Yoga for anxiety and depression – a

literature review
Chandra Nanthakumar

Abstract Chandra Nanthakumar is

Purpose – The purpose of this paper is to investigate the effectiveness of classical yoga not only as a based at the Faculty of
complementary therapy but also as a viable option in the management of anxiety and depression. Foundation Studies, HELP
Design/methodology/approach – Papers were retrieved using a combination of databases including University, Kuala Lumpur,
PubMed/MEDLINE and PsycINFO. Malaysia.
Findings – The findings revealed that the practice of yoga as complementary therapy and also as a
stand-alone therapy is effective in managing and reducing anxiety and depression.
Research limitations/implications – All the studies reviewed in this paper were methodologically
limited in terms of sample size, sample heterogeneity, yoga intervention styles, duration of practice and
teaching methods. Further research is needed to address key areas such as how much yoga is needed
per week, duration of each class and specifically the types of asanas and pranayama to practise to bring
about change in the anxiety and depressive states.
Practical implications – This review has provided substantial insight to yoga as a complementary and/
or stand-alone therapy for anxiety and depression which is much needed in this contemporary society.
The Malaysian community especially teenagers and adults, should consider incorporating yoga as part
of their daily routine to experience and reap its benefits. It is suggested that yoga be included as part of
the physical education curriculum in learning institutions and as a recreational activity for staff in public
and private organisations.
Originality/value – The findings of this review provide an avenue for victims to cope with and manage
anxiety and depression through the practice of yoga.
Keywords Depression, Anxiety, Intervention of yoga
Paper type Literature Review

Introduction
The number of people in the Malaysian community suffering from anxiety and depression is
on the rise. According to the statistics of the 2017 National Health and Morbidity Survey, 29
per cent of Malaysians suffer from some form of depression and anxiety disorder compared
to a mere 12 per cent in 2011 (The Star online, 2018). It appears that three in every ten
adults of age 16 years and above are inflicted with some sort of mental health problems,
with depression being the most common one (Wan Mustapha, 2018). The common
diagnoses for anxiety in adults are separation anxiety disorder, social anxiety disorder,
generalised anxiety disorder and specific phobia; whereas depression diagnoses include
major depressive disorder and dysthymic disorder (Garber and Weersing, 2010).
In the recent findings, Malaysian teenagers aged 13-17 years have been diagnosed with
mental health disorders; the statistics being one in five suffering from depression, while two
in five suffering from anxiety (Lee et al., 2018). The Healthy Mind Programme, which was
implemented by the Malaysian Education Ministry in 2017, revealed that out of 284,516
students who participated, approximately 5,100 students received various forms of
Received 27 September 2019
intervention from school counsellors to address the issue. These statistics and figures are Revised 7 January 2020
disconcerting because if they continue to escalate, it will eventually become a serious social Accepted 7 January 2020

