- Email: [email protected]
Mindfulness: An Effective Prescription for Depression and Anxiety
Mindfulness: An Effective Prescription for Depression and Anxiety Lindsay Maxwell, NP, MN, and Elsie Duff, NP, PhD(c) ABSTRACT
Depression and anxiety are common mental illnesses that are associated with substantial economic burdens. Mindfulness practices focus on being present in the moment and can thereby alleviate the suffering that often accompanies depression and anxiety. The benefits of mindfulness practices, including meditation, body recognition, and yoga, have been demonstrated in evidence-based research. In addition, research suggests that an understanding of Buddhist philosophy, and how it complements Western psychology, can help maximize the role of mindfulness in the treatment of mental illness. Nurse practitioners are in an ideal position to identify patients who may benefit from mindfulness-based interventions. Keywords: anxiety, body recognition, Buddhist philosophy, depression, meditation, mindfulness, yoga Ó 2016 Elsevier, Inc. All rights reserved.
he economic burden of common mental illness on the health care system is compounded by the fact that anxiety is often a comorbidity of depression.1 Anxiety and depression are frequent complaints in primary care with individually tailored treatment needs, thus nurse practitioners (NPs) need to be familiar with a variety of treatment modalities. NPs may utilize cognitive behavioral therapy techniques to treat patients diagnosed with mental illness, including anxiety and depression. In recent years, mindfulness-based interventions have been effectively combined with cognitive behavioral therapy and used for patients suffering from depression and anxiety. The purpose of this article is to provide a review of the epidemiology of depression and anxiety, and to summarize the empirical evidence of mindfulness-based interventions for NPs to make informed decisions regarding mindfulness practices in patient care.
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people worldwide and is the primary cause of disability.1 In the United States, an estimated 16 million adults (6.9% of the population) suffered from depression in 2012.2 Although depression may present as a single mental health disorder, those with comorbidities, such as common primary care conditions of diabetes mellitus, cardiovascular disease, pulmonary disease, cancer, and arthritis, are at higher risk for developing depression.3 In addition, depression increases the probability of underlying anxiety, personality, and substance use disorders.4 Furthermore, there is a strong association between depressive disorders and suicide.4 Evidence supports moderate improvements in depression and anxiety symptoms in a recent review of 47 studies involving > 3,500 participants using mindfulness intervention programs.5 NPs can play a vital role in the management of anxiety and depression prevention with effective primary care.
EPIDEMIOLOGY
PHYSIOLOGY
Anxiety and depressive disorders are common mental illnesses in Western society. Anxiety and depression are most often managed in primary care settings and, therefore, patients frequently do not receive optimal treatments. Depression affects more than 350 million
Mindfulness interventions change prefrontal cortex and anterior cingulate cortex activations, with significant increases in alpha and theta activity on electroencephalographic studies, as well as clinical improvements in depression, blood pressure, and
www.npjournal.org
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substance abuse.6 Mindfulness consistently transformed brain segments of meditation practitioners associated with executive attention (ability to stay focused by blocking distraction), body awareness, empathy, emotion learning and regulation, tactile information processing, and memory consolidation and reconsolidation.7 Use of this approach also reduced cortisol levels during periods of acute psychological stress.8 Chronic psychological stress decreases telomerase activity, which is associated with accelerated cellular aging.9 Psychological stress responses in Buddhist meditators showed significantly greater telomerase activity conferred through increased perceived control and life purpose, as well as decreased neuroticism, which could lead to decreased cellular aging.9 With mindfulness-based cognitive therapy (MBCT), positive effects on depression were noted due to increased mindfulness and compassion toward oneself.10 Mindfulness is also effective for treating chronic insomnia.11 Because sleep disturbances can be problematic for individuals living with depression and anxiety, mindfulness can be a positive, nonpharmacologic option for these individuals. Overall, meditation or mindfulness strategies may help decrease health care costs and improve health outcomes for anxiety- and depression-related comorbidities concurrently with first-line medication treatment. MINDFULNESS-BASED INTERVENTIONS
The 2 main secular interventions of Western mindfulness are mindfulness-based stress reduction (MBSR) and MBCT. Both MBSR and MBCT have origins in Buddhist philosophy, but the spiritual and Buddhist content has been removed.12 The MBSR approach teaches stress reduction, coping strategies, and purposefulness.12 Although MBCT is based on MBSR, it is actually a blend of Buddhist mindfulness meditation and cognitive therapy.12,13 MBCT was originally designed to help those in remission from major depression.13 Cognitive therapy (CT) and MBCT differ in their approaches to negative thinking; while mindfulness seeks to change the understanding of thoughts, CT focuses on changing the content of thoughts.14 Research has shown that MBCT is a cost-effective and practical approach for 2
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the treatment of depression, particularly in cases of recurrent depression.14,15 The MBCT process focuses on teaching individuals to become aware of their negative ruminating thought patterns, detect early warning signs of mood changes, and develop strategies to avoid reacting to thoughts and moods.15 Buddhist mindfulness practice is a lifelong, selfexploration process accompanied by meditationbased practices that are similar to CT, yet deeply rooted in Buddhist philosophy (see Box 1).12,16 Both the Western and Buddhist mindfulness paths can effectively transform psychological and physical health and affect positive change, regardless of secular or spiritual beliefs. Buddhist philosophies can work in harmony with Western CT to address treatment for anger, self-indulgence, and involuntary patterns of distressing emotions. The main premise of Buddhist mindfulness is that it emphasizes insight and the cessation of suffering by promoting a sense of present awareness.17,18 Teasdale and Chaskalson19 translated Buddhist teachings and described how The Buddha believed that all humans are bound by the same patterns of thoughts that
Box 1. Buddhist Guiding Principles The Four Noble Truths 1. 2. 3. 4.
