Yoga-based lifestyle intervention as a potential adjuvant in addressing anxiety, fear, depression, and perceived health in mild-to-moderate COVID-19 patients. A pilot study

Jainraj Russel; N Manavalan; M Alli; Kahlil Subramanian; Nisha Gayathiri; Pradeep M K Nair

doi:10.4103/AYUHOM.AYUHOM_35_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 8 | Issue : 1 | Page : 32-37

Yoga-based lifestyle intervention as a potential adjuvant in addressing anxiety, fear, depression, and perceived health in mild-to-moderate COVID-19 patients. A pilot study

Jainraj Russel¹, N Manavalan², M Alli³, Kahlil Subramanian², Nisha Gayathiri⁴, Pradeep M K Nair⁵
¹ Department of Yoga and Naturopathy, Life Style Clinic, Government Medical College Hospital, Ramanathapuram, Tamil Nadu, India
² Government Yoga and Naturopathy Medical College and Hospital, Chennai, Tamil Nadu, India
³ Dean, Ramanathapuram Government Medial College Hospital, Ramanathapuram, Tamil Nadu, India
⁴ Department of Yoga and Naturopathy, JSS Yoga and Naturopathy College, Coimbatore, Tamil Nadu, India
⁵ Indian Academy for Scientific Writing and Research, Pune, Maharashtra; Department of Research, Sant Hirdaram Medical College of Naturopathy and Yogic Sciences for Women, Bhopal, Madhya Pradesh, India

Date of Submission	22-Jun-2021
Date of Decision	23-Aug-2021
Date of Acceptance	24-Aug-2021
Date of Web Publication	26-Nov-2021

Correspondence Address:
Dr. Pradeep M K Nair
Sant Hirdaram Medical College of Naturopathy and Yogic Sciences for Women, Bhopal, Madhya Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AYUHOM.AYUHOM_35_21

Abstract

Introduction: Coronavirus infection (COVID-19) has led to a serious public health crisis that has affected both physical and mental health. As we are racing toward a solution for containing the virus, there is a profound need to address the mental health impact of COVID-19 such as anxiety, stress, and depression. The present study evaluates the impact of yoga on mental health issues arising in COVID-19 pandemic. Materials and Methods: Patients who are diagnosed as COVID-19 by polymerase chain reaction and graded as mild-to-moderate COVID-19 as per the ICMR criteria were enrolled for adjuvant yoga and naturopathy-based lifestyle modification, which includes postures, breath regulation, meditation, and eucalyptus essential oil inhalation for 14 days. SpO₂ (saturated oxygen) and anxiety, stress, depression, fear, and health were assessed through the depression, anxiety, and stress scale (DASS) at baseline (day 1 of admission) and 7^th day, as well as visual analog scale (VAS) at baseline and 7^th and 14^th day. Results: Statistically significant changes reduction were observed in DASS-21 scores and VAS scores (P < 0.05) but not on SpO₂. Slight increase in mean anxiety, depth of fear, sleep disturbance, and health status was observed in VAS between 7^th and 14^th day, which was statistically nonsignificant. Discussion: Supervised yoga sessions are reported to be of significant impact in alleviating the mental health issues in COVID-19 compared to nonsupervised sessions. Our results suggest the inclusion of yoga therapy into COVID-19 care as an adjuvant considering its impact on mental health. However, future randomized control trials are warranted with more specific end points to ensure enhanced acceptance of yoga in scientific community.

Keywords: Anxiety, COVID-19, mental health, posttraumatic stress, yoga

How to cite this article:
Russel J, Manavalan N, Alli M, Subramanian K, Gayathiri N, K Nair PM. Yoga-based lifestyle intervention as a potential adjuvant in addressing anxiety, fear, depression, and perceived health in mild-to-moderate COVID-19 patients. A pilot study. AYUHOM 2021;8:32-7

How to cite this URL:
Russel J, Manavalan N, Alli M, Subramanian K, Gayathiri N, K Nair PM. Yoga-based lifestyle intervention as a potential adjuvant in addressing anxiety, fear, depression, and perceived health in mild-to-moderate COVID-19 patients. A pilot study. AYUHOM [serial online] 2021 [cited 2022 Jun 29];8:32-7. Available from: http://www.ayuhom.com/text.asp?2021/8/1/32/331319

