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Does Mindfulness Meditation Improve Anxiety and


Mood Symptoms? A Review of the Controlled Research

Tony Toneatto, PhD*'^ Linda Nguyen,

Objective: To review the impact of mindfulness-based stress reduction (MBSR) on


symptoms of anxiety and depression in a range of clinical populations.
Method: Our review included any study that was published in a peer-reviewed journal,
used a control group, and reported outcomes related to changes in depression and anxiety.
We extracted the following key variables from each ofthe 15 studies identified: anxiety or
depression outcomes after the MBSR program, measurement of compliance with MBSR
instructions, type of control group included, type of clinical population studied, and length
of follow-up. We also summarized modifications to the MBSR program.
Results: Measures of depression and anxiety were included as outcome variables for a
broad range of medical and emotional disorders. Evidence for a beneficial effect of MBSR
on depression and anxiety was equivocal. When active control groups were used, MBSR
did not show an effect on depression and anxiety. Adherence to the MBSR program was
infrequently assessed. Where it was assessed, the relation between practising mindfulness
and changes in depression and anxiety was equivocal.
Conclusions: MBSR does not have a reliable effect on depression and anxiety.
(Can J Psychiatry 2007;52:260-266)
Information on funding and support and author affiliations appears at the end of the article.

Clinical Implications
• MBSR is increasingly being used to improve medical and emotional symptoms in a wide
range of clinical populations.
• Depression and anxiety are almost always measured in such research and may be the
mechanism by which improvement in quality of life and improved functioning occur.
• Evaluating the effect of MBSR on depression and anxiety is important to evaluate the
effectiveness of this emerging modality.

Limitations
• Methodological variability in the studies reviewed precludes strong conclusions.
• The paucity of randomized clinical trials with active control groups limits the support for the
unique efficacy of MBSR when changes in depression and anxiety symptoms are found.
• Depression and anxiety do not reliably improve after patient participation in MBSR.

Key Words: mindfulness-based stress reduction, depression, anxiety, review, therapy

260 La Revue canadienne de psychiatrie, voi 52, no 4, avril 2007


Does Mindftilness Meditation Improve Anxiety and Mood Symptoms? A Review of the Controlled Research

ood and anxiety disorders are among the most common present-moment awareness and (e) diminishing
M psychiatric disorders in Canada and are frequently
comorbid with other mental and medical disorders. '''^ Despite
habitual pattems of cognitive, behavioral and
physiological reactivity.'^'''''^^
the growing availability of effective pharmacotherapies and
Thus regular mindfulness practice may produce improve-
psychotherapies specific to anxiety and depressive dis-
ments in mood and anxiety symptoms by reducing the ten-
orders,''"'' innovative conceptual and therapeutic models of
dency to react to negative mental and physical states with
care continue to emerge that may be relevant to the ameliora-
ruminative thought or maladaptive behaviour (for example,
tion of anxiety and depression in a broad range of medical and
phobic behaviour or impulsivity). Individuals suffering from
emotional disorders. MBSR, in particular, has emerged as one
anxiety disorders may misconstrue experiences that others
ofthe better-known clinical applications of mindfulness med-
may judge as normative in such a way as to elicit intense feel-
itation,^'* that has been shown to significantly benefit individ-
ings of panic and fear. Individuals suffering from depression
uals with a diverse set of medical and psychiatric conditions,
may hold their negative self-perceptions with excessive con-
including chronic pain,^ cancer,' anxiety disorders,^ depres-
viction. Sustained mindfulness practice, through its repeated
sion,' eating disorders,'" and fibromyalgia." (Kabat-Zinn
retum of conscious awareness to the breath or the immediate
defines mindfulness as the "awareness that emerges through
present, interrupts the anxiogenic or depressogenic thought
paying attention on purpose, in the present moment, and
pattems that would otherwise increase the probability of
nonjudgmentally to the unfolding of experience moment by
maladaptive behaviours (such as phobic behaviour, social
moment."''^''' '''^) The reduction of depression and anxiety
withdrawal, substance abuse, and suicidality.'''''^ Salmon et
symptoms after MBSR may be a primary pathway by which
al'^ argued that mindfrilness meditation may lead to the detec-
an individual experiences enhanced mental and physical
tion of early signs of stress, ruminative thought, and physio-
health (for example, through less pain, reduced disability, or
logical arousal and thereby afford the individual an
greater hope and confidence) and thus may be an important
opportunity to respond with more effective coping responses.
indicator ofthe efficacy of MBSR, given the often chronic and
recurrent nature of many of the medical conditions (such as The goal of this article is to review the empirical evidence for
cancer) with which MBSR participants present. the effectiveness of mindfulness meditation on symptoms of
Persistent symptoms of depression and anxiety possibly mood and anxiety in a wide range of clinical populations.
refiect deficiencies in coping that MBSR may be able to
improve. Segal and colleagues' have defined the core mind- Method
fulness skill as the capacity to respond to aversive cognitions, Through a literature search conducted on MEDLINE, we
sensations, and emotions with an attitude of nonjudgmental, identified controlled studies that administered MBSR to a
accepting, present-moment awareness. The ability to recog- clinical (that is, medical or psychiatric) population, including
nize and disengage from dysfunctional thinking pattems (that those adopting a waiting list or no-treatment control group
is, process focus) associated with chronic medical and emo- and published in peer-reviewed joumals. Although most stud-
tional disorders is a defining feature of mindfulness that is in ies randomized participants, we also included studies that
contrast to approaches that attempt to change specific beliefs adopted a quasi-experimental or convenience comparison
(content focus), common within traditional psychotherapies. sample. We reviewed each study for basic descriptive vari-
Salmon and associates have summarized mindfrilness prac- ables (sample size, clinical population, and age), measures of
tices as the depression or anxiety, depression or anxiety outcomes, adher-
(a) conscious allocation of attention in the service of ence to MBSR practice recommendations, follow-up, and
(b) non-judgmental awareness; ideally cultivated (but modifications to the standard MBSR program.
not necessarily limited to) a state of (c) physiological
hypo-arousal; with the intention of (d) enhancing
Results
We identified 15 studies,''"''^^' which are summarized in
Abbreviations used in this article
Table 1. Diversity in the subject samples and methodologies
BDI Beck Depression Inventory
(for example, sample size, control group, follow-up, random-
DAS Dysfunctional Attitudes Scale ization, and assessment methods) was evident. Only 4 stud-
MBSR mindfulness-based stress reduction ies "'^*'^^'^' explicitly treated individuals with mood disorders,
POMS Profile of Mood States while the remainder included populations with medical condi-
SCL-90 Symptom Check List-90 tions (such as pain, cancer, and heart disease) or nonclinical
STAI State-Trait Anxiety Inventory populations (such as community samples and undergradu-
ates). Program adherence and follow-up data were relatively

