Jan E. Patterson, MD, MS

In my education as an infectious diseases physician, I was trained to give antibiotics when needed. However, after more than 30 years of practicing and teaching medicine, I've observed that though our traditional medical approach of offering a pill is often helpful for treating a physical condition, it is not adequate for helping the mind and spirit cope with difficulties in life, such as stress, anxiety, depression, and grief. I found myself wanting tools other than pharmaceuticals to help patients who struggled with these emotions. This led me to train in integrative medicine, and I learned simple yet effective measures that can empower a patient to help themselves by integrating self-care with conventional medical care.

I recently reviewed the evidence for using four self-care practices — breathwork, movement, nutrition, and spirit — to enhance health and wellness. It can be challenging for patients to incorporate these modalities without some guidance. Because yoga combines these four self-care practices to support wellness, recommending or "prescribing" yoga for patients can be a helpful step.

As a meditation movement, yoga can be a key strategy for coping with the stresses of life. There is evidence for significant health benefits from yoga, and research continues to show rewards from this practice.

Not only can yoga relieve stress but it supports healthy sleep and emotional health. In particular, it can help people manage anxiety or depressive symptoms that may accompany difficult life situations. Yoga combined with breathwork has been shown to increase levels of gamma-aminobutyric acid, a calming neurotransmitter, in the thalamus, a part of the brain that influences mood. A deficit of this neurotransmitter is thought to contribute to mood disorders such as depression.

Yoga is now one of the first-line recommendations as a noninvasive treatment for acute, subacute, and chronic low back pain by the American College of Physicians. There is also evidence for relief of headaches and osteoarthritis. Yoga has also been shown to improve health-related fitness in those with type 2 diabetes. For those who have overweight, yoga may help people lose pounds. In addition, three sessions of yoga per week was shown to significantly reduce blood pressure in those with hypertension, especially when combined with breathing techniques and meditation.

Yoga offers many benefits for women's health, including management of premenstrual syndrome, relief of depression and anxiety in pregnancy and the prenatal period, and reversal of osteoporosis.

Yoga practice entails the elements of breathwork, movement, nutrition, and spirit, which help to relieve stress, anxiety, depression, and grief. This is a discussion of these self-care elements of yoga and its effect on these difficulties in life.

Breath. The intentional breathing practice in yoga, pranayama, has been shown to improve lung function, decrease the amount of oxygen consumption used during work, increase the relaxation response, and decrease the stress response. The characteristics of the intentional breathing in yoga that induce these responses include nasal breathing with a slower breath response from the diaphragm as well as even, rhythmic, deep breaths. Deep, slow, regular, abdominal breathing can change the stress response to the relaxation response. Routine use of yogic breathing also contributes to lower blood pressure, enhanced metabolism of glucose, improved immunity, and better cognition.

Movement. Though other typical physical aerobic (vigorous or moderate) exercise such as running, cycling, swimming, and walking have health benefits, yoga movements appear to be equal or superior in many aspects. In yoga, as commonly practiced in Europe and the United States, breathing techniques (pranayama), meditation (dhyana), and physical postures (asanas) are used. Thus, yoga can be more than just a set of movements; it can be a contemplative, meditative practice. Depending on the style of practice, yoga can be low intensity, as is often practiced, or aerobic. Low-intensity movements tend to lower cortisol (the body's stress hormone) and increase relaxation, whereas typical aerobic exercise stimulates the stress response in the short-term. The resistance movements using body weight can be considered weight training, which is recommended at least twice weekly.

The shift away from the stress response improves the immune system; many inverted yoga poses increase lymphatic drainage, and lymphocytes are a key part of the immune response. Yoga can also decrease the body's inflammatory response, as measured by inflammatory markers. The inverted poses also have unique effects on the heart and lungs. Though they initially increase volume to the heart, when practiced regularly, these poses increase the body's detection of pressure in the blood vessels, and ultimately reduce heart rate and blood pressure. Yoga is also less likely to cause injury than is typical vigorous exercise.

A review comparing yoga and exercise showed that yoga was equal to or better than typical physical exercise in relieving some symptoms of diabetes, multiple sclerosis, menopause, and kidney disease. Both yoga and typical exercise improved glucose metabolism. In a group with chronic illness, yoga was better than gentle range-of-motion exercises in reduction of pain, fatigue, and insomnia. In summary, yoga has been assessed as being equal or superior to typical exercise in virtually all outcomes measured except for cardiovascular fitness. And in those who do more aerobic forms of yoga, cardiovascular fitness can improve as well.

Nutrition. How does yoga affect eating behavior and body weight? Yoga burns calories and increases muscle tone, but many types, such as hatha yoga, are considered a low-intensity exercise. More vigorous types of yoga such as the Sun Salutation involving vinyasas increase aerobic activity and can increase cardiovascular fitness. However, in addition to burning calories, the stress reduction and improved sleep that occur with yoga can decrease the production of cortisol. This is beneficial since cortisol leads to increased abdominal fat and cravings for foods with high sugar content. Thus, yoga can encourage healthier eating habits.

