Tai Chi/Qigong in Adults with Depression and Anxiety: A Pilot Retrospective Study

Abstract

Objective:

Treatment options for individuals suffering from depression and anxiety are limited in terms of both accessibility and feasibility. Finding alternative, scalable, and cost-effective treatments remains important. This study aimed to investigate the efficacy and feasibility of a 13-week Tai Chi/qigong intervention in the treatment of depression and anxiety.

Methods:

Sixty-six adult psychiatric outpatients (mean age 47.83 ± 15.30 years) were recruited to participate in a 13-week Tai Chi/qigong program. Measures of depression (Patient Health Questionnaire [PHQ-9]), anxiety (General Anxiety Disorder-7 [GAD-7]), and insomnia (Athens Insomnia Scale-8 [AIS-8]) were compared pre- and post-intervention. Feasibility was measured using the Acceptance Feasibility Questionnaire.

Results:

Participants who completed the 13-week intervention (n = 31) reported significant reductions in depression (d = −0.67), anxiety (d = −0.70), and insomnia symptomatology. Participants who completed the Tai Chi/qigong intervention reported enjoying the intervention and exercises, and having little difficulty in setting a home practice.

Conclusions:

Findings suggest that Tai Chi/qigong interventions may be an accessible, well-tolerated, and cost-effective intervention for psychiatric outpatients suffering from depression and anxiety. Limitations from the pilot study identify the use of small sample sizes and lack of an active control group. Larger randomized control trials that include active control groups are warranted.

Introduction

Depression and anxiety disorders are among the most prevalent and burdensome psychiatric disorders worldwide, affecting roughly 1 in 10 people.^1–4 These disorders cost the global economy approximately USD $1 trillion dollars per year⁴ and are also associated with disability,⁵ premature termination of education,⁶ increased sick days and diminished work performance,^7–10 increased risk of morbidity and mortality,¹ and suicide.² While depression alone is estimated to reach second place in the ranking of disability-adjusted life years by 2020,¹¹ anxiety disorders are currently the sixth leading cause of nonfatal health loss.¹² As such, there is a clear and urgent need to find viable strategies that not only foster the development and implementation of novel interventions to better treat these disorders¹ but also to support the growing population of depression and anxiety researchers and health care practitioners aiming at implementing evidence-based prevention approaches.¹³

Current treatments for depression and anxiety disorders often rely on psychopharmacological interventions, although their efficacy is limited due to adverse effects,¹⁴ as well as multidrug interactions.¹⁵ Moreover, treatment barriers also include patient preferences for nonpharmacological interventions and treatment nonadherence to pharmacotherapy.¹⁶ Psychotherapeutic approaches are commonly used as important alternatives but are also hindered by significant help-seeking barriers including increased pricing¹⁷ and being of limited accessibility among psychiatric populations.¹⁷ As a consequence of these limitations, complementary therapies (e.g., nonpharmacological/psychotherapeutic interventions) have gained popularity as potentially viable and effective treatment options.¹³

Mind–body interventions have become increasingly studied as potential alternatives in the treatment of a variety of psychiatric disorders,¹⁸ especially in the treatment of depression and anxiety.¹³ These interventions use a holistic framework embedding the brain, the mind, the body, and human behavior.¹⁹ One such intervention, Tai Chi/qigong, incorporates self-awareness, intrapersonal mind–body alignment,²⁰ mental concentration,²¹ smooth body movements, breathing techniques, and attentional training¹⁸ and has shown promise as a potential alternative treatment for these disorders.^22,23 Specifically, recent studies reported that Tai Chi and qigong interventions have been shown to be effective in reducing depression and anxiety symptoms in a variety of adult populations, including healthy adults, adults with chronic physical illness, and adults with mental health outcomes.^22–25

For instance, a recent randomized control trial (RCT) examined 34 adults with cerebral vascular disorder who received either Tai Chi or standard rehabilitation once a week for 12 weeks, reporting improvements in depression and anxiety symptoms for patients participating in Tai Chi.²⁵ Similarly, in an RCT examining 20 patients with rheumatoid arthritis to receive either Tai Chi or an attention control intervention twice a week for 12 weeks, patients in the Tai Chi condition experienced significantly greater improvements in both depression and anxiety symptoms.²⁶ Another study found significant improvements in anxiety symptoms in a sample of 76 older adults who received a 50 min Tai Chi intervention three times a week for 12 weeks compared with a sedentary control group.²⁷

