Clinical Practice Guidelines for Yoga and Other Alternative Therapies for Patients with Mental Disorders.

INTRODUCTION

Demand of complementary and alternative (CAM) treatments has been increasing over a period of time. Some studies have reported that up to 56% of patients with depression have used CAM methods while they have been used in other psychiatric disorders with or without conventional treatment.

In ancient India and till the middle ages before British rule in India, yoga and Ayurveda were the sciences for health and disease. Modern medicine as described during British period gradually replaced these sciences in India. In other words, in olden times, yoga and Ayurveda were practiced as a way of life.

Although yoga has its roots in Vedic and Upanishadic writings, it was 100 years BC that Patanjali emphasized on different aspects of yogic practices and advocated their role in day-to-day practice as well as healthy lifestyle. The scientist-sage Patanjali, in his Yoga Sutras (4), described Ashtanga Yoga meaning the eight-fold path of yoga and the way it should be practiced to live healthy lifestyle and prevent the diseases.

It is thought that yoga is a spiritual science partly it is true but the latest advances have proven that we not only achieve an ideal state of psychophysiological health by practice of yoga, it helps in improving the individuals spiritual status and optimal functioning of body and mind.

Yoga as a therapy has been used since 1400 BC described in Charak Samhita and has been popular in India since then. Yoga as therapy has gained its status in India and internationally after reported benefits of regular practice in stress reduction regulating of emotions improving mood, general well-being, and cognitive functioning. Utility of Pranayam has been proven in respiratory and cognitive functioning, while Yoga Asanas have their impact in physical flexibility, muscular strength, and neuromuscular performance.

In health sciences, there has been a recent focus on research in Yoga therapy in various conditions including psychiatric disorders [Table 1]. In mental health, the major focus has been on research in depressive disorder and anxiety states with proven reports of its utility. Research is also being focused on posttraumatic stress disorders and substance use disorder. Some work has gone on in its utility in attention deficit disorders, autism, and obsessive–compulsive disorders. In some places, yoga therapy is being used as an adjunctive therapy. It also works as a preventive therapy where patients are having high risk for mental disorders.

Table 1

Evidence base of efficacy of yoga in major depressive disorder

Therapy	Techniques	Evidence base
Yoga	Ashtanga Yoga “1. Yam, 2. Niyam, together these help the individual toward self-regulation, 3. Asanas, 4. Pranayama,5. Pratyahar, 6. Dharna, 7. Dhyana, 8. Samadhi”Yogic disciplines  Karma Yoga (being involved in action) Bhakti Yoga (being in devotion) Gyana Yoga (attaining knowledge and wisdom to understand and live the present life and life after) Hath Yoga (which primarily deals with yogic asanas) Mantra Yoga (enchanting a particular rhyme which suits the individual normally taught by a guru to attain higher level of consciousness it utilizes sound vibrations) Laya Yoga (singing individually or in a group to attain union with the soul and attaining transcendence) Raj Yoga (which primarily deals with physical and mental purity - Shuddhi)Various types of Yoga Iyengar Kundalini Vinyasa Ashtanga Kripalu Siddhi Samadhi yoga Hatha Antenatal Integrated	Kumar et al. (1993) reported Yoga as significantly superior in MDD in RCTsSharma et al., 2005, reported IyengarYoga monotherapy significantly superior in the treatment of MDD RCT; 2 groupsSahaj Yoga meditation reported to be superior in 2 RCTs in an 8-week trialWoolery et al., 2004, reported yoga significantly superior in reducing depressionKrishnamurthy and Telles, 2007, reported in RCT; 3 groups Yoga monotherapy to Ayurvedic medicines and control group

MDD – Major depressive disorder; RCTs – Randomized controlled trials

YOGA

Yoga truly means that our mind and body work together in a good harmony and we attain peace. Some authors have given the idea of harmony of mind–body and spirit together; however, the concept of spirit has not been so commonly used in modern medicine and the practice of yoga has no conflict with personal believes of individuals.

The yogic practices include Pranayam which is a practice of controlling and regulating one's breath in specific described manner and meditation which is a practice of concentrating the thought on a particular figure or reciting spiritual rhymes repetitively to attain a higher level of consciousness. Asanas, the physical activity of group of muscles in specific postures and concentrating on self while reflecting on self, has also been described in yogic techniques.

Yoga therapy or Yoga Chikitsa treats the individual by understanding the underlying cause of disease and prescribing specific techniques of yoga. It is indicated for individuals, families and in work place. For example, if someone is diagnosed suffering from anxiety disorders, he/she is advised Pranayam (the breathing techniques), asanas (the calming postures), and meditation or mindfulness-based techniques to change his/her lifestyle, which benefits him/her and does not cause any adverse effects. The yogic concept talks of vibrant health and emphasizes on the goal of self-realization and well-being.

