Yoga as Medicine

We’re back in deep lockdown here in Ireland and the kids are again unable to go to school. Although Covid earthquakes have profoundly rocked the world’s reality since 2020, another silent tsunami of ill health is also hitting global shores. A mental health crisis looms now as a direct consequence of the isolation, fear and economic fall-out of how the world has turned. A recent issue of the Irish Medical Journal approximated that “one person in every five in the general population in Ireland (and elsewhere) has significantly increased psychological distress.” (Kelly, 2020) Particular risk factors include being female, living alone, being a healthcare worker, and being hospitalised. As well as isolated elderly people, I feel that children and teens also bear a particular burden in this situation, being denied access to their friends, peers and education for long periods and having the stability, belonging and comfort of these repeatedly withdrawn at short notice.

In the UK, the president of the Royal College of Psychiatrists recognises the mental health consequences of Covid as equivalent to the trauma of the Second World War. The Gaurdian reported on December 27th, that in the UK “As many as 10 million people, including 1.5 million children, are thought to need new or additional mental health support as a direct result of the crisis,” (www.thegaurdian.com, 2020) with significant long-term effects predicted. There have been brief periods since last March that we have been allowed to gather in small numbers to practice yoga, but in the last window of opportunity, despite the fact that the industry had responded positively to providing every possible precaution, gyms were deemed ‘safe’, but yoga and similar small-gathering classes were excluded.

As a yoga teacher, I sorely miss practicing and connecting with a community of like-minded people. I could be called biased on the subject, but I have to wonder why complementary medicine and mind-body practices seem to be actively excluded in different iterations of restrictions. It’s also an eternal source of mystery to me why simple, non-patentable, preventative measures like vitamins D, C and Zinc have rarely make it into the collective narratives around the virus in the past year. I wonder will yoga feature in the story when the worst of the mental health tsunami hits, or will conventional approaches continue to herd us along the dubious medication route we are currently on? 

Given its benefits, if yoga was available as a pill, we’d be lining up for the prescription.

Did you know how reliant we have become on medication for mental health? Let’s just lift one corner of this questionable ‘band-aid’ for a peek. In 2018 it was reported that there was a whooping 512% rise in Sertraline prescriptions and a 181% rise in Prozac prescriptions issued to under 18s over a ten year period to 2017 in Ireland (thejournal.ie, 2018). Sertraline is a Select Serotonin Reuptake Inhibitor, (SSRI) typically prescribed for depression, OCD, panic disorder, PTSD and various dysphoric and anxiety disorders. It has a long list of child and adolescent specific side-effects including slowed growth and menstrual complications. Other uncommon but serious side effects include an exacerbation of psychiatric symptoms. Prozac is generally well tolerated by young people, but likewise, rare side effects can include panic, mania, violent and suicidal states.

Yoga, on the other hand, once practiced gently, with proper instruction, has side-effects like temporarily stiff muscles. Uncomfortable reactions include unexpected tears that can well up as trapped emotions release, or accidental snores that escape during relaxation. Forgive my sarcasm. It is born out of a rising frustration that drugs with significant side-effects seem to be the first and only solution sought, while the ‘powers that be’ have clearly decided that yoga classes are an unnecessary, possibly fruity and decidedly flippant activity. I wonder have they any idea what powerful benefits the practice has been proven to bring? What tectonic plates will have to move before these ‘powers’ and the people who look to them for advice, realise the bounty of possibilities we have for self-healing in our own Bodyminds

Yoga is only one of many alternative health interventions that people were (before lockdowns), reaching towards in their droves. Where research is available on the prevalence of people making these choices, the uptake is significant. In the US, 34% of the population ‘voted with their feet’ and used alternative and complementary health approaches in the ten years prior to 2012. (Clarke et al., 2015), and I would hazard a guess that this figure is indicative of other countries, and also that the figures were on the steady rise, up until our reality changed. If you are not among those who’ve already made the choice based on tacit experience, and need some scientific evidence to take yoga seriously, read on. (If you don’t need more evidence, read on to confirm your own wisdom!) What follows is just the ‘tip of the iceberg’ of what scientific proof exists that yoga works, and to focus it further, I will concentrate just on a selection of what evidence is available for yoga as a mental health intervention.

An ancient system for self-understanding and healthy living, yoga originated in India approximately 3500 years ago. It is often misunderstood today as merely a form of physical exercise (or, if your frame of reference is Instagram, you could be forgiven for thinking its a form of modelling for bendy, skinny people). It’s important to note however that originally the focus was not solely on achieving physical tone. Once yoga’s ancient oral tradition was eventually recorded by the sage Patanjali, he defined the practice as “the cessation of the fluctuations of the mind” (Yoga Sutra 1.2, circa 500 BC). The many processes of classical or Raja yoga (poses, mantra, breathing exercise etc.) are all ultimately aimed at preparing for meditation, and training the mind to be quiet, focused, and self-aware. This aim, of a still, non-fluctuating mind is shared by Buddhism’s mindfulness, (albeit, the goal is arrived at a little differently), and these days, meditation and mindfulness have become almost interchangeable terms. The scientific evidence that these practices soothe the nervous system is mounting, and a 2016 review of ‘gold-standard’ research in the field (i.e. randomised controlled studies), concluded that “meditation practice increases parasympathetic nervous system activation, as well as decreases anxious symptomatology in diverse populations” (Pascoe & Crewther, 2016). 

