Keywords
meditation - mindfulness - mind–body - neurology
Over the past several decades, there has been growing interest in the use of mind–body
interventions (MBIs) among both healthy and clinical populations in the United States.
MBIs encompass a group of therapies broadly focused on harnessing the interactions
between brain, mind, body, and behaviors to improve health and well-being.[1] Some of the most common MBIs and techniques include meditation-based programs, promotion
of mindful awareness, relaxation practices (e.g., guided imagery, progressive muscle
relaxation), yoga, and tai chi. While these interventions are often rooted in ancient
practices, many of them have been secularized and tailored for medical settings. Growing
evidence suggests that these interventions are relatively safe[2]
[3] and may be effective for reducing physical and emotional symptoms commonly associated
with neurological disorders.
MBIs are multimodal in nature and incorporate several mind and body strategies (e.g.,
breath awareness, movement, meditation, mindfulness). In this narrative review, we
will focus primarily on MBIs with a meditative or mindfulness component. A comprehensive
review of all meditative- and mindfulness-focused interventions is beyond the scope
of this article; instead, we will focus on select therapies with promise in neurology.
Specifically, we will (1) define meditation and mindfulness; (2) provide an overview
of select therapies with meditative or mindfulness components; (3) review the evidence
of these therapies for neurological disorders and common neuropsychiatric symptoms;
and (4) highlight structural and patient factors relevant to patient selection for
these therapies.
Definition and Principles of Meditation and Mindfulness
Definition and Principles of Meditation and Mindfulness
Meditation consists of a group of mental practices that involve the regulation of
attention from moment to moment on an object of awareness to foster various states,
including emotional balance and well-being.[4] The type of meditation depends on the specific object of awareness, which can include
interoceptive sensations (e.g., the breath, parts of the body), mental images and
phrases (e.g., mantra), or external objects (e.g., a flame). Practices can involve
a sustained focus on one object (i.e., focused attention), shifting focus from one
object to another, or attending to one's moment-to-moment experiences without an explicit
focus (i.e., open monitoring). Further, these practices can be completed in a stationary
position or with movement.
Specific forms of meditation (e.g., focused attention, open monitoring) are used to
cultivate mindfulness. Mindfulness, which is a key component of many MBIs, is defined
as the self-regulation of attention to present moment experiences with an attitude
of openness, curiosity, and acceptance.[5] The self-regulation of attention refers to purposefully guiding attention to present
moment internal (e.g., thoughts, emotions, body sensations) or external (e.g., environment)
experiences. These experiences are greeted without mental elaboration or judgment,
regardless of their valence or desirability.[5] Mindfulness is conceptualized as both a state (i.e., actively attending to present
moment experiences)[6] and a trait (i.e., one's disposition to be mindful in daily life),[7] and higher levels of state and trait mindfulness are associated with lower levels
of emotional and physical symptoms.[8]
[9]
[10] Several interventions and techniques have been shown to improve state and trait
mindfulness, including mindfulness-based interventions, yoga, tai chi, and other psychological
interventions with a mindfulness focus (e.g., acceptance and commitment therapy).[11]
[12]
[13] Mindfulness-based interventions utilize various meditation practices (e.g., focused
attention, open monitoring) to cultivate mindfulness, all of which involve regulating
attention to present moment experiences with openness, curiosity, and nonjudgment.[5]
Mindfulness is often contrasted with automaticity, or automatic responding without
deliberate intention.[14] It is well known that automatic and habitual responding to uncomfortable internal
experiences (e.g., thoughts, emotions, body sensations) can have negative consequences.
Indeed, automatic reactions can lead to efforts to avoid, suppress, or change uncomfortable
internal experiences, which paradoxically exacerbate or maintain these experiences
and increase emotional or physical distress.[15] As such, mindfulness-focused interventions help individuals change their relationship
with difficult internal experiences. Specifically, mindfulness promotes decentering
from (i.e., taking a step back from), rather than over-identifying with, thoughts,
emotions, and body sensations.[16] In turn, this decouples the relationship between internal experiences and behaviors
(e.g., an urge to avoid and subsequent avoidance), allowing individuals to choose
a more adaptive response.[17]
Neurobiological Mechanisms of Mindfulness
Neurobiological models of mindfulness suggest that mindfulness practice may exert
its effects through structural and functional changes in brain regions and networks
implicated in attention regulation, emotion regulation, and self-perspective and self-awareness.[18]
[19]
[20] Indeed, mindfulness interventions have been shown to improve various aspects of
attention (e.g., selective, executive)[21]; in this regard, MBIs can be powerful forms of brain retraining—underscoring that
brain–behavior relationships are bidirectional. In neuroimaging studies, mindfulness
meditation was associated with functional changes in the cognitive control network,
particularly the anterior cingulate cortex (ACC), which supports attention and control
through conflict monitoring and decision-making, and the dorsolateral prefrontal cortex
(PFC), which is essential for executive function.[19] There may also be structural changes in the ACC with mindfulness practice.[19]
There is also robust evidence that mindfulness interventions improve various indices
of emotion regulation.[22] Neuroimaging studies suggest that functional changes may differ by level of experience
(see [Fig. 1]). In beginners, mindfulness practice may be linked to enhanced activation in PFC
regions and reduced activation of the amygdala in response to affectively valenced
cues, indicative of top-down regulatory processes.[19]
[23] Long-term practice, on the other hand, may be associated with bottom-up emotion
regulation strategies, characterized by reduced emotional reactivity without activation
in PFC regions.[19]
[23]
Fig. 1 (A) Changes observed with mindfulness in early practitioners include increased dorsolateral
and ventrolateral prefrontal cortex (PFC) activity in response to emotional stimuli
(gray), and reduced amygdala activation (black). (B) Experienced meditators demonstrate reduced activation of precuneus and ventromedial
PFC during meditation (black) and increased activation of ventral sensorimotor structures such as insula and thalamus
in response to emotional or painful stimuli (gray).
