Reductions in cortisol associated with primary care brief mindfulness program for veterans with PTSD

Investigating the Impact of Ashwagandha and Meditation on Stress Induced Obesogenic Eating Behaviours

Obesity has been identified as a rapidly rising pandemic within the developed world, potentially increasing the risks of type 2 diabetes and cardiovascular disease. Various studies have identified a positive association between stress, elevated cortisol levels and obesity. Mechanisms of the stress response lead to hyperpalatable food preference and increased appetite through the activation of the HPA axis, elevated cortisol and the resulting interactions with the dopaminergic system, neuropeptide Y, ghrelin, leptin and insulin. The methodology of this review involved a Systematic Search of the Literature with a Critical Appraisal of papers considering ashwagandha, mediation and mindfulness in relation to mechanisms of the stress response. It incorporated 12 searches yielding 330 hits. A total of 51 studies met the inclusion criteria and were critically appraised with ARRIVE, SIGN50 and Strobe checklists. Data from the 51 studies was extracted, coded into key themes and summarized in a narrative analysis. Thematic analysis identified 4 key themes related to ashwagandha and 2 key themes related to meditation. Results provide an overview of evidence assessing the efficacy of ashwagandha and meditation in relation to weight loss interventions by supporting the stress response and the pathways highlighted. Results of Clinical studies indicate that ashwagandha supports weight loss through reduced stress, cortisol and food cravings. Pre-clinical studies also suggest that ashwagandha possesses the capacity to regulate food intake by improving leptin and insulin sensitivity and reducing addictive behaviors through dopamine regulation. Clinical studies on meditation indicate it may enhance a weight loss protocol by reducing the stress response, cortisol release and blood glucose and improving eating behaviors.

Serotonin Transporter (SLC6A4) and FK506-Binding Protein 5 (FKBP5) Genotype and Methylation Relationships with Response to Meditation in Veterans with PTSD

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.

Randomized Controlled Trial of a Brief Mindfulness-Based Intervention for Suicidal Ideation Among Veterans

INTRODUCTION

This study was a preliminary evaluation of a manualized, brief mindfulness-based intervention (MB-SI) for veterans with suicidal ideation (SI), admitted into an inpatient psychiatric unit (IPU).

MATERIALS AND METHODS

A randomized, controlled pilot study of 20 veterans aged 18-70 years with SI, admitted into a psychiatric unit, assigned to treatment as usual (TAU) or MB-SI groups. Outcome data were collected at three time points: preintervention (beginning of first session), postintervention (end of last session), and 1-month postintervention. Primary outcomes were safety and feasibility. Secondary outcome measures were SI and behavior, mindfulness state and trait, cognitive reappraisal, and emotion regulation. Additionally, psychiatric and emergency department admissions were examined. Data analysis included Generalized Linear Models, Wilcoxon Signed-Rank, Mann-Whitney U, and Fisher's exact tests for secondary outcomes.

RESULTS

Mindfulness-based intervention for suicidal ideation was feasible to implement on an IPU, and there were no associated adverse effects. Mindfulness-based intervention for suicidal ideation participants experienced statistically significant increase in Toronto Mindfulness Scale curiosity scores 1-month postintervention compared to preintervention and greater Toronto Mindfulness Scale decentering scores 1-month postintervention compared to TAU. Emotion Regulation Questionnaire Reappraisal scores significantly increased for the MB-SI group and significantly decreased for TAU over time. IPU and emergency department admissions were not statistically different between groups or over time. Both TAU and MB-SI participants experienced a significant reduction in Columbia-Suicide Severity Rating Scale-SI scores after the intervention. MB-SI participants experienced a higher increase in Five-Facet Mindfulness Questionnaire scores postintervention compared to TAU.

CONCLUSIONS

Mindfulness-based intervention for suicidal ideation is feasible and safe to implement among veterans during an inpatient psychiatric admission with SI, as it is not associated with increased SI or adverse effects. Preliminary evidence suggests that MB-SI increases veterans' propensity to view experiences with curiosity while disengaging from experience without emotional overreaction. Further, more rigorous research is warranted to determine efficacy of MB-SI.

TRIAL REGISTRATION

The clinicaltrials.gov registration number is NCT04099173 and dates are July 16, 2019 (initial release) and February 24, 2022 (most recent update).

The sleep response to stress: how sleep reactivity can help us prevent insomnia and promote resilience to trauma

Sleep reactivity is a predisposition to sleep disturbance during environmental perturbations, pharmacological challenges, or stressful life events. Consequently, individuals with highly reactive sleep systems are prone to insomnia disorder after a stressor, engendering risk of psychopathology and potentially impeding recovery from traumatic stress. Thus, there is tremendous value in ameliorating sleep reactivity to foster a sleep system that is robust to stress exposure, ultimately preventing insomnia and its downstream consequences. We reviewed prospective evidence for sleep reactivity as a predisposition to insomnia since our last review on the topic in 2017. We also reviewed studies investigating pre-trauma sleep reactivity as a predictor of adverse post-traumatic sequelae, and clinical trials that reported the effect of behavioural treatments for insomnia on mitigating sleep reactivity. Most studies measured sleep reactivity via self-report using the Ford Insomnia Response to Stress Test (FIRST), demonstrating high scores on this scale reliably indicate a sleep system with a lower capacity to tolerate stress. Nascent evidence suggests elevated sleep reactivity prior to trauma increases the risk of negative posttraumatic outcomes, namely acute stress disorder, depression, and post-traumatic stress disorder. Lastly, sleep reactivity appears most responsive to behavioural insomnia interventions when delivered early during the acute phase of insomnia. Overall, the literature strongly supports sleep reactivity as a premorbid vulnerability to incident acute insomnia disorder when faced with an array of biopsychosocial stressors. The FIRST identifies individuals at risk of insomnia a priori, thereby guiding early interventions toward this vulnerable population to prevent insomnia and promote resilience to adversity.

Decision-making for concurrent reward and threat is differentially modulated by trauma exposure and PTSD symptom severity

Trauma exposure, particularly interpersonal violence (IPV) traumas, are significant risk factors for development of mental health disorders, particularly posttraumatic stress disorder (PTSD). Studies attempting to disentangle mechanisms by which trauma confers risk and maintenance of PTSD have often investigated threat or reward learning in isolation. However, real-world decision-making often involves navigating concurrent and conflicting probabilities for threat and reward. We sought to understand how threat and reward learning interact to impact decision-making, and how these processes are modulated by trauma exposure and PTSD symptom severity. 429 adult participants with a range of trauma exposure and symptom severities completed an online version of the two stage Markov task, where participants make a series of decisions towards the goal of obtaining a reward, that embedded an intermediate threat or neutral image along the sequence of decisions to be made. This task design afforded the possibility to differentiate between threat avoidance vs diminished reward learning in the presence of threat, and whether these two processes reflect model-based vs model-free decision-making. Results demonstrated that trauma exposure severity, particularly IPV exposure, was associated with impairment in model-based learning for reward independent of threat, as well as with model-based threat avoidance. PTSD symptom severity was associated with diminished model-based learning for reward in the presence of threat, consistent with a threat-induced impairment in cognitively-demanding strategies for reward learning, but no evidence of heightened threat avoidance. These results highlight the complex interactions between threat and reward learning as a function of trauma exposure and PTSD symptom severity. Findings have potential implications for treatment augmentation and suggest a need for continued research.

