Rao, R.M., Raghuram, N., Nagendra, H.R., Usharani, M.R., Gopinath, K.S., Diwakar, R.B., . . . Rao, N. (2015). Effects of an integrated yoga program on self-reported depression scores in breast cancer patients undergoing conventional treatment: A randomized controlled trial. Indian Journal of Palliative Care, 21, 174–181. 

To evaluate the effects of a yoga program versus supportive care on symptoms of depression among women with breast cancer during treatment

Patients were randomized to the yoga program or a control supportive therapy program. Yoga included education, breathing exercises, meditation, and relaxation techniques with imagery. Subjects were provided with audiotapes of the practices for use at home. Home practice was monitored via telephone calls, weekly home visits, and a daily patient log. Subjects were to practice at home for at least one hour three times per week. The comparison group used supportive, expressive therapy and education provided by therapists in an unstructured approach aimed at addressing fears and concerns and improving support from others among other issues. The intervention took place over a 24-week period including the time of surgery and following adjuvant chemotherapy or radiotherapy. There were four to six study assessments, depending on the treatment, that were scheduled pre- and postsurgery and mid- and postradiation or chemotherapy. Interventions were done on an individual basis.

• N = 69
• AGE: Not provided
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: 87% of participants had grade 3 breast cancer.

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: India

• PHASE OF CARE: Active antitumor treatment

Single, blinded, randomized, controlled trial

• Beck Depression Inventory (BDI)
• Symptom checklist

Both groups reported decreased depression over time. An analysis of covariance showed a larger decrease in depression at all time points measured in the yoga group (p < 0.01). The study sample was appropriate according to the authors' power analysis. Depression scores were directly and strongly correlated (ranged from 0.49–0.77, p < 0.001) with symptom distress scores.

Yoga was shown to be beneficial in reducing symptoms of depression among women with breast cancer during the trajectory of active treatment. Depression was strongly related to symptom scores.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Questionable protocol fidelity
• Subject withdrawals ≥ 10% 
• Other limitations/explanation: There was an initial drop-out rate of about 30% that was fairly evenly spread across both study groups. Patients were not blinded. This study had a repeated measures design with a potential testing effect. There was no information regarding the patients' actual adherence to the prescribed frequency of yoga practice. Control patients had only one session in the perioperative phase and one follow-up session compared to the weekly visits for the intervention group. Baseline depression scores were higher in the control group. No information was provided regarding symptom management.

The findings of this study suggest that yoga is beneficial to women with breast cancer during active treatment to manage depressive symptoms. They also show that adverse symptoms were strongly related to depression, and depression was higher with more severe adverse symptoms. This points to the importance of effective symptom management as part of the overall reduction of depression.