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Paul Kiritsis, PsyD candidate, DPhil., MA (Psychology), MA (History)

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The Therapeutic Efficacy of Mindfulness Meditation on Depression

Paul Kiritsis - Wednesday, December 03, 2014

In the last twenty years there has been a swift increase in the publication of clinical studies about alternative and complementary treatments to conventional medicine like mindfulness-based interventions and their efficacy in contending with a whole continuum of psychological conditions from anxiety and depression to more organic variants like stress-related somatic symptoms (Baer, 2003; Strosahl & Wilson, 1999; Salsman & Linehen, 2006). One of the most common types is Mindfulness Meditation (MM), which has been defined as the process of “bringing one’s complete attention to the present experience on a moment to moment basis (Marlatt & Kristeller, 1999)” as well as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally (Kabat-Zinn, 1994).”

Meditation can be understood as the intentional focusing of attention to internal or external phenomena for the purpose of acquiring a sense of peaceful repose. Mindfulness, on the other hand, is the detached, impartial observation of sensation, thought, feeling, proprioception, and what not that might drift in and out of conscious awareness from moment to moment. Together they suspend the habitual patterns of the mind and its tendencies to cogitate about past and future, amplifying awareness of the present moment. More importantly they foster a ‘stillness’ through which increments in self-awareness, self-compassion, and insight may be cultivated. Because this ability doesn’t come naturally to human beings, researchers subjecting their experimental groups to MM will frequently evoke segues with animate imagery such as insignificant events at a train station or vicissitudes in the morphology of the heavens (Baer, 2003). The degree of decentering and detachment experienced during MM has led some researchers to label the entire process ‘metacognitive insight’ (Teasdale, 1999). Experimental studies have found that sustained MM practice both breaks down regimented cognitive schemas so that they become more adaptive and flexible in nature and promotes constructive experiences in objectivity, acceptance, and meta-cognition (Baer, 2003; Brown & Ryan, 2003; Hayes & Kelly, 2003). Deploying such practices in one’s day-to-day routine should expedite mind-brain-body balance and health along with heightened, improved, or deeper feelings of wellbeing, or so the rationale underlying these momentous research finds inform us.

Despite the contemporary experimental emphasis on relapse prevention, there is ample research supporting the contention that MM practice alleviates the symptomology of depression (Broderick, 2005; Teasdale, Segal, & Williams, 1995). And what exactly is depression?  From a purely clinical standpoint, the loosely connected conglomeration of dysphoric symptoms parading under the banner of ‘depression’ may involve different psychological mechanisms but are united by dysfunctional attitudes which consistently generate internal, global, and stable attributions (Abramson, Seligman, & Teasdale, 1978). Depressive clients will consistently perceive causes with negative consequences as having something to do with them; they’ll identify these causes as encompassing the ability to profoundly influence multiple areas of their life; and they’ll believe the cause to be a permanent and immutable fixture in their lives.

Hence we have an attributional process that is internal, global, and stable. This detrimental and sabotaging way of relating to self-referent content is intimately bound with rumination, the propensity of the mind to ponder past and future, and with a genuine incapacity to disengage from the interconnected nexus of negative thoughts, negative emotional appraisals, dysphoric moods, and consequent maladaptive behaviors. If such a vicious cycle is allowed to continue uninterrupted for protracted periods, the respective individual suffers injuries to the somatic self through dysregulation of the nervous and immune systems and organic disease; loses homeostatic balance between higher-order functions of cognition and emotion; and disengages from the social synapse because of a genuine inability to maintain healthy interpersonal relationships (Cozolino, 2014). MM is effective because it redirects focal attention to foreground processing of mental and somatosensory stimuli in the unappraised present, severing the link between conscious awareness and an attributional process ready to conform to unfavorable appraisals and judgments that have gone before once rumination begins (Ramel, Philippe, Carmona, & McQuaid, 2004). Logically, then, the best way of countering a flow of self-referent thoughts imbued with negativity and dysphoria is to displace them. What's more the displacement appears to motivate profound insights concerning the manner in which incoming sensory information may be blanketed and incapacitated by maladaptive cognitive schemas (Baer, 2003; Hayes & Kelly, 2003). Who would have thought that a small tweak in cognitive tendencies could have such profound implications?

