Tuesday, November 25, 2008

only one more paper and 2 tests to go!

Here's a paper i just finished for my women and contemporary health class. skim it if you're interested in yoga and mental health...

(note-i'll try to post the appendix one of these days)

Yoga: A Prescription for Anxiety and Depression

A 2002 study by the Public Health Agency of Canada found that twenty percent of Canadians experience mental illness at some point in their lifetime. Due to this high prevalence, nearly all Canadians are affected by mental illness in some way: themselves, a family member, friend, or colleague. The study defines mental illness as “alterations in thinking, mood or behaviour associated with significant distress and impaired functioning” (Public Health Agency, 2002). This paper will focus on two of the most common mental health issues, depression and anxiety. I will explore how these issues are of importance to women’s health, share why the issue is of particular personal interest to me, and offer an argument for the application of yoga as a solution in treatment of depression and anxiety.
Anxiety disorders are the most prevalent mental illness, affecting 12% of the population (Public Health Agency, 2002). There are a number of anxiety disorders. Generalized Anxiety Disorder is characterized by excessive anxiety and worry about events and activities that occurs more days than not for a period of at least six months. Other anxiety disorders include Specific Phobia, Post Traumatic Stress Disorder, Social Anxiety Disorder, Obsessive-Compulsive Disorder, and Panic Disorder. Symptoms related to anxiety disorders include fatigue and poor concentration, palpitations, sweating, gastrointestinal discomfort, and in the more serious cases, Panic Attacks (Public, 2002).
Depression is the second most common mental illness in Canada. Eight percent of adults experience a major depression at some point in their lives (Public, 2002). Some common symptoms of depression include feelings of worthlessness, sadness and emptiness, poor concentration, loss of interest in normal activities, change in appetite and sleep patterns, decreased sexual desire and decreased energy (Public Health Agency, 2002). Depression can occur at any age, but often appears in adolescence or young adulthood.
The Public Health Agency study explains that research consistently documents rates of depression in women to be twice as high as in men. Another study by Klerman and Weissman found that the risk of depression is consistently two to three times higher among women than among men in all age groups (1989). In 1999 women were hospitalized for anxiety disorders at higher rates than men in all age groups (Public, 2002). There are many possible explanations for the higher prevalence. Some explanations are different biological and social risk factors such as the major hormonal and identity changes that occur throughout the female lifecycle through menarche, childbirth and menopause. Another explanation is that women maybe more likely than men to seek help, so that depression and anxiety in males more often goes undetected.
Whatever the cause for higher prevalence in women, depression and anxiety are of critical importance for studies of women and health. With rates of anxiety and depression so high, the detriments to society are great. Mental illness is costly to individuals, families, the health care system and entire communities. The Public Health Agency study estimates that the economic cost of mental illness was over seven billion dollars in 1993 in health care costs and lost productivity (Public, 2002). Additionally, mental illness can increase chances of other physical illnesses. Prevention and treatment of mental illness should be addressed on a wider scale, beyond just the mainstream medical profession and within the support of whole communities.
There are many complimentary and alternative treatments available for treatment of mental illness. These treatments can be taken alongside conventional medical treatments (pharmacotherapy) or as an alternative for those with milder cases who wish to avoid drug therapies. Some options include psychotherapy and counselling, biofeedback, naturopathy, acupuncture, reiki, and yoga.
Many Canadians associate yoga with the popularized styles of Bikram, Moksha and Power Yoga that focus primarily on a vigorous physical practice. Yoga has much more to offer than an intense workout. Other styles of yoga, such as Iyengar and Anusara, incorporate conscious breathing (pranayama), meditation, and emphasize the therapeutic benefits of physical postures (asanas). It is the Iyengar and Anusara methods that I will be referring to when I use the term “yoga” throughout the remainder of this paper. Iyengar Yoga is a system developed by master B.K.S. Iyengar. It is a form of Hatha Yoga that emphases correct alignment of the body in asanas and is known for its use of props to safely support beginning students. Anusara, which means, “flowing with grace,” is a method of yoga founded by John Friend. It stems from Iyengar’s teachings and similarly emphasizes alignment and the therapeutic benefits of yoga, both physically and mentally. Both Iyengar and Anusara Yoga incorporate pranayama (yogic breathing), but they do so gradually as the body becomes more open.
The therapeutic application of yoga in treating depression and anxiety is of personal interest and concern to me for a number of reasons. I struggled with both anxiety and depression throughout my adolescence and into early adulthood. Yoga has been an important practice for me in dealing with both mental illnesses. I used prescription medications to deal with these illnesses for many years as well as some periods of psychological counselling. These were sufficient treatments, but neither helped me to recover. It is through my practice of yoga, which I continue to do daily, that I no longer need these medications.
In the summer of 2008 I completed my yoga teacher training, based in the Anusara method, and I am now a Certified Hatha Yoga Teacher. During my teacher training I met a number of women who have also dealt with periods of anxiety and depression and have found yoga to be incredibly beneficial in dealing with these illnesses and as a means of recovery. Through my own experience, and the stories of these other women I am encouraged by the prospect of using yoga therapeutically in my work as a yoga instructor to compliment conventional medical treatment for depression and anxiety and even as an alternative treatment in more mild cases. The following sections will explain the findings of published, peer-reviewed studies on the efficacy of yoga in treating mental illness. I will supplement these findings with anecdotal evidence from my own experience and those of my colleagues.
