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Yoga Research: Can Yoga Be an Effective Adjunct Therapy for Trauma, Depression and Anxiety?
Now that yoga is an established part of mainstream culture, there is an increased interest in using yoga as therapy for psychological problems such as depression, anxiety and PTSD. A new meta-review of all published studies on yoga for trauma, anxiety and depression in the journal, Trauma, Violence and Abuse, suggests that yoga can be beneficial as an adjunct therapy, but those delivering services need sufficient training and expertise to be effective.
Mental illness presents a major public health problem in the United States. Prevalence rates for depression, anxiety and post-traumatic stress disorder (PTSD) in the U.S. suggest that millions of adult Americans suffer from the symptoms of one or more of these illnesses.
Anxiety disorders are the most common mental health problem in America, affecting roughly 18% of the adult population (40 million) at any given time. Approximately 6.6% of adults (15.7 million) experienced a diagnosable depressive illness during 2014, and the lifetime prevalence rates of PTSD are approximately 3.6% among men, 9.7% among women.
Traditional evidence-based treatments for these disorders consist of a combination of psychotherapy and medication. However, in recent years more adults are exploring alternative treatment options, primarily to avoid the side effects of psychotropic medication. One of these potential options is yoga therapy.
The number of yoga-based treatment options for psychological conditions has steadily risen in the past decade, however high-quality research has lagged behind. This is due, in large part, to limited funds being allocated for yoga therapy research. Even so, a substantial number of studies exist in which yoga was used as a primary intervention to relieve the symptoms of depression, anxiety, PTSD or their combination.
Yoga Research for Trauma, Depression and Anxiety
What can we learn from these yoga studies, and how can they inform clinical decision-making and treatment?
A group of researchers in North Carolina sought to answer this question by assessing all of the literature reviews examining yoga for depression, anxiety and PTSD published up until 2014. They were motivated by concerns that well-intended primary care and mental health providers and yoga educators might not be aware of evidence and best practices for including or recommending yoga as therapy, and wanted to offer not only empirical findings but practice recommendations as well.
These researchers initially intended only to explore the effects of yoga for relieving PTSD symptoms, but quickly discovered that very few studies have been devoted specifically to PTSD. Consequently they included review articles examining the effects of yoga for depression and anxiety as well. This means that they examined published literature reviews for each of these conditions rather than assessing each of the 185 identified studies independently.
The 13 literature reviews included in their analyses were published between 2005 and 2013 and included 185 distinct studies published between 1973 and 2012. They consisted of research in which yoga postures, breathing techniques, meditation or relaxation were used as a primary intervention. Some of the major styles of yoga included hatha yoga, Ashtanga, Iyengar, Viniyoga, Kundalini yoga and Bikram yoga.
The majority of the review articles selected included a rigorous analysis of the existing literature. These reviews revealed considerable heterogeneity in research methods including the duration, type of intervention, style of yoga used, research design, sample characteristics and many other key components.
Yoga As Adjunct Therapy for Trauma
There were two review articles found that focused explicitly on yoga for relieving the symptoms of trauma. These reviews included a total of 36 independent studies. The populations involved had a broad variety of traumatic experiences including war, natural disasters, incarceration, physical and sexual assault, religious and cultural persecution, torture and child abuse.
In general, yoga and meditation were found to be effective in reducing PTSD symptoms. This is, the authors concluded, because of their ability to decrease the physical and mental stress response. To that end, the primary mechanisms for reducing PTSD symptoms included “breath work,” which was shown to reduce PTSD symptoms as well as PTSD-related anxiety.
Overall these two review articles concluded that the evidence for using yoga and meditation as a complementary intervention for those with PTSD was “very limited,” and that subsequent, empirically rigorous research is needed to better understand yoga’s benefits as well as the effects of particular practices on reducing symptoms.
Yoga As Adjunct Therapy for Depression
The majority of articles included in this meta-review examined the use of yoga as a treatment for depressive symptoms or disorders. These disorders covered a wide range and included major depressive disorder, dysthymia, as well as mild, moderate and severe depressive episodes.
In some cases yoga was used as a sole intervention without additional therapies, however most examined yoga as an adjunct therapy to complement other therapeutic modalities including psychotherapy, psychoeducation and antidepressant and anti-anxiety medication. Populations studied included veterans, survivors of natural disasters, survivors of interpersonal violence, and children with high levels of exposure to violence.
In general, most studies provided support for the benefits of yoga in reducing the symptoms of depression. This was particularly the case for those interventions that used breathing and meditation as primary components.
One review reported that meditation-based yoga was superior to exercise-based yoga in reducing the symptoms of depression. Many reviews provided support for the link between regular yoga practice and a decrease in sadness, restlessness and other negative emotions and an increase in attention, sleep quality, and perceived life satisfaction.
