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Yoga: A spiritual practice with therapeutic value in psychiatry
Asian Journal of Psychiatry 5 (2012) 186–189
Contents lists available at SciVerse ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Yoga: A spiritual practice with therapeutic value in psychiatry Shivarama Varambally *, B.N. Gangadhar Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 April 2012 Accepted 1 May 2012
Yoga is one of the spiritual practices derived from the orthodox school of Hindu philosophy. The practices were codified by Patanjali under the title of Ashtanga Yoga. Although Yoga was traditionally seen as a practice meant for achieving self-realization, in recent years there has been significant attention given to the effects of yoga practices on physical and mental health. Yoga as a therapy has proven to be effective as a sole or additional intervention in several psychiatric disorders. Conclusions: The literature suggests that yoga can lead to significant symptomatic improvements in psychiatric disorders, along with neurobiological effects which may underlie these changes. This suggests that mental health professionals should be open to the potential benefits of spiritual practices for their patients, either as complementary interventions to modern treatments or as sole treatment in some disorders. ß 2012 Elsevier B.V. All rights reserved.
Keywords: Spirituality Yoga therapy Psychiatry
1. Introduction The word spirituality is derived from the Latin ‘Spiritulitas’ meaning breath. Spirituality is a broader concept than religion. Being religious may not include being spiritual and vice versa. However, all faiths value the spiritual outlook and employ different methods to attain this. These may be in the form of prayer to a ‘Divine Being’ or object, attempts to realize the divine potential within by meditation or to connect to the universal cosmic energy by various methods or mediums which may be unique to the culture and geographic location, rather than a particular religion. Some of these methods used by different cultures include the practice of Vipassana meditation which derives from Buddhist philosophical principles, Tai chi derived from Chinese philosophy and Yoga which is one of the six a¯stika (orthodox) schools of Hindu philosophy. Yoga is derived from the Sanskrit ‘‘yuj’’ meaning ‘‘to yoke’’ or ‘‘to unite’’. It probably originated as a way to achieve perfect physical and mental balance as a precursor to attaining self-realization (‘mukti’). The primary subdivisions of Yoga are Mantrayoga, Layayoga, Hathayoga and Ra¯jayoga, the last of which is the highest (or royal) practice. Sage Patanjali, in his Yoga Sutras (Iyengar, 1993), which form the theoretical and philosophical basis of Raja Yoga, codified the various practices under the system of Ashtanga Yoga (eight-limbed path) which offers a blueprint to achieve the
* Corresponding author at: Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India. Tel.: +91 80 26995253/9480829484; fax: +91 80 26564830. E-mail address: [email protected] (S. Varambally). 1876-2018/$ – see front matter ß 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2012.05.003
ultimate objective of self-realization. The eight limbs or levels enunciated by Patanjali are Yama (self control), Niyama (observance of rules), Asana (assuming certain postures), Pranayama (regulation of breath), Pratyahara (restraint of senses), Dharana (steadying of mind), Dhyana (meditation) and Samadhi (contemplation of universal consciousness). Yama and Niyama are preparatory phases, and along with Asana, Pranayama, and Pratyahara are classified as Bahiranga sadhana (external aids to yoga) and the last three levels Dharana, Dhyana and Samadhi are classified as Antharanga sadhana (internal aids to yoga). Thus, in the Indian tradition, yoga has been seen as a pathway for attaining a spiritual goal. However, with the influence of modern medicine and evidence-based scientific research, over the last 3–4 decades there has been much attention given to the ‘byproducts’ of yogic practices. There has been systematic documentation of the benefits of various yoga-based practices on physiological functioning in terms of physical effects such as metabolic efficiency as well as cognitive aspects such as memory in healthy subjects of different age groups. The natural corollary of this has been the use of such practices as therapeutic interventions in physical disorders such as diabetes, hypertension, asthma, and later in mental disorders such as depression and anxiety. This has not gone down well with some traditional yoga schools, who feel that this is not what yoga should be used for. However, this process now seems irreversible, with yoga-based treatments becoming quite popular worldwide. There are now yoga-based interventions available for most common disorders, although some of these ‘packages’ may not have passed the test of validity and research. Evidence-based research demonstrating the benefit of yogabased modules is now available for many physical disorders such as diabetes and asthma. In the field of mental health, evidence is
S. Varambally, B.N. Gangadhar / Asian Journal of Psychiatry 5 (2012) 186–189
accumulating that such modules may be used safely and effectively as an adjuvant, and even as a sole modality of therapy in some disorders like depression. However, evaluating treatment modalities like yoga using modern research methodologies such as randomized double-blinded controlled trials has several limitations, which will be discussed later in this paper. Given this, as well as several other factors unique to yoga, convincing the medical fraternity about yoga as an intervention remains a difficult challenge. Nevertheless, some evidence for yoga-based therapies in the management of mental disorders is briefly reviewed here. 2. Yoga therapies in depression In depression, stress plays an important role and its relief can improve depressive symptoms. Sudarshan Kriya Yoga (SKY) is part of the stress management package offered by the Art of Living foundation. Studies have shown that SKY has neurobiological effects like increased parasympathetic drive, calming stress response systems, neuroendocrine release