Archives of Psychiatric Nursing 33 (2019) 371–376

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

East meets west in psychiatry: Yoga as an adjunct therapy for management T

of anxiety
Nadia K. Bukara, , Luann M. Eberhardtb, Judy Davidsonc
⁎

a
Senior Behavioral Health Intensive Outpatient Program (SBH IOP), UC San Diego Medical Center, 410 Dickinson Street, San Diego, CA 92103, United States of America
b
Neurobehavioral Medicine Unit (NBMU), UC San Diego Medical Center, 415 Dickinson Street, San Diego, CA 92103, United States of America
c
Nursing Education, Development, and Research, UC San Diego Medical Center, 200 West Arbor Drive, San Diego, CA 92103, United States of America

ABSTRACT

Purpose: Provide yoga for coping and symptom management in a locked, adult inpatient psychiatric unit.
Design: Hatha yoga was offered to inpatients with mood disorders and/or psychosis 3 times per week in this evidence-based practice change project. Impact on sleep
was examined using recorded sleep hours. Anxiety symptoms were assessed using 6 of the 7 symptoms recorded on the Generalized Anxiety Disorders (GAD) 7.
Sustainability of benefits was examined. A self-assessment was conducted at discharge to determine acquisition of new coping skills.
Results: No difference in sleep hours or interruptions was noted. A statistically significant increase in the total anxiety scores (z = −1.9815, p = 0.02385) and
sustainability of benefits (z = −2.0894, p = 0.03662) between the first and second yoga class were observed. A positive change from baseline in sustainability of
symptoms for “less anxiety” (k = 0.108) and “more relaxed” (k = 0.083) was found. There was a significant increase in utilization of yoga (p = 0.0015) and
meditation (p = 0.013) as coping mechanisms at discharge.
Conclusions: Adults in an acute inpatient psychiatric unit who participated in yoga practice identified yoga and meditation as newly-acquired coping mechanisms and
reported significant improvement in anxiety symptoms with sustained benefits ranging from half day to full day.

Introduction improvements in perceived quality of life in both psychological and

physical domains. They also pointed out that all elements of the Posi-
Yoga is a multicomponent practice that unifies the mind and body tive and Negative Syndrome Scale (PANSS) improved significantly
by linking breath to movement, remaining present in the moment while (positive syndrome, negative syndrome, general psychopathology, an-
holding postures of variable difficulty. Although the mechanism of the ergia, activation, paranoid/belligerence, depression), except for
effects of yoga in the body are not well understood, the use of yoga thought disorder. This improvement in symptomatology aligns with the
among young adults have doubled between 2002 and 2012 (Clarke, results demonstrated by Duraiswamy, Thirthalli, Nagendra, and
Black, Stussman, Barnes, & Nahin, 2015) while publications regarding Gangadhar (2007) and Muckherjee, Kumar, Singh, and Singh (2008),
the practice of yoga have tripled over the last decade (Jeter, Slutsky, particularly when yoga is combined with traditional western medicine.
Singh, & Khalsa, 2015). This uptake in the practice of yoga could in- Patients with schizophrenia showed improvements in quality of life,
dicate increasing recognition of yoga as an invaluable holistic inter- social and occupational functioning, discipline, adaptive functioning
vention in clinical practice encompassing the mind, body, and spirit, and symptoms. These studies underscore the importance of utilizing
particularly in the field of mental health. A meta-analysis published by antipsychotic medication when indicated, along with other non-
Cramer, Lauche, Langhorst, and Dobos (2013), reported low to mod- pharmacological interventions like yoga. Yoga has also been shown to
erate level evidence of short-term decreases in anxiety and depression improve physical fitness and energy level with any form of asana
severity in this patient population. A systematic review performed by practice (Shapiro & Cline, 2004). This is especially important in Psy-
Jeter et al. (2015) identified consistently positive results for reduction chiatry since patients with mental illness are at a significantly higher
in depression when yoga was used for any medical condition. Ad- risk of physical complications when psychotropic medications are
ditionally, there has been growing evidence of the effects of yoga coupled with unhealthy lifestyle behaviors (Stanton & Happell, 2014).
among patients with psychosis. Visceglia and Lewis (2011) conducted The introduction of yoga may decrease this risk. Additionally, yoga has
an 8-week yoga therapy program wherein yoga was shown to have an been demonstrated to work as a stress reduction agent during inpatient
effect in alleviating positive and negative symptoms of schizophrenia, psychiatric admissions (Lavey et al., 2005), improve social functioning
paranoia, activation, depression, general psychopathology, and (Varambally et al., 2012), modulate immune responses during stress