A soothed nervous system, otherwise known as parasympathetic activation, or ‘rest and digest’, is the body’s natural antidote to the uncomfortable fear states triggered by ancient survival mechanisms, known as ‘fight or flight.’ In a modern context, endless news cycles, quoting hospital ICU numbers, death tolls and mutating virus strains, as well as necessary adaptations to masks, home-schooling, multitasking, deadlines, etc., can lead to chronic stress states. (Sometimes grim reality has us wound so tight we find ourselves in the supermarket in the grip of an inexplicable toilet-roll frenzy.) These ‘anxious symptomatologies’ naturally contribute to the escalation of various mental disorders, that leave us at a good remove from things like relaxed social interaction, problem solving and creative flow that can characterise us humans at our best. If yoga or mediation was a pill that could help us fight this invisible wall of stress, I reckon we’d be lining up for the prescription. There would be public information campaigns. As it stands today, we can’t gather, even socially distanced, to practice these nourishing activities, while simultaneously connecting, calming and co-regulating our nervous systems. 

The nourishing activity of group yoga and meditation; simultaneously calming, connecting and co-regulating. 

Another significant piece of research outlines yoga as “a complex, adaptive and widely applicable method of physical and mental training with multiple tools for self-development, and […] for improving self-regulation through both top-down and bottom-up mechanisms.” (Gard et al., 2014). By ‘bottom-up’ they mean physical process that have the potential to change mental states, and by ‘top-down’ they mean conscious intention that has the potential to bring physical changes. As it turns out, yoga does both, very, very well.  Let’s look briefly at ‘bottom-up’ first. Many body-based yoga practices work to regulate the mind, creating an upward pathway towards body/mind integration. Yoga asana (postures) and pranayama (breathing techniques) for example, can bring about calm through improving interoception, the process by which the nervous system interprets the internal landscape of mind and body. Interoception is increasingly recognised as an essential element of psychological wellbeing, and the lack of it is linked to a variety of mental illnesses including anxiety, mood, eating, addictive and other somatic disorders (Khalsa at al, 2018). Heightened interoception is cultivated, (as well as deep muscular-skeletal ease) as part and parcel of ‘savasana’ the relaxation that is typically practiced at the end of asana, whereby you lie out flat and bring awareness to your internal sensations.

Yoga also provides ‘top-down’ frameworks for integration and positive change through practices such as sankalpa (goal setting), mantra (motivational chant), affirmations, visualisations, ethical teachings and, of course, meditation . A frequently repeated affirmation can help you to break out of habitual patterns and change behaviours that can in turn bring about physical improvements. Mantra, for example, can help to disrupt the mind’s internal chatter, and bring you towards a stable, peaceful internal state. The Sanskrit word mantra, comes in fact, from the roots manas meaning linear thinking and tra, to cross over. Hence, the repeated sonic cue helps to disrupt rumination processes, where negative thoughts can cycle repeatedly in the mind. Breaking unhelpful thought patterns can in turn unwind mental tension eventually relaxing the body in measurable ways, e.g. intrinsic muscle tension, heart rate, blood-pressure regulation and the lowering of the stress hormones, including cortisol.

One of the richest lines of yoga research looks at GABA, a calming neurotransmitter known to be lacking where mood and anxiety disorders are present. In one study, the researchers found that the “yoga intervention was associated with greater improvements in mood and anxiety than a metabolically matched walking exercise.” Additionally the study marked “the first time that a behavioral intervention (i.e., yoga postures) has been associated with a positive correlation between acute increases in thalamic GABA levels and improvements in mood and anxiety scales” (Streeter et al., 2010). Given that medications are used to artificially increase GABA to improve mood and decrease anxiety, it is very significant that a natural alternative has been identified in yoga. The study considered participants who were new to yoga and undertook a twelve-week intervention. Their GABA levels showed a 13% increase, but an earlier study by the same researchers looked at experienced yoga practitioners and found a 26% increase, which suggests that GABA levels may increase with experience (Streeter at al, 2007).

For now, your yoga practice, will have to be at home.

