Randomised clinical non-inferiority trial of breathing-based meditation and cognitive processing therapy for symptoms of post-traumatic stress disorder in military veterans

A meta-analytic review of cognitive processing therapy with and without the written account

There are two versions of the Cognitive Processing Therapy (CPT) protocol: one that includes a trauma narrative and one that does not. Despite both versions being used in clinical practice, to date, there has not been a comprehensive comparison of posttraumatic stress disorder (PTSD) treatment outcomes associated with these two protocols. The current study is a meta-analytic review of 29 randomized controlled trials of CPT+A (k = 13) and CPT-C (k = 16) in which we investigated whether there are differences in treatment outcome effect sizes and treatment dropout between the two protocol versions. Sample type (military/veteran versus non-military/non-veteran) as a moderator was examined, given that less robust PTSD treatment outcomes have been typically observed in military and veteran samples. Meta-regression analyses revealed that there were no significant differences between the two CPT protocol versions in pre-post PTSD treatment effect sizes, t(26) = -0.743, p = .463. As expected, studies that enrolled a military or veteran sample reported an average smaller symptom reduction (g = 0.95) than studies that enrolled a non-military or non-veteran sample (g = 1.41), t(26) = 2.48, p = .019. There were also no significant differences between the two CPT protocols for treatment dropout, t(26) = 1.69, p = .104, or between studies enrolling military/veteran and non-military/non-veteran samples t(26) = -1.10, p = .282. The findings support the use of either CPT protocol in practice, but also demonstrate that veterans and service members may be less responsive to either CPT protocol than other trauma samples.

Capnometry-Guided Respiratory Intervention in Veteran PTSD: Impact on Symptom Clusters

Background/Objectives: Post-traumatic stress disorder (PTSD) is a challenging psychiatric condition to treat, with suboptimal recovery and difficulty tolerating exposure-based psychotherapies often noted in outcomes research. The aim of this study was to examine patterns of symptom reduction in veterans with PTSD treated with a Capnometry-Guided Respiratory Intervention (CGRI), a 28-day treatment teaching about the normalization of respiratory rate and exhaled carbon dioxide levels via biofeedback. We hypothesized reductions in total PCL-5 scores and all symptom clusters immediately post-treatment but with relative resistance to changes in hyperarousal symptoms, as reported in the outcomes of research using other evidence-based psychotherapies. Methods: In this report of real-world outcomes, we included 164 veterans treated with CGRI. Pre- and post-treatment PTSD Checklists for DSM-5 (PCL-5) scales were recorded and analyzed based on the total, cluster, and item scores. Subjects were additionally classified into Recovered, Improved, or Suboptimal subgroups based on their response to treatment. Data were compiled during routine clinical care and are available for retrospective analysis. Results: Treatment response was reported in 53% of participants, with a mean total PCL-5 score reduction of 12 points post-treatment (effect size, Glass's Δ = 0.99, large) and individual PCL-5 clusters showing medium to large effect sizes (effect size = 0.71 to 0.98). Contrary to our hypothesis, a large effect size was found in the hyperarousal cluster, with post-treatment scores being significantly improved compared to pre-treatment scores (effect size = 0.98). In the Recovered group, all 20 PCL-5 items showed significant declines, while significant reductions were reported in some items in the Improved group and no item improvements were noted in the Suboptimal group. Conclusions: Consistently with prior published trials reporting overall improvements in PTSD symptoms, in this report, the CGRI produced clinically meaningful reductions in PCL-5 cluster scores in addition to total scores. Unlike reports from several trials of cognitive therapies, this study found hyperarousal symptoms to be responsive to treatment. The CGRI shows evidence of improvement across the range of PTSD symptoms in the immediate post-treatment interval. The absence of an extended post-treatment follow up introduces uncertainty concerning the durability of benefits experienced, although previous CGRI research on both panic disorder and PTSD has shown the maintenance of symptom reduction in six- to twelve-month intervals.

Effectiveness of Meditation Techniques in Treating Post-Traumatic Stress Disorder: A Systematic Review and Meta-Analysis

