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Title: Meditation

  • Anjali Dhurandhar, MD

  • Definition
  • Historical
  • Types of meditation
  • Use of meditation
  • Biology
  • Evidence
  • Conclusion

  • Meditate derived from Latin meditari which means
    to think or reflect upon
  • Meditationthe practice of becoming aware, of
    paying attention or the act of inward
  • Meditation includes techniques such as
  • listening to the breath
  • repeating a mantra
  • detaching from the thought process, to focus the
    attention and bring about a state of self
    awareness and inner calm

  • Meditation has been practice for thousands of
  • Viewed as a process for training attention, for
    facilitating transcendence, ending suffering and
    transforming human consciousness
  • Originally part of Eastern philosophies
  • Meditation has become more widespread in the past
    few decades
  • Can be an adjunct to conventional medical therapy

Eastern theories of Meditation
  • Buddhist meditators the first scientists
    because thousands of years of detailed
    observation of inner experience
  • Buddha means the awakened one
  • 3 causes of suffering
  • attachment, aversion, delusion
  • Desired effects of meditation practice include
  • equanimity, detachment, clearer sensory perception

Western Theories of Meditation
  • Jung examined meditation and eastern philosophy
  • Bensons theory of the relaxation response, based
    on transcendental meditators
  • Physiological changes note
  • decreased O2 consumption, CO2 elimination, heart
    rate, RR, minute ventilation, arterial blood
  • increased frequency and intensity of EEG slow
    alpha and some theta wave activities (as occurs
    during relaxation)
  • decreased SNS activity (? counterpart to fight or
    flight response)

More on Bensons relaxation response
  • Technique to elicit relaxation response
  • Use of a mental device
  • Passive attitude
  • Decreased muscle tone
  • Quiet environment
  • Benson notes that over the centuries all major
    world religions have mentioned achieving an
    altered state of consciousness, mystical state
    or unified state with God
  • All of these religions employ similar means to
    transcendental meditation for gaining this state
    such as repetition of a word/phrase, passive
    attitude comfortable posture, quiet space
  • (Benson, H The Relaxation response, Psychiatry,

How is meditation done?
  • 2 general approaches to attentional strategies
  • Concentrative form
  • Focus on any of the senses, or on a specific
    object, frequently the breath or a mantra
  • Purpose learned control to focus ones attention
  • Principle technique of transcendental meditation
  • Mindfulness meditation
  • Open receptivity and awareness of all stimulation
  • Purpose maximize breadth and clarity of
  • Mindfulness practiced during meditation, then
    over time integrate mindfulness into all aspects
    of life
  • Dunn, BR, Concentration and Mindfulness
    Meditations unique forms of Consciousness?, 1999

  • Buddhist meditations such as Vipassana and Zen
    focus on mindfulness, but have a concentrative
  • Original roots of mindfulness are found in Hindu
    yoga practices
  • Other common meditation nonreferential
    compassion meditation (dmigs med snying rje in
  • Focuses on achieving a state of compassion by
    using techniques such as contemplating the
    loving kindness of others

Meditation today
  • More than 2 million Americans have learned
    transcendental meditation (popular form,
    originating from Hinduism)
  • Mindfulness meditation taught as the basis for gt
    200 stress reduction programs (as part of medical
    centers) in US
  • 1997 telephone survey 42.1 of adult population
    in US use complementary-alternative medicine
  • Total visits to alternative medicine
    practitioners exceeded that of total visits to
    primary care physicians
  • More billions of out of pocket dollars spent for
    alternative therapies than for out of pocket
    spending for all hospitalizations
  • Use more by women and those of higher SES
  • Mostly used for chronic conditions headaches,
    anxiety, depression, arthritis, back and neck
  • 12 of those surveyed used meditation
  • Eisenberg DM. Davis RB. Ettner SL. Appel S.
    Wilkey S. Van Rompay M. Kessler RC. Trends in
    alternative medicine use in the United States,
    1990-1997 results of a follow-up national
    surveyJAMA. 280(18)1569-75, 1998 Nov 11.
  • Ernst, E The Prevalence of Complementary/Alternati
    ve Medicine in Cancer, 1998, Cancer (31.4 use
    avg, range 7-64)

