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Guille monsterMECHANISMS OF CHANGE OF PRANAYAMA: A QUALITATIVE STUDY
EXPLORING HOW VOLUNTARILY CONTROLLED BREATHING REDUCES
DEPRESSION
Dissertation presented to the Faculty of the
California School of Professional Psychology
Alliant International University
San Diego
In partial fulfillment of the requirements for the degree of
Doctor of Psychology
by
Anthony J. Benicewicz
2015
Approved by:
Marina Dorian, Ph.D., Chairperson
Steven Hickman, Psy.D.
Donald Eulert, Ph.D.
UMI Number: 3702426
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MECHANISMS OF CHANGE OF PRANAYAMA ii
© Anthony J. Benicewicz, 2015
MECHANISMS OF CHANGE OF PRANAYAMA iii
Acknowledgements
I’d like to thank the following individuals for their support and contributions to this
project. First, the highest praises to my lovely research assistant and supplemental data analyst,
Kaoto Nakanishi. You have added validity, reliability, and merriment to this study. I am forever
appreciative for all your help. I also extend endless gratitude to the venerable, legendary Dr.
Robert “Bob” Jackson. Although hackneyed, I couldn’t have done it without you.
A yogi’s obeisance for my two excellent yoga teachers, Yogacharya Pradeep Muthaiya at
Alliant International University and Jaruska Solyova at the Cove in La Jolla, California. Thank
you both for teaching me the ancient principles of pranayama, as outlined in the Yoga-Sūtras. I
wouldn’t have begun this research without your generous teachings.
My reverence to the members of my dissertation committee: Chairperson Dr. Marina
Dorian, Dr. Steven Hickman, Dr. Donald Eulert, and Dr. Gary Lawson. I’ve appreciated your
energy, knowledge, guidance, and support over these years. I am proud of the study we created
together and have enjoyed working with you all. Thanks also to: Dr. Thuy Do for defense
preparation, Staff Sergeant Steven Browning for technical support, Kevin Kelly for general
assistance, Stancy Merwin and Victoria Pak for editing, and everyone who participated.
Here, gratitude for Dad and Kathy, Mom, and Matthew for all the love, encouragement,
support, finances, and forward momentum that saw this research to completion. With special
recognition for Catharine “Grandmom” Benicewicz, “bless her soul and collar buttons.” I’d also
like to acknowledge all remaining magnanimous friends and family members on both coasts.
And lastly, a proper O.B. shout out for Beth and Derek, who granted me squatter’s rights
and unlimited access to Jason Statham movies while putting the final touches on this magnum
opus. With special thanks to Russell Crowe, Biscuit, and BonBon. We miss you Beegun.
MECHANISMS OF CHANGE OF PRANAYAMA iv
Abstract
Pranayama is the fourth-limb of the ancient Ashtanga yoga system and involves voluntarily
controlled breathing to promote health and personal growth. Twelve RCTs have found various
yogic interventions efficacious for depression, with five suggesting that the pranayama
component played an important role. Sudarshan Kriya Yoga (SKY), a pranayama-based
program, is the most applied, empirically supported yogic intervention for depressive disorders
with: two RCTs, three open trials, and various case reports. While several quantitative studies
have found yogic breathing effective in treating depressive disorders, little qualitative research
has explored the experiences of adult participants who reduced depression with pranayama.
This study used a qualitative research design to explore the experiences of 10 adult
participants who reduced clinical depression using pranayama, with a focus on discovering
mechanisms of change. The primary investigator conducted an in-person, semi-structured
interview with each participant. The constant comparative method and NVivo software
identified, analyzed, and organized units of meaning into emergent themes and categories.
Qualitative data analysis yielded 15 themes falling into 6 categories, with five additional findings
that did not meet the research criteria to be considered emergent themes.
The results were generally consistent with the literature on pranayama. This study
uncovered multiple experiential mechanisms, synergistic mind-body experiences, and new
insights and behaviors underlying antidepressant change; possibly rooted in parasympathetic
nervous system dominance. With regular pranayama, most participants experienced: focused
attention, a sense of control, increased energy, oxygenation, positive shifts in consciousness,
clearing of the mind, reduced negative thoughts, mindfulness, physiological benefits, and
relaxation. Participants described pranayama as being a reliable, transferable practice that
MECHANISMS OF CHANGE OF PRANAYAMA v
managed depression and cultivated holistic health. Emergent themes shared similarity and some
overlap with other populations undertaking pranayama, including: adolescent sex offenders,
breast cancer survivors, patients living with HIV or AIDS, individuals with chronic pain, and
healthy participants. However, the present study found that pranayama might be uniquely suited
for disrupting depressive thought patterns and reducing ruminations that perpetuate unipolar
depression. This research added to a small, but growing body of knowledge for clinicians
integrating pranayama into therapy with clients experiencing depressive disorders.
MECHANISMS OF CHANGE OF PRANAYAMA vi
Table of Contents
Acknowledgements ...................................................................................................................... iii!
Abstract......................................................................................................................................... iv!
List of Tables ............................................................................................................................... xii!
CHAPTER I. Introduction........................................................................................................... 1!
Background of the Problem ........................................................................................................ 1!
The Scope of Depression. ....................................................................................................... 2!
The Personal Costs of Depression. ......................................................................................... 3!
The Social and Financial Burden of Depression..................................................................... 4!
Statement of the Problem ............................................................................................................ 5!
Purpose of the Study ................................................................................................................... 6!
Clinical Relevance ...................................................................................................................... 6!
CHAPTER II. Review of the Scientific Literature .................................................................... 8!
An Overview of Complementary and Alternative Medicine ...................................................... 8!
Defining. ................................................................................................................................. 8!
Yoga as a Form of CAM. ........................................................................................................ 9!
An Overview of Yoga ............................................................................................................... 10!
An Overview of Pranayama ...................................................................................................... 12!
Defining and Conceptualizing. ............................................................................................. 12!
Origins and Outlining. .......................................................................................................... 14!
The Practice. ......................................................................................................................... 15!
Safe and Effective Use. ......................................................................................................... 17!
MECHANISMS OF CHANGE OF PRANAYAMA vii
A Brief History of Pranayama in the Scientific Literature ....................................................... 18!
Pranayama in Clinical Treatment.......................................................................................... 24!
Physiological Disorders. ................................................................................................... 24!
Mental Disorders............................................................................................................... 24!
Special Populations. .......................................................................................................... 25!
Caveats and Clinical Contraindications. ........................................................................... 25!
Pranayama in the Treatment of Depressive Disorders. ......................................................... 26!
An Overview of Sudarshan Kriya Yoga ................................................................................... 26!
Preliminary SKY Research. .................................................................................................. 28!
Case Reports Exploring SKY for Depression. ...................................................................... 30!
Controversial Issues Regarding SKY. .................................................................................. 31!
The Evidence of Efficacy of Yoga for Depression ................................................................... 32!
A Review of RCTs using Yoga with Pranayama for Depression ............................................. 34!
Additional RCTs and Future Directions ................................................................................... 37!
The Neurophysiologic Model ................................................................................................... 39!
Hypothesized Mechanisms of Change ...................................................................................... 40!
Psychological Mechanisms. .................................................................................................. 41!
Mindfulness. ..................................................................................................................... 41!
Attention Control. ............................................................................................................. 42!
Metacognitive Awareness. ................................................................................................ 42!
Positive thinking. .............................................................................................................. 43!
Psychophysiological Mechanisms. ....................................................................................... 43!
MECHANISMS OF CHANGE OF PRANAYAMA viii
Neurochemical Regulation................................................................................................ 43!
Relaxation. ........................................................................................................................ 44!
Cardiorespiratory Optimization. ....................................................................................... 44!
Brainwave Alteration. ....................................................................................................... 45!
Sleep Regulation. .............................................................................................................. 46!
Metaphysical Mechanisms. ................................................................................................... 47!
The Higher Mind............................................................................................................... 47!
Prana Expansion/Control. ................................................................................................. 47!
A Need for Qualitative Research .............................................................................................. 48!
Relevant Mixed-Methods Research. ..................................................................................... 49!
Summary ................................................................................................................................... 52!
CHAPTER III. Methods ............................................................................................................ 54!
Research Design........................................................................................................................ 54!
Participants................................................................................................................................ 55!
Inclusion Criteria. ................................................................................................................. 56!
Exclusion Criteria. ................................................................................................................ 57!
Protection of Human Participants ............................................................................................. 58!
Measures ................................................................................................................................... 59!
Telephone Screening Interview. ........................................................................................... 59!
Demographic Questionnaire. ................................................................................................ 59!
Semi-Structured Interview. ................................................................................................... 59!
Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I). ......................... 59!
MECHANISMS OF CHANGE OF PRANAYAMA ix
Recruitment of Participants....................................................................................................... 60!
Data Collection ......................................................................................................................... 60!
Data Analysis ............................................................................................................................ 61!
Presentation of the Data ............................................................................................................ 62!
Provisions of Trustworthiness .................................................................................................. 63!
CHAPTER IV. Results ............................................................................................................... 65!
Description of the Participants .................................................................................................. 65!
Participant # 1 – Jennifer. ..................................................................................................... 67!
Participant # 2 – Mary........................................................................................................... 68!
Participant # 3 – Andrew. ..................................................................................................... 69!
Participant # 4 – John. ........................................................................................................... 70!
Participant # 5 – Sarah. ......................................................................................................... 71!
Participant # 6 – Ann. ........................................................................................................... 72!
Participant # 7 – Joseph. ....................................................................................................... 73!
Participant # 8 – Henry. ........................................................................................................ 74!
Participant # 9 – Julie. ........................................................................................................... 75!
Participant # 10 – Kathleen. .................................................................................................. 76!
Categories and Themes ............................................................................................................. 77!
Category 1: Psychological Mechanisms. .............................................................................. 79!
Theme 1: Focused and/or Refocused Attention. ............................................................... 79!
Theme 2: Sense of Control. .............................................................................................. 80!
Category 2: Psychophysiological Mechanisms. ................................................................... 82!
MECHANISMS OF CHANGE OF PRANAYAMA x
Theme 3: Energy/Prana Regulation. ................................................................................. 82
Theme 4: Oxygenation. ..................................................................................................... 83!
Theme 5: A Foundational Exercise................................................................................... 84!
Category 3: Psychological Results of Practice. .................................................................... 85!
Theme 6: Psychological State Change. ............................................................................. 86!
Theme 7: Clearing the Mind. ............................................................................................ 87!
Theme 8: Reduced Negative Thoughts. ............................................................................ 89!
Theme 9: Mindfulness Cultivation. .................................................................................. 90!
Theme 10: Unity/Oneness................................................................................................. 93!
Category 4: Psychophysiological Results of Practice. .......................................................... 95!
Theme 11: Relaxation Response. ...................................................................................... 95!
Theme 12: A Mind/Body Connection............................................................................... 96!
Category 5: Physiological Results of Practice. ..................................................................... 98!
Theme 13: Physiological Benefits. ................................................................................... 98!
Category 6: Practice Attitudes and New Insights. ................................................................ 99!
Theme 14: Regular Practice. ............................................................................................. 99!
Theme 15: Adopting an Integrative Approach. .............................................................. 100!
Additional Finding #1: Unknown Mechanisms. ................................................................. 101!
Additional Finding #2: Releasing of Negative (and/or Repressed) Emotions. ................... 102!
Additional Finding #3: Chakra/Meridian Balancing. ......................................................... 102!
Additional Finding #4: Using Breathing with Visualization. ............................................. 103!
Additional Finding #5: Outlying Experiences. ................................................................... 104!
CHAPTER V. Discussion ......................................................................................................... 105!
MECHANISMS OF CHANGE OF PRANAYAMA xi
Integration with Previous Theory and Research ..................................................................... 105!
Discussion of Categories and Themes .................................................................................... 110!
Mechanisms of Change. ...................................................................................................... 111!
Results of Practice............................................................................................................... 112!
New Insights. ...................................................................................................................... 115!
Additional Findings. ........................................................................................................... 115!
Clinical Implications ............................................................................................................... 117!
Assumptions and Limitations ................................................................................................. 118!
Recommendations for Future Research .................................................................................. 121!
Conclusions ............................................................................................................................. 123
References .................................................................................................................................. 126
APPENDIX A. Interview Guidelines ...................................................................................... 146!
APPENDIX B. Letter of Introduction .................................................................................... 148!
APPENDIX C. Informed Consent ........................................................................................... 150!
APPENDIX D. Telephone Screener ........................................................................................ 154!
APPENDIX E. Demographic Questionnaire .......................................................................... 156!
APPENDIX F. Recruitment Flyer ........................................................................................... 160!
MECHANISMS OF CHANGE OF PRANAYAMA xii
List of Tables
Table 1. Participant Demographics ...............................................................................................66
Table 2. Categories and Themes ...................................................................................................78
MECHANISMS OF CHANGE OF PRANAYAMA 1
CHAPTER I
Introduction
Pranayama is an ancient yogic practice that uses voluntarily controlled breathing to
engender health and personal growth. Pranayama has been used to treat a wide variety of mental
and physical disorders in the literature, but the scientific study of these practices is still in the
early stages (Brown & Gerbarg, 2005a; Sovik, 2000). Two bibliometric analyses of the medical
literature found depression to be among the most common disorders treated with yoga (Cramer,
Lauche, & Dobos, 2014; Khalsa, 2004). Twelve randomized controlled trials (RCTs) have found
yogic interventions effective in treating depressive disorders (Cramer, Lauche, Langhorst, &
Dobos, 2013; Pilkington, Kirkwood, Rampes, & Richardson, 2005). Several of these RCTs
suggested that the pranayama component played an important role in reducing depression
(Cramer et al., 2013; Pilkington, Rampes, & Richardson, 2006). However, very little qualitative
research has investigated pranayama for the treatment of depressive disorders. Thus, this study
utilized a qualitative research design to explore the experiences of adult participants who had
reduced clinical depression with pranayama.
Background of the Problem
Depressive disorders include: “Major Depressive Disorder, Dysthymic Disorder, and
Depressive Disorder Not Otherwise Specified” (American Psychiatric Association, 2000, p.
345). Unipolar depression is the characteristic hallmark of depressive disorders. Depressive
disorders cause significant suffering, have a high mortality and morbidity rate, and create serious
impairment in various realms of functioning (Cassano & Fava, 2002). Depressive disorders are
often chronic in nature, and individuals with these diagnoses could experience recurrent episodes
of depression (Greden, 2001).
MECHANISMS OF CHANGE OF PRANAYAMA 2
The Scope of Depression. Depression affects people of all ages, genders, and
backgrounds (World Health Organization, 2012). Approximately 350 million people worldwide
suffer from depression, and the majority of this population does not receive effective treatment.
Moreover, as few as 10% of individuals diagnosed with depression will receive adequate care in
certain countries. Results from the Global Burden of Disease Study 2010 found that major
depressive disorder (MDD) rose from the 15th to the 11th ranked position, for a total increase of
37% from 1990 (Murray et al., 2012). Depressive disorders contributed to 42.5% of years lived
with disability (YLDs) and 40.5% of disability-adjusted life years (DALYs); thus comprising the
majority of the non-fatal global burden of disease (GBD) for mental and substance abuse
disorders (Whiteford et al., 2013). The GBD of depression is expected to rise for all ages and
genders (World Health Organization, 2012). Demographic changes, heightened life expectancy,
and recent reports that depression is affecting individuals at an earlier age indicate that
depressive disorders will significantly rise in the future (Sartorious, 2001).
Depressive disorders pose a formidable problem in the United States. Andrade et al.
(2003) analyzed data from 10 countries using a sample of approximately 37,000 participants and
found that the lifetime prevalence for a major depressive episode (MDE) had a low of 3% in
Japan and a high of 16.9% in the United States. Nationwide epidemiologic research by Kessler
et al. (2003) interviewed a sample of 9,090 adults and found that 16.2% reported having MDD in
their lifetime, with 6.6% experiencing a MDE within the past 12 months. When extrapolated,
these numbers indicated that approximately 32.6 to 35.1 million American adults would
experience MDD in their lifetime, with 13.1 to 14.2 million reporting a MDE during the past
year. Hasin, Goodwin, Stinson, and Grant (2005) similarly found that 13.23% of American
adults reported experiencing MDD in their lifetimes with 5.28% indicating a MDE within the
MECHANISMS OF CHANGE OF PRANAYAMA 3
last year. In a survey of 2,049 adults, Kessler et al. (2001) found that 7.2% of the respondents
reported experiencing severe depression within the past 12 months. Using a sample of 9,282
adult respondents, Kessler, Tat-Chui, Demler, and Walters (2005) found that MDD was the third
most prevalent mental disorder reported during the previous 12-month period. In a survey of
6,694 adult participants, Ohayon (2007) found that 5.2% met the diagnostic criteria for MDD
during the month preceding the interview.
The Personal Costs of Depression. Depressed mood and a loss of interest or pleasure in
daily activities are defining features of depressive disorders (American Psychiatric Association,
2000; Cassano & Fava, 2002). Individuals with depression often report significant
psychological, behavioral, and physical symptoms. Globally, depression was reported to be the
leading cause of disability (World Health Organization, 2012). Individuals with depression are
often as seriously disabled as patients suffering from chronic medical diseases (Berto, D’llario,
Ruffo, DiVirgilio, & Rizzo, 2000).
Depressive disorders also share a high comorbidity with other psychiatric disorders
(Sartorious, 2001). Kessler et al. (2003) found that nearly three-fourths of people who reported
experiencing major depression in their lifetime also met DSM-IV criteria for at least one other
psychiatric diagnosis. Sartorius (2001) highlighted that depressive disorders cause severe
suffering and functional impairment not only for the affected individual, but for their friends and
families as well.
Suicide is one of the most serious outcomes associated with depressive disorders
(Cassano & Fava, 2002). Several studies have underscored the correlation between depression
and suicidal behavior, noting that individuals suffering from mood disorders are at higher risk for
suicide than the general public (Berto et al., 2000; Bostwick & Pankratz, 2000; Sartorious,
MECHANISMS OF CHANGE OF PRANAYAMA 4
2001). Sartorius (2001) reported that depression is likely the most salient risk factor for suicide.
Reports have indicated that as many as 60-66% of all completed suicides are committed by
individuals suffering from a depressive disorder (Berto et al., 2000; Sartorious, 2001). The
World Health Organization (2012) estimated that approximately one million individuals
worldwide commit suicide each year. Globally, approximately 1,000 people kill themselves
each day, and more than 30,000 people in the United States alone will commit suicide this year
(Sartorious, 2001). It was estimated that 21% of patients with recurrent depressive disorders
would attempt suicide at some point in their lifetime.
The Social and Financial Burden of Depression. Depressive disorders cause
significant financial strain for industrialized and post-industrialized societies (Berto et al., 2000).
Depression has consistently been associated with unemployment and poverty (Weich & Lewis,
1998). In addition, the diagnosing and treatment of depressive disorders significantly impacts
public health (Cassano & Fava, 2002). Stoudmire, Frank, Hedemark, Kamlet, and Blazer (1986)
included both direct and indirect costs when calculating the financial burden of depression.
Direct costs included expenditures for the diagnosis, treatment, and ongoing care of depressed
patients. Indirect costs involved time and finances lost due to individuals suffering from
depression. Absenteeism, diminished quality of work, and reduced productivity are common
examples of indirect costs of depression (Greden, 2001). Stoudmire et al. (1986) collected data
from community mental health centers, surveys, and hospitals to determine the financial burden
of depression in the United States. For 1980, it was estimated that depression had a total direct
cost of 2.1 billion dollars with indirect costs of over 10 billion dollars. When years of lost
productivity due to suicide were included in these figures, the research projected a total mortality
cost of 4.2 billion dollars. Overall, the total cost of depression for 1980 was estimated to be 16.3
MECHANISMS OF CHANGE OF PRANAYAMA 5
billion dollars, with the average cost per patient approximated at 3,400 dollars annually. Berto et
al. (2000) used the medical consumer price index to adjust these figures for the year of 1998.
After extrapolation, the total cost of depression in the United States for 1998 was calculated to be
52.7 billion dollars, with an 11,000 dollar annual cost per patient.
Statement of the Problem
Depressive disorders cause significant personal, social, and economic problems
worldwide. Depression comprises a major portion of the GBD, and its prevalence is expected to
rise for all ages and genders. Depression causes significant suffering and functional impairment
for millions of individuals each year, and may directly or indirectly impact all those around
them. For these reasons, it becomes extremely important to explore safe, practicable, and
empirically supported interventions to meet the growing challenges posed by this enormous
problem.
Increased attention has recently been placed on ancient methods of treatment for the role
they may have in improving health (Vera et al., 2009). This redirected focus has resulted in an
increase in the number of scientific studies applying traditional holistic practices to treat mental
and physical disorders. Yoga is one such approach gaining empirical support. It was stated,
“evidence-based research has found that the regular practice of yoga produces important physical
as well as psychological benefits” (p. 164). Two systematic reviews concluded that yoga-based
interventions appear to be demonstrating effectiveness in treating depressive disorders (Cramer
et al., 2013; Pilkington et al., 2005). Sudarshan Kriya Yoga (SKY), a pranayama-based yogic
intervention, has been found effective in reducing depression across several RCTs
(Janakiramaiah et al., 2000; Rohini, Pandey, Janakiramaiah, Gangadhar, & Vedamurthachar,
MECHANISMS OF CHANGE OF PRANAYAMA 6
2000; Vedamurthachar et al., 2006). While these early findings are encouraging, more research
is needed to explore what role pranayama might have in the treatment of depressive disorders.
Purpose of the Study
To date, virtually all studies evaluating pranayama for depressive disorders have used
quantitative research designs. Quantitative research aims to test hypotheses using statistical
analysis focusing on large groups of people. While quantitative studies have found pranayama-
based interventions efficacious for depressive disorders, in-depth qualitative research has not yet
investigated why or how yogic breathing decreases depression. The biomedical and
psychological research has largely overlooked the perspectives and experiences of adult
participants who have undertaken pranayama for depression. Thus, this study aimed to explore
the experiences of adult participants who reduced clinical depression using pranayama, with a
concentration on uncovering mechanisms of change. A qualitative research design was applied
to meet the goals of this study. It was hoped this inquiry could provide the field of clinical
psychology with a rich source of new data to better understand this phenomenon.
Clinical Relevance
As abovementioned, this study aimed to discover the experiential mechanisms of change
of voluntarily controlled breathing that ameliorate unipolar depression. This information might
be beneficial to those currently suffering from depressive disorders. The findings could provide
new ideas or effective techniques for individuals attempting to prevent recurrent depressive
episodes. This data might also inform clinicians considering integrating yogic breathing into
treatment planning for clients with unipolar depression. In addition, the findings could add to the
body of scientific knowledge regarding pranayama and highlight new directions for research.
MECHANISMS OF CHANGE OF PRANAYAMA 7
Considering the scope of depression, many features of pranayama make it a practical
clinical intervention. Pranayama is a safe, cost-efficient treatment. Under a trained yoga teacher
or psychotherapist, the breathing techniques can be taught to large groups of people in short
amounts of time. Once acquired, the exercises can be practiced independently virtually
anywhere and at any time. The techniques are nondenominational and can be used by anyone
regardless of age, race, gender, or socioeconomic status. In addition, pranayama has been taught
and practiced across many cultures worldwide. The breathing exercises can be easily modified
to accommodate a wide variety of physical problems or mental disorders. These features make
pranayama an ideal intervention to explore for the treatment of depressive disorders.
MECHANISMS OF CHANGE OF PRANAYAMA 8
CHAPTER II
Review of the Scientific Literature
This chapter reviewed complementary medicine, yogic theory, pranayama, Sudarshan
Kriya yoga, relevant clinical research, and mechanisms of change associated with pranayama.
The need for qualitative research in this area concluded this section.
An Overview of Complementary and Alternative Medicine
Zollman and Vickers (1999) noted a general confusion surrounding complementary
medicine. Problems appeared to arise when determining how these practices should be viewed
in relation to conventional forms of medicine. Berman (1997) stated that “complementary
medicine comprises a wide spectrum of delivery models, and the boundaries between
complementary medicine and the dominant system are not always sharp or fixed” (p. 192). What
is considered complementary medicine can change over time, across cultures, and in context;
especially as new treatment approaches emerge and existent practices gain empirical support
(Pilkington et al., 2006). This article highlighted the broad diversity existing across practices
and treatments included under this term. Berman (1997) reported that over 200 types of
complementary therapies exist, ranging from self-help to provider-dependent modalities. These
issues posed major challenges in clarifying and conceptualizing what complementary medicine is
specifically, often leaving the field a nebulous entity.
Defining. A review of the literature found that the terms complementary medicine,
unconventional therapy, alternative health care practices, and complementary and alternative
medicine (CAM), were often used synonymously. This finding likely compounded the confusion
already surrounding the field (Zollman & Vickers, 1999). Berman (1997) defined
complementary medicine as “any therapy that is considered unorthodox or outside the domain of
MECHANISMS OF CHANGE OF PRANAYAMA 9
conventional medicine in several countries” (p. 192). Zollman and Vickers (1999) described
complementary medicine as “a group of therapeutic and diagnostic disciplines that exist largely
outside the institutions where conventional health care is taught and provided” (p. 693). The
Office of Alternative Medicine of the National Institutes of Health held a conference in April of
1995 to address research and methodological issues for the field of CAM. At this meeting, a
panel on definition and description defined CAM as:
A broad domain of healing resources that encompasses all health systems, modalities, and
practices and their accompanying theories and beliefs, other than those intrinsic to the
politically dominant health system of a particular society or culture in a given historical
period (“Defining and Describing Complementary and Alternative Medicine,” 1997, p.
50).
Collectively, these definitions emphasized that CAM is used primarily outside of a
society’s prevailing medical institutions. However, this review suggested that at least some
CAM practices are now being integrated into mainstream treatment models. The present study
used the term CAM unless otherwise noted.
Yoga as a Form of CAM. Yoga therapy centers are now an international phenomenon
(Khalsa, 2004). Saper, Eisenberg, Davis, Culpepper, and Phillips (2004) conducted a nationally
representative telephone survey involving 2,005 respondents to evaluate the patterns and
prevalence of yoga use in America. The results found that 7.5%, or an estimated 15 million
adults had used yoga at least once in their lifetime. Approximately half of these individuals
(49.3%) reported that they had used yoga in 1998. When projected, this figure indicated 7.4
million current yoga practitioners in the United States.
MECHANISMS OF CHANGE OF PRANAYAMA 10
Yoga can be conceptualized as a form of CAM (da Silva, Ravindran, & Ravindran,
2009). Yoga has traditionally been used in Eastern cultures to cultivate and support holistic
health. However, the popularity of yoga appears to be increasing in Western societies. Yoga
was noted to be a cost-effective, non-invasive practice with minimal risks of harm. Yoga does
not require elaborate medical supervision, avoids the side effects of medication, and can improve
physical fitness. Yoga could be viewed as a unique form of CAM that involves both mind and
body exercises (Brown & Gerbarg, 2005a; Jensen & Kenny, 2004; Meeks & Jeste, 2007).
An Overview of Yoga
Yoga is an ancient Hindu discipline (Singh, Wisniewski, Britton, & Tattersfield, 1990).
Yoga originated in India and was recorded in the Vedas, the Upinashads, and other ancient texts
(Sharma, Yadava, & Hooda, 2005). Sulekha, Thennarasu, Vedamurthachar, Raju, and Kutty
(2006) stated that the word yoga ( ) originates from the Sanskrit root Yuj, which means
“union” (p. 207). Yoga is the practice of “yoking together or unifying body and mind” (Kabat-
Zinn, 2005, p. 101). This theme of joining appears present in all meanings of yoga (Taimni,
1992). The ultimate goal of yoga is to unite the individual soul with the universal consciousness
by progressively learning to control the body and mind (Singh et al., 1990). Yoga therefore aims
to unite the mind, body, and spirit (Sharma et al., 2005).
