Original article

The Efficacy of Body-Oriented Yoga in Mental Disorders

A Systematic Review and Meta-Analysis

Dtsch Arztebl Int 2016; 113(12): 195-202; DOI: 10.3238/arztebl.2016.0195

Klatte, R; Pabst, S; Beelmann, A; Rosendahl, J

Background: The efficacy of body-oriented yoga in the treatment of mental disorders has been investigated in numerous studies. This article is a systematic review and meta-analysis of the relevant publications.

Methods: All studies in which the efficacy of hatha-yoga, i.e., body-oriented yoga with asanas and pranayama, was studied in adult patients suffering from a mental disorder (as diagnosed by ICD or DSM criteria) were included in the analysis. The primary endpoint was disorder-specific symptom severity. The publications were identified by a systematic search in the PubMed, Web of Science, PsycINFO and ProQuest databases, supplemented by a search with the Google Scholar search engine and a manual search in the reference lists of meta-analyses and primary studies, as well as in specialized journals.

Results: 25 studies with a total of 1339 patients were included in the analysis. A large and significant effect of yoga was seen with respect to the primary endpoint (symptom severity) (Hedges’ g = 0.91; 95% confidence interval [0.55; 1.28]; number needed to treat [NNT]: 2.03), with substantial heterogeneity (I2 = 69.8%) compared to untreated control groups. Small but significant effects of yoga were also seen in comparison with attention control (g = 0.39; [0.04; 0.73]; NNT: 4.55) and physical exercise (g = 0.30; [0.01; 0.59]; NNT: 5.75); no difference in efficacy was found between yoga and standard psychotherapy (g = 0.08; [−0.24; 0,40]; NNT: 21.89). In view of the relatively high risk of bias, these findings should be interpreted with caution.

Conclusion: Body-oriented yoga with asanas and pranayama as central components is a promising complementary treatment for mental disorders and should be investigated in further high-quality studies.

Some 2.6 million people in Germany practice yoga. The main reasons for this are improved physical and mental wellbeing (e1). The different types or forms of yoga have in common the fundamental principle of asanas (body posture) and pranayama (breathing techniques); dhyana (meditation) and relaxation are also often components of yoga (e2).

The form of yoga that is practiced most commonly outside India is hatha yoga, a body-oriented variant that includes mostly asanas, pranayama, and dhyana. The different body postures, controlled breathing/breathing exercises, and meditation aim to harmonize a person’s mental and physical state (e3). The first objective is to relax the body before controlling the five senses and reduce mental activity (e4). Consequently, yoga ranges among the “mind-body interventions,” which are based on the idea that physiological states affect emotions, thoughts, and attitudes (e5).

Yoga has been described as a promising interventional approach in treating mental disorders (13). One of its advantages lies in the fact that it is an easily accessible therapeutic approach that has become widely accepted (e1). Furthermore, numerous additional benefits are being discussed for yoga in the treatment of mental disorders. In addition to the relatively low costs associated with yoga as a group activity, yoga is associated with hardly any risks nor side effects compared with pharmacological treatment (4). Yoga exercises can be easily integrated into everyday life (5) and therefore possibly contribute to preventing relapses (6).

The effects of yoga on the endocrine system, the nervous system, and physical health are well documented. Lower cortisol concentrations and raised concentrations of serotonin and melatonin after regular yoga have been shown empirically, as has a reduction in pro-inflammatory cytokines (7). Increased satisfaction, self-confidence, and improved self-control after yoga are associated with a lower degree of perceived stress and a higher degree of wellbeing (7).

Some of the fundamental ideas and elements underlying yoga are now also applied in the concept of mind-body medicine in treating physical illness (e6) or in the context of psychotherapy. Approaches such as mindfulness-based stress reduction (MBSR) or acceptance and commitment therapy (ACT) have been developed accordingly (e7).

Several systematic reviews and meta-analyses analyzed the efficacy of yoga in treating mental disorders (1, 812), the results are summarized in eTable 1. The meta-analyses reported promising findings and mostly concluded that yoga is effective in treating different mental disorders in regard to diverse disorder-specific outcome measures. Only a meta-analysis of data from schizophrenia patients (10) found no significant effects on symptom-related endpoints, only on quality of life.

Existing meta-analyses of the efficacy of yoga in mental disorders*1
eTable 1
Existing meta-analyses of the efficacy of yoga in mental disorders*1

In evaluating the available evidence from meta-analyses it needs to be borne in mind that differential effects of yoga have thus far barely been investigated in the treatment of mental disorders. Meta-analyses across mental disorders have not yielded any data; in the disorder-specific analyses, the small number of included studies makes subgroup analyses impossible.

The present article aims to investigate the efficacy of body-oriented yoga in treating mental disorders and to study possible factors of influence. To this end, we conducted a systematic review and meta-analysis of randomized controlled studies.

Methods

The objectives, inclusion criteria, and methods of this review were pre-specified in a review protocol (PROSPERO Reg. No.: CRD42014015347).

Inclusion criteria

The systematic review included studies that met the criteria listed in Table 1.

Inclusion criteria
Table 1
Inclusion criteria

Literature search

In order to identify relevant studies, searches were conducted in the electronic databases PubMed, Web of Science, PsycINFO, ProQuest, and by using the search engine Google Scholar (eTable 2). Furthermore, manual searches for additional relevant studies were undertaken for the specialized journals International Journal of Yoga, International Journal of Yoga Therapy, Journal of Yoga and Physical Therapy, and Indian Journal of Psychiatry (special issue vol. 55, suppl.3), as well as the reference lists of review articles published to date and the included primary studies.

Search strategy
eTable 2
Search strategy

Study selection and extraction of relevant information

Firstly, we checked whether titles and summaries/abstracts provided any information of whether the studies met the inclusion criteria. We then obtained the full text of relevant studies and, where appropriate, extracted relevant information from those studies.

