Single-arm Pilot Trial of Hatha Yoga for Adolescents with Depression

Abstract

The prevalence of adolescent depression is increasing, particularly among girls. Existing evidence-based treatments have limitations and/or may not be acceptable to all adolescents and parents. There is evidence that hatha yoga may be useful as an adjunctive treatment for depression in adults. The purpose of the current study was to assess acceptability and feasibility of hatha yoga for depression in teens. We conducted a single-arm pilot trial of 12 weeks of manualized yoga classes specifically targeted toward teens with elevated depression symptoms. We assessed acceptability and feasibility by several metrics and compared our results against a priori benchmarks. We also collected qualitative feedback on the classes. We enrolled 11 teens. We met a priori benchmarks for recruitment and retention rates, credibility of the yoga classes, satisfaction with classes, and (lack of) adverse events causally related to classes. Class attendance and amount of home practice fell below planned benchmarks. Qualitative feedback was positive from the majority, although not all, participants. Results from this study may be used to further refine yoga classes for depressed teens.

Introduction

Adolescent depression is increasing. Even prior to COVID, the National Surveys on Drug Use and Health found that the 12-month prevalence rate of major depressive disorder in adolescents increased from 8.7% in 2005 to 13.2% in 2017 (Twenge, Cooper, Joiner, Duffy, & Binau, 2019). Particularly notable was the increase in depression in girls. This increase occurred during a time in which all socioeconomic groups experienced improved access to health care (Larson, Cull, Racine, & Olson, 2016) and when there were a number of evidenced-based treatments for adolescent depression, e.g., cognitive behavioral therapy (Weersing, Jeffreys, Do, Schwartz, & Bolano, 2017). Nonetheless, even with adjunctive pharmacotherapy, 30–55% of adolescents fail to sufficiently respond to empirically supported treatments (Treatment for Adolescents With Depression Study, 2004). Furthermore, use of psychopharmacology to treat adolescent depression has declined since the 2004 black box warning of a possible increased risk of suicidality among pediatric patients taking SSRIs (Gibbons et al., 2007).

There are a number of notable limitations to existing evidence-based treatments for depression. These include high cost of treatment, side effects associated with antidepressants, limited number of professionals qualified to deliver evidence-based treatments, and insufficient dissemination of these treatments in community-based settings. Thus, there is an urgent need to test alternative approaches for adolescent depression, with a focus on approaches that do not rely on the limited pool of adolescent mental health providers and can be administered concurrent with other treatments.

Hatha yoga has shown promise as a treatment for depression in adults. Yoga is an ancient Indian system of philosophy and practice (Iyengar, 1993). In the U.S., hatha yoga is the most common form. Hatha yoga is focused on training the body through breath control (pranayama), physical postures (asanas), and meditation (dhyana) as a means to promote mental, physical, and spiritual well-being. A meta-analysis of 12 studies of yoga for depressive disorders or elevated depression symptoms in adults reported yoga was superior to usual care, relaxation exercises, and aerobic exercise (Cramer, Lauche, Langhorst, & Dobos, 2013). More recent research confirms these findings (de Manincor et al., 2016; Prathikanti et al., 2017; Zou et al., 2018).

Other aspects of hatha yoga make it attractive as an adjunctive treatment. Hatha yoga combines physical activity and mindfulness practices in a unified way, potentially allowing for the benefits of both. Unlike physical activity, yoga practices may be employed to manage stressful situations at a moment’s notice and in almost any situation (i.e., using mindful breathing practices). Unlike sitting meditation practices, yoga involves movement. Given that greater than 40% of adolescents with depression may also meet criteria for attention deficit hyperactivity disorder (Weller, Blanford, & Butler, 2018), and many students have difficulty sustaining attention in classes for long periods (Bunce, Flens, & Neiles, 2010), having the opportunity to move may increase acceptability to adolescents.

There are many hypotheses about mechanisms by which yoga may be helpful for stress or depression (Riley & Park, 2015; Uebelacker et al., 2010). Potential mechanisms include increased self-compassion (Bluth, Campo, Futch, & Gaylord, 2017; Gard et al., 2012) and metacognitive awareness (Kessel et al., 2016; Teasdale et al., 2002). With higher levels of metacognitive awareness, “rather than … identifying personally with negative thoughts and feelings [or emotions], patients relate to negative experiences as mental events in a wider context or field of awareness” (Teasdale et al., 2002, p. 276).

