Research Commentary  October 2018
Oct 4, 2018
This is the fourth and final part of the review series on complementary and alternative healthcare in New Zealand, which focuses on mindfulness, meditation and relaxation programmes.
When compared to active control groups mindfulness, meditation and relaxation programmes can help reduce pain (Johannsen, 2018; Smith et al, 2018), reduce PTSD symptoms (Bormann et al., 2018) and can help reduce anxiety and depression in migrant groups (Goyal, 2014). A study by Rojiani, et al. (2017) shows that differences such as gender and cultural identity impact on responses to mindfulness-meditation techniques. We need to tailor interventions to maximise the benefits for different populations.
Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development
The following articles are reviewed:
Article 1: Relaxation techniques for pain management in labour [Intervention review].
The pain of labour can be intense, with body tension, anxiety and fear making it worse. Many women would like to go through labour without using drugs, or invasive methods such as an epidural, and turn to complementary therapies to help to reduce their pain perception and improve management of the pain. Many complementary therapies are tried, including acupuncture, mind-body techniques, massage, reflexology, herbal medicines or homoeopathy, hypnosis, music and aromatherapy. Mind-body interventions such as relaxation, meditation, visualisation and breathing are commonly used for labour, and can be widely accessible to women through teaching of these techniques during antenatal classes. Yoga, meditation and hypnosis may not be so accessible to women, but together these techniques may have a calming effect and help the women to manage by providing a distraction from pain and tension.
The review of eleven randomised controlled trials, with data reported on 1374 women, found that relaxation techniques and yoga may help manage labour pain. However, in these trials there were variations in how these techniques were applied in the trials. Single or limited numbers of trials reported less intense pain, increased satisfaction with pain relief, increased satisfaction with childbirth and lower rates of assisted vaginal delivery. The authors conclude that massage may have a role in reducing pain, and improving women's emotional experience of labour. However, there is a need for further research.
Authors: Smith, C., Levett, K., Collins, C., Armour, M., Dahlen, H. & Suganuma, M.
Citation: Smith, C., Levett, K., Collins, C., Armour, M., Dahlen, H. & Suganuma, M. (2018). Relaxation techniques for pain management in labour [Intervention review]. Cochrane Database of Systematic Reviews, 3. CD009514. doi: 10.1002/14651858.CD009514.pub2.
Article 2: Mindfulness-based cognitive therapy and persistent pain in women treated for primary breast cancer: Exploring possible statistical mediators—Results from a randomized controlled trial.
Improvements in the detection and treatment of breast cancer have resulted in an increasing number of women living long lives after treatment. Unfortunately, many are left with long-term physical and psychosocial morbidities. Persistent post-treatment pain is of considerable concern, affecting one of five breast cancer survivors and with moderate to severe pain lasting, on average, 5–9 years. This form of chronic cancer pain typically leads to complex combinations of physical, psychological, and social distress. Thus, there is growing interest in the use of mindfulness based cognitive therapy (MBCT) approaches that therapeutically target multiple physical and psychosocial symptoms.
Johannsen et al. (2018) based at Aarhus University Hospital in Denmark has evaluated the effectiveness of mindfulness-based cognitive therapy (MBCT) for persistent pain in women treated for primary breast cancer. They conducted a randomised wait-list controlled trial with 129 breast cancer survivors reporting post-treatment pain (score ‡3 out of 10 on pain intensity or pain burden). Participants were randomly assigned to a manualised 8-week MBCT program or a wait-list control group.
Few large scale randomised trials have been designed specifically to evaluate pain. This study suggests that MBCT is effective for managing chronic cancer pain and offers an approach that negates or minimises the need for pharmacological pain management, which adds additional risks and side-effects. Of note, this study reported modest, yet statistically significant reductions in neuropathic pain, which is especially resistant to treatment, thus warranting further investigation. Another strength of this study is exploratory analyses of effect moderators, which identified larger effects in patients with attachment avoidance behaviours, but dampened responses in patients exposed to radiotherapy. Further analyses identified the constructs of mindfulness non-reactivity and pain catastrophising as important mediators of response.
This study illustrates how a well-designed and adequately powered study can address questions of the clinical efficacy of approaches such as MBCT, and also contributes insights into moderators and mediators that can inform the design and delivery of mindfulness-meditation interventions for optimal benefits to patients.
Authors: Johannsen, M., O’Connor, M., O’Toole, M.S., et al.
Citation: Johannsen, M., O’Connor, M., O’Toole, M.S., et al. (2018). Mindfulness-based cognitive therapy and persistent pain in women treated for primary breast cancer: Exploring possible statistical mediators—Results from a randomized controlled trial. Clin J Pain, 34 (1) 59-67.