⁎
Corresponding author.
E-mail addresses: [email protected] (N.K. Bukar), [email protected] (L.M. Eberhardt), [email protected] (J. Davidson).

https://doi.org/10.1016/j.apnu.2019.04.007
Received 6 November 2018; Accepted 18 April 2019
0883-9417/ © 2019 Elsevier Inc. All rights reserved.
N.K. Bukar, et al. Archives of Psychiatric Nursing 33 (2019) 371–376

(Arora & Bhattacharjee, 2008), reduce unnecessary procedures and the Table 2
number of hospital visits (Sober, 2000), making it a cost-effective Sustainability questionnaire.
complementary therapy in psychiatric treatment (Shapiro et al., 2007). After yoga… N/A No change 1 Hr Half day Full day
The aim of this evidence-based practice (EBP) change project was to
investigate the effects of yoga, as a holistic approach in symptom I feel less nervous, anxious, or on
edge
management, in addition to standard treatments currently offered in an
I am less worried
acute, locked, 18-bed adult inpatient psychiatric unit. I am more relaxed
I am less restless I can sit still
Materials and methods I feel less annoyed/irritable
I am less afraid something awful
might happen
This project was excused from IRB oversight as a low risk evidence-
based practice (EBP) change by the Institutional Review Board (#
160674QI). This project was determined EBP and not research because questionnaire was assessed 24 h after the yoga class to determine if
of the evidence supporting this practice in this patient population. benefits lasted for 1 h, half a day, or full day (Table 2). Additional
When implementing best practices tested by others, outcomes are option for “not applicable/no change” was included.
measured to assure that research translates into the unique culture of
the organization as planned. Monitoring change is important for sus-
Coping skills assessment
tainability of the new practice. (Fineout-Overholt, Williamson,
Gallagher-Ford, Melnyk, & Stillwell, 2011; Melnyk & Fineout-Overholt,
A coping skills assessment tool developed by these authors was
2011). Measures of success for this EBP change project were: sleep
administered at the time of discharge to ascertain if yoga and medita-
hours, sleep interruptions, symptoms of anxiety, duration of benefit,
tion were identified as newly-acquired coping skills in managing their
dose response, and addition of yoga as a coping strategy. In this three-
symptoms (Table 3). A distractor (colonoscopy) was included to ob-
month feasibility pilot project, patients voluntarily participated in a
jectively eliminate patients who were too ill to answer the questions
one-hour class, offered three times per week. The classes were taught by
correctly.
two registered nurses and a volunteer certified yoga instructor.

Results
Sleep hours and number of sleep interruptions

A total of 55 patients who attended at least one yoga class had the
Yoga's effect on sleep was investigated by calculating the hours of
following diagnoses: mood disorders (n = 6), mood with psychotic
sleep obtained from the observation rounds conducted every 15 min,
features (n = 20), and psychosis (n = 29). Thirty of these patients at-
identifying where a patient is and what the patient is doing at a given
tended at least 2 classes: mood (n = 3), mood with psychotic features
point in time within a 24-h period. The sum of the sleep hours recorded
(n = 10), and psychosis (n = 17).
on observation rounds was calculated, defining day time sleep as 0800
to 2100 and night time sleep as 2125 to 0745. The number of sleep
interruptions during night time sleep were also counted to identify Sleep hours and number of sleep interruptions
patients who were getting good quality sleep. The total hours of sleep
and interruptions among participants and nonparticipants, before and Yoga had no effect on sleep (Fig. 1). There was no statistically sig-
after yoga practice were compared. nificant difference of paired comparisons in sleep hours (two tailed
p = 0.4246, t = 0.8118, df = 25) or sleep interruptions (two-tailed
p = 0.1078, t = 1.6679, df = 25) among participants (n = 26) before
Symptoms of anxiety
and after yoga practice. In addition, no statistically significant differ-
ence was found looking at the same parameters, sleep hours (two tailed
The anxiety questionnaire (Table 1) is a “yes/no” retrospective self-
p = 0.3536, t = 0.9354, df = 57) and sleep interruptions (two tailed
assessment administered after yoga practice, asking patients about 6
p = 0.5647, t = 0.5793, df = 57), when comparing participants
validated symptoms of anxiety: whether they felt less anxious, less
(n = 26) and nonparticipants (n = 33). The sleep hours were normal-
worried, more relaxed, less restless, less irritable, and less afraid
ized and analyzed using unpaired t-test. The same process was utilized
(Spitzer, Kroenke, Williams, & Löwe, 2006). This assessment tool was
in comparing sleep interruptions between the participants and non-
constructed to have a total possible score of 6, reflecting improvement
participants.
of all 6 symptoms. Though higher scores are better, any score over 0
There was a slight increase in sleep hours (x̄ = 8.2 SD = 1.5 to x̄ =
reflects symptom improvement. Data analysis was performed on results
8.5 SD = 1.6) and a slight decrease in the number of sleep interruptions
obtained from patients who attended at least two classes during their
(x̄ = 1.7 SD = 1.8 to x̄ = 1.0 SD = 0.7) before and after yoga class but
hospital stay (average length of stay is 10.5 days).
the same trend was seen among the nonparticipants (sleep hours: x̄ =
8.0 SD = 2.2 to x̄ = 8.6 SD = 1.5 and sleep interruptions: x̄ = 1.7
Sustainability questionnaire

