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 blind￾ing was not feasible and the outcomes self-reported, some bias is likely to have been introduced. The attri￾tion 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 gen￾eralising 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 rando￾mised 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 pre￾treatment but had reached significance at mid and post treatment. There were no adverse effects. However, as with the previous study, basic details of the methodol￾ogy 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 Depres￾sion 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 depres￾sive 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 cycli￾cal breathing). Concealment of allocation and blinding of assessors on this occasion were adequate and posi￾tive 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 consid￾ered 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 stand￾ing 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 interven￾tion. 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 bene￾ficial effects on depressive disorders. However, sev￾eral aspects require consideration. Firstly, the interventions varied incorporating a variety of asanas and/or breathing exercises. Therefore, it is not possi￾ble 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