Barriers to Yoga as an Add-On Treatment for Common Mental Health Disorders in India

Abstract

Background:

Yoga has increasingly been recognized as a beneficial adjunctive therapy for mental health disorders in India. However, participation barriers persist. This study examines the factors influencing participation in yoga as an add-on treatment for Common Mental Disorders (CMDs) in India.

Methodology:

As the part of a larger open-label comparative study assessing in-person versus virtual yoga, 1147 patients with CMDs were screened at a tertiary care center in Southern India. Of these, 968 were eligible and 130 consented to participate (13.43%). Reasons for refusal were recorded and analyzed.

Results:

The overall refusal rate was 86.57%. The most common barriers were lack of time (30.78%), disinterest in yoga (21.12%), and distance to the yoga center (19.09%). Additional factors included ongoing psychotherapy (11.57%), preference for virtual sessions (10.26%), and unwillingness to randomization (7.04%). Participants who consented were significantly more educated and more females than males refused participation. The preference for virtual sessions reflected growing demand for accessible, technology-assisted interventions post-COVID-19.

Conclusion:

Despite increased awareness of yoga, participation remains low because of logistical barriers. These findings underscore the need to develop and validate virtual yoga programs tailored to patient convenience and contemporary healthcare delivery models.

Introduction

An earlier study of an add-on Yoga therapy for Schizophrenia in India in 2012 indicated several barriers. Of the 857 patients screened, 392 (45.7%) were found eligible for the study. Among them, 223 (56.8%) declined to take part in the trial. The reasons for declining included the need to attend supervised Yoga sessions regularly for extended periods, distance from the center, lack of a person to accompany them for training, a busy work schedule, and unwillingness to participate in Yoga therapy, among others.[1]

In the last decade, the introduction of Yoga as a complementary or alternative treatment to psychiatric disorders in India has been considered feasible and acceptable in persons with psychiatric disorders.[2] Yoga improves psychopathology, quality of life, depression, acute stress, and anxiety in cases of psychiatric disorders.[3]

Methodology

The present study is a part of a larger open-label comparative study assessing the efficacy of in-person versus virtual Yoga in Common Mental Disorders (CMDs). Initially, the study was designed as randomized study and later shifted to convenience sampling. In this study, patients with the following diagnoses were included: Anxiety disorders, phobic anxiety disorders, adjustment disorders, dissociative (conversion) disorders, somatoform disorders, and mild-to-moderate depressive episodes (ICD-10). They belonged to both sexes and were aged between 18 and 60 years. Their illness severity on clinical global impression was ≤4. They had to have access to the internet and web-camera facility to enable participation in virtual yoga sessions, and the ability to read, write, and a working knowledge of English/Kannada. The data were collected using a convenience sampling method among patients visiting the psychiatry outpatient department of a tertiary hospital in the southern part of India.

Results

Of the total screened patients (n = 1147), 968 were found eligible for the study. One hundred and thirty agreed and 838 refused to participate (86.57%). The reasons for refusal included (a) no time (n = 258; 30.78%); (b) not interested in doing Yoga (n = 177, 21.12%); (c) distance to the yoga center (n = 160, 19.09%); (d) refused, as undergoing psychotherapy (n = 97, 11.57%); (e) need only online yoga sessions (n = 86; 10.26%); (f) not ready for randomization (n = 59; 7.04%); and (g) religious reasons (n = 1, 0.11%).

The mean age of patients who refused to participate in the study was 32.29 ± 12.24 years and 38.90% of them were male and 61.09% were female. Participants who agreed to participate were significantly more educated than those who did not agree to participate (Participants who agreed to participate were significantly more educated [15.00 ± 3.62 years] than those who refused [11.86 ± 4.97 years]; Mann–Whitney U-test, P < 0.001). More females refused to participate (545 females [61.09%] as compared to males [n = 347, 38.90%; Chi-square test [P = 0.025]). Further, more employed refused to participate (647 employed [75.58%]) as compared to unemployed (n = 26 [3.03%]) and 183 others (21.37%) on the Chi-square test (P < 0.001).

Discussion

As compared to the earlier study, a higher percentage of patients refused Yoga. Although most of the reasons were similar, i.e., distance from center, not willing for yoga, and no time; the percentages of those reporting these reasons in the current study were less; new reasons included the need for virtual yoga sessions was prominent. The main reasons for choosing virtual Yoga sessions over in-person Yoga sessions were that in-person Yoga sessions require traveling, whereas virtual Yoga sessions can be attended from the comfort of home or workplace. Traveling for Yoga sessions requires time and money, which can be saved when attending virtual Yoga sessions. On the other hand, a few participants preferred in-person Yoga sessions as they believed that they could learn the module better face-to-face rather than via virtual mode.

Post 2015, with the United Nations recognizing the International Yoga Day on 21^st June, the assumption that more persons would participate in yoga than in the earlier study was not supported by the results of this study. One of the reasons for the same could be that the earlier study looked at barriers to yoga in persons with severe mental disorders, however, the current study looked at barriers to participating in yoga among persons with Common Mental Disorders (CMDs). Possibly, the drive to seek alternative interventions, such as Yoga, may be lower in the CMD population due to the lower severity of illness.[4] Further, with the advent of COVID-19 and technology, patients may want to practice from the comfort of their homes and not want to participate in a trial. This was one of the main reasons also found in this study. This study throws light on whether the earlier barriers to yoga are still relevant and provides potential answers. With the advent of the COVID-19 pandemic and the impetus given to digital technology, these data depict that virtual yoga may be the new normal and that we need to have more studies to understand the barriers and efficacy of virtual yoga as compared to in-person yoga in the next few years.

The 86.57% refusal rate represents a significant barrier to implementing yoga as an adjunctive treatment, with practical concerns such as time constraints and distance being the primary deterrents and the stigma toward yoga in psychiatric settings, fear of additional time commitment, research-related burden, and randomization concerns are some secondary deterrents. The emergence of a preference for virtual over in-person sessions suggests that future research should prioritise developing and validating remote yoga interventions that address patient convenience while maintaining therapeutic efficacy, while also recognizing that such approaches represent only one component within a broader engagement framework aimed at addressing underlying psychological and psychosocial barriers.

Furthermore, a higher proportion of refusals was observed among women compared to men, suggesting that gender-related and psychosocial factors may have influenced participation decisions and engagement with alternative therapeutic interventions.[5]

Conclusion

Despite the limitations of a small sample size and convenience sampling from a single center and possible selection bias, our findings highlight the urgent need for healthcare providers and researchers to adapt intervention delivery methods to meet evolving patient preferences. The diagnostic-wise data within the common mental disorder sample were not collected, which may have limited the understanding of refusal patterns across different disorder, the shift toward digital health solutions post-COVID-19 appears to be significant, requiring mental health services to innovate in treatment delivery approaches.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This study is a part of a project titled “Effect of virtual-yoga and in-person yoga for individuals with common mental health disorders in the community: A randomized controlled trial” funded by DST-SATYAM.