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Fry KM, Bennett DC, Roberge EM, McClain CM, Rugo-Cook K, Brewczynski J, Pryor C. The effects of Religiosity, Spirituality, and sense of purpose on posttraumatic stress disorder treatment outcomes among Veterans. J Psychiatr Res 2024; 176:276-281. [PMID: 38905760 DOI: 10.1016/j.jpsychires.2024.05.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 05/17/2024] [Accepted: 05/29/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Religion/spirituality (R/S) is an important and commonly used resource for coping with difficult experiences and has been shown to reduce the development of posttraumatic stress disorder (PTSD) symptoms following a trauma. However, it is not clear how R/S affects response to treatment of PTSD. OBJECTIVE The aim of this paper was to understand how Veterans' R/S and sense of purpose were related to clinical outcomes when engaging in Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE). It was predicted that Veterans identifying as R/S would have a higher sense of purpose, be more likely to complete treatment, and have greater symptom change during treatment. METHOD The study included 91 military Veterans from a VA Medical Center outpatient PTSD Clinical Team who initiated CPT or PE and responded to a question about the importance of R/S in their lives at intake. RESULTS Forty nine percent of the Veterans in this sample reported R/S were important to them and had mixed feelings about whether their life had a clear sense of purpose. Neither R/S nor sense of purpose were associated with treatment completion or response to PTSD treatment. CONCLUSION These findings suggest that once PTSD has developed, R/S or sense of purpose may not play a significant role in completion of or response to evidence-based psychotherapies (EBPs) for PTSD. EBPs for PTSD are equally effective for Veterans identifying as R/S and those who do not, which may be reflective of administering EBPs in a culturally responsive manner.
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Affiliation(s)
- Katie M Fry
- VA Salt Lake City Healthcare System, United States.
| | - Diana C Bennett
- VA Salt Lake City Healthcare System, United States; Department of Psychiatry, University of Utah Spencer Fox Eccles School of Medicine, United States
| | - Erika M Roberge
- VA Salt Lake City Healthcare System, United States; Department of Psychiatry, University of Utah Spencer Fox Eccles School of Medicine, United States
| | | | | | - Jacek Brewczynski
- VA Salt Lake City Healthcare System, United States; Department of Psychiatry, University of Utah Spencer Fox Eccles School of Medicine, United States; Department of Psychology, University of Utah, United States
| | - Cosette Pryor
- VA Salt Lake City Healthcare System, United States; Department of Psychology, University of Utah, United States
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Merrigan JJ, Klatt M, Quatman-Yates C, Emerson A, Kronenberg J, Orr M, Caputo J, Daniel K, Summers R, Mulugeta Y, Steinberg B, Hagen JA. Incorporating biofeedback into the Mindfulness in Motion Intervention for health care professionals: Impact on sleep and stress. Explore (NY) 2024; 20:103022. [PMID: 38981179 DOI: 10.1016/j.explore.2024.103022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 06/16/2024] [Accepted: 06/22/2024] [Indexed: 07/11/2024]
Abstract
CONTEXT Health care providers (HCP) experience high stress and burnout rates. Mindfulness Based Interventions (MBI) with biofeedback may help improve resiliency but require further research. DESIGN AND STUDY PARTICIPANTS Aims were to evaluate changes in sleep patterns, nocturnal physiology, stress, mood disturbances, and perceived experience with biofeedback during the Mindfulness in Motion (MIM) intervention. Data from 66 HCP were included after removing those below 75 % compliance with wearable sensors and wellness surveys. Participants were enrolled in MIM, including eight weekly one-hour virtually delivered synchronous group meetings and ∼10 min of mindfulness home practice at least 3 times per week using a mobile application. Participants wore wearable sensors to monitor sleep and nocturnal physiology and completed short daily stress and mood disturbances. RESULTS According to mixed effect models, no sleep nor physiological metrics changed across MIM (p > 0.05). More time was spent in bed after MIM sessions (8.33±1.03 h) compared to night before (8.05±0.93 h; p = 0.040). Heart rate variability was lower nights after MIM (33.00±15.59 ms) compared to nights before (34.50±17.04 ms; p = 0.004) but was not clinically meaningful (effect= 0.033). Significant reductions were noted in perceived stress at weeks 3 through 8 compared to Baseline and lower Total Mood Disturbance at weeks 3, 5, 6, and 8 compared to Baseline (p < 0.001). CONCLUSIONS Participating in the MIM with mobile applications and wearable sensors reduced perceived stress and mood disturbances but did not induce physiological changes. Additional research is warranted to further evaluate objective physiological outcomes while controlling for confounding variables (e.g., alcohol, medications).
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Affiliation(s)
- Justin J Merrigan
- Human Performance Collaborative, Office of Research, The Ohio State University, Columbus, OH, USA.
| | - Maryanna Klatt
- Center for Integrative Health, Department of Family and Community Medicine, College of Medicine, Columbus, OH, USA; Gabbe Health and Wellbeing, The Ohio State University Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
| | - Catherine Quatman-Yates
- School of Health and Rehabilitation Sciences, Division of Physical Therapy, The Ohio State University, Columbus, OH, USA.
| | - Angela Emerson
- Human Performance Collaborative, Office of Research, The Ohio State University, Columbus, OH, USA
| | - Jamie Kronenberg
- Human Performance Collaborative, Office of Research, The Ohio State University, Columbus, OH, USA
| | - Morgan Orr
- Human Performance Collaborative, Office of Research, The Ohio State University, Columbus, OH, USA
| | - Jacqueline Caputo
- Center for Integrative Health, Department of Family and Community Medicine, College of Medicine, Columbus, OH, USA
| | - Kayla Daniel
- Center for Integrative Health, Department of Family and Community Medicine, College of Medicine, Columbus, OH, USA
| | - Riley Summers
- School of Health and Rehabilitation Sciences, Division of Physical Therapy, The Ohio State University, Columbus, OH, USA
| | - Yulia Mulugeta
- Center for Integrative Health, Department of Family and Community Medicine, College of Medicine, Columbus, OH, USA
| | - Beth Steinberg
- Center for Integrative Health, Department of Family and Community Medicine, College of Medicine, Columbus, OH, USA; Gabbe Health and Wellbeing, The Ohio State University Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Joshua A Hagen
- Human Performance Collaborative, Office of Research, The Ohio State University, Columbus, OH, USA; Department of Integrated Systems Engineering, The Ohio State University, Columbus, OH, USA.
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Lee A, Thuras P, Baller J, Jiao C, Guo B, Erbes CR, Polusny MA, Liu C, Wu B, Lim KO, Bishop JR. Serotonin Transporter (SLC6A4) and FK506-Binding Protein 5 (FKBP5) Genotype and Methylation Relationships with Response to Meditation in Veterans with PTSD. Mol Neurobiol 2024:10.1007/s12035-024-04096-6. [PMID: 38671329 DOI: 10.1007/s12035-024-04096-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/04/2024] [Indexed: 04/28/2024]
Abstract
Meditation-based interventions are novel and effective non-pharmacologic treatments for veterans with PTSD. We examined relationships between treatment response, early life trauma exposure, DNA polymorphisms, and methylation in the serotonin transporter (SLC6A4) and FK506-binding protein 5 (FKBP5) genes. DNA samples and clinical outcomes were examined in 72 veterans with PTSD who received meditation-based therapy in two separate studies of mindfulness-based stress reduction (MBSR) and Transcendental Meditation (TM). The PTSD Checklist was administered to assess symptoms at baseline and after 9 weeks of meditation intervention. We examined the SLC6A4 promoter (5HTTLPR_L/S insertion/deletion + rs25531_A/G) polymorphisms according to previously defined gene expression groups, and the FKBP5 variant rs1360780 previously associated with PTSD disease risk. Methylation for CpG sites of SLC6A4 (28 sites) and FKBP5 (45 sites) genes was quantified in DNA samples collected before and after treatment. The 5HTTLPR LALA high expression genotype was associated with greater symptom improvement in participants exposed to early life trauma (p = 0.015). Separately, pre to post-treatment change of DNA methylation in a group of nine FKBP5 CpG sites was associated with greater symptom improvement (OR = 2.8, 95% CI 1.1-7.1, p = 0.027). These findings build on a wealth of existing knowledge regarding epigenetic and genetic relationships with PTSD disease risk to highlight the potential importance of SLC6A4 and FKBP5 for treatment mechanisms and as biomarkers of symptom improvement.
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Affiliation(s)
- Adam Lee
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Room 7-115 Weaver-Densford Hall, 308 Harvard St SE, Minneapolis, MN, 55455, USA
| | - Paul Thuras
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, USA
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Joshua Baller
- Minnesota Supercomputing Institute, University of Minnesota, Minneapolis, MN, USA
| | - Chuan Jiao
- Department of Psychiatry, State University of New York Upstate Medical University, Syracuse, NY, USA
- Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Team Krebs, Université Paris Cité, 75014, Paris, France
| | - Bin Guo
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Christopher R Erbes
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, USA
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Melissa A Polusny
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, USA
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Chunyu Liu
- Department of Psychiatry, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Baolin Wu
- Department of Epidemiology and Biostatistics, Program in Public Health, University of California-Irvine, Irvine, CA, USA
| | - Kelvin O Lim
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, USA
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Geriatric Research, Education, and Clinical Center, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Jeffrey R Bishop
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Room 7-115 Weaver-Densford Hall, 308 Harvard St SE, Minneapolis, MN, 55455, USA.
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MN, USA.
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Contractor AA, Blumenthal H, Rosenfield D, Shea MT, Taylor DJ, Fentem A, Vingren JL. Study protocol and rationale for a pilot randomized clinical trial comparing processing of positive memories technique with supportive counseling for PTSD. Contemp Clin Trials 2024; 138:107455. [PMID: 38253251 DOI: 10.1016/j.cct.2024.107455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/29/2023] [Accepted: 01/19/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Research indicates that positive memories have a role in posttraumatic stress disorder's (PTSD) symptomatology and treatment. Following treatment development guidelines, a novel PTSD intervention - Processing of Positive Memories Technique (PPMT) - was developed and subsequently examined for its effects and feasibility in pilot studies. Extending this research, the proposed pilot randomized clinical trial with PPMT and Supportive Counseling (SC) arms will examine PPMT's effects on PTSD severity and biomarkers of stress systems' dysregulation (awakening salivary alpha amylase [sAA] and cortisol concentrations); examine mechanistic targets (affect) underlying PPMT's effects; and refine PPMT. We hypothesize that the PPMT arm will report greater decreases in PTSD severity and greater decreases in awakening sAA/cortisol ratio compared to the SC arm; and that improved affect (more positive affect and less negative affect) will mediate associations between intervention arm and changes in PTSD severity. METHODS We will recruit 70 individuals aged 18-65 years with PTSD. They will be randomized to 5 weekly therapy sessions of PPMT or SC, and will be assessed at baseline, weekly during treatment, 1-week post-treatment, and 3-months post-treatment. Primary outcomes are past-week PTSD severity, past-week positive and negative affect levels, and feedback data on PPMT's feasibility, format, and content. The secondary outcome is the awakening sAA/cortisol ratio. Statistical analyses include mixed-effect models and within-subjects cross-lag longitudinal mediation analyses. CONCLUSION Study results will advance knowledge of trauma interventions by examining effects and feasibility of a novel PTSD intervention, and by elucidating potential mechanisms underlying PPMT's effects. Clinical Trials #: NCT05523453.
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Affiliation(s)
- Ateka A Contractor
- Department of Psychology, University of North Texas, Terrill Hall, Denton, TX, 76201, United States of America.
| | - Heidemarie Blumenthal
- Department of Psychology, University of North Texas, Terrill Hall, Denton, TX, 76201, United States of America
| | - David Rosenfield
- Department of Psychology, Southern Methodist University, Expressway Tower, Dallas, TX, 75275, United States of America
| | - M Tracie Shea
- Box G-BH, Brown University, Providence, RI 02912, United States of America
| | - Daniel J Taylor
- Department of Psychology, University of Arizona, 1503 W University Blvd, Tuscon, AZ 85721, United States of America
| | - Andrea Fentem
- Department of Psychology, University of North Texas, Terrill Hall, Denton, TX, 76201, United States of America
| | - Jakob L Vingren
- Department of Kinesiology, Health Promotion and Recreation, University of North Texas, Denton TX 76203, United States of America
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Kaplan J, Somohano VC, Zaccari B, O’Neil ME. Randomized controlled trials of mind-body interventions for posttraumatic stress disorder: a systematic review. Front Psychol 2024; 14:1219296. [PMID: 38327501 PMCID: PMC10847595 DOI: 10.3389/fpsyg.2023.1219296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 12/18/2023] [Indexed: 02/09/2024] Open
Abstract
Mind-body interventions (MBIs) include mindfulness-based interventions (MiBIs), meditation- and mantra-based interventions (MMIs), and movement-based interventions (MoBIs). These approaches have demonstrated preliminary efficacy in improving posttraumatic stress disorder (PTSD) symptoms. However, previous systematic reviews and meta-analyses have noted that this area of research is limited by inadequate comparator conditions, heterogeneity of measurement, and absence of objective outcome measures. For these reasons, an updated review of the highest-quality evidence available is warranted. We used the Agency for Healthcare Research and Quality (AHRQ)-funded evidence tables for the PTSD-Repository to identify relevant studies and assess the risk of bias as follows: The search was conducted between June 2018 and June 2022, and databases included PTSDpubs (formerly PILOTS), Ovid® MEDLINE®, Cochrane CENTRAL, Embase®, the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), SCOPUS, and PsycINFO®. Twenty-six randomized controlled trials met our inclusion criteria. After identifying studies and retrieving risk of bias information from the PTSD-Repository evidence tables, we extracted additional data and synthesized the evidence. The strength of evidence was rated as low for MiBIs and MMIs, largely due to contradicting results, inconsistent use of active versus passive comparators, and high risk of bias. The strength of evidence for MoBIs was rated as moderate due to individual studies consistently favoring the intervention and a relatively large number of studies and participants. Of the 26 included studies, only two included objective outcome measures. Implications for future MBI research and clinical applications for treating PTSD are discussed.
