Table 4.
Summary of studies examining yoga as an adjunct to or integrated within evidence‐based psychological treatments for common mental disorders
| Mental disorder | Author(s) year country | Interventions (adjunct or integrated) | Aims | Sample | Study design | Outcome measures | Results | Conclusions and future directions | Quality appraisala |
|---|---|---|---|---|---|---|---|---|---|
| Depressive Disorders | |||||||||
| Major and persistent depressive disorders |
Butler et al. (2008) USA |
Adjunct Hypnosis: 10 weekly group sessions of 1.5 h. 2‐h booster session in Week 12. Yoga Intervention: 8 weekly group sessions of 2 h each, one 4‐h retreat and one booster session in Week 12. Psychoeducation: Readings, internet resources, and the self‐help book Feeling Good (Burns, 1999) |
To examine the effects of three interventions on diagnostic status and symptom levels for depressive disorders: 1) Hypnosis and psychoeducation 2) Yoga and psychoeducation 3) Psychoeducation only. |
46 adults (74% women) diagnosed with a depressive disorder: − 50% (n = 23) dysthymia − 28% (n = 13) dysthymia + major depressive episoder (MDE) − 15.2% (n = 7) MDE in partial remission − 6.5% (n = 3) chronic major depression of two+ years. Yoga + psychoeducation group (n = 17) Hypnosis + psychoeducation group (n = 17) Psychoeducation (control group; n = 18) Aged: 22–80 years. Attrition rate: 6/46 (13%). |
RCT pilot with follow‐up |
Hamilton Rating Scale for Depression (HRSD) (Hamilton, 1960) Cornell Dysthymia Rating Scale‐Self Report (CDRS‐SR) (Mason et al., 1995) |
Significantly more participants in the yoga group experienced remission (n = 10; 77%) than those in the control group (n = 5; 36%) (p < 0.03) at follow‐up, but not compared to the hypnosis group (n = 8; 62%). No participants in the intervention groups developed a new MDE at follow‐up compared with the control group (n = 3). |
Preliminary support for the use of group hypnosis or yoga in conjunction with psychoeducation to improve depressive diagnostic status and prevent development of further MDEs. The impact on remission rates indicates potential for hypnosis or yoga as treatments for long‐term depressed mood, in conjunction with psychoeducation. Findings warrant the conduct of larger, more controlled studies examining the separate interventions of yoga, meditation and hypnosis to identify individual treatment effects. |
Level 2 Randomized trial or observational study with dramatic effect |
| Moderate depressive symptoms |
USA |
Adjunct psychological intervention: Manualized individual Acceptance and Commitment Therapy delivered across 6 weekly sessions, approximately 50–60 min each, by graduate therapists. Yoga intervention: Six weekly group sessions of yoga, approximately 60 min each, including practices of mindful awareness via deep breathing, connection to body, breath, and movement, mindful body scan and brief relaxation. Group classes also included nonparticipants. |
To examine whether an adjunct yoga program further reduces depressive symptoms when provided alongside ACT compared to ACT as a standalone treatment. |
24 college students (75% women) with moderate depressive symptoms (as measured by the BDI‐II) ACT + Yoga (n = 12) ACT (control group; n = 12) Aged: 18–25 years (Mean = 20.17 years). Comorbidity: Not specifically reported, 33.3% self‐reported previous mental health diagnoses. Attrition rate: 9/35 (26%) |
RCT |
Beck Depression Inventory‐II (BDI‐II) (A. Beck et al., 2000) Mindfulness Attention Awareness Scale (MAAS) (Brown & Ryan, 2003) Acceptance and Action Questionnaire‐II (AAQ‐II) (Bond et al., 2011) World Health Organization Quality of Life – short form (WHOQOL‐BREF) (The WHOQoL Group, 1998) |
No significant differences observed on outcomes between groups. Significant improvements were observed pre‐post analyses for mindfulness, overall quality of life, psychological quality of life and physical. Nonsignificant improvements observed on pre‐post analyses for depression, acceptance, and environment quality of life. |
