ORIGINAL RESEARCH PAPER
Assessment of the effectiveness of yoga therapy as an adjunct in patients with alcohol dependence syndrome
Dipesh Bhagabati1, Anil Kumar2, Shamiul Akhtar Borbora3, Utpal Bora4, Hemanta Sharma5
1Professor, Department of Psychiatry, Gauhati Medical College & Hospital, Guwahati, Assam, India
2Senior Resident, Department of Geriatric Mental Health, King George’s Medical University, Lucknow, Uttar Pradesh, India
3Senior Resident, Department of Psychiatry, Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam, India
4Assitant Professor, Department of Psychiatry, Gauhati Medical College & Hospital, Guwahati, Assam, India
5Psychiatric Social Worker, Department of Psychiatry, Gauhati Medical College & Hospital, Guwahati, Assam, India
Abstract
Introduction: Substance use disorders, alcohol use in particular, are among the leading disorders in psychiatry in terms of prevalence. They put a lot of burden on health as well as family, society, and economic status of the patient. What more challenging is that such patients often suffer from comorbid anxiety and depression, which has the potential to perpetuate the alcohol use. Yoga is an alternative and complementary therapy which is widely practiced by people in India. However, its effectiveness in alcohol use disorders is not tested systematically.
Aims and objectives: To study the effectiveness of yoga as an adjunctive therapy in patients of alcohol use disorders and to evaluate its ability to reduce comorbid depression, anxiety, and craving.
Materials and methods: Hundred patients of alcohol use disorders as per the tenth revision of the International Classification of Diseases and Related Health Problems (ICD-10) were selected and were divided into two groups each containing 50 patients. The case group received structured yoga session in addition to standard pharmacotherapy while the control group received only pharmacotherapy. Assessment of depression (Hamilton depression rating scale [HAM-D]), anxiety (Hamilton anxiety rating scale [HAM-A]), and craving (Obsessive-compulsive drinking scale [OCDS]) was done at baseline, two weeks, and at one month. Results were compared between the two groups and statistical analysis was done.
Results: Both the case and control groups were similar in HAM-D (p=0.9634), HAM-A (p=0.7744), and OCDS (p= 0.8626) scores at baseline. There was significant reduction in HAM-A score at one month (p=0.0091), and OCDS score at two weeks (p=0.0428) and one month (p<0.0001) respectively in yoga group as compared to control group. Within case group, only reduction in HAM-A (p<0.001 and p<0.01) and OCDS (p<0.0001 and p<0.0001) scores were progressively better statistically at two weeks and one month while reduction in HAM-D score was significant only till two weeks (p<0.05).
Conclusion: Yoga therapy significantly reduced anxiety symptoms and craving in patients of alcohol dependence but not depressive symptoms. Secondly, practicing yoga for a longer period of time has progressive benefits.
Keywords: Depression. Anxiety. Craving.
Correspondence: Dr. Anil Kumar, MD, Room No. G/601, Gautam Buddha Hostel, King George’s Medical University, Lucknow-226003, Uttar Pradesh, India. anil2005kumar5@gmail.com
Received: 23 June 2016
Revised: 25 June 2016
Accepted: 2 October 2016
Epub: 12 November 2016
DOI: 10.5958/2394-2061.2016.00041.0
Introduction
Yoga therapy has been gaining popularity in the treatment of many psychiatric disorders both as adjunctive as well as single therapy. Yoga therapy has been found to help patients in many ways such as- increasing calmness, increasing awareness of self and surroundings, achieving higher levels of consciousness, increasing attention span, producing a sense of security, and reducing stress.[1] It has also been shown to produce neurochemical changes in the brain like increasing brain-derived neurotrophic factor (BDNF) levels, decreasing cortisol levels, and increasing plasma oxytocin levels.[2-4] On structural level it brings about neuroplasticity.[5]
Historically, yoga is a set of mind-body practice whose ultimate goal is achievement of higher level of consciousness. The three main yoga practices include meditation, breathing exercises, and physical postures.[6]
Alcohol use disorders are difficult to treat which is evident from high relapse rates and the current pharmacological options thus appear inadequate. The reason behind this helplessness of psychiatrists is not clearly known. But patients with alcohol use disorders have high comorbidity of depression and anxiety disorders.[7,8] Furthermore, alcohol users find it extremely difficult to control their craving. This study tries to examine a relatively less practiced modality of treatment- yoga, and will try to find out if this mode of treatment can significantly reduce comorbid depression, anxiety, and craving in patients of alcohol use disorders.
Aim
To study the effectiveness of yoga therapy as an adjunct in the treatment of alcohol use disorders.
