Yoga intervention reduces symptoms of depression and anxiety

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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 (14).

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 (912).

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 (1819), anxiety (20), and physiological measures of stress (2122). For mindfulness and meditation interventions, reviews have assessed mood, and general functioning of students (23), employee mental health (24), stress management (2526), depression, stress and wellbeing (27), recurrent depression (28), and anxiety (2729).

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.

StudyCountryTarget groupNInterventionControlN interventionN ControlExam settingMeasureFollow-upN groups
Malathi and Damodaran (48)IndiaMedical university students50YogaWait list2525YSTAINo2
Tloczynski (49)USAUniversity students10MeditationNo treatment3–43NCAS2 weeks, 4 weeks3
Chang (50)USAMusic major and graduate students19MeditationWait list910YPAINo2
Nidich et al. (51)USAUniversity students207MeditationWait list93114NPOMSNo2
Gopal et al. (52)IndiaMBSS students60YogaNo treatment3030YGARS, STAI-SNo2
Kim (53)KoreaNursing students30YogaNo treatment1515NISSCSNo2
Nemati (54)IranMA post graduate students107YogaNo treatment5849YTASNo2
Shankarapillai et al. (55)IndiaDental students100YogaActive control (Psycho-education)5050YSTAINo2
Sharma et al. (56)IndiaMedical, nursing and allied medical sciences90Fast pranayama (Yoga) OR slow pranayama (Yoga)No treatment30–3030NPSSNo3
Erogul et al. (57)USA1st year medical students57Mindfulness Based Stress ReductionNo treatment2829NPSS6-months2
Song and Lindquist (58)KoreaNursing students44Mindfulness Based Stress ReductionWait list2123NDASS-216-months2
Esch et al. (59)GermanyUniversity students43Mindfulness Based Stress ReductionWait list2419NPSSNo2
Shapiro et al. (32)USAPremedical and medical students78Mindfulness Based Stress ReductionWait list3741YSTAI, SCL-90-DNo2
van Dijk et al. (60)NetherlandsFirst year clinical clerkship students167Mindfulness Based Stress ReductionNo treatment8384NBSI3, 7, 12, 15, 20-months2
Paholpak et al. (61)ThailandFifth year medical students58MeditationNo treatment3028NSCL-90No2
Call et al. (47)USAPsychology students91Yoga or MindfulnessWait list29–2735NDASS-21No3
Danilewitz et al. (62)CanadaPre-clerkship students30MindfulnessWait list1515NDASS-21No2
Greeson et al. (63)USAUndergraduate, graduate, professional students90Meditation (and Mindfulness)Wait list4545NPSSNo2
Kvillemo et al. (64)SwedenUniversity students76Mindfulness Based Stress ReductionActive control (Expressive writing)4036NCES-DNo2
Chen et al. (29)ChinaNursing students60Meditation (and Mindfulness)No treatment3030NSAS, SDSNo2
Kang et al. (65)KoreaNursing students32Mindfulness (and Meditation)No treatment1616NSTAI, BDI, PWI-SFNo2
Ratanasiripong et al. (66)ThailandNursing students89Meditation (and Mindfulness)Active control (Biofeedback training)29–2931NSTAI-S, PSSNo2
Shearer et al, (67)USAPsychology students74Mindfulness Based Stress ReductionNo treatment or active control (Dog therapy)27–2522NSTAI-S, BDI1 and 2 weeks3
Yazdani et al. (68)IranNursing students38YogaNo treatment1919NGHQ4-weeks2

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.

StudyIntervention typeDescription of interventionGuidanceDeliveryAverage duration per week (min.)Length (weeks)Exposure
Call et al. (47)Hatha yoga (Yoga) Body scan (Mindfulness)Psychoeducation, breathing exercises, awareness, and acceptanceGuidedGroup453135
Chang (50)MeditationPsychoeducation, discussion about personal meditation experiences, discussions about personal meditation experiences.GuidedGroup22581,800
Chen et al. (69)MeditationPsychoeducation, breathing, awareness of thoughts, and feelingsGuidedGroup2101210
Danilewitz et al. (62)MindfulnessCommon problems of medical students (work-life-balance, perfection etc.), being mindful in clinical experiencesGuidedGroup758600
Erogul et al. (57)Mindfulness based stress reductionPsychoeducation on stress, body scan, breathingGuidedGroup253.582,028
Esch et al. (59)Mindfulness based stress reductionPsychoeducation on stress and related topics, relaxation exercises, retrospectionGuidedGroup1208960
Gopal et al. (52)YogaYogic prayer, micro and macro exercises, asanas postures, pranayama, and dhyana meditationGuidedGroup245122,940
Greeson et al. (63)MeditationKoru meditation. Breathing exercises, walking meditation, guided imagery, eating meditationGuidedGroup1454580
Kang et al. (65)MindfulnessBody scan, breathing meditation, walking meditation, gratitude exercisesGuidedGroup908720
Kim et al. (53)YogaBreathing and relaxation exercises, mediationGuidedGroup420125,040
Kvillemo et al. (64)MindfulnessTheoretical 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 exercisesUnguidedOnline self-help226.2582,130
Malathi, and Damodaran (48)YogaYogic prayernana180122,160
Nemati (54)YogaPranayama Yoga. Sitting quietly, breathing techniques, positive mantrasGuidedGroupUnclearOne full semesterUnclear
Nidich et al. (51)MeditationTranscendental Meditation, psychoeducation about TM and discussion about effectivenessGuidedGroupUnclear12Unclear (at least 460)
Paholpak et al. (61)MeditationBreathing Meditation. mindful awareness, breathing exercisesGuidedGroup1454580
Ratanasiripong et al. (66)MeditationPsychoeducation on Vipassana meditationGuidedGroup + self-helpUnclear4Unclear
Shankarapillai et al. (55)YogaYoga postures, breathing exercises, guided relaxationGuidedGroup60160
Shapiro et al. (32)Mindfulness based stress reductionSitting Meditation, body scan, Hatha Yoga, loving kindness, and forgiveness mediationGuidedGroup15071050
Sharma et al. (56)Yoga (2 types)Fast pranayama: various rapid breathing techniques, relaxation techniques; slow pranayama: slow breathing techniques, relaxation techniquesGuidedGroup90121,080
Shearer et al, (67)MindfulnessBreathing exercises, stretching and balancing exercises, psychoeducation on stressnaGroup604240
Song and Lindquist (58)Mindfulness based stress reductionBody scan, sitting meditation, Hatha yoga, mindful walking, standing, and eatingGuidedGroup1208960
Tloczynski (49)MeditationOpening up meditation, attending uncriticallyGuidedna1674668
van Dijk et al. (60)Mindfulness based stress reductionInteractive 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 balanceGuidedGroup1208960
Yazdani et al. (68)YogaLaughter yoga. Relaxation techniques, breathing exercises, laughter yoga techniquesGuidedGroup1204480

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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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