Mindfulness

Buddhist background and the modern term

Van Dam and colleagues, in a 2018 review in Perspectives on Psychological Science, describe mindfulness as an umbrella term for many practices, processes and characteristics, defined mainly in relation to attention, awareness, memory or retention, and acceptance or discernment. They state that the term has its historical footing in Buddhism and that it spread through psychology, psychiatry and medicine largely by way of Mindfulness-Based Stress Reduction (MBSR).

Robert Sharf, a scholar of religion, traces the present-centred "bare attention" approach to Burmese Buddhist reform movements of the first half of the twentieth century and calls it arguably at odds with more traditional Theravada doctrine and practice. He adds that comparable innovations appeared in medieval Chinese Chan (Zen) and in Tibetan Dzogchen, partly to make practice accessible to lay people, and that traditional Buddhist quarters met them with suspicion. Only the abstract of his 2014 article was reviewed here.

Clinical programmes from the late 1970s

A 2019 Cochrane review states that MBSR was developed in the USA in the 1970s by Jon Kabat-Zinn, who founded the MBSR clinic at the University of Massachusetts in 1979. The review describes the programme as free of cultural, religious and ideological factors while associated with the Buddhist origins of mindfulness. Van Dam and colleagues likewise place MBSR's introduction in the late 1970s, as a complementary therapy for medically ill people.

Kabat-Zinn's 1982 report in General Hospital Psychiatry described a 10-week Stress Reduction and Relaxation Program for 51 chronic pain patients who had not improved with conventional medical care. He proposed that the meditation "uncouples" the sensory dimension of pain from the emotional alarm reaction. At 10 weeks, 65% of patients showed at least a one-third reduction in a pain rating index, but the study had no control group, a limitation its author states.

Adaptation for recurrent depression

Teasdale and colleagues described MBCT in a 2000 trial as a group intervention intended to help people who had recovered from recurrent depression disengage from thinking patterns triggered by low mood, which they proposed might mediate relapse. This is the researchers' stated rationale rather than a tested mechanism. The trial's findings are summarised under Research and Evidence.

An umbrella term with several meanings

Van Dam and colleagues write that the term mindfulness has a plethora of meanings, which they attribute partly to its popularity alongside misunderstanding and a lack of methodologically rigorous research. Their reference list includes a 2011 paper by Grossman and Van Dam on the trials and tribulations of sati, the Buddhist term at issue, in Western psychology and science. The sources opened for this page do not set out the meaning of sati, so readers should consult that specialist literature directly.

Mindfulness-based programmes

Crane and colleagues, a group that includes Kabat-Zinn and Mark Williams, propose a framework for the family of mindfulness-based programmes (MBPs) that originate from MBSR. They state that such programmes are informed by contemplative traditions, science, medicine, psychology and education, develop a new relationship with experience marked by present-moment focus, decentering and an approach orientation, and involve sustained intensive training in meditation, inquiry-based learning and exercises to develop understanding. The framework also addresses the teacher. Only the abstract was reviewed.

Labels used in research and guidance

Usage varies by setting. NICE's 2022 depression guideline lists the option as group mindfulness and meditation, delivered through a programme such as mindfulness-based cognitive therapy that is designed for people with depression, and uses the abbreviation MBCT in its relapse-prevention recommendations. A 2014 meta-analysis reviewed meditation programmes as a wider category and reported mindfulness meditation programmes as one subgroup, so findings labelled by either term may not describe the same intervention.

The MBSR format

The Cochrane review describes MBSR as usually delivered to groups of up to 20 people over eight weekly two-hour sessions, with a one-day retreat of about six hours between sessions six and seven and daily home assignments of about 45 minutes using recorded practices. Its three main formal practices are the body scan, gentle yoga and sitting meditation, alongside informal exercises that apply mindfulness to daily routine, stress or pain. Only four of the ten trials in its meta-analysis delivered the standard programme, and the others varied it, for example by omitting the retreat.

The MBCT format in clinical guidance

NICE describes group mindfulness for depression as provided preferably by two practitioners, at least one with therapy-specific training and competence. It usually consists of eight regular sessions with about 8 to 15 participants, focused on concentrating on the present and observing thoughts, feelings and bodily sensations, with homework that includes using mindfulness recordings between sessions. For relapse prevention it describes about eight sessions over two to three months, with optional further sessions in the following 12 months.

A general-population adaptation of MBCT studied by Baer and colleagues consisted of eight weekly 90-minute sessions with suggested home practice of 10 to 20 minutes a day. Teachers in one study discussed contraindications with potential participants beforehand.

Teachers, training and regulation

Baer and colleagues report that teachers in their UK studies met good practice guidelines developed by the UK Network for Mindfulness-Based Teacher Training Organizations and had received further training and supervision. The content of those guidelines could not be opened for this page. No statutory regulation or training standard for mindfulness teachers was found in the sources reviewed, and requirements are likely to differ by country and provider.

Uses described in programme and research literature

The sources reviewed describe mindfulness programmes being applied to chronic pain, psychological stress, anxiety, depression and relapse prevention in recurrent depression. The Cochrane review notes that MBSR has been widely practised in hospitals and in complementary medicine, mainly in cancer care. A 2014 meta-analysis assessed meditation programmes against outcomes that included anxiety, depression, stress, mood, attention, substance use, eating habits, sleep, pain and weight. Being studied for an outcome does not mean the outcome is supported.

Recognition in clinical guidance

NICE's 2022 guideline on depression in adults includes group mindfulness and meditation among treatment options for a new episode of less severe depression. It also advises that, for people who have remitted on antidepressants alone and are assessed as being at higher risk of relapse, clinicians consider group cognitive behavioural therapy or MBCT for those who do not wish to continue antidepressants, or alongside continued medication. The guideline was published on 29 June 2022.