In earlier posts, (and no doubt again in future posts) I have looked in some detail at yoga’s ability to tone the vagus nerve and in turn modulate the nervous system, but I’ll refrain from climbing my vagus nerve soap box today. In closing however, I must mention the breath’s incredible ability to calm the mind. Yoga has a dedicated ‘limb’ or area of specialisation called Pranayama; the yogic science of breathing.  Science is now beginning to map the huge promise breathing practices have to be recognised as evidence-based mental health treatments. A randomized controlled trial from 2017 reported that among adults with treatment-resistant depression, meditative diaphragmatic breathing together with antidepressant medications resulted in greater improvements in depressive symptoms compared to medication-only treatment, (Sharma et al, 2017). Similarly, breathing was a key component of a meditation intervention found to decrease stress hormone levels, depressive symptoms and self-perceived stress, when compared to a no-treatment control group in a trial involving women with a painful physical disorder associated with mood problems. The participants also reported increased life satisfaction and perceived quality of life (Stefanaki et al., 2015). 

As a yoga teacher with a special interest in mental health, I am confident that science will continue to make ‘discoveries’ that confirm the wellbeing benefits of these ancient practices. I even look forward optimistically to a future where it might be ‘prescribed’ by doctors and mental health professionals who have informed themselves of its many therapeutic possibilities. Can I even dare to dream about a time when the ‘powers that be’ don’t close down classes because they recognise the positive results possible from yoga as a prevention and intervention for good mental health? Unfortunately however, this medicine can’t be patented, bought or dispensed. For the desired results you have to put in a bit of effort and get yourself to a mat and practice it again and again. For now, that mat will have to be in the comfort of your own home. The side-effects are ones you can live with though!

The Guardian (2020).’Covid poses ‘greatest threat to mental health since second world war” Available at : https://www.theguardian.com/society/2020/dec/27/covid-poses-greatest-threat-to-mental-health-since-second-world-war (Accessed Jan 24 2021)

Kelly, B.D. (2020) ‘Impact of Covid-19 on Mental Health in Ireland: Evidence to Date’, Irish Medical Journal, 113, (10), p. 214.

The Journal (July 2018). ‘HSE prescriptions for antidepressants and anxiety medications up by two thirds since 2009.’ Available at: https://www.thejournal.ie/ireland-antidepressant-anxiety-medicine- prescriptions-4157452-Aug2018/ [Accessed 10 November 2020]. 

Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. (2015) ‘Trends in the use of complementary health approaches among adults: United States, 2002-2012’, National Health Statistics Reports, (79), pp.1–16.

Pascoe, M., Crewther, S. (2016) A Systematic Review of Randomised Control Trials Examining the Effects of Mindfulness on Stress and Anxious Symptomatology. Available at: http://www.smgebooks.com/anxiety-disorders/chapters/ANXD-15-01.pdf [Accessed 22 December 2020].

Gard, Tim, Jessica J. Noggle, Crystal L. Park, David R. Vago, and Angela Wilson. (2014) ‘Potential self-regulatory mechanisms of yoga for psychological health’, Frontiers in Human Neuroscience, 8 (1), pp. 770.

Khalsa, S. S., Adolphs, R., Cameron, O. G., Critchley, H. D., Davenport, P. W., Feinstein, J. S., Feusner, J. D., Garfinkel, S. N., Lane, R. D., Mehling, W. E., Meuret, A. E., Nemeroff, C. B., Oppenheimer, S., Petzschner, F. H., Pollatos, O., Rhudy, J. L., Schramm, L. P., Simmons, W. K., Stein, M. B., Stephan, K. E.(2018) ‘Interoception and Mental Health: A Roadmap’ , Biological psychiatry. Cognitive neuroscience and neuroimaging, 3 (6), pp. 501–513.

Streeter, C. C., Whitfield, T. H., Owen, L., Rein, T., Karri, S. K., Yakhkind, A., Perlmutter, R., Prescot, A., Renshaw, P. F., Ciraulo, D. A., & Jensen, J. E. (2010) ‘Effects of Yoga Versus Walking on Mood, Anxiety, and Brain GABA Levels: A Randomized Controlled MRS Study’ , The Journal Of Alternative And Complementary Medicine, 16, (11), pp. 1–8. 

Streeter CC, Jensen JE, Perlmutter RM, Cabral HJ, Tian H, Terhune DB, Ciraulo DA, Renshaw PF. (2007) ‘Yoga Asana sessions increase brain GABA levels: a pilot study’ , Journal of Alternative o f Complementary Medicine,13 (4), pp. 419-26.

Sharma, A., Barrett, M. S., Cucchiara, A. J., Gooneratne, N. S., & Thase, M. E. (2017) ‘A Breathing-Based Meditation Intervention for Patients With Major Depressive Disorder Following Inadequate Response to Antidepressants: A Randomized Pilot Study’, The Journal of clinical psychiatry, 78(1), pp. 59–63.

Stefanaki, C., Bacopoulou, F., Livadas, S., Kandaraki, A., Karachalios, A., Chrousos, G. P., & Diamanti-Kandarakis, E. (2015) ‘Impact of a mindfulness stress management program on stress, anxiety, depression and quality of life in women with polycystic ovary syndrome: a randomized controlled trial’, Stress (Amsterdam, Netherlands), 18 (1), pp. 57–66.

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