Exercise, Yoga, and Meditation for Depressive and Anxiety Disorders (original) (raw)

Many persons with clinical anxiety or depression turn to nonpharmacologic and non-conventional interventions, including exercise, meditation, tai chi, qigong, and yoga. There is increasing scientific interest in the potential effectiveness of these interventions for the treatment of anxiety and depression, especially for mild to moderate levels of disorder severity. These interventions have appeal because their use seems unlikely to have severe adverse effects and they are easily available. This article summarizes the available evidence on the effectiveness of these approaches for treating clinical anxiety and depression.

Depression Treatment

EXERCISE

There is extensive literature on a wide range of exercise interventions for depression. Several systematic reviews1–3 and a synthesis of systematic reviews4 focused on exercise interventions for persons with clinically diagnosed depression. Another systematic review focused on exercise in older persons with depression.5 All reviews reported that exercise produces meaningful reductions in depression symptoms that are comparable with cognitive behavior therapy (CBT),1–5 and two studies6,7 found it was at least comparable with sertraline (Zoloft). A Cochrane meta-analysis is the largest review of this type, analyzing 25 randomized controlled trials (RCTs).2 It found that exercise produced marked clinically positive effects. It also noted important methodologic weaknesses in the majority of studies. Analysis of the only three methodologically rigorous trials in the review found smaller, nonsignificant positive effects. However, even this analysis was flawed because it mixed trials with differing levels of exercise and duration.

Two RCTs demonstrated that high-energy (i.e., weekly expenditure of at least 17.5 kcal per kg) aerobic exercise or resistance training produces greater reductions of depression symptoms than low-energy (i.e., weekly expenditure of 7 kcal per kg or less) exercise.8,9 Two small RCTs showed that the positive effects of exercise were the same in group and individual settings,9 and that supervised exercise in the clinic produced the same positive effect as unsupervised exercise in the home.10 Although exercise reduces depression in adults, it has not been tested in homogenous diagnostic groups of adolescents. The few studies on clinically treated patients 11 to 19 years of age have not shown statistically significant positive effects.11 Table 1 outlines the overall effectiveness evidence of exercise for depression treatment.1–5,8–11

YOGA

Yoga has been used to address a variety of health problems, including mental health. A systematic evidence review12 and two subsequent studies13,14 showed that yoga is an effective intervention for depression treatment. Findings were based on a small number of trials with significant methodologic weaknesses, including short duration of treatment, small numbers of participants, and variability in interventions and severity of depression. Most participants were young and relatively fit, raising questions about generalizability. Adverse effect reporting was limited, but no safety issues or adverse effects were identified. Table 2 outlines the overall effectiveness evidence of yoga for depression treatment.13–19

TAI CHI AND QIGONG

Tai chi and qigong originated in China and are internal martial arts consisting of slow, deliberate movements, relaxed breathing, and deep mental focus. The limited amount of literature suggests that tai chi and qigong are effective in reducing depression symptoms, at least in the short term.20,21 The positive effects may be partially related to the social support of practicing in a group format. One study focused on qigong for anxiety and depression treatment in a clinical population of older adults with chronic medical illnesses.20 Ratings on the Geriatric Depression Scale showed significant improvement in the qigong group during the active practice period, but improvements faded within a month of completion. Another trial compared older patients who had depression with wait-list control participants, and concluded that the positive effects of tai chi were mediated by the social support in the group lessons and practices.21

MEDITATION

Mindfulness-based stress reduction (MBSR) is a standardized intervention that aims to increase mindfulness through meditation by systematically focusing attention on each part of the body in sequence, practicing gentle Hatha yoga, and participating in group discussion. MBSR has been studied in participants with a variety of medical problems, and has been shown to reduce stress, depression, fatigue, pain, and binge eating.22 However, a recent review of 15 studies on the effects of MBSR found no clear positive effects on depression symptoms in patients with comorbid medical disorders or in patients with mood disorders alone.23 Mindful meditation is also combined with CBT to treat depression and prevent relapse.24 Although there is little evidence for the effectiveness of MBSR or meditation as an alternative treatment of depression, there are some indications that mindfulness may complement CBT in changing thinking patterns associated with depression.25,26 Adding mindfulness training as a means of preventing relapse is effective in patients whose depression has recurred three or more times.25,26

Anxiety Treatment

EXERCISE

Little research has been conducted on the effects of exercise on anxiety disorders.27 However, the effects of short- and long-term physical activity on anxiety symptoms in healthy participants or those with medical problems have been studied.28 Two studies have examined the effect of exercise on anxiety sensitivity, which is thought to trigger panic attacks in susceptible persons.29,30

A study of 46 outpatient participants with panic disorder compared the effectiveness of a 10-week duration of treatment with aerobic exercise, clomipramine (Anafranil), or placebo.31 The exercise and clomipramine groups had statistically significant reductions in panic symptoms compared with the placebo group, although clomipramine treatment was most effective and faster acting overall.

YOGA

A systematic review of the effects of yoga on anxiety treatment identified five trials of persons with clinically diagnosed anxiety disorders.32 However, these were small, methodologically flawed controlled trials with variability in conditions treated and interventions used (Table 333–37 ). The limited results were consistently positive, including substantial improvement in one trial37 of participants with obsessive-compulsive disorder and another trial38 of patients with mixed anxiety and depression. Safety and contraindications were not addressed and high attrition rates may reflect the effect of motivation on patient compliance.

TAI CHI AND QIGONG

There is essentially no evidence for the effectiveness of tai chi or qigong in treating anxiety disorders. The limited data supporting tai chi and qigong in the treatment of depression suggest that there is no basis for recommending these approaches for anxiety disorders.20,21

MEDITATION

A 2006 Cochrane review of meditation approaches for treating anxiety disorders found only two RCTS.39 One compared transcendental meditation with electromyographic biofeedback and with relaxation therapy. The other compared mindful meditation with a form of yoga. Drop-out rates were high in both studies, and neither was of high quality. Studies of meditation have not allowed any conclusions to be drawn about its effectiveness in the treatment of anxiety disorders.

Contraindications

Exercise programs must be tailored to individual needs, taking into consideration each patient's age and health status. If a patient has a known cardiovascular problem or is at an increased risk, exercise testing should be selectively performed at the discretion of the physician. Physical practices of yoga can range from gentle to vigorous. Physicians should be clear about what types of yogic practices would be appropriate with regard to each patient's physical limitations, and patients should seek out appropriately trained instructors. When an appropriate method, intensity, and duration of activity are chosen, yoga and exercise can be made accessible to almost anyone. The National Center for Complementary and Alternative Medicine can serve as a resource for physicians and patients with information on yoga (http://nccam.nih.gov/health/yoga/introduction.htm), meditation (http://nccam.nih.gov/health/meditation/overview.htm), and tai chi (http://nccam.nih.gov/health/taichi/).

Bottom Line

Meditation, tai chi, and qigong do not have clear indications of effectiveness in the treatment of depression or anxiety. Exercise and yoga, on the other hand, have multiple studies demonstrating their effectiveness, which is sometimes comparable with mainstream treatments and consistently superior to placebo. Exercise and yoga are tested as alternatives to standard pharmacologic and psychotherapeutic treatment approaches, and show limited but positive data as complementary treatments in combination with these standard treatment approaches.