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There is growing interest in developing a holistic and integrative approach for the treatment of severe mental illnesses (SMI), such as schizophrenia, major depression, posttraumatic stress disorder (PTSD), and anxiety disorders. Western medicine has traditionally focused on the direct treatment of symptoms and separated the management of physical and mental health, but increasing attention is being given to complementary and alternative medicine (CAM) for patients with SMI.
Recognizing the connectedness of the mind and body, these complementary or alternative approaches incorporate nontraditional therapeutic techniques with mainstream treatment methods, including psychopharmacology and psychotherapy.1 Patients with SMI may particularly benefit from a mind-body therapeutic approach, because they often experience psychological symptoms such as stress, anxiety, depression and psychosis, as well as a preponderance of medical comorbidities, including obesity, diabetes mellitus, and cardiovascular disease, some of which are compounded by adverse effects (AEs) of essential pharmacologic treatments.2-4 Mind-body interventions might also be particularly advantageous for veterans, who often experience a range of interconnected physical and psychological difficulties due to trauma exposure and challenges transitioning from military to civilian life.5
Related: Complementary and Alternative Medicine for Chronic Musculoskeletal Pain
In 2002, the White House Commission on Complementary and Alternative Medicine Policy issued a report supporting CAM research and integration into existing medical systems.6 The DoD later established Total Force Fitness, a holistic health care program for active-duty military personnel.7 The VA has also incorporated mind-body and holistic strategies into veteran care.8 One such mind-body intervention, yoga, is becoming increasingly popular within the health care field.
Recent research has documented the effectiveness of yoga, underscoring its utility as a mind-body therapeutic approach. Yoga is associated with improvement in balance and flexibility,9 fatigue,10 blood pressure,11 sleep,12 strength,13 and pain14 in both healthy individuals and patients with medical and psychiatric disorders.15 The literature also illustrates that yoga has led to significant improvements in stress and psychiatric symptoms in individuals with PTSD, schizophrenia, depression, and anxiety.16-22 A previous meta-analysis conducted by the authors, which considered studies of the effectiveness of yoga as an adjunctive treatment for patients with mental illness, found that 212 studies with null results would need to be located and incorporated to negate the positive effects of yoga found in the literature.17
Because yoga emphasizes the practice of mindfulness and timing movement with breath awareness, it is a calming practice that may decrease stress and relieve psychiatric symptoms not treated through psychopharmacology and psychotherapy.17,21 Recent research has postulated that the physiological mechanisms by which this occurs may include (a) reduction in sympathetic and increase in parasympathetic activity23,24; (b) increases in heart-rate variability and respiratory sinus arrhythmia, low levels of which are associated with anxiety, panic disorder, and depression23,24; (c) increases in melatonin and serotonin 25-27; and (d) decrease in cortisol.28,29
Related: Enhancing Patient Satisfaction Through the Use of Complementary Therapies
As yoga may calm the autonomic nervous system and reduce stress, it may benefit patients with SMI, whose symptoms are often aggravated by stress.30 In addition, veterans experience both acute stressors and high levels of chronic stress.5 Therefore, because they experience mind-body comorbid illnesses as well as high levels of stress, the authors believe that veterans with SMI could benefit greatly from a tailored yoga-based program as part of a holistic approach that includes necessary medication and evidence-based therapies.
In order to evaluate the effects of a yoga program on veterans receiving mental health treatment across the VA Greater Los Angeles Healthcare System (VAGLAHS), the authors developed a set of yoga-based wellness classes called Breathing, Stretching, Relaxation (BSR) classes. This article describes the process of developing these classes and outlines the procedures and results of a study to assess their effects.
BSR Classes
The development of BSR classes took place at the West Los Angeles VA Medical Center (WLAVAMC), within the Psychosocial Rehabilitation and Recovery Center (PRRC) program. The PRRC is a psychoeducational program that focuses on the biological, psychological, social, and spiritual aspects of life in order to help veterans with SMI rehabilitate and reintegrate into the community. The program allows veterans to create their own recovery curriculum by selecting from diverse classes led by program staff members, including physicians, psychologists, nurses, social workers, nutritionists, and recreational therapists.
Development of BSR Protocols
The primary goal of this project was to develop a yoga-based program tailored to the specific needs of veterans with SMI. To the authors’ knowledge, BSR is the first yoga-based program customized for SMI. The BSR classes were developed within interdisciplinary focus groups that included professional yoga teachers, the director of the PRRC, psychiatrists, psychologists, nurses, occupational therapists, and physical therapists. Drawing on their experience with SMI and yoga, members of the focus groups identified 3 aspects of yoga that would be most beneficial to veterans with SMI, and the program was designed to optimize these effects. Because SMI can both create and be exacerbated by stress, BSR classes were designed to reduce stress and provide veterans with the tools to monitor and manage their stress.
Breathing and meditative techniques were adapted from yoga in order to facilitate stress reduction. In addition, aerobic elements of yoga have the potential to help veterans manage their incidence of medical diseases, such as cardiovascular disease, obesity, and diabetes. Patients with SMI are at a greater risk for developing these diseases, so classes were designed to incorporate physical stretching elements to promote overall health.4,31-33 Finally BSR was designed to improve veteran self- efficacy and self-esteem, and to place veterans at the center of their care by equipping them with skills to practice BSR independently.
Related: Mindfulness to Reduce Stress
The focus groups also identified the logistic requirements when implementing a yoga-based program for veterans with SMI, including (a) obtaining participant or conservator consent; (b) obtaining medical clearance from care providers, given the high prevalence of medical comorbidities; (c) removing the traditional yoga terms, taking a secular approach, and naming the class “Breathing, Stretching, Relaxation” without directly referencing yoga; (d) asking veterans’ permission before incorporating physical contact into demonstrations, because veterans with SMI, especially those with PTSD, might be uncomfortable with touching from instructors; (e) creating protocols of varying duration and intensity so that BSR was approachable for veterans with diverse levels of physical ability; and (f) ensuring that a clinician who regularly works with SMI patients be present to supervise classes for the safety of patients and instructors.
Yoga instructors and clinicians collaborated to create adaptable 30- and 50-minute protocols that reflected best practices for an SMI population. The 30-minute seated BSR class protocol is included in eAppendix A. Once protocols were finalized, a Train the Trainer program was established to facilitate dissemination of BSR to clinicians working with veterans with SMI throughout the VAGLAHS.
Interested clinicians were given protocols and trained to lead BSR classes on their own. Subsequently, clinician-led BSR classes of various lengths (depending on clinician preference and program scheduling) were established at PRRCs and other mental health programs, such as Mental Health Recovery and Intensive Treatment and Dual Diagnosis Treatment Program, throughout the VAGLAHS. These programs were selected, because they are centered on recovery and improvements in symptoms of SMI. The adoption of a Train the Trainer model, through which VA clinicians were trained by professional yoga instructors, allowed for seamless integration of BSR into VA usual care for veterans with SMI.
Assessment of Classes
The authors conducted a study to assess the quality and effectiveness of BSR classes. This survey research was approved by the VAGLAHS institutional review board for human subjects. The authors hypothesized that there would be significant improvements in veterans’ stress, pain, well-being, and perception of the benefits of BSR over 8 weeks of participation in classes. Also hypothesized was that there would be greater benefits in veterans who participated in longer classes and who attended classes more frequently.
Methods
A total of 120 veterans completed surveys after participating in clinician- and yoga instructor-led BSR classes at the 3 sites within the VAGLAHS: WLAVAMC, Los Angeles Ambulatory Care Center (LAACC), and Sepulveda Ambulatory Care Center (SACC). At the WLAVAMC, surveys were collected at 10-, 30-, 60-, and 90-minute classes. At LAACC, surveys were collected at 30- and 60-minute classes. At SACC, surveys were collected at 20- and 45-minute classes. A researcher noted the duration of the class and was available to assist with comprehension. Veterans completed identical surveys after classes at a designated week 0 (baseline), week 4, and week 8. Of the 120 patients with an initial survey, 82 completed at least 1 follow-up survey and 49 completed both follow-up surveys.
Survey packets included (a) demographic questions, including age, gender, and ethnicity; (b) class participation questions, including frequency of class attendance, patients’ favorite aspect of class, and dura tion of class attendance (in months of prior participation); (c) a pain rating from 0 (no pain) to 10 (the worst pain imaginable); (d) the BioPsychoSocial-Spiritual (BPSS) Scale (eAppendix B), developed at the WLAVAMC, which provides wellness scores from 0 (low) to 10 (high) in 4 areas as well as a holistic wellness score from 0 (low) to 40 (high); (e) the Perceived Stress Scale (PSS), developed by Cohen and colleagues, which generates a stress score for the past month from 0 (low) to 40 (high)34; and (f) the Perceived Benefits of Yoga Questionnaire (PBYQ) (eAppendix C), which rates participants’ opinions about the benefits of yoga from 12 (low) to 60 (high) and is based on the Perceived Benefits of Dance Questionnaire.35
Statistical Analysis
Pearson’s r correlation coefficients were calculated between PBYQ scores and quantitative survey items at each time point (weeks 0, 4, and 8). Linear mixed-effects models were used to test for effects of multiple predictor variables on individual outcomes. Each model had a random intercept by participant, and regressors included main effects for the following: survey week (0, 4, or 8), class duration (in minutes), age, sex, ethnicity, frequency of attendance (in days per week), and duration of attendance (in months). For all statistical analyses, a 2-tailed significance criterion of α = .05 was used.