Mindfulness is also known to change various aspects of self-perspective (e.g., decentering,
or taking a step back from thoughts)[16] and self-awareness (e.g., interoceptive awareness, or sensing and appraising internal
physiological signals).[24]
[25]
[26] Neuroimaging studies have shown that activity and connectivity of the default mode
network (cortical midline structures), which is thought to be involved in self-referential
processing, is reduced in mindfulness meditators.[19] Examples of negative self-referential processing include rumination, worry, and
self-criticism.[27] Studies have also demonstrated structural changes in regions associated with the
experience of the self, such as the posterior cingulate cortex[18] and the insula.[19]
Overview of Meditative- and Mindfulness-Focused Interventions
Overview of Meditative- and Mindfulness-Focused Interventions
See [Table 1] for an overview of the structure, components, and space requirements of select meditative-
and mindfulness-focused interventions. See [Table 2] for an example of a brief 5-minute mindfulness exercise.
Table 1
Structure, components, and space requirements of select meditative- and mindfulness-focused
interventions
|
Mind–body Intervention
|
Structure
|
Components
|
Space requirements
|
|
MBSR/MBCT
|
2 hours per week for 8 weeks + retreat day
|
Mindfulness principles, yoga, meditative practices, incorporating mindfulness into
everyday life
|
Floor space for yoga mats; chairs for discussion
|
|
SMART
|
90 minutes per week for 8 weeks
|
Relaxation training, cognitive therapy, sleep hygiene, guided imagery, gentle yoga
|
Conference room with chairs
|
|
Yoga interventions
|
Vary: 6–12 weeks typical, group classes often 1 hour
|
Varies based on type, typically involves stretching postures held while attending
to sensations of the breath and body
|
Dependent on type, usually floor space for yoga mats
|
|
Tai chi
|
Vary: 12 weeks, 1-hour classes, 2–3 days per week typical
|
Gentle physical movement performed while standing, attending to the breath and body
movements
|
Open floor space or outdoor space
|
|
Mentalizing imagery therapy
|
4 weekly 2-hour sessions
|
Gentle chair yoga, mindfulness and guided imagery practices, group discussion
|
Conference room with chairs
|
Abbreviations: MBCT, mindfulness-based cognitive therapy; MBSR, mindfulness-based
stress reduction; SMART, Stress Management and Resiliency Training.
Table 2
Brief 5-minute mindfulness exercise instructions
|
Close your eyes and allow the muscles of your jaw and tongue to relax gently down.
Bring your attention to your breathing. Notice how the breath feels as it enters the
nose, flows into the head and down the throat. Pay attention to the natural movements
of your body with the breath, the gentle expansion of the chest and abdomen with the
inhalation, and their relaxation with the exhalation. If distracting thoughts arise,
that is ok, simply acknowledge them, and return attention to your breathing.
|
Mindfulness-Based Interventions
Mindfulness principles and practices were adapted by Jon Kabat-Zinn from Buddhism
and were secularized and packaged to improve accessibility for use in clinical practice.[28] “Mindfulness-based” interventions emphasize mindfulness meditation and incorporate
mindfulness principles into a range of activities. The two most common mindfulness-based
interventions are Mindfulness Based Stress Reduction (MBSR)[29] and Mindfulness Based Cognitive Therapy (MBCT).[30] MBSR was originally developed to treat patients with chronic pain who failed other
treatment modalities.[29] MBSR has subsequently been shown in meta-analyses to improve depression and anxiety
symptoms not only in chronic pain populations, but also in community samples.[31] MBCT was adapted from MBSR to prevent relapse of depression among individuals with
recurrent depressive episodes.[30] Specifically, MBCT incorporates more attention to cognitive therapy elements as
applied to ruminative depressive thinking. MBCT has subsequently been applied across
a range of neuropsychiatric conditions (e.g., anxiety, chronic pain).
