Alternative and Complementary Therapies: A Review Exploring the Role of Yoga and Ayurveda-based Herbal Medicines in Alleviating Hypothyroidism and Its Neuropsychiatric Manifestations

Abstract

Background

Hypothyroidism is the most prevalent endocrine disorder characterised by low thyroid hormone production, leading to a wide spectrum of cognitive and neuropsychiatric manifestations such as fatigue, depression, anxiety, cognitive impairment, peripheral neuropathy, Parkinsonism, tremor, ataxia, seizures and dementia. Although conventional treatment with levothyroxine replacement remains the standard of care, neuropsychiatric symptoms often persist, highlighting the need for safer and more effective alternative therapeutic strategies.

Purpose

This narrative review aims to explore the effects of yoga-based interventions and Ayurveda-based herbal medicines in mitigating hypothyroidism and related neuropsychiatric symptoms.

Methods

A comprehensive literature search was conducted across PubMed, Scopus, Cochrane and Google Scholar. Studies examining the effects of yoga practices (asanas, pranayama, meditation) and Ayurveda-based herbal medicines such as Withania somnifera, Coriandrum sativum, Melissa officinalis, Commiphora wightii and other adaptogenic herbs on levels of thyroid hormones and neuropsychiatric outcomes of hypothyroidism were selected and included.

Results

Emerging evidence suggests that yogic interventions improve thyroid function and mental well-being by modulating the hypothalamic–pituitary–thyroid axis and neuroendocrine pathways. Ayurveda-based herbal medicines have been shown to exhibit antioxidant, anti-inflammatory and adaptogenic properties, contributing to enhanced thyroid function and neuroprotection. However, most studies are limited by small sample sizes, heterogeneity in intervention protocols, lack of standardisation and short follow-up periods, restricting the reproducibility and generalisability of study findings.

Conclusion

Holistic interventions such as yoga and Ayurveda-based herbal medicines may offer potential benefits in managing hypothyroidism and addressing its neuropsychiatric manifestations. However, current evidence remains preliminary and heterogeneous. High-quality, randomised controlled trials with standardised protocols are necessary to substantiate these findings and assess their efficacy, safety, long-term outcomes and clinical relevance.

Keywords

Hypothyroidism yoga mind–body interventions Ayurveda neuropsychiatric symptoms

Introduction

Hypothyroidism is among the most prevalent thyroid gland disorders, characterised by insufficient production of thyroid hormones, affecting people worldwide, with overt hypothyroidism (OH) affecting 1%–4%, whereas subclinical hypothyroidism (SCH) affects 4%–40% of individuals.¹ OH is characterised by high serum thyroid-stimulating hormone (TSH) levels with low serum triiodothyronine (T3) and thyroxine (T4) levels, whereas SCH involves elevated TSH with normal serum T3 and T4 levels.²

Population-based studies have reported that the prevalence of SCH among adults ranges from 5% to 10%.^{3, 4} Hypothyroidism can lead to various metabolic dysfunctions and manifests as a spectrum of neuropsychiatric symptoms, including fatigue, weight gain/obesity, cold intolerance, dysphoria, stress, anxiety, depression, cognitive decline, peripheral neuropathy, Parkinsonism, ataxia, tremor, seizures, dementia and impaired quality of life (QoL).^5–7

Conventional management typically involves lifelong thyroid hormone replacement therapy; however, many patients continue to experience residual symptoms or adverse effects associated with synthetic medications.^{8, 9} In this context, there is a growing interest in complementary and alternative therapies, particularly yoga and Ayurveda, which have been historically practiced in India as a holistic health measure.

Yoga, rooted in Hatha yogic texts, is an ancient Indian mind–body discipline that integrates shatkarma (cleansing techniques), asana (various physical postures), pranayama (breathing exercises), bandha (neuromuscular locks), mudra (seal or gestures), pratyahara (withdrawal of the senses), dharana (concentration or mindfulness) and dhyana (meditation), to improve holistic health and promote overall well-being.^{10, 11} Meanwhile, Ayurveda, an ancient system of medicine from India, focuses on balancing the vitiated doshas, dhatus and malas, thereby addressing the root causes of disease, supporting health and preventing illness.¹² Both practices mentioned above offer unique approaches to enhance physical and mental health, potentially reducing all metabolic and neuropsychiatric symptoms associated with hypothyroidism. These are perceived as safer and potentially complementary and alternative approaches to modern pharmacotherapy, with a lower risk of adverse effects of synthetic drugs or rebound withdrawal symptoms. Yoga motivates individuals to adopt a more active lifestyle rather than remaining sedentary.

This review aims to explore the existing literature on the effects of yoga and Ayurveda-based herbal medicines in managing hypothyroidism and its related neuropsychiatric symptoms. This article synthesises current evidence to provide a comprehensive overview of how yoga and Ayurveda-based herbal medicines may serve as valuable adjuncts in the holistic management of hypothyroidism, exploring the way for more personalised and effective therapeutic interventions.

Neuropsychiatric Manifestations of Hypothyroidism

Thyroid hormones play a significant role in the development and functioning of the central nervous system (CNS). In peripheral tissues, biologically inactive T4 is converted into its active form, T3. T3 then binds to nuclear receptors in brain glial cells and osteoblastic cells in bone, where it regulates gene transcription. This interaction activates the nuclei and endoplasmic reticulum within these cells to drive key metabolic processes, including gene expression, protein and lipid synthesis and calcium storage. These functions are essential for maintaining cellular health and overall homeostasis in the brain.¹³ In adults, thyroid dysfunction, particularly hypothyroidism, is associated with a spectrum of neuropsychiatric disorders, including mood and cognitive disturbances, fatigue, depression, anxiety, stress, peripheral neuropathy, Parkinsonism, tremor, seizures and dementia.^{14, 15}

Hypothyroidism and Cognitive Impairment

The prevalence of cognitive impairment has been reported as 27.3% in adults with hypothyroidism and 30.09% in individuals with SCH.^{16, 17} Cognitive impairment involves a decline in mental functions, including memory, thinking, reasoning, decision-making, problem-solving and the ability to perform daily activities smoothly. The prefrontal cortex of the brain is responsible for cognitive functions such as decision-making and problem-solving. Previous research has shown that decreased cerebral blood flow in the prefrontal cortex is associated with cognitive impairment, particularly in the early stages of cognitive decline.¹⁸ Conversely, the hippocampus, a brain region rich in thyroid hormone receptors (THRs), plays a central role in learning, memory and emotional regulation. Elevated TSH levels in SCH and OH are associated with hippocampal atrophy and altered hippocampal metabolite profiles, leading to impaired brain function and an increased risk of neuropsychiatric conditions.^{19, 20}

Throughout history, various theories have emerged explaining neurocognitive impairments related to hypothyroidism. In hypothyroidism, deficiency of thyroid hormone transporters, such as the monocarboxylate transporter (MCT) and the organic anion-transporting polypeptide (OATP1C1), results in various neurocognitive impairments.^{21, 22} Additionally, decreased cardiac output and reduced blood flow to the temporal lobe and thalamus in hypothyroidism lead to decreased cerebral perfusion, which increases the risk of adverse effects on brain regions responsible for memory and various neurocognitive functions.^{14, 23} In age-related hypothyroidism, the increased transport of liver-derived apolipoprotein E (ApoE4) into exosomes and into the brain leads to elevated cholesterol levels in neural cells, triggering neuroinflammation and impairing cognitive function, locomotion and mood regulation.²⁴

Hypothyroidism and Mood

Thyroid hormones influence mood and behaviour by affecting the activity of neurotransmitters, particularly serotonin and norepinephrine systems.²⁵ In hypothyroidism, levels of 5-hydroxytryptamine (5-HT) metabolite and 5-HT_1A auto-receptor activity are increased in the brainstem, and levels of 5-HT and 5-HT_2A receptor density are decreased in the cortex. These changes lead to a decrease in serotonin synthesis, release and turnover.²⁶ Hypothyroid patients have increased plasma levels of norepinephrine and decreased adrenergic stimulation and responsiveness to catecholamines, leading to limited metabolic responses.²⁷

