Critical Analysis of the Efficacy of Meditation Therapies for Acute and Subacute Phase Treatment of Depressive Disorders: a Systematic Review

UC Irvine UC Irvine Previously Published Works

Title Critical analysis of the efficacy of meditation therapies for acute and subacute phase treatment of depressive disorders: a systematic review.

Permalink https://escholarship.org/uc/item/8790p0mx

Journal Psychosomatics, 56(2)

ISSN 0033-3182

Authors Jain, Felipe A Walsh, Roger N Eisendrath, Stuart J et al.

Publication Date 2015-03-01

DOI 10.1016/j.psym.2014.10.007

License https://creativecommons.org/licenses/by/4.0/ 4.0

Peer reviewed

eScholarship.org Powered by the California Digital Library University of California Psychosomatics 2015:56:140–152 & 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved. Review Articles

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; 56:140–152)

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, order (MDD) and dysthymia, have a 12-month Los Angeles, CA (FAJ, SC); Department of Psychiatry, University of California, Irvine, CA (RNW); Department of Psychiatry, University 1 prevalence of approximately 7% 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 2 Creativity Institute, University of Southern California, Los Angeles, ized patients with medical illness and ambulatory CA (BRC). Send correspondence and reprint requests to Felipe A. Jain, 3,4 medical patients. 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.

140 www.psychosomaticsjournal.org Psychosomatics 56:2, March/April 2015 Jain et al. 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 practices while retaining stationary meditation groupings 23 Definition of Meditation was not provided.

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

Psychosomatics 56:2, March/April 2015 www.psychosomaticsjournal.org 141 Meditation Therapies for Depression

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

142 www.psychosomaticsjournal.org Psychosomatics 56:2, March/April 2015 Jain et al. 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 ﬁ speci c 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 41 attentional foci and techniques. With the exception and mental imagery theory. 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 meditation, 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 practice (MBCT, Patañjali Yoga, qigong, and Sahaj following formula: (ū1 ū2)/Sp, where ū1 is the mean of the treatment group (for between-group compar- Yoga). Of the 7 techniques, 2 (MBCT and inner resources meditation) provided additional therapeutic isons) or baseline (for within-group comparisons), ū2 is 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 exception of Sahaj Yoga, for which this was indeterminate) isons), and Sp is the pooled variance. Effect sizes were 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

Psychosomatics 56:2, March/April 2015 www.psychosomaticsjournal.org 143 eiainTeaisfrDepression for Therapies Meditation 144 TABLE 1. Elements of Meditation Therapies Technique Overview Mental imagery Attention Holistic philosophical overview Additional therapeutic elements www.psychosomaticsjournal.org 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 Becoming more aware of what is Attitudinal: Relate to symptoms Mindfulness- Mindfulness meditation with Somatic: during body scan Somatosensory: to sensations of happening “in the moment” of depression not as personal “ ” based focus on bringing an ( feel or imagine the breath eating, breathing, breath and provides a greater choice in failings but as parts of an cognitive equanimous, observing moving into body parts to body as a whole, walking. relationship to life experience. impersonal syndrome. During therapy awareness to present-moment aid in bringing attention to Emotional: awareness of Developing a stance of an body scan, bringing an experience of breath, body, each area of the body) feelings. Cognitive: awareness equanimous observing “interested and friendly sound, thought, and of thoughts as events in the awareness toward the contents awareness,” having “lightness “ ” fi awareness itself, yoga eld of awareness as if of awareness and the craving/ of touch” in awareness. As a “ ” asanas (low impact and projected on: bringing a screen, full aversion tendencies of mind way of accepting into nonaerobic), and cognitive Externalawareness to senses generally provides access to decreased awareness difficult sensations/ therapy. Emphasis on and awareness of “pleasant rumination and identification feelings/thoughts, may silently developing mindfulness during events” with thought, deeper wisdom, repeat “It's ok. Whatever it is, formal practice and also and self-compassion it's ok. Let me feel it.” Other implementing this mindful CBT components include awareness during day-to-day creating pleasant and activities, especially unpleasant events calendars, emotionally challenging times making an action plan for activities to help respond to negative moods, raising awareness of depleting vs scooais5:,MrhArl2015 March/April 56:2, Psychosomatics nourishing activities, raising awareness of personal warning signs for onset of depression. Conducted in group setting 1 d/wk for 8 wk and an optional 6-h retreat day; Ethical behavior and Conductedhomework in 6 a d/wk group setting Patañjali 5 Components: Yoga asanas Visual: during dharana stage, Somatosensory: to body during withdrawal from sensory 6 d/wk for 8 wk Yoga (nonaerobic, gradual and focusing attention on an yoga, pranayama. Cognitive: preoccupation leads to feelings sustained tonic stretch), “object or symbol—mostly aboutto “3 types“random” of” thoughtsexperiences,— of well being Pranayama (breath control a visual image” disturbing thoughts, and with slow alternate nostril desiring to change breathing), Pratyahara (withdrawal of attention from sense objects), Dharana (focused concentration), and Dhyana (steadfast meditation) scooais5:,MrhArl2015 March/April 56:2, Psychosomatics 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) Unclear Somatosensory: to body during Not in these studies Conducted in a group setting T'ai Chi Seriesnonstrenuous, of repetitive, nonaerobic, slow, movement. External: to visual 1 d/wk physical movements with a surroundings during mindful, present-oriented movement attentional focus on the movements

