Mindfulness Matters

Mindfulness Matters


The Science of Mindfulness

posted by Dr. Arnie Kozak

BS16096A recent analysis of mindfulness research studies (known as a meta-analysis) was published by the Association for Health and Research Quality (AHRQ). This government agency does major reviews of various therapies.

The good news is that mindfulness has come of age to attract such a review. The bad news, if you will, is that the modest results appear to run counter to the current wild enthusiasm for mindfulness. How can we understand this apparent incongruity?

The main reason is methodology. AHRQ reviews only include studies that meet stringent criteria. The vast majority of mindfulness studies did not meet these criteria. In fact, only .2 percent were included. Not all of these excluded studies focused on mindfulness, many implemented transcendental meditation.

Peer review versus gold standard. Grant supported versus Many of the mindfulness studies published over the last thirty-five years have appeared in peer-reviewed journals. However, peer review is not the most stringent criteria. The AHRQ study concludes:

After reviewing 18 753 citations, we included 47 trials with 3515 participants. Mindfulness meditation programs had moderate evidence of improved anxiety (effect size, 0.38 at 8 weeks and 0.22  at 3-6 months), depression 0.30 at 8 weeks and 0.23 at 3-6 month, and pain (0.33) and low evidence of improved stress/distress and mental health–related quality of life. We found low evidence of no effect or insufficient evidence of any effect of meditation programs on positive mood, attention, substance use, eating habits, sleep, and weight. We found no evidence that meditation programs were better than any active treatment (ie, drugs, exercise, and other behavioral therapies).

Understanding this study is part understanding scientific literacy, part philosophy of science, and part epistemology.For more on research methodology read the interview with Willoughby Britton, a neuroscience researcher at Brown University Medical School.

The popular consumption of science contains much misunderstanding. If you read that something has been “proven” be careful. It is very difficult to prove anything. What science can do, with well constructed studies, is disprove things. This is the principle of falsifiability.

If a study gets a positive result that is evidence that supports the hypothesis that this treatment, let’s say, works better than chance. But you never know when future evidence may contradict what you’ve found. Accumulated evidence is good but it is not definitive. A study that finds a negative result may be more definitive if the methodology of the study is robust enough to support that claim. this is known as “power” in statistics and a study must have a sufficient number of subjects and other design characteristics before you conclude that the difference between the treatment group and the non-treatment group (placebo) were no different than chance variations. If scientists replicate such studies and consistently find a non-result, it is reasonable to conclude that the treatment offers nothing beyond a placebo response.

With mindfulness, we simply don’t know enough yet. There is much to encourage that with sufficient methodological rigor, mindfulness intervention studies will continue to demonstrate benefit. There are many other effective forms of treatment, such as cognitive behavioral therapies. Mindfulness may not be superior to these other forms of treatment and this does not mean that it not effective, just not incrementally more effective. Studies study groups and the results of a study report group averages. Individual results will vary.

Efficacy is not the same as effectiveness and a placebo response is always part of a positive result. Studies attempt to remove sources of variability and create a controlled labaroatory envireonment. These conditions do not replicate real life. There is a difference between participating in a research study on stress and being referred by your physician to a mindfulness-based stress reduction group in the community.

The small mindfulness database does not mean that mindfulness does not work. It means that there is not enough rigorous scientific studies yet. It costs more to run a high level study. It requires more subjects and an active control group. this adds complexity and expense. Mindfulness studies are just now getting funded.

In the “real” world outside the laboratory, when people seek treatment, they bring with them a set of expectations for response. This is the power of the placebo response and it is active in almost every treatment, including drug treatments (and especially with drugs that treat anxiety and depression). The goal in clinical practice is not to eliminate the placebo effect. In fact, the opposite. What you don’t want is a treatment that works only via placebo. The results of the AHRQ study suggest this not the case for mindfulness, but more research needs to be done. When people undergo mindfulness-based interventions, they receive benefit.



  • saijanai

    You mention the recent AHRQ study, but don’t mention the review published last year by the American Heart Association that found that only Transcendental Meditation had sufficiently robust and consistent evidence that it lowered blood pressure, while other meditation practices could not be supported. Basically, the AHA said that doctors could recommend TM to their patients, but explicitly said that MBSR and other practices were not recommended at this time:

    Beyond Medications and Diet: Alternative Approaches to Lowering Blood Pressure
    http://hyper.ahajournals.org/content/61/6/1360.full

    .

    The AHA called for head-to-head studies of TM vs whatever to be absolutely certain that this was the situation…

    …the question of which meditation is best for what purpose, based on which study you look at, is the subject of on-going debate and this will continue for quite a few years, probably for several decades.

    The biggest problem is not the lack of studies that use “active controls” because even those studies have several major flaws, not the least of which is that the attitude of the researchers rubs off on the people conducting the seminars for the active controls.

    What is actually needed are jointly-done, head-to-head studies conducted by researchers with competing agendas, where mindfulness researchers, TM researchers, etc, jointly design and conduct studies that compare various practices.

    One such study was done 25 years ago by a team that included mindfulness researcher and Harvard Professor Ellen Langer, and TM researcher, Charles Alexander.

    The teachers of meditation were all trained to be as professional in their appearance and attitude as the TM teachers, memorizing what they would say, using professionally done graphics, and wearing professional business attire when speaking to their students.

    Students were randomly assigned to TM, mindfulness, Relaxation Response (called “low-mindfulness relaxation” due to politics at Harvard), or no treatment.

    Students received an intro lecture from their new meditation teacher, and were given a questionaire to determine their level of expectations. No significant differences were found in the various groups. All researchers were blind to subject participation, and data was collected by graduate students from Harvard University who didn’t know any details either.

    The study is the poster child for how meditation research should be conducted but no-one outside the TM organization has been willing to try to redo it for reasons that will be obvious:

    http://www.ncbi.nlm.nih.gov/pubmed/2693686
    Transcendental meditation, mindfulness, and longevity: an experimental study with the elderly.

    Abstract
    Can direct change in state of consciousness through specific mental techniques extend human life and reverse age-related declines? To address this question, 73 residents of 8 homes for the elderly (mean age = 81 years) were randomly assigned among no treatment and 3 treatments highly similar in external structure and expectations: the Transcendental Meditation (TM) program, mindfulness training (MF) in active distinction making, or a relaxation (low mindfulness) program. A planned comparison indicated that the “restful alert” TM group improved most, followed by MF, in contrast to relaxation and no-treatment groups, on paired associate learning; 2 measures of cognitive flexibility; mental health; systolic blood pressure; and ratings of behavioral flexibility, aging, and treatment efficacy. The MF group improved most, followed by TM, on perceived control and word fluency. After 3 years, survival rate was 100% for TM and 87.5% for MF in contrast to lower rates for other groups.

    .

    Until studies like this become common, you won’t be able to tell what is what, with certainty, concerning the various meditation practices.

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