Results
Veterans who completed surveys were predominantly male (90.8%) and averaged 61.4 years of age. Table 1 shows demographic information. Table 2 displays the number of participants who were involved in short (< 30 min), medium (30-59 min), and long (> 60 min) classes. Veteran participants also had a wide range of prior BSR experience (Table 3).
At all time points, PBYQ scores were significantly positively correlated with class duration and biological, psychological, social, spiritual, and total well-being as measured by the BPSS. The PBYQ scores at all time points were also significantly negatively correlated with age, pain ratings, and PSS scores. Table 4 includes specific Pearson’s r values.
Survey week was not significantly associated with any individual outcome measures. There were no significant regressors for total PSS score or total BPSS score within the linear models. However, participants’ PBYQ scores were significantly associated with age (t(98) = -2.13, P = .036), frequency of attendance (t(103) = 2.10, P = .038), and class duration (t(98) = 4.35, P < .001). Additionally, class duration was significantly associated with pain (t(98) = -3.01, P = .003), with longer duration associated with less pain. Ethnicity was also associated with pain, with African American veterans reporting less pain than did white (t(98) = -2.41, P = .017) and Hispanic (t(98) = -2.31, P = .023) veterans. Because ethnicity was significantly associated with class duration (F(5,339) = 3.81, P = .002), the authors used an analysis of covariance to test for a mediating effect of ethnicity on the relationship between class duration and pain. Although there was a partial mediation (F(5,203) = 2.57, P = .028), the main effect of class duration remained significant.
Discussion and Limitations
The goals of this project were to develop a yoga-based program tailored for veterans with SMI and assess the program in a sample of veterans with SMI on subjective reports of stress, pain, well-being, and benefits of yoga. The authors hypothesized that significant improvements in these measures in veterans with SMI would be observed over 8 weeks of participation in BSR classes and that there would be greater benefits in veterans who participated in longer classes and who attended classes more frequently.
The authors succeeded in developing an adaptable yoga-based wellness program for veterans with SMI that can be both practiced in structured classes and incorporated into veterans’ everyday routines. The BSR classes were well tolerated by veterans with SMI, caused no discernible AEs, and are readily available for dissemination across other mental health programs. Veterans described integrating the tools they learned within BSR classes into their daily lives, helping them to manage pain; feel more flexible; reduce stress, anxiety, depression, and PTSD symptoms; and increase relaxation and feelings of self-control and confidence. Table 5 shows qualitative feedback collected from veterans. In addition, the Train the Trainer model optimized clinical applicability and flexibility, demonstrating that clinicians can seamlessly integrate BSR classes into a health care plan for veterans with SMI.
In assessing quantitative measures of stress, pain, well-being, and perceived benefits of a yoga-based program, veterans who reported BSR classes as beneficial experienced lower levels of pain and stress and higher levels of biological, psychological, social, spiritual, and overall well-being. Those veterans who perceived BSR as more beneficial tended to be younger and attend longer classes with greater frequency. Veterans who attended longer classes also reported experiencing less pain. This may be because the more rigorous stretching and posing involved in longer BSR classes made them more effective at reducing pain; however, it is also possible that veterans who were experiencing more pain avoided these longer classes due to their rigor and length.
Results suggest that longer classes attended with greater regularity may be more beneficial to veterans than short and infrequent classes, particularly in regards to their pain. Despite the relationships between class and outcome variables, the authors did not find significant improvements in measures of wellness, pain, stress, or perceived benefits of BSR over time, as was hypothesized. This may be because the data collection for this study began after classes had been established for some time. In fact, only 35 of 120 veterans included in this study reported having < 1 month of BSR experience at week 0, suggesting that results collected from week 0 did not represent a true baseline measurement. Although no relationship was found between prior duration of attendance and any outcome measures, the fact that most veterans in the sample had attended classes for several months prior to completing surveys may have biased the results by favoring the responses of veterans who were more invested in the classes. Improvements may have been better captured in a BSR-naïve sample.
The finding that the PBYQ score was significantly correlated with all other outcome measures (pain, BPSS score, and PSS score) raises some questions about the ways in which these classes were beneficial to veterans. It may be that veterans who experienced more positive outcomes from classes saw BSR as more beneficial, but it is also possible that veterans who entered classes with greater expectations experienced better outcomes due to a placebo effect—that is, outcomes may have been influenced more by the expectation than by the content of the classes. In the case of well-being (BPSS scores) and stress (PSS score), this could explain why these outcomes were significantly correlated with perceived benefits of BSR but were not significantly related to any class-related variables such as duration and frequency of attendance. Pain ratings, however, were related to class variables and perceived benefits of BSR.
In a post hoc analysis, the main effect of the PBYQ score as a regressor was added to the linear model for pain, resulting in the PBYQ score having a significant main effect (t(100) = -2.98, P = .004). The main effect of class duration remained significant (t(97) = -1.99, P = .050) but was less substantial when the PBYQ score was added, suggesting some correlation between class duration and pain, independent of BSR’s perceived benefits. Future research should consider the possible mediating effect of perceptions of the effectiveness of a yoga-based program a priori or control for placebo effects in order to address the degree to which outcomes are influenced by participant expectations.
This study had a few other notable limitations. Because it was an observational study administered within a clinical mental health program, a control group was not included. Measurement began after BSR classes were established, so veterans had varying levels of prior experience. Specific SMI and medical diagnosis information was not collected from individual veterans. Data were collected from classes of varying length and intensity. The BSR classes often took place within larger programs at the VA, which offered comprehensive care, so some effects of the BSR classes might have been confounded with concurrent evidenced-based treatments or other holistic care programs. Due to these limitations, particularly the absence of a control group, the relationships between BSR participation and health outcomes cannot be assumed to be causal, because a multitude of other variables, such as patient contact and expectancy effects, may have influenced outcomes.
Future Directions
Future research should aim to utilize a control group and collect data from classes of the same intensity and length to better examine whether BSR can be causally linked with improvements in measures of stress, pain, and well-being and to attempt to control for expectancy and contact effects. In addition, future research should aim to recruit a BSR-naïve sample to account for prior experience. Future studies should also aim to parse out whether BSR is differentially effective for each SMI or medical diagnosis, whether there is a relationship between class time and outcomes (as these results suggest that longer class times might be more beneficial for pain), and whether any pain-management benefits from BSR influence other measures of functionality and well-being. Finally, future research can further divide BSR into its active components, such as meditative breathing and aerobic stretching, in order to examine which aspect leads to the greatest effect on each measure; the current results imply that the more rigorous components of BSR classes have the greatest effects on pain.
Conclusion
A yoga-based class affects the mind and body, making it particularly useful for veterans with SMI who experience a range of physical and psychological symptoms and comorbidities.4 Other studies have demonstrated that when practiced alone, yoga leads to improvements in both physical and psychological symptoms.15,17 Looking forward, yoga-based classes may be implemented as part of a larger biopsychosocial-spiritual care plan that is being embraced both within and outside of the VA.7,8,36,37 This integrative health care model suggests that psychosocial and CAM modalities are additive and should be practiced concurrently.37
Although little research has assessed the effects of comprehensive psychosocial and CAM treatment programs, initial research indicates that these programs are associated with reductions in symptoms of medical and mental illness.37-40 Participants in BSR classes may derive further benefits if classes are incorporated into a larger holistic health care plan that includes both traditional psychiatric treatment modalities and CAM therapies that integrate biopsychosocial-spiritual components.
Acknowledgements
The authors would like to thank Nancy Mohler, Anne Platt, and Matthew Crowder, all professional yoga instructors, for their integral role in developing classes, providing classes to veterans, and assisting VA staff with training. The authors also acknowledge Rosie Dominguez, LCSW, for expertly leading BSR classes at LAACC. The authors also thank Irina Arnold, MS, MD, and Vanessa Streiff, MA, for their vital assistance with data collection at SACC.
Funding for the development of BSR protocols, quality improvement research, and expenses associated with classes was provided by the Disabled American Veterans Charitable Service Trust. Support for dissemination of classes to multiple VA programs was provided by a grant from the VA Center of Innovation for Patient Centered Care, headed by Sandra Robertson, RN, MSN, PH-CNS.
The authors are very grateful to the veterans and staff of the Mental Health Intensive Case Management, Psychosocial Rehabilitation and Recovery Centers, Mental Health Clinics, and Domiciliary throughout Greater Los Angeles for their support of the BSR classes.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
1. National Center for Complementary and Integrative Health. Complementary, alternative, or integrative health: what's in a name? U.S. Department of Health and Human Services, National Institutes of Health Website. http://nccam.nih.gov/health/whatiscam. Updated March 2015. Accessed August 27, 2015.
2. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
3. Fleischhacker WW, Cetkovich-Bakmas M, De Hert M, et al. Comorbid somatic illnesses in patients with severe mental disorders: clinical, policy, and research challenges. J Clin Psychiatry. 2008;69(4):514-519.
4. Wirshing DA, Boyd JA, Meng LR, Ballon JS, Marder SR, Wirshing WC. The effects of novel antipsychotics on glucose and lipid levels. J Clin Psychiatry. 2002;63(10):856-865.
5. Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation; 2008.
6. White House Commission on Complementary and Alternative Medicine Policy. Final Report. Washington, DC: White House Commission on Complementary and Alternative Medicine Policy; 2002.
