OU R N AL O F DISORDERS ELSEVIER Journal of Affective Disorders 89 (2005)13-24 www.elsevier.com/locate/jad Review Yoga for depression:The research evidence Karen Pilkington*,Graham Kirkwood,Hagen Rampes,Janet Richardsond Research Council for Complementary Medicine,London.UK School of Integrated Health.University of Westminster.115 New Cavendish Street.London WIW 6UW.UK Barnet,Enfield and Haringey Mental Health NHS Trust Northwest Community Mental Health Team.Edgware.Middlesex.UK Health and Social Work.University of Plymouth and Research Council for Complementary Medicine,London.UK Received 8 April 2005;received in revised form 31 August 2005;accepted 31 August 2005 Available online 26 September 2005 Abstract Background:Yoga-based interventions may prove to be an attractive option for the treatment of depression.The aim of this study is to systematically review the research evidence on the effectiveness of yoga for this indication. Methods:Searches of the major biomedical databases including MEDLINE,EMBASE,CINAHL,PsycINFO and the Cochrane Library were conducted.Specialist complementary and alternative medicine (CAM)and the IndMED databases were also searched and efforts made to identify unpublished and ongoing research.Searches were conducted between January and June 2004.Relevant research was categorised by study type and appraised.Clinical commentaries were obtained for studies reporting clinical outcomes. Results:Five randomised controlled trials were located,each of which utilised different forms of yoga interventions and in which the severity of the condition ranged from mild to severe.All trials reported positive findings but methodological details such as method of randomisation,compliance and attrition rates were missing.No adverse effects were reported with the exception of fatigue and breathlessness in participants in one study. Limitations:No language restrictions were imposed on the searches conducted but no searches of databases in languages other than English were included. Conclusions:Overall,the initial indications are of potentially beneficial effects of yoga interventions on depressive disorders. Variation in interventions,severity and reporting of trial methodology suggests that the findings must be interpreted with caution.Several of the interventions may not be feasible in those with reduced or impaired mobility.Nevertheless,further investigation of yoga as a therapeutic intervention is warranted. 2005 Elsevier B.V.All rights reserved. Keywords:Yoga;Depression;Depressive disorder;Systematic review Corresponding author.School of Integrated Health,University of Westminster,115 New Cavendish Street,London WIW 6UW.United Kingdom.Tel.:+442079115000x3920. E-mail address:k.pilkington@westminster.ac.uk (K.Pilkington). Now Health Services Research Department,Institute of Psychiatry,London,UK. 0165-0327/S-see front matter 2005 Elsevier B.V.All rights reserved. doi:10.1016M.jad.2005.08.013
Review Yoga for depression: The research evidence Karen Pilkington a,b, *, Graham Kirkwood a,1 , Hagen Rampes c , Janet Richardson a,d a Research Council for Complementary Medicine, London, UK b School of Integrated Health, University of Westminster, 115 New Cavendish Street, London W1W 6UW, UK c Barnet, Enfield and Haringey Mental Health NHS Trust, Northwest Community Mental Health Team, Edgware, Middlesex, UK d Health and Social Work, University of Plymouth and Research Council for Complementary Medicine, London, UK Received 8 April 2005; received in revised form 31 August 2005; accepted 31 August 2005 Available online 26 September 2005 Abstract Background: Yoga-based interventions may prove to be an attractive option for the treatment of depression. The aim of this study is to systematically review the research evidence on the effectiveness of yoga for this indication. Methods: Searches of the major biomedical databases including MEDLINE, EMBASE, ClNAHL, PsycINFO and the Cochrane Library were conducted. Specialist complementary and alternative medicine (CAM) and the IndMED databases were also searched and efforts made to identify unpublished and ongoing research. Searches were conducted between January and June 2004. Relevant research was categorised by study type and appraised. Clinical commentaries were obtained for studies reporting clinical outcomes. Results: Five randomised controlled trials were located, each of which utilised different forms of yoga interventions and in which the severity of the condition ranged from mild to severe. All trials reported positive findings but methodological details such as method of randomisation, compliance and attrition rates were missing. No adverse effects were reported with the exception of fatigue and breathlessness in participants in one study. Limitations: No language restrictions were imposed on the searches conducted but no searches of databases in languages other than English were included. Conclusions: Overall, the initial indications are of potentially beneficial effects of yoga interventions on depressive disorders. Variation in interventions, severity and reporting of trial methodology suggests that the findings must be interpreted with caution. Several of the interventions may not be feasible in those with reduced or impaired mobility. Nevertheless, further investigation of yoga as a therapeutic intervention is warranted. D 2005 Elsevier B.V. All rights reserved. Keywords: Yoga; Depression; Depressive disorder; Systematic review 0165-0327/$ - see front matter D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2005.08.013 * Corresponding author. School of Integrated Health, University of Westminster, 115 New Cavendish Street, London W1W 6UW, United Kingdom. Tel.: +44 207 911 5000x3920. E-mail address: k.pilkington@westminster.ac.uk (K. Pilkington). 1 Now Health Services Research Department, Institute of Psychiatry, London, UK. Journal of Affective Disorders 89 (2005) 13 – 24 www.elsevier.com/locate/jad
14 K.Pilkington et al.Journal of Affective Disorders 89 (2005)13-24 Contents 1. Introduction 4 2. Yoga.·· 15 3. Aim and objectives......·· 15 4. Methods.-.········ 4.1. Summary of the search strategy 15 4.2. Databases searched......... 5. Search terms.,,....,··· 18 6. Filtering...········ 18 7. Selection criteria.·· 18 7.1. Types of studies 7.2. Types of participants.. 18 7.3. Types of intervention. 18 7.4. Types of outcome measures 18 8. Data collection and analysis.... 8 9. Clinical commentaries..··· 9 10. Main results........... 19 11. Summary of the studies. 19 12. Conclusions.····· Acknowledgements 2 References.···· 22 1.Introduction in the USA to examine the relationship between mental disorders and the use of complementary therapies.The Mental health problems such as depression,anxiety sample of 14,985 included those reporting psychologi- and insomnia are amongst the most common reasons cal distress or mental health service use in addition to for individuals to seek treatment with complementary non-distressed nonusers.Analysis of the 9585 com- therapies.Consequently.several surveys have been pleted interviews indicated a high rate of use of com- conducted which focus on this area. plementary therapies in adults who met criteria for Davidson and colleagues carried out a study to common psychiatric disorders.22.4%of respondents determine the frequency of psychiatric disorders in who met the criteria for major depression had used patients receiving complementary medical care in the complementary and alternative medicine during the UK and the USA (Davidson et al.,1998).The authors past 12 months.A similar survey of a nationally repre- found that psychiatric disorders were relatively fre- sentative sample of 2055 respondents revealed that 7.2% quent.Based on rates of lifetime psychiatric diag- reported suffering from"severe depression"(Kessler et noses,a total of 74%of the British patients and al.,2001).A total of 53.6%of those with severe 60.6%of the American patients had a diagnosis. depression reported using complementary and alterna- Major depression(52%of UK and 33.3%of USA) tive medicine for treatment in the past 12 months. and any anxiety disorders(50%of UK and 33.3%of A trend towards increasing use of complementary USA)were the commonest lifetime diagnoses.Rates therapies among people with major depression was of current psychiatric disorder were 46%of the UK demonstrated by a study conducted in Canada (Wang patients and 30.3%of the USA patients.Six percent et al.,2001).Analysis of data from the National of the total suffered from major depression and 25.3% Population Health Surveys indicated that the preva- of the total met the criteria for at least one anxiety lence of use in those with major depression was 7.8% disorder. (19.4%including chiropractic)in 1994-1995 and Unutzer et al.(2000)used data from a national 12.9%(23.8%including chiropractic)in 1996-1997 household telephone survey conducted in 1997-1998 Finally,the findings of a recent Australian postal
Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2. Yoga. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 3. Aim and objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 4. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 4.1. Summary of the search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 4.2. Databases searched . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 5. Search terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 6. Filtering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 7. Selection criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 7.1. Types of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 7.2. Types of participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 7.3. Types of intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 7.4. Types of outcome measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 8. Data collection and analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 9. Clinical commentaries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 10. Main results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 11. Summary of the studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 12. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1. Introduction Mental health problems such as depression, anxiety and insomnia are amongst the most common reasons for individuals to seek treatment with complementary therapies. Consequently, several surveys have been conducted which focus on this area. Davidson and colleagues carried out a study to determine the frequency of psychiatric disorders in patients receiving complementary medical care in the UK and the USA (Davidson et al., 1998). The authors found that psychiatric disorders were relatively frequent. Based on rates of lifetime psychiatric diagnoses, a total of 74% of the British patients and 60.6% of the American patients had a diagnosis. Major depression (52% of UK and 33.3% of USA) and any anxiety disorders (50% of UK and 33.3% of USA) were the commonest lifetime diagnoses. Rates of current psychiatric disorder were 46% of the UK patients and 30.3% of the USA patients. Six percent of the total suffered from major depression and 25.3% of the total met the criteria for at least one anxiety disorder. Unutzer et al. (2000) used data from a national household telephone survey conducted in 1997–1998 in the USA to examine the relationship between mental disorders and the use of complementary therapies. The sample of 14,985 included those reporting psychological distress or mental health service use in addition to non-distressed nonusers. Analysis of the 9585 completed interviews indicated a high rate of use of complementary therapies in adults who met criteria for common psychiatric disorders. 22.4% of respondents who met the criteria for major depression had used complementary and alternative medicine during the past 12 months. A similar survey of a nationally representative sample of 2055 respondents revealed that 7.2% reported suffering from bsevere depressionQ (Kessler et al., 2001). A total of 53.6% of those with severe depression reported using complementary and alternative medicine for treatment in the past 12 months. A trend towards increasing use of complementary therapies among people with major depression was demonstrated by a study conducted in Canada (Wang et al., 2001). Analysis of data from the National Population Health Surveys indicated that the prevalence of use in those with major depression was 7.8% (19.4% including chiropractic) in 1994–1995 and 12.9% (23.8% including chiropractic) in 1996–1997. Finally, the findings of a recent Australian postal 14 K. Pilkington et al. / Journal of Affective Disorders 89 (2005) 13–24
K.Pilkington et al.Journal of Affective Disorders 89 (2005)13-24 15 survey of 6618 randomly selected adults suggested Additionally,many of the trials of yoga are small that self-help strategies including complementary and the results difficult to generalise therapies were very commonly used to cope with However,a recent bibliometric analysis has demon- depression,particularly in mild-moderate psychologi- strated an increase in publication frequency of research cal distress (Jorm et al.,2004). on the clinical application of yoga and growing use of A range of therapeutic approaches is available for randomised controlled trials (Khalsa,2004).Clinical the management of depressive disorders but patients trials were located on the use of yoga for depression, may turn to complementary therapies due to adverse anxiety,cardiovascular conditions (e.g.hypertension, effects of medication,lack of response or simply heart disease),respiratory problems(e.g.asthma),dia- preference for the complementary approach. betes and a variety of others.Systematic reviews of these trials have not yet been conducted although a systematic review of trials of yoga in epilepsy(Ramar- 2.Yoga atnam and Sridharan,2000)concluded that insufficient robust evidence was available.No systematic reviews Yoga has its origins in Indian culture and in its of yoga in depression have been published. original form consisted of a complex system of spiritual,moral and physical practices aimed at attaining 'self-awareness'.Hatha yoga,the system 3.Aim and objectives on which much of Western yoga is based,has 3 basic components,asanas (postures),pranayama The aim of this study was to evaluate the evidence (breathing exercises)and dhyana (meditation).The on the effectiveness of yoga for the treatment of postures involve standing,bending,twisting and bal- depression. ancing the body and consequently improve flexibility and strength.The controlled breathing helps to focus the mind and achieve relaxation while meditation 4.Methods aims to calm the mind (Riley,2004).Although yoga has its origins in Indian religion,it can be 4.1.Summary of the search strategy practised secularly and has been used clinically as a therapeutic intervention.Several explanations based A comprehensive search for clinical research was on Western physiology have been proposed to carried out.Systematic searches were conducted on a account for potential effects of yoga in the treatment range of databases,citations were sought from rele- of various conditions.These can be summarised as vant reviews and several websites were also included modulation of autonomic nervous tone and conse- in the search,including those of MIND and the Men- quent reduction in sympathetic tone,activation of tal Health Foundation. antagonistic neuromuscular systems,which may increase the relaxation response in the neuromuscular 4.2.Databases searched system,and stimulation of the limbic system primar- ily by meditation(Riley,2004). General databases: A national survey conducted in the US demon- CINAHL,Cochrane Central Register of Con- strated that 7.5%of respondents had used yoga at trolled Trials (CENTRAL),Cochrane Database least once in their lifetime and 3.8%had used it in of Systematic Reviews,Database of Abstracts the previous year.Users were more likely to be of Reviews of Effects,EMBASE,IndMED female,college educated and urban dwellers and use (Indian Medlars Centre),MEDLINE (and was for both wellness and specific health conditions PubMed),PsycINFO. (Saper et al.,2004).The authors point out that despite Specialist CAM and condition based databases: greater prevalence of use than other CAM therapies AMED,CISCOM,Cochrane Depression,Anxi- such as acupuncture and homeopathy,yoga receives ety and Neurosis (CCDAN)Review Group less coverage in the Western biomedical literature. register
survey of 6618 randomly selected adults suggested that self-help strategies including complementary therapies were very commonly used to cope with depression, particularly in mild–moderate psychological distress (Jorm et al., 2004). A range of therapeutic approaches is available for the management of depressive disorders but patients may turn to complementary therapies due to adverse effects of medication, lack of response or simply preference for the complementary approach. 2. Yoga Yoga has its origins in Indian culture and in its original form consisted of a complex system of spiritual, moral and physical practices aimed at attaining dself-awarenessT. Hatha yoga, the system on which much of Western yoga is based, has 3 basic components, asanas (postures), pranayama (breathing exercises) and dhyana (meditation). The postures involve standing, bending, twisting and balancing the body and consequently improve flexibility and strength. The controlled breathing helps to focus the mind and achieve relaxation while meditation aims to calm the mind (Riley, 2004). Although yoga has its origins in Indian religion, it can be practised secularly and has been used clinically as a therapeutic intervention. Several explanations based on Western physiology have been proposed to account for potential effects of yoga in the treatment of various conditions. These can be summarised as modulation of autonomic nervous tone and consequent reduction in sympathetic tone, activation of antagonistic neuromuscular systems, which may increase the relaxation response in the neuromuscular system, and stimulation of the limbic system primarily by meditation (Riley, 2004). A national survey conducted in the US demonstrated that 7.5% of respondents had used yoga at least once in their lifetime and 3.8% had used it in the previous year. Users were more likely to be female, college educated and urban dwellers and use was for both wellness and specific health conditions (Saper et al., 2004). The authors point out that despite greater prevalence of use than other CAM therapies such as acupuncture and homeopathy, yoga receives less coverage in the Western biomedical literature. Additionally, many of the trials of yoga are small and the results difficult to generalise. However, a recent bibliometric analysis has demonstrated an increase in publication frequency of research on the clinical application of yoga and growing use of randomised controlled trials (Khalsa, 2004). Clinical trials were located on the use of yoga for depression, anxiety, cardiovascular conditions (e.g. hypertension, heart disease), respiratory problems (e.g. asthma), diabetes and a variety of others. Systematic reviews of these trials have not yet been conducted although a systematic review of trials of yoga in epilepsy (Ramaratnam and Sridharan, 2000) concluded that insufficient robust evidence was available. No systematic reviews of yoga in depression have been published. 