Available via license: CC BY 3.0
Content may be subject to copyright.
Hindawi Publishing Corporation
Depression Research and Treatment
Volume 2012, Article ID 401513, 9 pages
doi:10.1155/2012/401513
Review A rticle
Managing Mental Health Disorders Resulting from
Trauma through Yoga: A Review
Shirley Telles, Nilkamal Singh, and Acharya Balkrishna
Department of Yoga Research, Patanjali Research Foundation, Haridwar, Uttarakhand 249408, India
Correspondence should be addressed to Shirley Telles, shirleytelles@gmail.com
Received 15 October 2011; Revised 5 March 2012; Accepted 13 March 2012
Academic Editor: Rachel Yehuda
Copyright © 2012 Shirley Telles et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
There are many and varied types of trauma. The extent to which trauma influences the mental health of an individual depends
on the nature of trauma, as well as on the individual’s coping capabilities. Often trauma is followed by depression, anxiety, and
PTSD. As the pharmacological remedies for these conditions often have undesirable side-effects, nonpharmacological remedies
are thought of as a possible add-on treatment. Yoga is one such mind-body intervention. This paper covers eleven studies indexed
in PubMed, in which mental h ealth disorders resulting from trauma were managed through yoga including meditation. The aim
was to evaluate the use of yoga in managing trauma-related depression, anxiety, PTSD and physiological stress following exposure
to natural calamities, war, interpersonal violence, and incarceration in a correctional facility. An attempt has also been made to
explore possible mechanisms underlying benefits seen. As most of these studies were not done on persons exposed to trauma that
had practiced yoga, this is a definite area for further research.
1. Introduction
The definitions of trauma are many and varied. One des-
cription states that an event is traumatic if it is extremely
upsetting and at least temporarily overwhelms the individ-
ual’s inner resources [1]. In the United States, surveys of the
general population suggest that at least half of all the adults
have experienced at least one major traumatic stressor [2, 3].
2. Trauma: Types of Trauma and Their
Physiological Consequences
The types of trauma include (i) natural disasters, ( ii) mass
interpersonal violence, (iii) large-scale transportation acci-
dents, (iv) house or other domestic fires, (v) motor vehicle
accidents, (vi) rape and sexual assault, (vii) stranger physical
assault, (viii) partner battery and emotional abuse, (ix)
torture, (x) war, (xi) child abuse, (xii) exposure of emergency
workers to trauma, and (xiii) major accident or illness. In
listing traumas separately there may be an erroneous impres-
sion that such traumas are independent of one another. This
is applicable to noninterpersonal traumas such as natural
disasters or house fires. However, it is also recognized that
vict ims of interpersonal traumas are at greater risk of addi-
tional interpersonal traumas. For example those who have
experienced child abuse are more likely to be victimized as
adults [4, 5].
People respond to trauma in different ways. When expos-
ed to the same trauma, some people develop posttraumatic
stress disorder, whereas others are less affected or respond
with symptoms such as depression or generalized anxiety [6].
It is well recognized that severe psychological trauma
causes impairment of the neuroendocrine systems in the
body, with sympathetic activation and suppression of the
parasympathetic nervous system. There is also an increase in
the level of circulating cortisol which has adverse effects on
different systems. Severe trauma in early childhood especially
has serious consequences. It can affect all aspects of develop-
ment, including cognitive, social, emotional, physical, psy-
chological, and moral development [7]. This has serious con-
sequences in adolescence and can influence adult life as well.
Van der Kolk et al. (1996) described the long-term effects
of trauma, which were: generalized hyper-arousal and diffi-
culty in modulating arousal, alterations in neurobiological
processes involved in stimulus discrimination, conditioned
fear responses to trauma related stimuli, loss of trust and
2 Depression Research and Treatment
hope, social avoidance, and lack of interest and participation
in preparing for the future [8]. With these changes, it is
understandable that if the trauma is severe, and if support is
inadequate and hereditar y factors are also present, a person
may develop symptoms of depression.
The pharmacological management of psychological dis-
orders resulting from trauma is best supplemented with non-
pharmacological healing techniques which would allow the
person to regulate their internal states and response to exter-
nalstress[9].
The Indian science of living, yoga, includes several pra-
ctices such as physical postures (asanas), voluntary regulat-
ed breathing (pranayamas), meditation, conscious sen-
sory withdrawal (pratyahara), and philosophical principles
[10].
3. Yoga and the Management of
the Consequences of Trauma
It is often difficult for people who have been subjected to
acute or prolonged trauma to regain a sense of normalcy and
balance in their lives [11]. In many cases, psychiatric help is
sought [12]. Also, since yoga requires involvement and ulti-
mately trains the person to practice on their own, learning
yoga can help a person regain their sense of being in control
of their lives, as well as increase their self-dependence.
Yoga is a nonpharmalogical remedy which has been used
to help in managing trauma related to (i) natural disasters,
(ii) combat and terrorism, (iii) interpersonal violence, and
(iv) being incarcerated in a correctional facility. Studies pub-
lished in journals indexed in PubMed were reviewed. Those
indexed in other bibliographic databases or which did not
use yoga, including meditation as an intervention, were
excluded.
