Psychiatric Annals

CME Article 

Yoga as a Treatment for Depression: Applications for Mental Health Practitioners

Maren Nyer, PhD; Cayla M. O'Hair, BA; Lindsey B. Hopkins, PhD; Regina Roberg, BA; Richard Norton, BS; Chris Streeter, MD

Abstract

Yoga is an ancient mind-body philosophy from the East, commonly associated in the West with physical postures (asana), breath work (pranayama), and meditation. Empirical research has found generally positive effects, with yoga practice and interventions associated with reduced symptoms of depression. This article provides a brief introduction to yoga philosophy and an overview of the current empirical support for yoga as a treatment for depression. Yoga as a monotherapy versus treatment augmentation strategy, as well as potential physiological mechanisms of action and transdiagnostic use, are briefly addressed. Clinical considerations are also discussed from the perspective of the mental health clinician. [Psychiatr Ann. 2019;49(1):11–15.]

Abstract

Yoga is an ancient mind-body philosophy from the East, commonly associated in the West with physical postures (asana), breath work (pranayama), and meditation. Empirical research has found generally positive effects, with yoga practice and interventions associated with reduced symptoms of depression. This article provides a brief introduction to yoga philosophy and an overview of the current empirical support for yoga as a treatment for depression. Yoga as a monotherapy versus treatment augmentation strategy, as well as potential physiological mechanisms of action and transdiagnostic use, are briefly addressed. Clinical considerations are also discussed from the perspective of the mental health clinician. [Psychiatr Ann. 2019;49(1):11–15.]

The popular use and evidence base of yoga as an approach to enhancing mental health has increased over the past several decades in the United States.1,2 Yoga has been studied as an add-on treatment (augmentation strategy) and a stand-alone treatment (monotherapy) for depression. In the West, yoga is typically associated with physical postures and breathing, and sometimes mistaken as being only a method of physical exercise. However, yoga is an ancient mind-body practice, and in full form includes philosophical and spiritual components. The earliest documentation of yoga philosophy, the Yoga Sutras of Patanjali, outlined an eight-limb path consisting of (1) moral restraints (yamas), (2) observances (niyamas), (3) postures (asana), (4) breath regulation (pranayama), (5) turning inward (pratyahara), (6) concentration (dharana), (7) meditation (Dhyana), and (8) union of the self with the object of meditation (samadhi).3,4 The restraints (yamas) and the observances (niyamas) have therapeutic implications, as they are ethical codes of conduct with both internal (intrapersonal) and external (interpersonal) applications that could be explored with psychotherapy by a patient who is interested in the philosophical roots of yoga.

There are various types of yoga practiced. In the US, Hatha yoga, which focuses primarily on physical postures, is the most widely practiced and investigated. Different forms of Hatha yoga vary in their relative emphasis on each component of the eight-limb path. Popular variations practiced in the West are listed in Table 1.5,6

Variations of Hatha Yoga

Table 1:

Variations of Hatha Yoga

Overview of the Evidence Base: Yoga as a Treatment for Depression

The most recent systematic review of randomized controlled trials (RCTs) investigating yoga for patients with major depressive disorder (MDD) was conducted in 2017 and included seven RCTs of patients with MDD.7 Conclusions from this systematic review indicated that yoga was comparable to both exercise and medication in reducing unipolar depressive symptoms, although electroconvulsive therapy (ECT) demonstrated stronger effects than yoga.7,8 Since the publication of this review, four additional RCTs have been published.9–12

Streeter et al.11 explored the effect of two versus three sessions per week of Iyengar yoga plus breathing at 5 breaths-per-minute (coherent breathing) for 12 weeks in patients with MDD, both with and without antidepressant medication. Both doses were associated with similar remission rates, with remission operationalized as a Beck Depression Inventory II (BDI-II) score of <14. However, the higher dose group (3 times/week) showed greater remission rates than the lower dose group (2 times/week) when operationalizing remission as a BDI-II score of ≤10.11

Uebelacker et al.12 compared a 10-week Hatha yoga intervention to a health education control condition in patients with persistent depression taking a stable regimen of antidepressant medication. For the yoga condition, one class per week was required, but two were recommended. No condition differences were found at post-treatment, but yoga participants showed significantly greater reductions in depression symptoms than control participants at the 3- and 6-month follow-ups. On average, yoga and control participants practiced yoga for 36 minutes and 2 minutes per week at the 3-month follow-up and for 34 minutes and 2 minutes at the 6-month follow-up, respectively.12

Prathikanti et al.10 compared the effects of twice-weekly Hatha yoga to an attention education group for 8 weeks among participants with mild-to-moderate MDD who were not taking antidepressant medication. Remission rates, defined as BDI-II total score ≤9, were greater for those randomized to yoga than to the control condition.10

Chu et al.9 compared a twice-weekly, nonspecified yoga intervention to a waitlist control for 12 weeks. Participants had at least mild depression (BDI-II ≥14) at baseline and were not taking antidepressant medication. Yoga outperformed the control condition in reducing depressive symptoms.9

The results of these recent RCTs bolster earlier reviews promoting yoga's promise for reducing depression symptoms among participants both taking and not taking antidepressant medication. However, these findings are preliminary and require replication in larger, definitive RCTs. Nevertheless, if a patient is interested in adding yoga to their treatment, there is presently enough evidence to encourage their participation.

