Mechanisms of Hyperthermic Yoga for the Treatment of Depression
Phase: NA
Conditions: Depression, Major Depressive Disorder
Sponsor: Massachusetts General Hospital

1 
 
 
 
Mechanisms of Hyperthermic Yoga for the Treatment of 
Depression 
 
Principal Investigator: Maren Nyer, PhD 
 
Supported by: National Center for Complementary and Integrative Health 
(NCCIH); 1K23AT008043-01A1 
 
Study Intervention Provided by: Bikram Yoga Boston and Bikram Yoga 
Cambridge 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

2 
 
Tool Revision History 
Version Number 1.9 
Version Date: August 24th, 2020 
Summary of Revisions to be Made: 
We are proposing the following changes: 1) We are adding updated information regarding a 
Data Use Agreement (DUA) that we intend to submit. 
 
Version Number 1.8 
Version Date: July 13th, 2020 
Summary of Revisions to be Made: 
We are proposing the following changes: 1) We are adding information specifying the locations 
of where the analyses of biological samples (blood samples) collected will take place. 
 
Version Number 1.7 
Version Date: November 13th, 2019 
Summary of Revisions to be Made: 
We are proposing the following changes: 1) We are adding the ability to recontact patients for 
the sake of accurate reporting of yoga class attendance after they had finished participation in 
the study. Patient’s will be contacted up to three times before they are considered “Lost to Re-
Contact” 
 
Version Number 1.6 
Version Date: April 22, 2019 
Summary of Revisions Made: 
We are proposing the following changes: 1) We are increasing the language concerning 
enrollment from 80 to 160, as 80 is our target of patients to be randomized, while 160 is the 
number we plan to enroll to achieve this goal of randomization. 
 
Version Number: 1.5 
Version Date: January 11, 2019 
Summary of Revisions Made:  
We are proposing the following changes: 1) We are allowing clinician rated measures to be 
completed by phone for all visits when needed/indicated to reduce subject burden and protocol 
deviations. Subsequently, we have added a protocol for patients expressing active suicidal 
ideation over the phone. 2) We are updating the protocol to allow for the initial screening 
physical exam and EKG to be conducted at the baseline visit to accommodate clinician 
availability. 3) When blood cannot be obtained during the study visit by a member of the 
research staff, we are allowing the blood to be drawn at the phlebotomy lab at the MGH main 
hospital to accommodate the subject’s schedule. 4) The psychoeducational session that takes 
place during the initial baseline (visit 2) and the repeat baseline (DYG, Visit 7) can now take 
place over the phone with Dr. Nyer to accommodate patient’s schedules. 5) We are allowing 
participants to bring back their sleep diaries and saliva samples at the following visit if they 
forget them, as long as they were collected during the appropriate time. 6) We are adding the 
option to be re-contacted for future research studies to the informed consent. 7) The yoga 
studios have changed names and owners. 
 

3 
 
Version Number: 1.4  
Version Date: July 10, 2017 
Summary of Revisions Made:  
We are proposing the following changes: 1) We are increasing the amount of blood collected 
throughout the study from a total of 13ml to 30ml per visit, resulting in a total amount of blood 
collected of 131mL for the immediate yoga group, and 221mL for the delayed yoga group. 2) 
We have added the University of Rhode Island Change Assessment Scale (URICA), which 
assess for readiness to change, to the baseline and end-of-study visits. 3) We are modifying 
our inclusion/exclusion criteria to specify that the consumption of coffee or other caffeinated 
beverages is allowable, and to alter the length required for a participant to be on a stable 
psychiatric medication prior to enrolling to the study from <3 months to <2 months, with a 
stable dose for <4 weeks. 4) We would like to ask participants to complete two paper-copy 
surveys (the EIFI and the STAI-State) 30 minutes pre and post each yoga class they attend. 
The questionnaires will be handed to participants after they are randomized at the end of their 
Baseline visit. 5) We included a column on the C-SSRS conducted at screen to assess for 
symptoms in the “past year”, in addition to “lifetime”. 6) We created an “informational form” to 
hand out to participants at baseline, which contains information about the studio locations and 
class scheduled, as well as reminders of how many classes to attend, which classes to attend, 
and that participants can attend classes at both studios for free for the duration of the study. 7) 
We updated the study protocol to specify how our randomization procedures are conducted 
(i.e., that participants are randomized at the end of their baseline visits by a research 
coordinator, and only informed of their group assignment once they have completed all study-
measures). 8) We have changed the frequency of Dr. Nyer’s check-in calls with participants to 
once every two weeks, on weeks when participants do not come in to the program for an in-
person assessment visit.  
 
 
 

4 
 
STUDY TEAM ROSTER  
Principal Investigator: Maren Nyer, PhD 
One Bowdoin Square, 6th Floor 
Boston, MA 02114 
Phone: 617-643-4897 
Fax: 617-724-3028 
Email: mnyer@partners.org 
 
Primary Mentor: Maurizio Fava, MD 
Bulfinch, Room 351 
55 Fruit St. 
Boston, MA 02114  
Phone: 617-724-0838 
Fax: 617-726-2688 
Email: mfava@partners.org 
 
Co-Mentor: David Mischoulon, MD, PhD 
One Bowdoin Square, 6th Floor 
Boston, MA 02114 
Phone: 617-724-5198 
Fax: 617-724-3028 
Email: dmischoulon@partners.org 
 
Co-Mentor: Chris Streeter, MD 
85 East Newton Street, 9th Floor 
Boston, MA 02118 
Phone: (617) 638-8008 
Fax: (617) 638-8007 
Email: streeter@bu.edu 
 
Medical Monitor: Darshan Mehta, MD, MPH 
4th Floor, 151 Merrimac St. 
Boston, MA 02114-4719 
Phone: 617-643-6046 
Fax: 617-643-6077 
Email: dmehta@partners.org 
 
 
 

5 
 
 
1. STUDY OBJECTIVES 
1.1 Primary Objective 
Primary Aim I: To recruit and retain adults with depressive symptoms into a controlled trial of 
hyperthermic yoga, randomizing 40 participants to each the immediate yoga group (IYG) and 
delayed yoga group (DYG; control group) with seventy-five percent retention in both groups.  
 
 
 
Hypothesis Ia: Seventy-five percent of the each group will complete a week-8  
 
 
assessment.  
 
Hypothesis Ib: Acceptability of hyperthermic yoga will be high on the Acceptability  
Interview.  
 
 
 
Primary Aim II: To collect the Inventory of Depressive Symptomatology – Clinician Rated (IDS-
CR) scores at screening;  baseline; and weeks-1, -3, -5 and -8 to evaluate the efficacy of 
hyperthermic yoga for depressive symptoms. 
 
Hypothesis II: The IYG will have greater decreases in Inventory 
of Depressive Symptomatology – Clinician Rated (IDS-CR) scores after 8-weeks 
compared to the DYG.  
 
Primary Aim III: To collect (a) physiological and (b) psychological mediators of hyperthermic 
yoga in the IYG and DYG group at screening; baseline; weeks-1, -3, -5 and -8 to evaluate 
treatment response in the IYG compared to the DYG. 
 
Hypothesis IIIa: Salivary cortisol, and inflammatory markers (i.e., Tumor Necrosis Factor  
[TNF-α], Interleukin-6 [IL-6], and C-Reactive Protein [CRP]) will significantly decrease 
following 5- and 8-weeks of hyperthermic yoga in the IYG compared to the DYG. 
Hypothesis IIIb: Perceived stress, mindfulness, and rumination will improve by 5- and 8-
weeks in the IYG compared to the DYG.  
 
1.2 Secondary Objectives 
Secondary Aim I: To collect measures of quality of life, general health, physical functioning, 
decreased perceived stress, anxiety, and sleep in the IYG and DYG at screening; baseline; 
and weeks-1, -3, -5 and -8 to evaluate hyperthermic yoga for secondary outcome measures.  
 
Secondary Hypothesis I: The IYG will have significant improvements in quality of life, 
general health, physical functioning, perceived stress, anxiety, and sleep compared to 
the DYG.  
 
Secondary Aim II (exploratory): To evaluate the long-term effects of the yoga intervention (1-
month post intervention), while controlling for continued yoga participation. 
 
Secondary Hypothesis II: Subjects who choose to continue the yoga practice, either in the 
IYG or DYG, will have increased effects at 1-month post intervention, per the primary 
and secondary outcome measures compared to the week-8 assessment. 

6 
 
2. 
BACKGROUND AND RATIONALE 
2.1 
Background on Condition, Disease, or Other Primary Study Focus 
Depression is associated with significant mortality, morbidity, and disability, and is the fourth 
leading cause of global disease burden1. By 2020, Major Depressive Disorder (MDD) is 
projected to be the second leading cause of global disability in developed nations2.  Even 
though more people are receiving treatments for depression, there is no evidence that the 
associated morbidity and mortality have significantly decreased. The Sequenced Treatment 
Alternatives to Relieve Depression (STAR*D) Study suggested relatively “weak effects” of 
antidepressants3. In addition, antidepressants also have common side effects, such as weight 
gain, sexual dysfunction, fatigue, and others4. Electroconvulsive therapy, and more recently 
ketamine infusion, provide more immediate relief to those with severe depression3, though 
these benefits are often short-lived. Cognitive Behavioral Therapy (CBT), although effective, 
demonstrates remission rates no better than antidepressants5,6. The modest effects of current 
treatments may be due to their inability to fully address the physiological dysregulation of the 
stress response system7.    
 
2.2  
Study Rationale 
Proposed Intervention: Bikram Yoga (BY) is a standardized type of hyperthermic yoga, which 
synergistically combines Hatha Yoga postures, intensive exercise, mindfulness, and thermal 
therapy. It consists of 26 sequenced postures and two breathing exercises, practiced for 90 
minutes in a room heated to 105-110˚F with 40–60% relative humidity. Table 1 summarizes 
the hypothesized active elements of BY.  
 
Table 1. Mechanisms of Bikram Yoga. 
Mechanism and Evidence Base 
Inclusion in Bikram Yoga Protocol 
Yoga: Yoga demonstrates antidepressant 
effects8-12.   
Includes postures indicated for depression, 
i.e., backbends and inversions8. 
Intensive Exercise: Exercise demonstrates 
antidepressant effects13, and more intensive 
exercise produces higher remission rates as an 
augmentation for resistant MDD14.  
BY presents a more intensive form of 
exercise than most yoga modalities, and 
produces high metabolic energy output15.  
Mindfulness: Mindfulness-based interventions 
reduce depressive symptoms and prevent 
relapse16. 
The practice discharges agitation and 
facilitates mindfulness. Mastery of 
uncomfortable sensations may generalize to 
maintaining a calm mind during times of 
high stress.  
Thermal Therapy: Heat17-19, thermal therapy20-
23 and fever24 demonstrate antidepressant 
potential.  
The heat (105-110˚F) may enhance the 
benefits of the standard Hatha Yoga 
postures and allow for greater stretching of 
muscles25, in addition to providing anxiolytic 
effects26.  
 
Characteristics of Bikram Yoga for Clinical Trials: Table 2 outlines the features that 
differentiate Bikram Yoga from other forms of yoga, and highlights the suitability of its use in 
clinical trials for depression.   
 

7 
 
Table 2. Features of Bikram Yoga. 
Bikram Yoga Features 
Clinical Trial Applicability 
Classes are standardized in time, dialogue, posture 
sequence/duration, and room conditions. The unified 
consistent protocol allows for a rigorous clinical trial 
design because all patients assigned to yoga get the 
same intervention. 
The lack of standardized yoga 
protocols27 hinders methodological 
rigor in the yoga for depression 
literature base9. 
The standardized Bikram Yoga dialogue was 
designed to allow inexperienced students to safely 
complete the yoga postures25.  
The practice was developed so that 
participants of all levels would be 
able to take the classes25.  
Bikram Yoga focuses almost exclusively on the 
physicality of the practice, rather than the spiritual 
components of yoga. 
Yoga modalities range in degree of 
physical and/or spiritual 
emphasis27. The physical focus 
may have broader, secular-based 
appeal to US public. 
Widely Available: 285 Bikram Yoga studios in the US 
and 217 Bikram Yoga studios abroad, covering 42 
countries and 464 cities; 18 Bikram Yoga studios in 
Massachusetts. 
The intervention has broad potential 
for quick dissemination.  
 