The Canadian Journal of Psychiatry, Voi 52, No 4, April 2007 261


Brief Communication

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262 La Revue canadienne de psychiatrie, vol 52, no 4, avril 2007


Does Mindfulness Meditation Improve Anxiety and Mood Symptoms? A Review of the Controlled Research

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The Canadian Journal of Psychiatry, Voi 52, No 4, April 2007 263


Brief Communication

Table 2 Summary of key study variables


Positive change on Compliance with
depression or mindfulness Active control Random
Study anxiety measured group used assignment Follow-up

Goldenberg"

V V V
Shapiro" V

Teasdale^' V
Williams^" V V V
Marcus^'
Carlson^^; Speca^ V V

Davidson^'' V V
Tacon^^

V V
Ramel^'
Sagula^'
Weiss'^

studied. The most common difference was the exclusion of depression and anxiety may not ameliorate when they are not
the day-long retreat advocated by Kabat-Zinn.^ This modifi- the explicit focus of an MBSR intervention (that is, when sub-
cation would reduce by up to 8 hours any additional training jects with medical conditions are included). However, the risk
and practice in mindfulness. Other changes included variabil- for relapse after successfully treated depression does appear
ity in the recommended length of time for daily meditation to be reduced by exposure to an MBSR-influenced interven-
(ranging from 20 to 60 minutes) and the inclusion of addi- tion, suggesting that the benefits of this approach for alleviat-
tional components and exercises that were unique to a specific ing anxiety and depression may be most evident when it is
study (such as loving-kindness, stress management, exer- used as an adjunctive treatment rather than as the primary
cises, and readings). It is difficult to evaluate the impact of intervention. In a recent metaanalysis of mindfulness-based
these program changes on the changes in anxiety and depres- interventions^ demonstrating a medium effect size (clustering
sion because the results of studies that most closely adhered to around a coefficient of 0.50), only 1 ofthe 10 controlled stud-
the MBSR model did not differ from those of the modified ies included in that review was actually published,^ in contrast
interventions. to our study.

Conclusion An issue that has yet to be adequately addressed is the extent


On the basis of this overview's results, MBSR appears to have and quality of the mindfulness practice during the interven-
equivocal effects on symptoms of anxiety and depression. The tion period. In this review, the few studies that actually did
benefits of MBSR were most evident when there was no measure mindfulness practices and correlate them with out-
active control group, suggesting that the symptomatic comes did not find support for the amount of mindfulness
improvements might have been due to nonspecific variables practice, calling into question the role of mindfulness practice
rather than the effect of mindfulness intervention per se. as the mechanism for the symptomatic improvements. To
Better controlled studies found no evidence for the efficacy of evaluate the unique efficacy of this intervention, researchers
MBSR. Since the empirical evaluation of MBSR is relatively will need to ensure that their research design is able to validly
new, the adoption of waiting list control subjects may be justi- measure the practice of mindfulness during and between
fied in the effort to establish the effectiveness of MBSR. As treatment sessions.
this area of research matures, increased emphasis on research
designs with active control groups will be necessary to assess Funding and Support
the unique efficacy of this intervention. Symptoms of This study received no flinding and no support.

