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Significant outcomes
Yoga therapy, as an add-on treatment along with antipsychotics is benecial in psychopathology and
other outcome measures in schizophrenia.
Limitations
Single-blind nature of the study: only the rater was blind to the group-status.
Intent-to-treat analysis could not be performed.
Extrapyramidal symptoms were the only side-effects systematically assessed.
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Yoga therapy for the management of patients with schizophrenia
been examined in schizophrenia. Several features study period. Sixty-one patients were recruited into
of yoga make it an attractive option in schizo- the study between March 2003 and August 2004.
phrenia: It has been shown to improve cognitive
functions in normal individuals (1215); it is also
Assessments
useful in reducing stress (9). Since schizophrenia is
associated with cognitive decits, and relapse of Psychopathology was assessed using Positive And
schizophrenia is associated with stress (16, 17), Negative Syndrome Scale for Schizophrenia,
yoga may be particularly helpful in this condition. PANSS (23). An MD trainee (GD) with a 2-year
Furthermore, yoga has positive eects on the experience in clinical psychiatry administered the
blood glucose, cholesterol and total lipids (18, PANSS. He was trained in administering PANSS
19). This aspect makes it an interesting add-on using eight training videos. The subjects were also
treatment, as a majority of schizophrenia patients rated on the following: (a) social and occupational
treated with antipsychotic medication suer from functioning was assessed using Social and Occu-
dyslipidemia and obesity (20). pational Functioning Scale [SOFS (24)]; (b) side-
eects were assessed using the Simpson Angus
Scale for Extrapyramidal Symptoms (25) and
Aims of the study
Abnormal Involuntary Movement Scale [AIMS
The primary objective of this study was to examine (26)]; (c) quality of life was assessed using WHO
the eect of 4 months of yoga therapy (YT) as an Quality of Life BREF Version, WHOQOL-BREF
add-on treatment on the psychopathology of (27). All assessments were done twice before
schizophrenia patients. The secondary objectives randomization and after 4 months. After the
were to examine its eects on the quality of life and baseline assessments were done, subjects were
social functioning. To control for changes due to randomly assigned, using a computer-generated
non-specic factors, the eect of yoga was com- random number table, to receive either YT (n
pared to that of physical training (PT). Subjects 31) or PT (n 30) for the next 4 months. The two
with schizophrenia were randomized to receive YT groups were similar in demographic and illness
or PT as add-on treatments to their antipsychotic characteristics and in the psychopathology ratings
drugs, and their clinical outcome was evaluated at baseline (Table 1).
after 4 months.
Training
Material and methods A therapist trained to teach both YT and PT
taught the subjects in their allocated treatment
Subjects
groups. He taught yoga and exercise in separate
The subjects for this study were schizophrenia
Table 1. Demographic profile, illness parameters and psychopathology scores of
patients attending the out-patient and in-patient
subjects in Y.T. and P.T. groups
services of National Institute of Mental Health and
Neuro Sciences, Bangalore, India. They belonged Variables YT group PT group t-value P-value
to the age group of 1855 years. Patients with
Age, years 32.53 7.9 31.30 7.9 0.38 0.70
severe physical ailments like recent and decompen- Sex ratio*, M : F 19:12 23:7 1.68 0.27
sated myocardial infarction, fracture, seizure dis- Unmarried : married* 24:7 19:11 1.45 0.27
orders, mental retardation or comorbid substance Duration of illness (months) 99.1 96.1 81.1 81.4 0.82 0.41
CGI illness severity score 4.8 0.8 5.2 0.9 )1.55 0.12
dependence (except nicotine dependence) were Antipsychotic dosage 469.7 195.7 476 205 )0.12 0.90
excluded. Only patients with Clinical Global PANSS scores
Impression Severity Scale (21) score of 4 or more Positive score 17.03 6.5 20.17 6.8 )1.8 0.07
and who were cooperative for YT were included. Negative score 21.31 5.7 22.83 6.3 )0.78 0.43
Depression subscore 10.54 3.3 10.33 3.9 0.23 0.82
Written informed consent was obtained from all Anergia subscore 9.61 2.6 10.33 3.3 0.93 0.36
the participants. At least one family member SOFS score 13.1 10.5 14.5 6.6 0.51 0.68
accompanied each subject; the family members Total AIMS score 4.2 7.9 2.2 3.2 1.2 0.22
helped the subjects to understand and consent Total Simpson Angus score 2.0 1.8 1.7 2.3 0.50 0.61
Quality of life
for the study. The diagnosis was conrmed by Psychological QOL 49.3 19.8 48.4 19.1 )0.71 0.47
using Structured Clinical Interview for DSM-IV Physical QOL 52.9 21.5 56.5 14.8 0.86 0.93
[SCID-IV (22)]. All patients were on antipsychotic Social QOL 49.7 22.1 56.6 22.1 )1.2 0.21
medication for several months, and there was no Environmental QOL 52.0 19.9 55.7 15.9 0.73 0.47
change in their medication dose for at least 4 weeks All values except * are mean standard deviation; v2-value; Chlorpromazine
before their entry into the study and through the equivalents in mg/day.
