Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138

Systematic review to explore the effect of yoga on

anxiety in adults

Mr Mehmet Deveci, Mr Antony Laban-Sharman, Dr Rebecca Laban-Sharman

Faculty of Sport, Allied Health & Performance Sciences, St. Mary’s University, London, United Kingdom

Abstract

Introduction: The National Health Service cannot chronically sustain the overwhelming demands

being placed on it due to financial cuts, staff numbers and recent presence of Covid-

19. As a

result, anxiety levels are on the rise thus increasing the need for effective first-line treatment.

Purpose: The purpose of this systematic review was to examine the efficacy of yoga as a first-line

treatment for anxiety. Previous systematic reviews have produced mixed results.

Methodology: The inclusion criteria followed the PICO research statement. The popula

tion (P)

were either healthy or diagnosed with anxiety and the intervention (I) was yoga. The comparison

intervention design. The outcome (O)

was the change in the level of anxiety post-intervention.

Results and Discussion: After the review of 64 studies, 7 studies fit the inclusion criteria: four

randomized controlled studies, one longitudinal study, and two pre- and post-intervention

comparisons. All the studies included provided statistically signif

icant results for the beneficial

effect of yoga on anxiety.

Conclusion: This study adds to preceding literature on the current anxiety levels of adults and the

potential utility of yoga as a first-line treatment for self-management of anxiety levels. This review

stresses the issue of heterogeneity, mode of yoga and calls for more robust randomised

controlled trials to pioneer the subject matter to help, if not prevent, to slow down the rising cases

of anxiety and ill mental health worldwide.

Keywords

Anxiety, Mental Health, Yoga, Systematic Review, Adults

Address for correspondence:

Mr Antony Laban-Sharman, Postal Address: St. Mary’s University, Twickenham, TW1

4SX, E-mail: antony.laban-sharman@stmarys.ac.uk

This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International

License (CC BY-NC 4.0).

©Copyright: Laban-Sharman, 2023

Publisher: Sciendo (De Gruyter)

DOI: https://doi.org/10.56508/mhgcj.v6i1.150

Submitted for publication: 04

January 2023

Revised: 04 March 2023

Accepted for publication: 06

March 2023

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138

Introduction

According to the “Diagnostic and Statistical

Manual of Mental Disorders V” (DSM V) anxiety

disorders that are divided into subtypes all of

which are characterised by excessive worrying

about events and situations over a period of six

months and occurring on more days than not

(American Psychiatric Association, 2013).

Neuroimaging studies have demonstrated that

those with anxiety demonstrated increased activity

in the amygdala, interior insula and areas of the

prefrontal cortex and decreased activity in some

areas of the ventrolateral prefrontal cortex. The

result is an increased sensitivity to negative

events and more effortful cognitive reappraisal of

an event (Buhle et al., 2013; Gorka et al., 2019;

Groenewold et al., 2013). Anxiety disorders are

one of the two most common mental illnesses

globally and are most prevalent among those in

the 20 to 39 age group and among women.

Worldwide, anxiety disorders were ranked eighth

among mental disorders with respect to years

lived with disability and the twenty-fourth leading

cause of disability-adjusted life years (Ferrari et

al., 2022). Anxiety has been associated with

poorer physical health, a decreased tendency to

engage in healthy behaviours, and an increased

tendency to engage in unhealthy behaviour

(Hearon et al., 2014; Morissette et al., 2007;

Sareen et al., 2005). Subtypes of anxiety

frequently overlap and are frequently comorbid

with other mental conditions. For example,

generalised anxiety disorder is frequently

comorbid with depression (Bandelow & Michaelis,

2015). In a systematic review, Horenstein and

Heimberg (2020) determined that anxiety, in

particular the generalised anxiety disorder, was

associated with a greater utilisation of healthcare

resources. In summary, anxiety is a common

mental disorder, associated with a reduced

number of years spent in good health, and a

burden on healthcare delivery.

Yoga

Yoga has different forms and the ones most

frequently offered in the western world are Yin,

Kundalini, Vinyasa, and Hatha yoga (Khalsa,

2004). Yin, Kundalini, and Hatha yoga are slower

paced with pauses between poses whereas

Vinyasa is a more vigorous activity without pauses

(Khalsa, 2004). Yoga is a practical as well as a

spiritual practice that focuses on breathing

techniques and postures that are believed to bring

the mind and body into union (Khalsa, 2004). The

suspected biomechanism in yoga is a deep

relaxation achieved by a modification of the

autonomic nervous system and the hypothalamic

pituitary axis (Anand et al., 1961; Benson, 1975).

