- Email: [email protected]
Meditation for the management of adjustment disorder anxiety and depression
Complementary Therapies in Clinical Practice 17 (2011) 241e245
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Meditation for the management of adjustment disorder anxiety and depression Malini Srivastava a, *, Uddip Talukdar b, Vivek Lahan b a b
Department of Holistic Medicine, H.I.H.T. University, Swami Ram Nagar, Jollygrant Doiwala, Dehradun 248140, Uttarakhand, India Department of Psychiatry, H.I.H.T. University, Swami Ram Nagar, Jolly Grant Doiwala, Dehradun-248140, Uttarakhand, India
a b s t r a c t Keywords: Meditation Anxiety Depression Mental health Adjustment disorder Yoga
Objective: To examine the effect of Meditation training on patients with adjustment disorder with anxiety and depression. Method: In a pre-test/post-test control group design, patients (N ¼ 30) with adjustment disorder with mixed anxiety and depression, were screened through a Clinical Global Impression-severity/Improvement Scale, Beck’s Anxiety, Beck’s Depression Inventory, and Global Assessment of Functioning. Sessions of meditation training (28 weeks) were held using the model of Yoga Meditation. The difference of means (pre- and post-assessment) was tested using a paired t-test method. Results: Experimental group and control groups were similar at base line, whereas after concluding the 28th week of meditation practice a significant mean difference (t value: CGI-S 2.47 > .05; CGII2.82 > 0.05; BAI 17.58 > 0.05; BDI 10.13 > 0.05; GAF 12.29 > 0.05) was found between both groups. There was an incremental change in selected assessment parameters in both groups. But changes were more significant in pre- and post-assessment of experimental group. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction
symptom reduction has been found in somatization, insecurity in social contact, obsessive-anxiety, anger/hostility, phobic anxiety, paranoid thinking and psychoticism.6 The modulation effects of meditation on oxidative stress have been increasingly investigated for acute, short and long-term effects.7 A significant improvement in somatisation and anxiety was found in a study on Transcendental Meditation designed to monitor the effect of meditation on general mental health, however no evidence was found on adjustment disorder or any other specific mental disorder.8 The present study sought to examine the effect of meditation therapy on adjustment disorder with mixed anxiety and depression mood (DSM IV TR code 309.28). The main aim was to explore how to engender a positive, constructive life style to prevent stress. This study is also useful in understanding how meditation can offer a dynamic and self-therapeutic process in alleviating the stressful life event(s)/stressor(s).
An individual’s health is a reflection of his or her ability to meet life’s challenges and maintain their capacity for optimal functioning. Mixed anxiety with depressive disorder followed by major depression and schizophrenia are common psychiatric diagnoses in suicidal indicators, but among suicide attempters adjustment disorder is recorded as the most common diagnosis.1 Adjustment disorder is ranked as the second most common diagnosis among non-psychotic patients (31% of 290)2 along with co-morbidly with personality disorder and organic mental disorder.3 Diagnosis of adjustment disorder has an estimated incidence of 2e21% among psychiatric consultation services for adults and is a widespread problem, affecting 12% of people seeking mental health treatment in hospitals.3,4 Although, the usefulness of psychotherapy is supported by clinical evidence, there are a lack of efficacy surveys concerning treatment5 related to preventive alternatives to alleviate the symptoms of adjustment disorder. One research study indicated that the promotion of mindfulness during training of psychotherapists, influences the treatment results of their patients. Greater
* Corresponding author. Tel.: þ91 135 2471230(O), þ91 9411190397. E-mail addresses: [email protected] (M. Srivastava), uddiptalukdar@ rediffmail.com (U. Talukdar), [email protected] (V. Lahan). 1744-3881/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2011.04.007
2. Materials and methods 2.1. Participants Between September 2009 and November 2009, 245 patients reported to the psychiatric OPD with a range of problems including: agitation, depression, palpitations, trembling and headaches without having any physical co-morbidity. Psychiatric review diagnosed
242
M. Srivastava et al. / Complementary Therapies in Clinical Practice 17 (2011) 241e245
Table 1 Demographic profile of the participants.
Age range (years) Gender Locale Patients’ educational background Patients’ socioeconomic background Marital status Time period Symptoms severity range GAF range Reason for referrals Onset of the complaints Total duration of illness Co-morbidity
Experimental Group
Control Group
30e45 (mean:35) Male (04) & Female (11) Rural setting (2) Urban setting (13) Between high school and graduation Middle level of socioeconomic status Patients in both group were married (range 3e14 years) Total of 10 months (therapeutic intervention of 7 months) 5e7 48e50 Agitation, depression, palpitations, physical complaints, trembling or twitching, marital conflicts, headache Gradual Six months to five years at the time of first visit Selected patients had no other co-morbidity related physical or mental illness.