An important aim of yoga is to help the practitioner experience connectedness and
wholeness through progressive discipline (Kabat-Zinn, 2005). Thus, yoga can be conceptualized
as a holistic approach with practices oriented toward increasing self-control and self-awareness
(Latha & Kaliappan, 1991). A holistic approach strives for health management on physical,
mental, emotional, and intellectual levels (Chatta, Raghuram, Venkatram, & Hongasandra,
2008). In addition to these spheres of being human, Bhobe (2000) highlighted the role that yoga
MECHANISMS OF CHANGE OF PRANAYAMA 11
has on improving spiritual heath. Harinath et al. (2004) suggested that when yoga is adopted as a
way of life, spiritual health is restored. Acknowledging the holistic nature and intentions of yoga
remained an important consideration for the present study.
Gimbel (1998) noted that much confusion exists as to whether yoga is “a religion, a
philosophy, or a way of being” (p. 244). Sharma et al. (2005) emphasized that yoga is not a
religion, but is instead “a practical aid” (p. 37). Yoga is often viewed as a form of spiritual
training that can be practiced by people of all religious denominations (Slater, 1975). Sovik
(2000) outlined core elements common to most yogic practice. Here, yoga is a disciplined
method of training that often incorporates meditation, relaxation, controlled breathing, physical
postures, and ethical guidelines for students. Yoga is typically studied under an experienced
teacher and is best described as “a method for gaining self-knowledge” (p. 492). Watts (2000)
inclusively defined yoga as “a science and philosophy of the human person, mind and body; it is
also in the fullest sense a way of life, moral as well as practical” (p. 72). The terms yogi (male),
yogini (female), or yogin (general usage/plural) can be applied to those pursuing the yogic path
(Iyengar, 1975; Vijayalakshmi & Jayabal, 2013).
Yoga targets the roots of an individual’s lifestyle to promote wellness (Bijlani et al.,
2005). It was suggested that if yoga is presented to students in a comprehensive manner, they
might choose to make positive lifestyle changes because they want to, rather than because they
feel forced. From this viewpoint, yogic interventions could be conceptualized as a form of
behavioral modification (Taneja et al., 2004). Uebelacker, Tremont, et al. (2010) conceptualized
yoga as a “multifaceted behavioral intervention” (p. 259).
Many different schools of yoga exist (Sovik, 2000). Each tradition offers a unique
philosophy and framework for regular practice. Yoga has also changed significantly as it has
MECHANISMS OF CHANGE OF PRANAYAMA 12
been recorded, modified, taught, and practiced over thousands of years (Slater, 1975). Da Silva
et al. (2009) listed 11 different types of yoga commonly found in the scientific literature that
included: Agni, Hatha, Iyengar, Kripalu, Kundalini, Patañjali-based, Sahaj, Shavasana,
Sudarshan Kriya, Vinyāsa, and Vivekanada. Ashtanga, Bikram, and Restorative yoga (or an
integration of types) were also present (DiStasio, 2008).
Hatha yoga is the most common tradition practiced in Western countries (Danucalov,
Simoes, Kozasa, & Leite, 2008). Riley (2004) outlined the three major components of Hatha
yoga that included: physical postures (asanas), breathing exercises (pranayamas), and
meditation (dhyana). Postures (e.g., standing, balancing, bending, stretching, etc.) strengthen the
body and increase flexibility in a deliberate manner. Consciously controlled breathing helps the
practitioner focus the mind and cultivate deeper states of relaxation. Meditation serves to further
clear the mind and cultivate an internal state of peace. Consistent with the unifying themes of
yoga, these three components work together in an integrated way to offer a complete mind-body
experience. Yogic postures and their names are often derived from, or symbolize elements of
nature including: plants, trees, and animals (Gimbel, 1998). Many yogic traditions include
specialized forms of breathing called pranayama, which remained the focus of this paper.
An Overview of Pranayama
Yoga is taught in a progressive method, and a foundational step in the practice is
pranayama (Singh et al., 1990). Pranayama is one of the most common exercises of yoga
(Kjellgren, Bood, Axelsson, Norlander, & Saatcioglu, 2007).
Defining and Conceptualizing. Authors across the scientific literature defined
pranayama somewhat differently. Some definitions were more metaphysical and focused on the
etymology of the word itself in relation to the practice. Prāṇāyāma ( ) is a
MECHANISMS OF CHANGE OF PRANAYAMA 13
Sanskrit compound word consisting of the root Prāṇā, with either: āyāma or yāma modifying
(Sovik, 2000; Taimni, 1992). Halpern (2000) explained, “prana means life force and ayama
means expansion, manifestation, or prolongation” (p. 37). Pranayama is therefore, the practice
of “expanding our own prana so that it harmonizes with the universal prana” (p. 37). Pranayama
could be interpreted as the prolongation of this “‘vital force’ or ‘life energy’” (Telles & Naveen,
2003, p. 70). However, Sovik (2000) distinguished that the Sanskrit word yāma means to
control, and pranayama might also translate to “the control of energy” (p. 492). It was therefore
suggested that pranayama could encompass both meanings, and “the context determines which
meaning is emphasized” (p. 492). Yogic philosophy theorizes that the uninterrupted flow of
prāna will balance and cleanse the mind and body (Gimbel, 1998). Thus, in the yogic system of
knowledge, the conscious control of prāna becomes a primary aim of those seeking
enlightenment (Halpern, 2000).
Authors conducting clinical research with pranayama adopted a more practical or
scientific definition. Brown and Gerbarg (2005a) operationally defined pranayama as “forms of
voluntarily controlled breathing” (p. 190). Sulekha et al. (2006) similarly defined pranayama as
“voluntarily regulated breathing” (p. 1801). Franzblau, Echevarria, Smith, and Van Cantfort
(2008) designated pranayama as “breath control” (p. 1801). Pratap, Berrettini, and Smith (1978)
described pranayama as a series of respiratory exercises crucial to yogic practice. During yogic
breathing, the inhalation, retention, and exhalation of breath are done in a consciously controlled
manner.
Other terms for pranayama were found in the literature. Kitko (2007) noted that in much
of the Western medical research, the term rhythmic breathing was used in place of pranayama.
Pranayama and rhythmic breathing were both defined as “the science of breath control” (p. 86).
MECHANISMS OF CHANGE OF PRANAYAMA 14
Lee and Speier (1996) reported that the general term breathwork was often applied in
psychotherapeutic settings to teach practices that “primarily involve breathing or manipulation of
the breath” (p. 366). Across the literature, the terms pranayama, voluntarily controlled breathing,
rhythmic breathing, and breathwork were often used synonymously and interchangeably. The
use and unique definition applied in each study typically depended upon the personal
experiences or professional aims of the researcher(s). The present study used the operational
definition voluntarily controlled breathing as proposed by Brown and Gerbarg (2005a).
Virtually all definitions of pranayama across the literature emphasized the conscious and
controlled nature of the breathing exercises. This review suggested that pranayama would build
upon the beginning yogic practice of simply becoming aware of the breath. Kabat-Zinn (2005)
stated, “paying attention to your breathing means just paying attention. Nothing more.” (p. 51).
When practicing breathing at a novice level, “there is no need to try to control it now just
because you have decided to pay attention to it” (p. 52). Sovik (2000) discussed the preliminary
practice whereupon students attend the breath to observe the natural flow of their breathing. This
cornerstone, preparatory exercise for more advanced forms of pranayama was described as
breath training or breath awareness.
Origins and Outlining. The origins of pranayama are unclear (Kitko, 2007). An early
source of information on the importance of conscious breath control can be found in an ancient
Hindu text called the Bhagavad-Gītā. It was stated:
Shutting out all external sense objects, keeping the eyes and the vision
concentrated between the two eyebrows, suspending the inward and out-
ward breaths within the nostrils, and thus controlling the mind, senses and
intelligence, the transcendentalist aiming at liberation becomes free from
MECHANISMS OF CHANGE OF PRANAYAMA 15
desire, fear, and anger. One who is always in this state is certainly
liberated (Bhaktivedanta Swami Prabhupāda, 1972, p. 303).
The Yoga-Sūtras of Patañjali recorded some of the earliest methodical writings on yogic
breathing (Sengupta, 2012; Taimni, 1992). Scholars place the Hindu yogi Patañjali as living
somewhere in India between 400 BCE and 400 CE (Danucalov et al., 2008; Feuerstein, 1979;
Prabhavananda & Isherwood, 1981; Sengupta, 2012). However, debate exists whether this
Patanñjali was the same person as the 2nd BCE era grammarian, a distinct scribing yogi, or if the
Yoga-Sūtras were a compiled work of an unknown author or authors (Prabhavananda &
Isherwood, 1981; Tola, Dragonetti, & Prithipaul, 1987). Taimni (1992) provided a conscientious
translation of the 196 Sūtras (aphorisms) comprising this edifying work with in-depth
commentary. The text was divided into four systematized sections outlining the core philosophy
and practice of yoga. Patañjali’s “classical” system is known as Āṣṭāṅga-Yoga (Sovik, 2000;
Taimni, 1992). The word “Ashtanga” comprises the Sanskrit roots ashta (eight) and anga
(limbs). Sovik (2000) outlined this comprehensive eight-limbed system that included: 1. Yama
(ethical restraints), 2. Niyama (practice attitudes), 3. Asana (postures), 4. Pranayama (the science
of breath), 5. Pratyahara (calming of the senses), 6. Dharana (concentration), 7. Dhyana
(meditation), and 8. Samadhi (self-realization). Pranayama is the fourth limb of the Ashtanga
yoga path and is undertaken after the previous steps have been learned.
The Practice. Breathing is under direct voluntary and involuntary control. While a
comprehensive discussion of the neurophysiology of respiration is beyond the scope of this
paper, research has implicated elaborate feedback mechanisms involving: the autonomic nervous
and neuroendocrine systems, cortical areas, the limbic system, and brainstem regions including
the pons and medulla oblongata (Brown & Gerbarg, 2005a; Ley, 1999). Pranayama is used to
MECHANISMS OF CHANGE OF PRANAYAMA 16
consciously control the breath, which facilitates positive changes within the mind and body
(Sovik, 2000). The basic components of pranayama include: the inhalation, exhalation, and
retention of breath (Sharma et al., 2005).
Rapgay, Rinpoche, and Jessum (2000) described pranayama as a specific type of
“attention meditation” (p. 510). Here, the practitioner can focus on a single object (i.e., the
breath) by consciously excluding all other stimuli from the awareness. The attention is
continually returned to the breath when the individual becomes distracted to “attend to the object
completely with minimal effort” (p. 510). Pranayama could also be considered a form of
“breathing meditation” (p. 514). The practice aims to withdraw consciousness from the external
world to cultivate an inner state of awareness (Slater, 1975). Practitioners gain a deeper
knowledge of their unique breathing style and its relationship to the mind and body (Sovik,
2000).
According to yogic philosophy, “breathing functions as the intermediary between the
mind and body” (Sovik, 2000, p. 405). Gimbel (1998) stated, “yoga and the breath are the
bridges that allow people to experience the mind-body connection essential for wellness” (p.
251). Ancient yoga adherents believed they could more easily gain a state of internal calmness
by controlling the passage of air in and out of their body (Kitko, 2007).
Voluntarily controlled breathing may also be used to alter or induce a variety of mental
and physical states. An illustrative example would be Holotropic Breathwork, where clients
perform deep rapid breathing to promote the surfacing of unconscious material (Grof, 1988;
Holmes, Morris, Rose-Clance, & Putney, 1996; Rhinewine & Williams, 2007).
Just as different types of yoga exist, Kjellgren et al. (2007) highlighted the many unique
forms and variations of pranayama found in the literature. Specific pranayamas could involve a
MECHANISMS OF CHANGE OF PRANAYAMA 17
variety of different breathing methods. Variations might include: abdominal breathing, alternate
nostril breathing, breathing against airway resistance, and breath holding (Brown & Gerbarg,
2005a). Telles and Naveen (2008) reviewed the literature and created a classification system of
six common types of yogic breathing patterns. The categories were based upon the intentions
and methods for specific breathing practices, and included: 1. Breathing through one or both
nostrils, 2. Altering the depth of breathing, 3. Periods of breath holding, 4. Exhaling with the
production of a sound, 5. Breathing through the mouth, and 6. Techniques that alter the rate of
breathing. Specific pranayamas were described under each category to provide readers with an
illustrative example. Virtually all pranayamas alter the rate of normal breathing, with the
majority slowing and extending the breath in a conscious, deliberate manner. Most pranayamas
make breathing deeper. However, certain breathing exercises (e.g., kapalabhati) increase the
rate of respiration.
It should be noted that any specific pranayama could involve multiple breathing
techniques. Brown and Gerbarg (2005b) provided one such example in the form of Om
chanting. Here, the sound Om is made aloud during a prolonged controlled expiration, followed
by a brief period of breath holding. Slow, conscious inhalation follows, and the cycle is
repeated. Om chanting illustrates an inherent difficulty of classifying pranayamas as the practice
involves multiple technical elements. Therefore, some scientific skepticism should be exercised
in classifying or analyzing specific pranayamas.
Safe and Effective Use. Voluntarily controlled breathing should always be learned and
initially performed under an experienced yoga teacher or psychotherapist (Brown & Gerbarg,
2005a; Brown & Gerbarg, 2005b; Sovik, 2000). An ideal yoga environment is one that is safe,
clean, quiet, and having a temperate climate (Halpern, 2000).
MECHANISMS OF CHANGE OF PRANAYAMA 18
The improper practice of pranayama could cause adverse consequences (Brown &
Gerbarg, 2005b). Johnson, Tierny, and Sadlight (2004) reported the case of a 29-year-old
woman who presented at the emergency room with chest pains and shortness of breath. A
medical investigation revealed the patient had suffered a spontaneous pneumothorax caused by
an advanced pranayama known as kapalabhati or “breath of fire” (p. 1951). The patient was
successfully treated with a chest tube and released from the hospital. Brown and Gerbarg
(2005b) cautioned that pregnant women, individuals with high blood pressure, and those with
cerebral vascular disease should not engage in breath holding exercises. Patients with asthma or
respiratory problems may also require extra supervision. A knowledgeable and experienced
yoga teacher or psychotherapist can help ensure that the practice will be both safe and effective
for students and clients. It was recommended that physicians and psychotherapists work closely
with yoga instructors to best serve patients choosing to integrate yogic breathing into their
treatment plans.
A Brief History of Pranayama in the Scientific Literature
The use of pranayama for health, spiritual, or other reasons is ancient (Danucalov et al.,
2008; Singh et al., 1990). However, the translation of ancient yogic texts during the 19th century
helped disseminate yoga throughout Western cultures (Sengupta, 2012). Swami Vivekananda
also played an important role in introducing yogism to the United States and Europe, presenting
lectures in major cities about Rāja yoga with an early translation of The Yoga-Sūtras
(Vivekananda, 1913). His lecture entitled “The control of psychic prana” overviewed
pranayama for new students and taught several rhythmic breathing techniques to beginners
during the late 19th and early 20th centuries.
MECHANISMS OF CHANGE OF PRANAYAMA 19
In 1924, Swami Kuvalayānanda founded the Kaivalyadhama Yoga Institute in Lonavla,
India, and published Yoga-Mīmāṅsā; a scientific journal dedicated to yogism and investigating
various aspects of practice using empirical methods (Tiwari & Kulkarni, 2012). The journal’s
earliest publications explored anatomical, physiological, and biochemical processes affected by
pranayama conducted in a laboratory setting (Kuvalayānanda, 1924; Kuvalayānanda, 1931).
Several authors have highlighted French cardiologist Thérèse Brosse’s 1935
psychophysiological study that explored yogic breathing in India (Sovik, 2000; Wenger, Bagchi,
& Anand, 1961). Brosse (1946) took electrocardiograph (ECG) recordings of “authentic” Hatha
yogis as they attempted to control their heart rate with respiratory exercises and deep states of
concentration. The article provided ECG readings from an experienced yogi, revealing an
extreme decrease in voltage the moment he announced that prana would be withdrawn from his
heart. The voltage returned to normal and elevated levels when the yogi declared he was
controlling his proper heart functioning. Another yogi had himself buried alive for 10 hours
under the supervision of the Medical Corps of Baroda. Here, a rapid pulse of 160 was observed
which quickly returned to normal levels. It was hypothesized that the yogi accomplished this
remarkable feat by controlling his prana, allowing him to induce a physiological state similar to
animal hibernation. The study discussed implications for clinical treatment based on these initial
observations, which involved educating patients about the benefits of yoga for health and self-
mastery.
Behanan (1937) published early empirical research on yoga, with much emphasis on
pranayama. As a graduate student at Yale University, Behanan traveled to India for one year to
study yoga under Swami Kuvalayānanda of Lonavla. Following his retreat and dissertation
defense, Behanan published the book Yoga: A Scientific Evaluation in 1937. The work provided
MECHANISMS OF CHANGE OF PRANAYAMA 20
an educational and in-depth overview of yoga, written from a scientific standpoint. After
objectively addressing metaphysical aspects of yogic theory, the book detailed his experiments
conducted at Yale during 1935. This research aimed to evaluate specific elements of yoga that
could be tested under experimental conditions. Behanan used himself as the sole participant in
the research and strongly cautioned that the initial findings were exploratory. The research
outlined a series of experiments designed to measure the rate of oxygen consumption during
various pranayamas which included: ujjayi, bhastrika, and kapalabhati. He hypothesized that
unlike exercise, yogic breathing increased oxygen consumption without physical exertion in a
process that restored energy and facilitated a healthy state of being.
Narain (1938) published one of the first articles to explore pranayama in the Western
scientific literature. In reviewing ancient yoga texts, it was found that the majority of writings
described pranayama in a mystical context that often attributed supernatural qualities to the
practice. This study instead attempted to explore what psychological and psychophysical effects
could be attributed to pranayama. The review found two main outcomes associated with
pranayama that included: focused attention and increased feelings of happiness. It was
hypothesized that focusing attention on the breath could free a yoga practitioner from mental
conflicts such as worry or want. The study also suggested that pranayama positively affected the
emotions.
Wenger et al. (1961) reevaluated Brosse’s (1946) initial findings that at least one yogi in
her sample could stop his heart using yoga. ECG and other physiological measures were used to
evaluate four advanced yoga practitioners in India, three of whom claimed to voluntarily stop
their heart. Of note, a yogi from Brosse’s original sample was included in this reexamination.
This yogi used pranayama during his attempts to control heart rate. During his trials, the
MECHANISMS OF CHANGE OF PRANAYAMA 21
researchers found “no absence of heart sounds, but at one time the radial pulse was not
detectable in either wrist” (p. 1322). Radial pulse sounds were also weakened or reduced during
the attempts of the remaining two yogis. However, the heart rate never stopped entirely for any
participant. It was hypothesized that the yogis were able to increase intrathoracic pressure by
using various yogic techniques that reduced venous return to the heart. A fourth participant
markedly slowed his heart rate by using maintained inspiration and specific yogic postures. In
conclusion, Wenger et al. stated, “it is obvious that the subjects we tested do not voluntarily
control the heart rate directly” (p. 1324). However, the findings suggested that yogic exercises
implementing muscular and respiratory control affected circulatory functioning on some level.
The advanced yogis demonstrated autonomic changes in respiratory patterns as measured by
physiologic recordings when using various pranayamas. The study noted a particular yogi whose
method involved steady focused breathing and concluded, “certainly one of the goals of future
research in this area should be to learn more about the effects of respiration and behavior” (p.
318). It was emphasized that Brosse (1946) did not take in-depth ECG readings, which more
than likely would have found weakened, but continual cardiac rhythms among her participants.
Sovik (2000) also noted technical problems with the Brosse study, making valid interpretations
of the initial data difficult.
Pranayama has been used to treat patients with asthma for over 50 years in yoga centers
across India (Nagarathna & Nagendra, 1985). Nurse practitioners have implemented pranayama
for patients in the United States since the 1940s (Kitko, 2007). Research indicated that the
practice of yoga became popular in America during the 1950s and 1960s (Saper et al., 2004;
Sengupta, 2012). Lamaze (1965) popularized voluntarily controlled breathing among the
American public after outlining the Lamaze Method in his book Painless Childbirth; first
MECHANISMS OF CHANGE OF PRANAYAMA 22
published in 1965. This method taught controlled breathing as a non-pharmacologic strategy to
help women reduce pain and stress during childbirth. Public interest in a variety of alternative
healing therapies has continued to grow since the 1960s in many Western societies (Baarts &
Pedersen, 2009). This review found that scientific studies evaluating yoga in clinical settings
began to proliferate during the 1970s. Around this time, Rebirthing-Breathwork introduced
novel breathing techniques to Americans in the context of psychotherapy (Orr & Ray, 1983).
Higashi (1964) was one of the first researchers to treat mental illness using pranayama.
Here, 50 participants diagnosed with chronic schizophrenia practiced pranayama in daily
therapeutic sessions for one year. The study found that the regimen created a quiet atmosphere
and calmer patients. After one year the average number of patients with schizophrenia using
pranayama had increased from 51% to 81%. These preliminary findings suggested that, “any
exercise which controls breathing favorably influences the psychiatric regimen” (p. 1178).
Vahia et al. (1972) published one of the first studies to treat depression with pranayama at
the K.E.M. Hospital in Bombay. The study applied a five-step yoga therapy program (including
pranayama) to treat 200 patients with a variety of psychiatric disorders. In this sample, 54
participants were diagnosed with a depressive illness. The results found the yoga treatment
effective in ameliorating a variety of mental disorders. Patients who undertook more than 30
sittings of yoga showed significant levels of symptom improvement. The use of yoga to treat
various mental disorders appeared encouraging. Harvey (1983) conducted one of the first trials
in the psychological literature to specifically evaluate the efficacy of pranayama for mood states.
In this study, 12 participants were recruited from a yoga center and then assigned to one of two
equal groups. The first group undertook four classes of yogic breathing while the second
condition practiced six sessions of meditation. In addition, eight students were recruited from an
MECHANISMS OF CHANGE OF PRANAYAMA 23
introductory psychology class to serve as a control group. After completion of the courses, the
results found that both the yogic breathing and meditation conditions significantly reduced levels
of depression as measured by the Profile of Mood States (POMS). However, the yogic breathing
group showed significantly greater improvement on measures of physical activity, anxiety, and
total mood disturbance. It was hypothesized that yogic breathing could increase energy and
reduce physical tension, creating an overall effect of positive mood. While this study provided
some of the earliest evidence that yogic breathing could positively affect mood and emotional
states, it remained uncertain how this change occurred.
More recently, Brown and Gerbarg (2005a) analyzed four pranayamas (i.e., ujjayi,
bhastrika, Om chanting, & Sudarshan Kriya) comprising the Sudarshan Kriya Yoga (SKY)
program, and created a neurophysiologic model of yogic breathing. This research outlined
plausibly interacting pathways between anatomical structures, organ systems, specific hormones,
and neurotransmitters affected by these pranayamas. The model synthesized various complex
physiological mechanisms of change associated with yogic breathing in an attempt to guide new
directions for clinical research. Kuntsevich, Bushell, and Theise (2010) recommended a
systems-biology-approach to more fully study, interpret, and conceptualize pranayamic
mechanisms of change in future research. At present, the research and clinical experience of
Brown and Gerbarg (2005b) suggested that yogic breathing has the potential to treat many
mental disorders. Studies aimed at exploring the connections between yoga and mental health
are becoming more important in “the age of managed care and evidence-based medicine”
(Bennet, Weintraub, & Khalsa, 2008, p. 56). Yoga is now often viewed as preventative
healthcare (Sovik, 2000). Moreover, the National Institutes of Health (NIH), the Department of
MECHANISMS OF CHANGE OF PRANAYAMA 24
Veterans Affairs, and the Department of Defense have taken increased interest in the role that
yoga may hold for the treatment of medical illnesses and mental conditions (Meyer et al., 2012)
Pranayama in Clinical Treatment. Pranayama has been used to treat both mental and
physical disorders in clinical settings (Jerath, Edry, Barnes, & Jerath, 2006). The following
sections overviewed the various health problems and unique populations treated with pranayama.
Physiological Disorders. Khalsa (2004) conducted a bibliometric analysis of the
published clinical research using yoga to treat both medical and psychiatric conditions. This
review yielded 181 studies in 81 different journals from 15 countries. The search included
uncontrolled trials, controlled trials, and RCTs. The results found that the specific medical
conditions receiving the most attention with yogic interventions included asthma, hypertension,
and heart disease. Yoga incorporating pranayama has shown efficacy in treating medical
populations with: asthma (Nagarathna & Nagendra, 1985; Singh et al., 1990), cancer (Bower,
Woolery, Sternlieb, & Garet, 2005; DiStasio, 2008), cardiovascular disease (Donesky-Cuenco,
Nguyen, Paul, & Carrieri-Kohlman, 2009; Gilbert, 2003), chronic pain (Kwekkeboom &
Gretarsdottir, 2006; Miller, 1987), diabetes mellitus (Bijlani et al., 2005), epilepsy (Yardi, 2001),
hypertension (Latha & Kaliappan, 1991), irritable bowel syndrome (Taneja et al., 2004), and
menopausal symptoms (Chatta et al., 2008). Yoga incorporating pranayama has also been used
in nursing practice to treat individuals with multiple sclerosis, human immunodeficiency virus,
and terminally ill patients in hospice care (Gimbel, 1998).
Mental Disorders. Mood and anxiety disorders were the most common psychiatric
diagnoses treated with yogic interventions in a bibliometric analysis of the literature (Khalsa,
2004). Clinical trials have also found yoga with pranayama effective in treating populations with
specific DSM-IV-TR mental disorders including: alcohol dependence (Vedamurthachar et al.,
MECHANISMS OF CHANGE OF PRANAYAMA 25
2006); anxiety disorder not otherwise specified (Brown & Gerbarg, 2005b); attention deficit
hyperactivity disorder (Jensen & Kenny 2004; Saadat-Abadi, Madgaonkar, & Venkatesan,
2008); insomnia (Brown & Gerbarg, 2005b); nicotine dependence (Kochupillai et al., 2005;
Melver, O’Halloran, & McGartland, 2004); obsessive-compulsive disorder (Shannahoff-Khalsa,
2004); panic disorder (Dattilio, 2001; Meuret, Wilhelm, Ritz, & Roth, 2003); post-traumatic
stress disorder (Carter & Byrne, 2004); social phobia (Brown & Gerbarg, 2005b), and specific
phobia (Brown & Gerbarg, 2005b).
Special Populations. Although limited, preliminary research has suggested that yoga
incorporating pranayama could be beneficial for treating populations including: incarcerated
adults (Brown & Gerbarg, 2005b), male adolescent sex offenders (Derezotes, 2000), and
survivors of mass disaster and terrorism (Brown & Gerbarg, 2005b; Descilo et al., 2009).
Caveats and Clinical Contraindications. Although 12 RCTs have evaluated yoga for
depression, there has been little to no reporting of adverse effects or safety issues on this subject
(Cramer et al., 2013; da Silva et al., 2009; Pilkington et al., 2005). Of note, Lee and Speier
(1996) reported the case of D, a 36-year-old male who suffered from a lifelong history of
depression. During his breathwork session, D reported feeling “enclosed, suffocated, and
hopeless” (p. 373). Following the breathing, he indicated that he felt even more depressed,
experiencing “a great sense of futility” (p. 373). Although the specific details of the session
remained unknown, D noted that any attempts to deal with his feelings were unsuccessful. This
negative experience appeared to seriously affect D, and he later sought emergency psychiatric
treatment for suicidal ideation. This unique report underscored how certain cases of severe
depression could be treatment-resistant or even exacerbated by yogic breathing. With such
limited data on this topic, future RCTs evaluating yoga for depression should establish rigorous
MECHANISMS OF CHANGE OF PRANAYAMA 26
methodologies with careful reporting of results to expand knowledge on safety and tolerability
(Cramer et al., 2013; Uebelacker, Epstein-Lubow, et al., 2010).
