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Abstract

Yoga has been in use for thousands of years in the East as a healing modality. Western practitioners are now starting to recognize the potential of yoga-based treatments. The purpose of this article is to explore the evidence-base of yoga-based treatments for depression and anxiety with the purpose of furthering the integration of yoga into conventional Western mental health treatment plans.
Yoga has been practiced in Eastern cultures as a form of spiritual development and healing for over 4,000 years. In the West, while yoga was initially practiced as a form of physical exercise, it is now being studied as a treatment for a variety of disorders. A large-scale survey (N=31,044) showed that yoga was already self-reportedly commonly used to treat mental health conditions and musculoskeletal conditions; most subjects reported that yoga helped these symptoms (1). Because individuals are already using yoga to self-manage mental health conditions, it would be reasonable for mental health professionals to evaluate the evidence and, as appropriate, integrate the use of yoga-based treatments (YBTs) into their treatment plans. Yoga is not a substitute for conventional mental health care, but it may be a valuable adjunct to mental health treatment.
During the past decade, yoga has grown in popularity in the West. The National Health Interview Survey showed that, from 2002 to 2012, the number of Americans who practice yoga increased among all age groups: from 6.3% to 11.2% for those 18–44 years of age; from 5.2% to 7.2% for those 45–64 years of age; and from 1.3% to 3.3% for those 65 years of age and older (2). This increased interest is reflected in the growing number of research studies and publications that investigate yoga as an intervention to treat various physical and mental health conditions (3). It is notable that some of the medical conditions that have shown benefits from yoga-based interventions are disorders that are exacerbated by stress, such as: cardiovascular disorders (4), chronic low back pain (5), breast cancer (6), hypertension (7), irritable bowel syndrome (8), and fibromyalgia (9). In the United States, the National Health Statistics Reports of 2007 reported that, in the past 12 months, various yoga-based practices (YBPs) were used, with 12.7% using deep-breathing exercises, 9.4% practicing meditation, and 6.1% participating in yoga (10).
There is a gap between the usage of yoga by individuals and yoga’s integration into conventional health care. A survey by the Epilepsy Foundation of Arizona reported that 44% of the epileptic population had used complementary and alternative medicine (CAM) treatments for management of their seizures, including acupuncture, botanicals/herbals, chiropractic care, magnets, prayer, stress management, and yoga. In this survey, 22% of the responders used stress management for seizure control, and of that group, 68% perceived this intervention as beneficial. Yoga was used by 6% of responders for seizure control, and of that group, 57% perceived yoga as beneficial. Only five of the 46 (10%) health care professionals surveyed reported actively encouraging CAM therapies in the form of stress management or prayer (11). This study suggests that patients with epilepsy are choosing CAM-related therapies as adjunctive treatments for the management of their seizure disorder at a greater rate than physicians are recommending it. In another study, 61% of surveyed yoga users felt that yoga was important for maintaining health, but only 25% disclosed their yoga practice to their medical professionals (1). In December 2014, Congress changed the name of the National Center for Complementary and Alternative Medicine (NCCAM) to the National Center for Complementary and Integrative Health (NCCIH) to reflect the trend toward integrating complementary methodologies into conventional medical treatment programs and to convey that “alternative” approaches are no longer seen as alternative to Western medicine but are used in conjunction with Western medical approaches (12). One of the limits to integrating YBPs into a conventional treatment plan is the lack of training and education that mental health professionals receive in this discipline. To address that gap, the following information regarding evidence-based studies on YBTs is provided.

What Is Yoga?

The Yoga Sutras of Patanjali conceptualizes the practice of yoga as comprising the following eight limbs (13): yamas (the five moral restraints—nonviolence, truthfulness, nonstealing, moderation, and nonhoarding); niymas (the five observances—purity, contentment, zeal/austerity, self-study, and devotion to a higher power); asanas (postures); pranayama (mindful breathing); pratyahara (turning inward); dharana (concentration); dhyana (meditation); and samadhi (union of the self with object of meditation) (13, 14). Most research studies focus on asanas (postures), pranayama (mindful breathing), and dhyana (meditation). The eight limbs were developed to be used together so that the ability to study them in isolation is difficult. This poses a challenge to the scientific method that is designed to measure changes in clearly defined dependent variables. Yoga was designed so that all eight limbs were to be practiced in sequence. The Western proclivity for studying component parts, such as postures, mindful breathing, and meditation, highlights the difference between Eastern and Western approaches to healing. There is, accordingly, a conflict between the Western view of dissecting healing modalities into component parts and the practice of yoga in which the component parts are designed to be used simultaneously. For example, it is hard to perform a posture correctly without simultaneously concentrating on the form and breath. This creates problems regarding a consistent means of describing YBTs in the scientific literature.
Breath, or pranayama, is essential to life. Breathing abnormalities are associated with distress and discomfort. For example, panic is associated with rapid shallow breathing. Rapid breathing can make one feel anxious by increasing sympathetic activity, the part of the nervous system responsible for the fight-or-flight response (15). Alternatively, slow breathing (two to four breaths per minute) with exhalation greater than inhalation, and holding of the breath at the end of inhalation or exhalation, increases parasympathetic activity and is associated with relaxation (16). Cultures all over the world have figured out the importance of the breath and breathing practices. Chants and singing are examples of “exhalation greater than inhalation” practices that improve balance in the autonomic nervous system (ANS) (17). Many disorders that mental health professionals treat, such as depression, anxiety, and posttraumatic stress disorder (PTSD), have low parasympathetic activity (18).