30e45 (mean: 35) Male (05) & Female (10) Rural setting (3) Urban setting (12)
85 patients with adjustment disorder. Of these, 30 patients were included in this study. Patients were selected randomly on predesigned equaling dimensions of demographic characteristics. Selected patients had no other psychiatric diagnosis or comorbidity and were not on any prescribed medicines for reported symptoms. A key inclusion criteria was a commitment to participate in the meditation-training program. The research design was pre-test/post-test control group design. The experimental group had 15 subjects with mean age ¼ 35 years (Table 1); control group comprised 15 subjects (mean age ¼ 35 years) with similar demographic characteristics (Table 1). The research was carried out in the Department of Holistic Medicine, Himalayan Institute of Medical Sciences at Dehradun, India. 2.2. Materials: assessment tools Selection of assessment parameters was two fold. Firstly, to monitor alleviation of severity and improvement in reported symptoms. To monitor this a Clinical Global Impression-Severity scale (CGI-S), Clinical Global Impression-Improvement scale (CGII), and Global Assessment of Functioning (GAF) as defined in the DSM IV TR were used. The second criterion was to identify changes in psychometric values of associated anxiety, and depression. Beck’s anxiety Inventory (BAI) and Beck’s depression Inventory (BDI) were employed. The Clinical Global Impression-Severity scale (CGI-S) is a 7-point scale requiring the clinician to rate the severity of a patient’s illness. Studies conducted to test the reliability of CGI-S show a moderate correlation between changes in the severity of illness and global improvement. A relatively good reliability score for the CGI severity of illness rating and assessing validation, demonstrating concurrent validity has been found.9,10 The Clinical Global Impression-Improvement scale (CGI-I) is a 7-point scale allowing the clinician to assess changes in a patient’s illness when compared to base line states at the beginning of the
intervention. CGI-I is a valid clinical outcome measure suitable for routine use in psychiatric OPD and psychiatric research.11 The Global Assessment of Functioning (GAF) is a numeric scale (0 through 100) used by mental health clinicians and physicians to subjectively rate the social, occupational, and psychological functioning of adults. Discriminant validity of the GAF was confirmed in research indicating that the GAF and other organizational measures were highly consistent, over time GAF proved to be a reliable and valid measure of psychiatric disturbance. The results in this study provided strong support for their use as standard functional performance monitors.12,13 The Beck Anxiety Inventory (BAI) is a 21-question multiplechoice, self-report inventory used to measure the severity of an individual’s anxiety. BAI obtained high internal consistency (ranged from 0.92 to 0.94 for adults, and item-total correlations14). Concurrent validity (the correlation with the Hamilton Anxiety Rating ScaledRevised) was 0.51. Correlation with the anxiety subscale of the Cognition Check List, measuring the frequency of dysfunctional cognitions related to anxiety, was 0.51. The BAI significantly correlates with Trait (0.58) and State (0.47) subscales of the State-Trait Anxiety Inventory with a the mean 7-day anxiety rating (0.54) of Weekly Records of Anxiety and Depression.15 The Beck Depression Inventory (BDI) is a 21-question multiplechoice, self-report inventory and one of the most widely used instruments for measuring the severity of depression. BDI testeretest and internal consistency reliability is above 0.65 with concurrent validity above 0.5. Coefficients of 0.65 and 0.67 were obtained in comparing results of the BDI with psychiatric ratings of patients.16 The Himalayan Yoga Meditation Tradition was used in the present study. The United States National Center for Complementary and Alternative Medicine published a report which reviewed 813 studies involving five categories of meditation: Mantra mediation, Mindfulness meditation, Yoga Meditation, Tai Chi, and Chi Gong.17 The Himalayan Yoga Meditation tradition, was selected for
Table 2 Pre- and post-assessment difference in selected assessment parameters. S.N.
Assessment parameters
Pre-therapy assessment difference Mean
1. 2. 3. 4. 5.
CGI-S CGI-I BAI BDI GAF
Post-therapy assessment difference t Value
Experimental group
Control group
6.13 2.4 33.33 32.4 50
6.46 2.13 33.37 32 59.86
0.8 0.81 0.05 0.74 0.05
Mean
p at 0.05 t value
Experimental group
Control group
1.6 6.8 8.93 12.4 86.33
5.8 4 29.33 29.93 45.66
2.47 2.82 17.58 10.13 12.29
2.05
M. Srivastava et al. / Complementary Therapies in Clinical Practice 17 (2011) 241e245 Table 3 Pre- and post-difference in assessment parameters of experimental group. S.N.
Assessment parameters
Pre- & post-therapy assessment difference in experimental group
p at 0.05
Mean
1. 2. 3. 4. 5.
