research paper on stress management through yoga

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• J Ayurveda Integr Med
• v.14(5); Sep-Oct 2023
• PMC10520539

Role of yoga in stress management and implications in major depression disorder

Padmavathi r.

a Department of Physiology, Sri Ramachandra Medical College and Research Institute, SRIHER, Porur, Chennai, Tamil Nadu, India

Archana P. Kumar

b Medical Education Unit, College of Medicine and Medical Sciences, Arabian Gulf University, Bahrain Arabian Gulf University, Bahrain

Dhamodhini K S

V. venugopal.

c Department of Yoga, Government Yoga and Naturopathy Medical College and Hospital, Chennai, India

Santhi Silambanan

d Department of Biochemistry, Sri Ramachandra Medical College and Research Institute, SRIHER, Porur, Chennai, Tamil Nadu, India

Maheshkumar K

e Department of Physiology and Biochemistry, Government Yoga and Naturopathy Medical College and Hospital, Chennai, India

Pankaj Shah

f Department of Community Medicine, Sri Ramachandra Medical College and Research Institute, SRIHER, Porur, Chennai, Tamil Nadu, India

Associated Data

This is a review paper and content is taken from the approved scientific literatures.

Major Depressive Disorder (MDD) is one of the leading causes of disability affecting more than 340 million people and second largest contributor to global burden of disease. Chronic stress is a common risk factor and important contributor for MDD. Stress could be defined as the “perceived inability to cope”. Stressful life events are shown to provoke a sequence of psychological and physiological adjustments including nervous, endocrine and immune mechanisms. Stress can lead to elevation of a variety of inflammatory cytokines and stress hormones, can cause autonomic dysfunction and imbalance in neurotransmitters. Yoga can reduce depressive symptoms by alleviating stress. Studies have shown that yoga can reduce inflammation, maintain autonomic balance and also has a role in maintaining the neurotransmitters. It has role on hypothalamic–pituitary–adrenal (HPA) axis, the peripheral nervous system including GABA, limbic system activity, inflammatory and endocrine responses. Yoga along with antidepressants can help in reducing the depressive symptoms in patient with MDD. Yoga is an ideal complementary and alternative therapy for mental health disorders.

1. Introduction

Stress is a normal, universal human experience and is being practiced for many years. Stress is broadly defined as “the nonspecific response of the body to any demand” . Eustress or good stress is the stress that benefits our health (eg., Physical exercise, getting first mark in exams, getting promotions in workplace). Distress or bad stress is the stress that harms the health which often results from imbalances between needs and resources for dealing with those needs [ 1 ].

Intensity and duration of stress differs from one person to another. The performance may be affected if there is insufficient amount of stress(meaning lower motivation or boredom). However symptoms of stress that are sustained for a longer duration can be detrimental leading to lethargy, lack of confidence, and disturbed sleep [ 2 ]. When stress levels are too high, it could lead to mental health issues such as depression and anxiety, as well as behavioural changes which includes increased alcohol consumption, drug abuse, and eating disorders. It also causes many medical consequences like: gastrointestinal disorders, headaches, cardiac disorders, musculoskeletal weakness, etc [ 3 ]. Behavioural coping strategies are those which denotes the different strategies that an individual might apply while experiencing a stressful situation [ 4 ]. Coping denotes the method of dealing problems to get rid of negative emotions which allows us to maintain control of our emotions to present conditions and demands. Psychological stress can clearly trigger a depressive episode, especially when the psychological impact of a stressor exceeds the coping ability of the individual [ 5 ]. Yoga is one of the most beneficial coping strategies for reducing stress, through release of neurochemicals in the brain. Breathing exercises which could be as simple as a simple deep breath concentration to advanced breathing practices which makes one to perceive the effects of meditation, induces complete relaxation [ 6 ]. This review article focuses on the pathophysiological mechanism of stress and depression, and the role of yoga in reducing stress and depression.

2. Pathophysiology of stress and depression

Stressful life events are shown to provoke a sequence of psychological and physiological adjustments including nervous, endocrine and immune mechanisms [ 7 ]. Stimulation of hypothalamic-pituitary-adrenal (HPA) axis, activation of Sympathetic Nervous System (SNS) and initiation of cascade of inflammatory responses are some of the well-recognized effects of stress [ 8 ]. Stress causes higher cortical areas to send impulses to hypothalamus via limbic system. Certain areas of Para Ventricular Nucleus (PVN) are activated to release Corticotrophin Releasing Factor (CRF) [ 9 ]. Meanwhile additional neurotransmitters like serotonin, Nor-epinephrine (NE), and Acetylcholine (Ach) are released into the blood stream. CRF acts on corticotrophs and PVN to produce Proopiomelanocortin (POMC) and Arginine Vasopressin (AVP) respectively. POMC eventually divides to produce Adreno Cortico Tropic Hormone (ACTH) and alpha Melanocyte Stimulating Hormone (α-MSH) [ 10 ]. AVP acts synergistically with CRF stimulating excess release of ACTH, which ultimately acts on adrenal cortex to produce Glucocorticoids (GC) [ 11 ]. SNS releases Catecholamines (CC) into circulation at the same time. Therefore, GCs and CCs are the main stress hormones which impact several aspects of the brain functions including formation and endurance of neurons, size of the hippocampus, metabolism and immunity [ 11 ]. Even though, there is no obvious documented evidence about the neural mechanisms involved in the pathogenesis of depression due to stress, the various symptoms of depression suggest that areas such as hippocampus, prefrontal lobe, amygdala, thalamus, corpus striatum and cingulate cortex may be involved very commonly [ 12 ]. Chronic stress is shown to trigger inflammatory responses as well, thereby altering physical and mental health. Fig. 1 shows the interaction between stress, brain, HPA axis, SNS and inflammatory cytokines [ 13 ].

Pathophysiological mechanisms of stress.

It is well-known that stress responses in the body leads to the release of cytokines such as interleukin-6 (IL-6), interleukin-1β (IL-1β), tumor necrosis factor-alpha (TNF-α) which are already proved to produce depression symptoms [ 14 ]. These inflammatory markers may affect various functions of central nervous system (CNS) resulting in sleep disturbance, cognitive decline, reduction of monoamine levels all of which collectively aggravate the manifestation of depression [ 15 ]. In addition, IL-1β is shown to control the expression of genes related to serotonin transport, IL-6 is capable of neuronal inhibition of hippocampus and TNF-α has the potential to induce pathways which catabolize tryptophan, the primary substrate for serotonin formation [ 16 ]. Advanced research in this field may reveal newer neuronal pathways linking the stress induced cytokines with somatic and behavioral effects of depression.

A major downstream consequence of MDD is elevated glucocorticoid (the most important of these being cortisol) levels, which are present in the majority of depressed individuals but not all [ 17 ]. High cortisol levels may be particularly harmful alongside elevated levels of inflammatory cytokines, which inhibit the action of cortisol by downregulating cortisol receptor activity [ 17 ]. High cortisol levels may directly contribute to cell damage and death in a variety of cell types, including hippocampal cells, in part by impairing effective regulation of cellular glutamate [ 18 ]. Unmedicated depressives display low levels of neurosteroids, including GABA-A, DHEA, and allopregnanolone; treatment and remission of depression restores normal levels. Stress (which, as you saw, produces powerful hormones like glucocorticoids into the blood) appears to diminish the levels of BDNF generated in the hippocampus by disrupting neurons in the hippocampus, according to experimental research. ADM therapy appears to prevent or reverse this decrease in BDNF levels [ 19 ].

