Can yoga help with depression?

This past summer I took a class called Fundamentals of Mind-Body Medicine and The Psychology of Well-being (which, by the way, ended up being a phenomenal course). Part of our coursework was to explore one specific mind-body medicine modality as it has been applied to a particular psychological condition. The paper that follows is the culmination of my research on yoga as applied to depression, which includes an extensive literature review and interviews with yoga teachers and students. When I told some of my friends who practice yoga about my research, they encouraged me to share my findings on my blog here--so here we go!

Depression is a serious condition diagnosed by depressed mood and/or loss of interest in life activities every day for at least two weeks causing significant impairment in daily living, including at least 5 of the following symptoms:

1) feeling sad or having a depressed mood,

2) loss of interest or pleasure in activities once enjoyed,

3) significant unintentional weight loss or gain,

4) insomnia or sleeping too much,

5) loss of energy or increased fatigue,

6) agitated or slowed movements and speech (observable by others),

7) feelings of worthlessness or guilt,

8) difficulty thinking, concentrating or making decisions, or

9) suicidal thoughts.

One in six people will experience depression at some point in their lifetime and nearly one-third of all women will experience a major depressive episode at least once in their life (1).

Conventional treatments for depression generally consist of medications and/or psychotherapy. The American College of Physicians recommends cognitive-behavioral therapy (CBT) or second-generation antidepressants (e.g., bupropion, nefazodone, venlafaxine, or other SSRIs) for depression but their 2016 guideline review was unable to evaluate yoga compared to antidepressants for lack of eligible trials (2). The American Psychiatric Association recommends choosing a treatment based on the individual, which could include antidepressant medication, psychotherapy, electroconvulsive therapy, light therapy or a combination of treatments. Exercise is mentioned as an aside as beneficial for general health (3). Complementary and integrative approaches to depression may include herbs (e.g., St. John’s Wort), exercise, massage, Tai Chi, meditation, and/or yoga. Patients may turn to alternative treatments such as yoga due to medication adverse effects, treatment nonresponse, or simply preference (4).

Yoga is an ancient Indian practice originating around 2000 BC. ‘Yoga’ is the Sanskrit word for ‘union’, referring to the union of the body, mind, and spirit. Originally an eight-limbed approach combining ethical, spiritual, and physical practices, yoga practice has evolved over the years (5). Today many forms of yoga exist, including hatha, ashtanga vinyasa, Iyengar, Bikram, Kundalini, yoga nidra, and LifeForce Yoga (specifically created for depression). Hatha yoga, from which Western yoga is based, is the most common type of yoga practiced in the United States today and consists of asanas (physical postures), pranayama (breathwork), and dhyana (meditation). Yoga usually consists of a sequence of standing, bending, twisting, balancing, and sitting movements while focusing on the breath, but specific movements vary greatly from one practice session to the next. Each session may also begin with mindful grounding intention setting and end with a brief savasana, or silent meditation.

Yoga has become a popular practice in Western culture to improve general health and wellbeing with 28% of the US population having participated in a yoga class at some point and up to 75% of Americans believing that yoga is a stress-reliever and good for you (6,7). It has also been shown to be particularly useful in chronic pain conditions and to decrease perceived stress and anxiety (8). As such, yoga has recently been explored for use in major depressive disorder (MDD) and depressive symptoms. While yoga practices vary greatly and no one protocol has been established for treatment in depression, some practitioners have attempted to create a yoga practice specifically for depression. LifeForce Yoga (created by Amy Weintraub) has attempted to formalize yoga for depression and is characterized by an integration of ancient yoga teachings and evidence-based practices consisting of breathing techniques, visualization, intention setting, hand gestures, chanting, postures, relaxing yoga nidra, and seated meditation. Anecdotal evidence and early pilot studies of yoga and Mindfulness-Based Stress Reduction programs (which include a yoga component) have shown to improve depressed mood (9). Since yoga consists of both exercise and mindfulness practices, a regular mindful yoga practice may then be beneficial as an alternative and/or complementary treatment for depression.

The existing evidence supporting the use of yoga in the treatment of depression, either alone, or as an adjunct treatment is still very mixed. Early research on the effects of yoga on depressive symptoms was quite promising and indicated potentially beneficial effects, however, the heterogeneity and methodological issues of studies warranted caution and further investigation (5). Anecdotal and clinical evidence, theoretical bases, and promising early research prompted much more research on yoga in depression in the past 10 years.

