Introduction and background
Depression is a global health problem but which can be contained using non-pharmacological and pharmacological approaches (Dhingra and Parle, 2011). It is the leading cause of mental disability in the whole world and it remains one of the most undertreated health issues in old age (Barry, et al, 2012). In United States, a tenth of the adult population is affected by depression each year and it is estimated that by the end of this decade depression will be the second leading cause of health disability (Dhingra and Parle, 2011). According to Dhingra, in 2011, depression was the fourth most costly disease and it is predicted that by the end of this decade it will be the second. In United States, depression costs the U.S. economy more than $80 billion in treatment and lost productivity (Dhingra and Parle, 2011). Based on the findings it is apparent that depression is an indeed a serious problem among the adult population and it is likely to cost the world economy many funds for its management.
I developed interest in studying an alternative treatment mode for depressive disorders after examining the costs and challenges suffered by older adults and the society. Given the possibility to address depressive disorders using non-pharmacological options coupled with the problems and challenges suffered in managing individuals suffering from depressive disorders, it becomes emphatically crucial that the society makes it a priority to address this challenge. If the current and future trends are anything to believe (Dhingra and Parle, 2011), the millions of dollars are of taxpayer money will be wasted in the prevention of such depressive disorders. For this reason, identifying a non-pharmacological alternative to address this issue would be of significant benefit to the healthcare sector.
Depression among older adults leads to increased cases of morbidity and morbidity, and increased need for healthcare services (Philip, St. John, and Montgomery, 2009, p. 674), thereby causing increased risks to the health of affected individuals. Despite a plethora of emerging interventions and studies undertaken over the past decade regarding depression in older patients, there is still need to utilize other non-pharmacological interventions in containing the mental health disorder. Other challenges associated depression among older persons includes frailty, dementia, and disability (Han and Richardson (2010). Han and Richardson (2010) argue that depression affects other functional abilities such as cognitive functioning and instrumental activities. Other issues associated with depression in older adults include higher chances of committing suicide risks, and high costs of healthcare (Mridula, and Rajesh, 2001).
In order to contain the costs, Dhingra and Parle (2011) suggest that there is need to embrace the non-pharmacological interventions in the management of depression. Some of the non- pharmacological interventions include psychological therapies, exercise and lifestyle interventions, and complementary and alternative treatments. To this end, Dhingra and Parle (2011) examined the efficacy of these all these non-pharmacological intervention include the efficacy of acupuncture, animal assisted therapy, homeopathy, light therapy, massage therapy, yoga, aromatherapy, emotional freedom technique, reflexology, Reiki, Tai chi chuan and thought field therapy in the management of depression. According to Dhingra and Parle (2011), studies that have examined complementary and alternative therapies have failed to find evidence on the use of these therapies as stand-alone treatment for patients with depression except for yoga. This paper revisits past studies that have examined yoga as a stand-alone treatment for patients with depression. This topic is important to nursing and the healthcare setting because depression in older adults is a common occurrence and hence, it is imperative that nurses and other healthcare practioners consider using the non-pharmacological interventions in the management of depression (Dhingra and Parle, 2011).
Focus clinical question
Past article reviews, randomized controlled trials, systematic reviews, metal-analysis, cohort and case-control studies have explored the efficacy of different types of yoga in treatment of depression and the possible mechanisms by which yoga may have an impact on depression. In reviewing past studies that have examined this subject this paper will be guided by this clinical question- Do yoga therapy reduces depression symptoms in adult patients compared to non-yoga therapy patients with same condition. Studies will be reviewed on an individual basis and their suitability will be judged on the basis on which they adequately help us to answer this question.
List database search
The studies were collected from ClNAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PubMed/Medline, and PsycINFO. The following keywords were used separately and in combination with each other: yoga therapy, depression, adults, and efficacy. Only articles relevant to the PICO question were selected.