CBT ¼ cognitive-behavioral therapy. www.psychosomaticsjournal.org Jain 145 tal. et eiainTeaisfrDepression for Therapies Meditation 146 TABLE 2. Meditation Therapy Trials for Acute Depression Study/country Design Homework Subjects Duration Results Effect size Relative deficiencies www.psychosomaticsjournal.org Inner resources meditation (IRM) 61 Butler et al., 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 χ 2 test); no difference short-term mix of patients with different disorder lasting Z2y 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) þ ¼ – Z Barnhofer MBCT TAU vs 6 d/wk N 31, age 18 65 y, 3 8 wk Greater reduction in BDI-II in WS: 1.07 Mix of acute and subacute depressive 44 þ ¼ et al.,UK TAU MDEs or current MBCT TAU group (p 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 43 Chiesa et al., 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 þ ¼ Z fi Geschwind MBCT TAU vs 6 d/wk N 130, age 18 y, 8 wk Greater reduction in HAM-D in WS: 0.73 TAU not well de ned, therapist and 46 o et al., TAU history of MDD, MBCT group (p 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 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,

scooais5:,MrhArl2015 March/April 56:2, Psychosomatics Manicavasgar 45 et al., augmentation of unipolar MDE, not II BS: 0.15 some groups not randomized, not Australia current treatment if melancholic rigorously designed to assess 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 49 ¼ – Z Shahar et al., MBCT vs wait list, 6 d/wk N 52, age 24 64 y, 3 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 ADM (12 wk episode (if symptoms in brooding and increase in without change “fluctuated toward mindfulness (both p o 0.05) before study) remission”) scooais5:,MrhArl2015 March/April 56:2, Psychosomatics van Aalderen MBCT þ TAU vs 6 d/wk N ¼ 219, age 47.3 Ϯ 8 wk Greater reduction in HAM-D in WS: 0.33 TAU not well defined (participants 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) 56 ¼ – Vahia et al., PY vs pseudo- None, but N 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 57 Vahia et al., 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) 52 ¼ Z Chou et al., TC vs wait list None, TC N 14, age 60 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 51 et al., 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 59 ¼ Z Tsang et al., Qigong vs newspaper Daily N 97, age 65 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, www.psychosomaticsjournal.org elevated GDS not rigorously designed to assess nonequivalence between therapies 53 Yeung et al., TC vs wait list (WL), TC sessions N ¼ 39, age 50 Ϯ 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 treatment (if any) Chinese American rates (20% in TC vs 0% in WL, p ¼ 0.30) between groups Sahaj Yoga (SY) 60 ¼ – Sharma et al., Augmentation of None, but N 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 Jain 8wk(p ¼ 0.02) 147 tal. et Meditation Therapies for Depression