Introduction

Coronavirus infection (COVID-19) has adversely affected the health, economy, and day-to-day functioning of the global population across 198 countries. Uncertainty around the prognosis, unfamiliar public health measures that have impinged personal freedom, and concomitant financial crisis have emerged as major stressors that are expected to impact the emotional well-being of both individuals and communities.^[1] Public health emergencies are thus thought to disturb the emotional equilibrium, especially in those who contract the disease or vulnerable population who are likely to contract the disease.^[1] A recent study has reported stress, anxiety, depression, insomnia, denial, anger, and fear as the most commonly seen mental health issues associated with COVID-19 in India.^[2]

Mental health traumas brought by infectious diseases or pandemics are a major concern. Earlier reports from the Ebola outbreak of 2014 reported that a large number of people suffered from posttraumatic stress disorder, anxiety–depression during the outbreak.^[3] Preliminary reports suggest that 16%–18% have shown the symptoms of anxiety or depression.^[4],[5] Although the impact of pandemics on mental health is widely reckoned, addressing them is seldom prioritized as majority of resources are employed in containing the pandemic.^[2] Experts across the globe have univocally acknowledged the necessity of mental health strategies during this public health emergency.^[6]

Yoga, the ancient mind–body wisdom originated from India, is widely reckoned for its mastery over mind. Yogic techniques such as asanas (postures), pranayamas (breathing techniques), and meditation promote both mental and physical well-being.^[7] Numerous studies have suggested the importance of integrating yoga into the pandemic care strategy owing to its homeostatic potential that can effectively address the mental health imbalances and immunocompromised state.^{[7],[8],[9],[10]} Many studies recommend yoga as an ancillary therapy for treating posttraumatic stress disorders, especially stress, anxiety, and depression.^{[11],[12],[13]} Besides, this yoga has also been proven beneficial in alleviating the mental trauma arising from testing conditions such as natural calamities.^[14],[15] Owing to these benefits, postulates for the inclusion of yoga into mental health crisis arising due to COVID-19 are on the rise.^{[7],[8],[9],[10],[16],[17],[18]}

Based on the compelling literature, we evaluated whether a modified yoga protocol along with aromatherapy a naturopathic intervention alongside the standard care is effective in reducing depression, anxiety, and stress among mild-to-moderate COVID-19 patients.

Materials and Methods

Setting

The study was conducted as a quasi-experimental study at an isolation ward for COVID-19 at a Government Medical College Hospital, Tamil Nadu, India. The study protocol was approved by the Institutional Ethics Committee of the hospital.

Participants

The study participants were those who were detected positive for SARS-CoV-2 by means of polymerase chain reaction assay and were classified as mild to moderate based on the disease severity scale.^[19] We excluded all those patients who were classified as severe symptomatic cases, pregnant women, and COVID-positive patients with other comorbidities, except Type 2 diabetes mellitus and hypertension. All the enrolled participants signed informed consent to participate in this study.

Interventions

In addition to the standard care,^[20] the participants were given modified yoga protocol for 30 min every day which includes yogic postures, breath regulation, and meditation [Table 1]. Reports suggest that comprehensive yoga programs including asanas, breathing techniques, and meditation can be considered as a potential adjuvant in treating or preventing SARS-CoV-2 infection and COVID-19 disease.^[21] This is specifically due to the potential of yoga practices to improve lung health,^[22] improve the immune response,^[23] modulate inflammatory response,^[24] and enhance mental vitality.^[25] Further, all the participants were provided with tissue paper that contains two drops of eucalyptus essential oil. The participants were advised to keep the tissue paper 5 cm away from the nose and have to inhale and exhale for 15 min continually. Studies show that eucalyptus oil inhalation alleviates inflammation,^[26] reduces anxiety,^[27] and has been used as a medium of inhalation in treating influenza infection, bronchitis, asthma, and chronic obstructive pulmonary disease.^[28] Yoga therapy and eucalyptus oil inhalation are found to be effective in alleviating inflammation and stress and can be easily delivered in COVID care settings. Patients were trained on both yoga protocol and inhalation of eucalyptus essential oil by a qualified yoga and naturopathy physician.

