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ABSTRACT
Schizophrenia is a serious mental illness characterized by incoherent or illogical thoughts,
bizarre behavior and speech, and delusions or hallucinations, such as hearing voices. Person
suffering from the disorder may be seriously impaired. Also, family members may be seriously
affected. However, through proper treatment many individuals suffering from schizophrenia can
recover. Anti-psychotic drugs play a crucial role in schizophrenia treatment. However, anti-
psychotics may treat the positive symptoms of schizophrenia and do little to improve the lost
ability of the patient due to negative symptoms. Second-generation anti-psychotics are slightly
more effective than first-generation anti-psychotics in treating positive symptoms of symptoms,
but their efficacy against negative symptoms has not been borne out.
Many patients continue to suffer from persistent symptoms and relapses, particularly when they
fail to adhere to prescribed medication. This underlines the need for multimodal care that include
psychosocial and physical therapies such as yoga, adjunct to anti-psychotic medication to help
alleviate symptoms and improve patient’s quality of life. Yoga as an additional treatment along
with anti-psychotics can be use, as it has proved to deal with both the positive and negative
symptoms of schizophrenia. Unlike anti-psychotic drugs, yoga has no side effects. This paper
evaluates research on efficacy of yoga as an add-on treatment of schizophrenia. Review shows
that yoga is useful in treating negative symptoms of schizophrenia in stabilized patients though
more research is required to understand yoga’s effect on schizophrenia.
Keywords: Schizophrenia, Medication, Yoga, Add-on treatment
INTRODUCTION
Of all psychiatric disorders, schizophrenia is one of the most severe mental disorders. It has a
debilitating course as the persons suffering from it are not themselves any more. For
schizophrenia patients, there is a breakdown in the relation between thought, emotion, and
behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from
reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation.
About 1% of general population is affected by schizophrenia (Comer, 2010). The disorder sets in
early in one's productive years and only a minority of patients will have a remitting course.
Majority will have a relapsing course with or without severe deficits. Both sexes and all
communities are affected by schizophrenia. There is a strong genetic contribution, but drugs of
abuse like cannabis and other stimulants or environmental stressors can bring on the illness
earlier in life and also make the outcome of treatment unsatisfactory.
Schizophrenia accounts for 1.1% of total disability-adjusted life years and for 2.8% and 2.6% of
years lived with disability for men and women, respectively. In addition, it is the fifth leading
cause of disability-adjusted life years worldwide in people who are 15 to 44 years old (Burden of
disease: DALYs, WHO, 2004).
Schizophrenia symptoms
Schizophrenia symptoms can be grouped into the following three categories:
Positive symptoms
Negative symptoms
Psychomotor symptoms
Positive symptoms: These symptoms are “pathological excesses”, or bizarre additions, to a
person’s behavior. These symptoms include delusions, disorganized thinking and speech,
heightened perceptions and hallucinations, and inappropriate affect.
Negative symptoms: These symptoms refer to “pathological deficits” which include poverty of
speech, blunted and flat affect, loss of volition, and social withdrawal. These are commonly
found in schizophrenia patients (Messinger et al, 2011). Such deficits greatly affect one’s life
and activities.
Psychomotor symptoms: These symptoms represent unusual movements or gestures or motor
agitation. In their extreme form, these may lead to Catatonic behavior characterized by a marked
decrease in reaction to the immediate surrounding environment, sometimes taking the form of
motionless and apparent unawareness, rigid or bizarre postures, or aimless excess motor activity.
Difficulty in treating negative symptoms with drugs
Mesolimbic dopaminergic hyperactivity is believed to be part of the underlying pathology
associated with the positive symptoms of schizophrenia (Keshavan et al, 2008) but the patho-
physiology of its negative symptoms is poorly understood. The negative symptoms therefore
remain a relatively treatment-refractory and debilitating component of schizophrenia (Stahl &
Buckley, 2007). Traditionally, it was argued that the positive symptoms developed as a reaction
to stress, whereas the negative symptoms developed as a process, occurring slowly over a period
of time. Some people with schizophrenia are more dominated by the positive symptoms and
others by the negative symptoms, although both kinds of symptoms are typically displayed to
some degree. Over the course of the disease and with age, the positive symptoms lose their
sharpness.
