Effectiveness of Rajyoga meditation as an adjunct to first-line treatment in patients with obsessive compulsive disorder

Abstract

Background:

Yoga is a set of mental, physical, and spiritual practices with its origin in ancient India. The renewed interest in Yoga has led to the exploration of its benefits in a variety of psychiatric disorders such as schizophrenia, depression, and anxiety disorders. There is a dearth of literature on the effect of yoga in obsessive compulsive disorder (OCD) in the Indian context.

Aim:

The present study was conducted to find out the efficacy of Rajyoga meditation (RM) as an adjunct to the first-line treatment in the treatment of OCD.

Materials and Methods:

Patients with OCD (diagnosed according to Diagnostic and Statistical Manual of Mental Disorders fifth edition) were divided into two groups – (i) The meditation group (MG), which included 28 patients and (ii) The nonmeditative group (NMG), which included 22 patients. MG practiced RM protocol for 3 months duration in addition to the pharmacological treatment. The NMG continued on pharmacological management as usual. The symptomatology was assessed at baseline and 3 months using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS).

Results:

At 3 months, both groups demonstrated improvement in symptoms. The improvement in MG was statistically significant with a change of 9.0 ± 3.16 in Y-BOCS and a 49.76 ± 9.52% reduction in symptoms. Improvement scores of NMG were also statistically significant with a change of 3.13 ± 2.59 in Y-BOCS and 18.09 ± 14.69% reduction in symptoms. MG showed significantly more improvement in Y-BOCS scores (49.76 ± 9.52) as compared to NMG (18.09 ± 14.69) using the student's paired t-test (P < 0.001).

Conclusion:

The present study suggests that the RM is an effective adjunctive therapy to reduce obsessions and compulsions in patients with OCD.

INTRODUCTION

Obsessive compulsive disorder (OCD) is a common neuropsychiatric disorder which is known to affect nearly 1%–3% of the adult population[1,2] It is listed among the top ten causes of disability in the world.[3] The onset is usually in childhood or early adulthood with peaks occurring between 9–11 and 20–23 years of age.[4,5] OCD typically has a lifelong fluctuating course[3,6] with complete remission in about 30%–40% while unremitting course in <30% as reported in two studies from India.[7,8]

The existing treatment strategies include pharmacological as well as psychotherapeutic interventions such as cognitive behavioral therapy (CBT). However, these are only partially effective.[9,10] It usually takes 2–4 weeks for the medications to show clinical response while CBT is known to take a longer time before the clinical response is evident. Although the effects of CBT usually persist for some time even after its discontinuation,[6,11] the discontinuation of pharmacological agents almost always result in complete relapse.[12,13]

Yoga is a Sanskrit word which means union. There are many systems of yoga such as Hatha yoga, Mantra or Japa yoga, Surat-shabd yoga, Kundalini yoga (KY), Tantra yoga, and Rajyoga. There have been systematic reviews and meta-analysis to substantiate the role of Yoga in psychiatric disorders.[14,15,16,17] KY has already shown efficacy in OCD.[18,19,20] Other forms of yoga such as Sudarshankriya have been found to be beneficial in depression.[21] Yoga has also been found to be helpful in improving sleep in patients with minimal cognitive impairment.[22]

Rajyoga is a behavioral intervention practised by Brahma Kumaris and is primarily a form of meditation. As the word “Raj” means the king, sovereign, or the supreme, Rajyoga is the supreme or the highest Yoga that empowers the self to rule the mind, sense organs, and the body. Rajyoga meditation (RM) is a meditation sans rituals or mantras and can be practiced anywhere at any time with “open eyes,” making it simple yet versatile.

RM helps to strengthen the mind, and therefore, individuals are able to dismiss and separate their awareness and self-identity from obsessive thoughts. The underlying mechanism is believed to be a significant increase in the serotonin levels coupled with decrease in the levels of monoamine oxidase, an enzyme that breaks down neurotransmitters and cortisol. This leads to decrease in anxiety[23] and the mindfulness result in a shift toward parasympathetic nervous system dominance, possibly through direct vagal stimulation.[24]

With this background in mind, the present study was undertaken to find out the efficacy of RM as an adjunctive treatment in OCD.

