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, meth￾ods 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 pre￾viously 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 pro￾gramme 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 com￾pleted 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 contrib￾utory 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 treat￾ment 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 uti￾lised 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 mobi￾lity 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 high￾lighted 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