Healing Depression From an Ayurvedic PerspectiveDonna Petko, MSN, RN, APN, FNP-BCUniversity of Massachusetts, AmherstNursing 697Q: Integrative Therapies

Objective

To increase understanding of the treatment of depression from an Ayurvedic perspective

• Therapies that will be reviewed include the following:– Yoga– Meditation– Massage

AbstractAyurveda is an Indian Hindu System of healing that was developed thousands of years ago. When it comes to treating chronic conditions, the Ayurvedic system of natural healing has a variety of practices which promote health and well-being. The goal of this system is to maintain health through the elimination of impurities, reduction of symptoms, reduction of worry, increase in harmony, and elimination of physical and psychological distress. According to a review of the literature, Ayurvedic practices such as yoga, meditation, and massage have all been shown to be beneficial in the treatment of depression.

Keywords: Ayurveda, complementary and alternative medicine, dysthymic disorder, depression, integrative health, persistent depressive disorder, whole medical systems

IntroductionThe purpose of this presentation is to explore the treatment of depression from an Ayurvedic perspective. The history, country of origin, and integrative health uses of this modality will be explored along with the available evidence. Indication for the use of this system of natural healing will be examined in the context of treating depression and a summary of the findings will be presented.

Additionally, risks, benefits, insurance coverage, health care policy, and ethical and legal considerations will be discussed and analyzed.

What is Ayurveda and Where Did it Come From?

Ayurveda is the Indian Hindu system of healing (Keegan, 2001):

• Originated in India

• Developed >2000 years ago

• Whole medical system that is based on various theories of health and illness

• Focuses on prevention, management, and the treatment of health problems

What is Ayurveda and Where Did it Come from?• The system focuses on eight branches of medicine

(Keegan, 2001): – pediatrics, gynecology, obstetrics, ophthalmology, geriatrics,

otolaryngology, general medicine, and surgery

• Ailments are addressed through five elements (Keegan, 2001): – air, earth, fire, and water; the humors of the body; the tissues of the

body; bodily excretions; and the trinity of life which consists of awareness of the body, mind, and spirit; these are all necessary to healing

BeliefsPeople who subscribe to the Ayurvedic system have some basic beliefs about health and illness (NCCAM, 2006):

• Individuals, their health, and the Universe are related

• Illness can occur when relationships are out of balance

• An individual’s composition is called prakriti – Prakriti is a combination of physical and psychological characteristics

which influence the body – 3 qualities, doshas, form significant aspects of the prakriti

Beliefs Cont. – Each person has a balance of doshas:

– corresponds with body and personality types– impacts health

– What can cause an imbalance in doshas?– unhealthy lifestyle and diet– too little or too much mental and physical stimulation– not being properly protected from environmental elements

• In the Ayurvedic system, it is believed that health and illness are related to the balance or imbalance of the doshas (NCCAM, 2006)

Integrative Health Uses• The goal of Ayurveda is to integrate and balance the mind,

body, and spirit (NCCAM, 2006)

• Patients are expected to be active participants in their care– Active participation is needed because it is up to the patient to make

diet and lifestyle changes

Integrative Health Uses• When Ayurvedic methods are included with Western

Medicine, the approach is considered integrative.

• Integrative medicine includes aspects of both Eastern and Western medicine.

Integrative Health Uses Cont.The goals of Ayurvedic treatment include the following (NCCAM, 2006):

• Eliminate impurities

• Reduce symptoms

• Reduce worry

• Increase harmony

• Elimination of physical and psychological distress

Integrative Health Uses Cont.• Ayurvedic practitioners may recommend a variety of

methods such as:– Yoga– Meditation– Massage – Diet– Herbs

• We will examine Yoga, Meditation, & Massage

Integrative Health Uses Cont.• Yoga:

– Mind-body practice that utilizes movement, postures, breathing exercises

• Meditation: – Contemplation, reflection, relaxation; spiritual awareness

• Massage:– Rubbing different parts of the body to release tension and reduce

pain

Depression• While there are several forms of depression and episodes

can vary in duration, recurrent or prolonged episodes of depression can be considered a chronic condition which impacts an individual’s ability to eat, sleep, work, and play (National Institute of Mental Health [NIMH], 2015).

Depression Cont.• Depression is a serious medical condition with mood,

cognitive, and physical symptoms (Pratt & Brody, 2014).

• Common symptoms of depression include (NIMH, 2015):– poor appetite or overeating– insomnia or hypersomnia– low energy or fatigue– low self-esteem– poor concentration or difficulty making decisions– feelings of hopelessness

Depression Cont. • In persistent depressive disorder (i.e., dysthymia,) a

depressed mood lasts for at least two years.

• Depression is associated with other chronic conditions (Pratt & Brody, 2014):– Increases healthcare utilization, costs, and overall expense

• Of the various forms of depression, major depression is one of the most common mental disorders in the United States (NIMH, 2015).

