OBJECTIVE:To evaluate feasibility, efficacy, and tolerability of Sudarshan Kriya yoga (SKY) as an adjunctive intervention in patients with major depressive disorder (MDD) with inadequate response to antidepressant treatment.

METHODS:Patients with MDD (defined by DSM-IV-TR) who were depressed despite≥ 8 weeks of antidepressant treatment were randomized to SKY or a waitlist control (delayed yoga) arm for 8 weeks. The primary efficacy end point was change in 17-item Hamilton Depression Rating Scale (HDRS-17) total score from baseline to 2 months. The key secondary efficacy end points were change in Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) total scores. Analyses of the intent-to-treat (ITT) and completer sample were performed. The study was conducted at the University of Pennsylvania between October 2014 and December 2015.

RESULTS:In the ITT sample (n = 25), the SKY arm (n = 13) showed a greater improvement in HDRS-17 total score compared to waitlist control (n = 12) (-9.77 vs 0.50, P = .0032). SKY also showed greater reduction in BDI total score versus waitlist control (-17.23 vs -1.75, P = .0101). Mean changes in BAI total score from baseline were significantly greater for SKY than waitlist (ITT mean difference: -5.19; 95% CI, -0.93 to -9.34; P = .0097; completer mean difference: -6.23; 95% CI, -1.39 to -11.07; P = .0005). No adverse events were reported.

CONCLUSIONS:Results of this randomized, waitlist-controlled pilot study suggest the feasibility and promise of an adjunctive SKY-based intervention for patients with MDD who have not responded to antidepressants.

TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT02616549.

BACKGROUND:Depression is one of the most common mental disorders. Finding effective treatments for such a disorder with higher efficiency lower side effects and affordability is an active area of research in psychiatry. This study aimed to comparatively analyze the effects of the cognitive group therapy and aerobic exercises on depression, automatic negative thoughts and dysfunctional attitudes of students at Kermanshah University of Medical Science.

METHODS:In this clinical trial, 46 associate and undergraduate students at Kermanshah University of Medical Science were randomly divided into three groups: cognitive therapy, aerobic exercise, and control. The data was gathered both before and 8 weeks after the intervention. Beck Depression Inventory (BDI-II), automatic negative thoughts (ATQ), and the Dysfunctional Attitude Scale (DAS) were used as the data collection instruments. The data were analyzed with SPSS version 15 using paired samples T-test, chi-square test, Kruskal-Wallis test, and analysis of variance (ANOVA).

RESULTS:Cognitive therapy caused a significant decrease in depression, belief in automatic negative thoughts, and dysfunctional attitudes in comparison to the control group (p<0.05). Although aerobics compared to the control group causes more reductions in the variables, however, It was only meaningful for the depression variable (p=0.049). Cognitive therapy also reduced the variables more than the aerobic exercise, but the decrease was not statistically significant.

CONCLUSIONS:Cognitive group therapy and aerobic exercise are effective in treating depression. For treating depression, aerobic exercise can be used as a therapy itself or along with cognitive-behavioral therapy and pharmacotherapy.

Despite its prevalence and significance, late life depression is underrecognized and undertreated. This study aimed to investigate the effect of a long-term exercise intervention on depressive symptoms in older Korean women. Thirty older women were assigned to exercise (n = 15, age of 80.8± 3.8 years) or control group (n = 15, age of 78.6 ± 3.2 years). The exercise group underwent a resistance exercise plus walking two times weekly on nonconsecutive days for 6 months. Post-intervention change in depressive symptoms was regarded as the primary outcome. Secondary outcomes included changes in body composition and physical performance. Repeated measures analysis of variance showed significant group by time interactions for depressive symptoms (F(1,23) = 37.540, p<0.001), percent body fat (F(1,23) = 6.122, p = 0.021), lean body mass (F(1,23) = 5.662, p = 0.026), waist circumference (F(1,23) = 4.330, p = 0.049), handgrip strength (F(1,23) = 10.114, p = 0.005), 6-min walking (F(1,23) = 28.988, p<0.001), and 2.44-m Up&Go (F(1,23) = 28.714, p<0.001). The current findings support regular exercise as a therapeutic strategy to promote overall and mental health in older Korean women with depressive symptoms.