Development of a mobile mindfulness smartphone app for post-traumatic stress disorder and alcohol use problems for veterans: Beta test results and study protocol for a pilot randomized controlled trial

BACKGROUND

Post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) are highly prevalent, and co-occurring among post-9/11 veterans. Mobile health (mHealth) applications, specifically those focused on mindfulness-based techniques, may be an effective avenue to intervene with veterans who cannot or will not seek care at traditional in-person settings. Thus, to address areas of improvement in mHealth for veterans, we developed Mind Guide and prepared it for testing in a pilot randomized controlled trial (RCT) with veterans.

METHODS

We have completed phase 1 (treatment development) and Phase 2 (beta test) of our mobile mHealth app, Mind Guide. In this paper we describe the methods for Phase 1 as well as results for our beta test (n = 16; inclusion criteria included screen for PTSD, AUD, a post-9/11 veteran, and not currently receiving treatment) for Mind Guide as well as outline procedures for our pilot RCT of Mind Guide (Phase 3). The PTSD Checklist, self-reported alcohol use, the Perceived Stress Scale, Penn Alcohol Craving Scale, and the Emotion Regulation Questionnaire were used.

RESULTS

Results of our beta test of Mind Guide show promising past 30 day effects on PTSD (d = -1.12), frequency of alcohol use (d = -0.54), and alcohol problems (d = -0.44), and related mechanisms of craving (d = -0.53), perceived stress (d = -0.88), and emotion regulation (d = -1.22).

CONCLUSION

Our initial beta-test of Mind Guide shows promise for reducing PTSD and alcohol related problems among veterans. Recruitment is ongoing for our pilot RCT in which 200 veterans will be recruited and followed up for 3 months.

CLINICALTRIALS

gov Identifier: NCT04769986.

Only Small Effects of Mindfulness-Based Interventions on Biomarker Levels of Inflammation and Stress: A Preregistered Systematic Review and Two Three-Level Meta-Analyses

Mindfulness-based interventions (MBIs) have a positive effect on biomarkers of inflammation and stress in patients with psychiatric disorders and physical illnesses. Regarding subclinical populations, results are less clear. The present meta-analysis addressed the effects of MBIs on biomarkers in psychiatric populations and among healthy, stressed, and at-risk populations. All available biomarker data were investigated with a comprehensive approach, using two three-level meta-analyses. Pre-post changes in biomarker levels within treatment groups (k = 40 studies, total N = 1441) and treatment effects compared to control group effects, using only RCT data (k = 32, total N = 2880), were of similar magnitude, Hedges g = -0.15 (95% CI = [-0.23, -0.06], p < 0.001) and g = -0.11 (95% CI = [-0.23, 0.001], p = 0.053). Effects increased in magnitude when including available follow-up data but did not differ between type of sample, MBI, biomarker, and control group or duration of the MBI. This suggests that MBIs may ameliorate biomarker levels in both psychiatric and subclinical populations to a small extent. However, low study quality and evidence of publication bias may have impacted on the results. More large and preregistered studies are still needed in this field of research.

Feasibility, Acceptability, and Efficacy of Mindfulness Training in People With Upper Motor Neuron Disorders: A Systematic Review

OBJECTIVES

This systematic review aims to gain a comprehensive understanding of the feasibility, acceptability, and efficacy of mindfulness-based interventions (MBIs) on depression, anxiety, fatigue, and health-related quality of life among individuals with upper motor neuron disorders (UMNDs).

DATA SOURCES

PubMed, PsycINFO, Excerpta Medica Database, and Cumulative Index to Nursing and Allied Health Literature were searched for relevant studies published between January 2001 and June 2021.

STUDY SELECTION

Clinical trials published in English evaluating MBIs in adults with the 4 most common UMNDs (multiple sclerosis, brain injury including stroke, spinal cord injury, amyotrophic lateral sclerosis) were included.

DATA EXTRACTION

Two reviewers independently performed the risk of bias assessment using standardized tools and extracted desired data electronically.

DATA SYNTHESIS

A total of 44 studies were included: 26 randomized controlled trials, 10 nonrandomized controlled trials, and 8 pre-post intervention studies. The average ± SD duration of MBIs was 8±2 weeks. On average, 85%±14% of participants completed the MBI, and the retention rate at follow-up was 80%±16%. Only 14% of the studies delivered MBIs virtually, and feasibility metrics were similar to in-person studies. Among studies reporting acceptability data, most participants reported satisfaction with the MBI. Randomized controlled trials that evaluated the effects of MBI on depression, anxiety, fatigue, and quality of life revealed greater relative improvement in these outcomes among MBI participants compared with controls, with differences greater when compared with passive control than active control participants. None of the studies included in this review studied dose response.

CONCLUSIONS

Based on current data, MBIs are feasible and offer a promising approach to address the biopsychosocial needs of individuals with UMNDs. MBIs are associated with a high acceptance rate among participants, with notable improvements in depression, anxiety, fatigue, and quality of life post intervention. Future studies are needed to evaluate alternate models of delivery of MBIs and the dose-response relationship.

Impact of a Mindfulness-Based Stress Reduction Program on Psychological Well-Being, Cortisol, and Inflammation in Women Veterans

BACKGROUND

Women veterans experience higher levels of stress-related symptoms than their civilian counterparts. Psychological stress is associated with greater inflammation and may increase risk for cardiovascular disease (CVD). Mindfulness-based stress reduction (MBSR) has been found to improve psychological well-being in other populations but no randomized controlled trials (RCT) have been conducted examining the impact of MBSR on well-being and inflammation in women veterans at risk for CVD.

OBJECTIVE

Determine the effectiveness of MBSR in improving psychological well-being, cortisol, and inflammation associated with CVD in women veterans.

DESIGN

The design is a RCT comparing MBSR to an active control condition (ACC) consisting of a health education program.

PARTICIPANTS

Women veterans (N=164) with risk factors for CVD from the Chicagoland area participated in the study.

INTERVENTION

An 8-week MBSR program with weekly 2.5-h classes was compared to an ACC consisting of an 8-week health promotion education program with weekly 2.5-h classes.

MAIN MEASURES

The outcomes were psychological well-being [perceived stress, depressive symptoms, loneliness, and post-traumatic stress disorder (PTSD)] symptoms and stress-related markers, including diurnal salivary cortisol and cytokines interleukin-6 (IL-6) and interferon gamma (IFN-γ). Data were collected at baseline, 4 weeks (mid-point of intervention), 8 weeks (completion of intervention), and 6 months after completion of MBSR or ACC.