Objectives
1. To assess the changes in anxiety and depressive symptoms in patients of alcohol dependence after yoga therapy.
2. To assess the changes in craving in these patients after yoga therapy.
Methodology
The study was conducted in a tertiary care hospital, Gauhati Medical College & Hospital, Department of Psychiatry. Total 100 numbers of patients of alcohol dependence syndrome diagnosed according to the tenth revision of the International Classification of Diseases and Related Health Problems (ICD-10)[9] criteria were taken for the study. After taking written informed consent samples were divided into two groups each containing 50 patients. Both the groups (case and control) underwent detoxification for the required time period. After this phase was over both the groups were given anticraving drugs as per the suitability. The anticraving drugs used in this hospital are acamprosate, naltrexone, topiramate, and baclofen. Additionally, the case group was given thrice weekly yoga therapy (Monday, Wednesday, and Friday) by a professional yoga teacher employed at this hospital. Both groups also attended once weekly Alcoholic Anonymous (AA) sessions as well as group therapy.
This psychiatry department of this hospital has general wards as well as a separate drug-deaddiction ward. Patients with substance use disorders are usually admitted in drug deaddiction ward but sometimes due to non-availability of beds some patients are randomly admitted in general wards. The case group consisted of the patients who were admitted in drug deaddiction ward while the control group consisted of patients admitted in general wards. Additionally, some of the patients who had medical comorbidities and who were unsuitable for yoga sessions were kept in control group.
Yoga sessions were administered to the case group for one hour duration on every alternate day for one month. The patients are instructed to practice yoga on rest of the days on their own. The standard yoga session consists of different ‘asanas’ and meditation. Following are the ‘asanas’- ‘Surya Namaskar’, ‘Hasthamudra’, ‘Padamudra’, ‘Grivamudra’, ‘Singhasana’, ‘Bhujangasana’, ‘Shalabhasana’, ‘Dhanurasana’, ‘Pavanmuktasana’, ‘Tadasana’, ‘Vrikshasana’, ‘Katichakrasana’, ‘Ardha-Mastyendrasana’, ‘Uddiyanbandhamudra’, ‘Sahajagnishei’, ‘Shavasana’, ‘kapalbhati’, ‘pranayam’, and meditation.
Assessment of depressive symptoms, anxiety symptoms, and craving was done at baseline, at two weeks, and after one month of starting of sessions. Two independent assessors assessed the case and control groups. If the patients in the two groups were found to have anxiety or depression, they were given appropriate medications.
Inclusion criteria
1. Patients diagnosed as alcohol dependent syndrome as per ICD-10 criteria
2. Patients admitted in ward
3. After detoxification period is over
Exclusion criteria
1. Patients in delirium, mental retardation, severe physical illness, or serious orthopaedic problems
2. Other axis I psychiatric diagnosis other than anxiety and depression
Tools used
Hamilton depression rating scale (HAM-D):[10] The 17-item HAM-D was used to assess depressive symptoms and score the severity of depression. This scale was developed by Max Hamilton in 1960 to monitor the severity of depression, with a focus on somatic symptomatology. It is an observer-rated scale consisting of 17 items and the score ranges from 0-52. It offers an advantage of comparing severity after administering treatment.
HAM-D score interpretation guide-
0-7: No depression
8-17: Mild depression
18-25: Moderate depression
≥26: Severe depression
Hamilton anxiety rating scale (HAM-A):[11] This scale was used to assess anxiety symptoms. Developed in late 1950s this scale has 14 items with a total score of 56. It is clinician administered with good reliability and validity. Similar to HAM-D, this scale is also used to see the treatment response.
HAM-A score interpretation guide-
0-13: No anxiety
14-17: Mild anxiety
18-24: Moderate anxiety
≥25: Severe anxiety
Obsessive Compulsive Drinking Scale (OCDS):[12] The OCDS is a tool which was made to elicit obsessions and compulsions related to drinking. Measuring obsessive behaviour in turn elicits craving for drinking. The tool has been found both sensitive and specific in measuring the obsessive thoughts and compulsive behaviours related to drinking. This tool has also been found sensitive for predicting relapse drinking. The scale consists of 14 questions reflecting both obsessive and compulsive characteristics of drinking. It is a self administered type of scale and takes about five to ten minutes to evaluate the total score, which in turn is obtained by simply adding the scores of each of the 14 items. The tool is both reliable and valid. To meet the needs of local population it was translated in Assamese. Reliability and validity was established.
Statistical analysis
Socio-demographic variables were analysed with Fisher test. Data related to alcohol use pattern was analysed using Chi-square test. Mean scores of HAM-D, HAM-A, and OCDS at each of the three intervals were compared between the two groups with the help of analysis of variance (ANOVA). Similarly to compare the effect of yoga with respect to time (two weeks vs one month) mean scores within case group were compared using ANOVA. Free version of Graphpad Instat statistical software was used for this purpose.
The study was approved by the ethical committee of Gauhati Medical College & Hospital.
Results
The results are shown in following tables 1 to 6.
Discussion
Table 1 shows the socio-demographic variables of the two groups. Both case and control groups are comparable on all the parameters and no statistical significant difference exists. Maximum number of patients in the case group fall in age group of 18-39 years while in the control group, maximum number fall in 40-59 years age group. All the 100 enrolled subjects are males, majority of subjects in both groups are Hindu, married, educated below class ten, and belong to rural areas. More number of patients in the case group are employed while more number of patients in the control group are unemployed. However, no significant difference is seen between the groups in terms of employment.