Suffering exists (dukkha). Attachment to desire is the origin of dukkha. Cessation of dukkha is possible. The Noble Eightfold Path is the key to
cessation of dukkha. The Noble Eightfold Path 1. Right view to understanding the Four Noble Truths. 2. Right intention to free oneself from attachment. 3. Right speech by refraining from destructive communication. 4. Right action to abide by the 5 vows. 5. Right livelihood. 6. Right effort to abandon harmful thoughts and habits. 7. Right mindfulness to be aware. 8. Right concentration.
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prevent true happiness and self-fulfillment; in other words, our distracted minds maintain us in a perpetual state of suffering. His teachings are based on the Four Noble Truths, which are meant to be a call for individual action, exploration, and understanding, rather than be passively accepted at face value.19 DEPRESSIVE RUMINATION AND EMOTION REGULATION
Rumination is a thought process comprised of repetitive behaviors and thoughts. In individuals with depressive disorders, rumination can create negative thoughts based on symptoms, causes, meaning, and feelings (see Box 2).20 Repetitive thought is partly responsible for turning a minor unpleasant thought into depression.19 Repetitive thought is also capable of changing momentary feelings of fear into unremitting anxiety.18 Rumination is a factor in the onset and relapse of depression, and can be targeted and significantly reduced through MBCT.21 Buddhist philosophy can affect positive change in 2 ways: by ceasing negative thinking and by ceasing rumination. Buddhist teachings identify 5 methods to shift negative thinking and cease rumination. First, one must make attempts to replace the negative thought with a compassionate thought.22 Second, one must learn to recognize that negative thoughts create pain.22 Third, when faced with thoughts too difficult to change, one can distract the mind by engaging in entirely different thinking.22 Fourth, one must explore the origin of the negative thought. Fifth, one must recognize that we are stronger
than our thoughts; we are resilient and, with resolve, can overcome any negative thought.22 Buddhist translations describe 3 approaches to overcoming the mind’s constant rumination of unpleasant thoughts23; success with all 3 approaches is determined by the degree of awareness.23 The initial approach is to distract the mind from the content of the negative thought.23 To accomplish distraction of the mind, one must focus on how the body feels; for example, by focusing on the passage of air through the lungs23 (see Box 3). A focus on breathing is frequently used as a strategy in meditation and is particularly useful when unpleasant emotions are present.23 The second approach is to focus on the thought, examining the thinking process with curiosity in an attempt to understand, rather than allowing the mind to unconsciously ruminate.23 Attempts to redefine the thought or experience as something neutral, constructive, or valuable is one manner in which emotion can be regulated through mindfulness.24 The third approach is to change the manner in which the unpleasant situation is understood.23 In other words, one must not take negative thoughts personally because the brain is conditioned to view experiences unreliably, permanently, and personally.19,23 A more favorable approach would be to acknowledge the unpleasant experience as simply something that is unpleasant at that moment in time.23 Strategies that focus on reframing negative thoughts and experiences are linked to improved emotion regulation.8 The literature shows that MBCT interventions are effective, producing significant positive effects on emotional stability that are mediated
Box 2. Cessation of Rumination Five methods to shift negative thinking and cease rumination: 1. Replace a negative thought with a compassionate thought. 2. Recognize that negative thoughts create pain. 3. Distract one’s self from thoughts too difficult to change. 4. Examine what led to the negative thought. 5. Recognize the strength and resilience to overcome negative thoughts.
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Box 3. Achieving Focused Concentration17 Become aware of one’s breath. For example, notice the air moving through the nostrils, into the lungs, and back out of the nostrils. Become aware that the mind has drifted off. For example, planning or criticizing. Leave the thought there. Do not engage in the thought. Return focus to the breath.
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by the restraint of destructive rumination patterns.25 Negative, ruminating thought patterns can be altered through examination, compassion, distraction, and determination, as well as through the reframing of thoughts and experiences. This process thereby regulates emotions and represents important elements for psychological health. MINDFULNESS THERAPIES
Mindfulness philosophies can be cultivated through a variety of practices, including meditation, body recognition, and yoga.12 Meditation combines 2 complementary paths known as: (a) samantha, the development of awareness, attention, or concentration through stillness of the mind; and (b) vipassana, the development of wisdom regarding the 3 marks of existence.22 The vipassana’s 3 marks of existence include: nothing is permanent; suffering is part of existence because of our misconceptions; and there is “no self” because everything is interconnected in a constant state of change.22 Through evolution, humans were conditioned by the ego to be attached to ourselves.26 Survival of the human species was dependent upon this egocentric approach to life that created a strong attachment to independence and separation from others.12 Attachment to the self creates anxiety and lifelong unhappiness, as everything that has meaning will eventually be lost and the self to which we are attached will eventually die.12 The Buddha teaches that nothing is permanent, not even pleasant experiences, and that attachment creates dependence and eventual suffering because all things are in a constant state of change.27 Mindfulness meditation is more than just an awareness of a sensory perception or thought; mindfulness also promotes the release of thoughts from any selfindulgence, misconceptions, or anger, which can eventually evoke insight and loving-kindness.27 Loving-kindness is a shift from automatic selffocused, judging and categorization of people to a sense of interconnectedness with all.27 Focusing on one’s own breath is a staple of meditation and a seemingly easy task that can be fully experienced by all 5 senses. However, individuals may consciously or unconsciously become bombarded with endless judgmental, wandering 4
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thoughts.28 It is critical to become aware of these thoughts, observe each thought nonjudgmentally, release the negative thought, and refocus on the breath to regulate attention. After the mind has drifted, refocusing on the breath or pondering a wise question can foster awareness and facilitate a return to concentration.22 Meditation does not imply that one will cease to have judgmental thoughts or opinions; rather, it develops the ability to recognize negative or positive thought and choose whether or not to react to each thought.16 Although mindfulness is cultivated in meditation, it is not limited to time spent in this practice. Mindfulness lessons are to be utilized in everyday life and, over time and with intent, may cultivate compassion toward oneself and others.12,16 MINDFULNESS AS AN EFFECTIVE TREATMENT INTERVENTION
Mindfulness-based interventions are positive treatments that can be used for depression, anxiety, stress, and suicidal ideation,13,29 as well as drug-dependent depression and addiction.30 Mindfulness and MBCT may be superior to psychoeducation in the treatment of unremitting or recurrent major depression,13 yet can be used concomitantly with first-line medication. Because MBCT has been found to be as effective as antidepressant treatments in preventing depressive relapse, patients who do not want, or cannot tolerate, long-term antidepressant treatment can use MBCT as an alternative therapy.31 Research has shown that MBCT is as cost-effective as antidepressant medications when comparing all health and social services, and loss of productivity.31 Mindfulnessbased interventions positively affect individuals with depression and other comorbid conditions and are useful to address in primary care NP practice with or without medication therapy. THE NP’s ROLE
Although few contraindications for mindfulness exist, these interventions should be tailored to individuals to yield the best results. It is important to note that, although there is considerable evidence in the literature to support the benefits of MBSR and MBCT, some limitations exist. The limited number of trained professionals, nonadherence to therapy, the extra time needed for therapy, or refusal to embrace Volume
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Box 4. Pre-mindfulness‒based Intervention Questionnaire28 Have you previously participated in group workshops? If yes, please describe. Have you experienced trauma in your life? If yes, please describe. Screen for substance use disorders. Inquire about mental health disorders. Discuss the program expectations and time commitment with patient. Have patient identify 3 goals they wish to achieve from the program.