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Affiliation(s)
- Josh Kaplan
- Department of Neurology, Oregon Health & Science University, Portland, OR, United States
| | | | - Belle Zaccari
- Veterans Affairs Portland Health Care System, Portland, OR, United States
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
| | - Maya E. O’Neil
- Veterans Affairs Portland Health Care System, Portland, OR, United States
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, United States
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Sun L. Social media usage and students' social anxiety, loneliness and well-being: does digital mindfulness-based intervention effectively work? BMC Psychol 2023; 11:362. [PMID: 37904182 PMCID: PMC10617103 DOI: 10.1186/s40359-023-01398-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/16/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND The increasing integration of digital technologies into daily life has spurred a growing body of research in the field of digital psychology. This research has shed light on the potential benefits and drawbacks of digital technologies for mental health and well-being. However, the intricate relationship between technology and psychology remains largely unexplored. PURPOSE This study aimed to investigate the impact of mindfulness-based mobile apps on university students' anxiety, loneliness, and well-being. Additionally, it sought to explore participants' perceptions of the addictiveness of these apps. METHOD The research utilized a multi-phase approach, encompassing a correlational research method, a pretest-posttest randomized controlled trial, and a qualitative case study. Participants were segmented into three subsets: correlations (n = 300), treatment (n = 60), and qualitative (n = 20). Data were gathered from various sources, including the social anxiety scale, well-being scale, social media use integration scale, and an interview checklist. Quantitative data was analyzed using Pearson correlation, multiple regression, and t-tests, while qualitative data underwent thematic analysis. RESULTS The study uncovered a significant correlation between social media use and the variables under investigation. Moreover, the treatment involving mindfulness-based mobile apps led to a reduction in students' anxiety and an enhancement of their well-being. Notably, participants held various positive perceptions regarding the use of these apps. IMPLICATIONS The findings of this research hold both theoretical and practical significance for the field of digital psychology. They provide insight into the potential of mindfulness-based mobile apps to positively impact university students' mental health and well-being. Additionally, the study underscores the need for further exploration of the intricate dynamics between technology and psychology in an increasingly digital world.
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Affiliation(s)
- Li Sun
- School of Marxism, Zhoukou Vocational and Technical College, Zhoukou, 466000, China.
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Malik H, Usman M, Arif M, Ahmed Z, Ali G, Rauf K, Sewell RDE. Diosgenin normalization of disrupted behavioral and central neurochemical activity after single prolonged stress. Front Pharmacol 2023; 14:1232088. [PMID: 37663254 PMCID: PMC10468593 DOI: 10.3389/fphar.2023.1232088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction: Post-traumatic stress disorder (PTSD) is a chronic mental illness triggered by traumatic experiences such as wars, natural disasters, or catastrophes, and it is characterized by anxiety, depression and cognitive impairment. Diosgenin is a steroidal sapogenin with known neuroprotective and antioxidant properties. This study aimed to assess the pharmacological potential of diosgenin in a single prolonged stress (SPS) model of PTSD, plus other behavioral models along with any consequent alterations in brain neurochemistry in male mice. Methodology: SPS was induced by restraining animals for 2 h, followed by 20 min of forced swim, recuperation for 15 min, and finally, exposure to ether to induce anesthesia. The SPS-exposed animals were treated with diosgenin (20, 40, and 60 mg/kg) and compared with the positive controls, fluoxetine or donepezil, then they were observed for any changes in anxiety/depression-like behaviors, and cognitive impairment. After behavioral screening, postmortem serotonin, noradrenaline, dopamine, vitamin C, adenosine and its metabolites inosine and hypoxanthine were quantified in the frontal cortex, hippocampus, and striatum by high-performance liquid chromatography. Additionally, animal serum was screened for changes in corticosterone levels. Results: The results showed that diosgenin reversed anxiety- and depression-like behaviors, and ameliorated cognitive impairment in a dose-dependent manner. Additionally, diosgenin restored monoamine and vitamin C levels dose-dependently and modulated adenosine and its metabolites in the brain regions. Diosgenin also reinstated otherwise increased serum corticosterone levels in SPS mice. Conclusion: The findings suggest that diosgenin may be a potential candidate for improving symptoms of PTSD.
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Affiliation(s)
- Hurmat Malik
- Department of Pharmacy, COMSATS University Islamabad, Abbottabad, Pakistan
| | - Muhammad Usman
- Department of Pharmacy, COMSATS University Islamabad, Abbottabad, Pakistan
| | - Mehreen Arif
- Department of Pharmacy, COMSATS University Islamabad, Abbottabad, Pakistan
| | - Zainab Ahmed
- Department of Pharmacy, COMSATS University Islamabad, Abbottabad, Pakistan
| | - Gowhar Ali
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Khalid Rauf
- Department of Pharmacy, COMSATS University Islamabad, Abbottabad, Pakistan
| | - Robert D. E. Sewell
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, United Kingdom
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Merrigan JJ, Quatman-Yates C, Caputo J, Daniel K, Briones N, Sen I, Bretz S, Duchemin AM, Steinberg B, Hagen JA, Klatt M. Assessment of Virtual Mindfulness-Based Training for Health Care Professionals: Improved Self-Reported Respiration Rates, Perceived Stress, and Resilience. GLOBAL ADVANCES IN INTEGRATIVE MEDICINE AND HEALTH 2023; 12:27536130231187636. [PMID: 37434793 PMCID: PMC10331219 DOI: 10.1177/27536130231187636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
Background Mindfulness in Motion (MIM) is a workplace resilience-building intervention that has shown reductions in perceived stress and burnout, as well as increased resilience and work engagement in health care workers. Objective To evaluate effects of MIM delivered in a synchronous virtual format on self-reported respiratory rates (RR), as well as perceived stress and resiliency of health care workers. Methods Breath counts were self-reported by 275 participants before and after 8 weekly MIM sessions. MIM was delivered virtually in a group format as a structured, evidence-based workplace intervention including a variety of mindfulness, relaxation, and resilience-building techniques. Participants counted their breaths for 30 seconds, which was then multiplied by 2 to report RR. Additionally, participants completed Perceived Stress Scale and Connor-Davidson Resiliency Scale. Results According to mixed effect analyses there were main effects of MIM Session (P < .001) and Weeks (P < .001), but no Session by Week interaction (P = .489) on RR. On average, RR prior to MIM sessions were reduced from 13.24 bpm (95% CI = 12.94, 13.55 bpm) to 9.69 bpm (95% CI = 9.39, 9.99 bpm). When comparing average Pre-MIM and Post-MIM RR throughout the MIM intervention, Week-2 (mean = 12.34; 95% CI = 11.89, 12.79 bpm) was not significantly different than Week-1 (mean = 12.78; 95% CI = 12.34, 13.23 bpm), but Week-3 through Week-8 demonstrated significantly lower average Pre-MIM and Post-MIM RR compared to Week-1 (average weekly difference range: 1.36 to 2.48 bpm, P < .05). Perceived stress was reduced from Week-1 (17.52 ± 6.25) to after Week-8 (13.52 ± 6.04; P < .001), while perceived resiliency was increased from Week-1 (11.30 ± 5.14) to after Week-8 (19.29 ± 2.58); P < .001). Conclusion Thus far, completion of MIM sessions has shown acute and long-term effects on self-reported RR, but more research is required to determine the extent of improved parasympathetic (relaxed) states. Collectively, this work has shown value for mind-body stress mitigation and resiliency-building in high stress acute health care environments.
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Affiliation(s)
- Justin J. Merrigan
- Human Performance Collaborative, Office of Research, The Ohio State University, Columbus, OH, USA
| | - Catherine Quatman-Yates
- School of Health and Rehabilitation Sciences, Division of Physical Therapy, The Ohio State University, Columbus, OH, USA
| | - Jacqueline Caputo
- School of Health and Rehabilitation Sciences, Division of Physical Therapy, The Ohio State University, Columbus, OH, USA
| | - Kayla Daniel
- Center for Integrative Health, Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Nadia Briones
- Center for Integrative Health, Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Ilayda Sen
- Center for Integrative Health, Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Slate Bretz
- Center for Integrative Health, Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Anne-Marie Duchemin
- Stress, Trauma and Resilience Program, Department of Psychiatry, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Beth Steinberg
- Center for Integrative Health, Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA
- Gabbe Health and Wellbeing, The Ohio State University Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Joshua A. Hagen
- Human Performance Collaborative, Office of Research, The Ohio State University, Columbus, OH, USA
- Department of Integrated Systems Engineering, The Ohio State University, Columbus, OH, USA
| | - Maryanna Klatt
- Center for Integrative Health, Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA
- Gabbe Health and Wellbeing, The Ohio State University Wexner Medical Center, The Ohio State University, Columbus, OH, USA
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Wallman-Jones A, Palser ER, Benzing V, Schmidt M. Acute physical-activity related increases in interoceptive ability are not enhanced with simultaneous interoceptive attention. Sci Rep 2022; 12:15054. [PMID: 36064565 PMCID: PMC9445090 DOI: 10.1038/s41598-022-19235-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/25/2022] [Indexed: 01/23/2023] Open
Abstract
Interoception, the sense of the internal body, is proposed to support self-regulation, and consequently influence mental health. Researchers have therefore shown interest in improving the ability to accurately monitor internal signals (i.e., interoceptive accuracy, IAcc). Research suggests that cardiac IAcc is modifiable by both manipulations of interoceptive attention (guided attention towards the internal body), and interoceptive exposure (strategically inducing somatic signals e.g., via physical activity). Whilst successful in isolation, it is unclear whether a combined approach (i.e., directing attention towards the internal body when signals are more salient) could elicit greater benefits. In a 2 × 2 within-subject design, 48 healthy adults (Mage = 25.98 ± 4.73 years, 50% female) completed four 20-min conditions varying in both attentional focus (interoceptive vs exteroceptive) and physical activity (active vs rest), with cardiac IAcc measured immediately after. Results revealed a main effect for physical activity (p < 0.001), however, there was no effect for attentional focus (p = 0.397), and no interaction effect (p = 0.797). Differential analyses showed that a higher sporting background increased sensitivity to physical activity-related increases in cardiac IAcc (p = 0.031). Findings indicate that (irrespective of attentional focus) moderate-vigorous physical activity-based interventions have the potential to increase cardiac IAcc, with certain individuals potentially benefiting more.
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Affiliation(s)
- A Wallman-Jones
- Institute of Sport Science, University of Bern, 145 Bremgartenstrasse, 3012, Bern, Switzerland.
| | - E R Palser
- Department of Neurology, University of California, San Francisco, CA, 94158, USA
| | - V Benzing
- Institute of Sport Science, University of Bern, 145 Bremgartenstrasse, 3012, Bern, Switzerland
| | - M Schmidt
- Institute of Sport Science, University of Bern, 145 Bremgartenstrasse, 3012, Bern, Switzerland
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Biological markers in clinical psychological research - A systematic framework applied to HPA axis regulation in PTSD. COMPREHENSIVE PSYCHONEUROENDOCRINOLOGY 2022; 11:100148. [PMID: 35967927 PMCID: PMC9363642 DOI: 10.1016/j.cpnec.2022.100148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/17/2022] [Accepted: 06/07/2022] [Indexed: 11/21/2022] Open
Abstract
Biological markers, particularly endocrine measurements, are increasingly being integrated into clinical psychological research. We introduce a systematic framework that classifies different functions of such biomarkers. The framework distinguishes between diagnostic biomarkers which add a biological perspective to conventional clinical assessments, prognostic biomarkers that inform about an individual’s risk to develop or maintain a mental health disorder, and intervention-related biomarkers. Regarding interventions, including prevention and treatment, it further distinguishes between prescriptive biomarkers which predict an individual’s response to an intervention, outcome biomarkers which evaluate intervention-related changes on a biological level and indicators of change mechanisms. We demonstrate how to apply the framework by exemplarily classifying and describing previously published systematic reviews and primary empirical studies on endogenous, peripheral cortisol concentrations as a biomarker for posttraumatic stress disorder (PTSD). The evidence on cortisol’s diagnostic and prognostic value is heterogeneous and still sparse regarding parameters based on multiple cortisol measurements, such as the cortisol awakening response. With regard to interventions, most research focused on trauma-focused psychotherapy and cortisol reactivity to trauma reminders. This field of research appears to be growing and very promising due to its potential to optimize PTSD-related interventions. The proposed framework can help in gaining a systematic overview of existing research. It can assist in structuring, comparing, summarizing and evaluating empirical studies, and in identifying research gaps. Iagnostic biomarkers can inform about biological alterations in mental disorders. Prognostic biomarkers can help to predict the development of a mental disorder. Biomarkers can indicate the outcome, differential effects, or mechanisms of change of clinical psychological interventions.
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Gan R, Zhang L, Chen S. The effects of body scan meditation: A systematic review and meta-analysis. Appl Psychol Health Well Being 2022; 14:1062-1080. [PMID: 35538557 DOI: 10.1111/aphw.12366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022]
Abstract
Standardized mindfulness-based stress reduction (MBSR) has been proved to be effective across many populations while the time commitment for the standardized intervention leads to high attrition rate. To address the problem, there has been a growing interest in conducting a single component of MBSR such as body scan. However, the impact of a sole mindfulness-based intervention (MBI) remains unclear. The aim of this study was to investigate the effects of body scan meditation. A search of databases, including PubMed, Embase, EBSCO, Cochrance, Proquest Dissertations, and Theses, was conducted for randomized controlled trials with no population restriction. Fourteen independent articles were identified and outcomes were divided into seven categories. A meta-analysis with robust variance estimation was conducted separately for different outcome categories. Body scan only had small effect on mindfulness when compared with passive control (Hedge's g = .268, 95% CI = [0.032, 0.504], p < .05). The attrition rate of long-term interventions was low. The quality of these studies was low. There was high heterogeneity across studies. A sole body scan meditation is not effective enough to improve health-related outcomes.
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Affiliation(s)
- Ruochen Gan
- Department of Psychology and Behavioral Sciences, Zhejiang University, Hangzhou, Zhejiang, China
| | - Liuyi Zhang
- Department of Psychology and Behavioral Sciences, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shulin Chen
- Department of Psychology and Behavioral Sciences, Zhejiang University, Hangzhou, Zhejiang, China
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Chan SHW, Lui D, Chan H, Sum K, Cheung A, Yip H, Yu CH. Effects of mindfulness-based intervention programs on sleep among people with common mental disorders: A systematic review and meta-analysis. World J Psychiatry 2022; 12:636-650. [PMID: 35582336 PMCID: PMC9048455 DOI: 10.5498/wjp.v12.i4.636] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/24/2021] [Accepted: 03/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sleep problems are particularly prevalent in people with depression or anxiety disorder. Although mindfulness has been suggested as an important component in alleviating insomnia, no comprehensive review and meta-analysis has been conducted to evaluate the effects of different mindfulness-based intervention (MBI) programs on sleep among people with depression or anxiety disorder.
AIM To compare the effects of different MBI programs on sleep among people with depression or anxiety disorder.
METHODS Related publications in Embase, Medline, PubMed and PsycINFO databases were systematically searched from January 2010 to June 2020 for randomised controlled trials. Data were synthesized using a random-effects or a fixed-effects model to analyse the effects of various MBI programs on sleep problems among people with depression or anxiety disorder. The fixed-effects model was used when heterogeneity was negligible, and the random-effects model was used when heterogeneity was significant to calculate the standardised mean differences (SMDs) and 95% confidence intervals (CIs).