Table 1: Yoga interventions provided for the patients

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These interventions were given continuously for 7 days. The participants performed the therapies under direct observation of a qualified yoga and naturopathy physician on every alternative day (day 1, day 3, day 5, and day 7) and practiced the same by themselves on days 2, 4, and 6. The participants were asked to practice the same at home after discharge from the hospital up to the 14^th day.

Outcome measures

Visual analog scale

The participants were assessed on day 1, day 7, and day 14 using a 10 cm visual analog scale (VAS),^[29] where the participants will rate their depth of fear, anxiety, disturbed sleep, and health status. The scoring of VAS was calculated by measuring the distance from the left end of the analog scale which corresponds to “zero” and right end which corresponds to “ten,” the right end being the highest stage of anxiety, fear, disturbed sleep, and sadness and left end being the least.

Depression, anxiety, and stress scale-21

The depression, anxiety, and stress scale-21 items (DASS-21) is a set of three self-report scales designed to measure the emotional states of depression, anxiety, and stress.^[30] This scale was used on day 1 and day 7. Each of the three DASS-21 scales contains seven items, divided into subscales with similar content. The depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia, and inertia. The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. The stress scale is sensitive to levels of chronic nonspecific arousal. It assesses difficulty in relaxing, nervous arousal, and being easily upset/agitated, irritable/overreactive, and impatient. Scores for depression, anxiety, and stress are calculated by adding the scores for the relevant items.

Oxygen saturation

A pulse oximeter was used to measure the oxygen saturation levels (SpO₂) in the blood on day 1 and day 7. Low oxygen levels can be an early warning sign that advanced care is needed.^[31]

Results

The study has 20 participants enrolled at the commencement of which 16 participants (male = 12, female = 4) completed the study. The number of male participants was more in the study, this difference existed largely due to more number of males got infected with COVID-19 infection compared to females. Of all the participants, n = 9 were aged between 35 and 55, n = 5 were aged between 20 and 30, and n = 2 were above 65. There was a mean rise in the values of SpO₂ from 96.38% ± 2.630% to 97.12% ± 1.360% after 7 days of intervention. However, this change was statistically not significant.

DASS-21 scores for depression, anxiety, and stress after 7 days of intervention have shown a statistically significant reduction. Similarly, a repeated-measures analysis of variance with a Greenhouse–Geisser correction determined that mean anxiety, depth of fear, sleep disturbance, and health status of VAS score differed statistically significantly between time points. The results are tabulated in [Table 2].

Table 2: Comparison of pre- and postassessment of depression, anxiety, and stress scale-21, visual analog scale, and saturated oxygen scores

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Post hoc tests using the Bonferroni correction revealed that there was a slight increase in all the four VAS scores on the 14^th day which was not statistically significant [Figure 1]. Profile plots for the anxiety, depth of fear, sleep disturbance, and health status of VAS score at different time points are plotted in [Figure 2], [Figure 3], [Figure 4], [Figure 5].

Figure 1: Comparison of VAS scores in different time periods

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Figure 2: Estimated marginal means of anxiety

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Figure 3: Estimated marginal means of depth of fear

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Figure 4: Estimated marginal means of perceived health

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Figure 5: Estimated marginal means of sleep disturbance

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Discussion

Although various reviews suggested the need for introducing yoga therapy for the treatment, primary evidence on integrating yoga in alleviating mental health sufferings of COVID-19 is scarce. To our knowledge, this is the first study exploring the effect of yoga on depression, anxiety, and other prominent mental health symptoms in COVID-19 patients. The role of yoga therapy in treating mental health issues arising from extremely challenging situations such as natural calamities has been acknowledged by the earlier studies.^{[32],[33],[34],[35],[36]} These studies reported reduction in stress, depression, anxiety, and improvement in health-related quality of life. The current study also has reported similar changes in our participants. Inhalation of essential oils such as eucalyptus oil has been thought to induce psychological relief by inducing hormonal, glandular, emotional, circulatory, calming effects.^[37],[38] Similar property of eucalyptus oil might have complemented or enhanced the beneficial action of yoga. However, the study results are suggestive of using yoga as a potential tool in treating mental health symptoms/diseases, owing to the gravity of agony induced by COVID-19 and the number of people affected. Unlike natural disasters, COVID-19 has affected the mental health of both infected and noninfected population. Considering our findings alongside the proven mental health benefits of yoga, it definitely warrants a place in COVID-19 prevention and prophylactic strategies.

