The Effects of Tai Chi and Qigong

on Anxiety and Depression 16
Albert Yeung, Benjamin Campbell, and Jessie S. M. Chan

Case Vignette
antidepressants. She also did not want to rely on medi-
Ms. Chen is a 61-year-old married Chinese female cations for her depression with which she had been
who emigrated from Taiwan more than 30 years ago. suffering intermittently for a long time. She denied
She lives with her husband and has an adult child who having a history of bipolar disorder, psychotic symp-
has a part-time job. She came to the United States as a toms, posttraumatic stress disorder, or substance use
student, attended a 4-year college, and worked in an disorder. She reported depressed mood, loss of inter-
office for about 20 years until she was laid off 3 years ests, insomnia, fatigue, loss of appetite, and guilt feel-
ago. She reported she had her first onset of depression ings, and her job performance and family relationship
when she was in her late twenties. She received fluox- had been affected by her depression. Her total score on
etine treatment for a brief period during one of her the Patient Health Questionnaire was 18, compatible
previous episodes, but stopped taking the medication with being moderately depressed. She saw the adver-
after experiencing some side effects. The onset of her tisement for a depression study that offered Tai Chi as
current depressive episode was about 3  months ago. a treatment. She had never practiced Tai Chi or other
She reported life stressors including marital issues and mind-body interventions, but had heard that these
worries about her son who had difficulty finding full- could be good for her health. She contacted the study
time employment after he finished college and had not staff and was enrolled into the study after she was
been more proactive to build up his career. She had not interviewed and deemed eligible for the study. During
received psychiatric treatment during the current epi- that episode, Ms. Chen did not receive medication or
sode, because she questioned the usefulness of taking psychotherapy treatment for depression.
Ms. Chen joined seven other study participants who
were also recruited into the 8-week study to receive Tai
Chi for their depression. They were taught by an expe-
rienced Tai Chi instructor with more than 20 years of
experience. The class met twice weekly for 8  weeks,
and each class was 90  min long. Each class started
with warm up exercises, including some stretching and
movements to loosen up the body. The instructor taught
the first 1/3 of the Yang-style (details of this form will
A. Yeung (*) · B. Campbell be described later) long-form Tai Chi over the course
Depression Clinical and Research Program, of 8 weeks. The lessons involved repeated demonstra-
Department of Psychiatry, Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
tions, practice by the students, and ample opportuni-
e-mail: ayeung@partners.org; bcampbell7@mgh.harvard.edu ties for questions and discussion. The students were
encouraged to interact and support each other during
J. S. M. Chan
Department of Psychology, The University of Hong Kong, the classes and practice at home daily for 30 min or
Laboratory of Neuropsychology, Laboratory of Social Cognitive more at least 5 days a week. After 3–4 weeks, partici-
Affective Neuroscience, Hong Kong, China pants were gradually able to complete the first section
e-mail: chansm5@hku.hk

© Springer Nature Switzerland AG 2019 211

B. G. Shapero et al. (eds.), The Massachusetts General Hospital Guide to Depression, Current Clinical Psychiatry,
https://doi.org/10.1007/978-3-319-97241-1_16
212 A. Yeung et al.

designed to satisfy specific training needs. For example,

of the Yang-style Tai Chi form on their own, and they many of the weapon forms of Tai Chi aim to strengthen the
used the remaining classes to refine their postures and upper extremities (e.g., grip strength), shoulder flexibility,
movements. The participants showed great enthusiasm and eye-hand coordination.
in learning Tai Chi, obtained and provided support to Today, most students practice Tai Chi as a noncompeti-
each other, gained confidence in both practicing Tai tive, self-paced, graceful form of physical exercise and
Chi moves and in themselves, and showed gradual stretching. It involves a series of movements performed in a
alleviation of their depression symptoms during the slow, focused manner and accompanied by deep breathing.
study. At the end of the 8 weeks, Ms. Chen’s depression Each posture flows into the next without a full pause, ensur-
had remitted with minimal residual symptoms. She ing that your body is in constant motion. Because calmness
reported that while situations at home had not changed is a central tenet of Tai Chi Quan, and the practice uses a
too much, she was less concerned about them. She meditative approach, it is now mostly practiced as a form of
became more optimistic that things would become bet- meditative movement (MM) focusing on the mind, gentle
ter over time. flowing movements, and breathing to attain a deeply relaxed
state for health and self-cultivation [3].

What Is Tai Chi?

