Yoga for anxiety and depression – a literature review

Chandra Nanthakumar (Faculty of Foundation Studies, HELP University, Kuala Lumpur, Malaysia)

The Journal of Mental Health Training, Education and Practice

ISSN: 1755-6228

Article publication date: 18 February 2020

Issue publication date: 12 May 2020

Abstract

Purpose

The purpose of this paper is to investigate the effectiveness of classical yoga not only as a complementary therapy but also as a viable option in the management of anxiety and depression.

Design/methodology/approach

Papers were retrieved using a combination of databases including PubMed/MEDLINE and PsycINFO.

Findings

The findings revealed that the practice of yoga as complementary therapy and also as a stand-alone therapy is effective in managing and reducing anxiety and depression.

Research limitations/implications

All the studies reviewed in this paper were methodologically limited in terms of sample size, sample heterogeneity, yoga intervention styles, duration of practice and teaching methods. Further research is needed to address key areas such as how much yoga is needed per week, duration of each class and specifically the types of asanas and pranayama to practise to bring about change in the anxiety and depressive states.

Practical implications

This review has provided substantial insight to yoga as a complementary and/or stand-alone therapy for anxiety and depression which is much needed in this contemporary society. The Malaysian community especially teenagers and adults, should consider incorporating yoga as part of their daily routine to experience and reap its benefits. It is suggested that yoga be included as part of the physical education curriculum in learning institutions and as a recreational activity for staff in public and private organisations.

Originality/value

The findings of this review provide an avenue for victims to cope with and manage anxiety and depression through the practice of yoga.

Keywords

Citation

Nanthakumar, C. (2020), "Yoga for anxiety and depression – a literature review", The Journal of Mental Health Training, Education and Practice, Vol. 15 No. 3, pp. 157-169. https://doi.org/10.1108/JMHTEP-09-2019-0050

Publisher

:

Emerald Publishing Limited

Copyright © 2020, Emerald Publishing Limited


Introduction

The number of people in the Malaysian community suffering from anxiety and depression is on the rise. According to the statistics of the 2017 National Health and Morbidity Survey, 29 per cent of Malaysians suffer from some form of depression and anxiety disorder compared to a mere 12 per cent in 2011 (The Star online, 2018). It appears that three in every ten adults of age 16 years and above are inflicted with some sort of mental health problems, with depression being the most common one (Wan Mustapha, 2018). The common diagnoses for anxiety in adults are separation anxiety disorder, social anxiety disorder, generalised anxiety disorder and specific phobia; whereas depression diagnoses include major depressive disorder and dysthymic disorder (Garber and Weersing, 2010).

In the recent findings, Malaysian teenagers aged 13-17 years have been diagnosed with mental health disorders; the statistics being one in five suffering from depression, while two in five suffering from anxiety (Lee et al., 2018). The Healthy Mind Programme, which was implemented by the Malaysian Education Ministry in 2017, revealed that out of 284,516 students who participated, approximately 5,100 students received various forms of intervention from school counsellors to address the issue. These statistics and figures are disconcerting because if they continue to escalate, it will eventually become a serious social stigma in the country. According to the World Health Organization (2012), one in five people is expected to experience depression at some time in their life and disclose that this mental health disorder will become the world’s leading health issue by 2020. Anxiety and depression interfere with not only interpersonal relationships but also academic achievement. In some situations, they increase the risk of suicide and other psychopathology. If these two disorders are not treated, the negative effects may propagate into adulthood (Weissman et al., 1999).

According to Tiller (2013), patients with depression more often than not show symptoms of anxiety disorders, while those with anxiety disorders exhibit signs of depression. It is evident that both disorders tend to co-exist (Garber and Weersing, 2010). Anxiety appears to be more prevalent during childhood, while depression increases during adolescence (Woodward and Fergusson, 2001). The symptoms of anxiety disorders include elevated heart rate, profuse perspiration feelings of queasiness, palpitations and muscle tension (Bandelow et al., 2017), while the symptoms for depression are feelings of sadness, outbursts of anger, lethargy, disturbed sleep, unexplained physical problems such as back pain, and the list goes on. These symptoms are irrefutable as both diseases are disorders of the biochemical and neurophysiological systems which have an impact on not only the release of mood-regulating chemicals such as serotonin, dopamine and noradrenaline, but also on the cortisol and gamma amino-butyric acid (GABA) levels (Cramer et al., 2013).

