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Mr. A, age 45, reports irritability, loss of interest, sleep disturbance, increased self-criticism, and decreased self care during the last month after a promotion at work. He has a history of 3 major depressive episodes, 1 of which required hospitalization. For the last 2 years his depressive symptoms had been successfully managed with escitalopram, 10 mg/d, plus bupropion, 150 mg/d. Mr. A wants to discontinue these medications because of sexual dysfunction. He asks if nonpharmacologic strategies might help.
One option to consider for Mr. A is mindfulness-based cognitive therapy (MBCT), which was originally developed to help prevent depressive relapse. MBCT also can reduce depression and anxiety symptoms. More recently, MBCT was shown to help individuals discontinue antidepressants after recovering from depression.
Regular mindfulness meditation has been shown to result in structural brain changes that may help explain how the practice effectively addresses psychiatric symptoms ( Box ). With appropriate training, psychiatrists can help patients reap the benefits of this cognitive treatment.
Regular mindfulness practice has been shown to increase cortical thickness in areas associated with attention, interoception, and sensory processing, such as the prefrontal cortex and right anterior insula.a This supports the hypothesis that mindfulness is a way of attuning the mind to one’s internal processes, and that this involves the same social neural circuits involved in interpersonal attunement—middle prefrontal regions, insula, superior temporal cortex, and the mirror neuron system.b
Amygdala responses. Mindfulness improves affect regulation by optimizing prefrontal cortex regulation of the amygdala. Recent developments in understanding the pathophysiology of depression have highlighted the lack of engagement of left lateral-ventromedial prefrontal circuitry important for the down-regulation of amygdala responses to negative stimuli.c Dispositional mindfulness is associated with greater prefrontal cortical activation and associated greater reduction in amygdala activity during affect labeling tasks, which results in enhanced affect regulation in individuals with higher levels of mindfulness.d
Left-sided anterior activation. Other researchers have examined mindfulness’ role in maintaining balanced prefrontal asymmetry. Relative left prefrontal activation is related to an affective style characterized by stronger tendencies toward positive emotional responses and approach/reward oriented behavior, whereas relative right-sided activation is associated with stronger tendencies toward negative emotional responses and avoidant/withdrawal oriented behavior.
One study found significant increases in left-sided anterior activation in mindfulness-based stress reduction participants compared with controls.e Similarly, in a study evaluating the effect of mindfulness-based cognitive therapy (MBCT) on frontal asymmetry in previously suicidal individuals, MBCT participants retained a balanced pattern of prefrontal activation, whereas the treatment-as-usual group showed significant deterioration toward decreased relative left frontal activation. These findings suggest a protective effect of the mindfulness intervention.f
Source: For references to studies described here see this article at CurrentPsychiatry.com
What is mindfulness meditation?
Meditation refers to a variety of practices that intentionally focus attention to help the practitioner disengage from unconscious absorption in thoughts and feelings. Unlike concentrative meditation—in which practitioners focus attention on a single object such as a word (mantra), body part, or external object—in mindfulness meditation participants bring their attention to a wide range of objects (such as breath, body, emotions, or thoughts) as they appear in moment-by-moment awareness.
Mindfulness is a nonjudgmental, present-centered awareness in which each thought, feeling, or sensation that arises in the attentional field is acknowledged and accepted as it is.1-3 Bishop et al4 defined a 2-component model of mindfulness:
- self-regulating attention of immediate experience, thereby allowing for increased recognition of mental events in the present moment
- adopting an orientation of curiosity, openness, and acceptance toward one’s experiences in each moment.
Mindfulness-based interventions
Buddhist and Western psychology inform the theoretical framework of most mindfulness-based clinical interventions, such as:
- acceptance and commitment therapy (ACT)
- dialectical behavioral therapy (DBT)
- mindfulness-based stress reduction (MBSR)
- MBCT.
Because mindfulness is only 1 of several components of ACT and DBT,5 this review focuses on MBCT and MBSR, in which teaching mindfulness skills is the central focus of treatment.
MBCT and MBSR. MBCT incorporates many aspects of the manualized MBSR treatment program developed for managing chronic pain.6,7 MBSR is devoted almost entirely to cultivating mindfulness through:
- formal mindfulness meditation practices such as body scan (intentionally bringing awareness to bodily sensations), mindful stretching, and mindfulness of breath/body/sounds/thoughts
- informal practices, including mindfulness of daily activities such as eating.1
MBSR typically involves 8 to 10 weekly group sessions of 2 to 2.5 hours with 10 to 40 participants with heterogeneous or homogenous clinical presentations. At each session, patients are taught mindfulness skills and practices. Typically, a full day of meditation practice on a weekend follows session 5 or 6. Participants also engage in a daily meditation practice and homework exercises directed at integrating awareness skills into daily life.
Meta-analytic and narrative reviews generally support MBSR’s efficacy for a wide range of clinical presentations, including improved quality of life for chronic pain and cancer patients.5,8-11 Variability in the methodologic rigor of clinical trials of mindfulness-based interventions—such as lack of active control groups and small sample sizes—limits the strength of these studies’ conclusions, however.8
MBCT integrates the mindfulness training of MBSR with cognitive therapy techniques ( Table 1 ) to prevent the consolidation of ruminative, negative thinking patterns that contribute to depressive relapse.2 These cognitive therapy techniques include:
- psychoeducation about depression symptoms and automatic thoughts
- exercises designed to demonstrate the cognitive model
- identifying activities that provide feelings of mastery and/or pleasure
- creating a specific relapse prevention plan.
In addition, MBCT introduces a new informal meditation—the 3-minute breathing space—to facilitate present-moment awareness in upsetting everyday situations.
Evidence supporting MBCT comes from randomized, controlled trials (RCTs) and uncontrolled trials ( Table 2 ).12-18 A systematic review of RCTs supported using MBCT in addition to usual care to prevent depressive relapse in individuals with a history of ≥3 depressive episodes.19 Since that review was published, a large RCT (123 patients) comparing antidepressant medication alone to antidepressants plus adjunctive MBCT with support to taper/discontinue antidepressant therapy found:
- MBCT comparable to maintenance antidepressant medication in preventing depressive relapse for individuals with ≥3 depressive episodes
- no difference in cost between these 2 treatments.12
In this study, MBCT was more effective than maintenance pharmacotherapy in reducing residual depressive symptoms and in improving quality of life; 75% in the MBCT group discontinued antidepressants. MBCT is included in the United Kingdom’s National Institute for Clinical Excellence Clinical Practice Guidelines for Depression20 for prevention of recurrent depression.
RCTs and uncontrolled studies have shown that MBCT reduces depressive and anxious symptoms in individuals suffering from mood disorders. In an open-label pilot study of MBCT’s efficacy in reducing depressive symptoms in patients with treatment-resistant depression and ≥3 depressive episodes, 61% of patients achieved a post-MBCT Beck Depression Inventory-II (BDI-II) score <14, which represents normal or near-normal mood (mean BDI-II scores decreased from 24.3 to 13.9; effect size 1.04).17
Mindfulness for other psychiatric conditions. A review by Toneatto and Nguyen21 of MBSR in the treatment of anxiety and depression symptoms in a range of clinical populations concluded that the evidence supporting a beneficial effect was equivocal. On the other hand, several uncontrolled studies and 1 RCT indicate that mindfulness-based treatments can reduce symptoms in other psychiatric conditions, including eating disorders,22 generalized anxiety disorder,23 bipolar disorder,24 and attention-deficit/hyperactivity disorder.25 Many of these studies were developed to target mood and anxiety symptoms by linking mindfulness and symptom management; this differs from MBSR, which focuses on stress reduction. Methodologically rigorous studies are necessary to evaluate mindfulness-based treatments in these and other psychiatric conditions.