of hormones and effects on thalamic generators (Brown and Gerbarg, 2005). Pilkington (Pilkington et al., 2005) reviewed the role of Yoga in depression, with a positive conclusion as regards its role in the treatment of depression. In a 4-week clinical trial, 45 consenting inpatients of major depression with melancholia were randomized to SKY/Electroconvulsive Therapy (ECT)/Imipramine (IMN), with 15 patients in each group. Patients were given daily SKY practice under supervision or 3ECT’s/week, or imipramine 150 mg/day under their respective group. Weekly assessment was done with Hamilton depression rating scale. SKY produced significant reductions in depression scores comparable to IMN, but less than ECT (SKY 67% vs. ECT 93%, IMN 73% remission) (Janakiramaiah et al., 2000). In a second clinical trial, 30 major depressive disorder inpatients were given SKY or partial SKY for 4 weeks under supervision. Partial SKY had Ujjayi, Bhastrika but normal breathing in place of Kriya (cyclical breathing). Patients were assessed on weekly basis with Beck Depression Inventory. Both groups had significant reduction in depression scores and were comparable; but 75% of full SKY patients had responded as against 45% of partial SKY at the end of four weeks (a trend-worthy difference) (Rohini et al., 2000). In another clinical trial in dysthymia, 46 outpatients were given SKY training for 1 week, after which they practiced at home for the next month. 25 out of 37 patients who completed the trial showed remission by the end of first month of practice and maintained the same for next 3 months. This ‘dose-dependent’ effect suggests the possible role of SKY (all remitted had practiced regularly) in dysthymia (Janakiramaiah et al., 1998). With the above results it can be concluded that SKY has antidepressant effects comparable to imipramine and optimal benefit is obtained with the full Kriya of at least thrice a week. In a randomized controlled trial (RCT), 30 major depressive disorder patients were randomized to Sahaj yoga or no yoga, with both the groups on antidepressants. The patients were assessed with Hamilton Rating Scale for Depression (HAM-D) and Hamilton Rating Scale for Anxiety (HAM-A) before and after 8 weeks of yoga intervention. Both the groups showed significant improvements in HAM-D and HAM-A, however percentage of improvement was significantly higher in the Sahaj yoga group than the other group. The number of patients who remitted was also significantly higher in Sahaj yoga group (Sharma et al., 2006).
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anxiety disorders has been noted. Hence yoga has been tried as treatment for anxiety disorders. In a small open uncontrolled pilot study of Kundalini Yoga (KY) in obsessive compulsive disorder (OCD), 5 of 8 pts showed 55.6% improvement in the mean psychopathology scores in a 12 month trial. In a 2nd trial which compared KY with relaxation response plus mindfulness meditation, the KY group had greater and statistically significant improvement on the rating scales for OCD and anxiety. An intent-to-treat analysis for baseline and 3 month tests showed that only KY group had improved on all scales (Shannahoff-Khalsa et al., 1999). A review in 2005 suggested that there was not enough evidence to definitely conclude that yoga was an effective treatment for anxiety disorders (Kirkwood et al., 2005). However, Brown and Gerbarg concluded that there is sufficient evidence to consider SKY to be a beneficial, low risk, low cost adjuvant to treatment of stress, anxiety, post traumatic stress disorder and stress-related medical illnesses (Brown and Gerbarg, 2005). A recent comprehensive review (da Silva et al., 2009) was able to draw some conclusions about the efficacy of yoga in depression and anxiety disorders, despite paucity of studies and methodological shortcomings in the published literature. The authors concluded that in depressive disorders, yoga may be comparable to medication, and the combination superior to medication alone. They also found reasonable evidence for its use as second-line monotherapy or augmentation to medication in mild to moderate major depression and dysthymia. In anxiety disorders, yoga may be superior to medication for a subgroup of patients with anxiety disorders, but the evidence for its benefits in specific conditions such as obsessive compulsive disorder and post-traumatic stress disorder are preliminary. They also reported that yoga therapy has shown good safety and tolerability in the short-term. 4. Yoga therapies in schizophrenia Schizophrenia is a more severe psychiatric disorder that has benefited from yoga. Initial results in chronic inpatients exposed to yoga were encouraging (Nagendra et al., 2000). This led to a randomized trial comparing yoga and exercise in outpatients of schizophrenia. While both interventions benefited the negative symptoms and quality of life, yoga was better (Duraiswamy et al., 2007). Independently, Visceglia et al. confirmed, though from a smaller sample, better effects of yoga over exercise in schizophrenia (Visceglia and Lewis, 2011). Although a systematic review in 2012 (Vancampfort et al., 2012) included only 3 RCT’s, the results indicated that yoga therapy can be an useful add-on treatment to reduce general psychopathology, positive and negative symptoms, and Health-related Quality of Life in patients with schizophrenia. Using a waitlist control, recently we were able to demonstrate benefits of yogasana over both exercise and waitlist in medicationstabilized outpatients of schizophrenia (Gangadhar et al., in press). Yogasana also benefited social cognition. Patients’ ability to recognize facial emotions on a standardized test improved after yoga, better than either exercise or mere waiting (Behere et al., 2010). Neurobiological basis for this benefit is proposed in the form of elevations in the ‘cuddle’ hormone, oxytocin (Jayaram, 2012). A caveat, however, is that the practice of meditation in patients with psychosis is controversial, as some theoretical and clinical evidence (Walsh and Roche, 1979) points to precipitation or worsening of psychosis with such practices. Most yoga modules for such patients do not include meditative practices.
