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Laughter Yoga
versus
group exercise program in elderly
depressed women: a randomized controlled trial
Mahvash Shahidi
1
, Ali Mojtahed
2
, Amirhossein Modabbernia
2
, Mohammad Mojtahed
2
, Abdollah Shafiabady
1
,
Ali Delavar
3
and Habib Honari
3
1
Department of Counseling, School of Psychology & Training Sciences, Allameh Tabatabai University, Tehran, Iran
2
Student Research Office, Research Deputy, Imam Khomeini Hospital Complex, Iran
3
Faculty of Psychology, Allameh Tabatabai University, Tehran, Iran
Correspondence to: M. Shahidi, PhD, E-mail: Mahvash.shahidi@gmail.com
y
Assistant Professor, PhD of Counselling.
Background: Laughter Yoga founded by M. Kataria is a combination of unconditioned laughter and yogic
breathing. Its effect on mental and physical aspects of healthy individuals was shown to be beneficial.
Objective: The objective of this study was to compare the effectiveness of Kataria’s Laughter Yoga and
group exercise therapy in decreasing depression and increasing life satisfaction in older adult women of a
cultural community of Tehran, Iran.
Methods: Seventy depressed old women who were members of a cultural community of Tehran were
chosen by Geriatric depression scale (score >10). After completion of Life Satisfaction Scale pre-test and
demographic questionnaire, subjects were randomized into three groups of laughter therapy, exercise
therapy, and control. Subsequently, depression post-test and life satisfaction post-test were done for all
three groups. The data were analyzed using analysis of covariance and Bonferroni’s correction.
Results: Sixty subjects completed the study. The analysis revealed a significant difference in decrease in
depression scores of both Laughter Yoga and exercise therapy group in comparison to control group
(p<0.001 and p<0.01, respectively). There was no significant difference between Laughter Yoga and
exercise therapy groups. The increase in life satisfaction of Laughter Yoga group showed a significant
difference in comparison with control group ( p<0.001). No significant difference was found between
exercise therapy and either control or Laughter Yoga group.
Conclusion: Our findings showed that Laughter Yoga is at least as effective as group exercise program in
improvement of depression and life satisfaction of elderly depressed women. Copyright #2010 John
Wiley & Sons, Ltd.
Key words: laughter therapy; laughter yoga; exercise therapy; depression; life satisfaction; older women
History: Received 13 January 2010; Accepted 16 April 2010; Published online 16 September 2010 in Wiley Online Library
(wileyonlinelibrary.com).
DOI: 10.1002/gps.2545
Introduction
Despite emergence of new diagnostic and therapeutic
strategies, late life depression—defined as depression
after age 65—continued to show unfavorable out-
comes (Alexopoulos, 2005). Although pharmacologi-
cal treatment has an important role in the treatment
plan, psychotherapeutic interventions as well as
complementary and alternative medicine are also
important particularly in older who have co-morbid
medical conditions and may experience more side
effects with pharmacological treatment because of drug
interactions and altered drug metabolism (Noyes,
1997; Noble, 2003).
One of the alternative modalities, which were
developed recently by Dr M. Kataria, an Indian
physician, is a kind of laughter exercise named as
Laughter Yoga. Laughter Yoga combines uncondi-
RESEARCH ARTICLE
Copyright #2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 322–327.
tional laughter with yogic breathing. In this activity,
one laughs without relying on humor, jokes, or comedy
and laughter is simulated as a body exercise in a group.
Kataria believes that both fake and real laughter has the
same effect on the body (Kataria, 2005). However, as
stated in a review on humor and laughter, number of
scientific works on laughter and humor are limited
(Bennett and Lengacher, 2008). Nevertheless, many of
existing works showed the beneficial effects of laughter
on different body systems such as muscle relaxation
and changes in immunological, hormonal, and mental
parameters (Bennett and Lengacher, 2008). In the case
of Laughter Yoga there is even more lack of
methodologically robust data. There are only two
articles in which effects of Laughter Yoga were assessed
on healthy individuals, both of which showed
promising results (Beckman et al., 2007; Nagendra
et al., 2007). Till date, no work was done on the effects
of this alternative treatment on mental illness,
particularly depressive disorder.