What Is Qigong?
Tai Chi or Tai Chi Quan (boxing) is an ancient Chinese tradi-
tion created by Mr. Chen Wang Ting, a retired General from Qigong (pronounced “chee-gung”) is translated from two
the army, as martial arts in the 1600s for self-defense. Tai Chi Chinese words; Qi (气) is the fundamental life energy
Quan is different than most martial art forms. It relies on responsible for health and vitality according to traditional
being sensitive to the opponent’s movements and center of Chinese philosophy, and “qong” (功) is to cultivate. Put
gravity to generate appropriate responses to unbalance the together, Qigong refers to “energy cultivation” or “working
opponent. Thus, the primary training in Tai Chi Quan is to with the life energy” for health, spirituality, and martial arts
effectively destabilize the opponent’s center of gravity upon training. According to traditional Chinese medicine (TCM)
contact. It consists of leveraging, coordinating, and relaxing theories, Qi exists in three main Dantian energy centers in
the joints, as opposed to tensing muscles, in order to neutral- the body, located between the eyebrows, at mid-chest, and
ize, yield, or initiate attacks. The philosophy of Tai Chi is below the umbilicus (Fig. 16.1), and it circulates through-
that if force is used to resist force, then both sides will be out the body via 12 main meridians or pathways (Fig. 16.2).
injured to some extent. To prevent this, Tai Chi martial art It is believed that a free-flowing, well-balanced Qi system
students are taught to embrace a force with softness instead reflects good health, while illnesses, including psychoso-
of with firm resistance. Students are taught to remain in matic disorders, are the result of Qi blockage in certain
physical contact with their opponent to deplete their forces areas of the body. Qigong and Tai Chi, as mind-body tech-
by redirection, thus meeting hardness (yang) with softness niques, are believed to promote equilibrium of Qi and alle-
(yin) [1]. As commonly stated in Tao Te Ching by instructor viate Qi blockages and may potentially prevent or delay the
Lao Tzu, “The soft and the pliable will defeat the hard and progression of diseases. To move Qi inside the body, prac-
strong” [2]. titioners use techniques centered on intent and imagery to
Tai Chi was originally designed as a bare-handed soft guide the flow of Qi in the directions of the meridians.
martial art, characterized by coordinated body posture and Experienced Tai Chi and Qigong practitioners frequently
movements, deep rhythmic breathing, meditation, and men- claim that they can feel the sensation of Qi flowing in spe-
tal focus. There are five major Tai Chi styles, each named cific directions in their bodies [4].
after the Chinese family from which it originated: Chen The origin of Qigong as a means of promoting health dates to
style (large, quick, powerful movements with low stance), more than 4000 years ago. In ancient China, knowledge about
Yang style (slow-flowing, continuous, large movements self-healing practices was passed down from refined masters
with high stance), Sun style (smooth, compact movements), to students in the family lineage as a form of secretive train-
and two Wu styles (mid-paced, compact movements with ing. The practice originally consisted of exercises created by
high stance). More recently, Tai Chi-based weapon forms a wide variety of practices and forms that were developed
(e.g., Tai Chi sword and Tai Chi cane) have been developed. within different segments of Chinese society: in TCM for pre-
In addition, Tai Chi Fan and Tai Chi Softball exercises are ventive and curative functions; in Confucianism to become a
used for training concentration and balance. These new Junzi (君子) or a refined person through awareness of moral-
forms are rooted in the principles of Tai Chi, but they were ity; in Daoism to provide a way to achieve longevity and
16  The Effects of Tai Chi and Qigong on Anxiety and Depression 213

Fig. 16.1  The three Dantiens

energy centers [5]. (Adapted
from NYC Qigong (http:// Upper dantian
www.nycqigong.com/
qigong_dantian.php))

Middle dantian

Lower dantian

spiritual enlightenment, as well as a closer connection with perspective, Qigong can be classified into two systems: (1)
the natural world; in Buddhism as part of meditative practice internal Qigong, which focuses on self-care and self-culti-
or a spiritual path that leads to enlightenment or Buddhahood; vation, and (2) external Qigong, which involves treatment
and in Chinese martial arts to enhance fighting abilities. by a therapist who directs or transmits Qi.
Contemporary Qigong combines many aspects of these
diverse traditions. For example, Qigong has blended the
ancient meditative practices of “circulating Qi” (Xing Qi 行 Qigong Techniques
氣) and “standing meditation” (Zhan zhuang 站桩), the
Daoist meditative practice of “internal alchemy” (Neidan 內 While Qigong came from diverse traditions and sects, there
丹术), and the slow breathing exercise of “guiding and pull- are principal techniques that are used in most Qigong prac-
ing” (Dao yin 導引) [7]. tices: They employ intentional movement usually in a care-
Qigong comprises a diverse set of practices that coordi- ful, flowing, and balanced style with slow, deep, rhythmic
nate body (調身), breath (調息), and mind (調心) based on breathing coordinated with fluid movement and calm,
Chinese philosophy. Practices include moving and still focused meditative state with awareness, visualization of Qi
meditation, massage, chanting, sound meditation, and trans- flow, philosophical tenets, aesthetics, use of chanting/sound
mitting Qi without bodily contact to heal, performed in a as a focal point of attention, soft gaze with expressionless
broad array of body postures. Qigong is commonly classi- face, solid stance with firm footing and erect spine, relaxed
fied into two foundational categories: (1) dynamic or active muscles, and training of balance and counterbalance with
Qigong (dong gong), with slow, flowing movement, and (2) continued shifts in the center of gravity. In advanced stages,
meditative or passive Qigong (jing gong), with still posi- practitioners may attain the goals of equanimity, tranquility,
tions and inner movement of the breath. From a therapeutic and stillness (see Table 16.1).
214 A. Yeung et al.

