Senior Doctors write scathing open letter protesting IMA's Yoga based workshop for medicos
' Shameful and appalling initiative '
Bengaluru, July 04: A group of senior medical practitioners from Karnataka have written a scathing open letter to the president of the Indian Medical Association protesting its decision to hold a 'Yoga based workshop for young medicos. In their letter to the IMA president Dr. Ravi Wankhedkar, which they have released to the media, these senior doctors have slammed the IMA for 'organising such a workshop in association with self styled 'yoga' teaching centres'. They have alleged that 'IMA is promoting these dubious methods as stress busters, thereby denying the well proven methods in modern scientific medicine to treat and prevent stress, depression, anxiety etc.'
These doctors have urged the IMA to immediately dismantle this initiative and stop the Doctor Know Thyself Workshop, failing which they have threatened to 'openly oppose such misadventures.'
Here is the full text of the letter :
From
Dr B Srinivas Kakkilaya, Consultant Physician, Mangaluru, Karnataka,
Dr KS Madhava Rao, Senior Neuropsychiatrist, Mangaluru, Karnataka,
Dr Shashidhar Bilagi, Senior Neuropsychiatrist, Bengaluru, Karnataka,
Dr. P Venkataraya Bhandary, Senior Neuropsychiatrist, Udupi, Karnataka,
Dr Ravichandra Karkal, Consultant Neuropsychiatrist, Mangaluru, Karnataka,
Dr Santosh Prabhu, Consultant Neuropsychiatrist, Mangaluru, Karnataka,
Dr Yogananda Reddy, Consultant Paediatrician, Ballary, Karnataka,
Dr Rakshit Kedambady, Consultant Neurologist, Mangaluru, Karnataka,
Dr Prakash C Rao, Senior Family Physician, Bengaluru, Karnataka.
To,
Dr. Ravi Wankhedkar,
President,
Indian Medical Association,
New Delhi
Dear Dr. Ravi Wankhedkar,
Sub: Decision of the IMA to organise Yoga based workshop for medical students – protest reg
It has been brought to our notice that the Indian Medical Association has decided to start IMA Initiative for Emotional Health & Emotional Well-Being of Medical Students and Doctors in India, ostensibly considering the increased rate of mental illness and in some cases even suicides, especially in young medicos, and under its auspices, a workshop is being organised at IMA House, Bengaluru on Sunday, 8th July, 2018, comprising of presentations and orations by Isha Yoga Foundation, Banjara Academy, Laughter Yoga, and Art of Living Foundation.
It is indeed shameful and appalling that IMA is organising such a workshop in association with self styled 'yoga' teaching centres. It's also shameful that IMA is promoting these dubious methods as stress busters, thereby denying the well proven methods in modern scientific medicine to treat and prevent stress, depression, anxiety etc.
We hereby bring to your notice the studies on depression, anxiety and stress among medical students that have comprehensively detailed the causes for such problems and have also suggested remedial measures based on such causes; none of these studies have even mentioned yoga and such other unproven methods as remedial or preventive measures for medical students suffering from depression or anxiety. The possible causes of depressive and suicidal symptomatology in medical students revealed in these studies include stress and anxiety secondary to the competitiveness of medical school; inability to cope with the vast curriculum; repeated examinations; high expectations of the parents, teachers, and patients, and time constraints for pursuing their alternate interests etc. Remedial measures suggested in these reports include restructuring of medical school curricula and student evaluations, reducing barriers to mental health services, including addressing the stigma of depression, having a dedicated psychological help clinic in the campus or having alternate means of communication through a helpline or E‑mail, peer mentorship programs, consultation by psychiatrists and clinical psychologists, life skills counsellingetc. [1-4]
We also bring to your notice the evidence that exists to disprove the utility of yoga or such methods in preventing or treating depression, anxiety or stress. A systematic review of yoga in neuro-psychiatry concluded that the available research is limited by small sample size, few randomized studies, inadequate control, diversely modified yoga practices, limited assessments and lack of safety data that preclude any firm conclusions on efficacy of yoga on the various psychiatric and neurological disorders. The authors advocated requirement of more research to decisively assess the validity of applying yoga as a mainstream therapeutic treatment for neuro-psychiatric disorders.[5] A systematic review of yoga for neuropsychiatric disorders included 16 of the 124 trials that met rigorous criteria. It found Grade B evidence (sparse high grade data or substantial amount of low grade data) for a potential acute benefit in depression (four RCTs), and Grade C evidence (low grade data without the volume) in sleep complaints (three RCTs). The authors concluded that biomarker and neuroimaging studies, those comparing yoga with standard pharmaco- and psychotherapies, and studies of long-term efficacy are needed to fully translate the promise of yoga for enhancing mental health.