Meditation Anjali Dhurandhar

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Meditation Anjali Dhurandhar, MD


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


Background Meditate derived from Latin meditari which means to think or reflect upon Meditation=the practice of becoming aware, of paying attention or “the act of inward contemplation” 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


Historical Meditation has been practice for thousands of years 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: 

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: 

Western Theories of Meditation Jung: examined meditation and eastern philosophy Benson’s theory of the relaxation response, based on transcendental meditators Physiological changes note: decreased O2 consumption, CO2 elimination, heart rate, RR, minute ventilation, arterial blood lactate 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 Benson’s relaxation response: 

More on Benson’s 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, 1974)

How is meditation done?: 

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 one’s attention Principle technique of transcendental meditation Mindfulness meditation: Open receptivity and awareness of all stimulation Purpose: maximize breadth and clarity of awareness 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 component Original roots of mindfulness are found in Hindu yoga practices Other common meditation: nonreferential compassion meditation (dmigs med snying rje in Tibetan) Focuses on achieving a state of compassion by using techniques such as contemplating the “loving kindness of others”

Meditation today: 

Meditation today More than 2 million Americans have learned transcendental meditation (popular form, originating from Hinduism) Mindfulness meditation: taught as the basis for > 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 therapies 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 problems 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/Alternative Medicine in Cancer, 1998, Cancer (31.4% use avg, range 7-64%)

Benefits of meditation: 

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 awareness 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: 

Meditation and the Brain

EEG studies: is meditation a form of relaxation?: 

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 relaxation Dunn, BR, Concentration and Mindfulness Meditations: unique forms of Consciousness?, 1999

Changes in the brain: 

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 general 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

Meditation, the brain, the immune system: 

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 group 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: 

Reduction in anxiety

Asymmetric activation : 

Asymmetric activation

Effects on titers: Greater antibody response in meditation group: 

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 : 

Those with greater increase in left sided activation over time, had greater antibody response to influenza vaccine

Meditation and EEG: 

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, sleep These results therefore may be confounded by another factor

Meditation and the body: 

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: 

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: 

Transcendental meditation Different types of meditation

Transcendental meditation (TM): 

Transcendental meditation (TM) Concentrative meditation: focus on any of the senses, or on a specific object 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 categories Lower frequency of office visits Limitations of studies: Selection bias Unable to assess if TM actually being practiced at home

Case report: 

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: 

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 2x/day) Results: TM group with improved exercise tolerance, higher maximal workload and delayed onset ST segment depression on ETT Limitations: Small numbers, selection bias, confounding factors Zamarra JW. American Journal of Cardiology. 77(10):867-70, 1996 Apr 15.

Use of TM for carotid stenosis: 

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 controls Limitations: Selection bias High drop out rate

BP and TM: 

BP and TM 2 RCTs compared TM, other behavioral stress-lowering interventions and usual tx for htn 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 controls 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/c’ed meds for trial or were kept on stable dose

TM effects on BP, HR: 

TM effects on BP, HR Methods: 73 middle school students randomly assigned by classroom to meditation or health education control 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

Hypertension: transcendental meditation: 

Hypertension: transcendental meditation Review: 6 trials found Procedure for baseline BP only adequate in 1 trial 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 organization 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 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 one’s mind such as thoughts, sensations, imagery and emotions Over time mindfulness is practiced during activities such as walking, eating

Benefits of mindfulness meditation: 

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

Mindfulness-based Stress Reduction: 

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?: 

What is it? A combination of mindfulness meditations including: 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: 

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 Jun.


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 > 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: 

MBSR for treatment of fibromyalgia Methods: 300 random fibromyalgia pts invited to participated 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: 

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 > men Outcomes of mood: POMS Outcomes of stress: SOSI Randomized to intervention group or wait-list control 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, confusion 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: 

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


Results 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.



MBSR in patients with heart disease: 

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 yoga Tacon AM. Family & Community Health, 2003 Jan-Mar.


Results 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


Psoriasis 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 tape 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 assignment Selection bias Kabat-Zinn, J , Psychosom med, 1998

Mindfulness meditation in solid organ transplant patients: 

Mindfulness meditation in solid organ transplant patients 20 solid-organ tx recipients in 8 week MBSR course: 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 Jun.

MBSR for chronic medical illness: 

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 post-intervention 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 stress Participants very satisfied with program (4.9/5) 1 year follow up: 30% response rate Majority continued some type of meditation practice 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: 

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: 

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 Jul.