Review of Literature
Brain GABA levels and Yoga sessions; directly compared
Chris, Eric, Ruth, Haward, Hua, Devin, Domenic, & Perry (2007) conducted a level I evidence systematic review comparing the effectiveness of Yoga sessions in increasing the GABA levels, which was clearly hypothesized by the end of the review. The subjects who met the inclusion criteria were eight while the treatment practitioners conducting the review were eleven. Two independent reviews were carried consisting of the treatment groups as well as the control groups. As such, the control group completed a sixty-minute reading session while the treatment group completed a sixty-minute Yoga session (Chris, Eric, Ruth, Haward, Hua, Devin, Domenic, & Perry, 2007). Limitations of this review include random selection of participants that creates biasness in terms of selection and allocation. For this reason, the results obtained are not replicable in a wider population. The fact that the sample size used was small lowers the evidence level of the study, and makes it difficult to generalize the results in a wider population distribution (Chris, Eric, Ruth, Haward, Hua, Devin, Domenic, & Perry, 2007).
Yoga and depression
Karen, Graham, Hagen & Janet (2005) conducted a level II evidence randomized control trials seeking to investigate the efficacy of Yoga in managing varied depression symptoms. This study gave valid results because the selection criteria employed elaborate and systematic searches conducted form reputable databases (Karen, Graham, Hagen & Janet, 2005). Despite giving effective results in managements of depression, this study had its limitations aligned to methodological limitations and inadequacies. The study was further limited due to lack of methodologies for attrition rate and randomization rates.
Andrew, Xin-Hua, Barbara, Jonathan, Adam, Thomas, Christine, Elizabeth & David (2008) used a level III randomized pilot study comparing the stated research question of effectiveness of Yoga treatments with utilization of Psycho education alongside hypnosis group therapy relative to the use of psycho education alone. A small (N=46) random sample consisting of 26% male and 74 % dysthymia (minor depression condition) patients were assessed for symptoms of superimposed dysthymia using clinical interviews (Andrew, Xin-Hua, Barbara, Jonathan, Adam, Thomas, Christine, Elizabeth & David, 2008). Patients received a score related to severity of superimposed dysthymia symptoms. Inclusion criteria for the study entailed subjects exhibiting depressive symptoms having lasted for the previous two years. However, study subjects meeting the mentioned criteria but having had current bipolar disorder aligned with psychotic features were excluded from the study Andrew, Xin-Hua, Barbara, Jonathan, Adam, Thomas, Christine, Elizabeth & David, 2008). Analysis was carried out using Chi-squares seeking to establish whether a proportion of the study subjects had developed dysthymia superimposed over the period of study. Results were presented in tables, which gave a clear indication that a high number of the study subjects had remissions as at the ninth month of follow up (Andrew et al., 2008). Some portion of the participants had hypnosis which differed from the controls, hence, were considered insignificant statistically.
Yoga and treatment in mood for psychiatric inpatients
Roberta, Tom, Kim, Donna, Currier, & Wolfe (2005), clearly answered the question as to whether Yoga plays a role in the treatment of moods experienced by inpatient psychiatric. The participants in the study consisted of 113 psychiatric inpatients. As such, the psychiatric inpatients constituting the study subjects were not blind to the study. The expected outcomes were reduction of stress experienced by the participants due to their condition (Roberta, Tom, Kim, Donna, Currier, & Wolfe, 2005). In addition, reduction in psychiatric symptoms was expected. The study utilized a few number of participants and this occurred as a shortcoming to the study. Another shortcoming occurred due to lack of control of the treatment group, which increases the chances that the observed improvements were caused by other factors are not aligned to Yoga management plans (Roberta, Tom, Kim, Donna, Currier, & Wolfe, 2005).