Most patients remain with negative syndrome and defective cognition (defect state), which sets
in, in the early stages of the illness and does not respond well to medication (Edward et al 1999,
Buckley & Stahl, 2007). Around half of the people with schizophrenia display significant
difficulties with memory and other kinds of cognitive functioning (Comer, 2010). The
progressive decline in cognitive functioning is associated with overt behavior that disturbs
thought, affect and perception. Gross cognitive state and sensorium are unaffected for most part
of the disease. However, these patients are socially less sensitive and this social cognition deficit
negatively influences their normal social activities (Kee et al, 2003, Hofer et al, 2007).
Diagnosis of Schizophrenia
Although the clinical description of the schizophrenia patient and the duration of the
schizophrenia symptoms help in diagnosis, one month to six months of the symptomatic state is
needed to assign a diagnosis of schizophrenia by ICD10 (WHO, 1996) or DSM-IV (APA, 1994).
In acute, first-time presentations, patients may need to undergo some investigations to rule out a
possible neuro-pathological basis of the illness. Some common neurological conditions may
present as schizophrenia-like psychosis, albeit rare.
Yoga
Yoga is an ancient Indian art or knowledge which provides the complete essence of the way of
life. Derived from the Sanskrit word yuj, yoga means union of the individual consciousness or
soul with the universal consciousness or spirit. Yoga is not only the physical exercises where
people flex their bodies and breathe in the most complex ways. Rather it is a profound science of
unfolding the infinite potential of the human mind and soul. Most yoga gurus do not consider
yoga as a therapy or intervention but a way of living.
Over the last few decades, researchers have shown an increased interest in tapping yoga’s ability
to deal with mental disorders. In one evaluation of randomized control trials, researchers found
support for yoga’s efficacy as a treatment for a wide variety of psychiatric conditions and
distress, like depression, schizophrenia, eating disorders, ADHD, sleep complaints, and cognitive
impairments (Balasubramaniam et al, 2012).
One of the first modules to test the yoga effect in schizophrenia treatment was created at Swami
Vivekananda Yoga Anusandhana Samsthana (SVYASA). This module included loosening
exercises (Shithileekarana Vyayama); asanas (Suryanamaska, sitting, prone, supine postures);
breathing exercises and relaxation (Shavasana) (Nagendra et al, 2000). Since then the same yoga
package is being used by a number of researchers.
METHODOLOGY
Aim/Objective
a) To review evidence for the efficacy of the yoga therapy in patients who suffer from
schizophrenia.
b) To discuss and interpret studies which are done in this area.
c) To address the barriers that limit the use of yoga by schizophrenia patients.
d) To understand future directions for research that will help in finding the use of yoga in
severe mental disease like schizophrenia.
To fulfil the objectives of this study, relevant research literature was searched. Various sources
such as PubMed/MEDLINE, EBSCO and Google Scholar, were used. The search terms
included “use of yoga in schizophrenia treatment”, “yoga as a treatment for schizophrenia” and
“efficacy of yoga on schizophrenia treatment”. Research on yoga as an add-on treatment for
schizophrenia is scant, so related researches of yoga’s implication in other mental disorder were
also included in study.
REVIEW OF LITERATURE
Studies on yoga as a mode of schizophrenia treatment
Studies done to assess the efficacy of yoga as an add-on treatment in schizophrenia have
generally used randomized controlled trials, where the people in the study are randomly allocated
to one or the other treatment under study. Most studies have usually compared the patients
undergoing the yoga treatment with those undergoing exercises as add-on treatment or the
waitlisted group (getting no add-on treatment). Under the yoga treatment, most exercises include
either asanas and pranayama/breathing patterns but no meditative practices because meditation
has shown to worsen/provoke psychosis in patients with psychosis (Walsh & Roche, 1979).
One of the first researches that scientifically tested a yoga package on chronically ill
schizophrenia patients was undertaken at the Swami Vivekananda Yoga Anusandhana
Samsthana (SVYASA). In this study, institutionalized patients with schizophrenia were able to
learn yoga under supervision, and the yogasana package produced some cognitive benefits in
schizophrenia subjects without causing disturbing side effects (Nagendra et al, 2000).
