Library of Research Articles on Veterans and CIH Therapies
Library of Research Articles on Veterans and Complementary and Integrative Health Therapies and Chiropractic Care
January 2021 Edition
Beck D, Cosco Holt L, Burkard J, Andrews T, Liu L, Heppner P, Bormann JE. Efficacy of the Mantram Repetition Program for Insomnia in Veterans With Posttraumatic Stress Disorder: A Naturalistic Study. ANS Adv Nurs Sci. 2017 Apr/Jun;40(2):E1-E12. doi: 10.1097/ANS.0000000000000144.
Statistics show that more than 80% of Veterans mention posttraumatic stress disorder (PTSD)-related symptoms when seeking treatment. Sleep disturbances and nightmares are among the top 3 presenting problems. Current PTSD trauma-focused therapies generally do not improve sleep disturbances. The mantram repetition program (MRP), a mind-body-spiritual intervention, teaches a portable set of cognitive-spiritual skills for symptom management. The aim of this study was to evaluate the efficacy of the MRP on insomnia in Veterans with PTSD in a naturalistic, clinical setting. Results show that participation in the MRP significantly reduced insomnia, as well as decreased self-reported and clinician-assessed PTSD symptom burden.
Bormann JE, Hurst S, Kelly A. Responses to Mantram Repetition Program from Veterans with posttraumatic stress disorder: a qualitative analysis. J Rehabil Res Dev. 2013
This study describes ways in which a Mantram Repetition Program (MRP) was used for managing posttraumatic stress disorder (PTSD) symptoms in 65 outpatient Veterans with PTSD. The MRP consisted of six weekly group sessions (90 min/wk) on how to (1) choose and use a mantram, (2) slow down thoughts and behaviors, and (3) develop one-pointed attention for emotional self-regulation. Critical incident research technique interviews were conducted at 3 mo postintervention as part of a larger randomized clinical trial. The setting was an academic-affiliated Department of Veterans Affairs hospital in southern California. Categorization and comparison of the types and frequency of incidents (i.e., triggering events) were collected. Participants reported a total of 268 triggering events. Content analysis of the outcomes resulted in 12 discreet categories, including relaxing and calming down, letting go of negative feelings, thinking clearly and rationally, diverting attention away from triggering events, focusing attention, refining mantram skills, dealing with sleep disturbances, coming back from flashbacks, slowing down, communicating thoughts and feelings more effectively, feeling in touch spiritually, and letting go of physical pain. The study shows that the MRP was helpful in managing a wide range of emotional reactions in Veterans with PTSD.
Bormann JE, Oman D, Walter KH, Johnson BD. Mindful attention increases and mediates psychological outcomes following mantram repetition practice in veterans with posttraumatic stress disorder. Med Care. 2014 Dec;52(12 Suppl 5):S13-8. doi: 10.1097/MLR.0000000000000200. PubMed PMID: 25397817
Several evidence-based treatments are available to veterans diagnosed with posttraumatic stress disorder (PTSD). However, not all veterans benefit from these treatments or prefer to engage in them.
The current study explored whether (1) a mantram repetition program (MRP) increased mindful attention among veterans with PTSD, (2) mindful attention mediated reduced PTSD symptom severity and enhanced psychological well-being, and (3) improvement in mindful attention was due to the frequency of mantram repetition practice.
Data from a randomized controlled trial comparing MRP plus treatment as usual (MRP+TAU) or TAU were analyzed using hierarchical linear models.
Subjects: A total of 146 veterans with PTSD from military-related trauma were recruited from a Veterans Affairs outpatient PTSD clinic (71 MRP+TAU; 75 TAU).
Measures: The Clinician Administered PTSD Scale (CAPS), PTSD Checklist (PCL), the Brief Symptom Inventory-18 depression subscale, Health Survey SF-12v2, and Mindfulness Attention Awareness Scale (MAAS) were used. Frequency of mantram repetition practice was measured using wrist-worn counters and daily logs.
Intent-to-treat analyses indicated greater increases in mindful attention, as measured by the MAAS, for MRP+TAU as compared with TAU participants (P<0.01). Mindful attention gains mediated previously reported treatment effects on reduced PTSD symptoms (using both CAPS and PCL), reduced depression, and improved psychological well-being. Frequency of mantram repetition practice in turn mediated increased mindful attention.
The MRP intervention and specifically, mantram practice, improved mindful attention in veterans with PTSD, yielding improved overall psychological well-being. MRP may be a beneficial adjunct to usual care in veterans with PTSD.
Bormann JE, Thorp SR, Smith E, Glickman M, Beck D, Plumb D, Zhao S, Ackland PE, Rodgers CS, Heppner P, Herz LR, Elwy AR. Individual Treatment of Posttraumatic Stress Disorder Using Mantram Repetition: A Randomized Clinical Trial. Am J Psychiatry. 2018 Oct 1;175(10):979-988. doi: 10.1176/appi.ajp.2018.17060611. Epub 2018 Jun 20. PubMed PMID: 29921143.
Previous studies suggest that group "mantram" (sacred word) repetition therapy, a non-trauma-focused complementary therapy for posttraumatic stress disorder (PTSD), may be an effective treatment for veterans. The authors compared individually delivered mantram repetition therapy and another non-trauma-focused treatment for PTSD.
The study was a two-site, open-allocation, blinded-assessment randomized trial involving 173 veterans diagnosed with military-related PTSD from two Veterans Affairs outpatient clinics (January 2012 to March 2014). The mantram group (N=89) learned skills for silent mantram repetition, slowing thoughts, and one-pointed attention. The comparison group (N=84) received present-centered therapy, focusing on currently stressful events and problem-solving skills. Both treatments were delivered individually in eight weekly 1-hour sessions. The primary outcome measure was change in PTSD symptom severity, as measured by the Clinician-Administered PTSD Scale (CAPS) and by self-report. Secondary outcome measures included insomnia, depression, anger, spiritual well-being, mindfulness, and quality of life. Intent-to-treat analysis was conducted using linear mixed models.
The mantram group had significantly greater improvements in CAPS score than the present-centered therapy group, both at the posttreatment assessment (between-group difference across time, -9.98, 95% CI=-3.63, -16.00; d=0.49) and at the 2-month follow-up (between-group difference, -9.34, 95% CI=-1.50, -17.18; d=0.46). Self-reported PTSD symptom severity was also lower in the mantram group compared with the present-centered therapy group at the posttreatment assessment, but there was no difference at the 2-month follow-up. Significantly more participants in the mantram group (59%) than in the present-centered therapy group (40%) who completed the 2-month follow-up no longer met criteria for PTSD (p<0.04). However, the percentage of participants in the mantram group (75%) compared with participants in the present-centered therapy group (61%) who experienced clinically meaningful changes (≥10-point improvements) in CAPS score did not differ significantly between groups. Reductions in insomnia were significantly greater for participants in the mantram group at both posttreatment assessment and 2-month follow-up.
In a sample of veterans with PTSD, individually delivered mantram repetition therapy was generally more effective than present-centered therapy for reducing PTSD symptom severity and insomnia.
Bormann JE, Weinrich S, Allard CB, Beck D, Johnson BD, Holt LC. Chapter 5 mantram repetition: an evidence-based complementary practice for military personnel and veterans in the 21st century. Annu Rev Nurs Res. 2014;32:79‐108. doi:10.1891/0739-6686.32.79
Today in the digital age, with our advances in modern technology and communication, there are additional stressors for our military personnel and Veterans. Constant dangers exist both on and off the battlefield, unlike prior wars that had clearly-defined war zones. In addition, medical advances have assisted in saving the lives of many more gravely injured troops than ever previously possible. As the wars in Iraq and Afghanistan come to an end, large numbers of service men and women are returning home with multiple injuries. This group of Veterans has significantly higher rates of posttraumatic stress disorder (PTSD) and traumatic brain injury than ever before reported. Although existing PTSD therapies have been found to be highly effective for many Veterans, there is a substantial minority unsatisfactorily treated. Mantram repetition, an innovative, complementary, evidence-based treatment, is proving to be successful for these new Veterans. When used regularly it helps with "road rage, impatience, anger, frustration, and being out of control." A mantram is a brief, sacred word or phrase that embodies divine power or the greatest positive energy one can imagine (Easwaran, 2008a). Mantram repetition is a simple, quick, personal, portable, and private complementary practice that may be used as an adjunct to current treatments for PTSD. Growing research evidence supports mantram repetition's value for dissemination and adoption in the 21st century. This chapter summarizes Mantram Program research conducted from 2003 to 2014. It describes the health-related benefits of the Mantram Program in various populations. The current research focuses on benefits for managing psychological distress and promoting quality of life in Veterans. Future areas for research are suggested.
Bravo AJ, Witkiewitz K, Kelley ML, Redman JC. Prevalence of Mental Health Problems and Willingness to Participate in a Mindfulness Treatment: An Examination among Veterans Injured in Combat. Mindfulness (N Y). 2019 May
Numerous studies have demonstrated that combat-exposed military veterans are at risk for numerous psychiatric disorders and rates of comorbid mental health and substance use disorders are high. Veterans wounded in combat are a particularly high-risk group of military veterans, however treatment services are often underutilized among this group and it is unclear whether an online treatment program that targets emotional and physical distress (including mental health symptoms and substance use disorders) would be appealing to Veterans wounded in combat. The goal of the current study was to conduct formative research on whether veterans wounded in combat would be interested in an online mindfulness-based treatment to help them cope with emotional and physical discomfort. We recruited Veterans from Combat Wounded Coalition (n = 163; 74.2% non-Hispanic White; 95.7% male) to complete an online survey of mental health and substance use disorder symptoms and willingness to participate in mindfulness treatment. The majority of participants reported significant mental health symptoms and indicated that they would be willing to participate in mindfulness treatment, either at the VA (54.0%) or online (59.5%). Those with problems in multiple health domains and lower self-compassion were significantly more likely to express interest in treatment and likely to represent a very high need group of veterans. The development of a mindfulness-based treatment for this group of individuals could be very helpful in reducing mental health symptoms and improving quality of life among wounded warriors.
Bremner JD, Mishra S, Campanella C, Shah M, Kasher N, Evans S, Fani N, Shah AJ, Reiff C, Davis LL, Vaccarino V, Carmody J. A Pilot Study of the Effects of Mindfulness-Based Stress Reduction on Post-traumatic Stress Disorder Symptoms and Brain Response to Traumatic Reminders of Combat in Operation Enduring Freedom/Operation Iraqi Freedom Combat Veterans with Post-traumatic Stress Disorder. Front Psychiatry. 2017 Aug 25;8:157.
Brain imaging studies in patients with post-traumatic stress disorder (PTSD) have implicated a circuitry of brain regions including the medial prefrontal cortex, amygdala, hippocampus, parietal cortex, and insula. Pharmacological treatment studies have shown a reversal of medial prefrontal deficits in response to traumatic reminders. Mindfulness-based stress reduction (MBSR) is a promising non-pharmacologic approach to the treatment of anxiety and pain disorders. The purpose of this study was to assess the effects of MBSR on PTSD symptoms and brain response to traumatic reminders measured with positron-emission tomography (PET) in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat veterans with PTSD. We hypothesized that MBSR would show increased prefrontal response to stress and improved PTSD symptoms in veterans with PTSD.
Twenty-six OEF/OIF combat veterans with PTSD who had recently returned from a combat zone were block randomized to receive eight sessions of MBSR or present-centered group therapy (PCGT). PTSD patients underwent assessment of PTSD symptoms with the Clinician-Administered PTSD Scale (CAPS), mindfulness with the Five Factor Mindfulness Questionnaire (FFMQ) and brain imaging using PET in conjunction with exposure to neutral and Iraq combat-related slides and sound before and after treatment. Nine patients in the MBSR group and 8 in the PCGT group completed all study procedures.
Post-traumatic stress disorder patients treated with MBSR (but not PCGT) had an improvement in PTSD symptoms measured with the CAPS that persisted for 6 months after treatment. MBSR also resulted in an increase in mindfulness measured with the FFMQ. MBSR-treated patients had increased anterior cingulate and inferior parietal lobule and decreased insula and precuneus function in response to traumatic reminders compared to the PCGT group.
This study shows that MBSR is a safe and effective treatment for PTSD. Furthermore, MBSR treatment is associated with changes in brain regions that have been implicated in PTSD and are involved in extinction of fear responses to traumatic memories as well as regulation of the stress response.
Buttner MM, Bormann JE, Weingart K, Andrews T, Ferguson M, Afari N. Multi-site evaluation of a complementary, spiritually-based intervention for Veterans: The Mantram Repetition Program. Complement Ther Clin Pract. 2016 Feb;22:74-9. doi: 10.1016/j.ctcp.2015.12.008. Epub 2015 Dec 19.
Mental and physical symptoms affect Veterans' quality of life. Despite available conventional treatments, an increasing number of Veterans are seeking complementary approaches to symptom management. Research on the Mantram Repetition Program (MRP), a spiritually-based intervention, has shown significant improvements in psychological distress and spiritual well-being in randomized trials. However, these findings have not been replicated in real-world settings.
In this naturalistic study, we analyzed outcomes from 273 Veterans who participated in MRP at six sites and explored outcomes based on facilitator training methods. Measures included satisfaction and symptoms of anxiety, depression, and somatization using the Brief Symptom Inventory-18; Functional Assessment of Chronic Illness Therapy-Spiritual Well-being questionnaire; and the Mindfulness Attention Awareness Scale.
There were significant improvements in all outcomes (p's < .001) regardless of how facilitators were trained. Patient satisfaction was high.
The MRP was disseminated successfully yielding improvements in psychological distress, spiritual well-being, and mindfulness.
Colgan DD, Christopher M, Michael P, Wahbeh H. The Body Scan and Mindful Breathing Among Veterans with PTSD: Type of Intervention Moderates the Relationship Between Changes in Mindfulness and Post-treatment Depression. Mindfulness (N Y). 2016;7(2):372-383. doi: 10.1007/s12671-015-0453-0. Epub 2015 Oct 20. PMID: 32863982; PMCID: PMC7451147.
Mindfulness-based stress reduction (MBSR) is a promising intervention for veterans with post-traumatic stress disorder (PTSD) and depression; however, a more detailed examination of the different elements of MBSR and various facets of mindfulness to determine what works best for whom is warranted. One hundred and two veterans with PTSD were randomly assigned to one of four arms: (a) body scan (BS; n= 27), (b) mindful breathing (MB; n=25), (c) slow breathing (SB; n=25), or (d) sitting quietly (SQ; n=25). The purpose of this study was to (a) examine two separate components of MBSR (i.e., body scan and mindful breathing) among veterans with PTSD when compared to a nonmindfulness intervention (SB) and a control group (SQ), (b) assess if changes in specific mindfulness facets were predictive of post-treatment PTSD and depression for individuals who participated in a mindfulness intervention (BS vs. MB), and (c) investigate if type of mindfulness intervention received would moderate the relationship between pre- to post-treatment changes in mindfulness facets and post-treatment outcomes in PTSD and depression. Participants in the mindfulness groups experienced significant decreases in PTSD and depression symptom severity and increases in mindfulness, whereas the nonmindfulness groups did not. Among veterans who participated in a mindfulness group, change in the five facets of mindfulness accounted for 23 % of unique variance in the prediction of post-treatment depression scores. Simple slope analyses revealed that type of mindfulness intervention moderated the relationship among changes in facets of mindfulness and post-treatment depression.