RESULTS We identified 397 articles, of which 10 randomised controlled trials, involving a total of 541 participants, were included in the meta-analysis. Studies of internet mindfulness meditation intervention (IMMI), mindfulness meditation (MM), mindfulness-based cognitive therapy (MBCT), mindfulness-based stress reduction (MBSR) and mindfulness-based touch therapy (MBTT) met the inclusion criteria. The greatest effect sizes are reported in favour of MBTT, with SMDs of -1.138 (95%CI: -1.937 to -0.340; P = 0.005), followed by -1.003 (95%CI: -1.645 to -0.360; P = 0.002) for MBCT. SMDs of -0.618 (95%CI: -0.980 to -0.257; P = 0.001) and -0.551 (95%CI: -0.842 to -0.260; P < 0.0001) were reported for IMMI and MBSR in the pooling trials, respectively. Significant effects on sleep problem improvement are shown in all reviewed MBI programs, except MM, for which the effect size was shown to be non-significant.
CONCLUSION All MBI programs (MBTT, MBCT, IMMI and MBSR), except MM, are effective options to improve sleep problems among people with depression or anxiety disorder.
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Affiliation(s)
- Sunny Ho-Wan Chan
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
| | - Danielle Lui
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
| | - Hazel Chan
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
| | - Kelly Sum
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
| | - Ava Cheung
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
| | - Hayley Yip
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
| | - Chong Ho Yu
- School of Behavioral and Applied Science, Azusa Pacific University, Azusa, CA 91702, United States
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Reed DE, Bokhour BG, Gaj L, Barker AM, Douglas JH, DeFaccio R, Williams RM, Engel CC, Zeliadt SB. Whole Health Use and Interest Across Veterans With Co-Occurring Chronic Pain and PTSD: An Examination of the 18 VA Medical Center Flagship Sites. Glob Adv Health Med 2022; 11:21649561211065374. [PMID: 35174004 PMCID: PMC8841911 DOI: 10.1177/21649561211065374] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/19/2021] [Indexed: 12/16/2022] Open
Abstract
Objective Veterans Healthcare Administration (VHA) conducted a large demonstration project of a holistic Whole Health approach to care in 18 medical centers, which included making complementary and integrative health (CIH) therapies more widely available. This evaluation examines patterns of service use among Veterans with chronic pain, comparing those with and without PTSD. Methods We assessed the use of Whole Health services in a cohort of Veterans with co-occurring chronic pain and PTSD (n = 1698; 28.9%), comparing them to Veterans with chronic musculoskeletal pain only (n = 4170; 71.1%). Data was gathered from VA electronic medical records and survey self-report. Whole Health services were divided into Core Whole Health services (e.g., Whole Health coaching) and CIH services (e.g., yoga). Logistic regression was used to determine whether Veterans with co-occurring chronic pain and PTSD utilized more Whole Health services compared to Veterans with chronic pain but without PTSD. Results A total of 40.1% of Veterans with chronic pain and PTSD utilized Core Whole Health services and 53.2% utilized CIH therapies, compared to 28.3% and 40.0%, respectively, for Veterans with only chronic pain. Adjusting for demographics and additional comorbidities, Veterans with comorbid chronic pain and PTSD were 1.24 ( 95% CI: 1.12, 1.35, P ≤ .001) times more likely than Veterans with chronic pain only to use Core Whole Health services, and 1.23 ( 95% CI: 1.14, 1.31, P ≤ .001) times more likely to use CIH therapies. Survey results also showed high interest levels in Core Whole Health services and CIH therapies among Veterans who were not already using these services. Conclusion Early implementation efforts in VHA led to high rates of use of Core Whole Health and CIH therapy use among Veterans with co-occurring chronic pain and PTSD. Future assessments should examine how well these additional services are meeting the needs of Veterans in both groups.
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Affiliation(s)
- David E. Reed
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
| | - Barbara G. Bokhour
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Boston, MA, United States
| | - Lauren Gaj
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States
| | - Anna M. Barker
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States
| | - Jamie H. Douglas
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
| | - Rian DeFaccio
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
| | - Rhonda M. Williams
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | - Charles C. Engel
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Steven B. Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
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14
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A survey of brain network analysis by electroencephalographic signals. Cogn Neurodyn 2022; 16:17-41. [PMID: 35126769 PMCID: PMC8807775 DOI: 10.1007/s11571-021-09689-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/25/2021] [Accepted: 05/31/2021] [Indexed: 02/03/2023] Open
Abstract
Brain network analysis is one efficient tool in exploring human brain diseases and can differentiate the alterations from comparative networks. The alterations account for time, mental states, tasks, individuals, and so forth. Furthermore, the changes determine the segregation and integration of functional networks that lead to network reorganization (or reconfiguration) to extend the neuroplasticity of the brain. Exploring related brain networks should be of interest that may provide roadmaps for brain research and clinical diagnosis. Recent electroencephalogram (EEG) studies have revealed the secrets of the brain networks and diseases (or disorders) within and between subjects and have provided instructive and promising suggestions and methods. This review summarized the corresponding algorithms that had been used to construct functional or effective networks on the scalp and cerebral cortex. We reviewed EEG network analysis that unveils more cognitive functions and neural disorders of the human and then explored the relationship between brain science and artificial intelligence which may fuel each other to accelerate their advances, and also discussed some innovations and future challenges in the end.
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15
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Levis M, Ludmer DJ, Cornelius S, Scott R, Watts BV, Shiner B. An implementation and effectiveness study evaluating Conflict Analysis in VA residential substance abuse services: Whole Health informed self-guided online care. Explore (NY) 2022; 18:688-697. [DOI: 10.1016/j.explore.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022]
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16
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Kim DY, Hong SH, Jang SH, Park SH, Noh JH, Seok JM, Jo HJ, Son CG, Lee EJ. Systematic Review for the Medical Applications of Meditation in Randomized Controlled Trials. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031244. [PMID: 35162267 PMCID: PMC8834867 DOI: 10.3390/ijerph19031244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/04/2022] [Accepted: 01/21/2022] [Indexed: 11/23/2022]
Abstract
Background: Meditation has been increasingly adapted for healthy populations and participants with diseases. Its beneficial effects are still challenging to determine due to the heterogeneity and methodological obstacles regarding medical applications. This study aimed to integrate the features of therapeutic meditation in randomized controlled trials (RCTs). Methods: We conducted a systematic review of RCTs with meditation for populations with diseases using the PubMed database through June 2021. We analyzed the characteristics of the diseases/disorders, participants, measurements, and their overall benefits. Results: Among a total of 4855 references, 104 RCTs were determined and mainly applied mindfulness-based (51 RCTs), yoga-based (32 RCTs), and transcendental meditation (14 RCTs) to 10,139 patient-participants. These RCTs were conducted for participants with a total of 45 kinds of disorders; the most frequent being cancer, followed by musculoskeletal and connective tissue diseases and affective mood disorder. Seven symptoms or signs were frequently assessed: depressive mood, feeling anxious, quality of life, stress, sleep, pain, and fatigue. The RCTs showed a higher ratio of positive outcomes for sleep (73.9%) and fatigue (68.4%). Conclusions: This systematic review produced the comprehensive features of RCTs for therapeutic meditation. These results will help physicians and researchers further study clinical adaptations in the future as reference data.
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Affiliation(s)
- Do-Young Kim
- Korean Medical College, Daejeon University, 62, Daehak-ro, Dong-gu, Daejeon 34520, Korea; (D.-Y.K.); (S.-H.H.); (S.-H.J.); (S.-H.P.); (J.-H.N.); (J.-M.S.); (H.-J.J.)
| | - Soo-Hwa Hong
- Korean Medical College, Daejeon University, 62, Daehak-ro, Dong-gu, Daejeon 34520, Korea; (D.-Y.K.); (S.-H.H.); (S.-H.J.); (S.-H.P.); (J.-H.N.); (J.-M.S.); (H.-J.J.)
| | - Seung-Hyeon Jang
- Korean Medical College, Daejeon University, 62, Daehak-ro, Dong-gu, Daejeon 34520, Korea; (D.-Y.K.); (S.-H.H.); (S.-H.J.); (S.-H.P.); (J.-H.N.); (J.-M.S.); (H.-J.J.)
| | - So-Hyeon Park
- Korean Medical College, Daejeon University, 62, Daehak-ro, Dong-gu, Daejeon 34520, Korea; (D.-Y.K.); (S.-H.H.); (S.-H.J.); (S.-H.P.); (J.-H.N.); (J.-M.S.); (H.-J.J.)
| | - Jung-Hee Noh
- Korean Medical College, Daejeon University, 62, Daehak-ro, Dong-gu, Daejeon 34520, Korea; (D.-Y.K.); (S.-H.H.); (S.-H.J.); (S.-H.P.); (J.-H.N.); (J.-M.S.); (H.-J.J.)
| | - Jung-Mi Seok
- Korean Medical College, Daejeon University, 62, Daehak-ro, Dong-gu, Daejeon 34520, Korea; (D.-Y.K.); (S.-H.H.); (S.-H.J.); (S.-H.P.); (J.-H.N.); (J.-M.S.); (H.-J.J.)
| | - Hyun-Jeong Jo
- Korean Medical College, Daejeon University, 62, Daehak-ro, Dong-gu, Daejeon 34520, Korea; (D.-Y.K.); (S.-H.H.); (S.-H.J.); (S.-H.P.); (J.-H.N.); (J.-M.S.); (H.-J.J.)
| | - Chang-Gue Son
- Department of Liver and Immunology Research Center, Daejeon Oriental Hospital of Daejeon University, 75, Daedeok-daero 176, Seo-gu, Daejeon 35235, Korea
- Correspondence: (C.-G.S.); (E.-J.L.)
| | - Eun-Jung Lee
- Department of Korean Rehabilitation Medicine, Daejeon Oriental Hospital of Daejeon University, 75, Daedeok-daero 176, Seo-gu, Daejeon 35235, Korea
- Correspondence: (C.-G.S.); (E.-J.L.)
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Mindfulness-Based Strategies for Improving Sleep in People with Psychiatric Disorders. Curr Psychiatry Rep 2022; 24:645-660. [PMID: 36227451 PMCID: PMC9633492 DOI: 10.1007/s11920-022-01370-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 01/29/2023]
Abstract
PURPOSE OF THE REVIEW To review the recent literature on mindfulness-based strategies for improving self-report and objective measures of sleep, in individuals with psychiatric disorders. RECENT FINDINGS Currently, research provides some support for the use of mindfulness-based interventions to improve sleep amongst individuals with psychiatric comorbidities. The strongest evidence was for the use of standardized programs, particularly for improving sleep in anxiety and depressive disorders. There is a paucity of well-controlled studies using validated subjective or objective measures of sleep. As these interventions were not specifically designed to target sleep, observed improvements may be an indirect consequence of reduced psychiatric symptoms. There is insufficient research into the application of mindfulness-based strategies to improve sleep or treat sleep disorders in people with psychiatric disorders. Well-controlled studies using standardized, mindfulness-based interventions developed to target sleep, such as mindfulness-based therapy for insomnia, may optimize the potential benefits of mindfulness for sleep in psychiatric populations.
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Kaplan J, Somohano V, Eddy A, Oken B, Wahbeh H. Mindful nonreactivity moderates the relationship between posttraumatic stress disorder and depression. JOURNAL OF LOSS & TRAUMA 2022; 27:593-607. [PMID: 36618880 PMCID: PMC9815478 DOI: 10.1080/15325024.2022.2030019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PTSD and depression represent major individual and societal burdens. Depression is commonly comorbid with PTSD among veterans, although buffers of this relationship are unclear. We evaluated whether facets of mindfulness moderated the relationship between PTSD and depression in veterans with PTSD (N = 70). Three facets - nonjudging, acting with awareness, and nonreactivity - were assessed as moderators. Results indicated nonreactivity significantly attenuated the relationship between PTSD and depression (p=.013), such that veterans with high nonreactivity (+1 SD) showed a nonsignificant relationship between PTSD and depression, whereas veterans with average (Mean; p<.001) and low (-1 SD; p<.001) nonreactivity exhibited a significant relationship.
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Affiliation(s)
- Josh Kaplan
- Department of Neurology, Oregon Health & Science University,Department of Neurology, Oregon Health & Science University, 3250 SW Sam Jackson Park Road, Portland, OR 97239,
| | - Vanessa Somohano
- Mental Health and Neuroscience Division, VA Portland Healthcare System
| | - Ashley Eddy
- School of Graduate Psychology, Pacific University
| | - Barry Oken
- Department of Neurology, Oregon Health & Science University
| | - Helané Wahbeh
- Department of Neurology, Oregon Health & Science University,Research, Institute of Noetic Sciences
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19
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Raz S, Lahad M. Physiological indicators of emotional arousal related to ANS activity in response to associative cards for psychotherapeutic PTSD treatment. Front Psychiatry 2022; 13:933692. [PMID: 36419970 PMCID: PMC9676269 DOI: 10.3389/fpsyt.2022.933692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
SEE FAR CBT is an integrative treatment protocol for PTSD and anxiety disorders which combines CBT, body-mind (somatic experience) and imagery-based (fantastic reality; FR) methods. FR is introduced using associative therapeutic cards (COPE cards) to represent both "a pleasant/safe place" and the re-narrating process of the traumatic story. Although some preliminary evidence exists regarding the impact of COPE cards integration in psychotherapy, further validation is needed as to whether these cards can induce distinct arousal-affective states in the observer. The aim of this study was to examine whether exposure to COPE cards evoke different emotional-psychophysiological states using objective physiological measures reflecting autonomic nervous system responses; hence, to further validate its use as a potentially effective tool within the context of SEE FAR CBT therapeutic process. Ninety-five healthy under-graduate participants were first exposed to high-arousal, negatively-valenced cards and asked to put themselves in a state of emotional/physical arousal. Afterwards, they were exposed to low-arousal, positively-valenced cards and were asked to try to calm and relax to the best of their ability. Heart rate, blood pressure and heart rate variability (HRV) were measured at baseline, at the arousal phase and finally at the relaxation phase. It was found that exposure to arousing negative cards resulted in significant increase in blood pressure and a decrease in HRV, while exposure to relaxing positive cards resulted in significant decrease in blood pressure and an increase in HRV. These findings support the efficacy and utility of associative COPE cards in affecting psychophysiological arousal.
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Affiliation(s)
- Sivan Raz
- Department of Psychology, Tel-Hai College, Upper Galilee, Israel.,Department of Behavioral Sciences, Max Stern Yezreel Valley College, Emek Yezreel, Israel
| | - Mooli Lahad
- Department of Psychology, Tel-Hai College, Upper Galilee, Israel
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Poli A, Gemignani A, Soldani F, Miccoli M. A Systematic Review of a Polyvagal Perspective on Embodied Contemplative Practices as Promoters of Cardiorespiratory Coupling and Traumatic Stress Recovery for PTSD and OCD: Research Methodologies and State of the Art. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11778. [PMID: 34831534 PMCID: PMC8619958 DOI: 10.3390/ijerph182211778] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 12/12/2022]
Abstract
Baseline respiratory sinus arrhythmia (RSA) has been proposed as a transdiagnostic biomarker of stress vulnerability across psychopathologies, and a reliable association between PTSD, OCD and lower resting RSA was found. Contemplative practices have been linked to the activation of the vagus as well as to an increased RSA that, according to the polyvagal theory, reflects the activation of the ventral vagal complex (VVC) and may promote PTSD and OCD recovery. PubMed and Scopus databases were selected to conduct a search following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines, and A MeaSurement Tool to Assess systematic Reviews-2 (AMSTAR-2) was used to appraise the methodological quality for this systematic review. Six articles met the inclusion criteria (one cross-sectional study, one study with pre-post measurements, two cohort studies and two RCT studies). Mindfulness-related interventions promoted parasympathetic activity, an increased vagal tone and improvements in PTSD and OCD symptoms. According to the polyvagal theory, mindfulness-related and compassion-related meditations would be conceptualized as neural exercises expanding the capacity of the ventral vagal complex to regulate the present state and to promote resilience. Clinical and methodological issues are discussed.