Hypothyroidism and Depression

The incidence of depression in SCH is 10%–40%, whereas in OH it is 4%.²⁸ Women with hypothyroidism were found to be 3.13 times more prone to developing depression.²⁹ Approximately 280 million people across the globe are affected by depression.³⁰ Hypothyroidism contributes to a decrease in somatostatin and serotonergic endocrine responses, influencing the hypothalamic–pituitary–adrenal (HPA) and hypothalamic–pituitary–thyroid (HPT) axes, which play a significant role in increased susceptibility to depression.^{1, 28} A study reported that severe hypothyroidism is associated with reduced brain activity, cerebral blood flow and cerebral glucose metabolism, and the patients were more depressed and anxious.³¹ Depression is associated with dysregulation of various inflammatory and neurotrophic factors, including elevated levels of several cytokines, including interleukin-6 (IL-6), soluble IL-6 receptors (SIL-6R), interleukin-1 beta (IL-1β), tumour necrosis factor-alpha (TNF-α), interferon-gamma (IFN-γ), interleukin-10 (IL-10), interleukin-2 (IL-2) and soluble IL-2 receptors (SIL-2R). Additionally, increased concentration of inflammatory markers such as C-reactive protein (CRP), monocyte chemoattractant protein-1 (MCP-1) and serum amyloid A1 (SAA1) has been observed, along with alterations in metabolites of the kynurenine pathway. Furthermore, decreased availability of brain-derived neurotrophic factors (BDNF), tryptophan and monoamines (dopamine, serotonin and noradrenaline) has been observed in depression.^{30, 32}

Hypothyroidism and Anxiety

Previous studies have reported that the prevalence of anxiety among hypothyroid individuals is 63% in India and Iran and 52% in China.^33–35 Furthermore, women with hypothyroidism were found to have a 2.37 times higher risk of suffering from anxiety.²⁹ Anxiety involves persistent, excessive and unrealistic worry about things. Pathophysiology of anxiety involves disruptions in neurotransmitters (specifically monoamines), cortisol and gamma-aminobutyric acid (GABA).^{36, 37} Monoamine and GABA deficiency are associated with the development of anxiety. Intracellular T3 regulates the levels of serotonin and norepinephrine, enhancing their physiological effects. Decreased intracellular T3 in hypothyroidism impairs the activity of serotonin and norepinephrine systems, contributing to the development of anxiety.³⁸ Furthermore, in hypothyroidism, elevated TSH and other metabolic variables (triglycerides (TG), total cholesterol (TC), fasting blood sugar (FBS) level, low-density lipoprotein (LDL), anti-thyroglobulin, thyroid peroxidase (TPO) antibodies and hypertension) are associated with elevated anxiety scores.³⁴ Alpha waves in the brain are associated with calm and alert states of mind, while theta waves are related to alertness and quick information processing. Both alpha and theta waves or oscillations are inversely correlated with anxiety scores.¹⁸

Hypothyroidism and Fatigue

Previous studies have shown that about one-third (33.3%) of individuals with hypothyroidism experience fatigue, and women are 2.9 times more likely than men to report persistent fatigue.^{39, 40} Fatigue is both a symptom and an illness. The perception of fatigue is subjective, encompassing both physiological and psychological factors that result in tiredness and a lack of energy. The pathophysiology of fatigue encompasses dysregulation of inflammatory cytokines, alterations in the hypothalamic regulatory circuits, disturbances in the serotonin system and disruptions in the circadian rhythm of melatonin secretion.⁴¹ Moreover, OATP1C1 is expressed at the blood–brain barrier and is associated with the transport of T4 to the brain and increased frequency of hypothyroid symptoms, including fatigue and depression.⁴²

Hypothyroidism and Peripheral Neuropathy

The prevalence of peripheral neuropathy is 10%–70% in hypothyroid patients.^{43, 44} Hypothyroidism often manifests initially as neuropathy, particularly in autoimmune thyroiditis cases. In a case report of a 60-year-old woman with severe burning feet, neurological examination showed mild sensory neuropathy, and skin biopsy demonstrated reduced intraepidermal nerve fibre density and blood examination revealed SCH. After thyroid hormone replacement therapy, she experienced a gradual and progressive decrease in neuropathic pain intensity.⁴³ Neurological examinations, in another case report of a 30-year-old man with severe hypothyroidism secondary to autoimmune thyroiditis, reported sensorimotor polyneuropathy featuring axonal degeneration and demyelination.⁴⁵ An electrophysiological study in patients diagnosed with hypothyroidism revealed increased latency and decreased amplitude of the median, ulnar, tibial and sural nerves, alongside delayed brainstem auditory evoked potential waves and increased P100 latency of visual evoked potentials, suggesting peripheral and central neuropathy in hypothyroid patients.⁴⁶

Hypothyroidism and Seizures

The prevalence of developing seizures in untreated hypothyroid patients is approximately 20%.⁴⁷ Severe cases of untreated hypothyroidism may be associated with epilepticus.⁴⁷ A seizure represents a sudden disruption of neurological function triggered by excessive, hypersynchronous neuronal discharge in the brain.⁴⁸ The most prevalent seizure pattern observed was the onset of focal seizures with progression to generalisation.⁴⁹ Thyroid hormones play a crucial role in the development and function of GABAergic neurons as well as in modulating glutamatergic neurotransmissions, and dysregulation in these is associated with epileptic seizures.⁵⁰ Thyroid dysfunction and epilepsy are both linked with mitochondrial dysfunction and oxidative stress.⁵⁰

Hypothyroidism, Tremors and Ataxia

Autoimmune hypothyroidism often features hyperkinetic movement disorders, including tremor in 20%–80%, myoclonus in 42%–65% and ataxia in 33%–65%.⁵¹ Hypothyroidism is associated with 5%–52% cases of cerebral ataxia, and it can be reversible with T4 replacement.⁵² Still, in some cases, it cannot be reversed with the treatment.⁵² A case report described a 74-year-old left-handed male with type 2 diabetes mellitus and hypothyroidism who, despite no family history of Parkinson’s, tremors and ataxia, experienced imbalance, incoordination, dysarthria and dysphagia. He was diagnosed with essential tremors by a neurologist.⁵²

Hypothyroidism and Dementia

Dementia is characterised by cognitive impairments, including orientation, memory, judgement and intellect. Dementia is associated with elevated TSH levels, while Mini-Mental State Examination (MMSE) scores are inversely associated with age.⁵³ Hypothyroidism elevates the risk of dementia, with every 6 months of elevated TSH, the risk of dementia increases by 12%.⁵⁴

Hypothyroidism and Parkinson’s Disease

Hypothyroidism elevates the risk of developing Parkinson’s disease (PD) by approximately 1.6-fold.⁵⁵ Hypothyroidism leads to a reduced number and activity of mesencephalic dopaminergic neurons, and thyroid dysfunction increases oxidative stress, reduces muscle strength and impairs physical performance, which may serve as a possible mechanism to develop PD.^{55, 56}

Methods

This narrative review conducted a comprehensive literature search across PubMed, Scopus, Cochrane Library, and Google Scholar. Studies evaluating the effects of yoga practices (asanas, pranayama, meditation) and Ayurveda based herbal interventions (such as Withania somnifera, Coriandrum sativum, Melissa officinalis, Commiphora wightii, and other adaptogens) on thyroid hormone levels and neuropsychiatric outcomes in hypothyroidism were selected and included.

