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Patricia A. Bloom, MD, FACP, AGSF
Clinical Associate Professor
Brookdale Department of Geriatrics and
Palliative Medicine
Mount Sinai Medical Center
New York, NY
The Benefits of Mindfulness: What Is the Evidence?
LEARNING OBJECTIVES
At the conclusion of the session, participants will be able to:
1) DESCRIBE the physiology of the stress response
2) DISCUSS the evidence for the benefits of mindfulness for
physical and psychological conditions
3) TEACH a simple mindfulness practice to their patients
Financial Disclosure
None
Mindfulness Experience
What Is Mindfulness?
▶ Involves the deliberate cultivation of specific qualities of attention and awareness
▶ Focus on the reality of the present moment, accepting and acknowledging it, without getting caught up in thoughts about, or emotional reactions to, it
▶ Approach to stressful situations which promotes response rather than reaction
▶ “Buddhist meditation without the Buddhism” (Kabat-Zinn)
Mindfulness in the Mainstream
▶ Academic medical literature
– 1982: 1 article; 2015: 641 • Mindfulness Research Monthly, David Black PhD
• www.amra.org
▶ MBSR (MBPM, MBSR-T, MBRP, MBCP, MBEC = MBIs)
▶ Psychiatry: MBCT (Oxford grad program), ACT, DBT
▶ Psychology: many therapies
▶ Education (SMART in Education, Mindful Schools)
▶ Law
▶ Business executives/corporations (Mindful Leadership)
▶ Spiritual practice
McMindfulness, Inc.
Mindfulness-Based Stress Reduction
U Mass Worcester Center
for Mindfulness 1979-
present
22,000 patients, referred
by 5,000+ MDs, at Umass
16,000+ professionals
have been trained
750+ clinical sites around
the world
Extensive body of
research
MBSR Program Structure
▶ 8-week course
▶ Mixed diagnoses
▶ 1 session/week, 2.5 hours + daylong retreat
▶ Learning formal mindfulness practices and how to apply in everyday life
▶ Daily practice and “homework”
MBSR at Mount Sinai
Stress: The Good
(the “Acute Stress Response”)
▶ Brain stem activates sympathetic NS: increased BP, P
▶ Hypothalamus secretes CRH, pituitary secretes ACTH, cortisol from adrenals mobilizes glucose
▶ Immune system releases inflammatory cytokines
▶ Muscles able to contract instantly for “fight or flight”
Slides13, 14, 15, 20: Sapolsky RM. Why Zebras Don’t Get Ulcers. Henry Holt, NY, 2004.
Many Diseases are Associated with Stress
▶ Cardiovascular: Hypertension, heart failure, coronary artery disease, “broken heart”
▶ Metabolic: diabetes, obesity
▶ Gastrointestinal: ulcers, functional disease
▶ Reproductive: decreased hormone secretion, sexual function and libido in males and females
▶ Psychiatric: anxiety, depression
The BAD: Chronic Stress
▶ Over time, the stress response becomes
damaging
▶ Chronic or repeated stressors have the
potential to produce illness
The Default Network of the Brain
“Like Velcro
for the
negative,
and Teflon for
the positive”
-Rick Hanson
Stress and Cellular Aging
▶ High levels of perceived stress and duration of
stress in mothers of disabled children
significantly associated with:
– Higher levels of oxidative stress
– Lower telomerase activity
– Shorter telomere length
Epel ES, Blackburn EH, Lin J et al, Accelerated telomere shortening in response
to life stress, PNAS 2004, 101: 17312-17315
McEwen BS, Protective and Damaging Effects of Stress Mediators, NEJM
1998; 338: 171-179.
Understanding the Mechanisms of the Benefits of Meditation
Stress: The Good
(the “Acute Stress Response”) ▶ Brain stem activates
sympathetic NS: increased BP, P
▶ Hypothalamus secretes CRH, pituitary secretes ACTH, cortisol from adrenals mobilizes glucose
▶ Immune system releases inflammatory cytokines
▶ Muscles able to contract instantly for “fight or flight”
Sapolsky RM. Why Zebras Don’t Get Ulcers. Henry Holt, NY, 2004.