As both disorders are affiliated with morbidity and mortality, it is imperative to identify and treat both the illnesses. Common treatments for depression and anxiety include psychological therapies such as cognitive behaviour therapy and antidepressants. The latter augmented with antipsychotics have shown positive results in treating not only depression but also anxiety (Tiller, 2013). Some of the drug-based treatments for anxiety have been reported to produce significant reduction in depressive symptoms (Kendall et al., 2004; Manassis et al., 2002); however, the strategy involved in preventing depression by treating anxiety successfully warrants further clinical investigation. Benzodiazepine, a common drug-based medication that enhances the effects of GABA at its receptor, on the other hand, is only effective in treating anxiety and not depression (Tiller, 2013).

Even though treatments are available, some do not seek treatment because of financial issues, fear of being stigmatised for visiting a mental health counsellor, ignorance or for no apparent reason at all. Moreover, there are concerns about the side-effects and compliance of these drugs (De Manincor et al., 2015).

Complementary and alternative medicine treatments have grown exponentially as it has become popular among all and sundry in many parts of the world. Mindfulness-based interventions such as meditation and yoga have become widely used in the therapy of both psychological and also physical ailments as research has shown a link between these practices and physical and psychological health changes (Cuijpers et al., 2010). There is an underlying notion that yoga has the ability to positively affect the biochemical and neurophysiological systems by regulating the autonomic nervous system and stress response, thus decreasing the stress, anxiety and depression levels (Salmon et al., 2009). Moreover, there is evidence that patients prefer these traditional methods of treatment compared to mainstream approaches such as psychotherapy or psychotropic medications (Kessler et al., 2001).

The purpose of this review is to look at recent research done on the intervention of yoga as an adjunct or stand-alone therapy for anxiety and depression, the effectiveness of this mind–body regime and its implications for the sufferers of the current society and also the health-care professionals. Recent research here refers to studies that were conducted in the past five years that used yoga as therapy for anxiety and depression.

Yoga as a complementary therapy

Yoga, an ancient mind–body movement practice, originated in India more than 5,000 years ago. It is also called a meditative movement practice as it involves movement, a meditative state of mind, breath focus and deep relaxation. Yoga appears to be a form of alternative medicine (Bridges and Sharma, 2017), and its philosophy is based on the eight limbs schematised by Maharishi Patanjali, one of the main pillars of classical yoga. These eight limbs comprise yama (universal ethics), niyama (internal attitudes for personal discipline), asana (yoga posture), pranayama (expansion of life force), prathyahara (withdrawal of senses), dharana (contemplation of one’s true nature), dhyana (meditation) and Samadhi (liberation). While there exist numerous definitions of this ancient practice, yoga has been commonly interpreted as a practice of uniting the mind, body and breath for purposes of enhancing or healing the physical, mental and emotional well-being (Satchidananda, 2012; Stiles, 2013). As yoga is not a religion, anyone irrespective of age, creed or gender can practise it.

While the practice of yoga is a continuous journey for the genuine seeker who wishes to experience the universal self within (Stiles, 2013), it can be simplified and practised in several ways to suit the practitioner. The practice of yoga is so flexible that the practitioner can use some, if not all, of the limbs. Nevertheless, in a traditional 1-h yoga session, it is not uncommon to integrate the practices of pranayama, asana, prathyahara, dharana and dhyana. Having said so, there are many styles of yoga: precision and alignment, asthanga yoga, flow yoga, asana yoga, gentle yoga and hot yoga are some of the common styles. As a complementary therapy for physiological and psychological disorders, yoga has been widely studied in adults (Nanthakumar, 2018). Upon scrutinizing all the eight limbs in yoga, mindfulness, which is a state of being aware in the present moment, appears to be the active ingredient to combat anxiety and depression (Knight et al., 2014). Broadly speaking, yoga focuses on being present in the moment. As the practice of yoga requires mindfulness even when the practitioner is in motion especially when performing an asana, some of the preliminary research have advocated that yoga may increase levels of mindfulness in the practitioner (Brisbon and Lowery, 2011; Conboy et al., 2010). Yoga appears to be a form of moving meditation. There have been suggestions that the movement aspect of yoga may be more appealing to the practitioner as it stimulates the cognitive processes related to mindfulness (Butterfield et al., 2017).