3. Mechanisms of stress management through Yoga

Yoga plays a beneficial role to manage stress related mental illness like depression and anxiety. Regular practice of yoga promotes physiological changes such as reducing blood glucose, blood pressure and cortisol levels and improves general wellbeing [ 20 , 21 ]. Depression is a psycho-physiological disorder which majorly involves alteration in the monoamine (noradrenaline, serotonin, dopamine) metabolism [ 22 ]. Central neurotransmitters such as gamma-aminobutyric acid (GABA) play an important role in depression as well. There are multiple mechanisms through which yoga helps in the management of depression. Yoga is mind-body medicine widely found to be beneficial in various psycho-somatic disorders. Yoga includes physical postures, breathing practices, meditation and also moral principles (yama & niyama) which helps in emotional culturing to reduce inner conflicts [ 23 ]. According to a recent review of yoga's effect on stress, a yoga intervention resulted in a significant reduction in stress [ 24 ].

Numerous biological mechanisms suggested that yoga may reduce stress which include the Autonomic nervous system (ANS), HPA axis, the peripheral nervous system including GABA, limbic system activity, endocrine functions and inflammatory responses [ 25 ]. Previous literature reveals the possible effects of yoga on endothelial function, release of nitric oxide, endogenous cannabinoids, opiates and gene expression [ 26 ]. Yoga is suggested to have immediate and beneficial effects on baroreflex sensitivity and heart rate variability (HRV), which has a stimulating effect on vagal nerve [ [27] , [28] , [29] ]. It decreases vagal stimulation, which decreases the activation and reactivity of the sympathoadrenal system and the HPA axis and that leads to parasympathetic activation, thus shifting of sympathetic to parasympathetic activity occurs, and also decreases the release of stress hormones.

Yoga shifts the balance from the sympathetic nervous system and the fight–or–flight reaction to the parasympathetic nervous system and the relaxation response [ 30 ]. Yoga practice regulates the HPA axis and SNS, both of which could be the reasons for the reduction of stress hormones cortisol and catecholamines release and leads to the reduction of stress and induces relaxation [ 31 ].

3.1. Corticosteroids and catecholamines

Yoga acts on hypothalamus which inhibits the activity of the anterior pituitary gland and decreases the production of ACTH, this reduction in ACTH production affects the adrenal gland and reduces the synthesis of cortisol. Many studies have observed this decrease in cortisol levels after practicing yoga [ 32 ], whereas Cortisol activates phenyl ethanolamine- N -methyl transferase (PNMT). Decrease in cortisol production after yoga practices simultaneously decreases PNMT. This decrease in PNMT along with sympathetic inhibition also decreases catecholamine formation. Thus the decreased levels of corticosteroids and catecholamines together decreases the stress responses [ 33 ].

3.2. Dopamine

Practicing yoga increases the levels of dopamine in the human body. Another study confirmed that, 11C–raclopride binding in ventral striatum decreased by 7.9% while practicing yogic meditation which corresponds to a 65% increase in endogenous dopamine release [ 34 ]. Increase in dopamine release concomitantly decreases the stress level.

3.3. Serotonin

The “serotonin hypothesis” denotes that the diminished activity of serotonin pathways leads to the pathophysiology of depression. Increasing serotonin activity in depressed individuals promotes positive shifts in automatic emotional responses [ 35 ]. Yogic practices have been proved to increase the plasma levels of Serotonin [ 36 ]. Regular yogic practices increase serotonin levels associated with reductions in monoamine oxidase levels, which is an enzyme that breaks down neurotransmitters and cortisol and thus reduces stress.

3.4. Melatonin

Melatonin is a regulatory circadian hormone which has a hypnotic and an antidepressive effect [ 37 ]. Meditation has been shown to boost melatonin levels by decreasing its hepatic metabolism or increasing its production in the pineal gland [ 37 ]. Thus, yoga reduces stress.

3.5. Noradrenaline

Yoga practices are proved to enhance noradrenalin and decreases the plasma levels of adrenalin which in turn reduces stress [ 38 ].

3.6. Inflammatory markers

Yoga reduces inflammatory markers such as NK cells, IL 6 and TNF-α and hs-CRP [ 39 ]. According to previous study, yogic meditation reduces the activity of NF–B-related transcription of pro-inflammatory cytokines and decreases the transcription of innate antiviral response genes by Interferon Response Factors (IRF1), both of which are regarded important stresses.

Yogic practices increases the levels of BDNF in the human body. Improvements in BDNF levels after yoga practise may be related to lower stress levels, as evidenced by lower cortisol levels, and improved HRV parameters [ 40 ].

3.8. Gene expression

Regular yogic practices have an effect at the molecular level [ 41 ] and it modifies gene expression positively [ 42 ].

3.9. Sirtuins

There is a relationship between the Sirtuin1 gene (rs3758391) and depressive disorders, according to studies, and Sirt1 expression in the peripheral blood of depressed people is much lower than in healthy people [ 43 , 44 ]. By activating SIRT1, The progress of depression-related phenotypes and aberrant dendritic architecture caused by persistent stress exposure will be prevented [ 45 ]. According to previous reports, activating Sirt1 may improve mood function and have an antidepressant impact [ 46 ]. Researchers have proved that the yoga and meditation-based lifestyle increases sirtuin-1 levels and hence serve the purpose of producing antidepressive effects and reducing stress [ 41 ].

3.10. Proposed psychological mechanism

Psychological mechanisms of the effects of yoga on stress and depressive symptoms has been proved to improve self - awareness, positive attitude towards stress, calmness and mindfulness [ 25 ]. Yoga slows the breath, helps to focus on the present and reassure relaxation, slow the breath and focus on the present. It improves self-confidence, attentiveness, relaxing sensations, well-being sensations, an optimistic outlook on life, achieves tranquility of the mind and lowers irritability [ 47 ]. Patanjali's Yoga sutras is one of the traditional texts which mentions depression ( dhaurmanasya ) as one of the important distractions of the mind ( chitta vikshepa ) and is considered as an obstacles in the path of yoga [ 48 ]. Sage Patanjali mentions many ways to overcome the mental distractions and first of which is one-pointedness ( eka tattwa abhyasa ) which is applied in both pranayama, concentration ( dharana ) and meditation [ 49 ].

Yoga induces relaxation by reducing physiological excitement which is most helpful in coping emotional stress [ 50 ]. It has been indicated that simple breathing and concentration techniques, are the two important modules of yoga, which can support individuals mentally manage with stress that permits enormous health benefits. As a result, Yogic breathing practises serve as a link between the mind and the body, and can be viewed as an important element in one's everyday life for cultivating mindfulness [ 51 ]. Yoga is the ultimate skill to calm down mind, says the traditional text of Yog Vashishta (mana prashamanopayah yoga ityabhidhiyate) and this is achieved through various techniques, such as practicing the principles of yama/niyama and through yogic breathing techniques for coping with stressors in a better manner, better perception of stress and reducing stress & stress-related illness [ 49 ]. Mindfulness techniques involve self-awareness, self-control, self-encouragement, without avoidance, judgement, or self-criticism, to recognize and sustain stressors as they are [ 52 ]. Yogic techniques enhance well-being, mood, attention, mental focus, and stress tolerance [ 53 ]. For depression and anxiety disorders, Mindful meditation and Yoga has been proved to have positive effects [ 54 ].

Individuals are advised to concentrate on their breathing patterns throughout the practice without any distractions. This mindfulness helps the practitioners to be aware of the present and won't be affected or disturbed by the past incidents [ 55 ]. It is evident that deep yogic breathing has many functional benefits, which in turn regulates the imbalances in the ANS and thus alleviates stress by stimulating parasympathetic activity [ 56 ].