We conducted the present study to compare the
effect of this method with a better-known alternative
modality: the exercise therapy. A recent systematic
review showed the beneficial effect of exercise (in
general) on the treatment of diagnosed depressive
disorder (Mead et al., 2009). The same finding was
shown in a review by Palmer about the effect of
different kinds of exercise on the treatment of late life
depression (Palmer, 2005).
This study was designed to assess the real efficacy of
Laughter Yoga in the treatment of late life depression.
As mentioned above, we chose exercise therapy as a
well-known alternative for comparison, and to
strengthen our findings, we also included a control
group. We chose elderly population because of high
prevalence of co-morbid conditions and thus poten-
tially more exposure to drug adverse effects and we
selected women both because they are a more
susceptible population in our country (Mohammadi
et al., 2005) and were more accessible.
Methods
Participants
Participants were aged depressed women with an age
range of 60–80 years of age. They were selected from
members of a cultural community center for older
women named ‘Kanoone Jahandidegan’ which was
located in District 13 and was chosen randomly out of
22 districts of Tehran, capital of Iran. The center is a
place for spending leisure time designed for older
individuals. The calculated sample size was 60, and
with a predicted drop out rate of 15%, 70 old depressed
women were chosen out of 500 members of this district
using geriatric depression scale (GDS). Participants
with the GDS of 10 or more were included. They were
randomly assigned to Laughter Yoga (n¼23), exercise
therapy (n¼23), and control groups (n¼24). The
study was approved by the ethical committee of
University and the individuals gave informed consent
to participate in the experiments.
Assessment instruments
Three instruments were used for assessment of
participants.
(1) Baseline characteristics questionnaire: this ques-
tionnaire assessed age, level of education, occu-
pation, number of children, and living status of
individuals and was designed by the researcher.
(2) Yesavage Geriatric depression scale (GDS): this
scale contains 30 yes or no questions and divides
individuals into without depression (0–9), moder-
ately depressed (10–19), and severely depressed (20
and more) ones. This questionnaire was validated
in 30 Iranian patients; using Spearman Brown
formula the validity was calculated 96%. Corre-
lation with Hamilton scale and Beck inventory
were r¼0.84 and 0.73, respectively and Test retest
reliability was 0.85.
(3) Diener life satisfaction scale (LSS): this is a five-
item seven-degree Likert type scale, which was
designed to assess life pleasure in general. Both
validity and reliability have been shown to be
acceptable. Cronbach’s acoefficient is 0.87 and
correlation with other life satisfaction inventories is
moderate to high.
Intervention
Two kinds of intervention were used for participants.
(1) Laughter Yoga: As mentioned above, this is a
method founded by M. Kataria in 1995. Laughter
Yoga was performed in 10 sessions by one of the
researchers who were trained in Laughter Yoga.
Each session consisted of:
A brief talk about something delightful like
national and religious ceremonies, having
positive attitudes to everyday life affairs, living
Copyright #2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 322–327.
Laughter Yoga
versus
exercise in older depressed women 323
in the ‘present time’, having activity, working,
etc. This stage acted as a mental preparation for
laughter exercise.
Clapping hands parallel to each other for full
finger-to-finger and palm-to-palm contact;
Kataria explained this stage stimulate acupres-
sure points in hands to increase energy levels.
This is accompanied by rhythm i.e., 1, 2, 3.
Moving hands up and down and swinging from
side to side, with corresponding movements of
the upper and lower extremities.
A simple chant is added to the clapping, nor-
mally HO, HO, HA-HA-HA. Kataria believes
these chants worked as heavy exhalations that
come from the abdomen, to stimulate diaphrag-
matic breathing.