CGI-S CGI-I BAI BDI GAF
t value
Pre-therapy
Post-therapy
6.13 2.4 33.33 32.4 50
1.6 6.8 8.93 12.4 86.33
8.82 7.71 20 28 16
2.05
the present study. The technique comprised of 4 steps, 1) stretching exercise, 2) systematic relaxation of the whole body, 3) breathing practices and, 4) meditation.18 2.3. Procedure After initial psychiatric diagnosis, all patients were evaluated individually using a detailed structured interview SCID-clinical version (Structured Clinical Interview for DSM IV TR). Patients showing adjustment disorder with mixed anxiety and depression but without other psychiatric diagnosis recieved CGI-S, CGI-I, GAF, BAI, and BDI. The meditation training program was described in a group meeting. After base line recording, participants from the experimental group were given ‘Yoga Meditation’. Each session (group session) was 60 min divided into: 1) stretching exercise (10 min), 2) systematic relaxation of the whole body (10 min), 3) breathing practices (10 min), and 4) meditation (30 min). Theses sessions
were conducted on daily basis for the first four weeks. From week 5 onwards, therapy sessions moved from daily to weekly sessions (total 24 weeks). However, patients were asked to practice meditation technique on their own at home for the rest of each week. Patients in the control group were given general counseling (group counseling 30 min per session) once in a week throughout the study period. After 28 weeks, both groups were reassessed and asked to maintain a daily diary. Besides clinical evaluation, patients’ care-givers were interviewed fortnightly, to explore subjective changes in patients’ over all well-being. Scoring occured at the end of 28 weeks of meditation. Paired t-test method was used to identify any difference in the mean preand post-assessment of CGI-S, CGI-I, GAF, BAI, and BDI. 3. Results The demographic profile of both groups (experimental and control) was similar (Table 1). The range of symptoms severity was 5e7 and range of GAF level was 48e50 for both groups (Table 1). Differences between control and experimental group in the base line scores of all the selected assessment parameters was insignificant (Table 2). Mean differences between the experimentals and control group (t value: CGI-S 2.47 > 0.05; CGI-I2.82 > 0.05; BAI 17.58 > 0.05; BDI 10.13 > 0.05; GAF 12.29 > 0.05) were found to be significant after concluding the 28th week of meditation practice (Table 2). Results showed significant differences in pre- and post-meditation training assessment in all the selected parameters of the experimental group (t value: CGI-S 8.82 > 0.05; CGI-I 7.71 > 0.05; BAI 20.00 > 0.05; BDI 28.00 > 0.05; GAF 16.00 > 0.05) (Table 3). As shown in Fig. 2, there was an incremental change in all the selected assessment parameters in both groups. Changes were
100
90
80
70 Pre Therapy Experimental. Group 60 Pre Therapy Control Group 50 Post Therapy Experimental. Group 40
Post Therapy Control Group
30
20
10
0 CGI-S
CGI-I
BAI
243
BDI
GAF
Fig. 1. Pre- and post-therapy assessment difference between experimental and control group.
244
M. Srivastava et al. / Complementary Therapies in Clinical Practice 17 (2011) 241e245
100
90
86.33
80
CGI-S
70
CGI-I 60
BAI
50 50
BDI 40
33.33 32.4
GAF score as defined in DSM IV TR.
30
20
12.4 10
6.8
6.46 2.4
8.93
1.6
0
BEFORE Therapy
AFTER Therapy
Mean Fig. 2. Pre- and post-therapy assessment difference in experimental group.
more significant in pre- and post-assessment of the experimental group. These results suggest that meditation therapy can play an effective role in managing the symptoms of adjustment disorder with mixed anxiety and depression. 4. Discussion The prognosis for a person suffering with an adjustment disorder is good, but due to lack of research, treatment recommendations are limited.19,20 The primary aim of the present study was to see the effect of meditation in relieving symptoms of adjustment disorder with anxiety and depression. The meditation used was a complementary technique to help patients return to the level of functioning they had before symptoms occurred. Yoga Meditation was chosen as the meditation technique. Significant differences were observed in pre- and post-meditation training assessment in all the selected parameters of the experimental group (Table 3). The aim of meditation is to reduce or eradicate irrelevant thought processes by developing physical and mental relaxation leading to stress reduction, psycho-emotional stability and enhanced concentration. Meditation induces biochemical and physical changes in the body. These are referred to as the “relaxation response”.21 Results of this study support previous findings where experimental and control groups displaying parity at the base line pre-intervention (Table 2), showed significant improvement in all the symptom assessment parameters (Fig. 1) post-intervention.