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Duraiswamy et al.
groups. The yogasanas were from the integrated Table 2. Comparison of demographic profile, illness parameters and psychopa-
thology scores between completed and dropped out patients
yoga treatment developed by Swami Vivekananda
Yoga Anusandhana Samsthana (SVYASA) (28). It Completed Dropout
was a 1-h programme consisting of (a) Sithilikar- Variables (n 41) (n 20) t/v2-value P-value
ana Vyayama; (b) asanas including surya namaskar;
Yoga : exercise 21:20 10:10 0.01 0.93
(c) breathing practice; and (d) relaxation tech- Age, years 30.41 7.9 34.3 6.6 )1.8 0.06
niques. The ratio of Vyayama:asana:breathing Sex ratio*, M : F 28:13 14:6 0.01 1.00
practice was 1:1:1. Meditation was not a part of Unmarried : married* 31:10 12:8 1.5 0.24
Duration of illness (months) 77.7 82.1 119.6 99.1 )1.7 0.08
the yoga module. The exercises were adapted from Antipsychotic dosage 479.0 183.4 460 231 0.34 0.72
the National Fitness Corps Handbook for CGI illness severity score 5.02 0.8 5.05 0.6 )0.11 0.91
Middle High and Higher Secondary Schools (29). Positive score 18.9 7.2 18.0 5.2 0.48 0.62
This 1-h module of PT consisted of brisk walking, Negative score 22.5 6.5 20.8 4.9 1.1 0.27
Anergia score 9.95 3.1 10.0 3.0 )0.05 0.95
jogging and exercises in standing and sitting Depression score 10.7 3.7 9.95 3.4 0.74 0.46
postures and relaxation (see Appendix). The sub- SOFS scores 14.6 10.7 12.5 8.5 0.83 0.41
jects in both groups underwent training for 15 days Total AIMS score 2.7 3.8 2.3 2.2 0.28 0.77
(1 h a day; 5 days a week for 3 weeks). Both Total Simpson Angus Scale score 14.6 10.7 12.5 5.8 0.83 0.41
training sessions were held in the same therapy hall The difference was not significant (P < 0.05) All values except * are mean SD;
at dierent time points of the day. Of the 61 v2-value; Chlorpromazine equivalents in mg/day.
recruited, 16 (26%) did not complete the training.
The reasons for non-completion included disinter-
est and long distance from the hospital for out-
Results
patients. The subjects who completed the training
period continued to practice their respective ther- The PANSS total and subscores signicantly
apies for the next 3 months in the same sequence dropped from pre- to post-assessment in both the
and for the same duration as in the training groups. Likewise, signicant reduction in SOFS
sessions. The therapist reviewed the adherence and total score occurred in both the groups. On the
the correctness of yoga or physical exercises once a other hand, QOL scores changed signicantly only
month; the subjects were also reminded through in the YT group (Table 3 and Fig. 1). ancova
telephone and letters about practicing the exercises. results indicated that the scores diered signi-
cantly between groups at the end of 4 months after
controlling for the corresponding baseline scores,
Follow up
age, sex, marital status, duration of illness, dose of
All but four subjects who completed 3 weeks of antipsychotics and the type of antipsychotic. The
training were available for follow-up assessment subjects in the YT group scored signicantly lower
after 4 months. The nal sample of 41 patients (21 in dierent symptom dimensions (except positive
in YT and 20 in PT) and the remaining 20 from the syndrome score) and PANSS total score. They also
original sample were comparable on demographic scored signicantly better on SOFS and QOL
and clinical variables. Comparable proportions scores. There were no serious adverse events such
(33% each) of patients allocated initially to each as delirium, confusion, suicidality or any serious
of the two groups were available for the nal physical complications in either group during the
sample (Table 2). four-month period.