Where important data were missing we contacted the authors. Where insufficient relevant statistical data were reported for the effect size calculation and these could not be obtained by contacting the authors, these were approximated by using diverse estimation procedures. Two assessors undertook the study selection and coding (RK, JR). Disagreements were resolved by consensus discussions.

Risk of bias in the individual studies

The risk of bias in the individual studies was assessed by applying the following quality criteria from the Cochrane Collaboration (e9): selection bias (randomization, allocation concealment), performance bias (blinding of patients and staff), detection bias (blinded collection of endpoints), attrition bias (handling missing data because of subjects dropping out of studies), and reporting bias (selective reporting of results). Furthermore, we collected data in potential conflicts of interest of the study authors.

Effect size estimates

We calculated adjusted mean differences (Hedges’ g) for each study endpoint (e10). In case of dichotomous endpoints we determined odds ratios and converted these into Hedges’ g (e11). If a study reported several effects for the same endpoint, these were pooled. All effect size estimates were reported with 95% confidence intervals (CI). Positive effects indicate an advantage in favor of the yoga intervention, negative effects in favor of the control intervention. The effect size Hedges’ g provides in small samples more precise estimates. In analogy to the conventions of Cohen’s d, values of 0.20 are interpreted as small effects, 0.50 as medium-sized effects, and 0.80 as large effects (e12). Furthermore, the effect sizes were transformed into numbers needed to treat (NNT, e13).

Synthesis of results

The effect sizes of individual studies were aggregated in a meta-analysis by using a random effects model and were weighted by using the inverse variance method. The heterogeneity of study results was estimated by using the method of DerSimonian and Laird (e14). Heterogeneity between studies was tested for significance by using Q heterogeneity tests (Cochran’s Q), and I2 was calculated as the common measure for heterogeneity. I2 values of >50% were interpreted as substantial, any generalizability of the results is consequently limited (e15).

We conducted separate meta-analyses for the comparison of the yoga intervention groups with the untreated control groups (waiting list) and the active control groups (psychotherapeutic standard treatment, attention control group, exercise).

Risk of bias across studies

In order to check for publication bias, funnel plots were assessed visually, and Egger’s test (e16) and the Trim and Fill procedure (Duval and Tweedie, e17) were conducted.

Additional analyses

To compare the yoga intervention groups with untreated control groups, meta-regression analyses and subgroup analyses were undertaken, in order to study heterogeneity of study effects and potential factors of influence.

The software package Comprehensive Metaanalysis (CMA; version 3.0; Biostat Inc) was used to conduct all data analyses.

Results

Study selection

A total of 2644 references were identified during the literature search; of these, 25 studies with 27 comparisons were included (Figure 1).

Flow diagram for study selection
Figure 1
Flow diagram for study selection

Study characteristics

Central characteristics of the included studies are summarized in eTable 3. In total, studies from nine different countries were evaluated that had been published between 1997 and 2014. Most of the studies came from India (n=7) or the United States (n=8). The total sample from all included studies amounted to 1339 subjects, of whom 656 were in the yoga intervention groups and 683 in the control groups. The dropout rate in the yoga intervention groups was 13.0% (standard deviation [SD]=13.1) and in the control groups 16.4% (SD=17.8; P=0.408). The participants’ mean age was between 22 and 59 years (median 36; interquartile range [IQR]: 30–43). The proportion of women in the total sample was 61.7%. The included studies investigated the efficacy of yoga in relation to nine different mental disorders, albeit exclusively axis-1 disorders. Only 11 primary studies reported the mean duration of illness, which was between five and 313 months (median: 86; IQR: 74.3–162.8).

Selected charakteristics of the included studies
eTable 3
Selected charakteristics of the included studies

In most of the studies (n=19) the intervention was directed by a yoga teacher. Yoga was conducted in groups in all studies. Group sizes varied between three and 25 participants (median:11.5; IQR: 5.8–15.0). The total duration of the yoga intervention was between five and 100 hours (median: 15; IQR: 10–32) over a time period of two to 24 weeks. In 17 of 25 studies, patients received a co-intervention (baseline treatment) in the intervention group as well as in the control group. Further characteristics of the included studies are described in eTable 4.

Characteristics of included studies
eTable 4
Characteristics of included studies

Risk of bias within studies

The way in which the risk of bias was assessed in the included studies by using the quality criteria of the Cochrane Collaboration is shown in eTable 5.

Assessment of risk of bias of the included studies by using the Cochrane Collaboration’s quality criteria*1
eTable 5
Assessment of risk of bias of the included studies by using the Cochrane Collaboration’s quality criteria*1

Altogether, the included studies were subject to comparably high bias risks, especially in relation to blinding patients/staff. In most studies, incomplete data resulted in a high risk of bias (completer analysis).

Results from individual studies and synthesis of results

Comparisons between yoga intervention groups and untreated control groups in terms of primary outcome variables at the end of treatment showed a significant, large effect for yoga; Hedges’ g=0.91; 95% CI [0.55; 1.28]; P<0.001; k=13; NNT=2.03 (Figure 2). However, the effects were subject to substantial heterogeneity (I2=69.8%). The comparison of yoga intervention groups and active control groups showed a small significant overall effect in favor of the yoga intervention; Hedges’ g=0.26; [0.09; 0.44]; P=0.004; k=12 (Figure 3). Although yoga showed small significant effects compared with exercise (g=030; [0.01; 0.59]; P=0.040; k=5; NNT=5.75) and attention control group (g=0.39; [0.04; 0.73]; P=0.027; k=4; NNT=4.55), comparable effects were seen for yoga and psychotherapeutic standard treatment (g=0.08; [–0.24; 0.40]; P=0.625; k=3; NNT=21.89) when used as complementary treatment with medication. The study effects were not or only very slightly heterogeneous (I2=15.6% for the comparison with exercise; I2=0% for all other comparisons). Comparable effects were seen for secondary outcome variables (eTables 6 and 7).

