Scientific studies already support yoga practice as a means to reduce symptoms of depression and anxiety.
Now a new study out of Boston University School of Medicine (BUSM) provides evidence that yoga and breathing exercises can improve symptoms of depression and anxiety in both the short term–with each session as well as cumulatively in the longer term, over three months.
Published online in the Journal of Psychiatric Practice, these findings suggest yoga can be a helpful complementary treatment for clinical depression or major depressive disorder.
A group of 30 clinically depressed patients were randomly divided into two groups. Both groups engaged in lyengar yoga and coherent breathing with the only difference being the number of instructional and home sessions in which each group participated.
Over three months, the high-dose group (HDG) spent 123 hours in sessions while the low-dose group (LDG) spent 87 hours.
Results showed that within a month, both groups’ sleep quality significantly improved. Tranquility, positivity, physical exhaustion and symptoms of anxiety and depression significantly improved in both groups, as measured by several validated clinical scales
“Think of it this way, we give medications in different doses in order to enact their effects on the body to varying degrees.
Here, we explored the same concept, but used yoga. We call that a dosing study.
Past yoga and depression studies have not really delved deeply into this,” explained corresponding author Chris Streeter, MD, associate professor of psychiatry at BUSM.
“Providing evidence-based data is helpful in getting more individuals to try yoga as a strategy for improving their health and well-being.
These data are crucial for accompanying investigations of underlying neurobiology that will help elucidate ‘how’ yoga works,” said study collaborator and co-author Marisa M. Silveri, PhD, neuroscientist at McLean Hospital and associate professor of psychiatry at Harvard Medical School.
Results showed that within a month, both groups’ sleep quality significantly improved. Tranquility, positivity, physical exhaustion and symptoms of anxiety and depression significantly improved in both groups, as measured by several validated clinical scales.
Depression, a condition that affects one of every seven adults in the U.S. at some point in their lives, is treated with a variety of modalities, including counseling (especially through cognitive-behavioral therapy) and medication. Research has shown combining therapy and medication has greater success than either treatment alone. Although studies with more participants would be helpful in further investigating its benefits, this small study indicates adding yoga to the prescription may be helpful.
Funding: Funding for this study was provided by grants R21AT004014 and R01AT007483 (CCS), M01RR00533 from the Boston University Clinical and Translational Science Institute (CTSI), and U11RR025771 (General Clinical Research Unit at Boston University Medical Center) and K23AT008043 (MBN).
Drs. Brown and Gerbarg teach and have published Breath-Body-Mind©, a multi-component program that includes coherent breathing. Dr. Streeter is certified to teach Breath-Body-Mind©. The other authors declare no conflicts of interest.
Background: Meditation, yoga, and mindfulness are popular interventions at universities and tertiary education institutes to improve mental health. However, the effects on depression, anxiety, and stress are unclear. This study assessed the effectiveness of meditation, yoga, and mindfulness on symptoms of depression, anxiety, and stress in tertiary education students.
Methods: We searched Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, PsycINFO and identified 11,936 articles. After retrieving 181 papers for full-text screening, 24 randomized controlled trials were included in the qualitative analysis. We conducted a random-effects meta-analysis amongst 23 studies with 1,373 participants.
Results: At post-test, after exclusion of outliers, effect sizes for depression, g = 0.42 (95% CI: 0.16–0.69), anxiety g = 0.46 (95% CI: 0.34–0.59), stress g = 0.42 (95% CI: 0.27–0.57) were moderate. Heterogeneity was low (I2 = 6%). When compared to active control, the effect decreased to g = 0.13 (95% CI: −0.18–0.43). No RCT reported on safety, only two studies reported on academic achievement, most studies had a high risk of bias.
Conclusions: Most studies were of poor quality and results should be interpreted with caution. Overall moderate effects were found which decreased substantially when interventions were compared to active control. It is unclear whether meditation, yoga or mindfulness affect academic achievement or affect have any negative side effects.
Rationale
Every 12 months, between 7 and 16% of students in tertiary education experience a mood or anxiety disorder and a further 30% of students report experiencing moderate to severe levels of stress (1–4).
It is important to tackle poor mental health early as unattended symptoms can contribute to poorer clinical outcomes such as an increased risk of developing a clinical diagnosis or relapse (5). When in distress, few students seek or receive treatment (6). This is due to several barriers such as stigma and lack of awareness of services (6).
Mindfulness, meditation, and yoga have been coined as a non-stigmatizing alternative to traditional mental health support. They are highly popular tools at tertiary education institutes and used for stress reduction, improve productivity and general mental health (7).
Yoga, mindfulness, and meditation are part of a suite of interventions called mind-body interventions (8). They are closely related practices and share underlying common principles and therapeutic elements grounded in religion and spirituality (9–12).