However, the efficacy of this intervention has not yet been thoroughly investigated in psychiatric outpatients suffering from depression and anxiety disorders,²⁸ which are in high need of alternative venues of treatments, as symptomatology display has been identified as an important barrier to treatment and a possible predictor of treatment adherence and retention to treatment.²⁹ A Chinese RCT examining 14 geriatric patients with depression to a 45 min thrice a week of Tai Chi and a wait-list control group reported that patients in the Tai Chi group experienced significant reductions in depression symptoms,¹⁹ and a recent review reported that Tai Chi may lead to significant improvement in depression and anxiety in older adults.³⁰

While the results of these studies are encouraging, it remains unclear to determine the efficacy of Tai Chi in the treatment of depression,²² and in an adult psychiatric outpatient population. The validity of Tai Chi and qigong as a viable alternative treatment for depression and anxiety is confounded by methodological caveats, such as publication bias, small sample size (N = 36,²⁵ N = 20,²⁶ N = 14¹⁹), and poor study design (i.e., with no or limited follow-up assessments).^22–24 In addition, significant symptoms including anxiety and insomnia remain yet to be explored.

The purpose of this study was to explore the feasibility and efficacy of a 13-week Tai Chi/qigong intervention in the treatment of psychiatric outpatients suffering from depression and/or anxiety. The authors hypothesized that a 13-week Tai Chi/qigong program was feasible to implement and that it may reduce depression, anxiety, and insomnia symptoms in a population of adults attending specialized care psychiatric outpatient services.

Materials and Methods

Patient population

The authors conducted a retrospective cohort study of a Tai Chi/qigong program offered to adults aged 18+ years in the tertiary care outpatient clinic of the Jewish General Hospital's (JGH) Department of Psychiatry in Montreal, Canada. Patients with a diagnosis of anxiety and/or depression were referred to the program by their clinician at the JGH (e.g., psychiatrist, psychologist, nurse, social worker, or occupational therapist). Patients were excluded if presenting cognitive impairment, and/or acute suicidal ideation or intent. Data analyzed in this article include four Tai Chi/qigong groups held from February to April 2016, October to December 2016, October to December 2017, and January to April 2018.

The study was approved by the JGH/CIUSSS-CO Hospital Research Ethics Committee in compliance with the Declaration of Helsinki. Informed consent was obtained from all patients included in the research project.

Tai Chi/qigong program description

The JGHs adult outpatient psychiatry clinic has been offering the Tai Chi/qigong program since February 2016. The program combines Chinese martial arts and meditative movements. It involved a series of slowly performed, dance-like postures that flow from a moment to the next. This 12-week Tai Chi/qigong program was provided to participants once a week, for 1 h. The intervention was facilitated by two senior Tai Chi/qigong instructors with more than 7 years of experience, and the instructors were blinded to patient's pretest scores. The interventionists reviewed the techniques together to ensure intervention consistency.

Due to the gentle and nonstrenuous nature of the Tai Chi/qigong program, the same program was applied to all participants. For a detailed summary of the characteristic exercises included in the Tai Chi/qigong program, please refer to Table 1.

Table 1.

Characteristic Exercises Included in the Tai Chi/Qigong Program

Breathing techniques	Abdominal and spinal breathing
Qigong movements	The connection with the universe Sharing the energy with the universe Fill and share the ball of energy Exchange & harmonize the universal energy Harmonization front-back Sow, harvest, and share luminous flowers with nature Dance with the energy of the luminous ball Carry the moon Meditate with the ball of luminous energy Move hands like clouds Scoop from the sea Spread your wings
Tai Chi movements	Repulse the monkey Brush the knee Part the horse's mane Wave hands like clouds Golden rooster standing on one leg Kick heel Grasp sparrow's tail Cross hands
Meditation exercises	Bringing attention to the breath and focusing on positive thoughts, including acceptance, healing, balance, success, harmony, gratitude, peace, and love

Outcome measures

As part of the Tai Chi/qigong program, patients were asked to fill in self-report questionnaires. All patients completed self-administered symptomatology measures before the beginning of the Tai Chi program (pretest) and within 2 weeks after (post-test), with a 13-week interval between test–retest. The Tai Chi/qigong Acceptability Questionnaire was only completed post-intervention.

