YOGA AND THE PSYCHE: DISCOVERING THE PERSONAL BENEFITS OF THE

MIND, BODY, AND SPIRITUAL CONNECTION

MELISSA BOCK

SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF EDUCATION

NIPISSING UNIVERSITY SCHULICH SCHOOL OF EDUCATION NORTH BAY, ONTARIO

@ Melissa Bock May 2017

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Abstract

Exercise and recent research, demonstrate the value of both for psychiatric illness. Studies suggest that 1 in 5 Canadians will be affected by a mental health diagnosis at least once through the span of their lifetime. With 21% of Canada’s total population being diagnosed,

12% are specifically affected by anxiety, the most commonly diagnosed mental health disorder (Canadian Mental Health Association, 2016a). A close second is depression, affecting 9% of all Canadians (Canadian Mental Health Association, 2016b). New evidence suggests that yoga has a positive influence on the reduction of symptoms associated with mild depression and anxiety. Through an extensive literature review, and my own personal story, this research paper will discuss the positive benefits of exercise, specifically yoga, on mental health. It will highlight the types of yoga practice, the benefits to the implementation, and the positive psychological and physiological outcomes of practice. This is a narrative, autobiographical research paper of my journey to balanced and holistic health and the development of an enhanced mind, body, and spiritual connection.

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Table of Contents Page

Abstract ...... i List of Appendices ...... i

Chapter One: Introduction ...... 1 Background ...... 1 Purpose ...... 1 Methodology ...... 3

Chapter Two: Literature Review ...... 7 Search Strategy ...... 7 Yoga ...... 9 Depression ...... 14 Anxiety ...... 17 Yoga as Therapy ...... 19 Mainstay Treatments ...... 22

Chapter Three: Something About Me ...... 26 The Mind ...... 29 The Body ...... 37 Spirituality...... 41

Chapter Four: Recommendations and Conclusions ...... 46 Future Directions for Research ...... 46 Conclusion ...... 49

References ...... 51

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List of Appendices

Appendix A: Patient Health Questionnaire ...... 57

Appendix B: Generalized Anxiety Disorder 7-Item ...... 60

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Chapter One: Introduction

Background

The use of yoga as an adjunctive therapy for mild mood disorders has surged in

popularity over the past decade. Currently, yoga is among the 10 most widely practiced

forms of complementary healthcare in the United States and Canada (Barnes, Powell-Griner,

McFann, & Nahin, 2002 p. 2). Alternatively, depression and anxiety are the most commonly

diagnosed mental health disorders identified within Canada in the last year (Canadian Mental

Health Association, 2016a, 2016b). Research suggests that the practice of yoga can alleviate

symptoms of anxiety, depression, and chronic pain disorders, as well as assist with symptoms

associated with insomnia, arthritis, autoimmune disorders, and cardiovascular conditions

(Field, 2011). This study will explore how the implementation of consistent yogic practice

assists with the reduction of both mild anxiety and mild depressive symptoms. I chose this

research topic because the mind, body, and spiritual connection are of great interest to me. I

have practiced yoga for many years and I have reaped the benefits of mental clarity and

relaxation. I am someone who uses yoga regularly to improve my mental precision and to

quiet the ever-racing world around me, and I want to share my positive experiences in the

hope that others may benefit from a yoga practice in the same way that I do.

Purpose

The purpose of this research paper is to write a narrative, an autobiographical

research study addressing the implementation of yoga as a holistic treatment for mild anxiety

and depressive symptoms. It explores a personal journey on what I learned through my

practice of yoga and the effects on my own mental health on my voyage to a more balanced

holistic health. The research took place over the course of an 8-week, intensive yoga

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2 challenge. Data were collected through previously written personal journal entries that were completed at the end of every yoga class attended. The time-period was from May 1, 2016 to

July 31, 2016. The interest of this topic comes from two driving forces. First, I work in a traditional medical environment where many times throughout the course of my day I am diagnosing patients with either anxiety, depression, or both. In my experience, I find that while offering treatment to my patients, such as traditional and alternative methods (e.g., yoga, counseling, cognitive behavioral therapy, etc.), most patients (myself included) opt for a more holistic approach initially. The second area of interest is that I am a long-time practicing yogi who has always known the benefits of yoga, and this research paper has provided the opportunity to explore this topic on a deeper level. This personal narrative will confirm what I have known about yoga for many years as well as assist with a better understanding of both the mind and the body connection. I have participated in yoga on and off for the past 10 years and I have always walked away with an enhanced sense of positivity following a yoga class. Practicing yoga has improved my sense of balance both spiritually and emotionally. It has improved my physical capabilities, enriched my psychological flexibility, and improved my stamina. I have at many points in my life found myself gravitating back to the mat when my life and emotions were feeling unbalanced. This led me to consider the scientifically significant benefits of yoga for those who suffer from anxiety and depression. I am cognizant of the positivity that yoga has brought to my personal life, which was the leading force for my pursuit of a better, more formal understanding of how yoga can influence psychological health. The significance of this study also is to address the magnitude that exercise has on both physical and mental health, an area of research that, I believe, should be given more consideration in the traditional medicine realm.

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Methodology

For most researchers, teachers, and students, storytelling is the most effective and natural way of sharing an experience. Narrative research is a more formal method of telling these stories and “creating reasonable order out of experience” (Moen, 2006, p. 2). Narrative research is being used more and more for educational experiences and in practice because it bridges the gap between the lived experience and those who are able to live the experience simply through the shared story. The methodology for this major research paper is that of narrative research with a focus on an autobiographical perspective.

The main foundation of narrative research is the use of storytelling and retelling for the purposes of enlightening others. Narrative research is a study in which “humans experience the world” (Connelly & Clandinin, 1990, p. 2) both figuratively and literally.

Narratives are a “frame of reference, a way of reflecting during the entire inquiry process, a research method, and a mode for representing the research study” (Moen, 2006, p. 2) from the lived perspective of the narrator/researcher. This major research paper is my personal story of the discovery of spiritual balance, one that I acquired through the implementation of a regular yoga practice and how this assisted me to overcome mild anxiety and depressive symptoms. This narrative is my personal understanding, self-reflection, and spiritual awakening with a holistic health approach to conquer mild anxiety and depression.

Narrative research consists of “ significance, value, and intention” (Connelly &

Clandinin, 1990, p. 9), which I plan to use as my literary framework. Connelly and Clandinin outline that narrative research is a beautiful compilation of life and social meaning, with the principle attraction being “its capacity to render life experiences both personal and social in a relevant and meaningful way” (p. 10), which will be reflective of my life and my story.

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Connelly and Candinin (1990) write that narrative inquiry is the “focus on experience, and the qualities of life and education, is situated in a matrix of qualitative research” (p. 3), and as educators, patients, and people we use narrative to tell our stories, and our journeys, both formally and informally. Moen (2006), describes narrative research as

“the study of how human beings experience the world, narrative researchers collect these stories and write narratives of experiences” (p. 2) which allow life lessons to be passed on and situations to be experienced by others. Narrative inquiry is a collection of personal stories that allow others to learn through that lived experience, which further validates that

“human knowledge is thus relative” (Moen, 2006, p. 57), regardless of the manner in which it is shared.

Narratives are often used by teachers because, like all humans, teachers “are storytellers who individually and socially lead storied lives” (Moen, 2006, p. 56), which allows for ease of knowledge sharing. The past life lessons interpreted by others allows us as a society to learn through the lens of someone else. Narrative inquiry allows for a moment in time when the researcher can have the venue and opportunity to tell their stories to others, offering meaning and authority to a lived experience. Narratives are dependent on the values, interpretations, and representations of others in which the “perspective perhaps has the ability to produce, some kind of authentic view of reality, the belief in the potential attainment of an objective reality or truth is rejected” (Moen, 2006, p. 57), making the reality of the narrative that of the researcher. Connelly and Clandinin (1990) also outline that narrative inquiry is a

“process of collaboration involving mutual storytelling and re-storing as the research proceeds” (p. 4), allowing for the wisdom of others to be shared in multiple forums. Moen goes on to say that “narrative approach is not a method but, rather a frame of reference in a

5 research process, wherein narratives are seen as producers and transmitters of reality” (p. 2).

This is my reality and my story to be shared in hopes of changing the perspective of at least one person for the better. I have experienced firsthand the powerful tool yoga is, and I wanted to share that perspective.

The data collection methods behind narrative research come in many different forms: field notes, pictures, metaphors, personal writing, shared experiences, journal entries, and storytelling. The data collection for this paper came in the form of personal journal entries.

Data were collected over the course of an 8-week intensive yoga program in which a daily journal entry reflected my emotions and spiritual awareness, and the impact yoga was having on my psychological and physical health. These are my personal notes, obtained during the time period of May 1, 2016 to July 31, 2016, which is longer than 8 weeks; however, I continued to attend workshops and classes. There is on one occasion a letter-writing component in which I wrote my future self a letter to address the progress I would like to make, my willingness for change, and the personal stressors I wanted to overcome. The bulk of this paper will be autobiographical in nature; therefore, my emotions can be accurately portrayed throughout my personal passage into a holistic healthy state of mind.

This paper also was developed from a “narrative truth” (Connelly & Clandinin, 1990, p. 8) consisting of both spiritual connections and my personal life lessons. Connelly and

Clandinin demonstrate the importance of not only listening but also telling personal stories to enhance the purpose of others. The reason that I chose to write a narrative, autobiographical paper is that “when I disclose what I have seen, my results will invite other researchers to look where I did and see what I saw” (Connelly & Clandinin, 1990, p. 8), and hopefully to allow others to appreciate the association of physical health with mental health. My goal is

6 also to “organize (my) human experiences into meaningful episodes” (Moen, 2006 p. 6) and demonstrate the positive effects yoga has on my life.

