Qigong and Tai Chi for Treatment of Depression

Albert Yeung, M.D., Sc.D.

Director of Primary Care StudiesMGH Depression Clinical and Research Program

Associate ProfessorHarvard Medical School

Co-Medical DirectorSouth Cove Community Health Center

Albert Yeung, M.D. - Disclosures

No Conflict of Interest to Disclose

What is Major Depressive Disorder (MDD)?Diagnostic Criteria :1. Depressed mood and/or2. ↓Interest or pleasure3. Sleep disturbance4. Guilt or feelings of worthlessness5. ↓ Energy 6. ↓Concentration7. Appetite change with significant weight loss or weight gain 8. Psychomotor agitation or retardation 9. Suicidal ideation, recurrent; suicide attempt

5 out of these 9 s/s, ≥ 2 wks, + subjective distress and/or functional impairment

American Psychiatric Association, Diagnostic & Statistical Manual 5th ed. 2013

Treatment Types

Pharmacological therapies Psychotherapy Somatic therapies Complimentary & holistic treatment

5

Qigong: A Movement Meditation

Qi

gong

6

Bajuanjin Qigong

7

Qigong

Tai Chi

What is Qigong?A form of meditative movement that involves: Relaxed, quiet postures sitting, standing, lying, Low impact movements, Stretching, Muscle resistance Slow breathing, Mental focusing exercises, and Visualization

Qigong: What does it do?Hypothesis 1

It might affect the practitioner’s subjective state or they might reflect an underlying physiological

process; or a somatic feeling may trigger… a feedback loop … that in turn produce an

alteration in physiological processes.

Kerr C: Culture, Medicine and Psychiatry 26: 419–447, 2002.

Qigong: What does it do?Hypothesis 2

It may be that qigong practitioners re-map the experiences of their own bodies, using embodied

visualization in a focused, concentrated and positive way. This sensory re-mapping can bring about a kind

of immediate healing of small strains…through stretching and dissolving, and these small healings

may encourage the practitioner’s sense that a deeper healing is also taking place.

Kerr C: Culture, Medicine and Psychiatry 26: 419–447, 2002

Self-Efficacy: The Social Cognition Theory

11

Proprioception, Kinesthesis, Interoception and Emotions

Avery JA et al. (2013). Biological Psychiatry

Qigong and Bodily Sensations Meditative movements are exercises that use movement in

conjunction with meditative attention to body sensations, including proprioception, kinesthesis and interoception. Proprioception:

sensation pertaining to stimuli originating from within the body relatedto spatial position and muscular activity or to the sensory receptors that they activate

Kinesthesis: the perception of one's own body parts, weight, and movement

Interoception: pertaining to stimuli originating from within the body that are related to the functioning of the internal organs or the receptors they activate

Payne and Crane-Godreau; Frontiers in Psychiatry 2013

Somatosensory Cortex:Homunculus

The cerebellum is largely responsible for coordinating the unconscious aspects of proprioception.

Propioception and Balancing

Increase awareness re-balancing homeostasis

Interoception and affective stability (I)

Damasio A. The Feeling of What Happens: Body and Emotion in the Making of Consciousness (2000).

Visceral information Insular, Affective and Autonomic State Accessible by Consciousness

Damasio A,Carvalho GB. The natureoffeelings: evolutionary and neurobiologicalorigins. Nat Rev Neurosci (2013) 14(2):143–52.

Interoceptive and Homeostasis

Major Depressive Disorder is associated with Abnormal Interoceptive Activity and

Functional Connectivity in the Insular

Avery JA et al. (2013). Biological Psychiatry

Tai Chi and Brain Functional Plasticity

Wei GX et al. Frontiers in Aging Neuroscience April 2014 | Volume6 | Article 74

blue colors indicate decreases in 2dReHo, while red colors indicate increases in 2dReHo

Qigong and Psychological Well-Being

Methods: Hospital Staff were randomized to either 6-wkQigong class (N=16) or waitlist (N=21)

Results: Subjects in Qigong class had significant reduction in perceived stress (Perceived Stress Scale), improved in social functioning (SF-36), and reduction in pain (100mm Analog)

Results: Short term Qigong training resulted in reduced stress in hospital staff

Griffith J et al., 2008 J Altern Comple Med 14:939-945

Qigong for Patients with DepressionMethods: 82 elderly adults with depression were randomized to 1) 16 wk qigong, 2) control (newspaper reading group)

Results: Qigong group improved more in mood, self-efficacy, and personal well-being in 8 weeks. After 16 weeks of practice, the improvement generalized to daily task domain of the self-concept

Conclusion: Qigong practice could relieve depression, improve self-efficacy and personal well-being among elderly persons with chronic physical illness and depression

Tsang et al., 2006, Int J Geriatric Psychiatry

Qigong Treatment for Depressed Chinese Americans: A Pilot Study

A clinical trial to use Qigong for treating Chinese American patients with MDD is feasible and safe.

A twelve-week Qigong intervention may be effective in improving symptoms and inducing remission in Chinese Americans with MDD.

Qigong exercises, a Chinese folk well-being practice, has a potential to augment conventional treatment of depression.