3.1. Yoga and Coping with Natural Disasters. In December
2004, a tsunami occurred in South East Asia [13]. Two
studies were conducted to assess the effects of yoga on the
survivors. A single group study on 47 tsunami survivors wi th
ages between 28 and 50 years was evaluated to see the effects
ofa7-dayyogaprogram[14]. The yoga program included
loosening exercises, yoga postures, breathing practices, and
guided relaxation for 60 minutes daily. Participants were
assessed for self-rated symptoms of stress (viz., fear, anxiety,
disturbed sleep, and sadness) using linear analog scales. The
electrocardiogram (to assess heart rate variability), breath
rate, and skin resistance were recorded using a portable four-
channel polygraph. Data were analyzed using paired t-tests
and all self-rated symptoms significantly reduced along with
the breath rate. Effect sizes were not calculated. The three
main limitations of the study were (i) the absence of a control
group, (ii) use of scales whose reliability and validity had
not been established, and (iii) the short duration of the
intervention with no long-term foll ow up. To a large extent,
these shor tcomings were overcome in the second study which
evaluated 183 tsunami survivors who were above the age of
18 years and who scored 50 or above on the Posttraumatic
Check List-17 (PCL-17) [15]. They were allocated to three
groups. The groups were (i) yoga breath intervention,
(ii) yoga breath intervention followed by 3 to 8 hours trauma
reduction exposure technique, and (iii) a wait list control
group. The participants were assessed at the beginning and
end of 24 weeks, as well as intermittently usingthe Posttrau-
matic Check List (PCL-17) for PTSD and Beck Depression
Inventory (BDI-21) for depression. The data were analyzed
using a three-way ANOVA. The scores of PCL-17 signif-
icantly reduced with yoga breath intervention and yoga
breath intervention followed by 3–8 hours trauma reduction
exposure technique. This study used scales whose validity
and reliability had been established and the participants were
followed up for 24 weeks. The effect sizes were not calculated.
The only weakness of the study was that the allocation of the
participants to three different groups was not random.
A meditation technique called Inner Resources was used
in a single study on 20 health workers (aged between 31 and
67 years) who were involved in relief work, 10 weeks after
Hurricane Katrina [16]. Meditation was taught as a 4 hour
workshop followed by an 8-week home study program. The
participants were assessed using disaster exposure questions,
PTSD Checklist-Specific Version (PCL-S), the Center for
Epidemiological Studies-Depression Scale (CES-D), the 20-
item state portion of the State-Trait Anxiety Inventory
(STAI-S) and a follow up questionnaire. Intention-to-treat
regression analyses and one-sample t-tests showed that the
persons’ PTSD scores assessed by PCL-S and anxiety sym-
ptoms assessed by STAI-S significantly decreased with the
intervention. Treatment effect size based on Cohen’s d was
calculated for PCL-S total (d
= .38), CES-D (d = .12) and
STAI-S (d
= .45). The limitations of the study were the small
sample size and absence of a control group.
Both the tsunami and the hurricane were unexpected
natural disasters. In certain cases, natural disasters occur
repeatedly. An example is the floods in the north eastern
Indian state of Bihar caused by seasonal rain and a breach
in a river [17]. In a cross-sectional study 1289 people (aged
between 15 to 85 years) who had been directly exposed to
the floods were screened for PTSD and depression using the
Screening questionnaire for disaster mental health (SQD)
[17]. In this study, no intervention was given. Two factor
ANOVAs showed that people over 60 years of age had higher
scores of PTSD and depression. From the larger sample of
1289 p ersons, a small sample of 22 persons (with an age
range of 20 to 40 years) were selected based on their w illing-
ness to participate in the trial and randomized as two groups,
a yoga group and a control group who continued with
their regular activities [18]. The yoga intervention was for 7
days and included loosening exercises, yoga postures, breath-
ing exercises, and guided relaxation for 60 minutes everyday.
The self-rated symptoms of distress, namely, fear, anxiety,
disturbed sleep, and sadness were assessed with linear analog
scales, the heart rate variability based on the electrocardio-
gram and breath rate were recorded with a four channel
polygraph. The yoga group showed a significant decrease in
sadness while anxiety significantly increased in the control
group (paired t-tests were used for analyses). Effect sizes were
not calculated in this study. Limiting factors were the use of
analog scales which have not been validated and the small
sample size.
Depression Research and Treatment 3
3.2. Yoga and Coping with Exposure to Combat and Terrorism.
In Kosovo, 139 high school students with ages ra nged from
12 to 19 years took part in a single group study in which the 6
week program included meditation, biofeedback, drawings,
autogenic training, guided imagery, genograms, movement,
and breathing techniques [19]. They were trained in the
program in three separate groups. Although there were no
inclusion or exclusion criteria and screening for PTSD was
not done using standardized methods, the children included
in the study were directly exposed to assault and atrocities of
war. The symptoms of PTSD were assessed using the PTSD
Reaction Index and were lower after the program. A paired
t-test was used to analyze pre and posttest differences in
mean PTSD scores. There was a reduction in PTSD scores
after the program (P<.001). Effect sizes were calculated
using Cohen’s d with values of 0.6, 2.1, and 2.4 for changes
in pre and posttest measurements of Groups I, II, and
III, respectively, indicating a moderate clinical difference
(d
= 0.5) in Group I and large clinical differences (d = 0.8)
in groups II and III. The main limitation of this study was the
absence of a control group. A later study by the same author
randomized 82 adolescents who met the criteria for PTSD
according to the Harvard Trauma Questionnaire [20]. They
were randomly assigned to a 12 session mind body group
program or a wait list control group. Here, again the mind
body program included meditation, guided imagery, breath-
ing techniques, self-expression through words, drawings and
movement, autogenic training, biofeedback, and genograms.