KEY RESULTS

Compared to the ACC, women who participated in MBSR reported less perceived stress, loneliness, and symptoms of PTSD. Although there were no significant differences between groups or changes over time in IL-6 or IFN-γ, participants in the MBSR program demonstrated a more rapid decline in diurnal salivary cortisol as compared to those in the ACC.

CONCLUSIONS

MBSR was found to improve psychological well-being and decrease diurnal salivary cortisol in women veterans at risk for CVD. Health care providers may consider MBSR for women veterans as a means by which to improve their psychological well-being.

Impact and Risk of Moral Injury Among Deployed Veterans: Implications for Veterans and Mental Health

The impact of "moral injury" (MI) among deployed veterans, defined as actions in combat that violate a veteran's moral beliefs and result in psychological distress, has increasingly become a significant clinical concern separate from other trauma- and stressor-related disorders. MI involves severe distress over violations of core beliefs often followed by feelings of guilt and conflict and is common among veterans with PTSD. While the psychological impact of PTSD is well-documented among veterans, this has been done less so with respect to MI. We studied MI among 1,032 deployed veterans who were outpatients in a large non-profit multi-hospital system in central Pennsylvania. The study included active duty and Guard/Reserve members, as well as veterans who were not Department of Veterans Affairs (VA) service users. Our hypothesis was that, controlling for other risk factors, veterans with high MI would have current mental disorders. Our secondary hypothesis was that MI would be associated with other psychopathologies, including chronic pain, sleep disorders, fear of death, anomie, and use of alcohol/drugs to cope post deployment. Most veterans studied were deployed to Vietnam (64.1%), while others were deployed to post-Vietnam conflicts in Iraq and Afghanistan and elsewhere. Altogether, 95.1% of the veterans were male and their mean age was 61.6 years (SD = 11.8). Among the veterans, 24.4% had high combat exposure, 10.9% had PTSD, 19.8% had major depressive disorder, and 11.7% had a history of suicidal thoughts. Based on the Moral Injury Events Scale (MIES), 25.8% had high MI post deployment, defined as a score above the 75th percentile. Results show that high MI among veterans was associated with current global mental health severity and recent mental health service use, but not suicidal thoughts. In addition, as hypothesized, MI was also associated with pain, sleep disorders, fear of death, anomie, use of alcohol/drugs to cope post-deployment, and poor unit support/morale during deployment. Deployed veterans with MI are more likely to have current mental health disorders and other psychological problems years after deployment. Further research is advised related to the screening, assessment, treatment, and prevention of MI among veterans and others after trauma exposures.

Mindful nonreactivity moderates the relationship between posttraumatic stress disorder and depression

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.

Feasibility, Acceptability, and Preliminary Efficacy of an App-Based Meditation Intervention to Decrease Firefighter Psychological Distress and Burnout: A One-Group Pilot Study (Preprint)

Background

Firefighters are often exposed to occupational stressors that can result in psychological distress (ie, anxiety and depression) and burnout. These occupational stressors have only intensified with the onset of the COVID-19 pandemic and will likely persist in the postpandemic world.

Objective

To address occupational stressors confronting firefighters, we pilot tested a novel, cost-effective, smartphone app–based meditation intervention created by Healthy Minds Innovations that focused on mindfulness (awareness) training along with practices designed to cultivate positive relationships (connection), insight into the nature of the self (insight), and a sense of purpose in the context of challenge (purpose) with a sample of professional firefighters from a large metropolitan area in southwestern United States.

Methods

A total of 35 participants were recruited from a closed online group listserv and completed the self-guided 10-unit meditation app over the course of 10 days, at 1 unit per day. We assessed anxiety symptoms, depression symptoms, burnout, and negative affect as well as saliva diurnal cortisol rhythm, an objective indicator of stress-related biology, before and after use of the meditation app.

Results

This study demonstrated the meditation app was both feasible and acceptable for use by the majority of firefighters. We also found significant reductions in firefighters’ anxiety (P=.01), burnout (P=.05), and negative affect (P=.04), as well as changes in cortisol diurnal rhythm, such as waking cortisol (P=.02), from before to after use of the meditation app.

Conclusions

Our study findings call for future research to demonstrate the efficacy of this meditation app to reduce psychological distress and burnout in firefighters.

Therapeutic role of yoga in neuropsychological disorders

Yoga is considered a widely-used approach for health conservation and can be adopted as a treatment modality for a plethora of medical conditions, including neurological and psychological disorders. Hence, we reviewed relevant articles entailing various neurological and psychological disorders and gathered data on how yoga exerts positive impacts on patients with a diverse range of disorders, including its modulatory effects on brain bioelectrical activities, neurotransmitters, and synaptic plasticity. The role of yoga practice as an element of the treatment of several neuropsychological diseases was evaluated based on these findings.

Mechanisms of Mindfulness Meditation, Cognitive Therapy, and Mindfulness-based Cognitive Therapy for Chronic Low Back Pain

OBJECTIVES

This study evaluated theoretically derived mechanisms and common therapeutic factors to test their role in accounting for pain-related outcome change during group-delivered cognitive therapy, mindfulness meditation, and mindfulness-based cognitive therapy for chronic low back pain.

METHODS

A secondary analysis of a pilot randomized controlled trial was used to explore the primary mechanisms of pretreatment to posttreatment changes in pain control beliefs, mindful observing, and pain catastrophizing, and the secondary common factor mechanisms of therapeutic alliance, group cohesion, and amount of at-home skill practice during treatment. The primary outcome was pain interference; pain intensity was a secondary outcome.

RESULTS

Large effect size changes in the 3 primary mechanisms and the outcome variables were found across the conditions. Across all 3 treatment conditions, change in pain control beliefs and pain catastrophizing were significantly associated with improved pain interference, but not pain intensity. Therapeutic alliance was significantly associated with pain intensity improvement and change in the therapy-specific mechanisms across the 3 conditions. Mindful observing, group cohesion, and amount of at-home practice were not significantly associated with changes in the outcomes.

DISCUSSION

Cognitive therapy, mindfulness meditation, and mindfulness-based cognitive therapy for chronic low back pain were all associated with significant changes in the primary mechanisms to a similar degree. Change in perceived pain control and pain catastrophizing emerged as potential "meta-mechanisms" that might be a shared pathway that contributes to improved pain-related outcomes across treatments. Further, strong working alliance may represent a critical therapeutic process that both promotes and interacts with therapeutic techniques to influence outcome.

Mindfulness-based interventions for military veterans: A systematic review and analysis of the literature

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.

Efficacy and acceptability of mindfulness-based interventions for military veterans: A systematic review and meta-analysis

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.