Monotherapy Versus Adjunctive Treatment

The majority of RCTs examining yoga as a treatment for depression allowed for stable antidepressant medication use.7 Three RCTs included only medication-free participants with depression and had positive results.9,10,13 Two studies examining patients not taking depression medication found significant reductions in depression symptoms compared to a waitlist control for 12 weeks9 and an attention-control education group for 8 weeks.10 In a three-arm study, Janakiramaiah et al.13 randomized inpatients to ECT versus imipramine versus Sudrashan Kriya yoga (SKY; practiced for 45 minutes at a time, 6 times/week). The SKY group was comparable to the imipramine group at the end of the 4-week period.13

The most rigorous and recent RCT to explore the antidepressant effects of yoga among patients on a stable regimen of antidepressant medication had mixed findings. Uebelacker et al.12 compared 10 weeks of Hatha yoga to a health education control group, but they did not find group differences post-treatment. These null findings may have been due, in part, to the low dose of yoga, illness severity of the population, and the potentially active control condition. Nevertheless, the yoga group emerged with significantly greater improvements in symptoms at both the 3- and 6-month follow-ups. The authors suggest that the benefits of yoga may take time to accumulate.12

Heated Versus Nonheated Yoga

Some popular forms of yoga are practiced in a heated room. There are no current RCTs of heated yoga for depression nor any RCTs comparing heated yoga to nonheated yoga for the treatment of depression. There have been two RCTs of Bikram yoga for those with high levels of stress; both resulted in positive findings for reducing perceived stress and improving related psychophysiological measures (eg, quality of life, mindfulness, self-efficacy, cortisol reactivity to stress).14,15

There is some pilot evidence suggesting that heat alone may have antidepressant effects. A recent double-blinded RCT demonstrated that just one session of whole-body hyperthermia (WBH; temperature of 38.5°C/101.3°F) in 34 medication-free patients with MDD reduced depression scores, with notably large and lasting effect sizes (Cohen's d = 2.23 at 1-week follow-up; d = 1.66 at 6 weeks) when compared to a sham condition (ie, mild heat in the same environment).16 The hypothesized mechanism by which WBH exerted its antidepressant effects was thermoregulatory system dysregulation.16

Transdiagnostic Potential of Yoga

Depression often co-occurs with disorders associated with stress including anxiety, posttraumatic stress disorder, and medical conditions such as epilepsy.17 There is preliminary but mounting evidence supporting the use of yoga-based therapies as a transdiagnostic approach to target known mechanisms implicated in commonly co-occurring psychiatric and medical conditions; specifically by reducing the physiological impact of stress.17,18 The impact of stress on the body can be objectively quantified through measurements of neurotransmitter and cortisol levels, heart rate variability (HRV), and inflammatory markers. Future studies should assess the impact of yoga practice on such transdiagnostic markers to further our understanding of the mechanisms of yoga's ameliorative effects.

Yoga is associated with changes in the following biologic markers consistent with stress reduction.

Neurotransmitters

Patients diagnosed with MDD have significantly lower levels of gamma-aminobutyric acid (GABA) compared to people with no history of psychiatric illness.2 RCTs have demonstrated an association between yoga practice and increased thalamic levels of GABA, as well as improvements in mood and anxiety, suggesting that GABA may mediate the positive effects of yoga on mood.19,20

Cortisol

Patients with MDD have demonstrated higher levels of cortisol as predictors of both onset and recurrence of major depressive episodes.21 One RCT demonstrated that, compared to a waitlist control, an 8-week Bikram yoga intervention resulted in decreased cortisol reactivity to stress among participants with elevated reactivity at baseline.14

Heart Rate Variability

Chronic stress can generate an imbalance between the sympathetic and parasympathetic nervous system (ie, overactivity of the sympathetic and underactivity of the parasympathetic). Yoga has been associated with increased high-frequency HRV and an overall improved regulation of the autonomic nervous system.9,17,22

Inflammatory Markers

Research has shown that a larger concentration of inflammatory cytokines in the central nervous system is associated with depression, the causality of which is unknown.14 Long-term yoga practitioners show decreased inflammatory markers (tumor necrosis factor-alpha, interleukin-1 beta, interleukin-6) when compared to new practitioners.23,24

Clinical Considerations and Recommendations

Styles of Yoga

There have been no head-to-head studies comparing different yoga styles for the treatment of depression. However, in their systematic review of RCTs, Cramer et al.25 compared different forms of yoga in their likelihood of reaching a positive outcome. They found that different yoga styles did not differ in odds of achieving a positive outcome. Given the general lack of research comparing different styles of yoga practice, the literature does not currently support any particular style of yoga for treating depression. Extrapolating from the exercise literature, however, enjoyment of physical activity has been shown to be a strong predictor of continued physical activity at 12 months of follow-up.23 Therefore, encouraging patients to explore different styles of yoga until they find a class or style that they enjoy could increase long-term maintenance of a yoga practice.

