more_vert
IT’S the flavour of the month at the moment, with promises it can fix everything from stress to chronic pain.
The US Army is even using the psychological technique to prepare soldiers for the stress and dangers of battle, believing it can equip them with a sort of “mental armour”.
But should we perhaps be a bit more mindful about the vaunted benefits of mindfulness?
The idea that we can make our lives better, improve our wellbeing and our health, simply by shifting the way we think about things is immensely seductive.
Recent studies, though, raise questions about whether the benefits are as impressive as has sometimes been claimed.
A 2014 review, for example, revealed mixed results.
The researchers did find moderate evidence for small improvements in anxiety, depression and pain. Although small, the improvements in anxiety and depression were actually similar in magnitude to those achieved with antidepressants, but that’s another story.
There was little or no evidence of benefit, however, for the other conditions studied, which included stress, mental health-related quality of life, mood, attention, substance use, eating habits, sleep and weight.
The researchers, from Johns Hopkins University in the US, ended up giving qualified support for clinical use of mindfulness-based techniques in some patients, while cautioning that the scarcity of properly conducted trials made it difficult to draw definite conclusions.
From the more than 18 000 citations they identified, only 47 trials met their quality criteria for inclusion (ie, randomised controlled trials with adequate controls for placebo effects).
- Related: MJA — Mindfulness training: an adjunctive role in the management of chronic illness?
- Related: MJA — Mindfulness-based cognitive therapy: an efficacious community-based group intervention for depression and anxiety in a sample of cancer patients
Previous reviews had been more enthusiastic about the benefits of mindfulness meditation, but the reason could be that they had also been more willing to include poorer quality studies.
Another study, published this month, raises further questions about the quality of the evidence.
Canadian researchers examined 124 published trials of mindfulness-based therapy and found a suspiciously high rate of statistically significant benefits being reported.
Based on the small size of most trials, the researchers calculated that just over 50% of them might have been expected to report a statistically significant finding.
In fact, 88% concluded mindfulness-based therapy was effective.
“A concern … is that the overwhelmingly statistically significant results in favour of [mindfulness-based therapy] interventions that can be seen in the published literature, despite very low power in many studies, may be influenced by reporting biases,” the researchers wrote.
Reporting bias is, of course, a concern across most fields of science. It’s not really surprising that researchers and journals are more motivated to publish studies with significant findings of benefit than those with equivocal results.
But a serious overestimation of benefits has consequences, even when you’re dealing with something as apparently innocuous as mindfulness.
It may be unlikely anybody will suffer toxic side effects from an overdose of meditation, as they might with an overhyped drug therapy.
But there’s always the risk a seriously ill person will neglect evidence-based treatment if they have somehow become convinced that an alternative approach is the panacea for all their problems.
A recent article by Princeton philosopher Dr Andreas Schmidt makes a case for “cautious optimism” about the usefulness of mindfulness-based interventions, while also discussing potential ethical concerns.
Could mindfulness programs be used, for example, by corporations (or presumably the US military) to make individual employees responsible for the stress they experience at work, rather than adopting organisational strategies to mitigate it?
“This is indeed a good argument not to overstate the role and effectiveness of mindfulness,” Dr Schmidt writes.
We must not allow the current hype about the technique to “crowd out discussion of organisational and social determinants of stress, lowered well-being, and mental illness and the collective measures necessary to address them”, he writes.
Because, in the end, no matter how much we might want one, there’s no such thing as a panacea.
Jane McCredie is a Sydney-based science and medical writer.
“Could mindfulness programs be used, for example, by corporations (or presumably the US military) to make individual employees responsible for the stress they experience at work, rather than adopting organisational strategies to mitigate it”
Yes, heaven forbid! People might actually have to be more responsible for their behaviours. This is hardly a balanced report. The author is almost gleeful that she’s found reports that are not emphatically supportive of mindfulness therapy! As far as I’m aware no one has ever said it was a panacea and has never been reported as such.
Jane McCredie is right to ask for vigilance about hype but there are some big problems with one of the evidence reviews that she relies on.
The JAMA review (Goyal et al) only includes psychological outcomes and not other important clincial outcomes. So studies looking at pain, or blood pressure, or function, are not in the JAMA examination. This review also excluded studies with “existing practice” control groups, so comparisons against usual care were also dismissed. The authors (Goyal et al) agreed post publication with some of these problems. This Evidence Map of Mindfulness prepared by investigators from the Evdience-based Synthesis Program in LA may be of interest to readers as an alternative approach to the evidence. It documents effect-size and literature size. A lack of evidence shouldn’t be seen as a lack of effect.
The big challenge for mindfulness at the moment is that it’s being spruiked intensively and there are people teaching it who have little training or skill. These things are feeding the mindfulness backlash that we currently see.
The components of a mindfulness based intervention should include a 6 to 8 week structured program led by a credentialled or experienced faciltator with a minimum of 9 hours of instruction to the particpant along with home practice. One way in which mindfulness works as an intervention is that by engaging in a number of “mindfulness practices” and with expert facilitation, an individual can begin to recognise the ways they relate to their experience and then choose to respond differently.
Yes, mindfulness, especially mindfulness meditation is not a cure all for psychological distress and DSM labelled illnesses. However, the evidence base is indeed growing to show that Dialectical Behviour Therapy is a transdiagnostic treatment for many mental health disorders (Linehan 2015). DBT contains a focus skilful action including mindfulness. Linehan carefully describes mindful behaviour, which may look different to the ‘flavour of the month’ mindfulness and meditation as taught in the community and in others treatments. DBT is not a panacea and does fail especially when people do not undertake the new behaviours correctly. The principles of DBT skills can easily be taught in schools as a cheap and safe preventative intervention. The rationale for this suggestion is clear – effective treatments shine a light on required prevention interventions – we do not hesitate to promote abstinence from tobacco smoking… I consider it urgent to roll out prevention and early intervention strategies to more people because there is a need to contain the fiscal costs of mental health treatments in an environment of significantly broken public sector systems and increasing demand. Mental health and substance use problems are steadily becoming a public health issue. It remains unclear how we, in the medical profession, can best influency public health policy.