Various other mindfulness-based interventions have been developed for specific populations
or conditions (e.g., Mindfulness-Oriented Recovery Enhancement for chronic pain),[32] most of which were adapted from MBSR or MBCT. In general, mindfulness interventions
are completed in a group format and include eight weekly 1- to 2-hour sessions and
daily home practice (as well as a retreat day in some programs). Each session includes
meditations, group discussion/inquiry, and didactics. Mindfulness interventions utilize
both formal (e.g., meditation, yoga) and informal (e.g., mindful walking, eating)
practices to build mindfulness skills to be applied in daily life.
SMART Program
The Benson–Henry Institute for Mind Body Medicine has studied MBIs for over 40 years
based on the pioneering work of Dr. Herbert Benson to define a “relaxation response,”
which is thought to be the physiological inverse of the fight/flight response. The
origins of this work began with meditative practices consisting of mental repetition
of a word or short phrase in rhythm with the breath, and to passively attend to distracting
thoughts, returning focus once again to the breath. This focused awareness practice
has since been incorporated into a more diverse set of cognitive and physical practices
that comprise the “SMART program,” or Stress Management and Resiliency Training program,
which includes relaxation response training, stress awareness, and cognitive approaches
to stress management.[33] In addition, it provides training in a variety of other resilience enhancement approaches
including positive psychology, acceptance, social support and pro-sociality, spiritual
connectedness, and healthy lifestyle. SMART is a group program and involves 90- to
120-minute weekly sessions for 8 weeks. The program has been successfully implemented
with patients who have a variety of symptoms, including chronic pain, fatigue, anxiety,
and depression.[34]
Mindful Movement-Based Therapies
Mindful movement-based therapies, such as tai chi and yoga, are perhaps the most widely
implemented MBIs in community settings. Tai chi is a multimodal intervention that
includes movement, breath awareness, breathing exercises, postural and strength training,
and mindful attention.[35] In tai chi, slow purposeful movements are coordinated with breathing or imagery
to strengthen the mind and body and improve health.[35] Although the style and dose of tai chi varies in community settings, more standardized
tai chi interventions have been developed for medical and research settings. These
interventions typically include 1-hour sessions, conducted two to three times per
week for 12 weeks. While more systematic documentation of adverse events is needed,
tai chi appears to be relatively safe, including for individuals with more chronic
diseases (e.g., Parkinson's disease [PD]).[36]
Many variations of yoga practice can be found. Overall, yoga aims to unite the mind
and body and improve health through breathing exercises, movement (i.e., yoga postures),
and meditation. Yoga practices range from gentle passive stretching (e.g., Hatha yoga)
to active repetitions of yoga postures (e.g., Vinyāsa, Ashtanga) to intense sequences
in environments heated to more than 100°F (e.g., hot yoga or power yoga). In a meta-analysis
of randomized controlled trials (RCTs) employing a variety of yoga interventions,
yoga appeared to be as safe as usual care and exercise but was associated with an
increase in intervention-related and nonserious adverse events (but not serious adverse
events) compared with psychological/educational interventions.[2] However, almost 70% of the located trials in this meta-analysis did not report safety
data, pointing to the need for more comprehensive safety monitoring and reporting
in yoga RCTs.
Mentalizing Imagery Therapy
Mentalizing refers to the process of understanding the mental processes of self and
others and their links to behaviors, including in the challenging interpersonal situations
that often worsen or cause psychological symptoms. Caregivers of patients with chronic
neuropsychiatric illness often struggle with the challenge of mentalizing those whose
minds process information differently and evince less cognitive control. Mentalizing
Imagery Therapy (MIT) is a newly developed intervention that seeks to incorporate
fundamental principles of mentalizing into a set of mindfulness and guided imagery
practices that caregivers can use to nonjudgmentally observe their experience and
aid mentalization of the person whom they support.[37] MIT, which consists of four weekly 2-hour sessions, includes chair yoga, mindfulness,
and imagery practices.
Evidence for Common Neurological Disorders
Evidence for Common Neurological Disorders
In this section, we review the evidence of meditative- and mindfulness-focused interventions
for headache, functional neurological disorder (FND), epilepsy, neurodegenerative
disorders, movement disorders, stroke, mild cognitive impairment (MCI), and caregivers
of individuals with neurological disorders.
