Integrating yoga in mental health services

The international community has accorded recognition to yoga through the UN, and 21^st June will in future be observed as International Yoga Day world over. Yoga means union; of one's personal consciousness with the cosmic. Yoga is a spiritual way of life, practiced by many over millennia. Practitioners have recognized other benefits of the yoga lifestyle, positive effects on the mental faculties being the robust and most consistent. The sage Patanjali, recognized as the father of modern yoga, mentions the positive effects of yoga on mind; Yogah Chittavritti Nirodah’ in the very first aphorism of his yoga sutras. It means ‘Yoga steadies one's mind’. Considering the recognized benefits of yoga in helping the mind to achieve positive health, its role in relieving psychiatric disorders is being put to use by several psychiatrists1. Among the milder form of the psychiatric conditions, anxiety and depression have been extensively investigated. Yoga's positive benefit in these has been well demonstrated2. Yoga's effects in these conditions are brought about by relieving stress. Yoga is a part of most stress-relief packages.

Besides stress relief, yoga-based interventions have been used in severe mental disorders, one of which is schizophrenia3. The results of clinical trials are encouraging. The negative and cognitive symptoms of schizophrenia, which have been a challenge for conventional treatments, have responded to yoga4. These reports have led to the inclusion of yoga as a complementary therapy for schizophrenia in the most recent National Institute for Health and Care Excellence (NICE) guidelines of the UK5. Yoga holds promise in another population, the elderly with cognitive failure6. Studies have also supported yoga therapy as a sole or adjunct therapy for various categories of depressive disorders, from dysthymia to major depressive disorder7,8. Though the term “Yoga” in most studies refers to the postures (asanas) and breathing (pranayama), meditation has also been used and even independently, with success in improving psychiatric disorders. A variant of meditation -mindfulness - has been extensively researched9.

Benefits of yoga in treatment of psychiatric conditions have been corroborated by several positive physiological effects. Reduction in cortisol, increases in neurotropic factors (BDNF), plasma oxytocin, heart rate variability, amplitude of the cognitive event related potential, and gray matter volume are reported in different studies10,11,12,13. However, there exist several challenges in yoga therapy research in the psychiatrically ill. Illness severity in psychiatric ailments is measured based on patient interviews and self-reports. Patients who are inclined for yoga therapy may report better effects. Likewise, people who choose yoga in preference to other interventions are likely to report better outcomes. These issues call for double blind placebo-controlled and/or multicentric studies. Can there be an ideal blinding procedure in yoga trials? Some attempts have been made to use exercise as a control group with an independent rater who is ‘blind’14. Yet patients cannot be ‘blinded’ to treatment. The suggestion effect of an emotionally significant intervention, i.e. yoga, cannot hence be excluded.

To overcome these methodological challenges objective parameters of yoga effect deserve attention, for example, change in gray matter volume in brain15, gene expression16, telomerase activity17, etc. Lastly, is there uniformity in yoga procedures? Yoga schools differ in the module used in therapy. This is compounded by the variations in the frequency of its use, the length of training sessions and the competence of the yoga therapist18. The school that introduces yoga for therapy can also influence the patients, governed by its stature in the society. Hence, there is a need to evolve generic and uniform modules of yoga for clinical applications. There are also several barriers in availing yoga for therapy19. Clinicians need to recognize this, and attempts should be made to develop easily accessible yoga therapy services.

Given the growth of evidence for yoga as therapy in mental health services, would a yoga therapist, in near future, become an integral part of mental health team just as psychologists and psychiatric social workers? Mental health professional teams may observe the International Yoga Day and pay tribute to yoga by integrating yoga services in mental health service delivery.