After learning to work with their body and breath systematically, patients in the experimental group became more aware of their reaction to stressors. The problems initially reported by subjects in the present study included agitation, depression, palpitations, physical complaints, trembling, headaches (Table 1). These are similar to other research studies in which, stress related, short-term, non-psychotic disturbances and maladaptive reactions to identifiable stressful life events can be termed adjustment disorder.22,23 Non-adaptive response to the stressors may be diminished if the stress can be “eliminated, reduced or accommodated”.24 Meditation has two major principles: reduction in reactivity, and abolishing thought patterns. Preventive interventions involve changing patterns of cognitive processing. From this perspective meditative training can help to prevent depressive relapses.25 The results of the present study support those findings where meditation reduces levels of depressive and anxiety symptoms (Fig. 1). Similar results were seen in a study in which patients undergoing long-term psychotherapy participated in a 10-week group meditation program. Results demonstrated a significant improvement in subject well-being and reduction in anxiety and depression. These results indicate that meditation can be an important adjunct to psychotherapy.26 Meditation enhanced the ability of the experimental group to function completely. A significant improvement in GAF level was found post-intervention (Table 3). It was noted that levels of GAF worsened in the control group at the end of the assessment showing a deterioration in psychological, social and occupational
M. Srivastava et al. / Complementary Therapies in Clinical Practice 17 (2011) 241e245
functioning (Table 2). A pilot study on the effects of meditation for post-traumatic stress disorder (PTSD), depression, and anxiety symptoms indicated that participants’ PTSD and anxiety symptoms significantly decreased with the majority of participants reporting good treatment adherence and improvements in well-being.27 Yoga Meditation practice adopted by the experimental group resulted in a significant reduction in the severity of symptoms as screened by CGI-S (Table 2). Similarly it has been found that Transcendental Meditation technique helped women with breast cancer to reduce stress and improve their mental health and emotional well-being.28 The results of this study show a significant improvement in patients in the experimental group after using “Yoga Meditation” (Table 2). Improvements (after 28 weeks of meditation practice) included: 1) The level of severity of illness decreased: 6.13 (mean of preassessment) to 1.6 (Fig. 2). 2) Global improvement increased: 2.4 to 6.8 (Fig. 2). 3) Level of anxiety and level of depression reduced respectively from 33.33 and 32.4 to 8.93 and 12.4 (Fig. 2). 4) Ability to function on a daily basis (GAF Level) rose from 50 to 86.33 (Fig. 2). Interview with care-givers and family members revealed observational positive improvement in mood, ability to relate to others, and attitudes toward psychosocial stressors. 5. Conclusion It is acknowledged that these results should be addressed by further research. This study does however, indicate that meditation techniques can be beneficial in helping to alleviate symptoms of adjustment disorder, anxiety and depression. Outcomes of the study suggest the procedure to develop a holistic approach instead of putting patients only on symptomatic treatment, can help patients become aware of ways to adapt and react to the stressful psychosocial environment. In conclusion, meditation techniques can be effective with patients suffering from adjustment disorder with mixed anxiety and depression. Role of funding resources None to declare. Acknowledgment This research study would not have been possible unless my clients had supported me. Especially their commitment to undertake daily meditation practice. We are indebted to H.H. Swami Rama who introduced the Himalayan Meditation Tradition and to Swmai Janeshwer Bharti ji for granting open access to use “Yoga Meditation” model of the Himalayan Tradition for this study. We acknowledge Dr. Aaron T. Beck for Beck’s anxiety Inventory and Beck’s depression inventory, and the editors of the CGI-S, CGI-I, DSM IV TR. We are indebted to many of our colleagues who supported us throughout this work. We thank the librarians, other staff members and authors of citied references who helped us in this work.
245
References 1. Bhatia MS, Aggarwal NK, Aggarwal BB. Psychosocial profile of suicide ideators, attempters and completers in India. Int J Soc Psychiatry 2000 Autumn;46(3):155e63. 2. Pelkonen M, Marttunen M, Henriksson M, Lönnqvist J. Adolescent adjustment disorder: precipitant stressors and distress symptoms of 89 outpatients. Eur Psychiatr 2007 Jul;22(5):288e95. Epub 2006 Dec 20. 3. Strain JJ, Smith GC, Hammer JS, et al. Adjustment disorder: a multisite study of its utilization and interventions in the consultation-liaison psychiatry setting. Gen Hosp Psychiatr 1998 May;20(3):139e49. 4. Diagnostic and statistical manual of mental disorders. 4th ed.: American Psychiatric Association; [p. 681]. 5. Carta MG, Balestrieri M, Murru A, Hardoy MC. Adjustment disorder: epidemiology, diagnosis and treatment. Clin Pract Epidemiol Ment Health 2009 Jun 26;5:15. 6. Grepmair L, Mitterlehner F, Loew T, Bachler E, Rother W, Nickel M. Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: a randomized, double-blind, controlled study. Psychother Psychosom 2007;76(6):332e8. 7. Mahagita C. Roles of meditation on alleviation of oxidative stress and improvement of antioxidant system. J Med Assoc Thai 2010 Nov;93(Suppl. 6):S242e54. 8. Yunesian Masud, Aslani Afshin, Homayoun Vash Javad, Yazdi Abbas Bagheri. Effects of Transcendental Meditation on mental health: a before-after study. Clin Pract Epidemiol Ment Health 2008;4:25. doi:10.1186/1745-0179-4-25. Published online 2008 November 1. 