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Affiliation(s)
- Andrea Poli
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Angelo Gemignani
- Department of Surgical, Medical and Molecular Pathology and of Critical Care Medicine, University of Pisa, 56126 Pisa, Italy;
| | | | - Mario Miccoli
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
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Maher AR, Apaydin EA, Hilton L, Chen C, Troxel W, Hall O, Azhar G, Larkin J, Motala A, Hempel S. Sleep management in posttraumatic stress disorder: a systematic review and meta-analysis. Sleep Med 2021; 87:203-219. [PMID: 34634573 DOI: 10.1016/j.sleep.2021.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 08/04/2021] [Accepted: 08/12/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Post-traumatic stress disorder (PTSD) can lead to many negative secondary outcomes for patients, including sleep disturbances. The objective of this meta-analysis is (1) to evaluate the effect of interventions for adults with PTSD on sleep outcomes, PTSD outcomes, and adverse events, and (2) to evaluate the differential effectiveness of interventions aiming to improve sleep compared to those that do not. METHODS Nine databases were searched for relevant randomized controlled trials (RCTs) in PTSD from January 1980 to October 2019. Two independent reviewers screened 7176 records, assessed 2139 full-text articles, and included 89 studies in 155 publications for this review. Sleep, PTSD, and adverse event outcomes were abstracted and meta-analyses were performed using the Hartung-Knapp-Sidik-Jonkman method for random effects. RESULTS Interventions improved sleep outcomes (standardized mean difference [SMD] -0.56; confidence interval [CI] -0.75 to -0.37; 49 RCTs) and PTSD symptoms (SMD -0.48; CI -0.67 to -0.29; 44 RCTs) across studies. Adverse events were not related to interventions overall (RR 1.17; CI 0.91 to 1.49; 15 RCTs). Interventions targeting sleep improved sleep outcomes more than interventions that did not target sleep (p = 0.03). Improvement in PTSD symptoms did not differ between intervention types. CONCLUSIONS Interventions for patients with PTSD significantly improve sleep outcomes, especially interventions that specifically target sleep. Treatments for adults with PTSD directed towards sleep improvement may benefit patients who suffer from both ailments.
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Affiliation(s)
- Alicia Ruelaz Maher
- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA
| | - Eric A Apaydin
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA; Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Lara Hilton
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA; Center for Work & Family Life, University of Southern California, Los Angeles, CA, USA
| | - Christine Chen
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA
| | - Wendy Troxel
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Pittsburgh, PA, USA; Department of Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Owen Hall
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA
| | - Gulrez Azhar
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jody Larkin
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Pittsburgh, PA, USA
| | - Aneesa Motala
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA; Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Susanne Hempel
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA; Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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22
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The Impact of Mindfulness Meditation on the Wandering Mind: a Systematic Review. Neurosci Biobehav Rev 2021; 131:313-330. [PMID: 34560133 DOI: 10.1016/j.neubiorev.2021.09.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/14/2021] [Accepted: 09/19/2021] [Indexed: 01/02/2023]
Abstract
Through the practice of Mindfulness Meditation (MM), meditators become familiar with the observation of ongoing spontaneous thoughts, while maintaining an attitude of openness and equanimity. The aim of this systematic review is to present a synthesis of available findings of the short and long-term effects of MM on mind wandering (MW). We included studies that considered both first-person and behavioral/physiological measures of MW. The search resulted in 2035 papers, 24 of which were eligible. Reviewed studies revealed a high heterogeneity in designs, outcome measures and interventions. Most of the pre-post intervention studies showed that a protracted practice of MM (at least 2 weeks) reduced MW, limiting its negative effects on different cognitive tasks. Cross-sectional studies highlighted differences between expert meditators and naïve individuals: meditators self-reported less MW and showed decreased Default Mode Network activity, during meditation and resting-state. Further studies are needed to replicate available findings and to more deeply explore how MW is influenced by meditation, also considering its qualitative characteristics that remain largely unexplored.
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Trombka M, Creedon TB, Demarzo M, Cuoco LT, Smith L, Oxnard AC, Rozembaque AT, Hirayama MS, Moreno NB, Comeau A, Gawande R, Griswold T, Cook BL, Rocha NS, Schuman-Olivier Z. Mindfulness Training for Primary Care for Portuguese-Speaking Immigrants: A Pilot Study. Front Psychiatry 2021; 12:664381. [PMID: 34566708 PMCID: PMC8458702 DOI: 10.3389/fpsyt.2021.664381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Portuguese-speaking immigrants are a growing underserved population in the Unites States who experience high levels of psychological distress and increased vulnerability to mental health disorders such as depression and anxiety. Current evidence shows that mindfulness-based interventions (MBIs) are effective to promote physical and mental health among educated English speakers; nonetheless, the lack of diversity in the mindfulness literature is a considerable limitation. To our knowledge, the feasibility and acceptability of MBIs among Portuguese-speaking immigrants have not yet been investigated. Methods: This single-arm pilot study (N = 30) explored the feasibility, acceptability, and cultural aspects of Mindfulness Training for Primary Care (MTPC)-Portuguese among Portuguese-speaking immigrants in the Boston area. MTPC is an 8-week, primary care-adapted, referral-based, insurance-reimbursable, trauma-informed MBI that is fully integrated into a healthcare system. The study also examined intervention preliminary effectiveness on mental health outcomes (depression and anxiety symptoms) and self-regulation (emotional regulation, mindfulness, self-compassion, interoceptive awareness), and initiation of health behavior was explored. Results: Primary care providers referred 129 patients from 2018 to 2020. Main DSM-5 primary diagnoses were depression (76.3%) and anxiety disorders (6.7%). Participants (N = 30) attended a mean of 6.1 (SD 1.92) sessions and reported a mean of 213.7 (SD = 124.3) min of practice per week. All survey finishers would recommend the program to a friend, found the program helpful, and rated the overall program as "very good" or "excellent," and 93% would participate again, with satisfaction mean scores between 4.6 and 5 (Likert scale 0-5). Participants and group leaders provided feedback to refine MTPC-Portuguese culturally responsiveness regarding materials language, settings, time, food, and community building. Patients exhibited reductions in depression (d = 0.67; p < 0.001) and anxiety (d = 0.48; p = 0.011) symptoms, as well as enhanced emotional regulation (d = 0.45; p = 0.009), and among survey finishers, 50% initiated health behavior change through action plan initiation. Conclusion: This pilot study suggests that MTPC-Portuguese is feasible, acceptable, and culturally appropriate among Portuguese-speaking patients in the Boston area. Furthermore, the intervention might potentially decrease depression and anxiety symptoms, facilitate health behavior change, and improve emotional regulation. MTPC-Portuguese investigation with larger samples in controlled studies is warranted to support its dissemination and implementation in the healthcare system. Clinical Trial Registration: Identifier: NCT04268355.
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Affiliation(s)
- Marcelo Trombka
- Postgraduate Program in Psychiatry and Behavioral Sciences, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Department of Psychiatry–Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Innovations and Interventions for Quality of Life Research Group, Porto Alegre, Brazil
- Clinical Research Center–Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Timothy B. Creedon
- Cambridge Health Alliance, Health Equity Research Lab, Cambridge, MA, United States
| | - Marcelo Demarzo
- Department of Preventive Medicine, Mente Aberta–Brazilian Center for Mindfulness and Health Promotion, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Letícia T. Cuoco
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
| | - Lydia Smith
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
| | - Alexandra C. Oxnard
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
| | - Alana T. Rozembaque
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
| | - Marcio S. Hirayama
- Mente Aberta—Brazilian Center for Mindfulness and Health Promotion, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Natalia B. Moreno
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
| | - Alexandra Comeau
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
| | - Richa Gawande
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Todd Griswold
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Benjamin L. Cook
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
- Cambridge Health Alliance, Health Equity Research Lab, Cambridge, MA, United States
| | - Neusa S. Rocha
- Postgraduate Program in Psychiatry and Behavioral Sciences, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Department of Psychiatry–Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Innovations and Interventions for Quality of Life Research Group, Porto Alegre, Brazil
- Clinical Research Center–Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Zev Schuman-Olivier
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
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Sun LN, Gu JW, Huang LJ, Shang ZL, Zhou YG, Wu LL, Jia YP, Liu NQ, Liu WZ. Military-related posttraumatic stress disorder and mindfulness meditation: A systematic review and meta-analysis. Chin J Traumatol 2021; 24:221-230. [PMID: 34099359 PMCID: PMC8344114 DOI: 10.1016/j.cjtee.2021.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/13/2021] [Accepted: 05/06/2021] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Posttraumatic stress disorder (PTSD) is a significant global mental health concern, especially in the military. This study aims to estimate the efficacy of mindfulness meditation in the treatment of military-related PTSD, by synthesizing evidences from randomized controlled trials. METHODS Five electronic databases (Pubmed, EBSCO Medline, Embase, PsychINFO and Cochrane Library) were searched for randomized controlled trials focusing on the treatment effect of mindfulness meditation on military-related PTSD. The selection of eligible studies was based on identical inclusion and exclusion criteria. Information about study characteristics, participant characteristics, intervention details, PTSD outcomes, as well as potential adverse effects was extracted from the included studies. Risk of bias of all the included studies was critically assessed using the Cochrane Collaboration's tool. R Statistical software was performed for data analysis. RESULTS A total of 1902 records were initially identified and screened. After duplicates removal and title & abstract review, finally, 19 articles in English language with 1326 participants were included through strict inclusion and exclusion criteria. The results revealed that mindfulness meditation had a significantly larger effect on alleviating military-related PTSD symptoms compared with control conditions, such as treatment as usual, present-centered group therapy and PTSD health education (standardized mean difference (SMD) = -0.33; 95% CI [-0.45, -0.21]; p < 0.0001). Mindfulness interventions with different control conditions (active or non-active control, SMD = -0.33, 95% CI [-0.46, -0.19]; SMD = -0.49, 95% CI [-0.88, -0.10], respectively), formats of delivery (group-based or individual-based, SMD = -0.30, 95% CI [-0.42, -0.17], SMD = -0.49, 95% CI [-0.90, -0.08], respectively) and intervention durations (short-term or standard duration, SMD = -0.27, 95% CI [-0.46, -0.08], SMD = -0.40, 95% CI [-0.58, -0.21], respectively) were equally effective in improving military-related PTSD symptoms. CONCLUSION Findings from this meta-analysis consolidate the efficacy and feasibility of mindfulness meditation in the treatment of military-related PTSD. Further evidence with higher quality and more rigorous design is needed in the future.
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Affiliation(s)
- Lu-Na Sun
- Lab for Post-traumatic Stress Disorder, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China,The Emotion & Cognition Lab, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China
| | - Jing-Wen Gu
- The Battalion 3 of Cadet Brigade, School of Basic Medicine, Naval Medical University, Shanghai, 200433, China
| | - Li-Jun Huang
- Department of Radiology, Changshu Hospital Affiliated to Suzhou University, Changshu, 215500, Jiangsu Province, China
| | - Zhi-Lei Shang
- Lab for Post-traumatic Stress Disorder, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China,The Emotion & Cognition Lab, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China
| | - Yao-Guang Zhou
- Lab for Post-traumatic Stress Disorder, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China,The Emotion & Cognition Lab, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China
| | - Li-Li Wu
- Lab for Post-traumatic Stress Disorder, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China,The Emotion & Cognition Lab, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China
| | - Yan-Pu Jia
- Lab for Post-traumatic Stress Disorder, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China,The Emotion & Cognition Lab, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China
| | - Nian-Qi Liu
- Lab for Post-traumatic Stress Disorder, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China,The Emotion & Cognition Lab, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China
| | - Wei-Zhi Liu
- Lab for Post-traumatic Stress Disorder, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China,The Emotion & Cognition Lab, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China,Department of Radiology, Changshu Hospital Affiliated to Suzhou University, Changshu, 215500, Jiangsu Province, China,Corresponding author. Lab for Post-traumatic Stress Disorder, Faculty of Psychology and Mental Health, Naval Medical University, Shanghai, 200433, China.
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25
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Brown L, Rando AA, Eichel K, Van Dam NT, Celano CM, Huffman JC, Morris ME. The Effects of Mindfulness and Meditation on Vagally Mediated Heart Rate Variability: A Meta-Analysis. Psychosom Med 2021; 83:631-640. [PMID: 33395216 PMCID: PMC8243562 DOI: 10.1097/psy.0000000000000900] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Heart rate variability (HRV) is a marker of autonomic nervous system function associated with both physical and mental health. Many studies have suggested that mindfulness and meditation-based interventions (MBIs) are associated with improvements in HRV, but findings are mixed, and to date, no comprehensive meta-analysis has synthesized results. METHODS Systematic literature searches were conducted using PsycINFO, Embase, Medline, CINAHL, ERIC, and Scopus to identify randomized controlled trials (RCTs) investigating the effects of predominantly seated MBIs on resting-state vagally mediated HRV. Risk of bias was judged using the Cochrane Risk of Bias tool. RESULTS Nineteen RCTs met the criteria for inclusion in the meta-analysis. Random-effects meta-analysis found that MBIs were not efficacious in increasing vagally mediated resting-state HRV relative to control conditions (Hedges g = 0.38, 95% confidence interval [CI] = -0.014 to 0.77). When removing an outlier (g = 3.22), the effect size was reduced, CI narrowed, and findings remained nonsignificant (g = 0.19, 95% CI = -0.02 to 0.39). High heterogeneity in results (I2 = 89.12%) could not be explained by a priori-determined moderators including intervention duration, study setting, and control type. CONCLUSIONS There is currently insufficient evidence to indicate that MBIs lead to improvements in vagally mediated HRV over control conditions. Future large, well-designed RCTs with low risk of methodological bias could help add to the current evidence to elucidate any role MBIs might play in impacting HRV.