The primary outcomes of this study are depression and anxiety symptomatology. Depression symptomatology was measured using the Patient Health Questionnaire (PHQ-9), which is a self-reported 9-item depression scale taken from the PHQ.³¹ The PHQ-9 is based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for major depressive disorder with responses to questions ranging from 0 (“not at all”) to 3 (“nearly every day”) for each item. Summed scores of ≥10 are considered clinically significant. Construct validity studies have demonstrated its internal consistency (Cronbach's α = 0.89) and test–retest reliability (intraclass correlation = 0.87) to be excellent.³¹

To measure anxiety symptomatology, the General Anxiety Disorder-7 (GAD-7) was used. This is a 7-item self-report scale intended to measure generalized anxiety disorder symptom severity on a 0 (“not at all”) to 3 (“nearly every day”) scale for each item.³² Summed scores of ≥10 are considered clinically significant. Similar to the PHQ-9, it has excellent internal consistency (Cronbach's α = 0.92) and test–retest reliability (intraclass correlation = 0.83).³¹

Insomnia symptomatology was assessed using the Athens Insomnia Scale-8 (AIS-8), an 8-item self-report scale intended to quantify sleep difficulty on a 0 (“no problem at all”) to 3 (“very serious problem”) scale for each item.³³ The AIS-8 is considered to be a psychometrically validated instrument, as suggested by its excellent internal consistency (Cronbach's α = 0.89) and test–retest reliability (Pearson's correlation = 0.89).³³

Furthermore, the Tai Chi/qigong Acceptability Questionnaire was developed by the research team as a measure of the program's feasibility. It is a self-report acceptability questionnaire completed by participants at the end of the program that uses a Likert scale ranging from 0 “not at all” to 10 “very much” for satisfaction, or from 0 “very difficult” to 10 “not difficult at all” for difficulty. Questions inquire about how much participants enjoyed the program and particular movements, assess levels of difficulty, and explore the duration of home practice. The questionnaire also allows participants to report any negative reactions that resulted from practicing Tai Chi/qigong, as well as any other general comments they had regarding the program.

Data analysis

Patients' baseline demographic and clinical characteristics were described. A z-test was applied for normality test using skewness and kurtosis. Based on the small sample size included in the analyses (N = 31), z values of ±1.96 were deemed sufficient to establish normality of the data. Repeated-measures t-tests were conducted, and effect sizes were calculated using Cohen's d to compare pre- and post-program outcomes measures. A coefficient of d = 0.2 is suggested to indicate a “small” effect, whereas d = 0.5 is a “medium” effect, and d = 0.8 and higher is indicative of a “large” effect.^34,35 Missing data were excluded from the analysis. The Statistical Package for Social Sciences (SPSS) for Windows (version 24.0) was used to analyze data. A two-tailed p < 0.05 was considered statistically significant.

Results

Baseline characteristics

A total of 66 patients were recruited to participate in the program. Patients were aged 19 to 82 years (mean 50.19 ± 16.43 years). Of 66 participants, 31 patients included pre- and post-assessments. By using an intention-to-treat analysis, data pertaining to the 31 patients who completed pre- and post-assessments were determined to be the final sample of this study. At baseline, the final sample (N = 31) had a mean PHQ-9 of 11.90 (±8.03), GAD-7 of 10.03 (±6.11), and AIS-8 of 8.94 (±4.97). Of the final sample included in this analysis, 74.2% were female, 32.3% were married, and 93.5% used psychotropic medications. For more information pertaining to baseline characteristics of the sample, please refer to Table 2.

Table 2.

