Yoga for psychiatry and mental health: an ancient practice with modern relevance.

Although yoga in modern society has been often thought of as a form of physical exercise, traditionally, yoga practice has been a multicomponent discipline involving postures and physical exercises, breath regulation techniques and the control of attention and enhancement of mindful awareness through the practice of meditation. These practices are often accompanied by a distinct psychology and philosophy in the practice of a “yoga life-style.” Historically, the practice of yoga was a spiritual discipline whose goal was spiritual advancement and these component practices were intended to create an ideal state of psychophysiological health and optimal functioning of body and mind in support of contemplative states of consciousness. However, in modern society, these yoga practices have often been used in a more limited application in order to maintain physical fitness and psychological well-being and also as a therapeutic intervention for psychological and medical disorders, or so called “yoga therapy,” both of which have become highly popular in the general public internationally.[1] Documented evidence for the systematic use of yoga as therapy appears in the early 20th century in India,[2] and the popularity of yoga therapy has grown steadily both in India and internationally. Scientific research studies on the psychophysiological benefits of yoga practice also date back to the early 20th century,[3] and this growing body of research reveals that some of the most consistent and reproducible effects of yoga practice include stress reduction, emotion regulation, improved mood and well-being, improved cognitive functioning, enhanced respiratory function, improved physical flexibility, muscular strength and neuromuscular performance.[4] These studies have provided hints as to the possible mechanisms of action of yoga in patient populations. Many of these outcomes, especially those relating to stress and mood, are influencing key risk factors or contributors to severity of a wide variety of disorders and these are likely to account for a significant part of yoga's therapeutic benefit. However, it is also believed that specific yoga practices may be of particular efficacy for specific disorders, e.g., the improvement in negative rumination in anxiety and depressive disorders with the practice of meditation. Furthermore, the overall enhancement of physical and mental fitness from yoga practice is likely to provide additional reduction in disease severity through a number of indirect pathways. Yoga therapy research began much more recently. The first study of yoga in a population including psychological conditions appeared in the Journal of the Yoga Institute in 1971 and reported on improvements in symptoms of patients with anxiety, depression and schizophrenia.[5] Notably, the prominent Indian Psychiatrist Professor N.S. Vahia and colleagues published several papers on yoga for psychological conditions in 1972-3, including studies published in the Indian Journal of Psychiatry and elsewhere, in which he presented the rationale for the use of yoga as therapy[6] as well as the results of clinical application of yoga to hundreds of patients in Mumbai.[7,8,9,10,11] His stated rationale still holds value in modern yoga therapy research: “It may be stressed that the psychophysiological therapy represents a new approach to the treatment of psychiatric disorders. Most of the current psychotherapeutic methods aim at adjustment to society - i.e., the interaction with the environment should be such as to result in getting pleasure and avoiding pain. According to Patanjali (Vivekananda, 1966), it is this preoccupation with the environmental gratifications and frustrations that is the root cause of many psychiatric disorders. In this therapy, the object is to remove or at least reduce this preoccupation. The aim is self-realisation - A better integration of personality resulting in actualization of one's creative potentialities.”[9] Yoga therapy research is a rapidly growing field and research on psychological conditions has been one of its major subfields.[12,13] The majority of yoga for mental health research has focused on depression and/or anxiety and the literature has grown to the extent that reviews of this literature are now being published.[14,15,16,17,18] This is not surprising given the dominance of these two disorders in psychiatry and in the general public. In addition to a rapid growth in quantity of research on yoga for mental health conditions, the quality of the clinical trials has also been improving. Furthermore, the efficacy of yoga for a variety of disorders not previously examined has begun to be evaluated and the results are somewhat surprising. Just 10 years ago the idea of yoga as a treatment for conditions such as schizophrenia would have been considered questionable at best. We now have yoga research studies on post-traumatic stress disorder, schizophrenia, obsessive-compulsive disorder, addictive behaviors, attention-deficit disorders and even autism.[19,20,21] The author of one recent review paper of yoga for mental health conditions[21] that received widespread media attention asserted in a US television interview that “If there was a drug that could mimic the effects of yoga, it would probably be the world's best-selling drug,” and that “it should be a national priority to do more studies of yoga.” http://www.cbsnews.com/video/watch/?id=50140580n CBS News, Feb. 6, 2013. This special issue on yoga for psychiatric conditions is therefore timely and also appropriate in the Indian Journal of Psychiatry given the Indian origins of yoga, the significant number of Indian researchers who have contributed to this field and the history of yoga research publications in this journal. There are over a dozen yoga research reports in this special issue and not surprisingly, six of them evaluate yoga in depression, consistent with the prevalence of yoga therapy studies on depression in the existing literature. Aside from basic efficacy studies, it is encouraging to see that three of these studies have included biochemical outcome measures that may provide more objective measures of benefit and possibly information on mechanisms of action. Studies on yoga for ADHD, epilepsy and sleep quality in this issue provide valuable new contributions to disorders which still have few preliminary yoga studies published. Reports evaluating the effects of yoga on cognitive impairment and brain imaging are also welcome contributions and supplement a popular and growing field of research on meditation practices with these outcomes. Finally, the randomized controlled trial on yoga for psychotic patients was conducted with significant sample size and is, to my knowledge, the first published, systematic evaluation of yoga for this disorder. Yoga practices have a place in the healthcare system as a treatment for a variety of psychiatric conditions, at least as an adjunctive if not as a primary therapy. However, I believe the strongest contribution to mental health would be the preventive application of yoga in society in general, given what we know about the excellent benefits of yoga practice on risk factors for psychiatric conditions. It is clearly more cost-effective and efficacious to prevent mental health diseases, than to treat them once they have manifested as clinically significant conditions. I look forward to a future in which yoga practices are applied as a routine hygienic practice within our educational system, which will require the completion of a supportive body of research that justifies this inclusion.[22,23,24] Ultimately, yoga deserves to become an integrated and universal mind-body practice in our modern culture.