Table 1
Skills and practices taught in mindfulness training
| MBCT session themes | Mindfulness skill | Associated practices |
|---|---|---|
| ‘Automatic pilot’ (acting without conscious awareness) | Awareness of automatic pilot Awareness of body | Mindful eating Body scan (intentionally bringing awareness to bodily sensations) |
| Dealing with barriers | Awareness of how the chatter of the mind influences feelings and behaviors | Body scan Short breathing meditation |
| Mindfulness of the breath | Awareness of breath and body | Breathing meditation 3-minute breathing space Mindful yoga |
| Staying present | Awareness of attachment and aversion | Breathing meditation Working with intense physical sensations |
| Acceptance | Acceptance of thoughts and emotions as fleeting events | Explicit instructions to practice acceptance are included in the breathing meditation and the 3-minute breathing space |
| Thoughts are not facts | Decentering or re-perceiving | Sitting meditation (awareness of thoughts) |
| How can I best take care of myself? | Awareness of signs of relapse; develop more flexible, deliberate responses at time of potential relapse | 3-minute coping breathing space |
| Dealing with future depression | Awareness of intention | Identifying coping strategies to address barriers to maintaining practice |
| MBCT: mindfulness-based cognitive therapy | ||
| Source: Reference 2 | ||
Table 2
Evidence of reduced depressive symptoms, anxiety with MBCT
| Study | Patients | Findings |
|---|---|---|
| Randomized controlled trials | ||
| Kuyken et al, 200812 | 123 patients with recurrent depression treated with antidepressants received maintenance antidepressants alone or adjunctive MBCT with support to taper/discontinue antidepressant therapy | Adjunctive MBCT was as effective as maintenance antidepressants in reducing relapse/recurrence rates but more effective in reducing residual depressive symptoms and improving quality of life; 75% in the MBCT group discontinued antidepressants |
| Kingston et al, 200713 | 19 outpatients with residual depressive symptoms following a depressive episode assigned to MBCT or treatment as usual | MBCT significantly reduced depressive symptoms, and these improvements were maintained over a 1-month follow-up period |
| Williams et al, 200814 | 14 patients with bipolar disorder who had no manic episodes in the last 6 months and ≤1 week of depressive symptoms in the last 8 weeks | MBCT resulted in a significant reduction in anxiety scores on the BAI compared with wait-list controls |
| Uncontrolled trials | ||
| Eisendrath et al, 200815 | 15 patients with treatment-resistant depression (failure to remit with ≥2 antidepressant trials) | MBCT significantly reduced anxiety and depression; increased mindfulness and decreased rumination and anxiety were associated with decreased depression |
| Finucane and Mercer, 200616 | 13 patients with recurrent depression or recurrent depression and anxiety | MBCT significantly reduced depression and anxiety scores on BDI-II and BAI |
| Kenny and Williams, 200717 | 46 depressed patients who had not fully responded to standard treatments | MBCT significantly reduced depression scores |
| Ree and Craigie, 200718 | 26 outpatients with mood and/or anxiety disorders | MBCT significantly improved symptoms of depression, anxiety, stress, and insomnia; improvements in insomnia were maintained at 3-month follow-up |
| BAI: Beck Anxiety Inventory; BDI-II: Beck Depression Inventory; MBCT: mindfulness-based cognitive therapy | ||
CASE CONTINUED: Explaining the potential benefits
You inform Mr. A that MBCT has been shown to improve acute mild-to-moderate depressive symptoms, may decrease his risk of depressive relapse by 50%26 and could help him discontinue his medications.12 He asks how mindfulness exercises will help his symptoms.
How mindfulness works
The assumption that increased mindfulness mediates treatment outcomes4 has been addressed systematically only recently, following the development of operational definitions of mindfulness and self-report mindfulness measures, including the:
- Mindful Attention Awareness Scale (MAAS)27
- Five Facet Mindfulness Questionnaire (FFMQ)12
- Toronto Mindfulness Scale (TMS).28
Uncontrolled studies using these measures demonstrated that self-reported mindfulness increased following MBSR28,29 and MBCT15,18 in individuals with general stress, anxiety disorder or primary depression, cancer, chronic pain disorder, diabetes, and multiple sclerosis. Accumulating evidence from 1 RCT30 and 2 other uncontrolled studies28,31 demonstrates that mindfulness is associated with symptom reduction following MBSR.
Researchers have begun to focus on how mindfulness skills reduce symptoms. Baer9 proposed several mechanisms, including:
- cognitive change
- improved self-management
- exposure to painful experiences leading to reduced emotional reactivity.
Cognitive change—also called meta-cognitive awareness—is the development of a “distanced “or “decentered” perspective in which patients experience their thoughts and feelings as “mental events” rather than as true, accurate versions of reality. This is thought to introduce a “space” between perception and response that enables patients to have a reflective—rather than a reflexive or reactive—response to situations, which in turn reduces vulnerability to psychological processes that contribute to emotional suffering. Some preliminary evidence suggests that MBCT-associated increases in metacognitive awareness reduce risk of depressive relapse.32
Teaching mindfulness
Guidelines for psychiatrists who wish to become MBCT instructors suggest undergoing formal teacher development training, attending a 7- to 10-day meditation retreat, and establishing your own daily mindfulness practice ( Table 3 ).33 Segal et al2 also recommend recognized training in counseling, psychotherapy, or as a mental health professional, as well as training in cognitive therapy and having experience leading psychotherapy groups.
The recommendation that a mindfulness teacher should practice meditation derives from the view that instructors teach from their own meditation experience and embody the attitudes they invite participants to practice. In an RCT, patients of psychotherapists in training (PiTs) who practiced meditation had greater symptom reductions than those of PiTs who did not engage in meditation.34
To cultivate your own mindfulness practice, consider enrolling in an MBSR group, participating in an MBCT training retreat (see Related Resources ), or attending a mindfulness meditation retreat.
Although patient access to MBCT and MBSR programs has been increasing, formal MBSR/MBCT group programs led by trained therapists are limited. Patients can go through an MBSR/MBCT book with a trained clinician or listen to audio recordings with guided meditation instructions. Alternately, they can join a meditation sitting group or an insight meditation correspondence course ( Table 4 ).
Table 3
Recommended process for becoming an MBCT instructor
| Complete a 5-day residential MBCT training program |
| Attend a 7- to 10-day residential mindfulness meditation retreat |
| Establish your own daily mindfulness meditation practice |
| Undergo professional training in cognitive therapy |
| Gain experience leading psychotherapy groups |
| MBCT: mindfulness-based cognitive therapy |
| Source: References 2,33 |
Table 4
Useful mindfulness resources for interested patients
| Insight Meditation Society: www.dharma.org |
| Kabat-Zinn J. MBSR meditation CDs/tapes: www.stressreductiontapes.com |
| Recordings of meditation (dharma) talks: www.dharmaseed.org |
| Salzberg S, Goldstein J. Insight meditation: an in-depth correspondence course. Louisville, CO: Sounds True, Inc; 2004 |
| Williams M, Teasdale J, Segal Z, et al. The mindful way through depression: freeing yourself from chronic unhappiness. New York, NY: Guilford Press; 2007 |
CASE CONTINUED: Daily mindfulness practice
Mr. A enrolls in and completes a group MBCT program. He rearranges his schedule to include 30 minutes of formal mindfulness practice daily. During an office visit after completing the MBCT course, he describes decreased irritability and self-criticism, newfound self-acceptance, an increased ability to tolerate previously distressing affect, and the ability to set realistic expectations of himself, particularly in light of increased responsibilities at work. He also reports an increased sense of engagement in and reward in his personal life.
Several months later he requests and successfully completes an antidepressant taper and has no recurrence of depressive episodes at 18-month follow-up. He participates in monthly meditation groups to support his home practice.
- Germer CK, Siegel R, Fulton PR, eds. Mindfulness and psychotherapy. New York, NY: Guilford Press; 2005.
- Mindfulness-based cognitive therapy. www.mbct.com; www.mbct.co.uk; www.bangor.ac.uk/mindfulness.
- Center for Mindfulness in Medicine, Health Care, and Society. www.umassmed.edu/cfm.
- Neurobiology of mindfulness. www.mindfulness-matters.org.