Results

Ayurvedic Management of Hypothyroidism and Its Neuropsychiatric Manifestations

Ashwagandha (Withania somnifera) has adaptogenic, anxiolytic, antioxidant, anti-stress, thyroid-modulating, anti-inflammatory, neuroprotective, cognitive-enhancing and rejuvenating properties.⁵⁷ It also influences the endocrine, cardiopulmonary and CNS and can improve neuropsychiatric disorders.^{58, 59} In a preclinical study, methanolic extract of ashwagandha significantly decreased TSH and increased T3 and T4 in propylthiouracil (PTU)-induced hypothyroid rats, producing effects comparable to the standard drug Eltroxin.⁶⁰ A previous clinical study evaluating the effects of ashwagandha in hypothyroid patients reported the normalisation of thyroid hormones (T3, T4 and TSH) after 8 weeks of treatment with ashwagandha as compared with placebo.⁶¹ Other research has highlighted the beneficial impacts of ashwagandha in reducing stress and anxiety levels.^{62, 63} Moreover, several studies evaluating the effects of ashwagandha reported a significant decrease in depression, anxiety and stress.^{64, 65} Additionally, these studies revealed a reduction in cortisol levels, fatigue and improvement in sleep quality, vitality, memory and overall QoL, encompassing both physical and psychological well-being.^63–67 Overall, these investigations suggest that ashwagandha may offer a multifaceted approach to enhancing health in individuals dealing with thyroid dysfunction and associated psychiatric conditions.

Dhania (Coriandrum sativum) possesses memory-improving, anxiolytic, anti-depressant, anti-inflammatory, antioxidant, antiepileptic, anticonvulsant, antimutagenic, fatigue-alleviating, sleep-promoting and neuroprotective properties.^68–70 In a previous preclinical study on thyroidectomised male rats, coriander seed extract significantly increased total T3, decreased TSH and T4 and reduced testicular oxidative stress, suggesting partial thyroid-supportive effects with antioxidant protection.⁷¹ Another previous preclinical study in mice reported that 100 and 200 mg/kg of the hydroalcoholic extract of C. sativum produced anxiolytic effects similar to those of a standard dose of diazepam.⁷² Furthermore, in a randomised controlled trial (RCT), university students were assigned to either a C. sativum seed group or a placebo-controlled group. The findings revealed that the C. sativum seeds receiving group showed significant improvements in anxiety levels, depression, memory retention and sleep quality compared to the control group.⁷³

Kachnar (Bauhinia variegata) exhibits thyroid-modulating, anti-goitrogenic, anti-depressant, anti-inflammatory, anti-helminthic, antioxidant and immuno-modulatory properties.^{74, 75} In an RCT on 40 hypothyroid patients, the patients were divided into two groups: a 500 mg of Kachnar guggul group and a 25 mg levothyroxine (LT4) group. The results reported a significant decrease in TSH and an increase in T3 and T4 in both groups.⁷⁶ A pilot clinical study evaluating the effects of Kanchnar Shunti Ghanavati (combination of Kachnar and ginger) reported a significant reduction in TSH, fatigue, body weight and an increase in T4 and T3 in 10 primary hypothyroid patients.⁷⁷ A past preclinical study assessing the anti-depressant effects of 200 mg/kg of Bauhinia variegata in rats found its efficacy and properties to be comparable to those of imipramine, a well-known tricyclic anti-depressant medication.⁷⁸ In another preclinical study, treatment with Bauhinia variegata significantly recovered chronic stress-induced alterations in plasma corticosterone levels and monoamine neurotransmitters in rats.⁷⁹

Lemon balm (Melissa officinalis) exhibits thyroid-modulatory, antioxidant, anti-anxiety, anti-depressant, mood and cognition-enhancing, sleep-enhancing, anti-inflammatory and neuroprotective properties.^{80, 81} It exhibited modulatory effects on neuropsychiatric health by influencing inflammatory cytokines, HPA axis, GABAergic, cholinergic and serotonergic pathways.⁸² In a preclinical study, M. officinalis leaves extract reduced TSH and elevated T3 and T4 levels toward normal in PTU-induced hypothyroid albino rats.⁸³ In a double-blind, randomised, placebo-controlled clinical trial, 16 weeks of ethanolic lemon balm extract administration significantly improved cognitive function compared to placebo in patients with Alzheimer’s disease.⁸⁴ In another placebo-controlled trial, administration of 3 g of lemon balm daily for 2 months significantly reduced anxiety, depression and stress and improved sleep quality in patients with stable chronic angina.⁸⁵

Rose root (Rhodiola rosea) is reported to improve stress, depression, anxiety, mental and physical fatigue, physical strength and endurance, mood and nervous system disorders, while promoting overall health.^{86, 87} Salidroside, a key active compound in R. rosea, demonstrated anti-hypothyroid effects in preclinical rat models by reducing TSH and increasing T3 and T4 levels.⁸⁸ Administration of R. rosea for 14 days in an open-label, RCT showed a significant reduction in anxiety, stress and depression and also reported positive effects on mood. Additionally, no significant effects were found on fatigue.⁸⁹ Results of an open-label study showed improvement in stress, fatigue, QoL, mood, concentration, disability and functional impairment with 4 weeks of rose root administration.⁹⁰

Guggul (Commiphora wightii) balances all three doshas—vata, pitta and kapha. Guggul increases the levels of thyroid hormones and endogenous antioxidants, ameliorating the condition of hypothyroidism.⁹¹ In a preclinical study, PTU-induced hypothyroid mice were marked by reduced thyroid hormone (T3 and T4) levels and hepatic 5′-deiodinase (5′D-I) activity. Guggul administration for 30 days reversed these changes, ameliorating the condition of hypothyroidism. It also increased the endogenous antioxidants—superoxide dismutase (SOD) and catalase (CAT)—indicating the safe and anti-peroxidative nature of the herb.⁹¹ In a clinical study in hypothyroid patients, guggul significantly lowered the elevated TSH, though T3 and T4 changes were non-significant versus controls.⁹² Guggul exhibits anti-inflammatory properties and suppresses the production of inflammatory cytokines, including nuclear factor kappa-light-chain enhancer of activated B cells (NF-κB), IFN-γ, IL-12, TNF-α and IL-1β.⁹³ Guggul is a nervine tonic that can relieve neuropathic pain and has been used in treating kapha-type depression.⁹⁴ A previous study reported the antioxidant, anti-dementia and memory-enhancing effects of guggul and explored its potential benefits as a cognitive function enhancer.⁹⁵

Black pepper (Piper nigrum) and Long pepper (Piper longum): Piperine exhibits diverse pharmacological properties, including antiproliferative, anticancer, antioxidant, antidiabetic, anti-obesity, cardioprotective, hepatoprotective, neuroprotective, anti-allergic, anti-inflammatory, antibacterial, antiaging and immunomodulatory effects.⁹⁶ Piperine supplementation in a preclinical study improves the plasma T3 and T4 levels and reduces TSH in hyperlipidemic rats.⁹⁷ Oral administration of piperine, in albino male Wistar rats with cognitive deficit Alzheimer’s disease, showed improvement in memory impairment and neurodegeneration in the hippocampus.⁹⁸ The possible mechanisms might involve reductions in lipid peroxidation and acetylcholinesterase activity.⁹⁸ Piperine enhances the serotonin levels, while its derivative antiepilepserine enhances both serotonin and dopamine levels in the hypothalamus and hippocampus regions in the brain, showing its anti-depressant effects.⁹⁹

Black seed or black cumin (Nigella sativa): N. sativa and its active ingredients possess antioxidant, anti-inflammatory, immune-modulatory, anti-tumour and anti-microbial properties.¹⁰⁰ A double blind RCT (n = 40) in patients with Hashimoto’s thyroiditis reported a significant decrease in TSH and anti-TPO antibodies, while an increase in T3, with no notable change in T4 levels, after 8 weeks of treatment with N. sativa compared to placebo. The treatment group also exhibited a decrease in body weight, body mass index (BMI) and serum vascular endothelial growth factor (VEGF) concentration.¹⁰¹ Another RCT (n = 80) evaluating the effects of N. sativa-based herbal mix with Trachyspermum ammi and Citrus aurantifolia for 8 weeks reported a reduction in TSH with improvements in weight and BMI.¹⁰² In a clinical trial, administration of 10 weeks of N. sativa oil extract significantly reduced depression, anxiety and stress scores while elevating serum BDNF levels in the treatment group compared to placebo, supporting its neuroprotective and mood-stabilising effects.¹⁰³