Findings suggest that an adjunct yoga program to ACT does not enhance reductions to depressive symptoms compared to ACT as standalone treatment. ACT and yoga resulted in significant improvements to mindfulness, but not depression. Future research with larger samples is needed to replicate findings and review potential confounding variables. |
Level 2 Randomized trial or observational study with dramatic effect |
| Pre or postpartum depression |
Zuehlke USA |
Integrated Psychological Intervention: Eight manualized group sessions of two hours each, combining CBT and Interpersonal Psychotherapy with psychoeducation and yoga. Yoga Intervention: Low impact 20‐minute yoga sessions via a video following psychological aspects of the intervention, tailored to postnatal women, incorporating relaxation training and physical activity. |
To develop an integrative group therapy manual for decreasing depressive symptoms and increasing overall wellbeing in women with postnatal depression. | Designed for adult women within six months of their first childbirth diagnosed with MDD, prepartum or postpartum depression. | Protocol Only | Not available due to study design. | Not available due to study design. | Not available due to study design. |
Level 5 Mechanism‐based reasoning |
| Perinatal depression and bipolar spectrum disorder |
Miklowitz et al. (2015) USA |
Integrated psychological intervention: Eight weekly 2‐h group mindfulness‐based cognitive therapy (MBCT) sessions facilitated by trained clinicians based on a standardized manual (Segal et al., 2013). Yoga intervention: Mindful yoga, body scan, and sitting meditations included in sessions. |
To examine the feasibility, acceptability, and benefits of an eight‐session MBCT program incorporating yoga for women with perinatal depression (MDD) or bipolar spectrum disorder (BSD); and to secondarily compare findings across MDD and BSD participants. |
39 pregnant women with a lifetime diagnosis of a mood disorder and current subthreshold symptoms (break down of diagnoses not reported). Aged: Over 18 years (mean = 33.7 years for group with bipolar disorder; 35.2 years for group with depression). Attrition rate: 7/39 (18%) |
Quasi‐experimental with follow‐up |
Client satisfaction questionnaire (CSQ‐8) (Larsen et al., 1979) BDI‐II (Beck et al., 2000) HRSD (Hamilton, 1960) Young Mania Rating Scale (YMRS) (Young et al., 1978) State‐Trait Anxiety Inventory‐Current Status Scale (STAI‐C) (Spielberger, 1983) Longitudinal Interval Follow‐Up Evaluation (LIFE) (Keller et al., 1987) Five Facet Mindfulness Questionnaire (FFMQ) (Baer et al., 2008) |
32 participants completed the program and reported high levels of satisfaction. BDI‐II scores decreased significantly across both groups over time, from a mildly to a minimally depressed state. Participants with depression showed greater reductions in depression and increases in mindfulness than participants with bipolar disorder. No significant changes were observed in anxiety or mania scores. |
Preliminary findings in support of MBCT as a promising treatment for both pregnant and postnatal women with depression, with high levels of treatment satisfaction, completion rates and reductions in depressive symptoms that maintain over time. Future research is needed to focus specifically on pregnant women with bipolar disorder and incorporate larger more rigorous research designs. |
Level 3 Non‐randomized controlled cohort/follow‐up study |
| Major depressive disorder (MDD) |
Niemi et al. (2016) Vietnam |
Adjunct Eight weekly group sessions including: Psychoeducation: Based on standardized manual (Patel et al., 2010) including information about symptoms, effects on interpersonal difficulties, support to engage in treatment and strategies to alleviate symptoms. Yoga Intervention: Including slow movements and breathing exercises, with some components of Qigong for cultural relevance. |
To evaluate the effectiveness of a collaborative stepped‐care community‐based intervention including psychoeducation and yoga for depression management in primary healthcare. |