Benefits of meditation
  • Reduction in anxiety
  • Alleviation of pain
  • Lower depression
  • Enhance mood and self-esteem
  • Lower stress
  • Improvement in clinical symptoms

  • Increase self-transcendence
  • less reliance on externals and stronger inner
    strength and spirituality
  • Improved sense of coherence
  • Personality factor that impacts health
  • If higher sense of coherence, then able to
    understand events of life, feel these events are
    manageable, and despite challenges, find that
    life is meaningful

  • Useful for chronic illness especially mindfulness
    meditation that uses both concentration and
  • Can be used as primary, secondary or tertiary
    prevention in diseases
  • Lower utilization of health care resources
  • Less frequent visits to doctors
  • Fewer inpatient days
  • Fewer inpatient admissions
  • Roth, B mindfulness-based stress reduction and
    healthcare, Altern Ther Health Med, 2002 Jan-Feb
  • Orme-Johnson, D, Psychosomatic Medicine, 1987

Meditation and the Brain
EEG studies is meditation a form of relaxation?
  • Probably a unique state of consciousness
  • Study of concentration and mindfulness
  • students given formal training in concentrative
    and mindfulness meditation
  • EEGs done afterwards relaxation compared to
    concentration and mindfulness, then concentration
    and mindfulness compared
  • Results
  • more delta, theta amplitude (low frequency bands)
    for relaxation vs mindfulness vs concentration
  • More alpha, beta 1 amplitude (high frequency
    bands) for mindfulness vs concentration vs
  • Dunn, BR, Concentration and Mindfulness
    Meditations unique forms of Consciousness?, 1999

Changes in the brain
  • Study Insight meditation
  • Improves attention and mindfulness
  • 20 participants trained in Insight meditation
  • 2 were full-time meditation teachers
  • 3 part-time yoga or meditation teachers
  • Rest meditated avg 40 mins per day
  • Participants had an avg of 9.1 /- 7.1 years of
    meditation experience and practiced 6.2 /- 4
    hours per week
  • Intervention
  • Participants attended at least 1 week-long
    Insight meditation retreat with 10 hours per day
    of meditation
  • 15 controls without meditation or yoga
    experience, matched for age, sex, race, education
  • Lazar SW. Meditation experience is associated
    with increased cortical thickness. Neuroreport.
    16(17)1893-7, 2005 N

  • Results
  • overall no difference in cortical thickness in
  • right anterior insula, right middle and superior
    frontal sulci were thicker in meditators
  • Older meditators had less frontal cortical
    thinning than controls
  • Limitations
  • subjects not similar in culture, language
  • major confounding variables not controlled

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Meditation, the brain, the immune system
  • Emotion-related brain activity
  • Hypotheses
  • those who meditate will have decreased anxiety
    and increased positive affect because left
    frontal of regions of brain are activated
  • immune system would be more activated in
    meditation group
  • b/c anterior activation of brain associated with
    enhanced immune fxn
  • Davidson RJ. Psychosomatic Medicine.
    65(4)564-70, 2003 Jul-Aug.

  • Methods
  • brain activity (EEG) measured in both groups
    prior to random assignment and again at the end
    of intervention and then at 4 months f/u
  • EEG recorded also after subjects wrote about very
    positive and negative events in past
  • Meditation series 2.5-3 hour class per week 1
    hour meditation per day, 6 days per week
  • Both groups given influenza vaccine at the end of
    8-week meditation series

  • Results
  • meditation group with reduction in anxiety and
    also decreased levels of negative effect over
    time vs control group
  • Greater left-sided activation noted in meditation
  • Increased left anterior temporal activation
    (anterior activation asymmetry) and positive
    emotion induction noted
  • Benefits seen in spite of those in meditation
    group not actually following what was prescribed