Baseline Demographics of the Full Sample Recruited for the Study (N = 66) and the Final Sample (N = 31)

Characteristic	Full sample	Final sample
	Mean (SD)	Mean (SD)
Age	47.83 (15.30)	50.19 (16.43)
No. of years depressed/anxious	13.76 (13.63)	13.23 (15.53)
Tai Chi/qigong sessions attended	5.02 (3.28)	6.61 (3.18)
PHQ-9 baseline score	11.19 (7.42)	11.90 (8.03)
GAD-7 baseline score	9.42 (5.68)	10.03 (6.11)
AIS baseline score	8.25 (4.77)	8.94 (4.97)

	N	%	N	%
Gender
Male	16	24.6	8	25.8
Female	49	75.4	23	74.2
Education
Elementary school	4	6.2	3	9.7
High school	22	33.8	10	32.3
CEGEP	17	26.2	9	29.0
Bachelor's degree	16	24.6	8	25.8
Graduate degree	5	7.7	1	3.2
Marital status
Married	15	23.1	10	32.3
Single	45	69.2	19	61.3
Common law	5	7.7	2	6.5
Living with someone
Yes	37	56.9	19	61.3
No	27	41.5	11	35.5
Assisted living
Yes	6	9.68	3	10.35
No	56	90.32	27	89.66
Psychiatric diagnosis
Anxiety	5	7.8	3	10.3
Depression	15	23.4	6	20.7
Depression/anxiety	22	34.4	11	37.9
Psychotic disorder	9	14.1	3	10.3
Bipolar disorder	10	15.6	5	17.2
Personality disorder	2	3.1	1	3.4
Health comorbidities
Physical	23	34.8	10	33.3
Mental	43	65.2	20	66.7
Use of psychotropic medications
Yes	61	93.8	29	93.5
No	4	6.2	2	6.5
Reason for medication use
Anxiety	7	13.7	6	20.0
Depression	13	27.5	4	13.3
Anxiety/depression	11	21.6	7	23.3
Bipolar disorder	10	19.6	4	13.3
Anxiety/depression/insomnia	3	5.9	2	6.7
N/A	6	11.8	6	20.0
MH follow-up
Yes	62	95.4	30	96.8
No	2	3.1	1	3.2
Type of MH follow-up
Psychiatrist	26	39.4	13	41.9
Psychologist	3	4.5	2	6.5
Psychiatrist and psychologist	6	9.1	3	9.7
Psychiatrist, psychologist, and OT	5	7.6	3	9.7
Psychiatrist and social worker	13	19.7	5	16.1
Psychotherapist	1	1.5	1	3.2
Psychiatrist, social worker, and OT	2	3.0	1	3.2
Other or N/A	9	13.6	3	9.7
Prior psychiatric hospitalizations
None	33	52.4	21	70.0
One	21	33.3	6	20.0
Two	9	14.3	3	10.0
Smoker
Yes	12	18.5	3	9.7
No	53	81.5	28	90.3
Alcohol use
Yes	15	23.1	9	29.0
No	50	76.9	22	71.0
Recreational drug use
Yes	4	6.2	2	6.5
No	61	93.8	29	93.5
Practice Tai Chi in the past
Yes	27	42.2	14	45.2
No	37	57.8	17	54.8
Practice Tai Chi in the present
Yes	19	29.7	12	38.7
No	45	70.3	19	61.3

CEGEP, Collège d'enseignement général et professionnel; MH, mental health; N/A, not applicable; OT, occupational therapist.

Depression symptomatology

Statistically significant changes in depression symptoms (Table 3) were observed after the Tai Chi/qigong program. For the final sample of patients (N = 31), PHQ-9 scores were significantly lower at post-assessment compared with those at baseline [8.00 ± 6.17 vs. 11.90 ± 8.03, T(30) = 3.70, p < 0.001], with a moderate effect size on depression symptom reduction (d = −0.67) from pre- to post-assessment (p < 0.001).

Table 3.