The main Table 16.1  Main techniques practiced in Qigong exercises

meridian channels Main techniques Description
Intentional movement Careful, flowing balanced style
Rhythmic breathing Slow, deep, coordinated with fluid
movement
Awareness Calm, focused meditative state
Visualization Visualization of qi flow, philosophical
tenets, aesthetics
Chanting/sound Use of sound as a focal point
Softness Soft gaze, expressionless face
Solid stance Firm footing, erect spine
Relaxation Relaxed muscles, slightly bent joints
Balance and Motion over the center of gravity
counterbalance
Advanced techniques
Equanimity More fluid, more relaxed
Tranquility Empty mind, high awareness
Stillness Smaller and smaller movements, eventually
to complete stillness

viduals developed significant influence and attracted sizable

followings. This trend alarmed the Chinese government,
which banned all activities related to Qigong in the late
1990s. In 2000, the prohibition was relaxed, and the Chinese
Health Qigong Association (CHQA) was established to stan-
Small intestine
Triple heater dardize Qigong practices [8]. Since then, only state-approved
Large intestine Health Qigong can be practiced under the supervision of a
Stomach
Liver certified Health Qigong instructor. The standardization and
Spleen public promotion of Qigong and Tai Chi by CHQA have
Kidney
Heart facilitated their dissemination, both in China and worldwide.
Governing vessel There are many heath Qigong forms that have been devel-
Lungs
Bladder oped by various training schools in Chinese society through-
Gall bladder out history. Currently, the most popular officially recognized
The Association for Meridian & Energy Therapies
forms of Health Qigong include Muscle-Tendon Change
http://TheAMT.com Classic (Yi Jin Jing), Five Animals (Wu Qin Xi), Six Healing
Sounds (Liu Zi Jue), Eight-Section Brocade (Baduanjin), Tai
Fig. 16.2  Meridian channels [6]. Property of The Guild of Energists/ Chi Health Qigong Cane, Twelve-Section Brocade (Twelve
Web: https://goe.ac/about.htm. The Association for Meridian and
Energy Therapies. http://TheAMT.com. (Reprinted with permission) Duanjin), Twelve Daoyin Sheng Yang, Mawangdui Daoyin,
and Da Wu [9, 10].
Many of these Qigong forms include repetitive move-
 istory in the Coining of Qigong and Its
H ments designed to attain specific health effects by cultivating
Development well-balanced and fluid Qi flow. These movements can be
learned fairly easily and usually do not require strenuous
In the late 1940s, the Chinese government consolidated a physical and cognitive effort [11]. Practice of Qigong usu-
wide range of self-cultivating and self-healing practices ally includes slow, formalized routine of musculoskeletal
under the umbrella of Qigong, based on the concept of Qi in relaxation and symmetrical, balanced postures and move-
TCM. The Chinese government encouraged the practice of ments coordinated with diaphragmatic breathing control, all
Qigong between 1976 and 1990. During that period of time, to be done in a meditative state of mind. Common Qigong
an estimated 200 million Chinese people participated in forms usually take about 8–12 min to complete. Novice prac-
Qigong and Tai Chi practices. As Qigong grew in great popu- titioners can start by learning the physical movements and
larity, some Qigong masters claimed to possess supernatural focusing on the form. After they learn the sequences of both
powers linked to Qigong practice and used pseudoscientific isometric (increase in muscle tone without shortening in
explanations and exaggerations of the power of Qigong to muscle length) and isotonic (the muscle maintains the same
impress the masses for personal benefit. Many of these indi- tension as it shortens) segmental movements in upper and
16  The Effects of Tai Chi and Qigong on Anxiety and Depression 215

