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Joga kao alternativa standardnoj terapiji za shizofreniju.

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Referencias

References to studies included in this review

Behere 2011 {published data only}

Behere RV, Arasappa R, Jagannathan A, Varambally S, Venkatasubramanian G, Thirthalli J, et al. Effect of yoga therapy on facial emotion recognition deficits, symptoms and functioning in patients with schizophrenia. Acta Psychiatrica Scandinavica 2011;123(2):147‐53. CENTRAL

Bhatia 2017 {published data only}

Bhatia T, Mazumdar S, Mishra NN, Gur RE, Gur RC, Nimgaonkar VL, et al. Protocol to evaluate the impact of yoga supplementation on cognitive function in schizophrenia: a randomised controlled trial. Acta Neuropsychiatrica 2014;26(5):280‐90. [PUBMED: 25241756]CENTRAL
Bhatia T, Mazumdar S, Wood J, He F, Gur RE, Gur RC, et al. A randomised controlled trial of adjunctive yoga and adjunctive physical exercise training for cognitive dysfunction in schizophrenia. Acta Neuropsychiatrica 2017;29(2):102‐14. [PUBMED: 27514629]CENTRAL

Duraiswamy 2007 {published data only}

Duraiswamy G, Thirthalli J, Nagendra HR, Gangadhar BN. Yoga therapy as an add‐on treatment in the management of patients with schizophrenia ‐ a randomized controlled trial. Acta Psychiatrica Scandinavica 2007;116(3):226‐32. CENTRAL

Lin 2015 {published data only}

Chen EYH, Lin J, Lee EHM, Chang WC, Chan SKW, Hui CLM. Yoga exercise for cognitive impairment in psychotic disorders. Schizophrenia Research 2014;153:S26. CENTRAL
Chen EYH, Lin X, Lam MML, Chan KW, Chang WC, Joe G, et al. The impacts of yoga and aerobic exercise on neuro‐cognition and brain structure in early psychosis‐a preliminary analysis of the randomized controlled clinical trial. Schizophrenia Research 2012;136:S56. CENTRAL
Lin J. The Impacts of Aerobic Exercise and Mind‐Body Exercise (Yoga) on Neuro‐cognition and Clinical Symptoms in Early Psychosis: A Single‐Blind Randomized Controlled Clinical Trial (Dissertation). The University of Hong Kong, 2013. CENTRAL
Lin J. Yoga and exercise in psychosis (YEP). http://ClinicalTrials.gov/show/NCT01207219 [Date Accessed: October 20, 2012]. CENTRAL
Lin J, Chan SK, Lee EH, Chang WC, Tse M, Su WW, et al. Aerobic exercise and yoga improve neurocognitive function in women with early psychosis. NPJ Schizophrenia 2015;1:15047. CENTRAL
Lin J, Geng X, Lee EH, Chan SK, Chang WC, Hui CL, et al. Yoga reduces the brain's amplitude of low‐frequency fluctuations in patients with early psychosis results of a randomized controlled trial. Schizophrenia Research 2017;184:141‐2. CENTRAL
Lin J, Geng X, Su W, Chan KW, Lee EHM, Chang WC, et al. The impacts of yoga on cortical thickness, neural connectivity and cognitive function in early psychosis: Preliminary results from a randomized controlled clinical trial. European Psychiatry 2015;30:789. CENTRAL
Lin J, Lam M, Chiu C, Tse M, Khong PL, Chan C, et al. The impacts of yoga and exercise on neuro‐cognitive function and symptoms in early psychosis. Schizophrenia Bulletin 2011;37:171. CENTRAL
Lin JJ, Lee HM, Chan KW, Chang WC, Su W, Honer WG, et al. The impacts of aerobic exercise and mind‐body exercise (yoga) on neuro‐cognition and clinical symptoms in early psychosis a single‐blind randomized controlled clinical trial. Schizophrenia Research2014; Vol. 153, issue Suppl 1:S260. CENTRAL
Lin JJX, Lee EHM, Chang WC, Chan SKW, Tse M, Phong PL, et al. Aerobic exercise and yoga hold promises for improving neuro‐cognition and symptom in early psychosis. Schizophrenia Bulletin 2015;41:S320. CENTRAL
Pansy CCL. The Long‐Term Effects of Yoga and Aerobic Exercise on Cognitive Function and Clinical Symptoms in Early Psychosis: A Follow‐up Randomized Control Trial (Dissertation). The University of Hong Kong, 2014. CENTRAL

Manjunath 2013 {published data only}

Manjunath RB, Varambally S, Thirthalli J, Basavaraddi IV, Gangadhar BN. Efficacy of yoga as an add‐on treatment for in‐patients with functional psychotic disorder. Indian Journal of Psychiatry 2013;55(7 (Suppl.)):S374‐8. CENTRAL

Varambally 2012 {published data only}

Varambally S, Gangadhar BN, Thirthalli J, Jagannathan A, Kumar S, Venkatasubramanian G, et al. Therapeutic efficacy of add‐on yogasana intervention in stabilized outpatient schizophrenia: randomized controlled comparison with exercise and waitlist. Indian Journal of Psychiatry 2012;54(3):227‐32. CENTRAL

References to studies excluded from this review

Bhatia 2012 {published data only}

Bhatia T, Agarwal A, Shah G, Wood J, Richard J, Gur RE, et al. Adjunctive cognitive remediation for schizophrenia using yoga: an open, non‐randomized trial. Acta Neuropsychiatrica 2012;24(2):91‐100. CENTRAL

Hu 2014 {published data only}

胡光霞, 顾克鹏. 瑜伽练习对长春市某医院精神分裂症住院患者社会功能的影响. 医学与社会 2014;27(2):85‐7. CENTRAL

Ikai 2013 {published data only}

Ikai S, Uchida H, Suzuki T, Tsunoda K, Mimura M, Fujii Y. Effects of yoga therapy on postural stability in patients with schizophrenia‐spectrum disorders: a single‐blind randomized controlled trial. Journal of Psychiatric Research2013; Vol. 47, issue 11:1744‐50. CENTRAL

Ikai 2014 {published data only}

Ikai S, Suzuki T, Uchida H, Saruta J, Tsukinoki K, Fujii Y, et al. Effects of weekly one‐hour hatha yoga therapy on resilience and stress levels in patients with schizophrenia‐spectrum disorders: an eight‐week randomized controlled trial. Journal of Alternative and Complementary Medicine2014; Vol. 20, issue 11:823‐30. CENTRAL

Isuru 2015 {published data only}

Isuru LL, Dahanayake DMA, de Alwis A, Weerasinghe A, Hewage SN, Ranasinghe CK. Impact of dance, drama, yoga and music therapy workshops on symptom reduction in patients with Schizophrenia:A randomized controlled study. South Asian Journal of Psychiatry 2015;3:2, March:1‐7. CENTRAL
SLCTR‐2013‐008 http://trials.slctr.lk/trials/113. Developing social skills, communication skills and self‐confidence through dance, drama and yoga in patients with long term mental illness at NIMH, Angoda. Trial Registry. CENTRAL

Jayaram 2013 {published data only}

Jayaram N, Varambally S, Behere RV, Venkatasubramanian G, Arasappa R, Christopher R, et al. Effect of yoga therapy on plasma oxytocin and facial emotion recognition deficits in patients of schizophrenia. Indian Journal of Psychiatry 2013;55(7 Suppl):S409‐14. CENTRAL