Article 3: Effectiveness of the Relaxation Response-Based Group Intervention for Treating Depressed Chinese American Immigrants: A Pilot Study.
This pilot study provides preliminary information on the potential impact of a Relaxation Response (RR)-based group intervention for treating depressed immigrant Chinese Americans with lower education and acculturation levels. This population historically underutilises conventional mental health treatment options. Patients were taught to use muscle relaxation, breathing techniques, focused awareness, meditation, yoga and guided imagery to elicit RR. The group was conducted in Cantonese for Chinese Cantonese immigrants.
This study demonstrates the feasibility and safety of using an RR-based group intervention as an intervention for Chinese Americans with Major Depressive Disorder (MDD) in a primary health centre setting. During recruitment, many Chinese patients responded favourably to the idea of stress management, which does not carry the stigma associated with treatment of mental disorders. At baseline evaluation, all participants had positive expectations of the intervention for treatment of depression. 68% of participants completed the intervention (defined as ≥75% attendance), demonstrating satisfactory compliance with treatment. Participants reported high levels of satisfaction and many (64%) were willing to continue their mind-body practice at the end of the study.
The RR-based group intervention showed response rates of 40% and remission rate of 27%. The limitations of the study are the small sample size and there was no control group in which all participants received the intervention. Future studies using a randomised control design are needed. Another limitation is the issue of generalisability. As participants in this study were predominantly recent Chinese immigrants, these results cannot be generalised to other populations.
The RR-based group intervention, an eight-week mind-body intervention, appears to be a feasible and acceptable intervention for immigrant Chinese Americans with MDD in primary health settings. However, future studies with larger sample sizes using randomised controls will be needed to provide more rigorous outcomes analyses.
Authors: Yeung, A., Slipp, L.E., Niles, H. et al.
Citation: Yeung, A., Slipp, L.E., Niles, H. et al. (2014). Effectiveness of the Relaxation Response-Based Group Intervention for Treating Depressed Chinese American Immigrants: A Pilot Study. Int. J. Environ. Res. Public Health, 11, 9186-9201. doi:10.3390/ijerph110909186
Article 4: Individual Treatment of Posttraumatic Stress Disorder Using Mantram Repetition: A Randomized Clinical Trial.
Previous studies suggest that group "mantram" (sacred word) repetition therapy, a non-trauma-focused complementary therapy for posttraumatic stress disorder (PTSD), may be an effective treatment for veterans. This is the first randomised trial to demonstrate the efficacy of mantram therapy delivered individually compared with an active comparison treatment. The study compared individually delivered mantram repetition therapy and another non-trauma-focused treatment for PTSD. In the randomised trial of 173 veterans receiving non-trauma-focused interventions, mantram repetition therapy was associated with greater reductions in the clinician-rated primary outcome measure at the post-treatment and 2-month follow-up assessments than present-centred therapy, with a moderate effect size at both time points.
Mantram therapy was also associated with greater reductions in self-reported PTSD symptom severity at the post-treatment assessment but not at the 2-month follow-up assessment. More mantram participants no longer met criteria for a PTSD diagnosis at the 2-month follow-up. The proportion of participants with a reduction of 10 points in CAPS score did not differ between treatment arms. Finally, mantram therapy was associated with moderate effect-size reductions in insomnia at both time points.
Mantram therapy delivered individually appears to be more effective than the group format used in previous studies. This trial’s design addressed frequent criticisms of complementary therapy research, including the absence of an active comparison arm to control for nonspecific effects of therapy. The findings add to the literature showing that non-trauma- focused therapies for PTSD can yield substantial improvements in PTSD symptoms. Mantram therapy is also briefer than some other PTSD psychotherapies, and the authors observed a 78% retention rate during active mantram treatment.
Authors: Bormann, J.E., Thorp, S.R., & Smith, E., et al.
Citation: Bormann, J.E., Thorp, S.R., & Smith, E., et al. (2018). Individual Treatment of Posttraumatic Stress Disorder Using Mantram Repetition: A Randomized Clinical Trial. American Journal of Psychiatry. doi: 10.1176/appi.ajp.2018.17060611.
Article 5: Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis.
To purpose of this review and meta-analysis was to evaluate the efficacy of meditation programmes in improving stress-related outcomes in diverse adult clinical populations. Eligible studies were randomised controlled trials that compared structured meditation programmes against active controls (matched for time and attention to intervention) for adults (18 years or older) with a medical or psychiatric diagnosis or with stress-related symptoms that may not have been medically or psychiatrically diagnosed. Meditation programmes had to consist of a minimum of four hours of training with instructions to practice outside the training sessions and could include mindfulness based programmes, mantra-based programmes and other meditation programmes. Programmes where meditation was not the foundation or major part of the intervention were excluded.