lower extremities, the practitioners can then incorporate Values clarification involves identifying one’s important per-
breathing techniques. It is believed that the combination of sonal values, with the intention of increasing values-consis-
physical movements and coordinated breathing will tent behaviors. Exposure, similar to distress tolerance, refers
strengthen the effects of Qigong to guide the flow of Qi in the to the ability to endure and “stay with” negative emotional
body. states. Self-regulation refers to the ability to monitor and
adapt one’s behavior to changing circumstances to achieve
relevant goals. Cognitive flexibility is described as the ability
 heorized Mechanisms for Tai Chi
T to process important available information in one’s environ-
and Qigong’s Health Effects ment to produce adaptive behavioral responses. In both Tai
Chi and Qigong training, these qualities are frequently com-
The exact mechanisms of how Tai Chi and Qigong effect the municated implicitly by instructors in their teaching to avoid
body is not clear. Several theories have been proposed based using force against force and in their demonstration of calm-
on the literature on the psychological and physiological ness, emotional tranquility, and non-reactivity throughout
effects of meditation and mindfulness. Based on his physio- the practices.
logical studies on meditation practices, Benson posited that Tai Chi and Qigong exercises could lead to improvements
meditation produces a “relaxation response” which attenu- in health through their effects on changes in different areas
ates the stress response mediated by the hypothalamus-pitu- of the brain. Tang et al. performed systematic reviews of the
itary-adrenal (HPA) axis during stress [12]. In responding to functional and structural magnetic resonance imaging stud-
stress, the hypothalamus is triggered to activate the pituitary ies on the brain regions which are affected by mindfulness
gland to secrete the adrenocorticotropic hormone, which training [18]. They reported that brain areas including the
stimulates the adrenal cortex to produce cortisol. Cortisol anterior cingulate cortex (ACC), prefrontal frontal cortex
increases blood pressure and blood sugar levels, turns fatty (PFC), posterior cingulate cortex (PCC), insula, striatum
acids into energy, and suppresses the immune system. At the (caudate and putamen), and amygdala show consistent
same time, stress triggers the sympathetic nervous system to changes associated with mindfulness meditation. They also
stimulate the adrenal medulla to produce catecholamine hor- pointed out that the changes in the brain areas can be elicited
mones, such as adrenaline (epinephrine) or noradrenaline through attaining a meditative state, which can be achieved
(norepinephrine). This pathway prepares the body for force- using different meditation techniques including Tai Chi and
ful muscular action. The sympathetic nervous system also Qigong. The brain region to which the effects of mindfulness
leads to pupillary dilation, increased heart rate and blood training on attention is most consistently linked is the ante-
pressure, bronchial dilatation, and decreased movement of rior cingulate cortex and striatum; emotion regulation is
the large intestine. People who have chronic HPA axis and linked to multiple prefrontal regions, the limbic system, and
sympathetic tone activation tend to develop muscle tension, striatum; and self-awareness is linked to the insula, medial
headaches, upset stomach, racing heartbeat, and shallow prefrontal cortex, posterior cingulate cortex, and precuneus.
breathing among a range of other physical, emotional, and The meditative state elicited by Tai Chi and Qigong
behavioral symptoms including depression. Benson et  al. through self-awareness and increased proprioceptive senses
studied the physiological changes during meditation and may involve the insula, medial prefrontal cortex, posterior
found that meditation counteracts many of the stress cingulate cortex, and precuneus and result in calmness and
responses, presumably by activating the parasympathetic psychological well-being based on the findings of the earlier
nervous system [13, 14]. imaging studies on mindfulness interventions [19–22].
In addition to eliciting a relaxation response, meditative Instead of providing a top-down influence through the
movements of Tai Chi and Qigong may lead to new prefrontal cortex, mindfulness meditation might also directly
­psychological skills such as observing, describing, acting modulate stress reactions in the brain via a “bottom-up”
with awareness, nonjudging of inner experience, and non- pathway, in which it alters the sympathetic-adrenal-medul-
reactivity to inner experience [15], which have been shown lary and hypothalamic-pituitary-adrenal axes by increasing
to contribute to mood regulatory abilities and well-being. activity in the parasympathetic nervous system and counter-
Shapiro and colleagues proposed a different psychological acts activation of the sympathetic nervous system from stress
model of the mechanisms of mindfulness on health-related responses. This process subsequently decreases stress-asso-
outcomes [16, 17]. This model theorizes that meditative ciated mood symptoms [23, 24]. It has also been proposed
practices may be associated with reperceiving or decenter- that contemplative practices, which attend to interoceptive
ing, which refers to decreased attachment to one’s thoughts sensations, enhance non-reactivity to aversive thoughts and
and emotions. Reperceiving was posited to lead to changes impulses and provide time for autonomic processes to restore
in at least four psychological mechanisms: values clarifica- homeostasis and generate adaptive regulatory insights [25].
tion, exposure, self-regulation, and cognitive flexibility. Slow breathing from Qigong and other mindfulness medita-
216 A. Yeung et al.

tion have been shown to inhibit the sympathetic nervous sys- adhere to the same standards as conventional research,
tem and enhance function of the immune system [26–29]. including statistically significant sample sizes, adequate con-
Genetic factors may influence health outcomes including trols, definition of response specificity, and reproducibility
depression. Recent research has shown that meditation and of results. Consequently, they recommended substantial
activation of the relaxation response can positively affect increases in funding for rigorous research.
epigenetic activities, which are heritable changes in a chro- Most of the existing clinical trials on Tai Chi and Qigong
mosome that affect gene activity and expression without have small sample sizes, and many have inadequate compari-
modifications of the genome. Meditation has been shown to son groups. These studies face several challenges that are
enhance expression of genes associated with energy metabo- different from those in pharmacological studies. For exam-
lism, mitochondrial function, insulin secretion, and telomere ple, double blinding and the use of sham treatment are diffi-
maintenance and reduced expression of genes linked to cult, if not impractical for performing randomized clinical
inflammatory response and stress-related pathways [30]. trials on Tai Chi and Qigong. Also of concern is the choice of
which Tai Chi/Qigong form to use and how to standardize
the treatment or dose with respect to the skill of the practitio-
 he Emergence of Chinese Medical Qigong
T ner leading or administering the treatment, the tradition of
(CMQ) personalized (i.e., tailoring the treatment approach to each
individual participant’s needs and abilities) rather than stan-
Qigong has been recognized as a “standard medical tech- dardized treatments, and the treatment length, intensity, and
nique” in China since 1989 and is sometimes included in the frequency.
medical curriculum in TCM trainings of major universities
in China. The 2013 English translation of the official Chinese
Medical Qigong textbook used in China defines CMQ as Increasing Popularity of Tai Chi and Qigong
“the skill of body-mind exercise that integrates body, breath,
and mind adjustments into one” and emphasizes that Qigong Tai Chi and Qigong have increased in popularity worldwide
is based on “adjustment” (tiao 調, also translated as “regula- and are widely practiced by people of all ages. For example,
tion,” “tuning,” or “alignment”) of body, breath, and mind a study conducted by Kachan et al., which investigated the
[31]. As such, Qigong is viewed by practitioners as being prevalence of mindfulness-based practices in the US work-
more than common physical exercise, because Qigong com- force, estimated that nearly 131 million practitioners took
bines postural, breathing, and mental training in one to pro- part in at least one type of mind-body exercise (e.g., Tai Chi,
duce a particular psychophysiological state of being. While Health Qigong, Yoga, breathing technique, and Pilates) in the
CMQ is still based on traditional and classical theory, mod- past 12 months. Individuals who practice Tai Chi do so pri-
ern practitioners emphasize the importance of a strong scien- marily to promote physical and psychological well-being
tific basis. According to the 2013 CMQ textbook, and to treat various health conditions [34].
physiological effects of Qigong are numerous. They include Tai Chi and Qigong practices are low-impact, moderate-
improvement of respiratory and cardiovascular function, as intensity aerobic exercises that are suitable for a diverse
well as possible beneficial effects on neurophysiology [31]. patient population with regard to gender, age, and health sta-
In China, CMQ is commonly prescribed to treat a wide tus. Qigong and Tai Chi are generally viewed as safe exer-
variety of conditions, including hypertension, coronary cises across diverse populations [35]. No adverse effects
artery disease, peptic ulcers, chronic liver diseases, diabetes have been observed in clinical trials. Caveats associated with
mellitus, obesity, menopausal symptoms, chronic fatigue Qigong are typically the same as those associated with any
syndrome, insomnia, tumors and cancer, lower back and leg physical activity, including risk of muscle strains or sprains,
pain, cervical spondylosis, and myopia [32]. Outside of advisability of stretching to prevent injury, general safety for
China, Qigong is used in integrative medicine to comple- use alongside conventional medical treatments, and consult-
ment or supplement accepted medical treatments, with indi- ing with a physician when combining with conventional
cations such as relaxation, fitness, rehabilitation, and treatment. In addition to their excellent safety records,
treatment of specific conditions [33]. Qigong and Tai Chi are inexpensive to learn and to practice
Nevertheless, mind-body interventions including Tai Chi and are cost-efficient for group-delivered training. These
and Qigong still need to gain more legitimacy as appropriate benefits may explain why Tai Chi and Qigong have been
complementary treatments. The White House Commission widely used as nonpharmacologic practices for treatment,
on Complementary and Alternative Medicine (CAM) Policy self-healing, promotion of psychological well-being, and
recognized challenges and complexities to rigorous research treatment and prevention of psychosomatic disorders (e.g.,
concerning effectiveness and safety of CAM therapies such arthritis, fibromyalgia).
as Qigong. The Commission emphasized that research must
16  The Effects of Tai Chi and Qigong on Anxiety and Depression 217

