Mind-Body Interventions for Mood Disorders in Older Adults

September 9, 2013

Nonpharmacological interventions-such as mind-body interventions-can improve a partial response to antidepressants via stress reduction, improved physical functioning, increased socialization, and reduced risks of polypharmacy.

Complementary use of mindful exercise, such as Tai Chi and yogic meditation (Kirtan Kriya), can improve clinical outcomes of mood disorders in older adults-as demonstrated in brain scans, biomarkers of cellular aging, and mental health rating scales.

This according to Helen Lavretsky, MD, MS, an expert in geriatric psychiatry and holistic medicine, who spoke on this topic at the recent the American Psychiatric Association’s annual meeting.

“Mind-body exercise, which includes yoga, Qi Gong, and Tai Chi, is used to improve psychological well-being, hypertension, cardiovascular disease, balance, pain, insulin resistance, depression, and anxiety,” she said.

Acknowledging that colleagues and others often ask her to differentiate between aerobic and mind-body exercise as regards individual responses, Lavretsky described an observational study she and others conducted at a local YMCA that clarified the distinctions.1

The study involved 42 participants (mean age, 64.6 years; SD = 13.6 years).[[{"type":"media","view_mode":"media_crop","fid":"17459","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4218398376391","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"977","media_crop_rotate":"0","media_crop_scale_h":"166","media_crop_scale_w":"160","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]] Twenty routinely participated in a yoga or Tai Chi class and 22 routinely participated in an aerobic exercise class for at least 60 minutes per week. Questionnaires profiling participants’ mood states, general health functioning, sleep, and pain levels were reviewed.

In general, Lavretsky said, participants in yoga or Tai Chi classes had significantly greater levels of vitality and lower levels of tension, depression, anger, confusion, and fatigue, as determined from their mental health component scores. Furthermore, they had significantly higher mental health composite summary scores on the 12-Item Short Form Health Survey and fewer sleep problems than did those in the aerobic exercise group.

Augmenting antidepressants

Despite gains in the treatment of major depression in recent decades, Lavretsky said that “only about 30% of older depressed patients achieve remission with the first-line antidepressant pharmacotherapy.”

“Therefore, nonpharmacological interventions-such as mind-body interventions-can improve a partial response to antidepressants via stress reduction, improved physical functioning, increased socialization, and reduced risks of polypharmacy.” She noted that her average depressed older patient takes between 10 and 15 drugs.

Lavretsky described one of the first randomized controlled trials to test the efficacy of complementary use of Tai Chi Chih (TCC), an abbreviated form of Tai Chi that involves 20 movements, versus health education (HE), an active control intervention, as an adjunct to standard antidepressant treatment of geriatric depression.2

In depressed older adults, the prevalence of apathy and anxiety is higher than in younger adults, Lavret­sky said. “Symptoms of depression contain some pain and somatic symptoms that may overlap with under­lying medical conditions, comorbid diseases, and the effects of multiple medications. Cognitive impairment is also more common in older adults.”

For the study, Lavretsky and her team recruited 112 adults with major depression who were 60 years and older. They were treated with standard doses of escitalopram (Lexapro; 10 mg/d) for the first 4 weeks. Dosage adjustments up to 20 mg/d were made in the following 2 weeks. Thirty-nine participants dropped out in the dosage-adjustment phase.

Then 73 partial responders to escitalopram were randomized to receive 10 weeks of adjunctive TCC or HE for 2 hours per week.

All participants were evaluated for depression, anxiety, resilience, health-related quality of life, cognition, and inflammation at baseline and during 14-week follow-up.

“Both TCC and HE participants demonstrated decreases in severity of depression, but the improvement was significantly greater in the TCC participants,” Lavretsky said.

According the published study, 94% of the participants in the escitalopram/TCC group achieved Hamilton Depression Rating Scale (HDRS) scores of 10 or less, and 65% achieved remission (HDRS score of 6 or less). Their scores were better than those of the escitalo-pram/HE group, in which 77% achieved HDRS scores of 10 or less and 51% achieved remission. Those in the escitalopram/TCC group also showed significantly greater improvements in 36-Item Short Form Health Survey physical functioning and cognitive tests and a decline in C-reactive protein levels.

While adherence and satisfaction did not differ between the two groups, Lavretsky said, there was 1 dropout from the escitalopram/HE group and 4 from the escitalopram/TCC group.

The “bad news” from the study for her as a researcher, Lavretsky noted, was that participants in the escitalopram/HE group actually enjoyed their group.

“These were socially isolated older adults with medical problems who didn’t go anywhere, so coming to the study was a big intervention for them. They liked the teacher of the HE class, it was easy to follow, and they really enjoyed it,” she said.

A few participants in the escitalopram/TCC found the TCC practice relatively difficult, although those “who got it were able to improve and continue the practice after the end of the study,” said Lavretsky, who is Professor of Psychiatry and Behavioral Sciences at UCLA and Director of the Late-Life Depression, Stress, and Wellness Research Program at the Semel Institute for Neuroscience and Human Behavior at UCLA. She is also board-certified in holistic and integrative medicine.

She observed that a personalized approach to mind-body medicine might improve treatment response in those who understand the approach and who are willing to continue to practice it.

The study findings, she said, also provide “an opening for the complementary use of mind-body exercise combined with standard antidepressants. The mechanisms would be stress reduction, decreased inflammation, and improved social support.”