Buddhist principles may prohibit the care provider or patient from mindfulness therapy. As a result, it is recommended that practitioners exercise caution when using MBSR and MCBT as complementary interventions.12 A brief pre-MBSR interview can quickly assist NPs to determine a patient’s suitability for mindfulness-based interventions (see Box 4).4 Practitioners can utilize 5 approaches to determine whether MBSR programs are appropriate for individual clients. The first step in determining suitability for MBSR is to screen clients for psychiatric conditions, such as posttraumatic stress disorder, alcohol and drug
Box 5. Mindfulness-based Intervention Suitability Assessment28 1. Are there any pre-existing mental health or addictions that may interfere with mindfulness interventions? 2. Has the patient been referred to the most suitable intervention? 3. Is the patient motivated to do independent practice at home? 4. Are there instructors and resources available for patients to help overcome common challenges? 5. Have the appropriate mindfulness techniques been matched with individual strengths and abilities?
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addictions, and severe untreated depression, which impair a patient’s ability to participate in an MBSR program.4 Second, practitioners must ensure psychopathology is being treated by a qualified practitioner who can ensure individuals are referred to the most suitable program; for example, MCBT may be best suited for individuals with recurrent depression, whereas others may benefit from supportive group therapy (see Box 5).4 Third, a large portion of mindfulness work involves at-home, independent practice. To ensure suitability, practitioners need to discuss the commitment required and potential challenges the patient may face.4 Fourth, practitioners must ensure that the common challenges faced by mindfulness patients are mediated by instructors who are knowledgeable about mindfulness practices and available community resources.4 Finally, practitioners need to encourage individual patients to recognize the types of mindfulness practices that may or may not be appropriate; for example, although yoga may not be appropriate for an individual with a musculoskeletal disorder, other forms of mindfulness practices may still be helpful.4 Practitioners need to focus on inspiring individuals to utilize the practices that work for their individual circumstances.4 NPs play a pivotal role in determining patients’ suitability for mindfulness-based interventions by ensuring each individual has the ability, resources, and desired commitment to achieve success. There has been a recent spike in popularity of mindfulness-based interventions and a growing body of empirical evidence to support the use of these interventions in the treatment of depression, anxiety, and other mental health disorders. As a result, NPs can use mindfulness approaches (Boxes 1-3) to effectively treat patients in primary care settings. As with any other intervention, NPs must ensure patient suitability before initiation of mindfulness-based intervention (Box 4 and Table). Mindfulness-based interventions are cost-effective, but require collaboration or referral with well-trained mindfulness instructors. For clients considered suitable for this therapy but who lack access to resources, NPs can become familiar with and recommend the numerous, reputable online resources, books, and audiobooks on mindfulness and Buddhist philosophy. The Journal for Nurse Practitioners - JNP
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Table. Examples of Mindfulness-based Intervention Resources Buddhist and Jon Kabat-Zinn mindfulness Pema Chodron authors Jack Kornfield Thich Nhat Hanh Ronald D. Siegel Mark Epstein Free MBSR Palouse mindfulness online course http://palousemindfulness.com/ selfguidedMBSR.html/ Online resources
UCLA’s Mindfulness Awareness Research Center http://marc.ucla.edu/body.cfm?id¼22/ Peter Morgan’s Free Mindfulness http://www.freemindfulness.org/ download/ UCSD Center for Mindfulness http://health.ucsd.edu/specialties/ mindfulness/Pages/default.aspx/
MBSR ¼ mindfulness-based stress reduction; UCLA ¼ University of California, Los Angeles; UCSD ¼ University of California, San Diego.
3.
4.
5.
6.
7.
8.
9. 10. 11.
12. 13.
14.
CONCLUSION
Mindfulness-based interventions combine Western psychology and Eastern mindfulness practices. An understanding of both philosophies is critical to maximize the role of mindfulness in the treatment of mental illness. Buddhist philosophy complements Western psychology to effectively treat patients with negative ruminating or worrisome thoughts and assist in emotion regulation. Mindfulness therapy can effectively reduce anxiety, depressive symptoms, and the likelihood of relapse. In light of the spiritual component of Buddhist philosophy, mindfulness practices may help patients achieve a better sense of life purpose, compassion for oneself and others, and, ultimately, a deeper, longer lasting sense of happiness. Primary care NPs have a vital role in promotion of positive long-term outcomes by providing mindfulness-based interventions or advocating for appropriate referrals for this patient population. References 1. World Health Organization. Depression: Facts Sheet No. 369. 2012. http://www.who.int/mediacentre/factsheets/fs369/en/. Accessed February 5, 2016. 2. US Department of Health and Human Services. Results from the 2012 National Survey on Drug Use and Health: Mental Health Findings.