Kavak 2016 {published data only}

Kavak F, Ekinci M. The effect of yoga on functional recovery level in schizophrenic patients.. Archives of Psychiatric Nursing 2016;30(6):761‐7. CENTRAL

Lin 2006 {published data only}

Lin Y, Wang J, Xie J. Effectiveness of yoga alleviating side effects caused by antipsychotic medications [瑜珈健身法减轻抗精神病药物不良反应的效果观察]. Journal of Nursing Science [护理学杂志] 2006;21(3):56‐7. CENTRAL

Mahal 1976 {published data only}

Mahal AS, Ramu NG, Chaturvedi DD. Double‐blind controlled study of brahmyadiyoga and tagara in the management of various types of unmada (schizophrenia). Indian Journal of Psychiatry 1976;18(4):283‐92. CENTRAL

Paikkatt 2012 {published data only}

Paikkatt B, Singh AR, Singh PK, Jahan M. Efficacy of yoga therapy on subjective well‐being and basic living skills of patients having chronic schizophrenia. Industrial Psychiatry Journal 2012;21(2):109‐14. CENTRAL

Ramu 1999 {published data only}

Ramu MG, Chaturvedi DD, Venkataram BS, Shankara MR, Leelavathy S, Janakiramiah N, et al. A double blind controlled study on the role of brahmyadiyoga and tagara in jirnomada (chronic schizophrenia). Ayurvedic Management of Unmada (Schizophrenia). Central Council for Research in Ayurveda and Siddha, 1999:77‐88. CENTRAL

SLCTR‐2013‐008 {published data only}

SLCTR‐2013‐008. Developing social skills, communication skills and self confidence through dance, drama and yoga in patients with long term mental illness at NIMH, Angoda. http://apps.who.int/trialsearch/Trial2.aspx?TrialID=SLCTR/2013/008 (accessed March 2015). CENTRAL

Vancampfort 2011 {published data only}

Vancampfort D, Probst M, Sweers K, Maurissen K, Knapen J, De Hert M. Relationships between obesity, functional exercise capacity, physical activity participation and physical self‐perception in people with schizophrenia. Acta Psychiatrica Scandinavica 2011;123(6):423‐30. CENTRAL

Varambally 2013 {published data only}

Varambally S, Vidyendaran S, Sajjanar M, Thirthalli J, Hamza A, Nagendra HR, et al. Yoga‐based intervention for caregivers of outpatients with psychosis: a randomized controlled pilot study. Asian Journal of Psychiatry 2013;6(2):141‐5. CENTRAL

Visceglia 2011 {published data only}

Visceglia E, Lewis S. Yoga therapy as an adjunctive treatment for schizophrenia: a randomized, controlled pilot study. Journal of Alternative and Complementary Medicine 2011;17(7):601‐7. CENTRAL

Wu 2014 {published data only}

吴春芳, 王朔, 王文胜. 瑜伽训练对精神分裂症患者个人和社会功能的改善作用. 山东医药 2014;54(7):99‐100. CENTRAL

Xie 2006 {published data only}

Xie J, Lin YH, Guo CR, Chen F. Study on influences of yoga on quality of life of schizophrenic inpatients [瑜伽练习对精神分裂症住院患者生活质量的影响]. Nanfang Journal of Nursing [南方护理学报] 2006;13:9‐10. CENTRAL

JPRN‐UMIN000013746 {published data only}

JPRN‐UMIN000013746. Effects study of yoga therapy on the association of mental illness with metabolic disorders, including the carbonyl stress. http://apps.who.int/trialsearch/Trial.aspx?TrialID=JPRN‐UMIN000013746 (2014). CENTRAL

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References to other published versions of this review

Broderick 2016a

Broderick J, Crumlish N, Waugh A, Vancampfort D. Yoga versus non‐standard care for schizophrenia. Cochrane Database of Systematic Reviews 2016, Issue 1. [DOI: 10.1002/14651858.CD012052]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Behere 2011

Methods

Allocation: randomised.
Blinding: single‐blinded. Raters were blind to group status.
Duration: 3 months, assessed at baseline, at '2nd month' and at '4th month'.
Design: parallel.
Setting: outpatient services of the Department of Psychiatry, NIMHANS Bangalore, India.

Participants

Diagnosis: schizophrenia (DSM IV).
History: patients on stabilised antipsychotic medications for 6 weeks or longer before recruitment.
N=91.
Age: 18‐60 years.
Sex: 32M, 12F.
Inclusion criteria: CGI score less than or equal to 3 as assessed by treating psychiatrist.

Exclusion criteria: any comorbid psychiatric disorder, medical or neurological illness.

Interventions

1. Yoga: Yoga training (one month) from a trained yoga instructor developed from a particular school (Swami Vivekananda Yoga Anusandhana Samsthana), followed by two months of self‐practice at home, caregivers were instructed to monitor the yoga therapy at home and keep a log of the yoga sessions practised, the techniques consisted of the following components, (i) shithileekarana vyayama (loosening exercises) for 10 minutes, (ii) asanas (yoga postures) for approximately 20 minutes) (iii) breathing exercises for 18 minutes, (iv) quick relaxation techniques for 3 minutes, meditation was not included .(n=34)

2. Exercise: one‐month exercise training from a trained yoga instructor followed by two months practice of exercises at home, ‘physical exercises’ were adopted from the National Fitness Corps*, with duration of 1 hour in total, consisted of brisk walking (10 minutes), jogging (5 minutes), exercise in standing (20 minutes), and sitting posture exercises (20 minutes), with 2‐minute breaks with a non‐specific instruction of ‘just relax now’ between different exercises, exercise in standing included 8 components consisting of moving arms and/or legs from the ‘’position: attention’’, and sitting posture exercises consisted of exercises in cross‐legged sitting, no details of caregivers instructed to monitor exercise at home, therapist:participant ratio not detailed. (n=31)

3. Wait‐list control group: in which patients did not receive any add‐on intervention. (n=26)

Patients in all the three groups continued to receive stable dose of antipsychotic medications until the end of the study.

Outcomes

Leaving the study early.

Mental state: PANSS.

Social functioning: SOFS, TRACS ‐ emotional functioning.

Notes

Same yoga intervention as Duraiswamy 2007; Manjunath 2013; Varambally 2012. Included only data from intervention groups 1 and 3.Same exercise intervention as Duraiswamy 2007; Manjunath 2013; Varambally 2012.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: ''Using computer‐generated random numbers, 91 patients were allocated to three treatment groups''

Response: Low risk

Allocation concealment (selection bias)

High risk

Quote: ''The randomization was performed by one of the authors in the study (Dr JT)''.

Response: This could potentially be high risk as the order of allocation could be known, which could influence the allocation of participants to either intervention.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Participants and personnel delivering the yoga intervention will be aware they are undertaking or delivering the yoga intervention.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Quote: ''The raters were blind to the status, and the raters were not involved in imparting yoga therapy or exercise''

Response: Low risk

Incomplete outcome data (attrition bias)
All outcomes

High risk

Quote: ''The number of patients who completed the study and included in the final analysis was 27 in the Yoga group, 17 in the Exercise Group and 22 in the Waitlist group''

Response: Extent of withdrawal broadly similar between yoga and control group, but rated as high risk as not all participants randomised were included in the final analysis (7 in Yoga group, 14 in Exercise group, and 4 in Waitlist group ‐ 27.5% overall).