Depression Cont. • Major depressive disorder affects > 14 million Americans

annually– Approx. 6.7% of the US population age 18+

• In the US (CDC, 2015):– 8% of those age 12+ had depression in any 2 week period from

2007-2010– >8 million ambulatory care visits for depression occurred between

2009-2010 – As many as 1 in 33 children and 1 in 8 adolescents has a diagnosis of

clinical depression

Depression Cont.• Those with depression are 4 times more likely to

experience a heart attack than those without depression (CDC, 2015):– After a heart attack, those with depression have an increased risk of

death, or a second heart attack, compared to those without

Evidence for Practice

Healing depression from an Ayurvedic perspective using yoga, meditation, and massage

YogaSystematic review and meta-analysis for yoga in the treatment of depression (Cramer et al., 2013):

• Medline, Pub Med, Scopus, the Cochrane Library, PsychINFO, and IndMed – Reviewed for randomized controlled trials of yoga for patients with

depression

• Main outcomes consisted of depression severity and remission rates

• Secondary outcomes consisted of anxiety, safety, and quality of life

• Of the 12 randomly controlled trials that were reviewed, 619 participants were included.

Yoga Cont.

Yoga Cont.• Moderate evidence for short-term effects of yoga when

compared to standardized care:– Standardized mean difference (SMD) = −0.69; 95% confidence

interval (CI) −0.99, −0.39; P < .001

• Limitations to this study include no meta-analyses on the long-term effects of yoga

• Findings are significant because they show promise in the treatment of depression with yoga.

• Yoga can be considered one treatment option for patients with depression which may be a cost-effective approach.

MeditationSystematic review conducted on the effectiveness of meditation on depression (Jain et al., 2014):

• Researchers reviewed all randomly controlled trials of techniques meeting the Agency for Healthcare Research and Quality’s definition of meditation.

• Participants with a clinical diagnosis of depression, who were not in remission, were selected for participation in the study.

• Meditation techniques were separated into categories and the outcomes reviewed.

• Of the 18 studies meeting inclusion criteria, 7 meditation techniques and 1,173 participants were included.

• Mindfulness-based cognitive therapy was the most commonly employed therapy.

Meditation Cont. • For the diagnosis of major depression, n = 10 studies

• For those with subacute depression, n = 8 studies

• Both groups demonstrated a moderate to large reduction in symptoms within the group as opposed to the controls.

• Limitations include (Jain et al., 2014):– methodological insufficiencies, trial heterogeneity, and the need for

large-scale, randomly controlled trials with better described interventions and measures

– the role of meditation in depression must also be better clarified

Meditation Cont.• Significance of these findings include (Jain et al., 2014):

– substantial evidence that meditation may have beneficial effects on patients experiencing clinical depression

– No risk was demonstrated in the use of this approach – Meditation may offer a low-cost option and cost-effective approach to

treating and managing depression

MassageRandomly controlled study to determine the effectiveness of yoga and massage therapy on prenatal depression and neonatal outcomes (Field et al., 2011):

• 84 prenatally depressed women randomly assigned to yoga, massage therapy, or a standard prenatal care control group

• After 12 weeks of an intervention, either yoga or massage therapy, twice a week for 20 minutes, both therapy groups, when compared to the control, had a greater decrease in depression, anxiety, and physical pain.

• Analyses conducted utilized repeated measures of group ANOVAS which suggested significantly greater clinical improvements in the intervention groups

Massage Cont.• Decreased depression scores (F= 82.40, p<.001); 2)

• Decreased anxiety scores (F= 26.23, p< .001); 3)

• Decreased anger scores (F= 14.59, p<.001); 4)

• Decreased back pain scores (F= 39.06, p<.001); 5)

• Decreased leg pain scores (F= 19.77, p>.001)

• Increased relationships scores (F= 7.88, p<.001)” (Field et al., 2011, p. 206).

Massage Cont.• When yoga and massage therapy groups were compared,

no differences existed between maternal/neonatal outcomes– this suggests that both yoga and massage were equally beneficial

• Limitations to this study include its small sample size and population of interest

Massage Therapy Cont.• The significance of these findings include:

– Beneficial nature of both yoga and massage therapy on the reduction of depression in prenatal women and on neonatal outcomes.

– No risk was demonstrated in the use of yoga or massage therapy.– Because conventional medicine and pharmaceutical approaches can

increase the risk of fetal harm, yoga and massage may offer a safer alternative.

Risks and BenefitsYoga, meditation, and massage therapy are all safe activities when provided under the guidance of trained professionals when no contraindications are present.

• Yoga that is performed under the guidance of a professionally trained instructor is considered a low-impact and safe activity (NCCIH, 2014)– Caution must be taken with pregnant women or with individuals with

physical restrictions

Risks & Benefits Cont.• Meditation is also considered safe for most people (NCCIH,

2014):– Individuals with physical restrictions may need to refrain from certain

practices involving movement

• Massage therapy has few associated risks when conducted by a trained professional (NCCIH, 2014)

Access to Care & Health Care Policy• Many alternative, integrative, or complementary

treatments, as used in Ayurveda, are not covered by insurance.