The most commonly known and offered mindfulness program is Mindfulness-Based Stress Reduction (13). MBSR includes a set of specific mindfulness practices including focused attention on the breath, “body-scanning,” prosocial meditation (e.g., loving kindness and compassion), and gentle hatha yoga. MBSR is different from Mindfulness-Based Cognitive Therapy (MBCT) as it includes cognitive therapeutic elements such as cognitive restructuring and is aimed at reducing depressive relapse (14).
Yoga is defined as a variety of practices which includes postures, breathing exercises, meditation, mantras, lifestyle changes spiritual beliefs, and/or rituals (15). A frequently practiced form of yoga is Hatha Yoga, which includes asanas (postures, pranayama (breathing exercises) and meditation, usually integrated throughout the practice (16).
Several reviews have been conducted to assess the effects of mindfulness and yoga-based interventions on a range of outcomes and populations. Reviews assessing the evidence for yoga have covered PTSD (17), depression (18, 19), anxiety (20), and physiological measures of stress (21, 22). For mindfulness and meditation interventions, reviews have assessed mood, and general functioning of students (23), employee mental health (24), stress management (25, 26), depression, stress and wellbeing (27), recurrent depression (28), and anxiety (27, 29).
The reviews are wide-ranging in their conclusions and offer mixed results. Whilst the majority of reviews suggest preliminary evidence for their effectiveness, the authors often comment on the need for more rigorous research in this area.
The debate about the effects of these alternative medicine interventions thus remains. A recent review by Goyal et al. (27) found a pool of low-quality studies, with limited evidence for effect especially when compared to specific active treatment control conditions such as behavioral therapies, relaxation interventions, or exercise.
It is important to address the effects of these interventions for students, clinicians and commissioners to make evidence-based decisions about the provision of mental health support at university. Whilst widely accessed, it is unclear whether yoga, mindfulness, or meditation have a beneficial effect on mental health or academic achievement in young adults beyond placebo.
Objectives
This systematic review and meta-analysis aims to study the effectiveness of both yoga and mindfulness-based interventions on stress, depression, anxiety, and academic achievement for students in tertiary education.+
Results
Selection and Inclusion of Studies
After screening 11,936 abstracts, 181 studies were retrieved and coded. Of these 181 studies, 58 studies covered a meditation, yoga or mindfulness intervention. Subsequently, we identified 24 studies as fitting our inclusion criteria, for further detail on study selection, please see Figure 1.
Study Characteristics
Out of 24 included studies in both the quantitative and qualitative analysis, nine were conducted on the North American continent, 12 in Asia, and three in Europe. Eighty-three percent of participants were female. All studies used a “convenience sample” and most studies were conducted with participants from a medical faculty (N = 14).
With regards to symptom levels in the sample, only one study excluded participants with low scores on the Penn State Worry Questionnaire (47). All other studies were aimed at a healthy or subclinical population. A further overview of study characteristics can be found in Table 2.
Table 2
Study characteristics.
| Study | Country | Target group | N | Intervention | Control | N intervention | N Control | Exam setting | Measure | Follow-up | N groups |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Malathi and Damodaran (48) | India | Medical university students | 50 | Yoga | Wait list | 25 | 25 | Y | STAI | No | 2 |
| Tloczynski (49) | USA | University students | 10 | Meditation | No treatment | 3–4 | 3 | N | CAS | 2 weeks, 4 weeks | 3 |
| Chang (50) | USA | Music major and graduate students | 19 | Meditation | Wait list | 9 | 10 | Y | PAI | No | 2 |
| Nidich et al. (51) | USA | University students | 207 | Meditation | Wait list | 93 | 114 | N | POMS | No | 2 |
| Gopal et al. (52) | India | MBSS students | 60 | Yoga | No treatment | 30 | 30 | Y | GARS, STAI-S | No | 2 |