Chapter Two: Literature Review

Search Strategy

For the purpose of this paper, a literature review was performed of peer reviewed journal articles through the databases of ERIC, CINAHL, Health Sources: Nursing

Education/Academic Edition ((Nipissing Website), PUBMED and Google Scholar. A broad search using key words, such as depression, anxiety, yoga, and holistic health, was performed. This was followed by a more specific, focused search using key words such as yoga as therapy, depression and holistic treatments, anxiety, mindfulness, meditation, relaxation, and exercise. All articles had the inclusion criteria of being full text journals, being published in English, and between the years of 2004-present. Due to the lack of pertinent journal articles, the search had to be increased to predate 2007. There are three articles included which are dated in the 1990s because of the significance of the content.

Despite increased access to health care, mental illnesses are quickly becoming a national and international health concern. Anxiety and depression are the leading causes of disability worldwide (The World Health Organization, 2016). The WHO has estimated that

“37% of the loss of healthy years from non-communicable diseases is from mental illness”, which is more prevalent than asthma, cardiac diseases, and diabetes. Depression at its worst can lead to suicide and is the “second leading cause of death in 15-29-year-olds” (WHO,

2016). It has also been estimated that approximately 800,000 people die due to suicide every year worldwide (WHO, 2016).

Comparable data outline that anxiety disorders have a “10-15% prevalence rate with an even higher prevalence rate in developed countries”(Kessler et al., 1994, p. 9) such as

Canada and the United States. The, “availability of psychopharmacological treatments has

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increased, but the response and tolerability remain unpredictable and inconsistent”

(Balasubramaniam, Telles, & Doraiswamy, 2012, p. 2), which is a major contributing factor to more people selecting holistic approaches to manage their symptoms.

Holistic health has also grown in popularity. Holistic and collaborative therapies are

surging in attractiveness for those who experience symptoms of anxiety and depression, but

are less likely to be formally diagnosed with mental illness because of the lack of severity of

symptoms. More popular holistic treatments, such as those outlined in a recent study by

Andrea Forfylow (2011), suggest that with such a high percentage of the population being

diagnosed with depression and/or anxiety, more people are engaging in self-help methods

and the use of complementary and alternative medicine (CAM) choices. Forfylow goes on to

solidify her claims by outlining the reasons for this surge is because “conceivably, they may

choose to engage in self-help treatments in an effort to maximize financial savings, to refrain

from consuming synthetic medications, or to avoid negative stigmatization” (p. 132).

Physical exercise has been "documented to be associated with a range of physiological health

benefits while absence of physical exercise is associated with a wide plethora of common

causes of mortality including coronary heart disease, certain forms of cancer, obesity,

hypertension and diabetes" (Swan & Hyland, 2012, p. 5) and completed while in the

comforts of a known space, such as a personal dwelling.

Yoga therapy has been identified as the most prevalent self-help therapy associated

with anxiety and depression. People diagnosed with either are more likely to engage in CAM

treatments than any other chronic disease. CAM treatments are broken down into five

domains; more specifically, one of the most utilized domains is that of the “mind-body

interventions” which is defined as the “interactions among the brain, mind, body and

9 behaviour with the intent to use the mind to affect physical functioning and promote health”

(Forfylow, 2011, p. 133) yoga was deemed as the most prevalent mind body intervention for people diagnosed with mental illness. We know from scientific research that depression and anxiety can have physical effects on the body. Patients can experience symptoms of fatigue, lack of energy, and lack of motivation with depression. Patients also can experience symptoms of a racing heart and nervousness with anxiety, which leads to the conclusion that the mind and body connection is much more persuasive on our overall health. Most health care professionals would likely agree that there is a definitive connection between the mind and the body, but they are less likely than naturopathic doctors to prescribe alternatives to the traditional methods of treatment, such as yoga. Douglass (2009) found in his research that while most mental health professionals agreed that yoga was beneficial as an add-on therapy, few followed through with the recommendation of a first-line alternative therapy for those who were diagnosed with mild depression and anxiety symptoms. Traditional medicine doctors tend to veer away from holistic treatments because there is not a tangible measurement. Holistic health tends to be a grey area for most providers.

Yoga

Yoga is a solitary exercise that enhances the mind, body, and spiritual connection and has been utilized by practitioners for decades to assist with both physical and mental awareness. “The primary focus of Yoga is to restore the mind to simplicity and peace, to free it from confusion and distress” (Ingra, 2001, p. 35). A 3,000-year-old practice, yoga originated in India and was developed to bring balance to life, both physically and psychologically. Unlike other exercise that strains the muscles of the body, yoga is used to restore and regenerate the mind, body, and spirit. Derived from its Sanskirt origin, the

10 liturgical language of Hinduism, yoga (yuj), means to “yoke, or join” (Woodyard, 2011, p.

49), and unify the concentration and attention of those who practice. In a philosophical sense, yoga means “the conscious connection of the limited little ergodic self with the unlimited, eternal, higher Self” (Forfylow, 2011, p.134), freeing the mind of egotistic thinking. Metaphorically, yoga is often referred to as a tree because it is composed of “eight aspects or limbs yama (universal ethics), niyana (individual ethics), asana (physical postures), pranayanan (breath control), pratyanhara (control of the senses), dharana

(concentration), dyana (meditation) and samadhi (bliss)” (Ross & Thomas, 2010, p. 3).

A solitary form of exercise, yoga is performed on a mat, either rubber or fabric, that is rectangular in shape and provides the platform for practice. The performance of yoga is referred to as a practice because it is a journey, which is perfected, and practicing the postures makes for a more perfected performance. There are several types of yoga; however, the two most popular in the Eastern world are that of Iyengar and Vinyasa. Iyengar is more specific to alignment and endurance- holding each posture/pose for duration of time using blocks, straps, and mats to avoid injury to the participant. Vinyasa is more rhythmic and is considered “flow” yoga as it represents flowing from one posture to the next with coordinated breathing for a more “intense mind-body workout” (Louie, 2014, p. 266). Both are a series of postures, standing, lying, and sitting, that represent the limbs of the tree through the movements.

Bikram yoga is a more vagarious form of Iyengar yoga (Ueblacker & Brougton,

2016). Based on the same principles of breathing, meditation, and postures, it is practiced in a room that is between 95-105 degrees Celsius. This specific practice has a series of 26 postures, which activate both the musculoskeletal system as well as the internal body systems

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(heart, lungs, digestion). The addition of heat promotes detoxification, prevents injuries, and

enhances flexibility (Yoganada, 2016). This yoga is also known as hot yoga.

Hatha, the most popular form of Vinyasa yoga, is basic. Its postures (poses) are easy

for beginners and have become very popular as a form of exercise both in the United States and Canada (Forfylow, 2011, p. 134). This slow, graceful practice is ideal for developing the foundational principles of yoga. Hatha, like Bikram, can be performed in a heated room and, for the purposes of this paper where yoga is discussed, it will be understood that the form of yoga practiced is Hatha/Iyengar yoga, which was completed in a heated room. It is believed

that the “continued practice of yoga will lead you to a sense of peace and well-being, and a

feeling of being one with the environment” (Forfylow, 2011, p. 134). Bussing, Michalsen,

Khalsa, Telles, and Sherman (2012) describe yoga as "physical exercises that may increase

patients physical flexibility, coordination, and strength, while the breathing practices and

meditation may calm and focus the mind to develop greater awareness and diminish anxiety,

and thus results in higher quality of life" (p. 1).

Regardless of the specific type of yoga, all are grounded in a foundation of breath

work, postures, and mindfulness. Breath work, the foundation of all yoga practices, is as it

sounds, the concentration of breathing. It is thought that in most yogic practices, breathing is

the concept of “creating energy” (Forfylow, 2011, p. 134). The rhythmical inhalation,

exhalation, and preservation of breath during yoga can assists with reaching a “pure mind”

(Forfylow, 2011, p. 134). The breathing associated with Hatha yoga, “focuses on conscious

prolongation of inhalation, breath retention and exhalation” (Khanna & Greeson 2013, p.

245), otherwise known as yogic breath. Those who achieve this method of yoga breathing are

then able to achieve a “mind that is clear and free of thoughts and cravings (which) may be

12 considered pure: carefree, motionless and mindless” (Forfylow, 2011, p. 134). Mindfulness, a stillness of the mind according to research, can alleviate symptoms of anxiety and depression. Forfylow outlines this mastery of controlled breathing allowing participants the ability to have control over their senses. This essentially clears the mind of unwanted thoughts and unnecessary worry which can ease the symptoms of the restlessness. These symptoms are often associated with anxiety and the worthlessness associated with depression.

One particular study focused on college students and how yoga brought them a sense of stillness, both emotionally and spiritually (Villate, 2015). Villate is a physical educator who felt that college students could benefit from yoga to assist them in overcoming the hectic schedules of college life and assist them to shift their focus and have a greater sense of perspective. Participants were asked to participate in twice weekly yoga classes that were an hour and 15 minutes long. Each session began with an introduction and discussion of practice. At the end of each week, students were asked to provide a reflective journal entry through an online classroom application. Sixty students participated in the study and the findings were that most, if not all, students found that yoga had a calming effect and they felt more relaxed during their day-to-day events. They had better focus at the academic level and improved concentration. “Something I didn’t realize until I took yoga was how important the actual way you breath is” (Villate, 2015, p. 54), which was the remark from a participant in the study. Other comments were that yoga had an enhanced effect on their sleep patterns; they became more astute at clearing their minds with concentrated breath work for a more restful sleep. Throughout the study, the students commented on how yoga provided them with a better perspective on what was important. Villate reported that students were “able to

13 connect with their inner selves and unite their mind, body, and soul, so an increased perspective is a common outcome” (p. 62).