Despite the potential value of hatha yoga for depressed adolescents, there are few relevant existing studies. One study showed decreases in distress from pre- to post-hatha yoga class amongst hospitalized adolescent psychiatric patients (Re, McConnell, Reidinger, Schweit, & Hendron, 2014). There are also reports of multicomponent programs for adolescents that included yoga. One was demonstrated to be acceptable and feasible in depressed and/or anxious adolescents (Henje Blom et al., 2016). A second, in a single-arm trial, was associated with reduced anxiety and increased treatment engagement in anxious youth (McDowell, Valleru, Adams, & Fristad,2020). Studies of yoga for other conditions, including weight management (Benavides & Caballero, 2009), eating disorders (Hall, Ofei-Tenkorang, Machan, & Gordon, 2016), and irritable bowel syndrome (Kuttner et al., 2006) also demonstrate feasibility of yoga classes for adolescents.

The primary aim of the current project was to assess feasibility and acceptability of a hatha yoga program for adolescents with depression.

Methods

Participants and Setting

To meet inclusion criteria, adolescents must have: 1) had elevated depressive symptoms, defined by a score of 11 or higher on the Quick Inventory of Depression–Adolescent Version—Clinician Rating (QIDS-A-CR; Bernstein et al., 2010; Rush et al., 2003), including endorsement of either sad mood or anhedonia; 2) been aged 13–18; 3) been medically cleared for moderate physical activity by their primary care provider; 5) been able to read and write in English; 6) assented to be in the study, and their parent or legal guardian consented to their participation (if aged 13–17) OR consented to be in the study (if aged 18); and 7) been able to attend Saturday morning classes. Adolescents were excluded if they: 1) had a QIDS-A-CR score greater than 21; 2) met criteria for lifetime bipolar I or II disorder; 3) met criteria for anorexia or bulimia in the past 3 months; 4) met criteria for substance use disorder in the previous 12 months, with current symptoms of sufficient severity to interfere with study participation; 5) had autism spectrum disorder symptoms of sufficient severity to interfere with study participation; 6) had current suicide ideation or behavior that warranted immediate treatment; 7) were engaged in yoga classes currently; 8) had substantive changes in ongoing treatment for depression in the previous 8 weeks; or 9) were pregnant.

Procedure

The protocol was approved by the Butler Hospital IRB. Participants were recruited via social media and paper advertisements in the community. The study was advertised as a yoga program for teens with depression or stress. After a participant expressed interest, research staff conducted an initial phone screen, followed by an in-person appointment at which they obtained written informed consent and assent for participation. Once staff ascertained that a teen met all inclusion criteria, they were enrolled in the study. After enrollment, participants were invited to start attending weekly yoga classes for 12 weeks. We provided classes free of charge to participants. Participants completed a brief assessment every week; longer assessments occurred at baseline, Month 1, Month 2, and Month 3. Parents and teens were paid for completing assessments. Enrollment occurred on a rolling basis.

Assessments

Safety.

Each week, participants completed a questionnaire asking whether they experienced any injuries related to yoga. At the 3-month timepoint, we administered the Systematic Assessment of Treatment-Emergent Events – General Inquiry (SAFTEE; Levine & Schooler, 1986) to review the previous 3 months. Any report of a new medical problem made to study staff at any time was also recorded as an adverse event.

Acceptability.

We measured intervention credibility and patient expectations for intervention success with the Credibility Expectancy Questionnaire (CEQ; Devilly & Borkovec, 2000); this was administered after the initial class attended. Score ranges for both the credibility and expectancy subscales are 0–1, with higher scores indicating higher credibility or expectancy. We used the Client Satisfaction Questionnaire (CSQ-8; Nguyen, Attkisson, & Stegner, 1983) post-treatment to assess satisfaction with treatment. The total score ranges from 8–32. Higher scores indicate higher levels of satisfaction. A study research assistant conducted a post-treatment qualitative interview to gain participants’ and parent/guardians’ feedback about intervention components and research procedures (see Supplementary Table 1).

Psychiatric symptoms.

We used the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID; Sheehan et al., 2010) to assess exclusion criteria. Depression severity was assessed using the QIDS-A-CR, which is psychometrically validated for adolescents (Bernstein et al., 2010; Rush et al., 2003).

Amount of yoga.