Table 2 depicts the alcohol use pattern of the two groups. Both the groups are comparable on parameters such as type of alcohol used, duration of alcohol used, frequency of alcohol used, amount of current daily use, family history of alcohol use, and past admission for alcohol use. The commonest anticraving drug used in both the groups is acamprosate.
Table 3 depicts that 30% and 26% of patients in case group and control group have depression respectively. While 40% of case group patients and 50% of control group patients had comorbid anxiety respectively. A systematic review of 35 studies found median prevalence of comorbid depression and alcohol use in current or lifetime alcohol use as 16% (range 5-67%) and 30% (range 10-60%), respectively.[13]
When both the groups were compared at baseline for scores of depression (HAM-D), anxiety (HAM-A), and craving they did not differ significantly (Table 4).
In case of comorbid alcohol dependence and depression, the HAM-D scores were not significantly different between the yoga group and non-yoga group when the two groups were treated till two weeks and one month. In another study which randomised patients of alcohol dependence (N=60) to either receive two weeks of Sudarshan Kriya (a type of yoga) or not, findings revealed that the group which received yoga intervention had significantly lower Beck’s Depression Inventory (BDI) score at two weeks as compared to the controls. There was also reduction in plasma cortisol and adrenocorticotropic hormone (ACTH) in the yoga group which correlated with reduction in BDI score.[14] However, it is not clear if the depressed patients in this study received antidepressant or not, while in our study patients in both the groups received antidepressants if they were found to be depressed.
In case of comorbid alcohol use and anxiety, HAM-A score was similar in the two groups at two weeks of treatment but at one month the patients in yoga group had significantly greater reduction in anxiety severity. A previous randomised controlled pilot study was conducted evaluating the effectiveness of 12-session yoga therapy in women of age 18-65 years. These women had comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder. The Alcohol Use Disorder Identification Test (AUDIT) and Drug Use Disorder Identification Test (DUDIT) were done before intervention, immediately after intervention, and one month after intervention. The women in yoga group showed reduction in mean AUDIT, DUDIT scores, as well as reduction in PTSD symptoms.[15]
On parameter of craving the yoga group reported significant reduction in OCDS score both at two weeks and at one month. There are no previous studies which assessed the effectiveness of yoga therapy on craving in alcohol dependence. But there is systematic review of literature on the effectiveness of mind-body practices on smoking cessation. The systematic review included 14 clinical trials and reported that yoga and meditation based therapies are helpful in attaining drug-free smoking cessation.[16]
Another pilot study was conducted in Sweden on small number of patients of alcohol dependence (N=18), who were randomised to receive either the usual treatment (psychological and pharmacological treatment) or treatment as usual plus ten-week yoga therapy. The groups were assessed before treatment and six months after treatment. Alcohol consumption reduced more in the yoga group. However, the findings were not statistically significant and were limited by small sample size.[17]
Next, we tried to see if any improvement in the yoga group in terms of HAM-D, HAM-A, and OCDS scores varied with respect to time (Tables 5 and 6), i.e. whether the benefits continued to increase if yoga was practiced for longer time. The reduction in HAM-D scores after two weeks and one month in case group was significant from baseline but not at one month as compared from two weeks. This means that the antidepressant effect of yoga therapy was maximum at two weeks and although the benefit continued to increase at one month, it was not statistically significant. However, the reduction in HAM-A and OCDS scores was significant both at two weeks and one month from baseline as well as at one month as compared to two weeks. In other words anxiety symptoms and craving continued to improve if yoga was practiced for longer duration.
Conclusion
Patients with alcohol dependence have high prevalence of comorbid depression and anxiety symptoms. This comorbidity can be both causal as well as an effect of alcohol use. Additionally patients of any substance dependence including alcohol report craving which limit their capacity to become abstinent even if they have adequate motivation. Our hospital is using yoga as an adjunctive mode of intervention in patients with alcohol dependence. This study tried to see if instituting a structured yoga regimen to these patients can benefit them in lowering the depressive and anxiety symptoms, and craving.
The study found benefit of yoga as an adjunctive method in reducing anxiety symptoms and craving for alcohol. In case of yoga group the reduction in depressive symptom is greatest at two weeks and no added benefit at one month as compared with the benefit at two weeks. The reduction in anxiety symptoms and craving is progressively better at two weeks and at one month.
Limitations of the study and future directions
There are certain limitations of the study. First, this is an open label study leading to potential bias and which may have impact on the results. Second, the study was done taking smaller number of cases. Similar studies can be conducted taking larger sample size. It would also be interesting to see the effects of yoga in other substance use disorders.
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Bhagabati D, Kumar A, Borbora SA, Bora U, Sharma H. Assessment of the effectiveness of yoga therapy as an adjunct in patients with alcohol dependence syndrome. Open J Psychiatry Allied Sci. 2017;8:40-5. doi: 10.5958/2394-2061.2016.00041.0. Epub 2016 Nov 12.
Source of support: This study is funded by a grant from the Srimanta Sankaradeva University of Health Sciences, Guwahati, Assam. Declaration of interest: None.
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