Effects of RU486 treatment after single prolonged stress depend on the post-stress interval

The Single Prolonged Stress protocol is considered a model for PTSD, as it induces long lasting changes in rat behaviour and endocrine regulation. Previous work demonstrated that some of these changes can be prevented by treatment with the glucocorticoid receptor antagonist RU486, administered a week after the stressor. The current study evaluated the effects of an earlier intervention with RU486, as evaluated 1 week after SPS-exposure. Most RU486 effects occurred independent of prior stress, except for the reversal of a stress-induced increase in locomotor behaviour. The accompanying changes in gene expression depended on gene, brain region, and time. DNA methylation of the robustly down-regulated Fkbp5 gene was dissociated of changes in mRNA expression. The findings reinforce the long term effects of GR antagonist treatment, but also emphasize the need to evaluate changes over time to allow the identification of robust correlates between gene expression and behavioural/endocrine outcome of stressful experiences.

A Brief Report on an 8-Week Course of Mindfulness-based Care for Chronic Pain in the Treatment of Veterans With Back Pain: Barriers Encountered to Treatment Engagement and Lessons Learned

BACKGROUND

Chronic pain and associated symptoms are debilitating for veterans. Medical costs of treatments are high and current treatment options, most notably with opioid medications, have been associated with significant risk. Mindfulness-based interventions appear promising for chronic pain, but require additional testing in veteran care settings.

OBJECTIVE

This project was designed to test the feasibility of engaging and retaining veterans with chronic lower back pain in a new mindfulness protocol tailored for veterans, mindfulness-based care for chronic pain (MBCP). Clinical outcomes were also assessed.

DESIGN

An open pilot trial of an 8-week MBCP course that included meditation, gentle yoga, and psychoeducation.

SUBJECTS

Twenty-two veterans (mean age=49.77; 18% women) were recruited from a VA Medical Center in the Northeastern US. After screening for inclusion/exclusion criteria, 20 were eligible at baseline.

MEASURES

Veterans were assessed at baseline and postintervention for functional impairment, pain intensity and bothersomeness, depression, and mindfulness.

RESULTS

The average number of sessions completed was 5; only 4 (20%) attended all sessions. Eleven of the 20 participants (55%) attended 5 or more sessions and had complete preintervention and postintervention visits. Five of the 11 had a clinically meaningful decrease in pain intensity and in depressive symptoms, while 6 of 11 had a meaningful decrease in pain bothersomeness and functional impairment.

CONCLUSIONS

It was challenging to enroll and retain participants in this study, even with our intervention designed for veterans. We discuss possible adaptations and refinements in MBCP for veterans with chronic pain to enhance feasibility and improve upon these interventions.

Veterans' interests, perceptions, and use of mindfulness

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.

Meditation interventions efficiently reduce cortisol levels of at-risk samples: a meta-analysis

Previous meta-analytic results showed beneficial effects of meditation interventions for cortisol levels. In the present meta-analysis we tested whether effects are larger for those who might be in need of such stress reduction programs due to a risk for elevated cortisol levels as compared to no-risk samples. We included RCTs that measured change in cortisol levels. Based on 10 studies using blood samples meditation interventions had a significant, medium effect from pre-to post-test compared to the control group. Upon closer inspection, this effect was only present for at-risk samples, that is, patients with a somatic illness. In the 21 studies using saliva samples the effect was small and not significant, but there was a marginally significant effect for groups living in stressful life situations. This pattern may suggest that that meditation interventions are most beneficial for at-risk populations. These interventions might provide people with strategies of stress management that can contribute to well-being. Preliminary results suggest that benefits of meditation interventions might not fade with time.

Dysregulation of inflammation, neurobiology, and cognitive function in PTSD: an integrative review

Compelling evidence from animal and human research suggest a strong link between inflammation and posttraumatic stress disorder (PTSD). Furthermore, recent findings support compromised neurocognitive function as a key feature of PTSD, particularly with deficits in attention and processing speed, executive function, and memory. These cognitive domains are supported by brain structures and neural pathways that are disrupted in PTSD and which are implicated in fear learning and extinction processes. The disruption of these supporting structures potentially results from their interaction with inflammation. Thus, the converging evidence supports a model of inflammatory dysregulation and cognitive dysfunction as combined mechanisms underpinning PTSD symptomatology. In this review, we summarize evidence of dysregulated inflammation in PTSD and further explore how the neurobiological underpinnings of PTSD, in the context of fear learning and extinction acquisition and recall, may interact with inflammation. We then present evidence for cognitive dysfunction in PTSD, highlighting findings from human work. Potential therapeutic approaches utilizing novel pharmacological and behavioral interventions that target inflammation and cognition also are discussed.

The Impact of Preoperative Mindfulness-Based Stress Reduction on Postoperative Outcomes in Lumbar Spine Degenerative Disease: 3-Month and 12-Month Results of a Pilot Study

BACKGROUND

We previously reported inpatient and 30-day postoperative patient-reported outcomes (PROs) of a controlled, noncrossover pilot study using preoperative mindfulness-based stress reduction (MBSR) training for lumbar spine surgery. Our goal here was to assess 3-month and 12-month postoperative PROs of preoperative MBSR in lumbar spine surgery for degenerative disease.

METHODS

Intervention group participants were prospectively enrolled in a preoperative online MBSR course. A comparison standard care only group was one-to-one matched retrospectively by age, sex, surgery type, and prescription opioid use. Three-month and 12-month postoperative PROs for pain, disability, quality of life, and opioid use were compared within and between groups. Regression models were used to assess whether MBSR use predicted outcomes.

RESULTS

Twenty-four participants were included in each group. At 3 months, follow-up was 87.5% and 95.8% in the comparison and intervention groups, respectively. In the intervention group, mean Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF) was significantly higher, whereas mean Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) and Oswestry Disability Index were significantly lower. The change from baseline in mean PROMIS-PF and PROMIS-PI was significantly greater than in the comparison group. At 12 months, follow-up was 58.3% and 83.3% in the comparison and intervention groups, respectively. In the intervention group, mean PROMIS-PI was significantly lower and change in mean PROMIS-PI from baseline was significantly greater. MBSR use was a significant predictor of change in PROMIS-PF at 3 months and in PROMIS-PI at 12 months. No adverse events were reported.

CONCLUSIONS

Three-month and 12-month results suggest that preoperative MBSR may have pain control benefits in lumbar spine surgery.