6
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15.
16. 17.
18. 19.
20.
21.
22. 23.
24.
25.
26. 27. 28.
29.
http://archive.samhsa.gov/data/NSDUH/2k12MH_FindingsandDetTables/ 2K12MHF/NSDUHmhfr2012.htm/. Accessed February 5, 2016. Kang H-J, Kim S-Y, Bae K-Y, et al. Comorbidity of depression with physical disorders: research and clinical implications. Chonnam Med J. 2015;51(1): 8-18. Dobkin P, Irving J, Amar S. For whom may participation in a mindfulnessbased stress reduction program be contraindicated? Mindfulness. 2012;3(1): 44-50. National Center for Complementary and Integrative Health. 2014. Meditation: what you need to know. https://nccih.nih.gov/health/meditation/overview .htm/. Accessed February 5, 2016. Chiesa A, Serretti A. A systematic review of neurobiological and clinical features of mindfulness meditations. Psychol Med. 2010;40(8): 1239-1252. Fox KCR, Nijeboer S, Dixon ML, et al. Is meditation associated with altered brain structure? A systematic review and meta-analysis of morphometric neuroimaging in meditation practitioners. Neurosci Biobehav Rev. 2014;43:48-73. Hölzel BK, Lazar SW, Gard T, Schuman-Olivier Z, Vago DR, Ott U. How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspect Psychol Sci. 2011;6(6):537-559. Epel ES, Blackburn EH, Lin J, et al. Accelerated telomere shortening in response to life stress. Proc Natl Acad Sci USA. 2004;101(49):17312-17315. Kuyken W, Watkins E, Holden E, et al. How does mindfulness-based cognitive therapy work? Behav Res Ther. 2010;48(11):1105-1112. Ong JC, Ulmer CS, Manber R. Improving sleep with mindfulness and acceptance: a metacognitive model of insomnia. Behav Res Ther. 2012;50(11): 651-660. Marchand WR. Mindfulness meditation practices as adjunctive treatments for psychiatric disorders. Psychiatry Clin North Am. 2013;36(1):141-152. Chiesa A, Mandelli L, Serretti A. Mindfulness-based cognitive therapy versus psycho-education for patients with major depression who did not achieve remission following antidepressant treatment: a preliminary analysis. J Altern Complement Med. 2012;18(8):756-760. Fennell M, Segal Z. Mindfulness-based cognitive therapy: culture clash or creative fusion? Contemp Buddhism. 2011;12(1):125-142. Williams JMG, Kuyken W. Mindfulness-based cognitive therapy: a promising new approach to preventing depressive relapse. Br J Psychiatry. 2012;200(5): 359-360. Kabat-Zinn J. Some reflections on the origins of MBSR, skillful means, and the trouble with maps. Contemp Buddhism. 2011;12(1):281-306. Williams JMG, Kabat-Zinn J. Mindfulness: diverse perspectives on its meaning, origins, and multiple applications at the intersection of science and dharma. Contemp Buddhism. 2011;12(1):1-18. Bodhi B. What does mindfulness really mean? A canonical perspective. Contemp Buddhism. 2011;12(1):19-39. Teasdale JD, Chaskalson (Kulananda) M. How does mindfulness transform suffering? I: The nature and origins of dukkha. Contemp Buddhism. 2011;12(1):89-102. Nolen-Hoeksema S. Responses to depression and their effects on the duration of depressive episodes. J Abnorm Psychol. 1991;100(4):569-582. Michalak J, Hölz A, Teismann T. Rumination as a predictor of relapse in mindfulness-based cognitive therapy for depression. Psychol Psychother Theory Res Pract. 2011;84(2):230-236. Batchelor M. Meditation and mindfulness. Contemp Buddhism. 2011;12(1): 157-164. Teasdale JD, Chaskalson (Kulananda) M. How does mindfulness transform suffering? II: The transformation of dukkha. Contemp Buddhism. 2011;12(1): 103-124. Garland E, Gaylord S, Fredrickson B. Positive reappraisal mediates the stressreductive effects of mindfulness: an upward spiral process. Mindfulness. 2011;2(1):59-67. Keune PM, Bostanov V, Hautzinger M, Kotchoubey B. Mindfulness-based cognitive therapy (MBCT), cognitive style, and the temporal dynamics of frontal EEG alpha asymmetry in recurrently depressed patients. Biol Psychol. 2011;88(2-3):243-252. Shonin E, van Gordon W. Practical recommendations for teaching mindfulness effectively. Mindfulness. 2014;4:1-4. Salzberg S. Mindfulness and loving-kindness. Contemp Buddhism. 2011; 12(1):177-182. Grossman P, van Dam NT. Mindfulness, by any other name.: trials and tribulations of sati in Western psychology and science. Contemp Buddhism. 2011;12(1):219-239. Forkmann T, Wichers M, Geschwind N, et al. Effects of mindfulness-based cognitive therapy on self-reported suicidal ideation: results from a randomised controlled trial in patients with residual depressive symptoms. Compr Psychiatry. 2014;55(8):1883-1890.
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30. Hosseinzadeh Asl N, Barahmand U. Effectiveness of mindfulness-based cognitive therapy for co-morbid depression in drug-dependent males. Arch Psychiatr Nurs. 2014;28(5):314-318. 31. Kuyken W, Hayes R, Barrett B, et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet. 2015;386(9988):1814-1815.