Pre- and Post-Treatment Differences Across Global Scores of Depression, Anxiety, and Insomnia in the Final Sample

Measure	Mean (SD) pretest	Mean (SD) post-test	N	Statistics	Effect size
PHQ-9	11.90 (±8.03)	8.00 (±6.17)	31	T(30) = 3.70, p < 0.001	d = −0.67
GAD-7	10.03 (±6.11)	7.03 (±5.81)	31	T(30) = 3.89, p < 0.001	d = −0.70
AIS-8	8.94 (±4.97)	5.74 (±4.16)	31	T(30) = 4.00, p < 0.001	d = −0.72

AIS-8, Athens Insomnia Scale-8; GAD-7, Generalized Anxiety Disorder-7; PHQ-9, Patient Health Questionnaire-9.

Anxiety symptomatology

Statistically significant changes in anxiety symptoms were observed in the final sample of patients after the Tai Chi/qigong program. Post-assessment GAD-7 scores were found to be significantly lower than those at baseline [7.03 ± 5.81 vs. 10.03 ± 6.11, T(30) = 3.89, p < 0.001] with a moderate-to-large effect size on anxiety symptom reduction (d = −0.70) from pre- to post-assessment (p < 0.001).

Insomnia measure

Statistically significant changes in insomnia symptoms were observed in the final sample of patients after the Tai Chi/qigong program. Post-assessment AIS scores were found to be significantly lower than those at baseline [5.74 ± 4.16 vs. 8.94 ± 4.97, T(30) = 4.00, p < 0.001], with a moderate-to-large effect size on insomnia symptom reduction (d = −0.72) from pre- to post-assessment (p < 0.001).

Program feasibility

Attendance

The attendance record for the Tai Chi/qigong program revealed that the mean number of sessions attended in the final sample (N = 31) was 6.61 (±3.18).

Acceptability questionnaire

Results from the Tai Chi/qigong Acceptability Questionnaire indicate that the program's feasibility was attained (Table 4). The final sample of participants (N = 31) reported high enjoyment of the class (7.97 ± 3.79, out of 10), of the meditation tree pose (7.16 ± 4.45, out of 10), and of the visualization exercises (7.90 ± 3.71, out of 10). Results showed moderate levels of enjoyment in the qigong movement (7.03 ± 2.65, out of 10) and Tai Chi movement (6.65 ± 2.79, out of 10). Participants also reported moderate levels of difficulty in their ability to set a home routine for Tai Chi/qigong (3.94 ± 3.51, out of 10).

Table 4.

Tai Chi Acceptability Questionnaire for the Final Sample (N = 31)

Characteristic	Mean (SD)
Enjoyed the class	7.97 (3.79)
Enjoyed the meditation tree pose	7.16 (4.45)
Enjoyed the visualization exercises	7.90 (3.71)
Enjoyed qigong movement	7.03 (2.65)
Enjoyed Tai Chi movement	6.65 (2.79)
Ability to complete meditation tree pose	6.74 (3.25)
Difficulty in setting home routine	3.94 (3.51)
Days of home practice	1.84 (1.64)
Number of minutes per practice	3.23 (5.94)

Likert scale ranging from 0 “not at all” to 10 “very much” for satisfaction, or from 0 “very difficult” to 10 “not difficult at all” for difficulty.

Adverse effects

Of the full sample, there were only three individuals who spontaneously reported negative reactions from the program. Reasons for these negative reactions included getting dizzy, finding the exercises difficult, and reacting emotionally to bending one's knees.

For a breakdown of participants' global scores on the main outcome measures (i.e., depression, anxiety, insomnia, and program acceptability) by gender and age group, please refer to Table 5.

Table 5.