[6] A Cochrane review on meditation therapy for anxiety disorders included two RCTs of moderate quality that used active control comparisons. The overall dropout rate in both studies was high (33-44%). Neither study reported on adverse effects of meditation. The authors concluded that the small number of studies included in the review do not permit any conclusions to be drawn on the effectiveness of meditation therapy for anxiety disorders and suggested that more trials are needed. [7] Another review found the risk of selection bias to be unclear for most RCTs and the effects were robust against potential methodological bias and no effects were found for patients with anxiety disorders diagnosed by Diagnostic and Statistical Manual criteria, only for patients diagnosed by other methods, and for individuals with elevated levels of anxiety without a formal diagnosis. [8] Yet another review of CAM for anxious patients concluded that only few controlled studies evaluated yoga for anxiety disorders, and all have significant methodologic limitations and/or poor methodology reporting; the diagnostic conditions treated and both yoga interventions and control conditions varied; there is little information regarding safety or contraindications of yoga; the reported attrition rates were high in most studies, which may raise concerns about patient motivation and compliance.[9] A systematic review and meta-analysis of yoga for depression included 12 RCTs with 619 participants. There was moderate evidence for short-term effects of yoga compared to usual care and limited evidence compared to relaxation and aerobic exercise. Limited evidence was found for short-term effects of yoga on anxiety compared to relaxation. Due to the paucity and heterogeneity of the RCTs, no meta-analyses on long-term effects were possible. No RCT reported safety data.[10] Another systematic review and meta analysis of Mindfulness Based Cognitive Therapy for psychiatric disorders concluded that several methodological shortcomings including small sample sizes, non-randomized design of some studies and the absence of studies comparing MBCT to control groups designed to distinguish specific from non-specific effects of such practice underscore the necessity for further research.[11]
On the other hand, there are innumerable resources regarding suicidal risk, its identification and management, including emergency care. There is enough evidence regarding the effectiveness of dialectical behavioural therapy and cognitive behavioural therapy in preventing suicides. A recent systematic review and meta analysis of cognitive behavioural therapy for suicidal behaviour, that included ten trials, concluded that cognitive behavioural therapy reduces not only repeated self-harm but also repeated suicide attempts by half and therefore was recommended as the preferred treatment for all patients with depression.[12] There are several other reports and resources as well regarding CBT and DBT in the management of depression and suicidal behaviour. [13-19] None of these guidelines mention yoga or meditation or any such unproven methods. It is in fact dangerous to promote yoga and such methods for anyone with suicidal ideation, and will deny the evidence based critical interventions required for such people. It will also make the Department of Psychiatry, psychiatrists and psychologists in all the medical colleges redundant and unnecessary, and send a very wrong message to the students of modern scientific medicine. Already in India, there is a treatment gap of 87.2-95.7 for depression in community-based studies; therefore, promotion of methods such as yoga will create further confusion and denial of care for the needy.[20]
Therefore, it is amply clear that the proposed initiative does not have any support of evidence, will possibly do more harm than good, and is therefore totally reckless and unnecessary. If any of the committee members or office bearers of the IMA have any personal experience with yoga or such other methods, they can keep the practice to themselves and they should desist from promoting baseless methods to others. IMA should instead focus on scientific analysis of the causes for increasing psychological problems among medical students and practitioners and find remedial measures based on such analysis and promote such scientifically proven methods. We also point out the fact that none of the most proven and life saving methods of modern medicine are ever supported or promoted by the so called alternative therapists, who instead always scorn and discredit these modern scientific methods so as to promote their own fakery. That being the reality, the acts of IMA or any other organisation or individual representing the modern scientific medicine supporting and promoting the unproven, unscientific claims of the so called alternative therapists will only offer credibility and honour to such dubious methods at the cost of defeating and demeaning our own evidence based medical practice, and by doing so, we are certainly playing into their hands, and providing the boost that they seek from us, only to misuse for their own propaganda and fund raising.