Winnipeg. Lindsay Maxwell, MN, NP, is a primary care nurse practitioner. She can be reached at [email protected]. Elsie Duff, NP, PhD(c) is an instructor. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
Both authors are affiliated with the College of Nursing, Helen Glass Center for Nursing, at the University of Manitoba in
1555-4155/16/$ see front matter © 2016 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.02.009
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Depression and anxiety are common mental illnesses that are associated with substantial economic burdens. Mindfulness practices focus on being present in the moment and can thereby alleviate the suffering that often accompanies depression and anxiety. The benefits of mindfulness practices, including meditation, body recognition, and yoga, have been demonstrated in evidence-based research. In addition, research suggests that an understanding of Buddhist philosophy, and how it complements Western psychology, can help maximize the role of mindfulness in the treatment of mental illness. Nurse practitioners are in an ideal position to identify patients who may benefit from mindfulness-based interventions. Keywords: anxiety, body recognition, Buddhist philosophy, depression, meditation, mindfulness, yoga Ó 2016 Elsevier, Inc. All rights reserved.
he economic burden of common mental illness on the health care system is compounded by the fact that anxiety is often a comorbidity of depression.1 Anxiety and depression are frequent complaints in primary care with individually tailored treatment needs, thus nurse practitioners (NPs) need to be familiar with a variety of treatment modalities. NPs may utilize cognitive behavioral therapy techniques to treat patients diagnosed with mental illness, including anxiety and depression. In recent years, mindfulness-based interventions have been effectively combined with cognitive behavioral therapy and used for patients suffering from depression and anxiety. The purpose of this article is to provide a review of the epidemiology of depression and anxiety, and to summarize the empirical evidence of mindfulness-based interventions for NPs to make informed decisions regarding mindfulness practices in patient care.
T
people worldwide and is the primary cause of disability.1 In the United States, an estimated 16 million adults (6.9% of the population) suffered from depression in 2012.2 Although depression may present as a single mental health disorder, those with comorbidities, such as common primary care conditions of diabetes mellitus, cardiovascular disease, pulmonary disease, cancer, and arthritis, are at higher risk for developing depression.3 In addition, depression increases the probability of underlying anxiety, personality, and substance use disorders.4 Furthermore, there is a strong association between depressive disorders and suicide.4 Evidence supports moderate improvements in depression and anxiety symptoms in a recent review of 47 studies involving > 3,500 participants using mindfulness intervention programs.5 NPs can play a vital role in the management of anxiety and depression prevention with effective primary care.
EPIDEMIOLOGY
PHYSIOLOGY
Anxiety and depressive disorders are common mental illnesses in Western society. Anxiety and depression are most often managed in primary care settings and, therefore, patients frequently do not receive optimal treatments. Depression affects more than 350 million
Mindfulness interventions change prefrontal cortex and anterior cingulate cortex activations, with significant increases in alpha and theta activity on electroencephalographic studies, as well as clinical improvements in depression, blood pressure, and
www.npjournal.org
The Journal for Nurse Practitioners - JNP
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substance abuse.6 Mindfulness consistently transformed brain segments of meditation practitioners associated with executive attention (ability to stay focused by blocking distraction), body awareness, empathy, emotion learning and regulation, tactile information processing, and memory consolidation and reconsolidation.7 Use of this approach also reduced cortisol levels during periods of acute psychological stress.8 Chronic psychological stress decreases telomerase activity, which is associated with accelerated cellular aging.9 Psychological stress responses in Buddhist meditators showed significantly greater telomerase activity conferred through increased perceived control and life purpose, as well as decreased neuroticism, which could lead to decreased cellular aging.9 With mindfulness-based cognitive therapy (MBCT), positive effects on depression were noted due to increased mindfulness and compassion toward oneself.10 Mindfulness is also effective for treating chronic insomnia.11 Because sleep disturbances can be problematic for individuals living with depression and anxiety, mindfulness can be a positive, nonpharmacologic option for these individuals. Overall, meditation or mindfulness strategies may help decrease health care costs and improve health outcomes for anxiety- and depression-related comorbidities concurrently with first-line medication treatment. MINDFULNESS-BASED INTERVENTIONS
The 2 main secular interventions of Western mindfulness are mindfulness-based stress reduction (MBSR) and MBCT. Both MBSR and MBCT have origins in Buddhist philosophy, but the spiritual and Buddhist content has been removed.12 The MBSR approach teaches stress reduction, coping strategies, and purposefulness.12 Although MBCT is based on MBSR, it is actually a blend of Buddhist mindfulness meditation and cognitive therapy.12,13 MBCT was originally designed to help those in remission from major depression.13 Cognitive therapy (CT) and MBCT differ in their approaches to negative thinking; while mindfulness seeks to change the understanding of thoughts, CT focuses on changing the content of thoughts.14 Research has shown that MBCT is a cost-effective and practical approach for 2
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the treatment of depression, particularly in cases of recurrent depression.14,15 The MBCT process focuses on teaching individuals to become aware of their negative ruminating thought patterns, detect early warning signs of mood changes, and develop strategies to avoid reacting to thoughts and moods.15 Buddhist mindfulness practice is a lifelong, selfexploration process accompanied by meditationbased practices that are similar to CT, yet deeply rooted in Buddhist philosophy (see Box 1).12,16 Both the Western and Buddhist mindfulness paths can effectively transform psychological and physical health and affect positive change, regardless of secular or spiritual beliefs. Buddhist philosophies can work in harmony with Western CT to address treatment for anger, self-indulgence, and involuntary patterns of distressing emotions. The main premise of Buddhist mindfulness is that it emphasizes insight and the cessation of suffering by promoting a sense of present awareness.17,18 Teasdale and Chaskalson19 translated Buddhist teachings and described how The Buddha believed that all humans are bound by the same patterns of thoughts that
Box 1. Buddhist Guiding Principles The Four Noble Truths 1. 2. 3. 4.