- Siegel DJ. The mindful brain: reflection and attunement in the cultivation of well-being. New York, NY: Norton; 2007.
- University of California, San Diego Center for Mindfulness. http://cme.ucsd.edu/mindfulness.
Drug brand names
- Bupropion • Wellbutrin
- Escitalopram • Lexapro
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgment
The authors would like to thank Amanda Yu for her assistance in preparing the manuscript.
1. Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain and illness. New York, NY: Dell Publishing; 1990.
2. Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression: a new approach for preventing relapse. New York, NY: Guilford Press; 2002.
3. Shapiro SL, Schwartz GE. Intentional systemic mindfulness: an integrative model for self-regulation and health. Adv Mind Body Med. 2000;15:128-134.
4. Bishop SR, Lau MA, Shapiro S, et al. Mindfulness: a proposed operational definition. Clin Psychol Sci Pr. 2004;11:230-241.
5. Brown KW, Ryan RM, Creswell JD. Mindfulness: theoretical foundations and evidence for its salutary effects. Psychol Inq. 2007;18(4):211-237.
6. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiat. 1982;4(1):33-47.
7. Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985;8(2):163-190.
8. Bishop SR. What do we really know about mindfulness-based stress reduction? Am Psychosom Soc. 2002;64:71-83.
9. Baer RA. Mindfulness training as a clinical intervention: a conceptual and empirical review. Clin Psychol Sci Prac. 2003;10(2):125-143.
10. Grossman P, Nieman L, Schmidt S, et al. Mindfulness-based stress reduction and health benefits: a meta-analysis. J Psychosom Res. 2004;57(1):35-43.
11. Salmon P, Sephton S, Weissbecker I, et al. Mindfulness meditation in clinical practice. Cog Behav Ther. 2004;11(4):434-446.
12. Kuyken W, Byford S, Taylor RS, et al. Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. J Consult Clin Psych. 2008;76(6):966-978.
13. Kingston T, Dooley B, Bates A, et al. Mindfulness-based cognitive therapy for residual depressive symptoms. Psychol Psychother. 2007;80:193-203.
14. Williams J, Alatiq Y, Crance C, et al. Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: preliminary evaluation of immediate effects on between-episode functioning. J Affect Disord. 2008;107(2):275-279.
15. Eisendrath SJ, Delucchi K, Bitner R, et al. Mindfulness-based cognitive therapy for treatment resistant depression: a pilot study. Psychother Psychosom. 2008;77(5):319-320.
16. Finucane A, Mercer SW. An exploratory mixed methods study of the acceptability and effectiveness of mindfulness-based cognitive therapy for patients with active depression and anxiety in primary care. BMC Psychiatry. 2006;6:14.-
17. Kenny MA, Williams JGM. Treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. Behav Res Ther. 2007;45(3):617-625.
18. Ree MJ, Craigie MA. Outcomes following mindfulness-based cognitive therapy in a heterogeneous sample of adult outpatients. Behav Cog Psychother. 2007;24(2):70-86.
19. Coelho HF, Canter PH, Ernst E. Mindfulness-based cognitive therapy: evaluating current evidence and informing future research. J Consult Clin Psych. 2007;75(6):1000-1005.
20. National Institute for Clinical Excellence. Depression: management of depression in primary and secondary care. Clinical guideline 23. 2004. Available at: http://www.nice.org.uk/CG023NICEguideline. Accessed September 30, 2009.
21. Toneatto T, Nguyen L. Does mindfulness meditation improve anxiety and mood symptoms? A review of the controlled research. Can J Psychiatry. 2007;52(4):260-266.
22. Kristeller JL, Hallett B. An exploratory study of a meditation-based intervention for binge eating disorder. J Health Psychol. 1999;4(3):357-363.
23. Evans S, Ferrando S, Findler M, et al. Mindfulness-based cognitive therapy for generalized anxiety disorder. J Anxiety Disord. 2008;22(4):716-721.
24. Williams J, Alatiq Y, Crane C, et al. Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: preliminary evaluation of immediate effects on between-episode functioning. J Affect Disord. 2008;107(2):275-279.
25. Zylowska L, Ackerman DL, Yang MH, et al. Mindfulness meditation training in adults and adolescents with ADHD: a feasibility study. J Atten Disord. 2008;11(6):737-746.
26. Ma SH, Teasdale JD. Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin Psychol. 2004;72:31-40.
27. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003;84:822-848.
28. Lau MA, Bishop SR, Segal ZV, et al. The Toronto Mindfulness Scale: development and validation. J Clin Psychol. 2006;62:1445-1467.
29. Carmody J, Reed G, Kristeller J, et al. Mindfulness, spirituality, and health-related symptoms. J Psychosom Res. 2008;64(4):393-403.
30. Shapiro SL, Oman D, Thoresen CE, et al. Cultivating mindfulness: effects on well-being. J Clin Psychol. 2008;64(7):840-862.
31. Carmody J, Baer RA. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. J Behav Med. 2008;31(1):23-33.
32. Teasdale JD, Moore RG, Hayhurst H, et al. Metacognitive awareness and prevention of relapse in depression: empirical evidence. J Consult Clin Psych. 2002;70:275-287.
33. Lau MA, Segal ZV. Mindfulness based cognitive therapy as a relapse prevention approach to depression. In: Witkiewitz K, Marlatt A, eds. Evidence-based relapse prevention. Oxford, UK: Elsevier Press; 2007:73–90.
34. Grepmair L, Mitterlehner F, Loew T, et al. Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: a randomized, double-blind, controlled study. Psychother Psychosom. 2007;76:332-338.
Mr. A, age 45, reports irritability, loss of interest, sleep disturbance, increased self-criticism, and decreased self care during the last month after a promotion at work. He has a history of 3 major depressive episodes, 1 of which required hospitalization. For the last 2 years his depressive symptoms had been successfully managed with escitalopram, 10 mg/d, plus bupropion, 150 mg/d. Mr. A wants to discontinue these medications because of sexual dysfunction. He asks if nonpharmacologic strategies might help.
One option to consider for Mr. A is mindfulness-based cognitive therapy (MBCT), which was originally developed to help prevent depressive relapse. MBCT also can reduce depression and anxiety symptoms. More recently, MBCT was shown to help individuals discontinue antidepressants after recovering from depression.
Regular mindfulness meditation has been shown to result in structural brain changes that may help explain how the practice effectively addresses psychiatric symptoms ( Box ). With appropriate training, psychiatrists can help patients reap the benefits of this cognitive treatment.
Regular mindfulness practice has been shown to increase cortical thickness in areas associated with attention, interoception, and sensory processing, such as the prefrontal cortex and right anterior insula.a This supports the hypothesis that mindfulness is a way of attuning the mind to one’s internal processes, and that this involves the same social neural circuits involved in interpersonal attunement—middle prefrontal regions, insula, superior temporal cortex, and the mirror neuron system.b
Amygdala responses. Mindfulness improves affect regulation by optimizing prefrontal cortex regulation of the amygdala. Recent developments in understanding the pathophysiology of depression have highlighted the lack of engagement of left lateral-ventromedial prefrontal circuitry important for the down-regulation of amygdala responses to negative stimuli.c Dispositional mindfulness is associated with greater prefrontal cortical activation and associated greater reduction in amygdala activity during affect labeling tasks, which results in enhanced affect regulation in individuals with higher levels of mindfulness.d
Left-sided anterior activation. Other researchers have examined mindfulness’ role in maintaining balanced prefrontal asymmetry. Relative left prefrontal activation is related to an affective style characterized by stronger tendencies toward positive emotional responses and approach/reward oriented behavior, whereas relative right-sided activation is associated with stronger tendencies toward negative emotional responses and avoidant/withdrawal oriented behavior.
One study found significant increases in left-sided anterior activation in mindfulness-based stress reduction participants compared with controls.e Similarly, in a study evaluating the effect of mindfulness-based cognitive therapy (MBCT) on frontal asymmetry in previously suicidal individuals, MBCT participants retained a balanced pattern of prefrontal activation, whereas the treatment-as-usual group showed significant deterioration toward decreased relative left frontal activation. These findings suggest a protective effect of the mindfulness intervention.f
Source: For references to studies described here see this article at CurrentPsychiatry.com
What is mindfulness meditation?