The benefits of yoga are tremendous. As meditative movement involves not only stretching but also dynamic movements connected to breath, yoga increases physical stamina, balance, flexibility and induces relaxation.

However, existing research unveils that the benefits of yoga are not limited to only improving flexibility and promoting weight loss; yoga also enhances emotional and psychosocial health and an increase in proprioceptive and interoceptive awareness (Woodyard, 2011). There have been suggestions that yoga, if practised consistently, induces neuroplasticity i.e. changes in the neural pathways of the brain, thus improving psychological skills (Brown and Gerbarg, 2005). This augurs well for the yoga practitioner as it implies that the brain can be rewired just like a muscle in the physical body. Research shows that the practice of certain yoga techniques can bring about positive effects in the practitioner’s mental health because of the down-regulation of the hypothalamo–pituitary adrenal axis and the sympathetic nervous system (SNS) (Sengupta, 2012).

Methods

A thorough search was carried out using a combination of databases inclusive of PubMed, MEDLINE and PsycINFO. Articles that incorporated yoga as an intervention for anxiety and depression were identified. Keywords used to facilitate the search were “anxiety”, “depression”, “intervention of yoga”, “stress”, “panic”, “anxious” and “stress disorder”. The search was however restricted to only full text and peer-reviewed articles that were written in the English language. As one of the main aims of this review is to investigate the impact of yoga on depression and anxiety in this contemporary society, only articles that were published in the past five years were included. To streamline the review, only studies that were conducted with teenagers and/or adults as participants, irrespective of gender or creed, were included, while those that were conducted with children below the age of 12 were excluded completely. In addition, studies that included teenagers and adults suffering from multiple diseases and/or mental health issues, such as psychosis, obsessive-compulsive disorder and health-related aspects of physical fitness were rejected. Studies that incorporated pregnant and post-partum participants were omitted from this review as it is not unusual for this category of participants to undergo depression and anxiety during that period. In terms of the intervention, only studies that integrated classical yoga were deemed to have met the inclusion criteria.

The practice of yoga comes in variety of styles (hot yoga, vinyasa, hatha yoga, meditation and pranayama to mention a few), duration and frequency. Nevertheless, only interventions of yoga that embraced asanas, pranayama, prathyhara, dharana and dhyana were included in this review even though the duration of each class and frequency of sessions varied considerably. While this review was not limited to qualitative and quantitative studies, the instruments used in each study varied quite significantly. Lastly, studies that incorporated transcendental meditation or mindfulness meditation (or any other forms of meditation) or pranayama as a stand-alone practice were not included in this review.

Results

In this review, a total of eight studies fulfilled the inclusion criteria. Table I provides a summary of the author(s), year of publication, place of study, demographics, diagnosis and instruments used in the respective studies, whereas Table II presents details of the intervention and findings of each study in a sequential order.

A total of five studies were conducted in the USA, and one in Iran, Australia and Italy, respectively. It is noteworthy that the minimum age of the participants was 18 years, while the maximum was 72. As indicated in Table I, participants in all the studies were diagnosed with either depression, anxiety or both, with the exception of one study where participants suffered from anxiety, depression and also stress.

The review encompassed studies of several designs; one study had used the pre-test/post-test, two were quasi-experimental studies and the remaining five were randomised controlled trials (RCTs). One of the RCTs was a stratified-randomised controlled with repeated measures (Falsafi, 2016). The sample size incorporated in all the studies was small, ranging from 18 (Falsafi and Leopard, 2015) to a maximum of 122 (Uebelacker et al., 2017).

It is evident that the intervention of yoga in all the eight studies was heterogeneous. The duration of the studies varied quite substantially from four weeks (Shonani et al., 2018) to six months (Doria et al., 2015). However, all studies assimilated aspects of classical hatha yoga specifically asana, pranayama, prathyahara, dharana and dhyana. One of the studies had also included chanting (Doria et al., 2015).