One of the earliest studies directly examining the effects of yoga specifically created for depression was naturalistic observational study of the LifeForce Yoga Program. In this study, 94 individuals underwent an intense 5-day onsite LifeForce Yoga program training (40-50 hours total) consisting of yoga postures, breathing and mantra chanting, and yoga nidra (relaxation) and then were encouraged to continue their practice at home. Participants were followed up two weeks and two months post-training and asked to complete the same questionnaires. Overall they found significant reductions in depression scores two weeks post-training, which were maintained at the two month follow up. Interestingly, they found reductions in depression symptom scores appeared to be related to the frequency of posture and meditation practice, but not breathing practice. This study had significant limitations, however, including a lack of control group, short duration (5 days), small sample size (only 33 participants returned the two-month follow-up questionnaire), and a lack of participant exclusion criteria (participants both with and without depressive symptoms were included) (10).

Following this promising study, two more prospective, randomized, controlled intervention trials were conducted on hatha yoga, adapted from LifeForce Yoga. Both trials were limited to women with a diagnosis of MDD and included an active control. In the first study, women with MDD were randomly assigned to either an 8-week hatha yoga intervention consisting of a 75-minute weekly group class and daily home practice or to an attention-control 8-week health education program that included 75-minute weekly group meetings, but no yoga. Both groups experienced an improvement in depressive symptoms from moderately severe to minimal, but a significant reduction in ruminative thoughts (repetitive negative thinking, typical with depression) was unique to the yoga intervention group (11). A trial by Schuver & Lewis (12) varied from the earlier study by using an active walking control (versus an attention-control) and both interventions took place in the home rather than in the community. Schuver & Lewis compared 40 randomly assigned women with MDD to either a mindful hatha yoga or walking intervention for 12 weeks. The yoga group was provided a LifeForce Yoga DVD that participants were asked to complete for 60-75 minutes twice per week. They also received 8 15-minute telephone calls over the intervention period based on the MBSR curriculum. The walking group was given a similar DVD with walking instructions and received the same phone calls, which discussed health & wellness and goal-setting, but not based on MBSR. Perhaps unsurprisingly, both groups reported decreases in depressive symptoms, but only the mindful yoga group reported significantly lower levels of ruminative thoughts as also seen in the former study. MBSR alone has shown to reduce rumination so the focus on mindfulness in both yoga interventions could account for the decrease in ruminative thoughts. While Schuver & Lewis explicitly introduced MBSR concepts into the yoga intervention group, mindfulness skills were also taught in both yoga interventions, but not the active walking or health education controls. Although neither study found yoga to significantly differ from the controls in reducing depressive symptoms, a reduction in depressive symptoms was seen in both yoga interventions. It is hypothesized in the former that voluntarily participating in an activity to get out of the house, social support, and self-care accounted for the improvement in depressive symptoms in the control and in the later study that exercise itself may explain the improvements in depression for both groups. Schuver & Lewis concluded that ultimately yoga was no more beneficial than exercise for decreasing depressive symptoms and it remains unclear what effect yoga itself has on depression. But is yoga ineffective? Not exactly.

The degree of mindfulness in yoga practices can vary widely. One study of 66 college students participating in an 8-week iRest yoga nidra intervention found statistically significant decreases in perceived stress and depression from mild to minimal (13). Yoga nidra is a type of meditative relaxation yoga, essentially a guided meditation practice. It is unsurprising then, given the strength of research supporting mindfulness-based meditation for decreasing perceived stress and depressive symptoms that the researchers found similar results.

Dosage and length of exposure are also of interest to yoga for depression researchers. Studies with yoga interventions for only 60 minutes per week for 5 weeks is barely enough to notice endocrinological changes, let alone depressive symptom scores (14). A study published last year of women with MDD on antidepressant medications in a 10-week yoga intervention showed greater depressive symptom improvement 6-months post-intervention than the active health education control. They did not, however, find a significant difference in depressive symptoms in the yoga group versus the active health education group at 10 weeks post-intervention. The authors proposed that yoga may have a more enduring effect than health education as some weekly yoga practice was continued post-intervention, such that beneficial effects accumulated over time (15).

There are many theories on yoga’s effect on depression. The act of practicing yoga can have a top-down effect on depression in that repetitive practice of yoga provides a sense of accomplishment (often lacking in depression), reinforcing healthy coping (16). Breathing techniques are common in yoga practice and it’s known that slow breathing stimulates the vagus nerve, which increases dopamine, serotonin, and norepinephrine (16). Studies on yoga have also shown that it increases GABA (an important neurotransmitter) and heart rate variability, which is found to be decreased in depressed individuals (17). Twice weekly 60-minute yoga classes (consisting of yoga postures, breath focus, and savasana relaxation) for 12 weeks was found to be effective at improving HRV (increasing parasympathetic tone) and reducing depressive symptoms and perceived stress in women with mild to moderate depression symptoms (17).