Colgan DD, Wahbeh H, Pleet M, Besler K, Christopher M. A Qualitative Study of Mindfulness Among Veterans With Posttraumatic Stress Disorder: Practices Differentially Affect Symptoms, Aspects of Well-Being, and Potential Mechanisms of Action. J Evid Based Complementary Altern Med. 2017
This qualitative study explored and compared the subjective experiences of 102 veterans with posttraumatic stress disorder (PTSD) who were randomly assigned to 1 of 4 arms: ( a) body scan, ( b) mindful breathing, ( c) slow breathing, or ( d) sitting quietly. Qualitative data were obtained via semistructured interviews following the intervention and analyzed using conventional content analysis. The percentage of participants within each intervention who endorsed a specific theme was calculated. Two-proportion z tests were then calculated to determine if the differences among themes endorsed in specific groups were statistically significant. Six core themes emerged from analysis of participant responses across the 4 groups: ( a) enhanced present moment awareness, ( b) increased nonreactivity, ( c) increased nonjudgmental acceptance, ( d) decreased physiological arousal and stress reactivity, ( e) increased active coping skills, and ( f) greater relaxation. More participants in the mindfulness intervention groups reported improvement in PTSD symptoms when compared to participants in non-mindfulness groups. Different types of intervention targeted different symptoms and aspects of well-being. Furthermore, type of intervention may have also differentially targeted potential mechanisms of action. This article highlights the importance of employing both quantitative and qualitative research methods when investigating the dynamic process of mindfulness and may inform how practices can be tailored to the needs of the veteran with PTSD.
Cosio D, Swaroop S. The Use of Mind-body Medicine in Chronic Pain Management: Differential Trends and Session-by-Session Changes in Anxiety. J Pain Manag Med. 2016 Mar
The evidence to date suggests that the use of mind-body medicine in chronic pain management can improve physical and psychological symptoms. However, past research evidence has largely relied on global measures of distress at pre- and post-intervention. Even though it is plausible that reported anxiety occurs in the context of pain, there is also evidence to suggest a reciprocal relationship. Thus, the purpose of the current study was to determine the differential impact that mind-body medical interventions have on anxiety among Veterans with chronic, non-cancer pain. The current study utilized multiple, repeated assessments of anxiety to better understand changes made over time between two mind-body interventions (Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral Therapy (CBT)) used for chronic pain management. Ninety-six Veterans elected to participate in either intervention following the completion of a pain health education program at a Midwestern VA Medical Center between November 3, 2009-November 4, 2010. A 2 × 7 repeated measures multivariate analyses of variance indicated significantly lower levels of global distress by the end of both the ACT and CBT interventions. Trend analysis revealed differential patterns of change in levels of anxiety over time. Helmert contrast analyses found several modules of ACT were statistically different than the overall mean of previous sessions. Implications related to timing and patterns of change for the interventions are discussed.
Crawford JN, Talkovsky AM, Bormann JE, Lang AJ. Targeting hyperarousal: Mantram Repetition Program for PTSD in US veterans. Eur J Psychotraumatol. 2019 Sep 30;10(1):1665768. doi: 10.1080/20008198.2019.1665768.
Hyperarousal appears to play an important role in the development and maintenance of posttraumatic stress disorder (PTSD) symptoms, but current evidence-based treatments appear to address this symptom type less effectively than the other symptom clusters. The Mantram Repetition Program (MRP) is a meditation-based intervention that has previously been shown to improve symptoms of posttraumatic stress disorder (PTSD) and may be especially helpful for hyperarousal. If MRP is an effective tool for decreasing this often treatment-resistant symptom cluster, it may become an important clinical tool.
The goal of this secondary analysis was to examine the effect of the MRP on hyperarousal and other PTSD symptom clusters and to examine hyperarousal as a mediator of treatment response.
Secondary analyses were conducted on data from a randomized controlled trial in which Veterans with PTSD (n = 173) were assigned to the MRP or a non-specific psychotherapy control and assessed pre-treatment, post-treatment and 8 weeks after treatment completion. The impact of the interventions on PTSD symptom clusters was examined, and time-lagged hierarchical linear modelling was applied to examine alternative mediation models.
All PTSD symptom clusters improved in both treatments. MRP led to greater reductions in hyperarousal at post-treatment (Hedge's g = 0.57) and follow-up (Hedge's g = 0.52), and in numbing at post-treatment (Hedge's g = 0.47). Hyperarousal mediated reductions in the composite of the other PTSD symptom clusters. Although the reverse model was significant as well, the effect was weaker in this direction.
Interventions focused on the management of hyperarousal may play an important role in recovery from PTSD. The MRP appears efficacious in reducing hyperarousal, and thereby impacting other PTSD symptom clusters, as one pathway to facilitating recovery.
Cushing RE, Braun KL. Mind-Body Therapy for Military Veterans with Post-Traumatic Stress Disorder: A Systematic Review. J Altern Complement Med. 2018 Feb;24(2):106-114. doi: 10.1089/acm.2017.0176. Epub 2017 Sep 7. Review. PubMed PMID: 28880607.
About one-third of service members returning from post-9/11 deployment in Afghanistan and Iraq report combat-related mental health conditions, but many do not seek conventional treatment. Mind-body therapies have been offered as alternative approaches to decreasing post-traumatic stress disorder (PTSD), but no review of studies with veterans of post-9/11 operations was found. The objective of this study was to fill that gap.
A systematic literature review was conducted following the preferred items for systematic reviews and meta-analyses (PRISMA) guidelines. PubMed MeSH terms were used to capture articles reporting on the military population (veteran and veterans) with PTSD who received a portable mind-body intervention (e.g., mindfulness, mind-body therapy, and yoga). PubMed/MEDLINE and PsycINFO were searched. Studies were included if participants were a mixed group of war veterans, as long as some post-9/11 veterans were included. In addition, participants must have had a diagnosis of PTSD or subthreshold PTSD, and the PTSD must have been attributable to combat, rather than another event, such as sexual trauma or natural disaster.
Of 175 records identified, 15 met inclusion criteria. Studies reported on seated or gentle yoga that included breath work, meditation, mantra repetition, or breathing exercises. For 14 of the 15 studies, study retention was 70% or higher. Overall, studies reported significant improvements in PTSD symptoms in participants in these interventions. Although each study included post-9/11 veterans, about 85% of participants were from other conflicts, predominantly Vietnam.
Dahm KA, Meyer EC, Neff KD, Kimbrel NA, Gulliver SB, Morissette SB. Mindfulness, Self-Compassion, Posttraumatic Stress Disorder Symptoms, and Functional Disability in U.S. Iraq and Afghanistan War Veterans. J Trauma Stress. 2015 Oct;28(5):460-4. doi: 10.1002/jts.22045. Epub 2015 Oct 1.
Mindfulness and self-compassion are overlapping, but distinct constructs that characterize how people relate to emotional distress. Both are associated with posttraumatic stress disorder (PTSD) and may be related to functional disability. Although self-compassion includes mindful awareness of emotional distress, it is a broader construct that also includes being kind and supportive to oneself and viewing suffering as part of the shared human experience--a potentially powerful way of dealing with distressing situations. We examined the association of mindfulness and self-compassion with PTSD symptom severity and functional disability in 115 trauma-exposed U.S. Iraq/Afghanistan war veterans. Mindfulness and self-compassion were each uniquely, negatively associated with PTSD symptom severity. After accounting for mindfulness, self-compassion accounted for unique variance in PTSD symptom severity (f(2) = .25; medium ES). After accounting for PTSD symptom severity, mindfulness and self-compassion were each uniquely negatively associated with functional disability. The combined association of mindfulness and self-compassion with disability over and above PTSD was large (f(2) = .41). After accounting for mindfulness, self-compassion accounted for unique variance in disability (f(2) = .13; small ES). These findings suggest that interventions aimed at increasing mindfulness and self-compassion could potentially decrease functional disability in returning veterans with PTSD symptoms.
Davis L, et al. A Multisite Randomized Controlled Trial of Mindfulness‐Based Stress Reduction in the Treatment of Posttraumatic Stress Disorder. Psychiatric research & clinical practice. 2018
Posttraumatic stress disorder (PTSD) is often difficult to treat, and many patients do not achieve full remission. Complementary and integrative health approaches, such as mindfulness meditation, are intended to be integrated with evidence‐based treatment. This study examined the efficacy of mindfulness‐based stress reduction (MBSR) in the treatment of PTSD in U.S. military veterans.
Veterans with a diagnosis of PTSD (N=214) were randomly assigned to either 90‐minute group MBSR or present‐centered group therapy (PCGT) for eight weeks. Follow‐up assessments were obtained at baseline and weeks 3, 6, 9 (primary endpoint), and 16.
Both the MBSR and PCGT groups achieved significant improvement in PTSD as measured by the Clinician‐Administered PTSD Scale for DSM‐IV (CAPS‐IV), with no statistically significant differences between groups. However, compared with PCGT, the MBSR group showed a statistically significant improvement in PTSD on the self‐reported PTSD Checklist for DSM‐IV over the nine weeks. This difference was not maintained posttreatment, at week 16. Strengths of the study include its large sample size, multisite design, active control group, single‐blind outcome ratings, fidelity monitoring, large minority representation, and randomized approach. The study was limited by its high attrition rate and low representation of women.
Both MBSR and PCGT appear to have beneficial effects in treating PTSD in veterans, with greater improvement observed in self‐reported PTSD symptoms in the MBSR group. No differences between groups were observed on the CAPS‐IV scale.
DiNardo M, Saba S, Greco CM, Broyles L, Terhorst L, Chasens ER, Bair B, Charron-Prochownik D, Cohen S. A Mindful Approach to Diabetes Self-Management Education and Support for Veterans. Diabetes Educ. 2017 Dec;43(6):608-620. doi: 10.1177/0145721717738019. Epub 2017 Oct 27.
The purpose of this study is to determine feasibility, satisfaction, and preliminary effects of Mindful Stress Reduction in Diabetes Education (Mind-STRIDE), a mindfulness-based intervention for veterans.
The study used a single-group pretest-posttest repeated-measures design. The 90-minute Mind-STRIDE training, adapted from Mindfulness Based Stress Reduction (MBSR), was provided as the final component of a half-day diabetes self-management education class at a Veterans Affairs (VA) outpatient diabetes clinic. Following initial training, participants were asked to practice mindfulness at home for 10 minutes each day during the 3-month study. Study recruitment and retention were calculated as rates. Veteran and diabetes educator satisfaction were assessed by rating scales and open-ended comments. Psychosocial-behavioral and metabolic outcomes were assessed at baseline and 3 months after initial training. Bivariate correlations were performed to describe relationships between mindfulness and other outcome variables. Gain scores and Wilcoxon matched-pair signed rank tests were used to assess pre to post changes; Cohen's d was applied to estimate the magnitude of effects.
Twenty-eight of 49 eligible veterans (57%) enrolled in the study. Of those, 11 veterans (39%) demonstrated participation in home practice, and 20 veterans (71%) completed the study. Overall, participants and diabetes educators were highly satisfied with the Mind-STRIDE intervention. Significant improvements were found in diabetes distress, diabetes self-efficacy, diabetes self-management behaviors, mindful-describing, and A1C.
Results suggest feasibility, satisfaction, and positive preliminary effects. Efficacy testing by randomized controlled trial with analysis of covariance structures is warranted.
Eaton E, Swearingen HR, Zand Vakili A, Jones SR, Greenberg BD. 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. Med Care. 2020;58 Suppl 2 9S:S94-S100.
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.
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.
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.
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.
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.
Elwy AR, Johnston JM, Bormann JE, Hull A, Taylor SL. A systematic scoping review of complementary and alternative medicine mind and body practices to improve the health of veterans and military personnel. Med Care. 2014 Dec;52(12 Suppl 5):S70-82. doi: 10.1097/MLR.0000000000000228.
Meditation, imagery, acupuncture, and yoga are the most frequently offered mind and body practices in the Department of Veterans Affairs. Yet, the research on mind and body practices has been critiqued as being too limited in evidence and scope to inform clinical treatment.
We conducted a systematic scoping review of mind and body practices used with veterans or active duty military personnel to identify gaps in the literature and make recommendations for future primary research.
Following systematic literature review methodology, we searched 5 databases using 27 different National Center for Complementary and Alternative Medicine-defined mind and body practices as text words, keywords, and MeSH terms through June 30, 2014. We also conducted handsearches of 4 previous reviews.
Subjects: Active duty military members or veterans 18 years or older participating in mind and body practice interventions globally.
Measures: Data were extracted from studies meeting 5 inclusion criteria. The quality of randomized controlled trials (RCTs) was assessed using an existing checklist.
Of 1819 studies identified, 89 interventions (50 RCTs) published between 1976 and 2014, conducted in 9 countries, using 152 different measures to assess 65 health and well-being outcomes met our inclusion criteria. Most interventions took place in the United States (n=78). Meditation practices (n=25), relaxation techniques including imagery (n=20), spinal manipulation including physical therapy (n=16), and acupuncture (n=11) were the most frequently studied practices. Methodological quality of most RCTs was rated poorly.
Meditation and acupuncture practices are among the most frequently offered and studied mind and body practices. Future research should include yoga as it is currently understudied among veterans and military personnel. A repository of mind and body intervention outcome measures may further future research efforts, as would conducting pragmatic trials and more robust RCTs.
Evans APB, Mascaro JS, Kohn JN, Dobrusin A, Darcher A, Starr SD, Craighead LW, Negi LT. Meditation Training for Emotional Numbing Symptoms Among Veterans with Post-Traumatic Stress Disorder. J Altern Complement Med. 2019
The aims of this study were (1) to examine the acceptability of CBCT (cognitively-based compassion training) among veterans who continued to report social disconnection and emotional numbing symptoms after completing empirically supported PTSD treatment and (2) to make preliminary estimates of the impact of CBCT on emotional numbing symptoms.
Felleman B, Stewart D, Simpson T, Heppner P, Kearney D. Predictors of Depression and PTSD Treatment Response Among Veterans Participating in Mindfulness-Based Stress Reduction. Mindfulness, 2016, Volume 7, Number 4, Page 886
Posttraumatic stress disorder (PTSD) and depression are prevalent and often co-occur among veterans. There is growing interest in the effects of mindfulness-based interventions among veterans. This study examined PTSD and depression outcomes, and baseline predictors of response, among veterans who participated in mindfulness-based stress reduction (MBSR). Participants included 116 veterans with PTSD before and after MBSR. Multilevel modeling assessed baseline predictors of change in PTSD and depressive symptoms. There were clinically significant reductions in PTSD and depression symptoms posttreatment and at 4 months follow-up. For PTSD, effect sizes were in the medium range posttreatment (d = −.63) and at follow-up (d = −.69), and for depression posttreatment (d = −.58) and at follow-up (d = −.70). Baseline PTSD was a significant predictor of slope (β = .03, p = .04) on PTSD outcomes; higher baseline PTSD predicted greater rate of reduction in symptoms. For depression (β = .04, p < .01,), those with severe or moderately severe depression exhibited the greatest rate of improvement. However, veterans with high symptom severity did remain symptomatic post-MBSR. These findings show preliminary support for MBSR in facilitating symptom reduction for veterans with severe PTSD and co-occurring depression.
