Psychosomatics 2015:]:]]]–]]] & 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Review Article
Critical Analysis of the Efficacy of Meditation Therapies
for Acute and Subacute Phase Treatment of Depressive
Disorders: A Systematic Review
Felipe A. Jain, M.D., Roger N. Walsh, M.D., Ph.D., Stuart J. Eisendrath, M.D.,
Scott Christensen, B.A., B. Rael Cahn, M.D., Ph.D.
Background: Recently, the application of meditative largest proportion of studies. Studies including patients
practices to the treatment of depressive disorders has having acute major depressive episodes (n ¼ 10
met with increasing clinical and scientific interest, owing studies), and those with residual subacute clinical
to a lower side-effect burden, potential reduction of symptoms despite initial treatment (n ¼ 8), demon-
polypharmacy, and theoretical considerations that such strated moderate to large reductions in depression
interventions may target some of the cognitive roots of symptoms within the group, and relative to control
depression. Objective: We aimed to determine the state groups. There was significant heterogeneity of techni-
of the evidence supporting this application. Methods: ques and trial designs. Conclusions: A substantial body
Randomized controlled trials of techniques meeting the of evidence indicates that meditation therapies may have
Agency for Healthcare Research and Quality definition salutary effects on patients having clinical depressive
of meditation, for participants having clinically diag- disorders during the acute and subacute phases of
nosed depressive disorders, not currently in remission, treatment. Owing to methodologic deficiencies and
were selected. Meditation therapies were separated into trial heterogeneity, large-scale, randomized controlled
praxis (i.e., how they were applied) components, and trials with well-described comparator interventions
trial outcomes were reviewed. Results: 18 studies and measures of expectation are needed to clarify
meeting the inclusion criteria were identified, encom- the role of meditation in the depression treatment
passing 7 distinct techniques and 1173 patients. armamentarium.
Mindfulness-Based Cognitive Therapy comprised the (Psychosomatics 2015; ]:]]]–]]])
INTRODUCTION
Received September 30, 2014; revised October 15, 2014; accepted
October 16, 2014. From Department of Psychiatry, Semel Institute for
Depressive disorders, including major depressive dis- Neuroscience and Human Behavior, University of California,
Los Angeles, CA (FAJ, SC); Department of Psychiatry, University of
order (MDD) and dysthymia, have a 12-month California, Irvine, CA (RNW); Department of Psychiatry, University
prevalence of approximately 7%1 in the general of California, San Francisco, CA (SJE); Department of Psychiatry,
population, and the prevalence is higher in hospital- University of Southern California, Los Angeles, CA (BRC); Brain and
Creativity Institute, University of Southern California, Los Angeles,
ized patients with medical illness2 and ambulatory CA (BRC). Send correspondence and reprint requests to Felipe A. Jain,
medical patients.3,4 However, initial trials of currently M.D., UCLA Psychiatry & Biobehavioral Sciences, 760 Westwood Plaza,
available pharmacologic and psychotherapeutic treat- 57-436 Semel Institute, Los Angeles, CA 90095-1759; e-mail: fjain@
mednet.ucla.edu
ments result in depression remission less than 50% of & 2015 The Academy of Psychosomatic Medicine. Published by
the time with multiple trials5,6 and overall have Elsevier Inc. All rights reserved.
Psychosomatics ]:], ] 2015 www.psychosomaticsjournal.org 1
Meditation Therapies for Depression
moderate effect sizes.7 Furthermore, in patients with create expectations regarding the practice; and “self-
comorbid medical illness, pharmacotherapeutics for induced state” distinguishes meditation from hypnosis
depression carry the risk for polypharmacy, drug-drug or guided imagery practices. A few examples of
interactions, and increased side effects. There is a need practices identified as meditation-based included
for new depression treatments with a more favorable mindfulness, many types of yoga, Tai Chi, Tran-
risk/benefit profile and different mechanisms of action scendental Meditation, and qigong. However, this
from existing treatments. Interest in the use of mind- definition met with some criticism owing to its relative
body therapies for MDD and other psychiatric dis- nonspecificity.22 A more recent iteration from the
orders is high among patients8 and increasing among Agency for Healthcare Research and Quality was to
practitioners: for example, “mindfulness” is highest dissociate “purely meditative” techniques, done while
among the therapeutic orientations rated most likely maintaining a stationary posture, from those that used
to increase in use over the coming decade by psycho- a meditative awareness during movement; however, a
therapy experts.9 detailed rationale for excluding the movement prac-
tices while retaining stationary meditation groupings
Definition of Meditation was not provided.23
The term meditation refers to a broad set of Meditation and Acute Psychologic Symptoms
psychosomatic practices that involve training and
regulating attention toward interoceptive or extero- When performing meta-analysis of the clinical
ceptive foci, or intentionally created mental images, literature on meditation techniques used as therapeu-