In the study piloted by Kinser et al. (2014), there was a decrease in depression in both groups, the yoga group (YG) and control group (CG), even though the latter was not subjected to any form of yoga practice. While both groups underwent pharmacotherapy during the intervention, the YG experienced not only a distinctive trend in decreased ruminations, but also found the yoga practice to be a strategy to help cope with negative/ill thoughts and other symptoms of depression in their daily life. It appears that the guided meditation (yoga nidra) component in the yoga session may have helped in enhancing self-regulatory capacities in the participants. Another positive impact of the intervention of yoga in this study is that participants from the YG acknowledged that the practice of yoga had heightened their confidence and that it had become an internal motivator for continued participation.

Similarly, participants in the study of Doria et al. (2015) experienced positive effects of Sudharshan Kirya yoga (SKY). The fact that there was hardly a difference in the scores between the two groups (one group did SKY with pharmacotherapy and one group did SKY without pharmacotherapy) indicates that SKY may be effective as an adjunct therapy for patients undergoing medical treatment and it may also be effective as a stand-alone therapy. The study had also incorporated chanting in the yoga session. Chanting is known to heal the physical, emotional, mental and spiritual body. It is beneficial to the practitioner as it provides the drifting mind with a focal point. Albeit the chanting was brief in this study, previous research has shown that chanting has the potential to bring about deactivation in the amygdala, parahippocampal and hippocampal brain regions (Kalyani et al., 2011).

Besides, it also stimulates the auricular branches of the vagal nerves creating vibrations at cellular level. It is the vibrations created during chanting that are of utmost importance. The vibrations create neuro-linguistic effects which induce calmness in the body and mind. It is believed that the sounds of the mantra have the ability to mask the negative voices in the brain. When deleterious thoughts are eliminated, the mind will have room for positive reflections.

Participants in the study of Falsafi and Leopard (2015) who underwent eight weeks of yoga intervention were in favour of this meditative practice as findings showed a significant reduction in depressive symptoms. In another study which was a stratified-RCT among college students in the USA, Falsafi (2016) found that yoga and mindfulness practice were equally effective in reducing not only depression and anxiety, but also stress. However, the self-compassion scores were only significant in the mindfulness intervention group. This is probably because of the fact that the mindfulness practices, which are self-regulated practices that focus on training attention and awareness (which is similar to dharana in yoga), have helped bring the mental processes under greater voluntary control.

In the Australian study among a subsyndromal population, a six-week yoga program was found to reduce the depressive and anxiety symptoms effectively in the YG (De Manincor et al., 2016). As both groups, the YG and the CG, were on pharmacotherapy during the study, it is evident that the yoga intervention has positively impacted the depressive participants in the YG. The findings also reveal that there was a reduction in psychological distress and negative thoughts, improvement in mental well-being and increase in resilience among the yoga participants. It is noteworthy that during the study, some of the yoga participants took it upon themselves to decrease their medication dosage and frequency of visiting the counsellor. The reasons for these actions are inconclusive and definitely warrant further investigation.

In another RCT among a community suffering from depression in San Francisco (Prathikanti et al., 2017), the findings reveal that participants who did yoga for eight weeks showed a greater decrease in depressive symptoms when compared to the CG who only attended yoga history workshops for the same duration. The Beck Depression Inventory (BDI) score for the YG was much lower compared to the CG (p value = 0.034). What was even more promising is that in this study, the participants in the YG requested for not only more practical yoga sessions per week, but also permission to attend the yoga history sessions. This clearly indicates how concerned the participants were in doing yoga for the benefit of their own mind–body health.

On the other hand, the study of Uebelacker et al. (2017) did not show significant differences between the YG and CG even though there was a reduction in depressive symptoms in the YG. Also, there was evidence of better social and role functioning and health perceptions in the YG. This could be because of the relaxation techniques incorporated in the yoga session which not only reduce the sympathetic activity, but also balance the autonomic nervous system responses.

The Iranian study on 52 women, however, demonstrated a positive impact of yoga as a stand-alone therapy on mental health disorders (Shonani et al., 2018). Even though it was reported that all participants in the study were free from medication for mental disorders, it is not clear if they were totally free from any form of therapy for the depression and anxiety they were suffering from. Nevertheless, there was a significant reduction in anxiety, depression and also stress levels (p = 0.001) in the participants who did 12 sessions of yoga over 4 weeks.

Discussion

The main aim of this review was to look at recent studies (2014-2018) that had used yoga intervention as an adjunct therapy for depression and anxiety. The review also aimed at studying the efficacy of yoga as a meditative movement practice in reducing symptoms of the said mental health disorders.

