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Original Investigation
August 12, 2020

Efficacy of Yoga vs Cognitive Behavioral Therapy vs Stress Education for the Treatment of Generalized Anxiety Disorder: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Psychiatry, New York University Grossman School of Medicine, New York, New York
  • 2Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
  • 3Department of Psychology, Southern Methodist University, Dallas, Texas
  • 4Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston
  • 5Department of Psychiatry, Georgetown University Medical Center, Washington, DC
  • 6Departments of Medicine and Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Psychiatry. Published online August 12, 2020. doi:10.1001/jamapsychiatry.2020.2496
Key Points

Questions  Are yoga and cognitive behavioral therapy (CBT) each more efficacious than a psychological control condition, and is yoga noninferior to CBT for the treatment of generalized anxiety disorder?

Findings  In this randomized clinical trial of 226 adults with generalized anxiety disorder, 12-week group treatment with either Kundalini yoga or CBT was more effective than the stress education control condition, but the noninferiority test did not find Kundalini yoga to be as effective as CBT.

Meaning  Kundalini yoga can reduce anxiety for adults with generalized anxiety disorder, but study results support CBT remaining first-line treatment.

Abstract

Importance  Generalized anxiety disorder (GAD) is common, impairing, and undertreated. Although many patients with GAD seek complementary and alternative interventions, including yoga, data supporting yoga’s efficacy or how it compares to first-line treatments are lacking.

Objectives  To assess whether yoga (Kundalini yoga) and cognitive behavioral therapy (CBT) for GAD are each more effective than a control condition (stress education) and whether yoga is noninferior to CBT for the treatment of GAD.

Design, Setting, and Participants  For this randomized, 3-arm, controlled, single-blind (masked independent raters) clinical trial, participants were recruited from 2 specialty academic centers starting December 1, 2013, with assessment ending October 25, 2019. Primary analyses, completed by February 12, 2020, included superiority testing of Kundalini yoga and CBT vs stress education and noninferiority testing of Kundalini yoga vs CBT.

Interventions  Participants were randomized to Kundalini yoga (n = 93), CBT for GAD (n = 90), or stress education (n = 43), which were each delivered to groups of 4 to 6 participants by 2 instructors during twelve 120-minute sessions with 20 minutes of daily homework.

Main Outcomes and Measures  The primary intention-to-treat outcome was acute GAD response (Clinical Global Impression–Improvement Scale score of much or very much improved) after 12 weeks as assessed by trained independent raters.

Results  Of 538 participants who provided consent and were evaluated, 226 (mean [SD] age, 33.4 [13.5] years; 158 [69.9%] female) with a primary diagnosis of GAD were included in the trial. A total of 155 participants (68.6%) completed the posttreatment assessment. Completion rates did not differ (Kundalini yoga, 60 [64.5%]; CBT, 67 [74.4%]; and stress education, 28 [65.1%]: χ2 = 2.39, df = 2, P = .30). Response rates were higher in the Kundalini yoga group (54.2%) than in the stress education group (33.%) (odds ratio [OR], 2.46 [95% CI, 1.12-5.42]; P = .03; number needed to treat, 4.59 [95% CI, 2.52-46.19]) and in the CBT group (70.8%) compared with the stress education group (33.0%) (OR, 5.00 [95% CI, 2.12-11.82]; P < .001; number needed to treat, 2.62 [95% CI, 1.91-5.68]). However, the noninferiority test did not find Kundalini yoga to be as effective as CBT (difference, 16.6%; P = .42 for noninferiority).

Conclusions and Relevance  In this trial, Kundalini yoga was efficacious for GAD, but the results support CBT remaining first-line treatment.

Trial Registration  ClinicalTrials.gov Identifier: NCT01912287

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    2 Comments for this article
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    The Felt Need for Further Exploration into Yogic Practices
    Mandeep Guragai, Medical Student | Kathmandu Medical College and Teaching Hospital, Nepal
    I read with interest the randomized controlled trial by Naomi M. Simon and colleagues1 published in the JAMA Psychiatry. The authors found the efficacy of Kundalini Yoga (KY) for Generalized Anxiety Disorder (GAD), although lesser than Cognitive Behavioral Therapy (CBT), was significant.1 As the authors mentioned, GAD is a stigmatized psychiatric illness, which is a barrier against patients opting for treatment.2 Therefore, new and alternative treatments should be welcomed. However, I have a couple of interrelated observations that seem important to be considered while reading the paper.

    First, the readers must be made aware that the practices done and
    studied under KY were specifically taught by Yogi Bhajan.3 The yogic tradition is an ancient and well-developed system with various practices contributed to by many yogis and spiritual gurus over many years. Similarly, the KY also includes various techniques found to be specific for treating specific diseases.4 "The KY is a type of Kriya yoga," says Dr. Raju Adhikari, who did his doctorate in Human Consciousness and Yoga Science, "which involves physical practices that help in enhancing the health and awareness of the self." According to him, the system devised by Yogi Bhajan is a specification of the broader KY.

