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Review of the Research: Effects of Yoga, CBT, and stress education on Anxiety.

A recent study by Simon et al (2021) investigated the effects of yoga on anxiety. The researchers were scientists, medics, psychologists and yoga teachers - and the results are fascinating.

What was the Research Question?

Which treatment was the most effective for Generalised Anxiety Disorder (GAD): cognitive behavioural therapy (CBT), yoga, or stress education?

What was the method?

A randomized controlled trial – which is the highest quality of research study possible. It means that participants are randomly allocated to treatment groups and compared on a specific measure before and after they take part in the study.

All the participants had a primary diagnosis of GAD and were assessed before and after treatment using standardised scale in which trained clinicians rate the participants symptoms. In this case, there were 3 groups: 67 people were given CBT for GAD (an evidence based talking therapy considered the gold standard in Clinical Psychology); 60 people practiced Kundalini Yoga; 28 people attended a stress education course*.

The treatments were equal in terms of duration and intensity (12 weeks: 1 session per week (120 minutes), with daily ‘homework’ (20 minutes)), and instructor contact (3-6 participants per group, with 2 instructors).

What were the results?

Participants were assessed every fortnight during the treatment, and at a 6-month follow-up. It’s important to note that the clinicians that rated participants’ GAD symptoms did not know which intervention each participant had been given.

At the end of the treatment, and at the 6-month follow-up, results showed that yoga and CBT were significantly more effective at treating GAD than stress education. However, yoga was not as effective as CBT.

What does this mean?

The authors state that yoga is an effective treatment for generalised anxiety disorder, but the results suggest that CBT remains first-line treatment.

Image from Simon et al., and talk by Sat Bir S Khalsa on Give Back Yoga University

The longer story…

Generalised anxiety disorder (GAD) is a common condition in which people suffer from significant distress and impairment. Symptoms are psychological (e.g., restlessness, difficulty concentrating, irritability, a sense of dread) and physical (shortness of breath, headaches, fatigue, nausea, muscle aches, dry mouth, excessive sweating, irregular heartbeats). It is believed to affect up to 5% of the UK population, although many people do not seek help.

Cognitive Behavioural Therapy (CBT) is an evidence-based first-line treatment for GAD, although it is not always available due to cost and resources. Patients have increasingly turned to alternative interventions, such as yoga, outside the medical system.

The effects of yoga practice on anxiety are promising, but relatively little research has been conducted. In this study, the impact of Kundalini yoga on GAD was systematically investigated. In this study, trained instructors led the participants through a 12-week standardized yoga protocol, which included individual breathing practices (e.g., Alternate Nostril Breathing), a full hour-long Kundalini yoga series, and individual yoga mediations with coordinated breathing). The 20-minute home practice involved physical movements for spinal flexibility and release of tension, coordination with breath, and mind-body awareness.

The results of the study show that a regular yoga practice can have significant effects on symptoms of anxiety, that go beyond any placebo effects or control conditions (i.e., engaging in ‘something’ with the expectation that it might improve the problem). What is really important is that the effects were still present 6 months after the study was over – in fact – for all 3 treatments the positive impacts continued to increase. The authors of this study predicted that the yoga would be as effective as the CBT – but results did not support this hypothesis. Why not? Well, CBT interventions have benefitted from extensive research and clinical investigation, leading to the refinement of treatment style for this condition and population. Also, the Psychologists that deliver CBT sessions are highly skilled and trained clinicians with a thorough understanding of the condition, and it is not really a surprise that their treatments remain the gold-standard.

There are 3 things to think about as we move forward:

  • With ongoing research and practice, the positive effects of yoga-based practices are likely to improve as we understand more about what works and what doesn’t.

  • GAD is a heterogeneous condition, meaning different people have different combinations of symptoms. Therefore, some people will respond better to particular interventions than others. Finding out more about who will respond to what is a key aim of future research.

  • There is no reason why yoga could not be offered / recommended alongside first-line interventions, and this approach may prove to be even more effective than either treatment alone.

From, a practical point of view, yoga is far more accessible to many people than CBT and can be engaged with as a long-term lifestyle habit. People who engage in this may also find that positive impacts emerge on other aspects of life (e.g., social engagement, healthy routines, physical fitness).

In sum, this research is really promising. It is published in a high-quality journal, includes a reasonably large sample size, and is well controlled. The yoga intervention can be replicated (see study by Hofmann et al. 2015 for full details of yoga practice). Future research from this group, and others, will help us to understand more about the effects of yoga and to refine our practices with specific populations.

PLEASE NOTE: You should consult a medical practitioner if you are concerned that you are suffering from GAD or another anxiety disorder. If you do decide to engage in any yoga-practices, we recommend that you let you teacher know that you are suffering from anxiety symptoms.

1. Simon NM, Hofmann SG, Rosenfield D, Hoeppner SS, Hoge EA, Bui E, Khalsa SBS. Efficacy of Yoga vs Cognitive Behavioral Therapy vs Stress Education for the Treatment of Generalized Anxiety Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2021 Jan 1;78(1):13-20. doi: 10.1001/jamapsychiatry.2020.2496. PMID: 32805013; PMCID: PMC7788465.

3. Hofmann SG, Curtiss J, Khalsa SBS, Hoge E, Rosenfield D, Bui E, Keshaviah A, Simon N. Yoga for generalized anxiety disorder: design of a randomized controlled clinical trial. Contemp Clin Trials. 2015 Sep;44:70-76. doi: 10.1016/j.cct.2015.08.003. Epub 2015 Aug 6. PMID: 26255236; PMCID: PMC4744580.

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