New Advances and Research Support Chi group or a stretching and wellness education group.
After the 12-week study, the Tai Chi group showed signifi-
Both Tai Chi and Qigong have been shown to have signifi- cantly greater improvements in depressive symptoms than
cant effects on reducing anxiety and depression symptoms the wellness education group, and the between-group dif-
among healthy populations, patients with chronic medical ference was also statistically significant [41]. In another
conditions, and patients with psychiatric conditions. single-blind, 12-week study, 40 patients with knee osteoar-
thritis were assigned to either a Tai Chi or a wellness educa-
tion group. Here too, the investigators found that the Tai
 ealthy Populations and Patients with Chronic
H Chi group experienced greater reductions in depressive
Medical Conditions symptoms compared to the control group and the difference
between groups was significant [42]. In a 2008 RCT with
There is substantial evidence that Tai Chi and Qigong help to 14 elderly patients from an outpatient clinic, participants
reduce symptoms of anxiety and depression among healthy were randomized to a 3-month Tai Chi intervention or a
populations and those suffering from a chronic medical con- waitlist control group. In this study, only the Tai Chi group
dition. For instance, a 2014 review by Abbott and Lavretsky showed reductions in depressive symptoms [36]. In another
suggests that a majority of studies examining the impact of trial with 112 healthy, older adults, participants were placed
Tai Chi and Qigong on anxiety and depressive symptoms in a 25-week Tai Chi class or a health education program.
among these populations have a positive effect [36]. In these In this case, both groups showed significant reductions in
studies, healthy populations consisted of individuals with depressive symptoms [36]. Furthermore, in 2005, an RCT
symptoms that did not meet threshold for a diagnosis. with 311 people aged 70–97 showed that those who under-
went 48 weeks of Tai Chi experienced significantly greater
Anxiety reductions in depressive symptoms than those assigned a
Of the ten randomized controlled trials (RCTs) investigating wellness education program of the same length [43]. Lastly,
the effects of Tai Chi on anxiety, nine showed significantly in a 1998 trial, 51 patients between the ages of 18 and 60
positive effects [36]. One trial conducted in Japan random- with chronic low back pain were placed in either a 6-week
ized 34 patients with cerebral vascular disorder into either Tai Chi group or a control group. Here too, the Tai Chi
an intervention group, which received Tai Chi, or a control group experienced fewer depressive symptoms compared
group, comprising of standard rehabilitation. In this study, with the control group [44].
the Tai Chi group experienced improvements in anxiety
comparable to the standard rehabilitation [37]. Likewise, in  eview Studies and Meta-analyses
R
a 2008 study, 20 patients with rheumatoid arthritis were ran- The above findings are corroborated by a 2009 review of Tai
domized to either a Tai Chi group or a control group. Results Chi and Qigong in older adults, which examined 36 clinical
for this study showed that the Tai Chi group experienced trials with a total of 3799 participants and concluded that Tai
greater improvements than the control group when it came Chi and Qigong practice led to significant improvements in
to measures of anxiety and depression [38]. In another study depression and anxiety [45].
of 65 patients with chronic heart failure, participants were These findings are further strengthened by a 2012 article
randomized to either 16 weeks of Tai Chi or standard care. by Lee and Ernst which consolidated 35 systematic reviews
Both groups showed a significant reduction in anxiety (SRs) to identify the evidence for the effectiveness of Tai Chi
scores, but there was no significant difference between the on different areas of health [46]. Of these SRs, six examined
groups [39]. Furthermore, a study by Frye et al. placed 84 the effect of Tai Chi on psychological health and well-being,
sedentary, elderly adults into two groups: one receiving Tai with the majority showing positive results. In one SR, Wang
Chi and one receiving low-impact exercise for 12  weeks. et al. found that 17 randomized controlled trials showed that
The study found that both groups experienced reductions in Tai Chi had a positive effect on psychological well-being and
anxiety and that the reduction was comparable between the reduced anxiety and depressive symptoms [47]. In another
two groups [40]. SR by Berghmans et  al., 47 randomized controlled trials
were assessed, showing that there is a positive correlation
Depression between Tai Chi practice and an improvement in psychologi-
In addition to having a positive effect on anxiety, these cal well-being, including reductions in anxiety and depres-
practices have also been shown to play a key role in reduc- sive symptoms [48]. Three other SRs with relatively small
ing depressive symptoms. Of 14 RCTs evaluating the samples of randomized controlled trials also showed an
effects of Tai Chi and Qigong on depressive symptoms, 13 improvement of psychological well-being, including a
showed positive results [36]. In 1 study with 66 fibromyal- reduction in depressive symptoms, associated with conduct-
gia patients, participants were randomized into either a Tai ing Tai Chi [49–51].
218 A. Yeung et al.