Headache
Research examining mindfulness interventions for headache is growing. A 2019 meta-analysis
(n = 5 studies) found that MBSR did not improve headache frequency, duration, or intensity
among individuals with tension type and migraine headaches.[38] Despite these negative results, two more recent RCTs demonstrated some potential
benefits of MBSR. The first study compared MBSR to a control condition (headache education)
among 89 adults with migraine.[39] While both groups showed improvements in migraine days, MBSR was associated with
greater improvements in headache-related outcomes such as disability, catastrophizing,
quality of life, and pain intensity and unpleasantness. In the second study among
individuals with episodic migraine, compared with a stress management for headache
program, enhanced MBSR (i.e., 12 sessions) was associated with greater reductions
in headache days and headache-related disability at 20 weeks, but not 52 weeks.[40] Thus, the evidence for treating chronic headache with mindfulness meditation is
somewhat mixed, but recent findings show some promise for migraine. Future research
should address better targeting mindfulness therapies in this population.
In terms of medication use outcomes in headache, a nonrandomized study of a mindfulness-based
intervention was conducted in 44 subjects with chronic migraine-medication overuse
headache.[41]
[42]
[43]
[44] Participants who completed a medication withdrawal program chose a prophylactic
medication regimen or a 6-week group-mindfulness training. Headache frequency and
medication use decreased in both groups. However, there were no improvements in self-reported
anxiety in either group, even though catecholamine levels were reduced. Randomized
trials are needed, but nevertheless this study suggests that mindfulness may have
similar benefits to a standardized pharmacological treatment for refractory migraine-medication
overuse headache among patients who select a nonpharmacological approach.
Findings from a recent meta-analysis (n = 5 RCTs) suggested that yoga may improve headache frequency, headache duration,
and pain intensity among individuals with tension headaches, but not migraines.[45] However, the quality of evidence was considered low due to methodological limitations,
pointing to the need for more research in this area.
Functional Neurological Disorder
There has been increasing interest in employing mindfulness approaches to help patients
with FND. In an uncontrolled study in a neurological population referred for evaluation
(n = 98) with a variety of diagnoses including FND, participation in a mindfulness-based
intervention correlated with moderate decreases in anxiety and depression.[46] A subgroup analysis showed small size effects in FND subjects, medium size effects
in those with nonprogressive neurological conditions, and large size effects in those
with progressive conditions. All groups had improvements in stress coping. This may
suggest that while mindfulness meditation is effective in reducing stress, there may
be value added with efforts to enhance resilience through active coping using cognitive
skills, positive psychology, and social support.
Treatment interventions for functional (psychogenic nonepileptic/dissociative) seizures
(FSs) have become a focus of study, but few high-quality RCTs exist. In an uncontrolled
study, Baslet and colleagues[47] examined a mindfulness-based intervention for individuals with FS. Despite high
levels of dropout, individuals who completed the mindfulness intervention demonstrated
improvements in FS frequency, intensity, and quality of life. This preliminary study,
along with a case series with similar findings,[48] suggests that a mindfulness intervention may be feasible for individuals with FS
and that more research is warranted.
Epilepsy
Thompson and colleagues[49] studied a distance-delivered MBCT group for preventing major depressive disorder
(MDD) among individuals with both epilepsy and mild to moderate depressive symptoms.
Results showed lower incidence of MDD episodes in the MBCT group (0%) compared with
the treatment as usual group (10.7%). Greater decreases in depressive symptoms dimensionally
were also found in the MBCT group. Similar effects occurred for web- and telephone-based
MBCT. These findings suggest that there may be potential for MBCT in preventing depressive
episodes among individuals with epilepsy.
There is more limited evidence for mindful exercise therapies in epilepsy. A Cochrane
review identified only two studies of yoga among individuals with epilepsy, which
demonstrated promising effects for seizure outcomes and quality of life.[50]
[51]
[52] Overall, more research is needed to better understand mindful movement therapies
for individuals with epilepsy.
Neurodegenerative Disorders
There are a growing number of studies examining mindfulness interventions for multiple
sclerosis (MS). In an RCT among individuals with MS, compared with treatment as usual,
a mindfulness-based intervention was associated with small-to-medium reductions in
anxiety, depression, and fatigue, as well as a large improvement in quality of life.[53] Effects were generally maintained at the 6-month follow-up and improvements were
particularly pronounced in the more severely symptomatic subgroup (i.e., clinical
levels of depression, anxiety, fatigue).
A 2019 meta-analysis of 12 RCTs examined the effects of mindfulness-based interventions
on mental well-being in a total of 744 individuals with MS.[54] The authors found a moderate effect of mindfulness interventions on overall well-being.
In terms of specific outcomes, there were small to medium effects for anxiety, depression,
and stress reduction. Taken together, these results suggest that mindfulness-based
interventions may be effective for improving common neuropsychiatric symptoms among
individuals with MS.