while observing or redirecting attention from distract- tics for psychologic symptoms, many authors have
ing thoughts.10–15 Examples of interoceptive foci are collapsed across different meditation therapies using
sensations associated with the breath or other parts of the same type of meditation (e.g., Mindfulness-Based
the body, or “awareness itself”; exteroceptive foci may Stress Reduction and Mindfulness-Based Cognitive
include such things as a statue or flame; and mentally Therapy [MBCT]), or broad categories of meditation
generated imaginal representations may include ver- or mindfulness techniques, such as focused attention
bal mantras (repetitive words or sets of syllables) or and open monitoring, or with and without movement,
visual images.16,17 Those meditation techniques and tried to draw conclusions about the effect size of
involving sustained attention to a specific focus or meditation or mindfulness techniques as a group.24–29
limited range of inner or outer experience have often These meta-analyses have generally concluded that
been referred to as concentrative or focused attention meditation techniques provide small to moderate
practices, whereas those incorporating a broader salutary benefits for symptoms of depression or
attentional spotlight to an array of changing stimuli anxiety, and for patients with comorbid medical
have been called mindfulness, open-awareness, or illnesses such as cancer, rheumatoid arthritis, fibro-
open monitoring practices.18–20 Open monitoring myalgia, and heart disease. Of these meta-analyses,
practices de-emphasize delineation of an explicit focus 2 also analyzed meditation therapies by technique, but
in favor of nonreactive but clear and vivid observation when doing so collated subjects with divergent symp-
of moment-to-moment experiences.19 tom types (anxiety and mood) and severity, potentially
There is disagreement about which therapies are confounding the results.28,29
based on meditation and are comparable in mecha- There are difficulties in identifying the efficacious
nism of action. In attempting to address this con- components across meditation therapies for several
troversy, the Agency for Healthcare Research and reasons. First, a rigorous comparison of the praxis
Quality proposed a consensus definition of meditation elements of individual meditative therapies has not
using a modified Delphi process.21 This definition been undertaken, and thus the extent of commonality is
suggested that there are 3 principles essential to not known. Because there is evidence to suggest that
meditation: a defined technique, logic relaxation, different meditative practices involve different neuro-
and a self-induced state or mode. “Defined technique” nal substrates, it is likely that meditation therapies that
denotes a describable set of instructions; “logic relax- incorporate different practices affect the biologic sub-
ation” refers to a lack of “intent” to analyze, judge, or strates of target psychologic symptoms differently.20,30
2 www.psychosomaticsjournal.org Psychosomatics ]:], ] 2015
Jain et al.
It is also unclear that all meditation therapies based on who are currently in remission,33–39 and most of these
a particular form of meditation, such as “mindfulness- have demonstrated a reduction in relapse rate relative
based therapies,” share a common neural mechanism to treatment as usual or placebo.33,35–38 Systematic
of action. For example, it may be that the cognitive meta-analysis indicated that MBCT is an effective
component to MBCT engages neural mechanisms not treatment for depressive relapse in patients with MDD
present within the less cognitively-oriented Mind- who have had 3 or more (but not 2 or less) previous
fulness-Based Stress Reduction Intervention.20,30 By MDEs.40 However, the specific role of meditation
grouping different forms of meditation, authors may be practice in these results remains unclear because a
obscuring individual differences among meditation dismantling study failed to differentiate MBCT effects
therapies that might result in different effect sizes. on relapse prevention from a cognitive therapy
Therefore, we have not attempted to collapse across designed to mimic MBCT but without experiential
meditation practices to compute an effect size in the mindfulness elements, except in a secondary analysis
current review. that indicated increased efficacy of MBCT in subjects
with high levels of childhood trauma.39
Meditation as a Treatment Across Systematic review has never been undertaken to
the Depression “Life Cycle” elucidate the evidence base for the treatment of
clinically diagnosed depressive disorders across the
Treatments for clinical depressive disorders occur spectrum of meditative therapies. Our objective was to
during distinct phases of the illness: acute, continu- determine the evidence base for meditation therapies
ation, and maintenance phases, and relapse prevention as depression therapeutics during these phases by
in the acute or continuation phase.31 Because initial answering the following 3 questions:
treatments for depression result in remission only
about one-third of the time,5 there is often also a (1) What are the similarities and differences among
subacute phase in which those who have experienced the praxis elements of the therapies (and thus the
partial benefit from an initial treatment receive aug- extent to which generalizations can be made across
mentation with either medications or psychotherapy. techniques)?