Pranayama in the Treatment of Depressive Disorders. A comprehensive review of
the literature found major depression and dysthymia among the most common psychiatric
disorders treated with yogic interventions (Khalsa, 2004). The following sections reviewed
various yogic interventions that have used pranayama to treat depressive disorders.
An Overview of Sudarshan Kriya Yoga
Sudarshan Kriya Yoga (SKY) is a pranayama-based program; and one of the most
applied yogic interventions in the literature (Cramer et al., 2014; Meyer et al., 2012; Sulekha et
al., 2006). SKY is the most empirically supported yogic intervention for the treatment of both
major depression and dysthymic disorder (da Silva et al., 2009). At present, SKY has eight
published RCTs in the scientific literature for various medical and psychiatric disorders (Cramer
et al., 2014).
Janakiramaiah et al. (2000) provided the Sanskrit origins of the words Sudarshan and
Kriya that described the aims of practice. The word Su translates to right while the root Darshan
means vision. The term Kriya most closely resembles the English word procedure or action.
SKY could be interpreted as “proper vision by purifying action” (Brown & Gerbarg, 2005b, p.
711). SKY might be best viewed as a practical self-help and stress-management technique
(Janakiramaiah et al., 2000).
SKY was created by Sri Sri Ravi Shankar and is offered exclusively through the Art of
Living Foundation headquartered in Bangalore, India (Janakiramaiah et al., 2000). SKY
programs have been implemented across many countries and taught to over six million people
(Brown & Gerbarg, 2005a). The courses are available worldwide and are typically taught as part
MECHANISMS OF CHANGE OF PRANAYAMA 27
of a six-day workshop (Kochupillai et al., 2005; Sulekha et al., 2006). The practice is non-
denominational, easy to learn, and has few clinical contraindications (Janakiramaiah et al.,
1998). SKY courses also incorporate lecture, group discussion, physical postures, and
meditation (Brown & Gerbarg, 2005b). Advanced courses are available for students who wish to
pursue and develop their practice (Brown & Gerbarg, 2005a).
SKY involves three distinct pranayamas that include: ujjayi, bhastrika, and the Sudarshan
Kriya (Sharma et al., 2003). Brown and Gerbarg (2005a; 2005b) comprehensively overviewed
these techniques in their neurophysiologic research. SKY first involves ujjayi, or victorious
breath, a slow breathing exercise where students take two-to-four breaths per minute. Ujjayi
cultivates physical and mental calmness while bringing increased awareness to the present
moment. Second, students practice bhastrika, or bellows breath, a fast-paced yogic breathing
technique. Here, air is rapidly inhaled and forcefully exhaled at a rate of 30 breaths-per-minute.
Bhastrika induces feelings of excitation and alertness, followed by a period of calmness. Finally,
students perform the Sudarshan Kriya, an advanced pranayama where breath is taken in
repeating cycles of slow, medium, and fast rates. Due to its complex and nuanced nature, it is
imperative that new students learn and practice the Sudarshan Kriya under the close supervision
of an experienced teacher. The entire SKY regimen concludes with ten minutes of rest in a
supine position with a guided meditation (Kochupillai et al., 2005). It was recommended that all
SKY breathing exercises be performed in a seated position with the spine erect. For a
comprehensive overview of the SKY program, readers should review the articles of Brown and
Gerbarg (2005a; 2005b). This research also included Om chanting as a fourth breathing rhythm.
Bhatia et al. (2003) described SKY as a “well standardized relaxation technique” (p.
162). Thus, the easily reproducible sequence of SKY makes it a feasible therapy to apply in
MECHANISMS OF CHANGE OF PRANAYAMA 28
clinical or research settings (Brown & Gerbarg, 2005a). A structured respiratory rhythm
provides researchers with an observable indication that participants have remained actively
engaged in the treatment (Telles, Joseph, Venkatesh, & Desiraju, 1992). This ideal feature may
not be present in other forms of yogic practice (e.g., meditation), where no external indicator
exists to allow researchers to conclude with certainty that a participant has used the treatment
under evaluation.
SKY can be taught to large groups of people in short periods of time (Brown & Gerbarg,
2005b). In addition, the low cost and overall efficacy of SKY makes it an ideal intervention
(Brown & Gerbarg, 2005a). During clinical trials, participants typically practice the entire SKY
regimen for 30-minutes a day at home or in research settings (Naga Venkatesha Murthy,
Gangadhar, Janakiramaiah, & Subbakrishna, 1997; Naga Venkatesha Murthy, Janakiramaiah,
Gangadhar, & Subbakrishna, 1998; Janakiramaiah et al., 1998). SKY is typically taught by a
trained yoga teacher for the first week to ensure that participants are practicing correctly before
using the program on their own (Naga Venkatesha Murthy et al., 1998). The postures and
techniques learned during SKY can also be modified to accommodate a wide variety of physical
problems or mental disorders (Brown and Gerbarg, 2005a).
Preliminary SKY Research. The majority of research investigating SKY for the
treatment of depression has come from the National Institute of Mental Health and
Neurosciences [NIMHANS] in Bangalore, India. Three open trials conducted at the NIMANS
used SKY as a monotherapy to treat various depressive disorders.
Naga Venkatesha Murthy et al. (1997) used SKY to treat 15 adult outpatients diagnosed
with dysthymia (DY). For comparison, two control groups were added that included: 15 patients
with melancholic depression (DM) and 15 participants with no history of psychiatric illness.
MECHANISMS OF CHANGE OF PRANAYAMA 29
Nine participants in the DM group were also taught SKY. Melancholic depression was defined
as “having a depressive episode with somatic symptoms” (p. 740). Participants were
administered: the Hamilton Rating Scale for Depression (HRSD), the Beck Depression Inventory
(BDI), and the Clinical Global Impression scales (CGI) before treatment, at one month, and
finally after three months. Auditory “oddball” P300 event related potential (ERP) was also
recorded. Patients with depression often exhibit abnormally low brainwave activity as measured
by P300 ERP amplitude. The study found SKY beneficial for both DY and DM patient groups.
For both patient groups, the results found significant reductions in depression and P300 ERP
amplitude normalization with their clinical recovery (i.e., P300 ERP amplitude increased for
both SKY patient groups at one and three month assessments, concurrent with their symptom
improvement). Post-treatment P300 ERP measures revealed that brainwave activity had
increased for both DY and DM treatment groups, with endpoint levels comparable to that of the
non-psychiatric controls.
Naga Venkatesha Murthy et al. (1998) used SKY to treat 15 patients with dysthymia and
15 patients with melancholic depression. Here, melancholic depression was defined as having a
“depressive episode or recurrent depression with somatic syndrome” (p. 46). Patients completed
the HRSD, BDI, and CGI scales at pre-treatment, one month, and after three months. The study
found that depression significantly improved for both treatment groups practicing SKY, as
measured by the HRSD and BDI. Participants who scored lower than two on the CGI scales of
severity at one and three month assessments were classified as responders. The results found
that 22 participants responded to SKY treatment, supporting its use as a monotherapy for
depressive disorders. The findings also indicated that SKY began to reduce symptoms of
depression after about three weeks of regular practice (i.e., half-an-hour daily).
MECHANISMS OF CHANGE OF PRANAYAMA 30
Janakiramaiah et al. (1998) used SKY to treat 46 patients diagnosed with dysthymia.
Participants were not using any psychotherapeutic or psychopharmacologic treatment during the
course of the study. SKY was taught daily for one week at the NIMHANS followed by three
months of independent home practice. Practicing less than three days a week was classified as
irregular. Eleven “irregularly” using participants were advised to continue SKY daily, and four
were practicing regularly by the end of the study. The study administered: the HRSD, BDI, CGI,
Subjective Global Impression scale (SGI), Comprehensive Psychopathology Rating Scale
(CPRS), and a functional assessment scale at pretreatment, one month, and after three months
(post-test). Nine participants did not complete the study and all of these individuals had
discontinued therapy within the first month. Of the 37 patients who completed the study, 25
(67.5%) remitted from depression. The results also found that regular SKY practice was less
frequent among participants who did not remit at both one and three months. This finding
possibly underscored the positive relationship between regular practice and treatment gains.
SKY appeared to be a beneficial monotherapy for both the acute care and relapse prevention
stages of dysthymia. SKY was also noted for being a feasible, cost-efficient treatment that
encouraged self-determination among participants that primarily practiced in their home.
Overall, these open trials indicated that SKY was a feasible and tolerable second-line
monotherapy and/or adjunct for depressive disorders (da Silva et al., 2009; Uebelacker, Epstein-
Lubow, et al., 2010). Two RCTs investigating SKY for depression at the NIMHANS followed
this preliminary research (Janakiramaiah et al., 2000; Rohini et al., 2000).
Case Reports Exploring SKY for Depression. Brown and Gerbarg (2005b) reported
anecdotal benefits of SKY gathered from their private practice treating approximately 400
patients over a six-year period. These clinical observations suggested that patients with mild-to-
MECHANISMS OF CHANGE OF PRANAYAMA 31
moderate levels of depression typically respond rapidly to SKY treatment, often reporting
symptom improvement by day five. In some cases, patients reduced or discontinued their
antidepressant medication entirely while maintaining regular practice. It was observed that
severely depressed patients typically respond more slowly to treatment, showing gradual
improvement over a three-to-nine month period. Again, the frequency of practice appeared to be
a major factor in the treatment response of severe depression. SKY was recommended once a
day, or even twice daily for severely depressed patients. Individuals with severe depression
might fare better if they repeat the SKY program multiple times.
Controversial Issues Regarding SKY. Thachil, Mohan, and Bhugra (2007) evaluated
the evidence of efficacy of SKY for depression. After review, the findings listed SKY as having
grade-three evidence, indicating a negative level. It also remained impossible to draw valid
conclusions from the SKY research due to significant methodological problems. This study cited
non-blind conditions, a small sample, and short treatment duration as specific problems. These
serious methodological issues rendered the data insufficient to adequately assess the therapeutic
value of SKY. However, this analysis included only one SKY RCT (i.e., Janakiramaiah et al.,
2000).
The Yunus News reported in 2007 that Sri Sri Ravi Shankar had trademarked the
Sudarshan Kriya for commercial use. This article discussed that his “new” and self-revealed
SKY technique was more likely a repackaged ancient pranayama. Therefore, most clients
interested in learning SKY would be required to take the Art of Living Foundation’s expensive
introductory course (“How Genuine is,” 2007).
The Yunus News also reported that the Art of Living Foundation has made exaggerated
claims about the benefits of SKY. While the organization endorsed clinical research conducted
MECHANISMS OF CHANGE OF PRANAYAMA 32
on SKY from the NIMHANS, it simultaneously advertised statements unsupported by empirical
evidence. For example, an Art of Living Foundation webpage purported that the Sudarshan
Kriya breathing technique:
is a potent energizer. Every cell becomes fully oxygenated and flooded with new life.
Negative emotions that have been stored as toxins in the body are easily uprooted and
flushed out. Tension, frustrations and anger get released. Anxiety, depression and
lethargy are washed away (“The Art of Living,” 2008, p. 1).
The scientific research has not supported these extraordinary claims, nor has it found SKY
entirely effective in eliminating depression for everyone. Such statements could mislead clients
seeking treatment for a depressive disorder.
The Evidence of Efficacy of Yoga for Depression
Over the last decade, increased attention has been placed on examining the efficacy
evidence of yoga for depression. Several reviews suggested that yoga could be a potentially
efficacious treatment for depressive disorders (Cramer et al., 2013; da Silva et al., 2009; Meyer
et al., 2012; Pilkington et al., 2005; Uebelacker, Epstein-Lubow, et al., 2010). Although each
review used different inclusion criteria for trial selection and analysis, the overall trend showed a
small but steadily growing body of RCTs supporting yoga for depression.
While the research evidence of yoga for depression appeared promising at this early
stage, each review emphasized the preliminary and inconclusive nature of their findings.
Pilkington et al. (2005) noted the small number of RCTs available for review. The low
methodological quality of reviewed RCTs was also highlighted as an underlying limitation
(Cramer et al., 2013). Other methodological concerns threatening the internal validity of these
RCTs included: predominantly short-term study durations and an overall lack of long-term data
MECHANISMS OF CHANGE OF PRANAYAMA 33
(Cramer et al., 2013; da Silva et al., 2009; Thachil et al., 2007; Uebelacker, Epstein-Lubow, et
al., 2010), little-to-no reporting of adverse effects or safety issues (Cramer et al., 2013; da Silva
et al., 2009; Pilkington et al., 2005), high risk of attrition and performance bias (Cramer et al.,
2013), small sample sizes (Meyer et al., 2012; Thachil et al., 2007), and methodological
heterogeneity (Pilkington et al., 2005; Uebelacker, Epstein-Lubow, et al., 2010). The
methodological heterogeneity across RCTs examining yoga for depression could greatly affect
the generalizability of findings, and involved: the specific levels of depression treated ranging
from mild-to-severe (Cramer et al., 2013; Pilkington et al., 2005), different psychological
inventories used to diagnose the severity of depression and assess treatment gains (Pilkington et
al., 2005), antidepressant medication and/or psychotherapy allowed outside of trial (Cramer et
al., 2013), and limitations regarding the age and gender of participants included (Cramer et al.,
2013; Pilkington et al., 2005).
A methodological issue of special importance involved the heterogeneity of the yogic
interventions applied across clinical trials (Cramer et al., 2013; Pilkington et al., 2005). Each
specific yogic intervention is guided by a unique set of principles, instructions, aims, and
practices. Intervention heterogeneity made it difficult, if not impossible, to determine which type
of yoga, or which specific component of each treatment was most effective in reducing
depression (Pilkington et al., 2005).
Future RCTs evaluating yoga for depression should establish rigorous methodologies
with careful reporting of results (Cramer et al., 2013; Uebelacker, Epstein-Lubow, et al., 2010).
These steps could minimize bias and increase the internal validity of future research, thus
ensuring adequate: sample sizes, randomization, allocation concealment, and blinding of
assessors or interventionists (Cramer et al., 2013; Pilkington et al., 2006).
MECHANISMS OF CHANGE OF PRANAYAMA 34
A Review of RCTs using Yoga with Pranayama for Depression
At present, two systematic reviews have found yoga effective in treating depression
(Cramer et al., 2013; Pilkington et al., 2005). Pilkington et al.’s (2005) initial systematic review
included five RCTs; a low number that precluded a meta-analysis. Rhythmic breathing played
an important part of treatment in four of these trials (Pilkington et al., 2006).
Cramer et al. (2013) expanded upon this preliminary research by systematically
reviewing 12 RCTs and conducting the first meta-analysis on this subject. This updated review
found “limited-to-moderate evidence for short-term improvements in severity of depression and
anxiety” (p. 1079). A subgroup analysis revealed that meditation- and breathing-based yogic
interventions demonstrated limited short-term efficacy for depression severity; a finding not
observed among complex- and exercise-based yoga conditions. These results indicated that yoga
interventions, especially meditation- and breathing-based types, were effective in treating
depressive disorders. It was suggested that yoga could be a beneficial adjunct treatment for
depression.
Five of the 12 systematically reviewed RCTs investigating yoga for depression included
pranayama (Broota & Dhir, 1990; Janakiramaiah et al., 2000; Khumar, Kaur, & Kaur et al.,
1993; Rohini et al., 2000; Shahidi et al., 2011). The remaining seven trials used yogic
interventions that primarily involved either meditation (e.g., Sahaj or Kirtan Kriya yoga) or
physical postures (e.g., Iyengar or exercise-based yoga). Here, two meditation-based
interventions included limited elements of breath awareness or deep breathing for relaxation
(Butler et al., 2008; Lavretsky et al., 2013).
Regarding the present study, the two RCTs of primary importance again examined SKY
for depression at the NIMHANS (Janakiramaiah et al., 2000; Rohini et al., 2000). Due to a lack
MECHANISMS OF CHANGE OF PRANAYAMA 35
of eligible trials, Cramer et al (2013) collapsed meditation- and breathing-based yogic
interventions into one category (i.e., meditation-based interventions) to conduct a subgroup
analysis. Thus, the SKY trials were included among the meditation-based interventions found to
be particularly effective for depression. This meta-analysis also indicated that both SKY trials
were included among those as having the lowest risk of bias. Cramer et al.’s systematic review
further supported SKY for the treatment of depression, both clinically and methodologically; a
finding somewhat in conflict with the earlier reporting of Thachil et al. (2007).
In a prospective RCT, Janakiramaiah et al. (2000) compared the antidepressant efficacy
of SKY, electroconvulsive therapy (ECT), or Imipramine for clinical depression. The study
recruited 45 inpatients diagnosed with severe melancholic depression (DSM-IV). Participants
were randomly assigned to one of three equal treatment conditions. An unaffiliated outcome
assessor evaluated participants on measures of the BDI and HRSD before treatment (week 0),
and weekly until the study concluded after four weeks. The results revealed significant
reductions in depression for all treatment conditions. ECT was found to be the superior
treatment for depression, demonstrating a 93% remission rate. However, SKY produced a 67%
remission rate comparable to that of Imipramine with 73% efficacy. Although these early
findings were promising for the use of SKY for melancholic depression, the researchers
emphasized the novel and experimental nature of this treatment. The study recommended
additional research to further explore what role yogic breathing may have in the treatment of
clinical depression.
Rohini et al. (2000) compared two variations of SKY using a sample of 30 inpatients
diagnosed with MDD. This RCT applied either: full SKY (i.e., ujjayi, bhastrika, & cyclical
breathing) or partial SKY (i.e., ujjayi, bhastrika, & regular breathing). SKY was the sole
MECHANISMS OF CHANGE OF PRANAYAMA 36
treatment modality and participants discontinued antidepressant medication four weeks prior to
the start of the study. The sample was then randomly assigned to either treatment condition.
Both treatment groups practiced their respective SKY separately in the mornings under the same
yoga teacher. A blind outcome assessor (i.e., psychiatrist) evaluated participants using the BDI
at pretreatment and weekly for four weeks. The results indicated that both full and partial SKY
were effective in reducing depression, although no significant difference among groups was
found. Twelve participants in the full SKY group and seven in the partial SKY condition
responded to treatment (defined as a total reduction in BDI score of 50% or more). These results
required a reexamination of the role that bhastrika might play in treatment. It was hypothesized
that bhastrika could involve elements and effects similar to cyclical breathing (e.g.,
hyperventilation). Further investigation into the specific effects of the cyclical breathing
component of SKY was indicated. If larger studies reconfirmed equal benefit between both
methods of SKY (i.e., full & partial), replacing cyclical breathing with regular breathing might
be indicated for MDD. This study provided continued support for the use of SKY for
depression.
Three additional RCTs included in the systematic reviews (Cramer et al., 2013;
Pilkington et al., 2005) found yoga with pranayama effective in treating depression. The primary
findings, specific types of yoga, and unique pranayamas involved in these trials were reviewed.
A RCT conducted by Broota and Dhir (1990) found the Broota Relaxation Technique
(BRT) superior to Jacobson’s Muscle Relaxation for reducing symptoms of depression in a
sample of 30 outpatients (diagnosed as depressive). A control group was applied for
comparison. The BRT involved four separate exercises that included: deep breathing, spine
stretching, leg raises, and leg cycling. The BRT group practiced five cycles of diaphragmatic
MECHANISMS OF CHANGE OF PRANAYAMA 37
breathing while vocalizing the word “relax” after exhaling. This breathing component aimed to
reduce negative thinking by cultivating a new state of mental focus. It was recommended that
patients with depression remain on their standard antidepressant treatment to optimize results
when using the BRT.
Khumar et al. (1993) conducted a RCT that found Shavasana yoga effective in treating
severe depression among a sample of 50 female post-graduates. The treatment condition
practiced Shavasana yoga under a trained teacher while the control group undertook no
treatment. During Shavasana, practitioners lay supine while being taught to create slow rhythms
of diaphragmatic breathing. This exercise aimed to keep participants alert and relaxed while the
mind remained focused on the breath. It was suggested that Shavasana yoga be integrated into
daily living to promote optimal wellness.
Shahidi et al. (2011) compared Laughter Yoga (LY) and traditional exercise therapy for
depression in a RCT. A sample of 70 older-aged females with late-life depression was recruited
from a community center in Iran. The LY was practiced indoors under a trained researcher for
10 sessions that combined “unconditional laughter with yogic breathing” (pp. 322-323). The
study found that both LY and exercise therapy reduced depression when compared to a control
group. However, only the LY condition evidenced significant improvements on measures of life
satisfaction.
Additional RCTs and Future Directions
A review of the literature revealed additional RCTs that found yoga with pranayama
effective in reducing depression. These trials were excluded from the aforementioned systematic
reviews for not specifically treating depressive disorders (Cramer et al., 2013; Pilkington et al.,
MECHANISMS OF CHANGE OF PRANAYAMA 38
2005). However, these trials collected outcome data using depression inventories as dependent
variables.
In a RCT conducted at the NIMHANS de-addiction center, Vedamurthachar et al. (2006)
compared SKY with standard care for the treatment of alcohol dependence. Sixty male
inpatients with a DSM-IV diagnosis of alcohol dependence were recruited, and first completed a
seven-day detoxification program. The sample was then randomly assigned and received either:
SKY or standard inpatient care (control group). SKY was the sole treatment prescribed,
although participants were allowed benzodiazepines for sleep disturbances. Both groups
completed pre- (day 7) and post-test (day 21) measures of the BDI. Blood samples (5 ml) were
also collected during assessment days to analyze: prolactin, cortisol, and ACTH levels. There
were no statistical differences between groups (i.e., BDI scores and hormone levels) prior to
beginning treatment. The results found that both groups significantly reduced levels of
depression, cortisol, and ACTH. However, the reductions for these measures were more
pronounced in the SKY group. A reduction in BDI score was positively correlated with
decreased cortisol levels only for the SKY group. It remained unclear how pranayama helped
patients, or if the SKY therapy merely augmented standard inpatient care. This research further
supported the antidepressant efficacy of SKY, and possibly discovered a biologically rooted,
stress-reduction mechanism of change.
Additional RCTs have suggested that pranayama could be a particularly beneficial
technique for depression. Nandi-Krishnamurthy and Telles (2007) compared the efficacy of
yoga against ayurvedic medicine for the treatment of depression using a sample of 69 elderly
participants living in a residential home in Bangalore, India. The yoga involved: physical
postures, pranayama, guided relaxation, breathing awareness, and devotional songs. The study
MECHANISMS OF CHANGE OF PRANAYAMA 39
found that only the yoga group evidenced a significant decrease in depression at both three and
six month assessments. It was noted that the breathing exercises appeared especially beneficial
for elderly individuals and could easily be practiced while relaxing in a chair. Kozasa et al.
(2008) compared Siddha Samadhi Yoga (SSY) with a wait-list control group for the treatment of
depression and anxiety using a sample of 22 participants with no history of psychiatric illness.
The SSY is a broad mindfulness program that incorporates both meditation and pranayama. The
findings revealed a significant reduction in both anxiety and depression for only the SSY group.
These RCTs augmented the small but growing body of empirical research supporting
yoga with pranayama for the treatment of depressive disorders (and/or elevated levels of
depression). The available data on the efficacy of yoga for depression remained promising at
this early stage, although quite limited (Cramer et al., 2013; Pilkington et al., 2005). Recent
reviews have recommended that future RCTs compare efficacies of different forms of yoga for
depression (Cramer et al., 2013; Pilkington et al., 2005). It also remained unknown how the
different components of yoga influenced depression (Pilkington et al., 2005; Uebelacker,
Epstein-Lubow, et al., 2010). At present, two ongoing NIH clinical trials have used yogic
interventions to treat unipolar depression (Centre for Addiction & Mental Health, 2007;
University of California, San Francisco, 2010).
The Neurophysiologic Model
Brown and Gerbarg (2005a; 2005b) investigated SKY for the treatment of anxiety,
depression, and stress to create the neurophysiologic model. This comprehensive work
integrated: clinical observations, polyvagal theory, neurophysiological data, and yogic breathing
research in an effort to provide heuristic value and new directions for scientific inquiry. This
research analyzed psychophysiological effects of the four pranayamas comprising the SKY
MECHANISMS OF CHANGE OF PRANAYAMA 40
regimen (i.e., ujjayi, bhastrika, Sudarshan Kriya, & Om chanting). In summary, the
neurophysiologic model posited:
1. Strengthening, balancing, and stabilizing the autonomic and stress response systems;
2. Decreasing chemoreflex sensitivity;
3. Improved baroreflex response;
4. Shifting to parasympathetic dominance via vagal stimulation;
5. Balancing of cortical areas (synchronization) by thalamic nuclei;
6. Quieting of cortical areas involved in executive functions (such as anticipation, planning,
and worry);
7. Activation of the limbic systems leading to stimulation of forebrain reward systems and
emotional release; and
8. Increased release of prolactin and oxytocin enhancing feelings of calmness and social
bonding. (Brown & Gerbarg, 2005a, p. 198-199)
Hypothesized Mechanisms of Change
A comprehensive search of biomedical, psychological, and other scholarly online
databases (Google Scholar, MEDLINE, PsycINFO, PubMed, University OPACs) retrieved very
little research that investigated antidepressant mechanisms of pranayama. The neurophysiologic
model appeared to provide the most synthesized, in-depth analysis on this subject (Brown &
Gerbarg, 2005a). However, at the time of writing this study, the neurophysiologic model
remained untested by the scientific community.
Uebelacker, Epstein-Lubow, et al. (2010) hypothesized that yoga could ameliorate
depression through mechanisms that are behavioral, biological, and psychological in nature.
Vera et al. (2009) emphasized that yoga is “based on a mind-body interconnection which
MECHANISMS OF CHANGE OF PRANAYAMA 41
inextricably links psychological and biological processes” (p. 164). Some scientific analysis has
suggested that multiple mechanisms of change may operate simultaneously and/or bidirectionally
during yogic breathing (Brown & Gerbarg, 2005a; Ley, 1999; Sovik, 2000). Sovik (2000)
stated, “the distinctive feature of breathing in the context of yoga is that it is guided by an
increasing awareness and understanding of the relationship between cognitive states, physical
functioning, and breathing styles” (p. 495). Voluntarily controlled breathing invariably involves
a mind-body connection, and the following sub-sections reviewed pranayamic mechanisms of
change hypothesized to reduce depression.
Psychological Mechanisms. Reported psychological mechanisms of change of
pranayama included: mindfulness, attention control, metacognitive awareness, and positive
thinking.
Mindfulness. Pranayama may cultivate mindfulness. A review of the literature by
Brown and Ryan (2003) found that mindfulness was most commonly defined as “the state of
being attentive to and aware of what is taking place in the present” (p. 822). Samuelson,
Carmody, Kabat-Zinn, and Bratt (2007) similarly defined mindfulness as “moment-to-moment
awareness” (p. 255). Brown and Ryan (2003) stated that moment-to-moment awareness is easily
overlooked. This is especially true when people multitask or become preoccupied with thoughts.
The breath is often ignored unless something happens that prevents a person from breathing
normally (Kabat-Zinn, 2005). Without training, many people do not reflect upon the importance
of breathing and may even find the topic boring. Most individuals do not concentrate on the
breath because it is a continuous and automatic bodily function (Kitko, 2007). However, yoga
students learn to create a new relationship with the breath characterized by conscious control
MECHANISMS OF CHANGE OF PRANAYAMA 42
(Sovik, 2000). By purposefully changing the rate, depth, and quality of the breath, breathing
becomes a conscious, rhythmic bodily function (Rajalakshmi & Veluchamy, 2000).