In the research article by David, Ian, Dmitry, Cristina, Andrew & Michelle (2007), two specific questions aligned to Yoga treatment of depression were explored. First, does Yoga affect the traits of its subject treatment outcomes? Secondly, does Yoga affect the mood of the subject treatment outcome? Preface findings of the study indicated the ability of Yoga to act as a complimentary management procedure for patients exhibiting depressed symptoms (David et al., 2007). The study utilized patients under antidepressant medications and exhibited symptoms of partial remission. The research article further gave a presentation of data on intervention for patients diagnosed with emotional, psychological as well as biological processes causing effects on the treatment outcomes (David, Ian, Dmitry, Cristina, Andrew & Michelle, 2007). The subjects used for the study included ten men and twenty-seven women.
Of the mentioned subjects, only 17 managed to complete the intervention assessment data. In addition, the research incorporated twenty classes managed by Yoga teachers. The study subjects were diagnosed with depression symptoms. The participants exhibited significant reduction in depression symptoms and neurotic symptoms (David, Ian, Dmitry, Cristina, Andrew & Michelle, 2007). The traits of those who remitted and those who did not for the treatment differed, giving a clear indication of the ability emotion regulation in treating depression symptoms. There was a significant improvement of mood for the participants when compared to the beginning of the treatment (David et al., 2007). This gave a clear indication of the ability of Yoga treatments as if results in favorable biological, emotional as well as psychological effects. To this purpose, the research article findings justify the capability of Yoga treatments for use in clinical applications aimed at providing effective treatment for depression and a variety of mental disorders (David, Ian, Dmitry, Cristina, Andrew & Michelle, 2007).
Yoga and work stress
Monacha, Sarris, and Stough (2003) conducted a randomized control trial seeking to establish the efficiency of Yoga in managing clinical conditions. 178 adult workers were randomly incorporated as the study sample. Yoga treatment was administered double blind format. This allowed for prevention of the knowledge on group allocation from influencing the outcome of the assessments. The outcomes of the randomization were represented in diagram format with clear indication of the attrition rates. Overall, the trial results indicated the efficacy of Yoga treatments in managing depression emanating from work related conditions (Monacha et al., 2003). Precisely, with evidence from the study, use of mental silence medication, often referred to as Sahaja Yoga, provides a viable avenue for reducing work related stress. Nonetheless, the study gave further recommendations for detailed exploration to validate its findings. Precisely, the intervention is less costly; hence, the meditation is essential as it offers crucial socio economic benefit for the society. In addition, the trial clearly indicates the safety in utilization of Sahaja Yoga meditation as intervention initiative for addressing issues aligned to work stress. Overall, treatment forms aligned to meditation have precise effects relative to relaxation techniques, essential in health care system delivery (Wollery, Myers, Sternlieb, and Zelter, 2004).
Synthesis
Limitations
The literatures reviewed herein have varied limitations because they failed to address the PICO question. Such limitations ranged from questionable sample sizes (Sharma, Mondal, Goswampi, and Gandhi), failure to satisfy the threshold of the clinical question (Wollery, Myers, Sternlieb, and Zelter, (2004), and biasness in the strategy used in sample selection (Streeter et al (2007). Other challenges included the failure of controlled trials to justify the types of methodological inadequacies such as the case of the Yoga in depression (Pilkington, Kirkwood, Rampes, and Richardson, 2005). For the reason, the study outcomes are not replicable in various settings, as it should. The evaluated studies also happened in different settings hence the failure to achieve uniformity in outcome. The population in the different studies consisted of mixed adults both young and old and as such, no specific Yoga strategy can be adopted or recommended as an alternative cure to depression in adults (Wollery, Myers, Sternlieb, and Zelter, 2004). Other than these identifiable challenges and limitations, the reviews clearly indicate that Yoga offers a viable avenue for treatment of depression.
Strengths of these studies
While there were a plethora of limitations in the above studies, majority of them did provide important information that suited the problem under study. For instance, findings from Sharma, Mondal, Goswampi, and Gandhi did show that Sahaj Yoga had huge potential in managing depressive disorders among older adults. Similarly, hypothesis for the Streeter, Jensen, Perlmutter, Cabral, Devin, Terhune, and Renshaw, (2007) were later not rejected but confirmed that Yoga Sessions did improve the levels of GABA. This can be attributed to lack of biasness in both the treatment group and the control group. Karen, Graham, Hagen, & Janet, (2005) not only conducted five randomized controlled trials but also examined the efficacy of five different symptoms with varying degrees. The study had a strong systematic review, because it had systematic and elaborate selection criteria coupled with credible supporting materials from reputable databases.