Several authors who have reviewed the efficacy of (2) What does the empirical evidence from random-
meditation techniques for reduction of depressive ized controlled trials (RCTs) demonstrate?
symptoms have grouped together patients with depres- (3) How can future research be designed to advance
sive disorders across the depression life cycle, and not our knowledge of the role of meditation therapies
differentiated among patients at different phases of in treating depression?
their depressive illnesses.26,27,32 However, this
approach might underestimate or overestimate the MATERIAL AND METHODS
effect size for meditation depending on the depressive
phase. For example, patients amid an acute severe Literature Search
major depressive episode (MDE) might lack the
concentration needed to meditate as effectively as MEDLINE, the Cochrane Collaboration, and Psy-
during partial remission, and thus the effects of cINFO were searched according to the PRISMA
meditation might be larger during partial remission. guidelines through January 2014 for RCTs, including
Alternatively, effects of meditation might be weaker articles with the terms “meditation,” “yog*,” “mind-
for patients with subacute depressive illness in partial fulness*,” “Tai Chi,” “T'ai Chi,” “Qigong,” “Vipas-
remission owing to a ceiling effect for improvement. It sana,” “prayer,” combined with “depressi*,” or
is therefore important that reviews of meditation for “dysthymi*,” combined with “random*,” or “RCT.”
depressive symptoms take phase of depressive illness Articles were selected that (1) identified the subject
into consideration. population as suffering from a depressive disorder, i.e.,
Accounting for phase of depressive illness has MDD, dysthymia, or both and (2) had as a primary
been systematically accomplished only with MBCT. outcome reduction of current depressive symptoms.
Several trials have aimed to determine whether MBCT Thus, the many articles that studied depressive symp-
may reduce the relapse rate for patients with MDD toms as an outcome but in clinically nondiagnosed
Psychosomatics ]:], ] 2015 www.psychosomaticsjournal.org 3
Meditation Therapies for Depression
populations were excluded. Reference lists were articles were identified from other systematic reviews.
reviewed from these articles to identify additional These 18 depression trials included 1173 subjects and
publications, and other review articles were also used. used 7 different meditation techniques (Table 1).
Meditation Therapy Component Evaluation Meditation Techniques
The descriptions of the meditation therapies within The most frequently studied techniques included
the articles were studied, and cited references obtained. MBCT, 8 studies43–50; Tai Chi, 3 studies51–53; Sudar-
In cases of lack of clarity regarding components of a shan Kriya Yoga (SKY), 2 studies54,55; and Patañjali
specific intervention, corresponding authors were Yoga, 2 studies.56,57
contacted and asked to provide further details. Com- None of the interventions used an exclusively one-
ponents of meditation practices, focusing on praxis, pointed focus of attention throughout the interven-
were derived using descriptive principles drawn from tion, but generally consisted of multiple different
Patañjali's Yoga Sutras,16 the Satipatthana Sutta,17 attentional foci and techniques. With the exception
and mental imagery theory.41 Resultant categories of Sahaj Yoga, therapies contained a significant
included the role of movement, spirituality, mental amount of meditative awareness during nonaerobic
imagery (internal representations of somatic, visual, or movement exercises, in addition to stationary pos-
verbal/auditory domains), object of attention (soma- tures, whereas only one (Tai Chi) focused exclusively
tosensory, emotional, cognitive, and external), the on meditative engagement during movement. At least
provision of a holistic philosophical viewpoint, and 4 of the 7 therapies used imagery to modulate feeling
any other associated therapeutic elements. state during some practices (inner resources medita-
tion, MBCT during body scan practice, Patañjali
Statistical Analysis
Yoga, and Sahaj Yoga), and 4 of the 7 explicitly
Effect sizes (Hedges g) were calculated using the included a holistic philosophical overview for the
following formula: (ū1 ū2)/Sp, where ū1 is the mean practice (MBCT, Patañjali Yoga, qigong, and Sahaj
of the treatment group (for between-group compar- Yoga). Of the 7 techniques, 2 (MBCT and inner
isons) or baseline (for within-group comparisons), ū2 is resources meditation) provided additional therapeutic
the mean of the control group (for between-group elements drawn from cognitive-behavioral therapy
comparisons) or end point (for within-group compar- (CBT), whereas all of them (with the possible excep-
isons), and Sp is the pooled variance. Effect sizes were tion of Sahaj Yoga, for which this was indeterminate)
corrected for small sample sizes.42 included an element of group support.