In addition, our study revealed an interesting feature that regular practice of yoga therapy under supervision has significantly improved the health status and reduced anxiety, sleep disturbance, and depth of fear in the participants. However, self-practice of yoga therapy at home did not yield the same significant outcome. This entails the need for supervision and constant guidance in improving adherence and better clinical outcomes while deploying yoga therapy.

Irrespective of these positive inferences, smaller sample size, lack of a control group and methodological limitation in follow-up measures remains as a limitation of this study. Nevertheless, the results are encouraging to conduct a randomized control trial with more stratified samples.

Conclusion

COVID-19 pandemic has created a state of mental disruption across the globe owing to its multi-laden impact on various aspects of human life including mental health. Yoga, a proven mind–body therapy, has shown to offer the much-needed mental stability by ameliorating anxiety, depression, and perceived stress which make yoga, an evidence-based and imperative regimen in dealing with COVID-19.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Pfefferbaum B, North CS. Mental health and the COVID-19 pandemic. N Engl J Med 2020;383:510-2.
2.	Roy A, Singh AK, Mishra S, Chinnadurai A, Mitra A, Bakshi O. Mental health implications of COVID-19 pandemic and its response in India. Int J Soc Psychiatry 2020;67:587-600 [doi: 10.1177/0020764020950769].
3.	Jalloh MF, Li W, Bunnell RE, Ethier KA, O'Leary A, Hageman KM, et al. Impact of Ebola experiences and risk perceptions on mental health in Sierra Leone, July 2015. BMJ Glob Health 2018;3:e000471.
4.	Rajkumar RP. COVID-19 and mental health: A review of the existing literature. Asian J Psychiatr 2020;52:102066.
5.	Vindegaard N, Benros ME. COVID-19 pandemic and mental health consequences: Systematic review of the current evidence. Brain Behav Immun 2020;89:531-42.
6.	Moreno C, Wykes T, Galderisi S, Nordentoft M, Crossley N, Jones N, et al. How mental health care should change as a consequence of the COVID-19 pandemic. Lancet Psychiatry 2020;7:813-24.
7.	Nagarathna R, Nagendra HR, Majumdar V. A perspective on yoga as a preventive strategy for coronavirus disease 2019. Int J Yoga 2020;13:89-98. [Full text]
8.	Telles S. Positioning yoga in the COVID-19 pandemic. Yoga Mimamsa 2020;52:1-4. [Full text]
9.	Nagendra HR. Yoga for COVID-19. Int J Yoga 2020;13:87-8. [Full text]
10.	Nair P. Integrated approach of yoga and naturopathy alongside conventional care: A need of the hour healthcare strategy in the management of COVID-19 in India – An overview. Yoga Mimamsa 2020;52:70-5. [Full text]
11.	Cramer H, Lauche R, Langhorst J, Dobos G. Yoga for depression: A systematic review and meta-analysis. Depress Anxiety 2013;30:1068-83.
12.	Kirkwood G, Rampes H, Tuffrey V, Richardson J, Pilkington K. Yoga for anxiety: A systematic review of the research evidence. Br J Sports Med 2005;39:884-91.
13.	Cramer H, Anheyer D, Saha FJ, Dobos G. Yoga for posttraumatic stress disorder – A systematic review and meta-analysis. BMC Psychiatry 2018;18:72.
14.	Macy RJ, Jones E, Graham LM, Roach L. Yoga for trauma and related mental health problems: A meta-review with clinical and service recommendations. Trauma Violence Abuse 2018;19:35-57.
15.	Telles S, Singh N, Balkrishna A. Managing mental health disorders resulting from trauma through yoga: A review. Depress Res Treat 2012;2012:401513.
16.	Tillu G, Salvi S, Patwardhan B. AYUSH for COVID-19 management. J Ayurveda Integr Med 2020;11:95-6.
