if they were not published in English language, were not peer-reviewed, were not original research articles, involved participants younger than 18 years, or were conducted exclusively in female or clinical patient populations. Studies including participants with pre-existing conditions were considered where they otherwise met the review criteria. Moreover, studies recruiting from general population samples were eligible where some participants had pre-existing health conditions.

Two authors (EBa and EBe) independently screened retrieved studies. Inter-rater agreement was 92.8% (Cohen’s κ = 0.596), indicating moderate agreement [11]. Disagreements were resolved through discussion and consensus. Search results were entered into Microsoft Excel, where duplicates were removed.

Data extraction and quality appraisal were undertaken independently by both reviewers using a pilot-tested extraction form. Extracted information included study characteristics, participant details, intervention type, stress measures, outcome assessment timeframes, and findings. Discrepancies were resolved by discussion and consensus.

Methodological quality were assessed using the Critical Appraisal Skills Programme (CASP) Randomised Controlled Trial Checklist [12]. Assessments were conducted independently by two reviewers (EBa and EBe) and summarised.

A meta-analysis was not considered appropriate because of substantial heterogeneity in stress types, participant characteristics, intervention approaches, and outcome measures.

3.1 Study selection

The primary searches yielded 2201 studies. After removal of duplicates (n = 185), 2016 studies were screened by title and abstract, and full-text articles were retrieved and screened for 159 studies. Of these, 143 full-text articles did not meet our inclusion and/or exclusion criteria and were excluded. This left 16 studies that were included in the systematic review. A flow diagram summarising article inclusion/exclusion is provided (Fig. 2).

Fig. 2.PRISMA flow diagram. Showing studies identified, screened, excluded and included in this systematic review. MEDLINE, MEDical Literature Analysis and Retrieval System Online; CINAHL, Cumulative Index to Nursing and Allied Health Literature; PsycINFO, Psychological Information Database; BNI, British Nursing Index; EMBASE, Excerpta Medica Database; AMED, Allied and Complementary Medicine Database; EMCARE, Excerpta Medica Care; HMIC, Health Management Information Consortium.

A subsequent surveillance search covering 15 December 2022 to 27 July 2026 identified 792 records, of which 10 articles underwent full-text review and all were excluded due to the absence of male-specific outcomes.

3.2 Study overview

Study characteristics details are presented in Table 1 (Ref. [13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28]) and interventions, results, and conclusions of the 16 studies are included in Table 2 (Ref. [13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28]). Six studies were published in 2018 [13, 14, 15, 16, 17, 18], five in 2019 [19, 20, 21, 22, 23], one in 2020 [24], three in 2021 [25, 26, 27], one in 2022 [28].

3.3 Synthesis of results

Across the included studies, all intervention categories reported improvements in at least one stress-related outcome. The largest body of evidence related to dietary supplements and mindfulness-based interventions. Although positive findings were reported across intervention types, comparisons were limited by small sample sizes, mixed-sex populations, inconsistent outcome measures, and limited male-specific analyses. Consequently, no intervention category could be identified as consistently more effective than another for reducing stress in men.

3.4 Study quality

The CASP checklist [12] was used to assess study quality. Although the tool does not provide a formal scoring system, the CASP frequently asked questions (FAQs) [42] indicate that studies not achieving “Yes” responses to the first two or three questions may represent lower-quality evidence. In the present review, 14 of the 16 studies answered “Yes” to questions one to three, while the remaining two studies answered “Yes” to two of the first three questions, suggesting at least moderate methodological quality across all included studies.

As CASP is not designed to generate quantitative scores, studies were categorised pragmatically to facilitate comparison of methodological quality and applicability. These categories should be interpreted as a narrative summary of study quality rather than a formal risk-of-bias assessment.

Particular attention was given to the precision of intervention effects, the balance of benefits and harms, and the applicability of findings to practice (CASP Questions 8–11). The results of the CASP appraisal are presented in Table 3.

4.1 Green social prescribing

The single study in this category [13] found that park prescriptions may be a promising approach for reducing parental stress. However, generalisability to men is uncertain given that 87% of participants were female. Furthermore, both study groups received physician counselling about nature, limiting the ability to determine which component of the intervention was responsible for the observed effects.

4.2 Oral administration of a medication or dietary supplement

The sole study to involve a medication was Bershad et al.’s [15] simulated stressful situation to test the impact of the intervention, which raises questions as to the effectiveness of the medication in vivo. Outcomes were assessed in the immediacy following the application of the stressor leaving the longer-term outcomes on stress unknown and the study lacked power to compare men and women systematically.

Five studies investigated alternative and complementary supplements for stress reduction, making this the largest grouping of studies in this review. On review of the findings from Patterson et al. [24] it was noted that there was no intervention effect when specifically looking at males.