3. Aim and objectives The aim of this study was to evaluate the evidence on the effectiveness of yoga for the treatment of depression. 4. Methods 4.1. Summary of the search strategy A comprehensive search for clinical research was carried out. Systematic searches were conducted on a range of databases, citations were sought from relevant reviews and several websites were also included in the search, including those of MIND and the Mental Health Foundation. 4.2. Databases searched General databases: ClNAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, EMBASE, IndMED (Indian Medlars Centre), MEDLINE (and PubMed), PsycINFO. Specialist CAM and condition based databases: AMED, CISCOM, Cochrane Depression, Anxiety and Neurosis (CCDAN) Review Group register. K. Pilkington et al. / Journal of Affective Disorders 89 (2005) 13–24 15
云 Table 1 Randomised controled trials of yoga for depression Pilkington Study Sample Inclusion criteria Yoga intervention Control/comparison Outcome measure(s) Results Methodological appraisal Clinical comments 色 Broota and 30 outpaticnts Clinical diagnosis of Treatment 1:Broota's Tretmerd 2:Iacobson's Symptom checklist一 Percentage reduction Randomisation,concealment Intervention appropriate, Dhir.1990 depression(mainly Relaxation Technique Progressive Relaxation 26 common symptoms in symptoms significant of allocation and blinding Adjunxct to'chemotherapy', by psychiatrist neurtic-depressive or (BRT:4 exercises (PR)for 20 min of depression taken (p<0.05)for BRT and of assessors:unknown Are 3 sessions sufficient 10 per group reactive-depressive) adapted from yoga一 Control:No treatment from DSM-Ⅲand PK compared韩th Baseline characteristics: for an effect?Presertod Age:19-48 yrs Medication for (to narrate present ICD.9 and fiom control (BRT more comparison of groups global symptom <I year,no asana,raising the complaints patient responses efective than jpr bu时 not reported reduction-would hive ECTp向ysical legx,cycling combined and state of mind) in a pilot study no significance given) been helpful to know if disability or with autosuggestion Measures taken pre Tiredness and any specific sympiom neurological and post cach session breathlessness after BRT was affected Affective damage 20 min on 3 if no previous exercise Compliance:unknown consecutive days Attrition:】in each treatment group. reasons not given Disorders Janakiramaiah DSM-IV diagnosis of SKY (Sudarshan Kriya ECT-modified ECT BDI 17.item HRSD Significant reductions in Randomisation. Intervention appropriate 名 et al.,2000 recmaited melncholic depression Yogal:3 soquential 3 times weckly At baseline and BDI and HRSD scores concealment of allocation: (moderately depressed consecutively (score of 17+on HRSD) components of thythmic MN((imipramine:一 weekly for 4 weeks unknown assessors not patients),Outcomes (2005) 15 per group Untreated for current hyperventilation Imipramine 150 mg for all 3 groups.ECT blinded appropriate and measured Age:mean (SDc episode,medically fit interspersed with nommal orally at night group had lowest mean Baseline characteristics using appropriate methods, sKY36.07.8). breathing followed by scores at wecks 3 and 4. reported as comparable Adequate dose of ECT36.72.5), 10-15 min relaxation 45 Remission rates:SKI cmg巴，sex,illness antidepressant used,ECT MN43.411.9 min in total 10(67%,ECT14(93%. duration and severity given 3 times weckly Once daily,6也ysa IMN II (73%)at 4 weeks wreek for 4 weeks No clinically significant Compliance:not side effects observed mentiooed for IMN Attrition:unknown Khumar et al.N-50 students in Severe depression Yoga (Shavasana) No intervention Zung Depression Randomisation,concealment 50 cases of'severe 1993 university hostels diagnosed by Amritsar basod primarily on Self Rating Scale and pre-post depression scores of allocation and blinding depression but 25 in each group Depression Inventory. thythmic breathing Personal Interview for yoga group. of assessors:unkcnown authors have not Zung Depression and relacation Schedule,All Significant differences Baseline characteristics:no given any cut-off scores Self Rating Scale 30 min daily ore-treatment.Zung between treatment and comparison except similar for 30 days cale only after 15 control group at mid and scores at baseline Age:20-25 yrs No medical coodition, and 30 days post treatment (p-001)
Table 1 Randomised controlled trials of yoga for depression Study Sample Inclusion criteria Yoga intervention Control/comparison Outcome measure(s) Results Methodological appraisal Clinical comments Broota and Dhir, 1990 30 outpatients selected by psychiatrist Clinical diagnosis of depression (mainly neurotic-depressive or reactive-depressive) Treatment 1: Broota’s Relaxation Technique (BRT): 4 exercises adapted from yoga — deep breathing, bow asana, raising the legs, cycling combined with autosuggestion Treatment 2: Jacobson’s Progressive Relaxation (JPR) for 20 min Symptom checklist — 26 common symptoms of depression taken from DSM-III and ICD-9 and from patient responses in a pilot study Percentage reduction in symptoms significant ( p b0.05) for BRT and JPR compared with control (BRT more effective than JPR but no significance given) Randomisation, concealment of allocation and blinding of assessors: unknown Intervention appropriate, Adjunct to dchemotherapyT, Are 3 sessions sufficient for an effect? Presented global symptom reduction — would have been helpful to know if any specific symptom was affected 10 per group Medication for b1 year, no ECT, physical disability or neurological damage 20 min on 3 consecutive days Control: No treatment (to narrate present complaints and state of mind) Measures taken pre and post each session Tiredness and breathlessness after BRT if no previous exercise Baseline characteristics: comparison of groups not reported Age: 19–48 yrs Compliance: unknown Attrition: 1 in each treatment group, reasons not given Janakiramaiah et al., 2000 45 patients recruited consecutively 15 per group Age: mean (SD): SKY 36.0 (7.8), ECT 36.7 (2.5), IMN 43.4 (11.9) DSM-IV diagnosis of melancholic depression (score of 17+ on HRSD) Untreated for current episode, medically fit SKY (Sudarshan Kriya Yoga): 3 sequential components of rhythmic hyperventilation interspersed with normal breathing followed by 10–15 min relaxation 45 min in total Once daily, 6 days a week for 4 weeks ECT — modified ECT 3 times weekly IMN (imipramine): — Imipramine 150 mg orally at night BDI 17-item HRSD At baseline and weekly for 4 weeks Significant reductions in BDI and HRSD scores on successive occasions for all 3 groups. ECT group had lowest mean scores at weeks 3 and 4. Remission rates: SKY 10 (67%), ECT 14 (93%), IMN 11 (73%) at 4 weeks No clinically significant side effects observed Randomisation, concealment of allocation: unknown assessors not blinded Baseline characteristics reported as comparable on age, sex, illness duration and severity Compliance: not mentioned for IMN Attrition: unknown Intervention appropriate (moderately depressed patients), Outcomes appropriate and measured using appropriate methods, Adequate dose of antidepressant used, ECT given 3 times weekly Khumar et al., 1993 N = 50 students in university hostels 25 in each group Age: 20–25 yrs Severe depression diagnosed by Amritsar Depression Inventory, Zung Depression Self Rating Scale and interviews No medical condition, Yoga (Shavasana) based primarily on rhythmic breathing and relaxation 30 min daily for 30 days No intervention Zung Depression Self Rating Scale and Personal Interview Schedule, All pre-treatment, Zung scale only after 15 and 30 days Significant differences in pre–post depression scores for yoga group. Significant differences between treatment and control group at mid and post treatment ( p = 0.01) Randomisation, concealment of allocation and blinding of assessors: unknown Baseline characteristics: no comparison except similar scores at baseline 50 cases of dsevere depressionT but authors have not given any cut-off scores K. Pilkington et al. / Journal of Affective Disorders 89 (2005) 13–24 16