Adding harmonic movements to boost feelings
of happiness and joy.
Having gibberish that is languages of sounds
without meaning like what children do when
playing. Gibberish may be used as a warm up
exercise in Laughter Yoga, to help individuals to
reduce inhibitions and shyness.
Laughter exercises are interspersed with deep
breathing exercises to bring physical and mental
relaxation.
One of the objectives of Laughter Yoga is to
encourage childlike playfulness that helps individ-
uals to laugh without reason. A happy chant to use
after a laughter exercise: very good (clap forward).
Performing Laughter Yoga techniques, each for
30–45 s following by clapping and hands and
saying HO HO HA-HA-HA and two deep
breaths. These techniques include: hearty laugh,
silent laugh with mouth wide open, jumping
laugh with mouth closed, medium laugh, cock-
tail laugh, arm swinging laugh, and one-meter
laugh (see ‘Laugh for no reason’ by M Kataria for
more details’).
In the end of each session, each participant
shouts ‘I am the happiest person in the world’,
then claps hands and looks at others and laughs.
(2) Exercise therapy: Ten sessions of aerobic group
exercise program including jogging and stretching
exercise were used for this group. Time of each
session was about 30 min and each session was
different from the others in the time and intensity
of each exercise and individuals ended with cooling
down in about 5 min. Group program was used
because it is more effective than individual exercise
program. Besides, by using this program we could
match two groups in this regard (Timonen et al.,
2002).
Data analysis
Data were analyzed using SPSS version 15.00 for
Windows. Descriptive statistics were reported in tables
and as meanstandard deviation or frequency and
percentage. Main outcomes were presented as box plot
graphs. Analysis of covariance was used for controlling
the possible effect of pre-test scores. Bonferroni’s test
was used for multiple comparisons of scores among
study groups. pvalue of less than 0.05 was considered
significant.
Results
Sample characteristics
A total of 60 individuals aged 60–80 (mean ¼66.56)
completed the study. Table 1 presents the main
characteristics of each group.
Changes in depression scores
We found that individuals in both laughter therapy and
exercise therapy group showed significant improvement
in their GDS scores (Table 2, Figure 1) when
Bonferroni’s correction was used for multiple com-
parisons between groups ( p<0.001 for laughter
therapy vs. control group and p<0.01 for exercise
therapy vs. control group). There was no significant
difference between two experimental groups ( p¼0.4)
(Table 3). To control the effect of pre-test on post-test
scores we used analysis of covariance (ANCOVA) and
showed significant difference among the means of the
three groups (Table 4).
Changes in life satisfaction scores
Only subjects in Laughter Yoga group showed
significant improvement in their LSS scores compared
with controls (Table 2) ( p<0.001 after Bonferroni’s
correction). There was no significant difference in the
LSS scores between exercise therapy and control group
(Table 3) ( p¼0.1). Although in a student sample ttest
analysis significant difference was found between
Laughter Yoga and exercise therapy group ( p¼0.04),
this was not true when a Bonferroni’s correction was
carried out ( p¼0.2). Again ANCOVA was performed to
control for pre-test scores effect and showed significant
difference between means of the three groups
(Table 4).
Copyright #2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 322–327.
324 M. Shahidi et al.
Discussion
Our aim was to provide scientific evidence for efficacy
of Laughter Yoga in late life depression and our
findings showed the equal efficacy of laughter therapy
and exercise therapy in the improvement of depression
and superior efficacy of laughter therapy over control
in improving life satisfaction. So our study was the
first, to our knowledge, which provided evidence for
efficacy of Laughter Yoga in mental disorders.