Selective reporting (reporting bias)

Low risk

All stated outcomes were reported.

Other bias

High risk

Funding: not stated. One of the authors may be invested in intervention due to affiliation with Swami Vivekananda Yoga Anusandhana. Yoga for this study was developed from this school.

Bhatia 2017

Methods

Allocation: randomised.
Blinding: single‐blinded. Raters were blind to group status.
Duration: 6 months, assessed at baseline, 21 days (end of training), 3 and 6 months.
Design: parallel.
Setting: Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, Dehli, India.

Participants

Diagnosis: schizophrenia (DSM IV).
History: clinically stable outpatients with a clinical diagnosis of schizophrenia.
N=340.
Age: yoga group 34.8 +/‐ 9.6 years, physical exercise training 35.2 +/‐ 9.5 years, control 35.7 +/‐ 10.1 years.
Sex: yoga group 62M, 42F, physical exercise training 62M, 28F, control 57M, 35F.
Inclusion criteria: DSM IV diagnosis of schizophrenia, age 18 years or greater, resident of Dehli and willing to participate, attending outpatient clinic from December 2010 ‐ January 2014.

Exclusion criteria: Prior participation in yoga study in research centre, mental ''retardation'' sufficient to impact trial understanding, presence of comorbid conditions that may worsen with exercise, neurological illnesses that may cause cognitive impairment independent of schizophrenia, presence of physical disability or illness for which yoga or physical exercise are contra‐indicted.

Interventions

1.Yoga: yoga delivered by a 'qualified instructor', programme was developed by a yoga expert and was approved by the Central Council of Research and Naturopathy, Indian Ministry of Health and Family Welfare.

Consisted of chanting and breathing exercises, warming/'loosening exercises', standing postures, supine lying postures, prone lying postures, sitting postures, pranayamas (breathing exercises), jalneti (cleaning of nostrils) and prayer for 1 hour in total (every day for 21 consecutive days) with follow‐up at end training (21 days, with the exception of Sundays and bank holidays), 3 and 6 months (n=104).

2. Exercise: delivered by a trained physical exercise instructor, consisted of 15 minutes of brisk walking and 45 minutes of exercises adapted from the Ministry of Education 1965, details not supplied but was 'based' on programme adapted by Duraiswamy 2007* (n=90).

Therapist: participant ratio was 1:5 for yoga and exercise, with a separate yoga and exercise instructors for these sessions. Participants advised to continue with yoga, exercise or treatment as usual ''past the training period''.

3. Control: treatment as usual, (n=92).

119 allocated to yoga group, 79 assessed at 6‐month follow‐up (33.6% dropout from initial randomisation), 104 included in final analysis, 106 allocated to exercise group overall, 71 assessed at 6 month follow‐up (38.7% dropout from initial randomisation), 90 included in final analysis.

A yoga training booklet supplied to yoga group after completion of 21‐day programme. Particpants in both groups were required to maintain a compliance chart, which documented self‐practice was collected at 3 and 6 months.

No adverse effects were reported for either group. Changes in prescribed doses or types of antipsychotics drugs during the study period did not change between groups.

Outcomes

Leaving the study early

Unable to use:

Cognitive function (University of Pennsylvania Computerized Neurocognitive Battery): no total scores provided.

Independent Living Skills Survey (ILSS): listed as an outcome in protocol, but no follow‐up data provided.

Global assessment of function (GAF): listed as an outcome in protocol, but no follow‐up data provided.

Schedule for Assessment of Negative Symptoms (SANS): listed as an outcome in protocol, but no follow‐up data provided.

Schedule for Assessment of Positive Symptoms (SAPS): listed as an outcome in protocol, but no follow‐up data provided.

Assessed at baseline, 3 and 6 months.

Notes

*Exercise group: based on protocol devised by Duraiswamy 2007. Therefore exercise intervention also consisted with Behere 2011a; Manjunath 2013; Varambally 2012.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: ''the principal study investigator (T.B.) randomised participants to the YT, PE or TAU in blocks of 12, using an online randomisation program (http://www.randomization.com)''.

Response: Low risk.

Allocation concealment (selection bias)

Low risk

Quote: ''the randomisation lists were stored ina password‐protected computer by TB, who did not collect outcome measures, administer any interventions or treat the participants''.

Response: Low risk.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Participants and personnel delivering the yoga intervention will be aware they are undertaking or delivering the yoga intervention.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Quote: ''all recruiters and raters, (who administered the cognitive evaluations) were blinded to participants allocation''.

Response: Low risk.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Intention‐to‐treat analysis was employed and reasons given for dropout.

Selective reporting (reporting bias)

Low risk

All stated outcomes were reported.

Other bias

Unclear risk

A yoga training booklet was supplied 'to participants' after completion of 21 day programme. Presumably booklet was supplied to exercise group also which may have systematically influenced effect of randomisation.

Duraiswamy 2007

Methods

Allocation: randomised.
Blinding: single‐blinded. Raters were blind to group status.
Duration: 4 months, assessed at baseline and 4 months.
Design: parallel.
Setting: outpatient and inpatient services of the NIMHANS, Bangalore, India.

Participants

Diagnosis: schizophrenia (DSM IV).
History: patients on stabilised antipsychotic medications for 4 weeks or longer before recruitment.
N=88.
Age: 18‐55 years.
Sex: 42M, 19F.
Inclusion criteria: CGI ≥ 4 ''who were cooperative for yoga therapy''

Exclusion criteria: severe physical ailments such as recent and decompensated myocardial infarction, fracture, seizure disorders, mental retardation or comorbid substance abuse (except nicotine) any comorbid psychiatric disorder, medical or neurological illness.

Interventions

1.Yoga: Yoga delivered by a certified yoga trainer from a particular school (Swami Vivekananda Yoga Anusandhana Samsthana). Consisted of shithileekarana vyayama (loosening exercises) for 10 minutes, asanas (yoga postures) for approximately 20 minutes, breathing exercises for 18 minutes and a quick relaxation technique for 3 minutes, 15 sessions (5 days a week for 3 weeks) with 3‐month follow‐up, no meditation included, expected adherence to the yoga intervention was > 75%. (n=31)

2. Exercise: 15 sessions (5 days a week for 3 weeks) of ‘physical exercises’ were adopted from the National Fitness Corps*, with duration of 1 hour in total, consisted of brisk walking (10 minutes), jogging (5 minutes), exercise in standing (20 minutes), and sitting posture exercises (20 minutes), with 2‐minute breaks with a non‐specific instruction of ‘just relax now’ between different exercises, exercise in standing included 8 components consisting of moving arms and/or legs from the ‘’position: attention’’, and sitting posture exercises consisted of exercises in cross‐legged sitting, exercise was 5 days a week for 3 weeks. (n=30)

A therapist trained to teach both yoga and exercise taught the subjects in their allocated treatment groups.

Twenty‐six per cent (n=16) did not complete the training due to disinterest, long distance from the hospital for outpatients. Participants were expected to continue their training for next 3 months at home, reviewed by the therapist once a month and reminder telephone calls and letters about maintaining practice. No adverse effects were reported for either group.

No change to medication was made for at least 4 weeks before entry into the study and through the study period. Reported that medication was changed during the study period in two patients (one in each group) as they had exacerbation of symptoms.