Participants completed a yoga home practice questionnaire on a weekly basis (Uebelacker, Feltus, Jones, Tremont, & Miller, 2019). This tool captures frequency of both “micro” practice (less than 5 minutes in length) as well as extended home practice (lasting 5 minutes or longer).

Yoga Program

The teen yoga program included a weekly manualized 45-minute class. See Table 1 for elements contained in each class. In terms of teaching style, the teacher’s manual recommended that teachers discuss and model acceptance of one’s own physical abilities; promote self-compassion; demonstrate and encourage meta-cognitive awareness; use clear, simple, and direct language; emphasize breath practice; and encourage home practice. Teachers used some guidelines from trauma-informed yoga as well, arranging mats so no one was behind another person, avoiding hands-on assists, inviting teens to half-close (rather than close) their eyes if they wished, and staying on their own mat modeling poses.

Table 1.

Key elements of yoga classes

	Element	Sub Elements	Minutes
1	Greeting	1.1. Welcome 1.2. Arrival activity: writing word describing one’s inner state on an index card	5
2	Warm-Ups	2.1. Sequence:  Seated spinal waves, circles, twists, side bends  Seated pigeon or figure four on back  Prone – side/ chest rolls with T arms  Soft locust  Cobra	8
3	Energetic and Rhythmic Practices	3.1. Half sun salutation, three times, with variations 3.2 Optional breathing practices	8
4	Stability Building Āsanas	4.1. Āsana series. Instructor may choose 2–4 standing postures from a pre-determined list of common āsanas. 4.2. Camel or supported fish pose 4.3. Seated pose	9
5	Prāṉāyāma	5.1. Awareness of natural breath or Abdominal breathing 5.2. Optional: alternate nostril breathing 5.3. Brief Stillness	5
6	Relaxation	6.1. Relaxation posture, e.g., savasana	5
7	Closing Practices	7.1. Ending activity: writing word describing one’s inner state on an index card 7.2. Optional sharing of experience in class 7.3. Discussion of home practice	5

One primary yoga teacher, a white woman and an author on this paper (KC), taught 15 of the 21 study classes provided. In addition, there were three yoga teachers (all women) who were trained in the manual, attended monthly meetings, and were available to serve as substitute teachers so that there would never be a need to cancel class. Each substitute teacher taught 2 classes. All teachers were Registered Yoga Teachers (RYTs) with the Yoga Alliance. Prior to teaching, teachers had approximately 5 hours of training in procedures and protection of human subjects. Throughout the study, teachers met monthly for group consultation and supervision. Because this was a pilot project, we did not do formal ratings of adherence with the teachers. Instead, in monthly meetings, we discussed aspects of the manual that were difficult to follow or could be improved and, in some cases, made minor adjustments and clarifications to the manual to increase future adherence. We did not make any major changes to the manual during the course of this study.

Data Analysis

We summarized data using descriptive statistics. Prior to starting the study, we set targets for acceptability and feasibility metrics; see Table 2 for a list. These a priori targets were based on previous research with group treatments for teens with depression, previous research on yoga classes for adults, and our best clinical judgment on what could be feasible for the teens and represent an adequate “dose” of yoga. To analyze qualitative data from the post-treatment interview, we used Applied Thematic Analysis (Guest, MacQueen, & Namey, 2011). One of the study PIs developed a codebook with deductive codes derived from interview questions. Two staff members independently coded each transcript of the interviews using the codebook; they proposed inductive codes as needed to capture emergent concepts raised by participants. Coders then met and reviewed all codes; for any discordant codes, they agreed upon final codes via consensus (Guest et al., 2011). Agreed-upon codes were entered into NVivo software, and then the study PI wrote thematic memos summarizing each code. One coder then read each memo, adding additional comments or clarifications as needed. Code categories are underlined, and codes are in italics below.

Table 2.