Yoga as a Treatment for Depression: Evidence is accumulating to support yoga as a treatment 
for depression. A 2005 literature review found 5 randomized controlled trials (RCTs)11, 
whereas a 2013 meta-analysis found 12 RCTs12. Reviews suggest that yoga is a promising 
treatment for depression, but consistently note that a lack of rigorous study methodology 
prevents the firm conclusion that yoga be considered a treatment for depression9, 12,  28. 
Methodological limitations include: heterogeneity of yoga interventions and patient samples; 
inadequate sample size and randomization procedures; lack of intention-to-treat analysis and 
blinding of outcome assessors; inadequate control groups; and unreported dropout, relapse, 
and remission rates9, 12. Despite these flaws, the 2013 meta-analysis12 did find moderate 
evidence for the short-term effects of yoga compared to usual care. A 2013 systematic review 
of yoga for depression10 affirmed “Grade B” evidence for yoga as an acute treatment for 
depression. One controlled study used an Iyengar yoga treatment, a form of hatha yoga, that 
included back bends, inversions and vigorous standing postures thought to be particularly 
effective for alleviating depression8. These postures are also used in Bikram Yoga, which is 
also a form of hatha yoga. The Beck Depression Inventory (BDI) and Spielberger State-Trait 
Anxiety Index (STAI) measured mood and anxiety. Subjects had baseline BDI scores of 10 to 
15 (mild-to-moderate depressive symptoms), similar to the proposed study. The 5-week yoga 
intervention decreased depression and anxiety, using similar measures to the proposed study. 
The evidence has been promising enough to warrant two current rigorous NIH R01 funded 
RCTs for non-heated yoga (NIH RePORTER: 1) PI: Streeter [NCCAM], and 2) PI: Uebelacker 
[NINR]). The proposed study has been constructed to address the concerns and apply 
rigorous methodology to an unexplored form of yoga.   
 
Bikram Yoga Research: While there is no literature on Bikram Yoga for depression, several 
studies of Bikram Yoga demonstrate improvements in physiological and psychological 
processes implicated in depression. Physiologically: In a recent 8-week pilot trial, 3 weekly 

8 
 
Bikram Yoga classes improved glucose tolerance in 15 older obese adults compared to 14 
young lean subjects. This supports Bikram Yoga as a therapeutic tool for metabolic 
dysfunction29, and depression is associated with metabolic disorders30. Another study found 
that 8 weeks of 3 weekly Bikram Yoga classes improved arterial stiffness in 24 younger adults 
(30±1 years), and significantly reduced insulin resistance in 18 older adults (53±2 years)31. The 
relationship between depressive and anxiety disorders and early markers of arterial stiffness32, 
indicates a common pathophysiology with depression. Psychologically: In an uncontrolled 
study of 54 healthy individuals, Bikram Yoga improved mindfulness and decreased stress33, 
suggesting benefits in depression via effects on mindfulness and perceived stress. In an 
unpublished dissertation, DeBoer et al.34 reported preliminary completer data of twice weekly 
Bikram Yoga classes (n=27) versus a waitlist control (n=25) for women (ages 25-45) with 
stress-induced eating and high perceived stress. This study demonstrated a dropout rate of 
11.5%, lower than in most depression trials. The 4 subjects who discontinued yoga did so in 
the initial stages of the practice. This study provided preliminary evidence of the acceptability 
of recruiting and retaining a psychiatric population for this intervention. The effect size for the 
change in the Beck Depression Inventory (BDI-II)35, based on Cohen’s d, was medium (0.54), 
suggesting an advantage for Bikram Yoga over the waitlist. As this study did not require 
depressive symptoms for entry, the effect size for depression in the proposed study will likely 
be higher. The Beck Anxiety Inventory (BAI)36 demonstrated a large effect for Bikram Yoga 
over control (d=1.19). There were also large effects for Bikram Yoga’s ability to reduce scores 
on the Ruminative Responses Scale (RRS)37 (.76), the Perceived Stress Scale (PSS)38 (.83), 
and the Response to Positive Affect Scale39 (.76). I will include the PSS and RRS in our study 
as secondary outcome measures, due to these results.  
 
Thermal Therapy for Depression: Whole-body hyperthermia is receiving attention as an 
antidepressant. A large effect size (d=1.13) was found 5-days post a single total-body 
hyperthermia session (mean time 126.7 minutes) in 16 medically healthy adults with MDD on 
the Centers for Epidemiological Studies Depression Scale (CES-D). Only 3 of the 16 subjects 
were on antidepressants (SSRIs). When the 13 SSRI-free subjects were analyzed separately, 
the effect sizes increased (d=1.4). These findings are consistent with studies of mood induced 
hyperthermia in medically ill populations23, 40. In another study, fever induction in medication-
free patients with melancholic MDD produced improvements in mood for all patients the day 
after induction, perhaps via inflammatory cytokines suppressing REM sleep, thus improving 
mood24. In another study, 28 medication-free patients with mild depression and somatic 
complaints randomized to 4 weeks of 5x/week (20 sessions) thermal therapy vs. non-thermal 
therapy (60°C for 15 minutes followed by 30 minutes of bed rest with blanket) demonstrated 
improvement in somatic and mental complaints, hunger, and relaxation21. Other preliminary 
data also support heat’s beneficial effect on mood17-19, 22. Recent data suggest that Bikram 
Yoga similarly raises core body temperature15. There is evidence for a relationship between 
thermal regulation and serotonergic neural circuits controlling cognitive function and mood41. 
Depressed patients have disruption in thermoregulatory cooling, implicated in the maintenance 
of the disease42. Bikram Yoga offers both a mechanism for understanding this interaction and 
a means of treatment. 
 
Yoga’s Effects on the Stress Response Systems: Depression is linked to the body’s 
physiological reaction to stress43. Yoga may restore homeostasis by increasing 

9 
 
parasympathetic nervous system (PNS) activity, restoring gamma-amino-butyric acid (GABA) 
activity, and reducing physiological effects of stress7. This may occur through a variety of 
mechanisms, including stimulation of the vagus nerve7, related to vagus nerve stimulation for 
depression. Hypothalamic-Pituitary-Adrenal Axis (HPA): depression is commonly 
associated with increased cortisol levels43. Across populations yoga consistently reduces 
cortisol levels47-55. Immune System Markers/Inflammatory Markers: Inflammatory processes 
have been consistently implicated in the pathophysiology of depression56. In a meta-analysis of 
dozens of studies, medically-healthy MDD patients exhibit elevated serum interleukin (IL)-6, IL-
1 (esp. IL-1-beta), and acute phase C reactive protein (CRP)57. Other studies report increased 
serum tumor necrosis factor alpha (TNF-α) in MDD patients56, 58. Expert hatha yoga 
practitioners, compared to novices, had lower levels of inflammatory markers at baseline, 
during, and after a protocol of stress induction and subsequent participation in hatha yoga59. In 
a non-randomized sample of patients with chronic diseases, inflammatory markers decreased 
after just ten days of yoga practice60. These data support our rationale for measuring HPA 
(cortisol), and immune system function (inflammatory markers) in our sample before, during, 
and after treatment. 
 
Yoga and Functional Measures: Yoga may improve quality of life and functional measures 
associated with MDD. Quality of Life: Yoga has demonstrated improvements in quality of life 
in medically ill populations 61-66. Since depression has a strong relationship with decreased 
quality of life67, yoga may be of significant benefit. Physical Functioning: Depressed people 
have impairments in physical functioning similar to common chronic physical conditions68-70. 
Additionally, those with MDD and chronic illnesses have greater risk of subsequent illness, 
disability, and premature mortality71. In a meta-analysis of older adults, yoga may hold greater 
benefits than conventional exercise for health status, aerobic fitness, and strength72. In a 
recent literature review, yoga helped improve multiple markers of physical health73.  
 
Yoga and Secondary Outcomes: Anxiety: Symptoms of anxiety are often 40-50% comorbid 
with MDD74-76. Yoga may treat anxiety, though similar to the depression and yoga literature 
base, studies are methodologically flawed77. Sleep: Sleep disturbance and depression have 
been linked to fragmentation of sleep architecture and likely share common biological 
pathways78. Experienced Bikram Yoga practitioners using transition analysis had a faster 
return to sleep after nocturnal awakenings on nights when yoga was practiced that day 
compared to non-yoga days79. Bikram Yoga may directly and/or indirectly improve mood by 
simultaneously improving sleep. Improved sleep regulation, via improved sleep efficiency and 
quality, may be a mechanism for yoga’s antidepressant effects9. 
  
3. 
STUDY DESIGN 
 
The project is an acceptability, feasibility, and pilot efficacy trial of hyperthermic yoga vs. a 
waitlist control for 80 adults with at least mild depressive symptoms. The target enrollment for 
the study will be 160 to properly screen the number of needed randomized participants. The 
hyperthermic yoga intervention will take place in two community Bikram Yoga studios in the 
Boston area. Bikram Yoga Boston is owned by Jill Koontz and Bikram Yoga Cambridge is 
owned by Lucas Lambert. Participants will attend classes at either of these studios, free of 
charge – i.e., the intervention will be community-delivered. Participants will be asked to attend 

10 
 
at least two weekly 90-minute Bikram Yoga classes during the 8-week intervention phase of 
the study. All research related assessments will take place at the Depression Clinical and 
Research Program (DCRP) at the Massachusetts General Hospital (MGH). The enrollment 
period for participants will depend upon the arm to which they are randomized: 1) immediate 
yoga group (IYG) will complete the protocol in approximately 15weeks; and 2) the control or 
delayed yoga group (DYG) will complete the protocol in approximately 24weeks.  
 
Retention Strategies: Patients with depressive symptoms frequently have impaired motivation. 
In the only known RCT of hyperthermic yoga for a psychiatric population, subjects who 
dropped out tended to do so after 1-2 sessions. Most who got through this critical period 
completed the study34. To address this: 1) study staff, the PI or designee, will administer a 50-
minute pre-yoga baseline psychoeducation session with a preparatory handout, which they 
take home with them. 2) Participants will receive a bi-weekly telephone call from the PI, and 
when not available, another study staff member. 
 
Subject Remuneration: Subjects in the DYG will be compensated for their time during the 
waitlist period ($25 for baseline; week 1, 3, 5 and 8; total=$125) to encourage participation. 
Subjects in IYG will only be paid for the 1-month follow up visit ($25), as they will receive free 
yoga classes at the outset of the study. All subjects will receive $30 per cortisol assessment.  
 
