You can’t go a day without hearing about how mindfulness can treat everything.
We use and recommend it here at Health, Counselling and Disability Services, as a stress reliever, and also as a way of improving academic outcomes.
But the hype for mindfulness is far ahead of the science.
In this blog post, I want to explore an article by Hedman-Lagerlof et al. on the empirical support for mindfulness-based interventions for common psychiatric disorders.
Put more simply – can mindfulness be used to treat common mental health problems like anxiety and depression?
Hedman-Lagerlof et al. looked at studies where mindfulness-based interventions (MBI) were used as the primary treatment for different mental disorders (depression, PTSD, social anxiety, generalised anxiety, insomnia, hypochondriasis, and elevated stress).
Taken together as a whole, they found that whilst MBI were typically better than no treatment (i.e. a wait list control), they did not outperform placebo or another active treatment (Strike 1). Essentially MBI weren’t able to beat a fake treatment, and certainly couldn’t beat an established treatment.
Second, when they looked on a disorder-by-disorder basis, they found that it was only in studies of depression that MBI reliably outperformed the comparison group. This was not the case for any other disorders (Strike 2).
Finally, with the exception of health anxiety (of which there was just one decent study), the authors concluded that based on the current evidence, MBI can only be considered as ‘experimental’ treatments for common mental disorders (Strike 3).
The findings of this paper are in stark contrast to the enthusiasm and hype surrounding mindfulness.
Other reviews of the impacts of mindfulness-based interventions have been more hopeful about their impacts. Some of these reviews have formed the basis of enthusiasm about MBI.
But these reviews have included studies not just of individuals with mental health disorders, but also high levels of stress. They have also looked at quality of life outcomes, in addition to mental health disorder symptoms. Basically, they included a much greater variety of participants than the Hedman-Lagerlof et al. study.
What the Hedman-Lagerlof et al. study has shown, is that when you look specifically at individuals with diagnosed mental health disorders, MBI do not appear to be an appropriate first-line treatment, that is, the treatment you would start someone with. Instead MBI for the primary treatment of common mental health problems are experimental at best.
The take-home message is this: If you have been diagnosed with a mental health disorder (e.g. anxiety, depression, PTSD), MBI should not be the first treatment option that you explore. This is not to say they won’t be helpful, but there are already existing evidence-based treatments for common mental health problems, and these should be explored first.
MBI do however remain a very interesting and potentially fruitful interventions for managing stress and coping with chronic illness. We’ll look at some of the reviews for mindfulness in these areas in coming posts.
Notes (these are the notes I take while reading the article)
https://www.ncbi.nlm.nih.gov/pubmed/29455695
research on mindfulness based interventions (MBI) has increased dramatically
coping with chronic illness, relapse treatment for depression are two evidence-based uses
but now MBI being recommended as treatments for common mental disorders CMD (e.g. anxiety and depression)
Previous reviews suggested MBI are ‘promising’ treatment for reducing anxiety, stress and preventing relapse prevention
have not explored MBI as stand-alone treatment for CMD
most studies have explored impact of MBI on symptoms, not disorders OR explored just specific MBI protocols
Goal: systematic review, meta-analysis of MBI for CMD in acute phase
quantify the size of treatment effect, explore moderator variables, status of MBI for different CMD
Outcome measures were symptoms of disorders
compared to waitlist, no treatment control, placebo and active treatment (psychological or pharmacological) – only included RC
Method
5 databases – mindful*, MBSR, MBCT + random* + using reference lists
inclusion: paediatric and adult, CMD (depression, anxiety, insomnia, adjustment, exhaustion), structured MBI as core treatment, comparison, validated symptom scale, RCT
exclusion: remission, healthy individuals, severe psychiatric, drug and alcohol, neuropsychiatric, somatic, secondary symptoms, MBI not foundation of treatment, global measures of wellbeing as outcome, nonrandomised designs
extracted: research design, sample, intervention, outcomes (categorical or continuous), potential moderators
methodological quality: Psychotherapy Outcome Study Methodology Rating Form, first author trained, 20% random selection of articles for secondary assessment
Risk of bias: Cochrane criteria – randomisation, allocation concealment, incomplete outcome, selective reporting, low/unclear/high
Assessment of evidence status: EST system developed by APA combines methodological critieria (study design, independent variable, population, outcome, analysis) + evidence-status – well established/probably efficacious/possibly efficacious/experimental/ controversial
Analysis: Comprehensive Metal-Analysis Software (Windows, v3) – main outcome measure of symptom reduction, effect sizes Hedges g, I2 and Cochran’s Q for heterogeneity, Egger’s Regression Intercept and Duval and Tweedie’s trim and fill method for publication bias, variety of moderators tested using sub-group and meta-regression analyses
Results
19 studies down from 4222 in the search
1291 participants
average attrition rate total 12.1%
depression, PTSD, social anxiety, generalised anxiety, insomnia, hypochondriasis, elevated stress
mean age 44.7
50% women
MBSR, MBCT, mindful awareness practice (MAP), brief mindfulness training (BMT), body-scan mindfulness meditation (MM)
no-treatment control, waitlist, TAU, placebo, anti-depressant, CBT, mindfulness based CBT, biofeedback, aerobic exercise
Methodological quality: internal validity considered low – few had checks for treatment adherence or therapist competence, no report of how blindness was achieved in 9 of 19, 11 had only 1 therapist – confounding therapist and treatment effects or didnt assess therapist as potential moderator
Risk of bias: only 2 studies low risk of bias across all dimensions, high risk of detection bias, high risk of bias cause of allocation concealment
Effect size across all treatments – small and significant – more effective than waitlistcontrol but NOT placebo or other active treatment
Only significant effect size for depression, not other disorders
Moderators: poorer outcome study – better outcomes, treatment duration – better outcomes
within group: large effects for MBI, but also effects or placebo and other active treatments. MBI didn’t have lasting effects
Evaluation of evidence base: possibly efficacious for health anxiety, experimental for the rest
Discussion
average effect size across all comparison conditions was small
only superior to waitlist control – i.e. non active conditions
Depression is only disorder for which effects were significant – consistent with MBCT for depression relapse
experimental for all but health anxiety
low quality = greater effect casts doubt on all studies of low qualty in this area as they might be exxagerating effect
MBI lacking empirical support due primarily to methodological shortcomings – a common issue in this area
Difference between this and previous trials – they were not just looking at mental disorders
This trial is on the conservative side
not a first-hand treatment for CMD