Dru-gu Choegyal
Rinpoche, of the
Mind Life Institute
studies
22
Advances in Neuroimaging:
MR Diffusion Tensor Imaging
Mindfulness practice leads to increases in
regional brain gray matter density
▶ 16 healthy, meditation-naïve participants underwent 8-week MBSR course, c/w 17 wait-list controls
▶ Pre and post anatomical MR images investigated
changes in gray matter concentration ▶ Significant increases in gray matter concentration in
participants in L hippocampus, posterior cingulate cortex, temporoparietal junction, and cerebellum
▶ Suggests ability of mindfulness training to increase
gray matter concentration in areas of brain assoc w learning, memory and emotion regulation
Holzel et al, Psychiatry Research: Neuroimaging 191: 2011; 36-43
Insel TR. Faulty Circuits. Scientific American, April 2010
The Depression Circuit
“Neurons that fire together, wire together”
Thalamus
Pre-frontal
cortex
Amygdala Hypothalamus
Pituitary Brain
stem
Sympathetic
response
Adrenal
steroids
+
-
Limbic loop
Train Your Brain Engage Your Heart Transform Your Life (Sood A, MD)
“Neurons that fire together,
wire together” – Donald Hebb
Thalamus
Pre-frontal
cortex
Amygdala Hypothalamus
Pituitary Brain
stem
Sympathetic
response
Adrenal
steroids
Cortical Loop
- -
Train Your Brain Engage Your Heart Transform Your Life (Sood A, MD)
The Evidence: How Good Is It?
MBIs for Physical Conditions:
Levels of Evidence ▶ Level 1 (meta-analysis of RCTs)
– Reduction in BP
– Improvement in anxiety, depression, stress, QOL in cancer patients
▶ Level 2 (RCTs using TAU, waitlist, active controls) – Decrease in proinflammatory cytokines, cortisol in cancer patients
– Decreased chronic pain (including weaker evidence for headaches)
– Decreased low back pain
– Decreased fibromyalgia pain
– Improvement in RA
– Decreased mortality, nonfatal MI, stroke (48%) in CAD patients
– Improved glycemic control in diabetics
– Improved psychological functioning and stability of CD-4 T-cell cts in HIV/AIDS
– Improvement in IBS
– Improved anxiety and sleep in organ transplant patients
Carlson LE. Mindfulness-Based Interventions for Physical Conditions. ISRN Psychiatry, Vol 2012
Article ID 651583 doi: 10.5402/2012/651583
MBIs for Psychological Conditions
Goyal M, Singh S, Sibinga EM et al. Meditation programs for psychological
stress and well-being: A systematic review and meta-analysis. JAMA Intern
Med. Doi:10.1001/jamainternmed.2013.13018
- Reviewed 18,753 citations, included 47 trials, 3515 participants.
- Mindfulness meditation programs had moderate evidence of improved
- anxiety (effect size 0.38 @ 8wks, 0.22 @ 3-6 mo)
- depression (0.30 @ 8 wks, 0.23 @ 3-6 mo)
- pain (0.33)
- Conclusion “Physicians should be prepared to talk with their patients
about the role that a meditation program could have in addressing
psychological stress. Stronger study designs are needed to determine the
effects of meditation programs in improving the positive dimensions of
mental health and stress-related behavior.”
30
Mindfulness and Cardiovascular Disease Risk
▶ Evidence of possible impacts of mindfulness on:
– Physical activity
– Smoking
– Diet
– Obesity
– Blood pressure
– Diabetes regulation
▶ Plausible mechanisms:
– Improved attention control (ability to hold attention on experiences of smoking, diet,
physical activity, medication adherence)
– Emotion regulation (improved stress response, self-efficacy, & skills to manage craving
for cigarettes, certain foods, sedentary activities)
– Self-awareness (of physical sensations related to cardiovascular risk factors)
31
Loucks EB, Schuman-Olivier Z, Britton WB et al, Curr Cardiol Rep (2015) 17:112.
MBSR for Physicians
▶ Krasner MS, Epstein RM, Beckman H et al. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. JAMA. 2009;302(12): 1284-1293.