Gallegos AM, Crean HF, Pigeon WR, Heffner KL. Meditation and yoga for posttraumatic stress disorder: A meta-analytic review of randomized controlled trials. Clin Psychol Rev. 2017 Dec;58:115-124. doi: 10.1016/j.cpr.2017.10.004. Review. PubMed PMID: 29100863; PubMed Central PMCID: PMC5939561.
Posttraumatic stress disorder (PTSD) is a chronic and debilitating disorder that affects the lives of 7-8% of adults in the U.S. Although several interventions demonstrate clinical effectiveness for treating PTSD, many patients continue to have residual symptoms and ask for a variety of treatment options. Complementary health approaches, such as meditation and yoga, hold promise for treating symptoms of PTSD. This meta-analysis evaluates the effect size (ES) of yoga and meditation on PTSD outcomes in adult patients. We also examined whether the intervention type, PTSD outcome measure, study population, sample size, or control condition moderated the effects of complementary approaches on PTSD outcomes. The studies included were 19 randomized control trials with data on 1173 participants. A random effects model yielded a statistically significant ES in the small to medium range (ES=-0.39, p<0.001, 95% CI [-0.57, -0.22]). There were no appreciable differences between intervention types, study population, outcome measures, or control condition. There was, however, a marginally significant higher ES for sample size≤30 (ES=-0.78, k=5). These findings suggest that meditation and yoga are promising complementary approaches in the treatment of PTSD among adults and warrant further study.
Gallegos AM, Cross W, Pigeon WR. Mindfulness-based stress reduction for veterans exposed to military sexual trauma: rationale and implementation considerations. Mil Med. 2015 Jun;180(6):684-9. doi: 10.7205/MILMED-D-14-00448.
Military sexual trauma (MST) represents a significant public health concern among military personnel and Veterans and is associated with considerable morbidity and suicide risk. It is estimated that 22% of Veteran women and 1% of Veteran men experienced sexual assault or repeated, threatening sexual harassment during their military service. Exposure to traumatic stress has detrimental effects on emotion regulation, which refers to a set of strategies used to modulate different components of emotion at different points on the trajectory of an emotional response. Mindfulness-based interventions offer approaches to health that focus on mind and body practices that can help regulate the experience and expression of difficult emotions. Mindfulness-based stress reduction (MBSR) is an evidence-based therapy shown to be effective for depression, anxiety, and post-traumatic stress disorder. This article discusses the rationale for providing MBSR to Veterans who have been exposed to MST. The article also discusses ways to facilitate implementation of this practice in the U.S. Department of Veterans Affairs health care system. We address potential barriers to care and ways to facilitate implementation at the patient, provider, organization/local, and policy levels. MBSR is likely to be an important component of a comprehensive approach to care for Veterans exposed to MST.
Goldberg S, Zeliadt S, Hoggatt K, Simpson T, Fortney J, Taylor SL. Utilization and Perceived Effectiveness of Mindfulness Meditation in Veterans: Results from a National Survey. Mindfulness. Sep 2019: 1-10.
Complementary and integrative health (CIH) approaches are increasingly utilized in health care, and mindfulness meditation is one such evidence-based CIH practice. More information is needed about veterans' utilization of mindfulness to inform integration within the Veterans Health Administration (VHA).
This study involved secondary data analysis of a national survey to evaluate utilization and perceived effectiveness of mindfulness relative to other CIH approaches among military veterans. Military veterans (n = 1230) enrolled in VHA reported CIH utilization rates, reasons for use, perceived effectiveness, treatment barriers, and demographics.
Approximately 18% of veterans reported using mindfulness meditation in the past year, exceeding the proportion using all other CIH approaches (p < .001), with the exception of massage and chiropractic care. Mindfulness was most commonly used for stress reduction and addressing symptoms of depression and anxiety. Among mindfulness users, veterans rated mindfulness with a mean score of 3.18 out of 5 (SD = 0.82) in terms of effectiveness, reflecting a response in the "somewhat helpful" to "moderately helpful" range. This was similar to ratings of other CIH approaches (mean = 3.20, p = .391). Of those who used mindfulness, nearly all (78%) reported only using it outside the VHA. Veterans identified not knowing if the VHA offered mindfulness as the most common reason for using mindfulness outside VHA.
In summary, veterans use mindfulness for a range of reasons and report receiving benefit from its use. Low awareness and potentially low availability of VHA's mindfulness programs need to be addressed to increase access.
Goldstein LA, Mehling WE, Metzler TJ, Cohen BE, Barnes DE, Choucroun GJ, Silver A, Talbot LS, Maguen S, Hlavin JA, Chesney MA, Neylan TC. Veterans Group Exercise: A randomized pilot trial of an Integrative Exercise program for veterans with posttraumatic stress. J Affect Disord. 2018 Feb;227:345-352.
Posttraumatic stress disorder (PTSD) is prevalent among military veterans and is associated with significant negative health outcomes. However, stigma and other barriers to care prevent many veterans from pursuing traditional mental health treatment. We developed a group-based Integrative Exercise (IE) program combining aerobic and resistance exercise, which is familiar to veterans, with mindfulness-based practices suited to veterans with PTSD. This study aimed to evaluate the effects of IE on PTSD symptom severity and quality of life, as well as assess the feasibility and acceptability of IE.
Veterans (N = 47) were randomized to either IE or waitlist control (WL). Veterans in IE were asked to attend three 1-h group exercise sessions for 12 weeks.
Compared with WL, veterans randomized to IE demonstrated a greater reduction in PTSD symptom severity (d = -.90), a greater improvement in psychological quality of life (d = .53) and a smaller relative improvement in physical quality of life (d = .30) Veterans' ratings of IE indicated high feasibility and acceptability.
The sample was relatively small and recruited from one site. The comparison condition was an inactive control.
This initial study suggests that IE is an innovative approach to treating veterans with symptoms of PTSD that reduces symptoms of posttraumatic stress and improves psychological quality of life. This approach to recovery may expand the reach of PTSD treatment into non-traditional settings and to veterans who may prefer a familiar activity, such as exercise, over medication or psychotherapy.
Harding K, Simpson T, Kearney DJ. Reduced Symptoms of Post-traumatic Stress Disorder and Irritable Bowel Syndrome Following Mindfulness-Based Stress Reduction Among Veterans. J Altern Complement Med. 2018 Aug 30
Post-traumatic stress disorder (PTSD) and irritable bowel syndrome (IBS) are highly comorbid conditions associated with reduced health-related quality of life. Comorbid prevalence is especially high among veterans, ranging from 23% to 51%, but there is limited research on integrative treatments.
To improve treatment of comorbid PTSD and IBS, this study examined the impact of mindfulness-based stress reduction (MBSR) on symptom reduction and mindfulness skill building among veterans with this comorbidity. We hypothesized that veterans would report reduced trauma-related, gastrointestinal (GI) symptom-specific anxiety (GSA), and depression symptoms and greater mindfulness skills post-treatment. We also hypothesized that veterans who reported lower trauma-related GSA and depression symptoms, and reported greater mindfulness skills and MBSR session attendance would report lower irritable bowel symptoms post-treatment.
Settings/Location: VA (Veterans Administration) Puget Sound Health Care System, Seattle, Washington.
Subjects: Participants were 55 veterans with PTSD and IBS.
Iinterventions: Veterans participated in an 8-week open trial of MBSR group.
Outcome Measures: This study measured the impact of MBSR on PTSD, IBS, GSA, and depression symptoms as well as mindfulness skills.
Veterans reported reduced trauma-related, irritable bowel, GSA, and depression symptoms and greater mindfulness skills immediately post-treatment. Trauma-related and depression symptom reduction were maintained 4 months post-treatment, but irritable bowel and GSA symptoms were nonsignificant. Lower baseline GSA predicted lower irritable bowel symptoms immediately post-treatment. At 4 months post-treatment, 77.50% met PTSD criteria and 40.38% met IBS criteria compared with 100% veteran comorbidity pretreatment.
MBSR holds promise as a transdiagnostic intervention for individuals with comorbid trauma-related, depression, GSA, and irritable bowel symptoms, with maintenance of trauma-related and depression symptom improvement 4 months post-treatment.
Heffner KL et al. Psychol Trauma. (2016) Meditation programs for veterans with posttraumatic stress disorder: Aggregate findings from a multi-site evaluation. Psychol Trauma. 2016 May;8(3):365-74. doi: 10.1037/tra0000106. Epub 2016 Jan 11.
Interest in meditation to manage posttraumatic stress disorder (PTSD) symptoms is increasing. Few studies have examined the effectiveness of meditation programs offered to Veterans within Department of Veterans Affairs (VA) mental health services. The current study addresses this gap using data from a multisite VA demonstration project.
Evaluation data collected at 6 VA sites (N = 391 Veterans) before and after a meditation program, and a treatment-as-usual (TAU) program, were examined here using random effects meta-analyses. Site-specific and aggregate between group effect sizes comparing meditation programs to TAU were determined for PTSD severity measured by clinical interview and self-report. Additional outcomes included experiential avoidance and mindfulness.
In aggregate, analyses showed medium effect sizes for meditation programs compared to TAU for PTSD severity (clinical interview: effect size (ES) = -0.32; self-report: ES = -0.39). Similarly sized effects of meditation programs were found for overall mindfulness (ES = 0.41) and 1 specific aspect of mindfulness, nonreactivity to inner experience (ES = .37). Additional findings suggested meditation type and program completion differences each moderated program effects.
VA-sponsored meditation programs show promise for reducing PTSD severity in Veterans receiving mental health services. Where meditation training fits within mental health services, and for whom programs will be of interest and effective, require further clarification. (PsycINFO Database Record
Held P, Owens GP, Monroe JR, Chard KM. Increased Mindfulness Skills as Predictors of Reduced Trauma-Related Guilt in Treatment-Seeking Veterans. J Trauma Stress. 2017 Aug;30(4):425-431. doi: 10.1002/jts.22209. Epub 2017 Jul 25.
The present study examined the predictive role of increased self-reported mindfulness skills on reduced trauma-related guilt in a sample of veterans over the course of residential treatment for posttraumatic stress disorder (PTSD; N = 128). The residential treatment consisted of seven weeks of intensive cognitive processing therapy (CPT) for PTSD, as well as additional psychoeducational groups, including seven sessions on mindfulness skills. Increased mindfulness skills describing, acting with awareness, and accepting without judgment were significantly associated with reductions in trauma-related guilt over the course of treatment. Increases in the ability to act with awareness and accept without judgment were significantly associated with reductions in global guilt, R2 = .26, guilt distress, R2 = .23, guilt cognitions, R2 = .23, and lack of justification, R2 = .11. An increase in the ability to accept without judgment was the only self-reported mindfulness skill that was associated with reductions in hindsight bias, β = -.34 and wrongdoing, β = -.44. Increases in self-reported mindfulness skills explained 15.1 to 24.1% of the variance in reductions in trauma-related guilt, suggesting that mindfulness skills may play a key role in reducing the experience of trauma-related guilt during psychotherapy. Our results provide preliminary support for the use of mindfulness groups as an adjunct to traditional evidence-based treatments aimed at reducing trauma-related guilt, though this claim needs to be tested further using experimental designs.
Hempel S, Taylor SL, Marshall NJ, Miake-Lye IM, Beroes JM, Shanman R, Solloway MR, Shekelle PG. Evidence Map of Mindfulness [Internet]. Washington (DC): Department of Veterans Affairs (US); 2014 Oct. Available From http://www.ncbi.nlm.nih.gov/books/NBK268640/PubMed PMID: 25577939.
This evidence map provides an overview of "mindfulness" intervention research and describes its volume and focus. It summarizes patient outcomes as reported in systematic reviews of randomized controlled trial evidence. We searched 10 electronic databases to February 2014, screened reviews of reviews, and consulted topic experts. We used a bubble plot as a visual overview of the distribution of evidence and synthesized results narratively in an executive summary. In total, 81 systematic reviews met inclusion criteria and the largest review included 109 mindfulness RCTs. Most research is available for general overviews on health benefits or psychological wellbeing. Reviews on chronic illness, depression, substance use, somatization, distress, and mental illness included 10 or more RCTs. Reviews suggest differential effects of mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and other mindfulness-based interventions, and definitions of "mindfulness-based" varied. The most consistent effect was reported for depression but published meta-analyses also indicated effects compared to passive control of MBSR on overall health, chronic illness, and psychological variables; MBCT for mental illness; and mindfulness interventions for somatization disorders. Limited evidence is also available for mindfulness interventions for pain, anxiety, and psychosis compared to passive control groups. More detail is provided for priority areas post-traumatic stress disorder, stress, depression, and wellness. The evidence map provides a broad overview (not detailed or definitive effectiveness evidence) over the existing research to help interpret the state of the evidence to inform policy and clinical decision making.
Herrmann T, Marchand WR, Yabko B, Lackner R, Beckstrom J, Parker A. Veterans' interests, perceptions, and use of mindfulness. SAGE Open Med. 2020;8:2050312120938226. Published 2020 Jul 31.
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.
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.
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.
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.
Herron RE, Rees B. The Transcendental Meditation Program's Impact on the Symptoms of Post-traumatic StressDisorder of Veterans: An Uncontrolled Pilot Study. Mil Med. 2018 Jan 1;183(1-2):e144-e150. doi: 10.1093/milmed/usx059.
Current treatments for post-traumatic stress disorder (PTSD) are only partially effective. This study evaluated whether an extensively researched stress reduction method, the Transcendental Meditation (TM) technique, can reduce the PTSD symptoms of veterans. Previous research suggested that TM practice can decrease veterans' PTSD symptoms.
A one-group pretest-posttest design was used to evaluate the impact of TM practice on reducing PTSD symptoms. A convenience sample of 89 veterans completed PTSD Checklist-Civilian (PCL-5) questionnaires. Among those, 46 scored above 33, the threshold for provisional diagnosis of PTSD, and were included in this evaluation. The PCL-5 measured PTSD symptoms at baseline and 30 and 90 d after intervention. Regularity of TM practice was recorded. Paired sample t-tests were used to assess within-group changes from baseline to post-intervention periods. Analysis of variance was used to compare full-dose (two 20-min TM sessions per day) and half-dose (one 20-min TM session per day) groups.
After 1 mo of TM practice, all 46 veterans responded; their PCL-5 average decreased from 51.52 in the pre-intervention period to a post-intervention mean of 23.43, a decline of 28.09 points (-54.5%); standard deviation: 14.57; confidence interval: 23.76-32.41; and effect size: -1.93; p < 0.0001. The median PTSD scores declined from 52.5 to 22.5, a decrease of 30 points (-57%), while 40 veterans (87%) had clinically significant declines (>10 points) in PTSD symptoms, and 37 (80%) dropped below the clinical level (<33). At the 90 d posttest, 31 of the 46 responded and three more dropped below the 33 threshold. Intent-to-treat analyses revealed clinically and statistically significant effects. A dose-response effect suggested a causal relationship. The full-dose group exhibited larger mean declines in PTSD symptoms than the half-dose group. Averages of the 46 veterans' responses to 20 PCL-5 questions exhibited significant (p < 0.0001) declines from the pre-intervention period to the 30-d post-intervention assessment.
