The Effects of Mindfulness Training on Individuals With
Depression and Coronary Heart Disease
Julia R. Daigle
Montana State University
Abstract
Mindfulness Based Stress Reduction (MBSR) has been slowly popularized as an alternative approach to standard health care since 1979. The primary intention of MBSR was to effectively train medical patients in the practice of mindfulness meditation and of its immediate applications to stress, pain, and illness (Kabat Zin, 2003). While most agree that the issue deserves attention, health care professionals continue to question the effectiveness of mindfulness and its necessity as a main staple of health care. In the present study, 48 participants who had been diagnosed with depression or Coronary Heart Disease (CHD) underwent a 6 month long program involving MBSR treatment. Participants who were diagnosed with CHD and depression were measured pre and post treatment and compared to a control group of participants to compare effects of the mindfulness based treatment program. Results show a significant decrease in depression as well as significantly moderated blood pressure levels post treatment in both psychological and physiological participants. This evidence suggests an integrative relationship of mind and body, in that our psychological well-being promotes healthier mental and physical states. With growing evidence of data suggesting the health benefits of MBSR, it is suggested to implement these mindfulness based treatments into the mainstream; in everyday living as well as an active allegiance of our health care system.
The Effects of Mindfulness Training on Individuals With
Depression and Coronary Heart Disease
What is a possible definition of optimal mental health? How could a practice promoting optimal mental health affect the functional processes of our bodies, both psychologically and physiologically? Many philosophical, spiritual, and psychological traditions emphasize the importance of the quality of consciousness for the maintenance and enhancement of well-being (Wilber, 2000). One attribute of consciousness that has been discussed in relation to well-being is mindfulness, which has to do with particular qualities of attention and awareness that can be cultivated and developed through meditation. Historically, mindfulness has been called “the heart” of Buddhist meditation (Thera, 1962). Without sustained and disciplined inner attention, it is almost impossible to discover, enter, or abide into this absolute ground of steady awareness. One practice that has the potential to bridge this gap is referred to as Mind Body Stress Reduction (MBSR), developed in 1979 as a training vehicle for the relief of suffering, both mentally and physically. Jon Kabat-Zinn, the founder of MBSR, has largely dedicated his life work to bringing mindfulness into the mainstream of medicine and society. The primary intention of MBSR was to effectively train medical patients in the practice of mindfulness meditation and of its immediate applications to stress, pain, and illness that people were grappling with in their lives (Kabat-Zinn, 2003). In this study, I am implementing Kabat-Zinns’ techniques to individuals with either depression, Coronary Heart Disease (CHD), or a combination of both. By implementing this mindfulness based treatment program on participants with one of these diseases, I expect to find a decrease in reports that measure depression levels as well as blood pressure levels of these participants, respective to their chief complaints at the end of the treatment program.
The elements that comprise ‘optimal mental health’ are composed of all of the characteristics that embody well-being, or happiness. Happiness is a multi-faceted phenomenon, with innumerable signs and symptoms that represent a sort of freedom from the mind. It can be thought of as a release from the pressures, restrictions, and disfiguring illusions that the mind has a capacity to bestow. Happiness is merely an emotion, stemming from the constant perceptual motion of the brain. The mind—a manifest functioning of the brain—and the other body systems interact in ways critical for health, illness, and well-being (Ray, 2004). It is believed that there are four interacting information-processing systems in human existence: the mind (the functioning of the brain), the endocrine system, the nervous system, and the immune system (Maier et al, 1994). These four systems are believed to continually communicate with each other, with the science and paradigm of health incorporating all of these systems representing the developing field of psychoneuroimmunology. This field has been critical in clarifying how these systems interact to ensure health by promoting treatment programs that aid the process of endogenous health, and thereby fighting disease. Siegal (2009) says that integration, or the linkage of differentiated parts has the promise of being a scientifically grounded view that allows us to link each of the domains from mindfulness to mental health to secure attachment to brain function.