RESULTS Efficacy of Meditation Therapies in the
Acute Phase of Major Depression Treatment
Search Results
Eleven trials included participants with a current
Of 1673 trials of meditation identified, 926 dupli- MDE (or a mix of patients with MDEs, dysthymia,
cates were removed. The remaining 747 abstracts were and residual subacute symptoms Table 2). Of these, 5
screened, and publications excluded that were non– included patients only with MDEs and found large
English language, review articles, and nonclinical within-group effect sizes ranging from 0.93–3.33,
populations, and also those not using techniques that whereas the rest of the studies included mixed pop-
were considered to be meditation were excluded. 119 ulations and demonstrated effect sizes ranging from
articles were selected for full-text review, of which 105 0.33–1.47.58 Of the 5 studies including only subjects
articles for relapse prevention, theses, adolescent with MDEs, 3 included a mix of patients who were
populations, secondary articles from RCTs, and non- receiving meditation as a primary treatment or aug-
clinically diagnosed populations were removed. 14 mentation therapy,45,53,60 whereas 2 of the studies
articles were found to be RCTs focused on treatment were carried out in an inpatient setting with unmedi-
of active depression symptoms in clinically diagnosed cated patients.54,55 The largest of the 11 studies
populations (not in remission), and an additional 4 to include subjects with a MDE (219 subjects) found
4 www.psychosomaticsjournal.org Psychosomatics ]:], ] 2015
Psychosomatics ]:], ] 2015
TABLE 1. Elements of Meditation Therapies
Technique Overview Mental imagery Attention Holistic philosophical overview Additional therapeutic elements
Inner Mantra meditation (attention to Somatic: breathing imagery Somatosensory: “surrender” to Unclear Bibliotherapy (Feeling Good
resources a word or phrase with passive (e.g., imagine lungs as body during yoga and Handbook) provided to all
meditation disregard for passing balloons filling with air). breathing meditation. participants, conducted in a
thoughts), mindfulness, yoga Visual: guided imagery to Emotional: “surrender” to group setting 1 d/wk for
asanas (low impact and help “let go” of thoughts emotion during meditation 12 wk; homework 6 d/wk
nonaerobic), and a subject- and feelings. Verbal: mantra exercises. Cognitive:
dependent spiritual repetition “surrender” to thought during
component meditation exercise
Mindfulness- Mindfulness meditation with Somatic: during body scan Somatosensory: to sensations of Becoming more aware of what is Attitudinal: Relate to symptoms
based focus on bringing an (“feel or imagine the breath” eating, breathing, breath and happening “in the moment” of depression not as personal
cognitive equanimous, observing moving into body parts to body as a whole, walking. provides a greater choice in failings but as parts of an
therapy awareness to present-moment aid in bringing attention to Emotional: awareness of relationship to life experience. impersonal syndrome. During
experience of breath, body, each area of the body) feelings. Cognitive: awareness Developing a stance of an body scan, bringing an
sound, thought, and of thoughts as events in the equanimous observing “interested and friendly
“awareness itself,” yoga field of awareness as if awareness toward the contents awareness,” having “lightness
asanas (low impact and “projected on a screen,” of awareness and the craving/ of touch” in awareness. As a
nonaerobic), and cognitive External: bringing full aversion tendencies of mind way of accepting into
therapy. Emphasis on awareness to senses generally provides access to decreased awareness difficult sensations/
developing mindfulness during and awareness of “pleasant rumination and identification feelings/thoughts, may silently
formal practice and also events” with thought, deeper wisdom, repeat “It's ok. Whatever it is,
implementing this mindful and self-compassion it's ok. Let me feel it.” Other
awareness during day-to-day CBT components include
activities, especially creating pleasant and
emotionally challenging times unpleasant events calendars,
making an action plan for
activities to help respond to
negative moods, raising
awareness of depleting vs
nourishing activities, raising
awareness of personal warning
www.psychosomaticsjournal.org
signs for onset of depression.
Conducted in group setting
1 d/wk for 8 wk and an
optional 6-h retreat day;
homework 6 d/wk
Patañjali 5 Components: Yoga asanas Visual: during dharana stage, Somatosensory: to body during Ethical behavior and Conducted in a group setting
Yoga (nonaerobic, gradual and focusing attention on an yoga, pranayama. Cognitive: withdrawal from sensory 6 d/wk for 8 wk
sustained tonic stretch), “object or symbol—mostly to “3 types” of thoughts— preoccupation leads to feelings
Pranayama (breath control a visual image” about “random” experiences, of well being
with slow alternate nostril disturbing thoughts, and
breathing), Pratyahara desiring to change
Jain et al.
(withdrawal of attention from
sense objects), Dharana
(focused concentration), and
Dhyana (steadfast meditation)
5
6
Meditation Therapies for Depression
www.psychosomaticsjournal.org
TABLE 1 (continued )
Technique Overview Mental imagery Attention Holistic philosophical overview Additional therapeutic elements
Qigong Series of physical postures (low Unclear Somatosensory: to body during Balancing and training the flow Conducted in a group setting
impact and nonaerobic), while movement. External: to sight of “qi” promotes health 2 d/wk; daily homework
focusing on breathing and during movement practice “under trained family
present-moment physical supervision”
sensations and “clearing the
mind”
Sahaj Yoga Meditation practice beginning Verbal: internally generating Cognitive: witnessing thoughts Prayer asking God for “divine Participants encouraged to
with a standardized set of “questions and assertions” until a “thought-free state” knowledge” and “self- practice 3 times a week for
spiritual “questions and emerges realization” 30 min and also to repeat the
assertions” by the subject, practice at night with their feet
repeated several times, with resting in salt water before bed
hands placed in different
gestures, followed by a period
of direct witnessing of
thoughts until a “thought-
free” state emerges
Sudarshan Pranayama consisting of None Somatosensory: to sensations of Not in these studies Attitudinal: during yoga nidra,
Kriya “focused hyperventilation” breathing participants instructed to
Yoga with attention directed toward “relax and let go”; conducted
the breath, followed by yoga in a group setting 6 d/wk
nidra (lying down, deeply
restful meditation)
T'ai Chi Series of repetitive, slow, Unclear Somatosensory: to body during Not in these studies Conducted in a group setting
nonstrenuous, nonaerobic, movement. External: to visual 1 d/wk
physical movements with a surroundings during
mindful, present-oriented movement
attentional focus on the
movements
Psychosomatics ]:], ] 2015
CBT ¼ cognitive-behavioral therapy.