Attention Control. Mindfulness-Based Cognitive Therapy (MBCT) teaches patients with
unipolar depression attention control training (Segal, Williams, & Teasdale, 2002). Attention
control training aims to “combine mindfulness and cognitive approaches to enable patients to
increase their awareness” (p. 51). As awareness increases, patients become more attentive to
their changing mood states and cognitive processes. When patients become aware of a negative
thought or feeling, they can continually redirect their attention back to the breath. A study by
Franzblau et al. (2008) found that pranayama significantly reduced symptoms of depression
among 20 women who had suffered physical, sexual, or emotional abuse in an intimate
relationship. It was found that focused attention on the breath brought increased awareness to
the mind and body. This refocused attention possibly helped the women inhibit negative,
ruminative thoughts associated with the abuse. It was hypothesized that pranayama operated
through a “cognitive-physiological process” (p. 1806). The role of focused attention in
inhibiting negative thoughts was one of the first mechanisms of yogic breathing discussed in the
literature (Narain, 1938).
Metacognitive Awareness. Metacogntive awareness is another important feature of
MBCT and is taught to patients after they have learned attention control training. As patients
progressively become more aware of their shifting mood states, metacognitive monitoring can be
implemented (Segal et al., 2002). Here, the breath is used to facilitate metacognitive monitoring,
the process of “seeing thoughts as thoughts” (p. 163). Patients learn to distance or decenter
themselves from their negative thoughts or feelings and ultimately view them as “passing events
in the mind” (Segal, Teasdale, & Williams, 2004, p. 56). Metacognitive awareness helps
MECHANISMS OF CHANGE OF PRANAYAMA 43
individuals see that their thoughts are not necessarily true representations of themselves, others,
or the world. Decentering the consciousness from psychological experiences (e.g., thoughts,
feelings, memories, etc.) cultivates mindfulness. Ruminative, automatic, and habitual modes of
living are replaced with a new state of being characterized by awareness, presence, and direct
experience. Mindfulness can be more easily attained through the continual practice of
decentering the mind from mental events.
Positive thinking. Besides decreasing the intensity and frequency of the negative,
ruminative thoughts that characterize depression, Uebelelacker (2010) suggested that yoga could
also positively alter the actual content of cognitions. It was hypothesized that yoga could help
practitioners increase feelings of self-efficacy, self-acceptance, and meaning in their lives.
Psychophysiological Mechanisms. Reported psychophysiological mechanism of change
of pranayama included: neurochemical regulation, relaxation, cardiorespiratory optimization,
brainwave alteration, and sleep regulation.
Neurochemical Regulation. Pranayama could affect depression through complex
neurochemical processes (Brown & Gerbarg, 2005a; Uebelacker, Epstein-Lubow, et al., 2010).
Neurochemical change was one of the first antidepressant mechanisms of yogic breathing
proposed in the literature (Schulte & Abhyanker, 1979). The neurophysiologic model postulated
that pranayama increases levels of prolactin and oxytocin, producing feelings of peace and
interpersonal connectedness (Brown & Gerbarg, 2005a). Uebelacker, Epstein-Lubow, et al.
(2010) theorized that yoga might reduce depression by regulating neurotransmitters. However,
the research in this area was limited and often controversial, although it remained plausible that
yoga could rebalance neurotransmitter physiology (e.g., norepinephrine, serotonin, & dopamine).
MECHANISMS OF CHANGE OF PRANAYAMA 44
Relaxation. Stress can be social, psychological, or physical (Sharma et al., 2008). Stress
is “by nature, a mind-body problem” (Sovik, 2000, p. 493). While stress causes serious
physiological symptoms, its roots are often psychological. Pranayama may help relieve stress by
creating a state of relaxation. Sharma et al. (2008) defined relaxation as “the tendency of a
physiological system to return to its original state” (p. 216). Relaxation was theorized to be a
compensatory mechanism. Certain yogic practices could affect the autonomic nervous system
(Brown & Gerbarg, 2005a; Harinath et al., 2004). Rhythmic breathing might cultivate relaxation
by influencing the sympathetic nervous system (Kitko, 2007). Kwekkeboom and Gretarsdottir
(2006) stated that a primary goal of pranayama is to “slow the physical and mental activity
sufficiently to decrease the sympathetic nervous system response” (p. 275). Relaxation was
hypothesized to be an important mechanism of change in several RCTs that found yoga with
pranayama effective in treating depression (Broota & Dhir, 1990; Khumar et al., 1993; Nandi-
Krishnamurthy & Telles, 2007; Vedamurthachar et al. 2006).
Cardiorespiratory Optimization. Several of the earliest studies exploring pranayama
proposed a cardiorespiratory mechanism of change (Behanan, 1937; Brosse, 1946; Wenger et al.,
1961). Pranayama increases lung capacity and allows the respiratory system to achieve optimum
ventilation (Rajalakshmi & Veluchamy, 2000). Pranayama provides a fresh supply of oxygen to
various tissues and organs while accumulated waste is eliminated from the body. Researchers
have observed a slowing of the heart rate in participants undertaking pranayama, which provides
rest to the cardiac muscles. A slowing of the heart rate during pranayama could allow
practitioners to conserve and restore energy (Brown & Gerbarg, 2005a). Respiratory exercises
can increase or decrease energy supply to the brain, inducing very different subjective
experiences (Vaitl et al., 2005).
MECHANISMS OF CHANGE OF PRANAYAMA 45
Brainwave Alteration. Research has shown that pranayama influences brainwave
activity, which could positively affect mood states and consciousness. Bhatia et al. (2003)
compared resting EEG, brainstem auditory evoked responses (BAER), and P300 measurement
between regular SKY practitioners and a control group. Group one (experimental condition)
consisted of 19 advanced practitioners and teachers of SKY, while group two (controls)
consisted of 15 healthy participants matched on age, gender, socioeconomic status, and
education level. All participants in Group 1 had completed basic, advanced, and teaching
courses in SKY prior to the study. The research also excluded individuals with mental disorders,
neurological conditions, or prolonged medication use. After electrophysiologic assessments, the
results showed a significant increase in beta activity (primarily localized in the left fronto-
occipital and midline regions) only for the regular SKY practitioners. This finding indicated
cortical activation among regular SKY practitioners without external stimuli. There were no
significant differences found between groups for all other electrophysiologic measures. This
study was notable for using SKY and investigating long-term or “trait” effects of yogic
breathing.
Using EEG, Kamei, Toriumi, Kimura, and Kimura (2001) investigated brainwave activity
in a sample of eight experienced yoga instructors. Electrical activity was measured continuously
during periods of rest, pranayama, and mediation using electrodes attached to the forehead. The
study found an increase in alpha rhythm activity for all eight participants. Of importance, this
increase was most pronounced during their pranayama. The researchers hypothesized that
pranayama helped the yoga instructors create a stress-free state conducive to mental health.
Kumar and Joshi (2009) evaluated the effects of a yoga regimen on alpha wave activity in a
sample of 40 college students. For forty consecutive days (excluding weekends), the participants
MECHANISMS OF CHANGE OF PRANAYAMA 46
practiced a 30-minute yoga regimen followed by 15 minutes of Pranakarshan pranayama. The
results found that the yogic training significantly altered the alpha rhythm activity of the
participants as measured by EEG. Predominant alpha rhythm activity often coincides with a
subjective experience of calmness. In addition, healthy alpha rhythm production has been
associated with a mental state of alertness, acuity, and relaxation.
Vialatte, Bakardjian, Prasad, and Cichocki (2009) explored the effects of Bhramari
Pranayama (BhPr) on brainwave activity. The study recruited eight men with no history of
neurological, epileptic, or psychiatric disorders. During BhPr, a prolonged vibrating sound is
made while exhaling through the nose, followed by a short inhalation period. This cycle repeats
for five-to-ten minutes. One participant undertook no BhPr (Beginner); six individuals practiced
BhPr twice daily for 31-34 days (Intermediate); and one man used BhPr twice a day for four
months (Expert). After this duration, the participants were measured on EEG while performing
approximately 20 breathing cycles of BhPr. Results found an increase in theta range activity for
all participants during practice. This pattern of altered brainwave activity remained stable for
several minutes following BhPr among participants with at least one month of practice (i.e.,
Intermediate & Expert conditions). The participants also reported feeling “peaceful” during the
yogic breathing. However, it remained unknown how brainwave alteration induced a subjective
state of peacefulness.
Sleep Regulation. Sleep disturbances (e.g., insomnia, hypersomnia) can be a serious
symptom of depression (American Psychiatric Association, 2000). Yoga could benefit
individuals with depressive disorders by regulating their sleep (Uebelacker, Epstein-Lubow, et
al., 2010). It was hypothesized that regulated sleep could reduce symptoms of depression, and
possibly prevent depressive episodes. In a study using polysomnographic recordings, Sulekha et
MECHANISMS OF CHANGE OF PRANAYAMA 47
al. (2006) found that 13 middle-aged, long-term SKY practitioners exhibited significant
increases in slow wave sleep and shorter REM onset when compared to 13 controls. The results
suggested that pranayama could compensate for age-related changes in sleep quality and
architecture, and further research in this area was indicated.
Metaphysical Mechanisms. Reported metaphysical mechanisms of change of
pranayama included: the higher mind and prana expansion/ control.
The Higher Mind. In the Ashtanga yoga philosophy, pranayama prepares the yogi or
yogini for higher states of consciousness including: calming of the senses, concentration,
meditation, and self-realization (Sovik, 2000; Taimni, 1992). Sovik (2000) described the
intuitive or observing mind developed through progressive breath awareness. Here, the mind is
withdrawn from internal and external stimuli or experience, and the awareness remains centered
upon itself. Advanced students of yoga might use the breath to actualize a transpersonal state of
being called buddhi ( ), a Sanskrit term meaning to awaken or understand. Ultimately,
the yogi can become more familiar with, and adept at achieving higher states of unclouded
consciousness through disciplined practice.
Prana Expansion/Control. Yogic philosophy holds that its practitioners can conserve
prana through the conscious control of the breath (Gimbel, 1998). Advanced students of yoga
may also use pranayama to master prāna ( ), the vital life energy (Halpern, 2000). It was
stated that pranayama is “breath control on the physical level and prana control on the subtle
level” (p. 37). Yogic tradition holds that the controlled flow of prana expands consciousness,
induces contentment, increases energy, and restores health. Mystical and creative states could be
accessed through these practices (Rapgay et al., 2000). Certain aspirants of yoga may seek to
unite their individual prana with a universal consciousness (Halpern, 2000; Singh et al., 1990).
MECHANISMS OF CHANGE OF PRANAYAMA 48
In this philosophy, the etiology of mental disorders could involve disturbances in the natural
flow of prana (Halpern, 2000). Depressive disorders are characterized by depressed mood and
often include somatic and psychological symptoms involving decreased energy (American
Psychiatric Association, 2000). Pranayama would restore mental and physical health by
increasing and rebalancing prana (Kumar & Joshi, 2009). Yogic breathing raises the prānic
levels of the yogi or yogini by culling and conserving this vital energy from the universe.
A Need for Qualitative Research
The scientific study of pranayama by Western medicine is still in the very early stages
(Brown & Gerbarg, 2005a; Sovik, 2000). Understanding the mechanisms of change of yoga
(i.e., biomedical and/or psychological) is a current focus of the National Institutes of Health
(Sherman, 2006).
Pilkington et al. (2005) emphasized the lack of qualitative research that has explored
yoga for the treatment of depression. Qualitative studies could provide new insight into the
experiences of individuals who have reduced depression with yogic interventions. It remains
unknown exactly how pranayama influences mental states (Telles & Naveen, 2008). Further
research exploring this subject could uncover “why pranayama practice has the many and diverse
effects that are reported” (p. 72). Qualitative research investigating yogic breathing could help
reveal meaningful change for participants that cannot be readily assessed using quantitative
measures (Brazier, Mulkins, & Verhoef, 2006). Unlike quantitative data which typically
explores the relationship between specified variables, a qualitative focus of inquiry is often best
suited to answer process-oriented inquiries, such as why and how questions (Leech &
Onwuegbuzie, 2007). Kjellgren et al. (2007) recommended additional qualitative research on
pranayama, noting that such exploration “appears to be a method with the potential of generating
MECHANISMS OF CHANGE OF PRANAYAMA 49
insight into the psyche” (p. 8). Watts (2000) suggested that a naturalistic approach has the
advantage of being able to explore the unique experiences of individuals who have pursued the
yogic path in “a broad and authentic way” (p. 72).
Relevant Mixed-Methods Research. A review of the literature revealed little
qualitative research that explored the experiences of individuals who reduced their depression
using pranayama. Schulte and Abhyanker (1979) published one of the earliest studies on this
topic entitled Yogic Breathing and Psychologic States; but here included qualitative data from
the perspectives of the yoga teachers. Coauthor V. V. Abhyanker traveled to a yogic
institute/ashram in India and interviewed several advanced yogis who had taught pranayama to
individuals experiencing emotional disorders. In the first of two cases reported, a 35-year-old
Indian widow presented at the ashram with worsening symptoms of depression over the past 10
weeks that left her unable to fulfill her daily obligations. She had lost her husband one year
earlier, and now experienced depressive symptoms that included: apathy, difficulty
concentrating, crying spells, insomnia, and weight loss. She began a yogic regimen that
integrated: simple yoga breathing, a vegetarian diet, and the continual support of her mentoring
yogi and ashram culture. Her yogic breathing technique involved sitting upright while
cultivating equally paced inhalations and exhalations with a short pause after expiration. She
could soon practice two 10-minute breathing sessions per day, and after 12 weeks the depression
had remitted and she returned home to her family. At a two-year follow-up, the depression
remained in sustained remission and she had resumed normal functioning. Although this study
did not involve controlled experimentation and was limited in scope, Abhyanker’s observational
data and interviews with the yogis led the researchers to “believe that pranayama was a critical
MECHANISMS OF CHANGE OF PRANAYAMA 50
ingredient” (p. 682). It was hypothesized that yogic breathing could improve depression through
a neurochemical mechanism of change.
Two mixed-method studies explored the experiences of adult participants who used the
pranayama-based, SKY intervention. Both trials collected open-ended qualitative data from the
participants to supplement findings from the primary quantitative research designs. These
qualitative findings were reviewed.
Brazier et al. (2006) conducted in-depth, qualitative interviews with 14 adult participants
who completed a specialized Art of Living Foundation program designed for individuals living
with HIV or AIDS. These participants used SKY in a residential facility for 15 days followed by
12 weekly follow-up sessions. The results found that most participants reported “positive and
profound changes in their experience of day-to-day living” which was captured in a major theme
entitled “a new way of living” (p. 194). This theme encompassed three unique features that
included: “engaging in life in new ways, being ‘okay,’ and trying new activities” (p. 194).
Overall, the new way of living theme indicated that the participants felt they were now living
more fully, openly, and meaningfully. They were also able to live more comfortably with the
uncertainty accompanying a serious illness. The treatment program helped participants learn
new skills and cultivate positive experiences reflected in four main themes that involved:
increased self-awareness, living more mindfully, a greater capacity for acceptance, and learning
mind-body awareness. These new skills and experiences allowed the participants to live more
consciously and constructively while embracing their life journey and current health situations.
The qualitative research component uncovered meaningful data about the benefits of the SKY
program that quantitative measures alone could not assess.
MECHANISMS OF CHANGE OF PRANAYAMA 51
Kjellgren et al. (2007) conducted a pilot study that explored the effects of SKY on
feelings of wellbeing in a sample of healthy adult participants. The two-way split plot design
included adults who expressed an interest in practicing yoga for six weeks and excluded
individuals with chronic psychiatric illness or clinical depression. The results found that SKY
significantly reduced levels of depression in 48 members of the treatment group; a finding not
observed among 55 control participants. Post-treatment qualitative written reports were
collected from treatment group participants who had used SKY at least three times a week at
home for the duration of the study. This qualitative data revealed new insight into the
psychological experiences of non-clinical adult participants who reduced depression with
pranayama. Participants reported feeling increased: peace, optimism, balance, joy, emotional
control, energy, and calmness. The SKY treatment also appeared to reduce: tension, negative
sensations, and blocked emotions. Respondents also indicated a greater sense of living in the
present moment. Certain individuals explained being able to feel the life force flowing through
their bodies during pranayama. Some participants reported experiencing an altered state of
consciousness (ASC). The Merriam-Webster’s Medical Dictionary (2006) defined an ASC as
“any of various states of awareness that deviate from and are usually clearly demarcated from
ordinary waking consciousness” (p. 24). Thus, an ASC could facilitate a unique condition of
deep mental and physical relaxation. An ASC could be unlike the normal waking consciousness
and might have contributed to the positive psychological changes experienced by the consistent
SKY practitioners.
Lastly, Uebelacker, Tremont, et al. (2010) conducted an open pilot study to evaluate the
acceptability and feasibility of Vinyasa yoga as an adjunct for 11 persistently depressed
participants. Vinyāsa yoga aims to synchronize the breath with movement. Participants were
MECHANISMS OF CHANGE OF PRANAYAMA 52
yoga naïve and remained on their respective psychiatric medications. The study used a mixed-
methods design. Quantitative measures included: the Patient Health Questionnaire (PHQ-9),
Quick Inventory of Depression Symptoms – Clinician Rating (QIDS), Treatment Response to
Antidepressant Questionnaire (TRAQ), Rumination Response Scale (RRS), Behavioral
Activation for Depression Scale (BADS), and the Five Facet Mindfulness Questionnaire
(FFMQ). After eight weeks, participants also completed in-person, qualitative interviews
focusing on what was enjoyable and effective about the treatment. Quantitative results found
significant reductions in depression; hypothesized to have been mediated by measured increases
in behavioral activation and mindfulness. Qualitative data analysis yielded three themes that
included: emotional, physical, and social benefits. Participants found the pranayama component
of the treatment important and positively endorsed this focus. Although a feasibility and
acceptability trial, this study provided some of the only available qualitative data gathered from
participants who undertook a yogic intervention with pranayama for a depressive disorder.
Summary
Depressive disorders affect people of all ages, genders, and backgrounds. Research has
shown that depression is one of the leading public health problems worldwide, and its prevalence
is expected to rise significantly in the future. Epidemiological studies have indicated that
millions of Americans will experience a MDE this year, with even more developing MDD
during their lifetime. The financial burden of depression for developed countries is estimated to
be in the billions of dollars annually. Moreover, the personal and relational toll that depression
causes for affected individuals and their friends and families is incalculable.
Western medicine is now integrating various ancient holistic practices into treatment
models. Over the last four decades, increasing numbers of clinical trials have used yoga to treat
MECHANISMS OF CHANGE OF PRANAYAMA 53
specific mental and physical disorders. Although preliminary, a growing body of scientific
literature supported yoga for the treatment of depression. Pranayama is a core component of
many forms of yoga, and uses voluntarily controlled breathing to cultivate wellness and personal
growth. SKY, a pranayama-based program, is currently the most applied, empirically supported
yogic intervention for depressive disorders. At present, two systematic reviews, five RCTs, and
one meta-analysis have suggested that pranayama could play an important role in reducing
depression. However, the systematic study of pranayama is still in the very early stages.
While quantitative studies have found yoga- and pranayama-based interventions
efficacious for depressive disorders, very little qualitative research has explored the experiences
of adult participants who had undertaken yogic breathing for unipolar depression. Therefore,
this study used a qualitative research design to investigate the experiences of adult participants
who reduced clinical depression using pranayama, with a focus on uncovering mechanisms of
change. It was hoped this inquiry could provide the field of clinical psychology with a rich
source of new data to better understand the role that pranayama might have in the treatment of
depressive disorders..
MECHANISMS OF CHANGE OF PRANAYAMA 54
CHAPTER III
Methods
This chapter covered the research design, participants, protection of human subjects,
measures, recruitment, data collection, data analysis, data presentation, and provisions of
trustworthiness.
Research Design
This study aimed to explore the experiences of adult participants who reduced unipolar
depression with pranayama, placing an emphasis on discovering mechanisms of change. A
phenomenological, qualitative research design was used. Qualitative research is exploratory,
descriptive, and open-ended in nature (Denzin & Lincoln, 2000). The focus of inquiry is initially
broad in scope, with an emergent design that allows for new meaning to be continually
uncovered from the data (Maykut & Morehouse, 1994). A qualitative methodology was chosen
for several important reasons. At present, almost no qualitative research has explored pranayama
for the treatment of depressive disorders. While numerous quantitative studies have found
pranayama effective in reducing clinical depression, little is known about the experiences or
mechanisms that facilitate the recovery process. Thus, this study was one of the first efforts to
utilize the qualitative research design to explore why and how pranayama reduces depression.
A qualitative approach attempts to understand the world through the participant’s viewpoint
to discover the meaning of their experiences (Kvale, 1996). This method has been called
indwelling, or “being at one with the persons under investigation, walking a mile in the other
person’s shoes, or understanding the person’s point of view from an empathic rather than
sympathetic position” (Maykut & Morehouse, 1994, p. 25). A qualitative research design
allowed adult pranayama users the opportunity to describe their experiences, inner realities,
MECHANISMS OF CHANGE OF PRANAYAMA 55
thoughts, feelings, and perceptions with the practice and depression firsthand. This study
attempted to expand knowledge in the field of clinical psychology by providing a rich source of
new data from the viewpoints of the pranayama practitioners. Ultimately, a qualitative
methodology can uncover new information and/or personal experiences that might be important
in understanding why and how pranayama ameliorates depression.
The questions that guide qualitative research attempt to understand what is important
about a particular phenomenon (Maykut & Morehouse, 1994). For this study, an in-person,
semi-structured interview was conducted with each participant in the most natural setting
available. The semi-structured Interview Guide (see Appendix A) comprised several open-ended
questions designed to elicit specific information regarding pranayama and depression.
Although semi-structured, the qualitative interviews remained adaptable as to allow each
participant the opportunity to discuss new ideas or issues they felt relevant to the topic under
investigation. An emergent design allowed the research to continually explore and integrate new
areas of the phenomenon that might not have been fully addressed by the original interview
guide.
Participants
This study used purposive sampling to recruit participants. Purposive sampling increases
the probability that a wide range of multiple realities will be discovered surrounding a particular
phenomenon (Lincoln & Guba, 1985). Specifically, this sampling method increased the
likelihood of recruiting a unique array of participants with a wide range of direct experiences
with pranayama and clinical depression. Kvale (1996) stated that the number of participants
required for qualitative research depends on the purpose of the study. If the number of
participants is too large, it becomes difficult to make valid interpretations from the interview
MECHANISMS OF CHANGE OF PRANAYAMA 56
data. If the sample is too small, it is difficult to form meaningful hypotheses. While the
qualitative research design does not specify a set number of participants required for a sample
size, the grounds for terminating sampling can be outlined (Maykut & Morehouse, 1994). For
this study, the number of participants depended upon what information was necessary to reach
saturation. Saturation was operationally defined as the point at which data collection becomes
redundant or uncovers no new information (Maykut & Morehouse, 1994). This study began with
ten participants and subsequently reached saturation at this point. Efforts were also taken to
ensure a demographically diverse sample based on variables including: age, disability, religion,
ethnicity/race, socioeconomic status, sexual orientation, indigenous heritage, national origin, and
gender (Hays, 1996). These recruitment procedures were outlined in a later section of this
chapter.
Inclusion Criteria. In order to qualify for this study, participants met the following:
1. Individuals who were at least 18 years old.
2. Individuals who had found pranayama effective in reducing depression within
the last five years. Although much variation was found across the DSM-IV-TR
diagnostic criteria for the various depressive disorders, depressed mood over some
extended period of time (e.g., two weeks) was a common feature in most diagnoses. In
order to recruit potential participants that may have never been professionally
diagnosed or aware of their specific psychiatric diagnosis, the mood disorders module
(Module D) of the Structured Clinical Interview for DSM-IV-TR Axis I Disorders
(SCID-I) was administered. The SCID-I (Module D) assessed both current and
lifetime history for a major depressive episode or dysthymia. In order to qualify for a
diagnosis of depressive disorder NOS (e.g., minor depressive disorder, recurrent brief
MECHANISMS OF CHANGE OF PRANAYAMA 57
depressive disorder, etc.), symptoms during the episode must have caused “clinically
significant distress or impairment in social, occupational, or other important areas of
functioning” as outlined by the DSM-IV-TR (p. 775-778).
3. Individuals who had used pranayama at least three days a week for a period of one
month while experiencing a DSM-IV-TR depressive disorder. The rationale for this
criterion was based on clinical research indicating that pranayama reduced mild-to-
moderate levels of depression from 5-21 days of regular practice (Brown & Gerbarg,
2005b; Naga Venkatesha Murthy et al., 1998). An additional week was added because
more severe levels of depression may take longer to respond to yogic breathing (Brown &
Gerbarg, 2005b). Research has also found that the frequency of pranayama plays an
important role in recovery, with regular practice promoting optimal treatment response
(Brown & Gerbarg, 2005b; Janakiramaiah et al., 1998; Vahia et al., 1972).
Exclusion Criteria. The following criteria excluded participation in the present study:
1. Individuals who were under the age of 18 years old.
2. Non-English speaking individuals.
3. Individuals who reported a symptom history or known diagnosis of any of the bipolar
disorders as outlined by the DSM-IV-TR. Respondents having ever met a bipolar
disorder diagnosis after being assessed by the SCID-I (Module D) were also excluded.
4. Individuals who reported a symptom history or known diagnosis of any of the other
mood disorders as outlined by the DSM-IV-TR. Respondents having ever met an other
mood disorder diagnosis after being assessed by the SCID-I (Module D) were also
excluded.
5. Individuals having any other DSM-IV-TR mental disorder or ICD-10 medical
MECHANISMS OF CHANGE OF PRANAYAMA 58
condition that would make participating in a 60-90 minute, face-to-face interview
difficult or impossible.
Protection of Human Participants
To protect participants, this study adhered to the guidelines of the Institutional Review
Board at Alliant International University in San Diego, California. In addition, the Ethical
Principles of Psychologists and Code of Conduct of the American Psychological Association
(2002) were followed. Each participant received a comprehensive explanation of the research
forms (see Appendices B & C) before beginning the interview. Participants were also informed
that all audio files and transcribed interviews are to be safely maintained as a provision of
trustworthiness for two years after completion of the study, whereupon all confidential
information will be destroyed. To ensure the privacy of each participant, all names and
identifying information was disguised. Participants created a pseudonym to be applied in the
final presentation of results. The primary investigator tried to ensure that each participant fully
understood that the research was voluntary, and that they had the right to refuse to participate,
decline to answer questions, and withdraw from the study at any time, for any reason, without
penalty.
While the risks of harm associated with taking part in this study were minimal, discussing
experiences with depression could foreseeably have caused psychological distress for
participants. The primary investigator took extra care to establish rapport with each individual at
the outset of the meeting. Sufficient time was allowed for the participant to ask questions or
voice concerns before their interview. During the interview, the primary investigator remained
attentive to the mental state and body language of the interviewee to be aware if any negative
reactions were experienced. Referrals for appropriate mental health services were made
MECHANISMS OF CHANGE OF PRANAYAMA 59
available to ensure the safety and care of each participant. Participants were advised to call their
primary care physician or 911 immediately if they required emergency psychiatric services at
any point after the interview.
Measures
This study used the following measures: a telephone screening interview, a demographic
questionnaire, a semi-structure interview, and the Structured Clinical Interview for DSM-IV-TR
Axis I Disorders (SCID-I).
Telephone Screening Interview. The Telephone Screening Interview (see Appendix D)
was used to assess the eligibility of each individual who responded to the recruitment flyer.
Eligibility for participation was based on the inclusion and exclusion criteria outlined by this
study.
Demographic Questionnaire. Each participant completed a Demographic
Questionnaire (see Appendix E) developed for this study.
Semi-Structured Interview. The research team created a semi-structured Interview
Guide (see Appendix A) to collect data for this study. This form was comprised of broad, open-
ended questions designed to promote discussion and meet the exploratory aims of qualitative
research. The emergent design allowed for additional follow-up questions to be asked, based on
the participant’s narrative, in order to elicit more information relevant to the phenomenon under
investigation.
Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I). The
SCID-I is a widely used psychiatric diagnostic interview that was administered to assess the
current and lifetime occurrence of a depressive disorder.
MECHANISMS OF CHANGE OF PRANAYAMA 60
Recruitment of Participants
A variety of methods were used to ensure an equitable selection of participants.