 

11 
 
4. 
SELECTION AND ENROLLMENT OF PARTICIPANTS  
 
Inclusion Criteria 
 
1. Adults ages 18-60 
2. English language proficiency 
3. Ability to provide informed consent 
4. Score of >23 on the Inventory of Depressive Symptomatology – Clinician Rated  (IDS-
CR)80 
5.  Able and willing to attend two 90-minute hyperthermic yoga sessions per week 
6. Willingness to keep existing exercise regimen (even if that is sedentary) stable over 
study course 
7. Women of childbearing potential must use an acceptable form of birth control 
8. Membership to the Bikram Yoga Boston and Bikram Yoga Cambridge studios via studio 
websites  
9. Willingness to adhere to hydration requirements (i.e., an additional four 8 oz servings of 
water pre- and post-yoga classes) 
 
4.2 
Exclusion Criteria 
1. Pregnancy or planned pregnancy during study 
2. History of psychiatric hospitalization within the past year 
3. Active suicidal intent within the past year (“yes” on item 4 or 5 on the Columbia-Suicide 
Severity Rating Scale81) 
4. History of neurologic disorders that could interfere in study participation 
5. History of bipolar disorder, psychotic disorders, eating disorders, and/or substance 
abuse or dependence (within the last year), as per the Mini-International 
Neuropsychiatric Interview (MINI)82 
6. Psychotropic medication use that has been stable for <2 months, and at a stable dose 
for <4 weeks 
7. Use of stimulant medications or diet pills during the study, or any pre-workout powders 
or liquids designed to provide excessive energy (excluding coffee or caffeinated 
beverages) 
8. Positive urine toxicology screen due to illicit drug use or other exclusionary medications. 
(Potential false positives will be addressed on a case-by-case basis at the discretion of 
the investigator) 
9. Active conditions which may also cause depressive symptoms (e.g. epilepsy, 
hypothyroidism) 
10. Medical conditions that may make participation unsafe (e.g., diabetes [I & II], 
cardiovascular disease, hypertension [>140 systolic and/or >90 diastolic], hypotension 
[<90 systolic and/or <60 diastolic, during screening], orthostatic hypotension [systolic 
drop of 20 points or 10 point diastolic or heart rate increase by 10], autoimmune 
disorders, malignancy, or autonomic dysfunction) 
11. > 6 one hour classes of meditation or other mind-body disciplines (e.g., Tai chi or yoga) 
within the last 6 months 
12. Current individual or group psychotherapy established for <3 months 
13. A subject who in the opinion of the Principal Investigator would not be able to safely 
complete the study or would jeopardize study integrity 

12 
 
14. History of heat intolerance or heat stroke  
15. Unsafe cardiac status as defined by abnormal ECG reading at screening visit as 
determined by medical monitor, study doctor, or subject’s PCP or cardiologist 
 
4.3 
Study Enrollment Procedures  
 
Recruitment: Clinician referral and advertisement for our program in local newspapers, 
internet, radio, and television; advertisements through internal research listings distributed via 
e-mail and posted online by MGH, RSVP for Health (a registry of MGH and Brigham and 
Women’s Hospital where individuals receive information about clinical trials); a listing on 
ClinicalTrials.gov; flyers posted on hospital-approved bulletin boards or in local health clinics; 
study-specific postings on Craigslist; meetings with community organizations to recruit non-
MGH patients; and study flyers posted at the Bikram Yoga Boston and Bikram Yoga 
Cambridge studios and on their websites.  
 
Procedures: A Study Coordinator will determine possible subject eligibility by phone, utilizing 
the IRB approved Depression Clinical and Research Program (DCRP) General Recruitment 
Protocol (Protocol #: 2007P002312) - once this protocol is added by an approved amendment. 
Eligible subjects will be invited for a screen visit at the DCRP, where they will complete the 
consent process with MD or PhD-level staff. Prior to coming in for the screening visit, subjects 
will be asked to sign up for an online account with both yoga studios,” through the Bikram 
Yoga Boston and the Bikram Yoga Cambridge websites. A screening log will be kept to 
document reasons for ineligibility and for non-participation of eligible subjects. Consented 
subjects who continue to meet inclusion criteria will be randomized to hyperthermic yoga or the 
waitlist control by their baseline visit.  
 
5. 
STUDY INTERVENTIONS  
 
5.1 
Interventions, Administration, and Duration  
 
The study intervention is hyperthermic yoga, and in this case, Bikram Yoga, a form of 
hyperthermic yoga. The intervention will be community-delivered (free of charge) by two local 
Bikram Yoga studios, Bikram Yoga Boston and Bikram Yoga Cambridge.  Participants will be 
asked to attend at least two weekly 90-minute classes over the course of an 8-week 
intervention period at either studio. The intervention period will be followed by a 1-month post-
intervention visit; however, during the 1-month period between the active intervention and 
follow-up visit, yoga will not be provided free to participants. Participants may continue the 
intervention at their own cost, but this is entirely of their own volition. 
 
Potential Adverse Effects: Bikram Yoga is performed in a heated room (105-110˚F), which 
may be uncomfortable. Discomfort may include cramping or feeling hot, lightheaded, dizzy, 
fatigued, or nauseous. More extreme and less frequent heat related risks include fainting, heat 
stroke, or cardiovascular events. Hydration is the best way to avoid these reactions to the heat, 
as such hydration recommendations will be provided to participants during their baseline visit 
prior to their first yoga class (i.e., an additional four 8 oz servings of water pre- and post-yoga 
classes). Bikram Yoga instructors may encourage participants to stay in the heated room 

13 
 
despite feeling overwhelmed, though they are free to leave the room – this point is emphasized 
during their baseline visit. Participation in yoga classes could also potentially aggravate old 
injuries and/or cause new injuries. Women experiencing hot flashes related to perimenopause 
or menopause may experience increased discomfort in the heated yoga room; however, there 
is no reason to believe that participation is unsafe. Stimulant and recreational drug use during 
the study may increase subject risk for heat related side effects during yoga classes (e.g., 
fatigue, nausea, dizziness). It is possible that participants may experience feelings of 
frustration and/or self-criticism due to the intensity of the exercise. 
 
 

14 
 
5.2 
Handling of Study Interventions  
 
The infrastructure of the MGH DCRP will permit blinded MD and PhD-level clinician assessors 
or psychology interns (under supervision by a licensed clinical psychologist) at no additional 
cost to the study. Any unblinded assessors (MD and PhD- level staff or psychology interns 
designated prior to the start of the study) will not have access to data nor involvement in data 
monitoring or analyses. All psychology interns are closely supervised by MD and PhD-level 
staff, and are trained in the administration and rating of depression diagnostic scales. 
 
Blinded DCRP assessors will perform primary and secondary endpoint collection. The 
research assistant welcoming the subject will remind the subject not to unblind the blinded 
assessors at each assessment visit. The research assistant will not be blinded, as they will be 
collecting attendance data from the yoga studios. If assessment visits are conducted by phone 
(on an as needed basis to reduce subject burden), blinded assessors will remind participants 
not to unblind them at the beginning of the call. 
 
5.3 
Concomitant Interventions  
5.3.1 Allowed Interventions 
Psychotropic medication use, other than stimulants, and ongoing stable psychotherapy 
(individual or group) is allowable as long as medications/psychotherapy have been stable for at 
least two months and at a stable dose for at least 4 weeks prior to screening visit.  
 
If during the study subjects require regular care (i.e., worsening depression or safety issues) 
and do not have a provider, they will be allowed to begin 3-month free follow-up psychiatric 
care at DCRP and will be discontinued from the intervention at study clinician’s discretion. 
 
5.3.2 Required Interventions 
N/A 
5.3.3 Prohibited Interventions 
Use of stimulant medications or diet pills, or any pre-workout powders or liquids designed to 
provide excessive energy are exclusionary. The consumption of coffee or other caffeinated 
beverages is acceptable. 
 
5.4 
Adherence Assessment  
Participants are asked to attend at least two weekly hyperthermic yoga classes over an 8-week 
intervention, a minimum total of 16 yoga classes. Adherence will be defined at 75% of the 
minimum prescribed dose of the study intervention – i.e., adherence means that participants 
attended at least 12 out of 16 yoga classes over the 8-week study intervention period. The two 
yoga studios track attendance via computer systems. Attendance data will be collected by 
study staff (usually a research assistant) who will either email via Send Secure email, or utilize 
Dropbox to communicate with the studio owners, Jill Koontz (Bikram Yoga Boston) and Lucas 
Lambert (Bikram Yoga Cambridge), to obtain attendance data. All yoga students, whether 
study participants or not, are required to sign in at the front desk of the studios prior to class. 

15 
 
Yoga instructors act as front desk attendants for their own classes and sign participants into 
the computer system at this time.  
 
Fidelity Assessment: The adherence of each of the two Bikram Yoga studios to the Bikram 
Yoga protocol will be established, prior to starting the proposed study and every six months 
thereafter with an adherence measure designed by Dr. Streeter. 
 
Temperature Measurement: We will measure the temperature and humidity in the three heated 
yoga rooms with HOBO Bluethooth Low Energy Temperature/Relative Humidity Data. HOBO 
MX1101 data logger measures and transmits temperature and relative humidity data wirelessly 
to mobile devices via Bluetooth Low Energy (BLE) technology. These devices will be mounted 
in each of the three rooms. Study staff will collect data prior to study initiation and quarterly 
thereafter to monitor temperature and humidity- and to store the data for later analyses. These 
devices provide wireless and time stamped temperature and humidity data to smart phone 
device. The self-contained wireless data logger works with Onset’s free HOBOmobile app for 
logger setup and data management. Data is accessible anytime from a mobile device for iOS 
or Android over a 100-foor range.  
 
6. 
STUDY PROCEDURES 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
16 
 
 
6.1.1 Immediate Yoga Group (IYG) Schedule of Evaluations 
Assessment 
V1 
V2 
V3 
V4 
V5 
V6*** 
V7 
V8 
V9 
V10 
V11 
V12 
Informed Consent Form 
X 
 
 
 
 
 
 
 
 
 
 
 
Demographics/Contact 
Information 
X 
 
 
 
 
 
 
 
 
 
 
 
Clinician-Administered 
Psychiatric History Form 
X 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
 
 
 
 
 
 
 
 
Safety Labs (collected by 
research coordinator) 
1. Blood 
2. ECG 
3. Urine drug screen 
4. Urine pregnancy test 
(Female) 
X 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
Physical Examination by 
DCRP psychiatrist 
X 
 
 
 
 
X 
X 
 
 
 
 
 
Habits Questionnaire 
X 
 
 
 
 
X 
X 
 
 
 
 
 
MINI 
X 
 
 
 
 
 
 
 
 
 
 
 
C-SSRS (lifetime and past 
year V1; since last visit all 
other visits) 
X 
 
 
 
X 
X 
X 
 
 
 
 
 
Reproductive Status 
Questionnaire (Female) 
X 
 
 
 
 
 
 
 
 
 
 
 
IDS-CR 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
HAM-D-28 
 
X 
 
 
 
X 
X 
 
 
 
 
 
Self-Rated Questionnaires: 
STAI; SF-36; Q-LES-Q; 
EIFI; PSS; PSQI; FFMQ; 
RRS, URICA 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
URICA 
 
X 
 
 
 
X 
 
 
 
 
 
 
Concomitant Medications 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
Vital Signs collected by 
research coordinator 
X 
X 
X+ 
X+ 
X 
X 
X 
 
 
 
 
 
Randomization 
 
After 
baseline 
visit 
 
 
 
 
 
 
 
 
 
 

 
17 
 
 
 
 
 
 
 
 
 
 
  
  
Psychoeducational Session 
 
X 
 
 
 
 
 
 
 
 
 
 
Waist-to-Hip Ratio 
measured by research 
coordinator 
 
X 
 
 
X 
X 
X 
 
 
 
 
 
Physiological Markers 
1. Inflammatory markers 
(blood) 
2. Cortisol (salivary)* 
 
X 
 
 
X 
X 
X 
 
 
 
 
 
Sleep Diary 
 
X 
 
 
X 
X 
X 
 
 
 
 
 
Adverse Events 
 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
Hot Yoga Beliefs Scale  
 
X 
 
 
 
X 
X 
 
 
 
 
 
Acceptability Interview  
 
 
 
 
 
X 
 
 
 
 
 
 
MINI Mood Module 
 
 
 
 
 
X 
X 
 
 
 
 
 
QIDS-C and Weekly Phone 
Monitoring Form 
-------------------------------------------------------------------------------------------> 
On weeks in between V2-V3, V3-V4, V4-V5, V5-V6 and V6-V7 
 
 
 
 
 
Pre- and Post-Yoga Scales 
(STAI State, EIFI) 
30 minutes prior to and 30 minutes post each yoga class 
 
 
 
 
 
hone 

 
18 
 
 
6.1.2 Delayed Yoga Group (DYG) Schedule of Evaluations 
Assessment 
V1 
V2 
V3 
V4 
V5 
V6*** 
V7 
V8 
V9 
V10 
V11 
V12 
Informed Consent Form 
X 
 
 
 
 
 
 
 
 
 
 
 
Demographics/Contact 
Information 
X 
 
 
 
 
 
 
 
 
 
 
 
Clinician-Administered 
Psychiatric History Form 
X 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
 
 
 
 
 
 
 
 
Safety Labs (collected by 
research coordinator) 
1. 
Blood 
2. 
ECG 
3. 
Urine drug screen 
4. 
Urine pregnancy 
test (Female) 
X 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
Physical Examination by 
DCRP psychiatrist 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
Habits Questionnaire 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
MINI 
X 
 
