Aarti Jagannathan
Assistant Professor, Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samasthana (SVYASA), Bangalore - 560 019, India

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1. Desire to self heal: All the case histories reported in this book have been successful in healing the patient, because of their 'desire to self heal' (Chapter 2, Page 53). However, the basic challenge in treating any psychiatric patient with the conventional modalities of treatment and more so with the yogic protocols is the patients' lack of insight regarding their own disorder. The Mental Status Examination (MSE) of any psychiatric patient involves assessing his insight which in turn enables the psychiatrist to prescribe pharmacological/non-pharmacological treatment. ^[2] The level of insight (about one's own disorder) in a patient can indirectly predict his co-operation to treatment and recovery. ^[2] Psychiatrists, hence, aim to first stabilize the patient's symptoms and insight through pharmacological treatment modalities, and once the patient is amenable to suggestions of a therapist, the patient could be prescribed conventional or alternative therapy. In cases of severe psychiatric disorders like schizophrenia, personality disorders and autism, yoga as a therapy, requires the patient to have at least a moderate level of insight ^[2] ('desire to self heal'), without which results could be discouraging.
2. Add-on therapy with medication: In continuation with the above point of discussion, yoga could possibly be looked at as a more effective add on treatment, than a stand alone treatment especially in psychiatric disorders such as schizophrenia, where some psychiatric symptoms (positive symptoms of schizophrenia) show initial good response only to drugs. ^[2] This issue is indirectly validated in this book as two out of three cases of psychosis mentioned, were either already on medications when they started the yoga treatment or were advised to start yoga along with medication treatment. Kundalini yoga could be looked at as a stand alone treatment in the case of personality disorders and pervasive developmental disorders where the mainstay of treatment is non-pharmacological. Therapists however need to be cognizant that in dealing with 'multimorbid' psychiatric disorders, the decision to prescribe yoga as a stand alone treatment could be complex.
3. Continuing yoga therapy: Yoga is as an effective alternative treatment in patients who do not obtain remission or satisfactory symptom-relief even after taking pharmacological treatment. ^[3] This effectiveness is, however, pronounced only if yoga is practiced on a continuous basis over a period of time. ^[4] The negative symptoms of schizophrenia such as lack of motivation deter patients from indulging in any activity. Further lack of insight about ones disorder may make the patient believe that they do not require the treatment. Research studies in yoga have reported logistic as well as illness related barriers to yoga therapy which requires to be understood before prescribing yoga to patients with psychiatric problems. ^[5] Most of the cases in this book were referred by the consultant doctor or by the family member of the patient, a possible cause for continuing with the treatment.
4. Chakras stimulation/ Meditation: The Kundalini yoga meditation techniques mentioned in this book are novel in the field of psychiatry as most other studies on patients with psychiatric disorders are limited to yogasanas and pranayama variants only. This is because, studies have depicted that meditation could possibly result in a risk of exacerbating psychosis. Some patients have the risk of activation of psychosis during meditation. ^[6] In patients with schizophrenia, a good proportion of who suffer from motivational defects, ensuring these mindful practices is a challenge. ^[7] The effectiveness of Kundalini yoga meditation techniques though seen to be effective in this book could require further investigation in large sample randomized controlled studies to counter the criticism of including meditation techniques in yoga protocols for treatment of (especially) patients with psychosis.
5. Tackling macro issues of mental health care through Yoga: The author has concluded his book with an epilogue which discusses yoga as an effective preventive treatment to counter the health care market forces. It is true that in the USA (where health care is privatized) as well as in developing countries like India, liberalization, privatization and globalization of mental health care have caused rise in the costs of medication and mental health care treatment. Despite the success of District Mental Health Programme in some states, the common person of India finds it difficult to access affordable mental health care in the community. To tackle this growing issue, introduction of yoga as a preventive, alternative and complementary treatment for patients with psychiatric disorders in India could be an effective solution for three basic reasons: (1) yoga which originated in India is seen to be a practical and accepted therapy for patients to practice at home, (2) the number of yoga therapists is more than the number of mental health professionals available in India, and finally, (3) yoga is cost-effective and has no side-effects as in the case of psychiatric medications.

References

1.	Angst J, Sellaro R, Ries Merikangas K. Multimorbidity of psychiatric disorders as an indicator of clinical severity. Eur Arch Psychiatry Clin Neurosci 2002;252:147-54.   [PUBMED]  [FULLTEXT]
2.	Sadock BJ, Sadock VA. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 7 th Ed. USA: Lippincott Williams & Wilkins; 2000.
3.	Buckley PF, Stahl SM. Pharmacological treatment of negative symptoms of schizophrenia: Therapeutic opportunity or cul-de-sac? Acta Psychiatr Scand 2007;115:93-100.
4.	Patañjali (1989; Feuerstein, G. translation). The Yoga-Sutra of Patañjali: A New Translation and Commentary, Inner Traditions International; Rochester, Vermont, Verse/Page: 1.14.
5.	Baspure S, Jagannathan A, Kumar S, Varambally S, Thirthalli J, Venkatasubramanain G, et al. Barriers to yoga therapy as an add-on treatment for schizophrenia in India. Int J Yoga 2012;5:70-3.   [PUBMED]
6.	Walsh R, Roche L. Precipitation of acute psychotic episodes by intensive meditation in individuals with a history of schizophrenia. Am J Psychiatry 1979;136:1085-6.
7.	Gangadhar BN, Varambally S, 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 J Psychiatry 2012 [in press].

Correspondence Address:
Aarti Jagannathan
Assistant Professor, Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samasthana (SVYASA), Bangalore - 560 019
India

Source of Support: None, Conflict of Interest: None

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