7. Land BC. Current Department of Defense guidance for total force fitness. Mil Med. 2010;175(suppl 8):3-5.
8. U.S. Department of Veterans Affairs, Veterans Health Administration. Pain Management. VHA Directive 2009-053. Washington, DC: U.S. Department of Veterans Affairs, Veterans Health Administration; 2009.
9. Oken BS, Zajdel D, Kishiyama S, et al. Randomized, controlled, six-month trial of yoga in healthy seniors: effects on cognition and quality of life. Altern Ther Health Med. 2006;12(1):40-47.
10. Bower JE, Garet D, Sternlieb B, et al. Yoga for persistent fatigue in breast cancer survivors: a randomized controlled trial. Cancer. 2012;118(15):3766-3775.
11. Cade WT, Reeds DN, Mondy KE, et al. Yoga lifestyle intervention reduces blood pressure in HIV-infected adults with cardiovascular disease risk factors. HIV Med. 2010;11(6):379-388.
12. Innes KE, Selfe TK. The effects of a gentle yoga program on sleep, mood, and blood pressure in older women with restless leg syndrome (RLS): a preliminary randomized controlled trial. Evid Based Complement Alternat Med. 2012;2012:294058.
13. Van Puymbroeck M, Payne LL, Hsieh PC. A phase I feasibility study of yoga on the physical health and coping of informal caregivers. Evid Based Complement Alternat Med. 2007;4(4):519-529.
14. Rani K, Tiwari SC, Singh U, Agrawal GG, Srivastava N. Six-month trial of Yoga Nidra in menstrual disorder patients: effects on somatoform symptoms. Ind Psychiatry J. 2011;20(2):97-102.
15. Ross A, Thomas S. The health benefits of yoga and exercise: a review of comparison studies. J Altern Complement Med. 2010;16(1):3-12.
16. Banerjee B, Vadiraj HS, Ram A, et al. Effects of an integrated yoga program in modulating psychological stress and radiation-induced genotoxic stress in breast cancer patients undergoing radiotherapy. Integr Cancer Ther. 2007;6(3):242-250.
17. 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(4):doi:10.4088/PCC.10r01068.
18. Katzman MA, Vermani M, Gerbarg PL, et al. A multicomponent yoga-based, breath intervention program as an adjunctive treatment in patients suffering from generalized anxiety disorder with or without comorbidities. Int J Yoga. 2012;5(1):57-65.
19. Köhn M, Persson Lundholm U, Bryngelsson IL, Anderzén-Carlsson A, Westerdahl E. Medical yoga for patients with stress-related symptoms and diagnoses in primary health care: a randomized controlled trial. Evid Based Complement Alternat Med. 2013;2013:215348.
20. Krishnamurthy MN, Telles S. Assessing depression following two ancient Indian interventions: effects of yoga and ayurveda on older adults in a residential home. J Gerontol Nurs. 2007;33(2):17-23.
21. 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(2):152-164.
22. Visceglia E, Lewis S. Yoga therapy as an adjunctive treatment for schizophrenia: a randomized, controlled pilot study. J Altern Complement Med. 2011;17(7):601-607.
23. Brown RP, Gerbarg PL. Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression, part I-neurophysiologic model. J Altern Complement Med. 2005;11(1):189-201.
24. Brown RP, Gerbarg PL. Yoga breathing, meditation, and longevity. Ann N Y Acad Sci. 2009;1172:54-62.
25. Harinath K, Malhotra AS, Pal K, et al. Effects of hatha yoga and Omkar meditation on cardiorespiratory performance, psychologic profile, and melatonin secretion. J Altern Complement Med. 2004;10(2):261-268.
26. Tooley GA, Armstrong SM, Norman TR, Sali A. Acute increases in night-time plasma melatonin levels following a period of meditation. Biol Psychol. 2000;53(1):69-78.
27. Walton KG, Pugh ND, Gelderloos P, Macrae P. Stress reduction and preventing hypertension: preliminary support of a psychoneuroendocrine mechanism. J Altern Complement Med. 1995;1(3):263-283.
28. Banasik J, Williams H, Haberman M, Blank SE, Bendel R. Effect of Iyengar yoga practice on fatigue and diurnal salivary cortisol concentration in breast cancer survivors. J Am Acad Nurse Pract. 2011;23(3):135-142.
29. Vadiraja HS, Raghavendra RM, Nagarathna R, et al. Effects of a yoga program on cortisol rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: a randomized controlled trial. Integr Cancer Ther. 2009;8(1):37-46.
30. Esch T, Stefano GB, Fricchione GL, Benson H. The role of stress in neurodegenerative diseases and mental disorders. Neuro Endocrinol Lett. 2002;23(3):199-208.
31. Lingjaerde O, Ahlfors UG, Bech P, Dencker SJ, Elgen K. The UKU side effect rating scale. A new comprehensive rating scale for psychotropic drugs and a cross-sectional study of side effects in neuroleptic-treated patients. Acta Psychiatr Scand Suppl. 1987;334:1-100.
32. Schwartz TL, Nihalani N, Jindal S, Virk S, Jones N. Psychiatric medication-induced obesity: a review. Obes Rev. 2004;5(2):115-121.
33. Wirshing DA, Spellberg BJ, Erhart SM, Marder SR, Wirshing WC. Novel antipsychotics and new onset diabetes. Biol Psychiatry. 1998;44(8):778-783.
34. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-396.
35. Quiroga Murcia C, Kreutz G, Clift S, Bongard S. Shall we dance? An exploration of the perceived benefits of dancing on well-being. Arts Health. 2010;2(2):149-163.
36. The Duke Center for Integrative Medicine; Liebowitz R, Smith L. The Duke Encyclopedia of New Medicine: Conventional and Alternative Medicine for All Ages. London, UK: Rodale Books International; 2006.
37. Walsh R. Lifestyle and mental health. Am Psychol. 2011;66(7):579-592.
38. Frattaroli J, Weidner G, Dnistrian AM, et al. Clinical events in prostate cancer lifestyle trial: results from two years of follow-up. Urology. 2008;72(6):1319-1323.
39. Khaw KT, Wareham N, Bingham S, Welch A, Luben R, Day N. Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk prospective population study. PLoS Med. 2008;5(1):e12.
40. Sidhu KS, Vandana P, Balon R. Exercise prescription: a practical, effective therapy for depression. Curr Psychiatr. 2009;8(6):38-51.
There is growing interest in developing a holistic and integrative approach for the treatment of severe mental illnesses (SMI), such as schizophrenia, major depression, posttraumatic stress disorder (PTSD), and anxiety disorders. Western medicine has traditionally focused on the direct treatment of symptoms and separated the management of physical and mental health, but increasing attention is being given to complementary and alternative medicine (CAM) for patients with SMI.
Recognizing the connectedness of the mind and body, these complementary or alternative approaches incorporate nontraditional therapeutic techniques with mainstream treatment methods, including psychopharmacology and psychotherapy.1 Patients with SMI may particularly benefit from a mind-body therapeutic approach, because they often experience psychological symptoms such as stress, anxiety, depression and psychosis, as well as a preponderance of medical comorbidities, including obesity, diabetes mellitus, and cardiovascular disease, some of which are compounded by adverse effects (AEs) of essential pharmacologic treatments.2-4 Mind-body interventions might also be particularly advantageous for veterans, who often experience a range of interconnected physical and psychological difficulties due to trauma exposure and challenges transitioning from military to civilian life.5
Related: Complementary and Alternative Medicine for Chronic Musculoskeletal Pain
In 2002, the White House Commission on Complementary and Alternative Medicine Policy issued a report supporting CAM research and integration into existing medical systems.6 The DoD later established Total Force Fitness, a holistic health care program for active-duty military personnel.7 The VA has also incorporated mind-body and holistic strategies into veteran care.8 One such mind-body intervention, yoga, is becoming increasingly popular within the health care field.
Recent research has documented the effectiveness of yoga, underscoring its utility as a mind-body therapeutic approach. Yoga is associated with improvement in balance and flexibility,9 fatigue,10 blood pressure,11 sleep,12 strength,13 and pain14 in both healthy individuals and patients with medical and psychiatric disorders.15 The literature also illustrates that yoga has led to significant improvements in stress and psychiatric symptoms in individuals with PTSD, schizophrenia, depression, and anxiety.16-22 A previous meta-analysis conducted by the authors, which considered studies of the effectiveness of yoga as an adjunctive treatment for patients with mental illness, found that 212 studies with null results would need to be located and incorporated to negate the positive effects of yoga found in the literature.17
Because yoga emphasizes the practice of mindfulness and timing movement with breath awareness, it is a calming practice that may decrease stress and relieve psychiatric symptoms not treated through psychopharmacology and psychotherapy.17,21 Recent research has postulated that the physiological mechanisms by which this occurs may include (a) reduction in sympathetic and increase in parasympathetic activity23,24; (b) increases in heart-rate variability and respiratory sinus arrhythmia, low levels of which are associated with anxiety, panic disorder, and depression23,24; (c) increases in melatonin and serotonin 25-27; and (d) decrease in cortisol.28,29
Related: Enhancing Patient Satisfaction Through the Use of Complementary Therapies
As yoga may calm the autonomic nervous system and reduce stress, it may benefit patients with SMI, whose symptoms are often aggravated by stress.30 In addition, veterans experience both acute stressors and high levels of chronic stress.5 Therefore, because they experience mind-body comorbid illnesses as well as high levels of stress, the authors believe that veterans with SMI could benefit greatly from a tailored yoga-based program as part of a holistic approach that includes necessary medication and evidence-based therapies.