Results indicated that TM practice reduced PTSD symptoms without re-experiencing trauma. Because of the magnitude of these results and dose-response effect, regression to the mean, spontaneous remission of symptoms, and placebo effects are unlikely explanations for the results. Major limitations were absence of random assignment and lack of a control group. Participants chose to start and continue TM practice and to complete PCL-5 questionnaires. Those who self-selected to enter this study may not be representative of all veterans who have PTSD. Those who did not complete follow-up questionnaires at 90 d may or may not have had the same results as those who responded. The design and sampling method affect the generalizability of the results to wider populations. When taking into account these results and all previous research on the TM technique in reducing psychological and physiological stress, the convergence of evidence suggests that TM practice may offer a promising adjunct or alternative method for treating PTSD. Because of the widely recognized need to identify effective new approaches for treating PTSD, randomized research with control groups is warranted to further investigate the effectiveness of TM practice as a treatment for PTSD.
Hilton L, Maher AR, Colaiaco B, Apaydin E, Sorbero ME, Booth M, Shanman RM, Hempel S. Meditation for posttraumatic stress: Systematic review and meta-analysis.Psychol Trauma. 2017 Jul;9(4):453-460. doi: 10.1037/tra0000180. Epub 2016 Aug 18. Review. PubMed PMID: 27537781.
We conducted a systematic review and meta-analysis that synthesized evidence from randomized controlled trials of meditation interventions to provide estimates of their efficacy and safety in treating adults diagnosed with posttraumatic stress disorder (PTSD). This review was based on an established protocol (PROSPERO: CRD42015025782) and is reported according to PRISMA guidelines. Outcomes of interest included PTSD symptoms, depression, anxiety, health-related quality of life, functional status, and adverse events.
Meta-analyses were conducted using the Hartung-Knapp-Sidik-Jonkman method for random-effects models. Quality of evidence was assessed using the Grade of Recommendations Assessment, Development, and Evaluation (GRADE) approach.
In total, 10 trials on meditation interventions for PTSD with 643 participants met inclusion criteria. Across interventions, adjunctive meditation interventions of mindfulness-based stress reduction, yoga, and the mantram repetition program improve PTSD and depression symptoms compared with control groups, but the findings are based on low and moderate quality of evidence. Effects were positive but not statistically significant for quality of life and anxiety, and no studies addressed functional status. The variety of meditation intervention types, the short follow-up times, and the quality of studies limited analyses. No adverse events were reported in the included studies; only half of the studies reported on safety.
Meditation appears to be effective for PTSD and depression symptoms, but in order to increase confidence in findings, more high-quality studies are needed on meditation as adjunctive treatment with PTSD-diagnosed participant samples large enough to detect statistical differences in outcomes. (PsycINFO Database Record
Hilton LG, Libretto S, Xenakis L, Elfenbaum P, Boyd C, Zhang W, Clark AA. Evaluation of an Integrative Post-Traumatic Stress Disorder Treatment Program. J Altern Complement Med. 2019
Post-traumatic stress disorder (PTSD) and combat-related stress can be refractory, pervasive, and have a devastating impact on those affected, their families, and society at large. Challenges dealing with symptoms may in turn make a servicemember more susceptible to problems, including alcohol abuse, interpersonal conflict, and occupational problems. An effective treatment strategy will address multifactorial issues by using a holistic multimodal approach. Back on Track is an intensive outpatient program utilizing a holistic philosophy and multimodal treatments to provide a whole systems approach for the treatment of combat-related stress reactions and PTSD in active duty servicemembers.
An explanatory, sequential, mixed-methods program evaluation was conducted to assess the effectiveness of a PTSD and combat stress treatment program. Quantitative outcomes were collected and analyzed on 595 participants at pre- and postinterventions and 6-week follow-up and qualitative data were gathered through participant interviews.
The manualized program uses a multimodal, psychoeducational group therapy format with a holistic approach for treating combat stress, increasing resiliency, and assisting with reintegration. Rotating providers visit from other programs and services to deliver content in bio–psycho–social–spiritual domains, including didactic lectures on mindfulness and the relaxation response and daily sessions of yoga nidra and meditation.
The primary outcome measure was PTSD symptom severity assessed with the PTSD Checklist-Military Version (PCL-M). Secondary outcomes included self-efficacy, knowledge, use, and satisfaction. Quantitative data were contextualized with interview data.
Results demonstrated a highly statistically significant effect of the program when comparing within-subject PCL-M scores before and after program participation, signed rank S (N= 595) = -47,367, p < 0.001. This translates to a moderate effect size, Cohen's d (N= 595) = -0.55, 95% confidence interval = -0.62 to -0.47, and a mean decrease of 7 points on the PCL-M at postintervention, demonstrating response to treatment. There were significant increases in knowledge and self-efficacy and high levels of satisfaction with the program overall, content, materials, and delivery.
The treatment program has served *800 servicemembers since inception and has since expanded to five installations. The provision of whole systems care where the approach is holistic, multimodal, and multidisciplinary may be a way forward for the successful treatment of PTSD and other debilitating behavioral health conditions in military contexts and beyond.
Hudak J, Hanley AW, Marchand WR, Nakamura Y, Yabko B, Garland EL. Endogenous theta stimulation during meditation predicts reduced opioid dosing following treatment with Mindfulness-Oriented Recovery Enhancement. Neuropsychopharmacology. 2020 Sep 12.
Veterans experience chronic pain at greater rates than the rest of society and are more likely to receive long-term opioid therapy (LTOT), which, at high doses, is theorized to induce maladaptive neuroplastic changes that attenuate self-regulatory capacity and exacerbate opioid dose escalation. Mindfulness meditation has been shown to modulate frontal midline theta (FMT) and alpha oscillations that are linked with marked alterations in self-referential processing. These adaptive neural oscillatory changes may promote reduced opioid use and remediate the neural dysfunction occasioned by LTOT. In this study, we used electroencephalography (EEG) to assess the effects of a mindfulness-based, cognitive training intervention for opioid misuse, Mindfulness-Oriented Recovery Enhancement (MORE), on alpha and theta power and FMT coherence during meditation. We then examined whether these neural effects were associated with reduced opioid dosing and changes in self-referential processing. Before and after 8 weeks of MORE or a supportive psychotherapy control, veterans receiving LTOT (N = 62) practiced mindfulness meditation while EEG was recorded. Participants treated with MORE demonstrated significantly increased alpha and theta power (with larger theta power effect sizes) as well as increased FMT coherence relative to those in the control condition-neural changes that were associated with altered self-referential processing. Crucially, MORE significantly reduced opioid dose over time, and this dose reduction was partially statistically mediated by changes in frontal theta power. Study results suggest that mindfulness meditation practice may produce endogenous theta stimulation in the prefrontal cortex, thereby enhancing inhibitory control over opioid dose escalation behaviors.
Hull A, Reinhard M, McCarron K, Allen N, Jecmen MC, Akhter J, Duncan A, Soltes K. Acupuncture and meditation for military veterans: first steps of quality management and future program development. Glob Adv Health Med. 2014 Jul;3(4):27-31. doi: 10.7453/gahmj.2013.050.
Veterans of all war eras have a high rate of chronic disease, mental health disorders, and chronic multi-symptom illnesses (CMI).(1-3) Many veterans report symptoms that affect multiple biological systems as opposed to isolated disease states. Standard medical treatments often target isolated disease states such as headaches, insomnia, or back pain and at times may miss the more complex, multisystem dysfunction that has been documented in the veteran population. Research has shown that veterans have complex symptomatology involving physical, cognitive, psychological, and behavioral disturbances, such as difficult to diagnose pain patterns, irritable bowel syndrome, chronic fatigue, anxiety, depression, sleep disturbance, or neurocognitive dysfunction.(2-4) Meditation and acupuncture are each broad-spectrum treatments designed to target multiple biological systems simultaneously, and thus, may be well suited for these complex chronic illnesses. The emerging literature indicates that complementary and integrative medicine (CIM) approaches augment standard medical treatments to enhance positive outcomes for those with chronic disease, mental health disorders, and CMI.(5-12.).
Kang SS, Erbes CR, Lamberty GJ, Thuras P, Sponheim SR, Polusny MA, Moran AC, Van Voorhis AC, Lim KO. Transcendental meditation for veterans with post-traumatic stress disorder. Psychol Trauma. 2018 Nov;10(6):675-680. doi: 10.1037/tra0000346. Epub 2018 Jul 19.
Transcendental Meditation (TM) is a mental technique using a mantra to facilitate meditation. TM has a potential for treating symptoms of posttraumatic stress disorder (PTSD), but its clinical efficacy remains to be clarified. This pilot study evaluated the acceptability, preliminary effectiveness, and neurophysiology of TM for veterans with PTSD.
Twenty-nine veterans (20.7% female) were recruited from a major medical center and enrolled in the study. TM instruction was provided by certified TM teachers from the Maharishi Foundation and consisted of 8 weeks of individual and group-based meditation instruction and practice. Outcomes were assessed at baseline, during treatment, posttreatment, and at 2-month follow-up, and included clinical interviews, self-report questionnaires, and electroencephalography (EEG) recorded during resting and meditation states.
From baseline to posttreatment, participants reported reductions in PTSD symptoms, experiential avoidance, and depressive and somatic symptoms, as well as increases on measures of mindfulness and quality of life. Gains were either maintained or continued to improve through the 2-month follow-up. Compared to baseline, EEG spectral power increased in low-frequency bands (1-7 Hz) at posttreatment and follow-up and only during meditation states suggesting TM-specific changes in brain state associated with the intervention.
TM appears to be an acceptable and effective treatment for veterans with PTSD that warrants further study regarding specific outcomes and beneficial changes in brain function. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
Kearney DJ, Malte CA, McManus C, Martinez ME, Felleman B, Simpson TL. Loving-kindness meditation for posttraumatic stress disorder: a pilot study. J Trauma Stress. 2013
Loving-kindness meditation is a practice designed to enhance feelings of kindness and compassion for self and others. Loving-kindness meditation involves repetition of phrases of positive intention for self and others. We undertook an open pilot trial of loving-kindness meditation for veterans with posttraumatic stress disorder (PTSD). Measures of PTSD, depression, self-compassion, and mindfulness were obtained at baseline, after a 12-week loving-kindness meditation course, and 3 months later. Effect sizes were calculated from baseline to each follow-up point, and self-compassion was assessed as a mediator. Attendance was high; 74% attended 9-12 classes. Self-compassion increased with large effect sizes and mindfulness increased with medium to large effect sizes. A large effect size was found for PTSD symptoms at 3-month follow-up (d = -0.89), and a medium effect size was found for depression at 3-month follow-up (d = -0.49). There was evidence of mediation of reductions in PTSD symptoms and depression by enhanced self-compassion. Overall, loving-kindness meditation appeared safe and acceptable and was associated with reduced symptoms of PTSD and depression. Additional study of loving-kindness meditation for PTSD is warranted to determine whether the changes seen are due to the loving-kindness meditation intervention versus other influences, including concurrent receipt of other treatments.
Kearney DJ, McDermott K, Malte C, Martinez M, Simpson TL. Effects of participation in a mindfulness program for veterans with posttraumatic stress disorder: a randomized controlled pilot study. J Clin Psychol. 2013 Jan;69(1):14-27.
To assess outcomes associated with Mindfulness-Based Stress Reduction (MBSR) for veterans with PTSD.
Forty-seven veterans with posttraumatic stress disorder (PTSD; 37 male, 32 Caucasian) were randomized to treatment as usual (TAU; n = 22), or MBSR plus TAU (n = 25). PTSD, depression, and mental health-related quality of life (HRQOL) were assessed at baseline, posttreatment, and 4-month follow-up. Standardized effect sizes and the proportion with clinically meaningful changes in outcomes were calculated.
Intention-to-treat analyses found no reliable effects of MBSR on PTSD or depression. Mental HRQOL improved posttreatment but there was no reliable effect at 4 months. At 4-month follow-up, more veterans randomized to MBSR had clinically meaningful change in mental HRQOL, and in both mental HRQOL and PTSD symptoms. Completer analyses (≥ 4 classes attended) showed medium to large between group effect sizes for depression, mental HRQOL, and mindfulness skills.
Additional studies are warranted to assess MBSR for veterans with PTSD.
Kearney DJ, Simpson TL, Malte CA, Felleman B, Martinez ME, Hunt SC. Mindfulness-based Stress Reduction in Addition to Usual Care Is Associated with Improvements in Pain, Fatigue, and Cognitive Failures Among Veterans with Gulf War Illness. Am J Med. 2016 Feb
Many Gulf War I veterans report ongoing negative health consequences. The constellation of pain, fatigue, and concentration/memory disturbances is referred to as "Gulf War illness." Prior research suggests that mindfulness-based stress reduction may be beneficial for these symptoms, but mindfulness-based stress reduction has not been studied for veterans with Gulf War illness. The objective of this trial was to conduct a pilot study of mindfulness-based stress reduction for veterans with Gulf War illness.
Veterans (N = 55) with Gulf War illness were randomly assigned to treatment as usual plus mindfulness-based stress reduction or treatment as usual only. Mindfulness-based stress reduction was delivered in 8 weekly 2.5-hour sessions plus a single 7-hour weekend session. Pain, fatigue, and cognitive failures were the primary outcomes, assessed at baseline, after mindfulness-based stress reduction, and 6 months follow-up. Secondary outcomes included symptoms of posttraumatic stress disorder and depression.
In intention-to-treat analyses, at 6-month follow-up, veterans randomized to mindfulness-based stress reduction plus treatment as usual reported greater reductions in pain (f = 0.33; P = .049), fatigue (f = 0.32; P = .027), and cognitive failures (f = 0.40; P < .001). Depressive symptoms showed a greater decline after mindfulness-based stress reduction (f = 0.22; P = .050) and at 6 months (f = 0.27; P = .031) relative to treatment as usual only. Veterans with posttraumatic stress disorder at baseline randomized to mindfulness-based stress reduction plus treatment as usual experienced significantly greater reductions in symptoms of posttraumatic stress disorder after mindfulness-based stress reduction (f = 0.44; P = .005) but not at 6 months follow-up (f = 0.31; P = .082).
Mindfulness-based stress reduction in addition to treatment as usual is associated with significant improvements in self-reported symptoms of Gulf War illness, including pain, fatigue, cognitive failures, and depression.