Previously, yoga was regarded as an alternative

and complementary therapy in the west. Now

yoga is being examined as a cost-effective first-

line therapy for anxiety (Kirkwood et al., 2005).

The fact that the physical and mental benefits of

yoga are now generally accepted is evidenced by

the National Health Service endorsement of yoga

on their website (NHS, 2021). The effect of yoga

on anxiety has become the subject of formal

systematic literature reviews, e. g. Cramer et al.

(2018), Khalsa (2004), Kirkwood et al. (2005), and

Volbehr et al. (2018).

Research on Yoga and Anxiety

Cramer et al. (2018) conducted a systematic

review and meta-analysis on eight randomised

controlled trials and concluded that yoga could be

an effective intervention for anxiety disorders or

elevated anxiety, but the evidence was

inconclusive. Further, an explanation of a

biomechanical mechanism was lacking. No effects

were found for participants who had been

diagnosed with an anxiety disorder in accordance

with the DSM-V guidelines (American Psychiatric

Association, 2013). Supportive evidence was

found only for those with elevated anxiety and

without a formal diagnosis or diagnosed by means

other than the DSM-V. Some forms of yoga were

specified, e. g. Vinyasa, Agni (meditative), but

most were unspecified. Volbehr et al. (2018)

conducted a systematic review and meta-analysis

of 18 studies. The inclusion criteria were studies

on Hatha yoga and participants with a formal

diagnosis of an acute or chronic mood disorder

and/or anxiety disorder in accordance with the

guidelines of the DSM V or earlier editions, or the

International Classification of Disease 10

(American Psychiatric Association, 2013; World

Health Organization, 1993). The authors found

that Hatha yoga was not effective for anxiety

disorders and that the results were equivalent to

control groups or treatment as usual groups.

Other factors to be considered in a systematic

review of the effect of yoga on anxiety are

comorbidities. Anxiety disorders and depression

are frequently comorbid, which makes the

assessment of anxiety as an independent factor

difficult (Ionescu et al., 2013). Also, most recent

research focuses on the effect of yoga on anxiety

in a clinical population with a specific disease,

such as cancer and Parkinson (Hardoerfer &

Jentschke, 2018; Kwok et al., 2019). Overall, the

systematic reviews and meta-analyses concluded

that the results are weak for the effects of yoga on

anxiety. The investigators stated that the

inconclusive results could be due to the inclusion

of studies that lacked: (1) adequate methods, (2)

consistent means of diagnosis, (3) diagnosis at

baseline, and (4) adequate description of yoga

practice (Cramer et al., 2018; Kirkwood et al.,

2005; Vollbehr et al., 2018). Cramer et al. (2018)

commented that in-depth systematic reviews and

meta-analyses are hampered by the sheer lack of

volume of yoga and anxiety studies, a high risk of

bias arising from methodology issues such as

Mental Health: Global Challenges Journal

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variations in blinding and lack of participant

randomising, and the lack of control groups.

Purpose

This systematic review attempts to fill some of

the above gaps by including studies that had

adequate research designs, specified the type of

yoga intervention, and included only participants

who were healthy or had a diagnosis of anxiety at

baseline. The objective of the study is to perform

a systematic review of recent literature to assess

the evidence for the effect of yoga practice as a

first-line therapy for anxiety. The rationale of the

study is to determine if yoga practice should be

recommended as part of a low-cost self-care

regime for adults.

Methodology

The following databases were used to identify

studies on anxiety and yoga: PubMed, Cochrane

Library, British Medical Journal, and

ScienceDirect. As the search tools differed by

database, they are described individually.

PubMed’s advanced search function allowed a

Boolean algorithm to filter by words in the title and

abstract. The following terms were entered:

anxiety AND yoga, NOT depression, NOT

children, NOT meditation. NOT depression was

specified in the title and abstract search because

anxiety and depression are frequently comorbid

and studied together. This review wanted to

assess the effect of yoga on anxiety alone.