¼ that the efﬁcacy of MBCT did not differ whether 17-

¼ patients had an MDE or had subacute residual symptoms.50

Efﬁcacy of Meditation Therapies in the Subacute Phase of Treatment ciencies Center for Epidemiologic ﬁ

¼ Three studies included only patients with residual depression symptoms after acute phase treatment, and

psychoeducation group; SCID – therapist and patient expectations not assessed, not rigorously designed to assess equivalence between therapies not assessed, not rigorously designed to assess nonequivalence between therapies these demonstrated effect sizes ranging from 0.65 ¼ 1.02.43,46,51 Geriatric Depression Scale; HAM-D 0.23 0.85 ¼ Efﬁcacy of Meditation Therapies Relative to Control Groups BS (IMN): WS: 2.07 Lack of blinding to study hypotheses, BS: 0.64 WS: 3.34 Patient and therapist expectations BS (ECT): Relative to wait list or treatment-as-usual controls, studies demonstrated moderate to large effect sizes (0.47–2.12),44,46,47,49,50,52 with the exception of Yeung cognitive-behavioral therapy; CES-D 53 0.06)

¼ et al. (2012). In the latter study, the wait list control major depressive episode; PED o ¼ group exhibited an abnormally large reduction in p depressive symptoms (within-group effect size 1.54) electroconvulsive therapy; GDS 0.04) ¼

¼ relative to the control groups of other studies (within- p group effect sizes: 0.60 to 0.35). Among studies that used psychoeducation nondifferent reductions in HAM-D; ECT superior to both ( nondifferent reductions in BDI. F-SKY tended tohigher have response a rate (80%) than P-SKY (47%) ( or pseudotherapy control group arms, between- between subjects; CBT within subjects. ¼

¼ group sizes favored meditation and were moderate to large (0.39–1.54).43,51,55,59,60 The within-subject 4 wk SKY and ADM showed 4 wk F-SKY and P-SKY showed effects in psychoeducation groups ranged from

18, – major depressive disorder; MDE 0.02 0.59. 7.8 y, Z ¼ 60 y,

Ϯ Three studies for MDD, and one for a depressed – subpopulation diagnosed with psychoneurosis, also used as controls validated, ﬁrst-line depression treat- 17, hospitalized

treatment as usual; WS 45,48 54

30, age 18 ments: MBCT vs CBT, SKY vs imipramine, and Z ¼ 45, age 36.0 57 ¼ ¼ current MDE, HAM- D current MDE, not on ADM HAM-D hospitalized Patañjali Yoga vs amitryptiline. These showed no N N ﬁ

imipramine; MDD signi cant differences in reduction of depressive Beck Depression Inventory II; BS ¼ ¼ symptoms between the meditation and the control groups. The study of SKY also used a second-line sessions 6 d/wk treatment sessions daily None, SKY None, but treatment for depression, electroconvulsive therapy, as

Diagnostic and Statistical Manual of Mental Disorders IV; ECT a further control condition, and this demonstrated ¼ inferiority of the SKY intervention (effect size of SKY 0.94 relative to electroconvulsive therapy).