King AP, Block SR, Sripada RK, Rauch S, Giardino N, Favorite T, Angstadt M, Kessler D, Welsh R, Liberzon I. ALTERED DEFAULT MODE NETWORK (DMN) RESTING STATE FUNCTIONAL CONNECTIVITY FOLLOWING A MINDFULNESS-BASED EXPOSURE THERAPY FOR POSTTRAUMATIC STRESS DISORDER (PTSD) IN COMBAT VETERANS OF AFGHANISTAN AND IRAQ. Depress Anxiety. 2016
Recent studies suggest that mindfulness may be an effective component for posttraumatic stress disorder (PTSD) treatment. Mindfulness involves practice in volitional shifting of attention from "mind wandering" to present-moment attention to sensations, and cultivating acceptance. We examined potential neural correlates of mindfulness training using a novel group therapy (mindfulness-based exposure therapy (MBET)) in combat veterans with PTSD deployed to Afghanistan (OEF) and/or Iraq (OIF).
Twenty-three male OEF/OIF combat veterans with PTSD were treated with a mindfulness-based intervention (N = 14) or an active control group therapy (present-centered group therapy (PCGT), N = 9). Pre-post therapy functional magnetic resonance imaging (fMRI, 3 T) examined resting-state functional connectivity (rsFC) in default mode network (DMN) using posterior cingulate cortex (PCC) and ventral medial prefrontal cortex (vmPFC) seeds, and salience network (SN) with anatomical amygdala seeds. PTSD symptoms were assessed at pre- and posttherapy with Clinician Administered PTSD Scale (CAPS).
Patients treated with MBET had reduced PTSD symptoms (effect size d = 0.92) but effect was not significantly different from PCGT (d = 0.46). Increased DMN rsFC (PCC seed) with dorsolateral dorsolateral prefrontal cortex (DLPFC) regions and dorsal anterior cingulate cortex (ACC) regions associated with executive control was seen following MBET. A group × time interaction found MBET showed increased connectivity with DLPFC and dorsal ACC following therapy; PCC-DLPFC connectivity was correlated with improvement in PTSD avoidant and hyperarousal symptoms.
Increased connectivity between DMN and executive control regions following mindfulness training could underlie increased capacity for volitional shifting of attention. The increased PCC-DLPFC rsFC following MBET was related to PTSD symptom improvement, pointing to a potential therapeutic mechanism of mindfulness-based therapies.
King AP, Erickson TM, Giardino ND, Favorite T, Rauch SA, Robinson E, Kulkarni M, Liberzon I. A pilot study of group mindfulness-based cognitive therapy (MBCT) for combat veterans with posttraumatic stress disorder (PTSD). Depress Anxiety. 2013 Jul;30(7):638-45. doi: 10.1002/da.22104.
"Mindfulness-based" interventions show promise for stress reduction in general medical conditions, and initial evidence suggests that they are accepted in trauma-exposed individuals. Mindfulness-based cognitive therapy (MBCT) shows substantial efficacy for prevention of depression relapse, but it has been less studied in anxiety disorders. This study investigated the feasibility, acceptability, and clinical outcomes of an MBCT group intervention adapted for combat posttraumatic stress disorder (PTSD).
Consecutive patients seeking treatment for chronic PTSD at a VA outpatient clinic were enrolled in 8-week MBCT groups, modified for PTSD (four groups, n = 20) or brief treatment-as-usual (TAU) comparison group interventions (three groups, n = 17). Pre and posttherapy psychological assessments with clinician administered PTSD scale (CAPS) were performed with all patients, and self-report measures (PTSD diagnostic scale, PDS, and posttraumatic cognitions inventory, PTCI) were administered in the MBCT group.
Intent to treat analyses showed significant improvement in PTSD (CAPS (t(19) = 4.8, P < .001)) in the MBCT condition but not the TAU conditions, and a significant Condition × Time interaction (F[1,35] = 16.4, P < .005). MBCT completers (n = 15, 75%) showed good compliance with assigned homework exercises, and significant and clinically meaningful improvement in PTSD symptom severity on posttreatment assessment in CAPS and PDS (particularly in avoidance/numbing symptoms), and reduced PTSD-relevant cognitions in PTCI (self blame).
These data suggest group MBCT as an acceptable brief intervention/adjunctive therapy for combat PTSD, with potential for reducing avoidance symptom cluster and PTSD cognitions. Further studies are needed to examine efficacy in a randomized controlled design and to identify factors influencing acceptability and efficacy.
Kline A, Chesin M, Latorre M, Miller R, St Hill L, Shcherbakov A, King A, Stanley B, Weiner MD, Interian A. Rationale and study design of a trial of mindfulness-based cognitive therapy for preventing suicidal behavior (MBCT-S) in military veterans. Contemp Clin Trials. 2016 Sep;50:245-52. doi: 10.1016/j.cct.2016.08.015. Epub 2016 Aug 31. PMID: 27592123.
Although suicide ranks 10th as a cause of death in the United States, and 1st among active military personnel, there are surprisingly few evidence-based therapies addressing suicidality, and development of new treatments is limited. This paper describes a clinical trial testing a novel therapy for reducing suicide risk in military veterans. The intervention, Mindfulness-Based Cognitive Therapy for Preventing Suicide Behavior (MBCT-S), is a 10-week group intervention adapted from an existing treatment for depression (Mindfulness-Based Cognitive Therapy - MBCT). MBCT-S incorporates the Safety Planning Intervention, which is currently implemented throughout the Veterans Health Administration (VHA) for veterans at high suicide risk.
MBCT-S is being tested in a VHA setting using an intention-to-treat, two-group randomized trial design in which 164 high suicide risk veterans are randomized to either VHA Treatment As Usual (TAU; n=82) or TAU+MBCT-S (n=82). Our primary outcome measure, suicide-related event, defined to include suicide preparatory behaviors, self-harm behavior with suicidal or indeterminate intent, suicide-related hospitalizations and Emergency Department (ED) visits, will be measured through five assessments administered by blinded assessors between baseline and 12months post-baseline. We will measure suicide attempts and suicide deaths as a secondary outcome, because of their anticipated low incidence during the study period. Secondary outcomes also include severity of suicidal ideation, hopelessness and depression.
This study has the potential to significantly enhance the quality and efficiency of VHA care for veterans at suicide risk and to substantially improve the quality of life for veterans and their families.
Kopacz MS, Connery AL, Bishop TM, Bryan CJ, Drescher KD, Currier JM, Pigeon WR. Moral injury: A new challenge for complementary and alternative medicine. Complement Ther Med. 2016 Feb;24:29-33. doi: 10.1016/j.ctim.2015.11.003. Epub 2015 Nov 27.
Moral injury represents an emerging clinical construct recognized as a source of morbidity in current and former military personnel. Finding effective ways to support those affected by moral injury remains a challenge for both biomedical and complementary and alternative medicine. This paper introduces the concept of moral injury and suggests two complementary and alternative medicine, pastoral care and mindfulness, which may prove useful in supporting military personnel thought to be dealing with moral injury. Research strategies for developing an evidence-base for applying these, and other, complementary and alternative medicine modalities to moral injury are discussed.
Lang AJ, Malaktaris AL, Casmar P, Baca SA, Golshan S, Harrison T, Negi L. Compassion Meditation for Posttraumatic Stress Disorder in Veterans: A Randomized Proof of Concept Study. J Trauma Stress. 2019 Apr;32(2):299-309. doi: 10.1002/jts.22397. Epub 2019 Mar 31. PubMed PMID: 30929283.
There is considerable interest in developing complementary and integrative approaches for ameliorating posttraumatic stress disorder (PTSD). Compassion meditation (CM) and loving-kindness meditation appear to offer benefits to individuals with PTSD, including symptom reduction. The present study was a pilot randomized controlled trial of CM for PTSD in veterans. The CM condition, an adaptation of Cognitively-Based Compassion Training (CBCT®), consists of exercises to stabilize attention, develop present-moment awareness, and foster compassion. We compared CM to Veteran.calm (VC), which consists of psychoeducation about PTSD, rationale for relaxation, relaxation training, and sleep hygiene. Both conditions consist of 10 weekly 90-min group sessions with between-session practice assignments. A total of 28 veterans attended at least one session of the group intervention and completed pre- and posttreatment measures of PTSD severity and secondary outcomes as well as weekly measures of PTSD, depressive symptoms, and positive and negative emotions. Measures of treatment credibility, attendance, practice compliance, and satisfaction were administered to assess feasibility. A repeated measures analysis of variance revealed a more substantive reduction in PTSD symptoms in the CM condition than in the VC condition, between-group d = -0.85. Credibility, attendance, and satisfaction were similar across CM and VC conditions thus demonstrating the feasibility of CM and the appropriateness of VC as a comparison condition. The findings of this initial randomized pilot study provide rationale for future studies examining the efficacy and effectiveness of CM for veterans with PTSD.
Leary S, Weingart K, Topp R, Bormann J. The Effect of Mantram Repetition on Burnout and Stress Among VA Staff. Workplace Health Saf. 2018 Mar;66(3):120-128.
In this study, the authors determined the effect of a structured Internet-delivered Mantram Repetition Program (MRP) on burnout and stress of conscience (SOC), stress related to ambiguity from ethical or moral conflicts among health care workers (HCWs) within the Veteran Affairs (VA) Healthcare System. A secondary purpose was to determine whether practicing meditation prior to the study combined with MRP affected burnout or SOC. The MRP teaches the mindful practices of repeating a mantram, slowing down, and one-pointed attention for managing stress. Thirty-nine HCW volunteers who provided direct patient care completed the Internet-delivered MRP. The outcomes of burnout (i.e., exhaustion, cynicism, and professional efficacy) and SOC (i.e., frequency of stressful events and troubled conscience about those events) were measured at baseline (T1), postintervention (T2), and 3-months postintervention (T3). Repeated measures ANOVA indicated that exhaustion significantly ( p < .05) declined between T1 and T3; professional efficacy and cynicism did not change during the study. The same statistical model also indicated the frequency of stressful events significantly declined between T1 and T2 and troubled conscience declined between T1 and T3. Secondary analysis demonstrated that individuals who did not practice meditation at baseline ( n = 16, 41%) significantly decreased exhaustion, frequency of stressful events, and troubled conscience between T1 and T3, and improved professional efficacy between T1 and T2. Individuals who practiced meditation at baseline ( n = 23, 59%) did not demonstrate significant change on any study outcomes. An MRP intervention may reduce burnout and SOC in those individuals who are naïve to practicing meditation.
Luedtke, B., Davis, L. & Monson, C. Mindfulness-Based Cognitive-Behavioral Conjoint Therapy for Posttraumatic Stress Disorder: A Case Study. J Contemp Psychother 45, 227–234 (2015). https://doi.org/10.1007/s10879-015-9298-z
With as many as 1.9 million men and women deployed as part of the wars in Iraq and Afghanistan, increased recognition is being placed on the effect of returning Veterans' combat experiences on their adjustment and mental health, particularly those with symptoms of posttraumatic stress disorder (PTSD) and associated effects on families and relationships. Cognitive-behavioral conjoint therapy (CBCT) for PTSD is a manualized intervention with demonstrated efficacy in clinical trials with Veterans who have experienced trauma and their intimate partners. This case study involves the successful application of Mindfulness-based CBCT for PTSD to treat an operation Iraqi freedom male Veteran and his wife referred for PTSD and relationship dissatisfaction. In the current study, mindfulness interventions were integrated into the existing CBCT for PTSD protocol and treatment duration was shortened by including a weekend group retreat for couples. Baseline and post-treatment data from self- and partner-report measures demonstrates symptom reduction in posttraumatic stress symptoms as well as an increase in relationship satisfaction. The advantages of incorporating mindfulness strategies into this treatment protocol and recommendations for future work are discussed.
Marchand WR, Klinger W, Block K, VerMerris S, Herrmann TS, Johnson C, Paradiso N, Scott M, Yabko B. Mindfulness Training plus Nature Exposure for Veterans with Psychiatric and Substance Use Disorders: A Model Intervention. Int J Environ Res Public Health. 2019 Nov 27;16(23).
There is a need to develop novel complementary interventions aimed at enhancing treatment engagement and/or response for veterans with psychiatric and substance use disorders. There is evidence that both mindfulness training and nature exposure (MT/NE) may be beneficial for this population and that combining the two approaches into one intervention might result in synergistic benefit. However, to date, the MT/NE concept has not been tested. This article reports a pilot feasibility and acceptability study of MT/NE which was, in this case, provided via recreational sailing. The primary aim of this project was to develop a model intervention and evaluation process that could be used for future studies of MT/NE interventions using a variety of methods of nature exposure (e.g., hiking, skiing, mountain biking). Results indicate preliminary evidence that it is feasible to utilize MT/NE interventions for the population studied and that the MT/NE model described can serve as a template for future investigations. Further, there were significant pre- to post-intervention decreases in state anxiety, as well as increases in trait mindfulness. Three psychological instruments were identified that might be used in future studies to evaluate MT/NE outcomes. Results from this project provide a model MT/NE intervention template along with evaluation metrics for use in future studies.
Marchand WR, Yabko B, Herrmann T, Curtis H, Lackner R. Treatment Engagement and Outcomes of Mindfulness-Based Cognitive Therapy for Veterans with Psychiatric Disorders. J Altern Complement Med. 2019
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.
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).
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.
Martinez ME, Kearney DJ, Simpson T, Felleman BI, Bernardi N, Sayre G. Challenges to Enrollment and Participation in Mindfulness-Based Stress Reduction Among Veterans: A Qualitative Study. J Altern Complement Med. 2015 Jul;21(7):409-21. doi: 10.1089/acm.2014.0324. Epub 2015 May 28.
Mindfulness-Based Stress Reduction (MBSR) is associated with reduced depressive symptoms, quality of life improvements, behavioral activation, and increased acceptance among veterans. This study was conducted to increase the reach and impact of a veterans' MBSR program by identifying barriers to enrollment and participation to inform modifications in program delivery.
Verify or challenge suspected barriers, and identify previously unrecognized barriers, to enrollment and participation in MBSR among veterans.
A retrospective qualitative analysis of semistructured interviews.
Setting: VA Puget Sound Health Care System (Seattle, WA).
Subjects: 68 interviewed, and 48 coded and analyzed before reaching saturation.
Approach: Content analysis of semistructured interviews.
Of the participants who enrolled, most (78%) completed the program and described MBSR positively. Veterans identified insufficient or inaccurate information, scheduling issues, and an aversion to groups as barriers to enrollment. Participants who discontinued the program cited logistics (e.g., scheduling and medical issues), negative reactions to instructors or group members, difficulty understanding the MBSR practice purposes, and struggling to find time for the practices as barriers to completion. Other challenges (cohort dynamics, teacher impact on group structure and focus, instructor lack of military service, and physical and psychological challenges) did not impede participation; we interpreted these as growth-facilitating challenges. Common conditions among veterans (chronic pain, posttraumatic stress disorder, and depression) were not described as barriers to enrollment or completion.
Women-only MBSR groups and tele-health MBSR groups could improve accessibility to MBSR for veterans by addressing barriers such as commute anxiety, time restrictions, and an aversion to mixed gender groups among women. Educating MBSR teachers about veteran culture and health challenges faced by veterans, adding psychoeducation materials that relate mindfulness practice to conditions common among veterans, and improving visual aids for mindful movement exercises in the workbook could better accommodate veterans who participate in MBSR.
