Sat Bir S. Khalsa, PhD, on Yoga for Generalized Anxiety Disorder
Kundalini yoga can help to reduce symptoms of generalized anxiety disorder (GAD) but is not as effective as cognitive behavioral therapy (CBT) in this population, according to the results of a recent study.
The researchers conducted a randomized, 3-arm, controlled, single-blind clinical trial involving 226 patients with GAD assigned to twelve 120-minute session of kundalini yoga, CBT, or stress education with 20 minutes of daily homework.
Overall, response rates were higher in the yoga and CBT group than in the stress education group, but noninferiority testing showed that yoga was not as effective as CBT.
Consultant360 spoke with study author Sat Bir S. Khalsa, PhD, assistant professor of medicine at Harvard Medical School and Brigham and Women's Hospital in Boston, Massachusetts, and the director of yoga research at Yoga Alliance headquartered in Arlington, Virginia, for more information.
Consultant360: Can you tell us more about why it was important to examine the effectiveness of alternative interventions like yoga for patients with generalized anxiety disorder (GAD)?
Sat Bir S. Khalsa, Ph.D.: In general, the more treatment options available for any mental health condition the better. The major conventional treatments for GAD include pharmacotherapy and CBT. Both of these treatments are not 100% effective for GAD, pharmacotherapy has negative side effects, and CBT is not widely available or accessible. Furthermore, many GAD patients may be reluctant to see a therapist for these conventional treatments. With surveys showing that yoga is now practiced by over 15% of U.S. adults, it is becoming well known as an attractive and healthful practice that is widely available. Yoga includes techniques including physical postures/exercises, breath regulation and meditation, each of which alone have been shown in some studies to have some efficacy for anxiety. These techniques are typically not included in, or addressed by, conventional therapies. Yoga therefore has the potential for addressing additional characteristics important for GAD treatment beyond those of conventional treatments, and this may be particularly relevant for GAD patients who have not derived benefit from conventional treatments.
C360: Why was Kundalini yoga specifically chosen, and were any other forms of yoga or meditative exercise considered?
SBSK: Early on, Dr. Hofmann and myself had collaborated on a few studies evaluating yoga as an intervention for music performance anxiety. Subsequently, we were involved in research evaluations with two clinical psychologists who were instructors of this particular style of kundalini yoga, Kundalini Yoga as taught by Yogi Bhajan (KY-YB). They both worked with GAD patients and were applying KY-YB practices as a sole or complementary GAD treatment with positive benefit. These studies have been published (see: https://meridian.allenpress.com/ijyt/article-pdf/28/1/97/1737752/2018-00003.pdf and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4224639/pdf/nihms-587964.pdf) and were used as pilot data for the grant application from the National Center for Complementary and Integrative Health. Furthermore, I have been practicing KY-YB for over 45 years, I am a certified teacher, and I am also the research director for the Kundalini Research Institute, which supports research KY-YB. I therefore was in an ideal position to serve as an expert in coordinating the KY-YB intervention and working with and overseeing the yoga teachers delivering it to the patients in the study. Importantly, KY-YB has a history of research showing its efficacy for psychological conditions including insomnia, cognitive decline and obsessive compulsive disorder. As a comprehensive traditional style of yoga that incorporates not only postures and exercises but also breath regulation, deep relaxation and meditation practices it is more likely to be effective as a therapeutic intervention as compared with some yoga styles that are predominantly posture-based. There is evidence that all four of these components (exercise, breath regulation, relaxation, meditation) alone have efficacy for anxiety, and so it is logical to conclude that a traditional multicomponent yoga style that incorporates all of them is more likely to be efficacious. It is certainly possible that other styles/schools of yoga may also be beneficial for GAD and our edited medical textbook The Principles and Practice of Yoga in Health Care (see: https://www.handspringpublishing.com/product/principles-practice-yoga-health-care/) is a testament to the potential role of yoga for the treatment of many conditions.
C360: Overall, you found that while Kundalini yoga was an effective treatment option for GAD, it was not as effective as CBT. Was this the expected result, or was this surprising?
SBSK: CBT has for decades been the gold standard treatment for GAD and has been refined and optimized over time. In order to evaluate the efficacy of a new treatment it is useful to compare that treatment with the gold standard, and also with a control comparison treatment that is believed to have minimal efficacy such as stress education. It is not really that surprising that our yoga intervention was not quite as efficacious as CBT. This is really the first rigorous test of a yoga intervention for GAD and, on the positive side, the efficacy of this first trial is very encouraging for yoga. All new therapies undergo evolution and refinement, and it is quite possible that with continued research, refinement and optimization, yoga interventions will show greater efficacy over what we determined in this study.
C360: What effect do you think that your research could have on treatment practices for GAD, and what knowledge gaps still exist in this area?
SBSK: Our study has demonstrated that yoga has an appreciable degree of efficacy for GAD, and could lead to therapists beginning to recommend yoga practice as a complementary therapy. Given that yoga has multiple benefits both physically and psychologically, and negligible negative side effects, this is a win-win situation for GAD treatment. However, much research remains to be done to further evaluate yoga for GAD. One issue is determining the optimal “dose” of yoga as to how often to practice (frequency in sessions per week), the optimal practice session duration (e.g. how many minutes), and the overall duration (number of weeks). Another issue is optimizing the content as to which components of yoga to emphasize amongst postures/exercises, breath regulation, and meditation, and which specific types of postures/exercises, breath regulation techniques and meditations to practice. It would also be helpful to study what types of GAD patients are most receptive to, and would receive most benefit from, yoga practices. Finally, it would be useful to determine whether yoga could demonstrate benefit for GAD patients who are treatment resistant, i.e. those who have not benefited from CBT and pharmacotherapy.
Simon NM, Hofmann SG, Khalsa SBS, et al. Efficacy of yoga vs cognitive behavioral therapy vs stress education for the treatment of generalized anxiety disorder. JAMA Psychiatry. 2021;78(1):13-20. doi:10.1001/jamapsychiatry.2020.2496