To recruit a demographically diverse sample, a Recruitment Flyer (see Appendix F) was
distributed to various public settings, yoga studios, and integrative health venues in a large
metropolitan city. The advertisement was posted on Craigslist, a centralized network of online
communities. The recruitment flyer was also disseminated through online yoga communities
and meet-up groups. In addition, psychotherapists teaching pranayama or breathwork in therapy
sessions were contacted to recruit potential participants. The primary investigator and an
advanced doctoral candidate in the field of clinical psychology screened respondents (see
Appendix D; SCID-I) to ensure each met inclusion criteria. If an individual was determined to
be eligible, a convenient meeting time and location was established for the interview. Eligible
candidates had an equal opportunity to participate based on a first come, first-served basis.
Data Collection
The primary investigator began each meeting with a brief, standardized introduction
outlining the purpose of the study and the procedures to be followed (see Appendix B). The
participant was given time to ask questions or address concerns about the research. The
participant then gave written Informed Consent (see Appendix C) for participation in accordance
with the standards of the Institutional Review Board of Alliant International University at San
Diego. The informed consent agreement overviewed: the purpose and the aims of the study,
possible risks and benefits of participation, consent for audio-recording, confidentiality and the
limits to confidentiality, mandatory reporting laws, researcher contact information, and other
important stipulations. This form also included permission to use direct quotes from the audio-
MECHANISMS OF CHANGE OF PRANAYAMA 61
recorded interview in the final presentation of results. Of importance, this document outlined the
participant’s specific rights as a volunteer in clinical research.
Next, the participant was asked to complete the Demographic Questionnaire (see
Appendix E). If there were no further issues or questions, the primary investigator began the
interview using the semi-structured Interview Guide (see Appendix A). The qualitative
interview gathers a rich description of each individual’s perceived reality to interpret the
meaning of the phenomenon under investigation (Kvale, 1996). Important data includes all of
the experiences, abilities, background, knowledge, and biases of the participant (Maykut &
Morehouse, 1994). The overarching goal of this interview was to gather an accurate,
experiential, and in-depth understanding of each participant’s unique experiences with
pranayama and depression. Each interview lasted approximately 60-90 minutes.
A debriefing immediately followed each interview to answer any new questions or
concerns that may have arisen for the participant. The debriefing also helped the primary
investigator assess and minimize any unpleasant or negative reactions that may have emerged for
the participant during their interview. A concluding member check allowed participants to
provide feedback and reflect upon their experience. Following the debriefing, participants
received $25 compensation for their involvement in the study. Data collection continued until
the point of saturation, which included 10 participants.
Data Analysis
Qualitative data analysis has been conceptualized as “a systematic search for meaning”
(Hatch, 2002, p. 148). Qualitative research most often takes an inductive approach to data
analysis (Maykut & Morehouse, 1994). To begin this process, each participant’s demographic
information was converted and summarized in table format. The Constant Comparative Method
MECHANISMS OF CHANGE OF PRANAYAMA 62
as outlined by Maykut and Morehouse (1994) was used to analyze narrative information
gathered from interviews. To prepare the information for analysis, all raw data (e.g., field notes,
audio-recorded data, and other relevant documents) was transcribed verbatim, printed, and then
photocopied in an easy-to-read typescript format. Each interview was then read carefully
multiple times to give the primary investigator a sense of familiarity and wholeness with the
material. To uncover common themes within the data, each interview was analyzed for specific
“units of meaning” (Maykut & Morehouse, 1994, p. 134). Kvale (1996) described these “units”
as condensations of meaning expressed by participants during their interviews. Each interview
held multiple units of meaning. The qualitative data analysis (QDA) software NVivo 10 was
used to identify and organize units of meaning within the data. Through this analysis, units of
meaning were gathered and sorted for relevance. It was hypothesized that the identification and
analysis of units of meaning would result in the emergence of common themes. Themes would
therefore provide deeper insight into the unique, subjective experiences of the participants.
Significant themes were identified based upon the primary researcher’s awareness and
understanding of the phenomenon under investigation (Maykut & Morehouse, 1994). Grounded
theory aimed to identify categories and concepts that emerged from the data to form meaningful
and substantive theories (Charmaz, 2000).
Presentation of the Data
A case study approach was used to report research outcomes (Maykut & Morehouse,
1994). Information gathered from the Demographic Questionnaire was summarized in a table
(see Table 1) and included in the results section of this study. Any identifying information was
disguised via pseudonym to protect the privacy of each participant. If a participant’s interview
transcript revealed additional demographic information relevant to the phenomenon under study,
MECHANISMS OF CHANGE OF PRANAYAMA 63
it was also added. A second table (see Table 2) listed the categories and emergent themes.
Direct quotes were culled from the interview data to provide an illustrative, experiential example
of specific themes. A discussion chapter was included to highlight the major findings of the
study. Major findings were interpreted in relation to earlier research, and implications for
clinical practice were discussed. Limitations of the study were addressed and future directions
for psychological research were outlined.
Provisions of Trustworthiness
This study followed the four guidelines outlined by Lincoln and Guba (1985) to enhance
the validity of findings. First, this research included multiple sources of data collection (e.g.,
qualitative interviewing, field notes, & reviews of relevant documents). This provision helped
ensure that the phenomenon under investigation was being explored from multiple worldviews
and/or ways of knowing. Audio files and interview transcripts were carefully compared and
screened for any errors or discrepancies that occurred during transcription. Second, all data was
securely maintained until the conclusion of the study to provide an audit trail. Third, a research
team (i.e., the dissertation committee) comprised of licensed psychologists with expertise in the
fields of integrative psychology and mindfulness was assembled to help formulate and supervise
the study. Of importance, the primary investigator has used pranayama and experienced some
depression in the past. This artifact could have potentially influenced the data collection process
and/or interpretation of results, and therefore injected bias into the study. To minimize
researcher bias and maintain objectivity, an advanced doctoral candidate in clinical psychology
undertook the role of supplemental data analyst (SDA). The SDA reviewed the original
interview transcripts after completion of the initial data analysis. This third party review
generated a secondary list of emergent themes and conclusions drawn independently from the
MECHANISMS OF CHANGE OF PRANAYAMA 64
preliminary findings of the primary researcher. Relevant feedback from the supplemental data
analysis was then integrated into the final results of the study. The primary researcher also
consulted with a Yogacharya from India to prepare comprehensive and diverse qualitative
interview questions. Fourth, member checks were conducted at the conclusion of each interview.
The member check gave participants an opportunity to provide feedback and/or describe whether
or not they felt their experiences had been explained in a full and accurate manner. Each
participant could reflect on his or her interview experience and amend or clarify any unresolved
issues. Relevant information gleaned during any phase of data collection was recorded in a
research journal that contributed to the final synthesis of this study’s conclusions.
MECHANISMS OF CHANGE OF PRANAYAMA 65
CHAPTER IV
Results
Participant demographic information was summarized in Table 1, followed by a brief
narrative description of each of the 10 individuals. Qualitative data analysis yielded 15 themes,
which were organized into 6 categories. Table 2 overviewed these results and included five
additional findings that did not meet the criteria to be considered emergent themes, yet still
provided valuable data. Emergent themes were then described, using direct quotes from
interview transcripts to illustrate core features of the participants’ experiences.
Description of the Participants
Table 1 summarized demographic information gathered from questionnaires completed
by participants before each interview. Pseudonyms were applied to protect the identity and
privacy of all participants. Additional information culled from interview transcripts was
included to provide a fuller picture of the participants’ lives and backgrounds.
Maximal demographic diversity was sought in the recruitment of participants regarding
multicultural factors (Hays, 1996). A wide range of experiences with unipolar depression and
pranayama was attained. Participants included four men and six women ranging in age from 33
to 81. The mean age of the participants was 46.3 years old. The racial/ethnic backgrounds of the
sample included: seven Caucasians, one Asian/Caucasian, one Native American/Caucasian, and
one Hispanic/Latino participant. Eight participants identified as being heterosexual in sexual
orientation, one as gay, and one as bisexual. Seven participants were single, two were divorced,
and one was widowed. Five participants identified as being spiritual but not religious, one as
spiritual, one as spiritual and religious, one as Buddhist and spiritual, one as Christian, and one
as Agnostic. Table 1 provided a more detailed description of participant demographic data.
Table 1
Participant Demographics
Participant Depression Depression
Ethnicity/Religious Occupation/ Onset of Clinician Type/Context of Duration/Frequency
Sex/Age BEFORE AFTER
Beliefs Education/Income Depression Diagnosed? Pranayama Used of Practice
Practice Practice
Unspecified 5 years
Jennifer Caucasian
Bachelor’s degree Lifetime Yes Hatha Yoga Mild Very Little (1x per week
F/35 Spiritual but not religious
Unspecified recently)
Self-employed
Mary Asian/Caucasian Hatha Yoga/ 10 years
Master’s degree Lifelong Yes Moderate Mild
F/44 Spiritual but not religious Bikram Yoga (Varies/Daily)
$25,000-49,999
Unemployed Yes Breathing 5 years
Andrew Caucasian
Some college/vocational 25+ Years Meditations/ Some Moderate Mild (15 min. every
M/50 Spiritual & Religious
Under $25,000 Yoga morning)
Native American/ Handyman Circular/Continuous
John 18 years 3 years
Caucasian Some college No Breathing; Severe Mild
M/45 (On & off) (2-3 times daily)
Buddhist/Spiritual Under $25,000 OM chanting
Yoga teacher/therapist Yes
Sarah Caucasian Very Little 18 years
Master’s degree From birth Ashtanga Yoga Severe
F/54 Spiritual to None (Everyday)
Unspecified
Non-profit management Yes 10 years
Ann Caucasian Approx. Vinyasa Yoga/
Master’s degree Moderate Mild (1x day/5-7 days
F/33 Spiritual but not religious 20 years Meditation/MBSR
$25,000-49,999 per week recently)
Retired Yes
Joseph Caucasian 2 years
Master’s degree 6 years Ashtanga Yoga Severe Very Little
M/81 Christian (5x per week)
$50,000-74,999
Driver Yes
Henry Hispanic/Latino Slow Controlled 3 years
Bachelor’s degree 10 years Moderate Very Little
M/38 Agnostic Breathing (Everyday)
$25,000-49,999
Personal assistant Yes
Julie Caucasian 10 years
Some college/vocational 30 years Biofeedback/Yoga Moderate Mild
F/46 Spiritual but not religious (3x per week)
$25,000-49,999
Salesperson
Kathleen Caucasian 15 years
Bachelor’s degree 30+ years Yes Iyengar Yoga Severe Severe
F/37 Spiritual but not religious (3x per week)
$25,000-49,999
MECHANISMS OF CHANGE OF PRANAYAMA 67
Nine of the participants had been professionally diagnosed with a depressive disorder
while one individual never sought treatment. Nine of the participants reported a history of
depression lasting for 10 or more years. The self-reported levels of depression within the sample
ranged from mild to severe. The majority of participants had used conventional treatment for
depression at some point in their lifetime, with nine undertaking psychotherapy (e.g., individual,
group, art, music, etc.) and six using some form of psychopharmacologic intervention.
Participants also used a variety of complementary and alternative interventions that included:
yoga (8), exercise (4), nutrition (2), supplements/herbs (2), acupuncture (2), hypnosis (1), Reiki
(1), massage (1), and the Emotional Freedom Technique (1).
Voluntarily controlled breathing was learned and practiced in a variety of therapeutic
contexts and settings that included: yoga classes (7), meditation services or gatherings (2), self-
facilitated coursework (2), psychotherapeutic biofeedback (1), and an MBSR program (1). The
various pranayamas practiced included techniques from: Hatha, Bikram, Ashtanga, Vinyasa, and
Iyengar traditions of yoga. One participant primarily used deep breathing biofeedback taught
during group psychotherapy and one participant practiced continuous breathing learned from
Michael Brown’s The Presence Process program.
Participant # 1 – Jennifer. Jennifer is a 35-year-old, single, heterosexual, Caucasian
female who lives in San Diego, CA. She holds a Bachelor’s degree and did not specify an
occupation. Jennifer reported suffering from depression for most of her lifetime. She has sought
treatment and been diagnosed with a depressive disorder.
Jennifer first learned pranayama in 2007 when she began taking yoga classes out of
curiosity. A yoga teacher introduced the pranayama, and she initially found the rapid breathing
techniques to be more like exercise that became easier with practice. She highlighted ujjayi as
MECHANISMS OF CHANGE OF PRANAYAMA 68
being a particularly helpful pranayama for her depression. During the depressive episode for
which she regularly used pranayama, she rated her depression as being mild. After using
pranayama, she reported experiencing very little depression. Currently, yoga is the only
modality used to manage her depression.
The participant had prepared notes for the interview but forgot to bring them. She
reported less consistent pranayama use in the months preceding the interview, sometimes
averaging only one session per week. This lapse in practice was attributed to more events
occurring in her life recently. She noted that she was now finding it easier to fall back into
depressive patterns of thought, which allowed “outside things” to upset her, sometimes even
immediately following a yoga class.
Participant # 2 – Mary. Mary is a 44-year-old, single, heterosexual, Asian/Caucasian
female who lives in San Diego, CA. She holds a Master’s degree and is a self-employed
salesperson. She reported a lifelong struggle with depression, has sought professional treatment,
and been diagnosed with a depressive disorder. She stated that her depression manifests in
different ways and intensities (e.g., ranging from mild to “extreme”), and surmised about
possible triggers (e.g., specific events, nutritional imbalances, and unknown variables). Self-
reported symptoms of her depression included: depressed mood, hopelessness, negative thinking,
reduced motivation, social isolation, and withdrawing inward.
Mary used various conventional treatments for the depression that included:
psychotherapy, psychopharmacology, and Eye Movement Desensitization and Reprocessing
(EMDR). She believed psychotherapy to be very helpful because it was important to have
someone with whom to talk. She also tried various complementary treatments that included:
dietary/nutritional modification, herbal supplements, and yoga.
MECHANISMS OF CHANGE OF PRANAYAMA 69
Mary first learned pranayama while taking yoga classes around 2003. She became
interested in yogic breathing because she believed herself to be a “naturally shallow breather,”
especially when feeling depressed. She primarily practices Bikram and Hatha types of yoga.
During a specific depressive episode from the past, she reported a moderate level of depression
that reduced to a mild amount when using pranayama consistently. She also finds it helpful to
implement yogic breathing in daily circumstances when her depression arises. She strives to
practice yoga daily but its regularity varies depending upon her busy schedule.
Participant # 3 – Andrew. Andrew is a 50-year-old, single, gay, Caucasian male who
lives in San Diego, CA. He reported some college/vocational experience but is currently
unemployed. He discussed a history of chronic depression spanning over 25 years, which was
exacerbated by the death of his father in 2009. He has used both psychotherapy and
antidepressant medication in the past and has been diagnosed with MDD. His self-reported
symptoms of depression included: depressed mood, feeling sad much of the time, experiencing
low self-esteem, long crying spells, racing negative thoughts, and an intense anxiety element. He
stated that he was off the antidepressant medications Lexapro and Celexa “for now.”
Discontinuation has allowed him to cry again, sometimes for up to two-minutes; a process he
considers “cleansing.”
Andrew described multiple psychosocial stressors contributing to his depression that
included: a recent break-up with a long-term partner, moving to San Diego and losing much of
his social support, having a diagnosis of HIV, unemployment, and financial difficulties. He
stated that he was recently “just one day away from homelessness,” and is not used to asking for
help or relying on social assistance. He also found it extremely stressful living in a halfway-
MECHANISMS OF CHANGE OF PRANAYAMA 70
house with many other people; some of whom he described as “emotional vampires.” Being a
private person, he avoids the other residents by taking walks and volunteering.
Andrew learned voluntarily controlled breathing while attending a weekly spiritual group
meeting during 2009. Each service began with a 15-minute breathing meditation facilitated by a
reverend or minister. He also tried yoga in the past, but practices sparingly because he does not
enjoy the heavy stretching element. He indicated that voluntarily controlled breathing reduced
his depression from a moderate to mild level.
Andrew is diligent about practicing voluntarily controlled breathing first thing every
morning. He created a private space for the practice, which he called his “Zen 15-minutes.” His
particular breathing techniques involve: slow deep breathing, Om chanting, and guided
visualizations using the breath. He described metaphysical experiences resulting from the
practice, including receiving signs from his deceased father in the form of scents or
remembrances. He enjoys walking, meditation, and journaling to stay positive and manage his
depression.
Participant # 4 – John. John is a 45-year-old, single, heterosexual, Caucasian/Native
American male who lives in San Diego, CA. He listed some college/vocational experience and
works as a handyman. He reported experiencing severe, debilitating levels of depression “off
and on” during the last 18 years. However, he never sought professional treatment for his mental
condition. His depression began around 1995 during a stressful period that involved: an abruptly
ended relationship, the resulting feelings of betrayal, an illness, a car accident, legal problems,
and relocating to California. During this time he felt “shut down emotionally.” He described his
depression as “super-debilitating” and “a very circular process” of negative thoughts, emotions,
fatigue, and hopelessness.
MECHANISMS OF CHANGE OF PRANAYAMA 71
John first tried breathwork around 1995 or 1996 in therapeutic rebirthing classes. He
practiced for three months in a group setting, but soon felt the instructor was pushing him to have
a breakthrough for which he was not psychologically prepared. He discontinued the therapy
although he noted some benefits from accessing childhood experiences. In 2010 he discovered a
10-week, self-study course conducted by Michael Brown called The Presence Process. The
breathing technique (circular or continuous breathing) involved slow, conscious, elongated
breaths taken through the nose with no pause in between inhalations and exhalations. John
discussed experiencing severe episodes of depression during this time, sometimes to the point of
being confined to bed for days. The Presence Process course prompted him to begin an intense
practice for one year that put him in the habit of always trying to be conscious of the breath.
Over several years, regular practice brought John from a severe to a mild level of depression.
John has been using circular breathing exclusively to cope with his depression since
2010. He practices two-to-three times daily and employs the technique during routine activities
for its healing qualities. He also maintains a Buddhist meditation practice that incorporates Om
chanting. He experienced his last severe depressive episode five-to-six years ago. At present, he
rated his depression as mild, considering himself “definitely though the hump.”
Participant # 5 – Sarah. Sarah is a 54-year-old, divorced, heterosexual, Caucasian
female who lives in San Diego, CA. She holds a Master’s degree and works as a yoga teacher
and therapist. She discussed an extensive history of severe depression beginning “from birth.”
Prior to learning yoga, she tried a variety of conventional and complementary treatments to
manage her depression including: psychotherapy, sleeping pills, migraine medications,
acupuncture, Reiki, and massage. She has sought psychotherapeutic intervention and been
diagnosed with a depressive disorder, although she was uncertain of the specific diagnosis. Her
MECHANISMS OF CHANGE OF PRANAYAMA 72
depressive symptoms included: depressed mood, sadness, crying spells, suicidal ideation,
somatic complaints, fatigue, and feeling hopeless.
Sarah was born in a Central European country and stated that she was a “sickly child.”
An oppressive Communist social climate and authoritarian home environment resulted in her
developing an early pattern of repressing emotions. She noted breathing problems beginning in
early childhood and “wasn’t a natural free breather.” A pattern of serious depression and
shallow breathing continued for approximately 38-39 years until she began yoga in 1996.
Sarah began pranayama in 1996 while attending a yoga school in San Diego, CA. Here,
ujjayi breathing allowed her to experience calmness and ease of the breath for the first time. She
pursued yogic coursework and later trained under a master yoga teacher. The yogic path had a
profound and transformative effect on her overall health and daily functioning. Dedicated yoga
practice helped her reintegrate a sense of identity, increase self-worth, develop courage, and
improve mental health. The severe levels of depression experienced in the past have reduced to
very little or none; a benefit she attributed to regular yoga practice.
Her daily yoga regimen includes: asanas, pranayamas, mudras, mantras, yantras,
meditation, and movement. She uses pranayama daily and adapts the practice to meet her
individual needs. She continues to teach yoga and enjoys writing poetry, watching movies, and
traveling.
Participant # 6 – Ann. Ann is a 33-year-old, divorced, bisexual, Caucasian female
living in San Diego, CA. She holds a Master’s degree and works in non-profit management.
She reported suffering from depression since she was a teenager, with the condition reaching a
peak within the past year. Ann described a long history of recurrent major depressive episodes
and chronic depression often triggered by acute anxiety. She has sought professional treatment
MECHANISMS OF CHANGE OF PRANAYAMA 73
for her mental health and been diagnosed with MDD. Her self-reported symptoms of depression
included: sadness, lethargy, and apathy. She has used a variety of conventional treatments to
manage her depression that included: individual therapy, group therapy, and antidepressant
medication. She has also tried hypnosis.
Ann learned voluntarily controlled breathing as part of meditation in 2003. She also
began practicing Vinyasa yoga (i.e., breath by movement) for the physical benefits around this
time. Within the last six months, she undertook an 8-week MBSR course that incorporated
conscious breathing. She practices yogic or meditative breathing at least once a day, five to
seven times per week. She rated her depression before using pranayama as moderate, reducing
to a mild level with regular practice.
Ann discussed a turning point in her mental health occurring this past year. After
experiencing a peak in depression while pursuing education overseas, she chose to take a
proactive approach to recovery. She has since adopted mindfulness practice as an imperative,
non-negotiable, long-term management strategy for the depression. For fun she enjoys surfing,
cooking, and journaling.
Participant # 7 – Joseph. Joseph is an 82-year-old, widowed, heterosexual, Caucasian
male. He identified as being Christian and is now retired. He reported a long career in a branch
of the military and pursued graduate education in the social sciences.
Joseph first experienced depression in 2007 after the brutal murder of his wife.
Following the trial and conviction of the offender, this extraordinarily tragic event prompted him
to seek solitude in a secluded cabin. Here, his bereavement appeared to transition into MDD.
He reported that his loneliness, suicidal ideation, chronically depressed mood, and alcohol
consumption increased while at the cabin. Concerned family members persuaded him to seek
MECHANISMS OF CHANGE OF PRANAYAMA 74
professional treatment. He stated that he was “pulled” by his family to San Diego where he
began traditional talk therapy with two “excellent” counselors. A main goal of psychotherapy
focused on helping Joseph confront his loneliness and reconnect with society. Around this time,
he also attended a support group for the families of victims of violent crime. Both
psychotherapy and group support appeared instrumental in getting him to open up and reconnect
with the world. At the suggestion of his counselor and family members, he tried yoga in 2012.
Joseph gradually found himself attending Ashtanga yoga classes regularly with the
support of the teacher and other students. He also began slowly integrating yogic principles and
practices into his daily life. After using yoga with pranayama consistently for two years, he rated
his current depression as “a two or three” (indicating very little); significantly reduced from a
previously severe level of 10. He attributed powerful, unpredictable depressive triggers (e.g.,
specific things, memories, places, etc.) to his continuing struggle with depression. He practices
yoga at least five days a week, sometimes twice daily, in both group classes and at home. In his
spare time he enjoys walking, hiking, visiting family, and volunteering. He considers his yogic
path a new journey and expressed renewed optimism about the future.
Participant # 8 – Henry. Henry is a 38-year-old, single, heterosexual, Latino male who
lives in San Diego, CA. He identified as being Agnostic, but expressed spiritual beliefs in his
interview. He holds a Bachelor’s degree and drives a truck for a living. He reported suffering
from depression for the last 10 years, initially triggered by the death of his mother in 2003. He
also discussed a genetic predisposition to depression on the paternal side of his family. His
depressive symptoms included: depressed mood, insomnia, negative automatic thoughts, guilt,
reduced energy, and a strong anxiety component.
MECHANISMS OF CHANGE OF PRANAYAMA 75
Henry was diagnosed with MDD at a university clinic in 2009. Psychotherapy helped
him realize that his depression likely existed many years prior. He tried various psychiatric
medications for his mental condition including: Xanax, Wellbutrin, and Trazadone. However, he
developed a serious addition to Xanax resulting in convulsions and complete exhaustion. With
the help of a close family member, Henry retreated to Mexico to purge himself of prescription
medication “cold turkey” for one month. He considers this experience a turning point or
“miracle” that positively changed his life.
After the detoxification, Henry developed an interest in CAM (e.g., acupuncture, yoga, &
chiropracty). He subsequently learned voluntarily controlled breathing from an alternative
medicine practitioner. He has since used consciously controlled breathing on a daily basis for
the past three years. His specific practice involves taking deep, controlled inhalations and
exhalations, ideally regulating four-to-five breaths per minute. He employs the technique at
home, during stressful driving situations, and as needed. If necessary, he will pull over and
practice breathing in the quiet cab of his truck. Voluntarily controlled breathing helped him
reduce moderate depression to a very low level.
Participant # 9 – Julie. Julie is a 46-year-old, single, heterosexual, Caucasian female
who lives in San Diego, CA. She listed some college education/vocational training and works as
a personal assistant. She has experienced depression for at least 30 years and has been diagnosed
with MDD. She benefited from a variety of psychotherapeutic approaches that included:
individual, group, art, and music therapy. Julie stated that the hardest part about her depression
is the racing mind, negative thoughts, and uncontrollable emotions. She discussed depressive
symptoms including: depressed mood, lethargy, crying spells, hopelessness, sadness, and
reduced appetite.
MECHANISMS OF CHANGE OF PRANAYAMA 76
Julie was the only participant in the sample to learn voluntarily controlled breathing in a
psychotherapeutic setting. She first practiced breathwork in 2003 after a clinician taught her
psychotherapy group biofeedback techniques. She continued to use the consciously controlled
breathing on her own at least three times a week, but also on an “as needed basis” during
stressful situations. She has also practiced yoga with pranayama.
Julie indicated that the regular use of deep breathing biofeedback reduced her depression
from a moderate to mild level. She did however, note limitations to the breathing techniques.
When her depression was severe in the past, breathing techniques alone were often not enough to
help her regain normal daily functioning. She stated that a severe depressive episode would
likely require additional clinical intervention (e.g., psychotherapy, medication management).
However, she suggested that the biofeedback deep breathing could likely bring a moderate level
of depression under control. For recreation she enjoys walking her dog, the outdoors, watching
sports, and taking care of animals.
Participant # 10 – Kathleen. Kathleen is a 37-year-old, single, heterosexual, Caucasian
female who lives in San Diego, CA. She holds a Bachelor’s degree and works in sales. She
reported suffering from severe depression for over 30 years; ever since she was a small child.
She stated that her depression is active more often than not, and that she has been diagnosed with
a depressive disorder.
She first sought treatment for unipolar depression during college around the age of 18 or
19. After attending psychotherapy for one year and not seeing a significant benefit, she opted for
psychopharmacologic intervention. She has since tried various antidepressant medications
intermittently over the past 17 years. She has also used yoga, exercise, herbs, and dietary
MECHANISMS OF CHANGE OF PRANAYAMA 77
modification to manage the mental condition. Despite these varied interventions, her depression
remains chronic and severe.
Kathleen learned pranayama in 1998 at the age of 20 after trying yoga for its physical
benefits. In 1999, she discovered Iyengar yoga and has since remained a devoted student of this
tradition. She practices a variety of pranayamas daily as outlined in B.S. Iyengar’s books Light
on Prānāyāma and Light on Yoga. It took her time to develop a consistent home practice. At
present, she considers herself to be at the intermediate level of this yogic system. Of note, she
rated the level of her depression as severe both before and after using pranayama, likely
reflecting the chronicity of her depressive disorder.
Kathleen’s case was somewhat unique with regard to the sample, in that she did not
cumulatively reduce depression with pranayama (and other conventional treatments). All other
participants reported sustained levels of remitted depression after using pranayama and their
respective treatment regimens (see Table 1). Instead, Kathleen indicated that pranayama helped
her cultivate a transcendental state of “pure being” that temporarily suspended depression in the
present moment and created a new lens through which to view suffering in general.
