Assessment of the effectiveness of yoga therapy as an adjunct in patients with alcohol dependence syndrome

1Professor, Department of Psychiatry, Gauhati Medical College & Hospital, Guwahati, Assam, India, 2Senior Resident, Department of Geriatric Mental Health, King George’s Medical University, Lucknow, Uttar Pradesh, India, 3Senior Resident, Department of Psychiatry, Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam, India, 4Assitant Professor, Department of Psychiatry, Gauhati Medical College & Hospital, Guwahati, Assam, India, 5Psychiatric Social Worker, Department of Psychiatry, Gauhati Medical College & Hospital, Guwahati, Assam, India


Introduction
Yoga therapy has been gaining popularity in the treatment of many psychiatric disorders both as adjunctive as well as single therapy.Yoga therapy has been found to help patients in many ways such as-increasing calmness, increasing awareness of self and surroundings, achieving higher levels of consciousness, increasing attention span, producing a sense of security, and reducing stress.[1] It has also been shown to produce neurochemical changes in the brain like increasing brain-derived neurotrophic factor (BDNF) levels, decreasing cortisol levels, and increasing plasma oxytocin levels.[2][3][4] On structural level it brings about neuroplasticity.[5] Historically, yoga is a set of mind-body practice whose ultimate goal is achievement of higher level of consciousness.Th e three main yoga practices include meditation, breathing exercises, and physical postures.[6] Alcohol use disorders are diffi cult to treat which is evident from high relapse rates and the current pharmacological options thus appear inadequate.Th e reason behind this helplessness of psychiatrists is not clearly known.But patients with alcohol use disorders have high comorbidity of depression and anxiety disorders.[7,8] Furthermore, alcohol users fi nd it extremely diffi cult to control their craving.Th is study tries to examine a relatively less practiced modality of treatment-yoga, and will try to fi nd out if this mode of treatment can signifi cantly reduce comorbid depression, anxiety, and craving in patients of alcohol use disorders.

Aim
To study the eff ectiveness of yoga therapy as an adjunct in the treatment of alcohol use disorders.

Objectives
1. To assess the changes in anxiety and depressive symptoms in patients of alcohol dependence aft er yoga therapy.2. To assess the changes in craving in these patients aft er yoga therapy.

Methodology
Th e study was conducted in a tertiary care hospital, Gauhati Medical College & Hospital, Department of Psychiatry.Total 100 numbers of patients of alcohol dependence syndrome diagnosed according to the tenth revision of the International Statistical Classifi cation of Diseases and Related Health Problems (ICD-10) [9] criteria were taken for the study.Aft er taking written informed consent, samples were divided into two groups each containing 50 patients.Both the groups (case and control) underwent detoxifi cation for the required time period.Aft er this phase was over both the groups were given anticraving drugs as per the suitability.Th e anticraving drugs used in this hospital are acamprosate, naltrexone, topiramate, and baclofen.Additionally, the case group was given thrice weekly yoga therapy (Monday, Wednesday, and Friday) by a professional yoga teacher employed at this hospital.Both groups also attended once weekly Alcoholic Anonymous (AA) sessions as well as group therapy.
The psychiatry department of this hospital has general wards as well as a separate drug-deaddiction ward.Patients with substance use disorders are usually admitted in drug deaddiction ward but sometimes due to non-availability of beds some patients are randomly admitted in general wards.The case group consisted of the patients who were admitted in drug deaddiction ward while the control group consisted of patients admitted in general wards.Additionally, some of the patients who had medical comorbidities and who were unsuitable for yoga sessions were kept in control group.
Yoga sessions were administered to the case group for one hour duration on every alternate day for one month.Th e patients were instructed to practice yoga on rest of the days on their own.Th e standard yoga session consisted of diff erent 'asanas' and meditation.Following are the 'asanas'-'Surya Namaskar' , 'Hasthamudra' , 'Padamudra' , 'Grivamudra' , 'Singhasana' , 'Bhujangasana' , 'Shalabhasana' , 'Dhanurasana' , 'Pavanmuktasana' , 'Tadasana' , 'Vrikshasana' , 'Katichakrasana' , ' Ardha-Mastyendrasana' , 'Uddiyanbandhamudra' , 'Sahajagnishei' , 'Shavasana' , 'kapalbhati' , 'pranayam' , and meditation.Assessment of depressive symptoms, anxiety symptoms, and craving was done at baseline, at two weeks, and aft er one month of starting of sessions.Two independent assessors assessed the case and control groups.If the patients in the two groups were found to have anxiety or depression, they were given appropriate medications.