Mathersul DC, Tang JS, Schulz-Heik RJ, Avery TJ, Seppälä EM, Bayley PJ. Study protocol for a non-inferiority randomised controlled trial of SKY breathing meditation versus cognitive processing therapy for PTSD among veterans. BMJ Open. 2019 Apr 3;9(4):e027150. doi: 10.1136/bmjopen-2018-027150.
Post-traumatic stress disorder (PTSD) is a debilitating, highly prevalent condition. Current clinical practice guidelines recommend trauma-focused psychotherapy (eg, cognitive processing therapy; CPT) as the first-line treatment for PTSD. However, while these treatments show clinically meaningful symptom improvement, the majority of those who begin treatment retain a diagnosis of PTSD post-treatment. Perhaps for this reason, many individuals with PTSD have sought more holistic, mind-body, complementary and integrative health (CIH) interventions. However, there remains a paucity of high-quality, active controlled efficacy studies of CIH interventions for PTSD, which precludes their formal recommendation.
METHODS AND ANALYSES
We present the protocol for an ongoing non-inferiority parallel group randomised controlled trial (RCT) comparing the efficacy of a breathing meditation intervention (Sudarshan Kriya Yoga [SKY]) to a recommended evidence-based psychotherapy (CPT) for PTSD among veterans. Assessors are blinded to treatment group. The primary outcome measure is the PTSD Checklist-Civilian Version and a combination of clinical, self-report, experimental and physiological outcome measures assess treatment-related changes across each of the four PTSD symptom clusters (re-experiencing, avoidance, negative cognitions or mood and hyperarousal/reactivity). Once the RCT is completed, analyses will use both an intent-to-treat (using the 'last observation carried forward' for missing data) and a per-protocol or 'treatment completers' procedure, which is the most rigorous approach to non-inferiority designs.
ETHICS AND DISSEMINATION
To the best of our knowledge, this is this first non-inferiority RCT of SKY versus CPT for PTSD among veterans. The protocol is approved by the Stanford University Institutional Review Board. All participants provided written informed consent prior to participation. Results from this RCT will inform future studies including larger multi-site efficacy RCTs of SKY for PTSD and other mental health conditions, as well as exploration of cost-effectiveness and evaluation of implementation issues. Results will also inform evidence-based formal recommendations regarding CIH interventions for PTSD.
Mehling WE, Chesney MA, Metzler TJ, Goldstein LA, Maguen S, Geronimo C, Agcaoili G, Barnes DE, Hlavin JA, Neylan TC. A 12-week integrative exercise program improves self-reported mindfulness and interoceptive awareness in war veterans with posttraumatic stress symptoms. J Clin Psychol. 2018 Apr;74(4):554-565. doi: 10.1002/jclp.22549. Epub 2017 Oct 27. PMID: 29076530.
Innovative approaches to the treatment of war-related posttraumatic stress disorder (PTSD) are needed. We report on secondary psychological outcomes of a randomized controlled trial of integrative exercise (IE) using aerobic and resistance exercise with mindfulness-based principles and yoga. We expected-in parallel to observed improvements in PTSD intensity and quality of life-improvements in mindfulness, interoceptive bodily awareness, and positive states of mind.
A total of 47 war veterans with PTSD were randomized to 12-week IE versus waitlist. Changes in mindfulness, interoceptive awareness, and states of mind were assessed by self-report standard measures.
Large effect sizes for the intervention were observed on Five-Facet Mindfulness Questionnaire Non-Reactivity (d = .85), Multidimensional Assessment of Interoceptive Awareness Body Listening (d = .80), and Self-Regulation (d = 1.05).
In a randomized controlled trial of a 12-week IE program for war veterans with PTSD, we saw significant improvements in mindfulness, interoceptive bodily awareness, and positive states of mind compared to a waitlist.
Meyer EC, Frankfurt SB, Kimbrel NA, DeBeer BB, Gulliver SB, Morrisette SB. The influence of mindfulness, self-compassion, psychological flexibility, and posttraumatic stress disorder on disability and quality of life over time in war veterans. J Clin Psychol. 2018 Jul;74(7):1272-1280. doi: 10.1002/jclp.22596. Epub 2018 Feb 28.
Posttraumatic stress disorder (PTSD) strongly predicts greater disability and lower quality of life (QOL). Mindfulness-based and other third-wave behavior therapy interventions improve well-being by enhancing mindfulness, self-compassion, and psychological flexibility. We hypothesized that these mechanisms of therapeutic change would comprise a single latent factor that would predict disability and QOL after accounting for PTSD symptom severity.
Iraq and Afghanistan war veterans (N = 117) completed a study of predictors of successful reintegration. Principal axis factor analysis tested whether mindfulness, self-compassion, and psychological flexibility comprised a single latent factor. Hierarchical regression tested whether this factor predicted disability and QOL 1 year later.
Mindfulness, self-compassion, and psychological flexibility comprised a single factor that predicted disability and QOL after accounting for PTSD symptom severity. PTSD symptoms remained a significant predictor of disability but not QOL.
Targeting these mechanisms may help veterans achieve functional recovery, even in the presence of PTSD symptoms.
Millegan J, Denninger JW, Bui E, Jakubovic RJ, Ram V, Bhakta J, Hiller Lauby MD, Mehta DH, Sager JC, Fricchione G, Sylvia LG. A mind-body program for pain and stress management in active duty service members and veterans. Psychol Serv. 2019 Jul 8.
The Mind-Body Medicine (MBM) program at the Naval Medical Center San Diego, created in collaboration with the Benson-Henry Institute for Mind Body Medicine and the Home Base Program at Massachusetts General Hospital, is a 7-week program designed to facilitate stress management habits into patient treatment plans. The aim of this study is to test the feasibility and acceptability of a mind-body program for service members and veterans. Participants (N = 239) were primarily active duty service members of the U.S. Navy and Marine Corps reporting significant perceived stress (Stress Resiliency (SR) group; n = 124), or meeting criteria for chronic pain (Pain Management (PM) group; n = 115). Participants completed measures at preprogram and post-program assessing for perceived stress, pain, functional impairment, quality of life, and psychological and somatic symptoms. Changes in self-reported psychological symptoms and knowledge and practice of mind-body principles were examined. Participants across groups had significant improvement in most outcomes (perceived stress, response to stressful experience, functional impairment, sleep disturbance, depression, PTSD, and anxiety symptoms; and each quality of life domain aside from social relationships), with p values < .0017 (Bonferroni corrected level of significance). The SR group demonstrated significant improvements in primary outcomes of perceived stress and response to stressful experience, and the PM group demonstrated significant improvement in pain severity, but not perceived stress. Significant change was observed in knowledge and practice of mind-body medicine principles, and high satisfaction was reported. Results suggest that a mind-body program may improve physical and psychological functioning for service members, including those facing significant perceived stress and chronic pain.
Munro, S., Komelski, M., Lutgens, B., Lagoy, J., & Detweiler, M. (2019). Improving the Health of Veterans Though Moving Meditation Practices: A Mixed-Methods Pilot Study. Journal of Veterans Studies, 5(1), 16–23. DOI: http://doi.org/10.21061/jvs.v5i1.128
This study explores the use of low-to-moderate intensity mindfulness-based exercises ("moving meditation") to improve Veteran physical activity level and physiological health and psychological well-being including posttraumatic stress disorder (PTSD) symptomology. 12-week, pre- and post-test intervention, mixed methods pilot. Setting/Subjects: Veterans with a history of posttraumatic stress disorder receiving care at the Department of Veterans Affairs Medical Center in Salem, Virginia. All Veterans participated in bi-weekly classroom instruction prior to a 6-10 minute warm up period of Qigong exercises, followed by a 30 minute period of Taijiquan/Qigong or mindful-meditative walking, followed by a 6-10 minute cool down period of light movement. Overall physical activity was measured for a one-week period before and after the 12-week intervention period with an Actigraph accelerometer. Physiological health indices were measured pre- and post- 12-week intervention, including salivary cortisol, Hgb A1C, fasting glucose, gonadal panel (FSH, LH, testosterone), albumin, hs-CRP, and sex hormone-binding globulin. Veterans' mental well-being was measured by the Center for Epidemiological Studies-Depression Scale, the PTSD Checklist (PCL-C), the Cohen Perceived Stress scale, and the Beck Anxiety Inventory. Participants reported increased frequency and enjoyment of physical activity; improvement in Hgb A1C; improvement in balance and movement awareness; improvement in emotional regulation and focus; and reported reduced depression, stress and anxiety, and PTSD symptoms that benefitted social interactions. Moving meditation as part of a multifaceted treatment approach may increase physical activity, improve physiological health, and enhance mental well-being, particularly with respect to PTSD.
Nakamura Y, Lipschitz DL, Donaldson GW, Kida Y, Williams SL, Landward R, Glover DW, West G, Tuteja AK. Investigating Clinical Benefits of a Novel Sleep-Focused Mind-Body Program on Gulf War Illness Symptoms: A Randomized Controlled Trial. Psychosom Med. 2017 Jul/Aug;79(6):706-718
Mind-Body Bridging (MBB) has been shown to be effective for improving disturbed sleep. In this prospective randomized controlled trial, we evaluated the efficacy of sleep-focused MBB compared with sleep education control (SED) for improving sleep in previously deployed Gulf War veterans.
US military service members with sleep and physical health complaints who were deployed in 1990-1991 were randomized to receive three weekly sessions of either MBB (n = 33) or SED (n = 27) between 2012 and 2015. The primary outcome of Medical Outcomes Study Sleep Scale was completed at baseline, weekly during treatment, postintervention, and 3-month follow-up. Secondary outcome measures for posttraumatic stress disorder, depression, fatigue, quality of life, symptom severity, and mindfulness were completed at baseline, postintervention and 3-month follow-up. Salivary samples were collected at five time points per day at each visit for cortisol and α-amylase assessment. Clinician-administered assessments of sleep and co-occurring conditions were conducted at baseline and postintervention.
MBB was significantly more efficacious than SED in reducing disturbed sleep at follow-up (F(1,180.54) = 4.04, p = .046). In addition, self-reported posttraumatic stress disorder (F(1,56.42) = 4.50, p = .038) for the treatment effect, depression (F(1,93.70) = 4.44, p = .038), and fatigue symptoms (F(1,68.58) = 3.90, p = .050) at follow-up improved in MBB compared with those in SED. Consistently higher percentages of veterans in MBB reported improvements of sleep, pain, and composite sleep/general co-occurring symptoms at the postclinical evaluation, as compared with veterans in SED. Finally, the mean waking level of salivary α-amylase in the MBB declined to a greater extent than that in the SED, at follow-up (F(1,88.99) = 3.78, p = .055), whereas no effects were found on cortisol.
Sleep-focused MBB can improve sleep and possibly also co-occurring symptoms in Gulf War veterans.
Nassif H, Chapman J, Sandbrink F et al. (2016) Mindfulness meditation and chronic pain management in Iraq and Afghanistan veterans with traumatic brain injury: A pilot study. Military Behavioral Health, 4:1, 82-89, DOI: 10.1080/21635781.2015.1119772
This study examined the effectiveness of iRest meditation for chronic pain in veterans with moderate traumatic brain injury (TBI). Veterans were randomly assigned to iRest (n = 4) or treatment as usual (n = 5) for eight weeks. Patient-reported pain intensity and interference were assessed at baseline, end point, and four-week follow-up. Veterans receiving iRest reported clinically meaningful reductions in pain intensity (23% to 42%) and pain interference (34% to 41%) for most outcome measures and time points. Effect sizes were large for pain interference (g = 0.92–1.13) and medium to large for intensity (g = 0.37–0.61). We conclude that iRest is a promising self-management approach for chronic pain in veterans with moderate TBI.
Nassif TH, Start AR, Toblin RL, Adler AB. Self-reported mindfulness and soldier health following a combat deployment. Psychol Trauma. 2019 May;11(4):466-474. doi: 10.1037/tra0000413. Epub 2018 Nov 5.
Combat exposure has been linked to health-related challenges associated with postcombat adjustment, including mental health symptoms, behavior-related problems, physical pain, and functional impairment. Mindfulness, or acceptance of the present moment without reactivity or judgment, may be associated with better mental health following a combat deployment. This study examined whether self-reported mindfulness predicted soldier health outcomes over the course of the postdeployment period.
U.S. soldiers (n = 627) were surveyed 4 months after a deployment to Afghanistan (T1) and again 3 months later (T2). Mindfulness was assessed using the nonreactivity to inner experience subscale of the Five-Facet Mindfulness Questionnaire. Hierarchical linear regressions examined how mindfulness (T1) moderated the impact of combat exposure (T1) on outcomes at T2.
Controlling for rank, the interaction between combat exposure and mindfulness significantly predicted posttraumatic stress disorder (PTSD) symptoms, depression symptoms, risk-taking behaviors, pain symptoms, and functional impairment. The interaction term explained 1% to 2% of the variance in these health outcomes. Simple slopes analyses revealed that combat exposure was associated with more PTSD symptoms, depression symptoms, risk-taking behaviors, pain symptoms, and functional impairment when soldiers reported low levels of mindfulness. There was no effect for alcohol misuse, sleep difficulties, or aggressive behaviors.
Nonreactivity to inner experience may mitigate the detrimental effects of high-levels of combat exposure on both mental and physical health outcomes. These findings indicate that mindfulness strategies such as nonreactivity may be particularly useful for employees facing potentially traumatic stressors in a high-risk occupational context. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
Nidich S, Mills PJ, Rainforth M, Heppner P, Schneider RH, Rosenthal NE, Salerno J, Gaylord-King C,. Non-trauma-focused meditation versus exposure therapy in veterans with post-traumatic stress disorder: a randomised controlled trial. Lancet Psychiatry. 2018
Post-traumatic stress disorder (PTSD) is a complex and difficult-to-treat disorder, affecting 10-20% of military veterans. Previous research has raised the question of whether a non-trauma-focused treatment can be as effective as trauma exposure therapy in reducing PTSD symptoms. This study aimed to compare the non-trauma-focused practice of Transcendental Meditation (TM) with prolonged exposure therapy (PE) in a non-inferiority clinical trial, and to compare both therapies with a control of PTSD health education (HE).
We did a randomised controlled trial at the Department of Veterans Affairs San Diego Healthcare System in CA, USA. We included 203 veterans with a current diagnosis of PTSD resulting from active military service randomly assigned to a TM or PE group, or an active control group of HE, using stratified block randomisation. Each treatment provided 12 sessions over 12 weeks, with daily home practice. TM and HE were mainly given in a group setting and PE was given individually. The primary outcome was change in PTSD symptom severity over 3 months, assessed by the Clinician-Administered PTSD Scale (CAPS). Analysis was by intention to treat. We hypothesised that TM would show non-inferiority to PE in improvement of CAPS score (Δ=10), with TM and PE superior to PTSD HE. This study is registered with ClinicalTrials.gov, number NCT01865123.