DOI 10.1108/JMHTEP-09-2019-0050 VOL. 15 NO. 3 2020, pp. 157-169, © Emerald Publishing Limited, ISSN 1755-6228 j THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE j PAGE 157
 stigma in the country. According to the World Health Organization (2012), one in five people
is expected to experience depression at some time in their life and disclose that this mental
health disorder will become the world’s leading health issue by 2020. Anxiety and
depression interfere with not only interpersonal relationships but also academic
achievement. In some situations, they increase the risk of suicide and other
psychopathology. If these two disorders are not treated, the negative effects may
propagate into adulthood (Weissman et al., 1999).
According to Tiller (2013), patients with depression more often than not show symptoms
of anxiety disorders, while those with anxiety disorders exhibit signs of depression. It is
evident that both disorders tend to co-exist (Garber and Weersing, 2010). Anxiety
appears to be more prevalent during childhood, while depression increases during
adolescence (Woodward and Fergusson, 2001). The symptoms of anxiety disorders
include elevated heart rate, profuse perspiration feelings of queasiness, palpitations and
muscle tension (Bandelow et al., 2017), while the symptoms for depression are feelings
of sadness, outbursts of anger, lethargy, disturbed sleep, unexplained physical
problems such as back pain, and the list goes on. These symptoms are irrefutable as
both diseases are disorders of the biochemical and neurophysiological systems which
have an impact on not only the release of mood-regulating chemicals such as serotonin,
dopamine and noradrenaline, but also on the cortisol and gamma amino-butyric acid
(GABA) levels (Cramer et al., 2013).
As both disorders are affiliated with morbidity and mortality, it is imperative to identify and
treat both the illnesses. Common treatments for depression and anxiety include
psychological therapies such as cognitive behaviour therapy and antidepressants. The
latter augmented with antipsychotics have shown positive results in treating not only
depression but also anxiety (Tiller, 2013). Some of the drug-based treatments for anxiety
have been reported to produce significant reduction in depressive symptoms (Kendall
et al., 2004; Manassis et al., 2002); however, the strategy involved in preventing depression
by treating anxiety successfully warrants further clinical investigation. Benzodiazepine, a
common drug-based medication that enhances the effects of GABA at its receptor, on the
other hand, is only effective in treating anxiety and not depression (Tiller, 2013).
Even though treatments are available, some do not seek treatment because of financial
issues, fear of being stigmatised for visiting a mental health counsellor, ignorance or for no
apparent reason at all. Moreover, there are concerns about the side-effects and compliance
of these drugs (De Manincor et al., 2015).
Complementary and alternative medicine treatments have grown exponentially as it has
become popular among all and sundry in many parts of the world. Mindfulness-based
interventions such as meditation and yoga have become widely used in the therapy of both
psychological and also physical ailments as research has shown a link between these
practices and physical and psychological health changes (Cuijpers et al., 2010). There is
an underlying notion that yoga has the ability to positively affect the biochemical and
neurophysiological systems by regulating the autonomic nervous system and stress
response, thus decreasing the stress, anxiety and depression levels (Salmon et al., 2009).
Moreover, there is evidence that patients prefer these traditional methods of treatment
compared to mainstream approaches such as psychotherapy or psychotropic medications
(Kessler et al., 2001).
The purpose of this review is to look at recent research done on the intervention of
yoga as an adjunct or stand-alone therapy for anxiety and depression, the
effectiveness of this mind–body regime and its implications for the sufferers of the
current society and also the health-care professionals. Recent research here refers to
studies that were conducted in the past five years that used yoga as therapy for
anxiety and depression.

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Yoga as a complementary therapy
Yoga, an ancient mind–body movement practice, originated in India more than 5,000 years
ago. It is also called a meditative movement practice as it involves movement, a meditative
state of mind, breath focus and deep relaxation. Yoga appears to be a form of alternative
medicine (Bridges and Sharma, 2017), and its philosophy is based on the eight limbs
schematised by Maharishi Patanjali, one of the main pillars of classical yoga. These eight
limbs comprise yama (universal ethics), niyama (internal attitudes for personal discipline),
asana (yoga posture), pranayama (expansion of life force), prathyahara (withdrawal of
senses), dharana (contemplation of one’s true nature), dhyana (meditation) and Samadhi
(liberation). While there exist numerous definitions of this ancient practice, yoga has been
commonly interpreted as a practice of uniting the mind, body and breath for purposes of
enhancing or healing the physical, mental and emotional well-being (Satchidananda, 2012;
Stiles, 2013). As yoga is not a religion, anyone irrespective of age, creed or gender can
practise it.
While the practice of yoga is a continuous journey for the genuine seeker who wishes to
experience the universal self within (Stiles, 2013), it can be simplified and practised in
several ways to suit the practitioner. The practice of yoga is so flexible that the practitioner
can use some, if not all, of the limbs. Nevertheless, in a traditional 1-h yoga session, it is not
uncommon to integrate the practices of pranayama, asana, prathyahara, dharana and
dhyana. Having said so, there are many styles of yoga: precision and alignment, asthanga
yoga, flow yoga, asana yoga, gentle yoga and hot yoga are some of the common styles. As
a complementary therapy for physiological and psychological disorders, yoga has been
widely studied in adults (Nanthakumar, 2018). Upon scrutinizing all the eight limbs in yoga,
mindfulness, which is a state of being aware in the present moment, appears to be the
active ingredient to combat anxiety and depression (Knight et al., 2014). Broadly speaking,
yoga focuses on being present in the moment. As the practice of yoga requires mindfulness
even when the practitioner is in motion especially when performing an asana, some of the
preliminary research have advocated that yoga may increase levels of mindfulness in the
practitioner (Brisbon and Lowery, 2011; Conboy et al., 2010). Yoga appears to be a form of
moving meditation. There have been suggestions that the movement aspect of yoga may
be more appealing to the practitioner as it stimulates the cognitive processes related to
mindfulness (Butterfield et al., 2017).
The benefits of yoga are tremendous. As meditative movement involves not only stretching
but also dynamic movements connected to breath, yoga increases physical stamina,
balance, flexibility and induces relaxation.
However, existing research unveils that the benefits of yoga are not limited to only improving
flexibility and promoting weight loss; yoga also enhances emotional and psychosocial health
and an increase in proprioceptive and interoceptive awareness (Woodyard, 2011). There have
been suggestions that yoga, if practised consistently, induces neuroplasticity i.e. changes in
the neural pathways of the brain, thus improving psychological skills (Brown and Gerbarg,
2005). This augurs well for the yoga practitioner as it implies that the brain can be rewired just
like a muscle in the physical body. Research shows that the practice of certain yoga
techniques can bring about positive effects in the practitioner’s mental health because of the
down-regulation of the hypothalamo–pituitary adrenal axis and the sympathetic nervous
system (SNS) (Sengupta, 2012).