Meditation refers to a variety of practices that intentionally focus attention to help the practitioner disengage from unconscious absorption in thoughts and feelings. Unlike concentrative meditation—in which practitioners focus attention on a single object such as a word (mantra), body part, or external object—in mindfulness meditation participants bring their attention to a wide range of objects (such as breath, body, emotions, or thoughts) as they appear in moment-by-moment awareness.
Mindfulness is a nonjudgmental, present-centered awareness in which each thought, feeling, or sensation that arises in the attentional field is acknowledged and accepted as it is.1-3 Bishop et al4 defined a 2-component model of mindfulness:
- self-regulating attention of immediate experience, thereby allowing for increased recognition of mental events in the present moment
- adopting an orientation of curiosity, openness, and acceptance toward one’s experiences in each moment.
Mindfulness-based interventions
Buddhist and Western psychology inform the theoretical framework of most mindfulness-based clinical interventions, such as:
- acceptance and commitment therapy (ACT)
- dialectical behavioral therapy (DBT)
- mindfulness-based stress reduction (MBSR)
- MBCT.
Because mindfulness is only 1 of several components of ACT and DBT,5 this review focuses on MBCT and MBSR, in which teaching mindfulness skills is the central focus of treatment.
MBCT and MBSR. MBCT incorporates many aspects of the manualized MBSR treatment program developed for managing chronic pain.6,7 MBSR is devoted almost entirely to cultivating mindfulness through:
- formal mindfulness meditation practices such as body scan (intentionally bringing awareness to bodily sensations), mindful stretching, and mindfulness of breath/body/sounds/thoughts
- informal practices, including mindfulness of daily activities such as eating.1
MBSR typically involves 8 to 10 weekly group sessions of 2 to 2.5 hours with 10 to 40 participants with heterogeneous or homogenous clinical presentations. At each session, patients are taught mindfulness skills and practices. Typically, a full day of meditation practice on a weekend follows session 5 or 6. Participants also engage in a daily meditation practice and homework exercises directed at integrating awareness skills into daily life.
Meta-analytic and narrative reviews generally support MBSR’s efficacy for a wide range of clinical presentations, including improved quality of life for chronic pain and cancer patients.5,8-11 Variability in the methodologic rigor of clinical trials of mindfulness-based interventions—such as lack of active control groups and small sample sizes—limits the strength of these studies’ conclusions, however.8
MBCT integrates the mindfulness training of MBSR with cognitive therapy techniques ( Table 1 ) to prevent the consolidation of ruminative, negative thinking patterns that contribute to depressive relapse.2 These cognitive therapy techniques include:
- psychoeducation about depression symptoms and automatic thoughts
- exercises designed to demonstrate the cognitive model
- identifying activities that provide feelings of mastery and/or pleasure
- creating a specific relapse prevention plan.
In addition, MBCT introduces a new informal meditation—the 3-minute breathing space—to facilitate present-moment awareness in upsetting everyday situations.
Evidence supporting MBCT comes from randomized, controlled trials (RCTs) and uncontrolled trials ( Table 2 ).12-18 A systematic review of RCTs supported using MBCT in addition to usual care to prevent depressive relapse in individuals with a history of ≥3 depressive episodes.19 Since that review was published, a large RCT (123 patients) comparing antidepressant medication alone to antidepressants plus adjunctive MBCT with support to taper/discontinue antidepressant therapy found:
- MBCT comparable to maintenance antidepressant medication in preventing depressive relapse for individuals with ≥3 depressive episodes
- no difference in cost between these 2 treatments.12
In this study, MBCT was more effective than maintenance pharmacotherapy in reducing residual depressive symptoms and in improving quality of life; 75% in the MBCT group discontinued antidepressants. MBCT is included in the United Kingdom’s National Institute for Clinical Excellence Clinical Practice Guidelines for Depression20 for prevention of recurrent depression.
RCTs and uncontrolled studies have shown that MBCT reduces depressive and anxious symptoms in individuals suffering from mood disorders. In an open-label pilot study of MBCT’s efficacy in reducing depressive symptoms in patients with treatment-resistant depression and ≥3 depressive episodes, 61% of patients achieved a post-MBCT Beck Depression Inventory-II (BDI-II) score <14, which represents normal or near-normal mood (mean BDI-II scores decreased from 24.3 to 13.9; effect size 1.04).17
Mindfulness for other psychiatric conditions. A review by Toneatto and Nguyen21 of MBSR in the treatment of anxiety and depression symptoms in a range of clinical populations concluded that the evidence supporting a beneficial effect was equivocal. On the other hand, several uncontrolled studies and 1 RCT indicate that mindfulness-based treatments can reduce symptoms in other psychiatric conditions, including eating disorders,22 generalized anxiety disorder,23 bipolar disorder,24 and attention-deficit/hyperactivity disorder.25 Many of these studies were developed to target mood and anxiety symptoms by linking mindfulness and symptom management; this differs from MBSR, which focuses on stress reduction. Methodologically rigorous studies are necessary to evaluate mindfulness-based treatments in these and other psychiatric conditions.
Table 1
Skills and practices taught in mindfulness training
| MBCT session themes | Mindfulness skill | Associated practices |
|---|---|---|
| ‘Automatic pilot’ (acting without conscious awareness) | Awareness of automatic pilot Awareness of body | Mindful eating Body scan (intentionally bringing awareness to bodily sensations) |
| Dealing with barriers | Awareness of how the chatter of the mind influences feelings and behaviors | Body scan Short breathing meditation |
| Mindfulness of the breath | Awareness of breath and body | Breathing meditation 3-minute breathing space Mindful yoga |
| Staying present | Awareness of attachment and aversion | Breathing meditation Working with intense physical sensations |
| Acceptance | Acceptance of thoughts and emotions as fleeting events | Explicit instructions to practice acceptance are included in the breathing meditation and the 3-minute breathing space |
| Thoughts are not facts | Decentering or re-perceiving | Sitting meditation (awareness of thoughts) |
| How can I best take care of myself? | Awareness of signs of relapse; develop more flexible, deliberate responses at time of potential relapse | 3-minute coping breathing space |
| Dealing with future depression | Awareness of intention | Identifying coping strategies to address barriers to maintaining practice |
| MBCT: mindfulness-based cognitive therapy | ||
| Source: Reference 2 | ||
Table 2
Evidence of reduced depressive symptoms, anxiety with MBCT
| Study | Patients | Findings |
|---|---|---|
| Randomized controlled trials | ||
| Kuyken et al, 200812 | 123 patients with recurrent depression treated with antidepressants received maintenance antidepressants alone or adjunctive MBCT with support to taper/discontinue antidepressant therapy | Adjunctive MBCT was as effective as maintenance antidepressants in reducing relapse/recurrence rates but more effective in reducing residual depressive symptoms and improving quality of life; 75% in the MBCT group discontinued antidepressants |
| Kingston et al, 200713 | 19 outpatients with residual depressive symptoms following a depressive episode assigned to MBCT or treatment as usual | MBCT significantly reduced depressive symptoms, and these improvements were maintained over a 1-month follow-up period |
| Williams et al, 200814 | 14 patients with bipolar disorder who had no manic episodes in the last 6 months and ≤1 week of depressive symptoms in the last 8 weeks | MBCT resulted in a significant reduction in anxiety scores on the BAI compared with wait-list controls |
| Uncontrolled trials | ||
| Eisendrath et al, 200815 | 15 patients with treatment-resistant depression (failure to remit with ≥2 antidepressant trials) | MBCT significantly reduced anxiety and depression; increased mindfulness and decreased rumination and anxiety were associated with decreased depression |
| Finucane and Mercer, 200616 | 13 patients with recurrent depression or recurrent depression and anxiety | MBCT significantly reduced depression and anxiety scores on BDI-II and BAI |
| Kenny and Williams, 200717 | 46 depressed patients who had not fully responded to standard treatments | MBCT significantly reduced depression scores |
| Ree and Craigie, 200718 | 26 outpatients with mood and/or anxiety disorders | MBCT significantly improved symptoms of depression, anxiety, stress, and insomnia; improvements in insomnia were maintained at 3-month follow-up |
| BAI: Beck Anxiety Inventory; BDI-II: Beck Depression Inventory; MBCT: mindfulness-based cognitive therapy | ||
CASE CONTINUED: Explaining the potential benefits
You inform Mr. A that MBCT has been shown to improve acute mild-to-moderate depressive symptoms, may decrease his risk of depressive relapse by 50%26 and could help him discontinue his medications.12 He asks how mindfulness exercises will help his symptoms.