OBJECTIVE:This pilot, randomized clinical trial investigates the effectiveness of tai chi as the primary treatment for Chinese Americans with major depressive disorder (MDD).

METHODS:67 Chinese Americans with DSM-IV MDD and no treatment for depression were recruited between March 2012 and April 2013 and randomized (1:1:1) into a tai chi intervention, an education program, or a waitlisted group for 12 weeks. The primary outcome measure was the 17-item Hamilton Depression Rating Scale (HDRS₁₇); positive response for this outcome was defined as a decrease in total score of 50% or more, and remission was defined as HDRS₁₇ ≤ 7.

RESULTS:Participants (N = 67) were 72% female with a mean age of 54± 13 years. No serious adverse events were reported. After the end of the 12-week intervention, response rates were 25%, 21%, and 56%, and remission rates were 10%, 21%, and 50% for the waitlisted, education, and tai chi intervention groups, respectively. The tai chi group showed improved treatmentresponse when compared to both the waitlisted group (odds ratio [OR] = 2.11; 95% CI, 1.01-4.46) and to the education group (OR = 8.90; 95% CI, 1.17-67.70). Tai chi intervention showed significantly improved remission rate over the waitlisted group (OR = 3.01; 95% CI, 1.25-7.10), and a trend of improved remission compared to the education group (OR = 4.40; 95% CI, 0.78-24.17).

CONCLUSIONS:As the primary treatment, tai chi improved treatment outcomes for Chinese Americans with MDD over both passive and active control groups.

TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT01619631.

BACKGROUND:Yoga interventions offer promise for the treatment of major depressive disorder (MDD), yet their safety and potential impact on suicidal ideation (SI) have not been well documented. This study evaluated the safety of a randomized controlled dose-finding trial of Iyengar yoga plus coherent breathing for individuals with MDD, as well as the potential effects of the intervention on SI without intent.

METHODS:Participants with Beck Depression Inventory-II (BDI-II) scores ≥14 and a diagnosis of MDD (using DSM-IV criteria) were randomized to either a low dose group (LDG) or high dose group (HDG) and received a 12-week manualized intervention. The LDG included two 90-min yoga classes plus three 30-min homework sessions weekly. The HDG offered three 90-min classesplus four 30-min homework sessions weekly.

RESULTS:Thirty-two individuals with MDD were randomized, of which 30 completed the protocol. At screening, SI without intent was endorsed on the BDI-II by 9 participants; after completing the intervention, 8 out of 9 reported resolution of SI. There were 17 adverse events possibly-related and 15 definitely-related to the intervention. The most common protocol-related adverse event was musculoskeletal pain, which resolved over the course of the study.

CONCLUSIONS:The Iyengar yoga plus coherent breathing intervention was associated with the resolution of SI in 8 out of 9 participants, with mild side effects that were primarily musculoskeletal in nature. This preliminary evidence suggests that this intervention may reduce SI without intent and be safe for use in those with MDD.

BACKGROUND:Yoga interventions offer promise for the treatment of major depressive disorder (MDD), yet their safety and potential impact on suicidal ideation (SI) have not been well documented. This study evaluated the safety of a randomized controlled dose-finding trial of Iyengar yoga plus coherent breathing for individuals with MDD, as well as the potential effects of the intervention on SI without intent.

METHODS:Participants with Beck Depression Inventory-II (BDI-II) scores ≥14 and a diagnosis of MDD (using DSM-IV criteria) were randomized to either a low dose group (LDG) or high dose group (HDG) and received a 12-week manualized intervention. The LDG included two 90-min yoga classes plus three 30-min homework sessions weekly. The HDG offered three 90-min classesplus four 30-min homework sessions weekly.

RESULTS:Thirty-two individuals with MDD were randomized, of which 30 completed the protocol. At screening, SI without intent was endorsed on the BDI-II by 9 participants; after completing the intervention, 8 out of 9 reported resolution of SI. There were 17 adverse events possibly-related and 15 definitely-related to the intervention. The most common protocol-related adverse event was musculoskeletal pain, which resolved over the course of the study.