– 8 wk MBSR program plus 10 month maintenance phase
– Participants demonstrated improvements in
• Mindfulness
• Burnout
• Physician belief scale
• Total mood disturbance
• Personality (conscientiousness and emotional stability)
Mindfulness and Pain
Hypotheses Concerning the Role of Mindfulness in
Reducing Chronic Pain
▶ By “turning towards the pain”, mindfulness increases non-reactivity and reinterpretation of pain symptoms
▶ Mindfulness reduces pain attentional bias (i.e.hyper-vigilance towards pain) and pain severity
▶ Mindfulness rewires brain circuitry that accentuates pain perception
From Eric Garlands’s MORE Program 34
MBSR vs. CBT vs. Usual Care for Chronic Low Back Pain
▶ Randomized, interviewer-blind, clinical trial
▶ MBSR (n=116) and CBT (n=113) delivered in 8 weekly 2 hour groups; usual care (n=113)
▶ Back pain mean duration 7.3 years
▶ Clinically meaningful improvement in Roland Disability Questionnaire seen in 60.5% of MBSR and 57.7% of CBT participants on intention-to-treat analyses at 26 weeks, vs. 44.1% for usual care (p = .04)
▶ Clinically meaningful improvement in pain bothersomeness seen in 43.6% of MBSR and 44.9% of CBT participants at 26 weeks, vs. 26.6% UC
▶ MBSR & CBT improvements persisted with little change at 52 weeks
Cherkin DC, Sherman KJ, Balderson BH et al. JAMA. 2016; 315(12):1240-49. doi:10.1001/jama.2016.2323
35
JAMA Medical News and Perspectives (online 5/20/16)
As Opioid Prescribing Guidelines Tighten,
Mindfulness Meditation Holds Promise for Pain Relief
“The relative low risk of adverse events makes it not
inappropriate to recommend mindfulness practice to
patients as a supplement to other ongoing strategies to
control chronic pain.”
-Josephine Briggs, MD
Director, NIH Center for Complementary
and Integrative Health (NCCIH)
36
ACP Clinical Guideline
Noninvasive Treatments for Acute, Subacute, and
Chronic Low Back Pain
Recommendation 2: For patients with chronic low back pain,
clinicians and patients should initially select nonpharmacologic
treatment with exercise, multidisciplinary rehabilitation,
acupuncture, mindfulness-based stress reduction (moderate-
quality evidence), tai chi, yoga, motor control exercise,
progressive relaxation, electromyography biofeedback, low-level
laser therapy, operant therapy, cognitive behavioral therapy, or
spinal manipulation (low-quality evidence). (Grade: strong
recommendation)
Qaseem A, Wilt TJ, McLean RM, Forciea MA. Ann Intern Med. Doi: 10.7326/M16-2367. February 14, 2017.
Mindfulness for Spine Surgery Patients
Mindfulness for Memory and Cognition
Neurocognitive Studies of Meditators
▶ Increased sustained attention
▶ Reduction in response time
▶ Improved cognitive flexibility and speed of processing visual information (Moore A, Malinowski P. 2009; Conscious Cogn. 18: 176-186)
▶ Improvement in working memory
▶ Decreased anxiety, negative affect, and depression
Newberg AB, Serruya M, Wintering N. Meditation and neurodegenerative
diseases. Ann NY Acad Sci 2013; xxxx: 1-12.
Potential Effects of Meditation on Age-Related Cognitive
Decline: A Systematic Review
12 studies/6 RCTs, wide variety meditation techs
Positive effects:
Attention, memory, executive fnctn, processing
High risk of bias, small sample sizes
Low dropout, high compliance
Gard, Holzel, Lazar. Ann NY Acad Sci. 2014. 1307: 89-103 41
Mindfulness Caveats
1. Adverse effects of Mindfulness
Lindahl JR, Fisher NE, Cooper DJ, PLOS ONE, May 24, 2017
2. We don’t know that much about how the brain works
Leichtman, Harvard neuroscientist
3. Mindfulness is not for everyone!
Mindfulness With
Your Patients
Breath Rising and Falling
“Breathe in naturally, and observe what
happens to the body: it rises a bit. You can
feel this if you put your hand on your chest or
belly. Breathe out and it falls a bit and
relaxes. Continue, paying attention to the
rising and falling sensation. If your mind
wanders, don’t worry, that’s natural, just
come back to the awareness of breath in the
body, rising and falling.”
46
Stop
Take a breath
Observe (body,
emotions,
thoughts)
Proceed
Experience:
Take a Breath
Experience: Feel Your Body
Experience: Name Your Emotion Notice Your Thoughts
Stop
Take a breath
Observe (body,
emotions,
thoughts)
Proceed