Psychiatric Conditions 12  weeks, the Qigong group experienced a significant

reduction in depressive symptoms [55].
The above studies were conducted in patient populations In 2012, Yeung et al. conducted a study examining the
without known mental disorders. However, there is increas- effectiveness of Tai Chi on Chinese Americans with
ing evidence suggesting that Tai Chi and Qigong may have major depressive disorder (MDD). In the study, 39 par-
a positive effect on depression and anxiety among those ticipants were randomized in a 2:1 ratio into the inter-
with clinically diagnosed depression. The following are vention group, which involved a 12-week Tai Chi
studies, which examined the effects of Tai Chi and Qigong practice, and a waitlisted control group. Overall, partici-
as either augmenting an existing treatment or as pants in the intervention group showed 24% improve-
monotherapy. ment in depressive symptoms compared to 0% in the
control group [56]. In a similar pilot study, which exam-
Augmentation ined the effects of providing Qigong treatment to Chinese
In the only study to date that has tested Tai Chi as an aug- Americans with MDD, 14 participants received a
mentation, 112 adults age 60 and older with major depres- 12-week Qigong intervention and showed statistically
sion were treated with escitalopram for approximately significant improvement. Specifically, participants
4 weeks. From the 112, 73 participants responded but did showed a 60% positive treatment response rate and a
not achieve remission with escitalopram. This group con- 40% remission rate [57].
tinued to receive the medication daily and was additionally More recently, in 2017, a randomized clinical trial inves-
assigned to either Tai Chi for 2 h per week or health educa- tigated the effectiveness of Tai Chi as a primary treatment for
tion, both over a 10-week period. Results showed that major depressive disorder (MDD) among Chinese Americans.
those in the Tai Chi group were significantly more likely to In this study, which involved 67 Chinese Americans, partici-
show reduction of depressive symptoms and to achieve pants were randomized into one of three groups: the inter-
depression remission compared to the health education vention group, which involved 12 weeks of Tai Chi practice;
group [52]. an active control group, which received an educational pro-
gram; and a passive control group, which consisted of a wait-
Mono-treatment list. Overall, results showed that Tai Chi reduced depressive
In another study conducted by Chou et al., 14 depressed symptoms compared to both active and passive control
patients aged 60 or over entered a randomized clinical groups [58].
trial in which half were trained in Tai Chi and the other Lastly, a 2016 review examined 21 studies in which Tai
half entered a waitlist control group. Those in the Tai Chi Chi was used as an intervention for mental illness. In this
group participated in a Tai Chi training program that con- analysis, the studies overall showed many positive effects of
sisted of three 45-min sessions per week for 3  months. Tai Chi on mood and anxiety, and the authors suggested that
The results showed that Tai Chi reduced depressive symp- healthcare providers should consider recommending the
toms compared with no treatment in older patients with practice to people with mental health issues [59]. Results
depression [53]. from the RCTs evaluating Tai Chi and Qigong for specific
Two studies similarly looked at the effect of Tai Chi or mental diseases suggest that they may be effective for
Qigong on depressive symptoms among depressed elders. improving symptoms of Parkinson’s disease, traumatic brain
One, conducted in Hong Kong, examined the effects of injury, sleep disturbance, substance abuse, and cognitive
Tai Chi on elderly depressed patients. Here, 82 patients impairment.
with a diagnosis of depression were randomized into one It is important to note that while these results suggest
of two groups: the intervention group, which underwent that Tai Chi and Qigong may be effective augmentative or
16 weeks of Qigong practice, and the control group, which monotherapies for patients with clinical depression, these
participated in a newspaper reading group over the course studies have important limitations. Most of the trials have
of the study. The study showed that the Qigong interven- relatively small numbers of participants and a homogenous
tion, at both 8 and 16  weeks, led to significantly more study population (e.g., Chinese Americans), making it dif-
reductions in depressive symptoms than the control group ficult to generalize results to broader populations. The
[54]. The second was a randomized controlled trial con- open-label nature of these studies, i.e., with patients know-
ducted to examine the effectiveness of Qigong in reducing ing what intervention they are getting as opposed to being
depressive symptoms among depressed elders. The 38 blinded to the treatment, also raises concerns about pla-
participants were randomized into either the intervention cebo effects that may contribute to lack of separation
group, which went through a 12-week Qigong exercise between interventions. More research is needed to assess
program, or the control group, which participated in a the effects of these interventions on diverse populations
newspaper reading program. The study found that at and age groups.
16  The Effects of Tai Chi and Qigong on Anxiety and Depression 219