Further filters included publication date of 2019 to

the present and in English. The search identified

78 records. An additional search of the results

filtered by clinical trial, randomised controlled trial,

and the availability of a full text reduced the

number of records to 11. The Cochrane Library

has a database that includes only studies that are

clinical trials. The advanced search keywords

used were anxiety AND yoga, NOT children, NOT

depression. The search was further filtered by a

publication date range of January 2019 to January

2022. The search identified 46 studies. The

ScienceDirect database allowed a search by

keywords, publication date range, and article type.

The search terms yoga AND anxiety NOT

depression, date range of 2019 to 2022, filtered

by research type article yielded 23 results. For the

British Medical Journal database, the keyword

was generalised to yoga with an expanded

publication date between 2017 and 2022 and

limited to research articles. The search yielded

two studies. The next step was to eliminate the

duplicates from a total of 135 articles, which left

64. The method is outlined according to the 2009

PRISMA flow diagram in figure 1.

Exclusion and Inclusion Criteria

The eligibility requirements were based on the

PICO formula (Population, Intervention,

Comparison, Outcome). The population selected

was healthy adults or adults with a primary

diagnosis of anxiety and age 18 years or above.

The intervention was yoga practice. The

comparison was either a control group, or a pre

and post-intervention assessment of anxiety. The

outcome is a change in the level of anxiety as

measured by a validated anxiety scale or

symptom inventory. Other inclusion criteria were

publication date of 2019 or later, in the English

language, and a full text was available. An

exception was made for publication date for

articles in the BMJ database as few records were

located. Studies were excluded if the methods

were poor, the participants were children or were

recruited from a clinical population, e. g.

participants with cancer or Parkinson’s. The

Critical Appraisal Skills Programme was used in

the assessment of the studies and in the

formatting of the study synthesis (CASP, 2020).

Results

Table 1. Synthesis of Studies

Author

Study

Participants

(Ss)

Study

Descripti

Aim/desi

gn/metho

Main Findings

Comment

Strengths

/Limitatio

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Brene

s et al.

(2020)

500 adults

over the

age of 60

Recruited

from the

general public

Diagnosis:

score of ≥

26 on Penn

State

Worry

Questionna

ire

Abbreviate

Aim: Compare the efficacy

of CBT and Hatha yoga on

worry, anxiety, and sleep and

to determine if preference for

CBT or yoga modified the

results.

Design: Randomised

controlled trials.

Intervention: Group Hatha

yoga.

3 arms. 250 Ss were

randomised to either CBT

intervention or a yoga trial.

The remaining Ss chose

whether to enter the CBT (n

= 120) or yoga intervention

(n = 130).

Method: anxiety

assessed with Patient-

Reported Outcomes

Measurement

Information System

(PROMIS®), anxiety

section.

Anxiety assessed pre-

intervention,

at week 6, week 11, and week

37.

Logistic regressions

controlled for age,

psychotropic medication,

race. For the randomised

trial, both groups showed

reduced anxiety symptoms

post-intervention.

However, there was no

statistically significant

differences between the yoga

and CBT groups for change

in anxiety score. CBT and

yoga interventions did not

differ by anxiety score in the

preference group. There were

no differences in anxiety

reduction between the

randomized groups and when

Ss chose their intervention

Strengths: large sample

size. Follow-up

assessment Limitations:

In this age bracket, Ss had

comorbidities such as

hypertension, diabetes,

depression, anxiety, heart

disease. Logistic

regression analyses

controlled for

comorbidities, but they could

have an impact on the agility

needed for yoga. Over 80%

of Ss were women.

Lemay et

al. (2021)

United

States

Healthy

adults. N

= 20.

Age 18 to 66.

Aim: Assess the effect of a

6-week Yin yoga class plus

guided meditation on stress

perception, anxiety, and

mindfulness skills.

Design: quasi-experimental.

Pre- and Post-intervention

assessments. Intervention:

Yin yoga plus guided

meditation

Compared to baseline, scores

showed a statistically

significant reduction in

anxiety, stress, and

mindfulness skills at post-

intervention, at 3 months,

and 6 months.

Strengths: Ss

demonstrated the

increasing benefit of

yoga over 4 points in

time.