Yoga and Mindfulness as a Tool for Influencing Affectivity, Anxiety, Mental Health, and Stress among Healthcare Workers: Results of a Single-Arm Clinical Trial

Mindfulness-based interventions have emerged as unique approaches for addressing a range of clinical and subclinical difficulties such as stress, chronic pain, anxiety, or recurrent depression. Moreover, there is strong evidence about the positive effects of yoga practice on stress management and prevention of burnout among healthcare workers. The aim of this study was to conduct a single-arm clinical trial to assess the effectiveness of an intervention based on mindfulness-based stress reduction and yoga in improving healthcare workers' quality of life. Healthcare workers of two hospitals in Rome were enrolled in a 4-week yoga and mindfulness course. Four questionnaires were administered at different times (Short Form-12 (SF-12), State-Trait Anxiety Inventory (STAI) Y1 and Y2, and Positive and Negative Affect Schedule (PANAS)) to evaluate the efficacy of the intervention. Forty participants took part to the study (83.3 %). The Mental Composite Score-12, that is part of the quality of life assessment, passed from a median of 43.5 preintervention to 48.1 postintervention (p = 0.041), and the negative affect passed from a score of 16 in the preintervention to 10 in the postintervention (p < 0.001). Both the forms of the STAI questionnaires showed a decrease after the intervention. Yoga and mindfulness administered together seem to be effective to reduce stress and anxiety in healthcare workers, providing them with more consciousness and ability to manage work stressful demands.

Psychoneuroendocrinoimmunology-based meditation (PNEIMED) training reduces salivary cortisol under basal and stressful conditions in healthy university students: Results of a randomized controlled study

BACKGROUND

Meditation represents an effective and safe practice to lower distress and promote well-being. PsychoNeuroEndocrinoImmunology-based Meditation (PNEIMED) is a validated method that can reduce stress-related symptoms and salivary cortisol secretion. To date, few randomised controlled trials (RCTs) have assessed cortisol levels through salivary samples, collected both in the morning phase and during acute mental stress elicitation, in healthy young subjects following brief meditation training.

AIM

The present study aims to investigate, in healthy young undergraduate students, the effects of a brief PNEIMED training course on HPA axis by measuring salivary cortisol levels.

METHODS

Forty students attending the Faculty of Psychology, without comorbidities and previous experience of meditation, were enrolled in the study. Twenty subjects were randomly assigned to 30 h of PNEIMED training (intervention group, IG), and twenty subjects were randomly assigned to 30 h of academic lessons (control group, CG). Salivary cortisol measures included basal morning (t0 = baseline time, collected 30 min after waking) and under stress-eliciting task values. Cortisol measurement under the stress-eliciting task was provided through the Subtraction Stress Task (SST) at scheduled time intervals (t1 = 5 min pre-SST, t2 = 10 min post-SST, t3 = 30 min = post-SST). Salivary cortisol was measured among all subjects (IG + CG) at the beginning (pre-test) and at the end (post-test, four days later) of the study.

RESULTS

ANOVA between-group analysis of basal diurnal salivary cortisol showed a significant hormone deflection in the IG at the end of the PNEIMED course (post-test) when compared to the CG (IG post-test 5.64 ± 4.2 vs CG post-test 9.44 ± 4.9; F_1,38 = 6.838; p = 0.013). RM-ANOVA within-group analysis for the IG also showed that time and condition effects were statistically significant, with Ftime = 5.438; p = 0.002 and Fcondition = 10.478; p = 0.004, respectively. The IG group presented a significant reduction in basal morning cortisol at the end of the PNEIMED course (post-test) compared to the salivary concentration at baseline (pre-test) (IG pre-test 9.42 ± 6.0 vs IG post-test 5.64 ± 4.2; F_1,38 8,354; p = 0.009). RM-ANOVA for the control group showed only the main effect of time (F_1,38 = 40.348; p < 0.001). Regarding cortisol measures under the SST-stress eliciting task, ANOVA between-groups analysis showed higher cortisol levels in the IG than in the CG before the PNEIMED course, with significant differences between groups at time t2 and time t3. After the PNEIMED course, the cortisol levels in the IG had decreased, although the differences between groups were not significant. Interestingly, ANOVA within-groups analysis showed that in the IG, the cortisol levels post-test (after the PNEIMED course) were lower than at pre-test (before the PNEIMED course), showing a significant difference of cortisol salivary concentration between conditions at t3 (F = 5.326; p = 0.032). In the control group, the post-hoc analyses for pairwise comparisons between conditions (pre-test vs post-test) did not show significant differences.

CONCLUSION

Although the low number of subjects enrolled in the study does not allow for definitive conclusions to be drawn, the present findings confirmed the capability of the PNEIMED method to lower stress hormone secretion both at baseline and under acute mental stimulation in a group of young naïve practitioners and make a contribution to the existing literature by increasing the number of published RCTs about the topic.

Transcendental meditation and hypothalamic-pituitary-adrenal axis functioning: a pilot, randomized controlled trial with young adults

Transcendental meditation (TM) is effective in alleviating stress and anxiety and promoting well-being. While the underlying biological mechanisms of TM are not yet fully explored, the hypothalamic-pituitary-adrenal (HPA) axis represents an index providing important clues embodying the stress system cascade. In this pilot study, young adults were randomly assigned to TM training followed by 8 weeks of meditation practice or a wait-list control condition. TM was conducted over 8 weeks. Thirty-four young adult participants were randomized; 27 participants completed the HPA outcome assessments (41% male). To assess HPA axis functioning, salivary samples to assess cortisol awakening response (CAR) that were collected in the morning, both at baseline and at week-4. Salivary cortisol in the context of a social stressor using the Trier Social Stress Test (TSST) was collected at week-8. The results indicate that participants who were randomly assigned to TM had lower awakening salivary cortisol levels and a greater drop in CAR from baseline to week-4 than the control group. There were no significant differences in HPA axis functioning in the context of the TSST. Primary limitations of this randomized controlled trial were the small sample size, the use of a wait-list as opposed to an active control, and the limited scope of HPA axis assessments. The results of this pilot study provide tentative evidence that TM may impact biological stress system functioning and suggests that this may be a worthwhile avenue to continue to examine. It will also be useful to extend these findings to a broader array of meditative and mindful practices, particularly for those who are experiencing more distress.

Mindfulness and psychoeducation to manage stress in amnestic mild cognitive impairment: A pilot study

Objectives: Amnestic mild cognitive impairment (aMCI) often corresponds to the prodromal stage of Alzheimer disease (AD). The aMCI stage represents a crucial time window to apply preventive interventions in an attempt to delay cognitive decline. Stress, one of AD's modifiable risk factors frequently co-occurring with aMCI, stands out as a key intervention target. The goal of this study was to assess the impacts of two non-pharmacological interventions, mindfulness and psychoeducation, on stress at the psychological and physiological levels among aMCI older adults. Methods: Forty-eight aMCI participants were randomized between a mindfulness-based intervention (MBI) and a psychoeducation-based intervention (PBI) for eight weekly sessions. Anxiety symptoms, perceived stress levels, cortisol awakening response (CAR), and coping strategies were assessed pre- and post-intervention. Mindfulness attitudes and time dedicated to at-home meditative practices were evaluated in the MBI group. Results: The main results revealed a slight reduction of the CAR among MBI participants who practiced meditation at home the most and a decrease in perceived stress levels in the PBI group. Both interventions enhanced problem-focused coping strategies. Conclusion: In sum, this pilot study supports the potential of MBI and PBI to reduce stress at the physiological and psychological level, respectively, and increase coping strategies in older adults at risk for AD.

