it has been reported that stress and anxiety stimulate adrenal gland and sympathetic nervous system which , in a sophisticated process , leads to an increase in bp , respiratory irregularities , dyspnea , an increase in the rate of respiration and hearth rate , and in case of frequent prolonged exposure to chronic stress and anxiety , it results in hypertension and other diseases . restlessness , sorrow and sadness , loss of appetite , hypertension , an increase in respiratory irregularities , palpitation , and disturbance in concentration and doing daily activities are among the signs and symptoms of these depressive and stress - causing factors . studies investigating anxiety , stress , and depression in patients families have been conducted , and it has been revealed that a disease creates a stressful situation for both the patients and their families . research showed that hospitalization of a family member imposes high stress on other members and leads to depression , especially when their patient is to undergo invasive interventions . on the other hand , family , as the first social unit in iranian society , has a specific role and acts as a base for physical , cultural , and social health . therefore , supporting the families whose patients undergo treatment is one of the main duties of nurses . this can be given by nurses to families as psychological , mental , and social support . as the families have a key role in maintenance of patients health after discharge , relieving their anxiety is helpful and of great importance . one of the factors which play a major role in the reduction of anxiety , depression , and stress is individuals religious beliefs . muslims always remember god when exposed to anxiety and stress and seek help from him . remembering god can be in the form of litany and prayer . one type of litany is recommended azkar , as muslims believe zekr can relax , clear heart , treat pain , meditate the soul , and light wisdom . it has been shown in muslim countries that prayer can decrease pain in addition to reducing anxiety , stress , and depression . rosmarin ( 2009 ) showed that strong belief in god can also reduce stress and anxiety and increase happiness in non - muslims . international studies reported that individuals , to seek help , refer to clergymen ( 42% ) , a general physician ( 29% ) , a psychologist or a psychiatrist ( 18% ) , and social workers institutes ( 11% ) . in some countries , there is a nurse at the operating room who tries to help families reduce their anxiety , stress , and depression through various methods . meanwhile , where there are no such supporting systems , nurses should not forget the patients families and should try to find methods to reduce patients families anxiety , stress , and depression . with regard to high prevalence of anxiety , stress , and depression in families of patients before surgery and with respect to the importance of making peace for families , and the treatment property of recommended azkar as well as the socio - cultural conditions of iranian society , the present study was conducted to investigate the effect of religious recommended azkar on anxiety , stress , and depression of the families of the patients undergoing an open heart surgery . this is a pre - experimental study conducted on 120 family members of the patients undergoing open heart surgery in shafa medical center in kerman , iran in the first half of 2011 . the researcher referred to the surgical waiting room on different days when the families of the patients undergoing open heart surgery existed . after giving them information about the study and obtaining a written consent from them , it was such that all eligible individuals who fulfilled the inclusion criteria had equal chance to enter any of the groups ( study or control ) . the inclusion criteria were no history of mental diseases , no history of intake of psychotropic medication including anti - depressants and anti - anxiety medication , no drug abuse , being a muslim , being an immediate family member of the patient ( father , mother , spouse , sister , or brother ) , being literate at least to the extent of reading and writing persian to fill the questionnaire , and being over 20 years of age ( in order to be mature enough to understand the meanings of recommended azkar ) . the exclusion criteria was having open heart surgery for more than one time . to conduct the intervention , the researcher randomly selected a patient referring for open heart surgery to the cardiac surgery ward through lotto and assigned his / her accompanying person to the study group if he / she was an immediate family member of the patient . on another day , another patient was randomly selected ( through lotto ) and his / her accompanying person was assigned to the control group if he / she was an immediate family member of the patient . the depression , anxiety , and stress scales ( dass 21 ) questionnaire was filled by both groups before intervention . then , the study group underwent training about the use of azkar including hamd - va - soureh for seven times and la - ilaha - illallah for 100 times for 20 min at the session of selection . the importance of recommended azkar such as la - ilaha - illallah and generally , muslims believe in two types of recommended azkar : 1 ) verbal recommended azkar , which is naming god and saying tasbih , tahmid , takbir , and tahlil ( la - ilaha - illallah ) and 2 ) internal recommended azkar , which is remembering god from the bottom of heart . among the recommended azkar causing relaxation and reducing anxiety and restlessness , hamd - va - soureh and la - ilaha - illallah ( no so , the researcher used those recommended azkar , and 1 h after intervention , the questionnaire was filled again . in the control group , no training on recommended azkar was given and just the routine interventions were administered , and the questionnaire was filled after 1 hour . as an open heart surgery lasts for an average of 3 h and the highest level of anxiety , stress , and depression of patients families is observed in these 3 h , the researcher devoted the first hour in explaining to patients families , obtaining a signed consent form , and in initial filling up of the questionnaire . the second hour was devoted to educating them on recommended azkar and making them say that , and the third hour was devoted to refilling the questionnaires . at the end of research , if any