The Ashtanga yoga, the eight-fold path of yoga, includes:

Yam (restraining self from many activities which are not approved by social norms and which lead to unhealthy lifestyle as described by yogic tradition)

Niyam (observing discipline)

Asanas (the physical activity of group of muscles in specific postures and concentrating on self)

Pranayama (practice of controlling and regulating once breath in a specific described manner)

Pratyahar (withdrawing many pleasures or habits of life)

Dharna (focusing once attention at a particular thought or activity)

Dhyana (concentrating the thought on a particular figure or reciting spiritual rhymes repetitively to attain a higher level of consciousness)

Samadhi (a blissful state of consciousness where one attains complete tranquility and has a feeling on oneness with the cosmos). The first five ingredients are by regulating self and the external word while the last three are manipulating the internal self which Patanjali has described as Bahiranga (external) and Antaharanga (internal) practices, which may run in consonance to each other or parallel.

Yogic disciplines which have been described in Upanishad

Karma Yoga (being involved in action)

Bhakti Yoga (being in devotion)

Gyana Yoga (attaining knowledge and wisdom to understand and live the present life and life after)

Hath Yoga (which primarily deals with yogic asanas)

Mantra Yoga (enchanting a particular rhyme which suits the individual normally taught by a guru to attain higher level of consciousness it utilizes sound vibrations)

Laya Yoga (singing individually or in a group to attain union with the soul and attaining transcendence)

Raj Yoga (which primarily deals with physical and mental purity-Shuddhi).

It is believed that each one of them helps an individual for self-realization and self-actualization.

In the present-day practice, most people use the Hath Yoga and prayan techniques for specific disorders of body and mind. In Ayurvedic tradition, Sath karmas (six actions – Neti, Dhauti, Basti, Nauli, Kapalbhati, and Trataka) are commonly prescribed. Some authors have added balanced diet (Mitahara) and nonviolence (Ahimsa to these techniques).

Iyengar – Laid emphasis on support to maintain proper body position even in less flexible students. Easily accessible. Training for teachers is more formal and precise than with other disciplines

Kundalini – Emphasize breathing techniques with more of spiritual aspects. Much suitable for physically fit students

Vinyasa – Fluid, flowing style involving continuous movement between postures with coordinated breathing. Most classes are geared toward fit, physically able students

Ashtanga – Students move quickly and smoothly from one posture to next in this vigorous school of yoga. Recommended for more athletic students

Kripalu – Similar to psychotherapy; it involves emotional and spiritual aspects. Breathing and postures are pooled in classes, which can be physically challenging

Siddhi Samadhi yoga – Less physically focused style which combines meditation and breathing techniques in short successions

Hatha – A basic, beginner style incorporating postures, as opposed to breathing or meditation exercises. Described to have not much challenging postures

Antenatal – Includes postures and relaxation/breathing techniques, based on the mild, Hatha, form of yoga

Integrated - Combination of physical postures, breathing exercises, and meditation.

Evidence for the use of yoga has been reported in managing major depressive disorders as an adjunct treatment in anxiety and depressive disorder by Canadian Network for Mood and Anxiety Treatments. Some studies have reported level 3 evidence of benefit.

MEDITATION

Derived from a Sanskrit word Dhyana Meditation is concentrating the thought on a particular figure or reciting spiritual rhymes repetitively to attain a higher level of consciousness and contemplation of thoughts within.

Meditation techniques

Focused

Mantra

Walking.

Meditation is an approach to training the mind, and many meditation techniques exist, so how do we pick up proper technique? In a very broad sense, [Table 2] mediation techniques can be those involving concentration (focusing on single point) and those involving mindfulness (observing the wandering thoughts).

Table 2

Meditation evidence base

Therapy	Techniques	Evidence base
Meditation	FocusedConcentrating on a deity or picture or syllable OM or a simple dotMantraThis meditation technique takes about5-20 min or even longerWalking Walk back and forth for 10-15 steps at a place that is relatively peaceful Walk 10-15 steps along the lane you have chosen, and then pause and breathe for as long as you like. When you are ready, turn, and walk back in the opposite direction to the other end of the lane, where you can pause and breathe again While walking concentrate on your breath and the movements of the feet and legs and contact of your feet to the ground. Concentrate on all perceptions through your sensory organs	Observational statements noRCT

RCTs – Randomized controlled trials

Focused breathing

In the recent times, mindfulness technique has been gaining attention as an integrated approach in schizophrenia, major depressive disorder, and bipolar disorder. The most basic way to do mindful breathing is simply to focus attention on breath, the inhale, and exhale. A basic method is to focus attention on own breathing – a practice simply called “mindful breathing.” Time required for mindful breathing is 15 min/day for at least a week. Mindfulness breathing is a good antidote to restlessness and anxiety and a good way to relax: concentration on the breath has a positive effect on the entire physical and mental state.