Psychosomatics ]:], ] 2015
TABLE 2. Meditation Therapy Trials for Acute Depression
Study/country Design Homework Subjects Duration Results Effect size Relative deficiencies
Inner resources meditation (IRM)
Butler et al.,61 IRM vs hypnosis vs 6 d/wk N ¼ 52, age Z18 y, 12 wk Greater remission in IRM vs Not calculated Lack of blinding, short-term
USA bibliotherapy; all chronic unipolar bibliotherapy at 9 mo (p o due to lack of outcome posttherapy not reported,
groups þ TAU DSM-IV depressive 0.05 with χ2 test); no difference short-term mix of patients with different
disorder lasting Z2 y between IRM and hypnosis; postinterven- depressive illnesses, not rigorously
rate of change of HAM-D tion data designed to assess nonequivalence,
nondifferent inappropriate statistical test for
sample size
Mindfulness-based cognitive therapy (MBCT)
Barnhofer MBCT þ TAU vs 6 d/wk N ¼ 31, age 18–65 y, Z3 8 wk Greater reduction in BDI-II in WS: 1.07 Mix of acute and subacute depressive
et al.,44 UK TAU MDEs or current MBCT þ TAU group (p ¼ BS: 0.88 phases, therapist and patient
MDE Z 2 y, and 0.001). Fewer MBCT þ TAU expectations not assessed
current MDE or still in MDE (SCID, p ¼ 0.03)
residual symptoms
Chiesa et al.,43 Augmentation of 6 d/wk N ¼ 18, age Z18 y, 8 wk Greater reduction in HAM-D in WS: 1.02 Lack of blinding, therapist and
Italy ADM with MBCT unipolar MDD, MBCT group at week 8 (p ¼ BS: 0.75 patient expectations not assessed
or PED HAM-D 4 0.04)
7 following ADM
treatment
Geschwind MBCT þ TAU vs 6 d/wk N ¼ 130, age Z18 y, 8 wk Greater reduction in HAM-D in WS: 0.73 TAU not well defined, therapist and
et al.,46 TAU history of MDD, MBCT group (p o 0.001) BS: 0.57 patient expectations not assessed
Netherlands residual symptoms
with HAM-D Z 7
Hamidian MBCT þ ADM vs 6 d/wk N ¼ 50, age Z18 y, 8 wk Greater reduction in BDI-II in WS: 1.23 Patients poorly defined, mix of
et al.,47 Iran ADM dysthymia or double MBCT group than ADM BS: 0.66 patients with different depressive
depression group (p o 0.0001) illnesses, ADM not described,
expectations not assessed
Manicavasgar MBCT vs CBT; 6 d/wk N ¼ 69, age Z18 y, 8 wk Nondifferent reductions in BDI- WS: 0.93 Lack of blinding to study hypotheses,
et al.,45 augmentation of unipolar MDE, not II BS: 0.15 some groups not randomized, not
Australia current treatment if melancholic rigorously designed to assess
www.psychosomaticsjournal.org
any equivalence between therapies
Omidi et al.,48 MBCT modified 6 d/wk N ¼ 90, age 18–45 y, 8 wk General severity index of brief Not calculated Lack of blinding to study hypotheses,
Iran with “behavioral MDD on ADM, symptom inventory (BSI) due to not rigorously designed to assess
enhancement” þ phase of illness not showed nondifferent nonstandard equivalence between therapies,
TAU vs CBT þ established reductions between MBCT and depression TAU not well defined; phase of
TAU vs TAU CBT, greater than TAU (p o outcome illness poorly defined
0.01) measure
Shahar et al.,49 MBCT vs wait list, 6 d/wk N ¼ 52, age 24–64 y, Z3 8 wk Greater reduction in BDI in WS: 0.87 Mix of patients with different phases
USA subjects could MDEs, residual MBCT group. Effects of BS: 1.09 of depression, lack of active control
continue on stable symptoms or current MBCT mediated by reduction group
Jain et al.