Table 3
The sustainability of the benefits initially reported on the anxiety
Coping skills assessment tool.

Table 1 What helps you relax? Admission Discharge

Anxiety questionnaire.
Medication
After yoga… N/A Yes No Deep breathing/meditation
Exercise
I feel less nervous, anxious, or on edge Talking to others
I am less worried Listening to music
I am more relaxed Reading
I am less restless I can sit still Being alone in room
I feel less annoyed/irritable Colonoscopy
I am less afraid something awful might happen Yoga

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N.K. Bukar, et al. Archives of Psychiatric Nursing 33 (2019) 371–376

8.5 8.6 Fig. 1. Sleep hours and number of sleep interruptions before
8.2 8.0 and after yoga class.
There was no statistically significant difference of paired
comparisons in sleep hours (two tailed p = 0.4246,
t = 0.8118, df = 25) or sleep interruptions (two-tailed
p = 0.1078, t = 1.6679, df = 25) among participants
(n = 26) before and after yoga practice using Paired and
Unpaired t-test.
1.7 1.7
1.0 1.3

Participants NonParticipants Participants NonParticipants

Hours No. of Interruptions

Before After

SD = 1.3 to x̄ =1.3 SD = 1). after the first yoga class for the symptoms “less anxiety,” “less worry,”
and “more relaxed” (Fig. 4). Just under 50% reported feeling “less
Anxiety assessment after first yoga class afraid” (43%) and feeling “less irritable” (49%). Several patients in-
itially reported “no benefit” on the anxiety questionnaire but later re-
Patients who participated in the yoga and meditation class reported ported benefit ranging from 1 h to full day on the sustainability ques-
improvement in symptoms of anxiety after their first yoga class tionnaire.
(n = 55). The symptoms listed on questionnaire are shown on the x-axis
(Fig. 2). The average % of participants reporting benefit was calculated
Reported sustainability: first class vs second class
accordingly and ranged from 47% of patients feeling “less afraid” to
76% feeling “more relaxed.”
The reported sustainability of the first class versus the second class
were also compared and analyzed using Cohen's Kappa (n = 30). The y
Total anxiety score: first yoga class versus second yoga class
axis represents the first class while the x axis represents the second class
(Fig. 5). In this assessment, a poor agreement is desired as it reflects a
The anxiety assessments of patients who participated in 2 yoga
change from baseline. “Poor agreement” for symptoms of “less anxiety”
classes were compared
(κ = 0.029, 95% CI -0.183 to 0.242) and “more relaxed” (κ = 0.083,
(n = 30), assigning “1” to symptoms where a patient answered
95% CI-0.129 to 0.294) were obtained indicating a positive statistically
“yes” and “0” for “no change or improvement.” The sum of the symp-
significant change between the classes. Additionally, when comparing
toms (maximum score of 6) was calculated and averaged. The total
the percent of participants reporting half day to full day benefit on the
anxiety score of the first and second yoga class were then compared and
first class (x̄ = 39.45% SD = 11.59%) versus the second class (x̄ =
analyzed using Wilcoxon Signed Rank Test (Fig. 3). The results showed
53.4% SD = 12.55%), a significant increase on the second class was
a statistically significant increase (z = −1.9815, two tailed p = 0.02)
noted (z = −2.0894, two tailed p = 0.03662) when the Wilcoxon
in the total anxiety score on their second class (x̄ = 4.41 SD = 2.04)
Signed Rank Test was used (Fig. 3).
compared to their first class (x̄ = 3.52 SD = 2.47). Sixty-five percent of
patients reported a decrease in anxiety symptoms after their first class
versus 91% after their second class. Coping skills assessment