Partition of Scores on Depression, Anxiety, Insomnia, and Tai Chi Acceptability by Gender and Age Group

Measure	Gender		Age
	Male (n = 8)	Female (n = 23)	Younger than 65 years (n = 22)	65 Years and older (n = 9)
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
PHQ-9
Pretest	14.38 (7.95)	11.04 (8.05)	13.27 (8.10)	8.56 (7.20)
Post-test	9.75 (7.25)	7.39 (5.81)	9.32 (6.45)	4.78 (4.12)
GAD-7
Pretest	11.38 (6.30)	9.57 (6.12)	11.14 (6.03)	7.33 (5.77)
Post-test	9.63 (5.50)	6.13 (5.76)	8.27 (5.80)	4.00 (4.90)
AIS-8
Pretest	7.63 (5.63)	9.39 (4.77)	9.36 (5.35)	7.89 (3.98)
Post-test	5.00 (3.38)	6.00 (4.44)	6.59 (4.40)	3.67 (2.69)
Tai Chi Acceptability Questionnaire
Enjoyed the class	8.14 (1.77)	7.39 (3.43)	7.50 (3.11)	7.75 (3.33)
Enjoyed the meditation tree pose	8.29 (1.98)	6.26 (4.15)	6.91 (3.75)	6.25 (4.23)
Enjoyed the visualization exercises	7.86 (1.84)	7.39 (3.30)	7.41 (2.92)	7.75 (3.41)
Enjoyed qigong movement	5.43 (2.64)	7.52 (2.57)	6.95 (2.75)	7.25 (2.71)
Enjoyed Tai Chi movement	5.71 (2.98)	6.87 (2.80)	6.59 (2.94)	6.63 (2.72)
Ability to complete tree pose	7.14 (2.12)	6.57 (3.62)	6.50 (3.38)	7.25 (3.24)
Difficulty in setting home routine	3.00 (3.56)	4.09 (3.55)	3.59 (3.42)	4.50 (3.96)
Days of home practice	1.86 (1.46)	1.74 (1.69)	1.68 (1.29)	2.00 (2.39)

Discussion

This study aimed to investigate the feasibility and impact of a 13-week Tai Chi/qigong program in an adult population attending a Psychiatric Rehabilitation Outpatient Program. Based on a sample of 31 adult participants, results suggest that the program is feasible and potentially effective in reducing symptoms of depression, anxiety, and insomnia.

Results from this study suggest that the Tai Chi/qigong program had a significant effect on the reduction of depression symptoms between baseline and post-assessment as demonstrated by a moderate effect size (d = −0.67). This finding is compared with that of similar studies that have observed small-to-moderate effect sizes for the impact of Tai Chi and qigong interventions on depressive symptoms.^23,24 On average, participants scored 3.90 points lower on the PHQ-9 after receiving the intervention. The clinical implications of this finding are significant given that a 4-point reduction on this scale changes the severity of one's depression diagnosis (i.e., from moderate to mild depression). The clinically significant improvements observed in depression symptoms following the administration of a Tai Chi/qigong intervention lend additional support to similar findings suggesting the positive effects of Tai Chi on depression symptoms in patients with depressive disorders and other psychiatric illnesses.^22,23,27

The Tai Chi/qigong program also demonstrated significance in reducing symptoms of anxiety between baseline and post-assessment as demonstrated by a moderate-to-large effect size (d = −0.70). Interestingly, the effect size observed in this study was larger than that observed by Yin and Dishman,²⁴ where only a small effect size was found for Tai Chi on anxiety symptom reduction. In comparison, a recent meta-analysis on the effects of Tai Chi and qigong in individuals with substance use disorders reported a large effect size for qigong in the improvement of anxiety symptoms when compared with medication.³⁶

On average, participants in the present study scored 3.00 points lower on the GAD-7 after receiving the intervention. Although a reduction of 3.00 points is not enough to alter the classification of anxiety severity, it nonetheless highlights the potential therapeutic properties of Tai Chi/qigong. These findings parallel those of similar studies that have demonstrated the positive effects of Tai Chi programs on anxiety symptoms in older adults,³⁷ veterans,³⁸ and healthy adults.²⁷

Results from this study also suggest that Tai Chi/qigong had a significant effect on the reduction of insomnia symptoms between baseline and post-assessment as demonstrated by a moderate-to-large effect size (d = −0.72). Insomnia symptoms showed a notable decrease of 3.20 points from pre- to post-intervention. The positive impact observed in this study from Tai Chi/qigong on insomnia symptoms is further supported by similar findings suggesting that Tai Chi and qigong can be beneficial for improving sleep quality and insomnia.^39,40 Given that Tai Chi has produced clinically significant improvements in insomnia symptoms in cancer survivors and has been found to be statistically noninferior to cognitive-behavioral therapy for insomnia, the gold standard behavioral treatment for insomnia, the findings of the present study highlight the need to further explore the therapeutic utility of Tai Chi for insomnia in psychiatric populations.⁴⁰