9. Guy W. Clinical Global Impressions (CGI) Scale. Modified From: Rush J, et al: Psychiatric measures. Washington DC: APA; 2000. 10. Kadouri Alane, Corruble Emmanuelle, Falissard Bruno. The improved global Impression scale (iCGI): development and validation in depression. BMC Psychiatr:7, http://www.biomedecentral.com/1471-244x/7/7, 2007;7. E-publishing Inc. 11. Berk M, Ng F, Dodd S, Callaly T, Campbell S, Bernardo M, et al. The validity of the CGI severity and improvement scales as measures of clinical effectiveness suitable for routine clinical use. Eval Clin Pract 2008 Dec;14(6):979e83. Epub 2008 May 2. 12. Greenberg G, Rosenheck R, AcademyHealth. Assessing the validity of general assessment of functioning as a mental health outcome performance measure in the Veterans health Administration. Abstr AcademyHealth Meet 2003;20. abstract no. 572. 13. Jones SH, Thornicroft G, Coffey M, Dunn G. A brief mental health outcome scale-reliability and validity of the Global Assessment of Functioning (GAF). Br J Psychiatr 1995;166:654e9. 14. Charles M Morin, Philippe Landreville, Cheryl Colecchi, et al. The Beck anxiety inventory: psychometric properties with older adults. J Clin Geropsychol; 5(1):19e29. doi:10.1023/A:1022986728576. 15. Beck Aaron T, Steer Robert A. Beck anxiety inventory (BAI), 800. The Psychological CORPORATION, www.psychcorpcenter.com/content/bai.htm; 1993. 228e0752. 16. Beck Aaron T, Steer Robert A. Beck depression inventory (BDI-II). 2nd ed., 800. The Psychological Corporation, www.psychcorpcenter.com/content/bai.htm; 1996. 228e0752. 17. Barnes Patricia M, Barbara Bloom MA, et al. National Health Statistics reports. United States National Center for Complementary and Alternative Medicine, National Institutes of Health; 2007. Number 12, December 10, 2008. 18. Rama Swami. Meditation and its practice. 6th ed. Honesdale, P.A./843/USA: Himalayan Institute Press; 2008. 19. Bronish T. Adjustment reactions: a long-term prospective and retrospective follow-up of former patients in a crisis intervention ward. Acta Psychiatr Scand 1991;84:86e93. 20. Greenberg WA, Rosenfeld DN, Ortega EA. Adjustment disorder as an admission diagnosis. Am J Psychiatr 1995;152:459e61. 21. Benson H. The relaxation response: therapeutic effect. Science 1997 Dec 5;278(5344):1694e5. PMID: 9411784. 22. Jones R, Yates WR, Zhou MH. Readmission rates for adjustment disorders: comparison with other mood disorders. J Affect Disorder 2002;71:199e203. 23. Casey P, Dowrick C, Wilkinson G. Adjustment disorders: Fault line in the psychiatric glossary. Br J Psychiatr 2001;179:479e81. 24. Montgomery C, Lydon A, Lloyd K. Psychological distress among cancer patients and informed consent. J Psychosom Res Mar 1999;46(3):241e5 [Medline]. 25. Teasdale JD, Segal Z, Williams JMG. How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behav Res Ther 1995;33(1):25e39. 26. Kutz I, Borysenko JZ, Benson H. Meditation and psychotherapy: a rationale for the integration of dynamic psychotherapy, the relaxation response, and mindfulness meditation. Am J Psychiatr 1985;142:1e8. 27. Lynn Waelde C, Uddo Madeline, et al. A pilot study of meditation for mental health workers following Hurricane Katrina. J Traum Stress 2008;21(5):497e500. Published Online: 27 Oct. 28. Peer-reviewed integrative cancer therapies; 8(3):September 2009.
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Meditation for the management of adjustment disorder anxiety and depression Malini Srivastava a, *, Uddip Talukdar b, Vivek Lahan b a b
Department of Holistic Medicine, H.I.H.T. University, Swami Ram Nagar, Jollygrant Doiwala, Dehradun 248140, Uttarakhand, India Department of Psychiatry, H.I.H.T. University, Swami Ram Nagar, Jolly Grant Doiwala, Dehradun-248140, Uttarakhand, India
a b s t r a c t Keywords: Meditation Anxiety Depression Mental health Adjustment disorder Yoga
Objective: To examine the effect of Meditation training on patients with adjustment disorder with anxiety and depression. Method: In a pre-test/post-test control group design, patients (N ¼ 30) with adjustment disorder with mixed anxiety and depression, were screened through a Clinical Global Impression-severity/Improvement Scale, Beck’s Anxiety, Beck’s Depression Inventory, and Global Assessment of Functioning. Sessions of meditation training (28 weeks) were held using the model of Yoga Meditation. The difference of means (pre- and post-assessment) was tested using a paired t-test method. Results: Experimental group and control groups were similar at base line, whereas after concluding the 28th week of meditation practice a significant mean difference (t value: CGI-S 2.47 > .05; CGII2.82 > 0.05; BAI 17.58 > 0.05; BDI 10.13 > 0.05; GAF 12.29 > 0.05) was found between both groups. There was an incremental change in selected assessment parameters in both groups. But changes were more significant in pre- and post-assessment of experimental group. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction
symptom reduction has been found in somatization, insecurity in social contact, obsessive-anxiety, anger/hostility, phobic anxiety, paranoid thinking and psychoticism.6 The modulation effects of meditation on oxidative stress have been increasingly investigated for acute, short and long-term effects.7 A significant improvement in somatisation and anxiety was found in a study on Transcendental Meditation designed to monitor the effect of meditation on general mental health, however no evidence was found on adjustment disorder or any other specific mental disorder.8 The present study sought to examine the effect of meditation therapy on adjustment disorder with mixed anxiety and depression mood (DSM IV TR code 309.28). The main aim was to explore how to engender a positive, constructive life style to prevent stress. This study is also useful in understanding how meditation can offer a dynamic and self-therapeutic process in alleviating the stressful life event(s)/stressor(s).