Patients undergoing yoga treatment versus waitlisted patients
Researchers compared the yoga-treated patients with the waitlisted group (no additional
treatment). Results from this comparison came out in favor of yoga. Researchers found that the
patients in the yoga group unlike the waitlisted group showed improvements in the quality of life
and reduction in the Positive and Negative Syndrome Scale. Also, secondary outcomes like
reduced aggression and improved medical compliance were observed in the patients of the yoga
group (Visceglia & Lewis, 2011). Another study by Paikkatt and colleagues (2015) replicated
these findings. It reported that the patients who received the yogic intervention showed better
rating than those in pharmacotherapy alone on the Positive and Negative Syndrome Scale.
Randomized controlled comparison between exercise and yoga
Evidence shows efficacy of both yoga and exercise in schizophrenia treatment but it is more in
the favor of yoga. For example, Duraiswamy and colleagues (2007) found that the yoga group
had significantly less psychopathology and greater social and occupational functioning and
quality of life than those in the physical exercise group at the end of four months. Similarly,
Varambally and colleagues (2012) demonstrated that the yoga group had significant
improvements in the Positive and Negative Syndrome Scale and the Social and Occupational
Functioning Scale, unlike the exercise and waitlisted groups that had fewer benefits.
Other researchers have found that yoga and aerobic exercises may not differ much in the
magnitude of the change they bring in schizophrenia patients. Hence, people with schizophrenia
and physiotherapists could choose either yoga or aerobic exercise in reducing acute stress and
anxiety taking into account the personal preference of each individual (Vancampfort et al, 2011).
Yoga’s implication on negative symptoms (facial expressions)
As medication has not been proved effective in treating the negative symptoms of schizophrenia,
many researchers emphasize the role of psycho-social therapies like yoga in treating these
symptoms. Among them are Behere et al (2010) who replicated the earlier findings. They found
significant improvement in tackling the positive and negative symptoms and the socio-
occupational functioning of schizophrenia patients undergoing the yoga therapy. Yoga also
improved facial emotion recognition in these patients. Similarly, Jayaram and colleagues (2013)
found yoga to reduce facial emotion recognition deficits. Improvements in social cognition help
schizophrenic patients interact more with the people around them, and this also may reduce their
engaging in delusions and hallucinations. Though evidence for the good yoga effect in treating
the negative symptoms exists, studies are yet to demonstrate whether improvement in social
cognition is accompanied by a demonstrable physiological change in the brain. In this regard,
Jayaram and colleagues (2013) have demonstrated some biological evidence that will be discuss
below.
Biological implications of yoga
Studies on patient groups have demonstrated the association of the low oxytocin level with
impaired performance on social cognition tasks in autism and schizophrenia (Hollander, 2003;
Modahl, 1998; Goldman, 2008). However, the yoga therapy can help increase the oxytocin level
in schizophrenia patients. In this regard, positive evidence is provide by Jayaram and colleagues
(2013) who among other findings reported increase in the plasma oxytocin level in antipsychotic
stabilized schizophrenia patients. This finding is important when seen in the light of the research
done on the important role of oxytocin in processing positive socio-emotional cues, facilitating
interpersonal trust and pro-social interactions in humans (Domes, 2007). It can also modulate
neural responses to recognition of faces and enhance the ability to accurately, discriminate facial
emotions. However, further studies are required to replicate the findings and clarify the potential
neurobiological mechanisms by which the yoga therapy can exert its beneficial effects in
schizophrenia.
Clinical evidence for yoga as an intervention
It is imperative to assess randomized control trials (RCTs) for the efficacy of procedures
undertaken during yoga studies. This assessment helps us validate the study findings.
Balasubramaniam et al (2012, 2013) assessed three randomized control trials — Duraiswamy
(2007), Behere (2011) and Visceglia and Lewis (2011). The quality of RCTs was scored using
the guidelines recommended by the Agency for Healthcare Research and Quality (Wynne, B.
n.d.), with a maximum possible score of 17. The AHRQ ratings depend on the study question,
clearly focused sample, randomization, blinding, interventions, outcomes, statistical analysis,
results and discussions. Balasubramaniam et al (2012, 2013) gave 13 ARHQ rating to the
Duriaswamy study (2007) and 15 each to Behere (2011) and Visceglia and Lewis (2011).