What Is Hatha Yoga?

Hatha yoga is the most popular form of yoga in the United States and, frequently, the yoga practice used in research studies. Although the book The Yoga Sutras of Patanjali describes the postures as physical, the postures and breathing exercises are practiced so that the mind can be still for meditation and concentration. The schools of Hatha yoga vary in emphasis on breath, postures, and meditation. There is a range of physical intensity and spiritual focus across different forms of yoga practice (19). Some popular types of Hatha yoga include Iyengar yoga (alignment of the body postures, or asanas), Vinyasa yoga (from the word meaning “to flow,” breath-linked movement involving asanas and pranayama), Sudarshan Kriya yoga (SKY; almost exclusively breathing [pranayama]), Bikram yoga (physically intense and posture focused, with two breathing exercises; performed in a heated environment), and Ashtanga yoga (which involves synchronizing the breath with a progressive series of postures).

Socioeconomic and Gender Considerations as Barriers to Yoga Practice

Research has shown that yoga users tend to be primarily female, Caucasian, younger, and college educated (1, 20). Mental health professionals, therefore, need to be aware of the potential barriers to entry for low-socioeconomic populations. Leisure time and access to a yoga studio (both financially and geographically) must be considered when working with marginalized populations, particularly considering the demands of working multiple jobs and child-care/family responsibilities. A study of chronic low back pain in low-income minority participants found that, although yoga was perceived as effective for pain relief, mood improvement, and stress management, lack of time represented the greatest barrier to practice (21). Given the increased burden of disease found in lower socioeconomic populations (22), this study highlights the need to make yoga-based interventions accessible to lower income populations.

Scope

The primary focus of this article is on the potential of yoga postures and/or breathing as a treatment for depression and anxiety disorders, because these disorders have been the most formally studied. The use of yoga for individuals with psychosis, bipolar disorder, eating disorders, and addiction is beyond the scope of this article. Although there is mounting evidence that mindfulness and other meditative practices are helpful for a variety of mental health conditions, these interventions are also beyond the scope of the present article.

Depression and Yoga: Empirical Evidence and Clinical Considerations

Of the major psychiatric disorders, depression has a compelling literature supporting the use of yoga as a treatment, even though there are limitations in the current literature base. A 2013 meta-analysis of yoga for the treatment of depressive symptoms and major depressive disorder (MDD) included 12 randomized controlled trials (RCTs) and found evidence to support short-term ancillary effects, despite methodological limitations (23). The most recent systematic review of yoga as a treatment specifically for patients with MDD found 7 RCTs (N=240) that compared yoga to different control conditions: 2 studies used attentional controls (24, 25); 1 study used exercise as the control intervention (26); 1 study used electroconvulsive therapy (ECT) or antidepressant medication as the active control (27); 1 study used medication monotherapy as an active control (27); and 2 studies tested yoga as an add-on to antidepressant medication (28, 29). Yoga was comparable with exercise and medication only, although ECT produced stronger effects. For add-on medication and attentional control groups, one study found positive effects and the other did not (30). A recent RCT of yoga versus health education classes found that, for individuals with residual symptoms of depression (N=122), reductions in depression in the yoga group emerged at 3 and 6 months after 10 weeks of yoga but not at the primary 10-week endpoint (31).
A substantial proportion of patients with MDD (approximately 30%–40%) do not achieve full remission with antidepressants (32, 33). Open-label studies suggest that the addition of a yoga-based intervention for those who are taking antidepressant medications but who are still symptomatic is worthy of consideration and additional research (18, 34, 35). Some advantages of using YBTs include the lack of medication side effects and interactions, subjects’ reluctance to take antidepressant medications, the potential application in pregnant populations where concerns about medication-related toxic effects on the fetus are common (36, 37), and the lack of stigma. This supports consideration of YBTs as an adjunct for symptomatic individuals.
There are few dosing studies related to the use of yoga as a treatment for mental health disorders. A recent randomized controlled dosing study of individuals with MDD found that both twice- or thrice-weekly 90-min sessions of Iyengar yoga plus coherent breathing of 5 breaths per minute in addition to homework were equally effective for both remission and response, as measured by the Beck Depression Inventory–II (BDI-II) (38); the thrice-weekly dose outperformed the twice-weekly regimen with respect to reducing BDI-II scores ≤10 (34). This was the first study to explore dosing in an MDD population, and it suggests that 90-min Iyengar yoga classes two to three times per week plus homework may be enough to reduce depressive symptoms. More evidence-based research is needed to define treatment parameters. This does not mean, however, that individuals who are currently suffering should be deprived of this potential form of treatment.