Outcomes

Mental state: PANSS
Social functioning: SOFS

Quality of life: WHOQOL‐BREF

Unable to use:

Extrapyramidal symptoms (SIM): not listed as an outcome

Abornal movement (AIMS): not listed as an outcome

Assessed at baseline and at 4 months

Notes

Same exercise intervention as Behere 2011; Manjunath 2013; Varambally 2012. Same yoga intervention as Behere 2011; Manjunath 2013; Varambally 2012.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: ''Subjects were randomly assigned, using a computer‐generated
random number table''.

Response: Low risk

Allocation concealment (selection bias)

Unclear risk

No details of allocation concealment were given.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Participants and personnel delivering the yoga intervention will be aware they are undertaking or delivering the yoga intervention.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No details regarding blinding of outcome assessment were given.

Incomplete outcome data (attrition bias)
All outcomes

High risk

Quote: ''All but four subjects who completed 3 weeks of training were available for follow‐up assessment after 4 months''.. .''comparable proportions (33% each) of patients allocated initially to each of the two groups were available for the final
sample''.

Response: Not clear to which groups the 4 participants who did not complete training were randomised, rated as high risk as not all participants randomised were included in the final analysis.

Selective reporting (reporting bias)

Low risk

All stated outcomes were reported.

Other bias

Unclear risk

Same exercise intervention as Behere 2011; Manjunath 2013; Varambally 2012. Same yoga intervention as Behere 2011; Manjunath 2013; Varambally 2012.

Lin 2015

Methods

Allocation: randomised.
Blinding: single‐blind (outcomes assessor).
Duration: 12 weeks, assessed at baseline, post‐intervention at 12 weeks and 18 months.
Design: parallel.
Setting: recruited from the Early Assessment Service for Young People with Psychosis Program (EASY) in three outpatient clinics in Hong Kong.

Participants

Diagnosis: schizophrenia, diagnosis based on DSM‐IV criteria.
History: female outpatients with non‐affective functional psychosis within the first five years of their illness.
N=140.*
Age: 18‐55 years.
Sex: 140 females*.
Inclusion criteria: schizophrenia based on DSM‐IV criteria, schizoaffective disorder, schizophreniform psychosis, brief psychotic disorders, psychosis not otherwise specified and delusional disorder, duration of illness less than 5 years (including 5 years).

Exclusion criteria: severe physical illness (myocardial infarction, hypertension, fracture, spinal problem), seizure disorders, mental retardation or comorbid substance dependence, unstable psychotic symptoms, known pregnancy or other contraindication to MRI, a history of brain trauma or organic brain disease, known history of intellectual disability or special school attendance.

Interventions

1.Yoga: 12 weeks of Hatha yoga therapy delivered by certified yoga instructor (three sessions per week, each 40/50 minutes per session which included (i) breathing control (10 minutes), (ii) warming up (10 minutes), (iii) asanas (yoga postures) for 30 minutes (iv) relaxation for 10 minutes, 5‐10 participants per class, no meditation included, expected adherence to the yoga intervention was >70%, average yoga class attendance was 47%. (n=48)

2. Aerobic: 12 weeks of treadmill walking(three sessions per week, each 1 hour) carried out by a certified coach, for 15‐20 minutes and stationary cycling for 25‐30 minutes, each participant's heart rate was continuously monitored during the exercise session using a portable recorder, the heart rate was maintained in the range of 45%‐49% of the VO2 max value, expected adherence to the aerobic intervention was >70%, average attendance rate was 58%. (n=46)

3. Wait‐list control group: treatment as usual. (n=46)

Patients in both groups continued on an unchanged dosage of medication as much as possible, more than a 25% change in dosage in the first 6 weeks after commencement of the intervention was not permitted.

Outcomes

Mental state: PANSS

Mental state: negative symptoms CDS total score
Adverse effects: routine reporting of physical adverse events..

Quality of life: SF 36.

Leaving the study early.

Unable to use ‐

Cognitive functioning (verbal learning‐assessed by Hong Kong List Learning test, working memory‐assessed by the Digid Span test, attention and concentration‐assessed by the Letter Cancellation test Q score, cognitive flexibility‐assessed by the Stroop Color and Word Test) as no reported total end scale measure.

MRI: not listed as an outcome.

Physical fitness (VO2max test) as < 50% data reported (41/94=43%).

Balance (SEBT): not listed as an outcome and < 50% data reported (40/96=41.6%).

Flexibility (Sit‐and‐Reach Test): not listed as an outcome and < 50% data reported (40/96=41.6%).

Standing balance test: not listed as an outcome and no data reported

Body perception and drug adherence measure (Figure rating scale, cognitive attitude towards body size, compliance rating scale, drug attitude inventory): not listed as an outcome and no data reported.

DXA: not listed as an outcome and no data reported.

Side effects rating scale (UKU rating scale): as no reported total end scale measure.

Notes

'61 (53.5%) were diagnosed with schizophrenia, 13 (11.4%) had schizoaffective disorder, and 39 (34.2%) had schizophreniform, brief psychotic disorders and psychosis not otherwise specified'.

Data extracted from two main sources; 1 dissertation and 1 published paper.

A dissertation pertaining to this study revealed that unfortunately that at some time point between the 12‐week and 18‐month time point the control group received a 'compensated' 12 week yoga or exercise programme which systematically negated the control group condition, also > 50% attrition, so 18‐month follow‐up data could not be included.

*of the 85 randomised, 69 provided data

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: ''A randomization list was created using a random number generator. The random list had a block size of 12 (i.e. for every 12 subjects, 4 would be assigned to the yoga group, 4 to the aerobic group and 4 to the control group''

Response: Low risk.

Allocation concealment (selection bias)

Low risk

Quote: ''The randomization list was concealed from research staff involved in recruitment, assessment and intervention''.

Response: Low risk.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Participants and personnel delivering the yoga intervention are aware they are undertaking or delivering the yoga intervention.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Qoute: ''Two research assistants will be well trained and recruited to do the assessment, and remains blind to the treatment allocation''.

Response: Low risk.

Incomplete outcome data (attrition bias)
All outcomes

High risk

Quote: 48 allocated to yoga group but 45 reported to be included in intention‐to‐treat analysis, 46 allocated to aerobic exercise group but 40 reported to be included in intention‐to‐treat analysis, and data for lesser number of participants reported for all measures, e.g. for PANSS and quality of life scores data reported for 38 participants in yoga group and 31 for the non‐standard care group.

Response: High risk, as not all participants randomised were included in the analysis.

Selective reporting (reporting bias)

High risk

Balance listed as an outcome but data not supplied in published paper.

Manjunath 2013

Methods

Allocation: randomised.
Blinding: unclear.
Duration: 6 weeks, assessed at 2‐week and 6‐week time points.
Design: parallel.
Setting: inpatient setting of a large psychiatric institute in India.

Participants

Diagnosis: schizophrenia (DSM IV and later confirmed using the Mini International Neuropsychiatric Interview by the first author).
History: newly admitted patients (within 1 week), illness duration 119.5 (102) months yoga group, 97.3 (90.8) exercise group.
N=88.
Age: 31.7 (8.8) yoga group, 31.1 (7.8) exercise group.
Sex: 39F, 49M.
Inclusion criteria: ''newly admitted (within past 1 week) patients with a diagnosis of functional non‐affective psychosis formed the study population’’

Exclusion criteria: No exclusion criteria specified.