According to the RAND/UCLA Appropriateness method, applied to the above studies, Grade B
evidence supports a potential benefit for yoga as an adjunct to anti-psychotic treatment in chronic
schizophrenia. The Research and Development/University of California at Los Angeles
(RAND/UCLA) Appropriateness Method is used to combine the evidence provided by RCTs
with collective judgment of the experts to yield a statement regarding the appropriateness of
performing a procedure at the level of patient-specific symptoms, medical history, and test
results. This method specifies recommendation categories of A (recommended), B (suggested),
or C (may be considered) for each diagnosis.
Using both AHRQ ratings and the RAND\UCLA method, Balasubramaniam et al (2013) found
yoga as a suitable add-on treatment for most patients of schizophrenia. However, other
researchers have not been able to confirm this assessment.
Another study (Cramer et al, 2013) systematically reviewed and conducted a meta-analysis of
yoga studies to find the effects of yoga on the symptoms of schizophrenia, quality of life,
functioning, and hospitalization in patients with schizophrenia. But, this study found moderate
evidence for short-term effects of yoga on the quality of the patient’s life. It also stated that these
effects could not be distinguished from bias, and safety of the intervention was unclear; so, no
recommendation can be made regarding yoga as a routine intervention for schizophrenia
patients.
DISCUSSION
Need for combining traditional treatment with multimodal care
Many people with schizophrenia continue to have persistent symptoms and relapses, particularly
when they fail to adhere to prescribed medication regimens. This can add to care-givers burden
and lead to their burn-out. Patients who do not recover may find themselves socially isolated and
generally end up in after-care homes. Divorce/separation is a common social complication. This
situation underlines the need for using multimodal care, including psychosocial therapies, as an
adjunct to anti-psychotic medication to help alleviate symptoms and to improve adherence,
functional outcomes, and health-related quality of life (Kern et al, 2009).
The need for treating schizophrenia patients with psychosocial therapies also arises because of
medication’s side effects and its little effect on the negative symptoms. Mostly antipsychotic
drugs that block dopamine receptors are the main treatment for people with schizophrenia
(Tandon et al, 2010). But they have their side-effects. First-generation antipsychotics (such as
chlorpromazine and haloperidol) are effective in the management of psychotic symptoms but
they often lead to the motor side effect tardive dyskinesia. Now we have second-generation
antipsychotics (like aripiprazole, olanzapine, quetiapine and risperidone) that have been
developed for better symptom management. These cause motor side effects less frequently.
Though second-generation antipsychotics are as effective as first-generation anti-psychotics in
managing the positive symptoms, their promise of greater efficacy against the negative and
cognitive symptoms has not been borne out (Van & Kapur, 2009). Additionally, these drugs are
associated with other problems like obesity and dyslipidemia (abnormal amounts of lipid). In
contrast to medication, yoga has been able to show improvements in the negative symptoms
(Jayaram et al, 2013), leading to cognitive benefits (Nagendra et al, 2000) and greater
psychosocial adjustments (Behere et al, 2010).
Yoga and socialization
An additional benefit of yoga treatment is the process of socialization it starts for schizophrenia
patients. Usually, schizophrenia patients are socially less sensitive and their social cognition
deficit negatively influences their functioning (Kee et al, 2003, Hofer et al, 2007). In various
yoga studies, exercises or asanas were done in groups under the supervision of a trainer, which
might have helped patients improve their social cognition leading to reduction in the negative
symptoms. Most yoga studies have been able to find improvement in social functioning and
social cognition (Behere et al, 2010, Duraiswamy et al, 2007, Varambally et al, 2012, Jayaram et
al, 2013). The socialization process, initiated by the yoga therapy, is quite important for
schizophrenia treatment. In future, more studies examining the nature of group therapies using
yoga can help us understand the impact of the socialization process on schizophrenia treatment.
Contrary evidence
Some researchers have found not much support for the yoga therapy as an add-on treatment for
schizophrenia. A recent meta-analysis of five yoga studies found moderate evidence for short-
term effects of yoga on the quality the patient’s life. But researchers speculate that these effects
could not be free from bias, and safety of the intervention was unclear, so no recommendation
can be made regarding yoga as a routine intervention for schizophrenia patients (Cramer et al,
2013). At the same time, as discussed earlier, Balasubramaniam and colleagues (2012, 2013) had
evaluated three yoga studies and found a favorable picture of yoga. Other studies have also been
able to find improvement in social functioning and social cognition and reduction in positive and
negative symptoms (Behere et al, 2010, Duraiswamy et al, 2007, Varambally et al, 2012,
Jayaram et al, 2013). In future, more research is needed to conclusively establish the yoga
efficacy in treating schizophrenia.