CONCLUSIONS:The Iyengar yoga plus coherent breathing intervention was associated with the resolution of SI in 8 out of 9 participants, with mild side effects that were primarily musculoskeletal in nature. This preliminary evidence suggests that this intervention may reduce SI without intent and be safe for use in those with MDD.

BACKGROUND:Due to the clinical challenges of treatment-resistant depression (TRD), we evaluated the efficacy of mindfulness-based cognitive therapy (MBCT) relative to a structurally equivalent active comparison condition as adjuncts to treatment-as-usual (TAU) pharmacotherapy in TRD.

METHODS:This single-site, randomized controlled trial compared 8-week courses of MBCT and the Health Enhancement Program (HEP), comprising physical fitness, music therapy and nutritional education, as adjuncts to TAU pharmacotherapy for outpatient adults with TRD. The primary outcome was change in depression severity, measured by percent reduction in the total score on the 17-item Hamilton Depression Rating Scale (HAM-D17), with secondary depression indicators of treatment response and remission.

RESULTS:We enrolled 173 adults; mean length of a current depressive episode was 6.8 years (SD = 8.9). At the end of 8 weeks of treatment, a multivariate analysis showed that relative to the HEP condition, the MBCT condition was associated with a significantly greater mean percent reduction in the HAM-D17 (36.6 vs. 25.3%; p = 0.01) and a significantly higher rate of treatment responders (30.3 vs. 15.3%; p = 0.03). Although numerically superior for MBCT than for HEP, the rates of remission did not significantly differ between treatments (22.4 vs. 13.9%; p = 0.15). In these models, state anxiety, perceived stress and the presence of personality disorder had adverse effects on outcomes.

CONCLUSIONS:MBCT significantly decreased depression severity and improved treatment response rates at 8 weeks but not remission rates. MBCT appears to be a viable adjunct in the management of TRD.

BACKGROUND:Due to the clinical challenges of treatment-resistant depression (TRD), we evaluated the efficacy of mindfulness-based cognitive therapy (MBCT) relative to a structurally equivalent active comparison condition as adjuncts to treatment-as-usual (TAU) pharmacotherapy in TRD.

METHODS:This single-site, randomized controlled trial compared 8-week courses of MBCT and the Health Enhancement Program (HEP), comprising physical fitness, music therapy and nutritional education, as adjuncts to TAU pharmacotherapy for outpatient adults with TRD. The primary outcome was change in depression severity, measured by percent reduction in the total score on the 17-item Hamilton Depression Rating Scale (HAM-D17), with secondary depression indicators of treatment response and remission.

RESULTS:We enrolled 173 adults; mean length of a current depressive episode was 6.8 years (SD = 8.9). At the end of 8 weeks of treatment, a multivariate analysis showed that relative to the HEP condition, the MBCT condition was associated with a significantly greater mean percent reduction in the HAM-D17 (36.6 vs. 25.3%; p = 0.01) and a significantly higher rate of treatment responders (30.3 vs. 15.3%; p = 0.03). Although numerically superior for MBCT than for HEP, the rates of remission did not significantly differ between treatments (22.4 vs. 13.9%; p = 0.15). In these models, state anxiety, perceived stress and the presence of personality disorder had adverse effects on outcomes.

CONCLUSIONS:MBCT significantly decreased depression severity and improved treatment response rates at 8 weeks but not remission rates. MBCT appears to be a viable adjunct in the management of TRD.

BACKGROUND:Yoga may be well suited for depressed and anxious pregnant women, given reported benefits of meditation and physical activity and pregnant women's preference for nonpharmacological treatments.

METHODS:We randomly assigned 46 pregnant women with symptoms of depression and anxiety to an 8-week yoga intervention or treatment-as-usual (TAU) in order to examine feasibility and preliminary outcomes.

RESULTS:Yoga was associated with high levels of credibility and satisfaction as an intervention for depression and anxiety during pregnancy. Participants in both conditions reported significant improvement in symptoms of depression and anxiety over time; and yoga was associated with significantly greater reduction in negative affect as compared to TAU (β = -0.53, SE = 0.20, p = .011).

CONCLUSION:Prenatal yoga was found to be a feasible and acceptable intervention and was associated with reductions in symptoms of anxiety and depression; however, prenatal yoga only significantly outperformed TAU on reduction of negative affect.