As we noted before, there is few publications
regarding Laughter Yoga in a scientific manner and no
work exists which addressed the efficacy of this
alternative treatment in mental disorders particularly
depression. Nagendra et al. studied the effect of seven
20–30 min sessions of Laughter Yoga on 200 healthy IT
professionals (both male and female) in a randomized
controlled trial and found that the blood pressure and
cortisol level as well as perceived level of stress was
Table 1 Baseline characteristics of individuals
Characteristics Laughter therapy
(n¼20)
Exercise therapy
(n¼20)
Control
(n¼20)
Age (mean SD) 65.5 4.8 65.7 4.2 68.4 6.3
Marital status
Single 0(0%) 0(0%) 0(0%)
Married 11(55%) 9(45%) 8(40%)
Divorced 2(10%) 0(0%) 1(5%)
Widow 7(35%) 11(55%) 11(55%)
Level of education
Illiterate 1(5%) 4(20%) 3(15%)
Before diploma 13(65%) 14(70%) 15(75%)
Diploma 5(25%) 2(10%) 2(10%)
After diploma 1(5%) 0(0%) 0(0%)
Occupation
Working 4(20%) 2(10%) 2(10%)
Retired 0(0%) 1(5%) 0(0%)
Housewife 16(80%) 17(85%) 18(90%)
Number of children
0–2 4(20%) 5(25%) 7(35%)
3–5 13(65%) 11(55%) 8(40%)
6 or more 3(15%) 4(20%) 5(25%)
Living situation
Living alone 5(25%) 4(20%) 7(35%)
Living with spouse or children 15(75%) 16(80%) 13(65%)
Table 2 Pre and post-test scores for Geriatric depression scale and life satisfaction scale in groups
Tests Laughter therapy (n¼20) Exercise therapy (n¼20) Control (n¼20)
Geriatric depression scale
Pre-test (mean SD) 16.05.3 15.3 5.4 15.2 3.9
Post-test (mean SD) 10.0 6.9 11.1 6.2 15.2 6.1
Life satisfaction scale
Pre-test (mean SD) 19.24.1 21.5 6.8 20.2 6.2
Post-test (mean SD) 25.9 5.6 24.3 7.7 20.0 5.1
Figure 1 Changes in depression and life satisfaction scores after inter-
ventions in the study groups.
Copyright #2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 322–327.
Laughter Yoga
versus
exercise in older depressed women 325
significantly lower in the intervention group (Chaya
et al., 2008). Results from another study showed that
15 sessions of aerobic laughter exercise significantly
increased positive feelings, social identification,
personal efficacy, and morale of healthy employees
in the workplace (Beckman et al., 2007).
Studies on effects of humor on late life depression
exist, and showed promising results; for example, a
study investigated the effect of humor therapy on the
depression scores and quality of life of depressive older
and Alzheimer’s disease patients and found that
depressive patients in the humor therapy group had
the highest quality of life (Walter et al., 2007).
However, it may not be appropriate to compare this
study with our study. Humor is something mental while
laughter is something physical. This is particularly true in
the context of Laughter Yoga, which its founder, Kataria
believes whether one laughs with or without reason he
may obtain the same benefits. Laughter Yoga is primarily
an exercise rather than a mental activity; although it has
mental components and affects mind. On the other hand
the above-mentioned work is focused on the humor,
although its output was laughter.
Humor coping was also shown to be effective in the
improvement of life satisfaction (Celso et al., 2003).
However, there are few findings about the effect of
Laughter Yoga on life satisfaction. The life satisfaction
itself has many determinants, which were shown in a
meta-analysis of 245 studies in 32 countries; mental
and physical health as well as personal self-efficiency
are important in this regard (Veenhoven, 1991). As we
mentioned previously, Beckman and colleagues showed
an increased improvement of mental health as well as
personal efficiency in individuals practicing Laughter
Yoga (Beckman et al., 2007).
As noted before, Laughter Yoga combines yoga
breathing, stretching and laughter exercise. In a
systematic review, yoga itself was shown to be effective
in the treatment of depressive disorder, although the
same was not true for subclinical depression (Morgan
and Jorm, 2008).