An individual’s health is a reflection of his or her ability to meet life’s challenges and maintain their capacity for optimal functioning. Mixed anxiety with depressive disorder followed by major depression and schizophrenia are common psychiatric diagnoses in suicidal indicators, but among suicide attempters adjustment disorder is recorded as the most common diagnosis.1 Adjustment disorder is ranked as the second most common diagnosis among non-psychotic patients (31% of 290)2 along with co-morbidly with personality disorder and organic mental disorder.3 Diagnosis of adjustment disorder has an estimated incidence of 2e21% among psychiatric consultation services for adults and is a widespread problem, affecting 12% of people seeking mental health treatment in hospitals.3,4 Although, the usefulness of psychotherapy is supported by clinical evidence, there are a lack of efficacy surveys concerning treatment5 related to preventive alternatives to alleviate the symptoms of adjustment disorder. One research study indicated that the promotion of mindfulness during training of psychotherapists, influences the treatment results of their patients. Greater
* Corresponding author. Tel.: þ91 135 2471230(O), þ91 9411190397. E-mail addresses: [email protected] (M. Srivastava), uddiptalukdar@ rediffmail.com (U. Talukdar), [email protected] (V. Lahan). 1744-3881/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2011.04.007
2. Materials and methods 2.1. Participants Between September 2009 and November 2009, 245 patients reported to the psychiatric OPD with a range of problems including: agitation, depression, palpitations, trembling and headaches without having any physical co-morbidity. Psychiatric review diagnosed
242
M. Srivastava et al. / Complementary Therapies in Clinical Practice 17 (2011) 241e245
Table 1 Demographic profile of the participants.
Age range (years) Gender Locale Patients’ educational background Patients’ socioeconomic background Marital status Time period Symptoms severity range GAF range Reason for referrals Onset of the complaints Total duration of illness Co-morbidity
Experimental Group
Control Group
30e45 (mean:35) Male (04) & Female (11) Rural setting (2) Urban setting (13) Between high school and graduation Middle level of socioeconomic status Patients in both group were married (range 3e14 years) Total of 10 months (therapeutic intervention of 7 months) 5e7 48e50 Agitation, depression, palpitations, physical complaints, trembling or twitching, marital conflicts, headache Gradual Six months to five years at the time of first visit Selected patients had no other co-morbidity related physical or mental illness.
30e45 (mean: 35) Male (05) & Female (10) Rural setting (3) Urban setting (12)
85 patients with adjustment disorder. Of these, 30 patients were included in this study. Patients were selected randomly on predesigned equaling dimensions of demographic characteristics. Selected patients had no other psychiatric diagnosis or comorbidity and were not on any prescribed medicines for reported symptoms. A key inclusion criteria was a commitment to participate in the meditation-training program. The research design was pre-test/post-test control group design. The experimental group had 15 subjects with mean age ¼ 35 years (Table 1); control group comprised 15 subjects (mean age ¼ 35 years) with similar demographic characteristics (Table 1). The research was carried out in the Department of Holistic Medicine, Himalayan Institute of Medical Sciences at Dehradun, India. 2.2. Materials: assessment tools Selection of assessment parameters was two fold. Firstly, to monitor alleviation of severity and improvement in reported symptoms. To monitor this a Clinical Global Impression-Severity scale (CGI-S), Clinical Global Impression-Improvement scale (CGII), and Global Assessment of Functioning (GAF) as defined in the DSM IV TR were used. The second criterion was to identify changes in psychometric values of associated anxiety, and depression. Beck’s anxiety Inventory (BAI) and Beck’s depression Inventory (BDI) were employed. The Clinical Global Impression-Severity scale (CGI-S) is a 7-point scale requiring the clinician to rate the severity of a patient’s illness. Studies conducted to test the reliability of CGI-S show a moderate correlation between changes in the severity of illness and global improvement. A relatively good reliability score for the CGI severity of illness rating and assessing validation, demonstrating concurrent validity has been found.9,10 The Clinical Global Impression-Improvement scale (CGI-I) is a 7-point scale allowing the clinician to assess changes in a patient’s illness when compared to base line states at the beginning of the
intervention. CGI-I is a valid clinical outcome measure suitable for routine use in psychiatric OPD and psychiatric research.11 The Global Assessment of Functioning (GAF) is a numeric scale (0 through 100) used by mental health clinicians and physicians to subjectively rate the social, occupational, and psychological functioning of adults. Discriminant validity of the GAF was confirmed in research indicating that the GAF and other organizational measures were highly consistent, over time GAF proved to be a reliable and valid measure of psychiatric disturbance. The results in this study provided strong support for their use as standard functional performance monitors.12,13 The Beck Anxiety Inventory (BAI) is a 21-question multiplechoice, self-report inventory used to measure the severity of an individual’s anxiety. BAI obtained high internal consistency (ranged from 0.92 to 0.94 for adults, and item-total correlations14). Concurrent validity (the correlation with the Hamilton Anxiety Rating ScaledRevised) was 0.51. Correlation with the anxiety subscale of the Cognition Check List, measuring the frequency of dysfunctional cognitions related to anxiety, was 0.51. The BAI significantly correlates with Trait (0.58) and State (0.47) subscales of the State-Trait Anxiety Inventory with a the mean 7-day anxiety rating (0.54) of Weekly Records of Anxiety and Depression.15 The Beck Depression Inventory (BDI) is a 21-question multiplechoice, self-report inventory and one of the most widely used instruments for measuring the severity of depression. BDI testeretest and internal consistency reliability is above 0.65 with concurrent validity above 0.5. Coefficients of 0.65 and 0.67 were obtained in comparing results of the BDI with psychiatric ratings of patients.16 The Himalayan Yoga Meditation Tradition was used in the present study. The United States National Center for Complementary and Alternative Medicine published a report which reviewed 813 studies involving five categories of meditation: Mantra mediation, Mindfulness meditation, Yoga Meditation, Tai Chi, and Chi Gong.17 The Himalayan Yoga Meditation tradition, was selected for
Table 2 Pre- and post-assessment difference in selected assessment parameters. S.N.