Methods
A thorough search was carried out using a combination of databases inclusive of PubMed,
MEDLINE and PsycINFO. Articles that incorporated yoga as an intervention for anxiety and
depression were identified. Keywords used to facilitate the search were “anxiety”,
“depression”, “intervention of yoga”, “stress”, “panic”, “anxious” and “stress disorder”. The

VOL. 15 NO. 3 2020 j THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE j PAGE 159
 search was however restricted to only full text and peer-reviewed articles that were written
in the English language. As one of the main aims of this review is to investigate the impact of
yoga on depression and anxiety in this contemporary society, only articles that were
published in the past five years were included. To streamline the review, only studies that
were conducted with teenagers and/or adults as participants, irrespective of gender or
creed, were included, while those that were conducted with children below the age of 12
were excluded completely. In addition, studies that included teenagers and adults suffering
from multiple diseases and/or mental health issues, such as psychosis, obsessive-
compulsive disorder and health-related aspects of physical fitness were rejected. Studies
that incorporated pregnant and post-partum participants were omitted from this review as it
is not unusual for this category of participants to undergo depression and anxiety during
that period. In terms of the intervention, only studies that integrated classical yoga were
deemed to have met the inclusion criteria.
The practice of yoga comes in variety of styles (hot yoga, vinyasa, hatha yoga, meditation
and pranayama to mention a few), duration and frequency. Nevertheless, only interventions
of yoga that embraced asanas, pranayama, prathyhara, dharana and dhyana were
included in this review even though the duration of each class and frequency of sessions
varied considerably. While this review was not limited to qualitative and quantitative studies,
the instruments used in each study varied quite significantly. Lastly, studies that
incorporated transcendental meditation or mindfulness meditation (or any other forms of
meditation) or pranayama as a stand-alone practice were not included in this review.

Results
In this review, a total of eight studies fulfilled the inclusion criteria. Table I provides a
summary of the author(s), year of publication, place of study, demographics, diagnosis and
instruments used in the respective studies, whereas Table II presents details of the
intervention and findings of each study in a sequential order.
A total of five studies were conducted in the USA, and one in Iran, Australia and Italy,
respectively. It is noteworthy that the minimum age of the participants was 18 years, while
the maximum was 72. As indicated in Table I, participants in all the studies were diagnosed
with either depression, anxiety or both, with the exception of one study where participants
suffered from anxiety, depression and also stress.
The review encompassed studies of several designs; one study had used the pre-test/post-
test, two were quasi-experimental studies and the remaining five were randomised
controlled trials (RCTs). One of the RCTs was a stratified-randomised controlled with
repeated measures (Falsafi, 2016). The sample size incorporated in all the studies was
small, ranging from 18 (Falsafi and Leopard, 2015) to a maximum of 122 (Uebelacker et al.,
2017).
It is evident that the intervention of yoga in all the eight studies was heterogeneous. The
duration of the studies varied quite substantially from four weeks (Shonani et al., 2018) to six
months (Doria et al., 2015). However, all studies assimilated aspects of classical hatha yoga
specifically asana, pranayama, prathyahara, dharana and dhyana. One of the studies had
also included chanting (Doria et al., 2015).
In the study piloted by Kinser et al. (2014), there was a decrease in depression in both
groups, the yoga group (YG) and control group (CG), even though the latter was not
subjected to any form of yoga practice. While both groups underwent pharmacotherapy
during the intervention, the YG experienced not only a distinctive trend in decreased
ruminations, but also found the yoga practice to be a strategy to help cope with negative/ill
thoughts and other symptoms of depression in their daily life. It appears that the guided
meditation (yoga nidra) component in the yoga session may have helped in enhancing self-
regulatory capacities in the participants. Another positive impact of the intervention of yoga

