Prescribing Yoga for Mental Wellness: Need for a Nuanced Approach

Yoga is a 5000-year-old practice from India that originated as a spiritual practice. The term “yoga” is derived from the Sanskrit word “Yuj,” meaning union. ¹ Yoga is done by stretching and forming positions with one’s body while achieving self-realization and reducing bodily and mental suffering. Yoga aims to unite an individual’s soul with absolute reality and is rapidly gaining popularity. ² It has become a well-known lifestyle intervention for most psychiatric illnesses. ³

Modern yoga practices in the west include physical postures (asanas), breathing techniques (pranayama), and meditation (dhyana). The National Institute of Health in the USA recently categorized Yoga as a complementary and alternative medicine technique. ⁴ In the west, Yoga is often interpreted as a form of exercise and relaxation, while in other regions of the world, it is seen as a more comprehensive way of living that balances the body and thus encourages a healthy mind. ⁵

Therefore, studies examining Yoga’s advantages for psychiatric disorders have increased. A slogan from an advertisement states, “To thrive in your work life, the knowledge and skills of meditation and mindfulness are a necessity in the current lives we live.” We must investigate the background of such information lest this assertion be deemed exaggerated. Innumerable people are following the trend of Yoga to increase their strength and flexibility, and many self- proclaimed yogis are on the internet.

Yoga in Different Populations: A Critical Appraisal

Benefits of     Yoga in Nonpsychiatric Populations

In patients with certain neurodegenerative diseases, Yoga has possible beneficial effects on memory, anxiety, depression, and stress.^{6, 7} Because many case studies lacked a control group, it is difficult to say whether the outcomes are attributable to the yoga intervention. Some research used yogic intervention in conjunction with medicine, physical activity, or soothing music to study changes in biological markers, making it challenging to quantify the impact of Yoga alone. ⁸ Because of these limitations, the effects of Yoga on mental health warrant further extensive research.

Yoga has physiological benefits, too. A study that trained the participants in yoga poses, breathing techniques, and relaxation revealed a statistically significant increase in the vital capacity of smokers, people with asthma, and those without any underlying lung disease. ⁹ In a different study, young adults were enlisted and given the option of enrolling in the control group’s two one-hour yoga sessions per week for five weeks or being put on a waitlist. It found that the yoga group had lessened anxiety and depressive symptoms and also mentioned a decrease in weariness and levels of pessimism. ¹⁰

Yoga enhances mental wellness in those with mental illness and healthy individuals. Yoga significantly increased psychological well-being and positive mental health among healthy individuals compared to no intervention, according to a systematic review of 17 randomized controlled trial (RCTs). ¹¹ In a study among healthy volunteers conducted in Japan, salivary amylase was checked before and after Yoga. ¹² A decrease in salivary amylase indicated a reduction in sympathetic response and signified the ability of Yoga to reduce immediate and long-term anxiety.

Research on Yoga and Mental Health

Asanas and pranayama are the two forms of Yoga most frequently studied in schizophrenia. ³ An RCT showed that Yoga improves attention in schizophrenia compared to physical exercise. ¹³ However, a Cochrane review found only minimal differences between Yoga and nonstandard care in schizophrenia and that the studies are mainly single group studies with limited sample sizes and short-term follow-up. ¹⁴ As an add-on therapy in schizophrenia, Yoga improves the quality of life (QOL), cognitive skills, and negative symptoms. ¹⁵ For patients and caregivers of outpatients with functional psychotic disorders, yoga could be beneficial, and in an RCT, yoga significantly reduced burden scores and improved QOL compared to the waitlist controls. ¹⁶ The treatment of illnesses for which it is determined that the current treatments are insufficient or pose substantial risks may benefit most from findings in favor of alternative and supplementary strategies. Yoga may be an effective, much less toxic supplemental treatment option for severe mental illness, as current psychopharmacologic therapies are linked to an increased risk of weight gain and other metabolic side effects that raise patients’ risk for cardiovascular disease. ¹⁷ Though no clear recommendations can be made based on available evidence, in a narrative review, Sathyanarayanan and others reported that cognition and functioning improved and general psychopathology scores decreased while performing Yoga. ² There is also an advantage in both negative and positive symptoms. ¹⁸ Although the evidence base for mindfulness-based approaches are sparse, available research suggests that it can help reduce psychotic symptoms, enhance functioning, and regulate affect. Both Yoga and mindfulness have been shown to significantly lessen the intensity of depressive symptoms in patients with MDD. ¹⁹

Life-threatening physical disorders are associated with significant comorbid psychopathology. In individuals with cancer, depression and anxiety symptoms are reduced with yoga interventions. ¹⁷ A systematic review of RCTs on women with breast cancer looked at 24 studies with a total of 2166 participants and found that Yoga is superior to no therapy or psychosocial interventions in terms of enhancing health-related QOL, reducing fatigue, decreasing sleep disturbances, and lowering depressive and anxiety symptoms. ²⁰ A systematic review that looked at 12 RCTs involving 619 participants who had depressive disorders found some evidence that Yoga produces short-term benefits compared to conventional therapy. ²¹ In a systematic review of six RCTs, including 375 pregnant women, prenatal yoga therapies were shown to be beneficial in at least partially lowering depressive symptoms. ²² The depressive symptom scores were significantly decreased in the integrated yoga group, which comprised pranayama, meditation, or deep relaxation besides physical exercises.