subject in the control group had accidentally used recommended azkar , he / she was left out of the study . before completing the questionnaire , an informed written consent was obtained from the subjects and the questionnaires were anonymous . the subjects were assured that their acceptance or rejection to participate in the study had no effect on their patients treatment . dass 21 questionnaire includes 21 questions through which signs of anxiety , stress , and depression are separately measured by seven questions , respectively . each question is scored in a 4-point likert 's scale ( none  many ) ranging from 0 to 3 , and the scores are summed up at the end . in this scale , scores 0 - 4 show normal level of depression , 0 - 3 show normal level of anxity and 0 - 7 show normal level of sress , 5 - 7 show low level of depression , 4 - 5 show low level of anxity and 8 - 9 show low level of sress , 8 - 11 show moderate level of depression , 5 - 7 show moderate level of anxity and 10 - 13 show moderate level of sress , 12 - 15 show severe level of depression , 8 - 9 show severe level of anxity and 14 - 17 show severe level of sress , 25 + show extremely severe level of depression , 10 + show extremely severe level of anxity and 18 + show extremely severe of sress , . this questionnaire was suggested firstly by loviband ( 1995 ) and tested in a larger sample of humans . it was adopted on numerous subjects in england and its reliability and validity were confirmed . gylensten et al . , in a study titled  investigation of the association between stress and work ,  used dass 21 questionnaire . aghebati , in a study on the effect of touch therapy on the level of pain and mental signs of depression , anxiety , and stress in cancer patients , used this questionnaire and reported its reliability as 0.9 in iran . one of the limitations was the contact between subjects and the families of the patients who had already undergone surgery , which could have an effect on the obtained results . descriptive and inferential statistical tests ( chi - square , independent t - test , and paired t - test ) were used to analyze the data in spss . scientific and ethical contents of the research project have been approved by kerman university of medical sciences , iran . there was no significant difference in the demographic characteristics concerning age , gender , and level of education in the study and control groups ( p > 0.05 ) . there was also no significant difference in anxiety , depression , and stress before intervention in the two groups ( p > 0.05 ) . independent t - test showed a significant difference in the mean scores ( sd ) of anxiety , depression , and stress in the study and control groups ( p < 0.05 ) . tables 1 and 2 compare the mean and sd values before and after intervention in both groups . independent t - test ( based on relative changes ) was used to compare the mean ( sd ) of changes in the two groups with regard to neutrality of values before intervention . this means that the values before the intervention decreased the value after the intervention intervention and then the calculated sum was divided to values before intervention . mean ( sd ) values of relative change index have been presented in table 3 . comparison of mean ( sd ) in the control group before and after intervention comparison of mean ( sd ) in the study group before and after intervention mean ( sd ) relative changes in the study and control groups paired t - test showed a significant difference in anxiety , stress , and depression in the study group before and after intervention ( p < 0.05 ) , but in the control group in which no extra intervention except routine interventions were administered , no significant difference was observed . the findings showed that recommended azkar can reduce anxiety , stress , and depression of the patients undergoing open heart surgery . so , this method can be used to reduce tension and to prevent anxiety , stress , and depression . in the past two decades , numerous studies have been conducted on reduction of anxiety , but few studies have been carried out to reduce patients accompanying persons anxiety . the present study showed that patients open heart surgery imposes anxiety , stress , and depression to their accompanying persons . in this , in a study on the factors related to anxiety of accompanying persons of the patients hospitalized in icu , showed that 77% of patients families had anxiety and the families that encouraged the patients to surgery faced sixfold more of anxiety . pochard et al . showed that observing a beloved person in a critical condition is stressful . present study showed that askar can reduce anxiety , stress , and depression of patients accompanying persons . nikbakht nasrabadi ( 2002 ) , in a study comparing the effect of benson relaxation method and recommended azkar on reduction of patients anxiety status before an abdominal surgery , concluded that recommended azkar had more effect on reduction of anxiety compared to benson relaxation method , which shows the effect of relying on god and its role in giving peace to humans . hosini ( 2008 ) , in a study on the effect of prayer with emphasis on cognitive processes , showed that during praying , stimulation and activity starts in a special part of a human being 's brain . this activity includes processing of the meaning of pray words , which causes recalling the saved information in the memory in addition to their related events and memories . it consequently leads to lowering stress , bp , and heart rate , which gives us the ability to face the high - risk events appropriately . peterson et al . , in a study on patients undergoing open heart surgery , found out that praying was effective on patients rapid recovery as well as control of stress signs . vasegh , in a study on muslim students , showed that although religious beliefs lower anxiety , they can not reduce stress and depression . in a study conducted by rosmarin et al . , they concluded that remembering god increases the feeling of well - being in psychological and mental dimensions ( anxiety , stress , and depression ) . the present study showed that recommendation of religious recommended azkar can reduce anxiety , depression , and stress in families of patients undergoing open heart surgery , and the nurses in muslim countries and in other countries where patients families believe in god can use this method to lower families anxiety .