DISCUSSION Yoga (SKY) vs ADM (imipramine) vs ECT vs Partial SKY (P- SKY) Sudarshan Kriya Full SKY (F-SKY) 55

antidepressant medication; BDI-II The data from RCTs suggest that meditative inter- Continued ¼ India . ventions may have substantial effects on depressive 54 symptoms in patients with clinically diagnosed depres- ADM India et al., sive disorders, including those currently having an item Hamilton Depression Rating Scale; IMN Studies Depression Scale; DSM-IV Structured Clinical Interview for DSM Disorders; TAU Study/country Design Homework Subjects Duration Results Effect size Relative de Sudarshan Kriya Yoga (SKY) Janakiramaiah Rohini et al., TABLE 2 acute MDE and those in partial remission. Across

148 www.psychosomaticsjournal.org Psychosomatics 56:2, March/April 2015 Jain et al. 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 categorization accorded in part with the framework that, while increasing the generalizability of the provided by Shear, which included the types of mental findings across depressive condition type and illness faculties used (e.g., attention and visual imagery), how stage, limited their commonality. Patient populations the faculties were used (e.g., active and passive), the contained a mixture of patients with different depres- foci for these faculties (e.g., thoughts, bodily sensa- sive illnesses in several of the trials, including MDD tions, and spirit/God).14 However, groupings based on and dysthymia,47,61 and multiple “psychoneurotic elements other than praxis are possible, such as a focus disorders.”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

Psychosomatics 56:2, March/April 2015 www.psychosomaticsjournal.org 149 Meditation Therapies for Depression 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, M.D., established therapeutic armamentarium for depression. 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 ing meditation with antidepressant medication.66 and Alternative Medicine, USA (R01AT004572). Indeed, interviews with meditators taking antidepres- Dr. Jain was supported by an institutional sants provide preliminary suggestions that this may Ruth L. Kirschstein National Research Service Award be the case.67 Studies comparing different kinds of no. 5T32MH017140.

References 1. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE: 3. Nielsen AC, Williams TA: Depression in ambulatory Prevalence, severity, and comorbidity of 12-month DSM-IV medical patients. Arch Gen Psychiatry 1980; 37:999–1004 disorders in the National Comorbidity Survey Replication. Arch 4. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ: The Gen Psychiatry 2005; 62(6):617–627 prevalence of comorbid depression in adults with diabetes: 2. Koenig HG, Meador KG, Cohen HJ, Blazer DG: Depres- a meta-analysis. Diabetes Care 2001; 24(6):1069–1078 sion in elderly hospitalized patients with medical illness. 5. Trivedi MH, Rush AJ, Wisniewski SR, et al: Evaluation Arch Intern Med 1988; 148(9):1929–1936 of outcomes with citalopram for depression using

150 www.psychosomaticsjournal.org Psychosomatics 56:2, March/April 2015 Jain et al.