 
 
 
 
 
 
 
 
 
 
C-SSRS (lifetime and past 
year V1; since last visit all 
other visits) 
X 
 
 
 
X 
X 
 
 
 
X 
X 
X 
Reproductive Status 
Questionnaire (Female) 
X 
 
 
 
 
 
 
 
 
 
 
 
IDS-CR 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
HAM-D-28 
 
X 
 
 
 
X 
X 
 
 
 
X 
X 
Self-Rated Questionnaires: 
STAI; SF-36; Q-LES-Q; 
EIFI; PSS; PSQI; FFMQ; 
RRS 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
URICA 
 
X 
 
 
 
X 
X 
 
 
 
X 
 
Concomitant Medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vital Signs by research 
coordinator 
X 
X 
X+ 
X+ 
X 
X 
X 
X+ 
X+ 
X 
X 
X 
Randomization 
 
After 
baseline 
visit  
 
 
 
 
 
 
 
 
 
 
Psychoeducational 
Session 
 
X 
 
 
 
 
X 
 
 
 
 
 

 
19 
 
 
Waist-to-Hip Ratio 
measured by research 
coordinator 
 
X 
 
 
X 
X 
X 
 
 
X 
X 
X 
Physiological Markers 
1. 
Inflammatory 
markers (blood) 
2. 
Cortisol 
(salivary)* 
 
X 
 
 
X 
X 
X** 
 
 
X 
X 
X 
Sleep Diary 
 
X 
 
 
X 
X 
X 
 
 
X 
X 
X 
Adverse Events 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Hot Yoga Beliefs Scale  
 
X 
 
 
 
X 
X 
 
 
 
X 
X 
Acceptability Interview  
 
 
 
 
 
 
 
 
 
 
X 
 
MINI Mood Module 
 
 
 
 
 
X 
 
 
 
 
X 
X 
QIDS-C and Weekly 
Phone Monitoring Form 
----------------------------------------------------------------------------------------------------------------------------------------------------------
> 
On weeks in between V2-V3, V3-V4, V4-V5, V5-V6, V6-V7, V7-V8, V8-V9, V9-V10, V10-V11, V11-V12 
Pre- and Post-Yoga Scales 
(STAI State, EIFI) 
30 minutes prior to and 30 minutes post each yoga class 
over the 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
20 
 
6.2 
Description of Evaluations  
 
Figures 6.1.1 and 6.1.2 above outline a detailed description of evaluation visits. Additional 
information not included in this figure is listed below.  
 
6.2.1 Screening Evaluation 
 
Consenting Procedure 
Prior to engaging in any study related activities, informed consent will be obtained by an MD- 
or PhD-level clinician or supervised psychology intern at the DCRP. One informed consent will 
be obtained for the screening and study procedures. Patients will be informed during the 
consent process that their participation is voluntary and their relationship with their prescribing 
physician will be unaffected by any choice to discontinue study participation. All participants 
will be informed that they can decline to answer any questions that they find upsetting and may 
withdraw from study participation at any time. The consent form will include the study 
procedures, information about potential risks and benefits of participation, and information 
regarding who they can contact with further questions or concerns. Patients will be alerted to 
the nature of the hyperthermic yoga practice during the consent process. Participants will have 
24-hour pager access to an internal medicine physician, Darshan Mehta, MD, whose specialty 
is in alternative medicine. This information will be given in the consent form. Documentation of 
informed consent will be kept in the Documentation of the Informed Consent Process for 
Onsite Subject File. 
 
Visit 1: Screen – IYG and DYG 
The screening visit will last approximately 3 hours. The purpose of this visit is to determine 
study eligibility. The two Figures above (6.1.1 and 6.1.2) outline the procedures for the 
screening visit, which are the same for the IYG and DYG. All of the screening items will be 
completed prior to the baseline visit (within 21 days of the screening visit).  
 
• Informed Consent Form 
• Demographics/Contact Information 
• Clinician-Administered Psychiatric History Form  
• Inclusion/Exclusion Criteria 
• Safety Labs (i.e., blood, ECG, urine drug screen, urine pregnancy test [female] collected by 
a trained research coordinator) 
o Blood draw: A phlebotomy trained research coordinator at the DCRP will draw 11mL 
of blood (one 8mL tiger top tube and one 3mL lavender top tube). 
• Medical History 
• Physical Examination conducted by DCRP psychiatrist 
• Habits Questionnaire 
• MINI 
• C-SSRS Lifetime and Past Year 
• Reproductive Status Questionnaire (female) 
• IDS-CR 
• Self-Rated Questionnaires: STAI, SF-36, Q-LES-Q, EIFI, PSS, PSQI, FFMQ, RRS 
• Concomitant Medications 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
21 
 
• Vital signs  
• Give salivettes and instructions to bring back salivary cortisol samples to their baseline visit 
• Give Sleep Diary 
6.2.2 Enrollment, Baseline, and/or Randomization 
 
Enrollment 
Enrollment is defined as the date all of the screening criteria are met– occurring between 
screening (visit 1) and baseline (visit 2).  
 
Baseline Assessments (Visit 2 for IYG; Visits 2 and 7 for DYG) 
At this visit subjects will meet with a study clinician for a 50-minute psychoeducational (see 
First Heated Yoga Class: What to Expect) and motivational session. Subjects will be asked to 
discuss reasons for wanting to try the hyperthermic yoga and also to discuss potential barriers 
to participation.  
 
Visit 2: Baseline - IYG and DYG 
• IDS-CR 
• HAM-D-28 
• Self-Rated Questionnaires: STAI, SF-36, Q-LES-Q, EIFI, PSS, PSQI, FFMQ, RRS, URICA 
• Concomitant Medications 
• Vital Signs  
• Psychoeducational Session 
• Waist-to-Hip Ratio  
• Physiological Markers (i.e., inflammatory markers [blood], cortisol [saliva]) 
o Please see section 9.5.2 for details 
• Collect Sleep Diary (can bring to the following visit as long as it was completed for the right 
week) 
• Collect salivates (can bring to the following visit as long as it was collected at the right time 
period) 
• Adverse Events  
• Hot Yoga Beliefs Scale 
 
Visit 7: Repeat Baseline - DYG 
• IDS-CR 
• HAM-D-28 
• Self-Rated Questionnaires: STAI, SF-36, Q-LES-Q, EIFI, PSS, PSQI, FFMQ, RRS, URICA 
• Concomitant Medications 
• Vital Signs  
• Psychoeducational Session (refresher) 
• Waist-to-Hip Ratio  
• Physiological Markers^ (i.e., inflammatory markers [blood], cortisol [saliva])  
• Collect Sleep Diary (can bring to the following visit as long as it was completed for the right 
week) 
• Adverse Events 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
22 
 
• Hot Yoga Beliefs Scale 
 
^If this visit takes place within 14 days of Visit 6, Physiological Markers will not be repeated at 
this visit.  
 
At the end of the Baseline Visit that occurs before they start the yoga (V2 or V7), participants 
will be handed a packet of self-rated questionnaires (i.e. STAI-State and EIFI) to complete 
within 30 minutes prior and 30 minutes post each yoga class they attend. We will ask 
participants to note time and date on the top of each form. These questionnaires will provide 
data on acute mood changes pre- and post-yoga. Dr. Nyer’s co-mentor Dr. Streeter uses these 
questionnaires to gather the same data in her RO1 (5R01AT007483-05). Including this will 
allow us to compare data across studies.  
 
Participants will also be handed a “Yoga Information” form at the end of the Baseline Visit that 
occurs before they start the yoga (V2 or V7), which will provide information about the studio 
locations and the class logistics.   
 
Pre- and Post-Yoga Classes Scales – IYG and DYG 
• Self-Rated Questionnaires (STAI-State only, EIFI) 
 
Randomization 
Patients will be randomized prior to visit 3, assessment visit 1. Research Coordinators will 
conduct the randomization and will inform Dr. Nyer and participants of which group they have 
been randomized too at the end of their Baseline Visit, once all measures have been 
completed.  
 
6.2.3 Blinding 
The study clinician-assessors will be blinded. The research assistant welcoming the subject 
will remind the subject not to unblind the assessors at each assessment visit. Blinded 
assessors will complete all primary and secondary endpoint collection.  
 
The randomization scheme will be executed by our biostatistician who will be blinded to 
treatment assignment and will also have no influence on outcome assessments. Our 
biostatistician will establish the blind and deliver it to the designated research assistant for this 
study. The Principal Investigator (PI) will not be blinded, since the PI will be delivering the 
psychoeducation preparatory visit (pre-yoga start) and also will be performing the bi-weekly 
phone monitoring. The PI will not have access to the data until the study database is locked. 
The DSMB identified in the submission will have access to unblinded data and will monitor 
adverse and serious adverse events.  
 
Breaking the Blind: the PI, Maren Nyer, PhD, and Medical Monitor, Darshan Mehta, MD, are 
both unblinded to the intervention arm of each subject. In the event of a medical AE/SAE, Dr. 
Mehta or his designee will be responsible for assuring safety of the patient. In the event of a 
psychiatric AE/SAE, Dr. Nyer or her designee will be responsible for assuring to the safety of 
the patient.   

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
23 
 
6.2.4 Follow-up Visits 
Phone visits will occur bi-weekly from baseline through the end of the study intervention 
period. During the 1 month follow-up period, there will be a phone call during the midpoint (2-
weeks into the follow-up period).  
 
Assessment visits will be completed within a reasonable time frame (+/- 3 workday window), 
but may occur outside this window if deemed appropriate by study staff.  
 
Visit 3 (Week-1 Assessment)* – IYG and DYG 
• IDS-CR 
• Self-Rated Questionnaires: STAI, SF-36, Q-LES-Q, EIFI, PSS, PSQI, FFMQ, RRS 
• Concomitant Medications 
• Vital Signs+ 
• Adverse events 
 
Visit 4 (Week-3 Assessment)* – IYG and DYG 
• IDS-CR 
• Self-Rated Questionnaires: STAI, SF-36, Q-LES-Q, EIFI, PSS, PSQI, FFMQ, RRS 
• Concomitant Medications 
• Vital Signs+ 
• Give salivettes 
• Give Sleep Diary (can bring to the following visit as long as it was completed for the right 
week) 
• Adverse Events 
 
Visit 5 (Week-5 Assessment) – IYG and DYG 
• C-SSRS since Last Visit 
• IDS-CR 
• Self-Rated Questionnaires: STAI, SF-36, Q-LES-Q, EIFI, PSS, PSQI, FFMQ, RRS 
• Concomitant Medications 
• Vital Signs 
• Waist-to-Hip Ratio 
• Physiological Markers (i.e., inflammatory markers [blood], cortisol [saliva]) 
• Give salivettes 
• Collect and give Sleep Diary (can bring to the following visit as long as it was completed for 
the right week) 
• Adverse Events 
 
Visit 8 (Week-1 Yoga Assessment) – DYG 
• IDS-CR 
• Self-Rated Questionnaires: STAI, SF-36, Q-LES-Q, EIFI, PSS, PSQI, FFMQ, RRS 
• Concomitant Medications 
• Vital Signs+ 
• Adverse Events 
 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
24 
 
Visit 9 (Week-3 Yoga Assessment) – DYG 
• IDS-CR 
• Self-Rated Questionnaires: STAI, SF-36, Q-LES-Q, EIFI, PSS, PSQI, FFMQ, RRS 
• Concomitant Medications 
• Vital Signs+ 
• Give salivettes 
• Give Sleep Diary 
• Adverse Events 
 
Visit 10 (Week-5 Yoga Assessment) – DYG 
• C-SSRS since Last Visit 
• IDS-CR 
• Self-Rated Questionnaires: STAI, SF-36, Q-LES-Q, EIFI, PSS, PSQI, FFMQ, RRS 
• Concomitant Medications 
• Vital Signs 
• Waist-to-Hip Ratio 
• Physiological Markers (i.e., inflammatory markers [blood], cortisol [saliva]) 
• Give salivettes 
• Collect and give Sleep Diary (can bring to the following visit as long as it was completed for 
the right week) 
• Adverse Events 
 
+Note that assessment visits will in most cases take place in person, however may take place 
over the phone in extenuating circumstances to reduce subject burden or accommodate 
subject schedules. In these cases, visits may be split into two separate occasions within the 
appropriate window with clinician-rated measures taking place by phone if needed. If 
assessment visits 3, 4, 8, and 9 take place by phone, no vital signs will be obtained.  For all 
other visits blood is required for either safety procedures or outcome data.  
 