Interventions

1.Yoga: Yoga delivered by a certified yoga trainer from a particular school (Swami Vivekananda Yoga Anusandhana Samsthana). Consisted of shithileekarana vyayama (loosening exercises) for 10 minutes, asanas (yoga postures) for approximately 20 minutes, breathing exercises for 18 minutes and a quick relaxation technique for 3 minutes, in total 51‐minute session over 2 weeks in the wards (at least 10 sessions), with 4 months of self‐practice, no meditation included, (n=44)

2. Exercise: ‘physical exercises’ were adopted from the National Fitness Corps, with duration of 1 hour in total, consisted of brisk walking (10 minutes), jogging (5 minutes), exercise in standing (20 minutes), and sitting posture exercises (20 minutes), with 2‐minute breaks with a non‐specific instruction of ‘just relax now’ between different exercises, exercise in standing included 8 components consisting of moving arms and/or legs from the ‘’position: attention’’, and sitting posture exercises consisted of exercises in cross‐legged sitting, in total 45‐minute session over 2 weeks in the wards (at least 10 sessions), with 4 months of self‐practice . (n=44)

Yoga and exercise were delivered by the same therapist who was qualified to teach both. For yoga and exercise groups; after 2 weeks, participants were advised to practice the same for the next 4 weeks. Family members, who were observing their training during their inpatient stay, were requested to monitor their performance at home after discharge. Participants came to the 6‐week follow‐up alone or ‘’with different caregivers/kin and hence the report of practice at home was not reliably obtained’’.

Outcomes

Mental State: PANSS (termed clinical state), HDRS, CGIS

Leaving the study early

Unable to use:

Extra‐pyramidal side effects (SAS): not listed as an outcome.

Notes

Participants in both groups were routinely offered "games, exercise and chanting" by nurses between 8am and 9am which was routine practice. Adherence to this was not maintained. The majority (n=83) had a diagnosis of schizophrenia,the major subgroup was paranoid schizophrenia (46.6%), the rest of the patients were diagnosed to have other subtypes of schizophrenia (41.9%) and unspecified psychosis (11.5%). Content of exercise and yoga interventions were the same as Behere 2011, Duraiswamy 2007 and Varambally 2012.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: ''A randomization table was generated for 90 patients to have equal representation of yoga or exercise as an add‐on/complementary treatment''.

Response: Likely to be adequate

Allocation concealment (selection bias)

Unclear risk

No details of allocation concealment given.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Participants and personnel delivering the yoga intervention will be aware they are undertaking or delivering the yoga intervention.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No details were given regarding blinding of outcome assessment.

Incomplete outcome data (attrition bias)
All outcomes

High risk

Quote: ''Among the 88 patients, 82 completed the 2‐week intervention successfully and were assessed at that time point. During follow‐up at 6 the week, more patients dropped out (n=28) and only 60 were available for third assessment (completed sample)''.

Response: Rated as high risk as not all participants randomised were included in the final analysis (44 randomised to each group but data provided for 35 in yoga group and 25 in exercise group).

Selective reporting (reporting bias)

Low risk

All stated outcomes were reported.

Other bias

High risk

Funding: not stated. One of the authors may be invested in intervention due to affiliation with Swami Vivekananda Yoga Anusandhana. Yoga for this study was developed from this school.

Varambally 2012

Methods

Allocation: randomised.
Blinding: single‐blind (outcomes assessor).
Duration: four months, assessed at baseline and 4 months.
Design: parallel.
Setting: Outpatient services of the NIMHANS, India.

Participants

Diagnosis: schizophrenia confirmed by a psychiatrist according to DSM‐IV criteria.
History: outpatients on follow‐up.
N=120.
Age: of those who completed trial, yoga group:32.8(10.0), wait list:33.6 (9.5) years.
Sex: 56M, 36F.
Inclusion criteria: receiving antipsychotic medication without changes in dosages in the last three months, rated as moderately symptomatic with a score of 3 or more on clinical global impression.
Exclusion criteria: ECT in the past three months.

Interventions

1.Yoga: Yoga delivered by a certified yoga trainer from a particular school (Swami Vivekananda Yoga Anusandhana Samsthana). Consisted of shithileekarana vyayama (loosening exercises) for 10 minutes, asanas (yoga postures) for approximately 20 minutes, breathing exercises for 18 minutes and a quick relaxation technique for 3 minutes, in total 45 minutes per session, daily for one month (about 25 sessions), with 3‐month follow‐up of self‐practice at home, no meditation included, expected adherence to the yoga intervention was > 75%. (n=47)

2. Exercise: ‘physical exercises’ were adopted from the National Fitness Corps, with duration of 1 hour in total, consisted of brisk walking (10 minutes), jogging (5 minutes), exercise in standing (20 minutes), and sitting posture exercises (20 minutes), with 2‐minute breaks with a non‐specific instruction of ‘just relax now’ between different exercises, exercise in standing included 8 components consisting of moving arms and/or legs from the ‘’position: attention’’, and sitting posture exercises consisted of exercises in cross‐legged sitting, in total 45 minutes per session, daily for one month (about 25 sessions), with 3‐month follow‐up of self‐practice at home. (n=37)

3. Wait‐list control group: receiving no yoga intervention. (n=36)

No changes were made to medication status unless absolutely needed.

Outcomes

Mental state: PANSS.

Social functioning: SOFS.

Unable to use ‐

Adverse events: extra‐pyramidal symptoms rating scale (no data reported).

Notes

Yoga and exercise content same as Behere 2011, Duraiswamy 2007, Manjunath 2013. Included only data from intervention groups 1 and 3. No incentive was offered for participation in the study but to ''facilitate participation'' the cost of bus travel between their home and the yoga centre was covered for study participants and their relative between their home and the yoga centre. It was not specified if exercise was delivered by the yoga instructor.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: ''one investigator (JT) uninvolved in the treatments or assessment generated random numbers''

Response: Lacking detail if sequence‐generation strategy was adequate

Allocation concealment (selection bias)

Unclear risk

Quote: ''subject's allocation to one of these groups was kept concealed and only ascertained after consent and before he/she was to be randomized''

Response: Unclear risk, as concealment strategy was not described.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Quote: ''only the social worker and the yoga therapist were informed to start the corresponding intervention''

Response: Unclear risk, participants as well as social worker and yoga therapist were aware of group allocation.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Quote: ''the rater was unaware of group allocation''

Response: Low risk

Incomplete outcome data (attrition bias)
All outcomes

High risk

Quote: ''some did not turn up at the 4th month follow‐up and therefore final sample was smaller; 39, 22 and 34 in yogasana, exercise and waiting list groups''

Response: High risk, as more participants withdrew from the exercise group (40.5%) than the yoga group (17%) and 26% overall not followed up and not included in analysis.

Selective reporting (reporting bias)

High risk

Extrapyramidal symptoms scale (adverse events) listed as an outcome but no data reported.

Other bias

High risk

Funding: not stated. One of the authors may be invested in intervention due to affiliation with Swami Vivekananda Yoga Anusandhana. Yoga for this study was developed from this school.

CDS: Calgary Depression Scale
CGI: Clinical Global Impression Severity
DSM IV: Diagnostic and Statistical Manual of Mental Disorders
HDRS: Hamilton Depression Rating Scale
MRI: magnetic resonance imaging
PANSS: Positive and Negative Syndrome Scale
SOFS: Social Occupational Functioning Scale
TRACS:TRENDS Accuracy Score (TRENDS=Tool for Recognition of Emotions in Neuropsychiatric DisorderS)
WHOQOL‐BREF: World Health Organisation Quality Of Life

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Bhatia 2012

Allocation: not randomised.