Reduction in anxiety
Asymmetric activation
Effects on titers Greater antibody response in
meditation group
Those with greater increase in left sided
activation over time, had greater antibody
response to influenza vaccine
Meditation and EEG
  • Multiple studies demonstrating differences in
    alpha, theta, gamma activity
  • Control and experimental groups differed in age,
    ethnicity, language, country of origin, diet,
  • These results therefore may be confounded by
    another factor

Meditation and the body
  • Effect of zen meditation on serum NO activity and
    oxidative stress (lipid peroxidation)
  • Experimental group
  • 20 Zen meditators from meditation center
  • Control age and sex matched
  • Results
  • Meditation group with higher level of serum
    nitrate nitrite concentration and lower level
    of serum MDA
  • Limitations
  • Many confounding factors b/c groups not similar
  • Kim DH. Effect of Zen Meditation on serum nitric
    oxide activity and lipid peroxidation. Progress
    in Neuro-Psychopharmacology Biological
    Psychiatry. 29(2)327-31, 2005 Feb.

More on biology
  • Methods
  • Randomized study
  • 19 pts with CHF, 74.8 yrs avg, on diuretics, ACEi
    or ARBs, carvedilol, spironolactone
  • After 2 months of max dose tolerated of
    carvedilol, randomized pts into 2 groups
  • meditation group listened to 30 min audiotape 2 x
    day for 12 weeks and weekly meeting or control
    group with weekly meetings
  • Results
  • Meditation group with lower norepi levels,
    improved heart failure quality of life scores,
    reduced VE/VCO2 slopes
  • no change in LV EF, LVEDVI or VO2
  • Curiati JA. Journal of Alternative
    Complementary Medicine. 11(3)465-72, 2005 Jun.

Transcendental meditation
Different types of meditation
Transcendental meditation (TM)
  • Concentrative meditation
  • focus on any of the senses, or on a specific
  • Transcendental Meditation program
  • Established by Maharishi Mahesh Yogi
  • 2 million TM participants worldwide
  • Taught by experienced practitioners
  • Includes introduction, lectures, meditation twice
    per day

  • Physiologic effects of TM in studies
  • Reduced minute ventilation, RR, lactate levels
  • Increased alpha band activity on EEG
  • Reduction in cortisol levels
  • TM practitioners may have
  • significantly lower SBP and also longer survival
    rates than those in relaxation or control groups
  • different physiological changes than those in
    sleep, hypnosis, hibernation, and biofeedback

  • Effects of TM on healthcare utilization
  • Lower number of inpatient days
  • Lower number of admissions for several disease
  • Lower frequency of office visits
  • Limitations of studies
  • Selection bias
  • Unable to assess if TM actually being practiced
    at home

Case report
  • Pt with spontaneous recovery from dermatomyositis
    who practiced TM and visual imagery
  • Methods
  • measured arm strength and skin condition (rash,
    pain) daily for 294 days and psychological stress
    events TM, visual imagery
  • Results
  • pt recovered without any conventional therapy
  • Use of meditation and visual imagery appeared to
    affect arm strength, rash, pain
  • Stress worsened skin sx, but not arm strength
  • Limitations
  • Case report, no causal relationship can be
    determined from this
  • Collins, mp, j atl comple med 2005

TM and CAD
  • VA pts with documented CAD
  • Assigned to TM or wait-list control
  • TM group had instruction, group classes,
    individual meetings, home practice (20 mins
  • Results
  • TM group with improved exercise tolerance, higher
    maximal workload and delayed onset ST segment
    depression on ETT
  • Limitations
  • Small numbers, selection bias, confounding
  • Zamarra JW. American Journal of Cardiology.
    77(10)867-70, 1996 Apr 15.

Use of TM for carotid stenosis
  • Methods
  • 138 volunteer hypertensive AA pts
  • Pre and post-intervention measures of carotid
    intima-media thickness done (as a surrogate
    marker for CAD)
  • Subjects randomly assigned
  • intervention (TM) vs control (health education)
  • Castillo-Richmond. Stroke. 31(3)568-73, 2000 Mar.