The Biomedical Model has been the predominant model used by physicians
in determining disease since the mid nineteenth century. The model’s focus is on physical processes such as pathology, biochemistry, and the physiology of disease, but does not account for social factors or patient subjectivity. The Biopsychosocial Model is an approach that postulates that biological, psychological, and social factors are all integral in human functioning when concerning disease. Psychological and social factors are thought to influence disease processes via two main mechanisms: psychosocial processes and health behaviors. Psychosocial processes are important because they include factors that affect the interpretations of and responses to life events and stressors, such as mental health, mood factors, personality characteristics, and resources such as social relationships (Lutgendorf, 2003). Psychoneuroimmunology provides an understanding of some of the fundamental mechanisms involved in this Biopsychosocial Model. Fundamental to understanding the biopsychosocial approach is an awareness that three of the systems—nervous, endocrine, immune (mentioned above) —have receptors on critical cells that can receive information (via messenger molecules) from each of the other systems (Dantzer, 2001; Raison et al, 2001; Trautmann et al, 2001). Our thoughts, our feelings, our beliefs, and our hopes are nothing more than chemical and electrical activity existing in the nerve cells of our brains. It is true that as experience changes our brains and thoughts, that is, changes our minds, we are changing our biology (Ray, 2004). From the biopsychosocial perspective, the mind is considered one activity of the brain, and this activity of the brain is believed to be the body’s first line of defense against illness, against aging, against death, and is consequently crucial for health and well-being (Ray, 2004).
Concerning practices that encourage healthy activity of the brain, mindfulness is
the cornerstone of MBSR. The MBSR program was designed to be long enough for participants to grasp the principles of self-regulation through mindfulness and to develop skills and autonomy in mindfulness practice. Mindful awareness has been demonstrated to alter brain function, mental activity, and interpersonal relationships toward well-being (Siegel, 2009). Mindfulness is an ‘internal attunement’ that catalyzes the fundamental process of integration. Integration, or the linkage of differentiated elements of a system, leads to the flexible, adaptive, and coherent flow of energy and information in the brain, the mind, and other relationships (Siegal, 2009). Mindfulness is not merely a good idea such that, upon hearing about it, one can immediately decide to live in the present moment, with the promise of reduced anxiety and depression and heightened performance and life satisfaction, and then instantly and reliably realize that state of being. Rather, it is more akin to an art form that one develops over time, one that is greatly enhanced through regular disciplined practice, both formally and informally, on a daily basis (Kabat-Zin, 2003). MBSR is designed to enhance health in physiological, psychological, as well as social domains. Concerning physiological applications, meditational training has been shown to positively effect a range of autonomic physiological processes, such as lowering blood pressure and reducing overall arousal and emotional reactivity (Mindful Living, n.d.). Psychologically speaking, it appears that self-reported mindfulness increases with the amount of formal home mindfulness practice that participants report doing and that these increases in mindfulness appear to mediate increases in well-being (Carmody & Baer, 2008; Lau et al., 2006). With MBSR, there is a modification of emotional regulation abilities that are believed to aid in social interactions. One study found improvement in patients with generalized social anxiety disorder on mood, functionality, and quality of life with an 8-week MBSR program (Goldin, P., 2010).
Although past studies have shown the relationship between mindfulness practices and disease, there are many implications to expand this research, to provide additional empirical data. Psychosomatic approaches can be better integrated into clinical practice by the inclusion of somatic awareness as a form of tacit knowing. Somatic awareness involves directing a patient’s attention to interoceptive or body experience and associated feelings for the purpose of self-healing and achieving health (Bakal, 2006). The use of this healing heuristic in primary care would advance the understanding of how the body self-heals (Bakal, 2008). In comparing a regimented, long-term treatment program geared to promote well-being in both physiological and psychological patients, with a control group suffering from the same disorder, I hope to exemplify effects of mindfulness training. The MBSR techniques that I am implementing also showcase the participant’s willingness to engage in proposed mindful techniques, providing for autonomous and self-determined behavior. With a 6-month time frame of habitual MBSR training, I predict that the participants will embody proposed techniques, which will positively affect both psychological and physiological measures. Psychologically, my predictions are that both males and females will report lower levels of depression after treatment and physiologically, I predict that both males and females will report moderated levels of blood pressure after treatment. I also predict that there will be no difference in men and women’s scores of effectiveness of treatment, despite the nature of the disorder. Although MBSR has been shown to reduce symptoms of depression and CHD, there has been limited studies involving treatment programs that last longer than 8 weeks. With my 6- month treatment regimen, I would have the opportunity to explore the long-term effects of MBSR. In addition, I have the opportunity to compare MBSR and its effectiveness between the groups of patients with depression as well as with patients with CHD for an extended period of time.
