Running Head: THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 1 The Effect of Yoga on Depression and Anxiety related to IBS C Katherine Kasmer University of Florida College of Nursing
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 2 Abstract Background : Irritable bowel syndrome (IBS) is a functional bowel disorder affecting 20% of adults at some point in their lives. Constipation predominant IBS (IBS C) comprises one third of IBS cases and is characterized by chronic recurrent abdominal pain and constipation that can be debilitating. It has also been associated with stress, fatigue, depression, and anxie ty. The aim of this study was to determine if yoga had a therapeutic effect on the depression and anxiety reported by individuals suffering from IBS C Methods : Data will be derived using three instruments: the Hospital Anxiety and Depression Scale, the Pe rceived Stress Scale, and the IBS Quality of Life Survey Scale. A total of fifteen subjects are to participate in a six week yoga intervention program to determine the effect of yoga on self reported anxiety and depression. The participants will keep a d aily stool diary as well as participate in at home yoga poses and positions. The instruments will be utilized in the pre designed intervals. Results : At this point in time, no subjects have been found eligible to participate in the study. Rigorous recru itment is planned to continue until the goal participant quota of fifteen is reached. Conclusions : No conclusions can be drawn thus far due to lack of participants Subject words : IBS, yoga, IBS C, constipation predominant IBS, Hatha yoga, anxiety, depression, psychosocial, psychosomatic, functional bowel disorder, stress, CAM, complementary alternative methods therapies,
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 3 Background Irritable bowel syndrome (IBS) is characterized by an abdominal pain or discomfort that occurs in association with altered bowel habits for at least three months (Brandt & Chey, 2009). Symptoms include: abdominal pain, change in bowel habits, specifically diarrhea or constipation, bloa ting, and incomplete defecation or feeling of evacuation (Lacy, Weiser & Noddin, 2007). Rome III criteria are commonly used to diagnose IBS. For example, an IBS diagnosis can be made if there is recurrent abdominal pain or discomfort at least three days a month during the previous three months and associated with at least two of the following: improvement in symptoms with defecation, onset associated with a can in frequency of stool, and onset associated with a change in the form/appearance of stool (Dros sman & Douglas, 2006). Current diagnostic criteria are based on subjective symptoms. T herefore, definitive IBS diagnosis can be difficult due to symptom overlap of other bowel conditions and diseases such as lactose intolerance, the inflammatory bowel di celiac disease, and small intestinal bacterial overgrowth (Yoon & Grundmann, 2011) Due to this, it is believed that more than three quarters of those suffering from IBS in the United States go undiagnosed (H ungin & Chang, 2005). Prevalence rates vary due to the wide variety of presentation forms as well as differing diagnostic criteria, but are estimated to be between 2.1 22 percent with women being 1.5 2 times as likely to be affected compared to men (Rey & Talley, 2009). As a result of the high prevalence, it is estimated that the direct and indirect costs attributed to IBS is $200 billion worldwide. Direct costs include medical services and hospitalizations and indirect costs include the loss of work ho urs and productivity due to time spent away from work due to symptoms, medical treatment and lost future earnings (McFarland 2008)
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 4 Since the pathophysiology of IBS is not clearly understood and is unable to be defined by any gross organic or biochemical abnormality, experts hypothesize that IBS involves diet, gene mutations, psychosocial factors, interference of neurotransmission between the central nervous system and enteric nervous system, and/or immune mediated processes (Mathew & Bhatia, 2009). Asid e from the physical symptoms of IBS such as abdominal pain and bloating, sufferers also note the negative impact on quality of life, specifically self confidence and symptoms often leading to the avoidance of social settings (Ringel & Williams, 2009). Ir ritable bowel syndrome is hypothesized to be associated with psychosocial factors such as anxiety and depression. It is of question whether the IBS causes the anxiety an d depression or vice versa. A recent study evaluated whether it is the brain via anxi ety and depression that drives gut symptoms, or whether gut dysfunction precipitates the central nervous system characteristics such as the depression and anxiety. In the twelve year longitudinal study, it was determined that in those free of any gastroin testinal disorder, including IBS, higher levels of anxiety was a significant predictor of developing new onset functional gastrointestinal disorders twelve years later at follow up Therefore it was determined that the central nervous system and the gut i nteract bidirectionally with functional gastrointestinal disorders (Koloski, Jones & Kalantar, 2012). The brain gut pathway also explains the relationship between somatization or the unconscious process in which psychological distress is expressed as ph ysical symptoms, in patients with IBS. The patients with the highest somatization scores tend to have the most severe IBS, the most concurrent psychiatric disorders, and the highest total medical costs for the year (Creed, Tomenson & Guthrie, 2008). It is estimated that half the population reporting a lifetime IBS diagnosis also have a lifetime mood or anxiety disorder (Mykletun & Jacka, 2010) and displayed definite and clinically