Yeung et al. Evid Based Compl & Altern Med 2013

Meta-analysis: Effects of Tai Chi on Depression

Wang C (2010) BMC Compl & Altern Med

Systematic Review of Effects of Qigong on Anxiety, Depression, & Psychological Well-Being

Methods: Relevant studies on Qigong published between 2001 and 2011 in Chinese and English data-bases were searched. Fifty studies with randomized clinical trial or quasi-experimental design were reviewed and meta-analyses were performed on 3 studies.

Results: In the reviewed studies, Qigong was found to reduce depression, anxiety, somatic complaints, and improve quality of life. Meta-analyses were performed on 3 studies of patients with type-II diabetes, based on homogeniety assessment; Qigong was found to reduce depression (ES=-0.29; 95% CI, -0.58--0.00) and anxiety (ES=-0.37, 95% CI, -0.66 --0.08), and improve psychological well-being (ES=-0.58, 95% CI, -0.91--0.25).

Conclusion: Preliminary evidence suggests that qigong may have positive effects on psychological well-being among patients with chronic illnesses.

Wang et al, Evidence-Based Compl & Altern Medicine. 2012.

Meta-analysis: Effects of Qigong on Depression

Oh et al. (2013) Evid Based Compl & Altern Med

The evidence suggests potential effects of Qigong in the treatment of depression,

the review of the literature shows inconclusive results. Further research using

rigorous study designs is needed

Tai Chi Treatment for Depressed Chinese Americans: A Randomized Trial

Objective: To examined the feasibility, safety, and efficacy of using Tai Chi for treating depressed Chinese Americans

Subjects: Sixty-seven Chinese Americans with MDD with no treatment for depression were randomized (1:1:1) into a tai chi invention, an education program, or a waitlist group for 12 weeks

Intervention

Intervention Group: Two instructors followed a standard protocol, which included 12 weeks of training, and taught the first section (24 basic movements) of the traditional 108 movements of Yang-style tai chi.

Education Group: Participants in the education group received didactic training and discussed stress, mental health, depression and its treatment for one hour, twice per week, for 12 weeks.

Waitlisted Group: Participants in the waitlisted group were assessed at weeks 6 and 12, but received no other interventions during their waiting and follow-up periods.

Figure 1. Flow Chart of Subject Recruitment, intervention, and follow-up

Tai Chi Treatment for Depressed Chinese Americans

93 potential participants were interviewed

Tai Chi Intervention group Baseline

N=23

Education Control Group Baseline

N=22

Waitlisted Control group Baseline

N=22

8 Withdrew

Week 6 N=18

5 Withdrew

Week 6 N=14

Week 6 N=20

2 Withdrew

Week 12 N=17

Week 12 N=14

Week 12 N=19*

1 Discontinued#

Week 18 N=17

1 Discontinued#

Week 24 N=17*

Week 18 N=14

Week 24 N=14

Week 18 N=18

Week 24 N=17*

1 Discontinued#

1 Discontinued#

67 Eligible were Randomized

26 Not eligible/Withdrew

Waitlist Education Tai Chi Tai Chi vs. Education

Tai Chi vs. Waitlist

Education vs. WaitlistN=20 N=14 N=18

n % n % n % OR (95% CI) OR (95% CI) OR (95% CI)

Wk 12 (post-intervention)HAMD Response (yes)

5 25 3 21 10 56

8.90 (1.17, 67.70) 2.11 (1.01, 4.46) 1.1 0(.18, 6.75)

Wk 12 (post-intervention)HAMD Remission (yes)

2 10 3 21 9 50

4.40 (.78, 24.17) 3.01 (1.25, 7.10) 4.10 (.40, 43.78)

Wk24 (follow-up)HAMD Response (yes)

8 40 8 57.1 13 72.2

2.26 (.47, 10.84) 2.51 (1.11, 5.70) 1.96 (.48, 7.93)

Wk 24 (follow-up)HAMD Remission (yes)

6 35.3 6 42.9 11 64.7

2.40 (.53, 10.85) 2.20 (1.04, 4.64) 2.09 (.42, 10.34)

Tai Chi for Treatment of Depression: Primary Outcomes

Yeung et al., J Clin Psych 2017

Conclusions1. Existing evidence suggest that qigong/Tai Chi is

beneficial for promoting well-being and for treating a range of physical conditions including diabetes and fibromyalgia, and depression symptoms in medically ill patients.

2. A small number of studies suggested possible effectiveness of qigong for treating patients with major depressive disorder (MDD).

3. Future studies are needed to establish whether qigong is effective for well-being, and for treating patients with various medical illnesses; whether it is effective as monotherapy or as adjunctive treatment with conventional interventions, and whether it can be used to prevent the onset, relapse, or recurrence of illnesses.

Clinical Trials on Qigong/Tai Chi Treatment for Depression:

Methodological Considerations for Future Studies:■ How to define the study population?■ Is the intervention standardized? ■ How to assess the reliability among Qigong/Tai Chi instructors?■ What is the choice of the control group?

■ Waitlist? Attention controls? ■ Blinding of the subjects?■ Blinding of the raters?■ What are the outcome variables?■ Are there confounding variables?■ Are results statistically and clinically significant? ■ Are results generalizable?■ Can results be disseminated in the real world?