Forest plot of the total effect of the yoga intervention group
Figure 2
Forest plot of the total effect of the yoga intervention group
Forest plot of the total effect of yoga compared with different active control groups
Figure 3
Forest plot of the total effect of yoga compared with different active control groups
Effects on secondary endpoints in the yoga intervention groups compared with untreated control groups
eTable 6
Effects on secondary endpoints in the yoga intervention groups compared with untreated control groups
Effects on secondary endpoints in the yoga intervention groups compared with active control groups
eTable 7
Effects on secondary endpoints in the yoga intervention groups compared with active control groups

Risk of bias across studies

In the comparison of yoga intervention groups and untreated control groups the Trim and Fill analysis found two missing studies. The adjusted effect size (g=0.75; [0.36; 1.13]) did not differ substantially from the observed effect size; furthermore, Egger’s regression test did not reach significance (P=0.239). For the comparison of yoga intervention groups with active control groups, no indications of the existence of publication bias were seen, neither in the Trim and Fill analysis nor in Egger’s regression test (P=0.299) (eFigure).

Funnel plots of Hedges’ g against its standard error (SE)
eFigure
Funnel plots of Hedges’ g against its standard error (SE)

Additional analyses

Meta-regression analyses were conducted to gain clarity about the effects of the duration and frequency of the yoga intervention and of the publication year on effect size estimates. Only the effect of the publication year reached significance (β=–0.13; [–0.24; –0.02]; P=0.026), with more recent studies reporting lower effects. Furthermore, subgroup analyses were conducted, which showed a significant effect for the treatment context and the type of recruitment. In subjects who were being treated as inpatients or outpatients, yoga had a significantly lower effect on symptom-related outcomes than in subjects who were not currently therapeutically treated. Studies that had recruited subjects through the healthcare system had a significantly lower effect than studies in which recruitment had been realized by using different media. Furthermore, studies conducted in an Eastern cultural setting showed lower effects than studies from the Western cultural setting.

No effect was confirmed for diagnosis, standardization, and disorder-targetedness of the yoga intervention (Table 2). Neither did risks of bias have a moderating influence on effects (eTable 8).

Subgroup analyses of the efficacy of yoga compared with untreated control groups (primary endpoint)
Table 2
Subgroup analyses of the efficacy of yoga compared with untreated control groups (primary endpoint)
Subgroup analyses of the effect of individual risks of bias on the efficacy of yoga intervention groups compared with untreated control groups (primary end point)
eTable 8
Subgroup analyses of the effect of individual risks of bias on the efficacy of yoga intervention groups compared with untreated control groups (primary end point)

Discussion

The comparison of yoga intervention groups and untreated control groups found medium-sized significant effects in favor of yoga for primary and secondary outcomes. However, study effects for disorder-specific symptoms were characterized by substantial heterogeneity. Compared with exercise and attention control group, yoga was found to have small, significant effects. Furthermore, the findings indicate equal efficacy for yoga and psychotherapeutic standard treatment when used complementary to medication treatment. Additionally, other studies have shown that the efficacy of yoga combined with psychotherapeutic treatment—for example, cognitive behavioral therapy—exceeds the individual effects of the interventions (40).

The findings of this systematic review are comparable to those of existing meta-analyses, most of which reported moderate to large positive effects of yoga in disorder-specific symptoms (1, 8, 9, 11, 12). For the comparison of yoga intervention groups with untreated control groups, different factors were identified that influenced the efficacy of yoga. Among other factors, the year of publication has a role: more recent studies found smaller effects than older studies. This effect was also seen in other meta-analyses (e18, e19). Among the possible explanations that have been discussed for this finding are larger numbers of endpoints and their increasing standardization in more recent studies.

Furthermore, the treatment context was found to be a significant factor of influence. Patients who were being treated on an inpatient or outpatient basis benefited less from yoga than subjects who were not currently receiving treatment because of their psychological symptoms. These results possibly reflect the fact that the severity of the disorder may be a relevant factor of influence on the efficacy of yoga, something that one meta-analysis has already confirmed (12).

The fact that the way in which subjects are recruited has an influence possibly reflects selection bias: subjects that were recruited through media campaigns may have a more positive attitude towards yoga and may therefore benefit more from it. The marginal significant difference in efficacy related to subjects’ cultural setting can possibly be explained by the fact that yoga represented a lower added value for patients from an Eastern cultural setting because it is very popular in these settings, and many people practice it.

Limitations

Comparing yoga intervention groups with untreated control groups identified substantial heterogeneity of the study effects, which can be explained only partly in moderator analyses. The relevant findings can therefore be generalized only to a limited degree. Compared with untreated control groups, indications were found of publication bias, but the adjusted effects do not differ substantially. Furthermore, the risk of bias within the studies is altogether to be considered as high, and for many studies the relevant assessment was not possible because of lacking data. Lacking information in the studies further makes it difficult to assess central study characteristics, such as characteristics of the interventions or patients (for example, group size, components of the yoga intervention, affinity of recruited subjects for yoga). This often leads to a situation whereby these studies cannot be considered in analyzing factors of influence, which ultimately reduces statistical power or renders relevant analyses completely impossible. The results of the available analyses should therefore be interpreted with caution. It also should be noted that they relate exclusively to axis-I disorders.

Conclusion

In spite of the listed limitations, the results of this meta-analysis provide indications that body-oriented yoga with the central components asanas and pranayama represent a promising complementary approach to the treatment of mental disorders. Further high-quality studies are needed in order to support these findings.

Our meta-analysis included 25 studies and provides a comprehensive overview of the efficacy of yoga in mental disorders. We were able to analyze a large proportion of studies that had not previously been included in systematic reviews. Additionally, potential factors influencing the efficacy of yoga were studied for the first time. The results provide indications for the differential efficacy of yoga, which future studies should investigate in a targeted fashion.