Anxiety Disorders and Yoga: Empirical Evidence and Clinical Considerations

Generalized Anxiety Disorder (GAD) and Yoga

There are some studies that provide evidence for the use of yoga as a treatment for anxiety disorders. In terms of GAD, there are two single-arm trials of a yoga intervention as an adjunctive treatment for GAD. Results from both studies showed improved anxiety symptoms over time (39). One study evaluated the efficacy of SKY as an adjunctive treatment in patients with GAD. Of the 31 participants, 73% responded with a significant reduction in GAD symptoms, with a 41% remission rate as measured on the Hamilton Anxiety Rating Scale (40). Yoga has also been used in conjunction with cognitive-behavioral therapy (CBT) in GAD; this suggests that yoga could potentially be used as an adjunct to antidepressant and anxiolytic medications, as well as in combination with CBT (41)

Obsessive–Compulsive Disorder (OCD) and Yoga

To date, there has been one small RCT (N=21) for OCD using Kundalini yoga, with an emphasis on breathing practices. Three months of Kundalini yoga and mantra meditation was compared with the relaxation response plus mindfulness meditation. The Kundalini yoga group showed a statistically significant decrease in Yale-Brown Obsessive Compulsive Scale scores when compared with the relaxation response plus mindfulness meditation condition (42).

PTSD and Yoga

Numerous studies have shown that practicing yoga on a regular basis can reduce PTSD symptoms, even in people with chronic, treatment-resistant PTSD. In a study investigating the impact of a yoga intervention for PTSD in a group of 80 members (9 men, 71 women; median participant age=41 years), the yoga group showed significantly greater improvement in scores for PTSD, insomnia, perceived stress, positive and negative affect, resilience, stress, and anxiety in comparison with the waitlist control group (43). A 10-week RCT assessing the efficacy of trauma-sensitive yoga treatment in a sample of women with chronic PTSD found that the yoga significantly reduced PTSD symptoms; 52% of participants in the yoga group, compared with 21% in the supportive health education condition, no longer met criteria for PTSD at the end of the study (44).
These studies suggest that YBTs can be helpful in decreasing symptoms in a variety of anxiety disorders. Additional research in this area is required to determine the potential efficacy, safety, and usefulness of these interventions.

Transdiagnostic Potential of Yoga: Possible Mechanism of Action

The transdiagnostic potential of yoga is in line with a shift of perspective, which focuses on symptoms versus discrete diagnoses (45). There is evidence that depression, anxiety, and PTSD (18), along with frequently comorbid medical disorders such as epilepsy (18), hypertension (46), and cardiovascular disease (47), are all associated with an imbalance of the ANS. This imbalance is manifested by decreased parasympathetic nervous system (PNS) activity and increased sympathetic nervous system (SNS) activity, which is associated with negative affective states and may be the final common pathway between negative emotions and ill health (48, 49). In addition, low PNS activity, manifested by low vagal tone or high frequency heart rate variability (HRV), is also associated with decreased activity in the GABA system in depression (50, 51), PTSD (5254), anxiety (55, 56), and epilepsy (5759). The vagal-GABA theory provides an explanation as to why yoga may decrease symptoms in disorders associated with stress (18). This theory is based on polyvagal theory, which identifies SNS activity and PNS activity in the myelinated vagus nerve as being associated with certain behavioral states (60). Although it is adaptive to have increased SNS activity during acute stress, it is not adaptive to maintain increased SNS activity chronically, as seen in chronic stress associated with noncommunicable disorders. This imbalance has implications for everyday functioning, since myelinated vagal states facilitate self-regulation and interpersonal interactions (61). The ability to socially interact or maintain social relationships is associated with improved mental and physical health, as seen in octogenarians (62). A transdiagnostic approach that considers the comorbidity of both mental and physical disorders is consistent with the results from a STAR*D report (N=2,541), which found that general medical comorbidity was 50% in a large sample of outpatients with MDD who also demonstrated greater rates of somatic symptoms, gastrointestinal symptoms, and sympathetic arousal (63).
Interventions that decrease stress and allostatic load (i.e., the physiological burden of stress on the body) and allow the individual to return to homeostasis and health are important. The ability to return from allostasis to homeostasis is a marker of resilience. The ability of YBPs to restore balance to the ANS, so that SNS activity is not too high and PNS is not too low (64, 65), should be considered as a part of a treatment plan, since it has relatively low cost (compared with conventional mental health treatments), has a low side-effect profile, and can potentially address the symptoms of mental and noncommunicable disorders (e.g., cardiovascular disease, cancer, chronic respiratory diseases, and diabetes).
Most pharmacologic treatments for MDD involve drugs that work via the monoamine system (e.g., norepinephrine, serotonin, and dopamine) so that interventions emphasizing ANS or the GABA system are novel. There is evidence that increased vagal stimulation, such as that produced by an implanted vagal nerve stimulator (VNS), improves symptoms in treatment-resistant depression (66) and epilepsy (67, 68). This is consistent with the vagal-GABA theory. There is additional evidence that low HRV and low activity in the GABA system are associated with numerous disorders exacerbated by stress such as epilepsy, depression, and PTSD (18).