Ginger (Zingiber officinalis): It has anti-inflammatory, antioxidant, analgesic and immunomodulatory effects and is used in various conditions, including fatigue.¹⁰⁴ In a preclinical study, ginger and LT4 administration significantly elevated the T3 and T4 levels in hypothyroid rats.¹⁰⁵ In another preclinical study, cypermethrin (CYP)-treated rats showed histopathological and ultrastructure changes of thyroid follicles associated with a highly significant increase in TSH and a decrease in T3 and T4. Administration of ginger along with CYP ameliorated the damaging effects of CYP on thyroid tissues. A preclinical study reported that active constituents of ginger (such as 10-shogaol, 1-dehydro-6-gingerdione) activate serotonin 5-HT1A receptors, reporting anxiolytic and mood-modulating effects of ginger.¹⁰⁶ Gingerol-enriched extract in male rats with diabetic neuropathy alleviated anxiety and depressive behaviours by improving gut microbiome, mitochondrial function and neuro-inflammation.¹⁰⁷ Ginger extract exhibits strong antioxidant properties and effectively protects against bisphenol A (BPA)-induced thyroid oxidative damage and enhances thyroid hormone synthesis by activating Nrf2/HO-1 gene expression.¹⁰⁸ In a double-blind RCT, administration of ginger powder for 30 days significantly reduced Thyroid Symptom Rating Questionnaire (ThySRQ) scores, laboratory indices (TSH, FBS, TG and TC) and anthropometric measures (body weight, BMI and waist circumference [WC]) compared to placebo in controlled primary hypothyroid patients.¹⁰⁹ Another RCT involving 62 patients with chronic fatigue syndrome reported that ginger-separated moxibustion significantly improved each subscale score of the Short Form Health Survey (SF-36), the Pittsburgh Sleep Quality Index (PSQI) and the self-rating depression scale (SDS) compared to controls.¹¹⁰ A further placebo-controlled RCT evaluating the effects of ginger extract in 60 middle-aged healthy women reported enhanced working memory, word recognition, choice reaction time, numeric and spatial working memory and decreased latency to auditory stimuli.¹¹¹

Sahjan or Moringa (Moringa oleifera): It exhibits broad therapeutic potential, including anti-pathogenic and anti-inflammatory, and also alleviates autoimmune conditions such as rheumatoid arthritis, atopic dermatitis and multiple sclerosis.¹¹² In a preclinical study on male albino rats, aqueous leaf extract of Moringa significantly reduced TSH, TC and LDL, while increased T3 and T4 levels, with no significant changes in high-density lipoprotein (HDL) levels.¹¹³ An observational study in primary hypothyroid patients reported a significant decrease in serum TSH and an increase in serum T3 and T4 levels after 45 days of M. oleifera treatment.⁷⁷ A single-arm, open-label trial reported that administration of Shigru patra churna (Moringa leaf powder) for 42 days significantly reduced TSH, T3 and body weight, without affecting T4 levels, and no adverse effects were reported in thirty patients with SCH.¹¹⁴

Peepal (Ficus religiosa): It exhibits diverse medicinal properties, including anti-inflammatory, antioxidant, cognitive enhancer, antidiabetic, wound healing, anticonvulsant, anti-microbial, hypolipidemic, immunomodulatory, parasympathetic modulatory, estrogenic, anti-anxiety, antihelmintic, endothelin receptor antagonistic, hypotensive and thyroid stimulatory effects.¹¹⁵ In a preclinical rat study, PTU treatment significantly lowered thyroid hormone levels (T3 and T4) and 5′D1 enzyme activity while raising TSH, liver enzymes (alanine transaminase [ALT], aspartate aminotransferase [AST]), inflammatory markers (TNF-α, IL-6), TC and TG. Treatment with F. religiosa leaf extract effectively reversed these adverse effects, restoring thyroid function while improving liver health by decreasing ALT, AST and hepatic lipid peroxidation. It also increased antioxidant levels and suppressed the inflammatory cytokines (TNF-α and IL-6).¹¹⁶ In another preclinical study, F. religiosa treatment showed a reduction in malondialdehyde (MDA) as well as IL-6 levels, while improving total antioxidant activity (TAO) and neuronal architecture in rats.¹¹⁷ In a previous study, the methanol extract of F. religiosa leaf inhibited lipopolysaccharide-induced nitric oxide production by inhibiting inducible nitric oxide synthase (iNOS) upregulation during microglial activation. It also reduced pro-inflammatory cytokines (TNF-α, IL-1 and IL-6) via regulating their gene transcriptional levels in activated microglia.¹¹⁸

Brahmi (Bacopa monnieri): In a preclinical study, cypermethrin administration induced hypothyroidism in rats, resulting in deformed thyroid follicles, elevated TSH and thyroid/body weight and oxidative stress, while reduced T3 and T4 levels along with expression of thyroid hormone receptor (THRβ1). Co-administration of B. monnieri extract ameliorated these hypothyroid effects, reversing the adverse effects of cypermethrin on thyroid architecture, hormone levels and oxidative stress.¹¹⁹ In another preclinical study, comparing the effects of B. monnieri, Aegle marmelos and Aloe vera leaf extracts on thyroid hormone levels in male mice, A. marmelos extract reduced T3 by 62%, indicating its potential for hyperthyroidism management, while B. monnieri extract increased T4 by 41%, highlighting its potential for hypothyroidism management. B. monnieri and A. marmelos leaf extracts lowered hepatic lipid peroxidation and enhanced SOD and CAT activities, showing their antioxidant effects.¹²⁰ Results of a few RCTs also showed improved cognition and decreased depression and anxiety scores.^{121, 122} Refer to Table 1 for the details of RCTs on the effects of Ayurveda-based herbal medicines on hypothyroidism and its neuropsychiatric manifestations.

Table 1.

Randomised Controlled Trials (RCTs) on the Effects of Ayurveda-based Herbal Medicines on Hypothyroidism and Its Neuropsychiatric Symptoms.