Butler, Lynn, Andrew, Xin-Hua, Barbara, Jonathan, Adam, Thomas, Christine, Elizabeth, & David, (2008) provided extensive details, when compared to other studies, regarding the methodology, participant details, and inclusion criteria of the sample size. While many studies had limitations in terms of smaller sample sizes, the randomized study conducted by Manocha, Black, Sarris, & Stough, (2003) had a significantly high sample size. It, as well, had carefully designed control measures that prevented priori knowledge from influencing the outcome of the group. This study was critical in proofing that Sahaja Yoga was indeed effective and safe for addressing depressive symptoms.
Yoga therapy does provide alternative, cheap, and effective intervention in the treating depression among older adults. Findings from the critiqued articles add immense importance to the body of already expanding literature documenting the effectiveness of Yoga as an alternative treatment to depression among older adults (Robert, Eisenberg, Roger, Laryy, & Russell). Because majority of studies recommend the use of Yoga therapy as an alternative for treating depression among older adults, a specific study should be conducted on a large number of older adults and similar methodological procedures should be followed. It is also emphatically crucial that this non-pharmacological intervention be compared with other possible alternatives before recommending its treatment. Negative side effects associated with Yoga therapy coupled with its low cost means that the risks are fewer.
According to Dhingra & Parle, (2011), methodological significance was not met in studies when a systematic review regarding the use of Yoga therapy to cure depression symptoms was used. It is important for future studies to use large samples, use rigorous methodology and taken more effort in excluding nonspecific of nonspecific factors. For instance, the systematic review revealed several inadequacies ranging from inappropriate sample sizes and lack of uniformity in the ages of adults (Dhingra & Parle, 2011). This makes it difficult to generalize findings from such studies when recommending the use of Yoga therapy to treat depression symptoms in adults. Therefore, it could be more practical for Yoga therapy to be adopted as an alternative for treating depression symptoms among older adults if more studies could be undertaken with attention being paid on the accuracy of ages and using large samples.
Recommendations
Treatment of depression among adult patients can be highly effective when Yoga therapy is adopted as a treatment alternative (Shapiro, Cook, Daydov, Xristina, Leuchter, and Michelle, 2007). However, it is important to discuss with the patient the possibility of him accepting the Yoga therapy program in addition to explaining its importance in minimizing depression related symptoms. Another important measures includes professional training in Yoga therapy among nurses and healthcare providers to enable them recommending Yoga therapy and as well, in identifying signs of improvement among patients (Butler, Lynn, Andrew, Xin-Hua, Barbara, Jonathan, Adam, Thomas, Christine, Elizabeth, & David, 2008). With this recommendation, adult patients are more likely to experience reduced cases of depression symptoms and effects from other disorders that accompany depression.
Based on these findings it can be concluded that there is no conclusive evidence that yoga as effective against depression although it has a huge potential and that’s why more detailed clinical trials need to be conducted (Shapiro, Cook., Daydov., Xristina, Leuchter, and Michelle, 2007). Consequently, yoga therapy should be used as the last resort- after other effective interventions such as behavioral activation, cognitive behavioral therapies and anti-depressants have failed (Wollery, Myers, Sternlieb, and Zelter, 2004). However, because yoga interventions do not have any side effects it is preferable for nurses to try use this intervention in instances where there is no other effective intervention available. In addition, yoga intervention is more resourceful than failing to use any use any intervention at all for patients suffering from depression.