Sustainability of benefits reported There was a significant increase in the utilization of yoga
(p = 0.0001) and meditation (p = 0.0002) at discharge versus prior to
Half of participants (n = 52) reported half day to full day benefit admission (n = 40) using McNemar's test of proportions (Fig. 6).
% of Participants Reporting Benefit

76%

64% 65%
62%
55%
47%

< anxious < worry > relaxed < restless < irritable < afraid

Fig. 2. Anxiety assessment after first class

Patients who participated in the yoga and meditation class reported improvement in anxiety after their 1st yoga class (n = 55).

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N.K. Bukar, et al. Archives of Psychiatric Nursing 33 (2019) 371–376

% of Participants Reporting
Sustained Benefit (x)
Total Anxiety Score (x)
53.3

39.4 1st class

4.41
2nd class
3.52

Fig. 3. Total anxiety score and sustainability: first yoga class versus second yoga class
There is a statistically significant increase (z = −1.9815, two tailed p = 0.02) in the total anxiety score (n = 30) on their 2nd class (x = 4.41 SD = 2.04) compared
to their 1st class (x = 3.52 SD = 2.47) using Wilcoxon Signed Rank Test.

< anxious < worry > relaxed <restless < irritable < afraid
% of Participants Reporting Benefit

17% 19% 17%

15% 15% No or N/A

50% 13% 1 hour
13%
17%
Half Day
21% 12%
17% Full Day
12%

40% 44%
37%
33% 33% 31%

Fig. 4. Sustainability of reported benefits 24-hr after yoga class

Half of participants (n = 52) reported half day to full day benefit after the 1st yoga class for the symptoms less anxiety, less worry, and more relaxed.

< Anxiety > Relaxed

2nd class 2nd class
0 1hr 12hr 24hr 0 1hr 12hr 24hr
5 5

0 0
4 4
1st class

1st class

1hr 3 1hr 3

2 2
12hr 12hr

1 1
24hr 24hr

0 0

Fig. 5. Sustainability of reported benefits:

first class versus second class
“Poor agreement” for symptoms of “less anxiety” (κ = 0.029, 95% confidence interval from −0.183 to 0.242) and “more relaxed”(κ = 0.083, 95% confidence
interval from −0.129 to 0.294) were obtained indicating a positive change between the classes (n = 30) using Cohen's Kappa.

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N.K. Bukar, et al. Archives of Psychiatric Nursing 33 (2019) 371–376