  • Results
  • 60 pts completed study
  • TM group had significant decrease in thickness of
    intima via ultrasound vs increase in thickness in
  • Limitations
  • Selection bias
  • High drop out rate

BP and TM
  • 2 RCTs compared TM, other behavioral
    stress-lowering interventions and usual tx for
  • 202 pts
  • 77 white, age 81 125 AA age 66
  • Baseline BP mild htn or prehtn
  • Mean f/u 7.6 /- 3.5 yrs
  • TM group
  • 23 decrease in all cause mortality
  • 30 decrease in CV death
  • 49 decrease in cancer death compared with
  • Schneider RH. American Journal of Cardiology.
    95(9)1060-4, 2005 May 1.

  • Limitations
  • TM group more males
  • fewer in TM group taking antihypertensives
  • mean age of TM group younger
  • Participants d/ced meds for trial or were kept
    on stable dose

TM effects on BP, HR
  • Methods
  • 73 middle school students randomly assigned by
    classroom to meditation or health education
  • 38 AA, 35 white
  • 34 females
  • Age 12.3 /- 0.6 yrs
  • Anger levels measured and neighborhood conditions
    (such as violence) and also physical activity
  • Meditation and control groups similar with regard
    to age, gender, ethnicity, height, weight, BMI
  • Barnes VA. Journal of Hypertension. 17(4)366-9,
    2004 Apr.

  • Meditation group
  • concentration meditation focusing on breath
  • 10 min session at school and at home afternoons
    daily for 3 months
  • Control group
  • weekly 20-minute sessions on prevention of htn
    and CAD risk factor reduction
  • prescribed 20 minute walks per day

  • Resting SBP, DBP and HR tested pretest on 3
    consecutive school days and again posttest
  • 86 compliance with meditation at home
  • Ambulatory SBP, DBP, HR measured over 24 hour
    periods pre and post test
  • q 20 mins while awake and q 30 mins during sleep
  • Results
  • Meditation group with decreases in resting
    SBP(-2.7 vs 1.1), daytime SBP(-2 vs 3.6), DBP(0.1
    vs 4.3), HR (-5.3 vs 0.3) after school

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Hypertension transcendental meditation
  • Review 6 trials found
  • Procedure for baseline BP only adequate in 1
  • if BP taken only on 1 day, then more likely to
    report positive results
  • Only 1 trial had f/u assessment
  • Only 1 trial tested TM in hypertensive pts
  • 3 found positive results 2 did not
  • No long-term follow up
  • All of the authors of trials were linked to TM
  • Authors of review compared to TM organization to
    a cult
  • Canter PH. Journal of Hypertension.
    22(11)2049-54, 2004 Nov.

Mindfulness meditation
Mindfulness meditation
  • Mindfulness
  • being in the present and to observe sensations,
    emotions and thoughts, to let them go, and then
    to return to the breath
  • links the mind and body as well as the
    environment together and creates wholeness
  • Mindfulness practiced during meditation
  • Observation of breathing, heartbeat
  • Observing ones mind such as thoughts,
    sensations, imagery and emotions
  • Over time mindfulness is practiced during
    activities such as walking, eating

Benefits of mindfulness meditation
  • Increased self-efficacy and motivation and
    ability to cope with problems
  • Increased feelings of trust and connection with
  • Feel as part of greater whole

Mindfulness-based Stress Reduction
  • Program founded by Jon Kabat-Zinn in 1979 at
    Stress Reduction Clinic, University of
    Massachusetts Medical Center
  • Widely employed program
  • 240 MBSR programs in North America
  • Programs have been employed with groups of
    varying SES, ethnicity, language
  • Many studies on its uses and benefits

What is it?
  • A combination of mindfulness meditations
  • body scan
  • sitting meditation
  • hatha yoga
  • Also includes weekly meetings in small groups
    with meditation, support and instruction
  • All day meditation retreat during 8 week course
  • Home practice
  • generally 20-30 mins per day, 6 days per week