 linical Application and Recommendation

C tice of these mind-body interventions has been associated
for Practitioners with improved quality of life and well-being. Given that Tai
Chi and Qigong are nonpharmacologic and noninvasive
There are many advantages in practicing Tai Chi and/or treatments, it appears appropriate for clinicians to recom-
Qigong as a physical exercise with low costs and low adverse mend these exercises to patients with mental disorders, par-
events, for self-training and cultivation, and as a group activ- ticularly for the elderly who are susceptible to adverse events
ity to be integrated in the society. It is important for clini- from pharmacological treatments. Further research is needed
cians to be knowledgeable about these mind-body practices to better understand the extent to which Tai Chi can help in
and the evidence related to their usefulness in managing reducing depressive symptoms and how the intervention
medical and psychiatric conditions, with illness prevention, may effect diverse populations.
and for promoting health and well-being so that they can
make educated recommendations to their patients/clients.
One important role of clinicians is to dispel some of the FAQs: Common Questions and Answers
misconceptions about these mind-body interventions. Some
consider Qigong a form of religion or mystical worship ritu-
als, and Tai Chi an exercise for older people only. At another Q1. Why should I consider Tai Chi or Qigong?
extreme, some overstate the promise and claims about the A1. Tai Chi and Qigong are a kind of exercise integrating
use of Tai Chi and Qigong in the treatment of chronic, irre- soft, rhythmic, flowing gentle movements with deep
versible diseases: that they are effective stand-alone treat- breathing. They are an effective exercise in stress reduc-
ments for cancer, osteoarthritis, stroke, substance use tion and improvement of physical health and emotional
disorders, psychosis, etc. Such exaggerated claims frequently well-being. They are non-strenuous and can be utilized
lead to disappointment and sometimes delayed evidence- by people of any age group with any fitness or health
based treatments and potentially tragic outcomes. level. Sometimes, Tai Chi and Qigong are more effective
Clinicians are in an excellent position to educate patients ways of strengthening the body than strenuous exercises.
and to encourage them to use Tai Chi/Qigong where there is They are easy to learn and basically safe and can be per-
strong supporting evidence. For example, there is clear evi- formed anywhere and anytime without any additional
dence that Tai Chi is effective for fall prevention and was equipment.
associated with general health benefits for older people [43]. Q2. Do I have the risk of learning the wrong form of Tai Chi/
In addition, both Tai Chi and Qigong have been shown to Qigong if I do not find the right teacher?
improve psychological health, particularly among those with A2. Yes. If you practice the wrong form of Tai Chi/Qigong
chronic medical conditions, which are highly prevalent in for a long time, it may lead to harmful effects such as
our society. Tai Chi and Qigong could be recommended as knee pain and injury. Therefore, we suggest finding an
augmentative treatment for those who are receiving standard effective instructor to learn from. Nowadays, effective
therapies for their chronic conditions, such as chronic pain, instructor can be trained and got the lenience from China
mood disorders, and substance abuse, to improve their physi- General Administration of Sport in China and Hong
cal stamina and psychological well-being, as well as for Kong. The instructor with the effective Qigong license
stress reduction in healthy populations. Tai Chi and Qigong will be safety for Qigong learning.
may also be used for improving symptoms of Parkinson’s Q3. Are instructors affordable?
disease, traumatic brain injury, sleep disturbance, substance A3. Yes. For some simple forms of Qigong, such as the Eight
abuse, and cognitive impairment [36]. Clinicians who them- Section Brocade, an instructor would be needed for only
selves practice Tai Chi and/or Qigong can be great advocates four sessions with 1.5  h per session. After getting the
and role models for their patients and inspire them to explore instruction and learning the correct movements, people
these exercises. are able to do practice on their own.
Tai Chi and Qigong can be used as augmentative treat- Q4. Is Qigong a religion?
ment for antidepressants in the treatment of geriatric depres- A4. Qigong is not a religion, although some religious practi-
sion [52]. Recently, there is some preliminary evidence that tioners may do Qigong. Qigong, as a kind of mind-body
Tai Chi and Qigong could be used as a first-line treatment for practice, is a simple, effective method for improving the
patients who suffer from mild or moderate depression, under physical, mental, and spiritual aspects of life and enhanc-
the monitoring of mental health providers who are available ing the holistic well-being.
to provide conventional mental health treatment when such Q5. You usually see older people practice Tai Chi/Qigong. Is
treatments are not adequate or if the patient’s condition Tai Chi/Qigong mainly for old people?
worsens. While the efficacy of Tai Chi and Qigong as treat- A5. No. Tai Chi/Qigong is suitable not only for old people
ment for specific mental disorders is still unclear, the prac- or patients with chronic diseases but also for healthy
220 A. Yeung et al.