The influence of mindfulness and social support on stress reactivity during pregnancy

Exaggerated stress reactivity can lead to negative health outcomes, which can be especially harmful during important periods of development such as pregnancy. Therefore, studies are needed to examine potential protective factors associated with lower perceived stress reactivity and lower cortisol awakening response (CAR) during pregnancy. The current cross-sectional study examined whether low-income women (n = 152) with higher mindfulness (attentiveness and awareness of the present moment) and more perceived social support had lower levels of perceived stress reactivity and a lower CAR during pregnancy. Women completed self-report measures of mindfulness (Mindful Attention Awareness Scale), social support (Medical Outcomes Study-Social Support Scale), and perceived stress reactivity (Perceived Stress Reactivity Scale) during their first trimester of pregnancy and collected saliva using the passive drool procedure at home (at awakening and at 30 min after awakening). Results showed that women with greater mindfulness and greater perceived social support had significantly lower perceived stress reactivity, but not a lower CAR. These results provide preliminary support for mindfulness and social support as potential protective factors of perceived stress reactivity and have implications for experimental studies aimed at improving pregnant women's mindfulness and social support for reducing their stress reactivity and potentially improving health outcomes.

Treatment Engagement and Outcomes of Mindfulness-Based Cognitive Therapy for Veterans with Psychiatric Disorders

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.

The anxiolytic-like effects of puerarin on an animal model of PTSD

Post traumatic stress disorder (PTSD) is a mental illness that affected numerous people. The anti-PTSD-like effects of puerarin is unknown, although the antidepressant- and anxiolytic- like effects of puerarin have been reported. The PTSD behavioral deficits in rats were induced by single prolonged stress (SPS), mainly including the reduced time/entries in the open arms and the elevated time/entries in the closed arms in elevated plus maze test, increased freezing duration in contextual fear paradigm and lowered time/entries in the central zone in open field test. However, the behavioral deficits were attenuated by puerarin (50 and 100 mg/kg) without affecting the locomotor activity. For the evaluation of mechanism, the decreased levels of progesterone, allopregnanolone, and the increased levels of corticosterone, corticotropin releasing hormone, and adrenocorticotropic hormone in the brain or serum were induced by SPS, which is blocked by puerarin. In summary, the anti-PTSD-like effects of puerarin were associated with biosynthesis of neurosteroids and normalized levels of stress hormones in HPA axis.

Cortisol levels before and after cognitive behavioural therapy in patients with eating disorders reporting childhood abuse: A follow-up study

The etiopathogenesis of eating disorders (EDs) is complex and still not well understood. Biological, psychological and environmental factors (e.g. childhood abuse) have all been considered to be involved in the onset and the persistence of EDs. The hypothalamic-pituitary-adrenal (HPA) axis is a relevant biological factor capable of influencing the onset and the course of EDs and not many information are available about the impact of a Cognitive Behavioral Therapy (CBT) on cortisol changes in EDs. The HPA-axis functioning has been evaluated before and after CBT in a group of patients with Anorexia Nervosa (n = 34) and Bulimia Nervosa (n = 35) according to the presence/absence of a history of sexual/physical abuse. At baseline, only patients reporting childhood abuse showed lower morning cortisol levels as compared with other patients of the same diagnostic group and Healthy Controls. After CBT, a variation of cortisol levels has been found only in patients without abuse, suggesting a role of childhood adversities in the persistence of HPA-axis alterations in Eating Disorders.

PTSD psychotherapy improves blood pressure but leaves HPA axis feedback sensitivity stable and unaffected: First evidence from a pre-post treatment study

Although key to development of tailored drugs for augmentation treatment of psychotherapy for posttraumatic stress disorder (PTSD), the biological correlates of PTSD remission are still unknown, probably because pre-post treatment studies searching for them are rare. Not even the feedback sensitivity of the otherwise well-studied hypothalamic-pituitary-adrenal (HPA) axis nor arterial blood pressure (BP), which was previously reported to be elevated in PTSD patients, have so far been analyzed during PTSD treatment. To narrow this knowledge gap, we first performed an overnight dexamethasone suppression test (DST) in a mixed-sex cohort of 25 patients with severe PTSD vs. 20 non-traumatized healthy controls (nt-HC). In addition to hormones, BP and heart rate (HR) were measured at each of the four assessment points (APs). Second, the same parameters were assessed again in 16 of these patients after 12 sessions of integrative trauma-focused cognitive behavioral therapy (iTF-CBT). In relation to nt-HC, PTSD patients showed a significant elevation in HR and diastolic BP while their systolic BP, DST outcomes and basal serum cortisol levels (BSCL) were not significantly altered. In response to iTF-CBT, PTSD symptoms and dysfunctional stress coping strategies improved significantly in PTSD patients. Most important, also their systolic and diastolic BP levels ameliorated at distinct APs while their DST outcomes and BSCL remained unchanged. To our knowledge, this is the first pre-post treatment study assessing the stability of the DST outcome and BP levels during PTSD treatment. Our results provide first evidence for a non-involvement of HPA axis feedback sensitivity in PTSD symptom improvement and, furthermore, suggest a possible role for BP-regulating pathways such as the sympathetic nervous system in PTSD remission. Limitations arise from the small sample size, the lack of an untreated patient group and drug treatment of patients.

The effect of a service dog on salivary cortisol awakening response in a military population with posttraumatic stress disorder (PTSD)

Recent studies suggest a therapeutic effect of psychiatric service dogs for military veterans with posttraumatic stress disorder (PTSD), but are limited by self-report biases. The current study assessed the effect of PTSD service dogs on the salivary cortisol awakening response (CAR) and arousal-related functioning in a population of military veterans with PTSD. Participants included 73 post-9/11 military veterans with PTSD including 45 with a service dog and 28 on the waitlist to receive one. Saliva samples were collected on two consecutive weekday mornings at awakening and 30 min later to quantify the cortisol awakening response (CAR) and its area under the curve (AUCi) in addition to standardized survey measures of anxiety, anger, sleep quality and disturbance, and alcohol abuse. There was a significant main effect of having a service dog on both the CAR and the AUCi, with individuals with a service dog exhibiting a higher CAR and AUCi compared to those on the waitlist. Results also revealed that those with a service dog reported significantly lower anxiety, anger, and sleep disturbance as well as less alcohol abuse compared to those on the waitlist, with medium to large effect sizes. Although those with a service dog reported significantly less PTSD symptom severity, CAR was not significantly associated with PTSD symptoms within or across group. In conclusion, results indicate that the placement of a PTSD service dog may have a significant positive influence on both physiological and psychosocial indicators of wellbeing in military veterans with PTSD. Although clinical significance cannot be confirmed, a higher CAR/AUCi among those with a service dog may indicate better health and wellbeing in this population. Future within-subject, longitudinal research will be necessary to determine potential clinical significance and impact of individual differences.

