Damian Sendler: It is a constant awareness of one’s thoughts and feelings as well as one’s physical sensations and surroundings. Being mindful means being open, non-judgmental, friendly, curious, accepting, compassionate, and kind to oneself and others. 1 Consciousness is the ultimate goal of all mindfulness practices. Formal (such as deep breathing, sitting still, walking slowly, or performing a body scan) or informal (e.g. mindfulness in everyday life). There are a large number of mindfulness-based intervention (MBI) programs. The most widely used MBIs are Jon Kabat-19792 Zinn’s introduction of mindfulness-based stress reduction (MBSR) and Segal, Teasdale, and Williams’ MBCT, which is based on MBSR3,4. One-day retreats are included in both of these programs, which run for eight weeks.
Damian Jacob Sendler: Buddhism has a long history of cultivating mindfulness. Secular populations in health care, education, and the workplace, ranging from preschoolers to senior citizens, have begun using it more frequently in recent years. The number of articles addressing the topic of mindfulness has skyrocketed in the last decade. Increasingly, publications on mindfulness are being compared to those on cognitive behavioral therapy (CBT), a psychotherapy that is very commonly used in the United States.
Dr. Sendler: The efficacy of MBIs for depression and anxiety has been confirmed by meta-analyses that show moderate to strong reductions in the two conditions. Although MBIs can help reduce perinatal anxiety of moderate to large magnitude, the effects are less consistent in reducing perinatal depression, according to an extensive review of studies. 9 The web-based interventions on mindfulness that are becoming increasingly popular are also effective in reducing depression and anxiety in people with anxiety disorders. 10 As a stand-alone intervention, mindfulness practices may still have some benefits, but it is difficult to separate the effects of social interaction and psychoeducation, which are integrated in many MBIs (e.g. group MBCT), from the effects of standalone mindfulness practices due to the complex nature of these interventions.
However, more rigorous studies are needed to draw clear conclusions about MBIs’ effects on stress in different populations. In healthy adult populations, a meta-analysis of five randomized control trials examined the effects of MBIs on cortisol levels, a stress-mediated hormone. However, the overall effect size (g = 0.41; P = 0.025) was moderately low. Nonetheless, another meta-analysis found that meditation interventions had a significant, medium effect on cortisol levels in at-risk populations such as those who were living in stressful situations. Some studies have shown inconclusive results among specific populations, such as tertiary students14 and older adults15. Interventions for stress management had a moderate effect size (g = 0.42, 95 percent CI: 0.27–0.57) among college students, but the majority of the studies were of poor quality. 14 In older adults, there was no clear evidence that MBIs could reduce stress.
Current research suggests that MBIs may be effective in treating insomnia and other sleep-related problems. When compared to attention/education and waitlist control, MBIs have medium to large effects (g = 0.67, 95 percent CI = 0.30–1.05) and appear to have lasting effects at 3 months postintervention (g = 1.06, 95 percent CI = 0.48–1.64), according to a meta-analysis. 16 The Pittsburgh Sleep Quality Index, used in several other meta-analyses, consistently found improvements in insomnia and sleep quality.
MBIs may have some impact on eating disorders, according to recent research (EDs). In a systematic review and meta-analysis, anorectic and bulimic participants were found to benefit from MBIs in terms of ED symptoms, emotional eating, negative affect, and body dissatisfaction, as well as BMI, compared to pre-assessment. 20 Another meta-analysis and systematic review found that MBIs may help reduce negative feelings and concerns about one’s body image while promoting an appreciation for one’s own physical appearance. 21 For the efficacy of MBIs to be confirmed, more rigorous studies need to be done.
MBIs have been found to be effective in treating both substance and behavioral addictions, according to research. Addiction symptoms like dependence, craving, and emotional dysregulation were all reduced and mood and emotion dysregulation were improved by MBIs in a systematic review of 54 randomized controlled trials. 22 It has been found that MBIs have small to large effects in reducing craving levels, stress severity, substance misuse frequency and severity, anxiety and depressive symptomatology (including major depression), negative affectivity (such as sadness or irritability), and post-traumatic symptoms (such as depression or irritability). More research is needed on long-term follow-up assessments and diverse populations, despite the promising results.