It is evident that in the past five years, researchers have shown interest in examining the effectiveness of yoga in the management of anxiety and depression. As per this review, most studies, if not all, exhibited appreciable outcomes; the intervention of yoga with (De Manincor et al., 2016; Falsafi and Leopard, 2015; Falsafi, 2016; Kinser et al., 2014; Uebelacker et al., 2017) or without (Doria et al., 2015; Prathikanti et al., 2017; Shonani et al., 2018) regular pharmacotherapy appeared effective in decreasing the symptoms of depression and anxiety, and also stress in one study (Shonani et al., 2018).

Research in mind–body practices suggests that the practice of yoga advocates changes in the neural pathways of the brain, thus bringing about positive effects on the brain activity (Brown and Gerbarg, 2005; Desai et al., 2015). It is thought that yoga, if practised consistently, activates the alpha, beta and theta brainwaves, and these have been linked to improvement in not only memory, but also mood and anxiety.

All studies reviewed in this article incorporated the fundamental limbs of Patanjali yoga, that is, asanas, pranayama, prathyahara, dharana and dhyana. According to Nyer et al. (2019), the first two limbs in yoga (yamas and niyamas) are therapeutic in nature as both are code of ethics that work at intrapersonal (yama) and interpersonal (niyama) levels. Yama includes practices such as ahimsa (non-violence), satya (non-stealing), asteya (non-lying), brahmacharya (non-excessiveness) and aparigraha (non-greediness), while niyama encompasses traits such as saucha (cleanliness), santosha (contentment), tapas (sacrifice), swadyaya (self-study) and Ishwara pranidana (surrendering to the almighty).

While none of the studies in this review highlighted the inclusion of these two limbs as part of their yoga interventions, the yamas and niyamas may have been embedded into the yoga session informally. In my coaching and therapy sessions, the students are prompted to practise ahimsa especially when performing a challenging asana during class. They are constantly reminded to refrain from forcing themselves into the pose and eventually hurting themselves. While they are holding a pose (being in the pose), they are then reminded to be aware of the joy and wonderful feelings that they are experiencing at that moment; this is an example of santosha. Similarly, all the other yamas and niyamas are directly or indirectly demonstrated and elucidated during class at the Malaysian Yoga Academy.

The instructors conducting the yoga sessions in the eight studies (Table I) may have incorporated the first two limbs but did not see a need to highlight the details in the methodology. The details of the yoga intervention, if had been reported for each and every study, would definitely provide invaluable information not only to the researcher and the reader, but also to the participant who may want to explore the philosophical roots of yoga.

It is noteworthy that despite the heterogeneity in the sample population, small sample size, varied duration of the intervention and style of yoga taught, most studies in this review demonstrated positive results in reducing the scores in depression and anxiety. Woodyard (2011) and Sherman (2012) reported that the practice of asanas, pranayama, dharana and dhyana in a yoga class can help calm the mind, hence lower the anxiety levels. These are precisely the effects observed in the studies reviewed in this article.

Nevertheless, another factor to consider is the time (duration) required for participants to master the yoga asanas, especially those with limited flexibility and breathing techniques (pranayama). The time taken for the psycho-physiological factors mediating specific mood benefits of yoga to develop and exert a measurable effect in the participant is equally important and should not be neglected. Even pharmacological interventions for depression and anxiety more often than not produce a delay of approximately four weeks before exerting significant mood effects over placebo. It has been reported that it may take up to 12 weeks to achieve full anti-depression effects with medication (Uher et al., 2011), so time is definitely a plausible factor for consideration in yoga intervention.

A five day per week practice of yoga of approximately 30 min per session has been reported to suffice for the general population (De Manincor et al., 2016); however, at the Malaysian Yoga Academy where the author teaches yoga, students, regardless of their mental health conditions, are encouraged to practise at least 45 min of yoga daily. This is merely a measure to maintain good health and keep diseases at bay as research has shown that a great number of individuals suffer from some form of anxiety and/or mood disorder at some point in their life (Ferreira-Vorkapic et al., 2018). The duration of a yoga session, frequency and the duration for each and every component of yoga to be practiced definitely warrants further investigation.