Heated Yoga for Mental Health Indications

There is very little empirical literature regarding the use of heated yoga for mental health conditions. One RCT (N=52) found that, for women with emotional eating, Bikram yoga (performed in a room heated to 105°F with 40% humidity) outperformed a waitlist control for cortisol reactivity in response a stress test (69). In this same RCT, distress tolerance increased for those in the yoga condition compared with the waitlist control group (70). Another recent RCT found that, for physically inactive and stressed adults (N=63), Bikram yoga, compared with a no-treatment control, was associated with improvements in perceived stress, self-efficacy, general health, and energy/fatigue (71). In an uncontrolled study (N=54) of healthy individuals, Bikram yoga improved mindfulness and decreased stress (72). There were acute effects for regular Bikram yoga participants (N=53) after a 90-min session, regarding negative affect and state anxiety, that were greater for those with higher stress (73). The lack of an active control is a weakness is this area of the literature and needs to be addressed in future studies.
Studies have suggested that heat itself may have independent mood-enhancing properties (4047), which is reflected by the use of heat around the world; for example, sweat lodges, saunas, and hot springs. A recent article showed promising results for whole-body hyperthermia as a treatment for MDD in individuals not taking antidepressant medications, when compared with a blinded sham condition (74). Although this study was not the first of its kind (75), it was the most robust in design and effect sizes thus far. There are no known studies comparing heated versus nonheated forms of yoga for mental health indications.

Empirical Limitations and Lack of Safety Data

There are methodological limitations in the literature base with regard to yoga as treatment for mental health conditions. These include: the heterogeneity of yoga interventions and patient samples; variability in use of home practice; inadequate sample size and randomization procedures; lack of intention-to-treat analysis and blinding of outcome assessors; limited fidelity assessments; inadequate control groups; unreported dropout, relapse, and remission rates; and lack of conclusive and large-scale RCTs (3, 23, 76, 77).
There is also a lack of safety data across the board for use of yoga in mental health conditions. A recent systematic review explored the incidence of yoga-associated injuries and adverse events in international observational yoga studies (N=9,129 yoga practitioners; N=9,903 nonyoga practitioners). The lifetime incidence of adverse events during a yoga class was 22.7%, with a 12-month prevalence of 4.6%. The most common adverse events were musculoskeletal, most commonly sprains or strains and mostly of a mild or transient nature. No precautions were recommended for healthy individuals, although the authors state that studies of YBP may have lower rates of adverse events because they are highly supervised (78). This suggests that the inclusion of a qualified yoga instructor as part of a treatment plan has advantages over self-study with no supervision. A meta-analysis of RCTs of yoga found that most do not report safety data; in those studies reporting safety data, 2.2% of practitioners reported yoga-related adverse events (79). More safety data are warranted.

Overall Clinical Considerations

To date, there are no known RCTs comparing different styles of yoga against each other for different patient populations or symptoms. Providers are, therefore, without conclusive evidence regarding what form of yoga to recommend for different conditions and symptoms. As such, the optimal choice of modality or discipline of yoga cannot yet be inferred from RCTs. Clinicians will need to rely on a patient’s self-report or intuitive sense of the helpfulness or efficaciousness of a certain modality. Of course, clinician instincts and experience may be useful as well, as may discussion with yoga teachers.
The swath of yoga practices and disciplines is wide; thus, there is variability in the literature of studied forms of yoga. As with all behavioral interventions, individual differences between instructors, even with a manualized protocol, must be considered. It is difficult to standardize or know exactly what components are in each class or intervention (19). The state of yoga teacher licensure is another methodological complication of yoga research, because yoga certification is not regulated by the government. There is no consensus on standardized yoga protocols (76), although one has been detailed and published as effective for use in MDD (34). More details of YBTs would enrich future reports of rigorous trials.
There is mounting evidence that yoga is helpful for a variety of conditions and symptoms that are directly or indirectly related to mental health concerns (i.e., depression and anxiety) (3, 80), and there are no clear contraindications for the use of yoga as an adjunctive treatment. For patients who do not like to take antidepressant medications because of side effects or personal beliefs, yoga may offer an alternative. Despite limited safety data on yoga overall, and specifically across disorders/symptoms (79), it is likely that yoga has fewer side effects compared with some psychiatric medications that carry a heavy side-effect burden.
There are some barriers to the use of yoga in mental health conditions. Yoga requires a significant amount of motivation and effort, not only to attend class but also to complete a class and to maintain frequent enough practice to maximize yoga's effect on mental health. A severely depressed patient may first need to achieve at least partial symptomatic relief prior to initiating yoga practice. To maintain benefits, yoga likely requires frequent and consistent practice, which requires persistence and discipline. Postures are not easy in the beginning and can trigger frustration and self-criticism. A mental health practitioner could work through the anticipated responses to the initiation of a yoga practice, such as comparison of self to others and responding to harsh internal criticism. It may be useful to remind patients of mindfulness and noticing, or “tagging,” the self-critical thought and returning the attention back to the breath, muscles being worked, or instructor’s directions. Additionally, a clinician may want to use a standardized clinical measurement at each visit to track the patient’s progress in yoga practice to give validity to the progress being made and increase awareness around the gains that the patient has worked hard to achieve.
As it stands, patients tend to start yogic practices independently of their prescribed health care treatment plan. As a medical provider, recommending that patients alert yoga instructors to any injuries or specific needs before initiating a practice should be encouraged and may help patients feel validated in bringing their concerns to their yoga instructor. Patients could exacerbate old injuries by attempting to perform each posture without considering physical limitations, especially since a new practitioner may not know what kind of accommodations are possible or necessary. Although there are still significant gaps in the literature, it is hoped that further research will allow health care providers to prescribe dosages and modalities of yoga, modify the regimen as treatment progresses, and systematically track improvement. Yoga should not be considered a first-line treatment for any psychiatric condition at this time. Following the standard of care, especially for more acute conditions, is recommended. For example, psychotic disorders, bipolar disorder, and severe depression such as that with prominent suicidality need immediate and evidence-based approaches. That said, YBTs can likely be considered as an adjunctive intervention when designing a comprehensive treatment plan.