Mindfulness-based resilience training to reduce health risk, stress reactivity, and aggression among law enforcement officers: A feasibility and preliminary efficacy trial

The primary objective of this study was to assess feasibility and gather preliminary outcome data on Mindfulness-Based Resilience Training (MBRT) for law enforcement officers. Participants (n = 61) were randomized to either an 8-week MBRT course or a no intervention control group. Self-report and physiological data were collected at baseline, post-training, and three months following intervention completion. Attendance, adherence, post-training participant feedback, and interventionist fidelity to protocol all demonstrated feasibility of MBRT for law enforcement officers. Compared to no intervention controls, MBRT participants experienced greater reductions in salivary cortisol, self-reported aggression, organizational stress, burnout, sleep disturbance, and reported increases in psychological flexibility and non-reactivity at post-training; however, group differences were not maintained at three-month follow-up. This initial randomized trial suggests MBRT is a feasible intervention. Outcome data suggest MBRT targets key physiological, psychological, and health risk factors in law enforcement officers, consistent with the potential to improve officer health and public safety. However, follow-up training or "booster" sessions may be needed to maintain training gains. A fully powered longitudinal randomized trial is warranted.

Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence

Mindfulness-based treatments for posttraumatic stress disorder (PTSD) have emerged as promising adjunctive or alternative intervention approaches. A scoping review of the literature on PTSD treatment studies, including approaches such as mindfulness-based stress reduction, mindfulness-based cognitive therapy and metta mindfulness, reveals low attrition with medium to large effect sizes. We review the convergence between neurobiological models of PTSD and neuroimaging findings in the mindfulness literature, where mindfulness interventions may target emotional under- and overmodulation, both of which are critical features of PTSD symptomatology. Recent emerging work indicates that mindfulness-based treatments may also be effective in restoring connectivity between large-scale brain networks among individuals with PTSD, including connectivity between the default mode network and the central executive and salience networks. Future directions, including further identification of the neurobiological mechanisms of mindfulness interventions in patients with PTSD and direct comparison of these interventions to first-line treatments for PTSD are discussed.

Methylation of FKBP5 and SLC6A4 in Relation to Treatment Response to Mindfulness Based Stress Reduction for Posttraumatic Stress Disorder

Mindfulness Based Stress Reduction (MBSR) is an effective non-pharmacologic treatment for veterans with PTSD. Extensive work has identified epigenetic factors related to PTSD disease risk and pathophysiology, but how these factors influence treatment response is unclear. Serotonin signaling and hypothalamic-pituitary-adrenal (HPA) axis functioning may be perturbed in PTSD and are molecular pathways targeted by PTSD treatments. To identify potential biomarkers for treatment response, we utilized genomic DNA isolated from peripheral blood samples from veterans with PTSD who were responders (n = 11) or non-responders (n = 11) to MBSR as part of a clinical trial. We assessed methylation levels at CpG sites in regions of the serotonin transporter (SLC6A4) previously associated with expression and depression outcomes, as well as the Intron 7 region of the FK506 binding protein 5 (FKBP5) containing known glucocorticoid response elements suggested to regulate this gene. Selected subjects were matched across MBSR responder status by baseline symptoms, age, sex, current smoking status, and current antidepressant use. Percent methylation was compared between responders and non-responders at baseline (pre-MBSR treatment). Additionally, percent change in methylation from baseline to post-treatment was compared between responders and non-responders. There was a significant time x responder group interaction for methylation in FKBP5 intron 7 bin 2 [F _{(1, 19)} = 7.492, p = 0.013] whereby responders had a decrease in methylation and non-responders had an increase in methylation from before to after treatment in this region. Analyses of the three CpG sites within bin 2 revealed a significant time x responder group interaction for CpG_35558513 [F _{(1, 19)} = 5.551, p = 0.029] which resides in a known glucocorticoid response element (GRE). Decreases in FKBP5 methylation after treatment in responders as compared to increases in non-responders suggest that effective meditation intervention may be associated with stress-related pathways at the molecular level. These preliminary findings suggest that DNA methylation signatures within FKBP5 are potential indicators of response to meditation treatment in PTSD and require validation in larger cohorts.

Efficacy of 8- and 4-Session Mindfulness-Based Interventions in a Non-clinical Population: A Controlled Study

Background: Many attempts have been made to abbreviate mindfulness programmes in order to make them more accessible for general and clinical populations while maintaining their therapeutic components and efficacy. The aim of this study was to assess the efficacy of an 8-week mindfulness-based intervention (MBI) programme and a 4-week abbreviated version for the improvement of well-being in a non-clinical population.

Method: A quasi-experimental, controlled, pilot study was conducted with pre-post and 6-month follow-up measurements and three study conditions (8- and 4-session MBI programmes and a matched no-treatment control group, with a sample of 48, 46, and 47 participants in each condition, respectively). Undergraduate students were recruited, and mindfulness, positive and negative affect, self-compassion, resilience, anxiety, and depression were assessed. Mixed-effects multi-level analyses for repeated measures were performed.

Results: The intervention groups showed significant improvements compared to controls in mindfulness and positive affect at the 2- and 6-month follow-ups, with no differences between 8- vs. 4-session programmes. The only difference between the abbreviated MBI vs. the standard MBI was found in self-kindness at 6 months, favoring the standard MBI. There were marginal differences in anxiety between the controls vs. the abbreviated MBI, but there were differences between the controls vs. the standard MBI at 2- and 6-months, with higher levels in the controls. There were no differences in depression between the controls vs. the abbreviated MBI, but differences were found between the controls vs. the standard MBI at 2- and 6-months, favoring the standard MBI. There were no differences with regard to negative affect and resilience.

Conclusion: To our knowledge, this is the first study to directly investigate the efficacy of a standard 8-week MBI and a 4-week abbreviated protocol in the same population. Based on our findings, both programmes performed better than controls, with similar effect size (ES). The efficacy of abbreviated mindfulness programmes may be similar to that of a standard MBI programme, making them potentially more accessible for a larger number of populations. Nevertheless, further studies with more powerful designs to compare the non-inferiority of the abbreviated protocol and addressing clinical populations are warranted.

Clinical Trials.gov Registration ID: NCT02643927

The Role of Mindfulness in Reducing the Adverse Effects of Childhood Stress and Trauma

Research suggests that many children are exposed to adverse experiences in childhood. Such adverse childhood exposures may result in stress and trauma, which are associated with increased morbidity and mortality into adulthood. In general populations and trauma-exposed adults, mindfulness interventions have demonstrated reduced depression and anxiety, reduced trauma-related symptoms, enhanced coping and mood, and improved quality of life. Studies in children and youth also demonstrate that mindfulness interventions improve mental, behavioral, and physical outcomes. Taken together, this research suggests that high-quality, structured mindfulness instruction may mitigate the negative effects of stress and trauma related to adverse childhood exposures, improving short- and long-term outcomes, and potentially reducing poor health outcomes in adulthood. Future work is needed to optimize implementation of youth-based mindfulness programs and to study long-term outcomes into adulthood.