Recognizing the disability associated with MS, studies have relied upon distance interventions
being provided via telehealth.[55] A 2015 survey of over 2,800 individuals with MS found that there was considerable
unmet psychological need.[56] This underscores the need to optimize the accessibility of psychological services
and support.[56] Mindfulness-based interventions provided through distance telemedicine provide an
opportunity for health promotion in patients with neurodegenerative diseases like
MS.
Movement Disorders
Among the movement disorders, PD has been most studied using mindfulness-based interventions.
In a recent systematic review of MBSR for PD (n = 3 studies),[57] one study showed improvements for PD outcomes, depression, mindfulness, and quality
of life, and a second found an increase in gray matter density on magnetic resonance
imaging following MBSR compared with usual care. While these results are promising,
the review authors concluded that there is limited evidence to support the use of
MBSR for PD given the small number of studies, methodological limitations, and lack
of adverse event reporting. Larger RCTs with longer follow-ups and systematic safety
monitoring are warranted.
Motor symptoms, as well as neuropsychiatric symptoms such as anxiety and depression,
are known to increase due to stress in PD. In a survey study (5,000 PD patients and
1,292 controls), Van der Heide and colleagues[58] found that individuals with PD perceived more stress than controls and stress was
associated with increased rumination, lower quality of life, lower self-compassion,
worsening motor symptoms, and lower dispositional mindfulness. Mindfulness was practiced
by 38.7% of individuals with PD in the past 3 months, with varying amounts of practice
across patients (e.g., 53.2% reported weekly practice and 21.5% reported practicing
less than once per month). Individuals with PD who practiced mindfulness endorsed
improvements in both motor (e.g., gait, tremor) and nonmotor (e.g., anxiety, depression)
symptoms, with the greatest effects for anxiety and depressive symptoms. These results
suggest acceptability of mindfulness among a large proportion of patients with PD
and support the further study of mindfulness-based interventions in PD.
A 2019 meta-analysis examined the effects of cognitive behavioral therapy (CBT) and
mindfulness-based interventions among individuals with MS, PD, and Huntington's disease
(HD).[59] Across 12 studies (n = 8 in MS and n = 4 in PD), these interventions demonstrated a medium decrease in psychological distress.
In seven studies involving patients with MS, there were small reductions in distress.
There were no studies identified in HD populations. Despite the positive effects among
individuals with MS and PD, the overall quality of studies was considered low, pointing
to the need for more rigorous research in this area.
Tai chi has also been studied among individuals with PD. In a large RCT (n = 195), tai chi outperformed resistance training and stretching in improving in postural
stability.[60] Tai chi also demonstrated greater improvements in gait and strength when compared
with stretching and greater improvements in stride length and functional reach compared
with resistance training. Moreover, tai chi lowered the incidence of falls compared
with stretching, but not resistance training. A 2017 meta-analysis suggested that
tai chi was associated with improvements in motor outcomes, balance, timed walking,
falls, depressive symptoms, and quality of life among individuals with PD.[61] Cognition did not improve. Tai chi shows promise as an intervention for PD.
Poststroke Recovery
Mindfulness-based interventions may be helpful poststroke. Results from a 2013 systematic
review involving four studies (n = 160) suggested that there were favorable trends for mindfulness-based interventions
following a stroke with regard to biopsychosocial outcomes, including anxiety, depression,
fatigue, blood pressure, perceived health, and quality of life.[62] Another study demonstrated that a 2-week home-based mindfulness intervention was
feasible among chronic stroke survivors with spasticity (n = 10).[63] There were preliminary effects for decreasing spasticity and increasing quality
of life. This is a very small study, but it is supportive of a short, low-risk, and
low-cost mindfulness intervention that may potentially benefit both physical and mental
symptoms poststroke. Prospective and controlled research with larger sample sizes
will be required to confirm these findings.
There is also limited but promising evidence for mindful movement therapies in stroke.
A meta-analysis of 19 RCTs suggested that tai chi may improve balance function and
exercise capacity following stroke.[64] In a systematic review of eight studies, tai chi and yoga both showed promise for
improving psychological stressors and quality of life among poststroke patients.[65] However, more rigorous and adequately powered RCTs are needed to better evaluate
movement-based therapies in stroke.
Mild Cognitive Impairment
A 2019 meta-analysis of 40 randomized controlled studies including 3,551 older adult
participants addressed the question of whether mind–body interventions affected cognition
in older adults.[66] MBIs were classified as meditation (which included mindfulness as well as other
styles), yoga, tai chi, and other mindful movement therapies (e.g., Qigong). Small
to moderate effects across cognitive domains were found with low risk of bias. Further
analysis suggested a higher effect size for patients with MCI. These results demonstrated
that effects were more robust for longer term interventions (i.e., >12 weeks) with
session practice frequency of at least three times per week and longer session duration
(i.e., at least 45 minutes of practice time). Such interventions are longer than those
offered in the usual clinical setting (such as MBSR or MBCT). Recent mindfulness studies
have focused on molecular pathways thought to be mechanistically related to MCI and
found sex-specific reductions in C-reactive protein in females but not in males with
MCI,[67] but no effect on circulating amyloid-β 42 levels.[68] Mindfulness interventions may more likely modify immune activity related to MCI
than amyloid level.