ADM (12 wk episode (if symptoms in brooding and increase in
without change “fluctuated toward mindfulness (both p o 0.05)
before study) remission”)
7
8
Meditation Therapies for Depression
TABLE 2 (continued )
Study/country Design Homework Subjects Duration Results Effect size Relative deficiencies
van Aalderen MBCT þ TAU vs 6 d/wk N ¼ 219, age 47.3 ⫾ 8 wk Greater reduction in HAM-D in WS: 0.33 TAU not well defined (participants
www.psychosomaticsjournal.org
et al.,50 TAU; subjects 11.5 y, Z 3 MDEs, MBCT group (p o 0.001). No BS: 0.47 needing to stay on ADM without
Netherlands could continue on current MDE or difference between those with change suggests not a true TAU
stable ADM (6 wk residual symptoms acute and subacute phase control); expectations not assessed
without change depression reductions
before study)
Patañjali Yoga (PY)
Vahia et al.,56 PY vs pseudo- None, but N ¼ 95, age 15–50 y, 6 wk 74% improvement in PY vs 43% Not calculated Subjects poorly characterized,
India Patañjali Yoga treatment “psychoneurosis” in PPY on target symptom owing to expectations of patients and
(PPY) sessions (including depression relief (p ¼ 0.04) missing therapists not assessed
6 d/wk subpopulation) information
Vahia et al.,57 PY vs medication None, but N ¼ 39, age 15–50 y, 6 wk HAM-D nondifferent between Not calculated Subjects poorly characterized,
India (amitryptyline and treatment psychoneurotic and both groups owing to expectations not assessed, not
chlordiazepoxide) sessions psychosomatic missing rigorously designed to assess
6 d/wk disorders (25% information nonequivalence between therapies
depression)
Qigong and Tai Chi (TC)
Chou et al.,52 TC vs wait list None, TC N ¼ 14, age Z60 y, 12 wk TC showed greater reduction in WS: 1.47 No active control, mix of patients
Hong Kong, sessions unipolar MDE or CES-D (p o 0.01) BS: 2.12 with different depressive illnesses
China 3 d/wk dysthymia, CES-D Z
16
Lavretsky TC vs PED Not N ¼ 73, age Z60 y, 8 wk TC showed greater reductions in WS: 0.65 Lack of blinding, therapist and
et al.,51 USA men- unipolar MDD, no HAM-D (p o 0.05). BS: 0.39 patient expectations not assessed
tioned, remission on
TC escitalopram
sessions
1 d/wk
Tsang et al.,59 Qigong vs newspaper Daily N ¼ 97, age Z65 y, 16 wk GDS showed greater reductions in WS: 0.79 Mix of patients with different
Hong Kong, reading group history of diagnosed Qigong than in NRG (p o 0.05) BS: 1.54 depressive illnesses, therapist and
China (NRG) depressive disorder or patient expectations not assessed,
elevated GDS not rigorously designed to assess
nonequivalence between therapies
Yeung et al.,53 TC vs wait list (WL), TC sessions N ¼ 39, age 50 ⫾ 10 y, 12 wk No difference in HAM-D or WS: 1.67 No active control, underpowered
USA all subjects 2 d/wk current MDE with response (24% in TC vs 0% in BS: 0.10
continued current HAM-D Z 18, all WL, p ¼ 0.15) or remission
Psychosomatics ]:], ] 2015
treatment (if any) Chinese American rates (20% in TC vs 0% in WL,
p ¼ 0.30) between groups
Sahaj Yoga (SY)
Sharma et al.,60 Augmentation of None, but N ¼ 30, age 18–45 y, 8 wk HAM-D reduction in SY group WS: 2.80 Expectations of patients and
India ADM with SY or SY current MDE greater than PSY (p ¼ 0.003). BS: 0.71 therapists not assessed, medication
Pseudo-Sahaj sessions Greater remission in SY group protocol and dosages not described
Yoga (PSY) 3 d/wk (47%) than PSY group (13%) at
8 wk (p ¼ 0.02)
Jain et al.
that the efficacy of MBCT did not differ whether
Studies Depression Scale; DSM-IV ¼ Diagnostic and Statistical Manual of Mental Disorders IV; ECT ¼ electroconvulsive therapy; GDS ¼ Geriatric Depression Scale; HAM-D ¼ 17-
Lack of blinding to study hypotheses,
ADM ¼ antidepressant medication; BDI-II ¼ Beck Depression Inventory II; BS ¼ between subjects; CBT ¼ cognitive-behavioral therapy; CES-D ¼ Center for Epidemiologic
item Hamilton Depression Rating Scale; IMN ¼ imipramine; MDD ¼ major depressive disorder; MDE ¼ major depressive episode; PED ¼ psychoeducation group; SCID ¼
designed to assess nonequivalence
BS (IMN): 0.23 therapist and patient expectations
Patient and therapist expectations
designed to assess equivalence patients had an MDE or had subacute residual
symptoms.50
BS (ECT): 0.85 not assessed, not rigorously
not assessed, not rigorously
Efficacy of Meditation Therapies
between therapies
between therapies
in the Subacute Phase of Treatment
Three studies included only patients with residual
depression symptoms after acute phase treatment, and
these demonstrated effect sizes ranging from 0.65–
1.02.43,46,51
Efficacy of Meditation Therapies
WS: 2.07
WS: 3.34
BS: 0.64
Relative to Control Groups
Relative to wait list or treatment-as-usual controls,
BDI. F-SKY tended to have a
higher response rate (80%) than
studies demonstrated moderate to large effect sizes
HAM-D; ECT superior to
F-SKY and P-SKY showed
nondifferent reductions in
nondifferent reductions in
(0.47–2.12),44,46,47,49,50,52 with the exception of Yeung
P-SKY (47%) (p o 0.06)
SKY and ADM showed
et al. (2012).53 In the latter study, the wait list control
group exhibited an abnormally large reduction in
both (p ¼ 0.04)
depressive symptoms (within-group effect size 1.54)
Structured Clinical Interview for DSM Disorders; TAU ¼ treatment as usual; WS ¼ within subjects.