Authors (Year)	Design	Participants	Intervention	Comparator	Intervention Duration	Outcome Measures	Results
Sharma et al. (2018)⁶¹	RCT	50 subclinical hypothyroid patients	Ashwagandha root extract (n = 25)	Starch as placebo (n = 25)	8 weeks	TSH, T3 and T4	Ashwagandha root extract significantly improved TSH, T3 and T4 levels.
Joshi et al. (2021)¹⁶²	RCT	50 hypothyroid patients	Ayurvedic herbal formulation (n = 25)	Ayurvedic herbo-mineral formulation (n = 25)	4 weeks	TSH	Decrease in TSH in both groups, but the decrease is more pronounced in the Ayurvedic herbal formulation group.
Kombe and Kuchewar (2020)⁷⁶	RCT	40 subclinical hypothyroid patients	Kanchanar guggul (n = 20)	25 mg levothyroxine (LT4) (n = 20)	30 days	TSH, T3, T4, lipid profile (TC, LDL, HDL, TG), body weight and BMI	Significant decrease in TSH and increase in T3 and T4 levels in both groups. Body weight and BMI are significantly decreased in the intervention group. Significant decrease in TC and LDL, whereas improvement in HDL in both groups. There was no significant difference in TG levels in either group.
Iqbal et al. (2023)⁹²	RCT	40 hypothyroid adults	Commiphora mukul drug (n = 20)	50 mcg Thyrox tablets (n = 20)	60 days	TSH, T3 and T4	Significantly decreased TSH and non-significant changes in T3 and T4
Javidi et al. (2024)¹⁰²	RCT	80 primary hypothyroid patients	Herbal powder (Trachyspermum ammi, Nigella sativa and Citrus aurantifolia) (n = 40)	Placebo (n = 40)	8 weeks	TSH, T3, T4 FBS and lipid profile BMI, body weight, WC and HC QoL and depression	Non-significant decrease in TSH, T3 and fT4 Significantly decreased BMI, body weight, WC and HC Significantly improved QoL and depression
Ashraf et al. (2022)¹⁰⁹	RCT	60 hypothyroid patients	Ginger (n = 30)	Placebo (n = 30)	30 days	TSH, FBS, TG and TC levels Body weight, BMI, TC ThySRQ score	Decrease in serum TSH, FBS, TG and TC levels Decrease in body weight, BMI and TC Improved ThySRQ score
Zadeh et al. (2022)¹⁰³	RCT	54 male patients with major depressive disorder	1,000 mg capsules of N. sativa oil extract (n = 27)	Placebo capsules (n = 27)	10 weeks	Depression, anxiety, stress and BDNF	Significant decrease in depression, anxiety and stress, while significant increase in BDNF
Kale et al. (2024)¹⁶³	RCT	121 adults with cognition, energy and mood problems	Ashwagandha root extract (ARE) (n = 61)	Placebo (n = 60)	8 weeks	Cognitive function, mood, mental fatigue and executive function	ARE improved cognitive function, mood, mental fatigue and executive function in comparison to placebo.
Eraiah et al. (2024)¹²²	RCT	80 healthy subjects	B. monnieri extract (n = 40)	Placebo (n = 40)	12 weeks	Memory and cognition by CBT Anxiety by BAI Sleep quality by PSQI BDNF and cortisol levels	Significant improvements in memory (verbal short-term, spatial short-term, working, visuospatial working and episodic memory) and cognition skills (concentration, alertness, reasoning and mental flexibility) Increase in BDNF levels and sleep quality scores Significant reduction in serum cortisol levels and anxiety scores.
Alqudah et al. (2024)⁷³	RCT	86 students	500 mg Coriander seeds	Placebo	–	Anxiety, depression, sleep quality and memory	Improvement in anxiety, depression, sleep quality and memory in the coriander group.
Gopukumar et al. (2021)⁶³	RCT	130 healthy participants	Ashwagandha root extract capsule 300 mg (n = 65)	Placebo (n = 65)	3 months	Cognitive function, stress score, serum cortisol level, happiness score, sleep quality and serum BDNF levels	Reduced stress score, cortisol levels and PSQI score, but improved cognitive functions, happiness and sleep quality in the ashwagandha group. No change in BDNF levels.
Zhang et al. (2021)¹⁶⁴	RCT	26 college students	Coriander plants (n = 13)	Control (n = 13)	50 min	Salivary alpha-amylase, cortisol and emotional states	Coriander group showed a reduction in salivary alpha-amylase, cortisol, negative emotions, TMD and improvement in theta power of different brain areas. Coriander reduces scores by affecting brain activity. Participants experienced an improved emotional state and more active brains in the intervention group.
Lopresti et al. (2019)⁶⁵	RCT	60 adults	Ashwagandha (n = 30)	Placebo (n = 30)	2 months	DHEAS, cortisol and testosterone levels, depression, anxiety, stress	Improvement in depression, anxiety, stress, cortisol and DHEAS levels. Testosterone levels were increased in males.
Haybar et al. (2018)⁸⁵	RCT	80 patients with chronic stable angina	Melissa officinalis (MO) (lemon balm) supplement (n = 40)	Placebo (n = 40)	8 weeks	Depression, anxiety, stress and sleep disturbances	Reduction in depression, anxiety and stress scores, and total sleep disturbances in the MO group compared with the placebo.
Kumar et al. (2016)¹⁶⁵	RCT	60 healthy medical students	Standardised extract of B. monnieri	Placebo	6 weeks	Serum calcium and lipid parameters (TC, TG, LDL and HDL) Neurological tests (DSMT, PAT, LMT, MSNS) Computerised tests (FTT, SRT, CRT, CDT, DPST)	Significant increase in calcium and HDL levels while significant decrease in TC levels. Significant improvement in DSMT (backwards) and LMT tests
Cropley et al. (2015)⁸⁹	RCT	80 mildly anxious patients	Rose root (n = 39)	Control (no treatment) (n = 41)	14 days	Anxiety, stress, mood, sleepiness, sleep and cognitive tests	Significant reduction in self-reported anxiety, stress, anger, confusion, depression, and a significant improvement in total mood.
Abedon et al. (2008)⁶²	RCT	130 stressed patients	Ashwagandha root and leaf extract (WSE) in three groups (n = 30, WSE = 125 mg QD) (n = 35, WSE = 250 mg BID) (n = 35, WSE = 125 mg BID)	Placebo (n = 30)	2 months	Anxiety and stress symptoms. Biochemical parameters (serum cortisol, serum DHEAS, serum CRP, FBG and blood cholesterol)	Significantly decreased anxiety and stress symptoms, serum cortisol and serum C-reactive protein, and increased serum DHEAS and haemoglobin in the WSE groups.
Saenghong et al. (2012)¹¹¹	RCT	60 middle-aged healthy women	Ginger extract (GE) (n = 20, GE = 400 g) (n = 20, GE = 800 g)	Placebo (n = 20)	2 months	Working memory, word recognition, choice reaction time, numeric and spatial working memory and latency to auditory stimuli	Enhanced working memory, word recognition, choice reaction time and numeric and spatial working memory, and decreased latency to auditory stimuli.
Calabrese et al. (2008)¹²¹	RCT	48 elderly without clinical signs of dementia	B. monnieri extract (n = 24)	Placebo (n = 24)	12 weeks	Cognition and working memory (AVLT delayed word recalls, STRT, DAT and WAIS) Affective parameters (mood measured with POMS, depression measured with CESD and anxiety with STAI) Heart rate and blood pressure	Enhanced AVLT delayed word recall memory and STRT Decreased depression, anxiety and heart rate No effects on the DAT, WAIS, mood or blood pressure.
Akhondzadeh et al. (2003)⁸⁴	RCT	42 Alzheimer’s patients	M. officinalis extract (n = 21)	Placebo (n = 21)	4 months	ADAS-cog and CDR	Improved ADAS-cog and CDR scores showed improved cognitive functions.

Note: ADAS-cog: Cognitive subscale of Alzheimer’s disease assessment scale; ARE: Ashwagandha root extract; AVLT: Auditory verbal learning test; BAI: Beck anxiety inventory; BDNF: Brain-derived neurotrophic factor; BMI: Body mass index; CBT: Creyos battery of tests; CDR: Clinical dementia rating scale; CDT: Choice discrimination test; CESD: Center for Epidemiologic Studies Depression scale; CRP: C-reactive protein; CRT: Choice reaction test; DAT: Divided attention task; DHEAS: Dehydroepiandrosterone sulfate; DPST: Digit picture substitution test (symbol digit modalities test); FBG: Fasting blood glucose; FBS: Fasting blood sugar; FTT: Finger tapping test; HC: Hip circumference; HDL: High-density lipoprotein; LDL: Low density lipoprotein; LMT: Logical memory test (story recall), LT4: Levothyroxine; MSNS: Memory span for nonsense syllables; PAT: Paired associate task; POMS: Profile of mood states; PSQI: Pittsburgh sleep quality index; QoL: Quality of life; SRT: Simple reaction test; STAI: State-trait anxiety inventory; STRT: Stroop task reaction time; TC: Total cholesterol; T4: Thyroxine; TG: Triglycerides; ThySRQ: Thyroid symptom rating questionnaire; TMD: Total mood disturbance; TSH: Thyroid-stimulating hormone, T3: Triiodothyronine; WAIS: Wechsler adult intelligence scale; WC: Waist circumference; WSE: Withania somnifera extract (Ashwagandha).

The human RCTs evaluating the effects of herbs in hypothyroidism are limited; however, the possible mechanism of anti-hypothyroid activity of herbs may involve stimulation of thyroid hormone synthesis, antioxidant protection against oxidative stress in thyroid tissue, HPT and HPA axes modulation and anti-inflammatory actions, aligning with the adaptogenic properties of herbs.