PURPOSE:To compare 2 mild-to-moderate group exercises and treatment as usual (TAU) for improvements in physical function and depressive symptoms.

METHODS:Patients with heart failure (n = 70, mean age = 66 yr, range = 45-89 yr) were randomized to 16 wk of tai chi (TC), resistance band (RB) exercise, or TAU.

RESULTS:Physical function differed by group from baseline to follow-up, measured by distance walked in the 6-min walk test (F = 3.19, P = .03). Tai chi participants demonstrated a nonsignificant decrease of 162 ft (95% confidence interval [CI], 21 to -345, P = .08) while distance walked by RB participants remained stable with a nonsignificant increase of 70 ft (95% CI, 267 to -127, P = .48). Treatment as usual group significantly decreased by 205 ft (95% CI, -35 to -374, P = .02) and no group differences occurred over time in end-systolic volume (P = .43) and left ventricular function (LVEF) (P = .67). However, groups differed over time in the Beck Depression Inventory (F = 9.2, P<.01). Both TC and RB groups improved (decreased) by 3.5 points (95% CI, 2-5, P<.01). Treatment as usual group decreased insignificantly 1 point (95% CI, -1 to 3, P = .27).

CONCLUSIONS:Tai chi and RB participants avoided a decrease in physical function decrements as seen with TAU. No groups changed in cardiac function. Both TC and RB groups saw reduced depression symptoms compared with TAU. Thus, both TC and RB groups avoided a decrease in physical function and improved their psychological function when compared with TAU.

In this pilot study, a convenience sample of 24 chronic pain patients (17 with chronic fatigue syndrome/fibromyalgia) were randomized into WHEE treatment and wait-list control groups for 6 weeks. Assessments of depression, anxiety, and pain were completed before, during, and at 1 and 3 months after treatment. Wait-listed patients then received an identical course of WHEE and assessments. WHEE decreased anxiety (P<.5) and depression (P<.05) compared with the control group. The wait-list-turned-WHEE assessments demonstrated decreased pain severity (P<.05) and depression (P<.04) but not pain interference or anxiety. WHEE appears a promising method for pain, anxiety, and depression in patients with chronic pain, compared to standard medical care alone. Though a small pilot study, the present results suggest that further research appears warranted. An incidental finding was that a majority of patients with chronic pain had suffered psychological trauma in childhood and/or adulthood.

In this pilot study, a convenience sample of 24 chronic pain patients (17 with chronic fatigue syndrome/fibromyalgia) were randomized into WHEE treatment and wait-list control groups for 6 weeks. Assessments of depression, anxiety, and pain were completed before, during, and at 1 and 3 months after treatment. Wait-listed patients then received an identical course of WHEE and assessments. WHEE decreased anxiety (P<.5) and depression (P<.05) compared with the control group. The wait-list-turned-WHEE assessments demonstrated decreased pain severity (P<.05) and depression (P<.04) but not pain interference or anxiety. WHEE appears a promising method for pain, anxiety, and depression in patients with chronic pain, compared to standard medical care alone. Though a small pilot study, the present results suggest that further research appears warranted. An incidental finding was that a majority of patients with chronic pain had suffered psychological trauma in childhood and/or adulthood.

OBJECTIVE:Affective disorder during pregnancy is a common condition requiring careful judgment to treat the depression while minimizing risk to the fetus. Following up on promising pilot trials, we studied the efficacy of light therapy.

METHOD:Twenty-seven pregnant women with nonseasonal major depressive disorder according to DSM-IV (outpatients, university polyclinic) were randomly assigned to 7,000 lux fluorescent bright white or 70 lux dim red (placebo) light administered at home in the morning upon awakening for 1 h/d in a 5-week double-blind trial carried out between October 2004 and October 2008. Clinical state was monitored weekly with the 29-item Structured Interview Guide for the Hamilton Depression Rating Scale (HDRS) with Atypical Depression Supplement (SIGH-ADS). Changes of rating scale scores over time were analyzed with the general linear model. Differences from baseline of SIGH-ADS and 17-item HDRS scores at every time point were the dependent variables, time was the within-subjects factor, and treatment was the between-subjects factor. The model also included baseline score of depression and gestational age at intervention start.