It appears that MBIs may be beneficial for people suffering from psychosis, but more research is needed.
25 MBIs have moderate short-term effects on total psychotic symptoms, positive symptoms, hospitalization rates, length of hospitalization and mindfulness in patients with psychosis. MBIs also have long-term effects on total psychotic symptoms and hospitalization duration. 26 Other studies show that MBIs can help people with mental health issues, such as improving their negative symptoms and measures of functioning, as well as enhancing their quality of life. 27 To better understand the mechanisms and long-term efficacy of MBIs in people with psychosis, future large trials using randomization procedures are recommended.
Participants with PTSD were more likely to have less conclusive results from MBIs. A meta-analysis of ten randomized controlled trials examining the effects of meditation on post-traumatic stress disorder (PTSD) found some benefit, but the results were not statistically significant. 28 Meditation intervention types, short follow-up times, and high-quality studies hampered the evaluations of the findings. 28 However, a number of systematic reviews have come to similar conclusions regarding the efficacy of MBIs such as mindfulness, yoga, and relaxation in the treatment of post-traumatic stress disorder (PTSD). 29,30 Increased confidence in the efficacy of MBIs among PTSD-diagnosed participants requires additional high-quality studies.
Before concluding on the effectiveness of MBIs in the treatment of attention-deficit hyperactivity disorder (ADHD), further research is needed. ADHD core symptoms like inattention, hyperactivity, and impulsivity can be reduced by MBIs, according to a systematic review and meta-analysis (children and adolescents: Hedge’s g = –0.44, 95 percent confidence interval (CI): 0.69 to 0.19, I2 zero percent; adults: Hedge’s g = –0.66, 95 percent confidence interval (CI): 1.21 to 0.01; I2 81.81%). 31 Even though there are only a few studies, there is a high risk of bias and a lack of sufficient evidence to support the efficacy, according to the authors. 31 A number of other systematic reviews have come to similar conclusions and findings. 32–34
Currently, there is very little research on MBIs for people with autism spectrum disorders (ASD) or their caregivers. People with autism and their caregivers may benefit from MBIs, but the results of a 2017 systematic review of 16 eligible studies were inconclusive. 35 Due to their diverse age groups and outcomes, these studies covered a wide range of ASD sufferers and their families’ subjective well-being. 35 People with autism spectrum disorder (ASD) may benefit from MBIs in the following ways: they can help alleviate anxiety and rumination; they can help alleviate parental stress; they can help improve their mental health; and they can help improve the mental health of their loved ones.
There is currently insufficient evidence to support the use of MBIs to improve cognition. MBIs have been shown to improve cognitive function and everyday activity functioning in older adults with mild cognitive impairment, according to a systematic review. 39 However, the available studies had small sample sizes, lacked control comparisons, and lacked follow-up to understand the effects on delaying dementia progression. 39 MBIs’ cognitive benefits need to be tested in more rigorous studies and on a wider range of populations.
MBIs have been shown to reduce pain in a wide range of populations.
40,41 An RCT meta-analysis of 30 RCTs on chronic pain in 2017 found that mindfulness meditation improved chronic pain management. 40 There was a statistically significant difference in the percentage change of the mean in pain between the intervention and control groups (0.19 percent (SD, 0.91; min, 0.48; max, 0.110)). 40 Even though more studies are needed to confirm this, a network meta-analysis found MBSR to be effective for chronic pain and that the effects are not significantly different between MBSR and CBT. 41 In addition, current evidence is insufficient to support the efficacy of brief MBIs with a total contact time of less than 1.5 hours on acute and chronic pain.
Multiple studies and meta-analyses show that MBIs can lower blood pressure (BP).
