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Yoga-Based Classes for Veterans With Severe Mental Illness: Development, Dissemination, and Assessment

Throughout 8 weeks of yoga-based wellness classes, veterans were assessed for perceived benefits, pain, stress, and biological, psychological, social, and spiritual wellness.

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There is growing interest in developing a holistic and integrative approach for the treatment of severe mental illnesses (SMI), such as schizophrenia, major depression, posttraumatic stress disorder (PTSD), and anxiety disorders. Western medicine has traditionally focused on the direct treatment of symptoms and separated the management of physical and mental health, but increasing attention is being given to complementary and alternative medicine (CAM) for patients with SMI.

Recognizing the connectedness of the mind and body, these complementary or alternative approaches incorporate nontraditional therapeutic techniques with mainstream treatment methods, including psychopharmacology and psychotherapy.1 Patients with SMI may particularly benefit from a mind-body therapeutic approach, because they often experience psychological symptoms such as stress, anxiety, depression and psychosis, as well as a preponderance of medical comorbidities, including obesity, diabetes mellitus, and cardiovascular disease, some of which are compounded by adverse effects (AEs) of essential pharmacologic treatments.2-4 Mind-body interventions might also be particularly advantageous for veterans, who often experience a range of interconnected physical and psychological difficulties due to trauma exposure and challenges transitioning from military to civilian life.5

Related: Complementary and Alternative Medicine for Chronic Musculoskeletal Pain

In 2002, the White House Commission on Complementary and Alternative Medicine Policy issued a report supporting CAM research and integration into existing medical systems.6 The DoD later established Total Force Fitness, a holistic health care program for active-duty military personnel.7 The VA has also incorporated mind-body and holistic strategies into veteran care.8 One such mind-body intervention, yoga, is becoming increasingly popular within the health care field.

Recent research has documented the effectiveness of yoga, underscoring its utility as a mind-body therapeutic approach. Yoga is associated with improvement in balance and flexibility,9 fatigue,10 blood pressure,11 sleep,12 strength,13 and pain14 in both healthy individuals and patients with medical and psychiatric disorders.15 The literature also illustrates that yoga has led to significant improvements in stress and psychiatric symptoms in individuals with PTSD, schizophrenia, depression, and anxiety.16-22 A previous meta-analysis conducted by the authors, which considered studies of the effectiveness of yoga as an adjunctive treatment for patients with mental illness, found that 212 studies with null results would need to be located and incorporated to negate the positive effects of yoga found in the literature.17

Because yoga emphasizes the practice of mindfulness and timing movement with breath awareness, it is a calming practice that may decrease stress and relieve psychiatric symptoms not treated through psychopharmacology and psychotherapy.17,21 Recent research has postulated that the physiological mechanisms by which this occurs may include (a) reduction in sympathetic and increase in parasympathetic activity23,24; (b) increases in heart-rate variability and respiratory sinus arrhythmia, low levels of which are associated with anxiety, panic disorder, and depression23,24; (c) increases in melatonin and serotonin 25-27; and 
(d) decrease in cortisol.28,29

Related: Enhancing Patient Satisfaction Through the Use of Complementary Therapies

As yoga may calm the autonomic nervous system and reduce stress, it may benefit patients with SMI, whose symptoms are often aggravated by stress.30 In addition, veterans experience both acute stressors and high levels of chronic stress.5 Therefore, because they experience mind-body comorbid illnesses as well as high levels of stress, the authors believe that veterans with SMI could benefit greatly from a tailored yoga-based program as part of a holistic approach that includes necessary medication and evidence-based therapies.

In order to evaluate the effects of a yoga program on veterans receiving mental health treatment across the VA Greater Los Angeles Healthcare System (VAGLAHS), the authors developed a set of yoga-based wellness classes called Breathing, Stretching, Relaxation (BSR) classes. This article describes the process of developing these classes and outlines the procedures and results of a study to assess their effects.

BSR Classes

The development of BSR classes took place at the West Los Angeles VA Medical Center (WLAVAMC), within the Psychosocial Rehabilitation and Recovery Center (PRRC) program. The PRRC is a psychoeducational program that focuses on the biological, psychological, social, and spiritual aspects of life in order to help veterans with SMI rehabilitate and reintegrate into the community. The program allows veterans to create their own recovery curriculum by selecting from diverse classes led by program staff members, including physicians, psychologists, nurses, social workers, nutritionists, and recreational therapists.

Development of BSR Protocols

The primary goal of this project was to develop a yoga-based program tailored to the specific needs of veterans with SMI. To the authors’ knowledge, BSR is the first yoga-based program customized for SMI. The BSR classes were developed within interdisciplinary focus groups that included professional yoga teachers, the director of the PRRC, psychiatrists, psychologists, nurses, occupational therapists, and physical therapists. Drawing on their experience with SMI and yoga, members of the focus groups identified 3 aspects of yoga that would be most beneficial to veterans with SMI, and the program was designed to optimize these effects. Because SMI can both create and be exacerbated by stress, BSR classes were designed to reduce stress and provide veterans with the tools to monitor and manage their stress.


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