Obsessive compulsive drinking scale (OCDS):[12]
Th e OCDS is a tool which was made to elicit obsessions and compulsions related to drinking.Measuring obsessive behaviour in turn elicits craving for drinking.Th e tool has been found both sensitive and specifi c in measuring the obsessive thoughts and compulsive behaviours related to drinking.Th is tool has also been found sensitive for predicting relapse drinking.Th e scale consists of 14 questions refl ecting both obsessive and compulsive characteristics of drinking.It is a self-administered type of scale and takes about fi ve to ten minutes to evaluate the total score, which in turn is obtained by simply adding the scores of each of the 14 items.Th e tool is both reliable and valid.To meet the needs of local population it was translated in Assamese.Reliability and validity was established.

Statistical analysis
Socio-demographic variables were analysed with Fisher test.Data related to alcohol use pattern was analysed using Chisquare test.Mean scores of HAM-D, HAM-A, and OCDS at each of the three intervals were compared between the two groups with the help of analysis of variance (ANOVA).
Similarly to compare the eff ect of yoga with respect to time (two weeks vs one month) mean scores within case group were compared using ANOVA.Free version of Graphpad Instat statistical soft ware was used for this purpose.
Th e study was approved by the ethical committee of Gauhati Medical College & Hospital.

Results
Th e results are shown in following tables 1 to 6.

Discussion
Table 1 shows the socio-demographic variables of the two groups.Both case and control groups were comparable on all the parametres and no statistically signifi cant diff erence existed.Maximum number of patients in the case group fall in age group of 18-39 years while in the control group, maximum number fall in 40-59 years age group.All the 100 enrolled subjects were males, majority of subjects in both groups were Hindu, married, educated below class ten, and belonged to rural areas.More number of patients in the case group were employed while more number of patients in the control group were unemployed.However, no signifi cant diff erence was seen between the groups in terms of employment.
Table 2 depicts the alcohol use pattern of the two groups.Both the groups were comparable on parametres such as type of alcohol used, duration of alcohol used, frequency of alcohol used, amount of current daily use, family history of alcohol use, and past admission for alcohol use.Th e commonest anticraving drug used in both the groups was acamprosate.
Table 3 depicts that 30% and 26% of patients in case group and control group had depression respectively.While 40% of case group patients and 50% of control group patients had comorbid anxiety respectively.A systematic review of 35 studies found median prevalence of comorbid depression and alcohol use in current or lifetime alcohol use as 16% (range fi ve to 67%) and 30% (range ten to 60%), respectively.[13] When both the groups were compared at baseline for scores of depression (HAM-D), anxiety (HAM-A), and craving they did not diff er signifi cantly (Table 4).
In case of comorbid alcohol dependence and depression, the HAM-D scores were not signifi cantly diff erent between the yoga group and non-yoga group when the two groups were treated till two weeks and one month.In another study which randomised patients of alcohol dependence (N=60) to either receive two weeks of Sudarshan Kriya (a type of yoga) or not, fi ndings revealed that the group which received yoga intervention had signifi cantly lower Beck's Depression Inventory (BDI) score at two weeks as compared to the controls.Th ere was also reduction in plasma cortisol and adrenocorticotropic hormone (ACTH) in the yoga group which correlated with reduction in BDI score.[14] However, it is not clear if the depressed patients in this study received antidepressant or not, while in our study patients in both the groups received antidepressants if they were found to be depressed.In case of comorbid alcohol use and anxiety, HAM-A score was similar in the two groups at two weeks of treatment but at one month the patients in yoga group had signifi cantly greater reduction in anxiety severity.A previous randomised controlled pilot study was conducted evaluating the eff ectiveness of 12-session yoga therapy in women of age 18-65 years.Th ese women had comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder.Th e Alcohol Use Disorder Identifi cation Test (AUDIT) and Drug Use Disorder Identifi cation Test (DUDIT) were done before intervention, immediately aft er intervention, and one month aft er intervention.Th e women in yoga group showed reduction in mean AUDIT, DUDIT scores, as well as reduction in PTSD symptoms.[15] On parametre of craving, the yoga group reported signifi cant reduction in OCDS scores both at two weeks and at one month.Th ere are no previous studies which assessed the eff ectiveness of yoga therapy on craving in alcohol dependence.But there is systematic review of literature on the eff ectiveness of mind-body practices on smoking cessation.Th e systematic review included 14 clinical trials and reported that yoga and meditation based therapies are helpful in attaining drug-free smoking cessation.[16] Another pilot study was conducted in Sweden on small number of patients of alcohol dependence (N=18), who were randomised to receive either the usual treatment (psychological and pharmacological treatment) or treatment as usual plus ten-week yoga therapy.Th e groups were assessed before treatment and six months aft er treatment.Alcohol consumption reduced more in the yoga group.However, the fi ndings were not statistically signifi cant and were limited by small sample size.[17] Next, we tried to see if any improvement in the yoga group in terms of HAM-D, HAM-A, and OCDS scores varied with respect to time (Tables 5 and 6), i.e. whether the benefi ts continued to increase if yoga was practiced for longer time.Th e reduction in HAM-D scores aft er two weeks and one HAM-D=Hamilton depression rating scale, SD=standard deviation, ANOVA=analysis of variance, HAM-A=Hamilton anxiety rating scale, OCDS=Obsessive-compulsive drinking scale month in case group was signifi cant from baseline but not at one month as compared from two weeks.Th is means that the antidepressant eff ect of yoga therapy was maximum at two weeks and although the benefi t continued to increase at one month, it was not statistically signifi cant.However, the reduction in HAM-A and OCDS scores was signifi cant both at two weeks and one month from baseline as well as at one month as compared to two weeks.In other words anxiety symptoms and craving continued to improve if yoga was practiced for longer duration.