Conflict of interest statement

The authors declare that no conflict of interest exists.

Manuscript received on 22 September 2015, revised version accepted on
16 December 2015.

Corresponding author
PD Dr. phil. Jenny Rosendahl
Universitätsklinikum Jena
Institut für Psychosoziale Medizin und Psychotherapie
Stoystr. 3
07743 Jena, Germany
jenny.rosendahl@med.uni-jena.de

@Supplementary material
For eReferences please refer to:
www.aerzteblatt-international.de/ref1216

eTables, eFigures:
www.aerzteblatt-international.de/16m0195

1.
Cabral P, Meyer HB, Ames D: Effectiveness of yoga therapy as a complementary treatment for major psychiatric disorders: a meta-analysis. Prim Care Companion CNS Disord 2011; 13 CrossRef
2.
Meyer HB, Katsman A, Sones AC, Auerbach DE, Ames D, Rubin RT: Yoga as an ancillary treatment for neurological and psychiatric disorders: a review. J Neuropsychiatry Clin Neurosci 2012; 24: 152–64 CrossRef MEDLINE
3.
Ross A, Thomas S: The health benefits of yoga and exercise: a review of comparison studies. J Altern Complement Med 2010; 16: 3–12 CrossRef MEDLINE
4.
Cramer H, Ward L, Saper R, Fishbein D, Dobos G, Lauche R: The safety of yoga: a systematic review and meta-analysis of randomized controlled trials. Am J Epidemiol 2015; 182: 281–293 CrossRef MEDLINE
5.
Qureshi NA, Al-Bedah AM: Mood disorders and complementary and alternative medicine: a literature review. International Neuropsychiatric Assoc 2013; 9: 639–58 CrossRef
6.
Piet J, Hougaard E: The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis. Clin Psychol Rev 2011; 31: 1032–40 CrossRef MEDLINE
7.
McCall MC: How might yoga work? An overview of potential underlying mechanisms. J Yoga Phys Ther 2013; 3: 130.
doi: 10.4172/2157–7595.1000130 CrossRef
8.
Pabst SEP: Die Wirksamkeit von Yoga bei psychischen Störungen Erwachsener: Eine Meta-Analyse randomisierter Studien. Diplomarbeit. Jena: Friedrich-Schiller-Universität Jena 2011.
9.
Knobben S: A meta-analysis of the effectiveness of yoga on mental health: taking on a dual perspective reflecting the medical and positive perspective of mental health. Masterarbeit. Niederlande: Universität Twente 2013. http://essay.utwente.nl/63524/ (last accessed on 20 July 2015).
10.
Cramer H, Lauche R, Klose P, Langhorst J, Dobos G: Yoga for schizophrenia: a systematic review and meta-analysis. BMC Psychiatry 2013; 13. doi: 10.1186/1471–244X-13–32 CrossRef
11.
Cramer H, Lauche R, Langhorst J, Dobos G: Yoga for depression: a systematic review and meta-analysis. Depress Anxiety 2013; 30: 1068–83 CrossRef MEDLINE
12.
Gong H, Ni C, Shen X, Wu T, Jiang C: Yoga for prenatal depression: a systematic review and meta-analysis.
BMC Psychiatry 2015; 15. doi 10.1186/s12888–015–0393–1 CrossRef
13.
Afonso RF, Hachul H, Kozasa EH, et al.: Yoga decreases insomnia in postmenopausal women: a randomized clinical trial. Menopause 2012; 19: 186–93 CrossRef MEDLINE
14.
Buttner MM: Efficacy of yoga for depressed postpartum women: a randomized controlled trial. Ann Arbor: The University of Iowa 2013. http://search.proquest.com/docview/1443876609?accountid=14626 (last accessed on 20 July 2015).
15.
Carter JJ, Gerbarg PL, Brown RP, et al.: Multi-component yoga breath program for Vietnam veteran post traumatic stress disorder: randomized controlled trial. J Trauma Stress Disord Treat 2013; 2: 1–10 CrossRef
16.
Hallgren M, Romberg K, Bakshi AS, Andreasson S: Yoga as an adjunct treatment for alcohol dependence: a pilot study. Complement Ther Med 2014; 22: 441–5 CrossRef
17.
Jayaram N, Varambally S, Behere RV, et al.: Effect of yoga therapy on plasma oxytocin and facial emotion recognition deficits in patients of schizophrenia. Indian J Psychiatry 2013; 55: 409–13 CrossRef MEDLINE PubMed Central
18.
McIver S, O’Halloran P, McGartland M: Yoga as a treatment for binge eating disorder: a preliminary study. Complement Ther Med 2009; 17: 196–202 CrossRef MEDLINE
19.
Oretzky S: The effects of yoga on elevated depressive and somatic symptoms in young adults. San Diego: Alliant International University 2006. http://search.proquest.com/docview/ 304913141?accountid=14626 (last accessed on 20 July 2015).
20.
Parthasarathy S, Jaiganesh K, Duraisamy: Effect of integrated yoga module on selected psychological variables among women with anxiety problem. West Indian Med J 2014; 63: 83–5.
21.
Sarubin N, Nothdurfter C, Schule C, et al.: The influence of Hatha yoga as an add-on treatment in major depression on hypothalamic-pituitary-adrenal-axis activity: a randomized trial. J Psychiatr Res 2014; 53: 76–83 CrossRef MEDLINE
22.
Varambally S, Gangadhar BN, Thirthalli J, et al.: Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia: randomized controlled comparison with exercise and waitlist. Indian J Psychiatry 2012; 54: 227–32 CrossRef MEDLINE PubMed Central
23.
Visceglia E, Lewis S: Yoga therapy as an adjunctive treatment for schizophrenia: a randomized, controlled pilot study. J Altern Complement Med 2011; 17: 601–7 CrossRef MEDLINE
24.