PTSD symptoms were assessed using the Harvard Trauma
Questionnaire. The intervention group had significantly
lower PTSD symptoms compared to the wait list control
group. After the wait list control group received the interven-
tion, their PTSD symptoms were reduced. This study meets
most of the criteria for rigor as the sample size was adequate,
participants were randomized to two interventions and the
assessment tool was standardized for assessment of trau-
ma.
A single group study was conducted on 122 preteen
Israeli school children (ages between 8 and 12 years) affected
by the second Lebanon war [21]. Those schools approved for
participation by the school principals were included in this
study. The yoga program consisted of 13 yoga sessions w hich
included yoga postures and breathing practices conducted
for 4 months. The assessments were made using the WHO
Well-Being Index and a satisfaction questionnaire for the
children. The teachers were given the Connor Abbreviated
Questionnaire to assess the behavior of the students. The
significant finding was improvement in attention span,
restlessness and inattention based on Connor Abbreviated
Symptoms rated by the teacher. There was no significant
difference in the WHO Well-Being measures though the
children expressed satisfaction w ith the yoga training they
had received. The first and third scales are validated w hereas
the second (satisfaction questionnaire) was de veloped by the
authors. The data were analyzed w ith non parametric statis-
tics (i.e., Wilcoxon paired signed ranked test and Kruskall-
Wallis test). Effect sizes were not calculated in this study. The
advantage of the study is that the responses of the children
as well as the observations of the teachers were taken into
account using valid questionnaires. The disadvantages of the
study were that there was no control group.
Children between 6 and 12 years of age (n
= 226) who
experienced the terrorist bomb explosion in Bali in 2002 and
who were subsequently diagnosed with PTSD were studied
[22]. The design was a longitudinal, quasi-exper imental,
single blind, and randomized control design. Forty-eight
children received group Spiritual-Hypnosis Assisted Therapy
(SHAT) while 178 did not. Posttraumatic stress disorder
symptom scores reduced at the two year follow up after
SHAT with 77.1 percent improvement compared to 24 per-
cent in the control group.
In north eastern Sri Lanka, 71 children who were affected
by the civil war and the tsunami participated in a study [23].
They were diagnosed for PTSD through an interview. The
age range was between 8 a nd 14 years. Those with men-
tal retardation, psychosis, or a ny psychological disorder were
excluded from the study. They were randomized as two
groups; one received six-session narrative exposure therapy
for children (KIDNET) while the other group had six ses-
sions of meditation-relaxation (MED-RELAX). Assessments
were made after one and six months using the UCLA PTSD
index for DSM IV in interview form. In addition, a 5-item
scale was used to assess problems in functioning in di fferent
areas of children’s lives (e.g., social relationships, family life,
and general life satisfaction). Also children were asked 5
questions related to the tsunami (e.g., “Did you see the
big wave close by?”). The data were analyzed with repeated
measures ANOVA and chi-square tests to compare postval-
ues of the two groups for one and six months. Symptoms
of PTSD were significantly reduced for both groups at one
month and remained stable at six months. Within-group
effect sizes based on Cohen’s d were calculated, effect sizes for
the KIDNET were 1.76 (CI 0.9–2.5) at one-month posttest
and 1.96 (CI 1.1–2.8) at 6-month follow up while for MED-
RELAX they were 1.83 (CI 0.9–2.6) and 2.20 (CI 1.2–3.0) at
one and six months posttest, respectively. This study used
standardized questionnaires and randomized participants to
two interventions. The only possible limitation is the absence
of a no intervention group. The study is particularly useful as
the children had been traumatized by both war and tsunami
and they improved with the interventions.
3.3. Interpersonal Violence. Usefulness of mindfulness med-
itation was evaluated for 97, fourth grade (mean age of 9.7
years, n
= 55) and fifth-grade (mean age of 10.6 years, n =
42) students from Baltimore city [24]. Most of these child-
ren lived in low-income neighborhoods with high levels of
violence. They were randomized as two groups, one received
mindfulness meditation and yoga (n
= 51) and the other
wasacontrolgroup(n
= 46). Assessments were taken at
the beginning and end of 12 weeks. Both groups were asses-
sed using (i) the response to stress questionnaire (RSQ) from
which the involuntary engagement coping scale was select-
ed, (ii) the short mood and feelings questionnaire-Child
version for depressive symptoms (SMFQ), (iii) the emotion
profile inventory (EPI), and (iv) relations with peers and the
school were assessed with the “People in my Life (PIML)”
self-report measure. Data were analyzed using ANOVA for
4 Depression Research and Treatment
continuous variables and chi-square tests for categorical vari-
ables. The findings suggest that a mindfulness based inter-
vention shows promise in reducing physical and cognitive
ways of responding to stress among youth faced with violence
in their daily life. Effect sizes were calculated for emotional
profile positive affect (d
= .04), Emotional profile negative
affect (d
= .13), SMFQ depression scores (d = .13), PIML
trust in friends (d
= .40), PIML communications with
friends (d
= .17), PIML Teacher Affiliation (d = .09), PIML
dissatisfaction with teachers (d
= .08), and RSQ (d = .83).