If the IMA has no reason to promote modern scientific methods and instead finds it necessary to promote unproven methods, for whatever reasons, let the IMA state its policy openly that it no longer cares about evidence based medical practice and is ever available to promote any kind of hoax, fake claims, alternative therapies and unproven methods of diagnosis and treatment. Lending support and cooperation to unscientific and baseless claims of alternative therapists, and promoting unproven methods such as yoga, will not only be detrimental to the interests of the IMA and the medical fraternity, but also to the health and safety of the people at large. It is indeed saddening to note that the position of the IMA has seen such a U-Turn, after its open challenge and opposition in 2008 to the false claims of Baba Ramdev. Therefore, we urge the IMA toimmediately dismantle this initiative and stop the Doctor Know Thyself Workshop, failing which we shall openly oppose such misadventures.
References:
1.Rotenstein LS et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA.2016;316(21):2214-2236. doi:10.1001/jama.2016.17324.
2.Sarkar S, Gupta R, Menon V. A systematic review of depression, anxiety, and stress among medical students in India. J Mental Health Hum Behav 2017;22:88-96.
- Datar MC, Shetty JV, Naphade NM. Stress and coping styles in postgraduate medical students: A medical college-based study. Indian J Soc Psychiatry 2017;33:370-4.
4.Garg K, Agarwal M, Dalal PK. Stress among medical students: A cross-sectional study from a North Indian Medical University. Indian J Psychiatry 2017;59:502-4.
- Anand KS, Verma R. Yoga in Neuro-Psychiatry. J Yoga Phys Ther. 2014;5:e119.
- Balasubramaniam M, Telles S, Doraiswamy SM. Yoga on our minds: a systematic review of yoga for neuropsychiatric disorders. Front. Psychiatry. 2013 Jan 25;3:117.
7.Krisanaprakornkit T, Sriraj W, Piyavhatkul N, Laopaiboon M. Meditation therapy for anxiety disorders. Cochrane Database of Systematic Reviews. 2006, Issue 1. Art. No.: CD004998. DOI: 10.1002/14651858.CD004998.pub2.
- Cramer H et al. Yoga for anxiety: A systematic review and meta-analysis of randomized controlled trials. Depress Anxiety. 2018 Apr 26. doi: 10.1002/da.22762.
- Antonacci DJ et al. CAM for your anxious patient: What the evidence says. Current Psychiatry Oct 2010;9(10):43.
10.Cramer H, Lauche R, Langhorst J, Dobos G. Yoga for Depression: A Systematic Review and Meta-Analysis. Depression and Anxiety 11/2013;30(11).
- Chiesa A, Serretti A. Mindfulness based cognitive therapy for psychiatric disorders: A systematic review and meta-analysis. Psychiatry Research. 2011;187(3):441–453.
- Gøtzsche PC, Gøtzsche PK. Cognitive behavioural therapy halves the risk of repeated suicide attempts: systematic review. Journal of the Royal Society of Medicine. 2017;110(10):404-410. doi:10.1177/0141076817731904.
- Linehan MM et al. Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder. Arch Gen Psychiatry. 2006;63(7):757-766. doi:10.1001/archpsyc.63.7.757
- Fleischhaker C et al. Dialectical Behavioral Therapy for Adolescents (DBT-A): a clinical Trial for Patients with suicidal and self-injurious Behavior and Borderline Symptoms with a one-year Follow-up. Child and Adolescent Psychiatry and Mental Health. 2011;5:3.
- Linehan MM et al. Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. JAMA Psychiatry. 2015 May;72(5):475-82. doi: 10.1001/jamapsychiatry.2014.3039.
- Wenzel A, Brown GK, Beck AT. Cognitive therapy for suicidal patients: Scientific and clinical applications. 2009. Washington, DC, US: American Psychological Association
- Wenzel A, Jager-Hyman S. Cognitive Therapy for Suicidal Patients: Current Status. The Behavior therapist / AABT. 2012;35(7):121-130.
- Stanley B, Brown G, Brent D, et al. Cognitive Behavior Therapy for Suicide Prevention (CBT-SP): Treatment Model, Feasibility and Acceptability. Journal of the American Academy of Child and Adolescent Psychiatry. 2009;48(10):1005-1013. doi:10.1097/CHI.0b013e3181b5dbfe
- Mewton L, Andrews G. Cognitive behavioral therapy for suicidal behaviors: improving patient outcomes. Psychology Research and Behavior Management. 2016;9:21-29. doi:10.2147/PRBM.S84589.
- Chisholm D et al. Scaling-up treatment of depression and anxiety: a global return on investment analysis. Lancet Psychiatry. 2016;3:415-24.
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