43–45 People with hypertension or elevated blood pressure saw a reduction in systolic and diastolic blood pressure after a meta-analysis of five studies on MBSR. There is a lack of evidence on ambulatory blood pressure due to the fact that most studies focused solely on clinical blood pressure. 43 In people with non-communicable diseases, the systolic and diastolic BPs were reduced after the eight-week MBSR, the 12-week breathing awareness meditation, and the eight-week mindfulness-based intervention. 44 The systolic blood pressure (d+ = 0.89, 95 percent confidence interval [CI] = 0.26, 1.51) and psychological symptoms (d+s = 0.49–0.64) improved, but the diastolic blood pressure (d+s = 0.49–0.64) did not. 45 Another systematic review by Zou found that mindful exercises for stroke patients improved sensorimotor function in both the lower and upper limbs (SDM = 0.79; 95 percent CI, 0.43–1.15; I2 = 62.67 percent). 46 Gait speed, leg strength, aerobic endurance, motor function, cognitive function, and gait parameters can be measured in additional studies, as well.
The comorbidities that accompany being overweight or obese are a significant source of disease burden. 47 If you’ve ever struggled with weight gain, mindful eating can be a useful weight-loss strategy. Conventional diet programs, which restrict energy intake and limit food choices, may not have long-term effects because mindful eating tends to be more sustainable and also addresses emotional issues that may influence unhealthy diets. 48–52 Ten studies on mindful eating and weight control were reviewed in 2019 and found significant weight loss after the program (0.348 kg, 95 percent confidence interval [CI], 0.591–0.105) compared to control groups. 53 In addition, the effects of MBIs were comparable to those of conventional diets. 53 Short study durations and biased samples were found to be flaws in the research (unbalanced sex ratio, source and place of living). Longer studies and different methods of subject selection may be necessary in the future to assess long-term improvements in various populations.
There is currently no conclusive evidence that MBIs have any effect on the physiological outcomes of diabetes. The effectiveness of MBIs in controlling physiological outcomes (such as blood sugar and blood pressure) in patients with type 1 and type 2 diabetes was found to be mixed in a systematic review. 54 An additional meta-analysis found that meditative movements significantly improved glycemic control in type 2 diabetes mellitus (T2DM) patients, including fasting glucose, glycated hemoglobin (HbA1c), and postprandial glucose. 55 In spite of this, the authors pointed out that it’s difficult to draw any firm conclusions about the effectiveness of MBIs because of the small sample sizes, short study durations, and wide variety of delivery methods that have been reported so far on. 55 The improvement in psychological symptoms such as anxiety,54 depressive symptoms,54,56, and quality of life, in addition to better glycaemic control, was also found in systematic reviews. 57 To determine whether MBIs are effective in the treatment of diabetes, more research is needed to address the limitations.
The physical health outcomes of cancer patients may benefit from MBIs, particularly cancer-related fatigue and pain, as well as psychological benefits.
There was a statistically significant decrease in cancer-related fatigue (CRF) score amongst cancer patients (SMD = -0.51, 95 percent CI [0.81–0.20]),59 particularly among lung cancer patients. 60 Another systematic review and meta-analysis found improvements in sleep disturbances, pain, and other psychological symptoms such as anxiety, depression, and fear of cancer recurrence. 61 Further high-quality studies are still required, even though MBIs appeared to be effective in reducing CRF and other symptoms, to provide additional insights and to confirm the existing evidence.
MBIs’ ability to improve respiratory health remained a mystery. A meta-analysis of 16 studies found that patients with chronic obstructive pulmonary disease (COPD) may benefit from meditative movement to improve lung function and physical activity. 62 Walking distance and forced expiratory volume in one second (FEV1) were both improved by the intervention when compared to the nonexercised group (3 months: MD = 25.40 m, 95 percent CI; 16.25–34.54; 6 months: MD = 35.75 m, 95 percent CI: 22.23–49.27) and when compared to the nonexercised group (6 months: MD = 35.75 m, 95 percent CI: 22.23–49.27). 62 However, the authors cautioned that further studies are needed to confirm the findings due to the small sample sizes, inconsistency in study quality, and the variety of meditative movement styles in studies. 62 Further high-quality studies are needed to confirm the effectiveness of MBIs on respiratory health in COPD65 and asthma63, according to other systematic reviews and meta-analysis.