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Affiliation(s)
- Lydia Brown
- La Trobe University, Melbourne, VIC, Australia
- Melbourne School of Psychological sciences, University of Melbourne, Parkville, VIC, Australia
- North Eastern Rehabilitation Centre, Healthscope Hospitals, Melbourne, VIC, Australia
| | | | - Kristina Eichel
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Nicholas T. Van Dam
- Melbourne School of Psychological sciences, University of Melbourne, Parkville, VIC, Australia
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher M. Celano
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jeff C. Huffman
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Meg E. Morris
- La Trobe University, Melbourne, VIC, Australia
- North Eastern Rehabilitation Centre, Healthscope Hospitals, Melbourne, VIC, Australia
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26
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Bourassa KJ, Hendrickson RC, Reger GM, Norr AM. Posttraumatic Stress Disorder Treatment Effects on Cardiovascular Physiology: A Systematic Review and Agenda for Future Research. J Trauma Stress 2021; 34:384-393. [PMID: 33277952 PMCID: PMC8035275 DOI: 10.1002/jts.22637] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 10/01/2020] [Accepted: 10/26/2020] [Indexed: 11/06/2022]
Abstract
Posttraumatic stress disorder (PTSD) is linked to both altered physiological functioning and poorer cardiovascular health outcomes, including an increased risk for cardiovascular disease and cardiovascular-related mortality. An important question is whether interventions for PTSD might ameliorate the risk for poorer health by improving cardiovascular physiological intermediaries. To begin to characterize the literature addressing this question, we conducted a systematic review of empirical studies examining the impact of PTSD interventions on cardiovascular physiological intermediaries, including blood pressure (BP), heart rate (HR), cardiac impedance, and subclinical atherosclerosis. Outcomes included both tonic (i.e., resting) cardiovascular functioning and cardiovascular reactivity (CVR). A total of 44 studies met the inclusion criteria. There was mixed evidence regarding whether PTSD treatment improved tonic cardiovascular functioning. There was stronger evidence that PTSD treatments reduced CVR to trauma-related stressors, particularly for higher-quality studies of cognitive behavioral interventions. No studies examined cardiac impedance or subclinical atherosclerosis. The studies had a high degree of heterogeneity in the populations sampled and interventions tested. Moreover, they generally included small sample sizes and lacked control conditions. Interventions for PTSD may improve cardiovascular physiological outcomes, particularly CVR to trauma cues, although additional methodologically rigorous studies are needed. We outline changes to future research that would improve the literature regarding this important question, including the more frequent use of control groups and larger sample sizes.
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Affiliation(s)
- Kyle J. Bourassa
- VA Puget Sound Healthcare System, Seattle, Washington USA,Duke University Medical Center, Center for Aging and Human Development, Durham, North Carolina, USA
| | - Rebecca C. Hendrickson
- VISN 20 Northwest Network Mental Illness Research, Education and Clinical Center (MIRECC) Seattle, Washington USA,University of Washington School of Medicine, Department of Psychiatry Seattle, Washington, USA
| | - Greg M. Reger
- VA Puget Sound Healthcare System, Seattle, Washington USA,University of Washington School of Medicine, Department of Psychiatry Seattle, Washington, USA
| | - Aaron M. Norr
- VISN 20 Northwest Network Mental Illness Research, Education and Clinical Center (MIRECC) Seattle, Washington USA,University of Washington School of Medicine, Department of Psychiatry Seattle, Washington, USA
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27
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Leyro TM, Versella MV, Yang MJ, Brinkman HR, Hoyt DL, Lehrer P. Respiratory therapy for the treatment of anxiety: Meta-analytic review and regression. Clin Psychol Rev 2021; 84:101980. [PMID: 33540222 PMCID: PMC8302658 DOI: 10.1016/j.cpr.2021.101980] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 11/30/2020] [Accepted: 01/19/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Respiratory abnormalities are a hallmark of anxiety symptomatology and may serve as clinically useful modifiers for alleviating anxiety symptoms. However, gold-standard anxiety treatments (e.g., cognitive-behavioral interventions) often do not directly address respiratory components despite their theoretical utility and clinical accessibility. This review examined the clinical effectiveness of respiratory interventions, interventions that directly target respiration abnormalities and processes, in treating trait anxiety symptoms. METHODS The final analysis included 40 randomized controlled trials including at least one measure of trait anxiety, a respiratory-focused intervention group, and a non-respiratory control-group (active or inactive treatment). Overall effects of respiratory focused interventions were examined, as well as the effect of hypothesized moderators. RESULTS Respiratory component interventions yielded significantly greater improvements (moderate to large effect) in anxiety symptoms than controls, with the stronger effects observed in comparison to inactive, rather than active, control conditions. Significant heterogeneity in findings suggests that variability in intervention design, population, and control comparison may obfuscate interpretation of findings. CONCLUSIONS Evidence supports the clinical utility of respiratory interventions as either an independent anxiety treatment, or as an adjunct to other interventions. Clinical and research implications of findings along with recommendations for ongoing investigations in this domain are discussed.
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Affiliation(s)
- Teresa M Leyro
- Department of Psychology, Rutgers, The State University of New Jersey, United States.
| | - Mark V Versella
- Department of Psychology, Rutgers, The State University of New Jersey, United States
| | - Min-Jeong Yang
- Department of Psychology, Rutgers, The State University of New Jersey, United States; Department of Health Outcomes and Behavior, Moffitt Cancer Center, United States
| | - Hannah R Brinkman
- Department of Psychology, Rutgers, The State University of New Jersey, United States
| | - Danielle L Hoyt
- Department of Psychology, Rutgers, The State University of New Jersey, United States
| | - Paul Lehrer
- Department of Psychiatry, Rutgers Robert Wood Johnson Medical School, United States
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Kirk U, Axelsen JL. Heart rate variability is enhanced during mindfulness practice: A randomized controlled trial involving a 10-day online-based mindfulness intervention. PLoS One 2020; 15:e0243488. [PMID: 33332403 PMCID: PMC7746169 DOI: 10.1371/journal.pone.0243488] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/23/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The goal of the present study was to probe the effects of mindfulness practice in a naturalistic setting as opposed to a lab-based environment in the presence of continuous heart rate variability (HRV) measurements. The specific experimental goals were to examine the effects of a brief 10-day online-based mindfulness intervention on both chronic and acute HRV responses. METHOD We conducted a fully randomized 10-day longitudinal trial of mindfulness practice, explicitly controlling for practice effects with an active-control group (music listening) and a non-intervention control group. To assess chronic cardiovascular effects, we asked participants in the 3 groups to complete 2-day HRV pre- and post-intervention measurement sessions. Using this experimental setup enabled us to address training effects arising from mindfulness practice to assess physiological impact on daytime as well as nighttime (i.e. assessing sleep quality) on the underlying HRV response. To assess acute cardiovascular effects, we measured HRV in the 2 active intervention groups during each of the 10 daily mindfulness or music sessions. This allowed us to track the development of purported training effects arising from mindfulness practice relative to the active-control intervention in terms of changes in the HRV slope over the 10-day time-course. RESULTS Firstly, for the acute phase we found increased HRV during the daily practice sessions in both the mindfulness and active-control group indicating that both interventions were effective in decreasing acute physiological stress. Secondly, for the chronic phase we found increased HRV in both the day- and nighttime indicating increased sleep quality, specifically in the mindfulness group. CONCLUSION These results suggest causal effects in both chronic and acute phases of mindfulness practice in formerly naïve subjects and provides support for the argument that brief online-based mindfulness interventions exert positive impact on HRV.
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Affiliation(s)
- Ulrich Kirk
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- * E-mail:
| | - Johanne L. Axelsen
- Department of Psychology, University of Southern Denmark, Odense, Denmark
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Marchand WR, Sandoval K, Lackner R, Parker SC, Herrmann T, Yabko B, Velasquez T, Lewis L, Butler J. Mindfulness-based interventions for military veterans: A systematic review and analysis of the literature. Complement Ther Clin Pract 2020; 42:101274. [PMID: 33276226 DOI: 10.1016/j.ctcp.2020.101274] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/14/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND In recent years, mindfulness-based interventions (MBIs) have experienced exponential growth in terms of development, application, and research. However, few studies have examined implementation and efficacy of these interventions in particular populations, such as military Veterans. Such studies are needed as one cannot assume that the literature on MBIs implemented with the general population or other specific populations apply equally well to Veterans. This population is unique regarding professional competencies, military ethos, high degrees of medical comorbidities and barriers to treatment. The aim of this work was to review and summarize the literature over the previous five years (2014-2020) assessing the use of MBIs among military Veterans to guide clinical care and future research. METHODS Systematic literature review. RESULTS A total of 88 articles were found. Screening titles and abstracts resulted in 49 articles being excluded. The remaining 39 articles were read in full, and of these, 12 were excluded due to not fully meeting the inclusion criteria. Thus, the present review included a total of 27 articles, 3 of which used qualitative methods and 24 of which used quantitative methods. CONCLUSIONS MBIs hold promise as complementary adjunctive interventions for Veterans with PTSD and possibly other psychiatric disorders. Currently there are significant gaps in the literature that must be addressed to move the field forward. The main deficiency is, with a few exceptions, the lack of rigorous RCTs. Another major concern is the lack of generalizability to female and non-white Veterans given that the subject samples across all studies reviewed were 85% male and 76% white. At this time, MBSR, PCBMT and MBCT can be recommended as adjunctive complementary interventions for the reduction of PTSD symptoms. Research recommendations to move the field forward are provided.
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Affiliation(s)
- William R Marchand
- VISN 19 Whole Health Flagship Site Located at VA Salt Lake City Health Care System, 500 Foothill, Salt Lake City, UT, 84148, USA; University of Utah School of Medicine Department of Psychiatry, 501 Chipeta Way, Salt Lake City, UT, 84108, USA.
| | - Kristin Sandoval
- VISN 19 Whole Health Flagship Site Located at VA Salt Lake City Health Care System, 500 Foothill, Salt Lake City, UT, 84148, USA
| | - Ryan Lackner
- VISN 19 Whole Health Flagship Site Located at VA Salt Lake City Health Care System, 500 Foothill, Salt Lake City, UT, 84148, USA
| | - Suzanne C Parker
- VISN 19 Whole Health Flagship Site Located at VA Salt Lake City Health Care System, 500 Foothill, Salt Lake City, UT, 84148, USA
| | - Tracy Herrmann
- VISN 19 Whole Health Flagship Site Located at VA Salt Lake City Health Care System, 500 Foothill, Salt Lake City, UT, 84148, USA
| | - Brandon Yabko
- VISN 19 Whole Health Flagship Site Located at VA Salt Lake City Health Care System, 500 Foothill, Salt Lake City, UT, 84148, USA; University of Utah School of Medicine Department of Psychiatry, 501 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Tania Velasquez
- VISN 19 Whole Health Flagship Site Located at VA Salt Lake City Health Care System, 500 Foothill, Salt Lake City, UT, 84148, USA; Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA, Salt Lake City Health Care System, Salt Lake City, UT, 84148, USA
| | - Lacey Lewis
- VISN 19 Whole Health Flagship Site Located at VA Salt Lake City Health Care System, 500 Foothill, Salt Lake City, UT, 84148, USA
| | - Jorie Butler
- VISN 19 Whole Health Flagship Site Located at VA Salt Lake City Health Care System, 500 Foothill, Salt Lake City, UT, 84148, USA
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Yount G, Delorme A, Radin D, Carpenter L, Rachlin K, Anastasia J, Pierson M, Steele S, Mandell H, Chagnon A, Wahbeh H. Energy Medicine treatments for hand and wrist pain: A pilot study. Explore (NY) 2020; 17:11-21. [PMID: 33162335 DOI: 10.1016/j.explore.2020.10.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/30/2020] [Accepted: 10/31/2020] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The term "energy medicine" describes healing modalities that manipulate or channel purported subtle energies associated with the body. The objectives of this pilot study were to determine the feasibility of studying energy medicine for people with carpal tunnel pain and gathering relevant preliminary data. METHODS Following a prospective, within-participant design, participants were recruited to experience a 30 min treatment from one of 17 energy medicine practitioners. Of 374 adults experiencing carpal tunnel pain who were screened for the study, 190 received an energy medicine treatment. Practitioners delivered treatments at close distance, some with and some without light, stationary touch. Outcome measures were collected before, during, and immediately after the treatment, and three weeks later. The primary outcome measure was self-reported pain. Secondary subjective measures included credibility regarding energy medicine and expectancy regarding the efficacy of treatments, pain interference, sleep quality, well-being, mood, and sense of personal transformation. Physiological measures included median nerve conduction velocity, heart rate variability, heart rate synchrony (between the participant and practitioner), and expression levels of neuroinflammation-related genes. RESULTS On average, self-reported current pain scores decreased 2.0 points post-session and 1.3 points at three weeks compared to baseline values using a 0-10 point scale with 10 denoting worst pain (F(2, 565) = 3.82 p <0.000005). This effect was not influenced by the participants' level of expectancy or credibility regarding the energy medicine modality. Well-being, negative emotion, and sleep quality scores significantly improved at the follow-up visit. Multiple heart rate variability measures significantly changed reflecting increased parasympathetic activity which may indicate decreased stress. No other secondary outcome showed significant change. DISCUSSION Studying the administration of energy medicine to people with carpal tunnel pain is feasible, although requiring a documented carpal tunnel syndrome diagnosis proved to be prohibitive for recruitment. Our finding of preliminary evidence for positive effects in pain and pain-related outcomes after a single session of energy medicine warrants further controlled investigation.
