4. Meditation and Depression

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source [16]

See also Treatments for Major Depression Disorder

According to the World Health Organization more than 350 million people suffer from depression and 1 million people commit suicide each year. The research to find effective treatments for Major Depression Disorder (MDD) is incredibly relevant. Recent research shows meditation is comparably effective to antidepressants in relieving symptoms of MDD[1] . In addition, Mindfulness-Based Cognitive Therapy is shown to be particularly effective in reducing relapse rates of depression [1] . Further studies suggests there are neurophysiological mechanisms that underlie the efficiency of meditation as a therapy for depression. For example, meditation has been shown to increase monoamines and decrease amygdala activity[2] . It is evident and relevant that more research into meditation and depression should be encouraged in the neuroscience community.

1.1 Meditation and its effects on Major Depression Disorder

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source: [18]

Meditation and its effects have been shown through multiple studies that it is as effective as an antidepressant in alleviating symptoms of depression and anxiety [3]. Moreover, further studies show that the integration of mediation with various forms of psychotherapy to be particularly effective in reducing relapse rates[4]. Therefore, psychotherapies are being developed and implemented to treat people who suffer from depression and anxiety disorders. Furthermore, studies about the physiological changes that take place in the brain during and after meditation have been used to explain the effectiveness of meditation as a treatment. Changes in the brain that have been associated with alleviating depression and the reduction in relapse rates are of structural, functional and chemical in nature. All changes seen in the brain through neuroimaging techniques correlates with areas in the brain that are deregulated and/or dysfunctional in depressed individuals [2]. It is generally seen through all the studies and clinical trials that meditation and its effects can help people who suffer from depression.

1.2 Integrating Meditation in Clinical Practice

See also Psychotherapy

Meditation as psychotherapy has caught the attention of neuroscientists and psychologists due a number of reasons. Firstly, it is seen to be cost effective compared to receiving traditional pharmacology treatments for MDD, especially for patients taking antidepressants to avoid relapse[5]. Secondly, antidepressants have been controversial due to the concern of toxicity and other possible adverse effects; therefore the appeal of using a non-pharmacological treatment for MDD and stress is of great interest to the medical and psychotherapy community. Although Mindfulness-Based Cognitive Therapy and Mindfulness-Based Stress Reduction are the most studied therapies incorporating meditation, other traditional psychotherapies such as existential psychotherapies like Mindfulness-Based Existential Therapy (MBET) and Dialect Behaviour Therapy have also integrated meditation[6]. MBET has been argued that mindfulness can help the client and the therapist access and be aware of the moment-to-moment experience and emotions during existential therapy, whereby they can investigate with more clarity the issues that affect the client such as death, freedom and meaning in accordance to the principles of existentialism[6]. Since research has illustrated the benefits of meditation for those who suffer from mood disorders and stress, many individual psychotherapists have been integrating meditation into their own practices. Michael Stone, a renowned psychotherapist in Toronto has successfully incorporated meditation in his own practice. He is the founder of the Centre of Gravity, a centre where Zen meditation is the core of the therapeutic process. Mindfulness based therapies are being more established internationally, here is a list of established MBCT therapists and clinics. It is clear that meditation is an evidence-based psychotherapy that should be more accessible to patients and be further studied.

1.2a Zindel Segal and Mindfulness-Based Cognitive Therapy

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Zindel Segal
Source: [19]