Yoga meditation for caregivers

A more comprehensive investigation of mechanisms was conducted by Lavretsky and colleagues,3 who examined the effects of daily brief yogic meditation on distress and coping in caregivers of family members with dementia.

“Currently there are more than 5 million people with dementia and as many caregivers-so it is almost a 1 to 1 ratio,” Lavretsky said. “Most caregivers are elderly women, and about 40% provide care for 5 years or longer, so it is a chronic stress exposure model.” On average, the incidence and prevalence of clinical depression among family dementia caregivers approaches 50%, and caregivers are twice as likely as noncaregivers to report high levels of emotional distress.

Even though they are mildly depressed, many caregivers decline to use antidepressants because of the associated cost and adverse drug effects, according to Lavretsky. Instead, they prefer to use complementary and alternative medicine approaches for stress reduction.

For their study, Lavrestsky and her team recruited stressed and mildly depressed adult children and spouses who were taking care of family members with dementia. The 39 caregivers (mean age, 60.3 years; SD = 10.2) were randomized to learn and practice Kirtan Kriya or to listen to instrumental music on a relaxation CD for 12 minutes per day for 8 weeks.

“Many of the caregivers had not had 12 minutes to themselves in years,” Lavretsky added.

Kirtan Kriya (pronounced KEER-tun KREE-a) is a meditation from the Kundalini yoga tradition, and it has multiple components. Practitioners are asked to close their eyes and imagine the sound flowing in through the top of their heads and out the middle of their foreheads (the third-eye point). They are asked to repeat mudras, pressing the fingers one after another, and to simultaneously chant the mantra “Sa, Ta, Na, Ma,” which means birth, life, death, and rebirth in Sanskrit. The mantra is sung in a normal voice for 2 minutes, then a whisper for 2 minutes, then silently for 4 minutes, then a whisper for 2 minutes, and then out loud for 2 minutes.4

“There are several action sequences they have to alternate that give rise to brain metabolic changes as those seen on the PET scan as a result of this practice,” Lavretsky said (Figures 1 and 2).5

For the caregiver study, the researchers assessed the severity of depressive symptoms, mental and physical functioning, and cognition at baseline and at the end of the 8-week study or on early termination. They analyzed changes in telomerase levels. They looked at neural activation as measured in functional MRI (fMRI) and fludeoxyglucose (18F)-PET. Genome-wide transcriptional profiles were collected from peripheral blood leukocytes sampled at baseline and 8-week follow-up.

Lavretsky said they found an improvement across measures of mental health and cognitive functioning, psychological distress, and telomerase activity in caregivers who performed daily Kirtan Kriya as compared with the relaxation group.

Of those in the meditation group, 65.2% showed 50% improvement on the HDRS and 52% showed 50% improvement on the Mental Health Composite Summary (MCS) score of the Short Form-36 scale. In contrast, 31.2% of the relaxation group showed improvement on the HDRS and 19% showed improvement on the MCS.

Shortened telomere length and reduced telomerase (the cellular enzyme primarily responsible for telomere length and maintenance) have been proposed as biomarkers of cellular aging. In the study, the meditation group showed a 43.3% improvement in telomerase activity, compared with a 3.7% improvement in the relaxation group.

The study also sought to determine whether meditation might alter the activity of inflammatory and antiviral proteins that shape immune cell gene expression. “Our analysis showed a reduced activity of those proteins linked directly to increased inflammation,” Lavretsky said.

In a separate journal article, Lavretsky and her team reported that the Kirtan Kriya intervention suppressed nuclear factor-κB–related transcription of proinflammatory cytokines and up-regulated interferon regulatory factor 1–related transcription of innate antiviral response genes.6

Lavretsky said the research team also arranged for caregivers to receive PET scans and fMRI scans. They were able to compare each component of the meditation (eg, chanting, visualization, mudras, and resting) and its effects on different brain regions. In addition, they demonstrated that meditation is not the same as relaxation.

Patient interest in these techniques is spreading rapidly, Lavretsky said, adding that the baby boomers, in particular, are “very keen on alternative and complementary approaches.”

Disclosures:

Figures 1 and 2 are reproduced from Aging Health, October 20125 with permission of Future Medicine Ltd.

References:

1. Siddarth D, Siddarth P, Lavretsky H. An observational study of the health benefits of yoga or Tai Chi compared with aerobic exercise in community-dwelling middle-aged and older adults. Am J Geriatr Psychiatry. 2013 May 1; [Epub ahead of print].

2. Lavretsky H, Alstein LL, Olmstead RE, et al. Complementary use of tai chi chih augments escitalopram treatment of geriatric depression: a randomized controlled trial. Am J Geriatr Psychiatry. 2011;19:839-850.

3. Lavretsky H, Epel ES, Siddarth P, et al. A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity. Int J Geriatr Psychiatry. 2013;28:57-65.

4. Alzheimer’s Research and Prevention Foundation. Practice the 12-minute yoga medication exercise. https://www.alzheimersprevention.org/research/12-minute-memory-exercise. Accessed August 12, 2013.

5. Pomykala KL, Silverman DH, Geist GL, et al. A pilot study of the effects of meditation on regional brain metabolism in distressed dementia caregivers. Aging Health. 2012;8:509-516.

6. Black DS, Cole SW, Irwin MR, et al. Yogic meditation reverses NF-κB and IRF-related transcriptome dynamics in leukocytes of family dementia caregivers in a randomized controlled trial. Psychoneuro­endocrinology. 2013;38:348-355.