Woolery A, Myers H, Sternlieb B, Zeltzer L: A yoga intervention for young adults with elevated symptoms of depression. Altern Ther Health Med 2004; 10: 60–3 MEDLINE
25.
Yi-Huan L, Jun-Qing W, Hua-Na Z: Study for the effects on negative emotion and self-efficacy for patients with depression by YOGA relaxation training. Journal of Nurses Training 2010; 23: 2125–7.
26.
Duraiswamy G, Thirthalli J, Nagendra HR, Gangadhar BN: Yoga therapy as an add on treatment in the management of patients with schizophrenia: a randomized controlled trial. Acta Psychiatr Scand 2007; 116: 226–32 CrossRef MEDLINE
27.
Manjunath RB, Varambally S, Thirthalli J, Basavaraddi IV, Gangadhar BN: Efficacy of yoga as an add-on treatment
for in-patients with functional psychotic disorder.
Indian J Psychiatry 2013; 55: 374–8 CrossRef MEDLINE PubMed Central
28.
Raina N, Chakraborty PK, Basit MA, Samarth SN, Singh H: Evaluation of yoga therapy in alcohol dependence syndrome. Indian J Psychiatry 2001; 43: 171–4.
29.
Kinser PA, Bourguignon C, Whaley D, Hauenstein E, Taylor AG: Feasibility, acceptability, and effects of gentle hatha yoga for women with major depression: findings from a randomized controlled mixed-methods study. Arch Psychiatr Nurs 2013; 27: 137–47 CrossRef MEDLINE PubMed Central
30.
Mitchell KS, Dick AM, DiMartino DM, et al.: A pilot study of a randomized controlled trial of yoga as an intervention for PTSD symptoms in women. J Trauma Stress 2014; 27: 121–8 CrossRef MEDLINE
31.
Ranjbar F, Broomand M, Akbarzadeh A: The effect of yoga on anxiety symptoms in women with obsessive compulsive disorder. Life Sci J 2013; 10: 565–8.
32.
van der Kolk BA, Stone L, West JI, et al.: Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. J Clin Psychiatry 2014; 75: e559–65 CrossRef MEDLINE
33.
Ikai S, Uchida H, Suzuki T, Tsunoda K, Mimura M, Fujii Y: Effects of yoga therapy on postural stability in patients with schizophrenia-spectrum disorders: a single-blind randomized controlled trial. J Psychiatr Res 2013; 47: 1744–50 CrossRef MEDLINE
34.
Ikai S, Suzuki T, Uchida H, et al.: Effects of weekly one-hour hatha yoga therapy on resilience and stress levels in patients with schizophrenia-spectrum disorders: an eight-week randomized controlled trial. J Altern Complement Med 2014; 20: 823–30 CrossRef MEDLINE
35.
Shaffer HJ, LaSalvia TA, Stein JP: Comparing hatha yoga with dynamic group psychotherapy for enhancing methadone maintenance treatment: a randomized clinical trial. Altern Ther Health Med 1997; 3: 57–66 MEDLINE
36.
Behere RV, Arasappa R, Jagannathan A, et al.: Effect of yoga therapy on facial emotion recognition deficits, symptoms and functioning in patients with schizophrenia. Acta Psychiatr Scand 2011; 123: 147–53 CrossRef MEDLINE
37.
Dick AM, Niles BL, Street AE, DiMartino DM, Mitchell KS: Examining mechanisms of change in a yoga intervention for women: the influence of mindfulness, psychological flexibility, and emotion regulation on PTSD symptoms. J Clin Psychol 2014; 70: 1170–82 CrossRef MEDLINE
38.
Paikkatt B, Singh AR, Singh PK, Jahan M: Efficacy of yoga therapy on subjective well-being and basic living skills of patients having chronic schizophrenia. Ind Psychiatry J 2012; 21: 109–14 CrossRef MEDLINE PubMed Central
39.
Zhuang SM, An SH, Zhao Y: Yoga effects on mood and quality of life in Chinese women undergoing heroin detoxification: a randomized controlled trial. Nurs Res 2013; 62: 260–8 CrossRef MEDLINE
40.
Vorkapic CF, Rangé B: Reducing the symptomatology of panic disorder: the effects of a yoga program alone and in combination with cognitive-behavioral therapy. Front Psychiatry 2014; 5: 177 CrossRef MEDLINE PubMed Central
e1.
Berufsverband der Yoga-Lehrenden in Deutschland (BDY): Yoga in Zahlen. http://yoga-prive.de/hatha-yoga/studie-yoga-deutschland-wirksamkeit/bdy_yoga_in_deutschland/ (last accessed on 20 July 2015).
e2.
National Center for Complementary and Alternative Medicine: About yoga. http://nccam.nih.gov/health/yoga/ (last accessed on 20 July 2015).
e3.
Knowles A, Chadwick J, Vancampfort D: Yoga for schizophrenia. Cochrane Database Syst Rev 2013; 6.
e4.
Mehta P, Sharma M: Yoga as a complementary therapy for clinical depression. Complement Health Pract Rev 2010; 15: 156–70.
e5.
Monk-Turner E, Turner C: Does yoga shape body, mind and spiritual health and happiness: differences between yoga practitioners and college students. Int J Yoga 2010; 3: 48–54 CrossRef MEDLINE PubMed Central
e6.
Cramer H, Lauche R, Paul A, Langhorst J, Michalsen A, Dobos G: Mind-body medicine in the secondary prevention of coronary
heart disease—a systematic review and meta-analysis. Dtsch Arztebl Int 2015; 112: 759–67 MEDLINE PubMed Central
e7.
Grossman P, Niemann L, Schmidt S, Walach H: Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res 2004; 57: 35–43 CrossRef
e8.
Pigott TD: Handling missing data. In: Cooper H, Hedges LV, Valentine JC, eds.: The handbook of research synthesis and meta-analysis. New York: Russell Sage 2009; 399–416.
e9.