3. Yoga therapies in anxiety disorders 5. Alcohol dependence syndrome and yoga therapy Yoga has been demonstrated to cause change in the neurophysiological markers of stress and anxiety like GSR and stress hormone levels. With practice of relaxation techniques, improvement in the
Depression is a common co-morbidity with alcohol dependence syndrome (ADS) and predicts relapse especially in early
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S. Varambally, B.N. Gangadhar / Asian Journal of Psychiatry 5 (2012) 186–189
withdrawal state, with the relapse rate of around 50%. In a randomized controlled trial, 60 inpatients of ADS, detoxified in the first week, were randomized into SKY or treatment as usual groups. Assessment was done with Beck’s Depression Inventory (BDI) at the baseline and 2 weeks after the practice of yoga along with assay of plasma cortisol, adrenocorticotrophic hormone (ACTH) and prolactin levels. There was more reduction in depression scores in SKY group compared to non-SKY group. Plasma cortisol and ACTH levels dropped in both groups, more so in the SKY group. The reduction in depression scores correlated with that of the plasma cortisol level in the SKY group. Reduction in stress hormone levels along with BDI scores reduction support the possibility of a biological mechanism of Sudarshana Kriya Yoga (Vedamurthachar et al., 2006). 6. Yoga therapy in psychiatric disorders of childhood The maximum literature on the therapeutic application of yoga in child psychiatric disorders has been in Attention Deficit Hyperactivity Disorder (ADHD). A study showed that scores on attention tasks and parent ratings of ADHD symptoms after yoga training was superior to the conventional motor training, with effect sizes in the medium-to-high range (0.60–0.97). The training was particularly effective for children undergoing pharmacotherapy with methylphenidate (Haffner et al., 2006). Another study reported similar findings, with specific benefits in the evening time after medication effects become less (Jensen and Kenny, 2004). Although replication with larger sample sizes and more intensive supervised practice programs are ideal, reviews of multiple studies suggest that yoga can be an effective complementary or concomitant treatment in the overall treatment plan in ADHD. 7. Neurobiological effects of yoga While symptomatic changes in psychiatric disorders with yoga have been described, the biological basis of action underlying these changes remains unclear. As described above, studies on SKY have demonstrated neurobiological changes such as increase in P300 amplitude (Naga Venkatesha Murthy et al., 1998) and reduction in levels of serum cortisol and ACTH (Vedamurthachar et al., 2006) which correlate with symptom improvements, in patients with psychiatric disorders. Similarly, an acute session of yoga has been shown to increase brain levels of Gamma Amino Butyric Acid (GABA) in healthy subjects (Streeter et al., 2007). GABA levels have been shown to be decreased in mood and anxiety disorders, and this offers a possible rationale for the efficacy of yoga in these disorders. A recent functional imaging (fMRI) study demonstrated deactivation of limbic brain regions in healthy volunteers while chanting OM (used in yoga as well as other spiritual practices), possibly indicating effects of yoga on emotional regulation (Kalyani et al., 2011). Yoga has also produced increase in oxytocin levels in patients with schizophrenia who improved in their ability to recognize facial emotions (Jayaram, 2012). Further research linking neurobiological markers with improvements in psychopathology is needed to confirm and extend these preliminary findings. 8. Methodological issues in yoga research Several methodological issues have been pointed out specific to research in complementary therapies such as yoga. The primary ones are difficulty in double-blinding and finding a suitable placebo-control for yoga. Also, selection of a yoga package for a given condition has been variable, and consensus of different yoga schools/traditions is difficult to achieve. In fact, whether modern research methods such as Randomized Double Blind Controlled
Trials are suitable to test practices such as yoga is a relevant question by itself. However, with the objective of convincing mainstream medical practitioners about the utility of yoga-based practices, several researchers have tried innovative research methodologies and published results in peer-reviewed journals (Bijlani, 2008; Gangadhar and Varambally, 2011). In summary, the literature suggests that yoga, a spiritual practice originally designed for self-realization, can lead to significant symptomatic improvements in psychiatric disorders, along with neurobiological effects which may underlie these changes. This may be equally true of other spiritual practices from different faiths. The message for psychiatrists and the mental health fraternity would be that