The selection of asanas in a yoga intervention does play a part in improving one’s mental health. Prathikanti et al. (2017) found that specific asanas such as ardhakati chakrasana (half waist wheel pose), ardha chakrasana (half wheel pose), bhujangsana (cobra pose), dhanurasana (bow pose), setu bandhasana (bridge pose), sarvangasana (shoulder stand) and matsyasana (fish pose) were doable and effectual in helping the participants manage with depression and anxiety. Upon observing all the asanas closely, it can be deduced that most of them, if not all, are heart/chest openers. In the process of expanding the chest and rib cage to oxygenate the lungs efficiently, heart/chest openers may also be good for releasing grief, anger and frustration, which are all symptoms of depression.

In all the studies reviewed, pranayama was also key in the yoga intervention. In Patanjali’s yoga sutras (Satchidananda, 2012), pranayama is defined as the regulation of breath or control of prana to stop inhalation and exhalation, which is achievable after securing steadiness in the posture. Studies have shown that pranayama bring about change in brain activity; it also lowers the oxidative stress; hence, the mind can be controlled through the control of prana.

The deep relaxation component is essential in any yoga session; most studies, if not all, reported incorporating shavasana (dead corpse pose) followed by deep relaxation (yoga nidra) in the yoga intervention. Qualitatively, yoga nidra is not the same as shavasana; it is a form of relaxation which is much more intense than ordinary sleep (Khushbu et al., 2011). During the performance of certain asanas in yoga, the SNS is activated causing an increase in the blood pressure and heart rate. To lower the SNS stress response, participants are then lulled into a deep relaxation mode, i.e. yoga nidra. At this time, the parasympathetic function is increased, thus, causing the blood pressure, heart rate and breath rate to be normalised. Research has shown that the reduction of these parameters is linked to the reduction in anxiety levels (Brown and Gerbarg, 2005).

Dharana and dhyana were also key components of yoga in almost all the studies reviewed. According to the Yoga Sutras of Patanjali (Satchidananda, 2012), dharana, which helps the practitioner focus and be aware on an object, and dhyana, which helps the practitioner go deeper into holding an unbroken flow of awareness, bring about peace and bliss. In the process of practising dharana and dhyana, accumulated stresses are released bringing about a state of general well-being (Sharma, 2015). Participants from one study described yoga as an internal stimulus for continued participation (Kinser et al., 2014). In another study, participants requested for extra sessions of yoga after experiencing the immediate benefits (Prathikanti et al., 2017). This probably explains why participants in the studies reviewed found yoga to be beneficial in dealing with their emotions and general well-being that they continued with the practice upon completion of the study; in one study (De Manincor et al., 2016), some participants, upon witnessing an improvement in their mental health, took it upon themselves to decrease the dosage of their medication and reduce visits to the counsellor.

Nevertheless, in most, if not all, of the studies reviewed in this paper, there were limitations. A few of the studies were predominantly a female sample (Kinser et al., 2014; Shonani et al., 2018). Although research has shown that there is a greater tendency for women to suffer from depression compared to men (Kessler et al., 2003), the sample size in these studies was notably disproportionately represented. Secondly, most of the studies were limited by the insignificant sample population and heterogeneity. Because of the absence of CGs in certain studies, it was not easy to establish whether the results obtained were due intervention of yoga or something else. Even though RCTs are intervention research of high standards, the studies investigated in this review were challenged because of inappropriate randomisation, large variation in yoga styles in terms of the postures, breathing and meditative techniques used, dissimilar duration and frequency of yoga sessions and incongruence in teaching methods.

Despite the limitations, it appears that participants who have benefitted from these yoga sessions may now have an extra tool at hand to manage their anxiety and depression. No adverse effects were reported in any of the studies, thus making it a safe practice.

Conclusion

Subject to the limitations outlined above, this literature review has demonstrated the efficacy of yoga as a complementary therapy and also as a stand-alone therapy in the management of anxiety and depression. The intervention of yoga encompassing asanas, pranayama, prathyahara, dharana, dhyana and chanting appears to provide sustained benefits to the individual. The chest opener type of asanas, pranayama and shavasana (dead corpse pose) provide downtime for the neural path of the brain activity and balances the sympathetic and the parasympathetic functions of the autonomous system. The meditative state in the practice of yoga activates the self-regulatory system, thus increasing positive emotions, reducing ruminations, depression and/or anxiety levels and improving quality of life.