measurement-based care in STAR*D: implications for clinical health of adults with a chronic medical disease: a meta- practice. Am J Psychiatry 2006; 163(1):28–40 analysis. J Psychosom Res 2010; 68(6):539–544 6. Thase ME, Friedman ES, Biggs MM, et al: Cognitive 25. Chen KW, Berger CC, Manheimer E, et al: Meditative therapy versus medication in augmentation and switch therapies for reducing anxiety: a systematic review and strategies as second-step treatments: a STAR*D report. meta-analysis of randomized controlled trials. Depress Am J Psychiatry 2007; 164(5):739–752 Anxiety 2012; 29(7):545–562 7. Whooley MA: Diagnosis and treatment of depression in 26. Hofmann SG, Sawyer AT, Witt AA, Oh D: The effect of adults with comorbid medical conditions: a 52-year-old mindfulness-based therapy on anxiety and depression: a man with depression. J Am Med Assoc 2012; 307(17): meta-analytic review. J Consult Clin Psychol 2010; 78 1848–1857 (2):169–183 8. Kessler RC, Soukup J, Davis RB, et al: The use of 27. Klainin-Yobas P, Cho MA, Creedy D: Efﬁcacy of complementary and alternative therapies to treat anxiety mindfulness-based interventions on depressive symptoms and depression in the United States. Am J Psychiatry 2001; among people with mental disorders: a meta-analysis. Int J 158(2):289–294 Nurs Stud 2012; 49(1):109–121 9. Norcross JC, Pfund RA, Prochaska JO: Psychotherapy in 28. Sedlmeier P, Eberth J, Schwarz M, et al: The psychological 2022: a Delphi poll on its future. Prof Psychol Res Pract effects of meditation: a meta-analysis. Psychol Bull 2012; 2013; 44(5):363–370 138(6):1139–1171 10. Davidson RJ, Goleman DJ: The role of attention in 29. Strauss C, Cavanagh K, Oliver A, Pettman D: Mindfulness- meditation and hypnosis: a psychobiological perspective based interventions for people diagnosed with a current on transformations of consciousness. Int J Clin Exp Hypn episode of an anxiety or depressive disorder: a meta-analysis 1977; 25(4):291–308 of randomised controlled trials. PLoS One 2014; 9(4):e96110 11. Benson H: The Relaxation Response. New York, NY: 30. Chiesa A, Serretti A: A systematic review of neurobiological Morrow; 1975 and clinical features of mindfulness meditations. Psychol 12. Goleman D: The Meditative Mind: The Varieties of Med 2010; 40(8):1239–1252 Meditative Experience. New York, NY: J.P. Tarcher; 1988 31. American Psychiatric Association: Practice Guidelines for 13. Gunaratana H: Mindfulness in Plain English. Boston, MA: the Treatment of Major Depressive Disorder: 3rd ed. Wisdom Publications; 1993 Arlington, VA: American Psychiatric Association; 2010;152 14. Shear J: Introduction. In: Shear J, (ed). The Experience of 32. D'Silva S, Poscablo C, Habousha R, Kogan M, Kligler B: Meditation: Experts Introduce the Major Traditions. 1st ed. Mind-body medicine therapies for a range of depression St. Paul, MN, Paragon House; 2006, xiii-xxii. severity: a systematic review. Psychosomatics 2012; 53 15. Walsh R, Shapiro SL: The meeting of meditative disciplines (5):407–423 and Western psychology: a mutually enriching dialogue. 33. Kuyken W, Byford S, Taylor RS, et al: Mindfulness-based Am Psychol 2006; 61(3):227–239 cognitive therapy to prevent relapse in recurrent depression. 16. Patañjali: The Yoga Sutras of Patañjali. Mineola, NY: J Consult Clin Psychol 2008; 76(6):966–978 Dover Publications; 2003 34. Bondolﬁ G, Jermann F, der Linden MV, et al: Depression 17. Anālayo: Satipatthāna: The Direct Path to Realization. relapse prophylaxis with mindfulness-based cognitive ther- ˙˙ Chiang Mai, Thailand: Silkworm Books; 2003 apy: replication and extension in the Swiss health care 18. Shapiro DH, Walsh RN: Meditation, Classic and Contem- system. J Affective Disord 2010; 122(3):224–231 porary Perspectives. New York, NY: Aldine Pub. Co., 1984 35. Teasdale JD, Segal ZV, Williams JM, Ridgeway VA, 19. Lutz A, Slagter HA, Dunne JD, Davidson RJ: Attention Soulsby JM, Lau MA: Prevention of relapse/recurrence regulation and monitoring in meditation. Trends Cogn Sci in major depression by mindfulness-based cognitive ther- 2008; 12(4):163–169 apy. J Consult Clin Psychol 2000; 68(4):615–623 20. Cahn BR, Polich J: Meditation states and traits: EEG, ERP, 36. Ma SH, Teasdale JD: Mindfulness-based cognitive therapy and neuroimaging studies. Psychol Bull 2006; 132(2):180–211 for depression: replication and exploration of differential 21. Ospina MB, Bond K, Karkhaneh M, et al: Meditation relapse prevention effects. J Consult Clin Psychol 2004; 72 practices for health: state of the research. Evid Rep Technol (1):31–40 Assess (Full Rep) 2007; 155:1–263 37. Segal ZV, Bieling P, Young T, et al: Antidepressant mono- 22. Orme-Johnson DW: Commentary on the AHRQ report on therapy vs sequential pharmacotherapy and mindfulness- research on meditation practices in health. J Altern Comple- based cognitive therapy, or placebo, for relapse prophylaxis ment Med 2008; 14(10):1215–1221 in recurrent depression. Arch Gen Psychiatry 2010; 67(12): 23. Agency for Healthcare Research and Quality: Meditation 1256–1264 Programs for Stress and Well-Being. Available from: http:// 38. Godfrin KA, van Heeringen C: The effects of mindfulness- effectivehealthcare.ahrq.gov/index.cfm/search-for-guides- based cognitive therapy on recurrence of depressive epi- reviews-and-reports/?productid=981&pageaction=display sodes, mental health and quality of life: a randomized product#4742. [cited 09-04-2013] controlled study. Behav Res Ther 2010; 48(8):738–746 24. Bohlmeijer E, Prenger R, Taal E, Cuijpers P: The effects of 39. Williams JM, Crane C, Barnhofer T, et al: Mindfulness- mindfulness-based stress reduction therapy on mental based cognitive therapy for preventing relapse in recurrent