The physical component of yoga is often overlooked as being therapeutic. The limbs or postures are seen as typically the “spark of relaxation” (Agrawal, 2013, p. 4). The thought is that physical postures can elicit a psychological component that assists with emotional responses that leads to positive responses in energy levels, thus making a person feel less anxious and more settled. The flow of postures assist with making practitioners feeling more grounded, both physically and emotionally. Forward bends, backward flexion, and seated postures all have a calming effect and improve digestion. Supine or lying postures assist with relaxation on the participants. Yoga postures can “induce a variety of effects, such as to ground, soothe, stimulate, or revitalize one’s energy level (Austin & Laeng, 2003, as cited in

Forfylow, 2011, p. 135), making yoga a positive exercise for those with even limited mobility.

Mindfulness is the final component of yoga, which is thought to have the most positive effects on mental health. Defined as “a state in which one is able to maintain awareness of the present, releasing control and attachment of beliefs, thoughts and emotions”

(Agrawal, 2013, p. 53); mindfulness is a term that is interchangeable with meditation.

Meditation is thought to enhance the mind body connection by allowing participants the ability to let go of one’s present thoughts and have a greater sense of self. With the assistance of concentrated breath work and postures, meditation can be achieved once the senses are relaxed and the mind is undistracted (Forfylow, 2011). Interestingly, most of the studies reviewed for this paper outlined that consistent yoga practitioners utilized both concentrated breathing and meditation outside the yoga studio. Meditation is being aware of what thoughts

14 are occurring, how to clear the thoughts, and how to shift to a positive mental frame of reference. Research also suggested that those who practice yoga on a regular basis are much more in tune with how to accept and react to stress inducing situations. A research review of

30 studies that was conducted by Hofmann et al. (2015) at Boston University evaluated the usefulness of mindfulness as a therapy for depression and anxiety. Their findings were that of

1,140 participants who took part in some form of mindfulness treatment (i.e., counseling, yoga, or other) demonstrated there were improved symptoms for those who implemented mindfulness. While the results were encouraging, Hofmann et al., reported that the results of the comparative study demonstrate many limitations such as length of treatment and method of treatment. In light of the limitations of their research, the comparative study does yield positive symptom improvements for those with anxiety and depression. Being able to shift one's thoughts from a negative perspective to a place of gratitude and positive self-worth can improve a practitioner's self-confidence and self-esteem, and decrease anxiety. Meditation is a powerful tool that those who have anxiety and depression often lack, and can assist with the ever-racing minds of those who have mental illness.

Depression.

Depression. According the American Psychiatric Association (2016), depression is more than simply being sad. People with:

depression may experience a lack of interest and pleasure in daily activities,

significant weight loss or gain, insomnia or excessive sleeping, lack of energy,

inability to concentrate, feelings of worthlessness or excessive guilt and recurrent

thoughts of death or suicide. (p.)

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According to WHO (2016), “800,000 suicides have occurred per year, that is a suicide every

40 seconds." Like anxiety, depression can range in severity from being mild to being very significant and even life-altering. Depression or depressive symptoms can occur at any time throughout the life span. Symptoms can be triggered spontaneously or precipitated by a tragic event. The symptoms can remit easily or be life-long. Depressive disorder “is another well- known chronic, recurrent and disabling mental disease with both high direct and indirect costs to society” (Doria, de Vuono, Sanlorenzo, Irtelli, & Mencacci, 2015, p. 311).

Depression is a “common and serious medical illness that negatively affects how you feel, the way you think and how you act” (American Psychiatric Society, 2016). According to the

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), depression is described as

“a depressed mood or loss of interest or pleasure for more than two weeks” (American

Psychiatric Society, 2013, p.). Depression can cause negative effects on personal lives, such as effectiveness at work, lack of concentration, focus, and lack of motivation, and can also cause physical symptoms of pain, restlessness, fatigue, low energy, insomnia, and/or oversleeping.

Depression is a pathophysiological disorder, which defined simply is a chemical imbalance in the brain. Research has found that depression is the result of “polymorphic variant of the serotonin transporter that exist either as a “short allele or long allele”

(McCance & Huether, 2006, p. 658). Cowen (2002) finds that “major depression exhibits decreased brain serotonin (5-hydroxy-trytamine, 5HT) function and elevated cortisol” (p. 1) because of life-stressors. The elevation in cortisol may result as a decrease in 5HT, which would exhibit depressive symptoms such as decreased mood. “Acute psychological stressors may produce an increased cortisol response and cortisol levels are associated with an

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increase in negative emotions” (Louie, 2014, p. 267). Depression is also associated with a

heightened level of hypothalamic-pituitary adrenal axis (HPA) and the sympathetic nervous

system (SNS), both of which are tripped by a “physical or psychological demand (stressor)

leading to a cascade of physiological, behavioral and psychological effects” (Ross &

Thomas, 2010, p. 3). The cascade of increased release of cortisol and the engagement of the fight or flight hormones, known as epinephrine and norepinephrine, over time can lead to an imbalance in the chemical composition of the brain. This rise will lead to a depressed mood, cardiovascular diseases, obesity, diabetes, and depression. Those who experience this shift in consistently, unbalanced ratios of epinephrine and norepinephrine, are individuals who experience a depressive mood. The variance of changing hormones will reflect the variance and the degree of the depressive symptoms; hence, this is why depression is a spectrum disorder with fluctuating intensity from person to person. Each brain is unique in its chemical composition; some researchers feel that depression is not only a chemical shift it also is an

“illness that stems from a complex interplay between susceptible genes and environmental factors” (Salmon et al., 2004, p. 60). The interactive relationship between serotonin (a chemical produced by the SNS) and life stressors has been proven to increase the risk for depression. Because depression is self-perceived, it is evaluated based on personally experienced symptoms, and treatment may become slightly more complicated. Mainstay treatments are medications, which do not have a consistent effect on the people who will trial them. For this reason, it is becoming increasingly more important to recognize add-on therapies such as yoga.

All primary healthcare providers can diagnose depression; unfortunately, because it is a spectrum disorder, most patients do not seek professional assistance until their symptoms

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are significantly hindering their everyday lives. Diagnosis is made through a series of

questions, generally addressing if there are or have there been any thoughts of suicide; this

would require urgent attention at an inpatient facility. If the response is that there are no

thoughts of suicide or self-harm behaviors present, the practitioner will proceed to a series of questions from the Patient Health Questionarrie-9. This 9-question, self-administered test is used to determine the depth of the patient’s depression. This testing is helpful in assisting with the “screening, diagnosing, monitoring, and measuring” (Manea, Gilbody, & McMillan,

2011, p. 194) of depression. Scores are based on a scale from 1-3 per question. A score of 0-4 suggests that symptoms are within the normal range. Five-9 mild depressive symptoms, 11-

14 major depression- mild severity, and 15-20 major depression (Pfizer Inc., 2017)

(Appendix A). “Depression and anxiety are closely linked to structural and functional abnormalities in a number of stress and mood related brain regions” (Pascoe & Bauer, 2015, p. 270) and is often why people will continue to have a dual diagnosis of both depression and anxiety.

Anxiety.

According to the Canadian Mental Health Association (2016a), anxiety is a normal human response which can occur or manifest itself as the sensation of being worried, feeling nervous, or on edge. Generalized Anxiety Disorder (GAD) is “characterized by excessive anxiety and worry that last for at least six months” (Doria et al., 2015, p. 311). Anxiety can vary in severity, ranging from mild symptoms such as uneasiness to significant panic attacks, that prevent people from performing even the smallest of tasks. Anxiety can also provoke the

“fight or flight response” (Doria et al., 2015, p. 311). The University of Nottingham, outlines the fight, or flight response as “a physiological response triggered when we feel a strong

18 emotion like fear” (Middleton, Shaw, Hull, & Feder, 2005). This fight or flight response is our body’s means of detecting danger. Both life-threatening situations as well as personal pressures, otherwise known as worries, can activate our internal alarm system. This alarm system can generate physical symptoms such as racing heart, sweating, abdominal pain, shortness of breath, hyperventilation, nausea, vomiting, diarrhea, muscle aches, and restlessness (American Psychiatric Association, 2016).

DMS-V criteria define generalized anxiety disorder’s features as “excessive fear and anxiety and related behavioral disturbances” (American Psychiatric Association, 2013). The

DSM-V outlines that those with anxiety can experience persistent cognitive dysfunction associated with excessive worrying, forgetfulness, lack of ability to concentrate and restlessness. Anxiety can have physical symptoms such as racing heart, sweating, muscles aches associated with tension, sense of nervousness, insomnia and the typical fight or flight response wanting to flee from anxiety provoking situations. Anxiety has been identified as, the “most common mental health disorder” by the WHO (2016). Most research suggesta that the general population experiences some form of anxiety symptoms and are those “that do not reach the level of clinical diagnosis but still contribute to a substantial degree of suffering for the individual” (Swan & Hyland, 2014, p. 2), and often employ self-help methods. The symptoms can vary in severity and can be debilitating in nature, resulting in social isolation, withdrawal from familiar situations, and increased risk of suicide. Anxiety can cause people to become “hyper vigilant to perceived” dangers, which may not actually occur, and have a sense of impending doom. Anxiety, like depression, can affect one’s concentration and focus leading to disturbances in social interactions, absences from employment, and relationship turmoil.