MBSR for pain syndromes
  • Chronic pain
  • Initial study
  • Methods
  • 90 pts with chronic pain
  • 10 wk MBSR program
  • Results
  • significant reductions in pain, anxiety,
    depression and improvement in self-esteem
  • Use of analgesics decreased
  • Comparison group did not have these benefits
  • Improvements were maintained at 15 months of
    follow up
  • Most patients continued to be adherent to
    meditation practice
  • Kabat-Zinn. Journal of Behavioral Medicine. 1985

  • Follow up study
  • Methods
  • Total of 225 pts with chronic pain enrolled
    (included previous 90) over 4 years
  • Mailed questionnaires about program and about
    pain scales assessed at points over time, up to 4
    years for initial group
  • Intervention
  • 8 week program, including formal and informal
    meditation practice, gentle yoga
  • Kabat-Zinn JClin J of Pain, 1987

  • Results
  • 53-70 responded to questionnaires female gt male
  • Most reductions in pain maintained, except for on
    Pain Rating index (present moment pain)
  • 43 attributed improvements in pain to stress
    reduction program
  • 86 felt that they had received lasting benefit
    from the program
  • 40 noted better ability to cope with pain
  • 93 continued to use one of the skills learned
  • Only 30 regular meditators at 4 years
  • Limitations
  • No control group, recall bias, selection bias

MBSR for treatment of fibromyalgia
  • Methods
  • 300 random fibromyalgia pts invited to
  • First 77 enrolled, but screened extensively first
  • Intervention
  • 10 weekly 2 hour sessions that included
    meditation, group discussion, lectures
  • Home practice of daily meditation and journaling
  • Kaplan, KH, The impact of a MBSR program on
    Fibromyalgia, Gen Hosp Psych, 1993

  • Results
  • 59 pts completed program
  • Most pts were female
  • All pts showed improvement on the inventories,
    though about half of patients had significant
    response to intervention and had improvement in
    pain scores, sleep, fatigue
  • Limitations
  • No control group
  • Selection bias
  • No long term follow up data

MBSR for cancer patients
  • Study 1 RCT
  • Eligibility any patient with dx of CA
  • 109 enrolled in study, 90 completed study
  • Mean age 51, women gt men
  • Outcomes of mood POMS
  • Outcomes of stress SOSI
  • Randomized to intervention group or wait-list
  • Intervention 7 weekly 1.5 hour sessions, daily
    home practice

  • Results
  • Average total daily meditation time 32 mins
  • Intervention group with significant reduction in
    mood disturbances anxiety, depression, anger,
  • Number of minutes practice predicted change in
    mood disturbance, but attending groups did not
  • For stress, intervention group did have
    significant reduction of certain symptoms such as
    emotional irritability and overall had a
    reduction in total stress symptoms
  • Limitations
  • Control group had more patients with late stage
    cancer, selection bias, high drop out rate

Speca, M Psychosom med 2000
Cancer and MBSR
  • Study 2 8 week MBSR
  • 49 pts with breast ca (stage 0-II) and 10 pts
    with localized prostate ca
  • 42 of 59 pts completed the study
  • 33 breast ca, 9 prostate ca
  • 14 stage I, 26 stage II
  • those who completed study more likely to be
    married or living with someone (vs single,
    divorced, widowed)
  • No other demographic differences noted, but
    completers with lower baseline scores of
    depression, anger, confusion, but no differences
    on stress inventory
  • quality of life questionnaire (EORTCQLQ-C30)
    POMS mood, SOSI stress inventory

  • Avg 24 mins meditation per day and 13 mins yoga
    per day
  • Improvements in overall quality of life, sx of
    stress, sleep quality
  • No changes in mood (but low level disturbance
    baseline) or lymphs or cell subsets
  • T cell pxn of IL-4 increased and IFN gamma
    decreased and NK cell pxn of IL-10 decreased
  • Carlson LE, International Journal of Behavioral
    Medicine. 12(4)278-85, 2005.

