Efficacy of yoga therapy on subjective well-being and basic living skills of patients having chronic schizophrenia

Abstract

Background:

Scientific studies demonstrate efficacy of yogic treatment methods in stress and anxiety related disorders, psychosomatic disorders and physical illness. Very few studies have been conducted on schizophrenic patients.

Aims:

This study was conducted to determine the efficacy of yoga therapy on subjective well-being, basic living skills, self-care, interpersonal, communicational and routine functions of schizophrenic patients.

Materials and Methods:

Thirty chronic schizophrenic hospitalized patients were selected from Ranchi Institute of Neuro-Psychiatry and Allied Sciences, Ranchi and were randomly assigned to the experimental group (yoga therapy along with Pharmacotherapy, n=15), and to control group (Pharmacotherapy alone, n=15). Baseline assessment was done using Post Graduate Institute general well-being measure (GWBM), Checklist for basic living skills and Indian disability evaluation and assessment scale (IDEAS). The experimental group attended yoga therapy every day for about 1½ h including motivational and feedback session. After 1 month post-assessment was done for both the groups.

Statistical Analysis:

Pearson Chi-square test was used for comparing the results.

Results:

At the end of 1 month experimental group showed better rating in comparison to control group in PGI GWBM, basic living skills and IDEAS.

Conclusion:

Yoga could improve patients’ subjective well-being, their daily basic living functioning, personal hygiene, self-care, interpersonal activities and communication, and prompted more involvement in routine work.

Yoga is the oldest system of holistic health in the world with its roots originating in Indian philosophy. The contribution of yoga on mental health practice has been acknowledged worldwide and is used as an adjunct to psychotherapy in several countries. Yoga means union, as it harmonizes the body, breath, mind and spirit. The aim of yoga therapy is to teach the brain and body to work in harmony. Specific asanas work on the various systems of the body, bringing alertness to mind, while soothing nervous system and glands, relaxing brain, and maintaining a physical, physiological, and emotional balance. The yoga sessions involve the practice of floor, sitting, and standing poses, inversions (headstand, shoulder stand), breathing exercises (pranayama), and meditation. Since, yoga has a holistic approach encompassing body, mind and soul and therefore, yoga is a combination of physiotherapy, psychotherapy, and spiritual therapy.

General well-being may be defined as the subjective feeling of contentment, happiness, satisfaction, with life's experiences and of one's role in the world of work, sense of achievement, utility, belongingness, and no distress, dissatisfaction or worry, etc. It may well be maintained in adverse circumstances and conversely, may be lost in favorable situation. The general well-being may show some degree of positive correlation with quality of life, job satisfaction/general satisfaction level, sense of achievement, etc., and negatively related with neuroticism, psychoticism and other such variables.

There is a large body of literature and scientific data regarding the pharmacological and psychosocial interventions and the rehabilitation of patients with schizophrenia, however, efficacy of yoga therapy in the management of patients with schizophrenia is understudied. Several features of yoga make it an attractive option for treating schizophrenia. Yoga practice, including physical postures, yoga breathing, and meditation and guided relaxation improved delayed recall of spatial information in children.[1] Sharma[2] demonstrated that yoga practice could improve executive functions like manipulation of information in the verbal working memory, attention span and visuo-motor speed of the patients suffering from major depression. Yoga has been shown to improve social and occupational functioning, better adjustments to day to day life problems, positive outlook towards life, work, useful in reducing stress, improved mood, and improvement in overall quality of life.[3,4,5] Yoga could bring a significant reduction in scores on anxiety, depression and tension as well as an increase in well-being.[6,7]

Studies also showed effectiveness of yoga in physical, physiological and psychological well-being,[8,9] neurobiological changes,[10,11] general well-being,[12] mental health,[13] psychosomatic disorders like asthma,[14] chronic back pain,[15] cancer,[16] migraine,[17] and diabetes mellitus.[18] Yoga practice, in conjunction with conventional medical treatment, may improve schizophrenic symptoms, social and occupational functioning, quality of life, discipline, and adaptive functioning among schizophrenic patients.[19,20] Yoga has been shown to reduce heart rate and blood pressure, increase lung capacity, increase the amount of time the breath can be held, improve muscle relaxation and body composition, cause weight loss and increase overall physical endurance.[21]

The present study is an attempt to demonstrate whether yoga therapy could help schizophrenics to improve their general well-being, self-care, interpersonal and routine functioning, provide better adjustment to daily life difficulties, and inculcate positive outlook toward oneself, others and towards life.

Hypotheses

There will be no significant difference in pre- and post-assessment between experimental and the control group in their subjective well-being, daily basic living functioning, self-care, interpersonal activities and communication.