was realized during the data analysis when the patients in question had
Yoga 5% 83% already been discharged. Moreover, the sustainability questionnaire
Admission was initially designed with the option of “no change” and “N/A” used
interchangeably on some of the questionnaires. In hindsight, these
Discharge
Meditation 30% 70% options should have been differentiated. In effect, some patients
checked “no change” for symptoms they did not have and would have
0% 20% 40% 60% 80% 100% otherwise been “N/A,” rendering the data less robust. As with the an-
% of Participants xiety symptom questionnaire, the sustainability questionnaire would
benefit from validation.
Fig. 6. Utilization of yoga and meditation as coping skills on admission versus Patients identified yoga and meditation as coping skills they
prior to discharge planned to utilize after discharge. Some patients did not participate
Significant increase in the utilization of yoga (p = 0.0001) and meditation
during their hospitalization yet identified both as means to help
(p = 0.0002) at discharge versus prior to admission (n = 40) using McNemar's
manage their symptoms. The exact reason for this is unknown, but it is
test of proportions.
possible that these patients were positively influenced by the feedback
from their peers.
Discussion Among this project's other limitations, the sample size was small,
and because the project was quality improvement and not research, the
The aim of this evidence-based change project was to provide pa- intervention was not randomized. Therefore, there is no active or in-
tients a holistic approach to symptom management and to investigate active control. Since providing patient assessment questionnaires both
the effects of yoga and meditation as an adjunct therapy to management before and after yoga practice was deemed to be too cumbersome for
of anxiety among patients with varying diagnoses in a locked, inpatient this patient population, a retrospective pre-post assessment was utilized
psychiatric setting. The benefits of yoga in decreasing anxiety have (Archibald, Trumpower, & MacDonald, 2014).
been widely reported (Vancampfort et al., 2011) but no reports to date Patient Perspectives:
have looked at the sustainability of benefits received, or the utilization XXX [Blinded for review] serves many of the indigent population
of yoga and meditation as newly-acquired coping skills in an inpatient who otherwise would not have gained exposure to yoga and meditation.
setting. Their hospitalization provided a unique opportunity to explore the ef-
There was no improvement in night time sleep hours and inter- fects of yoga and meditation in alleviating their symptoms. Patients and
ruptions among participants versus nonparticipants, before and after their families have expressed positive feedback of the many benefits of
yoga class. This lack of improvement in sleep, although disappointing, yoga as part of their treatment. To follow we provide clinical vignettes
is not surprising in an inpatient psychiatric setting. Rooms have mul- regarding the response to implementing yoga into standard of practice.
tiple occupants, each with varying degrees of function. This could ex- A patient who had a history of assaultive behavior eagerly attended
plain, in part, why there was no noticeable difference in sleep hours and yoga, celebrating with hands up in the air every time he attended.
interruption when comparing participants to nonparticipants. Another patient constantly tormented by the voices he heard in his head
Furthermore, established protocols dictate the utilization of flash lights described yoga as “the only time I get one hour of peace.” On one oc-
to perform nightly safety checks, which could disrupt sleep. It is also casion, this patient had a notable increase in heart rate (110) and blood
important to note that some patients have standing orders for sleep pressure (148/97) secondary to agitation prior to attending yoga. His
medication while others do not. In this pragmatic EBP change project, vital signs were taken again after the yoga class and returned to base-
no treatment was changed because yoga was initiated. Consequently, line without the use of anxiolytics. Yoga was the only group activity he
sleep medications would have been administered if ordered routinely. attended. A middle-aged woman diagnosed with Bipolar Disorder was
Lastly, the inter-rater variability in recording sleep hours is a limitation admitted to the hospital restless, elevated, and pressured claimed she
of this project. These above-mentioned limitations could explain the felt “less manic” every time she attended yoga. A mother, whose son
inconsistency with what has been previously reported in a national suffered his first psychotic break and was introduced to yoga in the unit,
survey where 55% of yoga users self-reported improved sleep saw yoga as an opportunity to reconnect with her son: “perhaps this is
(Stussman, Black, Barnes, Clarke, & Nahin, 2015). something we can do together as a family.” These are only a few of the
Adults in an acute inpatient psychiatric unit who participated in stories of those whose lives were changed by the introduction of yoga.
yoga practice showed significant reduction in symptoms of anxiety after As further testimony to the success of the project, patients requested a
their first yoga class, ranging from 47% of patients feeling “less afraid” referral list to locate yoga groups following discharge. A referral list for
to 76% feeling “more relaxed” when looking at the 6 different symp- yoga practice in the general community was then prepared to be used in
toms. These results are consistent with published work on the allevia- discharge planning and aftercare.
tion of anxiety among yoga practitioners (Anderson, Mammen, Paul,
Pletch, & Pulia, 2017). A significant increase in the total anxiety score Conclusion
was noted when comparing the first and the second class, suggesting a
dose response to yoga in improving anxiety symptoms. The same trend The results of this project show that yoga is an effective, adjunct
is observed in sustainability of half day to full day benefits reported on therapy for management of anxiety, and benefits the patient as a whole.
the first class (39%) versus second class (54%), again suggesting dose It is an essential tool that staff can offer, and patients can utilize in an
response to yoga. inpatient psychiatric setting in symptom management. Given the posi-
Forty-seven out of 121 questionnaires were initially filled out with tive program results, a contracted yoga instructor was hired at a salary
“no benefit” on the anxiety questionnaire, but patients later reported of $50/h to continue providing yoga as standard of practice at XXX
benefit ranging from 1 h to full day on the sustainability questionnaire. [Blinded for Review] NeuroBehavioral Medicine Unit, making yoga a
It is unclear if these patients did not initially notice a change and later cost-effective, holistic treatment modality that improves physical and
recognized a sustained benefit in anxiety symptoms over the course of mental well-being. The practice was also implemented at the Senior
the previous day. It is also possible that this discrepancy is simply due Behavioral Health Unit inpatient and outpatient due to the success of
to patients' disorganization and could have been avoided if patients this project. It was not feasible to continue using on-duty nurses to
were interviewed instead of filling out questionnaires independently. perform the yoga classes after the conclusion of this EBP project. Yoga
However, this would incur a trade-off where the patients may be less as an adjunct to traditional medical therapy was well-received, cost
forthcoming in providing authentic feedback. This interesting variance effective, and effective in reducing symptoms of anxiety in psychiatric

