Yoga and mental health services

Abstract

United Nations and International community recognized our Indian National Wisdom - “Yoga” by declaring “June-21” as “International Day of Yoga.” The word Yoga means “union,” that is, union of one's personal consciousness with the cosmic consciousness. Yoga helps the evolution from “I” to “WE;” that is, from limited individual to global human being.[1] For a psychiatrist, this “union” could also mean, the union of thought and affect as well as mind and body, which could have therapeutic potential. Yoga is a spiritual lifestyle that transcends all religions. Yoga is successfully applied in various psychiatric disorders over the globe with encouraging evidence coming from scientific publications in reputed journals, especially in last three decades. These reports suggest a need to integrate yoga in mental health services. Yoga has been used with success both in severe and less severe mental disorders as an intervention either with other conventional treatments or even solely. Different forms of yoga viz., Sudarashankriya, Sahajyoga, yogasanas, have been investigated with promising results in the treatment of depression.[2 3] These investigations were prompted by the observation that yoga led to a feeling of well-being and reduced dysphoria in clinically healthy subjects. Studies of varying research results indicate that patients benefited with regards to reduction in depression scores following yoga. In randomized comparisons, yoga fared nearly as well as an antidepressant drug (imipramine).[4] Yogasana-based therapy alone too reduced depression to the level of remissions.[5] In anxiety states too, yoga has proven benefits not only in the nonclinical population but also in clinical populations.[6] Patients with the obsessive compulsive disorder have been treated with Kundalini yoga and the effects have been encouraging.[7] Well-conducted clinical trials have confirmed the benefits of yoga added to ongoing, stabilized antipsychotic therapy in outpatients of schizophrenia. Benefits of Yoga on the negative and cognitive symptoms of the disorder are notable.[8 9] These two symptoms have been implicated in the functional outcome of schizophrenia patients. These promising findings of yoga in schizophrenia have led to an international guideline to recommend yoga in the treatment of schizophrenia along with medications.[10] The chronic nature of this disease puts demands and on the caregivers, thus subjecting the latter to stress and burden. In a randomized trial, yoga has also shown promise in helping such caregivers of schizophrenia outpatients.[11] Though there is no direct evidence of yoga helping patients of drug/alcohol dependence to remain abstinent, research indicates that depression symptoms during withdrawal in alcohol dependent subjects are reduced better if a yoga practice is added during such acute detoxification program.[12] Isolated reports suggest a role for yoga in other conditions such as attention deficit hyperkinetic disorder and autism.[13 14] Chronic back pain, a condition for which psychiatric intervention is often sought, has been treated with yoga. A review on this subject supports a role for yoga.[15] Success with yoga in reducing functional pain in somatoform disorders is recently reported.[16] Senior citizens with minimal cognitive impairment (MCI) have experienced improvements in sleep, cognitive function, and quality of life following yoga practice.[17 18] It is known that MCI is a forerunner of later dementia. Would yoga delay the onset of dementia if applied as a lifestyle package in the elderly? Well-designed longitudinal trials comparing yoga with appropriate control intervention can provide an answer to this question. These clinical benefits from yoga also have correspondence with changes in certain biological markers. Lowered mentation in depression is indicated by smaller amplitudes of an event-related potential (P300). This physiological marker is “normalized” to a higher value in depressed patients after treatment with yoga as the sole intervention over 3 months.[19] Yoga also reduced cortisol levels in alcohol dependent subjects undergoing detoxification as well as in patients with depression disorder.[12 20] In depressed patients who as a group had lower levels of a brain-derived neurotrophic factor (BDNF), yoga therapy increased the levels of BDNF in serum. Interestingly, BDNF response has also been implicated in the therapeutic effects of antidepressant drugs and electroconvulsive therapy. Both these biological effects were correlated with the antidepressant effects of yoga.[20 21] Cortisol-reducing effects of yoga suggest attenuation of the hypothalamo-pituitary-adrenal axis that is otherwise overactive in depression and other stress-related states. In schizophrenia patients, yogasana-based therapy increased the levels of oxytocin and improved social cognition as well.[22] It is known that oxytocin in related to social cognition and it is now being tested as an intranasal spray to benefit such disorders with compromised social cognition.[23] Although the exact mechanisms of yoga in mediating these therapeutic and biological effects are not known, some observations are relevant. Yoga involves imitating the movements and postures of the influential therapist in the process of learning. Would this facilitate mirror neurons? Mirror neuron activity is implicated in social cognition.[24] Typically, yoga practices involve mindfulness all through and even while performing asanas. In the classical ashtanga yoga, mindfulness is emphasized as dharana and dhyana. Mindfulness practices have shown positive effects on neuroplasticity.[25] This neuroplastic effect may explain the cognitive benefits of yoga. Acute yogasana session elevates brain GABA levels in the brain as demonstrated by magnetic resonance spectroscopy.[26] It is known that GABAergic drugs have mood-stabilizing properties. Could this be yet another mechanism of yoga that explains therapeutic effects in depression and anxiety? One of the procedures during yoga includes chanting “OM.” There is some evidence, from functional magnetic resonance imaging research, that chanting OM is known to deactivate certain brain regions (implicated in emotions) possibly through vagal afferent stimulation.[27 28] Vagal stimulation is used as an invasive therapy in depression. Despite these encouraging clinical observations and theories, clinicians are confronted with serious challenges regarding generating evidence to support yoga. This is particularly relevant as yoga has to compete with pharmacotherapies in the era of evidence-based medicine. Yoga is handicapped without the “identical-looking placebo capsule.” There is no perfect placebo in yoga research. Double-blind clinical trials with yoga are, therefore, close to impossible.[29] It is unknown if any one of the yoga components carries most or all the therapeutic potential. The dose-response effect of yoga, hence, deserves to be understood. The yoga practices recommended from influential schools of yoga carry certain inherent biases or suggestion effects with them. Faith-based influence is another concern that modern physicians air. Generic yoga modules can offset partly these influences, though. Such generic practices would also let formally-trained (undergraduate and postgraduate) yoga specialists to use them in the therapy sessions. In summary, yoga is emerging as a potential therapeutic intervention and has already reached the armamentarium of psychiatrists. There is a need to objectively evaluate yoga therapy further in multicenter trials and integrate yoga into clinical practice. A yoga therapist could become a very useful member of the mental health team in the days to come.