Psychosomatics 56:2, March/April 2015 www.psychosomaticsjournal.org 151 Meditation Therapies for Depression

depression: a randomized dismantling trial. J Consult Clin 54. Janakiramaiah N, Gangadhar BN, Naga Venkatesha Psychol 2014; 82(2):275–286 Murthy PJ, Harish MG, Subbakrishna DK, Vedamurtha- 40. Piet J, Hougaard E: The effect of mindfulness-based char A: Antidepressant efficacy of Sudarshan Kriya Yoga cognitive therapy for prevention of relapse in recurrent (SKY) in melancholia: a randomized comparison with major depressive disorder: a systematic review and meta- electroconvulsive therapy (ECT) and imipramine. J Affect analysis. Clin Psychol Rev 2011; 31(6):1032–1040 Disord 2000; 57(1-3):255–259 41. Kosslyn SM, Pomerantz JR: Imagery, propositions, and form 55. Rohini V, Pandey R, Janakiramaiah N, Gangadhar BN, of internal representations. Cogn Psychol 1977; 9(1):52–76 Veadmurthachar A: A comparative study of full and partial 42. Hedges LV, Olkin I: Statistical methods for meta-analysis. Sudarshan Kriya Yoga (SKY) in major depressive disorder. Orlando, FL: Academic Press; 1985 NIMHANS J 2000; 18(1&2):53–57 43. Chiesa A, Mandelli L, Serretti A: Mindfulness-based 56. Vahia NS, Doongaji DR, Jeste DV, Kapoor SN, cognitive therapy versus psycho-education for patients with Ardhapurkar I, Ravindranath S: Further experience with major depression who did not achieve remission following the therapy based upon concepts of Patañjali in the treat- antidepressant treatment: a preliminary analysis. J Altern ment of psychiatric disorders. Indian J Psychiatry 1973; Complement Med 2012; 18(8):756–760 15:32–37 44. Barnhofer T, Crane C, Hargus E, Amarasinghe M, Winder R, 57. Vahia NS, Doongaji DR, Jeste DV, Ravindranath S, Williams JM: Mindfulness-based cognitive therapy as a Kapoor SN, Ardhapurkar I: Psychophysiologic therapy treatment for chronic depression: a preliminary study. Behav based on the concepts of Patañjali. A new approach to the Res Ther 2009; 47(5):366–373 treatment of neurotic and psychosomatic disorders. Am J 45. Manicavasgar V, Parker G, Perich T: Mindfulness-based Psychother 1973; 27(4):557–565 cognitive therapy vs cognitive behaviour therapy as a 58. Manicavasgar V, Perich T, Parker G: Cognitive predictors treatment for non-melancholic depression. J Affect Disord of change in cognitive behaviour therapy and mindfulness- 2011; 130(1-2):138–144 based cognitive therapy for depression. Behav Cogn Psy- 46. Geschwind N, Peeters F, Huibers M, van Os J, Wichers M: chother 2012; 40(2):227–232 Efficacy of mindfulness-based cognitive therapy in relation 59. Tsang HW, Fung KM, Chan AS, Lee G, Chan F: Effect of a to prior history of depression: randomised controlled trial. qigong exercise programme on elderly with depression. Int J Br J Psychiatry 2012; 201(4):320–325 Geriatr Psychiatry 2006; 21(9):890–897 47. Hamidian S, Omidi A, Mousavinasab SM, Naziri G: 60. Sharma VK, Das S, Mondal S, Goswampi U, Gandhi A: Comparison of the effect of