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: 

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 (INSPIRIT) Limitations: Selection bias, group too small Astin JA, Psychotherapy & Psychosomatics. 66(2):97-106, 1997

MBSR for medical and premedical students: 

MBSR for medical and premedical students RCT: 8 week MBSR program for medical and pre med students: 7 weekly 2.5 hour sessions, daily journals, home practice 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 (INSPIRIT) 78 participants, 37 randomized to intervention Shapiro: J Behav Med, 1998


Results 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 < .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 beneficial: Meditation vs journaling vs group discussions Small group discussions and sharing of stories shown to beneficial in itself

MBSR for nursing students: 

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 techniques 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 group Limitations: selection bias, recall bias, lack of randomization

MBSR for nurses: burnout: 

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 (>>work 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: 

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, analgesics Smoking cessation Weight loss

Reduction in overall medical costs: 

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: 

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: 

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 hadn’t 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 mindfulness…that 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: 

Yoga-meditation for caregiver stress 12 caregivers 6 sessions of yoga and meditation and group discussion 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 meditation 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- report) Subjective improvement (questionnaire) Reductions in depression, anxiety improvements in self-efficacy, but no changes in subjective or objective caregiving burden


Participants did avg 91 (0-173) minutes per week at home (vs 180 mins prescribed) Type spent at home (# mins) increased over the weeks 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 well-being 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 Jun.

Adverse effects of Meditation: 

Adverse effects of Meditation Up to 53.8% of those meditating experience anxiety Beginners experience difficulty with meditation practice 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: 

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: 

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


Conclusions 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: 

The End


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Kabat-Zinn J. Lipworth L. Burney R., Sellers, W. Four-Year follow-up of a meditation-based prgoram for the self-Regulation of chronic pain: treatment outcomes and compliance. Clin J of Pain, 2:158-173, 1987 Astin JA. Stress reduction through mindfulness meditation. Effects on psychological symptomatology, sense of control, and spiritual experiences. Psychotherapy & Psychosomatics. 66(2):97-106, 1997 Carlson LE. Garland SN. Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients. International Journal of Behavioral Medicine. 12(4):278-85, 2005. Carlson LE. Speca M. Patel KD. Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosterone sulfate (DHEAS) and melatonin in breast and prostate cancer outpatients. Psychoneuroendocrinology. 29(4):448-74, 2004 May. Carlson LE. Speca M. Patel KD. Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosomatic Medicine. 65(4):571-81, 2003 Jul-Aug. Carlson LE. Ursuliak Z. Goodey E. Angen M. Speca M. The effects of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients: 6-month follow-up. Supportive Care in Cancer. 9(2):112-23, 2001 Mar. Speca M. Carlson LE. Goodey E. Angen M. A randomized, wait-list controlled clinical trial: the effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosomatic Medicine. 62(5):613-22, 2000 Sep-Oct. Tacon AM. McComb J. Caldera Y. Randolph P. Mindfulness meditation, anxiety reduction, and heart disease: a pilot study. Family & Community Health. 26(1):25-33, 2003 Jan-Mar. Roth B. Creaser T. Mindfulness meditation-based stress reduction: experience with a bilingual inner-city program.Nurse Practitioner. 22(3):150-2, 154, 157 passim, 1997 Mar. Roth B. Robbins D. Mindfulness-based stress reduction and health-related quality of life: findings from a bilingual inner-city patient population. Psychosomatic Medicine. 66(1):113-23, 2004 Jan-Feb. Gross CR. Kreitzer MJ. Russas V. Treesak C. Frazier PA. Hertz MI. Mindfulness meditation to reduce symptoms after organ transplant: a pilot study. Advances in Mind-Body Medicine. 20(2):20-9, 2004.