Suffering exists (dukkha). Attachment to desire is the origin of dukkha. Cessation of dukkha is possible. The Noble Eightfold Path is the key to
cessation of dukkha. The Noble Eightfold Path 1. Right view to understanding the Four Noble Truths. 2. Right intention to free oneself from attachment. 3. Right speech by refraining from destructive communication. 4. Right action to abide by the 5 vows. 5. Right livelihood. 6. Right effort to abandon harmful thoughts and habits. 7. Right mindfulness to be aware. 8. Right concentration.
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prevent true happiness and self-fulfillment; in other words, our distracted minds maintain us in a perpetual state of suffering. His teachings are based on the Four Noble Truths, which are meant to be a call for individual action, exploration, and understanding, rather than be passively accepted at face value.19 DEPRESSIVE RUMINATION AND EMOTION REGULATION
Rumination is a thought process comprised of repetitive behaviors and thoughts. In individuals with depressive disorders, rumination can create negative thoughts based on symptoms, causes, meaning, and feelings (see Box 2).20 Repetitive thought is partly responsible for turning a minor unpleasant thought into depression.19 Repetitive thought is also capable of changing momentary feelings of fear into unremitting anxiety.18 Rumination is a factor in the onset and relapse of depression, and can be targeted and significantly reduced through MBCT.21 Buddhist philosophy can affect positive change in 2 ways: by ceasing negative thinking and by ceasing rumination. Buddhist teachings identify 5 methods to shift negative thinking and cease rumination. First, one must make attempts to replace the negative thought with a compassionate thought.22 Second, one must learn to recognize that negative thoughts create pain.22 Third, when faced with thoughts too difficult to change, one can distract the mind by engaging in entirely different thinking.22 Fourth, one must explore the origin of the negative thought. Fifth, one must recognize that we are stronger
than our thoughts; we are resilient and, with resolve, can overcome any negative thought.22 Buddhist translations describe 3 approaches to overcoming the mind’s constant rumination of unpleasant thoughts23; success with all 3 approaches is determined by the degree of awareness.23 The initial approach is to distract the mind from the content of the negative thought.23 To accomplish distraction of the mind, one must focus on how the body feels; for example, by focusing on the passage of air through the lungs23 (see Box 3). A focus on breathing is frequently used as a strategy in meditation and is particularly useful when unpleasant emotions are present.23 The second approach is to focus on the thought, examining the thinking process with curiosity in an attempt to understand, rather than allowing the mind to unconsciously ruminate.23 Attempts to redefine the thought or experience as something neutral, constructive, or valuable is one manner in which emotion can be regulated through mindfulness.24 The third approach is to change the manner in which the unpleasant situation is understood.23 In other words, one must not take negative thoughts personally because the brain is conditioned to view experiences unreliably, permanently, and personally.19,23 A more favorable approach would be to acknowledge the unpleasant experience as simply something that is unpleasant at that moment in time.23 Strategies that focus on reframing negative thoughts and experiences are linked to improved emotion regulation.8 The literature shows that MBCT interventions are effective, producing significant positive effects on emotional stability that are mediated
Box 2. Cessation of Rumination Five methods to shift negative thinking and cease rumination: 1. Replace a negative thought with a compassionate thought. 2. Recognize that negative thoughts create pain. 3. Distract one’s self from thoughts too difficult to change. 4. Examine what led to the negative thought. 5. Recognize the strength and resilience to overcome negative thoughts.
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Box 3. Achieving Focused Concentration17 Become aware of one’s breath. For example, notice the air moving through the nostrils, into the lungs, and back out of the nostrils. Become aware that the mind has drifted off. For example, planning or criticizing. Leave the thought there. Do not engage in the thought. Return focus to the breath.
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by the restraint of destructive rumination patterns.25 Negative, ruminating thought patterns can be altered through examination, compassion, distraction, and determination, as well as through the reframing of thoughts and experiences. This process thereby regulates emotions and represents important elements for psychological health. MINDFULNESS THERAPIES
Mindfulness philosophies can be cultivated through a variety of practices, including meditation, body recognition, and yoga.12 Meditation combines 2 complementary paths known as: (a) samantha, the development of awareness, attention, or concentration through stillness of the mind; and (b) vipassana, the development of wisdom regarding the 3 marks of existence.22 The vipassana’s 3 marks of existence include: nothing is permanent; suffering is part of existence because of our misconceptions; and there is “no self” because everything is interconnected in a constant state of change.22 Through evolution, humans were conditioned by the ego to be attached to ourselves.26 Survival of the human species was dependent upon this egocentric approach to life that created a strong attachment to independence and separation from others.12 Attachment to the self creates anxiety and lifelong unhappiness, as everything that has meaning will eventually be lost and the self to which we are attached will eventually die.12 The Buddha teaches that nothing is permanent, not even pleasant experiences, and that attachment creates dependence and eventual suffering because all things are in a constant state of change.27 Mindfulness meditation is more than just an awareness of a sensory perception or thought; mindfulness also promotes the release of thoughts from any selfindulgence, misconceptions, or anger, which can eventually evoke insight and loving-kindness.27 Loving-kindness is a shift from automatic selffocused, judging and categorization of people to a sense of interconnectedness with all.27 Focusing on one’s own breath is a staple of meditation and a seemingly easy task that can be fully experienced by all 5 senses. However, individuals may consciously or unconsciously become bombarded with endless judgmental, wandering 4
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thoughts.28 It is critical to become aware of these thoughts, observe each thought nonjudgmentally, release the negative thought, and refocus on the breath to regulate attention. After the mind has drifted, refocusing on the breath or pondering a wise question can foster awareness and facilitate a return to concentration.22 Meditation does not imply that one will cease to have judgmental thoughts or opinions; rather, it develops the ability to recognize negative or positive thought and choose whether or not to react to each thought.16 Although mindfulness is cultivated in meditation, it is not limited to time spent in this practice. Mindfulness lessons are to be utilized in everyday life and, over time and with intent, may cultivate compassion toward oneself and others.12,16 MINDFULNESS AS AN EFFECTIVE TREATMENT INTERVENTION
Mindfulness-based interventions are positive treatments that can be used for depression, anxiety, stress, and suicidal ideation,13,29 as well as drug-dependent depression and addiction.30 Mindfulness and MBCT may be superior to psychoeducation in the treatment of unremitting or recurrent major depression,13 yet can be used concomitantly with first-line medication. Because MBCT has been found to be as effective as antidepressant treatments in preventing depressive relapse, patients who do not want, or cannot tolerate, long-term antidepressant treatment can use MBCT as an alternative therapy.31 Research has shown that MBCT is as cost-effective as antidepressant medications when comparing all health and social services, and loss of productivity.31 Mindfulnessbased interventions positively affect individuals with depression and other comorbid conditions and are useful to address in primary care NP practice with or without medication therapy. THE NP’s ROLE
Although few contraindications for mindfulness exist, these interventions should be tailored to individuals to yield the best results. It is important to note that, although there is considerable evidence in the literature to support the benefits of MBSR and MBCT, some limitations exist. The limited number of trained professionals, nonadherence to therapy, the extra time needed for therapy, or refusal to embrace Volume
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Box 4. Pre-mindfulness‒based Intervention Questionnaire28 Have you previously participated in group workshops? If yes, please describe. Have you experienced trauma in your life? If yes, please describe. Screen for substance use disorders. Inquire about mental health disorders. Discuss the program expectations and time commitment with patient. Have patient identify 3 goals they wish to achieve from the program.