In order to evaluate the effects of a yoga program on veterans receiving mental health treatment across the VA Greater Los Angeles Healthcare System (VAGLAHS), the authors developed a set of yoga-based wellness classes called Breathing, Stretching, Relaxation (BSR) classes. This article describes the process of developing these classes and outlines the procedures and results of a study to assess their effects.
BSR Classes
The development of BSR classes took place at the West Los Angeles VA Medical Center (WLAVAMC), within the Psychosocial Rehabilitation and Recovery Center (PRRC) program. The PRRC is a psychoeducational program that focuses on the biological, psychological, social, and spiritual aspects of life in order to help veterans with SMI rehabilitate and reintegrate into the community. The program allows veterans to create their own recovery curriculum by selecting from diverse classes led by program staff members, including physicians, psychologists, nurses, social workers, nutritionists, and recreational therapists.
Development of BSR Protocols
The primary goal of this project was to develop a yoga-based program tailored to the specific needs of veterans with SMI. To the authors’ knowledge, BSR is the first yoga-based program customized for SMI. The BSR classes were developed within interdisciplinary focus groups that included professional yoga teachers, the director of the PRRC, psychiatrists, psychologists, nurses, occupational therapists, and physical therapists. Drawing on their experience with SMI and yoga, members of the focus groups identified 3 aspects of yoga that would be most beneficial to veterans with SMI, and the program was designed to optimize these effects. Because SMI can both create and be exacerbated by stress, BSR classes were designed to reduce stress and provide veterans with the tools to monitor and manage their stress.
Breathing and meditative techniques were adapted from yoga in order to facilitate stress reduction. In addition, aerobic elements of yoga have the potential to help veterans manage their incidence of medical diseases, such as cardiovascular disease, obesity, and diabetes. Patients with SMI are at a greater risk for developing these diseases, so classes were designed to incorporate physical stretching elements to promote overall health.4,31-33 Finally BSR was designed to improve veteran self- efficacy and self-esteem, and to place veterans at the center of their care by equipping them with skills to practice BSR independently.
Related: Mindfulness to Reduce Stress
The focus groups also identified the logistic requirements when implementing a yoga-based program for veterans with SMI, including (a) obtaining participant or conservator consent; (b) obtaining medical clearance from care providers, given the high prevalence of medical comorbidities; (c) removing the traditional yoga terms, taking a secular approach, and naming the class “Breathing, Stretching, Relaxation” without directly referencing yoga; (d) asking veterans’ permission before incorporating physical contact into demonstrations, because veterans with SMI, especially those with PTSD, might be uncomfortable with touching from instructors; (e) creating protocols of varying duration and intensity so that BSR was approachable for veterans with diverse levels of physical ability; and (f) ensuring that a clinician who regularly works with SMI patients be present to supervise classes for the safety of patients and instructors.
Yoga instructors and clinicians collaborated to create adaptable 30- and 50-minute protocols that reflected best practices for an SMI population. The 30-minute seated BSR class protocol is included in eAppendix A. Once protocols were finalized, a Train the Trainer program was established to facilitate dissemination of BSR to clinicians working with veterans with SMI throughout the VAGLAHS.
Interested clinicians were given protocols and trained to lead BSR classes on their own. Subsequently, clinician-led BSR classes of various lengths (depending on clinician preference and program scheduling) were established at PRRCs and other mental health programs, such as Mental Health Recovery and Intensive Treatment and Dual Diagnosis Treatment Program, throughout the VAGLAHS. These programs were selected, because they are centered on recovery and improvements in symptoms of SMI. The adoption of a Train the Trainer model, through which VA clinicians were trained by professional yoga instructors, allowed for seamless integration of BSR into VA usual care for veterans with SMI.
Assessment of Classes
The authors conducted a study to assess the quality and effectiveness of BSR classes. This survey research was approved by the VAGLAHS institutional review board for human subjects. The authors hypothesized that there would be significant improvements in veterans’ stress, pain, well-being, and perception of the benefits of BSR over 8 weeks of participation in classes. Also hypothesized was that there would be greater benefits in veterans who participated in longer classes and who attended classes more frequently.
Methods
A total of 120 veterans completed surveys after participating in clinician- and yoga instructor-led BSR classes at the 3 sites within the VAGLAHS: WLAVAMC, Los Angeles Ambulatory Care Center (LAACC), and Sepulveda Ambulatory Care Center (SACC). At the WLAVAMC, surveys were collected at 10-, 30-, 60-, and 90-minute classes. At LAACC, surveys were collected at 30- and 60-minute classes. At SACC, surveys were collected at 20- and 45-minute classes. A researcher noted the duration of the class and was available to assist with comprehension. Veterans completed identical surveys after classes at a designated week 0 (baseline), week 4, and week 8. Of the 120 patients with an initial survey, 82 completed at least 1 follow-up survey and 49 completed both follow-up surveys.
Survey packets included (a) demographic questions, including age, gender, and ethnicity; (b) class participation questions, including frequency of class attendance, patients’ favorite aspect of class, and dura tion of class attendance (in months of prior participation); (c) a pain rating from 0 (no pain) to 10 (the worst pain imaginable); (d) the BioPsychoSocial-Spiritual (BPSS) Scale (eAppendix B), developed at the WLAVAMC, which provides wellness scores from 0 (low) to 10 (high) in 4 areas as well as a holistic wellness score from 0 (low) to 40 (high); (e) the Perceived Stress Scale (PSS), developed by Cohen and colleagues, which generates a stress score for the past month from 0 (low) to 40 (high)34; and (f) the Perceived Benefits of Yoga Questionnaire (PBYQ) (eAppendix C), which rates participants’ opinions about the benefits of yoga from 12 (low) to 60 (high) and is based on the Perceived Benefits of Dance Questionnaire.35
Statistical Analysis
Pearson’s r correlation coefficients were calculated between PBYQ scores and quantitative survey items at each time point (weeks 0, 4, and 8). Linear mixed-effects models were used to test for effects of multiple predictor variables on individual outcomes. Each model had a random intercept by participant, and regressors included main effects for the following: survey week (0, 4, or 8), class duration (in minutes), age, sex, ethnicity, frequency of attendance (in days per week), and duration of attendance (in months). For all statistical analyses, a 2-tailed significance criterion of α = .05 was used.
Results
Veterans who completed surveys were predominantly male (90.8%) and averaged 61.4 years of age. Table 1 shows demographic information. Table 2 displays the number of participants who were involved in short (< 30 min), medium (30-59 min), and long (> 60 min) classes. Veteran participants also had a wide range of prior BSR experience (Table 3).
At all time points, PBYQ scores were significantly positively correlated with class duration and biological, psychological, social, spiritual, and total well-being as measured by the BPSS. The PBYQ scores at all time points were also significantly negatively correlated with age, pain ratings, and PSS scores. Table 4 includes specific Pearson’s r values.
Survey week was not significantly associated with any individual outcome measures. There were no significant regressors for total PSS score or total BPSS score within the linear models. However, participants’ PBYQ scores were significantly associated with age (t(98) = -2.13, P = .036), frequency of attendance (t(103) = 2.10, P = .038), and class duration (t(98) = 4.35, P < .001). Additionally, class duration was significantly associated with pain (t(98) = -3.01, P = .003), with longer duration associated with less pain. Ethnicity was also associated with pain, with African American veterans reporting less pain than did white (t(98) = -2.41, P = .017) and Hispanic (t(98) = -2.31, P = .023) veterans. Because ethnicity was significantly associated with class duration (F(5,339) = 3.81, P = .002), the authors used an analysis of covariance to test for a mediating effect of ethnicity on the relationship between class duration and pain. Although there was a partial mediation (F(5,203) = 2.57, P = .028), the main effect of class duration remained significant.
Discussion and Limitations
The goals of this project were to develop a yoga-based program tailored for veterans with SMI and assess the program in a sample of veterans with SMI on subjective reports of stress, pain, well-being, and benefits of yoga. The authors hypothesized that significant improvements in these measures in veterans with SMI would be observed over 8 weeks of participation in BSR classes and that there would be greater benefits in veterans who participated in longer classes and who attended classes more frequently.
The authors succeeded in developing an adaptable yoga-based wellness program for veterans with SMI that can be both practiced in structured classes and incorporated into veterans’ everyday routines. The BSR classes were well tolerated by veterans with SMI, caused no discernible AEs, and are readily available for dissemination across other mental health programs. Veterans described integrating the tools they learned within BSR classes into their daily lives, helping them to manage pain; feel more flexible; reduce stress, anxiety, depression, and PTSD symptoms; and increase relaxation and feelings of self-control and confidence. Table 5 shows qualitative feedback collected from veterans. In addition, the Train the Trainer model optimized clinical applicability and flexibility, demonstrating that clinicians can seamlessly integrate BSR classes into a health care plan for veterans with SMI.
In assessing quantitative measures of stress, pain, well-being, and perceived benefits of a yoga-based program, veterans who reported BSR classes as beneficial experienced lower levels of pain and stress and higher levels of biological, psychological, social, spiritual, and overall well-being. Those veterans who perceived BSR as more beneficial tended to be younger and attend longer classes with greater frequency. Veterans who attended longer classes also reported experiencing less pain. This may be because the more rigorous stretching and posing involved in longer BSR classes made them more effective at reducing pain; however, it is also possible that veterans who were experiencing more pain avoided these longer classes due to their rigor and length.