people including adults and adolescents. There are A10. Yes. There are thousands of different Qigong forms, and
many schools and forms of Qigong/Tai Chi with differ- they roughly fall into five different schools: medical
ent levels of physical intensity. People can choose a Qigong, martial Qigong, Buddhist Qigong, Taoist Qigong,
suitable type of Tai Chi/Qigong according to their inter- and Confucian Qigong. The summary of these five differ-
est or health condition. Healthy people also may prac- ent schools is described in detail in Table 16.2 [60].
tice Tai Chi/Qigong as a way to cultivate physical Q11. What are the differences between Tai Chi and Qigong?
vitality, mental focus, and emotional calmness to make A11. Tai Chi is one kind of Qigong and belongs to martial
them more physically fit, energetic, flexible, and strong Qigong. It was designed to train the fighter to gain
for the purpose of disease prevention and health physical fitness, and it teaches sophisticated methods
enhancement. of self-defense and martial arts. It is more complicated
Q6. Should I learn Tai Chi or Qigong or Yoga? than other types of Qigong and requires more physical
A6. Tai Chi, Qigong, and Yoga are all mind-body exercises and cognitive effort, which is more suitable for young
with gentle and meditative movements. Qigong and Tai and healthy people.
Chi, which originated in ancient China, may regulate the Q12. Is Tai Chi useful as a self-defense tool?
body, mind, and breathing. Tai Chi focuses on body and A12. Yes. Tai Chi not only may benefit for your physical
breathing and is a kind of martial arts for self-deference or health and mental well-being but also may be used as a
fighting. Yoga is a group of physical, mental, and spiritual self-defense tool for you if attacked.
practices, which originated in ancient India (see Chap. 17 Q13. What are the differences between Tai Chi/Qigong and
for a detailed discussion of Yoga). You can determine the other exercises?
best fit depending on your interests or situations. A13. Tai Chi/Qigong exercises are designed based on
Q7. What are possible side effects of Tai Chi/Qigong? Traditional Chinese Medicine theories. They aim to pro-
A7. Tai Chi and Qigong are highly safe. Sometimes, people mote circulation of “Qi” or vital energy in the meridian
may get sore muscles or sprains if they do not practice it
properly. Usually, people are recommended not to prac-
Table 16.2  Major Qigong schools [60]
tice Tai Chi or Qigong right after they eat, when they are
very tired or hungry, or when they have an active infec- School Basic principle and characteristics
Medical Medical Qigong originated from a kind of dance
tion. People should practice them with caution if they
Qigong called Xuan Dao Wu (宣導舞) in 3000–2000 BC. The
have a health condition or are pregnant, or if they are application of guiding, pulling, and massaging the
elderly or have chronic diseases such as joint problems, body, which is called Daoyin Anqiao (導引按蹺) in
fractures, or severe osteoporosis. Chinese, as the beginning of Qigong, was first
recorded in Haungdi Neijin (黃帝內經) over
Q8. Can I learn from online teachers or recorded sessions
2000 years ago. It has the fastest development and the
online? richest content, which was absorbed from other
A8. While online instruction can be helpful, we do not sug- schools of Qigong. Its forms and applications were
gest this as the sole source for learning Qigong/Tai Chi. designed and selected for health prevention,
treatment, and rehabilitation mainly based on the
Learning in-person from a qualified teacher, who can
philosophy of Chinese medicine
give you guidance and teach you personally, is the best Taoist Taoist Qigong can be traced back to Laozi (老子) and
way to ensure that you are developing the proper tech- Qigong Zhuangzi (莊子). Its practice was integrated with
niques. After learning from an instructor, you can sup- Taoist philosophical theory, which focuses on the
plement your learning with online materials. cultivation of both spirit and body (性命雙修) and
forming the internal alchemy (neidan, 內丹)
Q9. How long does it take to learn these disciplines, and how
Buddhist Buddhist Qigong mainly focuses on the cultivation of
frequently should I practice them? Qigong the spirit by regulating the mind and breathing. Its
A9. It depends on which type of Tai Chi and Qigong you practice usually is static as meditation
want to learn. Compared with Tai Chi, Qigong is typi- Confucian Confucius (孔子), father of Confucianism, and his
cally easier to learn. Usually, people can learn it in four Qigong students were the earliest practitioners of Confucian
Qigong. They regarded Confucian Qigong practice as
to six sessions of 60–90 min each. This can be accom-
the prerequisites to governing the states well and
plished in 4–6  weeks with one session per week. For keeping world peace. They used the static Qigong to
some simple Qigong, for example, it requires only nourish the mind and the movement to train the body
15 min to perform a set of eight movements repeating Martial art Early martial art Qigong may originate from the
six times for each movement. According to our previous Qigong dynamic Qigong of medical, Taoist, and Confucian
schools. It focuses more on shaping the body to train
research, people need to practice Qigong exercise at the tendon, bone, muscle, and skin for self-defense
least three times per week for 30 min each time to have and fighting. It is more complicated and requires more
positive outcomes. physical and cognitive effort, which is more suitable
Q10. Are there different forms of Qigong? for young and healthy people
16  The Effects of Tai Chi and Qigong on Anxiety and Depression 221

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