Yogic Management of Hypothyroidism and Its Neuropsychiatric Manifestations

Yoga encompasses mind–body practices that address hypothyroidism and neuropsychiatric conditions such as anxiety, depression, stress, fatigue, decline of cognition and mood changes. Yoga mitigates distress and depression by influencing serum levels of corticosteroids, catecholamines, dopamine, serotonin, melatonin, noradrenalin, sirtuin-1 and various inflammatory markers.¹²³

Yoga on Thyroid Hormones (T3, T4 and TSH)

Previous studies reported the beneficial effects of yoga on thyroid disorders, including improvements in thyroid hormone levels. A past clinical study reported significant improvement in T3, T4 and TSH after yogic intervention (asanas, pranayama, bandha, savasana and yoga nidra) for 3 months in hypothyroid patients.¹²⁴ A previous pilot study evaluating the effect of yoga in depression in hypothyroid patients reported a decrease in TSH, depression, BMI, fatigue, anxiety, lipid profile (increase in HDL), stress levels and 23.5% decrease in mean T4 dose after a 3-month integrated yoga intervention (surya namaskar, breathing practices, asanas, pranayama and meditation).¹²⁵ Nilkantham et al. reported a significant reduction in serum TSH and an elevation in T3 levels (but not in T4 levels) after 6 months of yoga (asana, pranayama, meditation and counselling).¹²⁶ An RCT reported a significant decrease in serum TSH and an increase in T3 and T4 levels after 3 months of yoga.¹²⁷ A case report showed a significant decrease in TSH levels with 6 months of regular Ujjayi pranayama.¹²⁸ In a past study, 1 month of yoga techniques (asana, pranayama and relaxation) showed significant improvements in T3, T4 and TSH levels.¹²⁹ A recent RCT on the effects of yogic management of hypothyroidism in females reported a significant decrease in serum TSH levels, LT4 dose, BMI, blood TC, LDL and TG while showing a significant increase in serum T4 and blood HDL levels.¹³⁰ Refer to Table 2 for more details on yogic effects on thyroid hormones.

Table 2.

Randomised Controlled Trials (RCTs) on the Effects of Yoga on Hypothyroidism and Its Neuropsychiatric Symptoms.

Authors (Year)	Design	Participants	Intervention	Comparator	Intervention Duration	Outcome Measures	Results
Bhandari et al. (2025)¹³⁰	RCT	62 hypothyroid females	LT4 + yoga (cleansing technique, asana, pranayama, mudra, bandha and savita meditation) (n = 31)	LT4 (n = 31)	3 months	TSH, T3, T4 and LT4 dose, BMI and lipid profile Daytime sleepiness and depressive symptoms	Significant increase in T4 and HDL Significant decrease in TSH, LT4 dose, BMI, TC, TG, LDL, daytime sleepiness and depressive symptoms.
Nilkantham et al. (2025)¹²⁶	RCT	134 hypothyroid patients	Tele-yoga module (asana, mudra, bandha, pranayama, meditation, surya namaskar and counselling) (n = 67)	Wait-list control group (n = 67)	6 months	T3, T4 and TSH, QoL, BMI, BP, stress, fatigue and yoga performance	Significant improvement in levels of TSH and T3, but not in T4 levels Significant improvement in QoL, BMI, BP, fatigue, stress, yoga performance.
Sharma et al. (2024)¹⁶⁶	RCT	112 hypothyroid patients	Standard care + yoga (prayer, sukshma vyayama, asana, pranayama and om/mindfulness meditation) (n = 55)	Standard care control group (n = 57)	8 weeks	TSH, T3, T4 and BMI Inflammatory marker (IL-6) Oxidative stress markers (catalase, SOD, GSH and MDA)	Significant reduction in TSH, BMI and inflammatory markers in yoga group. Non-significantly decreased oxidative stress in yoga group. No significant change in fT3 and fT4 in yoga group.
Soni et al. (2022)¹²⁷	RCT	80 hypothyroid females	Yoga (loosening practice, asana, pranayama, meditation and relaxation in savasana)	Control group	3 months	T3, T4, TSH, BMI and body weight	Significant reduction in serum TSH levels and an increase in serum T3 and T4 levels in the study group. Significant reduction in body weight and BMI in the study group.
Shetty et al. (2020)¹⁶⁷	RCT	60 obese hypothyroid patients	Naturopathy and yoga (asana, pranayama and relaxation) (n = 30)	Wait-list control group (n = 30)	10 days	T3, T4, TSH, BMI, WC, HC and serum lipid	Significant reduction in TSH, body weight, BMI, WC and HC. Significant improvement in serum lipid levels. No significant changes in serum levels of T3 and T4.
Akhter (2019)¹⁶⁸	RCT	60 hypothyroid patients	Yoga (n = 30) (details of practices not mentioned)	Control group (n = 30)	6 months	QoL	Significant improvement in the physical and psychological domains of QoL.
Chawla et al. (2019)¹⁶⁹	RCT	100 hypothyroid patients	Yoga (om chanting, loosening practice, surya namaskar, asana, bandha, pranayama and kriyas) + LT4	Control (LT4) group	4 months	fT3, fT4, TSH, anti-TPO antibody, blood glucose, HbA1c, LFT, muscle-related enzymes, KFT and lipid profile	Significant increase in fT4 levels and significant decrease in serum TSH, anti-TPO antibodies, fasting blood glucose and cholesterol level and insignificant increase in serum fT3 levels in yoga + LT4 group
Kanhere et al. (2018)¹⁷⁰	RCT	20 children with epilepsy	Yoga (asana, breathing techniques, mudra, pranayama, exercises for body balance and neuromuscular coordination, surya-namaskar, relaxation through chanting, prayers and shavasana) + antiepileptic drug (n = 10)	Control group (n = 10)	6 months	Seizure frequency and EEG	No seizures in yoga group. One in the yoga and seven in the control group have abnormal EEG after yoga intervention.
Chintala et al. (2019)¹⁵⁸	RCT	50 hypothyroid patients	Loosening practices and pranayama (chandranadi, bhramari, nadi shuddhi and pranav pranayama) and shavasana (n = 25)	Control (n = 25) (standard medical treatment)	1 month	Parameters of HRV in hypothyroid patients	More significant reduction in LFnu and improvement in HFnu of HRV.
Tolahunase et al. (2018)¹³⁹	RCT	58 MDD patients	Yoga (prayer, loosening practice, surya namaskar, asana, pranayama, relaxation, Omkar recitation, meditation, shanti mantra and interactive session) (n = 29)	Control (n = 29)	12 weeks	Depression and neuroplasticity markers (BDNF, IL-6, DHEAS, Sirtuin 1, cortisol and telomerase activity levels)	Significantly decreased depression score, BDNF, cortisol and IL-6, while significantly increased DHEAS, sirtuin 1 and telomerase activity levels.
Van Puymbroeck et al. (2018)¹⁷¹	RCT	30 patients with Parkinson’s disease	Yoga group (yoga postures – sitting, standing, supine lying, pranayama and meditation and relaxation in savasana) (n = 18)	wait-list control (n = 12)	8 weeks	UPDRS and MHYS for motor and symptoms’ examination, FGA and FoG for functional gait and Mini-BESTest for postural stability and balance control	Improvements in motor function, postural stability, functional gait and freezing gait, and reductions in fall risk.
de Manincor et al. (2016)¹⁴²	RCT	107 participants with symptoms of depression and anxiety	Yoga (physical postures, breathing exercises, relaxation, mindfulness, meditation and other aspects of yoga such as cultivation of positive values, thoughts and attitudes and lifestyle factors) (n = 47)	Wait-list controls (n = 54)	6 weeks	Depression, anxiety and well-being	The yoga group showed a significant reduction in depression score and a non-significant reduction in anxiety score, and an improvement in mental health composite score compared to the wait-list.
Kiecolt-Glaser et al. (2014)¹³⁶	RCT	200 breast cancer survivors	Hatha yoga (asana and pranayama)	Wait-list controls	3 months	Pro-inflammatory cytokines (IL-6, TNF-α and IL-1β), fatigue, vitality and depression.	Yoga lowered IL-6, TNF-α, IL-1β and fatigue, while enhanced vitality after intervention.
Michalsen et al. (2012)¹⁴³	RCT	72 distressed females	Two groups: 12 Iyengar yoga (Iyengar style asanas and meditation in shavasana) sessions (n = 24) and 24 Iyengar yoga (Iyengar style asanas and meditation in shavasana) sessions (n = 24)	Wait-list control group (n = 24)	3 months	Perceived stress, anxiety, depression and physical and psychological QoL (body complaints, mood states and well-being)	The yoga group showed improvement in stress, anxiety, depression, psychological QoL, body complaints, mood states and well-being.
Suresh (2021)¹⁶¹	Pilot RCT	13 adults with Parkinson’s disease	Iyengar yoga (deep breathing exercises, relaxation techniques, yoga postures—lying, seated and standing posture using props, meditation—breathing, visualisation and positive affirmation)	Control group with no intervention	12 weeks	Motor examination by UPDRS and BBS scores, Strength, ROM and flexibility of hip and ankle, Onset time of foot unloading and foot lift off	Significant improvement in UPDRS and BBS scores, Improved strength, ankle dorsiflexion and flexibility of hip, positive effects on onset time of foot unloading and foot lift off.
Streeter et al. (2010)¹³³	RCT	34 healthy participants	Iyengar style yoga (n = 19)	Walking (n = 15)	12 weeks	Mood, anxiety and GABA levels	A greater improvement in mood and a greater decrease in anxiety in the yoga group. Positive correlation of GABA levels with mood.
Lundgren et al. (2008)¹⁷²	RCT	18 patients with drug-refractory seizures and epilepsy	Yoga (yama, niyama, pranayama, asana and dhyana) (n = 8)	Acceptance and commitment therapy (ACT) (n = 15)	12 months	Seizure index (frequency and duration) and QoL measured with SWLS and WHOQOL-BREF	Both ACT and yoga significantly reduce seizure index and increase quality of life.