Recent clinical studies showing consistencies between the deployment of MM and reductions in depression and depressive mood have definitely been instrumental in cementing the abovementioned correlation. In a MM study incorporating aspects of yoga movement, meditation, and controlled breathing (Ando, Morita, Akechi, Ito, Tanaka, Ifuku, & Nakayama, 2009), Japanese patients undergoing anticancer treatment were guided through one experimental session and then expected to deploy the techniques at home for a two-week period. For the pre and post intervention quantification of anxiety, depression, and wellbeing, experimenters utilized the Hospital Anxiety and Depression Scale [HADS] and the Functional Assessment of Chronic Illness Therapy–Spiritual [FACIT-Sp]. Upon completion of the trials and subsequent analysis of the questionnaires they discovered significant decreases in both HADS (p = 0.004) and FACIT–Sp (p = 0.69) scores, indicating that MM is a constructive and favorable adjunct for Japanese cancer patients. In yet another study with a non-equivalent, control group, and pre and post-test design (Kang, Choi, & Ryu, 2009), nursing students from Korea consigned to an experimental group were subjected to a ninety-minute sessions of MM for eight consecutive weeks. Kang and her associates measured stress with Chang’s 5-point PWI-SF, anxiety with Spieberger’s state anxiety inventory, and depression with the Beck depression inventory. Interestingly the results revealed a statistical significance for both stress (F = 6.145, p = 0.020) and anxiety (F = 6.985, p = 0.013) but not depression (t = 1.986, p = 0.056). This curious phenomenon warrants further investigation.

Perhaps the greatest vindication of MM worth has been bequeathed by a randomized clinical trial with rigorous experimental controls that examined whether cognitive behavioral therapy (CBT) or MM might elicit improvements in subjective experiences of chronic stress, pain ,and depression by sufferers of rheumatoid arthritis (Zautra, Davis, Reich, Nicassario, Tennen, Finan, & Irwin, 2008). A total of 144 participants were assigned to one of three groups: a CBT test group for pain, a MM test group for the regulation of emotion, and a control group which received educational material. The MM group was exposed to sitting experiential exercises of 10-minute duration designed to cultivate awareness and the ownership of both positive and negative emotional experiences, an approach pioneered by Kabat-Zinn’s (1990) Mindfulness-Based Stress Reduction (MBSR) approach and Segal et al.’s (2002) Mindfulness-Based Cognitive Therapy (MBCT).

According to the experimenters, the 2-hour long treatments were all administered over an 8-week period under austere protocols. The subjective pre and post effects of this particular intervention on negative and positive affect were all reckoned using the Positive and Negative Affect Schedule (Watson, Clark, & Tellegen, 1988) while depressive symptoms were evaluated with 6-item questionnaires incorporating subjective rankings for interest, general appetite, degree of restlessness, availability of energy, level of self-esteem, and concentration levels. The assessments also factored in those individuals who had a known history of depression and recurrent dysphoria. Juxtaposed with the control and CBT groups, pre and post analysis revealed that the MM group experienced more significant increments in positive affect (p < .001) and efficacy in pain management (p < .01) as well as more significant reductions in negative affect (p <.01). Interestingly individuals in the MM group who possessed a history of recurring depression benefitted most, drawing attention to the powers of ‘metacognitive awareness’ (Teasdale, 1999) and its fundamental role in subverting habitual inclinations of a maladaptive nature.   

Recently, Hofmann, Sawyer, Witt, and Oh (2010) conducted a meta-analytic review of the available clinical samples (individuals diagnosed with medical and psychological disorders) regarding the efficacy of MM on the treatment of depression. Their analysis took into consideration some 39 experimental studies involving 1,140 participants suffering from depression, generalized anxiety disorder, cancer, and other psychiatric and medical illnesses. Certain fundamentals needed to be met for inclusion. The researchers, for instance, deemed it necessary that the MM adjunct used should not have been paired with either Acceptance and Commitment Therapy (ACT) or Dialectical Behavior Therapy (DBT); that there had been pre and post evaluation of symptomologies associated with depression like anxiety and dysphoric mood; that the participants gathered were consenting adults between 18-66 years; and that the congregated data satisfied effect size analyses.

Extrapolating from the effect size estimates, Hofmann et al. (2010) stipulated a moderate effectiveness for MM interventions on the reduction of anxiety (Hedges’ g = 0.63) and mood symptoms (Hedges’ g = 0.59). Evoking the finds of the aforementioned study, those suffering from chronic and recurrent depressive disorders seemed to have experienced greater subjective diminutions in anxiety (Hedges’ g = 0.97) and mood (Hedges’ g = 0.95) than those who did not. The researchers claim that publication bias, treatment lengths, and study quality had nothing to do with the significant effect sizes obtained. An inability to moderate effect size estimates and explicit study selection criteria indicates the presence of some methodological limitations, however the homogeneity and general quality of the studies used were superior to those comprising recent meta-analyses for psychodynamic interventions (Leichsenring & Rabung, 2008; Leichsenring, Rabung, & Leibing, 2004).