no other treatment, Compliance:unknown duration of depression Attrition:unknown 2-3 months Rohini et al 30 consecutive Major depressive Full SKY Partial SKY BDI BAI Total scores reduced for Randomisation unknown, No specific comments 2000 patients attending disorder (DSM-IV) (as described above) (full SKY without both groups.No significant Concealment of allocation, psychiatric services cyclical breathing) difference between groups blinding of assessors:adequate 15 in each group ≥18 on HRSD, Onae山ily in the At baseline then 12 full SKY and 7 partial Baseline characteristics: Age:mean (SD) drug free moming for 4 weeks weckly SKY responded,based on Full SKY:29.5 50%or greater redaction duration (longer in full (82)Partial in BDI total scores SKY group) sKY:34.2(11.7) Compliance:unknown Attritio工anknown 28 volunteers Mild depression Yoga (lyeng一 Waiting list, BDI Pre-test,mid Significant reduction in Mild depression,Beck et aL,2004 via a variety (10-15 on BDI) back bends,standing no active course and post-dest) BDI and STAl tor of allocation,blinding of depression inventory of strategies poses and inversions intervention STAI (pre and post) yoga group but not for assessors,unknown is not a diagnostic Yoga group I王， diagnosts or t杠eatment. followed by POMS (pre and post cca山ooup Baseline characteristics: instrument,its purpase Pilkington Waiting list, no medical relaxation postures 60 Ist,5th and lst class) Significant changes in age/sex reported is to assess the severity control 15 min in the moming. Also cortisol POMS pre to post class but no group comparison of depression Age:18-29 yrs Same asanas for all Compliance:unknown (mean 21.5) (no inversions for menstruating women). Twice a week for 5 wks (practice at home not encouraged) Attrition:3 yoga,2 control but no reasons given of Affective STAI-State-Trait Anciety Inventory,POMS-Profile of Moods Scale,BDI-Beck Depression Inventory.HRSD-Hamilton Rating Scale for Depression,BAl-Beck Amxiety Inventory 老 2005
no other treatment, duration of depression 2–3 months Compliance: unknown Attrition: unknown Rohini et al., 2000 30 consecutive patients attending psychiatric services Major depressive disorder (DSM-IV) Full SKY (as described above) Partial SKY (full SKY without cyclical breathing) BDI BAI Total scores reduced for both groups. No significant difference between groups Randomisation unknown, Concealment of allocation, blinding of assessors: adequate No specific comments 15 in each group Age: mean (SD) Full SKY: 29.5 (8.2) Partial SKY: 34.2 (11.7) z18 on HRSD, drug free Once daily in the morning for 4 weeks At baseline then weekly 12 full SKY and 7 partial SKY responded, based on 50% or greater reduction in BDI total scores Baseline characteristics: similar except for illness duration (longer in full SKY group) Compliance: unknown Attrition: unknown Woolery et al., 2004 28 volunteers via a variety of strategies Yoga group 13, Waiting list, control 15 Age: 18–29 yrs (mean 21.5) Mild depression (10–15 on BDI) No current psychiatric diagnosis or treatment, no medical contraindications Yoga (Iyengar) — back bends, standing poses and inversions followed by relaxation postures 60 min in the morning. Same asanas for all (no inversions for menstruating women). Waiting list, no active intervention BDI Pre-test, mid course and post-test), STAI (pre and post), POMS (pre and post 1st, 5th and last class) Also cortisol Significant reduction in BDI and STAI for yoga group but not for control group Significant changes in POMS pre to post class Randomisation, concealment of allocation, blinding of assessors, unknown Baseline characteristics: age/sex reported but no group comparison Compliance: unknown Mild depression, Beck depression inventory is not a diagnostic instrument, its purpose is to assess the severity of depression Twice a week for 5 wks (practice at home not encouraged) Attrition: 3 yoga, 2 control but no reasons given STAI — State-Trait Anxiety Inventory, POMS — Profile of Moods Scale, BDI — Beck Depression Inventory, HRSD — Hamilton Rating Scale for Depression, BAI — Beck Anxiety Inventory. K. Pilkington et al. / Journal of Affective Disorders 89 (2005) 13–24 17
18 K.Pilkington et al.Journal of Affective Disorders 89 (2005)13-24 Yoga websites: excluded.Attempts were also made to locate relevant International Association of Yoga Therapists qualitative studies. (http://iayt.org/) No language restrictions were imposed at the Yoga Biomedical Trust(http://www.yogatherapy. search and filtering stage and translations would org） have been obtained for any potentially relevant studies Yoga Research and Education Center (http:// in languages other than English. www.yrec.org/) 7.2.Types of participants All searches,except those of the CCDAN register and IndMED,were conducted between January to Participants with depression or a depressive disorder. June 2004 and covered databases from their inception. The CCDAN register was searched in December 2004 7.3.Types of intervention and IndMED was searched in July 2005. Yoga and yoga-based exercises.Studies that involved interventions based solely on meditation 5.Search terms and those involving complex or multiple interventions (e.g.MBSR-mindfulness based stress reduction pro- The basic search terms for yoga were Yoga/or grammes)were excluded. Yoga.mp or Yogic.mp or Pranayama.mp or Dhya- na.mp or Asanas.mp.Terms for depression were 7.4.Types of outcome measures Exp depression or Exp depressive disorder(s)or Exp dysthymia or Exp dysthymic disorder(s)or Depress* Depression rating scales. or Dysthym*or Exp affective disorder(s).Additional terms used as required included Yog*,Affective, Depressi*,Mood. 8.Data collection and analysis Search strategies were adapted for each of the databases searched.Efforts were made to identify Data was extracted systematically using a specially unpublished and ongoing research using relevant data- designed data extraction form.Data extracted bases such as the National Research Register (UK) included details of selection criteria and procedure. and Clinicaltrials.gov (US). the participants,the intervention and any comparison or control intervention,aspects of the methodology and outcome measures and results. 6.Filtering Clinical trials were appraised using a standardised appraisal framework specifically developed for this Relevant research was categorised by study type project and based on criteria recommended in the according to a flow-chart system developed for this Centre for Reviews and Dissemination(2001)Report project.Animal research and basic lab-based research Undertaking Systematic Reviews of Research on were not included in the categorisation process. Effectiveness.Criteria included method of randomisa- tion,allocation concealment and level of blinding (if relevant),baseline comparison of characteristics, 7.Selection criteria method of dealing with missing values,loss to fol- low-up/withdrawals,measures of compliance and out- 7.1.Types of studies come measures reported.For each study,data extraction and appraisal were conducted indepen- All clinical studies,whether controlled trials, dently by two researchers and any disagreements or uncontrolled studies or observational studies,were discrepancies were resolved by discussion.Where identified.Only randomised controlled studies were consensus could not be obtained,a third reviewer selected for inclusion in this review.Abstracts were was available for consultation
Yoga websites: International Association of Yoga Therapists (http://iayt.org/) Yoga Biomedical Trust (http://www.yogatherapy. org/) Yoga Research and Education Center (http:// www.yrec.org/) All searches, except those of the CCDAN register and IndMED, were conducted between January to June 2004 and covered databases from their inception. The CCDAN register was searched in December 2004 and IndMED was searched in July 2005. 5. Search terms The basic search terms for yoga were Yoga/ or Yoga.mp or Yogic.mp or Pranayama.mp or Dhyana.mp or Asanas.mp. Terms for depression were Exp depression or Exp depressive disorder(s) or Exp dysthymia or Exp dysthymic disorder(s) or Depress* or Dysthym* or Exp affective disorder(s). Additional terms used as required included Yog*, Affective, Depressi*, Mood. Search strategies were adapted for each of the databases searched. Efforts were made to identify unpublished and ongoing research using relevant databases such as the National Research Register (UK) and Clinicaltrials.gov (US). 6. Filtering Relevant research was categorised by study type according to a flow-chart system developed for this project. Animal research and basic lab-based research were not included in the categorisation process. 7. Selection criteria 7.1. Types of studies All clinical studies, whether controlled trials, uncontrolled studies or observational studies, were identified. Only randomised controlled studies were selected for inclusion in this review. Abstracts were excluded. Attempts were also made to locate relevant qualitative studies. No language restrictions were imposed at the search and filtering stage and translations would have been obtained for any potentially relevant studies in languages other than English. 7.2. Types of participants Participants with depression or a depressive disorder. 7.3. Types of intervention Yoga and yoga-based exercises. Studies that involved interventions based solely on meditation and those involving complex or multiple interventions (e.g. MBSR—mindfulness based stress reduction programmes) were excluded. 7.4. Types of outcome measures Depression rating scales. 8. Data collection and analysis Data was extracted systematically using a specially designed data extraction form. Data extracted included details of selection criteria and procedure, the participants, the intervention and any comparison or control intervention, aspects of the methodology and outcome measures and results. Clinical trials were appraised using a standardised appraisal framework specifically developed for this project and based on criteria recommended in the Centre for Reviews and Dissemination (2001) Report Undertaking Systematic Reviews of Research on Effectiveness. Criteria included method of randomisation, allocation concealment and level of blinding (if relevant), baseline comparison of characteristics, method of dealing with missing values, loss to follow-up/withdrawals, measures of compliance and outcome measures reported. For each study, data extraction and appraisal were conducted independently by two researchers and any disagreements or discrepancies were resolved by discussion. Where consensus could not be obtained, a third reviewer was available for consultation. 18 K. Pilkington et al. / Journal of Affective Disorders 89 (2005) 13–24
