YOGA AS A COMPLEMENTARY TREATMENT IN MENTAL DISORDERS: A DECADINAL REVIEW

– Dr Aarti Jagannathan
Assistant Professor, Division of Yoga and Life Sciences, SVYASA, Bangalore
It is only in the last two decades that mental health professionals have started looking at yoga as a possible treatment option for various psychiatric disorders. The introduction of yoga as an alternative and/or complementary treatment for patients with psychiatric disorders could be an effective solution for three basic reasons: (1) yoga which originated in India, is seen to be a practical and accepted intervention for patients to practice at home, (2) the number of yoga therapists is more than the number of mental health professionals available in India, (3) yoga is cost-effective and has no side-effects as in the case of psychiatric medications.
However, the psychiatric illness outcome with yoga as treatment modality would depend on (1) whether yoga can be effectively used as an independent or add-on treatment to pharmacology, (2) compliance to yoga and its effect in case of non-adherence – effectiveness of brief yoga practice versus continued practice, (3) establishment of community yoga groups – where the patient can get supervised and continued training. Answers to the above research questions could help propagate yoga as an effective solution to problem of accessing, affording and availing quality mental health care services and treatment in the Indian community. In this paper I have attempted to review all intervention studies that have used yoga as a treatment method for minor and major psychiatric disorders and that have been published in scientific journals in the last one decade.
Yoga for schizophrenia: Schizophrenia is considered as a major psychiatric disorder where the patients experiences symptoms such as hallucination, delusion, amotivation, affective flattening etc (Kaplan and Sadock, 2003). There have been only four published yoga intervention studies for patients with schizophrenia in the last one decade – two non-Indian and two Indian studies.
  • Visceglia et al., (2011), in a randomized controlled study depicted that patients with schizophrenia, when provided with an 8-week therapeutic yoga program showed significant improvements in psychopathology and quality of life compared with controls (small sample size).
  • Vancampfort et al., (2011), in their comparative study using yoga and aerobic exercise concluded that the magnitude of the changes did not differ significantly between yoga and aerobic exercise and hence people with schizophrenia and physiotherapists could choose either yoga or aerobic exercise in reducing acute stress and anxiety taking into account the personal preference of each individual.
  • Behere et al., (2011) in their randomized controlled study stated that Yoga therapy can be a useful add-on treatment to improve psychopathology, facial emotional recognition deficits, and socio-occupational functioning in antipsychotic-stabilized out-patients with schizophrenia.
  • Duraiswamy et al., (2007) in their comparative study showed that subjects in the yoga therapy group had significantly less psychopathology greater social and occupational functioning and quality of life than those in the physical training group at the end of 4 months.
Yoga for depression: Depression is considered a major psychiatric illness with symptoms of sad mood, fatigability, feelings of guilt, suicidal ideations etc (WHO, 1992; International Classification of Diseases -10). There have been only four published yoga intervention studies for patients with depression in the last one decade – two non-Indian and two Indian studies
  • Uebelacker et al., (2010) from USA, in a qualitative study showed that practice of Vinyasa yoga over the 2-month period, exhibited significant decreases in depression symptoms and significant increases in an aspect of mindfulness and behavior activation in patients suffering with depression.
  • Shapiro et al, (2007) from Italy in a non-controlled study showed significant reductions in depression, anger, anxiety, neurotic symptoms and low frequency heart rate variability in the 17 patients with depression who completed a yoga training programme.
  • Sharma et al, (2006) in their randomized controlled study showed that Sahaj Yoga practice can lead to additional improvement in executive functions like manipulation of information in the verbal working memory, attention span and visuo-motor speed of patients suffering from depression.
  • Sharma et al, (2005) in their randomized controlled study showed that the number of patients who went into remission after two months of Sahaj Yoga practice were significantly higher those of the control.
Yoga for psychiatric disorders in childhood: Only two Indian papers from the same study have been published testing the efficacy of yoga for autistic children. However no published literature in the last one tear looks ate the effect of yoga for childhood psychiatric disorders such as Attention Deficit Hyperactivity Disorder (ADHD), Mental Retardation (MR) or Learning Disability (LD).
  • Radhakrishna (2010) in an uncontrolled study presented a specially designed Integrated Approach to Yoga Therapy module children with Autism Spectrum Disorders over a period of two academic years. They concluded that guided imitation of therapist body positions stimulated mirror neuron activation, resulting in improved sense of self.
  • Radhakrishna et al., (2010) in another paper described that the  Integrated Yoga Therapy Approach (IAYT) is an effective tool to increase imitation, cognitive skills and social-communicative behaviors in children with Autism spectrum disorders
In the last one decade no studies have been published which have used yoga as an intervention for treatment of anxiety related disorders (such as Obsessive Compulsive Disorder (OCD), Post Traumatic Stress Disorder (PTST), Panic Disorder) or for drug induced psychiatric disorders (such as alcohol dependent syndrome, nicotine dependent syndrome etc).