Interventions varied between studies and included mindfulness-based stress reduction, cognitive therapy or meditation; mantra; and transcendental meditation. Control groups included non-specific active comparisons such as education and support and specific active comparisons such as relaxation, cognitive behavioural therapy, exercise or drugs. Outcomes were measured by a wide variety of tools. Patients included those with anxiety, depression, stress, chronic worry and insomnia, smokers, alcoholics, chronic pain or mixed populations with diverse medical conditions including heart disease, lung disease, breast cancer, diabetes mellitus, hypertension and HIV.
Forty-seven trials (3,515 participants) were included in the review. Ten trials were rated good quality, 24 were rated fair and 13 were rated poor. Trial duration ranged from three weeks to 5.4 years but most were reported to be short term. Comparison with nonspecific active controls: Mindfulness meditation programmes had moderate evidence of improved anxiety, depression and pain and low evidence of 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 programmes on positive mood, attention, substance use, eating habits, sleep and weight gain. There was insufficient evidence that meditation programmes had an effect on health-related behaviours affected by stress, including substance use and sleep. There was low evidence of no effect or insufficient evidence of an effect for mantra meditation programmes on any psychological stress or well-being outcomes.
Comparison with specific active controls: There was low evidence of no effect or insufficient evidence that any of the meditation programmes were more effective than exercise, progressive muscle relaxation, cognitive-behavioural therapy or other specific comparators in changing any of the outcomes of interest. There was no evidence of any potential harm reported in the nine trials evaluating this outcome.
The authors concluded that meditation programmes resulted in small to moderate reductions of multiple negative dimensions of psychological stress. Therefore, clinicians should be prepared to talk with their patients about the role that a meditation programme could have in addressing psychological stress.
Authors: Goyal, M., Singh, S., Sibinga, E.M.S. et al.
Citation: Goyal, M., Singh, S., Sibinga, E.M.S. et al. (2014). Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis. JAMA Intern Med, 174(3), 357-368.
Article 6: Women benefit more than men in response to college-based meditation training.
This study by Rojiani et al. (2017) found that mindfulness meditation, in which practitioners focus on attending to the present moment without judgment, may have greater benefits for women. The study looked at 77 undergraduate students taking a 12-week course on mindfulness that featured 30 minutes of meditation three times per week. Compared with men, women showed greater decreases in negative affect (including emotions like guilt or irritability) and greater increases in mindfulness and self-compassion. Moreover, for women, decreases in negative affect were significantly correlated with improvements in mindfulness and self-compassion. In contrast, men’s improvements in mindfulness and self-compassion did not correlate with improvements in negative affect, on average (to the extent that negative affect did improve for men, changes were correlated with the ability to identify, describe, and differentiate one’s emotions).
This study suggests that college-age men and women may have divergent responses to meditation training. Specifically, women benefit more by demonstrating decreased negative affect and improved mindfulness and self-compassion skills. Conversely, men did not show improvements in negative affect, nor did improvements in mindfulness and self-compassion translate to improved affect as it did in women. This is one of the first studies to show affective gender differences in response to meditation training. These results have significant implications for the potential of mindfulness training, particularly to help close gaps in psychological wellbeing between men and women. This research also contributes to the general understanding of gender-specific emotion regulation pathways. The results suggest gender-specific treatment outcomes may become increasingly salient for men, as they may require mindfulness interventions better matched to the particular coping styles they tend to use. It is also important to consider that mindfulness interventions may be contra-indicated for some individuals. Furthermore, these interventions may require greater attention toward the particular ways men may present issues of psychological or emotional distress.
The authors suggest that rather than focusing too much on whether mindfulness meditation is “better” for women, a key finding of the study is the importance of tailoring of interventions for different populations. For example, for anyone who identifies more with masculinity and prefers more active methods of processing stress, a more active mindful activity like Tai Chi or yoga might be more beneficial than meditation. Differences such as gender and cultural identity impact on responses to mindfulness-meditation and relaxation techniques and we need to tailor interventions better to recognise these differences in response.
Authors: Rojiani, R., Santoyo, J.F., Rahrig, H., et al.
Citation: Rojiani, R., Santoyo, J.F., Rahrig, H., et al. (2017). Women benefit more than men in response to college-based meditation training. Front Psychol, 8, 551.