K.Pilkington et al.Journal of Affective Disorders 89 (2005)13-24 19 9.Clinical commentaries frameworks were specifically developed for this pro- ject and these incorporate a number of closed and A clinician with relevant training and experience open questions with space for further comments. was asked to comment on each study focusing on Summaries of these commentaries are provided in clinical relevance and practical issues.Commentary the table of studies (Table 1). 10.Main results Searches of the databases resulted in a total of 342 citations for initial screening (numbers do not include searches of the yoga websites).Screening resulted in the identification of 35 potential clinical trials,which were retrieved for closer examination.Of these,30 did not meet the inclusion criteria and these are listed below together with the reasons for exclusion. A total of 5 randomised controlled trials are included in this review(Broota and Dhir,1990;Janakiramaiah et al.,2000;Khumar et al.,1993;Rohini et al.,2000;Woolery et al.,2004),each of which utilised different forms of yoga interventions.These trials are presented in Table 1 together with an appraisal of the reported methodology and comments on clinical relevance.No studies in languages other than English were located. Excluded studies: Study Reason for exclusion Girodo,1974:Janakiramaiah et al.,1998;Kaye,1985;Kessell. No control group 1994;Naga Venkatesha Murthy et al 1997 and 1998 Berger and Owen,1988,1992;Blumenthal et al.,1989,1991; Healthy volunteers Harvey,1983;Khasky and Smith,1999;Netz and Lidor. 2003;Ray et al,2001;Schell et al.,1994 Kawano,1999 Abstract only but measures general mood,no specific measure of depression Sridevi and Krishna Rao,1996 Menstrual distress,no specific measure of depression Bedard et al.,2003 (brain injuries);Galantino et al.,2004 Primary focus on treatment of medical/physical condition and (back pain);Manocha et al.,2002 (asthma);Massion et al., levels of depression measured as one of range of outcomes 1997 (cancer):Oken et al..2004 (multiple sclerosis): Robinson et al..2003 (HIV) Cohen et al,2004 (cancer) Focus on psychological outcomes but low depression scores at baseline Shapiro et al..2003(cancer) Primary outcome measure sleep disturbance not depression Platania-Solazzo et al..1992 Complex intervention-yoga,massage and progressive muscular relaxation Shapiro et al.,1998 MBSR not yoga(and in healthy volunteers) Teasdale et al.,2000 Mindfulness-based cognitive therapy not yoga Monti,unpublished (cancer) Mindfulness-based art therapy not yoga Speca et al,2000(cancer) Focus on psychological outcomes but MBSR not yoga 11.Summary of the studies intervention,which was to narrate present complaints and state of mind.The interventions were given for Broota and Dhir (1990)reported the results of a short periods over 3 consecutive days.Limited meth- randomised controlled trial of two relaxation techni- odological details are reported:the method of rando- ques,one of which is adapted from yoga,in 30 out- misation is unknown and a baseline comparison of patients diagnosed with mainly neurotic or reactive groups was not reported.Positive results were obtained depression and selected by a psychiatrist.Broota for both treatment groups compared with the control relaxation (yoga-based)and Jacobson's progressive intervention.The Broota technique was reported to be relaxation technique were compared against the control more effective.However,outcomes were based on
Study Reason for exclusion Girodo, 1974; Janakiramaiah et al., 1998; Kaye, 1985; Kessell, 1994; Naga Venkatesha Murthy et al., 1997 and 1998 No control group Berger and Owen, 1988, 1992; Blumenthal et al., 1989, 1991; Harvey, 1983; Khasky and Smith, 1999; Netz and Lidor, 2003; Ray et al., 2001; Schell et al., 1994 Healthy volunteers Kawano, 1999 Abstract only but measures general mood, no specific measure of depression Sridevi and Krishna Rao, 1996 Menstrual distress, no specific measure of depression Bedard et al., 2003 (brain injuries); Galantino et al., 2004 (back pain); Manocha et al., 2002 (asthma); Massion et al., 1997 (cancer); Oken et al., 2004 (multiple sclerosis); Robinson et al., 2003 (HIV) Primary focus on treatment of medical/physical condition and levels of depression measured as one of range of outcomes Cohen et al., 2004 (cancer) Focus on psychological outcomes but low depression scores at baseline Shapiro et al., 2003 (cancer) Primary outcome measure sleep disturbance not depression Platania-Solazzo et al., 1992 Complex intervention—yoga, massage and progressive muscular relaxation Shapiro et al., 1998 MBSR not yoga (and in healthy volunteers) Teasdale et al., 2000 Mindfulness-based cognitive therapy not yoga Monti, unpublished (cancer) Mindfulness-based art therapy not yoga Speca et al., 2000 (cancer) Focus on psychological outcomes but MBSR not yoga 9. Clinical commentaries A clinician with relevant training and experience was asked to comment on each study focusing on clinical relevance and practical issues. Commentary frameworks were specifically developed for this project and these incorporate a number of closed and open questions with space for further comments. Summaries of these commentaries are provided in the table of studies (Table 1). 10. Main results Searches of the databases resulted in a total of 342 citations for initial screening (numbers do not include searches of the yoga websites). Screening resulted in the identification of 35 potential clinical trials, which were retrieved for closer examination. Of these, 30 did not meet the inclusion criteria and these are listed below together with the reasons for exclusion. A total of 5 randomised controlled trials are included in this review (Broota and Dhir, 1990; Janakiramaiah et al., 2000; Khumar et al., 1993; Rohini et al., 2000; Woolery et al., 2004), each of which utilised different forms of yoga interventions. These trials are presented in Table 1 together with an appraisal of the reported methodology and comments on clinical relevance. No studies in languages other than English were located. Excluded studies: 11. Summary of the studies Broota and Dhir (1990) reported the results of a randomised controlled trial of two relaxation techniques, one of which is adapted from yoga, in 30 outpatients diagnosed with mainly neurotic or reactive depression and selected by a psychiatrist. Broota relaxation (yoga-based) and Jacobson’s progressive relaxation technique were compared against the control intervention, which was to narrate present complaints and state of mind. The interventions were given for short periods over 3 consecutive days. Limited methodological details are reported: the method of randomisation is unknown and a baseline comparison of groups was not reported. Positive results were obtained for both treatment groups compared with the control intervention. The Broota technique was reported to be more effective. However, outcomes were based on K. Pilkington et al. / Journal of Affective Disorders 89 (2005) 13–24 19