Caregivers
Meditative- and mindfulness-focused interventions have also shown promise for caregivers
of individuals with neurological disorders. For example, a recent review found low-quality
evidence that MBSR may lead to short-term reductions in depressive and anxiety symptoms
in caregivers of those with dementia.[69] Lavretsky and colleagues[70] demonstrated that Kirtan Kriya yoga, which involves approximately 20 minutes of
repeated chanting of a mantra with guided imagery, resulted in improvements in depression
and executive function in family dementia caregivers. MIT has also shown feasibility
and acceptance. In a small trial of MIT compared with a waitlist control augmented
by optional relaxation exercises, family dementia caregivers who received the MIT
intervention exhibited greater improvements in depression and anxiety symptoms.[71] Neuroimaging findings revealed increased dorsolateral PFC connectivity with an emotion
regulation network in the MIT group, but not waitlist. Qualitative findings suggested
improvements in well-being, mood, anxiety, and sleep, as well as in perceiving themselves
more objectively within challenging relationship situations.[72] Clearly, larger randomized, controlled trials of these interventions are needed.
Evidence for Common Neuropsychiatric Symptoms
Evidence for Common Neuropsychiatric Symptoms
In this section, we review the evidence of meditative- and mindfulness-focused interventions
for neuropsychiatric symptoms, including depression, anxiety, chronic pain, and sleep
difficulty.
Depression
Research suggests that mindfulness-based interventions are effective for reducing
depressive symptoms and preventing relapse of depression. In one of the most recent
meta-analyses of RCTs, mindfulness-based interventions (e.g., MBCT, MBSR) were found
to be superior to no treatment and other active therapies, and equivalent to existing
evidence-based therapies (e.g., CBT) for individuals with a depression diagnosis or
elevated symptoms.[73] In a meta-analysis exclusively among individuals with a current depressive or anxiety
disorder, mindfulness interventions demonstrated a medium-to-large effect on depressive
symptom severity, and overall effects on primary symptom severity were particularly
pronounced for MBCT.[74]
MBCT has also been shown to effectively reduce the risk of depressive relapse within
a 60-week follow-up period among individuals with recurrent depression in full or
partial remission, particularly among individuals with higher residual symptoms at
baseline.[75] Further, MBCT was found to be comparable to active treatments, including antidepressant
medication.[75] MBCT may reduce the risk of depression relapse through improvements in trait mindfulness,
rumination, decentering, worry, and self-compassion.[76]
The SMART program has demonstrated promise for reducing depressive symptoms in a variety
of populations. For example, in a small open-label study among individuals with MDD,
SMART was associated with improvements in resilience and reductions in depressive
symptoms and perceived stress.[77]
Yoga and tai chi have also shown potential for reducing depressive symptoms.[78] In a 2013 meta-analysis, yoga reduced the severity of depression among individuals
with a depressive disorder or elevated symptoms compared with usual care, with more
limited evidence of reductions compared with relaxation and aerobic exercise.[79] Tai chi may also reduce depressive symptoms, although more high-quality studies
are needed.[80]
Anxiety
There is evidence that mindfulness-based interventions may effectively reduce anxiety
symptoms among individuals with a range of conditions. In a meta-analysis among individuals
with various conditions (e.g., cancer, other medical conditions, depression), mindfulness-based
interventions demonstrated a medium effect on anxiety symptoms.[81] Subsequent meta-analyses have shown that mindfulness-based interventions reduce
anxiety symptoms among healthy adults[82] and individuals with chronic pain conditions (e.g., fibromyalgia).[83]
The evidence for mindfulness-based interventions among individuals with anxiety disorders
is somewhat less consistent. Vøllestad and colleagues[84] found that in controlled studies, mindfulness interventions moderately improved
anxiety symptoms among individuals with anxiety disorders. However, results from a
recent meta-analysis suggested that mindfulness-based interventions (e.g., MBCT, MRSR)
were superior to no treatment controls, but equivalent to other active therapies and
evidence-based treatments for individuals with anxiety disorders or elevated symptoms.[73] Moreover, in a meta-analysis among individuals with current anxiety disorders, there
was no significant effect of mindfulness-based interventions on symptom severity.[74]
In pilot trials, the SMART program has been shown to improve anxiety symptoms in several
populations, including parents of children with learning and attentional disabilities,
breast cancer survivors, and patients with other medical conditions such as hypertension
and neurofibromatosis.[85]
[86]
[87]
[88]
In terms of mindful movement-based therapies, Cramer and colleagues[89] found that yoga reduced anxiety symptom severity when compared with no treatment
and active controls for individuals with elevated anxiety symptoms, but not individuals