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Yoga therapy for the management of patients with schizophrenia
PANSS
Positive 18.19 7.1 12.19 5.9 19.10 7.2 14.60 5.9 1.40 0.24
Negative 21.90 6.2 14.19 5.1 24.05 6.9 19.75 7.3 10.1 <0.01
Depression score 10.54 3.3 5.71 2.3 10.93 3.3 8.60 4.04 8.5 <0.01
Anergia score 9.6 2.6 6.9 2.6 10.33 3.3 9.30 3.6 4.7 0.03
Total 76.14 16.9 51.05 16.4 83.85 20.2 66.00 23.2 5.0 0.03
SOFS score 14.62 11.4 7.05 8.0 14.85 10.2 11.40 9.9 7.98 <0.01
QOL
Physical 53.57 24.0 65.82 12.8 54.10 14.4 56.60 18.1 4.4 0.04
Psychological 51.79 20.2 66.87 17.5 44.79 17.4 49.17 19.0 11.4 <0.01
Social 53.17 24.1 68.45 20.4 55.83 21.5 47.70 23.0 7.8 <0.01
Environmental 55.65 20.7 66.22 15.2 53.13 14.8 48.13 18.6 12.8 <0.01
AIMS 3.2 4.3 1.3 2.1 2.3 3.3 1.5 2.4 0.54 0.46
Simpson Angus Scale 2.0 1.9 1.1 1.2 1.7 2.4 1.6 1.8 3.02 0.09
YT PT
Fig. 1. Charts showing the changes in psychopathology, social and occupational functioning and quality of life in both groups over
time. BL, baseline; 4M, 4 months.
end of 4 months was 0.74 and that for SOFS score expectation-bias. In 74% of the subjects medica-
was 0.48, suggesting that the dierences were tions and their dosages were unchanged for at least
moderate-to-large. 8 weeks before entering the study, and in all
It appears that the addition of YT oers benets subjects there was no change for at least 4 weeks.
across several dimensions in schizophrenia. How- Medication was changed during the study period in
ever, no signicant dierence was seen between the only two patients (one from each group) as they
groups in the positive syndrome score on PANSS. had exacerbation of symptoms. Thus the results
This could be because the positive symptoms were are not attributable to changes in antipsychotic
already very low (mean total positive syndrome medications. The trainer was qualied to train
score 18.6) achieved perhaps by the use of both forms of treatments. Furthermore, the exer-
antipsychotics. At this low level of positive symp- cises taught in the PT group were very simple.
toms, further improvement from YT could not be Having a separate physical therapist for the PT
demonstrated. group would not have inuenced the quality of
This is the rst study to nd the clinical eects training, but would have introduced a confounding
specically of addition of YT in schizophrenia in a factor in the form of therapist variable. Use of the
randomized controlled design. The rater was blind same trainer to train both the groups for an equal
to the group status of the patients at both stages of duration of time and for equal number of days
the assessment. The rating on the second occasion avoided this confound.
was done without referring to the previous scores. Some other methodological issues should be
These steps minimized the scope for any rater- or considered while interpreting the results. It was a
229
Duraiswamy et al.
single-blind study. In the YT group, the knowledge 5. Siris SG. Diagnosis of secondary depression in schizo-
that the subjects were receiving yoga might have phrenia: implications for DSM-IV. Schizophr Bull
1991;17:7598.
had a positive eect. This eect can only be 6. Stahl SM, Buckley PF. Negative symptoms of schizo-
removed by a double-blind study. However, this is phrenia: a problem that will not go away. Acta Psychiatr
not practical, as subjects in India are quite aware of Scand 2007;115:411.
yoga techniques and cannot be blinded. An intent- 7. Gaebel W, Frommann N. Long-term course in schizophre-
to-treat analysis of all randomized subjects would nia: concepts, methods and research strategies. Acta Psy-
chiatr Scand 2000;102:4953.