The limitations include the fact that the recruitment may
have resulted in highly motivated students and/or those with
enthusiastic parents taking part. Also the self-report mea-
sures may have been influenced by various sources of bias.
3.4. Youth Incarcerated in a Correctional Facility. Youthful
offenders are committed to legal custody and interventions
are needed to help them cope with the stress and adjustment
to the environment [25]. A randomized controlled trial was
carriedouton28girlsbetween12and16yearsofagewho
were living in a community h ome as they had a history of
committing legal offences [26]. The 28 girls were matched
for age
±6 months and duration of stay in the community
home
±2 months. Participants were then assigned to two
groups randomly, namely, yoga or games. The yoga training
included postures and guided relaxation sessions for 60
minutes daily for 5 days a week. At the end of 6 months,
both groups’ heart rate, breath rate and skin resistance were
assessed to evaluate their physiological stress levels. Data
were analyzed using Wilcoxon paired-sample test for pre
and postcomparisons. Following 6 months of practice, both
groups significantly reduced their heart rate, but the yoga
group alone showed a decrease in breath ra te. Effect sizes
were not calculated in this study. The findings of the study
were limited by (i) the small sample size, (ii) absence of tests
for self reported stress and wellbeing, and (iii) the objective
variables used were very simple a nd apart from the skin
resistance do not directly relate to physiological stress [27].
The studies cited above have been summar ized in Table 1.
4. Mechanisms Underlying
the Improvement in the Psychological
State Following Trauma with Yo ga
Given the possibility of using yoga to positively modify the
mental state following trauma, it is interesting to speculate
about the mechanisms underlying the benefits seen. The
amygdala is one of the main sites where alterations in the
regulation of the serotonin transporter (5-HTT) may alter
the stress response [28]. Based on a positron emission tomo-
graphy scan, abnormally reduced amygdala 5-HT binding
was found in PTSD and was associated with higher symp-
toms of anxiety and depression in posttrauma patients, parti-
cularly those with diagnosed PTSD. Hence, abnormal 5-HT
signaling within neural systems possibly underlies threat
detection and fear learning.
Whole blood serotonin levels and mood state changes
were assessed before and after focused attention on Tanden
breathing, which is a part of Zen meditation, in 15 healthy
right-handed participants [29]. Recordings were m ade of
the (i) elec tromyogr a phy (EMG) to monitor the abdominal
muscle contraction, (ii) the electroencephalograph (EEG)
from three scalp locations for monopolar recordings, (iii)
electrooculography (EOG) and electrocardiography (ECG),
(iv) near infrared spectroscopy (NIRS) u sing a 24-channel
system, and (v) whole blood serotonin levels measured
within 2 weeks of the experiment using standard high-per-
formance liquid chromatography- (HPLC-) based methods.
Different statistical tests were used for the different measures
such as two way repeated measures ANOVA for EEG, one-
way repeated measures ANOVA for serotonin levels, paired
t-tests for the mood scores and one way repeated measures
ANOVA for oxy-hemoglobin levels derived from the NIRS
data. Effect sizes were not calculated in this study. During
focused attention on Tanden breathing, there was a signifi-
cant increase in the oxy-hemoglobin level in the anterior pre-
frontal cortex, increased alpha activity with decreased theta
activity, and increase in whole blood serotonin levels cor-
related with increased alpha activity and reduced negative
feelings.
Apart from changes in serotonin levels, animal models
of depression often use traumatic experiences of pain, isola-
tion, or social defeat to cause changes in mesolimbic and
mesocortical dopamine systems, which alter cortical control
of midbrain defenses [30]. Imbalance within the ascending
dopaminergic tracts may cause rapid fluctuations in the level
of arousal and in the associated mood, drive, and motivation.
Stress reduction, positive affect, and levels of plasma
catecholamines were assessed in 67 regular (range 3–144
months) meditators (aged 18–36 years) and 57 non-medi-
tators (aged 19–37 years). The meditation pract ice was called
“Brain Wave Vibration Mind Body Training” which is con-
sidered to change negative thoughts into positive ones [31].
The technique used natural rhythmic movements and hence
it is a moving meditation. All participants were assessed
using the stress response inventory, Positive Affect Negative
Affect Scale (PANAS), as well as blood samples to estimate
norepinephrine, epinephrine and dopamine levels using
high-performance liquid chromatography (HPLC). Com-
parisons between the two groups were made with t-tests
and Pearson’s correlation coefficient was used to analyze the
relationship between the two variables. Effect sizes were not
calculated in this study. The meditation g roup had higher
scores on positive affect and lower scores on negative affect
compared with non meditators. Their plasma dopamine
levels were also higher. The control group showed a negative
correlation b etween stress and positive effect. A positive cor-
relation was found between somatization of stress and nore-
pinephrine/epinephrine and dopamine/epinephrine ratios.