4. Studies on yoga & depression

A randomized control trial (RCT) comparing yoga with usual conventional treatment for a period of six weeks showed a substantial decrease in the depression scores when matched to control group [ 57 ]. Another study done in major depressive disorder (MDD) of mild to moderate severity found yoga to have greater reduction in symptoms when compared to control group and were also more likely to achieve remission [ 58 ]. A study done in older women also proved that there was a reduction in depression and anxiety symptoms [ 59 ]. A RCT done in college students, observed a significant improvement in depression and anxiety symptoms compared to the control group. But interestingly, the comparison between yoga and meditation did not show any significant difference between each other [ 60 ]. Likewise, another study done in pregnant women with depression and anxiety, showed significant reduction in the depression scores [ 61 ]. A RCT comparing yoga with usual treatment in women with breast cancer showed a significant improvement in the state and trait anxiety in the yoga group [ 62 ]. Yoga was also observed to be effective in reducing depression scores in women with premenstrual syndrome [ 63 ]. In patients with depression, yoga was found to increase plasma serotonin levels [ 65 ]. Brain imaging studies have also documented that yoga increases the release of endogenous dopamine in the ventral striatum and also an increase in the thalamic GABA levels [ 64 ]. Another mechanism through which yoga might probably help depression is through correcting the dysregulation of hypothalamic-pituitary-adrenal (HPA) axis which is commonly observed in depression [ 65 ]. Depression is also associated with increased cortisol levels which decreases to normal levels after effective yoga treatment [ 66 ]. Studies have reported that yoga could reduce subjective stress and levels of both plasma cortisol levels & salivary cortisol [ 67 ]. A recent systematic review and meta-analysis article has highlighted the positive effects of yoga in reduction of depressive symptoms in a dose -response manner [ 68 ].

5. Recognition of yoga

The United Nations General Assembly has recognized the overall advantages of yoga and its natural connection with the UN's objectives and values by declaring June 21 as International Yoga Day. National Mental health Policy in Vision 2014 has highlighted the importance of Indigenous system of medicine in management of mental health disorder and increase the therapeutic choice. AYUSH clinics are now a part of the hospitals Government is also building research capacities by providing research funds through DST- SATYAM, ICMR and AYUSH funding agencies. Yoga is now included in the school and college curriculum [ 69 ].

6. Discussion

Stress is defined as “perceived inability to cope”. Stress and MDD are associated with elevation of a variety of inflammatory cytokines, stress hormones and imbalance in neurotransmitters. Yoga is an ideal complementary therapy for mental health disorders. Yoga is a complex and holistic system that encompasses (i) physical postures to promote strength and flexibility; (ii) breathing exercises to enhance respiratory functioning; (iii) deep relaxation techniques to reduce mental and physical tension; (iv) meditation and mindfulness practices to increase mind–body awareness and (v) enhanced emotion regulation skills through the practice of yama and niyama . The COVID-19 pandemic has increased stress related disorders and depression in recent times, hence the need of the day is to have an integrated therapeutic and preventive approach of allopathy with complementary and alternative medicine. Yoga could be a good complementary and alternative treatment modality for Major Depressive Disorder.

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All the authors consent for publication and have submitted the copyright form.

Availability of data and materials

Declaration of competing interest.

The authors declare no competing interests.

Acknowledgement

Authors would like to express their sincere gratitude to the Management of SRIHER, Chennai and Government College of Yoga and Naturopathy, Chennai.

Peer review under responsibility of Transdisciplinary University, Bangalore.

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Peer-reviewed

Research Article

Yoga an effective strategy for self-management of stress-related problems and wellbeing during COVID19 lockdown: A cross-sectional study

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation National Resource Centre for Value Education in Engineering, Indian Institute of Technology Delhi, Noida, India

Contributed equally to this work with: Kamlesh Singh, Nitesh Sharma, Rahul Garg

Roles Conceptualization, Formal analysis, Project administration, Resources, Supervision, Writing – review & editing

Affiliations National Resource Centre for Value Education in Engineering, Indian Institute of Technology Delhi, Noida, India, Department of Humanities and Social Sciences, Indian Institute of Technology Delhi, New Delhi, India

Roles Conceptualization, Data curation, Formal analysis, Writing – review & editing

Roles Conceptualization, Supervision, Writing – review & editing

Affiliations National Resource Centre for Value Education in Engineering, Indian Institute of Technology Delhi, Noida, India, Department of Computer Science and Engineering, Indian Institute of Technology Delhi, New Delhi, India, Amar Nath and Shahsi Khosla School of Information Technology, Indian Institute of Technology Delhi, New Delhi, India

• Pooja Swami Sahni, 
• Kamlesh Singh, 
• Nitesh Sharma, 

• Published: February 10, 2021
• https://doi.org/10.1371/journal.pone.0245214
• Peer Review
• Reader Comments

This cross-sectional research aims to study the effect of yoga practice on the illness perception, and wellbeing of healthy adults during 4–10 weeks of lockdown due to COVID19 outbreak. A total of 668 adults (64.7% males, M = 28.12 years, SD = 9.09 years) participated in the online survey. The participants were grouped as; yoga practitioners, other spiritual practitioners, and non-practitioners based on their responses to daily practices that they follow. Yoga practitioners were further examined based on the duration of practice as; long-term, mid-term and beginners. Multivariate analysis indicates that yoga practitioners had significantly lower depression, anxiety, & stress (DASS), and higher general wellbeing (SWGB) as well as higher peace of mind (POMS) than the other two groups. The results further revealed that the yoga practitioners significantly differed in the perception of personal control, illness concern and emotional impact of COVID19. However, there was no significant difference found for the measure of resilience (BRS) in this study. Yoga practitioners also significantly differed in the cognitive reappraisal strategy for regulating their emotions than the other two groups. Interestingly, it was found that beginners -those who had started practicing yoga only during the lockdown period reported no significant difference for general wellbeing and peace of mind when compared to the mid- term practitioner. Evidence supports that yoga was found as an effective self- management strategy to cope with stress, anxiety and depression, and maintain wellbeing during COVID19 lockdown.

Citation: Sahni PS, Singh K, Sharma N, Garg R (2021) Yoga an effective strategy for self-management of stress-related problems and wellbeing during COVID19 lockdown: A cross-sectional study. PLoS ONE 16(2): e0245214. https://doi.org/10.1371/journal.pone.0245214

Editor: Gagan Deep, Wake Forest Baptist Medical Center, UNITED STATES

Received: October 10, 2020; Accepted: December 23, 2020; Published: February 10, 2021

Copyright: © 2021 Sahni et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data underlying this study are available on OSF (DOI: osf.io/q7xy9 ).

Funding: The author(s) received no specific funding for this work.

Competing interests: No authors have competing interests.

Introduction

A report by the World Economic Forum estimates that about 2.6 billion people around the world have been in some kind of lockdown that may lead to second form of stress-related disorder epidemic in the second half of 2020 [ 1 ]. Similar to the World economic forum estimations, a survey by the Indian Psychiatric Society shows that two-fifth of the people are experiencing common mental disorders, due to lockdown and the prevailing COVID19 pandemic in India [ 2 ]. This indicates the need for an urgent action to reduce the adverse effects of the COVID19 lockdown on the general well-being of people.

Various factors have been suggested to be contributing to the worsening of mental health. One of the major factors reported causing stress, anxiety and depression is fear of getting infected with the virus/disease (COVID19) [ 3 ]. Previous studies examining illness perception in the context of other chronic diseases such as; diabetes, AIDS and myocardial infarction found that people create their representations of the illness related to its risk of contracting, cause, time the illness will last for, and the consequence of the illness [ 4 – 6 ]. Further, it is also suggested that beliefs plays an important role in the way people create notions for the controllability and cure of the illness [ 7 ]. These representations and notions are argued to determine the stress response, and the ways of coping, which is believed to affect the wellbeing [ 8 ]. On the other hand, some of the factors that influences the perceived effects of the illness are suggested to be the physical and mental health status of the individuals, with healthy people reporting less cognitive and emotional representations of illness [ 9 ]. Even the type of treatment and the preventive measures received are suggested to drive the illness coherence/ understanding and perception about personal control over the illness [ 10 ].