Method
Participants
A total of 48 individuals (24 female and 24 male) from Bozeman, MT participated in this experiment. All individuals responded to an advertisement that was posted in the local Bozeman newspaper. The advertisement stated that a local health facility was interested in doing a study in which the participant’s blood pressure and depression levels were measured to assess effects of current physician prescribed medication. The advertisement did not mention MBSR as an alternative treatment in the study. The advertisement requirements were for those suffering from conditions of depression or CHD, and had been taking their respective medications for more than one year. Only the first participants to respond to the advertisement that met the proposed criteria were used. Of the respondent’s, 24 individuals were chosen (12 female and 12 male) from the CHD condition and 24 individuals from the depressed condition, to participate in the study. The chosen participants had been taking prescribed medication for over a year, did not smoke, and engaged in relatively healthy lifestyle habits (i.e. proper diet, exercise, and limited alcohol consumption). The participants ranged in age from 24 to 64. Race, SES, and sexual orientation were not perceived to confound results and were omitted from participant criteria. In order to enhance autonomy and client care, each participant was asked to sign a consent form, which provided a debriefing of the research project and all of the necessary requirements that would be needed. The individuals were motivated to participate in the study on the subjective basis that their current treatment program was insufficient in alleviating symptoms of their current disease and were interested in alternative perspectives.
Materials
A health facility was used in order to take base measurements prior to and following the treatment program. All 48 participants had their blood pressure taken, using a sphygmomanometer by a volunteer medical professional. Several measures were taken over a two-day period prior to the beginning of the experiment and over a two-day period following the experiment. To detect, assess, and monitor changes in depressive symptoms, the long form of the Becks Depression Inventory (BDI) was administered by a trained professional one day before the experiment began and one day following the experiment. Individual questions of the BDI assess mood, pessimism, sense of failure, self-dissatisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas, crying, irritability, social withdrawal, body image, work difficulties, insomnia, fatigue, appetite, weight loss, bodily preoccupation, and loss of libido. Items 1 to 13 assess symptoms that are psychological in nature, while items 14 to 21 assess more physical symptoms. The breakdown of the BDI in terms of diagnosing the individual with ranges of depression differs from a healthy individual and an individual diagnosed with depression. If the individual has not been previously diagnosed with depression, a score of over 21 is considered depressed. If the individual has been previously diagnosed with depression, then the breakdown is as follows: 0-9 is minimal depression, 10-16 is mild, 17-29 is moderate, and 30-63 is severe. The BDI has been shown to be valid and reliable, with results corresponding to clinician ratings of depression in more than 90% of all cases (Beck et al, 1984). I will be evaluating the groups (depression and CHD) mean scores within the BDI, not individual subscores. A yoga studio was used to facilitate MBSR training once a week, facilitated by a trained professional. This studio was also made availabe for practice at the participant’s convenience.
Design
This experiment used a randomized complete block design. The independent variables include the nature of the disorder and the treatment involved (experimental vs. control). Gender was a quasi-independent variable. The dependent measures were the self report BDI and blood pressure measurements, taken both pre and post treatment.
12 participants from each block (depression and CHD) were randomly assigned to a control group by a random number generator. All participants were instructed to continue their use of current physician-prescribed medications. The 24 participants in the treatment group received weekly MBSR training as a treatment. The 24 participants in the control group came in for the BDI and blood pressure measurements prior to the experiment to establish a baseline and were not told of the MBSR treatment that was administered to the experimental group. The control group was instructed to continue their current daily regimens and to return in 6 months at the end of the experiment to be seen again for both BDI and blood pressure measurements.