20 K.Pilkington et al.Journal of Affective Disorders 89 (2005)13-24 percentage symptom reduction measured using a SKY was also the subject of a study by Rohini et al. symptom checklist developed for the trial,completed (2000).The inclusion criteria and size of the study by the patient before and after each session.As blind- were similar to those of the study by Janakiramaiah et ing was not feasible and the outcomes self-reported, al.(2000).Thirty participants,each with major depres- some bias is likely to have been introduced.The attri- sive disorder (DSM-IV,score of 18+on HRSD),were tion rate was low(1 patient per group)but this would be enrolled in the study.The overall aim was to compare expected with a short intervention such as this.No full SKY against partial SKY (full SKY without cycli- difficulties with these programmes or with associated cal breathing).Concealment of allocation and blinding adverse effects with the exception of fatigue were of assessors on this occasion were adequate and posi- reported.However,as the participants were all under tive results were still obtained with a non-significant 50 years of age,there are some limitations with gen- reduction in total scores for both groups.However, eralising the results to the wider population. more full SKY than partial SKY responded based on The effectiveness of Shavasana,which consists of 50%or greater reduction in BDI total scores rhythmic breathing and relaxation,has been studied in In the most recent study,Woolery et al.(2004)tested cases of severe depression (Khumar et al..1993).A a short-term course of lyengar yoga in patients with total of 50 female university students were rando- mild depression as measured using BDI(scores of 10- mised to either a group that practised Shavasana for 15)but without a psychiatric diagnosis.lyengar yoga is 30 min daily for 30 days or to a group that received no based on the teachings of B.K.S.Iyengar who consid- intervention.The Amritsar Depression Inventory and ered specific asanas and sequences of asanas to be Zung Depression Self Rating Scale were used for the particularly effective for alleviating depression.The initial diagnosis and the latter scale was also used as asanas recommended are those that involve opening one of the outcome measures.There was a significant and lifting of the chest,inversions and vigorous stand- reduction in depression score mid and post treatment ing poses.The 28 adult volunteers,all aged less than 30 for the yoga group but not for the control group.A years,were randomly assigned to two 1-h yoga classes between group comparison was non-significant at pre- each week for 5 weeks or to a waiting list control group treatment but had reached significance at mid and post Methods of randomisation,allocation concealment and treatment.There were no adverse effects.However,as blinding of assessors were not reported.A total of 5 with the previous study,basic details of the methodol- patients withdrew (3 out of 13 in the yoga group,2 out ogy were not reported including loss to follow up and of 15 in the control group),a significant proportion in a withdrawals. small trial such as this and the reasons were not given. Janakiramaiah et al.(2000)conducted a triple arm However,a significant reduction in BDI and State Trait RCT involving 45 patients with a DSM-IV diagnosis Anxiety Inventory(STAI)was observed in the yoga but of melancholic depression(score of 17+on Hamilton not in the control group who had received no interven- Rating Scale for Depression)recruited consecutively. tion.The effects emerged by the middle of the course The three interventions were Sudarshan Kriya Yoga and were maintained at the end. (SKY),ECT (electroconvulsive therapy)and drug From the findings of these studies it appears that therapy (imipramine)for 4 weeks.SKY consists of yoga-based interventions may have potentially bene- 3 sequential components based on specified rhythms ficial effects on depressive disorders.However,sev- of breathing.Significant reductions in Beck Depres- eral aspects require consideration.Firstly,the sion Inventory (BDD)and Hamilton Rating Scale for interventions varied incorporating a variety of asanas Depression (HRSD)for all 3 groups were achieved and/or breathing exercises.Therefore,it is not possi- and although the response to SKY did not match that ble to assess which of these interventions or which achieved with ECT,it was comparable to that aspect of each intervention is most effective.The yoga achieved with drug therapy.Respective remission methods used were well-described with the exception rates were SKY 67%,ECT 93%and drug therapy of the two studies of SKY.For a full description of 73%.Again various methodological details,such as SKY,the authors of these papers direct the reader to method of randomisation,are unknown.No adverse either previous reports or a demonstration video effects were reported. (Janakiramaiah et al..2000:Rohini et al..2000)
percentage symptom reduction measured using a symptom checklist developed for the trial, completed by the patient before and after each session. As blinding was not feasible and the outcomes self-reported, some bias is likely to have been introduced. The attrition rate was low (1 patient per group) but this would be expected with a short intervention such as this. No difficulties with these programmes or with associated adverse effects with the exception of fatigue were reported. However, as the participants were all under 50 years of age, there are some limitations with generalising the results to the wider population. The effectiveness of Shavasana, which consists of rhythmic breathing and relaxation, has been studied in cases of severe depression (Khumar et al., 1993). A total of 50 female university students were randomised to either a group that practised Shavasana for 30 min daily for 30 days or to a group that received no intervention. The Amritsar Depression Inventory and Zung Depression Self Rating Scale were used for the initial diagnosis and the latter scale was also used as one of the outcome measures. There was a significant reduction in depression score mid and post treatment for the yoga group but not for the control group. A between group comparison was non-significant at pretreatment but had reached significance at mid and post treatment. There were no adverse effects. However, as with the previous study, basic details of the methodology were not reported including loss to follow up and withdrawals. Janakiramaiah et al. (2000) conducted a triple arm RCT involving 45 patients with a DSM-IV diagnosis of melancholic depression (score of 17+ on Hamilton Rating Scale for Depression) recruited consecutively. The three interventions were Sudarshan Kriya Yoga (SKY), ECT (electroconvulsive therapy) and drug therapy (imipramine) for 4 weeks. SKY consists of 3 sequential components based on specified rhythms of breathing. Significant reductions in Beck Depression Inventory (BDI) and Hamilton Rating Scale for Depression (HRSD) for all 3 groups were achieved and although the response to SKY did not match that achieved with ECT, it was comparable to that achieved with drug therapy. Respective remission rates were SKY 67%, ECT 93% and drug therapy 73%. Again various methodological details, such as method of randomisation, are unknown. No adverse effects were reported. SKY was also the subject of a study by Rohini et al. (2000). The inclusion criteria and size of the study were similar to those of the study by Janakiramaiah et al. (2000). Thirty participants, each with major depressive disorder (DSM-IV, score of 18+ on HRSD), were enrolled in the study. The overall aim was to compare full SKY against partial SKY (full SKY without cyclical breathing). Concealment of allocation and blinding of assessors on this occasion were adequate and positive results were still obtained with a non-significant reduction in total scores for both groups. However, more full SKY than partial SKY responded based on 50% or greater reduction in BDI total scores. In the most recent study, Woolery et al. (2004) tested a short-term course of Iyengar yoga in patients with mild depression as measured using BDI (scores of 10– 15) but without a psychiatric diagnosis. Iyengar yoga is based on the teachings of B.K.S. Iyengar who considered specific asanas and sequences of asanas to be particularly effective for alleviating depression. The asanas recommended are those that involve opening and lifting of the chest, inversions and vigorous standing poses. The 28 adult volunteers, all aged less than 30 years, were randomly assigned to two 1-h yoga classes each week for 5 weeks or to a waiting list control group. Methods of randomisation, allocation concealment and blinding of assessors were not reported. A total of 5 patients withdrew (3 out of 13 in the yoga group, 2 out of 15 in the control group), a significant proportion in a small trial such as this and the reasons were not given. However, a significant reduction in BDI and State Trait Anxiety Inventory (STAI) was observed in the yoga but not in the control group who had received no intervention. The effects emerged by the middle of the course and were maintained at the end. From the findings of these studies it appears that yoga-based interventions may have potentially beneficial effects on depressive disorders. However, several aspects require consideration. Firstly, the interventions varied incorporating a variety of asanas and/or breathing exercises. Therefore, it is not possible to assess which of these interventions or which aspect of each intervention is most effective. The yoga methods used were well-described with the exception of the two studies of SKY. For a full description of SKY, the authors of these papers direct the reader to either previous reports or a demonstration video (Janakiramaiah et al., 2000; Rohini et al., 2000). 20 K. Pilkington et al. / Journal of Affective Disorders 89 (2005) 13–24
