Meditation

1
Meditation

• Anjali Dhurandhar, MD

2
Overview

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

3
Background

• 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
  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

4
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

5
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

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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
  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)

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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,
  1974)

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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
  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

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• 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

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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
  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/Alternati
  ve Medicine in Cancer, 1998, Cancer (31.4 use
  avg, range 7-64)

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Benefits of meditation

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

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• 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

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• 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

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Meditation and the Brain
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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

16
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

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• 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

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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.

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• 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

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• 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

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Reduction in anxiety
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Asymmetric activation
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Effects on titers Greater antibody response in
meditation group
25
Those with greater increase in left sided
activation over time, had greater antibody
response to influenza vaccine
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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

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Meditation and the body
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• 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.

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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.

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Transcendental meditation
Different types of meditation
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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

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• 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

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• 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

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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

35
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.

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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.

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• 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

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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.

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• 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

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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.

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• 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

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• 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
  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.

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Mindfulness meditation
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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

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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

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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

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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

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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.

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• 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

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• 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

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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

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• 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

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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
  control
• Intervention 7 weekly 1.5 hour sessions, daily
  home practice

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• 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
57
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

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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.

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Results
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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
  yoga

Tacon AM. Family Community Health, 2003
Jan-Mar.
62
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

63
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

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• 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

65
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.

66
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

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• 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

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• 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

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

70
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.

71
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.

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• 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

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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

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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

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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

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• 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

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• 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

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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

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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

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• 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

81
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

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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

83
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

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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)

85

• 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

86
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

87

• 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

88
(No Transcript)
89

• 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

90

• 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.
91
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
92
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

93
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.

94
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)

95
The End
96
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