Even though there are some studies supporting that yoga can be used as complementary and alternate therapy for mental health, there is need for empirical research studies to provide evidence for yoga as effective strategy for self-management of stress-related problems during COVID19. Further, to the best of our knowledge the empirical investigation for the effects of yoga and other spiritual practices on illness perception and wellbeing related problems experienced by people during COVID19 has not been examined so far. The present research uses a cross-sectional study design to examine the effect of the practice of yoga and other spiritual practices on illness perception, and wellbeing of adults. In this study, wellbeing has been assessed through measures of depression, stress, anxiety, resilience, peace of mind and the strategies employed to regulate the emotional upheavals. This approach has been reported in earlier studies that have examined wellbeing in terms of anxiety, stress, and depression [ 11 – 13 ], emotion regulation [ 14 ]and as a measure of peace of mind [ 15 ]. Wellbeing has also been shown to positively correlate with resilience [ 16 ]

Previous research has suggested that yoga can be used as a non-pharmaceutical measure or as a complement to drug therapy for treatment or cure of modern epidemic diseases like mental stress, obesity, diabetes, hypertension, coronary heart disease, and chronic obstructive pulmonary disease [ 17 ]. Some recent studies also propose that yoga can assume a ground-breaking complementary and alternative therapy in the battle against the novel coronavirus while improving the physical and mental wellbeing of people in this pandemic circumstance [ 18 , 19 ]. However, for long researchers have debated the role of yoga and other spiritual practices in the mental health of people [ 20 ]. The practice of yoga is most commonly perceived as physical exercise that helps in gaining flexibility, physical strength and helps to relax. In Indian philosophical texts, yoga is treated as a spiritual practice that is related to training of the mind. Patanjali yoga sutra describes yoga as a practice of ‘Chitta vritti nirodha’ literally translating as controlling or calming of the mind. Most commonly, a typical yoga schedule follows a combination of asanas (postures), pranayama (breath control), pratyahara (withdrawal of senses), Dharana (concentration), dhyana (meditation) and Samadhi (absorption). While asanas are reported to help in improving the physical strength and flexibility, it is argued to also help in building concentration [ 21 ]. Preliminary research suggests that pranayama calms the nervous system and helps in regulating the blood pressure [ 22 ]which is further argued to improve the stress response. Pratyahara , Dharana , Dhyana includes techniques such as; mantra chanting, yoga nidra , and antar mouna that are said to help in developing an ability to internally witness the sensory inputs [ 23 ]. This witnessing capacity is speculated to help one in the reappraisal of the problem in hand, control the fluctuations of the mind and reduce the unconscious negative mental perceptions. Apart from yoga, there are some other spiritual practices such as listening to satsang [ 24 ], swadhyaya (reading Holy Scriptures) [ 25 ] and rendering seva (selfless service to the community) that have been reported to help maintain wellbeing, reduce stress, anxiety and depression [ 26 , 27 ].

Materials and methods

In this research three groups; yoga practitioners, other spiritual practices and non-practitioners were examined for the differences in the measures of illness perception and wellbeing. Additionally, differences based on the duration of practice were also examined in three categories; long-term, mid- term and beginner group. A cross-sectional study was designed using standardized scales for wellbeing related measures and illness perception, questions about daily practices and demographics. An online questionnaire booklet was prepared using google forms and data was collected via social networking groups and email mailing lists. The responses were analyzed using SPSS ver. 26.0.

Participants

The sample consisted of a total of 668 adults, out of which 96.26% (n = 643) chose to participate and 3.74% (n = 25) declined. Out of the 643 participants, there were 64.7% males (n = 416), 34.7%, females (n = 223), and four preferred not to say about their gender. The age range was 18–72 years (M = 28.12 years, SD = 9.09 years). In the sample, a total of 59% (n = 380) were students and 41% (n = 263) were from non- student groups. The non-student group had 34.4% (n = 221) working adults and the remaining 6.5% (n = 42) were from other categories (retired, homemaker). Concerning qualification, 53.2% (n = 342) participants were from postgraduate and higher qualification, 20.8% (n = 134) from graduate, 23.3% (n = 150) from intermediate or pursuing graduate, and the remaining 2.6% (n = 17) were from high school or below education level. Majority (73.2%) of the participants were from urban (n = 471), whereas 16.5% (n = 106) were from semi-urban, and 10.26% (n = 66) reported being from rural areas of residence.

Within the study sample, 59.6% (n = 384) reported that they practice yoga (includes asana, pranayama, meditation, mantra chanting or any other form of yogic practice) and were categorized as yoga practitioners and 40.4% (259) responded not following any yogic practice. Out of the participants that reported not following any yogic practice, 17.6% (n = 113) reported following one or more of the other forms of spiritual practices for example; watching online spiritual programs (50%), online satsang (14.37%), reading holy scriptures(23.25%), performing seva (12.5%), and were categorized as other spiritual practitioner group. The remaining 22.7% (n = 146) participants reported that they do not follow yogic or any other spiritual practices and they were termed as a non-practitioner group. Further, among the yoga practitioners, 35% (n = 134) were beginners (those who had started yoga practice during COVID19 lockdown period), 39.7% (n = 152) were mid- term (1≤year of practice≤4), and 25.32% (n = 97) were Long term (≥ 5 years of practice) practitioners. Within the beginners, 39.9% reported practicing yoga for all days in the week, 23.9% for 5–6 days, 23.2% for 3–4 days and 13% for 1–2 days in a week. For mid-term practitioners 32.4% reported practicing yoga for all days in the week, 30.4% for 5–6 days, 29.7% for 3–4 days and 7.4% for 1–2 days in a week. For long term practitioners, 58.8% reported practicing yoga for all days in the week, 19.6% for 5–6 days, 11.3% for 3–4 days and 10.3% for 1–2 days in a week. The data for frequency in terms of hours of practice per day was asked as an open choice question,’ How many minutes in a day do you practice yoga? Beginners reported on an average spending 31.24 mins, mid-term practitioner average of 39.10mins, and long term practitioners reported spending average of 51.25 mins, for their daily yoga practice.

Brief Illness Perception.

(BIPQ) [ 3 ] was used to measure the individual’s perception of COVID19 by adapting the Brief Illness Perception Questionnaire. The adapted version of BIPQ had 12 items designed to rapidly assess the cognitive and emotional representations of COVID19 illness. The five dimensions of cognitive representation of COVID19 illness was assessed through 9 items; identity—the label the person uses to describe the illness and the symptoms they view as being part of the disease (sample item: How much do you think the infected person experiences symptoms from this illness?); consequences—the expected effects and outcome of the illness (sample item: How much does this illness affect the person who suffers from it?); understanding—personal understanding about the cause of the illness (sample item: How well do you feel you understand this illness?); timeline—how long the patient believes the illness will last (sample item: How long do you think the illness last for those who have it?); and cure or control—the extent to which the patient believes that they can recover from or control the illness (sample item: How much control do you feel you have over this illness?). The emotional representation of COVID19 was assessed by 2 items incorporating negative reactions such as fear, anger, and distress (sample item: How much does thinking about this illness affect you emotionally? e.g. does it make you angry, scared, upset or depressed?). Assessment of the causal representation is by an open-ended response item adapted from the IPQ-R, which asks patients to list the three most important causal factors in rank order. All of the items except the causal question are rated using a 0-to10 response scale. The higher the score is, the greater the perception of the illness for that particular item. The total scale alpha coefficient in this study sample was 0.64.

Depression, Anxiety and Stress Scale.

(DASS-9) [ 28 ] was used to measure the depression, anxiety and stress experienced by the participants during the COVID19 lockdown period using DASS-9. It is the shorter version of DASS-42 [ 29 ] and consists of three sub-factors with 3 items each viz., depression (sample item: I found it difficult to work up the initiative to do things), anxiety (sample item: I experienced trembling eg. in the hands), and stress (sample item: I tended to overreact to). The instructions were modified to suit the current research and participants were asked to rate how much each statement applied to them during the lockdown period. Cronbach’s alpha for the total DASS-9 was reported by Yusoff (2013) equal to .72 whereas for Depression, Anxiety and Stress factors, alphas were .52, .57, and .55, respectively [ 29 ]. In this study sample the Cronbach alpha for total DASS-9, depression, anxiety and stress was found to be 0.73, 0.63, 0.64, and 0.53 respectively.