practitioners should not close their minds to the potential benefits of spiritual practices for their patients, nor treat it as a purely personal concern of the patients. If used appropriately based on the belief system of individual patients, they may serve as powerful augmenting agents for modern treatments, or indeed a sole method of treatment in some disorders. Conflict of interest The authors report no conflict of interest in relation to this work. Funding support Some of the studies mentioned above were done under the aegis of the Advanced Center for Yoga at NIMHANS. Dr B N Gangadhar was the Program Director, and the Centre was run in collaboration with the Morarji Desai National Institute of Yoga, New Delhi and funded by the Dept. of AYUSH, Government of India. We also acknowledge funding support from the Dept. of AYUSH, Government of India to Dr B N Gangadhar for the research project ‘‘Efficacy of Yoga as an Add-on Treatment in Schizophrenia’’. Acknowledgements We acknowledge contributions from Dr. G. Venkatasubramanian, Kalyani B.G., Dr. Rishikesh Behere, Dr. H.R. Nagendra, Dr. Naveen Jayaram in the research quoted in this paper. Appendix A. Brief note on some of the terms used in the manuscript Sudarshana Kriya (Su = right, darshana = vision, kriya = action): Essentially a variant of pranayama or breath control, developed by Sri Sri Ravishankar of the Art of Living Foundation. Sudarshana Kriya Yoga (SKY) is the adaptation of Sudarshana Kriya for clinical application (Janakiramaiah et al., 1998). Ujjayi: a pattern of slow breathing (2–3 cycles/min), which is part of the SKY module (Janakiramaiah et al., 1998). Bhastrika: a pattern of rapid, forced exhalation (20–30 cycles/min), which is also part of the SKY module (Janakiramaiah et al., 1998). Sahaj yoga: literally means ‘‘natural union with the divine’’. Comprised of meditation focused on the Sahasrara chakra (located on the top of the head), developed by Nirmala Srivastava in the 1970s as a pathway to self-realization (Sharma et al., 2005). Kundalini Yoga (KY): developed by Yogi Bhajan in the 1960s. It focuses on the psychic energy points (‘‘chakras’’) of the body to stimulate spiritual energy or ‘‘kundalini’’ energy. It is based on sustained, relaxation-focused postures in conjunction with chanting, controlled breathing, hand and finger gestures, visualization exercises and meditation (Shannahoff-Khalsa, 2004).
S. Varambally, B.N. Gangadhar / Asian Journal of Psychiatry 5 (2012) 186–189
References Behere, R.V., Arasappa, R., Jagannathan, A., Varambally, S., Venkatasubramanian, G., Thirthalli, J., Subbakrishna, D.K., Nagendra, H.R., Gangadhar, B.N., 2010. Effect of yoga therapy on facial emotion recognition deficits, symptoms and functioning in patients with schizophrenia. Acta Psychiatrica Scandinavica 123, 147–153. Bijlani, R.L., 2008. Beyond Scientific Research? Medical Research: All You Wanted to Know But Did Not Know Whom to Ask. Jaypee, New Delhi, pp. 149–165. Brown, R.P., Gerbarg, P.L., 2005. Sudarshan Kriya Yogic breathing in the treatment of stress, anxiety, and depression. Part II—clinical applications and guidelines. Journal of Alternative and Complementary Medicine 11, 711–717. da Silva, T.L., Ravindran, L.N., Ravindran, A.V., 2009. Yoga in the treatment of mood and anxiety disorders: a review. Asian Journal of Psychiatry 2, 6–16. Duraiswamy, G., Thirthalli, J., Nagendra, H.R., Gangadhar, B.N., 2007. Yoga therapy as an add-on treatment in the management of patients with schizophrenia—a randomized controlled trial. Acta Psychiatrica Scandinavica 116, 226–232. Gangadhar, B.N., Varambally, S., 2011. Yoga as therapy in psychiatric disorders: past, present, and future. Biofeedback 39, 60–63. Gangadhar, B.N., Varambally, S., Thirthalli, J., Jagannathan, A., Kumar, S., Nagendra, H.R., Venkatasubramanian, G., Muralidhar, D., Subbakrishna, D.K. Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia: randomized controlled comparison with exercise and waitlist. Indian Journal of Psychiatry, in press. Haffner, J., Roos, J., Goldstein, N., Parzer, P., Resch, F., 2006. The effectiveness of body-oriented methods of therapy in the treatment of attention-deficit hyperactivity disorder (ADHD): results of a controlled pilot study. Zeitschrift fur Kinder- und Jugendpsychiatrie und Psychotherapie 34, 37–47. Iyengar, B.K.S., 1993. Light on the Yoga Sutras of Pantanjali. Harper Collins, London. Janakiramaiah, N., Gangadhar, B.N., Nagavenkatesha Murthy, P., Shetty, T.K., Subbakrishna, D.K., Meti, B.L., Raju, T.R., Vedamurthachar, A., 1998. Therapeutic efficacy of Sudarshan Kriya Yoga (SKY) in dysthymic disorder. NIMHANS Journal 17, 21–28. Janakiramaiah, N., Gangadhar, B.N., Naga Venkatesha Murthy, P.J., Harish, M.G., Subbakrishna, D.K., Vedamurthachar, A., 2000. Antidepressant efficacy of Sudarshan Kriya Yoga (SKY) in melancholia: a randomized comparison with electroconvulsive therapy (ECT) and imipramine. Journal of Affective Disorders 57, 255–259. Jayaram, N., 2012. Effect of yoga therapy on plasma oxytocin and facial emotion recognition deficits in patients of schizophrenia (Unpublished thesis), Psychiatry. National Institute of Mental Health and Neurosciences, Bangalore. Jensen, P.S., Kenny, D.T., 2004. The effects of yoga on the attention and behavior of boys with attention-deficit/hyperactivity disorder (ADHD). Journal of Attention Disorders 7, 205–216. Kalyani, B.G., Venkatasubramanian, G., Arasappa, R., Rao, N.P., Kalmady, S.V., Behere, R.V., Rao, H., Vasudev, M.K., Gangadhar, B.N., 2011. Neurohemodynamic corre-