RESULTS:The superiority of bright light over dim light placebo was shown for both SIGH-ADS (R² = 0.251; F(3,23) = 3.91; P<.05) and HDRS (R² = 0.338; F(3,23) = 5.42; P<.01) when analyzing the week-by-week change from baseline, and HDRS scores showed a significant interaction of treatment with time (F(4,92) = 2.91; P<.05). Categorical analysis revealed that the response rate (HDRS≥ 50% improvement) at week 5 was significantly greater for bright light (81.3%, n = 16) than for placebo light (45.5%, n = 11) (P<.05). Remission (final score≤ 8) was attained by 68.6% versus 36.4%, respectively (P<.05). Expectation ratings did not differ significantly between groups.

CONCLUSIONS:Bright white light treatment for 5 weeks improved depression during pregnancy significantly more than placebo dim red light. The study provides evidence that light therapy, a simple, cost-effective antidepressant modality with minimal side effects for the mother and no known risk for the unborn child, may be a useful nonpharmacologic approach in this difficult situation.

TRIAL REGISTRATION:clinicaltrials.gov Identifier: NCT01043289.

BACKGROUND:Commuting routes with natural features could promote walking or cycling for commuting. Commuting through natural environments (NE) could have mental health benefits as exposure to NE can reduce stress and improve mental health, but there is little evidence. This study evaluates the association between NE and commuting, whether active or not, and the association between commuting (through NE), whether active or not, and mental health. We also evaluate the moderating effect of NE quality on the association between NE commuting and mental health.

METHODS:This cross-sectional study was based on adult respondents (n = 3599) of the Positive Health Effects of the Natural Outdoor Environment in Typical Populations in Different Regions in Europe (PHENOTYPE) project. Data were collected in four European cities in Spain, the Netherlands, Lithuania and the United Kingdom. Data on commuting behavior (active commuting at least one day/week, daily NE commuting) and mental health were collected with questionnaires. Associations were estimated with multilevel analyses including random intercepts at city- and neighborhood level.

RESULTS:Adjusted multilevel analyses showed that daily NE commuters were more often active commuters (OR 1.42; 95% CI 1.19, 1.70). There was no association between active commuting and mental health, but daily NE commuters had on average a 2.74 (95% CI 1.66, 3.82) point higher mental health score than those not commuting through NE. The association with mental health was stronger among active commuters (4.03, 95% CI 2.13, 5.94) compared to non-active commuters (2.21; 95% CI 0.90, 3.51) when daily commuting through NE, but NE quality did not have a moderating effect.

CONCLUSIONS:Daily NE commuting was associated with better mental health, especially for active commuters. Daily NE commuters were likely to be active commuters. Active commuting itself was not associated with mental health. These findings suggest that cities should invest in commuting routes with nature for cycling and walking.

Acupuncture has increasingly been used to treat many conditions, including psychiatric disorders and immunological-related disorders. However, the effects of acupuncture as stress management and immune functions in the elderly are largely unclear. Here we investigated the effects of acupuncture on stress-related psychological symptoms and cellular immunity in young adults and elderly subjects. The acupuncture treatment consisted of six sessions and the procedures included the insertion of needles at bilateral acupoints LI4, SP6 and ST36. Psychological variables (depression, anxiety and stress) were investigated by means of self-assessment inventories. Peripheral blood mononuclear cells were isolated and cultured in vitro to measure mitogen-induced T-cell proliferation as well as cellular sensitivity to dexamethasone. All data were assessed before and after the intervention. Acupuncture was able to significantly reduce depression (p<0.001), anxiety (p<0.001) and stress (p<0.001) scores. The intervention also increased T-cell proliferation, with greater intensity in the elderly group (p=0.004). No changes in cellular sensitivity to dexamethasone were observed following acupuncture. We conclude that acupuncture was efficient to attenuate the psychological distress as well as to increase an important feature of cellular immunosenescence.