Categories and Themes
This study used the constant comparative method to analyze data and identify common
units of meaning, themes, and categories across interview transcripts and field notes (Lincoln &
Guba, 1985; Maykut & Morehouse, 1994). NVivo QDA software was applied to supplement
some data organization and coding.
Fifteen themes emerged from the qualitative data analysis. These themes were organized
into six categories: psychological mechanisms, psychophysiological mechanisms, psychological
MECHANISMS OF CHANGE OF PRANAYAMA 78
MECHANISMS OF CHANGE OF PRANAYAMA 79
results of practice, psychophysiological results of practice, physiological results of practice,
and practice attitudes and new insights. Five additional findings did not meet the criteria
to be considered emergent themes, yet provided valuable information about this
phenomenon. Additional findings included: unknown mechanisms, releasing of negative
(and/or repressed) emotions, chakra/meridian balancing, using breathing with
visualization, and outlying experiences. Table 2 outlined these categories, themes, and
additional findings. This chapter then described categories and themes in more detail
using direct quotes from the qualitative interview transcripts to illustrate each finding.
Category 1: Psychological Mechanisms. Themes in this category included pranayamic
mechanisms believed to generate antidepressant change psychologically. Here, participants
described specific mental activities or efforts, psychological experiences, and cognitive changes
occurring with pranayama that facilitated antidepressant effects.
Theme 1: Focused and/or Refocused Attention. Ten participants endorsed the focusing
and/or refocusing of their attention on the breath as being important for reducing depression.
During pranayama, the breath served as a neutral stimulus that participants could attune and
return their focus to on a moment-to-moment basis. Two participants’ conceptualized the breath
as being an “anchor” or a “constant” to hold attention. Thus, focus helped participants settle,
center, and ground themselves to begin the more inward journey of pranayama.
This theme held a variety of antidepressant properties. Focused attention on the breath
appeared to crowd-out headspace for negative thoughts and feelings to proliferate. When
participants lost focus or noticed depressive thoughts arising, refocus could be implemented to
redirect the attention back to the breath. Focusing on the breath also helped restore concentration
that had been impaired by depression. By choosing to focus on the breath, participants could
MECHANISMS OF CHANGE OF PRANAYAMA 80
interrupt longstanding patterns or cycles of depressive thinking. This theme facilitated
antidepressant effects including: a psychological state change, clearing of the mind, reduced
negative thoughts, and mindfulness cultivation. The following quotes illustrated this theme:
ANN: I think it just gives me a main focal point. And so that if I get distracted by
something else, which I do when I’m not focusing on breathing and I’m not doing any
meditation, if I’m upset about something, if I’m dealing with some depression, then I’m
probably obsessing about… whatever: a life change, body image stuff, relationships,
whatever it is. There will be sort of that hamster wheel of continually worrying about
something and how can I fix this? What am I going to do about it? This is hopeless or
whatever.
MARY: So if you are depressed, or if you are anxious, you’re kind of wrapped up in that
emotion and in that state. And so this is kind of a break from that state because your
focus shifts to the pranayama and the breathing, and then the state is shifted because it’s
very calming and it gives you kind of this sense of peace, which then disrupts the
depression or the anxiety.
JULIE: For me, the hardest part with my depression is again, like the racing mind and
thinking thoughts. So with the yoga, again, it’s this… it’s the centering. And so for me,
with my breathing, I’m trying to just stay focused and not let other things get into me. So
anytime I concentrate on my breathing, it tends to just bring me centered.
Theme 2: Sense of Control. Nine participants reported feeling a sense of control over
their depression with pranayama. These individuals viewed pranayama as a reliable, transferable
tool that could be applied inconspicuously anytime depressive triggers arose. One participant
juxtaposed the constant, dependable nature of the breath alongside impermanent psychological
MECHANISMS OF CHANGE OF PRANAYAMA 81
states and unpredictable external events. These participants felt empowered in having an
effective technique to offset depression in the present moment. Pranayama instilled a feeling
that something proactive could be done to manage their depression, particularly in moments of
crisis or during MDEs. In addition, pranayama helped certain participants reframe the nature of
their relationship with depression into being seen as something endurable and manageable.
Overall, this theme captured experiences of self-empowerment, self-confidence, proactivity, and
hope. The following quotes supported this finding:
MARY: I think maybe, with people that are depressed is they feel helpless sometimes
and that they don’t know what to do, or they don’t feel like it’s in their control. And this
gives some control. This gives you something that you can rely on yourself. You’re not
helpless. There is something you can do. So maybe it could give some confidence that
way too.
ANN: If there are specific things that are triggering my anxiety or depression, the
focusing on my breath… not only is it kind of generally calming and soothing, but that it
is a reminder that my breath is a constant. It’s always there. I can stop and have that
deep breathing and kind of tap into that sort of slightly soothing, comforting kind of
experience whenever I want. And that other things are going to change and that’s okay.
You know, how I react to it. Whether I react to it is up to me. And so I think that has
been something that has really come out of the meditative breathing, is that shift in
perspective on what’s permanent or constant or in my control… and what’s not. And
how I relate to that.
JOHN: I take it anywhere. I’ve got it to the level where I don’t just… it’s not some kind
of formal thing where I just sit down and do it. Though I do practice that too. But no, I
MECHANISMS OF CHANGE OF PRANAYAMA 82
take my breathing practice with me everywhere. Wherever I go. Cuz’ I need it,
wherever I go.
Category 2: Psychophysiological Mechanisms. Themes in this category included
mechanisms of pranayama believed to affect depression through psychophysiological processes
or pathways. Here, pranayama induced mind-body changes that participants’ attributed to
reducing their depression.
Theme 3: Energy/Prana Regulation. Nine participants endorsed pranayama as being
an exercise that significantly improved their energy. This theme encapsulated perceived benefits
in the quality, level, flow, and dispersion of energy throughout the mind and body with practice.
Pranayama facilitated positive shifts in energy, vigor, and vitality. Certain participants felt less
heavy and more uplifted after their practice while others described feeling the energy flowing
more easily throughout their body. Six individuals with yoga training conceptualized the source
of this energy as being pranic in nature, while three, non-yogic participants described this shift in
terms of an energetic increase. Two advanced yoga practitioners focused on generating,
harnessing, purifying, and dispersing prana throughout their minds and bodies.
An increased and regulated flow of energy throughout the mind and body helped
participants experience a psychophysiologic state diametrically opposite depression. Increased
energy ameliorated many specific symptoms of major depression, including: depressed mood,
psychomotor retardation, hypersomnia, fatigue, and suicidal ideation. Feeling more alive,
energized, or rejuvenated via pranayama caused change in a healthful direction. Two
participants discussed how their breathing techniques provided them a “jumpstart” during MDEs,
helping them get out of bed and retain some level of daily functioning. Two other participants
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suggested that pranayama helped them protect, conserve, and utilize the energy they already had
from negative people or stressful environments. The following quotes described this theme:
JENNIFER: I mean, I know that it’s only breathing you’re talking about with pranayama
or any breathing exercises, but I feel like it opens space for the energy to flow more in
your body.
SARAH: Without energy, it’s hard to change. From being depressed into not being
depressed or being less depressed, I need energy. That energy comes from breathing.
JOHN: It’s bringing breath back into my body. And bringing breath into my body means
that I want to live again, you know? And the more I breathe, the more I want to live.
KATHLEEN: And then pranayama is introduced at the point where the amount of energy
that is being generated is significant and should be regulated and dispersed effectively
throughout the system. So if asana practice is, let’s say, like the wind turbine or the
water turbine that’s generating all the power, pranayama is the… I don’t know, what do
you call it… the power plant I guess? Where they have all of the different wires going
out in all different directions you know, and it’s the grid. And pranayama is the practice
of regulating how much, and what quality of, and when that energy is dispersed along the
grid.
Theme 4: Oxygenation. Eight participants experienced a significant increase in their
oxygen consumption during pranayama. These participants attributed a diverse array of health
benefits to oxygenation, which included: increased energy, improved blood flow, higher brain
functioning, cellular nourishment, and revitalization. Participants who felt they were inherently
shallow breathers could now intake adequate oxygen. Two participants speculated about
oxygen’s role in calming their nervous system, facilitating a host of systemic physiological
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improvements. These global psychophysiological benefits suggested that oxygenation shared
overlap with other antidepressant experiences including: energy/prana regulation and the
relaxation response). The following quotes illuminated this theme:
JOHN: Every cell in your body becomes alive when you consciously breathe. When I
consciously breathe, my whole… that’s what pranayama breathing is. It actually lights
up every single cell in your body. It gets oxygen to every single cell and that’s what
facilitates healing.
MARY: I think that getting lots of oxygen is probably very beneficial to the brain.
Especially if you have been shallow breathing because you probably haven’t been getting
enough.
HENRY: If I could measure it, I guarantee you it would increase oxygen to my brain and
blood flow to my body and brain. Because you know, I’m used to taking short breaths.
Theme 5: A Foundational Exercise. Seven participants endorsed pranayama as being a
foundational exercise that offset depression. Across these interviews, pranayama was similarly
described as a base, a support, or a core exercise to begin a holistic practice. Correct practice
introduced postural adjustments that immediately counterbalanced the physically depressed state.
Spinal and skeletal structural improvement allowed depressed participants to experience feelings
of uprightness, strength, steadiness, and body awareness. The natural, rhythmic flow of breath
provided participants with a continuous sense of inner stability. The breath supported
participants in cultivating self-reliance, centeredness, and grounding. This theme was deemed
important for its reversing effects on the general depressed state. The following quotes reflected
this theme:
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JENNIFER: I guess at first I just felt like it was a great core exercise almost, like helping
to form posture. But then I realized that learning more about it, I realized that it
definitely… it almost like, alters your state you know?
SARAH: Also, there was an awareness of a deep freely flowing breath as the support. So
the main difference is that whatever I do now, I pay attention to my breathing first.
MARY: I believe that when people are depressed they tend to kind of collapse inward
and all their processes sort of slow down to a certain extent. And when you reverse that
by the breathing, or maybe just by standing up straighter or taking that on, you’re starting
to counteract some of that and help support some of the other direction of being healthier,
of functioning better.
KATHLEEN: It brings a feeling of self-containment that is an empowering self-
containment, rather than an, ‘I’m down in my hole’ kind of self-containment. It’s more
like, ‘I’m bringing myself into this position of alertness and receptivity so that I can begin
the practice and focus inward in a positive way. To heal myself from the inside out,’
right?’ And so, just the very physical act of sitting up in a posture where your spine is
upright, it instills confidence and stability. The stability of the physical body contributes
to the mental stability that you feel. I mean, it’s hard to be frantic in your mind when
your body is stable like this.
Category 3: Psychological Results of Practice. This category encapsulated themes
involving antidepressant effects of pranayama occurring primarily within the mind. Here,
alleviated mental states resulting from the practice were reported, plausibly facilitated through
pranayamic mechanisms of change. Thus, themes in this category captured unique mental states
and psychological experiences that reduced participants’ depression.
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Theme 6: Psychological State Change. Ten participants experienced a marked, positive
change in consciousness using pranayama. Participants variably endorsed increased feelings of:
peacefulness, contentedness, positivity, blissfulness, and courageousness with pranayama. While
the specific psychological benefits were idiosyncratic and diverse across participants, the trend
was always toward feeling “better.” This shift in normal waking consciousness was deemed
important for its ability to move participants away from the depressive pole and more toward
mental health, even if the benefits were temporary. This psychological shift had both immediate
and long-term antidepressant effects on the intensity, frequency, and content of recurrent
depressive thoughts. Participants also experienced decreased emotional reactivity during and
after practice. Of importance, regular practice helped two participants psychologically reframe
tragic events from their past into a more positive light. Pranayama appeared to give these two
individuals a new lens through which to view these difficult events; including a spiritual context.
The following quotes described this theme:
MARY: When I’ve done it, I’ve noticed that it’s kind of a little bit of a state change. You
feel a little bit more alert. You feel more peaceful and calm.
JENNIFER: I realized that it definitely, almost like alters your state, like your state of
mind. Then your thoughts, because it kind of makes you feel more at ease, and kind of
creates this open space around you or in your head.
HENRY: The biggest thing was my Mom. Her passing was probably the biggest thing
that contributed to my depression. And now, with these techniques and being able to
look at life differently… her passing is more like a cure to my depression. I don’t see her
passing as a negative. Even though I miss her, it’s more like… it’s almost like it was
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meant. It was a natural process. And not to turn it into the Ying and Yang type… now
it’s a positive type of thing.
Some of the reported changes in consciousness suggested possibly deeper stages of
psychological functioning beginning to emerge (e.g., contentedness, peacefulness). Of note, four
participants with yogic training stated that pranayama served as a preparation for their
meditation. These endorsements were in line with the classical teachings of yoga, where
pranayama aims to calm the mind to begin turning the senses inward for meditation. The
following quotes illustrated pranayama’s role in facilitating meditation.
SARAH: You know there are these eight limbs of yoga? The Yamas and Niyamas,
which in yoga is ahimsa; non-harming, truthfulness, contentment. All that stuff and
study of the text. So those are like a basic ten commandments of the yogis. Then asana
comes, move your body. For what? To be able to sit still. For what? For pranayama.
Because, then you do pratyahara, turn your senses inward. Because you’re ready to
meditate. Why do you meditate? To become, you know, enlightened or in samhadi. So
that’s why… that is the why.
JOSEPH: But coming to yoga and how we get into the meditative state. Yoga allegedly
is, not allegedly… gets us ready to do meditation. And that’s supposedly what yoga is all
about. The ultimate, to get you in a meditative… to do the meditation.
Theme 7: Clearing the Mind. Nine participants endorsed a mental clearing effect of
pranayama. Pranayama helped these participants ameliorate depression by significantly
reducing, and/or entirely removing depressive psychological experiences, cultivating a clear
headspace. A clearer mind held less of the negative, ruminative thoughts that perpetuated
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depression. Several participants stated that this clearer mindset engendered clarity and level-
headedness, creating a new mind-space by which to make wiser and healthier choices.
Clearing depressive psychological material appeared to have a lightening effect on
participants. Feeling more energized was an effect of not being weighed down by heavy,
depressive thoughts. One participant postulated that increased oxygen facilitated this mental
clearing. Focused attention on the breath was another plausible pranayamic mechanism creating
a clearer mind. This theme shared overlap with other psychological results of practice including:
reduced negative thoughts and mindfulness cultivation. The quotes below described this theme:
ANDREW: I think that it clears my mind more. It definitely makes me become more
focused on my day. I feel better after I do the deep breathing in the morning because I
sometimes can make up stuff in my head… sort of like a tornado of activity, and it helps
that. This might sound weird, but that tornado to just calm down and focus on one thing
at a time.
JENNIFER: And then it felt like it sort of cleared your mind a little bit. Kind of like,
lifted you know? Like if you felt sort of foggy or tired before. I guess clear after getting
more oxygen into you helps with that, on that base level. But it definitely makes you feel
like it clears something in your mind. It’s hard to differentiate sometimes, but I think it’s
definitely mental in the way it feels like it clears your mind. It’s mental in that sense.
ANN: I feel like it kind of helps me to put some mental space around myself and
whatever situation is happening that’s causing the anxiety. And that space of calmness
and diminished anxiety helps me to generally think more clearly about the situation. So,
it’s kind of a space or an opportunity to shift my perspective or to consider what other
perspectives might be there if this is something maybe I can’t control. Or, what is it
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about this situation that is causing the anxiety? Is there something that can change? So,
that diminished anxiety or diminished sort of emotional intensity I think helps me to think
a little bit more clearly too, about what kind of attitude or perspective I should adopt and
whether or not maybe I need to take some action.
JOSEPH: It gets my head clear. It gets all that junk out of your head to where you’re
more or less in a meditative state, rather than a thinking state.
Theme 8: Reduced Negative Thoughts. Eight participants discussed a reduction in
negative or depressive thoughts resulting from pranayama. Experiencing fewer negative
thoughts provided a therapeutic respite from the weighted, ruminating mind that often propelled
clinical depression. Focused attention on the breath emerged as a salient mechanism to explain
how negative thoughts were reduced. For certain participants, pranayama also shifted the
content of their thoughts toward a more positive quality. This finding shared overlap with all
psychological results of practice themes, which counteracted depression synergistically. The
following quotes described this theme:
SARAH: I would say that probably the most significant change is the way I think today
and the way I used to think. When I used to think before, I would slip into negative
thinking very easily. I would dwell there with a lot of rehashing and analyzing and
contentment was missing. My mind was running into circles. And it was staying in a
very frontal mind in comparing, in judging, and in also not really being in that spiritual
dimension where the brain shifts more back, and then we are also aware of things which
are not that personal. So I was a lot in self-pity. I wasn’t looking inward from this divine
dimension.
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HENRY: Because you’re distracted a lot and all these negative thoughts come in your
head and… I’m not suicidal or anything like that, but more like negative thoughts, like
drama. I was never to that point luckily. And just like I said, just more positive thoughts
come into your head and everything. And they just, almost like a filtering system, get rid
of all the negative activity. And you feel almost like your mind and body just like (deep
relieved exhale). To be in this state of like, okay, now we can go on with our day type of
thing.
JENNIFER: It gets rid of those depressive thoughts, at least for the time being. And then
going into yoga after that leaves you with that calm feeling for longer I think.
Theme 9: Mindfulness Cultivation. Eight participants variably endorsed core elements
of mindfulness resulting from pranayama. Mindfulness was operationally defined as “the
awareness that arises by paying attention on purpose, in the present moment, and non-
judgmentally” (Kabat-Zinn, 2013, p. xxxv).
Regarding this theme, increased awareness emerged as the most salient effect of
pranayama reducing depression, a finding endorsed by seven participants. Participants
experienced awareness in a variety of ways, beginning with simple breath awareness, to having a
heightened understanding of what it means to be human. With this awareness, these participants
gleaned new insight into their depression allowing for more informed choices, healthier
approaches, and expanded self-insight. Certain participants used self-awareness to hone their
breathing practice while others learned new ways to view their condition and manage depression.
The following quotes described increased awareness:
ANN: The better solution is to find something I can do on a daily basis as maintenance,
so that I can manage that initial kind of trigger period. And to be aware of the fact that
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during periods of high stress or high transitions that I’m more likely to experience
depression.
KATHLEEN: And it’s like, you break it down into pieces and you work on one piece at a
time, bringing your awareness to each and every piece. But at a certain point, you know,
to each component of the breath. To exercise inhalation, or exhalation, or retention. But
we have to keep the goal in mind, which is to bring it back into a holistic experience that
involves every aspect of your embodiment. Body, mind, breath, senses, emotions…
awareness.
Six participants experienced presence with pranayama. Pranayama immersed these
individuals in the present moment, where maladaptive psychological patterns of dwelling in the
past or future dissolved in the now. Becoming more present had both antidepressant and
anxiolytic effects for participants. The following quotes reflected presence cultivated through
pranayama:
JOHN: When I do it, I get thrown into the moment you know? I’m pulling myself out of
any… cuz’ my addiction to regretting the past, and my addiction to future trippin’ is
powerful. I’ve lived most of my life that way. You know, future trippin,’ which creates
anxiety. And regretting the past, which creates despair and depression… and anxiety too.
SARAH: The breath brings us into the present moment. And when I was depressed, I
was depressed more about my future. Some people who are depressed are more
depressed of the past.
Three participants described a metacognitive experience of decentering with pranayama.
Pranayama helped these individuals mindfully disengage from the depressive thoughts or
feelings arising in their mind. In this state, negative psychological experiences were observed,
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accepted, and allowed to pass without identification, attachment, analysis, or judgment.
Decentering with mindfulness was illustrated by the following quotes:
ANN: The type of meditative breathing that I learned teaches you not so much to empty
your mind of thoughts, or try to force yourself not to be thinking about anything, but
rather just sort of let thoughts come up and then return your focus back to your breathing.
JULIE: If I’m gonna’ start crying or whatever it is, if I focus and take some of the yoga
breaths… some deep breaths and focus, it will pass. And it passes quickly. I won’t get
caught up in it. I won’t get stuck in it. It won’t accelerate. I can reel it back in. Now, it
might surface again in an hour or two, or it might get triggered by something else, but in
that moment you can control it.
Two advanced yoga practitioners used pranayama to cultivate equanimity. Equanimity, a
quality of mindfulness, and was defined as “an even-minded mental state or dispositional
tendency toward all experiences or objects, regardless of their origin or their affective valence”
(Desbordes et al., 2014, p. 1). The following quotes illustrated this aspired to state of
equanimity:
SARAH: I would start to focus to empty first. Then I will probably do inhale and exhale
equally long to establish equanimity of the mind. No forcing. I would not use any
specific technique. I will focus on the ratio. Do you understand what that means, the
difference between ratios? Which is, let’s say inhale eight, exhale eight.
KATHLEEN: So rather than saying ‘oh, because I do a pranayama practice so therefore
my feelings of sadness are reduced or my feelings of happiness are increased throughout
the day,’ like, I wouldn’t go that far and even say that. I would say that it just gives me
an experience of pure being where I know that a state of peacefulness is possible. Where
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a state of equanimity is possible. So that even though the dualities of pleasure and pain
may exist in my mind, in the monkey mind, or in my body, or just throughout the day as I
go about dealing with some bullshit or whatever. It’s like those feelings, those emotions
are still there, but there is a river of peace and tranquility and understanding that runs
underneath all of that. And so just knowing that that is there, and that I can return to that.
That is how it… the practice, reduces depression for me.
Lastly, two participants described nonjudgmental acceptance resulting from pranayama.
The following quotes reflected this finding:
ANN: The meditation and meditative breathing works so closely and so much of that
practice is about acceptance.
HENRY: You know, everything’s all conjunctive and that you just have to accept it. And
all the baggage comes… and once you accept it… once you accept it you just let all the
baggage roll off your shoulders. On an emotional level, I guess being less judgmental of
myself. Being less guilty of all the mistakes that I did. If I did them, they happened and
you gotta let em’ go. You can’t just cling to the past. With the breathing I’m able to put
things in context better. I don’t know if it’s because I have more oxygen or more energy
in my brain or whatever, more blood flow probably.
Theme 10: Unity/Oneness. Six participants endorsed feelings of unity or oneness
resulting from practice. Pranayama helped these participants feel more connected to themselves,
others, and their surroundings. Of special importance, two participants highlighted that
pranayama helped them manage loneliness, a significant contributor to their depression. This
theme often included a deep spiritual element where certain participants felt more a part of the
“whole,” “a bigger picture,” or the universe. These experiences had significant antidepressant
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effects for endorsers, as feeling more interpersonal and universal belongingness reduced both
situational and existential loneliness, respectively. A deeper sense of connectedness allowed five
participants to feel as though they were part of the whole and helped three individuals integrate
and find meaning in difficult events in their lives. Reframing difficult events within a bigger
picture cultivated: belongingness, meaning, a sense of oneness, acceptance, and resilience. The
following quotes elucidated this theme:
JOHN: The more I practice the breathing, the more I’m actually able to get a hold of that
picture. To actually be able to see that more and more and more. Like, the more I
practice breathing, the more it’s less like I just described as far as not being able to see
the bigger picture and not seeing all that, and the more I do see what that is and know
what to do on it.
HENRY: In terms of the way I view life, this technique has really helped me feel like I’m
part of something bigger, without getting all, you know, philosophical. But more like,
we’re so used to feeling separate from everything else, like ourselves or the surroundings
and stuff. Now I feel like I’m part of everything you know? Like I said, you’re almost in
a field instead of a particle, like physicists talk about electrons and stuff like particles and
things. They’re all separate from each other. And I feel like I’m… even though I look
like one, I’m part of something greater, like a field you know?
JOSEPH: I’d say it’s really helped loneliness. Helped me through periods of loneliness.
And it really doesn’t happen that much anymore. It used to be constant. But if I’m in the
apartment and for some reason I haven’t been active for a day or two, I’ll start feeling a
little bit lonely. And what I’ve been doing lately is getting down on the floor and just
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doing some very basic positions and breathing. And my ratio is 10-0-10-0. That’s the
one I like to work with.
KATHLEEN: If you feel divinely connected to the air that you breathe, to the energy that
runs through your body, and to your own physical manifestation of that energy that you
come into contact with through the practice… or that you become aware of through the
practice… that reduces the despair of loneliness that humans are apt to feel.
Category 4: Psychophysiological Results of Practice. Themes in this category
encapsulated psychophysiological effects of pranayama that helped participants reduce
depression. This category captured antidepressant experiences occurring within the mind and
body simultaneously.
Theme 11: Relaxation Response. Ten participants reported that pranayama relieved
their depression by inducing relaxation. Relaxation was experienced mentally and physically,
often concurrently and bidirectionally. Five participants reported that pranayama helped calm an
anxious, distressed mind during MDEs and remissions. Certain participants described their
depressive mind-space as feeling “frantic,” “helpless,” “tornado-like,” or “overloaded.”
Pranayama helped quiet, allay, and rebalance an emotionally reactive, depressed mind. Three
participants described how intentionally slowing the breath slowed their racing mind. One
participant found that by taking the time to include pranayama in his busy schedule, it
experientially added more time to his day. The following quotes showed how mental relaxation
eased depression:
JULIE: When I’m breathing, I’m breathing and concentrating on emotional things and
feeling better and slowing my emotions down. And with my breath, if I’m slowing my
breath down, it tends to slow my emotions down too. The racing feeling slows down.
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ANDREW: Would I say that breathing has helped me 100 percent? I would not say one
hundred, but it helps me definitely calm that tornado activity in my mind down.
HENRY: By taking time to do this, it would add time in my day, so it would be like,
actually more beneficial. Instead of taking time away from your day, which is probably
the reason a lot of people don’t do this, it would actually add time to your day. It slows
everything down, instead of you being in a rush to do everything.
Relaxation also helped participants reduce physical symptoms of depression, especially
psychomotor agitation. Three participants described the soothing, physical response of their
body during pranayama as either: “melting,” “dropping,” or “softening.” Moreover, awareness
could remain intact or even sharpened during stages of deep relaxation. One participant
identified somatic anxiety as being an especially powerful trigger for MDEs, and relaxation
became an effective technique to manage depression. The following quotes illustrated physical
relaxation that reduced depression:
JOSEPH: When I’m breathing properly, it’s a whole different outlook. I mean, my whole
body is just relaxed. I just know from feeling it. You can just feel the… what’s the
term? Your body just kind of… softens. That’s what I’m trying to say. It just softens.
ANN: It calms me. So that if I am feeling physically very agitated, that I think it helps to
release some of that physical tension. And absolutely it calms my mental agitation if I’m
upset. It’s soothing. And I feel like it kind of helps me to put some mental space around
myself and whatever situation is happening that’s causing the anxiety. And that space of
calmness and diminished anxiety helps me.
Theme 12: A Mind/Body Connection. Seven participants experienced mind-body
connectedness using pranayama. A holistic, mind-body union helped participants withdraw from
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their depressed headspace, experience embodiment, and cultivate mindfulness. Three
participants stated that pranayama helped them connect to their heart center, which instilled a
deeper sense of self and spirituality. One advanced yoga practitioner highlighted the breath as
being the bridge that unites inner and external realms. This participant viewed pranayama as the
medium through which to begin the inward journey of self-realization. Overall, pranayama
appeared to rebalance and reintegrate the mind and body toward a healthier, more harmonized
state of being. Much like the earlier theme of unity/oneness, this finding was symbolic of yoga’s
underlying aim of union. This theme also shared overlap with mindfulness cultivation. The
following quotes described this theme:
SARAH: I think pranayama brought me the aspect of purification of the perception, and
also connecting my mind, and my body, and my heart. So, to make me more whole as a
person.
KATHLEEN: Pranayama is the gateway between the external and the internal quest.
Asana is considered external, because it’s dealing with your physical body. Right? Your
Prakṛti, your nature, rather than your Purusha or everlasting consciousness. And
pranayama bridges the nature and the consciousness. It brings them together in one
practice.