Damian Sendler
MBIs have been shown to have a positive impact on social well-being and prosocial behavior (i.e. voluntary behaviour intended to benefit another).
65,66 Study after study has found medium effects on prosocial behavior, and the results are consistent with known and unknown effects. 65 Research shows that mindfulness promotes ethical and cooperative behaviors in a variety of interpersonal contexts and may reduce intergroup bias. 65 Also, according to a recent review of 29 studies, MBIs reliably improve compassionate helping and reduce prejudice and retaliation with effect sizes ranging from small to medium. 66 As a further benefit, MBIs have been shown to reduce anger, violence, and aggression. 69 Social and ecological sustainability may also be improved through improved well-being and connection to others, the community, as well as the natural world. 70
A public health issue, especially during COVID-19 and among the elderly, is loneliness and social isolation. It appears that mindfulness training may help reduce feelings of isolation and loneliness, according to some preliminary research. 71–74 An early study found that MBSR was effective in reducing loneliness in senior citizens. 71 Another study found that social support for HIV-positive women had a positive impact on their feelings of isolation. 72 In a study of Chinese college students, mindfulness was found to have a positive effect on the reduction of loneliness. 73 In a study comparing smartphone-based mindfulness training to an active control program, Lindsay et al. found that mindfulness training decreased feelings of isolation while increasing social interactions.
More and more schools are implementing mindfulness programs. Schools around the world have implemented a variety of mindfulness programs, including “.b,” “Mindful Schools,” “WELL,” and “Resilience.” 79,80 Many of these programs are aimed at both students and educators. 81 MBIs have the potential to improve resilience to stress, cognitive performance such as attention, and emotional problems in children and adolescents, according to recent systematic reviews. 82,83 Results showed that resilience had a significant effect when it came to well-being (positive and constructive emotional states), as well as social and interpersonal skills, and self-esteem. In the meta-analysis, the results showed that the effects (effect size = 0.36–0.80) were comparable to or better than those of school-based social and emotional learning programs (overall effect size = 0.30). 84 It’s encouraging to see MBIs being taught in preschools, elementary schools, middle schools, and high schools as a life skill. Students may benefit from a weekly 90-minute mindfulness session (i.e. 18 minutes on average per day). 85 Integrating mindfulness into the curriculum, teacher training, leadership development, and other aspects of the learning environment is important when establishing mindful schools.
Damian Jacob Markiewicz Sendler: Nonclinical samples showed that trait mindfulness was linked to higher levels of self-confidence, greater job satisfaction, and better interpersonal relations; it was also linked to higher levels of burnout and work withdrawal. It has been found that mindfulness-based interventions (MBIs) reduce stress, burnout, mental distress and somatic complaints in the workplace as well as improve mindfulness and well-being in the workplace with small to large effect sizes ranging from Hedge’s g = 0.32–0.77. However, the effect on work engagement and productivity was limited by a small number of studies.
They can be used in a variety of ways, including in groups or as individual self-help interventions.89 MBIs can also be integrated into educational programs for clinicians and other professionals in order to benefit themselves as well as their students as well as the people in their immediate environment.
90 Even though cognitive behavioral interventions have nearly identical benefits, mindfulness may require less training and less time for both workers and clients to master, and they may be less expensive to provide. 91 According to studies, teachers in a mindfulness program can expect to pay between US$515 and US$1850 per teacher for their training, which varies depending on the number of teachers being trained and the ancillary and opportunity costs. 92 There must be more research done, however, to prove their effectiveness. Early evidence suggests that it is cost-effective93, including but not limited to the treatment of breast cancer-related pain, fibromyalgia-related pain, low back pain, and training for caregivers 97 Online and face-to-face MBCT are both effective treatments for improving the quality of life of cancer patients in need of emotional support. 98 Many health problems still need to be studied for their cost-effectiveness in the workplace,99 as well as in other areas.