Background and Objectives: Post-traumatic stress disorder (PTSD) is a debilitating condition worldwide. The limited effectiveness of current psychological and pharmacological treatments has motivated studies on meditation techniques. This study is a comprehensive, multiple-treatments meta-analysis comparing the effectiveness of different categories of meditation in treating PTSD. Methods and Materials: We followed Prisma guidelines in our published protocol to search major databases and to conduct a meta-analysis of the studies. Results: We located 61 studies with 3440 subjects and divided them logically into four treatment groups: Mindfulness-Based Stress Reduction (MBSR, 13 studies); Mindfulness-Based Other techniques (MBO, 16 studies), Transcendental Meditation (TM, 18 studies), and Other Meditations that were neither mindfulness nor TM (OM, 14 studies). Trauma populations included war veterans, war refugees, earthquake and tsunami victims, female survivors of interpersonal violence, clinical nurses, male and female prison inmates, and traumatized students. Of those offered, 86% were willing to try meditation. The baseline characteristics of subjects were similar across meditation categories: mean age = 52.2 years, range 29-75; sample size = 55.4, range 5-249; % males = 65.1%, range 0-100; and maximum study duration = 13.2 weeks, range 1-48. There were no significant differences between treatment categories on strength of research design nor evidence of publication bias. The pooled mean effect sizes in Hedges's g for the four categories were MBSR = -0.52, MBO = -0.66, OM = -0.63, and TM = -1.13. There were no appreciable differences in the study characteristics of research conducted on different meditations in terms of the types of study populations included, outcome measures, control conditions, gender, or length of time between the intervention and assessment of PTSD. TM's effect was significantly larger than for each of the other categories, which did not differ from each other. No study reported serious side effects. Conclusions: All categories of meditation studied were helpful in mitigating symptoms of PTSD. TM produced clinically significant reductions in PTSD in all trauma groups. We recommend a multisite Phase 3 clinical trial to test TM's efficacy compared with standard treatment.

Efficacy of yoga for posttraumatic stress disorder: A systematic review and meta-analysis of randomized controlled trials

Yoga is an increasingly popular complementary intervention to reduce posttraumatic stress disorder (PTSD) symptoms and related comorbidities, but its safety and treatment efficacy are not firmly established. We conducted a systematic review and meta-analysis of existing randomized control trials (RCTs) of yoga interventions for PTSD and related secondary outcomes (e.g., depression). Initial search results found over 668 potential papers. Twenty met inclusion criteria (e.g., RCTs on adult participants with PTSD that evaluated safety or efficacy outcomes). Meta-analysis indicated that, compared to control interventions, participation in yoga interventions significantly improved self-report PTSD (standardized mean difference [SMD]: -0.51; 95 % confidence interval [CI]: -0.68, -0.35) and immediate (SMD: -0.39; 95 % CI: -0.56, -0.22) and long-term (SMD: -0.44; 95 % CI: -0.74, -0.13) depression symptoms. However, using clinician-reported assessments, yoga interventions were not associated with improved PTSD symptoms. Type of yoga differentially predicted outcomes. Sensitivity analysis showed consistent effect sizes when omitting each study from main analyses. Six studies reported whether any serious adverse events occurred. None were indicated. No publication bias was found, although individual intervention studies tended to be high in bias. Results suggest yoga is likely a safe and effective complementary intervention for reducing PTSD and depressive symptoms in individuals with PTSD. More rigorous RCTs are warranted.

Integrative Treatment for Substance Use Disorders: Improving Outcomes Through Evidence-based Practice of Yoga-derived Breathwork and Meditation

BACKGROUND

Among 20.4 million US adults diagnosed with substance use disorders (SUDs), up to 60% return to use despite treatment or attempted abstinence. Standard care for SUDs is pharmacotherapy and/or behavioral interventions in either an inpatient or outpatient setting. Both national and international epidemiological data suggest this approach to treatment is insufficient and use of an integrative protocol can better promote recovery.

OBJECTIVE

To determine the efficacy of integrating yoga-derived breathwork and meditation into substance use treatment with emphasis on a specific practice, Sudarshan Kriya yoga (SKY).

METHODS

Literature review conducted in PubMed, OVID, and SCOPUS. The initial search term was " Sudarshan Kriya" alone. Subsequent searches combined the search term " Sudarshan Kriya" with a series of substance use-related terms using AND to link the terms.

RESULTS

SKY practice impacts quality of life, well-being, functioning, and substance use behavior. In patients with alcohol use disorder, SKY contributes to significant reduction in depressive symptoms, stress biomarkers, and alcohol use up to 6 months after treatment completion. SKY practitioners engaging in opioid partial agonist therapy may experience buprenorphine potentiation such that concurrent nonprescribed opioid use is eliminated. SKY practitioners can achieve tobacco cessation at a rate comparable to bupropion pharmacotherapy.

CONCLUSION

SKY has established efficacy in the treatment of anxiety, depression, and posttraumatic stress disorder. Currently available evidence also supports integration of SKY into the management of SUDs, and expanded SKY research can ensure optimal use of this promising intervention within this clinical subspecialty.

Emotion regulation and heart rate variability may identify the optimal posttraumatic stress disorder treatment: analyses from a randomized controlled trial

Introduction

High variability in response and retention rates for posttraumatic stress disorder (PTSD) treatment highlights the need to identify "personalized" or "precision" medicine factors that can inform optimal intervention selection before an individual commences treatment. In secondary analyses from a non-inferiority randomized controlled trial, behavioral and physiological emotion regulation were examined as non-specific predictors (that identify which individuals are more likely to respond to treatment, regardless of treatment type) and treatment moderators (that identify which treatment works best for whom) of PTSD outcome.