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MBSR in patients with heart disease
  • 20 women with CAD recruited and randomized to
    experimental group or wait-list control
  • Measures
  • Anxiety
  • Emotional control
  • Coping skills
  • Health locus of control
  • MBSR
  • met weekly for 2 hours x 8 weeks
  • Included body scan, sitting meditation, Hatha

Tacon AM. Family Community Health, 2003
  • Experimental group with significantly
  • decreased levels of state anxiety
  • Decreased tendency to suppress negative emotions
  • Less impulsive, reacting coping style
  • No change in health locus of control
  • Note experimental group have avg age younger
    than control group

  • Study
  • Evaluation of MBSR on rates of skin clearing in
    pts with psoriasis
  • 37 pts with mod to severe psoriasis, scheduled
    for phototherapy or photochemotherapy
  • Subjects randomly assigned to audiotape or no
  • Intervention group given mindfulness tape during
    sessions, total of 20
  • Unblinded nurses assessed clearing of lesions,
    but blinded physicians also assessed lesions

  • Results
  • Rate of clearing of skin lesions more rapid in
    intervention group
  • Trend towards reduction in psychological distress
    on inventory
  • Limitations
  • high drop out rate
  • nurses checking skin lesions not blinded to group
  • Selection bias
  • Kabat-Zinn, J , Psychosom med, 1998

Mindfulness meditation in solid organ transplant
  • 20 solid-organ tx recipients in 8 week MBSR
  • various forms of meditation, Hatha yoga,
    audiotapes for home practice, diaries
  • Results
  • improvements in quality of sleep that continued
    for 6 months after course completion
  • improvements in anxiety and depression also noted
  • Not RCT, unclear if results due to intervention
    or just time post-tx
  • Kreitzer MJ. Progress in Transplantation, 2005

MBSR for chronic medical illness
  • Study
  • Methods
  • Intervention
  • 12 separate 8 wk MBSR courses
  • weekly 2.5 hour group sessions and 6 hour
    meditation retreat, home practice meditation 20
    mins per day
  • Patients given questionnaires pre- and
  • Reibel, DK, MBSR and health-related quality of
    life in a heterogenous patient population, Gen
    Hosp Psych, 2001

  • Patients
  • 136 pts with different medical conditions
  • 71 female
  • Several pts with multiple medical problems
  • Pre-intervention almost all pts believed that
    intervention would reduce stress, pain and other
    bodily symptoms

  • Outcomes
  • 121 pts completed program 104 completed pre
    post intervention questionnaires
  • Overall group had improvement in stress, medical
    symptoms, and overall health quality
  • 97 reported much better ability to cope with
  • Participants very satisfied with program (4.9/5)
  • 1 year follow up
  • 30 response rate
  • Majority continued some type of meditation
  • Maintenance of improvement in health quality,
    symptoms, stress

  • Limitations
  • Selection bias
  • Lack of control group
  • High positive expectations pre-intervention
    (placebo effect)
  • Recall bias

MBSR for inner city population
  • Methods
  • Intervention
  • MBSR 8 weekly 2 hour sessions, home practice
  • Results
  • 68 pts intervention group, 18 control
  • Majority female, Hispanic, Spanish-speaking only
  • Low SES, multiple medical problems
  • Overall improvement in most health measure, but
    not sleep or family harmony
  • Roth BPsychosomatic Medicine. 2004 Jan-Feb.

MBSR for anxiety disorders
  • Pilot study
  • 24 outpts with anxiety disorders
  • Intervention 8 week MBSR
  • Results
  • 22 completed program
  • improvements in objective and subjective symptoms
    of anxiety, maintained at 3 month follow up
  • Follow up study
  • Original 22 pts followed up at 3 years
  • 18 pts participated in 3 yr f/u
  • Interviews conducted 10 in person, 8 phone
  • Miller, JJ, American Journal of Psychiatry. 1992

  • Results
  • Improvements in objective and subjective anxiety
    symptoms persisted at 3 year f/u
  • 16 of 18 practiced one of the techniques learned
  • 4 were highly compliant with taught practices
  • 16 of 18 felt that the program had lasting value
  • Limitations
  • Lack of randomization, selection bias, recall bias