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 Table I Summary of the demographics of the selected population and instrumentation used
Authors (year),
place of study Basic demographics of population Sample population Instruments used

Kinser et al. (2014), Age: 18 and above Short-term study SF; RRS; STAI; PHQ-9;
USA Ethnicity: Majority non-White; (8 weeks) – 27 women PSS
20 out of 27 are divorced/single
Diagnosis: MDD
Doria et al. (2015), Italy Age: 25-64 69 HRSA; HRSD;SCL-90;
Ethnicity: Caucasians Men: 28 ZASI; ZDSI
Diagnosis: DSM-IV mood and/or anxiety Women: 41
disorders
Falsafi and Leopard Age: 18-65 18 BDI; HRSA; SCS; PWS
(2015), USA Ethnicity and gender: Not reported
Diagnosis: Anxiety
De Manincor et al. Age: 18-65 101 DASS-21; K10; SF-12;
(2016), Ethnicity: Not reported but all are English- Men = 20 SPANE; FS; CD-RISC2;
Australia speaking Women = 81 HAQ; CEQ
50 out of 101 are married
Majority are degree holders
Diagnosis: Anxiety and depression
Falsafi (2016), Age: min 18 years 90 (men and women) BDI; HAM-A
USA Ethnicity: Not reported YG: 30
All are undergraduate students CG: NR
Diagnosis: Depression and anxiety MIG: NR
Prathikanti et al. (2017), Mean age: 43.4 years (range: 22-72) 38 MMSE; BDI; GSES; RSES
USA Ethnicity: Not reported but from a metropolitan YG: 20
US population CG: 18
Diagnosis: Severe depression
Uebelacker et al. Mean age: 46.5 years (SD 612.16) 122 (men and women) QIDS; PHQ-9; SF-20
(2017), Ethnicity: Majority Whites or Caucasians YG = 63
USA (84.4%); Blacks (3.3%); and others (12.3%). CG = 59
83.5% have college education
Diagnosis: Major depression
Shonani et al. (2018), Age: 33.5 6 6.5 years 52 women DASS-21
Iran Ethnicity: Iranians
34 out of 52 are married
Majority: Diploma/degree holders
Diagnosis: Depression, anxiety and stress
Notes: BDI: Beck Depression Inventory; CD-RISC2: Connor–Davidson Resilience Scale; CG: control group; CEQ: Credibility-Expectancy
Questionnaire; DASS-21: Depression Anxiety Stress Scale-21; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, fourth
edition; FS: Flourishing Scale; HAM-A: Hamilton Anxiety Rating Scale; HRSA: Hamilton Rating Scale for Anxiety; GSES: General Self-
Efficacy Scale; HRSD: Hamilton Rating Scale for Depression; HAQ: Health Activities Questionnaire; K10: Kessler Psychological Distress
Scale; MDD: Major depressive disorder; MIG: Mindfulness Intervention Group; MMSE: Folstein Mini Mental Status Exam; NR: not
reported; PHQ-9: Patient Health Questionnaire; PSS: Perceived Stress Scale; PWS: Perceived Wellness Survey; QIDS: Quick Inventory of
Depression Symptomatology; RRS: Ruminative Responses Scale; RSES: Rosenberg Self-Esteem Scale; SPANE: Scale of Positive and
Negative Experience; SCL-90: Symptom Checklist-90; SCS: Self-compassion Scale; SF-12: Short Form Health Survey Version; SF-20:
Short-form Survey; SKY: Sudarshan Kriya yoga; SPANE: Scale of Positive and Negative Experience; STAI: State Trait Anxiety Inventory;
YG: yoga group; ZASI: Zung Self-Rating Anxiety Scale Inventory; ZDSI: Zung Self-Rating Depression Scale Inventory

in this study is that participants from the YG acknowledged that the practice of yoga had
heightened their confidence and that it had become an internal motivator for continued
participation.
Similarly, participants in the study of Doria et al. (2015) experienced positive effects of
Sudharshan Kirya yoga (SKY). The fact that there was hardly a difference in the scores
between the two groups (one group did SKY with pharmacotherapy and one group did
SKY without pharmacotherapy) indicates that SKY may be effective as an adjunct
therapy for patients undergoing medical treatment and it may also be effective as a
stand-alone therapy. The study had also incorporated chanting in the yoga session.