Yoga As Adjunct Therapy for Anxiety
Several review articles examined the effects of yoga as a treatment for a wide variety of anxiety-related disorders and symptoms. Participants in these studies included those with generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD) and “psychoneurosis.” Sample characteristics covered a wide swath of conditions including eating disorders, menstrual problems, chronic pain, fibromyalgia, chronic illness, schizophrenia and childhood cancer.
In general, positive results were reported when yoga was used as a complementary treatment to psychotherapy or medication for GAD and OCD. One comprehensive review found that yoga interventions of two to three months in duration were more effective in reducing anxiety symptoms than shorter-term durations. They also concluded that yoga programs that included meditation were more effective than those that did not incorporate a meditation practice, and that group interventions led by a trained yoga instructor were more effective than home-based programs.
Feasibility and Accessibility of Yoga Programs
While not all studies reported feasibility, accessibility and safety data, of those that did yoga appears to have minimal risk and few negative side effects. Having said that, the absence of risk information cannot be considered an endorsement of safety.
A number of reviews suggest that yoga should be used with caution for a number of populations including those who have experienced severe trauma, have serious psychiatric illness, older adults, pregnant women and individuals with physical disabilities. They stressed that yoga is adaptable to accommodate individual needs, and suggested that styles such as Viniyoga, which emphasize customizing yoga practices for the needs of each person, be used.
In addition, one review article stressed the need for caution when using physical postures for those with trauma histories, and that some yoga types may evoke discomfort, flashbacks, and retraumatization. Further, one review cautioned that meditation and yogic breathing may be risky for those with trauma histories or psychosis.
Quality of Yoga Research
In spite of the potential benefits of yoga as an ancillary treatment for depression, anxiety and PTSD, across the board review articles pointed to serious methodological issues and limitations in the existing research. To date, this has been a common theme for much of yoga research that hampers our ability to draw definitive conclusions about the ways in which yoga can be of benefit.
While emerging studies are now making use of more rigorous designs and more consistent evaluation structures, a lack of consensus around the style of yoga, the use of particular practices (postures, breath, meditation, study etc.), dosage, duration, and high drop-out rates continue to make the prospect of yoga research challenging. But these challenges are not insurmountable and will undoubtedly be addressed in future studies.
Perhaps one of the greatest difficulties in conducting yoga research lies in the tension between the need for empirical rigor, clear definition and operationalization of practices and outcomes, and the inherent foundation of yoga as a holistic and often spiritual practice. Although the need for a strong evidence base is essential to move the field forward and to gain credibility in medical and mental health settings, the process of research for many is reductionistic, and largely unsatisfying. To date we have yet to find a successful resolution to this issue and probably will not for some time.
Recommendations for Service Providers
In the meantime, the authors of this meta-review make the following recommendations to service providers and yoga educators interested in incorporating yoga into their work with those with trauma histories, anxiety and depression.
Yoga holds promise as a feasible, acceptable, beneficial, practical and low-risk intervention for those with symptoms of trauma, depression and anxiety.
Yoga may be beneficial as an adjunctive treatment when used with other treatments such as psychotherapy and medication.
Clinicians working with those with trauma histories, depression and anxiety should consider using yoga as a supplemental intervention in conjunction with other, evidence-based, well-established treatments.
Individuals working with those with symptoms of trauma, depression and anxiety should be educated as both mental health professionals and credentialed yoga educators or create partnerships that combine these skill sets prior to working with those with psychological conditions.
Yoga should be used cautiously with those who have experienced severe trauma, have significant mental health problems, or are elderly, pregnant or have physical limitations.
Another article/book review from YogaUOnline on yoga and depression: Review: Amy Weintraub-Yoga for Depression- A Compassionate Guide to Relieving Suffering.
Study with YogaUOnline and Richard Miller: Fostering Resilience and Well Being On and Off The Mat.
B Grace Bullock, PhD, E-RYT 500 is a psychologist, research scientist, educator, author, yoga and mindfulness expert and creator of BREATHE: 7 Skills for Mindful Relationships. Her mission is to reduce stress, increase health and wellbeing and improve the quality of relationships. She offers classes, workshops, writing and research that combine the wisdom of applied neuroscience, psychophysiology, psychology and contemplative science and practice. Her goal is to empower individuals, groups, leaders and organizations to reduce chronic stress and increase awareness, attention, compassion, mindfulness and effective communication to strengthen relationships, release dysfunctional patterns and unlock new and healthy ways of being. Dr. Bullock is a Certified Viniyoga Therapist and Faculty at the Integrated Health Yoga Therapy (IHYT) Training program. She is the former Senior Research Scientist at the Mind & Life Institute and former Editor-in-Chief of the International Journal of Yoga Therapy. For more information see www.bgracebullock.com
Macy, R.J. , Jones, E., Graham, L.M. & Roach, L. Yoga for trauma and related mental health problems: A meta-review with clinical and service recommendations. Trauma, Violence, & Abuse, 1-23. DOI: 10.1177/1524838015620834.