Hence in comparison with the control group, the regular
meditators had lower stress, higher positive affect, and higher
plasma dopamine levels.
While changes in serotonin and dopamine levels follow-
ing meditation may explain at least in part the positive affect
and reduction in stress following meditation the explanation
for the anxiety lowering effect of the yoga practices may
be related to another neurotransmitter, namely, Gamma
Aminobutyric Acid (GABA). Two studies demonstrated that
Depression Research and Treatment 5
Table 1: Summary of the twelve studies reviewed
Sl.
Number
Category of trauma
Sample: (1)
Age, (2)
Gender, (3) n
Study design
Assessment tools and their
reliability/validity
Statistics Effect sizes Limitations
(1)
Natural disaster (tsunami)
(Location: the Andaman
islands) [14]
(1) 28–50 years
(2) both
genders
(3) n
= 47
Single group
longitudinal design
with before, after (7
dayyogaprogram)
(i) Linear analog scales for fear,
anxiety, disturbed sleep, and
sadness (the reliability and
validity has not been
established),
(ii) Heart rate variability from
the electrocardiogram),
(iii) breath rate and,
(iv) skin resistance
(ii), (iii), (iv) were recorded
with a polygraph and were
standardized
Paired t-tests Not reported
(i) Absence of a control
group, (ii) use of scales
whose reliability and
validity had not been
established, and (iii)
short duration of the
intervention.
(2)
Natural disaster (tsunami)
(Location: South-east
coast of India) [15]
(1) 18–65 years
(2) Both
genders
(3) n
= 183
Allocation (non
random) to 3 groups
(a) yoga breath
intervention, (b) yoga
breath intervention
followed by trauma
reduction exposure
technique, a nd (c) a
wait list control.
(d) Longitudinal
assessments before,
after (24 weeks) as
well as intermittently
(i) The PTSD check list-17
(PCL-17).
(ii) Beck depression inventory
(BDI-21) reliability and validity
are established
Three factor
ANOVA, with
post hoc analysis
using Newman
Keuls tests
Not reported
Allocation to the 3
groups was not random
(3)
Natural disaster
(Hurricane Katrina)
(Location: New Orleans,
U.S.A.) [16]
(1) 31–67 years
(2) Both
genders
(3) n
= 20
(i) Single group
(ii) longitudinal
assessments before,
after (8 weeks of
intervention)
(i) PTSD checklist-Specific
version (PCL-S)
(ii) Centre for (CES-D)
(iii) State subscale of STAI
(STAI-S)
(iv) a follow up questionnaire
(i), (ii), and (iii) are reliable and
valid
Intention-to-
treat regression
analysis and one
sample t-tests
PCL-S (d
= .38) CES-D (d = .12)
STATE-S (d
= .45)
(i) Small sample size
and (ii) absence of a
control group
(4)
Natural disaster (floods)
(Location: Bihar, India)
[17]
(1) 15–85 years
(2) Both
genders
(3) n
= 1289
Cross sectional single
group study
evaluating r i sk for
PTSD and depression
in different age
groups
Screening questionnaire for
disaster mental health (SQD)
with known reliability and
validity
Two fa ctor
ANOVAs
followed by
post-hoc
analyses
Not reported
Confounding variables
which could influence
susceptibility other
than age and gender
were not reported
6 Depression Research and Treatment
Table 1: Continued.
Sl.
Number
Category of trauma
Sample: (1)
Age, (2)
Gender, (3)n
Study design
Assessment tools and their
reliability/validity
Statistics Effect sizes Limitations
(5)
Natural disaster (floods)
(Location: Bihar, India)
[18]
(1) 20–40 years
(2) Males
(3) n
= 22
(i) Randomized
controlled study
(ii) Longitudinal with
before, after
assessment after 7
days of intervention
(i) Linear analog scales to assess
fear, anxiety, disturbed sleep and
sadness, (ii) heart rate
variability based on
electrocardiogram, and (iii)
breath rate.
reliability and validity of linear
analog scales are not established
and (ii) and (iii) were recorded
on a polygraph with
standardized methods
Paired t-tests Not reported
(i) Small sample size
and
(ii) use of analog scales
which are not valid
(6)
Exposure to combat and
terrorism (Location:
Kosovo) [19]
(1) 12 to 19
years
(2) Both
genders
(3) n
= 139
(i) Single group.
(ii) Longitudinal with
before, after (6 weeks)
assessments
(i) PTSD reaction Index
With known reliability and
validity
Paired t-tests
RMANOVA for
one group and
the subset of
another group
Effect size for group 1 (d
= 0.5)
and group II and II (d
= 0.8)
Absence of a control
group
(7)
Exposure to combat and
terrorism (Location:
Kosovo) [20]
(1) 12–19 years
(2) Both
genders
(3) n
= 82
(i) Randomized
control study
(ii) Longitudinal
before, after (3
months)
Harvard trauma questionnaire
(valid and reliable)
Repeated
measures
ANOVA
Not obtained possibly reported NIL
(8)
Exposure to combat and
terrorism (Location:
Israel) [21]
(1) 8–12 years
(2) Both
genders
(3) n
= 122
(i) Single group
(ii) Longitudinal
before, after (4
months)
(i) WHO well being index
(ii) A satisfaction questionnaire.