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 Table II Summary of the intervention and findings of the selected studies
Authors (year) Description of intervention Findings

Kinser et al. (2014) RCT YG experienced multiple benefits of yoga

YG: 75 min of hatha yoga (asanas, breathing including a boost of confidence
techniques, relaxation and guided meditation) Gained new skills to be used in daily life to
per week over eight weeks manage depression and stress
Daily home practice (DVD and handouts
provided)
CG: Health education activities (lectures, videos
and discussions)
Both groups continued with prescribed
medication and maintained their lifestyle
activities
Doria et al. (2015) Pre-test/post-test A reduction in anxiety and depression levels in
Group 1: Medication þ SKY treatment þ self- both groups
help group weekly No significant differences in scores between
Group 2: SKY treatment þ self-help group both groups
weekly but no medication six months prior to
study
Intervention: 10 sessions of 2 h SKY in 2 weeks
followed by weekly SKY for 6 months (asanas,
pranayama, chanting, prathyhara and dharana)
Falsafi and Leopard Quasi-experimental (repeated measures with Significant decrease (p < 0.05) in depressive
(2015) one group) symptoms
Intervention: 90 min yoga per week for 8 weeks
(asanas, pranayama and mindfulness practice)
De Manincor et al. RCT A significant reduction in depression and
(2016) YG: A 6-week yoga program; 30 min of vini yoga anxiety scores
practice (asanas, pranayama, relaxation, YG showed greater reduction compared to CG
mindfulness and meditation) for 4.8 days per
week þ TAU
CG: TAU – yoga was given after waitlist period
Falsafi (2016) RCT (stratified-randomised controlled repeated YG and MIG showed significant reduction in
measures) depression, stress and anxiety compared to CG
YG: 8 weeks hatha yoga; 75 min session once a (p < 0.01); no significant change in CG
week; and 20 min daily home practice No difference between YG and MIG, but self-
CG: No yoga compassion scores only significant in MIG
MIG: Mindfulness practice
Prathikanti et al. (2017) RCT (stratified-randomised controlled) YG showed a significant decrease in depression
YG: A 8-week yoga program (asana, compared to CG (p = 0.034)
pranayama, dharana and prathyahara); 90 min YG more likely to achieve remission
per session, two sessions a week; props used; YG requested for more sessions per week and
and TAU also permission to attend yoga history workshop
CG: 90 min of yoga history workshop twice a
week for 8 weeks and TAU
No medication for both groups
Uebelacker et al. (2017) RCT (stratified-randomised controlled) Insignificant difference between YG and CG
YG: A 10-week yoga program (asana, YG demonstrated lower levels of depressive
pranayama, dharana, dhyana and prathyahara); symptoms, better social and role functioning
80 min per session; one or two sessions per and general health perceptions when compared
week; and TAU to CG
CG: A 10-week healthy-living workshop; 60 min
per session; one or two sessions per week; and
TAU
Shonani et al. (2018) Quasi-experimental (pre/post-test) A significant, decrease in depression, stress
YG: 60-70 min hatha yoga, 3 times a week for and anxiety in the YG (p < 0.001)
4 weeks (12 sessions in total)
Notes: CG: control group; MIG: mindfulness intervention group; RCT: randomised controlled trial; TAU: treatment as usual; YG: yoga
group