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Anxiety is diagnosed by a variety of methods but most primary healthcare providers use evidence based practice tools for easy diagnostic evaluation. The Generalized Anxiety

Disorder 7 item scale (GAD-7) is an evidence practical tool consisting of seven questions, developed and validated by the DSM-V; the GAD-7 (Appendix B) is used to determine the severity of a patient’s symptoms. The GAD-7, like that of the depression questionnaire, uses a scale of 1-3 per question and the responses vary from “'not at all', 'several days', 'more than half the days', and 'nearly every day'” (Locke, Kirst, & Shultz, 2015, p. 617). Adding together the scores for the seven questions provides a numerical value and understanding of the patient’s symptoms. Scores of 5 or less indicate mild symptoms, 6-10 moderate symptoms, and 11-15 severe anxiety symptoms. The evidence-based practice tool suggests that any person who scores 10 or higher requires further investigation. Some medical conditions such as cardiac arrhythmias, thyroid disorders, and medication overuse (i.e., caffeine) can mimic anxiety symptoms and, therefore, should be ruled out as a cause of symptoms. “ Mood and anxiety disorders tend to be chronic and highly co-morbid with each other, as well as other psychiatric disorders” which is why most patients have a dual diagnosis of both anxiety and depression (da Silva, Ravindran, & Ravindran, 2009, p. 7).

Yoga As Therapy

Researchers suggest that GABA (y-aminobutyric acid) is often low in people with depression and anxiety. A study completed in 2010 by Streeter et al., outlines that “GABA systems has been found in mood disorders, anxiety disorders and epilepsy” (p. 1145), validating that GABA neurotransmitters have an impact on mood. The GABA system is one of two major neurotransmitting pathways in the brain. It primarily affects the central nervous system (CNS) and “many clinical conditions including psychiatric disorders appear to

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involve an imbalance in the excitation and inhibition” (Olsen, 2002, p. 159) of the GABA

system, which is also known to control anxiety and restore calmness to the body. The study

goes on to outline that anxiety and depression respond to medications that have been

identified as agents that increase GABA production such as the mainstay treatments for

anxiety and depression which are known as serotonin reuptake inhibitors (SSRI) medications.

Yoga is thought to decrease this chemical imbalance by a “down regulation of the

HPA and SNS” (Ross & Thomas, 2010, p. 3) without the use of synthetic medications.

Altering the chemical makeup in a downward regulation of HPA and SNA elicits a decrease in cortisol levels, improving symptoms. Streeter et al. (2010) went on to investigate GABA production within this study; he enlisted 34 participants who were in one of two streams: a walking group or yoga group. Participants were followed over the course of 12 weeks, receiving MRI brain scan at three separate intervals within the timeframe of the course program. Of the 19 people who participated in the yoga group, a significant increase in their

GABA production was noted, resulting in improved mood, more energy, and overall better- rated quality of life. Decreased anxiety was also reported upon those within the yoga group, which was significantly higher than the walking group. MRI scans also showed a “nearly significant increase in acute thalamic GABA levels in the yoga group” (Streeter et al., 2010, p. 1150). The study goes on to outline that there were “positive correlations of changes in mood and anxiety scores with changes in mean GABA levels” (Streeter et al., 2010, p. 1150).

The conclusion of the study was that there was a significant improvement with positive mood changes for those who participated in yoga against those who did not, suggesting that “this is the first study to report a positive correlation between thalamic GABA levels and improved mood” (Streeter et al., 2010, p. 1151) as measured by an MRI scan.

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A study by Doria et al. (2015) demonstrated the effectiveness of Surdashan Kriya

Yoga (SKY) in a recent study. The trial consisted of a mix of both men and women who had

a diagnosis of anxiety and/or depression according to the criteria outlined in the Diagnostic

and Statistical Manual of Mental Disorders (DSM- V). A total of 69 participants, who ranged in ages from 25-69, participated in SKY therapy for 6 months. They were assessed at strategically timed intervals throughout their trial and their anxiety and depression were evaluated using multiple assessment scales such as the Hamilton Rating scale for Anxiety

(HRSA) the Hamilton Rating Scale for Depression (HRSD) the Zung self-rating scale for

anxiety, the Zung Rating Scale for Depression, and Symptoms Checklist (SCL-90). The

results were that all participants showed a significant reduction in their HRSA/HRSD scores

for anxiety as well as depression. At all evaluation intervals throughout the 6-month period,

all participants within the study demonstrated a reduction in the symptoms of both anxiety

and depression. Initially the anxiety group had a much more significant decrease in anxiety

symptoms; however, over the duration of a 6-month period, the depression scores also

dropped showing a statistically significant reduction of symptoms using “five different

psychological scales” (Doria et al., 2015, p. 314). The overall results using the SKY therapy

demonstrated a statistical significant improvement in four main inclusive groups: (a) those

with depression being treated with medications, (b) those with depression not being treated

with medications, (c) those with anxiety being treated with medications, and (d) those with

anxiety not being treated with medications, all of whom participated in this study.

Most research articles reviewed outlined the influx of patients employing self-help methods prior to seeking professional assistance for those with or without a confirmation of diagnosis. Andrea Forfylow (2011) from the Applied Psychology Consortium outlines that

22 most people seek self-help methods to “maximize financial savings, refrain from consuming synthetic medication, or to avoid negative stigmatization” (p.132); the latter being the major driving force to seeking self-help. In fact, the research article goes on to suggest that more and more people are utilizing “complementary and alternative medicine (CAM) practices”

(Fortfylow, 2011 p.132) such as yoga. The research study by Forfylow reported that breath work was outlined as having a significant impact on participants of yoga who had also been experiencing anxiety symptoms, stating that “after one month of participating in breath work and meditation, both state and trait anxiety scores had significantly reduced” (p. 136).

Ueblacker and Broughton (2016) report, “Yoga can easily be used in combination with traditional mental health treatments”(p. 20) and should not be overlooked as a possible addition. Subramanya and Telles (2009) reviewed the effects of meditation and shavasana

(supine posture) on perceived levels of anxiety. After 20 minutes of meditation in the shavasana posture, participants were noted to have a significantly decreased level of anxiety.

The physical postures of yoga were found to improve not only physical flexibility of participants but also improved levels of self-confidence, ultimately reducing anxiety symptoms. While the research pertaining to the effectiveness of anxiety reduction among those who practice yoga is less than that outlining the effectiveness of practice for depression, yoga research has demonstrated a significant impact on the mood of those who practice.

Mainstay Treatments.

As previously stated, both anxiety and depression are spectrum disorders ranging from mild symptoms to severely debilitating. Finding the best treatment for each individual may prove to be difficult. Evidence-based medical guidelines used as a template to treat

23 patients in a primary care setting outline first-line therapies are medications to treat both anxiety disorders and depression While common mainstay first-line treatments are medical and come in the form of antidepressants and antianxiety medications, each will affect individuals differently because of the individual biochemical makeup of those being treated.

There is evidence that suggests programs, such as cognitive behavioral therapies (CBT) and counseling, are also deemed first-line treatment options. Most of the research reviewed suggests that even those who suffer from either anxiety or depression continue to experience symptoms despite treatment with traditional pharmacological treatment methods and the adjunct of counseling.

According to the Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines (2016), the mainstay treatments for depression and anxiety are pharmacological. Falling under the general class of antidepressants, selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs) are among those that are considered first line treatments (CANMAT, 2016). SSRIs and SNRIs are usually considered as initial steps in the management of both anxiety and depression. Both have a better safety profile and fewer side effects than TCAs and MAOIs (CANMAT, 2016). SSRIs and SNRIs work to balance the serotonin in the brain for a more balanced emotional state.

The use of pharmacological treatments has both benefits and risks. Some side effects are

“gastrointestinal bleeding, low bone mineral density”, as well as possible insomnia, dizziness, increased thirst, and diarrhea (Katzman et al., 2014, p. 7). Depending on the severity of those being diagnosed, these medications may contribute to the increased intensity of anxiety and increase suicidal ideation and self-harm behaviors (CANMAT,

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2016). While these methods may be effective in the treatment for some, not everyone will benefit from pharmacotherapy. For mild symptoms or those who are nonreactive/nonresponsive to medications, second line therapies are often given, usually as an adjunctive treatment; a second medication or medication class switch (changing from one drug to another). The main interference of the use of medications is that most therapeutic effect takes upwards of 4-8 weeks. Patients will take the medications for a month to a month and a half before they notice an improvement in their mood. If treatment fails, and/or they do not respond to a medication and require a medication switch, it is an additional month before they again can anticipate an improvement.

Psychotherapy treatments are classified as second-line therapy and consist of

Cognitive Behavioral Therapy (CBT), mindfulness-based cognitive therapy and all forms of therapy either individual or group (The Canadian Mental Health Association, 2016c). CBT is a process in which patients are addressing the facets that contribute to their specific symptoms. There are five components to CBT and they are: exposure, safety and response, cognitive strategies, arousal, and surrender of safety signals. Exposure is as it sounds; it encourages patients to “face their fears" (Katzman et al., 2014, p. 6). Patients learn to implement corrective measures to address their perceived experiences. Exposure also allows patients to develop self-compassion, “successful coping enhances self-efficacy” (Katzman et al., 2014, p. 6) which contributes to patients becoming proactive in their management of mental illness. Safety response inhibition allows patients to “restrict their usual anxiety- reducing behaviors (e.g., escape, need for reassurance)” (Katzman et al., 2014, p. 6) which assists with people addressing and acting to defuse the fight or flight response. Cognitive strategies provide education for people to target their fears. This approach allows those

25 participating in CBT therapies to understand and develop skills to correct the negative hindering behaviours. Arousal management educates participants on methods such as deep breathing, self-compassion, and positive self-talk, which can enable participants to control their anxiety and perceived level of severity. Lastly, surrender of safety signals in CBT is when “patients learn adaptive self-efficacy levels” (Katzman et al., 2014, p. 6); this development allows participants the ability to mindfully manage their own symptoms as well as allow them to prepare for future anxiety provoking situations.

Counseling and psychotherapy sessions are also listed as adjunctive treatments for those who are living with anxiety and depression (The Canadian Mental Health Associaton,

2016). Both are available in forms of individual and group settings. Individual counseling is generally self-directed and provides a forum that is nonjudgmental allowing patients to address their symptoms within their timeframe with the assistance of an unbiased, neutral party (the therapist or counselor). This often helps participants to understand their specific triggers and needs. Group therapy sessions are more based on education, providing an understanding of disease process, triggers, and techniques that may assist with the development of individual coping strategies. The unfortunate reality of counseling either group or independent is that it often worsens anxiety. Anxiety has an obvious impact on social interaction, which makes participation in counseling with an unknown individual almost impossible for those who have significant symptoms. What should occur in traditional medicine is a fine balance between traditional treatment and holistic treatments.