Buddhist principles may prohibit the care provider or patient from mindfulness therapy. As a result, it is recommended that practitioners exercise caution when using MBSR and MCBT as complementary interventions.12 A brief pre-MBSR interview can quickly assist NPs to determine a patient’s suitability for mindfulness-based interventions (see Box 4).4 Practitioners can utilize 5 approaches to determine whether MBSR programs are appropriate for individual clients. The first step in determining suitability for MBSR is to screen clients for psychiatric conditions, such as posttraumatic stress disorder, alcohol and drug
Box 5. Mindfulness-based Intervention Suitability Assessment28 1. Are there any pre-existing mental health or addictions that may interfere with mindfulness interventions? 2. Has the patient been referred to the most suitable intervention? 3. Is the patient motivated to do independent practice at home? 4. Are there instructors and resources available for patients to help overcome common challenges? 5. Have the appropriate mindfulness techniques been matched with individual strengths and abilities?
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addictions, and severe untreated depression, which impair a patient’s ability to participate in an MBSR program.4 Second, practitioners must ensure psychopathology is being treated by a qualified practitioner who can ensure individuals are referred to the most suitable program; for example, MCBT may be best suited for individuals with recurrent depression, whereas others may benefit from supportive group therapy (see Box 5).4 Third, a large portion of mindfulness work involves at-home, independent practice. To ensure suitability, practitioners need to discuss the commitment required and potential challenges the patient may face.4 Fourth, practitioners must ensure that the common challenges faced by mindfulness patients are mediated by instructors who are knowledgeable about mindfulness practices and available community resources.4 Finally, practitioners need to encourage individual patients to recognize the types of mindfulness practices that may or may not be appropriate; for example, although yoga may not be appropriate for an individual with a musculoskeletal disorder, other forms of mindfulness practices may still be helpful.4 Practitioners need to focus on inspiring individuals to utilize the practices that work for their individual circumstances.4 NPs play a pivotal role in determining patients’ suitability for mindfulness-based interventions by ensuring each individual has the ability, resources, and desired commitment to achieve success. There has been a recent spike in popularity of mindfulness-based interventions and a growing body of empirical evidence to support the use of these interventions in the treatment of depression, anxiety, and other mental health disorders. As a result, NPs can use mindfulness approaches (Boxes 1-3) to effectively treat patients in primary care settings. As with any other intervention, NPs must ensure patient suitability before initiation of mindfulness-based intervention (Box 4 and Table). Mindfulness-based interventions are cost-effective, but require collaboration or referral with well-trained mindfulness instructors. For clients considered suitable for this therapy but who lack access to resources, NPs can become familiar with and recommend the numerous, reputable online resources, books, and audiobooks on mindfulness and Buddhist philosophy. The Journal for Nurse Practitioners - JNP
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Table. Examples of Mindfulness-based Intervention Resources Buddhist and Jon Kabat-Zinn mindfulness Pema Chodron authors Jack Kornfield Thich Nhat Hanh Ronald D. Siegel Mark Epstein Free MBSR Palouse mindfulness online course http://palousemindfulness.com/ selfguidedMBSR.html/ Online resources
UCLA’s Mindfulness Awareness Research Center http://marc.ucla.edu/body.cfm?id¼22/ Peter Morgan’s Free Mindfulness http://www.freemindfulness.org/ download/ UCSD Center for Mindfulness http://health.ucsd.edu/specialties/ mindfulness/Pages/default.aspx/
MBSR ¼ mindfulness-based stress reduction; UCLA ¼ University of California, Los Angeles; UCSD ¼ University of California, San Diego.
3.
4.
5.
6.
7.
8.
9. 10. 11.
12. 13.
14.
CONCLUSION
Mindfulness-based interventions combine Western psychology and Eastern mindfulness practices. An understanding of both philosophies is critical to maximize the role of mindfulness in the treatment of mental illness. Buddhist philosophy complements Western psychology to effectively treat patients with negative ruminating or worrisome thoughts and assist in emotion regulation. Mindfulness therapy can effectively reduce anxiety, depressive symptoms, and the likelihood of relapse. In light of the spiritual component of Buddhist philosophy, mindfulness practices may help patients achieve a better sense of life purpose, compassion for oneself and others, and, ultimately, a deeper, longer lasting sense of happiness. Primary care NPs have a vital role in promotion of positive long-term outcomes by providing mindfulness-based interventions or advocating for appropriate referrals for this patient population. References 1. World Health Organization. Depression: Facts Sheet No. 369. 2012. http://www.who.int/mediacentre/factsheets/fs369/en/. Accessed February 5, 2016. 2. US Department of Health and Human Services. Results from the 2012 National Survey on Drug Use and Health: Mental Health Findings.