Results from this study support the hypothesis that Tai Chi/qigong is feasible and well accepted in a sample of psychiatric outpatients with depression and/or anxiety, as demonstrated by enjoyment scores, reports of low difficulty in practicing the exercises, and minimal adverse reactions. Although only 31 participants attended long enough to complete pre- and post-assessments, it is still remarkable to find that half of the sample was able to complete the intervention, and this may be accounted for by positive outcome expectancies of Tai Chi/qigong and the rewards of social participation.^41,42

Despite the small sample size, these results are of great importance. The moderate effect size observed in insomnia symptoms calls out for further exploration of the impact of Tai Chi/qigong on sleep. However, the absence of an active control group controlling for the confounding effect of group social support is an important limitation of this study. Similarly, due to the study design, the authors were unable to control for the effects of other activities (i.e., physical activity routines outside the program) and treatment regimens (i.e., psychotherapy) maintained by patients participating in the Tai Chi/qigong program. Future RCTs are required to fully characterize the effect of this modality and further explore participant's characteristics that seem to benefit best from this intervention.

Future studies should also include investigations of the temporal effects of Tai Chi/qigong interventions (e.g., by administering assessments of well-being and psychiatric symptomatology at multiple time points throughout the intervention) as this would provide a more solidified understanding of the length of treatment required to produce clinically significant improvements in patients. If demonstrated to be clinically effective, Tai Chi/qigong could represent an accessible, well-tolerated, and resource-efficient adjunct to current psychiatric management as an alternative venue to mental health treatment support.

Conclusions

Alternative, scalable, and cost-effective strategies to treat and prevent depression and anxiety disorders require special attention. Psychiatric outpatients diagnosed with depression and/or anxiety are in need of accessible and viable sources of treatment support, particularly nonpharmacological approaches, to complement psychiatric management. The practice of Tai Chi/qigong presents a feasible therapeutic approach to implement in psychiatric outpatient populations. While future research warrants the use of strong methodologically designed RCTs to better address the effects on psychiatric symptomatology change, Tai Chi/qigong programs have the potential to reduce clinical symptoms of depression, anxiety, and insomnia in psychiatric outpatients. In addition to the utility of Tai Chi/qigong in improving psychiatric symptomatology, this practice also demonstrates broader benefits at the level of patients' general sense of well-being. For these reasons, it may be appropriate to establish and implement these programs in psychiatric settings as treatment adjuncts.

Footnotes

Authors' Contributions

J.N. and K.C.: played a leading role in design of the work, analysis and interpretation of data for the work, lead drafting. A.P.: design of the work, analysis and interpretation of data for the work, drafting. Z.T.: design of the work, analysis and interpretation of data for the work. J.I., A.C., M.S., and K.J.L.: interpretation of data for the work. M.N.: analysis and interpretation of data for the work. S.G.T.-P.: acquisition, analysis and interpretation of data for the work. L.M. and J.D.: design of the work, acquisition, analysis and interpretation of data for the work. R.F.: acquisition, interpretation of data for the work. S. Rouleau: design of the work, interpretation of data for the work. S. Rej: conception and design of the work, analysis and interpretation of data for the work, supervised K.C. and J.N. in drafting the work.

All authors: revision of the work critically for important intellectual content. All authors gave final approval of the version to be published. All authors also agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Author Disclosure Statement

Dr. Rej is supported by a Fonds de Recherche Santé Québec (FRQS) Clinician-Scientist Award and has investigator-initiated grant funding from Satellite Healthcare (dialysis company) for an unrelated project. The remaining authors declare no conflict of interest.

Funding Information

Funding for the project was supported by the following institutions: Jewish General Hospital Foundation; Canadian Institutes of Health Research (Fellowship Award). There was no grant number associated with either of these funding sources.

Abbreviations Used

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