Results suggest that longer classes attended with greater regularity may be more beneficial to veterans than short and infrequent classes, particularly in regards to their pain. Despite the relationships between class and outcome variables, the authors did not find significant improvements in measures of wellness, pain, stress, or perceived benefits of BSR over time, as was hypothesized. This may be because the data collection for this study began after classes had been established for some time. In fact, only 35 of 120 veterans included in this study reported having < 1 month of BSR experience at week 0, suggesting that results collected from week 0 did not represent a true baseline measurement. Although no relationship was found between prior duration of attendance and any outcome measures, the fact that most veterans in the sample had attended classes for several months prior to completing surveys may have biased the results by favoring the responses of veterans who were more invested in the classes. Improvements may have been better captured in a BSR-naïve sample.
The finding that the PBYQ score was significantly correlated with all other outcome measures (pain, BPSS score, and PSS score) raises some questions about the ways in which these classes were beneficial to veterans. It may be that veterans who experienced more positive outcomes from classes saw BSR as more beneficial, but it is also possible that veterans who entered classes with greater expectations experienced better outcomes due to a placebo effect—that is, outcomes may have been influenced more by the expectation than by the content of the classes. In the case of well-being (BPSS scores) and stress (PSS score), this could explain why these outcomes were significantly correlated with perceived benefits of BSR but were not significantly related to any class-related variables such as duration and frequency of attendance. Pain ratings, however, were related to class variables and perceived benefits of BSR.
In a post hoc analysis, the main effect of the PBYQ score as a regressor was added to the linear model for pain, resulting in the PBYQ score having a significant main effect (t(100) = -2.98, P = .004). The main effect of class duration remained significant (t(97) = -1.99, P = .050) but was less substantial when the PBYQ score was added, suggesting some correlation between class duration and pain, independent of BSR’s perceived benefits. Future research should consider the possible mediating effect of perceptions of the effectiveness of a yoga-based program a priori or control for placebo effects in order to address the degree to which outcomes are influenced by participant expectations.
This study had a few other notable limitations. Because it was an observational study administered within a clinical mental health program, a control group was not included. Measurement began after BSR classes were established, so veterans had varying levels of prior experience. Specific SMI and medical diagnosis information was not collected from individual veterans. Data were collected from classes of varying length and intensity. The BSR classes often took place within larger programs at the VA, which offered comprehensive care, so some effects of the BSR classes might have been confounded with concurrent evidenced-based treatments or other holistic care programs. Due to these limitations, particularly the absence of a control group, the relationships between BSR participation and health outcomes cannot be assumed to be causal, because a multitude of other variables, such as patient contact and expectancy effects, may have influenced outcomes.
Future Directions
Future research should aim to utilize a control group and collect data from classes of the same intensity and length to better examine whether BSR can be causally linked with improvements in measures of stress, pain, and well-being and to attempt to control for expectancy and contact effects. In addition, future research should aim to recruit a BSR-naïve sample to account for prior experience. Future studies should also aim to parse out whether BSR is differentially effective for each SMI or medical diagnosis, whether there is a relationship between class time and outcomes (as these results suggest that longer class times might be more beneficial for pain), and whether any pain-management benefits from BSR influence other measures of functionality and well-being. Finally, future research can further divide BSR into its active components, such as meditative breathing and aerobic stretching, in order to examine which aspect leads to the greatest effect on each measure; the current results imply that the more rigorous components of BSR classes have the greatest effects on pain.
Conclusion
A yoga-based class affects the mind and body, making it particularly useful for veterans with SMI who experience a range of physical and psychological symptoms and comorbidities.4 Other studies have demonstrated that when practiced alone, yoga leads to improvements in both physical and psychological symptoms.15,17 Looking forward, yoga-based classes may be implemented as part of a larger biopsychosocial-spiritual care plan that is being embraced both within and outside of the VA.7,8,36,37 This integrative health care model suggests that psychosocial and CAM modalities are additive and should be practiced concurrently.37
Although little research has assessed the effects of comprehensive psychosocial and CAM treatment programs, initial research indicates that these programs are associated with reductions in symptoms of medical and mental illness.37-40 Participants in BSR classes may derive further benefits if classes are incorporated into a larger holistic health care plan that includes both traditional psychiatric treatment modalities and CAM therapies that integrate biopsychosocial-spiritual components.
Acknowledgements
The authors would like to thank Nancy Mohler, Anne Platt, and Matthew Crowder, all professional yoga instructors, for their integral role in developing classes, providing classes to veterans, and assisting VA staff with training. The authors also acknowledge Rosie Dominguez, LCSW, for expertly leading BSR classes at LAACC. The authors also thank Irina Arnold, MS, MD, and Vanessa Streiff, MA, for their vital assistance with data collection at SACC.
Funding for the development of BSR protocols, quality improvement research, and expenses associated with classes was provided by the Disabled American Veterans Charitable Service Trust. Support for dissemination of classes to multiple VA programs was provided by a grant from the VA Center of Innovation for Patient Centered Care, headed by Sandra Robertson, RN, MSN, PH-CNS.
The authors are very grateful to the veterans and staff of the Mental Health Intensive Case Management, Psychosocial Rehabilitation and Recovery Centers, Mental Health Clinics, and Domiciliary throughout Greater Los Angeles for their support of the BSR classes.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
There is growing interest in developing a holistic and integrative approach for the treatment of severe mental illnesses (SMI), such as schizophrenia, major depression, posttraumatic stress disorder (PTSD), and anxiety disorders. Western medicine has traditionally focused on the direct treatment of symptoms and separated the management of physical and mental health, but increasing attention is being given to complementary and alternative medicine (CAM) for patients with SMI.
Recognizing the connectedness of the mind and body, these complementary or alternative approaches incorporate nontraditional therapeutic techniques with mainstream treatment methods, including psychopharmacology and psychotherapy.1 Patients with SMI may particularly benefit from a mind-body therapeutic approach, because they often experience psychological symptoms such as stress, anxiety, depression and psychosis, as well as a preponderance of medical comorbidities, including obesity, diabetes mellitus, and cardiovascular disease, some of which are compounded by adverse effects (AEs) of essential pharmacologic treatments.2-4 Mind-body interventions might also be particularly advantageous for veterans, who often experience a range of interconnected physical and psychological difficulties due to trauma exposure and challenges transitioning from military to civilian life.5
Related: Complementary and Alternative Medicine for Chronic Musculoskeletal Pain
In 2002, the White House Commission on Complementary and Alternative Medicine Policy issued a report supporting CAM research and integration into existing medical systems.6 The DoD later established Total Force Fitness, a holistic health care program for active-duty military personnel.7 The VA has also incorporated mind-body and holistic strategies into veteran care.8 One such mind-body intervention, yoga, is becoming increasingly popular within the health care field.
Recent research has documented the effectiveness of yoga, underscoring its utility as a mind-body therapeutic approach. Yoga is associated with improvement in balance and flexibility,9 fatigue,10 blood pressure,11 sleep,12 strength,13 and pain14 in both healthy individuals and patients with medical and psychiatric disorders.15 The literature also illustrates that yoga has led to significant improvements in stress and psychiatric symptoms in individuals with PTSD, schizophrenia, depression, and anxiety.16-22 A previous meta-analysis conducted by the authors, which considered studies of the effectiveness of yoga as an adjunctive treatment for patients with mental illness, found that 212 studies with null results would need to be located and incorporated to negate the positive effects of yoga found in the literature.17
Because yoga emphasizes the practice of mindfulness and timing movement with breath awareness, it is a calming practice that may decrease stress and relieve psychiatric symptoms not treated through psychopharmacology and psychotherapy.17,21 Recent research has postulated that the physiological mechanisms by which this occurs may include (a) reduction in sympathetic and increase in parasympathetic activity23,24; (b) increases in heart-rate variability and respiratory sinus arrhythmia, low levels of which are associated with anxiety, panic disorder, and depression23,24; (c) increases in melatonin and serotonin 25-27; and (d) decrease in cortisol.28,29
Related: Enhancing Patient Satisfaction Through the Use of Complementary Therapies
As yoga may calm the autonomic nervous system and reduce stress, it may benefit patients with SMI, whose symptoms are often aggravated by stress.30 In addition, veterans experience both acute stressors and high levels of chronic stress.5 Therefore, because they experience mind-body comorbid illnesses as well as high levels of stress, the authors believe that veterans with SMI could benefit greatly from a tailored yoga-based program as part of a holistic approach that includes necessary medication and evidence-based therapies.
In order to evaluate the effects of a yoga program on veterans receiving mental health treatment across the VA Greater Los Angeles Healthcare System (VAGLAHS), the authors developed a set of yoga-based wellness classes called Breathing, Stretching, Relaxation (BSR) classes. This article describes the process of developing these classes and outlines the procedures and results of a study to assess their effects.
BSR Classes
The development of BSR classes took place at the West Los Angeles VA Medical Center (WLAVAMC), within the Psychosocial Rehabilitation and Recovery Center (PRRC) program. The PRRC is a psychoeducational program that focuses on the biological, psychological, social, and spiritual aspects of life in order to help veterans with SMI rehabilitate and reintegrate into the community. The program allows veterans to create their own recovery curriculum by selecting from diverse classes led by program staff members, including physicians, psychologists, nurses, social workers, nutritionists, and recreational therapists.