K.Pilkington et al.Journal of Affective Disorders 89 (2005)13-24 21 Rhythmic breathing did,however,form an important in programmes such as those reported in these trials. component of the intervention in 4 of the trials Low levels of attrition were reported in 2 studies (Broota and Dhir,1990;Janakiramaiah et al.,2000; (Broota and Dhir,1990;Woolery et al.,2004)but Khumar et al.,1993;Rohini et al.,2000).Secondly, attrition rate was not reported in the remaining studies, the levels of depression being treated ranged from therefore it is difficult to comment on this aspect.An mild to severe with different measures being used to exploratory study by Grover and colleagues (1989)of diagnose and/or assess severity.Finally,basic details 186 'neurotic'patients compared those who com- of trial methodology were not reported.Thus,meth- pleted a 4-6 week yoga programme with those who ods of randomisation are unknown and while it is not dropped out before completion.The only difference possible to blind participants or care givers to the between dropouts and nondropouts was in the severity intervention,blinding of assessors takes on a greater of illness at intake,with those with more severe significance and was either not ensured or not symptoms being more likely to continue with the reported except in one study (Rohini et al.,2000). programme.Initial attitude to yoga was not a contrib- Consequently,the findings must be interpreted with utory factor.This study was conducted some time ago caution and for this reason,a meta-analysis was not and in view of the lack of qualitative studies in this considered appropriate. field,a further exploration of this aspect particularly Other considerations include the feasibility of related to those participating in programmes in a range some of the interventions in the older patient or of contexts would probably prove valuable.However, those with reduced or impaired mobility.Adverse even with conventional management such as drug effects were not reported with the exception of therapy,discontinuation of treatment for depression breathlessness and fatigue in those who had not pre- is a considerable problem;Linden et al.(2000) viously exercised in one study (Broota and Dhir, reported rates of termination of antidepressant treat- 1990)but the participants in two of the studies ment of between 31%and 48%in the first 10 weeks were less than 30 years of age (Khumar et al., while Lawrenson et al.(2000)reported that over 50% 1993 and Woolery et al,2004)and none of the of patients had ceased treatment in the first 6 weeks. participants in the yoga interventions in any study were over 50 years of age.With regard to other potential safety issues,a brief survey of published 12.Conclusions literature reveals that a small number of cases of adverse psychological effects have been reported Overall,the initial indications are of potentially (Hansen,1980;Yorston,2001)although these appear beneficial effects of yoga interventions on depressive to be related specifically to meditation.Other reports disorders.However.variation in the interventions uti- of single cases have suggested that serious adverse lised and in the severity of the depression reported events are possible (e.g.Hanus et al.,1977;Vogel et was encountered in the studies located together with a al.,1991;Mattio et al.,1992;Margo et al.,1992; lack of details of trial methodology.Consequently,the Fong et al.,1993;Cohen et al.,1995;Biswas et al., findings must be interpreted with caution.A further 2002;Johnson et al.,2004).However,these problems consideration is that of the feasibility of some of the are likely to be rare based on the limited number of interventions in those with reduced or impaired mobi- case reports in the literature.Nevertheless,in the lity as the majority of participants in the studies were absence of systematic evaluations of the risks and young and relatively fit.Nevertheless,yoga-based while practice of yoga is often without the knowledge interventions may prove to be an attractive option of the health care professional,any adverse events are for the treatment of depressive disorders.As high- likely to be underreported and any risks difficult to lighted previously,yoga is non-pharmacological, assess.The recommendation that any exercise pro- appears to have minimal adverse effects if practised gramme should only be undertaken on the advice of a as recommended and enjoys international acceptance health professional appears reasonable. (Ramaratnam and Sridharan,2000).Thus further The final consideration is related to compliance investigation of yoga as a therapeutic intervention in and motivation of those with depression to participate depressive disorders is warranted
Rhythmic breathing did, however, form an important component of the intervention in 4 of the trials (Broota and Dhir, 1990; Janakiramaiah et al., 2000; Khumar et al., 1993; Rohini et al., 2000). Secondly, the levels of depression being treated ranged from mild to severe with different measures being used to diagnose and/or assess severity. Finally, basic details of trial methodology were not reported. Thus, methods of randomisation are unknown and while it is not possible to blind participants or care givers to the intervention, blinding of assessors takes on a greater significance and was either not ensured or not reported except in one study (Rohini et al., 2000). Consequently, the findings must be interpreted with caution and for this reason, a meta-analysis was not considered appropriate. Other considerations include the feasibility of some of the interventions in the older patient or those with reduced or impaired mobility. Adverse effects were not reported with the exception of breathlessness and fatigue in those who had not previously exercised in one study (Broota and Dhir, 1990) but the participants in two of the studies were less than 30 years of age (Khumar et al., 1993 and Woolery et al., 2004) and none of the participants in the yoga interventions in any study were over 50 years of age. With regard to other potential safety issues, a brief survey of published literature reveals that a small number of cases of adverse psychological effects have been reported (Hansen, 1980; Yorston, 2001) although these appear to be related specifically to meditation. Other reports of single cases have suggested that serious adverse events are possible (e.g. Hanus et al., 1977; Vogel et al., 1991; Mattio et al., 1992; Margo et al., 1992; Fong et al., 1993; Cohen et al., 1995; Biswas et al., 2002; Johnson et al., 2004). However, these problems are likely to be rare based on the limited number of case reports in the literature. Nevertheless, in the absence of systematic evaluations of the risks and while practice of yoga is often without the knowledge of the health care professional, any adverse events are likely to be underreported and any risks difficult to assess. The recommendation that any exercise programme should only be undertaken on the advice of a health professional appears reasonable. The final consideration is related to compliance and motivation of those with depression to participate in programmes such as those reported in these trials. Low levels of attrition were reported in 2 studies (Broota and Dhir, 1990; Woolery et al., 2004) but attrition rate was not reported in the remaining studies, therefore it is difficult to comment on this aspect. An exploratory study by Grover and colleagues (1989) of 186 dneuroticT patients compared those who completed a 4–6 week yoga programme with those who dropped out before completion. The only difference between dropouts and nondropouts was in the severity of illness at intake, with those with more severe symptoms being more likely to continue with the programme. Initial attitude to yoga was not a contributory factor. This study was conducted some time ago and in view of the lack of qualitative studies in this field, a further exploration of this aspect particularly related to those participating in programmes in a range of contexts would probably prove valuable. However, even with conventional management such as drug therapy, discontinuation of treatment for depression is a considerable problem; Linden et al. (2000) reported rates of termination of antidepressant treatment of between 31% and 48% in the first 10 weeks while Lawrenson et al. (2000) reported that over 50% of patients had ceased treatment in the first 6 weeks. 12. Conclusions Overall, the initial indications are of potentially beneficial effects of yoga interventions on depressive disorders. However, variation in the interventions utilised and in the severity of the depression reported was encountered in the studies located together with a lack of details of trial methodology. Consequently, the findings must be interpreted with caution. A further consideration is that of the feasibility of some of the interventions in those with reduced or impaired mobility as the majority of participants in the studies were young and relatively fit. Nevertheless, yoga-based interventions may prove to be an attractive option for the treatment of depressive disorders. As highlighted previously, yoga is non-pharmacological, appears to have minimal adverse effects if practised as recommended and enjoys international acceptance (Ramaratnam and Sridharan, 2000). Thus further investigation of yoga as a therapeutic intervention in depressive disorders is warranted. K. Pilkington et al. / Journal of Affective Disorders 89 (2005) 13–24 21