Assessment parameters
Pre-therapy assessment difference Mean
1. 2. 3. 4. 5.
CGI-S CGI-I BAI BDI GAF
Post-therapy assessment difference t Value
Experimental group
Control group
6.13 2.4 33.33 32.4 50
6.46 2.13 33.37 32 59.86
0.8 0.81 0.05 0.74 0.05
Mean
p at 0.05 t value
Experimental group
Control group
1.6 6.8 8.93 12.4 86.33
5.8 4 29.33 29.93 45.66
2.47 2.82 17.58 10.13 12.29
2.05
M. Srivastava et al. / Complementary Therapies in Clinical Practice 17 (2011) 241e245 Table 3 Pre- and post-difference in assessment parameters of experimental group. S.N.
Assessment parameters
Pre- & post-therapy assessment difference in experimental group
p at 0.05
Mean
1. 2. 3. 4. 5.
CGI-S CGI-I BAI BDI GAF
t value
Pre-therapy
Post-therapy
6.13 2.4 33.33 32.4 50
1.6 6.8 8.93 12.4 86.33
8.82 7.71 20 28 16
2.05
the present study. The technique comprised of 4 steps, 1) stretching exercise, 2) systematic relaxation of the whole body, 3) breathing practices and, 4) meditation.18 2.3. Procedure After initial psychiatric diagnosis, all patients were evaluated individually using a detailed structured interview SCID-clinical version (Structured Clinical Interview for DSM IV TR). Patients showing adjustment disorder with mixed anxiety and depression but without other psychiatric diagnosis recieved CGI-S, CGI-I, GAF, BAI, and BDI. The meditation training program was described in a group meeting. After base line recording, participants from the experimental group were given ‘Yoga Meditation’. Each session (group session) was 60 min divided into: 1) stretching exercise (10 min), 2) systematic relaxation of the whole body (10 min), 3) breathing practices (10 min), and 4) meditation (30 min). Theses sessions
were conducted on daily basis for the first four weeks. From week 5 onwards, therapy sessions moved from daily to weekly sessions (total 24 weeks). However, patients were asked to practice meditation technique on their own at home for the rest of each week. Patients in the control group were given general counseling (group counseling 30 min per session) once in a week throughout the study period. After 28 weeks, both groups were reassessed and asked to maintain a daily diary. Besides clinical evaluation, patients’ care-givers were interviewed fortnightly, to explore subjective changes in patients’ over all well-being. Scoring occured at the end of 28 weeks of meditation. Paired t-test method was used to identify any difference in the mean preand post-assessment of CGI-S, CGI-I, GAF, BAI, and BDI. 3. Results The demographic profile of both groups (experimental and control) was similar (Table 1). The range of symptoms severity was 5e7 and range of GAF level was 48e50 for both groups (Table 1). Differences between control and experimental group in the base line scores of all the selected assessment parameters was insignificant (Table 2). Mean differences between the experimentals and control group (t value: CGI-S 2.47 > 0.05; CGI-I2.82 > 0.05; BAI 17.58 > 0.05; BDI 10.13 > 0.05; GAF 12.29 > 0.05) were found to be significant after concluding the 28th week of meditation practice (Table 2). Results showed significant differences in pre- and post-meditation training assessment in all the selected parameters of the experimental group (t value: CGI-S 8.82 > 0.05; CGI-I 7.71 > 0.05; BAI 20.00 > 0.05; BDI 28.00 > 0.05; GAF 16.00 > 0.05) (Table 3). As shown in Fig. 2, there was an incremental change in all the selected assessment parameters in both groups. Changes were
100
90
80
70 Pre Therapy Experimental. Group 60 Pre Therapy Control Group 50 Post Therapy Experimental. Group 40
Post Therapy Control Group
30
20
10
0 CGI-S
CGI-I
BAI
243
BDI
GAF
Fig. 1. Pre- and post-therapy assessment difference between experimental and control group.
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M. Srivastava et al. / Complementary Therapies in Clinical Practice 17 (2011) 241e245
100
90
86.33
80
CGI-S
70
CGI-I 60
BAI
50 50
BDI 40
33.33 32.4
GAF score as defined in DSM IV TR.