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lates of ‘OM’ chanting: a pilot functional magnetic resonance imaging study. International Journal of Yoga 4, 3–6. Kirkwood, G., Rampes, H., Tuffrey, V., Richardson, J., Pilkington, K., 2005. Yoga for anxiety: a systematic review of the research evidence. British Journal of Sports Medicine 39, 884–891 (discussion 891). Naga Venkatesha Murthy, P.J., Janakiramaiah, N., Gangadhar, B.N., Subbakrishna, D.K., 1998. P300 amplitude and antidepressant response to Sudarshan Kriya Yoga (SKY). Journal of Affective Disorders 50, 45–48. Nagendra, H.R., Telles, S., Naveen, K V., 2000. An integrated approach of Yoga therapy for the management of schizophrenia. Final Report submitted to Dept. of ISM & H, Ministry of Health and Family Welfare, Government of India. Pilkington, K., Kirkwood, G., Rampes, H., Richardson, J., 2005. Yoga for depression: the research evidence. Journal of Affective Disorders 89, 13–24. Rohini, V., Pandey, R.S., Janakiramaiah, N., Gangadhar, B.N., Vedamurthachar, A., 2000. A comparative study of full and partial Sudarshan Kriya Yoga in major depressive disorder. NIMHANS Journal 18, 53–57. Shannahoff-Khalsa, D.S., 2004. An introduction to Kundalini yoga meditation techniques that are specific for the treatment of psychiatric disorders. Journal of Alternative and Complementary Medicine 10, 91–101. Shannahoff-Khalsa, D.S., Ray, L.E., Levine, S., Gallen, C.C., Schwartz, B.J., Sidorowich, J.J., 1999. Randomized controlled trial of yogic meditation techniques for patients with obsessive-compulsive disorder. CNS Spectrums 4, 34–47. Sharma, V.K., Das, S., Mondal, S., Goswami, U., Gandhi, A., 2005. Effect of Sahaj Yoga on depressive disorders. Indian Journal of Physiology and Pharmacology 49, 462–468. Sharma, V.K., Das, S., Mondal, S., Goswami, U., Gandhi, A., 2006. Effect of Sahaj Yoga on neuro-cognitive functions in patients suffering from major depression. Indian Journal of Physiology and Pharmacology 50, 375–383. Streeter, C.C., Jensen, J.E., Perlmutter, R.M., Cabral, H.J., Tian, H., Terhune, D.B., Ciraulo, D.A., Renshaw, P.F., 2007. Yoga Asana sessions increase brain GABA levels: a pilot study. Journal of Alternative and Complementary Medicine 13, 419–426. Vancampfort, D., Vansteelandt, K., Scheewe, T., Probst, M., Knapen, J., De Herdt, A., De Hert, M., 2012. Yoga in schizophrenia: a systematic review of randomised controlled trials. Acta Psychiatrica Scandinavica 1–9. Vedamurthachar, A., Janakiramaiah, N., Hegde, J.M., Shetty, T.K., Subbakrishna, D.K., Sureshbabu, S.V., Gangadhar, B.N., 2006. Antidepressant efficacy and hormonal effects of Sudarshana Kriya Yoga (SKY) in alcohol dependent individuals. Journal of Affective Disorders 94, 249–253. Visceglia, E., Lewis, S., 2011. Yoga therapy as an adjunctive treatment for schizophrenia: a randomized, controlled pilot study. Journal of Alternative and Complementary Medicine 17, 601–607. Walsh, R., Roche, L., 1979. Precipitation of acute psychotic episodes by intensive meditation in individuals with a history of schizophrenia. American Journal of Psychiatry 136, 1085–1086.
Contents lists available at SciVerse ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Yoga: A spiritual practice with therapeutic value in psychiatry Shivarama Varambally *, B.N. Gangadhar Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 April 2012 Accepted 1 May 2012
Yoga is one of the spiritual practices derived from the orthodox school of Hindu philosophy. The practices were codified by Patanjali under the title of Ashtanga Yoga. Although Yoga was traditionally seen as a practice meant for achieving self-realization, in recent years there has been significant attention given to the effects of yoga practices on physical and mental health. Yoga as a therapy has proven to be effective as a sole or additional intervention in several psychiatric disorders. Conclusions: The literature suggests that yoga can lead to significant symptomatic improvements in psychiatric disorders, along with neurobiological effects which may underlie these changes. This suggests that mental health professionals should be open to the potential benefits of spiritual practices for their patients, either as complementary interventions to modern treatments or as sole treatment in some disorders. ß 2012 Elsevier B.V. All rights reserved.