6.2.5   Completion/Final Evaluation 
 
Visit 6: Study Primary Endpoint (Week-8) for IYG and DYG (repeated for DYG in Visit 11 
as 9-week Yoga Assessment)/Early Discontinuation Visit – IYG and DYG 
• Physical Examination 
• Habits Questionnaire  
• C-SSRS since Last Visit 
• IDS-CR 
• HAM-D-28 
• Self-Sated Questionnaires (STAI, SF-36, Q-LES-Q, EIFI, PSS, PSQI, FFMQ, RRS, URICA) 
• Concomitant Medications 
• Vital Signs 
• Waist-to-Hip Ratio 
• Physiological Markers (i.e., inflammatory markers [blood], cortisol [saliva]) 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
25 
 
• Collect Sleep Diary (can bring to the following visit as long as it was completed for the right 
week) 
• Adverse Events 
• Hot Yoga Beliefs Scale 
• Acceptability Interview (completed at Visit 11 for DYG) 
• MINI Mood Module 
 
Final Evaluation: 1-Month Follow-Up Post-Yoga Visit – IYG (Visit 7) and DYG (Visit 12) 
• Physical Examination 
• Habits Questionnaire 
• C-SSRS since Last Visit 
• IDS-CR 
• HAM-D-28 
• Self-Rated Questionnaires (STAI, SF-36, Q-LES-Q, EIFI, PSS, PSQI, FFMQ, RRS) 
• Concomitant Medications 
• Vital Signs 
• Waist-to-Hip Ratio 
• Physiological Markers (i.e., inflammatory markers [blood], cortisol [saliva]) 
• Collect Sleep Diary 
• Adverse Events 
• Hot Yoga Beliefs Scale 
• MINI Mood Module 
 
Potential Reasons for Early Termination 
Subjects can be potentially dropped from the intervention due to: 1) adherence to yoga or 
assessment visits, 2) being deemed unsafe to continue the yoga intervention, 3) worsening of 
depressive symptoms, or 4) suicide risk.  
 
Please see section 8 (Intervention Discontinuation) for operational definitions of the above. 
 
 
 
 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
26 
 
7. 
SAFETY ASSESSMENTS  
Patients will be called on a bi-weekly basis to assess for AE/SAEs and worsening symptoms of 
depression and suicidality throughout the active intervention and once during the 1-month 
follow-up period. 
 
Suicide risk will be assessed through clinical interview and clinical assessment items on the 
MINI, BDI, PHQ-9 and CSSR-S. Homicidality, a less common occurrence, will be assessed as 
per all our clinical trials at the DCRP, through MD or PhD level or supervised psychology intern 
assessors trained to assess for homicidality on clinical interview. All necessary legal 
standards, including duty to protect, will be followed in the event of a serious homicidal threat. 
 
Expected AE/SAEs 
Heat related side effects could occur, including: cardiac events, cramping, dehydration, 
fainting, fatigue, heatstroke, light headedness, muscle soreness, nausea, or worsening of hot 
flashes (for peri – or menopausal women).    
7.1 
Specification of Safety Parameters 
Any abnormalities in psychiatric status, labs, vital signs, ECG, or physical exam on any 
assessment visit will be assessed for safety. Dr. Mehta (or his designee) will be responsible for 
any medical abnormalities, and Dr. Nyer (or her designee) will be responsible for any 
psychiatric abnormalities.  
7.2 
Methods and Timing for Assessing, Recording, and Analyzing Safety Parameters 
Please see section above. Any abnormalities will be addressed within a 48 hour workday 
window.  
7.3 
Adverse Events and Serious Adverse Events  
 
An adverse event (AE) is generally defined as any unfavorable and unintended diagnosis, 
symptom, sign (including an abnormal laboratory finding), syndrome or disease which either 
occurs during the study, having been absent at baseline, or if present at baseline, appears to 
worsen. Adverse events are to be recording regardless of their relationship to the study 
intervention.   
 
A serious adverse event (SAE) is generally defined as any untoward medical occurrence that 
results in death, is life threatening, requires inpatient hospitalization or prolongation of existing 
hospitalization, results in persistent or significant disability/incapacity, or is a congenital 
anomaly. 
 
Any abnormal (outside the normal range) liver function values or thyroid values will be followed 
up on and if necessary referred for appropriate clinical care.  
 
AEs that will be solicited on bi-weekly phone call (Bi-Weekly Phone Monitoring Form) will be: 
depression, suicidality, muscle soreness, or AEs/SAEs.  
 
Unsolicited events will be captured during bi-weekly phone calls (Bi-Weekly Phone Monitoring 
Form) or during assessment visits (Adverse Events Form).  

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
27 
 
 
Reporting procedures are described in section 7.4 below. 
7.4 
Reporting Procedures 
 
The PI will be responsible for the reporting of any SAEs or AEs to the IRB, DSMB, and NCCIH 
as necessary. Study-related adverse events will be reported to the IRB and NCCIH as soon as 
they are discovered by any study staff member and discussed with PI or designee (within 24 
hours). AE and SAE reports and annual summaries will not include subject- or group-
identifiable material. Each report will only include the identification code. Other adverse events 
will be reported following the rules of the Partners IRB. Short-term elevations in participant 
distress are not considered adverse events.  
SAEs that are unanticipated, serious, and possibly related to the study intervention will be 
reported to the mentorship team, Independent Monitors, IRB, and NCCIH in accordance with 
requirements. 
Unexpected fatal or life-threatening AEs related to the intervention will be reported to the 
NCCIH Program Officer within 7 days. Other serious and unexpected AEs related to the 
intervention will be reported to the NCCIH Program Official within 15 days. 
 
Anticipated or unrelated SAEs will be handled in a less urgent manner but will be reported to 
the IRB, NCCIH, and other oversight organizations in accordance with their requirements.  
 
7.5 
Follow-up for Adverse Events 
Subjects will continue to be monitored for safety after an AE/SAE has occurred until the issue 
has resolved or is considered stable. Subjects will be called or asked to come in to assess 
AE/SAEs if determined necessary by study clinician.   
7.6 
Safety Monitoring  
A data safety monitoring board (DSMB) has been assembled prior to the start of the study. The 
board consists of three staff-level investigators who are not key personnel involved with this 
grant. They are qualified to review the patient safety data generated by this study. One has 
expertise in mind-body interventions (John Denninger, MD, PhD); the second has expertise in 
clinical trial design (Andrew Nierenberg, MD); the third has expertise as a statistical consultant 
(Johannes Laferton, PhD). The DSMB will meet at least quarterly per year to review study 
progress, address any difficulties with recruitment, and address any safety related matters that 
may arise. Details of the logistics of the DSMB are as follows: 
 
a. Unblinded Reporting – Safety information for this study will be reported to the DSMB 
in an unblinded manner.  A statistical penalty will not be assessed for the ongoing 
unblinded review of safety by the DSMB. Unblinded data will not be released to the 
investigators unless necessary for safety reasons. 
 
b. Range of Safety Reporting to the DSMB – It is considered necessary for the purpose 
of monitoring the safety of the study that the DSMB review not only AEs and SAEs, but 
other data that may reflect differences in safety between treatment groups. This 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
28 
 
includes treatment retention rates, reasons for drop-out, and laboratory values reflecting 
potential danger to patient. 
 
c. Serious Adverse Events – Expedited review will occur for all events meeting the FDA 
definition of SAEs. This also includes any event that a study investigator or the DSMB 
judges to impose a significant hazard, contraindication, side effect, or precaution.  
 
d. Non-Serious Adverse Events – At periodic intervals (quarterly during the course of the 
study and then again at its completion), the DSMB will be provided with un-blinded 
summaries of the numbers and rates of adverse events by treatment group. These 
reports will include types of events, severity, and treatment phase.  Data on individual 
non-serious adverse events is not expected to be needed for this review. 
 
e. Other Safety-Related Reports – At twelve-month intervals throughout the course of 
the study, the DSMB will also receive unblinded summary reports of treatment retention 
and reasons for drop-out, by treatment arm and study phase.   
 
f. Study Stopping Rules – If at any time during the course of the study, the DSMB 
judges that risk to subjects outweighs the potential benefits, the DSMB shall have the 
discretion and responsibility to recommend that the study be terminated. 
 
 
 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
29 
 
8. 
INTERVENTION DISCONTINUATION  
 
If a subject’s overall depressive symptoms significantly increase, or if a subject develops 
suicidal intent, he/she will be evaluated by a study clinician to determine if referral for clinical 
intervention is needed. This will be determined per study clinician judgment.  
• Subjects who demonstrate an increase in the IDS total score of 25% or greater over 
baseline or whose QIDS-C score is a >16 (indicating severe depression) will be assessed 
for referral to evidence-based clinical treatment.  
• A “yes” on items 4 or 5 on the Columbia-Suicide Severity Rating Scale, a score of 3 on the 
suicidal ideation question of the QIDS-C, or a score of 3 on the IDS-CR suicide item will 
prompt assessment, and if necessary, appropriate referral.  
• If a subject reports that worsening severity is due to situational factors and there appears to 
be no acute risk of self harm or other significant worsening, they will be given the option to 
be reassessed within 72 hours (most likely via phone) to determine the safety of 
continuation.  
• Patients will also be dropped from the study if they are, in the judgment of the study 
clinician, deemed to be a safety risk, the intervention appears to making their condition 
worse, or if new information is uncovered re: an untreated condition (e.g., onset of 
substance abuse or physical condition) that would affect participation or threaten the 
integrity of the study.   
 
Disconsolation due to Non-Adherence: if a subject does not attend a yoga session for two 
weeks, he or she will be discontinued from the intervention – though he or she will be asked to 
come in for a final assessment visit. If a subject misses more than two consecutive 
assessment visits, he or she will also be discontinued from the intervention, unless there are 
extenuating circumstances communicated to the study team. Subjects will be allowed to 
continue if they are only attending one yoga class during any specified week, though this will 
be controlled for in analyses – their data will still be useful. If subjects are discontinued from 
the intervention, they will be included in the modified ITT (MITT) analyses (see section 9 
below) and invited for a Visit 6 (final exit visit).  
9. 
STATISTICAL CONSIDERATIONS  
9.1 
General Design Issues  
 
This study is a randomized controlled trial (RCT) with a waitlist control group with a crossover 
design. This is a relatively rigorous design for this stage of investigation. Double blinding is not 
possible in this study, as the participants will know whether or not they are attending the yoga 
classes. The waitlist intervention will control for time, attention during assessment visits, and 
the cyclical nature of depression for this early stage investigation.  
 
Hypotheses are clearly outlined in section 9.6 below. Primary and secondary outcome 
measures are outlined in sections 9.5.1 and 9.5.2 below. 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
30 
 
 
9.2 
Sample Size and Randomization 
Sample Size and Power Estimation: Although this study will test for statistical significance, the 
primary aim of this pilot RCT is to estimate the intervention’s effect size to conduct a more 
definitive R01 study, as is outlined in NIH guidelines for developing behavioral interventions83. 
The study was powered conservatively based on an 80% (n=64) ITT sample. Effect sizes for 
the degree of change in IDS-CR (primary outcome) were estimated for the hyperthermic yoga 
versus the control using Cohen’s d (effect size for t-test). A power analysis found that with an 
ITT sample of 64 (32 per arm), a two-tailed t-test with an alpha level of .05 will yield a statistical 
power of 79% to detect a large effect size of .70 and 50% to detect a moderate effect size 
(.50). Thus, if the effect size falls between moderate and large, power would approach 80%, 
since the evaluable sample should be between 64 and 80. Preliminary data suggested a 
moderate effect size of .54 for depression34. We predict a more robust effect size of at least 
.60-.70, as this is a larger sample recruited specifically for depressive symptoms.  
 