MATERIALS AND METHODS

Patients with OCD diagnosed according to the Diagnostic and Statistical Manual of Mental Disorder, fifth edition (DSM-5) criteria[4] were recruited by consecutive sampling from the outpatient department of psychiatry in a tertiary care hospital in this quasi-experimental study. We used the nonequivalent control group design.

Inclusion criteria

1. Patients in the age group of 18–60 years diagnosed according to the DSM-5 criteria for OCD

2. A minimum score of 15 on the Yale–Brown Obsessive Compulsive Scale (Y-BOCS).

Exclusion criteria

1. Patients with other DSM-5 psychiatric conditions as the primary disorder (schizophrenia, bipolar disorder, depression, mania, and mental retardation)

2. Comorbid substance abuse disorder

3. Patients with trichotillomania or nail biting as their only compulsion

4. Any contraindications for practicing yoga such as history of spinal injury, recent surgery, fracture, stroke, and epilepsy.

Patients were stabilized on pharmacological management for a period of 3 months (sertraline in a dose of 150–200 mg/day, fluoxetine 60–80 mg/day, fluvoxamine 200–250 mg/day, clomipramine 150–200 mg/day as monotherapy; in some patients lower doses were allowed when they were taking a combination of two drugs).

After this, the patients were motivated by the treating psychiatrist to enrol for the meditation classes conducted by a trained yoga instructor with 20 years of personal and teaching experience in RM who volunteered to participate in the study. Prior to enrolment, all patients were informed about the meditation protocol to be followed for a duration of 3 months. They were neither allowed to take any other psychotropics besides their prescribed medication nor allowed to take any other form of therapy for OCD during the study period. Hence, the participants were divided into two groups. Meditative group (MG) included patients who were taught RM and were continued on medications. Nonmeditative group (NMG) included OCD patients on medication who did not want to follow the meditation protocol and were taken as controls. Using standard sample size calculation formula, we initially estimated the sample size of 35 patients in each arm. However, we could recruit a total of 50 patients during the study period as per the availability of the Rajyoga instructor.

Written informed consent was obtained from all the participants. The study was conducted in compliance with the Code of Ethics of World Medical Association, Declaration of Helsinki. The study was approved by the Research and Ethics committee of the institute.

Intervention

Meditation meetings were held twice a week on Tuesdays and Fridays between 10 a.m. and 2 p.m. in the department of Psychiatry in a quiet room. All the participants in the MG were instructed to practice their respective protocols on a daily basis to the best of their ability and visit the department once a week for meditation with the expert. The caregivers of the patients were also instructed to remind and help them maintain a daily routine of meditation. Personal calls and repeated messages were also made to the subjects to follow the routine pattern diligently to ensure compliance.

Meditation sessions began each day by sitting quietly. Patients were asked to withdraw their mind from all the worldly thoughts, including the thoughts of their own body, and collect their consciousness, at least for some time, and think of the shining and peaceful self as a point of divine and conscientious light and then focus their attention on the Supreme Soul. For Rajyoga meditation, there is neither a need to practice breath-control, physical postures, or use a mantra, or an image nor does it require one to stop all thoughts but stop only worldly or negative thoughts and concentrate the mind on God. The total protocol lasted for 45 min while the meditation lasted 20 min per session.

Assessments

Y-BOCS is a clinician rated 10 items scale. Each item is rated from 0 (no symptoms) to 4 (extreme symptoms) (total rating 0–40) with separate subtotal for obsessions and compulsions. It is a reliable tool to measure severity of illness in patients with OCD.[25,26] The Y-BOCS was administered by the psychiatrist as a semi-structured interview. The Y-BOCS scale was administered at baseline before the start of the meditation protocol and at the end of 3 months. The rater for Y-BOCS was unaware of the group allocation of the patients.

Statistical analysis

Statistical analysis was done using the SPSS Statistics for Windows, Version 17.0. (Chicago, SPSS Inc.). Data were expressed as number, percent, range, mean, and SD wherever appropriate. Nonparametric variables such as gender and marital status were compared among two groups using the Chi-square test. Parametric variables such as age and duration were compared among groups using unpaired t-test. Intragroup change was assessed using the paired t-test. The repeated measure ANOVA was used to evaluate the effect of Rajyoga on OCD, measured through the Y-BOCS at baseline and after 3 months. Hedges's g was used to measure effect size; Hedges's g is used as a variation of Cohen's d to correct for sample size <20.[27]

RESULTS

A total of 50 patients were recruited for this study of 6-month duration (initial 3 months for stabilization of symptoms of OCD with pharmacological agents followed by meditation protocol of 3 months). Out of these, 28 volunteered for participation in the MG, while 22 who continued on medications formed the control group, i.e., NMG.