| Kim (53) | Korea | Nursing students | 30 | Yoga | No treatment | 15 | 15 | N | ISSCS | No | 2 |
| Nemati (54) | Iran | MA post graduate students | 107 | Yoga | No treatment | 58 | 49 | Y | TAS | No | 2 |
| Shankarapillai et al. (55) | India | Dental students | 100 | Yoga | Active control (Psycho-education) | 50 | 50 | Y | STAI | No | 2 |
| Sharma et al. (56) | India | Medical, nursing and allied medical sciences | 90 | Fast pranayama (Yoga) OR slow pranayama (Yoga) | No treatment | 30–30 | 30 | N | PSS | No | 3 |
| Erogul et al. (57) | USA | 1st year medical students | 57 | Mindfulness Based Stress Reduction | No treatment | 28 | 29 | N | PSS | 6-months | 2 |
| Song and Lindquist (58) | Korea | Nursing students | 44 | Mindfulness Based Stress Reduction | Wait list | 21 | 23 | N | DASS-21 | 6-months | 2 |
| Esch et al. (59) | Germany | University students | 43 | Mindfulness Based Stress Reduction | Wait list | 24 | 19 | N | PSS | No | 2 |
| Shapiro et al. (32) | USA | Premedical and medical students | 78 | Mindfulness Based Stress Reduction | Wait list | 37 | 41 | Y | STAI, SCL-90-D | No | 2 |
| van Dijk et al. (60) | Netherlands | First year clinical clerkship students | 167 | Mindfulness Based Stress Reduction | No treatment | 83 | 84 | N | BSI | 3, 7, 12, 15, 20-months | 2 |
| Paholpak et al. (61) | Thailand | Fifth year medical students | 58 | Meditation | No treatment | 30 | 28 | N | SCL-90 | No | 2 |
| Call et al. (47) | USA | Psychology students | 91 | Yoga or Mindfulness | Wait list | 29–27 | 35 | N | DASS-21 | No | 3 |
| Danilewitz et al. (62) | Canada | Pre-clerkship students | 30 | Mindfulness | Wait list | 15 | 15 | N | DASS-21 | No | 2 |
| Greeson et al. (63) | USA | Undergraduate, graduate, professional students | 90 | Meditation (and Mindfulness) | Wait list | 45 | 45 | N | PSS | No | 2 |
| Kvillemo et al. (64) | Sweden | University students | 76 | Mindfulness Based Stress Reduction | Active control (Expressive writing) | 40 | 36 | N | CES-D | No | 2 |
| Chen et al. (29) | China | Nursing students | 60 | Meditation (and Mindfulness) | No treatment | 30 | 30 | N | SAS, SDS | No | 2 |
| Kang et al. (65) | Korea | Nursing students | 32 | Mindfulness (and Meditation) | No treatment | 16 | 16 | N | STAI, BDI, PWI-SF | No | 2 |
| Ratanasiripong et al. (66) | Thailand | Nursing students | 89 | Meditation (and Mindfulness) | Active control (Biofeedback training) | 29–29 | 31 | N | STAI-S, PSS | No | 2 |
| Shearer et al, (67) | USA | Psychology students | 74 | Mindfulness Based Stress Reduction | No treatment or active control (Dog therapy) | 27–25 | 22 | N | STAI-S, BDI | 1 and 2 weeks | 3 |
| Yazdani et al. (68) | Iran | Nursing students | 38 | Yoga | No treatment | 19 | 19 | N | GHQ | 4-weeks | 2 |
BDI, Beck Depression Inventory; BSI, Brief Symptom Inventory; CAS, College Adjustment Scale; CES-D, The Center for Epidemiologic Studies Depression Scale; DASS-21, Depression Anxiety Stress Scale-21; GARS, Global Assessment Of Recent Stress Scale; GHQ, Goldberg and Hiller’s General Health Questionnaire; LSSCS, Life Stress Scale for College Students; PAI, Performance Anxiety Inventory; POMS, Profile of Mood States; PSS, Perceived Stress Scale; PWI-SF, Psychosocial Well-being Index-Short Form; SAS, Self-Rating Anxiety Scale; SCL-90, Symptom Checklist-90; SCL-90-D, Symptom Checklist-90-Depression Scale; SDS: Self-Rating Depression Scale; STAI, State-Trait Anxiety Inventory (T, Trait; S, State); TAS, Test Anxiety Scale; VAS-A, Visual Analog Scale for Anxiety.
Out of 24 studies, the average rating of research allegiance was 2.63 and three studies scored 5/5. Eight studies provided information on ethnicity, of these, most participants were Caucasian (68%, N = 484), followed by Asian (12%, N = 88) and African/ African American (10%, N = 72).
The average length of the intervention was ~7 weeks. On average, participants practiced meditation yoga or mindfulness for 153 min each week, totalling to overall average exposure at 19 h and 36 min. All studies but two were offered in a group setting, with two offered as self-help, one of these approaches was an internet-based intervention. Four treatment-control comparisons utilized an active control, 10 studies used wait-list control and 10 provided no treatment. Please see Table 3 for a further specification of intervention characteristics.