Target feasibility and acceptability outcomes

Area of feasibility or acceptability	Method of assessment	A priori target that would indicate satisfactory acceptability or feasibility	Was the target met?
Recruitment rate		Average of 3 enrolled per month	Yes
Retention rate	Assessment attendance log	At least 90% complete M1 assessment, 85% complete M2 assessment, 80% complete post-intervention endpoint (Month 3) assessment	Yes
Credibility	CEQ, administered at baseline	Average > .50 (i.e., midpoint score between low and high credibility) on each of 3 items	Yes
Expectancy at baseline	CEQ, administered at baseline	Average > .50 (i.e., midpoint score) on each of 3 items	Yes
Program satisfaction	CSQ-8, administered at endpoint	Average > 24 (or a mean score of 3 on each of the 8 items)	Yes
Adverse events	SAFTEE; injuries due to yoga questionnaires	No serious adverse events or injuries that are possibly, probably, or definitely related to study participation.	Yes
Class attendance	Class attendance log	70% of all participants complete 8/12 classes.	No
Home practice	Homework questionnaire	70% of yoga participants engage in home practice at least 2 times per week for 7/11 possible weeks.	No
Acceptability	Qualitative interview	Most feedback positive; few substantive negative comments. Negative comments used to enhance procedures.	Yes

Results

Participant Demographics

We enrolled 11 adolescents, the majority of whom identified as female (90%). Mean age was 15.8 years, (SD = 1.8; range = 14–18). Nine participants reported being White or Caucasian, 1 reported being mixed race (White and American Indian/Alaskan Native), and one reported “other” race. One identified as Hispanic/ Latinx. Three participants reported living with both parents, 6 with their mother, 1 with their mother and stepfather, and 1 lived on campus (i.e., in college). On average, participants lived 12.8 miles (SD=6.1 miles) from the site of the yoga class. Note that, in an urban setting, it can take 30 minutes to go 12 miles. Seven participants had parents drive them, and 4 drove themselves to class.

Feasibility of Research Procedures

Recruitment and enrollment occurred on a rolling basis over a period of 3 months. We planned to enroll 12, but ultimately only enrolled 11 due to a period of recruitment where several consecutive potential participants were ruled out while the current cohort was completing yoga classes. We ended recruitment rather than have only one person in yoga class for several weeks. We met our goal for recruitment rate, recruiting 11 people over 3 months, or an average of 3.7 per month. We also met our goal for retention for assessments, with 10/11 (91%) of participants completing the Month 1 assessment, the same number completing Month 2, and 9/11 (or 82%) completing the Month 3 assessment.

Credibility, Expectancy, and Satisfaction

We assessed credibility and acceptability after the initial class for 10 participants (1 person never attended any classes). We met our target for these indices of acceptability: mean scores were higher than a priori target mean scores, indicating satisfactory credibility and acceptability. That is, mean item scores for the 3 items on the CEQ credibility scale ranged from 0.71 to 0.84, and mean scores for the 3 items on the CEQ expectancy scale ranged from 0.57 to 0.71. We assessed program satisfaction with the CSQ-8 for 9 participants. The average CSQ-8 score was 26.2 (SD= 6.1), with a minimum score of 16 and maximum of 32. This indicates that the average level of satisfaction was higher than our a priori target mean score.

Adverse Events

There were no serious adverse events possibly, probably, or definitely related to study participation. This met our a priori target.

Class Attendance and Adherence to Home Practice

We did not meet our targets on these indices of feasibility and acceptability. Six of 11 participants (55%) attended 8 or more classes; we had hoped that at least 70% would attend 8 or more classes. Seven of 11 (64%) attended 6 or more classes. Two participants formally dropped out of classes – one decided they were too busy, and one found that it interfered with their new work schedule. Regarding home practice, six of the 10 participants (60%) for whom we had home practice data engaged in home practice at least twice per week. The other 4 participants reported little or no home practice.

Qualitative Feedback

We conducted qualitative interviews at Month 3 with 9 teens and 7 parents. To protect participant confidentiality, we do not identify participants’ comments by ID number or gender. We present 2–3 quotes from each teen in this summary. Comments by parents are identified as such. The first category of codes referred to specific elements of the class. Participants commented on meditation or rest periods. Seven participants liked the final resting pose, finding it calming or relaxing. Others (n=2) liked the brief rests after challenging poses; one said these periods gave them a chance to “catch my breath.” Only one person cited these periods as being only “okay.” Participants mentioned a number of poses that they liked, including challenging poses, sun salutations, down dog, eagle, and warrior. One participant did not like balancing poses because they found them difficult; another two did not like poses for which they believed they were not sufficiently flexible. Seven participants had positive reactions to breathing exercises, often stating that they were calming. One person struggled with the breathing exercises, saying “it was hard for me – the breathing thing” and another found them to be okay, but not particularly helpful. Participants provided feedback on paying attention to sensations or feelings in the body. Five found this to be useful; two described how their understanding grew over time: “first few classes I didn’t really get but then…later on I started to understand it and feel it.” Two participants said they were not able to focus on sensations in their body, with one saying “it was just cheesy, typical yoga stuff”. Most participants found the pace or energy level of class to be acceptable, although two would have preferred a higher energy level or faster pace. One person said they liked having music in class because then it wasn’t “too silent.”