Procedure
The 24 participants in each condition (depression and CHD) were randomly assigned to be in either the control group or the treatment group, with the restriction that there would be 12 males and 12 females in each condition. All 48 participants were instructed to meet at the designated health facility at 9:00 a.m. for baseline measurements two days before the experiment began. All 48 participants received a consent form to review and sign. The participants were split into two groups according to the nature of their disorder; and by either control or treatment groups. The participants in the control group were told they were a part of a research project incorporating psychological and physiological measurements. They were not told of the mindfulness treatments facilitated to the other 24 participants, only that they were taking part in the study depicting their progress with their current medications. They were instructed to continue their daily regimen and to continue taking their physician prescribed medications. Blood pressure was taken by a volunteer trained professional at the times of 9 a.m, 1 p.m., and 5 p.m. The participants were instructed to return the following day to repeat blood pressure measurements, taken at the same times. In addition, these participants filled out the BDI form. The 6 blood pressure measurements taken from the combined two days were averaged and recorded. The participants were also asked to resume their daily regimen and to return in a period of 6 months to repeat the blood pressure and BDI measurements.
The participants in the treatment group were told that they were a part of a research project incorporating MBSR techniques that had the capacity to alleviate signs and symptoms of their disorder. The same protocol was then administered to each subject within the treatment group; with blood pressure and BDI measurements taken. These measurements of averaged blood pressure and completed BDI forms were then collected and recorderd, serving as baseline data. Each participant was instructed to attend a MBSR training practice held at the designated yoga studio every Monday from 9 a.m. to 11 a.m. for a 6 month period of time. These practices were guided by a trained professional, who employed strategies on mindfulness. The training practices served to teach the participants techniques affiliated with mindfulness and stress reduction, meditation, and the referral of yoga and tai chi practices. The MBSR training asked participants to draw on their inner resources and natural capacity to actively engage in caring for themselves and in finding greater balance and peace of mind. The training focused on cultivating a different relationship between the participants and naturally occurring events that may challenge them in their life, and to rely completely upon the tools they already had. Specifically, MBSR focused on accessing the ability to be non-judgmental, compassionate, patient, present and aware. Participants were trained to incorporate a healthy diet into their lifestyle, to engage in healthy activities, and to surround themselves with a supportive social group. Activities that were encouraged include yoga, tai chi, journaling, and off-site daily meditations. The only requirement asked from the participants was the weekly attendance to the MBSR training practices. The lifestyles that were encouraged by these practices were up to the participants to partake in, which provided healthy options for autonomous behavior. After 6 months of treatment, the particpants from the treatment group were asked to complete another BDI form and blood pressures were also taken again at the same times, averaged and recorded.
At the end of the experiment, participants were thanked for their participation and
were instructed not to discuss the case with anyone else. They were also informed that
within two weeks they could contact the experimenter to receive a detailed explanation of
the research project. Participants in the control group were given the option to partake in
an 8 week long MBSR treatment program solely because the true nature of the study had
been kept from them.
Results
The participants data was scored based on two dependent variables, measured pre and post treatment. The first dependent variable recorded was the subjects systolic blood pressure, and the second dependent variable was the subjects level of depression, by means of BDI. Independent variables include gender, nature of the disorder, and the application of MBSR treatment.
Four (2 by 4) ANOVA’s were used to identify main effects and significant interactions. For repeated measures, scores were analyzed using one way ANOVA’s to assess whether the groups changed in different ways over time. Post hoc tests were used to identify the relationship between all of the groups changed scores. It will be recalled that both males and females are expected to report lower levels of depression and moderated measures of blood pressure after treatment. In addition, it is expected that both males and females (both depressed and those with CHD) will report equal effects of treatment. As tables 1, 2, 3, and 4 reveal, males and females did, in fact, report lower levels of depression and moderated blood pressures after treatment, with table 1 showing that depressed males reported lower levels of depression after treatment, when compared to depressed females, which was an unexpected result.
As shown in table 1, an analysis of gender showed a main effect, where collectively males and females in the treatment group reported lower levels of depression post treatment (15) when compared to pre treatment (37.5). As shown in figure 1, there is a 3 way interaction of gender, time of test (pre vs. post) and treatment, such that the time of test has a greater effect for the treatment group then the control group, especially for males.