Keywords: Spirituality Yoga therapy Psychiatry
1. Introduction The word spirituality is derived from the Latin ‘Spiritulitas’ meaning breath. Spirituality is a broader concept than religion. Being religious may not include being spiritual and vice versa. However, all faiths value the spiritual outlook and employ different methods to attain this. These may be in the form of prayer to a ‘Divine Being’ or object, attempts to realize the divine potential within by meditation or to connect to the universal cosmic energy by various methods or mediums which may be unique to the culture and geographic location, rather than a particular religion. Some of these methods used by different cultures include the practice of Vipassana meditation which derives from Buddhist philosophical principles, Tai chi derived from Chinese philosophy and Yoga which is one of the six a¯stika (orthodox) schools of Hindu philosophy. Yoga is derived from the Sanskrit ‘‘yuj’’ meaning ‘‘to yoke’’ or ‘‘to unite’’. It probably originated as a way to achieve perfect physical and mental balance as a precursor to attaining self-realization (‘mukti’). The primary subdivisions of Yoga are Mantrayoga, Layayoga, Hathayoga and Ra¯jayoga, the last of which is the highest (or royal) practice. Sage Patanjali, in his Yoga Sutras (Iyengar, 1993), which form the theoretical and philosophical basis of Raja Yoga, codified the various practices under the system of Ashtanga Yoga (eight-limbed path) which offers a blueprint to achieve the
* Corresponding author at: Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India. Tel.: +91 80 26995253/9480829484; fax: +91 80 26564830. E-mail address: [email protected] (S. Varambally). 1876-2018/$ – see front matter ß 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2012.05.003
ultimate objective of self-realization. The eight limbs or levels enunciated by Patanjali are Yama (self control), Niyama (observance of rules), Asana (assuming certain postures), Pranayama (regulation of breath), Pratyahara (restraint of senses), Dharana (steadying of mind), Dhyana (meditation) and Samadhi (contemplation of universal consciousness). Yama and Niyama are preparatory phases, and along with Asana, Pranayama, and Pratyahara are classified as Bahiranga sadhana (external aids to yoga) and the last three levels Dharana, Dhyana and Samadhi are classified as Antharanga sadhana (internal aids to yoga). Thus, in the Indian tradition, yoga has been seen as a pathway for attaining a spiritual goal. However, with the influence of modern medicine and evidence-based scientific research, over the last 3–4 decades there has been much attention given to the ‘byproducts’ of yogic practices. There has been systematic documentation of the benefits of various yoga-based practices on physiological functioning in terms of physical effects such as metabolic efficiency as well as cognitive aspects such as memory in healthy subjects of different age groups. The natural corollary of this has been the use of such practices as therapeutic interventions in physical disorders such as diabetes, hypertension, asthma, and later in mental disorders such as depression and anxiety. This has not gone down well with some traditional yoga schools, who feel that this is not what yoga should be used for. However, this process now seems irreversible, with yoga-based treatments becoming quite popular worldwide. There are now yoga-based interventions available for most common disorders, although some of these ‘packages’ may not have passed the test of validity and research. Evidence-based research demonstrating the benefit of yogabased modules is now available for many physical disorders such as diabetes and asthma. In the field of mental health, evidence is
S. Varambally, B.N. Gangadhar / Asian Journal of Psychiatry 5 (2012) 186–189
accumulating that such modules may be used safely and effectively as an adjuvant, and even as a sole modality of therapy in some disorders like depression. However, evaluating treatment modalities like yoga using modern research methodologies such as randomized double-blinded controlled trials has several limitations, which will be discussed later in this paper. Given this, as well as several other factors unique to yoga, convincing the medical fraternity about yoga as an intervention remains a difficult challenge. Nevertheless, some evidence for yoga-based therapies in the management of mental disorders is briefly reviewed here. 2. Yoga therapies in depression In depression, stress plays an important role and its relief can improve depressive symptoms. Sudarshan Kriya Yoga (SKY) is part of the stress management package offered by the Art of Living foundation. Studies have shown that SKY has neurobiological effects like increased parasympathetic drive, calming stress response systems, neuroendocrine release of hormones and effects on thalamic generators (Brown and Gerbarg, 2005). Pilkington (Pilkington et al., 2005) reviewed the role of Yoga in depression, with a positive conclusion as regards its role in the treatment of depression. In a 4-week clinical trial, 45 consenting inpatients of major depression with melancholia were randomized to SKY/Electroconvulsive Therapy (ECT)/Imipramine (IMN), with 15 patients in each group. Patients were given daily SKY practice under supervision or 3ECT’s/week, or imipramine 150 mg/day under their respective group. Weekly assessment was done with Hamilton depression rating scale. SKY produced significant reductions in depression scores comparable to IMN, but less than ECT (SKY 67% vs. ECT 93%, IMN 73% remission) (Janakiramaiah et al., 2000). In a second clinical trial, 30 major depressive disorder inpatients were given SKY or partial SKY for 4 weeks under supervision. Partial SKY had Ujjayi, Bhastrika but normal breathing in place of Kriya (cyclical breathing). Patients were assessed on weekly basis with Beck Depression Inventory. Both groups had significant reduction in depression scores and were comparable; but 75% of full SKY patients had responded as against 45% of partial SKY at the end of four weeks (a trend-worthy difference) (Rohini et al., 2000). In another clinical trial in dysthymia, 46 outpatients were given SKY training for 1 week, after which they practiced at home for the next month. 25 out of 37 patients who completed the trial showed remission by the end of first month of practice and maintained the same for next 3 months. This ‘dose-dependent’ effect suggests the possible role of SKY (all remitted had practiced regularly) in dysthymia (Janakiramaiah et al., 1998). With the above results it can be concluded that SKY has antidepressant effects comparable to imipramine and optimal benefit is obtained with the full Kriya of at least thrice a week. In a randomized controlled trial (RCT), 30 major depressive disorder patients were randomized to Sahaj yoga or no yoga, with both the groups on antidepressants. The patients were assessed with Hamilton Rating Scale for Depression (HAM-D) and Hamilton Rating Scale for Anxiety (HAM-A) before and after 8 weeks of yoga intervention. Both the groups showed significant improvements in HAM-D and HAM-A, however percentage of improvement was significantly higher in the Sahaj yoga group than the other group. The number of patients who remitted was also significantly higher in Sahaj yoga group (Sharma et al., 2006).