Limitations: No control

group. Small sample size. 14

of the 20 Ss had prior

experience with yoga and

meditation. Some Ss

practiced as

home as well. Neither the

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Following the duplicates being removed, the

number of articles was reduced from 135 to 64.

Consequently, these 64 journal articles went

through screening as of the abstract and title

where 46 were excluded and 20 continued to

remain and be fully assessed. Thereafter, with a

full assessment using the CASP tool, 7 fully

eligible studies were included in the systematic

review and the procedure for this is conveyed

below (Figure 1). Furthermore, a complete

synthesis of studies is also displayed below

(Table 1)

Figure 1. PRISMA flow chart of search results

Summary of the Results

The details of the studies are included in Table

1. The studies varied in their level of evidence.

Four studies were randomised controlled trials,

one was longitudinal, and two were quasi-

experimental. All the studies included in the

systematic review indicated that most yoga styles

common in the west showed promise as a first-

line therapy for anxiety for healthy adults and

those diagnosed with anxiety. Different styles of

yoga were represented in the review — Hatha,

Yin, Kundalini, and Vinyasa. Four studies had

healthy participants and three studies had

participants with a diagnosis of anxiety in

accordance with the DSM V (American Psychiatric

Association, 2013). One of the eligibility criteria of

the Phaniskar and Mullen (2022) study was the

self-reporting of three or more symptoms on the

Generalised Anxiety Scale of the DSM V. Pre-

intervention mean scores of anxiety for the yoga

group were provided but the standard deviation

was quite high (mean 8.28, SD 4.15). Therefore,

some of the participants could have had high

levels of anxiety. Not all yoga styles were an

effective treatment for anxiety. Marshall et al.

(2020) compared two forms of yoga, Hatha and

Vinyasa, and found that Hatha yoga reduced

anxiety symptoms, but Vinyasa yoga did not.

Their results suggested that the style of yoga

could influence the effect of the practice on

anxiety. Two studies compared yoga with CBT for

the first-line therapy for anxiety (Brenes et al.,

2020; Simon et al., (2020). The findings of Simon

et al. (2020) suggested that Kundalini yoga was

as effective as CBT but not better than CBT.

Brenes et al. (2020) found that yoga was as

effective as CBT among older adults. The

evidence for the long-term effects of yoga on

anxiety symptoms were not clear. Lemay et al.

(2021) and Simon et al. (2020) examined the

long-term effects of yoga on anxiety with follow-up

assessments. In three- and six-month follow-up of

the effect of Yin yoga on anxiety, Lemay et al.

(2021) found that, compared to pre-intervention

scores, anxiety levels showed a statistically

significant reduction. However, the authors did not

mention how or if Yin yoga was practiced in the

follow-up periods. Simon et al. (2020) had two

interventions, CBT and Kundalini yoga, and a

control group. Compared to pre-intervention

scores, at post-intervention, both CBT and

Kundalini yoga produced a statistically significant

at reduction in anxiety. At a six- month follow-up,

the CBT group showed statistically significant

reductions in anxiety levels. However, the yoga

group anxiety scores were equivalent to the

control group. Except for Brenes et al. (2020),

none of the studies included individuals with

comorbidities. Also, Brenes et al. (2020) was the

only study that focused on adults aged 60 and

over, an age group in which a higher level of

comorbidities would be expected. In this large

randomised controlled study (n = 500), the

investigators compared the efficacy of CBT and

yoga on worry and anxiety. Worry and anxiety

were assessed as independent outcomes.

Logistic regressions controlled for potential

interactions between comorbidities and anxiety. A

subgroup analysis revealed that CBT produced

better results than yoga for participants with

comorbid depression. No conclusions could be

drawn on the safety of yoga as an intervention as

five of the seven studies did not report adverse

events. Brenes et al. (2020) and Simon et al.

(2020) reported adverse events, but the events

were not related to the interventions

Discussion

The findings for the effect of yoga on anxiety

remain mixed. The common factor in

compromising the findings of systematic studies

for this study and previous research on yoga are

small sample sizes and the inclusion of studies

with poorer levels of evidence, e. g. Cramer et al.

(2018), Kirkwood, et al. (2005) and Volbehr et al.