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Chanting is known to heal the physical, emotional, mental and spiritual body. It is
beneficial to the practitioner as it provides the drifting mind with a focal point. Albeit the
chanting was brief in this study, previous research has shown that chanting has the
potential to bring about deactivation in the amygdala, parahippocampal and
hippocampal brain regions (Kalyani et al., 2011).
Besides, it also stimulates the auricular branches of the vagal nerves creating vibrations at
cellular level. It is the vibrations created during chanting that are of utmost importance. The
vibrations create neuro-linguistic effects which induce calmness in the body and mind. It is
believed that the sounds of the mantra have the ability to mask the negative voices in the
brain. When deleterious thoughts are eliminated, the mind will have room for positive
reflections.
Participants in the study of Falsafi and Leopard (2015) who underwent eight weeks of
yoga intervention were in favour of this meditative practice as findings showed a
significant reduction in depressive symptoms. In another study which was a stratified-
RCT among college students in the USA, Falsafi (2016) found that yoga and mindfulness
practice were equally effective in reducing not only depression and anxiety, but also
stress. However, the self-compassion scores were only significant in the mindfulness
intervention group. This is probably because of the fact that the mindfulness practices,
which are self-regulated practices that focus on training attention and awareness (which
is similar to dharana in yoga), have helped bring the mental processes under greater
voluntary control.
In the Australian study among a subsyndromal population, a six-week yoga program was
found to reduce the depressive and anxiety symptoms effectively in the YG (De Manincor
et al., 2016). As both groups, the YG and the CG, were on pharmacotherapy during the
study, it is evident that the yoga intervention has positively impacted the depressive
participants in the YG. The findings also reveal that there was a reduction in psychological
distress and negative thoughts, improvement in mental well-being and increase in resilience
among the yoga participants. It is noteworthy that during the study, some of the yoga
participants took it upon themselves to decrease their medication dosage and frequency of
visiting the counsellor. The reasons for these actions are inconclusive and definitely warrant
further investigation.
In another RCT among a community suffering from depression in San Francisco (Prathikanti
et al., 2017), the findings reveal that participants who did yoga for eight weeks showed a
greater decrease in depressive symptoms when compared to the CG who only attended
yoga history workshops for the same duration. The Beck Depression Inventory (BDI) score
for the YG was much lower compared to the CG (p value = 0.034). What was even more
promising is that in this study, the participants in the YG requested for not only more
practical yoga sessions per week, but also permission to attend the yoga history sessions.
This clearly indicates how concerned the participants were in doing yoga for the benefit of
their own mind–body health.
On the other hand, the study of Uebelacker et al. (2017) did not show significant differences
between the YG and CG even though there was a reduction in depressive symptoms in the
YG. Also, there was evidence of better social and role functioning and health perceptions in
the YG. This could be because of the relaxation techniques incorporated in the yoga
session which not only reduce the sympathetic activity, but also balance the autonomic
nervous system responses.
The Iranian study on 52 women, however, demonstrated a positive impact of yoga as a
stand-alone therapy on mental health disorders (Shonani et al., 2018). Even though it
was reported that all participants in the study were free from medication for mental
disorders, it is not clear if they were totally free from any form of therapy for the
depression and anxiety they were suffering from. Nevertheless, there was a significant

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 reduction in anxiety, depression and also stress levels (p = 0.001) in the participants
who did 12 sessions of yoga over 4 weeks.

Discussion
The main aim of this review was to look at recent studies (2014-2018) that had used yoga
intervention as an adjunct therapy for depression and anxiety. The review also aimed at
studying the efficacy of yoga as a meditative movement practice in reducing symptoms of
the said mental health disorders.
It is evident that in the past five years, researchers have shown interest in examining the
effectiveness of yoga in the management of anxiety and depression. As per this review,
most studies, if not all, exhibited appreciable outcomes; the intervention of yoga with
(De Manincor et al., 2016; Falsafi and Leopard, 2015; Falsafi, 2016; Kinser et al., 2014;
Uebelacker et al., 2017) or without (Doria et al., 2015; Prathikanti et al., 2017; Shonani et al.,
2018) regular pharmacotherapy appeared effective in decreasing the symptoms of
depression and anxiety, and also stress in one study (Shonani et al., 2018).
Research in mind–body practices suggests that the practice of yoga advocates changes in
the neural pathways of the brain, thus bringing about positive effects on the brain activity
(Brown and Gerbarg, 2005; Desai et al., 2015). It is thought that yoga, if practised
consistently, activates the alpha, beta and theta brainwaves, and these have been linked to
improvement in not only memory, but also mood and anxiety.
All studies reviewed in this article incorporated the fundamental limbs of Patanjali yoga,
that is, asanas, pranayama, prathyahara, dharana and dhyana. According to Nyer et al.
(2019), the first two limbs in yoga (yamas and niyamas) are therapeutic in nature as
both are code of ethics that work at intrapersonal (yama) and interpersonal (niyama)
levels. Yama includes practices such as ahimsa (non-violence), satya (non-stealing),
asteya (non-lying), brahmacharya (non-excessiveness) and aparigraha (non-
greediness), while niyama encompasses traits such as saucha (cleanliness), santosha
(contentment), tapas (sacrifice), swadyaya (self-study) and Ishwara pranidana
(surrendering to the almighty).
While none of the studies in this review highlighted the inclusion of these two limbs as
part of their yoga interventions, the yamas and niyamas may have been embedded into
the yoga session informally. In my coaching and therapy sessions, the students are
prompted to practise ahimsa especially when performing a challenging asana during
class. They are constantly reminded to refrain from forcing themselves into the pose and
eventually hurting themselves. While they are holding a pose (being in the pose), they are
then reminded to be aware of the joy and wonderful feelings that they are experiencing at
that moment; this is an example of santosha. Similarly, all the other yamas and niyamas
are directly or indirectly demonstrated and elucidated during class at the Malaysian
Yoga Academy.
The instructors conducting the yoga sessions in the eight studies (Table I) may have
incorporated the first two limbs but did not see a need to highlight the details in the
methodology. The details of the yoga intervention, if had been reported for each and
every study, would definitely provide invaluable information not only to the researcher
and the reader, but also to the participant who may want to explore the philosophical
roots of yoga.
It is noteworthy that despite the heterogeneity in the sample population, small sample size,
varied duration of the intervention and style of yoga taught, most studies in this review
demonstrated positive results in reducing the scores in depression and anxiety. Woodyard
(2011) and Sherman (2012) reported that the practice of asanas, pranayama, dharana and