That being said, the intervention of yoga in all the studies reviewed has been challenged by numerous factors, including study design, insignificant sample size, large variation in yoga styles, duration of sessions, frequency of sessions per week and for the whole study, components of the yoga intervention, home practice and follow-up.

While this warrants more large-scale studies with improved quality, learning institutions and various organisations in Malaysia need to consider incorporating this mind–body regime as part of the physical education curriculum or as a recreational activity for staff, respectively. Highlighting the effects of yoga on anxiety and depression is important as it provides an option to existing pharmacotherapy and/or psychotherapy approaches to treat these two mental health disorders. Victims of anxiety and/or depression may incorporate yoga into their daily schedule while on medication; alternatively, they may start practising yoga consistently in the absence of pharmacotherapy. Finally, those who opt to go on medication for their depressive and/or anxiety conditions may have to endure the adverse effects of the drugs.

Summary of the demographics of the selected population and instrumentation used

Authors (year),
place of study
Basic demographics of population Sample population Instruments used
Kinser et al. (2014),
USA
Age: 18 and above
Ethnicity: Majority non-White;
20 out of 27 are divorced/single
Diagnosis: MDD
Short-term study (8 weeks) – 27 women SF; RRS; STAI; PHQ-9; PSS
Doria et al. (2015), Italy Age: 25-64
Ethnicity: Caucasians
Diagnosis: DSM-IV mood and/or anxiety disorders
69
Men: 28
Women: 41
HRSA; HRSD;SCL-90; ZASI; ZDSI
Falsafi and Leopard (2015), USA Age: 18-65
Ethnicity and gender: Not reported
Diagnosis: Anxiety
18 BDI; HRSA; SCS; PWS
De Manincor et al. (2016),
Australia
Age: 18-65
Ethnicity: Not reported but all are English-speaking
50 out of 101 are married
Majority are degree holders
Diagnosis: Anxiety and depression
101
Men = 20
Women = 81
DASS-21; K10; SF-12; SPANE; FS; CD-RISC2;
HAQ; CEQ
Falsafi (2016),
USA
Age: min 18 years
Ethnicity: Not reported
All are undergraduate students
Diagnosis: Depression and anxiety
90 (men and women)
YG: 30
CG: NR
MIG: NR
BDI; HAM-A
Prathikanti et al. (2017),
USA
Mean age: 43.4 years (range: 22-72)
Ethnicity: Not reported but from a metropolitan US population
Diagnosis: Severe depression
38
YG: 20
CG: 18
MMSE; BDI; GSES; RSES
Uebelacker et al. (2017),
USA
Mean age: 46.5 years (SD ±12.16)
Ethnicity: Majority Whites or Caucasians (84.4%); Blacks (3.3%); and others (12.3%).
83.5% have college education
Diagnosis: Major depression
122 (men and women)
YG = 63
CG = 59
QIDS; PHQ-9; SF-20
Shonani et al. (2018),
Iran
Age: 33.5 ± 6.5 years
Ethnicity: Iranians
34 out of 52 are married
Majority: Diploma/degree holders
Diagnosis: Depression, anxiety and stress
52 women DASS-21
Notes:

BDI: Beck Depression Inventory; CD-RISC2: Connor–Davidson Resilience Scale; CG: control group; CEQ: Credibility-Expectancy Questionnaire; DASS-21: Depression Anxiety Stress Scale-21; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, fourth edition; FS: Flourishing Scale; HAM-A: Hamilton Anxiety Rating Scale; HRSA: Hamilton Rating Scale for Anxiety; GSES: General Self-Efficacy Scale; HRSD: Hamilton Rating Scale for Depression; HAQ: Health Activities Questionnaire; K10: Kessler Psychological Distress Scale; MDD: Major depressive disorder; MIG: Mindfulness Intervention Group; MMSE: Folstein Mini Mental Status Exam; NR: not reported; PHQ-9: Patient Health Questionnaire; PSS: Perceived Stress Scale; PWS: Perceived Wellness Survey; QIDS: Quick Inventory of Depression Symptomatology; RRS: Ruminative Responses Scale; RSES: Rosenberg Self-Esteem Scale; SPANE: Scale of Positive and Negative Experience; SCL-90: Symptom Checklist-90; SCS: Self-compassion Scale; SF-12: Short Form Health Survey Version; SF-20: Short-form Survey; SKY: Sudarshan Kriya yoga; SPANE: Scale of Positive and Negative Experience; STAI: State Trait Anxiety Inventory; YG: yoga group; ZASI: Zung Self-Rating Anxiety Scale Inventory; ZDSI: Zung Self-Rating Depression Scale Inventory