JOHN: We’re becoming aliens. We’re alienating ourselves from our selves, from our
heart centers. We’re alienated. We’re alienating ourselves from our selves, you know?
So breathing actually brings you back. See, breathing brings you back into your body.
And head trippin’ and all this thought stuff is all about escaping from reality and escaping
from your body.
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Category 5: Physiological Results of Practice. This category encompassed
physiological effects of pranayama ascribed to reducing depression. Here, participants described
primarily physical or biochemical experiences resulting from practice that alleviated their
depression.
Theme 13: Physiological Benefits. Eight participants endorsed physiological effects of
pranayama that reduced depression. These benefits were diverse, and likely reflected the unique
background, training, and experience of each individual. The physiological effects of practice
ranged from simple postural improvements, to speculation regarding the complex neurochemical
mechanisms underlying depression. These experiences were either endorsed or opined across
qualitative interviews, and included: neurochemical regulation (e.g., cortisol, opiates,
endorphins, adrenaline), lowered heart rate, improved lung functioning, nervous system
rebalancing, corrected posture, and neurocognitive reprogramming. Of relevance, three
participants discussed improved sleep with regular pranayama. Improved lung functioning
allowed shallow breathers to optimize their oxygenation, which increased energy. The following
quotes illustrated this theme:
KATHLEEN: And even just the observation of the breath can lead to a profound
relaxation of the nervous system. And so that facilitates the ability to sleep better, just
right off the bat, without even beginning to regulate the breath in any way. Okay, so
there’s that right? It can take the edge off this hyper-aware, hyper-alertness for one thing,
because the nerves get a chance to relax.
JULIE: If my heart’s racing, the deep breathing slows your heart rate down. The same
with the emotional. If I’m going to cry, I mean, these are all physical reactions that I’m
having due to my depression. But with the breathing I can control them or it just stops. I
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mean, the overwhelming feeling to cry will pass. If you do the breathing long enough
your heart rate comes down.
JOHN: I’m thinking what the breathing does is, if it just short-circuits that thought
process and stuff that’s going on inside of me. At the bare minimum I’m not creating any
more of those stress hormones on a biochemistry level.
Category 6: Practice Attitudes and New Insights. Themes in this category
encapsulated new ideas, understandings, and beliefs emerging from the practice that helped
participants reduce depression. Here, participants relayed information about how they thought
pranayama helped them recover from depression, and offered insight and advice about its healing
properties.
Theme 14: Regular Practice. Ten participants discussed the importance of regular
pranayama for managing depression. As with any exercise, the benefits of pranayama increased
with correct, consistent practice. Most participants endorsed progressive gains occurring with
routine use. Practice improved posture and facilitated focus on the breath. Pranayama also
became viewed as an activity to be integrated into daily living. Two participants viewed the
breath as being something that became part of them. Of note, all but one participant discussed
pranayama helping cumulatively reduce depression. This theme included all the perseverance,
highs, lows, and working through that accompanies any disciplined practice. The following
quotes elucidated this theme:
SARAH: As we practice, it’s almost like finding the road. Almost being blind, because
the more you take the road, your car almost goes there automatically. So pranayama is
like that.
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ANN: I’ve really seen the benefits of it. And so then if a few days go by that I don’t do
it, I can tell. I can feel the anxiety level just changes. It’s a lot harder for me to just sort
of manage it. So I really have noticed a huge benefit from it. It’s my hope, my intention
is that it will become kinda’ part of my long-term arsenal against my depression. Cause
obviously nobody wants to feel that way forever.
KATHLEEN: It’s the steady, long, alertness. Steady, long, alert practice over a long
period of time with devotion brings the benefits you’re looking for.
JOHN: Once I’ve really sat down and started to practice, there is a period where you
might have to go through a hump of inner-resistance. Where there’s a kind of inner-
resistance sometimes because it’s so simple. Breathing, you know?
Theme 15: Adopting an Integrative Approach. At the conclusion of each interview,
participants were asked what advice they might give to someone struggling with depression. The
most significant finding to emerge from this inquiry included seven participants who advocated
an integrative approach to health. Pranayama was viewed as a valuable technique among many
effective interventions for depression that included: psychotherapy, antidepressant medication,
family and social support, CAM treatments, exercise, and other healing activities. Participants
recommended searching for and trying new things that fostered health on holistic levels. This
theme encapsulated an open-minded, proactive, integrative, and individualized approach to
health. Two advanced yoga practitioners emphasized the role of pranayama in the classical yoga
system. Here, pranayama was regarded as a fundamental step towards higher stages of yogic
advancement, and not something to be fractured, separated, and practiced apart from the whole
philosophy. The following quotes reflected this theme:
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ANN: I think tackling depression from lots of different treatments. I think there’s ways
to find a solution that works for everybody’s life, and that it’s going to look different for
everybody. The best thing to do is to be proactive about it and say, ‘okay, well, I’m
going to keep trying things until I find things that work, and when I find something that
works, that’s going to go into my toolkit.’
HENRY: Get as much information and try different techniques and whatever one works
for you, that you feel is actually making a healthy change in your life, and stick with it.
Because in the long run, it’s actually gonna’ add years to your life.
JOSEPH: It has been a combination of yoga, family, friends… you know? It’s
everything together that’s really helped.
Additional Finding #1: Unknown Mechanisms. Four participants indicated that certain
antidepressant mechanisms of pranayama remained elusive or mysterious to them. In one case,
this unknown factor referred to metaphysical mechanisms, while three other participants simply
did not know the medical and technical reasons why pranayama improved their depression. The
following quotes illustrated this theme:
JOSEPH: As far as all the technical stuff that goes on, I don’t really know. From a
medical point of view, I don’t know. I don’t know what’s happening when you do this
and you do that. But I just know from feeling it.
MARY: Maybe, even just to practice that rhythmic breathing just kind of makes some
shift that I’m not aware of what’s going on. That’s my guess. I don’t know.
JENNIFER: I don’t want to say it’s like a different realm of course, because it’s not
really. It’s like realms that are unaware. I mean, that humans on the whole are unaware
of because they just don’t pay attention, you know?
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Additional Finding #2: Releasing of Negative (and/or Repressed) Emotions.
Pranayama helped four participants release negative emotions. The releasing of deep-seated
(and sometimes repressed) negative emotions and experiences had a cathartic, detoxifying, and
rebalancing effect on the mind. This emotional purging helped these participants process their
negative psychological material to begin a new, healthier journey forward. The following quotes
illustrated this finding:
SARAH: I would start by elongating my exhale as to empty myself, of myself, and also
of my past. And of my past resentment or even of my past ideas and the way I perceive
my own misery, because even that, it’s so personal. By allowing myself to empty this
breath through extended exhale, I will also be in line with the great teachings of yoga; of
Patanjali’s own pranayama.
JOHN: More than anything, the breathwork also just brought up all kinds of unresolved
and unexpressed emotions of rage, and anger, and grief, and pain, and distress, and
anxiety, and stuff like that. So moving through that is what… well, that’s what that
breathwork does. It facilitates moving through all that stuff. And one of the ones of that
is also depression. And depression actually, from my studies, has been one of the harder
ones, that actually seems to be one of the more lingering ones that takes persistence.
ANDREW: I have a feeling that people who don’t breathe and hold all that anxiety and
stress in are the ones that die of cancer. Are the ones that die of loneliness. I think
they’re just dying inside.
Additional Finding #3: Chakra/Meridian Balancing. Three participants described
pranayama affecting metaphysical facets of their being. These individuals discussed pranayama
helping them rebalance and regulate their chakras and/or meridian system, facilitating an optimal
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flow of prana throughout their mind and body to promote wellness. The following quotes
reflected this theme:
SARAH: If you know about the chakras, they will be spinning so quickly. So let’s say if
I had to go for a minimal trip, I became also so afraid and nervous of flying actually that I
would feel the stomach pain. So now with the breathing, for digestion, and for
depression, I can access… and I have been doing it for years, whatever particular aspect
there is.
JENNIFER: When you think of the meridian lines of energy, like your chakras right? I
guess with like, acupuncture you know? I mean, I know that it’s only breathing your
talking about with pranayama or any breathing exercises, but I feel like it opens space for
the energy to flow more in your body.
Additional Finding #4: Using Breathing with Visualization. Three participants
incorporated visualization into their breathing practice. These participants added visualization to
supplement or personalize their breathing experience. Visualization was learned and practiced in
a meditation group, yoga classes, and psychotherapeutic biofeedback sessions. Breathing with
visualization helped these participants concentrate on specific areas they felt needed extra help
while cultivating a unique healing experience. The following quotes illustrated this theme:
ANDREW: I usually put some new age music on and then I close my eyes and then I take
a couple deep breaths and then kind of do the Om afterwards. And I visualize a golden
ball of light that starts at the top of your head, and then I breathe out and then in, and it
goes through all your chakras, the middle of your back, your tailbone, down through the
back of your legs, and then out of your feet, and then just imagine that gold light I always
imagine. Sometimes I see my Father’s blue eyes, cuz’ I was very close to my Dad.
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JULIE: When you’re doing your yoga practice and they say breathe into the areas that
you need… so it’s just a different way of applying it. Instead of applying it to a body
part, I apply it more to my thoughts or my feelings.
Additional Finding #5: Outlying Experiences. This theme captured outlying
experiences endorsed by participants. One participant increased self-compassion with
pranayama and another experienced gratitude. Although lesser endorsed, these unique
experiences did contribute information into the phenomenon under investigation. The following
quotes described this theme:
ANN: I think it also has helped develop a lot more compassion for myself, and kind of
what’s happening around me.
ANDREW: You’re almost thankful that you made it through another night. You woke
up and it’s like your rebirth, and to be thankful for the day. I would not say I’m like this
everyday; I’m not into pink cloud metaphysics where you know everything is wonderful
all the time. But I know that it definitely helps me, and I breathe.
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CHAPTER V
Discussion
This qualitative study explored the experiences of 10 adult participants who reduced
clinical depression using pranayama, with a concentration on discovering mechanisms of change.
The primary researcher conducted an in-person, semi-structured interview with each participant
to uncover the experiential, antidepressant qualities of pranayama. Qualitative data analysis
revealed fifteen themes, which fell into six categories. There were five additional findings that
did not meet the research criteria to be considered emergent themes, yet still provided valuable
information relevant to this phenomenon.
First, this chapter integrated results from the present study with earlier theory and
research. It then reviewed categories and themes, followed by a discussion of the clinical
implications of these findings. Next, the study addressed limitations and suggestions for future
research. Final remarks concluded this chapter.
Integration with Previous Theory and Research
To our knowledge, this was the first intensive qualitative study that investigated the
experiences of adult participants who reduced unipolar depression with pranayama. The results
found that all 10 participants endorsed antidepressant change occurring through multiple, holistic
experiences via pranayama. Thus, this study uncovered pranayamic mechanisms, synergistic
mind-body experiences, and new insights and behaviors underlying antidepressant change;
plausibly rooted in parasympathetic nervous system dominance.
With regular pranayama, most participants experienced: focused attention, a sense of
control, increased energy, oxygenation, positive psychological shifting, a clearer mind, reduced
negative thoughts, mindfulness, global physiological benefits, and relaxation (see Table 2).
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Lesser-endorsed themes included: feelings of unity/oneness and mind-body connectedness. In
synergy, these experiences reduced depression while cultivating holistic health. Consistent
practice also helped participants develop new insights and healthier behavioral approaches that
counteracted their depression. Five additional findings contributed to wellness and were
discussed in a later section of this chapter.
This study adopted a thematic approach, where all data was “taken holistically and
rearranged under themes which emerge as running through it’s totality” (Holliday, 2002, p. 103).
This approach organized categories as falling into one of four overarching classifications that
included: mechanisms of change, results of practice, new insights, and additional findings (see
Table 2). This research then categorized emergent, holistic themes based upon the predominant
psychological, psychophysiological, or physiological qualities of the experience(s). Thus,
categories and themes attempted to illustrate how specific pranayamic mechanisms generated
antidepressant experiences (e.g., mental, physical, emotional, or spiritual), which created
healthier thoughts, feelings, behaviors, and approaches toward living.
Of significance, this study captured a cluster of five themes categorized under psychological
results of practice. These primarily psychological experiences counteracted depression by:
positively shifting consciousness, clearing the mind, reducing negative thoughts, cultivating
mindfulness, and creating feelings of unity/oneness (see themes: 6-10). This meaningful cluster
suggested that pranayama impacted depression through unique mental pathways, positively
influencing the depressed mind. This finding supported data from two systematic reviews
examining yoga for depression (Cramer et al., 2013; Pilkington et al., 2005). Pilkington et al.
(2005; 2006) noted that yogic breathing played an important role in four of the five RCTs
reviewed. Cramer et al.’s (2013) systematic review and meta-analysis of 12 RCTs found
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meditation- and breathing-based yogic interventions particularly effective for depression. A
subgroup analysis found that meditation- and breathing-based yogic interventions had limited
short-term efficacy for depression severity; a finding not shown for complex- and exercise-based
yoga.
Reduced negative thoughts emerged as a salient theme, a finding relevant for depressed
populations. A review of five qualitative studies exploring yoga incorporating pranayama for
populations with: HIV/AIDS (Brazier et al., 2006), adolescent sex offenders (Derezotes, 2000),
breast cancer survivors (Galantino et al., 2012), healthy volunteers (Kjellgren et al., 2007), and
chronic pain (Tul et al., 2011) revealed less emphasis on reduced negative thoughts. In the
present study, pranayama appeared especially effective at disrupting depressive thought patterns
and reducing ruminations that perpetuated depression.
Of relevance, Kinser, Bourguignon, Whaley, and Taylor (2013) conducted a RCT using a
sample of 27 women diagnosed with MDD or dysthymia to compare the efficacy of Hatha Yoga
against attention control training. After random assignment, participants practiced either Hatha
yoga or attention-control training in weekly group sessions with routine homework for 8-weeks.
The results found that both treatment conditions significantly reduced depression, whereas only
the yoga group decreased rumination as measured by the Ruminative Responses Scale (RRS).
Decreased rumination found only among the yogic group could “provide insight into one
possible mechanism for yoga’s effect on depression” (p. 145). When integrated with the present
study, this data highlighted reduced negative thoughts as an important mechanism of change by
which yogic breathing affects depression.
Although limited, the theoretical research on pranayama has suggested complex
mechanisms, multiple pathways, and bidirectional processes underlying psychological effects
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(Brown & Gerbarg, 2005a; Jerath et al., 2006; Ley, 1999; Schulte & Abhyanker, 1979; Sovik,
2000). The present study supported this scientific consensus as all 10 participants endorsed
antidepressant change occurring through an interactive organization of mind-body experiences.
Qualitative data analysis revealed fifteen emergent, holistic themes generally consistent
with the eight proposals of the neurophysiologic model; particularly effects of autonomic
nervous system (ANS) and stress response stabilization and rebalance (Brown & Gerbarg,
2005a). Thus, it seemed plausible that many of the benefits experienced amongst our sample
resulted from an ANS shift toward parasympathetic dominance with pranayama (Brown &
Gerbarg, 2005a; Jerath et al., 2006). Specific themes, including: a psychological state shift,
mindfulness cultivation, and the relaxation response likely reflected a reduced sympathetic
response (i.e., fight or flight) and activated parasympathetic dominance (i.e., rest and digest).
Reduced negative thoughts could correlate with quieted cortical areas during pranayama,
decreasing ruminations of anticipation and worry (Brown & Gerbarg, 2005a). The
neurophysiological model proposed an ANS parasympathetic dominant shift occurring through
vagal stimulation by way of a plexus of mechanisms located primarily within the brain and
respiratory system. Vagal effects were hypothesized to elicit feelings of physical and emotional
calming. Of relevance, all participants in the present study experienced relaxation with
pranayama.
Four participants speculated about complex neurophysiological mechanisms underlying
their depression and recovery with pranayama. However, each individual expressed uncertainty
about specifics. Two participants endorsed a shift toward parasympathetic dominance while
another implicated reduced cortisol; both mechanisms playing an important role in the
hypotheses of the neurophysiologic model.
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The neurophysiologic model was based on SKY, the most applied and empirically
supported yogic intervention for depressive disorders. And while no participant in our sample
undertook this pranayama-based program, certain individuals reported feelings of connectedness,
belongingness, and wellbeing (see theme 11: unity/connectedness). The neurophysiologic model
proposed that increased levels of prolactin and oxytocin create feelings of calmness and social
bonding. According to Brown and Gerbarg (2005a), an increased release of prolactin and
oxytocin could account for enhanced feelings of “closeness, bonding, attachment, belonging, and
well-being that many people experience during and after SKY courses” (p. 198). It is interesting
that three participants who endorsed unity/connectedness with their yogic breathing had
practiced ujjayi and Om chanting, both components of the SKY program. Thus, it remained
plausible that complex biochemical processes regulated some of the antidepressant benefits
reported amongst the present sample.
Although no participant in our study discussed brainwave alteration occurring via
pranayama, many reported experiences that mirrored the scientific literature on this topic. For
example, Kumar and Joshi (2009) found that 40 college students who practiced 40 days of
Pranakarshan pranayama altered alpha rhythm activity as assessed by EEG. Healthy alpha
rhythm activity often coincides with subjective experiences of calmness, alertness, and acuity. In
our sample, participants often endorsed feelings of relaxation and mindfulness during
pranayama. Moreover, all 10 participants experienced a positive, restorative shift in
consciousness using pranayama, with some reporting increased peacefulness. Vialatte et al.
(2009) found that seven participants undertaking Bhramari Pranayama twice daily for 31-34
days evidenced increased theta range as measured by EEG and reported subjective feelings of
peacefulness during the exercise. Various studies have documented brainwave alteration among
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participants using different pranayamas, which remained a plausible antidepressant mediator
(Bhatia et al., 2003; Kamei et al., 2001; Sulekha et al., 2006).
Findings from the present study were also consistent with two mixed-method studies that
explored the experiences of SKY practitioners (Brazier et al., 2006; Kjellgren et al., 2007).
Brazier et al. (2006) conducted post-study qualitative interviews with 14 adult participants
having HIV or AIDS who undertook the SKY program. Emergent themes from this research
included: a new way of living, increased self-awareness, living more mindfully, a greater
capacity for acceptance, and learning mind-body awareness. Using post-treatment qualitative
data collection, Kjellgren et al. (2007) found that after six weeks of regular SKY practice,
healthy adult practitioners reported experiences of: peace, optimism, balance, joy, emotional
control, energy, and calmness. Although these two studies did not specifically investigate yogic
breathing for depressive disorders, certain findings overlapped, and could easily be integrated
with emergent themes of the present study (e.g., mindfulness cultivation, relaxation response,
etc.). Findings from this mixed-method research integrated with the present study might
highlight generalized experiences occurring with pranayama across diverse populations (e.g., a
transferability of pranayama, relaxation).
Discussion of Categories and Themes
A thematic approach elucidated how emergent, holistic themes counteracted depression.
Experiences with pranayama occurring in one theme often altered states or qualities of other
themes, sometimes bidirectionally. For example, focused attention on the breath almost always
induced a relaxation response, which made it easier to maintain concentration on the yogic
breathing. As focused attention and relaxation progressed, a participant might experience
mindfulness, clear-headedness, or other thematic experiences, and vice versa. This study
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prioritized specific themes based upon relevance and prominence, which were reviewed below
(see Table 2).
Mechanisms of Change. This study identified five pranayamic mechanisms stimulating
antidepressant change that included: focused and/or refocused attention, a sense of control,
energy/prana regulation, oxygenation, and a foundational element. Qualitative data analysis
deemed these themes mechanistic for the catalytic role they played in generating further
antidepressant experiences.
As highlighted by Sovik (2000), “the ability to observe the flow of breathing underlies all
other aspects of breath training” (p. 496). In choosing to focus attention on breathing, whether in
formal practice or during stressful situations, each participant cultivated an inward, conscious,
self-connected experience characterized by breath awareness. In becoming aware of, and
continually redirecting attention to the breath, participants could gradually become more
grounded, centered, and poised to create a vast array of mind-body experiences that offset
depression. Thus, focused and/or refocused attention on the breath emerged as a mainspring of
change endorsed by all participants.
The focused/refocused attention theme supported the cognitive-physiological hypothesis
proposed by Franzblau et al. (2008) and attentional control training as outlined by Segal et al.
(2002). In both theories, focused attention on the breath had an effect of bringing awareness to
the mind and body, while simultaneously reducing ruminative thoughts that drove depression.
Research has shown that attentional control training can help individuals recovering from MDD
reduce clinical relapses (Teasdale, Segal, & Williams, 1994; Teasdale et al., 2000). MBCT is
specifically designed for individuals in remitted stages of depression, emphasizing that the
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attention could be too impaired during a MDE to be effectively implemented, possibly
suggesting a prophylactic quality of voluntarily controlled breathing.
Pranayama provided participants in this study with a sense of control. This theme
encapsulated experiences of self-confidence, self-control, and self-empowerment in possessing
skills to manage depression as it arose in the present. Research has suggested that a distinct
advantage of pranayama is that it is a transferable skill, applicable across different environments
(Galantino et al., 2012; Sovik, 2000). Of relevance, participants in all five reviewed qualitative
yogic studies used pranayama outside of yoga classes as needed (Brazier et al., 2006; Derezotes,
2000; Galantino et al., 2012; Kjellgren et al., 2007; Tul et al., 2011). In a qualitative exploration
of 10 breast cancer survivors (BCS) who had undertaken an 8-week yoga program, Galantino et
al. (2012) reported a theme entitled Transferability of Yoga: Importance of Breathing. This
theme encapsulated the central importance of breathing in the yogic practice, and its
transferability to stressful situations. The available literature and present findings underscored
the foundational and transferable nature of yogic breathing, significant and possibly generalized
themes.
Most participants reported that pranayama increased their energy and oxygen. Some
individuals ascribed improvements in their energy, vigor, and mental functioning to oxygenation;
psychophysiological benefits that directly offset depressive symptoms. Thus, the energizing and
oxygenating mechanisms appeared to share a close relationship. These interrelated themes
positively stimulated participants from their depressed state, alleviating symptoms while
facilitating additional antidepressant experiences.
Results of Practice. The present study uncovered eight themes encapsulating
experiential effects of pranayama that reduced depression; five of which fell under the study’s
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largest category: psychological results of practice. This important category included the themes:
a psychological state changes, clearing the mind, reduced negative thoughts, mindfulness
cultivation, and feelings of unity/oneness (see Table 2). This finding suggested that pranayama
ameliorated depression via mental pathways, counteracting negative psychological events and
creating healthful mental experiences.
Of importance, all participants endorsed a positive psychological state shift with
pranayama (e.g., increased positivity, contentedness, feeling “good”); a finding reported in two
mixed-methods studies exploring the experiences of participants undertaking pranayama
(Kjellgren et al., 2007; Tul et al., 2011). A clearer mind provided relief from the negative
psychological symptoms of depression, while creating a space for healthier thoughts, feelings,
and beliefs to thrive, and possibly guide behavior.
This study deemed reduced negative thoughts a significant theme, a qualitative finding
less reported among: patients with HIV/AIDS (Brazier et al., 2006), adolescent sex offenders
(Derezotes, 2000), breast cancer survivors (Galantino et al., 2012), healthy populations
(Kjellgren et al., 2007) and individuals with chronic pain (Tul et al., 2011) undertaking yogic
breathing. Reduced negative thoughts with pranayama was also largely underrepresented in the
scientific yogic literature, except for Franzblau’s (2008) cognitive-physiological hypothesis.
This finding could represent an experiential difference between healthy populations, medical
patients, adolescent sex offenders, and individuals with unipolar depression using pranayama.
Having fewer negative thoughts facilitated further antidepressant experiences (e.g., a
psychological state shift, clearing the mind, mindfulness cultivation).
Mindfulness resulting from pranayama encapsulated experiences of: increased awareness,
presence, decentering, equanimity, and nonjudgmental acceptance. Mindfulness counteracted
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symptoms of depression by helping participants become more aware of their thoughts, feelings,
and body sensations in the present moment. Experiencing presence helped participants remain
conscious in the here and now, which prevented maladaptive cognitive patterns of dwelling in
the past (e.g., regret) or future (e.g., worry). Two mixed-methods studies exploring the
experiences of patients using yogic breathing reported mindfulness, including populations with
HIV or AIDS (Brazier et al., 2006) and chronic pain (Tul et al., 2011). Theoretical research
overviewing yoga has also emphasized mindfulness resulting from pranayama (Sovik, 2000;
Uebelacker, Epstein-Lubow, et al., 2010).
All participants endorsed relaxation resulting from pranayama. Experiencing mental and
physical relaxation had powerful antidepressant and anxiolytic effects. Deep relaxation calmed
both the mental tumult and somatic agitation of depression to help participants experience mind-
body peacefulness. Of importance, all retrievable mixed-method qualitative studies applying
either SKY or yoga with pranayama for various populations (Brazier et al., 2006; Kjellgren et al.,
2007; Galantino et al., 2012; Tul et al. 2011) reported relaxation among participants. These
studies and present findings suggested that relaxation might be a significant, generalized effect
among pranayama practitioners.
The biomedical literature has long documented the physiological benefits of pranayama
(Brown & Gerbarg, 2005a; Ley, 1999; Sovik, 2000). Pranayama helped many participants in the
present study reduce the psychomotor agitation and somatic aches associated with depression.
Improved respiration and circulation with pranayama also increased participants’ energy and
oxygen intake. Certain individuals shared ideas about ANS parasympathetic activation or the
complex neurophysiological processes underlying their depression and recovery with pranayama.
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New Insights. Pranayama had profound, transformative, and lasting effects on the lives
of this study’s participants that helped them manage clinical depression. In addition to any
antidepressant state changes experienced during pranayama, most participants developed new
insights, behaviors, and approaches toward their life through practice.
All 10 participants endorsed regular practice as being important, with some noting
setbacks in their mental health during lapses in use. Sovik (2000) analogized practicing yogic
breathing to learning a musical instrument (e.g., a violin), where initially novice skills are
continually built upon. Research has found that regular pranayama maximizes antidepressant
effects (Brown & Gerbarg, 2005b; Naga Venkatesha Murthy et al., 1998). However, clinical
research has often overlooked the spiritual aspect, self-insight, personal meaning, and sense of
connectedness arising from consistent practice. All participants saw great value in pranayama
and continued to practice at the time of their interview. Participation in this study reminded and
inspired certain participants to prioritize and bolster their breathing practice.
Several participants endorsed an individualized, integrative approach to health. These
participants viewed pranayama as a powerful technique among many within their “arsenal” or
“toolkit,” while remaining open-minded about other interventions. These endorsements
emphasized the importance of exploring and applying the most effective and empirically
supported treatments to combat unipolar depression, which could look very different for each
individual.
Additional Findings. Additional findings encapsulated lesser-endorsed experiences that
contributed relevant information to the phenomenon under investigation. These five findings
included: unknown mechanisms, the releasing of negative (and/or repressed) emotions,
chakra/meridian balancing, using breathing with visualization, and outlying experiences. These
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discoveries highlighted unique, perhaps less common experiences or aspects of pranayama that
would require further exploration.
Unknowing remained an aspect of some practice. Three participants speculated about
complex neurophysiological processes underlying their experiences with pranayama and
depression, but remained uncertain of specific mechanisms. These participants did not know
exactly how pranayama helped them in certain regards. The complex neurophysiological
mediators underlying pranayama remained an important area of scientific inquiry (Brown &
Gerbarg, 2005a; Jerath et al., 2006; Ley, 1999).
This study considered the rebalancing of chakras or unblocking of meridians a
metaphysical mechanism of change; a finding endorsed only by participants possessing a yogic
background. Thus, it remained plausible that the context in which voluntarily controlled
breathing was learned affected direct experience. For example, a participant with biofeedback
training did not implicate chakra or meridian system alterations, and might be having a very
different breathing experience than yoga students.
