1. Yoga as a complementary therapy for clinical depression Manoj Sharma, MBBS, CHES, Ph.D. Purvi Mehta, MS

2. Introduction The Behavioral Risk Factor Surveillance System in 2006 found that the prevalence of current depressive symptoms in general population was 8.7% and lifetime diagnosis of depression was 15.7% making it a common illness Approximately 20 million people experience some form of depression in the United States (National Institute of Health [NIH], 2010)

3. Symptoms for depression Sadness Loss of interest/pleasure in activities that are normally enjoyed Weight changes Sleeping problems/oversleeping Loss of energy Feeling worthless Thoughts of death/suicide

4. Factors that contribute to depression Genetics Chemical imbalance Hormonal factors Stress Medical illness

5. Treatment of depression Conventional treatment: antidepressants, therapy or a mixture of the two Interest in complementary & alternative treatments due to side effects of conventional treatment & lack of positive effects from conventional treatments Approximately 75% of patients have tried alternative forms of treatment. Yoga is one such form of alternative and complementary treatment

6. Purpose of this study The purpose of this study was to examine to what extent yoga is beneficial as a complementary therapy for depression. The study utilized a review of existing studies that have explored this association.

7. Methods Databases searched: CINAHL, Google Scholar, ERIC and Medline Inclusion criteria: (i) studies published between 2005 and June 2010 (ii) studies in the English language (iii) focus on studies that measured depression or depressive symptoms as an outcome (iv) studies that used yoga (from any school) as an intervention (v) randomized controlled design or quasi-experimental design or pre-test/post-test design. 18 interventions were found to meet the inclusion criteria The studies were from Brazil (1), Canada (1), India (6), Iran (1), Japan (1), Taiwan (1), and United States (7).

8. Study 1 StudyAgeInterventionDurationSalient findings Sharma et al., 2005 18-45Sahaj Yoga1 monthThere was significant improvement in HAM-D as well as HAM- A scores in yoga group (p<0.001).

9. Study 2 StudyAgeInterventionDurationSalient findings Vedamurth -achar et al., 2006 18-55Sudarshan Kriya program 2 weeksReductions in BDI, plasma Cortisol, and ACTH were found (p=.005).

10. Study 3 StudyAgeInterventionDurationSalient findings Culos- Reed et al., 2006 ~50Iyengar Yoga7 weeksSignificant improvement in quality of life (p<.05), emotional function (p<.01)

11. Study 4 StudyAgeInterventionDurationSalient findings Sharma et al., 2006 18-45Sahaj yoga (relaxation & meditation) 8 weeksSignificant decrease on Hamilton rating scale for Depression at 8 weeks (p<0.003)

12. Study 5 StudyAgeInterventionDurationSalient findings Krishna- murthy & Telles, 2007 60+A routine of regulated breathing, relaxation & philosophical discussion on yoga (non specific school) 24 weeks Significant reductions in Geriatric depression scale at 3 months (p<0.001) & 6 months (p <0.001)

13. Study 6 StudyAgeInterventionDurationSalient findings Shapiro et al., 2007 ~45Iyengar Yoga, brief relaxation and breathing 8 weeksSignificant decrease (p<.001) in HAM-D, QIDS, STAI, SF- 36

14. Study 7 StudyAgeInterventionDurationSalient findings Butler et al., 2008 ~50Inner Resources program (Hatha yoga, meditation, breathing, guided imagery & mantra repetition) 12 weeks Yoga group experienced remission for at least two months (p<.031) than the other two groups (hypnosis & control).

15. Study 8 StudyAgeInterventionDurationSalient findings Chen et al., 2008 60+Silver Yoga: Hatha yoga modified for the elderly 6 months Significant decrease in daytime dysfunction (F=4.38, p=.015), depression (F= 10.92, p=.000), and an increase in mental health perception (F=16.45, p=.000) in the intervention group.

16. Study 9 StudyAgeInterventionDurationSalient findings Danhauer et al., 2008 ~56Integral yoga, a form of restorative yoga that emphasizes poses with props, breathing and awareness 10 weeks Quality of life (p<.01) and depression scores (p<.01) were significantly decreased after the intervention and at follow up.