(iii) Connor abbreviated
questionnaire (rated by the
teacher).
(i) and (iii) are reliable and valid
(i) Wilcoxon
paired signed
ranked test
(ii) Kruskall
Wallis test
Not reported
Absence of a control
group
(9)
Exposure to combat and
terrorism (Location: Bali)
[22]
(1) 6–12 years
(2) Both
genders
(3) n
= 226
(i) Single blind,
randomized control
design.
(ii) Longitudinal
before, after (2 year
follow up)
Not obtained Not obtained Not obtained
Numbers in the 2
groups were unequal
(i.e., 48 in the SHAT
groupcomparedto178
in the control) this is
not usual in a
randomized control
design
(10)
Exposure to combat and
terrorism as well as
tsunami (Location: Sri
Lanka) [23]
(1) 8–14 years
(2) Both
genders
(3) n
= 71
Randomized to 2
interventions, before,
after (1, 6 months)
(i) (UCLA PTSD index for
DSM-IV.
(ii) 5 item scale for satisfaction.
(iii) 5 item scale related to the
tsunami.
(i) and (ii) had established
reliability and validity
Repeated
measures
ANOVA and
chi-square tests
Effect Sizes (i) KIDNET 1.76 (one
month post test), 1.96 (6 months
post test) (ii) MED-RELAX 1.83
(one month post test), 2.20 (6
month post test)
(i) Absence of a no
intervention control
group.
(ii) The third
questionnaire (related
to the tsunami) was not
standardized
Depression Research and Treatment 7
Table 1: Continued.
Sl.
Number
Category of trauma
Sample: (1)
Age, (2)
Gender, (3)n
Study design
Assessment tools and their
reliability/validity
Statistics Effect sizes Limitations
(11)
Interpersonal violence
(Location: Baltimore City,
U.S.A.) [24]
(1) 9–11 years
(2) Both
genders
(3) n
= 97
Randomized control
before, after (12
weeks) assessments
(i) Response to stress
questionnaire. (ii) The short
mood and feelings
questionnaire: Child version for
depressive symptoms.
(iii) Emotional profile inventory
(iv) “People in my life self report
measure”
(i) ANOVA for
continuous
variables.
(ii) chi-square
tests for
categorical
variables
Effect sizes were calculated for
Emotional profile positive affect
(d
= .04), Emotional profile
negative affect (d
= .13), SMFQ
depression scores (d
= .13),
PIML Trust in Friends (d
= .40),
PIML Communications with
Friends (d
= .17), PIML Teacher
Affiliation (d
= .09), PIML
Dissatisfaction with Teacher
(d
= .08) and RSQ (d = .83)
Recruitment may have
involved highly
motivated students
with enthusiastic
parents (the self-report
measures may have
been influenced by bias
(12)
Yo uth i n a co r r e c t i onal
facility (Location:
Bangalore, India) [26]
(1) 12–16 years
(2) Females
(3) n
= 28
Matched pair
allocation to
intervention and
control g roups (pairs
were matched for age
and duration of stay
in the community
home), before, after
(6 months)
assessments
(i) Heart rate from the
electrocardiogram.
(ii) Breath rate from a
respirogram.
(iii) Skin resistance. The 3
variables were recorded with a
polygraph using standard
methods
Wilcoxon
paired—sample
tests
Not reported
(i) The small sample
size. (ii) absence of tests
for self reported stress,
and (ii) simplistic
variables used are
inadequate to assess
physiological stress
8 Depression Research and Treatment
GABA-ergic activity increased after yoga practice. In the ear-
lier study, 8 experienced yoga practitioners were compared
with 11 non practitioners [32].Allsubjectswereevaluated
using the Structural Clinical Interview for DSM-IV Axis I
Disorders: Patient Edition (CID) and the Addiction Severity
Index (ASI). Persons with contraindications for magnetic
resonance evaluation were excluded from the study. The
yoga group completed a 60-minute session which included
yoga postures while the comparison subjects read periodicals
and popular fiction during a 60-minute session. GABA-
to-creatine ratio was measured using magnetic resonance
spectroscopy imaging (MRSI) immediately before and after
the intervention. The GABA levels increased by 27 percent
in the yoga practitioners after the yoga session while the
comparison group showed no change. In this study, effect
size was not calculated. The second study by the same authors
addressed the question of whether changes in GABA levels
are specific to yoga or related to physical activity [33].
Participants were randomized to a yoga group (n
= 19) or
a metabolically matched physical exercise group (n
= 15)
for 60 minutes, 3 times a week for 12 weeks. The age range
of the participants was 18–45 years. Magnetic resonance
spectroscopy scans demonstrated that thalamic GABA levels
increased in the yoga group and were positive ly correlated
with improved mood. The acute changes in GABA levels
in the yoga group approached significance (P
= 0.09, t-
test). In this study, also effect sizes were not calculated. The
thalamic GABA level was associated with improved mood
and decreased anxiety. These changes are usually obtained
by pharmacological agents designed to improve mood and
alleviate anxiety. Hence, this study was the first report of a
behavioral intervention producing the same effect.