MATERIALS AND METHODS

Sample

A total of 30 chronic schizophrenic male patients, age range of 20-50 years with minimum primary level education, diagnosed according to International Classification of Diseases-10 criteria with minimum duration of illness 2 years, positive and negative syndrome scale (PANSS) scores ranging from mild to moderate, admitted in different wards of Ranchi Institute of Neuro-Psychiatry and Allied Sciences, Kanke, Ranchi constituted the sample. The patients having major physical problems, co-morbid psychiatric disorder, history suggestive of MR, epilepsy, head injury, concurrent active medical disorder and active psychopathology that interfere with following and understanding instructions were excluded from the study.

Measures

Socio demographic and clinical data sheet

It is a semi-structured Performa contains information about the sociodemographic variables like age, sex, marital status, education, occupation, domicile, religion and monthly family income of the subjects, and the information about diagnosis, age of onset, mode of onset, course of illness, total duration of illness, and family history of mental illness.

Positive and negative syndrome scale

The PANSS,[22] is a typological and dimensional assessment instrument for schizophrenic phenomena. In this 30 item seven point rating instrument, the first seven items are grouped to form a positive scale which measures symptoms that are superadded to a normal mental status, and another seven items constitute a negative scale assessing features absent from a normal mental status. The last 16 items forms the general psychopathology scale, gauges the overall severity of schizophrenic disorder. Each of the items is rated on a seven rating points as absent (1), minimal (2), mild (3), moderate (4), moderate severe (5), severe (6), and extreme (7).

PGI general well-being measure

PGI general well-being measure,[23] was originally developed by Dr. H. Dubey in 1970. In the present study, the Hindi version of the measure, consisting of 20 items was used. The subjects are asked to ‘tick’ to the questions to which they agree and the number of ‘ticks’ which constitute the well-being score of the particular individual.

Checklist for basic living skills

It was used to assess the basic living skills of the patients. It defines living skills as those skills which help the patient to take care of themselves without depending upon others. It consists of questions related to personal hygiene such as toileting, brushing teeth, bathing, hair care, nail care, eating habits, and housekeeping. Rating is done on the basis of 4 point scale, that varies from 0 to 3 rating to where the score of 0 suggest that the patient perform skill by self and correctly without any help and the score 3 suggest that the patient cannot perform the skill correctly without any help.

Indian disability evaluation and assessment scale

IDEAS,[24] was developed by the Rehabilitation Committee of the Indian Psychiatric Society in 2002. IDEAS are suited best for the purpose of measuring and certifying disability in mental disorder. IDEAS assess disability in four areas: self-care, interpersonal activities (social relationship), communication and understanding, and work. Scores for each items range from 0 to 4, where- ‘0’ indicates no disability, ‘1’ indicates mild disability, ‘2’ indicates moderate disability, ‘3’ indicates severe disability, and ‘4’ indicates profound disability.

Procedure

After the selection of the participants according to the exclusion and inclusion criteria, they were contacted individually and explained about the purpose of the research and informed consent was taken to participate in the study. Subjects were divided into two groups, 15 patients were in the experimental group and 15 were in control group. After the base line assessment applying primary outcome measures such as PGI general well-being measure, checklist for basic living skills, and IDEAS, one group was assigned for yoga therapy along with Pharmacotherapy (experimental group, n=15), and the other group for Pharmacotherapy alone (control group, n=15). In yoga therapy, the following postures/asanas were included: Standing Postures (Tarasana, Trikonasana, Lolasana, Utkatasana, Santulanasan, Tadasan; Surya Namaskar_2 Chakra with Mantra, Savasan; Lying posture_supine (Uttanpadasan, Uttanasan, Sarvangasan, Pastchimotasan, Pavan Muktasan, Naukasan, and Savasan); Lying posture-prone (Bhujangasan, Salabhasan, Dhanurasan, and Makrasan); Sitting Posture (Vajrasan, Shasakasan, Gomukasan, Ardhmatsyendrasan, Yogmudrasan, and Padmasan); and Pranayam-breathing exercise (Bhastrika, Kapal-Bhati, Anulom vilom, Bhramari, and Omkar).

The patients attended yoga therapy every day, except holidays, for about 1½ h including motivational and feedback session, for about 1 month. All the sessions were conducted under the guidance of very well trained yoga teacher of the institute. At the beginning of every yoga session, the patients were motivated by explaining the rationale and positive effects of yoga practice. Finally, 28 patients completed the study (14 each was in experimental and control group). Then post-assessment was done for both the groups using the primary outcome measures.

Statistical analysis

The results were analyzed by using Statistical Package for Social Sciences version 16.0 (SPSS 16.0). The Pearson Chi-square test has been used to analyze and evaluate the data obtained by the pre and post-assessment.

