Synchronous Telehealth Yoga and Cognitive Processing Group Therapies for Women Veterans with Posttraumatic Stress Disorder: A Multisite Randomized Controlled Trial Adapted for COVID-19

Implementation of Virtual, Livestream Yoga Classes for Veterans at Home During the COVID-19 Pandemic: A Mixed-Methods Pilot Program Evaluation

Background

The COVID-19 pandemic and shut down of in-person complementary and integrative (CIH) wellness services at the San Francisco Veterans' Affairs Healthcare System (SFVAHCS) required implementation of virtual program delivery. In May 2020, VA in-person group yoga classes pivoted to virtual classes for existing attendees. In October 2020, we partnered with SFVAHCS Integrative Health and the VA Office of Rural Health to formalize the TeleYoga Program to expand yoga access to Veterans in SFVAHCS' geographically dispersed area.

Objective

This pilot study evaluated Veterans' experiences and self-reported health outcomes after participating in at-home tele-yoga groups during the COVID-19 pandemic.

Methods

The RE-AIM framework guided program delivery evaluation. Reach was assessed with medical record data. Adoption was assessed by the number of new facilities providing referrals to tele-yoga. Implementation, satisfaction, and patient-reported outcomes, were evaluated through structured interviews with Likert scale and open-ended responses.

Results

We offered 4-6 weekly livestreamed classes between October 2020-September 2021. The program reached 70 Veterans, including 40 new participants, with 1208 total unique encounters. Referrals increased from 2 to 6 SFVAHCS facilities. Fourteen participants completed structured interviews. Over half rated highly the convenience and overall experience of tele-yoga classes and reported improvement with pain, stress management, exercise, and flexibility. Open-ended responses indicated opportunities for social connection, maintaining mental health, cultivating resilience, improving function, and managing pain. Suggestions for improvement focused on technological aspects, including audiovisual quality.

Conclusions

During the COVID-19 pandemic, we successfully transitioned and expanded virtual group yoga delivery to Veterans from all geographic locations within SFVAHCS. We attribute this success to existing infrastructure for telehealth and CIH services and a virtual program orientation for new participants. The results of this pilot study suggest in-person group yoga may be successfully implemented virtually, serving as a viable modality that contributes to holistic wellbeing for Veterans.

Yoga vs Cognitive Processing Therapy for Military Sexual Trauma-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial

Importance

First-line treatment for posttraumatic stress disorder (PTSD) in the US Department of Veterans Affairs (VA), ie, trauma-focused therapy, while effective, is limited by low treatment initiation, high dropout, and high treatment refraction.

Objective

To evaluate the effectiveness of Trauma Center Trauma-Sensitive Yoga (TCTSY) vs first-line cognitive processing therapy (CPT) in women veterans with PTSD related to military sexual trauma (MST) and the hypothesis that PTSD outcomes would differ between the interventions.

Design, Setting, and Participants

This multisite randomized clinical trial was conducted from December 1, 2015, to April 30, 2022, within 2 VA health care systems located in the southeast and northwest. Women veterans aged 22 to 71 years with MST-related PTSD were enrolled and randomized to TCTSY or CPT.

Interventions

The TCTSY intervention (Hatha-style yoga focusing on interoception and empowerment) consisted of 10 weekly, 60-minute group sessions, and the CPT intervention (cognitive-based therapy targeting modification of negative posttraumatic thoughts) consisted of 12 weekly, 90-minute group sessions.

Main Outcome and Measures

Sociodemographic data were collected via self-report survey. The primary outcome, PTSD symptom severity, was assessed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and PTSD Checklist for DSM-5 (PCL-5). Assessments were conducted at baseline, midintervention, 2 weeks post intervention, and 3 months post intervention.

Results

Of 200 women veterans who consented to participate, the intent-to-treat sample comprised 131 participants (mean [SD] age, 48.2 [11.2] years), with 72 randomized to TCTSY and 59 randomized to CPT. Treatment was completed by 47 participants (65.3%) in the TCTSY group and 27 (45.8%) in the CPT group, a 42.6% higher treatment completion rate in the TCTSY group (P = .03). Both treatment groups improved over time on the CAPS-5 (mean [SD] scores at baseline: 36.73 [8.79] for TCTSY and 35.52 [7.49] for CPT; mean [SD] scores at 3 months: 24.03 [11.55] for TCTSY and 22.15 [13.56]) and the PCL-5 (mean [SD] scores at baseline: 49.62 [12.19] for TCTSY and 48.69 [13.62] for CPT; mean [SD] scores at 3 months: 36.97 [17.74] for TCTSY and 31.76 [12.47]) (P < .001 for time effects). None of the group effects or group-by-time effects were significant. Equivalence analyses of change scores were not significantly different between the TCTSY and CPT groups, and the two one-sided test intervals fell within the equivalence bounds of plus or minus 10 for CAPS-5 for all follow-up time points.

Conclusions and Relevance

In this comparative effectiveness randomized clinical trial, TCTSY was equivalent to CPT in reducing PTSD symptom severity, with both groups improving significantly. The higher treatment completion rate for TCTSY indicates its higher acceptability as an effective and acceptable PTSD treatment for women veterans with PTSD related to MST that could address current VA PTSD treatment limitations.

Trial Registration

ClinicalTrials.gov Identifier: NCT02640690.