Michalsen et al’s (2005) study investigates the impacts of Iyengar yoga on women’s levels of stress. In this study 24 self-referred female subjects who perceived themselves as emotionally distressed took bi-weekly Iyengar Yoga classes for three months. The study included only females because women manifest a 50% higher prevalence of “frequent mental distress” than men (Michalsen et al, 2005, 556). The results of the study supported the authors’ hypothesis that the yoga course would “result in a reduction of perceived stress and related symptoms of anxiety and depression…as well as increased emotional and physical well-being.” The classes included asanas (postures) that, according to the Iyengar method, are thought to alleviate stress: backbends, standing poses, forward bends and inversions.
At the beginning of Michalsen et al’s study participants had baseline scores of stress, anxiety and depression that indicated clinically relevant stress. Upon completion of the program there was a 50% and 30% yoga-induced improvement for depression and anxiety respectively. Additionally, overall psychological well being improved significantly, by 65%. There were also many reported physical benefits: lower frequency of back pain, headaches and sleep disturbances (2005, 557-8). These findings are suggestive of the interconnectedness of physical and mental well being. The authors explain, “there is growing evidence that perceived stress has a major impact on the initiation and progression of disease, i.e. cardiovascular disease and chronic pain syndromes” (Michaleson et al. 2005, 559). Lastly, there were no adverse effects associated with yoga for all subjects. In light of the positive effects of Iyengar Yoga on stress levels, yoga could be an important tool in preventative medicine, particularly in preventing anxiety and depression in women. Beyond preventative medicine, yoga may be an important tool in treatment.
“Yoga as Complementary Treatment of Depression” evaluated the effects of yoga on patients taking anti-depressants for a minimum of three months and who were in partial remission (Shapiro et. al, 2007). By partial remission the study means patients had self-reported improvement in depression severity through pharmacotherapy, yet still had residual symptoms of depression. The style of yoga taught to participants was again Iyengar Yoga. Classes were taught three times a week for a period of 8 weeks. The classes emphasized inverted postures, gentle backbends and restorative poses which use props to make the postures more passive and relaxing.
The study found significant immediate changes in mood before and after classes: negative moods decreased, positive moods increased and energy/arousal moods increased (Shapiro et. al, 2007, 6). Further the study found that over the course of the session both pre- and post-class average levels of happiness increased. They found that benefits of yoga were felt class-by-class and accrued over time. Lastly, the study observed that yoga not only affected depression, but also “affected psychological and biological processes indicative of improved mental health in general and more effective social behavior.”
The academic studies reviewed above include relatively short and infrequent yoga practices. Amy Weintraub, author of Yoga for Depression, and one of the leading practitioners and teachers in the therapeutic use of yoga for depression, explains that you would not take an anti-depressant just once and expect to no longer have symptoms. For yoga to have a significant and lasting effect it should be done regularly. Weintraub suggests, “the very commitment to practice can begin to diminish depressive symptoms” (2004, 59). Unlike using pharmacotherapy, when a woman who is experiencing mental illness practices regularly she is becoming “actively involved in the healing process.” In this she gains a sense of self-determination, which, Weintraub claims, has been proven to positively affect recovery from illness, including depression (2004, 60).
Anna*, who has suffered from anxiety disorders and specifically from Panic Attacks, found regular practice to be important in maintaining her mental health: “Whenever I feel angry or depressed I know its because I haven’t practiced in a while so I have to practice to feel better. Practicing asanas definitely releases tensions and makes me happier” (A.E., personal communication, Nov. 9, 2008) (*names changed for confidentiality). She also explained that whereas medications and counselling help in the short term, “yoga helps in the long term, not only temporarily.” Nancy*, who has also suffered from Panic Attacks concurs that regularity of practice has been vital to her recovery, “What really changed for me was when I started to do more yoga regularly at home.” In addition to yoga, Nancy sought the help of her family doctor, a Traditional Chinese Medicine practitioner, an Osteopath, and a Reiki therapist. She found, “The other medical interventions helped me maybe at 30% but yoga helped me at 70%. Yoga is a tool for everyone to do at their home, in their car, at work… every time they feel the anxiety coming, they can control it.”
A number of studies have show that yoga creates short-term biochemical changes in the brain, for example in cortisol levels (Weintraub 2004, 59; Michalesen et. al 2005). Weintraub explains that over time, these short-term changes build up and cause long-term biochemical changes (62). Over time and regular practice, yoga asanas target the major glands in the body. The hormones in these glands are in part responsible for moods and modes of thinking. Asanas thought to be particularly effective in targeting the master glands (pineal, hypothalamus and pituitary), which naturally stimulate the body and mind, will be examined in following sections and in the appendix.
The evidence of yoga’s success in treatment of mental illness is substantial. Shapiro et al conclude that yoga, as an intervention for depression, is both cost effective and easy to implement (2007, 9). There are a growing number of yoga professionals practicing “Yoga Therapy”. Yoga Therapy is an emerging field of practices that use yoga to prevent, reduce and alleviate mental and physical illness. Practitioners work one-on-one or in group settings, teaching clients how to use yoga postures, breath and meditation to promote healing. There is a need for greater regulation of Yoga Therapy through a professional organization and potentially the government in order to make practitioners more accountable and credible. The International Association of Yoga Therapists is a non-profit organization that promotes Yoga Therapy, but is not a regulating body in itself. An article on their site argues that without high standards for practitioners, therapeutic applications of yoga will be marginalized (Kepner et al, 2004).
In Quebec, some progress has been made in terms of making Yoga Therapy a more credible and accessible form of complimentary care. Heaven on Earth Yoga Institute of Montreal has a training program for Yoga Therapy. After completion of the program, which requires over 500-hours of study in yoga pedagogy and yoga’s therapeutic applications, graduates can register with the Association of Naturotherapists of Quebec (ANQ). By registering with the ANQ, Yoga Therapists in Quebec can give insurance receipts to clients, much like a massage therapist.