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anxiety disorders has been noted. Hence yoga has been tried as treatment for anxiety disorders. In a small open uncontrolled pilot study of Kundalini Yoga (KY) in obsessive compulsive disorder (OCD), 5 of 8 pts showed 55.6% improvement in the mean psychopathology scores in a 12 month trial. In a 2nd trial which compared KY with relaxation response plus mindfulness meditation, the KY group had greater and statistically significant improvement on the rating scales for OCD and anxiety. An intent-to-treat analysis for baseline and 3 month tests showed that only KY group had improved on all scales (Shannahoff-Khalsa et al., 1999). A review in 2005 suggested that there was not enough evidence to definitely conclude that yoga was an effective treatment for anxiety disorders (Kirkwood et al., 2005). However, Brown and Gerbarg concluded that there is sufficient evidence to consider SKY to be a beneficial, low risk, low cost adjuvant to treatment of stress, anxiety, post traumatic stress disorder and stress-related medical illnesses (Brown and Gerbarg, 2005). A recent comprehensive review (da Silva et al., 2009) was able to draw some conclusions about the efficacy of yoga in depression and anxiety disorders, despite paucity of studies and methodological shortcomings in the published literature. The authors concluded that in depressive disorders, yoga may be comparable to medication, and the combination superior to medication alone. They also found reasonable evidence for its use as second-line monotherapy or augmentation to medication in mild to moderate major depression and dysthymia. In anxiety disorders, yoga may be superior to medication for a subgroup of patients with anxiety disorders, but the evidence for its benefits in specific conditions such as obsessive compulsive disorder and post-traumatic stress disorder are preliminary. They also reported that yoga therapy has shown good safety and tolerability in the short-term. 4. Yoga therapies in schizophrenia Schizophrenia is a more severe psychiatric disorder that has benefited from yoga. Initial results in chronic inpatients exposed to yoga were encouraging (Nagendra et al., 2000). This led to a randomized trial comparing yoga and exercise in outpatients of schizophrenia. While both interventions benefited the negative symptoms and quality of life, yoga was better (Duraiswamy et al., 2007). Independently, Visceglia et al. confirmed, though from a smaller sample, better effects of yoga over exercise in schizophrenia (Visceglia and Lewis, 2011). Although a systematic review in 2012 (Vancampfort et al., 2012) included only 3 RCT’s, the results indicated that yoga therapy can be an useful add-on treatment to reduce general psychopathology, positive and negative symptoms, and Health-related Quality of Life in patients with schizophrenia. Using a waitlist control, recently we were able to demonstrate benefits of yogasana over both exercise and waitlist in medicationstabilized outpatients of schizophrenia (Gangadhar et al., in press). Yogasana also benefited social cognition. Patients’ ability to recognize facial emotions on a standardized test improved after yoga, better than either exercise or mere waiting (Behere et al., 2010). Neurobiological basis for this benefit is proposed in the form of elevations in the ‘cuddle’ hormone, oxytocin (Jayaram, 2012). A caveat, however, is that the practice of meditation in patients with psychosis is controversial, as some theoretical and clinical evidence (Walsh and Roche, 1979) points to precipitation or worsening of psychosis with such practices. Most yoga modules for such patients do not include meditative practices.