Scale of General Wellbeing.

(SGWB) [ 30 ] was used to measure the general wellbeing through fourteen common constructs as indicators of well-being viz., happiness, vitality, calmness, optimism, involvement, self-awareness, self-acceptance, self-worth, competence, development, purpose, significance, self-congruence and connection (sample item: I accept most aspects of myself). All items were phrased positively and rated on a Likert scale from 1 (Not at all) to 5 (very true), indicating experiences in life overall. Previous studies have reported a Cronbach alpha for SGWB ranging from 0.82 to 0.92 [ 30 ]. In this study sample, the Cronbach alpha for the total scale was found to be 0.93.

Brief Resilience Scale.

(BRS) [ 31 ] was used to measure resilience. The scale contains 6 items measuring the ability to bounce back from stress and difficulties (e.g., “I usually come through difficult times with little trouble”). The items are rated on a 5-point Likert scale from 1 (Strongly Disagree) to 5 (Strongly Agree). The possible score ranges from 1 (minimum resilience) to 6 (maximum resilience). Three items are negatively worded and are reversed scored. Adequate reliability, with Cronbach’s alpha ranging from .80 to .91 in 4 different samples was reported in an earlier study [ 31 ]. In this study sample, the Cronbach alpha was found to be 0.73.

Peace of Mind Scale.

(POMS) [ 15 ] was used to measure peace of mind through a single factor model presented by POMS. The scale consists of a 5 item scale that measures affective wellbeing. The items reflect the experiences of internal peace and harmony in general terms (e.g., I have peace and harmony in my mind) as well as in everyday circumstances (e.g., I feel content and comfortable with myself in daily life). Participants indicated how often they experience the internal states described in each of the items on a scale of 1 (not at all) to 5 (all the time). The five-item POMS (Cronbach alpha = 0.78) was used in this study which had previously been confirmed for the Indian population [ 32 ]. In this study sample, the Cronbach alpha was found to be 0.91.

Emotion Regulation Questionnaire.

(ERQ) [ 33 ] was used to assess the commonly used strategies to alter emotion through ERQ viz., 6 items on cognitive reappraisal (sample items: “When I’m faced with a stressful situation, I make myself think about it in a way that helps me stay calm”), and 4 items on expressive suppression (sample items: “When I am feeling negative emotions, I make sure not to express them”). Participants responded to each item using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The average of all the scores in each subscale of cognitive reappraisal and expressive suppression are used for analysis. The higher the score represents greater the use of that particular emotion regulation strategy, conversely lower scores means less frequent use. In a four study sample reported the Cronbach alpha ranging for reappraisal facet 0.75 to 0.82 and suppression factor 0.68–0.76 [ 34 ]. In this study sample, the Cronbach alpha for cognitive reappraisal and expressive suppression was found to be 0.83 and 0.75 respectively.

Apart from the standardized scales as described above, the data collection booklet included consent form, yoga schedule, and demographic information schedule. The categorization of the yoga practitioners, and non-practitioners was based on the dichotomous question; ‘Do you practice yoga (includes asana, pranayama, meditation, mantra chanting or any other form of yogic practice) in your daily routine?” The non-yoga practitioner group was further classified based on multiple response question; ‘Any other form of spiritual practice do you follow?’ for example; online Satsang (listening to devotional songs), watching spiritual programs, reading Holy Scriptures, selfless service or any other. This formed a group of other spiritual practitioners and the rest of non-yoga practitioners formed a third group classified as non-practitioners. The yoga practitioners were also asked about the duration of their practice. The demographic profile consisted of information about age, gender, qualification, working status and place of residence. An additional item on the three most important causal factors (in rank order) of stress during lockdown was also asked through a question ‘Please list in rank-order the THREE most important factors that you believe are reasons for stress due to lockdown’.

Preparation for the study.

The study was designed for both Hindi and English speaking population keeping in mind the diversity in the preference for language in the population. At the outset, the original English scales for which the Hindi version was not available (ERQ and BRS), were translated into Hindi by a bilingual expert working in the area of psychological assessment. The Hindi translations of all the scales were then evaluated by the first and second author to check for adequacy of translation. Modifications were made wherever the Hindi translations were not found to adequately capture the intended meaning. Further, a bilingual expert independently back-translated these scales from Hindi to English. The back translations were again reviewed by the first and second author and matched to the original scales. At this stage, most items were found to aptly represent the content of the original English scales. The finalized Hindi and English scales were used to prepare the data collection booklet.

Data collection and analysis

The cross-sectional study was conducted using an online survey. The sample for the study was recruited through the distribution of an online message consisting a brief introduction to the study and a link to the google form of data collection booklet using social networks, mailing lists and snowballing techniques. The online message with the link was especially circulated among the yoga practitioner groups. An electronic consent was obtained from each of the participants before beginning the survey. The data collected was anonymous and no personal details that could identify the participants were asked in the google form. Participants were assured that the data will be kept confidential and only be used for research purposes. The google form was available for responses from 26 th April -8 th June 2020 (beginning of Unlock 1.0), corresponding to four to ten weeks of the lockdown in India.

In the first step of data analysis, the responses for the Hindi (n = 96) and English (n = 547) scale were analyzed using an independent t-test that showed no significant difference in illness perception or wellbeing related measures in any of the practitioner groups due to difference in language (all ps>0.05). Therefore, the remaining analysis was conducted on the combined English and Hindi data. In the next step, the descriptive analysis was conducted and the internal reliability scores (Cronbach alpha) for each scale was computed. To confirm the factor structure of the scales used for this study sample, the data were subjected to confirmatory factor analysis. Multivariate analysis (MANOVA) was conducted to examine the differences in the mean scores of illness perception and wellbeing related measures among the yoga practitioners, other spiritual practitioners, and non- practitioner groups. The open-ended question was analyzed using percentage analysis. Lastly, MANOVA was also performed within the yoga practitioner group based on the duration of practice.

Descriptive analysis

The descriptive statistics of all the dependent variables were analyzed. Three outliers identified based on extreme values more than three IQR’s (interquartile range) [ 35 ] computed from Tukey’s hinges in SPSS, were deleted. Confirmatory factor analysis (CFA) showed that most of the fit statistics for all the scales were in the acceptable range. Statistics presented in Table 1 .

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Demographic variables

The relationship between demographic variables (age, gender, qualification, working status, and place of residence) was examined on illness perception (BIPQ), wellbeing related measures (DASS, SGWB, POMS, BRS) and Emotion regulation strategies (ERQ). MANOVA results indicated no statistically significant main effect of working status and qualification on the COVID19 perception, wellbeing measures (DASS, SGWB, POMS, and BRS) or emotion regulation strategies (ERQ). However, there was a significant effect of gender on the mean scores of illness concern F (1,634) = 11.14, p<0.001, partial eta squared = .02, and emotional representation of COVID19 F (1,634) = 10.50, p<0.001, partial eta squared = .02, partial eta squared = .02, with females reporting higher illness concern (M = 8.18, SD = 2.20),and higher emotional impact of COVID19 (M = 5.73, SD = 3.03) than males illness concern (M = 7.50, SD = 2.83), and emotional impact of COVID19 (M = 5.00, SD = 3.03), respectively. There was a significant effect place of residence on illness consequence of COVID19 F (1,634) = 5.61, p<0.05, partial eta squared = -.01, with urban participants reporting higher concern for consequences of COVID19 (M = 7.76, SD = 5.34) than semi-urban (M = 6.95, SD = 2.55) or rural (M = 7.22, SD = 2.88).