• Even if services are covered for one diagnosis, they may not be covered for another.

• It is up to the provider to work with the patient in terms of developing a patient-centered treatment plan which is both safe and cost-effective.

Access to Care & Healthcare Policy Cont.• In terms of health care policy, it is important for providers

to be knowledgeable on coverage and insurance issues

• Providers should advocate for necessary changes in policy which can decrease gaps in care, increase access to services, and increase the quality of care provided to patients.

Legal and Ethical Issues• Care must be taken when recommending any Ayurvedic

practice– Ayurveda utilizes a variety methods which may not have undergone

rigorous study

• Care must also be taken when integrating two or more approaches

• Any health care provider that utilizes Ayurvedic methods must review the literature for best practices: – This limits liability and allows the provider to provide high quality,

safe, and cost effective patient-centered care

Legal and Ethical Issues Cont.• Consideration must be given to cultural differences when

devising a treatment plan: – Individuals of different cultures may not be open to various

treatments

• After obtaining consent, the provider should discuss the pros and cons of each practice and allow the patient to make the best possible decisions based on the available evidence.

• The provider should exercise “do no harm” and keep all patient records confidential following Health Insurance Portability and Accountability Act guidelines.

Legal and Ethical Issues Cont.• When treating a patient with depression, it is of utmost

importance that the provider assess the patient for the risk of self-harm, suicidal risk, and the risk of harm to others.

• The patient should be given instructions for what to do in the case of an emergency, adverse effects, or if signs or symptoms worsen:– Dialing “911” or local emergency services number– Contacting the National Suicide Prevention Lifeline: 1-800-273-8255

Conclusion• In the Ayurvedic system, there are multiple ways to

achieve balance and maintain health and well-being such as:– Yoga– Meditation– Massage

• These approaches provide safe, cost-effective approaches in the management of depression– can be used alone or in conjunction with other approaches

• While these treatments may not work as the sole treatment of depression in some individuals, evidence suggests that they may be beneficial as an integrated approach.

References• Cramer, H., Lauche, R., Langhorst, J., & Dobos, G. (2013). Yoga for depression: A

systematic review and meta-analysis. Journal of Depression & Anxiety, 30(11), 1068-1083. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/da.22166/full

• Depression and Bipolar Support Alliance. (2015). Depression statistics. Retrieved from http://www.dbsalliance.org/site/PageServer?pagename=education_statistics_depression

• Field, T., Diego, M., Hernandez-Reif, M, Medina, J., Hernandez, A. (2011). Yoga and massage therapy reduce prenatal depression and prematurity. Journal of Body-Work and Movement Therapies, 16(2), 204-209. Retrieved from http://www.sciencedirect.com/ science/article/pii/S1360859211001409

• Jain, F.Q., Walsh, R.N., Eisendrath, S.J., Christensen, S., & Cahn, B.R. (2014). Critical analysis of the efficacy of meditation therapies for acute and subacute phase treatment of depressive disorders: A systematic review. Psychosomatics, 56(2), 140-152. Retrieved from http://www.sciencedirect.com/science/article/pii/S0033318214001674

References• Keegan, L. (2001). Healing with complementary and alternative

therapies. New York: Delmar Cengage Learning.

• National Center for Complementary and Alternative Medicine. (2006). A closer look at Ayurvedic medicine. CAM at the NIH: Focus on Complementary and Alternative Medicine, 4. Retrieved from https://web.archive.org/web/20061209114559/http://nccam.nih.gov/news/newsletter/2006_winter/ayurveda.htm

• National Center for Complementary and Integrative Health. (2014). Massage therapy for health purposes: What you need to know. Retrieved from https://nccih.nih.gov/ health/massage/massageintroduction.htm

• National Center for Complementary and Integrative Health. (2014). Meditation: What you need to know. Retrieved from https://nccih.nih.gov/health/meditation/overview.htm

References• National Center for Complementary and Integrative Health.

(2013). Yoga for your health. Retrieved from https://nccih.nih.gov/health/yoga/introduction.htm

• National Institute of Mental Health. (2015). What is depression? Retrieved from http://www.nimh.nih.gov/health/topics/depression/index.shtml

• National Suicide Prevention Helpline. (2015). Why call? Retrieved from http://www.suicidepreventionlifeline.org/

• Pratt, L.A., & Brody, D.J. (2014, December). Depression in the US household population, 2009-2012 (Issue Brief No. 172). Retrieved from http://www.cdc.gov/nchs/data/databriefs/db172.pdf

References• Saeed, S.A., Antonacci, D.J., & Bloch, R.M. (2010). Exercise, yoga,

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