I was able to speak with a San Francisco-based yoga therapist, Elaine Oyang, on the topic. Elaine sees herself in a supporting role, working primarily on the pain condition first, with depression secondary, but that it’s important to acknowledge any depression to ensure yoga postures chosen are appropriate for the individual. She explained that yoga for depression should focus on increasing prana, or “life force”, as depression in Ayurveda and yoga is considered to be low vitality, energy, and life force. A typical yoga session for someone with depression should include acknowledgment of their presence and that they are doing something for themselves, guided imagery to connect the person to the world, energizing breathwork, followed by some yoga postures (poses to make clients feel empowered and strong and getting the blood flow to their head with inversions), and ending with a guided seated meditation (minimizing silence). Elaine also describes the difficulty those with depression may find when attempting to try yoga:

“Yoga represented today is super bendy people in heated rooms and 110 chaturangas. It gets people there, they feel great afterward, but for depression, you need to seek out specific types of yoga that help with it. Vinyasa with 50 people can be overwhelming for someone with depression. They may not have access to the instructor and feel isolated. It can be too much for clients, so they need to seek out 1:1 support... need to know they're in safe hands. Unfortunately slower yoga isn’t as sexy as handstands, it’s not going to give you a six-pack.”

Instructors believe that slower yoga practices require the individual to really think about the movements (mindfulness) and leave space for applying other elements of yoga philosophy (i.e., ethics, mantras, imagery, and meditation) that benefit individuals by realizing that they are not their thoughts and can imagine goodness. When asked why she thinks yoga helps with depression, her response echoed how doing something that day for themselves gives them a sense of accomplishment and regular yoga practice builds confidence and awareness of the body. Students start to build self-agency that they didn’t have before. Another instructor also mentioned that the hips hold a lot of emotional energy and hip-opener movements have been known to release emotional energy: she has witnessed herself, students shedding tears during these movements.

Based on the current evidence, it’s very likely that yoga can be a beneficial mind-body modality to improve depressive symptoms in both MDD and mild undiagnosed depression when the appropriate type of yoga is consistently practiced for an extended period of time. Yoga can be just as effective as other types of exercise or antidepressant medications, has no known side effects or adverse effects, can be free, practiced without leaving the home, and is generally well-accepted by women with depression. Yoga has been shown in multiple randomized controlled trials to significantly decrease ruminative thoughts, which could improve women’s well-being over time. Yoga may also provide individuals with a sense of accomplishment, which can lead to trying more activities. It also produces autonomic changes by stimulating the parasympathetic nervous system, enhancing vagal tone, reducing inflammation, and improving brain chemistry. If an overactive stress response is a major component of depression, then yoga may also improve depressive symptoms by providing beneficial stress coping mechanisms (16).

The question still remains about which type of yoga is best for improving depression. That is, what about yoga works for depression? It’s difficult to make a blanket statement that “yoga can help depression”, especially when most of the yoga classes out there aren’t necessarily the types of yoga shown to be effective for depression in the above studies. Much of the research has been done on specific styles of yoga, focusing on slow, mindful movements, and meditation. No research has been done on more vigorous types of yoga (i.e., hot yoga, vinyasa, etc.) which may not incorporate as much mindful movement or meditation (18). The “dosage” remains unknown as well, but it seems as though it may not matter as much as how many minutes per week, practice sessions per week, or the number of weeks you practice, as much as the commitment to practice, progression, and sense of accomplishment felt matters. Positive benefits have been seen in as short as 2 weeks when students were very committed and practiced very frequently, but mixed results appear for longer study durations of only weekly practice (10,14).

I think it’s also worth addressing the important confounder of mindfulness meditation in much of the research. We know that meditation has profound beneficial effects on depressive symptoms, so it makes sense that a yoga program focused on mindful meditation would produce similar results (9). We also know that yoga can be a form of exercise, which has also been shown to help improve depressive symptoms. So perhaps it is really as simple as that: yoga may be beneficial for depression because it combines exercise with mindful meditation.

Practically speaking, I would safely recommend mindful yoga to those with depressive symptoms. It would recommend starting with an at-home LifeForce Yoga program for weekly practice at first, increasing in frequency as you are able and possibly graduating to a community-based hatha yoga class as confidence grows and depressive symptoms decline.