The releasing of negative emotions has also been reported among healthy SKY
practitioners (Kjellgren et al., 2007). One participant in the present sample had at one time
practiced rebirthing breathwork, which uses conscious breathing to release negative
psychological symptoms from birth trauma (Orr & Ray, 1983). At the conclusion of this study,
it remained unclear as to why certain individuals experienced this facet of practice.
Certain participants learned, and chose to integrate visualization into their breathing
practice. This combination appeared to be a way to keep practice diverse and suited for
individual needs. Lastly, outlying experiences were reported to include relevant data.
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Clinical Implications
This study uncovered plausible mechanisms of change, experiential effects, and self-
insights generated with pranayama that helped adult participants reduce depression. Of
importance, this study found that regular pranayama helped participants: learn to become aware
of and focus attention on the breath, gain a sense of control over their depression, improve
postural and physiological functioning, increase energy and oxygen, positively shift their
consciousness, clear a depressed mind-space, reduce negative thoughts, cultivate mindfulness,
and relax. The results suggested that pranayama uniquely and significantly impacted depression
through psychological pathways. These antidepressant experiences helped the participants create
healthier patterns in their thoughts, feelings, beliefs, and behaviors. This information could be
useful for individuals with depressive disorders, and clinicians treating this population.
While increasing empirical data has supported yoga for depression, the field of medicine
might have overlooked the importance of yogic breathing (Galantino et al., 2012). A growing
body of empirical evidence now supports pranayama for depressive disorders (Cramer et al.,
2013; Pilkington et al., 2006). If learned under a knowledgeable and skilled instructor,
pranayama is a safe, cost-efficient, practicable therapeutic tool for clients. Based upon the
literature and present findings, clinicians treating clients with unipolar depression may wish to
consider integrating pranayama into intervention planning.
The results suggested that health is an individualized, holistic journey. The findings
underscored the importance of an integrative approach to wellness, with participants’ endorsing
both conventional and complementary interventions. Thus, pranayama would be a suitable
adjunct for outpatient and inpatient treatment programs. Clinicians interested in pranayama may
opt to educate themselves about the various empirically supported yogic interventions (e.g.,
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Hatha, Iyengar, SKY, etc.) and acquire training and competence in this area. Alternatively,
psychologists could work closely with experienced yoga instructors and refer clients to
appropriate programs. When conducting the initial interview or collecting historical data,
clinicians could ask clients about past experiences with yoga or voluntarily controlled breathing,
and gauge an individual’s interest in taking part in a yogic intervention or psychotherapeutic
breathwork session.
When beginning a yogic or breathwork practice, clients need not have previous
experience. Certain psychotherapists and psychological interventions now incorporate the breath
into clinical practice (e.g., MBSR, MBCT, etc.). It is perhaps most important that clinicians
understand the yogic theory underpinning pranayama and have acquired the training and
competence to administer such techniques. It would be recommended that clinicians teaching
breathing techniques maintain their own yogic or mindfulness practice, to better understand
themselves and the effects of pranayama. Such a provision would maximize the highest level of
care for clients. In treating mood disorders with pranayama, precautions have been reported
(Brown & Gerbarg, 2005b; Lee & Speier, 1996). Safe and correct practice is paramount, and
clients should learn to honor, respect, and listen to their minds and bodies during pranayama
(Brown & Gerbarg, 2005a). This aspect of practice would also foster patience and self-
compassion in their life’s journey.
Assumptions and Limitations
Qualitative interviewing “begins with the assumption that it is possible to investigate
elements of the social by asking people to talk, and to gather or construct knowledge by listening
to, and interpreting what they say and how they say it” (Mason, 2002, p. 225). This study
presupposed that participants responded openly and honestly in their demographic questionnaire
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and qualitative interview, and possessed knowledge of the phenomenon under investigation.
Thus, the primary investigator took participants at their word regarding the narratives of their
experiences without being able to verify the information in every case.
One limitation of this study involved its use of a purposive sample. This study included
adult participants who reduced clinical depression with pranayama, and the results may not be
generalizable to other populations (Maykut & Morehouse, 1994). All research using a sample
will contain sampling errors (O’Dwyer & Bernauer, 2014). Sampling errors occur when the
sample is not representative of the population it intended to study. These findings represented
only the experiences of individuals who responded to an email invitation or recruitment flyer. A
selection bias could have culled a sample of pranayama practitioners unrepresentative of the
entire population intended for inclusion. Individuals opting not to respond to the advertisement
or overlooking it entirely might have comprised different personality characteristics and
experiences than those included in this study. Therefore, the results cannot be generalized to all
persons who have reduced depression with pranayama.
While this study did not aim to draw broad generalizations about the experiences of all
pranayama practitioners, the findings are still valuable, as they revealed ways in which yogic
breathing might reduce clinical depression. These results could also be the focus of further
inquiry. The findings might also form a base of knowledge from which clinicians draw upon in
their treatment of individuals experiencing unipolar depression.
In utilizing a qualitative research design, this study did not aim to infer causality between
pranayama and reduced depression (Bogdan & Biklen, 1992). A lack of causal relationships can
limit outlining clinical implications because it remained unknown if pranayama directly caused
the changes under investigation. Here, all but two participants used pranayama within a
MECHANISMS OF CHANGE OF PRANAYAMA 120
comprehensive program or yogic regimen. Thus, confounding practices (e.g., yogic postures,
meditation, etc.) could have contributed to, or caused the antidepressant experiences reported.
The majority of participants had also tried, or were currently using a variety of conventional and
complementary treatments for depression; including the possibility of spontaneous remission.
While the present study effectively recruited participants from various socioeconomic
statuses, age groups, and backgrounds, it did not represent an entirely culturally diverse sample.
Of the 10 participants included, nine were Caucasian or Caucasian with mixed ethnicity, and one
was Hispanic/Latino. The majority of participants were heterosexual in sexual orientation.
Seven participants were not religious, a finding that could affect generalizability. These issues
could limit relevance for persons having different multicultural backgrounds.
Another limitation involved the self-report method of data collection. Interviews are
subject to participants’ self-report bias (Paluck & Cialdini, 2014). Participants may have
withheld, distorted, or embellished certain information to favorably impress the primary
investigator. In addition, participants may not have had an awareness of all of their experiences
during pranayama. To increase the credibility of the data collected, the primary investigator took
time to establish rapport with each participant and provide reassurance about the confidentiality
of the study. The research design included member checks at the conclusion of each interview to
increase the validity of self-report measures.
As no participant possessed a SKY background, the qualitative integration of this
discussion should be interpreted with some caution regarding the proposals of the
neurophysiologic model (Brown & Gerbarg, 2005a). With more research, the results of the
present study could be interpreted, or possibly integrated with the neurophysiologic model to
MECHANISMS OF CHANGE OF PRANAYAMA 121
provide the field of clinical psychology with a more comprehensive theory or model of yogic
breathing.
The qualitative research design incorporated provisions of trustworthiness to minimize
sampling errors and increase the credibility and generalizability of findings (Lincoln & Guba,
1985; O’Dwyer & Bernauer, 2014). This study used triangulation to enhance the reliability and
validity of findings, including multiple methods of data collection and qualitative analysis to
form meaningful themes and categories (Denzin, 1989; Creswell & Miller, 2000; Golafshani,
2003; Jick, 1983).
Recommendations for Future Research
The application of yogic interventions in the literature has tripled since 2010; generating
increased research interest and empirical evidence. This proliferation was especially manifest
during the years of 2011-2012 (Cramer et al., 2014). A previous bibliometric analysis examining
yogic literature found 72 RCTs, with more than half conducted in India (Khalsa, 2004). A
bibliometric analysis from 2014 found 312 RCTs applying yogic intervention for various
disorders, spanning 23 countries and totaling 22,548 participants (Cramer et al., 2014). As of
2014, only 14 RCTs have applied yoga for depression.
In the present study, the participants’ depression was assessed through self-report (i.e.,
telephone screenings, demographic questionnaires, and qualitative interviewing). Having
participants retrospectively complete psychological inventories (e.g., the BDI-II, HRSD, etc.) to
assess depression both before and after pranayama use could have provided a more reliable
clinical picture.
Future research on this topic might also consider utilizing a mixed-methods research
design. Such a methodology would have the advantage of collecting qualitative data from
MECHANISMS OF CHANGE OF PRANAYAMA 122
participants enrolled in a quantitative RCT evaluating pranayama for clinical depression. As
highlighted by Jerath et al. (2006), specific pranayamas affect the nervous system differently,
and this method could be valuable to explore the experiences of depressed adult participants
undertaking the same structured, pranayama-based intervention (e.g., SKY).
In the present study, a meaningful cluster of five themes emerged encompassing
psychological effects of pranayama; including reduced negative thoughts. Traditional cognitive
therapy has long recognized the important role that negative thoughts play in the etiology of
depression (Beck, Rush, Shaw, & Emery, 1979; Segal et al., 2002). Future research may wish to
explore in more detail the role that pranayama plays in reducing ruminations driving unipolar
depression. Further investigation into pranayamic mechanisms implicated in ameliorating
depression via mental pathways could provide new directions for clinical research. In addition,
future qualitative research may wish to explore what elements of mindfulness cultivated through
pranayama were most effective in alleviating depression.
Unfortunately, no participant in this study undertook SKY, the most applied, empirically
supported yogic intervention for depressive disorders (Cramer et al, 2014; da Silva et al., 2009).
The primary investigator contacted many chapters of the Art of Living in San Diego to recruit
potential participants with a SKY background, but no instructors or students responded to the
invitations. However, six participants in the present study used ujjayi during their breathing
practice, an integral component of SKY. Two of these participants highlighted ujjayi as being
especially beneficial for their depression. In-depth qualitative research exploring the experiences
of SKY practitioners who reduced clinical depression could fill gaps in the psychological
literature.
MECHANISMS OF CHANGE OF PRANAYAMA 123
Our findings captured a broad range of experiences and inner realities among adult
pranayama practitioners with unipolar depression. Two outlying cases possessed advanced yoga
training that infused the data with esoteric yogic theory, adding variation to the phenomenon
(Strauss & Corbin, 1998). Future qualitative research may wish to explore the experiences of
participants using the same pranayama (e.g., SKY, ujjayi, kapalabhati, etc.) or possessing
comparable expertise with the practice. While this study uncovered plausible mechanisms and
experiential effects of practice, it remained unknown which specific theme, or combination
thereof contributed to the reported improvements in depression.
Regarding yogic interventions, Sherman (2006) noted that some research focused
primarily on postures, others more on breathing, some on meditation, and some exploring all
three components. The present study investigated only pranayama, except for one participant
using Vinyasa yoga (i.e., breath by movement). It could be valuable for future RCTs to examine
whether combining movement with yogic breathing had any additional antidepressant effect as
compared to seated pranayama. Additional RCTs could compare the efficacy of different
pranayama-based interventions for depressive disorders, as conducted by Rohini et al. (2000).
Conclusions
This study explored the common experiences, inner realities, and gleaned insights of 10
adult participants who reduced unipolar depression with pranayama. Due to the overall lack of
qualitative research on this topic, the findings could be useful for individuals suffering from
depressive disorders and clinicians treating this population.
While it was not within the scope of this study to determine causality, it was evident that
pranayama helped these participants improve clinical depression. With regular practice, most
participants experienced: focused attention, a sense of control, increased energy, oxygenation,
MECHANISMS OF CHANGE OF PRANAYAMA 124
positive shifts in consciousness, a clearer mind, reduced negative thoughts, mindfulness, global
physiological benefits, and relaxation. Thus, pranayama provided an experiential, holistic
approach to managing depression.
The results captured a meaningful cluster of five themes suggesting that pranayama
significantly reduced depression through synergistic psychological experiences. Pranayama
directly impacted the depressed mind, while possibly quieting cortical areas and activating ANS
parasympathetic dominance. Pranayama appeared especially effective at disrupting depressive
thought patterns and reducing ruminations that perpetuated depression; findings particularly
relevant for depressed populations. With regular practice, these direct, antidepressant
experiences engendered self-insight that paved a path for healthier mental and behavioral
choices. Although no participant attributed brainwave alteration to their recovery, certain
participants described psychological experiences with pranayama that mirrored clinical research
on this topic. Overall, the scientific literature and present findings suggested that pranayama
could be a particularly effective adjunct for depressive disorders.
This study adopted a thematic approach to illustrate the synergistic relationship between
themes and categories, thus preserving the unifying aims of yoga. Participants described
pranayama as a holistic practice that promoted wellness through a vast array of healing
experiences of mind, body, and spirit. Most participants viewed pranayama as a foundational,
reliable, transferable tool for continually managing depression and cultivating wellness.
However, yoga is a personal journey, and pranayama may not be indicated for everyone.
Participants in this study benefitted from a wide variety of empirically supported psychological
and psychiatric interventions; including complementary and alternative practices. Interested
readers are encouraged to learn more about pranayama in its original context as part of the
MECHANISMS OF CHANGE OF PRANAYAMA 125
Ashtanga yoga system as outlined in the Yoga-Sūtras of Patañjali. It is hoped that future
research continues to investigate the factors that contribute data on this topic so that this
knowledge may be passed on to those struggling with depressive disorders.
MECHANISMS OF CHANGE OF PRANAYAMA 126
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APPENDIX A
Interview Guidelines
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Interview Guide
This study aims to explore why and how pranayama (voluntarily controlled breathing)
reduces depression. Specifically, this interview will help me gain a better understanding of your
experiences using the breath to improve depression. Today, I’ll be asking you some very broad
questions designed to elicit information about this topic. If possible, I would like you to speak as
freely and openly as you can. The more forthcoming and genuine you can be during the
interview, the easier it will be for me to understand your worldview and experiences. If there is
anything I can do to make you feel more comfortable, or if you need to take a break at any time,
please let me know. As was outlined in the Informed Consent document, your personal
information will remain strictly confidential and there are no negative consequences if you decide
to terminate participation from this study at any time. Do you have any questions before we
begin?
1. To whatever extent you feel comfortable; can you tell me about your experiences with
depression?
2. Can you tell me about how you began practicing pranayama (e.g., voluntarily controlled
breathing, psychotherapeutic breathwork, rhythmic breathing, SKY, etc.)?
3. Can you broadly discuss your personal experiences with pranayama and depression?
4. Can you describe how pranayama helped you reduce any specific symptom(s) of depression?
5. Can you describe any specific changes that occurred with pranayama that helped you reduce
depression (i.e., mechanisms of change)?
a. What kinds of physical/bodily alterations occurred during or after pranayama that
helped you reduce depression?
b. Can you describe any changes that occurred in your thought processes or mental state
during or after pranayama that helped you reduce depression?
c. What changes occurred on an emotional level during or after pranayama that helped
you reduce depression?
d. Do you attribute any spiritual, metaphysical, or altered state changes to pranayama
that facilitated your recovery from depression?
6. Overall, why did pranayama influence your depression, or how do you think this change
process occurred (i.e., mechanisms of change)?
7. Can you describe a particular breathing session where these important changes in your mood
occurred?
8. When you were experiencing depression, what types of changes occurred immediately
following pranayama, and what benefits, if any, occurred over time (i.e., short-term vs. long-
term benefits)?
9. What advice might you give to someone struggling with depression?
10. I’ve finished with my questions. Is there anything you feel we did not cover today?
Debrief/Member-check
• I’ve asked a lot of questions and I want to check-in to see how you are doing.
• How was this experience for you? Do you have any questions or feedback?
• Do you feel you have fully and accurately described your experiences today?
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APPENDIX B
Letter of Introduction
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Letter of Introduction
Dear Participant:
I am a doctoral candidate in the clinical psychology program at the California School of
Professional Psychology at Alliant International University. I am conducting a qualitative study
investigating the role that pranayama (voluntarily controlled breathing) has in the treatment of
depressive disorders. More specifically, the purpose of this study is to explore the subjective
experiences of adult participants who have found pranayama effective in reducing their depression. I
will be working under the supervision of Marina Dorian, Ph.D.
To collect data for this study, a semi-structured interview will be conducted lasting from 60-
90 minutes. The interview will consist of several broad, open-ended questions designed to explore
the experiences, insights, ideas, and perceptions of adult participants who have found pranayama
beneficial in treating their depression. This interview will offer you the opportunity to reflect upon
and share your experiences with pranayama and depression. The results of this study could advance
knowledge in the field of clinical psychology. Ultimately, it is hoped that the findings can highlight
new directions for research and benefit other individuals suffering from depression.
Before we begin the interview, we will first review some important documents that outline
your rights as a volunteer participant in clinical research and other specifics concerning the study.
Participation will also involve filling out a brief (5-10 minutes) Demographic Questionnaire. After
you fully understand your rights and give written informed consent for participation, we will begin
the interview. A debriefing session will follow the interview, whereupon you will receive $25
compensation for your involvement in the study.
All data collected for this study will remain strictly confidential. Your name and identifying
information will be disguised via pseudonym to ensure your anonymity. Participants will also be
informed of any new or significant findings developed during this research. I hope you find this
encounter an interesting and enlightening experience. Please let me know if you have any questions
regarding the nature or the aims of this study. Thank you for your time and consideration in this
matter.
Sincerely,
Anthony Benicewicz, M.A.
Alliant International University
10455 Pomerado Road
San Diego, CA 92131
Phone: (443) 472-7721
Email: [email protected]
MECHANISMS OF CHANGE OF PRANAYAMA 150
APPENDIX C
Informed Consent
MECHANISMS OF CHANGE OF PRANAYAMA 151
INFORMED CONSENT AGREEMENT FOR PARTICIPATION IN
CLINICAL PSY.D. DISSERTATION RESEARCH
Alliant International University, San Diego Campus
10455 Pomerado Road
San Diego, CA 92131
An Investigation into the Mechanisms of Change of Pranayama: A Qualitative Study
Exploring How Voluntarily Controlled Breathing Reduces Depression.
You are being asked to participate in a research study. This study is part of a dissertation in
clinical psychology, which will be presented to the faculty at Alliant International University.
However, before you give your consent to be a volunteer, we want you to read the following and
ask as many questions as necessary to be sure that you understand what your participation will
involve.
INVESTIGATOR
Primary Investigator: Anthony Benicewicz, M.A., Phone: (443) 472-7721
Alliant Internal University, San Diego
Dissertation Chairperson: Marina Dorian, Ph.D., Phone: (858) 635-4630
Alliant International University, San Diego
PURPOSE OF THE RESEARCH
1. Unipolar depression is one of the leading public health problems worldwide, affecting
millions of people of all ages, genders, and backgrounds.
2. The purpose of this study is to explore the subjective experiences of adult participants
who have found pranayama (voluntarily controlled breathing) effective in reducing
depression.
3. A primary aim of this research is to investigate the mechanisms of change of
voluntarily controlled breathing that reduce depression.
DURATION OF PARTICIPATION IN THE RESEARCH AND NUMBER OF
PARTICIPANTS TO PARTICIPATE
You will be involved in this study for a period of 1½-2 hours. A total of 10 participants
will be included in the research.
PROCEDURES TO BE FOLLOWED DURING THE RESEARCH
Participation in this study will involve an initial telephone screening, an audio-recorded
interview, and a debriefing. If you agree to participate, you will first be given a detailed
step-by-step outline of the study, the procedures to be followed, and an overview of your
rights as a participant in clinical research. After giving written Informed Consent and
completing a Demographic Questionnaire, the qualitative interview will begin. You will
also be able to receive a summary of the aggregate results via email after the study has
concluded.
MECHANISMS OF CHANGE OF PRANAYAMA 152
EXPERIMENTAL PROCEDURES
The procedures involved are the kind that would be considered standard psychological
practice. The experimental part is that your interview data is being collected and
compared with information from other participants.
AUDIO RECORDING AND STORAGE OF DATA
The interview will be audio-recorded, transcribed, and analyzed for data. The primary
investigator will maintain all data in a locked file cabinet and/or password-protected
computer. Data will be shared only with members of the dissertation committee and a
supplemental data analyst. All raw data will be destroyed two years after completion of
the study via paper shredder. Electronic information will be destroyed with secure data
destruction software.
RISKS
The risks associated with participating are considered to be minimal. The risk of harm
anticipated is not greater than that ordinarily encountered in daily life or during the
performance of routine physical or psychological examinations or tests. However, it is
possible that you could experience negative reactions while discussing difficult
experiences from your life. If you appear to become upset or distressed during the
interview, the primary investigator will stop the questioning and remind you of your right
to withdraw from the study. If necessary, referrals for appropriate mental health services
will be provided to ensure your safety.
If you choose to participate, you must agree to the following instructions and
call the primary investigator immediately if you experience any negative reactions
resulting from your participation. If you need emergency psychiatric treatment
during the study, you must contact your doctor or call 911 immediately.
BENEFITS OF THE RESEARCH
Your participation could help you learn more about yourself and the recovery process
from depression. This study could also advance knowledge in the field of clinical
psychology. Ultimately, it is hoped that the major findings provide new directions for
research and can help others suffering from depressive disorders.
CONFIDENTIALITY
You have a right to privacy, and all of your identifying information will remain strictly
confidential, unless otherwise required by law. Identifying information will be disguised
using a pseudonym. The results, along with notes and direct quotes if appropriate, may
be published in scientific journals or presented at medical meetings as long as you are not
identified and cannot be reasonably identified. However, it is possible that under certain
circumstances the data could be subpoenaed by court order. It is also not guaranteed that
efforts to disguise identifying information regarding case studies will keep your identity
anonymous.
COMPENSATION FOR PARTICIPATION
Participants will be compensated with $25 upon completion of their interview.
MECHANISMS OF CHANGE OF PRANAYAMA 153
MANDATORY REPORTING OF SUSPECTED ABUSE OR NEGLECT
California law mandates the filing and reporting of reasonable suspicions of child,
dependent adult, or elder abuse and/or neglect. Participation could result in the primary
investigator being required to report any suspected abuse or neglect of these special
populations to the appropriate agency.
PREVIOUS RESEARCH PARTICIPATION
I have participated in the following research studies within the last 3 months:
______________________________________________________________
QUESTIONS ABOUT THE RESEARCH
If you have general questions regarding the rights of research participants,
please contact the IRB Coordinator Hoan Nguyen, J.D., M.B.A., at (858) 635-4074,
[email protected]. For any other questions regarding this study, please contact the
Primary Investigator during normal business hours.
PARTICIPATION RIGHTS AND RESEARCH WITHDRAW
Your participation in this study is voluntary. You have the right to refuse to participate,
decline to answer questions, and withdraw at any time once the study has started. If for
any reason you decide to withdraw from this study, you will not lose any benefits to
which you are otherwise entitled, nor will you be penalized.
We have tried to explain all the important details about this study to you. If you have any
questions that have not been answered at this point or after your interview, please feel
free to contact the Primary Investigator, Anthony Benicewicz, M.A. at (443) 472-7721,
[email protected] or the Dissertation Chairperson, Marina Dorian, Ph.D. at (858)
635-4630, [email protected].
SIGNATURE AND ACKNOWLEDGMENT
My signature below indicates that I have read the above information and I have asked
questions to help me understand what my own participation will involve. I agree to
participate in the study until I decide otherwise. I acknowledge having received a copy of
this agreement. I have been told that by signing this consent form I am not giving up any
of my own legal rights.
__________________________________ ______ __________
Signature of Participant Age Date
__________________________________ __________
Signature of Primary Investigator Date
MECHANISMS OF CHANGE OF PRANAYAMA 154
APPENDIX D
Telephone Screener
MECHANISMS OF CHANGE OF PRANAYAMA 155
Telephone Screener
1. How old are you?
2. Have you found pranayama (e.g., voluntarily controlled/regulated breathing, SKY,
psychotherapeutic breathwork, Holotropic breathwork, Transformational breathing,
rhythmic breathing, etc.) effective in reducing depression within the last five years?
3. Did you use pranayama at least three times a week for a period of one month while you
were experiencing depression?
4. When you began using pranayama, did you experience a depressive disorder as outlined
by the DSM-IV-TR (see SCID-I: Module D. Mood Disorders)?
5. Have you ever been diagnosed with a bipolar disorder or ever experienced a manic,
mixed, or hypomanic episode as outlined by the DSM-IV-TR (see SCID-I: Module D)?
6. Was your depression the direct result of substance use or a general medical condition (see
SCID-I: Module D)?
7. Do you have any mental disorder or medical condition that would make it very difficult
or impossible to participate in a 60-90 minute in-person interview (see DSM-IV-TR
and/or ICD-10)?
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APPENDIX E
Demographic Questionnaire
MECHANISMS OF CHANGE OF PRANAYAMA 157
DEMOGRAPHIC QUESTIONNAIRE
Name: _________________________________________
Telephone: (____)________________________________
Email: _________________________________________
Age: _____
Please circle one answer for each of the following categories:
1. Sex: Female Male
2. Sexual Orientation: Heterosexual Bisexual Lesbian Gay
3. Relationship Status: Single Married Divorced Separated
Cohabitating/Domestic Partnership Committed Relationship Widowed
4. Ethnicity: African American Native American Asian/Pacific Islander
Caucasian Hispanic/Latino Other (please specify): _______________
5. Spiritual/Religious Beliefs: Agnostic Atheist Buddhist
Christian Hindu Jewish Muslim Spiritual but not religious
Other (please specify): _______________
MECHANISMS OF CHANGE OF PRANAYAMA 158
6. Highest Level of Education Completed: Some High School High School
Diploma/GED Some College/Vocational Program Certificate
Associate’s Degree Bachelor’s Degree Master’s Degree Doctoral Degree
Other Professional Degree (please specify): _______________
7. Occupation: ___________________________________________
8. Yearly Income: Under $25,000 $25,000 – $49,999 $50,000 – $74,999
$75,000 - $149,999 Over $150,000
9. How long have you experienced depression? ________________________________
10. Have you ever sought professional treatment the depression and/or been diagnosed
with a specific depressive disorder? _______________________________________
11. Please list any techniques or interventions you currently use or have used to treat your
depression:
a. Conventional treatments: ___________________________________________
b. Complementary and alternative treatments: ____________________________
MECHANISMS OF CHANGE OF PRANAYAMA 159
12. How would you rate the severity of your depression BEFORE you began using
pranayama (voluntarily controlled breathing)? (please check one)
__None __Very little __Mild __Moderate __Severe
13. How would you rate the severity of your depression AFTER you used pranayama
(voluntarily controlled breathing)? (please check one)
__None __Very little __Mild __Moderate __Severe
14. How long have you been using pranayama? ___________________
15. Did you study the yogic breathing under a teacher or therapist? __________________
16. How often do you practice pranayama? (e.g., times per day and/or number of days per
week) ______________________________________________________
17. What specific pranayamas or breathing exercises do you practice? (if known)
___________________________________________________________
___________________________________________________________
___________________________________________________________
MECHANISMS OF CHANGE OF PRANAYAMA 160
APPENDIX F
Recruitment Flyer
MECHANISMS OF CHANGE OF PRANAYAMA 161
Recruitment Flyer
Has Voluntarily Controlled Breathing Helped You
Reduce Depression?
♦ Yogic breathing/Pranayama
♦ Breathwork (Psychotherapeutic,Transformational, Holotropic, etc.)
♦ Art of Living coursework (Sudarshan Kriya Yoga)
♦ Mindfulness-based breathing programs …etc.
This study is looking for adult participants who have used voluntarily
controlled breathing techniques at least 3 times a week for one month
within the last five years and during the episode(s) of depression.
• This study will administer a brief diagnostic screening via telephone
to assess a predetermined level of depression for eligibility.
• This study involves a 60-90 minute face-to-face interview with the primary
researcher designed to explore how voluntarily controlled breathing helped
you reduce depression.
• Your participation could advance knowledge in the field of clinical
psychology and help others suffering from depression.
An advanced doctoral candidate in the field of clinical psychology is
conducting this dissertation study. A licensed clinical psychologist will be
supervising the research. All information will be kept strictly confidential.
In addition, you will also receive $25 in appreciation for your time.
To find out if you are eligible for this study, please contact:
Anthony Benicewicz, M.A.
(443) 472-7721
[email protected]
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