Development of BSR Protocols
The primary goal of this project was to develop a yoga-based program tailored to the specific needs of veterans with SMI. To the authors’ knowledge, BSR is the first yoga-based program customized for SMI. The BSR classes were developed within interdisciplinary focus groups that included professional yoga teachers, the director of the PRRC, psychiatrists, psychologists, nurses, occupational therapists, and physical therapists. Drawing on their experience with SMI and yoga, members of the focus groups identified 3 aspects of yoga that would be most beneficial to veterans with SMI, and the program was designed to optimize these effects. Because SMI can both create and be exacerbated by stress, BSR classes were designed to reduce stress and provide veterans with the tools to monitor and manage their stress.
Breathing and meditative techniques were adapted from yoga in order to facilitate stress reduction. In addition, aerobic elements of yoga have the potential to help veterans manage their incidence of medical diseases, such as cardiovascular disease, obesity, and diabetes. Patients with SMI are at a greater risk for developing these diseases, so classes were designed to incorporate physical stretching elements to promote overall health.4,31-33 Finally BSR was designed to improve veteran self- efficacy and self-esteem, and to place veterans at the center of their care by equipping them with skills to practice BSR independently.
Related: Mindfulness to Reduce Stress
The focus groups also identified the logistic requirements when implementing a yoga-based program for veterans with SMI, including (a) obtaining participant or conservator consent; (b) obtaining medical clearance from care providers, given the high prevalence of medical comorbidities; (c) removing the traditional yoga terms, taking a secular approach, and naming the class “Breathing, Stretching, Relaxation” without directly referencing yoga; (d) asking veterans’ permission before incorporating physical contact into demonstrations, because veterans with SMI, especially those with PTSD, might be uncomfortable with touching from instructors; (e) creating protocols of varying duration and intensity so that BSR was approachable for veterans with diverse levels of physical ability; and (f) ensuring that a clinician who regularly works with SMI patients be present to supervise classes for the safety of patients and instructors.
Yoga instructors and clinicians collaborated to create adaptable 30- and 50-minute protocols that reflected best practices for an SMI population. The 30-minute seated BSR class protocol is included in eAppendix A. Once protocols were finalized, a Train the Trainer program was established to facilitate dissemination of BSR to clinicians working with veterans with SMI throughout the VAGLAHS.
Interested clinicians were given protocols and trained to lead BSR classes on their own. Subsequently, clinician-led BSR classes of various lengths (depending on clinician preference and program scheduling) were established at PRRCs and other mental health programs, such as Mental Health Recovery and Intensive Treatment and Dual Diagnosis Treatment Program, throughout the VAGLAHS. These programs were selected, because they are centered on recovery and improvements in symptoms of SMI. The adoption of a Train the Trainer model, through which VA clinicians were trained by professional yoga instructors, allowed for seamless integration of BSR into VA usual care for veterans with SMI.
Assessment of Classes
The authors conducted a study to assess the quality and effectiveness of BSR classes. This survey research was approved by the VAGLAHS institutional review board for human subjects. The authors hypothesized that there would be significant improvements in veterans’ stress, pain, well-being, and perception of the benefits of BSR over 8 weeks of participation in classes. Also hypothesized was that there would be greater benefits in veterans who participated in longer classes and who attended classes more frequently.
Methods
A total of 120 veterans completed surveys after participating in clinician- and yoga instructor-led BSR classes at the 3 sites within the VAGLAHS: WLAVAMC, Los Angeles Ambulatory Care Center (LAACC), and Sepulveda Ambulatory Care Center (SACC). At the WLAVAMC, surveys were collected at 10-, 30-, 60-, and 90-minute classes. At LAACC, surveys were collected at 30- and 60-minute classes. At SACC, surveys were collected at 20- and 45-minute classes. A researcher noted the duration of the class and was available to assist with comprehension. Veterans completed identical surveys after classes at a designated week 0 (baseline), week 4, and week 8. Of the 120 patients with an initial survey, 82 completed at least 1 follow-up survey and 49 completed both follow-up surveys.
Survey packets included (a) demographic questions, including age, gender, and ethnicity; (b) class participation questions, including frequency of class attendance, patients’ favorite aspect of class, and dura tion of class attendance (in months of prior participation); (c) a pain rating from 0 (no pain) to 10 (the worst pain imaginable); (d) the BioPsychoSocial-Spiritual (BPSS) Scale (eAppendix B), developed at the WLAVAMC, which provides wellness scores from 0 (low) to 10 (high) in 4 areas as well as a holistic wellness score from 0 (low) to 40 (high); (e) the Perceived Stress Scale (PSS), developed by Cohen and colleagues, which generates a stress score for the past month from 0 (low) to 40 (high)34; and (f) the Perceived Benefits of Yoga Questionnaire (PBYQ) (eAppendix C), which rates participants’ opinions about the benefits of yoga from 12 (low) to 60 (high) and is based on the Perceived Benefits of Dance Questionnaire.35
Statistical Analysis
Pearson’s r correlation coefficients were calculated between PBYQ scores and quantitative survey items at each time point (weeks 0, 4, and 8). Linear mixed-effects models were used to test for effects of multiple predictor variables on individual outcomes. Each model had a random intercept by participant, and regressors included main effects for the following: survey week (0, 4, or 8), class duration (in minutes), age, sex, ethnicity, frequency of attendance (in days per week), and duration of attendance (in months). For all statistical analyses, a 2-tailed significance criterion of α = .05 was used.
Results
Veterans who completed surveys were predominantly male (90.8%) and averaged 61.4 years of age. Table 1 shows demographic information. Table 2 displays the number of participants who were involved in short (< 30 min), medium (30-59 min), and long (> 60 min) classes. Veteran participants also had a wide range of prior BSR experience (Table 3).
At all time points, PBYQ scores were significantly positively correlated with class duration and biological, psychological, social, spiritual, and total well-being as measured by the BPSS. The PBYQ scores at all time points were also significantly negatively correlated with age, pain ratings, and PSS scores. Table 4 includes specific Pearson’s r values.
Survey week was not significantly associated with any individual outcome measures. There were no significant regressors for total PSS score or total BPSS score within the linear models. However, participants’ PBYQ scores were significantly associated with age (t(98) = -2.13, P = .036), frequency of attendance (t(103) = 2.10, P = .038), and class duration (t(98) = 4.35, P < .001). Additionally, class duration was significantly associated with pain (t(98) = -3.01, P = .003), with longer duration associated with less pain. Ethnicity was also associated with pain, with African American veterans reporting less pain than did white (t(98) = -2.41, P = .017) and Hispanic (t(98) = -2.31, P = .023) veterans. Because ethnicity was significantly associated with class duration (F(5,339) = 3.81, P = .002), the authors used an analysis of covariance to test for a mediating effect of ethnicity on the relationship between class duration and pain. Although there was a partial mediation (F(5,203) = 2.57, P = .028), the main effect of class duration remained significant.
Discussion and Limitations
The goals of this project were to develop a yoga-based program tailored for veterans with SMI and assess the program in a sample of veterans with SMI on subjective reports of stress, pain, well-being, and benefits of yoga. The authors hypothesized that significant improvements in these measures in veterans with SMI would be observed over 8 weeks of participation in BSR classes and that there would be greater benefits in veterans who participated in longer classes and who attended classes more frequently.
The authors succeeded in developing an adaptable yoga-based wellness program for veterans with SMI that can be both practiced in structured classes and incorporated into veterans’ everyday routines. The BSR classes were well tolerated by veterans with SMI, caused no discernible AEs, and are readily available for dissemination across other mental health programs. Veterans described integrating the tools they learned within BSR classes into their daily lives, helping them to manage pain; feel more flexible; reduce stress, anxiety, depression, and PTSD symptoms; and increase relaxation and feelings of self-control and confidence. Table 5 shows qualitative feedback collected from veterans. In addition, the Train the Trainer model optimized clinical applicability and flexibility, demonstrating that clinicians can seamlessly integrate BSR classes into a health care plan for veterans with SMI.
In assessing quantitative measures of stress, pain, well-being, and perceived benefits of a yoga-based program, veterans who reported BSR classes as beneficial experienced lower levels of pain and stress and higher levels of biological, psychological, social, spiritual, and overall well-being. Those veterans who perceived BSR as more beneficial tended to be younger and attend longer classes with greater frequency. Veterans who attended longer classes also reported experiencing less pain. This may be because the more rigorous stretching and posing involved in longer BSR classes made them more effective at reducing pain; however, it is also possible that veterans who were experiencing more pain avoided these longer classes due to their rigor and length.
Results suggest that longer classes attended with greater regularity may be more beneficial to veterans than short and infrequent classes, particularly in regards to their pain. Despite the relationships between class and outcome variables, the authors did not find significant improvements in measures of wellness, pain, stress, or perceived benefits of BSR over time, as was hypothesized. This may be because the data collection for this study began after classes had been established for some time. In fact, only 35 of 120 veterans included in this study reported having < 1 month of BSR experience at week 0, suggesting that results collected from week 0 did not represent a true baseline measurement. Although no relationship was found between prior duration of attendance and any outcome measures, the fact that most veterans in the sample had attended classes for several months prior to completing surveys may have biased the results by favoring the responses of veterans who were more invested in the classes. Improvements may have been better captured in a BSR-naïve sample.