How mindfulness works
The assumption that increased mindfulness mediates treatment outcomes4 has been addressed systematically only recently, following the development of operational definitions of mindfulness and self-report mindfulness measures, including the:
- Mindful Attention Awareness Scale (MAAS)27
- Five Facet Mindfulness Questionnaire (FFMQ)12
- Toronto Mindfulness Scale (TMS).28
Uncontrolled studies using these measures demonstrated that self-reported mindfulness increased following MBSR28,29 and MBCT15,18 in individuals with general stress, anxiety disorder or primary depression, cancer, chronic pain disorder, diabetes, and multiple sclerosis. Accumulating evidence from 1 RCT30 and 2 other uncontrolled studies28,31 demonstrates that mindfulness is associated with symptom reduction following MBSR.
Researchers have begun to focus on how mindfulness skills reduce symptoms. Baer9 proposed several mechanisms, including:
- cognitive change
- improved self-management
- exposure to painful experiences leading to reduced emotional reactivity.
Cognitive change—also called meta-cognitive awareness—is the development of a “distanced “or “decentered” perspective in which patients experience their thoughts and feelings as “mental events” rather than as true, accurate versions of reality. This is thought to introduce a “space” between perception and response that enables patients to have a reflective—rather than a reflexive or reactive—response to situations, which in turn reduces vulnerability to psychological processes that contribute to emotional suffering. Some preliminary evidence suggests that MBCT-associated increases in metacognitive awareness reduce risk of depressive relapse.32
Teaching mindfulness
Guidelines for psychiatrists who wish to become MBCT instructors suggest undergoing formal teacher development training, attending a 7- to 10-day meditation retreat, and establishing your own daily mindfulness practice ( Table 3 ).33 Segal et al2 also recommend recognized training in counseling, psychotherapy, or as a mental health professional, as well as training in cognitive therapy and having experience leading psychotherapy groups.
The recommendation that a mindfulness teacher should practice meditation derives from the view that instructors teach from their own meditation experience and embody the attitudes they invite participants to practice. In an RCT, patients of psychotherapists in training (PiTs) who practiced meditation had greater symptom reductions than those of PiTs who did not engage in meditation.34
To cultivate your own mindfulness practice, consider enrolling in an MBSR group, participating in an MBCT training retreat (see Related Resources ), or attending a mindfulness meditation retreat.
Although patient access to MBCT and MBSR programs has been increasing, formal MBSR/MBCT group programs led by trained therapists are limited. Patients can go through an MBSR/MBCT book with a trained clinician or listen to audio recordings with guided meditation instructions. Alternately, they can join a meditation sitting group or an insight meditation correspondence course ( Table 4 ).
Table 3
Recommended process for becoming an MBCT instructor
| Complete a 5-day residential MBCT training program |
| Attend a 7- to 10-day residential mindfulness meditation retreat |
| Establish your own daily mindfulness meditation practice |
| Undergo professional training in cognitive therapy |
| Gain experience leading psychotherapy groups |
| MBCT: mindfulness-based cognitive therapy |
| Source: References 2,33 |
Table 4
Useful mindfulness resources for interested patients
| Insight Meditation Society: www.dharma.org |
| Kabat-Zinn J. MBSR meditation CDs/tapes: www.stressreductiontapes.com |
| Recordings of meditation (dharma) talks: www.dharmaseed.org |
| Salzberg S, Goldstein J. Insight meditation: an in-depth correspondence course. Louisville, CO: Sounds True, Inc; 2004 |
| Williams M, Teasdale J, Segal Z, et al. The mindful way through depression: freeing yourself from chronic unhappiness. New York, NY: Guilford Press; 2007 |
CASE CONTINUED: Daily mindfulness practice
Mr. A enrolls in and completes a group MBCT program. He rearranges his schedule to include 30 minutes of formal mindfulness practice daily. During an office visit after completing the MBCT course, he describes decreased irritability and self-criticism, newfound self-acceptance, an increased ability to tolerate previously distressing affect, and the ability to set realistic expectations of himself, particularly in light of increased responsibilities at work. He also reports an increased sense of engagement in and reward in his personal life.
Several months later he requests and successfully completes an antidepressant taper and has no recurrence of depressive episodes at 18-month follow-up. He participates in monthly meditation groups to support his home practice.
- Germer CK, Siegel R, Fulton PR, eds. Mindfulness and psychotherapy. New York, NY: Guilford Press; 2005.
- Mindfulness-based cognitive therapy. www.mbct.com; www.mbct.co.uk; www.bangor.ac.uk/mindfulness.
- Center for Mindfulness in Medicine, Health Care, and Society. www.umassmed.edu/cfm.
- Neurobiology of mindfulness. www.mindfulness-matters.org.
- Siegel DJ. The mindful brain: reflection and attunement in the cultivation of well-being. New York, NY: Norton; 2007.
- University of California, San Diego Center for Mindfulness. http://cme.ucsd.edu/mindfulness.
Drug brand names
- Bupropion • Wellbutrin
- Escitalopram • Lexapro
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgment
The authors would like to thank Amanda Yu for her assistance in preparing the manuscript.
Mr. A, age 45, reports irritability, loss of interest, sleep disturbance, increased self-criticism, and decreased self care during the last month after a promotion at work. He has a history of 3 major depressive episodes, 1 of which required hospitalization. For the last 2 years his depressive symptoms had been successfully managed with escitalopram, 10 mg/d, plus bupropion, 150 mg/d. Mr. A wants to discontinue these medications because of sexual dysfunction. He asks if nonpharmacologic strategies might help.
One option to consider for Mr. A is mindfulness-based cognitive therapy (MBCT), which was originally developed to help prevent depressive relapse. MBCT also can reduce depression and anxiety symptoms. More recently, MBCT was shown to help individuals discontinue antidepressants after recovering from depression.
Regular mindfulness meditation has been shown to result in structural brain changes that may help explain how the practice effectively addresses psychiatric symptoms ( Box ). With appropriate training, psychiatrists can help patients reap the benefits of this cognitive treatment.
Regular mindfulness practice has been shown to increase cortical thickness in areas associated with attention, interoception, and sensory processing, such as the prefrontal cortex and right anterior insula.a This supports the hypothesis that mindfulness is a way of attuning the mind to one’s internal processes, and that this involves the same social neural circuits involved in interpersonal attunement—middle prefrontal regions, insula, superior temporal cortex, and the mirror neuron system.b
Amygdala responses. Mindfulness improves affect regulation by optimizing prefrontal cortex regulation of the amygdala. Recent developments in understanding the pathophysiology of depression have highlighted the lack of engagement of left lateral-ventromedial prefrontal circuitry important for the down-regulation of amygdala responses to negative stimuli.c Dispositional mindfulness is associated with greater prefrontal cortical activation and associated greater reduction in amygdala activity during affect labeling tasks, which results in enhanced affect regulation in individuals with higher levels of mindfulness.d
Left-sided anterior activation. Other researchers have examined mindfulness’ role in maintaining balanced prefrontal asymmetry. Relative left prefrontal activation is related to an affective style characterized by stronger tendencies toward positive emotional responses and approach/reward oriented behavior, whereas relative right-sided activation is associated with stronger tendencies toward negative emotional responses and avoidant/withdrawal oriented behavior.