A look at the above published literature in the last one decade reveals that a lot more of work and research to test the efficacy of yoga as an intervention either as a complementary or as an alternative therapy requires to be conducted for patients suffering from different psychiatric ailments. A critique of the above review would be: (1) Hardy any of the studies have developed and tested a yoga programme based on the needs of the subjects studied. (2) To enable yoga based studies to have far reaching implications and greater generalizability, sound methodology (i.e. controlled design, rater blinding) should be adopted to test the efficacy of yoga as an intervention. Only some studies randomly selected their sample and none of the studies used the method of rater blinding. Hence the role of researcher bias cannot be ruled out, (3) Yoga models described by authors have provided their own rationale behind the choice of yoga asanas/programme. However there is no mention whether these programmes have been endorsed by other specialists in the field than the researcher themselves. (4) Along with the efficacy of yoga, the barriers to yoga therapy also requires good discussion (attrition and drop-out in yoga) to translate yoga into an effective alternative treatment option in the community. Very few studies reviewed have discussed the reasons for attrition or retention in the yoga programme.
In order to make yoga widely acceptable and applicable to all patients suffering from psychiatric disorders, rigorous methodological trials testing the efficacy of yoga on each of the psychiatric disorders should be conducted. Caution should be taken to control all the biases and extraneous factors related to the research, so that the validity, reliability and generalizability of the results could be authenticated. Only if yoga emerges to be effective through the rigors of clinical research will ever the scientific as well as the mental health community consider accepting yoga as a valid treatment methodology for treatment of psychiatric patients.
References: 
  1. Behere RV, Arasappa R, Jagannathan A, Varambally S, Venkatasubramanian G, Thirthalli J, Subbakrishna DK, Nagendra HR, Gangadhar BN (2011). Effect of yoga therapy on facial emotion recognition deficits, symptoms and functioning in patients with schizophrenia. Acta Psychiatrica Scandinavia, Vol 123 (2); pp: 147 -53
  2. Duraiswamy G, Thirthalli J, Nagendra HR and Gangadhar BN (2007). Yoga therapy as an add-on treatment in the management of patients with schizophrenia–a randomized controlled trial. Acta Psychiatrica Scandinavia, 116 (3); pp: 226-32
  3. Radhakrishna S (2010). Application of integrated yoga therapy to increase imitation skills in children with autism spectrum disorder. International Journal of Yoga, 3 (1); pp:26-30.
  4. Radhakrishna S, Nagarathna R and Nagendra HR (2010). Integrated approach to yoga therapy and autism spectrum disorders. J Ayurveda Integr Med, 1 (2); pp: 120-4.
  5. 5 Sadock BJ and Sadock VA (2000). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 7th Edition. Lippincott Williams & Wilkins. USA
  6. Shapiro D, Cook IA, Davydov DM, Ottaviani C, Leuchter AF and Abrams M (2007). Yoga as a Complementary Treatment of Depression: Effects of Traits and Moods on Treatment Outcome. Evidence based complementary and alternative medicine, 4(4), pp: 493-502.
  7. Sharma VK, Das S, Mondal S, Goswami U and Gandhi A, (2006). Effect of Sahaj Yoga on neuro-cognitive functions in patients suffering from major depression. Indian J Physiol Pharmacol, Oct-Dec, 50(4); pp:375-83.
  8. Sharma VK, Das S, Mondal S, Goswampi U and Gandhi A (2005). Effect of Sahaj Yoga on depressive disorders. Indian J Physiol Pharmacol, Oct-Dec, 49(4); pp:462-8.
  9. Uebelacker LA, Tremont G, Epstein-Lubow G, Gaudiano BA, Gillette T, Kalibatseva Z and Miller IW (2010).  Open trial of Vinyasa yoga for persistently depressed individuals: evidence of feasibility and acceptability. Behav Modif, May, 34(3); pp: 247-64.
  10. Vancampfort D, De Hert M, Knapen J, Wampers M, Demunter H, Deckx S, Maurissen K and Probst M (2011). State anxiety, psychological stress and positive well-being responses to yoga and aerobic exercise in people with schizophrenia: a pilot study. Disabil Rehabil, 33(8); pp: 684-9.
  11. Visceglia E and Lewis S (2011). Yoga therapy as an adjunctive treatment for schizophrenia: a randomized, controlled pilot study. Journal of Alternative and complementary Medicine, 17(7), pp: 601-7
  12. WHO (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Helath Organization, Geneva.