with a Diagnostic and Statistical Manual of Mental Disorders (DSM)-diagnosed anxiety
disorder. Further, a recent meta-analysis found that yoga was superior to nonmindful
forms of exercise for reducing anxiety symptoms.[90] While more rigorous RCTs are needed, there is emerging evidence that tai chi may
be helpful for anxiety symptoms.[80]
Chronic Pain
There is growing evidence for the efficacy of mindfulness-based interventions for
chronic pain-related outcomes. Among individuals with a variety of chronic pain conditions
(e.g., headache, back pain, fibromyalgia), meta-analytic results (n = 30 RCTs) suggested that mindfulness-based interventions significantly improved
pain symptoms compared with treatment as usual, passive controls, and education/support
groups.[91] However, the quality of evidence was considered low due to heterogeneity of the
included studies and possible publication bias. In this review, only four studies
included analgesic use outcomes and results were mixed. One specific mindfulness intervention,
Mindfulness-Oriented Recovery Enhancement, has shown promise for improving opioid-related
outcomes (e.g., misuse risk).[92] In a meta-analysis of mindfulness interventions for individuals with chronic pain
conditions (n = 25 RCTs), these therapies had a small effect on pain intensity and disability,
and a moderate effect on pain interference when compared with waitlist, treatment
as usual, and education/support groups.[93] Interestingly, neural mechanisms of mindfulness-based pain reduction appear to vary
by level of training. While brief training is associated with reappraisal mechanisms
(e.g., activation of the subgenual ACC, orbitofrontal cortex, and right anterior insula),
longer training is associated with nonappraisal, or the ability to separate the physical
sensations of pain from the affective and evaluative reactions commonly associated
with pain (e.g., activation of somatosensory regions and deactivation of prefrontal
regions).[94]
Garland and colleagues[95] conducted a meta-analysis on a broad array of MBIs among individuals using opioids
for pain. Across 60 RCTs, MBIs (e.g., meditation, hypnosis, relaxation) were associated
with reductions in pain symptoms and opioid dose. Of the included MBIs, meditation
demonstrated the largest effect size for pain reduction. In addition, four out of
five meditation studies reported improvements in opioid-related outcomes (e.g., opioid
misuse, cravings).
Yoga and tai chi may also be helpful for specific chronic pain conditions. Meta-analyses
have shown that yoga is associated with short-term improvements in neck pain-related
outcomes (e.g., pain intensity, disability; n = 3 RCTs)[96] and both short- and long-term improvements in back pain-related outcomes (e.g.,
pain, disability, global improvement; n = 10 RCTs).[97] Tai chi may produce short-term improvements in pain and disability among individuals
with musculoskeletal pain conditions.[98] Importantly, American College of Physician guidelines recommend MBSR, yoga, and
tai chi for chronic low back pain.[99]
Sleep Difficulty
According to proposed theoretical frameworks, mindfulness-based interventions may
be helpful for sleep problems through reductions in rumination, arousal, sleep monitoring
and effort, and distorted perceptions.[100] In a meta-analysis of 18 RCTs, mindfulness-based interventions (e.g., MBSR, MBCT)
improved sleep quality among various patient populations with clinically significant
sleep problems when compared with active controls, but not evidence-based sleep treatments.[101] Mindfulness-based interventions may also reduce insomnia symptoms compared with
placebos and waitlist controls.[102] Overall, more rigorous research is needed to compare mindfulness-based interventions
to evidence-based sleep treatments.[100]
Mindful movement-based therapies have shown potential for sleep problems. Results
from a recent meta-analysis indicated that yoga modestly improved sleep quality in
women.[103] In a meta-analysis of 22 RCTs, tai chi was shown to have a moderate effect on sleep
quality among individuals with various conditions and sleep complaints when compared
with both inactive and active controls (e.g., exercise, health education).[104]
Approach to Patient Selection
Approach to Patient Selection
In this section, we highlight several structural and patient factors to consider when
referring to or recommending meditative- or mindfulness-focused interventions (see
[Fig. 2]).
Fig. 2 Structural and patient factors to consider when recommending and referring to meditative-
and mindfulness-focused interventions.
Structural Factors
From a provider perspective, there may be structural barriers when referring to or
recommending MBIs in clinical practice.[105]
Reimbursement
MBIs take time to deliver. Given the current reimbursement structure for most providers,
it is important to recognize that patients might have to self-pay and that the cost
for a course is often several hundred dollars. This is due to a lack of clear-cut
mechanisms for reimbursement, especially for providers who are not from mental health
care fields. Centers that offer MBIs often make them out of pocket expenses that are
not billed to insurance. Especially among underserved, and often underrepresented
populations of lower socioeconomic status, access to MBIs becomes an inherent barrier.