One study found significant increases in left-sided anterior activation in mindfulness-based stress reduction participants compared with controls.e Similarly, in a study evaluating the effect of mindfulness-based cognitive therapy (MBCT) on frontal asymmetry in previously suicidal individuals, MBCT participants retained a balanced pattern of prefrontal activation, whereas the treatment-as-usual group showed significant deterioration toward decreased relative left frontal activation. These findings suggest a protective effect of the mindfulness intervention.f
Source: For references to studies described here see this article at CurrentPsychiatry.com
What is mindfulness meditation?
Meditation refers to a variety of practices that intentionally focus attention to help the practitioner disengage from unconscious absorption in thoughts and feelings. Unlike concentrative meditation—in which practitioners focus attention on a single object such as a word (mantra), body part, or external object—in mindfulness meditation participants bring their attention to a wide range of objects (such as breath, body, emotions, or thoughts) as they appear in moment-by-moment awareness.
Mindfulness is a nonjudgmental, present-centered awareness in which each thought, feeling, or sensation that arises in the attentional field is acknowledged and accepted as it is.1-3 Bishop et al4 defined a 2-component model of mindfulness:
- self-regulating attention of immediate experience, thereby allowing for increased recognition of mental events in the present moment
- adopting an orientation of curiosity, openness, and acceptance toward one’s experiences in each moment.
Mindfulness-based interventions
Buddhist and Western psychology inform the theoretical framework of most mindfulness-based clinical interventions, such as:
- acceptance and commitment therapy (ACT)
- dialectical behavioral therapy (DBT)
- mindfulness-based stress reduction (MBSR)
- MBCT.
Because mindfulness is only 1 of several components of ACT and DBT,5 this review focuses on MBCT and MBSR, in which teaching mindfulness skills is the central focus of treatment.
MBCT and MBSR. MBCT incorporates many aspects of the manualized MBSR treatment program developed for managing chronic pain.6,7 MBSR is devoted almost entirely to cultivating mindfulness through:
- formal mindfulness meditation practices such as body scan (intentionally bringing awareness to bodily sensations), mindful stretching, and mindfulness of breath/body/sounds/thoughts
- informal practices, including mindfulness of daily activities such as eating.1
MBSR typically involves 8 to 10 weekly group sessions of 2 to 2.5 hours with 10 to 40 participants with heterogeneous or homogenous clinical presentations. At each session, patients are taught mindfulness skills and practices. Typically, a full day of meditation practice on a weekend follows session 5 or 6. Participants also engage in a daily meditation practice and homework exercises directed at integrating awareness skills into daily life.
Meta-analytic and narrative reviews generally support MBSR’s efficacy for a wide range of clinical presentations, including improved quality of life for chronic pain and cancer patients.5,8-11 Variability in the methodologic rigor of clinical trials of mindfulness-based interventions—such as lack of active control groups and small sample sizes—limits the strength of these studies’ conclusions, however.8
MBCT integrates the mindfulness training of MBSR with cognitive therapy techniques ( Table 1 ) to prevent the consolidation of ruminative, negative thinking patterns that contribute to depressive relapse.2 These cognitive therapy techniques include:
- psychoeducation about depression symptoms and automatic thoughts
- exercises designed to demonstrate the cognitive model
- identifying activities that provide feelings of mastery and/or pleasure
- creating a specific relapse prevention plan.
In addition, MBCT introduces a new informal meditation—the 3-minute breathing space—to facilitate present-moment awareness in upsetting everyday situations.
Evidence supporting MBCT comes from randomized, controlled trials (RCTs) and uncontrolled trials ( Table 2 ).12-18 A systematic review of RCTs supported using MBCT in addition to usual care to prevent depressive relapse in individuals with a history of ≥3 depressive episodes.19 Since that review was published, a large RCT (123 patients) comparing antidepressant medication alone to antidepressants plus adjunctive MBCT with support to taper/discontinue antidepressant therapy found:
- MBCT comparable to maintenance antidepressant medication in preventing depressive relapse for individuals with ≥3 depressive episodes
- no difference in cost between these 2 treatments.12
In this study, MBCT was more effective than maintenance pharmacotherapy in reducing residual depressive symptoms and in improving quality of life; 75% in the MBCT group discontinued antidepressants. MBCT is included in the United Kingdom’s National Institute for Clinical Excellence Clinical Practice Guidelines for Depression20 for prevention of recurrent depression.
RCTs and uncontrolled studies have shown that MBCT reduces depressive and anxious symptoms in individuals suffering from mood disorders. In an open-label pilot study of MBCT’s efficacy in reducing depressive symptoms in patients with treatment-resistant depression and ≥3 depressive episodes, 61% of patients achieved a post-MBCT Beck Depression Inventory-II (BDI-II) score <14, which represents normal or near-normal mood (mean BDI-II scores decreased from 24.3 to 13.9; effect size 1.04).17
Mindfulness for other psychiatric conditions. A review by Toneatto and Nguyen21 of MBSR in the treatment of anxiety and depression symptoms in a range of clinical populations concluded that the evidence supporting a beneficial effect was equivocal. On the other hand, several uncontrolled studies and 1 RCT indicate that mindfulness-based treatments can reduce symptoms in other psychiatric conditions, including eating disorders,22 generalized anxiety disorder,23 bipolar disorder,24 and attention-deficit/hyperactivity disorder.25 Many of these studies were developed to target mood and anxiety symptoms by linking mindfulness and symptom management; this differs from MBSR, which focuses on stress reduction. Methodologically rigorous studies are necessary to evaluate mindfulness-based treatments in these and other psychiatric conditions.
Table 1
Skills and practices taught in mindfulness training
| MBCT session themes | Mindfulness skill | Associated practices |
|---|---|---|
| ‘Automatic pilot’ (acting without conscious awareness) | Awareness of automatic pilot Awareness of body | Mindful eating Body scan (intentionally bringing awareness to bodily sensations) |
| Dealing with barriers | Awareness of how the chatter of the mind influences feelings and behaviors | Body scan Short breathing meditation |
| Mindfulness of the breath | Awareness of breath and body | Breathing meditation 3-minute breathing space Mindful yoga |
| Staying present | Awareness of attachment and aversion | Breathing meditation Working with intense physical sensations |
| Acceptance | Acceptance of thoughts and emotions as fleeting events | Explicit instructions to practice acceptance are included in the breathing meditation and the 3-minute breathing space |
| Thoughts are not facts | Decentering or re-perceiving | Sitting meditation (awareness of thoughts) |
| How can I best take care of myself? | Awareness of signs of relapse; develop more flexible, deliberate responses at time of potential relapse | 3-minute coping breathing space |
| Dealing with future depression | Awareness of intention | Identifying coping strategies to address barriers to maintaining practice |
| MBCT: mindfulness-based cognitive therapy | ||
| Source: Reference 2 | ||
Table 2
Evidence of reduced depressive symptoms, anxiety with MBCT
| Study | Patients | Findings |
|---|---|---|
| Randomized controlled trials | ||
| Kuyken et al, 200812 | 123 patients with recurrent depression treated with antidepressants received maintenance antidepressants alone or adjunctive MBCT with support to taper/discontinue antidepressant therapy | Adjunctive MBCT was as effective as maintenance antidepressants in reducing relapse/recurrence rates but more effective in reducing residual depressive symptoms and improving quality of life; 75% in the MBCT group discontinued antidepressants |
| Kingston et al, 200713 | 19 outpatients with residual depressive symptoms following a depressive episode assigned to MBCT or treatment as usual | MBCT significantly reduced depressive symptoms, and these improvements were maintained over a 1-month follow-up period |
| Williams et al, 200814 | 14 patients with bipolar disorder who had no manic episodes in the last 6 months and ≤1 week of depressive symptoms in the last 8 weeks | MBCT resulted in a significant reduction in anxiety scores on the BAI compared with wait-list controls |
| Uncontrolled trials | ||
| Eisendrath et al, 200815 | 15 patients with treatment-resistant depression (failure to remit with ≥2 antidepressant trials) | MBCT significantly reduced anxiety and depression; increased mindfulness and decreased rumination and anxiety were associated with decreased depression |
| Finucane and Mercer, 200616 | 13 patients with recurrent depression or recurrent depression and anxiety | MBCT significantly reduced depression and anxiety scores on BDI-II and BAI |
| Kenny and Williams, 200717 | 46 depressed patients who had not fully responded to standard treatments | MBCT significantly reduced depression scores |
| Ree and Craigie, 200718 | 26 outpatients with mood and/or anxiety disorders | MBCT significantly improved symptoms of depression, anxiety, stress, and insomnia; improvements in insomnia were maintained at 3-month follow-up |
| BAI: Beck Anxiety Inventory; BDI-II: Beck Depression Inventory; MBCT: mindfulness-based cognitive therapy | ||
CASE CONTINUED: Explaining the potential benefits
You inform Mr. A that MBCT has been shown to improve acute mild-to-moderate depressive symptoms, may decrease his risk of depressive relapse by 50%26 and could help him discontinue his medications.12 He asks how mindfulness exercises will help his symptoms.