relative to the control groups of other studies (within-
group effect sizes: 0.60 to 0.35).
Among studies that used psychoeducation
or pseudotherapy control group arms, between-
group sizes favored meditation and were moderate
to large (0.39–1.54).43,51,55,59,60 The within-subject
None, SKY N ¼45, age 36.0 ⫾ 7.8 y, 4 wk
4 wk
effects in psychoeducation groups ranged from
ADM HAM-D Z 18,
current MDE, HAM-
current MDE, not on
D Z 17, hospitalized
0.02–0.59.
Rohini et al.,55 Full SKY (F-SKY) None, but N ¼ 30, age 18–60 y,
Three studies for MDD, and one for a depressed
subpopulation diagnosed with psychoneurosis, also
hospitalized
used as controls validated, first-line depression treat-
ments: MBCT vs CBT,45,48 SKY vs imipramine,54 and
Patañjali Yoga vs amitryptiline.57 These showed no
significant differences in reduction of depressive
vs Partial SKY (P- treatment
symptoms between the meditation and the control
sessions
sessions
6 d/wk
daily
groups. The study of SKY also used a second-line
treatment for depression, electroconvulsive therapy, as
a further control condition, and this demonstrated
(imipramine) vs
Yoga (SKY) vs
inferiority of the SKY intervention (effect size of SKY
Janakiramaiah Sudarshan Kriya
0.94 relative to electroconvulsive therapy).
Sudarshan Kriya Yoga (SKY)
ADM
SKY)
ECT
DISCUSSION
et al.,54 India
The data from RCTs suggest that meditative inter-
ventions may have substantial effects on depressive
symptoms in patients with clinically diagnosed depres-
India
sive disorders, including those currently having an
acute MDE and those in partial remission. Across
Psychosomatics ]:], ] 2015 www.psychosomaticsjournal.org 9
Meditation Therapies for Depression
trials, the upper limit of effect sizes was larger for heterogeneity in praxis. These variations included
subjects having an acute MDE than those with elements of movement, spirituality, attention directed
residual symptoms, possibly owing to a ceiling effect toward different foci, mental imagery, and whether the
of improvement for subjects with residual symptoms. practices took place within the provision of a larger
However, variations among the subcomponents of the philosophical framework. Because almost all therapies
different meditation therapies resulted in our conclud- included substantial movement components in addi-
ing that the therapies were not similar enough to allow tion to sitting meditation practices, we could not
for derivation of a common effect size. rigorously differentiate therapies on this basis. Our
There were several factors across the trials that, categorization accorded in part with the framework
while increasing the generalizability of the findings provided by Shear, which included the types of mental
across depressive condition type and illness stage, faculties used (e.g., attention and visual imagery), how
limited their commonality. Patient populations con- the faculties were used (e.g., active and passive), the
tained a mixture of patients with different depressive foci for these faculties (e.g., thoughts, bodily sensa-
illnesses in several of the trials, including MDD and tions, and spirit/God).14 However, groupings based on
dysthymia,47,61 and multiple “psychoneurotic disor- elements other than praxis are possible, such as a focus
ders.”56,57 In several trials, exclusion of bipolar on the stated goal of the meditation practice, the
depressed subjects was not specifically men- contextual and historical background of the practice,
tioned.44,46,59 Even those studies that focused on the or the meditative state experienced as a result of the
same stage of depressive illness used meditation in practice.63 The heterogeneity in praxis, and thus
different ways, i.e., as treatment augmentation, or as likelihood of different neural mechanism, precluded
primary treatment. attributing the effects of the meditation therapies to a
Within trials, there were several common issues common mechanism of action.