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Affiliation(s)
- Garret Yount
- Institute of Noetic Sciences, 101 San Antonio Rd., Petaluma, CA 94952, United States.
| | - Arnaud Delorme
- Institute of Noetic Sciences, 101 San Antonio Rd., Petaluma, CA 94952, United States; University of California, San Diego, 9500 Gilman Dr., La Jolla, CA 92093, United States
| | - Dean Radin
- Institute of Noetic Sciences, 101 San Antonio Rd., Petaluma, CA 94952, United States
| | - Loren Carpenter
- Institute of Noetic Sciences, 101 San Antonio Rd., Petaluma, CA 94952, United States
| | - Kenneth Rachlin
- Institute of Noetic Sciences, 101 San Antonio Rd., Petaluma, CA 94952, United States
| | - Joyce Anastasia
- Institute of Noetic Sciences, 101 San Antonio Rd., Petaluma, CA 94952, United States
| | - Meredith Pierson
- Institute of Noetic Sciences, 101 San Antonio Rd., Petaluma, CA 94952, United States
| | - Sue Steele
- Institute of Noetic Sciences, 101 San Antonio Rd., Petaluma, CA 94952, United States
| | - Heather Mandell
- Institute of Noetic Sciences, 101 San Antonio Rd., Petaluma, CA 94952, United States
| | - Aimee Chagnon
- Sonoma Pain Management Clinic, 357 Perkins St, Sonoma, CA 95476, United States
| | - Helané Wahbeh
- Institute of Noetic Sciences, 101 San Antonio Rd., Petaluma, CA 94952, United States
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Gallegos AM, Heffner KL, Cerulli C, Luck P, McGuinness S, Pigeon WR. Effects of mindfulness training on posttraumatic stress symptoms from a community-based pilot clinical trial among survivors of intimate partner violence. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2020; 12:859-868. [PMID: 32969703 PMCID: PMC8052636 DOI: 10.1037/tra0000975] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objective: Exposure to intimate partner violence (IPV) is a significant public health issue associated with deleterious mental and medical health comorbidities, including posttraumatic stress disorder (PTSD). The hallmark symptoms of posttraumatic stress (PTS), even when not meeting the threshold for a diagnosis of PTSD, appear to be underpinned by poor self-regulation in multiple domains, including emotion, cognitive control, and physiological stress. Mindfulness-based stress reduction (MBSR) holds promise for treating PTS symptoms because evidence suggests it targets these domains. The current study was a pilot randomized clinical trial designed to examine changes in emotion regulation, attentional function, and physiological stress dysregulation among women IPV survivors with elevated PTS symptoms after participation in a group-based, 8-week MBSR program. Method: In total, 29 participants were randomized to receive MBSR (n = 19) or an active control (n = 10). Assessments were conducted at study entry, as well as 8 and 12 weeks later. Results: Between-group differences on primary outcomes were nonsignificant; however, when exploring within groups, statistically significant decreases in PTS symptoms, F(1.37, 16.53) = 5.19, p < .05, and emotion dysregulation, F(1.31, 14.46) = 9.36, p < .01, were observed after MBSR but not after the control intervention. Further, decreases in PTSD and emotion dysregulation were clinically significant for MBSR participants but not control participants. Conclusions: These preliminary data signal that MBSR may improve PTS symptoms and emotion regulation and suggest further study of the effectiveness of PTSD interventions guided by integrative models of MBSR mechanisms and psychophysiological models of stress regulation. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | | | | | - Patricia Luck
- Department of Medical Humanities and Bioethics, University of Rochester Medical Center
| | | | - Wilfred R Pigeon
- Department of Psychiatry, University of Rochester Medical Center
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Goldberg SB, Riordan KM, Sun S, Kearney DJ, Simpson TL. Efficacy and acceptability of mindfulness-based interventions for military veterans: A systematic review and meta-analysis. J Psychosom Res 2020; 138:110232. [PMID: 32906008 PMCID: PMC7554248 DOI: 10.1016/j.jpsychores.2020.110232] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/12/2020] [Accepted: 08/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Military veterans report high rates of psychiatric and physical health symptoms that may be amenable to mindfulness-based interventions (MBIs). Inconsistent prior findings and questions of fit between MBIs and military culture highlight the need for a systematic evaluation of this literature. OBJECTIVE To quantify the efficacy and acceptability of MBIs for military veterans. DATA SOURCES We searched five databases (MEDLINE/PubMed, CINAHL, Scopus, Web of Science, PsycINFO) from inception to October 16th, 2019. STUDY SELECTION Randomized controlled trials (RCTs) testing MBIs in military veterans. RESULTS Twenty studies (k = 16 unique comparisons, N = 898) were included. At post-treatment, MBIs were superior to non-specific controls (e.g., waitlist, attentional placebos) on measures of posttraumatic stress disorder (PTSD), depression, general psychological symptoms (i.e., aggregated across symptom domains), quality of life / functioning, and mindfulness (Hedges' gs = 0.32 to 0.80), but not physical health. At follow-up (mean length = 3.19 months), MBIs continued to outperform non-specific controls on general psychological symptoms, but not PTSD. MBIs were superior to specific active controls (i.e., other therapies) at post-treatment on measures of PTSD and general psychological symptoms (gs = 0.19 to 0.25). Participants randomized to MBIs showed higher rates of attrition than those randomized to control interventions (odds ratio = 1.98). Several models were not robust to tests of publication bias. Study quality and risk of bias assessment indicated several areas of concern. CONCLUSIONS MBIs may improve psychological symptoms and quality of life / functioning in veterans. Questionable acceptability and few high-quality studies support the need for rigorous RCTs, potentially adapted to veterans.
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Taylor J, McLean L, Korner A, Stratton E, Glozier N. Mindfulness and yoga for psychological trauma: systematic review and meta-analysis. J Trauma Dissociation 2020; 21:536-573. [PMID: 32453668 DOI: 10.1080/15299732.2020.1760167] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mindfulness-based interventions (MBIs), with postures, breath, relaxation, and meditation, such as Mindfulness-based Stress Reduction (MBSR) and yoga, are complex interventions increasingly used for trauma-related psychiatric conditions. Prior reviews have adopted a disorder-specific focus. However, trauma is a risk factor for most psychiatric conditions. We adopted a transdiagnostic approach to evaluate the efficacy of MBIs for the consequences of trauma, agnostic to diagnosis. AMED, CINAHL, Central, Embase, Pubmed/Medline, PsycINFO, and Scopus were searched to 30 September 2018 for controlled and uncontrolled trials of mindfulness, yoga, tai chi, and qi gong in people specifically selected for trauma exposure. Of >12,000 results, 66 studies were included in the systematic review and 24 controlled studies were meta-analyzed. There was a significant, pooled effect of MBIs (g = 0.51, 95%CI 0.31 to 0.71, p < .001). Similar effects were observed for mindfulness (g = 0.45, 0.26 to 0.64, p < .001), yoga (g = 0.46, 0.26 to 0.66, p < .001), and integrative exercise (g = 0.94, 0.37 to 1.51, p = .001), with no difference between interventions. Outcome measure or trauma type did not influence the effectiveness, but interventions of 8 weeks or more were more effective than shorter interventions (Q = 8.39, df = 2, p = .02). Mindfulness-based interventions, adjunctive to treatment-as-usual of medication and/or psychotherapy, are effective in reducing trauma-related symptoms. Yoga and mindfulness have comparable effectiveness. Many psychiatric studies do not report trauma exposure, focusing on disorder-specific outcomes, but this review suggests a transdiagnostic approach could be adopted in the treatment of trauma sequelae with MBIs. More rigorous reporting of trauma exposure and MBI treatment protocols is recommended to enhance future research.
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Affiliation(s)
- Jennifer Taylor
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney , Sydney, Australia.,Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney , Sydney, Australia
| | - Loyola McLean
- Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney , Sydney, Australia.,Westmead Psychotherapy Program for Complex Traumatic Disorders, Department of Psychiatry, Faculty of Medicine and Health, The University of Sydney, Cumberland Hospital , North Parramatta, Australia.,Consultant-Liaison Psychiatry, Royal North Shore Hospital , Sydney, Australia
| | - Anthony Korner
- Westmead Psychotherapy Program for Complex Traumatic Disorders, Department of Psychiatry, Faculty of Medicine and Health, The University of Sydney, Cumberland Hospital , North Parramatta, Australia
| | - Elizabeth Stratton
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney , Sydney, Australia.,Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney , Sydney, Australia
| | - Nicholas Glozier
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney , Sydney, Australia.,Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney , Sydney, Australia
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Melton H, Meader N, Dale H, Wright K, Jones-Diette J, Temple M, Shah I, Lovell K, McMillan D, Churchill R, Barbui C, Gilbody S, Coventry P. Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review. Health Technol Assess 2020; 24:1-312. [PMID: 32924926 DOI: 10.3310/hta24430] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people. OBJECTIVE To identify candidate psychological and non-pharmacological treatments for future research. DESIGN Mixed-methods systematic review. PARTICIPANTS Adults aged ≥ 18 years with a history of complex traumatic events. INTERVENTIONS Psychological interventions versus control or active control; pharmacological interventions versus placebo. MAIN OUTCOME MEASURES Post-traumatic stress disorder symptoms, common mental health problems and attrition. DATA SOURCES Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017. REVIEW METHODS Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist. RESULTS One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs. LIMITATIONS Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented. CONCLUSIONS Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder. FUTURE WORK Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities. STUDY REGISTRATION This study is registered as PROSPERO CRD42017055523. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hollie Melton
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Nick Meader
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Holly Dale
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | | | | | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Rachel Churchill
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Peter Coventry
- Centre for Reviews and Dissemination, University of York, York, UK.,Department of Health Sciences, University of York, York, UK
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35
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Herrmann T, Marchand WR, Yabko B, Lackner R, Beckstrom J, Parker A. Veterans' interests, perceptions, and use of mindfulness. SAGE Open Med 2020; 8:2050312120938226. [PMID: 32821386 PMCID: PMC7406919 DOI: 10.1177/2050312120938226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/08/2020] [Indexed: 01/01/2023] Open
Abstract
Objective: Mindfulness-based interventions are an evidence-based approach utilized in health care. There is developing evidence for effective use with military Veterans. However, little is known about Veterans’ view of mindfulness. This study aims to understand their interests, perceptions, and use of mindfulness to enhance educational outreach and treatment engagement. Methods: A cross-sectional study was conducted across the Veterans Health Administration in Salt Lake City, UT by administering a questionnaire to military Veterans. The questionnaire included the following themes: (1) demographics and respondents’ mindfulness practice; (2) respondents’ perceptions and beliefs about mindfulness; and (3) respondents’ knowledge and interest in learning about mindfulness. Results: In all, 185 military Veterans were surveyed; 30% practiced mindfulness in the past year, mainly for stress, posttraumatic stress disorder, sleep, and depression. Over 75% who practiced reported perceived benefit. Veterans rarely reported negative beliefs about mindfulness; 56% perceived an understanding of mindfulness and 46% were aware of Veterans Health Administration mindfulness offerings. In all, 55% were interested in learning about mindfulness, 58% were interested in learning how it could help, and 43% were interested in combining mindfulness with a pleasurable activity. Conclusion: Educational engagement approaches should be directed toward the benefits of mindfulness practice with minimal need to address negative beliefs. Outreach including education, with an experiential component, about mindfulness classes, availability of evening and weekend classes, individual sessions, and virtual offerings into Veteran’s homes, may enhance engagement in mindfulness-based interventions. Mindfulness-based interventions that combine mindfulness training with an experiential pleasurable activity may be one mechanism to enhance treatment engagement.
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Affiliation(s)
- Tracy Herrmann
- Whole Health Service, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Department of Nutrition and Integrative Physiology, The University of Utah, Salt Lake City, UT, USA
| | - William R Marchand
- Whole Health Service, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Department of Psychiatry, School of Medicine, The University of Utah, Salt Lake City, UT, USA
| | - Brandon Yabko
- Whole Health Service, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Department of Psychiatry, School of Medicine, The University of Utah, Salt Lake City, UT, USA
| | - Ryan Lackner
- Whole Health Service, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Julie Beckstrom
- Whole Health Service, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of Vascular Surgery, School of Medicine, The University of Utah, Salt Lake City, UT, USA
| | - Ashley Parker
- Whole Health Service, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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36
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Effect of Stress on Autonomic and Cardiovascular Systems in Military Population: A Systematic Review. Cardiol Res Pract 2020; 2020:7986249. [PMID: 32850146 PMCID: PMC7439199 DOI: 10.1155/2020/7986249] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 07/24/2020] [Indexed: 11/18/2022] Open
Abstract
Stress is regulated by the autonomous nervous system, increasing the sympathetic modulation when a threat is perceived. A multifactorial response usually leads to significant behavioural modifications and alterations on homeostasis and physical and psychological status. Moreover, stress is an emotional response that can lead to psychosocial and psychophysiological adversity. Regarding military population, military operations and combat exposure are important stressors that influence acute and chronic stress response in soldiers, affecting their performance and health. A bibliographic search was carried out between April and May 2019, focusing on recent studies (2013–2019) that analysed psychophysiological response, stress, stress regulation, heart rate, heart rate variability, and posttraumatic stress disorder in military population. Autonomic and cardiovascular chronic stress seems to be modulated by experience and previous specific training of each military unit. Physical exercise, music embedded with binaural beat technology, bidirectional sensory motor rhythm training, heart rate variability biofeedback, and transcutaneous vagal nerve stimulation are the main techniques applied to balance stress and to recover body homeostasis. Since military population are usually exposed to multiple stressors, knowing previous training and experience, together with developing techniques to balance stress, is the main practical application in this field of study to balance autonomic and cardiovascular systems.
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Psychological and pharmacological interventions for posttraumatic stress disorder and comorbid mental health problems following complex traumatic events: Systematic review and component network meta-analysis. PLoS Med 2020; 17:e1003262. [PMID: 32813696 PMCID: PMC7446790 DOI: 10.1371/journal.pmed.1003262] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Complex traumatic events associated with armed conflict, forcible displacement, childhood sexual abuse, and domestic violence are increasingly prevalent. People exposed to complex traumatic events are at risk of not only posttraumatic stress disorder (PTSD) but also other mental health comorbidities. Whereas evidence-based psychological and pharmacological treatments are effective for single-event PTSD, it is not known if people who have experienced complex traumatic events can benefit and tolerate these commonly available treatments. Furthermore, it is not known which components of psychological interventions are most effective for managing PTSD in this population. We performed a systematic review and component network meta-analysis to assess the effectiveness of psychological and pharmacological interventions for managing mental health problems in people exposed to complex traumatic events. METHODS AND FINDINGS We searched CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, International Pharmaceutical Abstracts, MEDLINE, Published International Literature on Traumatic Stress, PsycINFO, and Science Citation Index for randomised controlled trials (RCTs) and non-RCTs of psychological and pharmacological treatments for PTSD symptoms in people exposed to complex traumatic events, published up to 25 October 2019. We adopted a nondiagnostic approach and included studies of adults who have experienced complex trauma. Complex-trauma subgroups included veterans; childhood sexual abuse; war-affected; refugees; and domestic violence. The primary outcome was reduction in PTSD symptoms. Secondary outcomes were depressive and anxiety symptoms, quality of life, sleep quality, and positive and negative affect. We included 116 studies, of which 50 were conducted in hospital settings, 24 were delivered in community settings, seven were delivered in military clinics for veterans or active military personnel, five were conducted in refugee camps, four used remote delivery via web-based or telephone platforms, four were conducted in specialist trauma clinics, two were delivered in home settings, and two were delivered in primary care clinics; clinical setting was not reported in 17 studies. Ninety-four RCTs, for a total of 6,158 participants, were included in meta-analyses across the primary and secondary outcomes; 18 RCTs for a total of 933 participants were included in the component network meta-analysis. The mean age of participants in the included RCTs was 42.6 ± 9.3 years, and 42% were male. Nine non-RCTs were included. The mean age of participants in the non-RCTs was 40.6 ± 9.4 years, and 47% were male. The average length of follow-up across all included studies at posttreatment for the primary outcome was 11.5 weeks. The pairwise meta-analysis showed that psychological interventions reduce PTSD symptoms more than inactive control (k = 46; n = 3,389; standardised mean difference [SMD] = -0.82, 95% confidence interval [CI] -1.02 to -0.63) and active control (k-9; n = 662; SMD = -0.35, 95% CI -0.56 to -0.14) at posttreatment and also compared with inactive control at 6-month follow-up (k = 10; n = 738; SMD = -0.45, 95% CI -0.82 to -0.08). Psychological interventions reduced depressive symptoms (k = 31; n = 2,075; SMD = -0.87, 95% CI -1.11 to -0.63; I2 = 82.7%, p = 0.000) and anxiety (k = 15; n = 1,395; SMD = -1.03, 95% CI -1.44 to -0.61; p = 0.000) at posttreatment compared with inactive control. Sleep quality was significantly improved at posttreatment by psychological interventions compared with inactive control (k = 3; n = 111; SMD = -1.00, 95% CI -1.49 to -0.51; p = 0.245). There were no significant differences between psychological interventions and inactive control group at posttreatment for quality of life (k = 6; n = 401; SMD = 0.33, 95% CI -0.01 to 0.66; p = 0.021). Antipsychotic medicine (k = 5; n = 364; SMD = -0.45; -0.85 to -0.05; p = 0.085) and prazosin (k = 3; n = 110; SMD = -0.52; -1.03 to -0.02; p = 0.182) were effective in reducing PTSD symptoms. Phase-based psychological interventions that included skills-based strategies along with trauma-focused strategies were the most promising interventions for emotional dysregulation and interpersonal problems. Compared with pharmacological interventions, we observed that psychological interventions were associated with greater reductions in PTSD and depression symptoms and improved sleep quality. Sensitivity analysis showed that psychological interventions were acceptable with lower dropout, even in studies rated at low risk of attrition bias. Trauma-focused psychological interventions were superior to non-trauma-focused interventions across trauma subgroups for PTSD symptoms, but effects among veterans and war-affected populations were significantly reduced. The network meta-analysis showed that multicomponent interventions that included cognitive restructuring and imaginal exposure were the most effective for reducing PTSD symptoms (k = 17; n = 1,077; mean difference = -37.95, 95% CI -60.84 to -15.16). Our use of a non-diagnostic inclusion strategy may have overlooked certain complex-trauma populations with severe and enduring mental health comorbidities. Additionally, the relative contribution of skills-based intervention components was not feasibly evaluated in the network meta-analysis. CONCLUSIONS In this systematic review and meta-analysis, we observed that trauma-focused psychological interventions are effective for managing mental health problems and comorbidities in people exposed to complex trauma. Multicomponent interventions, which can include phase-based approaches, were the most effective treatment package for managing PTSD in complex trauma. Establishing optimal ways to deliver multicomponent psychological interventions for people exposed to complex traumatic events is a research and clinical priority.