Acupuncture has increasingly been used to treat many conditions, including psychiatric disorders and immunological-related disorders. However, the effects of acupuncture as stress management and immune functions in the elderly are largely unclear. Here we investigated the effects of acupuncture on stress-related psychological symptoms and cellular immunity in young adults and elderly subjects. The acupuncture treatment consisted of six sessions and the procedures included the insertion of needles at bilateral acupoints LI4, SP6 and ST36. Psychological variables (depression, anxiety and stress) were investigated by means of self-assessment inventories. Peripheral blood mononuclear cells were isolated and cultured in vitro to measure mitogen-induced T-cell proliferation as well as cellular sensitivity to dexamethasone. All data were assessed before and after the intervention. Acupuncture was able to significantly reduce depression (p<0.001), anxiety (p<0.001) and stress (p<0.001) scores. The intervention also increased T-cell proliferation, with greater intensity in the elderly group (p=0.004). No changes in cellular sensitivity to dexamethasone were observed following acupuncture. We conclude that acupuncture was efficient to attenuate the psychological distress as well as to increase an important feature of cellular immunosenescence.

Major depressive disorder (MDD) is a common disorder with a high prevalence and significant social and economic impacts. Nevertheless, the treatment of MDD is far from satisfactory. Acupuncture treatment has emerged as a promising method for treating MDD. However, the neural mechanism by which acupuncture reduces depressive symptoms is not fully understood. Studies have shown that the corticostriatal reward circuitry is associated with the pathophysiology of MDD; thus, we investigated the corticostriatal resting-state functional connectivity (rsFC) before and after real and sham acupuncture treatments combined with the antidepressant fluoxetine. Forty-six female major depressive patients were assigned to either verum acupuncture plus fluoxetine (n = 22) or sham acupuncture plus fluoxetine (n = 24) treatment for 8 weeks, and resting state functional magnetic resonance imaging (fMRI) data were collected before the first and after the last treatment sessions. The results showed that compared with sham acupuncture, the verum acupuncture group showed: (1) significantly increased rsFC between inferior ventral striatum and medial prefrontal cortex, ventral rostral putamen and amygdala/parahippocampus, as well as dorsal caudate and middle temporal gyrus; (2) significantly decreased rsFC between right ventral rostral putamen and right dorsolateral prefrontal cortex, and right dorsal caudate and bilateral cerebellar tonsil. The increased rsFC between the inferior ventral striatum and medial prefrontal cortex, ventral rostral putamen and amygdala/parahippocampus were significantly positively associated with decreased clinical scores (Montgomery-Åsberg Depression Rating Scale and Self-Rating Depression Scale scores) at the end of the eight-week treatment. Our findings suggest that acupuncture may achieve treatment effects by modulating the corticostriatal reward/motivation circuitry in MDD patients.

Major depressive disorder (MDD) is a common disorder with a high prevalence and significant social and economic impacts. Nevertheless, the treatment of MDD is far from satisfactory. Acupuncture treatment has emerged as a promising method for treating MDD. However, the neural mechanism by which acupuncture reduces depressive symptoms is not fully understood. Studies have shown that the corticostriatal reward circuitry is associated with the pathophysiology of MDD; thus, we investigated the corticostriatal resting-state functional connectivity (rsFC) before and after real and sham acupuncture treatments combined with the antidepressant fluoxetine. Forty-six female major depressive patients were assigned to either verum acupuncture plus fluoxetine (n = 22) or sham acupuncture plus fluoxetine (n = 24) treatment for 8 weeks, and resting state functional magnetic resonance imaging (fMRI) data were collected before the first and after the last treatment sessions. The results showed that compared with sham acupuncture, the verum acupuncture group showed: (1) significantly increased rsFC between inferior ventral striatum and medial prefrontal cortex, ventral rostral putamen and amygdala/parahippocampus, as well as dorsal caudate and middle temporal gyrus; (2) significantly decreased rsFC between right ventral rostral putamen and right dorsolateral prefrontal cortex, and right dorsal caudate and bilateral cerebellar tonsil. The increased rsFC between the inferior ventral striatum and medial prefrontal cortex, ventral rostral putamen and amygdala/parahippocampus were significantly positively associated with decreased clinical scores (Montgomery-Åsberg Depression Rating Scale and Self-Rating Depression Scale scores) at the end of the eight-week treatment. Our findings suggest that acupuncture may achieve treatment effects by modulating the corticostriatal reward/motivation circuitry in MDD patients.