56 adults with moderate level depression (42.9% women) Psychoeducation + Yoga (n = 34) Treatment as usual (Control group; n = 22) Aged: 17–96 years (mean 64.5) Comorbidity: Not reported. Attrition rate: 0/56 (0%) although 11/56 (20%) were lost to follow‐up. |
Cluster RCT | Patient Health Questionnaire‐9 (PHQ‐9) (Kroenke et al., 2001) |
Statistically significant reductions in the post‐intervention depression scores reported for the intervention group compared to treatment as usual. 42.9% of participants in the intervention group recovered from depression after 8‐weeks, while none did in the treatment as usual group. |
Findings suggest that the combined intervention of yoga and psychoeducation was more effective for treating moderate depression than standard care. Future research with larger sample sizes is needed to examine the cross‐cultural generalizability of these findings and feasibility of integrating such a combined program into primary care, along with long‐term follow up outcomes. |
Level 2 Randomized trial or observational study with dramatic effect |
| Anxiety disorders | |||||||||
| Generalized Anxiety Disorder (GAD) |
Khalsa et al. (2015) USA |
Integrated Six weekly one and a half hour sessions applying the group treatment of Yoga‐enhanced CBT (Y‐CBT) including: Psychological Intervention: instruction and experiential cognitive restructuring using both traditional and alternative CBT interventions Yoga Intervention: 30 min of Kundalini Yoga (Shannahoff‐Khalsa, 2006) in each session, including breathing practices, (long slow abdominal breathing), loosening warm‐up exercises (particularly for spinal flexibility), physical postures and movements, yoga meditations incorporating mindfulness, awareness, breath regulation, and deep relaxation practices. |
To evaluate the preliminary efficacy of Y‐CBT in relation to reducing anxiety and depression in a treatment‐resistant population. |
32 adult participants (81% female) diagnosed with “treatment resistant” GAD and at least one comorbid mental disorder in a community‐based mental health service. Aged: 23–62 years (Mean = 43.21 years). Comorbidity: ‐ Additional mood disorder (n = 24) ‐ MDD (n = 18) ‐ Substance use disorder (n = 4) ‐ ADHD (n = 2) ‐ PTSD (n = 4) ‐ Panic disorder (n = 3) ‐ Schizophrenia (n = 3) Attrition rate: 10/32 (31%). |
Single group pre‐post |
The State Trait Anxiety Inventory (STAI) (Spielberger, 1983) The Treatment Outcome Package (TOP) (Kraus et al., 2005) |
Statistically significant improvements reported for state and trait anxiety, as well as measures of depression, panic, suicidality, sleep disturbance, sexual function, and quality of life. |
Provides preliminary support for efficacy of the integrated Y‐CBT program for ‘treatment resistant’ presentations of GAD. Future research is needed in the form of a larger randomized control study incorporating qualitative data to supplement quantitative data as well as confirm and better understand the potential accessibility, adherence, and feasibility of Y‐CBT for GAD. |
Level 3 Nonrandomized controlled cohort/follow‐up study |
| Panic Disorder |
Vorkapic and Range (2014) Brazil |
Adjunct psychological intervention: Eight weekly group CBT sessions of 50 min. Yoga intervention: Group yoga sessions (for control group, once weekly sessions for group combined with CBT), of 50 min, over 8 weeks, involving physical postures (asana), breathing techniques (pranayama), relaxation (yoga nidra), and meditation (mindfulness). Participants completing yoga only received biweekly sessions and participants completing yoga and CBT received yoga sessions once per week. |
To investigate the efficacy of yoga in reducing symptoms of panic disorder compared to yoga combined with CBT. |
20 participants (99% female) were diagnosed with panic disorder. Yoga group (n = 10) Yoga + CBT (n = 10). Aged: Mean = 42.3 years (Yoga group); 40.9 years (Yoga + CBT group) Comorbidity: Not reported. Attrition: Not reported. |
Quasi‐experimental |
