Yoga-Based Classes for Veterans With Severe Mental Illness: Development, Dissemination, and Assessment

The finding that the PBYQ score was significantly correlated with all other outcome measures (pain, BPSS score, and PSS score) raises some questions about the ways in which these classes were beneficial to veterans. It may be that veterans who experienced more positive outcomes from classes saw BSR as more beneficial, but it is also possible that veterans who entered classes with greater expectations experienced better outcomes due to a placebo effect—that is, outcomes may have been influenced more by the expectation than by the content of the classes. In the case of well-being (BPSS scores) and stress (PSS score), this could explain why these outcomes were significantly correlated with perceived benefits of BSR but were not significantly related to any class-related variables such as duration and frequency of attendance. Pain ratings, however, were related to class variables and perceived benefits of BSR.

In a post hoc analysis, the main effect of the PBYQ score as a regressor was added to the linear model for pain, resulting in the PBYQ score having a significant main effect (t(100) = -2.98, P = .004). The main effect of class duration remained significant (t(97) = -1.99, P = .050) but was less substantial when the PBYQ score was added, suggesting some correlation between class duration and pain, independent of BSR’s perceived benefits. Future research should consider the possible mediating effect of perceptions of the effectiveness of a yoga-based program 
a priori or control for placebo effects in order to address the degree to which outcomes are influenced by participant expectations.

This study had a few other notable limitations. Because it was an observational study administered within a clinical mental health program, a control group was not included. Measurement began after BSR classes were established, so veterans had varying levels of prior experience. Specific SMI and medical diagnosis information was not collected from individual veterans. Data were collected from classes of varying length and intensity. The BSR classes often took place within larger programs at the VA, which offered comprehensive care, so some effects of the BSR classes might have been confounded with concurrent evidenced-based treatments or other holistic care programs. Due to these limitations, particularly the absence of a control group, the relationships between BSR participation and health outcomes cannot be assumed to be causal, because a multitude of other variables, such as patient contact and expectancy effects, may have influenced outcomes.

Future Directions

Future research should aim to utilize a control group and collect data from classes of the same intensity and length to better examine whether BSR can be causally linked with improvements in measures of stress, pain, and well-being and to attempt to control for expectancy and contact effects. In addition, future research should aim to recruit a BSR-naïve sample to account for prior experience. Future studies should also aim to parse out whether BSR is differentially effective for each SMI or medical diagnosis, whether there is a relationship between class time and outcomes (as these results suggest that longer class times might be more beneficial for pain), and whether any pain-management benefits from BSR influence other measures of functionality and well-being. Finally, future research can further divide BSR into its active components, such as meditative breathing and aerobic stretching, in order to examine which aspect leads to the greatest effect on each measure; the current results imply that the more rigorous components of BSR classes have the greatest effects on pain.

Conclusion

A yoga-based class affects the mind and body, making it particularly useful for veterans with SMI who experience a range of physical and psychological symptoms and comorbidities.⁴ Other studies have demonstrated that when practiced alone, yoga leads to improvements in both physical and psychological symptoms.^15,17 Looking forward, yoga-based classes may be implemented as part of a larger biopsychosocial-spiritual care plan that is being embraced both within and outside of the VA.^7,8,36,37 This integrative health care model suggests that psychosocial and CAM modalities are additive and should be practiced concurrently.³⁷

Although little research has assessed the effects of comprehensive psychosocial and CAM treatment programs, initial research indicates that these programs are associated with reductions in symptoms of medical and mental illness.^37-40 Participants in BSR classes may derive further benefits if classes are incorporated into a larger holistic health care plan that includes both traditional psychiatric treatment modalities 
and CAM therapies that integrate biopsychosocial-spiritual 
components.

Acknowledgements
The authors would like to thank Nancy Mohler, Anne Platt, and Matthew Crowder, all professional yoga instructors, for their integral role in developing classes, providing classes to veterans, and assisting VA staff with training. The authors also acknowledge Rosie Dominguez, LCSW, for expertly leading BSR classes at LAACC. The authors also thank Irina Arnold, MS, MD, and Vanessa Streiff, MA, for their vital assistance with data collection at SACC.