Table 3
Intervention characteristics.
| Study | Intervention type | Description of intervention | Guidance | Delivery | Average duration per week (min.) | Length (weeks) | Exposure |
|---|---|---|---|---|---|---|---|
| Call et al. (47) | Hatha yoga (Yoga) Body scan (Mindfulness) | Psychoeducation, breathing exercises, awareness, and acceptance | Guided | Group | 45 | 3 | 135 |
| Chang (50) | Meditation | Psychoeducation, discussion about personal meditation experiences, discussions about personal meditation experiences. | Guided | Group | 225 | 8 | 1,800 |
| Chen et al. (69) | Meditation | Psychoeducation, breathing, awareness of thoughts, and feelings | Guided | Group | 210 | 1 | 210 |
| Danilewitz et al. (62) | Mindfulness | Common problems of medical students (work-life-balance, perfection etc.), being mindful in clinical experiences | Guided | Group | 75 | 8 | 600 |
| Erogul et al. (57) | Mindfulness based stress reduction | Psychoeducation on stress, body scan, breathing | Guided | Group | 253.5 | 8 | 2,028 |
| Esch et al. (59) | Mindfulness based stress reduction | Psychoeducation on stress and related topics, relaxation exercises, retrospection | Guided | Group | 120 | 8 | 960 |
| Gopal et al. (52) | Yoga | Yogic prayer, micro and macro exercises, asanas postures, pranayama, and dhyana meditation | Guided | Group | 245 | 12 | 2,940 |
| Greeson et al. (63) | Meditation | Koru meditation. Breathing exercises, walking meditation, guided imagery, eating meditation | Guided | Group | 145 | 4 | 580 |
| Kang et al. (65) | Mindfulness | Body scan, breathing meditation, walking meditation, gratitude exercises | Guided | Group | 90 | 8 | 720 |
| Kim et al. (53) | Yoga | Breathing and relaxation exercises, mediation | Guided | Group | 420 | 12 | 5,040 |
| Kvillemo et al. (64) | Mindfulness | Theoretical foundations of mindfulness regarding relaxation, meditation, and the body-mind connection. Each weekly module consisted of a few pages of text (i.e., the lecture) and a set of exercises | Unguided | Online self-help | 226.25 | 8 | 2,130 |
| Malathi, and Damodaran (48) | Yoga | Yogic prayer | na | na | 180 | 12 | 2,160 |
| Nemati (54) | Yoga | Pranayama Yoga. Sitting quietly, breathing techniques, positive mantras | Guided | Group | Unclear | One full semester | Unclear |
| Nidich et al. (51) | Meditation | Transcendental Meditation, psychoeducation about TM and discussion about effectiveness | Guided | Group | Unclear | 12 | Unclear (at least 460) |
| Paholpak et al. (61) | Meditation | Breathing Meditation. mindful awareness, breathing exercises | Guided | Group | 145 | 4 | 580 |
| Ratanasiripong et al. (66) | Meditation | Psychoeducation on Vipassana meditation | Guided | Group + self-help | Unclear | 4 | Unclear |
| Shankarapillai et al. (55) | Yoga | Yoga postures, breathing exercises, guided relaxation | Guided | Group | 60 | 1 | 60 |
| Shapiro et al. (32) | Mindfulness based stress reduction | Sitting Meditation, body scan, Hatha Yoga, loving kindness, and forgiveness mediation | Guided | Group | 150 | 7 | 1050 |
| Sharma et al. (56) | Yoga (2 types) | Fast pranayama: various rapid breathing techniques, relaxation techniques; slow pranayama: slow breathing techniques, relaxation techniques | Guided | Group | 90 | 12 | 1,080 |
| Shearer et al, (67) | Mindfulness | Breathing exercises, stretching and balancing exercises, psychoeducation on stress | na | Group | 60 | 4 | 240 |
| Song and Lindquist (58) | Mindfulness based stress reduction | Body scan, sitting meditation, Hatha yoga, mindful walking, standing, and eating | Guided | Group | 120 | 8 | 960 |
| Tloczynski (49) | Meditation | Opening up meditation, attending uncritically | Guided | na | 167 | 4 | 668 |
| van Dijk et al. (60) | Mindfulness based stress reduction | Interactive presentation each week related to the session theme (e.g., awareness of stress)Recognizing Automatic Behavior, Influence of Perception, Recognizing Boundaries, Awareness of Stress, Communication, work-life balance | Guided | Group | 120 | 8 | 960 |
| Yazdani et al. (68) | Yoga | Laughter yoga. Relaxation techniques, breathing exercises, laughter yoga techniques | Guided | Group | 120 | 4 | 480 |
In two comparisons symptom scores were higher in the intervention group at post-test. In one case this was when the intervention was compared to an inactive control (69). In the other, the intervention performed worse compared to an active control (66). No studies reported any further adverse effects.
Source:
Boston University School of Medicine
Media Contacts:
Gina DiGravio – Boston University School of Medicine
Image Source:
The image is in the public domain.
Original Research: Closed access
“Psychological Function, Iyengar Yoga, and Coherent Breathing: A Randomized Controlled Dosing Study”. Chris Streeter at al.
Journal of Psychiatric Practice doi:10.1097/PRA.0000000000000435.
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