Popular and institutional uptake

Van Dam and colleagues describe mindfulness meditation moving within two decades from a fringe topic to an occasional replacement for psychotherapy, a corporate well-being tool and a widely implemented educational practice. They state that some media portrayals treated it as a universal remedy and that such claims exceed the evidence. These are descriptions of use and publicity, not evidence of benefit.

MBCT and relapse in recurrent depression

In a 2000 trial, 145 people who had recovered from recurrent depression were randomised to usual care or usual care plus MBCT and followed for 60 weeks. For the 77% with three or more previous episodes, MBCT reduced relapse risk; for those with two previous episodes it did not.

A 2016 individual patient data meta-analysis of nine randomised trials (1,258 patients) found a hazard ratio for relapse over 60 weeks of 0.69 (95% CI 0.58 to 0.82) against no MBCT and 0.79 (0.64 to 0.97) against active treatments including antidepressants. The effect appeared larger with more pronounced residual symptoms. The review population was in full or partial remission, so these results do not describe treatment of a current depressive episode.

MBCT compared with maintenance antidepressants

In the PREVENT trial, 424 adults with three or more previous depressive episodes who were taking maintenance antidepressants were randomised to MBCT with support to taper or stop medication, or to continue antidepressants, and followed for 24 months. Time to relapse did not differ (hazard ratio 0.89, 95% CI 0.67 to 1.18), and the authors found no evidence that MBCT was superior. Participants and therapists knew their allocation. No adverse events were attributed to either intervention.

Meta-analysis across conditions

A 2014 systematic review in JAMA Internal Medicine included 47 trials with 3,515 participants and active controls, searched to November 2012. For mindfulness meditation programmes it graded evidence as moderate for anxiety (effect size 0.38 at 8 weeks, 0.22 at 3 to 6 months), depression (0.30 and 0.23) and pain (0.33), and low for stress and mental-health quality of life. Evidence for positive mood, attention, substance use, eating, sleep and weight was low or insufficient. No evidence showed programmes outperforming drugs, exercise or other behavioural therapies.

A Cochrane review in breast cancer

A 2019 Cochrane review compared MBSR with no intervention in women with breast cancer, mostly early-stage and after treatment, using 10 trials with 1,571 participants in its meta-analysis. All trials had high risk of performance and detection bias because participants could not be blinded. Short-term depression fell (SMD -0.54, high-certainty), with moderate-certainty evidence for smaller reductions in anxiety and fatigue. Long-term anxiety and depression differed little, and no study reported survival or adverse events.

Adverse events in reviews and trials

A 2020 systematic review of 83 studies with 6,703 participants found that 55 (65%) reported at least one meditation-related adverse event. Pooled prevalence was 8.3% (95% CI 5% to 12%), ranging from 3.7% in experimental studies to 33.2% in observational studies. Anxiety (18 studies), depression (15) and cognitive anomalies (14) were most often reported, and events occurred in people with no previous mental health history.

Van Dam and colleagues state that fewer than 25% of meditation trials actively assess adverse events and that passive reporting can underestimate frequency more than 20-fold. The Cochrane review above found no study reporting adverse events, so an absence of reports in a trial should not be read as an absence of harm.

Unpleasant experiences during a mindfulness course

Baer and colleagues surveyed 84 schoolteachers and 74 university students after an eight-week MBCT-based course for the general population. In both uncontrolled studies about two-thirds reported unpleasant experiences, and 85% to 92% rated them as not at all or only somewhat upsetting. Harm from the course was reported by 3% to 7%, and reliable deterioration on symptom questionnaires by 2% to 7%, largely in different people, so questionnaires alone may miss harm.

Challenges in intensive Buddhist practice

The Varieties of Contemplative Experience study interviewed 60 Western Buddhist practitioners, 20 each from Theravada, Zen and Tibetan lineages, who were selected for having had challenging experiences. It catalogued 59 experiences across seven domains, with distress ranging from minimal and transient to severe and enduring. Challenges began during or after retreat for 72%. Because participants were selected, the study cannot estimate how common such experiences are, and its findings concern intensive practice rather than eight-week programmes.

Suitability and care boundaries

NICE notes that group mindfulness may be difficult for people experiencing intense or highly distressing thoughts, or who find focusing on the body difficult. Van Dam and colleagues report more than 20 case reports or observational studies of meditation-related experiences serious enough to need treatment, including psychosis, mania and panic, and warn that inflated claims can divert people from other effective care. Mindfulness should not delay or replace necessary medical or psychological assessment or treatment.

Methodological concerns in the field

Van Dam and colleagues, a group of 15 researchers in contemplative science, raise four concerns: insufficient construct validity in measures of mindfulness, weaknesses in clinical trial methodology, potential adverse effects, and questionable interpretation of neuroimaging findings. They argue that misinformation and poor methodology may lead consumers to be harmed, misled and disappointed. Their critique targets the research and its public portrayal, not the existence of benefit for every outcome.

A large school-based trial with null findings

The MYRIAD cluster trial randomised 84 UK secondary schools (8,376 students, aged 11 to 14) to a 10-lesson school-based mindfulness course or usual teaching. At one year it found no evidence of superiority on risk of depression (standardised mean difference 0.005, 95% CI -0.05 to 0.06), social-emotional-behavioural functioning or well-being, and no intervention-related adverse events. The authors concluded the findings do not support superiority over usual teaching in early adolescence, and the result should not be extended to adults or to other programme formats.