2. Why is this important in primary care?
■ Prevalence ofAnxiety:
– 40 million Americans affected in
a given year
– The most common mental
illness in U.S.
■ Prevalence of Depression:
– 15.7 million Americans affected
in a given year
– Most common cause of disability
• Anxiety and depression overlap: one-half of those diagnosed with depression are
also diagnosed with anxiety
• Women more affected than men
3. What can be done?
■ Treatment as usual
– Antidepressants, benzodiazepines
– Referral to psychology or psychiatry
– Referral to support groups
4. MEDITATION
A method of releasing the mind’s fixation on memories of the past as well as fixation on
the future, giving rise to a lessening of feelings of depression and anxiety
5. The identified problem
■ In adult patients with anxiety and depression, what is the
effect of meditation on anxiety and depression symptoms?
7. Validation: Review of Literature
Chiesa, A, Serrati,
A. (2011)
• Rated Excellent
• Meta-analysis of MBCT
versus active controls
measuring relapse rates in
MD, Depression
symptoms, anxiety
symptoms in those
diagnosed
• Standardized 8-week
program, some studies
w/o randomization, small
sample sizes
• Improved relapse rates
p<.003
• Improved depression
symptoms per self-report
BDI p<.003
• Reduced anxiety
symptoms p=.002
• Consider further
investigation of topic
secondary promising
research
Hofman, et al.
(2010)
• Rated Excellent
• Meta-analysis of RCTs and
observational studies for
efficacy of mindfulness-
based therapies on anxiety
and depression symptoms.
• 1,140 total participants
where (8) 1-hour sessions
took place
• Those patients having
symptoms but not
necessarily diagnoses of
MD or GAD were included.
• Some uncontrolled studies
• Improvements seen in
those diagnosed and those
having acute symptoms
p<.01 for both anxiety and
depression
• Could use per Stetler
Goyal, et al.,
(2014)
• Rated Excellent
• Meta-analysis of MBT on
stress-related outcomes in
a diverse adult population:
anxiety, depression, stress,
positive mood, substance
use, eating and sleeping
habits.
• 47 trials of MBT versus
active control; 3,515
participants with at least
one medical diagnosis,
physical impairment, or
stressed population.
• Control must be equally
matched in time &
attention to be included.
• Diverse population with
active controls
• Moderate improvements in
anxiety and depression
symptoms with
mindfulness meditation
• No statistically significant
results for mood, etc.
Hoge, et al.,
(2015)
• Rated Good
• RCT of MBSR versus stress
management education in
reduction of anxiety
symptoms
• N=93 GAD patients self-
reporting anxiety via
Hamilton Anxiety Scale
and Beck Anxiety Inventory
• Small sample size, only
extrapolate results to GAD
patients, some on
medications
• Strict quality controls: all
evaluators master’s
prepared.Controls were
equal in time and
attention.
• Results: greater reductions
in anxiety in MBSR group
p<.0001
• Could use per Stetler
Chen, et al.,
(2012)
• Rated Excellent
• Meta-analysis of all
“meditative therapies”,
including movement, in a
varied adult population
with anxiety symptoms.
• Determined that blinding
was not necessary for
inclusion
• Sample size>20, adult age,
control
• N=36, 2,446 participants
where baseline and post-
intervention data was
recorded.
• Practical quality
assessment algorithm and
author clarification.
• Pooled results favor MBT,
p<.001
• Attention control, p<.001
• Active control, p=.003,
MBT as effective as
exercise, etc.
• Use per Stetler
11. Implementation Plan
Screen all adults > 18
years
Positive Screening
Negative Screening
Referral to Mental
Health Specialist
RTC 4 weeks
Re-evaluate 1 year
GAD < 8, PHQ < 5
PHQ > 15 or suicidality
Symptom
review
&
exploration
GAD>8, PHQ 5-14 Meditation:
definition,
benefits,
evidence
Rx: 5 min
daily, 5x/wk x
4 wks
Evaluate:
Weekly logs
w/DASS 21
4 wk Follow
up: Endpoint
GAD-7, PHQ-9
Begin/Modify
medications or
refer as necessary
Referral to mental
health specialist
GAD >8, PHQ 5-14
PHQ>15 or suicidality
12. The Meditation Prescription
1
• Set aside a convenient, distraction-free time
2
• Sit or lie in a comfortable position with your eyes closed.
