Mr. A, age 45, reports irritability, loss of interest, sleep disturbance, increased self-criticism, and decreased self care during the last month after a promotion at work. He has a history of 3 major depressive episodes, 1 of which required hospitalization. For the last 2 years his depressive symptoms had been successfully managed with escitalopram, 10 mg/d, plus bupropion, 150 mg/d. Mr. A wants to discontinue these medications because of sexual dysfunction. He asks if nonpharmacologic strategies might help.
One option to consider for Mr. A is mindfulness-based cognitive therapy (MBCT), which was originally developed to help prevent depressive relapse. MBCT also can reduce depression and anxiety symptoms. More recently, MBCT was shown to help individuals discontinue antidepressants after recovering from depression.
Regular mindfulness meditation has been shown to result in structural brain changes that may help explain how the practice effectively addresses psychiatric symptoms ( Box ). With appropriate training, psychiatrists can help patients reap the benefits of this cognitive treatment.
Regular mindfulness practice has been shown to increase cortical thickness in areas associated with attention, interoception, and sensory processing, such as the prefrontal cortex and right anterior insula.a This supports the hypothesis that mindfulness is a way of attuning the mind to one’s internal processes, and that this involves the same social neural circuits involved in interpersonal attunement—middle prefrontal regions, insula, superior temporal cortex, and the mirror neuron system.b
Amygdala responses. Mindfulness improves affect regulation by optimizing prefrontal cortex regulation of the amygdala. Recent developments in understanding the pathophysiology of depression have highlighted the lack of engagement of left lateral-ventromedial prefrontal circuitry important for the down-regulation of amygdala responses to negative stimuli.c Dispositional mindfulness is associated with greater prefrontal cortical activation and associated greater reduction in amygdala activity during affect labeling tasks, which results in enhanced affect regulation in individuals with higher levels of mindfulness.d
Left-sided anterior activation. Other researchers have examined mindfulness’ role in maintaining balanced prefrontal asymmetry. Relative left prefrontal activation is related to an affective style characterized by stronger tendencies toward positive emotional responses and approach/reward oriented behavior, whereas relative right-sided activation is associated with stronger tendencies toward negative emotional responses and avoidant/withdrawal oriented behavior.
One study found significant increases in left-sided anterior activation in mindfulness-based stress reduction participants compared with controls.e Similarly, in a study evaluating the effect of mindfulness-based cognitive therapy (MBCT) on frontal asymmetry in previously suicidal individuals, MBCT participants retained a balanced pattern of prefrontal activation, whereas the treatment-as-usual group showed significant deterioration toward decreased relative left frontal activation. These findings suggest a protective effect of the mindfulness intervention.f
What is mindfulness meditation?
Meditation refers to a variety of practices that intentionally focus attention to help the practitioner disengage from unconscious absorption in thoughts and feelings. Unlike concentrative meditation—in which practitioners focus attention on a single object such as a word (mantra), body part, or external object—in mindfulness meditation participants bring their attention to a wide range of objects (such as breath, body, emotions, or thoughts) as they appear in moment-by-moment awareness.
Mindfulness is a nonjudgmental, present-centered awareness in which each thought, feeling, or sensation that arises in the attentional field is acknowledged and accepted as it is.1-3 Bishop et al4 defined a 2-component model of mindfulness:
- self-regulating attention of immediate experience, thereby allowing for increased recognition of mental events in the present moment
- adopting an orientation of curiosity, openness, and acceptance toward one’s experiences in each moment.
Buddhist and Western psychology inform the theoretical framework of most mindfulness-based clinical interventions, such as:
- acceptance and commitment therapy (ACT)
- dialectical behavioral therapy (DBT)
- mindfulness-based stress reduction (MBSR)
Because mindfulness is only 1 of several components of ACT and DBT,5 this review focuses on MBCT and MBSR, in which teaching mindfulness skills is the central focus of treatment.
- formal mindfulness meditation practices such as body scan (intentionally bringing awareness to bodily sensations), mindful stretching, and mindfulness of breath/body/sounds/thoughts
- informal practices, including mindfulness of daily activities such as eating.1
MBSR typically involves 8 to 10 weekly group sessions of 2 to 2.5 hours with 10 to 40 participants with heterogeneous or homogenous clinical presentations. At each session, patients are taught mindfulness skills and practices. Typically, a full day of meditation practice on a weekend follows session 5 or 6. Participants also engage in a daily meditation practice and homework exercises directed at integrating awareness skills into daily life.