Chapter Three: Methodology

My first yoga class was something of an accident. I was working at the time as a

registered nurse in the emergency room of a regional trauma center. My co-workers were my

lifeline, my social life, and my family all wrapped in a green scrub-wearing package. There

were about four of us that were really close. The environment of work was chaotic to say the

least. Being a regional trauma center, we received the worst in terms of accidents, heart

attacks, and other misfortunes. Not to mention the fact that we also assisted many community

members with healthcare, which made our center the busiest between two major

geographical metropolises.

Most shifts were pretty somber; we were not delivering babies, providing elective

surgeries to improve someone’s appearance, or even providing revolutionary cancer

treatments. We were working with those who were in the middle of the worst possible

moments in their lives, which can lead to large amounts of personal stress. That is why my

co-workers became such an integral part of my life. They were the ones who knew what I

was going through; they stood beside me and felt the same loss, the same sadness, and the

same sense of human destruction as I did.

When I was introduced to yoga, as I said before, it was more of a joke that turned into

a curious adventure. My friend had mentioned that there was a discounted trial, a week’s

worth of classes for a cheap introductory offer, and “why not?” Let us try it. It was hot Hatha

yoga. The first class was January 2007. Not having ever practiced before, I had this idea that

yoga was a slow person’s exercise. I, on the other hand, had always been a runner. From my

work life to my personal life, everything was fast paced. After a bad day at work, I would go

for a long run; after a bad date, I would go for a run; after an argument with someone, I

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would go for a run. I can remember coming home from a particularly difficult shift and my

dad met me at the door. We chatted for what seemed like seconds before he said, “you need

to go for a run!” That is how much running was a part of my life and to say I was high strung

was also an understatement. I was the ultimate adrenaline junkie. Therefore, when someone

suggested that I slow down long enough to do yoga, it was odd and intriguing all at the same

time.

That first class I was one of three people in the room my co-worker/friend, the

instructor, and myself. My first thought was: What have I gotten myself into? Having never

done anything like this before and being very much a type A person (competitive, self- critical, and always having a time urgency mentality), I was determined to be good at yoga for the simple fact I wanted to be able to say I was good at yoga.

I listened to every word the instructor said, the tone she used, and the instructions she gave as they were paramount to my success. The breathing component of yoga I found to be very similar to running; methodical. The stillness, on the other hand, was something I had to will myself to get used to. The postures I found both difficult and intriguing at the same time.

I could run 30 kilometers in under 3 hours, but ask me to hold a chair pose for five inhalations and I struggled. “What’s with that!” was my internal monologue at about breath three. The heat was another factor all onto itself. It was stiflingly hot in the room; just simply lying on my mat prior to the start of the class I was sweating. I walked away from that class both empowered and defeated; the latter was in a way that was not negative, but challenging.

I had a sense of stillness when I walked out of that first class, something that was a rare sensation for me. I only felt stillness when I was running, listening to my footsteps and the sounds of the surrounding world. I often ran first thing in the morning, so I could have quiet

28 and experience the world before it woke up for the day. Although I was moving I had "mind stillness"; I was not thinking about life or death scenarios, I was running down the street, wondering how I would get from point A to point B and in what timeframe I would do it. I never thought I would have had that at a yoga class. While the trial week came to an end, we went back to everyday life and I forgot the sensation of stillness I briefly felt while in those early morning yoga classes.

As the year came and went, my career was stagnant. The hours got longer. The satisfaction in my job turned to dread, and the friendships turned to the pillars of my survival and my happy upbeat self began to get pulled down by all the horrible things I saw, that I felt, that I was a part of, and I absorbed every one of them. I took home the family grieving the loss of a parent I took home the elderly persons who had only an unknown nurse to hold their hand while they died, and I took home the parents identifying their child’s body. I took this all home with me. I ran, I ran a lot, and still I saw those faces, felt those emotions; I was a sponge to all the negativity that surrounded me. I was becoming restless, anxious, sad, and despondent.

At that time, it was the lowest point emotionally for me. I was unsettled in my job, not because of the work I did but because of the things I had to do. I could no longer find the joy in being an Emergency room nurse. There was no joy there. It was death and dying what seemed like all day every day. I often over those years turned back to my mat for solitude and stillness, but I do not think I was ever really present enough to understand the gifts that I was being given. Fast-forward 3 years from that time; I had made the choice to leave my job and go back to school. I lived in Thunder Bay for a year, leaving my husband and my family behind so that I could go back to school and become a nurse practitioner. Once I had moved

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back, I started working as a nurse practitioner and it was about that time that there was again

another low-cost yoga trial taking place. This time it was an 8-week intensive yoga

challenge. "Challenge yourself to do mindfulness practice every day for 8 weeks and see how

your life changes" was somewhat of the caption. I did it. What I wanted from that challenge

was what I had experienced initially many years ago, stillness. Things were swirling around,

I was transitioning into a new job, I was undertaking a Masters program, and I was trying to

be an emotionally available spouse. All of these things were suddenly overwhelming, I

wanted personal gratitude, I wanted an inner peace, and I wanted to be present. At that time I

felt like my life was in a snow globe and someone was shaking everything up while I

helplessly waited for things to settle.

I have always been a journal writer and some of my best revelations of life come from looking back on those personal entries, my adventures, challenges, and journeys. Being able to see them again with a different perspective often changes how you proceed. That is what I

would do. I would document my adventure; my yoga adventure after all this was the longest

and most consistent yoga I would have practiced. I wanted to know if what I had felt all those

years ago with stillness and peace could be validated and for real. The timeframe was May 1,

2016 to July 31, 2016. Following every class I attended, I would reflect and write on what

happened during that class. What I found was that yoga not only had an impact on my

physical health, it balanced my psychological health. My yoga journey impacted my mind,

body, and spirit. This is that journey.

The Mind

The mind is a powerful organ that can affect everything about your life. I had never

experienced anxiety or depression before. They were sensations that were so far removed

30 from my frame of reference that I began to wonder if what I was feeling was maybe a result of the weather. Maybe I was running too much on a limited carb intake, or maybe, just maybe, it was that I was in a rut. It would pass surely. But when my heart would race as if I was a new graduate nurse every time a new patient would come through the door, or when I was not up for going for a venting breakfast after a long night shift with my colleagues, I knew it was more than being in a rut. I was now a nurse practitioner with more knowledge and more responsibility. After all, I would write my own prescriptions now and treat patients for chronic, episodic and acute illness. All of those things I thought were contributing to my restlessness. Maybe I thought because I was now in charge of patients’ health care outcomes, and that is a major responsibility, was that why I was down? Or was it because I was drinking too much coffee that I had a racing heart? When I realized all I wanted to do was sleep, I knew what I was experiencing was more than a shift in my nutritional intake. I was irritable, short, and anxious. I had a restlessness I could not fix and I was down, more than just sad. I was unhappy and miserable. The brain is so powerful. It fuels our thoughts, makes our decisions, and has this inherit knack of controlling our moods. It is about this time that I realized I was both anxious and depressed. I could flub my way through a laugh with friends but for the most part I was pretty despondent and I could not find joy; I could not remember the last time I laughed and, looking back, I was pretty broken emotionally. My anxiety came in the form of very minor panic attacks, racing heart, sweaty palms, and sensations of being overwhelmed. I was always having self-doubt and asking the questions: Am I good enough at my job, am I a good person, good friend, good daughter, good spouse? Not being able to control thoughts sometimes has a tremendous effect on self worth. I felt like I had no control anymore over my thoughts, or the way I felt, and I was down. I think the depression for me

31 was a result of not being able to control my thoughts. I could not control the intrusive self- doubt I had which made me really sad. I had never been this kind of person before. I was the one who lifted everyone else up. I was not able to do that for myself, which is likely why I loved running as much as I did. It was controllable; I could get lost in the sound of my footsteps, and I was good enough. I was good enough to run, I was good enough to run with,

I was good enough to participate in races, and I was good enough. For a while, the only time

I was not anxious was when I was running. I wanted to be more grounded, more grateful for the things I had and the gifts I was given. In and around this time, I found myself signing up for a yoga challenge. While I undertook this journey, I vowed to myself that I would also identify the things I was grateful for everyday, both in life and personally. If that meant my body, my family, or my friends, whatever it was at those moments after my classes I would write it down.

Week one, class one, May 1st was the start of the challenge. I remember looking back on the first day of that challenge and thinking I would record my emotions, my thoughts, and my rewards of this challenge for personal curiosity. This was the start of my journey to a more balanced self, or so I had hoped. The first class was a morning class, 6 a.m. start, and

Hatha hot yoga. I remember my anxiety was at an all-time high. These challenges were always busy so not only was I competing with myself to be present, I was completing with others to have a spot in this class. The start of the class was something of what I had remembered from the years prior that I had experienced: breathing, postures, stillness, and heat. Good god the heat. With my anxiety increased and my internal monologue so negative,

I was not good at it; I struggled with the postures, and my mind was never still as I lay there

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as savasana (the supine position, eye closed, palms up which often opens and closes a yoga

practice).

Following the hour-long class, I sat in my car and wrote in my journal. What

happened after that first class was not what I had initially thought would happen. I was

feeling exhausted. The class left me with such fatigue, but not muscle fatigue, mind fatigue.