References

1.
Birdee GS, Legedza AT, Saper RB, et al: Characteristics of yoga users: results of a national survey. J Gen Intern Med 2008; 23:1653–1658
2.
Clarke TC, Black LI, Stussman BJ, et al: Trends in the use of complementary health approaches among adults: United States, 2002-2012. Natl Health Stat Rep 2015; (79):1–16
3.
Balasubramaniam M, Telles S, Doraiswamy PM: Yoga on our minds: a systematic review of yoga for neuropsychiatric disorders. Front Psychiatry 2013; 3:117
4.
Cramer H, Lauche R, Haller H, et al: Effects of yoga on cardiovascular disease risk factors: a systematic review and meta-analysis. Int J Cardiol 2014; 173:170–183
5.
Saper RBM, Lemaster C, Delitto A, et al: Yoga, physical therapy, or education for chronic low back pain: a randomized noninferiority trial. Ann Intern Med 2017; 167:85–94
6.
Greenlee H, DuPont-Reyes MJ, Balneaves LG, et al: Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA Cancer J Clin 2017; 67:194–232
7.
Cramer H, Haller H, Lauche R, et al: A systematic review and meta-analysis of yoga for hypertension. Am J Hypertens 2014; 27:1146–1151
8.
Schumann D, Anheyer D, Lauche R, et al: Effect of yoga in the therapy of irritable bowel syndrome: a systematic review. Clin Gastroenterol Hepatol 2016; 14:1720–1731
9.
Lauche R, Cramer H, Häuser W, Dobos G, Langhorst J. A systematic overview of reviews for complementary and alternative therapies in the treatment of the fibromyalgia syndrome. Evid-Based Complement Altern Med ECAM. 2015;2015:610615.
10.
Barnes PM, Bloom B, Nahin RL: Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report 2008; (12):1–23
11.
Sirven JI, Drazkowski JF, Zimmerman RS, et al: Complementary/alternative medicine for epilepsy in Arizona. Neurology 2003; 61:576–577
12.
Frequently asked questions: name change. Bethesda, MD: National Center for Complementary and Integrative Health, 2017 [cited 2017 Oct 16]. Available from https://nccih.nih.gov/news/name-change-faq
13.
Bryant EF: The Yoga Sutras of Patanjali. New York, NY: North Point Press, 2009
14.
Gates R, Kenison K: Meditations from the Mat: Daily Reflections on the Path of Yoga. New York, NY, Anchor Books, 2002
15.
Besleaga T, Blum M, Briot R, et al: Individuality of breathing during volitional moderate hyperventilation. Eur J Appl Physiol 2016; 116:217–225
16.
Cappo BM, Holmes DS: The utility of prolonged respiratory exhalation for reducing physiological and psychological arousal in non-threatening and threatening situations. J Psychosom Res 1984; 28:265–273
17.
Bernardi L, Sleight P, Bandinelli G, et al: Effect of rosary prayer and yoga mantras on autonomic cardiovascular rhythms: comparative study. BMJ 2001; 323:1446–1449
18.
Streeter CC, Gerbarg PL, Saper RB, et al: Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Med Hypotheses 2012; 78:571–579
19.
Sherman KJ: Guidelines for developing yoga interventions for randomized trials. Evid Based Complement Alternat Med [Internet] 2012 [Accessed Oct 16 2017]. Available from: https://www.hindawi.com/journals/ecam/2012/143271/
20.
Quilty MT, Saper RB, Goldstein R, et al: Yoga in the real world: perceptions, motivators, barriers, and patterns of use. Glob Adv Health Med 2013; 2:44–49
21.
Keosaian JE, Lemaster CM, Dresner D, et al: “We’re all in this together”: A qualitative study of predominantly low income minority participants in a yoga trial for chronic low back pain. Complement Ther Med 2016; 24:34–39
22.
Banks J, Marmot M, Oldfield Z, et al: Disease and disadvantage in the United States and in England. JAMA 2006; 295:2037–2045
23.
Cramer H, Lauche R, Langhorst J, et al: Yoga for depression: a systematic review and meta-analysis. Depress Anxiety 2013; 30:1068–1083
24.
Kinser PA, Bourguignon C, Whaley D, et al: Feasibility, acceptability, and effects of gentle Hatha yoga for women with major depression: findings from a randomized controlled mixed-methods study. Arch Psychiatr Nurs 2013; 27:137–147
25.
Sharma VK, Das S, Mondal S, et al: Effect of sahaj yoga on depressive disorders. Indian J Physiol Pharmacol 2005; 49:462–468
26.
Schuver KJ, Lewis BA: Mindfulness-based yoga intervention for women with depression. Complement Ther Med 2016; 26:85–91
27.
Janakiramaiah N, Gangadhar BN, Naga Venkatesha Murthy PJ, et al: Antidepressant efficacy of Sudarshan Kriya Yoga (SKY) in melancholia: a randomized comparison with electroconvulsive therapy (ECT) and imipramine. J Affect Disord 2000; 57:255–259
28.
Sarubin N, Nothdurfter C, Schüle C, et al: The influence of hatha yoga as an add-on treatment in major depression on hypothalamic-pituitary-adrenal-axis activity: a randomized trial. J Psychiatr Res 2014; 53:76–83
29.