MBSR and Anxiety
  • Study RCT
  • Methods
  • 28 volunteers with chronic pain randomized to
    intervention or control
  • Intervention 8-week MBSR
  • Results
  • Significant reductions in stress, and increases
    in feeling of control and acceptance of their
    lives and increased scores of spirituality
  • Limitations
  • Selection bias, group too small
  • Astin JA, Psychotherapy Psychosomatics.
    66(2)97-106, 1997

MBSR for medical and premedical students
  • RCT
  • 8 week MBSR program for medical and pre med
  • 7 weekly 2.5 hour sessions, daily journals, home
  • Sitting meditation
  • Body scan
  • Hatha yoga
  • Loving kindness and forgiveness meditations
  • Experimental exercises to improve mindful
    listening skills and empathy
  • Measures empathy scores (Empathy construct
    rating scale), psychological distress (Hopkins
    SCL-90R, depression (subscale 4 SCL-90), state
    and trait anxiety (STAI form 1), spirituality
  • 78 participants, 37 randomized to intervention
  • Shapiro J Behav Med, 1998

  • 73 included
  • 32 male, 41 female
  • 35 pre med, 38 med
  • 79 white
  • No differences between groups gender, race,
    premed vs med
  • 97 completed program
  • Post measures during exam time
  • Intervention group
  • reduced reported state and trait anxiety
  • reduced overall psychological distress
  • increased spiritual scores

  • Improved compliance led to much lower trait
    anxiety ( p lt .001)
  • Lower trait anxiety led to decreased depression,
    decreased state anxiety and increase in empathy
  • Decreased in depression and state anxiety caused
    increase in spirituality
  • Note causal effects are hypothetical

  • Limitations
  • Selection bias
  • Response bias
  • Placebo effects
  • Difficult to tell which part of intervention
  • Meditation vs journaling vs group discussions
  • Small group discussions and sharing of stories
    shown to beneficial in itself

MBSR for nursing students
  • Methods
  • 3rd year nursing students invited to participate
  • 15 students enrolled, then 15 students
    volunteered to be in matched control group
  • Intervention
  • MBSR, 8 week course
  • Results
  • Initially some students had increased stress due
    to difficulty of learning and incorporating new
  • Students noted greater awareness of mind-body
    responses to stress
  • Students noted increased ability to cope with
    stresses and felt more connected to others in the
  • Limitations selection bias, recall bias, lack of

MBSR for nurses burnout
  • RCT MBSR for nurses
  • Methods
  • Volunteers randomized to intervention or
    wait-list control
  • 100 white female
  • Most chose to participate in program b/c of
    family stress (gtgtwork stress)
  • Results
  • Challenges with participation
  • Anxiety
  • Physical discomfort
  • Restlessness

  • Overall benefits
  • Felt comforted by hearing stories of others in
    the group
  • More calm, increased acceptance, less emotional
    reactivity, improved sleep, increased empathy and
    enhanced spirituality
  • Value of program (9.2/10)
  • Other changes
  • Meditation groups incorporated into workday
  • Cohen-Katz J. 2005 Mar-Apr

Overall benefits of MBSR program
  • Personal changes
  • Greater peace of mind
  • More patience, less anger
  • Improved interpersonal communication
  • More sense of well being
  • Behavior changes
  • Better sleep
  • Decreased use of anxiolytics, sedatives,
  • Smoking cessation
  • Weight loss

Reduction in overall medical costs
  • After completing MBSR
  • Moderate reduction in number of office visits
  • Reduction in hospital charges and length of
    hospital stay
  • Reduction in number of days of work missed
  • Studies were done with diverse patient groups as
    far as SES
  • Limitations
  • Studies had small sample size
  • Studies lacked control groups
  • Utilization assessed by chart review
  • Most patients completing MBSR program were female
  • Roth, B mindfulness-based stress reduction and
    healthcare, Altern Ther Health Med, 2002 Jan-Feb

Summary of MBSR studies
  • Methodological design flaws
  • Design limitations
  • Samples too small
  • Lack of control group or lack of randomized
    control group
  • Very few RCT
  • Differences between groups not controlled
  • Self-report measures used (recall bias)
  • Selection bias
  • High drop out rates
  • Placebo effects (patient expectations)
  • Not generalizable
  • Mostly female patients
  • Limited diversity