Higgins JPT, Altman DG, Sterne JAC: Assessing risk of bias in included studies. In: Higgins JPT, Green S, eds.: Cochrane handbook for systematic reviews of interventions version 5.1.0, updated March 2011. The Cochrane Collaboration 2011.
www.cochrane-handbook.org (last accessed on 20 July 2015).
e10.
Hedges LV, Olkin I: Statistical methods for meta-analysis. New York: Academic Press 1985.
e11.
Borenstein M, Hedges LV, Higgins JPT, Rothstein HR: Introduction to meta-analysis. Chichester: Wiley & Sons 2009.
e12.
Cohen J: A power primer. Psychol Bull 1992; 112: 155–9 CrossRef
e13.
Kraemer HC, Kupfer DJ: Size of treatment effects and their importance to clinical research and practice. Biol Psychiatry 2006; 59: 990–6 CrossRef MEDLINE
e14.
DerSimonian R, Laird N: Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177–88 CrossRef
e15.
Higgins JPT, Thompson SG, Deeks JJ, Altman DG: Measuring inconsistency in meta-analyses. Br Med J 2003; 327: 557–60 CrossRef MEDLINE PubMed Central
e16.
Egger M, Smith GD, Schneider M, Minder C: Bias in meta-analysis detected by a simple, graphical test. Br Med J 1997; 315: 629–34 CrossRef
e17.
Duval S, Tweedie R: Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56: 455–46 CrossRef
e18.
Gehr BT, Weiss C, Porzsolt F: The fading of reported effectiveness. A meta-analysis of randomised controlled trials. BMC Med Res Methodol 2006; 6: 25 CrossRef MEDLINE PubMed Central
e19.
Hofmann SG, Sawyer AT, Korte KJ, Smits JA: Is it beneficial to add pharmacotherapy to cognitive-behavioral therapy when treating anxiety disorders? A meta-analytic review. Int J Cogn Ther 2009; 2: 160–175 CrossRef
Institute of Psychosocial Medicine and Psychotherapy, University Hospital, Friedrich-Schiller-University Jena: M.Sc. Klatte, PD Dr. phil. Rosendahl
Institute of Psychology, Department of Research Synthesis, Intervention and Evaluation,
Friedrich-Schiller-University Jena: Dipl.-Psych. Pabst, Prof. Dr. phil. Beelmann
AHG Psychosomatische Klinik Bad Pyrmont: Dipl.-Psych. Pabst
Flow diagram for study selection
Figure 1
Flow diagram for study selection
Forest plot of the total effect of the yoga intervention group
Figure 2
Forest plot of the total effect of the yoga intervention group
Forest plot of the total effect of yoga compared with different active control groups
Figure 3
Forest plot of the total effect of yoga compared with different active control groups
Key messages
Inclusion criteria
Table 1
Inclusion criteria
Subgroup analyses of the efficacy of yoga compared with untreated control groups (primary endpoint)
Table 2
Subgroup analyses of the efficacy of yoga compared with untreated control groups (primary endpoint)
Funnel plots of Hedges’ g against its standard error (SE)
eFigure
Funnel plots of Hedges’ g against its standard error (SE)
Existing meta-analyses of the efficacy of yoga in mental disorders*1
eTable 1
Existing meta-analyses of the efficacy of yoga in mental disorders*1
Search strategy
eTable 2
Search strategy
Selected charakteristics of the included studies
eTable 3
Selected charakteristics of the included studies
Characteristics of included studies
eTable 4
Characteristics of included studies
Assessment of risk of bias of the included studies by using the Cochrane Collaboration’s quality criteria*1
eTable 5
Assessment of risk of bias of the included studies by using the Cochrane Collaboration’s quality criteria*1
Effects on secondary endpoints in the yoga intervention groups compared with untreated control groups
eTable 6
Effects on secondary endpoints in the yoga intervention groups compared with untreated control groups
Effects on secondary endpoints in the yoga intervention groups compared with active control groups
eTable 7
Effects on secondary endpoints in the yoga intervention groups compared with active control groups
Subgroup analyses of the effect of individual risks of bias on the efficacy of yoga intervention groups compared with untreated control groups (primary end point)
eTable 8
Subgroup analyses of the effect of individual risks of bias on the efficacy of yoga intervention groups compared with untreated control groups (primary end point)
1.Cabral P, Meyer HB, Ames D: Effectiveness of yoga therapy as a complementary treatment for major psychiatric disorders: a meta-analysis. Prim Care Companion CNS Disord 2011; 13 CrossRef
2.Meyer HB, Katsman A, Sones AC, Auerbach DE, Ames D, Rubin RT: Yoga as an ancillary treatment for neurological and psychiatric disorders: a review. J Neuropsychiatry Clin Neurosci 2012; 24: 152–64 CrossRef MEDLINE
3.Ross A, Thomas S: The health benefits of yoga and exercise: a review of comparison studies. J Altern Complement Med 2010; 16: 3–12 CrossRef MEDLINE
4.Cramer H, Ward L, Saper R, Fishbein D, Dobos G, Lauche R: The safety of yoga: a systematic review and meta-analysis of randomized controlled trials. Am J Epidemiol 2015; 182: 281–293 CrossRef MEDLINE
5.Qureshi NA, Al-Bedah AM: Mood disorders and complementary and alternative medicine: a literature review. International Neuropsychiatric Assoc 2013; 9: 639–58 CrossRef