17.	Ransing R, Pinto da Costa M, Adiukwu F, Grandinetti P, Schuh Teixeira AL, Kilic O, et al. Yoga for COVID-19 and natural disaster related mental health issues: Challenges and perspectives. Asian J Psychiatr 2020;53:102386.
18.	Tillu G, Chaturvedi S, Chopra A, Patwardhan B. Public health approach of ayurveda and yoga for COVID-19 prophylaxis. J Altern Complement Med 2020;26:360-4.
19.	Zu ZY, Jiang MD, Xu PP, Chen W, Ni QQ, Lu GM, et al. Coronavirus disease 2019 (COVID-19): A perspective from China. Radiology 2020;296:E15-25.
20.	Clinical Management Protocol: COVID-19; 2020. Available from: https://www.mohfw.gov.in/pdf/ClinicalManagementProtocolforCOVID19.pdf. [Last accessed on 2021 Aug 23].
21.	Bushell W, Castle R, Williams MA, Brouwer KC, Tanzi RE, Chopra D, et al. Meditation and yoga practices as potential adjunctive treatment of SARS-CoV-2 infection and COVID-19: A brief overview of key subjects. J Altern Complement Med 2020;26:547-56.
22.	Paudyal P, Jones C, Grindey C, Dawood R, Smith H. Meditation for asthma: Systematic review and meta-analysis. J Asthma 2018;55:771-8.
23.	Morgan N, Irwin MR, Chung M, Wang C. The effects of mind-body therapies on the immune system: Meta-analysis. PLoS One 2014;9:e100903.
24.	Bower JE, Irwin MR. Mind-body therapies and control of inflammatory biology: A descriptive review. Brain Behav Immun 2016;51:1-11.
25.	Jacobs GD. The physiology of mind-body interactions: The stress response and the relaxation response. J Altern Complement Med 2001;7 Suppl 1:S83-92.
26.	Jun YS, Kang P, Min SS, Lee JM, Kim HK, Seol GH. Effect of eucalyptus oil inhalation on pain and inflammatory responses after total knee replacement: A randomized clinical trial. Evid Based Complement Alternat Med 2013;2013:502727.
27.	Kim KY, Seo HJ, Min SS, Park M, Seol GH. The effect of 1,8-cineole inhalation on preoperative anxiety: A randomized clinical trial. Evid Based Complement Alternat Med 2014;2014:820126.
28.	Sadlon AE, Lamson DW. Immune-modifying and antimicrobial effects of Eucalyptus oil and simple inhalation devices. Altern Med Rev 2010;15:33-47.
29.	McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: A critical review. Psychol Med 1988;18:1007-19.
30.	Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther 1995;33:335-43.
31.	Shenoy N, Luchtel R, Gulani P. Considerations for target oxygen saturation in COVID-19 patients: Are we under-shooting? BMC Med 2020;18:260.
32.	Descilo T, Vedamurtachar A, Gerbarg PL, Nagaraja D, Gangadhar BN, Damodaran B, 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 Psychiatr Scand 2010;121:289-300.
33.	Durrani S, Contreras J, Mallaiah S, Cohen L, Milbury K. The effects of yoga in helping cancer patients and caregivers manage the stress of a natural disaster: A brief report on hurricane Harvey. Integr Cancer Ther 2019;18:1534735419866923.
34.	Telles S, Singh N, Joshi M, Balkrishna A. Post traumatic stress symptoms and heart rate variability in Bihar flood survivors following yoga: A randomized controlled study. BMC Psychiatry 2010;10:18.
35.	Telles S, Naveen KV, Dash M. Yoga reduces symptoms of distress in tsunami survivors in the Andaman Islands. Evid Based Complement Alternat Med 2007;4:503-9.
36.	Thordardottir K, Gudmundsdottir R, Zoëga H, Valdimarsdottir UA, Gudmundsdottir B. Effects of yoga practice on stress-related symptoms in the aftermath of an earthquake: A community-based controlled trial. Complement Ther Med 2014;22:226-34.
37.	Ali B, Al-Wabel NA, Shams S, Ahamad A, Khan SA, Anwar F. Essential oils used in aromatherapy: A systemic review. Asian Pac J Trop Biomed 2015;5:601-11.
38.	Svoboda KP, Deans SG. Biological activities of essential oils from selected aromatic plants. Int Symp Med Aromat Plants 1994;390:203-9.