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16. 17.
18. 19.
20.
21.
22. 23.
24.
25.
26. 27. 28.
29.
http://archive.samhsa.gov/data/NSDUH/2k12MH_FindingsandDetTables/ 2K12MHF/NSDUHmhfr2012.htm/. Accessed February 5, 2016. Kang H-J, Kim S-Y, Bae K-Y, et al. Comorbidity of depression with physical disorders: research and clinical implications. Chonnam Med J. 2015;51(1): 8-18. Dobkin P, Irving J, Amar S. For whom may participation in a mindfulnessbased stress reduction program be contraindicated? Mindfulness. 2012;3(1): 44-50. National Center for Complementary and Integrative Health. 2014. Meditation: what you need to know. https://nccih.nih.gov/health/meditation/overview .htm/. Accessed February 5, 2016. Chiesa A, Serretti A. A systematic review of neurobiological and clinical features of mindfulness meditations. Psychol Med. 2010;40(8): 1239-1252. Fox KCR, Nijeboer S, Dixon ML, et al. Is meditation associated with altered brain structure? A systematic review and meta-analysis of morphometric neuroimaging in meditation practitioners. Neurosci Biobehav Rev. 2014;43:48-73. Hölzel BK, Lazar SW, Gard T, Schuman-Olivier Z, Vago DR, Ott U. How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspect Psychol Sci. 2011;6(6):537-559. Epel ES, Blackburn EH, Lin J, et al. Accelerated telomere shortening in response to life stress. Proc Natl Acad Sci USA. 2004;101(49):17312-17315. Kuyken W, Watkins E, Holden E, et al. How does mindfulness-based cognitive therapy work? Behav Res Ther. 2010;48(11):1105-1112. Ong JC, Ulmer CS, Manber R. Improving sleep with mindfulness and acceptance: a metacognitive model of insomnia. Behav Res Ther. 2012;50(11): 651-660. Marchand WR. Mindfulness meditation practices as adjunctive treatments for psychiatric disorders. Psychiatry Clin North Am. 2013;36(1):141-152. Chiesa A, Mandelli L, Serretti A. Mindfulness-based cognitive therapy versus psycho-education for patients with major depression who did not achieve remission following antidepressant treatment: a preliminary analysis. J Altern Complement Med. 2012;18(8):756-760. Fennell M, Segal Z. Mindfulness-based cognitive therapy: culture clash or creative fusion? Contemp Buddhism. 2011;12(1):125-142. Williams JMG, Kuyken W. Mindfulness-based cognitive therapy: a promising new approach to preventing depressive relapse. Br J Psychiatry. 2012;200(5): 359-360. Kabat-Zinn J. Some reflections on the origins of MBSR, skillful means, and the trouble with maps. Contemp Buddhism. 2011;12(1):281-306. Williams JMG, Kabat-Zinn J. Mindfulness: diverse perspectives on its meaning, origins, and multiple applications at the intersection of science and dharma. Contemp Buddhism. 2011;12(1):1-18. Bodhi B. What does mindfulness really mean? A canonical perspective. Contemp Buddhism. 2011;12(1):19-39. Teasdale JD, Chaskalson (Kulananda) M. How does mindfulness transform suffering? I: The nature and origins of dukkha. Contemp Buddhism. 2011;12(1):89-102. Nolen-Hoeksema S. Responses to depression and their effects on the duration of depressive episodes. J Abnorm Psychol. 1991;100(4):569-582. Michalak J, Hölz A, Teismann T. Rumination as a predictor of relapse in mindfulness-based cognitive therapy for depression. Psychol Psychother Theory Res Pract. 2011;84(2):230-236. Batchelor M. Meditation and mindfulness. Contemp Buddhism. 2011;12(1): 157-164. Teasdale JD, Chaskalson (Kulananda) M. How does mindfulness transform suffering? II: The transformation of dukkha. Contemp Buddhism. 2011;12(1): 103-124. Garland E, Gaylord S, Fredrickson B. Positive reappraisal mediates the stressreductive effects of mindfulness: an upward spiral process. Mindfulness. 2011;2(1):59-67. Keune PM, Bostanov V, Hautzinger M, Kotchoubey B. Mindfulness-based cognitive therapy (MBCT), cognitive style, and the temporal dynamics of frontal EEG alpha asymmetry in recurrently depressed patients. Biol Psychol. 2011;88(2-3):243-252. Shonin E, van Gordon W. Practical recommendations for teaching mindfulness effectively. Mindfulness. 2014;4:1-4. Salzberg S. Mindfulness and loving-kindness. Contemp Buddhism. 2011; 12(1):177-182. Grossman P, van Dam NT. Mindfulness, by any other name.: trials and tribulations of sati in Western psychology and science. Contemp Buddhism. 2011;12(1):219-239. Forkmann T, Wichers M, Geschwind N, et al. Effects of mindfulness-based cognitive therapy on self-reported suicidal ideation: results from a randomised controlled trial in patients with residual depressive symptoms. Compr Psychiatry. 2014;55(8):1883-1890.
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30. Hosseinzadeh Asl N, Barahmand U. Effectiveness of mindfulness-based cognitive therapy for co-morbid depression in drug-dependent males. Arch Psychiatr Nurs. 2014;28(5):314-318. 31. Kuyken W, Hayes R, Barrett B, et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet. 2015;386(9988):1814-1815.
Winnipeg. Lindsay Maxwell, MN, NP, is a primary care nurse practitioner. She can be reached at [email protected]. Elsie Duff, NP, PhD(c) is an instructor. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
Both authors are affiliated with the College of Nursing, Helen Glass Center for Nursing, at the University of Manitoba in
1555-4155/16/$ see front matter © 2016 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.02.009
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