MEDITATION FOR ANXIETY AND DEPRESSION

Tara McDonald, BSN, RN

Why is this important in primary care?

■ Prevalence of Anxiety:

– 40 million Americans affected in a given year

– The most common mental illness in U.S.

■ Prevalence of Depression:

– 15.7 million Americans affected in a given year

– Most common cause of disability

• Anxiety and depression overlap: one-half of those diagnosed with depression are also diagnosed with anxiety

• Women more affected than men

What can be done?

■ Treatment as usual

– Antidepressants, benzodiazepines

– Referral to psychology or psychiatry

– Referral to support groups

MEDITATIONA method of releasing the mind’s fixation on memories of the past as well as fixation on

the future, giving rise to a lessening of feelings of depression and anxiety

The identified problem

■ In adult patients with anxiety and depression, what is the effect of meditation on anxiety and depression symptoms?

STETLER MODELPreparation Validation Decision

MakingApplication Evaluation

Validation: Review of LiteratureChiesa, A, Serrati,

A. (2011)• Rated Excellent

• Meta-analysis of MBCT versus active controls measuring relapse rates in MD, Depression symptoms, anxiety symptoms in those diagnosed

• Standardized 8-week program, some studies w/o randomization, small sample sizes

• Improved relapse rates p<.003

• Improved depression symptoms per self-report BDI p<.003

• Reduced anxiety symptoms p=.002

• Consider further investigation of topic secondary promising research

Hofman, et al. (2010)

• Rated Excellent

• Meta-analysis of RCTs and observational studies for efficacy of mindfulness-based therapies on anxiety and depression symptoms.

• 1,140 total participants where (8) 1-hour sessions took place

• Those patients having symptoms but not necessarily diagnoses of MD or GAD were included.

• Some uncontrolled studies

• Improvements seen in those diagnosed and those having acute symptoms p<.01 for both anxiety and depression

• Could use per Stetler

Goyal, et al., (2014)

• Rated Excellent

• Meta-analysis of MBT on stress-related outcomes in a diverse adult population: anxiety, depression, stress, positive mood, substance use, eating and sleeping habits.

• 47 trials of MBT versus active control; 3,515 participants with at least one medical diagnosis, physical impairment, or stressed population.

• Control must be equally matched in time & attention to be included.

• Diverse population with active controls

• Moderate improvements in anxiety and depression symptoms with mindfulness meditation

• No statistically significant results for mood, etc.

Hoge, et al., (2015)

• Rated Good

• RCT of MBSR versus stress management education in reduction of anxiety symptoms

• N=93 GAD patients self-reporting anxiety via Hamilton Anxiety Scale and Beck Anxiety Inventory

• Small sample size, only extrapolate results to GAD patients, some on medications

• Strict quality controls: all evaluators master’s prepared. Controls were equal in time and attention.

• Results: greater reductions in anxiety in MBSR group p<.0001

• Could use per Stetler

Chen, et al., (2012)

• Rated Excellent

• Meta-analysis of all “meditative therapies”, including movement, in a varied adult population with anxiety symptoms.

• Determined that blinding was not necessary for inclusion

• Sample size>20, adult age, control

• N=36, 2,446 participants where baseline and post-intervention data was recorded.

• Practical quality assessment algorithm and author clarification.

• Pooled results favor MBT, p<.001

• Attention control, p<.001

• Active control, p=.003, MBT as effective as exercise, etc.

• Use per Stetler

Decision Making

High Efficacy of Meditation

High quality research

Use research findings

Implementation

• PHQ-9

• GAD-7Proper diagnosing

• NoneRisks &

Contraindications

•Administrative/Physician approval•Labor costs•Additional time

Barriers & Costs

Implementation Plan

Screen all adults > 18 years

Positive Screening

Negative Screening

Referral to Mental Health Specialist

RTC 4 weeks

Re-evaluate 1 year

GAD < 8, PHQ < 5

PHQ > 15 or suicidality

Symptom review

& exploration

GAD>8, PHQ 5-14 Meditation:definition, benefits, evidence

Rx: 5 min daily, 5x/wk x

4 wks

Evaluate: Weekly logs w/DASS 21

4 wk Follow up: Endpoint

GAD-7, PHQ-9

Begin/Modify medications or

refer as necessary

Referral to mental health specialist

GAD >8, PHQ 5-14

PHQ>15 or suicidality

The Meditation Prescription

1• Set aside a convenient, distraction-free time

2• Sit or lie in a comfortable position with your eyes closed.