In our study, exercise therapy as a well-studied
treatment modality, was used primarily for compari-
son. It improved the GDS but not LSS scores. In a
review on the effect of exercise on late life depression
the overall positive effects of exercise on mood was
shown compared to other psychosocial or pharma-
cotherapeutic interventions; however, the author
raised debate about the methodology of some of these
studies (Blumenthal et al., 2007). Another review with
a similar subject also showed promising results of the
effect of exercise on depression in the elderly subjects as
individuals who frequently experience losses and
medical diseases (Palmer, 2005). In another study,
which was done on 156 older men and women, a 16-
week trial of exercise also improved life satisfaction
scores (Blumenthal et al., 1999). However, results from
our study did not show significant improvement in life
Table 3 Bonferroni’s Correction for comparison between study groups
Dependent Variable Group (I) Group (J) Mean Difference (IJ) Std. Error Sig. 95%
Confidence
Interval
Depression score Laughter therapy Exercise therapy 1.7 1.2 0.4 4.7 1.2
Control 6.0*1.2 <0.01 9.0 2.9
Exercise therapy Laughter therapy 1.7 1.2 0.4 1.2 4.7
Control 4.2*1.2 <0.01 7.2 1.2
Life satisfaction score Laughter therapy Exercise therapy 3.0 1.6 0.2 0.4 8.1
Control 6.5*1.6 <0.01 2.6 11.1
Exercise therapy Laughter therapy 3.0 1.6 0.2 8.1 0.4
Control 3.5 1.6 0.1 1.2 7.3
*Shows significant result.
Table 4 Analysis of covariance for the control of effect of pre-test scores on post-test scores
DF Sum of square Mean square Fvalue Pr >F
Depression score
Geriatric depression scale pretest 1 1523.02 1523.02 100.231 0.0001
Groups 2 383.46 191.73 12.62 0.0001
Life satisfaction scale
Life satisfaction pretest 1 806.24 806.24 31.09 0.0001
Groups 2 427.07 213.53 8.23 0.0001
Copyright #2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 322–327.
326 M. Shahidi et al.
satisfaction scores among exercise therapy group.
Several explanations may exist; first because the pvalue
is reaching toward significance, it may be a result of a
type II error ( p¼0.10) and another reason may be the
shorter duration of our study compared to above-
mentioned studies. Real absence of effect of exercise on
life satisfaction is less possible because other studies with
larger sample size or longer duration did not show this.
Our study had several limitations; first, the sample
size was not a large one and this may be responsible for
the absence of significant effect of exercise on life
satisfaction. Second, it is recommended that it should
be better to practice Laughter Yoga in green spaces
such as parks but because of socio-cultural reasons we
were unable to do this. Third, lack of sufficient relevant
literature limited us in the comparison of our study
with others. Finally, short duration of our study
prevented us from seeing the effect of longer duration
of Laughter Yoga practice on our subjects.
Conclusion
In general, our study showed promising results about
the effect of Laughter Yoga on the improvement of
depressed mood as well as life satisfaction in elderly
depressive women. However, women in this study are
member of a cultural community of the Tehran; so we
cannot generalize the findings to every depressed older
woman all over the country as the acceptability and
cultural adaptation to this exercise in more rural areas
may not be as high as it is in more civilized regions.
Further studies are warranted to determine the
acceptability of Laughter Yoga as an exercise as well
as its efficacy in larger samples including men and in
comparison to psychotherapies or pharmacotherapies
in late life depression.
Conflicts of interest
None declared.
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Key Points
Laughter Yoga, Founded by M Kataria, is a
combination of unconditioned laughter and yogic
breathing and was shown to improve psycho-
logical parameters in healthy individuals.
We evaluated its efficacy in a group of old
depressed women.
It resulted in improvement of both depression
and life satisfaction and was comparable to
exercise therapy.
This study was the first, to our knowledge, that
showed the efficacy of Laughter Yoga in a mental
illness.
Copyright #2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 322–327.
Laughter Yoga
versus
exercise in older depressed women 327
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