Hu 2014

Allocation: randomised.

Participants: people with schizophrenia.

Interventions: yoga plus occupational recreational therapy and conventional treatment versus occupational recreational therapy and conventional treatment, not 'non‐standard care'.

Ikai 2013

Allocation: randomised.

Participants: people with schizophrenia.

Interventions: yoga versus standard‐care not non‐standard care.

Ikai 2014

Allocation: randomised.

Participants: people with schizophrenia.

Interventions: yoga versus standard‐care not non‐standard care.

Isuru 2015

Allocation: randomised.

Participants: people with schizophrenia.

Interventions: yoga as a package of care versus standard care, not non‐standard care.

Jayaram 2013

Allocation: randomised.

Participants: people with schizophrenia.

Interventions: yoga versus standard‐care not non‐standard care.

Kavak 2016

Allocation: 'quasi' randomised not randomised as stated in protocol.

Lin 2006

Allocation: randomised.

Participants: people with schizophrenia.

Interventions: yoga versus standard‐care not non‐standard care.

Mahal 1976

Allocation: ''double blind''.

Participants: people with schizophrenia.

Interventions: 'Tagara' (local drug with anti‐psychotic properties) and 'Brahmyadiyoga' (a herbal compound) versus chlorpromazine versus placebo, not yoga.

Paikkatt 2012

Allocation: randomised.

Participants: people with schizophrenia.

Intervention: yoga plus motivational and feedback session versus waiting list, not yoga alone.

Ramu 1999

Allocation: ''double blind''.

Participants: people with schizophrenia.

Interventions: 'Tagara' (local drug with anti‐psychotic properties) and 'Brahmyadiyoga' (a herbal compound) versus chlorpromazine versus placebo, not yoga.

SLCTR‐2013‐008

Allocation: randomised.
Participants: people with schizophrenia.
Interventions: yoga combined with relaxation exercises, breathing exercises, body movement exercises, basic acting exercises, Alexander technique, theatre games, exercise ”to build self confidence”, creative work using props, use of music to enhance creativity and moods versus comparison group receiving standard care, which does not include any of the above, not yoga as a stand‐alone intervention versus non‐ standard care.

Vancampfort 2011

Allocation: randomised.

Participants: people with schizophrenia.

Interventions: cross‐over trial of yoga and exercise, not clear which randomised to first, exercise or yoga.

Varambally 2013

Allocation: randomised.

Participants: caregivers of people with schizophrenia, not sufferers of schizophrenia.

Visceglia 2011

Allocation: randomised.

Participants: people with schizophrenia.

Interventions: yoga versus standard‐care not non‐standard care.

Wu 2014

Allocation: participants randomly selected but not randomly allocated to intervention/control group.

Xie 2006

Allocation: randomised.

Participants: people with schizophrenia.

Intervention: yoga plus counselling versus standard care, not yoga alone.

Characteristics of ongoing studies [ordered by study ID]

JPRN‐UMIN000013746

Trial name or title

Effects study of yoga therapy on the association of mental illness with metabolic disorders

Methods

Allocation: randomised.

Blinding: no details given.

Duration: no details given.

Design: parallel.

Setting: Toyko Metropolitan Matsuzawa Hospital.

Participants

Diagnosis: schizophrenia (DSM IV).
History: no details given.
N=60 (target sample size).
Age: 18‐65 years.
Sex: males and females.
Inclusion criteria: males and females between 18 and 65 years diagnosed with schizophrenia according to DSM‐IV, patients with consent capacity.

Exclusion criteria: patients with diabetes, renal failure, pervasive development disorders, mental retardation.

Interventions

1. Yoga therapy: (no further details given).

2. 'A simple exercise': (no further details given).

Outcomes

Oxidative‐stress markers (no further outcomes listed).

Starting date

05 December 2014.

Contact information

Masanari Itokawa (itokawa‐[email protected]), Hiromi Idozawa (Chiken‐[email protected])

Notes

Contacted for study information 16 February 2016, no reply.

DSM IV: Diagnostic and Statistical Manual of Mental Disorders

Data and analyses

Open in table viewer
Comparison 1. YOGA versus NON‐STANDARD CARE

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mental state: 1. Clinically important change (PANSS ‐ not improved) short term Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

Analysis 1.1

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 1 Mental state: 1. Clinically important change (PANSS ‐ not improved) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 1 Mental state: 1. Clinically important change (PANSS ‐ not improved) short term.

1.1 overall

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

0.81 [0.62, 1.07]

1.2 specific ‐ negative symptoms

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

0.72 [0.57, 0.90]

1.3 specific ‐ positive symptoms

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

1.08 [0.84, 1.38]

2 Mental state: 2. Average endpoint score (various scales) short term Show forest plot

4

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

Analysis 1.2

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 2 Mental state: 2. Average endpoint score (various scales) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 2 Mental state: 2. Average endpoint score (various scales) short term.

2.1 overall (PANSS)

3

170

Mean Difference (IV, Fixed, 95% CI)

‐4.69 [‐8.35, ‐1.03]

2.2 specific ‐ depressive symptoms (CDS)

1

69

Mean Difference (IV, Fixed, 95% CI)

0.10 [‐1.01, 1.21]

2.3 specific ‐ depressive symptoms (HDRS)

1

60

Mean Difference (IV, Fixed, 95% CI)

‐1.41 [‐2.40, ‐0.42]

2.4 specific ‐ negative symptoms (PANSS)

4

214

Mean Difference (IV, Fixed, 95% CI)

‐1.15 [‐2.30, 0.01]

2.5 specific ‐ positive symptoms (PANSS)

4

214

Mean Difference (IV, Fixed, 95% CI)

‐0.36 [‐1.35, 0.63]

3 Global state: Average endpoint score (CGIS, low score=good) short term Show forest plot

1

60

Mean Difference (IV, Fixed, 95% CI)

‐0.85 [‐1.21, ‐0.49]

Analysis 1.3

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 3 Global state: Average endpoint score (CGIS, low score=good) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 3 Global state: Average endpoint score (CGIS, low score=good) short term.

4 Social functioning: 1. Clinically important change (SOFS ‐ not improved) short term Show forest plot

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.78, 1.04]

Analysis 1.4

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 4 Social functioning: 1. Clinically important change (SOFS ‐ not improved) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 4 Social functioning: 1. Clinically important change (SOFS ‐ not improved) short term.

5 Social functioning: 2. Average score at endpoint (two scales) Show forest plot

1

88

Mean Difference (IV, Fixed, 95% CI)

3.20 [‐0.57, 6.97]

Analysis 1.5

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 5 Social functioning: 2. Average score at endpoint (two scales).

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 5 Social functioning: 2. Average score at endpoint (two scales).

5.1 SOFS, high score=good

1

44

Mean Difference (IV, Fixed, 95% CI)

3.70 [‐0.70, 8.10]

5.2 Emotional recognition, TRACS, high score=good

1

44

Mean Difference (IV, Fixed, 95% CI)

1.80 [‐5.54, 9.14]

6 Quality of life: Average endpoint scores (various scales) short term Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

Analysis 1.6

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 6 Quality of life: Average endpoint scores (various scales) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 6 Quality of life: Average endpoint scores (various scales) short term.