References
Barry, L., C. et al (2012). “Under-Treatment of Depression in older persons”. Journal of
Affective Disorders, 136 (3), 789-796
Butler. L. W., Lynn, T., Andrew, H., Xin-Hua, C., Barbara, S., Jonathan, M., Adam, K., Thomas, F. N., Christine, M. B., Elizabeth, O. S. & David, S. (2008). Mediation with Yoga, group therapy with hypnosis and Psychoeducation for long term depressed mood: a randomized pilot trial. Journal of clinical psychology, 64(7), 806—820
Chris, C. S., Eric J., Ruth, M. P., Howard, J. C., Hua, T., Devin, B. T., Domenic, A. C., & Perry, F. R. (2007). Yoga Asana Sessions Increase Brain GABA Levels: A Pilot Study. The journal of alternative and complementary medicine, 13(4), 419–426
David, S., Ian, C., Dmitry, D., Xristina, O., Andrew, L. & Michelle, A. (2007). Yoga as a complementary treatment of depression: effects of traits and moods on treatment outcome. eCAM, 4(4), 493–502
Dhingra, S. & Parle, M. (2011). Non-drug strategies in the management of depression: A comprehensive study of systematic review and meta-analysis of randomized controlled trials, .Journal of Neuroscience and Behavioral Health, 3(5), 66-73,
Han, J., and Richardson, V. E., (2010). “The relationship between depression and
loneliness
among homebound older persons: does spirituality moderate this relationship? Journal
of Religion & Spirituality in social work: Social Thought, 29, 218-236. Retrieved from http://ehis.ebscohost.com/eds/pdfviewer/pdfviewer?sid=a523af54-9fd3-4e50-8efa-0dbceec30ecb%40sessionmgr112&vid=2&hid=102
Karen, P., Graham, K., Hagen, R. & Janet, R. (2005). Yoga for depression: The research evidence. Journal of Affective Disorders 89, 13-24
Manocha, R. Black, D. Sarris, J. & Stough, C, (2003). A randomized controlled trial of meditation of work stress, anxiety and depressed mood in fulltime workers. Evidence=Based Complementary and Alternative Medicine, 10(2), 44
Mridula, M. and Rajesh K. S. (2001). “Effect of Yogic Practices on Depression and
Anxiety”. SIS J. Proj. Psy. & Ment. Health (2001) 8: 23-27
Philip, D., St. John, and Montgomery, P. R., (2009). “Do depressive symptoms predict
mortality in older people?” Aging & Mental Health, 13 (5), 674-681.
Retrieved from http://ehis.ebscohost.com/eds/pdfviewer/pdfviewer?sid=9cb75801-2998-48a2-be7b-ed1a17bc1e2a%40sessionmgr114&vid=2&hid=3
Robert, S., Eisenberg.D. , Roger, D, Laryy, Culpepper & Russell, P. “Prevalence and
patterns of adult yoga use in the United States. Results of a
national survey.”
Journal of alternative therapies 10(2): 44
Roberta, L., Tom, S., Kim T. M., Donna D. O., Meiinda, C. & Rosemarie, W. (2005). The effects if yoga in mood in psychiatric inpatients. Spring, 28(4), 399- 402
Shapiro, D., Cook, I. Daydov, D. Xristina, O. Leuchter, A. and Michelle, A (2007). “Yoga
as a complementary treatment of depression: effects of traits and moods on treatment
outcome”. eCAM 2007; 4(4)493–502
Sharma VK, Das S, Mondal. S, Goswampi U, Gandhi, A (ud). Effect of Sahaj Yoga on
depressive disorders.
Streeter, C. C., Jensen, E. Perlmutter, R. Cabral, H., J., Devin B., Terhune, D., A. . and
Renshaw, P. (2007). “Yoga Asana Sessions Increase Brain GABA Levels: A Pilot
Study”. The journal of alternative and complementary medicine 13 (4): 419–426
Wollery, A., Myers, H. Sternlieb, B and Zelter, l. (2004). “A yoga intervention for young
adults
with elevated symptoms of depression.” Alternative Therapies in Health
and Medicine;
Mar/Apr 2004; 10, 2; ProQuest pg. 60