These studies suggest that certain changes in neurotrans-
mitters following yoga practice may be responsible for the
improved psychological state in trauma victims who prac-
ticed yoga. However, neurotransmitters have not been mea-
sured in any of the studies on trauma victims who improv-
ed with yoga. Hence, this is a speculation.
For this review, we examined in detail eleven studies
(indexed in PubMed) on people exposed to trauma who
received yoga including meditation as an intervention. There
was also a single group cross-sectional study conducted prior
to one of the intervention studies. Hence, 12 studies were
reviewed. Among them, there were 7 randomized controlled
trials (RCTs), 4 single group studies, and the one cross-
sectional single group survey referred to above. Even where
RCTs were conducted studies were limited by factors such as
small sample sizes and in a few cases use of assessment tools
whose reliability and validity were not established. Hence,
though yoga and other mind body interventions appear to be
useful in reducing mental health disorders following trauma
there is as yet no systematic randomized control trial which
meets all the requirements to state that these interventions
conclusively are useful in trauma management.
The last part of the article attempts to consider possible
mechanisms underlying the improvement with yoga. How-
ever, since none of these studies were conducted in trauma
survivors, they remain speculative, and a possible direction
for future study.
References
[1] J. Briere and C. E. Jordan, “Violence against women: outcome
complexity and implications for assessment and treatment,”
Journal of Interpersonal Violence, vol. 19, no. 11, pp. 1252–
1276, 2004.
[2] D. M. Elliott, “Traumatic events: prevalence and delayed recall
in the general population,” Journal of Consulting and Clinical
Psychology, vol. 65, no. 5, pp. 811–820, 1997.
[3] R. C. Kessler, A. Sonnega, E. Bromet, M. Hughes, and C. B.
Nelson, “Posttraumatic stress disorder in the national com-
orbidity survey,” Archives of General Psychiatry, vol. 52, no. 12,
pp. 1048–1060, 1995.
[4] C. Classen, R. Nevo, C. Koopman et al., “Recent stressful
life e vents, sexual revictimization, and their relationship with
traumatic stress symptoms among women sexually abused in
childhood,” Journal of Interpersonal Violence, vol. 17, no. 12,
pp. 1274–1290, 2002.
[5] P. Tjaden, N. Thoennes, and C. J. Allison, “Comparing stalking
victimization from legal and victim perspectives,” Violence and
Victims, vol. 15, no. 1, pp. 7–22, 2000.
[6] N.Breslau,G.C.Davis,P.Andreski,andE.Peterson,“Trau-
matic events and posttraumatic stress disorder in an urban
population of young adults,” Archives of General Psychiatry,
vol. 48, no. 3, pp. 216–222, 1991.
[7] W. W. Harr is, F. W. Putnam, and J. A. Fairbank, “Mobilizing
trauma resources for children,” in Proceedings of the Meeting of
the Johnson and Johnson Pe diatric Institute: shaping the Future
of Children’s Health, San Juan, Puerto Rico, February 2004.
[8]B.A.vanderKolk,D.Pelcovitz,S.Roth,F.S.Mandel,A.
McFarlane, and J. L. Herman, “Dissociation, somatization,
and affect dysregulation: the complexity of adaptation to trau-
ma,” American Journal of Psychiatry, vol. 153, no. 7, pp. 83–93,
1996.
[9] S. A. Saeed, D. J. Antonacci, and R. M. Bloch, “Exercise,
yoga, and meditation for depressive and anxiety disorders,”
American Family Physic ian , vol. 81, no. 8, pp. 981–987, 2010.
[10] I. K. Taimini, The Sc ience of Yoga, The Theosophical Publishing
House, Madras, India, 1986.
[11] M. Letica-Crepulja, E. Salcioglu, T. Franciskov i
´
c, and M.
Basoglu, “Factors associated with posttraumatic stress disor-
der and depression in war-survivors displaced in Croatia,”
Croatian Medical Journal, vol. 52, no. 6, pp. 709–717, 2011.
[12] T. L. Simpson, S. A. Moore, J. Luterek et al., “Psychiatric corre-
lates of medical care costs among veterans receiving mental
health care,” Journal of Interpersonal Violence,vol.27,no.6,
pp. 1005–1022, 2012.
[13] R. Deebaj, M. Castr
´
en, and O. Gunnar, “Asia tsunami disaster
2004: experience at three international airports,” Prehospital
and Disaster Medicine, vol. 26, no. 1, pp. 71–75, 2011.
[14] S. Telles, K. V. Naveen, and M. Dash, “Yoga reduces symptoms
of distress in tsunami survivors in the Andaman Islands,”
Evidence-Based Complementary and Alternative Medicine, vol.
4, no. 4, pp. 503–509, 2007.
[15] T. Descilo, A. Vedamurtachar, P. L. Gerbarg et al., “Effects of
a yoga breath intervention alone and in combination with
an exposure therapy for post-traumatic stress disorder and
depression in survivors of the 2004 South-East Asia tsunami,”
Acta Psychiatrica Scandinavica, vol. 121, no. 4, pp. 289–300,
2010.