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inpatients suffering from mood disorder and/or psychosis. This EBP Complementary Medicine, 23(6), 494–495. https://doi.org/10.1089/acm.2017.0046.
project resulted in a sustainable change that is now a standard treat- Archibald, D., Trumpower, D., & MacDonald, C. J. (2014). Validation of the inter-
professional collaborative competency attainment survey (ICCAS). Journal of
ment offered in the inpatient psychiatric unit. Interprofessional Care, 28(6), 553–558. https://doi.org/10.3109/13561820.2014.
917407.
Implications for research and practice Arora, S., & Bhattacharjee, J. (2008). Modulation of immune responses in stress by yoga.
International Journal of Yoga, 1(2), 45–55. https://doi.org/10.4103/0973-6131.
43541.
Mental illness requires a holistic approach and nursing at its core is Clarke, T. C., Black, L. I., Stussman, B. J., Barnes, P. M., & Nahin, R. L. (2015). Trends in
holistic (Cohen & Boni, 2018), taking into consideration the wholeness the use of complementary health approaches among adults: United States,
2002–2012. National Health Statistics Reports, 79, 1–16.
of the individual when providing care to attain higher degrees of sa- Cohen, B. S., & Boni, R. (2018). Holistic nursing simulation. Journal of Holistic Nursing, 36,
tisfaction and improve patient outcomes (Cowling, 2018). As demon- 68–78.
strated in this project, a holistic modality such as yoga is an effective Cowling, W. R., III (2018). Where is holistic nursing? Journal of Holistic Nursing, 36, 4–5.
Cramer, H., Lauche, R., Langhorst, J., & Dobos, G. (2013). Yoga for depression: A sys-
adjunct therapy to traditional treatment in inpatient psychiatry, ad-
tematic review and meta-analysis. Depression Anxiety, 30, 1068–1083. http://doi:10.
dressing the physical, psychological, and spiritual needs of a patient to 1002/da.22166.
provide optimal care. Furthermore, yoga may appeal to patients who Duraiswamy, G., Thirthalli, J., Nagendra, H. R., & Gangadhar, B. N. (2007). Yoga therapy
are reluctant to take medications, have incomplete success with psy- as an add-on treatment in the Management of Patients with schizophrenia – A ran-
domized controlled trial. Acta Psychiatrica Scandinavia, 116, 226–232. https://doi.
chopharmacologic interventions (Pitkanen, Hatonen, Kuosmanen, & org/10.1111/j.1600-0447.2007.01032.x.
Valimaki, 2009), and have refractory forms of schizophrenia (Pantelis & Fineout-Overholt, E., Williamson, K. M., Gallagher-Ford, L., Melnyk, B. M., & Stillwell, S.
Lambert, 2003). As such yoga may fill a gap to adequately manage B. (2011). Following the evidence: Planning for sustainable change. The American
Journal of Nursing, 111(1), 54–60. https://doi.org/10.1097/01.NAJ.0000393062.
symptoms without resorting to polypharmacy. With the addition of 83761.c0.
yoga, which includes meditative practice, health care providers can Jeter, P. E., Slutsky, J., Singh, N., & Khalsa, S. B. S. (2015). Yoga as a therapeutic in-
encourage patients to utilize non-pharmacological ways of coping to tervention: A bibliometric analysis of published research studies from 1967 to 2013.
Journal of Alternative and Complementary Medicine, 21(10), 586–592. http://doi.
reduce stress and promote an overall sense of well-being. Though not org/https://doi.org/10.1089/acm.2015.0057.
measured in this project, the consistent practice of yoga could lead to Lavey, R., Sherman, T., Mueser, K. T., Osborne, D. D., Currier, M., & Wolfe, R. (2005). The
decreasing the utilization of benzodiazepines as the primary interven- effects of yoga on mood in psychiatric inpatients. Psychiatric Rehabilitation Journal,
28(4), 399–402. https://doi.org/10.2975/28.2005.399.402.
tion for anxiety and agitation, which could in turn, inadvertently dis- Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing &
courage benzodiazepene-seeking behaviors among patients who are healthcare: A guide to best practice. Lippincott Williams & Wilkins.
already at risk for addiction. Future research is needed to explore this Muckherjee, P., Kumar, D., Singh, P. K., & Singh, A. R. (2008). Effect of yoga on social-