Some mindfulness-based interventions are offered by mental health providers and are
subject to standard referral procedures and insurance reimbursement. There has also
been an increased focus on developing insurance reimbursable mindfulness programs
to be delivered in primary care settings.[106]
Referral
MBIs require an administrative and referral structure. There must be administrative
assistance that supports patient navigation and agency around clinical services. This
is especially true in chronic neurological conditions, which historically have relied
upon pharmacologic and procedural management of care. As MBIs are behavioral modalities,
there may be more questions asked by patients—creating greater potential administrative
burden.
Patient Factors
Although not an exhaustive list, below we review several patient-specific factors
that should be considered when referring to MBIs.
Culture
The MBIs reviewed here were derived from Eastern meditative and spiritual disciplines,
which may not be agreeable to some patients based on their religious beliefs. While
in practice we have found most patients to be open to “anything that works,” a careful
discussion is merited regarding the practices that participants might expect within
the MBI, and whether it is expected that any culture-specific elements might be presented
(e.g., from Buddhism, Hinduism, or Taoism).
Self-Efficacy
One cognitive process that may be related to the success of MBIs is self-efficacy.
Self-efficacy refers to the ease or difficulty in performing a behavior. This is semantically
different from controllability, which refers to the belief about the extent to which
performing the behavior is up to the individual.[107] Self-efficacy has been found to act as a mediator of change in health behaviors
and in use of the health care system. In addition, self-efficacy has also been related
to increased energy, better sleep, and decreased pain and discomfort, as well as with
overall satisfaction with life.[108] As such, when there are neurobehavioral and physical symptoms that pose direct challenges
to self-efficacy, the resulting low levels of self-efficacy may present a barrier
to the adherence, and inevitably the success of the MBI—thereby creating a perpetual
negative feedback loop. Therefore, providers referring to or delivering MBIs may benefit
from assessing and understanding a patient's self-efficacy as this may help participation
and engagement with the MBI.
Catastrophizing
Cognitive psychological processes may also be important to consider in the context
of MBIs. One specific process, catastrophizing, is often studied in the context of
pain and has been shown to be associated with poor pain-related outcomes.[109] Pain catastrophizing refers to the tendency to magnify the threat of pain, ruminate
on pain, and feel helpless in regard to pain.[110] Patients with high degrees of catastrophizing may engage in maladaptive behaviors
(e.g., avoidance of activity) and experience psychological distress (e.g., depression,
anxiety).[110] Overall, this may magnify symptom intensity and disability, thereby affecting the
patient's willingness to participate in an MBI and implement positive health behavior
change. Therefore, it may be helpful for providers to assess for levels of catastrophizing,
particularly for patients with chronic pain, to better facilitate participation and
engagement with a MBI.
Ability to Tolerate Group Setting
Because many MBIs occur in groups, it is necessary to assess the patient's level of
ability to function in a setting that involves physical proximity to others and its
attendant distractions (e.g., visual stimulation from movements by other group members,
errant noises). Moderate to severe disturbances in memory or attention, or behavioral
symptoms resulting from loss of inhibition, paranoia, and hallucinations, might become
exacerbated in a group setting.
Freely Available Online Resources
While delivery of MBIs has largely been scientifically studied in person in the group
setting, several of the programs reviewed in this article have high-quality, free
online resources to which highly motivated and technologically sophisticated patients
can be directed. Palouse Mindfulness (https://palousemindfulness.com/) provides a free online MBSR course for self-study with peer support available through
a Facebook group. MIT audio recordings are freely available on the Fern Hill Center
Web site (https://www.fernhillcenter.org/). The Massachusetts General Hospital Department of Psychiatry has placed curated
online stress reduction resources and links to MBI trainings (for both patients and
providers) that can be accessed here: https://www.massgeneral.org/psychiatry/guide-to-mental-health-resources.
Conclusions
Meditative- and mindfulness-focused interventions may improve neuropsychiatric symptoms
commonly comorbid with neurological disorders. Mindfulness-based interventions (i.e.,
MBSR, MBCT) have the strongest evidence, particularly for preventing relapse to depression
and reducing depressive, anxiety, and chronic pain symptoms. Although mindful movement-based
interventions (i.e., yoga, tai chi) show promise for common neuropsychiatric symptoms,
higher quality studies that systematically track adverse events are needed. Overall,
more research is warranted examining meditative- and mindfulness-focused interventions
in neurological populations, specifically. Health care providers should consider structural
(e.g., insurance reimbursement) and patient factors (e.g., ability to tolerate group
formats) when referring to these mind–body therapies.