Zindel Segal who holds a head chair for the Centre for Addiction and Mental Health and is a Professor of Psychiatry at the University of Toronto, along with his colleagues John Teasdale and Mark Williams developed Mindfulness-Based Cognitive Therapy. MBCT is an eight-week program where participants complete a weekly group meditation class and a daily home meditation practice by a guided meditation CD [7]. The form of the therapy is the combination of traditional Cognitive Behavioural Therapy (CBT) and Mindfulness-Based Stress Reduction (MBSR) therapy developed previously by Jon Kabat-Zinn [7]. The reasoning behind the effectiveness of the therapy is that the type of thinking pattern of an individual who have suffered a depressive episode is different from one who has not experienced MDD[8]. Segal and colleagues have suggested that the negative rumination of people who have recovered from depression can trigger a lower mood that can cause a relapse of depression[8]. Therefore MBCT is developed for the patient to have a raised awareness of the moment-to-moment experience and to their emotions to develop a meta-cognitive relationship with their negative thinking patterns, which is hypothesized to cause prevailing relapses[8]. In fact, once one has suffered depression the percentage of relapse rate is around 80% in most cases, therefore the relevancy of finding an effective treatment to prevent relapse is undeniable[9]. Much research has gone into the effectiveness of this therapy, and has become a well-established form of therapy particularly in Canada and England.Overwhelming amount of research has shown that MBCT is comparably effective in relieving symptoms of depression as an antidepressant. A recent meta-analysis reviewed over 18 000 studies through statistical analysis such as testing for strength of evidence and magnitude of improvement have confirmed that MBCT is as effective as an antidepressant and improved relapse rates more than the controls[3]. Moreover, it showed that most mindfulness programs were moderately effective in relieving anxiety as well. Stress was not improved among the studies analyzed[3]. The same study also reported that mantra meditation showed little improvement compared to controls, and that mindfulness based therapies in particular were more effective[3]. In the most recent paper by Zindel Segal and his colleagues, he takes this research further and focuses on whether the effectiveness of this therapy differs with formal or informal mindfulness practice. The method of the study conducted at Centre for Addiction and Mental Health and St. Joseph’s Healthcare, took two groups of screened individuals who completed 8 weeks of treatment in either formal or informal mindfulness practice[19]. The study shows that formal but not informal mindfulness based practice is effective in relieving symptoms of MDD[19]. The authors again believe this effect is due to the reduction of rumination in patients.


Zindel Segal talks about MBCT
Source: YouTube

1.2b Jon Kabat-Zinn and Mindfulness-Based Stress Reduction

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Jon Kabat-Zinn
source : [16]

Jon Kabat-Zinn is the pioneer for mindfulness-based therapies developing Mindfulness-Based Stress Reduction (MBSR) therapy. This therapy is what inspired Segal Zindel and his colleagues to create his MBCT. Jon Kabat- Zinn is the founder of the Stress Reduction Clinic and the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School and he is also a professor of Medicine at the same university. He is usually credited for bringing meditation into the western world in general, where it gained a lot of attention outside the Buddhism traditions. He was inspired by being taught meditation from a recognized Zen meditator and saw the benefits of mindfulness and specifically zen meditation. MBSR is also an intensive eight-week therapy program where he guides people through meditations[20]. He has many guided meditations CD available for download or purchase outside of his MBSR program in his clinic. There are certain stages of the meditations, usually starting with one called “body scan”. The process is the meditator is to pay close attention to the breathes through the sensations felt through the body. Again many studies have been conducted that shows the effectiveness of this therapy with anxiety and depression. For example, a study conducted by Kabat-Zinn and his colleagues shows that the therapy has long lasting effects[5]. The study took 22 rigorously scanned individuals who completed the MBSR course three years prior, and using the Beck Depression Inventory and other similar assessments analyzed the results[5]. In this study he found that there were still low levels of relapse rates compared to controls post treatment[5]. The participants on average rated high on their value of meditation in their daily lives and found it to be life altering[5]. Furthermore the study found that most of the patients continued meditating throughout the three years after taking the program[5]. All these results make it evident that MBSR is a long-term strategy that can be used to help those who suffer from depression or anxiety disorders.