Sharma A, Barrett MS, Cucchiara AJ, et al: A breathing-based meditation intervention for patients with major depressive disorder following inadequate response to antidepressants: a randomized pilot study. J Clin Psychiatry 2017; 78:e59–e63
30.
Cramer H, Anheyer D, Lauche R, et al: A systematic review of yoga for major depressive disorder. J Affect Disord 2017; 213:70–77
31.
Uebelacker LA, Tremont G, Gillette LT, et al: Adjunctive yoga v. health education for persistent major depression: a randomized controlled trial. Psychol Med 2017; 47:2130–2142
32.
Rush AJ, Trivedi MH, Wisniewski SR, et al: Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 2006; 163:1905–1917
33.
Judd LL, Schettler PJ, Rush AJ, et al: A new empirical definition of major depressive episode recovery and its positive impact on future course of illness. J Clin Psychiatry 2016; 77:1065–1073
34.
Streeter CC, Gerbarg PL, Whitfield TH, et al: Treatment of major depressive disorder with iyengar yoga and coherent breathing: a randomized controlled dosing study. J Altern Complement Med 2017; 23:201–207
35.
Naveen GH, Thirthalli J, Rao MG, et al: Positive therapeutic and neurotropic effects of yoga in depression: A comparative study. Indian J Psychiatry 2013; 55(Suppl 3):S400–S404
36.
Curtis K, Weinrib A, Katz J: Systematic review of yoga for pregnant women: current status and future directions. Evid Based Complement Alternat Med [Internet] 2012 [Accessed Oct 17 2017]. Available from: https://www.hindawi.com/journals/ecam/2012/715942/
37.
Gong H, Ni C, Shen X, et al: Yoga for prenatal depression: a systematic review and meta-analysis. BMC Psychiatry 2015; 15:14
38.
Beck A, Steer RA, Brown G: Manual for the Beck Depression Inventory–II. San Antonio, TX, Psychological Corporation, 1996
39.
Uebelacker LA, Broughton MK: Yoga for depression and anxiety: a review of published research and implications for healthcare providers. R I Med J (2013) 2016; 99:20–22
40.
Katzman MA, Vermani M, Gerbarg PL, et al: A multicomponent yoga-based, breath intervention program as an adjunctive treatment in patients suffering from generalized anxiety disorder with or without comorbidities. Int J Yoga 2012; 5:57–65
41.
Khalsa MK, Greiner-Ferris JM, Hofmann SG, et al: Yoga-enhanced cognitive behavioural therapy (Y-CBT) for anxiety management: a pilot study. Clin Psychol Psychother 2015; 22:364–371
42.
Shannahoff-Khalsa DS, Ray LE, Levine S, et al: Randomized controlled trial of yogic meditation techniques for patients with obsessive-compulsive disorder. CNS Spectr 1999; 4:34–47
43.
Jindani F, Turner N, Khalsa SBS: A yoga intervention for posttraumatic stress: a preliminary randomized control trial. Evid Based Complement Alternat Med [Internet] 2015 [Accessed Oct 12 2017]. Available from: https://www.hindawi.com/journals/ecam/2015/351746/
44.
van der Kolk BA, Stone L, West J, et al: Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. J Clin Psychiatry 2014; 75:e559–e565
45.
Wilamowska ZA, Thompson-Hollands J, Fairholme CP, et al: Conceptual background, development, and preliminary data from the unified protocol for transdiagnostic treatment of emotional disorders. Depress Anxiety 2010; 27:882–890
46.
Mancia G, Grassi G: The autonomic nervous system and hypertension. Circ Res 2014; 114:1804–1814
47.
Carney RM, Freedland KE, Veith RC: Depression, the autonomic nervous system, and coronary heart disease. Psychosom Med 2005; 67(Suppl 1):S29–S33
48.
Thayer JF, Brosschot JF: Psychosomatics and psychopathology: looking up and down from the brain. Psychoneuroendocrinology 2005; 30:1050–1058
49.
Beauchaine T: Vagal tone, development, and Gray’s motivational theory: toward an integrated model of autonomic nervous system functioning in psychopathology. Dev Psychopathol 2001; 13:183–214
50.
Sanacora G, Mason GF, Rothman DL, et al: Increased occipital cortex GABA concentrations in depressed patients after therapy with selective serotonin reuptake inhibitors. Am J Psychiatry 2002; 159:663–665
51.
Sanacora G, Mason GF, Rothman DL, et al: Reduced cortical gamma-aminobutyric acid levels in depressed patients determined by proton magnetic resonance spectroscopy. Arch Gen Psychiatry 1999; 56:1043–1047
52.
Rossi S, De Capua A, Tavanti M, et al: Dysfunctions of cortical excitability in drug-naïve posttraumatic stress disorder patients. Biol Psychiatry 2009; 66:54–61
53.
Vaiva G, Thomas P, Ducrocq F, et al: Low posttrauma GABA plasma levels as a predictive factor in the development of acute posttraumatic stress disorder. Biol Psychiatry 2004; 55:250–254
54.
Mitani S, Fujita M, Sakamoto S, et al: Effect of autogenic training on cardiac autonomic nervous activity in high-risk fire service workers for posttraumatic stress disorder. J Psychosom Res 2006; 60:439–444
55.
Thayer JF, Friedman BH, Borkovec TD: Autonomic characteristics of generalized anxiety disorder and worry. Biol Psychiatry 1996; 39:255–266