An understanding and discussion of styles of yoga with your patient could be useful to set expectations and provide guidance. Styles of yoga vary in (1) physical intensity or rigor, (2) temperature of the room, (3) spiritual versus physical emphasis (which may have implications if patients have strong religious beliefs or philosophical leanings), and (4) focus on the breath (pranayama), the physical postures (asana), and/or meditation/mindfulness practice.

Speaking with your patient to ascertain their goals and encouraging them to think through these various continuums might be useful for setting them up for success. Some styles of yoga, including Iyengar or “chair yoga,” are designed to use props, which can be particularly helpful for facilitating yoga practice among people with physical limitations or disabilities.

Dose and Duration

The literature generally indicates that practicing yoga for a duration of 30 to 90 minutes, at least twice weekly, is likely to improve depressive symptoms.7,11,12 The length of tested interventions has generally ranged from 4 to 12 weeks.7 Although rigorous studies examining optimal frequency/duration of yoga practice are lacking, we can draw on the general physical activity and health behavior literature. These bodies of work would suggest that a more regular and sustained yoga practice is likely to optimize depression (and general mental health) outcomes. Basic psychoeducation is useful for informing patients that consistent and regular practice is likely necessary to achieve lasting symptom reduction.

Accessibility and Demographics

Research has confirmed the existence of the stereotype of yoga as an activity reserved for white, college-educated, younger women.24 Discussing such stereotypes may be important with some patients, as sociodemographic factors may present perceived and/or objective accessibility barriers, including but not limited to geography, (sub)cultural concerns, time commitment, family responsibilities, transportation, and cost. To address these accessibility-related barriers, researchers have begun to explore online yoga interventions as a potential way to reach rural patients and those with financial or time limitations. A recent study of 44 adults with mood disorders found that an online Hatha yoga class resulted in significantly reduced negative affect and good acceptability.26 Thus, online/remote yoga classes may be a viable alternative for patients who have barriers to attending in-person yoga classes.

Safety Considerations

Some patients may be hesitant to initiate yoga due to fear of injury, exacerbation of previous injuries, or physical limitations. The safety data for the use of yoga among those with depression is sparse,7,25 although one article demonstrated that Iyengar yoga was safe in terms of absence of serious adverse events among patients with MDD; in fact, those in the yoga group showed reduced suicidal ideation.27 Furthermore, a 2015 meta-analysis of 92 RCTs of yoga interventions found no difference in protocol-related adverse events or drop-outs due to adverse events when comparing yoga to usual care or exercise; results indicated that yoga was “as safe as usual care and exercise.”28 Moderate muscle soreness has been the most common adverse event in studies.11,19

Guiding patients to discuss preexisting injuries with yoga teachers prior to initiating a yoga practice could be useful for those with fears of injuries or preexisting conditions. Yoga teachers are best suited to make suggestions about modifications or guidance to reduce risk for injury.

Conclusion

The evidence base for including yoga in the treatment of depression is growing. Presently, if a patient expresses interest in engaging in yoga-based practices, there is no reason to believe that this would not be a useful add-on to conventional treatment. The current empirical literature has not explored the comparative effectiveness of different styles of yoga for depression or other mental health concerns. As such, patients should be encouraged to find a practice they enjoy.

References

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Variations of Hatha Yoga

VariationDescription
AshtangaFocuses on synchronizing the breath with a progressive series of postures29,30
IyengarFocuses on proper form and alignment of physical postures31
VinyasaEmphasizes linking one's breath to the postures32
Sudarshan KriyaAlmost exclusively focused on breath33
BikramA standardized 26 postures and two breathing exercises practiced in a heated room34
BaptisteA specific style of Vinyasa yoga practiced in a heated room35
Authors

Maren Nyer, PhD, is an Assistant Professor, Department of Psychiatry, Harvard Medical School; and a Clinical Psychologist, Department of Psychiatry, Massachusetts General Hospital. Cayla M. O'Hair, BA, is a Research Coordinator, Department of Psychiatry, Massachusetts General Hospital. Lindsey B. Hopkins, PhD, is a Clinical Research Psychologist, the Addiction Research Program (jointly housed by the San Francisco VA Health Care System and the University of California-San Francisco). Regina Roberg, BA, is a Research Coordinator, Department of Psychiatry, Massachusetts General Hospital. Richard Norton, BS, is a Research Coordinator, Department of Psychiatry, Massachusetts General Hospital. Chris Streeter, MD, is an Associate Professor of Psychiatry and Neurology, Boston University School of Medicine; a Staff Psychiatrist, Boston Medical Center; a Research Associate, McLean Hospital; and a Staff Psychiatrist, Edith Nourse Rogers Veterans Memorial Hospital.

Address correspondence to Maren Nyer, PhD, Depression Clinical and Research Program, Massachusetts General Hospital, One Bowdoin Square, 6th Floor, Boston, MA 02114; email: mnyer@partners.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20181203-01

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