It can be done while standing, but ideally sitting or even lying in a comfortable position. Sometimes, while trying to calm in a stressful moment, it might help start by taking an exaggerated breath: A deep inhale through nostrils (3 s), holding breath (2 s), and a long exhale through mouth (4 s).

Breathing practice, also known as “diaphragmatic breathing” or “deep breathing,” is defined as an integrative body–mind training for dealing with stress and psychosomatic conditions. Diaphragmatic breathing includes contraction of the diaphragm, expansion of the belly, and deepening of inhalation and exhalation, which ultimately decreases the respiration frequency and maximizes the amount of blood gases.

Focused meditation

Is a technique in which you direct your awareness onto something.

A picture or statue of a deity

A universal principle such as compassion or forgiveness

Or the syllable OM, the famous Hindu mantra.

Mantra

Mantra Yoga is enchanting a particular rhyme which suits the individual normally taught by a guru to attain higher level of consciousness it utilizes sound vibrations. Mantra is normally given by the guru/teacher to the disciple.

This meditation technique will take about 5–20 min or even longer. Select a mantra to chant, sit in a chair or on the floor, or in a position both aligned with the natural curves of the spine and relaxed. Close the eyes and take a few slow, deep breaths to relax breath completely. Repeat the mantra slowly, concentrating on its sound. Repeat it in unison with the natural rhythm of your breath for next 3–5 min. Repeat the mantra silently by moving only your lips for several minutes.

Mantra meditation also leads to relaxation of mind and body and reduces psychological distress.

Walking

Usefulness of walking has been reported in anxiety and depression. Brisk walking for 4 km/day at least 5 days a week in open environment has been advocated. Person should concentrate on his breath and tack as deep breath as possible it has relaxing effects on body and mind.

Techniques

Walk back and forth for 10–15 steps at a place that is relatively peaceful

Walk 10–15 steps along the lane you have chosen, and then pause and breathe for as long as you like. When you are ready, turn, and walk back in the opposite direction to the other end of the lane, where you can pause and breathe again

While walking concentrate on your breath and the movements of the feet and legs and contact of your feet to the ground. Concentrate on all perceptions through your sensory organs.

Transcendental meditation

Bhavateet Dhyana also known as transcendental meditation (TM) has been an ageold method of meditation it was propounded by Maharishi Mahesh Yogi in the Western world. It comes from the vedic tradition. Theory of TM is based on the presumption that TM if practiced regularly stimulates neurophysiological growth of the individual and leads to a higher state of consciousness. The TM school claims that its practice not only improves the psychological status of individual but also leads to overall change in his surroundings. Researches on TM have been carried out mainly by the TM group of scientists on psychological and biological parameters [Table 3].

Table 3

Evidence base- Transcendental Meditation

Therapy	Technique	Evidence
TM	Based on Mantras, consisting of seven steps	Significant reduction in stress and burnout was reported in 40 school teachers while evaluating them for the effect of TM on psychological distress and burnoutA comprehensive meta-analysis of RCTs on TM has suggested that TM is an effective and alternative treatment for individuals with high anxietySignificant improvement in ADHD symptoms have been reported in an exploratory study with use of TM in students of 11-14 years of ageIn an uncontrolled pilot study, TM was found effective in the treatment of PTSD

TM – Transcendental meditation; RCTs – Randomized controlled trials; ADHD – Attention deficit hyperactive disorder; PTSD – Post Traumatic Stress Disorder

Raja Yoga

The Sanskrit word “Yuj” is the origin of world yoga which means union or to join. It is the methods of transformation of consciousness which leads to attain liberation (Moksha) from the circle of karma. Karma is what we do in our daytoday life and it is presumed that based on our results of karma, we have rebirth (Punarjanma). Raj Yoga includes practice of Ashanas, Pranayam, and Samadhi. Raj Yoga is considered as supreme or highest form the yoga which empowers an individual to rule the self. In Raj Yoga meditation, there are no rituals and it can be practiced any time anywhere. It is practiced with open eyes or closed eyes sitting crossed legs on the ground or on the chair, which makes it simple and easy to practice. It is reported to have positive effects on nervous system, immune system, circulatory system, respiratory system, endocrine system, and digestive system, also reported to have antioxidant properties also and is helpful in the treatment and prevention of various disorders of nervous system, cardiovascular system, psychosomatic disorders, and pain disorders [Table 4].

