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The art of yoga is thousands of years old. Early indications of yogic postures are seen in the remains of the Indus Valley Civilization. While early texts such as Patanjali's Yoga Sutras (C. 400 AD) describe the basic principles of yoga, the techniques of this discipline have evolved over the last two millennia. Over the past several decades, yogic practice has rapidly become a burgeoning global industry with several variations being taught and practiced around the world. By contrast to the art of yoga however, the science of yoga and its application to mental health issues is relatively recent. The articles in this special issue of the Indian Journal of Psychiatry provide glimpses of emerging new research on treatment of various neuropsychiatric disorders. The articles examine different aspects of yoga-based interventions in different neuropsychiatric disorders ranging from validating a module to examining its efficacy to understanding the biological basis of its effects. While individual papers are of interest to specific disciplines, this collation is likely to provide a synthesis of diverse developing concepts and will be of interest to the reader community of the journal.  The first two papers discuss about designing and validating yoga modules for use in the patient population. Hariprasad et al.[1] describe the development of a yoga module for use in elderly and Naveen et al.[2] describe validation and feasibility of a yoga module for depression. Using traditional and contemporary yogic literature, these authors developed yoga modules and then examined the feasibility of their use in pilot studies. Limitations like a small number of subjects, inability to perform asanas and inability to remember complete sequences of asanas need to be addressed in future. These studies provide validated modules, which can be tested for their efficacy in patient populations.[1]  Four subsequent articles examine the efficacy of yoga as a treatment for different psychiatric disorders. Sivakumar et al. examined the benefits of yoga-based intervention compared with waitlist control group on cognitive function in the residents of elderly homes and report significant improvement in cognitive functions following yoga.[3] In addition, these residents also had a significant improvement in quality-of-life and total sleep quality.[4] In the study by Gangadhar et al.,[5] authors examined the efficacy of yoga intervention in depression. The study findings are interesting as yoga had better efficacy than pharmacotherapy and was devoid of side-effects. Manjunath et al.[6] examined the effect of add-on yoga therapy or physical exercise along with standard pharmacotherapy in treatment of in-patients with psychosis. Though, both groups were comparable at the end of 2 weeks yoga figured better than exercise in clinical improvement at the end of 6 weeks. These studies demonstrate the application of scientific rigour used in pharmacological clinical trials to yoga research. For example, authors followed a randomized trial design and used valid neuropsychological tests to measure cognitive functions comparable with contemporary pharmacological trials. Such methodological rigor is necessary for inclusion of yoga-based interventions into the physician's treatment options. These studies indicate the potential of yoga as a treatment for psychiatric disorders alone or in combination with pharmacotherapy. Future studies need to address limitations like absence of an active comparison group or bias of treatment selection by patients for further acceptance by the scientific community.  Three subsequent papers in the supplement describe the applicability of yoga in special populations. Hariprasad et al.[7] report the feasibility of yoga as a therapy in children with attention deficit hyperactive disorder. Their report establishes the potential of yoga in the treatment of childhood psychiatric disorders. This report is of special significance considering the patient population as yoga is relatively devoid of untoward side-effects, but long-term adverse effects of psychotropics on the developing brain is still debated. Again the small sample size in the study is a limitation to draw firm conclusions, but the results warrant further studies. Umadevi et al.[8] attempted to address an important issue in the care-giving aspect of chronic neurological conditions. As care-givers tend to have significant burn out and many conceivably have psychological concerns, they examined the efficacy of yoga in care-givers and reported a significant decrease in anxiety and depression scores, as well as improved quality-of-life. The randomized nature of this study and the use of structured assessments to measure the severity of clinical symptoms were major methodological strengths. The acceptability of this mode of therapy in the Indian context makes it an attractive option in this population. The report by Naveen et al.[9] explored the knowledge, attitude and practice of yoga among people living with epilepsy. The finding that one-third of patients believed in beneficial effect of yoga and more than half were willing to practice yoga suggests the acceptability of yoga and calls for further studies of yoga in epilepsy.  Finally, five papers explored the neurobiological basis of the beneficial effects of yoga using cutting edge technologies. Using magnetic resonance imaging (MRI) and voxel based morphometry, Hariprasad et al. examined the hippocampus volume changes following 6 months of yoga.[10] Though the study is limited by the number of subjects, the authors identified a significant increase in hippocampal, but not occipital gray matter following 6 months of yoga practice in elderly. In two related papers, Varambally et al. and Naveen et al. report the neurochemical changes following yoga; first, they demonstrate lower levels of brain-derived neurotrophic factor (BDNF) in patients with depression, compared with controls.[11] Subsequently, following yoga therapy the authors demonstrate an increase in serum BDNF.[12] Importantly, there was a significant correlation between fall in depression ratings and rise in serum BDNF levels suggesting the possibility that neuroplastic changes may be related to therapeutic effects of yoga in depression. The last two studies in the supplement report changes in peripheral hormones following yoga and their relation to psychiatric symptoms. Thirthalli et al.[13] examined the effect of yoga on serum cortisol levels as the potential mechanism in depressed patients; patients with depression had higher cortisol levels than controls, which decreased following yoga suggesting possible anti-stress effects of yoga at the level of the hypothalamus. Jayaram et al.[14] report effect of yoga therapy on facial emotion recognition deficits and plasma oxytocin levels in patients with schizophrenia. Using a randomized design, these authors demonstrated an improvement in endogenous plasma oxytocin levels and facial emotion recognition deficits in schizophrenia patients receiving yoga therapy. These studies provide important leads to understand possible mechanisms behind the effect of yoga and in doing so set the platform for further research.  All these studies point to the promise of yoga as a therapeutic option in psychiatry, provide the needed impetus for moving the field ahead, add to a body of recent literature showing beneficial effects of Yoga in mental health disorders.[15] However, some caution is in order, to ensure a healthy accumulation of a body of evidence based data. First, majority of the studies described in this issue point to the superiority of yoga over whatever the control intervention that was used. It is important to report negative findings as well and yoga researchers should avoid the tendency not to publish negative results, a practice leading to the so-called file-drawer problem.[16] Second, most of published yoga studies in psychiatric disorders, including those in this issue, have used relatively small sample sizes, which often lead to a profusion of type I as well as type II errors, making the studies often non-replicable. Admittedly, studies of this nature are difficult to implement and are often not well-funded by mainstream funding mechanisms, but leaders in this field should consider meta-analyses as well as multi-site collaborations that utilize uniform methodology to accrue large samples that can detect small to moderate effect sizes. Third, research designs have been often limited by lack of blinded assessments, appropriate choice of control groups and lack of data on durability of effects following cessation of treatment. Finally, as with any treatment study, it is important to examine and report adverse effects, (yoga has side-effects too, e.g.,[17]) as well as sample attrition.  Such limitations are not unique to yoga research, but are common in any emerging field that seeks to develop novel therapeutic interventions. However, it is important to remember that any intervention that has broad public appeal and is relatively non-invasive is of considerable potential for large scale application, even if effects are moderate. For this reason, rigorous studies to show efficacy are critical to then move on to effectiveness studies and dissemination in a community clinic settings. The neuroscientic basis of yoga interventions, exemplitied by studies of Yoga's structural MRI, functional MRI, BDNF, and oxytocin effects in this issue are exciting. These observations join recent observations of yoga effects on gene expression,[18] immune parameters[19] and brain gamma-aminobutyric acid levels[20] and once replicated, will further enhance the scientific credibility of yoga.

Yoga and mental health: Promising road ahead, but proceed with caution