6.Piet J, Hougaard E: The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis. Clin Psychol Rev 2011; 31: 1032–40 CrossRef MEDLINE
7.McCall MC: How might yoga work? An overview of potential underlying mechanisms. J Yoga Phys Ther 2013; 3: 130.
doi: 10.4172/2157–7595.1000130 CrossRef
8.Pabst SEP: Die Wirksamkeit von Yoga bei psychischen Störungen Erwachsener: Eine Meta-Analyse randomisierter Studien. Diplomarbeit. Jena: Friedrich-Schiller-Universität Jena 2011.
9.Knobben S: A meta-analysis of the effectiveness of yoga on mental health: taking on a dual perspective reflecting the medical and positive perspective of mental health. Masterarbeit. Niederlande: Universität Twente 2013. http://essay.utwente.nl/63524/ (last accessed on 20 July 2015).
10.Cramer H, Lauche R, Klose P, Langhorst J, Dobos G: Yoga for schizophrenia: a systematic review and meta-analysis. BMC Psychiatry 2013; 13. doi: 10.1186/1471–244X-13–32 CrossRef
11.Cramer H, Lauche R, Langhorst J, Dobos G: Yoga for depression: a systematic review and meta-analysis. Depress Anxiety 2013; 30: 1068–83 CrossRef MEDLINE
12.Gong H, Ni C, Shen X, Wu T, Jiang C: Yoga for prenatal depression: a systematic review and meta-analysis.
BMC Psychiatry 2015; 15. doi 10.1186/s12888–015–0393–1 CrossRef
13.Afonso RF, Hachul H, Kozasa EH, et al.: Yoga decreases insomnia in postmenopausal women: a randomized clinical trial. Menopause 2012; 19: 186–93 CrossRef MEDLINE
14.Buttner MM: Efficacy of yoga for depressed postpartum women: a randomized controlled trial. Ann Arbor: The University of Iowa 2013. http://search.proquest.com/docview/1443876609?accountid=14626 (last accessed on 20 July 2015).
15.Carter JJ, Gerbarg PL, Brown RP, et al.: Multi-component yoga breath program for Vietnam veteran post traumatic stress disorder: randomized controlled trial. J Trauma Stress Disord Treat 2013; 2: 1–10 CrossRef
16.Hallgren M, Romberg K, Bakshi AS, Andreasson S: Yoga as an adjunct treatment for alcohol dependence: a pilot study. Complement Ther Med 2014; 22: 441–5 CrossRef
17.Jayaram N, Varambally S, Behere RV, et al.: Effect of yoga therapy on plasma oxytocin and facial emotion recognition deficits in patients of schizophrenia. Indian J Psychiatry 2013; 55: 409–13 CrossRef MEDLINE PubMed Central
18.McIver S, O’Halloran P, McGartland M: Yoga as a treatment for binge eating disorder: a preliminary study. Complement Ther Med 2009; 17: 196–202 CrossRef MEDLINE
19.Oretzky S: The effects of yoga on elevated depressive and somatic symptoms in young adults. San Diego: Alliant International University 2006. http://search.proquest.com/docview/ 304913141?accountid=14626 (last accessed on 20 July 2015).
20.Parthasarathy S, Jaiganesh K, Duraisamy: Effect of integrated yoga module on selected psychological variables among women with anxiety problem. West Indian Med J 2014; 63: 83–5.
21.Sarubin N, Nothdurfter C, Schule C, et al.: The influence of Hatha yoga as an add-on treatment in major depression on hypothalamic-pituitary-adrenal-axis activity: a randomized trial. J Psychiatr Res 2014; 53: 76–83 CrossRef MEDLINE
22.Varambally S, Gangadhar BN, Thirthalli J, et al.: Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia: randomized controlled comparison with exercise and waitlist. Indian J Psychiatry 2012; 54: 227–32 CrossRef MEDLINE PubMed Central
23.Visceglia E, Lewis S: Yoga therapy as an adjunctive treatment for schizophrenia: a randomized, controlled pilot study. J Altern Complement Med 2011; 17: 601–7 CrossRef MEDLINE
24.Woolery A, Myers H, Sternlieb B, Zeltzer L: A yoga intervention for young adults with elevated symptoms of depression. Altern Ther Health Med 2004; 10: 60–3 MEDLINE
25.Yi-Huan L, Jun-Qing W, Hua-Na Z: Study for the effects on negative emotion and self-efficacy for patients with depression by YOGA relaxation training. Journal of Nurses Training 2010; 23: 2125–7.
26.Duraiswamy G, Thirthalli J, Nagendra HR, Gangadhar BN: Yoga therapy as an add on treatment in the management of patients with schizophrenia: a randomized controlled trial. Acta Psychiatr Scand 2007; 116: 226–32 CrossRef MEDLINE
27.Manjunath RB, Varambally S, Thirthalli J, Basavaraddi IV, Gangadhar BN: Efficacy of yoga as an add-on treatment
for in-patients with functional psychotic disorder.
Indian J Psychiatry 2013; 55: 374–8 CrossRef MEDLINE PubMed Central
28.Raina N, Chakraborty PK, Basit MA, Samarth SN, Singh H: Evaluation of yoga therapy in alcohol dependence syndrome. Indian J Psychiatry 2001; 43: 171–4.
29.Kinser PA, Bourguignon C, Whaley D, Hauenstein E, Taylor AG: Feasibility, acceptability, and effects of gentle hatha yoga for women with major depression: findings from a randomized controlled mixed-methods study. Arch Psychiatr Nurs 2013; 27: 137–47 CrossRef MEDLINE PubMed Central
30.Mitchell KS, Dick AM, DiMartino DM, et al.: A pilot study of a randomized controlled trial of yoga as an intervention for PTSD symptoms in women. J Trauma Stress 2014; 27: 121–8 CrossRef MEDLINE
31.Ranjbar F, Broomand M, Akbarzadeh A: The effect of yoga on anxiety symptoms in women with obsessive compulsive disorder. Life Sci J 2013; 10: 565–8.