6.1 mental health (SF‐36, average summary score, high score=good))

1

69

Mean Difference (IV, Fixed, 95% CI)

‐5.30 [‐17.78, 7.18]

6.2 physical health (WHOQOL‐BREF, high score=good)

1

41

Mean Difference (IV, Fixed, 95% CI)

9.22 [‐0.42, 18.86]

6.3 physical health (SF‐36, average summary score, high score=good) )

1

69

Mean Difference (IV, Fixed, 95% CI)

‐3.60 [‐11.98, 4.78]

6.4 psychological health (WHOQOL‐BREF, high score=good)

1

41

Mean Difference (IV, Fixed, 95% CI)

17.70 [6.50, 28.90]

6.5 social well being (WHOQOL‐BREF, high score=good)

1

41

Mean Difference (IV, Fixed, 95% CI)

20.75 [7.42, 34.08]

7 Adverse effects Show forest plot

1

Risk Difference (M‐H, Fixed, 95% CI)

Subtotals only

Analysis 1.7

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 7 Adverse effects.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 7 Adverse effects.

7.1 any serious

1

85

Risk Difference (M‐H, Fixed, 95% CI)

0.0 [‐0.05, 0.05]

7.2 others

1

85

Risk Difference (M‐H, Fixed, 95% CI)

0.0 [‐0.05, 0.05]

8 Leaving the study early ‐ short term Show forest plot

6

586

Risk Ratio (M‐H, Fixed, 95% CI)

0.66 [0.51, 0.86]

Analysis 1.8

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 8 Leaving the study early ‐ short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 8 Leaving the study early ‐ short term.

37Study flow diagram for 2015 searches
Figuras y tablas -
Figure 1

37Study flow diagram for 2015 searches

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 1 Mental state: 1. Clinically important change (PANSS ‐ not improved) short term.
Figuras y tablas -
Analysis 1.1

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 1 Mental state: 1. Clinically important change (PANSS ‐ not improved) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 2 Mental state: 2. Average endpoint score (various scales) short term.
Figuras y tablas -
Analysis 1.2

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 2 Mental state: 2. Average endpoint score (various scales) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 3 Global state: Average endpoint score (CGIS, low score=good) short term.
Figuras y tablas -
Analysis 1.3

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 3 Global state: Average endpoint score (CGIS, low score=good) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 4 Social functioning: 1. Clinically important change (SOFS ‐ not improved) short term.
Figuras y tablas -
Analysis 1.4

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 4 Social functioning: 1. Clinically important change (SOFS ‐ not improved) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 5 Social functioning: 2. Average score at endpoint (two scales).
Figuras y tablas -
Analysis 1.5

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 5 Social functioning: 2. Average score at endpoint (two scales).

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 6 Quality of life: Average endpoint scores (various scales) short term.
Figuras y tablas -
Analysis 1.6

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 6 Quality of life: Average endpoint scores (various scales) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 7 Adverse effects.
Figuras y tablas -
Analysis 1.7

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 7 Adverse effects.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 8 Leaving the study early ‐ short term.
Figuras y tablas -
Analysis 1.8

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 8 Leaving the study early ‐ short term.

Table 2. Comparisons relevant to other reviews suggested by excluded and included studies

Intervention

plus

Control

Participants

Reference tag

Relevant Cochrane review

Yoga

nil

standard care

people with schizophrenia

Behere 2011; Ikai 2013; Ikai 2014; Jayaram 2013; Lin 2006;Lin 2015;Varambally 2012a; Visceglia 2011

Yoga versus standard care for schizophrenia

counselling

standard care

motivational and feedback session

nil

caregivers of people with schizophrenia

Varambally 2013

Yoga

non‐standard care

people with schizophrenia

SLCTR‐2013‐008*; Paikkatt 2012; Xie 2006;

Yoga as part of a package of care versus non‐standard care

Chlorpromazine

nil

placebo

Mahal 1976; Ramu 1999

Chlorpromazine versus placebo for schizophrenia

'Tagara' (local drug with anti‐psychotic properties) and 'Brahmyadiyoga' (a herbal compound)

nil

Chlorpromazine versus herbal compounds for schizophrenia

chlorpromazine

* This particular study used yoga combined with relaxation exercises, breathing exercises, body movement exercises, basic acting exercises, the Alexander technique, theatre games, exercise ''to build self confidence'', creative work using props, use of music to enhance creativity and moods.

Figuras y tablas -
Table 2. Comparisons relevant to other reviews suggested by excluded and included studies
Table 3. Design of a future study

Methods

Allocation: randomised (clearly described).
Blinding: single‐blind (outcomes assessor).
Duration: minimum 1 year.
Design: parallel.
Setting: outpatient and inpatient settings.

Participants

Diagnosis: people with a clinical diagnosis of schizophrenia.
History: from waiting list and referred to research staff.
N=300.
Age: > 18 years.
Sex: males and females.
Inclusion criteria: .age 18 years or greater.
Exclusion criteria: presence of physical disability or illness which precludes participation in yoga intervention.

Interventions

1. Yoga: the yoga intervention should be clearly described and consist of the following components; (i) shithileekarana vyayama (loosening exercises) for approximately 10 minutes (ii) yoga postures (asanas) for approximately 20 minutes (iii) breathing exercises and relaxation techniques for approximately 20 minutes using a manualised protocol, yoga programme for 12 weeks, 3 times weekly, follow‐up at 6 months and 1 year, yoga delivered by a trained yoga instructor, meditation not included.

2. Standard care control*.

All groups stable pharmacotherapy.

Outcomes

Mental state (binary outcomes).

Relapses (binary outcomes).

QOL (binary outcomes).

Disability (binary outcomes).

Activities of daily living (binary outcomes).

Costs: cost of services, cost of care.

Adverse events related to yoga (number and type of injuries).

Service outcomes: days in hospital, time attending outpatient psychiatric clinic.

Notes

Adherence should be logged with patients expected to adhere to 70% to 75% of scheduled sessions.

* Regarding design of a future study, readers are directed to the first yoga review in this series (Broderick 2015) ‐ as a comprehensive yoga versus standard care study has not yet been published, this would be the initial priority. When this is conducted, many legitimate active comparators to yoga could be suggested; such as, but not limited to the following; yoga versus talking therapy, yoga versus expressive therapies, yoga versus other forms of exercise such as Tai'chi.

Figuras y tablas -
Table 3. Design of a future study
Table 4. Possible active comparators to yoga for the design of future trials

Intervention

plus

Active Comparator Broad Group

Specific interventions*

Yoga

nil

expressive therapy

art therapy

drama therapy

music therapy

dance therapy

writing therapy

talking therapies

cognitive behavioural therapy

dialectic behaviour therapy

humanistic therapies

exercise

aerobic‐based interventions

combined aerobic and resistance programme

resistance‐based interventions

Tai'chi

qi'gong

*This list of specific interventions is not exhaustive and merely provides some examples of legitimate active comparators to yoga which are not currently available. These interventions could also be considered alternatively. For instance, exercise consists of heterogeneous interventions, it is accepted there could be other equally justifiable intervention titles such as 'supervised' exercise, 'non‐supervised exercise', or 'group‐based exercise', 'individual exercise', or exercise could be considered in terms of intensity such as 'high intensity', 'moderate intensity' and 'low intensity'. Note the specific intervention should be delivered by suitably qualified personnel.