Summary of the intervention and findings of the selected studies

Authors (year) Description of intervention Findings
Kinser et al. (2014) RCT
YG: 75 min of hatha yoga (asanas, breathing techniques, relaxation and guided meditation) per week over eight weeks
Daily home practice (DVD and handouts provided)
CG: Health education activities (lectures, videos and discussions)
Both groups continued with prescribed medication and maintained their lifestyle activities
YG experienced multiple benefits of yoga including a boost of confidence
Gained new skills to be used in daily life to manage depression and stress
Doria et al. (2015) Pre-test/post-test
Group 1: Medication + SKY treatment + self-help group weekly
Group 2: SKY treatment + self-help group weekly but no medication six months prior to study
Intervention: 10 sessions of 2 h SKY in 2 weeks followed by weekly SKY for 6 months (asanas, pranayama, chanting, prathyhara and dharana)
A reduction in anxiety and depression levels in both groups
No significant differences in scores between both groups
Falsafi and Leopard (2015) Quasi-experimental (repeated measures with one group)
Intervention: 90 min yoga per week for 8 weeks (asanas, pranayama and mindfulness practice)
Significant decrease (p < 0.05) in depressive symptoms
De Manincor et al. (2016) RCT
YG: A 6-week yoga program; 30 min of vini yoga practice (asanas, pranayama, relaxation, mindfulness and meditation) for 4.8 days per week + TAU
CG: TAU – yoga was given after waitlist period
A significant reduction in depression and anxiety scores
YG showed greater reduction compared to CG
Falsafi (2016) RCT (stratified-randomised controlled repeated measures)
YG: 8 weeks hatha yoga; 75 min session once a week; and 20 min daily home practice
CG: No yoga
MIG: Mindfulness practice
YG and MIG showed significant reduction in depression, stress and anxiety compared to CG (p < 0.01); no significant change in CG
No difference between YG and MIG, but self-compassion scores only significant in MIG
Prathikanti et al. (2017) RCT (stratified-randomised controlled)
YG: A 8-week yoga program (asana, pranayama, dharana and prathyahara); 90 min per session, two sessions a week; props used; and TAU
CG: 90 min of yoga history workshop twice a week for 8 weeks and TAU
No medication for both groups
YG showed a significant decrease in depression compared to CG (p = 0.034)
YG more likely to achieve remission
YG requested for more sessions per week and also permission to attend yoga history workshop
Uebelacker et al. (2017) RCT (stratified-randomised controlled)
YG: A 10-week yoga program (asana, pranayama, dharana, dhyana and prathyahara); 80 min per session; one or two sessions per week; and TAU
CG: A 10-week healthy-living workshop; 60 min per session; one or two sessions per week; and TAU
Insignificant difference between YG and CG
YG demonstrated lower levels of depressive symptoms, better social and role functioning and general health perceptions when compared to CG
Shonani et al. (2018) Quasi-experimental (pre/post-test)
YG: 60-70 min hatha yoga, 3 times a week for 4 weeks (12 sessions in total)
A significant, decrease in depression, stress and anxiety in the YG (p < 0.001)
Notes:

CG: control group; MIG: mindfulness intervention group; RCT: randomised controlled trial; TAU: treatment as usual; YG: yoga group

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Further reading

Gard, T., Taquet, M., Dixit, R., Holzel, B.K., Dickerson, B.C. and Lazar, S.W. (2015), “Greater widespread functional connectivity of the caudate in older adults who practice kripalu yoga and vipassana meditation than in controls”, Frontiers in Human Neuroscience, Vol. 9 No. 137, pp. 1-12.

Corresponding author

Chandra Nanthakumar can be contacted at: chandratk@help.edu.my

About the author

Chandra Nanthakumar is based at the Faculty of Foundation Studies, HELP University, Kuala Lumpur, Malaysia.