precluding definitive conclusion that the efficacy of To advance the field, several kinds of experimental
assayed meditative practices was due to specific refinements will be necessary. First, because negative
elements of the therapies, as opposed to nonspecific studies are less likely to be published, clinical trial
factors. Subject numbers were small within most of the registration is essential. Selection of a control group is
trials, and none of the trials were conducted at more also critical. Our results suggested a large heteroge-
than 1 site. Follow-up data were often not obtained, neity in within-group effect sizes for wait-list and
and 4 of the studies lasted 6 weeks or less.54–57 treatment-as-usual controls, ranging from moderate
Uniformly, the expectations of therapists leading negative effects (0.60) to large positive effects (1.54).
sham or partial treatment control groups relative to This indicates that such controls are not always inert
those leading full meditation protocols were not and may have nocebo effects (possibly because of
assessed or accounted for. As has previously been subjects being told they will need to wait for a
noted, therapist expectations may account for a treatment that they believe will be beneficial), placebo
significant portion of the effect size of psychotherapy effects (possible resulting from increased clinical
interventions.62 Similarly, the expectations of subjects attention), or possibly even active effects depending
were often not addressed. Several trials did not specify on the extent of treatment within “treatment-as-usual”
which medications subjects were taking, or other groups. To understand why these control groups
forms of psychotherapy they might have been engaged evince such a range of effects, future studies using
in. Treatment-as-usual groups were not fully described these groups may benefit from measuring expectations
in any of the trials, nor were prior or concurrent regarding clinical symptom outcome after subjects
psychotherapies that patients might have received. In have been assigned to the control group or the
several trials, dropout rates were not explicitly stated. experimental treatment, as well as monitoring and
Additionally, possible adverse reactions to the med- reporting medication and psychotherapy changes,
itation practices were generally not described. along with their timing. Psychoeducation control
Although we used the Agency for Healthcare groups provided a more consistent range of effect size
Research and Quality definition for meditation to (0.02–0.54), and their use may thus facilitate compar-
include relevant studies, our component evaluation of isons among different meditation trials, while not
the meditation therapies themselves suggested major providing so much active effect as to obscure positive
10 www.psychosomaticsjournal.org Psychosomatics ]:], ] 2015
Jain et al.
effects of meditation. However, it would still be meditations, in which the same psychometric and
important to measure and adjust for expectations of neurophysiologic measures are used, may indicate
benefit in such trials. Recently, active control groups the extent to which the benefits of different meditation
such as health education control groups that incorpo- therapies are mediated by common mechanisms of
rate the same amount of group contact, focus on action.
healthy behaviors and homework time, but without In summation, although meditative therapies are
the inclusion of meditative practices, have been commonly used and increasingly advocated, this
advocated.64,65 Although we believe that such groups critical review clearly suggests that the role of med-
may minimize nocebo effects and help to account for itation techniques in the clinical armamentarium for
nonspecific effects, they also may provide active depression has not been firmly established. Existing
treatment with features of behavioral activation, such RCTs are uniformly positive in demonstrating reduc-
as exercise that may reduce symptoms of depression tions in depressive symptoms, and although the
and confound results. Studies that aim to determine variability both within the clinical populations and
the relative efficacy of meditation to known efficacious the techniques studied suggests wide generalizability
treatments, such as antidepressant therapy or across depressive condition type and illness stage, the
CBT, need to be adequately powered and delineate absence of well-matched control groups and the lack
in advance meaningful clinical criteria by which of large replication trials also limit the reliability and
differences (or noninferiority) will be determined. specificity of the results and conclusions that may be
All in all we suggest that an ideal study to confirm drawn. Using meditation in the clinical setting on a
the efficacy of meditation for depression would be first-line basis or as an adjunctive treatment for
adequately powered and have 3 arms: meditation, a depression appears promising—especially given their
credible active comparator (such as CBT), and a favorable risk/benefit profile—but carefully designed
modest psychoeducation group that allows for a studies that account for the various shortcomings
comparison of the effects of meditation to minimal of the studies reviewed are necessary. Further
treatment. studies should be conducted of these promising
Another important research question concerns techniques, particularly in patients with medical
elucidating the nature of the interaction between comorbidities who may be more vulnerable to
meditation and other depression treatments, including polypharmacy and side effects of antidepressant
psychotherapy, antidepressant medications, and other medications.
lifestyle changes. This is critically important for deter-
mining how meditative techniques best fit into the We would like to thank Dr. Andrew F. Leuchter,
established therapeutic armamentarium for depression. M.D., for his helpful comments on the manuscript.
Such interactions may be partially or fully additive, The funding sources were not involved in data
synergistic, or inhibitory. Just as combining psycho- collection, data analysis, manuscript writing, or pub-
therapy and antidepressant medication can result in lication. Dr. Eisendrath reports research funding
improved outcomes, the same may be true of combin- from the National Center for Complementary and
ing meditation with antidepressant medication.66 Alternative Medicine, USA (R01AT004572). Dr.
Indeed, interviews with meditators taking antidepres- Jain was supported by an institutional Ruth L.
sants provide preliminary suggestions that this may Kirschstein National Research Service Award no.
be the case.67 Studies comparing different kinds of 5T32MH017140.
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