264 La Revue canadienne de psychiatrie, vol 52, no 4, avril 2007


Does Mindfulness Meditation Improve Anxiety and Mood Symptoms? A Review of the Controlled Research

Table 3 Modifications to the MBSR program

Core iVlBSR Components

Sitting
Day-iong meditation, Yoga,
Study Duration retreat Breath mindfuiness body scan Modifications to the MBSR Program

Goldenberg" 10 sessions, no Readings assigned; advised to meditate 20


2 hours minutes daiiy; audio tapes provided
weekiy
Astin^^ 8 weeks, 2 no ^/ V V Asked to meditate 5 times weekly
hours weekly
Shapiro" 7 weeks, 2.5 no Loving-kindness and forgiveness meditation;
hours weekly exercises to develop empathy and listening skills;
information on physioiogy and psychology of
stress
Kabat-Zinn'^ 40 sessions no ^/ Delivered by audiotape; visualize ultraviolet light
over 13 and (or) medication slowing down skin cell
weeks division; discouraged from meditating at home;
tapes not taken home
Marcus^^ 8 weeks, 2.5 no V Yoga emphasized; breathing and sitting meditation
hours weekly deemphasized; practice 46 to 60 minutes of
meditation daiiy; information on stress;
Wiliiams^° 8 sessions, yes, 8 V Reading, assessment and planning materials
2.5 hours hours (e.g. Stress Map inventory. Action Planning
weekiy Workbook; Full Catastrophe Living); encouraged
to meditate 60 minutes daiiy
Carison^^; Speca'' 7 weeks, 90 no V Audiotape with relaxation induction and guided
minutes meditation
Teasdaie^' 8 sessions, 2 no V Follow-up meetings at 1, 2, 3, and 4 months
hours weekly post-MBCT
iVIcMiilan" 5 sessions, no V Audiotape provided; breathing exercises to
each 45 improve concentration and relaxation
minutes,
over 4 weeks
Davidson^"* 8 weeks, 2.5 yes, 7 V Meditate daiiy for 60 minutes, 6 days weekly
hours weekly hours
Tacon^^ 8 weeks, 2 no ^1 V Provided with audiotapes;
hours weekly
RameP' 8 weeks, 2 yes, V 30 minutes of meditation daily without audiotape
hours weekly one-haif or 45 minutes daily meditation with audiotape
day
Saguia^' 8 sessions, no Instructed to meditate 20 minutes daily
each 90
minutes'
Ma^' 8 weeks, 2 no V V Follow-up meetings at 1 and 6 months post-MBCT
hours weekly
Weiss^' 8 sessions, no Sessions 2 to 7 combined therapy and MBSR;
each 60 practice meditation 30 minutes daiiy, 6 days
minutes, weekly; audiotapes
over 12
weeks

The Canadian Journai of Psychiatry, Vol 52, No 4, April 2007 265


Brief Communication

patients with moderate to severe psoriasis undergoing phototherapy (UVB) and


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Resume : La meditation de pleine conscience ameliore-t-elle les symptomes d'anxiete et de


i'humeur? Une etude de la recherche controlee
Objectif: Etudier l'effet de la reduction du stress par la pleine conscience (RSPC) sur les symptomes
d'anxiete et de depression dans un eventail de populations cliniques.
Methode : Notre revue comprenait toute etude qui a ete publiee dans une revue revisee par les pairs, qui
utilisait un groupe temoin, et qui presentait des resultats relatifs aux changements dans la depression et
l'anxiete. Nous avons extrait les variables cles suivantes de ehacune des 15 etudes reperees : les resultats
de l'anxiete ou de la depression apres le programme de RSPC, la mesure de l'observance des instructions
de RSPC, le type de groupe temoin inclus, le type de population clinique etudiee, et la duree du suivi.
Nous avons egalement resume les modifications apportees au programme de RSPC.
Resultats : Les mesures de la depression et de l'anxiete etaient comprises comme variables de resultats
pour un vaste eventail d'affections medicales et de troubles emotionnels. Les preuves d'un effet benefique
de la RSPC sur la depression et l'anxiete etaient equivoques. Quand des groupes temoins actifs etaient
utilises, la RSPC ne montrait pas d'effet sur la depression et l'anxiete. L'observance du programme de
RSPC n'etait pas souvent evaluee. Quand elle l'etait, la relation entre la pratique de la pleine conscience et
les changements dans la depression et l'anxiete etait equivoque.
Conclusions : La RSPC n'a pas d'effet fiable sur la depression et l'anxiete.

266 La Revue canadienne de psychiatrie, vol 52, no 4, avril 2007