My thoughts were slightly more settled; however, I still had the sensation of worry. Here is a

snapshot of my journal entry from that day

May 1st: First class of the challenge done. What the hell was I thinking, it was so

crowded in there this morning, I felt claustrophobic, everyone so close. I am way

more tired that I had expected and I still have to work the rest of the day. The

instructor was calming, she brought up a good point…be present. Was I present? For

some reason I could not stop thinking about work. There is always so much to do

there, I don’t think I am doing a good enough job. My back is kind of sore too. Well

first class down. Grateful for my husband, he keeps me sane.

I remember thinking in those first few classes that I was equally as annoyed as anxious, someone was coughing when we were supposed to be meditating, which I found super irritating and distracting. Someone else came in late and was disruptive which broke my concentration. I was edgy, irritable, and definitely not myself.

By day 5, May 5th, I was having a particularly difficult internal struggle on why I was

working where I was, and what was going to happen next. And as always, I was having that

sensation of time urgency (as many type A people do), when at my yoga class something

changed. I could get through the chair pose for five solid breaths! There it was, like a little

personal victory. But I also noticed something else; my mood, my nervousness, my down in

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the dumps mentality was starting to shift. I was starting to feel a little glimmer of me. The

anxiety of getting to class, however, was still there, This occurred for at least the first 4

weeks, until I had one instructor say, “If you do nothing else this class, if you don’t do any of

the postures, give yourself the gift of being present.” Present? Gift? I did not understand that

word in the way he intended. Of course, I was present; I was there physically, which is not

what he meant. Mentally I had to be present. I actually did not do any of the postures that

class I just lay there focusing on my breathing, listening to it, perfecting it, and I let all the

stuff in my brain shut off. I got it! The gift of being present, I understood that it meant more

than just being somewhere, exercising, trying to be perfect. I understood that I could allow

myself to be something that was less than perfect. With that realization came such a sense of

peace.

June 1st. OMG I did not do a single move in yoga today. I just lay there. Breathing. I

learned to breath? Crazy right??! I know how to breath, I’ve been doing my whole

life, but I just learned the art of breathing and being in the moment! I thought I was

going cry when the class was over- imagine how dumb I would have looked. Grateful

for my husband, and the nice lady who bought my coffee this morning at the drive

thru-Pay it Forward!

My anxiety started to decrease, the veil of being down, restless and insecure, had started to lift. It is funny, looking back I feel almost silly at how much impact one particular class has had on my life, but I will forever cherish that class for what was a monumental moment for me. In my journal entries, there still was low self-esteem and limited self-worth, but I was starting to come back to life. It was a little gift of what was in store for the remainder of the challenge. Anxiety, for anyone who has experienced it, is pretty horrible. It

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is like you are giving a speech you have not prepared for in front of millions of people all day

every day.

Mid challenge something happened. If I look at my journal entries, my personal

thoughts about myself changed:

June 15th: Well I did a new type of class tonight; rest, relax and restore. Kind of a

challenge much more slow than the other classes. AND… I was also able to do a

HANDSTAND! What??!! Who would have thought that? Last week I had such a

hard time, but I actually held it today for a whole 3 breaths. Super proud of myself!

Grateful for my husband, the beautiful warm weather and my handstand!

I was actually becoming more kind to myself. My anxiety was almost completely gone, my smile was coming back, and I felt like me! I was also able to positively look at my life and recognize I was given gifts, not only in this challenge, but also in my life. I refer to them as gifts because they were like prizes, my bonuses of practice, the happily unexpected repercussion of this yoga challenge. I was able to find peace and gratitude. It may sound so simple, but I have always been the person who is looking for the next big thing in life, whether it was career goals, relationship goals, or financial goals. I have always been the

“what next” thinker. For the first time, I reflected on my life. I had extensive running achievements; I was an accomplished horse jumper; I travelled the world; I hold two diplomas, two degrees, and was working on my masters; I have a great job; I have the most amazing husband, and super supportive family, I suddenly realized I was actually living the next big thing. I was accomplished! I was able to see that I had so much to be grateful for. I had appreciation for the fact that I had these things and I have been successful at all of these goals I was also grateful for the smaller things, something I had never done before. I was

35 finding joy in things that I would never have even looked at before the weather, the smile from a stranger, the nice people I met while at the market, and even the people in my yoga classes. I was no longer annoyed. I understood that I had the internal strength to change these thoughts. I could and I did employ positive self-talk. I had more self-esteem and I was present and grateful. I was able to find joy in the smallest of things. Yoga offered me for the first time in a long time, stillness. My ever-racing mind, my nurse practitioner critical thinking mind was given a break. I was able to be still. No racing flight of ideas, no thinking next steps, I could be present in the moment without struggling to breath. My mind felt clear, lifted was the fog of reality and what remained was a clarity that changed every single time I practiced. My mind was affected in a way that brought out an inner peace that I was unsure I could have ever experienced without yoga. I overheard someone once say, “Change your mind and your body will follow." I get it. I had developed the power to change my own thoughts. I no longer looked to the negative in things; I looked to the positive.

June 30th: My Birthday! Almost half way through the challenge. I am feeling great!

Sleeping well, I can stop my mind from racing and I don’t feel as drained mentally as

I have been. Jeff says I am happier, I feel like I see joy in the smallest of things. I

went for a run today and I didn’t care how fast I was going or even if I walked, I was

totally OK with just catching up with Pauline (my running partner) and if we walked,

we walked. Oh and I totally bombed a job interview! I crumbed under the pressure of

questioning, but I feel like everything happens for a reason. Do I really want to work

under such rapid-fire pressure? The interviewers were intense. Probably not the right

fit for me.

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There was the sensation of calm that came over me class after class, each time lasting longer and longer. I think the greatest gift I was given during this challenge was that it is okay to be imperfect. I was imperfect which became perfect to me. I had the ability to shift my thinking; I was not longer anxious but grateful. I was blessed really to have the things I had and I understood the significance of slowing down. I needed to be present for myself and my husband. What I realized the most was that life is very short, too short to be self critical and abusive. I was good enough, I was smart enough, and I was kind enough. I just needed to remind myself of that. This yoga challenge was that opportunity. I stopped feeling depressed.

Nervousness, racing heart, and lack of self-worth all changed. I no longer felt down, I had energy. I felt like I was more positive and I no longer was irritable or argumentative. I also was able to implement this new sense of positivity into my work life and home life. I was able to control my mind from those intrusive negative thoughts and actually take a minute to be present and address those difficult situations, like confrontations with optimism and enthusiasm. Looking now at the trials I faced was a learning experience rather than disappointment or failure. The vivacious, life loving me was happy again and back, present in my own life and understanding how powerful the mind is on my emotions. “Mindful, awareness of experiences and emotions as they arise, without having to change them”

(Khanna & Greeson, 2013, p. 249). I was mindful.

It is amazing to think something as simple as yoga could have such an impact on my mental health. Nonetheless this was not the only gift I was given through this yoga challenge.

I was also given a body and spiritual connection that complimented my mind and newfound life’s perspective.

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The Body

Because I went into yoga as a long-distance runner, I foolishly assumed that I was

physically conditioned in a way that I could tackle any exercise. I was running several

hundred kilometers a month, and running 30 km races in under my expected time

qualifications, but, wow, those first few hot yoga classes! I felt like I was a concrete statue

who had never done anything physical before. I felt like my body was made of lead, my

hamstrings were tight, my flexibility was obsolete, and my intolerance of the heat made those

first few classes almost unbearable. Why was it so much hotter than I remember? Given that

I have a personality that is very much a nonquitter, I gave it my all. My best friend once

described me as “a jumper- feet first, all in, then ask questions later” type of person, to which

I would absolutely agree, and that was the primary reason that I was not about to give up on

this challenge. I had perfected the art of pushing my body to its limits, but yoga was a whole

new propensity.

May 12th: my body hurts! My legs are sore, my back feels like it is bruised and my

triceps are screaming. I don’t remember feeling this defeated before. Maybe I should

just go back to running? I don’t think I felt this beat up since the around the bay race.

How am I supposed to go back tomorrow? I almost passed out today, the heat is

incredible and they say it feels even hotter because it is hot outside. I hate this

challenge. Why did I do this?

The physical effects on my body were impressive. I started to build muscle in places, such as my arms, that I never knew I had. I was actually very surprised on how quickly my body started to transform, I could sit cross-legged without my knees being up around my ears. This happened about week three.

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May 20th Felt like I could vomit in the class today, the music the heat and the stench

from the man beside me were all overpowering. I did manage to do the entire abs

series, which could have also been a reason wanting to vomit. And I can actually sit

cross-legged! Imagine that- never could do this before- feels a bit strange not having

my knees up in the air.

I developed the ability to touch my toes, which may seem like a pretty standard thing to accomplish, but when you run as much as I did, tight hamstrings account for a total lack of forward flexion. Yoga was supposed to improve flexibility, which I was beginning to appreciate. My body began to tone, I had improved core strength, and I noticed an improvement in my energy levels. My stamina was good, or so I thought, but yoga improved it to a level that I had never experienced before. Weight loss was another surprise. I do not know why I did not expect it but basic science demonstrates that with muscle toning comes weight loss.

June 30th- my birthday!! And I feel amazing! My pants are too big, Hubby says I need

to eat more, but I feel like I’m eating everything that passes under my face. Salt

especially. I can't get enough salt. Maybe because I’m sweating so much. Going to

buy a new outfit today. Grateful for my hubby, my family, and my strength.

Any aches and pains I had were starting to diminish and my physical presence also changed as well. I was no longer the person hunched over desks. I could feel my confidence shift as my body changed. I walked taller, I held my head up, and I had better balance and posture. My posture was always something I was aware of. Being an amateur competitive horse jumper, posture was everything; it came so naturally during those weeks of my hot yoga practice that it only improved as the time went on. With my enhanced posture came

39 balance. My balance improved to the point where I was able to have horseback riding lessons without any reins. While I was on a lunge line (essentially a long leash that was controlled by my trainer), I could manipulate and ask for my horse to transition from walking to a canter with only the use of my core strength and legs, no hands. It is pretty amazing all on its own to be able to run a horse with no form of control other than that of your legs and stomach muscles. I was impressed.