Methods

There were 85 US Veterans with clinically significant PTSD symptoms randomized to 6 weeks of either cognitive processing therapy (CPT; n = 44) or a breathing-based yoga practice (Sudarshan kriya yoga; SKY; n = 41). Baseline self-reported emotion regulation (Difficulties in Emotion Regulation Scale) and heart rate variability (HRV) were assessed prior to treatment, and self-reported PTSD symptoms were assessed at baseline, end-of-treatment, 1-month follow-up, and 1-year follow-up.

Results

Greater baseline deficit in self-reported emotional awareness (similar to alexithymia) predicted better overall PTSD improvement in both the short- and long-term, following either CPT or SKY. High self-reported levels of emotional response non-acceptance were associated with better PTSD treatment response with CPT than with SKY. However, all significant HRV indices were stronger moderators than all self-reported emotion regulation scales, both in the short- and long-term. Veterans with lower baseline HRV had better PTSD treatment response with SKY, whereas Veterans with higher or average-to-high baseline HRV had better PTSD treatment response with CPT.

Conclusions

To our knowledge, this is the first study to examine both self-reported emotion regulation and HRV, within the same study, as both non-specific predictors and moderators of PTSD treatment outcome. Veterans with poorer autonomic regulation prior to treatment had better PTSD outcome with a yoga-based intervention, whereas those with better autonomic regulation did better with a trauma-focused psychological therapy. Findings show potential for the use of HRV in clinical practice to personalize PTSD treatment.

Clinical trial registration

ClinicalTrials.gov identifier, NCT02366403.

High ventilation breathwork practices: An overview of their effects, mechanisms, and considerations for clinical applications

High Ventilation Breathwork (HVB) refers to practices employing specific volitional manipulation of breathing, with a long history of use to relieve various forms of psychological distress. This paper seeks to offer a consolidative insight into potential clinical application of HVB as a treatment of psychiatric disorders. We thus review the characteristic phenomenological and neurophysiological effects of these practices to inform their mechanism of therapeutic action, safety profiles and future clinical applications. Clinical observations and data from neurophysiological studies indicate that HVB is associated with extraordinary changes in subjective experience, as well as with profound effects on central and autonomic nervous systems functions through modulation of neurometabolic parameters and interoceptive sensory systems. This growing evidence base may guide how the phenomenological effects of HVB can be understood, and potentially harnessed in the context of such volitional perturbation of psychophysiological state. Reports of putative beneficial effects for trauma-related, affective, and somatic disorders invite further research to obtain detailed mechanistic knowledge, and rigorous clinical testing of these potential therapeutic uses.

Virtually-delivered Sudarshan Kriya Yoga (SKY) for Canadian veterans with PTSD: A study protocol for a nation-wide effectiveness and implementation evaluation

BACKGROUND

Post-traumatic stress disorder (PTSD) remains a significant treatment challenge among Canadian veterans. Currently accessible pharmacological and non-pharmacological interventions for PTSD often do not lead to resolution of PTSD as a categorical diagnosis and have significant non-response rates. Sudarshan Kriya Yoga (SKY), a complementary and integrative health (CIH) intervention, can improve symptoms of PTSD. In response to the COVID-19 pandemic, this intervention has pivoted to virtual delivery and may be reaching new sets of participants who face multiple barriers to care.

OBJECTIVE

To evaluate the implementation and effectiveness of virtually delivered Sudarshan Kriya Yoga (SKY) on decreasing PTSD symptom severity, symptoms of depression, anxiety, and pain, and improving quality of life in Canadian veterans affected by PTSD.

METHODS AND ANALYSIS

Using a mixed-methods approach guided by the RE-AIM framework, we will conduct a hybrid type II effectiveness and implementation study of virtually delivered Sudarshan Kriya Yoga (SKY) for Canadian veterans. Effectiveness will be evaluated by comparing virtually delivered SKY to a waitlist control in a single-blinded (investigator and data analyst) randomized controlled trial (RCT). Change in PTSD symptoms (PCL-5) is the primary outcome and quality of life (SF-36), symptoms of depression (PHQ-9), anxiety (GAD-7), and pain (BPI) are secondary outcomes. The SKY intervention will be conducted over a 6-week period with assessments at baseline, 6-weeks, 12-weeks, and 30 weeks. The reach, effectiveness, adoption, implementation, and maintenance of the intervention will be evaluated through one-on-one semi-structured interviews with RCT participants, SKY instructors, health professionals, and administrators that work with veterans.

DISCUSSION

This is the first investigation of the virtual delivery of SKY for PTSD in veterans and aims to determine if the intervention is effective and implementable at scale.