MILITARY MEDICINE, 181, 9:961, 2016
The Emerging Role of Mindfulness Meditation as Effective Self-Management Strategy, Part 1: Clinical Implications for Depression, Post-Traumatic Stress Disorder, and Anxiety Marina A. Khusid, MD, ND, MSA; Meena Vythilingam, MD
INTRODUCTION Deployment to a war zone is associated with a significant increase in new-onset post-traumatic stress disorder (PTSD), major depressive disorder (MDD), substance use disorder (SUD), and chronic pain. Several reports estimate that 20 to 30% of troops returning from Operation Enduring Freedom and Operation Iraqi Freedom report symptoms of mental health disorders.1,2 The high prevalence of these conditions related to a war-zone deployment among U.S. service members and veterans results in high, long-term personal, health care, and societal costs.3 Their chronic, debilitating nature and frequent co-occurrence increase the risk of polypharmacy and adverse events, and makes the development of safe, efficacious, nonpharmacologic interventions of great public health importance. Self-management characteristic of such novel nonpharmacologic intervention is even more desirable since it is associated with improved health outcomes, patient engagement, and cost-effectiveness.4 This two-part review aims to assess if mindfulness-based interventions (MBIs) could provide effective self-management strategy to facilitate treatment and tertiary prevention of mental health conditions. Mindfulness meditation is increasingly accepted among veterans,5 is safe, easy to learn, affordable, and is associated with a growing evidence base. A 2014 Agency for Healthcare Research and Quality comparative effectiveness review concluded that mindfulness meditation is beneficial in reducing consequences related to psychological stress, including depression, substance use, sleep disturbances, and pain.6 Two Deployment Health Clinical Center, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, 1335 East-West Highway, No. 3-219, Silver Spring, MD 20910. doi: 10.7205/MILMED-D-14-00677
MILITARY MEDICINE, Vol. 181, September 2016
other systematic reviews that specifically assessed self-care interventions suggest that meditation improves stress-related mental health consequences.7,8 Neuroscientists define meditation as a combination of emotional and attentional training regimes developed to cultivate well-being and improve emotional regulation.9 Traditional cultures view meditation as a practice to train the mind to achieve spiritual and health benefits. Although there are many types of meditation, mindfulness meditation shows the most evidence for mental health, and is the focus of this review. Jon Kabat-Zinn describes mindfulness as the ability to maintain open, accepting, nonjudgmental awareness in each moment.10 Mindfulness meditation comes from Buddhism and takes many forms in different monastic traditions, such as Zen, Shambhala, and Vipassana. Although these various schools of mindfulness meditation differ slightly with respect to the physical posture assumed, they generally involve sitting still and observing one’s own breath. The process of constantly returning one’s attention to breathing helps train the mind to stay present and control otherwise automatic cognitive responses to stress, intrusive thoughts, and negative emotions. Traditional mindfulness meditation techniques were first adapted for chronic pain in 1982 by Kabat-Zinn. Several group-based protocols were then developed in an attempt to standardize the delivery of mindfulness meditation for specific clinical conditions. For example, mindfulness-based relapse prevention (MBRP) was developed for individuals with SUDs, and mindfulness-based cognitive therapy (MBCT) was developed to manage depression. Such group-based protocols use a certified instructor to lead 6 to 8 weekly training sessions, while participants practice mindfulness meditation as daily homework. After completion of an 8-week course, participants are encouraged to adopt meditation, practice long-term as a 961
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ABSTRACT Mindfulness-based interventions (MBIs) have been increasingly utilized in the management of mental health conditions. This first review of a two-part series evaluates the efficacy, mechanism, and safety of mindfulness meditation for mental health conditions frequently seen after return from deployment. Standard databases were searched until August 4, 2015. 52 systematic reviews and randomized clinical trials were included. The Strength of Recommendation (SOR) Taxonomy was used to assess the quality of individual studies and to rate the strength of evidence for each clinical condition. Adjunctive mindfulness-based cognitive therapy is effective for decreasing symptom severity during current depressive episode, and for reducing relapse rate in recovered patients during maintenance phase of depression management (SOR moderate [SOR B]). Adjunctive mindfulness-based stress reduction is effective for improving symptoms, mental health-related quality of life, and mindfulness in veterans with combat post-traumatic stress disorder (PTSD) (SOR B). Currently, there is no sufficient data to recommend MBIs for generalized anxiety disorder (SOR B). MBIs are safe, portable, cost-effective, and can be recommended as an adjunct to standard care or self-management strategy for major depressive disorder and PTSD. Future large, well-designed randomized clinical trials in service members and veterans can help plan for the anticipated increase in demand for behavioral health services.