As shown in table 2, an analysis of gender showed a main effect, where collectively males and females in the treatment group showed moderated levels of blood pressure post treatment (119.5) when compared to pre treatment (174.5). As shown in figure 2, there is a significant interaction of time of test (pre vs. post) and treatment, such that the time of test has a greater effect for the treatment group then the control group.
As shown in table 3, an analysis of gender showed a main effect, where collectively males and females in the treatment group reported lower levels of depression post treatment (9.5) when compared to pre treatment (30.5). As shown in figure 3, there is a significant interaction of time of test (pre vs. post) and treatment, such that the time of test has a greater effect for the treatment group then the control group.
As shown in table 4, an analysis of gender showed a main effect, where collectively males and females in the treatment group showed moderated levels of blood pressure post treatment (120) when compared to pre treatment (195). As shown in figure 4, there is a significant interaction of time of test (pre vs. post) and treatment, such that the time of test has a greater effect for the treatment group then the control group.
Thus, the hypothesis that MBSR practices are effective in both males and females regardless of the nature of the disorder, appears to receive strong support. In addition, there is support that males report lower depression levels than woman after treatment, regardless of their disorder, which will be discussed below.
All participants responded positively to the MBSR program, with figures 1 and 3 showing that males in general reported lower levels of depression before and after treatment when compared to women. Figures 2 and 4 show that all participants, regardless of gender, attained a healthy blood pressure after treatment. In comparing treatment effect of depression with CHD, the data suggests that MBSR is effective on participants with one or both of the disorders.
Discussion
Results were indicative of MBSR being a valid alternative treatment for achieving a healthier mind state as well as a healthier physical state. Concerning participants suffering from depression, those that reported the largest decrease in BDI were those participants that underwent MBSR for a 6 month period of time, as expected. Of these participants in the treatment group, males reported less depression after treatment than women, which was not predicted. The decreased levels of BDI and blood pressure measurements in the treatment groups show that the particpants were able to embody the treatments necessary and utilize them within their homelife. It is important to acknowledge men exhibiting decreased symptoms of depression pre and post treatment, regardless of the nature of their disorder (depression or CHD). This trend in depression and gender is evident in past studies concerning depression, where women are reported to experience depression significantly more often then men. Typically, studies report that women have a prevalence rate for depression up to twice that of men (Bebbington, 1996).
Concerning participants suffering from coronary heart disease, there was no significant differences between gender concerning blood pressure measurements before or after treatment. This is consistent with the present studies expected results, in that there would be an equal reduction in blood pressure measures across gender. This finding is important in that it suggests that MBSR is an effective form of treatment regardless of gender. There was an overall main effect of decreased blood pressure for both males and females who received MBSR treatment. The data found in tables 3 and 4 show that participants with CHD who completed the treatment regimen showed reduced levels of depression and healthier levels of blood pressure. This complements previous research, showing that our bodies are an integrative mechanism, with mindfulness promoting mental health which is linked to our physiological processes, such as regulating our blood pressure.
Previous research finding have shown that our psychological welfare is integral to a smoothly operating individual. Siegal (2009) suggests that integration leads to the flexible, adaptive, and coherent flow of energy and information in the brain, the mind, and relationships. Siegal (2009) has also found evidence indicating that mindfulness catalyzes this fundamental process of integration which has been demonstrated to alter brain function, mental activity, and interpersonal relationships toward well being. Numerous studies have also established that depression predicts the incidence of CHD in previously healthy people (Davidson, K., 2004). Although this study wasn’t directly involved in finding the linkage between depression and CHD, this research is indirectly involved, in that by alleviating symptoms of depression through mindfulness training, CHD incidence levels are therefore decreased. Complementing previous research on the mind body relationship between CHD and depression, figure 2 shows a link between CHD and depression, such that depressed participants had higher blood pressure levels before treatment, with MBSR treatment lowering these blood pressure levels to a normal and healthy range. Figure 3 also shows a link between the two disorders, such that participants with CHD showed decreased levels of depression post treatment.