Randomization: Our biostatistician will establish the blind and deliver it to the designated 
Research Coordinator. Randomization will be done by random permuted block design in 
blocks of 2 and 4. This method assigns subjects to each intervention group with equal 
probability, while at the same time generating a balanced design. The random permuted block 
randomization method also protects against bias due to temporal trends (e.g., experience of 
research staff, or seasonal effect). This randomization design should balance the 
heterogeneity of the subjects between groups.  
 
9.3  
Definition of Populations 
A completer will be defined as a subject who attends: 1) a screen, 2) baseline, 3) at least one 
midpoint assessment (week-1, -3, or -5), and 4) a week-8 assessment visit. We will complete 
two analyses: 1) a completer analysis and 2) a modified ITT (MITT) analysis. The MITT will 
include those who have attended at least one post-baseline assessment visit. Our primary 
analyses utilize data from the IYG and DYG prior to the crossover. 
 
9.4 
Interim Analyses and Stopping Rules 
We are not planning to conduct interim analyses due to the small sample size of this pilot 
study. The study is powered to require the full sample to assess efficacy. We do not anticipate 
any safety considerations that would warrant early discontinuation of the study. However, in 
the event that there are a high number of SAEs, the DSMB will guide the PI and study team on 
how to best proceed.  Other study performance metrics (e.g., slow accrual, high losses-to-
follow-up, and poor quality control) will be monitored by NCCIH and the DSMB.  
 
9.5 
Outcomes  
 
The blinded assessors will collect the primary outcome of interest, IDS-CR. The Advisory 
Committee and DSMB will be unblinded.  
9.5.1 Primary Outcome   
 
Primary Outcome Measures 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
31 
 
Acceptability Interview (primary aim I): A 19-question qualitative interview assesses perception 
of ease of participation, program likeability, and perceived benefits of the yoga program. 
Adapted from DeBoer et al.34.  
Inventory of Depressive Symptomatology (IDS-CR): A valid and reliable 30-item measure that 
is designed to assess severity of depression. The questions focus on neurovegetative and 
other depressive symptoms experienced over the past seven days. Higher scores indicate 
more severe pathology. A decrease of 50% or more in the IDS-CR score is considered to be a 
positive response to treatment, while a final score of 11 or less is considered typical remission. 
9.5.2 Secondary Outcomes   
 
Secondary Outcome Measures 
Spielberger State-Trait Anxiety Inventory (STAI)84.A 40-item commonly used measure that 
distinguishes between state vs. trait anxiety.  
Hamilton Depression Rating Scale (HAM-D-28)85. A 28 item scale commonly used as an 
observational rating measure of depression presence and severity. 
Medical Outcomes Study 36-item short-form survey (SF-36)86: Assesses bodily pain, general 
health perception, vitality, social functioning, physical and emotional impediments to role 
functioning, mental health, and includes an overall physical component scale (PCS) and 
mental component scale (MCS). Used in a trial of yoga for women in breast cancer 
treatment87.  
Quality of Life Satisfaction Questionnaire-Short Form (Q-LES-Q-SF)88: A measure of 
satisfaction and enjoyment in various domains.  
Exercise Induced Feeling Inventory (EIFI)89: Assesses feeling states associated with physical 
activity: Positive Engagement, Revitalization, Tranquility, and Physical Exhaustion. Sensitive to 
changes over the course of yoga treatment90.  
The Perceived Stress Scale (PSS)38: Measures perceived level of stress. 
University of Rhode Island Change Assessment Scale (URICA): Assesses participants’ 
readiness to change. 
 
 
Psychological Mechanisms of Actions 
Sleep Diary: Includes a Stanford Sleepiness Scale rating91, in addition to tracking caffeine, 
alcohol, smoking, exercise and naps.  
Pittsburg Sleep Quality Index (PSQI)92: A commonly used and well-validated self-rated 
measure of sleep-quality and disturbance.  
The Five Facet Mindfulness Questionnaire (FFMQ)93: A self-report instrument that measures 
mindfulness; derived from factor analytic study of five independent mindfulness questionnaires. 
Ruminative Responses Scale (RRS)37: A 22-item questionnaire, which assesses depressive 
rumination style. 
 
 
Potential Moderator  
Hot Yoga Beliefs Scale: Adapted from the Acupuncture Beliefs Scale55, a 36-item self-
administered instrument that to determine positive and negative beliefs about the study 
therapy. The data from this questionnaire can be used to assess how patient beliefs and 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
32 
 
clinical improvement may impact each other. For this study, the scale's questions have been 
adapted to reflect heated yoga rather than acupuncture as the therapy of interest. 
 
Physiological Mechanisms of Action 
Salivary Cortisol87: Saliva will be collected using salivettes. To account for diurnal variation, 
four samples will be obtained prior to each cortisol assessment (nighttime [1 and 2] and waking 
[3 and 4]).  
 
Inflammatory Markers: 30 mL of blood will be drawn per visit. 3 cc and 8 cc tubes will be used. 
Tubes will be centrifuged at 1500 rpm for 10 min at 4oC. Plasma will be transferred into 2 cc 
plastic tubes, capped and frozen at -80oC until processing. Levels of IL-6 and TNF-alpha 
cytokines will be assayed using commercially available radioimmunoassay or enzyme-linked 
immunosorbent assay at the Behavioral Neuroendocrinology Laboratory at the University of 
Colorado Boulder, led by Dr. Christopher A. Lowry. Hs-CRP will be assayed at Dr. Lowry’s lab 
using immunochemiluminometric assay (ICMA). These three markers have been heavily 
implicated in the pathophysiology of depression 58, 94 and shown to improve with yoga59. Dr. 
Foster’s add-on study, supported by her Reich award, will be performing RNA-sequencing and 
analysis of the neurosteroids allopregnanolone and progesterone. The RNA-sequencing will be 
performed by Genewiz, and the neurosteroid data will be processed by the PK/PD 
Bioanalytical Core Facility located at the UC Davis Medical Center. 
 
9.6 
Data Analyses  
Statistical Analyses: Analyses will be conducted using SPSS. Full descriptive data will be 
produced. Baseline differences between the yoga and control group (demographic variables 
and depressive severity) will be assessed and controlled for as necessary. Two analyses will 
be completed: 1) an MITT and 2) a "completer" analysis. Primary analyses will only include 
data from the IYG and DYG prior to the crossover. We will conduct exploratory analyses 
including crossover DYG subjects to increase power.  
 
Missing Data: We will test whether missing data occurred randomly across conditions, in which 
case it will be handled by replacing data with the scale or sub-scale mean. Where this is not 
feasible, missing data will be imputed through maximum likelihood estimation or multiple 
imputation. If missing data is not random, advanced statistical analyses taking into account 
assumptions of various tests will be conducted.  
 
Adherence: number of heated yoga classes attended will be used as a covariate in the efficacy 
analyses to determine if participants who go to more classes demonstrate greater 
improvement in depressive symptoms.  
 
Primary Aim I: To recruit and retain adults with depressive symptoms into a controlled trial of 
hyperthermic yoga, randomizing 40 participants to each the immediate yoga group (IYG) and 
delayed yoga group (DYG; control group) with seventy-five percent retention in both groups.  
 
 
 
Hypothesis Ia: Seventy-five percent of the each group will complete a week-8  
 
 
assessment.  
 
Hypothesis Ib: Acceptability of hyperthermic yoga will be high on the Acceptability  

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
33 
 
 
 
Interview. 
 
Screening logs will reveal the proportion of eligible screened individuals enrolled in the study. 
We will track factors that make participants ineligible or unwilling to participate. The goal is 
75% retention, with enrollment defined as completing at least one post-baseline assessment 
visit.  Attendance data will be characterized descriptively and compared between treatment 
arms by chi-squared analysis. Yoga attendance will be examined as a potential covariate in 
subsequent analyses. Participants who participated in Yoga will be re-contacted at completion 
of all patient study interventions for accuracy of Yoga attendance. Patient’s will be contacted 
up to three times before they will be labeled as “Lost to Recontact” in the screening logs.  
 
Primary Aim II: To collect the Inventory of Depressive Symptomatology – Clinician Rated (IDS-
CR) scores at screening;  baseline; and weeks-1, -3, -5 and -8 to evaluate the efficacy of 
hyperthermic yoga for depressive symptoms. 
 
Hypothesis II: The IYG will have greater decreases in Inventory 
of Depressive Symptomatology – Clinician Rated (IDS-CR) scores after 8-weeks 
compared to the DYG.  
 
Response over 8-weeks defined by 50% or greater decrease on IDS-CR total; remission <11 
on IDS-CR total. Continuous variables will be analyzed by generalized mixed effect modeling, 
which impute missing values based on maximum likelihood estimates of missing parameters, 
allowing analysis of all MITT participants. A time-by-condition interaction will be analyzed to 
test the intervention’s efficacy. Relevant potential covariates (e.g., attendance) will also be 
examined. 
 
Primary Aim III: To collect (a) physiological and (b) psychological mediators of hyperthermic 
yoga in the IYG and DYG group at screening; baseline; weeks-1, -3, -5 and -8 to evaluate 
treatment response in the IYG compared to the DYG. 
 
Hypothesis IIIa: Salivary cortisol, and inflammatory markers (i.e., Tumor Necrosis Factor  
[TNF-α], Interleukin-6 [IL-6], and C-Reactive Protein [CRP]) will significantly decrease, 
following 5- and 8-weeks of hyperthermic yoga in the IYG compared to the DYG. 
Hypothesis IIIb: Perceived stress, mindfulness, and rumination will improve by 5- and 8-
weeks in the IYG compared to the DYG.  
 
Latent growth curve modeling will assess potential mechanisms of the treatment effect. The 
slope (change over time) of the mediator variables will be regressed upon the independent 
variable (condition). The slope of the dependent variable will also be regressed upon the slope 
of the mediators. This model will permit assessment of the change in mechanisms as it 
predicts the change in the dependent variables. 
 
Secondary Aim I: To collect measures of quality of life, general health, physical functioning, 
decreased perceived stress, anxiety, and sleep in the IYG and DYG at screening; baseline; 
and weeks-1, -3, -5 and -8 to evaluate hyperthermic yoga for secondary outcome measures.  
 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
34 
 
Secondary Hypothesis I: The IYG will have significant improvements in quality of life, 
general health, physical functioning, perceived stress, anxiety, and sleep compared to 
the DYG.  
 
These will be analyzed by the same methods as outlined for Primary Aim II (above).  
 
Secondary Aim II (exploratory): To evaluate the long-term effects of the yoga intervention (1-
month post intervention), while controlling for continued yoga participation. 
 
Secondary Hypothesis II: Subjects who choose to continue the yoga practice, either in the IYG 
or DYG, will have increased effects at 1-month post intervention, per the primary and 
secondary outcome measures compared to the week-8 assessment. 
 
Within-participant treatment effects will be modeled via Generalized linear modeling, assessing 
depressive symptoms (and other secondary outcomes) at 1-month post-intervention compared 
to week 8.  
 
10. 
DATA COLLECTION AND QUALITY ASSURANCE 
10.1 Data Collection Forms  
Data will be collected on the specified CRFs. The Research Coordinator will be responsible for 
collecting all self-report and other non-doctoral level staff CRFs. We will designate a blinded 
Coordinator (not the primary Research Coordinator for the study) to manage the assessment 
data vis-a-vis quality checking, entering it in the database, and assisting with analysis, as 
needed. Doctoral level staff conducting clinician-ratings and/or medical assessments will be 
responsible for completing the appropriate CRFs. Blinded assessors will complete an IDS-CR, 
the primary study endpoint. All forms will have a participant ID with no other identifying 
information, as specified in section 11.3 below.  
 
10.2 Data Management  
Self-report data provided by study subjects will be reviewed by blinded study staff for 
completeness and quality (such as multiple answers when one response is allowed) and all 
attempts will be made to solve problems prior to the subject leaving the premises. Any 
incomplete data, illegible, or questionable data provided by blinded assessors will be resolved 
through feedback with the clinician, within one day following the study visit. This study will 
utilize REDCap (Research Electronic Data Capture), a browser-based, metadata-driven EDC 
software solution and workflow methodology for designing clinical and translational research 
databases. REDCap is secured with password protection. Individual subjects’ information will 
be entered into the database using study ID numbers. No personal identifiers will be stored.   
 