Participants commented on class logistics. Seven teens and six parents thought that 10:30 on Saturdays was a good day and time, providing “a nice start to the weekend.” One teen found the timing stressful because they went to work right after class; three suggested that there would be advantages to having class on a weekday afternoon instead – i.e., “it would be darker and calmer,” and they might be “less tired.” Eight teens thought 45 minutes was the right length of class; one thought it should be an hour long. Class size and room size were inter-related. When classes were bigger, the room felt more crowded. Participants thought the ideal class size was 3–6 people. One participant summed up concerns about class size: “At first, the less people made me kind of uncomfortable, because it was like, ‘oh there’s only one other person here, that’s like, weird.’ But at the same time, I don’t know, it was kind of nice. And the more people, sometimes I was like, ‘oh, I don’t want them to look at me,’ but also, I was like, ‘oh they’re not gonna look at me, there’s so many people here.’” All teens thought the age range (13–18) was acceptable. Mixed gender classes was acceptable to 8 of the 9 teens, and seen as a positive by three teens. Only one teen mentioned a concern, saying “I didn’t have a problem, but … some people might feel uncomfortable with it.”

We asked about barriers to class attendance. Barriers included other activities (n=8) such as important family events, sports, doctor’s appointments, and vacation. Transportation was a barrier for two participants. Finally, getting up on time was challenging at times for three participants.

We asked teens about home practice. Five teens watched videos, although none watched the videos that we had recommended. Six teens talked about using breathing exercises outside of class, particularly when they wanted to increase a sense of calm, e.g., when stressed, before bed, or after a panic attack. One teen said: “when I get stressed, I’ll do breathing. I’ll focus on my breath a couple seconds, then I’ll go back to what I’m doing. That helps.” Only one participant specifically stated that they did not use breathing exercises at home. Three teens, and one parent of another teen, reported using asana practice at home, e.g., doing poses they “knew and wanted to do” or “doing sun salutations four times a week.” Barriers to home practice included insufficient motivation (cited by two parents), forgetting to do it (cited by two teens and two parents), too busy (n=2), too tired (n=1) and lack of interest (n=3). Frequency of home practice varied, from daily use of breathing exercises, to 2–4x per week, to once every two weeks, to no home practice.

All nine teens commented on how well they liked the class overall. Five clearly enjoyed the class. One teen said “I think it was just a good way to end…a stressful school week;” their parent said that “I think [they] actually enjoyed it a little bit more than [they] thought [they] would.” Another parent noted, about their child, that “[they] didn’t want to miss yoga.” Of the remaining four participants, two reported their experience of class changed over time. One participant started to take ADHD medication during the time they were in class, and said “before I started taking the medication, they [the classes] were okay. I would get really distracted. But my first class on the medicine, I loved it and I was able to full enjoy it.” In contrast, another participant liked the classes at first, but found they got “really repetitive” over time. Finally, one participant thought classes were “okay,” and one participant did not like classes. This participant was “forced to do it” by their parents, and said “at first I hated it. Then I was like, ‘Fiiiiine.’”

Finally, we asked whether yoga was helpful. Teens and parents commented on the impact of yoga on mood, anxiety, or stress. Seven teens said yoga class was relaxing or peaceful. One teen said: “It calmed me down a lot. It made stop thinking cause I’m always thinking, constantly thinking, and it causes me to worry, then the anxiety…. the yoga really helped me to… relax, and focus on breathing.” Teens also said they came out of class feeling energized, refreshed, or “nice and stretched out.” Three teens or parents noted improvements in mood over the course of the study, although they thought that the yoga class was not the only factor in improvements in mood. One parent said “I don’t know that [they] think it was especially helpful, but I think it was.” Two teens stated that they did not think yoga changed anything with regard to their mood. Two teens commented on the impact of yoga on physical health. One noted that stretching decreased bodily tension, and another thought that home practice helped with back pain.