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 5 significant anxiety and/or depression Also, significantly higher stress scores are found in the irritable bowel syndrome patient group compared to normal controls. It is common for individuals suffering from IBS to use predominantly negative coping styles compared to control groups (Pinto & L ele, 2000). Another recent study found that 74% of the 256 IBS patients included in the study were diagnosed with anxiety depressive problems. Of those 190, 89 were suffering from pure anxiety disorders, 41 were suffering from depressive disorders, and 6 0 had co morbid anxiety depressive disorders (Modabbernia & Mansourghanaei. 2012). The published literature indicates that fewer than half of IBS sufferers seek out treatment. Of those who do, it is estimated that 50 90% have psychiatric disorders includ ing: panic disorder, generalized anxiety disorder, social phobia, posttraumatic stress disorder, and major depression, while those who do not seek out treatment tend to be psychologically normal (Lydiard, 2001). The high prevalence of anxiety depressive d isorders as well as the notion that those with these disorders are most likely to seek out treatment for IBS, indicates the necessity of psychiatric assessment, early diagnosis and treatment of the individual with IBS (Modabbernia & Mansourghanaei. 2012). Yoga as a type of complementary alternative medicine (CAM), has been shown to have a positive effect on depression and anxiety and therefore has been proposed for the treatment of IBS (Ubelacker, Epstein Lubow, et al., 2010) It has been found that part icipation in a two month yoga class can lead to significant reduction in perceived levels of anxiety in women who suffer from anxiety disorders (Javnbakht & Hejazi, 2009). Another study aimed to determine the effects of yoga on memory tests, salivary cort i sol levels and stress, anxiety and depression. Yoga practitioners showed improvement of the memory performance as well as improvements in psychophysiological parameters (Rocha & Riberio 2012). Subjects who participate in yoga
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 6 courses report significant d ecreases in the self reported symptoms of depression and trait anxiety. Changes are also observed in acute mood, with subjects reporting decreased levels of negative mood and fatigue following yoga classes (Woolery & Myers, 2004). Yoga is an appealing t herapy for individuals suffering from depression for three reasons. First, current methods for treating depression are not satisfactory to many individual and have concerns about the existing treatments and side effects of the medications. Second, the idea of mindfulness promotion and exercise are thought to be the reason for positive results from other successful depression treatments. Third, there are biological, psychological, and behavioral mechanisms by which yoga may have an impact o n depression (Ubelacker, Epstein Lubow, et al., 2010). Unlike the pharmacological treatments for depression, no adverse effects are associated with yoga practice with the possible exception of fatigue and breathlessness (Pilkington, Kirkwood & Rampes, 200 5). A few clinical studies have investigated the use of yoga in the treatment of IBS. One small study with 22 male patients between the ages of 20 and 50 years old, investigated the influence of yoga breathing exercises and posture exercises 2 times per day for 2 months in diarrhea predominant IBS, or IBS D compared to standard treatment with the anti diarrheal drug loperamide or Immodium. The investigators found that participants in both groups showed improvements in bowel symptoms with a reduction in anxiety after the two month study (Taneja, et al, 2004). Another study of yoga in adolescents between the ages of 11 and 18 with diagnosed IBS compared yoga intervention over a period of 4 weeks consisting of one hour instruction and daily practice at hom e for 4 weeks. The group receiving the yoga treatment showed significant improvements in both physical and psychological symptoms (Kuttner, et al, 2006) However, the first study only included male adults with diarrhea predominant IBS and the second stud y did
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 7 not specify the subtype of IBS. There are no other studies that address the use of yoga as an intervention fo r constipation predominant IBS. Therefore, a pilot study such as this could potentially open a new treatment option for individuals sufferi ng from IBS C. Specific Aims of the Study There were two aims of this study. The primary aim was to determine the effect of yoga on physical symptoms of IBS in adults with constipation predominant IBS. Physical symptoms of IBS are characterized by: cha nges in gastrointestinal motility such as stool frequency, stool consistency, and abdominal pain intensity/severity abdominal bloating/distension, and unpleasantness due to these symptoms ( Brandt & Chey, 2009 ). The second aim of the study was to investig ate the effect of yoga on psychological symptoms and feeling of general well being in adults with IBS. Psychological symptoms include: anxiety, sleep disturbances, depression, and general well being or quality of life ( Hungin & Chang, 2005 ). Hypotheses The hypothesis regarding the primary aim was that physical symptoms would be significantly lower in the yoga group compared to the control group as measured by the Bristol stool consistency scale, stool frequency by stool diary, IBS Symptom Severity Scale, and the Mechanical Visual Analogue Scale (M VAS). The second aim, concerning the effect of yoga on the psychological symptoms, specifically anxiety and depression as discussed in this paper, was that the psychological symptoms and feeling of general well being related to IBS symptoms would be significantly better in the yoga group compared to the control group as measured by the hospital anxiety and depression scale (HADS), Perceived Stress Scale, and IBS Quality of Life (IBS QOL).