Yoga not only improved my physical external appearance, it completely changed my cardiovascular strength. Not to say that those first few classes were not rough, they were.

Anyone who runs for prolonged periods of time knows that one of the benefits to running is improved cardiorespiratory health, a fancy way of saying your body’s ability to transport oxygen to muscles during prolonged physical exercise and how well that oxygen is utilized.

The respiratory and cardiovascular systems work together, creating the cardiorespiratory health system. The breath work associated with yoga was not a foreign concept to me but it was challenging in that I had to concentrate on not holding my breath. What was new was not speeding up breathing, when you run or exert yourself, you breath faster to compensate.

Yoga was actually the opposite. You return to a slow breath even during those cardiovascular challenging moves.

I also had to learn to move with my breath. Bend forward and exhale. While I have no scientific evidence that my cardiorespiratory health officially improved, here is what I know: yoga allowed me to breathe. As a human, we breathe without consciously identifying that we are doing it, but it remains an integral part of our presence. Yoga is the attentive practice of mindfulness breathing and movements; life is the oblivious act of existence.

40

What impressed me the most about this journey physically was my breathing. My

lung capacity completely shifted. I was always able to control my breathing while running,

but there were those times when you run so fast or for so long that by the time you stop you

realize that your are panting and that you were not even breathing at all. But what I noticed

when I ran after practicing yoga for several weeks consistently was that my breath was

steady, smooth, and calm. Almost instinctually, my yoga tool set had spilled into other areas

of my life. My breathing was unchanged from hills to even terrain. I was breathing. I was not

panting, I was not gasping, I was actually breathing.

June 6th: HOT HOT HOT! The class was so hot! I did a more challenging class today,

an intensive flow class which made me really work, the transitions were fast, almost

too fast, but I kept up. My thinking about the postures has changed. I don’t really care

if I am fast, I care about my form, and perfecting the movement I am in. I went

running last night and my breathing is different, I think I can control it more

effectively. No panting. We did sprint work and I didn’t die!

Another surprising moment for me during this challenge was the recognition that everything I was learning in these classes, from breathing to purposeful movements to gratitude and self-compassion, was spilling out into the real world. It was like the life lessons

I was learning were all developed in yoga class. Maybe, just maybe, the century old practice of yoga was on to something.

June 21st Went to yoga today and felt strong. I also noticed that my pants are fitting

me differently. I feel like I have more confidence. Had an argument at work and I

found myself breathing, slow methodical breaths. I was surprised that I did not stew

on the argument. I addressed it and moved on. Weird! Normally I would have

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analyzed it a million times by the time dinner rolled around. Breathing… so

simplistic, so integral and so very undervalued.

With the body changes came confidence, and with confidence came mindfulness, and with that came self-perseveration. I was beginning to feel like me. One hundred percent back

to my old self. This rut I was in, the depression, lack of energy, lack of motivation, panic, and

nervousness was all gone. I was able to be present, both physically and mentally in almost

every situation. Anxiety and depression have physical effects on the body. The lack of

motivation, lack of energy, fatigue, and self-deprecating mentality was all gone. When I was

faced with challenges in yoga and succeeded, it brought a self-assurance that I could not find

elsewhere. Whether it was holding an arm balancing posture such as the crow or a handstand,

I had an appreciation for my body. I appreciated my strength, my youth, and, most of all, my

health. These were not the only empowerments I was given through my practice of yoga. My

spirituality was impacted the most.

Spirituality

I really do not know if I would have been able to provide anyone with a definition of

what this meant before I set out on this impromptu journey of developing a consistent yoga

practice. I guess the ultimate question is: If spirituality means something different to

everyone, how is there a definition? What spirituality meant to me before this journey was

more structurally grounded religion. I thought that the two went hand and hand, religion

equaled spirituality. I guess that the beautiful thing about the definition of spirituality is that

if you asked all the people you know to define the word spirituality it would be different

from person to person. Solidifying that spirituality is individualized. “Spirituality emerges

and grows from our individual experience” (Grosso, 2015). It is the experience that one feels

42 when they have a sense of inner peace, and if I had never undergone this journey, I would still be under the assumption that spirituality and religion are interconnected, and maybe for some they are. Spirituality to me now means a compilation of things. It is the belief in something more powerful than us human beginnings, not to say that I believe in a god per say, but I do believe that there is a higher power than us. I believe that we identify with the people in our lives that we are intended to be in connection with. People cross our paths at integral junctions in our lives when we need them the most. I believe that I have the power to accomplish my goals, I am powerful in my beliefs, and I have the inspiration to change and be the change that I want to see. My spiritual journey through yoga began with my realization that I do not have to be perfect. My ever-racing mind was still good enough even if it slowed down long enough to enjoy the gifts of the environment around me. My spiritual journey allowed me to address the anxiety I have about my lack of self-esteem, my internal struggle to always be better. My spirituality allowed me to see things for what they are right now, not how they should be. It allowed me to recognize that I was not happy with the person

I had become while working in the Emergency Room. My lack of spirituality prior to this journey allowed me to think that I was defined by my job and that I was actually only perceived as an ER nurse. I think I realized during week seven of this challenge that I am so much more than a profession. I am a human being who believes I was put here to do good things. I believe that I have things to offer my fellow humans. I believe that my spiritually is something that is a journey, not a destination.

June 17th: this challenge has changed me- made me more aware. I don’t know why I

thought I would only ever be known as an ER RN. I am Melissa. I have a good heart,

a solid support system, and an amazing family who loves me. That is what defines

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me. That is why becoming a Nurse practitioner I think has been so hard. I thought I

was losing my identity. I thought I would no longer be looked at as someone of

significance. I realized today in meditation- hit me like a ton of bricks. I am defined

by the person I am, not by what I do. If I never tell anyone my job title ever again, it

will have no bearing on who I am. My yoga studio knows me as Melissa, my family

knows me as Meliss, my husband knows me as Meliss, my friends know me as

Meliss. I am Melissa I am not an ER nurse, I am someone who wants to be good. I

want people to find love and peace, I want people to recognize that there is still

goodness in the world and I am part of that. WHAT HAS THIS CHALLENGE

DONE TO ME J

I found myself in a quiet yoga class with devoutness to improve my time here. To be the best person I can be, the best wife, the best daughter, but most importantly to be the best

Melissa I would be. With this discovery, my spiritual awareness, my anxiety about daily life dissolved. My depressed, down in the dumps outlook lifted and I began to see more that what was just in front of me. I began to actually live my life. I saw things that I have never noticed before. I had a completely different approach to my job as well. I no longer dreaded going to work. I looked at my interactions with people at the worst time of their lives as being a gift, that I could actually make a difference in their perceptions of that experience. If you think back to the worst thing that has ever happened to you, there is always something that sticks out about that memory, whether it is a smell, the words someone used or the feeling you had in that experience. What I realized is that I could change that memory for people. I could, in the smallest of ways make it better. I offered up my own vulnerabilities to those I treated and in exchange they began to see me too as human, not just the ER nurse or a nurse practitioner,

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not someone who was better, but someone who understood what they were going through

and someone who offered sympathy and humanity when it is needed the most. What you put

out into the universe you will get back and I choose during week eight of my yoga challenge

to put a 100% into my universe to see what I would get in return.

As my yoga challenge came to an end, I found myself still going everyday, still

participating in the extra workshops about gratitude and about mindfulness. I understand

now, looking back, that this yoga challenge was probably the best intervention for my life

that I could have ever done. My life lessons, my stop and smell the roses mentality was and is

exactly what my mental health needed. Sometimes when we get caught up in the really fast-

paced lives we live, we lose sight of what matters. For me, what matters are my family, my

friends, and my surroundings. I am living the next best thing and I needed to be reminded

that material possessions and stuff, like professional titles, often clutter our lives both

physically and mentally. My spiritual journey was one that had a significant impact on my

life and those who surround me.

The life lessons I learned through this 8-week challenge are that our psychological

flexibility is very much impacted by our physical health and vice versa. Mental health

regardless of the severity of symptoms, can have a major impact on our body’s capabilities to

function and carry us through this world. With a consistent yoga practice, I learned

mindfulness, self-compassion, and kindness. I learned to let go of overpowering intrusive thoughts that hindered me from moving forward with my personal and professional goals.

My physical health improved when my psychological health improved, and I discovered a spirituality that will carry me forward in this life. I built a launchpad for success in my discovery of yoga. I established a foundation of personal security and strength that I did not

45 know I had, but knew I needed. “The primary focus of Yoga is to restore the mind to simplicity and peace, to free it from confusion and distress” (Ingra, 2001, p. 35), all of which

I discovered over the course of 8 weeks. I still practice today. I find things that once would irritate me or make me anxious no longer do. I am at peace with my world. I am grateful for the things I have, the people who surround me, and the life I live. I never underestimate the power of significance and I am significant. If you would have asked me at the beginning of this challenge what I had expected from it, I would have said that I expect some quiet and lots of sweating. I wanted stillness, and an inner peace. What I was given was so much more.

I was gifted with a positive outlook on myself. I was gifted the power to know I am good enough. I was gifted the strength to implement change. I was gifted the significance to appreciated those around me. I am no longer selfish; I am no longer looking for the next big thing. I am still, I am present, and I am grateful for who I have become. I have always known the positive benefits of yoga, but this paper has allowed me to address the magnitude of the impact it has had on me personally, and for that I am forever grateful.

Spirituality involves an awareness of the other, which may be god or other human or

divine beings or something else, which provides the basis for us to establish our needs

and desires for, understand our experiences of, and ask questions about, meaning,

identity, connectedness, transformation and transcendence. (Crisp, 2010, as cited in

Boynton, 2014 p. 244)

This is how I define spirituality now.