3. Yoga therapies in anxiety disorders 5. Alcohol dependence syndrome and yoga therapy Yoga has been demonstrated to cause change in the neurophysiological markers of stress and anxiety like GSR and stress hormone levels. With practice of relaxation techniques, improvement in the
Depression is a common co-morbidity with alcohol dependence syndrome (ADS) and predicts relapse especially in early
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withdrawal state, with the relapse rate of around 50%. In a randomized controlled trial, 60 inpatients of ADS, detoxified in the first week, were randomized into SKY or treatment as usual groups. Assessment was done with Beck’s Depression Inventory (BDI) at the baseline and 2 weeks after the practice of yoga along with assay of plasma cortisol, adrenocorticotrophic hormone (ACTH) and prolactin levels. There was more reduction in depression scores in SKY group compared to non-SKY group. Plasma cortisol and ACTH levels dropped in both groups, more so in the SKY group. The reduction in depression scores correlated with that of the plasma cortisol level in the SKY group. Reduction in stress hormone levels along with BDI scores reduction support the possibility of a biological mechanism of Sudarshana Kriya Yoga (Vedamurthachar et al., 2006). 6. Yoga therapy in psychiatric disorders of childhood The maximum literature on the therapeutic application of yoga in child psychiatric disorders has been in Attention Deficit Hyperactivity Disorder (ADHD). A study showed that scores on attention tasks and parent ratings of ADHD symptoms after yoga training was superior to the conventional motor training, with effect sizes in the medium-to-high range (0.60–0.97). The training was particularly effective for children undergoing pharmacotherapy with methylphenidate (Haffner et al., 2006). Another study reported similar findings, with specific benefits in the evening time after medication effects become less (Jensen and Kenny, 2004). Although replication with larger sample sizes and more intensive supervised practice programs are ideal, reviews of multiple studies suggest that yoga can be an effective complementary or concomitant treatment in the overall treatment plan in ADHD. 7. Neurobiological effects of yoga While symptomatic changes in psychiatric disorders with yoga have been described, the biological basis of action underlying these changes remains unclear. As described above, studies on SKY have demonstrated neurobiological changes such as increase in P300 amplitude (Naga Venkatesha Murthy et al., 1998) and reduction in levels of serum cortisol and ACTH (Vedamurthachar et al., 2006) which correlate with symptom improvements, in patients with psychiatric disorders. Similarly, an acute session of yoga has been shown to increase brain levels of Gamma Amino Butyric Acid (GABA) in healthy subjects (Streeter et al., 2007). GABA levels have been shown to be decreased in mood and anxiety disorders, and this offers a possible rationale for the efficacy of yoga in these disorders. A recent functional imaging (fMRI) study demonstrated deactivation of limbic brain regions in healthy volunteers while chanting OM (used in yoga as well as other spiritual practices), possibly indicating effects of yoga on emotional regulation (Kalyani et al., 2011). Yoga has also produced increase in oxytocin levels in patients with schizophrenia who improved in their ability to recognize facial emotions (Jayaram, 2012). Further research linking neurobiological markers with improvements in psychopathology is needed to confirm and extend these preliminary findings. 8. Methodological issues in yoga research Several methodological issues have been pointed out specific to research in complementary therapies such as yoga. The primary ones are difficulty in double-blinding and finding a suitable placebo-control for yoga. Also, selection of a yoga package for a given condition has been variable, and consensus of different yoga schools/traditions is difficult to achieve. In fact, whether modern research methods such as Randomized Double Blind Controlled
Trials are suitable to test practices such as yoga is a relevant question by itself. However, with the objective of convincing mainstream medical practitioners about the utility of yoga-based practices, several researchers have tried innovative research methodologies and published results in peer-reviewed journals (Bijlani, 2008; Gangadhar and Varambally, 2011). In summary, the literature suggests that yoga, a spiritual practice originally designed for self-realization, can lead to significant symptomatic improvements in psychiatric disorders, along with neurobiological effects which may underlie these changes. This may be equally true of other spiritual practices from different faiths. The message for psychiatrists and the mental health fraternity would be that practitioners should not close their minds to the potential benefits of spiritual practices for their patients, nor treat it as a purely personal concern of the patients. If used appropriately based on the belief system of individual patients, they may serve as powerful augmenting agents for modern treatments, or indeed a sole method of treatment in some disorders. Conflict of interest The authors report no conflict of interest in relation to this work. Funding support Some of the studies mentioned above were done under the aegis of the Advanced Center for Yoga at NIMHANS. Dr B N Gangadhar was the Program Director, and the Centre was run in collaboration with the Morarji Desai National Institute of Yoga, New Delhi and funded by the Dept. of AYUSH, Government of India. We also acknowledge funding support from the Dept. of AYUSH, Government of India to Dr B N Gangadhar for the research project ‘‘Efficacy of Yoga as an Add-on Treatment in Schizophrenia’’. Acknowledgements We acknowledge contributions from Dr. G. Venkatasubramanian, Kalyani B.G., Dr. Rishikesh Behere, Dr. H.R. Nagendra, Dr. Naveen Jayaram in the research quoted in this paper. Appendix A. Brief note on some of the terms used in the manuscript Sudarshana Kriya (Su = right, darshana = vision, kriya = action): Essentially a variant of pranayama or breath control, developed by Sri Sri Ravishankar of the Art of Living Foundation. Sudarshana Kriya Yoga (SKY) is the adaptation of Sudarshana Kriya for clinical application (Janakiramaiah et al., 1998). Ujjayi: a pattern of slow breathing (2–3 cycles/min), which is part of the SKY module (Janakiramaiah et al., 1998). Bhastrika: a pattern of rapid, forced exhalation (20–30 cycles/min), which is also part of the SKY module (Janakiramaiah et al., 1998). Sahaj yoga: literally means ‘‘natural union with the divine’’. Comprised of meditation focused on the Sahasrara chakra (located on the top of the head), developed by Nirmala Srivastava in the 1970s as a pathway to self-realization (Sharma et al., 2005). Kundalini Yoga (KY): developed by Yogi Bhajan in the 1960s. It focuses on the psychic energy points (‘‘chakras’’) of the body to stimulate spiritual energy or ‘‘kundalini’’ energy. It is based on sustained, relaxation-focused postures in conjunction with chanting, controlled breathing, hand and finger gestures, visualization exercises and meditation (Shannahoff-Khalsa, 2004).
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