Yoga’s effectiveness in treating mental illness is already reasonably well documented. The next step is to regulate the profession in a way that Yoga Therapists are seen as credible by the medical mental health profession so that doctors, psychologists and therapists may refer patients to Yoga Therapists. In addition to one-on-one work between Yoga Therapists and clients suffering from mental illness, yoga classes targeted to those suffering from depression and anxiety should be offered in mental health centres, hospitals, schools, and local yoga studios. A study conducted with 113 psychiatric inpatients at a New Hampshire hospital found yoga to be a useful way to improve mood and reduce stress during inpatient psychiatric treatment (Lavey et al, 2005). Classes targeted towards specific mental illnesses would also potentially provide a safe place for social support from people sharing similar experiences.
This final section will provide an explanation of what yogic techniques are most relevant for dealing with mental illness. In Michalsen’s et al (2005) study the classes focused on back bends, standing poses, forward bends and inversions. Back bends open the chest and improve posture. Often the posture of a person suffering from depression is hunched over. We often embody our mental state through our posture, so addressing muscular patterns in our posture may positively affect mood (Weintraub 2004, 67). By opening and expanding the chest through backbends, the mental state may follow becoming more open and receptive. I would recommend only gentle and more passive backbends in the beginning (Appendix, 5). Especially if a client is dealing with anxiety, the openness of backbends can make students feel vulnerable and much emotion can arise. Standing poses such as the Warrior series help students to cultivate balance and courage both physically and mentally (Appendix, 4). Instructing students to embody someone courageous helps them start to open to this possibility for themselves.
Inversions are perhaps the most important posture for people suffering from depression. Inversions are poses like Handstand, Shoulderstand, and Headstand, where the body is turned upside down. Weintraub explains that inversions increase tone and muscle extension of our postural muscles. So like backbends, inversions support a strong standing posture, which may in turn affect mood (2004, 67). Weintraub also explains a number of other physiological benefits of inversions. When inverted, the blood flow is altered and there is increased blood flow to the brain. The brain is bathed in blood, increasing the availability of oxygen and glucose. Both are important in the creation of neurotransmitters, such as dopamine and serotonin, two chemicals that greatly affect our moods. All type of inversions can be beneficial for depression and anxiety; however, experienced practitioners have discovered that pressure or stimulation closer to the front of the head (Appendix, 6) may lift a depressive attitude, while pressure on the crown stabilizes the mood in general. Additionally, pressure on the back of the head can be calming and neutralizing, especially beneficial for those suffering from anxiety (Appendix, 7). Inversions are more difficult to practice safely and it is important to learn more difficult inversion poses under the guidance of a qualified teacher. Also, it is important to respect several contra-indications for inversion. Women should not practice them while menstruating, nor should anyone with heart disease or glaucoma (Weintraub 2004, 68).
Forward bends are very useful, particularly for those suffering from anxiety (Appendix, 8). The Women’s Yoga Book explains that forward bends “calm the mind, soothe the nerves, and remove fatigue” (Clennel, 2007, 87). Nancy* explains, “I found it feels better for me and for my mental health if I do lots of forward bending pose, it is more calming and I go deeper into my soul” (N.C., personal communication, Nov. 10, 2008). Nancy also emphasized how much breathing techniques from yoga have helped her deal with anxiety. Julie* who has dealt with an anxiety disorder since her teens explains, “The tool that saved me when learning about yoga was the breathing. When I learned how to breathe and calm my mind I was able to understand and control my anxiety attacks” (J.Y., personal communication, Nov. 14, 2008).
Mindful breathing techniques are an essential part of yoga and may prove to be one of the most useful tools for students working with mental illness. Under stress, the sympathetic nervous system is activated (fight or flight response). We start to breath shallowly, overusing our chest, neck and shoulder muscles rather than the diaphragm. When stress is frequent, this can quickly become a habitual way of breathing, even when a person is not under stress. In shallow breathing, too much carbon dioxide is breathed out which changes the chemical make up of our blood and leads to feelings of apprehension and anxiety. This becomes a vicious cycle as the breathing pattern becomes even worse and a panic attack may ensue (Keller, 2003, 20).
By changing their breathing patterns Julie and Nancy found that they could stop a panic attack from developing. By breathing fully, starting in lower diaphragm (belly and lower ribs), the parasympathetic nervous system is activated and it helps the body and mind to relax (Appendix 1-2). Once diaphragmatic breathing is mastered, students can move to full yogic breath, where breath is even and full through the three distinct areas of the torso: belly/diaphragm, mid-chest, and upper chest (Appendix 2). Another technique particularly helpful for dealing with anxiety is counting breaths and making the exhale several counts longer than the inhale. Once experience with full yogic breath is gained, students dealing with depression can work with more energizing techniques such as “breath of joy” (Appendix, 3).
The costs of mental illness are great for individuals, families and society. Given the high rates of anxiety and depression in Canada, particularly among women, mental health care should not be limited to the mainstream medical establishment. Yoga, and particularly Yoga Therapy, is a promising aid for healing from both depression and anxiety. If rigorous professional standards are developed, the value of Yoga Therapy may become more recognized as a mode of complimentary and alternative care. The studies and personal stories recounted in this paper demonstrate that yoga holds great potential in both prevention and treatment of mental illness. Through yoga, I have overcome years of intermittent anxiety and depression. I am now free of prescription medicines to deal with these illnesses. When feelings of anxiety and depression do arise, my strong practice of yoga has given me the tools necessary to deal with these feelings fully and then move on to a more contented mental state.