56.
Goddard AW, Mason GF, Almai A, et al: Reductions in occipital cortex GABA levels in panic disorder detected with 1h-magnetic resonance spectroscopy. Arch Gen Psychiatry 2001; 58:556–561
57.
Ansakorpi H, Korpelainen JT, Huikuri HV, et al: Heart rate dynamics in refractory and well controlled temporal lobe epilepsy. J Neurol Neurosurg Psychiatry 2002; 72:26–30
58.
Petroff OA, Rothman DL, Behar KL, et al: Low brain GABA level is associated with poor seizure control. Ann Neurol 1996; 40:908–911
59.
Petroff OAC, Hyder F, Rothman DL, et al: Topiramate rapidly raises brain GABA in epilepsy patients. Epilepsia 2001; 42:543–548
60.
Porges SW: Orienting in a defensive world: mammalian modifications of our evolutionary heritage. A polyvagal theory. Psychophysiology 1995; 32:301–318
61.
Porges SW: The polyvagal theory: phylogenetic substrates of a social nervous system. Int J Psychophysiol 2001; 42:123–146
62.
Guilley E, Pin S, Spini D, et al: Association between social relationships and survival of Swiss octogenarians. A five-year prospective, population-based study. Aging Clin Exp Res 2005; 17:419–425
63.
Yates WR, Mitchell J, John Rush A, et al: Clinical features of depression in outpatients with and without co-occurring general medical conditions in STAR*D: confirmatory analysis. Prim Care Companion J Clin Psychiatry 2007; 9:7–15
64.
Bhaskar L, Kharya C, Deepak KK, et al: Assessment of cardiac autonomic tone following long Sudarshan Kriya Yoga in art of living practitioners. J Altern Complement Med 2017; 23:705–712
65.
Chu I-H, Wu W-L, Lin I-M, et al: Effects of yoga on heart rate variability and depressive symptoms in women: a randomized controlled trial. J Altern Complement Med 2017; 23:310–316
66.
Nemeroff CB, Mayberg HS, Krahl SE, et al: VNS therapy in treatment-resistant depression: clinical evidence and putative neurobiological mechanisms. Neuropsychopharmacology 2006; 31:1345–1355
67.
Henry TR, Votaw JR, Pennell PB, et al: Acute blood flow changes and efficacy of vagus nerve stimulation in partial epilepsy. Neurology 1999; 52:1166–1173
68.
Henry TR, Bakay RA, Votaw JR, et al: Brain blood flow alterations induced by therapeutic vagus nerve stimulation in partial epilepsy: I. Acute effects at high and low levels of stimulation. Epilepsia 1998; 39:983–990
69.
Hopkins LB, Medina JL, Baird SO, et al: Heated hatha yoga to target cortisol reactivity to stress and affective eating in women at risk for obesity-related illnesses: a randomized controlled trial. J Consult Clin Psychol 2016; 84:558–564
70.
Medina J, Hopkins L, Powers M, et al: The effects of a hatha yoga intervention on facets of distress tolerance. Cogn Behav Ther 2015; 44:288–300
71.
Hewett ZL, Pumpa KL, Smith CA, et al: Effect of a 16-week Bikram yoga program on perceived stress, self-efficacy and health-related quality of life in stressed and sedentary adults: a randomised controlled trial. J Sci Med Sport [Internet]. 2017 Aug 24; S1440-2440(17)30994-5
72.
Hewett ZL, Ransdell LB, Gao Y, et al: An examination of the effectiveness of an 8-week Bikram yoga program on mindfulness, perceived stress, and physical fitness. J Exerc Sci Fit 2011; 9:87–92
73.
Szabo A, Nikházy L, Tihanyi B, et al: An in-situ investigation of the acute effects of Bikram yoga on positive- and negative affect, and state-anxiety in context of perceived stress. J Ment Health 2017; 26:156–160
74.
Janssen CW, Lowry CA, Mehl MR, et al: Whole-body hyperthermia for the treatment of major depressive disorder: a randomized clinical trial. JAMA Psychiatry 2016; 73:789–795
75.
Hanusch K-U, Janssen CH, Billheimer D, et al: Whole-body hyperthermia for the treatment of major depression: associations with thermoregulatory cooling. Am J Psychiatry 2013; 170:802–804
76.
Uebelacker LA, Epstein-Lubow G, Gaudiano BA, et al: Hatha yoga for depression: critical review of the evidence for efficacy, plausible mechanisms of action, and directions for future research. J Psychiatr Pract 2010; 16:22–33
77.
Pilkington K, Kirkwood G, Rampes H, et al: Yoga for depression: the research evidence. J Affect Disord 2005; 89:13–24
78.
Cramer H: Injuries and other adverse events associated with yoga practice: A systematic review of epidemiological studies. J Sci Med Sport [Internet]. 2017 [Accessed Oct 16 2017]; Available from: https://phstwlp2.partners.org:2103/science/article/pii/S1440244017310502
79.
Cramer H, Ward L, Saper R, et al: The safety of yoga: a systematic review and meta-analysis of randomized controlled trials. Am J Epidemiol 2015; 182:281–293
80.
Uebelacker LA, Broughton MK. Yoga for depression and anxiety: a review of published research and implications for healthcare providers. R I Med J (2013) 2016; 99:20–22.