Age had a significant effect on depression (DASS-D) F (1,634) = 9.34, p<0.005, partial eta squared = -.01 and Peace of Mind (POMS) F (1,634) = 13.02, p<0.001, partial eta squared = -.02, with participants from age group 18–25 years reporting higher depression (DASS-D)(M = 0.97, SD = 0.70) than age group 26–35 years (M = 0.81, SD = .60), age group 36–45 years (M = 0.64, SD = 0.62) and age group 46 and above (M = 0.61, SD = 0.57). Lower mean scores for Peace of Mind (POMS) were reported by the participants of age group 18–25 years (M = 3.09, SD = 0.94) than age group 26–35 years (M = 3.42, SD = 1.07), age group 36–45 years (M = 3.55, SD = 1.07) and age group 46 and above (M = 3.80, SD = 1.00).

Effect of yoga and other spiritual practice on illness perception, and wellbeing measures

Before conducting the MANOVA, Pearson correlation was performed between all dependent variables to test the multivariate assumption that the dependent variables would be correlated with each other in the moderate range [ 40 ]. A meaningful pattern of correlations was observed amongst most of the dependent variables (r = - 0.460 to r = 0.448), suggesting the appropriateness of MANOVA. Correlations are presented in S1 Table . Additionally, the BOX’s M value of 575.82 was associated with less than a p-value of 0.001, which was interpreted as non-significant based on Huberty and Petoskey’s (2000) guidelines (i.e p < .005) [ 41 ]. Thus, the covariance matrices between the groups were assumed to be equal for the MANOVA.

The MANOVA was conducted to test the hypothesis that there would be one or more mean differences between the spiritual practitioner levels (yoga practitioners, other spiritual practitioners, and non-practitioners) and COVID19 perception, wellbeing related measures, as well as in their emotion regulation strategies. After controlling for the confounding effect of demographic variables a statistically significant MANOVA effect was obtained, Pillai’s’ Trace = .19, F (38, 1220) = 3.13, p<0.001. The multivariate effect size was estimated at .156.

A series of Levene’s F tests, to examine the homogeneity of variance assumption was conducted and the statistics are presented in Table 2 . In the third stage, a series of post hoc analyses (Tukey’s HSD) were performed to examine the individual mean difference comparisons across all three groups. The summary of post hoc comparisons is presented in Table 3 .

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COVID19 perception-BIPQ.

There was a statistically significant difference in group means for the personal control (IP3) F (2,639) = 14.81, p < .001, Coherence/ understanding (IP7) F (2,639) = 4.95, p < .01 Emotional representation (IP8) F (2,639) = 5.17, p < .0.01, Risk perception (IP10 and IP11) F (2,639) = 4.01, p < .01, Personal preventive Control (IP12) F (2,639) = 6.30, p < .01. However, there were no significant differences found in the COVID19 representation of illness perception with respect to consequence (IP1), timeline (IP2), treatment control (IP4), identity (IP5) and illness concern (IP6).

A post hoc analysis (Tukey HSD) revealed significant differences in mean scores of yoga practitioner group for personal control (IP3)(M = 6.22, SD = 2.72), coherence/understanding (IP7) (M = 7.58, SD = 2.22), and Emotional representation (IP8) (M = 4.95, SD = 3.20) when compared to the mean scores of other spiritual practitioner group for personal control (M = 5.06, SD = 2.62), coherence/understanding (IP7)(M = 7.29, SD = 2.44), emotional representation (IP8)(M = 5.74, SD = 2.87), and also for mean scores of non-practitioner for personal control (M = 4.88, SD = 2.6), Coherence/understanding (IP7) (M = 6.83, SD = 2.28), emotional representation (IP8)(M = 5.66, SD = 2.97), all ps<0.05 with higher mean interpreted as a higher perception of personal control over the illness /COVID19, higher coherence/understanding and higher emotional representation of COVID19. However, there was no significant difference between the other spiritual practices and the non-practitioner group, all ps >0.05.

There was also a statistically significant difference in the mean scores of yoga practitioner for risk perception (IP10 and IP11) (M = 5.88, SD = 2.75), when compared with the mean scores of non-practitioner risk perception (M = 6.59, SD = 2.58), p<0.05, with lower mean scores interpreted as a lower perception of risk to contract COVID19. However, there was no significant difference in the mean scores of other spiritual practitioner group when compared with the yoga practitioner group, and the non-practitioner group, both ps>0.05.

There was also a statistically significant difference in the mean scores for the perception of preventive control (IP12) of yoga practitioner (M = 7.10, SD = 2.44), when compared with other spiritual practitioner group (M = 6.75, SD = 2.23), and non-practitioner (M = 6.17, SD = 2.62), p<0.001, with higher mean scores interpreted as a higher perception of personal preventive control over COVID19. However, there was no significant difference in the mean scores of the other spiritual practitioner group, when compared with the yoga practitioner group and the non-practitioner group, both ps>0.05. Means plot is shown in Fig 1 .

Means Plot for COVID19 perception of (i) consequence; (ii) timeline; (iii) personal control; (iv) treatment control; (v) identity; (vi) illness concern; (vii) coherence/ understanding; (viii) emotional representation; (x) risk perception; (xi) peer risk perception; (xii) preventive control for three practitioner groups. Note: Error bars at 95% Cl.

https://doi.org/10.1371/journal.pone.0245214.g001

Percentage analysis of the causal representation of COVID19 on the responses received to the open-ended question (IP9) which asks patients to list the three most important causal factors in the rank order revealed that 48.25% ranked lack of adequate and timely information as the foremost reason for the spread of COVID19, followed by consumption of animal flesh (17.06%) and international movement of tourists and immigrants (16.74%). Other causal factors listed by participants included; lack of immunity, lack of medical facilities/treatment, improper/late action on lockdown measures etc.

Wellbeing related measure (DASS, SGWB, POMS, BRS).

There was a statistically significant difference in group means for depression (DASS-D) ( F (2,639) = 12.48, p < .001, partial eta square = .058, and stress (DASS-S) ( F (2,639) = 3.80, p < .05, partial eta square = .015. However, there was no statistically significant difference in group means for anxiety (DASS-A), p >.05.

Further, a post hoc analysis (Tukey HSD) revealed significant differences in mean scores for depression (DASS-D) among yoga practitioner group (M = 0.74, SD = .63), when compared with other spiritual practitioner group (M = .93, SD = .58), and non-practitioner group (M = 1.13, SD = .73), both ps< 0.001, with higher mean scores signifying higher depression. There was also a significant difference in mean scores for stress (DASS-S) for yoga practitioner group (M = .79, SD = .61) when compared with other spiritual practitioner group (M = .94, SD = .60), and non-practitioner group (M = .95, SD = .61), both ps< 0.001, with higher mean scores signifying higher stress. There was also a significant difference in the mean scores for stress (DASS-S) between other spiritual practitioners and the non- practitioner, p<0.05. Whereas, there was no statistically significant difference for anxiety or depression between the other spiritual practitioner group and non-practitioner group p>0.05.

Percentage analysis of the additional item on the three most important causal factors (in rank order) of stress during lockdown revealed that majority of the participants reported isolation due to lockdown (23.17%), fear of loss of job/business (financial insecurity) (18.57%), and fear of contracting virus (10.32%) as three main causes of stress during COVID19 lockdown. Other reasons of stress included; media reports and inadequate information (7.93%), the uncertainty of future (7.40%), routine disturbances (6.66%), educational loss (5.87%), and family issues (3.65%). Interestingly, 8.89% of the participants reported having no stress at all. A gender wise analysis of the causal factors of stress shows that females higher percentage of females (25.89%) reported stress due to isolation due to lockdown than males (22.11%). Whereas, financial insecurity was ranked as major cause of stress by more males (19.59%) than females (17.41%).