22 K.Pilkington et al.Journal of Affective Disorders 89 (2005)13-24 The aim of future studies should be to identify ment in four exercise modes:swimming,body conditioning. which of the potential yoga-based interventions is hatha yoga,and fencing.Res.Q.Exerc.Sport 59 (2),148-159. most effective and what levels of severity of depres- Berger,B.G.,Owen,D.R.,1992.Mood alteration with yoga and swimming:aerobic exercise may not be necessary.Percept.Mot. sion are likely to respond to this approach.Systema- Skills75,1331-1343. tic reviews on the effect of exercise in general on Biswas,R..Paul,A..Shetty,K.J.2002.A yoga teacher with depression have reported differing conclusions:Craft persistent reflux symptoms.Int.J.Clin.Pract.56.723. and Perna(2004)and North et al.(1990)concluding Blumenthal,J.A.,Emery,C.F,Madden,D.J.,George,L.K.,Cole- man,R.E.,Riddle,M.W..McKee,D.C.,Reasoner,J.,Williams. that exercise results in overall benefit while Lawlor R.S.,1989.Cardiovascular and behavioral effects of aerobic and Hopker (2001)concluded that the evidence was exercise training in healthy older men and women.J.Gerontol. insufficient.This topic is currently being revisited as 44(5),M147-M157. a Cochrane review is in preparation (Lawlor and Blumenthal,J.A.,Emery,C.F.,Madden,D.J.,Schniebolk,S., Campbell,2000).The recent NICE guidance on the Walsh-Riddle,M.,George,L.K.,McKee,D.C.,Higginbotham. management of depression provides support for M.B.,Cobb,F.R.,Coleman,R.E..1991.Long-term effects of exercise on psychological functioning in older men and women. "structured and supervised exercise"particularly in J.Gerontol.46(6).P352-P361. those with mild to moderate depression (NICE, Broota,A.,Dhir,R.,1990.Efficacy of two relaxation techniques in 2004).Consequently,an assessment of the compara- depression.J.Pers.Clin.Stud.6 (1).83-90. tive effectiveness of anaerobic exercise (such as Centre for Reviews and Dissemination(CRD),2001.Undertaking Systematic Reviews of Research on Effectiveness.Report Num- yoga)and aerobic exercise in depressive disorders, ber 4.2nd edition CRD.York. both in the short-and long-term,would also prove Cohen.J.A..Char.D.H..Norman.D.,1995.Bilateral orbital varices valuable. associated with habitual bending.Arch.Ophthalmol.113. 1360-1362. Cohen,L..Wameke,C..Fouladi,R.T..Rodriguez,M.A.,Chaoul- Reich.A..2004.Psychological adjustment and sleep quality in a Acknowledgements randomized trial of the effects of a Tibetan yoga intervention in patients with lymphoma.Cancer 100,2253-2260. Anelia Boshnakova,Electronic Information Offi- Craft,L.L.,Perna,F.M.,2004.The benefits of exercise for the cer,RCCM for advice and support with search stra- clinically depressed.Prim.Care Companion J.Clin.Psychiat. tegies and searches. 6(3).104-111. Hugh McGuire.CCDAN Trials Search Coordina- Davidson,J.R..Rampes,H.,Eisen,M.,Fisher,P.,Smith,R.d.. Malik,M..1998.Psychiatric disorders in primary care patients tor for the Cochrane Depression,Anxiety and Neuro- receiving complementary medical treatments.Compr.Psychia- sis Review Group for conducting searches on the ty39(1),16-20. CCDAN trial register. Fong,K.Y.,Cheung,R.T.,Yu,Y.L.,Lai,C.W.,Chang.C.M.,1993. The Project Advisory Group and Specialist Advi- Basilar artery occlusion following yoga exercise:a case report. sory Group (mental health)for the NHS Priorities Clin.Exp.Neurol.30.104-109. Galantino,M.L.,Bzdewka.T.M..Eissler-Russo.J.L..Holbrook. Project for advice and support to the project. M.L.,Mogck,E.P,Geigle,P.,Farrar,J.T.,2004.The impact The NHS Priorities Project is funded by the of modified hatha yoga on chronic low back pain:a pilot study. Department of Health.The views and opinions Altem.Ther.Health Med.10(2).56-59. expressed are those of the authors and do not neces- Girodo,M.,1974.Yoga meditation and flooding in the treat- sarily reflect those of the Department of Health. ment of anxiety neurosis.J.Behav.Ther.Exp.Psychiatry 5(2). 157-160. Grover,P.,Varma,V.K.,Verma,S.K.,Pershad,D.,1989.Factors influencing treatment acceptance in neurotic patients referred for yoga therapy:an exploratory study.Indian J.Psychiatry 31 (3). References 250-257. Hansen,W.,1980.Psychoses and meditation (Danish).Ugeskr Bedard,M.,Felteau,M.,Mazmanian,D.,Fedyk,K.,Klein,R.. Laeger143(1),20-22. Richardson,J..Parkinson,W.,Minthom-Biggs,M.B.,2003. Hanus,S.H.,Homer,T.D.,Harter,D.H.,1977.Vertebral artery Pilot evaluation of a mindfulness-based intervention to improve occlusion complicating yoga exercises.Arch.Neurol.34, quality of life among individuals who sustained traumatic brain 574-575. injuries.Disabil.Rehabil.25 (13),722-731. Harvey,J.R.,1983.The effect of yogic breathing exercises on Berger.B.G.,Owen,D.R..1988.Stress reduction and mood enhance- mood.J.Am.Soc.Psychosom.Dent.Med.30 (2).39-48
The aim of future studies should be to identify which of the potential yoga-based interventions is most effective and what levels of severity of depression are likely to respond to this approach. Systematic reviews on the effect of exercise in general on depression have reported differing conclusions: Craft and Perna (2004) and North et al. (1990) concluding that exercise results in overall benefit while Lawlor and Hopker (2001) concluded that the evidence was insufficient. This topic is currently being revisited as a Cochrane review is in preparation (Lawlor and Campbell, 2000). The recent NICE guidance on the management of depression provides support for bstructured and supervised exerciseQ particularly in those with mild to moderate depression (NICE, 2004). Consequently, an assessment of the comparative effectiveness of anaerobic exercise (such as yoga) and aerobic exercise in depressive disorders, both in the short- and long-term, would also prove valuable. Acknowledgements Anelia Boshnakova, Electronic Information Officer, RCCM for advice and support with search strategies and searches. Hugh McGuire, CCDAN Trials Search Coordinator for the Cochrane Depression, Anxiety and Neurosis Review Group for conducting searches on the CCDAN trial register. The Project Advisory Group and Specialist Advisory Group (mental health) for the NHS Priorities Project for advice and support to the project. The NHS Priorities Project is funded by the Department of Health. The views and opinions expressed are those of the authors and do not necessarily reflect those of the Department of Health. References Bedard, M., Felteau, M., Mazmanian, D., Fedyk, K., Klein, R., Richardson, J., Parkinson, W., Minthorn-Biggs, M.B., 2003. Pilot evaluation of a mindfulness-based intervention to improve quality of life among individuals who sustained traumatic brain injuries. Disabil. Rehabil. 25 (13), 722 – 731. Berger, B.G., Owen, D.R., 1988. Stress reduction and mood enhancement in four exercise modes: swimming, body conditioning, hatha yoga, and fencing. Res. Q. Exerc. Sport 59 (2), 148 – 159. Berger, B.G., Owen, D.R., 1992. Mood alteration with yoga and swimming: aerobic exercise may not be necessary. Percept. Mot. Skills 75, 1331 – 1343. Biswas, R., Paul, A., Shetty, K.J., 2002. A yoga teacher with persistent reflux symptoms. Int. J. Clin. Pract. 56, 723. Blumenthal, J.A., Emery, C.F., Madden, D.J., George, L.K., Coleman, R.E., Riddle, M.W., McKee, D.C., Reasoner, J., Williams, R.S., 1989. Cardiovascular and behavioral effects of aerobic exercise training in healthy older men and women. J. Gerontol. 44 (5), M147 –M157. Blumenthal, J.A., Emery, C.F., Madden, D.J., Schniebolk, S., Walsh-Riddle, M., George, L.K., McKee, D.C., Higginbotham, M.B., Cobb, F.R., Coleman, R.E., 1991. Long-term effects of exercise on psychological functioning in older men and women. J. Gerontol. 46 (6), P352 – P361. Broota, A., Dhir, R., 1990. Efficacy of two relaxation techniques in depression. J. Pers. Clin. Stud. 6 (1), 83 – 90. Centre for Reviews and Dissemination (CRD), 2001. Undertaking Systematic Reviews of Research on Effectiveness. Report Number 4, 2nd edition CRD, York. Cohen, J.A., Char, D.H., Norman, D., 1995. Bilateral orbital varices associated with habitual bending. Arch. Ophthalmol. 113, 1360 – 1362. Cohen, L., Warneke, C., Fouladi, R.T., Rodriguez, M.A., ChaoulReich, A., 2004. Psychological adjustment and sleep quality in a randomized trial of the effects of a Tibetan yoga intervention in patients with lymphoma. Cancer 100, 2253 – 2260. Craft, L.L., Perna, F.M., 2004. The benefits of exercise for the clinically depressed. Prim. Care Companion J. Clin. Psychiat. 6 (3), 104 – 111. Davidson, J.R., Rampes, H., Eisen, M., Fisher, P., Smith, R.d., Malik, M., 1998. Psychiatric disorders in primary care patients receiving complementary medical treatments. Compr. Psychiatry 39 (1), 16 – 20. Fong, K.Y., Cheung, R.T., Yu, Y.L., Lai, C.W., Chang, C.M., 1993. Basilar artery occlusion following yoga exercise: a case report. Clin. Exp. Neurol. 30, 104 – 109. Galantino, M.L., Bzdewka, T.M., Eissler-Russo, J.L., Holbrook, M.L., Mogck, E.P., Geigle, P., Farrar, J.T., 2004. The impact of modified hatha yoga on chronic low back pain: a pilot study. Altern. Ther. Health Med. 10 (2), 56 – 59. Girodo, M., 1974. Yoga meditation and flooding in the treatment of anxiety neurosis. J. Behav. Ther. Exp. Psychiatry 5 (2), 157 – 160. Grover, P., Varma, V.K., Verma, S.K., Pershad, D., 1989. Factors influencing treatment acceptance in neurotic patients referred for yoga therapy: an exploratory study. Indian J. Psychiatry 31 (3), 250 – 257. Hansen, W., 1980. Psychoses and meditation (Danish). Ugeskr. Laeger 143 (1), 20 – 22. Hanus, S.H., Homer, T.D., Harter, D.H., 1977. Vertebral artery occlusion complicating yoga exercises. Arch. Neurol. 34, 574 – 575. Harvey, J.R., 1983. The effect of yogic breathing exercises on mood. J. Am. Soc. Psychosom. Dent. Med. 30 (2), 39 – 48. 22 K. Pilkington et al. / Journal of Affective Disorders 89 (2005) 13–24