RESULTS AND DISCUSSION

The study aimed to determine the efficacy of yoga therapy on subjective well-being, basic living skills, social, communicational and occupational functions of schizophrenic patients. Both the groups were matched with regard to age, sex, marital status, education, occupation, domicile, religion, and family income per -month [Table 1. The] groups were also matched with regard to clinical characteristics such as age of onset, mode of onset, course of illness, family history of mental illness, and there was significant difference in duration of illness (χ²=4.762, P<0.05). At the end of 1 month schizophrenic patients in yoga therapy showed better rating compared to control group in the measures of general well-being [Table 2], basic living skills [Table 3], and in communication and understanding [Table 4].

Table 1.

Demographic characteristics of experimental and control group

Table 2.

The comparison of post graduate institute-general well-being measure scores, which showed significant difference between pre- and post-test for experimental and control group

Table 3.

The comparison of dysfunction scores of checklist for basic living skills between pre- and post-test for experimental and control group

Table 4.

The comparison of scores between pre- and post-test in Indian disability evaluation and assessment scale for the experimental and control group

Though there have not been many yoga studies conducted on patients suffering from schizophrenia to support the present findings, yoga therapy could bring a significant improvement in the areas of general well-being, basic living skills, interpersonal activities, communication and, understanding, discipline, and could help to inculcate positive outlook toward life.

In the measures of general well-being experimental group showed significant improvement in feeling happiness, feeling good, anger control, and feeling worthiness. Feeling satisfaction and feeling healthy showed significant improvement in both the group. Adequate sleep was significantly improved only in the control group. Another important thing to be noted is that in the experimental group while all other variables showed improvement, in the control group many variables such as feeling happiness, feeling energetic, feeling no anxiety, feeling enjoyment, and feeling of concern for others, give deteriorated scores and the variables like feeling good, interest in work and feeling worthiness reflects no change at all.

The practice of yoga resulted in positive moods, improved negative moods, and improved the subjective wellbeing and quality of life,[25] and could bring improvement in various parameters such as a better sense of well-being, feeling of relaxation, improved concentration, self-confidence, improved efficiency, good interpersonal relationship, increased attentiveness, lowered irritability level and an optimistic outlook in life in the yoga group.[8] Yoga practice could bring down scores on anxiety, depression and tension as well as improvement in well-being in self-evaluation scales.[7]

In the measures of basic living skills significant improvement was noted for the experimental group in the areas of personal hygiene in terms of toileting, brushing, bathing, hair care, nail care, eating habits and housekeeping, whereas in the control group significant improvement was noted only in few areas. In the area of toileting, patients in the control group also show significant improvement in terms of hygiene like using enough water, adjusting dress after toileting and clean hands. Scores of some areas like washes mouth and hand and cleans all parts of the body reveals deterioration in the control group.

Discipline of the mind and the body is the essence of yoga. The yoga group significantly improved in terms of personal hygiene, discipline, and daily basic living functioning. It was noted that after 1 week of yoga sessions the patients started to come in time with appropriate and neat dress. Most of the patients started to help other patients for maintaining personal hygiene, cooperated with ward staff and helped them in treatment procedures. Yoga practice could benefit mentally handicapped subjects by improving their mental ability including motor co-ordination and social skills. Socially disadvantaged adults and children in a remand home showed significant improvement in sleep, appetite and general well-being,[26] and reported better mental function after yogic practices.[9]

On measures of IDEAS, communication and understanding improved significantly in the experimental group, while all other areas was such as self-care, interpersonal activities, and routine work improved significantly in both the groups after the 1 month yoga practice. These changes suggest other factors like interaction with other patients and staffs, group meeting conducted in the wards, psychiatric medicines, etc., were also found to play a significant role in overall improvement of the patients functioning. However, better rating in experimental group suggests that yoga as a discipline promotes self-discipline improves physical and mental hygiene and provide positive outlook towards life. Improved communication and understanding in the yoga group support the studies that yoga could help to improve cognitive functions.[27,1]

The most important benefits of yoga is its application in relieving stress and fatigue, invigoration and vitality, relaxation and self-discipline, are well worked in the present study. Yoga practice could improve social and occupational functioning, quality of life, discipline, and adaptive functioning among schizophrenic patients.[19,20] However the current findings should be interpreted in light of the limitations like small sample size, samples were only inpatient male patients, could be controlled on limited parameters, and limited period of yoga practice.

CONCLUSION

Considering the positive findings in the yoga group like improved subjective well-being, daily basic living skills, personal hygiene, self-care, social-interpersonal activities and communication, and self-discipline, yoga therapy could be added as a daily discipline to improve their overall functioning. In Indian cultural environment patients suffering from schizophrenia can possibly be more easily motivated to undergo yoga therapy and interiorize its beneficial effects.