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Paap KR, Anders-Jefferson R, Zimiga B, Mason L, Mikulinsky R. Interference scores have inadequate concurrent and convergent validity: Should we stop using the flanker, Simon, and spatial Stroop tasks? COGNITIVE RESEARCH-PRINCIPLES AND IMPLICATIONS 2020; 5:7. [PMID: 32056032 PMCID: PMC7018919 DOI: 10.1186/s41235-020-0207-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/03/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Two-hundred one college undergraduates completed four nonverbal interference tasks (Simon, spatial Stroop, vertical Stroop, and flanker) and trait scales of self-control and impulsivity. Regression analyses tested 11 predictors of the composite interference scores derived from three of the four tasks and each task separately. The purpose of the study was to examine the relationships between laboratory measures of self-control, self-report measures, and the degree to which control might be related to extensive experience in activities that logically require self-control. RESULTS Fluid intelligence and sex were significant predictors of the composite measure, but bilingualism, music training, video gaming, mindfulness/meditation, self-control, impulsivity, SES, and physical exercise were not. CONCLUSIONS Common laboratory measures of inhibitory control do not correlate with self-reported measures of self-control or impulsivity and consequently appear to be measuring different constructs. Bilingualism, mindfulness/meditation, playing action video games, and music training or performance provide weak and inconsistent improvements to laboratory measures of interference control. Flanker, Simon, and spatial Stroop effects should not be used or interpreted as measures of domain-general inhibitory control.
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Affiliation(s)
- Kenneth R Paap
- Department of Psychology, San Francisco State University, San Francisco, CA, 94132, USA.
| | | | - Brandon Zimiga
- Department of Psychology, San Francisco State University, San Francisco, CA, 94132, USA
| | - Lauren Mason
- Department of Psychology, San Francisco State University, San Francisco, CA, 94132, USA
| | - Roman Mikulinsky
- Department of Psychology, San Francisco State University, San Francisco, CA, 94132, USA
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Ge F, Yuan M, Li Y, Zhang W. Posttraumatic Stress Disorder and Alterations in Resting Heart Rate Variability: A Systematic Review and Meta-Analysis. Psychiatry Investig 2020; 17:9-20. [PMID: 31995968 PMCID: PMC6992856 DOI: 10.30773/pi.2019.0112] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 10/14/2019] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE The functions of both the central and peripheral autonomic nervous system, indexed by heart rate variability (HRV), are affected by psychology and physiology. This review summarizes the results of studies comparing the evaluation of HRV parameters between individuals with posttraumatic stress disorder (PTSD) and healthy controls. METHODS Eligible studies (n=499) were identified through literature searches of the EMBASE, Medline, PubMed and Web of Science databases. Nineteen studies met our inclusion criteria. A random effects model was used, and standardized mean differences for highfrequency HRV(HF-HRV), low-frequency HRV(LF-HRV) and the root mean square of successive R-R interval differences (RMSSD) were calculated. RESULTS Significant effects were found for HF-HRV [p<0.0001, Z=4.18; Hedges'g=-1.58, 95% confidence interval (CI) (-2.32, -0.84); k=14] and RMSSD [p<0.00001, Z=4.80; Hedges'g=-1.96, 95% CI (-2.76, -1.16); k=9] relative to healthy controls. Considerable heterogeneity was revealed, but the main effects for HF-HRV and RMSSD were robust in subsequent meta-regression and subgroup analyses. CONCLUSION Given the relationships among low vagal state, inflammation, and alterations in brain structure and function, including executive function and emotion regulation, reduced HRV may be regarded as an endophenotype in PTSD research.
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Affiliation(s)
- Fenfen Ge
- Mental Health Center of West China Hospital, Sichuan University, Chengdu, China
| | - Minlan Yuan
- Mental Health Center of West China Hospital, Sichuan University, Chengdu, China
| | - Ying Li
- Embedded System and Intelligent Computing Laboratory, University of Electronic Science and Technology of China, Chengdu, China
| | - Wei Zhang
- Mental Health Center of West China Hospital, Sichuan University, Chengdu, China
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Montero-Marin J, Garcia-Campayo J, Pérez-Yus MC, Zabaleta-Del-Olmo E, Cuijpers P. Meditation techniques v. relaxation therapies when treating anxiety: a meta-analytic review. Psychol Med 2019; 49:2118-2133. [PMID: 31322102 DOI: 10.1017/s0033291719001600] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
To what extent meditation techniques (which incorporate practices to regulate attention, construct individual values, or deconstruct self-related assumptions), are more or less effective than relaxation therapy in the treatment of anxiety, is not clear. The aim of this study was to examine the effectiveness of meditation compared to relaxation in reducing anxiety. A systematic review from PubMed, Embase, PsycInfo and the Cochrane Central was conducted. A meta-analysis of 14 RCTs (n = 862 participants suffering from anxiety disorders or high trait anxiety) was performed. Effect sizes (ESs) were determined by Hedges' g. Heterogeneity, risk of publication bias, quality of studies/interventions, and researcher allegiance, were evaluated. Meditation techniques incorporated attentional elements, and five of them also added constructive practices. No studies were found using deconstructive exercises. The overall ES was g = -0.23 [95% confidence interval (CI) -0.40 to -0.07], favouring meditation (number needed to treat = 7.74). Heterogeneity was low (I2 = 2; 95% CI 0 to 56). There was no evidence of publication bias, but few studies and interventions were of high quality, and allegiance might be moderating results. Meditation seems to be a bit more effective than relaxation in the treatment of anxiety, and it might also remain more effective at 12-month follow-up. However, more research using the full spectrum of meditation practices to treat different anxiety disorders, including independent studies to avoid researcher allegiance, is needed if we are to have a precise idea of the potential of these techniques compared to relaxation therapy.
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Affiliation(s)
- Jesus Montero-Marin
- Primary Care Prevention and Health Promotion Research Network (RedIAPP), Zaragoza, Spain
| | - Javier Garcia-Campayo
- Primary Care Prevention and Health Promotion Research Network (RedIAPP), Zaragoza, Spain
- Miguel Servet University Hospital, University of Zaragoza, Zaragoza, Spain
- Aragon Institute of Health Research, Zaragoza, Spain
| | - Mari Cruz Pérez-Yus
- Primary Care Prevention and Health Promotion Research Network (RedIAPP), Zaragoza, Spain
- Aragon Institute of Health Research, Zaragoza, Spain
- Department of Psychology and Sociology, University of Zaragoza, Zaragoza, Spain
| | - Edurne Zabaleta-Del-Olmo
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Pim Cuijpers
- Department of Psychology, VU University, Amsterdam, The Netherlands
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Marchand WR, Yabko B, Herrmann T, Curtis H, Lackner R. Treatment Engagement and Outcomes of Mindfulness-Based Cognitive Therapy for Veterans with Psychiatric Disorders. J Altern Complement Med 2019; 25:902-909. [PMID: 31328956 PMCID: PMC6748402 DOI: 10.1089/acm.2018.0511] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objectives: The aim of this study was to evaluate utilization and outcomes of mindfulness-based cognitive therapy (MBCT) provided to veterans with psychiatric disorders. Design: Retrospective chart review. Settings: Veterans Administration Medical Center (VAMC). Subjects: Ninety-eight veterans with psychiatric illness who were enrolled in an MBCT class between May of 2012 and January of 2016. Subjects were predominately white (95%), male (81%), and >50 years old (74%). The most common psychiatric conditions were any mood disorder (82%) and post-traumatic stress disorder (54%). Intervention: Eight-week MBCT class. Outcome measures: Session attendance and pre- to postintervention changes in numbers of emergency department (ED) visits and psychiatric hospitalizations. Results: The average number of sessions attended was 4.87 of 8 and only 16% were present for all sessions. Veteran demographic variables did not predict the number of MBCT sessions attended. However, both greater numbers of pre-MBCT ED visits (p = 0.004) and psychiatric admissions (p = 0.031) were associated with attending fewer sessions. Among patients who experienced at least one pre- or post-treatment psychiatric admission in the 2 years pre- or postintervention (N = 26, 27%), there was a significant reduction in psychiatric admissions from pre to post (p = 0.002). There was no significant change in ED visits (p = 0.535). Conclusions: MBCT may be challenging to implement for veterans with psychiatric illness in, at least some, outpatient VAMC settings due to a high attrition rate. Possible mediation approaches include development of methods to screen for high dropout risk and/or development of shorter mindfulness-based interventions (MBIs) and/or coupling MBIs with pleasurable activities. The finding of a significant decrease in psychiatric hospitalizations from pre- to post-MBCT suggests that prospective studies are warranted utilizing MBCT for veterans at high risk for psychiatric hospitalization.
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Affiliation(s)
- William R. Marchand
- Whole Health Service, VA Salt Lake City Health Care System, Salt Lake City, UT
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT
- Address correspondence to: William R. Marchand, MD, Whole Health Service, VA Salt Lake City Health Care System, VHASLC 11H, 500 Foothill, Salt Lake City, UT 84148
| | - Brandon Yabko
- Whole Health Service, VA Salt Lake City Health Care System, Salt Lake City, UT
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT
| | - Tracy Herrmann
- Whole Health Service, VA Salt Lake City Health Care System, Salt Lake City, UT
| | - Heather Curtis
- Whole Health Service, VA Salt Lake City Health Care System, Salt Lake City, UT
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT
| | - Ryan Lackner
- Whole Health Service, VA Salt Lake City Health Care System, Salt Lake City, UT
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Gawande R, Pine E, Griswold T, Creedon T, Vallejo Z, Rosenbaum E, Lozada A, Schuman-Olivier Z. Insurance-Reimbursable Mindfulness for Safety-Net Primary Care Patients: A Pilot Randomized Controlled Trial. Mindfulness (N Y) 2019; 10:1744-1759. [PMID: 32042349 DOI: 10.1007/s12671-019-01116-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objectives Mindfulness is effective for reducing anxiety and depression and increasing chronic disease self-management. An accessible, insurance-reimbursable model for implementation in patient-centered medical homes within US healthcare systems has promise for patients with multi-morbid conditions. Clarifying both the dose needed to impact anxiety, depression and self-management, and the design requirements for accessible primary care implementation, is essential. Methods We tested feasibility, acceptability, and effectiveness of Mindfulness Training for Primary Care (MTPC), an 8-week, referral-based, insurance-reimbursable mindfulness program integrated within primary care, compared with a Low-Dose Comparator (LDC), consisting of a 60-minute mindfulness introduction plus referral to community and digital resources. Outcome measures were assessed at baseline and 8 weeks. MTPC is trauma-informed, incorporates mindfulness-oriented behavior change skills, and is designed to target anxiety, depression, stress, and chronic illness selfmanagement. Participants schedule a PCP visit to co-create a self-management action plan during week 6. Results Primary care providers (PCP) referred 344 patients over 14 months. Eighty-one participants with DSM-V anxiety disorders, depressive disorders, trauma- and stress-related disorders participated in this pilot randomized-controlled comparative effectiveness trial [MTPC (n=54); LDC (n=27)]. These data suggest that MTPC was more effective than LDC for reducing anxiety (p=0.01), enhancing mindfulness (p=0.02) and self-compassion (p=0.001), and for catalyzing selfmanagement behavior change through action plan initiation (OR=4.34, p=0.03). Conclusions MTPC was successfully integrated into a health system, was billed to insurance, and was acceptable to a diverse primary care population. Replication with a larger study and further accessibility adaptations are needed to confirm and expand these pilot results.