There was also a statistically significant difference in group means for wellbeing (SGWB) F (2,639) = 31.20, p < .001, partial eta squared = .112, and peace of mind (POMS) F (2,639) = 30.99, p < .001, partial eta square = .114. However, there was no statistically significant difference in group means for resilience (BRS), p < .05. Further, a post hoc analysis (Tukey HSD) revealed that mean scores of yoga practitioner group for wellbeing (SGWB) (M = 3.74, SD = .78), and peace of mind (POMS) (M = 3.565, SD = .96) differed significantly when compared with the other spiritual practitioner group mean scores for wellbeing (SGWB) (M = 3.28, SD = .67), peace of mind (POMS) (M = 3.13, SD = .96), and non-practitioner group mean scores for wellbeing (SWGB) (M = 3.11, SD = .85), peace of mind (POMS) (M = 2.73, SD = .99), all ps< 0.001. There was no significant difference between the mean scores for wellbeing (SWGB) between other spiritual practitioner groups and non-practitioner groups p>0.05. However, for peace of mind (POMS) there was a statistically significant difference between the other spiritual practitioner group and non-practitioner group p<0.001, with higher mean scores signifying higher wellbeing and higher peace of mind. Means plot is shown in Fig 2 .

Means plot for Wellbeing measures (i) Depression; (ii) Anxiety; (iii) Stress; (iv) Wellbeing; (v) Peace of Mind and (vi) Resilience for three practitioner groups. Note: Error bars at 95% Cl.

https://doi.org/10.1371/journal.pone.0245214.g002

Emotion regulation strategies (ERQ).

There was a statistically significant difference in group means for cognitive reappraisal strategies (ERQ-C) F (2,639) = 14.85, p < .001, partial eta square = .059. However, there was no significant difference in the group mean scores for Expressive suppression (ERQ-E), p>0.05). Further, a post hoc analysis (Tukey HSD) revealed significant differences in mean scores for yoga practitioner group (M = 5.24, SD = 1.07), other spiritual practitioner group (M = 4.85, SD = 1.17), and non-practitioner group (M = 4.57, SD = 1.19), both ps< 0.001. There was also a statistically significant difference between the other spiritual practitioner group and non-practitioner group p<0.001, with higher mean scores signifying higher emotion regulation through cognitive reappraisal strategies. Means plot is shown in Fig 3 .

Means Plot for Emotion regulation i) Cognitive appraisal ii) Expressive suppression for three practitioner groups. Note: Error bars at 95% Cl.

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Effect of duration of yoga practice on illness perception and wellbeing measures

The MANOVA was conducted to test the hypothesis that there would be one or more mean differences in the wellbeing for different groups of yoga practitioners differentiated based on the number of practice years. After controlling for the confounding effect of demographic variables a statistically significant MANOVA effect was obtained, Pillai’s’ Trace = .229, F (38, 716) = 2.43, p<0.001. The multivariate effect size was estimated at .114.

Before conducting a series of follow up ANOVAs, the homogeneity of variance assumption was tested for all the dependent variables. A series of Levene’s F tests, to examine the homogeneity of variance assumption was conducted and is presented in Table 4 . A series of one-way ANOVA was conducted followed by a series of post hoc analyses (Tukey's HSD) were performed to examine the individual mean difference comparisons across all three groups of spiritual practitioners and all the dependent variables. The results revealed statistically significant comparisons as listed in Table 5 .

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https://doi.org/10.1371/journal.pone.0245214.t005

COVID19 perception (BIPQ).

There was a statistically significant difference in group means for the Personal control (IP3) F (2,367) = 3.571, p < .05, partial eta squared = 0.02, Illness concern(IP6) F (2,367) = 6.70, p < .001, Emotional representation (IP8) F (2,367) = 3.31, p < .0.05, Risk perception(IP11) F (2,367) = 5.64, p < .005. However, there was no significant difference found in the mean scores of COVID19 representation of illness perception for the consequence (IP1), timeline (IP2), treatment control (IP4), identity (IP5) and Coherence/Understanding (IP7)

A post hoc analysis (Tukey’s HSD) revealed significant differences in mean scores of long term practitioner for personal control (IP3) (M = 6.68, SD = 2.79), illness concern(IP6) (M = 6.93, SD = 3.3), emotional representation (IP8) (M = 4.27, SD = 2.80), risk perception (IP10 and IP11) (M = 5.40, SD = 3.04) when compared with beginners mean scores of personal control (IP3) (M = 5.75, SD = 2.68),illness concern (M = 8.23, SD = 2.11), emotional representation (M = 5.44, SD = 2.89), risk perception(IP10 and IP11) ((M = 6.14, SD = 2.40), all ps<0.005, with higher mean interpreted as a higher perception of personal control, illness concern, emotional impact and higher risk perception of contracting COVID19. There was also a statistically significant difference in mean scores between beginners' illness concern (M = 8.23, SD = 2.11), and mid-term (M = 7.53, SD = 2.67) p<0.005. However, there was no significant difference between the long term and mid-term practitioners group for illness concern p>0.05. Means Plot shown in Fig 4 .

Means Plot for COVID19 perception of (i) consequence; (ii) timeline; (iii) personal control; (iv) treatment control; (v) identity; (vi) illness concern; (vii) coherence/ understanding; (viii) emotional representation; (x) risk perception; (xi) peer risk perception; (xii) preventive control for three yoga practitioner groups based on duration of the yoga practice. Note: Error bars at 95% Cl.

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Wellbeing related measures (DASS, SGWB, POMS, BRS).

There was a statistically significant difference in group means for depression (DASS-D) ( F (2,367) = 4.15, p < .05, partial eta square = .022, anxiety (DASS-A) F (2,367) = 5.19, p < .01, partial eta square = .03 and a trend in group means for stress (DASS-S), F (2,367) = 2.71, p = .068. Further, a post hoc analysis (Tukey HSD) revealed significant differences in mean scores between long term practitioner group depression (DASS-D)(M = 0.55, SD = .55), Anxiety (DASS)(M = .26, SD = .38), and mid-term practitioner group depression (DASS-D) (M = .81, SD = .67), anxiety (DASS-A) (M = .48, SD = .56), and beginners group depression (DASS-D) (M = .80, SD = .60), all ps< 0.005, with higher mean scores signifying higher depression, and anxiety. There was no statistically significant difference between the mid-term and beginner practitioner group.

There was a statistically significant difference in group means for SGWB ( F (2,367) = 22.60, p < .001, partial eta square = .110, and POMS ( F (2,375) = 15.10, p < .001, partial eta square = .076. However, there was no statistically significant difference found in group means for BRS, p < .05. Post hoc analysis (Tukey HSD) revealed significant differences in mean scores of Wellbeing (SGWB) of long term practitioner group (M = 4.10, SD = .64) when compared with mid- term practitioner group (M = 3.79, SD = .65) and beginners group (M = 3.42, SD = .84), both ps< 0.001. Mean scores of POMS for long-term practitioner group (M = 4.03, SD = .91) also differed significantly with the mean scores of mid-term practitioner group (M = 3.50, SD = .87), and beginner practitioner group (M = 3.27, SD = .94), both ps< 0.001. There was also a statistically significant difference in the wellbeing (SGWB) mean scores and peace of mind (POMS) mean scores between the mid-term practitioner group and beginner group p>0.05, with higher mean scores signifying higher peace of mind. Means plot is shown in Fig 5 .

Means plot for Wellbeing measures (i) Depression; (ii) Anxiety; (iii) Stress; (iv) Wellbeing; (v) Peace of Mind and (vi) Resilience for three yoga practitioner groups based on duration of the yoga practice. Note: Error bars at 95% Cl.

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Emotion regulation measure (ERQ).