Past research has not investigated a lengthy treatment program. MBSR treatment programs have not been documented to be carried out for longer than 10 weeks, which is a standard time frame that Jon Kabat-Zin implements in his mindfulness practices. Through these shorter periods of treatment, there are still reported significant effects. With the addition of time, given in the present study, it would be expected that the effect sizes of treatment should increase. These new findings contribute to discussion on promoting integration by practicing mindfulness as an alternative approach to healing. It is an opportunity to take another look at healing outside of the standard medical practice, in that promoting mindfulness and attuning our reflective practices may be a less invasive alternative in bringing psychological and physiological health into the world, both individually and collectively. In addition, the importance of regular practice and a long term commitment is stressed in this study, in that this effortfully created intentional state may be able to become an efffortlessly established trait of the individual to achieve long term health benefits. Mindfulness traits have been described by Baer (2006) as including the propensity in life to act with awareness, be less reactive, be nonjudgmental, develop the ability to be present enough so your left hemisphere’s labeling ability can talk about the internal world, and to observe oneself objectively. Additionally, mindfulness practice reveals that such mind training also cultivates nine middle prefrontal functions including body regulation, attuned communication, emotional balance, fear extinction, respopnse flexibility, insight, empathy, morality, and intuition (Siegal, 2009). The proposal is that mindfulness is an integrative process that promotes well being in body, mind, and relationships.
There are limitations that are posed in this present study. The participants in this study were instructed to meet once weekly for two hours to receive MBSR treatment. The weekly programs were designed to advise participants to enrich their lives by regular practice, however this practice is left up to the participant to carry out without structured home supervision. The participants did not have to report the levels of home practice, so there is no clear way of knowing how the results can correlate with amount of home practice. This leaves the actual treatment and out of clinic commitment in the participants hands, which can lead to individual confounds. Just a few of these potential confounds could include the participants motivation and social support system, which could largely influence the lack of commitment to practicing outside of structured and disciplined environment. However, by leaving participants open to engage in behaviors could also provide an avenue for autonomic behavior, which has been shown to increase self determination. Autonomy appears to be essential for facilitating optimal functioning of the natural propensities for growth and integration (Ryan, 2000). Choice, acknowledgment of feelings, and opportunities for self-direction were found to enhance intrinsic motivation because they allow people a greater feeling of autonomy (Deci & Ryan, 1985). In short, leaving the treatment regimen in the participants hands could serve as a beneficial construct or a negative construct, depending upon the nature of the individual.
It is suggested that this treatment be used for any individuals that many be suffering from any type or severity of psychological or physiological disorder. Since this experimental treatment has unknown variables such as deterministic time periods and possible characteristic confounds, it is encouraged that the individual taking part of this program to continue to stay on their prescribed medication. In that way, MBSR will complement the current health regimen. Once further research has been conducted to isolate and clear up some of these variables, then there is a possibility of using this program to potentially wean an individual off of prescribed medications.
It would be an interesting and beneficial study to implement a treatment program similar to this study, but include additional variables. These variables could include measuring the amount and type of home practice to compare with results of treatment. Another interesting component that could be added to future studies is a list of character attributes of the participants. Knowing a participants attributes and comparing these with amount and type of home practice may be useful in isolating particular characteristics that may influence autonomic behavior. By adding additional time to treatment programs, looking at autonomic behavior and the frequency and type of home practice, researchers can begin to understand more about how to design a treatment program that can accentuate desired constructs pertaining to the individual and time constraints.
Overall, the present research combined with previous studies is a large stepping stone for alternative approaches to healing. It is shown that the mind and body are differentiated parts that are integrated to achieve optimal mental and physical health. Through mindfulness practices, integration of these differentiated parts is promoted and upheld as principally important in maintaining a healthy body and mind. Through subsequent research, variables can be expounded upon to determine their role in potentially confounding results of MBSR treatment. With continual research and manipulation of design and variables, MBSR treatment may begin to be viewed not as the alternative therapy to standard medical practice, but as the standard practice of health.
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