(2018). The explanations provided by Cramer et

al. (2018) and Volbehr et al. (2018) for the

inconclusive results were the limited number of

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studies on yoga and anxiety, lack of a clear

diagnostic criteria, lack of diagnosis at baseline,

lack of independent evaluators and blinding of

evaluators, heterogeneity of yoga practice, and

inadequate description of yoga practice. This

review was able to address some of the gaps, but

not all. The research of Cramer et al. (2018) and

Volbehr et al. (2018) included more studies, but

most of the studies included suffered the common

problem of yoga studies and that is small sample

size that limits the credibility of the results. Three

of the studies included in this review have

reasonable sample sizes: Brenes et al. (2020) (n

= 500), Simon et al. (2020) (n = 230) and Telles et

al. (2019) (n = 320). The statistically significant

effectiveness of yoga was demonstrated across

the smaller and larger sample sizes. Three of the

studies included participants diagnosed with

anxiety and the diagnostic criteria were clearly

stated (Brenes et al., 2020; Phaniskar & Mullen,

2022; Simon et al., 2020). The findings indicated

that yoga was equally effective on those

diagnosed with anxiety and a healthy population.

As Cramer et al. (2018) and Volbehr et al.

(2018) commented, results are inconclusive due

to lack of rigorous research designs. This review

suggested that yoga was effective regardless of

the sample size or research design. Both Lemay

et al. (2021) and Sulastri et al. (2021) used quasi-

experimental designs and had small sample sizes,

but the results were statistically significant.

Credibility of the current review was enhanced by

only including studies with validated anxiety

assessment scales, i. e. Beck Anxiety Inventory,

State–Trait Anxiety Inventory, Hamilton Anxiety

Rating Scale. An exception was Simon et al.

(2020) who used a Clinical Global Impression of

Improvement scale (CGI-I) conducted by an

independent evaluator. The CGI-I is commonly

used in psychiatry and has been validated

(Forkmann et al., 2011).

Recommendations

The evidence for the efficacy remains

inconclusive. While this review found that except

for Vinyasa, yoga had a beneficial effect on

anxiety, Cramer et al. (2018) and Volbehr et al.

(2018) did not. Therefore, yoga as a first-line

therapy should be recommended with caution.

With respect to future research directions, this

review confirms the conclusion drawn by Cramer

et al. (2018) and Volbehr et al. (2018) that more

well- designed studies with larger samples are

needed. Other issues in need of further

examination are the impact of yoga on different

types of anxiety and different levels of anxiety.

Kirkwood et al. (2005) found that yoga was

effective with specific types of anxiety, such as

obsession compulsive disorder and snake anxiety,

and suggested that research that focussed on

specific types of anxiety might produce clearer

results.

Limitations and Strengths of the

Study

Limitations of the Study

As mentioned above, Cramer et al. (2018)

stated that systematic reviews and meta-

analyses on yoga and anxiety tend to have a

higher risk of bias, and this systematic review is

no exception. Few studies have been published

between 2017 and 2022 that fit the criteria of the

PICO statement and the sample sizes were small.

Participant blinding is not possible in a yoga class.

Three of the studies were nonrandomised and

had no control groups (Lemay et al., 2021;

Sulastri et al., 2021; Telles et al., 2019). As with

previous systematic reviews, the current study

includes research with varying levels of evidence

and small sample sizes. Yoga is an ancient multi-

dimensional practice and encompasses practical

aspects, such as breathing techniques and poses,

and more spiritually oriented aspects, such as the

underlying philosophy, that are not as easily

quantifiable. The content of the yoga classes was

not always well- described and, in any case,

would vary by instructor. The studies that included

long term data did not specify how and if yoga

was practiced during the follow-up periods. Except

for Telles et al. (2019), women were over-

represented in the studies. All the above

limitations compromise the generalisability of the

results.

Conclusions

There are not enough well-designed studies on

the effect of yoga on anxiety to draw conclusive

evidence. The results could be improved if the

heterogeneity of anxiety type and yoga form were

better addressed. For example, studies that

included only Hatha yoga and the sample only

included those diagnosed with obsessive-

compulsive disorder, could produce clearer

results.

Conflict of interest

The authors declare that they have no conflicts

of interest.

Acknowledgements

Special thanks goes to Mr Antony Laban-

Sharman and Dr Rebecca Laban-Sharman, for

their unpraralled support, expertise and counsel

throughout this study

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