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Transcendental meditation: Schneider RH. Alexander CN. Staggers F. Rainforth M. Salerno JW. Hartz A. Arndt S. Barnes VA. Nidich SI. Long-term effects of stress reduction on mortality in persons > or = 55 years of age with systemic hypertension. American Journal of Cardiology. 95(9):1060-4, 2005 May 1. Castillo-Richmond A. Schneider RH. Alexander CN. Cook R. Myers H. Nidich S. Haney C. Rainforth M. Salerno J. Effects of stress reduction on carotid atherosclerosis in hypertensive African Americans. Stroke. 31(3):568-73, 2000 Mar. Schneider RH. Nidich SI. Salerno JW. Sharma HM. Robinson CE. Nidich RJ. Alexander CN. Lower lipid peroxide levels in practitioners of the Transcendental Meditation program. Psychosomatic Medicine. 60(1):38-41, 1998 Jan-Feb. Wenneberg SR. Schneider RH. Walton KG. Maclean CR. Levitsky DK. Salerno JW. Wallace RK. Mandarino JV. Rainforth MV. Waziri R. A controlled study of the effects of the Transcendental Meditation program on cardiovascular reactivity and ambulatory blood pressure. International Journal of Neuroscience. 89(1-2):15-28, 1997 Jan. Weiss M. Nordlie JW. Siegel EP. Mindfulness-based stress reduction as an adjunct to outpatient psychotherapy. Psychotherapy & Psychosomatics. 74(2):108-12, 2005. Schneider RH. Alexander CN. Staggers F. Orme-Johnson DW. Rainforth M. Salerno JW. Sheppard W. Castillo-Richmond A. Barnes VA. Nidich SI. A randomized controlled trial of stress reduction in African Americans treated for hypertension for over one year. American Journal of Hypertension. 18(1):88-98, 2005 Jan. Alexander CN. Schneider RH. Staggers F. Sheppard W. Clayborne BM. Rainforth M. Salerno J. Kondwani K. Smith S. Walton KG. Egan B. Trial of stress reduction for hypertension in older African Americans. II. Sex and risk subgroup analysis. Hypertension. 28(2):228-37, 1996 Aug.


Canter PH. Ernst E. Insufficient evidence to conclude whether or not Transcendental Meditation decreases blood pressure: results of a systematic review of randomized clinical trials.Journal of Hypertension. 22(11):2049-54, 2004 Nov. Zamarra JW. Schneider RH. Besseghini I. Robinson DK. Salerno JW. Usefulness of the transcendental meditation program in the treatment of patients with coronary artery disease. American Journal of Cardiology. 77(10):867-70, 1996 Apr 15. Schneider RH. Staggers F. Alxander CN. Sheppard W. Rainforth M. Kondwani K. Smith S. King CG. A randomised controlled trial of stress reduction for hypertension in older African Americans. Hypertension. 26(5):820-7, 1995 Nov. Barnes VA. Treiber FA. Johnson MH. Impact of transcendental meditation on ambulatory blood pressure in African-American adolescents. American Journal of Hypertension. 17(4):366-9, 2004 Apr. Parati G. Steptoe A. Stress reduction and blood pressure control in hypertension: a role for transcendental meditation? Journal of Hypertension. 22(11):2057-60, 2004 Nov. King MS. Carr T. D'Cruz C. Transcendental meditation, hypertension and heart disease. Australian Family Physician. 31(2):164-8, 2002 Feb.


Biology: Lazar SW. Bush G. Gollub RL. Fricchione GL. Khalsa G. Benson H. Functional brain mapping of the relaxation response and meditation. Neuroreport. 11(7):1581-5, 2000 May 15. Lazar SW. Kerr CE. Wasserman RH. Gray JR. Greve DN. Treadway MT. McGarvey M. Quinn BT. Dusek JA. Benson H. Rauch SL. Moore CI. Fischl B. Meditation experience is associated with increased cortical thickness. Neuroreport. 16(17):1893-7, 2005 Nov 28. Lutz A. Greischar LL. Rawlings NB. Ricard M. Davidson RJ. Long-term meditators self-induce high-amplitude gamma synchrony during mental practice. Proceedings of the National Academy of Sciences of the United States of America. 101(46):16369-73, 2004 Nov 16 Davidson RJ. Kabat-Zinn J. Schumacher J. Rosenkranz M. Muller D. Santorelli SF. Urbanowski F. Harrington A. Bonus K. Sheridan JF. Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine. 65(4):564-70, 2003 Jul-Aug. Kim DH. Moon YS. Kim HS. Jung JS. Park HM. Suh HW. Kim YH. Song DK. Effect of Zen Meditation on serum nitric oxide activity and lipid peroxidation. Progress in Neuro-Psychopharmacology & Biological Psychiatry. 29(2):327-31, 2005 Feb. Walton KG. Fields JZ. Levitsky DK. Harris DA. Pugh ND. Schneider RH. Lowering cortisol and CVD risk in postmenopausal women: a pilot study using the Transcendental Meditation program. Annals of the New York Academy of Sciences. 1032:211-5, 2004 Dec. Curiati JA. Bocchi E. Freire JO. Arantes AC. Braga M. Garcia Y. Guimaraes G. Fo WJ. Meditation reduces sympathetic activation and improves the quality of life in elderly patients with optimally treated heart failure: a prospective randomized study. Journal of Alternative & Complementary Medicine. 11(3):465-72, 2005 Jun.

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