Beck Anxiety Inventory (BAI) (A. T. Beck & Steer, 1993) Hamilton Anxiety Rating Scale (HAM‐A) (Hamilton, 1959) The Panic Beliefs Inventory and Body Sensations Questionnaire (Chambless et al., 1984) Body Sensations Questionnaire (BSQ; Chambless et al., 1984) |
Significant reductions in anxiety and panic levels were reported across both groups. Greater nonsignificant reductions in panic related symptoms were reported in the yoga and CBT treatment group compared to the yoga only group. |
Improvements in mental health symptoms can be observed after the practice of contemplative techniques including yoga alone or when applied as an ancillary approach to CBT. Future research should focus on the mechanisms by which mind‐body therapies complement each other to potentially improve clinical outcomes for patients with panic disorder. |
Level 2 Randomized trial or observational study with dramatic effect |
| Transdiagnostic | |||||||||
| Depression and Anxiety |
O'Sheac (2020) Australia |
Adjunct Psychological Intervention: Eight weekly group CBT sessions of two hours each, adapted from The Mood Management Group (Nathan et al., 2004), representing treatment as usual (TAU). Yoga Intervention: In addition to TAU, therapeutic yoga program including eight weekly group sessions of one‐hour and individualized home practice. |
To assess the feasibility and acceptability of therapeutic yoga as an adjunct to CBT in a primary mental health setting. To explore whether an adjunctive therapeutic yoga program yields additional clinical benefits alongside standardized group CBT. |
Recruiting adults diagnosed with mild to moderate depression or anxiety attending a primary mental health clinic. | Pilot feasibility and acceptability mixed‐methods study with pre/post and follow up data |
Qualitative: Semi‐structured interviews with participants and stakeholders. Primary quantitative outcome: Depression Anxiety Stress Scales (DASS) (Lovibond & Lovibond, 1996) |
Not available | Not available |
Level 2 Randomized trial or observational study with dramatic effect |
| Depression and Anxiety |
O'Shea et al. (2021) Australia |
As above | To examine whether a personalized therapeutic yoga program was experienced by adults with anxiety and depression as an acceptable or complementary adjunct to group‐based CBT. |
Of the 32 participants who entered the adjunct yoga program, 27 (78% female) provided qualitative data, who were diagnosed with anxiety and/or depression. Aged: 19–66 years (mean = 41.2). Comorbidity: ‐ PTSD (n = 1) ‐ Eating disorder (n = 1). Attrition (of broader study): 7/32 (22%). |
Qualitative arm of above‐mixed methods study As above |
In‐depth semi‐structured interviews at post‐intervention and three‐month follow up timepoints |
Three primary themes with nine subthemes reflecting lived experiences of: 1. The combined therapies: − 1.1. Intuitively appealing, − 1.2. Enhanced therapeutic outcomes, − 1.3. The dance between yoga and CBT. 2. Complementary elements: − 2.1. Moving the body with the breath, − 2.2. Yoga is an embodied routine, − 2.3. A practice for me, and then others, − 2.4 A shared healing journey. 3. Engagement over time: − 3.1. The process of struggle and growth, − 3.2. Yoga as a self‐management tool. |
Adults with anxiety and depression described therapeutic yoga as a highly acceptable adjunct to CBT, that can enhance engagement and clinical outcomes from psychological treatment. Yoga seems to offer an accessible and sustainable practice for adults to self‐manage their mental health. Future research is needed to examine lived experiences of yoga for men, as well as longer‐term outcomes to further determine sustainability. |
As above |
| Posttraumatic stress disorder (PTSD) | |||||||||
| PTSD (caused by combat and military sexual trauma) |
Zalta et al., (2018) USA |
Integrated Three‐week intensive outpatient program including: Psychological Intervention: Cognitive Processing Therapy (CPT) and psychoeducation, delivered across 15 individual sessions and 13 group sessions. 13 group sessions of mindfulness‐based stress reduction (MBSR). Yoga Intervention: 12 group yoga sessions. |