32.van der Kolk BA, Stone L, West JI, et al.: Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. J Clin Psychiatry 2014; 75: e559–65 CrossRef MEDLINE
33.Ikai S, Uchida H, Suzuki T, Tsunoda K, Mimura M, Fujii Y: Effects of yoga therapy on postural stability in patients with schizophrenia-spectrum disorders: a single-blind randomized controlled trial. J Psychiatr Res 2013; 47: 1744–50 CrossRef MEDLINE
34.Ikai S, Suzuki T, Uchida H, et al.: Effects of weekly one-hour hatha yoga therapy on resilience and stress levels in patients with schizophrenia-spectrum disorders: an eight-week randomized controlled trial. J Altern Complement Med 2014; 20: 823–30 CrossRef MEDLINE
35.Shaffer HJ, LaSalvia TA, Stein JP: Comparing hatha yoga with dynamic group psychotherapy for enhancing methadone maintenance treatment: a randomized clinical trial. Altern Ther Health Med 1997; 3: 57–66 MEDLINE
36.Behere RV, Arasappa R, Jagannathan A, et al.: Effect of yoga therapy on facial emotion recognition deficits, symptoms and functioning in patients with schizophrenia. Acta Psychiatr Scand 2011; 123: 147–53 CrossRef MEDLINE
37.Dick AM, Niles BL, Street AE, DiMartino DM, Mitchell KS: Examining mechanisms of change in a yoga intervention for women: the influence of mindfulness, psychological flexibility, and emotion regulation on PTSD symptoms. J Clin Psychol 2014; 70: 1170–82 CrossRef MEDLINE
38.Paikkatt B, Singh AR, Singh PK, Jahan M: Efficacy of yoga therapy on subjective well-being and basic living skills of patients having chronic schizophrenia. Ind Psychiatry J 2012; 21: 109–14 CrossRef MEDLINE PubMed Central
39.Zhuang SM, An SH, Zhao Y: Yoga effects on mood and quality of life in Chinese women undergoing heroin detoxification: a randomized controlled trial. Nurs Res 2013; 62: 260–8 CrossRef MEDLINE
40.Vorkapic CF, Rangé B: Reducing the symptomatology of panic disorder: the effects of a yoga program alone and in combination with cognitive-behavioral therapy. Front Psychiatry 2014; 5: 177 CrossRef MEDLINE PubMed Central
e1.Berufsverband der Yoga-Lehrenden in Deutschland (BDY): Yoga in Zahlen. http://yoga-prive.de/hatha-yoga/studie-yoga-deutschland-wirksamkeit/bdy_yoga_in_deutschland/ (last accessed on 20 July 2015).
e2.National Center for Complementary and Alternative Medicine: About yoga. http://nccam.nih.gov/health/yoga/ (last accessed on 20 July 2015).
e3.Knowles A, Chadwick J, Vancampfort D: Yoga for schizophrenia. Cochrane Database Syst Rev 2013; 6.
e4.Mehta P, Sharma M: Yoga as a complementary therapy for clinical depression. Complement Health Pract Rev 2010; 15: 156–70.
e5.Monk-Turner E, Turner C: Does yoga shape body, mind and spiritual health and happiness: differences between yoga practitioners and college students. Int J Yoga 2010; 3: 48–54 CrossRef MEDLINE PubMed Central
e6.Cramer H, Lauche R, Paul A, Langhorst J, Michalsen A, Dobos G: Mind-body medicine in the secondary prevention of coronary
heart disease—a systematic review and meta-analysis. Dtsch Arztebl Int 2015; 112: 759–67 MEDLINE PubMed Central
e7.Grossman P, Niemann L, Schmidt S, Walach H: Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res 2004; 57: 35–43 CrossRef
e8.Pigott TD: Handling missing data. In: Cooper H, Hedges LV, Valentine JC, eds.: The handbook of research synthesis and meta-analysis. New York: Russell Sage 2009; 399–416.
e9.Higgins JPT, Altman DG, Sterne JAC: Assessing risk of bias in included studies. In: Higgins JPT, Green S, eds.: Cochrane handbook for systematic reviews of interventions version 5.1.0, updated March 2011. The Cochrane Collaboration 2011.
www.cochrane-handbook.org (last accessed on 20 July 2015).
e10.Hedges LV, Olkin I: Statistical methods for meta-analysis. New York: Academic Press 1985.
e11.Borenstein M, Hedges LV, Higgins JPT, Rothstein HR: Introduction to meta-analysis. Chichester: Wiley & Sons 2009.
e12.Cohen J: A power primer. Psychol Bull 1992; 112: 155–9 CrossRef
e13.Kraemer HC, Kupfer DJ: Size of treatment effects and their importance to clinical research and practice. Biol Psychiatry 2006; 59: 990–6 CrossRef MEDLINE
e14.DerSimonian R, Laird N: Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177–88 CrossRef
e15.Higgins JPT, Thompson SG, Deeks JJ, Altman DG: Measuring inconsistency in meta-analyses. Br Med J 2003; 327: 557–60 CrossRef MEDLINE PubMed Central
e16.Egger M, Smith GD, Schneider M, Minder C: Bias in meta-analysis detected by a simple, graphical test. Br Med J 1997; 315: 629–34 CrossRef
e17.Duval S, Tweedie R: Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56: 455–46 CrossRef
e18.Gehr BT, Weiss C, Porzsolt F: The fading of reported effectiveness. A meta-analysis of randomised controlled trials. BMC Med Res Methodol 2006; 6: 25 CrossRef MEDLINE PubMed Central
e19.Hofmann SG, Sawyer AT, Korte KJ, Smits JA: Is it beneficial to add pharmacotherapy to cognitive-behavioral therapy when treating anxiety disorders? A meta-analytic review. Int J Cogn Ther 2009; 2: 160–175 CrossRef

Deutsches Ärzteblatt international

Info