Chapter Four: Results/Findings

Future Directions for Research

As stated previously, yoga as therapy has become a popular area of research. While the outlets for future research are abundant, there are some specific areas of future research that I would like to see happen. Given the abundance of research in relation to anxiety, depression, and yoga practice, there are also many research limitations. These limitation vary from the type of yoga practiced, the duration of time, and the participants. Most of the research articles reviewed for this paper had a duration of no longer than 16 weeks, which is not a suitable amount of time to understand and fully grasp the benefits of a consistent practice. I have been in a regular yoga practice for over a year and I continue to see improvements, changes, and developments in my mind, body, and spirit. The long-term effects of a yoga practice would be a very interesting area of research.

The healing powers can be adapted from a thesis written by Deborah Willings- (2014) who breaks down the healing power into three categories: psychological flexibilities, mindfulness breathing, and valued living. Future research could focus on these areas, which could address the impact that yoga has on psychological flexibility. This is the way we view ourselves, and our interpretation of anxiety and depression. Yoga may change our psychological flexibility. Many people who experience anxiety and depression will often have a very rigid way of thinking, myself included. We tend to second guess ourselves and have very limited self-compassion( Kuzman, 2015). Psychological flexibility as an area of research study could look at how something as simple as changing our perspectives can lead to improved mood. Changing what are personal definitions are and how they define us can ultimately change our self-worth, our self-esteem, and our overall interpretation of perceived

46

47 stressors. Psychological flexibility developed from yoga may allow participants better capability to adapt to different environments, stressful or anxiety provoking situations.

Psychological flexibility is a positive byproduct of consistent practice and many of the research articles reviewed demonstrate that participants have noticed improvement after one class. The long-term effects of practice over an extended period of time have not been examined in depth.

Mindful breathing, specifically that which is practiced in yoga and meditation, could be a positive further area of research. Breathing techniques can decrease the symptoms of anxiety and depression through the fixation of being present. Focused breathing can reduce the noise of our minds and allow participants to focus on the moment rather than what it going to happen next. Many of the articles reviewed outline that the breathing component of yoga assists with stilling of the mind. Although no specific research article looked simply at mindful breathing, this could be a very valuable area to look at further.

The take-home message of most of the articles reviewed is that most of the participants were looking for some form of self-help treatment, something that they could implement without the direction of a doctor, without the use of pharmaceuticals, and without the stigma attached to counseling. What was underestimated in the research reviewed is that mindful-breathing and concentrated breathing can be implemented by anyone at a minimal cost. While some posttraumatic stress counseling incorporates deep breathing techniques, the present research does delve into the positive effects for those who have anxiety and depression.

Lastly, the "valued living" (Deborah Willings, 2014) component that comes from not only a positive mind but from the life lessons that are learned on the mat while practicing

48 yoga, could be a very beneficial area of future research. Yoga instills a sense of optimism and confidence for many of those who practice on a regular basis. Future research could address the sense of self-worth that is developed by those who practice, the established calmness that is acquired and the sense of accomplishment. The valued life metaphor is simply to appreciate things, life, and spirituality. Although spirituality is not often addressed in the current research, and it does have relevance to this topic. It is understood because the concept of spirituality and valued living is difficult to measure. The data obtained could change the perspectives of those who do not practice; appreciate the little life gifts that are offered and do not underestimate the significance of being present. I would like to see more research simply address the sense of self-confidence that many people who practice yoga develop.

There was one particular study that addresses young women with eating disorders and the development of self-confidence (Kinser, Bourguignon, Taylor, & Stevens, 2013), but little was found for those who have mental illness. All who participated valued the enhanced sense of self-confidence they achieved from their yoga practice.

It is amazing to think of what the body is capable of in terms of practice, but when you put the psychological component with the practice, the benefits are plentiful. The flexibility, stamina, and strength that yoga creates is not composed of just muscle and bones.

It is the inner strength of the mind that allows us who practice regularly to maintain a clear mind in order to achieve a productive practice. Future research should address the conceptual idea of the treasured inner strength that many consistent yoga participants develop. The monumental awareness of self during practice is often times overwhelming but very much a phenomenon, and again not discussed in current research.

49

I feel it would be of significance if future research could focus on the above-mentioned areas of mindfulness breathing, psychological flexibility, and valued life in relation to yoga, anxiety, and depression.

My hope for future research is that it focuses on less fortunate demographics, those who are at higher risk of mental illness; those who are not employed, living well below the socioeconomic standard; and/or those who are unfortunate enough to have one or more parents diagnosed with mental illness. The effects that yoga could have on those with posttraumatic stress could be beneficial to addressing their symptoms. I often have wondered if we know the benefits for students in elementary school practicing yoga (Velasques, Lopez,

Quinonez, & Paba, 2015) on a daily basis. What about people in other institutes such as prison? While there are a few small random controlled trials that outline the effect of Prison

Smart Programs, which incorporate yoga in prisons, more investigation is warranted on long- term effects (Brown & Gerbarg, 2005). With limited resources, such as counseling or traditional medical therapies, yoga could have a significant impact on the lives of those incarcerated at minimal financial impact.

Conclusion

When I started to write this paper, I thought that perhaps it would be easier than it was. It was challenging I felt vulnerable and stigmatized for admitting that I was anxious and mildly depressed. I have no good reason to be. As I travelled through this challenge, I felt that others could benefit from what I learned if they too were feeling unsettled in life. What this paper has allowed me to do is confirm what I have known about yoga since my first class. It is a powerful tool that allows me to focus on the now, connect with my inner spirit, and be present in a moment and a life that is what I make of it and want it to be. Yoga is the

50 outlet that can be used by people of all stages of life, all backgrounds, physical abilities, and religions. Yoga can be done at home, at work, or in a studio. “Yoga has a significant place in healthcare, at least as an adjunctive if not primary therapy”(Khala, 2013, p. 2) for mental illness. Yoga has been practiced for centuries and there is a reason that it is the number one self-help therapy for those with mental illness. Yoga is a compilation of postures, breathing, and mindfulness that allows for clarity of the mind that often is not acquired in other exercises. I have been a runner for a number of years and I have not sustained the same self- confidence and self-assurance as I have during my yoga practice.

While I have always known the benefits of the principles behind yoga practice, this paper has allowed me to research the specifics of what I was feeling in comparison with that in the current literature. The benefits from practice are abundant and my hope with the completion of this paper is that more healthcare providers and laymen will understand the beauty of an open mind and the powerful gifts that yoga provides to reduce the symptoms of anxiety and depression in harmony with mainstay treatments. I walk away from this paper with a more powerful appreciation for the lessons I have learned on my yoga mat, the challenges I have overcome, and the spiritual balance I have achieved.

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Appendix A

Patient Health Questionnaire (PHQ-9)

Patient name: ______Date: ______

1. Over the last 2 weeks, how often have you been bothered by any of the following problems?

More than Nearly Not at Several half the days every day all (0) days (1) (2) (3) a. Little interest or pleasure in doing things. r r r r b. Feeling down, depressed, or hopeless. r r r r c. Trouble falling/staying asleep, sleeping too r r r r much. d. Feeling tired or having little energy. r r r r e. Poor appetite or overeating. r r r r f. Feeling bad about yourself, or that you are a failure, or have let yourself or your family r r r r down. g. Trouble concentrating on things, such as r r r r reading the newspaper or watching TV. h. Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless r r r r that you have been moving around more than usual. i. Thoughts that you would be better off dead r r r r or of hurting yourself in some way.

2. If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? r Not difficult r Somewhat r Very at all difficult r Extremely difficult

TOTAL SCORE ______

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PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ® is a trademark of Pfizer Inc.

Instructions – How to Score the PHQ-9

Major depressive disorder is suggested if:

• • Of the 9 items, 5 or more are checked as at least ‘more than half the days’ • • Either item a. or b. is positive, that is, at least ‘more than half the days’

Other depressive syndrome is suggested if:

• • Of the 9 items, a., b. or c. is checked as at least ‘more than half the days’ • • Either item a. or b. is positive, that is, at least ‘more than half the days’

Also, PHQ-9 scores can be used to plan and monitor treatment. To score the instrument, tally each response by the number value under the answer headings, (not at all=0, several days=1, more than half the days=2, and nearly every day=3). Add the numbers together to total the score on the bottom of the questionnaire. Interpret the score by using the guide listed below.

Guide for Interpreting PHQ-9 Scores

Score Recommended Actions Normal range or full remission. The score suggests the patient may not need 0-4 depression treatment. 5-9 Minimal depressive symptoms. Support, educate, call if worse, return in 1 month. Major depression, mild severity. Use clinical judgment about treatment, based on 10-14 patient’s duration of symptoms and functional impairment. Treat with antidepressant or psychotherapy. Major depression, moderate severity. Warrants treatment for depression, using 15-19 antidepressant, psychotherapy or a combination of treatment. 20 or Major depression, severe severity. Warrants treatment with antidepressant and higher psychotherapy, especially if not improved on monotherapy; follow frequently.

Functional Health Assessment

The instrument also includes a functional health assessment. This asks the patient how emotional difficulties or problems impact work, things at home, or relationships with other

59 people. Patient responses can be one of four: Not difficult at all, somewhat difficult, Very difficult, Extremely difficult. The last two responses suggest that the patient’s functionality is impaired. After treatment begins, functional status and number score can be measured to assess patient improvement.

For more information on using the PHQ-9, visit www.depression-primarycare.org

Patient Health Questionnaire: PHQ9 retrieved from http://www.ubcmood.ca/sad/PHQ9.pdf

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Appendix B

Generalized Anxiety Questonnaire: GAD7. Retrieved from

http://www.integration.samhsa.gov/clinical practice/GAD708.19.08Cartwright.pdf