adaptive functioning of psychiatric patients. Indian Journal of Clinical Psychology, 35,
hypothesis.
74–81.
Yoga benefits the person as a whole. Regular yoga practice improves Pantelis, C., & Lambert, T. J. (2003). Managing patients with “treatment resistant”
physical fitness, facilitates socialization, enhances balance, flexibility, schizophrenia. Medical Journal of Australia, 178(9 suppl), S62–S66.
and strength, helps regulate emotions, influences mood, and potentially Pitkanen, A., Hatonen, H., Kuosmanen, L., & Valimaki, M. (2009). Individual quality of
life of people with severe mental disorders. Journal of Psychiatric and Mental Health
improves personal relationships. Future studies that look at the rate of Nursing, 16, 3–9. https://doi.org/10.1111/j.1365-2850.2008.01308.x.
recidivism with continued practice among patients who identified yoga Shapiro, D., & Cline, K. (2004). Mood changes associated with Iyengar yoga practices: A
as a coping skill for symptom management needs exploration. pilot study. International Journal of Yoga Therapy, 14, 35–44.
Shapiro, D., Cook, I. A., Davydov, D. M., Ottaviani, C., Leuchter, A. F., & Abrams, M.
Additionally, a larger sample and a project design including adminis- (2007). Yoga as a complementary treatment of depression: Effects of traits and moods
tering sleep medications, only if needed, would be required to address on treatment outcome. Evidence-Based Complementary and Alternative Medicine :
whether yoga improved sleep or reduced reliance on sleep aids. It eCAM, 4(4), 493–502. http://doi.org/https://doi.org/10.1093/ecam/nel114.
Sober, D. S. (2000). The cost effectiveness of mind-body medicine interventions. Progress
would be worthwhile to investigate if nightly meditation improves in Brain Research, 122, 393–412.
sleep. In this easily replicable project, we demonstrated that yoga is a Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for
feasible, cost-effective, sustainable, holistic modality which improves assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine,
166(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092.
symptoms anxiety among inpatients with mood disorders with or
Stanton, R., & Happell, B. (2014). Exercise for mental illness: A systematic review of
without psychosis. inpatient studies. International Journal of Mental Health Nursing, 23, 232–242.
https:// oi:https://doi.org/10.1111/inm.12045
Stussman, B. J., Black, L. I., Barnes, P. M., Clarke, T. C., & Nahin, R. L. (2015). Wellness-
Acknowledgement
related use of common complementary health approaches among adults: United
States, 2012. Natl Health Stat Report, 85, 1–12.
James Proudfoot, Jim Kane, Sherri Stolte, NBMU patients. Vancampfort, D., De Hert, M., Knapen, J., Wampers, M., Demunter, H., Deckx, S., ...
Probst, M. (2011). State anxiety, psychological stress and positive well-being re-
sponses to yoga and aerobic exercise in people with schizophrenia: A pilot study.
Appendix A. Supplementary data Disability and Rehabilitation, 33(8), 684–689. https://doi.org/10.3109/09638288.
2010.509458.
Supplementary data to this article can be found online at https:// Varambally, S., Gangadhar, B. N., Thirthalli, J., Jagannathan, A., Kumar, S.,
Venkatasubramanian, G., & Nagendra, H. R. (2012). Therapeutic efficacy of add-on
doi.org/10.1016/j.apnu.2019.04.007. yogasana intervention in stabilized outpatient schizophrenia: Randomized controlled
comparison with exercise and waitlist. Indian Journal of Psychiatry, 54(3), 227–232.
References https://doi.org/10.4103/0019-5545.102414.
Visceglia, E., & Lewis, S. (2011). Yoga therapy as an adjunctive treatment for schizo-
phrenia: A randomized, controlled pilot study. The Journal of Alternative and
Anderson, R., Mammen, K., Paul, P., Pletch, A., & Pulia, K. (2017). Using yoga Nidra to Complementary Medicine, 17, 601–607. https://doi.org/10.1089/acm.2010.0075.
improve stress in psychiatric nurses in a pilot study. Journal of Alternative and

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