Yoga has also been shown to increase body awareness and mindful eating, which can be beneficial for those with high caloric intake due to disordered eating habits. Studies have directly measured weight loss and related outcomes resulting from yoga. Some are small and have methodologic issues, but the effect of yoga is promising.

Spirit. Mindfulness and meditation are a part of experiencing spirituality. In a study comparing groups of young people using mindfulness and meditation, those using yoga with mindfulness and meditation, those using yoga alone, and a control (no intervention) group, the groups using yoga with mindfulness and meditation and yoga alone gained the most physiologic benefits. Each of the intervention groups but not the control group showed decreased anxiety. This may suggest that the practice of yoga alone has some meditative component and/or that yoga is the critical intervention.

A review of mind-body practices for cancer-related symptoms management showed that yoga was better than control (nonintervention) groups for improving quality of life and reducing stress, anxiety, and depression. Of note, other movement meditations studied showed that qigong was effective in decreasing fatigue related to cancer and tai chi was effective in reducing anxiety.

Another review evaluated yoga's role in healing psychological trauma and showed that yoga participants increased their sense of self-compassion, felt more centered, improved their coping skills, had a better mind-body relationship, and improved their relationships with others. All of these reflect spiritual progress. This suggests that yoga could play an important role in trauma recovery.

All of this evidence demonstrates the beneficial effects of elements of yoga, but is there further evidence that yoga has a direct effect on coping with difficulties in life, including stress, anxiety, depression, and grief?

Stress. A review of the effects of yoga on stress among healthy adults showed that most types of yoga decrease stress. A daily practice of an integrated yoga program taught during a single session was effective for lowering stress in school employees. In addition to the benefits of yoga on blood pressure, yoga is considered an important stress reduction technique in the nonpharmaceutical management of hypertension.

Anxiety and depression. Many studies have looked at the effect of yoga on mental health conditions. One review of multiple studies of yoga for anxiety showed that hatha yoga significantly lessened anxiety, and effectiveness was correlated with the number of hours practiced. Another study showed that yoga reduced anxiety, with an integrated yoga protocol showing the most reduction. A systematic review and analysis of high-quality studies for the effect of yoga on anxiety, showed that yoga was an effective intervention for those with elevated levels of anxiety, but evidence was not conclusive for the benefits of yoga for formally diagnosed anxiety conditions, such as generalized anxiety disorder.

A more recent detailed review suggested that yoga was a beneficial adjunct to other psychological treatments, such as cognitive-behavioral therapy for both anxiety and depression. Anxiety and depression are more common in cancer patients, and recent research evaluating this group showed that integrating yoga as a part of cancer treatment reduced anxiety and depression.

College students face multiple stressful situations as they transition from high school to college. A study of the effect of mindfulness training or yoga on a group of college students who had anxiety, depression, or both showed that yoga as well as mindfulness were successful in decreasing the anxiety and/or depression.

A 12-week program of breathwork and Iyengar yoga reduced symptoms in those with major depressive disorder, whether the classes were done twice weekly or three times weekly.

Finally, a systematic review of studies evaluating the effects of yoga on depressive symptoms in people with mental disorders showed a reduction in depressive symptoms; greater reductions were associated with more frequent yoga sessions.

Grief. Bereavement is a major psychological stressor and can result in stress, anxiety, as well as depression. Self-care is important when grieving because bereaved individuals have a higher risk for cardiovascular disease, cancer, high blood pressure, and death in the months after a loss. Evidence suggests that physical activity can improve the physical and psychological health of the bereaved. Philbin has studied integrative yoga therapy in a group of bereaved persons and found that it showed significant improvement in vitality, positive states, and a trend toward improved satisfaction with life. Latif has suggested four yoga poses especially for grief.

In summary, the practices of breathwork, movement, nutrition, and spirit are elements of yoga that can help manage stress, anxiety, depression, and grief. Yoga practice offers a way to combine these critical approaches for improving physical and mental health and coping with the difficulties in life.

In summary, the practices of breathwork, movement, nutrition, and spirit are all elements of yoga that can help manage stress, anxiety, depression, and grief. Not only is yoga a practical recommendation for patients, physicians may want to prescribe it for themselves, too.

Jan E. Patterson, MD, MS, MACP, is trained and board-certified in Integrative Medicine and is the medical director of the Integrative Medicine program at University Health, San Antonio. She is a professor of medicine/infectious diseases and Associate Dean of Quality & Lifelong Learning at the Joe R. and Teresa Lozano Long School of Medicine, UT Health San Antonio.

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