All the patients who did not follow the daily meditation routine or could not attend the departmental meditation class for 2 weeks in a row or did not take the medication properly or did not respond to correspondence were excluded from the study.

By the end of the study, we had a data of 31 patients (21 males and 10 females). 16 were in the meditation group (MG) (3 females) and 15 were in the NMG (7 females).

The mean age of the participants was 34.13 ± 11.38 years (range 18–60 years). Mean age was 35.75 ± 12.20 years in the MG which was comparable to 32.40 ± 10.57 years in the NMG. The mean duration of OCD in our study was 5.81 ± 4.67 years (range 1–20 years). Twenty-five patients had a duration of OCD <10 years. The mean duration of OCD was comparable between the two groups (6.0 ± 4.86 years in the MG; 5.6 ± 4.63 years in the NMG [Table 1].

Table 1.

Baseline characteristics of the participants

	Total	MG	NMG	P
Number of patients	31	16	15
Age (years)
Mean±SD	34.13±11.38	35.75±12.20	32.40±10.57	0.422 (NS)
Range	18-60	18-60	19-60
Male:females	21:10	13:3	8:7	0.097 (NS)
Unmarried	7	3	4
Duration of OCD
<10 years (n)	25	12	13	0.816 (NS)
≥10 years (n)	6	4	2
Mean±SD	5.81±4.67	6.00±4.86	5.60±4.63
Range	1-20	1-20	1-20

NS – P>0.05 (not significant); SD – Standard deviation; OCD – Obsessive compulsive disorder; MG – Meditators group; NMG – Nonmeditators group

The Y-BOCS scores were comparable in both the groups at baseline (18.44 + 6.22 and 17.60 ± 3.80) [Table 2].

Table 2.

Yale-Brown Obsessive-Compulsive Scale readings before and after meditation protocol/treatment in participants

	MG			NMG			MG versus NMG$
	Mean±SD	Change	P#	Mean±SD	Change	P#
At onset	18.44±6.22	-	-	17.60±3.80	-	-	0.657 (NS)
At 3 months	9.44±4.38	9.00±3.16	<0.001*	14.47±4.39	3.13±2.59	<0.001*	0.003*
Percentage improvement in symptoms		49.76±9.52			18.09±14.69		<0.001*

^#Paired t-test; ^$Unpaired t-test; NS – P>0.05 (not significant); *P<0.05 (Significant). MG – Meditators group; NMG – Nonmeditators group; SD – Standard deviation

Table 2 shows that both groups showed statistically significant improvement in Y-BOCS scores after the respective therapies. Y-BOCS scores decreased to 9.44 ± 4.38 in the MG and 14.47 ± 4.39 in the NMG. The improvement in Y-BOCS scores was also tested in both groups for statistical differences using a paired t-test. The percentage improvement in MG was 49.76 ± 9.52% as compared to NMG which showed an improvement of 18.09 ± 14.69% only, and this difference was statistically significant.

The repeated measure ANOVA was used to evaluate the effect of Rajyoga on the Y-BOCS at baseline and after 3 months. There was a significant effect of Rajyoga on the Y-BOCS scale, Wilk's Lamda 0.104, F (1, 15) = 129.6, P = 0.000.

The effect size measuring the difference between the mean improvement in the two groups was calculated using Hedges's g, which was found to be 1.2, suggesting significant positive outcome with RM in OCD.

Non-structured interview with the patients in MG revealed that patients felt much better, started performing better at their work places and felt more confident about themselves. Most of them wanted to continue the meditation protocol. The family members of patients were also happy to see the improvement in the patients. Some family members had also started practicing meditation to help their patients continue the meditation protocol. No adverse effects were reported by the participants after practicing yoga.

DISCUSSION

Our quasi-experimental study has explicitly demonstrated the therapeutic benefits of Rajyoga mediation in OCD over pharmacological management alone. While the therapeutic effectiveness of yoga in OCD has been demonstrated in various studies,[18,19,20,28,29,30] the literature in this regard is sparse from India.[31,32]

We used DSM-5 criteria for including patients in our study as compared to a study by Bhat et al.[31] who used DSM-IV criteria. DSM-5 criteria for OCD were revised in 2013 and are widely used criteria currently.