Learning mindfulness can be hindered by non-compliance. As much as a quarter of high school students fail to graduate as a result of a variety of factors.
Damian Jacob Sendler
There have been conflicting findings in previous studies about who will or will not adhere to MBIs. Even though women in general showed higher levels of compliance, those with higher levels of openness to experience, resistance to change and severer symptoms. 103,104 One systematic review of 28 studies found a small but significant correlation between participants’ self-reported home practice and intervention outcomes (r = 0.26, 95 percent CI: 0.19–0.34), but the relationship between participants’ compliance and intervention outcomes is inconsistent.105 106 A good natural setting is important, especially for beginners, in terms of factors associated with better compliance. 100 Furthermore, some researchers have advocated for the identification of meditation exercises that are both effective and adherent to MBIs. 107 There is still a need for more research to determine which types of MBIs are most likely to be adhered to and benefit from, as well as factors and strategies that can help increase compliance.
Changes in mindfulness, rumination, worry, self-regulation, compassion or meta-awareness are some of the mechanisms suggested by studies as being responsible for MBIs. These changes predicted or mediated the treatment effects.
Damien Sendler: It has been suggested that changes in attention, memory specificity, self-discrepancy, emotional reactivity, and momentary positive and negative affect, may be part of the mechanisms. 108 Recently, the MMT approach has also been recognized as providing a theoretical framework for the investigation of specific mindfulness components and their contributions to positive health outcomes. 112,113 Through an iterative process of appraisal, decentering, and metacognition, this approach would help people eliminate negative emotions and replace them with positive ones while also promoting eudaimonic meaning in their lives. 112,113 However, there are numerous unanswered questions concerning the mechanisms of MBIs.
It is possible that the changes in the brain and biomarkers of immune function and stress may have provided a neurophysiological basis for explaining the positive effects of MBIs. Medical brain imaging (MBI) has been found to affect the processing of self-relevant information, the regulation of behavior and the solution of problems, adaptive behavior and interoception in healthy and diseased individuals in systematic reviews. 114–119 It was found to be true in all of the eight areas of the brain that are linked to meta-awareness (frontopolar), body awareness, memory consolidation (hippocampus) as well as self- and emotion regulation (anterior cingulate; orbital frontal cortex) that mindfulness practices had a medium effect size. 118 Short-term meditators have not been shown to have structural brain changes, but experts have, especially in the areas of their brains that are involved in self-referential processes like self-awareness and self-regulation. 114 MBIs have modulatory effects on several brain regions in people with major depressive disorders, for example (e.g. the prefrontal cortex, the basal ganglia, the anterior and posterior cingulate cortices and the parietal cortex). 115 According to yet another systematic review of 78 studies using functional neuroimaging (fMRI and PET) to examine the effects of meditation on brain activity and deactivation, there were moderate effects on brain activation and deactivation for common meditation practices (focused attention, mantra recitation, open monitoring, and compassion/loving-kindness), suggesting practical significance. 116 It was found that increased alpha and theta power in both healthy and patient groups was associated with a relaxed alertness state that may contribute to mental health in the systematic review of EEG results. 117
RCTs have shown that mindfulness meditation can reduce stress and immune-related physiological markers of inflammation, cell-mediated immunity, and biological aging: NF-kB activity is reduced, C-reactive protein levels are reduced, CD4+ T cell counts are increased, and telomerase activity increases.
120 mindfulness meditation has been shown to reduce physiological markers of stress such as cortisol, C-reactive protein and systolic blood pressure, as well as triglycerides and tumor necrosis factor-alpha in various populations, according to another systematic review of RCTs. 121 More hours of meditation have been shown to have a greater impact on telomere biology than fewer hours of meditation. 122 These preliminary findings, however, require further replication, and the authors of the review call for studies to include physiological markers as a primary outcome of RCTs.