Inflammatory and mental health sequelae of COVID-19

The COVID-19 pandemic has caused significant negative consequences to mental health. Increased inflammatory factors and neuropsychiatric symptoms, such as cognitive impairment ("brain fog"), depression, and anxiety are associated with long COVID [post-acute sequelae of SARS-CoV-2 infection (PASC), termed neuro-PASC]. The present study sought to examine the role of inflammatory factors as predictors of neuropsychiatric symptom severity in the context of COVID-19. Adults (n = 52) who tested negative or positive for COVID-19 were asked to complete self-report questionnaires and to provide blood samples for multiplex immunoassays. Participants who tested negative for COVID-19 were assessed at baseline and at a follow-up study visit (∼4 weeks later). Individuals without COVID-19 reported significantly lower PHQ-4 scores at the follow-up visit, as compared to baseline (p = 0.03; 95% CI-1.67 to -0.084). Individuals who tested positive for COVID-19 and experienced neuro-PASC had PHQ-4 scores in the moderate range. The majority of people with neuro-PASC reported experiencing brain fog (70% vs. 30%). Those with more severe COVID-19 had significantly higher PHQ-4 scores, as compared to those with mild disease (p = 0.008; 95% CI 1.32 to 7.97). Changes in neuropsychiatric symptom severity were accompanied by alterations in immune factors, particularly monokine induced by gamma interferon (IFN-γ) (MIG, a. k.a. CXCL9). These findings add to the growing evidence supporting the usefulness of circulating MIG levels as a biomarker reflecting IFN-γ production, which is important because individuals with neuro-PASC have elevated IFN-γ responses to internal SARS-CoV-2 proteins.

Yoga as an Escape from Depreciating Mental Health due to COVID 19: A Qualitative study analyzing the factors associated with mental status based on the experiences of geriatric population's participation in an Online program during COVID 19 lockdown in India

Introduction

The COVID-19 pandemic has left an array of direct physical consequences unevenly on the elderly apart from leaving a wide range of indirect consequences of mental health problems on them. This study aims to understand the effect of a Yoga-Meditation based mobile phone application intervention to reduce the duress by mental health issues via a qualitative analysis.

Methods

A phenomenological qualitative succession of an explanatory sequential design of a prior quantitative study followed by a Yoga-Meditation mobile phone based intervention, where 30 participants who had mild or moderate Depression, Anxiety or Stress as assessed by DASS-21 were chosen by random sampling and were asked to take part in an interview. The interview was transcribed, coded, patterns identified and themes were created to understand the perceptions.

Results

Three major schools of thought were identified and explored to understand the general perception of Mental health, COVID-19 and the intervention: a) Knowledge Axis patterns of COVID-19, which included their prior knowledge about the disease, its consequences and their cues to action based on those beliefs, b) Mental Health and Strategies to Positivity, involves all their actions to promote, restore or propagate a positive mental attitude from religious activities to physical activities and c) Application related thoughts, involved their perceptions of the app, the barriers to use and suggestions to improve.

Conclusion

This study gave deeper insight into the schools of thought which will be important in designing future interventions and yoga-meditation based programs in the future, essentially for geriatric populations as it serves as a feasible simple measure for the same.

Perceived Stress, Resilience, and Wellbeing in Seasoned Isha Yoga Practitioners Compared to Matched Controls During the COVID-19 Pandemic

Background

Yoga practices, including breathing, meditation, and posture protocols (asanas), have been shown to facilitate physical and mental wellbeing.

Methods

Seasoned yoga practitioners were recruited from the Isha Foundation. Recruitment of the comparison group was achieved using snowball sampling and were not yoga practitioners. Participants in the non-yoga group were randomized to a 3-min Isha practice or a comparator group asked to perform 15-min of daily reading. Participants completed a series of web-based surveys (REDCap) at baseline, 6, and 12 weeks. These surveys include validated scales and objective questions on COVID-19 infection and medical history. The validated questionnaires assess for: perceived stress (PSS), mood states [anxiety and depression (PHQ-4), joy (DPES-Joy subscale)], mindfulness attention and awareness (MAAS), resilience (BRS), mental wellbeing (WEMWBS) and recovery from traumatic event (PTGI). Weekly activity diaries were employed as a tool for collecting compliance information from study participants. Perceived stress scale scores were identified as primary outcome for this study.

Findings

The median Perceived Stress Scale (PSS) score for the yoga practitioners compared to the active and placebo comparators was significantly lower at all time-points: baseline: 11 [IQR 7–15] vs. 16 [IQR 12–21] in both the active and placebo comparators (p &lt; 0.0001); 6 weeks: 9 [IQR 6–13] vs. 12 [IQR 8–17] in the active comparator and 14 [IQR 9–18] in the placebo comparator (p &lt; 0.0001); and 12 weeks: 9 [IQR 5–13] vs. 11.5 [IQR 8–16] in the active comparators and 13 [IQR 8–17] in the placebo comparator (p &lt; 0.0001). Among the randomized participants that were compliant for the full 12 weeks, the active comparators had significantly lower median PSS scores than the placebo comparators 12 weeks [10 (IQR 5–14) vs. 13 (IQR 8–17), p = 0.017]. Further, yoga practitioners had significantly lower anxiety at all three-time points (p &lt; 0.0001), lower depression at baseline and 6 weeks (p &lt; 0.0003), and significantly higher wellbeing (p &lt; 0.0001) and joy (p &lt; 0.0001) at all three-time points, compared to the active and placebo comparator groups.

Interpretation

The lower levels of stress, anxiety, depression, and higher level of wellbeing and joy seen in the yoga practitioners compared to the active and placebo comparators illustrate the impact of regular yoga practices on mental health even during the pandemic.

Trial Registration

ClinicalTrials.gov, identifier: NCT 04498442.