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dhyana in a yoga class can help calm the mind, hence lower the anxiety levels. These are
precisely the effects observed in the studies reviewed in this article.
Nevertheless, another factor to consider is the time (duration) required for participants to
master the yoga asanas, especially those with limited flexibility and breathing techniques
(pranayama). The time taken for the psycho-physiological factors mediating specific mood
benefits of yoga to develop and exert a measurable effect in the participant is equally
important and should not be neglected. Even pharmacological interventions for depression
and anxiety more often than not produce a delay of approximately four weeks before
exerting significant mood effects over placebo. It has been reported that it may take up to
12 weeks to achieve full anti-depression effects with medication (Uher et al., 2011), so time
is definitely a plausible factor for consideration in yoga intervention.
A five day per week practice of yoga of approximately 30 min per session has been
reported to suffice for the general population (De Manincor et al., 2016); however, at the
Malaysian Yoga Academy where the author teaches yoga, students, regardless of their
mental health conditions, are encouraged to practise at least 45 min of yoga daily. This is
merely a measure to maintain good health and keep diseases at bay as research has
shown that a great number of individuals suffer from some form of anxiety and/or mood
disorder at some point in their life (Ferreira-Vorkapic et al., 2018). The duration of a yoga
session, frequency and the duration for each and every component of yoga to be practiced
definitely warrants further investigation.
The selection of asanas in a yoga intervention does play a part in improving one’s mental
health. Prathikanti et al. (2017) found that specific asanas such as ardhakati chakrasana
(half waist wheel pose), ardha chakrasana (half wheel pose), bhujangsana (cobra pose),
dhanurasana (bow pose), setu bandhasana (bridge pose), sarvangasana (shoulder
stand) and matsyasana (fish pose) were doable and effectual in helping the participants
manage with depression and anxiety. Upon observing all the asanas closely, it can be
deduced that most of them, if not all, are heart/chest openers. In the process of
expanding the chest and rib cage to oxygenate the lungs efficiently, heart/chest openers
may also be good for releasing grief, anger and frustration, which are all symptoms of
depression.
In all the studies reviewed, pranayama was also key in the yoga intervention. In Patanjali’s
yoga sutras (Satchidananda, 2012), pranayama is defined as the regulation of breath or
control of prana to stop inhalation and exhalation, which is achievable after securing
steadiness in the posture. Studies have shown that pranayama bring about change in brain
activity; it also lowers the oxidative stress; hence, the mind can be controlled through the
control of prana.
The deep relaxation component is essential in any yoga session; most studies, if not all,
reported incorporating shavasana (dead corpse pose) followed by deep relaxation (yoga
nidra) in the yoga intervention. Qualitatively, yoga nidra is not the same as shavasana; it is a
form of relaxation which is much more intense than ordinary sleep (Khushbu et al., 2011).
During the performance of certain asanas in yoga, the SNS is activated causing an increase
in the blood pressure and heart rate. To lower the SNS stress response, participants are
then lulled into a deep relaxation mode, i.e. yoga nidra. At this time, the parasympathetic
function is increased, thus, causing the blood pressure, heart rate and breath rate to be
normalised. Research has shown that the reduction of these parameters is linked to the
reduction in anxiety levels (Brown and Gerbarg, 2005).
Dharana and dhyana were also key components of yoga in almost all the studies reviewed.
According to the Yoga Sutras of Patanjali (Satchidananda, 2012), dharana, which helps the
practitioner focus and be aware on an object, and dhyana, which helps the practitioner go
deeper into holding an unbroken flow of awareness, bring about peace and bliss. In the
process of practising dharana and dhyana, accumulated stresses are released bringing