Figuras y tablas -
Table 4. Possible active comparators to yoga for the design of future trials
Summary of findings for the main comparison. YOGA versus NON‐STANDARD CARE for schizophrenia

YOGA versus NON‐STANDARD CARE for schizophrenia

Patient or population: people with schizophrenia
Settings: hospitals, in India and China
Intervention: YOGA versus NON‐STANDARD CARE

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

YOGA versus NON‐STANDARD CARE

Mental state: clinically important change
PANSS ‐ not improved

Follow‐up: 4 months

Low1

RR 0.81
(0.62 to 1.07)

84
(1 study)

⊕⊕⊝⊝
low2

800 per 1000

648 per 1000
(496 to 856)

Moderate1

900 per 1000

729 per 1000
(558 to 963)

High1

1000 per 1000

810 per 1000
(620 to 1000)

Global state: relapse

No trial reported this outcome.

Social functioning: clinically important change
SOFS ‐ overall, not improved
Follow‐up: 4 months

Low1

RR 0.90
(0.78 to 1.04)

84
(1 study)

⊕⊕⊝⊝
low2

700 per 1000

630 per 1000
(546 to 728)

Moderate1

900 per 1000

810 per 1000
(702 to 936)

Adverse effects ‐ any

See comment

See comment

Not estimable

85
(1 study)

⊕⊕⊕⊝
medium7

Risks were calculated from pooled risk differences. The study reported no adverse effects.

Quality of life: clinically important change

SF‐36 average change score mental health *
Follow‐up: 12 weeks

The mean quality of life: average change ‐ mental health in the intervention (yoga) groups was
‐5.30 lower
(17.78 lower to 7.18 higher)

69
(1 study)

⊕⊕⊝⊝
low3,4,5

* no trial reported binary data; we chose 1 of 2 QOL measures as proxy measure

Physical health: clinically important change

WHQOL‐BREF ‐ average change score *
Follow‐up: 12 weeks

The mean physical health: average change in the intervention (yoga) groups was
9.22 higher
(0.42 lower to 18.86 higher)

41
(1 study)

⊕⊕⊝⊝
low3,4,6

* no trial reported binary data; we chose physical health dimension of QOL measure as proxy measure.

Costs: direct and indirect costs of care

No trial reported this outcome.

Leaving the study early: short term

Low1

RR 0.64
(0.49 to 0.83)

586
(6 studies)

⊕⊕⊕⊝
medium8

200 per 1000

120 per 1000
(88 to 166)

Moderate1

400 per 1000

240 per 1000
(176 to 332)

High1

600 per 1000

360 per 1000
(264 to 498)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

CI: confidence interval; RR: risk ratio

1 Moderate risk approximates to that of non‐standard care in trial(s).
2 Imprecision: Downgraded two levels due to small sample size and substantial loss to follow‐up which was uneven between groups (40.5% non‐standard care, 17% yoga)

3 Imprecision: Downgraded one level due to small sample size
4 Indirect: Downgraded one level as no trial reported binary data and review authors had to use one of 2 sub‐measures.
5 Indirect:Downgraded one level as unclear of clinical meaning of scores from 4 to 26.
6 Indirect:Downgraded two levels as no trial reported binary data and reviewers had to use one of 2 sub‐sets.

7 Imprecision: Downgraded one level as based on one study with no reported adverse events.

8 Risk of bias: Downgraded one level as a number of participants withdrew from one trial and it was not clear to which group they were randomised.

Figuras y tablas -
Summary of findings for the main comparison. YOGA versus NON‐STANDARD CARE for schizophrenia
Table 1. Yoga titles ‐ relevant to people with schizophrenia

Review title

Status

Yoga versus standard care for schizophrenia

Full review: Broderick 2015

Yoga versus non‐standard care for schizophrenia

This review.

Yoga as part of a package of care versus standard care

Protocol: Broderick 2016b

Yoga as part of a package of care versus non‐standard care

Broderick 2017

Figuras y tablas -
Table 1. Yoga titles ‐ relevant to people with schizophrenia
Comparison 1. YOGA versus NON‐STANDARD CARE

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mental state: 1. Clinically important change (PANSS ‐ not improved) short term Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 overall

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

0.81 [0.62, 1.07]

1.2 specific ‐ negative symptoms

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

0.72 [0.57, 0.90]

1.3 specific ‐ positive symptoms

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

1.08 [0.84, 1.38]

2 Mental state: 2. Average endpoint score (various scales) short term Show forest plot

4

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

2.1 overall (PANSS)

3

170

Mean Difference (IV, Fixed, 95% CI)

‐4.69 [‐8.35, ‐1.03]

2.2 specific ‐ depressive symptoms (CDS)

1

69

Mean Difference (IV, Fixed, 95% CI)

0.10 [‐1.01, 1.21]

2.3 specific ‐ depressive symptoms (HDRS)

1

60

Mean Difference (IV, Fixed, 95% CI)

‐1.41 [‐2.40, ‐0.42]

2.4 specific ‐ negative symptoms (PANSS)

4

214

Mean Difference (IV, Fixed, 95% CI)

‐1.15 [‐2.30, 0.01]

2.5 specific ‐ positive symptoms (PANSS)

4

214

Mean Difference (IV, Fixed, 95% CI)

‐0.36 [‐1.35, 0.63]

3 Global state: Average endpoint score (CGIS, low score=good) short term Show forest plot

1

60

Mean Difference (IV, Fixed, 95% CI)

‐0.85 [‐1.21, ‐0.49]

4 Social functioning: 1. Clinically important change (SOFS ‐ not improved) short term Show forest plot

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.78, 1.04]

5 Social functioning: 2. Average score at endpoint (two scales) Show forest plot

1

88

Mean Difference (IV, Fixed, 95% CI)

3.20 [‐0.57, 6.97]

5.1 SOFS, high score=good

1

44

Mean Difference (IV, Fixed, 95% CI)

3.70 [‐0.70, 8.10]

5.2 Emotional recognition, TRACS, high score=good

1

44

Mean Difference (IV, Fixed, 95% CI)

1.80 [‐5.54, 9.14]

6 Quality of life: Average endpoint scores (various scales) short term Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

6.1 mental health (SF‐36, average summary score, high score=good))

1

69

Mean Difference (IV, Fixed, 95% CI)

‐5.30 [‐17.78, 7.18]

6.2 physical health (WHOQOL‐BREF, high score=good)

1

41

Mean Difference (IV, Fixed, 95% CI)

9.22 [‐0.42, 18.86]

6.3 physical health (SF‐36, average summary score, high score=good) )

1

69

Mean Difference (IV, Fixed, 95% CI)

‐3.60 [‐11.98, 4.78]

6.4 psychological health (WHOQOL‐BREF, high score=good)

1

41

Mean Difference (IV, Fixed, 95% CI)

17.70 [6.50, 28.90]

6.5 social well being (WHOQOL‐BREF, high score=good)

1

41

Mean Difference (IV, Fixed, 95% CI)

20.75 [7.42, 34.08]

7 Adverse effects Show forest plot

1

Risk Difference (M‐H, Fixed, 95% CI)

Subtotals only

7.1 any serious

1

85

Risk Difference (M‐H, Fixed, 95% CI)

0.0 [‐0.05, 0.05]

7.2 others

1

85

Risk Difference (M‐H, Fixed, 95% CI)

0.0 [‐0.05, 0.05]

8 Leaving the study early ‐ short term Show forest plot

6

586

Risk Ratio (M‐H, Fixed, 95% CI)

0.66 [0.51, 0.86]

Figuras y tablas -
Comparison 1. YOGA versus NON‐STANDARD CARE