Table 4

Evidence base Raj Yoga

Therapy	Techniques	Evidence base
Raj Yoga	Raj Yoga is practiced with open eyes or closed eyes sitting crossed legs on the ground or on the chair	Positive effects on nervous system, immune system, circulatory system, respiratory system, endocrine system and digestive system, also reported to have antioxidant properties also and is helpful in the treatment and prevention of various disorders of nervous system, cardiovascular system, psychosomatic disorders, and pain disordersObservational statements no RCT

RCTs – Randomized controlled trials

Raj Yoga

Spiritual Meditation (Raj Yoga)

Application of spirituality in day-to-day life is applied spirituality

Application of godly knowledge

On the eternal world drama

On law of karma

On self-transformation for world transformation.

Interconnection at Macrolevel

State of Consciousness

Raj Yoga meditation

The four steps:

Visualization of the soul, supreme soul, basic attributes, relations

Perception experiencing each attribute, sweetness of different relations with God

Reception filling each attribute within the soul-battery

Distribution sharing the attributes with other souls in the world.

Preksha Dhyana

Preksha means looking into self vigilantly and deeply. Practitioners of Preksha Dhyana engage their mind to become fully aware of internal and inherent happenings of consciousness. Swas Preksha means looking into the breath and techniques are similar to Pranayam the individual follows the breath going in and breath coming out with full concentration on breath. Similarly, other experiments conducted by Acharya Mahapragya the propounder of this technique with whom the author has closely worked for almost 30 years include “Rang Preksha” the imagination of blue yellow and white colors on the fore head and inside the frontal part of the brain to attain different states of consciousness and to treat various disorders. Subsequently, it also involves contemplation of thoughts and concentration techniques [Table 5].

Table 5

Evidence base Preksha Dhyana

Therapy	Techniques	Evidence base
PrekshaDhyana	Therapeutic strategies Yogic Physical Exercise Yogic Asanas Pranayam Kayotsarg Dhyana Anupreksha Leshya Dhyana	Preksha Dhyana improves attention and concentrationIt reduced anxiety and depression scores in practitioners of Preksha DhyanaOpen-ended interventional studyJain Vishva Bharti Ladnu

The application of yoga, Preksha Meditation (PM) as a therapeutic intervention, takes advantage of the numerous psychophysiological benefits of the component practices. PM is a type of meditation based on the theory of perception. Yoga, PM practice, affects adjustment, behaviors, and self-awareness positively. “PM” is a special type of meditation propounded by Acharya Mahaprajna, the Jain Monk (1978) as a remedy for the humankind suffering from conditions such as stress, tension, frustration, depression, and ill health. Although primarily a mindfulness practice, PM has element of concentration also. It aims at awakening one's own mind resulting in changes in attitude, personality, behavior, and emotion. It has eight components. These are used in different combinations, i.e., kayotsarg (relaxation), anteryatra (internal trip), swaspreksha (perception of breathing), shareerpreksha (perception of body), Chaitanyakendrapreksha (perception of psychic centers), lesyadhyana (perception of psychic colors), anupreksha (contemplation), and bhavana (positive feelings).

Buddhist psychology

Insight meditation provides a methodology for Buddhist Psychology and Buddhist Psychotherapy.

The meditation object is one's own consciousness and mental factors.

Buddhist methods

Concentration mediation (Samatha Bhavana)

Insight meditation (Vipassana Bhavana).

Concentration meditation

Concentration meditation involves focusing our attention on a single object

It is used as a preparation for insight meditation.

Insight meditation

Insight meditation involves the experiential observation of mind and body (Namarupa) through the mode of impermanence, suffering, and nonself.

Vipassana

What is the meaning of “Vipassana”?

“Vipassana” - Pali word which means “insight,” “seeing things as they really are.”

What is Vipassana Meditation?

It is a technique of mental training whereby the systematic process of self-observation leads to increased awareness, self–control, and real peace of mind.

Vipassana techniques

Vipassana is an ageold technique of meditation which originates from the time of lord Buddha reportedly rediscovered 2500 years ago and forms a part of Buddhist psychology which means to see things as they really are. It is a technique of selfobservation concentration and selfawareness through meditation. Practitioners of Vipassana pay full attention to the physical sensations that continuously interact with mind and body [Table 6].

