Background

Mindfulness

Mindfulness is defined as “awareness, cultivated by paying attention in a sustained and particular way: on purpose, in the present moment, and non-judgmentally” (Jon Kabat-Zinn 1990). Derived from Buddhist tradition where it was meant to alleviate suffering and cultivate compassion, it has evolved into widespread, secular practice with a strong body of scientific evidence supporting its incorporation in the management of many medical and psychiatric conditions, psychological distress, and stress management (Ludwig and Kabat-Zinn 2008).

Jon Kabat-Zinn, a faculty at the University of Massachusetts (UMass) Medical School, in 1979 first adapted and applied Mindfulness practice in a program he called Mindfulness-Based Stress Reduction (MBSR), and subsequently established the Center for Mindfulness (CFM).  The MBSR is an 8-week class based program where participants meet once a week for 2.5 hours and during an 8-hour retreat at the halfway point. Participants are encouraged to practice 45 minutes daily at home and complete assigned homework. Training in mindfulness techniques is fundamental and includes sitting meditation, walking meditation, whole body scan, and yoga stretches. Group discussion, where participants share their experiences, is integral to the program. The program was initially studied for its efficacy in treating chronic pain and chronic medical conditions, and also managing mild anxiety and mood symptoms (Dakwar and Levin 2009). In his first published work on MBSR, Kabat-Zinn showed that 50% of 51 chronic pain patients who had not responded to traditional treatment reported improvement in their pain by 50% at the end of the program. These patients also reported improvement in their mood symptoms (Kabat-Zinn 1982).

The CFM reports that since the establishment of the MBSR program at UMass Medical School in 1979, over 22,000 people have completed it. More than 6,000 medical doctors and other healthcare professionals have referred their patients to this program because they understand the value of mindfulness to their patient’s health and well-being. Participants of the CFM’s Stress Reduction Program report a 38% reduction in medical symptoms, a 43% reduction in psychological and emotional distress, and a 26% reduction in perceived stress.  (http://www.umassmed.edu/cfm)

 

Mindfulness – Mechanism of Action

A major factor that has encouraged wide-spread acceptance of mindfulness-based interventions in the health care field has been the growing body of evidence supporting both a biological and psychological basis for its beneficial effects.

Biological. While the beneficial effects of Mindfulness practice is supported by the literature, the underlying biological processes through which it does are still being elucidated. Tang and colleagues in an excellent review of this topic concluded that there is “emerging evidence that mindfulness meditation might cause neuroplastic changes in the structure and function of brain regions involved in the regulation of attention, emotion, and self-awareness.” (Tang 2015).  Neuroimaging studies of mindfulness appear to impact the function of the medial cortex, associated default mode network, insula, and amygdala; these findings are consistent with structural imaging studies (Marchand 2014).

Mehrmann and Karmacharya in their excellent review of neurobiological correlates of meditation concluded that meditation or mindfulness-based therapies seem to positively 1) affect cellular processes that are influenced by stress and linked to disease, and 2) impact biomarkers of stress regulation, such as cortisol secretion, quality of sleep, and ability to remain mindful (Mehrmann and Karmacharya 2013).

Jacobs and colleagues in a controlled study of subjects who completed a 3-month meditation retreat vs controls looked at its effect on telomerase activity and two important factors contributing to stress: perceived control, associated with less stress and neuroticism, associated with increased subjective stress.  They found that telomerase activity was significantly greater in the meditation group (p<0.005). In addition, this group also had a significant increase in perceived control, decrease in neuroticism, and increases in mindfulness and perception of their purpose in life (p<0.01).

Pace and colleagues evaluated the effect of compassion meditation on immune, neuroendocrine, and behavioral response to psychological stress in a group of 61 healthy volunteers randomized to 6-weeks of compassion training (n=33) or engagement in a health discussion control group. After exposure to a standardized stressor (public speaking and mental arithmetic), serum levels of interleukin-6 (IL-6), cortisol, and distress scores from a standardized test were repeatedly assessed. Their findings indicated that subjects who engaged in compassion meditation more frequently tended to progressively have reduced stress-induced immune and behavioral responses stress responses (Pace 2009).

Brand and colleagues evaluated the effects of long-term and short-term mindfulness meditators on HPA activity (morning serum cortisol) and sleep quality (duration and quality). They found that long-term practitioners (Buddhist monks, mindfulness teachers) had significantly decreased morning cortisol levels (p<.03) relative to their length of practice. Individuals without prior meditation experience who completed an 8-week introductory course on MBSR also had reduced morning cortisol levels (p=0.04), improved sleep (p=0.008), and self-attribution of mindfulness (p=0.001) at the end of the course. However, there were no differences at the beginning and end of individual MBSR sessions.