Conclusion
Patients with alcohol dependence have high prevalence of comorbid depression and anxiety symptoms.Th is comorbidity can be both causal as well as an eff ect of alcohol use.Additionally patients of any substance dependence including alcohol report craving which limits their capacity to become abstinent even if they have adequate motivation.Our hospital is using yoga as an adjunctive mode of intervention in patients with alcohol dependence.Th is study tried to see if instituting a structured yoga regimen to these patients can benefi t them in lowering the depressive and anxiety symptoms, and craving.
Th e study found benefi t of yoga as an adjunctive method in reducing anxiety symptoms and craving for alcohol.In case of yoga group the reduction in depressive symptom was greatest at two weeks and no added benefi t at one month as compared with the benefi t at two weeks.Th e reduction in anxiety symptoms and craving was progressively better at two weeks and at one month.

Limitations of the study and future directions
Th ere are certain limitations of the study.First, this was an open label study leading to potential bias and which may have impact on the results.Second, the study was done taking smaller number of cases.Similar studies can be conducted taking larger sample size.It would also be interesting to see the eff ects of yoga in other substance use disorders.

Source of support:
This study is funded by a grant from the Srimanta Sankaradeva University of Health Sciences, Guwahati, Assam, India.Declaration of interest: None.

Table 6 :
Comparison of HAM-D, HAM-A, OCDS scores with each other at different intervals depression rating scale, HAM-A=Hamilton anxiety rating scale, OCDS=Obsessive-compulsive drinking scale Bhagabati D, Kumar A, Borbora SA, Bora U, Sharma H. Assessment of the effectiveness of yoga therapy as an adjunct in patients with alcohol dependence syndrome.Open J Psychiatry Allied Sci.2016 Nov 12. [Epub ahead of print].

Tools used Hamilton depression rating scale (HAM-D):[10] Th
e 17-item HAM-D was used to assess depressive symptoms and score the severity of depression.Th is scale was developed by Max Hamilton in 1960 to monitor the severity of depression, with a focus on somatic symptomatology.It is an observerrated scale consisting of 17 items and the score ranges from zero to 52.It off ers an advantage of comparing severity aft er administering treatment.
Hamilton anxiety rating scale (HAM-A):[11]Th is scale was used to assess anxiety symptoms.Developed in late 1950s this scale has 14 items with a total score of 56.It is clinician administered with good reliability and validity.Similar to HAM-D, this scale is also used to see the treatment response.HAM-A score interpretation guide: 0-13: No anxiety 14-17: Mild anxiety 18-24: Moderate anxiety ≥25: Severe anxiety

Table 1 :
Descriptive analysis of socio-demographic characteristics of the sample

Table 2 :
Descriptive analysis of alcohol use pattern

Table 3 :
Descriptive analysis of prevalence of depression and anxiety in the sample

Table 4 :
Comparison of HAM-D, HAM-A, and OCDS scores between case and control groups HAM-D=Hamilton depression rating scale, HAM-A=Hamilton anxiety rating scale, OCDS=Obsessive compulsive drinking scale, SD=standard deviation

Table 5 :
Comparison of HAM-D, HAM-A, and OCDS scores within case group with respect to time