A Guided Meditation (MBSR) by Jon Kabat-Zinn
Source: YouTube

1.3 Neurophysiological Mechanisms

See also Meditation and Brain Activity

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source:[19]

With new brain imaging technologies, meditation and its effects are being studied for its physiological and molecular mechanisms with regards to mood changes. Many studies have illustrated that numerous changes happen in the brain during meditation, even with new meditators. There are certain physiological associations with depression that meditation seems to act on or change in the brain. For example, the HPA Axis, certain areas that modulate emotions such as the prefrontal cortex and meditation also effects neurochemicals such as serotonin[2]. Research is usually conducted by using imaging techniques such as Electroencephalography (EEG) on participants of Mindfulness-Based programs, where researchers analyze and compare brain activity. Experiments such as taking experienced meditators such as traditional Buddhist monks and comparing grey matter in the prefrontal cortex with controls have also taken place. Monoamines are also studied in participants as well. All of these research groups have found structural, functional and neurochemical changes as well as changes in the Autonomic Nervous System. It is clear the benefits reported on meditation with depression and anxiety has an underlying physiological mechanism, thus considered as a neuroscientific phenomenon.

1.3a Neurochemical

Serotonin 5-HT, gamma-Aminobutyric acid (GABA), dopamine, norepinephrine, glutamate and melatonin have all been implicated to change with meditation[2]. Serotonin, for example when tested through urine samples after participants were meditating shows increased levels of this monoamine[2]. Researchers suggest that the effect of meditation on the Prefrontal Cortex modulates the secretion of serotonin 5-HT[2]. GABA, dopamine and melatonin have been shown to increase after meditation as well, which are neurochemicals that through previous research have been shown to be low in depressed individuals[2]. Norepinephrine and glutamate in the left thalamus has been shown to decrease after mediation[2]. Both of these monoamines are associated with calmness when they are decreased in an individual[2]. This can suggest the physiological the effect meditation has with regards to relieving symptoms and relapse rates of depression and anxiety disorders.

1.3b Structural

Meditation seems to modulate areas of the brain that is associated with emotion and executive functions for controlling emotion seen through various neuroimaging techniques. For example, studies show that the amygdala in experienced meditators, which is usually hyperactive in depressed individuals, is less active[12]. Zindel Segal and other researchers believe that the high activation in the prefrontal cortex and increased grey matter in the PFC seen in meditators may be used to help modulate the activation of emotional centres in the brain such as the amygdala[15]. Moreover, studies show that there is also less activity in the limbic system, which is thought to contribute to less rumination in patients, a key factor in the development of mindfulness-based therapies[14]. In addition, a study have suggested that after meditation neurogenesis in the hippocampus occurs[2]. It is well known from previous studies that the hippocampus is shown to be smaller in depressed individuals[2]. A common theme is seen in most of the studies, where the areas that are highly active in depressed individuals are decreased in meditators. And the areas which are associated with self regulation and emotional control are more active.

1.3c Autonomic Nervous System

Through studies regarding to the increase of serotonin and decrease of norepinephrine, it suggests that the HPA Axis is affected during meditation[13]. Further studies show that the parasympathetic activity is increased and the sympathetic activity is decreased[13]. Again these neurobiological findings correlates with reports from other studies mentioned above that researchers see decreased anxiety levels with people who have completed MBCT and MBSR.

1.4 Counteractive Effects

Within the Buddhism and meditation community the term “dark night” refers to a potential stage of the mindfulness journey for the meditator that is associated with cognitive impairments, disturbed heightened responses to stimuli, feelings of dissociation from the self and increased emotional responses[15] . While western science research has focus on the benefits of mindfulness in general, little research has been conducted into these prevalent adverse effects of meditation with regards to stress and mood disorders. However, the DSM-IV has referenced this phenomenon within the section on depersonalization disorder to differentiate this psychopathological disorder from the behavioural effects seen in meditation practitioners at this stage[15] . Neuroscience has yet to link these adverse effects to the neurophysiology of meditation. It is evident that more research should be done since MBCT and MBSR is becoming more established in clinical practices, whereby the risks involve should be well known for the teacher, therapist and the patient.