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 8 Methods Design, Sample and Setting This study involves as convenience sample of 15 participants aged 18 and over, diagnosed with IBS C who are living in the North Central Florida area. Inclusion criteria includes: must be over the age of 18, a clinical diagnosis of IBS C, a F unctional Bowel Disorder Severity Index (FBDSI) score of 37 or higher, have more than 25%of their stools be described as hard or lumpy, able to speak and understand English, and be willing to follow the research protocol during the study period. Exclusio n criteria includes: women who are currently pregnant, both men and women who are going to be treated with new medications for IBS C during the study period, any comorbidities that may affect the interpretation of the study findings (including but not limi ted to: cancer, diabetes mellitus, and any movement disorders), those with a history of drugs or alcohol abuse within the six months prior to screening those with a history of psychiatric illnesses with the exception of depression and anxiety dis order, th ose experiencing chronic pain conditions with the exception of fibromyalgia, and finally those with a history of practicing yoga within the past three months. We estimate a dropout rate of 30%, which would take our sample size from 15 to a minimum of te n participants. Subjects will be recruited from flyers posted around the University of Florida campus, in bathroom stalls, in the library, gyms, on bulletin boards, in grocery stores, and in health food and vitamin shops. The flyer is composed of multipl e pull off tabs that po tential participants can take. Each pull strip includes numbers.
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 9 Instruments Three instruments in specific will measure the effect of yoga on anxiety and depression in individuals with IBS. These are the Hospital Anxiety and Depression Scale (HADS), the Perceived Stress Scale (PSS), and the IBS Quality of Life Scale (IBS QOL). The H ospital Anxiety and Depression S cale (Zigmond & Snaith, 1983) consists of seven items to measure anxiety and de pression. The HADS has been a well validated and widely used assessment tool for measuring anxiety and depression. Each item features a four point Likert scale ranging from 0 3 with the total score ranging from zero to a maximum score of 21. Scores less he things I used to enjoy, I can laugh and see the funny side of things, worrying thought go through my mind, and I get The Perceived Stress Scale (PSS, Cohen et al., 1988) is widel y used to measure the perception of stress and can be applied to any subgroup population. The PSS 10 format will be used for this study, which consists of ten items, using a five point Likert scale, ranges from 0 4. Higher PSS scores indicate a higher lev el of stress. Eleven points or less indicates less than average level of stress, while 16 points indicates above average level of stress. Questions include asking how often in the last month the individual felt nervous or stressed, found they were unable to cope with all the things they have to do, and how often does the individual get angered because of things outside of their control. The IBS Quality of Life Questionnaire (IBS QOL) (Patrick et al., 1998; Drossman, et al., 2000) is comprised of 34 items on a 0 5 Likert scale. The IBS QOL analyzes body image,
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 10 dysphoria, interference with activity, health worry, food avoidance, social interaction, sexuality, and relationships. Higher scores i ndicate lower quality of life. Examples of questions include: I feel helpless because of my bowel problems, I feel my life is less enjoyable because of my bowel problems, I feel depressed about my bowel problems, and I feel isolated from others because of Procedures After receiving contact from participants, they were screened initially via a telephone script to determine if they met all the inclusion and exclusion criteria. Once a participant was deemed eligible, researchers met with them to determine their FBDSI score in order to indicate IBS severity as well as to obtain informed consent. Baseline information was collected which included demographic information, medical history, mediation use, and complimentary therapy and lifestyle questio nnaire for IBS. After initial screening, eligible subjects who agree to participate in the study, will continue their usual care and routine for two weeks in which the observations will be determined as baseline. The yoga intervention will be practiced for one hour per session with two sessions a week for six weeks. The yoga instructor, Tammy Bernard has been a certified Hatha Yoga practitioner for over 15 years. The yoga intervention will take place in Mrs. Bern through the Arts in Medicine program at Shands Hospital at the University of Florida In addition to the two sessions in studio a week, the subjects are encouraged to practice yoga throughout the week as home which should take between 15 20 m inutes. This study design allows for comparison between the pre treatment IBS symptoms of each individual with any post treatment changes based on the yoga intervention. This will allow