Other limitations
  • More motivated pts with positive expectations for
    MBSR program and adherence to meditation practice
    have positive correlation with outcome
  • Low motivation participants might not get much
    benefit or may have dropped out
  • Many pts with life-threatening illness that
    hadnt responded to treatments (so perhaps more
    motivated to participate)

  • Mechanism of how mindfulness works and who it
    might benefit is unknown
  • Shapiro theorizes intentional systemic
    mindfulnessthat improving attention, leads to
    better connection to oneself and others and
    improves self-regulation (internal
    communication), improved order and health
  • Quality of intention is non-judging, accepting,
    patient, empathetic, is important to quality of
    experience and to improving health

Yoga-meditation for caregiver stress
  • 12 caregivers
  • 6 sessions of yoga and meditation and group
  • Inner Resources protocol
  • Concentrative (vs mindfulness) Meditation
  • Gentle stretching (hatha yoga)
  • Breathing techniques
  • guided imagery
  • Mantras
  • Surrender technique of observing thoughts and
    feelings and letting them go through breathing
    and relaxing as they occur and also during
  • Methods 8 latina and 6 white female caregivers
    enrolled, but 2 white caregivers dropped out age
    39-69, avg 56, 1/3 full time employment
  • Waelde yoga and meditation intervention for
    dementia caregiver stress J clin psych 2004

  • Measures
  • Depression (CES-D scale)
  • Self-efficacy (SEC for caregivers)
  • Anxiety (STAI)
  • Caregiving burden (RMBPC)
  • Treatment adherence (weekly practice log, self-
  • Subjective improvement (questionnaire)
  • Reductions in depression, anxiety
  • improvements in self-efficacy, but no changes in
    subjective or objective caregiving burden

(No Transcript)
  • Participants did avg 91 (0-173) minutes per week
    at home (vs 180 mins prescribed)
  • Type spent at home ( mins) increased over the
  • Greater adherence led to lower levels of
    depression post intervention
  • Those who attended more sessions practice more
    mins at home

  • 70 reported feeling somewhat or much better than
    pre-intervention as far as
  • activity level, physical pain, sleep problems,
    depression, frustration, energy level, overall
  • about half felt better as far as
  • fatigue, coping with stress, physical illnesses
    and anger
  • 90 rated all parts of intervention at least
    moderately useful, except taped yoga only 80

Waelde LC.Journal of Clinical Psychology.2004
Adverse effects of Meditation
  • Up to 53.8 of those meditating experience
  • Beginners experience difficulty with meditation
  • Initial anxiety and confusion common
  • Other adverse effects unpleasant sensations,
    feelings of losing control and of vulnerability,
    myoclonic jerks, intrusive thoughts
  • However these adverse effects are to be expected
    sometimes with meditation and relaxation
    practices and may help the patient become more
    aware of thoughts and physical sensations (and
    can thus be used therapeutically)

Compton, WC, J of clin psychology, 1983
Limitations of Research on Meditation
  • Meditation research is challenging because
  • difficult to discern its specific effects
  • some of its effects are non-specific or placebo
    effects which may be important in its benefits
  • Challenges of meditation research includes
  • variability in meditation types
  • problems with meditation implementation
  • individual differences between those who meditate
  • not possible to do double-blind, placebo
    controlled studies
  • Caspi, Advances in Mind body medicine, 2005

Other considerations
  • Many studies employed integrated programs.
  • Often other components involved such as groups
    and journaling
  • Unclear which part of the intervention helped
  • Optimal frequency, duration and type of
    meditation is unknown.
  • In addition, an extended learning period may be
    necessary to derive benefits.

  • Meditation can be adjuncts to conventional
    medical therapy.
  • Meditation may be cost-effective and in certain
    conditions such as anxiety, stress, pain, it is
    probably beneficial.
  • Effectiveness of meditation is unknown due to
    unknown mechanism of action
  • studies employ several modalities
  • poor study design (lack of powered RCTs)

The End
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