17. Study 10 StudyAgeInterventionDurationSalient findings Franzblau et al., 2008 18- 45 Yoga breathing techniques (Pranayama) 4 days Significant decreases in scores were seen for the yogic breathing technique, testimony, and combination groups (p<.05).

18. Study 11 StudyAgeInterventionDurationSalient findings Groessl et al., 2008 55Anusara Yoga: alignment focused 10 weeks Significant decreases in pain (t= -4.27, p<.001), depression (t= - 4.20, p<.001) and fatigue (t= - 4.16, p<.001) were found

19. Study 12 StudyAgeInterventionDurationSalient findings Kozasa, et al., 2008 ~43Siddha Samadhi Yoga: meditation associated with pranayama (breathing exercises) 1 month A significant reduction in scores on anxiety, depression, and tension in the yoga group. Also an increase in well-being in yoga group compared to control group.

20. Study 13 StudyAgeInterventionDurationSalient findings Ando et al., 2009 ~60Mindfulness- based meditation: Yoga poses along with breathing and mindfulness meditation 2 sessions Scores for depression on the HADS scale significantly decreased from pre to post test (p=.01), along with the overall HADS scores (p=.004).

21. Study 14 StudyAgeInterventionDurationSalient findings Danhauer et al., 2009 ~56Integral yoga, a form of restorative yoga that emphasizes poses with props, breathing and awareness 10 weeksImprovement on the PANAS (p=.01), all of the FACT tests (p<.05), SF-12 (p=.004) and CES-D (p=.026).

22. Study 15 StudyAgeInterventionDurationSalient findings Javnbakht et al., 2009 31-41Ashtanga yoga 2 monthsDecrease in BDI and STAI scores were found, but they were not significant.

23. Study 16 StudyAgeInterventionDurationSalient findings Vadiraja et al., 2009 46- 58 Integrated Yoga: asanas, breathing techniques, meditation, relaxation w/ imagery 6 weeks Significant decrease in salivary cortisol levels at 6am in the intervention (p<.001), hospital anxiety and depression scale indicated a significant decrease in the intervention (p<.001)

24. Study 17 StudyAgeInterventionDurationSalient findings Williams et al., 2009 23-66Iyengar Yoga: therapeutic poses for chronic back pain 24 weeks Scores on ODI, VAS, BDI-II reduced significantly for the intervention group (p<.001) at weeks 12 and 24.

25. Study 18 StudyAgeInterventionDurationSalient findings Descilo et al., 2010 17+Breath, water, sounds with Sudarshan Kriya yoga 6 weeksFor BDI, a 90% decrease in scores was seen for the intervention group at weeks 6 & 24 (p<.001).

26. Discussion Schools of yoga included were: Anusara yoga (1), Ashtanga yoga (1), Inner resources program (1), Integral yoga (2), Integrated yoga (1), Iyengar yoga (3), Mindfulness-based meditation (1), Non specific (1), Pranayama (1), Sahaj Yoga (2), Siddha Samadhi Yoga (1), Silver Yoga (1), and Sudarshan Kriya Yoga (SKY) (2) Some of the designs utilized by the interventions were pre-test post test (2), quasi experimental (6), randomized controlled trials (9), & cluster randomized design (1).

27. Discussion It was found that majority of the interventions (17) were able to significantly reduce depressive symptoms in the patients under study. Duration of the study ranged from 2 sessions to 6 months: Even shorter interventions were successful.

28. Limitations of interventions Small sample sizes Not all interventions have used randomized controlled trials (RCTs) The effects of yoga on men and women of different ethnic backgrounds has not been determined. The activities and dose of yoga have not been standardized.

29. Limitations of the review Interventions published in English language were included and many interventions especially in international settings are published in other languages which were excluded from this analysis Only interventions published in four databases were included Differing evaluation methodologies and outcome indices were used in different studies. In the selection criteria attempts were not made to filter studies based on methodology or outcome indicators but effort was made to be more inclusive of various interventions