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done because the subjects who dropped out of the Muskin PR, ed. Complementary and alternative medicine in
study did so even before they received the treat- psychiatry. Washington, DC: American Psychiatric Press,
ment and could not be contacted for follow-up 2000.
assessments. There were no serious adverse eects 9. Brown RP, Gerbarg PL. Sudarshan Kriya yogic breathing
in the treatment of stress, anxiety, and depression. Part II
of either YT or PT during the study period. clinical applications and guidelines. J Altern Complement
A comprehensive assessment of side-eects using Med 2005;11:117.
scales developed for drug-trials [e.g. UKU Scale 10. Janakiramaiah N, Gangadhar BN, Naga Venkatesha M.
(30)] was not made. PANSS scores formed the Antidepressant ecacy of sudarshan kriya yoga (SKY) in
main measure in this study. Establishing inter-rater melancholia: a randomized comparison with ECT and
imipramine. J Affect Disord 2000;57:255259.
reliability with a senior psychiatrist would have 11. Nespor K. Treatment needs of alcohol dependent women.
enhanced the quality of the data. Furthermore, Int J Psychosom 1990;37:5052.
although the therapist conrmed the adherence to 12. Uma K, Nagendra HR, Nagarathna R, Vaidehi S, Seethal-
the respective treatments, it is possible that the akshmi R. The integrated approach of yoga; a therapeutic
level of adherence could have varied in the subjects. tool for mentally retarded children: a one year controlled
study. J Ment Dec Res 1989;33:415421.
A quantitative assessment of this by way of a 13. Vani PR, Nagarathna R, Nagendra HR. Progressive increase
written log could have thrown useful light on this. in critical icker fusion frequency following yoga training.
At this stage, it is dicult to comment on the Indian J Physiol Pharmacol 1997;41:7174.
possible mechanism by which YT helps in schizo- 14. Naveen KV, Telles S. Yoga and psychosis: risks and
phrenia. There is evidence that yoga helps in therapeutic potential. J Indian Psychol 2003;21:1.
15. Manjunath NK, Telles S. Improved performance in the
positive mental health (9). Yoga also reduces Tower of London tests following yoga. Indian J Physiol
stress (10). Stress is associated with the worsening Pharmacol 2001;45:351354.
of schizophrenia symptoms (31, 32) and, reduction 16. Ayuso-Gutierrez JL, Del rio vega JM. Factors inuencing
in stress is one putative mechanism of the benecial relapse in the long-term course of schizophrenia. Schizophr
eect of YT in schizophrenia. Future studies may Res 1997;28:199206.
17. Norman RM, Malla AK, Mclean TS et al. An evaluation of
include measures of stress also to examine this issue. a stress management program for individuals with schi-
This is particularly important, as there is a good zophrenia. Schizophr Res 2002;58:293303.
body of literature that suggests that regular phys- 18. Bijlani RL, Vempati RP, Yadav RK et al. A brief but
ical exercise also mitigates the eects of stress (33). comprehensive lifestyle education program based on
In conclusion, this study showed YT is benecial yoga reduces risk factors for cardiovascular disease and
diabetes mellitus. J Altern Complement Med 2005;11:267
in schizophrenia as an add-on treatment. This 274.
benet is seen across several dimensions of the 19. Innes KE, Bourguignon C, Taylor AG. Risk indices associ-
schizophrenia outcome. It remains to be estab- ated with the insulin resistance syndrome, cardiovascular
lished whether the benets extend to cognitive disease, and possible protection with yoga: a systematic
symptoms and are enduring. review. J Am Board Fam Pract 2005;18:491519.
20. Paton C, Esop R, Young C, Taylor D. Obesity, dyslipidae-
mias and smoking in an inpatient population treated with
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Appendix
Yoga therapy and physical exercise modules
Appendix A The integrated yoga therapy module (28); duration: 1 h
Appendix B Physical exercises: adopted from the national fitness corps. Handbook for middle high and higher secondary schools (29); duration: 1 h*
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*The therapist would give 2 min time in between the different exercises with a non-specific instruction, just relax now.
232