Table 6

Evidence base Vipassana

Therapy	Techniques	Evidence base
Vipassana	1. Anapanasati2. Vipassana3. MettaBhavana	Reported useful in anxiety and depressionStress reductionFew studies by chokhani et al. no RCT is available not advocated for withdrawn schizophrenics/depressive patientsObservational statements no RCT

RCTs – Randomized controlled trials

The insight meditation consists of three subunits:

Anapanasati (mindfulness of breathing)

Vipassana (insight meditation)

Metta Bhavana (universal love and compassion).

PRANAYAM

Pranayama is a form of breathing exercises which manipulate the breath. It acts as dynamic bridge between the body and mind. It involves three main stages: “Puraka” (inhalation), “kumbhaka” (retention), and “rechaka” (exhalation). These stages are regulated in a particular manner. Maharishi Patanjali has described it as an important ingredient of Ashtanga Yoga to be much more important than yogasanas for keeping sound health.

“Pranayama Sadhana - Holding of Breath = Kumbhak → Inhalation (Purak) → Pause (Kumbhak) → Exhalation (Rechak) → Pause (Kumbhak) Practice of Pranayama is the practice of Kumbhak, Practice of Kumbhak requires the practice of Purak and Rechak, Practice of Purak and Rechak is easy and effective. The practice of Kumbhak is difficult and dangerous if not practiced properly.”

SUDARSHAN KRIYA

Sudarshan kriya yoga originates from Bhastrika Pranayam as described in the yogic tradition. It involves cyclical controlled breathing practice and is reportedly useful in relief from depression. It has found attention of many researchers who have proven its utility in the reduction of anxiety, depression, and alcohol and tobacco dependence. The technique involves Ujjayi (Victorious Breath), Bhastrika (Bellows Breath), and chanting of OM.

The term Sudarshan Kriya translated from Sanskrit means “proper vision by purifying action.”

It is an advanced form of rhythmic, cyclical breathing with slow, medium, and fast cycles.

Its practice reportedly lowers the levels of blood lactate and improves antioxidant status [Table 7].

Table 7

Evidence base Sudarshan Kriya

Therapy	Techniques	Evidence base
Sudarshan Kriya	Ujjayi (Victorious Breath)BhastrikaChanting Om	Janakiramaiah et al., 2000, reported significant reductions in HDRS and BDI scores with Sudarshan KriyaRohini et al., 2000, reported partial remission in depression in theSudarshan Kriya group

BDI – Beck Depression Inventory; HDRS – Hamilton Depression Rating Scale

Other alternative methods of treatment which are being practiced in the Eastern world include Reiki, Pranic Healing, and mindfulness/mindful yoga. Scientific studies on these techniques are scarce and need evaluation on patients with various psychological disorders, which is a need of the day.

Evidence-based findings

Systematic research in this area is still inadequate, with a review of yoga as a therapy for depression and anxiety disorders in 2005 finding that the evidence was not strong enough to make any specific recommendations. Fortunately, the last few years has seen an exponential rise in studies of yoga in psychiatric disorders, with recent reviews making a case for yoga being an efficacious treatment strategy for major depression and psychosis. Most studies have used yoga interventions as an adjunct to conventional treatment approaches, although a few have trialed yoga-based modules as sole therapy in depression and anxiety disorders.

Among the CAM therapies used for depression, yoga is one of the methods used extensively across the world. A systematic review suggested that yoga may be an attractive alternative to or a good way to augment current depression treatment strategies. The review also described plausible biological, psychological, and behavioral mechanisms by which yoga may have an impact on depression.

Major depressive disorder

Yoga has demonstrated significant improvement in depression as an add-on to antidepressants in various trials. Other advantages of yoga in depression are improvement in anxiety, behavioral activation, and nonjudging facet of mindfulness. Shahidi et al. have showed significant improvement in depression and life satisfaction in elderly depressed women as compared to the TAU control group but not against the PE group. A study by Descilo et al. has shown significant improvement in depression among patients with posttraumatic stress disorder. Breathing interventions alone and in combination with exposure therapy in real life situations were useful in the improvement of symptoms.

Mechanisms by which the yoga improves depression include positive self-talk and self-acceptance. It reduces negative thinking bias, improves self-confidence, and helps in more adaptive thinking. Other possible mechanisms include increasing gamma aminobutyric acid neurotransmitter in the brain, improving sleep, decreasing ruminations, and promoting behavioral activation.

Specific types of yoga have been used to address depression and anxiety which include: Savasan, Pranayam, Sudarshan Kriya, Prekshadhyana, Vipassana, Transcendental Meditation and Raj Yoga. Evidence base on other techniques of alternative therapies has been narrative and descriptive in the management of psychiatric disorders. Utility of these techniques needs to be researched further in controlled trials. However, they may be recommended as adjuvant therapies at present.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.