3
• Take several deep breaths and try to relax; pay attention to the weight of your body on your floor or
cushion. Let go of the tension in the body.
4
• Notice your breath. Feel the sensation of it in your nose, chest, and abdomen. Notice how your chest rises
and falls. Continue to breathe naturally.
5
• You may notice that your mind begins to wander; this is natural. Gently redirect your attention back to the
sensation of your breath.
6
• Do this for five minutes.
7
• Once again, bring your attention to your body. Smile. Go on with your day.
13. Evaluation
Weekly logs of the following questions:
• How many times did you meditate this week?
• Did you feel that you had a clear
understanding of what to do?
• Did you find it difficult? If so, why?
• Did anything change in your life that has made
things especially difficult?
• Did anything change in your life that has made
things much easier?
• Did you smoke or drink more than usual this
week?
• Did you experience a benefit of any kind from
meditating this week?
• Do you think you need to explore other
avenues with respect to your symptoms?
14. Evaluation
(continued)
■ Baseline versus endpoint PHQ-9 and
GAD-7 data to be reviewed at 4 week
follow up appointment.
■ Weekly logs to account for variations
during intervention
– Encourage commitment
– Encourage curiosity
– Keep patients engaged
15. Evidence into
practice &
higher levels
of patient
well being
More
communication
and education
Proper
Diagnosis &
Treatment
Addition of
Meditation
16. References
■ Baer, R.A., Carmody, J., Hunsinger, M. (2012)Weekly Change in Mindfulness and Perceived Stress in a Mindfulness-Based Stress
Reduction Program. Journal of Clinical Psychology, 68(7), 755-765.
■ Chen, K.W., Berger, C. C., Manheimer, E., Forde, D., Magidson, J., Dachman, L., & Lejuez, C.W. (2012). Meditative therapies for
reducing anxiety: a systematic review and meta-analysis of randomized controlled trials. Depression and Anxiety, 29(7),
545-562. doi:10.1002/da.21964
■ Chiesa, A., Serretti, A. (2011). Mindfulness based cognitive therapy for psychiatric disorders: A systematic review and meta-
analysis. Psychiatry Research 187 (3). 441-453. doi:10.1016/j.psychres.2010.08.011
■ Goyal, M., Singh, S., Sibinga, E.S., Gould, N.F., Rowland-Seymour,A., Sharma, R., Berger, Z., Sleicher, D., Maron, D.D., Shihab,
H.M., Ranasinghe,P.D., Linn, S., Saha, S., Bass, E.B., Haythornthwaite, J.A. (2014). Meditation programs for psychological
stress and well-being: a systematic review and meta-analysis. Journal of the American Medical Association, 174(3): 357-
368. doi:10.1001/jamainternmed.2013.13018
■ Hofman, S. G., Sawyer, A.T.,Witt, A.A. & Oh, D. (2010).The Effect of Minfulness-basedTherapy on Anxiety and Depression: a Meta-
analytic Review. Journal ofConsulting andClinical Psychology, 2(78), 169-183. doi: 10.1037/a0018555
■ Hoge, E.A., Bui, E., Marques. L., Metcalf, C.A., Morris, L.K., Robinaugh, D.J.,Worthington, J.J., Pollack, Simon, N.M. (2013).
Randomized ControlledTrial of Mindfulness Meditation for Generalized Anxiety Disorder: Effects onAnxiety and Stress
Reactivity. Journal of Clinical Psychiatry, 74(8): 786-792. doi: 10.4088/JCP.12m08083
■ Meditation. (n.d.) In National Center for Complementary and Integrative Medicine. Retrieved online from
https://nccih.nih.gov/health/meditation/overview.htm
■ Ronk, F. R., Korman, J. R., Hooke, G. R., & Page, A. C. (2013). Assessing clinical significance of treatment outcomes using the
DASS-21. Psychological Assessment, 25(4), 1103-1110. doi:10.1037/a0033100
■ SiuA., & the U.S. Preventive ServicesTask Force (USPSTF). (2016) Screening for Depression inAdults: U.S. Preventive Services
Task Force Recommendation Statement. Journal of American Medical Association, 315(4), 380-387.
doi:10.1001/jama.2015.18392.