Between June 10, 2013, and Oct 7, 2016, 203 veterans were randomly assigned to an intervention group (68 to the TM group, 68 to the PE group, and 67 to the PTSD HE group). TM was significantly non-inferior to PE on change in CAPS score from baseline to 3-month post-test (difference between groups in mean change -5·9, 95% CI -14·3 to 2·4, p=0·0002). In standard superiority comparisons, significant reductions in CAPS scores were found for TM versus PTSD HE (-14·6 95% CI, -23·3 to -5·9, p=0·0009), and PE versus PTSD HE (-8·7 95% CI, -17·0 to -0·32, p=0·041). 61% of those receiving TM, 42% of those receiving PE, and 32% of those receiving HE showed clinically significant improvements on the CAPS score.
A non-trauma-focused-therapy, TM, might be a viable option for decreasing the severity of PTSD symptoms in veterans and represents an efficacious alternative for veterans who prefer not to receive or who do not respond to traditional exposure-based treatments of PTSD.
Niles, B. L., Klunk-Gillis, J., Ryngala, D. J., Silberbogen, A. K., Paysnick, A., & Wolf, E. J. (2012). Comparing mindfulness and psychoeducation treatments for combat-related PTSD using a telehealth approach. Psychological Trauma: Theory, Research, Practice, and Policy, 4(5), 538–547. h
This pilot study examined two telehealth interventions to address symptoms of combat-related posttraumatic stress disorder (PTSD) in veterans. Thirty-three male combat veterans were randomly assigned to one of two telehealth treatment conditions: mindfulness or psychoeducation. In both conditions, participants completed 8 weeks of telehealth treatment (two sessions in person followed by six sessions over the telephone) and three assessments (pretreatment, posttreatment, and 6-week follow-up). The mindfulness treatment was based on the tenets of mindfulness-based stress reduction and the psychoeducation manual was based on commonly used psychoeducation materials for PTSD. Results for the 24 participants who completed all assessments indicate that: (1) Telehealth appears to be a feasible mode for delivery of PTSD treatment for veterans; (2) Veterans with PTSD are able to tolerate and report high satisfaction with a brief mindfulness intervention; (3) Participation in the mindfulness intervention is associated with a temporary reduction in PTSD symptoms; and (4) A brief mindfulness treatment may not be of adequate intensity to sustain effects on PTSD symptoms.
Pigeon W, Allen C, Possemato K, Bergen-Cico D, Treatman S. Feasibility and Acceptability of a Brief Mindfulness Program for Veterans in Primary Care with Posttraumatic Stress Disorder. Mindfulness, 2015, Volume 6, Number 5, Page 986
Mindfulness-based stress reduction programs have improved psychological health for clinical populations including veterans with posttraumatic stress disorder (PTSD). Veterans with PTSD who seek services in Department of Veterans Affairs primary care are especially in need of brief treatments that can alleviate PTSD symptoms. A clinical demonstration project was carried out to assess the feasibility and acceptability of a brief mindfulness program consisting of four weekly 1.5-h class sessions. Veterans enrolled in primary care with diagnostic or subthreshold PTSD were recruited. The brief mindfulness intervention was feasible to deliver, and veterans were generally satisfied with the program. Despite good retention once a class session was attended, a large number of veterans provided a variety of reasons for not attending the program at all. Veteran feedback that can be addressed to improve the brief mindfulness program is discussed, including enhancing initial attendance.
Polusny MA, Erbes CR, Thuras P, Moran A, Lamberty GJ, Collins RC, Rodman JL, Lim KO. Mindfulness-Based Stress Reduction for Posttraumatic Stress Disorder Among Veterans: A Randomized Clinical Trial. JAMA. 2015 Aug 4;314(5):456-65. doi: 10.1001/jama.2015.8361. PubMed PMID: 26241597.
To compare mindfulness-based stress reduction with present-centered group therapy for treatment of PTSD.
DESIGN, SETTING, AND PARTICIPANTS
Randomized clinical trial of 116 veterans with PTSD recruited at the Minneapolis Veterans Affairs Medical Center from March 2012 to December 2013. Outcomes were assessed before, during, and after treatment and at 2-month follow-up. Data collection was completed on April 22, 2014.
Participants were randomly assigned to receive mindfulness-based stress reduction therapy (n = 58), consisting of 9 sessions (8 weekly 2.5-hour group sessions and a daylong retreat) focused on teaching patients to attend to the present moment in a nonjudgmental, accepting manner; or present-centered group therapy (n = 58), an active-control condition consisting of 9 weekly 1.5-hour group sessions focused on current life problems.
MAIN OUTCOMES AND MEASURES
The primary outcome, change in PTSD symptom severity over time, was assessed using the PTSD Checklist (range, 17-85; higher scores indicate greater severity; reduction of 10 or more considered a minimal clinically important difference) at baseline and weeks 3, 6, 9, and 17. Secondary outcomes included PTSD diagnosis and symptom severity assessed by independent evaluators using the Clinician-Administered PTSD Scale along with improvements in depressive symptoms, quality of life, and mindfulness.
Participants in the mindfulness-based stress reduction group demonstrated greater improvement in self-reported PTSD symptom severity during treatment (change in mean PTSD Checklist scores from 63.6 to 55.7 vs 58.8 to 55.8 with present-centered group therapy; between-group difference, 4.95; 95% CI, 1.92-7.99; P=.002) and at 2-month follow-up (change in mean scores from 63.6 to 54.4 vs 58.8 to 56.0, respectively; difference, 6.44; 95% CI, 3.34-9.53, P < .001). Although participants in the mindfulness-based stress reduction group were more likely to show clinically significant improvement in self-reported PTSD symptom severity (48.9% vs 28.1% with present-centered group therapy; difference, 20.9%; 95% CI, 2.2%-39.5%; P = .03) at 2-month follow-up, they were no more likely to have loss of PTSD diagnosis (53.3% vs 47.3%, respectively; difference, 6.0%; 95% CI, -14.1% to 26.2%; P = .55).
CONCLUSIONS AND RELEVANCE
Among veterans with PTSD, mindfulness-based stress reduction therapy, compared with present-centered group therapy, resulted in a greater decrease in PTSD symptom severity. However, the magnitude of the average improvement suggests a modest effect
Possemato K, Bergen-Cico D, Treatman S, Allen C, Wade M, Pigeon W. A Randomized Clinical Trial of Primary Care Brief Mindfulness Training for Veterans with PTSD. J Clin Psychol. 2016 Mar;72(3):179-93. doi: 10.1002/jclp.22241. Epub 2015 Nov 27.
Primary care (PC) patients typically do not receive adequate posttraumatic stress disorder (PTSD) treatment. This study tested if a brief mindfulness training (BMT) offered in PC can decrease PTSD severity.
VA PC patients with PTSD (N = 62) were recruited for a randomized clinical trial comparing PCBMT with PC treatment as usual. PCBMT is a 4-session program adapted from mindfulness-based stress reduction.
PTSD severity decreased in both conditions, although PCBMT completers reported significantly larger decreases in PTSD and depression from pre- to posttreatment and maintained gains at the 8-week follow-up compared with the control group. Exploratory analyses revealed that the describing, nonjudging, and acting with awareness facets of mindfulness may account for decreases in PTSD.
Our data support preliminary efficacy of BMT for Veterans with PTSD. Whether PCBMT facilitates engagement into, or improves outcomes of, full-length empirically supported treatment for PTSD remains to be evaluated.
Price CJ, McBride B, Hyerle L, Kivlahan DR. Mindful awareness in body-oriented therapy for female veterans with post-traumatic stress disorder taking prescription analgesics for chronic pain: a feasibility study. Altern Ther Health Med. 2007
Preliminary studies of body therapy for women in trauma recovery suggest positive results but are not specific to women with post-traumatic stress disorder (PTSD) and chronic pain.
OBJECTIVE AND PARTICIPANTS
To examine the feasibility and acceptability of body-oriented therapy for female veterans with PTSD and chronic pain taking prescription analgesics.
DESIGN AND SETTING
A 2-group, randomized, repeated-measures design was employed. Female veterans (N=14) were recruited from a Veterans Affairs (VA) healthcare system in the Northwest United States (VA Puget Sound Health Care System, Seattle, Washington). Participants were assigned to either treatment as usual (TAU) or treatment as usual and 8 weekly individual body-oriented therapy sessions (mindful awareness in body-oriented therapy group).
Written questionnaires and interviews were used to assess intervention acceptability; reliable and valid measures were administered at 3 time points to evaluate measurement acceptability and performance; and within-treatment process measures and a participant post-intervention questionnaire assessed treatment fidelity.
A body-oriented therapy protocol, "Mindful Awareness in Body-oriented Therapy" (MABT) was used. This is a mind-body approach that incorporates massage, mindfulness, and the emotional processing of psychotherapy.
Over 10 weeks of recruitment, 31 women expressed interest in study participation. The primary reason for exclusion was the lack of prescription analgesic use for chronic pain. Study participants adhered to study procedures, and 100% attended at least 7 of 8 sessions; all completed in-person post-treatment assessment. Written questionnaires about intervention experience suggest increased tools for pain relief/relaxation, increased body/mind connection, and increased trust/safety. Ten of 14 responded to mailed 3-month follow-up. The response-to-process measures indicated the feasibility of implementing the manualized protocol and point to the need for longer sessions and a longer intervention period with this population.
Rice VJ, Liu B, Schroeder PJ. Impact of In-Person and Virtual World Mindfulness Training on Symptoms of Post-Traumatic Stress Disorder and Attention Deficit and Hyperactivity Disorder. Mil Med. 2018 Mar 1;183(suppl_1):413-420. doi: 10.1093/milmed/usx227. PMID: 29635610
Mindfulness meditation training has been shown to reduce stress and improve short-term memory for military personnel. However, no studies have investigated the effects of in-person and virtual world (VW) mindfulness training on Post-Traumatic Stress Disorder (PTSD) or Attention Deficit Hyperactivity Disorder (ADHD) symptoms. In this study, U.S. military active duty service members and veterans were pseudo-randomized into two mindfulness training groups: in-person (IP) and online via a VW, and a wait-list control group. Volunteers answered a demographic questionnaire, and completed the PTSD Checklist-Military Version (PCL-M) and ADHD Current Symptoms Scale before and after training. The results showed practical and clinically relevant reductions in PTSD symptoms, particular for the IP group, but did not show statistical relevance with hypothesis testing. Results also showed post-training reductions in ADHD symptoms for both IP and VW groups, but no change for the control group. To investigate the effects of initial ADHD symptoms, IP and VW groups were combined into a single Mindfulness Training group. Those with high-initial ADHD symptoms attending training showed improvements, but the control group did not. These results expand research on the mindfulness training, and suggest that IP mindfulness training, rather than VW training, may be of greater benefit for those with PTSD symptoms, while either delivery system appears adequate for reducing attentional symptoms.
Rutledge T, Nidich S, Schneider RH, Mills PJ, Salerno J, Heppner P, Gomez MA, Gaylord-King C, Rainforth M. Design and rationale of a comparative effectiveness trial evaluating transcendental meditation against established therapies for PTSD. Contemp Clin Trials. 2014 Sep;39(1):50-6. doi: 10.1016/j.cct.2014.07.005. Epub 2014 Jul 25.
Although meditation therapies such as the Transcendental Meditation (TM) technique are commonly used to assist with stress and stress-related diseases, there remains a lack of rigorous clinical trial research establishing the relative efficacy of these treatments overall and for populations with psychiatric illness. This study uses a comparative effectiveness design to assess the relative benefits of TM to those obtained from a gold-standard cognitive behavioral therapy for posttraumatic stress disorder (PTSD) in a Veteran population.
METHODS AND DESIGN
This paper describes the rationale and design of an in progress randomized controlled trial comparing TM to an established cognitive behavioral treatment - Prolonged Exposure (PE) - and an active control condition (health education [HE]) for PTSD. This trial will recruit 210 Veterans meeting DSM-IV criteria for PTSD, with testing conducted at 0 and 3 months for PTSD symptoms, depression, mood disturbance, quality of life, behavioral factors, and physiological/biochemical and gene expression mechanisms using validated measures. The study hypothesis is that TM will be noninferior to PE and superior to HE on changes in PTSD symptoms, using the Clinician Administered PTSD Scale (CAPS).
The described study represents a methodologically rigorous protocol evaluating the benefits of TM for PTSD. The projected results will help to establish the overall efficacy of TM for PTSD among Veterans, identify bio-behavioral mechanisms through which TM and PE may improve PTSD symptoms, and will permit conclusions regarding the relative value of TM against currently established therapies for PTSD.
Schure MB, Simpson TL, Martinez M, Sayre G, Kearney DJ. Mindfulness-Based Processes of Healing for Veterans with Post-Traumatic Stress Disorder. J Altern Complement Med. 2018 Nov;24(11):1063-1068. doi: 10.1089/acm.2017.0404. Epub 2018 May 7.
U.S. veterans are at increased risk of developing post-traumatic stress disorder (PTSD). Prior studies suggest a benefit of mindfulness-based stress reduction (MBSR) for PTSD, but the mechanisms through which MBSR reduces PTSD symptoms and improves functional status have received limited empirical inquiry. This study used a qualitative approach to better understand how training in mindfulness affects veterans with PTSD.
Qualitative study using semistructured in-depth interviews following participation in an MBSR intervention.
Intervention: Eight-week MBSR program.
Outcome Measure: Participants' narratives of their experiences from participation in the program.
Interviews were completed with 15 veterans. Analyses identified six core aspects of participants' MBSR experience related to PTSD: dealing with the past, staying in the present, acceptance of adversity, breathing through stress, relaxation, and openness to self and others. Participants described specific aspects of a holistic mindfulness experience, which appeared to activate introspection and curiosity about their PTSD symptoms. Veterans with PTSD described a number of pathways by which mindfulness practice may help to ameliorate PTSD.
Seppälä EM, Nitschke JB, Tudorascu DL, Hayes A, Goldstein MR, Nguyen DT, Perlman D, Davidson RJ. Breathing-based meditation decreases posttraumatic stress disorder symptoms in U.S. military veterans: a randomized controlled longitudinal study. J Trauma Stress. 2014 Aug;27(4):397-405. doi: 10.1002/jts.21936.
Given the limited success of conventional treatments for veterans with posttraumatic stress disorder (PTSD), investigations of alternative approaches are warranted. We examined the effects of a breathing-based meditation intervention, Sudarshan Kriya yoga, on PTSD outcome variables in U.S. male veterans of the Iraq or Afghanistan war. We randomly assigned 21 veterans to an active (n = 11) or waitlist control (n = 10) group. Laboratory measures of eye-blink startle and respiration rate were obtained before and after the intervention, as were self-report symptom measures; the latter were also obtained 1 month and 1 year later. The active group showed reductions in PTSD scores, d = 1.16, 95% CI [0.20, 2.04], anxiety symptoms, and respiration rate, but the control group did not. Reductions in startle correlated with reductions in hyperarousal symptoms immediately postintervention (r = .93, p < .001) and at 1-year follow-up (r = .77, p = .025). This longitudinal intervention study suggests there may be clinical utility for Sudarshan Kriya yoga for PTSD.
Serpa JG, Taylor SL, Tillisch K. Mindfulness-based stress reduction (MBSR) reduces anxiety, depression, and suicidal ideation in veterans. Med Care. 2014 Dec;52(12 Suppl 5):S19-24. doi: 10.1097/MLR.0000000000000202. PubMed PMID: 25397818.