In the present study, the difference between the pretest and posttest scores show an improvement of 49% (49.76 ± 9.52) with Rajyoga and psychopharmacological management as compared to 18% (18.09 ± 14.69) improvement with psychopharmacological management alone. Our results are comparable to Shannahoff-Khalsa et al. who used Kundalini Yoga (KY) in their study and showed a 38.36% improvement at 3 months and 71% improvement after 15 months.[30] A study by Bhat et al. also showed an improvement of 39% with yoga after 2 weeks.[31] This reflects that the combination therapy of yoga and pharmacological management is definitely more effective than pharmacological management alone. However, in contrast to our study, the other studies have not directly compared the effect of yoga to pharmacological and psychotherapeutic management. Moreover, all the three studies have used different types of yoga protocols.

The beneficial effects of yoga in the treatment of OCD lie in its neuroprotective potential and in its ability to promote neuroplasticity. Voxel-based morphometric studies have demonstrated that long-term yoga is associated with larger volume in gray matter as well as several cortical and subcortical regions associated with sustained attention and self-control.[33] Yoga therapies have also been shown to increase GABA levels in the brain as measured by the magnetic resonance spectroscopy.[34] Patients in our study also reported that meditation helped them to handle their unpleasant emotions with more flexibility and increased willingness. This improvement can be attributed to this mechanism of self-directed neuroplasticity.

Another study by Hanstede et al. has demonstrated that a mindfulness intervention reduces symptoms of OCD, possibly by increasing the letting go capacity. The authors advocated that meditation and mindfulness may be possible alternative therapeutic options for treating symptoms of OCD.[35] In our study, meditation probably helped to discipline the mind from distraction by achieving a quiet, focused, and controlled mind. This provided an environment for patients to remove compulsive rituals and prevented falling back on them.

The results of the present study also showed significant improvement in the obsessive and compulsive behavior of the patients, which are quite encouraging. The positive results are probably attributed to a well-planned feedback and continuous motivation to the patients. The patients were telephonically contacted on an almost daily basis, reminding them of their weekly appointments with the practitioner and weekly meditation session with the expert and their daily meditation protocol. Another important aspect was the active involvement of the family members to stimulate, motivate, and encourage patients to follow the meditation protocol. In fact, many of the patient's relatives also learned meditation technique for the same reason from the practitioner. It can be said that any method which helps patients to sit calmly in a low arousal environment and induces a relaxation response in various domains would equally bring benefit to patients with OCD and anxiety disorders. This hypothesis is supported by Bhat et al. who also demonstrated that the Yoga asanas alleviate the stress and pranayama and chanting based meditation enhance awareness/mindfulness and help in reducing obsessions and compulsions in patients with OCD by producing a calming effect on the body thereby handling of the obsessions at their origin.[31]

We also observed that the patients in the MG reported substantial decrease in their anxiety although this was not measured objectively using clinical rating scales. There were no adverse effects reported in our study similar to the studies by Shannahoff-Khalsa et al.[18,30] and Bhat et al.[31]

Limitation

The main limitation, besides the selection bias, is the high dropout rate in our study. Such a high dropout is expected in these type of studies and is known across various studies involving Yoga meditation.[31,36,37] It seems obvious that adherence to the meditation therapy is a big concern in clinical settings and maintaining compliance is a known difficulty with this therapy. Another limitation is the nonrandomized design and lack of intention to treat analysis which could have diluted the effects of RM. Bias may be encountered in this intervention study due to Hawthorne effect owing to modification of subject's behavior due to the attention that they receive.

CONCLUSION

RM is an effective therapy in the treatment of OCD as an adjunct to pharmacological management. Motivation and adherence under supervision of a qualified therapist are essential ingredients. The present study suggests that the meditation techniques of Rajyoga are effective to reduce the obsessive thoughts and compulsive acts of symptoms of OCD. These approaches have to be practiced for a few weeks to a few months before improvement is apparent. The results of the present study have important implications in the treatment of OCD along with routine medications. However, more randomized controlled studies with a larger sample size for an extended period of time are required to confirm the relevance of the results as well as to look for further improvement in symptoms.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.