    Second, I'm unsure of the implications that might be encountered if readers cannot recognize the distinction between the broader KY and the practices studied. "Since KY involves physical practices including asanas, mudras, pranayama, etc, it has psychophysical dimensions as opposed to other forms of yogas like the Raaj yoga which includes psycho-spiritual practices," says Dr. Adhikari. He says such practices that involve physical exercises can sometimes have "side-effects" and must not be done without the supervision of a guru. Some adverse effects of self-administered and self-practiced yoga without supervision have also been documented.5 We must note that certified KY instructors administered the KY intervention in the study.3

    These clarifications suggest that the findings might not be generalizable to the entire KY. Therefore, the need for further exploration into the yogic system is felt. This study, however, exemplifies the significance of these "traditional" practices in the modern era.

    References
    1. Simon NM, Hofmann SG, Rosenfield D, et al. Efficacy of yoga vs cognitive behavioral therapy vs stress education for the treatment of generalized anxiety disorder: a randomized clinical trial. JAMA Psychiatry. 2020.
    2. Corrigan PW, Druss BG, Perlick DA. The impact of mental illness stigma on seeking and participating in mental health care. Psychol Sci Public Interest. 2014;15(2):37-70.
    3. Hofmann SG, Curtiss J, Khalsa SBS, et al. Yoga for generalized anxiety disorder: design of a randomized controlled clinical trial. Contemp Clin Trials. 2015;44:70-76.
    4. Shannahoff-Khalsa DS. An introduction to Kundalini yoga meditation techniques that are specific for the treatment of psychiatric disorders. J Altern Complement Med. 2004;10(1):91-101.
    5. Cramer H, Quinker D, Schumann D, Wardle J, Dobos G, Lauche R. Adverse effects of yoga: a national cross-sectional survey. BMC Complement Altern Med. 2019;19(1):190.
    CONFLICT OF INTEREST: None Reported
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    Efficacy of Kundalini Yoga for Generalized Anxiety Disorder
    KATHRYN HADLEY, BEd,PGDipPs,GradDipPsycAd | University of New England
    Evidence suggests that the use of yoga by U.S. adults for mental and physical health benefits is increasing (9.5% in 2012 to 14.3% in 2017)1. The study by Simon et al.2 examined the efficacy of Kundalini yoga, as compared with CBT and a control condition. In this study of 226 participants, with a primary diagnosis of GAD, 41.2% were randomized to Kundalini yoga condition, 39.8% to CBT condition, and 19.0% to stress education control condition. All participants had not participated in yoga for at least three years before study participation. Results indicated that, whilst Kundalini yoga and CBT were more effective than stress education (70.8% versus 33.0%, and 54% versus 33.0%, respectively), it could not be concluded that Kundalini yoga was non-inferior to CBT, nor that the response rate of CBT was significantly higher than Kundalini yoga in a test of superiority. Analyses of sample characteristics revealed that study participants were predominantly college or graduate/professional school educated (82.7%). However, several large-scale studies examining demographic factors associated with yoga practice, indicate that yoga practitioners are more likely college-educated (or above) (50% to 83.9%), as compared with nonpractitioners.3,4 It is therefore pertinent to question whether response rates in non-college-educated participants differed from their counterparts in the Kundalini yoga condition. Significant differences in response between non-college/graduate/professional school educated and college/graduate/professional school groups may be related to the effects of pre-study yoga experience in the latter group, due to this group being significantly more likely to engage in yoga practice. Prior yoga practice could lead to a higher response, as the participants may be able to engage more deeply in all aspects of the practice (e.g., correct postures, breathing techniques, and meditation/mindfulness). Conversely, previous training might also lead to a lower response, as the participant may merely employ previously learnt skills (practised for leisure) and not engage fully with the specific yoga practice required in the study. Therefore, the reported benefit of Kundalini yoga in the management of GAD could be significantly over or underestimated.

    References
    1. Clarke TC, Barnes PM, Black LI, Stussman BJ, Nahin RL. Use of yoga, meditation, and chiropractors among U.S. adults aged 18 and over. NCHS Data Brief. 2018;(325):1-8.

    2. Simon NM, Hofmann SG, Rosenfield D, et al. Efficacy of yoga vs cognitive behavioral therapy vs stress education for the treatment of generalized anxiety disorder: A randomized clinical trial. JAMA Psychiatry. 2020. doi:10.1001/jamapsychiatry.2020.2496

    3. Cramer H, Ward L, Steel A, Lauche R, Dobos G, Zhang Y. Prevalence, patterns, and predictors of yoga use: Results of a U.S. nationally representative survey. Am J Prev Med. 2016;50(2):230-235.

    4. Birdee GS, Legedza AT, Saper RB, Bertisch SM, Eisenberg DM, Phillips RS. Characteristics of yoga users: results of a national survey. J Gen Intern Med. 2008;23(10):1653-1658.

    Contributing Authors:
    Dr Helen Puusepp-Benazzouz, MD, PhD, FRACP1;
    Ben Benazzouz, BAfFin, GradDipPsych, BSC(Hons)Psych2;
    Kathryn Hadley, BEd (Hons), PGDipPsych, GradDipPsychAv2

    1. Ryde Hospital, Sydney, NSW, Australia
    2. University of New England
    CONFLICT OF INTEREST: None Reported
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