References

1) National Institute of Mental Health. (February 2018). Depression. Retrieved from https://www.nimh.nih.gov/health/topics/depression/index.shtml

2) Qaseem, A., Barry, M. J., & Kansagara, D. (2016). Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians. Annals Of Internal Medicine, 164(5), 350-359. Retrieved from http://annals.org/aim/fullarticle/2490527/nonpharmacologic-versus-pharmacologic-treatment-adult-patients-major-depressive-disorder-clinical

3) Gelenberg, A. J., Freeman, M. P., Markowitz, J. C., Rosenbaum, J. F., Thase, M. E., Trivedi, M. H., ... & Schneck, C. D. (2010). Practice guideline for the treatment of patients with major depressive disorder third edition. The American Journal of Psychiatry, 167(10), 1. Retrieved from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf

4) National Center for Complementary and Integrative Health. (2018). Depression. Retrieved from https://nccih.nih.gov/health/depression.htm

5) Pilkington, K., Kirkwood, G., Rampes, H., & Richardson, J. (2005). Review: Yoga for depression: The research evidence. Journal Of Affective Disorders, 8913-24.

6) Cramer, H., Anheyer, D., Lauche, R., & Dobos, G. (2017). Review article: A systematic review of yoga for major depressive disorder. Journal Of Affective Disorders, 21370-77.

7) Yoga Journal & Yoga Alliance (January 2016). 2016 Yoga in America Study. Retrieved from https://www.yogaalliance.org/Portals/0/2016%20Yoga%20in%20America%20Study%20RESULTS.pdf

8) Tekur, P., Nagarathna, R., Chametcha, S., Hankey, A., & Nagendra, H. (2012). A comprehensive yoga programs improves pain, anxiety and depression in chronic low back pain patients more than exercise: An RCT. Complementary Therapies In Medicine, 20107-118.

9) Carmody, J., & Baer, R. A. (2008). Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. Journal Of Behavioral Medicine, 31(1), 23-33.

10) Bennett, S. M., Weintraub, A., & Khalsa, S. S. (2008). Initial Evaluation of the LifeForce Yoga Program as a Therapeutic Intervention for Depression. International Journal Of Yoga Therapy, (18), 49-57. Retrieved from http://yogafordepression.com/wp-content/uploads/initial-eval-of-lifeforce-yoga.pdf

11) Kinser, P. A., Bourguignon, C., Whaley, D., Hauenstein, E., & Taylor, A. G. (2013). Feasibility, Acceptability, and Effects of Gentle Hatha Yoga for Women With Major Depression: Findings From a Randomized Controlled Mixed-Methods Study. Archives Of Psychiatric Nursing, (3), 137. Retrieved from http://yogafordepression.com/wp-content/uploads/Feasibility-Acceptability-and-Effects-of-Gentle-Hatha-Yoga-for-Women-With-Major-Depression.pdf

12) Schuver, K. J., & Lewis, B. A. (2016). Mindfulness-based yoga intervention for women with depression. Complementary Therapies In Medicine, 2685-91.

13) Eastman-Mueller, H., Wilson, T., Jung, A., Kimura, A., & Tarrant, J. (2013). iRest yoga-nidra on the college campus: changes in stress, depression, worry, and mindfulness. International Journal Of Yoga Therapy, (23), 15-24.

14) Sarubin, N., Nothdurfter, C., Schüle, C., Lieb, M., Uhr, M., Born, C., & ... Baghai, T. C. (2014). The influence of Hatha yoga as an add-on treatment in major depression on hypothalamic–pituitary–adrenal-axis activity: A randomized trial. Journal Of Psychiatric Research, 5376-83.

15) Uebelacker, L. A., Tremont, G., Gillette, L. T., Epstein-Lubow, G., Strong, D. R., Abrantes, A. M., & ... Miller, I. W. (2017). Adjunctive yoga v. health education for persistent major depression: a randomized controlled trial. Psychological Medicine, 47(12), 2130-2142. Retrieved from https://yogafordepression.com/wp-content/uploads/yogafordepression.com-uebelacker2017-had-rct-primary-outcome.pdf

16) Kinser, P. A., Goehler, L. E., & Taylor, A. G. (2012). How Might Yoga Help Depression? A Neurobiological Perspective. Explore: The Journal Of Science And Healing, (2), 118. Retrieved from http://yogafordepression.com/wp-content/uploads/Kinser-Goehler-Taylor-2012-How-might-yoga-help-depression1-1.pdf

17) Chu, I., Wu, W., Lin, I., Chang, Y., Lin, Y., & Yang, P. (2017). Effects of Yoga on Heart Rate Variability and Depressive Symptoms in Women: A Randomized Controlled Trial. Journal Of Alternative And Complementary Medicine (New York, N.Y.), 23(4), 310-316.

18) Uebelacker, L. A., & Broughton, M. K. (2016). Yoga for Depression and Anxiety: A Review of Published Research and Implications for Healthcare Providers. Rhode Island Medical Journal (2013), 99(3), 20-22.