CLINICAL BOTTOM LINE

When compared with an active control, mindfulness meditation programmes can help reduce negative dimensions of psychological stress such as anxiety, depression, stress/distress, in some clinical populations, but their effectiveness is uncertain for improving positive dimensions of mental health and stress-related behaviour.

CLINICAL SCENARIO

Mindfulness meditation has become fashionable for treating stress, stress-related health problems, and promoting wellbeing. You decide to review the evidence for the effectiveness of this therapy. In order to appraise the most robust evidence you are careful to choose evidence that has controlled for the placebo effect in its study design.

QUESTION

Is mindfulness an effective therapy for treating psychological stress, stress-related problems and promoting wellbeing?

SEARCH STRATEGY

PubMed-Clinical queries (Therapy/Narrow): mindfulness AND psychological stress, wellbeing

CITATION

Goyal, M., Singh, S., Sibinga, E.M., et al., Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA internal medicine, 2014. 174(3): pp. 357-368

STUDY SUMMARY

A systematic review assessing the efficacy and safety of meditation programmes on stress-related outcomes in a diverse adult clinical population. Inclusion criteria were:

Type of study: Randomised controlled trials (RCTs) with an active control conducted in a general or clinical setting. Studies were to include adults with a clinical (medical or psychiatric) diagnosis, defined as any condition (eg, high blood pressure, anxiety) including a stressor.

Types of interventions: Structured meditation programmes (any systematic or protocol meditation programme that follows predetermined curricula) consisting of at least four hours of training with instructions to practice outside the training session, including mindfulness-based programmes, mantra-based programmes, and other meditation programmes.

Comparison: Active control, defined as a programme that is matched in time and attention to the intervention group for the purpose of matching participants’ expectations of benefit.

OUTCOMES

Stress-related outcomes that included anxiety, depression, stress, distress, wellbeing, positive mood, quality of life, attention, health-related behaviours affected by stress, pain and weight. Adverse events.

STUDY VALIDITY

Search Strategy: A comprehensive search strategy was used to search electronic databases – MEDLINE, PsycINFO, EMBASE, PsycArticles, Scopus, CINAHL, AMED, and the Cochrane Library – through to June 2013. Reference lists of relevant reviews and included studies were also reviewed. No publication date or language restriction applied.

Review process: Initial screening of titles and abstract, and then full text of those meeting initial selection criteria, were independently reviewed by two trained investigators. Data extracted included intervention fidelity (dose, training, receipt of intervention and participant adherence). Study quality was assessed independently and in duplicate. Differences in opinion were resolved through consensus.

Quality assessment: Reputable methods were used to assess the risk of bias within the included studies. The strength of evidence for each outcome was graded after considering the following four domains: risk of bias, directness, consistency, precision. The assessment of publication bias and its impact on results provided.

Overall validity: A high-quality review involving a large number of RCTs of varying risk of bias.

STUDY RESULTS

A total of 18,753 citations were screened, of which 1,651 full-text articles were assessed for eligibility. From these, 47 RCTs met inclusion criteria and were included in this review. Most trials were short-term but duration ranged from three weeks to five years. Fifteen trials studied psychiatric populations, including those with anxiety, depression, stress, chronic worry, and insomnia. Five trials studied smokers and alcoholics, five studied populations with chronic pain, and 16 studied populations with diverse medical problems, including those with heart disease, lung disease, breast cancer, diabetes mellitus, hypertension, and human immunodeficiency virus infection.

There was moderate evidence that in comparison with non-specific active control (ie, not a known therapy), mindfulness meditation programmes resulted in small improvements in both anxiety and depression at eight weeks and at three to six  months, and pain severity (see table) and low evidence that mindfulness meditation improved stress/distress and mental health-related quality of life.

There was low evidence of no effect, or insufficient evidence of any effect, of meditation on positive mood, attention, sleep, substance abuse and weight. In comparison with specific active controls (comparing effectiveness against known therapies such as drugs, exercise, and other behavioural therapies), there was no evidence that meditation programmes were better for any outcomes. No harmful effects from meditation were reported.

Table: Summary of Results

COMMENTS

• In comparison with other reviews, restricting inclusion criteria to RCTs with an active control provides greater confidence in these results.
• Mindfulness meditation programmes are a useful option for addressing psychological stress but the optimum dose, duration and instructor experience for effective mindfulness training stress reduction programmes is unclear.
• The programmes involved in this review typically provided around 20 to 27.5 hours of training over eight weeks. This level of support may not be readily available to many clinical populations.
• High-quality research with a longer follow-up time is needed to confidently establish the effect of mindfulness meditation on positive dimensions of mental health and stress-related behaviour.

Reviewer: Cynthia Wensley RN, MHSc. Honorary Professional Teaching Fellow, University of Auckland and PhD Candidate, Deakin University, Melbourne. [email protected]