[16] L. C. Waelde, M. Uddo, R. Marquett et al., “A pilot study
of meditation for mental health workers following Hurricane
Katrina,” Journal of Traumatic Stress, vol. 21, no. 5, pp. 497–
500, 2008.
Depression Research and Treatment 9
[17] S. Telles, N. Singh, and M. Joshi, “Risk of p osttraumatic stress
disorder and depression in survivors of the floods in Bihar,
India,” Indian Journal of Medical Sciences, vol. 63, no. 8, pp.
330–334, 2009.
[18] S. Telles, N. Singh, M. Joshi, and A. Balkrishna, “Post
traumatic stress symptoms and heart rate variability in Bihar
flood survivors following yoga: a randomized controlled
study,” BMC Psychiatry, vol. 10, p. 18, 2010.
[19] J.S.Gordon,J.K.Staples,A.Blyta,andM.Bytyqi,“Treatment
of posttraumatic stress disorder in postwar Kosovo high
school students using mind-body skills groups: a pilot study,”
Journal of Traumatic Stress, vol. 17, no. 2, pp. 143–147, 2004.
[20]J.S.Gordon,J.K.Staples,A.Blyta,M.Bytyqi,andA.
T. Wilson, “ Treatment of posttraumatic stress disorder in
postwar Kosovar adolescents using mind-body skills groups:
a randomized controlled trial,” Journal of Clinical Psychiatry,
vol. 69, no. 9, pp. 1469–1476, 2008.
[21] M. Ehud, B. D. An, and S. Avshalom, “Here and now: yoga in
Israeli schools,” International Journal of Yoga,vol.3,no.2,pp.
42–47, 2010.
[22] C. B. J. Lesmana, L. K. Suryani, G. D. Jensen, and N. Tiliopou-
los, “A spiritual-hypnosis assisted treatment of children with
PTSD after the 2002 Bali terrorist attack,” American Journal of
Clinical Hypnosis, vol. 52, no. 1, pp. 23–34, 2009.
[23] C. Catani, M. Kohiladevy, M. Ruf, E. Schauer, T. Elbert, and F.
Neurer, “Treating children traumatized by war and tsunami: a
comparison between exposure therapy and meditation-relaxa-
tion in North-east Sri Lanka,” BioMed Central Psychiatry, vol.
9, p. 22, 2009.
[24] T. Mendelson, M. T. Greenberg, J. K. Dariotis, L. F. Gould, B. L.
Rhoades, and P. J. Leaf, “Feasibility and preliminary outcomes
of a s chool-based mindfulness intervention for urban youth,”
Journal of Abnormal Child Psychology, vol. 38, no. 7, pp. 985–
994, 2010.
[25] E. Rauhala, H. Alho, O. Hanninen, and P. Helin, “Relaxation
training combined with increased physical activity lowers
the psychophysiological activation in community-home boys,”
International Journal of Psychophysiology, vol. 10, no. 1, pp. 63–
68, 1990.
[26] S.Telles,S.Narendran,P.Raghuraj,R.Nagarathna,andH.R.
Nagendra, “Comparison of changes in autonomic and respi-
ratory parameters of girls after Yoga and games at a commu-
nity home,” Perceptual and Motor Skills, vol. 84, no. 1, pp. 251–
257, 1996.
[27] J. T. Cacioppo and L. G. Tassinary, Principles of Psycho-
physiology—Physical, Social, and Inferential Elements,Cam-
bridge University Press, Cambridge, UK, 1990.
[28]J.W.Murrough,Y.Huang,J.Huetal.,“Reducedamygdala
serotonin transporter binding in posttraumatic stress disor-
der,” Biological Psychiatry, vol. 70, no. 11, pp. 1033–1038, 2011.
[29] X. Yu, M. Fumoto, Y. Nakatani et al., “Activation of the ante-
rior prefrontal cortex and serotonergic system is associated
with improvements in mood and EEG changes induced by
Zen meditation practice in novices,” International Journal of
Psychophysiology, vol. 80, no. 2, pp. 103–111, 2011.
[30] J.W.Jahng,V.Ryu,S.B.Yoo,S.J.Noh,J.Y.Kim,andJ.H.
Lee, “Mesolimbic dopaminergic activity responding to acute
stress is blunted in adolescent rats that experienced neonatal
maternal separation,” Neuroscience, vol. 171, no. 1, pp. 144–
152, 2010.
[31] Y. H. Jung, D. H. Kang, J. H. Jang et al., “The effects of mind-
body t raining on stress reduction, positive affect, and plasma
catecholamines,” Neuroscience Letters, vol. 479, no. 2, pp. 138–
142, 2010.
[32] C. C. Streeter, J. E. Jensen, R. M. Perlmutter et al., “Yoga Asana
sessions increase brain GABA levels: a pilot study,” Journal of
Alternative and Complementary Medicine, vol. 13, no. 4, pp.
419–426, 2007.
[33] C. C. Streeter, H. W. Theodore, L. Owen et al., “Effects of yoga
versus walking on mood, anxiety, and brain GABA levels: a
randomized controlled MRS study,” Journal of Alternative and
Complementary Medicine, vol. 16, no. 11, pp. 1145–1152, 2010.