How mindfulness works
The assumption that increased mindfulness mediates treatment outcomes4 has been addressed systematically only recently, following the development of operational definitions of mindfulness and self-report mindfulness measures, including the:
- Mindful Attention Awareness Scale (MAAS)27
- Five Facet Mindfulness Questionnaire (FFMQ)12
- Toronto Mindfulness Scale (TMS).28
Uncontrolled studies using these measures demonstrated that self-reported mindfulness increased following MBSR28,29 and MBCT15,18 in individuals with general stress, anxiety disorder or primary depression, cancer, chronic pain disorder, diabetes, and multiple sclerosis. Accumulating evidence from 1 RCT30 and 2 other uncontrolled studies28,31 demonstrates that mindfulness is associated with symptom reduction following MBSR.
Researchers have begun to focus on how mindfulness skills reduce symptoms. Baer9 proposed several mechanisms, including:
- cognitive change
- improved self-management
- exposure to painful experiences leading to reduced emotional reactivity.
Cognitive change—also called meta-cognitive awareness—is the development of a “distanced “or “decentered” perspective in which patients experience their thoughts and feelings as “mental events” rather than as true, accurate versions of reality. This is thought to introduce a “space” between perception and response that enables patients to have a reflective—rather than a reflexive or reactive—response to situations, which in turn reduces vulnerability to psychological processes that contribute to emotional suffering. Some preliminary evidence suggests that MBCT-associated increases in metacognitive awareness reduce risk of depressive relapse.32
Teaching mindfulness
Guidelines for psychiatrists who wish to become MBCT instructors suggest undergoing formal teacher development training, attending a 7- to 10-day meditation retreat, and establishing your own daily mindfulness practice ( Table 3 ).33 Segal et al2 also recommend recognized training in counseling, psychotherapy, or as a mental health professional, as well as training in cognitive therapy and having experience leading psychotherapy groups.
The recommendation that a mindfulness teacher should practice meditation derives from the view that instructors teach from their own meditation experience and embody the attitudes they invite participants to practice. In an RCT, patients of psychotherapists in training (PiTs) who practiced meditation had greater symptom reductions than those of PiTs who did not engage in meditation.34
To cultivate your own mindfulness practice, consider enrolling in an MBSR group, participating in an MBCT training retreat (see Related Resources ), or attending a mindfulness meditation retreat.
Although patient access to MBCT and MBSR programs has been increasing, formal MBSR/MBCT group programs led by trained therapists are limited. Patients can go through an MBSR/MBCT book with a trained clinician or listen to audio recordings with guided meditation instructions. Alternately, they can join a meditation sitting group or an insight meditation correspondence course ( Table 4 ).
Table 3
Recommended process for becoming an MBCT instructor
| Complete a 5-day residential MBCT training program |
| Attend a 7- to 10-day residential mindfulness meditation retreat |
| Establish your own daily mindfulness meditation practice |
| Undergo professional training in cognitive therapy |
| Gain experience leading psychotherapy groups |
| MBCT: mindfulness-based cognitive therapy |
| Source: References 2,33 |
Table 4
Useful mindfulness resources for interested patients
| Insight Meditation Society: www.dharma.org |
| Kabat-Zinn J. MBSR meditation CDs/tapes: www.stressreductiontapes.com |
| Recordings of meditation (dharma) talks: www.dharmaseed.org |
| Salzberg S, Goldstein J. Insight meditation: an in-depth correspondence course. Louisville, CO: Sounds True, Inc; 2004 |
| Williams M, Teasdale J, Segal Z, et al. The mindful way through depression: freeing yourself from chronic unhappiness. New York, NY: Guilford Press; 2007 |
CASE CONTINUED: Daily mindfulness practice
Mr. A enrolls in and completes a group MBCT program. He rearranges his schedule to include 30 minutes of formal mindfulness practice daily. During an office visit after completing the MBCT course, he describes decreased irritability and self-criticism, newfound self-acceptance, an increased ability to tolerate previously distressing affect, and the ability to set realistic expectations of himself, particularly in light of increased responsibilities at work. He also reports an increased sense of engagement in and reward in his personal life.
Several months later he requests and successfully completes an antidepressant taper and has no recurrence of depressive episodes at 18-month follow-up. He participates in monthly meditation groups to support his home practice.
- Germer CK, Siegel R, Fulton PR, eds. Mindfulness and psychotherapy. New York, NY: Guilford Press; 2005.
- Mindfulness-based cognitive therapy. www.mbct.com; www.mbct.co.uk; www.bangor.ac.uk/mindfulness.
- Center for Mindfulness in Medicine, Health Care, and Society. www.umassmed.edu/cfm.
- Neurobiology of mindfulness. www.mindfulness-matters.org.
- Siegel DJ. The mindful brain: reflection and attunement in the cultivation of well-being. New York, NY: Norton; 2007.
- University of California, San Diego Center for Mindfulness. http://cme.ucsd.edu/mindfulness.
Drug brand names
- Bupropion • Wellbutrin
- Escitalopram • Lexapro
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgment
The authors would like to thank Amanda Yu for her assistance in preparing the manuscript.
1. Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain and illness. New York, NY: Dell Publishing; 1990.
2. Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression: a new approach for preventing relapse. New York, NY: Guilford Press; 2002.
3. Shapiro SL, Schwartz GE. Intentional systemic mindfulness: an integrative model for self-regulation and health. Adv Mind Body Med. 2000;15:128-134.
4. Bishop SR, Lau MA, Shapiro S, et al. Mindfulness: a proposed operational definition. Clin Psychol Sci Pr. 2004;11:230-241.
5. Brown KW, Ryan RM, Creswell JD. Mindfulness: theoretical foundations and evidence for its salutary effects. Psychol Inq. 2007;18(4):211-237.
6. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiat. 1982;4(1):33-47.
7. Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985;8(2):163-190.
8. Bishop SR. What do we really know about mindfulness-based stress reduction? Am Psychosom Soc. 2002;64:71-83.
9. Baer RA. Mindfulness training as a clinical intervention: a conceptual and empirical review. Clin Psychol Sci Prac. 2003;10(2):125-143.
10. Grossman P, Nieman L, Schmidt S, et al. Mindfulness-based stress reduction and health benefits: a meta-analysis. J Psychosom Res. 2004;57(1):35-43.
11. Salmon P, Sephton S, Weissbecker I, et al. Mindfulness meditation in clinical practice. Cog Behav Ther. 2004;11(4):434-446.
12. Kuyken W, Byford S, Taylor RS, et al. Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. J Consult Clin Psych. 2008;76(6):966-978.
13. Kingston T, Dooley B, Bates A, et al. Mindfulness-based cognitive therapy for residual depressive symptoms. Psychol Psychother. 2007;80:193-203.
14. Williams J, Alatiq Y, Crance C, et al. Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: preliminary evaluation of immediate effects on between-episode functioning. J Affect Disord. 2008;107(2):275-279.