Barriers to yoga as an intervention
Yoga also has its pros and cons. As yoga for schizophrenia is a relatively new treatment
methodology, both mental health practitioners and patients are likely to be skeptical about its
effectiveness. Also, there has been some debate on whether people from faiths other than
Hinduism should practice yoga (Miller, 2009). Yoga training, especially for treating persons with
mental illness, needs to be given by a trained yoga therapist (Brown et al, 2005) so as to ensure
that no unintended harm is done to the patient. Though yoga started in India, unfortunately today
we have few yoga instructors who are trained to use yoga as a treatment methodology and are
mostly located in urban places (Ramesh & Hyma, 1981). In the places which are far away from
urban centers, patients may not have access to yoga professionals. This may indeed be a potential
barrier. It must also be acknowledged that the very nature of schizophrenia, where patients
experience negative symptoms, may make it difficult for them to attend the yoga treatment
consistently for the required period of time. Medication and treatment adherence is a big barrier
in treating psychiatric illnesses like schizophrenia.
It is also obvious that adherence to treatment through yoga may pose much greater challenge
than adherence to medication. Medication adherence may require persuasion, advice and
reminders from the health care professional and family. But adherence to the yoga therapy is
much complicated. First, it may require efforts on the behalf of the patient’s family members to
accompany them to yoga sessions. Care-givers may also have their own personal commitments
due to which they may find it difficult to adhere to the yoga treatment regime. Secondly, when
sessions are completed, patients must be persuaded to keep themselves engaged in yoga on their
own. Thirdly, persuasion and reminders are important because the negative deficits may de-
motivate the patient to engage in any activity.
Scant research on treatment with yoga
Research on the effects of yoga is scant. The main reason for the scant research is that most
yogic schools define yoga as a way of life rather than a form of therapy. As the schizophrenia
patient shows deficits in thoughts, emotions and behavior, it is debated whether yogic
interventions can be performed by the patient. For example, meditation and yoga exercises are
often prohibited for schizophrenia patients who are in an active state of psychosis. Also not many
researchers have a complete insight into the concept of yoga. Poor adherence to treatment in
most patients also discourages researchers from recommending yoga to these patients. In the
yoga treatment, dropout rates are tremendous. Baspure, Jagannathan and colleagues (2012) in
their paper have discussed some major barriers to the yoga therapy as an add-on treatment for
schizophrenia in India. These barriers are listed in the following table.
Major barriers to yoga therapy as an add-on treatment for schizophrenia in India
S. No.
Reason for not taking yoga therapy
Percentage of patients
who cited this reason
1. Distance of home from the yoga center
37.2%
2. No one to accompany them for training
11.2%
3. Busy work schedule
9.4%
4. Unwilling to come for one month
4.9%
5. Not willing for yoga therapy
4.0%
6. Personal reasons
1.3%
7. Religious reasons
0.4%
8. No reason
31.6%
Adapted from (Baspure et al, 2012, Barriers to yoga therapy as an add-on treatment for
schizophrenia in India)
As is clear from the above table, logistic factors, such as the need for daily training under
supervision in a specialized center for long periods, are the most important barriers that prevent
schizophrenia patients from receiving the yoga therapy. Alternative models/schedules that are
patient-friendly must be explored to bring the benefit of yoga to patients with schizophrenia.
CONCLUSION
Yoga being a new construct in the field of mental health, we may not have conclusive evidence
of the yoga therapy’s implication in schizophrenia. Nonetheless, the start is promising and
further research may be required to have congruent evidence. Some research has clearly shown
that yoga can be quite effective in patients who have stabilized and have not experienced the
psychotic state for at least three months. The use of yoga as an adjunct treatment to anti-
psychotics with stabilized patients is recommend, as it has no side effects and most research
agrees with added moderate benefits. Benefits of the yoga practice in schizophrenia such as
improvement in negative symptoms is quite impressive, as medication has not been able to
improve the negative symptoms of the disease. Overall, after reviewing and understanding the
research literature, it can be concluded that use of yoga as an adjunct with medication has
contributed to improving the quality of the patient’s life that the medication alone cannot
achieve. More studies in the future will help understand how the ancient practice of yoga helps in
managing and improving mental problems.
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