Mind-Body Interventions for Mood Disorders in Older Adults

By Arline Kaplan © 2014 (All Rights Reserved)

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, an expert in geriatric psychiatry and holistic medicine said recently.

Presenting at the American Psychiatric Association’s annual meeting, Helen Lavretsky MD, MS, Director of the Late-Life Depression, Stress and Wellness Research Program at the Semel Institute for Neuroscience and Human Behavior at UCLA, briefed symposium attendees on several studies involving mind-body exercise and older adults.

“Mind-body exercise, which includes yoga, Qi Gong and Tai Chi, is utilized 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). Twenty of them 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. Further, they showed significantly higher mental health composite summary scores on the 12-Item Short Form Health Survey (SF-12) and less sleep problems compared to the aerobic exercise group.

Augmenting antidepressants

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

“Therefore the use of 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 said, noting that her average depressed older patient takes between 10 and 15 drugs.

Lavretsky, a Professor of Psychiatry in UCLA’s Department of Psychiatry and Biobehavioral Sciences, described one of the first randomized control trials to test the efficacy of complementary use of Tai Chi Chih (TCC), an abbreviated form of Tai Chi involving 20 movements, versus health education (HE), an active control intervention, as an adjunct to standard antidepressant medication treatment of geriatric depression. 2

Differences exist in the clinical features of depression in older adults versus younger adults, she explained.

“The presence of apathy and anxiety [in older adults] is higher,” 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 administered, “

Additionally, she said, “cognitive impairment is more common in older adults compared to younger adults.”

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

Then 73 partial responders to escitalopram were randomized to receive 10 weeks of adjunct use of TCC for 2 hours per week or health education for 2 hours per week.

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

“The results were that both Tai Chi Chih and health education participants demonstrated improvement in severity of depression, but the improvement was significantly greater in the Tai Chi 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 the escitalopram/HE group where 77% achieved HDRS scores of 10 or less and 51% achieved remission.

When compared to the escitalopram/HE group, the participants 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 the inflammatory marker, C-reactive protein.

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.

Compared to the escitalopram/HE group, a few participants in the escitalopram/TCC found the TCC practice relatively difficult, although those “who got it were able to improve and to continue the practice after the end of the study,” said Lavretsky, who is board certified in holistic and integrative medicine.

She observed that a personalized approach of mind-body medicine might improve treatment response in those who understand the approach and 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 in a recent study of Lavretsky et al.3 examining the effects of daily brief yogic meditation to improve 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 one-to-one ratio,” Lavretsky said. “Most of the caregivers are elderly and are women, and about 40% provide care for 5 years or longer, so it is a chronic stress exposure model. “

On average, according to Lavretsky, 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 drug side 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 old; 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 “Saa, Taa, Naa, Maa,” which means Birth, Life, Death and Rebirth in Sanskrit. The mantra is sung in a normal voice for 2 minutes, than a whisper for 2 minutes, then silently for four minutes, then a whisper for 2 minutes and then out loud for 2 minutes.

“There are several action sequences they have to alternate that give rise to brain metabolic changes as those seen on the positron emission tomography [PET} scan as a result of this practice,” Lavretsky said.

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 upon early termination. They analyzed changes in telomerase levels. They looked at neural activation as measured in functional magnetic resonance imaging (fMRI) and fludeoxyglucose (18F)-positron emission tomography (FDG-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 performing daily Kirtan Kriya as compared with the relaxation group.

As reported in the published study, 65.2% of the meditation group 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. according to Lavretsky. In the study, the meditation group showed a 43.3% improvement in telomerase activity, compared with a 3.7% improvement in the relaxation group.

Another aspect of the study, Lavretsky said in a UCLA interview, 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,” she said.

In a separate journal article, Lavretsky and her team reported that the Kirtan Kriya intervention suppressed nuclear factor (NF)-κB-related transcription of pro-inflammatory cytokines and upregulated Interferon Response Factor 1 (IRF1)-related transcription of innate antiviral response genes.4

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

During the question-answer section of the symposium, Lavretsky urged attendees to become more knowledgeable about mind-body medicine and its related modalities.

Patient interest in these techniques in spreading rapidly, she said, adding that the Baby Boomers, in particular, are “very keen on alternative and complementary approaches.”

 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(10):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(1):57-65.
  4. 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(3):348-355.

 

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