30
20
12.4 10
6.8
6.46 2.4
8.93
1.6
0
BEFORE Therapy
AFTER Therapy
Mean Fig. 2. Pre- and post-therapy assessment difference in experimental group.
more significant in pre- and post-assessment of the experimental group. These results suggest that meditation therapy can play an effective role in managing the symptoms of adjustment disorder with mixed anxiety and depression. 4. Discussion The prognosis for a person suffering with an adjustment disorder is good, but due to lack of research, treatment recommendations are limited.19,20 The primary aim of the present study was to see the effect of meditation in relieving symptoms of adjustment disorder with anxiety and depression. The meditation used was a complementary technique to help patients return to the level of functioning they had before symptoms occurred. Yoga Meditation was chosen as the meditation technique. Significant differences were observed in pre- and post-meditation training assessment in all the selected parameters of the experimental group (Table 3). The aim of meditation is to reduce or eradicate irrelevant thought processes by developing physical and mental relaxation leading to stress reduction, psycho-emotional stability and enhanced concentration. Meditation induces biochemical and physical changes in the body. These are referred to as the “relaxation response”.21 Results of this study support previous findings where experimental and control groups displaying parity at the base line pre-intervention (Table 2), showed significant improvement in all the symptom assessment parameters (Fig. 1) post-intervention.
After learning to work with their body and breath systematically, patients in the experimental group became more aware of their reaction to stressors. The problems initially reported by subjects in the present study included agitation, depression, palpitations, physical complaints, trembling, headaches (Table 1). These are similar to other research studies in which, stress related, short-term, non-psychotic disturbances and maladaptive reactions to identifiable stressful life events can be termed adjustment disorder.22,23 Non-adaptive response to the stressors may be diminished if the stress can be “eliminated, reduced or accommodated”.24 Meditation has two major principles: reduction in reactivity, and abolishing thought patterns. Preventive interventions involve changing patterns of cognitive processing. From this perspective meditative training can help to prevent depressive relapses.25 The results of the present study support those findings where meditation reduces levels of depressive and anxiety symptoms (Fig. 1). Similar results were seen in a study in which patients undergoing long-term psychotherapy participated in a 10-week group meditation program. Results demonstrated a significant improvement in subject well-being and reduction in anxiety and depression. These results indicate that meditation can be an important adjunct to psychotherapy.26 Meditation enhanced the ability of the experimental group to function completely. A significant improvement in GAF level was found post-intervention (Table 3). It was noted that levels of GAF worsened in the control group at the end of the assessment showing a deterioration in psychological, social and occupational
M. Srivastava et al. / Complementary Therapies in Clinical Practice 17 (2011) 241e245
functioning (Table 2). A pilot study on the effects of meditation for post-traumatic stress disorder (PTSD), depression, and anxiety symptoms indicated that participants’ PTSD and anxiety symptoms significantly decreased with the majority of participants reporting good treatment adherence and improvements in well-being.27 Yoga Meditation practice adopted by the experimental group resulted in a significant reduction in the severity of symptoms as screened by CGI-S (Table 2). Similarly it has been found that Transcendental Meditation technique helped women with breast cancer to reduce stress and improve their mental health and emotional well-being.28 The results of this study show a significant improvement in patients in the experimental group after using “Yoga Meditation” (Table 2). Improvements (after 28 weeks of meditation practice) included: 1) The level of severity of illness decreased: 6.13 (mean of preassessment) to 1.6 (Fig. 2). 2) Global improvement increased: 2.4 to 6.8 (Fig. 2). 3) Level of anxiety and level of depression reduced respectively from 33.33 and 32.4 to 8.93 and 12.4 (Fig. 2). 4) Ability to function on a daily basis (GAF Level) rose from 50 to 86.33 (Fig. 2). Interview with care-givers and family members revealed observational positive improvement in mood, ability to relate to others, and attitudes toward psychosocial stressors. 5. Conclusion It is acknowledged that these results should be addressed by further research. This study does however, indicate that meditation techniques can be beneficial in helping to alleviate symptoms of adjustment disorder, anxiety and depression. Outcomes of the study suggest the procedure to develop a holistic approach instead of putting patients only on symptomatic treatment, can help patients become aware of ways to adapt and react to the stressful psychosocial environment. In conclusion, meditation techniques can be effective with patients suffering from adjustment disorder with mixed anxiety and depression. Role of funding resources None to declare. Acknowledgment This research study would not have been possible unless my clients had supported me. Especially their commitment to undertake daily meditation practice. We are indebted to H.H. Swami Rama who introduced the Himalayan Meditation Tradition and to Swmai Janeshwer Bharti ji for granting open access to use “Yoga Meditation” model of the Himalayan Tradition for this study. We acknowledge Dr. Aaron T. Beck for Beck’s anxiety Inventory and Beck’s depression inventory, and the editors of the CGI-S, CGI-I, DSM IV TR. We are indebted to many of our colleagues who supported us throughout this work. We thank the librarians, other staff members and authors of citied references who helped us in this work.
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