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Affiliation(s)
- Richa Gawande
- Harvard Medical School, Department of Psychiatry.,Cambridge Health Alliance
| | | | - Todd Griswold
- Harvard Medical School, Department of Psychiatry.,Cambridge Health Alliance
| | - Timothy Creedon
- The Heller School for Social Policy and Management, Brandeis University.,IBM Watson Health
| | - Zayda Vallejo
- Cambridge Health Alliance.,The Heller School for Social Policy and Management, Brandeis University
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43
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Gawande R, To MN, Pine E, Griswold T, Creedon TB, Brunel A, Lozada A, Loucks EB, Schuman-Olivier Z. Mindfulness Training Enhances Self-Regulation and Facilitates Health Behavior Change for Primary Care Patients: a Randomized Controlled Trial. J Gen Intern Med 2019; 34:293-302. [PMID: 30511291 PMCID: PMC6374253 DOI: 10.1007/s11606-018-4739-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 06/08/2018] [Accepted: 10/26/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Self-management of health is important for improving health outcomes among primary care patients with chronic disease. Anxiety and depressive disorders are common and interfere with self-regulation, which is required for disease self-management. An insurance-reimbursable mindfulness intervention integrated within primary care may be effective for enhancing chronic disease self-management behaviors among primary care patients with anxiety, depression, trauma, and stress-related and adjustment disorders compared with the increasingly standard practice of referring patients to outside mindfulness resources. OBJECTIVE Mindfulness Training for Primary Care (MTPC) is an 8-week, referral-based, insurance-reimbursable program integrated into safety-net health system patient-centered medical homes. We hypothesized that MTPC would be more effective for catalyzing chronic disease self-management action plan initiation within 2 weeks, versus a low-dose comparator (LDC) consisting of a 60-min mindfulness introduction, referral to community and digital resources, and addition to a 6-month waitlist for MTPC. PARTICIPANTS Primary care providers (PCPs) and mental health clinicians referred 465 patients over 12 months. All participants had a DSM-V diagnosis. DESIGN AND INTERVENTIONS Participants (N = 136) were randomized in a 2:1 allocation to MTPC (n = 92) or LDC (n = 44) in a randomized controlled comparative effectiveness trial. MTPC incorporates mindfulness, self-compassion, and mindfulness-oriented behavior change skills and is delivered as insurance-reimbursable visits within primary care. Participants took part in a chronic disease self-management action planning protocol at week 7. MAIN MEASURES Level of self-reported action plan initiation on the action plan initiation survey by week 9. KEY RESULTS Participants randomized to MTPC, relative to LDC, had significantly higher adjusted odds of self-management action plan initiation in an intention-to-treat analysis (OR = 2.28; 95% CI = 1.02 to 5.06, p = 0.025). CONCLUSIONS An 8-week dose of mindfulness training is more effective than a low-dose mindfulness comparator in facilitating chronic disease self-management behavior change among primary care patients.
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Affiliation(s)
- Richa Gawande
- Department of Psychiatry, Harvard Medical School, Boston, USA
- Cambridge Health Alliance, Cambridge, USA
| | - My Ngoc To
- Cambridge Health Alliance, Cambridge, USA
| | | | - Todd Griswold
- Department of Psychiatry, Harvard Medical School, Boston, USA
- Cambridge Health Alliance, Cambridge, USA
| | - Timothy B Creedon
- The Heller School for Social Policy and Management, Brandeis University, Waltham, USA
- IBM Watson Health, Cambridge, USA
| | | | | | - Eric B Loucks
- Department of Epidemiology, Brown University School of Public Health, Providence, USA
| | - Zev Schuman-Olivier
- Department of Psychiatry, Harvard Medical School, Boston, USA.
- Cambridge Health Alliance, Cambridge, USA.
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44
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Brandmeyer T, Delorme A, Wahbeh H. The neuroscience of meditation: classification, phenomenology, correlates, and mechanisms. PROGRESS IN BRAIN RESEARCH 2019; 244:1-29. [PMID: 30732832 DOI: 10.1016/bs.pbr.2018.10.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Rising from its contemplative and spiritual traditions, the science of meditation has seen huge growth over the last 30 years. This chapter reviews the classifications, phenomenology, neural correlates, and mechanisms of meditation. Meditation classification types are still varied and largely subjective. Broader models to describe meditation practice along multidimensional parameters may improve classification in the future. Phenomenological studies are few but growing, highlighting the subjective experience and correlations to neurophysiology. Oscillatory EEG studies are not conclusive likely due to the heterogeneous nature of the meditation styles and practitioners being assessed. Neuroimaging studies find common patterns during meditation and in long-term meditators reflecting the basic similarities of meditation in general; however, mostly the patterns differ across unique meditation traditions. Research on the mechanisms of meditation, specifically attention and emotion regulation is also discussed. There is a growing body of evidence demonstrating positive benefits from meditation in some clinical populations especially for stress reduction, anxiety, depression, and pain improvement, although future research would benefit by addressing the remaining methodological and conceptual issues. Meditation research continues to grow allowing us to understand greater nuances of how meditation works and its effects.
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Affiliation(s)
- Tracy Brandmeyer
- Osher Center for Integrative Medicine, School of Medicine, University of California, San Francisco, CA, United States; Centre de Recherche Cerveau et Cognition (CerCo), Université Paul Sabatier, Toulouse, France; CNRS, UMR 5549, Toulouse, France.
| | - Arnaud Delorme
- Centre de Recherche Cerveau et Cognition (CerCo), Université Paul Sabatier, Toulouse, France; CNRS, UMR 5549, Toulouse, France; Institute of Noetic Sciences (IONS), Petaluma, CA, United States; Swartz Center for Computational Neuroscience, Institute of Neural Computation (INC), University of California, San Diego, CA, United States
| | - Helané Wahbeh
- Institute of Noetic Sciences (IONS), Petaluma, CA, United States; Oregon Health & Science University, Portland, OR, United States
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Psychotherapeutic treatment and HPA axis regulation in posttraumatic stress disorder: A systematic review and meta-analysis. Psychoneuroendocrinology 2018; 98:186-201. [PMID: 30193225 DOI: 10.1016/j.psyneuen.2018.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/29/2018] [Accepted: 08/01/2018] [Indexed: 12/20/2022]
Abstract
Posttraumatic stress disorder (PTSD) has been associated with dysregulation of the hypothalamic-pituitary- adrenal (HPA) axis. Research over the past years has investigated potential changes of these alterations in the context of psychotherapy. Yet, no systematic review has been conducted. To summarize the current state of research on psychotherapy and HPA hormones, namely cortisol, dehydroepiandrosterone and its sulfate form (DHEA(S)), we searched for studies investigating predictions or changes in hormones over treatment course within the databases PubMed, Scopus, Medline, PsychINFO, Pilots/ProQuest, and Web of Science, and in the grey literature up to May 2018. Controlled and uncontrolled trials investigating adult samples with a clinical status of PTSD were eligible for inclusion. Twelve studies (428 participants) were included. Study quality was overall sufficient. Hormone assessment designs differed considerably. Treatment efficacy on PTSD symptom reduction was mostly high, but predictions of pre-treatment hormone concentrations on treatment efficacy were largely non-significant. Changes from pre- to post-test in basal cortisol (g = -0.07, 95% CI = -0.36; 0.21) and in the cortisol awakening response (g = -0.07, 95% CI = -0.48; 0.35) were also non-significant. Future studies require comparable designs and need to be sufficiently powered to be able to detect potential associations with HPA regulation.
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46
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Laufer S, Engel S, Knaevelsrud C, Schumacher S. Cortisol and alpha-amylase assessment in psychotherapeutic intervention studies: A systematic review. Neurosci Biobehav Rev 2018; 95:235-262. [DOI: 10.1016/j.neubiorev.2018.09.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/25/2018] [Indexed: 01/23/2023]
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47
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Hedman-Lagerlöf M, Hedman-Lagerlöf E, Öst LG. The empirical support for mindfulness-based interventions for common psychiatric disorders: a systematic review and meta-analysis. Psychol Med 2018; 48:2116-2129. [PMID: 29455695 DOI: 10.1017/s0033291718000259] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Mindfulness-based interventions (MBIs) have become widely used for common mental disorders (CMDs) but the state of the evidence has not been sufficiently investigated. The aims for this study were: (1) to quantify the effect size of MBIs for CMDs in the acute phase; (2) to explore moderator variables; and (3) to evaluate the evidence status of MBIs for the CMDs it has been tried for. A comprehensive systematic review and meta-analysis of randomized controlled trials (RCTs) were conducted. RCTs that evaluated MBI and included patients with a primary manifest CMD was included. Methodological quality, the risk of bias, publication bias and evidence status were assessed. Literature searches gave 2448 hits and 19 studies were included. MBIs were more effective than no treatment (g = 1.07) and treatment-as-usual (g = 0.40) but not in comparison to placebo (g = 0.17) or other active treatments (g = -0.01). Methodological quality was negatively correlated with outcome. For all psychiatric disorders it has been tested, MBIs were judged to have weak or no empirical support. The conclusion of the study is that the evidence-base for MBIs for CMDs in the acute phase is weak.
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Affiliation(s)
- Maria Hedman-Lagerlöf
- Department of Clinical Neuroscience, Division of Psychology,Karolinska Institutet,Stockholm,Sweden
| | - Erik Hedman-Lagerlöf
- Department of Clinical Neuroscience, Division of Psychology,Karolinska Institutet,Stockholm,Sweden
| | - Lars-Göran Öst
- Department of Psychology,Stockholm University,Stockholm,Sweden
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48
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Gallegos AM, Crean HF, Pigeon WR, Heffner KL. Meditation and yoga for posttraumatic stress disorder: A meta-analytic review of randomized controlled trials. Clin Psychol Rev 2018; 58:115-124. [PMID: 29100863 DOI: 10.1016/j.cpr.2017.10.004] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 10/18/2017] [Accepted: 10/20/2017] [Indexed: 11/19/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a chronic and debilitating disorder that affects the lives of 7-8% of adults in the U.S. Although several interventions demonstrate clinical effectiveness for treating PTSD, many patients continue to have residual symptoms and ask for a variety of treatment options. Complementary health approaches, such as meditation and yoga, hold promise for treating symptoms of PTSD. This meta-analysis evaluates the effect size (ES) of yoga and meditation on PTSD outcomes in adult patients. We also examined whether the intervention type, PTSD outcome measure, study population, sample size, or control condition moderated the effects of complementary approaches on PTSD outcomes. The studies included were 19 randomized control trials with data on 1173 participants. A random effects model yielded a statistically significant ES in the small to medium range (ES=-0.39, p<0.001, 95% CI [-0.57, -0.22]). There were no appreciable differences between intervention types, study population, outcome measures, or control condition. There was, however, a marginally significant higher ES for sample size≤30 (ES=-0.78, k=5). These findings suggest that meditation and yoga are promising complementary approaches in the treatment of PTSD among adults and warrant further study.
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Affiliation(s)
- Autumn M Gallegos
- Department of Psychiatry, University of Rochester Medical Center, United States.
| | - Hugh F Crean
- School of Nursing, University of Rochester Medical Center, United States; U.S. Department of Veterans Affairs Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, United States
| | - Wilfred R Pigeon
- Department of Psychiatry, University of Rochester Medical Center, United States; U.S. Department of Veterans Affairs Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, United States
| | - Kathi L Heffner
- Department of Psychiatry, University of Rochester Medical Center, United States; School of Nursing, University of Rochester Medical Center, United States
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49
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Niles BL, Mori DL, Polizzi C, Pless Kaiser A, Weinstein ES, Gershkovich M, Wang C. A systematic review of randomized trials of mind-body interventions for PTSD. J Clin Psychol 2018; 74:1485-1508. [PMID: 29745422 DOI: 10.1002/jclp.22634] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 03/21/2018] [Accepted: 03/28/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To systematically review outcomes from randomized controlled trials (RCTs) of mind-body treatments for PTSD. METHODS Inclusion criteria based on guidelines for assessing risk of bias were used to evaluate articles identified through electronic literature searches. RESULTS Twenty-two RCTs met inclusion standards. In most of the nine mindfulness and six yoga studies, significant between-group effects were found indicating moderate to large effect size advantages for these treatments. In all seven relaxation RCT's, relaxation was used as a control condition and five studies reported significant between-group differences on relevant PTSD outcomes in favor of the target treatments. However, there were large within-group symptom improvements in the relaxation condition for the majority of studies. CONCLUSIONS Although many studies are limited by methodologic weaknesses, recent studies have increased rigor and, in aggregate, the results for mindfulness, yoga, and relaxation are promising. Recommendations for design of future mind-body trials are offered.
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Affiliation(s)
- Barbara L Niles
- National Center for PTSD and Boston University School of Medicine
| | - DeAnna L Mori
- VA Boston Healthcare System and Boston University School of Medicine
| | | | | | | | | | - Chenchen Wang
- Center for Complementary and Integrative Medicine at Tufts University School of Medicine
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50
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Cushing RE, Braun KL, Alden C-Iayt SW, Katz AR. Military-Tailored Yoga for Veterans with Post-traumatic Stress Disorder. Mil Med 2018; 183:e223-e231. [PMID: 29415222 PMCID: PMC6086130 DOI: 10.1093/milmed/usx071] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/23/2017] [Accepted: 11/04/2017] [Indexed: 11/13/2022] Open
Abstract
Introduction Among veterans of post-9/11 conflicts, estimates of post-traumatic stress disorder (PTSD) range from 9% shortly after returning from deployment to 31% a year after deployment. Clinical and pharmaceutically based treatments are underutilized. This could be due to concerns related to lost duty days, as well as PTSD patients' fears of stigma of having a mental health condition. Yoga has been shown to reduce PTSD symptoms in the civilian population, but few studies have tested the impact of yoga on veterans of post-9/11 conflicts. The purpose of this study is to test the impact of yoga on post-9/11 veterans diagnosed with PTSD. Materials and Methods Participants were 18 yr of age or older and veterans of post-9/11 conflicts. They had subthreshold or diagnostic-level PTSD related to their combat military service, as determined by a score of 30 or higher on the PTSD Checklist-Military version (PCL-M). Veterans participated in 60-min weekly yoga sessions for 6 wk taught by a Warriors at Ease-trained yoga instructor who is a, post-9/11 veteran. The yoga sessions incorporated Vinyasa-style yoga and a trauma-sensitive, military-culture informed approach advocated by two separate organizations: Warriors at Ease and Meghan's Foundation. Data were collected at baseline and again after 7 wk. The primary outcome was PCL-M score. Participants also completed the Patient Health Questionnaire, the Beck Anxiety Inventory, the Pittsburgh Sleep Quality Index, and the Mindful Attention Awareness Scale at both time points. Results Eighteen Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans completed the pre- and post-intervention self-report questionnaires. Age ranged from 26 to 62 yr (median = 43 yr), length of service ranged from 2 to 34 yr (median = 18.8 yr), and 13 (72.2%) had completed college. Decreased PTSD symptomatology was demonstrated in the three-symptom clusters represented in the PCL-M (i.e., hyperarousal, re-experiencing, and avoidance). In addition, the total score on the PCL-M decreased significantly, by both statistical and clinical measures. The participants also demonstrated improved mindfulness scores and reported decreased insomnia, depression, and anxiety symptoms. Conclusion This study demonstrates that a trauma-sensitive yoga intervention may be effective for veterans with PTSD symptoms, whether as stand-alone or adjunctive therapy. The impressive decrease in PTSD symptomatology may be due to the tailored military-specific nature of this intervention and the fact that it was led by a veteran of post-9/11 conflicts. More research is needed with a larger sample and a more diverse veteran population.
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Affiliation(s)
- Robin E Cushing
- 1st Infantry Division, Attn. DIV SURG Office Bld. 580, 1st Division Rd., Fort Riley, KS 66442
| | - Kathryn L Braun
- Office of Public Health Studies, University of Hawai'i at Manoa, 1960 East-West Road, Biomed D209, Honolulu, HI 96822
| | | | - Alan R Katz
- Office of Public Health Studies, University of Hawai'i at Manoa, 1960 East-West Road, Biomed D209, Honolulu, HI 96822
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