Qigong and Tai Chi for

Treatment of Depression

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

Director of Primary Care Studies

MGH Depression Clinical and Research Program

Associate Professor

Harvard Medical School

Co-Medical Director

South 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/or

2. ↓Interest or pleasure

3. Sleep disturbance

4. Guilt or feelings of worthlessness

5. ↓ Energy

6. ↓Concentration

7. 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;

including Mind Body Treatment

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Qigong (氣功)

Qi (氣): Fundamental life energy responsible for health & vitality

Qong (功): To Cultivate

Qigong (氣功) : Energy Cultivation

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Qigong Practices

Ancient Chinese exercises that cultivate Qi for health maintenance, spirituality, and for healing and increasing vitality. Various forms of exercises practiced 1) during stillness: lying, sitting, or standing; and 2) with movements.

They integrate mental focusing, physical movement, and breathing techniques.

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Bajuanjin Qigong

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Qigong

Tai Chi

Synchronizing the

Mind, Movement, and Breathe

Possible Mechanisms for Healing:

Traditional Chinese Medicine Theories

A free-flowing, well-balanced Qi system reflects good health.

Illnesses are the result of Qi blockage in certain areas of the

body.

Qigong and Tai Chi are believed to promote the flow of Qi

and alleviate Qi blockages, and may potentially prevent or

delay the progression of illnesses.

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12 Meridians in Traditional Chinese Medicine Theory

How Qigong Heals?

It is a Subjective Experience

The practitioner focuses on somatic feelings in

a positive way, which may trigger…

a feedback loop … that in turn produce an

alteration in physiological processes.

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

Proprioception, Kinesthesis, Interoception and Emotions

Avery JA et al. (2013). Biological Psychiatry

Homonculus of Sensory – Motor Cortex

Propioception and Balancing

Increase awareness re-balancing homeostasis

Possible Mechanisms of Healing:

Self-Efficacy: The Social Cognition Theory

1 1

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Post

Potential Mechanisms of Healing: Relaxation Response to Counteract Stress Responses

Pre

Benson H et. al. Psychosomatic Medicine (1974) Vol. 36, No. 2, 115-120

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12 min. 12 min. 12 min.

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The practice of Tai Chi decreased salivary cortisol

concentrations.1

Among older adults with high IL-6 levels at entry, Tai Chi

produced a drop in IL-6 levels, decrease in depressive

symptoms was correlated with decreases in IL-62

1Jin P. J Psychosom Res, 1989.

2Irwin & Olmstead R. Am J Geriatr Psychiatry, 2012.

Possible Mechanisms of Healing: The Psychological Effects of Mindfulness

Develop psychological skills such as observing,

describing, acting with awareness, nonjudging of

inner experience, and nonreactivity to inner

experience.1

The decrease in attachment to one’s thoughts and

emotions leads to clarification, exposure,

self-regulation, and cognitive flexibility

(reperceiving or decentering).2

1Baer RA: Assessment. 2008 Sep;15(3):329–42.

2Shapiro SL. J Clin Psychol. 2006 Mar;62(3):373–86.

Possible Mechanisms of Healing:

Qigong and Bodily Sensations

Qigong exercises involve movements and meditative

attention to body sensations, including proprioception,

kinesthesis and interoception.

Proprioception:

sensation pertaining to stimuli originating from within the body related

to 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

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

Possible Mechanisms of Healing:

Neuropsychological Effects on the Brain

Meditation modulates the structure and function of anterior

insula and ACC, key regions involved in interoception1.2

Tai Chi and Baduanjin significantly modulate the

cognitive control network, and the default mode network,

a network associated with self-inferencing in older adults.3,4

1Tang YY et al. Nat Rev Neurosci. 2015; 2Kong et al., Neurisci 2015.

3Kong J., et al. Brain Imaging Behav, 2018; 4Liu J. Soc Cogn Affect Neurosci, 2019

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-wk

Qigong 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 Depression

Methods: 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 Grpoup

8 Withdrew

Week 6 N=1 8

5 Withdrew

Week 6 N=1 4

Week 6 N=20

2 Withdrew

Week 1 2 N=1 7

Week 1 2 N=1 4

Week 1 2 N=1 9*

1 Discontinued#

Week 1 8 N=1 7

1 Discontinued#

Week 24 N=1 7*

Week 1 8 N=1 4

Week 24 N=1 4

Week 1 8 N=1 8

Week 24 N=1 7*

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.

Waitlist N=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

Conclusions 1. 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?