Change in Depression over Time

We examined change in depression symptoms for the 9 participants who completed the M3 assessment. Using a paired-test, we found a significant change over time: mean QIDS-A-CR at baseline was 12.78 (SD = 1.99), and mean at endpoint was 4.11 (SD = 2.26; t(df = 8) = 7.14, p < 0.001).

Discussion

This study was designed to assess feasibility and acceptability of yoga for depression symptoms in adolescents. We designated a priori targets for feasibility and acceptability. As summarized in Table 2, we met the targets for recruitment, retention, credibility of the yoga class, expectancy that the class would help, program satisfaction, and safety. Qualitative data supported the idea that some (although not all) participants enjoyed class, most found it relaxing and peaceful, and more than half of those interviewed reported using breathing exercises or other practices to cope with stress at home. Because this is a single arm trial, we cannot say that yoga caused changes in depression symptoms over time; however, we note that depressive symptoms decreased significantly over time.

We did not meet planned targets for class attendance or amount of home practice. Because this was a small-scale study, we only offered class once per week. We offered it on Saturday as our preliminary work (Uebelacker et al., 2021) indicated that this was the best option. However, as we learned, there were numerous unavoidable conflicts, such as one-time family events, vacations, or changes in sports schedules. Another potential problem was the time of year that teens enrolled in classes: some started classes during the school year but continued classes in the summer, when schedules change. Finally, most teens needed to have a parent or another person drive them to class, meaning that not only the teen but also a driver needed to be available.

Of course, another reason for lack of attendance or home practice may be that some teens did not like yoga or did not find it helpful. One teen said that their parents required them to do it; this type of requirement may backfire for teens, decreasing enjoyment and motivation. Another teen would have liked more variety in class structure, and a couple of teens would have enjoyed a more energetic pace. On the other hand, many teens liked the class and the sense of relaxation and even energy that it gave them. Further, consistent with reports from adults (Uebelacker et al., 2017), several teens discussed using breathing exercises at home to cope with stress and promote calm.

Given these data, we have several ideas about how to strengthen attendance and home practice. One way to increase class attendance is to offer class two times per week so that teens have more options for when to attend. Another option might be to extend the time period that teens have to attend classes and simply expect that they will not be able to attend every week due to the many other commitments that they have. However, over a longer period, they may get the same “dosage” and build self-efficacy and knowledge for home-based practice. Virtual yoga classes may help to overcome some barriers to class attendance (e.g., having difficulty getting a ride to class), although virtual classes may also have disadvantages such as decreased sense of community and decreased connection to the teacher. It may be beneficial to strengthen the assent process for teens, further emphasizing to families that teens should only be enrolled if they are genuinely interested in participating. Finally, it may be useful to provide more tools and guidance in class to strengthen home-based breathing practice.

Limitations of this study include the fact we only recruited one boy and had limited racial and ethnic diversity. We had expected more girls than boys, as girls are more likely to experience depression (Mojtabai, Olfson, & Han, 2016). Based on previous work, we know that teens see yoga as being a female activity (Uebelacker et al., 2021). However, we note that western media outlets often portray yoga students as female, young, physically fit, very physically flexible and strong, and white (Thomas, Warren-Findlow, & Webb, 2019; Webb et al., 2017). If yoga could helpful for people who do not fit these categories, then at both a societal and study level, we want to communicate that yoga is for every body, and portray yoga as such in images and print.

Because this is a pilot study, the sample size was small, and it was a single arm, open trial. Therefore, we cannot make any conclusions about efficacy. Although depression symptoms did decrease over time, there are many possible explanations, including regression to the mean and improved mood for the teens who started during the school year and finished in the summer (Shamseddeen et al., 2011).

In sum, this pilot study demonstrated acceptable levels of feasibility and acceptability for several pre-determined targets, but not all of the targets. More than half of the enrolled teens enjoyed the yoga classes the entire time they were enrolled, and 7 of 9 found them to be relaxing. Qualitative data point to ways to strengthen class attendance and use of yoga home practice. Directions for immediate future research include a pilot trial with modifications to the yoga teacher manual and study manual of procedures suggested by these results, a two-arm study to assess feasibility of randomization, and the development of a teacher adherence scale. Given that there are efficacious group interventions for teen depression (e.g., group CBT; Weersing et al., 2017), longer-term future research could include an adequately-powered non-inferiority trial comparing yoga classes to group CBT for teens with depression. Ideally, this trial would include an assessment of moderators to determine characteristics that predict differential response to these two types of interventions.