Daily supplementation with a specific amino acid composition with micronutrients [14] showed promising findings for male participants in relieving perceived stress. However, being a pilot study with a small sample size, the results need to be treated cautiously. Another natural therapy which shows promise is a probiotic called lactobacillus plantarum P8 which was found to alleviate stress and anxiety in participants with moderate perceived stress [16]. These findings suggest the supplement may represent a feasible approach to managing stress and anxiety, particularly in men. Further research is thought to be needed to understand its benefits specifically for men with stress and its effects combined with other interventions, such as those provided as standard treatment.

The water extract plus multivitamins supplement study [17] noted particular benefits in reducing physical stress related symptoms, but given no significant reduction was observed for behavioural or cognitive stress and no findings reported specifically for males, its potential impact in addressing stress in men is uncertain. Similarly, Kell et al. [19] did find their tested supplement to reduce stress and anxiety, but no findings were reported that were specific to males in this study. The small sample size also presents a serious limitation to any claim that the intervention acts on cortisol.

The interventions within this category are biologically diverse and may act through different mechanisms. For example, amino acid supplementation may support neurotransmitter synthesis and regulation of the stress response, whilst probiotic interventions have been proposed to influence stress through modulation of the gut-brain axis. Herbal and nutritional supplements may also act through effects on neuroendocrine and inflammatory pathways. However, the underlying mechanisms remain incompletely understood and require further investigation, particularly in male populations.

4.3 App/virtual-based meditation or mindfulness

An app-based mindfulness [18] and online mindfulness course [21] found beneficial effects were enhanced for females more so than for men. However, both found overall benefits in their interventions in addressing stress. Similarly, an online mindfulness programme [25] was found to be effective in reducing stress, but did not have enough male participants take part to stratify their sample.

The study by Weitzman et al. [27] used only a small sample which lacked blinding and therefore findings could have been subject to the Hawthorne effect in which research participants modify their behaviour while they are being observed.

Virtual delivery offers advantages including greater accessibility and reduced delivery costs. However, the available evidence suggests these interventions may provide more limited benefits for men than women.

4.4 CBT

Two studies with a primary focus on CBT were identified. Nakao et al.’s [20] study included only elderly men with amateur skills at shogi. Although findings were promising, the non-blinded design and highly specific participant group limit generalisability. In terms of generalisability, participants were all elderly men who were familiar with shogi, and they may already have had a shogi social network, which could distinguish them from elderly people who engage in no recreational activities.

In contrast, Young et al.’s [28] study included university students sampled specifically during the COVID-19 pandemic to investigate the CBT intervention’s effect in addressing pandemic-related stress. Participants were counselling students and may therefore have been more receptive to psychological interventions than the wider population. Some methodological limitations of this study include the generalisability of the research results as is limited by the small sample size, dominance of female participants, adopting convenience sampling, and the lack of a control group for comparison. Additionally, an attrition rate of 39.3% was reported in this study which may give rise to biased estimation of intervention effects.

4.5 Exercise and lifestyle

Wang & Boros [26] included a mix of student and non-student participants. Participants who were not students at Eötvös Loránd University were provided with a free yoga course voucher, resulting in differential treatment between participants. This introduces a potential source of bias and represents a threat to the study’s internal validity, as any effects observed may have been influenced by additional wellbeing support rather than the walking intervention alone.

The intervention also involved issuing pedometers to track the daily data of participants. With such devices, there was potential that they acted as an external motivation to exercise, also, the devices can encounter problems such as inaccurately recording activity levels. Additionally, while pedometers may encourage physical activity, they do not measure exercise intensity. Consequently, it is unclear whether reductions in stress were related to the amount of activity performed or the physiological demands of the exercise itself.

The study also encountered a relatively high dropout rate, which may relate to the efficacy and experience of the intervention. Furthermore, the intervention lacked standardisation of key exercise variables such as intensity, frequency, and duration. As a result, the observed improvements in stress cannot be confidently attributed to the exercise programme itself, limiting the strength of the study’s conclusions.

4.6 Manual therapy

The positive massage study [22] did not identify any male-specific benefits. Although participant blinding was not feasible due to the nature of the intervention, this increased the potential for demand characteristics and expectation effects.

4.7 Short periods of sleep

The study of the effect of different nap opportunity durations by Hsouna et al. [23] had a number of limiting factors, including relying primarily on subjective measures of stress. The absence of objective measures of stress and recovery limited the ability to corroborate participants’ self-reported outcomes. Other issues include the allocation of participants to randomised groups not being specified in terms of group size or baseline characteristics, and no details of blinding being provided. Although only a matter of minutes, the post-intervention questionnaires were completed at the same time; therefore, the later the nap intervention, the less time participants had for their post-intervention follow-up interval.

The finding that longer nap durations were associated with greater reductions in stress may suggest that sufficient sleep duration enables more effective physiological recovery and fatigue management. However, further research is needed to establish the optimal duration and mechanisms through which napping influences stress-related outcomes.