To examine the effects of an intensive outpatient program on symptoms of PTSD and compare difference to those participants with PTSD caused by combat to those caused by military sexual trauma. |
191 veterans and service members diagnosed with PTSD (11.5% women). Sample was represented by 19 program cohorts including 12 combat veteran focussed cohorts and 7 encompassing veterans with military sexual trauma Comorbidity: Not reported. Attrition rate: 15/191 (8%). |
Non‐randomized cohort study |
PTSD checklist for DSM‐5 (PCL‐5) (Weathers et al., 2013) PHQ‐9 (Kroenke et al., 2001) Posttraumatic Cognitions Inventory (PTCI) (Foa et al., 1999) |
Clinically meaningful reductions across all measures of PTSD symptoms from pre‐ to post‐intervention for both groups of veterans with combat and military‐sexual trauma. Improvements observed as greater for combat veterans, although difference was nonsignificant. |
Intensive and multicomponent interventions including yoga show promise for reducing symptoms of PTSD in veterans, alongside or over longer‐term interventions. Future researching is needed to examine level of variance and clinical change caused by each components of treatment (CPT, MBSR and yoga). |
Level 3 Non‐randomized controlled cohort/follow‐up study |
| Combat‐related PTSD |
Steele et al. (2018) USA |
Integrated Warrior Camp 7‐day treatment program: Psychological interventions: EMDR, equine‐assisted psychotherapy and narrative writing. Yoga Intervention: Seven daily sessions of yoga. No further information provided regarding protocol. |
To investigate the efficacy of the Warrior Camp (WC) treatment program for combat related PTSD. |
85 returned service members (29% women) diagnosed with PTSD who had served in the military and reported having been deployed to a combat zone. Aged: 22–72 years (Mean = 42.94) Comorbidity: Not reported. Attrition rate: Not reported. |
Single group pilot study with pre‐ post data |
Mississippi Scale for Combat‐related PTSD (Keane et al., 1988) PHQ‐9 (Kroenke & Spitzer, 2002) Revised Adult Attachment Scales (RAAS) (Collins, 1996) Moral Injury Events Scale (MIES) (Nash et al., 2013) Davidson Trauma Scale (Davidson et al., 1997) Dissociative Experiences Scale (Frischholz et al., 1990) |
Statistically significant improvements reported in symptoms of PTSD, depression, moral injury, dissociation, and adult attachment measures over time, with effect sizes ranging from small to large. |
Preliminary evidence to support the use of intensive integrative treatment approaches that include yoga alongside evidence‐based psychotherapy for PTSD. Future research is needed to examine the integrative treatment model in comparison to treatment as usual for PTSD and to determine the extent to which each individual modality affects positive change. |
Level 3 Nonrandomized controlled cohort/follow‐up study |
| PTSD |
Zepeda Medez et al. (2018) Netherlands |
Integrated Five‐day intensive inpatient program including: Psychological Intervention: Two 90‐minute individual EMDR sessions each day, with an additional session provided one week after treatment, aimed at reducing emotional distress associated with the most upsetting traumatic memories, based on the Dutch version of the EMDR protocol (Beer et al., 2015). Yoga Intervention: One hour of trauma‐informed yoga at the end of each day, consisting of postures, breathing exercises, guided meditation on body awareness and relaxation. |
To investigate the feasibility and preliminary effectiveness of an intensive five‐day inpatient treatment program incorporating EMDR and trauma‐informed yoga for PTSD. |
12 adults (25% women) diagnosed with PTSD. Aged: Mean = 44.2 years. Comorbidity: ‐ MDD (n = 7) ‐ Panic disorder with agoraphobia (n = 3) ‐ OCD (n = 2) ‐ Alcohol dependence disorder (n = 2) Attrition rate: 1/12 (8%). |
Single group pilot study with pre‐post and follow up data | PTSD checklist for DSM‐5 (PCL‐5) (Weathers et al., 2013) |