The finding that the PBYQ score was significantly correlated with all other outcome measures (pain, BPSS score, and PSS score) raises some questions about the ways in which these classes were beneficial to veterans. It may be that veterans who experienced more positive outcomes from classes saw BSR as more beneficial, but it is also possible that veterans who entered classes with greater expectations experienced better outcomes due to a placebo effect—that is, outcomes may have been influenced more by the expectation than by the content of the classes. In the case of well-being (BPSS scores) and stress (PSS score), this could explain why these outcomes were significantly correlated with perceived benefits of BSR but were not significantly related to any class-related variables such as duration and frequency of attendance. Pain ratings, however, were related to class variables and perceived benefits of BSR.
In a post hoc analysis, the main effect of the PBYQ score as a regressor was added to the linear model for pain, resulting in the PBYQ score having a significant main effect (t(100) = -2.98, P = .004). The main effect of class duration remained significant (t(97) = -1.99, P = .050) but was less substantial when the PBYQ score was added, suggesting some correlation between class duration and pain, independent of BSR’s perceived benefits. Future research should consider the possible mediating effect of perceptions of the effectiveness of a yoga-based program a priori or control for placebo effects in order to address the degree to which outcomes are influenced by participant expectations.
This study had a few other notable limitations. Because it was an observational study administered within a clinical mental health program, a control group was not included. Measurement began after BSR classes were established, so veterans had varying levels of prior experience. Specific SMI and medical diagnosis information was not collected from individual veterans. Data were collected from classes of varying length and intensity. The BSR classes often took place within larger programs at the VA, which offered comprehensive care, so some effects of the BSR classes might have been confounded with concurrent evidenced-based treatments or other holistic care programs. Due to these limitations, particularly the absence of a control group, the relationships between BSR participation and health outcomes cannot be assumed to be causal, because a multitude of other variables, such as patient contact and expectancy effects, may have influenced outcomes.
Future Directions
Future research should aim to utilize a control group and collect data from classes of the same intensity and length to better examine whether BSR can be causally linked with improvements in measures of stress, pain, and well-being and to attempt to control for expectancy and contact effects. In addition, future research should aim to recruit a BSR-naïve sample to account for prior experience. Future studies should also aim to parse out whether BSR is differentially effective for each SMI or medical diagnosis, whether there is a relationship between class time and outcomes (as these results suggest that longer class times might be more beneficial for pain), and whether any pain-management benefits from BSR influence other measures of functionality and well-being. Finally, future research can further divide BSR into its active components, such as meditative breathing and aerobic stretching, in order to examine which aspect leads to the greatest effect on each measure; the current results imply that the more rigorous components of BSR classes have the greatest effects on pain.
Conclusion
A yoga-based class affects the mind and body, making it particularly useful for veterans with SMI who experience a range of physical and psychological symptoms and comorbidities.4 Other studies have demonstrated that when practiced alone, yoga leads to improvements in both physical and psychological symptoms.15,17 Looking forward, yoga-based classes may be implemented as part of a larger biopsychosocial-spiritual care plan that is being embraced both within and outside of the VA.7,8,36,37 This integrative health care model suggests that psychosocial and CAM modalities are additive and should be practiced concurrently.37
Although little research has assessed the effects of comprehensive psychosocial and CAM treatment programs, initial research indicates that these programs are associated with reductions in symptoms of medical and mental illness.37-40 Participants in BSR classes may derive further benefits if classes are incorporated into a larger holistic health care plan that includes both traditional psychiatric treatment modalities and CAM therapies that integrate biopsychosocial-spiritual components.
Acknowledgements
The authors would like to thank Nancy Mohler, Anne Platt, and Matthew Crowder, all professional yoga instructors, for their integral role in developing classes, providing classes to veterans, and assisting VA staff with training. The authors also acknowledge Rosie Dominguez, LCSW, for expertly leading BSR classes at LAACC. The authors also thank Irina Arnold, MS, MD, and Vanessa Streiff, MA, for their vital assistance with data collection at SACC.
Funding for the development of BSR protocols, quality improvement research, and expenses associated with classes was provided by the Disabled American Veterans Charitable Service Trust. Support for dissemination of classes to multiple VA programs was provided by a grant from the VA Center of Innovation for Patient Centered Care, headed by Sandra Robertson, RN, MSN, PH-CNS.
The authors are very grateful to the veterans and staff of the Mental Health Intensive Case Management, Psychosocial Rehabilitation and Recovery Centers, Mental Health Clinics, and Domiciliary throughout Greater Los Angeles for their support of the BSR classes.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
1. National Center for Complementary and Integrative Health. Complementary, alternative, or integrative health: what's in a name? U.S. Department of Health and Human Services, National Institutes of Health Website. http://nccam.nih.gov/health/whatiscam. Updated March 2015. Accessed August 27, 2015.
2. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
3. Fleischhacker WW, Cetkovich-Bakmas M, De Hert M, et al. Comorbid somatic illnesses in patients with severe mental disorders: clinical, policy, and research challenges. J Clin Psychiatry. 2008;69(4):514-519.
4. Wirshing DA, Boyd JA, Meng LR, Ballon JS, Marder SR, Wirshing WC. The effects of novel antipsychotics on glucose and lipid levels. J Clin Psychiatry. 2002;63(10):856-865.
5. Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation; 2008.
6. White House Commission on Complementary and Alternative Medicine Policy. Final Report. Washington, DC: White House Commission on Complementary and Alternative Medicine Policy; 2002.
7. Land BC. Current Department of Defense guidance for total force fitness. Mil Med. 2010;175(suppl 8):3-5.
8. U.S. Department of Veterans Affairs, Veterans Health Administration. Pain Management. VHA Directive 2009-053. Washington, DC: U.S. Department of Veterans Affairs, Veterans Health Administration; 2009.
9. Oken BS, Zajdel D, Kishiyama S, et al. Randomized, controlled, six-month trial of yoga in healthy seniors: effects on cognition and quality of life. Altern Ther Health Med. 2006;12(1):40-47.
10. Bower JE, Garet D, Sternlieb B, et al. Yoga for persistent fatigue in breast cancer survivors: a randomized controlled trial. Cancer. 2012;118(15):3766-3775.
11. Cade WT, Reeds DN, Mondy KE, et al. Yoga lifestyle intervention reduces blood pressure in HIV-infected adults with cardiovascular disease risk factors. HIV Med. 2010;11(6):379-388.
12. Innes KE, Selfe TK. The effects of a gentle yoga program on sleep, mood, and blood pressure in older women with restless leg syndrome (RLS): a preliminary randomized controlled trial. Evid Based Complement Alternat Med. 2012;2012:294058.
13. Van Puymbroeck M, Payne LL, Hsieh PC. A phase I feasibility study of yoga on the physical health and coping of informal caregivers. Evid Based Complement Alternat Med. 2007;4(4):519-529.
14. Rani K, Tiwari SC, Singh U, Agrawal GG, Srivastava N. Six-month trial of Yoga Nidra in menstrual disorder patients: effects on somatoform symptoms. Ind Psychiatry J. 2011;20(2):97-102.
15. Ross A, Thomas S. The health benefits of yoga and exercise: a review of comparison studies. J Altern Complement Med. 2010;16(1):3-12.
16. Banerjee B, Vadiraj HS, Ram A, et al. Effects of an integrated yoga program in modulating psychological stress and radiation-induced genotoxic stress in breast cancer patients undergoing radiotherapy. Integr Cancer Ther. 2007;6(3):242-250.
17. 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(4):doi:10.4088/PCC.10r01068.
18. Katzman MA, Vermani M, Gerbarg PL, et al. A multicomponent yoga-based, breath intervention program as an adjunctive treatment in patients suffering from generalized anxiety disorder with or without comorbidities. Int J Yoga. 2012;5(1):57-65.
19. Köhn M, Persson Lundholm U, Bryngelsson IL, Anderzén-Carlsson A, Westerdahl E. Medical yoga for patients with stress-related symptoms and diagnoses in primary health care: a randomized controlled trial. Evid Based Complement Alternat Med. 2013;2013:215348.
20. Krishnamurthy MN, Telles S. Assessing depression following two ancient Indian interventions: effects of yoga and ayurveda on older adults in a residential home. J Gerontol Nurs. 2007;33(2):17-23.
21. 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(2):152-164.
22. Visceglia E, Lewis S. Yoga therapy as an adjunctive treatment for schizophrenia: a randomized, controlled pilot study. J Altern Complement Med. 2011;17(7):601-607.
23. Brown RP, Gerbarg PL. Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression, part I-neurophysiologic model. J Altern Complement Med. 2005;11(1):189-201.
24. Brown RP, Gerbarg PL. Yoga breathing, meditation, and longevity. Ann N Y Acad Sci. 2009;1172:54-62.
25. Harinath K, Malhotra AS, Pal K, et al. Effects of hatha yoga and Omkar meditation on cardiorespiratory performance, psychologic profile, and melatonin secretion. J Altern Complement Med. 2004;10(2):261-268.
26. Tooley GA, Armstrong SM, Norman TR, Sali A. Acute increases in night-time plasma melatonin levels following a period of meditation. Biol Psychol. 2000;53(1):69-78.
27. Walton KG, Pugh ND, Gelderloos P, Macrae P. Stress reduction and preventing hypertension: preliminary support of a psychoneuroendocrine mechanism. J Altern Complement Med. 1995;1(3):263-283.
28. Banasik J, Williams H, Haberman M, Blank SE, Bendel R. Effect of Iyengar yoga practice on fatigue and diurnal salivary cortisol concentration in breast cancer survivors. J Am Acad Nurse Pract. 2011;23(3):135-142.