 
The REDcap system will flag any remaining data quality problems (such as data values 
outside the expected range) during data entry; any problems will be resolved before the record 
is added to the database. Extensive quality control procedures for handling and assaying 
laboratory samples will be carried out to ensure complete and valid biological data. Early in the 
study and periodically throughout the period of data collection, data will be reviewed by the 
study Statistician for completeness, consistency, and other indicators of data quality in a 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
35 
 
blinded fashion. Missing data will be described but will be inexplicitly imputed in all analyses by 
using only available data. All primary endpoint data will be quality-assured and assessed by 
blinded raters. Any errors in completion will be reviewed to determine if directions or 
procedures need to be altered. In this case, permission from the IRB will be requested to 
change any procedure. If it is determined that patients are misinterpreting any instrument and 
answering incorrectly as a result, they will be given proper clarification and instruction.   
10.3 Quality Assurance  
10.3.1 Training 
All staff engaged in human subjects research are required to complete the Collaborative 
Institutional Training Initiative (CITI) human subjects training and refresher training every three 
years to be involved with human subject research. 
 
Yoga instructors and studio owners at Bikram Yoga Boston and Bikram Yoga Cambridge will 
undergo Partners IRB approved modified CITI training by the PI.  
10.3.2 Quality Control Committee  
N/A 
10.3.3 Metrics 
Missing data will be handled as specified in section 9.6. Data entry will be double checked by 
another individual.  
10.3.4 Protocol Deviations 
Protocol deviations will be collected and documented on the Protocol Deviation Log by the 
Research Coordinator, overseen by the PI. The PI and at least one member of her mentoring 
team will review these deviations for potential amendment to IRB approved protocol.   
10.3.5 Monitoring 
The DSMB, NCCIH, the Partners IRB, and/or OHRP will be monitoring the protocol 
compliance, data quality, and consent forms.  
 
10.3.6 Data Use Agreement 
In addition to the previously described samples analyses, we intend to obtain a Data User 
Agreement in order to collaborate and share data with an undergraduate student being 
mentored by Dr. Foster, whose previously approved study utilizing both assessment measures 
and biological data from the current protocol. The student is completing an undergraduate 
thesis and is affiliated with UCSI University in Malaysia, and holds an RA position at Harvard 
Medical School. The fully processed and deidentified data from this protocol with Dr Foster will 
be used for a requisite to complete his dissertation and ultimately graduation. All data will be 
securely stored in MGH Dropbox and  Harvard Medical School (HMS) O2 High Performance 
computing (HPC) cluster. The data will not be be transferred from the  HMS O2 HPC cluster. 
Upon approval of the DUA, the fully processed data in the form of graphs and summary tables 
will be transferred to UCSI servers using a secure file transfer portal using HMS resources. All 
data associated with the DUA will be de-identified. The student will be monitored and mentored 
remotely by Dr. Foster. No data will leave the HMS cluster or Boston. The data being utilized is 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
36 
 
from blood samples that are currently being processed for gene expression (RNA sequencing) 
and from clinician-rated primary outcome measures. No samples will be physically removed 
from the MGH premises. 
 
11. PARTICIPANTS RIGHTS AND RESPONSIBILITIES 
11.1 Institutional Review Board (IRB) Review  
This protocol and the informed consent document and any subsequent modifications will be 
reviewed and approved by the Partners IRB.  
 
11.2 Informed Consent Forms 
A signed consent form will be obtained from each participant. The consent form will describe 
the purpose of the study, the procedures to be followed, and the risks and benefits of 
participation. A copy will be given to each participant and this will be documented in the 
participant’s record.  
11.3 Participant Confidentiality 
Any data, specimens, forms, reports, and other records that leave the site will be identified only 
by a participant identification number (Participant ID, PID) to maintain confidentiality. All 
identifiable records will be kept in a locked file cabinet. All computer entry and networking 
programs will be done using PIDs only. Information will not be released without written 
permission of the participant, except as necessary for monitoring by IRB, the NCCIH, and the 
OHRP. 
 
11.4 Study Discontinuation  
The study may be discontinued at any time by the Partners IRB, the NCCIH, the OHRP, or 
other government agencies as part of their duties to ensure that research participants are 
protected.  
 
12. COMMITTEES 
Advisory Committee: All mentors (Drs. Fava, Mischoulon, and Streeter) will meet quarterly as 
an Advisory Committee throughout the PI’s K23 Award. The committee will provide guidance 
such that the following goals are met: 1) recruitment does not fall below 75% of projection, 2) 
treatment adherence is sufficient, and 3) authorship and future grant submission goals are 
met. Dr. Fava will oversee the PI’s formal progress evaluations. 
13. PUBLICATION OF RESEARCH FINDINGS  
The study governance includes an Advisory Committee (see 12 above). Publication of the 
results of this trial will be governed by the policies and procedures developed by the Advisory 
Committee. Any presentation, abstract, or manuscript will be made available for review by the 
sponsor and the NCCIH prior to submission.  
 
 
 
 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
37 
 
14. REFERENCES 
1. Ustun TB, Ayuso-Mateos JL, Chatterji S, Mathers C, Murray CJ. Global burden of 
depressive disorders in the year 2000. Br J Psychiatry. 2004;184:386-392. 
2. Murray C, Lopez A. The global burden of disease. Boston, MA: Harvard University Press; 
1996. 
3. Insel TR, Wang PS. The STAR*D trial: Revealing the need for better treatments. Psychiatr 
Serv. 2009;60(11):1466-1467. 
4. Cassano P, Fava M. Tolerability issues during long-term treatment with antidepressants. 
Ann Clin Psychiatry. 2004;16(1):15-25. 
5. Murphy GE, Simons AD, Wetzel RD, Lustman PJ. Cognitive therapy and pharmacotherapy. 
singly and together in the treatment of depression. Arch Gen Psychiatry. 1984;41(1):33-41. 
6. Hollon SD, DeRubeis RJ, Evans MD, et al. Cognitive therapy and pharmacotherapy for 
depression. singly and in combination. Arch Gen Psychiatry. 1992;49(10):774-781. 
7. Streeter CC, Gerbarg PL, Saper RB, Ciraulo DA, Brown RP. Effects of yoga on the 
autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, 
and post-traumatic stress disorder. Med Hypotheses. 2012;78(5):571-579. 
8. Woolery A, Myers H, Sternlieb B, Zeltzer L. A yoga intervention for young adults with 
elevated symptoms of depression. Altern Ther Health Med. 2004;10(2):60-63. 
9. Uebelacker LA, Epstein-Lubow G, Gaudiano BA, Tremont G, Battle CL, Miller IW. Hatha 
yoga for depression: Critical review of the evidence for efficacy, plausible mechanisms of 
action, and directions for future research. J Psychiatr Pract. 2010;16(1):22-33. 
10. Balasubramaniam M, Telles S, Doraiswamy PM. Yoga on our minds: A systematic review 
of yoga for neuropsychiatric disorders. Front Psychiatry. 2012;3:117. 
11. Pilkington K, Kirkwood G, Rampes H, Richardson J. Yoga for depression: The research 
evidence. J Affect Disord. 2005;89(1-3):13-24. 
12. Cramer H, Lauche R, Langhorst J, Dobos G. Yoga for depression: A systematic review and 
meta-analysis. Depress Anxiety. 2013;30(11):1068-1083. 
13. Rimer J, Dwan K, Lawlor DA, et al. Exercise for depression. Cochrane Database Syst Rev. 
2012;7:CD004366. 
14. Trivedi MH, Greer TL, Church TS, et al. Exercise as an augmentation treatment for 
nonremitted major depressive disorder: A randomized, parallel dose comparison. J Clin 
Psychiatry. 2011;72(5):677-684. 
15. Fritz ML, Grossman AM, Mukherjee A, Mukherjee A, Hunter SD, Tracy BL. Acute 
metabolic, cardiovascular, and thermal responses to a single session of bikram yoga. Talk 
presented at: Cardiovascular & Metabolic Benefits of Bikram Yoga; February 8, 2014; New 
York City, NY. 
16. Chiesa A, Serretti A. Mindfulness-based interventions for chronic pain: A systematic review 
of the evidence. J Altern Complement Med. 2011;17(1):83-93. 
17. Hayasaka S, Tsutsumi A, Noda T, Murata C, Ojima T. Effects of stone spa (ganban-yoku) 
on psychological states. Complement Ther Clin Pract. 2009;15(3):129-132. 
18. Hayasaka S, Nakamura Y, Kajii E, et al. Effects of charcoal kiln saunas (jjimjilbang) on 
psychological states. Complement Ther Clin Pract. 2008;14(2):143-148. 
19. Biro S, Masuda A, Kihara T, Tei C. Clinical implications of thermal therapy in lifestyle-
related diseases. Exp Biol Med (Maywood). 2003;228(10):1245-1249. 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
38 
 
20. Hanusch KU, Janssen CH, Billheimer D, et al. Whole-body hyperthermia for the treatment 
of major depression: Associations with thermoregulatory cooling. Am J Psychiatry. 
2013;170(7):802-804. 
21. Masuda A, Nakazato M, Kihara T, Minagoe S, Tei C. Repeated thermal therapy diminishes 
appetite loss and subjective complaints in mildly depressed patients. Psychosom Med. 
2005;67(4):643-647. 
22. Hooper PL. Hot-tub therapy for type 2 diabetes mellitus. N Engl J Med. 1999;341(12):924-
925. 
23. Koltyn KF, Robins HI, Schmitt CL, Cohen JD, Morgan WP. Changes in mood state 
following whole-body hyperthermia. Int J Hyperthermia. 1992;8(3):305-307. 
24. Bauer J, Hohagen F, Gimmel E, et al. Induction of cytokine synthesis and fever suppresses 
REM sleep and improves mood in patients with major depression. Biol Psychiatry. 
1995;38(9):611-621. 
25. Choudhury B. Bikram Yoga: The guru behind hot yoga shows the way to radiant health and 
personal fulfillment. New York, NY: Harper Collins Publishing; 2007. 
26. Gray L, Lang CW, Porges SW. Warmth is analgesic in healthy newborns. Pain. 
2012;153(5):960-966. 
27. Sherman KJ. Guidelines for developing yoga interventions for randomized trials. Evid 
Based Complement Alternat Med. 2012;2012:143271. 
28. Bussing A, Michalsen A, Khalsa SB, Telles S, Sherman KJ. Effects of yoga on mental and 
physical health: A short summary of reviews. Evid Based Complement Alternat Med. 
2012;2012:165410. 
29. Hunter SD, Dhindsa M, Cunningham E, Tarumi T, Alkatan M, Tanaka H. Improvements in 
glucose tolerance with bikram yoga in older obese adults: A pilot study. J Bodyw Mov Ther. 
2013;17(4):404-407. 
30. Butnoriene J, Bunevicius A, Norkus A, Bunevicius R. Depression but not anxiety is 
associated with metabolic syndrome in primary care based community sample. 
Psychoneuroendocrinology. 2014;40:269-276. 
31. Hunter SD, Dhindsa MS, Cunningham E, et al. The effect of bikram yoga on arterial 
stiffness in young and older adults. J Altern Complement Med. 2013;19(12):930-934. 
32. Seldenrijk A, van Hout HP, van Marwijk HW, et al. Depression, anxiety, and arterial 
stiffness. Biol Psychiatry. 2011;69(8):795-803. 
33. Hewett Z, Ransdell L, Yong G. An examination of the effectiveness of an 8-week bikram 
yoga program on mindfulness, perceived stress, and physical fitness. Journal of Exercise 
Science and Fitness. 2011;9(2):87-92. 
34. DeBoer L, Medina J, Powers M, Smits J. Yoga intervention for cortisol reactivity to stress 
and stress-induced eating. [Clinical Psychology PhD]. Dallas, TX: Southern Methodist 
University; 2013. 
35. Beck AT, Steer RA. Internal consistencies of the original and revised beck depression 
inventory. J Clin Psychol. 1984;40(6):1365-1367. 
36. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: 
Psychometric properties. J Consult Clin Psychol. 1988;56(6):893-897. 
37. Treynor W, Gonzalez R, Nolen-Hoeksema S. Rumination reconsidered: A psychometric 
analysis. Cognitive Therapy and Research. 2003;27:247-259. 
38. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc 
Behav. 1983;24(4):385-396. 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
39 
 
