Written by Calvin Yip, Canadian Forces Physical Rehabilitation Research Student (Federal Student Work Experience Program- FSWEP)
“[Mindfulness is] the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment”
What is mindfulness and why should Canadian Forces Health Services care?
Mindfulness has been defined as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment” (Kabat-Zinn, 2003). In 1982, Jon Kabat-Zinn authored one of the first articles documenting the use of a mindfulness-based therapy for clinical purposes. He found the intervention to be associated with marked decreases in the severity of chronic pain (Kabat-Zinn, 1982). Since then, the body of literature on mindfulness-based health interventions has grown substantially, with a review of systematic reviews identifying 81 systematic reviews (including hundreds of studies in total) in this topic area (Shekelle et al., 2014). Overall, the evidence implicated a potential positive effect of mindfulness-based interventions for 10 health conditions including depression, chronic illness and pain (Shekelle et al., 2014). In the U.S. military, many positive health impacts have been reported following mindfulness training including decreases in pain, stress and anxiety (Stanley et al., 2011; U.S. Army, 2015).
Why conduct additional reviews?
Despite the growing evidence suggesting that mindfulness-based interventions are likely beneficial for health in general, the information is insufficient to guide decision making within the Canadian Forces. Conclusions cannot be drawn from an individual study, and existing systematic reviews do not provide findings pertaining to a specific mindfulness-based intervention for a specific health condition. To address this knowledge gap, separate reviews were conducted for each of the 4 conditions of interest identified by mental health professionals in the Canadian Forces. These conditions were depression, post-traumatic stress disorder (PTSD), substance use disorders (SUDs) and traumatic brain injury (TBI).
Findings were promising and consistent for depression, where all 14 randomized control trials (RCTs) described the intervention as a variation of mindfulness-based cognitive therapy (MBCT), an intervention previously developed by Segal et al. (2002). All but one of the RCTs reported significant improvements in at least one main outcome, two found MBCT to be as effective as antidepressant medication, and two others found MBCT to be as effective as cognitive behavioural therapy (CBT). Results were also positive for PTSD, with all 7 RCTs reporting significant improvements in at least one main outcome attributable to the intervention. Multiple RCTs reported significant improvements in PTSD symptoms and quality of life measures. Interestingly, 6 of the RCTs were conducted in a veteran population, and every one of them used an intervention reminiscent of the mindfulness-based stress reduction (MBSR) program originally developed by Kabat-Zinn (1982).
Findings were less consistent for SUDs and TBI. Of the 9 RCTs that investigated SUDs, 8 reported significant improvements in at least one main outcome attributable to the intervention. Although mindfulness-based interventions may be beneficial for SUDs in general, conclusions cannot be drawn from the available evidence due to the heterogeneity in the type of intervention, outcome measures, and specific SUD. The review for TBI proved to be a challenge, as the limited size and scope of the existing literature made it infeasible to limit the review to only RCTs as with the other 3 reviews. Seven studies were retrieved and 6 of these reported improvements in at least one main outcome attributable to the intervention, though several key limitations must be considered. These include the particularly small sample sizes (the largest study included only 76 participants, and the mean number of participants for all studies was only 31) and concerns of methodological weakness (4 out of the 7 studies reviewed were not RCTs). Three studies lacked a control group and one lacked random assignment to conditions.
In light of the positive and consistent findings from the aforementioned reviews, MBCT-based interventions are recommended for depression and MBSR-based interventions are recommended for PTSD. Stemming from inconclusive and insufficient evidence, no recommendations can be made at the present time regarding the use of mindfulness-based interventions for individuals experiencing SUDs or TBI. Instead, further research on the impact of mindfulness on SUDs and TBI is recommended.
- Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry 1982;4:33-47.
- Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol Sci Pract 2003;10:144-156.
- Shekelle PG. Evidence map of mindfulness (2014). retrieved from http://www.hsrd.research.va.gov/publications/esp/cam_mindfulness-report.pdf
- Segal ZV, Williams JMA, Teasdale ID. Mindfulness-based cognitive therapy for depression: a new approach to preventing relapse (2002). Guilford Press: New York.
- Stanley EA, Schaldach JM, Kiyonaga A. Mindfulness-based mind fitness training: a case study of a high-stress predeployment military cohort. Cogn Behav Prac 2011;18:566-576.
- U.S. Army. Mndfulness-based stress reduction finds a place in the military (2015). retrieved from http://www.army.mil/article/151787/mindfulness_based_stress_reduction_finds_a_place_in_the_military/
So tell us: Are you using a mindfulness approach in your everyday practice?