MBIs should not overestimate the importance of organizational and social determinants in ill health, and ethical questions are essential in guiding the future direction of MBIs. Ethics of mindfulness are extensively discussed in the books “Practitioner’s Guide to Ethics and Mindfulness-Based Interventions” (edited by Lynette Monteiro, Jane Compson and Frank Musten) and “Handbook of Ethical Foundations of Mindfulness” (edited by Stanley Steven, Ronald Purser and Nirbhay Singh). For MBIs, there are many ethical issues that need to be addressed. The paradox of teaching mindfulness in business and military settings, for example, is that it prevents superiors from making use of subordinates through mindfulness regardless of other organizational factors causing stress or depression at work. While MBIs can provide personally meaningful and prosocial values, they can also improve ethical standards, as research shows that people who are more mindful place a higher value on moral principles than people who are less aware.124 This suggests that MBIs can help raise ethical standards.
MBIs are considered to be relatively risk-free.
126 Adverse events and side effects of MBIs, like many other psychological intervention studies, go largely unreported. MBSR and MBCT have been shown to be safe in a previous systematic review, but only one in five trials mentioned monitoring for adverse effects. 126 Factors associated with the program, with participants, and with clinicians or teachers all have the potential to cause negative outcomes. 1,126–132 As a result of previous research and real-world experience, a safety checklist is still needed. MBI practitioners and researchers are encouraged to report any potential adverse events using a checklist, as well as to continue taking safety precautions, such as screening and caring for vulnerable individuals, in future MBI programs. Seizures/epilepsies/acute psychosis/mania/suicidal thoughts may be among the health issues of concern for these individuals.
Despite the growing popularity of mindfulness research and applications, many questions remain. The first step is to improve the quality of research studies. A lack of quality study design, small sample size, short follow-up period, and inconsistent terminology and measurement tools are among the most frequently cited limitations in systematic reviews of MBI effectiveness and cost effectiveness. These caveats need to be addressed in future studies. More research is needed to determine whether online MBIs intervention and training can have the same or better effects and cost-effectiveness as face-to-face MBIs, though preliminary benefits have been observed. 10,134,135 In light of the current COVID-19 pandemic, online alternatives may be critical. Integrating both empirical and neurophysiological findings to gain a better understanding of the mechanisms. Fourth, more research is needed to examine the acceptance and compliance of MBIs in consideration of safety issues and ethical concerns in order to understand who might benefit more from MBIs and barriers and respective strategies (e.g. better meditation environment) for improving the acceptance and compliance. An examination of long-term compliance is also necessary. A large-scale cohort study on MBIs may be necessary. The fifth step is to develop more guidelines and regulations for mindfulness-related research and services, such as guidelines on adverse events monitoring and safety guarantee, as well as qualifications for mindfulness teachers. ‘ When MBIs are provided as a collective action in schools, businesses, or organizations, these may be important considerations. As a sixth option, consider Mindfulness Plus (or “Mindfulness+”), which is a combination of MBIs and other proven interventions (such as medication or behavioral activation in addition to MBIs, for example)136. Also, consider MBIs combined with reflection training and Qigong movement therapy138. This would allow for a wider range of applications for MBIs.
Different populations benefit from MBIs for a wide range of common health conditions. Depression, anxiety, stress, insomnia, addiction, psychosis, pain, high blood pressure, obesity, and cancer-related symptoms have all been found to be alleviated by MBIs. However, more research is still needed to examine MBIs’ efficacy on a wide range of biopsychosocial health conditions, such as depression, anxiety, and schizophrenia. MBIs are generally considered safe. During mindfulness-based trainings and interventions, ethical considerations must always be taken into account. Both empirical and neurophysiological findings have suggested mechanisms for MBIs. Some health issues can be cost-effectively addressed (e.g. breast cancer, fibromyalgia, low back pain or caregiver training). Studies with larger sample sizes and longer follow up periods are needed for a wide range of other issues and sub-groups to confirm its effectiveness and cost-effectiveness.