Goyal M, Singh S, Sibinga EMS, et al. Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis. JAMA Intern Med. 2014;174(3):357–368. doi:10.1001/jamainternmed.2013.13018
Importance Many people meditate to reduce psychological stress and stress-related health problems. To counsel people appropriately, clinicians need to know what the evidence says about the health benefits of meditation.
Objective To determine the efficacy of meditation programs in improving stress-related outcomes (anxiety, depression, stress/distress, positive mood, mental health–related quality of life, attention, substance use, eating habits, sleep, pain, and weight) in diverse adult clinical populations.
Evidence Review We identified randomized clinical trials with active controls for placebo effects through November 2012 from MEDLINE, PsycINFO, EMBASE, PsycArticles, Scopus, CINAHL, AMED, the Cochrane Library, and hand searches. Two independent reviewers screened citations and extracted data. We graded the strength of evidence using 4 domains (risk of bias, precision, directness, and consistency) and determined the magnitude and direction of effect by calculating the relative difference between groups in change from baseline. When possible, we conducted meta-analyses using standardized mean differences to obtain aggregate estimates of effect size with 95% confidence intervals.
Findings After reviewing 18 753 citations, we included 47 trials with 3515 participants. Mindfulness meditation programs had moderate evidence of improved anxiety (effect size, 0.38 [95% CI, 0.12-0.64] at 8 weeks and 0.22 [0.02-0.43] at 3-6 months), depression (0.30 [0.00-0.59] at 8 weeks and 0.23 [0.05-0.42] at 3-6 months), and pain (0.33 [0.03- 0.62]) and low evidence of improved stress/distress and mental health–related quality of life. We found low evidence of no effect or insufficient evidence of any effect of meditation programs on positive mood, attention, substance use, eating habits, sleep, and weight. We found no evidence that meditation programs were better than any active treatment (ie, drugs, exercise, and other behavioral therapies).
Conclusions and Relevance Clinicians should be aware that meditation programs can result in small to moderate reductions of multiple negative dimensions of psychological stress. Thus, clinicians should be prepared to talk with their patients about the role that a meditation program could have in addressing psychological stress. Stronger study designs are needed to determine the effects of meditation programs in improving the positive dimensions of mental health and stress-related behavior.
Many people use meditation to treat stress and stress-related conditions and to promote general health.1,2 To counsel patients appropriately, clinicians need to know more about meditation programs and how they can affect health outcomes. Meditation training programs vary in several ways, including the type of mental activity promoted, the amount of training recommended, the use and qualifications of an instructor, and the degree of emphasis on religion or spirituality. Some meditative techniques are integrated into a broader alternative approach that includes dietary and/or movement therapies (eg, ayurveda or yoga).
Meditative techniques are categorized as emphasizing mindfulness, concentration, and automatic self-transcendence. Popular techniques, such as transcendental meditation, emphasize the use of a mantra in such a way that it transcends one to an effortless state where focused attention is absent.3–5 Other popular techniques, such as mindfulness-based stress reduction, emphasize training in present-focused awareness or mindfulness. Uncertainty remains about what these distinctions mean and the extent to which these distinctions actually influence psychosocial stress outcomes.5,6
Reviews to date report a small to moderate effect of mindfulness and mantra meditation techniques in reducing emotional symptoms (eg, anxiety, depression, and stress) and improving physical symptoms (eg, pain).7–26 These reviews have largely included uncontrolled and controlled studies, and many of the controlled studies did not adequately control for placebo effects (eg, waiting list– or usual care–controlled studies). Observational studies have a high risk of bias owing to problems such as self-selection of interventions (people who believe in the benefits of meditation or who have prior experience with meditation are more likely to enroll in a meditation program and report that they benefited from one) and use of outcome measures that can be easily biased by participants’ beliefs in the benefits of meditation. Clinicians need to know whether meditation training has beneficial effects beyond self-selection biases and the nonspecific effects of time, attention, and expectations for improvement.27,28
An informative analogy is the use of placebos in pharmaceutical trials. A placebo is typically designed to match nonspecific aspects of the “active” intervention and thereby elicit the same expectations of benefit on the part of the provider and patient in the absence of the active ingredient. Office visits and patient-provider interactions, all of which influence expectations for outcome, are particularly important to control when the evaluation of outcome relies on patient reporting. In the situation when double-blinding has not been feasible, the challenge to execute studies that are not biased by these nonspecific factors is more pressing.28 To develop evidence-based guidance on the use of meditation programs, we need to examine the specific effects of meditation in randomized clinical trials (RCTs) in which the nonspecific aspects of the intervention are controlled.
The objective of this systematic review is to evaluate the effects of meditation programs on negative affect (eg, anxiety, stress), positive affect (eg, well-being), the mental component of health-related quality of life, attention, health-related behaviors affected by stress (eg, substance use, sleep, eating habits), pain, and weight among persons with a clinical condition. We include only RCTs that used 1 or more control groups in which the amount of time and attention provided by the control intervention was comparable to that of the meditation program.