Clennel, B., (2007). The Woman’s Yoga Book. Berkley: Rodmell Press.

Keller, D., (2003). Refining the Breath (3rd ed.). Do Yoga Productions.

Kepner, J., Knox, H., Lamb, T., & Zador V. (2004). Standards for Yoga Therapists? Retrieved Nov. 10, 2008, from http://www.iayt.org/site_Vx2/publications/articles/standards. htm?ProfileNumber=&UStatus=&AutoID=&LS=&AM=&Ds=&CI=&AT=&Return=../.. /site_Vx2/about/mission.htm

Klerman, G., & Weissman, M. (1989). Increasing rates of depression. Journal of the American Medical Association, 261, 2229-2235.

Lavey, R., Sherman, T. Mueser, K., Osborn, D., Currier, M., Wolfe, R. (2005). The effects of yoga on mood in psychiatric inpatients. Psychiatric Rehabilitation Journal, 28(4), 399- 402.

Michalsen, A., Grossman, P., Acil, A., Langhorst, J., Ludtke, R., Esch, T., et al, (2005). Rapid stress reduction and anxiolysis among distressed women as a consequence of a three- month intensive yoga program. Medical science monitor, 11, 555-561.

Public Health Agency of Canada. (2002) A Report on Mental Illnesses in Canada. Retrieved November 11, 2008, from http://www.phac-aspc.gc.ca/publicat/miic-mmac/sum-eng.php.

Shapiro, D., Cook, I., Davydov, D. Ottaviani, C. Leuchter, A., & Abrams., Michelle. (2007). Yoga as a Complementary Treatment of Depression: Effects of Traits and Moods on Treatment Outcome. Oxford Journals Online: eCAM. Retrieved Nov. 12, 2008, from http://ecam.oxfordjournals.org/cgi/content/full/nel114v1

Weintraub, A. (2004). Yoga for Depression. New York: Broadway Books.

(c) 2008 Leena Miller


somebird said...

this is really great, leena. you're a lucid writer.

Angie said...

whoops! that was me saying how great you are. i think you checked your email on my computer and i didn't switch it back to my account. or you're just vain and are posting nice comments about yourself... oh, think of the fun things I could have made you say! :)

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