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 11 the researchers to determine if in fact yoga has an effect on the ph ysical symptoms of constipation predominant IBS. Problems and Difficulties Encountered This project has not been without complications. The process of finding a certified Hatha yoga instructor that could fit into the schedule was difficult and by the tim e one was found, unforeseeable family difficulties arose and she had to remove herself from the project. Thankfully, the Principle Investigator of the study, Dr. S. Yoon found a replacement fairly quickly. Meanwhile, the study needed to go through a comp lete IRB approval that took over four months needing multiple revisions. The most current obstacle is the ability to recruit the fifteen necessary subjects. Multiple emails and phone calls have been exchanged, but none to date meet all the inclusion and exclusion criteria. The criterion that seems to be most limiting is the need for the potential subject to be clinically diagnosed with IBS C. Many people phone and email in with the symptoms, but unless they have been diagnosed by a physician they are un able to participate in the research. Due to the lack of participants, at best, the intervention will run into Clinical Practice Transition in which the researchers will have further scheduling difficulties. In order to combat this, the three student rese archers will alternate schedules to ensure that at least one is able to attend every yoga session. Ideas to increase participants have been considered such as changing the time of the yoga intervention to allow for better scheduling for potential subjects as well as advertising the study better. Hard copy flyers were distributed around the North Central Florida area, but perhaps more subjects could be found if able to advertise the study to reach more potential subjects. For
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 12 Also, use of social medial sites such as Facebook was considered to reach the target population. However, IRB approval does not allow for the electronic distribution of potential subject flyers, therefore options are limited. Recommendations for Junior Nursing Students For future students considering participating in research, the most important factor is to choose a topic that is interesting and enjoyable. Ample time will be spent performing a literature review, writing the consent, submitting IRB approval, an d conducting the study. T herefore it is important to be involved in something one finds interesting and is passionate about. There are endless options, and all it takes is a single idea to spark an amazing project. Research takes a lot of work, effort and time, but the experience is invaluable. Time management is a skill one needs to acquire a firm grasp of and do so quickly. Senior fall is a whirlwind of classes, clinical, and projects, therefore it is important to plan and anticipate any and all complications, foreseeable or unforeseeable. Regardless of how much planning, there will always be delays and circumstances out of the control of the researcher. This should not d iscourage one but instead encourage one to continue and work through the problem or issue. What the Student Researcher H as Learn e d Bachelor of science prepared nurses are to participate in research design and data collection and this project was a perfect stepping stone to future projects. With this project, numerous difficulties were encountered, which will only further prepare one in the future. The project allowed the beginner student researchers to learn about the research process and how to identify and create change through research. In order to advance nursing as a profession, all
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 13 nurses need to participate in evidence based p ractice and the only way to do so is to stay up to date on the research and current data. In addition to learning about the research process, the student researcher learned, in extensive detail, about irritable bowel syndrome and its prevalence. As a fu ture health care provider the researcher will definitely come in contact with clients with IBS and being involved in this research project will allow for competence and confidence when discussing the pathophysiology, diagnostic criteria, treatments, and c omplementary alternative therapy options such as yoga. Personally I am very passionate and interested in learning about alternative medicine options instead of using pharmaceutical medications. As stated earlier in this paper, pharmaceutical interventio ns usually have adverse side effects, some even been life threatening or fatal. Many times the side effects decrease quality of life as much as the disease the individual suffers from. It is also not unheard of, as stated above, for the side effects to b e as detrimental or fatal after extended use, thus requiring the Food and Drug Administration (FDA) In addition, wit h growing healthcare costs and Americans feeling the econom ic stress on their pocketbooks, it would be helpful if we were able to provide low cost treatment options that also allow for scheduling flexibility. Another part of this project I was very interested in I found during my literature review. While resear ching the topics of yoga and IBS separately from the effect of yoga and depression and anxiety symptoms, I would hypothesize that it is due to both the mental and physical relaxation felt during yoga sessions as well as the physical activity brought about by performing the poses
THE EFFECT OF YOGA ON DEPRESSION AND ANXIETY RELATED TO IBS C 14 Conclusion Although this project was not seen to completion, I still learned ample about the research process. When I first began this project, I would never have foreseen how difficult IRB approval can be, or how hard it is to f ind participants that meet both the inclusion and exclusion criteria. I hope that Dr. Yoon is able to take the work we have assisted for this research project thus far, and use it next year with the upcoming senior class. If taken to completion, this st udy could prove to help many individuals suffering from such a debilitating syndrome. I hope that one day in the near future I will be able to view the completed research experimentation results. I have no doubt this study will make an impact on the use of CAM for constipation predominant IBS patients.
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