In an internet survey, patients diagnosed with bipolar disorder provided information about the risks and benefits associated with yoga practices. ²³ The most frequently used styles were Hatha and vinyasa, and participants reported positive emotional effects, with reduced anxiety, beneficial cognitive effects, increased energy, and weight loss. Reported adverse events were physical injury and pain. ²³ A Canadian randomized, single-blind, crossover study found that Yoga with psychoeducation, as an add-on therapy, may improve residual symptoms of unipolar and bipolar depression. ²⁴

Change in Perception about Yoga

Before 2015, some viewed Yoga as a fad and it was not even thought of as a valuable form of exercise. Detractors have been disproven since Yoga has taken root in the wellness sector and has been recognized through International Yoga Day. The International Day of Yoga is celebrated worldwide annually on June 21 since 2015, following its inception in the United Nations General Assembly in 2014.

Yoga can be done at home also with minimal equipment and clothing; however, people may face difficulties in learning or practicing yoga due to the requirement for proper instructors and need for training time. In specific settings, attending yoga sessions and paying instructor fees may be difficult for low-wage and long-shift workers. Most yoga studios in western countries charge high membership fees. However, accessing yoga teaching sessions through online platforms may be more economically and logistically feasible, particularly during the COVID-19 pandemic. Online Yoga has ameliorated post-traumatic stress symptoms in women who have experienced stillbirth. ²³

Unwanted Effects of    Yoga

However, Yoga may not be a perfect fit for everyone. Not all yogic practices are suitable for all medical and psychiatric disorders. Pregnant women should not perform rigorous asanas in supine or prone positions. Asanas like Trikonasana, Virabhadrasana, Utkatasana, or Padmasana are contraindicated for those with knee pain. Inversion asanas such as Downward Dog, Sarvangasana, Handstand, or Setu Bandhasana are not recommended for hypertension as they may burden the heart.^{24, 25}

Adverse outcomes of yoga practices, such as injuries, have also been reported. A cross-sectional survey found that one in five yoga participants reported at least one acute adverse effect, and one out of 10 reported a chronic negative impact. ²⁴ The adverse events were mainly musculoskeletal and occurred when individuals performed specific complex postures of the hand, shoulder, and headstands. The probability increased when Yoga was practiced under self-supervision rather than with a professional. In an in-person survey conducted in India with more than 3000 people, though almost 95% reported benefits of Yoga (e.g., better physical fitness, mental state, and cognitive functions), less than 2% reported adverse effects, including soreness, pain, muscle injuries, and fatigue. ²⁵ In a study by Telles and others, 58 respondents (1.9%) reported adverse effects of Yoga. As a group, soreness and discomfort (n = 31; 0.99% of all respondents), muscle injuries (n = 7; 0.22% of all respondents), and fatigue (n = 4) accounted for the majority of the adverse effects reported. ²⁵

Use of   Yoga for Mental Health

Technically, we can learn and practice Yoga alone. However, to become proficient practitioners, we need to invest more time and money in this for adequate supervision and mentoring from a yoga expert. Otherwise, we have a higher chance of suffering disadvantages rather than advantages. We believe finding a structured online course is the best and easiest strategy for learning Yoga. Books, YouTube videos, online yoga classes, yoga studios, and private 1-on-1 sessions are the most popular ways to learn Yoga independently or at home.

First, those with chronic illnesses should observe caution and only enroll in yoga classes given by qualified instructors. Standard yoga classes might not be as beneficial as programs specifically designed for yoga therapy. People with pre- existing chronic ailments may find it wise to have a more in-depth conversation with their doctor or health professional before starting a yoga practice. In addition, it is suggested that people with specific conditions avoid taking certain professions that require involvement or adoption of specific complex postures (e.g., those with hypertension or glaucoma should avoid inversion poses, and individuals with joint problems should avoid extreme twists). Certified yoga instructors lower the possibility of adverse effects on yoga practitioners. Yoga beginners should practice under supervision and only independently after feeling confident and comfortable. ¹⁶

Conclusion

Yoga offers benefits by way of improving mental health of healthy adults and people with mental disorders, mainly when used with other therapies. Many mental health professionals frequently suggest adjunctive yoga for people with psychiatric conditions as a lifestyle change. Yoga is recommended to patients with mental illness, but this recommendation is quite ambiguous because Yoga is not covered in depth in the current postgraduate psychiatry curriculum. For persons with mental illnesses to benefit as much as possible from Yoga, it is necessary to include Yoga in the psychiatry curriculum to enhance the understanding of medical graduates and postgraduates. Yoga’s effectiveness in treating psychiatric problems is supported by some research, with some evidence that it is significant. Further randomized trials and follow-up studies in different sociocultural settings would be beneficial to position yoga in the therapeutic armamentarium for mental disorders.