Note: BBS: Berg balance scale; BDNF: Brain-derived neurotrophic factor; BMI: Body mass index; BP: Blood pressure; DHEAS: Dehydroepiandrosterone sulfate; DSMT: Digit span memory task; EEG: electroencephalogram; FGA: Functional gait assessment, FoG: Freezing of gait questionnaire, GABA: Gamma-aminobutyric acid, GSH: Glutathione; HbA1c: Haemoglobin A1C; HC: Hip circumference; HDL: High-density lipoprotein, HRV: Heart rate variability; IL-6: Interleukin-6; IL-1β: Interleukin-1β; KFT: Kidney function test; LDL: Low-density lipoprotein; LT4: Levothyroxine; MDA: Malondialdehyde; MDS-UPDRS: The Movement Disorders Society-Sponsored Revision of the Unified Parkinson’s Disease Rating Scale; MHYS: Modified Hoehn and Yahr Scale; Mini-BESTest: Mini-balance evaluation systems test; QoL: Quality of life; SOD: Superoxide dismutase; SWLS: Satisfaction with life scale; TC: Total cholesterol; T4: Thyroxine; TG: Triglycerides; TNF-α: Tumour necrosis factor-alpha; TSH: Thyroid-stimulating hormone, T3: Triiodothyronine; UPDRS: Unified Parkinson’s Disease Rating Scale, WC: Waist circumference; WHOQOL-BREF: World Health Organization Quality of Life instrument (short version).

Yoga on Neurotransmitters

Yogic practices relieve depression by increasing serotonin levels, decreasing monoamine oxidase and lowering cortisol levels in the blood.¹⁰ Practicing yoga nidra meditation increases the endogenous release of dopamine by 65% and suppresses the cortico-striatal glutamatergic transmission.¹³¹ The results of a past study demonstrated that yoga effectively reduced anxiety and norepinephrine levels in pregnant women.¹³² A 12-week yoga practice resulted in improvement in mood and anxiety, which showed a positive correlation with increased brain GABA levels, particularly in the thalamus.¹³³ Another past study showed that a 12-week Iyengar yoga intervention and coherent breathing exercises significantly elevated thalamic GABA levels and reduced depression in individuals with major depressive disorders.¹³⁴ The results of a prospective randomised-controlled study demonstrated that meditation practice lowered norepinephrine and improved the QoL.¹³⁵

Yoga on Inflammatory Cytokines

A 3-month yoga practice improved inflammatory cytokines (IL-6, TNF-α and IL-1β), fatigue and vitality in cancer survivors with no change in depression.¹³⁶ In a RCT, an 8-week yoga-based mind–body intervention significantly increased BDNF, serotonin, endorphins and anti-inflammatory cytokines, while reducing pro-inflammatory markers (ESR, CRP, IL-6, IL-17A and TNF) in patients with rheumatoid arthritis.¹³⁷ In another study, 12 weeks of yoga therapy significantly decreased IL-1α, IL-6, TNF-α and cortisol compared to the control group.¹³⁸ A 12-week yoga and meditation-based lifestyle significantly increased total antioxidant capacity, telomere activity, BDNF, sirtuin 1, decreased inflammatory cytokine (IL-6), cortisol and DNA damage and improved depression among individuals with major depressive disorders as compared to their controls.¹³⁹

Yoga on Neuropsychiatric Manifestations of Hypothyroidism

Yoga effectively reduces stress and anxiety levels, improving the general psychological health and well-being of individuals.¹⁴⁰ Yoga and meditation have beneficial effects on levels of fatigue, physical activity and QoL.¹⁴¹ After practicing 3 months of integrated yoga, a significant improvement in the state of depression, serum TSH levels, fatigability, anxiety and stress had been reported in females having hypothyroidism and depression.¹²⁵ A 6-week individualised yoga programme showed a significant reduction in the depression score of patients after intervention.¹⁴² Iyengar yoga significantly improved perceived stress, anxiety, depression, mood states and psychological and physical QoL in distressed women.¹⁴³ In a previous study, yoga and mindfulness practices significantly reduced anxiety and alleviated mental and physical fatigue.¹⁴⁴ In another study, a 4-week yoga intervention mitigated anxiety and stress and enhanced the QoL in healthcare professionals after the intervention.¹⁴⁵ Furthermore, a 3-month practice of Hatha yogic postures, breathing exercises and Omkar meditation improved the plasma melatonin levels and psychological profiles (anxiety, depression and well-being).¹⁴⁶ Additionally, a study revealed the positive correlation between salivary cortisol levels and anxiety and depression, while regular practice of yoga was found to decrease cortisol levels and improve anxiety and depression.¹⁴⁷ A randomised interventional study found that a 12-week integrated programme combining cold exposure, breathing and mindfulness techniques effectively improved cognition, fatigue, anxiety and depression in patients with multiple sclerosis.¹⁴⁸ Findings of a 12-month quasi-experimental prospective study reported that a multimodal intervention involving diet modifications, walking and breathing exercises improved mental QoL, fatigue, anxiety, attention and cognitive functions after intervention.¹⁴⁹ Mindfulness-based cognitive behavioural group programme, including mindfulness meditation and exercise, reported a significant improvement in QoL while significantly reducing depression, anxiety, fatigue and confusion.¹⁵⁰ In patients with PD, 8 weeks of yoga practice showed significant improvements in non-motor symptoms, including fatigue, balance confidence, one’s ability to manage falls, activity constraints and PD-specific QoL.¹⁵¹ Another interventional study in patients with PD reported better stability and balance, along with reduced disability following a structured yoga intervention.¹⁵² A pilot RCT reported a positive trend towards improvement in the Unified Parkinson’s Disease Rating Scale (UPDRS), SF-36 (QoL measure), tremor severity, blood pressure (BP), depression symptoms and forced expiratory volume after yoga intervention.¹⁵³ In a pilot study, 8 weeks of yoga intervention (Vinyasa style) demonstrated a decrease in perception and amplitude of Tremors on the Tremor Research Group Essential Tremor Rating Scale (TETRAS) and decrease in anxiety on the Beck Anxiety Inventory (BAI), while improvement in balance measured by Fullerton Advanced Balance (FAB) scale and QoL measured by the McGill Quality of Life Questionnaire.¹⁵⁴ A previous study in patients with refractory epilepsy reported a decrease in seizure frequency scores and improvement in parasympathetic parameters (max:min ratio and deep breathing ratio) after 10 weeks of yoga (yogasana and pranayama) practice.⁵³ A quasi-experimental study of 68 elder patients with dementia reported better physical and mental health, including reduced BP and respiratory rate (RR) and enhanced cardiopulmonary fitness, body flexibility, muscle strength and endurance, balance and joint motion compared to controls. Additionally, patients experienced reduced depression and problem behaviour.¹⁵⁵ For more details on the effects of yoga on hypothyroidism and associated symptoms, see Table 2.