Anxiety, depression, and pain are major problems among veterans, despite the availability of standard medical options within the Veterans Health Administration. Complementary and alternative approaches for these symptoms have been shown to be appealing to veterans. One such complementary and alternative approach is mindfulness-based stress reduction (MBSR), a brief course that teaches mindfulness meditation with demonstrated benefits for mood disorders and pain.
We prospectively collected data on MBSR's effectiveness among 79 veterans at an urban Veterans Health Administration medical facility. The MBSR course had 9 weekly sessions that included seated and walking meditations, gentle yoga, body scans, and discussions of pain, stress, and mindfulness. Pre-MBSR and post-MBSR questionnaires investigating pain, anxiety, depression, suicidal ideation, and physical and mental health functioning were obtained and compared for individuals. We also conducted a mediation analysis to determine whether changes in mindfulness were related to changes in the other outcomes.
Significant reductions in anxiety, depression, and suicidal ideation were observed after MBSR training. Mental health functioning scores were improved. Also, mindfulness interacted with other outcomes such that increases in mindfulness were related to improvements in anxiety, depression, and mental health functionality. Pain intensity and physical health functionality did not show improvements.
This naturalistic study in veterans shows that completing an MBSR program can improve symptoms of anxiety and depression, in addition to reducing suicidal ideations, all of which are of critical importance to the overall health of the patients.
Serpa, J.G., Bourey, C.P., Adjaoute, G.N. et al. Mindful Self-Compassion (MSC) with Veterans: a Program Evaluation. Mindfulness (2020).
This pilot study explores the impact of Mindful Self-Compassion (MSC) in veterans. Self-compassion, the capacity to hold one's suffering with kindness and a wish to alleviate it, is associated with improvements in well-being. Veterans have more medical conditions than non-veterans and higher prevalence rates of severe pain. Acceptability of the intervention with veterans is assessed along with the impact of MSC on the physical, mental, and social health of the participants.
A racially diverse, predominantly male group of veterans (n = 80) were assessed pre- and post-MSC group with the Patient-Reported Outcomes Measurement Information System (PROMIS) to evaluate physical, mental, and social health. Measures of self-compassion, happiness, self-report medication usage, and a global assessment of improvement measure were also included. Qualitative responses to the MSC program were also solicited and reviewed.
Engagement with MSC was high (74% completion rate) and 96% of treatment completers rated their participation in the intervention as positive. Completers demonstrated small to medium effect size increases in self-compassion, happiness, and social role satisfaction, 95% CIs (− 6.13, − 2.65), (− 2.62, − 1.06), and (− 4.28, − 1.05), and decreases in depression, anxiety, fatigue, and pain interference, 95% CIs (0.44, 4.13), (0.57, 4.84), (0.43, 3.71), and (0.13, 2.70). In exploratory analyses related to pain, veterans taking pain medication reported a significant decrease in use (χ2(2, N = 47) = 24.30, p < .001).
These results are suggestive of the positive effects of the MSC intervention to veterans, but await a randomized controlled trial to establish its effectiveness in this population.
Smeeding SJ, Bradshaw DH, Kumpfer K, Trevithick S, Stoddard GJ. Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for chronic pain and stress-related depression, anxiety, and post-traumatic stress disorder. J Altern Complement Med. 2010 Aug;16(8):823-35. doi: 10.1089/acm.2009.0510. PubMed PMID: 20649442.
The purpose of this longitudinal outcome research study was to determine the effectiveness of the Integrative Health Clinic and Program (IHCP) and to perform a subgroup analysis investigating patient benefit. The IHCP is an innovative clinical service within the Veterans Affairs Health Care System designed for nonpharmacologic biopsychosocial management of chronic nonmalignant pain and stress-related depression, anxiety, and symptoms of post-traumatic stress disorder (PTSD) utilizing complementary and alternative medicine and mind-body skills.
A post-hoc quasi-experimental design was used and combined with subgroup analysis to determine who benefited the most from the program. Data were collected at intake and up to four follow-up visits over a 2-year time period. Hierarchical linear modeling was used for the statistical analysis. The outcome measures included: Health-Related Quality of Life (SF-36), the Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). Subgroup comparisons included low anxiety (BAI < 19, n = 82), low depression (BDI < 19, n = 93), and absence of PTSD (n = 102) compared to veterans with high anxiety (BAI > or = 19, n = 77), high depression (BDI > 19, n = 67), and presence of PTSD (n = 63).
All of the comparison groups demonstrated an improvement in depression and anxiety scores, as well as in some SF-36 categories. The subgroups with the greatest improvement, seen at 6 months, were found in the high anxiety group (Cohen's d = 0.52), the high-depression group (Cohen's d = 0.46), and the PTSD group (Cohen's d = 0.41).
The results suggest IHCP is an effective program, improving chronic pain and stress-related depression, anxiety, and health-related quality of life. Of particular interest was a significant improvement in anxiety in the PTSD group. The IHCP model offers innovative treatment options that are low risk, low cost, and acceptable to patients and providers.
Stanton MV, Matsuura J, Fairchild JK, Lohnberg JA, Bayley PJ. Mindfulness as a Weight Loss Treatment for Veterans. Front Nutr. 2016 Aug 15;3:30. doi: 10.3389/fnut.2016.00030. eCollection 2016.
Despite substantial evidence for their effectiveness in treating disordered eating and obesity, mindfulness-based treatments have not been broadly implemented among Veterans. A number of reviews have reported mindfulness to be beneficial in promoting healthy eating behaviors and weight loss among non-Veteran samples. We discuss this approach in the context of the Veterans Affairs system, the largest integrated healthcare provider in the U.S. and in the context of Veterans, among whom obesity is at epidemic proportions. In this article, we discuss what is known about treating obesity using a mindfulness approach, mindfulness interventions for Veterans, a new pilot mindfulness-based weight loss program designed for Veterans, and future directions for this type of obesity treatment in Veterans. We conclude that this population may be uniquely poised to benefit from mindfulness-based treatments.
Staples JK, Gordon JS, Hamilton M, Uddo M. Mind-body skills groups for treatment of war-traumatized veterans: A randomized controlled study [published online ahead of print, 2020 Mar 5]. Psychol Trauma. 2020;10.1037/tra0000559. doi:10.1037/tra0000559
This study evaluated the effects of a mind-body skills group (MBSG) intervention on posttraumatic stress disorder (PTSD) symptoms.
Veterans (n = 108; mean age = 55.97 [SD = 11.72]; 96% male) at a PTSD specialty clinic in the Veterans Affairs Health Care System were randomized to a 10-week MBSG program or standard treatment. PTSD was the primary outcome measure. Secondary outcomes included anger, sleep, depression, anxiety, posttraumatic growth, and health-related quality of life.
MBSG participants had significantly greater improvement in the total PTSD score after 10 weeks compared to the standard treatment group. Hyperarousal and avoidance scores significantly improved at 10 weeks and improvements in the hyperarousal symptoms were maintained at 2-month follow-up. MBSG participants also had significant decreases in anger and sleep disturbance. There were no significant differences in the other secondary outcomes.
This MBSG intervention offers promise in helping Veterans with PTSD and its related symptoms.
Stephenson KR, Simpson TL, Martinez ME, Kearney DJ. Changes in Mindfulness and Posttraumatic Stress Disorder Symptoms Among Veterans Enrolled in Mindfulness-Based Stress Reduction. J Clin Psychol. 2017 Mar;73(3):201-217. doi: 10.1002/jclp.22323. Epub 2016 May 6. PMID: 27152480.
The current study assessed associations between changes in 5 facets of mindfulness (Acting With Awareness, Observing, Describing, Non-Reactivity, and Nonjudgment) and changes in 4 posttraumatic stress disorder (PTSD) symptom clusters (Re-Experiencing, Avoidance, Emotional Numbing, and Hyperarousal symptoms) among veterans participating in mindfulness-based stress reduction (MBSR).
Secondary analyses were performed with a combined data set consisting of 2 published and 2 unpublished trials of MBSR conducted at a large Veterans Affairs hospital. The combined sample included 113 veterans enrolled in MBSR who screened positive for PTSD and completed measures of mindfulness and PTSD symptoms before and after the 8-week intervention.
Increases in mindfulness were significantly associated with reduced PTSD symptoms. Increases in Acting With Awareness and Non-Reactivity were the facets of mindfulness most strongly and consistently associated with reduced PTSD symptoms. Increases in mindfulness were most strongly related to decreases in Hyperarousal and Emotional Numbing.
These results extend previous research, provide preliminary support for changes in mindfulness as a viable mechanism of treatment, and have a number of potential practical and theoretical implications.
Sylvia LG, Bui E, Chudnofsky R, Lakin L, McCarthy MD, Gupta CT, Furbish K, Mehta DH, Denninger JW, Park ER, Fricchione GL, Spencer TJ. A pilot study of a mind-body stress management program for student veterans. Complement Ther Clin Pract. 2020 Aug;40:101221.
Student veterans are an at-risk population given the challenges of military experience, reintegration to civilian life, and attending college. Therefore, there is a need for innovative programs to support student veterans. The present study sought to determine the acceptability and effectiveness of a 10-week mind-body stress reduction intervention for student veterans, or Resilient Student Warrior.
Materials and Methods
Eighty-six student veterans took part in the 10-week mind-body stress reduction course, Resilient Student Warrior.
Results showed a significant improvement in reports of stress reactivity, mindfulness, sleep disturbance and coping skills for stress (p < 0.05), but not self-efficacy, perceived stress, depressive or post-traumatic stress disorder symptoms. The intervention was reported as helpful by 96% of participants, with 95% of participants stating they would recommend the course to others.
Future studies should further assess the effectiveness of mind-body interventions among the student veteran population.
Taylor SL, Hoggatt KJ, Kligler B. Complementary and Integrated Health Approaches: What Do Veterans Use and Want. J Gen Intern Med. 2019 Jul;34(7):1192-1199. doi: 10.1007/s11606-019-04862-6. Epub 2019 Apr 22.
Non-pharmacological treatment options for common conditions such as chronic pain, anxiety, and depression are being given increased consideration in healthcare, especially given the recent emphasis to address the opioid crisis. One set of non-pharmacological treatment options are evidence-based complementary and integrative health (CIH) approaches, such as yoga, acupuncture, and meditation. The Veterans Health Administration (VHA), the nation's largest healthcare system, has been at the forefront of implementing CIH approaches, given their patients' high prevalence of pain, anxiety, and depression. We aimed to conduct the first national survey of veterans' interest in and use of CIH approaches.
Using a large national convenience sample of veterans who regularly use the VHA, we conducted the first national survey of veterans' interest in, frequency of and reasons for use of, and satisfaction with 26 CIH approaches (n = 3346, 37% response rate) in July 2017.
In the past year, 52% used any CIH approach, with 44% using massage therapy, 37% using chiropractic, 34% using mindfulness, 24% using other meditation, and 25% using yoga. For nine CIH approaches, pain and stress reduction/relaxation were the two most frequent reasons veterans gave for using them. Overall, 84% said they were interested in trying/learning more about at least one CIH approach, with about half being interested in six individual CIH approaches (e.g., massage therapy, chiropractic, acupuncture, acupressure, reflexology, and progressive relaxation). Veterans appeared to be much more likely to use each CIH approach outside the VHA vs. within the VHA.
Veterans report relatively high past-year use of CIH approaches and many more report interest in CIH approaches. To address this gap between patients' level of interest in and use of CIH approaches, primary care providers might want to discuss evidence-based CIH options to their patients for relevant health conditions, given most CIH approaches are safe.
Wahbeh H, Goodrich E, Goy E, Oken BS. Mechanistic Pathways of Mindfulness Meditation in Combat Veterans With Posttraumatic Stress Disorder. J Clin Psychol. 2016
This study's objective was to evaluate the effect of two common components of meditation (mindfulness and slow breathing) on potential mechanistic pathways.
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.
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).
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.
Wheeler, M.S., Glass, C.R., Arnkoff, D.B. et al. The Effect of Mindfulness and Acup on Psychological Health in Veterans: an Exploratory Study. Mindfulness (2018) 9: 564. https://doi.org/10.1007/s12671-017-0798-7
iRest Yoga Nidra® is a guided mindfulness approach that encourages relaxation, focused attention, experience of joy, observation of opposite feelings and emotions, non-judgment, and integration of these principles into daily life. iRest was developed for the military population, but the research on its effectiveness is in its infancy. This exploratory study examined the effectiveness of iRest in combination with acupuncture compared to acupuncture alone in improving psychological health in Veterans. The combined treatment yielded significant psychological benefit in depression, psychological symptom severity, depression or tension due to pain, and emotional interference with life activities, while the acupuncture-only treatment did not. Although both conditions showed significant decreases in perceived stress, the effect size for the treatment group was medium to large compared to a small effect size for those receiving acupuncture only. The combined treatment condition, iRest plus acupuncture, also demonstrated clinically meaningful change, with significant decreases in the number of Veterans meeting criteria for mild, moderate, and severe depression. Finally, the combined treatment was equally beneficial independent of factors such as age, gender, or race. Given the pervasiveness of psychological distress and depression in the Veteran population and the efficiency with which these group treatments can be provided, these findings lend preliminary support for the extension of complementary and integrative health offerings including iRest and acupuncture into more Veterans Administration hospitals across the country to improve military mental health. Indeed, the encouraging results of this exploratory study underscore the importance of expanded research on iRest and acupuncture for the treatment of psychological health.
Williams RM, Ehde DM, Day M, Turner AP, Hakimian S, Gertz K, Ciol M, McCall A, Kincaid C, Pettet MW, Patterson D, Suri P, Jensen MP. The chronic pain skills study: Protocol for a randomized controlled trial comparing hypnosis, mindfulness meditation and pain education in veterans. Contemp Clin Trials. 2020 Jan 8:105935. doi: 10.1016/j.cct.2020.105935.
To describe the protocol of a randomized controlled trial to evaluate the effectiveness and mechanisms of three behavioral interventions.
Participants will include up to 343 Veterans with chronic pain due to a broad range of etiologies, randomly assigned to one of three 8-week manualized in-person group treatments: (1) Hypnosis (HYP), (2) Mindfulness Meditation (MM), or (3) Education Control (EDU).
The primary aim of the study is to compare the effectiveness of HYP and MM to EDU on average pain intensity measured pre- and post-treatment. Additional study aims will explore the effectiveness of HYP and MM compared to EDU on secondary outcomes (i.e., pain interference, sleep quality, depression and anxiety), and the maintenance of effects at 3- and 6-months post-treatment. Participants will have electroencephalogram (EEG) assessments at pre- and post-treatment to determine if the power of specific brain oscillations moderate the effectiveness of HYP and MM (Study Aim 2) and examine brain oscillations as possible mediators of treatment effects (exploratory aim). Additional planned exploratory analyses will be performed to identify possible treatment mediators (i.e., pain acceptance, catastrophizing, mindfulness) and moderators (e.g., hypnotizability, treatment expectations, pain type, cognitive function).
The study treatments will be administered at a large Veterans Affairs Medical Center in the northwest United States. The treatments will be integrated within clinical infrastructure and delivered by licensed and credentialed health care professionals.