Almost all (11/12) participants completed the treatment program. Noting lack of statistical power, treatment outcomes were based on criteria of clinically significant change and the Reliable Change Index. PTSD symptoms improved over time for majority (n = 9) of participants, with a moderate effect size identified at follow up. Two participants no longer met criteria for PTSD after the program. |
A 5‐day intensive inpatient EMDR and yoga treatment appears acceptable for adults with PTSD and effective for reducing PTSD symptoms. Future research is warranted to examine optimal treatment format and duration, to examine the relative contribution to clinical change for EMDR compared to yoga, and to determine the long‐term effects of intensive integrative treatments. |
Level 3 Nonrandomized controlled cohort/follow‐up study |
| PTSD |
Staples c (2018) USA |
Integrated Eight weekly three‐hour treatment sessions including: Psychological Intervention: 1.5 h of group CBT Yoga Intervention: 1.5 h of (Kundalini) yoga |
To evaluate the effectiveness of a CBT and yoga program for improving PTSD symptoms and sleep quality in people who have experienced a traumatic event. | 45 participants (no further details available) | Single group with pre‐post and 2‐ month follow‐up data |
PTSD checklist for DSM‐5 (PCL‐5) (Weathers et al., 2013) Pittsburgh Sleep Quality Index (PSQI) (Smyth, 1999) |
Not available | Not available |
Level 3 Nonrandomized controlled cohort/follow‐up study |
| Eating disorders | |||||||||
| Anorexia or bulimia nervosa |
Cook‐Cottone et al. (2008) USA |
Integrated Eight weekly two‐hour group sessions of the attunement in mind, body, and relationship (AMBR) program including: Psychological Intervention: Cognitive behavioral and dialectic behavioral theory (DBT) with dissonance‐induction content. Yoga Intervention: 50 min of body‐focused yoga, including instructions on breathing and self‐talk, and 15 min of meditation/relaxation practices. |
To examine preliminary outcomes for treating eating disorders with the AMBR program. |
29 women diagnosed with anorexia or bulimia nervosa engaged in an eating disorder treatment clinic Aged: 14–30 years (Mean = 20). Comorbidity: Not reported. Attrition rate: 5/29 (17%). |
Single group pilot study with pre‐ post data |
Three subscales from the Eating Disorder Inventory‐2 (EDI‐2) (Garner, 1991) ‐ Drive for Thinness, ‐ Body Dissatisfaction, ‐ Bulimia. |
Significant reductions were reported in participants’ desires for thinness and body dissatisfaction scores after the program. No significant differences were reported in bulimia scores. |
Preliminary positive findings for an integrative mind body treatment encompassing aspects of CBT, DBT and relational theory in the treatment of eating disorders. Further research is warranted for empirical validation of such findings using more robust RCT design, as well as qualitative data collection to assess acceptability and feasibility through examination of participant experiences and feedback. |
Level 3 Nonrandomized controlled cohort/follow‐up study |
|
Beck b (2008) USA |
Published above | ||||||||
Abbreviations: ACT, acceptance and commitment therapy; ADHD, attention deficit hyperactivity disorder; AMBSR, attunement in mind, body, and relationship program; BSD, bipolar spectrum disorder; CBT, cognitive behavioral therapy; CPT, cognitive processing therapy; DBT, Dialectical behavior therapy; EMDR, eye movement desensitization reprocessing therapy; GAD, generalized anxiety disorder; MBCT, mindfulness‐based cognitive therapy; MBSR, mindfulness‐based stress reduction; MDD, major depressive disorder; MDE, major depressive episode; OCD, obsessive‐compulsive disorder; PTSD, posttraumatic stress disorder; RCT, randomized controlled trial; TAU, treatment as usual; USA, United States of America; WC, warrior camp; Y‐CBT, yoga enhanced cognitive behavioral therapy.
Quality appraisal based on Oxford Centre for Evidence‐based Medicine (OCEBM, 2011).
Unpublished dissertations.
Retrieved from clinical trials registry (trial in progress).