mindfulness-based cognitive Effect of Sahaj Yoga on depressive disorders. Indian J therapy accompanied by pharmacotherapy with pharma- Physiol Pharmacol 2005; 49(4):462–468 cotherapy alone in treating dysthymic patients. Iran Red 61. Butler LD, Waelde LC, Hastings TA, et al: Meditation with Crescent Med J 2013; 15(3):239–244 yoga, group therapy with hypnosis, and psychoeducation 48. Omidi A, Mohammadkhani P, Mohammadi A, Zargar F: for long-term depressed mood: a randomized pilot trial. Comparing mindfulness based cognitive therapy and tradi- J Clin Psychol 2008; 64(7):806–820 tional cognitive behavior therapy with treatments as usual 62. Gaffan EA, Tsaousis I, Kemp-Wheeler SM: Researcher on reduction of major depressive disorder symptoms. Iran allegiance and meta-analysis: the case of cognitive therapy Red Crescent Med J 2013; 15(2):142–146 for depression. J Consult Clin Psychol 1995; 63(6): 49. Shahar B, Britton WB, Sbarra DA, Figueredo AJ, Bootzin RR: 966–980 Mechanisms of change in mindfulness-based cognitive therapy 63. Awasthi B: Issues and perspectives in meditation research: for depression: preliminary evidence from a randomized con- in search for a definition. Front Psychol 2012; 3:613 trolled trial. Int J Cogn Ther 2010; 3(4):402–418 64. Rosenkranz MA, Davidson RJ, Maccoon DG, Sheridan 50. van Aalderen JR, Donders AR, Giommi F, Spinhoven P, JF, Kalin NH, Lutz A: A comparison of mindfulness-based Barendregt HP, Speckens AE: The efficacy of mindfulness- stress reduction and an active control in modulation of based cognitive therapy in recurrent depressed patients with neurogenic inflammation. Brain Behav Immun 2013; 27 and without a current depressive episode: a randomized (1):174–184 controlled trial. Psychol Med 2012; 42(5):989–1001 65. MacCoon DG, Imel ZE, Rosenkranz MA, et al: The 51. Lavretsky H, Alstein LL, Olmstead RE, et al: Comple- validation of an active control intervention for Mindfulness mentary use of tai chi chih augments escitalopram treatment Based Stress Reduction (MBSR). Behav Res Ther 2012; 50 of geriatric depression: a randomized controlled trial. Am J (1):3–12 Geriatr Psychiatry 2011; 19(10):839–850 66. Thase ME, Greenhouse JB, Frank E, et al: Treatment of 52. Chou KL, Lee PW, Yu EC, et al: Effect of Tai Chi on major depression with psychotherapy or psychotherapy- depressive symptoms amongst Chinese older patients with pharmacotherapy combinations. Arch Gen Psychiatry depressive disorders: a randomized clinical trial. Int J 1997; 54(11):1009–1015 Geriatr Psychiatry 2004; 19(11):1105–1107 67. Bitner R, Hillman L, Victor B, Walsh R: Subjective effects 53. Yeung A, Lepoutre V, Wayne P, et al: Tai chi treatment for of antidepressants: a pilot study of the varieties of depression in Chinese Americans: a pilot study. Am J Phys antidepressant-induced experiences in meditators. J Nerv Med Rehabil 2012; 91(10):863–870 Ment Dis 2003; 191(10):660–667

152 www.psychosomaticsjournal.org Psychosomatics 56:2, March/April 2015