Use of Salivary Diurnal Cortisol as an Outcome Measure in Randomised Controlled Trials: a Systematic Review

Background

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis is associated with diverse adverse health outcomes, making it an important therapeutic target. Measurement of the diurnal rhythm of cortisol secretion provides a window into this system. At present, no guidelines exist for the optimal use of this biomarker within randomised controlled trials (RCTs).

Purpose

The aim of this study is to describe the ways in which salivary diurnal cortisol has been measured within RCTs of health or behavioural interventions in adults.

Methods

Six electronic databases (up to May 21, 2015) were systematically searched for RCTs which used salivary diurnal cortisol as an outcome measure to evaluate health or behavioural interventions in adults. A narrative synthesis was undertaken of the findings in relation to salivary cortisol methodology and outcomes.

Results

From 78 studies that fulfilled the inclusion criteria, 30 included healthy participants (38.5 %), 27 included patients with physical disease (34.6 %) and 21 included patients with psychiatric disease (26.9 %). Psychological therapies were most commonly evaluated (n = 33, 42.3 %). There was substantial heterogeneity across studies in relation to saliva collection protocols and reported cortisol parameters. Only 39 studies (50 %) calculated a rhythm parameter such as the diurnal slope or the cortisol awakening response (CAR). Patterns of change in cortisol parameters were inconsistent both within and across studies and there was low agreement with clinical findings.

Conclusions

Salivary diurnal cortisol is measured inconsistently across RCTs, which is limiting the interpretation of findings within and across studies. This indicates a need for more validation work, along with consensus guidelines.

Electronic supplementary material

The online version of this article (doi:10.1007/s12160-015-9753-9) contains supplementary material, which is available to authorized users.

The Roles of Exercise and Yoga in Ameliorating Depression as a Risk Factor for Cognitive Decline

Currently, there are no effective pharmaceutical treatments to reduce cognitive decline or prevent dementia. At the same time, the global population is aging, and rates of dementia and mild cognitive impairment (MCI) are on the rise. As such, there is an increasing interest in complementary and alternative interventions to treat or reduce the risk of cognitive decline. Depression is one potentially modifiable risk factor for cognitive decline and dementia. Notably, exercise and yoga are two interventions known to both reduce symptoms of depression and improve cognitive function. The current review discusses the efficacy of exercise and yoga to ameliorate depression and thereby reduce the risk of cognitive decline and potentially prevent dementia. Potential mechanisms of change, treatment implications, and future directions are discussed.

Mechanistic Pathways of Mindfulness Meditation in Combat Veterans With Posttraumatic Stress Disorder

OBJECTIVE

This study's objective was to evaluate the effect of two common components of meditation (mindfulness and slow breathing) on potential mechanistic pathways.

METHODS

A total of 102 combat veterans with posttraumatic stress disorder (PTSD) were randomized to (a) the body scan mindfulness meditation (MM), (b) slow breathing (SB) with a biofeedback device, (c) mindful awareness of the breath with an intention to slow the breath (MM+SB), or (d) sitting quietly (SQ). Participants had 6 weekly one-on-one sessions with 20 minutes of daily home practice. The mechanistic pathways and measures were as follows: (a) autonomic nervous system (hyperarousal symptoms, heart rate [HR], and heart rate variability [HRV]); (b) frontal cortex activity (attentional network task [ANT] conflict effect and event-related negativity and intrusive thoughts); and (c) hypothalamic-pituitary-adrenal axis (awakening cortisol). PTSD measures were also evaluated.

RESULTS

Meditation participants had significant but modest within-group improvement in PTSD and related symptoms, although there were no effects between groups. Perceived impression of PTSD symptom improvement was greater in the meditation arms compared with controls. Resting respiration decreased in the meditation arms compared with SQ. For the mechanistic pathways, (a) subjective hyperarousal symptoms improved within-group (but not between groups) for MM, MM+SB, and SQ, while HR and HRV did not; (b) intrusive thoughts decreased in MM compared with MM+SB and SB, while the ANT measures did not change; and (c) MM had lower awakening cortisol within-group (but not between groups).

CONCLUSION

Treatment effects were mostly specific to self-report rather than physiological measures. Continued research is needed to further evaluate mindfulness meditation's mechanism in people with PTSD.

Veterans' Experiences using Complementary and Alternative Medicine for Posttraumatic Stress: A Qualitative Interpretive Meta-Synthesis

Combat Veterans struggling with combat-related post(*)traumatic stress disorder and subthreshold symptoms often look outside the conventional behavioral health care system for treatment because standard care has not met their needs. This study utilized a qualitative interpretive metasynthesis to describe the lived experience of combat Veterans seeking complementary and alternative health therapies for posttraumatic stress symptoms. This research aimed to understand what attracts these Veterans to complementary and alternative medicine techniques and how they benefit from their experiences with nonconventional therapies. Findings suggest the need for further research into increasing access and eliminating disparities for Veterans seeking more integrative care.

[Trauma-focused psychotherapy: Technique, area of application, and treatment outcome]

Traumatic events may lead to trauma-related disorders such as the posttraumatic stress disorder (PTSD) and constraints in quality of life. Meanwhile, there are different trauma-focused psychotherapies that aim to prevent PTSD shortly after experiencing a traumatic event and interventions that aim to treat PTSD. In Germany, cognitive-behavioral and psychodynamic trauma-focused approaches are commonly applied. While cognitive-behavioral programs aim at early exposure with the traumatic event, psychodynamic approaches emphasize the need of a period of stabilization before undergoing exposure. With regard to empirical evidence, cognitive-behavioral programs were able to prove their efficacy most often and are recommended in national and international guidelines. The German S3 guideline PTSD is currently under revision.

A time to be stressed? Time perspectives and cortisol dynamics among healthy adults

Perceptions of past, present, and future events may be related to stress pathophysiology. We assessed whether Time Perspective (TP) is associated with cortisol dynamics among healthy adults (N=61, Ages=18-35, M=22.9, SD=4.1) exposed to the Trier Social Stress Test (TSST). TP was measured according to two profiles: maladaptive Deviation from Balanced TP (DBTP) and adaptive Deviation from Negative TP (DNTP). Eight salivary cortisol samples were analyzed using area under the curve with respect to ground (AUCg) and to increase (AUCi). Statistic analyses involved partial correlations controlling for depressive symptoms. Results for both sexes showed that higher DBTP scores were associated with lower cortisol AUCg scores, while higher DNTP scores were associated with higher cortisol AUCg scores. These novel findings suggest that maladaptive TP profiles influence hypocortisolism, whereas adaptive TP profiles influence hypercortisolism. Thus, TP profiles may impact conditions characterized by altered cortisol concentrations.