3

• Take several deep breaths and try to relax; pay attention to the weight of your body on your floor or cushion. Let go of the tension in the body.

4

• Notice your breath. Feel the sensation of it in your nose, chest, and abdomen. Notice how your chest rises and falls. Continue to breathe naturally.

5

• You may notice that your mind begins to wander; this is natural. Gently redirect your attention back to the sensation of your breath.

6• Do this for five minutes.

7• Once again, bring your attention to your body. Smile. Go on with your day.

EvaluationWeekly logs of the following questions:

• How many times did you meditate this week?

• Did you feel that you had a clear understanding of what to do?

• Did you find it difficult? If so, why?

• Did anything change in your life that has made things especially difficult?

• Did anything change in your life that has made things much easier?

• Did you smoke or drink more than usual this week?

• Did you experience a benefit of any kind from meditating this week?

• Do you think you need to explore other avenues with respect to your symptoms?

Evaluation (continued)

■ Baseline versus endpoint PHQ-9 and GAD-7 data to be reviewed at 4 week follow up appointment.

■ Weekly logs to account for variations during intervention

– Encourage commitment

– Encourage curiosity

– Keep patients engaged

Evidence into practice &

higher levels of patient well being

More communication and education

Proper Diagnosis & Treatment

Addition of Meditation

References

■ Baer, R.A., Carmody, J., Hunsinger, M. (2012) Weekly Change in Mindfulness and Perceived Stress in a Mindfulness-Based Stress Reduction Program. Journal of Clinical Psychology, 68(7), 755-765.

■ Chen, K. W., Berger, C. C., Manheimer, E., Forde, D., Magidson, J., Dachman, L., & Lejuez, C. W. (2012). Meditative therapies for reducing anxiety: a systematic review and meta-analysis of randomized controlled trials. Depression and Anxiety, 29(7), 545-562. doi:10.1002/da.21964

■ Chiesa, A., Serretti, A. (2011). Mindfulness based cognitive therapy for psychiatric disorders: A systematic review and meta-analysis. Psychiatry Research 187 (3). 441-453. doi:10.1016/j.psychres.2010.08.011

■ Goyal, M., Singh, S., Sibinga, E.S., Gould, N.F., Rowland-Seymour,A., Sharma, R., Berger, Z., Sleicher, D., Maron, D.D., Shihab, H.M., Ranasinghe,P.D., Linn, S., Saha, S., Bass, E.B., Haythornthwaite, J.A. (2014). Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. Journal of the American Medical Association, 174(3): 357-368. doi:10.1001/jamainternmed.2013.13018

■ Hofman, S. G., Sawyer, A.T., Witt, A.A. & Oh, D. (2010). The Effect of Minfulness-based Therapy on Anxiety and Depression: a Meta-analytic Review. Journal of Consulting and Clinical Psychology, 2(78), 169-183. doi: 10.1037/a0018555

■ Hoge, E.A., Bui, E., Marques. L., Metcalf, C.A., Morris, L.K., Robinaugh, D.J., Worthington, J.J., Pollack, Simon, N.M. (2013). Randomized Controlled Trial of Mindfulness Meditation for Generalized Anxiety Disorder: Effects on Anxiety and Stress Reactivity. Journal of Clinical Psychiatry, 74(8): 786-792. doi: 10.4088/JCP.12m08083

■ Meditation. (n.d.) In National Center for Complementary and Integrative Medicine. Retrieved online from https://nccih.nih.gov/health/meditation/overview.htm

■ Ronk, F. R., Korman, J. R., Hooke, G. R., & Page, A. C. (2013). Assessing clinical significance of treatment outcomes using the DASS-21. Psychological Assessment, 25(4), 1103-1110. doi:10.1037/a0033100

■ Siu A., & the U.S. Preventive Services Task Force (USPSTF). (2016) Screening for Depression in Adults: U.S. Preventive Services Task Force Recommendation Statement. Journal of American Medical Association, 315(4), 380-387. doi:10.1001/jama.2015.18392.