Psychological.  While the underlying psychological mechanisms that mediate the beneficial effects of mindfulness interventions are not fully clear, Chiesa and colleagues postulate that  they 1) may enhance positive emotional regulation strategies, 2) increase self-compassion levels, 3) decrease rumination, and 4) decrease experiential avoidance (.i.e., acceptance of experience, even if unpleasant).  Clinically, these are associated with the reduction of stress and depression levels, as well as the improvement of positive emotions (Chiesa 2014). Mehrmann and Karmacharya state that mindfulness enhances cognitive flexibility and reappraisal through its improvement of faculty of present-centered, non-judgmental awareness of psychosomatic phenomena. Mindfulness practice appears to reduce stress by gradually enhancing non-reactive monitoring of body-mind sensations and learning to be continuously aware of and equanimous toward the sensate experience. (Mehrmann and Karmacharya 2013)

 

Mindfulness in Clinical Populations

Mindfulness practice has gained increasing clinical use and popularity in Psychiatry and in Medicine to manage many disorders.  It is the first mind-body intervention adopted by mainstream health care providers. While mindfulness by itself may not directly treat the medical conditions, the fact that these individuals learn to “be” in the present moment with an attitude of openness, curiosity, acceptance, and self-compassion help them self-regulate their perspective which translates into clinical benefit.  From a neurobiological perspective, the clinical benefits are associated with “significant changes in brain function and architecture that are suggestive of improved levels of attention, memory and executive functions, and of enhanced emotional balance, and by a favorable impact on various biological variables, such as cortisol” (Chiesa 2014, Mehrmann and Karmacharya 2013).

Psychiatry.  Mindfulness practice has shown to be efficacious in the treatment of depression, anxiety disorders, drug and alcohol addiction, insomnia, and various personality disorders. Mindfulness-based techniques have been incorporated as an integral part of several popular evidence-based therapeutic practices, such as Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), and Relapse Prevention Therapy (Dakwar and Levin 2009, Chiesa 2014, Mehrmann and Karmacharya 2013).

Medicine.  Mindfulness practice in Medicine has found widespread use, mainly as an alternative/adjunct to traditional medication-based treatment.  There is a large body of literature supporting its benefits in many different medical conditions. Its benefits have been shown in managing chronic pain, the stress of chronic illness (e.g., cancer, multiple sclerosis), weight loss, smoking cessation, and cardiovascular disease (e.g., hypertension) to name a few. Long term practice may even slow down cognitive decline.

 

Mindfulness in Healthy Populations

Mindfulness-based interventions have been used to reduce stress in a wide variety of non-clinical populations, including college students, nursing students, and medical students (Chiesa 2009).  Medical students, in particular, have high levels of psychological distress, burnout, depression and suicidal ideation compared to the general population and age-matched peers (van Dijk 2017, Rotenstein 2016).  Mindfulness has the potential to reduce stress and psychological distress, increase self-awareness, improve empathy, and prevent compassion fatigue and burnout in medical students; thus allowing them to better foster wellness in their patients.  Medical schools are increasingly considering implementing or have implemented some form of mindfulness interventions. Dobkin and Hutchinson identified 14 medical schools that taught mindfulness in various formats. They found that students who participated in these programs tended to report decreased psychological distress and improved quality of life (Dobkin and Hutchinson 2013).

Shapiro and colleagues first conducted a randomized controlled trial of MBSR (MBSR n=37, control n=36) in preclinical medical students whose participation was voluntary.  They found that the MBSR group had a significant decrease in depression, anxiety, and psychological distress; and a significant increase in empathy and spirituality (Shapiro 1998).  Erogul and colleagues in a randomized trial of first-year medical students found that those who had undergone MBSR (n=30) reported less perceived stress and more self-compassion than controls (n=28), but at 6 months, only the differences in self-compassion persisted (Erogun 2014).  More recently, van Dijk and colleagues conducted a cluster-randomized trial of an 8-week MBSR program (n=83) and clerkship as usual (n=84) among medical students in their first year of clerkships in a medical school in the Netherlands. During the 20-month follow-up, the MBSR group had a modest improvement in psychological distress and cognitive dysfunction; moderate improvement in positive mental health, mindfulness skills, and life satisfaction. There was no difference in physician empathy. They concluded that MBSR was feasible and acceptable to medical clerkship students with mild to moderate improvement in mental health (van Dijk 2017).

 

References