Information & Authors

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History

Published in print: Winter 2018
Published online: 24 January 2018

Keywords

  1. Administration &amp
  2. management, Administration

Authors

Details

Maren Nyer, Ph.D. [email protected]
Dr. Nyer is with the Department of Psychiatry, Harvard Medical School, and the Department of Psychiatry, Massachusetts General Hospital, Boston. Ms. Nauphal and Ms. Roberg are with the Department of Psychiatry, Massachusetts General Hospital, Boston. Dr. Streeter is with the Departments of Psychiatry and Neurology, and Harvard Medical School, Boston.
Maya Nauphal, B.A.
Dr. Nyer is with the Department of Psychiatry, Harvard Medical School, and the Department of Psychiatry, Massachusetts General Hospital, Boston. Ms. Nauphal and Ms. Roberg are with the Department of Psychiatry, Massachusetts General Hospital, Boston. Dr. Streeter is with the Departments of Psychiatry and Neurology, and Harvard Medical School, Boston.
Regina Roberg, B.A.
Dr. Nyer is with the Department of Psychiatry, Harvard Medical School, and the Department of Psychiatry, Massachusetts General Hospital, Boston. Ms. Nauphal and Ms. Roberg are with the Department of Psychiatry, Massachusetts General Hospital, Boston. Dr. Streeter is with the Departments of Psychiatry and Neurology, and Harvard Medical School, Boston.
Chris Streeter, M.D.
Dr. Nyer is with the Department of Psychiatry, Harvard Medical School, and the Department of Psychiatry, Massachusetts General Hospital, Boston. Ms. Nauphal and Ms. Roberg are with the Department of Psychiatry, Massachusetts General Hospital, Boston. Dr. Streeter is with the Departments of Psychiatry and Neurology, and Harvard Medical School, Boston.

Notes

Send correspondence to Dr. Nyer (e-mail: [email protected]).

Funding Information

This work was supported by NCCIH grants K23 AT008043 02 (MN); R21AT004014 and R01AT007483 (CS); and by M01RR00533 and Ul1RR025771 (General Clinical Research Unit at Boston University Medical Center).The authors report no financial relationships with commercial interests.

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