15. Eisendrath SJ, Delucchi K, Bitner R, et al. Mindfulness-based cognitive therapy for treatment resistant depression: a pilot study. Psychother Psychosom. 2008;77(5):319-320.
16. Finucane A, Mercer SW. An exploratory mixed methods study of the acceptability and effectiveness of mindfulness-based cognitive therapy for patients with active depression and anxiety in primary care. BMC Psychiatry. 2006;6:14.-
17. Kenny MA, Williams JGM. Treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. Behav Res Ther. 2007;45(3):617-625.
18. Ree MJ, Craigie MA. Outcomes following mindfulness-based cognitive therapy in a heterogeneous sample of adult outpatients. Behav Cog Psychother. 2007;24(2):70-86.
19. Coelho HF, Canter PH, Ernst E. Mindfulness-based cognitive therapy: evaluating current evidence and informing future research. J Consult Clin Psych. 2007;75(6):1000-1005.
20. National Institute for Clinical Excellence. Depression: management of depression in primary and secondary care. Clinical guideline 23. 2004. Available at: http://www.nice.org.uk/CG023NICEguideline. Accessed September 30, 2009.
21. Toneatto T, Nguyen L. Does mindfulness meditation improve anxiety and mood symptoms? A review of the controlled research. Can J Psychiatry. 2007;52(4):260-266.
22. Kristeller JL, Hallett B. An exploratory study of a meditation-based intervention for binge eating disorder. J Health Psychol. 1999;4(3):357-363.
23. Evans S, Ferrando S, Findler M, et al. Mindfulness-based cognitive therapy for generalized anxiety disorder. J Anxiety Disord. 2008;22(4):716-721.
24. Williams J, Alatiq Y, Crane C, et al. Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: preliminary evaluation of immediate effects on between-episode functioning. J Affect Disord. 2008;107(2):275-279.
25. Zylowska L, Ackerman DL, Yang MH, et al. Mindfulness meditation training in adults and adolescents with ADHD: a feasibility study. J Atten Disord. 2008;11(6):737-746.
26. Ma SH, Teasdale JD. Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin Psychol. 2004;72:31-40.
27. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003;84:822-848.
28. Lau MA, Bishop SR, Segal ZV, et al. The Toronto Mindfulness Scale: development and validation. J Clin Psychol. 2006;62:1445-1467.
29. Carmody J, Reed G, Kristeller J, et al. Mindfulness, spirituality, and health-related symptoms. J Psychosom Res. 2008;64(4):393-403.
30. Shapiro SL, Oman D, Thoresen CE, et al. Cultivating mindfulness: effects on well-being. J Clin Psychol. 2008;64(7):840-862.
31. Carmody J, Baer RA. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. J Behav Med. 2008;31(1):23-33.
32. Teasdale JD, Moore RG, Hayhurst H, et al. Metacognitive awareness and prevention of relapse in depression: empirical evidence. J Consult Clin Psych. 2002;70:275-287.
33. Lau MA, Segal ZV. Mindfulness based cognitive therapy as a relapse prevention approach to depression. In: Witkiewitz K, Marlatt A, eds. Evidence-based relapse prevention. Oxford, UK: Elsevier Press; 2007:73–90.
34. Grepmair L, Mitterlehner F, Loew T, et al. Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: a randomized, double-blind, controlled study. Psychother Psychosom. 2007;76:332-338.
1. Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain and illness. New York, NY: Dell Publishing; 1990.
2. Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression: a new approach for preventing relapse. New York, NY: Guilford Press; 2002.
3. Shapiro SL, Schwartz GE. Intentional systemic mindfulness: an integrative model for self-regulation and health. Adv Mind Body Med. 2000;15:128-134.
4. Bishop SR, Lau MA, Shapiro S, et al. Mindfulness: a proposed operational definition. Clin Psychol Sci Pr. 2004;11:230-241.
5. Brown KW, Ryan RM, Creswell JD. Mindfulness: theoretical foundations and evidence for its salutary effects. Psychol Inq. 2007;18(4):211-237.
6. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiat. 1982;4(1):33-47.
7. Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985;8(2):163-190.
8. Bishop SR. What do we really know about mindfulness-based stress reduction? Am Psychosom Soc. 2002;64:71-83.
9. Baer RA. Mindfulness training as a clinical intervention: a conceptual and empirical review. Clin Psychol Sci Prac. 2003;10(2):125-143.
10. Grossman P, Nieman L, Schmidt S, et al. Mindfulness-based stress reduction and health benefits: a meta-analysis. J Psychosom Res. 2004;57(1):35-43.
11. Salmon P, Sephton S, Weissbecker I, et al. Mindfulness meditation in clinical practice. Cog Behav Ther. 2004;11(4):434-446.
12. Kuyken W, Byford S, Taylor RS, et al. Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. J Consult Clin Psych. 2008;76(6):966-978.
13. Kingston T, Dooley B, Bates A, et al. Mindfulness-based cognitive therapy for residual depressive symptoms. Psychol Psychother. 2007;80:193-203.
14. Williams J, Alatiq Y, Crance C, et al. Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: preliminary evaluation of immediate effects on between-episode functioning. J Affect Disord. 2008;107(2):275-279.
15. Eisendrath SJ, Delucchi K, Bitner R, et al. Mindfulness-based cognitive therapy for treatment resistant depression: a pilot study. Psychother Psychosom. 2008;77(5):319-320.
16. Finucane A, Mercer SW. An exploratory mixed methods study of the acceptability and effectiveness of mindfulness-based cognitive therapy for patients with active depression and anxiety in primary care. BMC Psychiatry. 2006;6:14.-
17. Kenny MA, Williams JGM. Treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. Behav Res Ther. 2007;45(3):617-625.
18. Ree MJ, Craigie MA. Outcomes following mindfulness-based cognitive therapy in a heterogeneous sample of adult outpatients. Behav Cog Psychother. 2007;24(2):70-86.
19. Coelho HF, Canter PH, Ernst E. Mindfulness-based cognitive therapy: evaluating current evidence and informing future research. J Consult Clin Psych. 2007;75(6):1000-1005.
20. National Institute for Clinical Excellence. Depression: management of depression in primary and secondary care. Clinical guideline 23. 2004. Available at: http://www.nice.org.uk/CG023NICEguideline. Accessed September 30, 2009.
21. Toneatto T, Nguyen L. Does mindfulness meditation improve anxiety and mood symptoms? A review of the controlled research. Can J Psychiatry. 2007;52(4):260-266.
22. Kristeller JL, Hallett B. An exploratory study of a meditation-based intervention for binge eating disorder. J Health Psychol. 1999;4(3):357-363.
23. Evans S, Ferrando S, Findler M, et al. Mindfulness-based cognitive therapy for generalized anxiety disorder. J Anxiety Disord. 2008;22(4):716-721.
24. Williams J, Alatiq Y, Crane C, et al. Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: preliminary evaluation of immediate effects on between-episode functioning. J Affect Disord. 2008;107(2):275-279.
25. Zylowska L, Ackerman DL, Yang MH, et al. Mindfulness meditation training in adults and adolescents with ADHD: a feasibility study. J Atten Disord. 2008;11(6):737-746.
26. Ma SH, Teasdale JD. Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin Psychol. 2004;72:31-40.
27. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003;84:822-848.
28. Lau MA, Bishop SR, Segal ZV, et al. The Toronto Mindfulness Scale: development and validation. J Clin Psychol. 2006;62:1445-1467.
29. Carmody J, Reed G, Kristeller J, et al. Mindfulness, spirituality, and health-related symptoms. J Psychosom Res. 2008;64(4):393-403.
30. Shapiro SL, Oman D, Thoresen CE, et al. Cultivating mindfulness: effects on well-being. J Clin Psychol. 2008;64(7):840-862.
31. Carmody J, Baer RA. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. J Behav Med. 2008;31(1):23-33.
32. Teasdale JD, Moore RG, Hayhurst H, et al. Metacognitive awareness and prevention of relapse in depression: empirical evidence. J Consult Clin Psych. 2002;70:275-287.
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