29. Vadiraja HS, Raghavendra RM, Nagarathna R, et al. Effects of a yoga program on cortisol rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: a randomized controlled trial. Integr Cancer Ther. 2009;8(1):37-46.
30. Esch T, Stefano GB, Fricchione GL, Benson H. The role of stress in neurodegenerative diseases and mental disorders. Neuro Endocrinol Lett. 2002;23(3):199-208.
31. Lingjaerde O, Ahlfors UG, Bech P, Dencker SJ, Elgen K. The UKU side effect rating scale. A new comprehensive rating scale for psychotropic drugs and a cross-sectional study of side effects in neuroleptic-treated patients. Acta Psychiatr Scand Suppl. 1987;334:1-100.
32. Schwartz TL, Nihalani N, Jindal S, Virk S, Jones N. Psychiatric medication-induced obesity: a review. Obes Rev. 2004;5(2):115-121.
33. Wirshing DA, Spellberg BJ, Erhart SM, Marder SR, Wirshing WC. Novel antipsychotics and new onset diabetes. Biol Psychiatry. 1998;44(8):778-783.
34. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-396.
35. Quiroga Murcia C, Kreutz G, Clift S, Bongard S. Shall we dance? An exploration of the perceived benefits of dancing on well-being. Arts Health. 2010;2(2):149-163.
36. The Duke Center for Integrative Medicine; Liebowitz R, Smith L. The Duke Encyclopedia of New Medicine: Conventional and Alternative Medicine for All Ages. London, UK: Rodale Books International; 2006.
37. Walsh R. Lifestyle and mental health. Am Psychol. 2011;66(7):579-592.
38. Frattaroli J, Weidner G, Dnistrian AM, et al. Clinical events in prostate cancer lifestyle trial: results from two years of follow-up. Urology. 2008;72(6):1319-1323.
39. Khaw KT, Wareham N, Bingham S, Welch A, Luben R, Day N. Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk prospective population study. PLoS Med. 2008;5(1):e12.
40. Sidhu KS, Vandana P, Balon R. Exercise prescription: a practical, effective therapy for depression. Curr Psychiatr. 2009;8(6):38-51.
1. National Center for Complementary and Integrative Health. Complementary, alternative, or integrative health: what's in a name? U.S. Department of Health and Human Services, National Institutes of Health Website. http://nccam.nih.gov/health/whatiscam. Updated March 2015. Accessed August 27, 2015.
2. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
3. Fleischhacker WW, Cetkovich-Bakmas M, De Hert M, et al. Comorbid somatic illnesses in patients with severe mental disorders: clinical, policy, and research challenges. J Clin Psychiatry. 2008;69(4):514-519.
4. Wirshing DA, Boyd JA, Meng LR, Ballon JS, Marder SR, Wirshing WC. The effects of novel antipsychotics on glucose and lipid levels. J Clin Psychiatry. 2002;63(10):856-865.
5. Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation; 2008.
6. White House Commission on Complementary and Alternative Medicine Policy. Final Report. Washington, DC: White House Commission on Complementary and Alternative Medicine Policy; 2002.
7. Land BC. Current Department of Defense guidance for total force fitness. Mil Med. 2010;175(suppl 8):3-5.
8. U.S. Department of Veterans Affairs, Veterans Health Administration. Pain Management. VHA Directive 2009-053. Washington, DC: U.S. Department of Veterans Affairs, Veterans Health Administration; 2009.
9. Oken BS, Zajdel D, Kishiyama S, et al. Randomized, controlled, six-month trial of yoga in healthy seniors: effects on cognition and quality of life. Altern Ther Health Med. 2006;12(1):40-47.
10. Bower JE, Garet D, Sternlieb B, et al. Yoga for persistent fatigue in breast cancer survivors: a randomized controlled trial. Cancer. 2012;118(15):3766-3775.
11. Cade WT, Reeds DN, Mondy KE, et al. Yoga lifestyle intervention reduces blood pressure in HIV-infected adults with cardiovascular disease risk factors. HIV Med. 2010;11(6):379-388.
12. Innes KE, Selfe TK. The effects of a gentle yoga program on sleep, mood, and blood pressure in older women with restless leg syndrome (RLS): a preliminary randomized controlled trial. Evid Based Complement Alternat Med. 2012;2012:294058.
13. Van Puymbroeck M, Payne LL, Hsieh PC. A phase I feasibility study of yoga on the physical health and coping of informal caregivers. Evid Based Complement Alternat Med. 2007;4(4):519-529.
14. Rani K, Tiwari SC, Singh U, Agrawal GG, Srivastava N. Six-month trial of Yoga Nidra in menstrual disorder patients: effects on somatoform symptoms. Ind Psychiatry J. 2011;20(2):97-102.
15. Ross A, Thomas S. The health benefits of yoga and exercise: a review of comparison studies. J Altern Complement Med. 2010;16(1):3-12.
16. Banerjee B, Vadiraj HS, Ram A, et al. Effects of an integrated yoga program in modulating psychological stress and radiation-induced genotoxic stress in breast cancer patients undergoing radiotherapy. Integr Cancer Ther. 2007;6(3):242-250.
17. 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(4):doi:10.4088/PCC.10r01068.
18. Katzman MA, Vermani M, Gerbarg PL, et al. A multicomponent yoga-based, breath intervention program as an adjunctive treatment in patients suffering from generalized anxiety disorder with or without comorbidities. Int J Yoga. 2012;5(1):57-65.
19. Köhn M, Persson Lundholm U, Bryngelsson IL, Anderzén-Carlsson A, Westerdahl E. Medical yoga for patients with stress-related symptoms and diagnoses in primary health care: a randomized controlled trial. Evid Based Complement Alternat Med. 2013;2013:215348.
20. Krishnamurthy MN, Telles S. Assessing depression following two ancient Indian interventions: effects of yoga and ayurveda on older adults in a residential home. J Gerontol Nurs. 2007;33(2):17-23.
21. 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(2):152-164.
22. Visceglia E, Lewis S. Yoga therapy as an adjunctive treatment for schizophrenia: a randomized, controlled pilot study. J Altern Complement Med. 2011;17(7):601-607.
23. Brown RP, Gerbarg PL. Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression, part I-neurophysiologic model. J Altern Complement Med. 2005;11(1):189-201.
24. Brown RP, Gerbarg PL. Yoga breathing, meditation, and longevity. Ann N Y Acad Sci. 2009;1172:54-62.
25. Harinath K, Malhotra AS, Pal K, et al. Effects of hatha yoga and Omkar meditation on cardiorespiratory performance, psychologic profile, and melatonin secretion. J Altern Complement Med. 2004;10(2):261-268.
26. Tooley GA, Armstrong SM, Norman TR, Sali A. Acute increases in night-time plasma melatonin levels following a period of meditation. Biol Psychol. 2000;53(1):69-78.
27. Walton KG, Pugh ND, Gelderloos P, Macrae P. Stress reduction and preventing hypertension: preliminary support of a psychoneuroendocrine mechanism. J Altern Complement Med. 1995;1(3):263-283.
28. Banasik J, Williams H, Haberman M, Blank SE, Bendel R. Effect of Iyengar yoga practice on fatigue and diurnal salivary cortisol concentration in breast cancer survivors. J Am Acad Nurse Pract. 2011;23(3):135-142.
29. Vadiraja HS, Raghavendra RM, Nagarathna R, et al. Effects of a yoga program on cortisol rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: a randomized controlled trial. Integr Cancer Ther. 2009;8(1):37-46.
30. Esch T, Stefano GB, Fricchione GL, Benson H. The role of stress in neurodegenerative diseases and mental disorders. Neuro Endocrinol Lett. 2002;23(3):199-208.
31. Lingjaerde O, Ahlfors UG, Bech P, Dencker SJ, Elgen K. The UKU side effect rating scale. A new comprehensive rating scale for psychotropic drugs and a cross-sectional study of side effects in neuroleptic-treated patients. Acta Psychiatr Scand Suppl. 1987;334:1-100.
32. Schwartz TL, Nihalani N, Jindal S, Virk S, Jones N. Psychiatric medication-induced obesity: a review. Obes Rev. 2004;5(2):115-121.
33. Wirshing DA, Spellberg BJ, Erhart SM, Marder SR, Wirshing WC. Novel antipsychotics and new onset diabetes. Biol Psychiatry. 1998;44(8):778-783.
34. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-396.
35. Quiroga Murcia C, Kreutz G, Clift S, Bongard S. Shall we dance? An exploration of the perceived benefits of dancing on well-being. Arts Health. 2010;2(2):149-163.
36. The Duke Center for Integrative Medicine; Liebowitz R, Smith L. The Duke Encyclopedia of New Medicine: Conventional and Alternative Medicine for All Ages. London, UK: Rodale Books International; 2006.
37. Walsh R. Lifestyle and mental health. Am Psychol. 2011;66(7):579-592.
38. Frattaroli J, Weidner G, Dnistrian AM, et al. Clinical events in prostate cancer lifestyle trial: results from two years of follow-up. Urology. 2008;72(6):1319-1323.
39. Khaw KT, Wareham N, Bingham S, Welch A, Luben R, Day N. Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk prospective population study. PLoS Med. 2008;5(1):e12.
40. Sidhu KS, Vandana P, Balon R. Exercise prescription: a practical, effective therapy for depression. Curr Psychiatr. 2009;8(6):38-51.