There was a statistically significant difference in group means for ERQ (cognitive reappraisal) ( F (2,375) = 5.30, p < .005, partial eta square = .028. However, there was no significant difference in the group mean scores for ERQ (Expressive suppression), p>0.05), indicating that the duration of yoga practice affects cognitive reappraisal strategies for emotion regulation. Further, a post hoc analysis (Tukey HSD) revealed significant differences in mean scores between long-term practitioner group (M = 5.51, SD = .97), and beginner group (M = 5.0, SD = 1.02) with higher mean scores signifying higher emotion regulation through cognitive reappraisal strategies. There was no statistically significant difference between the mid-term practitioner group and beginner group p>0.05. Means plot is shown in Fig 6 .

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Discussion and conclusions

The aim of present research was to study the effect of practice of yoga and other spiritual practices on the illness perception, wellbeing measures and emotion regulation strategies for adults during COVID19 lockdown. Additionally, the effect of demographic variables such as age, gender, qualification, working status and place of residence was also analyzed. The confirmatory factor analysis confirmed the factor structure for the study sample, which strengthens the findings of this research.

The results examining the demographic variables demonstrate that females reported higher illness concern and were emotionally more impacted than males by the COVID19 lockdown. This finding is in line with an earlier review of literature that reported females to be twice more vulnerable to stress than males in conditions or events of adversity [ 16 , 17 , 19 ]. A recent study investigating depression, anxiety and stress due to COVID19 also found higher stress among females than males [ 42 ]. The reason for higher stress in females can be argued to be partially due to increase in the household chores in the absence of any house helps during lockdown, specially for those also managing their professional work. Further, it was also found that younger participants from age group 18–25 years reported feeling more depressed, and had lower peace of mind than older participants. A stressful situation such as fear of losing a job, uncertainty about the future can trigger anxiety, depression and is believed to affect the peace of mind. The rationale for the association of stress and age is given by a study investigating differences in coping strategies across lifespan. The study suggests that older adults use coping strategies that are indicative of greater impulse control and they tend to evaluate conflict situations more positively than younger adults [ 16 – 18 ]. In another study it was found that older adults had lower levels of psychological distress and better dispositional coping compared to younger adults [ 43 ]. Perhaps the fear arising from uncertainties was dealt more efficiently by the older population, such that it affected their wellbeing positively. Interestingly, in this study the urban population reported higher perception of the COVID19 consequences than reported by the participants from rural or semi-urban areas. Perhaps, the urban population felt that COVID19 lockdown is going to affect them more adversely than the rural or semi-urban. One of the reasons for this difference could be the job insecurity. Another plausible explanation for the difference in perception of the COVID 19 consequence can be derived from research that states that urban populations are reported more prone to psychological distress than their rural counterparts [ 44 ]. Since urban population consists of the majority of service class which is dependent on their jobs for livelihood, they are more likely to perceive graver consequences of COVID19 lockdown than their rural counterparts which comprise mostly of self- employed people.

The results examining the effect of yoga practice demonstrate that yoga practitioners perceived having higher personal control, higher coherence/understanding, lower emotional impact, lower risk and higher preventive control for contracting COVID19 than other spiritual practitioners and non-practitioners. A number of studies have reported physical and mental health benefits of yoga practice [ 45 – 47 ]. A healthy individual is found to perceive lower cognitive and emotional effects of the illness and a higher preventive control over the illness [ 9 ]. On the other hand, the participants who negatively perceived the COVID19 effects experienced greater levels of stress, anxiety or depression and lower wellbeing, also reported in a study on cancer patients [ 48 ]. Additionally, in light of the findings of the previous study, the notion that an individual is following a treatment or preventative control therapy positively affects the perception about how well the illness is understood and a sense of personal control over the illness [ 10 ]. In this study also yoga practitioners reported to have a better understanding and higher personal control over COVID19. Perhaps yoga practitioners felt that yoga is an effective therapy to cope with COVID19 both for physical as well as mental health.

In this study, it was also found that yoga practitioners had lower depression, lower stress, lower anxiety, higher wellbeing, and higher peace of mind than the other spiritual practitioners and non-practitioner group. Interestingly, the other spiritual practitioners were also found to have a significantly higher peace of mind than the non-practitioners. The other spiritual practitioner group also reported lower depression, anxiety, stress and higher wellbeing than the non-practitioner group, however the difference was not found to be statistically significant in this study. Possibly the other spiritual practices; reading Holy Scriptures and rendering seva (selfless service) to the needy and destitute provided solace and peace of mind. A previous study has also reported a positive association between reading scriptures and positive affect and sukha (happiness) and a negative association with negative affect and dukkha (unhappiness) [ 32 ]. As for the non-practitioner group, participants that reportedly followed none of the yoga or spiritual practices, also reported the highest mean score of depression, anxiety and stress and lowest wellbeing and peace of mind.

Results showed that there was no significant difference in resilience among the yoga practitioners, other spiritual practitioners and non-practitioner group. Resilience has for long been debated by researchers to be a trait construct. In this study also resilience was found to be perhaps a more trait-like construct that unfolds over time in response to internal strengths and external supports across lifespan that foster positive outcomes in the face of adversity.

In this study, a significant effect of duration of practice was found on illness perception, and wellbeing related measures. Long term practitioners reported higher personal control and lower illness concern in contracting COVID19 than the mid-term or beginner group. The long- term and mid-term practitioners also reported perceiving lower emotional impact of COVID19 and lower risk in contracting COVID19 than the beginners. The general wellbeing was reported higher by the long term and mid- term practitioners than the beginners group. Further, the long term practitioners were found to have highest peace of mind, lowest depression and anxiety with no significant difference in the mid-term and the beginner group. In an earlier study, sustained practice of yoga is reported to enhance physical strength, promote and improve respiratory and cardiovascular function. The improved physiological functions are believed to reduce stress, anxiety, depression, and enhance overall well-being. In line with the outcomes from this study, the regular practice has also been argued to lead changes in life perspective, self-awareness, a sense of balance between body and mind and generally a positive outlook to life that maintains general wellbeing even in difficulties [ 49 , 50 ]. Interestingly, in this study the beginner group, which had started practicing yoga during COVID19 lockdown, reported comparable mean scores of wellbeing and peace of mind with the mid-term practitioner groups. When compared with the non-practitioner group, the beginner group also had lower depression, anxiety, stress and higher wellbeing, peace of mind. Perhaps the routine practice of yoga helped the beginner practitioners to calm the mind and maintain a positive disposition during difficult times of COVID19 lockdown. The outcomes reveal that yoga practice helps in illness perception about COVID19 such that the long- term practitioners feel a better sense of preventive control with a notion of being less prone to contracting COVID19. This perception of lesser vulnerability and a better sense of control over COVID19 is argued to generate lesser stress problems and promote higher wellbeing. The emotion regulation strategy of cognitive reappraisal is further argued to breed a balanced and coherent understanding about the COVID19. The balanced representation of the unknown is argued to tone down the fear factor due to uncertainties caused by COVID19 lockdown thus decreasing the stress, anxiety and depression. Such a state of mind allows one to view an adverse situation with a more pragmatic approach and helps in maintaining a peaceful disposition.

Altogether, the findings from this study shows that yoga is found to be an effective way to manage the stress, anxiety and depression due to and during COVID19 lockdown. The evidence further supports that yoga could be used as a complementary and alternative therapy for the stress related problems due to COVID19. It may also help health practitioners in further promoting yoga-based interventions to facilitate the self-management of the mental health issues due to COVID19.

Supporting information

S1 table. correlations..

https://doi.org/10.1371/journal.pone.0245214.s001

Acknowledgments

The authors appreciates all those who participated in the study and helped to facilitate the research process.

• 1. Website. [cited 25 Sep 2020]. Available: Van Hoof, E. (2020, April). Lockdown is the world’s biggest psychological experiment-and we will pay the price. In World Economic Forum (Vol. 9). https://www.weforum.org/agenda/2020/04/this-is-the-psychological-side-of-the-COVID19-pandemic-that-were-ignoring
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