1.4a Willoughby Britton and her Current Research

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Willoughby Britton
source: [20]

Willoughby Britton is the first neuroscientist to study into these counteractive effects of meditation. She holds a PhD in Clinical Psychology and is currently doing her research at Brown University.
Her research is currently not published and is ongoing, however she has presented her preliminary results to the public including his holiness the Dali Lama. Her research comprises of conducting interviews with over forty meditation teachers and practitioners who has reported difficulties in their meditation practice [15]. Through this research people have reported to experience hallucinations, cognitive impairment, dissociation from reality, hyperactive emotional responses, adverse effects which are similar to the Buddhist definition of the “dark night” phenomena[15] . In addition, depersonalization has been strongly associated with mindfulness practice[15]. Further more, Britton has found that these effects can last up to three years, whereby some have suffered severe depression that has lead them to quit their jobs and to live normal lives[15]. Britton is interested how meditation which is proven to decrease symptoms of MDD can have such a strong polarizing effect, bringing people further more into depression. She found that these experiences are prevalent, on average each teacher she had interviewed had one or two cases of people during retreats each year who had to be hospitalized regarding to these adverse effects[15]. It is clear through her preliminary research that mindfulness meditation involves risks and neuroscience should fully explore this before more advancements of Mindfulness-Based Cognitive Therapy and other therapies.


Willoughby Britton's Public Lecture on her The Dark Night Project
Source : Vimeo

Bibliography
1. Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of consulting and clinical psychology, 68(4), 615.
2. Jindal, V., Gupta, S., & Das, R. (2013). Molecular Mechanisms of Meditation.Molecular neurobiology, 48(3), 808-811.
3. Goyal M, Singh S, Sibinga ES, et al. Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis. JAMA Intern Med. 2014;174(3):357-368.
4. Teasdale, J.D., Moore, R.G., Hayhurst, H., Pope, M., Williams, S. & Segal, Z.V. (2002). Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology, 70, 278-287.
5. Miller, J. J., Fletcher, K., & Kabat-Zinn, J. (1995). Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry, 17(3), 192-200.
6. Harris, W. (2013). Mindfulness-based existential therapy: Connecting mindfulness and existential therapy. Journal of Creativity in Mental Health, 8(4), 349-362.
7. Segal ZV, Bieling P, Young T, et al. Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Arch Gen Psychiatry. 2010;67(12):1256-1264.
8. Ma, S.H., & Teasdale, J.D. (2004). Mindfulness-based cognitive therapy for depression: Replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology, 72, 31-40.
9. Segal, Z.V., Kennedy, S., Gemar, M., Hood, K., Pedersen, R., & Buis, T. (2006). Cognitive reactivity to sad mood provocation and the prediction of depressive relapse. Archives of General Psychiatry, 63, 750-755.
10. Hawley, Lance, Danielle Schwartz, Peter Bieling, Julie Irving, Kathleen Corcoran, Norman Farb, Adam Anderson, and Zindel Segal. 2014. "Mindfulness Practice, Rumination and Clinical Outcome in Mindfulness-Based Treatment." Cognitive Therapy and Research 38 (1): 1-9.
11. Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert, L., Santorelli, S. F. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. The American Journal of Psychiatry, 149(7), 936-943.
12. Tang, Y., Ma, Y., Fan, Y., Feng, H., Wang, J., Feng, S., Posner, M. I. (2009). Central and autonomic nervous system interaction is altered by short-term meditation. Proceedings of the National Academy of Sciences of the United States of America, 106(22), 8865-8870.
13. Lazar, S. W., Bush, G., Gollub, R. L., Fricchione, G. L., Khalsa, G., & Benson, H. (2000). Functional brain mapping of the relaxation response and meditation. Neuroreport, 11(7), 1581-1585.
14. Luders, E., Toga, A., Lepore, N., Gaser, N. (2009). The underlying anatomical correlates of long-term meditation: Larger hippocampal and frontal volumes of gray matter. Neurimage, 45(3). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3184843/
15. Britton, W. (2014). The Dark Side of Meditation: an Empirical Research Study. [Presentation]. Preliminary Research presented at Mind Matters IV: The Darkness Within. University of Toronto.
20.

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