VOL. 15 NO. 3 2020 j THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE j PAGE 165
 about a state of general well-being (Sharma, 2015). Participants from one study described
yoga as an internal stimulus for continued participation (Kinser et al., 2014). In another
study, participants requested for extra sessions of yoga after experiencing the immediate
benefits (Prathikanti et al., 2017). This probably explains why participants in the studies
reviewed found yoga to be beneficial in dealing with their emotions and general well-being
that they continued with the practice upon completion of the study; in one study
(De Manincor et al., 2016), some participants, upon witnessing an improvement in their
mental health, took it upon themselves to decrease the dosage of their medication and
reduce visits to the counsellor.
Nevertheless, in most, if not all, of the studies reviewed in this paper, there were limitations.
A few of the studies were predominantly a female sample (Kinser et al., 2014; Shonani et al.,
2018). Although research has shown that there is a greater tendency for women to suffer
from depression compared to men (Kessler et al., 2003), the sample size in these studies
was notably disproportionately represented. Secondly, most of the studies were limited by
the insignificant sample population and heterogeneity. Because of the absence of CGs in
certain studies, it was not easy to establish whether the results obtained were due
intervention of yoga or something else. Even though RCTs are intervention research of high
standards, the studies investigated in this review were challenged because of inappropriate
randomisation, large variation in yoga styles in terms of the postures, breathing and
meditative techniques used, dissimilar duration and frequency of yoga sessions and
incongruence in teaching methods.
Despite the limitations, it appears that participants who have benefitted from these yoga
sessions may now have an extra tool at hand to manage their anxiety and depression. No
adverse effects were reported in any of the studies, thus making it a safe practice.

Conclusion
Subject to the limitations outlined above, this literature review has demonstrated the efficacy
of yoga as a complementary therapy and also as a stand-alone therapy in the management
of anxiety and depression. The intervention of yoga encompassing asanas, pranayama,
prathyahara, dharana, dhyana and chanting appears to provide sustained benefits to
the individual. The chest opener type of asanas, pranayama and shavasana (dead corpse
pose) provide downtime for the neural path of the brain activity and balances
the sympathetic and the parasympathetic functions of the autonomous system. The
meditative state in the practice of yoga activates the self-regulatory system, thus increasing
positive emotions, reducing ruminations, depression and/or anxiety levels and improving
quality of life.
That being said, the intervention of yoga in all the studies reviewed has been challenged by
numerous factors, including study design, insignificant sample size, large variation in yoga
styles, duration of sessions, frequency of sessions per week and for the whole study,
components of the yoga intervention, home practice and follow-up.
While this warrants more large-scale studies with improved quality, learning institutions and
various organisations in Malaysia need to consider incorporating this mind–body regime as
part of the physical education curriculum or as a recreational activity for staff, respectively.
Highlighting the effects of yoga on anxiety and depression is important as it provides an
option to existing pharmacotherapy and/or psychotherapy approaches to treat these two
mental health disorders. Victims of anxiety and/or depression may incorporate yoga into
their daily schedule while on medication; alternatively, they may start practising yoga
consistently in the absence of pharmacotherapy. Finally, those who opt to go on medication
for their depressive and/or anxiety conditions may have to endure the adverse effects of the
drugs.

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Further reading
Gard, T., Taquet, M., Dixit, R., Holzel, B.K., Dickerson, B.C. and Lazar, S.W. (2015), “Greater widespread
functional connectivity of the caudate in older adults who practice kripalu yoga and vipassana meditation
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Corresponding author
Chandra Nanthakumar can be contacted at: [email protected]

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