39. Feldman GC, Joormann J, Johnson SL. Responses to positive affect: A self-report 
measure of rumination and dampening. Cognit Ther Res. 2008;32(4):507-525. 
40. Beever R. The effects of repeated thermal therapy on quality of life in patients with type II 
diabetes mellitus. J Altern Complement Med. 2010;16(6):677-681. 
41. Lowry CA, Lightman SL, Nutt DJ. That warm fuzzy feeling: Brain serotonergic neurons and 
the regulation of emotion. J Psychopharmacol. 2009;23(4):392-400. 
42. Hale MW, Raison CL, Lowry CA. Integrative physiology of depression and antidepressant 
drug action: Implications for serotonergic mechanisms of action and novel therapeutic 
strategies for treatment of depression. Pharmacol Ther. 2013;137(1):108-118. 
43. Leuchter AF, Cook IA, Hamilton SP, et al. Biomarkers to predict antidepressant response. 
Curr Psychiatry Rep. 2010;12(6):553-562. 
44. Brown RP, Gerbarg PL. Sudarshan kriya yogic breathing in the treatment of stress, 
anxiety, and depression. part II--clinical applications and guidelines. J Altern Complement 
Med. 2005;11(4):711-717. 
45. Brown RP, Gerbarg PL. Sudarshan kriya yogic breathing in the treatment of stress, 
anxiety, and depression: Part I-neurophysiologic model. J Altern Complement Med. 
2005;11(1):189-201. 
46. Karavidas MK, Lehrer PM, Vaschillo E, et al. Preliminary results of an open label study of 
heart rate variability biofeedback for the treatment of major depression. Appl Psychophysiol 
Biofeedback. 2007;32(1):19-30. 
47. Gorman JM, Sloan RP. Heart rate variability in depressive and anxiety disorders. Am Heart 
J. 2000;140(4 Suppl):77-83. 
48. Khattab K, Khattab AA, Ortak J, Richardt G, Bonnemeier H. Iyengar yoga increases 
cardiac parasympathetic nervous modulation among healthy yoga practitioners. Evid Based 
Complement Alternat Med. 2007;4(4):511-517. 
49. Thirthalli J, Naveen GH, Rao MG, Varambally S, Christopher R, Gangadhar BN. Cortisol 
and antidepressant effects of yoga. Indian J Psychiatry. 2013;55(Suppl 3):S405-8. 
50. Michalsen A, Grossman P, Acil A, et al. Rapid stress reduction and anxiolysis among 
distressed women as a consequence of a three-month intensive yoga program. Med Sci Monit. 
2005;11(12):CR555-561. 
51. Vedamurthachar A, Janakiramaiah N, Hegde JM, et al. Antidepressant efficacy and 
hormonal effects of sudarshana kriya yoga (SKY) in alcohol dependent individuals. J Affect 
Disord. 2006;94(1-3):249-253. 
52. West J, Otte C, Geher K, Johnson J, Mohr DC. Effects of hatha yoga and african dance on 
perceived stress, affect, and salivary cortisol. Ann Behav Med. 2004;28(2):114-118. 
53. Ross A, Thomas S. The health benefits of yoga and exercise: A review of comparison 
studies. J Altern Complement Med. 2010;16(1):3-12. 
54. Rocha KK, Ribeiro AM, Rocha KC, et al. Improvement in physiological and psychological 
parameters after 6 months of yoga practice. Conscious Cogn. 2012;21(2):843-850. 
55. Vadiraja HS, Raghavendra RM, Nagarathna R, et al. Effects of a yoga program on cortisol 
rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: A 
randomized controlled trial. Integr Cancer Ther. 2009;8(1):37-46. 
56. Miller AH, Maletic V, Raison CL. Inflammation and its discontents: The role of cytokines in 
the pathophysiology of major depression. Biol Psychiatry. 2009;65(9):732-741. 
57. Howren MB, Lamkin DM, Suls J. Associations of depression with C-reactive protein, IL-1, 
and IL-6: A meta-analysis. Psychosom Med. 2009;71(2):171-186. 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
40 
 
58. Shelton RC, Miller AH. Eating ourselves to death (and despair): The contribution of 
adiposity and inflammation to depression. Prog Neurobiol. 2010;91(4):275-299. 
59. Kiecolt-Glaser JK, Christian L, Preston H, et al. Stress, inflammation, and yoga practice. 
Psychosom Med. 2010;72(2):113-121. 
60. Yadav RK, Magan D, Mehta N, Sharma R, Mahapatra SC. Efficacy of a short-term yoga-
based lifestyle intervention in reducing stress and inflammation: Preliminary results. J Altern 
Complement Med. 2012;18(7):662-667. 
61. Evans S, Moieni M, Lung K, et al. Impact of iyengar yoga on quality of life in young women 
with rheumatoid arthritis. Clin J Pain. 2013. 
62. Lakkireddy D, Atkins D, Pillarisetti J, et al. Effect of yoga on arrhythmia burden, anxiety, 
depression, and quality of life in paroxysmal atrial fibrillation: The YOGA my heart study. J Am 
Coll Cardiol. 2013. 
63. Cramer H, Lauche R, Hohmann C, et al. Randomized-controlled trial comparing yoga and 
home-based exercise for chronic neck pain. Clin J Pain. 2013;29(3):216-223. 
64. Bidwell AJ, Yazel B, Davin D, Fairchild TJ, Kanaley JA. Yoga training improves quality of 
life in women with asthma. J Altern Complement Med. 2012;18(8):749-755. 
65. Buffart LM, van Uffelen JG, Riphagen II, et al. Physical and psychosocial benefits of yoga 
in cancer patients and survivors, a systematic review and meta-analysis of randomized 
controlled trials. BMC Cancer. 2012;12(1):559. 
66. Michalsen A, Jeitler M, Brunnhuber S, et al. Iyengar yoga for distressed women: A 3-armed 
randomized controlled trial. Evid Based Complement Alternat Med. 2012;2012:408727. 
67. Trivedi MH, Rush AJ, Wisniewski SR, et al. Factors associated with health-related quality 
of life among outpatients with major depressive disorder: A STAR*D report. J Clin Psychiatry. 
2006;67(2):185-195. 
68. Strine TW, Chapman DP, Kobau R, Balluz L, Mokdad AH. Depression, anxiety, and 
physical impairments and quality of life in the U.S. noninstitutionalized population. Psychiatr 
Serv. 2004;55(12):1408-1413. 
69. Hays RD, Wells KB, Sherbourne CD, Rogers W, Spritzer K. Functioning and well-being 
outcomes of patients with depression compared with chronic general medical illnesses. Arch 
Gen Psychiatry. 1995;52(1):11-19. 
70. Schonfeld WH, Verboncoeur CJ, Fifer SK, Lipschutz RC, Lubeck DP, Buesching DP. The 
functioning and well-being of patients with unrecognized anxiety disorders and major 
depressive disorder. J Affect Disord. 1997;43(2):105-119. 
71. Gaynes BN, Burns BJ, Tweed DL, Erickson P. Depression and health-related quality of life. 
J Nerv Ment Dis. 2002;190(12):799-806. 
72. Patel NK, Newstead AH, Ferrer RL. The effects of yoga on physical functioning and health 
related quality of life in older adults: A systematic review and meta-analysis. J Altern 
Complement Med. 2012;18(10):902-917. 
73. Sengupta P. Health impacts of yoga and pranayama: A state-of-the-art review. Int J Prev 
Med. 2012;3(7):444-458. 
74. Fava M, Rankin MA, Wright EC, et al. Anxiety disorders in major depression. Compr 
Psychiatry. 2000;41(2):97-102. 
75. Zimmerman M, Chelminski I, McDermut W. Major depressive disorder and axis I diagnostic 
comorbidity. J Clin Psychiatry. 2002;63(3):187-193. 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
41 
 
76. Sanderson WC, Beck AT, Beck J. Syndrome comorbidity in patients with major depression 
or dysthymia: Prevalence and temporal relationships. Am J Psychiatry. 1990;147(8):1025-
1028. 
77. Li AW, Goldsmith CA. The effects of yoga on anxiety and stress. Altern Med Rev. 
2012;17(1):21-35. 
78. Bianchi M, Nyer M. Sleep deprivation and psychiatric disorders. In: Bianchi M, ed. Sleep 
deprivation and disease: Effects on the body, brain, and behavior. New York: Springer; 
2014:65-76. 
79. Kudesia RS, Bianchi MT. Decreased nocturnal awakenings in young adults performing 
bikram yoga: A low-constraint home sleep monitoring study. ISRN Neurol. 2012;2012:153745. 
80. Rush AJ, Giles DE, Schlesser MA, Fulton CL, Weissenburger J, Burns C. The Inventory for 
Depressive Symptomatology (IDS): Preliminary findings. Psychiatry Res 1986; 18:65– 87. 
81. Posner K, Brown GK, Stanley B, et al. The columbia-suicide severity rating scale: Initial 
validity and internal consistency findings from three multisite studies with adolescents and 
adults. Am J Psychiatry. 2011;168(12):1266-1277. 
82. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric 
Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric 
interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 Suppl 20: 22-33. 
83. Rounsaville BJ, Carroll  KM, Onken LS. A stage model of behavioral therapies research: 
Getting started and moving on from stage I. Clin Psychol Sci Pr. 2001;8:133.  
84. Spielberger C, Gorsuch R, Lushene R, Vagg P, Jacobs G. Manual for the state-trait anxiety 
inventory. Palo Alto, CA: Consulting Psychologists Press; 1983. 
85. Ware JE,Jr, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A. Comparison of 
methods for the scoring and statistical analysis of SF-36 health profile and summary 
measures: Summary of results from the medical outcomes study. Med Care. 1995;33(4 
Suppl):AS264-79. 
86. Chandwani KD, Perkins G, Nagendra HR, et al. Randomized, controlled trial of yoga in 
women with breast cancer undergoing radiotherapy. J Clin Oncol. 2014. 
87. Endicott J, Nee J, Harrison W, Blumenthal R. Quality of life enjoyment and satisfaction 
questionnaire: A new measure. Psychopharmacol Bull. 1993;29(2):321-326. 
88. Gauvin L, Rejeski W. The exercise-induced feeling inventory: Development & initial 
validation. Journal of Sport and Exercise Psychology. 1993;15:403-423. 
89. Streeter CC, Whitfield TH, Owen L, et al. Effects of yoga versus walking on mood, anxiety, 
and brain GABA levels: A randomized controlled MRS study. J Altern Complement Med. 
2010;16(11):1145-1152. 
90. Hoddes E, Dement W, Zarcone V. The development and use of the stanford sleepiness 
scale (SSS). Psychophysiology. 1972:9:150. 
91. Buysse DJ, Reynolds CF,3rd, Monk TH, Berman SR, Kupfer DJ. The pittsburgh sleep 
quality index: A new instrument for psychiatric practice and research. Psychiatry Res. 
1989;28(2):193-213. 
92. Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment 
methods to explore facets of mindfulness. Assessment. 2006;13(1):27-45. 
93. Dennehy EB, Webb A, Suppes T. Assessment of beliefs in the effectiveness of 
acupuncture for treatment of psychiatric symptoms. J Altern Complement Med. 2002 
Aug;8(4):421-5. 

 
 
Research Protocol 
 
Version 2.0 
 
 
 
           
42 
 
94. Shelton RC, Miller AH. Inflammation in depression: Is adiposity a cause? Dialogues Clin 
Neurosci. 2011;13(1):41-53. 
95. America Yo: YMCA fitness testing and assessment manual, 4th edition. Champaign, IL: 
Human Kinetics; 2000. 
96. Streeter CC. The treatment of depression with yoga and walking. 2012;5R01AT007483-02 
(745,798).