Yoga practices for various thyroid disorders include massage, rhythmic contraction and relaxation, vibration and stimulation of the gland to enhance blood supply to the organ.¹⁵⁶ The possible mechanism underlying the beneficial effects of yoga on hypothyroidism and associated symptoms may be via its immune-modulation (by decreasing inflammatory cytokines), HPT and HPA axes regulation, reduced oxidative stress, enhanced metabolic activities, conscious breathing and sympathovagal balance (increased high-frequency power of heart rate variability [HFnu] and decreased low-frequency power of heart rate variability [LFnu] via pranayama).^{139, 157–160}

Mechanism of action of Yoga on motor and neuropsychiatric manifestations includes the following:

Neuroplasticity, by which the brain can change and rearrange its responses to practice, compensating for the motor deficiencies.¹⁶¹

Improve muscle strength and flexibility, which has a direct impact on motor function and stability.¹⁶¹

Attentive and breath-control techniques alleviate stress and enhance concentration, leading to improved motor control.¹⁶¹

Developing a sense of community and support for one another, which may positively impact their overall well-being.¹⁶¹

Discussion of Gaps and Future Recommendations

Therapeutic Potentials

Integrative and holistic interventions, including evidence-based yoga interventions and Ayurveda-based herbal medicines, have shown their effectiveness in improving thyroid functions as well as alleviating psychiatric manifestations associated with hypothyroidism, including anxiety, depression, mood disturbances and cognitive dysfunction.

Research Gap

There is a lack of human RCTs evaluating the effects of standardised herbal and yoga interventions to manage hypothyroidism and its neuropsychiatric manifestations. Most existing studies concerning these interventions for hypothyroidism are limited by following factors:

Their small sample sizes.

Heterogeneity in protocols, interventions and outcome measures.

Lack of a robust theoretical framework, combination trials, long-term data and safety monitoring.

Inadequate comparator selection.

Lack analysis of cost-effectiveness.

Thereby restricting their validity and generalisability. Further, these critical research gaps might impede the integration of herbal and yoga interventions into mainstream clinical practice.

Future Recommendations

There is an urgent need for well-designed, large-scale and multimodal RCTs and longitudinal studies that employ rigorous methodology, an appropriate comparator, proper blinding and long-term follow-up to thoroughly evaluate the efficacy and safety of specific yoga practices and herbal treatments, particularly in relation to thyroid hormone regulation. Furthermore, advanced biomarker and neuroimaging studies will be critical to elucidate mechanistic pathways, dose–response relationships and long-term safety profiles. A translational framework integrating endocrinology and neuropsychiatry will be essential to establish evidence-based integrative guidelines for the management of hypothyroidism and its symptoms. These additions provide a clear research roadmap while contextualising current evidence limitations.

Current interventions vary significantly in terms of duration, intensity and dosage, leading to inconsistent outcomes across studies. Therefore, to strengthen the evidence base, the development of patient-centred standardised therapeutic protocols for yoga and Ayurveda-based herbal medicines is imperative to address the physiological and psychosocial dimensions of hypothyroidism. Additionally, such standardisation should include strict quality control measures, dosage consistency and clearly defined treatment durations to ensure therapeutic reproducibility, efficacy and safety.

Conclusion

Hypothyroidism is a multifaceted endocrine disorder with significant neuropsychiatric symptoms, including fatigue, cognitive impairment, anxiety and depression, which substantially impact QoL. Conventional LT4 replacement therapy provides thyromimetic effects in the body but may not fully address persistent neuropsychiatric symptoms in some subset of patients. This review emphasises the promising role of mind–body-based yoga practices and Ayurveda-based herbal medicines as complementary and alternative treatments. Emerging evidence highlights the therapeutic potential of integrative approaches that combine yoga-based interventions and Ayurveda-based herbal medicines for managing hypothyroidism and its neuropsychiatric sequelae. Studies indicate that yoga can influence HPT-axis activity, improve autonomic balance and alleviate neuropsychiatric symptoms. Certain herbal preparations, such as W. somnifera, C. sativum and M. officinalis, may exert thyroid-modulatory, anti-inflammatory, antioxidant, adaptogenic and neuroprotective effects. Incorporating evidence-based yoga and Ayurveda-based herbal treatments as management strategies may offer a holistic, patient-centred approach to improving thyroid function and mitigating neuropsychiatric symptoms, ultimately enhancing overall well-being.

Footnotes

Abbreviations

ALT: Alanine aminotransferase; ApoE4: Apolipoprotein E; AST: Aspartate aminotransferase; BDNF: Brain-derived neurotrophic factors; BMI: Body mass index; CAT: Catalase; CNS: Central nervous system; CRP: C-reactive protein; CYP: Cypermethrin; ESR: Erythrocyte sedimentation rate; FBS: Fasting blood sugar; 5-HT: 5-Hydroxytryptamine; GABA: Gamma-aminobutyric acid; HDL: High-density lipoprotein; HFnu: High-frequency power of heart rate variability (HRV); HPA: hypothalamic–pituitary–adrenal; HPT: Hypothalamic–pituitary–thyroid; IFN-γ: Interferon-gamma; IL-1β: Interleukin-1 beta; IL-2: Interleukin-2; IL-6: Interleukin-6; IL-10: Interleukin-10; IL-12: Interleukin-12; LDL: Low-density lipoprotein; LFnu: Low-frequency power of heart rate variability (HRV); LT4: Levothyroxine; MCP-1: Monocyte chemoattractant protein-1; MCT: Monocarboxylate transporter; NF-κB: Nuclear factor kappa-light-chain enhancer of activated B cells; OATP1C1: Organic anion-transporting polypeptide; OH: Overt hypothyroidism; PTU: Propylthiouracil, 5′D-I: 5′-Deiodinase; RCT: Randomised controlled trial; SAA1: Serum amyloid A1; SCH: Subclinical hypothyroidism; SIL-6R: Soluble interleukin-6 receptors; SIL-2R: Soluble interleukin-2 receptors; SOD: Superoxide dismutase; TC: Total cholesterol; T4: Thyroxine; TG: Triglycerides; ThySRQ: Thyroid Symptom Rating Questionnaire; TNF-α: Tumour necrosis factor-alpha; TSH: Thyroid-stimulating hormone; T3: Triiodothyronine; WC: Waist circumference.

Acknowledgements

First, the authors would like to thank Patanjali Research Foundation for the administrative support. Further, the authors thank Dr RN Das and Dr Neha Sharma for the initial review of the article.

Authors’ Contribution

GJ conceptualised and prepared the initial draft of the article. AB and AV provided the guidance and administrative support. All authors reviewed the article and provided their consent for publication.

Data Availability Statement

The corresponding author will provide the data upon reasonable request.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Statement of Ethics

Not applicable.

ORCID iD

Garima Jaglan

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