We know that research into the neurobiological pathways that make it permissible for psychophysiological alterations to occur is still in its infancy, nonetheless a number of fairly recent studies have illuminated how the regulation of emotional experiences wrought by MM in both clinical and nonclinical samples might be accounted for by explanations involving long-term structural and functional changes in the cortical and subcortical networks of the brain. Speaking about depression itself, there is a definite connection between its dysphoric symptoms and activation imbalance within the prefrontal cortex whereby the right hemisphere experiences much higher metabolic activity in relation to the left (Baxter, Phelps, Mazziotta, Schwartz, Gerner, & Selin, 1985; Field, Healy, Goldstein, Perry, & Bendall, 1988). Most pivotal for this development was an experimental animal model with rhesus monkeys in the late 90s which revealed an interesting phenomenon: when biased towards the right hemisphere, extreme frontal lobe activation correlated with overly fearful and defensive behaviors as well as abnormally high levels of stress hormones in the blood (Kalin, Larson, Shelton, & Davidson, 1998). In humans these neural phenomena have been causally linked with the symptoms of depression and mood disorders (Nikolaenko, Egorov, & Freiman, 1997).

In light of these neurophysiological studies MM therapies work to somehow rebalance the atypical metabolic activities amongst the abovementioned brain regions. In a recent systematic review Chiesa & Serretti (2010) used neuroimaging techniques and electroencephalography (EEG) studies to identify altered patterns of activation in the prefrontal cortices and anterior cingulate cortices of individuals engaged in MM. There were also significant increases in alpha and delta wave activity during this time, indicating that a cognitive state of deep relaxation had been harnessed. It appears those with dispositional mindfulness engage the integrative capacities of the prefrontal cortex as to inhibit emotional disinhibition and reactivity in the dorsal anterior cingulate cortex and amygdala (Creswell, Way, Eisenberger, & Lieberman, 2007). In recent times a structural Magnetic Resonance Imaging (MRI) study found abundant grey matter in the right anterior insula of experienced MM practitioners (Hölzel, Ott, Gard, Hempel, Weygandt, Morgen, & Vaitl, 2008). The right anterior insula is believed to buttress interoceptive awareness. In another MRI study focusing upon the effects of MBSR on depression (Farb, Segal, Mayberg, Bean, McKeon, Fatima, & Anderson, 2007) it came to light that individuals adhering to the experimental rigor of an 8-week intervention strategy experienced heightened metabolic activity in the dorsolateral and orbitomedial regions of the prefrontal cortex, areas responsible for self-referential mental activity and stimulus-independent thought (Cozolino, 2014). The common denominator here is the propensity of MM to stimulate orbitomedial and dorsolateral prefrontal areas collectively responsible for directing attention, concentration, the inhibitory control of emotional processing, the voluntary suppression of sadness, and the integration of cognition and emotion (Cozolino, 2014)–the same cortical regions and correlated psychological functions believed to be affected by depression, chronic stress, and mood disorders.

Despite its obvious methodological limitations, the research transcribed does suggest a plausible correlation between the introduction of an MBST technique, specifically MM, as a lifestyle choice and the amelioration of problematic conditions like depression and mood dysregulation in both clinical and nonclinical samples. Implicit in the empirical discourse are the beneficial effects of MM on psychological and physical health and general wellbeing, as well as the reality that MM can effect top-down causation. If the direction of present neurobiological studies is to be believed then what appears to happen across ontologies is that the purposeful direction of focal attention inhibits maladaptive emotional processing which in turn rebalances metabolic dysregulation amongst those brain regions (i.e. the prefrontal cortex, the dorsal anterior cingulate cortex, and the amygdala) adversely impacted by protracted anxiety and depression.

Future research should attempt to shed light upon the dose-response relationship and the amount of MM treatment needed to elicit a quantifiable response; the efficacy and proficiency of MM as an independent treatment method to conditions within the scope of contemporary psychopathology and the DSM; the precise neural pathways and mechanisms involved; the treatment of acute symptomology rather than relapse prevention; and the sustained benefits of MM in differing populations. The incorporation of research with tighter empirical controls and hypotheses into existing treatment models associated with MM would undoubtedly go far in illuminating what prevention strategies might be put in place to minimize the development of depression, anxiety, and mood disorders in clinical and nonclinical populations.        

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